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Title: The practice of osteopathy
Fourth edition
Author: Carl Philip McConnell
Charles Clayton Teall
Release date: March 23, 2025 [eBook #75696]
Language: English
Original publication: Kirksville: Journal Printing Co, 1920
Credits: Bob Taylor, Charlene Taylor and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive/American Libraries.)
*** START OF THE PROJECT GUTENBERG EBOOK THE PRACTICE OF OSTEOPATHY ***
Transcriber’s Note
Italic text displayed as: _italic_
Bold text displayed as: =bold=
THE PRACTICE OF
OSTEOPATHY
[Illustration]
CARL PHILIP McCONNELL
President American Osteopathic Association, 1904-05. Formerly of the
Faculty American School of Osteopathy. Member of the Faculty
Chicago College of Osteopathy
CHARLES CLAYTON TEALL
President American Osteopathic Association, 1902-03. Dean of the Faculty
and Professor of Practice and Clinical Osteopathy American School
of Osteopathy. Editor Journal of Osteopathy
FOURTH EDITION
Rewritten in collaboration with osteopathic specialists of note
with much new and original matter
1920
JOURNAL PRINTING CO.
KIRKSVILLE, MO.
COPYRIGHT 1920
CARL PHILIP MCCONNELL AND CHARLES CLAYTON TEALL
DEDICATED
TO THE MEMORY
OF
ANDREW TAYLOR STILL
FIRST EDITION 1899
SECOND EDITION 1902
THIRD EDITION 1906
FOURTH EDITION 1920
PREFACE TO THE FOURTH EDITION
A science is said to be known by its literature and, if that be true,
Osteopathy is backward for there are few available books on the subject
for the student and investigator although there is a vast amount of
unclassified journalistic matter. A pretentious start was made and,
for a time, it appeared that we should have texts on all subjects for
the teaching of Osteopathy but, for reasons not necessary to give
here, these books did not live although their value and need was never
questioned.
The third edition of the Practice of Osteopathy was exhausted very soon
after publication and there have been insistent calls for a fourth
which is now presented with the hope that it will find as friendly
a reception as was accorded the previous editions. Close attention
to current literature has been given and reports from experienced
practitioners in the field has been sought and this material made
use of wherever possible. Besides this, certain sections have been
written by specialists in their several lines whose signed articles
we confidently present. The subject of osteopathic practice has been
handled to avoid undue optimism in the light of experience but, also,
not to lose sight of the fact that osteopathy won its way by performing
the so-called impossible in a multitude of cases. Therefore, it has
been thought best not to draw a hard and fast line on our limitations.
The border line between osteopathy and surgery has been demonstrated
as well as can be done on paper without the actual patient in hand.
Medical literature has been called upon to give its store of knowledge
wherever our needs have appeared and all osteopathic prints have, also,
given from their accumulated wisdom and experience.
The authors acknowledge, with thanks, this information from the many
writers for osteopathic journals who have created a great fund of
knowledge on osteopathic subjects and particularly those who have
contributed special sections.
CARL PHILIP MCCONNELL.
CHARLES CLAYTON TEALL.
1920.
“Osteopathy is not so much a question of books as it is of
intelligence. A successful osteopath is in all cases, or should be, a
person of individuality with a mechanical eye behind all motions or
efforts to readjust any part of the body to its original normality,
because unguided force is dangerous, often doing harm and failing to
give relief that should be the reward of well directed skill.”—A. T.
STILL.
LIST OF CONTRIBUTORS
RAYMOND W. BAILEY, D. O.
Former member of the faculty, Philadelphia College of Osteopathy.
(_Defective Children_)
EDGAR S. COMSTOCK, D. O.
Professor of Principles of Osteopathy, and of Respiratory and
Infectious Diseases, Chicago College of Osteopathy.
(_Infectious Diseases_)
J. DEASON, M.S., Ph. G., D. O.
Professor of Rhinology, Laryngology and Otology, Chicago College of
Osteopathy.
(_Ear, Nose and Throat_)
L. VAN HORN GERDINE, A. M., M. D., D. O.
Neurologist, Still-Hildreth Sanatorium.
(_Mental Diseases_)
A. G. HILDRETH, D. O.
Superintendent, Still-Hildreth Sanatorium.
(_Mental Diseases_)
H. S. HAIN, D. O.
Professor of Orthopedics, American School of Osteopathy, Orthopedic
Surgeon, A. S. O. Hospitals.
(_Deformities_)
EARL R. HOSKINS, Sc. B., D. O.
Professor of Clinical Osteopathy, X-Radiance and Diagnosis, Chicago
College of Osteopathy.
(_Diseases of the Blood_)
CHARLES J. MUTTART, D. O.
Professor of Diagnosis and Technique and of Gastroenterology,
Philadelphia College of Osteopathy.
(_Diseases of the Stomach_)
GEORGE M. MCCOLE, D. O.
Osteopathic Practitioner and Writer.
(_Influenza_)
CHARLES C. REID, M. D., D. O.
President, Denver Polyclinic and Post-Graduate College.
(_Ophthalmology_)
GEORGE A. STILL, M. S., M. D., D. O.
Professor of Surgery, American School of Osteopathy, Surgeon in Chief,
A. S. O. Hospitals.
(_Post-Operative Treatment_)
TABLE OF CONTENTS
PART I.
INTRODUCTION 17
OSTEOPATHIC ETIOLOGY AND PATHOLOGY 24
Osteopathic lesion; Etiological factors; Osseous lesion; Muscular
lesion; Ligamentous lesion; Visceral lesion; Composite lesion;
Pathology; Spinal lesions; Proof.
OSTEOPATHIC DIAGNOSIS AND PROGNOSIS 38
The Spine; Examination; Vertebræ; Position in examination; Neck,
Head and Face, Atlas, Axis, Skull, Third Cervical, Muscles of the
Neck, Temporo-Maxillary Articulation, Scalp, Ribs, Clavicle, Sternum,
Dorso-Lumbar, Thorax, Abdomen, Gall Bladder, Spleen, Stomach,
Intestines, Kidneys, Lumbar, Pelvis, Coccyx, Arms, Legs.
OSTEOPATHIC PROGNOSIS 56
OSTEOPATHIC TECHNIQUE 60
Sense of touch, Definite principles, General treatment, Position, Neck,
Head, Ribs, Dorsal, Lumbar, Abdomen, Pelvis, Legs, Arms, How often to
treat, Length of treatment, Over-treatment, Misapplied treatment.
OSTEOPATHIC CENTERS, STIMULATION, INHIBITION, READJUSTMENT,
VASOMOTOR AND SENSORY NERVES 88
SPINAL CURVATURE 96
POTT’S DISEASE 102
SPRAINS 104
FLAT FOOT 112
FRACTURES 115
POSTURAL DEFECTS 120
Round Shoulders, Painful Shoulders, Pendulous Abdomen, Postural
Curvature of the Spinal Column.
PROLAPSED ORGANS 133
Prolapsed and Dilated Stomach, Prolapsed Kidney, Liver Prolapse,
Prolapsed Intestines, Prolapsed Uterus, Ovarian Displacements.
SKIN DISEASES 147
Eczema, Herpes Simplex, Herpes Zoster, Urticaria, Acne.
ANIMAL PARASITES 151
Tape Worm, Round Worm, Pin Worm, Hook Worm, Trichiniasis, Filaria.
HEMORRHAGES 160
Epistaxis, Hemoptysis, Hematemesis, Intestinal Hemorrhage,
Hematuria, Uterine Hemorrhage.
HICCOUGHS 165
VARICOSE VEINS 166
PHLEBITIS 168
THE RECTUM 169
Local Treatment, Proctitis, Hemorrhoids, Rectal Conditions.
GENITO-URINARY 175
Prostate Gland, Acute Prostatitis, Chronic Prostatitis, Seminal
Vesicles, Varicocele, Impotency.
HEAT STROKE 180
DEPARTMENT OF OPHTHALMOLOGY 183
Examination of the Eye, Ciliospinal Center, Somatic Reflexes,
Accommodation in the Eye, The Ophthalmoscope, Diseases of the Eye,
Neuralgia, Diseases of the Eyelids, Lachrymal Apparatus, Conjunctiva,
Ophthalmia Neonatorum, Trachoma, Phlyctenular Conjunctivitis, Vernal
Conjunctivitis, Diseases of the Cornea, Examination, Ulcer, Xerosis,
Keratitis Neuropatalytica, Pannus, Phlyctenular Keratitis, Interstitial
Keratitis, Diseases of the Iris and Ciliary Body, Diseases of the
Choroid, Glaucoma, Diseases of the Lens, Cataract, Diseases of the
Retina, Optic Neuritis, Optic Atrophy, Asthenopia.
DISEASES OF THE EAR, NOSE AND THROAT 236
Examination, Diseases of the Auditory Meatus, Diseases of the Middle
Ear, Acute Mastoiditis, Chronic Mastoiditis, Otitis Media, Catarrhal
Deafness, Normal Hearing, Diseases of the Middle Ear, Diseases of
the Nose, Rhinitis, Hay Fever, Sinuitis, Epistaxis, Diseases of the
Nasopharynx, Adenoids, Diseases of the Oropharynx, Tonsillitis,
Tonsillectomy, Quinsy.
MENTAL DISEASES 282
Dementia Praecox, Delirium, Confusion and Stupor, Manic Depressive
Psychosis, Involutional Psychosis, Senile Dementia.
DEFECTIVE CHILDREN 303
Tendencies, Amentia, Treatment.
POST-OPERATIVE TREATMENT 312
Vomiting, Backache and Headache, Neuritis, Phlebitis, Nephritis,
Pleurisy, Pneumonia.
PART II.
INFECTIOUS DISEASES
Fever 325
Typhoid Fever 329
Typhus Fever 344
Malarial Fever 347
Septicemia 355
Pyemia 356
Dengue 356
Cerebrospinal Meningitis 358
Diphtheria 362
Dysentery 368
Acute Ileocolitis 368
Amebic Dysentery 370
Chronic Dysentery 371
Erysipelas 372
Yellow Fever 374
Tetanus 377
Simple Continued Fever 379
Tuberculosis 380
Influenza 399
ACUTE ERUPTIVE FEVERS 412
Smallpox 413
Varioloid 420
Vaccination 424
Scarlet Fever 428
Measles 437
Rubella 444
Varicella 446
Mumps 449
Whooping Cough 452
CONSTITUTIONAL DISEASES
Rheumatic Fever 457
Chronic Articular Rheumatism 460
Arthritis Deformans 462
Muscular Rheumatism 465
Gout 467
Diabetes Mellitus 470
Diabetes Insipidus 476
Rickets 478
Obesity 480
Scurvy 481
Infantile Scurvy 482
Purpura 483
Hemophilia 484
DISEASES OF THE DIGESTIVE SYSTEM
Stomatitis 487
Catarrhal Stomatitis 487
Aphthous Stomatitis 488
Ulcerative Stomatitis 488
Parasitic Stomatitis 489
Diseases of the Gastro-intestinal Tract
Applied Anatomy 490
Acute Gastritis 502
Chronic Gastritis 505
Gastric Neuroses 510
Gastric and Duodenal Ulcer 513
Dilatation of the Stomach 517
Gastroptosis and Enteroptosis 521
Diseases of the Intestines
Acute Diarrhea 523
Chronic Diarrhea and Mucous Colitis 526
Diarrhea in Children 529
Acute Dyspeptic Diarrhea 529
Cholera Infantum 531
Acute Enterocolitis 532
Cholera Morbus 533
Intestinal Colic 535
Constipation 537
Intestinal Obstruction 541
Hernia 547
Appendicitis 547
Diseases of the Liver and Bile Duct
Hyperemia of the Liver 554
Simple Catarrhal Jaundice 555
Cholecystitis 557
Jaundice 558
Cirrhosis of the Liver 560
Fatty Liver 562
Amyloid Liver 562
Gall-stones 563
Diseases of the Spleen
Splenitis 567
DISEASES OF THE RESPIRATORY TRACT
Acute Laryngitis 569
Chronic Catarrhal Laryngitis 570
Laryngismus Stridulus 572
Spasmodic Laryngitis 573
Tuberculous Laryngitis 575
Syphilitic Laryngitis 577
Edematous Laryngitis 577
Diseases of the Bronchi
Acute Bronchitis 579
Chronic Bronchitis 582
Fibrinous Bronchitis 585
Bronchiectasis 587
Bronchial Asthma 589
Diseases of the Lungs
Emphysema 592
Acute Lobar Pneumonia 597
Bronchopneumonia 605
Chronic Interstitial Pneumonia 609
Congestion of the Lungs 610
Edema of the Lungs 611
Diseases of the Pleura
Pleurisy 611
Acute Pleurisy 612
Serofibrinous Pleurisy 612
Chronic Pleurisy 615
DISEASES OF THE URINARY SYSTEM
Diseases of the Kidneys
Renal Hyperemia 617
Acute Parenchymatous Nephritis 618
Chronic Parenchymatous Nephritis 621
Interstitial Nephritis 624
Amyloid Kidney 626
Pyelitis 627
Uremia 628
Renal Calculus 631
Diseases of the Bladder
Cystitis 635
DISEASES OF THE CIRCULATORY SYSTEM
Diseases of the Pericardium
Pericarditis 638
Endocarditis 641
Chronic Endocarditis 645
Hypertrophy of the Heart 655
Dilatation of the Heart 657
Myocarditis 659
Degeneration of the Heart Muscle 661
Neuroses of the Heart 662
Angina Pectoris 666
Diseases of the Arteries
Arteriosclerosis 669
DISEASES OF THE BLOOD
General Consideration 671
The Anemias 672
Costogenic Anemia 674
Chlorosis 676
Pernicious Anemia 678
The Leucemias 680
Splenomedullary Leucemia 681
Lymphatic Leucemia 682
Hodgkin’s Disease 684
DISEASES OF THE THYROID GLAND
Congestion 686
Inflammation of the Thyroid 686
Simple Goiter 687
Exophthalmic Goiter 690
Myxedema 697
Cretinism 698
DISEASES OF THE PARATHYROID GLAND
Tetany 699
Diseases of the Thymus 702
Diseases of the Adrenal Glands 703
Addison’s Disease 704
DISEASES OF THE NERVOUS SYSTEM
Diseases of the Nerves
Neuritis 706
Neuralgia 710
Diseases of the Cranial Nerves
Olfactory 715
Optic 715
Motor Oculi 716
Patheticus 716
Trigeminus 717
Facial 717
Auditory 718
Glosso-Pharyngeal 718
Pneumogastric 718
Spinal Accessory 719
Hypoglossal 719
Diseases of the Spinal Nerves
Cervical Nerves 719
Phrenic Nerve 720
Brachial Plexus 721
Dorsal Nerves 721
Lumbar Nerves 722
Sacral Nerves 722
GENERAL AND FUNCTIONAL DISEASES
Paralysis Agitans 723
Acute Chorea 725
Choreiform Affections 727
Infantile Convulsions 728
Epilepsy 729
Migraine 736
Occupation Neurosis 738
Hysteria 740
Neurasthenia 744
DISEASES OF THE SPINAL CORD
Acute Myelitis 748
Poliomyelitis 750
Acute Ascending Paralysis 753
Locomotor Ataxia 754
Friedreich’s Ataxia 759
Spastic Paraplegia 760
Ataxic Paraplegia 761
Syringomyelia 761
Amyotrophic Lateral Sclerosis 763
Progressive Muscular Atrophy 764
Bulbar Paralysis 765
ORTHOPEDIC SURGERY
Scoliosis 767
Functional Curvature 773
Organic Curvature 774
Congenital Dislocation of the Hip 778
Talipes 784
Pott’s Disease 788
Hip-Joint Disease 791
Tuberculosis of the Knee Joint 793
The Plaster Cast Bandage 795
Index 799
PART FIRST
INTRODUCTION
What Hippocrates was to the Allopath, what Hahnemann was to the
Homeopath, Andrew Taylor Still is to the Osteopath, and it is safe to
say that when another century shall have rolled away, his fame will be
equal to that of either. That he is a maker of history, even the most
skeptical will admit. His teachings are revolutionary but are borne out
in fact, and on that as a foundation, is built the superstructure of
the young therapeutic giant—Osteopathy.
It would be of great interest to trace the history of the first
inception of the thought that drugs were not only unnecessary but
harmful, then view the struggle to grasp something tangible to take
their place, then see the development of the idea that the human body
has within it all that is needed for its upbuilding and repair until he
came to this fundamental: “The power of the artery must be absolute,
universal and unobstructed or disease will result. The moment of its
disturbance means the period when disease begins to sow the seeds of
destruction in the human body; and in no case can it be done without
a broken or suspended current of arterial blood,” capped by the
epoch-making discovery of the cause for this interrupted flow of the
blood stream—the theory of obstruction by anatomical displacement. It
is the only theory of the etiology of disease that will stand the test
of science and its acceptance and practice means a revolution in the
field of therapeutics.
As it is, he sets the exact date, June 22, 1874, when the light dawned
and he saw the outline of his great philosophy—Osteopathy. Then came
the years of adversity and struggle. With the eye of a prophet he saw
the future of that philosophy, and with the firmness of a Spartan
has defended it since birth. It must be a separate, distinct system.
Outside the fact that it was to heal the sick and was founded on a
knowledge of anatomy and physiology it had nothing in common with
existing schools, and if it were ever to grow it must be alone, for
his brother practitioners would have none of it and if left to their
tender mercies it would have “died a-borning.” Even had it been taken
up the result would have been the same for they would never have fully
developed it. And so through the lean, terrible years he struggled,
buoyed by the faith of a discoverer, urged on by love of this child of
his brain, fanatical in his determination to win. And win he did for it
was vouchsafed to him in his vigorous old age to sit on his hearthstone
and see the results of his work, his struggle and his faith. It is
something to know that his fame has circled the earth, to be honored
and sung by millions; a boon not accorded many a sage or philosopher.
Not only has the public accepted it but the medical profession is
making tardy but forced recognition of certain cardinal principles of
osteopathy by using them, but, of course, without credit.
Osteopathy has been defined as “that science or system of healing
which emphasizes, (a) the diagnosis of disease by physical methods
with the view of discovering, not the symptoms but the cause of
disease in connection with misplacements of tissue, obstruction of
the fluids and interference with the forces of the organism; (b)
the treatment of disease by scientific manipulations in connection
with which the operating physician mechanically uses and applies the
inherent resources of the organism to overcome disease and establish
health, either by removing or correcting mechanical disorders and thus
permitting nature to recuperate the diseased parts, or by producing and
establishing antitoxic and antiseptic conditions to counteract toxic
and septic conditions of the organism or its parts; (c) the application
of mechanical and operative surgery in setting fractures or dislocated
bones, repairing lacerations and removing abnormal tissue growths or
tissue elements when these become dangerous to organic life.”[1] In
a word, osteopathy is adjustment and the osteopath is an anatomical
engineer who knows what is wrong and has the ability to correct it.
Dr. Still changed diagnosis from guess work to fact and on it his fame
may well stand, for when the cause of the disease was found, treatment
was easy. He has ever emphasized the necessity of thorough examination
and correct diagnosis. All treatment must be based on the definite,
specific object to accomplish certain definite, specific things.
“Osteopathy would expound and apply the true philosophy of
manipulation. While the hands are used, it is not this alone and
chiefly that distinguishes its method of operation, but the idea and
purpose that lie behind manipulation.”[2]
All manipulators are not osteopaths any more than all butchers are
surgeons. The need for deep study of the subject is apparent from this
characteristic statement of Dr. Still’s: “Osteopathy is a science; not
what we know of it, but the subject we are working is deep as eternity.
We know but little of it. I have worked and worried here in Kirksville
for twenty-two long years, and I intend to study for twenty-three
thousand years yet.”[3] This brings us to the point of the relations of
osteopathy with other manipulative forms of treatment. They are not
many, for Gerdine,[4] in closing a long article on the “Physiological
Effects of Mechanical Therapeutics” says: “I have striven to show that
in no way is Osteopathy similar to massage either in theory or practice
if Osteopathy is conceived of, according to its founder, Dr. A. T.
Still, as a system of healing in which a definite lesion in form of a
bony displacement is the causative factor and a removal of the same,
the curative factor in disease.”
The fact that use is made of the hands to the extent it is by both
osteopaths and masseurs or Swedish movement operators gives rise to the
mistaken idea of similarity in treatment.
“The essential distinction,” says G. D. Hulett, “between Osteopathy and
all other systems of healing based on manipulation, clusters around
the etiology of disease. While these other systems, as indicated at
least by their practice, look at disease from a peripheral standpoint,
osteopathy views it from a central standpoint.”[5]
Massage is a small branch of manipulative therapeutics, but conceding
that it is perfect and scientific it can only resemble osteopathic
treatment in one ramification of osteopathic practice, viz: relaxation
of muscles.
The fact that massage is often employed by osteopaths in connection
with their work shows the limitations of that form of treatment. Says
McConnell[6]: “In the human body, as in any delicate, complicated
mechanism, there is mechanism within mechanism; and, in order to
obtain certain mechanical effects, many times there is required a
series of complicated movements, all of which bear a ratio one to the
other according to the energy utilized and the mechanical principle
involved.” No other form of manual treatment takes this principle of
mechanics into consideration. It is possible, as Gerdine points out,
for an undeveloped osteopath to practice massage under another name.
That the two should be confounded before the public is due to his
ignorance and not from any fault of the system. Massage is a valuable
aid in the treatment of disease but it is not Osteopathy.
“In the bright lexicon of osteopathy there is no such word as rub[7].”
Osteopathy in its relation with medicine has little in common.
From the beginning, its founder realized their paths should run
divergently, so the first step, its teaching, must be considered from
a different viewpoint. To quote from an address by Teall[8]: “But
to adequately teach osteopathy a vast amount of original work must
be done. Anatomy is anatomy but there is a vast difference in its
application. Physiology must be taught to mean something more than an
interesting phenomenon. Pathology has an unfilled gap between cause
and effect which must be bridged. The post-mortem has a great story
to tell but an osteopath must tell it. A slide of degenerated tissue
under the microscope is of interest, but why the degeneration? It is
described at length by the authorities, but the reason for the causes
and morbific changes are not carried out. Obstetrics along strictly
natural and physiological lines insuring both mother and babe against
injury; gynecology, minus the knife and plus common sense; all these,
and more must be put into shape to teach the osteopathic student. The
archives of osteopathy were empty ten years ago. There was no precedent
to follow and the ideas in teaching which had prevailed for centuries
dominated. All this is changed. The colleges teach the science along
strictly osteopathic lines, making the application of the truths which
have escaped the notice of centuries of investigation.”
All schools recognize the wonderful recuperative power of nature, as
this from the introduction of a standard allopathic text book will
show[9]: “There is no scientific dogma better established than this:
that the living organism is in itself adequate to the cure of all its
curable disorders. This natural law sustains the medical skeptic in
his infidelity, enables the homeopath to report his sugar cures, and
helps all physicians out of more close places than they are generally
willing to acknowledge.” But at times, as all will agree, nature is not
able to overcome its maladies and assistance is needed. Here, again, is
a divergence as to the method and character of that assistance. There
is no system so trivial or absurd which cannot point to its cures, but
a school of medicine should have a settled system with established
methods of procedure. This is not true of any school employing drugs as
its principal therapy. In the President’s annual address at Cleveland
he says[10]: “The observant reader of the progressive medical press
is struck at once by the unsettled condition in the field of modern
therapeutics. The trend is emphatically away from drugs. But, in
the effort to get away from medicine, the medical investigator has
wandered far afield, cutting loose from nature and resorting to the
artificial.” It is the last paragraph of the extract quoted which
particularly emphasizes the point of divergence, natural _versus_
unnatural methods. It must be understood at once that the osteopath
admits the reality of drug action for “there is no doubt that the
pharmacopeia records many drugs whose action is rapid and effective so
far as securing activity or decrease of secretion is concerned, but the
element of danger, i. e., their destructive power is great. Oftentimes
their power does not stop at the point desired or limit its effect
to the therapeutic action sought[11].” This point of unreliability
of the drug is emphasized by the following from recognized medical
authority[12]: “We give drugs for two purposes: (1) To restore health
directly by removing the sum of the conditions which constitute
disease. Here we act empirically with no definite knowledge—often
indeed with little idea of the action of our drugs, but on the ground
that in our hands or in the hands of others they have restored health
in like cases. (2) To influence one or more of the several tissues
and organs which are in an abnormal state so as to restore them to or
toward the normal; with the hope that if we succeed in our purpose
recovery will take place. The purpose we effect by means of the
influence which the chemical properties or drugs exert on the structure
and function of the several tissues and organs. Minute information,
therefore, of the nature of drugs and their action is essential for
their proper employment.” Osteopathy brings into action the latent
or stagnant forces of nature by specific methods which are usually
reliable. Naturally there being such a wide difference in theory of
the cause of disease it would be also shown in diagnosis as well as
treatment. The most striking points to the layman in medical procedure
are: first, wide difference in the system of diagnosis and in its
findings by physicians of the same school; second, the great variance
in remedies employed by different physicians of the same school for the
same disease.
Osteopathic diagnosis is so physical in its character, depending upon
actual conditions found and not upon the subjective symptoms alone,
that the same patient examined by a number of experienced osteopaths
will be given the same diagnosis, and he will also be able to detect
in each the same effort to correct in all their technique. All the
methods of physical diagnosis are used plus the distinctive osteopathic
procedure. Results wherever used bear out the effectiveness of the
system.
The osteopath must and does consider the necessity of surgery, but
his effort is always to prevent the operation if possible. There can
be no doubt that surgery is carried to extremes and there is a strong
sentiment growing that much of it is unnecessary. Says Homer Wakefield,
M. D.[13]: “It is to the everlasting disgrace and mortification of
the medical man that the wealthy classes who are continually under
the observation and direction of eminent men, in dietary, and all
life habits, in health as well as in sickness, are not only the very
ones who develop appendicitis and most largely go to operation, but
are almost exclusively those who attain to this distinction.” The
operations of today are wonderful and the surgeon shows great skill and
genius in their performance, but great as he is in these matters how
infinitely greater is the man who can prevent them. The need of the
osteopath today is to be trained to recognize surgical conditions and
neither allow surgery unnecessarily nor make the more terrible error of
not acting soon enough. Where surgery is a necessity there is always
an etiological factor to be considered. The cause of the manifestation
not always being removed what is to prevent a recurrence or serious
sequela in spite of the operation? “The specialist ... if he has wit
enough to read the lesson presented to him, that it is not sufficient
to remove an ovarian tumor, e. g., and that if nothing is said at the
same time or subsequently as to the causes which induced it, a positive
damage may be done to the woman, who may, therefore, while considering
herself cured, proceed to manufacture one on the other side, or may
find herself in a few years suffering from cancer in the stump of the
previous one[14].” And so the combination of osteopathy with surgery
may be necessary that the cause shall be removed. Osteopathic treatment
before operations in reducing congestions and inflammations, also in
toning the nervous system, is particularly efficacious while the after
treatment gives gratifying results. In fact, the two go hand in hand
when conservatism rules both.
That diet should receive particular attention from the osteopath is not
strange, for his veneration of nature peculiarly fits him to realize
the necessity of correct feeding. Probably no subject is more discussed
or presents a wider range of opinion than diet. There is overfeeding
and underfeeding; long intervals and short between feedings. There is
the no breakfast and no supper plan, mixed diet and the vegetarian,
uncooked foods, and one exclusively of milk, anything you want so long
as you are hungry but chew it well, etc., ad. lib. All are represented
by osteopaths in their following as they are from other professions,
but probably this would more nearly represent the views of them as
a school. In health, first, most people eat too much and do not
thoroughly masticate and insalivate. This applies to all stations of
society. Second, meat forms too large an item in the daily dietary.
Third, there is not enough variety and the ration is not well balanced
as to elements. Fourth, not enough care is used in preparation of
foods. In illness, first, the stopping, complete or partial, of food
until the system can take care of it; second, the giving of easily
digested foods. The man who avoids violent extremes in diet as well
as in other habits of life will usually last longest. It is to be
hoped that some rational system can be evolved on which all factions
may agree, for the present confusion of authorities is bewildering.
The osteopath gives attention to hygiene, sanitation, exercise,
environment, mental attitude, etc., as they may affect the welfare of
his patient.
Osteopathy can cure all curable diseases, for the same forces which
will overcome one malady will overcome another when set in motion.
Forces that produce a diseased condition will it normalized restore the
established type.
FOOTNOTES:
[1] Littlejohn, (J. M.)—Journal of the Science of Osteopathy.
[2] Encyclopedia Americana.
[3] Booth—History of Osteopathy.
[4] Journal of Osteopathy, May, 1905.
[5] Principles of Osteopathy, p. 190.
[6] Journal of the Science of Osteopathy, Dec. 15, 1900.
[7] Osteopathic Calendar, 1900.
[8] Reported, Portland, (Me.), Advertiser, Feb. 27, 1905.
[9] Potter’s Materia Medica.
[10] Teall—Journal of the American Osteopathic Association, Aug., 1903.
[11] Tasker—Principles of Osteopathy, p. 110.
[12] Allbutt’s System of Medicine.
[13] Cyclopædia of Practical Medicine, June, 1906.
[14] Rabagliati—Air, Food and Exercise, p. 129.
OSTEOPATHIC ETIOLOGY AND PATHOLOGY
Osteopathic Etiology
Osteopathic etiology and pathology constitutes the most interesting
chapter of osteopathic science. The primal divergence of the
osteopathic schools from previous systems is to be found in the
osteopathic interpretation of disease causes and processes, and not in
osteopathic therapy as some may think. Osteopathy makes claim to an
independent school because it possesses a distinct etiology, pathology,
diagnosis and treatment. Thus osteopathic practice is not a mere
method, but instead a system, a school, a science.
At no period of medical history have physicians of the older schools
felt more keenly the futility of medical methods and the lack of an
all-embracing principle of medicine than at the present. A recent
writer[15] who claims to have discovered a principle that encompasses
the entire field of medicine, says: “We found, we may say, that the
backbone of medicine was the absent factor, and that if the patient
labors of so many great minds had not proven as useful in the
development of practical medicine as they should, it was because they
lacked such a fundamental framework to afford a fixed _nidus_ for each
discovery, wherein its true relation to other discoveries would at once
become evident.”
Since the conception of osteopathy its fundamental framework has not
changed one iota as to principle, although the application of the
principle has been greatly elaborated. When Dr. Still proclaimed that
“the rule of the artery is supreme” he gave utterance to a basic
physiological truth. But when he demonstrated that osseous and other
anatamo-mechanical lesions disturbed the artery and caused disease, and
that readjustment of the anatomical cured the disorder, thus allowing
the physiological to potentiate and revealing that the living body
contains all the attributes of a vital and physical mechanism, did his
teaching contain the germ of a comprehensive philosophy; this gave
osteopathic science a “backbone” with a consequent fixed _nidus_ for
all existing facts and future discoveries. And thus, it should always
be emphasized that mechanical readjustment of the component parts of
the vital body is the eternal keynote of the osteopathic school of
healing.
=The Osteopathic Lesion.=—Broadly speaking a lesion is “any morbid
alteration in a tissue whether attended by a recognizable structural
change or not; but especially a change in which the continuity of some
of the tissue elements is broken in upon.[16]” There are several kinds
of lesions expressing the tissue involved, character of degeneration,
locality of same, etc. But upon analyzing the medley of arbitrarily
defined lesions the fact will be evident that much of medical etiology
and pathology has not been logically and consistently sifted and
arranged; and moreover, it will be found the =cause of causes= of many
diseases is unknown.
Herein, arises the great significance of the osteopathic lesion, for
the lesion alters the very governing and controlling tissues of the
body, viz., the nervous tissue and the vascular channels. Hulett[17]
defined the osteopathic lesion as “any structural perversion which
by pressure produces or maintains functional disorder.” The constant
maintenance of the structural perversion will, also, cause organic
disease, although it is granted that functional disorder must
necessarily result prior to any organic change.
The osteopathic conception of a lesion, functional and organic disorder
caused by pressure from disturbed structures, does not bring us into an
absolute new field. Medical literature of all ages contains references
to diseases caused by pressure of tissues on nerves, blood vessels, or
other channels. But the osteopathic idea is an absolutely new one in
the application of this principle universally. It simplifies and makes
uniform the arbitrariness of present semeiology.
Thus the osteopathic idea that many diseases originate, primarily,
from anatomically malaligned, malpositioned, or malrelated tissues
causing a blockage of vital processes, immediate or remote, is a theory
inclusive of disturbances to all tissues. This principle is fundamental
and is supported by the physiological truth that uninterrupted vital
channels preserve health; moreover clinical and experimental data, as
will be shown later, substantiate this fundamental. It at once places
interpretation of a lesion in an entirely new light from preconceived
concepts, and is analogous to and co-extensive with etiology and
pathology.
=Etiological Factors.=—The osteopath believes in the potency of
inherited and environmental influences. There can be no question that
a few diseases and certain disease tendencies may be inherited, the
principle feature, however, from the standpoint of heredity is, various
organs and tissues have less vital resistance. These should not be
confounded with congenital weaknesses and diathetic tendencies.
Environmental influences are very important factors. One’s
surroundings and daily habits in the home, shop, or office count
for much in the aggregate. Food, drink, air, rest, sleep, clothing,
exercise, mental attitude, etc., are all factors in the sum total of
health, and consequently ill health may be traceable to their abuse.
In fact, all hygienic and sanitary measures are duly considered by the
osteopath. Various abuses, over use, and disuse of the functions will
certainly be followed by physiological discord.
The germ theory contains much truth, but in the very large percentage
of cases where the micro-organism is a factor its significance is
only of secondary consideration. Immunity and resistance comprise an
important part of the health problem, of which the intact anatomical is
of first consideration. Usually the micro-organism plays the role of an
exciting and determining factor; before it can multiply and grow there
must be a field that is first nutritionally disturbed. Nutrition of the
tissue is the one great point always to be considered. The constitution
of an individual is the pivot about which predisposing, environmental,
and exciting factors of disease center. Health represents the integrity
of the artery as well as a maintenance of that master tissue, the
nervous system, and anything that produces or influences, directly or
indirectly, a disturbance of physiological functioning borders on the
pathological.
Hence the osteopath recognizes many of the common medical causes of
disease, but reserves the privilege of rearranging their relative
positions, for the osteopathic cause of disease greatly modifies their
value.
=Osteopathic Etiology= distinctively emphasizes structural derangements
and perversions. Of =first= importance, owing to static requirements,
is the =osseous lesion=. This lesion is represented by any abnormal
change of position or relation of the many bony constituents of the
body. The framework of the body is subject to not only any and every
physical violence of any mechanism, but moreover being the corporeal
foundation of a vital mechanism is subject to both direct and indirect
biochemic changes and influences.
Thus the osseous lesion is caused (a) by traumatism, e. g., strains,
falls, blows, etc.; (b) indirectly by atmospheric changes, over and
violent exercise, the slumped posture, debilitating habits, etc.,
through the media of muscle changes and imbalance; (c) by nutritional
effects disturbing the elements of bony tissue; (d) by ligamentous
change such as thickening of a capsular ligament; (e) by infections;
(f) compensatorily and reflexly through the media of body distortions
and muscular irritability or debility, e. g., an innominate lesion
may be compensatory to a lumbar curvature, dietetic errors may cause
dorsal muscular irritation and contraction produce a constant osseous
lesion which in turn may result in chronic indigestion.
The pathological changes in the osseous lesion are commonly one of
structural derangement, deviation or complete displacement. The
vertebral segments are of primary consideration owing to their
important relations to the spinal nerves, spinal cord centers and
sympathetics; the ribs owing to the close sympathetic and spinal
nervous relations; and then other osseous tissues, as the innominata,
clavicles, etc., depending upon their importance to contiguous vessels,
nerves and organs. It should always be remembered and emphasized
that mechanical changes of the anatomical structures is the primary
essential in osteopathic etiology; this is the one great inception of
pathological variations from the distinctively osteopathic conception,
which the osseous lesion typifies. Consequently the osseous lesion
factor is actually a luxation (complete, or partial, even to a very
slight degree), or malalignment of the bony constituents, which by
virtue of their physical malposition impinge or irritate contiguous
tissues. The essential test is the functional one, movement. The degree
of involvement may be one of many gradations ranging from a slight
malposition or impaction to a marked deviation or firm anchorage.
=Second= in importance from the static requirement of support is the
=muscular lesion= though from the standpoints of movement and dynamics
it is often of the first consideration etiologically. Many interosseous
lesions are the result of spastic involvement of deep seated spinal
muscles, of fibrotic changes and of tensions and weaknesses that either
establish a rigidness of the segments, compromising nervous stimulus or
vascular channel, or produce an imbalance of muscular tone and tension.
In the latter instance some type of sidebending-rotation osseous
lesion occurs, commonly anchored within the physiologic movements of
the spine. The muscular lesion may be an actual dislocation of either
muscle or tendon, but rarely. Commonly it is a contracted, or tensed,
or contractured muscle. The muscle, also, may be diseased either from
primary or secondary causes through nutritional and infectious sources
and thus be an etiological feature.
The muscular lesion is caused, (a) by direct or indirect violence the
same as the osseous lesion; (b) by atmospheric influences; (c) by
slumped posture, debilitating habits and various errors of living; (d)
infections; (e) by reflex irritations; (f) by compensatory changes;
(g) by disease causing hypertrophy or atrophy; and, (h) secondary to
osseous lesions, being the result of impingement to the muscles’
nervous control. The tensed or stretched muscle may result from a
separation of the points of origin and insertion.
Herein the fundamental osteopathic concept is the resulting affection
due to the physical encroachment, directly or indirectly, of the muscle
tissue upon vascular channel or nerve fibre, or the effect upon the
movement or alignment of the osseous tissue.
Muscular contractions, displacements, and tensions play a most
important part in acute disorders, although muscular lesions that
are secondary to other lesions are usually taken into account when
treatment is given. Muscular lesions affect, (a) blood and lymph
vessels; (b) nerve fibres. Muscular contractions, especially, impede
mechanically the return of the venous blood to the heart. The lesions
to the nerves may be manifested in innumerable ways, depending upon the
location of the muscle and the function and distribution of the nerve
affected.
Then there is the relaxed, overstretched, and atonied muscle. This
condition results as a secondary effect to mechanical strains, these
being so severe and constant as to cause direct stretching and possibly
tearing of the muscle fibres. This should be distinguished from the
exhausted or debilitated muscle, e. g., as found in neurasthenia and
anemia.
Diagnostically there are, (a) contractions of more or less area, due to
atmospherical changes; (b) the deeply seated contractions involving a
very small area, caused by vertebral and rib lesions; (c) contractions
due to reflex disturbances; (d) contractions caused by postural effects
and deformities; (e) contractions from spasms of the blood vessels as a
result of nervous irritations; (f) contractions due to toxicity of the
blood. All of these characteristic muscular lesions give a direct hint
as to both etiology and prognosis.
=Third=, the =ligamentous lesion=, as a lesion _per se_, is usually of
secondary importance to the osseous lesion. In chronic cases affections
of the capsular ligament and muscular fibrosis commonly maintain
malalignment or rigidness. There are two features that should be noted
in particular when considering this lesion; first, thickenings and
adhesions; and, second, relaxations.
The tone and integrity of the ligaments cannot but be of vital concern
to the stability, suppleness, and adaptability of the bony framework in
all physical movements. No matter how slight the osseous lesion may be
the ligament must of necessity be involved. The osseous derangements
are either a source of irritation to the ligamentous tissue, resulting
in congestion and inflammation and hence thickening and adhesions,
or else the ligaments are so strained and tensed that in time atony
may occur. Probably, in a fair percentage of atonied cases the first
disturbance to the ligament is one of irritation and congestion, and
from long continued involvement irritation is supplanted by debility.
Consequently the primary consideration of the ligamentous lesion from
the etiological standpoint is the character of the tissue (ligament)
changes. This, also, gives us a direct hint that is of the utmost
value in prognosis. The independent displacement of a ligament is
rare, thus ligamentous lesions from the viewpoint of purely physical
displacements are secondary to if not an actual part of the osseous
lesion. Ligaments, when displaced or tensed, readily impinge or
irritate contiguous tissues, but the original cause of the structural
perversion is commonly either the osseous or muscular lesion. Hence,
whatever factors enter into the production of these lesions will at
least indirectly produce the ligamentous lesion.
=Fourth=, the =visceral lesion= is frequently overlooked as being of
much moment as an osteopathic lesion. Visceral displacements acting
as a source of functional and organic annoyance on the physical plane
(structural perversion which produces and maintains pressure) alone are
not in the least uncommon.
Any or all of the abdominal viscera, or even the organs of the thorax,
may be displaced (physically) pathologically. Actual displacement of
the viscus is a prolific source of distinct disorders and many obscure
symptoms. True it is the organs are most frequently displaced from
indirect causes, but nevertheless the actual physical malposition is in
turn a primary cause of still another train of symptoms and diseases.
Visceral lesions are caused by, (a) vertebral lesions; (b) postural
defects; (c) direct violence; (d) nutritional disorders; (e)
childbirth; (f) unhygienic measures (tight lacing, heavy skirts, etc.);
(g) congenital weakness.
From the displaced heart due to valvular and debilitating influences
to the displaced liver, the stomach, the kidneys, the intestines, the
ovaries, and the uterus, may arise a source of direct or indirect
irritations, a train of apparent or masked symptoms, or a group of
nutritional disturbances that include an extremely important chapter
in etiology. Moreover not only may one organ alone be involved but
several may be displaced or prolapsed as a whole as in splanchnoptosis;
and even these in turn may be the direct cause of further organic
displacements as the abdominal viscera prolapsing upon the pelvic
organs. Here is a very fruitful field for the diagnostician, for to
separate cause from effect requires keen perception, an acute sense of
touch, and above all, most careful weighing of all the factors that
enter into the maze.
=Fifth=, the =composite lesion= is not always recognized as an
extremely important osteopathic factor. By composite lesion is meant a
structural lesion that primarily includes the osseous, muscular, and
ligamentous tissues as a whole. This may be termed a lesion _en bloc_
or _en masse_.
Composite lesions are of exceedingly frequent occurrence. Indeed, many
composite lesions are overlooked and instead of treating the _en bloc_
disturbance as a consistent whole the component factors are treated
separately with no concern or attention to the whole.
Postural defects are excellent types of the composite lesion. The
various curvatures, the tilted pelvis, etc., are representative of the
composite lesion. Etiologically, pathologically, diagnostically, and
therapeutically the contour of the spine and ribs, the relation of
the innominata to the sacrum and spine, and the symmetry of the body
generally should be recognized and appreciated. The relation of the
part to the whole and of the whole to the part are of vital etiological
concern. An incipient curvature may be easily overlooked, a pendulous
abdomen neglected, and a slipped innominatum passed unnoticed wherein
as a result the entire vertebral column is malaligned in relation to
the physiological curves or to the perpendicular line of gravity.
Frequently attempts are made to correct individual lesions when
attention should be directed to the composite lesion and _vice versa_,
e. g., a displaced rib is usually dependent upon a corresponding
vertebral lesion, and thus the transverse plane or section of the body
should be considered as a whole. A single lesion may be dependent
upon a composite lesion or a composite lesion dependent upon one or
more single lesions. A slipped innominatum or a disordered hip joint
may bring about a strain to a greater or less section of the spinal
column, or a twisted vertebra may cause a curvature, whereas on the
other hand postural defects may cause a strain at its maximum focal
point resulting in over-stretching and relaxing of ligaments so that
an osseous lesion results, or a spinal curvature cause an innominatum
displacement. Thus there is a constant establishing of equilibrium,
physically and physiologically, through the medium of compensation,
but at some phase of the change there are apt to be pathological
phenomena resulting, and very frequently physiological harmony is
not reestablished but instead irritation, debility and other disease
symptoms are constant effects until relieved.
Consequently osteopathic etiology is many sided and complicated. To
know whether an osseous, ligamentous, muscular, visceral, or composite
lesion is primary or secondary, compensatory, reflex, predisposing, or
exciting, requires a command of theoretical knowledge backed by much
actual clinical experience.
In noting the above distinctive osteopathic etiologic features the
student should not lose sight of the constitutional status of the
patient which may be modified by inherited, congenital, diathetic, and
environmental influences, all of which go to make up the predisposition
of the individual and have an important relation to osteopathic
factors. Then it should be recalled that disease processes may be of
insidious progress, and the products and effects of pathologic changes
accumulative.
Osteopathic Pathology
In the etiologic study the osteopathic characteristics have been
designated structural maladjustment, although at the same time not
losing sight of the angle that the body is not only a physical
mechanism but also a vital organism. Structural perversions
characterize the osteopathic distinction when dealing with the
physical body, and remembering the vital or biochemic mechanism,
mental attitude, diet, hygiene, etc., are not forgotten. To retain or
attain health, thorough appreciation of both the physical and vital
mechanisms should be kept in view, for there is both an independent and
dependent interaction on the part of each. The living body being an
entity premises a system of therapeutics both physical and vital, that
acts in direct accord and harmony with physical laws and physiological
functioning.
Osteopathic pathology deals with the distinctive osteopathic lesion as
a factor in production and maintenance of disease. Then the province
of pathology is, first, to determine whether the lesion is in reality
an etiologic factor; second, the immediate character of the lesion
disturbance; and, third, how organic life becomes involved.
Inspection, palpation, clinical results, dissection and laboratory
experimentation include the methods employed to prove that the lesion
is of practical consequence. That the lesion is an etiological
factor can be known only through clinical and experimental proof;
the immediate character of the lesion disturbance can be determined
by dissection; and how organic life becomes involved requires the
summation of histological, physiological and pathological data.
The following outline assumes that the reader is familiar with anatomy,
physiology and pathology. Osteopathic pathology does not add to
medical pathology an absolutely new pathology in all of the present
known numerous details, but instead interprets much of clinical
pathology anew, and furthermore it presents absolutely new data that
is exclusive, but germane to the present general medical and surgical
fields.
Nervous tissue and arterial blood are the master tissues, the
controlling and governing factors in health, and disturbances of these
tissues are necessarily the cause of ill health. The rule of the artery
and the control of the nerve must continue uninterruptedly in order
that physiological functioning remains intact. The body should be
looked upon as a being complete, no more or less, each tissue and organ
essential to the whole and the organism as a whole essential to every
part. This is fundamental and germane to a living structure, and hence
disturbance to the governing and controlling tissues, the nerves and
vascular channels, must necessarily cause a break in the concatenation
and disease must logically follow.
Thus in the osteopathic pathology we look to those influences that
primarily disturb the nerve or artery, study the disease process or
extension from inception to effect and from primary lesion to morbid
results, and note action and interaction of tissue upon organ and organ
upon organ.
That all parts of the body are in intimate and dependent relations each
with the other through the media of the nervous and endocrine systems
is a well known fact based upon histological and physiological grounds.
The neurone being the physiological unit implies that any disturbance
to the cell quickly disturbs any or all of its processes. It may be
said that “nervous tissue is dependent for its integrity upon two
things, blood supply and trophic influences. The nerve cell is solely
dependent on a proper supply of blood, and dies when this is withdrawn.
But the nerve fiber is more dependent on the trophic influence of the
cell of which it is a prolongation. It dies when cut off from the cell
but it can get along for a time with but little direct blood supply. On
the other hand, if the nerve fiber is injured it reacts on the cell,
leading to a partial but curable degeneration of the cell body.”[18]
Here is the immediate pathologic key to many diseases. Whatever cuts
off or obstructs the artery leading to the cell is a primary etiologic
factor; this then leads to degeneration of protoplasmic processes and
axone. It should be carefully noted that if the obstructed blood vessel
is one to the nerve fiber only the resultant partial injury to the cell
is curable.
“When an axone degenerates the retrogressive process involves not only
the main axone, but also its terminals, together with the collaterals
belonging to it with their terminals.”[19] This is an exceedingly
important link in the explanation of osteopathic pathology, that
distant organs may be affected by the osteopathic lesion. Moreover,
“degenerations of a secondary character may occur in those systems of
neurones which are more or less dependent upon the peripheral sensory
neurone system for their impulses.”[20] This is equally true with the
central motor neurone, or any neurone. It shows how far-reaching a
degenerative process and its effects may be. It further makes clear
that nerve intactness is directly and absolutely dependent upon a
normal circulation, and that it is self-evident any blockage either to
blood vessels or to neurones will vitally affect those tissues that
govern and control the life processes of the body. The integrative
action of the nervous system is one of the outstanding facts of
physiology.
The above is presented so the student may see how osteopathic spinal
lesions, if deeply seated and effective enough, can involve remote
tissues and organs. No one will doubt that fractures and complete
dislocations of the spinal column will seriously affect visceral life,
or a prolapsed kidney will be a cause of nutritive disturbance, or a
displaced uterus the cause of ovarian congestion, or a dislocated hip
the cause of atrophy of the leg muscles, but it has remained for the
osteopath to offer proof that slight misplacements of the vertebræ or
ribs, incipient curvatures, postural defects, slight deformities, and
unsymmetrical bodies are of sufficient etiological importance on the
physical plane to affect neurone integrity and obstruct artery courses,
and thus organic life.
The question at once arises, what is the immediate or direct effect
upon blood vessel or nerve of the osseous, ligamentous, muscular,
visceral or composite lesion? The osseous lesion will be taken as
a type. The direct effect is usually one of hyperemia or ischemia,
generally the former, for as physiologists and clinicians observe
irritation commonly precedes debility. In the vertebral and rib lesions
there may be direct pressure upon the spinal nerve at its spinal
foramen exit or on the sympathetic chain directly contiguous to the
heads of the ribs. This causes congestion, inflammation, ecchymosis,
and degeneration of the nerve fiber, followed by macroscopic and
microscopic changes as connective tissue proliferations, arterial
scleroses, etc. Or, as seems probable in experimental work, the
inception of the pathology may be frequently the result of blockage to
nervous stimuli, which when maintained affects the efferent vasomotor,
secretory, trophic and other fibers so that circulation and nutrition
are definitely involved.
Thus the cells so sensitive to altered vascular changes are directly
and remotely affected, and disease characteristics dependent upon
structure and function of tissue, and degree of irritant are evident.
This can vary, in degree only, with the muscular lesion that involves
collateral spinal cord circulation, the visceral lesion that irritates
sympathetic life, or the composite lesion that deforms or perverts
structure en masse.
But is the physical noxa as potent an etiologic factor as the chemical
or bacteriologic? Adami[21] informs us whether an irritant is physical,
bacterial or chemical, no satisfactory distinction can be founded on
the duration of the irritation; that a local irritation of the nervous
system may lead apart from “direct reflex action, to changes of nervous
origin, in the region of the injury and in the reflexes affecting
associated regions, the higher centers; and through them the system
at large, may become affected by paths that it is not always easy to
trace.” Again he says that “centrifugal impulses alone, apart from any
local injury, may originate a succession of phenomena of inflammation
in a part.” And “in all probability a nervous and central origin must
be ascribed to some, at least, of the sympathetic inflammations seen
to occur in areas supplied by the other branches of a nerve supplying
a part primarily inflamed; and again in areas supplied from the same
region of the brain or cord as the inflamed organ.” Other inflammatory
changes, of course, may occur independently of centrifugal nervous
influences, and the vessels react independently of central influences.
This, then, presents a situation postulated thus:
1. The body follows definite structural relations and is influenced by
mechanical arrangements in its morphology.
2. The integrity of tissue depends upon structural freedom of nutritive
courses.
3. The above predicates a structural etiology as exact and precise as
structural relations are important to nutrition.
What proof, then, of the foregoing have we to offer?
First, the =clinical proof=. Clinical results have been obtained in
tens of thousands of cases that include disease of various types
and lesions, and of all sections and organs of the body. The art of
osteopathy has been perfected in many of its details, based upon actual
experience and splendid results. The cure of the patient is paramount
to all other consideration, and whereas the osteopathic school has
been shown a superior system it logically follows on _a priori_
grounds that relief and cure of suffering is of the first and final
importance.[22]
Were it not for clinical results no new system of therapeutics could
withstand criticism and calumny and finally triumph and be publicly,
legislatively, and scientifically recognized.
Second, the =autopsy proof=. Many dissections have been made and
autopsies held with the view of discovering the character and the
potency of the osteopathic lesion. This very important work has borne
out the osteopathic theory of disease. Vertebral and rib displacements
have been noted, corresponding ligamentous tissues thickened,
associated nerve tracts and vascular channels disturbed, and finally
the related organ found diseased.[23]
Third, the =experimental proof=. Experimental proof appeals, logically,
to the scientific mind. This proof[24] is being gradually developed.
Experimental investigation has been successfully carried out upon
numerous animals. The experiments conclusively prove that not only
spinal inhibitory and stimulatory manipulations (mechanical) are
productive of immediate physiological changes in the viscera, but that
the structural anatomical lesion or noxa is an important factor in
the etiologic field. Pathological changes in several organs directly
follow the artificially produced vertebral and rib lesions, showing
beyond doubt the reality and effectiveness of the osteopathic lesion.
This emphasizes the point that centrifugal impulses originate an
inflammation in a previously healthy and uninjured tissue or viscus.
And as “inflammatory phenomena may be sympathetically developed in
regions innervated from the same area in the brain or spinal cord”
it remains to prove the actuality of vertebral and rib lesions, i.
e., structural perversions really affect contiguous nerve courses
and vascular channels; and this has been demonstrated in laboratory
experiments and at the autopsy. Consequently the vertebral, rib, or
other lesion may be an important etiologic factor either to the nerve
strand from cord or brain to viscus or from viscus to cord or brain.
Dr. Still says in his Autobiography that “all nerves depend wholly on
the arterial system for their qualities, such as sensation, nutrition
and motion, even though by the law of reciprocity they furnish force,
nutrition and sensation to the artery itself.” It matters little in
this outline whether obstruction to nervous integrity is by way of
an impinged artery or by direct pressure, or both, or otherwise,
for the primary consideration is the noting that the osteopathic
lesion is a real and potent factor of disease. Sajous[25] informs
us that “a neurone is directly connected with the circulation (via
neuroglia-fibril) by one or more of its dendrites, which serve as
channels for blood plasma,” that a neurone receives its nutrition
directly from the general circulation, and that from the axone the
blood passes into a lymph space connected with a vein. Thus in reality
a part of the circulatory system is that of the entire cerebrospinal
system.
The student is referred to the various publications of the Research
Institute and Deason’s Physiology for experimental data confirming the
validity of the osteopathic theory, although it should be emphasized
that clinical evidence is quite conclusive. Malalignment injuries of
the vertebral articulations, for example, ranging from imbalance of
muscular tension to infections, is certain to result in some type of
rotation and sidebending of the segments to an extent that apposition
is compromised and abnormal anchorage supervenes. There are many
factors of the pathology: muscular tension and fibrosis; damaged
ligaments, particularly the capsular; interference of nervous stimuli,
blockage of impulse directly and reflexly as shown by pathologic
involvement in cord centers and sympathetic ganglia, and in certain
cases direct obstruction of nerve fibers as revealed by Wallerian
degeneration; involvement of circulation as shown by damage to
blood-vessels, local edema and local acidosis, and effect upon local
tissue respiration and drainage. Through a combination of these various
factors circulation, nervous equilibrium and chemism of related parts
are involved, both anatomical and physiologic balance is upset, and
resistance of corresponding viscera affected. Reciprocal innervation
and the axone reflex are also disturbed, all of which are important
predisposing causes that disturb resistance of tissues and organs,
upset their correlated mechanisms and render active various possible
infections and toxins that otherwise a normal circulation, nervous and
endocrine systems, and oxygen supply would rapidly and successfully
combat and restore the organism to normal. Thus from the practitioner’s
standpoint there are three points to always keep in mind: readjustment
of the lesion; correction of the forces, habits, environment, etc. that
produce the lesion; and hygienic attention of the body after lesion
adjustment in order that normal condition may be maintained. A thorough
study of the physiologic movements of the spine is a prerequisite
to an understanding of the various possible abnormal appositions,
though it should be appreciated that these movements are not consonant
or applicable to many abnormal conditions. Pathology reveals many
gradations and combinations not found in normal conditions. Frequently
the key of a successful technique rests upon an understanding of the
individual make up of the interosseous lesion.
It has not been the purpose of this section to go into details but
rather to follow logically an outline of osteopathic etiology and
pathology. The various details will be found in the osteopathic works
on Principles as well as in the experimental articles referred to. It
should be understood that the osteopath believes thoroughly in _vis
medicatrix naturae_ whether the indications are for stimulation or
inhibition or for the basic readjustment. Generally speaking, however,
therapeutic philosophy resolves itself (ultimately) into the principle
that a cure depends upon giving an impetus to impaired, habitual and
latent forces, which in the osteopathic field implies fundamentally
adjustive manipulation whereby the resultant impetus or physiological
stimulus is initiated.
In a word, osteopathy premises that the body is a vital and physical
mechanism subject to derangements, structural alterations, and
functional changes, as results of violence on the mechanical plane,
as well as disturbances on the psychic and biochemic planes. Hence,
osteopathic philosophy is inclusive of preventive, palliative and
curative measure.
FOOTNOTES:
[15] Sajous—The Internal Secretions and the Principles of Medicine.
[16] Foster—Medical Dictionary.
[17] Hulett—Principles of Osteopathy.
[18] Dana—Text Book of Nervous Diseases.
[19] Barker—Reference Hand Book of the Medical Sciences.
[20] Delafield & Prudden—Hand Book of Pathological Anatomy and
Histology.
[21] Adami—Inflammation, Allbutt’s System of Medicine.
[22] See Case Reports, American Osteopathic Association.
[23] Clark—Applied Anatomy.
[24] McConnell—Numerous articles Journal A. O. A. 1905-19, Bulletins
Research Institute; Deason, Bulletins Research Institute, Deason’s
Physiology; Burns’ Osteop. World, Aug. 1905; Basic Sciences, Bulletins
Research Institute; Pearce, Osteopathic Physician, Nov. 1905.
[25] Sajous—Internal Secretions and the Principles of Medicine.
OSTEOPATHIC DIAGNOSIS AND PROGNOSIS
Osteopathic Diagnosis
In osteopathic diagnosis the spine is the first and greatest object
of interest, for on the result of its examination will depend the
treatment to be given which is in turn hoped to bring about recovery.
As it is the structure on which rests the weight of the body the
practiced eye is able to detect at a glance, by the poise and gait
of the patient, if there is an abnormal condition affecting any
considerable area of the spinal column. It is well to observe these
points, especially in the female, before having them prepare for
examination, as it will often give a clue to sources of trouble through
faulty carriage, improper dress, particularly corset and shoes. Slight
changes of gait, unnoticed by the patient may be of great aid in
determining the beginning of disease in the spinal cord.
No osteopath is justified in accepting a patient who will not permit
every examination deemed necessary, as remote and obscure lesions are
frequently the cause of disease, so preparation of the patient for the
first scrutiny is of importance. This cannot be made with the patient
fully clothed, as visual observation is second only to the touch in
making one’s deductions. Neither can palpation be made through more
than one thickness of clothing with accuracy, and examination next
to the skin is always preferable. This need in no way ever cause
complaint, for with the use of a loose fitting short kimono, with all
outer clothing removed except the knit undergarment, and with skirt
bands loosed, a complete survey of the whole dorsum from occiput to
coccyx can be had without the slightest unnecessary exposure. It is
well to remember that the patient has come for help and the osteopath
is not justified in sacrificing thoroughness for any exaggerated
feelings of modesty. With tact and care in the use of the garments the
most sensitive ones need feel no hesitation in coming for treatment.
A complete history of the case should be taken before the examination
begins, former methods of treatment, symptoms, environment, etc., as
it will aid in the final conclusions. It is well to have blanks for
keeping records of all cases.
Probably the most comfortable manner to begin physical examination is
to seat the patient on a table squarely with hands placed upon the
knees, then raise the garment and expose the whole back. Begin by
noting the texture of the skin, if it is clear, pigmented, blotched,
or has eruptions. Try the capillary reflex by pinching or stroking
quickly with the finger tips or the blunt end of a pencil. Find if it
is moist or dry and also outline the areas of changed temperature, if
any. Then observe the general contour of the spine with the patient
sitting upright, to find how near it is to the normal body curve.
Occasionally having the patient alternately sit and stand will, by
comparison, throw light upon the condition. With the patient bending
forward place the hands on the crest of the ilia and see if they are of
equal height.
Occupation may result in over development of one side or there may be
congenital asymmetry[26]. Note position of the scapulæ and habit of
posture in sitting and standing.
Before taking up the subject of a critical examination of each vertebra
there are certain points it will be well to consider. It is easy to
know instantly, without counting, the number of the vertebra causing
the lesion if these landmarks are remembered: First, the spine of the
third dorsal is on a level with the spine of the scapula. Second, the
spine of the seventh dorsal is on a level with the inferior angle of
the scapula. Third, the spine of the last dorsal is on a level with the
head of the last rib. It will save much time for the busy osteopath to
have these well in mind.
The =pathognomonic symptoms= of the osteopathic lesion are: (a)
maladjustment; (b) contracted muscles; (c) tenderness; (d) limited
movement. To these might be added changes in local temperature and
disturbance of function, but the former is not constant and the
latter may be remote. Here the primary lesion is considered, for an
osteopathic lesion may be, also, secondary or compensatory. Forbes
speaks of compensatory changes as being an important diagnostic sign.
Diagnosis of the position of a vertebra is sometimes difficult to the
beginner from its having longer or shorter spines than normal. Horsley
speaks of the occasional congenital absence of a spinous process.
They may be bent laterally, upward or downward and thus have all the
appearances of a marked displacement, while occasionally the body
itself seems much at fault. These present what might be termed normal
abnormalities and make it necessary for the osteopath to be very sure
of his diagnosis before attempting to correct what is not abnormal, for
disappointment, at least, and injury, perhaps, may follow.
To avoid mistake, carefully palpate the transverse processes and
determine if they are at right angles with the adjoining normal spine.
In the cervical and lumbar vertebræ it is possible to reach the tips of
the transverse processes, and on moderate pressure, if a lesion exists,
pain will be elicited. Further, where tenderness is associated with
other diagnostic points it can be safely assumed that a lesion exists,
and by outlining the suspected vertebra with the finger and localizing
the sensitive spot one can be sure of the point of greatest irritation
and the character of the displacement. Associated also with these signs
will probably be evidence of congestion, such as thickened tissues,
contracted muscles, etc.
After having examined the condition of the spinal column thoroughly by
inspection, begin at the first dorsal and examine the spinal column
down to the sacrum. Place the middle and ring fingers over the spinous
processes and stand directly back of the patient and draw the flat
surfaces of these two fingers over the spinous processes from the upper
dorsal to the sacrum in such a manner that the spines of the vertebræ
pass tightly between the two fingers, thus leaving a red streak where
the cutaneous vessels press upon the spines of the vertebræ. In this
manner slight deviations of the vertebræ laterally can be noted with
the greatest accuracy by observing the red line. When a vertebra
or a section of vertebræ are too posterior a heavy red streak is
noticed and when a vertebra or vertebræ are anterior the streak is
not so noticeable. Thus when suspicious points are noticed a special
examination of the localized point can be given. This examination
simply takes into consideration the contour and superficial condition
of disordered portions of the spinal column. In a few cases such an
examination will not be necessary, for the symptoms and signs of the
disease will be so clearly manifested that one’s attention will be
called directly to the cause. Still, great care should be taken in the
majority of cases, as the osteopath finds causes of disease remote from
the seat of complaint. We must always bear in mind the significance of
reflex stimuli and sympathetic radiation.
In making a critical and exhaustive diagnosis of the spinal condition
after the foregoing general examination has been made, it will be best
to have the patient lie on the side upon the operating table. When the
patient is in this position a more thorough examination can be made,
as then the spinal muscles are not contracted unless abnormally so,
for when a person is in the upright position muscles are continually
contracting first on one side and then on the other, as one of their
functions is to act as a support in keeping the spinal column erect.
The patient lying on his side, the physician should then stand in front
of him and reach over upon the back and make a thorough examination of
the affected portions of the spinal column, chiefly through the dorsal
and lumbar regions.
Consideration should be given the contraction of the muscles along the
back, chiefly the deeper layers of muscles. It may even be necessary
to relax some of the muscles before a thorough examination of the
vertebræ can be made. From a pathological point of view too much stress
should not be put upon the contracted state of the muscles; although
in a number of instances the contracted muscles may be the primary
cause of the patient’s trouble; especially so when the affection is
due to atmospheric and other changes. Contraction of the muscles may
be secondary to the lesions presented in the bony frame work. For
instance, a dislocated vertebra may be the cause of an irritation to
the innervation of certain muscles along the spinal column and thus
cause them to contract. Still, we must not lose sight of the importance
of the contracted muscles from a diagnostic point of view. They are
oftentimes prominent signs that a lesion exists in the immediate region
and are thus faithful guides in locating the cause of diseases.
In closing the general consideration of the spinal column it is
well to emphasize the importance of training the faculties to grasp
at a glance the story told by the back as a region, instinctively
placing the proper value on each physical sign and weaving them into
a composite whole so that the patient’s condition stands out a vivid
picture on the osteopath’s mind. When this is accomplished the more
detailed observations are but incidental. Relative to the examination
of the spinal column Clark[27] says: “To the osteopathic physician,
the most important part of the human body is the spinal column. By its
changes in contour and condition the various visceral diseases can be
diagnosed, in most cases. I believe that every disease is characterized
by extreme changes or signs, and I further believe that every chronic
visceral disorder is manifest by changes in the spinal column that can
be, by the practical eye and touch, readily interpreted. In short,
there are various signs along the spinal column that point out the
weakened or diseased parts of the body. This method of diagnosing
disease, that is by noting these spinal changes, is distinctly
osteopathic, and I believe the time will come when it will become such
an exact science that the character of the spinal change or lesion is
diagnostic not only of the viscus affected, but the way it is affected.”
Regional examinations and diagnosis will now be taken up.
=Neck, Head and Face.=—To make a thorough diagnosis of the condition of
the cervical vertebræ probably requires more skill and a more acute
sense of touch than of any other region of the body. The irregularities
and variations of the cervical vertebræ, the numerous muscles and the
passage of many vessels through the neck are very liable to mislead one.
One may examine the cervical vertebræ by having the patient either
lying down or in a sitting posture. The former position is preferable,
as then the muscles of the neck are passive, and besides it is much
easier to relax the muscles if such should be necessary. Also one has
better control of the field of examination.
It is undoubtedly best for the student when learning to examine the
cervical vertebræ to first examine along the base of the skull the
condition of the occipital muscles (after the patient has assumed the
dorsal position upon the treating table) for any contractions; for if
disorder exists in the upper five cervical vertebræ the condition will
be manifested by contraction of muscular fibres along the base of the
occipital bone. The muscles of the occiput are supplied by fibres from
the posterior branches of the upper five pairs of spinal nerves, and if
lesions exist to these upper nerves a contracted state of more or less
extent of the occipital muscles will occur, no matter how slight the
lesion. Thus the examiner after locating contracted fibres under the
occiput has a direct clue to lesions existing somewhere in the upper
five cervical vertebræ. After locating these contracted fibres of the
occipital region and then still keeping the finger upon the contracted
muscular fibres and following them downward until the contractions
are lost and seem to enter the spinal cord, one has then located the
exact point of disorder that is causing the irritation to the muscular
fibres involved, and most probably the cause of the affection from
which the patient is suffering, i. e., provided one has reason to
suspect the trouble is in the cervical vertebræ. Simply follow the
contracted muscular fibre downward until it seems to enter the spinal
cord and there one will find a lesion. After the osteopath has become
expert in diagnosis this will not be necessary unless he has to make
a very fine diagnosis or unless he is examining a stout neck where it
is hard to examine through the heavy muscles. With this method one has
a firm, flat, broad surface to work on (the occipital bone) making it
very easy first to locate contracted muscles and second to trace the
course of contracted muscles and thus find the disorder. Otherwise the
beginner is apt to get confused by trying to examine the condition of
the cervical vertebræ. Later, when a student becomes more expert such a
procedure will rarely be necessary only in cases that require special
work in the examination.
When the point of disorder has been located the diagnosis as to
the exact character of the maladjustment has to be determined. The
abnormal position of the vertebra, tenderness at the point involved,
local contracted muscles, and limited motion are the four diagnostic
points, although the temperature of the affected part as compared with
the general cutaneous temperature and the state of the local vascular
channels (blood and lymphatics) will occasionally be of aid.
Owing to the irregularity of the spinous processes of the cervical
vertebræ in regard to their length, great care has to be taken in the
examination. Probably there is no other region of the body that will
tax the patience of the osteopathic student so much in his practical
work as making a diagnosis of disorders in the cervical spine. It
requires patient and persistent work to become a fair diagnostician of
the cervical region, and it will take much experience to become expert
in both the examination and treatment.
One can depend that lateral deviations of the spinous processes are
abnormal in most instances. Placing the finger upon the spinous
processes of two consecutive vertebras the student can readily tell
whether or not there is any lateral displacement; but telling as to
other features is impossible as the spinous processes vary greatly in
length. When a vertebra is lateral, a slightly twisted condition will
be felt by the finger when placed upon and between the two spinous
processes.
To elicit the various degrees and combinations of rotation and
sidebending one should depend upon the symmetry of the transverse
processes. Reaching anterior to the sternocleidomastoid muscle, or
better still, pushing the cleido muscles forward and reaching posterior
to them upon the transverse processes, a very fair examination can then
be given the vertebras. When the vertebras are deranged, especially
anteriorly or posteriorly, that is the apposition of the articular
facets, a slight elevation will be felt, possibly not any larger
than a very small pea, either the anterior or posterior aspects of
the transverse processes, depending upon which way the vertebræ are
deranged. Remember that accompanying this slight elevation will be
degrees of sensitiveness of the vertebra at the point deranged. In
cases where the vertebra is lateral a slight eminence will be noted
along the outside of the process. Commonly disordered vertebræ are
not entirely deranged in one direction but are oftentimes slightly
rotated, so we may find them dislocated antero-laterally or in various
combinations of sidebending-rotation. Several consecutive vertebras
may be deranged in like manner of direction; this condition is chiefly
found in pathological curves of the spinal column. Probably the most
common general lesion is a strained condition of several consecutive
vertebræ, each one being nearly intact but all of them as a whole
somewhat strained or twisted. Thus there are many pathological states
to take into consideration, although it is not surprising to the
osteopath when he realizes that many of our pains and aches are due to
anatomical derangement. Frequently bending the head strongly forward
and downward, or downward pressure with slight rotation will produce
pain at the point of lesion.
Subdislocations of the =atlas= are probably among the most common
lesions presented to the osteopath. Owing to the articulation of the
atlas and occipital bone being an anatomically weak point and the
neck muscles being exposed constantly to atmospheric changes, besides
the articulation between the head and neck receiving the brunt of
many jars, falls and strains, the atlas is especially susceptible to
derangements. On account of the intimate relation of the atlas to the
superior cervical ganglion of the sympathetic and to the vertebral
blood vessels it is certainly very necessary that the atlas should
be well taken care of. No other tissue maintains such a significant
position in relation to the blood and nerve supply to and from the
brain. To diagnose correctly the position of an atlas and to be able to
correct it is undoubtedly one of the most essential achievements of the
practitioner of osteopathy.
The most common disorders of the atlas are anterior and lateral
displacements. Next in order come “rotary” lesions of the atlas, i. e.,
where the atlas has been deranged diagonally or simply twisted. It may
also be luxated anteriorly and laterally, or posteriorly and laterally,
etc. A posterior derangement of the atlas is comparatively a rare
disorder, although owing to the many lesions that are found in atlases
one has, during the course of a year’s practice, several to correct.
The atlas may occasionally be slightly tipped laterally, anteriorly, or
posteriorly, and in a few cases it may be somewhat impacted against the
occipital bone. Many times when the atlas is displaced the axis is also
deranged on account of the close relation between the atlas and axis by
the odontoid process of the axis.
To examine the atlas the patient may be either in the sitting or dorsal
posture; it matters but little which position is taken. Possibly the
dorsal position is better, as then the neck muscles are more relaxed
and if necessary an examination of the cervical spine, below the atlas,
can easily be made.
By placing the middle finger of either hand on the transverse processes
of the atlas when the patient is in the sitting posture, or the thumbs
on the transverse processes when the patient is in the dorsal posture
and comparing the two sides, undue prominence of one side or the
other can easily be noted. Remember the transverse processes of the
atlas are slightly above and posterior to the angle of the inferior
maxilla. Always, in examining one side of the patient, compare it
with the other; it may save considerable embarrassment. One side may
seem abnormal when by comparing it with the other side, both sides
may be found the same and still be normal. With the fingers still
on the transverse processes note the distance between the process
and angle of the jaw, besides take into consideration the tenderness
of the locality, and, also, what is of essential importance in all
interosseous lesions, its articular range of movements. There should
be room enough (approximately) to just comfortably wedge the end of
a medium sized middle finger between the transverse process of the
atlas and the angle of the inferior maxilla when both are normal. Thus
with the fingers on the transverse processes an expert will be able to
readily determine whether or not an atlas is lateral or anterior. If
an atlas is posterior the distance between the angles of the jaw and
the transverse process will be increased, besides the atlas will be
quite prominent posteriorly. In conjunction with the abnormality of the
tissues (prominence or depression of the bone and state of the muscles)
the sensitiveness of the locality is extremely significant.
Outside of displacements of the atlas, a lesion between the =axis=
and =third cervical= is most common; following next in frequency are
lesions of the =skull= and =atlas=. By that is meant where all the
cervical vertebræ are intact as far as their individual relation is
concerned, but the skull is forward, backward or lateral upon the
spinal column. This condition occurs quite frequently. To determine
its condition the same methods are employed as in diagnosing a
deranged atlas; for if the dislocations exist between the atlas and
skull the same diagnostic points are presented as far as the skull is
concerned as when the atlas, or atlas and axis, are dislocated from
the occipital bone or from the axis or third cervical. Following the
preceding examinations, additional examination will have to be made to
see whether or not the atlas is intact with the vertebræ below. If the
atlas is found to be intact with the vertebræ below and lesions are
presented between the atlas and the skull, then the disorder must be
between the atlas and the skull and nowhere else. Occasionally there
are cases where the skull is so far posterior upon the spinal column
that the angles of the jaw strike against the transverse processes of
the atlas when the jaw is opened widely.
Derangement of the =muscles= of the anterior and lateral regions of
the =neck= are common. Especially are contractions of the muscles on
either side of the larynx liable to occur. In examining the cervical
region do not pay too much attention to the superficial muscles,
but examine carefully the deeper muscles. It is from these that
impingements of nerves and constrictions of vessels are likely to take
place in the contracted fibres. Also, imbalance of muscular tension
may be the source of the resulting malalignment. In examining for
contracted muscles do not gouge into the muscle nor grasp the muscle
roughly, but bear down lightly (inhibitory) upon the muscles and then
gradually exert firmer pressure. By carefully and firmly exerting
pressure over muscular areas the deep muscles can then be felt beneath
the superficial ones. Otherwise when the muscles are manipulated
severely the superficial ones will contract to such an extent that the
deeper ones cannot be felt. The muscles contracting on either side
of the larynx tend to draw the larynx downward and thus there may
arise a source of irritation. The various muscles contracting in the
antero-lateral region of the neck are very often the source of chronic
irritations of the pharynx or throat. The omo-hyoid muscle may become
contracted and cause slight traction on the hyoid bone and thus produce
an irritating cough. To examine the muscles of the neck thoroughly it
is best to have the patient flat upon the back, for then all the normal
muscles are relaxed.
Lesions quite frequently occur in the =temporo-inferior maxillary=
articulation. The lesion may be either unilateral or bilateral, more
commonly the former. The disorder usually consists of a relaxation of
the muscles and ligaments about the articulation which allows a slight
but perceptible dropping of the inferior maxilla on the side involved.
In other cases there may be presented a spasticity of tissue, while in
still others some degree of joint infection may be found. Lesions of
this articulation particularly impinge upon fibres of the fifth cranial
nerve. The points of diagnosis are clicking and tenderness at the
articulation. These two points are the symptoms of which the patient
complains; those noticed by the osteopath are a slight deviation of the
jaw to one side or the other when the jaw is opened and a flinching
of the patient due to tenderness when pressure is exerted over the
articulation of the jaw. When the physician places his fingers around
the jaw, anterior to the angles, and the thumbs over the bridge of the
nose, having patient open the mouth, at the same time exerting pressure
with the fingers and thumb, a sharp click may be elicited by the return
of the jaw into its articulation.
In disease of the =scalp= the condition of the muscles of the scalp
should be taken into consideration. The muscles are usually found
contracted. The contraction of the muscles is generally due, as well
as the disease of the scalp, to derangement existing in the posterior
branches of the upper five pairs of the cervical spinal nerves.
In the =neck=, anteriorly the =hyoid= is the only bone to consider. It
is easily palpated by standing at the head of the table and with the
second finger of each hand outline both ends to ascertain its relation
with the thyroid cartilage. Note carefully any contracted tissue or
glandular enlargements which might cause undue tension. The tilting
of either end of the hyoid from these contractions is productive of
much throat irritation. At the same time the =larynx= may be examined.
It may be prolapsed, causing irritation of the laryngeal group of
nerves. The =thyroid= and =cervical= glands should be palpated for
enlargements, and all the muscles and ligaments for contractions.
Externally the =tonsil= may be felt by deep pressure in front of the
angle of the inferior maxilla.
=The Ribs.=—Under the osteopathic diagnosis of the ribs will be
included the examination of the clavicle and sternum. To be able
to diagnose intelligently, the position of the ribs in detail is
very necessary to the osteopath. Many of the diseases of the heart
and lungs, besides a large number of the diseases of the digestive
tract, may be traced to a deranged rib; also, occasionally diseases
of different regions of the head and neck may be due to dislocated
ribs. In making a thorough examination of the ribs each rib should be
carefully noted as to its position. The ribs may be examined when the
patient is sitting up; but it is better to have the patient flat upon
the back and especially so if the floating ribs are to be carefully
examined, because the muscular tissues of the side if contracted will
interfere with the diagnosis. In many instances the rib lesion is
secondary to a vertebral subluxation.
An expert osteopathic diagnostician will be able to detect at once
by a single passage of the hands down over the ribs if there are any
disorders of them. In passing the flat of the hand, especially the flat
part of the fingers over the ribs, carefully observe if the intercostal
spaces are too narrow or too wide, and if any of the ribs are unduly
prominent or depressed. If an intercostal space is too narrow it shows
that the ribs on either side of the intercostal space are too close
together. Then the question arises, which one of the ribs is crowding
upon the intercostal space, or whether both of the ribs are crowded
together. Usually when the sternal end of the rib is displaced upward,
the involved rib is prominent and when displaced downward the rib is
depressed. Thus it is commonly easy to diagnose which is the involved
rib. Besides finding an abnormal position of the rib there will be more
or less tenderness over the rib. Finding a rib prominent or depressed
and tender is generally quite conclusive that the rib is displaced.
Then the range of movement as expressed through the sense of resistance
is a helpful guide in diagnosis.
If a =typical rib= is placed upon a flat surface and one end of it
is depressed the other end will be elevated and _vice versa_. This
peculiarity holds true as well when the ribs (typical) are dislocated
in the living body. If the anterior end is elevated the posterior
end is commonly depressed and _vice versa_. Care should be taken in
examining the first rib and the false ribs, for in these ribs this
peculiarity is not found.
As a whole a very complete diagnosis can be made of the condition of
the ribs by examining the anterior part of the thorax, although it is
always best to examine along the angles of the ribs if for nothing more
than to confirm the diagnosis made at the sternal ends. Still it must
be remembered that the preceding only holds good when the entire rib is
dislocated. Many times simply one end of the rib is deranged and the
other end is practically intact.
Besides careful examination of the sternal end of the rib, attention
should be paid to the condition of the costal cartilages. The costal
cartilages may become deranged at either the articulation with the
rib or with the sternum. The same rule holds good when the costal
cartilages are dislocated as when the ribs are dislocated, i. e., when
the cartilages are prominent, they are usually displaced upward and
when depressed the cartilage is displaced downward toward its neighbor.
One is apt to think that a rib is only dislocated at its vertebral
end. Although lesions of the vertebral end are generally of greater
significance as far as the etiological factors are concerned, still
the sternal end of the rib must not be overlooked. In examining the
vertebral end of a rib attention should be paid the angles of the
ribs, for at the angles a better opportunity for examination is given
on account of the prominence. It will be necessary in many cases to
find out whether or not the vertebral end of the rib is lying between
the transverse processes instead of in front of them. In many severe
lesions of the ribs the vertebral end of the rib is dislocated upward
or downward from the transverse process of the vertebra and lies
between the transverse processes of the vertebræ above and below
its attachment. This certainly requires considerable skill in the
diagnosis, for oftentimes the point to be found is barely an eighth
of an inch in diameter. It is usually best before making such a close
examination to relax the tissues well over the field of examination.
The =ribs= as a whole may be too transverse or too oblique upon one
side. This is chiefly found in pathological curves of the spine, but
still such conditions may exist where there are severely contracted
muscles, especially in some cases of paralysis. Thus the contour of
the ribs must be taken into consideration by comparing one side with
the other.
In examining the =first rib= an examination somewhat different from
the other ribs should be given. It is best to have the patient assume
a sitting posture; then place the middle fingers of each hand upon the
first ribs near their centers and compare one with the other. Also note
the difference of the spaces between the ribs and clavicles. Generally
the first rib is dislocated upward, rarely downward. Besides finding an
abnormal prominence or depression of the rib at its center considerable
tenderness will be noticed. Examinations of this region are every day
experiences with the osteopath.
When diagnosing the position of the =floating ribs= it is best to
have the patient lie flat upon the back with the thighs flexed upon
the abdomen, so that the tissues about the lower ribs may be entirely
relaxed. Then by placing the flat of the fingers carefully over the
ribs the outline and position of them can be easily discerned. The
floating ribs are oftentimes found deranged and are the source of a
great deal of suffering through the iliac regions. These ribs may
become dislocated from the vertebral ends and drop down obliquely
toward the iliac crest, or else the free end may become locked beneath
the rib above. Occasionally both ends of the rib drop down quite
perceptibly and consequently is the cause of considerable distress. In
such instances the rib is depressed inward so that the normal contour
of the lower thorax is lost.
An examination of the =clavicle= should be carefully made. Always
compare the clavicle with its fellow and examine thoroughly its
articulation with the sternum as well as at the acromial prominence.
Often the sternal end of the clavicle is slightly dislocated
posteriorly to the sternum; although it may become completely luxated.
The acromial end may be dislocated upward or downward.
In examining the =sternum= special attention should be given the
articulation of the manubrium and gladiolus. This is due to the
crowding anteriorly of the articulation of the sternal parts. Normally
until well along in adult life there should be some movement here due
to its membranous attachment. Occasionally the ensiform cartilage
is turned inward, producing a tender point, but this rarely occurs.
Also the articulation of the cartilages in the region of the eighth,
ninth, and tenth ribs may be found considerably deranged, causing local
tenderness and even stomach trouble.
=Dorsal= and =Lumbar Spinal Region=.—With the patient sitting on the
table abnormal deviations can be readily noted. There may be lateral
swerves, from muscular weakness, or unilateral tension, involving
the whole spine or less, or a reversal of natural curves, i. e., the
spine depressed anteriorly between the shoulders and posteriorly
in the lumbar making the straight spine. There may be, also, an
exaggerated normal curve in the dorsal region producing a kyphosis with
a compensatory lordosis in the lumbar region sufficiently great to
change its relations with the pelvis. By the method previously given,
now outline the spinal column for lateral and bilateral scoliosis.
These, frequently, are at their incipiency, and to the casual observer
would pass unnoticed. It is well to make an outline of the spine
before beginning treatment, and at times following, that progress
may be observed. A simple method is lead tape which can be had from
any plumber shop and can be molded to the deformity and traced on
paper together with date of examination. H. F. Goetz has perfected
an appliance for outlining and recording these deviations. Observe
well the ligaments, as well as extent of joint movement, under deep
palpation; from irritation they may become thickened and more or less
fill the spaces about the spines and transverse processes, causing a
rigid, smooth spine.
To make a detailed examination the patient should be stretched out on
one side upon a treating table, although the general examination may
be sufficient. Then, standing in front of the patient and reaching
over him, a most careful diagnosis can be made. Do not stand back of
the patient as the flat of the fingers can not be used to advantage
in outlining the different vertebræ. The various contracted muscles
that may be found along the spinal column will be of valuable aid
in locating derangements of the vertebræ and vertebral ends of the
ribs. By using contracted muscles along the spinal column as a guide
for locating lesions, reference to the large superficial muscles is
not made, but to the small areas of contracted fibres of the deep
muscles. It is the deep muscles that become more or less contracted,
and even fibrotic, when lesions of the vertebræ and ribs exist. The
superficial muscles are generally contracted by atmospheric changes,
slumped postures, wrong habits, etc., and are not generally the result
of disorders in the osseous system. The preceding points in regard to
contracted muscles cannot be too carefully observed for there is a
tendency among many osteopaths to treat the contracted deep muscles
as primary lesions in nearly every case. Remember that if they are
not due to the motor nerve fibres of the muscles being irritated by
the spinal lesion, or to a reflex stimulus, or to a compensatory
change, that although the muscular tension may be the inception of
the almost certain interosseous lesion, still the leverages secured
through bony adjusting are very essential not only in correcting the
osseous malposition but in loosening and releasing fibrous muscles and
thickened ligaments.
=Thorax.=—Examination of the thorax as a region has been largely
gone over in speaking of the ribs and their sternal attachment,
cartilages, sternum and the clavicles, but its appearance as a whole
should be carefully noted for it will be a valuable aid in diagnosis.
Deviations from the normal, such as the emphysematous or barrel-shaped
chest in asthmatic affections, or chronic cough, or accompanying
kyphosis, the flat chest and its association with phthisis, the
rachitic, etc., should be considered. Spinal deformities are reflected
in the thorax by marked changes in contour, such as elevations and
depressions corresponding to the spinal changes. These result in marked
interference with the thoracic organs and in young subjects are of
particular interest. Rib changes are frequently the result of vertebral
deviations.
=Abdomen.=—The position for examination of the abdominal viscera is
usually with the patient supine, head slightly elevated, knees drawn up
partially and supported to relieve any muscular strain, and with the
hands at the sides. In this position complete relaxation is obtained.
Observe any enlargements from gas, fluid, or tumor, muscular changes,
color, etc. The patient may, also, be placed upon the side, and in the
knee-chest position for further verification of the diagnosis. Where
the abdominal wall is much relaxed, or there is a pendulous abdomen
with enteroptosis, there will be found a change of relations of the
viscera by these different positions, allowing them to be palpated in
another position. When there is marked tenderness it is often possible
to go deeper with less discomfort with the patient in the knee-chest
position. The Trendelenburg position may also be utilized. Where
ascites is suspected palpation should be made with the patient in
various positions in order to note changes of location of the fluid.
Frequently much can be learned by inspection with the patient standing.
Clues to visceral disturbance can often be had by tracing the nerve
connection from the spinal lesions to the suspected part.
In examining the =liver= care must be taken that any gouging or severe
bruising of the organ does not take place. The liver can be outlined
by percussion and also by palpation of its lower and inner borders
Congestions, atrophy, enlargement or hardening should be noted, also
any change in position.
A rather complete examination can be given the =biliary tract= from the
=gall-bladder= to the =duodenal orifice= of the =biliary duct=. By a
careful inhibitory pressure over the duct the outline of the tract can
be discerned providing the patient is not too stout. When the tract
is swollen considerable tenderness will be present. The patient will
complain of a stabbing or piercing pain upon pressure and manipulation
if the duct is inflamed.
Usually the tenderness is greatest nearer the =duodenal orifice=. The
duodenal orifice is about one and one-half inches diagonally downward
to the right from the umbilicus. In cases of impacted =gall-stones= the
osteopath as a rule has very little trouble in locating the stone.
The =spleen= may be percussed and when in a markedly enlarged condition
its lower border can be palpated. Great care must be used in the latter
condition as there is danger of rupture.
In examining the =stomach= the usual methods of inspection, palpation,
percussion, analysis of the contents, etc., are employed.
Palpation and manipulation over the =intestines= are practiced a great
deal by the osteopath in various intestinal diseases. By his educated
sense of touch he is usually able to locate at once any =impactions= of
=fecal matter=. Such impactions are generally found in the ilio-cecal
and sigmoid regions. In the various acute =obstructions= from
invagination, tumors, twists, adhesions, spasticity, knots, etc., many
times one is able to readily locate the seat of the disturbance. There
is one point to specially emphasize; that is, do not overlook prolapsed
regions of the intestines; such occur frequently and are a source of
considerable distress, especially constipation. Simple manipulation
will never do much good, neither will spinal treatment or injections,
as a rule. A specific treatment must be given and, that is, after
locating the exact point of prolapse, to reach carefully beneath the
fold and replace it.
In emaciated subjects the =kidneys= can be readily located, and in
a few instances when they are diseased one can feel the contracted
tissues about them. Be very careful not to injure the =capsule= about
the kidney. Do not punch or gouge them in the least; but locate the
kidneys by a careful inhibitory palpation.
=Lumbar and Pelvis.=—The intimate relation between the lumbar spine
and pelvis make a consideration of them as a region necessary. Outside
of ordinary curvatures involving both the dorsal and lumbar regions
there are certain conditions which involve but one structure and
require careful differential diagnosis to determine whether the lumbar
or pelvis is at fault. In the former the fifth vertebra is a weak
point and is most frequently at fault. The deviations are usually a
sidebending and frequently accompanied with some rotation. Occasionally
a malstructure of the lower lumbar or pathologically relaxed ligaments
will approximate the spines and be misleading as to the real condition.
A rotation or lateral tilting of the fifth lumbar may have the effect
of elevating the crest of the ilium so that the innominatum would
appear involved. There will be a difference in the length of the legs,
angles of feet when patient is lying on the back, anterior spines out
of line and tenderness of the muscles attached near them. However,
other diagnostic points of innominate lesions, i. e., tenderness of
symphysis and sacro-iliac articulation, and prominence of the posterior
spine, will be lacking. Marked deviation of other lumbar vertebræ may
produce practically the same effect, but the lesion will be so apparent
that there will be no doubt as to the cause.
To be able to diagnose accurately and intelligently the pelvic region
requires nearly as much skill as in examining the cervical region.
The pelvic bones are liable to many subdislocations, especially in
the female. However, it should be remembered that many apparent
innominate lesions are secondary or compensatory changes due to lumbar
lesions. The pelvis as a whole may be tipped anteriorly or posteriorly
upon the spinal column. It also may be twisted or rotated laterally
upon the spinal column. The most common lesions are subluxations of
an innominatum forward, backward, upward, or downward, or various
combinations of these displacements, such as a tipping forward and
downward of an innominatum, or a tipping backward and upward, but these
combinations do not always exist in the manner given. As a rule when
the ilium is anterior, the ischium posterior, then the innominatum as a
whole is downward; when the ilium is posterior, the ischium anterior,
then the innominatum as a whole is upward. This is only a rule, there
are exceptions to it; for in some few cases when the ilium is anterior,
the ischium posterior, the innominatum may be higher, and when the
ilium is posterior and the ischium anterior the innominatum may be
lower.
To be able to diagnose such derangements will require skill and
practice; still there are symptoms and signs that are characteristic
of such disorders. In examining the pelvic bones have the patient flat
upon the back at first. Be sure he is flat upon the back for a very
slight variation may make considerable difference in the relation of
the pelvic bones, one to the other, so far as the diagnostic points
are concerned. Then go to the feet of the patient and grasp the ankles
firmly, rotate laterally both legs, first to one side and then to the
other, as well as pull and push both limbs slightly, and then bring the
heels together directly in the median fine of the body and compare the
length of the limbs at the heels. If there is any disorder whatever
in one innominatum, and the thigh muscles have been relaxed thoroughly
by the preceding movements and the heels are brought together in the
median line of the body, a difference in the length of the limbs
will readily be observed at the inner malleoli or the heels. For if
the ilium is forward the ischium must be backward and as a rule the
innominatum is thrown downward, thus causing an apparent lengthening of
the limb which will be noticed by comparing the heels; if the ilium is
backward the ischium must be forward and as a rule the innominatum is
then upward, causing an apparent shortening of the limb on the affected
side. A very slight variation in the pelvis will make considerable
difference in an apparent lengthening or shortening of the limbs. Such
conditions are generally met with several times a day by osteopaths.
The object of the lateral rotary movement and the pushing and pulling
of the limbs is to make sure that all the thigh muscles are thoroughly
relaxed, for it is a very easy matter for contracted muscles in one
thigh to produce an apparent shortening of the limb. Also be very
careful in comparing the length of the two limbs at the heels where
they come together that they are exactly in the median line of the
body, for if they should be to one side or the other, however slightly,
there would be an apparent lengthening of the outer limb as compared
with the limb near the median line. While the patient remains flat
upon the back it is a good plan to compare the anterior spines of the
ilia. It may be readily noticed that one is higher or more depressed
than the other, which will help to confirm the diagnosis. It is a
good plan also to have the patient sit up squarely upon the table and
compare the crests and posterior spines of the ilia; thus one may be
seen to be higher than the other. Then, also, note the angles of the
feet when patient is supine; an everted foot usually means that the
limb is shorter due to the tilted pelvis; the opposite is commonly true
when the foot is inverted. However, this is not an absolute rule. Care
should be taken in differential diagnosis of possible old fracture of
leg, of infantile paralysis, of asymmetry, etc.
There are =three diagnostic points= exclusive of all other signs that
are quite conclusive when coupled with the preceding examination. If
an innominatum is dislocated or subdislocated there will be tenderness
over the symphysis pubis on the side affected, tenderness over the
ilio-sacral articulation on the side affected, and tenderness along
the crest of ilium where the abdominal muscles are attached. When
tenderness is found at these three points it is quite conclusive that
the innominatum is deranged, for at the symphysis pubis and ilio-sacral
articulation tenderness must exist if the innominatum is disturbed,
and by a change in the crest of the ilium the abdominal parietes
will be affected, provided they are not too much debilitated. Marked
tenderness of the external cutaneous nerve as it passes over the crest
of the ilium below the anterior spine will be noticed on the unaffected
side (Dr. Still). There will be, on rectal examination, marked tension
of the tissues on the affected side. Possibly the patient may complain
of pain exclusively in one side along the pelvis and limb which will be
a leading symptom telling which side is affected.
=Additional diagnostic= signs will be rigidity of muscles along the
ilio-sacral articulation and abnormal prominence or depression of the
ilium at its articulation with the sacrum, depending upon which way the
innominatum has slipped. Considerable deviation of the pubic bones may
be noticed. The pubic bone on the side affected may be either thrown
upward or downward.
Radiographs have repeatedly revealed subluxations of the innominate
bones in many instances. This is certainly quite conclusive in
confirmation of the osteopathic ideas in regard to the pelvic bones
becoming dislocated.
=Sacrum.=—Examination of the sacrum is best made with the patient lying
on the side, with the osteopath standing in front and with the hand
palpate its posterior surface. In the sitting posture its relation with
both innominates can be determined. It is displaced posteriorly but
seldom, the most frequent being anterior, downward, and a combination
of the two. In the anterior conditions tenderness at the sacro-iliac
articulations is a good point, but it must not be confounded with an
innominate lesion. The downward displacement is shown by comparison
with the lower lumbar vertebræ. Observe the relation between the two,
as a change in contour of the spine will also change the angle of the
sacrum and _vice versa_.
=Coccyx.=—With the patient and operator in same position as for the
sacral examination outline the coccyx, as to first, =contour=; second,
=rigidity=; third, =sensitiveness=. If abnormalities are detected go
to the other side of the table and with a well lubricated index finger
palpate its anterior surface. Changed contour, displacements, and
old fractures can be readily determined. The most common deviation
is anterior at its union with the sacrum. The lateral form generally
resulting from muscular contraction is next, with posterior but
seldom. “If the lower part of the sacrum is rotated backward, the
sacro-coccygeal articulation or angle is affected or becomes more
acute, since the tip of the coccyx is not displaced, but held in
position by structures attached to it. If the sacrum is displaced
downward the effect is about the same. Often this sort of sacral lesion
is mistaken for an anterior luxation of the coccyx.”[28] Remember
that normally there should be some movement of the coccyx. It has a
fibro-membranous articulation.
=Uterine=, =ovarian= and =rectal= examinations are largely of the same
nature as those given by other practitioners, although osteopaths find
that oftentimes other practitioners are mistaken in regard to the
etiology of many diseases to which these organs are subject.
=Arms= and =Legs=.—There is comparatively little that is exclusively
osteopathic in regard to the diagnosis of disorders of the arms and
legs. One important feature that the osteopath finds in examining the
arms and legs is that many of the disorders supposed to originate
in the affected member are found to be caused from vertebral or rib
dislocations. Innominate and lumbar lesions are particularly fruitful
sources of trouble in the legs and feet. Always carefully examine the
spine in the region of innervation to the arms and legs when they are
affected. The shoulder and hip joints, as well as all joints, are
subject to partial dislocations. Many times when pain or other symptoms
are presented in the arms or legs the trouble is at the shoulder or
hip joint or in the spinal column. There are two regions that are
very apt to be overlooked in the examinations of the arms and legs
and they are the elbow joint and the fibula. The small bones of the
=ankle= and =wrist= as well as of the foot and hand are subject to many
dislocations which are easily discerned upon examination and often
overlooked. Special emphasis should be given in regard to many supposed
diseases of the knee joints which are really caused by lesions in the
spine or at the hip joint.
Osteopathic Prognosis
Everyone is of the opinion that to forecast the probable result of a
disease is one of the most difficult problems the physician has to
meet. To state the duration, course, and termination of an attack of
disease as presented by its nature and symptoms implies an accurate
knowledge of both disease processes and changes, and an insight into
the individual’s idiosyncrasies backed by ripe clinical experience.
And after each of these factors has been carefully considered to
balance one against the other, nothing short of superhuman knowledge
may present a sufficient insight in order to render an accurate
prognosis. A prognosis represents the culmination of one’s learning,
an understanding of disease characteristics, and an insight into
temperament.
C. M. T. Hulett[29] says: “Only when we can know all the conditions,
causative and sequential, with their possible complications and
terminations, together with a full history of therapeutic results in
a large number of similar cases, and carefully analyzing and weighing
these various elements, are we prepared to really make a prognosis.”
Nettie H. Bolles[30] writes as follows: “The prognosis depends upon
the cause of the disease, the possibility of removing the cause, or
the likelihood of recurrence of causes, and the chances of avoiding
such recurrence. The circumstances to modify the outlook are various
and deserve careful consideration.” It is not the purpose here to
go into the many essential details, for that would mean an outline
and forecast of all disease processes, and the effect of numerous
extenuating circumstances. The medical profession have been gathering
data for these three thousand years and prognosis with them is still
inaccurate and incomplete. Osteopathic science will add just so much to
the accuracy of prognosis as the sum total of the knowledge displayed
in the fields of osteopathic etiology, diagnosis, pathology and
therapeutics. Suffice it to give here a few salient practical hints as
noted in the osteopathic treating room and at the bedside.
Osteopathically it may be said that prognosis depends, first, upon the
true conception of osteopathy; second, upon the relative value of all
factors pertaining to health and disease; and, third, upon the skill
(technique and native ability) of the osteopath. The first and second
being granted, the third includes a remarkably practical and pregnant
field, for in no school does the physician get into as close touch
and understanding of the actual condition of the patient’s disorder
as in the osteopathic. Although the fundamentals and principles of
the osteopathic conception of diseases are really broad, liberal,
and all-inclusive, still owing to the fact that each individual (and
thus each disease) is more or less a law unto himself should there
not be absolute tables and prescriptions to be governed by; remember,
however, this does not imply our fundamentals are not basic or our
principles are not truths, but rather the application and execution of
the same are as varied as the individual’s constitution, temperament,
and disease. Herein rests the really difficult practical consideration
of etiology, pathology, diagnosis, treatment, and prognosis. In other
words, if the diagnosis and treatment are accurate the result rests
entirely with the patient.
First, too much emphasis cannot be placed upon the fact that prognosis
is dependent upon the osteopath—his education, training, ability,
experience, and technique. One’s fitness is most important. And fitness
and personality complement each other. An osteopath may know theory and
still not be practical; still one cannot be practical unless he knows
theory.
Second, osteopathic treatment frequently changes the usual course of
acute disease. It is well known that many diseases have a certain
regular course in their history. Many times the osteopath will be able
to abort, lessen the severity, or cut short the ailment, thus changing
the recognized symptoms and termination.
Third, the knack of treatment, or knowing how to treat, not only one
region of the body but all regions, not only one temperament but all
temperaments.
Fourth, the preparatory treatment before correcting the lesion.
Prevention, palliation, or cure, and thus prognosis, may be dependent
upon a necessary preparatory treatment. Here is where a study of the
patient’s temperament is very essential.
Fifth, a prolonged treatment may defeat one’s purpose. As a rule a
comparatively short, thoroughly indicated, specific treatment is best.
Sixth, much, relative to prognosis, can be told by the tone of the
vertebral ligaments. When a lesion corrects too easily or does not
remain well in place it shows a lack of tonicity on the part of the
ligaments and muscles. Improvement is in direct ration to the increase
of tonicity.
Seventh, special care should be taken with the irritable spine. This
spine commonly precedes the debilitated spine. Unless precaution is
taken to apply inhibition before treating specifically a cure may be
prevented or at least the disorder prolonged.
Eighth, relaxation of muscles is not always essential, although
the lack of it may prevent the correction of primary lesions. The
relaxation should be carried out with care in order that all shock and
irritation may be kept at a minimum.
Ninth, needless stretching, traction, extending, rotation, and snapping
of the neck is not only useless but may be positively dangerous.
Rarely is it necessary to go through the above “movements” as many are
accustomed to do.
Tenth, it may be necessary, but not always, to give as additional
treatment, after the anatomical defect has been specifically treated, a
certain amount of stretching and moulding of the parts.
Eleventh, owing to the close personal relations of physician and
patient, personality has a powerful influence on prognosis.
Twelfth, too much emphasis cannot be placed upon the uselessness and
injurious effects of over and misapplied treatment.
All of the above have a positive bearing on prognosis. The osteopath
should study his technique well. He will find that it gradually changes
and improves from year to year. In a word, as he gains in experience
he will become more skillful by giving careful attention to the
development of the sense of touch, by noting the resistance of the
tissues, and a score of details that are very hard to describe but the
sum total of which determines and indicates the successful osteopath.
Another practical point that bears upon prognosis as well as upon the
health of the osteopath is the manner of giving treatment. First, the
height of the treating table should correspond to the height of the
practitioner. The table should be made for the practitioner and not the
practitioner fitted and warped according to a certain table. Second,
give part of the treatments on a treating stool. Here there is greater
freedom of movement on the part of the patient, hence greater and more
effective leverage can be obtained. Suit your treatment to the patient,
not your patient to the treatment. Third, make your weight count for
energy expended in the treatment. As soon as one set of muscles become
tired substitute another set, e. g., the back muscles and the arms, the
arms and the hands. Fourth, whenever possible substitute the weight of
the patient for expended energy. Fifth, when lifting keep the spinal
column straight; do the bending of the body at the knees. Hence a
better treatment and a more favorable prognosis, and besides that new
occupation neurosis, the “=osteopathic back=,” will be materially
lessened in both severity and frequency.
FOOTNOTES:
[26] See Tubby, Deformities.
[27] Clark’s Applied Anatomy, p. 334.
[28] Clark’s Applied Anatomy, p. 331.
[29] Prognosis—Journal of the American Osteopathic Association, Jan.,
1906.
[30] Prognosis—Journal of the American Osteopathic Association, Nov.,
1902.
OSTEOPATHIC TECHNIQUE
The technique of treatment is, in a sense, a personal factor, for it is
a well known fact no two osteopaths treat just alike. Nevertheless, the
principles of technique are constant and universally applicable, and he
who applies them with specificity manifestly secures the best results,
and exhibits a technique that is finished and characteristically
osteopathic. General manipulations are not essentially osteopathic,
although by employing them a few definite results may be obtained;
still such technique should not be classed as distinctive osteopathic
therapy. Every case is a law unto itself and must be studied
individually in order to be able to understand it perfectly. So much
depends upon the ability of the osteopath in the treating of a case,
that in order to meet the indications intelligently he must have
command of the various anatomical details of the body, not only in his
mind but upon his finger tips.[31]
The =sense of touch= should be very acutely developed and this requires
months of persistent, practical experience. A carefully educated sense
of touch is the keynote to both osteopathic diagnosis and operative
technique. From the very nature of the osteopathic conception—the
physical body viewed as a mechanism whose disordered or diseased
conditions demand anatomical readjustment—it is imperative that a
delicate and educated sense of touch be acquired in order to logically
and successfully apply its tenets. Proficiency means not only being
able to note certain small physical irregularities, and various
degrees and areas of muscular contractions, and variations in body
temperature, but the extent and state of vital resistance, that is,
tissue condition, and the feeling of organic resistance, e. g., the
heart, lungs, liver. These are the special features wherein osteopathic
fingers detect disease causes and traces. To know the difference
between normal and abnormal structural deviations and distortions, as
well as organic changes, requires an accurate, detailed knowledge of
anatomy and pathology with a systematic daily education of the sense of
touch; but to realize, appreciate and know by tissue resistance feeling
that nutritional condition is improving requires much more practical
experience.
Thus two very practical points should be taught to and thoroughly
impressed upon every osteopathic student: First, =the sense of
resistance of the tissues=. This gives us an absolute clue to the
vitality of the patient. As has been stated, there is a vast difference
between the feel, the sense of resistance, of normal and abnormal
tissues; for instance, a normal muscle and a contractured muscle, a
normal liver and a congested liver, a normal intestine and a prolapsed
intestine and these differences comprise innumerable gradations.
Second, =the receptivity of the patient to treatment=. This is
dependent upon the vitality of the tissues. The sense of resistance
to touch gives us an important diagnostic clue; the receptivity of
the patient to treatment tells us much as to prognosis. After a few
treatments the receptiveness will be positive or negative; that is,
the patient is, or is not, responding to treatment. Consequently the
receptivity of the patient usually tells much as to the state of
nutrition.
Definite principles should be followed when applying the technique, for
the osteopathic lesion is a “structural perversion,” thus indicating
mechanical readjustment for its correction. The time is coming when the
technique will be taught graphically and mathematically. This would
not be a difficult thing to do, and it could not but prove invaluable
aid to the student. He can then the more readily and comprehensively
grasp the principles involved. To resolve and illustrate manipulative
readjustment to and by the principles of mechanics would add
considerable to osteopathic development. For example, how nicely
the correction of certain innominata maladjustments illustrates the
principle of the wheel and axle. Vertebral and rib displacements when
readjusted make application of the principles of the simple machines.
We are gradually approaching a more comprehensive understanding of
the physiologic movements of the spine and of the etiologic role
of muscle tension. This is part of the foundation work. Great care
must be exercised in correlating this data with the individual case,
for in therapy we are dealing with abnormalities—not alone normal
physiologic changes. If our distinctive dynamics and therapeutics were
taught in this manner the average osteopath would be more specific and
comprehensive in his work and as a consequence more scientific. And
consequently the principles involved in each and every case would stand
out clearly. Hence diagnosis would be more exact, routine pommeling
discarded, and better all around technique executed.
Two general rules are applicable to all dislocations, whether partial
or complete: 1. Exaggerate or increase the dislocation. This is to
relax the tissues about the dislocated articulation and to disengage
the articular points that have become locked. 2. Reduce the dislocation
by retracing the path along which the parts were dislocated. Hence to
=correct= a =lesion=, for example, a vertebral lesion: (1) Exaggerate
the lesion. (2) Place the fingers of the hand that are not employed in
exaggerating the lesion over the extended portion of the lesion. (3)
Extend the region that is flexed when the lesion was exaggerated. (4)
When the lesion is being extended produce traction and slight rotation
of the region. (5) At the same time extension, traction and rotation is
being produced push in upon the extended portion of the lesion. To this
might be added for sake of clearness and greater assurance of success:
(a) Be positive the focal point absolutely corresponds to the lesion,
or else most if not all of your effort will be useless. (b) Just before
reaching the maximum of exaggeration have your fingers correctly placed
for the readjustment, and at the very moment of maximum exaggeration or
just a fraction of a second prior begin to correct or readjust, or else
you will lose the vantage gained and the operation will probably be a
failure. (c) The general traction and rotation are to aid in unlocking
the lesion, not to readjust as some may think. Inhibiting and releasing
the soft tissues, such as spasms, contractions and contractures of
muscles, and stretching thickened and adherent ligaments is very
important preliminary work. Then, next to securing exact leverages
an essential point is to maintain the release or exaggeration until
the readjusting step is incepted. In other words, coordination of all
factors is the desideratum. The lack of this is the cause of many
failures. Hot fomentations frequently assist in relaxing irritable and
spastic soft tissues. This, however, is but a preliminary measure. All
rough handling, needless snapping of parts, and excessive rotation
and stretching are not only apt to tighten the lesion more, shock the
system and irritate the parts, but it may be absolutely dangerous.
It should not be forgotten that the osteopath includes many measures
in his treatment of various diseases, as nursing, dieting, hygiene,
sanitation, hydrotherapy, antidotes, antiseptics, etc., and does
not depend upon readjustive manipulation alone, although correcting
disordered anatomical structures and perversions are paramount in the
treatment.
=The General Treatment.=—A general treatment but accentuates the
ignorance, in a majority of cases, of many so-termed osteopaths. It is
a deplorable fact that there is a tendency among some osteopaths to
give general treatments in every case presented. The only explanation
of such a procedure that one can think of is a lack of conception as to
what osteopathy really is. To give a general treatment in every case is
not only actually detrimental to the patient but it is the height of
folly on the osteopath’s part, for it gets him into a slovenly habit of
procedure from both scientific and curative points of view, besides
giving the outside world an impression that osteopathy is but little
different from massage and Swedish movements instead of skillful,
mechanical engineering of the human body. But a “general treatment” is
not to be confused with definite attention to be a series of more or
less interrelated lesions. The essential point is to normalize the body
when and where distinctly indicated and after a skillful manner.
A general treatment, broadly speaking, should be given only under
three conditions: (1) Constitutional diseases that are to be treated
symptomatically. (2) Certain anemic cases. (3) When one is ignorant of
the real cause of the disease. Each of these conditions is self-evident
why a general treatment should be given. A fourth might be added, for
those individuals who think they are not getting value received unless
they are treated from head to foot. Such patients are usually ignorant
of the philosophy of osteopathy and it is the osteopath’s duty to teach
them differently.
The general treatment consists in stretching the spinal column from
the atlas to the coccyx and relaxing all contracted muscles along both
sides of the spinal column, besides giving special treatment to the
cervical region, between the scapulæ, the splanchnics and internal and
external rotation of the legs. It is no wonder that fake osteopaths
do cure a case occasionally. They are quite certain to correct some
disorder by pulling and hauling a patient around in such a manner.
Still on the other hand they are very likely to do injury to the
patient. Those who claim that no injury can come from osteopathic
treatment are mistaken. One can injure a person by treatment if he
is not careful. It does not stand to reason that the most delicately
constructed mechanism should stand any amount of manipulation and
misdirected force that may be given it.
=Positions of the Patient and Physician in Treating.=—The position
of the patient when a treatment is given depends altogether upon the
affection to be treated. Probably about one-half of the cases can be
treated to advantage upon a table, the remainder sitting on a stool.
Many osteopaths treat nearly all their patients upon a table. It is
much better to change back and forth, because to correct a certain
disorder may be hard upon the table, but will be comparatively easy
when the patient is on a stool, and _vice versa_. Besides, constantly
changing back and forth rests a physician greatly.
Learn to treat in various positions, because it will be impossible
to have all cases assume a certain position when being treated; and
especially in treating acute cases one is obliged to suit his treatment
to the patient and not the patient to the treatment. There is also a
tendency for one to get into slovenly habits of treating when patients
are all placed practically in one position, and certainly one cannot
treat all cases in one position to equal advantage. Also learn to treat
as well with one hand as the other. Many times one will be in such
positions that equal use of either hand will be required. Carefully
educate the sense of touch in both hands.
Another point should receive consideration: learn to shift the strength
exerted in treating from one set of muscles to others. For example,
when one is standing for a long time he will continually shift his
weight from one limb to the other. In the same manner in treating use
the strength of the hands awhile, then the arms, then the muscles of
the back, then the weight of the body, etc.; all in such a manner that
there is a constant change by utilizing certain groups of muscles for
the same work, as well as utilizing the weight of the body of both
physician and patient to advantage. It rests a physician greatly and
thus allows him to perform a maximum amount of work with a minimum
amount of strength and labor.
It is frequently an advantage to the physician to treat upon the nude
skin, thus preventing the fingers from becoming tender. Gowns can be
easily made that open down the back so that the patient does not have
to disrobe.
=The Neck and Head.=—In the treatment of the neck the patient may
assume the sitting posture or lie flat upon the back. The latter is
preferable, as then one has complete control of the neck and head.
Absolute control of a part is always necessary and when this is secured
the dangers are reduced to a minimum, provided always that reasonable
discretion as to the amount of strength, is used. Before correcting
the various deviations of the cervical vertebræ it is usually best to
thoroughly relax all the muscles, superficial and deep, about the field
of operation. In relaxing muscles three methods may be employed. The
muscle may be firmly grasped and manipulated until relaxed, or a firm
pressure may be exerted upon the muscle and thus inhibit its nerve
force until the muscle relaxes, or the muscle may be longitudinally
stretched. The second method is comparatively slow and is usually
given in acute cases where the patients are so weak and exhausted that
they cannot stand any severe manipulation. This method, however, has
certain advantages when employed as a preparatory step in interosseous
adjustments, though steady traction accompanied with slight rotation,
if precisely localized, has many advocates.
In relaxing muscles by manipulation, grasp firmly the belly of the
muscle and draw outward on the muscle several times until it relaxes.
If the patient is sitting, place one hand upon the head of the patient
or about the chin in such a manner that complete control of the head is
maintained throughout the procedure; then with the fingers of the other
hand upon the contracted muscular fibres a manipulating or kneading of
the muscle can be given. It is best to flex the neck and head to the
side where the contracted muscles are, so that a better hold of the
muscle may be maintained; then by a series of flexions and extensions
with manipulation of the contracted muscles outward, results can be
readily obtained. When the patient is lying on the back the physician
may stand to one side of the patient’s head and with one hand on the
forehead of the patient and the other hand around the opposite side
of the neck, a rotary motion of the head and neck, which is equal to
flexion and extension in the sitting posture, may be given by the hand
on the frontal region while the other hand relaxes the muscles; or the
osteopath may stand at the head of the patient and with either hand
on the side of the head and neck of the patient a series of rotary
movements of the head and neck may be given with manipulation of first
one side of the neck and then the other; the hands and fingers being
placed in such a manner that when the fingers of one hand are relaxing
the muscles on its side the other hand is executing the movements of
the head and neck, each hand continually alternating in the work. This
latter method requires some practice in order to do the work readily
and successfully, for quite a variety of movements are required.
In the former method after one has worked on one side he is obliged to
change to the other side and go through the same process. Movements may
also be given to stretch the contracted muscles, thus overcoming the
contraction and producing relaxation of the muscles.
After having relaxed the muscles over the field of operation,
correcting the vertebræ will generally be easier to accomplish. In
readjusting an atlas it matters but little whether the patient is
sitting up or lying down. A firm hold of the atlas can be gotten in
either instance. In correcting the middle and lower cervical vertebræ
it is best to place the patient upon the back.
In correcting dislocations, as heretofore suggested, two general rules
should be followed: (1) Exaggerate or increase the dislocation. This is
to relax the tissues about the dislocated articulation and to disengage
the articular points that have become locked. (2) Reduce the lesion
by retracing the path along which the parts were dislocated. One can
readily see that a dislocated ball and socket joint could be reduced
only by the dislocated bone retracing the path by which it left its
socket, for the capsular ligament would at once prevent its returning
to the socket by any path other than that taken when dislocated. This
applies to all dislocations to a greater or less extent.
After locating the exact position of the abnormal vertebra the first
rule is applied, i. e., exaggerating the lesion by flexing the head
in the opposite direction to which the vertebra is dislocated.
Then with one or two fingers placed firmly upon the side of the
vertebra in the direction dislocated, so that when the proper time
comes the vertebra may be pushed or slightly rotated back into its
normal position, with the other hand produce flexion of the neck,
so that the angle of flexion is exactly over the involved vertebra;
next produce slight traction, so as to be sure that the articular
points will be disengaged; and then with rotation and extension of
the head to a normal or upright posture, at the same time pushing
in on the disordered vertebra, are the movements to be executed in
reducing a dislocated vertebra. It takes considerable practice to
be able to correct a vertebra and to know when it is corrected. The
amount of force applied varies greatly in different cases. Cases of
recent subdislocation require but little force unless there is marked
spasticity of tissue, while in long standing cases many times the
amount of force required is about all that one wishes to exert. As a
rule in many chronic cases it is better to give a series of preparatory
treatments in order to reduce muscle fibrosis and thickening of
capsular ligament. Remember that often it is a slight rotary movement
or twist given that aids the most in executing rule second. No matter
to what position a vertebra is rotated or side-bent the principles
applied are the same in each case.
Be very careful when flexing, extending or rotating the neck that too
much strain is not brought to bear upon the ligaments. Some osteopaths
seem to take delight in rotating and flexing the neck to a great
degree. It is a dangerous procedure and moreover does not accomplish
anything in particular. It should be kept in mind that osteopathic
treatment is scientific and not a number of general movements of
various regions of the body. Locate the lesions exactly and then a
specific treatment can be given in every instance. To illustrate
the treatment according to the preceding rules we will assume that
a certain cervical vertebra is anterior, say the fourth cervical.
This means that there is an interosseous lesion between the fourth
and fifth. The inferior articular processes and facets of the fourth
have slipped upward and forward on the opposing facets of the fifth.
First, hyperextend the head in such a manner that the fulcrum comes
exactly over the displaced articulating planes, thus throwing the
fourth vertebra still more anterior, or in other words, exaggerating
the lesion or increasing the space anteriorly between the fourth and
fifth cervicals, so that when the head is flexed forward and pressure
is exerted upon the anterior part of the vertebra (body or transverse
process) the vertebra will have room and release enough to occupy its
normal position. Second, when the head is hyperextended place a finger
anterior to the transverse process of the dislocated vertebra and with
the other hand around the head, that is producing the hyperextension,
throw the head forward with slight traction and rotation and at the
same time push posteriorly quite strongly upon the dislocated vertebra.
Follow out the same principles in all cases, no matter in which way the
vertebræ are deranged.
There are several methods of applying the underlying principles of
adjustment. Relaxation and leverages may be secured in various ways.
Preciseness, expeditiousness and skillfulness can be attained only by
considerable personal experience.
In cases where the lesion is between the skull and atlas have the
patient sit on a stool with the back part of his head against your
chest, and reach around the head with one hand under the chin; then
with the other hand around the transverse processes of three or four
upper cervical vertebræ pull the spinal column toward the median line,
while at the same time lifting up on the skull with the other hand and
throwing the skull toward the median line. The object of lifting up on
the skull is to relax and disengage the articulations, by inhibition,
traction and rotation, between the occipital bone and atlas. This is
one method applicable to the various lesions of the occiput, which are
of frequent occurrence.
In treating the =pharynx=, =tonsils= and =larynx=, outside of
correcting spinal lesions, an anterior treatment to these organs is
very effective. Examine the deep muscles beneath the angle of the
jaw when the pharynx and tonsils are involved; and when the larynx
is affected note the condition of the muscles on either side of the
larynx. After locating deeply seated contracted muscles in the region
of the angle of the inferior maxilla place the fingers over the
contracted tissues, and then by a downward, inward sweeping motion
toward the median line the muscles may be readily relaxed. When
treating the larynx relax the tissues on both sides by an upward,
inward movement. These treatments are very effectual when applied
directly to the disordered tissues.
Attention should also be given to the lymphatics. In simple infections
treat the glands very lightly but attempt to break down the surrounding
edematous barrier. Release all the tissues down to and including
clavicles, first ribs and pectoral and axillary regions.
To treat slight lesions of the =inferior maxillary= articulation,
stand at the head of the patient when he is lying down and hook the
fingers about the jaw just in front of the angles, and with the thumbs
over the bridge of the nose have the patient open the mouth while
considerable force is exerted against his effort. This reduces any
slight dislocation of the inferior maxilla. When the jaw is completely
dislocated place a piece of wood or hard substance between the molars
and exert pressure upward and backward on the chin. If the dislocation
is bilateral work on one side at a time.
The object of treatment to the =face= is to stimulate or inhibit
points of the fifth nerve that come near the surface (see neuralgia of
fifth nerve). While the patient is lying flat upon the back carefully
stimulate these various points, especially the supraorbital and nasal,
with a downward and outward movement, or inhibit as indicated.
In treating the =scalp= relax the muscles over the scalp thoroughly.
This is secondary treatment to correcting the innervation to the scalp
at the upper four or five cervical vertebræ.
In cases of pharyngitis, tonsillitis, croup, hay fever, etc., an
effective local treatment may be given through the =mouth= upon the
soft and hard palate. Introducing a finger into the mouth clear back
upon the roof of the soft palate, and with a downward and backward
sweeping movement from the median line on either side toward the
tonsils, considerable relief can be given the patient. This treatment
relaxes the tissues, relieves the congestion, and gives a stimulating
treatment to the local nerves. A treatment of the same nature may be
given over the hard palate to affect the palatine nerves, especially in
hay fever, when the itching of the palate and sneezing are extreme. In
cases of young children it is best to protect the finger by wrapping a
piece of cloth around it.
An osteopath should never give a manipulation or movement unless he
understands why. Just as soon as one gives general imitating movements,
from that moment his work is not that of a scientific osteopath, but
of a Swedish movement curist and masseur and a poor one at that. The
osteopath’s work is to locate the anatomical derangement and correct
it, as a mechanic would adjust any disordered mechanism. General
treatment amounts largely to naught, although in some few instances it
is of benefit.
To give a detailed description of the treatment of all lesions that may
be found in the cervical vertebræ would be impossible in this sketch;
only a general survey of the work can be given. Each case calls for
special treatment, but the same general principles are applicable in
each case. If there is any one thing that should be eliminated from
osteopathic treatment it is those mechanical routine movements of
rotating, flexing, extending, and various Swedish-movement-massage-like
manipulations that certain osteopaths give in each and every case. It
shows that they are imitators and do not have a correct conception
of osteopathic therapeutics. True it is, that routine movements will
have stimulating and other effects upon the system. But does the body
require such treatment? Is it lack of exercise on the part of the
patient? If it is, then let the patient exercise himself. You do not
want to lower yourself to be a mere “engine wiper,” or an exerciser.
If it is not the lack of exercise and the system is in need of certain
treatment, then seek the cause and apply a specific treatment. Do not
hide behind generalities.
=The Ribs.=—In correcting dislocated ribs many methods may be employed,
but all are subject to the same principles as given under the treatment
of the neck and head.
One of the best methods to correct typical ribs is to have the patient
upon the side with the side of the affected ribs upward. Find out
exactly the nature of the dislocation, i. e., what is the relation
of the dislocated rib to the other tissues. Note whether the rib is
upward, downward, inward or forward, locate exactly the dislocated
rib. Then, while standing back of the patient, place your fingers upon
both ends of the rib. Place your fingers in such a manner that when
the proper time in the procedure arrives, all that will be necessary
will be to push the ends of the rib into their articulations. For
instance, if the rib is raised anteriorly and lowered posteriorly,
you will place the fingers on the sternal end, above the affected
rib and the fingers on the vertebral end, below the rib, so that
when the rib has been released from its abnormal position it may be
slipped into normal position. After having placed the fingers in the
exact position necessary, have an assistant take the arm and draw it
obliquely across the face, while at the same time the patient takes a
forced inhalation. The object of drawing the arm across the face and
the deep inhalation is to exaggerate the lesion—to draw the ribs out
of their locked position—so that the fingers upon either end of the
rib may push the rib into normal position. Drawing upon the arm raises
all the upper ribs as well as the dislocated typical rib, principally
by the use of the serratus magnus; also inhalation has an effect to
throw the rib outward and upward and thus away from its articulation.
Thus after the lesion has been increased sufficiently to loosen the rib
from its abnormal position, the arm is relaxed, the patient exhales,
and the fingers upon the ends of the rib correct the dislocation. This
treatment is used to the greatest advantage when there is a dislocation
of a typical rib; it can be given while the patient is lying down or
sitting up, although the former position is preferable.
An excellent method, when the =sternal end= of the rib is dislocated
is to have the patient sit upon a stool with his back toward the
physician; then by placing the knee in the back (while standing up, or
easier still for the physician to sit upon an operating table back of
the patient) over the vertebral end of the rib so that the rib may be
held rigid posteriorly, reach around with one hand over the dislocated
end of the rib and place the fingers upon the rib in the direction
dislocated; so that when the rib is sufficiently released from its
abnormal position it can be readily pushed into place; then with the
other hand under the axilla of the arm on the affected side, pull up
and back on the shoulder, so that the rib may be pulled away from its
sternal articulation; and at the same time have the patient take a
deep inhalation so as to aid in throwing the rib outward, upward and
away from its sternal attachment; then when the end of the rib has
been released sufficiently, relax the hold underneath the axilla, have
the patient exhale, and slip the rib into its normal position by the
fingers over the end of the rib. This is an excellent method. It is
easy to give and does the work admirably.
Practically the same procedure may be gone through when the =vertebral
end= is dislocated, by changing your position to the front of the
patient, but there is danger of the knee slipping off from the sternum
during the operation and injuring the ribs. Several other treatments
may be given to correct dislocations of the vertebral ends of the ribs.
For example, while the patient remains sitting the osteopath stands
in front of the patient and reaches around both sides upon the angle
of the ribs; then with an outward and upward movement of the fingers
upon the angle of the ribs, they are pulled away from their locked
position and allowed to slip into normal articulation. This treatment
is applicable only when the ribs are dislocated downward, but it is one
of the best treatments for such cases.
Another method oftentimes employed in correcting dislocations of the
vertebral end of the ribs is to have the patient lie flat upon the
side with the affected side upward; then by flexing the arm on the
forearm and placing the elbow against the chest or abdomen reach over
the patient upon the angle of the dislocated rib and pull it away
from the vertebra; when it is pulled away from the spinal column
sufficiently, push upward or downward on the angle of the ribs, as the
case may demand. The elbow placed against you gives complete control
of the patient and aids, by your weight, in throwing the rib upward or
downward.
A treatment somewhat like the preceding one which is commonly employed,
is to reach underneath the patient’s upper arm, when he is lying upon
his side, with the arm extended upward across the face; then by placing
the fingers of the hand underneath the patient’s arm over the angles
of the affected rib or ribs and reinforcing the hand by the fingers of
the other hand an upward, outward and rotary movement can be given the
ribs, which pulls them out of their abnormal position and allows them
to return to their normal articulations.
An effectual treatment to spread and raise the upper ribs is to have
the patient flat upon the back, and with the fingers of one hand
underneath the angles of the ribs and the other hand upon the elbow
of the patient’s arm of the same side throw the patient’s arm across
the chest transversely and bear down upon the elbow, at the same time
spring upward and outward on the angles of the ribs with the other
hand. By throwing the arm across the chest and bearing down upon the
elbow a strong leverage can be obtained upon the upper ribs, especially
those between the scapulæ. This treatment is very efficacious in
certain lung and heart diseases.
Still another method of adjusting ribs is to have the patient flat on
his face upon an operating table with the arms hanging down on both
sides of the table and a small pillow or folded blanket beneath the
upper part of the chest; then standing beside the table, or better
still, with one foot upon a low stool and the knee of the other limb
upon the table in such a manner that one is directly over the patient’s
dorsal region one is then in a position to have full control of the
vertebral end of the ribs. If the ends of the ribs are displaced
downward, placing the thumbs over the angles of the ribs and pushing
upward and outward on the angles, the ribs can be very readily crowded
into position. If the ribs, especially between the scapulæ, are
dislocated in any direction, they may be quite readily corrected by
placing the hand over the shoulder posteriorly and throwing it outward
and upward and away from the spinal column in such a manner that the
ribs are pulled away from the abnormal position; then upon relaxing the
hold upon the shoulder with the one hand, the fingers of the unemployed
hand may push upward or downward, as the occasion requires, on the
angles of the affected side so that the ribs may be slipped into place.
Many times one is obliged to treat the ribs of one side as a whole. In
such instances the ribs are almost invariably thrown downward except
on one side of scoliosis of the dorsal region. Several methods may be
employed to raise the ribs. Probably the best method is to have the
patient upon the side and with one hand upon the angles of the ribs and
the other hand holding the wrist of the upper arm of the patient, an
upward lifting movement is given both upon the angles of the ribs and
upon the arm of the patient while the patient inhales. The work upon
the angles of the ribs is to raise the ribs directly; the work upon
the arm is to raise the ribs indirectly, principally by the use of the
serratus magnus. Another effective treatment is to have the patient
upon the back and with one hand over the anterior ends of the ribs and
the other hand over the angles of the ribs an upward movement is given
them by springing the ends of the ribs toward each other and by strong
inhalation on the part of the patient. This treatment is most effective
where the false ribs are at fault and especially in case of hemiplegia.
While the patient is upon the back an assistant may take hold of
the arm and draw it upward over the head of the patient, producing
considerable additional upward tendency of the ribs, and the physician
giving the same treatment of the ends of the ribs as before; or the
physician may take an arm in one hand and raise it above the head of
the patient and with his other hand around the angles of the ribs, and
the patient inhaling deeply, the ribs may be raised.
A treatment used a great deal in raising the ribs as a whole is to have
the patient sit upon a stool, and reaching around the patient from the
front, place the fingers upon the angles of the ribs and raise them
upward on both sides at the same time. This treatment can also be given
by standing behind the patient and reaching around upon the anterior
ends of the ribs and lifting upward while the patient aids you by deep
inhalation. Remember that many times the ribs are drawn downward by
contraction of the muscles, due to atmospherical changes and slumped
postures. One should begin at the upper ribs in all treatments where
the ribs are to be raised, as a whole, and work downward.
To correct the =first= and the =floating ribs= a different treatment
has to be given than the foregoing.
An =upward displacement= is the most common lesion of the =first rib=.
To correct such a dislocation, have the patient sit upon a stool and
with one hand pull the head to the opposite side in order that the
lesion may be exaggerated by traction of the lateral muscles of the
neck (principally the scaleni) upon the rib; this disengages the rib
from its abnormal position; then with the fingers of the other hand
upon a point midway of the ends of the rib, exert a downward pressure
at the moment the extended head is relaxed describing a short arc. But
don’t relax head until readjusting pressure is exerted upon rib. If the
patient is unable to sit up, and it is not best to give the foregoing
treatment, have the patient flat upon the back, with one hand take hold
of the arm on the affected side and pull down and out upon the shoulder
so that the rib may be somewhat drawn away from its articulation and
released from its position; then with the fingers of the other hand
upon the center of the rib, or its highest point, press downward
when the hold upon the arm is being relaxed. Correction of an upper
displacement of the first rib is an every day occurrence. =Downward
dislocation of the first rib=, is rare. To reduce this dislocation,
place the thumb beneath the vertebral end of the rib, and with the
other hand lift up strongly on the shoulder from beneath the axilla, at
the same time exerting pressure upward with the thumb on the end of the
rib.
The =floating ribs= may be dislocated obliquely downward, or the free
end of the rib may be caught underneath the end of the rib above. In
either case, in order to correct the displacement, place the patient
upon the back with the thigh on the affected side flexed upon the
abdomen so that the tissues about the field of operation are relaxed;
then bear down carefully but firmly over the free end of the rib
with the fingers until one finger can be hooked underneath the end
of the rib; then with the other hand over the vertebral end of the
rib, have the patient take a deep breath, at the same time springing
the ends of the rib toward each other, thus relaxing the rib from its
locked position; then have the patient exhale quickly and at the same
time spring the rib into its normal position. It oftentimes requires
repeated trials, especially in stout persons, and quite often the
operation is painful to the patient. It is necessary that one should
understand this operation thoroughly, as it is one of the most common
treatments in osteopathic practice. The floating ribs are very liable
to dislocations and may be the cause of many pains in the side,
disturbances of the vessels as they pass through the diaphragm and
inflammation in the iliac region. A palliative treatment may be given
the floating ribs by having the patient lie flat either on the back or
on the side; then place the hand near the vertebral end of the ribs and
raise them upward while the patient takes a deep breath.
Treatment of lesions between the =manubrium= and =gladiolus= are best
given by placing the patient with the face downward upon the operating
table, and having the articulation of the manubrium and gladiolus
just over the edge of the table. An assistant should hold the patient
firmly upon the table while hyperextension or flexion, as the case may
require, with traction, is exerted upon the head, neck and shoulders,
and manipulation of the articular points is given to reduce the
dislocation. The same principles are employed here as in correcting
lesions elsewhere.
Correction of the =cartilages along the sternum= is very easily
accomplished by having the patient sit upon a stool and the osteopath
standing behind the patient places a knee in the back; then reaching
around with one hand over the cartilages and the other hand underneath
the axilla, execute the same movement as given in correcting
dislocations of the sternal ends of the ribs.
A treatment sometimes used to release a depressed condition of the
=cartilages= of the =false ribs= is to stand behind the patient while
he sits upon a stool and reach around him with fingers underneath the
cartilages and raise them upward as he inhales. By having the patient
take a deep breath and then exhale quickly while the fingers are over
the cartilages a much better grasp of them can be obtained. This
treatment should be carefully given, as there is danger of tearing the
cartilages loose from the ribs.
=The Dorsal and Lumbar Spinal Regions.=—Here, as in other regions of
the body, before an attempt is made to correct the vertebræ the muscles
should be thoroughly relaxed. One of the easiest methods to relax the
muscles is to have the patient lie upon the side, and then by standing
in front of the patient and reaching over him with the fingers upon the
contracted muscles an upward and outward rotary manipulation is given;
or the patient may sit upon a stool while the physician stands in front
with the arms around the patient and the fingers over the contracted
muscles manipulating them upward and outward. Another very easy method
is to stand behind the patient while he sits upon a stool and place
a thumb over the contracted fibres, with the other hand underneath
the axilla lifting the shoulder upward and backward so as to favor a
relaxation of the muscles, while the thumb manipulates them.
In relaxing the =muscles= of the =lumbar region= have the patient on
the side upon the table; then flex the thighs upon the abdomen with
your weight against the knees so as to control all movements of the
patient; reach over the patient with the fingers upon the contracted
tissues and manipulate them outward and upward on either side until
they are relaxed. A method sometimes employed to relax the muscles of
the dorsal, lumbar and sacral regions is to place the patient flat
on his face upon the table; then by pushing up on the muscles from
above downward with the flat of the hand they are easily relaxed. This
treatment should be especially given when the patient’s muscles are
contracted by atmospherical changes and from standing in one position
for a long time. When the muscles of the back are contracting they draw
downward and many times draw the ribs with them, as well as tensing
the tissues over the sacral foramina and obstructing or irritating
the sacral nerves. By using the modern table longitudinally relaxing,
or stretching, the lumbar and dorsal musculature saves considerable
strength and effort of the physician.
To correct =vertebral lesions= of the =dorsal region= the same rules
should be followed as in treating lesions of the cervical vertebræ.
Treatments may be given with almost equal ease whether the patient is
lying on the side or sitting up.
To illustrate the treatment of the dorsal region when the patient
is lying down, assume that there exists a lateral lesion, combined
rotation and sidebending, between two vertebræ; if the lesion is below
the seventh dorsal use the legs as a lever, and if the lesion is above
the seventh dorsal use the head and neck as the lever. Have the patient
lie upon the side toward which the lesion is pronounced, either reach
under the neck or around the limbs with one hand, and with the other
hand upon the lesion bend the head and neck or the thighs in such a
manner that the angle of the flexion is directly over the break in
the spinal column; this is to exaggerate the lesion; then by lightly
lifting up on the neck or limbs and with a slight rotation of this
lever the flexed parts should be extended, at the same time exerting
pressure with the hand over the lesion in such a manner that the
vertebra is pushed forward toward its normal position.
Practically, the same treatment is given when a patient is sitting
up, with the exception, of course, that the limbs cannot be used as
levers. Lesions of the dorsal region or even the lumbar region can be
corrected while the patient is sitting up. By this method considerable
lifting is done away with. In fact, the weight of the patient can be
used to great advantage by substituting it for one’s strength. No
matter in what direction the lesion is, the physician reaches around
the patient’s shoulders so that he just holds the weight of the patient
from falling to one side or the other; thus with one hand manipulating
the lesion the other arm is around the patient guiding the weight of
the body in flexion, rotation and extension. It is not always necessary
to lift up on the patient but just let the weight of the patient act
as strength applied to the power arm. Always make it a point when
working upon dislocated vertebræ in any region that just as soon as
one has obtained a slight movement in the lesion =do not attempt=
to correct it any more for the time being. A slight movement toward
the right direction may be all that is necessary to relieve the ill
effects of the lesion. In fact it might be impossible to get the lesion
anatomically correct as the shape of the vertebra may have conformed in
a greater or less extent to its abnormal position.
An excellent method to correct the various combinations of rotation and
sidebending of the third to ninth dorsals is to have the patient sit up
with the physician either sitting or standing, depending upon height
of seat, back of the patient. Have the patient lean back until head is
supported upon shoulder of physician, and the anterior and posterior
musculature of torso, abdomen and pelvis are thoroughly relaxed. Reach
around the patient’s chest with one arm, the hand of which is placed
beneath the axilla. The thenar eminence of the other hand is placed
upon the posteriorly prominent transverse process of the lesioned
segment. Then with careful hyperextension, traction, and rotation and,
sidebending of the torso, the anchorage is released, care being taken
that localization is exact; this moment of coordination is accompanied
with a thrust of the thenar eminence upon the transverse process.
Relaxation, leverages and thrust must be precise and thoroughly
coordinated.
To reduce vertebræ that are =deviated anteriorly= in the dorsal region,
especially between the scapulæ, is often a hard matter. A satisfactory
method is to stand behind the patient, while he is sitting upon a
stool, and reach around both sides of him upon the sternal ends of the
ribs corresponding to the anterior vertebræ; then have the patient
relax with the head upon the chest, and at the same time take a full
inhalation while pressure is exerted posteriorly upon the sternal ends
of the ribs. The object of this method is to pull back the rigid ribs
(the lungs being filled with air) which are attached to the anterior
surfaces of the transverse processes of the vertebræ, and thus upon the
anterior vertebræ pushing them posteriorly; all of the muscles of the
body being quite passive and the head relaxed on the body, a separation
of the vertebræ is accomplished, thus favoring a crowding posteriorly
of the subdislocated vertebræ.
To correct =vertebræ= of the =lumbar region= is on the whole much
easier than in the dorsal region. Here the legs can be used as levers
to great advantage. By the same method of flexion, rotation, and
extension, as employed in the dorsal region when the patient is lying
on the side, the result can generally be obtained.
Sidebending is the most common single lesion of the lumbar vertebræ,
though there may be some rotation at the lumbo-sacral juncture.
Occasionally malformation is found at the fifth. To correct the lumbar
lesions the following method is often used: place the patient upon the
side of the rotation or sidebending with knees flexed, buttocks well
back and entire spinal column straight. Next bring torso and head,
with spine straight, well forward to edge of table. Then with hand
upon ilium tilt it slightly forward, and with other hand upon shoulder
rotate entire spine, including head, so that spine is locked and the
point of localization exactly corresponds to the lesions. This brings
the spine back to nearly a straight position. Next, after a moment
or two of tension-relaxation, either thrust back upon the shoulder
or forward upon the ilium. Again exactly coordinating localization,
relaxation and leverages is the key of the method.
=The Abdomen.=—Direct treatment of the abdomen is given in many
diseases of its organs. The patient should lie flat upon the back, the
legs flexed upon the thighs and the thighs flexed upon the abdomen, so
that the abdominal muscles will be thoroughly relaxed; and then the
various organs of the abdomen can usually be manipulated with ease.
Remember that in many diseases of the abdominal viscera the treatment
of the splanchnics and vagi will be the primary treatment rather than
direct abdominal treatments.
In treating the =liver= directly, the ribs over the liver should be
raised and separated, and the lower border of the liver manipulated
directly, as considerable therapeutic results can be obtained,
particularly when the liver is congested and enlarged. Manipulation
of the =bile ducts= is very essential in many liver diseases. The
treatment relieves congestion of the ducts and removes any collections
of mucus in the ducts due to the congestion, as well as freeing
obstructed flow of bile. The manipulation should be a deep, downward
one, directly over the path of the ducts (from about the cartilage of
the ninth rib to the duodenal orifice of the biliary tract, the latter
being about one and one-half inches diagonally downward and to the
right of the umbilicus). Be very careful when first manipulating, and
bear down lightly over the duct so that the structures superficial to
it may be relaxed as the duct is deep below the surface of the abdomen.
Usually the gall-gladder can be emptied by light pressure over the
skin above the cartilages of the eighth, ninth and tenth ribs. The
light manipulation acts, probably, by way of the spinal segment, as a
stimulus to the dilators of the sphincters of the gall-bladder. Very
likely through reciprocal innervation relaxing the sphincter of the
bile duct will contract fibres of the gall bladder.
Manipulation of the =stomach= has considerable effect in strengthening
its circular fibres and toning up the coats in general. In cases of
gas formation, the gas in some instances may by manipulating over the
stomach, be forced through the cardiac or pyloric orifices.
Direct treatment over the =spleen= by raising the eighth, ninth, tenth
and eleventh ribs of the left side is effectual in congestion and
enlargement of the organ.
In thin subjects the =kidneys= can be treated directly by pressing
down carefully but deeply over the kidneys, and lightly crowding them
upward and outward. This treatment also has some effect in relieving
contracted tissues about the renal vessels and kidneys.
Treatment to the =intestines= through the abdomen is an effective
treatment. In the various obstructions to the intestines, constipation,
etc., the direct work is essential. Treatment of the intestines is to
correct any abnormal position that they may have assumed, to relieve
constrictions of the gut caused by contracted tissues, to relieve
impactions and adhesions, to increase peristalsis and to tone up the
intestinal coats in general. The treatment consists in a manipulation
of the intestines, especially in the right and left iliac fossæ, and
the pelvic colon, ascending colon and duodenum, as impactions and
prolapses of the gut are more liable to occur at these points than in
any other locality. In manipulating the intestines, work for a definite
purpose and not give a general kneading treatment unless the walls of
the abdomen and the coats of the intestines are weakened; in the latter
case the spinal treatment is the primary one. In treating over the
iliac region, draw upward and inward on the folds of the gut. It is
claimed by some authorities that nerves pass from the cutaneous surface
of the abdomen directly to the intestine by way of the peritoneum;
if such is the case, manipulation of the abdominal walls would have
direct effect upon these nerve fibres. The abdomen may be treated when
the patient is sitting up, but the treatment is not satisfactory. (See
Prolapsed Organs).
=The Pelvis.=—The treatment of the pelvis is easy, but the difficult
work is in making a diagnosis of the position of the pelvic bones.
The pelvis is especially apt to become deranged by jars and falls.
Some of the most successful osteopathic results have been obtained in
correcting the pelvic region.
To relax the muscles over the pelvis, the patient should be on the side
or upon the face; then relax the muscles by manipulating them upward,
chiefly those over the sacral foramina. It is a good rule to adjust the
lumbar first owing to release secured to the nerves supplying pelvic
muscles and also to the fact that many pelvic distortions are secondary
or compensatory to lumbar lesions. The easiest method to correct the
innominata is to have the patient lie upon his side; then by standing
in front of the patient slip one hand between the thighs and grasp
around the tuberosity of the ischium, and with the other hand upon the
crest of the ilium, the innominatum can be moved upward or downward
and forward or backward (wheel and axle principle). Simply pulling or
pushing upon these two points in whatever direction necessary is all
that is required providing the soft tissues are thoroughly relaxed. By
having the patient flat upon the back practically the same treatment
can be given, but not to so great an advantage. In cases where the
ilium is posterior and the ischium anterior, the physician may stand
back of the patient, while he is lying upon his side, and place one
knee against the sacrum and with one hand upon the ilium, with the
other take hold of the ankle of the affected side (the involved side
being uppermost in all cases where the patient is lying upon his side);
pressure can be exerted upon the ilium and the limb pulled backward,
thus correcting the derangement. This treatment should be avoided as
much as possible, as there is considerable danger of pulling back too
severely and injuring the patient; the lever is long and the amount of
force exerted upon it cannot be judged precisely.
Another method is, with the patient on the back, flex and evert the
knee to the side so the side of the foot lies flat on the table. Grasp
the ankle with one hand and with the other on the crest of the ilium
of the opposite side then, by pushing down firmly on the knee the
articulation is gaped and at the same time the operator pushes with his
body against the knee with a sharp thrust. This may have to be repeated
a few times before the articulation is released and if one is keen he
will easily detect the slight concussion carried down the femur as
the adjustment takes place. This will correct a forward and downward
innominate. For an upward and backward one, place the patient in
exactly the same position and go through the same motions except that
the knee is pulled toward the operator. If the desired “chug” is not
felt and adjustment is not definite, the leg may be pulled down rather
smartly by the ankle to a parallel with the other. This is a technique
that is easy, both for the patient and operator, and will correct any
but the most stubborn.
In the case of a greatly relaxed and atonic condition of the ligaments
of the pelvis much trouble is experienced, often, in making the
adjustment permanent. Many suggestions have been made and most of them
useless but, probably the use of a belt of non-elastic webbing about
two inches in width buckled tightly around the pelvis just below the
anterior spines will do as much as anything and is a procedure well to
follow in all such cases. Where there is a pendulous abdomen a support
in the shape of a simple belt which should be so fitted as to act as
a sling will transfer the weight of the abdominal viscera from the
muscles, already stretched and atonic, to the belt and put the burden
over the sacrum. This prevents the pulling of the innominatum in lesion
again. Overcorrection is suggested as a means on the ground that it
sets up irritation and induces fibrous ankylosis and for the same
reason W. W. Howard places his patient prone and with thumb works the
ligaments associated with the joint until they are thoroughly inflamed.
The patient is then put in bed a few days and after the inflammation
has cleared up the ligaments will be found to have shortened.
To correct a rotary lesion between the pelvis and fifth lumbar the
patient should be placed upon the side, and with the body held firmly,
the pelvis can be forced backward or forward as the occasion demands.
(See Coccyx).
=The Legs.=—The origin of many symptoms manifested in the legs, as in
the arms, are due to spinal lesions corresponding to the region of
innervation to the affected tissues. The derangements of the pelvic
bones are a frequent source of symptoms that are referred to the legs
and feet. The osteopath finds that a slight dislocation of the hip
may occur which is especially likely to affect the knee. This partial
dislocation is apt to be an upward-posterior one; the head of the
femur resting in the upper and posterior part of the acetabulum. Many
diseases of the legs and feet are due to local displacement of the
bones. The method of treatment is the same as given in surgical works.
(See Sprains).
A general treatment of the legs and thighs is oftentimes necessary;
it consists of flexing the thighs quite firmly upon the abdomen, and
executing thorough external and internal rotary movements of the thighs
and legs. In a few cases both limbs are flexed strongly at the same
time upon the abdomen. After giving these movements manipulation over
the saphenous opening and beneath the popliteal space is performed.
This general treatment tends to increase the circulation of the entire
limb and to relax thoroughly all contracted fibres.
=The Arms.=—In treating the arms, care has to be taken that the
affection is not due to spinal derangements; otherwise the arms are
manipulated according to the disorder. Complete dislocations of the
shoulder comes under the province of surgery. Many times the osteopath
locates slight or incomplete dislocations of the shoulder. Partial
dislocations of the shoulder are generally anterior. (See Sprains).
In cases where pain exists in the shoulder or arm, outside of locating
the cause in the shoulder joint, the affection may be due to fibres
contracting over the coracoid process, or a dislocation of the second
or third rib, and in some instances the clavicle is deranged. Special
care should be given to a possible bursitis and tendo-synovitis.
Occasionally muscular fibres may slip out of the bicipital groove.
Dislocations of the bones of the arm are treated according to surgical
methods. The pains and various troublesome symptoms that may be
manifested in the fingers or the hands are oftentimes caused by slight
dislocations of the elbow, shoulder, ribs, or vertebræ, as low as the
sixth to eighth dorsals.
=The coccyx.=—The coccyx, owing to its exposed position and rather
unstable attachment, is subject to many injuries; more indeed than come
to notice. Its injury results in many local and general disturbances
owing to its close relation to the sympathetics. Successful treatment
of deviations often bring startling results. They may be divided into
=fractures= and =displacements=.
In =complete= or =partial= fracture of the coccyx, as well as in
dislocation, if the patient can be seen with reasonable promptness
after the accident much can be done for relief of the pain and the
prognosis is good for complete recovery.
Examination should be made externally and internally and after the
condition is diagnosed about the same procedure is indicated for any of
the conditions. With the patient on the left side introduce the right
index finger, well lubricated, into the rectum and carefully relax all
tissue within reach of the tip. If there are spasms of the coccygeal
muscles, inhibition of the anterior nerves will quiet them. When this
has been done place the left index finger externally along the body of
the coccyx and holding it firmly both within and without release it
longitudinally and then adjust. After this has been done it is well to
hold it there until all danger of returning spasm, which might displace
it again, is over, when the finger can be withdrawn.
The pain following will depend on the severity of the injury, but will
keep up more or less constantly for several days. When severe, relief
is often given by introducing the finger and relaxing contracted tissue
which is pulling it from its position. Hot water bags placed next to
the part will be of benefit. The bowels should be kept confined for
forty-eight hours if possible in cases of fracture. Watch carefully the
progress of union that the bones are _in situ_ so there will not be
deformity.
In diagnosing the first injury be sure that there is no splitting
of the first segment or splinters which may require surgical
interference. In old cases of fracture where there is complete bony
ankylosis it is not justifiable to attempt any change, but where there
is motion and a fibrous union, after preparatory treatments about one
week apart, it can usually be replaced. Look well to any muscular
contractions which might interfere with it. Force must never be used
nor any attempt to replace until it has been first released from its
articular attachment. In the various forms of =displacement= the same
technique applies as in fractures, or the finger and thumb of one hand
may be used, the tip of the finger internally at the sacro-coccygeal
articulation and the thumb externally at the same point. Complete
control of the part is secured in this manner. Great care must always
be used in treatment of any displacement of the coccyx. Contractions
of its muscular attachments will often cause deviations in contour.
Removal of the irritation and relaxation will allow it to assume its
normal position.
=The sacrum.=—Adjustments of the sacrum as distinguished from the
ilium in strictly innominate lesions are not many. When posterior with
the patient on a stool the knee of the osteopath coveted by a pillow
and placed against the sacrum and both hands grasping the anterior
borders of the ilia, strong traction will move it into position. In a
downward displacement with the aid of an assistant from behind holding
the crests of the ilia firmly as the patient sits on the table, the
osteopath in front clasping both arms about the patient and with a
rocking motion from side disengages the sacrum and at the same time
lifts it into position.
For anterior displacements use the technique described in replacing
upward and backward innominate dislocation first right side and then
left, which will result in correcting the lesion.
The preceding osteopathic technique includes a few of the treatments
given by the osteopath. Although many osteopaths use methods not
given here, those outlined are sufficient for illustrative purposes.
A point which cannot be too thoroughly impressed upon the student is
that osteopathic treatment is in reality =constructive= work, that is,
readjustive, not only in detail, but in viewing the body structure
as a whole. Detailed readjustment is an essential, still do not lose
sight of the relation of the part to the whole. In our distinctive
work anatomical construction is the basis of physiological function,
although physiological stimulus is essential to anatomical development.
=How often to treat.=—How often to treat a case depends entirely upon
the nature of the disease from which the patient is suffering. Just
as in giving drugs the frequency of treatment is entirely dependent
upon the seat of the disease and its severity. Acute cases require a
thorough treatment at least once daily, and many times in severe cases
the treatment has to be repeated several times daily. In subacute and
chronic cases, as a rule, treatment should not be given as often as in
acute cases; possibly once a day, but usually alternate days is better.
In office practice cases are commonly treated two or three times
weekly. Still it is better not to treat some cases oftener than once a
week.
There is more danger in treating too often and too long than in
not treating often enough. The distinctive work of an osteopath is
to correct disordered anatomical structures; and when a certain
derangement has been corrected the tissues should have rest and plenty
of time for repair. When treatments are given often, it simply keeps
the tissues in an irritated state and nature does not have time to
heal the diseased tissues. Always make it a point at each treatment to
correct some definite lesion, and when the work is accomplished let
the parts alone until the tissues have recovered as much as possible
from the effects of the previous treatment before another treatment is
attempted. The reason why some cases do not get cured under osteopathic
treatment is simply because the osteopath keeps the diseased tissues in
an aggravated state by the constant treatment so that they do not have
the least chance to heal; the physician is thus adding irritation to
the disease.
It is only by experience that one can tell how often to treat. Each
case is a special study; what would be quite sufficient for a certain
individual with a given disease would not be at all suitable for a
second individual with the same disease. As in drugs what is suitable
for one person would not be adapted to another, because the make up
of each individual is entirely different; but here the parallelism
diverges, for in drugs there is a foreign agent introduced into the
system, while in osteopathic treatment the curative agent is entirely
harmonious with the idiosyncrasies of the individual. It is for this
reason that experience in practice is so essential.
Most cases should not be treated, as a rule, after a meal unless the
patient is suffering from some digestive disturbance; for treating
other regions of the body outside of the digestive tract causes more or
less stimulation of the parts treated and thereby draws blood away from
the organs of digestion. Cases of disordered brain circulation, where
the patient is unable to rest or sleep at night, should be treated at
about their retiring time so that the circulation of the body may be
equalized, thus giving the patient undisturbed rest.
To show in a practical way the methods of experienced osteopaths in
this matter G. J. Helmer[32] is quoted: “I submit the following table
to illustrate the frequency of treatment in one hundred cases taken
from my practice: one case three times per week, sixty-three cases
two times per week, twenty-two cases one time per week, nine cases
once every two weeks, five cases once every four weeks. Comparing
the present with the past, I find I am lengthening the time between
treatments with much better results.”
Another very practical side of the question and one which will be
greatly appreciated by the patient, is the lessened cost for the same
result in the less frequent treatments, as well as the saving in time.
With the loss in going to the office, rest after treatment, not to
mention possible wait while there, three times weekly represents more
time than the average person can well spare and not infrequently will
deter him from continuing. More especially is this true of those coming
from a distance.
=Length of Treatment and Overtreatment.=—Naturally the length of
treatment depends upon the case at issue and nothing more. There is no
reason why any two cases should be treated for the same length of time
unless they present identical lesions and then the personal equation
of the two might present such a wide difference of aspect as to forbid
such a proceeding.
The question of time has no place in the matter, save that it must not
exceed physiological limits and be sufficient for the needs of the
case. The patient should understand at once that it is to accomplish
a specific purpose that the treatment is given, just as definite as a
surgical or dental operation, and when the work is done it is time to
stop. He would hardly be attracted to the dentist who guaranteed to use
forty-five minutes in extracting a tooth. Good judgment is required in
this as in all matters pertaining to osteopathy. There is a generally
expressed opinion among the older osteopaths, based on experience,
that: first, a short specific treatment is productive of best results
and, second, treatments given under high tension when quick work is
necessary are most satisfactory. Long treatments are debilitating and
over stimulation amounts to inhibition. Further, in a long treatment
it is necessary to go over the whole body, thus dispersing the vital
forces (which have been stimulated for healing and upbuilding the
pathological area) to parts not involved, thus defeating the very
purposes intended. Dr. Still always advocated and gave the short,
specific treatment.
The point always to be considered is the individual characteristics of
the patient, and effects of the first treatment should be carefully
observed. After a patient has been under treatment for any considerable
time it is well to give him a vacation from treatment, and it is
remarkable what improvement will be shown at times by such a measure
and how seldom he will lose ground. Dr. Still presented this subject
vividly as follows: “To treat the spine more than once or twice a week
and thereby irritate the spinal cord, will cause the vital assimilation
to be perverted and become death producing by effecting an absorption
of the living molecules of life before they are fully matured and
while they are in the cellular system, lying immediately under the
lymphatics. If you will allow yourself to think for a moment of the
possible irritation of the spinal cord and what effect it will have on
the uterus, for example, you will realize that I have told you a truth.
Many of your patients are well six months before they are discharged.
They continue treatment because they are weak, and they are weak
because you keep them so by irritating the spinal cord.” It is not a
rare experience for a patient to leave apparently with little or no
improvement only to report a complete recovery a little later.
=Misapplied Treatment.=—Probably in spinal treatment more risks are
taken than in any other region of the body. To us as a school it is
by far the most important and interesting area we have to treat,
consequently it is not surprising that various general treatments
and methods have been devised with the idea of getting quicker and
easier results. Herein lies the danger outside of mistaken diagnosis,
for short cut treatments can never take the place of time and skill.
Technically speaking, if one thoroughly understands the philosophy of
osteopathy and is conversant with the underlying principles of its
therapeutics, there is absolutely no danger of even the slightest
injury. It is the one who takes chances by not properly diagnosing
and by not being cautious enough with delicate persons when applying
his treatments that is apt to overstrain some tissue or organ and
otherwise do bodily harm. Of the treatments considered dangerous not
one of them is without merit if judiciously applied, but unfortunately
in many cases they are in general and indiscriminate use. It is well
to remember that we are moving structures which have never been
moved before and that time enough has not elapsed to observe what
the ultimate result may be. Again, in adjusting a subluxation of the
spine do not forget that the force necessary for that adjustment, if
misapplied, is sufficient to produce a lesion, and there is no doubt
that this has happened. Your patient’s interests are above everything
and must never be sacrificed for any reason whatever, so if at any
time there is uncertainty always give the patient the benefit of the
doubt. On the other hand the osteopath must have the courage of his
convictions and fortunately when these are coupled with good judgment
the results are all that could be desired. The following should be used
with great caution if used at all:
First, =Indiscriminate stretching= of the spinal column with the aid of
an assistant. It is not good osteopathy although there are some cases
where it may be beneficial. While not specially dangerous, generally,
in delicate patients, elderly people, arteriosclerotic conditions, and
in some stages of Pott’s disease it is absolutely contraindicated.
Moreover in most spinal cases except impacted vertebræ and symmetrical
curvatures the stretching of the vertebral ligaments locks the lesion
firmer.
Second, =Extreme rotating= of the cervical region. This cannot be
considered good treatment in any case with the exception of the
muscle stretching. On the contrary it is dangerous; first, it is not
osteopathy for it is not specific; second, the nervous shock is severe,
an important consideration in delicate people; third, the cervical
ligaments become stretched and the vertebræ are easily displaced, while
damage to a diseased vertebra, an aneurism or in arteriosclerosis would
be irreparable. No other region of the body should have greater care in
treatment than the neck.
Third, =Hyperextension= of the spine with the patient on his face. This
treatment is rarely indicated. In fact, it is barbarous and a relic of
an early day. Possibly more cases have been injured by this treatment
than all others combined.
Fourth, =Rough separating= of the vertebræ and ribs while the patient
is on his face. This is a most excellent treatment in many cases, but
great judgment is necessary. Delicate patients, heart disease, and
necrosed vertebræ and ribs should be carefully excluded.
Fifth, =Innominate adjustments= such as placing the patient on the
side and putting the knee against the sacrum while grasping the leg
at the knee. Or, the placing of the patient face down with one hand
on the sacrum and the other holding the knee. In both these there is
a tremendous leverage and in the latter the strain is at the lumbar
rather than where needed. There are other unnecessarily risky methods
for this operation, while it is easy to perform in most cases and
without danger.
Sixth, =Abdominal treatment= gives wonderful results when intelligently
applied, but it may be productive of great harm in conditions of
tumors, malignancy, and pus formations.
=Misapplied treatment= is always dangerous, no matter to what part of
the body given, and it is proof of wrong diagnosis when given. As a
rule treatment is given without proper diagnosis in such cases, so a
misapplied treatment has two interpretations—first, ignorance; second,
laziness. In the former lies the greater danger for ignorance coupled
with force and lack of skill is an appalling combination.
Cases are frequently reported where tumors have passed from the vagina,
rectum, nose, etc., the osteopath thinking it was the result of good
treatment, without considering that it was simply the breaking of a
long pedicle with great danger from hemorrhage. The greatest care
should be exercised in treating cases where aneurism, osteomalacia,
and arteriosclerosis are present, also in the leg treatment of tabes
dorsalis and in the weak, thin ribs of elderly people and those with a
gouty or rheumatic diathesis. Imagine treating an abscess directly, yet
it has been done, as have varicose veins with the terrible danger of
rupture and embolism. Aneurisms have been ruptured in the same way.
One could go on indefinitely with this subject, but to sum up: if the
osteopath is not familiar with the feel of the living anatomy in its
giving and resisting under treatment both in health and disease and
does not know his osteopathy, nothing can prevent him doing harm. A
successful practitioner means an understanding of pathology, then
experience plus common sense.
FOOTNOTES:
[31] See Ashmore’s Osteopathic Mechanics.
[32] Journal of the American Osteopathic Association, Dec., 1903.
OSTEOPATHIC CENTERS
“Osteopathic spinal centers” was a term commonly used in the early
period of osteopathic development. From the facts, first, that
a few centers have been actually determined in the cord, viz.,
genito-urinary, vasomotor, etc.; second, that the innervation from
the spinal segment to various thoracic, abdominal and pelvic viscera
correspond with a considerable degree of accuracy to certain vertebral
sections, and third, displacements of tissues of the spinal column
affect viscus integrity, depending upon the locality of the structural
perversion as to the organ involved and is a clinical observation of
great import, arose the misnomer “osteopathic centers.” For one to ask
what “centers” should be “treated” in this or that disease shows a
lack of the conception of osteopathy as if he asked what “movements”
to give when “treating” a certain disorder. It is as unosteopathic, as
it is unscientific, broadly speaking, to suppose osteopathic technique
implies the application of movements to certain nerve centers.
Osteopathic Stimulation
“Osteopathic stimulation” is another term loosely used without
extensive clinical experience to support it. Mechanical stimulation
is frequently utilized in the physiological laboratory. But to employ
it extensively and comprehensively in the treating room or at the
bedside the therapeutic potency of it will be found wanting; that is,
to employ it to the exclusion of that most important basic treatment,
readjustment, is a great mistake.
Clinically, the pathologically slowed heart may be stimulated by a
stimulus to the cervical sympathies, the gall-bladder emptied by a
stimulus near the costal cartilages of the ninth and tenth ribs (this
is probably via the spinal segments), etc. Normally, these organs and
others may be temporarily stimulated. Experimentally, Burns[33] of
Los Angeles and Pearce[34] of San Francisco have shown the potency
of osteopathic mechanical stimulation. For example, stimulation
(mechanical) in the middle and lower dorsal regions irritates and
increases peristaltic action and vaso-constriction in the stomach and
intestines.
Osteopathic Inhibition
Likewise the term “osteopathic inhibition” has not always been
scientifically employed. Mechanical inhibition is probably used less
frequently than stimulation but still it is of more importance.
Probably the true interpretation of considerable of so-termed
stimulatory and inhibitory efforts, is simply one of normalization of
tissues, physiologic equilibrium resulting from such changes.
Clinically, to relax contracted muscles by inhibition, to relieve
neuralgia by impinging nerve courses, to relax the cardiac orifice
of the stomach by pressure at the ninth or tenth dorsal vertebra on
the left side, etc., are excellent examples of the therapeutic value
of inhibition. Experimentally Pearce and Burns produced the opposite
results to that of stimulation. Inhibition in the middle and lower
dorsal region caused relaxation of the muscles of both the stomach and
intestines, decreased peristalsis, and caused dilatation of the blood
vessels.
The employment of stimulation and inhibition rounds out to a certain
extent our therapeutics, that is, makes it more practical and specific.
We should not, however, over-rate the relative value of stimulatory and
inhibitory treatment as compared with the readjustive treatment. Not
but what the former is of considerable practical importance, but the
point to be emphasized is that it gives a scientific demonstration of
how pathological effects result, if long continued, from the various
osteopathic lesions. In a word, it shows the physiological process
from cause to effect, or rather a step in the beginning pathological
(perverted physiological) in many disturbances.
Therapeutically, all will agree with Cherry[35] that “stimulation
and inhibition should be employed in all forms of acute disease as
palliative measures until such time as the primary lesion may be
removed.”
As a preparation for adjustment of any bony lesion there is no
question but that simple inhibition for a brief time in the area will
bring about relaxation of soft tissues in a much more satisfactory
manner than the usual massage like method. McPherson, Montreal, has
developed a technique of sacral pressure which he uses exclusively in
his practice. Without going into the merits of his theory there is no
doubt that inhibition at the second and third sacral will bring about
relaxation of the muscles of the lower trunk in a most gratifying
manner. Another thing, if there is difficulty in introducing the finger
in making either a vaginal or rectal examination, a minute’s pressure
at these points will, in most cases, cause the sphincter to relax so as
to cause no discomfort to the patient. This pressure will, also, have a
great effect on the hypogastric plexus and the pelvic organs.
Osteopathic Readjustment
Readjustment or adjustment is many times particularly emphasized in
this work as the key to osteopathic therapeutics.
If the theory of readjustment can not stand the most searching tests
of science osteopathy will have to be relegated to a most subservient
place, on a par with massage, Swedish movements, and various medical
gymnastics. Consequently the readjustment theory is again referred to,
and especially so when the subjects of osteopathic centers, stimulation
and inhibition are outlined.
No doubt many stimulatory (so-called) and general treatments exert
their greatest influence by inadvertently readjusting tissues. Then
how much more effective would the readjustment treatment be if applied
intelligently. In certain acute disorders, e. g., “colds,” immediate
relief is often obtained by relaxing muscles through either stimulation
or inhibition; in reality the final result, as far as the muscle
is concerned, is one of readjustment. Likewise in stretching and
rotation of tissues and sections of the body the effect may either be
stimulatory or inhibitory, and still it may be, also, readjustive.
After all has been said the ultimate physiological effect of any
of these treatments, if of any therapeutic value, must be one of
stimulation to a part or to the body generally. But there is a vast
difference between physiological stimulation and the one method of
obtaining the same termed mechanical stimulation. It is not the purpose
here to enter into anything like an exhaustive survey of stimulation
and inhibition but simply to outline a few practical hints on the
relative values. Everyone is aware that overstimulation is equal
to inhibition, and even applying it to very delicate subjects the
therapeutic end we may wish to obtain may be lost and as a consequence
the patient exhausted; whereas at the same time readjustment possibly
could have been employed and real permanent effects secured.
So we should whenever possible utilize the basic principle of our
therapeutics, readjustment, for this represents in the majority of
cases, first, permanent results; second, a saving of much time, and
third, less exhaustion on the part of both patient and physician.
McConnell[36] has shown in his series of laboratory experiments on
animals the reality and potency of the readjustment fundamental.
The effect of malaligned vertebræ and ribs upon contiguous vascular
channels and nervous tissues, not only affects immediate skeletal
muscles by simple contractions but even produces interstitial myositis.
Through narrowing of the intervertebral foramina and tension upon the
fibrous tissue anchoring the spinal nerve in its exit, and through
pressure and strain on the sympathetics in contact with the heads of
the ribs, which are secured there by the parietal layer of the pleura,
organs in corresponding cavities become diseased. Some of the diseases
produced in the series of experiments were catarrhal and parenchymatous
changes in the stomach and intestines, congestion of the liver and
spleen, acute nephritis, goitre, inflammation of the lymphatics, edema
of the cornea, and degenerations of nervous tissues. Still too much
emphasis should not be placed upon the narrowing of the foramen for
certain pathologic changes are shown to be due to other conditions than
Wallerian.
The osteopath, as stated, may inadvertently correct osteopathic
lesions. _Vis medicatrix naturae_ undoubtedly corrects many osteopathic
lesions; this is evident from the fact that many bodily strains,
sprains, and injuries are overcome naturally or involuntarily, that
is, without any voluntary assistance from an osteopath. On the other
hand all osteopathic lesions are not due to outside influences or
forces, e. g., in pneumonia the severely contracted dorsal muscles
often partially dislocate the vertebral ends of the ribs and thus
increase the seriousness of the disease; and this is true in many acute
conditions wherein visceral changes will reflexly contract spinal
muscles and also through these contractions produce osseous lesions.
Here is where osteopathic treatment in acute diseases will not only
correct the primary lesion but also these secondary ones and thus
abort, or shorten, or lessen severity, or prevent complications of
the disease. But it should always be borne in mind that when certain
disease processes occur it will take a definite time at best for
curative changes to predominate. In other words pathological changes
are just as real and potent as physiological facts or anatomical data
and the character of the same should always be considered.
Consequently in readjustment work a distinctive etiology and pathology
has to be taken into account. The color, contour (whether the lesion is
simply a local one or there is a composite or group lesion), condition
(irritation, debility, contractions, and tenderness), and movement of
the several regions, and the spine as a whole should be noted. And
the student should always keep in mind that the osseous vertebral
lesion may be, (a) a twist between two vertebræ (this generally means
a rotation of one section of the spine on another section), (b)
malalignment of several vertebræ (the composite or group lesion), or
(c) the impacted or strained lesion, (this is a lesion that Clark
attaches considerable significance to, wherein there is injury to the
articular surfaces and ligaments without osseous derangement, followed
by exudation and other inflammatory products, limited motion, etc.).
VasoMotor Nerves
It is extremely important that the osteopath should be thoroughly
conversant with the regions where he may affect the vasomotor nerves to
various tissues and organs. Many anatomical derangements undoubtedly
involve the vasomotor nerves, and it is therefore necessary to know
where they may be affected. The following table is taken mostly from
the physiology of Landois and Stirling, but many of the statements have
been noted at various times; it is, therefore, impossible to give full
credit.[37]
The vasomotor center is in the medulla, consequently the osteopath
gives cervical treatment to influence this center. Treatment of the
upper cervical region has undoubtedly a marked effect in tending to
equalize the vascular system of the body, when it is disturbed.
=Head.=—The cervical sympathetic for the same side of the face, eye,
ear, salivary glands, tongue, etc., and possibly the brain. Lesions
are found in all the tissues about the cervical region, but usually in
the vertebræ, which influence these nerves. Deep contracted muscles
oftentimes involve them. The spinal vaso-constrictors for the vessels
of the head are from the first five or six thoracics. Many lesions are
located in the upper five or six dorsal vertebræ, or corresponding
ribs, that have apparently a direct influence upon the vessels of the
head. Not only congestive headache and congestion of the brain tissues
are influenced by lesions in this region, but disease of the eye, ear
and face occasionally arise from such derangements. It is always best
when the head, neck or even the arms are involved, to examine carefully
this region. Vaso-dilator fibres for the face and mouth are found from
the second to the fifth dorsals; these fibres unite almost entirely
with the trigeminus, and pass from the superior cervical ganglion of
the sympathetic, to the ganglion of Gasser. This fact is of great
importance to the osteopath, for oftentimes when inflammation of the
face and mouth occurs, lesions may be located along the upper dorsal
vertebræ or ribs, or in the deeply contracted muscles of this region.
Observation revealed in several cases of erysipelas that the causative
lesion was located in the upper dorsal region; and the cases were cured
by correcting these lesions, thus showing that probably the vasomotor
nerves were the seat of the trouble. Other dilator fibres arise
apparently in the trigeminus, for stimulation of this nerve between the
brain and Gasser’s ganglion causes dilatation of the vessels of the
face. The lingual and glosso-pharyngeal nerves are the dilators of the
lingual vessels. The sympathetic and hypo glossal are the constrictors;
these arise in the sympathetic and reach the nerves by way of the
superior cervical ganglion. Stimulation of the cervical sympathetic
causes constriction of the retinal vessels. This point is extremely
interesting to the osteopath, because diseases of the retina and optic
nerve are oftentimes due to subluxated cervical vertebræ, usually the
atlas or third cervical. The retinal fibres leave the sympathetic at
the superior cervical ganglion and pass along the communicating ramus
to the ganglion of Gasser, from whence they reach the eye through the
ophthalmic branch of the fifth nerve, the gray root of the ophthalmic,
the ganglion and the ciliary nerves. Almost all the fibres to the
anterior part of the eye are found in the fifth nerve; this, also,
is another important point for the osteopath’s consideration. Cases
of conjunctivitis, keratitis, corneal astigmatism and diseases about
the eyelids and tear ducts are usually caused by lesions to the fifth
nerve, due to a deranged atlas or third cervical. The vaso-dilators
for the anterior part of the eye, and also dilating fibres to the
iris may be affected at the first and second dorsals. This point is
also taken advantage of by the osteopath, for lesions of these fibres
occur oftentimes at the upper dorsal. It is claimed that important
fibres that aid in the control of the metabolism of the retina, may be
affected at the fourth and fifth dorsals.
=Lungs.=—Reflex constriction by stimulation of the intercostals,
central end of the sciatic, abdominal pneumogastric and abdominal
sympathetic. There is not a rich vasomotor supply.[38] The essential
feature to the osteopath is that the vaso-constrictors to the lungs
and bronchial tubes are very likely to be interfered with by rib
and vertebral dislocations, from the second to the seventh dorsals,
inclusive, but chiefly at the third, fourth and fifth. The heaviest
innervation being from the third, fourth and fifth spaces, probably
explains why asthma is often due to a dislocation of the third, fourth
or fifth rib.
=Heart.=—First to fifth thoracic via ganglion stellatum and inferior
cervical ganglion. Vasomotor fibres to the coronary arteries are found
in the vagi.
=Intestines.=—Sympathetic, chiefly through the splanchnic nerves.
Vaso-constrictors of the jejunum from the fifth dorsal down, for the
ileum slightly lower and for the colon still lower. There are none
below the second lumbar. Dilators are present in the same sheath, but
more abundant in the last three dorsals and the upper two lumbars; all
probably end in the solar and renal plexuses.
=Receptaculum Chyli.=—Stimulation of the splanclinics causes dilatation.
=Liver.=—The splanchnics chiefly on the right side. The vagus contains
vaso-dilators. There are also fibres from the inferior cervical ganglia
of the sympathetic.
=Kidneys.=—Vasomotor nerves from the sixth dorsal to the second lumbar,
but principally from the ninth to twelfth dorsals, inclusive. In the
large majority of kidney diseases, lesions are found from the tenth
to the twelfth dorsals. Stimulation of the sciatic centers causes
contraction. There are also fibres from the superior cervical ganglion.
=Spleen.=—Vasomotor fibres are in the splanchnics, third dorsal to
third lumbar, principally, on the left side. There are some fibres
direct from the brain. Stimulation of the vagi contracts the spleen.
=Portal System.=—Fifth to ninth dorsal.
=Generative Organs.=—For Fallopian tubes, uterus, vagina, vas deferens
and seminal vesicles, vasomotor fibres are found in the lower dorsal,
and the second, third, fourth and fifth lumbar nerves, principally.
=Coccyx and Immediate Region.=—Third lumbar down.
=Back Muscles.=—Dorsal Posterior branches of the lumbar nerves and
intercostal nerves. These nerves arise from the gray ramus of the
corresponding sympathetic ganglia.
=Arm.=—From the brachial plexus, the sympathetic, inferior cervical
ganglion and first thoracic ganglion, and sometimes lower.
=Leg.=—Second dorsal down, the sciatic and crural nerves, and the
abdominal sympathetics.
Sensory Nerves
Inhibition of various regions along the spinal column is frequently
given by the osteopath to lessen pain. It is only a temporary or
palliative treatment, but many times gives great relief. One should
inhibit usually over tender points and contracted muscles. These
(tender points and contracted muscles) are signs to the osteopath that
disturbances exist at these points. The following table is taken from
Quain, which is Head’s classification:
=Heart.=—First, second and third dorsals.
=Lungs.=—First, second, third, fourth and fifth dorsals.
=Stomach.=—Sixth, seventh, eighth and ninth dorsals. Cardiac end from
sixth and seventh. Pyloric end from ninth.
=Intestines.=—(a) Down to upper part of rectum, ninth, tenth, eleventh
and twelfth dorsals. (b) Rectum, second, third and fourth sacrals.
=Liver and Gall-bladder.=—Sixth, seventh, eighth, ninth and tenth
dorsals.
=Kidney and Ureter.=—Tenth, eleventh and twelfth dorsals. Upper part
of ureter, tenth dorsal. At lower end of ureter, first lumbar tends to
appear.
=Bladder.=—(a) Mucous membrane and neck of bladder; (first) second,
third and fourth sacrals; (b) over distension and ineffectual
contraction, eleventh and twelfth dorsals, and first lumbar.
=Prostate.=—Tenth, eleventh (twelfth) dorsals. First, second and third
sacrals, and fifth lumbar.
=Epididymis.=—Eleventh and twelfth dorsals and first lumbar.
=Testis.=—Tenth dorsal.
=Ovary.=—Tenth dorsal.
=Appendages, etc.=—Eleventh and twelfth dorsals, first lumbar.
=Uterus.=—(a) In contraction, tenth, eleventh and twelfth dorsals, and
first lumbar. (b) Os uteri; (first) second, third and fourth sacrals
(fifth lumbar very rarely).
Other points are used by the osteopath to relieve pain of certain
regions, for such the reader is referred to the article on neuralgia;
besides many tender points are found along the spine by the osteopath,
where inhibition gives relief to the patient, provided such points have
a connection with the case in question.
Hot fomentations if property applied, through reciprocal relationship
of the nervous system, are of value in relieving pain, releasing
spastic musculature and normalizing visceral function. Frequently,
in both acute and chronic cases, this is an excellent preparatory
measure, to be followed by careful adjustment. It will be recalled
that the functional test, movement of a vertebral lesion is of primary
consideration.[39]
FOOTNOTES:
[33] Burns—Partial Report of Experiments upon Visceral Reflexes. The
Osteopathic World, Aug., 1905.
[34] Pearce—Some Laboratory Demonstrations of Osteopathic Principles.
The Osteopathic Physician, Nov., 1905.
[35] Stimulation—Leslie E. Cherry, Journal of the American Osteopathic
Association, Feb., 1905.
[36] McConnell—The Osteopathic Lesion,—Journal of the American
Osteopathic Association.
[37] See also Gaskell, The Involuntary Nervous System; Pattenger,
Symptoms of Visceral Disease; Mackenzie, Symptoms and Their
Interpretation.
[38] MacLeod, Physiology and Biochemistry in Modern Medicine.
[39] See Luciani, Human Physiology, Vol. III; MacLeod, Physiology and
Biochemistry in Modern Medicine.
PATHOLOGICAL SPINAL CURVATURES
SPINAL CURVATURES
Any deviation of two or more consecutive vertebræ from the normal
curves of the spinal column is usually termed by the osteopath a
pathological curvature. Of the common pathological curvatures of the
spinal column there are found: (1) scoliosis or lateral curvature, (2)
kyphosis, or excurvation, an antero-posterior curve with the convexity
backward, and, (3) lordosis, or incurvation, an antero-posterior curve
with the convexity forward.
=Osteopathic Etiology.=—Of primary importance in the causation of
pathological curvatures of the spinal column, are injuries to the
spine, such as strains, falls, blows, and various physical forces,
acting directly or indirectly, as injuries to the chest, pelvis and
limbs. The osteopath in his daily work finds more curvatures, as well
as acute and chronic diseases, resulting from some simple injury to the
spine, as a slip, strain or twist, than from any other cause. The dire
effects of any violence to the spinal column cannot be overestimated.
Among =predisposing causes= may be mentioned, continued ill health,
general weakness, rapid growth, rachitis, tuberculosis, etc. Any
habitual one-sided position may result in a curvature. An injury to the
chest, adhesions from pleuritis, chronic liver disease, obliquity of
the pelvis producing unequal length of the legs, carrying heavy weights
on one side, and various morbid growths of the chest and abdomen, may
all produce curvatures. Many cases are found in school children who
are growing rapidly, and whose muscular strength and development do
not keep pace with their growth. Unilateral atrophy of the muscles,
due to central changes or overuse, may be the cause of deviations of
the spinal column. Sacro-iliac disease in some instances is a potent
factor. Thus there may be a great variety of causes productive of the
incipiency, and the spine being strained or irritated at a single point
and in a certain way gradually develops a curvature. Every spinal and
innominate lesion should be considered as a potential cause for a
curvature.
=Scoliosis.=—This is the most common spinal deformity and is
characterized by lateral deviation from the median line. In most
cases the curve is to the right in the upper dorsal region, with a
compensatory curve in the opposite direction in the lumbar region. The
curve being to the right in the majority of cases, is probably due to
the fact that most people are right-handed.
=Morbid Anatomy.=—The vertebræ in the region involved are rotated so
that their spinous processes point toward the concavity of the lateral
curve. The bodies of the vertebræ on the side next to the concavity
are thinner, due to absorption; the intervertebral discs are made thin
on the same side by pressure and absorption. The ribs are considerably
distorted, depressed on the concave side and prominent on the convex
side. The ligaments on the concave side are contracted, and stretched
on the convex side. The muscles on the concave side are more or less
contracted, and on the convex side they are stretched, causing atrophy
and fatty infiltration of their tissues.
=Kyphosis.=—This may be a slight posterior curve really amounting to
nothing, or it may be a very grave pathological condition as in Pott’s
disease. Therefore it is very necessary that one should make a most
careful diagnosis (see Pott’s disease).
The most common =causes= of kyphosis are Pott’s disease, rachitis,
occupation, general weakness, rheumatism and old age.
In Pott’s disease, the posterior curve is characterized by a sharp
angle, and by the spine being very rigid. This, taken in conjunction
with the history and other symptoms should be sufficient to enable one
to make a diagnosis. Radiographic examination should be made.
The condition of round shoulders, which in time produces marked
kyphosis, is rarely a habit as it is usually termed. In nearly every
case it indicates either a weakness of the back muscles or, what is
more apt to be the cause, a strained posterior condition of the dorsal
vertebræ, commonly of the lower dorsal region.
=Morbid Anatomy.=—In mild cases there is simply a relaxation of the
ligaments of the vertebræ and a separation of the laminæ and spinous
processes. In severe forms there may be absorption of the anterior
portion of the intervertebral discs and the bodies of the vertebræ
(Pott’s disease).
=Lordosis.=—This may be a congenital condition, especially when
occurring in the lumbar region. Anterior curves of the spine are
generally found in the lumbar or cervical regions, but occasionally
occur in the dorsal region, causing the spinal column to be more
or less straight, and thus weakening the individual. This curve is
commonly compensatory to kyphosis, hip-joint disease and congenital
dislocations of the hip.
=Treatment= of =Spinal Curvatures=.—The treatment of pathological
curves of the spinal column, by osteopathic methods, has been highly
satisfactory to both osteopath and patient. The success of the
osteopath in these cases has been due to his comprehensive and exact
knowledge of each vertebra, and of the spinal column in general. He
recognizes curvatures that the ordinary practitioner, and it is safe
to say the orthopaedic specialist, would not even notice or recognize.
On account of the highly developed sense of touch of the osteopath,
he is capable of detecting the slightest deviation of one vertebra
from another, and of the spine in general from the normal. Thus by
the uniqueness and peculiarity of his work he is capable, not only of
discovering a curvature, but also of reducing a curve when found.
The work consists of, first, relaxing any muscles that may have become
rigid over the seat of the curve. Then follows a treatment to each
vertebra involved, by attempting to replace it, and treatment to
the curve in general by springing it toward its normal position. At
each treatment effort should be made to accomplish something toward
correcting the spine; too many treatments are given in a “general”
way, and being unspecialized amount to nothing. One must become
familiar with the exact location of each vertebra involved, to attempt
a correction of a curvature intelligently. Upon this one point it is
impossible to speak too strongly, for a great many treatments have been
wasted and improvement of cases retarded by not paying enough attention
to the details of the diagnosis, either from pure slothfulness or from
an imperfect conception of osteopathy. Corrective exercises are always
of value in addition to treatment.
These remarks refer to incipient and certain moderate curvatures.
In other cases radical measures (Abbott) should be employed if age
and conditions permit. Remember, however, that the practitioner in
his daily work of adjusting the many combinations of rotation and
sidebending lesions corrects innumerable actual and impending curves.
=Lateral curvature= in the dorsal region is undoubtedly the hardest
to correct on account of the ribs, which complicate the condition.
A marked curve in the dorsal region is sure to be accompanied by a
dislocation of the vertebral end of one or more ribs. Treat each
distinct lesion separately, follow by general stretching, replacing and
molding of the tissues. A good method to stretch tissues and adjust
a moderate lateral curve is to utilize the swing, or in lieu of this
have the patient stand just at arm’s length from the wall with concave
side toward the wall with straight arm at right angles and palm resting
against the wall. Stand in front of patient whose feet are firmly on
the floor and reach around with both hands upon the spine. As the
patient sidebends toward the wall it tends to correct the deformity, so
if the operator coordinates his adjustment with that lateral movement
of the patient, precise fulcra can be obtained and a certain, definite
correction secured. The significance rests with the stretching of
tissues and the definite fulcra obtained, thereby securing a maximum
sidebending and rotation toward correction.
The =dislocation= of an =innominate= sometimes complicates matters, but
is a simple point to remedy, and should not be overlooked.
The correction of a curvature presents a special study to the
osteopath, whether it be scoliosis, kyphosis or lordosis, and special
rules cannot be laid down for treatment. Cases of rare occurrence are
what might be termed “symmetrical” curves; i. e., no vertebra presents
separately a marked lesion, the column on the whole being simply bowed.
Such cases can be treated by springing back the spinal column, and by
the use of methodical exercises. Unfortunately most curvatures are
characterized by various lesions between the vertebræ, and thus each
lesion requires special work.
In simple curves the use of braces, jackets, and the various mechanical
appliances are of very little use to the osteopath, in fact, more
harmful on the whole, than beneficial. Naturally they would apply to
a “symmetrical” curve, or where the patient is too weak to sit or
walk, but they can be of very little use to the average patient, in
place of correct osteopathic treatment. Mechanical appliances confine
the movements of the patient, interfere with the development of the
muscles, and impinge to a greater or less extent the spinal nerves.
Due attention to hygienic surroundings and diet are certainly of aid.
Proper exercises and occupation for the sufferer should be advised.
Special care should be taken in examining (radiographic) for infectious
lesions (arthritis).
=Straight Spine= is a term used particularly by osteopaths for a
condition seldom recognized by orthopedic surgeons. The following
is from H. W. Forbes[40]: Straight spine is “a departure from the
normal in the conformation of the chest; characterized anatomically
by bilateral diminution in size, decrease in the antero-posterior
diameter, relative increase in the transverse diameter and flattening
of the anterior and posterior walls; characterized clinically by
diminution of respiratory capacity, lowered lung and heart resistance,
impaired general nutrition and predisposition to neurosis.
“Of the many possible manipulations that may be used to lift and
overcome the morbid bend of the ribs I will attempt the description of
but one.
“Relax the musculature of the back and chest. Rotate, flex and extend
the dorsal spine. Examine all the ribs on each side and loosen any that
do not move freely. Having done this, the patient is prepared for the
specific treatment. Have the patient sit on a stool and lean forward
on a table. Have him separate the elbows, flex the forearms, place one
hand over the other and his forehead on the hands. Tell him to relax
all the muscles of the shoulders and arms and to breathe deeply without
using the muscles. After a few trials he is able to fully expand his
chest without contracting the muscles connecting the upper extremity
with the trunk. The physician then takes a position at side (either
side) of the patient and places the weight of his trunk on the ribs of
the side he is on, a little external to their angles. He passes his
arms around the patient’s body; the arms passing across the front of
the chest are carried around far enough to allow the hand to be placed
on the ribs just external to their angles. The other hand is placed
on the top of this one. In this position the physician’s body on one
side, and his hands on the opposite, occupy similar positions. The
patient is now told to inspire deeply and at the same time to relax
the shoulder muscles, as before instructed. As the chest expands drop
the weight of the trunk on one side and make pressure forward (forward
meaning toward the anterior surface of patient’s body) with the hands
on the other side. This lifts the ribs to a greater extent than the
patient unassisted could lift them. At the end of inspiration and
during the first third of expiration the chest is compressed laterally.
The compressing force, if applied correctly, will fix the ribs in a
position of less obliquity and will also correct the increased lateral
bending of them. The dorsal spine becomes more convex posteriorly
at the moment of lateral compression of the thorax, if correctly
made. Great force should not be used at the beginning. Repeat the
manipulation five to twenty times each treatment. Give treatment three
times a week. A similar movement may be given on the table.
“The greater number of flat chests in patients under thirty years
of age may be corrected. If the patient is above thirty, although
complete correction may not always be accomplished, the results are
satisfactory. Two to six months treatment is required.”
=A “typhoid spine”= comes as a sequel to typhoid fever. There is
constant pain, tenderness along the lumbar region and rise of
temperature. The pain is generally increased when the spine is moved
forward or sidewise. Such a condition is clearly understood by the
osteopath. There are always found distinct vertebral lesions along
the region that is tender on pressure. In fact these very lesions may
have been the predisposing cause of the attack of typhoid fever.
The treatment is rest and the indicated manipulation to correct the
derangements. It is of great interest to note that where the typhoid
patient is treated osteopathically the condition just described seldom
results. Observations by C. M. T. Hulett confirm this statement.
The =Neurotic Spine= may be the result of injury but the subject is
usually of a nervous, neurasthenic type. It occurs from the age of
puberty to adult, much more often in females than males.
The patient has dull pain in the back of the neck or in the lumbar or
sacral region, complains of a constant tired feeling and often of a
sharp neuralgic pain in certain parts of the spine. Generally there is
a drooping posture in the upper dorsal with shoulders thrown forward,
which is a sign of weakness. There is extreme tenderness along the
spine and usually the pain is confined to the sensitive places.
Treatment consists of a constitutional toning up, and increasing
muscular strength through judicious exercise. The posterior curve may
be pushed toward the median line by laying the patient on the face;
also with the knee in the back and the flat of both hands on the
sternal ends raise the ribs; or by the arms making use of the pectoral
muscles accomplish the same result. Deep breathing is also effective.
Relief can usually be given and a cure will depend upon the patient’s
general condition.
The =Hysterical Spine= is usually considered the same as the neurotic
spine, but there are many cases which have the sensitive spine without
being hysterical. There is more deformity usually present, particularly
in the lumbar region. Probably there will be a history of some injury.
The treatment is to correct the curvature and build up the general
health. These conditions are stubborn and progress is slow. In both the
neurotic and hysterical spines the ligaments of certain areas will be
found atonied and relaxed. This is especially noticed upon attempting
to spring a group of vertebræ when all of a sudden the section relaxes.
In either of these spines the lesions will irritate or obstruct nervous
courses, produce venous stagnation or arterial starvation, and disturb
lymph channels. H. F. Goetz has observed that in functional nervous
diseases the dorsal spine is flat, while in visceral displacement the
dorso-lumbar spine is posterior.
The =Spine of the Aged= wherein is found stooped shoulders and a
rigid spinal structure, can be distinctly improved by slow, cautious
traction. This tones weakened muscles, releases contractures, separates
the compressed intervertebral discs, and definitely tones the viscera.
Careful work is imperative.
FOOTNOTES:
[40] Journal of the American Osteopathic Association.
POTT’S DISEASE
An article on Pott’s disease does not really come within the province
of a practice of medicine. Still it will be acceptable to the
practitioners and students of osteopathy, as one of the objects of
osteopathic work is to improve, not only medical and obstetrical
practice, but also surgical practice, and besides the osteopath will
have many cases of spondylitis to treat. “Pott’s disease, or caries
of vertebral bodies, was first described by Percival Pott in 1779. It
consists of a destructive ostitis affecting the spongy tissue of one
or more of the bodies of the vertebræ. The ostitis is tuberculous, and
is similar in character to tubercular ostitis seen in the epiphysis
of the long bones. Owing to the superincumbent weight of the head
and shoulders pressing upon the carious vertebral bodies, the spine
and trunk become peculiarly and characteristically distorted. The
morbid process is limited, as a rule, to the bodies; the transverse,
articular, and spinous processes are rarely primarily affected.” (Park).
The first consideration in the =treatment= of Pott’s disease is rest.
If the disease is a progressive one, rest in bed in the recumbent
position is necessary. Naturally, the object of the treatment is to
secure resolution of the tubercular ostitis as soon as possible. To
do this, careful manipulative treatment should be applied to the
diseased vertebræ. The treatment must not be harsh, for there would
be danger of greater irritation to the parts, and possibly infected
particles from the destroyed tissue might gain entrance to the vascular
system. The osteopath must be extremely careful how he manipulates
the spinal column in Pott’s disease. The object of the manipulation
is not primarily to overcome the deformity, as some may think such an
act possible, but to separate the vertebræ enough to allow a freedom
of the circulation, and to remove impingements of the nerve tissue.
It is impossible to overcome the deformity to any extent when part
of the body of the vertebra is destroyed; but if one could treat the
case at the incipiency, most probably deformity would be prevented.
There is another danger in treating cases too severely, and that is
causing exhaustion of the patient. Treat the spinal column not only
to separate each articulation slightly, but to carefully crowd the
diseased vertebræ toward their normal position. When the disease is
in the dorsal region, considerable attention has to be paid to the
ribs, as they are invariably involved when the spinal curvature is
great. Hence it is necessary to treat each rib separately, and try to
correct them at least, and remove any obstruction to nerve fibres or
vessels that may be found. One of the strongest arguments against the
indiscriminate use of braces, jackets and various mechanical appliances
in spinal deformities, is that they tend to straighten the spine, by
simply crowding the vertebræ and ribs as a whole into place, besides
interfering with the cutaneous circulation. The osteopath should
realize that each vertebra and rib has to receive special treatment,
in order to correct the spinal column, and that mechanically exerting
pressure upon all the vertebræ at one time tends to lock the vertebræ
and ribs all the more securely. It is like trying to correct a certain
subdislocation of the cervical vertebræ by pulling and twisting the
neck instead of applying specific treatment—the lesion is all the more
firmly fastened. Young, in his Surgery, makes this observation: “Like
chronic abscess or chronic bone disease, this affection has its origin
in the fact that the tissues of the anterior parts of the bodies of
the vertebræ have been partly deprived of their nutrition because of
luxated ribs or subluxated or twisted vertebræ.”
After the tissue destruction has been limited, and the deformity
corrected as much as can be, an ankylosis should be secured if
possible. Promotion of ankylosis depends altogether upon the preceding
treatment—rest and an improved nutrition of the parts. A truss or
brace, if correctly applied, is often beneficial in such cases. The
treatment of spinal abscesses is entirely in accordance with surgical
treatment.
In all cases the general health of the patient has to be well taken
care of. The osteopath must not be over zealous for quick results.
It takes many months to perform a cure; however, there is always
a tendency toward a cure. Treatment of the spinal muscles and of
the limbs, and pure air, sunlight, massage and good food are very
necessary.
SPRAINS AND FRACTURES
SPRAINS
The osteopath is often called upon to treat sprains of various
sections of the body as well as to relieve after effects of fractures
and restore function to the part. The osteopathic treatment is very
effectual; therefore, an outline of the purpose and method is given.
Sprain is defined by Dorland as “the wrenching of a joint with partial
rupture or other injury of its attachments, and without luxation of
bones.” From an osteopathic viewpoint the above definition is not
fully explanatory, for there is in most cases a partial luxation of
the bones. The most common cause of a sprain becoming chronic is the
presence of partial bony displacements. Rupture of tissues may be the
cause of a chronic state but is not nearly so frequent as the bony
dislocation. In most sprains, the wrenching causes a displacement
of the bony tissues, which may or may not return to normal position
and relation. The function of the muscles is not primarily to hold
the bones in place; this is left to the ligaments, so when a wrench
of a joint is so severe as to cause rupture of muscles or tearing of
ligaments, partial luxation of the bones is almost certain to follow;
and even where such damage does not occur a change in the relation of
the bones is a frequent occurrence.
Unless a sprain can be seen very early it may be difficult to detect
just what has happened; whether it rests with a rupture of the areolar
and connective tissues, a displaced cartilage, tendon, or bone, a torn
ligament, or ruptured muscle. Hemorrhage and swelling take place so
rapidly that no time should be lost in critically examining the joint.
When in doubt as to the structural disturbances, particularly in acute
cases if there is a possibility of a fracture, and in chronic cases any
supposition that tubercular involvement is present, have a radiographic
examination.
There is comparatively little to be found in medical literature
relative to the =pathology= of sprains. Probably Moullin in his
excellent monograph on Sprains has given as good an outline as can be
found[41]. He says that “generally speaking, the tissues on one side
of a joint are overstretched and torn; those on the other compressed
and crushed together; but there is always so much twisting, and such
a difference in the strength and power of resistance of various
structures, that unless the part is examined with the greatest care it
is almost impossible to say what actually has given way.” Hemorrhage
due to torn vessels is the cause of most of the swelling within the
first few hours. Later on, there is considerable lymph mixed with the
blood. There is not only extravasation of blood into the surrounding
tissues but also into the synovial wall and cavity. This causes
considerable irritation and pain owing to the roughening of the
membrane, and the joint becomes inflexible. And if the joint or any
strained tissue is kept too long at rest the mass becomes organized and
is the cause of much discomfort and annoyance.
Similar changes may occur in the bursæ due to the extravasated blood.
Strong ligaments may be torn across, but not frequently. The tear
is usually a separation from the bone. Occasionally interosseous
ligaments, as for instance in the knee, may be injured.
The muscles may be severely torn, but more often they are “hurt by
their own sudden and spasmodic effort at recovery than by anything
else.” In a few cases the tendons and muscles will be found bruised,
lacerated, and dislocated.
The veins occasionally rupture and thus results more or less effusion,
so that rigidity and edema may persist for a long time. The bones are
very frequently damaged. This may be a simple bruising of the tissue
but more often, as osteopathic diagnosis shows, there is partial
displacement of the bony structure.
A point of great importance that every experienced osteopath will
agree to is the following from Moullin: “Diseases of the spine, hip,
and other joints in children may be due, in great measure, to some
constitutional taint, though it is open to question whether the
influence of this is not overrated; but it is quite certain that the
immediate starting point in nine cases out of ten is some chance
sprain, often so slight as scarcely to have been noticed at the time.”
Before treating a sprain there are one or two points the osteopath
should carefully note: first, that there is no complicative fracture;
second, in children that there is not an epiphysial separation; and,
third, note peculiarities of a constitutional character that would
complicate matters. Whatever is done, always give the patient the
benefit of the doubt.
If the patient can be seen early, before swelling has reached the
maximum, many times a very quick cure can be secured. Do not at
once put the part at rest and apply cold, but examine the sprain
most carefully and thoroughly and readjust first of all any bony
defects; then replace the softer tissues if displaced, and next relax
contractions; follow this by light massage and passive movements to
reduce and combat hemorrhage and swelling. This treatment alone in
a fair percentage of cases will be all that is necessary provided
frequent subsequent treatments of massage and passive movements are
continued to reduce and counteract inflammation and to prevent rigidity
and stiffness of the softer tissues. Where the osteopathic treatment is
distinctly indicated is in the readjustive manipulation. This is the
reason why the treatment is so efficacious, and the patient is cured in
a fraction of the usual time, and few sprains result in complications
and become chronic. In sprains that have become chronic there will
be found almost invariably some osseous tissue slightly displaced.
After correcting this, apply careful and thorough manipulation and
massage and movements to break up adhesions, to remove effusions and
extravasations, to relax muscles, and to promote normal circulation.
Care should be taken that there are no displaced cartilages, ligaments,
tendons, or muscles.
It is well to keep in mind that the osteopathic readjustive
manipulation is not an exercise or movement, but definite, specific
correction of the tissues anatomically. Do not treat the displacement
by any general “pommelling,” but apply the mechanical principles
indicated as in any dislocation. This will mean much to the patient in
more ways than one, and especially so should the sprain be so severe
and complicated as to demand anesthesia for correction.
There is no objection to the employment of cold and heat; in fact, both
are beneficial. Cold to prevent extravasation and swelling, and heat to
remove and relieve the same, is a sound and practical method. But do
not apply a wet bandage. Pouring cold water over the sprain is the best
method; even better than immersing the part. An ice bag is another good
way to apply cold. When the skin begins to look blanched and dull the
maximum amount of benefit has been secured. Heat at the very first may
be employed instead of cold, for it has a tendency to prevent bleeding
and inflammation, but the temperature of the application must be hot as
can be borne or else the desired effect will not be obtained. Later on
to relieve pain and rigidity, and to relax the muscles so that a better
circulation will be secured, moderate heat will be beneficial. Then the
application of heat and cold alternately will be of service, employed
as a douche for a tonic effect, when the part is weak, inactive,
and powerless after the elapse of several days. It should always be
remembered that the employment of heat and cold is only of temporary
benefit, so if used too long opposite effects to those desired will
result.
Bandaging the sprain may be helpful, but not always. Great care should
be taken as to how pressure is applied. Bandaging from periphery
toward the trunk, seeing that the bandage is smooth, and padding all
depressions so that the bandage does not touch bony prominences only,
are necessary. Unless the bandage is applied so that an even pressure
is secured, the material used not too warm, and the bandage attended to
each day, the effectiveness will amount to but little.
Next, do not make the mistake of resting the injured joint too much.
The function of a joint is movement, and it has been observed that
prolonged rest of a healthy joint may result in rigidity, stiffness,
and distension of the soft part, and even serious organic changes
in the ligaments, synovial membrane, and cartilages have occurred.
Consequently continued passive movements should be kept up from the
inception of the injury, although it must not be carried to extremes
so that inflammation, hemorrhage, or laceration will be aggravated.
Moullin says: “As a rule, passive movement may be commenced from the
second day with the certainty of preventing adhesions, and without
the least fear.” Osteopathically, with due attention to readjustive
manipulation, and care as to correct position and rest, passive motion
will be allowable usually from the first day.
There is much corroborative evidence in current medical literature that
bears in a general way upon part of the foregoing. The International
Text Book of Surgery says: “Massage should begin early, in order to
avoid, as far as possible, weakness of the muscles, and to ensure
security to the position of the joints by the retention of a proper
tone in them;” besides, early movement tends to reduce the effusion
into the tendon sheaths around the articulation, which in some cases,
particularly the ankle and wrist, may be a very prominent feature. The
Reference Hand Book of the Medical Sciences voices the same opinion;
and Mumford is referred to as follows: “Immobilization for more than
a few days, as under the older methods, is objectionable because
adhesions are apt to form, thus causing impairment of function, and
because when there is a =tubercular taint=, proper conditions for a
localized tuberculosis are established.” Among other statements Holder
Sneve in the Journal of the American Medical Association of June 1,
1901, says: “Immobilization of muscles is not rest. On the contrary,
in all sprains the muscles should have passive exercise the first few
hours and days, and active exercise after that. In the majority of
cases active exercise should be instituted from the beginning. The
plaster cast should not be used at all, even in cases where we have a
fracture, unless it be impossible to maintain a proper position of the
joint.”[42]
Again quotation is made from Moullin. These quotations are taken
from the chapters on Manipulation and Massage. It will be observed
he makes a distinction between the two methods. And the osteopath
should carefully keep in mind not only the difference between the two,
but beyond these the more fundamental treatment, readjustment. The
characteristic feature of osteopathy is anatomical readjustment, and
this in sprains should be supplemented by massage (superficial work),
and also manipulation (deep and more or less forcible work) in order to
remove stiffness, rigidity, and fibrous ankylosis.
The following is relative to forcible manipulation: “Manipulation
is much more useful than division; it can be employed for such a
variety of purposes. In the early stages it prevents the occurrence of
stiffness or the formation of adhesions. Later, when the swelling and
heat have disappeared, it is no less successful in restoring freedom
and ease of movement, and afterward, when all mechanical obstructions
have been cleared away by its use, it is one of the most effectual
methods known for bringing back the circulation and nutrition of the
part, and giving again to the muscles and nerves the energy which has
so long been wanting....
“To carry this out effectively two things are needed beyond all others.
The one is a sense of touch so delicate that it can appreciate the
least resistance or irregularity of movement; the other an accurate
knowledge, not merely of the ordinary anatomy of the part, but of
the different degrees of tension that fall on the ligaments in every
position of the limb.
“Each joint requires a different kind of manipulation according to its
construction....
“There should be no jerking. The movements must be vigorous and
forcible, but perfectly smooth; and they must be carried out
thoroughly, the joint being moved to its full extent in all directions
that are natural to it. Each kind of action should be combined
successively with the rest, one by one, so that the tension may fall in
turn upon all the different parts of the capsule.
“Movements which are especially restricted or painful, of course
require most attention, but the others, though they may not be affected
to the same extent, are not to be neglected. It sometimes happens if
these are dealt with first, that a considerable proportion of the main
obstruction is cleared away, as it were, by side attacks, so that when
its turn comes it yields more readily than it otherwise would.
“Recent slight adhesions give away at once without a sound, though the
sensation is generally conveyed to the hand. When they are older the
noise may be as loud and clear as when a bone is broken....
“The after treatment of these cases (cases where there has been
tearing and breaking of adhesions) should be in all respects the same
as that of a recent sprain, only if passive motion at an early date
is advisable to prevent the occurrence of stiffness in the one, it is
absolutely necessary in the other.”
The following pertains to massage of sprains: “Massage, in the strict
sense of the term, is a great deal more efficacious, especially with
older sprains. Its action is not limited to the skin and superficial
structures. These undergo immense changes, it is true; they become
softer and finer while under manipulation; their strength and
elasticity increase, the extreme tenderness diminishes, and the natural
appearance and texture return. The surface loses its dry, harsh
character and becomes warm and moist again; the livid bluish color
gives away to a brighter hue, and the deeper layers of fibrous tissue
yield and stretch, so that the hide-bound, shrunken condition that is
often present after long disuse gradually passes off. But the good
effect is not by any means limited to, or even most conspicuously shown
by, this. When properly carried out, massage exerts a simultaneous
influence on muscles, nerves, and vessels; in fact, on all the tissues
within its reach.
“The circulation is the first thing to feel its power. It has already
been explained how, after prolonged rest, the blood, as it were, lies
almost stagnant in the tissues, slowly circulating through them, and
neither giving them sufficient for their nutrition, nor removing from
them the waste products of their action. This is changed at once. The
life of the part is quickened. The veins and absorbents are emptied
first, and the fluid they contain driven out into the heart, which
fills more rapidly, and contracts more vigorously and firmly. Then
the pressure falls in the smaller vessels, and the tiny irregular
spaces, full of lymph, which extend in all directions through the
tissues. These, in their turn, are compressed and mechanically emptied,
their contents being driven on into the empty vessels, from which any
backward flow is prevented by the valves. The circulation becomes more
rapid; nutrition is carried on with greater energy, and the actual
amount of the blood in the tissues at any one time so much increased
that they become full and soft to the touch and regain the even and
rounded contour of active health....
“It is most essential to commence as gradually and as gently as
possible, working on the deeper tissues only after the more superficial
ones have become thoroughly accustomed, and have been unloaded of their
surplus fluid. The skin, the soft subcutaneous tissue, the muscles,
and the deeper layers, must all be worked in turn. Nor should the
manipulation be confined to the injured part. In a sprain of any
standing, the whole of the limb is affected more or less. It is usually
better to devote attention first to the parts nearer the trunk than to
deal with those around the injured area, and only afterward, when the
circulation is thoroughly reestablished, to manipulate the joint itself.
“The tendency is to make the sittings last too long. Deep manipulation
itself rarely requires more than =five minutes=; but in dealing with
a recent injury it may be advisable to spend a longer time than this
over the friction and other preparatory measures, so that a quarter
of an hour soon passes by. When the tenderness is very great, and the
amount of swelling excessive, much longer than this may be necessary,
but short, frequently repeated sittings are of greater benefit than one
long one. A skillful operator, too, will often effect more in a few
minutes than an ordinary rubber will in as many sittings.”
A summary of the general treatments of sprains would be as follows:
1. Readjustment of parts and removal of obstructions. Osteopathy is
especially adapted in these cases, for two of the primal therapeutic
factors in all cases from an osteopathic viewpoint are to readjust the
anatomical and to remove obstructions. One should constantly keep in
mind, “a temporary displacement followed immediately by a return to
place, constitutes a sprain.” The osteopath often finds that a perfect
returning does not take place, and even remote lesions may affect a
joint.
2. Manipulation, and massage of soft tissues, to restore circulation
and to prevent and remove debris from rupture of vessels and
inflammatory products.
3. The employment of cold, heat and pressure, and a certain amount of
rest.
4. Anatomical readjustment and manipulation in chronic cases to break
up adhesions, remove exudates, overcome the organized products of
inflammation, and cure synovitis.
5. Movements both passive and active to stimulate and exercise
functions of the joint.
=The Spinal Column.=—The osteopath is especially cognizant of the
fact that many sprains occur to the spinal column. These may affect a
single joint, or more or less of a section may be involved. The bones,
ligaments, tendons, muscles, or spinal cord may be found injured. Even
distant organs, through involvement of the circulation to the cord, or
through irritation or impingement of spinal nerves and sympathetics,
are frequently disordered. It is not necessary to go into detailed
description, for the points bearing upon this will be found under
Osteopathic Diagnosis, Etiology, and Technique, and the general
description will, also, apply. Readjustment, strapping, heat, massage,
manipulation, ironing, stretching of muscles, fomentation, etc., have
their place. There is no doubt that sprains, strains, and blows to the
spinal column are the cause of many spinal disorders and consequent
visceral disturbances.
=The Ribs.=—Sprains of the vertebral ends frequently occur, resulting
in a partial luxation, stretching of ligaments, contraction of muscles,
and exudative formation in the joint structures, which often is the
cause of irritation to the sympathetic nerves. The costal cartilages
are frequently strained, and may so irritate the intercostal nerve as
to cause considerable pain both locally and reflexly. The treatment is
essentially one of replacement, and relaxation of the softer tissues.
Adhesive strips to limit movement due to respiration may be helpful.
=The Innominata.=—Sprains of the innominata are also commonly met
with. Besides being a source of discomfort to the patient they are
an important cause of pelvic disorders and leg affections. Partial
displacements are the rule, the correction of which gives quick relief.
Where there is considerable spasm of muscles, examine carefully the
lumbar alignment. In chronic cases fibrosis of muscles and adhesions
may complicate matters.
=The Hip Joint.=—Sprains involving the hip joint may be readily
corrected, and again may be the exciting cause of serious involvement.
Previous tubercular disease can be aggravated in this manner, or
syphilitic changes in the joint disturbed. Care should be taken
that there are no complicating displacements of the innominata or
irritations to the spinal nerves. Possibly the hip may be so strained
as to cause a twist of the femur in the socket and thus simulate a
partial dislocation; this, in fact, would probably be termed a partial
dislocation. Strain of one set of muscles about the hip joint is
somewhat rare, and spinal lesions may disturb the innervation to one
set of muscles. In cases of =intracapsular fracture= considerable can
be done by careful massage and manipulation after union has taken
place, to secure greater freedom of movement and strength of the limb.
Likewise in =hip-joint disease=, after the disease is healed, massage
and manipulation will be very beneficial. Care must be taken if the
treatment causes spasticity of the muscles; this shows the treatment is
irritative and should be stopped until the spasticity has ceased. Where
the limb is shortened from either hip-joint disease or intracapsular
fracture apparent lengthening may be secured by careful abductive and
hyperextensive stretching.
=The Knee.=—The knee is the most complicated joint, and sprains are
apt to be very serious. The usual treatment for sprains is employed.
Occasionally the semilunar cartilages are displaced and may be a
source of difficulty in diagnosis; likewise injuries to the patellar
tendon and lateral ligaments. Another joint frequently overlooked is
the innominate. In a number of knee cases that terminate in chronic
synovitis there will be found a displacement of the innominate that
is preventing recovery. A villous synovitis may arise in strains from
faulty posture, especially in the obese. Injury to the hip-joint, also,
may cause strain or irritation at the knee. Occasionally tender points
about the knee, especially at the inner side, are due to irritation at
the hip, or possibly from the spine. Referred pain of the knee joint is
of frequent occurrence.
=The Ankle and Foot.=—The ankle is often sprained. One should examine
carefully for a possible fracture of the malleolus, and for fracture of
the tibia. There may be a dislocation of the fibula, also a separating
of the tibia and fibula at the ankle. The common bony displacement
takes place between the astragalus and os calcis. Then the cuboid is
frequently displaced, and occasionally the navicular. The treatment
should first of all be directed to correction of the osseous lesions.
The arch of the instep may be weakened from the ligamentous strain and
be an immediate step in the production of =flat foot=. Teall is of the
opinion that lumbar and innominate displacement are common predisposing
causes. Faulty position of the foot in walking may be an underlying
factor.
=Bunions= result from a malposition of the joint. =Morton’s disease=
due to a pinching of the metatarsal nerve will often yield to
osteopathic treatment alone. There is generally displacement of the
metatarsal bone. A pad worn directly under the painful point will be of
benefit. In many of the local neuralgias, some anatomical displacement
will be found as the exciting cause. =Hammer-toe= if not complicated
with gout, rheumatism, etc., will yield to treatment if kept at
persistently, otherwise surgical interference will be necessary.
Likewise various deformities of the foot and resulting neuralgias
may be traced to local sprains, ill-fitting shoes, or anatomical
maladjustments higher up of such a character as to affect the pedal
circulation.
Flat Foot
Flat foot or weak foot is one of the common disorders that the
osteopath is constantly called upon to treat. In the first place
the patient should be taught to walk correctly. The feet should be
parallel in walking so that the weakened muscles may be developed and
strengthened. This will be difficult at first, but recovery depends
upon this important point. In addition to this, special exercises, like
turning the toes under and tip toe exercises, should be persisted in
for a few minutes two or three times daily. Upon the other hand, do
not overdo the exercises but always carry them to a point of fatigue.
These two features, walking correctly and exercising, are essential
complementary measures to the adjusting treatment. In conjunction
with the above, the Scotch douche at the end of the day will prove of
considerable benefit.
In the technique work, first make certain that there are no innominate
or spinal lesions that bear upon the circulation and innervation of the
feet. Then frequently faulty walking is due to these lesions.
In recent cases, simply remolding the arches of the foot will be all
that is necessary, providing correct walking and foot exercising is
maintained. But in the more chronic cases considerable adjusting and
remolding of the tissues, bones, ligaments, muscles and fascia, are
demanded. Perfect apposition between the astragalus and navicular
bones, the highest point of the longitudinal arch, should be first
secured. Attention should also be given the other articulating
structures down to the metatarsal bones. This reestablishes the arch
and overcomes the everted tendency. Considerable repeated force is
often demanded to release the fibrotic tissues, but it is the important
part of this technique.
With the patient on the table, supine, place your thumb firmly at the
articulation of the navicular and astragalus. Then with the other hand
around the metatarsals to be used as a lever in extending, rotating
and inverting the foot with the fulcrum at the thumb of the first
hand, spring, thrust and adjust the arch. This requires considerable
strength and exactness of application. The tissues must give freely
before the result can be secured. This is often painful to the patient
but should be continued and repeated to the furthest point of motion
until recovery is complete. Treat as often as the condition permits.
Substituting the crotch of the thumb and forefinger or the knee for the
thumb will give added advantage. Follow this with thorough springing of
the plantar tissues by thumb and fingers.
If this is kept up with suitable exercises and correct walking, and
proper shoes (Munson last), excellent results will be obtained in the
great majority of cases. Same pair of shoes should not be worn two days
in succession.
Many times the anterior arch is involved, jointly or separately.
Persistent adjusting and remolding of the arch tissues will secure
satisfactory results unless the bones are markedly deformed and the
weight of the body is relatively too great. In this disorder, aside
from paying special attention to the metatarsal articulations, the
great toe requires a particular technique. For this grasp the toe
firmly, exert traction until the tissue gives slightly and rotate it
inward, toward the median line of the body, on its longitudinal axis.
Have the patient frequently turn the toes under, or attempt to do it
until the exercise can be easily accomplished.
Do not employ arch supporters except in hopeless cases. They simply
splint the foot and thus further weaken the foot muscles. If the above
methods are persistently followed to the point of actual adjustment,
accompanied by releasing of fibrous tissue and actual strengthening
of muscles through exercise, a very large percentage of cases will
recover. In a few cases adhesive strips will be of benefit.
=The Shoulder.=—Exclusive of muscular and other strains there may be a
partial dislocation. In these cases the acromial end of the clavicle is
frequently dislocated, and owing to a general lack of muscular tone may
be very hard to keep in place. The lower and inner part of the capsule
is often affected, so that freedom of function is lacking and there is
considerable pain. This is due to the thinness of the capsule and the
large amount of soft tissue, so that when the arm hangs at the side the
tissue is thrown into folds; and being very vascular is easily injured,
so that the vascular lymph readily organizes and the part becomes stiff
and unyielding. It requires patient, laborious treatment to break up
and absorb this fibrous tissue. Then the long tendon of the biceps in
some shoulder sprains is dislocated, but rarely. In shoulder injuries,
examine also, the upper ribs.
=The Elbow.=—The elbow is another complicated joint. One should be
careful that there is no fracture, and in children that there is not
=epiphysial separation=. Extending, flexing, pronating and supinating
the arm will aid much in the diagnosis. Examine well the rotation of
the radius at the elbow joint, and be positive that the olecranon
process drops normally into its fossa at the end of the humerus.
=The Wrist and Hand.=—The wrist is another joint commonly sprained.
Here, also, care should be taken that a fracture does not exist.
Colle’s fracture is frequent. The bursal and tendon sheaths are usually
markedly involved. The scaphoid and semilunar are apt to be displaced;
also, the os magnum and the unciform.
Sprains of the =fingers= are often met with. Outside of strains to the
muscles, ligaments, and other tissues the joint is apt to be somewhat
impacted. Traction will correct the latter. Care should be taken that a
fracture is not present. =Dupuytren’s contraction= occurs from sprains
or injuries, as the result of contraction of the fascia. The ring and
index fingers are members usually affected. In some cases the affection
will be found in both hands (symmetrical), and a spinal lesion will
be the predisposing factor. Treatment every day, by straightening the
fingers and stretching the tissue will at least retard the deformity,
but in a number of cases surgery will have to be resorted to.
A =ganglion= or “weeping sinew” is a swelling in connection with the
tendon sheath. It presents a round, firm outline, usually upon the back
of the wrist. There is generally found a displacement of one or more
of the wrist bones. If treatment of the joint and tendon sheath does
not remove the ganglion, surgery may be utilized. =Trigger-finger= is
a rare disorder. There is usually a history of local strain, which
probably resulted in some thickening of the tendon. Manipulation and
passive motion if continued will generally give relief.
Fractures
Immobilization and rest have been the paramount points with most
physicians in the treatment of fractures and sprains. They have claimed
that a sprain should be manipulated but rarely, much less a fractured
bone. Rest, quiet, and fixation of an injured joint or bone have been
rules that should not be violated under any consideration. In cases
of sprain the great cry has been to let the joint alone for fear of
spreading a possible =tubercular infection=. It is well to recall
Mumford’s statement that if immobilization is too long continued,
should there be a tubercular taint, proper conditions for a localized
tuberculosis is established. And still a word of caution here, that an
osteopath should not be over zealous and should carefully weigh all
possible factors, both local and constitutional, may not be amiss. In
previous tubercular, syphilitic, and other diseased states discretion
should be employed.
Reducing rest and immobilization to a minimum means much to the
patient, not only in the loss of valuable time but in annoying and
serious after effects. Many cases of sprains and fractures come to
the osteopath. In sprains that have become chronic through too much
rest of the part and improper treatment, almost invariably there is
found displacements of bone and adhesions that should never have
existed; then has followed organized exudates and chronic synovitis. In
fractures and even in complete dislocations the osteopath continually
observes that too much rest has been given the part, resulting in
unnecessary adhesions, contractions, atrophy of muscles, and impairment
of function. Treatment almost always cures the condition, or at least
materially relieves. How much better if the proper treatment had been
first instituted and thus a large percentage of cases prevented from
becoming chronic.
Of particular interest to the osteopath is the paper prepared by
Eisendrath on “Early Massage and Movements in the Treatment of
Fractures and Sprains,” and the discussion that followed before the
Chicago Medical Society. The Illinois Medical Journal, December, 1903,
contains a report.
Eisendrath said in part: “The former routine of immobilizing all
fractures and the adjacent joints for a period of four to six weeks
must, I feel, be subject to slight modification in the light of recent
experience, and it shall be the aim of this paper to show what these
changes are. When we are called to a case of fracture, it should be
one’s first duty after its reduction to consider how can I best aid
the patient in recovering the usefulness of his or her limbs? Can we
shorten the long convalescence with its resultant loss of valuable
time and earning capacity? How can we most rapidly restore to the limb
its normal joint functions and prevent an atrophy of muscles and an
ankylosis which will require many months to overcome?...
“The use of massage and of active and passive movements in the
treatment of fractures and of severe sprains has been gradually
gaining in the number of its advocates through the writings of
Lucas-Championniere of Paris. We owe him a great debt for calling the
attention of the profession to the employment of these methods in order
to prevent atrophy and ankylosis as well as to promote healing....
“Before taking up my subject in detail permit me to recall a few
salient points in the surgical pathology of fracture. Soon after the
injury the blood clot around and between the ends of the fragments is
absorbed and replaced by a jelly-like mass of young connective tissue
cells called the callus. It corresponds to the solder which the plumber
places over the ends of two pipes he desires to join. Bone begins to
form at the periphery of the callus about the tenth day and advances
toward the center rapidly, forming a ring of bone around the ends
of the fragments so that by the end of the third week there is but
slight abnormal motion at the point of fracture (exception to this is
the femur). This entirely disappears by the end of the fourth week,
especially in young people, and the union is firm. In the case of the
femur it requires six or eight weeks. The greater the displacement
of the ends of the fragment, the larger the callus and the slower the
healing of the fracture.
“During these changes (callus formation) the muscles which supply
the immobilized joints atrophy and the circulation in the skin and
neighboring tissues is sluggish, resulting in swelling, etc., of the
limb. The enforced rest causes more or less fluid to accumulate in
the tendon sheaths and joints. This becomes organized and results
in fibrous ankylosis of the joints and great impediment to the free
action of the tendons within their sheaths. It is this atrophy, fibrous
ankylosis and tenovaginitis which interfere with the restoration of the
normal functions of the limb....
“Can we decrease the amount of wasting of muscles and control the
stiffness of joints and tendons after fractures?
“It is the belief of the writer, based on a large experience, that the
earlier use of massage, active and passive motions, will to a great
extent eliminate the above conditions, which retard convalescence and
in some cases cause permanent disability.
“Massage of an injured limb increases the amount of blood supplied to
it, promotes the absorption of the swelling and prevents atrophy of
muscles. In the case of a joint injury the exudate rapidly disappears
and the articular surfaces can be again approximated so that movement
is facilitated. By the cautious use of active and passive movements,
either with or without the aid of apparatus, the normal functions of a
joint can be rapidly restored....
“The active and passive movements of the limbs can be carried out
immediately after the massage, but should only be permitted for
a period of =five minutes= at first and the time then gradually
increased. When a severe sprain, say the elbow or ankle, is first
massaged, the pain seems to be almost unbearable, but this discomfort
as well as the swelling rapidly disappears, and it is surprising to
those who have never applied this treatment how quickly the normal
function of the joint reappears. The same applies to the synovitis
which accompanies fractures in close proximity or even into joints.”
The relief given these cases by massage, movements and manipulations
by the osteopath is a daily experience, and results to him are not
surprising. Then in addition to what the surgeon would do, the
osteopath applies his principles of careful detail readjustment.
Eisendrath continues his paper by referring to the principal varieties
of fractures and giving the treatment for each. He says that if correct
treatment is carried out with proper massage and movements in fractures
of one or both bones of the leg, the patient will be at work in six or
seven weeks instead of three or four months, that in Colle’s fracture
some surgeons do not employ a splint, and that in fractures of the
olecranon, massage from the first week on is of the greatest use. This
part is very interesting but space forbids giving it.
He then concludes his article with citation of several very interesting
cases of fractures and severe sprains. These cases are exceptionally
interesting to the osteopath, but still the same good treatment and
results are duplicated every day in the osteopathic school.
The doctor’s contraindications to the use of early massage in fractures
or sprains are the following:
“1. Tendency to displacement of fragments in oblique fractures. Under
such conditions it is best not to begin either massage or movements
until the union is firm (fourth to fifth week).
“2. In compound fractures until the wound is healed.
“3. Whenever the condition of the skin is such as to permit of
infection; for example, the presence of blebs, or extensive abrasions.
“4. The presence of fragments which project but do not penetrate the
skin.”
His conclusions are:
“1. Massage, active and passive motions prevent atrophy of muscles,
tenovaginitis and ankylosis so frequently accompanying and following
fractures, especially those close to the shoulder, elbow, wrist, knee
and ankle joints.
“2. They give far better results than complete immobilization in the
majority of fractures.”
In the discussion that followed Henrotin said that for some time, “I
have never put a restraining apparatus of any kind, nor have I used any
lotions on any sprain, no matter how severe....
“It has taken many years to bring this subject before the profession.
It is a method that is absolutely effective as regards sprains and some
forms of fractures. I have treated several hundred such cases with the
greatest success.” He also said that, “In treating an inflamed joint
it is improper to use a restraining apparatus of any kind. I consider
that the plaster cast is the bane of all inflamed joints unless there
is a =specific form of infection=, a traumatic condition.” Neither does
he believe that an inflamed joint should be put at rest. He says the
patient is a good judge as to the amount of quiet the joint needs. He
has treated Colle’s fractures and fractured clavicles without bandages
or apparatus.
To sum up, the osteopathic procedure in the treatment of fractures
would be as follows:
1. Immobilization in those cases especially demanding it, from the
character of the fracture, until formation assures solid and firm union.
2. Manipulation and massage and movements of parts at an early period,
compatible with the above, to render soft tissues pliable, to remove
stiffness and adhesions, to restore a normal circulation, and to
exercise and function the parts.
3. In cases of laceration of soft tissues, abrasions, etc., great care
should be taken so as not to infect the parts.
4. Great care should be taken where fracture is compound, and where
fragments exist.
5. In all cases, both acute and chronic, critically examine for slight
anatomical deviations locally and remotely.
In dislocations the fundamentals of the above are applicable. Do not
let chronic stiffness, or rigidity, adhesions, or synovitis supervene
if possible to prevent.
An important consideration in all cases of sprains, fractures, and
dislocations that become chronic is the probable effect upon dependent
tissues by way of nerve impairment and vascular obstruction; for
examples, the sprained back may readily impair organic life, the
fractured elbow prevent use of the arm, the injured leg predispose
to flat foot. (See J. B. Littlejohn—Osteopathic Surgery, including
Treatment of Fractures, Journal of the American Osteopathic
Association, Nov., 1905.)
FOOTNOTES:
[41] See also Jones’ latest work, Injuries to Joints.
[42] See also Wharton Hood, Sprains and Fractures.
POSTURAL DEFECTS
A postural defect is any abnormal position, congenital or acquired,
of the body, assumed in sitting, standing or walking. This leads to a
symmetrical development, causes structural changes, and as a sequel,
disturbance of function and organic life results.
Defects in posture are of very common occurrence. A perfect posture, in
fact, is somewhat rare. Considerable is being accomplished, especially
of late years, by the laity through various physical methods and
exercises to correct the many defects of position in sitting, standing
and walking. The originators of the many so-termed systems of exercises
have gone so far as to even advertise to cure various diseases of the
body as well as attempting to improve the normal tissues and structure.
Exercises, undoubtedly, have their place, particularly in the life of
those of sedentary habits. Most of us do not exercise enough, neither
do we as a rule get enough fresh air and pure water. But there are many
defects of the anatomical that mere gymnastics can not adjust. And
there are still other defects that gymnastics may decidedly aggravate.
In these cases the mechanism of the body has become so deranged and
disturbed that nothing short of actual readjustment can be effective.
In the consideration of postural defects there are a few points that
should be particularly emphasized. First, these defects may not only be
the result of laziness or carelessness, but of more frequent occurrence
is some previous strain or injury to the spinal column or other parts
of the body framework. Some defect of position or symmetry of the body
may easily follow as a result. Here gymnastic work may reduce the
defect to a minimum, but rarely can the compensatory forces of nature
entirely obliterate the structural disorder, unless assisted by actual,
specific readjustment. Second, in the examination and treatment of the
patient due attention should be given the symmetry and figure of the
body as a whole so that relation of the part to the whole and _vice
versa_ may be rightly proportioned. Remember that the spinal column
is only one part of the body outline, thus one should consider the
transverse section of the body in relation to the spinal column and
not the spinal column alone. In a word, correction of postural defects
implies both structural rearrangement and molding of the contour. Do
not make the mistake, for example, when correcting a deformity that
involves the chest, of paying attention to the spine alone, but take
into consideration the thorax as a whole of which the spine is only a
part.
Round Shoulders
=Round Shoulders= are a defective posture with which everyone is
familiar. How many children have escaped the parents’ criticism to
sit, stand, and walk erect? And not a few of the afflicted have not
succeeded after persistently doing their best.
Round shoulders or stoop shoulders are commonly attributed to
indifference. Probably a few cases are due simply to laziness and
indifference, and others may be carelessness, and usually when they
arrive at an age where pride of their physical demeanor and powers
enters as a life factor, the child soon overcomes the postural
weakness. With still others the correct, persistent physical training,
as exemplified in military schools, will readjust the defect. But there
is a class, and by far the largest, where round shoulders are a very
real and active weakness of the physical body. And the weakness is not
primarily in the shoulders as nearly everyone thinks. The stoop is a
result. The origin is in the lower dorsal spinal column. Here will be
found a posterior curvature that involves nearly the entire dorsal and
lumbar areas. This is the real, the original cause of the larger number
of round shoulders.
This backward curve of the spinal column, instead of the forward curve
as it should normally be at the waist, obliterates the brace or truss
of the spinal column that is so essential in maintaining an erect
posture of the shoulders. It allows the individual to “fall into his
stomach,” to drop the shoulders, and as a consequence the chest cavity
is depressed. The spine is one continuous backward bow, and when he
does try to sit straight, and it is always with a constant effort, the
normal, the physiological curves of the spine are not apparent.
First, then, there is a spinal weakness in the region of the
innervation to the digestive organs. Indigestion of various forms
is a common accompaniment. Second, there is lessened lung and heart
capacity. The ribs are depressed, interfering with perfect aeration and
elimination on the part of the lungs and with normal activity and tone
of the heart muscles. Phthisis is predisposed. Is it any wonder the
child’s blood is impoverished and anemia results from the insufficient
aeration and poor digestion and assimilation? Costogenic anemia may
also be a result. And, third, the shoulders are “round” from the spinal
weakness and flattened chest, really an effect; but while the most
noticeable, it is the least serious.
It is evident from careful observation and study of these cases that
the treatment resolves itself into the treatment of a posterior spinal
curvature. Shoulder braces, steel braces and jackets, and casts have
very little place, if any, although there may be diseased bone of such
character and severity that a cast will be necessary; this, however,
would refer to treatment of Pott’s disease and similar conditions.
Hence, the =treatment= is, first to replace and readjust the malaligned
vertebræ. There must be an actual physical manipulation in order to
correct the vertebræ at fault. This is the essential, and by far the
primal, treatment for the key to the truss or brace that holds and
retains the body in an erect position is then replaced.
Second, raising the depressed ribs. Remember the depressed ribs are
dependent upon the spinal condition. The thorax should be treated as a
comprehensive whole, not the spinal column alone.
Third, exercises are a valuable aid. The individual’s part is as
necessary, in a way, as the physician’s, for in order to accomplish
the maximum there should be consistent and appreciative work on the
part of the patient. Holding the shoulders back, the head erect and
the chin in, drawing the abdomen in and up, all with deep breathing
by the use of the chest muscles, the patient will be able to retain
the correction obtained during treatments. “Setting up” exercises are
helpful. Developing the muscles of forced expiration is excellent. Thus
the patient must be conscious of the work required of him and act in
concert with the physician. Minute instruction on the requirements of
each case is demanded.
Good food, pure water, and fresh air are necessary, particularly in the
anemic. Right living and correct environment are always in order.
Painful Shoulders
Under this heading may come a variety of conditions affecting one or
both shoulders causing much distress and, at times, total disability.
The conditions may be the result of direct injury to the joint,
systemic, or from spinal lesions. Anatomically the shoulder offers
frequent opportunity to injury as it has the greatest range of motion
of any joint, is least secure in its articulation, and is most
vulnerable from location. Once the shoulder has been dislocated it
is rarely back to normal functioning again as this injury tears the
capsular ligament and stretches the structures in relation. Many times
there is only a =subluxation= in which the head of the humerus is
driven upwards in the fossa, usually from a fall or blow on the point
of the elbow. As a rule, after such an accident, the only thing done
is to rest the joint and apply a liniment and, after a time, begin
the use of the arm. It is, however, painful and to save himself, the
patient each time restricts movement until he reaches a point where he
is unable to dress without assistance. It is then found that normal
motion is reduced fully one-half and even this will be accompanied
by pain on movement and in bed. A radiograph will, usually, show the
condition. Articular crepitus and fibrous adhesions are present while
the adjoining structures have undergone changes so that a reduction is
impossible without certain preparation. Very often a trivial cause will
disable a joint; a sudden movement which finds the muscles about the
shoulder unprepared and the resulting lesion is so slight as to, often,
defy detection. At first there will be swelling and pain but, in time,
it settles down to a limited motion with more or less distress.
=Bursitis.=—This is a condition in which the subdeltoid bursa is
involved or where there have been a number of bursæ formed from
overuse of the joint. One authority reports as many as twenty-five
in a shoulder. There may be, also, tenosynovitis primarily or from
extension. These conditions may not be easily diagnosed at first.
=Brachial neuritis= (chronic) beginning with or without an acute attack
is usually from a cervical lesion involving the brachial plexus but
most frequently it is the 5th and 6th cervicals at the origin of the
circumflex nerve. From this the deltoid is particularly affected and
its contraction leads to pressure on the nerve and subsequent partial
or complete paralysis. Brachial neuritis is found in an increasing
number of osteopathic practicians and is the result of overwork of the
arms and to strain of the upper dorsals and lower cervicals. There are
contractions of structures about the joint constantly limiting motion
and pain when a strain is put on them.
Many methods for the treatment of the conditions described have
been employed, all involving the same principle but none of them
systematized. C. H. Spencer has worked out a technique which, while
originally intended for bursitis, has been found well adapted to all
conditions described. It gives a stretching of all structures and
gradually breaks up adhesions, both in the joint and in the tendon
sheaths, so there is no resulting irritation which could easily result
if suddenly done. His technique is[43]:
“First: The patient on the side, the affected shoulder up; operator
facing the patient, places one hand on the top of the shoulder, does
nothing more than fixing it; with the hand grasping the forearm above
the wrist, push the elbow backward, the arm parallel to and almost in
contact with the body, then pull forward in the same plane. Second:
Elevate the elbow with the hands of the operator in the same position
as before, carry the elbow in as wide a circle as possible. Third:
With the hands still in the same position, extend the forearm with
traction; carry it as high in front of the patient as possible. The
foregoing are designed to relieve the congestion about the shoulder,
bring pressure to bear on the subdeltoid bursa and moderate traction on
the supraspinatus, infraspinatus, subscapularis, teres minor and major,
latissimus dorsi and the tendon of the biceps. These manipulations
will be all that is possible in the more aggravated cases for some
considerable period of time. As the tenderness subsides, the second
group may be cautiously started, the hands in the same position as
above noted, with the arm extended as nearly as possible at right
angles with the body, carry the arm in as wide a circle as the pain
will permit. Again, with the arm flexed at the elbow, one hand of the
operator on the point of the shoulder and the forearm of the patient
across the forearm of the operator, the other hand of the operator
resting on the point of the patient’s elbow, push down toward the
middle line of the body and carry the elbow toward the head. Then flex
the arm and place the back of the hand behind the patient, flexing the
shoulder in front with one hand grasping the point of the elbow and
pull forward. This group of movements accomplishes with greater force
the same ends obtained in the previous, and the first in this group
is the most effective in overcoming swelling of the subdeltoid bursa.
Direct manipulation of the muscle masses and this bursa is desirable
from the first.” It will be noticed in all these movements that the
joint is protected by one hand of the operator while the other is
grasping the arm of the patient. This is desirable as it makes the
technique absolutely safe. An additional treatment will be found very
effective, especially where the deltoid is involved. With the patient
on the well side, facing the operator, locate the quadrilateral space
which is bounded by the subscapularis above, the teres minor below
and the long head of the biceps medially and the surgical neck of the
humerus externally, and the circumflex nerve can be easily palpated
along with the artery. If these structures are stretched and the
deltoid lifted from the shoulder it will be found to free the action of
both nerve and artery, one supplying the joint with nutrition and the
other innervating it.
Certain conditions for which these movements are contraindicated arise
and the following differential points by H. Glasscock are well to
remember[44]: =“Rheumatism=: Fever in the joint, with redness, swelling
and other joints involved. =Tuberculosis=: Daily temperature and other
tubercular foci. =Neuritis=: Pain in the neck and shoulder muscles,
also near insertion of deltoid and in the forearm, particularly
musculo spiral. Pain worse at night. No pain on movement. No swelling.
=Bursitis=: No pain in neck. Pain in anterior and posterior part of
joint and on motion. Pain near insertion of deltoid. Arm held close
to the body, motionless. =Infection=: Chill, limited motion, severe
pain with temperature. =Dislocation=: Deformity with preternatural
mobility. =Dislocation= of =acromio-clavicular= joint: Tenderness over
articulation. Arm cannot be raised beyond right angle with the body,
but elbow may be brought across the chest with external rotation of
arm and raised perpendicular with the body without pain.” The infected
joint should never be manipulated and all conditions showing swelling,
redness and pain on touch should be viewed with suspicion. Remember
that all other conditions will almost invariably have vertebral
lesions, primary or secondary and a permanent result will depend upon
their correction.
The Prominent Hip
A hip that is prominent and larger than its fellow is of frequent
occurrence. It may not be necessarily conducive to a defect in
posture, but it often is. The female is more frequently afflicted with
this anatomical irregularity than the male. In the first place, the
female pelvis is not so stable and rugged as the male pelvis, i. e.,
a mechanical wrench or fall will more easily displace the relative
position of the tissues in the female. Then, in the second place, the
dress of the woman accentuates irregularities of the figure, so that
possibly in some instances the defect, from a diseased or deformed
point of view, is more apparent than real. But of still more importance
is the fact that many cases of a prominent hip are due to a lateral
curvature of the lumbar spinal column. Lumbar curvatures are of common
occurrence in the woman; first, the spinal column is not so strong as
in man, simply on account of the physique not being so robust; second,
modern dress constricts the waist by the use of corsets and many
waist bands, and the weight of heavy skirts upon the waist, hips and
abdomen; and, third, severe strains from childbirth. Care should be
taken that there is no congenital abnormalities of the lumbar spine, or
that congenital asymmetry of one-half of body, or trunk or leg is not
present.
Thus the principal =cause= of a prominent hip is the lateral lumbar
curvature. This, through compensatory action, renders the hip on the
concave side prominent and high, while the hip on the convex side is
depressed and less pronounced in appearance. Dressmakers and tailors
are all too familiar with this feature of the irregularly outlined
figure, and, consequently, have to resort to “padding” to round
out the symmetry of the body. The mere irregularity of the figure,
unfortunately, is by far the less serious part of the defect. Many
ailments and diseases can be readily and directly traced to this. Not
that the prominent hip itself necessarily always plays a leading part,
but rather the lumbar curvature is the cause of very much suffering
and misery. To enumerate the many disorders that arise from malaligned
lumbar vertebræ may be unnecessary but a few will be given. A point to
be emphasized is that the prominent hip often plays the role of a sign
or symptom, or an effect, that an ailment or disease may be elsewhere.
In the female one of the most common causes, if not the most common
cause by far, of disorders of menstruation, whether painful, profuse,
or irregular, is irritation or obstruction of the lumbar spinal
nerves due to lumbar curvatures. It is well known the lumbar spinal
nerves control, to a large extent, the pelvic organs; consequently
the osteopath pays particular attention to this area. Then certain
intestinal disorders, such as appendicitis, typhoid fever, dysentery,
rectal diseases, owe their origin to predisposing lesions here; also,
bladder ailments, and sexual diseases of men, and many affections of
the legs, as sciatica, varicose veins, etc.
In a number of instances the prominent hip will be due to a displaced
innominatum. Then a lumbar curvature will result as a compensatory
condition. This reverses the compensatory act as heretofore referred
to; the prominent hip, in this instance, is the cause and not the
effect. To diagnose which is cause and which is effect will frequently
require considerable technical knowledge and experience. The slipped
innominatum then produces symptoms and disorders directly from its
changed anatomical relations; the points of diagnosis are given in the
chapter on Diagnosis. The prominent hip can easily be detected when the
subject sits down upon an even, firm surface, or stands up, and the
one side is compared with the other. In some cases where the prominent
hip is due to a lumbar curvature, and the prominence is a secondary
feature, the legs will be found uneven in length, but not always, for
the lumbar curvature may straighten out when the patient lies flat upon
the back. To diagnose the cause from effect and to differentiate the
maze of signs and symptoms that may be present is not always easy even
for the skilled practitioner.
The =correction= of a prominent hip is not ordinarily a difficult
matter. In the cases where lumbar vertebræ are principally at
fault, and these include the greater number, the problem is one of
correcting the spinal curvature. Lumbar curvatures are the easiest of
any of the curvatures to correct, for one is not hampered by the rib
articulations, and the lumbar section presents an area where a leverage
can readily be obtained. Where the innominatum is primarily at fault it
is simply a matter of readjusting this, with probably some attention
to the lumbar region. Care should be taken that the prominent hip is
not caused by a tubercular sacro-iliac disease, by hip-joint disease,
by a dislocated hip, or by an overlapping of thigh or leg bones from
fracture.
Standing erect will, of course, be a valuable help, for standing with
the weight on one foot will tend to make the hip on that side more
prominent. But generally the reason why one favors a certain side is
because the other side is weaker; a weak back, a slipped innominatum,
or an injured leg are common causes. There are many cases where the
skirts will have to be considerably altered after the hips have been
made symmetrical.
Pendulous Abdomen
The =pendulous abdomen= is another defect that is all too common. A
great many people have prominent abdomens because they do not stand
properly, but a pendulous or prominent abdomen is not necessarily
synonymous with a stout abdomen. They attempt to stand erect by
drawing the shoulders back and extending the abdomen. If they would
hold the head erect and the chin in, with the shoulders back and the
chest forward, and draw the abdomen inward and upward, their figures
and physiques would undergo shortly a wonderful transformation. These
directions also apply to pregnant women. Drawing the abdomen upward and
inward will at first require considerable effort. It certainly will not
be an involuntary act for the first few days.
The sagging of the abdomen not only causes an unsightly appearance
but results in great relaxation of the abdominal muscles, interferes
with digestive functions, displaces the pelvic organs, and weakens the
action of the lungs and heart.
The laxity of the abdominal muscles allows the abdominal organs—the
intestines, stomach, kidneys, etc.—to displace downward. This tends to
indigestion, constipation, inactivity of the liver, etc., and causes
a score of reflex symptoms. The organs become simply weakened from a
lack of proper tone. This is a frequent cause of nervous prostration.
Also it is one of the common causes of prolapsed and displaced pelvic
organs, because the abdominal organs sag down upon them and the pelvic
organs thus receive the brunt of the gravitative effect. Internal local
treatment of the pelvic organs can only be a makeshift in these cases.
The lungs and heart are weakened because the abdominal organs are
dragging on the chest, the lungs can not aerate the blood freely owing
to the abdominal weight and to the blood being obstructed in passing
from the abdominal organs through the liver to the heart and lungs. The
heart is handicapped in its work through lessened chest capacity and
obstructed circulation. Just “suck” up the abdominal organs and see how
much easier it is to expand the chest and to breathe.
There are other causes for a pendulous abdomen, such as a weakened
spinal nerve supply to the abdominal muscles and organs. The weakened
nerve supply may cause a loss of tone to the abdominal organs
themselves, so that certain organs, as the stomach and intestines,
become dilated and prolapsed; to the ligaments, and to the tissues and
organs as a whole so that they become gravitated.
Through childbirth muscular fibres of the abdominal walls often
rupture, leaving scars and a relaxed condition. Actual ruptures,
hernia, of the abdominal muscles occur and cause a pendulous abdomen.
Then there are cases of obesity where the pendulous abdomen is a
symptom.
Much can be done with all of these conditions through osteopathic
work; the patient must also help himself. The center of gravity of
the body must be changed, and kept changed; correct posture and a
constant effort will accomplish considerable. The “setting up” military
exercises are excellent. Even in some cases of obesity the abdominal
prominence can be markedly lessened by careful exercising and keeping
the abdomen drawn in so that the abdominal muscles, the diaphragm, and
the chest may be strengthened. For the relaxed, flabby abdomen, self
manipulation of the weak muscles when lying on the back will materially
aid.
Postural Curvatures of the Spinal Column
Undoubtedly, the great percentage of postural defects, or slumped
states, are dependent, directly or indirectly, upon weaknesses in the
spinal column. As was seen, round shoulders, the prominent hip, or
the pendulous abdomen, are often initiated by spinal deviations and
deformities, so naturally spinal column curvatures are a most fruitful
source of direct defects of posture.
It is somewhat uncommon to find an anatomically true spinal column,
although this does not preclude that one’s posture is defective, for
often through pride and effort one may consciously overcome a defective
posture.
It is the purpose here to offer a few suggestions relative to the
development of a greater symmetry of the body. Nearly every one is
more or less interested in physical exercises and development. And
especially to those of sedentary habits do means and methods of
exercise appeal. Curiously enough, in a way, nearly every layman looks
upon defects in posture, symmetry and stature as an effect arising
from lack of, or improper, exercise. He seems to be imbued with the
idea that the body in most instances is practically permanent in
construction and when irregularities in figure occur certain exercises
will correct the defect. Thus have individuals been prone to look upon
osteopathy as a method of passive exercises. Osteopaths should believe
most thoroughly in exercising, personal hygiene, etc., but the idea of
osteopathic manipulation is primarily one of anatomical reconstruction,
and not muscular development alone. The work of the osteopath is
to readjust or to re-mold the body framework and the many tissues
that clothe it so that normality of function may predominate. The
manipulation is not routinism but mechanical rebuilding of the tissues
so that perfect freedom of vital forces may be forthcoming.
The spinal column presents the most frequent as well as many
extremely interesting phases for re-correcting work. The number of
abnormalities as to contour to which it is subject are many and varied.
Emphasis should be placed upon possible congenital abnormalities and
developmental defects as sources of certain derangements. Any variation
or combination of variations with the normal or physiological curves
constitutes an abnormality or pathological curve. And as a consequence
defective posture, unless thoroughly compensated, is readily initiated.
Not only may the normal curves be exaggerated, lessened, eliminated or
reversed, but lateral and rotary curvatures are of frequent occurrence.
Curvatures involving the cervical region to the extent of producing
noticeable defects of posture are principally lateral deviations of
several vertebræ. Wry-neck is probably the most noticeable disturbance.
The head and neck being drawn and slightly twisted to one side is a
defect that is both noticeable and painful. Another common source
of postural affection is an exaggerated forward curving of the neck
vertebræ. This produces a stooped appearance of the neck.
The dorsal vertebræ are often curved backward too far. This produces
roundness with too decided a fullness of the upper back and shoulders.
The chest may be somewhat flattened as a secondary effect but not
necessarily so. Neither are the shoulders what may be termed “round
shoulders,” still such a condition may occur, for “round shoulders”
are more often caused by a backward swerve of the column at the waist
line. There is often a shortening of the anterior structures which pull
the point of the shoulders forward. Forcing them backward will aid in
correcting the fault. The dorsal vertebræ may be forward from what is
termed a “straight” spine; this results in an exaggerated “braced” back
position. Then lateral curvatures of the dorsal spine are common, which
in time may develop into a rotary curvature; that is, the vertebræ are
actually rotated on their axes. Lateral curvatures of the dorsal spine
are slow and difficult to correct, for the ribs complicate matters very
materially. Then, also, the vertebræ are apt to be deformed.
Curvatures of the lumbar spine, whether posterior, lateral or anterior,
are common. Both dorsal and lumbar curvatures, as any one can readily
see, are extremely common sources of postural defects. Erect positions
of the body are maintained through the support of the dorsal and lumbar
vertebræ. Stooped shoulders, one shoulder lower than its fellow,
sitting humped over, sitting on the sacrum instead of squarely on the
buttocks, the prominent hip, standing first on one foot and then on
the other in order to rest the back, and the many allied variations of
incorrect postures are largely dependent on the condition of the lumbar
and dorsal spines.
It is not to be supposed that the above defects are the only ailments
and disturbances that spinal curvatures cause, for, indeed, the
defective posture may be by far a minor consideration. Disorders of
body functions and affection of organic life itself are very often
traced to the malaligned vertebræ.
The =causes= of spinal curvatures are many, but without question one
of the most common causes is mechanical wrenching or twisting of
the column from falls, jars, etc. Often the strain or sprain of the
sections are readjusted through the inherent powers of the body, but
there is a point where _vis medicatrix naturae_ requires extraneous
help to correct the perversion; and, naturally, such aid, by virtue of
the cause of the disturbance, should be physical force mechanically
applied. Other causes of spinal curvatures are contractions of muscles
on one side of the column or paralysis of the muscles on one side;
in either instance, muscular action is greater on one side than the
other, which easily results in a curvature. This imbalance of muscular
tension, whether due to the above or other sources such as overfatigue
or various deleterious habits, is a prolific source of lesions. And
among still other causes may be noted, bone diseases of the spinal
column, compensatory deformities, and constitutional weakening and
irritating diseases. Also, some occupations predispose to certain
curvatures.
One can readily see that the =treatment= which is directed specifically
to the cause of the vertebral deviation would be the most scientific.
This is just what osteopathic work implies, direct readjustment of the
sections at fault—not exercises, or routine stretching, or braces;
although these latter methods may in some cases have their place as
secondary aids. Of course exercises are usually physiological and may
be employed, in many instances, as an auxiliary. Care should be taken
to eradicate infectious foci when present.
Where curvatures are extreme, complicating and deforming the ribs, and
absorbing the bodies of the vertebræ so they become wedge-shaped, and
resulting from abscesses, no one can expect within reason to absolutely
correct the posture. Some aggressive work can be accomplished, but a
perfect symmetry will not be forthcoming. It may be well to emphasize
again that where the ribs are involved the osteopath is not contending
with the deformity of the spinal column alone, but in addition the
entire transverse area of the body. (See also Spinal Curvatures).
=Conclusion.=—In concluding this rapid survey of a number of postural
defects the principal lesson to be drawn is not one of developing the
physique and thus perfecting a better posture, so much as curtailing
and eliminating insidious beginnings of disease. These little ailments
and deformities, of which postural defects may be the most noticeable,
are so often the inception of more serious disorders. The anatomical
structure being maladjusted, -aligned, or -positioned, easily and
readily leads to consequences that require much time and patience to
overcome.
Poise of body represents much to every one. Poise or correct posture
coupled with careful and methodical exercise and correct breathing are
material aids in constructive development, as well as in eliminating
disease, for not alone may abdominal, pelvic and thoracic integrity be
benefited, but the upper respiratory tract may be toned.
The most important goal that osteopathic science and art is striving
for is that of a fully developed and rounded out prophylaxis or
preventive treatment. When the public realizes that the proverbial
ounce of prevention is an established medical reality then it can truly
be said our science has reached its ultimate good. To those who are
familiar with osteopathic theory, facts, and development, it is an
open secret that this school holds the key to successful preventive
treatment. The time is rapidly approaching when the actual lessening
of diseases will be an established fact. Then will be the universal
practice of the layman going periodically to his osteopath to see if
there are any small or insidious beginnings of disorder or disease.
Not only must the many deleterious habits and errors of the daily
regimen be corrected, but after environmental, physiological and
structural adjustment, in so far as possible, has been attained, a
daily regimen to maintain the normal should be instituted.
FOOTNOTES:
[43] Journal American Osteopathic Association, Jan. 1916.
[44] Osteopathic Physician, Nov. 1919.
PROLAPSED ORGANS
Prolapse of various organs or tissues are among the very common
ailments that afflict all classes. Prolapse of the stomach, a kidney,
the uterus, or the rectum is a familiar term to every one. But this
condition may also rest with the intestines, the liver, an ovary, or
even the heart.
Outside of injuries, congenital weaknesses, and so-termed surgical
disorders, there are commonly two constant forces predisposing to
prolapsed organs, viz: gravitation and weakened innervation; the one,
of course, is a constant factor in either health or ill health, the
other is dependent upon acquirement. Here the latter, or acquired
nervous weakness, will especially demand our attention.
Where tissues are torn or lacerated, or congenital malformations are
present, or tissues are weakened from ulceration and with a resultant
scar tissue, or certain tumors are present, the disorder must be
amenable largely to surgical measures if at all.
The perpendicular position of the body favors a decided gravitation
of the abdominal and pelvic organs. This gravitative effect being a
constant one, many methods, both surgical and mechanical, have been
devised to hold in approximate and relative position certain organs and
tissues that may be prolapsed. But it is well known that outside of a
certain few instances where surgical measures are clearly indicated the
prevalent use of braces, bandages, supports and the like are usually
poor makeshifts.
The one great feature in these cases is that tonicity to organs and
supporting muscles and tissues is more or less impaired. The tissue
atony may vary from mere weakness to actual tearing and separating of
the fibres. The indications in the cases about to be described are
to stimulate a lowered nerve supply and to increase a lessened blood
supply; if this can be accomplished, supporting muscles, ligaments and
other tissues will be able to restore the prolapsed organs to normal
positions, thus improving functions and eliminating disease symptoms.
In discussing the prolapse of the following organs, perhaps it should
be noted here that all of the abdominal organs may be prolapsed as a
whole. The intestines, stomach, liver, kidneys, etc., may actually
prolapse together. This is more apt to occur in persons whose abdominal
walls are thin and flabby. In women pregnancy is a common cause. When
the abdominal organs have gravitated, the pelvic organs, also, are very
likely to be disturbed and displaced; in fact, the pelvic organs are
frequently disordered this way.
Prolapse and Dilatation of the Stomach
Dilatation of the stomach is a much more common and serious affection
than prolapse of the stomach, although usually the two are associated.
Prolapse, or ptosis, of the stomach means simply a downward
displacement of the organ. This is apt to take place in those cases
where all of the abdominal organs have gravitated. There is invariably
some dilatation of the organ as well.
Weakness of the abdominal walls and of the supports of the stomach
constitute the principal =causes= of the prolapse. Spinal deviations
that impinge or obstruct the nerve strands (or obstruct the blood and
lymph supply to these strands) to the supporting stomach tissues is
the most frequent cause of the ailment. General debilitating diseases,
as anemia, cancer, etc., are indirect causes of weakened organs with
consequent displacements.
In dilatation of the stomach the condition may be either acute or
chronic. The former is found where immense amounts of food or drink
have been introduced.
One of the principal causes of chronic dilatation is some obstruction
to the opening from the stomach into the intestine, so that the stomach
contents do not pass readily into the bowel. This leads to chronic
disturbances of the stomach walls, and the food remaining in the
stomach somewhat indefinitely weights down and stretches the walls
of the stomach. The obstruction may be a tumor, or some stricture or
adhesion from scar tissue resulting from ulceration or inflammation.
The treatment of these cases comes within the province of surgical
interference rather than other methods.
The second important cause of chronic dilatation is muscular weakness
of the walls from poor nerve supply. This is a common cause and
osteopathy is very successful in curing these cases. The splanchnic
nerves are below normal, usually from a slight lateral or posterior
spinal curvature. The nerve force to the walls of the stomach not
being normal causes atony of the muscles and dilatation results. This
nervo-muscular atony, also, results from a chronic catarrh, or from a
general nutritional disorder as tuberculosis or anemia. The treatment
of the former would imply direct correction of nerve and blood supply
with attention to diet; the latter can be cured only through relieving
the nutritional disorder of which the stomach condition is a symptom.
Dilatation of the stomach is most common in people of middle age or
older. The disease is usually easily diagnosed. The symptoms may
not be indicative of the trouble beyond showing that the stomach is
disturbed. Indigestion, uneasiness, and nausea are common. Vomiting
of large quantities of material from the stomach is likely to occur.
The patient is generally emaciated, the skin is dry, the bowels
constipated, and the urine scanty.
The =diagnosis=, as a rule, is not hard to make. Through the media
of inspection, palpation and percussion, the careful osteopath will
have little trouble to determine the size of the stomach. Kemp’s[45]
distinction between gastroptosia and dilatation of the stomach is as
follows: “In dilatation the lesser curvature retains its relation
to the diaphragm. The distance between the lesser and the greater
curvature is increased, but the lesser curvature still maintains its
relation to the diaphragm, with the exception that the pyloric end may
extend farther over and somewhat farther down.” Another instructive
point relative to diagnosis the above authors make is the importance
of the splashing sound. Owing to the fact that the stomach in health
closes concentrically about its contents and thus adapts itself to the
volume of ingesta, no splashing sound can be elicited. Three different
degrees of relaxation are diagnosticated as follows: “Splashing sound,
which can be elicited only during the normal period of digestion, means
simple atony; splashing sound produced after the legitimate time of
digestion has expired means motor insufficiency; and splashing sound
produced in the morning, after the night’s fasting, before liquid
or food has been introduced, may mean stagnation, dilatation of the
stomach, as understood by most writers.” (For a more complete outline
see Dilatation of the Stomach. The object of this section is to present
an outline of prolapsed organs as a whole, and to refer especially to
the effectiveness of osteopathic treatment in this condition).
This is a disease where osteopathy has been particularly successful in
not only relieving distressing symptoms, but in actually curing the
disorder. This refers to the nervo-muscular atony type, for where there
is obstruction due to stricture or tumor of the pylorus, resulting in
stomach dilatation, the treatment, from the very nature of things, must
be largely surgical. Stomachs that have been dilated and prolapsed
several inches have been entirely restored to function and organic
integrity. To =cure= these cases is a matter of stimulating nerve
control and blood supply to the stomach tissues, and, often of greater
importance, removing spinal impingements to the stomach nerve fibers,
thus allowing nature to fully assert herself. In reality, outside of
so-termed surgical cases and other cases where the stomach dilatation
is merely a symptom of general nutritional disorder, the primary
treatment, by far, is the spinal one. Treatment over the stomach
is a decidedly beneficial treatment; it aids materially in toning
both abdominal and stomach muscles; still this is mostly a secondary
treatment.
Dieting is essential. Careful dieting lessens the tendency to catarrhal
inflammation and reduces the work of the stomach to a minimum. Still,
nourishing food is necessary and the dieting can easily be carried to
an extreme. Liquids should not be taken freely. Fatty and starchy foods
should be eliminated. Give the patient food at short intervals. Various
nutritious meats are excellent.
In dilatation, and also general abdominal relaxation, daily abdominal
treatments may be indicated. If the relaxation is pronounced, keeping
the patient in bed with thorough spinal treatment two or three times a
week, daily abdominal treatment, having the patient exercise abdominal
parietes by drawing the walls in and up, upper thoracic breathing,
and frequent feeding will accomplish comparatively quick results. The
progress of each case depends very materially upon the general health,
the physical status of other tissues, constitution, inheritance,
environment, age, etc. Some cases will yield in two or three months,
others will require two or three years in order to obtain the greatest
possible benefit.
The Prolapsed Kidney
A =prolapsed kidney= is often termed a floating kidney, or movable
kidney, or dislocated kidney. It is of common occurrence, especially
in thin persons. Some authorities state that one woman out of every
four has a floating kidney. It is more common in women than in men, and
among the working class than other classes.
The condition is usually an acquired one, following severe strains from
lifting, falls, injuries, etc. It is claimed by some that a floating
kidney arises from congenitally weakened and relaxed tissues about
the kidney, that is, the tissues that keep the kidney normally at
anchorage. Thus a congenital looseness of the kidney would easily be a
predisposing cause whence mechanical violence, repeated pregnancies,
an enlarged liver, or tight lacing would act as an exciting cause.
Undoubtedly in some instances there is a congenital predisposition,
the peritoneal fold attaching the kidney to the spine being loose and
the capsule of fat retaining the kidney being scanty, but osteopathic
experience has amply demonstrated that the tissues anchoring the kidney
may in many case become atonied and relaxed from lower dorsal spinal
lesions. Rarely is a case presented to an osteopath that does not
exhibit two apparently characteristic causative features, viz: spinal
irregularity in the lower dorsal spine, and constriction of the zone
about the waist, i. e., dropping and constricting of the floating ribs.
Furthermore, correction of these lesions will almost invariably lessen
the mobility of the palpable kidney.
The =symptoms= of a floating kidney are many and variable. The kidney
may be slightly movable or it may be so loose that one can easily
grasp it through the walls of the abdomen. Most of the symptoms are
of a nervous reflex nature. Indigestion, which is likely to be very
persistent, flatulency, heart palpitation, painful menstruation,
irritable bladder, etc., are the most common symptoms. Still, blueness,
depression and morbidness are frequently present. The most distressing
direct disturbance is the feeling of weight in the abdomen, especially
on standing, running or lifting. Sometimes the ureter becomes twisted
and severe pain, colic and even collapse occurs. (Dietl’s crisis.)
The =diagnosis= of a dislocated kidney is not a particularly difficult
matter. A little experience coupled with a delicate sense of touch
will usually readily detect abnormal mobility of the kidney. A point
to always remember is that the kidney normally descends about one-half
an inch with each inspiration. Care should be taken not to mistake a
floating kidney for a movable spleen, although this is not likely, as
the shape of the spleen is different.
The =treatment= of a movable kidney under osteopathic measures is
usually successful. In the first place a number of cases require but
little attention, simply toning up the general health, and especially
directing attention to the abdominal walls and organs. There are a
number of cases where the kidney prolapse is incidental to general
abdominal laxness and weakness. In more severe cases, treating the
spine, raising the floating ribs, carefully manipulating over the
abdomen, keeping the bowels open, and lessening liver congestion should
it arise, will suffice; in fact, will remedy a good percentage of the
cases. With others, a well fitting, medium width, elastic bandage with
pad underneath will be beneficial. In these cases the patient should be
taught how to treat the abdominal organs, to manipulate the abdominal
walls, and to replace the prolapsed kidney; particularly after going
to bed this can be done successfully by the patient and will prove a
decided help in obstinate cases.
=Surgical measures= for fixing the kidney should seldom be resorted
to. If the patient will live a careful life, avoid unduly straining
himself, keep the bowels normal, and have the anatomical lesions
corrected, he will come very near being entirely relieved, if not
absolutely. Surgical measures are not always a success. Surgeons are
not operating for this disorder so often as in past years. (See Movable
Kidney—Diseases of the Kidney.)
Liver Prolapse
This is commonly termed a =floating liver=. There is prolapse of the
organ as well as its being abnormally movable. It is not of frequent
occurrence; women suffer from it much oftener than men.
Normally, the liver is partially held in place, in the concavity of the
diaphragm, by a number of peritoneal folds. The attachment of these
ligaments is to the spine and the diaphragm; their principal function
is to prevent extended lateral movements. Of greater importance in
supporting the liver in a normal position is the integrity of the
abdominal walls, and the position of the stomach and intestines. If
the abdominal walls are of normal tone the liver is very apt to be in
correct position. And the rest of the abdominal organs, especially
intestines and stomach, act as a cushion support. Often when the liver
is displaced the remaining abdominal organs are, also, out of normal
position and relation to each other; in fact, general prolapse of the
abdominal viscera is a frequent cause of liver prolapse. An additional
support of the liver is a certain cohesion of the liver and diaphragm,
and the elastic traction of the lungs.
Foremost among the =causes= that predispose to inelastic and atonied
abdominal walls are spinal irregularities, deviations, and curvatures,
which impinge nerve force and obstruct blood supply. These same lesions
weaken ligamentous supports of the liver and lessen tonicity of the
other abdominal organs, so that local or general displacements are
readily forthcoming. Strains, injuries, frequent pregnancies, etc.,
also act as causes that weaken the supports of abdominal tissues and
organs. In a word it is very often the pendulous abdomen that is the
immediate cause of a floating liver.
It is very rare to find the liver displaced to the lower region of the
abdomen. The ptosis is usually somewhat slight. The organ generally
rotates on descent, the right lobe being the lowest portion, owing to
the attachment of a ligament, the ligamentum teres, to the umbilicus.
Probably in some cases there is a congenital tendency to relaxation
of the ligaments, and, thus violent exertions and atonic and flabby
abdominal walls and diaphragm are secondary but important factors.
The principal =symptom= of a floating liver is a tumor in the right
side, which may be low down. Palpation will usually determine this.
Then the abdominal walls are flabby. Pain and bearing down of the right
side are common. There is apt to be considerable indigestion. Various
reflex symptoms are often present. The floating liver will seem larger
than normal, as the liver is below the costal arch and much of it can
be felt. Percussion will be of value in determining the extent of the
disorder.
Much can be accomplished by =treatment=, especially where the
displacement is of a lesser degree. Correcting the spinal lesions,
toning up the abdominal walls and diaphragm, and replacing the
displaced organs will be extremely effectual. The abdominal bandage may
be of service. Certainly abdominal exercises will be beneficial.
A point to remember is, stimulation over the abdomen beneath the right
costal arch will cause the liver to contract and retract. This is of
considerable osteopathic note. The liver will often recede at least a
half an inch. This is a liver reflex (Abrams).
Prolapsed Intestines
=Prolapse= of the =bowels=, as a whole, or, more frequent still,
of a part, is undoubtedly the most common form of organ prolapse.
The intestines are so situated that they readily feel the effect of
gravitative influences, of atonic and anemic states, and of weaknesses
and disorders of other abdominal organs.
Spinal irregularities come first as potent =causes= of bowel prolapse.
The spinal nerves to the supports of the intestines, to the muscular
coats of the intestines, and to the abdominal walls, are obstructed in
their normal activity, and consequently those tissues to which these
nerves are distributed are affected. Wasting diseases, as anemia,
consumption, cancer and the like predispose to intestinal atony.
The severe mechanical wrenches, strains, frequent pregnancies, tight
lacing, heavy skirts, large abdominal tumors, obesity, cause more or
less general or local weakness.
The pendulous abdomen, from wrong or careless posture, and exclusive
of other causes, is a common source of general bowel displacement.
This form of disorder, besides being unsightly, favors abdominal
stoutness. There are a number of instances where simply voluntarily
holding or “sucking” the abdomen into place, until it becomes strong
enough to support itself, has reduced one’s weight by five, ten or
fifteen pounds. These were cases where most of the adipose tissue was
about the abdomen. Thus exercising and toning the abdominal organs
by keeping them in normal position rectified a dormant blood and
lymph circulation, which was followed by absorption of the abdominal
stoutness.
Congenital weaknesses are to be considered in many cases. The muscular
ligaments may not be developed, the mesenteric attachments may be
too long, and various other abnormalities may result from congenital
disturbances.
Of particular local interest to the osteopath, outside of the bowels
dislocating as a whole, are: first, the hepatic flexure; second, the
ileo-cecal region; third, the sigmoid flexure; fourth, the rectum; and
fifth, hernias. Each of these sections are of separate interest and
will be considered presently.
The =symptoms= are extremely variable. Constipation, a feeling of
discomfort in the bowels, nervousness, depression, lassitude and anemia
are frequent. Colicky pains in the intestines, indigestion, hysteria
at times, are also among the symptoms. In reality a great variety of
symptoms may be present. The patient is likely to be emaciated. In some
cases exhaustion is marked.
=Diagnosis=, as a rule, is not a difficult matter. The various
neurasthenic symptoms in a lean patient with constipation, indigestion,
and stomach and intestinal distress would lead one to suspect
intestinal displacement. The outline or contour of the abdomen will
often reveal the character of the trouble. The atonic, thin and relaxed
walls of the abdomen may readily give view of the displaced organs.
Then careful examination by palpation and percussion will help very
materially in the diagnosis. Radiographic examination is a decidedly
helpful diagnostic method.
The =hepatic flexure= is frequently prolapsed. The bowel (colon)
ascends from below upward to beneath the costal arch and then angles
sharply into the transverse colon, which extends directly across the
abdomen to the left side. The ligaments that support this flexure
are apt to become weakened or stretched and allow a descent of this
section of the bowel, which is followed by constipation, indigestion,
etc. The ligament especially involved is the colo-hepatic ligament.
The =duodenum= may require attention. This can be raised by getting
beneath it where the organ descends alongside of the ascending colon.
The effect of treatment is to release tension of the duodeno-hepatic
ligament which is closely associated with the portal vein, hepatic
artery and bile-duct.
The =ileo-cecal region= is an area that readily becomes congested
and catarrhally inflamed, especially from constipation or impaction
at this point. The section often becomes atonic and prolapsed with
resultant clogging of fecal matter. Owing to the close proximity of
the vermiform appendix, appendicitis frequently results from the above
condition. The osteopath can do much in these cases of appendicitis.
Lesions are invariably found in the lumbar vertebræ or the floating
ribs are depressed.
The =sigmoid flexure= is also frequently prolapsed. The fecal mass
often becomes impacted here, owing to a settling or prolapse of this
part. In some cases the prolapse is so marked that it extends to the
rectum below and drags on the splenic flexure above.
Lumbar and innominate lesions are the usual causes, although, it seems
in a number of instances, that relaxed walls of the abdomen cause a
“contraction of the diaphragm resulting in kidney displacement and
followed by intestinal prolapse.” The vertebral lesions, probably,
first weaken the muscular coat of the bowel, then, second, the bowel
supports (other than its own inherent tonicity) and the abdominal walls.
Prolapse of the =rectum= is of such separate importance that it will
be but partly outlined here. As stated above, a source of rectal
displacement arises from the section of the bowel above settling
downward and ultimately causing invagination of one or more coats of
the rectum. Dislocation of the coccyx is a potent cause of rectal
disorders. Lumbar lesions, especially twists between the fourth and
fifth, and fifth and sacrum are common causes of rectal weaknesses.
Slips of the innominata are other causes of prolapse.
Osteopathy has had marked success in these cases. Cures may result
from a single treatment to readjust the coccygeal displacement or
temporarily relieve excessive physiological activity by dilating the
rectal sphincter, or the treatment may demand a number of months’
work in correcting general abdominal prolapse. Raising the sigmoid is
effectual.
A =hernia= is “the protrusion of a loop or knuckle of an organ or
tissue through an abdominal opening.” Two of the common hernias of
the intestines are inguinal and femoral. These conditions are most
often acquired from severe straining, so that a loop of the bowel
protrudes through a weakened and stretched area of the abdominal walls,
though there is reason to suspect that congenital defects are often
predisposing factors.
Mention of the hernia is here made because, in a way, it is a form
of bowel prolapse; that is, a limited form, and osteopathy contains
certain possibilities for a successful treatment. Hernia has always
been looked upon as purely a surgical disorder; i. e., remediable by
surgical measures only. Where a truss has failed to give relief surgery
has been resorted to. This is true in most instances, but where the
hernia is in the incipiency careful abdominal exercises (this should be
carried out with great care, for severe exercise may produce a hernia
or increase one already existing), massage to the tissues about the
hernia, attention to the bowels, and spinal stimulation corresponding
to the weakened tissue, and avoidance of strains may strengthen the
tissues materially about the hernia.
Occasionally a loop of the intestine will prolapse into the cul-de-sac
back of the uterus. A heavy dragging pain low down in the center of the
abdomen and constipation or complete obstruction are the pronounced
symptoms. Careful lifting of the loop of bowel by pressure within the
vagina and traction from above with a hand outside, with the patient,
on her back, with buttocks elevated, gives speedy relief.
The =treatment= of the prolapsed bowels represents those measures that
will replace and keep in position the displaced organs. Naturally, the
spinal and abdominal treatment comes first; this strengthens intestinal
ligaments, tones intestinal muscles, and contracts the abdominal
parietes, and at the same time the bowels are regulated, digestion
and nutrition improved, and the general health built up. In some
cases abdominal supporters will be of value. In a number of instances
attention to chest mobility and diaphragm tonicity will be of value.
Right living, which is represented by proper diet, sufficient outdoor
exercise and regular habits, is invaluable.
The really specific treatment is to correct spinal, rib and innominate
deviations and abnormalities. But direct local work will be, in many
instances, necessary. General abdominal manipulation is good, but this
should be supplemented by careful local treatment. The hepatic flexure
requires a direct stimulating and replacing treatment. The ileo-cecal
section should be raised, stimulated and emptied of the fecal mass.
Direct upward manipulation of the sigmoid flexure in the left iliac
fossa and of the splenic flexure beneath the left costal arch is
extremely efficacious. Care must be taken not to bruise the parts.
Getting beneath the prolapsed area and gently and intelligently raising
the bowel so that it is emptied, toned up, and vascular congestion
relieved, are the indications. This requires careful work and the
necessity of gentleness can not be emphasized too much. Still in all of
this treatment we should never forget the absolutely essential spinal
readjustment.
Rectal prolapse requires lacol internal treatment, external tissue
correction, especially of the coccyx, an innominatum or the lumbar
spine, and, of much importance, deep, careful and thorough work over
the sigmoid section.
Cases of bowel prolapse are every day experiences with the osteopath.
The osteopathic treatment is of great value in these and a successful
issue is very often the result. Cases of pendulous abdomen, of
obstinate constipation, of chronic indigestion, of many nutritional
disorders, of feeling pain, weight or dragging, locally or generally,
in the abdomen, are very apt to be in persons suffering from prolapsed
intestines.
A number of cases of bowel prolapse are associated with general
prolapse of abdominal organs; that is, displacement of the stomach,
kidneys, liver, spleen, etc. This general condition is termed
enteroptosis or Glenard’s disease. It usually requires several
months to treat it successfully. These patients are neurasthenic,
malnourished, and often hysteriacs. The symptoms from which they
suffer are innumerable. Mechanical weaknesses, lowered vitality, poor
innervation and blood supply, and auto-intoxication are causative
factors.
The Prolapsed Uterus
=Prolapse= of the =uterus= is of common occurrence. The prolapse may be
incomplete or complete; the latter when the organ is presented to the
external world. Of special interest are those affections exclusive of
surgical cases. Ptosis of the abdominal organs upon the pelvic organs
is a common cause of uterine prolapse. The abdominal prolapse crowds
uterine space, congests the uterus, weakens the ligaments, and drives
the uterus downward as a wedge.
Lumbar spinal curvatures are frequent causes of prolapse, as well as
other displacements of the uterus. In this region vasomotor nerves
to the pelvic organs make their exit, and, consequently congestions,
inflammations, and weaknesses of supports are results. Also, slips of
the innominata disturb the pelvic circulatory balance. Weakness of the
uterine support from below, the vaginal walls and perineum, most often
arises from lacerations at childbirth. Still, the vaginal walls may
become relaxed through other causes. Tumors and extreme congestions are
causes of prolapse. Heavy lifting is quite a frequent source of uterine
displacements. Osteopathy is very successful in uterine prolapses;
that is, any displacement of the uterus not of a surgical character.
Correction of the external causes comes first. Then local treatment
to replace, tone, and relieve congestion, and break up adhesions is
necessary. The external treatment is usually the primary treatment.
Local work is not always necessary. Lacerations and other surgical
indications, of course, require surgery.
Ovarian Displacements
The ovaries may be prolapsed, the left much oftener than the right.
When prolapsed, it drops backward, downward and inward.
Ovarian congestion, tumor, retroverted or retroflexed uterus, tubal
disease, and pregnancy are among the principal causes. Back of these
congestions, tumors and uterine displacements, are the osteopathic
causes, particularly spinal and rib lesions from the ninth dorsal
downward. Specific lesions at the ninth and tenth dorsals and
corresponding ribs, affecting directly ovarian tissues, and lumbar and
innominate lesions and abdominal prolapse disturbing uterine and tubal
tissues, are the most frequent osteopathic causes. A retroverted or
retroflexed uterus is often found. Uterine displacements bear down upon
the ovary and cause its descent, and also disturb ovarian circulation.
As has been stated, the left ovary is more apt to be displaced than
the right. This is owing to the absence of a valve in the ovarian vein
on the left side, and also, this vein opens at a right angle into the
renal vein; this anatomical feature easily leads to passive congestion
of the ovary, and thus to diseases of the organ. Then the rectum is
on the left side and large fecal masses are apt to crowd against the
ovary, which tends to its displacement.
Thus it is readily seen that osteopathic treatment is very applicable
to ovarian displacement unless the indications are surgical. A more
or less constant burning or sharp pain in the ovarian region, with
probably some feeling of weight, profuse and painful menstruation,
depression, irritability, etc., are =diagnostic=. However, a local
examination will reveal the status of the ovarian position and
congestion.
The same =treatment= as in other organ prolapse is indicated: toning
weakened tissues, relieving congestions, replacing organ, with careful
attention to the bowels and the general health. There are no tissue
disorders of any part of the body wherein osteopathy is more thoroughly
indicated and the results more generally satisfactory than in prolapse.
And especially should it be remembered that in prolapse of various
organs many vague intestinal and pelvic disorders and even ureteral and
bladder disturbances may be traced to bowel dislocations and excessive
kidney mobility in which osteopathic measures are often successful.
=Conclusion.=—The purpose of this section on Prolapsed Organs has been
to supplement the various articles on Dilatation of the Stomach,
Movable Kidney, etc., with an outline that may include relaxation of
a part or of the whole of the abdominal viscera. The physician is all
too prone to simply note the most offending or conspicuously disturbed
organ instead of carefully analyzing all the features, great and
trivial, that may be either apparent or marked. A general relaxation
of the abdominal and pelvic organs may be found, and a nearly complete
restoration take place under treatment, but still a lacerated perineum
may have to be repaired before a cure is completed. Or it may be in
a general abdominal ptosis that a floating kidney will resist all
measures for restoration, short of surgery, and before much improvement
can be obtained the kidney will have to be stitched into place. An
enlarged liver may crowd the kidney out of place or a transverse colon
may prolapse and drag on contiguous tissues and still the annoying
symptoms be referred elsewhere. Then the primal point of general
relaxation may not be in one organ, but there may be a simultaneous
displacement of several.
The thorax itself may be distorted from various diseases so that the
chest is narrowed, the diaphragm displaced with consequent descension
of the abdominal organs, and from the latter a displacement of the
pelvic.
“Far down displacement, marked changes of form, and real
disfigurements of the stomach are found in some cases of kyphosis and
scolio-kyphosis.”[46] The osteopath will not only find this true in
some cases, but in many cases, although he recognizes as causative
factors injuries to the spine causing curvatures and postural defects
as prolific sources of abdominal relaxation.
“Glenard’s whole theory of splanchnoptosia is based on the relaxation
of the suspensory ligaments of the intestines, especially that of the
transverse colon; and Stiller, the discoverer of the floating tenth
rib, says that splanchnoptosia is a descent of the atonic stomach, of
the colon (especially the transverse portion), of the kidney (the right
or both kidneys), exceptionally of the liver or the spleen. A descent
which has been developed mostly in tender age, in consequence of
general relaxation, especially of the peritoneal suspensory ligaments
in individuals with congenital general dyspeptic neurasthenia, tender
muscles, lean habit, and slender bone structure, manifested in a higher
degree by a floating tenth rib.” Stiller observed that when there is a
floating tenth rib there is a displaced stomach and a floating kidney,
although it is not found in every case, but never missing if the case
is pronounced. The tenth ribs in these cases have only a ligamentous
fastening and are as freely movable as the eleventh and twelfth.
That abdominal relaxation plays a very important part in many
diseases of the abdominal and pelvic organs, in cardiac and pulmonary
affections, disturbs the circulation in the legs, and is the source
of many reflex affections no one can gainsay. The osteopath should
always pay particular attention to tonic condition of the abdominal
viscera, for relaxation of the suspensory tissues and walls, and atony
and sluggishness of the organs are frequently paramount etiological
factors. And the osteopathic treatment is the remedy par excellence.
FOOTNOTES:
[45] Rose and Kemp—Atonia Gastricia.
[46] Rose and Kemp—Atonia Gastricia.
SKIN DISEASES
Various skin diseases have been treated osteopathically with varying
success. So much depends upon the cause of the disturbance and its
removal, in skin diseases, that the cure does not rest so much with
the mere treatment, as with the necessary skill in locating the
disturbing factor. One has to be continually on his guard to locate
external irritations and disorders of the digestive and genito-urinary
tracts. A great deal depends upon the avoidance of external influences;
eating nutritious food and having an unobstructed circulation. The
leading object of osteopathic treatment is to free the circulation
and thus promote a healthy and unobstructed flow of blood; in no
other class of diseases is this more essential than in skin diseases.
After the removal of cutaneous irritations and the correction of
internal disorders, the cure of the case depends upon the removal of
constrictions to the cutaneous blood-vessels. The osteopath corrects
the lesions found, relaxes the muscles thoroughly and stimulates the
circulation to the parts involved, and promotes a healthy activity of
all the excretory organs. When the upper part of the body is affected,
lesions are generally found at the atlas and axis, and when the lower
part of the body is affected, lesions at the fifth lumbar are of
common occurrence, although lesions may be located at various points
corresponding with the seat of disturbance. The constant use of hot
baths will be found a helpful measure in many skin diseases. But use
of soap must be considered as too much alkali will neutralize the oil
of the skin and cause undue dryness, but bran may be substituted to
advantage. Cleanliness is necessary but the result sought is, also,
flushing the cutaneous vessels. There are many cases where a specific
vertebral lesion will cause, through the peripheral nerves, a cutaneous
irritation with intense itching and discomfort. This, in turn, produces
an exudate with or without a crust and a condition results which is not
amenable to any local or constitutional treatment but an adjustment of
the lesion will in most cases bring immediate relief. Application of
this principle will aid greatly in treatment of any skin disease. In no
disturbance of health is it more necessary to find the cause than in
skin disease and once found to apply specific treatment.
=Eczema= is frequently met in osteopathic practice. It is the most
common form of skin disease, comprising nearly one-third of all these
disorders. For a differential diagnosis of the several varieties the
student is referred to special texts. It is well to remember that the
same underlying causes may be basic to the various forms, for several
varieties may occur at the same time or one variety pass into another,
though commonly one form is more prevalent. The limbs, face and
genitalia are the most common sites, though the eruption may occur on
various parts of the body.
=Etiology= includes a number of factors, constitutional and local.
Dietetic errors, indigestion and faulty elimination comprise the
principal underlying causes, often manifested through absorption of
toxins and leucomains. In fact any disorder of the abdominal viscera,
organic or functional, may be a predisposing factor, likewise various
disorders of the pelvis, tuberculosis, diabetes, anemia, etc. should
be considered. So-called gouty and rheumatic tendencies may be the
constitutional basis.
The many osteopathic lesions play a very important role in lowering not
only systemic resistance but of local tissue as well. This feature can
not be over-emphasized.
Then local irritants, mechanical, chemical and thermal, are not to be
neglected. These are usually of secondary importance. Micro-organisms
are probably a complicating factor after the lowered resistance has
been established. Vasomotor neurosis, through constitutional defects,
toxins and the very significant osteopathic lesion, is probably an
essential part of the pathogenesis.
=Treatment= is usually successful if the various etiologic factors
are eradicated. Early treatment is very important. If the disorder
is of more than local significance change the entire daily regimen
of the patient. Diet, outdoor exercise and sufficient sleep should
be definitely regulated. A certain amount of general treatment to
improve digestion, assimilation and elimination is imperative. An
unbalanced diet and over eating must be corrected. In certain moist
types, eliminating fatty foods will be helpful, while in dry forms the
starches and sugars should be reduced.
If there is an underlying disease this should be remedied if possible.
Particular attention should be paid to constipation.
Common sense in diet, rest, change of environment and free elimination,
coupled with due attention to the osteopathic lesions, will cure the
vast majority of cases. The greatest difficulty arises where there
is some underlying disease. The parts should be protected against
irritation such as dirt, cold, soap, and too much water. Meddlesome
local treatment is to be guarded against. A simple application is boric
acid, rice-flour or cornstarch, or where there is much itching add
carbolic acid to the saturated solution of boric acid. Substitute bran
for soap for cleansing purposes.
=Herpes Simplex=, fever-blister, or “cold sore” comprise two principal
varieties: =herpes facialis= and =herpes genitalis=. The first occurs
upon or near the lips, face, neck or ears. When the herpes is on the
tongue or the mucous membrane within the mouth it is commonly termed
“canker sores.”
Herpes genitalis is located on the prepuce, glans penis or farther back
upon the penis. In the female the labia majora and minora and vestibule
are the usual locations. Lack of cleanliness, sexual excitement and
adherent prepuce are causative factors, though predisposing factors
such as faulty circulation and disturbed innervation are to be
considered.
In “cold sores” there is often some gastro-intestinal disturbance,
especially intestinal stasis, cold in the head and other infections
that supply toxins which irritate the nerves. No doubt there are
underlying osteopathic lesions that lower the local nerve resistance or
block the impulses such as vertebral and inferior maxillary lesions.
The predisposing disturbance is probably due to the Gasserian ganglion.
Cold winds and excessive exposure to the sun’s rays will effect the
tissues over the mental and infraorbital foramina, tensing the muscles
and irritating the nerves at these points. On palpation they will be
found sensitive. Frequent rotary motion by tip of finger over foramina
will open them and allow congestion to drain.
=Herpes Zoster=, or shingles, is an acute inflammatory disease
characterized by groups of small vesicles, usually along the course of
the intercostal nerves on one side of the body. Before the vesicles
appear there is more or less severe neuralgia. The eruption is
unilateral, very rarely bilateral. The nearby lymphatics are usually
enlarged.
Though the intercostal nerves are the ones most frequently involved,
still the lumbar, thigh, trifacial and other cutaneous nerves may be
affected.
The most common lesion is an inflammation of the posterior spinal
ganglion which usually involves the fibers of the entire nerve.
Inflammation of the nerve outside of the ganglion will cause the
disorder. Toxins from various infectious sources are often exciting
causes. Vertebral and rib lesions are always found; and where the
Gasserian ganglion is involved lesions of the inferior maxilla and
upper cervical vertebræ are predisposing factors. Thus osteopathic
lesions from traumatism, cold and wet, and imbalance of muscular
tension are important. Exudates, tumors, pleuritic and pulmonary
affections are to be considered as possible sources.
=Treatment.=—Adjust vertebral lesions and carefully raise and separate
ribs if intercostals are affected. Look after vertebral origin of any
other nerve or nerves if otherwise. Local application of talcum or
starch or boric acid will generally be sufficient.
=Urticaria=, hives or nettle rash is a common affection often due to
some derangement of the digestive tract. This may be a mechanical
irritation or of a toxic nature. Every one is familiar with the various
foods that are apt to cause the hives, shell fish, strawberries,
cheese, pork, oatmeal, mushrooms, etc.
The irritation may be a reflex one from the visceral disturbance;
also, there may be irritation of the pelvic organs that would give
rise to the trouble. It is well known that certain drugs will produce
urticarial eruptions. There are cases where the irritation is simply
local due to the nettle, mosquito bites and wasp stings.
In chronic cases intestinal stasis, nervous exhaustion and nephritic
diseases are important.
No doubt osteopathic lesions frequently determine the location of the
wheals. These lesions affect the innervation and thus establish a basis
for the reflex vasomotor effect. This is in the nature of spasm of the
cutaneous vessels quickly followed by dilatation with exudation of
serum. The irritant probably acts on the walls of the blood vessels.
=Treatment= consists of thoroughly emptying the bowels by warm water
enema, correcting the diet, toning the viscera and adjusting the
osteopathic lesions. Thorough attention to the patient’s environment,
daily habits and occupation are of value. Warm soda baths will relieve
the itching.
=Acne= is a common skin disorder that is characterized by an
inflammation of the sebaceous glands of the nature of papules,
tubercles or pustules. The face, shoulders, chest and back are the
regions usually involved. It generally, appears about puberty.
Blackheads is the starting point; these are accompanied with greasy
skin and dust, and influenced by micro-organisms and more or less
intestinal disorder.
The general or systemic health no doubt affects the local disorder,
as in many skin diseases; for various intestinal derangements as
indigestion, constipation, etc.; pelvic and menstrual irregularities;
general ill health; anemia, etc. affect circulatory, glandular and
nervous integrity. Any disturbance of normal elimination is important.
The =treatment= consists of careful attention to the general health and
to the local innervation of the face or region involved. Measures that
tone the bodily organs such as outdoor life, regular habits, plenty of
sleep and correct diet are important. In some cases the X-ray is of
value.
ANIMAL PARASITES
Tape Worms
=Varieties.=—Taenia solium; taenia saginata; bothriocephalus latus.
The larvæ of tape-worms are introduced into the intestinal canal by
food and drink. The parasite reaches adult growth in the intestines.
The larval forms are then found again in the muscles and solid organs.
=Taenia Solium.=—This is derived from the hog, and is the most common
form in this country. When mature it is from two to four yards in
length. The head is small, about the size of a pin, and provided with
four cup-like suckers surrounded by a double row of hooklets, hence it
is called the armed tape-worm. The head is fastened to the body by a
thread-like neck, and following the neck, the body occurs in segments.
The sexual organs, both male and female, occur in the center of the
broad surface of the segment. The segments are about one millimeter in
length and seven or eight millimeters in breadth. There are thousands
of ova in each mature segment. The worm attains its growth in about
twelve to fifteen weeks, after which time the segments are shed and
passed. For further development the ova must gain entrance to the
stomach of a pig or of man, and passing from the stomach they may reach
the muscles and organs and develop into larvæ or cysticerci.
=Taenia Saginata.=—This is derived from beef, and is much longer and
larger than the taenia solium. It is from five to six yards in length;
the head is over two millimeters in breadth, is square shaped, and
has four large sucking discs, without hooklets; hence it is called
the unarmed tape-worm, in contra-distinction to the hooked variety.
The segments are thicker and the ova larger, and they are passed and
ingested in the same manner as the taenia solium.
=Bothriocephalus Latus.=—This is found especially in Europe and is very
long, measuring from eight to ten yards; it is derived from fish, is
not provided with hooklets, but has two lateral grooves. The segments
are short and wide, the sexual organs being on the narrow side of the
segment.
=Etiology.=—Unhealthy condition of the stomach and intestines is the
predisposing, and uncleanliness an important, factor in the occurrence
of tape-worm. Those eating imperfectly cooked beef, pork, fish or other
meats, and those handling fresh meats, are liable to be affected with
tape-worm.
When the ovum is taken into the stomach the capsule is dissolved and
the embryo passes into the small intestines, fastening itself into the
mucous membrane, by its hooklets and suckers and grooves.
=Symptoms.=—Tape-worms occur in the human being at all ages. Oftentimes
symptoms are absent, the expulsion of segments being noticed and thus
the worms accidentally discovered. The tape-worm is seldom dangerous,
but if a worm is known to exist it is always a source of considerable
anxiety on the part of the patient. Severe anemia may result and be
wrongly diagnosed.
There are dyspeptic symptoms, colicky pains, nausea and occasionally
diarrhea. The appetite is variable, sometimes ravenous. This condition
is followed by loss of flesh and various reflex phenomena, as vertigo,
headache, convulsions, palpitation, choreic movements, itching of the
nose and anus, paralysis, and rarely, insanity. In addition to these
symptoms there may be a wrinkled countenance, sensation of a cold
stream winding itself toward the back immediately after a meal, pain
in various parts of the body and ringing in the ears. The decisive
diagnostic symptom is to find segments of the worm in the stools.
=Diagnosis.=—Discovery of the ova or segments in the passages of the
bowels is the only proof of the presence of a tape-worm.
=Prognosis.=—Favorable in all cases.
=Treatment.=—Prophylactic treatment is necessary. Meats should be
thoroughly cooked so that the larvæ will be destroyed; and all segments
of tape-worms passed in the stools should be burned—by no means should
they be thrown outside or in the water-closet.
The immediate expulsion of a tape-worm is not a necessity. First of
all the mode of living, and then the general state of health should
be corrected. Tape-worms invariably result from a general state of
unhealthiness, and with improved health and corrected digestive
processes the worms cannot exist, and in a short time will be expelled.
Expulsion of the head is necessary before the case will be cured, for
if the head is not expelled new segments will continue to grow.
Stimulating the liver to increase the amount of bile, and increasing
the activity of the digestive glands of the stomach and intestines,
by a thorough treatment of the splanchnic region and direct treatment
over the abdomen, will usually be sufficient for the cure of intestinal
parasites. The treatment will probably have to be repeated several
times, in order that the intestines may regain a healthy tone, so that
the parasite will not find favorable conditions for its existence
within the intestines, and that the bile may be secreted in sufficient
quantities to dislodge the worm.
Hahnemann claimed, “that during a period of comparative health
tape-worms do not inhabit the intestines proper, but rather the
remnants of food and fecal matter contained in the intestines, living
quietly as in a world of their own without the least inconvenience to
the patient and finding their sustenance in the contents of the bowels.
During this state they do not come in contact with intestinal walls,
and remain harmless. But when from any cause a person is attacked by
an acute disease the contents of the bowels become offensive to the
parasite, which in its writhing and distress touches and irritates
the sensitive intestinal lining, thus increasing the complaints of
the patient considerably by a peculiar kind of cramp-like colic. (In
similar manner the human foetus in the womb becomes restless, twists
its body and moves whenever the mother is sick, but floats quietly in
the liquor amnii, without distressing her while she is well.)” This
but harmonizes with the osteopathic theory and practice with regard
to tape-worm, that there is an unhealthy condition of the intestines
which predisposes to the affection, and consequently the cure must be a
correction of such a disordered state.
During the treatment, if a light diet of milk and broths is given, it
will favor an earlier removal of the parasite, by helping to remove the
mucus in which the head is embedded. If this fails extract of male fern
is suggested.
Ascaris Lumbricoides (Round Worm)
This is the most common parasite, and is found principally in children;
it is also found in cattle and hogs. It is of a yellowish brown color
and in form resembles earth worms. The worm is cylindrical, pointed at
both ends; the female is from seven to twelve inches in length, and
the male from four to eight inches. They are probably introduced into
the stomach by food and drink. They occupy the upper part of the small
intestine, and are usually one or two in number, though they may be
numerous. Occasionally they migrate into the stomach and are ejected
by vomiting, or into the trachea and produce suffocation, or into the
larynx or Eustachian tube, or they may pass downward to the anus, or
into the bile ducts.
=Symptoms.=—Oftentimes symptoms are absent. There may be dyspepsia,
colicky pains, mucous stools, meteorism, vertigo, fretfulness,
voracious appetite, anemia, sallow complexion, headache, chorea and
convulsions. Other symptoms may be present, as grinding of the teeth
and itching of the nose and anus. Obstruction of the bowels has
occurred. If a worm enters the bile duct obstructive jaundice occurs. A
decisive diagnosis can be given only when the worm is seen.
=Treatment.=—Particular attention should be paid the liver, for it is
here that we must seek the natural remedy in the form of bile, in order
to eject and cleanse the system from nematodes.
Modes of improper living should be corrected; cleanliness is essential,
and there should be attention to the general health of the patient.
Thorough correction of all defects of the spinal column in the region
of the splanchnics, and careful direct treatment of the bowels is
indicated. The child may be put to bed and fasted twenty-four hours,
then the liver strongly stimulated to increase flow of bile.
If the above treatment is not successful oil of wormwood may be
employed.
Oxyuris Vermicularis
(Thread-worm; Pin-worm)
This small parasite, commonly seen in children, is from three to five
millimeters long in the male and about twenty millimeters in the
female, is blunt at one end and sharp at the other, and occupies the
colon and rectum. They are probably introduced into the intestines in
the ova, by uncooked fruits and vegetables, or by the dirty hands of
mothers and nurses of the infants. They vary greatly in number; migrate
to the rectum where they deposit their eggs, and are often discharged
in the feces, where they appear like pieces of ordinary white thread.
=Symptoms.=—Loss of appetite, anemia, restlessness and irritability
are marked. The itching becomes intolerable when the worms come down
in the rectum to the anus and within the folds about the anal orifice.
In the female the worms may wander into the vagina where they become
particularly distressing, and thus may produce excessive sexual
excitement and cause nymphomania and masturbation.
=Treatment.=—Cleanliness of the most scrupulous kind should be demanded
in every instance. Injections of cold salt water (repeated for at least
ten days) and other agents within the rectum will destroy the eggs as
soon as they are deposited, besides relieving the terrible itching. In
obstinate cases use quassia decoction.
Attention to the general health of the patient and great care of the
intestines and other digestive organs are absolutely necessary. The
spinal treatment to the intestines and other digestive organs, as well
as thorough direct treatment over the abdomen, is indicated.
Uncinariasis
(European hook-worm disease; Miner’s anemia; Ankylostomiasis; Hook-worm
disease)
This disease results from infection by the hook-worm of any of the
various types. In Europe it is found in Italy, Belgium, Germany,
France and Switzerland. In America it seems to be of Africo-Asiatic
origin but was first discovered in the Southern states and abounds
chiefly in Texas, Florida, Georgia, North and South Carolina as well
as in the West Indies. Infection comes from unprotected feces that are
allowed to be spread where the feet or hands may come in contact as
it is without doubt that the contagion occurs through the skin. One
authority states that hook-worm is rarely found except in cases where
ground itch has occurred within a period of eight years. Negroes harbor
the parasite and transmit it but seem immune to its effects while the
poorer whites are afflicted to a large degree. The worms are carried
from some abrasion of the skin, by the blood to the heart and lungs,
thence to the pharynx and swallowed, thence to the duodenum and jejunum
where they attach themselves to the lining walls. Here they not only
feed upon the blood but develop a toxin. The female worm is about twice
the size of the male, 10 to 18 mm. as against 6 to 11 mm. and there is
slight difference between the old and new world varieties. The head is
provided with four hook shaped teeth which form the attachment to the
intestine and it is very secure.
=Diagnosis.=—For years the languid, dull, expressionless, lack-luster
of eye and general unambitious characteristics of the inhabitants of
the great sand belt of the United States attracted attention and was
attributed to laziness but the discovery of the hook-worm explained the
cause. Children are stunted in mind and body and have a muddy, dirty
white complexion.
At the beginning there must be a very considerable colony of the
parasites to cause symptoms but as the disease advances there is a
distention of the abdomen from enlargement of the spleen and liver and
from flatulency. There is palpitation, shortness of breath, cardiac
bruits from the severe anemia while edema of the feet and legs is
rather common. The blood shows a severe secondary anemia with its
coagulation time much increased. Leucocytosis is not common; hemoglobin
is from one-tenth to one-half normal with erythrocytes about half
normal.
=Treatment.=—The removal of the worms with the least possible harm to
the body is indicated. Thymol is a poison which is not absorbed by the
body, when carefully given, and which is very toxic to the parasite.
The dose varies from eight grains for a child under five years of age,
to forty-five for an adult. Thymol is soluble in fats and in alcohol,
so that for a day or so before the thymol is given, and from one to
four days after, no fats or alcohol should be taken. The best way to
avoid poisoning by thymol is to give the patient charcoal, then no
fats or alcohol is permitted until the treatment is completed. When
the stools become black, the thymol is given on an empty stomach. A
purgative is given a few hours later. Enemas should be used very freely
in order to facilitate the removal of the injured or poisoned worms.
Another dose of charcoal is given, and when the stools are black again,
the patient may return to his ordinary diet. The denial of fats to the
person so thoroughly accustomed to bacon three times a day is a factor
met with difficulty in dealing with patients of the ordinary class with
the disease. (Clinical Osteopathy.)
=Prophylaxis.=—After treatment it is imperative to prevent reinfection
and to do that the most rigorous sanitary measures must be instituted.
All feces must be disposed of and habits of cleanliness in defecation
insisted upon while negroes, who harbor the worm without showing
symptoms, must be looked after as well as the actual victims. Care of
the feet is important and shoes should be worn in infected regions
and all abrasions of the skin protected. Drinking water must be
uncontaminated which presents a problem as wells and springs are
usually unprotected. Absolute and persistent cleanliness is the answer
to the question of prevention.
Trichiniasis
Trichiniasis is a name given to a disease produced by the embryos of
the trichina spiralis. In the adult condition the trichina spiralis
lives in the small intestines. The embryos migrate into the muscles
where they finally become encapsulated. Man is infected by eating
insufficiently cooked pork containing the encapsulated worm, which
is set free during the digestive process. About the third day they
attain their full growth and become sexually mature. Each one
discharges large numbers of embryos. As soon as born the young brood
is carried away from the bowel and invade the muscles through various
channels—principally by means of the blood stream and along the
connective tissue routes. The female trichina may bring forth several
broods of embryos in succession. In nine or ten days after infection
the first brood reaches its destination. They attain to maturity in
about two weeks after entering the muscular tissue. In this process an
interstitial myositis is excited and a fibrous capsule is formed in
four to six weeks. The capsule gradually becomes thicker and finally
calcareous infiltration may take place.
Thorough cooking destroys the parasite. The disease is most frequent
among the Germans who eat raw ham and sausages.
=Symptoms.=—These are sometimes absent, especially when only a few are
eaten. If large numbers have been ingested, gastro-intestinal symptoms
develop in the course of a few days. Vomiting, diarrhea, and pain in
the abdomen may be present.
In from one to two weeks muscular symptoms develop. There is fever,
muscular pain, especially during motion, and the muscles are stiff,
tense and sometimes swollen. When the respiratory muscles are involved
dyspnea is produced, which may prove fatal. Eosinophilia is a helpful
diagnostic point. Edema, especially of the face, is an important
symptom. Profuse sweats, itching and tingling of the skin have been
observed.
=Diagnosis.=—Epidemics of this disease are more easily diagnosed than
an isolated case. Among the Germans, if cases of apparent typhoid
fever occur after a picnic or other feasting occasion, where raw ham
or sausages have been indulged in, this disease should be suspected.
Examination of the stools and of the muscles will be of aid. The worms
may be discovered in the pork, a portion of which has been eaten by the
patient.
=Prognosis.=—This depends upon the number of worms ingested. The
prognosis should always be guarded. Early, marked diarrhea is favorable.
=Treatment.=—Prophylactic treatment is of great importance in
trichiniasis. Inspection of the meat supply, is doing much to prevent
trichiniasis; although the most practical way to prevent the disease is
to thoroughly cook all pork and sausages. The central portions of the
meat should be well cooked.
In the feeding of hogs care should be taken that they do not receive
any offal, but only milk, grain, vegetables, etc.
When a person is infected with trichiniasis, thorough and prompt
evacuation of the bowels should be performed at once, so that the
embryos will not have time to pass into the muscles, but will be
ejected from the body. This should be followed by a thorough and
persistent treatment for several days of the liver and intestines;
treat both the liver and intestines directly and through the spine.
The object of this treatment is to render all the digestive juices
active, so that they may dislodge the animal parasite, and to prevent
their passing into the muscles. Also keep the bowels active for several
days.
When the larval parasites have entered the muscles, a treatment cannot
be applied to affect them directly, but the health of the body should
be maintained if possible, and the severer symptoms, as the muscular
pains, weakness and insomnia combated. Thorough manipulation, massage
and hot baths will be of special aid in relieving the stiffness and
weakness of the muscles.
Filaria
(Filaria Sanguinis-Hominis)
There are two varieties. One is a thread-like worm with tapering, blunt
ends, appearing in the blood at night, hence called =nocturna=, while
the other is of slightly different form, appearing in the blood only by
day and is called =diurna=.
The mosquito is the communicating host of the parasite. During the
night, or should the patient sleep during the day, the =nocturna=
appears in the peripheral circulation, while during the other interval
they are probably in the other vessels, particularly the lungs.
After the mosquito has taken blood from an affected patient it requires
from six to seven days for the metamorphosis of the minute filaria
which are then lodged in the probosis of the mosquito and introduced
into the blood of the next victim. The adult parasite is from three to
four inches long and the thickness of a coarse hair, with clear sexual
distinction.
=Pathologically= there are no distinct lesions, as the parent worm
must establish one. Lymphatic engorgement may result from plugging of
the thoracic duct or of a large lymphatic with consequent engorgement
which may develop symptoms in the inguinal glands, pelvic and lumbar
lymphatic trunks. As these varicosities develop rupture may occur; if
into the genito-urinary tract chyluria or chylocele may result, or if
in the abdominal cavity chylous ascites.
Lymphangitis follows a lymph stasis, which later results in
=elephantiasis=. (Barbadoes leg.)
=Symptoms.=—Elephantiasis affects the legs, but the arms rarely; the
labia of the female and scrotum of the male; occasionally the breasts
and other parts of the body. Fever is present on account of the
lymphangitis, accompanied by rigors and delirium and there is marked
local inflammation. The attack terminates in a pronounced sweat. In
deeper parts there is deep seated pain and signs of sepsis, while
abscesses may develop over the inflamed area.
The varicose inguinal glands are doughy, soft and painless, with both
sides affected alike. The scrotum is affected by the extension, and at
times the testes.
=Treatment= is surgical, as the tumors must be removed. Unless the
female worm is also removed this is, however, only palliative.
Methylene blue is said to be destructive to the filaria and it is
practically harmless to the human body. The only treatment is one that
will aid in building up the general health.
HEMORRHAGES
Nasal Hemorrhage
(Nose bleed; Epistaxis)
=Osteopathic Etiology= and =Pathology=.—Traumatism, such as picking
the nose, blows, and surgical operations; straining when coughing;
nasal tumors and ulcerations; lesions of the atlas, or any lesion of
the upper cervical vertebræ, that would interfere with the vasomotor
distribution to the nose and cause local congestion or weakness of the
blood vessels; obstructions to the general circulation; irregularities
or suppression of the menstrual flow may result in nose bleed, as
a vicarious menstruation; suppression of a habitual hemorrhoidal
discharge.
=Pathologically= the great frequency of nasal hemorrhage is due to the
great vascularity of the nasal mucous membrane. Usually in cases of
spontaneous origin, bleeding is from the region of the septal artery.
Spontaneous bleeding may also occur from posterior hypertrophies or
adenoid vegetations. The blood flowing downward into the fauces, is
expectorated in such cases, and may be mistaken for a hemorrhage from
the lungs.
=Treatment.=—The position of the individual is important. He should
assume a sitting posture, or as nearly so as possible. Holding the
nostrils tightly, or plugging them with a piece of cotton, will favor
the formation and retention of a clot, so that the hemorrhage may be
controlled. Pressure upon the carotid artery, or upon the facial artery
at the angle of the inferior maxilla, will slow the blood current
and favor the formation of a clot, also pressure on the sides of the
bridge of the nose may influence it. Correcting any lesions that may
exist in the superior cervical region, as derangement of the vertebræ
or contracted muscles, will remove obstructions or irritations to the
vasomotor system of the affected region, and thus equalize the vascular
system. Holding the arms above the head, and the application of ice to
the nose are of aid in some cases. Also, injection of cold or hot water
into the nostrils. In serious and obstinate cases, where other methods
fail, a plugging of the anterior and posterior nares should be resorted
to, using absorbent cotton or gauze.
Broncho-pulmonary Hemorrhage
(Hemoptysis)
=Osteopathic Etiology= and =Pathology=.—Pulmonary congestion; croupous
pneumonia; tuberculosis; hemorrhagic infarction; ulcers of the larynx,
trachea or bronchi; gangrene of the lung; fibrinous bronchitis,
carcinoma of the lung; lesions of the ribs or vertebræ from the second
to the seventh dorsal inclusive, may cause diseases of the bronchial
tubes or lungs, that result in hemoptysis, or the hemorrhage may be
caused directly by extreme congestion resulting from the disordered
vasomotor nerves; diseases of the heart, such as mitral disease,
causing pulmonary congestion; aneurism of the branches of the pulmonary
artery; vicarious menstruation from deranged menstrual functions;
diseases of the vessel walls, or blood, as scurvy, anemia, hemophilia,
etc.
=Pathologically= in many cases, the lesions are microscopic, consisting
of ruptured capillaries. In other cases larger vessels may be ruptured,
or are the seat of erosion. Many other lesions may be observed. After
death the bronchial mucosa is occasionally found inflamed and the lung
tissues paler than normal.
=Diagnosis.=—A differential diagnosis must be made between epistaxis,
hemoptysis and hematemesis.
In =epistaxis= the blood may flow from the posterior nares into the
pharynx; it causes coughing and a discharge of the blood may occur the
same as in hemoptysis. A careful examination of the nasal region alone
can determine the source of the bleeding.
In =hemoptysis= the history of the case as to pulmonary or cardiac
diseases is to be considered. There is a feeling of weight and of
uneasiness in the chest. A salty taste and a tickling of the throat
precedes the bleeding. The blood is ejected by coughing and is bright
red, frothy, very little coagula, and is alkaline in reaction.
In =hematemesis= the history would indicate disease of the stomach,
spleen, liver or heart. Uneasiness, and occasionally nausea and
faintness, precedes the bleeding. The blood is ejected by vomiting, and
is dark, clotted or fluid, mixed with food, and is of acid reaction.
In a few instances the blood due to hemoptysis may be swallowed, and
vomited.
=Treatment.=—In all these cases of hemoptysis the patient should be
placed in bed and absolute rest demanded. An attempt should at once
be made to correct any lesion that may be found influencing the cause
of the bleeding. Correcting lesions to the vasomotor nerves of the
lungs and bronchial tubes, and equalizing the disturbed vascular area,
may be sufficient in a number of cases. These lesions will be found
principally in the upper dorsal region. In some cases, perhaps, there
is an impairment of the trophic nerves by the same lesions, thus
interfering with the tone of the vessel walls and pulmonary tissues.
The diet should be light, nutritious and non-stimulating. The use of
hot drinks is to be avoided. The rapidity of the heart’s action should
be reduced. This is best performed by thorough treatment of the dorsal
spinal nerves of the left side over the heart, and by inhibition in the
suboccipital region. The ice-bag to the precordia is also helpful. Iced
drinks and the eating of ice is of aid. Stimulation of the systemic
circulation will be of value in helping to relieve the pulmonary
congestion, although the two systems are somewhat independent of each
other. Also, hot foot baths and the evacuation of the bowels may be of
additional value. In cases due to organic disease of the heart, the
mind and body should receive absolute rest, so that the diseased areas
may be strengthened as much as possible; besides a tonic treatment for
the heart’s action is necessary.
After the hemorrhage has subsided care should be taken that bleeding
does not occur again. All irritations of the respiratory tract should
be avoided. A stimulating diet, tobacco and alcohol should be avoided.
Nutritious food and a moderate amount of exercise is indicated.
Hemorrhage of the Stomach
(Hematemesis)
=Osteopathic Etiology.=—Injuries to the stomach; local diseases, as
congestion, ulcers and cancer; vicarious menstruation; a mechanical
obstruction to the portal circulation; spinal lesions to the vasomotor
nerves of the stomach; alterations in the blood; perforation of the
stomach walls, involving a blood vessel; disease of some neighboring
organ.
=Diagnosis.=—A careful examination of the case and of the blood
ejected will be necessary to determine the nature of the cause. The
differential diagnosis as to the source of the blood, whether from the
stomach or lungs, was given under hemoptysis.
=Treatment.=—Correction of any lesions that may influence the blood
pressure in the region of the stomach, is the first requisite.
Treatment of the splanchnics has the greatest influence upon the
vasomotor nerves to the stomach. Treatment of the vagi nerves and of
the fourth and fifth dorsals, will quiet the violent movements of the
stomach, and thus aid in controlling the hemorrhage. Stimulation of
the cervical sympathetics and heat applied to the feet will tend to
equalize the vascular system, and thus lessen the gastric congestion.
The application of a broad flat ice-bag over the stomach will be of
great value. Keep the patient quiet in bed. Surgical interference may
be necessary.
Intestinal Hemorrhage
=Osteopathic Etiology.=—An obstructed circulation of the blood through
the venaporta, as in diseases of the heart, lungs and liver; lesions of
the vertebræ deranging spinal nerves to the intestinal blood supply;
injuries caused by corroding or cutting substances; mechanical injuries
to the intestines; degeneration or erosions of the blood-vessels from
ulcers of the intestines, as from typhoid fever, typhus, dysentery,
etc.; disordered menstrual or hemorrhoidal discharges.
=Diagnosis.=—The locality of the intestines affected can be
approximately determined by an examination of the discharged blood.
When the blood comes from the upper part of the intestines, it is
generally dark and mixed with the intestinal contents, which gives it
a tarry appearance. It is generally red and fluid when it comes from
the lower portion of the bowels. If from the stomach, the blood is
thoroughly mixed with fecal matter. Throwing the passage into water,
the water is colored red when it contains blood, and if the contents
contain bile the water is colored green or yellow. Also, noting the
areas of contracted muscles, as in intestinal colic, will aid in the
regional diagnosis.
=Treatment.=—Absolute rest in all cases is necessary, the patient
remaining as quiet as possible. Food, in severe cases, should not be
given for ten or twelve hours. The bed-pan should be used in caring for
the evacuations. Correction of the lesions along the spinal region,
chiefly of the lower dorsal and lumbar regions, that are impeding the
innervation to the intestines, should be attended to at once. This
treatment tends to relieve any hyperemic condition of the intestinal
mucosa and influences the whole vasomotor area of the mesentery. Direct
treatment of the abdomen in a few cases is of great value to relieve
obstructed and contracted vessels in the mesentery, but in certain
pathological conditions, e. g., typhoid fever, leave the abdomen alone.
Treatment (inhibition) along the spinal column from the sixth dorsal
to the coccyx is helpful in all cases to quiet the peristalsis of the
intestines. In severe cases cold drinks, eating of ice and an ice pack
to the abdomen are of aid. In a few instances surgical measures will be
necessary.
Hematuria
=Osteopathic Etiology.=—Congestion and acute inflammation of the
kidneys, exacerbations of pyelitis, renal calculi, chronic nephritis,
traumatism, tuberculosis, etc.; affections of the urinary tract, as
calculi or lacerations of the ureter; calculi, cystitis, ulcerations,
etc., of the bladder; calculi, gonorrhoea, parasites, etc., of the
urethra; general diseases, chiefly the acute specific fevers and blood
diseases; blows, wounds and traumatic influences, external to the
kidneys; lesions of the renal splanchnics.
=Diagnosis= of the locality of the hemorrhage in the urinary tract:
In hemorrhage from the =kidney= the blood is thoroughly mixed with
the urine, giving a uniform color. Blood casts and leucocytes are
present. In hemorrhage from the =ureters= the blood is usually molded
in clots which conform to the shape of the ureter. The clots appear
like small dark worms. In hemorrhage from the =bladder= the blood is
not thoroughly mixed with the urine and large clots form upon standing.
In hemorrhage from the =urethra= the blood often discharges without
micturition. When urine is passed the blood precedes the passage of
urine.
=Treatment.=—Rest is essential. A correction of the lesions to
the renal splanchnics is necessary to control the congestion and
inflammation of the kidneys. When the ureters, bladder or urethra is
involved, attention must be given to the condition of the spinal column
below the renal splanchnics. In all cases the inhibitory treatment to
the lower spinal column and ice to the loins are of value. If surgery
is indicated, do not delay operation.
Uterine Hemorrhage
Most of the causes of uterine hemorrhage come under the subject of
obstetrics; others under menorrhagia and metrorrhagia. Such will be
found in obstetrical and gynecological works.
=Treatment.=—The patient should assume the dorsal position with the
buttocks raised. If any displacement of the uterus is present or if
there is any foreign material in the uterus, usually such should
be corrected or removed at once. Stimulation of the clitoris is a
most effectual means to control uterine hemorrhage; it contracts the
circular fibres of the uterus. Stimulation of the uterus directly
through the vagina, and over the abdomen, and stimulation of the upper
wall of the vagina, will aid in contracting the uterus. A quick,
unexpected pull of the hair on the mons veneris will have the effect of
closing the capillaries by shock to the nervous control (Dr. Still).
Before closing the os, however, it is well to know that there is no
irritating foreign material within the body of the uterus. Correction
of obstructions of the vasomotor nerves of the uterus through the
splanchnic and lumbar region is important. Compression of the abdominal
aorta, and vaginal injections of hot water may be of aid, as will
also a hot water bag at the lumbar region and ice water bag over
symphysis. In severe cases inversion of the body, if it can be done
with safety, may be performed. Packing the vagina is a method resorted
to occasionally in severe cases.
Hiccoughs
Occasionally there is a case of hiccoughs that has been continuous for
hours or even days and that all efforts have failed to stop. They are
caused by an irritation to the peripheral distribution of the phrenic
nerve from some gastric disturbance or a local irritant acting upon the
center in the medulla. It may follow fright or great emotion and be
associated in persistent form in rheumatism, typhoid fever and other
febrile diseases. It follows abdominal operations at times and is very
distressing. When occurring in elderly people with pneumonia and in
peritonitis with distention it usually marks the end. The same may be
said in case of carcinoma of the stomach and bowels.
=Treatment.=—Go first to the origin of the phrenic nerve at the third,
fourth and fifth cervical and, if there is a lesion as there will
probably be, adjust it and note results. This will be sufficient in
many cases. Failing, bring direct pressure on the nerve just above
the clavicle and anterior to the sternomastoid muscle and release
the scaleni muscles. After this examine and treat at the fifth and
twelfth dorsals. Correct any lesions but best results will be had from
inhibition at these points. Another method is to stand beside the
patient and insert the fingers of both hands under the costal end of
the ribs and lightly pull. Firm pressure over the solar plexus with
flat of the hand is sometimes beneficial. In hysterical cases, drawing
out the tongue will often be effective and it has been suggested
that standing the patient on the head will stop them in short order.
Tickling the nose to produce violent sneezing is an ancient remedy.
Some one of these will cure the case, as osteopathy has never failed so
far as recorded.
The stomach should be emptied of all irritating matter to prevent
recurrence.
VARICOSE VEINS
In varicose veins there is a dilatation of the calibre of the veins
and their valves are insufficient. The walls are irregularly thinned,
lengthened and tortuous.
=Osteopathic Etiology= and =Pathology=.—The =internal saphenous= is
the vein most frequently affected, although any vein throughout the
body may become varicose. Commonly, varicose veins occur in the lower
extremities and occasionally in the arms.
The =valvular insufficiency= is caused by stretching of the wall
of the vein, thus separating the thin, free edges and leaving an
interspace that allows regurgitation of the blood. The valves becoming
insufficient, the column of blood in the veins has no support against
gravity, and being interrupted in its course does not flow normally
into collateral channels. The walls of the veins become thin, as does
also the adjacent skin, thus increasing the danger of a rupture, either
external or subcutaneous.
Varicose veins are most frequently found in females, following
uterine enlargements. The condition may be due to any obstruction
or constriction that prevents the free return of blood from the
veins, such as dislocations of the hip, either slight or complete,
dislocations of innominata, contractions of adductor magnus muscle
affecting femoral vein, prolapse of diaphragm obstructing vena
cava, tissue constrictions about the saphenous opening, garters,
and, in fact, anything that might impede the free venous flow. The
tendency to varicose veins increases as age advances, and many cases
are found among people of middle life who have been accustomed to
standing a great deal. Injuries to the pelvis, thigh or leg, lessening
the nutrition to the leg, or injuries to the nerves, as vertebral
dislocations in the lower dorsal or lumbar regions (the fourth lumbar
especially) may be causes of varicose veins. Pregnancy or tumors
in the abdomen or pelvis, causing pressure upon the iliac veins,
are occasionally causes. Distention of the sigmoid flexure, causing
pressure upon the left iliac vein, or distention of the cecum; pressing
upon the right iliac vein, are fruitful sources, as are also diseases
of the heart and lungs. Varicose veins of the upper extremities are due
to occupations requiring overuse of the arms.
=Complications.=—Varicocele, hemorrhoids, labial varix in the female,
varix over pubes, ulceration and eczema due to disturbances of
nutrition, edema and thrombus.
=Symptoms.=—=Lower Extremities.=—Cramping pains in the limbs upon
rising. Fullness and heaviness of the limbs. Inspection may reveal
superficial varicose veins near the saphenous opening, upon the
external thigh, in the popliteal space, upon the external leg or behind
the ankles. Edema and congestion of the foot and ankles occur in a few
cases. Pain is quite a prominent symptom, due to pressure upon the
nerve fibres. Eczema and itching are due to disturbed innervation and
blood supply to the skin. Ulceration may occur, due to the bursting of
a vein.
=Upper Extremities.=—Before the varicosity appears there is usually
pain or a feeling as of a sprain in the involved region of the arm. The
pain is usually confined to a muscle or group of muscles.
=Treatment.=—The majority of cases are due to disorders about the
pelvis, hip or thigh, and the treatment resolves itself into the
removal of these obstructions or constrictions. Occasionally cases are
caused by partial dislocations of the hip joint, which can be easily
overlooked during a hurried examination. The slipping of an innominatum
is an important factor. Rest in a recumbent position, attention to the
general health, and especial attention to the bowels and liver, are
essential in acute attacks. Occasionally the heart and lungs are at
fault. Treatment twice per week should consist of removing any of the
numerous causes of the condition, and spinal treatment as well; then
the leg should receive special attention. Remember, thrombi may form
and the vein must, under no circumstances, be touched in the treatment.
Begin by carefully rotating the leg to stretch contracted tissue about
the saphenous opening, then separate the tendons of the popliteal space
and follow the course of the vein to the abdomen and relax tissue about
it. Keep patient off the feet as much as possible and elevate the leg
when sitting.
In rupture of varicose veins the hemorrhage can be arrested by
elevating the limb and applying pressure with the fingers, above and
below the wound, until a compress and bandage can be applied. The
support of the varicose veins by elastic stockings will ease the
pain and prevent edema in many cases, but, as a rule, it is a direct
hindrance to the circulation on account of the necessity of having the
stocking fit closely. Surgical operations are rarely indicated.
Phlebitis
(Phlegmasia alba dolens; milk leg)
An inflammation of a vein. In the condition described here it is a
puerperal septic inflammation of the femoral vein. About the third
week after confinement there is a swelling of the leg with or without
redness. Great pain accompanies the condition and the temperature
gradually rises to 102°-3°. As understood by osteopaths, this is the
result of a partial closing of the saphenous opening during parturition
so that the venous flow is partly stopped.
=Treatment= consists in carefully rotating the leg at the hip so
that the fascia lata is spread, opening the lumen of the vein so
the congestion will drain out. There will, also, probably be found
innominate or lumbar lesions which must be adjusted with the result
that almost immediate relief is given as a rule.
Chronic Phlebitis
The chronic form shows considerable inflammation along the line of
the vein marked by tenderness, edema and thickening of tissue. The
entire leg may be more or less involved through circulatory injury.
In these cases will be found definite innominate lesions of a primary
type or the distortion is superinduced by lumbar lesions. A few cases
are quickly cleared up through adjustment that is readily secured.
However, in others, there being considerable thickening of the
sacro-iliac articulating tissues, some time may be required to get
complete adjustment and consequent restoration of femoral circulation.
In addition to this, careful abduction, flexion, hyperextension and
circumduction is indicated. This last technique should be executed with
great care and with due regard to pathology. If Dr. Still’s emphatic
command were followed, that all maternity patients should have both
legs rotated and innominates inspected, there would be no phlebitis
cases, acute or chronic.
THE RECTUM
To treat the rectum intelligently and thoroughly, requires special
knowledge on the part of the osteopath. A speculum should be used in
many cases when making an examination, and all abnormal conditions
carefully inspected with the eye; although much can usually be noted by
the examination with the finger alone. The best position in which to
give an examination and treatment is to have the patient on the side,
with thighs flexed upon the abdomen. In a few cases the patient may
lean over an operating table.
The =objects= of =rectal treatment= are many—to relieve hemorrhoids,
etc., of the mucous membrane; to correct a dislocated coccyx; to treat
an enlarged prostate gland; to replace a prolapsed rectum; to tone the
lower bowel in cases of constipation; to give reflex stimuli to the
heart and lungs, in cases of fainting, paroxysms, etc.; to relieve
severe pains in the rectum at the time of the menstrual period, and
to relieve congestion, inflammation, contracted tissues, etc., of
local sources; to relax spasms in croup, and to remove tension to the
nervous system in some forms of insomnia. In fact, so many diseases are
affected by reflex irritations from the rectum that its examination
is a necessity in many cases. The phrase “when in doubt treat the
rectum” was coined by a progressive student and there is an element of
truth in it. Surgical assistance to treatment will be considered under
hemorrhoids.
The principal need of osteopathic internal rectal treatment, is: (1)
To relax all contracted and constricted fibres about the walls of the
rectum and between the sacrum and coccyx. (2) To correct a dislocated
coccyx. (3) To dilate the sphincters thoroughly, in order to relieve
irritations about the sphincters, and to stimulate the sympathetic
nerves.
Work through the rectum to treat an enlarged prostate gland, to correct
a displaced uterus, and to make a more thorough examination of the
uterine tissues, the Fallopian tubes and the ovaries, is a frequent
occurrence.
In giving =local treatment=, cleanse the fingers and oil the index
finger; then, after introducing it into the rectum relax the contracted
tissues by an upward sweeping motion on all sides. This treatment
relieves all obstructions to vessels and nerves caused by contracted
fibres, and tones the rectal walls. In prolapsed sigmoid, causing
obstructive constipation, the finger can be used to separate the folds
of mucous membrane and open the lumen of the bowel. Frequently there
will be enough tone to the muscular coat so that the irritation
will set up slight peristalsis and cause the bowel to draw up to a
considerable degree. In children where there is much straining at the
stool, the sigmoid will often be found down and by using the little
finger the same results can be accomplished and much relief given.
To =dilate= and =stretch= the sphincters thoroughly a speculum or
dilator should be used under anesthesia; still, considerable can
be done by one or two fingers. The sphincter should be thoroughly
stretched in all directions, care being taken when an instrument is
used that too much force is not applied. Secure as much voluntary
relaxation of the sphincter as possible. Inhibition at 2d and 3d sacral
will aid. This treatment is of aid in cases of hemorrhoids and prolapse
of the rectum, in constipation due to the loss of tonicity of the lower
bowels, in tightness of the sphincters, in pain of the rectum, and in
stimulating the heart and lungs. In cases of a prolapsed rectum, due
to irritation about the sphincters, causing tenesmus, this treatment
is of special value, as it gives the sphincter a physiological rest.
Frequency of treatment per rectum must depend entirely on the patient
and disease. It can be given daily in many cases and is frequently so
indicated in acute hemorrhoids, prostatic troubles, etc.
According to Quain, the sensory nerves to the rectum are from the
second, third and fourth sacrals. Some of the motor fibres of the
circular muscles of the rectum are from the lower dorsal and upper
two lumbar nerves; these pass by the aortic plexus to the inferior
mesenteric ganglion. Associated with these fibres, are the inhibitory
fibres of the longitudinal muscles of the rectum. The sacral nerves
contain motor fibres to the longitudinal muscles, and inhibitory fibres
to the circular muscles of the rectum. In all cases of rectal trouble,
the lower dorsal and upper lumbar vertebræ may be found deranged, and
thus interfere with the rectal nerves. Relaxation of the sacral muscles
over the sacral foramina has a marked effect in relieving =tenesmus=.
In dysentery, where there is a constant desire to defecate, a thorough
upward relaxation of the sacral muscles will give great relief.
=Proctitis= or inflammation of the rectum is not an uncommon disorder.
The disease has been divided into acute, chronic, gonorrheal,
dysenteric, and diphtheritic. Foreign bodies, impacted feces, cold,
purgatives, prolapse of the sigmoid, and lumbar, coccygeal and
innominate lesions are the most important causative factors. The
=acute= form is more frequently found in older people. The =symptoms=
are tenesmus, frequent evacuations of blood and mucus (possibly pus),
prolapse of the mucous membrane, feeling of fullness, and radiating
pains. The gonorrheal, diphtheritic and dysenteric forms are of rare
occurrence, with the exception that the dysenteric may be somewhat
frequent. The =treatment= is to remove all local irritations, cleanse
the bowels, and put the patient in bed. All irritating foods are to be
prohibited. Use milk, soups, beef juice, soft boiled eggs and similar
foods. Correct all osteopathic lesions; especially will inhibition over
the sacral foramina relieve the tenesmus. Cold water in the rectum and
applied to the anus will be beneficial. If abscesses occur, employ
surgical measures.
=Prolapse= of the =rectum= is another common rectal disorder. Acute
cases are especially found in children, due to straining at stool. The
sacrum is more straight, and thus violent straining, coughing, etc.,
the more readily produces prolapse. Prolapse of the mucous membrane
is the most common, although all of the rectal coats may be involved.
Prolapse of the upper part of the rectum into the lower or invagination
is frequently met with by osteopaths. The sigmoid may prolapse and
also affect the rectum. The =treatment= is to return the mass, using
an anesthetic if necessary. If it is not retained, place straps across
the buttocks. Then with attention to lesions that may be disturbing
and weakening the rectal walls, and thorough local toning treatment,
the prognosis should be favorable. In high rectal prolapse local
attention is necessary as well as deep treatment through the abdominal
walls to the sigmoid and upper rectum. The use of Cole’s irrigator for
high enema will replace and elevate both the upper rectum and sigmoid
and greatly aid in a cure. Regularity of habits and proper food are
essentials.
Hemorrhoids
=Definition.=—A dilated or varicose condition of the plexus of veins
lying in the submucous tissue of the lower part of the rectum. The
dilatation of these hemorrhoidal veins may extend into the adjoining
subcutaneous tissues and mucous membrane, and the perirectal plexus and
adjoining venous plexuses of the bladder, uterus, vagina and sacral
canal may become involved.
=Osteopathic Etiology= and =Pathology=.—The chief predisposing cause
of piles is man’s erect position and the absence of valves in the
hemorrhoidal veins. Thus a retardation or stagnation of the portal vein
would cause a backward movement of the entire column. It is evident
that such a downward pressure of the blood in the portal system would
dilate and extend the blood vessels, to the very capillaries in the
rectal region.
This retardation may arise from several causes: obstruction of the
portal vein, from diseases of the liver; diseases of the heart;
obstruction or destruction of the capillaries of the lungs; pressure
from a gravid uterus, tumor, etc.; a general loss of tonicity of the
abdominal walls, as in persons who take but little exercise; the
excessive use of wine, tea and coffee; injuries to the spinal column,
especially in the lumbar, sacral and coccygeal regions; a dislocation
of an innominate bone; lifting; constipation; straining at stool;
carelessness of the calls of nature, etc. Catarrh of the bowels may
cause a congestion of the mucous membrane and consequently piles.
Hereditary influence may be a factor in a few cases.
Hemorrhoids are divided into two classes, =external= and =internal=.
An =external pile= is one that arises from the margin of the anus
outside of the external sphincter muscle. It differs from the internal
pile from the fact that it is always composed either of skin or
hypertrophied connective tissue, forming a mere cutaneous tag, or else
it is composed of a small cutaneous vein enlarged by a clot of blood.
The =internal hemorrhoids= are composed mostly of enlarged veins and
are connected by hypertrophied connective tissue. They have a free
arterial supply and are covered by the mucous membrane of the rectum.
They are due, usually, to an affection of the middle hemorrhoidal blood
supply, thereby being a part of the visceral vascular system. Internal
hemorrhoids, when protruding, can be returned within the rectum, while
the external ones cannot. The venous turgescence varies in size from
a pea to a walnut. They may be single or may surround the entire anal
opening like a bunch of grapes.
Repeated attacks of engorgement of the veins involved, will in time
change the mucous membrane or the submucous tissue, and cause catarrhal
swelling of the mucous membrane, or hyperplasia of the connective
tissue. At first the hemorrhoid is usually a blood tumor, but in
chronic cases it is oftentimes made up largely of connective tissue.
Owing to pressure of the varicose veins, atrophy of the mucous and
submucous tissue may occur. The white or slimy hemorrhoids occur when
these roughened parts of the mucous membrane become inflamed and
thickened, resulting in suppuration.
=Symptoms.=—The symptoms are quite diagnostic and need not be mistaken.
Besides the appearance of tumors, there may be constipation, pain
during stools, indigestion, headache and pain in the back. Hemorrhages
frequently occur, and if suddenly checked, as by cold, other
disturbances may occur, as congestion of the head, lungs, stomach,
liver, kidneys, etc., which may result in hemorrhages from these
organs. Fissures of the anus, contraction of the rectal sphincters and
prolapse of the rectum may occur. Occasionally in old people there is a
varicose state of the veins of the neck of the bladder, and in females,
of the uterus and vagina, which causes hemorrhages of these organs.
The communicating plexus of the spinal canal may be affected, causing
weight, numbness and pain, so as to simulate a lesion of the cord. The
patient may have a hypochondriacal disposition and be disinclined to
work, especially at mental labor.
=Prognosis.=—Depends upon the predisposing and immediate causes, but a
large majority of cases can be cured.
=Treatment.=—A thorough examination of the patient should be made, not
only to ascertain the extent of the local trouble, but to understand
thoroughly the general health of the sufferer, especially the state of
the heart, lungs and liver.
Many cases of hemorrhoids are caused by lesions in the lumbar and
sacral regions, and especially dislocations of the coccyx (usually
anterior) and the innominata. Correcting these lesions will oftentimes
cure the hemorrhoidal disorder. Simple dilatation of the rectum once
a week, in addition to other treatment, is of great aid in curing
hemorrhoids, not a few of the cases being cured by dilatation alone.
It relaxes the tissues about the tumefied vessels. Treatment is rarely
necessary above the second lumbar, (unless there is more or less of a
constitutional disorder) as the superior hemorrhoidal blood vessel of
the inferior mesenteric is given off about opposite the second lumbar.
In cases where the abdominal walls have become relaxed, a treatment
should be given to strengthen the abdominal muscles and viscera.
Particular attention should be given the liver. Treatment should be
given over the abdominal muscles directly, and also to the spinal
nerves of the same region. The diet should be strictly regulated and
the bowels kept loose, and stimulants, indigestible food, full meals
and too much meat should be avoided. Injection of cold water before
stools is a good prophylactic, and applications of cold water to the
protruding pile will be of some help in relieving the congestion. A
squatting position during defecation will relieve considerable strain.
=Hemorrhoids= in the =acute state=, within twelve or twenty-four hours
from the engorgement, yield quickly to treatment. The local technique
is to relax the tissues about the tumor, especially above and along
the line of the vein, then with pressure at its base carefully force
out the engorged blood. Follow this up by another treatment the next
day and continue until normal. The vein wall, not being permanently
stretched, will contract and if the irritating cause is found, there
is little danger of return. Remember, in a case like this, the danger
of embolism and be sure a clot has not formed. Cases of hemorrhage at
stool, during or immediately following evacuation, when not from a
bleeding pile, may be of considerable quantity and the source difficult
to locate. It may be due to ulcerations or easily ruptured capillaries
of the mucosa, but the cause will in many cases be found in the
innominata and a reduction of the lesion give relief.
=Rectal conditions=, associated with piles, and =requiring surgery=
after treatment has failed, are: =hemorrhoids=, which are of such long
standing as to become organized tissue, (these will keep up continual
irritation and cannot be absorbed); =saccules= or pocket, formed by
folds of mucous membrane catching and holding particles of feces,
gradually enlarging and ending with considerable reflex symptoms;
=fistulae=, complete or incomplete, may frequently be healed by
adjusting coccygeal or innominate lesions, but are apt to recur from
the tract not being clean in the center or bottom; =abscesses= in or
about the anus or rectum are usually traced to coccygeal, innominate,
or local interference to circulation; =fissure=, complete dilatation
under anesthesia to insure physiological rest of parts, is probably
the best treatment. It is suggested that a fissure may be healed
by making surgically clean, touching with iodine and coating with
collodium. =Papillae= are small, hard black-capped papules in the lower
rectum, each one involving a nerve terminal and causing much distress.
All these conditions give rise to much discomfort and with surgical
assistance can be cured without much trouble. It is not necessary
to make them a major operation and do uncalled-for things. The less
surgery about the rectal sphincter the better.
=Care= of the =anus= and =rectum= after operation or successful
treatment is a factor in preventing return. First, there should be
soluble, non-irritating stools, which do not tend to bring about
prolapse from straining. Diet and regularity contribute to this.
Second, absolute cleanliness. This can only be obtained by following
the stool with an enema of four or five ounces of cool water and
immediately passing it. It will bring forth a considerable quantity of
feces which would otherwise have been retained for another twenty-four
hours. This procedure following, as it does, the stool does not in any
way interfere with the normal function or create a habit. The anus
should then be thoroughly washed in cool water and as thoroughly dried.
Dusting with borated talcum powder, starch, etc., will prevent chafing.
GENITO-URINARY
THE PROSTATE GLAND
This gland is subject to several painful and annoying diseases,
controlling, as it does, the flow of urine and exerting such a
profound influence over the sexual functions. The nerves to the
prostate pass between the gland and the levator ani muscle, and the
secretory branches are from the sacral nerves, while Quain gives the
sensory as from the tenth, eleventh (twelfth) dorsal, first, second
and third sacral and fifth lumbar. Lesions affecting the prostate are
occasionally found at the tenth and eleventh dorsal and fifth lumbar,
while the innominate lesions are common causes of trouble. These should
be corrected, if present, and local treatment given to the gland.
“Massage of the prostate,” says Lydston,[47] “properly performed, is
one of the most valuable advances in genito-urinary therapeutics that
has been developed in many years.” Osteopathic technique is to place
the patient on the side, knees flexed, and standing in front insert
the index finger. Care must be used not to bruise the gland and it
must be touched lightly when sensitive. Relax tissue about the gland,
and, then, from the median line with an outward movement, massage the
surface of each lobe. This influences the blood and nerve supply, while
the pressure will tend to relieve congestion. Length of treatment, as
well as frequency, depends entirely upon conditions. Do not make the
mistake of treating the perineum instead of the gland and do not gouge
it with the finger. Remember it is sensitive tissue.
=Hypertrophy= is most commonly met with in practice, as twenty per cent
of men past middle life are said to be afflicted. It is probably not a
sequence of old age, but due to chronic, congestive and inflammatory
conditions. Anything which would produce these conditions—spinal
lesions, excessive venery, masturbation, or other more innocent
causes—would in time bring about enlargement. As the length of catheter
life is estimated at six years it is of great importance that the
condition be early recognized, for in advanced stages surgery is the
last resort. In early stages the prognosis is good, either for a
cure or to stop further enlargement, while many enlarged ones at the
catheter stage have been greatly benefited or cured. Treatment of the
gland once per week is usually enough, but in older cases can be given
semi-weekly. Look well to nerve and blood supply.
=Acute Prostatitis= is a serious and painful inflammation, causing
urinary retention usually. It results from trauma, horseback riding,
over exertion, gonorrhea and its maltreatment, etc. Lower dorsal and
lumbar lesions are frequent. This condition must be closely watched.
Inhibition of the sacral nerves will help control pain and stop any
spasm of the sphincter. Cold applications to the gland externally at
the perineum will aid in reducing inflammation. Local treatment should
at first be given to the adjacent tissues as the gland will be very
sensitive. Later direct massage will be of great benefit.
=Chronic Prostatitis= may follow an acute attack or it may originate
as a chronic or subacute affection. Frequent micturition and dull
pain, referred to the perineum and rectum, with the local examination,
make diagnosis sure. The spinal lesions should be corrected and the
gland massaged. This will induce absorption, by squeezing out the
inflammatory products and do much toward preventing future hypertrophy.
“Massage is done by the finger. The patient is placed in the knee-elbow
position and massage employed for four minutes daily. The value of
massage in chronic prostatitis is very great, but should be employed
with much caution and never in cases of suppuration.”[48]
=Prostatorrhea= is often taken for spermatorrhea and any irritation
of anterior sacral nerves would cause undue activity to the secretory
nerves to the gland. This is easily determined.
=The Seminal Vesicles= can be reached just above the prostate, and if
inflamed and tender or if engorged by inspissated seminal fluid, local
treatment will be of benefit. Frequent massage, daily in some cases, to
the gland and treatment to the sympathetic nerves above the trigone of
the bladder, to the nerve fibres passing along the spermatic cord, and
to the arteries directly, will be of the greatest aid in impotency.
In =Chronic Gonorrhea=, where the gonococcus has found lodgement in and
about the gland, it can be more readily dislodged by massage than by
any other form of treatment.
=Retention of urine= from nervous excitement or other minor causes, can
often be overcome by local massage of the prostate.
=Spastic stricture= can usually be cured by work about the prostate and
its innervation.
Varicocele
A varicose enlargement of the veins of the spermatic cord, epididymis
and testicle. In varicocele the pampiniform plexus is usually enlarged,
but all the veins of the cord may be involved. The swelling gets
smaller under compression or in a horizontal position and enlarges
again on standing erect. It is almost invariably found on the left
side, and the testicle on the affected side is generally smaller and
softer than its fellow.
The predisposing =causes= are a longer and tortuous spermatic vein on
the left side; the absence of support of the veins from surrounding
muscles; the imperfect valves; the entry of the left spermatic vein
into the renal vein at a right angle, instead of at an acute angle like
the right vein; the more liability of compression of the left spermatic
vein by accumulation of feces in the sigmoid flexure; the lack of
normal exercise of the sexual functions in young, unmarried adults.
Lesions in lower dorsal and upper lumbar affect the condition; the
eleventh dorsal particularly. A lesion at the second lumbar may cause
neuralgia of the testicle with engorgement of the vein.
The exciting causes are straining during stool, heavy lifting,
excessive sexual indulgence or anything that would determine more blood
to the testicles. Varicocele is similar to the varicose state of the
hemorrhoidal veins and may have like causes.
The =diagnosis= is easily made. The feeling of the veins between the
fingers like a convolution of earth worms; dull, aching, dragging
sensation, and possibly prostration, weakness and dejectedness of
spirits, are characteristic symptoms. “The condition is devoid of
danger, except that it often begets morbid fears on the part of the
patient, usually the result of suggestion.”[49]
The =treatment= consists of regulation of the bowels, removal of such
predisposing and exciting causes as may be found, treatment of the
vessels along the spermatic cord, and treatment to the lower dorsal
and lumbar regions. In severe cases a suspensory bandage will give
temporary relief. Surgical interference may be necessary in some cases
in order to effect a cure.
Impotency
Results from treatment in these conditions are particularly gratifying
and offer a great field of activity in this day of sensational medical
advertising. This condition can well be classed under four heads,
Exhaustive, Traumatic, Psychic and Organic.
=Exhaustive Impotency= is the result of functional abuse, masturbation
in early life, excessive venery, coupled with intemperate use of
alcohol and improper diet without sufficient sleep. It can be
symptomatic in neurasthenia. There is at first irritation of the spinal
centers, which causes exaggerated sexual activity, and later this is
followed by complete or partial loss of function. The first step is
for a radical reform in habits; regulation of the bowels, as they will
likely be constipated; direction of the mind into wholesome channels,
and then skillfully directed spinal treatment. Where there has been
masturbation, look well for sources of irritation to the parts; a
long foreskin or adherent prepuce indicates surgical aid, or there
may be a lesion at the sacrals involving the nervi erigentes or, of
greater importance, the pudic nerve. The innominatum can be at fault
in this. The lower dorsal, ribs and upper lumbar are of importance.
Kraft-Ebing says: “Conditions of absolute impotency are, however, rare,
and are caused =only= by severe vertebral and nervous diseases.” Nerve
irritation undoubtedly is the cause of sexual perversion (outside of
heredity and malformation) so their relief is as necessary to bring
about reform of habits as to effect a cure. Where the general health is
affected constitutional treatment should follow. Motschutkovsky uses
suspension in treating these cases with good results. The effect is to
separate the vertebræ, freeing spinal nerve and blood channels. The
prostate will probably be found in an irritated, sensitive condition,
as well as the seminal vesicles. Treat as outlined under the prostate
gland. Ligation of the dorsal vein of the penis is recommended by some
authorities as tending to aid turgescence of the organ. Prognosis is so
dependent on how well the patient follows directions, age, environment
and general condition that it is hard to give, but as a rule is rather
favorable.
=Traumatic Impotency= is a strictly osteopathic classification, for
the reason that sexual weakness is often traced to lesions resulting
from remote injuries. These injuries may be to the spine, ribs or
sacrum. The lower spine may be impacted from a fall or the result of
long continued riding on rough streets or the railway. This inhibits
the nerve supply to the extent of often seriously impairing the sexual
functions. If the cord is injured to any extent the results are more
serious. Treatment in these cases has given uniformly good results. It
will always be due to a specific lesion, so the examination must be
thorough.
=Psychic Impotency= is the form most frequently met with and generally
the most difficult to cure, yet it should not be if the patient’s
confidence can be secured, for in many cases sexual power is but
slightly impaired, but owing to the suggestions given by the medical
advertisers the victim diagnoses his own case as hopeless. “It is not
uncommon that virility returns with the peace of mind.”[50] Observe all
the procedure given and then inspire hope where it can be honestly
given, and if the patient is progressing favorably, other things being
equal, advise early marriage under strict rules of conduct. If already
married, conjugal relations should be most carefully investigated and
the wife taken into your confidence. Her cooperation in correcting very
possible errors in sexual matters, as well as sympathetic aid in easing
the patient’s anxiety and chagrin, will be invaluable. Nothing but
the frankest understanding between all parties is permissible and the
osteopath must be in absolute control.
=Organic Impotency= is the result of a cortical injury or disease. The
latter is the most common, as it follows tabes dorsalis, paralysis
affecting the lumbar cord, some cases of diabetes, etc. Also, any
congenital malformations or absence of all or part of the organs.
Prognosis in these cases is bad, as cure is seldom possible.
In no other class of cases will honesty, tact and good judgment count
for so much or the rewards be greater.
FOOTNOTES:
[47] Twentieth Century Practice of Medicine, Vol. XXI.
[48] C. Kruger, Munch Med. Woch.
[49] Deaver’s Surgical Anatomy, Vol. II, p. 652.
[50] Vecki, Sexual Impotence.
HEAT STROKE
(Heat Exhaustion: Sunstroke)
An affection produced by exposure to excessive heat. Two varieties are
recognized; heat exhaustion and thermic fever.
=Heat Exhaustion.=—This is caused by prolonged exposure to high
temperatures, combined with physical exertion. Fatigue, overeating,
alcoholic drinking, and poor sanitation predispose. This may occur
without exposure to the direct rays of the sun, the heat being
artificial, or in mid-summer, in close, confined rooms the same result
will be produced. There is vasomotor paralysis, the surface of the body
is usually cool, the temperature may be as low as 95 degrees F., while
the pulse is small and rapid.
=Sunstroke= or =Thermic Fever=.—This is usually caused by prolonged
work under the direct rays of the sun in a humid, very hot and sultry
atmosphere. This is caused by the action of the heat upon the heart
centers producing a paralysis of those centers.
=Pathologically=, rigor mortis develops early and is marked.
Putrefactive changes appear early, owing to the high temperature of
the cadaver. The various organs are deeply congested, the venous
engorgement is extreme in the cerebrum. There is rigid contraction of
the left ventricle; while the right is dilated and filled with blood.
The blood is fluid and dark. Parenchymatous changes take place in the
liver and kidneys.
In heat exhaustion with lowered temperature there is a paralysis of
the vasomotor center in the medulla, and the heat is dissipated more
rapidly than it is produced. In thermic fever the heat regulating
centers become paralyzed by the action of the excessive temperature and
more heat is produced, and less dissipated than normal.
=Symptoms.=—=Heat Exhaustion.=—This may occur gradually or suddenly
with a severe attack of faintness, pallor, dizziness, headache,
cold perspiration and sometimes blindness as the first symptoms.
Consciousness is rarely entirely lost. In severe cases there is more
permanent collapse. The pulse is rapid and feeble and there is great
restlessness and delirium. Under prompt treatment mild cases may
recover in a few hours, while in extreme cases death may occur almost
at once from heart failure.
=Thermic Fever.=—In some cases the patient is struck down, becomes
quickly unconscious, and may die within an hour, or death may be
almost instantaneous. In other cases there is pain in the head,
oppression, dizziness, nausea, vomiting and sometimes diarrhea or
frequent micturition. Soon unconsciousness sets in, the face is
flushed, the eyes injected, the breathing labored and there is a
temperature of from 105° to 110° F. The pulse is full and rapid, the
skin hot and dry and the pupils are contracted. There is usually
complete relaxation of the muscles, and in some cases there is
twitching and jactitation. Epileptiform convulsions are rare. In fatal
cases the coma deepens, the pulse becomes feeble, rapid and irregular,
the breathing hurried and shallow and death occurs in a few hours.
Favorable cases are indicated by a fall in the temperature and by the
return of consciousness. In these cases recovery may be complete. In
some cases the patient may never be able to stand even moderate degrees
of temperature, which often produce excitement, headache and pain in
the cervical region. Failure of the memory, and the loss of power to
concentrate the mind are sometimes sequelæ. Meningitis, epilepsy and
insanity are also sequelæ.
=Diagnosis.=—This presents little difficulty. The history and
circumstances preceding the attack are very important in making the
diagnosis. The diagnosis between heat exhaustion and sunstroke fever
is readily made. In heat exhaustion the temperature is =lowered=, the
pulse is feeble, consciousness is rarely completely lost; in sunstroke
fever the temperature is extremely =high=, there is usually complete
unconsciousness, and the pulse is full and rapid.
=Prognosis.=—This should be guarded, depending upon the severity of the
case.
=Treatment.=—In cases of =heat exhaustion= remove the patient to a
shady place and apply water to the face, chest and spine. Thoroughly
treat the upper cervical region, in order to control the impaired
vasomotor centers and nerves. If the temperature is below normal a hot
bath should be given. Keep the heart and lungs stimulated.
In =sunstroke=, place the patient in a recumbent position and loosen
all constricted clothing, and stimulate the heart’s action. The high
fever is to be met promptly. Place the patient in a bath of water,
to which add ice freely. The patient may also be rubbed with ice,
and ice water enemata may be employed. The muscles of the neck will
be found contracted, probably due to cerebral hyperemia. A thorough
relaxation of these muscles will be of great aid in equalizing the
vascular system. It is a good plan to thoroughly relax all the muscles
along the spinal column for the same purpose. When the temperature
nears normal the baths should be stopped. After the temperature has
been reduced place the patient upon a cot with ice to the head. The
cervical treatment should be repeated as often as necessary. The diet
of the patient should be liquid for a few days. Plenty of water and
stimulation of the kidneys and bowels will be found beneficial. The
sequelæ are to be treated according to the condition. Much can be done
for the sequelæ of heat exhaustion and sunstroke. Lesions will be found
corresponding to the regions involved. Deep contracted muscles are
common.
DEPARTMENT OF OPHTHALMOLOGY
By C. C. REID
It is the desire to make this discussion on the eye the most useful
possible to the whole profession. Let it be plainly understood that
there is no effort to cover every phase of eye pathology but to
elaborate eye diseases and therapeutics strictly from the standpoint
of osteopathy. There are many very elaborate and extensive text books
and even encyclopediæ written on the eye by the medical profession.
The world of ophthalmic literature is extensive and profound. Just so
are the elaborations on the general field of medicine. Such things as
hereditary influences, congenital deformities, amblyopias, albinism,
coloboma and the field of ophthalmic surgery does not concern us at
the present time in an osteopathic text book. This department is
dedicated to a scientific development of ophthalmic therapeutics along
osteopathic lines of thought. Some things in the therapeutics of the
eye concern all schools alike. For instance, proper cleanliness and
antiseptic precautions in regard to the eye, dietetics, hygiene and
the care of the general health. The same anatomy and many of the same
methods of examination and diagnosis obtain in all schools. It is
the intention to go into the opthhalmic therapeutic field in these
discussions where osteopathy has a different outlook with a definite
distinct reform to offer in the viewpoint of the anatomy, methods of
diagnosis and the system of treatment.
How to Examine an Eye
It has been said that one should be a good general man in order to be a
competent specialist. This is especially true in regard to ophthalmic
therapeutics. Many systemic diseases have eye symptoms and pathology.
The same blood and lymph that nourishes and bathes different parts
of the body, also circulates in the structures of the eye. In the
examination of the eye, heredity, occupation and environment are to be
taken into consideration. Osteopathic lesions may exist from falls,
strains, twists, blows, colds and exposure and impair the integrity
of the metabolic processes of the eye through the nerve connections
and blood supply and lay the foundation for a great variety of eye
diseases. With these lesions existing about the neck and upper dorsal,
it is only required to have some insignificant local irritant to start
symptoms and cause pathology apparently out of all proportion to the
etiology. It is important then that one understand the nerve centers
and reflexes and the osteopathic logic underlying these conditions or
else he must frequently work without a satisfactory explanation of the
etiology and consequently be more or less unscientific in his treatment.
The eye examination should consist of the case history, the family
history, inspection, osteopathic examination, especially from the
fourth dorsal vertebra to the occiput and especial examination of the
eye by inspection and other methods.
=1. The Case History.=—Thoroughness of the doctor, or the lack of it,
will be readily displayed at this point. Every little thing, as far
as possible, that has a bearing on the case should be observed and
uncovered in the case history. The physician should want to know every
fact that helps him to better understand his case. Patience in hearing
the history will often be of great assistance. It gives light on the
physical and mental condition of the patient. Much can be gained by
being careful and attentive. Notice carefully what he emphasizes and
what he thinks is the most important. Inquire in regard to headaches,
nervous symptoms, previous eye trouble and past illnesses. Get a
venereal history if present, as many eye diseases are complicated or
caused by syphilis or gonorrhea.
=2. The Family History.=—Inquire as to blindness in the family and
about the age it occurred, if any. Get a venereal history if possible.
=3. Inspection.=—Much inspection can go on while the history is being
taken. Observe the countenance, whether there is strabismus or frowning
due to eye strain, photophobia as suggested by the effort to avoid the
light; note symmetry. Look closely at the lashes, lids, conjunctiva,
cornea and iris. Note any scales or crusts on the lids at the root of
the lashes. Turn the lids for further inspection. Note the size and
relation of the eyes. Exophthalmos may be due to an enlarged globe
in high myopia, to Graves’ disease, orbital tumor and paralysis of
the extrinsic muscles, or staphyloma. In blepharospasm there may be a
corneal ulcer or a rupture of the eyeball. An exact examination must
be made at the first visit in order for a diagnosis to institute the
best treatment possible. Study the conjunctival sac for congestions,
hypertrophy, swelling, tumors, foreign bodies, trachoma bodies and
secretions. In all forms of conjunctivitis the congestion is most
marked in the fornix and decreases toward the sclerocorneal junction.
In iritis and cyclitis there is a circumcorneal injection, a pink or
red color radiating from the cornea. Note any corneal pathology in the
way of ulcers or abrasions and foreign bodies. Compare the tension of
the eyes.
=4. The Osteopathic Examination of the Eye.=—This heading is put
here in order to show what osteopathy has to offer that is distinct
as belonging to our system and not practiced by any other school.
Osteopathic research so far has shown that osteopathic science has much
to offer on etiology and diagnosis and treatment in eye diseases. The
case history, family history and inspection should require but a few
minutes but they are essential to a proper examination and may aid us
in what to expect osteopathically. Weak nerves will cause asthenopia.
A broken arch, an innominate lesion or a slipped axis may cause weak
nerves. The osteopathic eye examination then should consider the whole
mechanism of the body. In case glasses are being worn for asthenopia
they may readily be made unnecessary by osteopathic treatment in
the correction of the lesions and building up the system. Some time
ago some parents sent their daughter to me to have her eyes fitted
for glasses. They stated that she had been to different doctors and
opticians and no one had ever given satisfaction. They said she was all
right every other way if her eyes were properly fitted with glasses.
They did not want her examined or treated otherwise because she would
be well every other way with correct glasses. Her vision was right
eye 5-20, left eye 5-15 or about one fourth vision in each eye. A
plus .87 diopter sphere combined with a plus 3 diopter cylinder in
axis 90 gave her perfectly normal 5-5 vision in each eye. This gave
her perfect satisfaction until she started to school in September,
a couple of months later. Before the end of the first month she was
having trouble with her eyes and was again sent to me by her parents.
Her vision was reduced to 6-15 in each eye with her glasses on. She
wondered and no doubt the parents did, if it was not another case of a
misfit in glasses similar to all her previous experiences. This time I
insisted upon a thorough physical examination against all protest. The
following lesions were discovered: the left innominate was up and back
or tilted posteriorly, first lumbar anterior and to the right, sixth
and first dorsals to the right. The case was not refracted again. I
took particular care the first time and I was quite sure the refractive
error was corrected. It was all explained to the parents and regular
osteopathic treatment was begun. In less than a month practically
every lesion was corrected, her vision returned to normal and she also
was cured of an annoying backache with which she had been bothered
for years. Her nerves were depleted a great deal. She got benefit in
ways that she had not dreamed of. This approach to the eye is not
considered by physicians in general, even the oculists. I have had
about ten special courses in medical colleges and hospitals on the eye,
ear, nose and throat, and I have never heard anything mentioned that
would indicate any ideas of the logic involved in this case. Surely
osteopathy has much to offer in eye troubles that is new and unique.
The osteopathic examination of the eye then should begin with the
feet, going then to the innominates, lumbar, dorsal, ribs and cervical
regions. Oculists are too prone to rely upon crutches (glasses) in the
treatment of asthenopia.
It is easy for the osteopath to conceive how lesions of the upper
dorsal and cervical regions may occur and disturb the nerve and blood
supply to the eye. This is why asthenopia appears so frequently with
ordinary use of the eyes, even without abuse or refractive errors.
The Lumbar Region
The lumbar region should be carefully examined, especially for any
curvature which might cause a disturbance of the equilibrium above.
Compensatory curves or individual lesions would be the result with a
consequent interference with the integrity of the nervous reflexes to
the eye.
The Dorsal Region
The same may be said of the dorsal region as of the lumbar in regard
to curvatures. There is one individual lesion in this region that very
frequently exists with eye troubles, i. e., the 2nd dorsal vertebra
lateral. Any of the upper four dorsals in lesion may be a causative
factor in predisposing to disease of the eye but it has been my
observation that the 2nd is involved most often. In severe headaches
due to eye strain from refractive error, a good diagnostic symptom is
tenderness and contraction at the 2nd dorsal even when there is no
subluxation.
The Cervical Region
This region should have particular care in search for individual
lesions. It is quite easy to pass over some small cervical lesion that
may be causing serious disturbance, especially if the neck happens to
be fleshy. I have corrected cervical lesions and stopped twitching of
the eyelids (orbicularis palpebrarum) and other muscles about the face.
The first case I ever saw was twenty-two years ago when I was a junior
at Kirksville. Dr. F. P. Millard, now of Toronto, was a room mate of
mine. He was constantly annoyed by a twitching of an eyelid. I did not
find any lesion for it. We went one day to see Dr. Still at his home
and told him of our difficulty. He said without examination that the
3rd cervical was in lesion. There was a senior student present whom
the “Old Doctor” directed how to use the proper technique. There was
a sharp pop, the vertebra evidently went into right relation, the
twitching stopped. I understand the patient has had very little trouble
since.
Injuries, exposure and strains to the spine may have antedated an
innominate lesion and caused weak joints, muscular and ligamentous
tension, local inflammations and partial immobilization of joints.
All this would have its modifying effects upon the manifestation of
secondary lesions from the innominate abnormality. This makes the study
of the bony relations very complex and the effect upon the numerous
blood vessels, nerves and other soft tissues still more complicated.
The Ciliospinal Center
Following osteopathic examination and giving proper importance to
lesions below the fourth dorsal vertebra, we must remember a special
significance to be attached to lesions of the =upper dorsal= in
relation to the eye.
Almost any author on nervous diseases or diagnosis will discuss this
center. Many of us have it not sufficiently impressed, hence I repeat
some known relations. The =ciliospinal= center consists of a nuclear
group of cells in the lateral horn of the last cervical and two upper
dorsal segments of the spinal cord. From this nucleus fibers pass to
the anterior division of the eighth cervical and first and second
dorsal nerves and become the white rami communicantes which are
efferent in their function. These fibers pass to the =inferior cervical
sympathetic ganglion=, thence upward with the sympathetic trunk through
the =middle= and =superior cervical sympathetic ganglia=, along the
carotid plexus to the vessels of the face and eye, to the glands of
that region, to the unstriped muscular fibers of the levator palpebræ
superioris and to the =dilator pupillae muscle=.
Any strong feeling or emotion (which of course is perceived and
interpreted by the brain cortex) will cause a dilatation of the pupil
of the eye. The cervical sympathetic being cut, dilatation does not
take place. The rami of the cervical, first and second dorsal cut, the
phenomenon stops. It is evident the ciliospinal center is under the
influence of a center or centers in the brain. Bing says “There is even
an idiomotor mydriasis, which may be brought about by a very vivid
mental conception of darkness.”
It has been noted that paralyzing lesions of the cervical sympathetic,
of the last cervical and two upper dorsal segments of the cord, and of
the anterior roots and rami communicantes of the same, will result in
myosis.
The efferent rami are also vasomotor, secretory and trophic. It must
necessarily follow that congestive and inflammatory conditions,
secretory perversion of the lachrymal, Meibomian, Zeissian and
perspiratory glands, and disturbance of the normal nutrition of any of
the orbital tissues may result from lesions of the lower cervical and
upper dorsal vertebræ.
Osteopathically we know that such a lesion may not be sufficient to
be paralytic in its effect, but stimulatory. In this case we may
note a pupil habitually too wide and more or less photophobia from a
superabundance of light. The unstriped muscle fibers in the levator
palpebræ superioris may be unduly contracted making an appearance of a
slightly bulging eyeball when it is only a wide open eye.
One who has eye strain from a refractive error, overuse of the eyes, or
unbalanced muscles will as a rule have tenderness at some spot in the
region of the =ciliospinal= center. A mechanical lesion at that part of
the spine may or may not exist in such conditions, but I believe the
soreness is there every time. This is one of the diagnostic points in
differentiating =headache= of eye strain from other conditions.
White rami are only in the dorsal region and to the second lumbar
and from the second, third and fourth sacral. It has been noted
that lesions of the cervical vertebræ do not have as profound
an effect upon the eyes as do lesions of the first three dorsal
vertebræ. The plausible explanation of that is that the cervical
vertebræ have no white rami from their corresponding nerves in the
bulbo-spino-sympathetic-ciliary arc as have the upper dorsal.
From all the foregoing statements one can readily contemplate the
intricate complexity of our osteopathic problems in relation to the
eye. Combine this logic of the lesions outlined and the ramifications
of the structures with their normal and perverted functions and combine
it with contributing causes, such as infection, exposure, irritants,
etc., and amidst the great diversity we reduce much miscellaneous,
unclassified material to a degree of simplicity. Many otherwise
unexplainable conditions become reasonably clear.
Dr. Louisa Burns under “The Experimental Demonstration of Osteopathic
Centers” has this to say:
“Somatic Reflexes”
“In the first series of experiments, the electrodes were placed upon
the nasal mucous membrane of animals under anesthesia. The muscles near
the third thoracic vertebra were at once strongly contracted....
“The electrodes were then placed upon the conjunctivæ. The muscles near
the second vertebra were then contracted. There were also slight and
inconstant contractions of the cervical muscles....
“The electrodes were placed upon the eye ball. The muscular
contractions were sometimes noted near the second thoracic vertebra,
but the reaction was not constant. The cervical muscles were scarcely
contracted at all.
“The electrodes were placed upon the outer surface of the eye lids.
The facial muscles were contracted very quickly and forcibly, but no
contraction of the muscles of the upper dorsal region were noted....
“The =superior cervical ganglion= was exposed to view, and the
electrodes placed upon it. The pupils became greatly dilated, the
conjunctivæ became lighter in color, and the mucous membranes of the
nose and throat were also lightened....
“The =Gasserian ganglion= was exposed to view. The ganglion was
stimulated directly. The upper thoracic muscles were very strongly
contracted, and the blood vessels in the area of the distribution of
the fifth nerve were immediately and strongly contracted. Some of the
sympathetic fibers are carried by way of the fifth nerve. In order to
exclude the effect of the direct stimulation of these fibers, the fifth
nerve was cut, and the central end was stimulated by the electrodes.
The muscles of the upper thoracic region were contracted, as before.
The vessels in the area of distribution of the fifth nerve were
contracted after latent period of a minute or so....
“The stimulation of the central end of the cut fifth nerve caused
strong muscular contractions in the upper thoracic region, and also
constriction of the vessels in the area of distribution of the fifth.
Direct stimulation of the superior cervical ganglion produced effects
identical with those produced before the mutilation.
“The spinal cord was cut above and below the superior cervical
ganglion. This cut was made from behind, and the sympathetic chain was
uninjured. The effects noted after both operations were the same, and
can be described as one.
“The stimulation of any cranial structure failed to cause reflex
contraction of the muscles in the upper dorsal or the cervical region.
“Stimulation of the cranial structures did not produce any vascular
changes except those which might be referred to the direct effects of
the electricity upon the vessel walls.
“Direct stimulation of the =superior cervical ganglion= produced the
effects noted before mutilation.
“Therefore the cervical portion of the spinal cord is an essential
element of the reflex arc by way of which sensory impulses from the
cranial structures are able to affect the condition of the upper
dorsal muscles, and also in the path by which these impulses are able
to affect the size of the blood vessels of the cranial structures
themselves....
“Mechanical stimulation of the tissues near the second thoracic spine
was followed by a contraction of the blood vessels of the cranial
mucous membranes and the conjunctivæ, by a dilatation of the pupils,
and an increased secretion of saliva. These effects were practically
invariable....
“The superior cervical ganglion was subjected to mechanical stimulation
by the manipulation of the tissues over it. In animals, this maneuver
was followed by dilatation of the pupils and by a contraction of the
cranial vessels, which was soon followed, if the stimulation continued,
by a dilatation which was rather persistent.
“After the =extirpation= of the =Gasserian ganglion= without the
injury of the sympathetic nerves, the mechanical stimulation of the
tissues near the second and third thoracic vertebræ caused the same
vaso-constriction and =pupilo-dilation= as was observed in the animal
before mutilation.
“After the destruction of the cervical portion of the sympathetic
chain, and after the extirpation of the Gasserian ganglion in most
animals, the mechanical stimulation of the tissues in the upper dorsal
region did not produce any perceptible effects....
“Mechanical stimulation of the tissues near the second and third
thoracic spines caused dilatation of the pupils and contraction of the
vessels of the cranial mucous membranes.
“Inhibition, or the maintenance of an artificial lesion, caused
dilatation of the vessels of the nasal mucous membranes and of the
conjunctivæ. The eye ball was also somewhat congested. The pupils were
dilated in this case also.”
The Nose and Throat in Eye Trouble
An examination of the eye would not be complete without a careful
inspection of the =nose and throat=. The same nerve and blood supply
that go to the eye is tied up so definitely with the nose and throat
that when there are lesions of the nose and throat the eye is often
affected secondarily. Just recently a case of =dacryocystitis= came
into my office. After I had carefully examined her eye, spine, nose
and throat, she informed me that she had been to three eye specialists
before and not one of them had ever looked at her nose and throat,
not to mention the spine. She had cervical and dorsal lesions, and
=diseased tonsils=. The =inferior turbinate= on the side of the
dacryocystitis was curled out so that it lay against the external
wall of the nose almost if not altogether blocking the entrance of
the =lacrymal duct= to the inferior meatus. This was evidently the
predisposing cause of her dacryocystitis.
In =neuralgia= of the eye, =blepharitis=, =obscure pain=,
=conjunctivitis= and often deeper troubles you will find a bad
condition of the =nasopharynx=, such as adenoids, vegetations, pus
pockets, adhesions in the fossa of Rosenmuller, contraction of the
soft palate, disturbed relations of the septum and turbinates, sinus
trouble, poor drainage, exostoses and polyps. In eye disease all these
things should be discovered if they are present, in order to get best
results and in order to make a careful diagnosis.
Examination of the Eye by Special Methods
The first thing after the family history, personal history, inspection
of the eye and the osteopathic examination, is to find out how well the
patient can see. To test the acuteness of vision certain test letters
are used. Snellen’s Test Letters are good. The normal eye can read 3-8
inch letters at twenty feet. The test letters on the cards usually
range in size to be read at 10, 15, 20, 30, 40, 50, 70, 100 and 200
feet. The most desirable distance is 20 feet. If at the distance of
twenty feet he reads the 3-8 inch letters his acuteness of vision would
be marked 20-20 or normal. Always use the distance between patient
and chart as the numerator of the fraction and the number above the
letters which he reads as the denominator. If he is twenty feet away,
the numerator remains twenty and the denominator changes according to
the line of letters seen on the test cards thus: 20-15, 20-30, 20-70,
or 20-200 may express the vision. If the patient could not see the 200
feet letters at 20 feet he must be brought nearer, say 10 feet, for him
to see the large letters; his vision would be 10-200. These fractions
representing the acuteness of vision may be expressed in meters. Some
charts have letters numbered that way.
If the vision is good enough for small objects to be clear, the near
point should be taken. This would show the amount of accommodation of
the eye. This is expressed in diopters.
A =diopter= is the unit of measurement of the =refractive= power of
lenses. =Lenses= are numbered by their refractive power in diopters. A
lens that has a curvature that will refract parallel rays of light and
bring them to a focus at one meter distance is said to be a one diopter
lens. This unit of measurement for the refractive power of lenses was
proposed by Nagel in 1866. It soon became quite generally used.
The focal distance of a lens decreases as the strength of a lens
increases. One diopter lens (written 1 D) has a focus of one meter (1
M) or 100 cm distance. A 2 D lens has a focal distance of ½ M or 50
cm. A 4 D lens has 25 cm focal distance and a ½ D lens has 100 cm ÷
½ = 200 cm distance or 2 M. Trial cases have in them lenses varying in
strength from .12 D or .25 D to 20 D of the spheric form. We will not
discuss the trial case here.
Accommodation in the Eye
=Accommodation= in the eye is the ability of the eye to vary its focal
point. When the normal eye (emmetropic) is at rest its focal point is
at infinity so far as parallel rays are concerned. This is called the
far-point or the “=punctum remotum=” (P. R.).
When the eye looks at letters twenty feet away it scarcely accommodates
at all to get a focus, or so little that it may be disregarded in
ordinary practice. Now if one brings fine print close to the eye he
will find a point so close that it becomes indistinct. This point is
the near-point of focus or the =“punctum proximum”= (P. P.). The range
of accommodation is the difference between the refractive power of the
eye when it is at rest and when the accommodation is exerted to the
utmost, the difference between the P. R. and the P. P.
If one must accommodate one diopter to get a focus at one meter or
forty inches distance, at thirteen inches or reading distance one must
accommodate at least 3 D in order to see the letters clearly. If 3 D
were the total of his accommodation he could not read at that distance
but a few minutes; because the accommodation could not be held at its
maximum for long at a time. Eye strain with its train of symptoms would
result. Hence it is quite important to find the near-point or punctum
proximum in order to judge in regard to eye strain in an emmetropic
eye. If there is a refractive error, allowance for it must be made
accordingly.
As a person gets older the accommodation in the eye becomes less
and less until at 45 years of age he can only use 4 to 5 D of
accommodation. This is so close to the amount required for reading
that he has some eye strain. He begins to hold his paper farther away
from him so he requires less accommodation. This condition we call
“old sight” or =presbyopia.= An emmetropic eye at forty-five to fifty
years of age requires a plus glass to make up for some accommodation in
reading.
Frequently there are latent disturbances of equilibrium of the
extrinsic muscles of the eye. This is =heterophoria.= If it is a
latent convergence it is =esophoria=; if a latent divergence it is
=exophoria=. The latter is more frequent. Hyper- and hypophoria are
used for upward or downward tendencies. Normal muscular balance is
=orthophoria=.
Cause the patient to fix on an object about thirteen inches away with
both eyes; push a sheet of paper in front of one eye and watch behind
the paper, the eye thus covered. If heterophoria exists the eye will
move slightly from its point of fixation since it no longer sees the
object. In orthophoria it will remain fixed as long as the other eye
sees the object; the innervation to the different muscles is properly
distributed.
A Maddox rod found in any complete trial case may be placed before one
eye. Have the patient fix on a candle flame, say twenty feet away.
The flame appears drawn out into a luminous line. This line can not
be fused with the candle flame as the other eye sees it if there is
heterophoria. The amount and kind of disturbance is somewhat indicated
by the distance and direction of the luminous line and the flame. The
exact amount can be measured by the use of a prism that will cause them
to fuse.
Next the patient should be taken to the dark room and a careful
inspection of the anterior segment of the eye should be made with
oblique illumination. First use the unaided eye, then use a lens that
magnifies. The 20 D plus lens from your trial case will suffice for the
magnification. Note the transparency or lack of it in the cornea and
crystalline lens; the depth of the anterior chamber and the appearance
of the pupil and iris. Now we are ready for the ophthalmoscopic
examination.
=The Ophthalmoscope.=—This is an instrument that commands great
respect. Any one who is interested in eye troubles must have and use
the ophthalmoscope if he expects to be efficient in diagnosis, upon
which, of course, intelligent treatment must forever depend. One must
try and try again in order to become proficient in the use of the
ophthalmoscope.
A Schematic Eye is of great assistance to a beginner who does not
have clinics or patients on whom to practice. Such an eye with full
directions can be obtained at almost any optical goods store. It will
make the study of ophthalmoscopy easy and interesting. The pupil can
be regulated to any size and the eye can be made short (hyperopic),
long (myopic) or normal (emmetropic) for study.
The efficient use of the ophthalmoscope makes the diagnosis of internal
diseases of the eye as easy as the diagnosis of external diseases of
the eye. Only some rare conditions will puzzle, and that is true of any
part of the anatomy.
The ophthalmoscope is a simple instrument; its chief function is to
illuminate the interior of the eye. The value of ophthalmoscopic
findings depends on their correct interpretation by the examiner.
The ophthalmoscope has a mirror to reflect the light into the eye. It
has two discs on which are mounted convex (plus) and concave (minus)
lenses. The larger disc has seven plus and eight minus lenses. To these
may be added the lenses in the smaller disc making many combinations.
A drop of a 2% solution of cocaine or homatropine may be used as a
mydriatic where one can not otherwise see clearly the fundus. If no
mydriatic is used a somewhat weak illumination should be employed in
order not to arouse the accommodation to much activity and make the
pupil small. If there is any opacity in the media a strong illumination
should be used. The room should be dark; the darker the better.
There are two methods of using the ophthalmoscope. The =indirect= and
the =direct= methods. One is more useful at one time and the other at
another time. By the indirect method we view the whole field of the
fundus more readily but less in detail. With the ophthalmoscope before
his eye the examiner’s face is twelve to fifteen inches from that of
the patient. When the “=red reflex=” of the eye is seen a plus 13 or 16
D lens is interposed near the patient’s eye. This magnifies the field.
The image is inverted. As a rule it is best seen with a +4 D lens in
the aperture of the ophthalmoscope.
This method is especially more satisfactory in high degrees of myopia
and astigmatism. The =optic disc= is the objective point. One may see
a retinal vessel first; this should be followed to its emergence from
the disc. From this point view all parts of the fundus by having the
patient look in different directions. This is better by the indirect
method than for the examiner to vary his position.
The direct method of ophthalmoscopy is better for detail work and in
all cases except high degrees of myopia and astigmatism. It is also
better in determining errors of refraction. The patient looks straight
across the room. For a beginner it may be essential to dilate the
pupil, hence the schematic eye as suggested.
If the examiner has a refractive error, he should wear his own glasses
or correct by throwing in front of his eye proper lenses in the
ophthalmoscope. Face the patient and sit on the side of the eye to be
examined. Use left eye to examine the patient’s left eye and right eye
for the patient’s right. Examiner and patient keep both eyes open. The
examiner may not be able to suppress the image of his other eye and may
have to close it part of the time. Catch the “red reflex” some 15 to 18
inches away and move close to the patient’s eye. The “red reflex” color
varies with the error of refraction, the transparency of the media, the
degree of pigmentation and the size of the pupil. A blood clot will
make it redder, some exudates will make it gray or yellow.
The examiner may approach as close as half an inch from the eye to be
examined. Find the optic disc and examine all points of the fundus from
it. Rotate in glasses to correct the patient’s refractive error if he
has any. The strongest plus glass with which the fine retinal vessels
can be clearly seen will represent the =hyperopia= of the eye. This
is true only if the examiner’s accommodation is at rest. The weakest
minus glass with which the fine retinal vessels can be clearly seen
represents the =myopia=.
=A Normal Fundus.=—The color of the fundus is due to the blood vessels
of the retina and choroid and the connective tissue of the choroid and
sclera. Variation is due to the pigment. In the albino it is light
pink. In the negro it is dark reddish. There are all gradations between
the two.
The =optic disc= is the end of the optic nerve as it comes into the
eye; it is circular in shape, pink in color, and sharply defined. It is
about 1-16th of an inch in diameter; about 15° to the nasal side of the
pole of the eye and slightly above the horizontal. There may be a dark
=choroidal ring= around the disc or part way around. There may also
be a white ring caused by the sclera. As a rule there is a depression
in the center of the disc out of which the retinal vessels emerge and
spread out over the fundus.
The =fovea centralis= or point of clearest vision is located two and a
half disc diameters to the temporal side of the disc. Around this is a
circular area of light yellow, the =macula lutea=.
The subject of ophthalmoscopy has been touched upon somewhat in detail
because of its great importance to the general practitioner. Every
osteopathic physician should know the ophthalmoscope well enough
to recognize the ordinary lesions inside the eye. When we take up
pathological conditions of the eye we will have occasion frequently
to refer to the ophthalmoscopic appearance. Without the use of this
instrument all of our clinical field research on internal diseases of
the eye is valueless. Many have told me they have cured cataract with
osteopathic treatment, some say they have cured specific neuroretinitis
with no sequelæ, others testify to opacities and blindness from
various causes. Invariably we ask if they used the ophthalmoscope in
their diagnosis and with it watched the progress of the case. Almost
invariably the answer is “no, it looked like it,” “the symptoms
indicated it,” or “Dr. so and so, an oculist diagnosed it as such.”
Fellow Osteopaths! we can not base our claims on this kind of data.
With a little study and practice the ophthalmoscope can be mastered.
Not till then can we get reliable statistics on internal diseases of
the eye in our case reports. Osteopathy has much to reveal to us in
this field and for the sake of the science and our patients we appeal
to every one to do the work here set forth.
Diseases of the Eye
OSTEOPATHIC MANIPULATION FOR EYE DISEASES
A general correction of lesions should be made in order to give perfect
alignment and equilibrium. Lesions that affect the nerve and blood
supply will be found from the fourth thoracic to the occiput; more
often at the occiput, atlas and axis in the cervical region and the
second and third thoracic in the dorsal region including the ribs.
Correction of these lesions must have specific attention in every case
of eye disease that shows any tendency to chronicity or in repeated eye
disease and exacerbations.
A thorough upper spinal treatment to insure good mobility of all joints
and establish freedom of fluids and forces is recommended.
The =nose=, _throat_ and =sinuses= should be examined for pathology. If
the tonsils and pharynx are not normal the cotted index finger should
be introduced into the mouth until the anterior pillar of the fauces
is reached. A mouth gag may or may not be used. Massage the tonsil
through the anterior pillar then move to the top and press down on
the tonsil with a pumping motion. Repeat this from below the tonsil
and posteriorly. Slip the finger under the soft palate and stretch it
thoroughly. Clean out any adhesions and vegetations in the vault of the
nasopharynx and fossa of Rosenmuller. Stretch the pillars of the fauces
by pressing down on each side at the root of the tongue.
If the sinuses are diseased they should be drained. If the nose is
diseased and has abundance of secretion, first use irrigation for
cleanliness.
Manipulation in the nose will be of great benefit in some eye diseases
as pathology there frequently has an important bearing on diseases of
the eye. The nose is often too narrow and contracted. The first inch of
the nose is muscular and cartilaginous; it is of even more importance
to dilate the nose in contractured conditions than it is the sphincters
at the lower end of the rectum. The great benefit derived from rectal
dilatation has been recognized for years.
In dilating the contracted nose a wide blade nasal speculum may be
used. The cotted and oiled little finger may be used where it is
properly adapted in size. The dilating can be done with practically
no pain and no damage to membranes or other tissues. It should not be
extended beyond the cartilaginous and muscular part. Manipulation of
the turbinates and tissue further back may be done if needed, by the
use of instruments. The Edwards turbinate adjuster instrument (Aloe
Co., St. Louis) or the Ruddy Nasal Third Finger (Sharp and Smith,
Chicago) are the best instruments so far devised for this operation.
A thorough stretching of the =eyelids=, manipulation of the =eye ball=
and the points of the fifth nerve are indicated in many diseases.
The lids may be stretched by pulling them from side to side. The cotted
forefinger well oiled (sterile vaseline) may be slipped into the
conjunctival sac back of either lid and with the thumb on the outside
the lid may be massaged or stretched in any direction. The points of
the fifth nerve may readily be influenced at their respective exits
about the orbit. The eye ball and deeper contents of the orbit can be
profoundly treated by pressing the finger into the orbit above, below
and at the sides of the bulb and pushing it in all directions as far
as possible. The Ruddy eye finger instrument was devised for this deep
manipulation of the orbital and bulbar structures. It is of high value.
One finger may be laid on the closed eye and with a tapping motion with
the other hand a vibration or oscillation of the orbital structures may
be had. This is a useful treatment.
The wise selection and skillful use of these various methods of
treatment for the eye will solve most of our difficulties.
This short survey of osteopathic methods will aid us in the more
specific discussions to follow.
Neuralgia
A considerable number of people seem to be subject to attacks of pain
in one or both eyes. These attacks of pain come at varying intervals;
in some cases several times a day, in others as far apart as one
or two weeks. The pain will suddenly start almost without warning
and with very little provocation, and last from one to twenty-four
hours. It is very severe and the patient frequently thinks something
terrible is wrong. Something terrible is wrong so far as his comfort
is concerned. But in these cases to which I am referring there is no
organic trouble with the eye. The patient does not need glasses. There
is no sign of inflammation. Vision is not disturbed. Local examination
of the eye with the ophthalmoscope reveals that the fundus of the eye
is normal. There is no symptom connected with the eye except pain,
occasionally accompanied by a slight redness. I have had several cases
in my own practice and my attention has been directed to cases of other
physicians.
These cases differ from _tic douloureux_ in that there is no muscular
spasm. In fact, motor nerves do not seem to be involved. The
involvement seems to be largely in the =fifth cranial nerve=, usually
the supraorbital, or other smaller branches of the ophthalmic division
of the fifth cranial. Sometimes we note slight dilatation of the pupil
with more or less congestion. This would indicate an involvement of the
sympathetic branch to the eye.
The lesions discovered in these cases have been a subluxation of the
occiput upon the atlas or an upper cervical lesion and frequently some
involvement at the second dorsal. There has been noted also trouble in
the nasopharynx such as contractures of the muscles of the soft palate
and adhesions in the fossa of Rosenmuller.
Misplacements of the uterus have also been found in some cases.
Treatment
Nearly all these cases are curable with from one week to six weeks
treatment. Of course the treatment must be intelligently directed after
a correct diagnosis as to the cause. The cause can usually be removed.
One case to which my attention has been directed was that of a woman
about forty years of age who had very severe pains. With all the local
treatment of the eye and otherwise she got practically no results
until she had replacement of the uterus, which brought immediate
relief. Other cases have no trouble on that kind but have lesions of
the cervical region and on correction of these lesions the neuralgia
disappears. Other cases have had the nasopharynx cleaned out by the
finger operation and the stretching of the soft palate which relieved
the neuralgia immediately or in a few days. Numbers of cases have been
to medical physicians and had various eye remedies administered locally
with no permanent benefit. Of course the treatment was administered at
the wrong place.
The ramifications of the sympathetic and fifth cranial nerves are so
complex and far-reaching that we must keep in mind that one or more of
many causes for the trouble may exist and be quite remote from the seat
of the pain.
Diseases of the Eyelids
Occasional factors are bee stings or insect bites, which completely
occlude the palpebral fissure. We may have some palpebral edema from
lid abscesses, chalazion, hordeolum, dacryocystitis, panophthalmia and
so forth. In =hemorrhagia subdermalis= there is so much spongy tissue
beneath the skin about the eye that the blood extends easily and far.
The red tint will soon change to a reddish blue and then become dark,
what is known as a black eye (ecchymosis). This frequently results
from a blow. The skin is sharply attached around the orbital margin by
tense connective tissue so the area of the hemorrhage is limited to the
region of the orbit. There may be spontaneous rupture of some of the
vessels by hard sneezing or coughing, especially in young children.
In older people it may indicate a fragile condition of the vessels,
arteriosclerosis or some trouble with the kidneys. The diagnosis of the
eye condition is not difficult but the cause of the hemorrhage in that
region might be investigated further. Local treatment is of some value
in these conditions. They may be soothed by cold compresses. In bee
stings and insect bites use an alkaline compress. Manipulation about
the eye and osteopathic treatment of the neck with a view to directing
a better circulation to that region will aid much.
Herpes Zoster Ophthalmia
This affection of the supraorbital branch of the fifth cranial nerve
may extend to the eyelids. It may not go beyond the stage of blistering
and redness with some edema. However, it is possible for it to become
gangrenous and even extend to the conjunctiva and cornea. I had one
case of herpes zoster gangrenosa of this region. There were several
gangrenous spots as large as a dime on the forehead and extending down
in the region of the eyelid. The process extended to some extent on the
cornea and in healing left a condition of irregular astigmatism.
=Treatment.=—The prognosis in herpes zoster is always favorable under
osteopathic treatment. Lesions of the cervical region will almost
invariably be found interfering with the sympathetic connections of
the fifth cranial nerve causing the trophic disturbance to the region.
Osteopathic treatment applied to these conditions will always hasten
normalization. The affected part might be kept covered with some
soothing lotion to keep the skin soft.
Hordeolum
This is commonly known as a =sty=. It is due to suppuration of the
=glands of Zeiss=. It is a harmless affection but causes pain and
inconvenience.
=Diagnosis.=—Swelling and pain with a small inflammed nodule in the
palpebral margin is quite diagnostic.
=Treatment.=—The circulation is obstructed in this region. The effort
should be made to open the circulation before pus has formed. This can
frequently be done and the hordeolum aborted by carefully picking up
the eyelid and rolling the nodule between the fingers. This will cause
some pain but if it is kept up for a moment or two about every hour
through the day with an occasional thorough treatment of the neck the
sty will usually be aborted. If pus forms it should be opened as soon
as it points and then the squeezing and rolling process may be employed
again, which will aid rapidly in the freeing of the circulation.
Chalazion
This is a =Meibomian cyst= in the eyelid. It shows as a circumscribed
swelling on the inner side of the lid. It frequently becomes large
enough to produce some deformity of the lid. A chalazion is movable on
the tarsal cartilage. It is a chronic condition and the cyst may become
as large as a bean. There may be more than one in the same lid.
=Treatment.=—When a chalazion is small and not of long standing it can
frequently be cured by osteopathic treatment. Introduce the finger into
the conjunctival sac under the lid, and with the thumb externally,
grasp the chalazion between the finger and thumb; roll it thoroughly.
Squeeze and massage it two or three times a week for awhile. This,
combined with a thorough treatment of the neck, will result in a cure.
If at the end of six weeks the condition has not disappeared surgery
should be resorted to.
Blepharitis
This is an inflammation of the eyelid. It is either =acute= or
=chronic= according to the cause. Acute blepharitis may be due to heat
or injury. Chronic blepharitis affects the glands of the lid causing a
perversion of the secretions. There is usually the formation of crusts
and scales. This condition is known as =blepharitis sicca=. In some
cases infection will form little pustules at the roots of the cilia.
There is soreness and aching. There may be photophobia. The nasal
region may be involved. Osseous lesions of the cervical region are
usually present. Refractive errors frequently exist in these cases.
Occupation or environment may expose to dust or wind sufficient to keep
up the irritation.
=Treatment.=—Change environment. See that there is thorough cleanliness
of the lid. Rub or pick away all scales. Use a bland ointment. Correct
any cervical or upper dorsal lesions.
Ptosis
This is =congenital= or =acquired=. In congenital ptosis operation
seems to be the only treatment. Acquired ptosis is amenable to
treatment frequently. The cause is some lesion interfering with the
passage of proper nerve force to the levator muscle of the lid. The
lesion may be at the origin of the third nerve, at the cortical nucleus
in the sigmoid gyrus or in the trunk of the third nerve, or a lesion
of the muscle itself. Tumor, trauma, syphilis, sclerosis, hemorrhage,
gout or rheumatism, or anything that will produce a peripheral neuritis
are causative factors. Lesions of the cervical and upper dorsal by
reflecting back upon the nerve centers may produce a ptosis.
=Treatment.=—Remedial measures according to indications. Cases due
to osteopathic lesions as indicated will usually yield readily to
treatment. Where there are other factors treatment must be varied
accordingly.
Trichiasis
This is a condition in which part or all of the eye lashes turn
inward and touch the eye ball, due to cicatricial contractions in
the conjunctiva and tarsus. Many of the cilia are so small in these
conditions that it is very difficult to see them. A loupe or a
magnifying glass must be used in order to discover them.
=Dystrichiasis= is a condition where the cilia come in irregularly
growing in all directions, some of them turning in toward the eye ball
and causing irritation.
=Treatment.=—An epilatory should be used to extract all of the wild
hairs. Care should be taken to get out the finest ones as they will
frequently cause irritation if not removed.
Entropion and Ectropion
=Entropion= is a turning in of the eyelid and =ectropion= is a turning
out. These conditions may be spasmodic and temporary. Entropion is more
often due to cicatricial contraction in old blepharitis or trachoma
conditions. In some cases the condition may be corrected by the use
of strips of adhesive plaster. In cicatricial conditions operation is
the rule. Spasmodic ectropion may be corrected sometimes by curing the
conjunctivitis. Bandaging may be resorted to. In paralytic ectropion
osteopathic treatment may serve to produce a complete cure. Operative
procedure should be a last resort.
Diseases of the Lachrymal Apparatus Dacryocystitis
=Dacryocystitis= is an inflammation of the lacrymal sac. It is due
to some lesion in the nose, malposition of the inferior turbinate or
a poor blood and nerve supply to the lacrymal region as determined
by cervical lesions. The sac becomes infected and we have a
=dacryocystoblennorrhea.= Pus and tears are regurgitated into the eye
through the puncta. There is irritation and the conjunctiva may become
infected at any time, also the cornea. It is a dangerous and annoying
affection.
=Treatment.=—Osteopathic measures have something to offer along this
line. The medical idea seems to be completely surgical in recent years.
The first and only thing to be done surgically is to obliterate the sac
or dissect it out and curette the nasal duct, completely destroying
the apparatus. Lancing does not affect a cure. By treating for a good
nerve and blood supply to that region, the irrigation of the nose and
a thorough squeezing of the sac each time with a view to forcing the
solution in the sac down through the nasal duct into the nose, a cure
may be effected in many cases. If these cases can be gotten before
infection has taken place, in the state of epiphora or the backing up
of the tears into the eye, thorough treatment along the lines just
indicated will in nearly all cases result in a cure.
Boric acid solution should be used to wash out the sac when pus is
present. The attempt should be made to force it into the nose. Probing
properly done is of value in many cases. These cases should be followed
up with great care.
Treat the neck thoroughly and spring the inferior maxilla.
Diseases of the Conjunctiva Conjunctivitis
The conjunctiva is a mucous membrane that coats the posterior surface
of the eyelids and the anterior surface of the eyeball. It forms a sac,
which is slit open in front in the line of the palpebral fissure.
The conjunctiva consists of three parts (1) the conjunctiva tarsi, the
part on the lids; (2) the conjunctiva bulbi, the part on the eyeball,
and (3) the conjunctiva fornicis, the part connecting the first and
second; it is the retrotarsal fold or the region of transition, often
called the fornix. The first part can be seen by everting the lids. It
is adherent to the tarsus. It is covered with a laminated cylindrical
epithelium. The membrane contains an abundance of lymphocytes similar
to adenoid tissue. This increases with every inflammation of the
conjunctiva. This is why =chronic conjunctivitis= often results in
thickened lids.
The =blood supply= of the conjunctiva of the lids is from the muscular
branches of the ophthalmic artery. The =nerve supply= is from the
ophthalmic division of the 5th cranial and the sympathetic.
The bulbar conjunctiva continues over the cornea. It is covered
with layers of pavement epithelium. Its blood supply comes from the
posterior conjunctival vessels about the retrotarsal fold, and the
anterior ciliary arteries which accompany the tendons of recti muscles;
these two systems anastomose in the conjunctiva. Conjunctival injection
or congestion shows a superficial net work of larger or smaller vessels
that move with the conjunctiva. The color is scarlet or brick red.
Ciliary injection occurs as a rose-red or pale violet zone around the
cornea, spoken of as peri-or circumcorneal injection. It does not move
with the conjunctiva and occurs more with diseases of the cornea, iris
and ciliary body.
In the =etiology of conjunctivitis= a great variety of germs are
considered by different writers. Collins and Mayo give a report of
“germs found in normal conjunctiva.”
Bacillus Xerosis in 94% of normal conjunctivæ; Staphylococcus Albus in
79%; Pneumococcus in 9%; Diplobacillus in 6%; Staphylococcus Aureus in
6%; Streptococcus in 5%.
If this be true, and I do not doubt their statement, we are practically
compelled to say that these germs at least are only secondary in the
etiology of conjunctivitis. Just at this point osteopathy comes with
its flood of light and makes it easily explainable why some conjunctivæ
become inflamed while others do not, when all have germs present. The
lesion disturbing the integrity of blood supply and nerve force to
the eye is the primary cause while the presence of germs may be the
aggravating cause. The lesion prepares the soil in which the germs
thrive sufficiently to become an irritant. There are all gradations
of this soil preparation. The more fertile the field (i. e. the more
profound the effect of the lesion) the more virulent germ life may
become; the resistance is proportionately less.
=Conjunctivitis= is =classified= for convenience in study, diagnosis
and treatment as follows:
(1) Catarrhal, (a) acute, (b) chronic, (c) follicular; (2) gonorrhoeal;
(3) ophthalmia neonatorum; (4) trachoma; (5) diphtheritic; (6)
eczematosa (phlyctenulosa); (7) vernalis; (8) tubercular; (9)
traumatic. This is the clinical classification after Fuch.
Treatment of Conjunctivitis
In order to give the best care in these cases it is quite essential
that both the primary and secondary causes be given attention. Some
good =germicide= or =antiseptic= is to be used with intelligence. This
is in harmony with the great principles of antisepsis and cleanliness
taught by osteopathy from its inception. The use of the microscope in
the =bacteriology= of conjunctivitis aids in more definite diagnosis
and the selection of a proper germicide. For the Koch-Weeks bacillus,
the pneumococcus and the influenza bacillus silver nitrate 1% or a 25%
solution of argyrol is used; for the diplo bacillus (Morax-Axenfeld)
zinc sulphate 1 gr. to the ounce is almost a specific.
A good way to prepare the zinc prescription would be:
Boracic acid and water oz. 1.
Zinc sulphate gr. 1.
The boric acid and water of course being a saturated solution. Apply
one drop to each eye about four times a day. If one can not have
the use of the microscope to make specific the diagnosis, the zinc
solution may be alternated with the argyrol as the germicide. Ice cold
applications are good in many of these cases.
Catarrhal Conjunctivitis
=Acute=.—mostly affects the conjunctiva of the lids in the light form.
If severe it invades the bulbar conjunctiva. There is redness and
swelling and increased secretion which dries at night upon the edges of
the lids and glues them together. The eyes are better in the morning
and worse toward evening. =Corneal ulcers= and =iritis= may arise as
complications. Chronic inflammation may result.
=Etiology.=—Textbooks on the eye give =bacteria= as the chief cause;
some scarcely mention anything else. After discussing how the bacteria
get there and multiply, they usually bring in some statement to
indicate that in many cases no bacteria can be found in the secretions
from the conjunctiva. These latter are unaccounted for in the etiology.
=Catarrhal conjunctivitis= is non-specific in its origin.
The great science of osteopathy will fill in the missing links to works
otherwise very exhaustive on the eye.
If the cause is due only to a passing irritant as dust, smoke, pollen
or wind the disturbance may vary from hyperemia only, to a severe
attack of conjunctivitis. Fuch says the majority of cases are produced
by bacteria, but THAT IN NOT A FEW CASES OF CONJUNCTIVAL CATARRH THE
EXAMINATION OF THE SECRETIONS FOR BACTERIA PROVES NEGATIVE. He also
says that the usual course of the disease is from eight to fourteen
days, but NOT INFREQUENTLY THERE REMAINS A CONDITION OF CHRONIC
CATARRH PROTRACTED OVER A LONG TIME; THAT NOT INFREQUENTLY THE NORMAL
CONJUNCTIVAL SAC CONTAINS PATHOGENIC GERMS.
Some authors divide the =etiology= into (1) specific, (2) non-specific.
The first they account for by irritants due to dust, heat, smoke,
metal, pollen, cold, wind, glare of light, eye strain from overwork of
the eyes, ametropia and chronic alcoholism. The second they account
for by germ life, most often the Morax-Axenfeld diplobacillus or the
Koch-Weeks bacillus, the latter germ being found in the so-called
“pink-eye.” It is contagious. This is one condition for which the zinc
sulphate (½% to 2% solution) is almost a specific.
No doubt the irritants and the bacteria mentioned, with others, do
cause much of our catarrhal conjunctivitis and that one who fails
to consider properly the local conditions in practice will be sadly
lacking in best results.
On the other hand many cases, treated for local conditions only by
very competent men who used the best antiseptics and germicides, have
very indifferent results. The acute condition would continue and
gradually become chronic. From observation, study and experience there
are causes aside from local irritants, ametropia, bacteria, syphilis,
rheumatism or measles. There is some disturbance to the integrity of
the =spinociliary sympathetic arc=. In many cases of eye disease note
lesion and tenderness at the upper dorsal, the removal of which will
cause improvement of the eyes. Many cases of eye strain can be relieved
by correction of the first, second or third dorsal, and the use of
glasses made unnecessary.
Irritation of the eye will cause more or less tension of the muscles at
the second and third dorsal, and stimulation of the tissues near the
second and third dorsal spines will cause dilatation of the pupils and
contraction of vessels of the cranial mucous membranes; which means
vasomotor, secretory and trophic disturbances.
It follows then that an =osteopathic lesion= at the second or third
dorsal will cause or tend to cause disease of the eye. There may be all
gradations in the effect produced, the lighter being mere tendency,
while again it may be enough to set up profound vasomotor, secretory
and trophic changes in and about the eye. The first effect of the
lesion may be stimulatory, and later, inhibitory. The normal resistance
of the eye would be lowered and naturally, local irritants, bacteria
and ametropia would have a more profound effect. This will explain how
one can develop conjunctivitis in the absence of a local irritant with
no bacteria present, and no eye strain.
All of these causes, or any number of them, may be acting together, and
each more virulent because of the influence of the other.
=Lesions= of the =occipito-atlantal= joint or any of the cervical
articulations may cause eye disturbance. There are no efferent
ramicommunicantes in that region and the course of the physical
disturbance must be greater in proportion to the eye trouble produced,
than at the upper dorsal. It is important however to make a close
examination of the entire cervical region in eye trouble.
What has been said on the osteopathic causes of acute catarrhal
conjunctivitis applies with equal force to chronic and =follicular
concatarrhal conjunctivitis.=
What has been said on the osteopathic causes of =acute= catarrhal
conjunctivitis applies with even greater force to the =chronic=
form. The great variety of local irritants may account for acute
conjunctivitis, and does in most instances; but in chronic
conjunctivitis local irritants are more often secondary or
incidental while the osteopathic lesion with its effect upon the
=bulbo-spino-sympathetic= ciliary arc is the =fundamental= cause. Of
course some continuous local irritant, e. g., an uncorrected refractive
error, excessive light, heat, dust or germ life in the environment may
cause a chronic conjunctivitis. Other causes may be retracted lids
(lagophthalmus) leaving the eyeballs too prominently exposed; turning
in of the cilia (entropion, trichiasis or dystrichiasis) which impinge
upon and irritate the bulbar conjunctiva. =Chronic blepharitis= may
spread to the palpebral conjunctiva and then the bulbar. Foreign
bodies in the eye, or infarction of Meibomian glands may be causes.
The diplobacillus (Morax-Axenfeld) is the most common germ in chronic
catarrhal conjunctivitis.
=Symptoms and Course.=—In mild cases the redness is only moderate.
The conjunctiva is smooth and not swollen. Old cases have hypertrophy
with thickening. There was a small girl who came into the office
recently who had the conjunctiva of the lids decidedly swollen with
some hypertrophy. Her eyes were glued shut with pus every morning. Pus
pockets were forming along the follicles of the cilia and on the direct
edge of the lid. Her troubles started a year ago and got gradually
worse. A few osteopathic treatments were given during three months
(she was irregular in coming) and argyrol, 20%, used locally. All pus
and debris were cleared off the lids and conjunctiva each time. The
swelling all left and the thickening became inconsiderable; the eyes
looked almost clear. On pressure there was tenderness at the right side
of the second dorsal. No mechanical lesion was apparent there but in
treatment that region was thoroughly loosened.
The subjective symptoms are usually worse at night; pain, heaviness of
the lids; feeling of a foreign body in the eye; burning; itching and
dryness in many cases.
This condition is one of the most frequent of eye diseases in adults;
may be senile catarrh in advanced age. It is frequently complicated
with blepharitis, ectropion, epiphora and ulcerations of the cornea.
=Treatment.=—The osteopathic treatment depends on the findings in the
osteopathic examination. No case of chronic catarrhal conjunctivitis
should be treated without a thorough examination of the whole spinal,
rib and innominate mechanism. Careful and detailed adjustment should be
made of any lesions that might disturb the ciliary arc, the other nerve
connections, the blood supply or the body equilibrium.
This does not mean that local treatment of the eye should be neglected
in any way. Any measure that will aid in getting rid of local pathology
as quickly as possible should be ours. Where there is abundant
secretion, silver nitrate 1% to 2% solution put on the conjunctiva
with a brush when the lids are turned, or argyrol 20% to 25% dropped
into the eye are among the best antiseptics for local use. If the
diplobacillus is present zinc sulphate ½% solution is indicated.
The nose, nasopharynx and pharynx should never be overlooked in this
disease.
Follicular Conjunctivitis
=Follicular conjunctivitis= is of catarrhal origin. It is characterized
by the presence of follicles. There may be only a few or a great many.
If numerous they are often in rows on the palpebral conjunctiva.
Microscopically they show as circumscribed masses of adenoid tissue. In
this they resemble the granules of =trachoma=. Sometimes cases persist
for years with little or no inflammatory symptoms. On account of the
follicles this disease is frequently confused with trachoma.
We have heard numbers of well meaning conscientious osteopathic
physicians testify to curing cases of trachoma with a short course of
osteopathic treatment with no pathology remaining. We are absolute
believers in the effectiveness of osteopathic treatment and want
to give it full credit for doing all it will; but here we want to
enter a plea to the profession that we need more discrimination and
definiteness in our diagnosis. Technique is being emphasized and we say
Amen! It is proper for us to be thoroughly competent in technique but
diagnosis should be made just as emphatic because scientific technique
depends upon diagnosis for each individual case.
=Differentiation= of follicular conjunctivitis from trachoma.
=Follicular conjunctivitis= occurs (1) chiefly in the young; (2) the
follicles are smaller, more sharply limited, project more above the
conjunctiva, are often in rows, and oval in shape; (3) the disease
clears up with no bad after effects often without any treatment and the
tendency is to ultimately get well; (4) it never leads to shrinking of
the conjunctiva, to pannus or other destructive sequelæ; (5) it can
arise without contagion and is not considered contagious although, like
trachoma, it does attack large numbers of people who are confined in a
small place.
=Trachoma.=—(1) It seldom occurs in children; (2) the follicles are
larger, do not have sharp outlines, are less prominent under the
conjunctiva, are round in shape and never in rows; (3) tends to lead
to more or less pathology and seldom recovers spontaneously; (4) scar
tissue becomes a product of the inflammation in the conjunctiva and
leads to shrinking of the conjunctiva, causing in turn entropion and
trichiasis. Pannus is the sure result of unarrested cases as there is
a tendency to infection of the cornea from the infected conjunctiva
moving over it and remaining in contact; (5) trachoma has been proved
to be contagious. Trachoma bodies which are considered the infective
agent have been isolated.
The use of atropine in some instances will cause a follicular catarrh
which clears up on stopping the use of the poison.
Parinauds “Infectious conjunctivitis” has granulations but almost
always occurs in only one eye and is accompanied with constitutional
symptoms.
=Treatment of Follicular Conjunctivitis.=—The treatment should be
directed against the inflammation. The trophicity of the nerve
terminals to the conjunctiva may be altered by osteopathic lesions.
Suggestions under chronic catarrhal conjunctivitis apply here. If there
is no inflammation the follicles tend to disappear, leaving no trace
of pathology, hence a few osteopathic treatments of the lids and the
cervical region will hasten normalization.
Gonorrheal Conjunctivitis
This disease is sometimes called =purulent ophthalmia= or =acute
blennorrhea=, It is caused from an infection of the conjunctival sac
with the gonococcus of Neisser. Contact with soiled fingers or linen
may transfer the germ.
=Symptoms.=—Within 12-48 hours after inoculation the first symptoms of
redness and irritation occur. This is soon followed by much swelling
and tension of the lids and chemosis of the conjunctiva. There is much
pain and a copious discharge of pus coming from beneath the lids. At
first the pus is yellow or yellowish green.
Later the symptoms begin to subside; there is less tenseness and heat;
the lids can be more readily everted and the discharge ceases after 6
or 8 weeks. The puckered conjunctiva becomes rough and granular.
In these cases the =prognosis= is always grave; more so than in
ophthalmia neonatorum. The eye is almost always marred in some way.
One of the great dangers is involvement and destruction of the cornea.
If the cornea becomes hazy soon after symptoms begin it is not a
good omen. =Ulcers= will likely form and then there is a tendency
to puncture the cornea. In mild cases the cornea may escape without
injury. In severe cases it is likely to ulcerate. If it perforates,
the anterior chamber is emptied and the iris prolapses into the
perforation; adhesions take place and there is healing with reformation
partially of the anterior chamber. An adherent leucoma is the result
with practical loss of vision. There may be a bulging of the cornea
known as anterior staphyloma. The iris and ciliary body may become
involved, causing iritis and cyclitis, or the whole inner structures
may be affected making a =panophthalmitis= with =atrophy= of the
eyeball.
The cornea is affected by the infective material direct or the nutrient
vessels to the cornea at the limbus may be obstructed by the extreme
swelling and pressure.
=Complications= of arthritis, rhinitis, septicemia and endocarditis
may arise. If there is none of these, at least there is a general
debilitated condition which needs attention.
=Treatment.=—The treatment should be =local= and =constitutional=,
The diagnosis should be made quickly from the history, symptoms
microscopically, and local cleansing begun at once and followed
diligently. Excessive discharge should be wiped away with cotton. The
conjunctival sac should be thoroughly irrigated every hour or oftener
if necessary to keep it clean. This is to be done day and night. A
saturated solution of boric acid may be used, or corrosive sublimate
one grain to the pint, or permanganate of potassium solution 1-5000.
The irrigation should be followed by the free use of argyrol 25%. This
procedure will keep the eye clean and be the means often of saving the
cornea from destruction and the eye from blindness.
If there should be ulceration of the cornea a drop of atropine ½%
should be used in the eye often enough to keep the pupil dilated and
the ciliary body at rest.
Osteopathic physicians no less than other physicians should not
neglect this local, careful, persistent, antiseptic cleansing of the
eye in such cases. The osteopathist can do more. He is not limited
to antisepsis even in this kind of work, however important it might
be. The unaffected eye should be carefully protected. Buller’s shield
should be used.
The osteopath should give thorough treatments to the neck and the fifth
nerve.
Supporting treatment to the system according to indications should
be given e. g., bowels, kidneys, nerves, muscles, joints as in
constipation, nephritis, neurosis, rheumatism, arthritis, endocarditis,
septicemia, rhinitis etc.
Ophthalmia Neonatorum
This is an =acute purulent conjunctivitis= in the new-born. Neonatorum
comes from a junction of the Greek word Neos—new, to the Latin word
natus—born; new-born. This disease is the bugbear to the obstetrician.
He must always be on the lookout for it and act promptly in order to
save sight. Every general practician should make a careful study of
this disease if he expects to treat children.
Sixty to seventy percent of conjunctivitis neonatorum is due to the
infection with the gonococcus of Neisser. It usually comes from a
gonorrheal discharge from the genitals of the mother. The nurse or
anyone who handles the baby might be the agent in the transmission of
the infection.
The disease is not always of gonorrheal origin. Some cases are due
to the pneumococcus, streptococcus, diplobacillus or one variety of
staphylococci.
Thus there are two varieties or types of ophthalmia neonatorum; a
severe type which is =gonorrheal= or specific and a mild type which is
non-specific.
In some states there is a law which requires the use of silver nitrate
in the eyes of all babies at birth. Every baby’s eyes should be
thoroughly washed at birth, with boric acid and where there is the
least suspicion of gonorrhea silver nitrate 1% or argyrol 25% should be
used. A routine use of one of the silver salts would be good practice.
=Symptoms.=—Gonorrheal cases begin usually the third day after birth,
non-gonorrheal, on the fifth or sixth day. Both eyes are usually
involved, one worse than the other. The lids swell much. There is
chemosis of the conjunctiva which may put the cornea in a pit. The
discharge is abundant. It is yellow or greenish yellow.
The disease gradually declines and the discharge ceases in six to eight
weeks. The conjunctiva is thickened and looks granular. May be some
cicatricial changes.
The chief danger is to the cornea, more so if it becomes hazy the first
two days. Corneal lesions seldom occur in non-specific forms.
If the cornea is involved perforation is likely, with a general
inflammation of the eyeball (panophthalmitis) followed by atrophy
(phthisis bulbi).
Complications such as rhinitis, meningitis, endocarditis and general
septicemia may occur.
=Diagnosis= is made from the onset, character, symptoms and course with
the use of the microscope.
=Prognosis.=—Delayed or improper treatment in these cases will likely
be fatal to sight as sloughing of the cornea will occur. With prompt
and proper care the prognosis is favorable.
=Treatment.=—Mild cases (non-specific) are treated in the same manner
as simple conjunctivitis. In severe cases (specific) clean the eye
carefully and apply cold compresses of gauze 15 to 20 minutes at a
time every hour or two. Keep the gauze on a block of ice and change
every few minutes. If the cornea is involved heat may prove more
satisfactory. There must be constant removal of the discharge. Wipe
away the excess and irrigate freely with boric acid at least every hour
day and night and more often if necessary. After each washing use a
solution of argyrol 25%. Once a day silver nitrate 1% solution may be
used and washed out with a salt solution.
If the cornea should ulcerate the treatment need not be altered.
The attendants should be carefully instructed as to the importance of
the care and the contagious nature of the pus.
Antisepsis and cleanliness here is more essential, effective and
exclusive than in any other disease of the eye. Wisdom in the use of
antiseptics is a strong point in the armamentarium of every progressive
osteopath.
Trachoma
This disease is known as =granular lids= or =granular conjunctivitis=.
Although the germ has not been discovered, we know this is an
infectious disease. A roughness and hypertrophy of the conjunctiva
develops. There is development of follicles or granulations. Later
these products are absorbed and cicatrization of the tissues follows.
=Cause.=—Trachoma is found most common in Egypt and Arabia. It spreads
easily in crowded institutions. It is in many instances a mixed
infection with the Morax-Axenfeld bacillus, Koch-Weeks bacillus and the
gonococcus.
=“Trachoma bodies”= have been discovered which are claimed by some to
be a causative factor in the disease. These small bodies are not found
in all cases however.
Spinal lesions of the cervical and upper four thoracic vertebræ will
disturb the blood and nerve supply to the eye which will predispose to
the disease should some of the virus or germs of trachoma be present.
In practically all these cases there is tenderness if not an actual
twist at the second and third thoracic.
=Symptoms.=—A small boy came to our clinics complaining that his
left eye was smaller than the right. No inflammation or swelling
was prominent. The eye looked normal except slightly smaller than
the right. On turning the lid granules in the fornix of that eye
were readily noticed. Trachoma had a good start. The tissues were so
hypertrophied in that region that the eye could not be opened quite
as wide as the other one, hence the impression that that eyeball was
smaller. The granulation often develops so insidiously that the victim
may have the disease for months before he realizes he has a bad eye.
When symptoms appear there may be photophobia, lachrymation, gluing of
the lids from a scanty secretion, pain, and blurring of vision. The
granules are gray, translucent and roundish under the conjunctiva.
Hypertrophy increases to a certain height when cicatrization and
contraction begin. The duration may be years. The more the hypertrophy
the longer the duration and the greater the contraction. (Note here
that treatment should be directed toward combatting the hypertrophy by
establishing circulation).
=Sequelæ.= I merely mention the sequelæ here: pannus, ulceration of the
cornea, trichiasis, dystrichiasis, entropion, ectropion, symblepharon,
xerosis, corneal opacities. For the explanation, pathology and
treatment of these sequelæ not covered in this treatise, see any good
works on diseases of the eye as Weeks, Fuchs or De Schweinitz.
=Treatment of Trachoma.=—In reporting cases of trachoma treated and
cured by osteopathy we should be sure of our diagnosis.
The treatment is antiseptic, hydrotherapeutical, osteopathic and
operative. A saturated solution of boric acid should be used. Argyrol
20% is good if there is much secretion. Nitrate of silver 2% and copper
sulphate are still used in some cases to advantage as claimed by some
physicians. The osteopath should count on careful cleanliness.
Hot compresses over the eyes are often very agreeable.
Operations are often performed for trachoma. The granules are rolled
out with Knapp’s roller forceps, and other methods.
=Grattage= is practiced with some wonderful results. It is done as
follows: Get some fine sand paper and cut it in strips about one-half
inch wide by three or four inches long. Put it in alcohol in a vessel
for ten to fifteen minutes. Pour off all the alcohol except a few drops
that will cling to the vessel by capillary attraction. Touch a match
to the residue. This will burn just enough to make the sand paper
absolutely sterile without burning the latter. Put the patient under
somnoform. Use a small artery forceps to grasp the edge of the eyelid,
roll the lid back over the artery forceps to expose all granulations
clear to the fornix. Use a protector to the eyeball. Now with the
sandpaper quickly scrape or curette away all of the trachoma bodies and
granulations. Repeat the process on the other eye if it is involved.
Wash out well with a saturated solution of boric acid and bandage
the eyes for a few hours. This will cause considerable swelling and
inflammation. Use cold applications and keep the eyes disinfected. I
have seen some very good results from this method.
=Osteopathic.=—Following the sand paper operation a thorough treatment
of the cervical and upper dorsal region would add considerably to the
rapidity of the patient’s recovery and sense of well being. General
tonic treatment is of special benefit in nearly all trachoma cases as
they are subnormal in their general health.
One form of technique which has been used by myself and others
to advantage in these cases is as follows: Sterilize the fingers
carefully, lubricate with vaseline or K. Y. the forefinger of the
right hand. With the left hand raise the upper lid and introduce the
forefinger of the right hand with the thumb above. Catching the lid
between the thumb and finger squeeze and massage the whole structure
clear to the fornix as thoroughly as possible. Repeat the process on
the other eye.
A technique used by Dr. Edwards of St. Louis is as follows: After
sterilizing and lubricating the forefinger lift the lid and introduce
the finger as far as possible into the orbit pushing the fornix back
into the orbit. This stretches all the tissues around the fornix,
opening up a better conjunctival and palpebral circulation. The
ciliary vessels and nerves are stretched and stimulated. It is rather
surprising to one who has not tried it, how far the finger can be
introduced into the orbit.
One set of nerves that should be especially studied and considered in
trachomatous conditions is the cere-brobulbo-spino-sympathetic-ciliary
arc. This has already been elaborated. All spinal lesions should be
carefully diagnosed and corrected.
Dr. T. J. Ruddy’s third finger eye instrument is very useful in these
conditions in restoring normal circulation about the orbit.
See that the nose and throat are normal.
Phlyctenular Conjunctivitis
By some this disease is considered an =eczema= of the conjunctiva.
This will at least enable us to get an idea of the conjunctival
pathology. What is said of phlyctenular conjunctivitis applies largely
to its corresponding disease of the =cornea-phlyctenular keratitis=.
Scrofulous ophthalmia is applied by some because so many of these
phlyctenular patients have =scrofula=. Herpes conjunctivæ is used as a
name because of the small blisters or blebs that form in the beginning
stage. Little red eminences develop near the limbus (sclerocorneal
junction). They are cone shaped, slightly elevated about the
surrounding tissue. There may be one or several, usually not more than
one or two. After a few days the cone breaks and on top appears a small
gray ulcer. There is further breaking down and the cone disappears
leaving an ulcer on level with the conjunctiva. Vessels are congested
about it. There may often be noted an area of small vessels, fan like
in shape, running from the outer region of the conjunctiva to the ulcer
or phlyctenule.
=Etiology.=—This is a disease of frequent occurrence in children,
mostly among the poor classes. Such things as eczema, dirt, adenoids,
scrofula, rhinitis, malnutrition, abuse of tea and coffee and
exanthematous disease are mentioned by oculists as causes. I have
no doubt any or all these conditions predispose to phlyctenular
conjunctivitis.
De Schweinitz in “Diseases of the Eye,” 1916 edition, p. 242, says:
“The exact cause of ocular lesions, or phlyctenular eruption, has not
been determined.”
I have met Dr. De Schweinitz and heard him lecture on the eye. I
consider him one of the best eye specialists in the country. His
experience and study with the eye dates over many years and his book
has gone through eight editions. He is professor of ophthalmology in
the University of Pennsylvania; Ophthalmic Surgeon to the Philadelphia
Polyclinic Hospital, the Philadelphia General Hospital etc., etc.
His opinion represents the summary of the investigation of the
ophthalmic profession the world over and through all the past down to
the present time. “The cause of phlyctenular conjunctivitis is not
known.”
=Bacteriology.=—At times in the ulcers have been found the
staphylococcus pyogenes aureus and albus. They are also found in a
normal conjunctival sac. They could not with logic be taken as a
causative factor; at least they would be only secondary.
If oculists and other students of the eye all had a good deep
osteopathic vision to throw light upon these problems many causative
factors would take on a new meaning. Such supposed causes as have
been mentioned, e. g. eczema, adenoids, rhinitis and malnutrition may
easily be secondary to the osteopathic lesions. Micro-organisms may be
enabled to act because of trophic and circulatory disturbances to the
conjunctiva through disturbed nerve connections from lesions in the
cervical and upper dorsal regions. Herpes zoster is purely a trophic
nerve disturbance manifestation on the skin as blebs or blisters with
more or less neuritis. Any lesion that would affect the integrity of
the function of the fifth cranial nerve might easily manifest itself as
herpes of the conjunctiva.
We believe the osteopathic lesion is primary and fundamental in the
causation of most of our phlyctenular conjunctivitis. Of course
insanitation, scrofulous diathesis and the exanthemata play their role.
A good diagnostician should figure out the relative importance. The
history, onset and examination will usually eliminate these conditions.
=Symptoms.=—Lachrymation, photophobia, blepharospasm and injected
vessels are the chief symptoms. There is pain as well as fear of light.
The child fights examination.
The attack subsides in ten to fourteen days unless there is
multiplicity of blebs. Some patients have repeated attacks for months
or years. Many of these cases in medical clinics keep coming for months
with repeated attacks. Never leave out careful osteopathic treatment.
=Prognosis.=—This is favorable for a final cure. If there should be
multiple blebs and frequent recurrence and the cornea is invaded,
the prognosis is not good for perfect sight. The pathology goes deep
enough to affect Bowman’s membrane of the cornea disturbing the
substantia propria. This causes a macular condition of the cornea which
impairs sight.
=Therapy.=—Diet should be bland; the eyes should be protected from
irritants; yellow oxide ointment should be used in the eye once a day
or 10% argyrol. The ointment is preferred. Moist warm compresses on
the eye are comforting. A boric acid wash in almost all conjunctival
trouble is good. If there is much irritation giving a suspicion of iris
involvement a drop of atropine ½% should be used. The general regimes
of living should be regulated.
Osteopathic treatment should be directed toward building up the general
health and correcting all lesions, especially that may have a specific
bearing on the eye trouble. Such lesions will be found more often at
the first, second and third thoracic, but may be anywhere from there to
the occiput.
Vernal Conjunctivitis
This disease is known by many as =vernal catarrh= or =spring catarrh=
of the conjunctiva. It is a chronic inflammation which sets up changes
in the conjunctiva and tarsus. This disease may be confused with
trachoma unless one observes closely. There are broad flat papillæ on
the conjunctiva. These papillæ may readily be taken for granulations.
They are larger than the granules in trachoma. They somewhat resemble
the arrangement of cobble stones. The conjunctiva has a bluish-white
filmy appearance called by some, milky shimmer.
The disease was thought at first to appear only in the spring,
hence the name vernal. Many cases continue through the year with
exacerbations in the spring. It occurs more often in boys. Both eyes
are attacked. It may heal and leave no trace. It may last from four to
twenty years.
=Causes.=—Almost all works on the eye say the cause is not known. De
Schweinitz says, “Definite information in regard to the cause of this
disease is lacking.” There may be a micro-organism which has not been
discovered.
I wish to call the attention of the osteopathic profession to the great
fact that there are numbers of diseases of the eye as well as of other
parts of the body about which the medical profession are entirely
“at sea.” This gives valuable ground for scientific research by our
profession.
My experience with this disease is not sufficient for me to speak with
any positiveness or finality as to its cause. The altered trophic
parts and the very chronic condition existing leads me to the firm
belief that we will ultimately find the cause as a mechanical lesion
affecting the trigeminal or sympathetic (or both) nerve connections.
Glare of light and local irritants act only as secondary causes. Nasal
disease may be associated and act as a cause.
=Symptoms.=—There is photophobia, some mucus, slight pericorneal
injection, redness of the conjunctiva of both the bulb and lids; that
of the lids is thickened and of dull pale color due to sub-epithelial
hyaline thickening. The fact that there is no pannus, and flat
granulations and recurrence with spring, marks it from trachoma.
=Prognosis.=—Under medical treatment it is unfavorable; may last twenty
years. Slight opacity of the cornea may develop.
=Treatment.=—The eyes should be protected with dark glasses. Cold
compresses give some relief. Boric acid is good as a wash. Yellow oxide
of mercury ointment may be of service as an antiseptic and alternative.
If nasal disease exists, it, of course, should be treated according to
indications. Fundamentally the lesions in the spine in the cervical
and upper dorsal regions should be specifically corrected. When enough
cases of vernal catarrh have been observed and treated osteopathically
much light and benefit will be brought to bear upon this obscure and
intractable disease of the conjunctiva.
Diseases of the Cornea
Anatomy
The cornea with the sclera forms the outer coat or tunic of the eye
ball. The cornea is in front and forms one-sixth of the envelope.
It is a segment of a smaller globe than that of the sclera. It is
about 12 mm. horizontally and 11 mm. in the vertical diameter. Its
thickest part is at its junction with the sclera where it is about
1 mm. This junction is called the limbus. The cornea is inserted
into and rests on the sclera like a watch crystal. The fibers of the
cornea pass continuously into the sclera, however. The normal cornea
is transparent. Most morbid changes of the cornea cause a diminution
in this transparency. In old age a narrow gray line near the corneal
margin makes its appearance. This is known as the =arcus senilis=.
There is a little strip of perfectly clear cornea between the arcus
senilis and the limbus.
The cornea has five layers. These layers should be noted with care, as
in wounds of the eye, foreign bodies in the cornea and ulcerations, the
results depend much upon which layers are affected.
1. The =anterior epithelium= consists of pavement cells of several
layers. This layer of the cornea may be damaged or scratched off in
large patches and still it will heal readily leaving no trace of the
injury.
2. The =anterior elastic lamina= or =Bowman’s membrane= is very thin
and homogeneous; it is just beneath the epithelial layer and forms a
resisting sheath to prevent damage to the next layer.
3. The =stroma= or =substantia propria=. This layer composes about
nine-tenths of the cornea. It is composed of minute connective tissue
fibers between which lie some stroma cells or corneal corpuscles. Some
of these cells are fixed while others are motile. The motile ones are
the white blood-corpuscles which move about in the lymph passages of
the stroma. They increase in any irritation of the cornea.
4. =Descemet’s membrane.= This is a tough homogeneous hyaloid membrane
back of the stroma. When the stroma is diseased and breaks down
Descemet’s membrane may be sufficient to prevent a puncture of the
cornea.
5. The =Endothelial layer= is a single layer of flattened cells which
coat the posterior surface of Descemet’s membrane.
The margin of the cornea is in relation with three membranes, the
conjunctiva, the sclera and the uvea (iris and ciliary body). In a
disease of the cornea, a conjunctivitis, an iritis or a cyclitis is
easily started.
The cornea contains no vessels. It is nourished by imbibition. At
the limbus there is a rich network of marginal loops supplied by the
anterior ciliary vessels. From these loops the blood plasma passes into
the stroma of the cornea.
The nerves of the cornea come from the ciliary nerves and the nerves
of the bulbar conjunctiva. These are from the trigeminus and the
sympathetic. The nerves extend numerously in the stroma passing forward
through Bowman’s membrane into the epithelial layer. This makes the
cornea very sensitive to the touch.
Examination of the Cornea
Note the size and form. Both may be modified by morbid processes. Note
the surface with regard to curvature, evenness and smoothness. In
=keratoconus= the curvature is greatly increased. Noting the reflex
images in the cornea and comparing these with those of a normal cornea
will show any variation in curvature. Also any =unevenness of the
surface= may be noted by the irregularity or distortion of the images.
Uneven spots on the cornea may be =depressions or elevations= from loss
of substance; =wrinkles or collapse= from lowered tension.
If the smoothness or polish of the cornea is lost it looks like glass
that has been breathed upon or greased. It is lusterless and dull.
Note also the transparency of the cornea and determine the form, extent
and density of the opacity; whether it is diffuse or in spots; in the
deep or superficial layers. A magnifying glass should be used in the
study of opacities. According to the density of the opacity of the
cornea it is known as a =nebula= or a =nebulous opacity=, a =macula=
or a =leucoma.= The nebula is the least noticeable and the leucoma is
the densest opacity. A leucoma is a condition of complete opacity. The
cornea looks white.
Defects in the corneal epithelium may be made to show clearly by the
use of a 2% solution of fluorescein which stains them green.
Note the sensitiveness of the cornea by touching it with the end of
a thread, a little cotton or a shred of paper. The sensitiveness is
diminished or lost in glaucoma and some other diseases.
Diseases of the Cornea
Almost all diseases of the cornea have some form or degree of
inflammation. =Keratitis= is the word generally used for inflammation
of the cornea. In order to aid clearness in discussion there are
various subdivisions of keratitis made by different writers.
Suppurative and non-suppurative are the principal types. In
=suppurative keratitis= there is always some destruction of corneal
tissue which on healing leaves an opacity with partial loss of vision.
Germs gain entrance into the tissues usually from the exterior and some
form of ulceration results.
The following classification is taken from Fuchs:
=Suppurative Keratitis.=—(1) Ulcer of the cornea; (2) Serpiginous
ulcer; (3) Keratomalacia or Xerosis; (4) Keratitis neuroparalytica.
=Non-suppurative Keratitis.=—(A) SUPERFICIAL: (1) Pannus, or keratitis
with blood vessels; (2) Phlyctenular, or keratitis with vesicles. (B)
DEEP: (1) Parenchymatous or interstitial.
In keratitis there is first an infiltration or the increase of cells
in the substantia propria or the parenchyma of the cornea. This is
the exudate of the inflammation. It causes the cornea to look more
or less dull or cloudy. The disease may clear up at this point or
go on to suppuration. If it clears up it is known as =resorption=.
If the lamellæ of the substantia propria are not destroyed by the
process, resorption takes place with no loss of substance. The exudate
disappears and there is perfect transparency of the cornea again. There
may be slight damage of the stroma preventing perfect transparency.
Resorption of the exudate may not be quite complete which may
become partly organized and left permanently fixed in the cornea.
Cases resorbing without destruction of the stroma are forms of the
non-suppurative keratitis group.
If the stroma breaks, suppuration occurs. This is the second stage and
is associated with a localized destruction of the cornea. These cases
are known as =suppurative keratitis= or =ulceration of the cornea=.
The disintegration begins in the most anterior layers of the cornea.
A slight depression in the cornea can be noticed. The infiltration is
all about the ulcer, getting less as it is more remote from it. If the
floor and walls of the ulcer are foul with the infiltrate it is known
as a =progressive= ulcer. =Sloughing= may continue to spread the ulcer.
If the cloudiness around it disappears and the ulcer acquires a smooth
transparent base and edges it is known as a =retrogressive= or clean
ulcer.
The disintegrated areas of the cornea may be replaced by newly formed
tissue. This is the third stage or that of =cicatrization=. This new
tissue is connective tissue. It is opaque, leaving a permanent opacity.
=Stages of keratitis=:
=Suppurative.=—(1) Infiltration; (2) Suppuration and (3) Cicatrization
or Reparation. The suppuration is progressive or retrogressive.
=Non-suppurative.=—(1) Infiltration; (2) Resorption.
In the diagnosis of a keratitis one should look at it very carefully. A
loupe which has thick plus sphere lenses will magnify the field and may
be of great assistance in observing closely the condition.
If the cornea is clouded and dull the trouble is recent and if there
is no loss of substance it is an infiltrate (first stage). If there is
loss of substance it is a progressive ulcer (second stage.)
If the surface is lustrous but cloudy the trouble is an old one and if
there is loss of substance it is a retrogressive ulcer; if no loss of
substance it is a cicatrix.
Frequently blood vessels grow in from the margin in ulcerations of the
cornea. This is usually a process of healing of the corneal ulcer.
The advent of the blood vessels is favorable. After healing the blood
vessels gradually disappear. They never entirely disappear from large
cicatrices.
In some cases new vessels accompany the inflammatory process and like
the exudate are a part of the clinical picture of the disease as in
parenchymatous or interstitial keratitis. Pannus also has vessels. They
are not in the cornea but are in new tissue deposited upon it.
=Symptoms appearing in keratitis=:
1. =Ciliary injection= or a red area encircling the cornea. If the
keratitis is severe there will be considerable inflammation of the
conjunctiva which may hide to some extent the ciliary injection.
2. =Iritis or iridocyclitis= may set in. The iris and ciliary body are
in such intimate relation with the cornea that these structures are
very subject to involvement in any severe keratitis. With iritis would
come danger of =synechiae= or adherence of the iris to the anterior
surface of the lens.
3. =Hypopyon.=—In suppurative keratitis there is some exudate into the
anterior chamber of the eye. This exudate drops to the bottom of the
chamber and looks like pus had gathered in the bottom of the aqueous.
This condition is called hypopyon.
4. Other symptoms which are frequently prominent are =diminished
vision=, =pain=, =photophobia=, excessive =lachrymation= and
=blepharospasm=. Edema of the lids and conjunctiva may occur.
Intelligent treatment of keratitis of course is based upon the exact
conditions present. Great care in diagnosis and treatment should be
exercised.
Ulcer of the Cornea
Inflammation of the cornea sets in from some cause. There is an
infiltrate into the substantia propria. A spot becomes cloudy and the
surface over it becomes dull; at this point the epithelium breaks
down or exfoliates and the loss of substance in the parenchyma is the
beginning of an ulcer.
=Cause.=—The cause may be constitutional or local. The causes usually
thought of from the medical standpoint may be noted in such books as
“Diseases of the Eye” by De Schweinitz or Weeks. I wish especially
to call attention to the fact that there is frequently a primary and
underlying cause of corneal ulcers not mentioned in any medical texts,
i. e. the osteopathic lesion. By this I mean more than the spinal
lesion although the subluxation lesions that result from the occiput
to the fourth dorsal are of most importance. Any tension or change of
tissue in the cervical region that may interfere with perfect freedom
of circulation of blood to the tracts and centers in the cord, is to be
considered. The osteopath of course should take into consideration all
causes primary and secondary and govern himself accordingly.
=Symptoms and Course.=—There is a gray area surrounding the ulcer
at first, also the floor is grayish in color. In this condition it
is known as a =progressive= ulcer or a =foul= or =unclean= ulcer.
This cloudiness or gray area may increase in size and the ulcer keep
spreading, or it may go deeper even to perforation of the cornea.
Some ulcers advance or spread on one side and heal on the opposite
side so that they creep along on the cornea—these are the so-called
=serpiginous ulcers=.
With corneal ulcers there is irritation, pain, photophobia and
increased lachrymation. There is usually some ciliary injection which
is an indication of involvement of the iris and ciliary body. If
iritis occurs there is contraction of the pupil with slow reaction.
=Hypopyon= may develop. With iritis and the exudate there is likely to
be adhesions between the iris and the lens known as posterior synechia.
A few corneal ulcers are asthenic and do not have irritative symptoms
and yet are dangerous.
When the ulcer begins to heal it is called =retrogressive=. Dead
tissue is cast off; other tissue becomes transparent from resorption.
We have a =clean= ulcer. Symptoms disappear and cicatrization begins.
Vessels extend to the ulcers and soon it is leveled up with the corneal
surface. Cicatrization may leave it slightly below the corneal level or
above it.
If there should be perforation of the cornea from the ulcer there may
be =complications=, e. g. keratocele, loss of aqueous, dislocation
and expulsion of the lens, intra-ocular hemorrhage, flattening of the
cornea, fistula of the cornea, glaucoma, intra-ocular suppuration,
prolapse of the iris into the opening, etc. These complications and
sequelæ that occur occasionally will not be considered here.
After healing is complete by cicatrization there is opacity of the
cornea in proportion to the depth and size of the ulcer. In months
and years of time there is some clearing of the opacity so that small
superficial opacities may become invisible.
=Treatment of Corneal Ulcers.=—Most ulcers of the cornea are quite
amenable to proper treatment and the prognosis is favorable. Neglect
or wrong treatment is very dangerous. The treatment is local and
constitutional. Often the ulcer is kept going by unwholesome
constitutional conditions.
=Local Treatment.=—This varies according to the stage of the ulcer,
whether progressive or retrogressive. In a progressive or foul ulcer if
due to trauma any foreign bodies should be removed. If the ulcer is a
result of pathology of the conjunctiva it is of primary importance to
treat the conjunctival condition.
In mild cases of ulcer a dressing over the eye with atropine ½% to keep
the pupil dilated is sufficient local treatment. The bandage protects
the eye from bright light and other environment and the atropine puts
the iris and ciliary body at rest preventing complications and giving
nature her best chance to work.
If the ulcer is rapidly progressive, warm compresses an hour or two a
day are good; iodoform sprinkled on the ulcer or actual cautery may be
used. In the retrogressive stage (clean ulcer) healing has begun and
we desire to get as near as possible a resistant transparent cicatrix.
Yellow oxide ointment is useful at this stage.
=Osteopathic.=—The local measures just mentioned are not incompatible
with osteopathic theory or practice. They are merely adjunctive in
getting nature’s reaction toward normalization, as also are hot and
cold applications. Osteopathy comes in now in a most important and
fundamental way with the constitutional and specific lesion treatment.
The =bulbo-spino-sympathetic-ciliary arc= has been mentioned and
explained. Through this important nerve connection with the eye,
profound and wholesome effects on the eye may be gotten by osteopathic
treatment. Frequently lesions of the occiput, cervicals and upper
dorsals will affect the integrity of the ocular structures through
disturbances of nerve and blood supply.
The stomach, bowels, liver and kidneys should be carefully noted
in corneal ulcers. Poor circulation, indigestion, constipation and
auto-intoxication may have an important bearing on the recovery of the
ulcer.
Xerosis or Keratomalacia
This is a disease of the eye in children due to insufficient nutrition
of the cornea. Hereditary influences, depleting diseases and lesions
affecting the trophic nerves to the eye are causes.
=Treatment= consists of building up the nourishment of the child,
correction of lesions and careful dieting. Hot applications to the
palpebral region helps to bring the blood supply to the eye for local
effects.
Keratitis Neuroparalytica
This disease is due to a paralysis of the 5th cranial nerve. The cornea
becomes slightly cloudy. The epithelium gradually sloughs away. An
ulcer may or may not form. Pain and lachrymation are absent because of
paralysis of the trigeminus. There is usually ciliary injection.
=Treatment.=—The most important treatment for this unfortunate
condition is manipulation to restore the integrity of the 5th cranial
nerve and the blood supply to the eye. Cervical, spinal, nasal,
nasopharynx treatment should be given. Spring the inferior maxilla.
A drop of atropine (1%) should be used locally because of the ciliary
injection. Warm compresses used locally will help. The healing usually
leaves some opacity of the cornea. Keep the eye bandaged to protect the
cornea.
Pannus
This form of keratitis is superficial and is characterized by the
formation of blood vessels in the cornea. It is caused by some
irritative influence. Most often it is a complication of trachoma.
If the irritation can be removed the vascularity gradually recedes,
leaving a clear cornea unless the deeper structures of the cornea have
been involved.
Phlyctenular Keratitis
This disease is an involvement of the cornea with an eczematous process
similar to phlyctenular conjunctivitis. There is more likely to be
ciliary injection and iritis, in which case atropine should be used.
The treatment is the same otherwise as for phlyctenular conjunctivitis.
Parenchymatous or Interstitial Keratitis
This is shown by a diffuse inflammatory infiltration of the substantia
propria of the cornea. Part or whole of the cornea of one or both eyes
may be involved. Very fine blood vessels may invade the deep structures
of the cornea.
=Cause.=—Syphilis, tuberculosis, rheumatism, diabetes and rachitis are
systemic diseases found back of this trouble.
=Symptoms.=—Irritation, lachrymation, photophobia with ciliary
injection are the chief symptoms.
=Treatment= must be local and constitutional.
Locally atropine should be used. Dark glasses should be worn or the
patient must be kept in a dark room. Treatment to the trigeminal nerve
and tissues of the orbit should be given.
Constitutional treatment should be spinal with the idea of arousing all
the forces of the body to greater activity. Careful dieting should be
followed according to indications.
The infiltration and blood vessels will ultimately disappear. Sometimes
enough may remain to cloud the vision.
Diseases of the Iris and Ciliary Body
The iris and ciliary body have the same blood and nerve supply. That
is, they are supplied by the same set of vessels and nerves. For this
reason it is practically impossible to have an iritis absolutely
independent of a cyclitis or some inflammation of the ciliary body. If
the iris is the primary seat of the trouble there are certain symptoms
that may indicate such a state. However, when we are treating the iris
or diagnosing conditions of the iris we must remember that the ciliary
body is very likely more or less involved and may be the primary seat
of the trouble.
In =iritis= there are some symptoms which are caused from the
hyperemic condition of the eye, such as a slight change in color. The
pupil becomes rather inactive, there is some ciliary injection with
photophobia, lacrymation and pain. In case of an exudate in the iris
there may be thickening, and the exudate in the anterior chamber of the
eye will form a =hypopyon=. Sometimes the small vessels will break and
there will be a little bleeding which will be mixed with the debris in
the bottom of the anterior chamber. This is known as hyphemia. There
are likely to be adhesions between the iris and the anterior capsule
of the lens known as posterior =synechia=. The pupil is more or less
irregular. If atropine is dropped into the eye to dilate the pupil,
parts of the edge of the pupil will be adhered while the other parts
dilate making it very irregular.
In case of cyclitis there is an exudate from the ciliary body into
the posterior chamber. This may cause a total adherence of the iris
to the crystalline lens. With the ophthalmoscope, opacities in the
vitreous may be noticed. These are exudates. The tension of the eye is
liable to increase a little at first but as the exudates absorb there
is more or less softening. Vision is low. Also in cyclitis there is
ciliary injection, photophobia, lacrymation and pain, similar to that
of iritis. Pressure on the eye ball will reveal a very tender condition
around the sclerocorneal junction or over the area of ciliary injection.
The causes of iritis, cyclitis or iridocyclitis frequently are systemic
conditions and infection such as syphilis, rheumatism, gonorrhea,
tuberculosis, infectious diseases and metabolic changes, it may be of
traumatic origin or sympathetic. Fuchs says “There are many cases of
iritis for which no cause can be discovered and therefore which cannot
be placed under these causes.” We agree with him and advance the theory
of cervical and upper dorsal lesions or trouble in the sinuses, nose,
nasopharynx or throat. No doubt osteopathy can throw some important
light on the causes of diseases of the iris and ciliary body. The nose
and throat should be examined in all these cases.
=Treatment.=—Atropine must be used in the sore eye to put the iris
and ciliary body at rest and dilate the pupil to draw it back from
the lens so that adhesions may not form. Warm compresses will give
much comfort. Sweating should be brought about. All fluid should be
reduced to a minimum. Diet should be very moderate and the bowels kept
unusually free. The eye should be protected by dark goggles. Thorough
treatment of the neck and upper dorsal region with attention to the
nose and throat should be given. Constitutional treatment should be
given according to the indications mentioned under causes. If annular
synechia or total posterior synechia form or there is atrophy of the
eyeball operative work may be needed. Also for injuries, tumors,
anomalies and so forth of the iris see the latest medical works on this
subject.
Diseases of the Choroid
The =choroid= is the vascular tunic of the eye. With the iris and
ciliary body it forms the =uvea=. The iris and ciliary body are rich
in nerve terminals and when inflamed; pain is a prominent symptom. The
choroid has no sensory nerve terminals. When it is involved alone; pain
is not present however severe the pathology. Embryologically Descemet’s
membrane is a part of the uvea. When the uveal tract is diseased we
frequently note symptoms of a descemetitis as a turbidity of the
anterior chamber and spots on Descemet’s membrane. When one part of the
uvea is inflamed the tendency is to pass to the other parts because of
the intimate blood supply.
Choroiditis
There are many forms of choroiditis given by writers according to the
clinical picture and the pathology.
=Symptoms.=—No pain is experienced unless there are complications.
Vision is altered in some degree. The use of the ophthalmoscope may
reveal opacities in the vitreous. Pigmentation spots and exudation may
be noted in the fundus. In disseminated choroiditis spots of exudate
appear in the fundus which go on to atrophy, leaving irregular circular
light patches.
=Treatment.=—In all forms of choroiditis careful diagnosis of
constitutional conditions should be made and treatment given according
to indications.
Nasopharynx and orbital treatment as outlined under manipulation for
diseases of the eye should be given.
Rest and protect the eyes. Secure free elimination.
Panophthalmitis
By injury or otherwise pathogenic germs are introduced into the eye.
The trouble begins as a =suppurative choroiditis= and rapidly spreads
to all the eye structures. The vitreous chamber becomes filled with pus.
=Symptoms.=—Pain is severe and sight is lost early. The conjunctiva
and lids are much swollen. There is a mucopurulent discharge. The
cornea becomes gray and may slough. In about two weeks the inflammation
subsides and the globe passes into atrophy.
=Treatment.=—Elimination must be thorough. Spinal treatment for keeping
up strength. Cervical, upper dorsal and nasopharynx treatment for the
eye. Moist hot compresses to the eye. Operation, incision for drainage,
or evisceration may have to be performed.
Sympathetic Ophthalmia
The other eye may become inflamed by the process from the
panophthalmitis passing around through the circulation or the
continuous structures. All symptoms of a general inflammation appear
and vision gradually diminishes.
=Treatment.=—In panophthalmitis of one eye always watch the other eye
closely. If it becomes irritable or shows any signs of being affected
the diseased eye should be promptly removed, especially if vision is
lost in that eye. If no irritation occurs, continued conservative
treatment of the panophthalmitis may result in a subsidence of the
disease without the well eye becoming affected.
Sympathetic inflammation rarely develops earlier than a month after
injury to the exciting eye. Sooner than that or even a few minutes
after injury there may be some signs of sympathetic irritation and
the symptoms continue with no evidence except a slight circumcorneal
injection. It should be treated like iritis. A thorough toning of the
system by spinal treatment should be given. Order a limited diet.
Secure free elimination.
Glaucoma
Glaucoma is essentially an increase in the intra-ocular pressure. All
other symptoms of the trouble may be traced to this condition.
In =Primary Glaucoma= the increase in pressure sets in without any
discoverable antecedent disease of the eye.
In =Secondary Glaucoma= the increase in pressure is due to some other
disease of the eye. It is a symptom, a complication or accessory and is
confined to the eye diseased.
Primary glaucoma affects both eyes, but not always at the same time.
Fuchs says primary glaucoma constitutes about 1% of all eye diseases.
It is often mistaken for iritis or iridocyclitis and treated with
atropine which is contraindicated. It may be regarded as beginning
cataract and time lost in expecting it to become ripe. These delays and
wrong treatment have caused much blindness.
Palpation with the finger or the use of the tonometer may readily
detect any increase in tension. A correct diagnosis must be made early
and proper treatment instituted if vision is to be saved.
=Primary glaucoma= may or may not have signs of inflammation. If the
tension rises suddenly inflammatory symptoms develop (acute) while if
the increase in tension develops gradually these symptoms are lacking
(simple).
=Acute primary glaucoma—Symptoms.=—First stage, rise in tension, vision
obscured, sees a colored ring around lights, cornea dull, pupil dilated
and sluggish, some ciliary injection. The attack may clear up for a day
or for weeks. Gradually the symptoms become permanent after repeated
attacks. Second stage, when the attack comes there is much pain, visual
power fails rapidly, may be edema of the lids and chemosis of the
conjunctiva, all symptoms become much exaggerated, the cornea becomes
cloudy. After a violent attack the vision is more or less permanently
damaged. Third stage, after many attacks the optic nerve becomes
excavated and atrophy takes place.
Simple Primary Glaucoma
=Symptoms.=—Tension comes gradually; no inflammatory signs; pupil
somewhat dilated and sluggish, the cornea may look slightly smoky.
With the ophthalmoscope a cupped disc may be noted. There is gradual
diminution of sight, which begins by contraction of the field.
There are many theories advanced as to the cause of intra-ocular
tension in glaucoma. (Fuchs, Weeks, De Schweinitz).
=Treatment.=—Eserine is used instead of atropine. The object is to
contract the pupil and draw it away from the side wall of the eye
ball so the sinus (Schlemm’s canal) and the pectinate ligament (the
filtering angle) may become free. The good effect of this is more
marked in inflammatory glaucoma. In simple primary glaucoma miotics do
little good.
Reports from osteopathic treatment of this condition have been
favorable in a number of cases. Careful manipulation of the structures
of the orbit with the finger or with Dr. Ruddy’s third finger eye
instrument is good in restoring better circulation of the lymph and
blood. Special attention to the venous drainage should be given. Treat
the points of the fifth nerve, the nasopharynx and cervical region,
spring the jaw. Treat second dorsal.
Have the patient avoid strong emotions or excitement. Keep the bowels
free and use only a very bland diet.
Iridectomy is considered the best operation in glaucoma.
In the treatment of secondary glaucoma the other diseases or
complications must be considered in conjunction with the foregoing
treatment.
Diseases of the Lens
Opacities or Cataract
=Symptoms.=—Beginning opacities can best be recognized with the
ophthalmoscope. Advance opacities can be seen at a glance with the
naked eye.
Vision is disturbed according to degree and location of the opacity.
If the opacity is in the center of the lens and the periphery is
transparent they see better when the pupil is dilated. When the
opacities are in the periphery of the lens they see better by day.
Muscæ volitantes and polyopia are present until increasing opacity
closes up all clear areas shutting out these visual perversions.
There are many clinical varieties of cataracts which may be studied in
works on ophthalmology.
=Causes.=—Some interference with the nutrition of the lens accounts
for the condition. Heredity is supposed to play a part in some
cataracts. Rickets, convulsions, traumatism, old age, some drugs
(ergot), inflammation of iris, ciliary body and choroid are given
as causes. Cervical and upper dorsal lesions and disease of the
throat, nasopharynx and nose will interfere with perfect circulation
and drainage of the orbit, and may well have much to do with many
idiopathic cataracts.
=Treatment.=—Many cases have been reported cured by osteopathic
measures. Correct lesions and treat to establish free nerve force
and circulation of blood and lymph to the orbit. Manipulation of the
orbital tissues and mild vibration of the bulb are measures of value.
More hope may be held in symptomatic, toxic, secondary and progressive
cataracts. The process may be stopped and in many cases there is hope
of a clearing.
Diseases of the Retina
The retina lines the back part of the eye ball. It comes forward to the
ora serrata. It consists of ten layers which have been demonstrated
microscopically. One layer of it passes over the ciliary body and back
part of the iris to the pupil. The fibers of the optic nerve spread
out over the retina. The point of entrance of the optic nerve is the
papilla. It is to the inner side of the posterior pole of the eye. The
retinal vessels emanate there. The macula lutea is the yellow sensitive
spot at the posterior pole of the eye. The fovea is the center of
the macula. The rods and cones constitute the external layer of the
retina. This layer is the light perceiving stratum. For vision to be
perfect all the other layers must be perfectly transparent. The visual
purple is a chemical substance in the rods that gives the retina a
purplish-red color. The light shining into the eye forms images which
are converted into nervous stimuli by chemical action of the visual
purple and by physical changes and fibrillations in the rods and cones.
Retinitis
=Symptoms.=—The ophthalmoscope must be used in diagnosis. There is at
first cloudiness of the retina; the outlines of the papilla become
indistinct. We may note light patches of exudates. The vessels are
more tortuous and often there are hemorrhagic spots. Opacities in
the vitreous due to the exudate may be seen. Vision is disturbed in
proportion to the inflammation. Weeks or months are required for
recovery. Atrophy may set in and cause blindness.
=Cause.=—Many general diseases are found back of this trouble, e. g.
albuminuria, diabetes, leukemia, syphilis, gout and arteriosclerosis.
Idiopathic cases occur with none of these diseases present, which gives
a field for osteopathic research.
=Treatment= should be directed against the general disease when
present. For local effects treatment should be given to all the centers
and localities that affect the trophism, nerve supply and circulation
to the eye. Protect the eye by dark glass or confinement to a dark room
and complete rest. Keep the bowels free and produce diaphoresis.
Optic Neuritis
This disease when manifest in the eye ball is called papillitis. If
back of the bulb it is =retrobulbar neuritis=.
=Symptoms of papillitis.=—Pupils are dilated and sight diminishes. The
color of the papilla is altered to a white, reddish or gray and may
show extravasation of blood. The papilla is swollen (choked disc), the
arteries are thin and the veins are engorged. It takes months for the
inflammation to clear. Atrophy is likely to occur.
=Causes.=—Brain diseases are the most frequent cause, e. g. tumors.
Syphilis, febrile diseases, nutritive disturbances, lead poisoning,
heredity and growths in the orbit are cited as causes.
=Symptoms of Retrobulbar Neuritis.=—There is little or no change in
the papilla. The diagnosis must be made mostly from the way the vision
is affected. The rule is a central scotoma in the field of vision. The
first colors to disappear are red and green. In the acute form there
is quick disturbance of vision. The eye looks normal outside and shows
practically no change inside.
=Cause.=—Toxemia, cold, influenza; nasal, nasopharyngeal and sinus
disease (ethmoids), and infectious diseases are causes. Idiopathic
inflammation of the optic nerve is noted by most oculists. Here the
profound effects of spinal lesions upon the eye adds some important
light.
=Treatment of Papillitis and Retrobulbar Neuritis.=—In each individual
case the treatment requires consideration of the causal factor. There
may be required constitutional treatment in many cases. In others the
cause may be found in the nose, nasopharynx, or spine. Effort should be
made to remove the lesion in each case. Diaphoresis will aid in acute
stages.
Atrophy of the Optic Nerve
There are many causes for this condition such as optic neuritis,
meningitis, acute infectious diseases, locomotor ataxia,
arteriosclerosis, nasal disease, syphilis, traumatism, alcoholism,
exposure, embolism of the central retinal artery, diabetes and
poisoning. Diagnosis must determine the original cause.
=Treatment.=—I have mentioned conditions in the nose as frequently
accounting for various eye troubles. If these atrophies of the optic
nerve can be gotten early, many of them will be influenced very
favorably by osteopathic treatment. Spinal treatment to direct the
circulation to the area of the orbit at the base of the brain is
beneficial. Regulation of the patient’s diet, habits, methods of living
and so forth is important. Excessive mental strain, excessive sexual
intercourse and stresses of every kind should be prohibited. Special
treatment should then be given according to the causal factors entering
into the case.
Eye Strain and Its Reflexes
For the subject of refraction and refractive errors such as the
different forms of hypermetropia, myopia and astigmatism the reader
is referred to the many excellent works on ophthalmology which cover
these subjects quite thoroughly. They are only used here in the
relation to eye strain and its reflexes. The osteopathic logic here
given should be combined with a reading of the refractive errors in
such works as Fuchs, Weeks, De Schweinitz and others.
Asthenopia
=Eye strain, weak sight or asthenopia= embraces the group of symptoms
dependent upon fatigue of the ciliary muscles or of the extraocular
muscles.
There are three varieties of asthenopia. (1) Retinal or nervous, (2)
muscular and (3) accommodative.
The symptoms are headache—frontal, fronto-temporal or fronto-occipital.
It may extend into the neck between the shoulders. Eye balls may be
tender, diplopia at times, may be photophobia, lachrymation, congestion
of the eye, itching and burning of the lids.
=Accommodative Asthenopia.=—In this form the ciliary muscle is
fatigued. The cause is usually overuse of the eye when hyperopia and
astigmatism exist; sometimes in myopia or presbyopia.
=Treatment.=—In this form the treatment is the proper fitting of
glasses and improvement of the general health.
=Muscular Asthenopia= is due to tiring of the extraocular muscles,
usually the internal rectus. This may result in a phoria or a
non-paralytic squint.
Ametropia may exist but asthenopia may come even in emmetropia due to
overuse of the eye.
=Treatment.=—Correct ametropia if present, with glasses. Exercise the
weakened muscle. Correct the nerve supply to the weak muscle. Treat
cervical and upper dorsal. Manipulate tissues of the orbit. Spring the
jaw. Correct any nose and throat pathology.
=Nervous, Neurasthenic or Reflex Asthenopia.=—The cause is supposed to
be some functional disorder, more often found in females. May be due to
too dim or too bright light, overuse of the eyes. Hysteria may follow
ametropia.
=Treatment.=—Often the treatment is troublesome and the case is very
obstinate according to old school methods. Rest, hygiene, general
health and habits are looked after. The cause must be found or the
treatment cannot be specific.
These are the different forms of eye strain as ordinarily classified.
Now as we study the reflex symptoms from these and attempt to trace
out the reflexes from an osteopathic point of view, we may find some
more definite causes of these conditions and consequently some methods
of treatment not found in standard text books might naturally suggest
themselves.
Reflex symptoms that have been traced to eye strain by ophthalmologists
are as follows:
Constipation, indigestion, heartburn, nausea, vomiting, nervous
attacks, fear of impending calamity, irritability, despondency,
insomnia, restless sleep, epilepsy, nervous twitchings and enuresis.
All these symptoms have been seen to disappear after eye strain was
corrected. There is no absolute way of proving that all these symptoms
have existed because of eye strain. The existence and disappearance
of some of them at the time of treatment for eye strain may be a
coincidence. It is evident that eye strain in varying degrees may
produce a train of symptoms similar to many above mentioned.
A patient, nervous, anxious, uneasy, and despondent, constipated,
and having some indigestion, showed on examination contractures and
tenderness at the third dorsal. It was found he was suffering from eye
strain from overuse of glasses that were too strong for him. The eyes
were refitted. He was wearing a
(R)+4.50 D. S. = +.50 cyl. Ax. 180.
(L)+4.50 D. S. = +.50 cyl. Ax. 90
for close work and a (R)+2.00 D. S. = +.50 cyl. Ax. 180
(L)+2.50 D. S. = +.25 cyl. Ax. 90
for distance. The new glasses were—Reading—
(R)+3.00 D. S. = +.25 cyl. Ax. 180
(L)+3.00 D. S. = +.25 cyl. Ax. 180
Distance:
(R) + 1.50 D. S. = +.25 cyl. Ax. 180
(L) + 1.50 D. S. = +.25 cyl. Ax. 180
He was fitted two years previously. At that time the stronger glasses
were correct. Eyes change more or less constantly, especially between
the ages thirty-five to fifty-five years. When glasses are fitted, a
weak ciliary muscle after a rest may become stronger and allow weaker
glasses to be worn.
If a young person is fitted for myopia, in a few years he may discard
his glasses as presbyopia develops. A person fitted correctly, who has
a strong ciliary muscle may not be able for awhile to see as well with
the glasses as without them. After they are worn awhile the ciliary
muscle will cease its efforts to accommodate so much and the glasses
give the desired effect. In some cases the doctor’s reputation to fit
glasses properly may suffer at the hands of such people who sometimes
refuse to take glasses, or after getting them refuse to wear them.
In the case of the man just mentioned a refitting quieted the nervous
symptoms—he became more cheerful and ceased to worry. Indigestion and
constipation improved. The soreness and contractures were overcome in a
few treatments.
Now let us ask the question, why is it that eye strain will cause
nausea and vomiting? Also why will indigestion affect the eyes by
causing “spools” in the vision?
A little osteopathic logic, based as it always is or should be, upon
anatomy and physiology, may throw some light on this subject. No doubt
every one of us has demonstrated many times clinically that indigestion
from overeating will cause soreness and contractures at the third and
fourth dorsal, the nerve center in the spine for the stomach.
The reflexes between the viscera and the eye are complex and difficult
to follow. In giving the probable course of the nerve reflexes from
the optic nerve to the third nerve Dr. Louisa Burns suggests the
following: “The nerve elements of the retina start the impulse; it
passes over that portion of the optic nerves which enter the anterior
quadrigeminates, the cells of the quadrigeminates where the impulses
are coordinated, then by axons of these cells to the lateral or
viscero-motor nucleus of the third nerve, thence to the cells of the
ciliary ganglion, and by the non-medulated (sympathetic) fibers of
these, the short ciliary nerves to the non-striated muscles concerned,
viz: the ciliary muscle, some fibers of the levator palpebral and the
sphincter of the iris.”
The third nerve arises in the floor of the aqueduct of Sylvius from
two nuclei; a lateral nucleus which is a viscero-motor group of nerve
cells, and a central nucleus or a somato-motor group of cells. The
somato-motor nucleus supplies all the extrinsic muscles of the eye
except the external rectus and superior oblique which are supplied by
the sixth and fourth respectively. The nasal branch of the ophthalmic
division of the 5th sends fibers to the ciliary muscle. Association
fibers connect the nuclei of the 3rd, 4th, 6th and 7th. The evidence is
in favor of the 10th or pneumogastric having such association fibers.
We noted four places in the brain to which the optic tracts go before
the radiations reached the center of sight in the occipital lobe. If
we cannot follow all the reflexes through the brain and cord at least
with the facts we have it is not difficult to imagine abnormal impulses
coming over the third nerve from a straining of the ciliary nucleus,
thence over viscero-motor fibers in the lateral horn of the cord, over
the white ramicommunicantes, through the sympathetic ganglia, over the
splanchnics to the stomach, producing abnormal peristalsis, nausea and
vomiting. In turn we would have the somato-motor nerves to the muscles
affected as before described, contraction and congestion of muscles of
the spine.
When we have patients consult us and describe a train of symptoms
like nausea, vomiting, nervousness, frontal and occipital headache,
we should have eye strain in mind and inquire for lachrymation,
photophobia, itching and burning lids and congestion of the eye. Any
of these things should make us think of testing for ametropia in its
various refractive errors, as well as a careful spinal and a nose and
throat examination. General physical and laboratory diagnosis should
not be neglected.
References
Fuchs’s Text Book of Ophthalmology, Duane.
Headaches and Eye Disorders of Nasal Origin, Sluder.
External Diseases of the Eye, Greeff.
Vol. III Practical Medicine Series: The Eye, Ear, Nose and Throat by
Casey A. Wood, Albert H. Andrews, Geo. E. Shambaugh.
Diseases of the Eye, Weeks.
Diseases of the Eye, Ear, Nose and Throat, Posy and Wright.
Diseases of the Eye, De Schweinitz.
Diseases of the Eye, May.
Text Book of Ophthalmology, Roemer and Foster.
Diseases of the Eye, Jackson.
Ophthalmic Surgery, Meller.
DISEASES OF THE EAR, NOSE AND THROAT
By J. DEASON
Diseases of the Ear
=Methods and Technic of Examination.=—The external ear may be examined
by direct inspection with or without the aid of artificial light.
The external auditory meatus may be examined by means of a simple
conical ear speculum and reflected light from a head mirror. This
method requires considerable practice but efficiency can and should be
attained because it can be used under all conditions and therefore is a
reliable method.
The Holmes electric auroscope which we use and recommend for examining
the meatus and ear drum, is very efficient but like other electrical
equipment is not always dependable. There are many electrical
equipments for examining the ear, but so far I have found none other
than the one above mentioned that is worth space in an instrument
cabinet.
To examine the meatus, grasp the pinna and draw it firmly upward and
backward. This tends to straighten the canal so that the aural speculum
may be inserted well into the external canal. It must be remembered
that the auditory canal is always sensitive and while there is really
little danger of doing any harm by exercising ordinary care, the
patient is always afraid of being hurt and one can accomplish better
results by practicing careful technic.
If the electric auroscope is used, the eye should be placed very close
to the lens and every part of the canal, walls and drum membrane
carefully examined. The Holmes auroscope has a small tube and bulb,
pressure upon which will vary the air pressure in the meatus and cause
the drum to move. This must be done very carefully because in very
thin, atrophic membranes there is some danger of rupturing the drum.
Diseases of the Auditory Meatus
=Inspissated Cerumen=, or hardened ear wax is one of the most common
affections of the meatus. The cause in some cases can be traced to
lesions of the mandible, but in many cases the cause is unknown.
=Treatment.=—Protect the clothing by means of a towel or rubber neck
piece. By means of a soft rubber ear syringe, wash the canal thoroughly
by forcing warm soap solution into it. I prefer concentrated liquid
castile soap (any good soap will do) diluted about one to four in water
as warm as the patient can bear it. The soap solution is contained in a
pus bowl held tightly against the neck under the ear. There is little
danger of using too much force with the soft rubber syringe.
In most cases the hardened cerumen will be dislodged by the syringing
only. If this cannot be done, it may be well to discontinue the
treatment until the following day. The solvent action of the soap
solution will further reduce the hardened mass and it usually can be
removed by syringing the following day. This method is preferable in
many cases because patients dislike the pain which usually accompanies
the use of a curet.
The dull loop curet is the most efficient and safest instrument for
removing hardened cerumen that the syringe may fail to dislodge. This
instrument must be used with great care because the membranes, long
protected by the covering of cerumen are hypersensitive and bleed
easily.
After removing the cerumen, the canal should be thoroughly dried and
lubricated with some non-irritating lubricant. It is also well to
place a small pledget of absorbent cotton into the external opening to
protect the sensitive membranes from the cold, air and dust.
In drying the canal I prefer to use a small aluminum applicator,
twisting a small piece of absorbent cotton on the end in such a way as
to cover the tip well, thus making any injury from its use impossible.
Atrophic Meatus
Sensitive or itching ears as the patient commonly describes it, is a
very common disease caused by any atrophic condition of the membranes
of the auditory meati and frequently found in common with auditory or
other cranial nerve deficiency or degeneration. The direct cause of the
irritation is the collection of particles of dry cerumen.
=Treatment.=—The local treatment consists of syringing with warm
(118° to 120°F) soap solution until all of the scaly cerumen has been
removed. The canal is then dried and lubricated as described above.
Several such treatments may be required after which I prefer the use
of the continuous irrigating ear cup, using salt mixture instead of
the soap. The same salt mixture as is recommended for nose and throat
irrigation is satisfactory. After such irrigations the application of
phenol-glycerine (10% phenol in glycerine) seems to be an efficient
treatment.
The local treatment must, of course, be accompanied by corrective
treatment to the mandible and upper cervicals.
Furunculosis
There are three acute affections of the ear which may usually be
diagnosed from their points of tenderness or pain. Pain upon moving the
lobe or pinna indicates furunculosis. Pain on pressure posterior to the
angle of the jaw or externally in front of the ear indicates middle
ear infection and pain on pressure over the mastoid region suggests
mastoiditis.
Probably the most common of the painful diseases of the external meatus
is furunculosis, which is a subcutaneous infection of the lining
membrane of the meatus. The point of swelling may usually be seen but
in some cases the entire canal is closed.
=Treatment.=—In all cases of occluded pus, drainage must be obtained,
but in the early stages of furunculosis, it is not always possible
to determine the place of “pointing” or the most desirable point
to lance. As soon as the place of “pointing” can be located it is
advisable to lance deeply by means of a curved paracentesis knife.
The parts are thoroughly cleansed and anesthetized by applying phenol
and neutralizing with alcohol. The external parts are first painted
with alcohol to prevent “burning” from any phenol which may be
dropped upon them. A small cotton applicator is used, applying the
concentrated solution of phenol or the crystals (using only a small
amount of phenol) to the affected parts and immediately neutralizing
with alcohol. Care must be observed not to apply any phenol to the drum
membrane and the operator must be sure that the action of the carbolic
acid is completely neutralized by a liberal application of alcohol.
The knife blade is placed beyond the furuncle, its curved point turned
outward and quickly drawn forward through the furuncle, cutting
deeply. The canal is then packed with a pledget of cotton dipped into
phenol-glycerine.
If the place of pointing cannot be seen, palliative treatment may
be applied by thoroughly cleaning the meatus, drying and applying a
phenol-glycerine pack. Heat may be applied by means of a therapeutic
lamp. Any electric light bulb or the dry electric pack will do. The
external parts are well lubricated with paraffin oil and the heat
applied continuously or intermittently until the pain is relieved.
Infection of the Meatus
Infections of the meatus are frequently secondary to, or accompanied
by furunculosis. The treatment, therefore, is similar to that of
furunculosis.
Always try to locate the point of infection, lance or curet, apply
phenol or other chemical germicide, neutralize, dry and pack with
phenol-glycerine. After the point of infection has been thoroughly
drained, cleanliness and protection from dust or further infection is
all that is necessary.
In all cases of infection of the external meatus, suspect middle ear
abscess as a cause. There may be a pin-point opening through the drum,
from which the infection has originated and is being maintained.
=Otomycosis= or fungus infection of the auditory meatus is rare. It
usually resembles other infections symptomatically, but often without
pus. A microscopic examination will serve to diagnose the condition.
The treatment consists of thorough cleansing, drying and the free
application of alcohol. Alcohol is dropped into the ear until the canal
is full and a pledget of cotton applied to retain it. Usually two or
three applications are sufficient to effect a cure.
=Eczema= of the auricle and meatus is of two types, the squamous or
scaly form and the sclerotic form. Both forms are chronic and may be
readily diagnosed by the appearance.
=Treatment.=—Some cases are very difficult to cure but we have had
excellent results with the following treatment: Careful adjustment
of cervical and mandibular lesions; thorough treatment of any local
infections of head or neck; direct application of phenol-glycerine,
local cleanliness and protection from irritation.
Diseases of the Middle Ear
Clinically the middle ear consists of the tympanic cavity and its
contents, the Eustachian tube and the mastoid cells.
Acute Suppurative Otitis Media
Acute infections of the middle ear result from acute nasopharyngeal
affections such as colds, influenza, measles, mumps, whooping cough,
etc. Bathing in contaminated water often results in infection to the
middle ear through the Eustachian tube.
=Diagnosis.=—Earache, pain on pressure under the angle of the jaw and
sudden deafness are the symptoms. (There are also the common febrile
symptoms.) The chief physical signs are: redness and bulging of drum
membrane, and contraction and tenderness of upper cervical muscles.
=Treatment.=—If the patient is seen before the drum has ruptured it is
seldom necessary to lance the drum if the proper treatment is given
promptly.
Drainage must be obtained and maintained by catheter aspiration through
the tube irrigation of the nasopharyngeal cavity, irrigation of the
meatus by means of the continuous ear irrigator and application of
dry heat over the affected part. Heat is best applied by means of a
therapeutic lamp. (Any lamp with reflector that will furnish proper
heat is efficient as there is no virtue in colored light.) The skin
surface over the ear, side of face and mastoid region is first well
lubricated with some mineral oil to prevent blistering and the heat is
applied either constantly or intermittently. A pledget of absorbent
cotton dipped into phenol-glycerine is placed in the meatus and forced
loosely against the drum. This should be removed every few hours and a
fresh pledget put in.
The neck and upper dorsal muscles should be kept relaxed and adjustive
treatment given frequently.
Under this treatment the pain should be relieved and the bulging of
the drum should disappear in from two to twelve hours. If this is
not accomplished or if the condition grows worse, the drum should be
lanced. See some text on otology for technique. In my experience, very
few cases have required paracentesis.
It must be remembered that treatment should be continued regularly and
for some time after the pain and other symptoms have been relieved or
a recurrence is probable. Patients should have daily treatment until
the physician is sure that no complication or recurrence is likely to
result.
If the patient is not seen until after the drum has ruptured, the same
treatment may be applied except the irrigation or syringing of the
meatus. This, in case of ruptured drum, may force pus into the mastoid
cells resulting in mastoiditis. Instead of syringing, the auditory
meatus is cleaned by means of a cotton applicator or by aspirating with
a catheter. At all times drainage through the meatus must be maintained
until the drum begins to heal.
Acute Mastoiditis
Acute mastoiditis results from acute or chronic otitis media. In some
cases the otitis media may have been only a mild attack.
=Diagnosis.=—There is no one symptom that is positively diagnostic but
a number of signs and symptoms must be considered as follows:
1. Always suspect mastoid complications in acute otitis media and watch
for this complication daily. Most cases have some mastoid inflammation.
2. Pain or swelling over mastoid. Pain may not be present, but usually
is, sometimes radiating over temples and eye on affected side.
3. Tenderness on pressure not always present. May be very marked.
Tenderness extending to tip or above ear means extension of infection.
If persistent tenderness over tips with marked swelling and
discoloration—operation is indicated.
4. Swelling, not always present, but sometimes very marked. If extreme
swelling and bluish discoloration—usually means operation.
5. Temperature varies from normal to 104° or 105° F. Temperature of
more than one or two degrees means systemic absorption and suggests
surgical drainage. Streptococcus or staphylococcus infections cause
higher temperatures and require drainage earlier than other infections.
6. Transillumination not positive, but of some value. Like X-ray,
usually shows dark, because of inflammation, but must rely upon
symptoms, as above.
7. =Microscopic.=—Stain for pus, bacteria and bone debris. Hematoxylin
stain shows dark bone particles if there is bone disintegration.
8. =Blood Count.=—If absorption, there will be some variation in
proportions of leucocytes. Any high leucocytosis shows systemic
absorption and the natural attempt to overcome the infection.
=Non-Surgical Treatment.=—1. Drainage must be maintained from middle
ear through tube or drum or both. Catheter aspiration through tube.
Sometimes gentle inflation to clear the tube, followed by aspiration is
effective.
2. If drum is ruptured, aspirate middle ear by catheter or by Moore’s
method or both. =This is very important.= If no aspirating machine, use
syringe and pump meatus and tube persistently. Dry meatus and keep well
open.
3. Patient should be kept in bed if symptoms are marked, with light
diet and bowels well open.
4. =Heat.=—Apply oil or other lubricant over whole side of face and
head and apply heat by means of “therapeutic” lamp intermittently.
Thirty minutes light on and fifteen minutes light off. The light-heat
(any electric lamp with reflecting shade will do) is much better than
hot water bottle or electric pad or sand bag. The heat must be kept
going day and night if symptoms are marked until the pain has entirely
subsided. Heat is most efficient in the early stages. After symptoms
are well marked, the ice pack is more desirable.
5. If drum is not ruptured, heat may be applied by means of Deason’s
continuous irrigating cup. Start at 116° F. and gradually increase to
123° F. if patient can bear it.
=Surgical.=—If drum has not ruptured and symptoms continue, it is best
to make free incision of drum,—keep open and apply (2) above.
=Indications for Mastoid Operation.=—There are no definite signs,
symptoms or tests that will determine positively when operation should
be done. If the above non-surgical methods are practiced, few cases
will require operation, but many will develop into chronic mastoiditis
and so it is very difficult to decide whether a mastoid operation
should or should not be done. It is best to explain thoroughly the
possible complications to the patient and relatives and request them to
assume responsibility. Mastoid operations are attended by very little
danger when properly done.
=Signs and Symptoms Suggesting Operation.=—Acute otitis media with
mastoiditis.
(1) Persistent pain and swelling not relieved by non-surgical treatment.
(2) Marked protruding of posterior wall or meatus.
(3) Marked tenderness, swelling and discoloration above ear or over tip
of mastoid.
These with temperature of more than 102° usually are enough to demand
immediate drainage.
(4) Any evidence of extension of pus under skin of neck below tip. A
positive indication for drainage.
(5) Any indications of brain or meningeal involvement such as very
marked and persistent headache, partial or total loss of consciousness,
etc.
(6) Indications of labyrinthine involvement such as marked vertigo, etc.
(7) Sudden cessation of discharge means obstructed drainage from middle
ear or from mastoid into middle ear and if drainage cannot be restored
by aspiration, this means operation.
(8) The whole clinical picture must be carefully considered at all
times. Take no chances. Advise operation before someone else finds it
too late.
Chronic Mastoiditis
=Cause.=—Always from unsuccessfully treated acute form or from chronic
suppurative otitis media.
=Non-surgical treatment.=—See chronic suppurative otitis media. We have
had a few cases that were seemingly permanently cured by non-surgical
treatment, but believe they are rare.
=Indications for Operation.=—1. Recurrent exacerbation of acute or
chronic otitis media.
2. Constant discharge which resists treatment for chronic suppurative
otitis media.
3. Continued pain or recurrent pain and swelling following acute otitis
media.
4. Open sinus into mastoid either external or through meatus.
5. Cholesteatoma.
6. Symptoms of labyrinthine or brain involvement following acute otitis
media.
7. Definite evidence of bone disintegration in mastoid.
As stated above, none of these are definite indications. The whole
group of signs and symptoms are to be considered.
Chronic Suppurative Otitis Media
=Etiology.=—Chronic suppurative otitis media usually results from an
unsuccessfully treated acute otitis media. If in acute otitis media
there has been bone erosion or extensive destruction of the mucous
membrane by a virulent infection, chronic suppuration is likely to
result. A persistent mastoid infection following otitis media is likely
to result in chronic otitis media and this is strong argument for early
mastoid operation.
1. Otitis media resulting from some virulent infection such as the
recent influenza pandemic or scarlet fever is always more likely to
result in mastoiditis and chronic suppuration of the middle ear.
2. Such infectious agents as streptococcus, staphylococcus, long-chain
pneumococcus or bacillus influenzæ are likely to result in chronic
suppurations.
3. Lowered vitality from any cause.
4. Inefficient drainage from failure to aspirate the Eustachian tube,
delayed perforation or failure to lance drum sufficiently early.
5. Mastoid necrosis, which maintains drainage into the tympanic cavity.
6. Abnormal granulations, polypi, etc. in tympanic cavity.
7. Chronic inflammation with suppuration of the epipharynx or
Eustachian tubes.
8. Cholesteatoma resulting from perforated drum and growths of
epithelium extending into the middle ear cavity.
=Diagnosis.=—The diagnosis is easy because nearly every case of
discharging ear without pain is chronic suppurative otitis media. The
determination of the exact nature of the condition present is not only
very important but very difficult.
Differential diagnosis consists in determining the nature of the
infecting organism and the nature and extent of the pathology.
1. Direct examination of the external meatus after drying with cotton
applicator usually determines the location and extent of perforation
of the drum and the general nature of the discharge, whether purulent
or mucopurulent. Very rarely one finds a serious discharge which means
a very slight infection or discharge from non-infective inflammation.
The presence of whitish or greyish pus, mucoid and stringy, usually
means pneumococcus infection. Greyish, purulent non-mucoid discharge
usually indicates streptococcus or bacillus influenzæ infection.
Yellow, purulent discharge suggests staphylococcus infection. The
general appearance of the discharge, however, cannot be considered of
important diagnostic value because most chronic suppurations are mixed
infections, because of long exposure to external contamination.
2. After cleaning the meatus, several smears should be made directly
from the opening in the drum. By staining with methylin blue or gentian
violet, the nature of the bacterial infection can be determined and
this is very important.
By staining another smear with hematoxylin and washing in water, any
dark irregular particles, bone debris, may be found, which means bone
disintegration. This too, is very important.
3. Transillumination is sometimes of value. The mastoid may be
transilluminated by placing a good rubber covered transilluminating
lamp over the mastoid and observing the external meatus through an
aural speculum. If the mastoid is free from infection the light will
pass through and illuminate the meatus.
4. The X-ray plate is, of course, the best means of determining the
nature and extent of mastoid involvement.
=Treatment.=—This is certainly one of the most difficult diseases of
the ear that one is ever called upon to treat and the physician should
be cautioned against offering a favorable prognosis. Perhaps the most
difficult thing about its treatment that the doctor has to learn is
that practically none of the so-called antiseptic washes do any good,
but on the other hand they often do harm. Certain general principles
are important and the treatment must depend upon the nature and extent
of the infection and pathology present in each case.
The constitutional treatment consists of everything that will increase
the patient’s general resistance and certainly all lesions of the
cervical, upper dorsal and mandibles must be properly adjusted, but
this is not enough. All spinal lesions that may exert an influence on
metabolism and elimination are of important consideration. The diet,
habits and environment of the patient must be considered.
A careful examination of the nasopharyngeal tract may reveal some other
focal infection, such as chronic tonsillitis, pharyngitis or sinuitis,
which is maintaining the infection through the Eustachian tube. There
may be a focal or general infection of some other part of the body,
which is reducing resistance or causing a hematogenous infection of the
tympanic cavity or mastoid cells.
Drainage must be maintained in all cases, both through the Eustachian
tube by catheter aspiration and through the drum by aspirating and
drying. If the perforation in the drum is small or in the middle or
upper part, it should be opened down to the floor so that the contents
may be more easily removed and better drainage established. It is well
first to thoroughly cleanse the meatus and tympanic cavity by syringing
with salt mixture (salt 3 parts, borax 2 parts and soda 1 part, a
teaspoonful to a half pus bowl of water) at from 116° to 118° F. After
syringing, the meatus is carefully dried, and the middle ear cavity
aspirated through the tube and drum opening. The advantage of this
simple treatment is thorough cleanliness and drainage with the minimum
of irritation. This treatment given daily or thrice weekly will often
cure the case.
Staphylococcus and streptococcus infections usually respond to the
following treatment: After thoroughly cleansing as above, the meatus
and tympanic cavity is syringed with a one to four or one to five
dilution of Dakin-Carrel solution (Hyclorite may be used instead)
followed by aspiration, the fluid being drawn through the tube, thus
preventing reinfection from that source.
Pneumococcus infections do not respond to either of these methods of
treatment. The pneumococcus, because of its capsule, is not affected by
antiseptics, but on the other hand the irritation of the tissues caused
by their use, only gives the infective agent a better opportunity for
growth.
In pneumococcus infections we have found the following method
efficient: Thoroughly cleanse the meatus and middle ear cavity by salt
mixture syringing, aspiration and drying. The meatus and tympanic
cavity is then filled with a neutral mineral oil. The oil is also
pumped through the Eustachian tube. It is the purpose to fill the
entire cavity and its openings so thoroughly that no air can enter.
In some cases we have used bismuth paste after the oiling with
excellent results. The pneumococcus is aerobic and if all air can be
kept away for a considerable time, it furnishes an unfavorable culture
environment with little irritation to the membranes.
=Surgical treatment.=—The presence of bone debris indicates bone
disintegration in the tympanic cavity or mastoid cells. If the mastoid
cells are thus involved there is little chance for direct treatment.
If such cases do not respond in a short time to any of the above
methods of local treatment, ossiculectomy or mastoid operation may be
necessary. Some specialist surgeons claim from 80% to 90% favorable
results from mastoid operation in such cases.
Non-Suppurative Otitis Media—Catarrhal Deafness
Deafness is any impairment of normal hearing and is that symptom next
to pain and chronic discharge that causes the patient to visit the
doctor. If acute diseases of the ear, nose and throat could always be
successfully treated, there would be little trouble from the symptoms
of chronic pathology. It must be understood that catarrhal deafness is
a symptom of chronic otitis media and is, therefore, seldom of recent
origin.
=Etiology.=—Chronic otitis media is nearly always the result of the
extension of infection through the Eustachian tube and has come
from some acute or chronic nasopharyngeal infection. Chronic colds,
pharyngitis, tonsillitis, sinuitis, etc., resulting in acute or chronic
otitis media either with or without suppuration, constitutes the
beginning of catarrhal deafness.
=Symptoms.=—There is seldom any pain with this disease. Some cases have
an occasional acute attack with pain and other symptoms of acute otitis
media.
Deafness, varying with the progress of the pathologic changes, is
always present. The patient in the early stages will seldom admit
that he suffers from deafness and often he is honest because he may
not realize that he cannot hear normally until his otitis media has
progressed to the second or third stage. Most patients, in fact, do
not become alarmed about their hearing until it is too late to restore
normal hearing. For this reason, physicians should be on the lookout
for such conditions and should advise special treatment early.
The human species in its present environment, depends much less upon
the organs of special sensation than do the animals of the wild, and
they may therefore be very deficient in sight, hearing, smell, etc.
without actually realizing this loss.
In addition to deafness there are other symptoms such as occasional or
constant fullness or feeling of “stuffiness” as the patients express
it, due to partial or complete occlusion of the Eustachian tubes.
Tinnitus aurium or head noises is very common and often the most
annoying symptom. Autophony, or the loud sound of the patient’s voice
to himself, which often causes him to speak low and indistinctly,
occurs in the later stages. Presbyacusia, or the inability to adjust
the hearing apparatus to variations in pitch, commonly occurs in the
second stage and is evidenced by the fact that the patient does not
hear when more than one person is talking. Paracousis or perverted
phenomena of hearing, such as the better hearing of some persons in a
noisy environment, is a symptom of the third stage of otitis media and
often means an unfavorable prognosis, so far as marked improvement in
hearing is concerned.
=Pathologic Stages.=—For convenience of discussion we may consider
chronic otitis media in three stages.
=The First Stage.=—The active pathology is limited to the pharyngeal
portion of the Eustachian tube with some inflammation of the membranes
of the tympanic cavity. Closure of the tube followed by absorption of
the oxygen causes a decreased pressure in the tympanic cavity and thus
a retraction of the drum, decreased movement of the ossicles and a
general decrease in function of all tympanic structures. Deafness in
this stage may be very marked, especially if the Eustachian occlusion
has occurred from some nasopharyngeal acute inflammation. There may
be pain but there is always a characteristic “fullness” and sometimes
dizziness. Deafness in these cases varies with weather changes. If
proper treatment is had in time, the progress of the pathology can be
stopped and every case can be restored to normal hearing.
=The Second Stage.=—The active pathology has extended throughout the
Eustachian tube causing marked occlusion and some stenosis. There is
further inflammation of the tympanic structures with an increase in
the symptoms of the first stage. The drum membrane is less movable but
there is no fixation of the ossicles. Pressure upon the bulb of the
auroscope causes movement of that part of the drum to which the malleus
is attached. The drum is thicker, more retracted, and less movable
than in the first stage. Presbyacusia is common and often marked, but
there is no paracousis. More than 90% of these cases can be materially
improved and many can be made to hear normally if proper treatment is
given in due time.
=The Third Stage.=—The active pathology in the third stage consists of
an involvement of the entire mucous membrane lining the Eustachian tube
and tympanic cavity. These membranes are all chronically hypertrophied.
The Eustachian tube, however, is sometimes fairly well open, but the
ossicular attachments are more or less fixed by hypertrophied tissue
and adhesions and the drum is markedly retracted, thickened and usually
very immovable. The deafness is usually quite marked, head noises are
commonly present and often very annoying. Patients usually do not
notice a variation in their hearing from weather changes. Presbyacusia
is present in 80% of cases and their hearing for low tones is much
reduced.
Unless there is a complicating nerve affection these cases hear well
by telephone, which means that they can also use an electric hearing
instrument to advantage. These cases can never be restored to normal
hearing, but many of them (30% of my cases) can have some improvement
and in most cases I believe the progress of the pathology can be
stopped, and this is always well worth while because their hearing is
likely to be entirely lost if something is not done.
=Psychologic Stages.=—There are three rather distinct psychologic
stages in catarrhal deafness. The first, the period in which most
patients refuse absolutely to admit that they are deaf even to the
aurist upon whom they call for treatment. They insist that they hear
perfectly if people would only speak distinctly. This is partially
true, because up to the third stage of deafness the voice can be fairly
well heard if people would only articulate clearly. In the second
stage patients admit that they don’t hear well, but insist that they
are going to recover normal hearing and often resort to various kinds
of injurious treatment. In the third stage they give up all hope of
ever regaining their hearing, become morose, and avoid company. These
psychic stages do not always correspond with the pathologic stages
given above.
=Diagnosis.=—The external auditory meatus, drum membrane and ossicular
chain, constitute the apparatus whose function is that of conduction of
sound waves to the perception apparatus of the inner ear. The function
of the conduction apparatus varies inversely with the progress of
pathologic change in these structures. The perception apparatus, the
structures of the inner ear, are not necessarily affected by middle ear
pathology, but on the other hand, sounds transmitted by bone conduction
not only seem louder but they last longer because the “escape of the
excess” of sound thus transmitted is hindered by deficient conductive
mechanism. This explains why such persons hear well by telephone and
why the tuning fork, whose base is held to the mastoid (provided
there is no nerve affection) may be heard for a greater time than
normal. Likewise the prong of the vibrating tuning fork when held near
the concha is heard for a shorter time than normal, because of the
deficient function of the conduction mechanism.
Tuning forks are known by their number of vibrations per second, such
as 16, 32, 64, 128, etc. Three or more forks are required to make an
accurate measurement of the conduction and perception functions—a low
fork about a 32, for the low tones, 128 or a 512 for the medium tones
and a 2048 for the high tones.
A good set of forks should be selected and standardized, i. e., the
normal bone and air conduction of each fork determined by testing it
on a number of persons whose hearing is known to be normal. For the
general practitioner who cares only to get a general idea of the extent
of the pathology, one fork of medium pitch such as a 128 or 512 will be
sufficient.
To measure the function of hearing, the fork is set into maximum
vibration, its base held against the mastoid and the patient is asked
to state when he no longer hears it. This length of time in seconds is
recorded as “bone conduction.” The fork is then held near the concha
and the patient again states when he does not hear it. This length of
time in seconds is recorded as air conduction.
Normal Hearing
=Tuning Fork Test.=—The normal time rate in seconds set of forks is as
follows:
Fork 32 64 128 512 2048 4096
B. C. 25 30 30 20 10
A. C. tone 70 90 90 40 20
The tuning fork test, carefully made, is the only known method of
measuring the functions of the various structures concerned in audition.
=The Whisper Test= is made by producing a clear whisper from residual
air only, which should be heard about twenty feet by a normal ear.
=The Watch Test= is made by using some loud ticking watch (I prefer
an Ingersoll), holding it first near the ear until the patient
recognizes the tone, and then taking it beyond the hearing distance and
approaching the ear until it is heard. I prefer also to move away from
the ear until the limit is reached and strike an average of this with
the above results. The average eighteen size Ingersoll watch can be
heard for from 100 to 150 inches by the normal ear.
The practical test for the patient is his hearing from the spoken
voice, and is the most reliable so far as permanent results are
concerned.
=Low Tone Limit.=—The lowest limit of hearing is about sixteen double
vibrations per second, but the lowest practical limit is about
thirty-two. There are few people with normal hearing and with musically
trained ears who can recognize a definite tone lower than this, so I
consider the thirty-two fork sufficiently low for all practical tests.
=Conduction Deafness.=—Low tones are lost in tympanic involvement or
conduction deafness, and are diagnostic in such cases, but are of no
particular value in nerve deafness except when that is complicated by
catarrhal deafness.
=Practical Hearing Limits.=—The human voice varies from about 60 to 150
double vibrations per second, and most sounds that we really need to
hear are less than 700 vibrations per second. This is the reason for
using the low forks, 64, 128 and 512.
=Measurement of Nerve Force.=—To measure auditory nerve force, the fork
(say the 128, whose normal B. C. is 30 seconds) is set into vibration
and held gently and with even pressure against the mastoid and the
patient is asked to tell or signal the doctor when he ceases to hear
the tone. Two or more tests may be made to determine the patient’s
personal equation, but the use of control forks (the 64 and 512) will
show any such error. Granting that there is no complicating pathology,
tympanic or labyrinthine, the number of seconds of hearing over 30 will
be the patient’s auditory nerve force. For example, if he hears the
fork 30 seconds his hearing will be thirty-thirtieths or normal. If his
hearing is 25, 20, 15 or 10 seconds, his auditory nerve force will be
respectively 25-30, 20-30, 15-30 or 10-30.
By means of this method an accurate measurement of the functions of
hearing can be made and a definite prognosis can be given. I never use
any of the various named qualitative fork tests for hearing, because
they have no value to one who employs this system.
FOOT NOTE—In the chart T is used, meaning that tone is heard, while S
indicates sound but no tone.
FOOT NOTE—It is not the purpose to give any detailed or differential
methods of diagnosis because if one cares to treat these diseases he
will of course, study a special text on this subject. The methods here
given are only for the general practician who wishes a general idea of
the condition present.
Summary of Diagnosis of Different Stages of Catarrhal Deafness
=First Stage.=
1. Fork 32 128 2048
B. C. 35 20
A. C. T 70 40
2. The drum is only slightly retracted but freely movable.
3. Whisper heard from five to twenty feet.
4. Ingersoll watch heard from 30 to 150 inches.
=Second Stage.=
1. Fork 32 128 2048
B. C. 40 20
A. C. T 60 40
Note that the tone of the 32 fork is heard, the 128 fork has increased
in bone conduction and reduced in air conduction but that the bone-air
ratio is direct, that is the patient hears longer by air than by bone
conduction. Note also that the high fork is still normal.
2. The drum will be found retracted but that part to which the malleus
is attached is still movable when tested with the auroscope.
3. The whisper is heard from two to ten feet.
4. The Ingersoll watch is heard from six to sixty inches.
5. Presbyacusia but not paracousia is present.
=Third Stage.=
1. Fork 32 128 2048
B. C. 45 15
A. C. S 20 30
The typical diagnostic points in third stage catarrhal deafness are: 1.
Tone for the 32 fork is lost. 2. There is an inverted bone-air ratio
for the medium fork. The drum is retracted and the malleus fixed. 4.
The whisper may be heard at less than one foot or not at all. 5. The
Ingersoll watch is heard less than six inches from the mastoid. 6.
Paracousis Willisiani is present.
For the general practician this is important because he can make a
rather definite prognosis.
=Treatment.=—The treatment will be given briefly because space would
not permit of lengthy discussions of details of methods and technic.
FOOT NOTE—Note that the patient hears the tone of the low fork, that
the 128 fork has its bone conduction slightly increased (30 to 35)
that the air conduction is slightly decreased (90 to 70) and that the
high fork remains normal.
A careful examination should be made for some source of focal infection
about the nasopharyngeal tract. Chronic or subacute tonsillitis,
pharyngitis or sinuitis or root abscess are often a cause, and not much
will be accomplished in improving the otitis media until these focal
infections are found and properly treated. The original cause of these
focal infections may have been some bony lesion, but to successfully
correct such lesion now does not mean that the source of infection will
be removed.
Auto-intoxication from gastro-intestinal disease is common. In my
cases, 80% of the third stage have chronic constipation or other
chronic gastro-intestinal affection.
In many severe acute affections of the nasopharynx the inflammatory
process has left the Eustachian tube occluded or stenosed and the
pharyngeal fossa filled with adhesive bands. It is not uncommon to find
the epipharynx and pharyngeal fossa filled with partially atrophied
adenoid tissue or if the curet method has been used for removing
adenoids, there is often connective tissue adhesions and any or all of
these may prevent the normal ventilation of the tympanic cavity by way
of the Eustachian tube.
In such cases surgical removal of these obstructions and dilation
of the tube is necessary. My practice has been to give a general
anesthetic (nitrous oxide or somnoform will be sufficient in many
cases) and by means of an adenotome (La Force or Cradle, I never
use a curet) remove all adenoid tissue. Then by means of the finger
I carefully remove any adenoid tissue in the posterior nares and
pharyngeal fossæ that the adenotome may have failed to get and also
dilate the pharyngeal portion of the tube by inserting the finger.
This operation if carefully and thoroughly done and if preceded and
followed by the proper surgical cleanliness and supportive treatment,
will when indicated, accomplish excellent results. The after treatment
is even more important because if this is not well done, no results
or even unfavorable results may occur. The after treatment consists
of daily irrigations of the nasopharynx, thorough attention to upper
thoracic, cervical and mandibular lesions, aspiration of the Eustachian
tubes and other local treatment to the nasopharyngeal membranes. After
the operation has been done it is best to do no digital manipulation
of the pharynx for from three to six days. After this time digital
treatment, gentle dilation of the Eustachian orifice to maintain its
patency, stretching of the soft palate to reestablish proper nerve
function and the application of deep pressure in the pharyngeal fossæ
to stimulate the otic ganglion is important. This treatment is not
massage in any sense but definite, purposeful, manipulation and if
carefully done will be followed by excellent results.
Since the origin of this method of treatment, there has been much
comment on its value and many have tried or at least they thought
they tried it with unfavorable results. The causes of failure are,
attempting treatment in cases impossible of cure, or poor diagnosis,
improper technic of operator or incomplete operative procedure and
inefficient supportive treatment.
It must be understood that not all cases of otitis media even in the
beginning stages require the above method of treatment or will be
benefited by it. Those cases which have resulted from other causes than
acute pharyngitis seldom require such radical methods of treatment.
In every case, the cause must be found and consistent treatment
given. In my experience, the radical method of treatment has not been
found necessary in more than twenty per cent of cases of chronic
otitis media. In the other cases the treatment consists of removing
sources of focal infection (about forty per cent) and normalizing
nasopharyngeal reflexes by osteopathic and local treatment (about forty
per cent). In all cases, the treatment must be complete. To remove
thoroughly all obstruction from the epipharynx and leave a source of
focal infection in the tonsils will accomplish little, or to remove
carefully all pharyngeal obstruction and all sources of focal infection
will not restore normal functions of the middle ear structures if the
osteopathic lesions and gastro-intestinal perversions are neglected.
Surgery in itself, even though carefully and thoroughly done, is not
efficient treatment and this is why the medical specialists fail in
this disease. After the necessary surgery has been done, then normal
tone must be restored to the various tissues involved. Normal reflex
mechanisms must be reestablished and this can be done by thorough and
efficient osteopathic corrective work and the proper local treatment
directly to the structures affected.
Meniere’s Symptom Complex
This is a form of catarrhal deafness with all the characteristic
pathology of the first or second stage, but in which, due probably
to sudden tubal occlusion, there results a marked variation in the
intralabyrinthine pressure and there are, therefore, the symptoms of
conduction deafness combined with labyrinthine involvement somewhat
resembling Meniere’s disease. There is dizziness or even vertigo,
with head noises, but not the marked prostration and nausea which
characterizes Meniere’s disease.
=Treatment.=—The treatment is the same as in the first stages of
catarrhal deafness and the prognosis is always good. The labyrinthine
symptoms are usually completely relieved as soon as the middle ear is
ventilated.
Diseases of the Inner Ear
=Acute Suppurations.=—Acute suppurative diseases of the labyrinth
occasionally result from the extension of infection from the tympanum
but they are certainly very rare. Such conditions may result from
acute suppurative otitis media in which there has been an excessive
collection of pus without rupture of the drum or drainage through
the tube but this very rarely occurs and after drainage has been
established, labyrinthine infection is hardly possible.
=Diagnosis.=—Labyrinthitis is of several forms but in general, there
are the symptoms of labyrinthine involvement such as: nystagmus,
vertigo, nausea, vomiting, headache, earache, deafness and febrile
symptoms. When labyrinthitis is suspected, an aurist of much experience
should be called into consultation at once.
=Treatment.=—Suppurative labyrinthitis is not in itself a fatal disease
but dangerous complications may result because of the close proximity
to so many delicate structures. Threatened meningeal infection requires
surgical drainage, but unless meningeal infection is imminent, surgery
is contraindicated. Since the mortality, considering dangers of
complications, is not high (about 10%) and since such operations are
very complicated and require great surgical skill, we may conclude that
surgery is generally contraindicated.
Non-surgical treatment consists of keeping the patient quiet in bed,
liquid diet, and good elimination. Drainage through the middle ear or
Eustachian tube must be maintained.
Deep manipulation of the cervical structures will help to maintain
lymphatic drainage but any treatment which necessitates much movement
of the head should be avoided until the symptoms of vestibular
irritation have ceased.
Non-Suppurative Labyrinthine Diseases
=Meniere’s Disease.=—This disease is caused by hemorrhage into the
labyrinth with the following symptoms: There is sudden and intense
vestibular irritation such as vertigo, marked tinnitus, nausea,
vomiting and complete deafness on the affected side. There may also be
cerebral disturbances and loss of consciousness.
=The Prognosis= depends upon the extent and severity of the pathology.
It is probable that those cases in which recovery occurs quickly are
not true cases of Meniere’s disease but have some causes other than
labyrinthine hemorrhage. Such cases are perhaps Meniere’s Symptom
Complex.
=The Treatment= consists of complete rest in bed, light diet, and
good elimination until the marked irritation has passed. It has been
my practice to carry out further treatment similar to that of the
treatment of nerve deafness to be given later. Many of these cases will
make complete recovery.
Nerve Deafness
The term “nerve deafness” is generally used very carelessly to apply to
any chronic or non-suppurative process of the labyrinthine structures
other than those mentioned above, which cause impaired hearing.
Nerve deafness is not an uncommon disease. In my cases of deafness
there has been some involvement of the labyrinthine structures or
auditory nerve in 27% of the cases examined. I think the reason for
most authors putting the percentage of nerve deafness much lower than
this is because of inexact methods of diagnosis. The above percentage
is based upon the actual measurement of nerve force. See measurement of
nerve force under non-suppurative otitis media above.
A careful study of cases by the method of actual measurement of nerve
force, shows that there are two distinct forms of nerve deafness.
In one there is only a deficient function of the structures of the
labyrinth, due perhaps to some perverted physiologic function, and this
form we may call auditory nerve deficiency. The other form of nerve
deafness, due probably to an actual degeneration of the nerve or its
end organs in the labyrinth, may be properly known as auditory nerve
degeneration.
=Auditory Nerve Deficiency.=—A study of our case reports shows that in
64% of the cases in which the nerve force was 16-30 or higher (more
than half) favorable results were obtained, provided that there was
no complicating labyrinthine affection. These cases have been classed
as “nerve deficiency” and the pathology as functional. A favorable
prognosis (64%) may be offered.
Example of tuning fork findings:
Fork 32 64 128 512 2048 4096
B. C. 18 20 20 20 10
A. C. T 50 60 60 40 20
In addition to the tuning fork findings the voice and watch test will
be reduced to from one-tenth to two-thirds normal. The patient often
complains of itching meati and dry nares. There are usually no signs or
symptoms of labyrinthine affection.
=Treatment.=—The treatment consists of local treatment to the
nasopharynx, tubes and meati as described under the treatment of
chronic otitis media. Everything should be done to build up the
patient’s general health and improve the local nutrition. It is highly
essential to search the entire system for sources of focal and general
infection. Auto-intoxication from chronic gastro-intestinal disease
was found in 90% of our cases. Any treatment therefore that will
restore normal gastro-intestinal function is indicated. Recently we
have had some excellent results from colonic irrigation and the proper
adjustment of diet in such cases. Any source of focal infection must of
course receive proper attention.
The osteopathic corrective treatment consists largely of careful
attention to lesions of the splanchnic area because of the importance
of normal digestion, metabolism and elimination. This is certainly a
most important part of the treatment and should never be neglected.
Upper cervical and mandibular lesions have much to do with the local
nutrition to the ear structures and these must not be neglected. The
fact that we almost constantly find evidence of deficient nutrition
to the meati and drums in this disease together with lesions of the
mandible, suggests a local osteopathic cause.
=Auditory Nerve Degeneration.=—In those cases in which there is a
measurable deficiency of nerve function of less than half the normal we
have found that very few respond to treatment. (See table above.) The
cause has therefore been attributed to a structural pathology and the
condition called auditory degeneration.
Example Table:
Fork 32 64 128 512 2048 4096
B. C. 10 12 8 5 2
A. C. S 20 25 15 7 5
There is usually very marked impairment of hearing for voice and all
other sounds. The Ingersoll watch may be heard five or ten inches, but
usually not at all, and the whispered voice heard only a few inches or
not at all. There are nearly always signs and symptoms of labyrinthine
deafness and evidence of tone islands. The deafness in these cases is
usually progressive regardless of any treatment.
In this disease there is nearly always an associated affection of the
labyrinth as shown by the high forks. The fractions represented by the
high forks will agree in proportion provided there is no labyrinthine
involvement.
Our results in auditory nerve degeneration have been measurable
improvement in only 2% of the cases treated. The prognosis is therefore
very poor and I believe we should always tell our patients frankly
that there is almost no chance for improving their hearing in such
cases. The treatment is the same as that given for nerve deficiency and
because of the general good that may be had from treatment, that is,
the improvement of the general resistance, it is often well for the
patient to have such treatment to stop the progress of further special
sensory degeneration.
It should always be our purpose to treat the patient rather than to
treat some particular organ only and if this method is followed, our
general results will surely be much higher.
Diseases of the Nose
=Method of Examination.=—For use in nasal examinations and treatment,
a suitable chair with adjustable headrest is of much value because if
the patient is not comfortable and in a convenient position, the work
is very difficult. A few instruments, such as the following, are very
essential: A sterilizer for instruments, head mirror and reflecting
lamp, nasal speculum, tongue depressor, tonsil pillar-retractor, a
nasal packing forceps and a few aluminum cotton applicators. These
instruments are few and comparatively inexpensive, but are of more
practical value than a lifetime collection of electrical apparatus.
Any physician can readily learn the use of these instruments and the
methods of examination by attending the clinical sessions of our
conventions. Methods and technic of treatment, however, require much
practice and experience to develop efficiency.
Acute Rhinitis
This disease, commonly known as a “cold in the head” is one of the most
common, and because of the complications which so commonly result, a
disease which really requires careful consideration.
=Etiology.=—The predisposing cause is reduced resistance and individual
susceptibility to air-borne irritants and infective organisms.
Direct exposure of some insufficiently protected part of the body such
as the feet in cold, damp weather, exposure of some unprotected part
of the body to draughts or exposure of the whole body to slightly
reduced temperature for a considerable time, are the common causes. In
cold weather, it is very important that the proper indoor humidity be
maintained, because the drying of the mucous membranes renders them
susceptible to infection. This disease is not only contagious at times
but may even become endemic from some specific and virulent organism.
The complications which may and often do follow such infections
are laryngitis, bronchitis, pneumonia, etc. and any one or more of
the focal infections, such as sinuitis, tonsillitis, or middle ear
infection. A focal infection thus caused may become chronic and render
the patient constantly susceptible to head colds. In fact in those
persons who suffer from chronic head colds, there may nearly always
be found some focal infection, such as the above named, and it is
often impossible to get permanent relief until such sources of focal
infection have been properly treated.
The influence of gross structural lesions, osteopathic lesions of
the cervical and upper thoracic region, vertebræ and ribs must not
be overlooked because they exert a powerful influence upon the blood
supply, particularly the venous and lymphatic drainage and upon the
autonomic nervous mechanism, which regulates the physiologic control of
such functions.
Gross structural abnormalities of the intranasal chambers, such as
deflected septum, enlarged turbinates or cellular turbinates, which
cause deficient or abnormal breathing space, may cause and maintain
head colds.
=Diagnosis.=—The diagnosis is usually easy. Nasal congestion with the
usual “stuffy” feeling of the head, sneezing, headache, etc. are well
known symptoms. On direct examination the nares are congested, there is
a watery discharge and all of the membranes of the nasopharyngeal tract
are congested.
=Treatment.=—If there is ever a demand for good, thorough and specific
osteopathic work, certainly it is demanded in such cases. I am an
advocate of thorough, deep relaxing treatment followed by specific
adjustment in such cases.
Complete rest in bed with light diet and careful attention to the
elimination are very essential. Perhaps the most difficult problem is
to convince the patient that a head cold is really a serious disease
and demands thorough and prompt treatment. Every ear, nose and throat
specialist has had ample opportunity to know that most of the really
serious complications of the head and neck result from the lack of
prompt and proper attention to head colds.
The local treatment consists of irrigation of the nasopharynx followed
by oil spray to protect from further irritation and the maintenance of
proper drainage from the sinuses and middle ears. I am not an advocate
of the so-called “antiseptic sprays” because they neither destroy
bacteria sufficiently to be effective nor do they maintain drainage.
In all cases, the physician should be ever watchful for the
complications and should not hesitate to call consultation of a
specialist when such symptoms develop.
Purulent Rhinitis
Persistent inflammations of the nasal membranes are usually of a
purulent nature or at least have had such a cause in the beginning.
=Etiology.=—Purulent rhinitis may be a result of an unsuccessfully
treated infection of the nose or throat following some disease of
childhood or early life. It may be due to infection at birth. Commonly
there is a subacute or chronic sinus infection that maintains the
infection of the nasal mucosa. Polyps, enlarged or cellular turbinates,
adenoids or adhesions in the epipharynx, often retain the secretions
and cause chronic rhinitis. In many cases I have found that osteopathic
lesions of the cervical or upper thoracic region are effective causes
of chronic rhinitis.
=The Pathology= consists of hyperemia, hypertrophy and exfoliation of
the cellular membrane. The turbinates and all membranes become enlarged
and thickened and the breathing space is usually greatly decreased.
=The Symptoms= are nasal obstruction, and mucous or mucopurulent
discharge with usually hypersensitiveness, which causes sneezing and
other symptoms common to “head colds.”
=Treatment.=—The same treatment as given above for acute rhinitis
applies here. A thorough examination should be made for all of the
various causes given above and the proper corrective treatment given
for any or all such causes.
Chronic Hypertrophic Rhinitis
=Etiology.=—Chronic rhinitis is usually a result of an infective
rhinitis and has for its cause any one or more of the various causes
given above under purulent rhinitis.
=Pathology.=—The pathology in chronic rhinitis varies with the cause,
but is usually characterized by a series of changes beginning with
infection and hyperemia and followed by an actual and usually marked
hypertrophy of the interstitial tissue. The posterior ends of the
inferior or, less often, the middle turbinates are usually enlarged and
extend backward into the pharynx.
=The Symptoms= are much the same as in purulent rhinitis, except that
the purulent discharge is often not present. These cases usually suffer
from chronic head colds, headaches and persistent nasal obstruction.
The senses of smell and taste are usually impaired and there is a nasal
twang to the voice.
=Treatment.=—In these cases, it is common to find osteopathic causes
which prevent proper drainage from the head and neck and this is
important because, if all the local causes are properly corrected, this
is not sufficient to effect a cure.
Surgical treatment for the removal of polyps, synechia, adenoids,
adhesions, correction of septum, or hypertrophied or cellular middle
turbinates is often essential and certainly infected sinuses must be
properly drained. We have had cases in which root abscesses seemed to
be active causes, but it must not be thought that surgery and surgery
alone is likely to cure chronic rhinitis, and I want to caution against
the wholesale removal of turbinates for such conditions. The mere fact
that the turbinates are enlarged is not sufficient reason for their
removal. There has been a cause for this enlargement and turbinotomy or
turbinectomy does not remove this cause. Cautery is worse, because it
seldom accomplishes more than very temporary results and often leaves
the membranes worse than before. Cautery destroys mucous membrane,
leaving a dry and easily irritated surface which is often impossible to
normalize.
The proper surgery, carefully done, followed by efficient osteopathic
corrective work and thorough irrigation of the nasopharyngeal tract
with the necessary oil spray protection after irrigation, will
constitute efficient treatment. Treatment, thorough and long continued,
will in due time restore nutrition, drainage and normal reflex nerve
control to the tissues. Treatment after surgery is essential.
=Intranasal Treatment.=—Many cases are caused by the retention of
secretions under the turbinates and in the superior vault. In all
cases, therefore, it is essential to thoroughly free all possible
retention cavities by means of a small cotton-wound probe before
irrigation. The intranasal membranes are adrenalized and anesthetized
and a thorough examination is made using a good reflecting lamp, nasal
speculum and cotton tipped probe. Every part of the intranasal region
is inspected for sources of purulent discharge, mucus collections,
synechia and for hypersensitive areas. The probe is curved at the
end and passed under each turbinate and drawn forward and backward
with considerable pressure to insure that any collection of foreign
matter is thoroughly removed. Every part of the intranasal region
should be thoroughly treated in this way. The hiatus semilunaris must
be kept well open to permit free antrum drainage and all other sinus
openings should be kept free from any obstruction that may block the
drainage. This particular technic requires great care and practice,
but it is very effective and so commonly we have found that this work
thoroughly done will reduce much and in some cases all of the turbinate
hypertrophy rendering surgery unnecessary.
Atrophic Rhinitis
As the term suggests, this disease is just the opposite from
hypertrophic rhinitis in that the membranes are shrunken, the nares
are wide open and usually the membranes are coated with a mucopurulent
discharge, accompanied by a bad odor. It is a chronic disease and
progressive in nature.
=Etiology.=—Deficient nutrition, systemic or local, or some
degenerative infective process constitutes the cause. Some cases may be
traced to syphilis, but this is certainly not always the cause. Chronic
sinuitis, the cause of which is some virulent infection, is often the
cause. Too much or incorrect surgery and cautery is certainly a cause
in many cases.
=Pathology.=—The marked atrophic appearance, the retracted
turbinates, the excessive purulent or mucopurulent foul discharge are
characteristic and diagnostic.
The tissues underlying the mucous membranes are shrunken, and atrophic
and this tissue has usually been replaced, sometimes almost completely,
by connective tissue, and thus the blood supply is markedly deficient.
=Treatment.=—In chronic cases, those in which the atrophy is well
progressed, there is no hope of restoration to normal conditions, but
I believe that the progress of practically every case can be stopped
and that, in most cases, a permanent cure can be effected under proper
treatment.
Every possible source of focal infection, such as sinuitis,
pharyngitis, tonsillitis, etc. should receive proper attention
promptly. After this has been done and sufficient time allowed for
normalization, a blood count may reveal some other source of focal or
general infection, which may be reducing the general resistance.
Auto-intoxication from some gastro-intestinal affection is commonly
a cause and must receive proper attention. The general health of the
patient must be restored and maintained.
Thorough osteopathic treatment must be given for any cause of lowered
nutrition, local or general. The failure, I believe, in medical
practice (They admit failure in this disease) is due to the lack of
attention to the restoration of normal nutrition. Why drain a sinus
and leave an atlas or upper thoracic lesion which decreases the local
nutrition and leaves these membranes susceptible to further infection?
Before and after surgical drainage, irrigation of the nasopharyngeal
tract. Thorough irrigation to cleanse every part. Hot irrigation (one
gallon of salt mixture solution, salt 3 parts, borax 2 parts, and soda
1 part, a tablespoonful to the gallon at 118°F. to 123°F.) to cleanse,
to free all parts from infection and to restore blood supply to the
affected parts. Frequent irrigation, daily for a sufficient time to
thoroughly sterilize and restore circulation. After each irrigation,
an oil spray (any non-irritating petroleum oil) is applied freely to
protect the membranes from irritation and further infection.
Before each irrigation a thorough probe treatment, as described under
hypertrophic rhinitis, should be given that the membranes may be
thoroughly freed from all retained secretions.
After the membranes are once clean, the sinuses free from infection
and the blood supply reestablished, the treatment may be reduced in
frequency to three times weekly, but the treatment must be continued
for months or even years to effect a permanent cure. The patient can
be taught to do his own irrigation after the disease is well under
control. All irritating sprays, chemical cauteries, etc. must be
avoided. The so-called “antiseptic sprays” do harm by irritating the
membranes and certainly do no good, because they do not cleanse the
parts. They only serve to deodorize, but actually accomplish nothing in
the way of cure. It has been my experience that iodine and the silver
salts in any of their various preparations are not efficient but that
they actually do harm. My experience indicates that practically every
case can be cured if the proper treatment is given for sufficient time.
Pharmacodynamics
If I may be pardoned for discussing things pharmacological in a text on
practice, I want to urge that chemicals as such, are usually a failure
in treatment. My results from various series of experimental work both
laboratory and clinical, show quite conclusively that there are very
few, if any, chemical substances that have actual value by virtue of
their chemical properties alone. There are, however, cases in which
chemical agents may be used to advantage to obtain desirable physical
results and physiologic reactions.
The salt mixture mentioned above increases the solvent power of
the water for mucus, pus, and other collected material and it also
renders the water less irritating to the mucous membranes. Other than
this, it has no value so far as I know. This solution is certainly
not antiseptic or germicidal, further than that cleanliness may be
considered an antiseptic procedure.
The phenol-glycerine (10% phenol and 90% glycerine) which we have
recommended, is somewhat germicidal, non-irritating, except to the
nasal mucosa, is a protectant to inflamed membranes in some instances
and is also somewhat hygroscopic. These virtues to the limited extent
that they may be of advantage, depend chiefly upon physical qualities.
Adrenalin in high dilutions (1 to 5000 to 1 to 10,000) is of value
in retracting the erectile tissues of the nares for purposes of
examination and for obtaining better drainage, etc. It also constricts
the small blood vessels and thus reduces the chances for hemorrhage or
absorption of narcotic drugs which may necessarily be used as local
anesthetics. The effects of adrenalin are very temporary and it is,
therefore, of little value in treatment.
Following irrigation I have used the petroleum oils (liquid petrolatum)
to advantage as a protection to the mucous membrane. One-half gram
each of menthol and camphor and two or three drops of cinnamon oil to
the pint of this oil, is readily dissolved and produces a pleasant,
soothing effect to inflamed membranes, but further than this, the added
substances have no particular value. The above named chemical agents
constitute, except in rare instances, my stock of “drugs” for treatment
purposes.
Hyperesthetic Rhinitis—Hay Fever
There is perhaps no disease in which there has been more speculation
concerning the etiology than in hay fever, and while osteopathy has
accomplished a wonderful advance in the treatment of this disease, I am
not sure that the cause or causes are yet thoroughly understood.
=Etiology.=—The theoretic causes of this disease may be expressed in
the various names which have been given to it as follows: The term Hay
Fever suggests that it is a febrile condition caused by hay pollen
irritation. Peach cold, Rose cold, Rose fever, Rose catarrh, Rye fever
and Ragweed fever suggest similar specific causes. Idiosyncratic coryza
means nothing and this probably expresses what the theorists know about
its cause better than any other name. Hysteric rhinitis suggests a
probable psychic cause, which certainly does exist in some cases. If I
may be pardoned, and I know I never will be, let me suggest just one
more name—“Respiratory Reflex Inefficiency.”
=Intoxications.=—Auto-intoxication from focal infections or from
gastro-intestinal perversions certainly have an important influence
either directly or as predisposing factors and should always be
carefully considered in treatment.
=Osteopathic Lesions.=—Osteopathic lesions, such as interosseous,
muscular and ligamentous, seem to function as predisposing causes by
their general effects upon the system. It seems probable that their
effects upon the organs of metabolism and elimination are of greater
importance than any direct or specific effect in causing the immediate
symptoms. In practically all cases lesions of the upper thoracic
vertebræ and ribs and of the cervical region are present. It is my
opinion that such lesions are more often secondary than primary.
=Respiratory Reflex Inefficiency.=—Measurement of nerve force in these
cases shows that none are really possessed with “an excess of nerve
force,” but that practically all vary from two-thirds to four-fifths
normal, showing that probably all cases are deficient in nerve force.
This instability of the nervous system can be explained, I believe, in
the theory of peripheral reflex insufficiency. As evidence of this the
following facts may be cited:
1. It is known that peripheral irritation of almost any nature, to the
mucous membranes of the nasopharyngeal tract, will excite an attack in
susceptible individuals.
2. That any treatment which tends to increase the resistance of these
membranes will prevent or relieve an attack.
3. That peripheral inhibition to these surfaces will temporarily
relieve an attack.
4. That complete normalization of these membranes will make the patient
resistive to the so-called specific irritants, such as pollen, dust,
etc.
5. That the mucous membranes of the entire respiratory and
gastro-intestinal tract react to irritants to bring about “the hay
fever state” and that any treatment which tends to normalize these
membranes, renders the patient more resistive to hay fever attacks.
=Exciting Causes.=—There is no doubt that various air-borne irritants,
such as pollen, dust, chemical fumes, emanations from animals, etc.,
act as exciting causes of acute attacks, and yet there are cases that
develop acute attacks out of season or at a time when it seems that
there could be no air-borne irritation. From evidence which will be
offered later (see prognosis) I am led to believe that probably all
susceptible cases can be made entirely resistive to the air-borne
irritants.
Pathology
=Functional Pathology.=—Certainly in this disease there is ample
evidence of marked perversions of function or functional pathology.
Kyle believes that in many cases the cause of local irritation lies
in “some chemical change in the constituents of the mucus-secreting
glands,” and “it is a well known fact that in many cases of hay fever
the irritation is not limited to the nasal mucous membrane. The eyes
and mucous membrane of the stomach and bladder, and even the intestines
may be markedly irritated.”
These chemical changes in the secretion of the mucous membranes,
together with the excess of uric acid would seem to point either to
a general perversion of the secretory mechanism or to a deficient
elimination, or to both. The periodic occurrence may be accounted for
by assuming that the systemic strain is sufficient to initiate the
symptoms. The fact that the attack is actually delayed or hastened in
susceptible individuals by the late or early beginning of hot weather,
and that these cases get relief by going to a more moderate climate is
further evidence of this.
Again we are reminded of Dr. Still’s teaching, that the body maintains
its own chemical laboratory which adjusts or tends to adjust its work
to the needs of that body, but under abnormal strain this adjustive
mechanism may fail to meet all of the demands of function. It seems
here that the osteopathic concept may easily include all environmental
causes as well as internal causes in the predisposition to deficient
function or disease.
=Structural Pathology.=—During the attack there is a general catarrhal
inflammation of all nasopharyngeal membranes, accompanied by a watery
discharge and marked swelling of the turbinates. Sensitive areas may be
found on the middle turbinate and opposite wall of the septum. Probably
it is this hypersusceptibility to irritation that causes the attack
from the air-borne irritants.
The pseudo-membrane which may be found covering a part or all of the
mucous membranes of the nares probably results from this irritation and
is formed for the purpose of protection.
=Clinical Types.=—Clinically, three rather indefinite types of hay
fever may be recognized, viz.: Vernal, those cases which have their
attack sometime during May, June or July; Autumnal, in which the attack
occurs in August or September and usually lasts until the beginning of
cold weather, and an indefinite or pseudo form occurring at any time
of the year, with no characteristic attack, as in the other forms, but
with indefinite symptoms resembling hay fever.
=Symptoms and Diagnosis.=—Patients usually go to the physician self
diagnosed. The characteristic sneezing, the watery discharge from
the nose, and the irritation of all membranes of the nasopharynx and
conjunctiva will serve to make a diagnosis in most cases. Direct
examination will reveal the nasal congestion and other characteristic
pathology as described above.
=Termination.=—Most cases of the autumnal form, unless successfully
treated, continue with equal or increased severity until after
the first or second frost, when they usually terminate in asthma,
bronchitis or sinuitis, which lasts for several weeks or months. Each
year the attack lasts longer and is more severe and the asthma occurs
earlier and is more severe.
Treatment
=Intranasal Surgery.=—Intranasal abnormalities, such as deflected
septum, spurs on the septum, hypertrophied turbinates, polypi, etc.,
which materially reduce the breathing space, usually demand surgery.
Nasal surgery, carefully and properly done, is always a great aid and
often absolutely essential to the successful treatment of hay fever and
asthma, but nasal surgery carelessly done frequently does more harm
than good.
The correction of a deflected septum or the removal of a spur on the
septum by submucous operation often aids materially in the prevention
of pressure irritation, increases the breathing space and normalizes
drainage from the sinuses.
Surgery is therefore very essential in many cases of hay fever, but
surgery is never the all essential part of the treatment, because if
the proper after treatment is not given, the surgery alone will seldom
result in either temporary relief or cure.
=Focal Infection.=—The importance of focal infection of the sinuses,
tonsils, teeth and occasionally other parts, such as the nasal
cavities, epipharynx, middle ear and mastoid cavities cannot be
overestimated. Such conditions may be effective in causing hay fever,
by causing direct infection of the membranes of the nasopharyngeal
tract or by auto-intoxication.
=Digital Surgery,= for the removal of adhesions in the posterior nares
and pharynx, is in my opinion, very essential, and this work should be
done thoroughly. Massage of the soft palate or pharyngeal walls is of
no particular value. All adhesions and adenoid tissue must be removed
because this removes an effective source of constant irritation and
focal infection and tends to normalize the direct and reflex nerve
mechanism.
The practice of the radical intranasal technique as originated by J.
D. Edwards, D. O., is indicated, I believe, in some cases in which the
crushing of cellular middle turbinates, or the breaking of adhesions is
indicated, but I am not yet ready to accept this theory of “curetting”
the mucous membrane by radical digital technique. The fracture of
the turbinates is not necessarily a bad technique provided they are
properly readjusted as Dr. Edwards does it, but to fracture and not
readjust is a dangerous practice. The efficiency and safety of any
method depends upon the operator’s definite knowledge of what needs to
be accomplished and how it is to be done.
There are contraindications to digital, as well as any other kind of
nasopharyngeal surgery, such as: (1) Acute infection of any part of the
nasopharyngeal tract; (2) evidence of sinus involvement; (3) septal
deflections, spurs and hypertrophied turbinates, which would not permit
such work without undue trauma.
There are certain other precautions such as thorough cleanliness of the
parts to be treated; aspiration of the sinuses before and afterward,
and the use of a finger of sufficient size which will not produce undue
trauma. In my opinion very few doctors have such fingers.
Failure in accomplishing results is due to three things, viz., (1)
Insufficient knowledge of diagnosis and prognosis; (2) insufficient
knowledge of what should be accomplished and the technique of doing it,
and (3) the necessary additional or supportive treatment.
It is a great mistake to think that the removal of adhesions in the
pharynx or nares is sufficient, because if this is not followed by
the proper supportive treatment, no results or even bad results will
frequently occur. This treatment is not a massage in any sense, but a
definite operative procedure and requires as much care and skill as the
removal of adenoids or tonsils.
Space will not permit an explanation of the digital technique and
the radical treatment should not be attempted without some definite
knowledge of the methods and technique.
=Intranasal Treatment.=—The intranasal method of treatment as explained
above under hypertrophic rhinitis is very effective and if carefully
and thoroughly done is in most cases just as efficient as intranasal
digital surgery. This treatment followed by irrigation and oil spray
and nasal packing will be found effective in most cases if the
treatment is properly done.
=Nasal Packing.=—Thorough packing of the nasal cavities after all
sources of focal infection have been removed and after thorough
cleansing has been done, by means of long strips of absorbent cotton
is effective in reducing the swelling and irritation.
=The Radical Packing Method.=—This method can be done best in a
hospital. The nares are prepared as for surgical operation, by complete
retraction of all erectile tissue, thorough cleansing by irrigation
and the application of a local anesthetic. Anesthesia need not be
complete. A careful examination is then made for any synechia, or focal
infections. Packing should never be done until the doctor is sure there
is no sinus involvement. The entire nasal cavity is then packed very
firmly with sterile gauze. This is best done by means of a special
packing instrument or long nasal packing forceps, using narrow gauze
contained in tubes. In some cases the nasal cavity is lubricated before
packing.
The packing should be done early in the morning and removed just before
bed-time, so that the patient may sleep. This treatment is repeated
daily until all signs and symptoms of nasal irritation are gone and
then replaced by irrigation and oil spray.
If this treatment is properly done, there will be a complete sloughing
of the pseudo-membrane followed by a restoration of normal and
resistive tissue. The results of our two years’ experience (we have
tried this on only a few patients each year) are very encouraging.
Relief from the symptoms are very prompt and seemingly more permanent
than from other methods.
=Treatment of Auto-intoxication.=—All sources of focal infection are
thoroughly treated. Sinus infection is very common and must receive
proper attention before any other treatment can be effective.
Our experience shows that many cases have auto-intoxication of
gastro-intestinal origin. The hospital care of such cases makes
possible the thorough cleansing of the colon by irrigation and the
reestablishment of an acid producing flora which seems to prevent
fermentation.
=Osteopathic Corrective Work.=—Thoroughness of treatment for the
removal of all causes is the secret of success. To successfully
remove the immediate sources of auto-intoxication by treating a
sinus infection or by thoroughly freeing the colon from fermentation
products means only temporary results if the underlying causes are not
corrected. A thorough osteopathic examination is necessary to determine
such causes and certainly such treatment should not be neglected.
Correction of all cervical and upper thoracic lesions and particularly
the clavicles and ribs is important. These lesions seem to be the
result rather than the cause, but normal respiratory functions
seemingly cannot be maintained unless such treatment is done.
Sinuitis
Acute or chronic inflammatory disease of the nasal accessory sinuses
with or without suppuration is more common, I believe, and is
responsible for more complications and chronic affections of the nose
and throat than is generally known.
=Etiology.=—The cause in most cases lies in unsuccessfully treated
acute infections involving the nose and throat. Abnormalities of the
nasal respiratory passages such as deflected septum, enlarged or
cellular turbinates, adhesions resulting from cautery or careless
surgery, causing deficient drainage, constitute the local causes.
Underlying some of these direct causes, lesions of the cervical region
which impair the nutrition to and drainage from the head are to be
considered.
=Symptoms and Diagnosis.=—Acute or chronic headaches and neuralgic
pains of the head are common symptoms. Acute sinuitis of the frontal
sinuses is accompanied by marked and persistent frontal headache and
pain in the eyes. In infections of the maxillary sinus there is usually
pain over the affected part, but there is often referred pain to other
parts of the head. Sphenoidal sinuitis usually causes general headache
with no definite location.
By direct examination of the nasal cavities a purulent or mucopurulent
discharge may be seen and the source determined. In many cases,
however, the pus may be retained or insufficient in amount to detect by
direct examination.
Transillumination in a dark room by means of a good transilluminator
will usually show a darkened area over the affected part. The average
battery equipments commonly sold for this purpose are of little value.
The X-ray plate when properly done, is more dependable than the
transilluminator.
In some cases, all of these methods fail to locate the affected sinus
and the cause can be found only by opening into the sinuses, aspirating
with a catheter and making microscopic examination of the aspirated
material. The microscope is indispensable for this work. Every
suspicious discharge should be stained until pus is found and except
in well defined cases, this is the only practical method of positive
diagnosis.
=Treatment.=—Local treatment of the nasal cavities by retracting the
turbinates and irrigation will be successful in many cases, but unless
there is a large normal opening the pus will not drain sufficiently
and probe treatment is required. In acute cases in which the pain is
marked, osteopathic treatment of the cervical region, deep relaxation
of the submaxillary structures and the application of heat over the
affected part, together with the local nasal treatment should be given,
but if this does not relieve the pain within twenty-four hours, the
sinus should be opened and thoroughly drained. If efficient drainage is
not established early the symptoms will usually increase until the pain
is almost unbearable and serious complications may result.
In practically every case of acute sinuitis, I believe it is best to
make a good, free opening into the affected sinus first and secure
complete drainage by catheter aspiration. If this is properly done
every case will recover much more quickly and without complications or
danger of chronic infection.
Non-Suppurative Sinuitis
Cases of non-suppurative sinus involvement are not at all uncommon.
The so-called “Vacuum sinuitis” which results from a closure of the
normal opening, resulting in inflammation without pus formation, is
responsible for many of the complicated cases of referred pain, which
are so often improperly diagnosed. Chronic headaches and the various
symptoms of fifth nerve affections, the neuralgias of the head, are
frequently caused by non-suppurative sinus involvement.
=Treatment.=—The treatment consists of establishing good drainage
and proper ventilation of the affected sinus or sinuses followed by
thorough intranasal treatment as explained above. The osteopathic
corrective work must not be neglected.
Syphilis of the Nose
In osteopathic practice syphilis is not a common disease. The
occurrence of syphilis of the nose is still more rare but certainly
should be recognized.
=Diagnosis.=—The local lesions of the nose are of two types, those of
acquired syphilis and of congenital syphilis.
There are three characteristic manifestations of acquired syphilis
as follows. The primary lesion or hard chancre is a firm, indurated
ulcerated mass with only slight discharge. Chancre of the nose is
exceedingly rare. In secondary syphilis there is the mucous patch, the
result of mucous membrane necrosis. In tertiary syphilis the local
lesion is the gumma or more commonly, the ulceration left from necrosis
of the gumma. These lesions may appear from a few to many years after
the initial infection, but they never follow immediately. The lesions
may appear on almost any part of the intranasal structures. They
resemble the lesions of atrophic rhinitis but in atrophic rhinitis
there is never the extent of destruction that so frequently results
from tertiary syphilis.
=Treatment.=—It has been my practice to refer all suspected cases to
Dr. F. J. Stewart for differential diagnosis and treatment and his
method of the use of salvarsan has proven efficient.
Epistaxis—Nose Bleed
The causes of nose bleed may be divided into two general groups,
local and constitutional. The first group consists of trauma directly
to the nose either external or internal, from nasal operations and
other causes. The presence of a cluster of thin-walled veins on the
anterior part of the septum which readily rupture from slight cause,
constitutes perhaps the most common cause of nose bleed. The ulcers of
atrophic rhinitis or syphilis occasionally cause bleeding. Malignant
growths of the nose may cause frequent and profuse hemorrhage. The
constitutional causes of epistaxis are, the acute fevers, cardiac
and arterial diseases, which cause excessive tension; and cases of
altered composition of the blood such as the anemias, malaria, purpura,
chlorosis, hemophilia, etc.
=Diagnosis.=—Direct examination of the nose will usually reveal the
cause. If there are no signs of trauma or rupture of the anterior
group of vessels and the bleeding does not respond quickly to packing
of the affected side, there is either a rupture of a large vessel,
which requires long continued packing, or it belongs to the class of
constitutional disease.
If there is evidence of some necrotic disease of the nose or if there
are areas of exposed bone or cartilage from careless surgery, these may
usually be seen and the point of bleeding located.
=Treatment.=—Cold applications, irrigation of the nares with cold
normal salt solution and the application of an absorbent cotton or
gauze pack is usually sufficient to stop the average case of epistaxis
from any cause. The direct application of cold to the lower cervical
region will cause capillary restriction.
There are many cases in which the membranes of the nose have lost their
tone due to various irritants or from deficient nutrition to the parts.
These are cases of a wholly different type from that of the well known
necrotic diseases such as atrophic rhinitis and syphilis. Hay fever
is a result of such a cause. The treatment in such cases consists of
removing any local causes or osteopathic lesions and then normalizing
the resistance of the membranes by the methods described under the
treatment for hay fever.
The treatment for those cases of epistaxis due to constitutional
disease depends wholly upon the causative factors and the proper
treatment of these. Any local treatment in such cases will be expected
to produce only temporary results.
Diseases of the Nasopharynx
The nasopharynx may be the location of acute or chronic inflammations,
neoplasms, malignant or nonmalignant, processes of atrophy or
hypertrophy, adhesions, etc. It is important to remember that the
nasopharynx admits the Eustachian tubes and supports four superficially
located ganglia of the fifth nerve.
=Acute Nasopharyngitis.=—Acute inflammatory processes of this region
may result from rhinitis, infections of the lower pharynx, focal
infections of these parts or from direct involvement of its own
structures.
The symptoms are post nasal tenderness and mucus dropping. Some
patients experience the sensation of a foreign body in that location.
The thick, adherent collections of mucus are difficult to dislodge and
sometimes are so persistent that they cause nausea. There is usually
occlusion of the Eustachian tubes, resulting in partial deafness,
tinnitus and often dizziness.
=The Treatment= consists of thorough cleanliness by irrigation and
osteopathic corrective work to the cervical region. It is also
essential to keep the anterior neck structures particularly those of
the submaxillary region, thoroughly relaxed to maintain efficient
drainage.
Chronic Nasopharyngitis
This is one of most common diseases of the nasopharyngeal tract,
causative of many complications and yet perhaps the least recognized in
proportion to its significance. The frequent occurrence of adhesions
of the pharyngeal fossæ, hypertrophied membranes, enlarged spongy
extensions of the inferior and middle turbinates (the posterior
turbinate bodies) occlusion of the orifice of the Eustachian tubes and
chronic, excessive secretion of thick mucus all show that this disease
has either gone unrecognized or at least has not received proper
treatment.
=Treatment.=—Complete surgical removal of all abnormal growths,
adhesions, etc. as described under the treatment of chronic
non-suppurative otitis media and this followed by thorough irrigation
and other methods of local treatment described above are efficient.
The successful treatment of this disease requires time. There has been
a partial or, in some cases, almost a complete loss of the normal
functions of the nerve reflex mechanism of these parts, peripheral
reflex inefficiency and this must be restored. Efficient and long
continued treatment of the lesions commonly found in the cervical and
upper thoracic regions will do much to restore these normal functions,
but this alone without the surgical treatment will never effect a
permanent cure. Neither will the surgery and local treatment alone
effect a cure. The whole treatment is required.
Adenoids
Adenoids are the hypertrophied lymphoid tissue of the nasopharynx.
They occur commonly in children, as a result of acute inflammations.
Possibly the suckling process of the child produces a partial vacuum of
the epipharynx and thus causes excessive blood supply to the part and
therefore excessive growth of these soft tissues.
Adenoids, however, are not confined to children but frequently occur in
adults. In all cases they are a source of much annoyance and often the
cause of acute and chronic disease.
=Symptoms and Diagnosis.=—Mouth breathing, head colds, partial
deafness, etc. are the common symptoms. The flattened nose, the high
arch of the hard palate and the stupid appearance of the face are
diagnostic. By direct palpation to the nasopharynx the nature and
extent of the adenoid mass can be determined and this is the best
method of diagnosis.
=Treatment.=—Many methods of non-surgical treatment have been employed,
but there is nothing as satisfactory as complete surgical removal.
Adenoid tissue has no known function different from that of other
lymphoid tissue and there is always sufficient to perform any necessary
function without excess of adenoid growth. The excessive adenoid
growth is in every case a detriment to normal development, because it
impairs nasal respiration and usually causes chronic nasopharyngitis
and thus reduces resistance against all diseases of childhood. There
is therefore, no excuse, much less a reason, why excessive adenoid
growths should not be removed surgically, provided it is properly and
thoroughly done.
The operation for removing adenoids requires in children, a general
anesthetic. In adults, a local anesthetic is used by some operators.
I have found it best to first break the adenoid mass away from the
side walls of the pharynx digitally. A LaForce or Gradle adenotome is
then used to remove the adenoid mass. If either of these instruments
is properly used it will always remove the greater part of the
adenoid mass without undue trauma or injury to any of the pharyngeal
structures. Curets should never be used because they almost never
remove the adenoid mass properly, but they usually do injure the
pharynx. Many cases of pharyngeal adhesions, Eustachian tube occlusion
and nasopharyngitis result from direct injury caused by curets.
After the adenoid mass has been removed the finger is inserted into the
pharynx and any adenoid growths in the posterior nares are removed.
The pharyngeal fossæ are also thoroughly freed from adenoid tissue and
adhesions and the orifices of the pharyngeal portions of the tubes are
gently dilated. This method insures complete removal of all excessive
adenoid tissue, and normal functions of the nasopharynx. Adenoids thus
removed do not return.
After the surgical work has been completed the nasopharyngeal tract
should be thoroughly irrigated with hot salt mixture solution.
This thoroughly cleanses the membranes, hastens healing, prevents
hemorrhage and avoids post-operative infection. Irrigation of the
nasopharynx should be continued for some days or until all evidences
of inflammation have ceased. The pharynx should then be examined to be
sure that no adhesions have developed from inflammation, but if the
operation is carefully done, complications will never result.
Diseases of the Oropharynx
Acute Pharyngitis
Acute inflammations of the pharynx alone or in common with
inflammations of other parts of the nasopharyngeal tract are common.
This disease is most common as a result of the acute infections
affecting the nose and throat.
=Etiology.=—The predisposing causes are focal infections of the
nasopharynx, such as tonsillitis, sinuitis, etc. Deficient nutrition or
anemia of the pharynx or systemic anemia are common causes. Lesions of
the cervical, upper thoracic and hyoid are common predisposing causes.
Undue exposure of the neck in susceptible persons or too much or too
tight clothing about the neck may also predispose to inflammations of
the pharynx.
The exciting causes are the acute infections, colds and focal
infections. Perhaps the most common exciting cause is tonsillitis,
acute or chronic.
=Symptoms and Diagnosis.=—The characteristic dryness of the pharynx,
pain and persistent coughing are diagnostic. Upon direct examination,
the reddened, swollen appearance of the pharynx and posterior pillars
can be seen.
=Treatment.=—The treatment should be general and local and should
be determined by the causes and conditions present. This disease is
usually an acute infection and like other acute infections, the usual
systemic treatment should be applied.
The local treatment consists of thorough cleansing of the nasopharynx
(by irrigation if the patient can permit) and the frequent (or
occasional as required) use of some gargle until the inflammation
has subsided. Any cleansing nonirritative solution may be used for a
gargle. Equal parts of peroxide, alcohol and glycerine, a tablespoonful
to a half glass of very warm water or ten to fifteen drops of
phenol-glycerine to a half glass of warm water will make a good
cleansing gargle.
The osteopathic treatment consists of corrective work to the cervical,
upper thoracic and hyoid and thorough relaxation of the submaxillary
musculature to obtain good venous and lymphatic drainage. If sufficient
care be taken to avoid trauma, digital stretching of the soft palate
and pharyngeal muscles by the use of the finger internally, is very
efficacious.
Chronic Pharyngitis
Chronic pharyngitis may be hypertrophic, atrophic or granular. In
hypertrophic pharyngitis the pathologic changes have passed beyond the
stage of hyperemia and there is always hypertrophy or hyperplasia,
usually the latter, of the pharyngeal membranes. These changes in
most cases, have extended to and involved all of the nasopharyngeal
membranes.
Chronic granular pharyngitis, or so-called clergyman’s sore throat,
has a similar pathology to that described above, but with swollen
and inflamed lymph follicles. This condition seems to be a result of
excessive use of the voice.
Chronic atrophic pharyngitis has a similar etiology and the diagnostic
signs are also similar to atrophic nasopharyngitis with which it is
usually associated.
=Etiology.=—The causative factors are similar or the same as those of
nasopharyngitis. Lesions of the cervical and upper thoracic and chronic
focal infections such as tonsillitis, sinuitis, etc. are the common
causes.
=Treatment.=—The nature of the treatment should be determined by the
causes found. The nature of the pathology requires long continued
treatment and careful attention to all causes. Thorough osteopathic
corrective work, the removal of all sources of focal infection, proper
attention to any gastro-intestinal perversions which may be causing
auto-intoxication and thorough cleanliness of the parts by gargling
with some cleansing, non-irritating solution and by irrigation.
In most cases there is a considerable collection of adhesions in
the nasopharynx or posterior nares or in both. Enlarged “posterior
turbinate bodies” and the extension of the inferior turbinates into the
pharynx are also common results of the hypertrophic process. Complete
surgical removal of this excess tissue and the after treatment as
described above under chronic nasopharyngitis are frequently required
to obtain complete and permanent results.
These cases can be successfully treated if the proper attention is
given to all possible causes in each individual case. It is the
individualization, the specific and detailed attention to the cause or
causes, and such treatment continued for sufficient time, that will
obtain results.
In atrophic pharyngitis, normal nutrition to the parts and usually to
the entire system must be restored. Many such cases are secondary to
systemic anemia or to rheumatic intoxication. A careful examination
should be made for evidence of systemic causes. In many cases, I
believe that thorough osteopathic corrective work applied to the mid
and lower spine is the most essential part of the treatment. Other than
this the local treatment as described under atrophic rhinitis applies
here.
Tonsillitis
There is perhaps no other organ of the body, diseases of which have
caused a greater variance of opinion relative to treatment than
the tonsils. There are those who believe that every hypertrophied,
atrophied, or infected tonsil together with its fellow of the opposite
side should be removed. There are also those who believe that no
tonsils, regardless of their pathology, should ever be removed. These
are the radicals and their views are not at all in keeping with present
day facts.
Those physicians and surgeons who have tried to arrive at some safe
conclusion on this subject, believe that there are certain methods of
non-surgical treatment which are effective in many cases and they also
believe that in other cases, tonsillectomy is imperative.
=Functions of the Tonsils.=—Many and varied functions for the tonsils
have been held by various theorists such as: the absorption of the
products of salivary digestion; the secretion of an amylolytic ferment;
that they are atavistic structures and therefore have no function;
that they eliminate systemic toxins; that they serve as culture tubes
for the production of vaccines; that they protect the deeper cervical
tissues from bacterial invasion; the theory of internal secretion and
a score of other theories which so far, have never been substantiated
by either clinical or experimental evidence.
The hematopoietic theory or the theory of blood formation has a rather
definite basis because such a function would be possible from the
histologic structure. The formation of small lymphocytes has been
attributed to tonsil tissue (Flemming) and this view has been generally
accepted. Some of the lymphocytes however, find their way through
the epithelial walls into the crypts and are discharged as “mucous
plugs”, while others are carried by the efferent lymphatics into the
circulatory system. In this respect, the tonsils, like other lymphoid
tissue, produce lymphocytes which are essential constituents of the
blood. This function is particularly marked during the growing period,
but this function is also highly developed in all lymph nodules during
this period, and in the growing child there is an abundance of such
tissue and thus it seems that the tonsils, while important to the
growing child, would not be at all indispensable structures.
Some physicians claim to have observed deficiencies in growth and
development of children whose tonsils had been removed during the first
ten or fifteen years of life, but this is not commonly accepted. The
tonsils have their greatest cellular activity during the growing period
and unless chronically hypertrophied they atrophy during adult life.
Tonsillectomy
We may safely conclude from this evidence, that in the growing child,
it may be well to retain the tonsils providing they are not directly
affected in such a way as to endanger the general health of the child,
but that there is little, if any, danger in their early removal. In
adults, there seems to be no reason why they should not be removed in
cases in which there is evidence of involvement beyond restoration by
treatment or those cases in which there is evidence of toxic absorption.
When surgical removal of the tonsils is indicated, the complete
removal or tonsillectomy should always be done. A careful and complete
enucleation of the tonsils when properly done will never be followed
by any untoward results other than the temporary surgical sore throat.
There is never any excuse, much less a reason, for partial removal of
the tonsils or tonsillotomy, because such operations never accomplish
the desired result and they nearly always require tonsillectomy later.
In association with a reputable vocal teacher I have studied the
results of tonsillectomy on the voice. In none of the twenty cases
studied was there any impairment following the operation, but on the
other hand sixty per cent were improved either in range of pitch,
quality or endurance, in addition to their being more free from
laryngitis, pharyngitis, etc. for which the operation was done. Doctors
Ruddy, Edwards and Reid of our profession have told me of similar
experiences, so I am certain that tonsillectomy properly done will in
selected cases, improve the voice.
Acute Tonsillitis
Acute tonsillitis is an acute infectious and often a contagious disease
characterized pathologically by inflammation of the tonsils. Some
authors differentiate between follicular tonsillitis in which the
crypts or lacunæ are involved, and parenchymatous tonsillitis in which
the parenchyma is involved.
=Etiology.=—The predisposing and exciting causes are the same as in
other acute infections of the upper air passages except that there is
usually a chronic tonsillitis as a result of some previous attack.
=Symptoms and Diagnosis.=—The symptoms also are similar to other acute
infections of the nasopharyngeal tract, with sore throat, variable
temperature, headache, etc. By direct examination of the pharynx, the
protruding masses with white or yellow patches are readily seen.
=Treatment.=—Infection, drainage and elimination are three words
inseparable in the therapeutics. The local treatment (I doubt if many
will agree) in either acute or chronic tonsillitis is essentially the
same—radical aspiration drainage. In all cases, except young children
who will not permit it, I place a vacuum cup directly over the tonsil
and apply as much vacuum as can be obtained. This treatment will, when
properly done, empty the crypts of all pus. This accomplished, each
crypt is probed with a cotton applicator dipped into phenol-glycerine.
Cervical and upper thoracic treatment and deep relaxation of the
sub-tonsil tissues to increase the normal blood supply and to decrease
congestion by drainage elimination are essential. The lower thoracic
and lumbar should receive due attention for the purpose of increasing
general elimination. The diet and other treatment are no different from
that in other infectious fevers.
Peritonsillar Abscess
(Quinsy Sore Throat.)
Peritonsillar abscess results from the collection of pyogenic bacteria
and pus formation between the tonsil and the pillars of the fauces. It
is perhaps a result of the closing of an infected crypt causing deep
penetration of the pus.
=Diagnosis.=—The symptoms are those of acute tonsillitis but usually
more marked and with one tonsil decidedly more protruding than the
other. In some cases the location of the abscess can be seen and it is
comparatively easy to open with a knife or probe, but in many cases the
abscess is so situated that it cannot be located except by exploratory
probing.
=Treatment.=—Drainage by direct incision of the abscess pocket is
indicated as early as a definite diagnosis can be made. There is no
definite technic to be followed except to observe certain general
principles. If the “pointing” of the abscess can be located, it is
comparatively easy to make a good, free, direct incision and accomplish
complete drainage. In many cases the only way to locate the pocket
is to employ a probe or small, long, scalpel and explore between the
pillar and tonsil until the pus pocket is found. As soon as this is
located the pus pours out around the probe and this gives the location.
Free drainage by means of a liberal incision should then be made.
Aspiration of the pus pocket and filling with phenol-glycerine is
effective after drainage has been obtained, but a liberal drainage must
be maintained.
The non-surgical treatment as described under acute tonsillitis is to
be applied here.
Chronic Tonsillitis
Chronic tonsillitis usually is the result of one or many attacks of
acute infections of the tonsils. Occasionally cases of marked chronic
tonsillitis occur in which the patient denies ever having had an acute
attack.
The pathology consists of hypertrophy of the lymphoid tissue and
connective tissue.
=Diagnosis.=—The purpose in diagnosis is not to determine whether the
tonsil is hypertrophied but to determine whether the tonsil is causing
any local or general physiological perversions and if so, whether local
treatment or surgery should be applied.
The direct examination should be made very carefully, because otherwise
a bad tonsil may be readily overlooked. The mere fact that a tonsil is
large or has open crypts from which a whitish mass may be expressed
does not mean that such a tonsil is directly responsible for local or
systemic physiologic perversions.
The examination should be made by means of a tongue depressor, tonsil
retractor and a good head mirror and reflecting lamp. Every part of
the tonsil and surrounding pillars should be carefully examined. Firm
pressure applied against the tonsil from in front and behind will
often force material from the crypts or out around the capsular margin.
Any such material thus expressed should be examined microscopically. By
probing the crypts with a small pointed cotton-wound probe and staining
the material obtained, the condition of the deep parts of the tonsil
can be determined.
The symptoms in every case, are to be considered with the microscopic
findings, but there are cases in which either of these, together with
appearance on direct examination, is sufficient to determine the
advisability of tonsillectomy.
In general, we may say that the following factors would indicate
tonsillectomy.
1. Chronic, recurrent tonsillitis with or without complications, which
does not respond to non-surgical treatment.
2. Positive evidence of arthritis of any form with microscopic evidence
of some virulent organism, such as staphylococcus, streptococcus or
long-chain pneumococcus, present deep in the tonsillar tissue.
3. Any persistent discharge of pus from the tonsil in which the
microscope shows the presence of virulent bacteria and which will not
be relieved by treatment.
4. Markedly hypertrophied tonsils which directly interfere with the
voice, deglutition or respiration and which do not respond to treatment.
5. Persistent focal infections of the middle ears, or sinuses or root
abscesses which do not respond to treatment and in which case there
is a virulent infection of the deep parts of the tonsil, shown by
microscopic examination.
The above are only general conditions and there are probably many other
indications or groups of symptoms that would indicate tonsillectomy.
In most cases, unless the findings show positively that tonsillectomy
should not be delayed, we advise treatment. If treatment does not
restore to normal, it will probably reduce the time of the surgical
sore throat following the operation.
=Non-surgical treatment.=—The local direct treatment, as we practice
it, consists of: 1. Direct aspiration by means of the tonsil cup,
applying from fifteen to twenty inches of vacuum. 2. Application of
phenol-glycerine by means of cotton applicator to the full depth of
each crypt. 3. Irrigation of the crypts by means of a catheter and
hot salt mixture solution. 4. Syringing of the crypts by means of the
catheter and phenol 10%, alcohol 20% and glycerine 70%.
The digital treatment of the tonsil consists of: 1. Applying pressure
against the anterior pillar thus forcing the contents out of the
tonsil, the Ruddy method. 2. By the bidigital technic, the front
finger of one hand inside, posterior and inferior to the tonsil and the
fingers of the other hand outside exerting deep pressure and opposing
the finger inside. In this way the tonsil can be lifted forward and
upward and its contents expressed. The digital treatment is not as
effective as that described above.
The osteopathic corrective treatment consists of adjustment of the
atlas and axis and the mandibular articulation and the obtaining of
free movement of the hyoid and the relaxation of the submaxillary
musculature and other deep structures.
This treatment, if followed persistently, will relieve the local
symptoms of a very high percentage of cases of chronic tonsillitis, and
in many cases even the systemic complications will be relieved. Whether
in cases of systemic absorption this is the preferable treatment I am
not sure, because, once the local condition is improved the patient
will usually refuse operation and even if the physician finds definite
evidence of toxic absorption he cannot convince the patient that his
tonsils require surgery.
MENTAL DISEASES
BY
L. VAN H. GERDINE AND A. G. HILDRETH.
INTRODUCTION
The subjects herewith presented, while including certain of the most
important sections of mental disease, make no claim to completeness
either in the subject matter presented or in the attempt to cover the
entire field of the psychoses. They cover those portions, however, with
which we have come in closest touch at the Still-Hildreth Sanatorium,
and in which we have the most complete records. I have been aided in
the compilation of the essential facts and statistics by the able staff
of the institution and wish to acknowledge especially the valuable
cooperation of Dr. C. M. VanDuzer in the Dementia Praecox group, Dr. H.
P. Hoyle in the Manic Depressive group, Dr. B. L. Jemmette in the group
entitled Delirium, Confusion and Stupor, Dr. J. C. Snyder in the Senile
Dementia group and Dr. G. S. Elkins in the Involutional group. The
opinions concerning each type held by Dr. A. G. Hildreth are appended
under its appropriate heading. I wish to state emphatically that
the sole treatment carried out in the Macon Institution is specific
corrective work upon spinal lesions, and it is upon this treatment that
the statistics are based which are to be found throughout the text.
These records cover more than 700 cases, including complete histories
of the patients with the physical and mental findings on examination;
these represent, therefore, by far the largest body of statistics ever
accumulated in the study of osteopathic results in mental disorders.
While the results naturally vary in different types of mental disease
the grand total shows that more than one-half of all patients admitted
recovered. Details for each group will be mentioned under its
appropriate heading. While adjuncts such as diet and hydrotherapy have
been utilized; we certainly cannot attribute any curative value to
their influence.
It should be further emphasized that in no case whatsoever has medicine
been used as a curative agent. And the same may be said of surgery.
It has indeed been conclusively proved even in the medical world that
medicines and surgical procedures are absolutely ineffective; from
the osteopathic viewpoint this of course is perfectly reasonable
since the theory calls for definite lesions as causative factors and
these lesions can hardly be reached other than by the osteopathic
method of correction. The results obtained, therefore, could only
be attributed to the genuine osteopathic principle enunciated by Dr.
A. T. Still who kept in close touch with the work and gave it his
approval up to the time of his death. He had always maintained that
the osteopathic principle could accomplish remarkable results in this
field and considering the previous inefficiency of any other method his
confidence has been fully justified.
Dementia Praecox
This condition refers to mental disorders arising usually during the
period of puberty or adolescence, therefore, between the ages of
fourteen and twenty-five for the most part, although apparently similar
cases may arise in later years. The term dementia refers to mental
deterioration and enfeeblement, while “praecox” signifies adolescence,
though some writers infer that the term praecox may be used to indicate
the early or precocious development of the mental enfeeblement. Certain
it is that in most cases deterioration, with its resulting symptoms of
mental enfeeblement giving rise to the term dementia, usually occurs
in time, though by no means always early. It is a chronic progressive
disease which may terminate in a complete loss of mentality; in other
cases it may become arrested in any stage and remain so permanently;
in still others it may recover, though this is rare. By reason of the
variability of the symptoms, three groups are generally recognized,
first suggested by Kraepelin. Each is differentiated by more or
less characteristic symptoms and referred to under the head of the
Hebephrenic, Catatonic and Paranoid types, although all have certain
symptoms in common and there are mixed types.
=Etiology.=—According to the authorities some form of hereditary
factor can be found in some fifty per cent or more of all cases; this
is supposed to create a predisposition, a natural weakness of the
nervous system, which renders it unable to bear the ordinary storm and
stress of life, so that the mechanism becomes according to the French
expression, “wrecked upon the rock of puberty or adolescence;” in other
words, a premature giving way of the nervous system, being inherently
unable to stand the strain of life. Another suggestion is that it
represents the outcome of abnormal types or reactions of the individual
to the environment, with a failure of proper adjustment to surroundings
and the formation consequently of mental problems which to the patient
are incapable of solution. This may be called the psychological theory.
The most commonly accepted idea, however, is the physical causation.
According to this the disease results from auto-intoxication, the
intoxicant arising from the disturbances of the glands with internal
secretions, more particularly the sexual glands. This endocrine theory
is supposed to be supported by the fact of the appearance of this
disease most commonly at the time of puberty and shortly thereafter.
The osteopathic conception fits in very well with this latter view,
inasmuch as the spinal lesions are quite capable of explaining not
only a disturbance of innervation to the glands with the resultant
interference in their normal secretion, but also could produce disorder
of the circulation and nutrition to the brain.
=Symptomatology.=—Although each variety of Dementia Praecox has special
symptoms characteristic of the type there are certain symptoms common
to all forms, and these will be first considered. All the functions
of the mind in the course of time tend to become disturbed and to
be weakened, but in the earlier stages we find marked differences
as regards the disturbance of different functions, thus memory and
orientation in most cases seem good; on the contrary, attention and
association of ideas somewhat poor. Emotional life is almost always
markedly affected, even in the beginning. Very commonly at first there
is depression to be followed later by expansive feelings and then by
apathy in general. The will power is altered early and the conduct
is apt to be peculiar. The judgment becomes impaired. All of these
symptoms mentioned are deviations from the normal in the patient
and therefore presuppose that the patient was formerly normal. This
should sharply differentiate the praecox group from cases of defective
development (imbecility or idiocy). In this latter group there is an
arrest of development of the mind, whereas in praecox there is a loss
in a developed intellect. We see a young patient, for example, who
has lost interest in things about him, neglects his work at school or
at home, remains alone for long periods of time and seems unwilling
to mingle with other people. He gives the impression of one depressed
and worried about something he is trying to solve, perhaps he mutters
to himself or gives way to unprovoked laughter, he may refuse to eat,
or to talk unless questioned and may even then not answer. When he
does talk it will be discovered that he knows perfectly well where he
is, and knows people around him and understands everything that is
going on; his memory will be found good, he can usually recall past
incidents and tell what he has been doing recently. As the condition
progresses, however, while the patient may still for a long time retain
fair orientation and memory for past events, his accumulation of recent
ideas will be found poor, so that he will recall them with difficulty.
We notice that it is difficult to get the patient’s attention and
concentration seems to be impossible, he may answer a direct question,
but immediately seems to be occupied with other thoughts and it takes
some little effort to gain his attention again. If he continues to
talk it is plain that the association of ideas is poor, giving rise to
disconnected phrases which usually come forth sluggishly and without
show of emotion. Dissociation of ideas occurs; that is, different
ideas expressed may practically contradict themselves. For example,
the patient may say he is a king and yet when asked to sweep the floor
will do it perhaps without hesitation, not considering that is hardly
the kind of work a king would do. The dissociation is also marked in
the contradiction found between the content of the thought and its
associated emotional idea, for example, the patient may speak of a
near relative as dying recently, yet with no show of emotion, even
with a meaningless laugh. This dissociation may ultimately result in
complete incoherence, in which no sense can be found whatsoever in his
speech. Emotional indifference is noticeable early and sluggishness
of reactions to stimuli, even failure of such reactions; the patient
will neglect himself, stay away from meals, express no desires and make
no complaints. In the earlier stages, however, the patient who may
have been for some little time apathetic, suddenly without apparent
cause becomes angry, noisy, and possibly violent and destructive,
again gradually relapsing into his quiet, apathetic state. The thought
content is commonly associated with delusions, that is obviously false
ideas, but which the patient is unable to perceive are false. Delusions
of persecution are most common, the patient feeling in a dim way that
everything is not right; and in attempting to explain to himself the
reason, often attributes causes to people or forces outside of himself,
and on account of the feeling of bodily discomfort, also by reason
of the depression, he explains the external forces as unfriendly to
himself. Hallucinations may be present and furnish the material around
which the delusions form; on the other hand hallucinations may result
from the delusions. By hallucination is meant a false sense perception,
as the patient may state he sees someone before him who is not there,
or that he hears voices from individuals who are not around him; he may
also complain of receiving electrical shocks, or wireless messages,
which he usually states come from his persecutors. Symptoms of this
nature form a good example of the so-called split personality, or
“schizophrenia,” wherein certain idea complexes are split off from
the main personality and address themselves to the main portion, the
patient attributing these noises (voices), sensations (visceral and
tactile), tastes and smells to an objective rather than a subjective
source and subsequently forming delusions. However, unless we are
dealing with the paranoid form the delusions are fragmentary, transient
and absurd.
=Hebephrenia.=—This is a progressing mental enfeeblement, terminating
usually in deterioration, and without showing marked peculiarities
in thought or action aside from the progressing deficiency. The
patient appears in general inactive, lacking in energy and ambition,
indifferent, depressed, incapable of much concentration and hence
the efficiency becomes progressively impaired until he is unable
to accomplish anything. From time to time there may be periods of
confusion, depression, passivity, at other times periods of excitement.
=Catatonia.=—In this form the general symptoms are similar to those
of the simple type above described with the addition of the special
symptoms referred to as catatonic excitement and catatonic stupor. The
excitement period is manifested by an unrest and monotonous activity,
stereotyped actions and speech, the patient constantly repeating
some act, such as moving the hand, foot or head over and over again
in the same way, or repeating the same word or phrase indefinitely.
This occurs apparently involuntarily, the actions being automatic in
character. The patient who has been in a semistuporous state may pick
up a glass or chair and without show of emotion break it against the
wall. In catatonic stupor the patient may show in the lighter degrees
a simple loss of interest and feeling with sluggish reaction to
stimuli, or a profound inactivity and stupor in which state he cannot
apparently be reached by any stimuli; nevertheless, he apparently
retains consciousness. In this type we observe the interesting symptom
of negativism in which the patient always does the opposite of what
he is requested, or refuses outright to obey any command. There may
be a refusal of food so that the patient has to be fed by a tube,
mutism may be present, the patient may go for weeks or months without
saying a word; stereotype of attitude results in cataleptic poses and
rigidity, in which the patient may maintain any particular pose for
a prolonged period of time, and if placed in some other attitude may
similarly retain the new attitude for a long time. This constitutes
the so-called wax like rigidity, the patient reminding one of a wax
figure. Pathologic suggestibility occurs in which the patient imitates
movements, or repeats words and phrases that are spoken or performed
before him.
=Paranoiac Form.=—In this type delusions predominate and are
characterized by variability, inconsistency, illogicality and
transitoriness on the one hand, with many gradations to the opposite
extreme where they become more or less fixed, and often dovetail into
each other forming apparently a systematic whole. They tend to be
usually of a persecutory and hypochondriacal character and in later
stages when the mind is distinctly weakened are often of a grandiose
type. Sometimes the patients have some kind of explanations for them
and at other times none whatsoever, and they are often curiously
dissociated from the emotional accompaniment. The patient may state
there is poison in his food, in an indifferent tone of voice or even
with a laugh; he may claim that his teeth are all set in wrong and
offer no explanations to these obviously false ideas. The patient
commonly thinks that somebody “has it in for him,” someone will do
him mischief, will kill him, that people are talking about him and
criticizing him, everything that he hears or reads he thinks has some
bearing on himself, so-called “delusions of reference.” Hallucinations
may be present, the patient hearing voices, or receiving impressions
or ideas which he claims come from without. These external impressions
he misinterprets as voices or forces which are accusing, threatening
and slandering him. Later on, the patient tends to change from the
depressed persecutory stage to an expansive one, when he claims he is
some celebrated person, king or president, or pope. The impairment of
the judgment is clearly demonstrated in these cases since the patient
who may claim to be the king of England may beg the attendant to change
his place at the table or for a postage stamp.
=Pathologic Anatomy.=—This is obscure. Since a certain proportion
of cases recover, there can evidently be no degenerative changes at
the outset, though some cases deteriorate fairly early, others only
after several years. In some chronic cases there have been observed
degenerative changes in the cortical cells.
=Diagnosis.=—First, the common age of onset during puberty and
adolescence, fourteen to twenty-four in the vast majority of cases,
this being the only common mental disease occurring during this age
period. Second, the progressive character terminating in mental
enfeeblement or deterioration, that is “dementia” proper. Third, the
evidence of defect or deficiency symptoms indicating that the patient’s
mind has altered in the sense of deterioration from its former normal
condition, whereas, in imbeciles or idiots the mind has failed to
develop in the first place. Fourth, in the earlier stages particularly
the marked dissociation of the brain powers, some being well maintained
as memory and orientation (that is knowledge of time and space), others
being weakened, such as judgment, power of attention and the like.
Fifth, the early appearance of the emotional defect, a remarkable
indifference and apathy of the patient to people and surroundings,
the patient being unsocial and taking no interest in anything. Sixth,
all the peculiar motor reactions, which are mentioned above under
the catatonic head, and which very rarely occur in any other mental
disorder. Seventh, the delusional content nearly always refers to the
patient’s exterior, forces outside of him, people or things which are
exerting an unfavorable influence upon him, delusions of persecution
and reference. The patient practically never accuses himself, as is the
rule in cases of true melancholia, never blames himself, but always the
other party or the other force outside of him. Eighth, the delusions of
grandeur are usually indicative of a stage of deterioration.
=Prognosis.=—Some authorities are inclined to doubt if any case ever
completely recovers, claiming that in apparent recovery it may have
been a question of mistaken diagnosis, or that the recovery is more
apparent than real, that the patient is not truly well, or will have a
relapse, so that a permanent cure will be impossible. Other authorities
admit the possibility of recovery though in a very small minority
of cases. The statistics of the Still-Hildreth Sanatorium, covering
more than two-hundred fifty cases show total recoveries of at least
one-third. This includes all types and all stages of progress, many
being advanced on entrance. Of the less advanced cases and those of
not more than two or three years’ standing there have been some fifty
per cent recovery. Many cases make improvement or become stationary
in greatly improved condition, but are not included in the thirty per
cent. Of the three types, the catatonic offers the best prognosis, the
hebeprhenic the poorest, while the paranoiac occupies an intermediate
position.
=Treatment.=—Of the etiologic factors above mentioned, that of
auto-intoxication, resulting possibly from endocrine disturbances
or other sources, is most generally accepted in the medical world
and agrees excellently with the osteopathic point of view. Spinal
lesions are regularly found more particularly in the dorsal region,
which are quite capable of disturbing the innervation to the glands;
therefore, their nutrition and activity. A correction of these before
the disturbance has continued too long, and hence before deterioration
has set in, should theoretically normalize the glandular condition and
therefore prevent deterioration and enable the patient to recover.
Such is the probable explanation of the results, and in many cases the
recoveries were obtained in patients previously considered hopeless.
Remarks by Dr. Hildreth
In a great majority of the cases the cause lies in the interference
between the fourth dorsal vertebra and the eighth, which analyzed
means a disturbance of the great splanchnic nerves, through whose
interference would be caused the toxic condition and even the sexual
disturbance described in so many cases from standard authorities. The
same lesion, if deep seated enough, could produce an interference with
the vasomotors and reflexly interfere with the circulation to the
brain. In many we also find a first, second or third cervical lesion.
The effects of these lesions on the equilibrium of the circulation to
the brain are easily traced through the superior cervical sympathetic
ganglia. These lesions, namely, the mid-dorsal and upper cervical,
especially when corrected in the earlier stages, have thus far proven
to produce successful results. In a lesser number of cases we find the
cause to be from the first to the fourth dorsal vertebræ; our reasoning
here being that the interference or the physical disturbance must be
so deep that it reaches and interferes with the deeper nerve currents,
both downward and upward, thus disturbing the equilibrium of the
circulation to the brain. We have found this class to be the hardest
to respond to treatment; however, that may be due to the fact that
the physical defects at that point are harder to correct. Osteopathic
treatment applied to the lesions above described without question
offers therapeutics of intrinsic value to this class of patients.
Delirium, Confusion and Stupor
This clinical group has become well established, not only in its
recognition from the dominant symptoms as indicated above, but also
from rather definite causes. The immediate cause seems to be an
abnormal blood state, or so-called toxemia, which may result from
infectious diseases, or states of exhaustion, or autointoxications,
or foreign poisons; the poison acts as an irritant to the brain. In
states of exhaustion so-called “fatigue bodies” are formed and are
apparently toxic in character. The autointoxicants may have various
sources, such as chronic kidney disease, or diabetes, and the like.
The most important of the foreign poisons are alcohol and morphine.
This morbid group is further characterized not only by a toxic cause
and dominant symptom complex of delirium, or confusion, or stupor,
but by a similar onset and course. The onset is usually acute and
the course somewhat wave like, gradually reaching a climax and
subsiding, or resulting in death or becoming chronic. To emphasize the
clinical symptoms of confusion which is so important the term “acute
confusional insanity” has often been used, or “amentia,” according to
the common German terminology. Hallucinations also play a prominent
part, particularly those of vision; hence, another common appellation,
“acute hallucinatory confusion.” Heredity is mentioned at most as
creating a predisposition, though often the personal and family
histories show no such evidence whatsoever. Intellectually there is a
definite lack of orientation, the patient is unable to identify himself
or his surroundings in time and space. He cannot clearly understand
what goes on around him, that is, consciousness is “clouded;” the
clouding may be of such extreme degree the patient’s mind becomes
blank, due to complete psychic inhibition. This is referred to as
stupor. The emotional life plays a secondary role subordinate to the
intellectual content. The patient may be greatly excited for example,
resulting from a frightful hallucination. The hallucinations are mainly
of the visual type and are almost always present. The patient lives in
a perpetual state of sense deception as if he were constantly dreaming;
the hallucinations for the most part are of distressing, disagreeable
or even frightful character. These may give rise to delusions, which
are manifold, often fantastic and usually transitory.
Physical changes are always found associated with the disturbed mental
status. If it arises during the active stage of an infectious process
there is of course the high temperature and all other physical signs of
fever. In a certain number of cases with temperature no definite signs
can be found indicative of any of the well known fevers, hence has
been called by various names, such as “Bell’s Delirium,” “Acute Mania
Gravis,” or “Acute Febrile Delirium.” This ordinarily runs an acute
rapid course with very high temperature, very marked delirium, followed
by stupor and usually death from exhaustion. Even though no temperature
be present the physical condition reminds one very much of that found
in fever diseases. There is the lost appetite, resulting emaciation and
malnutrition, insomnia, exhaustion, etc.
=Osteopathic Theory.=—While it may be admitted that the various factors
mentioned above may take part as exciting or predisposing causes, it
is obvious that in numerous instances mental disorders do not arise
whatsoever, even when the patient is subjected to these factors. There
must necessarily be other elements essential to produce the psychosis.
The osteopathic theory comes in at this point to fill in and complete
the chain of causes and to initiate the onset by the introduction of
the idea of nutritional and circulatory disturbances resulting from the
spinal lesions.
The records of the Still-Hildreth Institution show 18 of the toxic
type, in which the poison is derived from without, who were treated,
with 17 recoveries. There were 25 cases connected with the infection
and exhaustion group, with 20 recoveries.
Remarks by Dr. Hildreth
In this group we have to do with blood disorders, resulting from the
infections, conditions producing exhaustion, and the various toxins, or
poisons, whether originating within the body or derived from without.
These disorders are largely functional in character, resulting from
brain irritation due to the toxemia or disturbance to the centers of
nutrition. The main object of the osteopathic treatment, therefore, is
to aid elimination and regulate and build up the nutrition. In most of
the patients the physical lesions are found in the mid-dorsal area,
chiefly from the 4th to the 7th, and in the cervical region, the 1st to
the 3d. In aiding the kidneys in elimination the 10th and 11th dorsal
vertebræ must be looked after. These conditions commonly respond very
rapidly to the treatment and represent one of our most successful
groups so far as results are concerned.
Manic Depressive Psychoses
The psychoses which are brought together under this classification
include mental disorders which at first glance would appear to be of
very wide variation, namely, conditions of maniacal excitement and
those of depression. Further consideration, however, reveals the very
evident reasons why they should be united as sub groups under the one
head. The fact that these two mental states of seemingly opposite
characteristics often appear alternately in the same individual, that
in certain cases of each type there is a wave like feature in the
nature of the attack and the frequency with which they tend to recur,
together with other points of similarity in respect to duration,
prognosis, etc., tend to point to their very close relationship.
Kraepelin was the first to draw attention to these facts and advocate
the present convenient and widely accepted classification of these
disorders.
The outstanding feature is the disturbed emotional state which
dominates and overshadows all other symptoms and is fundamentally
the same whether expressed through the excitement of mania or the
depression of melancholia.
=Etiology.=—Heredity is considered an important factor. Various
authorities claim to have demonstrated direct hereditary influences in
as many as eighty per cent and more of cases. Individual predisposition
resolves itself into a matter of constitution and temperament in which
there seems to be a greater tendency among those who are subject to the
emotional extremes.
Early adult life is by far its most frequent period of onset, though
it may arise also somewhat later. In certain cases the beginning
of the disorder dates from some psychic or emotional shock. Just
what importance these factors have as causes is little known since
other cases develop in which the constitutional element alone seems
responsible and no immediate exciting cause can be demonstrated.
The osteopathic viewpoint emphasizes the all important influence of
spinal lesions as exciting factors. In individuals who have a tendency
to this reaction their presence disturbing the cerebral circulation and
nutrition may act as the direct causative factor.
=Manic Phase.=—The manifestation of this condition is brought about
by the release of the inhibiting influences which normally govern all
psychic function. Various terms as hypomania, acute mania, delirious
mania, etc., have been used to differentiate the different degrees in
which the symptoms appear.
In the milder types we find the following symptoms present. There is
a marked feeling of well being. The patient, having lost sight of his
personal limitations, feels a consequent exalted opinion of himself.
His conduct is often rather boisterous, he talks a great deal, often
swearing and using obscene language. He is inconsiderate of others and
tries to impose his will upon those about him. There goes with this a
certain unstability of the emotional tone as manifested by the quickly
changing feeling of good humor, irritability and anger. There is a
rapid flow of ideas with a marked loss in the ability to concentrate
and direct thought. The ideas which pass through the mind do not
coordinate themselves toward a definite goal, but deviate from the
course of consecutive thinking by any passing association. Again there
is a restlessness and activity beyond all normal bounds. The individual
feels strong physically and mentally. The appetite is unusually good
and if activity is not too extreme there may be a gain in weight. The
period of sleep is diminished and the feeling of fatigue is reduced.
In the more exaggerated cases the flight of ideas becomes more marked,
the associations are more rapid and superficial and the attention is
focused but momentarily. Illusions and delusions may be present due
to the imperfect preceptions from inability to concentrate attention
and from abnormal associations. Rhyming speech, disconnection of
phrases and even apparent incoherence are often present. The state
of mind may be such that the patient tears his clothing, breaks up
furniture, jumps, dances and shouts and often will not take time to
eat. The most extreme cases which refuse food over some period of time
progress rapidly to exhaustion and measures to conserve strength become
imperative.
=Depressive Phase.=—In this phase of the disorder are encountered
manifestations which are in direct contrast to those presented in
the manic phase. In place of the exalted emotional state there is a
depression. There is a tendency to worry over trivial matters of the
daily routine and of instances in past life. Introspection is the
predominant mental attitude and the whole outer world is colored by
the inner feeling of worry and uncertainty. Replacing the rapidity
of thought in the manic phase there is a distinct slowing of mental
processes in the depressive phase. Thinking is more difficult and
labored, questions are answered slowly and with an apparent effort and
there is usually a tendency to avoid social life.
Again replacing the excessive activity in mania the depressions show
a retarded action. There is disinclination or disability toward any
effort either motor or mental. The patient feels weak and incapable of
effort, the body assumes a bent attitude and the facial expression is
one of despondency. The appetite is usually impaired with resultant
loss of weight, the bowels are sluggish, the period of sleep reduced.
In the more exaggerated cases the retardation may be complete.
Introspection is carried to the degree where the patient tries to
take unto himself the responsibility for all the sin in the world.
He himself is the arch sinner and he feels himself the subject of
punishment by divine wrath in a manner in which no other individual
was ever punished. Also the introspection tends to produce various
hypochondriacal ideas. The patient may feel that he has contracted
some incurable disease and that certain bodily functions have ceased
operating.
Mental processes become not only retarded and difficult, but actually
painful, a symptom which has been termed psychalgia. Suicidal
tendencies are also quite frequently present.
In extreme conditions the patient may become so retarded in thought and
activity that he apparently receives no stimulus from the outer world.
He lives in a more or less stuporous state, even requiring that food be
administered by tube.
=Circular Insanity and Mixed Forms.=—In addition to the conditions in
which simply mania or melancholia are manifest there are certain cases
which show variations and combinations of these forms. A common type
is that in which there is an alternation of the manic and depressed
conditions. The patient may pass directly from one state into the
other, or there may be an intervening period of lucidity. The term
circular insanity has been applied to this type. Other variations
are those in which there are recurrences of the manic or depressive
attacks often at more or less regular intervals, each recurrence being
a practical repetition of the preceding.
There is also possible a considerable intermingling of the
characteristics of the two types. In the manias may occur difficulty
of thinking, passing feelings of depression and even almost stuporous
conditions. In depressions there can exist a marked degree of
restlessness and activity and a rapidity in the flow of ideas.
=Prognosis.=—The outlook for recovery from the individual attack is
good. The attack may last from a period of days to one of a number
of months and recovery comes with rarely any evidence of mental
deterioration. There is a tendency to recurrence of the trouble.
In fact recurrence is the rule rather than the exception. In the
osteopathic handling of these cases it has been the endeavor to
demonstrate that the correction of lesions had a tendency to lessen
the duration of the individual attack and reduce the tendency to
recurrence. Judging from the experience thus far gained in the
observation of cases under treatment during the attack and the
comparative few recurrences reported both of these aims have been
attained.
=Treatment.=—The osteopathic measures are aimed at the correction of
the spinal lesions, especially those located in the upper dorsal and
the cervical regions. Some reflex effects from lesions in more remote
areas may have their influence so that it is wise to look to the
correction of any other structural variations when present.
Remarks by Dr. Hildreth
The mental disorders of this type are purely functional and may cover
a broad scope as to causes; however, from the osteopathic viewpoint a
great majority of them seem to have as their specific exciting cause,
lesions in the upper dorsal and upper cervical regions. The treatment
should be applied specifically to the cause which may range anywhere
from the 1st to the 8th dorsal, or from the 1st to the 3d cervical,
covering the nutritional and circulatory centers and thus controlling
the nutrition and circulation to the brain. There can be no question
but what the osteopathic theory of adjustment of physical defects
forms the basis of permanent cure, since many of our recoveries had
been previously under other methods of treatment without results. Our
records cover over 200 cases with recovery in more than two-thirds, and
very few recurrences up to the present.
Involutional Psychosis
In the mid years of life, between forty and sixty, a decline begins,
which in the older years results in decay; it is especially true at
this period of the sexual life and the organs underlying it. While
these organs undergo a very definite change constituting the so-called
climacteric period in women, it is not at first sight so evident in
men; however, the evidence is that a somewhat similar process, though
much slower, tends to occur in the male. Associated with the decay
of the sexual organs is a disturbance presumably of the internal
secretions; if this latter disturbance takes place slowly and evenly
the body may not notice any marked changes; on the other hand, if it
takes place more quickly, or unevenly, it may give rise to distinct
symptoms which indicate a disturbance of the nervous system in general
and often even of the mentality. Hence, the significance of the term,
Involutional Psychosis. In a large majority of cases the mental
disorder is marked by the dominance of depression and is frequently
referred to as melancholia. For a long time it was considered that
this represented a special mental disorder having little or nothing
in common with other psychoses. In recent times Dumas has studied
this group very carefully and shown that it in reality has very much
in common with the depressed phases of the Manic Depressive Group of
psychoses. Kraepelin himself, who was the first to demonstrate the
unity of the Manic Depressive Group, has accepted the conclusions of
Dumas and incorporated the Involutional Depressions as a sub type of
his Manic Depressive Psychosis. Among etiologic factors have been
mentioned hereditary elements, which have been claimed to have been
found in at least fifty per cent of all cases, forming presumably a
predisposition; it is also stated that a predisposition may be acquired
through various debilitating causes. Exciting factors are claimed
to be present, such as mental shock, grief, worry and the like. The
disease would then seem to occur when we have a combination of exciting
factors and predisposition. Careful consideration will show, however,
that no such mental disturbance occurs at this age in many people
who show evidences of such predisposition and of exciting factors,
therefore it would seem that still other causes were necessary; if
we consider the suggestion above mentioned that there are atrophic
processes taking place in the sexual glands leading to a loss of the
internal secretions and if we further consider that this may take
place unevenly and in an unbalanced way, thus aiding in giving rise
to the symptoms, we will find a definite point of contact for the
osteopathic conception. Osteopathically considered, we may say that
the spinal lesions lead to a disturbance of innervation and nutrition
to the ductless glands, and therefore produce disordered secretions in
those patients developing the disease, whereas such a condition may
not be present in others who at the same age period do not develop the
psychosis.
Symptomatology
The emotional tone of depression dominates the picture. Associated
symptoms are anxiety, fears, particularly of impending danger, the loss
of interest in the external world, with a concentration of attention
upon self; psychic distress is usually present, often to an extreme
degree, leading apparently to real mental pain, so-called psychalgia.
Delusions are usually present and manifold in variety; they mainly
refer to the patient himself and are of a self-accusatory nature;
they frequently refer to notions of sins having been committed, also
unworthiness of the patient, of poverty, nihilistic ideas, either about
his own body or external things. He may claim for example that he has
no stomach or kidney, or heart, that the external world is unreal and
the like. His motor reactions become retarded, or even in the more
extreme cases inhibited, producing a form of stupor. The inefficiency
which results along with the psychic pain and distress may determine
suicidal tendencies which are very frequent. Orientation is usually
good, the patient remaining aware of his own identity and that of his
surroundings; the judgment of course is impaired so that the patient
is unable to appreciate the unreality of his delusions; as a result
he sees no hope in the future and on account of present sufferings
prefers death to life. The patient may remain in a perfectly passive
mood, giving the appearance of extreme depression, paying no attention
to the surroundings, possibly mute, giving no regard to the necessity
of the toilet, paying no attention to his clothing and the like.
This may continue for hours or days. Food often has to be forced on
him, possibly even by the tube; the result is usually more or less
emaciation and may result in marked malnutrition; similarly the sleep
may be seriously interfered with, even though the patient is quiet.
The resulting loss of sleep and malnutrition sometimes lead to the
death of the patient. On the other hand, the patient may moan and wring
his hands in anguish, walking up and down, crying out that he is a
sinner and that he wants to die and the like. This is the so-called
melancholia agitata.
The physical symptoms of importance are sleep disturbances, poor
appetite, with emaciation, cyanosis, often a subnormal temperature, low
blood pressure, slowed heart action and weakened circulation. The hair
may become gray, the skin dry and harsh and indeed any of the signs of
senile decay may appear.
=Diagnosis and Prognosis.=—These depend partly upon the mental
symptoms, partly upon the physical. On the mental side is to be
emphasized marked depression, with the relatively clear orientation,
resembling the depressed phase of Manic Depressive insanity; also the
dominance of the self-accusatory delusions. On the physical side the
age period, and the evidence of previous attacks, even though very
slight. The prognosis from the study of the mental symptoms depends
on the presence or absence of signs of defect, or deterioration, as
for example foolish and silly delusions. On the physical side the
presence or absence of conditions like kidney or arterial disease; in
general, it may be said if the physical findings are negative and the
mental symptoms show no deterioration there should be a good outlook,
particularly if the condition has not become too chronic.
A favorable outlook is always possible if the disease is treated
early and the lesions disturbing the activities of the glands and of
nutrition and the circulation are corrected and if the other physical
findings are negative and signs of deterioration absent.
Since this is probably only a sub-group of the Manic Depressive
Psychoses, as has been mentioned above, the results obtained under
osteopathic treatment are noted under the Manic Depressive group.
Remarks by Dr. Hildreth
Our experience with this class of cases invariably lead us to the
nerve centers which regulate and control the process of nutrition and
circulation; it is a matter of keeping up normal equilibrium of all
organic life and especially the circulation to the brain. The basis of
the treatment therefore is to be found in the nutritive centers, as
well as those centers which control the circulation to the brain, the
ductless glands, etc.
Senile Dementia
Senile Dementia may be defined as an abnormal weakening of the mind
arising in old age. As the word dementia implies, the intellectual
change is quantitative rather than qualitative, the prime
characteristic of the disease being mental loss rather than mental
perversion.
It is commonly stated that a most important cause of the disease is the
general malnutrition incident to age. Since only a small proportion of
the aged develop dementia, this is probably only a cooperating factor.
Other causes mentioned are overwork, emotional strain, traumatisms,
intoxications (especially alcoholism), cerebral arteriosclerosis and
perhaps heredity.
=Pathologic Anatomy.=—The disease is organic, the brain exhibiting
definite pathological tissue changes. There is an atrophy of many nerve
cells and a proliferation of neuroglia fibers, so that the cerebrum
becomes shrunken and hard, with thickened meninges and thinned cortex,
and shows a loss of weight. The cerebral arteries may or may not
exhibit sclerosis, thrombosis, or miliary aneurisms, with resultant
areas of softening. The cells show pigmentary degeneration and many of
the association fibers have disappeared.
=Onset.=—The onset of this dementia is usually very gradual, the
condition not being recognized until rather marked. It occurs mainly
in the seventies and later and in the late sixties, being rare before
sixty. It often follows financial reverses, emotional shock, or
various diseases. The earliest symptoms are a change in the person’s
disposition, slight disorders of memory, and trivial lapses of various
sorts.
As the disease progresses the symptoms become more marked and
fundamental, involving not only the intellectual but also the emotional
and volitional phases of consciousness. Interest in the outside world
begins to flag, attention to wander, perception to be incomplete and
inaccurate, association of ideas to be slow, memory to weaken and
judgment to be impaired. Memory of the most recent incidents is the
first to be lost, of recent years next, and then of middle age so that
the patient may not recognize his own children or know, for example,
that his wife is dead; finally the memory even of youth is lost and the
patient is to all intents and purposes a child, his condition being
an exaggeration and aggravation of that commonly known as “second
childhood.”
Several forms of Senile Dementia exist, of which the most common
is probably the simple or non-delusional type. Other forms are
fundamentally the same as the simple, but with certain superimposed
symptoms. Fairly early in this type it becomes unsafe for the patient
to continue in business. Due to impairment of memory and judgment he
is apt to lose his property. Soon his work is poorly done or neglected
entirely. He becomes garrulous and annoys his associates with tiresome
repetitions of childish reminiscences, continually wandering from one
subject to another. His speech becomes incoherent and his sentences
fragmentary. He grows untidy and indifferent to the ordinary niceties
and conventions of life. His appetite is either poor or voracious; in
the latter case the weight may keep up fairly well. He may be either
apathetic or turbulent. If the former, he seems stupid, indifferent,
and sleepy. He is credulous, docile, and very suggestible. Patients
of the turbulent type are restless and always moving about, either
depressed or elated, giving unreasonable orders and then contradicting
them. Sleeping poorly, they are apt to get up and wander about the
house at night. In men, prostatic disease may cause a recrudescence
of sexual feeling. Patients of either type eventually become filthy,
soiling their clothing, etc. Even in well advanced cases, however,
senile dements are often able to perform well certain habitual
activities, such as signing their names, or playing certain games, such
as checkers or dominoes.
=Confusional Type.=—Another form of Senile Dementia, which may in
severe cases usher in the attack, but which usually, when present, is
sequent to the simple form, of which it is a more severe grade, is
the confusional. The additional symptoms of this type are probably
due to defective elimination and the consequent toxicity. Usually
unsystematized delusions, and sometimes hallucinations are present.
Except for a possible occasional period of remission the confusion is
continuous. It varies greatly in degree, now being mild and passive
and again active, perhaps developing into delirium. Orientation as to
both time and place may be lacking. Such patients may ask for dinner a
few minutes after a meal, go to bed at noon, be unable to find their
own room, or to recognize their own children. They are apt to be
obstinate and peevish. Delusions vary in type but both these and the
hallucinations are usually painful and, being referred to the patient’s
associates, give rise to the thought that they are trying to kill or
otherwise harm him.
=Delusional Type.=—A third type of Senile Dementia is the paranoid
form. Dements of this type, owing to delusions of persecution and
auditory hallucinations are sensitive and suspicious. Such cases may
sometimes show good orientation, apparently unclouded minds, and
little evidence of senility, requiring careful study to differentiate
the condition from true paranoia. A patient may, on account of
hallucinations of taste and smell, refuse food in the belief that it
is poisoned. Members of his family who are devotedly caring for him
are suspected of designs on his money, and this suspicious attitude
frequently leads to unjust wills. The delusions and suspicions may
be entirely concealed from the family. Wealthy paranoid elements
are peculiarly apt to become the prey of scheming adventuresses,
particularly in case of the above mentioned sexual recrudescence,
and marry them. Opposition of the family is regarded as part of their
general persecution or as due merely to their desire to get the estate.
Some patients merely appear odd, suspicious, untidy, peevish, and
childish. Some have expansive delusions and exhibit the euphoria so
frequently found in syphilitic dements.
=Senile Delirium.=—A fourth type has been described by some
psychiatrists under the title of senile delirium. This may appear as
the initial form of the disease or as an acute attack in one of the
above forms. It is characterized by great incoherence and restlessness,
entire absence of orientation, and numerous rapidly changing delusions
and hallucinations, the condition resembling delirium tremens. It is
probably due to some somatic cause, such as nephritis, pneumonia, or
cystitis, which is often fatal.
Complications may arise in Senile Dementia, such as apoplectic strokes,
hemiplegia, epileptiform seizures and aphasias.
=Prognosis.=—It is evident from the pathology of the conditions that
the prognosis is not at all good when the disease is well advanced. It
is a chronic disease and usually progressive until death, which is due
to one of the complications, malnutrition, or especially pneumonia.
However, many cases have shown improvement, and in incipient stages
recovery. A cure of advanced cases being impossible, the important
consideration is prevention or arrest in its incipiency.
It is evident that this can be done only by preventing, or removing
as far as possible, the predisposing causes. A glance at the list of
these shows that much depends upon the cooperation of the patient by
regulating his habits of life. Physical and mental overstrain must
be avoided, deleterious habits, such as the use of intoxicants or
narcotics given up. Much can be done by osteopathy to eliminate the
effects of these upon the organism. Cardio-vascular and renal symptoms
are very important and should be watched for in order that early
treatment may check the process initiated. To this end the patient’s
habits and diet must be regulated and treatment instituted to relieve
toxicity and promote elimination. Lesions must be corrected, special
attention being given to the lower dorsal that affect the kidneys, the
upper dorsal that affect blood pressure, and both the upper cervical
and upper dorsal that affect the blood supply and nutrition of the
brain.
=Arteriosclerotic Dementia.=—This is a mental enfeeblement arising
sometimes in the fourth, but chiefly in the fifth, decade of life, and
associated with symptoms of arterial hardening.
The cause is arteriosclerosis, which may be secondary to some form of
nephritis. The arterial hardening may be general or may be confined
to the arteries of the cerebrum. It is likely that the arterioles
supplying the cortical cells are especially involved in an atheromatous
condition. The disease is organic, chronic and progressive. Hemorrhage,
embolism, or thrombosis may occur, producing focal lesions and areas of
softening, with hemiplegia, aphasia, etc.
The earliest symptoms may be headaches and dizziness. The blood
pressure is usually found to be high but not invariably. An
atheromatosis may be present in some one of the palpable peripheral
arteries, such as the radials. Further symptoms on the physical side
are quick fatigue, loss of energy, numbness and paresthesias of the
extremities, and somnolence in the daytime or perhaps insomnia at
night. Strokes may occur, usually slight and temporary, probably due
to spasm in a degenerating artery or perhaps to serous effusion.
Toxic symptoms appear, due to disorder in kidneys, liver, and other
organs. Epileptiform seizures are possible. Mentally the patient shows
impairment of memory, and perhaps some confusion and hallucinations.
Rarely stupor occurs. He may be agitated and irritable or melancholy
and depressed. Suspicious and persecutory ideas of the paranoid type
may appear; also hypochondriacal ideas.
=Osteopathic Theory.=—In these psychoses of the older years of life the
termination is usually dementia, which means mental enfeeblement, and
which results from degenerative changes in the brain substance. As has
been shown it is largely a nutritional question and the nutritional
condition varies tremendously in different elderly people; it is well
known that many old people preserve their brain powers fairly well to
the end; on the other hand others fail relatively early, some even in
the fifties; these cases of earlier failure are referred to as the
“presenile type.” The osteopathic conception would be to find out the
source productive of the nutritional disorder and correct it at the
very outset, therefore making it quite possible to prevent the disease
process from taking place. The prognosis then in the earlier stages is
very good.
Remarks by Dr. Hildreth
While many cooperating factors may be found in the causation of the
mental disorder of elderly people, our experience shows there is
always very definite disturbance of nutrition and the nutritional
centers. We find chief physical interference between the 3d and 8th
dorsal vertebræ, most definite as a rule at the 4th, 5th and 6th, with
the corresponding ribs on the right side. Contributing causes may be
found in other areas, associated with the disturbances of the heart
and circulation and of the kidney. In the cardio circulatory disorders
we find abnormal spinal conditions in the upper dorsal region and
especially the 5th rib on the left side. In the kidney disorders we
find the lesions usually at the 10th, 11th and 12th dorsal. The above
mentioned areas in general represent the centers of control of the
splanchnic nerves and therefore the important processes of digestion,
metabolism and assimilation. Specific treatment applied to these
points is very helpful and results in marked improvement and indeed in
relieving the patient’s symptoms completely when in the earlier stages
of the disease.
DEFECTIVE CHILDREN
By RAYMOND W. BAILEY
It is our purpose here to impress on osteopaths the almost unlimited
possibilities in the study and treatment of mental conditions of
children, which heretofore have been considered hopeless. Osteopathy
has demonstrated that it has much to offer to this class of
defectives but the profession has not thoroughly appreciated its
great possibilities. It has been the custom to send these children
to institutions where they have received care with some attempt
toward education but with absolutely no effort being made through
physical treatment to overcome their debility. We shall show that the
osteopathic lesion is of prime importance in these cases, and that we
have been slow to realize the efficacy of osteopathic treatment for
such seemingly hopeless children. We cannot emphasize too strongly the
importance of accepting and treating these cases wherever possible.
The mental diseases are considered under two general heads: (1)
Inherited, and (2) Acquired Tendencies.
=1. Inherited Tendencies.=—In this class are those cases arising from
poor endowment of the protoplasmic structure through lowered vitality
of the parents or other progenitors. These taints may come from either
parent, or both, and may exist in the offspring from some preceding
generation. Such diseases are constitutional and are amenable to
supporting treatment in direct proportion to the amount of endowed
energy inherent in any given organism.
Of the inherited tendencies, we have two kinds:
=1. Congenital Diseases.= (a) From any influence of an inherited nature
not directly acting on the environment of the parent while the fetus is
in utero, and
(b) From any influence which directly affects the development of the
ovum through imperfect fertilization coming through either parent or
both.
=2. General Impairment.=—This condition exists (a) Where a similar
defect has existed in foregoing generations and is strictly hereditary;
(b) Where general vitality is diminished from such causes as
neuropathic parents, or where there have existed constitutional
defects, such as tuberculosis, syphilis, epilepsy, alcoholism, abuse,
overwork, strain, acute inflammatory diseases, and poor health of the
mother during gestation; also consanguinity.
(c) Premature birth tends to impairment physically and mentally
of growth of organism and frequently leaves its manifestations of
marasmus, rachitis and other nutritional disturbances.
(d) Prolonged labor may leave its mark on the child where more or less
asphyxia has occurred resulting in obstruction to cerebral circulation.
Causes acting after birth to the already impaired germ cell and
resulting in many of the afflictions of early life, both mentally and
physically, are
1. Traumatism.
2. Convulsions.
3. Rachitis.
4. Infectious fevers.
5. Meningitis.
All of these seriously affect the metabolism within the newly-born, a
process which is begun, doubtless with difficulty, and susceptible to
easy derangement, and the same effect magnified with growth into its
subsequent mental and physical deformity.
=2. The Acquired Tendency.=—In this the second great class are those
conditions arising subsequent to conception where germ plasm is healthy
but growth is arrested by some external factor either intra- or
extra-uterine. Thus the acquired tendency may be given to the fetus in
utero and not be considered congenital as in case of injury affecting
health and growth of otherwise healthy conception. In short, the
acquired has its beginning at conception or subsequent to it while the
congenital is previous to conception or already inherent in the germ
plasm leading to conception.
Any influence which retards the
1. Inherent capacity of cell for growth or,
2. Adequate blood supply either in quantity or quality results in
enfeebled offspring and these causes are enhanced by
(a) Traumatism or Injury
(b) Drink or Abuse
(c) Dirt or Unhygienic surroundings
(d) Depravity or Ignorance
Factors entering into acquired tendencies affecting offspring direct
are divided into three classes, those:
I. Before Birth such as
(a) Abnormal condition of mother’s health during pregnancy as in
disease of any nature, mental or physical or
(b) Injury to fetus direct by blow, fall of parent, or instrument.
II. During Birth from:
(a) Abnormal labor from any cause.
(b) Primogeniture.
(c) Premature birth.
III. After Birth.
(a) Traumatism.
(b) Toxic causes such as scarlet fever, whooping cough, meningitis,
measles, mumps and exanthemata.
(c) Convulsions.
(d) Nutritional disturbances.
Consanguinity or intermarrying of blood relations, or in-breeding
results in:
1. Instability of the nervous system.
2. Intensifying of constitutional defects.
3. Decrease in size of offspring.
4. Predisposition to disease through lowered vitality.
5. Impairment of reproductive function.
Immediate consanguinous offspring may manifest a high degree of
intellectual or physical attainment but successive processes tend to
neurotic types and are prone to physical weaknesses and insanity. This
practice is found among Quakers and Jewish peoples, inhabitants of the
Islands north of Scotland, in isolated rural localities, and among
African tribes.
Mental Deficiency in Children
=Synonyms.=—Amentia; feeble-mindedness.
There are three grades of amentia:
=1. Morons:= those whose mental age corresponds closely to their
chronological age or is nearly normal.
=2. Imbeciles:= those in whom there is a wide disparity between the
mental age and the chronological age.
=3. Idiots:= the lowest form of arrested mentality or those whom it is
impossible to teach.
=Definition.=—Mental deficiency is a pathological stage in which the
mind has failed to attain normal development.
=Various degrees of intelligence= or mental capacity in man lie between:
(=1=) =Genius= such as Bacon, Newton, Plato, Galileo, Shakespeare.
(=2=) =Lesser Ability= but still conspicuous in development such as our
great leaders in science, literature, reform and the arts and medicine,
furthering, each their respective causes. These merge easily into
(=3=) =Average= mass of mankind.
(=4=) =Dullards= or those of inferior intelligence.
(=5=) =Feeble minded=, merging imperceptibly into
(=6=) =Imbeciles= and by insensible gradation into
(=7=) =Idiots= and gross idiots.
The mentally defective is wholly incapable at maturity of adapting
himself to his environment or local conditions in order to maintain
existence independent of any external support.
=Dementia= is a disease of the mind or that which was once possessed,
and by some neuronic disturbance is lost totally or partially.
=Insanity= is a disturbance of neuronic function which may or may not
end in degeneration of brain tissue.
=Physiology.=—The normal brain begins its development shortly after
fertilization of the germ cell, by the expansion of the anterior end of
the rudimentary spinal cord into four primary cerebral vesicles. These
develop into a series of elaborate infoldings, each with multiple cells
around them. At or about the sixth month of fetal life this embryonic
brain assumes the shape of the adult brain, minus the secondary
fissures and convolutions which are characteristic of full development.
At birth there are sometimes many convolutions and the brain weighs
from 280 to 330 grams. Growth is then rapid and at six months it weighs
from 560 to 680 grams;
At one year, 750 grams. It continues to increase until
At 12 to 14 years it weighs 1150 grams in the female, and 1300 in the
male;
At 20 to 21 years the weight is 1244 grams in the female and 1374 in
the male.
Growth is slow from this time until at 25 to 35 years the average
weight of the brain is 1269 grams (45 oz.) in the female, 1421 grams
(50 oz.) in the male.
This growth of the brain is due, first to the rapid multiplication of
nerve cells and, secondly, to the individual enlargement of each nerve
cell. These cells arise from the floor of the four primary vesicles
and are each similar to its fellow. They finally show differences in
feature and become characteristic in size and shape which process
continues throughout life. This process of differentiation of nerve
cells results in the peculiar laminated appearance of the brain cortex.
At the period of lamination, the nerve cells throw out delicate
processes which pursue definite directions throughout the brain mass
constituting a system of association fibers which link together in a
most complicated manner all parts of the brain, and are called the
association fibers of Flechsig. Projections from these cells form the
various pathways by which the brain is connected to the various parts
of the body.
Nerve cells in the different parts of the brain mature at different
periods, those areas which have to do with the highest intellectual
functions, viz., the frontal and parietal regions, maturing last.
At the seventh month of intrauterine life the brain cell is a small
round type of neuroblast, undifferentiated, lying in a matrix. The
cells increase in size until about the second week (extra-uterine)
of life, tiny processes begin to develop. At the third to fifth year
these cells are mature and possess axons, dendrons and geminules. These
communicate, forming the above named association system conveying
impulses to and from all parts of the cerebrospinal system. They
multiply and elaborate after puberty into a complicated system up into
middle life after which growth ceases and they slowly diminish.
=Greatest Growth= is between the first appearance of the primitive
brain and the end of the sixth month of life (extra-uterine), hence
it is during this period that any adverse conditions relative to
development of nerve cells may cause the greatest damage.
=Mind and Brain.=—Whatever may be the connection between these two,
we know that the former develops with the growth of brain cells and
fails with their decay. =Amentia= is associated with the incomplete
development of brain cells and =Dementia= is coincident with their
degeneration and death.
=Pathology=—=Brain.=—Structural abnormality of the brain tissue may
exist without variation of mentality or defect. Early observers gave
these gross defects as a cause for amentia. However, it has been
demonstrated beyond doubt by microscopic examination of cerebral
neurosis that cellular changes occur and that imperfect and arrested
development exists and is an essential basis of amentia.
=Histology=—=Blood Cells.=—Cortical blood cells in the ament are
1. Numerically fewer.
2. Irregular in arrangement.
3. Imperfectly developed.
4. Microscope reveals changes proportionate to the deficiency during
life.
=Blood-vessels in Amentia= show no marked changes from those of the
normal brain. Hyaline degeneration may be present; also pigmentation.
These conditions are not constant in amentia hence cannot be considered
causal.
=Neuroglia in Amentia.=—Sclerosis and hypertrophy occur in a large
proportion of cases. This is diffuse throughout the brain, with here
and there certain circumscribed areas forming nodules.
=Nerve Fibres of Cortex in Amentia.=—Association system fibres are
always diminished in number and not so complicated.
=Clinical Varieties of Amentia.=—There are two varieties of amentia and
conventionally for sake of study we must arrange them into those from
(1) Congenital causes and (2) acquired causes.
Among those which arise from congenital causes we have the
microcephalous and Mongolian types. In both cases there exist
constitutional taints through successive or immediately forgoing
generations of such diseases as syphilis, tuberculosis, epilepsy, and
acute alcoholism affecting proper collaboration of germ cells previous
to fertilization and hence impaired germinal endowment through a
weakened nervous system.
Those arising from acquired causes are from injury to mother or fetus.
=Macrocephalus.=—A person whose skull measures less than seventeen
inches in its greatest circumference. This class comprises less than
10% of all aments.
=Cause.=—The type is neither a freak reversion of the species to a
lower grade of development nor accidental, but due to an inherited
blight on the nervous system arising from constitutional disease,
alcoholic and sexual excesses, consanguinous unions and too numerous
latter-life pregnancies in undermined health states. They come entirely
from neuropathic stock and their brothers and sisters are degenerates.
Many dwarfs exhibit this type.
=Characteristics of Microcephaly.=—(1) Circumference of skull
diminished; (2) Brain smaller; (3) Stature small (5 feet); (4) Rarely
live to advanced age; (5) Die of tuberculosis; (6) Mostly imbeciles and
idiots (few morons).
They have their sensory impressions intact and are generally vivacious
and muscularly active, even restless. They have good sight and hearing
and are highly initiative but have not the ability to any sustained
effort. They are actively observant and the majority are affectionate
and well behaved. Some are unsteady in walking, others are helpless,
and about one-half are subject to epileptic fits.
=Mongolian Amentia= (Mongolism).—This type (Kalunk or Tartar variety)
received its name from Dr. J. Langdon Down from their facial
resemblance to members of the Mongolian race. They number about 5%
of all aments including the semi-mongols who have only a few of the
characteristics of this type.
=Cause.=—Eleven out of twenty-five are from syphilitic origin.
Glandular or nutritional defects are suggested as a cause. They will
show negative Wassermann test and positive tuberculin tests. Uterine
exhaustion and ill health of mother during gestation are factors
suspected of entering into this condition. The latter-born of large
families are frequently affected.
=Pathology of Mongolian Idiocy.=—The brain of the Mongolian ament is
considerably under-sized and has less convolutions and is more shallow.
The pons, medulla, and cerebellum are about half the size of ordinary
feeble minded types. The cells by microscopic examination show an
immature condition. This lack of brain development results in deficient
expansion of base of skull, hence the characteristic physiognomy. There
is no glandular abnormality.
=Description of the Mongol Type.=—This type is distinguished by
characteristics of skull, eyes and tongue and is usually observed at
birth.
1. The skull (Brachycephalous) is rounded and diminished in size
particularly through the antero-posterior diameter. The face is
flattened, there being no recession of frontal and supra-occipital
regions.
=Eyes.=—The palpebral fissures are narrow and slope obliquely downward
and inward. Lids inflamed.
=Tongue= protrudes, is large and marked by large papillæ and scored by
transverse fissures due probably to tongue sucking, predisposing to
inflammation of the mucous membranes.
=Ears= are small and round and have poorly developed and irregular
lobules.
=Nose= is short and flat and has triangular nostrils.
=Teeth= are soft and ill formed and tend to decay.
=Hair= is usually scanty and wiry and very dry.
=Cheeks= are flushed. Palate is high and narrow and mouth is open, and
lips are cracked. Adenoids exist in all cases.
=Hands and Feet= are broad and clumsy. Flat foot and knock-knees are
common. Skin is rough, coarse and dry.
=Abdomen= is large and mushy. Umbilical hernia often present.
=Circulation= is rarely good, causing blueness and coldness of
extremities, with sores and chilblains. Heart lesions are frequent.
Lesions of a chronic inflammatory nature in respiratory and digestive
tracts exist. Nasal and bronchial catarrh and diarrhea are common.
Mongols die early (about 14 years) usually of phthisis.
Available statistics show the various types and variations of these
conditions in great detail; however, the above will enable the reader
to classify and properly diagnose in given cases. It is not the
writer’s intention to portray here what is easily a treatise by itself.
=Osteopathic Consideration of Amentia.=—During a period of five years,
observation of the various types has led me to believe that much can
be done to correct circulation to cerebral structure with consequent
development of brain tissue and function, where discoverable trauma
exists. From all available sources there is traumatic interference
in from 15 to 45% of these cases, according to different authors.
Where history involves constitutional findings (syphilis, tubercular,
glandular and chronic alcoholism) I have treated them with the intent
of relieving only until the next phase of the condition would appear.
Where trauma alone exists and the family history is good, I know the
case is in the field of osteopathy alone, and can be developed to a
degree limited only by the intelligent care of those having the case
in charge. Especial attention should be given to discipline, housing,
sanitation, personal hygiene and general environment.
=Lesions.=—Atlas, generally rotated. Rarely posterior but frequently
resting beneath a posterior occiput. Lateral mass on the posteriorly
resting portion of misplaced atlas will become interlocked with
transverse process of axis in a few instances, combining the amentia
with a progressive inflammatory tendency to the middle ear which by
successive abscesses ultimately destroys structure and function;
possibly traumatic epilepsy, and surely catarrhal inflammations in all
mucous membranes of the head.
Many bony and ligamentous irregularities exist in the various types of
mental defective where the cause is inherited weakness, nutritional
diseases or kindred sources. Spinal luxations exist singly and in
series, causing various palsies, spastic muscles, and deformity.
Postural defects, particularly of ribs and costal cartilages cause
functional disturbance throughout the thorax and abdomen.
=Treatment.=—Invariably the care of aments entails wisdom of procedure.
Reconstruction is the prime object in every instance, hence time
and number of treatments must not be considered. Treat to =correct
structure; teach= as far as possible; =train= always.
Deft and intelligently applied technique are certainly required in the
correction of these cervical lesions. Treatment should be given thrice
weekly (never less than twice for progress) with definitely established
mental tests before, to discern the mental level, and at succeeding
periods of three months each, noting progress, if any. The Binet-Simon
scale or some other available mental test should always be made and
record carefully kept of each case for your own benefit as well as
the patient’s. After six months, if no appreciable gain is shown
treatment is discontinued and the case must be cared for in another
manner as beyond your special field of effort. Usually it is apparent
by the end of the third month if anything can be done to improve the
mentality. The physical advantages, in some cases warrant continued
treatment where there is no appreciable mental gain. Institutional care
of these types is the only practical means of handling them properly
from an osteopathic standpoint, as it requires some one properly
equipped to make your tests and keep your record;—it is sufficient
for the doctor to do the work demanded. They can thus be classified
and progress systematically shown. The higher grades must be taught
and though self dependence may never be attained they can in many
cases by training be capable of useful pursuits and quite frequently
remunerative work. It makes for happiness at least to keep them busy
and forestalls the mischief that would otherwise result. Even imbeciles
can help in routine work of an institution or home, and idiots may,
by training, gain some power of self help and cleanliness. Training
depends on the individual capacity for such in each case—his habits,
and general character of his propensities. Prevention of their marriage
should be positive and for prevention of their propagation this and
their sterilization by operation are the only two measures at hand.
Sterilization, however, is repugnant to some elements of society and
could be abused, hence the segregation of aments would appear to be
our only solution at present. The ultimate intention of treating any
case is to use any measure tending to stabilize the nervous system.
Corrective effort alone is not sufficient but these osteopathic
endeavors in conjunction with proper discipline, good food, regular
rest and personal hygiene both mental and physical and a scrutinizing
restriction tending to any kind of excess is rendering the osteopathic
procedure in such cases rapidly indispensable for the treatment of
amentia.
POST-OPERATIVE TREATMENT
By GEORGE A. STILL
At the convention of the American Osteopathic Association held in
Boston in 1918, I gave a short talk on the above subject, and during
the day after I had given the lecture, two women and one man, graduate
osteopaths, asked me if I really meant to convey the impression that we
actually gave osteopathic treatments to recent surgical cases. I do not
know whether I convinced them or not, but I do know that they convinced
me that there are people practicing osteopathy who have absolutely no
concept of its merits and underlying principles.
To my surprise I have found that a great many osteopaths who consider
themselves absolutely “pure” are just a bit startled at the thought
of handling post-operative complications by treatment. These are
invariably fellows who have had most of their experience in office
work, and who do not come in contact with acute cases. Still it is
difficult to conceive how a man can believe that osteopathy is specific
for certain diseased conditions and not for others. As a matter of fact
osteopathic treatment has not proved itself more satisfactory in any
field of therapeutics than it has in post-operative conditions.
The common post-operative conditions are pneumonia, pleurisy, backache
and headache, nephritis, vomiting, neuritis, phlebitis.
Taking up these subjects and discussing the least serious first we
would of necessity discuss pneumonia last, as it is the most serious,
and is less influenced by other conditions. It will also serve to
illustrate many of the details in treatment.
We will therefore briefly take up the other conditions and then discuss
pneumonia more fully.
Vomiting
We believe there is no question that a good part of the prevention of
anesthetic vomiting is in the preparation of the patient, including
a good cleaning out of the bowels without debilitating cathartics.
In other words, the vomiting is increased if the alimentary tract is
loaded, or if on the other hand it has been irritated to the extent of
losing its tone. Combining a careful preparation with a straight ether
anesthesia and osteopathic treatment to the neck and splanchnics we
have been able to eliminate any serious post-operative nausea. I do
not recall a case in the last few years that vomited on the following
day unless the condition for which they were operated was one that
essentially in itself would cause vomiting; for instance if the patient
had peritonitis and had been vomiting due to the toxic ileus. They
might even vomit after the abdomen had been opened. This could hardly
be called “post-operative” vomiting.
The improvement in our records in post-operative vomiting is in
proportion to our increased faith and use of the osteopathic treatment.
Time and again patients have told us that they had taken anesthetics
before and were sick from three to five days and even a week.
Invariably we have been able to surprise these patients by the fact
that they were sick less than a day.
The usual treatment with bismuth sub-nitrate, cerium oxylate, sour
wine and the other usual remedies were not used in any case or in any
amount. No drugs whatever were employed.
Backache and Headache
There is practically no difference in the post-operative headache
and the office headache. There is of course the usual multiplicity
of causes, and as a matter of fact in this condition treatment
can more nearly approach the ordinary office treatment, and the
results are about the same. As for backache, we find that speed of
operating and not keeping the patient under the ether too long has
a marked influence. Also we have a four inch Seely mattress on the
operating table which helps some. Treatment does the rest and does it
effectively. For this complication even the ordinary nurse knows enough
to give a treatment of some sort.
Neuritis
Nine times out of ten the post-operative neuritis is really a local
osseous lesion, a slipped innominate, rib, vertebra, clavicle, biceps
tendon or something of the sort, and responds quickly to a specific
treatment.
Phlebitis
This complication usually comes on quite late after an operation and
at first it is sometimes hard to differentiate it from a neuritis.
Absolute rest of the involved part with lower spinal treatment gives
relief, but under no circumstances should the affected part be freely
moved while there is active inflammation. The reason for treatment of
the lower spinal area is that practically always one of the saphenous
veins is involved.
Nephritis
This complication is to a very big extent eliminated by a careful
urinalysis prior to the operation, and careful preliminary treatment in
indicated cases, and in other cases the postponement or if necessary
complete elimination of the operation where it is not a case of life
and death. Where the condition does appear we have found it the hardest
of the post-operative complications to control. Indeed it is the only
one that we have not found very easy to manage.
We do not vary the treatment for a post-operative nephritis from what
we would use in any ordinary case of nephritis. We have observed
treatment of this condition in many cases under medical management, and
while we are satisfied with the osteopathic treatment comparatively
we are not yet satisfied that we have it developed to its greatest
efficiency.
Pleurisy
This condition in nearly every instance can be corrected with one
or two treatments of a twisted rib unless it is the pleurisy of a
beginning pneumonia. As far as the pain is concerned the simpler type
hurts as much as the one that is going to develop a real complication.
For this reason relief obtained by a single treatment often seems
little short of miraculous to the patient.
Pneumonia
When I took charge of the surgical work at Kirksville, osteopathy
was not used in post-surgical treatment. Post-operative vomiting was
treated medically, as were other post-operative conditions, including
pneumonia. Cases of a real major surgical nature rarely got an
osteopathic treatment.
The idea seemed to be that osteopathic post-operative treatment had to
be along the same lines as it would be for such an illness as lumbago,
brachial neuritis, or ordinary pneumonia, and other non-surgical
conditions where the patient could be placed for giving a treatment in
a position that was not permissible following an operation, as it would
work great harm to the wound.
It seemed to me that if osteopathy was effective in a case of ordinary
non-surgical pneumonia, it should certainly be good for a case of
pneumonia that was post-operative and that all we had to do to handle
the condition was to apply a new technique of treatment that could be
used on a patient who had a surgical wound. All we had to do was to so
manipulate the spine that we would get the results locally, and yet
handle it in such a manner as not to affect the wound.
Many laymen, and even some physicians of our own school, express
surprise at the suggestion that we do much osteopathic work in the
after care of surgical patients. But the fact is we have worked it out
so that now, except for pain, during the immediate after effects of
the operation drugs are absolutely not used in our hospital for any of
the post-operative complications. The opiate immediately following the
operation, is really a follow up of the anesthetic, and we use that as
rarely as possible. Needless to say, there are cases such as un-united
fractures, extensive adhesions, etc., where the emergency conditions
positively call for some relief of the pain for a short while, but that
is the only condition that we cannot control with mechanical treatment.
I am very glad that I had the confidence to give this an early trial
and a thorough trial, without being afraid to leave off the drugs.
The big field, however, where osteopathic treatment has won the most
impressive success and proved itself a most absolute specific, is in
the field of post-operative pneumonia with which I am proud to announce
a one hundred per cent. success for combined osteopathic treatment in
my fourteen years continuous surgical work. Not to have lost a single
case is partly due to luck. In other words, with any series of serious
cases, it is impossible but that there be some fatality finally.
Post-operative cases have one advantage along with their disadvantage.
While they have the shock of the operation to contend with, and the
weakened condition from the disease for which they were operated, still
except in extreme emergency they would not have been operated on unless
they had a good heart and good kidneys and a good blood pressure, so
that in cases in which we are most concerned in combatting pneumonia,
we usually start with a patient who has those organs in a healthy
condition.
=First Post-operative Pneumonia Cases Treated Osteopathically.=—At
the Chicago Convention in 1911, I reported the first post-operative
pneumonia cases that had been treated osteopathically. I believe at
that time that there had been only three cases. At that meeting I
mentioned the fact that some of the doctors and some of the internes
who treated those cases felt sure that they were not treating them
properly because they could not get away from the idea that pneumonia
needed strychnin and other drugs. One of these cases got well in three
days from the developed lobar pneumonia symptoms. The results were so
miraculous that the young man treating it began to doubt whether it
could have been pneumonia. He could not understand how he, a senior
student, could overcome this dreaded disease by merely working on the
spine. He could not believe that osteopathy, a science that he had been
able to learn himself, so easily could cure a condition that he had
thought must be almost necessarily fatal.
One of the weaknesses of osteopathy is the fact that there is no
mysticism about it. It is so simple that any person with ordinary
intelligence can learn to use it, and yet it is so simple that it takes
an unusual intelligence to be able to grasp the fact that it is the
therapeutic discovery of the age. Many, many times I have had young
internes and students cure genuine lobar pneumonia and do it with such
obvious ease that it caused them to wonder, in a way, if it really
could be pneumonia. It is bred in our very tissues to look for some
mysticism, something impossible to understand, something supernatural,
something connected with the Unknown associated with the treatment of
disease and accordingly it is just human nature to find it difficult
to believe, even when we see it, that a simple method of treatment can
actually effect a cure.
Real pneumonia, as we understand it, is a consolidation of the lung
tissues characterized by fibrosanguinous exudate into the pulmonary
tissues and spaces, associated with one or more particular germs as
exciting factors and proved by the physical tests and the character
of the expectoration. How many cases have been cured that had not
entered consolidation I do not know because up until the time of actual
consolidation there may be a question as to whether or not they would
have had pneumonia. I know that many cases with marked symptoms of
pneumonia have failed to develop under treatment or the case has been
aborted.
Pneumonia lacks a great deal of being a self limited disease. The
number of cases with beginning symptoms that fail to develop is too
great to be ascribed to coincidence. Of course I know that some of
these might have been only pleuritis, some only neuritis, etc. However,
in giving the statistics of pneumonia cures we will give only those in
which pneumonia developed and showed a hardening or consolidation of
the lung tissue. In these cases there can be no argument as to whether
there was pneumonia.
When we have an acute condition associated with the symptoms of
consolidation, we can hardly be confused as to the diagnosis. We may
make a mistake in our physical findings, but hardly after a little
experience, and certainly when we are sure of the physical findings
there will be no trouble in naming the disease.
=The Clinical Findings.=—Post-operative pneumonia is a little
different from the common pneumonia. It always comes on a little more
insidiously. One has to watch for post-operative pneumonia more closely
than he would for the attack that we may meet in ordinary practice.
A patient may have considerable pain from his wound, may have some
pain in the back from the position he is in; there may be headache,
and an upset feeling from ether; and the pain comes in the chest. All
these symptoms are forerunners of pneumonia, but the pain in the chest
is not noticed until it gets quite severe. In other words, there are
other things to annoy the patient as well as the attendant, and at
first, this condition does not cause complaint. A strong and healthy
individual who feels a pain in his pleura, which is the forerunner of
pneumonia, knows it at once, because that is the only distress he has.
His entire attention is attracted and he asks for a physician’s help.
But in the post-operative case, the physician has to keep a look out
in order to prevent a case from getting well under way before it is
recognized.
As an example of this I had a case of a man who was with a party
driving an automobile and they tried to cross the railroad track in
front of a train. This patient I speak of was one of the survivors. He
had a fracture of the femur, fracture of the skull, fracture of three
ribs, and otherwise more or less bruised up. Naturally the preliminary
work consisted in getting the ribs and legs attended to as well as
possible and looking out for cerebral hemorrhage or meningitis.
This patient developed consolidation in both lungs in spite of regular
treatment, and it precipitated on him very rapidly, partly masked by
the disturbed breathing from other sources of irritation. We put him on
hourly treatment, but after a few hours his condition from the injuries
and the pneumonia was such that his wife asked us not to treat him any
more. She put it this way, that she knew he would die in spite of all
that could be done and as long as he was going to die he might as well
die easy. Every time he was treated it had the effect of bringing him
out of his stupor, and he would complain, and she thought it would be a
kind act to let him slide off into the next world uncomplaining.
Pneumonia in a case of this sort cannot be handled with kid gloves if
we wish to save the patient. We must give firm, strong treatment. Light
treatment in this condition will do no good. Indeed light treatments in
any sort of pneumonia are of little avail. Many times I have changed
internes in a pneumonic case that was not responding and the results
were immediate. That is, the turn for the better was obvious from the
beginning of the good strong treatment.
The case above mentioned was treated a good part of each hour for
twelve hours. He had no strychnin, no oxygen, nothing but treatments,
but he got well and is now living, and aside from a limp has no
evidence of either his injury or his illness.
Some cases, in private practice, may get well on a treatment a day, but
I would hate to handle the kind of cases we get in that manner. I have
had severe cases, especially hemorrhagic cases, where the treatment was
almost continuous for hours preceding the crisis. Of course, after the
crisis we can ease up. On the other hand, it is not infrequent that
a few good strong early treatments, given at the beginning of a case
absolutely stop it. I have seen cases where a consolidation area of the
apex of the lower right lobe as large as the palm was easily outlined,
and this together with the clinical symptoms would be cleared up in two
or three days.
There is no possible medical method by which this can be done. Medical
authorities agree that under their treatment pneumonia runs an
unshortened course; in other words, a course in the individual case
that has not been affected by the medication. Medically, even where
the crisis occurs early, the consolidation persists for some time, but
I have seen it cleared up time and again under osteopathic treatment
in the length of time that could have been brought about only by
osteopathic treatment.
I have previously called attention to the fact that many of the medical
text books on physical diagnosis mention a point that is a very
practical and very plain demonstration of the efficiency of osteopathy
in pulmonary conditions. These books only mention this fact without
pointing any moral or drawing any conclusions. The point is this:
that frequently when a professor is having a class or a section of a
class examining a case of pneumonia, they will outline the size of the
consolidation at the beginning, the instructor marking it off when he
makes the first examination; then after the students have examined it,
by percussion, palpation, etc., possibly a dozen or twenty of them,
the later students will find that the area has shrunken perhaps an
inch. This fact has been frequently noted. It is said, indeed, that if
careful examination is made it will always be noted.
How Manipulative Treatment Benefits
Doubtless this proved that accidental manipulations of the ribs helps
clear up the congestion about the real consolidation and reduces some
of the dull area. Very likely this explains some of the cases of
partial or real results from spondylotherapy. Naturally, scientific
osteopathic treatment would necessarily magnify such results very much.
It is a great wonder with the obvious failure of medical treatment in
pneumonia, that at least some crude from of manipulative treatment has
not been devised by those practitioners. We have already mentioned that
the treatment of post-operative cases varies mainly in the manner of
applying it. In other words, when we raise the ribs we keep the patient
on his back, in treating the spinal centers we treat with patient on
his back, and the physician who has no grip in his hands will not be
able to treat a post-operative pneumonia to any advantage.
In these cases one has to get at the patient’s back by reaching under
and the weight of the patient helps to give the treatment, but a strong
grip is necessary. It is much safer for the wound to handle the patient
in this way but not infrequently beginners wear their knuckles pretty
nearly off before they get the finer technique; after which it is easy.
In raising the ribs there is no more difficulty in treating in this
position than there is with a patient who can sit up or turn from side
to side and in some cases a patient can, of course, be partially turned.
Theory is all right but in these cases practice has been added to it
in something over three hundred cases treated in this manner, and in
this manner only. I have had no case die. None of my cases had oxygen
and none of them had strychnin or alcohol unless it was a person who
had used alcohol constantly or daily and in these cases I consider that
the system has become sufficiently used to it that it is practically
a food and that sudden withdrawal is apt to bring on delirium. It is
not necessary in those cases that indulge deeply now and then, but it
is advisable in those that take a small amount regularly, just as they
take food. These patients are used to a constant heart stimulant and
its withdrawal is also apt to be reflected in the heart action. These
are the only cases in which I have ever authorized anything in the way
of a chemical stimulant of the heart during pneumonia.
You will undoubtedly recall that in reading the newspaper accounts of
men who are big enough and prominent enough to have bulletins in the
newspapers when they are dying, that almost universally the next to the
last bulletin was that oxygen is being administered. The last bulletin
announces the time of death. You will also note that in case the
patient lives that oxygen then is not mentioned, and a few days later
the patient is all right. My observation is that the use of oxygen
may attract the attention of the family, it may attract the attention
of the patient, but as for any actual benefit on the patient I do not
believe it is in the least helpful, and that the only treatment for
pneumonia is osteopathic. I am so convinced of it that I am using only
that method.
As to strychnin, some say strychnin must be given. Some say it must be
given at the crisis, and others say it must be given from the inception
of the disease. I do not believe the majority of cases will do as well
under strychnin. I know they will not do as well under strychnin as
under osteopathic treatment. I will not say they will not do as well as
if under no treatment. It is possible that there would be an occasion
for its use at the crisis, and I have seen such cases, and I have used
it while studying medicine. I used it at the crisis, and I used it in
cases where I am convinced that it helped them over the crisis, but I
am also convinced now that by osteopathic treatment they would have
done still better and the crisis would not have been so acute. In other
words what strychnin does in favorable cases, osteopathic treatment
does better in all cases.
In our post-operative cases study the charts and you will see that
they do not have the acutely violent crisis that usually occurs under
other treatment. They are under better control and if we can get them
near the beginning, as we usually do, we can keep up the resistance so
that where they would otherwise have a hard crisis they have an easy
one. Instead of having a temperature of 105, pulse 165, respiration
70, or such a condition, they are more apt to run a temperature of
102, pulse 120, respiration 35 or 40 and they go through it without
that suddenness and acuteness that is common under other methods of
treatment.
In several instances, as an example of showing how this resistance is
kept up, I had letters from boys in the camps. One letter told of a
wide epidemic of severe tonsillitis. In one group of soldiers there
were three osteopaths who treated all the men and this was the only
group that was not sent to quarantine. This group developed sore throat
and was treated osteopathically and the sore throats checked so that
quarantine was unnecessary.
Among the detailed reports in the A. M. A. Journal there will be
nothing about this, nor about many other instances where osteopathic
treatment, given by men forced to remain in the ranks, has done
things that medicine cannot do. These examples are too frequent to be
coincidents. If I had had three cases of post-operative pneumonia and
they had all got well, it would not be surprising. If I had ten cases
and they all got well, there are medical hospitals that have been this
lucky. But there are no medical hospitals in the world that can report
one hundred cases or two hundred cases or three hundred with developed
pneumonia and all lived. The percentage of pneumonia cases that die
now in medical hospitals, is much less than formerly. But the cause of
this is not vaccine, antitoxin or drugs. It is due to the fact that
pneumonia cases now, like typhoid, are given very little medicine and
are turned over to general nursing treatment; that is, in the best
medical hospitals.
The mortality is in inverse ratio to the drugs given. The advance
medical teaching is against so much drugs in pneumonia, though of
course the hick doctors use it because they are practicing medicine of
the by-gone age, before Andrew Taylor Still forced on the world the
idea partly started by homeopathy, that the less drugs the better.
Homeopathy failed in not quite discarding drugs and in not having a
substitute that reproved drugs.
As a matter of interest I wish to mention that while in medical college
I had the advantage of being taught surgery by the greatest surgeon
that ever lived, John B. Murphy. I only wish that circumstances could
have permitted me to have shown him what osteopathy could do in
post-operative conditions, because Murphy was a broad minded man and
no man living ever thought less of orthodox medicine and old fashioned
drug treatment than Murphy.
He and the Old Doctor would have been great friends had they ever met.
Murphy, whom I considered a most wonderful surgeon, and whose skill I
never hope to approach, stated to me many times while a student that he
lost more cases from post-operative pneumonia than any other condition
and that in upper abdominal conditions like gall bladder, stomach, and
similar operations, post-operative pneumonia constituted the most of
his mortality.
This great man was afraid of post-operative pneumonia, while I, a much
less skilled surgeon, am no more afraid of post-operative pneumonia
than I am of something occurring in a distant state because with
osteopathic treatment, we have eliminated post-operative pneumonia as a
fatal condition.
PART SECOND
INFECTIOUS DISEASES
Fever
=Fever= is due to various causes, so that a definite statement cannot
always be given as to the cause of fever in every disease. Each fever
case, like all other disorders, is a law unto itself; different causes
are found in different cases. Moreover, often only theories, and not
absolute facts, can be given.
Fever may be present when a local disease assumes a constitutional
character or when the constitutional character is manifested from
the beginning of the disease. Fever may be a systemic disorder or
a symptom of disease, and is characterized by an increase of body
temperature. Other symptoms are usually present, as an accelerated
pulse, disturbances of distribution of the blood, increased catabolism,
and disordered secretions.
=Etiology.=—In infectious diseases fever is due chiefly to the action
of various toxic or harmful agents, produced by the disease, upon the
fluids of the body and upon the nervous system. Disturbances of the
thermogenic centers and nerves of the brain or cord by harmful agents,
or by lesions of the anatomical structures affecting these nerves, are
sources of fever. Also disturbances of the vasomotor centers (in the
medulla and auxiliary centers along the cord) and nerves are causes
of fever in many instances. A disturbed or lessened function of the
nerves controlling sweating is an important factor. The multiplication
of micro-organisms in the body, acting directly on the tissues or
by producing toxic substances which affect the nervous system, is a
fruitful source of fever. A few cases may be caused by direct affection
of the nervous system, as is shown by appearance of fever in epileptic
attacks, or by the passage of a catheter into the bladder. In a large
number of all cases a demonstrable cause can be found upon careful
examination, whether the fever be due to a necrosed mass of tissue, the
introduction into the system of decomposed food, infectious diseases, a
lesion of some anatomical structure affecting a thermogenic, vasomotor
or sweat center, a lesion to the innervation to the heart (vagi and
cervical sympathetic) causing a rapid heart, or a lesion to the
lymphatic system.
=Treatment.=—The treatment of fevers in a general way consists
principally of thorough inhibition to the posterior spinal nerves of
the upper cervical region in order that the center of the vasomotor
system in the medulla may be affected, probably by the way of the
superior cervical ganglion of the sympathetic. Thus the entire
vascular system is equalized, for there is always a disturbance in the
distribution of the blood in fever and if the center controlling the
nerves that govern the lumen of the blood-vessels can be brought under
control, there will result an equalization of the vascular system; if
such occurs, health must ensue. Besides the vasomotor nerves to the
blood-vessels being affected by this treatment, the nerves governing
the lymphatics and the sweat glands will also be controlled. The
sweat glands as a rule are rendered active by affecting directly the
innervation of the glands, also the glands are controlled indirectly by
the blood supply; this aids materially in lessening the temperature of
the body. Treatment for a few minutes to the upper posterior cervical
region would also affect the thermogenic centers and nerves of the
brain reflexly in the same manner as the vasomotor and sweat centers
and nerves are affected, thus tending to equalize the mechanism of the
thermogenic system. Besides this action on the vasomotor, sweat, and
the thermogenic nerves, there is produced an increased exhalation of
moisture from the lungs, on account of an increase of vascular area in
the lungs through vasomotor action. Also the large vascular area in the
abdomen, under control of the splanchnic nerves, becomes constricted.
Thus there is brought about a lessening temperature by evaporation,
heat radiation, and perspiration; and an increased action of the
general nervous system, a stronger cardiac force, an equalization of
the vascular system, and a more perfect elimination of toxic properties
by the skin, kidneys and lungs; consequently a reduction of the fever.
The foregoing treatment is successful to a limited extent, only in
such cases where causative factors of the fever are involving the
predominating centers controlling the heat production or dispersion
and the vasomotor system directly; for if the lesion that is causing
the disorder should be affecting an auxiliary center along the spinal
cord instead of the predominating center, as is oftentimes the case,
treatment of the predominating center would be useless as far as any
permanent benefit is considered; although a temporary effect will be
gained by lessening the fever at that point. Consequently, in many
cases, the lesion lies within the jurisdiction of auxiliary centers
which are situated at various points along the spinal cord. When
such is the case, it will be of little benefit to give the cervical
treatment. In such instances the lesion to the auxiliary center would
have to be removed in order to cure. One cannot depend upon a set rule
to reduce a fever; determine the cause, as in any other disease or
symptom, and remove it.
In addition to the treatment to the cervical region and along the
spinal column, as are indicated upon an examination, attention should
be given to the heart’s action. The equilibrium between the accelerator
and inhibitory nerves (cervical sympathetic and vagi) should be
maintained. The interchange of gases in the lungs should be rendered
as nearly normal as possible; this is best accomplished by raising
and spreading of the ribs from the second to the seventh dorsals,
particularly in the region of the fifth and sixth. Also stimulation
of the vagi will aid by increasing the motor power of the lungs.
The kidneys and bowels should be kept active so as to favor a rapid
elimination of various toxic properties; besides they have control
over large vascular areas. Treatment over the ureters will prevent any
clogging that might occur in them from a condensation of the urine.
Attention, also, should be given the tissues at the fifth lumbar and
over the iliac vessels to influence the circulation in the pelvis.
The =food= of the patient should be liquid—milk, soup, broths, etc.,
and almost any quantity of water allowed if called for, given little
at a time and at frequent intervals. The room should be well lighted,
ventilated, clean and kept at an even temperature.
=Two points= should always be remembered relative to fever:
First—That there are many causes of fever; and in order to reduce the
fever the cause must be determined and removed, the same as in any
disorder. A definite fever treatment cannot be given any more than a
definite constipation treatment; the case must be seen in order to
determine the cause.
Second—The reduction of fever is not necessary; the fever should be
treated only as a symptom of disease when it exists as such. In fact,
fever is beneficial, for it is one of nature’s methods to relieve an
over-burdened system from harmful agents, unless the temperature is
excessive and continuous and is likely to cause more harm than the
primary trouble.
Absolute =rest= in bed always is of decided benefit in lessening the
temperature.
=Hydrotherapy= is of immense value in reducing a fever. It is an agent
that has been greatly used, and if applied intelligently cannot but
be of aid. There is much ignorance in regard to the principles and
practice of hydrotherapy, not only among all classes of people, but
among well informed practitioners in medicine. The most important
function of the skin is as a heat regulator. Knowing this fact, the
osteopath treats the vasomotor nerves that control the cutaneous
circulation and the nerves that control the excretion of the skin;
the nerve supply being from the cerebrospinal and sympathetic nerves.
In many difficult and obstinate cases hydrotherapeutic measures
should be used to aid the skin in regulating the temperature, as well
as to enhance system functions for the same reason that osteopathic
manipulations are given. Maintaining an equilibrium in heat production
and heat dispersion is necessary in order that the standard of the
body temperature may be kept; and the amount of the arterial blood
circulating within a tissue determines its temperature.
The principal effect of water as a thermic agent when applied
externally is due to the influence of the action of the water upon the
cutaneous circulation. Lesser effects would be the mere extraction of
heat from the body by evaporation and the equalization of temperatures
of two bodies coming into contact. As the body is endowed with
compensatory powers, this latter means would apply only to a limited
extent. The temperature of the water used is important, as the colder
the bath the less effective would its power be in reducing internal
temperature. When a cold bath is used there is a driving of the blood
away from the surface on account of the contraction of the peripheral
vessels; consequently increasing the cutaneous circulation and cooling
by radiation is prevented and less heat is lost. A collateral hyperemia
occurs in the underlying parts which acts as a protection to the deeper
tissues. The cold also inhibits the vasomotor nerves controlling the
abdominal splanchnics, and thus a larger amount of blood passes to
this immense vascular area. On the other hand, when a warmer bath is
used the effect is opposite, and a lowering of the temperature is the
result. The cutaneous vessels being dilated, the superficial blood is
rapidly replaced by blood from the deeper vessels, thus allowing a
cooling of the body to a large degree.
In the various fevers where hydrotherapeutic measures are employed, the
object to be gained by such methods is not primarily an anti-thermic
one but an anti-febrile reaction; consequently the use of cold
water is employed. In mere heat reduction the warmer water would be
more effective; but by the aid of the colder water the cause of the
increased temperature, as in infectious fevers, is lessened; besides
a refreshing and stimulating effect upon the entire system is gained.
Thus the aim of the cold bath and friction, is not primarily to subdue
the temperature by heat radiation or evaporation, but to correct
disturbances governing the formation and the dissipation of heat
caused by infectious fevers, and, moreover, to stimulate the nervous
system, prevent heart failure, increase the eliminating power of the
skin, kidneys and lungs, and to influence the corpuscular and chemical
constituents of the blood to a more normal condition.
The full cold bath and friction (Brand Method) is commonly employed
in infectious fevers. The half bath, wet pack, or sponging may be
used. The modus operandi of each is given under the hydrotherapeutic
treatment of typhoid fever.
Typhoid Fever
(ENTERIC FEVER)
In writing of these acute diseases which are self-limiting, it is
understood that osteopathy aborts, overcomes symptoms and otherwise
changes conditions frequently. When this occurs the case is not typical
and it is a typical case which is here described.
=Definition.=—An acute, infectious disease caused by the bacillus
typhosus. It is characterized anatomically by hyperplasia and definite
lesions of Peyer’s patches and mesenteric glands, and enlargement of
the spleen, and clinically by its slow onset, often diarrhea, abdominal
tenderness, tympanites, fever, headache, and rose colored spots on the
abdomen.
=Osteopathic Etiology and Pathology.=—Lesions to the lower dorsal and
lumbar regions are always found, which impair the innervation and
vascular supply of the intestines and cause defective nutrition. This
is the most important predisposing cause, although general lowered
vitality from overwork, improper food, unhygienic environment, and
insanitary surroundings, are also of great importance. It is possible
that one’s vitality may be so lowered that the bacillus of Eberth,
if of sufficient numbers or virulency, will find a suitable medium
wherein to multiply and grow, and thus the spinal lesions found in
these cases are the result of reflex irritation. But the most probable
underlying cause is the spinal lesion, and given two individuals with
equal likelihood to infection, one with the spinal lesions and the
other not, the former within all probability will be the more likely
to suffer an attack. The severity and extent of the osteopathic lesion
undoubtedly bears a direct ratio to the probability of attack from
an infectious disease. Typhoid fever usually occurs between the ages
of fifteen and thirty years. Some families are more susceptible than
others. The autumn months, especially after a dry, hot summer, favor
the disease. One may be reasonably certain that whenever there is a
case of typhoid the individual has not been careful as to diet, or
drinking water, or some rule of health, and wherever there is an
epidemic it can always be traced to insanitary surroundings, the water
supply, contaminated garden truck or other food, sewage, etc.; although
this does not preclude the probability that the osteopathic lesion or
lowered vitality of Peyer’s patches and mesenteric glands from other
causes are important and many times primal etiological factors. The
specific poison may be so virulent that practically no one escapes and
again those of lowered vitality only will succumb to an attack.
The =exciting cause= is a special micro-organism, the bacillus of
Eberth. The contagion may be carried through the air from one person
to another, but this is rarely the case. Though the water is the most
common mode of conveyance, the bacillus has been found during epidemics
in both water and milk. The water may be contaminated by the intestinal
discharges which have not been properly disinfected. Extreme cold does
not destroy the typhoid germs. Milk may be infected from the milk-can
being washed with the contaminated water or the unclean hands of the
milker. In fresh milk the germs multiply rapidly. Salads, celery, ice
and fruits may be contaminated. Oysters have become infected while
being fattened or freshened. It is thought by some that the poison is
not eliminated from the sick in a condition capable of transferring
disease to a healthy person, but must undergo changes in the soil
before it is able to cause the disease in another. Typhoid fever may be
caused, however, by direct contact with the stools. Filth, sewers, or
cesspools do not directly cause the disease, but they form a suitable
medium for the preservation of the typhoid germs.
=Pathologically=, the characteristic lesions in typhoid fever consist
of changes in the lymphoid elements of the bowels. These changes
are most striking in the solitary glands and Peyer’s patches. The
alterations which occur may be divided into four well defined stages:
(1) =Infiltration=—the glands are enlarged from infiltration and there
is marked cell proliferation, particularly Peyer’s glands in the
jejunum and ileum and to a lesser extent those in the large intestine.
The glands become pale and prominent. Occasionally the solitary glands,
which are usually deeply imbedded in the submucosa, become prominent
also.
=Microscopically=, the capillary blood-vessels are at first
considerably dilated, but later become more or less contracted,
giving an anemic appearance to the follicles. The adjacent mucosa and
muscularis may become infiltrated. The cells have the character of
lymph corpuscles, some of which are larger, epithelioid in character,
containing several nuclei. From the eighth to the tenth day this
medullary infiltration reaches its height and then undergoes either
resolution or necrosis.
(1) =Resolution= takes place by a granular or fatty infiltration of the
cells. This produces pitting of the swollen follicles, which may cause
small hemorrhages.
(2) =Necrosis.=—With all the severe cases of cell infiltration,
hyperplasia of lymph follicles reaches a stage where resolution is
impossible and necrosis occurs. The necrosis is partly due to the
choking of the blood-vessels and partly to the direct action of the
bacilli. The necrosis may involve only the superficial layers of the
mucosa or it may extend deep into the muscular coat and even perforate
the outer or serous coat. Usually, however, this does not extend
below the submucosa, mucosa, or muscularis. Not all of the patches
necessarily slough, but as a rule it is always more intense toward the
ilio-cecal valve.
(3) =Ulceration.=—The extent and depth of the ulcers depend upon the
amount of the necrosis. Large ulcers are sometimes formed, especially
in the lower end of the bowel, by the union of several. The edges
are swollen and undermined. The base is usually smooth and formed of
submucosa. Perforation of the bowel occurs in a small percentage of
cases; more commonly the ulcers heal. The perforations may be multiple,
but rarely exceed two in number.
(4) =Healing.=—Cicatrization begins about the fourth week. This
granulation tissue covers the floor. It is sometimes formed with
connective tissue and a new growth of epithelium results. The gland
is ultimately replaced by a depressed scar with a smooth, pigmented
surface. The majority of deaths occur before this stage is reached. The
gland structure is never regenerated.
The =mesenteric glands= show intense hyperemia and later become
enlarged and softened, but rarely ruptured. The glands at the lower end
of the ileum are markedly involved.
The =spleen= is enlarged, softened, and diffluent. Occasionally rupture
occurs. Infarction is not a rare occurrence.
The =liver= shows parenchymatous and granular degeneration, and the
cells are found to contain much fat. Infarction abscesses and acute
yellow atrophy occur in rare instances. Diphtheritic inflammation of
the gall-bladder sometimes occurs and the bile is thinner and paler
than normal.
The =kidneys= also show parenchymatous degeneration. They are pale in
appearance, with slight cloudy swelling. Microscopically, there are
seen granular and fatty infiltration of the cells of the convoluted
tubules. Rarely, there is acute nephritis which may be hemorrhagic.
There may be miliary abscesses in which typhoid bacilli have been
found by some observers. Diphtheritic, but more frequently catarrhal,
inflammation of the pelvis of the kidney may occur. Catarrh of
the =bladder= is not infrequent and even sometimes diphtheritic
inflammation is present. Rarely orchitis is encountered.
=Hypostatic= congestion of the =lungs= is not uncommon. Gangrene and
hemorrhagic infarction are sometimes present. Lobar pneumonia may be a
complication.
In the =larynx= ulceration is sometimes met with bacilli, however, have
not yet been found in these ulcers. Diphtheritis of the pharynx and
larynx may occur. Catarrhal or croupous pharyngitis may occur; while
swelling of the follicles of the pharynx and base of the tongue is
frequently noticed.
=Peritonitis= is always present in fatal cases in which perforation
of the bowel has taken place. The perforation may occur in ulcers
from which the sloughs have already separated, or it may be caused by
a necrosis of all the coats. Extensive peritonitis may occur without
perforation, and is probably due to extension of the inflammation to
the peritoneum.
The =heart= may be affected. Endocarditis is rare, while pericarditis
is much more frequent. Myocarditis is frequently met with, the cardiac
muscles presenting parenchymatous and rarely hyaline degeneration.
The =arteries= are frequently found to be involved. These conditions
(obliterating arteritis and partial arteritis) may affect the smaller
vessels, especially those of the heart, but more commonly affect the
arteries of the lower extremities. Thrombosis of the veins, especially
of the femoral, and more rarely of the cerebral veins and sinuses,
occurs.
Granular and hyaline changes in the voluntary =muscles= may occur. This
degeneration does not affect the whole muscle but involves only certain
fibres. Regeneration takes place during convalescence.
With the nervous system meningitis is rare. The peripheral =nerves=
are frequently the seat of parenchymatous changes. The ganglia of the
trunks of the vagi present an inflammatory change.
The =blood= presents little change. During the first two weeks the
red corpuscles gradually decrease in number until the first week of
convalescence, after which they gradually increase in number. There is
often a marked decrease in the number of leucocytes. Leucocytosis is
absent. The hemoglobin is always reduced.
=Symptoms and Course.=—The incubation period varies from a few days to
two weeks or longer. During this time the patient may feel in his usual
health, but more often there is a feeling of languor and indisposition
to exertion, loss of appetite, slight coating of the tongue, nausea,
headache, chilliness, but seldom a decided rigor, pains in the back or
legs and nose-bleeding. Any of these symptoms may be present and last
usually from a few days to a week or more. These symptoms increase in
severity and the patient takes to his bed. The invasion as a rule is
gradual.
The =first week= dates from the onset of the fever which generally (but
by no means in all cases) rises steadily during the first week a degree
or a degree and one-half each day, reaching 103 or 104 degrees F. The
pulse is quickened to 90 to 110 per minute and is full, of low tension
and sometimes dicrotic. There is great thirst, also a coated tongue.
The skin is hot and dry and there is rather intense headache. Unless
the fever is high there is no delirium. The sleep is disturbed and
there may be mental confusion and wandering. Cough with some thoracic
oppression is not uncommon at the onset. The abdomen is slightly
distended and tender. There may be either constipation or diarrhea. The
spleen is somewhat swollen and a rose colored rash appears on the skin
of the abdomen and chest.
During the =second week= the fever remains high and exhibits the
continued type, the morning remission being slight. The pulse is
accelerated. The headache disappears, but there is marked mental
dullness and slowness and there may be a mild delirium at night. The
tongue is coated and the lips are dry. The abdomen is tympanitic and
tender. Diarrhea replaces constipation. The case may prove fatal during
this week from the result of nervous or pulmonary symptoms, hemorrhage,
or perforation.
The fever changes in the =third week= from a continuous to a remittent
type. The pulse ranges from 110 to 130. The patient is very weak.
Complications may arise, as pulmonary symptoms, feebleness of heart,
intestinal hemorrhage, perforation, and peritonitis.
In favorable cases during the =fourth week= the fever begins to decline
and the general and local symptoms gradually disappear. In protracted
cases the =fourth= and =fifth= weeks may present the symptoms of
the third week. Frequently the following aggravated symptoms are
added: stupor, delirium, increased weakness, rapid, feeble pulse,
and distended abdomen. Heart failure and inflammatory complications
increase the danger.
During the =fifth= and =sixth weeks= a few cases will show irregular
fever. Great care should be taken that complications do not occur.
The =fever= is the most important and characteristic symptom and from
the temperature alone a diagnosis may be made. During these stages of
development, which is the first four or five days, the temperature
rises steadily; the evening temperature being about a degree or a
degree and one-half higher than the morning remissions, reaching 104
or 105 degrees F. at the end of the first week. When the =fastigium=
is reached the fever persists with slight morning remissions. At the
end of the second and throughout the third week the temperature becomes
more remittent and there may be a difference of three or four degrees
between the morning and evening temperature. During the last stage the
fever falls by =lysis=, forming a more or less regular step-like line
of descent. The stage lasts from one week to ten days.
When the disease sets in with a severe rigor the fever frequently rises
at once to 103 or 104 degrees F. In the lightest forms the fastigium
may be almost absent; defervescence setting in upon the first day of
the fastigium and in many cases defervescence occurs at the end of
the second week and the temperature may fall rapidly, becoming normal
in ten or twenty hours. This fall in the temperature may take place
without any apparent cause or it may follow an intestinal hemorrhage.
The temperature often falls many hours before the blood appears in the
evacuations. The occurrence of peritonitis is also marked by a sudden
fall in the temperature. =Hyperpyrexia= in typhoid fever is not very
common except just before death.
After the temperature has been normal for several days there may be
a sudden rise of the temperature to 102 or 103 degrees F. This may
persist for a couple of days and then return rapidly to the normal.
These =recrudescences=, as they are called, are quite common and are
caused most frequently by errors in the diet, constipation, excitement
or mental emotion. These elevations in the temperature are found most
frequently in children and persons of a nervous temperament.
=Afebrile Typhoid= is of very rare occurrence. The patient has all the
characteristic symptoms of typhoid fever with the exception of a fever.
The =rash= is highly characteristic. It appears about the eighth or
tenth day, usually upon the skin of the abdomen or chest, rarely
found elsewhere on the body. It consists of a variable number of rose
colored spots distinctly elevated, and disappear on pressure. These
spots last three or four days and appear in successive crops. Vivid red
erythematous eruptions upon the chest and abdomen are commonly seen
during the first week of typhoid fever. Urticaria is rarely seen.
Sweating characterizes some cases of typhoid fever, but generally the
skin is dry. This may occur with or without chilly sensations or actual
rigors. In some cases there may be recurring paroxysms of chills,
fever, and sweats and they may be mistaken for intermittent fever.
Edema of the skin may occur and is usually due to anemia or cachexia
and sometimes to nephritis. Local edema may occur as the result of
vascular obstruction, particularly thrombosis of the femoral vein.
There is a peculiar musty odor exhaled from the skin in typhoid fever,
particularly if the skin has been neglected. In all protracted cases
=bed-sores= are likely to develop. The =hair= is apt to fall out but
is generally renewed. The nails also suffer and ridges can usually be
observed upon them.
=Intestinal symptoms= are very inconstant. Usually there is
constipation at the onset and this may persist throughout the disease
although a moderate diarrhea may occur throughout the disease. The
severity of the diarrhea is due most probably to the degree of the
catarrh rather than to the extent of the ulcers. It is probable that
the discharges are more frequent when the catarrh involves the large
intestine. The number of discharges average, as a rule, from two to
four or more daily. The stools are either fluid or of the consistency
of jelly, of a grayish-yellow color, alkaline in reaction and are very
offensive.
=Hemorrhage= is a serious symptom, but by no means always fatal. This
usually occurs in cases of considerable severity and it generally
occurs at the time of the separation of the sloughs during the third
week. When it occurs quite early in the disease it is generally the
result of hyperemia. It may be so slight as not to be noticed by the
eye or it may be from one to three pints. Intestinal hemorrhage,
however slight, is always a grave symptom. There may be symptoms of
collapse and fall of temperature, or it may occur without any symptoms.
=Meteorism= is an almost constant symptom, and when excessive adds to
the seriousness of the case and corresponds generally with the extent
of local lesions. Abdominal tenderness and gurgling upon pressure in
the right iliac fossa may be present; pain is generally absent, and
when present is usually slight.
=Perforation= almost invariably causes fatal diffuse peritonitis and
is the most serious complication. It may occur at any time but is most
common between the second and fourth weeks. It is usually indicated
by sudden acute pains in the abdomen and symptoms of collapse. As
a rule symptoms of =peritonitis= appear at once; distension of the
abdomen, great tenderness, and rigid abdominal walls. Vomiting, pinched
features, and rapid, small pulse shows general collapse of the
circulatory system.
=Bronchitis= is almost invariably present as an initial symptom. It is
indicated by the existence of sibilant rales. The cough is generally
slight.
Hypostatic congestion of the =lungs= and edema, due to enfeeblement of
the cardio-pulmonary circulation, in the latter part of the disease are
not infrequent.
The =pulse= as a rule is not very frequent and is generally not in
proportion to the fever until late in the disease; 90 to 120 is
the usual range. During the first week it is about 100, full, and
frequently dicrotic; later it becomes more rapid, feeble and small.
In severe cases during the extreme debility of the third week the
pulse may reach 150 or more (the so-called running pulse). During
convalescence the pulse occasionally becomes subnormal and bradycardia
is met with more frequently than after any other acute fever.
The =blood= presents definite changes, some of which are important.
In cases where there is profuse sweating or copious diarrhea, the
red corpuscles may be relatively increased; this is due to the loss
of water. In most cases there is little change until the end of the
second week. During the third week there is generally a decrease in the
number of corpuscles and of the hemoglobin, which is always reduced.
=Leucocytosis= is always absent. The white corpuscles are slightly
diminished especially toward the end of convalescence.
During the first week there is generally persistent headache, sometimes
neuralgia. There are a few cases in which the effects of the typhoid
bacilli or their poison is manifested in the =nervous system= from
the very onset. There are violent headaches, retraction of the head,
rigidity, photophobia, twitching of the muscles, rarely convulsions,
all indicating meningitis as which it is occasionally diagnosed.
It must be remembered however, that all nervous symptoms may occur
independently of a lesion of the nervous system.
=Delirium= may exist from the onset, but it usually is not present
until the second or third week and only in the severer cases. As a rule
it is most marked at night. It is generally of the low, muttering type,
very seldom maniacal. When the patient picks at the bed clothes or
grasps at imaginary objects there is indication of danger, as it is a
serious symptom. Convulsions are rare.
The =urine= is diminished in quantity, high specific gravity, and of
dark hue. Both urea and uric acid are increased and the chlorids are
diminished during the first stages. About the stage of decline the
urine becomes light in color and greater in quantity than normal. The
specific gravity is lowered, urea and uric acid are diminished, and the
chlorids are increased. Febrile albuminuria is very common but of no
special significance. Acute nephritis may develop as a complication.
Pyuria is not an uncommon complication and post-typhoid pyelitis may
also develop.
=Malarial fever= may be associated with typhoid, especially in malarial
districts. Persons with tuberculosis, epilepsy, chorea, and other forms
of chronic nervous diseases are liable to typhoid fever. In epilepsy
and chorea the movements and fits usually cease during the attack of
typhoid fever.
=Varieties of Typhoid= are numerous and are named with reference to
the degree of severity which varies from extreme mildness to extreme
severity.
The =mild= or =abortive= form is of frequent occurrence. The onset is
usually sudden. The symptoms are similar to those of a typical case but
much milder and appear earlier than in the usual type. This form runs
its course in about two weeks. The fever usually reaches 104 degrees F.
In the =severe= or =grave= form there is high fever and the nervous
symptoms show a profound intoxication of the system. The grave types
are those associated with serious complications or those cases which
set in with pneumonia, Bright’s disease, or cerebrospinal symptoms.
In the =latent= or =ambulatory= form (walking typhoid) the symptoms
are very slight, the patient being hardly sick enough to go to bed.
The symptoms may be of this character throughout the attack, and the
patient may be able to be up and about. In other cases the first
symptoms are very mild, but later they may develop symptoms of the
severest type.
The =Afebrile= form is rare. =Hemorrhagic= typhoid is a very fatal but
rare form. In this type there are cutaneous and mucous hemorrhages.
=Diagnosis.=—As a general rule typhoid fever is easily recognized.
The Widal test should be made. At times the diagnosis may have to
be delayed until the distinctive signs appear, especially in those
cases which come on with severe headache, delirium, twitching of the
muscles, and retraction of the head. In these cases the diagnosis of
cerebrospinal meningitis is invariably made, until the appearance of
the colored spots on the abdomen, which must decide the diagnosis;
cerebrospinal meningitis being a rare disease and typhoid fever with
severe nervous symptoms quite frequent, it is more probable that it is
typhoid. At least one-half of the cases termed brain fever belong to
this class of nervous typhoid.
=Prognosis.=—A positive prognosis can not be made, as even the mildest
cases are liable to have severe complications develop at any stage of
the disease. Under osteopathic treatment the prognosis is undoubtedly
more favorable than with the treatment of the older schools. If the
osteopath can see the case early, the first week, there is always a
chance to abort the attack. In all cases there is the probability that
the attack will be shortened; this is a common experience. Price of
Mississippi, has treated many cases, and invariably when the patient
is seen early the attack has been shortened to thirteen or fourteen
days, whereas under other treatment the disease runs the usual course.
Adsit of Kentucky, White of New York, and the staff of the American
School of Osteopathy (Kirksville), as well as many others, have had
the same experience. And if the attack cannot be aborted or shortened
there is the further probability that the severity will be lessened
and complications prevented. The prognosis is always more favorable in
winter than in summer, and especially favorable in children. More women
die than men, and fat persons stand the disease badly.
=Treatment.=—Typhoid fever is one of the diseases that practitioners
of all the schools are agreed that drug therapeutics avail but little
in its treatment. The treatment of the older schools consists of
prophylaxis, good nursing, attention to hygienic principles, dieting,
and hydrotherapy. All of these have their places and are recognized
by the osteopathic school. But the above methods are of the defensive
only—allowing the disease to run its usual course and reducing the
likelihood of complications. On the other hand the above treatment
coupled with osteopathy, not only attacks the ravages of the disease
defensively, but of more importance, the disorder is attacked
offensively. Herein is where attacks are aborted, or shortened,
or severity lessened, or complications prevented. The efficacy of
osteopathy is due to the ability of the osteopath to treat disease,
not only prophylactically and palliatively, but of more consequence,
aggressively.
The correction of the spinal lesions in typhoid fever is of first
importance. This treatment effects a tendency toward equalized
circulation of the intestines. The vasomotor nerves are disturbed by
the above lesions which in turn produces stasis in Peyer’s patches and
the mesenteric glands. Reversely some of the spinal lesions may be due
to reflex stimuli, for “Kirk ... states that muscular contractions
produced by reflex activity are often more sustained than those
produced by direct stimulation of the motor nerves themselves.”[51]
=Prophylactic= treatment is very essential, for typhoid fever as a rule
is a preventable affection. Modern hygienic and sanitary resources
enable a community to reduce the number of cases to a minimum. The
number of cases in a locality depends almost directly upon the
condition of the water supply and drainage. Care should always be
taken in regard to the source of drinking water and milk. During an
epidemic the water should be boiled for half an hour before being used.
The patient should be isolated. In hospitals they should have special
wards; in families a special apartment should be given them. Hygienic
principles should be followed as in other infectious diseases.
The methods of disinfection must be rigid to prevent the spread of an
infection. The excreta (stools, urine, vomitus, and sputum) are to
be received into a bed-pan or any appropriate receptacle containing
half a pint of carbolic acid (one to twenty). Three or four pints of
the carbolic acid (one to twenty) should then be added to the bed-pan
and the contents mixed carefully before emptying. All utensils used
in handling the excreta are to be carefully disinfected by the same
material, and dried. After every stool the nates of the patient should
be cleansed by a cloth compress, wet with a solution of carbolic acid
(one to forty) and the cloth burned. The sick room should be thoroughly
ventilated each day. All utensils used about the patient in feeding
should be boiled in water immediately after using. The bed and body
linen is to be changed as soon as soiled and these, with all changed
bath towels, blankets and rubber sheets, should be received in a sheet
rinsed in carbolic acid (one to forty) and placed where they may be
soaked in the solution for four or five hours. The clothes are to be
boiled for half an hour. The rubber blanket is to be washed in the
solution, dried and aired.
The =General Management=, careful nursing and a regulated diet, is of
paramount importance in the treatment of typhoid fever. The patient
should be placed in bed as soon as the disease is determined and there
remain until the end of the attack. The room should be well ventilated
and have a sunny exposure if possible. The single woven wire bed with
soft hair mattress and two folds of blankets is best. A rubber cloth
should be placed smoothly under the sheet. When a good nurse cannot
be had, the attending osteopath should write out directions regarding
diet, bed linen, and utensils, and the disinfection of the excreta.
A liquid =diet= should be administered. Milk is most commonly used;
care being taken that it is thoroughly digested. If milk is not borne
well by the patient, other foods, as whey, sour milk, buttermilk, and
broths may be substituted. Give food that is easily digested and which
leaves but little residue. When milk is used alone, three pints at
least may be given to an adult in the course of twenty-four hours; and
it should always be diluted, preferably with plain water. Beef juice,
mutton or chicken broth may also be used when milk is not agreeable.
Albumin water, prepared by straining the white of eggs through a
cloth and adding an equal amount of water, is an excellent food. Well
strained, thin barley gruel is considered by many an excellent food
for typhoid fever patients. Cases not able to take nourishment into
the stomach, on account of vomiting and other causes, should be fed
rectally to support life. Do not force feeding to an unwarranted degree.
Recently a number of new diets have received commendation. These
include the “high calory” diet, which includes three pints of milk
with one of cream, two to eight ounces of milk sugar, eggs, butter;
sometimes cereals, toast, potato, and other soft foods are given.
A full sugar diet, as of candy alone, is based upon the immediate
absorption of sugar, its value as a source of energy, and the fact that
a plentiful carbohydrate supply lessens the danger of acidosis.[52]
The best drink for fever patients is pure, cold water and they should
be encouraged to drink freely of it. Barley water, ice tea, lemonade,
or even moderate quantities of coffee or cocoa, may be given.
By =Osteopathic Treatment= many cases of typhoid fever may be aborted,
if treated correctly, during the first week. If the stage of necrosis
of Peyer’s patches has set in, one can either lessen the severity of
the attack or, at least, shorten the usual course. During the stage of
infiltration, treatment to the intestinal splanchnics (chiefly from the
ninth to twelfth dorsal, the innervation to the jejunum and ileum) and
careful treatment over the abdomen is indicated. This treatment will
tend to lessen the intestinal catarrh and diminish the infiltration and
cell proliferation of the lymphoid elements of the intestines, and thus
produce unfavorable the conditions for the bacillus of Eberth. In other
words, increase the tone and activity of the intestines so that the
micro-organisms of typhoid fever will not find the proper tissue-soil
in order to grow and multiply.
All cases of typhoid fever present lesions in the dorsal or lumbar
spine and this is really the great predisposing cause of typhoid
fever. Correcting these lesions is absolutely necessary in order to
abort the disease. Some patients may have such a lowered vitality
to begin with that the recuperative powers of the body cannot be
rendered forceful enough in a short time to combat the effects of the
micro-organism. Carefully raising the cecum is very effective (A.
T. Still), but this must be done with the greatest of caution and
judgment. Dr. Still considers a posterior condition of the third,
fourth and fifth lumbars as typical in typhoid and that it inhibits the
lymphatics to the intestines.
R. L. Price has had excellent success in shortening the usual typhoid
course. His first treatment is to thoroughly empty the bowels by
enemata. This is followed by spinal, liver and splenic treatment, and a
liquid diet.
E. C. White has also treated a large number of typhoid cases with
marked success. He prefers to employ the Brand method (and it must be
properly used) from the start. He is, also, a thorough advocate of the
spinal treatment. In cases of constipation give a very light treatment
over the left iliac fossa. With all patients observe careful dieting.
White believes that many lesions of the spine arise from reflex
irritations during acute attacks. Careful, frequent attention to the
spine is demanded.
Hildreth, relative to abdominal and spinal treatment, writes as
follows: “In the abdominal treatment of typhoid fever, too much care
cannot be exercised; or in the spinal treatment, too much judgment
used in giving just the right kind of manipulation. There can be no
question relative to the seat of the disease, and consequently there
should be no trouble in knowing where or how to affect the nerves to
control the same. That Peyer’s patches or the right iliac region is
always involved, we all know. The spinal treatment should be applied
from the eighth dorsal to the first lumbar inclusive; this affects all
the lesser splanchnics and thus controls the circulation of the entire
bowel. And this treatment should be given, according to the symptoms
indicated, in each and every case. If the patient is constipated,
then the treatment should be more of a stimulative character, but if
diarrhea is present, as is commonly the case, the treatment should be
an inhibitory one. In the above I always finish with a very careful
treatment of the floating ribs on the left side; this affects the
lesser splanchnic nerves. In all cases I always carefully treat
the lower two or three lumbar vertebræ, which directly affects the
hypogastric plexus of nerves, and thus controls the circulation to the
lower bowel.
“In all cases I always treat the bowels directly, more or less, but
this treatment =must= be given with the very greatest =care= and the
best judgment, always governed by the condition of the bowel. By
no means manipulate the bowel, but just lay your hands flat on the
abdomen, and with the most gentle pressure inhibit the peripheral
nerves, thus either quieting an excited peristalsis or equalizing a
disturbed circulation. And with this treatment remember that the two
specific points in typhoid fever are the lower dorsal and lower lumbar
nerves.
“The above treatment is used, of course, in connection with all the
other necessary treatments, such as dieting, nursing, sponging,
relieving the headaches, etc. I am unalterably opposed to ice-packs for
the bowels in typhoid, for the reason it is too much of a shock. Cold
cloths are good and much better than ice, and should always be used
instead of ice.”
After the disease has become thoroughly established always make it a
point during each visit to examine the entire length of the spinal
column carefully and readjust any tissue, whether it be vertebra, rib,
or muscle, that may be found disordered. The bowels are to be watched
carefully and if constipated, they should be moved with a light enema.
Great care must be taken not to treat the abdomen roughly, if at all,
after the first week. The treatment might be very injurious to the
structures diseased. A light treatment over the liver and kidneys
each time is a wise precaution. The heart’s action, should be watched
carefully. In addition to the hydrotherapeutic treatment, the general
fever treatment should be employed. The patient should usually be seen
twice a day.
=Abdominal pain= is best relieved by light treatment over the abdomen
and by thorough treatment of the lower dorsal or lumbar region.
Applications of hot water will be helpful.
=Meteorism= can be relieved by raising the lower ribs and by direct
treatment to the abdomen. A change of diet may be beneficial. When gas
is in the large bowel an enema may be given to remove it.
=Diarrhea= and =constipation= are best controlled by the usual
treatment given the spine in such cases, and over the abdomen and the
liver. Light enemata may be given for constipation. The stools should
be examined when diarrhea occurs, as the presence of curds may cause
the aggravation.
=Hemorrhage= from the bowels demands absolute rest. It is probably
better to have the patient use the draw sheet for the evacuation.
Immediate and thorough treatment must be given to the spinal column
in the region of the intestinal nerves to the diseased area, so
that existing lesions may be corrected and the vascular area of the
mesentery equalized. Ice should be given freely and an ice pack placed
over the abdomen. Food should be restricted for ten or twelve hours.
If the peristalsis of the intestines is increased, an effort should be
made to control it through the vagi and splanchnic nerves.
In =perforation= hot applications, rest and thorough treatment of the
innervation to the peritoneum are of value, but immediate operation is
usually advisable.
=Insomnia= is best relieved by attention to the cervical region.
Relaxation of the muscles in this region and a quieting treatment to
the posterior occipital nerves, coupled with cold sponge baths, will
usually induce sleep.
In =delirium= attention to the circulation of the brain, by careful
treatment of the vasomotor system, and the Brand method of baths will
relieve this distressing symptom.
During =convalescence= the patient should be restricted from any mental
or physical exercise for a week or ten days and then should move about
with care. Solid food should not be given for ten days or two weeks. If
the temperature has been normal for ten days, it is then safe to allow
such food as eggs, milk puddings, and milk toast. If diarrhea should
persist, being due to ulceration, the diet should be restricted and the
patient confined to the bed. If constipation is troublesome relieve it
by enemata.
There are several beneficial effects obtained by =hydrotherapeutic
measures= that should receive careful consideration. Probably it is
of the least significance to lower the temperature; other beneficial
effects being of greater importance. When the baths are systematically
carried out, (1) there is obtained a general improvement of the
nervous system, the mind is rendered clear, muscular twitchings are
lessened, sleep is induced and the heart’s action strengthened; (2)
the respiration is stimulated, thus diminishing the liability of lung
complications; (3) the activity of the renal function is increased,
consequently allowing more rapid elimination of toxic matter; (4)
reduction of the temperature, and overcoming ill effects of high fever.
A cold water bath, or what is generally termed the Brand method, is
commonly employed. The following plan is usually followed. When the
temperature is above 102.5 degrees F., rectally, a bath of 70 degrees
F. is wheeled to the patient’s bedside and he is placed into it for
ten or fifteen minutes. The patient should be lowered into the bath by
means of a sheet. Enough water is used to cover the body and neck of
the patient. The head is sponged and the limbs and trunk are rubbed
=thoroughly= during the entire procedure. When the patient is taken
out he is wrapped in a dry sheet and covered with a blanket. This
procedure is gone through with every three hours if the case is severe,
otherwise once every seven or eight hours will be sufficient.
The luke-warm bath is occasionally used in private practice when one is
unable to use the Brand method. A bath of 90 degrees F. is employed,
which is gradually cooled ten or twelve degrees, after the patient has
been placed in it, by pouring cold water on the patient. This bath is
found very helpful. Also in private practice the cold pack is found
satisfactory. The patient is wrapped in a sheet wrung out of water at
65 degrees F. and cold water is sprinkled over him. Whenever there is
objection to any of these methods the body may be sponged off with
tepid or cold water when the temperature rises above 102.5 degrees
F., rectally. One limb should be taken at a time and then the trunk,
occupying altogether some twenty or thirty minutes.
The Great War brought the subject of typhoid vaccination before the
world with emphasis but its results are not, as yet, in shape so an
unbiased opinion can be formed. The army medical department will tell
us that it was an unqualified success but we do know that there were
serious outbreaks among inoculated troops who were living under most
hygienic surroundings in America. There were, also, outbreaks among
protected troops in France to the extent that the medical authorities
felt called upon to warn all medical officers that vaccination should
not be considered as protecting against unsanitary surroundings
and that great precaution must be observed, the same as under
non-vaccination conditions. This does not imply implicit confidence.
It is, also, a historical fact that the Japanese army, during the
Russo-Japanese war had as low a rate of typhoid without vaccination as
can, probably, be shown with it in this war. At that time they depended
entirely upon pure water and sanitation.
See reports of typhoid fever in A. O. A. Case Reports as follows: C. M.
T. Hulett, Series I, p. 7, J. H. Wilson, Series III, p. 3, F. E. and H.
P. Moore, and F. A. and E. S. Cave, Series IV, pp. 4 and 5.
In =paratyphoid fever=, an acute infectious disease caused by the
paratyphoid bacillus, the treatment is the same as for typhoid fever.
It is milder and similar to typhoid fever.
Typhus Fever
=Definition.=—An acute, infectious disease; characterized by sudden
invasion, high fever, marked nervous symptoms, a peculiar maculated
and petechial eruption and a termination by crisis about the fourteenth
day.
=Etiology= and =Pathology=.—Typhus fever is becoming less frequent than
formerly and is rarely seen in this country. It was very destructive
during the Great War, particularly in the Balkan states. Filth,
over-crowding, famine, intemperance and bad food are the predisposing
causes. Typhus fever is highly contagious and is transmitted by the
pediculus corporis (cootie) as was first discovered by the American
Red Cross workers in Serbia. Probably infection may come by contact
and fomites. The specific organism is the bacillus typhi exanthematici
(Platz).
=Pathologically=, there are no constant lesions. There is a general
hyperplasia of the lymph follicles, but no ulceration. The blood is
dark, thin and lessened in fibrin. Hypostatic congestion of the lungs
and bronchial catarrh are frequently met with. The liver, kidneys and
spleen are found to be somewhat enlarged and softened. The petechial
rash remains after death.
=Symptoms.=—The =incubation period= is about twelve days. The onset is
usually sudden, ushered in by chills. The temperature quickly rises
to 104 or 105 degrees F. There is headache, pains in the muscles,
especially of the back, and early, profound prostration. The pulse
is at first full and strong, 100 to 140, but soon becomes weak and
frequent. There may be distressing vomiting. The face is flushed, the
eyes injected, the expression stupid, and there is generally low,
muttering delirium. The tongue is furred and white, soon becoming dry.
The bowels are constipated and the urine is usually scanty and of high
specific gravity. There is great thirst. Conjunctiva injected; pupils
contracted; early prostration.
The =eruption= appears about the fifth or seventh day. It first makes
its appearance upon the abdomen and chest. It rapidly extends all
over the body with the exception of the face. The eruption is of two
kinds—rose spots, which disappear upon pressure, and those which become
hemorrhagic (petechial); pressure has no effect upon them. During the
second week the symptoms are increased. The tongue is dry, brown and
fissured, and sordes appear on the teeth. Retention of the urine,
due to paralysis of the bladder, is common. The breathing becomes
more rapid and the heart’s action more feeble; the patient may die
from exhaustion. This ushers in the typhoid state with low, muttering
delirium, ataxic symptoms, subsultus, tremors, and maybe bronchial
symptoms. In favorable cases the crisis occurs at the end of the second
week. Patient sinks into a sound sleep, the temperature falls rapidly,
there is profuse sweating and a critical diarrhea but the patient now
gains rapidly.
=Convalescence= is usually rapid; relapses rarely occur. The urine is
scanty, high colored and frequently albuminous. Bed-sores are common.
The temperature continues high, reaching 106 degrees F., or more, with
slight nocturnal remissions. In fatal cases the fever often rises to
108 or 109 degrees F. just before death.
=Diagnosis.=—The sudden onset, frequent chills, early profound
prostration, character of the rash, history of exposure to the poison
and unhygienic surroundings decide the diagnosis. During an epidemic
there is usually no doubt, but in sporadic cases the diagnosis is
sometimes extremely difficult.
=Prognosis.=—This is usually grave, but the mortality rate is being
greatly reduced in consequence of the better sanitary arrangements.
=Treatment.=—Typhus fever is highly contagious and great care should
be taken in controlling the disease. Isolation, disinfection and
extermination is imperative. So far as known none of the osteopaths
have had experience in the treating of typhus fever osteopathically,
but there is no reason why the disease should not be treated with the
same success as is met with by osteopathic treatment in other diseases.
It is claimed that the disease should be treated in the open air, in
tents, as the recovery of the patient and the safety of the attendants
are greatly favored.
For high temperature, besides the treatment given to remove any
disorder that may be found, the general fever treatment is indicated,
and hydrotherapy would also be of aid—sponging the surface of the body,
or the use of the bath. Asthenia is wherein the greatest danger lies,
and a stimulating treatment along the spine and to the heart should be
given; although correction of the primary trouble may be sufficient.
Hydrotherapeutic measures, the systematic use of the cold bath, would
be of service the same as in typhoid fever.
Headache and delirium which are apt to arise, caused by too much blood
in the head, may be relieved by treatment of the cervical spine.
Also cold applied to the head will aid. The bowels should be watched
carefully; treat the splanchnics thoroughly and the intestines and
liver directly. Nourish the patient as in typhoid fever by nutritious
liquids—milk, broths, etc.
Although typhus is now a comparatively rare disease, an outline has
been given to emphasize what correction of unhygienic conditions and
insanitary surroundings will accomplish. It is particularly a disease
of filth.
Malarial Fever
(AGUE)
=Definition.=—An infectious disease caused by the hemocytozoon of
Laveran. “It is characterized by paroxysms of intermittent fever of
the quotidian, tertian or quartan type, a continued fever with marked
remissions, a pernicious or rapidly fatal form, and a chronic cachexia
with anemia and enlarged spleen.” (Halbert). The varieties of malarial
fever are: intermittent fever; pernicious intermittent; remittent
fever; malarial cachexia; masked intermittent; malarial hematuria.
=Osteopathic Etiology= and =Pathology=.—Malarial fevers are caused by
a parasite known as the hematozoon of Laveran. Three varieties of the
parasite have been separated, corresponding with the three leading
forms of the affection. The parasite of tertian fever is about as
large as a normal red blood-corpuscle, beginning as a small hyaline
ameba in the red blood-corpuscles. The parasite of quartan fever is
very similar in its appearance to the tertian parasite but smaller;
its ameboid movements are slower and the red blood-corpuscle embracing
it shrinks about the parasite, assuming a deeper greenish color. The
parasite of the estivo-autumnal fevers is still smaller. “If only one
group of parasites exists the paroxysms—quartan intermittent—will occur
every fourth day. Double quartan infection will result in paroxysms
on two successive days with an intermission of one day. Infection by
three groups of parasites will create daily paroxysms—the quotidian
intermittent. Infection by more than three groups is rare.” (Anders).
Only in the earlier stages of development, small hyaline bodies are to
be found in the peripheral circulation; being, in the later stages,
in the blood of certain internal viscera, spleen, and bone marrow,
particularly.
It is an accepted fact among medical observers that to the mosquito,
_anopheles_, is due the spread of malaria and it has been the subject
of much investigation in all parts of the world. The mosquito becomes
infected from biting an individual whose blood contains the malarial
parasite, this is then developed in the mosquito to maturity and later
is transmitted to the next subject bitten. This explanation would show
why certain localities favorable for the breeding of mosquitoes are
particularly given to malarial outbreaks. Low, marshy grounds, banks
of rivers, small ponds, etc., as well as warm weather, are needed to
produce the conditions for the development of the _anopheles_. As
the country has developed the intensity and extent of malaria has
diminished until it is now confined largely to the southern states.
It is practically unknown in the northwest and in the St. Lawrence
basin. Regions which have never had cases, however, have developed them
when the _anopheles_ has appeared. Whiting notes cases in Southern
California, the result of the insect being brought in by ships from
Mexican or Central American ports. In certain regions the _anopheles_
is present but has not apparently come in contact with a malarial
victim, so is incapable of spreading the disease. Also in colder
climates this species is harmless.
By draining the lands and preventing the breeding places, the number of
the pests is reduced, while the screening of houses and care against
exposure to the bites make it possible to live in malarial sections
and not become infected. Naturally the resisting power of a patient
is called into account when bitten by the mosquito. Where it is
epidemic the inhabitants will be found, generally, poorly nourished or
debilitated from climatic or other conditions. This renders infection
easy, for immunity must come from the ability of the blood to combat
the invading parasite.
The =osteopathic predisposing causes= for malaria are usually
interference with the vasomotor nerves to the spleen and liver, as
these two organs are so concerned in maintaining the stability of the
blood tissue. Ligon, of Alabama, notes that most cases have lesions
between the ninth and twelfth dorsal on the right side.
The chief =morbid changes= are clue to the direct effect of the
malarial parasite upon the blood. There are also changes in the
liver, kidneys, and spleen, which changes usually vary with the
duration and intensity of the disease. The disintegration of the red
blood-corpuscles, accumulation of the pigment thus formed, and the
toxin engendered by the malarial parasite are responsible for the
morbid lesions of the disease.
In =pernicious malaria= the blood is more or less hydremic, and the
discs are seen in all stages of destruction. The spleen is enlarged
and soft and the pulp dark from the accumulation of the pigment, and
spontaneous rupture has occurred in a number of cases. The liver is
swollen and turbid; pigmentation occurs, but is generally only visible
by means of the microscope. By the aid of the microscope all the
tissues of the body, even the brain, may be found to be pigmented.
The =spleen= in =chronic malaria= is greatly enlarged, firm, pigmented
and the capsule thickened. The =liver= is enlarged, the color varying
from a slight gray to a deep slate gray, according to the amount of
pigment. The =kidneys= may be enlarged and deeply pigmented, as is also
the mucous membrane of the =stomach= and =intestines=.
R. W. Connor observes that the kidneys and liver are most noticeably
involved, vasomotor obstructions the rule, the spleen in the majority
of cases shows engorgement and that special attention to these centers
will give the best results. He invariably finds spinal lesions from
the seventh dorsal to the first and second lumbar, most frequently the
eighth, ninth and tenth dorsals. A lowered vitality predisposes to
infection from the bite of the mosquito.
=Symptoms.=—=Intermittent Fever.=—This form is what is known as fever
and ague, in which chills, fever and sweat follow each other. The
period of incubation varies from six to fifteen days, but it may be
months after exposure before the first paroxysms set in. The paroxysm
is usually preceded by a feeling of uneasiness and discomfort,
sometimes by nausea or headache. The paroxysm consists of three stages,
cold, heat and sweating.
In the =cold stage= the chill usually begins gradually; it is generally
intense, the teeth chatter and the body shakes violently. The skin is
cool and pale, the lips are blue, the face is pinched and the patient
looks very cold. During the chill the temperature rises rapidly.
Nausea, vomiting and headache are common. The pulse is frequent, small
and hard. The urine is increased in quantity and of low specific
gravity. The chill lasts from a few minutes to a couple of hours.
The =hot stage= succeeds the chill. The skin gradually loses its
coldness and becomes hot. The face is flushed, there is great thirst,
the mouth is dry, and the tongue is coated. Usually at the termination
of the chill the temperature has reached its maximum level, from 104
to 106 degrees F. The pulse is full, and there may be a throbbing
headache. The duration of this stage is from half an hour to three or
four hours. During the =sweating stage= drops of perspiration appear
upon the face; the perspiration soon becomes profuse, extending all
over the body. The temperature soon falls, the headache disappears and
in a couple of hours the paroxysm is over.
The entire duration of the paroxysm is from eight to twelve hours;
the patient usually feeling perfectly well between the paroxysms.
The spleen is enlarged. If the paroxysms of fever occur daily at the
same hour they are called =quotidian= intermittent fever; if every
other day they are known as =tertian= intermittent; and if every
third day they are called =quartan= intermittent. If there are two
paroxysms in the same day the term =double quotidian= is used; if the
paroxysms occur a couple of hours later each successive day they are
called “=retarding=;” if a couple of hours earlier they are named
“=anticipating=.”
=Remittent Fever.=—(Estivo-Autumnal Fever).—This is characterized by a
continued fever with paroxysmal exacerbations and remissions. It occurs
especially in warm and tropical climates. In temperate climates it
usually occurs in the late summer and fall. It is also termed bilious
remittent fever on account of the intensity of the gastro-intestinal
manifestation. The estivo-autumnal parasite is the exciting cause.
It is very often preceded by malaise, headache, nausea and vomiting.
The onset is usually gradual and the chill may be wholly absent. As a
rule, however, a chill generally occurs at the onset, but it is less
severe than that of intermittent fever. After the chill the temperature
rises rapidly to 102 or 104 degrees F. or even higher. The pulse is
full, rising to 100 or 120. There is violent headache, flushed face,
pains in the limbs and loins, nausea and vomiting, and delirium when
the temperature is very high. The urine is scanty or even suppressed,
slightly albuminous, sometimes bloody, high colored, and deposits a
sediment of urates. Jaundice is not infrequent; the spleen is enlarged
and herpes labialis is quite common. After six to twenty-four hours
the symptoms abate and slight sweating occurs. The temperature usually
drops to 100 degrees F., the headache disappears and vomiting ceases;
this is followed by a new exacerbation of fever at the end of about
twelve hours, generally without the chill; and this hot stage is in
turn again followed by the remission. These attacks may last three or
four weeks.
=Pernicious Malarial Fever.=—This is rare in temperate climates and
is always associated with the estivo-autumnal parasite. The principal
types are the cerebral and algid.
The =cerebral type= usually begins with a severe chill; sometimes,
however, the chill is absent. The patient is violently seized with
grave cerebral symptoms, as acute delirium or sudden coma. The comatose
condition lasts from twelve to twenty-four hours when consciousness
usually returns, the primary paroxysm rarely proving fatal; it is,
however, often followed in a short time by fatal relapse.
The =Algid= variety is characterized by intense prostration and extreme
coolness of the surface with the internal temperature high. The gastric
symptoms are extreme nausea and vomiting. The pulse is feeble; the
breathing frequent and shallow. There is intense thirst. The voice is
feeble and indistinct. The mind is clear. The urine is suppressed. In
this type the parasites gain entrance to the gastro-intestinal mucosa,
sometimes forming distinct thromboses of the smaller vessels. This form
may be confused with yellow fever.
=Malarial Cachexia.=—This is a chronic condition which often occurs in
cases that have not been properly treated or in persons that live in
malarial districts and are constantly exposed to the infection. The two
most striking symptoms of this condition are anemia and an enlarged
spleen or “ague cake.” There is fever at intervals, but chills rarely
occur. The skin is of a dirty yellow color. The spleen is greatly
enlarged and the blood is profoundly anemic. There is debility, and
frequent sweating, and the hands and feet are cold. The digestion may
be deranged and there may be slight jaundice. Sometimes there is edema
of the feet and even dropsy occurs. Hemorrhages of the various mucous
surfaces are common. Paraplegia and orchitis are rare symptoms. These
cases usually do well under proper treatment, and if the patient can be
moved from the malarial district.
=Masked Intermittent.=—Malarial neuralgia most frequently involves
the supraorbital branch of the trigeminus; also the occipital, the
intercostals, sciatic and brachial nerves may be affected. Such forms
of malaria are called “masked malaria.” In this form there is no fever
and as a rule it is very hard to diagnose. A blood analysis should be
made to confirm the diagnosis. In some cases one or more stages in the
paroxysm of intermittent fever is omitted; this is especially true with
the chill, in which case it is termed “dumb ague.” Malarial cachexia is
also sometimes called “dumb ague” and both are found among the older
inhabitants of malarial districts. Persons living in malarial districts
are sometimes affected with constipation, headache, loss of appetite,
nausea, vomiting and a languid feeling; this is called “latent
intermittent fever.” Frequently “bilious attacks” are of a malarial
origin.
=Malarial Hematuria.=—Hemorrhages may occur from the mucous membrane in
all severe and persistent types of malarial infection. It is a frequent
symptom of the pernicious variety. The parasites destroy the red
blood-corpuscles; this is the cause of the hemoglobinuria. Prostration
and anemia are marked. In =blackwater fever=, a tropical disorder,
acute hemolysis, is the cause of the hemoglobinuria.
=Diagnosis.=—This is usually easy. The characteristic stages of the
paroxysms, the periodicity, residence in malarial districts and the
alterations in the blood will usually remove every doubt as to the
diagnosis.
=Typhoid Fever= may simulate malarial fever, but a careful analysis of
symptoms and blood examination will differentiate.
=Prognosis.=—This is almost always favorable under early and persistent
treatment. The unfavorable symptoms are uremia, hemorrhage and marked
jaundice.
=Treatment.=—Attention should first be given to =prophylactic
measures=. Environment, isolation of the patient, and destruction of
the mosquito are important considerations. Cases of malarial fever
present distinct lesions in the vertebræ and ribs corresponding to
the vasomotor nerve supply of the spleen and liver. The most common
lesion found is a marked lateral deviation between the ninth and tenth
dorsal vertebræ and a consequent downward displacement of the tenth
ribs. A disturbance will always be found in the region of the eighth
to the eleventh dorsal vertebra, inclusive, or in the corresponding
ribs on either side. These lesions undoubtedly derange the vasomotor
nerves to the spleen and liver; thus permitting a weakness or lowered
resistance of the system, especially of the blood. The blood resisting
powers are lessened, probably on account of the spleen being affected,
as it is an elaborating gland of the blood; and the liver’s action is
somewhat dependent upon the action of the spleen; besides, the liver is
a secretory and excretory organ.
The principal =osteopathic treatment= given in cases of malarial fever
is correction of these subdislocations, and thorough treatment to the
liver and spleen directly. Ligon observes that when the case does not
respond quickly to treatment it is very liable to be of considerable
duration, although in the majority of cases the disease is controlled
from the third to seventh day; the most constant lesions found are from
the eighth to tenth dorsal and also the fourth lumbar.
During the =chilly stage= thorough treatment of the vasomotor nerves in
the upper cervical, the upper dorsal, the lower dorsal and the lumbar
regions is indicated; this treatment is given to equalize the vascular
system.
During the =hot stage= the same treatment as in the chilly stage should
be given to control the vascular system; besides a thorough treatment
of the spleen and liver is necessary. Sponging the body with water will
be of some aid in reducing the temperature.
During the =sweat stage= thorough inhibition at the superior cervical
ganglion to control the sweat center of the medulla, and treatment at
the upper dorsal and first lumbar to control auxiliary sweat centers
are indicated.
The bowels should be kept active. When in a comatose form and when
internal temperature is high, place the patient in a bath. In chronic
cases, change of climate with thorough systematic treatment will
usually result in recovery.
Tete[53], of Louisiana, makes the following interesting statement: “A
specific osteopathic treatment given within an hour before the expected
chill is a specific cure for malaria.” He follows this up by treating
on the third, fifth, seventh, fourteenth, and twenty-first days, on
account of the tendency of the return of an attack on those days. His
observation of the value of treatment just before the attack is borne
out by a report by Teall[54] where the case was cured in one treatment,
but the lesion was as high as the fourth dorsal. N. Chapman confirms
this as being her experience in many cases. The spleen has been
observed by Bandel to become engorged and upon emptying there would
follow a rise of temperature of one fourth to half a degree. This has
also been spoken of by Tucker as the “splenic wave.” Ligon makes the
statement that where the osteopathic lesion (the predisposing cause)
has been of long standing prior to the attack, and as a consequence
hard to correct, it is difficult to shorten the malarial attack.
This would emphasize the point that the essential treatment must be a
thoroughly readjustive one, and that stimulatory and inhibitory work
can only palliate. This is borne out by several practitioners who
have had considerable experience. Very satisfactory results follow
adjustment of the seventh to tenth dorsals.
Quinine has been accepted by medical authorities as a specific for
malaria. It is supposed to act directly upon the intracorpuscular
hematozoa. That it is not infallible is shown by the numerous cases
which come to the osteopath, suffering from both the disease and the
quinine. And even drug authorities state that other treatment is also
required. It has remained for Dr. Still to demonstrate that excellent
results follow osteopathic treatment in malaria. Frequently a single
treatment has been sufficient to free and regulate the body fluids and
forces so that the parasite was rendered inert, and this treatment
was directed chiefly to the fourth and twelfth dorsals. Whereas the
osteopath recognizes and appreciates the importance of micro-organisms
as exciting and determining factors in many diseases, still he values
them as secondary factors only and relies primarily upon removing
the predisposing and true etiologic factors, so that nature’s forces
may not be obstructed and thus predominate. Osteopathic etiology and
pathology has shown so conclusively, in a large number of cases, that
the existence of micro-organisms is dependent upon devitalized tissue,
whether the tissue is a local one or a circulating one, as the blood;
and just so soon as the anatomical is adjusted the physiological will
function and antitoxic and antimicrobic substances are secreted.
“When the patient has the quartan parasite, as soon as the temperature
begins to fall I give him from two to six ounces of red meat juice,
extracted from rare beefsteak, sometimes as much as five pounds in the
first twenty-four hours following the chill. In almost all cases of
quartan malaria the blood is built up sufficiently by the time they
reach the second cycle to pass without the paroxysm, or chill. By the
time for the third cycle, which is the seventh day, I always have
built up the patient’s resistance so as to enable him to pass by this
cycle without any symptoms of malaria whatever. In cases of double or
triple I find the same treatment causes about the same results. I do
not give any other diet, except dry toast if they eat the beef instead
of taking the juice. If they can take the steak I prefer their taking
it, but almost all cases prefer the juice. * * * The treatment for the
tertian type of malaria is practically the same as the treatment for
the quartan.
“The estivo-autumnal type of malaria differs from the quartan and
tertian types; first, in that the paroxysms are, as a rule, much more
irregular; second, they are much longer in duration; third, the chills
are more frequently absent; fourth, the fever is often irregular,
intermittent, remittent, or continuous in character. This type very
often takes the form of blackwater or hemoglobinuric type with
hemorrhagic symptoms, with hemorrhage from nose, gums, and bowels. The
first thing to do in a case of hemorrhagic malaria is to put an ice
bag on the abdomen, which will tend to control the hemorrhage from the
kidneys. Give the patient all the red beef juice you can get him to
take, provided he has not developed a very sick stomach; if so, give
him high saline enemas and in one-half hour give him four ounces red
beef juice per rectum. Repeat the feeding per rectum in four hours. As
soon as he can retain anything on stomach give him all the juice he can
take comfortably. Treat the liver thoroughly—at least three times in
the first twenty-four hours. At the end of thirty-six hours the yellow
cast will be very much lighter, which is a sure sign that the patient
is getting better. Watch the urine closely. The third day there may
occur a suppression. If so, give strong stimulation to the renal plexus
through the abdomen, and be sure there is a thorough relaxation of the
dorsal and lumbar muscles.
“It is an established fact that people in the malarial districts eat
very little beef. I find that ninety-nine per cent of the cases of
malaria never eat it, or when they on rare occasion do, it has been so
overcooked that all the blood-building substances have been destroyed.
The beef raw would be better in my opinion; although, the possible
chance of getting a tape-worm or animal parasite is so considerable
that I would advise that the beef should be heated to 250 degrees.”—E.
C. ARMSTRONG, Clinical Osteopathy.
Septicemia
This term is applied to any toxic condition caused by the invasion of
the blood by pathogenic micro-organisms, with or without any visible
site of infection.
=Etiologically=, the micrococci, streptococci, pneumococci, or
staphylococci, as to frequency, in order named, are the cause. The
infection is usually introduced by a wound, of any degree of severity.
The uterus is a frequent seat following miscarriage, parturition or
operation. The virus may be absorbed by the mucous membrane. It may
also arise from infection of the deeper tissues. =Pathologically=,
the changes are not marked, but consist in brownish color of the
muscles, ecchymotic spots in the pia mater and dark appearance of the
blood, which is also less coagulable. Spleen, liver and lymphatics are
enlarged with some changes in the other organs.
=Symptoms.=—The incubation period is from four to six days and the
onset is gradual, though often announced by a distinctive chill,
followed by a profuse sweat. The most common type is the continuous
form of fever, which may, in morning remissions, become subnormal.
Pulse is rapid at the beginning, but as cardiac failure comes on,
it becomes weaker. In the earlier stages there may be vomiting with
diarrhea later. There are punctiform hemorrhages of the skin and
possibly other eruptions. Blood examination will settle any doubt as to
diagnosis.
=Prognosis= is good in large percent of cases and depends upon the
general health of the patient.
=Treatment.=—“Incise and drain the infected part; if possible, apply
hot boracic acid compresses or keep part suspended in hot boracic acid
solution. Osteopathic treatment will aid materially in stimulating
and strengthening the patient. Bowels, kidneys and skin must be kept
active. Normal salt solution, hypodermically or per rectum is of value.
Diet should be liquid, fruit juices, broths, soups until temperature
has remained normal twenty-four hours then milk, eggs etc., in
gradually increasing amounts until general diet is restored. Amputation
of the part may be necessary.”—L. E. BROWNE.
Pyemia
A febrile disease arising from an invasion of the blood by pathogenic
bacteria, wherein sepsis and multiple abscesses occur from absorption
and metastasis.
=Etiologically=, the cause may be traced to various specific organisms
which enter the blood stream and produce thrombophlebitis. From these
points and from other bacteria, new foci are established. Occasionally
the lymphatics carry the germs. The disease may also start from
ulcerative endocarditis or when the appendix is infected.
=Pathologically=, thrombosis of the vein may take place in any region.
Abscesses may form in the lungs, liver, spleen or other internal
organs. The small abscesses may unite and form a large one. The skin
presents eruptions and hemorrhagic extravasations, while there may
be ulcers of the mucous membrane, also the serous surfaces may be
purulently inflamed. The muscles, subcutaneous and osseous tissue
occasionally have abscesses. Ulcerative and suppurative heart lesions
occur.
=Symptoms.=—The incubation period is short. There may be slight fever,
but commonly a chill is the first symptom, which may reoccur for some
time. The fever is either remittent or intermittent and when the
temperature is low, sweating is a feature. The pulse becomes rapid and
weak, when the disease is severe; breathing becomes difficult. Skin
symptoms, such as eruptions and pustules, generally occur. In a word,
there is a general intoxication. There is a lessened number of red
blood corpuscles and leucocytosis is a characteristic. In grave cases,
delirium and coma are present.
=Diagnosis.=—The history of the case and symptoms will usually
render diagnosis easy, although care is necessary to determine from
septicemia. Malaria, typhoid and acute tuberculosis must be excluded.
=Prognosis.=—Much depends on asepsis and surgery but on the whole it is
unfavorable.
=Treatment.=—Surgical interference and treatment as outlined under
septicemia is the only hope.
Dengue
(BREAKBONE FEVER)
=Definition.=—An acute infectious disease; characterized by a double
febrile paroxysm, severe pains in the muscles and joints and sometimes
a skin eruption.
=Etiology.=—It is a disease of tropical and subtropical regions.
Unhygienic conditions predispose to an attack. During an epidemic a
single attack is the rule. The disease spreads from place to place
along the lines of travel, attacking both sexes, and all ages. It
occurs in epidemics, practically affecting every one. The specific germ
has never been isolated as it is probably ultra-microscopic but there
is no doubt but that it is carried by the mosquito _Culex fatigans_.
=Symptoms.=—The incubation period lasts about four days. The onset is
abrupt with a slight chill, headache, and extreme pain in the joints
and muscles, of a boring or breaking character. The joints become red,
swollen and painful. The fever rises gradually to 103 or 106 degrees
F., or over. The pulse is rapid and full and the respirations are
much quickened. The face is flushed, the tongue coated, the appetite
is lost, and slight nausea occurs. “Black vomit,” similar to that of
yellow fever, has been observed in this disease. Hemorrhages from
various organs may occur and the lymphatic glands are swollen. The
urine is scanty and the bowels constipated. Febrile albuminuria and
delirium are rare.
At the end of three or four days the temperature falls and there is
a period of remission; the patient is free from pain, but profoundly
prostrated. During this time the eruption generally appears, but is
never constant in character. After a remission of two or three days,
the symptoms reappear and a second febrile paroxysm sets in. This is
usually milder and shorter than the first, lasting two or three days,
when convalescence begins. The duration is, according to medical
writers, from seven to ten days, and convalescence slow. Death seldom
occurs, so practically no pathological changes have been recorded. By
osteopathic treatment, E. B. Ligon has been able to confine the attack
to four or five days duration; this is confirmed by the experience of
N. Chapman.
=Diagnosis.=—During an epidemic the disease attacks all classes alike,
and the distinct remission renders the diagnosis comparatively easy. An
occasional case might be mistaken for acute rheumatism, but the absence
of any glandular swelling or eruption, while the pain is more closely
limited to the joints, will aid in the diagnosis. Care has to be taken
that yellow fever is not mistaken for dengue.
=Treatment.=—The indications of the treatment are to maintain the
patient’s strength and to treat the leading symptoms as they arise.
The severity of an attack can probably be lessened at the start by
strong and thorough treatment of the suboccipital, upper dorsal, lower
dorsal and lower lumbar regions, respectively, so as to control the
large vascular areas by means of the vasomotor nerves of the cranial
region, of the lungs, of the splanchnic region, and of the lower limbs,
thus equalizing the entire vascular system. Elimination should be
pushed and the excretory organs stimulated. Ligon has observed that the
cervical and lumbar regions are especially tender on the second day
and the lower dorsal region on the third day. The most severe symptoms
disappeared within a few hours after treatment and the attack was
markedly shortened.
The high fever may be treated by the usual methods and by the external
application of cold water. The pain is to be controlled, according to
the region affected, by a correction of parts impinging upon the nerve
tissues and by strong inhibition. The entire spinal region should be
kept constantly in a relaxed condition, as far as muscular contractions
are concerned. Particularly should the treatment be extensive along the
spine during prostration. N. Chapman, in addition to the osteopathic
treatment, has the patient drink considerable hot water; also employs
the hot bath. The treatment frequently shortened the attack. During the
entire attack of the disease, the patient should be kept in bed and a
carefully regulated diet administered. Relapses are not infrequent. A
suitable change of air may hasten convalescence.
Cerebrospinal Meningitis
=Definition.=—A specific, infectious disease caused by the diplococcus
intracellularis meningitidis, occurring sporadically and in epidemics.
It is characterized by inflammation of the membranes of the brain and
spinal cord and an irregular course.
=Osteopathic Etiology= and =Pathology=.—The specific exciting cause of
the cerebrospinal meningitis is due to the diplococcus intracellularis
meningitidis of Weichselbaum. Lesions are found in the vertebræ
corresponding to the cervical and dorsal enlargement of the cord, as
well as in corresponding deep muscles; also, as is well known, the
muscles of the entire back are severely contracted, especially of the
cervical, upper and lower dorsal regions. More commonly it attacks
the young, although it may occur at any age. Overexertion, exposure,
overcrowded and illy-ventilated buildings, barracks and tenements, and
depressing mental influences are predisposing causes. Many times the
disease occurs among the poorer classes. Sometimes the disease prevails
in the country rather than in the city.
In cases that prove speedily fatal there may be no characteristic
changes; simply marked congestion. Other cases in which death occurs
after the disease has been fully developed, there is found every degree
of inflammation from slight hyperemia to suppurative changes. There can
be no doubt that the osteopathic lesion, as vertebral and rib lesions
and deep muscular contractions, affects the circulation of the meninges
of the brain and cord and thus favors the invasion of the specific
micro-organism. The arteries, veins and sinuses are greatly engorged.
The walls of the ventricles soften and the ventricles contain serous
exudate. The brain matter may be congested and softened in spots. In
the spinal membranes similar changes take place and at times there is
extravasation of blood. The changes are more marked on the posterior
than the anterior surface of the cord. Abscesses sometimes form. The
exudate may follow the lymph sheaths of the cranial nerves, especially
the auditory and optic. In long standing cases the membranes become
thick and adherent and areas of softening or atrophy of the cortex
develop. The thickening and adhesions of the membranes may cause
various symptoms for months or even years after recovery from the acute
disorder.
The spleen may be normal in size, but when the fever has been intense,
it is apt to be slightly enlarged. Bronchitis, pneumonia, endocarditis
and pleurisy may occur. The liver may become hyperemic and the kidneys
congested.
=Symptoms.=—The prodromes vary, although the onset is apt to be
sudden with a decided chill; headache; vomiting, and pain in the
neck and back, which is usually severe, but may be so slight as not
to be noticed by the patient. The temperature rises to 101 to 102
degrees F., in most cases. However, it may rise to 105 degrees or
106 degrees and even to 108 degrees in fatal cases, and the pulse is
full. Hyperesthesia, photophobia, and dread of noise are apt to be
prominent symptoms. The muscles of the neck and back become rigid,
and there are pains in the limbs. Orthotonos occurs more frequently
than opisthotonos. Convulsions are common in children. There may be
paralysis, especially of the muscles of the face and eyes. Delirium
usually appears early; it may be mild, but it is often maniacal. The
bowels are usually confined, though there may be diarrhea. There is
moderate and constant leucocytosis and jaundice has been met with.
The urine is sometimes albuminous, and sugar has been noted in rare
cases. The urine may be increased, but more often it is lessened as in
other infectious diseases.
Herpes facialis occurs shortly after the onset in more than half the
cases. The contents of the vesicles may be purulent and one or two may
coalesce. The petechial eruptions are occasionally numerous and cover
the entire skin; they do not disappear upon pressure and the number of
spots varies greatly. Other eruptions as sudamina, ecthyma, pemphigus,
urticaria, erysipelas, rose colored spots, and gangrene of the skin
(rarely) have been met with.
In cases that are =rapidly fatal=, the onset is sudden, usually
with violent chills, headache, depression, and in a few hours coma
and collapse, which are soon followed by a fatal termination. The
temperature may rise slightly, but it is often subnormal. The pulse is
feeble; breathing is labored. These cases occur more frequently at the
beginning of an epidemic. They occasionally occur sporadically.
The =abortive= form terminates abruptly after the development of one or
more pronounced, characteristic symptoms.
The =mild= form can only be recognized during the prevalence of an
epidemic. The symptoms are very mild; slight vomiting, little or no
fever, headache and slight pain in the back and limbs.
The =intermittent= form is characterized by increase in the fever
every day or second day. The strict periodicity seen in malaria is not
observed; the fever resembles that of pyemia.
In the =chronic= form the condition may persist for weeks or months.
=Complications.=—Pneumonia (lobar and lobular) is a frequent
complication. Pleurisy, pericarditis, parotitis, arthritis, enteritis,
optic neuritis and otitis media may be other complications.
=Sequelæ.=—Blindness, deafness, keratitis (rarely), persistent
headache, chronic hydrocephalus, abscess of the brain, mental
feebleness, defective articulation, aphasia, and paralysis of certain
cranial nerves or of the lower extremities have occurred.
=Diagnosis.=—=Typhoid fever= begins slowly and is unaccompanied by
vomiting, muscular spasms or rigidity, or hyperesthesia. In typhoid
the fever is higher and there is a characteristic temperature curve.
Widal’s test will confirm.
=Tubercular meningitis= is not epidemic and has no characteristic
eruption. It is usually less sudden in its development and is
invariably fatal. Retraction of the neck, muscular spasms of the legs
and arms are not so marked as in spinal meningitis.
=Pneumonia= may be complicated with meningitis, especially when the
meningitis is confined to the cerebrum. If the case is not seen early,
it is almost impossible to say which is the primary affection, as
pneumonia may have meningeal complications or cerebrospinal meningitis
may be associated with pneumonia. There will be motor spasms and
tremors, but the head is rarely retracted, and there is less myalgiac
pain than in cerebrospinal meningitis.
=Prognosis.=—This varies according to the severity of the type. It
is a grave disease. Cases have been treated successfully by several
osteopaths. The duration is very variable—from two or three days to
weeks or even months, but probably in all cases this time can be
materially shortened by judicious osteopathic treatment. Convalescence
is very slow and relapses are prone to occur.
=Treatment.=—The osteopathic treatment of cerebrospinal meningitis
requires most thorough, but very careful, work along the spinal column,
especially the cervical region and the region of the dorsal enlargement
of the spinal cord, in relaxing and keeping relaxed the deep muscles
on either side of the spine and correcting the derangements of the
vertebræ, particularly in the upper cervical spine. Such treatment
has a marked effect on the circulation of the spinal cord and brain.
Probably, a large amount of the work along the spine, in all cases
where muscles are relaxed, has a direct effect upon the circulation of
the spinal cord. This treatment constitutes the primary osteopathic
work in cerebrospinal fever and should be frequently applied until a
cure is obtained. Even in chronic cases where limbs have been greatly
affected by pressure upon the nerve centers, due to a thickened
membrane, continued osteopathic treatment along the spine has had a
marked effect in absorbing the pathological condition and restoring
strength.
The preceding spinal treatment is also a very great safeguard in
keeping the various viscera healthy and thus preventing complications.
In all constitutional diseases of an acute nature, it is a wise
precaution to thoroughly examine the entire length of the spinal
column at each visit; and if such precaution is taken many serious
complications will never occur that might otherwise have taken place.
The patient should be isolated in a somewhat darkened room, and care
taken that the disease is not allowed to spread. Keep the patient upon
his sides as much as possible. The diet should be a nutritious one of
milk and broths. They should drink freely of water. Cold to the head
and spine will be of service in controlling the inflammation; it should
be applied with an ice-cap and a spinal ice-bag. Sponging the body
should be employed if the temperature is above 102° F. The general
bath, as in typhoid fever, may be employed if practicable. Direct
treatment to the bowels, kidneys, liver and spleen should be given at
each treatment.
Lumbar puncture and the Flexner-Jobling serum are considered of value
by those who have had an extensive experience.
Diphtheria
=Definition.=—An acute, infectious disease, caused by the
Klebs-Loeffler bacillus, and characterized by a membranous exudation
on the mucous membrane of the fauces, larynx or nose, and by
constitutional symptoms. The presence of the Klebs-Loeffler bacillus
distinguishes true diphtheria from any other form of membranous
inflammation. The term diphtheroid is applied to all such forms as are
not due to the Klebs-Loeffler bacillus.
=Osteopathic Etiology= and =Pathology=.—The exciting cause is the
Klebs-Loeffler bacillus. The predisposing cause is obstruction to the
circulation of the pharynx and tonsils by subdislocations of upper
cervical vertebræ, and even the lower cervical and upper dorsal, and
severely contracted deep muscles of the neck. The stasis of blood
favors the growth of the bacillus.
Link[55] says: “The cause of nasal, pharyngeal or laryngeal diphtheria
is obstruction of the blood and lymph through the neck and the
obstruction occurs as a result of lesions in the cervical region,
affecting the cervical sympathetics, or lesions in the upper thoracic
region whence the vasomotor fibers arise. A derangement of the
vertebral articulation of the first rib is usually found. (This affects
the stellate ganglion and fibers of the sympathetic chain). These
lesions cause a condition of lowered vitality of the mucosa of the nose
and throat; the abnormal secretion favoring the rapid multiplication of
the Klebs-Loeffler bacillus—the exciting cause of the disease.”
Dr. Still believed that, among other lesions, contracting of tissues
involving the scaleni and disturbing the relations of the first
rib with the clavicle and vertebra are causative factors. The
constitutional symptoms are produced by the toxins generated by the
bacillus and absorbed from the diseased spots by the lymphatics
and blood-vessels. The bacillus is non-motile and does not usually
penetrate the mucosa, but remains very near the site of the local
changes although there are instances where it may enter the blood and
other tissues. The bacillus is very resistant and can maintain an
existence for months outside of the body. There is great variation in
the virulence of the Klebs-Loeffler bacillus; it has been found in
healthy throats, and sometimes the bacillus may exist in the throat
after an attack of diphtheria for months after all the membrane has
disappeared. It has also been found in cases of simple catarrhal angina
without membrane, and in simple tonsillitis Of the bacteria associated
with the bacillus of diphtheria, the streptococcus pyogenes is the most
common and probably the most active. The staphylococcus, micrococcus
lanceolatus and bacillus coli communis are also found.
The contagion is communicated, as a rule, through the air, by means of
fomites from the membranous exudate or discharges from the diphtheritic
patients, or during convalescence, from secretions of the nose and
throat. Infected milk may cause the disease. Most cases occur in
childhood, between the second and seventh year. The disease is most
prevalent in the cold autumn and spring months. It is most frequently
met with in temperate and cold climates. Defective drainage, catarrhal
conditions of the throat, enlarged tonsils, general weakness, and
feeble resisting power are predisposing factors. One attack does not
confer immunity from another, but rather predisposes to a second.
The =false membrane= is usually found on the tonsils, the pillars of
the fauces and the pharynx, and in fatal cases it may be extensive
and involve the uvula, the soft palate and the posterior nares, and
even the trachea and bronchi. At first this membrane is yellowish
white, but later may become gray; it is more or less adherent and
when torn off leaves a raw surface. The diphtheritic poison coming in
contact with the throat leads to, first, a necrosis or death of the
epithelial cells, especially the more superficial, and the leucocytes.
The second change is the hyaline transformation, and simultaneously
coagulation; hence the term coagulation-necrosis. The irritation
produced by the bacilli causes a migration of leucocytes and these are
destroyed and undergo hyaline transformation. This process proceeds
from without inward and is usually superficial, and the necrosis may
be extensive, involving the deeper tissues, causing ulceration and a
gangrenous condition of the parts. The erosion of the tonsils may be
so severe as to attack the carotid artery. The lymphatic glands are
considerably swollen. The spleen is commonly enlarged. The kidneys show
parenchymatous changes. The blood is dark and fluid. Fatty degeneration
of the heart is not infrequent. Sometimes fibrinous coagula are found
in the heart. Capillary bronchitis, catarrhal pneumonia and areas of
collapse are almost constantly found on examination of the lungs in
fatal cases. The =urine= is typically febrile with early albumin and
often tube casts and renal epithelium. The =blood= shows an excess
of red blood cells which may reach 7,500,000. Hemoglobin is slightly
reduced. There is considerable anemia during convalescence depending
upon severity of toxemia.
=Symptoms.=—The incubation period varies from one to ten days, usually
two or three days. According to the location, diphtheria may be divided
into pharyngeal, laryngeal and nasal forms.
In =Pharyngeal Diphtheria=, which is most common, there is first a
slight chill or chilliness, followed by fever and sore throat, both of
which increase rapidly. The throat is swollen and red and the patient
complains of difficult swallowing. The membrane begins on the tonsils
in the form of grayish-white patches; it then spreads from the tonsils
to the soft palate, sometimes covering the uvula. The cervical glands
are swollen and tender. The neck muscles are contracted and somewhat
difficult to relax. The temperature rises to 102 or 104 degrees F. The
pulse is rapid and feeble, ranging from 120 to 140. There is loss of
appetite. There is more or less prostration depending upon the gravity
of the constitutional symptoms. The average duration is from one to two
weeks.
=Laryngeal Diphtheria= (Membranous Croup) may be secondary to extension
from the fauces or it may be primary. At first there is slight
hoarseness and a harsh, metallic, ringing cough. These symptoms may
persist for a day or two, when the child suddenly becomes worse; there
is marked dyspnea and the lips and finger tips become livid. The child
soon becomes very restless. The temperature may be slightly above
normal and the pulse increased in frequency. In favorable cases the
dyspnea is not very marked and the child probably will have only one
or two paroxysms, when it will fall asleep and wake in the morning
feeling very comfortable. The next night, however, the attack may be
more pronounced. In extreme cases death may result from suffocation.
In some cases the suffocation is slower and results from extension of
the membrane downward into the bronchi. Dr. Still found same conditions
as in diphtheria, but also the hyoid is involved with the superior
laryngeal nerve. The sacral and lumbar nerves are also involved. He
always emphasized chilling of gluteal region as a cause for croup and
that heat should be applied at the inception of the disease.
=Nasal Diphtheria= is generally secondary, but it may be a primary
affection. In many cases no membrane is found; in others there may
be a pseudo-membrane formed in the nose, but there is absence of any
systemic disturbance. The Klebs-Loeffler bacillus is sometimes present
in these membranes. Nasal diphtheria may be a very grave disease—the
constitutional symptoms being great prostration, high fever, marked
glandular swelling, irritating and offensive discharges from the nose,
and epistaxis. Inflammation occasionally extends through the tear duct
to the conjunctiva.
A diphtheritic membrane may grow where the skin has been cut or
bruised, but the bacillus cannot live on normal skin. It nourishes on a
raw, moist surface and membranes have grown on the lips, tongue, vulva,
glans penis, and on ulcerative surfaces and wounds. Diphtheria occurs
occasionally in the conjunctiva and the external auditory meatus.
It should be remembered that there are many atypical forms of
diphtheria. Bacteriological examination should always be made in
suspicious and puzzling cases.
The complications of diphtheria are nephritis, hemorrhages, rashes,
capillary bronchitis, pulmonary collapse, catarrhal pneumonia,
myocarditis, arthritis, otitis media, and paralysis.
=Diagnosis.=—The presence of the Klebs-Loeffler bacillus will at once
decide the diagnosis of diphtheria.
=Prognosis.=—The prognosis should always be guarded. The nasal and
laryngeal forms are always grave. The causes of death are involvement
of the larynx, septic infection, heart failure, bronchopneumonia during
convalescence, and rarely, uremia.
=Treatment.=—Hygienic and prophylactic measures are important. A room
should be selected that is ventilated and exposed to the sunlight. All
unnecessary articles of furniture should be removed. Great care must be
taken against the spread of the disease. Always isolate the patient and
disinfect everything that has come in contact with him. The greatest
danger lies in the spread of the disease during convalescence and in
the ambulatory form, when patients are about and coming in contact with
individuals, especially children with catarrhal conditions of the nose
and throat. The physician should be careful about disinfecting himself.
In view of the fact that many osteopaths have treated successfully
numerous cases of diphtheria and that the osteopathic treatment is
peculiarly indicated and effective, the probable requirement of
antitoxin (the use of which we do not feel called upon to discuss)
would be lessened. Relative to the antitoxin Osier says: “The principle
of action depends on the circumstance that the blood serum of an animal
rendered immune, when introduced into another animal, protects it
from infection with the diphtheria bacilli, and has also an important
curative influence upon diphtheria, whether artificially given to
animals, or spontaneously acquired by man.”
“The treatment of diphtheria by osteopathic methods is often a pleasure
rather than a trial because of the success which rewards us for our
efforts. There has been considerable discussion by the members of
our profession regarding the methods to be employed in successfully
overcoming this disease, and many have expressed the view that since
antitoxic serum is a physiological remedy, which naturally belongs
to all schools of healing, it should be employed by the osteopathic
physician in cases of diphtheria. I have no objections to the use of
the serum therapy by members of the profession who conscientiously feel
that they need it in their practice to secure the highest success.
However, I feel, on the other hand, that if they were well acquainted
with the technique of the methods * * * they would not feel it to their
advantage, from the standpoint of success, to use injections in a
single case.”—R. D. EMERY, Clinical Osteopathy.
The local treatment should be carefully, but vigorously, given. By
proper treatment of the throat the extension of the disease may be
prevented. The muscles about the throat, especially the deep ones,
should be thoroughly relaxed and the cervical vertebra; corrected if
displaced. The vasomotor nerves to the blood vessels of the affected
region require careful treatment at the superior cervical ganglion,
and the cervical lymphatics from the atlas to the first rib should be
closely watched. The nerves to control are the vagi, glosso-pharyngeal,
spinal accessory, and sympathetic nerves to the pharyngeal plexus,
and in cases of nasal diphtheria the fifth nerve has to be carefully
treated. An external treatment to the pharynx will have the greatest
effect on these nerves. An internal treatment to the nerves of the soft
palate will be of considerable service. The parts diseased should be
disinfected and kept as clean as possible. Bichloride of mercury (1 :
4000) used as a spray will be found satisfactory, although there are
several other disinfectants and germicides that may be used. Pellets
of ice in the mouth will be a comfort to the patient. Cold applied
externally will be found best for the adult; heat externally is better
for the child.
Every possible means should be used to prevent the disease from
spreading. One of the chief dangers of diphtheria is the spread of
the disease to the larynx, trachea and bronchi. When the disease has
extended to these parts it presents all the symptoms of =true croup=.
The deep cervical muscles should be thoroughly relaxed to aid in
relieving the passive hyperemia and with a view of disorganizing the
exudate. Attention should be given to the upper ribs, as interferences
with the vasomotor nerves of the mucous membrane of the trachea and
bronchial tubes usually occur. Direct treatment over the larynx and
local treatment through the mouth upon the soft palate will be of
aid. A thorough relaxation of all the dorsal muscles, even as low as
the tenth dorsal, should be given. Inhalations of slaked, freshly
burnt lime may be useful in loosening the exudation. In desperate
cases tracheotomy or intubation of the larynx should be performed.
Willard[56] says, relative to membranous croup: “It matters not whether
or not the laryngeal inflammation was immediately caused by a germ; it
would not, nor could not, have been produced by such had there not been
an unnatural condition of the circulation of and about the larynx.”
A constitutional treatment should always be given with a view of
preventing the spread of the disease from one organ to another and to
prevent complications. The heart’s action should be carefully watched
throughout the entire course of the disease. Treatment of the spinal
cord will guard against paralysis that sometimes follows the venous
hyperemia of the vascular linings and substance of the brain and spinal
cord. Pay particular attention to the upper dorsal region to prevent
possible heart involvement. Post-diphtheritic paralysis seldom if ever
occurs in cases that are treated osteopathically. This is a common
sequela and is present in from 10 percent to 30 per cent of cases,
appearing within three weeks of apparent recovery. Sometimes it is the
only result to show diphtheria was present. It seems to follow use of
antitoxin rather frequently. Attention to the splanchnics and to the
abdomen directly will tend to keep the stomach, liver, kidneys, and
intestines in a healthy state. The diet of the patient should consist
of liquid food—milk, broths, meat juice, raw eggs and barley water.
Let the patient drink freely of water. Treatment of the rectum may be
employed with benefit when the pharynx is greatly disturbed.
Various =sequelæ= and =complications= are best relieved or prevented,
according to Link, as follows: “First, limiting the production of
toxins by a most thorough relaxation of the muscles of the neck,
thereby favoring the unobstructed circulation of the blood and lymph;
second, by the correction of lesions which affect the vasomotor of
the head and neck; third, by spinal treatment affecting the vasomotor
to the areas involved; fourth, by increasing the activity of the
excretory organs, by treatment in the splanchnic and lumbar areas, that
the toxins may be more rapidly eliminated. In cases where laryngeal
stenosis is marked and suffocation is imminent, intubation should not
be delayed.” Post-diphtheritic paralysis usually yields to osteopathic
treatment. Apply treatment according to location.
Dysentery
(BLOODY FLUX).
=Dysentery= is an infectious disease wherein the large intestine is
inflamed, with ulceration of the mucous membrane; is characterized,
clinically, by frequent stools containing blood and mucus; fever and
exhaustion. =Osteopathic lesions= of an osseous character and deep
muscular contractions of the lumbar region are always present. These
involve the vasomotor nerves to blood vessels and lymph channels.
Catarrh of the intestinal tract is an important predisposing cause. The
disease usually occurs in the summer and autumn, and is more common
in hot, malarial regions, although it is found in various climates.
Unhygienic conditions are also important predisposing factors. In no
disease more than dysentery does specific correction of the osseous
lesion effect quick and satisfactory results.
Acute Ileocolitis
(BACILLARY DYSENTERY)
This is the variety most frequently found in temperate climates. It
occurs either sporadically or endemically. The Flexner bacillus is
frequently found, as well as pus micro-organisms. There are various
strains of the bacillus. There is a catarrhal inflammation of part or
the whole of the large bowel. Other forms may occur, as ulcerative and
membranous.
=Osteopathic Etiology= and =Pathology=.—Sudden atmospheric changes and
simple irritants, such as unripe and indigestible food, are usually the
immediate causes. The predisposing cause of acute catarrhal dysentery
is always found by the osteopath to be due to spinal derangements in
the lumbar region. The lesion is generally a slight lateral deviation
of a vertebra. It is generally found at the second or third lumbar;
still, the trouble may be found at any point in the lumbar section. The
lesion involves vasomotor nerves to the intestinal mucous membrane,
thus causing the inflammation. The drinking of impure water in itself
may not be the cause of the disease, but is a favorable medium for the
development of the organisms which may excite it. Dyspeptic conditions
and constipation seem to predispose to the disease.
The mucous membrane is injected and swollen and often covered with
bloody mucus. The follicles of Lieberkuhn are enlarged from retention
of their contents, the result of the swelling; the follicles are often
ruptured and the mucous membrane sloughs off in patches, forming
ulcers. These may extend along the whole colon and frequently into the
ileum.
=Symptoms.=—Diarrhea is the most common initial symptom; the stools
being copious and painless. The stools soon become small and frequent,
covered with mucus and streaked with blood. These are passed with
straining and tenesmus, accompanied by colicky abdominal pains of a
griping character. Chills are rare. The tongue is furred and moist:
later it becomes dry. Nausea and vomiting may be present, but not as
a rule. There is fever and often excessive thirst. Later the stools
become green in color, due to the bile which causes a burning sensation
in the rectum.
On examination there are found red blood-corpuscles and leucocytes,
and large, round and oval epithelioid cells containing fat drops
and vacuoles. In mild cases, the course is about eight days; severe
cases subside within four weeks, but if the =osteopathic treatment=
is careful and specific, the usual duration can generally be reduced
one-half.
=Prognosis.=—The prognosis is generally favorable in the catarrhal form
when the disease is treated properly. The previous general health,
hygienic conditions, and sanitary surroundings are of great importance.
When there is ulceration or membranes the prognosis should be guarded.
The condition may become =chronic=.
=Treatment.=—The bowel should be thoroughly washed out by warm water
enema, several times, if necessary, to remove irritating material.
Invariably a lesion of the spinal column is found at the third and
fourth lumbars or near by. It is generally a subluxation, of a lateral
nature, between these vertebræ: rarely is the lesion above or below
this point. The treatment should be applied immediately and directly
to this region. Time is valuable in these cases and one should go to
work at once to correct the irritation. An attempt should be made at
each treatment to correct the disorder. This should not be delayed
by wasting time in relaxing muscles and inhibiting, for unusually
this gives only temporary relief. When a slight movement has been
accomplished between disordered vertebræ, treatment should be stopped
and results watched, because the adjustment may have released all
obstructions or irritations causing the disease. In many cases, to
get an anatomically correct spine is an impossibility, from the fact
that the displacements may be of long standing and naturally the
subluxated vertebræ have conformed themselves to some extent to their
unnatural position. In other words, what has been lost in the position
and relation of a vertebra may have been compensated by reducing the
effect of the lesion to a minimum. A lesion of this nature at the
third lumbar impairs the innervation to the colon and consequently
produces a stasis of blood in the mesenteric circulation, followed by
inflammation, bloody discharges, cramps, etc. A single treatment is
usually quite sufficient in milder cases. Other cases require treatment
every few hours or thereabouts, until recovery.
Treatment directly over the abdomen through the mesenteric circulation
and glands is an effective treatment in most cases and especially when
the attack is severe. It relaxes the tissues about the mesentery,
thereby relieving the stasis and freeing the circulation. The greatest
care, however should be exercised in giving this treatment.
The constant desire to defecate, that is common to many cases, is a
very annoying symptom. Strong, thorough treatment over the sacral
region, by inhibition over the sacral foramina and by relaxing the
tense muscles of the sacrum, will relieve this condition. In relaxing
these muscles, place the whole hand against the muscles and push upward
toward the occiput. This treatment inhibits the nerves to the rectum
and lessens the =tenesmus=.
Attention should be paid to the liver to keep it active. Washing out
the large bowel with tepid water produces a soothing effect, besides
having a tendency to allay inflammation. The blandest of liquid foods,
as peptonized or boiled milk, broths, beef juice, barley and rice,
should be given. The patient should remain in bed until completely
cured.
Amebic or Tropical Dysentery
This form prevails in the tropical and subtropical countries for
the most part, and is caused by an animal parasite, the _ameba
dysenteriae_. This is constantly found in the stools, the tissue of
the intestine and also in the pus of the liver abscesses, which are
secondary to dysentery. Amebae are sometimes found in the stools of
healthy men, having probably entered the system through the drinking
water or uncooked food.
=Pathologically=, the mucous membrane of part or whole of the large
intestine is swollen. Round or irregular ulcers which undermine the
mucous membrane, especially of cecum, ascending and pelvic colon, are
found. In later stages there is infiltration of the connective tissue
followed by necrosis. In some cases false membranes and sloughs are
formed.
=Symptoms.=—The onset may be either sudden or gradual, with a very
irregular diarrhea, moderate fever, and copious, liquid stools,
abounding with the amebae coli. The straining may be less severe and
persistent than in catarrhal dysentery and may be absent. Sometimes
there is nausea and vomiting.
Abscess of the liver is the most common complication, which may
be single or multiple. When single it usually involves the right
lobe. Multiple abscesses are small. The more recent abscess walls
are necrotic; the older have whitish, smooth, fibrous walls. These
abscesses do not contain pure pus, but a fatty and granular debris
containing the amebae and a few cellular elements. Sometimes they
extend into the lung.
=Diagnosis.=—This depends upon severity of attack and general condition
of the patient. Relapses often occur and the case may become chronic.
Cases have been treated osteopathically with success.
=Treatment.=—In this form of dysentery the treatment is largely
the same as in acute ileo-colitis. The spinal lesions affect the
innervation to the intestine, thus producing a stasis in the
circulation; this condition favoring, and in fact, inviting the
retention of the ameba coli in the system at this point.
The diet is the same as in other forms of dysentery. Rectal injections
and hot applications to the abdomen are useful. In all cases where
strong treatment has been given to the spinal column, a quieting
treatment to the nervous system and an inhibitory treatment to the
heart will be gratefully received by the sufferer. Both of these
effects can be accomplished at the same time by simple inhibition to
the occipital nerves. The stools should be taken care of immediately
and disinfected. Ice water enemas given frequently are reported as
giving good results. For the tenesmus, inhibit strongly at 3d, and 4th,
sacrals.
Chronic Dysentery
This is generally resultant from an acute attack, though the amebic
form may be subacute from the onset.
=Pathologically=, the coats are generally thickened, especially the
submucosa and the muscular coats being hypertrophied. Ulcers are
usually present, although there are cases in which there are no ulcers.
Cicatricial contractions sometimes follow and the calibre of the bowels
is reduced, strictures being rare.
=Symptoms.=—There is a progressive loss of flesh and strength, little
or no tenesmus, slight, colicky pain and extreme anemia. The stools
contain mucus, at times blood, and the bowels move from two to twelve
times a day.
=Diagnosis.=—The history of the initial symptoms will establish the
diagnosis. It is not always possible to distinguish between chronic
dysentery and chronic diarrhea. The duration is from a few months to
several years, although osteopathic treatment has proven very efficient
in many instances.
=Treatment.=—Rest and a liquid diet are most essential. Foods that are
easily assimilable and nourishing, with a minimum amount of residue,
are required. Beef juice, beef peptonoids and peptonized milk are the
types of food. Change of air, hygienic measures and environment are
important.
In cases that become chronic, the spinal column oftentimes exhibits
lesions above and below the lumbar region. Undoubtedly they are
lesions of secondary importance in comparison to the lumbar lesions,
but it is important that they be corrected. The treatment requires
thorough, careful work of the disordered spinal column and lower ribs.
Occasionally a slight kyphosis is present in the dorso-lumbar region
that demands persistent work in order to correct it. An occasional
rectal injection is beneficial, especially in cases that have slight
ulceration of the sigmoid flexure or rectum causing colicky pains and a
few loose stools in the morning, the patient being fairly comfortable
during the rest of the day.
Erysipelas
=Definition.=—An acute, infectious, specific disease, characterized
by a peculiar inflammation of the skin, due to the streptococcus
erysipelatis, with a tendency to spread.
=Osteopathic Etiology= and =Pathology=.—Osteopathically, lesions are
found to the vasomotor nerves and lymphatics of the affected area. Dr.
Still gives lesions of the “inferior maxilla, the cervical vertebræ,
the clavicles or the upper ribs” as specially important factors.
These lead to congestion and predispose to infection. It occurs in
epidemic form, especially in the late winter and spring. One attack
predisposes to a second. Family predisposition exercises a slight
influence. Abrasions, lacerated wounds, especially of the scalp, may
be the starting point of an attack. Persons having skin diseases and
wounds, and women who have been recently delivered are liable to be
affected. Chronic Bright’s disease, chronic alcoholism, syphilis,
debility, phthisis, organic heart disease and unhygienic surroundings
are predisposing causes.
The specific virus is the streptococcus erysipelatis, which acts as a
local irritant producing the dermatitis. These are found in the lymph
vessels and cutaneous connective tissue. The fever and constitutional
symptoms are due to toxic agents.
It is an inflammation of the skin, and if uncomplicated, no other
structures are involved. Subcutaneous and mucous tissues may be
involved, but rarely; if so, there is apt to be suppuration. Visceral
complications are of a septic character. Endocarditis, pericarditis,
pleuritis-pneumonia, and nephritis are possible complications.
=Symptoms.=—The incubation period varies from two to seven days. The
onset is generally sudden with chill, followed by fever, 104 or 105
degrees F. There may be nausea, headache, and pain in the back and
limbs. The local inflammation of the skin follows, usually on cheeks
and bridge of nose, or at site of an abraded surface. The area is red,
smooth, and edematous. It spreads rapidly, the patch being elevated
above the surrounding tissue and tense. The swelling may be so great
as to close the eyes and distort the features. The cervical glands are
swollen. The temperature continues high for four or five days and falls
by crisis. The eruption begins to subside and a moderate desquamation
occurs. If the disease takes a fresh start the fever again rises and
continues as long as the disease spreads. There is usually headache
and sometimes delirium. The tongue is furred, and bowels constipated
and the urine scanty. As a result of intense infiltration the part may
become gangrenous. Suppuration frequently occurs in facial erysipelas.
The inflammation may extend to the mucous membrane of the throat and
mouth.
=Diagnosis.=—This is not difficult. The fever, the acuteness of the
disease, the rapidily spreading eruption, and the constitutional
disturbances will serve to distinguish it from all others.
=Prognosis.=—This is usually favorable; healthy persons rarely die.
Convalescence may be slow.
=Treatment.=—Isolate the patient for the disease is contagious, and a
third person may convey the virus. The poison may cling to clothing,
furniture, etc. The physician should not take care of confinement cases.
A number of cases of erysipelas have been cured by correcting disorders
in the region of the second, third, fourth and fifth dorsals. The
lesions are principally subluxations of the ribs and severely
contracted muscles. The disorder at the points named interferes with
the vasomotor nerves to the face, thus predisposing to an attack of
erysipelas by allowing the micro-organism congenial tissue for its
devastations. In many other cases derangements have been found higher
than the upper dorsal, principally through the middle and upper
cervical vertebræ. Lesions in these regions would also interfere with
vasomotor fibres, especially through the fifth nerve directly.
The treatments on the whole are to examine for lesions to the
innervation of the affected region and remove them, besides giving
special attention to the bowels, a nutritious diet, and absolute rest.
In cases where there is much restlessness and insomnia, treat the upper
cervical region, especially the deep posterior muscles[57]. Locally,
use cold water applications; adhesive strips applied near the inflamed
area or tincture of iodine, may prevent the disease spreading.
Yellow Fever
=Definition.=—An acute, infectious disease, characterized by a febrile
paroxysm followed by short remission and then relapse, jaundice,
toxemia, suppression of the urine, and gastric hemorrhage.
=Osteopathic Etiology= and =Pathology=.—While a specific germ is the
cause of yellow fever, it has not as yet been isolated. Extended
tests by United States Army surgeons in Cuba show conclusively that
the infection is alone carried by the _stegomyia fasciata_, but “It
remains somewhat uncertain whether the mosquito is the sole means
of transmission.” (Anders). Season is the chief predisposing cause
as the outbreak is usually in summer and a frost ends its spread.
Immunity is generally conferred by one attack. Tucker[58] noted that
all cases examined had liver lesions and that most of the patients
were of the malarial or bilious type. Spinal lesions were not marked
in some cases, but when present were in the liver and renal areas.
Tete[59] believes it to be a virus secreted in the human organism under
certain atmospheric and other conditions in certain types, i. e. people
subject to hepatic and renal disturbances. He also says the vagus is an
important factor.
=Pathologically=, there is more or less jaundice and hemorrhagic
extravasations under the skin. The blood serum is red-tinted, owing
to the destruction of the red cells. The liver is pale and presents
extensive fatty degeneration, with necrotic masses in and between the
cells. The gastro-intestinal mucous membrane is swollen, congested and
presents numerous minute hemorrhages. The kidneys show parenchymatous
inflammation. The spleen is not enlarged. The heart sometimes shows
fatty degeneration. The stomach contains more or less of the “black
vomit,” which is a mixture of transuded serum and transformed blood
pigment.
=Symptoms.=—The incubation period varies from one to five days. The
attack generally begins with a chill, fever, 102 to 105 degrees,
headache and pains in the loins and legs. The pulse is accelerated,
the face is flushed, the tongue is coated, the throat sore, the bowels
constipated and the urine scanty and albuminous. Recent observers state
that bile is present in most cases before the albumin is noted. Nausea
and vomiting may be present at the onset, but become more severe about
the second or third day when the black vomit appears. The =febrile
stage= or stage of invasion, lasts from a few hours to several days
and is followed by a decline in the fever when the severity of the
other symptoms abates. This is called the =stage of remission= and in
favorable cases convalescence sets in or the patient may pass into the
second febrile paroxysm. The temperature rises again, jaundice appears
rapidly, nausea and vomiting return. The tongue becomes dry and coated.
The stools are black and offensive, the urine is albuminous, scanty and
may be suppressed; there may also be hematuria. Death may occur from
exhaustion or from uremia. Recovery may follow the gravest symptoms,
even when there has been black vomit. The duration of the entire attack
covers about one week. Relapses sometimes occur.
Price says there is a point in differential diagnosis in yellow fever
and it is a symptom not met with in any other febrile affection. It
is the progressive fall of the pulse-rate during the congestive stage
of the first sixty or seventy hours, i. e., a variation of from five
to ten beats less each morning and evening. He adds, “As long as the
kidneys are active there is but little to fear.”
=Diagnosis.=—=Remittent fever= has not the deep jaundice, the clear
mind, the black vomit, or the albuminuria of yellow fever. The enlarged
spleen and the presence of the organism of Laveran in the blood in
remittent fever will decide the diagnosis. =Dengue= is sometimes
confused with yellow fever.
=Prognosis.=—This is always a grave disease, and in its severe forms
very fatal. Recovery, however, may occur after the severest symptoms
have been manifested. Black vomit is not always a fatal sign. Enough
cases have been treated osteopathically to state that osteopathy is
particularly effective. Improved sanitation is doing much to reduce
mortality.
=Treatment.=—Prophylactic treatment should be carefully carried out.
All patients should be quarantined and carefully screened so they
cannot be bitten by the mosquito and the disease spread further. People
that are not acclimated should keep away from infected districts. All
pools, cisterns and other places which can breed mosquitoes should be
drained or screened. A systematic warfare should be waged against them.
The patient must be put to bed at once and plentifully supplied with
fresh air. Everything must be scrupulously clean—body and bed linen.
Use a tube for nourishment and a bed-pan for excretions as the patient
must not make the slightest exertion.
Spinal lesions may or may not be found. They have been observed in the
cervical, eighth dorsal and second lumbar.
The treatment on the whole is symptomatic. The chills and fever of
the first stage should be controlled by thorough work at the upper
cervical, upper dorsal, lower dorsal and lower lumbar regions.
Treatment at these points controls the superficial and deep vascular
areas of the body through the vasomotor nerves. The irritable stomach,
delirium and severe neuralgic pains of the head, back, epigastrium
and limbs are to be treated according to the conditions and severity
of the symptoms. The kidneys and bowels should be watched carefully,
and at the onset should be freely opened and control of the kidneys
never lost. Let the patient drink freely of water, which will aid.
Hydrotherapeutic measures, as a cold bath or sponging, may be employed
to aid in controlling the fever, the nervous symptoms, and the
eliminative power of the excretory organs. Discontinue the use of
hydrotherapy when a spontaneous fall of temperature occurs.
At the beginning of the first stage and during the stage of remission
are the periods that the osteopath should do very effectual work
by paying particular attention to the four large vascular areas of
the body, viz.: head, lungs, abdomen and legs. Treat the vasomotor
nerves to these regions, thoroughly, as given in the treatment of the
first stage. During the third stage everything should be done that is
possible to support the system. Ice slowly dissolved in the mouth will
be of aid to an irritable stomach. Hemorrhages and the various symptoms
are to be treated as they arise.
Good nursing, dieting, ventilation and keeping the skin, kidneys and
bowels active are the primary points to consider. During the period of
depression, the heart must be closely watched. The diet should be a
light, liquid one, of the nature of peptonized milk or light broths.
No food is recommended by some at the onset nor until the crisis is
passed. Others feed during the stage of remission and give stimulants.
During the last stage rectal feeding is suggested if gastric
irritability is pronounced.
Tetanus
(LOCK-JAW)
=Definition.=—An infectious disease, caused by Nicolaier’s tetanus
bacillus, characterized by persistent, tonic spasms of the muscles with
violent exacerbations.
=Etiology= and =Pathology=.—The exciting cause of tetanus is a specific
bacillus which usually gains access to the system through some wound.
The site of infection is the only place the germs are found.
The disease is much more prevalent in some localities than in others.
It is found in hot countries, as in India and the West Indies, far more
commonly than in temperate regions. Exposure to damp cold is one of the
recognized causes, also those localities where there are rapid changes
from cold. Such regions seem to produce conditions favorable to the
existence and growth of the bacilli.
Earth mould, particularly where putrefaction is taking place, as in
soil that has been manured, is especially favorable to the existence
of the bacillus. It is frequently found in the intestinal tract of the
horse, so that the soil about stables is apt to contain the germs. The
highly fertilized soil of France and Belgium rendered it a special
menace to the wounded of the Great War. Antitetanic serum, according to
all reports, was particularly efficacious.
Wounds and abrasions of various kinds, particularly contused and
punctured wounds of the hands and feet, favor the excitation of
tetanus. When an open wound is present, the term =traumatic tetanus=
is given to the disease; =idiopathic tetanus= when no wound is
discoverable; =tetanus neonatorum= when it attacks infants—this form
is usually due to insanitary conditions, especially the improper care
of the umbilical cord; =lock-jaw= or trismus when the jaw alone is
affected; =cephalic tetanus= when the throat and face is involved.
Characteristic lesions have not been found in the cord or the brain.
The bacilli develop at the site of the wound where the toxin is
manufactured. The bacilli do not invade the blood and organs. The
toxalbumin is one of the most virulent poisons known.
Congestion occurs in various organs, due to obstruction of the movement
of the blood during a spasm. The brain, cord, lungs and muscles are
congested. The nerves are often found swollen.
=Symptoms.=—The period of incubation is from one to twenty days. This
is time required for the poison “to be absorbed by the end plates in
the muscles and to pass up the motor nerves to the spinal cord.” In
most cases the incubation is from five to ten days. A chill precedes
other symptoms in a few cases. The onset is quite sudden, with
stiffness in the neck, jaw and tongue. There are headache, stomach
disturbance and languor. Opening the mouth is difficult, but is not
painful. Deglutition is difficult. The stiffness increases and extends
to the spinal muscles, abdomen and legs which are held in a firm spasm.
Thus, the trunk and legs are inflexible.
These symptoms vary in degree of severity, dependent upon the extent
of involvement. The jaws may be firmly locked or they may yield to
forced extension—“lock-jaw.” The muscles of the face may be involved,
the angle of the mouth drawn out, and the eyebrows raised—“risus
sardonicus.” The neck and trunk muscles affected produce opisthotonos.
Spasms of the pharynx and esophagus may occur, especially when there
are injuries to the fifth nerve.
Associated with these tonic convulsions is intense pain. The distress
of the patient is extreme when the chest muscles are affected. All
symptoms are increased during the paroxysm. A foot fall, the slamming
of a door, a draught of air or any slight sensory impression may excite
a paroxysm. The paroxysm may relax and during the interval the patient
may walk about. The spasms vary in frequency from a few minutes to
one in several hours. During spontaneous or induced sleep the spasm
usually ceases. The febrile reaction is generally slight and apparently
of nervous origin; in many cases 102 degrees F. In severe cases the
temperature may be considerably higher. Perspiration is excessive. The
urine is scanty and high colored. The bowels are usually constipated.
The mind remains clear throughout. Death is generally caused by
exhaustion. =Chronic tetanus= presents similar symptoms, but less
marked, and it develops slowly.
=Diagnosis.=—The history of a wound followed by the characteristic
symptoms would rarely occasion an error. =Strychnine poisoning=
differs from tetanus in the history, in the more rapid development of
the symptoms, no trismus at the beginning, marked involvement of the
extremities, and absence of rigidity between the paroxysms. In =tetany=
the extremities are chiefly affected by the spasms, the muscles are
relaxed during intervals, and trismus is a late or very rare condition.
In =hydrophobia= trismus does not occur and the respiratory spasm is
caused by attempts at swallowing. The mental symptoms increase.
=Prognosis.=—The prognosis is unfavorable. Eighty per cent of traumatic
and fifty per cent of the idiopathic cases prove fatal. Cases that
are fatal usually die within six days. Cases where there is slight
elevation of temperature, and where the spasm is localized to the
muscles of the face, neck and jaw, or where muscle stiffness is late in
appearing, are more likely to recover.
=Treatment.=—Free incision and thorough disinfection with hydrogen
peroxide and cauterization with pure carbolic acid, of the wound are
necessary. The patient should be put in a dark room and there remain as
quietly as possible. Avoid all sources of peripheral irritation. Liquid
food is to be given, and if the jaws are firmly set, rectal feeding may
be employed or food may be passed through the nose with a catheter.
For the spasms, strong inhibition of the nerve centers controlling the
affected muscles may be of use. Probably the most effectual treatment
for the paroxysms would be strong, thorough treatment of the upper
cervical region. Hot baths give relief to the spasms. All the excretory
organs should be greatly stimulated, particularly the kidneys, lungs
and bowels. Other symptoms are to be treated as they arise. Tetanus
antitoxin is highly commended by surgeons who used it during the Great
War. As death is at a two to one ratio any method of treatment is
justified. A few cases have been treated osteopathically with fair
success, following antiseptic measures.
Simple Continued Fever
=Definition.=—An acute, febrile disease, mild in character, of short
duration, not excited by any special organism and depending on a
variety of irritating causes.
=Osteopathic Etiology.=—The most frequent cause of this form of fever
is probably gastro-intestinal disturbance. In children it may be due to
gastro-intestinal derangement, or to the eating of decomposing food or
to exposure to wet and cold. It may be caused by exposure to the sun
or great heat, or mental or physical fatigue. It may be the result of
exposure to cold sufficient to produce a slight bronchitis, tonsillitis
or other affection producing an unnoticed localized inflammation. It
may follow a prolonged exposure to noxious odors or gas. Lesions,
osseous or muscular, are always present, corresponding to the tissues
and organs disturbed. Muscular lesions, especially, are prominent.
=Symptoms.=—The onset is usually sudden with a feeling of lassitude,
weariness, chilliness, and headache. The temperature rises quickly to
102 or 103 degrees F. or over, and is usually apt to terminate suddenly
by crisis on the third or fourth day. The pulse is frequent and the
face is flushed. The child is often irritable. Mild delirium may occur.
Anorexia is present, and the bowels are constipated. Convalescence is
rapid.
=Diagnosis.=—This depends upon excluding other probable diseases. If
the fever cannot be attributed to some of the causes already referred
to, there may be a doubt as to its character for the first twenty-four
hours, but, if after a careful examination, one finds no other cause
and no symptoms develop of any of the recognized diseases, acute
continued fever can hardly be mistaken for any other disease.
=Prognosis.=—Always favorable, recovery without sequelæ being the rule.
=Treatment.=—It is necessary to find out the irritative cause in order
for one to be able to treat intelligently. Rest in bed with treatment
of the disturbing factor of the disease, whatever that may be, is the
principal treatment to be given. Careful examination of all the organs,
with due consideration of the symptoms, will generally leave no doubt
as to the cause, and treatment applied accordingly will be sufficient.
If there is any gastro-intestinal disorder, thorough treatment of the
splanchnics, anterior treatment to the abdomen and thorough evacuation
of the bowels are indicated. Use an enema if necessary. Besides the
usual fever treatment, sponging the body with tepid water at the time
of day when the fever is highest will aid in lessening the temperature
and render the patient more comfortable. In cases where nervous
symptoms are prominent, care should be taken against any excitement
and, if insomnia results, a quieting treatment in the cervical region
is usually sufficient. Use plenty of water internally, which is not
only necessary for the tissues on account of the fever, but is of great
aid in keeping the skin and kidneys active, and thus a great help in
the elimination of waste material. A liquid, nutritious diet is best.
Milk, broths and soups will be enough. The demands on the digestive
tract are not great when a light diet is administered, besides not
exciting the nervous and vascular systems unduly.
Tuberculosis
=Definition.=—A general or local infectious disease caused by the
bacillus tuberculosis of Koch. The bacillus produces specific lesions
of the form of nodular bodies called tubercles that undergo caseous
necrosis with a tendency to involve neighboring tissue. There may be
a diffusion of the infection by way of the lymph and blood vessels to
various tissues and organs.
=Osteopathic Etiology and Pathology.=—Tuberculosis exists in all
countries. It generally prevails more extensively in warm than in cold
climates, and is of more frequent occurrence in the city than in the
country. Altitude, however, exerts more influence than latitude. The
disease rarely occurs in mountainous countries, owing to the purity of
the atmosphere. The disease is very prevalent in the West Indies and
the South Sea Islands. Tuberculosis is frequently met with in Canada
among the French Canadians and the English. All races are subject
to tuberculosis, but the Indians of this continent, the South Sea
Islanders and the colored race are very susceptible to the disease. It
is estimated that from seven to ten percent of the present death rate
in the United States is due to tuberculosis.
The tubercle bacillus was discovered by Koch in 1881. It is a short,
straight or slightly bent, rod. This bacillus has an exceedingly
tenacious hold on life and is found in greater or less numbers in all
tuberculous lesions.
It can live almost indefinitely outside the body. The bacilli are found
in great numbers in the sputum, which dries and flies in the atmosphere
in the form of dust. The organism is thus widely spread in regions
frequented by phthisical patients. The bacillus gains entrance into the
body by way of the respiratory tract in the vast majority of cases.
Milk from tuberculous cows will produce the disease, especially in
children, causing intestinal and mesenteric tuberculosis. The meat of
tuberculous animals is not necessarily infectious, although there is a
possibility of infection by this means. Tuberculosis may be transmitted
by direct inoculation; this does not often occur in man, but when it
does, the disease usually remains local, although general infection may
occur. Persons who follow certain occupations, as butchers, dissectors
of dead bodies, and handlers of hides, are more or less subject to
local tubercles of the skin. The virus may enter the body through any
fissure or excoriation on the skin; thus by washing the clothes or bed
linen of phthisical patients, by the bite of a consumptive, or by a cut
from a broken sputum glass of a consumptive, one may become infected.
It is stated that there may be hereditary transmission. In some cases
the virus may be transmitted and the disease may not appear for many
years.
=Predisposing Causes.=—Hereditary predisposition, which renders the
person more liable to accidental infection; delicate constitution;
scrofulous tendency; previous infectious diseases, as influenza,
whooping cough, measles, typhoid fever; diabetes mellitus, etc.
In young children meningeal, mesenteric and lymphatic forms of
tuberculosis are the most frequent. Pulmonary tuberculosis is usually
met with in adults, especially between twenty and thirty years or
age. The development of tuberculosis is favored by damp localities;
by improper and insufficient food; constant inhalation of impure
air; injuries to the chest, with or without laceration of the lungs,
and various osteopathic lesions that weaken the tissue through faulty
nutrition. Corresponding to the innervation of the organ or tissue
diseased will always be found anatomical derangements. “Every case has
a defective spine and thorax.” (Hayden[60]).
Bronchial catarrh, tonsillitis, diseases of the stomach and intestines,
especially enterocolitis, tubercular pneumonia, pleurisy (rarely),
intrathoracic tumors and congenital or acquired contraction of the
orifice of the pulmonary artery increase the susceptibility to
infection. Lessened vitality of the tissues, whether inherited or
acquired, is necessary before the germ can become implanted and
proliferate, producing tuberculosis of the tissues and organs. In
nearly every instance, when the lungs are involved, lesions are found
at the second, third, or fourth ribs. These lesions undoubtedly
predispose to the tubercular infection, by lessening the vitality
of the lung tissues through interference with the innervation or
vascular supply. Possibly a lesion at the second rib or second dorsal
vertebra would interfere directly with the vasomotor nerves of the
upper thoracic ganglia. The condition of the middle and lower cervical
vertebræ should be carefully examined, for lesions at that point would
involve the lymphatics of the lungs. The lowered vitality caused by the
lesion is the predisposing cause and the tubercular bacillus is the
=exciting cause= which determine the character of the affection.
C. A. Whiting in Clinical Osteopathy says:
“=The spinal outline= characteristic of tuberculosis and of the
pretubercular stages presents the following peculiarities: The cervical
spine presents various abnormalities, usually lesions involving single
vertebræ and associated with irregular muscular tensions. The upper
thoracic spine is anterior, the ribs drooping and rather more freely
movable than normal; the vertebral articulations are less movable than
normal; the tissues in the neighborhood of the upper two or three
dorsal spines are abnormally sensitive and the muscles innervated from
these segments are contracted irregularly when the disease involves the
apices. The lower interscapular region is found sensitive and these
muscles are contracted when the lower lobes of the lung are involved,
and the location of these sensitive areas may be employed in the
localization of the lung area infected.
“In every case recorded in this clinic, lesions involving the area of
the origin of the upper and middle splanchnic nerves have been found.
The typical tuberculosis spine must include lesions of the lower dorsal
area. Probably these lesions are predisposing factors in tuberculosis,
partly because of the effects produced upon nutrition thereby, but
doubtless the lack of the normal mobility of this part of the spine
prevents the normal stimulation of the liver, the spleen, perhaps the
pancreas, thus the normal opsonic index is lost, and immunity broken.
The treatment of tubercular cases should include careful attention
to the splanchnic area, the maintenance of the normal mobility
and structural relationship of the entire spinal column, and such
stimulating movements to the ninth and tenth thoracic neighborhood as
is indicated in each individual case.”
=Pathology.=—In adults the most common site of tubercles is the lungs;
in children it is the lymphatic glands, joints and bones. No organ
is exempt; the salivary glands and pancreas are the least frequently
involved. The military tubercle is the beginning of tubercular
deposits. This may develop in any tissue where the tubercle bacillus
is found and it is only distinguished by the presence of a tubercle
bacillus, as similar conditions are produced by the aspergillus glaucus
and actinomyces.
In the development of a tubercle there is proliferation of the fixed
tissue cells, particularly those of the connective tissue and the
endothelium of the capillaries, due to the irritation of the bacillus,
producing the epithelioid cells and in some instances the giant cells,
in both of which bacilli may be found. The epithelioid cells vary in
shape. The giant cells are formed by enlargements of the epithelioid
cells and a repeated division of their nuclei or possibly by fusion
of several cells. On account of the inflammation produced by the
bacillus, there is migration of leucocytes from the adjacent vessels
and lymphoid cells. The leucocytes are largely polynuclear and are
rapidly destroyed, but later mononuclear leucocytes appear, which
are able to resist the action of the bacilli so that they are not so
readily destroyed. A reticulum of connective tissue is formed around
the various cells. The tubercles are non-vascular and when once formed
undergo caseation and sclerosis.
=Caseation= is a process of coagulation-necrosis or destructive change,
beginning at the central part of the growth, due to the action of the
bacilli. The primarily transparent tubercular tissue may become a
gray gelatinous body containing bacilli. Frequently the caseation is
followed by softening; less frequently, calcification, or it may be
surrounded by fibrous tissue.
During the time the cell destruction is going on at the center of
the tubercle, hyaline and fibrous changes may render the tissues
=sclerotic=. These changes, =caseation=, the destruction of forces,
which are dangerous to the patient, or =sclerosis=, which is a healing
process, depend upon the power of the body to produce an antitoxin to
overcome the effects of the special toxin produced by the bacilli.
There may be a widespread =tuberculous involvement=. This is the result
of fusion of the new foci of infection or of miliary tubercles. The
lungs are the usual site of infection, varying from a small area, to a
lobe or a still greater area.
The irritation of the bacilli is capable of producing =associated
inflammatory processes= in its own neighborhood. There may be an
overgrowth of interstitial tissue. In other instances, changes to
catarrhal or croupous pneumonia may occur. Suppuration is associated
with tuberculosis, especially of the lungs, and is due to a mixed
infection or the presence of pus organisms. Some authorities claim that
the tubercle bacilli alone are able to produce suppuration; it is,
however, more probable that suppuration is due to a mixed infection.
The constitutional features in tuberculosis are more dependent upon
this secondary infection, especially by the streptococci, than upon the
primary infection.
Tuberculosis of the Lymph Glands
(SCROFULA)
=Scrofula= is a true tuberculosis of the lymphatic glands. The virus is
less virulent than that from other sources, which accounts for the slow
development and milder course of tuberculosis of the glandular system.
=Tuberculous Adenitis= may occur at all ages, but is most common
in children and young adults. It is rarely congenital. Catarrhal
inflammation of the mucous tissues weakens the resisting power of the
lymph tissue, thus allowing the bacilli to develop, and is an important
predisposing cause. The glands most frequently affected are those of
the neck; more rarely there is involvement of all the lymphatic glands
of the body. Invariably lesions of the upper and middle cervical
vertebræ and upper dorsals and corresponding ribs are found, as well as
lesions to the lymphatics at various points along the spinal column and
ribs. These lesions affect the innervation to the lymph glands, as well
as mucous membranes, and thus predispose to the disease. In all cases
anatomical derangements are found in the region of the innervation to
the involved gland.
In =general tuberculous adenitis= all the lymph glands of the body are
more or less involved, while the other organs and tissues are rarely
affected. All the visible glands are found to be swollen, tender and
painful. There is more or less protracted fever, with wasting and
debility. This is a rare affection.
In =local adenitis= the glands of the neck are most frequently affected
and this is especially the case with children. Negroes are more
frequently affected than whites. It is seen especially among those
living in an unsanitary environment. Measles, whooping cough and an
hereditary tendency are predisposing factors. The submaxillary glands
are usually the first affected. At first they are swollen to various
degrees and are tender; later they suppurate and rupture if one is not
able to cure them. There may be fever. The skin over the glands is
usually freely movable; it may, however, be adherent.
The glands above the clavicle, those in the posterior cervical
triangle, and the axillary glands may all be affected. In such cases it
is likely that the bronchial glands are also involved and may infect
the living tissue.
Lesions of the upper and middle cervicals and deep muscles are always
found and undoubtedly are the underlying causes. Lesions of the lower
cervical, upper dorsal, ribs and clavicle, are of frequent occurrence.
Infection may gain entrance by way of the pharynx and tonsils.
The affection often runs a slow course.
The =bronchial= glands may be affected primarily, but usually
secondarily to infection of the lungs. The primary form is seen most
commonly in children and is apt to be associated with suppuration.
Lesions of the upper and middle dorsals and of the cervicals will be
found. Catarrh of the bronchial tubes is a predisposing cause. The
X-ray is of great value in the diagnosis.
The most noticeable symptoms are those due to pressure or irritation.
Systemic infection may follow rupture into a vessel. Local infection of
the lung may occur and the pericardium become infected.
=Mesenteric= cases occur among children and may be primary or
secondary. The primary form is rare. Swallowed sputum is a frequent
cause. The trunk and limbs are puny. The child is anemic, and often
the abdomen is tympanitic. Diarrhea is marked and there is pain and
indigestion. Fever is almost constantly present and of an intermittent
type. The disease is most frequently met with among poor children
in unhygienic, poorly ventilated houses. There may be an associated
tuberculosis of the peritoneum.
Acute Tuberculosis
This shows best the truly infectious nature of tuberculosis. In it
miliary tubercles develop in many and various parts of the body. In
some cases these growths seem to be uniformly distributed throughout
all the viscera. In other instances they are localized in the lungs
or in the meninges of the brain. In nearly every instance it is an
auto-infection, arising from an old tuberculous focus, which may be
latent and quite unsuspected. General infection, in most instances,
arises from the rupture of a nodule into a vein, from tuberculous lymph
glands, tuberculosis of the bones, joints, or even the skin.
=General Miliary Tuberculosis or Typhoid Form.=—This is similar to a
general infection of the body and resembles, to a marked degree, the
symptoms of typhoid fever. The onset is rarely rapid.
In most cases there is a period of incubation, during which the health
fails, the appetite is lost, headache occurs, and the patient soon
becomes feverish, with increased debility. The temperature rises and
the pulse is rapid and feeble. The tongue is dry. The respirations are
increased. Delirium may be present. In rare cases, there may be little
or no fever. The temperature ranges from 101 to 103 or even 105 degrees
F. It is irregular and marked by evening exacerbations and morning
remissions. Occasionally there is an inverse type of temperature in
which it rises in the morning and falls in the evening. In some cases
the pulmonary symptoms are marked, while in others the meningeal
symptoms are more prominent. Tubercle bacilli are rarely found in the
sputum.
The spleen is usually enlarged. Constipation is present, as a rule, but
there may be diarrhea, and hemorrhage from the bowels may occur. The
urine may contain traces of albumin. There may be excessive sweating,
and herpes is often present. Choroid tuberculosis is frequently met
with. In doubtful cases the blood should be examined for tubercle
bacilli, although they are not always present. The duration is from two
to four weeks, the disease usually terminating unfavorably.
=Diagnosis.=—It is often very hard to differentiate between this form
of tuberculosis and typhoid fever. In =typhoid fever= epistaxis is a
common, early symptom. The temperature curve of the continued type
is quite diagnostic. The Widal test should be made. The respirations
are moderately hurried and the pulse is often dicrotic. Diarrhea is
frequent. Typhoid rash is diagnostic. No tubercles are found on the
choroid. No tubercle bacilli are found in the blood. Hemorrhages from
the bowels are common.
=Pulmonary Form.=—When the lungs are chiefly affected the pulmonary
symptoms are marked from the onset. It may develop suddenly or there
may be a long period during which the general health fails markedly.
In children the disease may follow measles or whooping cough. There
is dyspnea, cough and the expectoration is mucopurulent. There is
broncho-vesicular breathing with sibilant and subcrepitant rales. The
temperature is high, ranging from 103 to 105 degrees F., or higher.
Respiration and pulse are rapid.
The disease may last from several weeks to months, or, on the other
hand, it may prove fatal within a few days. As the end draws near the
signs of suffocation become intensified.
=Diagnosis.=—The history and general symptoms, together with the
dyspnea and cyanosis, will generally decide the diagnosis. The blood
should be examined for malarial parasites. The Widal test will
differentiate typhoid.
=Cerebral or Meningeal= (Tuberculous Meningitis).—This form which is
sometimes called acute hydrocephalus, occurs quite frequently and is an
infection of the pia mater of the brain or cord.
It occurs most frequently in the first two years of life, although
it may occur later. It is usually tuberculous in some other region,
especially in the bronchial glands. Rarely does the disease involve the
meninges primarily.
The meninges at the base of the cerebrum is the principal involvement.
There is more or less inflammation, with fibrous purulent exudation.
There are tubercles along the blood vessels. The ventricles may be
distended.
=Symptoms.=—The onset is slow, lasting one or more weeks. Headache,
constipation, vomiting and chills, followed by a fever, are the initial
symptoms. When the onset is sudden, the disease is generally ushered in
with a convulsion. The fever rarely rises above 102 or 103 degrees F.
The pain is often severe, causing the child to give a sudden cry—the
hydrocephalic cry. During sleep the child is restless and there are
slight muscular twitchings.
The =irritative symptoms= now abate. The child becomes quiet and
is dull and apathetic. Constipation still persists. The abdomen is
boat-shaped, and the neck may be retracted. The pupils are dilated.
Convulsions and other cerebral symptoms may occur. The temperature
ranges from 100 to 103 degrees F. The respiration is irregular and
sighing.
Following this, the mental faculties are lost and coma occurs.
Convulsions or spasmodic contractions of the muscles of the neck,
back and limbs may occur. The pupils are dilated and do not respond
to light. The pulse is frequent, irregular and small. The temperature
rises to 103 to 105 degrees F., or it may be subnormal. The duration is
from two to five weeks; chronic cases may last for a number of months.
=Prognosis.=—Generally very unfavorable.
Acute Pneumonic Phthisis
The infection of the lungs is rapid and may be primary or secondary.
This form is met with most frequently in children and young adults, but
may occur at any age.
The =Pneumonic form= is more rare than the bronchopneumonic form and
may be very rapid in its course. The attack sets in abruptly with a
chill and the temperature rises rapidly. There is pain in the side;
cough; dyspnea and mucous and rusty sputum, which may contain tubercle
bacilli. There is impairment of resonance, increased fremitus, and
bronchial breathing. The whole or part of the lung may show signs
of consolidation and dullness, all the symptoms of pneumonia being
present. The patient rapidly loses flesh. This attack may come on a
person in good health after exposure to cold; but there may have been a
debilitated condition, or a predisposition to phthisis. Death may occur
in the second or third week or the case may continue from three to four
months.
One or both lungs may be involved. The lung is heavy and airless,
sinking quickly in water. There is destruction of lung tissue and upon
section, cavities are found. The cavities are generally small and are
surrounded by tubercles. Older caseous areas of a yellowish white color
may be visible. Miliary tubercles are found upon careful examination.
The =bronchopneumonic form= is the most common and occurs most
frequently in children. It often follows the infectious diseases,
especially measles and whooping cough. The child may be taken ill
suddenly with what seems to be an ordinary bronchitis, the temperature
rises, the cough is severe, and there may be consolidation with
submucous and subcrepitant rales. Rapid respiration and sweating are
often marked. The course of the disease varies. There is rapid loss of
flesh, and in many cases the disease develops into chronic phthisis. In
other instances death occurs in from three to eight weeks.
The disease may attack the adult whose resistance is impaired. Chills,
fever, pain in the chest, hemorrhages, wasting are most noticeable
symptoms; these are the various signs of bronchopneumonia. Tubercle
bacilli are often found in the sputum. The course is usually from three
to eight weeks, while a number pass into a chronic stage.
Areas of caseous tubercles are found, which later suppurate, break down
and form cavities. The bronchial lymph nodes are found enlarged, and
usually there is acute tuberculous pleurisy.
=Diagnosis.=—In the =pneumonic form= it may be impossible to make a
diagnosis early in the disease. Tuberculosis may be suspected if the
patient has been in bad health, has a predisposition to phthisis, or
has had any pulmonary disorder. Pneumonia will present the typical
symptoms, but if fever continues, tuberculosis will be suspected.
Examination of the sputum will probably decide.
In the =bronchopneumonic= form it is very difficult, in the early
stages, to distinguish it from simple bronchitis and bronchopneumonia.
The irregular fever and rapid loss of flesh are important signs. The
sputum will show elastic tissue and tubercle bacilli early in the
disease and should be carefully examined.
Chronic Pulmonary Tuberculosis
The chronic form of the disease is more common than the acute. It
seems probable that many cases of pulmonary tuberculosis are due to
inhalation of the tubercle bacillus, though no doubt, particularly in
children the bacillus frequently gains entrance to the system through
the intestinal tract from infected milk and food. =Deformities= of the
chest, especially where there is constriction and rigidness of the
upper part, with more or less immobility of the first, second and third
ribs and the junction of the manubrium and gladiolus, associated with
weak muscles and a stooped posture are definite predisposing factors.
This condition may be congenital or acquired. The local innervation,
blood supply and lymphatic drainage is involved, so that the individual
is less resistant and consequently susceptible to infection. The
bronchi are thus weakened, favoring the infectious process so that
the disease may advance and involve the neighboring tissues, or if
infection has gained entrance to the lymph or blood stream elsewhere,
the susceptible pulmonary organs may become diseased.
Owing to the above predisposing factors the =primary lesion= of the
lungs is often in the bronchus a little below the apex near to the
posterior and external borders. A lower lobe may be involved, or
several lesions may occur at the same time, involving one or both
lungs. Frequently the other lung is infected from the lesion or lesions
of the first.
In the acute cases the exudative process involves the lung tissue,
becomes caseous and softened, and later necrotic with cavity formation.
In the =chronic type= the exudative process is slower, with thickening
of the walls of the air vesicles and increase of fibrous tissue.
=Cavities=, the result of caseation, are of various size, ragged,
often coalesce and open into the bronchus. Fibrous tissue forms about
them and frequently arrest the process. In the necrotic involvement
blood vessels are often injured causing hemorrhages. Pleurisy,
empyema, catarrhal bronchitis, and bronchiectasis are often associated
involvements.
In addition to the tubercle bacillus, other micro-organisms,
streptococcus and staphylococcus pyogenes, influenza bacillus, and
diplococcus pneumoniæ, are often found, and no doubt are important
exciting factors.
The =bronchial glands= are swollen, and contain tubercles. They may
undergo purulent disintegration. Tuberculosis of the =larynx= is
common. In severe cases there may be amyloid changes of =liver=,
=kidneys=, spleen, and mucous membrane of the intestines. Tuberculous
lesions are found in the intestines, spleen, kidneys, and brain in
nearly equal proportions; then come the liver and pericardium.
=Symptoms.=—The onset of the disease is either abrupt or gradual.
Frequently it succeeds influenza, measles, or bronchitis. There is
a cough, expectoration, loss of weight, afternoon temperature and
probably night sweats. The disease is likely to develop slowly. In
other cases gastro-intestinal disorders are the first symptoms,
especially with weakness and debility. Again, the disease may follow
pleurisy. When the attack is abrupt, pneumonia is simulated. However,
the apex of the lung, instead of the middle or lower lobe, is involved;
expectoration is considerable and the fever is not so high and
pronounced. Hemoptysis frequently occurs.
The =local symptoms= are important. =Pain= is an early either moderate
or severe, symptom, although there are cases where it is absent. When
associated with pleurisy, it is severe. The pain is usually situated at
the base, anteriorly or laterally, of the scapulæ, but may be between
them. =Cough= is present, in the majority of cases, throughout the
entire course. It usually grows worse, and is dry and hacking at the
beginning but looser and paroxysmal and accompanied by a mucopurulent
expectoration later on. The =expectoration=, at first, is slight and
there may be more or less blood mixed with it, or even hemorrhage may
occur. With the formation of cavities, the expectoration increases
and is of a greenish-gray or greenish yellow color. In some instance
the sputum is more or less fetid. The expectoration is composed of
pus cells, blood, elastic tissue, fat globules and tubercle bacilli.
=Hemoptysis= is present in a majority of cases. Early hemorrhages
are usually slight, due to rupture of weakened vessels. When there is
softening or cavity formation, erosion of vessels may be pronounced
and hemorrhage considerable. Dyspnea is a variable symptom, but is
characteristic of lung changes.
=Fever= is a characteristic symptom. It is probably always present at
the beginning and the afternoon increase of temperature is common.
Where there is softening and formation of cavities, a remittent or
intermittent type is present. The pulse is frequent, regular and
compressible. =Sweats= may occur at any time, but especially during
sleep. They indicate fever activity, and are increased during cavity
formation. =Emaciation= is a prominent symptom. This is due to
gastro-intestinal disorders and prolonged fever. Loss of weight is
gradual, especially if the disease is advancing. Where the lung is
considerably diseased, heart disturbances are common.
Other disorders, as of the gastro-intestinal tract, genito-urinary,
cutaneous, and nervous systems, are frequent, especially in long
standing cases. The =gastro-intestinal disturbances= are gastric
catarrh, vomiting, loss of appetite, coated tongue, constipation, and
later on, diarrhea. Among =genito-urinary symptoms=, albuminuria is
frequent. The kidney involvement may be either of an acute or chronic
character. Pyelitis and cystitis are present in some cases, and amyloid
degenerations are not uncommon. With the =cutaneous symptoms=, the
skin is frequently dry and scaly, and the hair of the head dry. The
hectic flush is common. Upon the chest and back there may be pigmentary
stains. The =nervous symptoms= vary according to the involvement.
Tuberculous meningitis is rare. The mind usually is clear and even in
advanced stages the patient is always hopeful.
=Physical Signs.=—=Inspection= reveals that the shape of the chest
is often characteristic. A phthisical thorax is flat, especially
the thoracic opening with wide intercostal spaces, prominent costal
cartilages, and depressed sternum. Sometimes the lower sternum forms
a deep concavity (funnel breast). Another type of thorax is long
and narrow, with very oblique ribs, and little expansion. In other
instances the chest is of apparently normal build. Defective expansion
is observed early, especially at the apex of the affected side. The
clavicle of the affected side often stands out more prominently.
=Palpation= shows there is decreased expansion and increased fremitus.
Normally, the fremitus is stronger at the right than at the left apex.
If the pleura is thickened, the fremitus is decreased, but increased in
lung involvement.
On =percussion=, if the diseased areas are minute, the percussion
note may not be changed. Always compare the two sides of the chest.
Dullness is first noted, as a rule, above, on or below the clavicle.
As the disease progresses, the dull sound increases. The size of the
cavity, its walls and the amount of secretion modify the note. Large,
thin-walled cavities elicit the “cracked-pot” sound. Consolidation,
thickened pleura, large amount of material in a cavity and a connecting
bronchus impair resonance.
On =auscultation= the breathing is harsh and the expiration is
prolonged and high-pitched (bronchial). Early in the disease crackling
rales may be heard. After consolidation takes place there is bronchial
breathing and crepitant rales. When softening occurs they become moist,
louder and sometimes bubbling. These may be heard upon inspiration and
expiration. Pleuritic friction sounds, as in case of pleurisy, may be
heard at any stage. Vocal resonance is increased.
The =signs= of =cavity= are: =Percussion.=—There is more or less
defective resonance or tympany. Over large cavities a “cracked-pot”
resonance is obtained. This is best obtained when the patient has his
mouth open. There may be normal resonance if the cavities are covered
with a considerable thickness of unaffected air cells.
=Auscultation= may detect cavernous or amphoric breathing, pectoriloquy
and coarse, bubbling rales. Metallic tinkling may be heard over large
cavities. Vocal resonance is increased.
=Complications.=—The larynx and trachea frequently undergo tubercular
inflammation, due to invasion from the lung tissue. Pneumonia is of
common occurrence. Gangrene, pleurisy and endocarditis are other
complications.
=Diagnosis.=—Bacilli may be found in the sputum before the physical
signs are well developed. It may be necessary to examine the sputum
several times before the tubercle bacilli are detected. The presence of
bacilli will set the diagnosis at rest, provided clinical symptoms are
present. Fever, hemoptysis, cough, emaciation and a continuous, local
induration are diagnostic. The X-ray should be employed as an aid in
diagnosis.
=Prognosis.=—The prognosis of pulmonary tuberculosis varies greatly in
different cases. Undoubtedly a number of cases have been cured; many
arrested; even spontaneous cures have occurred. A great deal can be
done to prolong life and to make the patient comfortable. The average
duration is about three years, although by careful treatment this time
is probably being increased.
Fibroid Phthisis
This term is applied to a form in which there is induration, followed
by contraction of the affected lung tissue, due to an overgrowth of
fibroid tissue. The greater number of cases are primarily tubercular,
but have run a fibroid course. Other cases are primarily fibroid,
followed by tuberculous infections. It may begin as an ordinary
ulcerative phthisis, or it may begin as an inhalation bronchitis. In
other instances it may follow a chronic tuberculous bronchial pneumonia
or pleurisy.
The =onset= is extremely insidious. There is persistent cough, often
paroxysmal in character. Dyspnea is marked, especially on exertion,
but little or no fever is present. The expectoration is profuse and
mucopurulent. There is slight loss of weight. In the later stages edema
is marked. It is a disease of long duration, lasting from ten to twenty
years. The patient is often able to pursue some occupation and may have
fair health.
There is marked dullness over the affected side, which is commonly much
depressed. There is distinct bronchial breathing at the base, while
at the apex there may be cavernous sounds. The heart is frequently
displaced and the right ventricle hypertrophied. The bronchi are
dilated. The clinical history is identical with that of simple
cirrhosis of the lung from which it is often separated with difficulty.
Both lungs may become the seat of tuberculous disease. Prolonged
suppuration results in amyloid changes in the liver, spleen, kidneys
and intestines. X-ray plates are of value in diagnosis.
Tuberculosis of Other Tissues
The =alimentary tract= is frequently the seat of tubercular
inflammation. The intestines may be involved primarily or else
secondarily from the lungs or peritoneum. The =primary form= is
most common in children. There is slight fever, pains of a colicky
nature, irregular and persistent diarrhea. The disorder is commonly
unrecognized, being mistaken for appendicitis or other intestinal
disorders, until emaciation, sweats, the continued fever or lung
involvement are manifested.
The stomach, esophagus, pharynx, tonsils, palate, tongue and lips may
be the seat of a tubercular lesion.
The =serous membranes= are usually secondarily involved. The peritoneum
is generally invaded from contiguous organs, especially the intestines,
although the pleurae may be the starting point (and in the female the
generative tract is a source). The disease may be either acute or
chronic. In the former it starts abruptly with vomiting, pain in the
abdomen, fever, and possibly diarrhea. In the chronic form there are
fever, pains, emaciation, weakness and the abdomen is distended. The
enlarged glands may be felt through the walls. There may be ascites, or
the walls of the peritoneum are adherent, or the tubercles may ulcerate.
The endocardium is occasionally the seat of acute or chronic
tuberculosis. It is usually secondary. Likewise the pleurae are
sometimes involved. The chronic form is more common.
The =genito-urinary system= is subject to tuberculosis. The bladder,
ureters and pelvis of the kidney are attacked, and from these the
kidney; or possibly the kidney involvement is part of a general
tuberculosis. (See pyelitis). The ovaries, Fallopian tubes and uterus
are also subject to tubercular invasion. The =diagnosis= depends
upon finding the bacilli, the symptoms indicating, oftentimes, an
inflammation only. Also the prostate, testicles and seminal vesicles
are attacked.
Tuberculosis of the mammary glands is rare. In miliary tuberculosis
the liver is commonly affected, often secondary to other tissues,
especially the peritoneum, lymphatics and lungs.
The blood-vessels and heart are sometimes involved from nearby organs
or from miliary tuberculosis. The brain and cord are also at times
invaded. This has been described under meningeal tuberculosis.
=Diagnosis and Prognosis of Tuberculosis.=—The osteopath should be
familiar with the various forms of the disease. An understanding of
the pathology and clinical symptoms is essential. The finding of the
bacillus, provided there are symptoms of inflammation, is diagnostic.
Much depends upon the patient’s constitution, hygiene, sanitation,
food, fresh air and general management. The osteopathic lesion is
decidedly an important factor, but the treatment must be balanced from
both the distinctive osteopathic view and that of general management.
Then the patient’s part is as necessary as the osteopath’s. Under
proper care and treatment, unless the disease has progressed to a
marked degree, there is always a tendency toward recovery, but, to
emphasize again, the osteopathic treatment, the environment and
general hygiene should be thoroughly understood and appreciated, for
at best, the disease is treacherous. Even after an apparent recovery
is made, the patient should be under observation; there is always
danger of recurrence. Tuberculosis can often be treated successfully,
or arrested, provided the disease has not progressed to a late stage;
although many times, in the later stages, life can be considerably
prolonged by careful treatment.
=Treatment of Tuberculosis.=—The =prophylactic treatment= of
tuberculosis should receive first consideration. The sputum should
be thoroughly disinfected and care taken that the patient does not
spit about carelessly. A spit-cup should be provided and the sputum
collected and destroyed by burning and the cup sterilized. The patient
should be well taken care of and given a separate apartment, so that
the danger of conveying the disease to others is reduced to a minimum.
He should occupy a single bed. All unnecessary furnishings of the room
should be removed and the objects that remain in the room should be
frequently aired and disinfected. The general and sanitary environment
of the patient should be as favorable as possible to hygienic living.
Many times a change of residence is of great benefit. When possible
the patient should be out of doors and light exercise taken. The body
should be well protected by flannels, the year around.
Keene[61] would carry prophylaxis to careful examination of the
pregnant woman to avert a sudden development of tuberculosis after
parturition; also of the child, after birth, to remove any predisposing
lesions. The mother with a tubercular tendency should, under no
circumstance, nurse the child and should be instructed to observe
any disposition on the part of the child to acquire malpositions in
sitting, standing or walking.
Another important consideration in the prophylactic treatment is
the inspection of dairies and slaughter houses. The disease may be
transmitted by infected milk. There is less danger of infection through
meat; although all animals that present distinct lesions should be
confiscated. Sanatoria and other special arrangements for the care of
patients should be encouraged.
The =Treatment of the disease= consists primarily in locating the
cause of the devitalized condition of the cellular tissue. This is
the vital point to be considered and requires a thorough examination
of anatomical structures in the region involved. There is a reason
why the tissues are in a depraved state and it is our work to examine
thoroughly the structures that might become deranged anatomically and
cause an obstructed innervation or vascular supply. The disease is
not primarily due to the bacilli; the bacilli would not have infected
the system had it been in a healthy state. Hence, the object of
the treatment in tuberculosis is to favor a building up of normal,
well-nourished tissues so that it is impossible for the bacilli to
infect the region. Of course, destruction of the bacilli is important,
but we cannot expect to do much by the use of a parasiticide, for we
are not then influencing or affecting the real cause of the disease.
If we can improve the arterial circulation to the diseased tissues,
we will be striking at the root of the disease and the healthy blood
will be the only parasiticide necessary. This is where the osteopathic
theory of the cause of disease differs from that of other schools
of medicine. At the local points of infection there is a decided
malnutrition of the tissues, due to a lack of proper blood to the
parts, thus favoring the lodging of micro-organisms; by reestablishing
normal nutrition nature will repair the tissues if the condition is
curable. Hence, it can be seen at once that if the case is curable
osteopathic treatment will meet the demands scientifically.
The preceding is the keynote of osteopathic therapeutics; not
only in the treatment of tuberculosis, but in all diseases where
micro-organisms play an important part. In =tuberculosis of any part
of the body=, it is the duty of the osteopath to carefully examine
the structures that may become anatomically deranged, from any cause,
affecting the nerve, blood and lymphatic supply to the tissues or
organs diseased. Correction of anatomically deranged tissues and
attention to the hygiene, diet and general health of the patient
constitute the treatment.
On the subject of Pulmonary Tuberculosis, W. Banks Meacham says:
“In cases of =pulmonary tuberculosis= it should be remembered that
the pathological lesion in the lung is a result of a general systemic
interference—an interference so great that the body as a whole loses
its stored-up heat in excessive temperature, loses its reserve
nutrition, as manifested by early and continuous loss of weight.
“Therefore the causative osteopathic lesion should not be sought alone
over the site of the pathological lung lesion but rather in that area
where general nutrition is osteopathically affected.
“A few general considerations of =osteopathic mechanics= involved in
nutrition should be ever present with the searcher for the cause of
pulmonary tuberculosis. For instance we know that ingested fat is acted
upon by the pancreatic enzymes; that the invertin of the intestine is
an endocrine secretion. In diet we seek to administer an excess of fats
to take the place of fat-loss in this disease, often losing sight of
the fact that some mechanical maladjustment prevents fat-splitting into
a form suitable for tissue assimilation.
“It is common osteopathic knowledge that lesions of the upper dorsal
area have a profound influence on general nutrition. Consequently it
is to this area that we must look for the causative osteopathic lesion
in this disease. The influence of this area is due to the fact that
the nervous mechanism of the secretory glands gets its most direct
disturbance in this area where the nerves leave the spinal cord to
become distinct innervation to these organs.
“Apart from the nutritive and general circulatory influence of
upper dorsal lesions we must consider the germicidal action of the
endocrinous secretions in devitalizing the specific bacterial agent in
tuberculosis. Undoubtedly these internal secretions have marked effect
in agglutinating the bacilli, thus enabling the phagocytes to perform a
larger duty.
“The correction of upper dorsal lesions, with due regard for the
pathological condition within the thoracic cavity gives a scientific
physiological and bacteriological therapeutic action in tuberculosis.
“=Other lesions= may and do demand attention and correction when
possible. But we must not lose sight of the fact that our specific
action comes from a corrected relation of the upper dorsals. In the
cloud of unproved theories and guesses in the literature of pulmonary
tuberculosis nothing seems nearer an established truth than that
it is a disease contracted in infancy, that it develops, later, in
those persons who retain the infantile type of chest—thorax of large
antero-posterior diameter in contrast with the lateral diameter.
“In the progress of the disease we do get a costal malformation giving
the ‘horse-collar’ thorax, with an apparent lesion of the osseous walls
of the thoracic cavity. But these lesions are the result of nutritive
changes brought on by the active infection already present; and are
not in any true sense, causative factors in the establishment of
pathological areas within the lung.
“The =osteopathic treatment=, then, of this disease is, manifestly, a
correction of a plastic posterior upper dorsal lesion. And where the
pathological lesion of the lung contraindicates forceful correction,
mobility of the area should be sought.
“The =general care= of the case should look to the normal functioning
of all organs, with emphasis on ease to the patient. The =diet= should
be what the patient can assimilate properly even though it be much less
than the amount a normally active person should ingest. =Altitude=
has a favorable effect in selected cases only. It is remarkable that
many cases recover in the extremes of the Rockies and the coasts of
California and Florida.
“No violent =exercise= should be undertaken on account of the possible
embarrassment of an already overworked heart and in consideration of
the possibly engorged pulmonary vessels. For these reasons, too, rest
in bed is advisable with temperature above 99° F. and pulse above 85.”
In =scrofula=, lesions will be found to the lymphatic glands, impairing
their innervation and function. The treatment is not to be applied
over the glands directly. First, it is necessary to locate the lesions
of the bones, ligaments and muscles or such tissues that would cause
disturbances to the glands, then readjust the parts. The object of
the treatment is to modify the soil conditions on which the bacilli
multiply, by correcting the local derangement of the tissues. The
entire body is not in such a depraved state that the bacilli will grow
and multiply wherever they happen to come in contact with the body;
tissues of any organ favor a receptivity for the bacillus only when
these local tissues are in a morbid condition. It is then our work to
aid nature in relieving obstructed forces that are causing such an
effect.
There are =general measures= which influence the tubercular process.
The diet of the patient should be nutritious. A diet of milk,
buttermilk, egg albumen and meat juice will probably be found best,
although many will be able to take ordinary food. The patient should be
out of doors as much as possible. Meacham[62] says “Fresh, pure air,
wherever found, is essential; elevation is an individual requirement,
an even temperature is not necessary and sunshine is important only
as it allows the patient to be out of doors. Exercise should not be
taken when the patient has a temperature above 99 degrees.” The dry,
even climate of the Southwest certainly tempts the patient to be out
of doors more than one with opposite conditions. Even when the patient
is greatly debilitated and weakened, insist upon his taking outdoor
exercises or rides. Gymnastic and methodical breathing exercises
are essential in widening and strengthening the chest. Bolles[63]
believes that the appetite should control the diet and forced feeding
be not insisted upon. Fasting, to test the sense of food desires, has
points well worth looking into, as gastric disturbances with a loss
of strength follow overfeeding. He also recommends deep breathing and
physical culture to elevate the ribs and increase thoracic expansion.
Outdoor sanatoria are being established over the country, in many
cases by state appropriation as, “the treatment of tuberculosis itself
has not been a satisfactory procedure except by climatic changes or
the outdoor treatment persistently applied.” (Halbert). The fresh
air treatment may be taken at home by sleeping in the open air or by
appliances fitted to the window of the room so only the head is exposed
to the air. The only factor is to get the air. The skin, as well as the
excretory organs, should be kept active. Always make it as comfortable
for the patient as possible.
The =fever= is indicative of the activity of the disease, so that
treatment to influence the process and to promote elimination is best.
Sponging with either cold or tepid water will be helpful. The =cough=
is a troublesome symptom. Attention to the underlying irritation is
demanded, although one cannot hope to influence, to any great extent,
the cough dependent on cavity formation. Catarrhal processes in the
respiratory tract can be lessened. Lesions that are acting as a cause
of irritation, will frequently be found in subluxated ribs or vertebræ.
The seventh and eighth dorsals are frequent sources of cough. The
tissues about the pharynx and larynx, and the hyoid bone, disturbing
the vagus and other nerves, should be carefully watched, also possible
reflex irritation from the abdomen and pelvis. =Night sweats= are due
to tubercular processes weakening the system and particularly lessening
nervous control. These will subside as the body is strengthened.
Sponging will be of service. Disorders of the =stomach= and
=intestines=, such as nausea, vomiting and diarrhea, require treatment
of the splanchnic area and regulation of diet. Considerable can be done
to relieve =tubercular laryngitis= by careful treatment of the larynx
and contiguous tissues. =Hemorrhage= is likely to be self-limiting.
Attention to the upper dorsal vertebræ and ribs and muscles will tend
to equalize the circulation. Rest and use of ice upon the chest, as
well as internally, will be beneficial.
McIntyre, in an article on “Fat Food in Consumption,” sums up the
treatment for tuberculosis in the following words: “The treatment,
then, for consumption should include rich, stimulating diet,
proportioned to the digestive power of the patient, containing an
excess of fats in most digestible form, of which sweet cream, fresh
butter and well-cured bacon are the best examples, and the free use
of pure drinking water, coupled with the promotion of blood flow,
respiration and elimination of waste by osteopathic means.”
Surgical measures may be necessary where glandular or other tissue has
broken down and is a menace to recovery.
Spanish or Epidemic Influenza[64]
By GEORGE M. MCCOLE
The epidemic of influenza which swept over the world and reached the
United States in August 1918, starting in at the Atlantic sea-board
cities, developed rapidly there and passed westward over the country.
It reappeared the following winter.
=Epidemiology.=—In the United States it was called Spanish influenza,
as it was at its worst in Spain at the time it broke out here and was
thought to have been brought from that country.
In Europe it was called the Ukrainian influenza and in southern Russia
it was said to have emanated from the Orient. No country in the world
was exempt. It was at one time thought to be a type of the pneumonic
plague and while plague is the severest toxemia known many cases of
Spanish influenza were equally as prostrating and fatal as the ordinary
type of pneumonic plague. The bacillus pestis was never proved to be
the cause of this pandemic of influenza but the clinical analogy was
very evident.
A study of European conditions of health and hygiene shows how
reasonable it is to believe that some disease would develop and sweep
a world lowered in vitality and immunity by the abnormal conditions
of war. Every known communicable disease was raging in Europe and
Asia where millions of people existed under exceedingly poor hygienic
conditions.
The period of incubation of influenza was extremely short, averaging
about two days. All ages were attacked, although persons over 60
rarely. Those between 25 and 35 seemed to be the most susceptible but
it was, perhaps, because they were in active life and more exposed.
There is considerable evidence that the disease was not air-borne but
conveyed by contact with active cases. The secretions of the mouth,
nose and eyes were considered the active carriers. Masks, made of
several layers of gauze fastened over the face, have been worn by many
people but experience taught that their use did not avail against
infection.
=Mortality.=—The mortality under drug medication as shown in a
statement by Henry S. Bunting was as follows: “New York City 9.8%;
Chicago 14.5%; Boston 27%. Osteopathy’s influenza salvage represents
the difference between these figures and the low score of one fourth of
1%.” He gives the following statistics on pneumonia following influenza
under drug medication. “Reports from 148 health commissioners show
an estimate (called conservative) of 33% of fatalities in epidemic
pneumonia under medical care. In some large centers it ran as high as
68% to 73%. As officially compiled to date, the fatalities in epidemic
=pneumonia= in our army and navy cantonment hospitals amounted to
34½. Osteopathy’s fatalities were only 10% which included all those
eleventh-hour appeals to Osteopathy.
“The Chicago and New York departments of health figures, each show
total death losses of 18% in all of their epidemic cases. Osteopathy’s
remarkable salvage of life is best measured from this point of
comparison. Its total death rate from both influenza and pneumonia has
been actually less than one percent.” And this is based on 110,000
cases reported to the American Osteopathic Association.
=Pathology.=—The pathology of Spanish influenza is practically a study
of lung involvement. There we find an exudative pneumonia of a rapidly
confluent type, a transudate of blood serum and red cells appearing in
the lower lobes of both lungs and rapidly flooding the entire space.
Air bubbles were scattered through the serum soaked lungs, giving a
frothy appearance to some parts. At times some parts of the lungs
showed drops of liquid pus.
Where pneumonia did not develop there was no typical pathology. The
toxins left an irritated bronchial tube, intestine or kidney just as in
any other severe toxemia.
Bronchial and the old type of lobar pneumonia also appeared as a
complication of Spanish influenza, making three types of pneumonia
which were to be guarded against.
=Symptoms.=—The attack is usually ushered in by a chill or prolonged
chilly sensations, sometimes lasting for two or three hours; fever 103°
to 105° F.; if it does not fall in three days or if it comes up after
once falling, pneumonia is to be suspected; pulse, full and bounding
with a varying rate; headache usually general in type and in severity
from slight discomfort to a most violent type; intense pain in the
back and legs; tenderness the whole length of the spine but especially
distressing in the upper dorsal, lower lumbar and sometimes the upper
cervical; a dyspnea which is best described as being a constricted
feeling of the chest with air hunger; often the bronchial tubes are raw
and dry, the patient feeling as if the breathed-in air were hot to the
bronchial tubes, an active exudative bronchitis developing; sometimes
there is an active bronchitis with distressing cough; nose bleed is a
frequent symptom (and is often a sign of threatening pneumonia); most
cases sweat more or less, some have drenching sweats; sleeplessness;
albuminuria frequent.
When the temperature breaks it practically always falls below normal
during the course of that day. A typical case of severe character often
presents all of the above symptoms; the lighter cases perhaps only two
or three of them, of which the chilly sensations, fever and bounding
pulse are the most common encountered.
A severe case is impossible to differentiate from the first symptoms
of smallpox. Where a case of this type is encountered, it is always
advisable to get history of vaccination or smallpox.
=Examination.=—The successful treatment of disease calls for attention
to little things. Some little thing properly cared for very often gives
us our margin over adverse conditions and spells success in the care of
our patient.
During the epidemic I found a few cases which ran a temperature much
below normal, sometimes as much as three or four degrees, and still
with enough symptoms to be easily diagnosed as influenza.
=Pulse= was taken at the time the thermometer was in the mouth. Pulse
was practically always bounding and hard. Its rate varied widely, being
influenced by many other conditions. I often, early in the attack and
where other symptoms were indefinite, made a diagnosis principally from
the pulse.
=Respiration= was taken while holding the watch and with the finger
on the pulse so that patient would not know that breathing was being
watched.
Many patients complained of a sensation of weight on the chest and
difficult breathing—hardly what one would term true =dyspnea= yet a
real air hunger and sensation of constriction in the chest. The breath
was often tainted with the odor of acetone, indicating a high degree of
acidosis and giving an important diagnostic point.
The =heart= was then examined, both by auscultation and percussion.
The examination was then extended over the lungs and pleural rub
listened for.
Patient was questioned as to having had a chill, general health,
occupation, undue exposure, fatigue, what physic if any, had been taken
or other drugs used, bowel movements and bloody stools, food taken,
sleep the night before, and dreams, headache and backache.
The full examination could not be given at each call and not all of
it to each patient, as time would not permit during the height of the
epidemic.
Throat was always examined. This is an important point.
The urine was examined in a great many cases and often albumin and
sometimes casts were found.
=Treatment.=—I consider it advisable to give a strong deep treatment if
the patient is seen before the attack has gained full headway; after
that I give short light treatments.
If the disease has not developed much at the time of the first visit
vigorous treatment with adjustment of the deep-lying and tightened-up
ligaments over the spinal cord is indicated. Subsequent treatments are
given to overcome the invariable and recurring contractions along the
spinal cord. The spine is gently sprung and the muscles pulled away
from the intervertebral foramina so that arteries, veins and nerves of
the spinal cord are free to function.
I might note here that I consider Spanish Influenza does its damage
through the attack of its peculiar and virulent toxin and the
accompanying acidosis, on the body’s reservoir of energy—the spinal
cord and related structures, the vegetative glands and nerves.
If the patient is in a serious condition he is often treated in the
position in which found, so as not to disturb him. Care is particularly
taken to keep a patient who is moist with sweat from taking cold
or being exposed. An extra covering is thrown across the neck and
shoulders, and pulled down as the bed covers are moved to get to the
area to be treated.
The musculature of the upper dorsal and cervical region is given
special attention, the region of the first and second cervical and
the first to sixth dorsal being special seats of trouble. The region
between the spine and scapula on the left side, first to sixth ribs
left, and the region of the suprascapular notch on the left side are
given specific treatment to free them of contractions. The tissues of
the suprascapular notch are in direct connection with the nerve supply
of the heart muscle and treatment here is astonishingly effective.
This treatment for the heart is best given with the patient lying on
the right side, leaning a little forward, with his left forearm against
the chest, hand at neck or chin. Stand then at the patient’s head and
with the thumbs give all the region on the left side at the base of the
neck and around the suprascapular notch thorough muscular adjustment
for circulation and removal of contractions which disturb the heart’s
vitality. Treat first to sixth dorsal region.
I consider this treatment specific for the heart debility of influenza
and many other heart conditions, as well. I have found it especially
effective in the weakened and nervous states following influenza and in
so-called “run down conditions” generally.
Vibration with the tips of the fingers on the anterior chest wall is
often used. Tender and contracted tissues are often found along the
anterior ends of the ribs which are involved at their spinal ends.
These are gently treated. Children are often given vibration, holding
their chests with my hands under their arms.
If the patient is stout and not easy to treat I have him sit up in bed
and give the upper dorsal thorough percussion with the side of the
hand[65]. About 100 strokes at each treatment are usually given. I
remember one very fat patient in the eighth month of pregnancy to whom
I could give hardly any other treatment. It was especially valuable
here and we saved the mother after a hard fight, though the child was
still-born.
When nature is meeting the emergency and holding her own in the battle
against infection we have a moderate fever—a benign fever. When the
body is overworked with other duties and irritations the fever may rise
dangerously high. Here it is that the physician must give further aid.
Here it is that osteopathic treatment further aids by giving rest to
the patient, easing pain and promoting general circulation (this in
itself often quickly reduces fever). Here it is that the attention we
give to clothing, diet, ventilation, quietness, good nursing, etc.,
comes in. The body is relieved of all duties but the one. Its functions
are all turned to one end—the destruction of the invading infection.
The osteopathic physician adjusts. Nature cures. It is all a matter of
adjustment.
For labored breathing, an effective treatment is to have the patient
with hands clasped and arms raised above the head, patient being in
bed, face up. Stand directly at head of patient. Reach over patient’s
arms and under the upper dorsal and lift up against the heads of the
ribs with your fingers, thus raising the chest, beginning as far down
the spine as you can and working up as you treat. Relax the muscles at
the same time.
=Frequency and Amount of Treatment.=—Frequency and extent of treatment
depend upon the condition of the patient. In influenza the patient is
approached with the idea of a daily visit. If then there is any doubt
about his being entirely safe for 24 hours he is seen in 12 hours or as
often as the condition indicates. Patients are usually seen more than
once a day.
The average time which the patients are confined to the bed is about
five days. Some are free from fever in three days; some not for six or
seven days. According to conditions they are then kept in bed from one
to three days longer.
As to the amount and length of treatment, I agree with James M. Fraser,
who says adjustment of the soft tissues should be made and made with
as little disturbance to the patient as possible. He says[66]: “The
ill effects of too long-drawn-out general treatments, or in short,
over-treatment, I consider one of the most important questions
for osteopaths because I incline to the belief that in many acute
infections more harm may be done by such fatiguing over-treating than
if the patient were really not treated at all. A “flu” or pneumonia
patient should never be treated over fifteen minutes at the longest in
one treatment. It is much better to treat often and not treat so long,
as over-treatment may result from a desire to be thorough. If we always
would stop and think what we are doing and just what we are trying to
prevent we would be more careful when we treat these infectious cases.
A patient’s resistance may really be lowered, his bowels inhibited, his
heart overstimulated, his muscles fatigued and his nerve force depleted
by treating overtime. When the reaction begins, stop.”
Congestions and contractions should be removed wherever they are found,
be it in the region of the throat, spine, ribs, liver or spleen. I
order a daily enema and give positive instructions—after having had one
or two almost fatal cases from this cause—to use no physics. Purging
killed more people here than any one other thing. If a heavy physic be
given two or three times and the patient comes to a crisis, so much
vitality has been taken out of the blood that he does not have enough
strength to carry him over and he dies.
If the patient comes to pneumonia I find it good and effective to use
the “constipation treatment.” It is best to let the bowel take care of
itself. Nature can do many things, and caring for the bowel in a crisis
is one of them, providing the correct diet has been given the patient.
If the patient is getting nothing but fruit juices there may be a
natural bowel movement and even if he has been getting other food it is
better to leave the bowel alone until after the crisis and then give
the enema.
A patient with a frank pneumonia following influenza has but little
chance of living if his strength is being drained from the blood stream
through the bowel every few hours.
I see to it that no draft blows on the patient’s bed. In a windy
location a cold draft can appear suddenly and do great damage in a
short time. The patient should not breathe cold air. Fresh air is all
right but it must not be cold air. I order extra covering for the neck,
arms, shoulders, back and chest. I like a wool workshirt best but use
pneumonia jackets, extra undershirts, sweaters, etc., when the wool
shirt is not to be had. In fact continued warmth seems to be an almost
necessary condition to the proper handling of influenza. It is because
heat, even the heat of the fever itself seems to aid the nervous system
in building up antitoxins.
The patient is instructed that if a sweat comes on, either from a hot
bath, hot drink or as a result of the disease, to lie and take it,
for throwing off the covers is a sure way of taking cold and inviting
pneumonia.
If the house is cold or the patient weak or very sick the urinal and
bed pan are used. In fact I prefer their use even when those conditions
are not present, as the less the exposure the less chance of pneumonia
and the quicker recovery. =Rest= lying in bed is absolutely necessary
to a satisfactory course and quick recovery.
For lung congestions and bronchial irritation, in addition to
osteopathic treatment along the spinal cord, raising the ribs and
chest, and vibration of the chest wall, I sometimes use the old
fashioned mustard plaster (made with one teaspoon each of flour and
mustard, mixed with olive oil or with water and white of egg), keeping
it on about ten to thirty minutes or until a good, red reaction is
brought about. The feet must be kept warm with hot water jugs. A hot
mustard foot bath is excellent when the feet persist in staying cold.
At first I did not use the hot tub-bath. I am now ordering it if I see
the patient early in the attack and where there is no contraindication,
such as a dangerous heart condition. I do not use it unless it can be
given properly and without undue exposure to the patient. I never give
it late in the disease.
A good method is to get the patient into the tub, lay two canes or
sticks across the tub, and cover all with a blanket or rug. Place a
bath towel for the head to rest on and pull the blanket around the
neck. The patient can then take a good hot sweat in comfort. His arms
and shoulders, his knees and legs will not be exposed to chill. When
he gets up the blanket can be drawn about him if desired. He then goes
back to bed for a good rest and sweat. A cold towel is placed on the
head and water given to drink.
Every patient should have a good sweat early in the attack. Another
good method is to cover with a blanket and place outside fruit jars or
jugs filled with hot water, cold towel to the head and several glasses
of water or lemonade to drink.
The use of cold compresses on the chest I do not favor. They are used
by some osteopathic physicians, but I believe the result is better with
other methods. Applied in a hospital where the technique is well in
hand they might be successful, but personally I fear them. I am even
careful about putting an ice bag on the heart. Cold packs are sometimes
used in my practice but only on the head for pain or delirium. Chill
must be avoided. Warmth must be conserved, even the fever is benign.
Neither do I favor “rub-on” of camphor, turpentine or onions when they
irritate the patient. If the patient has been used to them or has
faith in them and wants them I order them. I also order something of
the kind where “something must be done”. When a family calls a doctor
they “want something done,” and it is best to do something; ever
keeping in mind, however, that our patient’s strength must be conserved.
I do favor “rub-ons” in that I think it is well to keep the skin soft
with some oil. It helps to keep an even temperature and the skin
active. The skin should be wiped dry often, however, to remove the skin
secretions which if left on become stale.
I remember being called to see one little girl who could not get her
breath, and found she was holding her nose with the bed clothes. She
told me that the smell and stickiness of the lard and turpentine and
the onions made her so sick and uncomfortable that she felt she could
stand it no longer. When she was cleaned up, and clothed in nice clean
white cotton she showed a wonderful improvement, and it was real as
well as apparent.
As to =baths= in influenza, I instruct the nurse to bathe the patient
only as necessary for cleanliness and his comfort. Dabbling around in
water is not a safe procedure in a disease where pneumonia is so easily
contracted.
I do not use alcohol rubs where the patient is in anything like a
serious condition, as alcohol closes the pores and dries out the skin.
A rubbing or massage by the nurse is good for a restless, nervous
patient, but it had better be done with olive oil or some other good
oil. In influenza we do not want the pores closed. We need elimination,
and all we can get. A small saving of vitality or a little elimination
of toxins may be the margin that saves a patient for us. I do not favor
the use of turpentine, for if it is absorbed it irritates an already
sick kidney; if it is not absorbed it is useless. Why disturb the
patient?
For the bronchial irritation, in addition to osteopathic treatment,
and the accessory mustard plasters, inhalation of steam is often used.
A pan of boiling water is set by the bed and the patient leans over
the edge of the bed with a bed-sheet or paper over the head and steam
vessel, breathing the steam as long as it lasts.
For the =throat= most any cleansing gargle can be used but I prefer the
use of the common baking soda gargle. I have about one-half teaspoonful
of soda placed in a glass and boiling hot water poured over it. As soon
as this is cool enough to use I have the patient gargle thoroughly. The
idea is to get the mouth, pharynx and tonsillar area clean and free
from accumulations. Lemon-water gargle is often gratefully accepted.
If a very sick patient breathes through a dirty and dried-out mouth,
all the stage is set for him to draw into the devitalized lung large
quantities of infectious material. For this reason if not for the
comfort of the patient it is necessary that the mouth be kept clean and
also moist.
It is not possible to kill this germ life with any antiseptic. The
field must be made and kept clean.
The =nasal passage= also should be looked after, to keep it clean as
possible and also to allow the patient to breathe through the nose.
For the nasal passage any good non-irritating oil is effective but
I like best 2½ iodine in oil. It is a good lubricant and as far as
possible we do get the germicical action of the iodine.
Patients asking me what to do to avoid influenza are advised to keep
the mouth clean and closed and to use the oily solution of iodine in
the nasal passages.
And when treating the respiratory tract we must keep in mind the fact
that all healing comes from the blood side of a membrane. No healing
ever comes to a membrane from its exposed surface. Local treatment to
a membrane must be a treatment which removes irritation, not one which
adds more. Healing must come from within. “The rule of the artery is
supreme.”
=Diet.=—The diet used is liquid, so that the digestive functions will
be taxed as little as possible, for they are weak at this time. Fruit
and vegetable juices only are used.
The influenza germ propagates largely in the intestine and if the
intestine has in it the products of a full diet the bacterial growth
soon overpowers the patient. Germ life cannot develop on fruit and
vegetable juices.
Another reason for using the liquid and fruit diet is that influenza is
a disease running a short course and feeding is not necessary. If it
were a disease such as typhoid, running a fever for several weeks, we
would then give a more liberal diet, but the patient’s strength will
not be lost on a liquid and fruit-juice diet in three or even eight
days.
The frequency with which the urine contains albumin in this disease
shows us what a heavy load the kidneys are carrying. This makes a
salt-free diet advisable and again brings fruit juice to our favorable
attention.
To activate the kidneys and thus relieve the headache we give always
plenty of water and often hot lemonade. Orange juice and lemonade are
used frequently as are blackberry, raspberry, pineapple, loganberry and
grape juices. When the acid juices are not well borne we use non-acid
juices, such as pear and raspberry juice. A ripe, cooked pear mashed
with a fork and mixed with one or two different fruit juices makes a
satisfying dish.
Bottled sweet cider is also a most valuable food and a good beverage.
We use it in almost every case and find it the most acceptable to the
patient of any food offered. I am of the opinion that apple cider has
been neglected as an article of diet, both in disease and health, but
especially in fevers. It contains considerable iron for the blood, as
well as having considerable food value. It has the added virtue of
being pleasing to the patient.
In addition to these juices we often use spinach juice. I have the
nurse get a can of the best grade spinach and serve the juice hot, as
a broth, with a little salt and pepper and perhaps celery salt and a
piece of bacon in it to flavor it and to appeal to the patient. Spinach
juice contains much iron and iodine in a form readily absorbable by the
blood. It also is useful in maintaining the alkalinity of the blood and
body fluids, thus counteracting the acidosis of the disease. It renders
the urine alkaline and thus relieves the kidneys of the irritation of
acidosis and of an acid urine. Where the kidneys are or are likely to
be involved the spinach juice must be served without salt.
All the mentioned fruit juices tend to counteract acidosis and produce
alkalinity, but are not so effective as the spinach juice. They have
the advantage, however, of being used in larger quantities. The spinach
juice has considerable food value and has the added value of appealing
to the patient’s reason, when the iron and iodine content is explained
to him. It is especially useful when treating those patients who are
wondering if they should not be getting some sort of “tonic.”
The juice taken from ground fresh lettuce is also valuable. It contains
more iron, iodine and phosphates than the spinach but it is not so easy
to prepare. I have used it in the cases of several anemic and quite
sick babies and consider it well worth all the expense and effort it
took to secure it.
The breaking down of the alkaline reserve of the body and the
consequent acidosis, comes early in the disease and is disastrous, and
all the attention given to the diet is amply repaid in results. Careful
attention to the diet is the only way the acidosis can be overcome.
Raw fruit and vegetable juices also supply that most valuable element,
vitamines. For this one thing alone is the raw fruit juice most
valuable. I do not believe too much attention can be given to securing
a liberal supply of vitamines for the body, especially during an attack
of fever.
Some especially interesting points are brought out by contributors
to the Journal of the American Osteopathic Association in the March,
1919 number. I wish here to add a discussion of these points. The
contributors are physicians and good representatives of our profession
and they report uniform and excellent success in handling the recent
epidemic.
It seems to be the consensus of opinion that the treatment should be
specific and light to avoid fatigue, with the possible exception of the
first treatment, which often should be general and vigorous.
All are agreed that the patient should be kept in bed, not even leaving
it to go to the bath room. The patient must be protected in every
way from fatigue and exposure. The enema was used by all. A number
of writers state plainly their opposition to the use of physics and
laxatives. A hot tub-bath is recommended by several, but there is
opposition to much bathing.
Practically all the writers used the fruit-juice diet. However, a few
gave a heavier diet and were successful with their patients, which is
one more proof that the osteopathic treatment is the deciding factor in
bringing about a cure.
J. R. Thornton wrote after having had about 100 cases. He speaks
especially of his cases of pneumonia. They resolved by crisis.
There were no deaths. He says: “All cases were, preceding the first
treatment, given a generous plain water enema. Orders were left for two
enemas per day until told to discontinue, and in most cases the patient
got the enema. A few cases, with the highest fever, the stationary
fever, were given tap-water enemas, one each hour until the temperature
dropped two or three degrees.
“Sponge baths were given to reduce fever in every case. Diet was liquid
until the temperature was normal.
“The osteopathic treatment of the usual spinal work, paying special
attention to cervical and dorsal areas, and strong inhibition.
“Pneumonia cases were treated three to five times a day and had as much
time as they required at each visit. They required action. Heating
compresses were used on each case, except the ice bag to the heart
when rapid. One case of delirium was treated with ice caps to the head
and neck. Normal salt solution per rectum. Murphy drip was given in
each case. Diet, liquid consisting of egg-nog, milk, strained soup and
broth.”
Mary Alexander Patton: “Treatment should be quick, every motion
significant so as not to tire the patient, for exhaustion is always
present. Each patient was treated two or three times a day until
temperature became normal. The nasal douche was given twice a day
followed by K-Y jelly. Hot soap bath followed by soap enema and
enteroclysis when fever persisted.”
W. Curtis Brigham ordered “Hot packs the full length of the spine
twenty to thirty minutes, three times a day. This will produce profuse
sweating and often put the patient to sleep.”
I have used this same treatment, especially in nervous cases, and hold
it in high esteem. I have the patient put a bath robe on backwards
so that the arms and legs are well protected but the spine easily
accessible. The hot packs can then be used and covered over and the
patient not exposed.
R. H. Nuckles maintains that lung and ear trouble will not follow
influenza where osteopathic treatment has been given to adjust the
cervical and upper dorsal circulation.
H. A. Price: “We have kept particularly in mind, first, the nerve,
blood and lymphatic supply to the lungs; second, the circulation to the
spine (meaning spinal cord); third, the internal secretory functions
and to the general excretion.”
Ralph M. Crane says: “A great deal of my work is among the Italians. It
was necessary to give quick specific treatment that I might do as much
good as possible to the greatest number. I did not treat them as often
as I would like to, and because of this fact I learned that osteopathy
got control of the ‘flu’ immediately, the first treatment sufficing to
start them on the road to recovery; in fact, many of them got no more
than one treatment.”
FOOTNOTES:
[51] Hinckle—The Scientific Basis of Osteopathy.
[52] Clinical Osteopathy.
[53] Journal of Osteopathy—Prize Article July, 1906.
[54] A. O. A. Case Reports—Series I.
[55] E. Link, Diphtheria—The Bulletin, 1905.
[56] A. M. Willard, Membranous Croup—Journal of Osteopathy, March, 1904
[57] See Dr. Still—Philosophy and Mechanical Principles of Osteopathy.
[58] Journal of Osteopathy, October 1905.
[59] Journal of Osteopathy, October 1905.
[60] Journal of the American Osteopathic Association, March 1906.
[61] Journal American Osteopathic Association, December 1904.
[62] Journal American Osteopathic Association, May, 1905.
[63] Journal American Osteopathic Association, May, 1905.
[64] Rewritten from article in Osteopathic Physician, June 1919.
[65] This treatment was described by Henry M. Stovel, in The
Osteopathic Physician of January 1917.
[66] O. P. June 1919.
ACUTE ERUPTIVE FEVERS, MUMPS AND WHOOPING COUGH
By EDGAR S. COMSTOCK
GENERAL CONSIDERATION
In the consideration of these diseases, it is well to bear in mind
that lowered resistance is the primary condition that has made the
infections possible, and that lowered resistance implies an imbalance
of or obstruction to the vital fluids and forces of the body, thereby
interfering with the functional activity of the body’s normal
protective mechanism.
The imbalance of or the obstruction to these vital fluids and forces,
which is structural in nature, is produced by many conditions, as
fatigue, exposure, sudden changes of heat and cold, emotions, dietetic
errors, physical force or violence, etc. These conditions, because
of the response of the tissues of the body to environmental changes,
produce contractures of the elastic tissues, such as muscle, fascia,
etc., which disturbs the structural integrity of the body and thus
produces obstructions, irritations or interference with the media of
exchange of these vital fluids (blood and lymph) and forces (nervous
energy) of the body.
It is evident, then, that the most potent curative factor in the
treatment of these diseases, as in all others, is the removal, whenever
possible, of the obstructions and interferences that pervert the
activity of these protective forces. It is necessary, therefore, to
remove the exciting causes (fatigue, dietetic error, etc.) and by such
physiological means as may seem necessary to readjust the structures
of the body so as to remove the above mentioned obstructions and
interferences.
The structural lesions most frequently found in the infectious
diseases are of the muscular and fascial type and are very evident
to the careful observer. The interosseous lesions are probably often
the predisposing factors to the susceptibility of the softer tissues
to reaction to environmental changes, but it has been the experience
of the writer that the adjustment of the softer tissues was of
greater primary importance in the acute stages of these diseases.
The interosseous lesions may be easily adjusted in the very early
stages of these diseases, that is before the severe symptoms have
appeared, but after the more severe conditions have appeared it has
been our experience that the soft tissue work was sufficient unless the
interosseous lesions were very easily adjusted.
It is the writer’s desire to impress upon the reader the necessity of
careful attention to the structural lesions that are always constant
in these diseases, using whatever physiological means seem necessary
to adjust these lesions and keep them adjusted, and to insist upon
carefully restricted diet; continuous, thorough elimination of the
waste products of the body; hygienic surroundings and well-regulated
environments both mental and physical. Then Nature, which has given
the body its own protective mechanism, may have full control of the
situation and all of the normal protective chemicals and forces in the
body organism are utilized in the battle with the invading infective
forces: the glands secrete the chemicals of protection; the antibodies
are rapidly developed and thrown into the battle area; metabolism
begins to return to normal; elimination becomes increased because of
the stimulating action of foreign substances in the body structures;
and the work of repair and recuperation begins.
If reliance is placed upon the inherent protective forces of the body,
the knowledge of the special type or character of the invading organism
is of little importance from the standpoint of the treatment of the
disease after it has become established. The value of the knowledge
of the specific organisms is in preventive medicine, in seeking out
the habitat and breeding ground of the organism and its mode of
transmigration. Knowing these, effective measures may be adopted to
prevent their propagation and spread. Examples of this are Yellow Fever
and Malaria.
Variola
(SMALLPOX)
=Definition.=—=Variola= is an acute, specific, highly infectious and
contagious, epidemic disease. Its beginning is sudden with a chill,
vomiting, severe headache and lumbo-sacral pains. It has a typical
fever curve and a typical eruption on the skin and mucosæ of macules,
papules, pustules and crusts successively.
=History.=—Prevailed in China and India at least 1000 years before the
Christian era. Epidemics occurred in the sixth century and during the
crusades. Its first clinical description was given in Arabia during the
ninth century. It was brought into Mexico about 1520 by the Spaniards
and between three and four million people contracted the disease. In
1718 preventive inoculation was introduced into England and in 1796
Jenner discovered vaccination.
=Etiology.=—The specific agent which is the cause of this disease is
unknown, but the virulence of the agents is retained for a long period
and is the most virulent found in all diseases. There is no period
from the initial fever to the final desquamation that the disease is
not contagious, although the stage of suppuration is the most violent.
Although the disease is so highly contagious and the entrance of this
particular poison into the system produces this disease, still no
one has yet been able to discover a germ nor what the nature of the
infective agent is. To contract the disease it is not necessary to
touch an individual already afflicted, not to even approach the sick
room. It may be only necessary to touch a garment that has once been
in contact with a smallpox patient, or which has simply hung in his
vicinity.
The blood is infectious at a very early stage. As smallpox is
contagious without eruption it seems that the secretions and
excretions convey the virus. The dried pustules seem to have the
greatest infectiousness. Cadavers of smallpox (Variola) victims are
very dangerous and relatives of them should be carefully warned. The
disease often persists in infected communities for years. The disease
is evidently spread by fomites, contact with the pustular contents, and
crusts or scales of the desquamating skin. It attacks all classes, ages
and conditions of people, which is unlike other erythematous diseases.
A previous attack usually confers immunity. Vaccination is claimed to
confer immunity but apparently in not all instances, for there are
records of “successfully vaccinated” individuals having severe attacks
of the disease.
The susceptibility to smallpox, as to all other infectious diseases,
varies in different individuals, in different races, and under
the influence of conditions as yet unknown. Some persons are not
susceptible to the disease, nor are they to vaccination, and yet others
have been known to have had the disease as much as three times. The
Negro and Indian races seem to be more susceptible than the Caucasian.
Then again at intervals of a few years, the general susceptibility of
the people seems to be increased so that cases of smallpox become far
more numerous than usual.
A point of considerable interest is the fact that the child, while in
the mother’s womb, may experience the disease along with the mother
and thereby acquire, before birth, the usual immunity conferred by one
attack of the disease. In most cases of smallpox in pregnant women,
abortion or miscarriage occurs, yet a sufficient number of instances
are on record in which healthy children have been born, exhibiting the
characteristic pitting of smallpox, and possessing no susceptibility to
vaccination. Again there are other cases in which pregnant women have
smallpox and the babes in the wombs have escaped entirely; while the
most singular fact is that while the fetus may experience the disease,
the mother through whom the exposure was effected, escapes, either
because of a previous attack or possibly because of vaccination.
While there seems to be no reason for believing that an attack of
smallpox can be, or ever has been, aborted by artificial means, yet
there is a prevalent belief that this process occurred during certain
epidemics of smallpox, cases having been known in which individuals
presented all the symptoms indicating the invasion of smallpox, and
yet no eruption occurred, and yet such individuals were thereafter
insusceptible to smallpox or vaccination.
The mortality of smallpox varies like the susceptibility of it—with the
age of the patient and with some unknown conditions of the atmosphere
or soil which favor the occurrence of the epidemics. The average in
scattered cases—sporadic—is probably not greater than one in nine or
ten. A fatal result occurs more frequently in the second week of the
disease than at any other time.
=Pathology.=—Granular and fatty degeneration occurs in the liver,
spleen, kidneys and heart. Infiltration is found in the adrenal glands
and testicles. During the papular stage, there is local hyperemia of
the papillæ, with interstitial exudation and colliquative necrosis
of rete cells, so that a vesicle is formed, peculiar in that it is
traversed by delicate bands of epithelial cells. This, with the fact
that coagulation-necrosis occurs mainly in the center, gives it the
umbilicated, or depressed appearance. The contents of the vesicle are
plasma, fibrin and cell detritus. Leucocytic invasion converts vesicles
into pustules. This has a more globular, elevated appearance than the
umbilicated vesicle. Pyogenic organisms are found in the pus. When the
inflammation injures the corium, scars are apt to result; this occurs
when the skin is scratched. The actinic light rays increase the danger.
=Diagnosis.=—Mistakes in the diagnosis of the first cases of smallpox
in an epidemic are almost inevitable. Hemorrhagic scarlatina or measles
sometimes cause confusion; in the hemorrhagic scarlatina the mucous
membrane hemorrhages are less frequent than in smallpox. The prodromal
eruptions plus purpura are very suggestive. The invasion stage lasts
about three days.
Smallpox is characterized by sudden onset with violent chill and
shivering; agonizing pain in the back and legs; intense headache,
mostly frontal; temperature rapidly reaching 102 to 104 degrees
F.; full, strong, rapid pulse, going to 100 to 140; uncontrollable
vomiting; pharyngitis; red face, bright eyes, coated tongue; anorexia;
constipation; sleeplessness; delirium; often copious perspiration and
extreme prostration.
An “initial exanthem,” clearing within 24 to 48 hours, appears. It
is either hemorrhagic or erythematous. About the third day the true
eruption appears, first upon the forehead and in the scalp, then the
rest of the face, the backs of the wrists, trunk, arms, and lastly the
legs, most abundant upon the parts exposed to the atmosphere. With the
appearance of the eruption, all symptoms abate, the temperature falls,
and the patient may feel quite comfortable. The eruption consists of
coarse, red spots upon the body, like flea-bites, rapidly becoming,
within 24 hours, slightly raised red papules, feeling hard and shotty
to the touch, and each surrounded by a broad red inflammatory band,
the areola. Usually by the sixth day the papules become converted into
umbilicated vesicles, at first clear, then turbid. They are hard and
indurated to the touch, and on the eighth or ninth day they become
pustular. The areola becomes much darker, the temperature rises to 103
to 105 degrees F., and the pulse to 110 to 120. The other symptoms
all reappear, with salivation and delirium. Marked edema of the skin
renders the skin unrecognizable. The pustules are painful, especially
in places where the skin is thickened. The maturation lasts about three
days, when the fever falls by lysis. If fatal, death usually takes
place about the tenth day, preceded by feeble and more rapid pulse,
marked delirium, subsultus and sometimes diarrhea. About the eleventh
day, desiccation begins, the pustules begin to dry, forming tight scabs
which are closely adherent. The fever and other symptoms subside but
itching becomes annoying. The odor from the pustular stage on is a
peculiar greasy one.
After the rupture of large pustules the centers frequently dry and sink
in, often in the shape of the Maltese cross. This is most typically
seen on the backs of the hands and is pathognomonic. Toward the end
of the third week the scabs fall, leaving red glistening pits which
disappear or change into deep white striated scars. The hair falls but
may grow again. The diagnosis is not certain until the eruption is
seen. In the smallpox without eruption the diagnosis must be made from
the history of exposure, the presence of an epidemic, fever, lumbar and
head pains, delirium, and possibly the initial rash.
Mistakes in diagnosis may be made even by smallpox experts, but
attention to the history, somatic findings and the course of the
disease, rather than to the eruption, will prevent disastrous results.
Always isolate any and all suspected patients.
Varicella Compared with Variola
Vaccination and smallpox never Smallpox may closely resemble
prevent. chicken pox; especially mild
cases.
AGE—usually before puberty, may Usually after puberty (many
occur in adults. exceptions.)
Initial stage practically absent. Initial stage severe, even in mild
cases.
TEMPERATURE,—no remission on Typical remission and secondary
onset of rash. fever.
White cells normal or decreased. Leukocytosis.
Prodromal rash very exceptional. Prodromal rash quite frequent.
Vesicles in crops. Vesicles never in crops.
Vesicles rarely shotty. Vesicles, following macules, are
hard and shotty.
RASH EVOLUTION,— RASH EVOLUTION,—
Very rapid, vesicles on first or Much slower, vesicles on seventh
second day. day.
Eruption is universal, successive Development progresses downward,
crops, most abundant on back, face first, then wrists,
begins on body, less on face, trunk, arms and lastly legs. Less
scalp, hands and feet. on trunk.
Vesicle is superficial and fluid Fluid pearl-colored and NOT
transparent. transparent. Thicker covering.
Halo (areola) usually absent. Areola is marked.
Involution is quite rapid. Involution is slow.
The =Secondary Toxic or Septic Rash= appears during the stage
of decrustation, sometimes with a mild fever. It may be either
scarlatiniform, morbilliform, or hemorrhagic. The skin immediately
surrounding the drying pocks is often exempt leaving an anemic halo.
The rash lasts about three days and fades or desquamates. With the
development of the skin eruption, an exanthem appears upon the mucous
membranes of the body cavities, developing into ulcers. This may
develop before the dermal rash and be of diagnostic importance.
Forms or Varieties
I. Variola Vera. { a. Discrete.
{ b. Confluent.
{ c. Purpura variolosa
II. Variola Hemorrhagica. { (black smallpox)
{ d. Variola hemorrhagica pustulosa.
III. Varioloid. e. Smallpox modified by vaccination
or partial immunity.
=Discrete Variola Vera.=—Incubation symptomless and averages 12 days.
Prodromal stage, from first symptom to eruption. Averages three days.
The longer the stage the more severe the infection. Intensity bears
little if any relation to prognosis; however, if onset is mild, disease
will not be confluent or hemorrhagic.
Invasion begins with severe chill, often repeated. Initial fever
rises suddenly to 103° or 104°, and reaches maximum on second or
third day. Pulse is rapid and full. Skin is red, hot and dry. There
may be sweating in the discrete form and in the favorable cases. The
headache appears with the chill and is usually frontal. When severe
and accompanied with neckache and vomiting it may suggest meningitis.
The backache appears with the chill and lasts about two days. It is a
lumbar pain, very like lumbago; it occurs slightly less frequently than
the headache and vomiting. This pain is rare in other fevers likely to
be confused with smallpox. Vomiting is constant in children and usual
in adults. The initial eruptions, which are present in about 10 to 12
per cent, are of considerable diagnostic importance. They are usually
limited to the lower abdomen, inner side of the thighs, axillæ, and
sometimes on the extensor surfaces of the knees and elbows.
=The Eruptive stage= consists of the following sub-stages: =macules and
papules; vesicles, and pustules=.
The macules and papules occur on the fourth day and progress for about
three days. They begin on the forehead, near the hair, with itching and
burning and resemble flea-bites. These soon become papules, which are
reddish, elevated, circular, hard or shotty and discrete. On second
day of this stage they appear on the body, and on the next day on the
extensor surfaces of the extremities. If the eruption appears on the
second day the confluent type may be anticipated; if on the third day
of the disease, the discrete type.
The vesicles which occur on about the seventh day of the disease,
contain lymph. Umbilication occurs in the centers of many of the
vesicles, and it is suggestive of smallpox.
The suppurative stage begins about the ninth day with clouding of the
vesicles and inflammation around them. This continues for three days.
The pustules become opaque, then yellow, and a thick pus obliterates
the umbilication. The inflammatory “halo” becomes more vivid and edema
may follow around these haloes. This edema causes increased tension
and deformity, particularly of the face, and produces great tenderness
and pain. The pustulation follows in the order of eruption, from the
face downward, and are the thickest on the extremities and head. The
pustules evacuate spontaneously, or may dry up without rupture. The
skin gives off a peculiar, offensive odor. Bed-sores are now most
likely to develop.
The eruptions also may occur in the mucous membranes, particularly in
the mouth and nasopharynx. These pass through the successive stages as
do those of the skin, but less typically. With the pustulation there
is usually a gradually rising =secondary fever=. In the discrete type
the secondary fever does not remain high more than twenty-four to
thirty-six hours, with morning remissions. A marked leucocytosis occurs
with the secondary fever and its extent depends upon the severity
of the infection. Delirium, albuminuria, acute exhaustion and heart
paralysis are to be guarded against during this stage.
The state of involution, or decrustation, begins about the twelfth day.
It follows the order of eruption, and is accompanied with a decrease
in edema, redness and pain, but is attended with intolerable itching.
Crusts form, the hair falls out and by the end of the second week the
temperature returns to normal. If fever persists during this stage
it indicates some complications. Scars occur when the true skin is
involved and lasts three or four weeks. Complete convalescence follows
the disappearance of the last crust.
=Confluent Variola Vera.=—This is a malignant type and used to be more
prevalent than now. The initial stage is violent, and the headache and
backache very agonizing. The fever remission is very slight or absent,
and attended with hardly any improvement in symptoms. The earlier the
exanthem occurs in variola the more likely it will be of the confluent
type. The confluent eruptions occur especially upon the face and head,
sometimes on the hands and feet. It is largely discrete on the body
and extremities. Great edema appears with the fusion of the eruption,
with the swelling and erosion of the mucous membrane, the eyes close
and the nostrils become obstructed. The fever is high, pulse high and
rapid (often irregular), dilirium, albuminuria, persistent nausea
and vomiting, great thirst, husky voice, enlarged cervical glands,
salivation in adults and diarrhea in children are symptoms present.
Death occurs from acute toxemia, usually within a week, but may last a
little longer. Recovery from confluent variola is very infrequent.
=Purpura Variolosa.=—This is “Black Smallpox.” That is, smallpox with
primary hemorrhage in the initial stages. It is the worst type and
results almost invariably in death. It is very important because it is
so difficult to diagnose. Its incubation period is short (6 to 8 days),
invasion very severe, lumbar pains almost unbearable, prostration
great, pulse soft, small and rapid and respiration unusually high. The
initial pains and vomiting may last until death.
On the first or second day a plum colored eruption appears, with
brick-red, purple or inky ecchymoses particularly about the eyes.
The condition is desperate. Hemorrhages may occur from any cavity
of the body, sometimes accompanied by gangrene of the pharynx. The
disease does not usually reach the period of real eruption, because
death usually occurs within four or five days. The diagnosis of this
condition is by history of exposure to smallpox and the characteristic
prodromes.
=Variola Hemorrhagica Pustulosa.=—This is the type with the =secondary
hemorrhage=, or the hemorrhage after the eruption appears, and is more
common than primary hemorrhage. It occurs in weakly and alcoholic
subjects. The initial stage is severe, and the hemorrhages occur
into the vesicles or pustules. There may be epistaxis, hematuria and
metrorrhagia. The outcome is almost always fatal, though the hemorrhage
at the vesicular stage may be followed by rapid abortion of the rash
and recovery.
=Varioloid.=—This is modified or mitigated smallpox; also known as
variola benigna. Persons exposed to smallpox sometimes suffer from
varioloid, and persons who have had smallpox may suffer from varioloid
at subsequent exposure to smallpox. Vaccination appears to initiate an
attack in persons peculiarly susceptible, or as a result of improperly
performed vaccination. The lesions remain in the epidermis, the course
of the eruption is shorter, the papules vesicate by the fifth day, the
process of suppuration is abridged, decrustation occurs rapidly with
little or no scarring, and all symptoms are milder. There are many
modifications.
=Other varieties= are (1) Variola sine exanthemate, which has the usual
symptoms without the eruption; (2) Variola verrucosa, which has large,
solid, conical papules with small vesicles at their apices, which
rapidly desicate and form crusts, and finally disappear without scars;
(3) Variola cornea (horn pox) which is known by the large mahogany
crusts.
=Complications and Sequelæ.=—Variola is often accompanied by many
complications and sequalæ which are an early severe toxemia and a
later secondary infection. During the secondary fever, there may be
bronchopneumonia, pleurisy, dysentery, hemorrhages of all kinds,
ulcerative eye, ear or laryngeal conditions, purulent arthritis,
orchitis, gangrene when the swelling is great and subcutaneous
abscesses form, often attacking the penis and scrotum, erysipelas
attacking the face, and rarely nephritis.
During convalescence, carbuncles, boils and other subcutaneous
abscesses are very common. Disturbances of the peripheral nervous
system as neuritis, paralyses especially of the palatal muscles,
neuroretinitis, and otitis media are less common. The sequalæ most
common are boils, abscesses, deep pitting, otitis media, blindness and
permanent baldness.
The =urine= has the usual febrile changes. =White blood= cells reach
10,000 to 20,000 or more. Lymphocytosis occurs during pustulation;
polymorphonuclear cells are decreased to 40%, sometimes to 12%;
myelocytes and irritation forms are found. During the febrile stage
there is a polycythemia followed by an anemia to 3,000,000 or less
during the pustular stage. Regeneration is slow, lasting about
fourteen days. Normoblasts are rare except in hemorrhagic forms.
Exudate taken from the pustules show streptococci, staphylococci, and
pseudodiphtheria bacilli.
=Treatment.=—The imperative demands of treatment are isolation,
ventilation, cleanliness and disinfection.
If symptoms are suspicious of smallpox, =notify the proper authorities
at once and isolate patient=. When diagnosis is made, cut hair and
beard very short.
1. Isolate patient in room free from draperies, rugs, carpets,
curtains, pictures, etc.
2. Disinfect all vessels used in room of the patient in carbolic acid
solution or in bichloride of mercury solution.
3. Family of patient should be isolated for from sixteen to twenty days.
4. Room should be well ventilated, with windows screened and slightly
darkened with red curtains to exclude the ultra-violet rays of light.
Temperature should be maintained at 65 degrees. Door-way may be
protected by a sheet dampened with a 1:60 carbolic solution.
5. Nurse must be robust, perfectly immune and not afraid. If male
nurse, hair must be very short and must have no beard; if female, hair
must be short and must wear close fitting cap.
6. Absolute cleanliness is secured by plenty of baths, clean bed and
personal linen, and careful nursing. Physician must put on special
suit with cap and gloves which are kept in the house, but not in the
sickroom.
The first symptoms being the headache, nausea and vomiting and the
lumbar pains, the first points of attack in the treatment would be the
relief of these pains in the head and back by thorough relaxation of
the spinal muscles, paying particular attention to the suboccipital,
mid-dorsal and lumbar areas. The headache may be partially relieved
by steady pressure between the frontal and occipital regions. No
interosseous adjustments requiring painful or difficult technique
should be given after the more severe symptoms have appeared. Patient
should be visited from one to three times per day, and the reflex
contractures of the muscles must be relieved as often as they occur.
Dysentery and diarrhea are controlled by strong inhibitory pressure in
the sacral and lumbar regions. Give vasomotor treatment to the superior
cervical ganglion. Stimulate the anterior aspect of the solar plexus to
stir up its acid function, the blood being alkaline in smallpox.
During all the stages up to the stage of pustulation, the patient
responds very readily and successfully to osteopathic treatment. The
headache, the backache and the aching joints respond to treatment as
readily as, if not more readily than, the headache and backache of
influenza do to osteopathic care. The constipation is usually quite
readily relieved. It has been the experience of those who have handled
smallpox cases, that the tendency to the confluent type is greatly
reduced by this treatment and that the response of the patient to
osteopathic treatment is very gratifying. Indeed, those of experience
have less fear of the outcome of their smallpox cases than do they have
of scarlet fever or pneumonia.
After the pustules have formed, each pustule is treated with iodine
painted on the pustule with a camel’s hair brush. During the pustular
stage it is not necessary to give manipulative treatment, and indeed
it is sometimes impractical because of the tenderness of the skin.
However, about all that is needed during this period is good hygienic
treatment and good nursing. During convalescence constitutional
treatment should be given.
=Diet.=—During period of vomiting, pellets of ice in the mouth are
comforting. During periods of fever give plenty of water with,
preferably, lemon juice. As the fever declines begin with barley and
oatmeal water with lemon juice; then follow with easily digested and
nutritious diet of milk, eggs, broths, beef juice and gruels. Feed
every three hours during that period but not large quantities. During
convalescence a full, well-regulated, nutritious diet should be ordered.
=Hygienic Care.=—Keep nose cleansed with glycerine, cold cream or
olive oil, which keeps the crusts soft. The mouth and nasopharynx may
be cleansed with any mild antiseptic. The eyes are washed with warm
boric acid solution. Cold compresses applied over the eyelids assist in
reducing the edema. A daily tepid sponge bath is necessary. Bath may be
given with bichloride of mercury solution (1:20,000) or creolin (1:500).
=Headache.=—Deep, steady digital pressure in the suboccipital fossa and
at eighth thoracic spine; ice bag to the head; or a mustard plaster at
the back of the neck may relieve.
=Vomiting.=—Thorough relaxation and adjustment of the great splanchnic
and cervical areas, with deep, steady digital pressure in the occipital
triangles, and at the fourth and fifth dorsal vertebræ on the right
side will usually control the condition.
=Fever.=—Relaxation of the upper dorsal area, relaxation of the
cervical area, and deep, steady pressure in the suboccipital region
often reduce temperature. Warm sponging in lower grades of fever, bath
at 70° F., and cold pack may be needed. If temperature goes very high
give a continuous cool colonic irrigation.
=Pitting.=—Cold wet dressings of lint soaked in any comfortable mildly
antiseptic solution, or of ice water and glycerine, are to be used on
the hands and face to prevent pitting. Hot water dressings are more
comfortable to some patients. It is well to protect the skin from the
light, especially from the ultra-violet rays. This, however, must not
lead to any lack of ventilation. When crusts are forming keep them
moist with vaseline, oil, glycerine, or carbolic acid in lanolin or
vaseline.
=Odor.=—Baths, the daily toilet and the use of dusting powder or 5%
iodoform powder, an open bottle of smelling salts or of weak ammonia
are good. Plenty of fresh air is best of all.
=Cardiac Weakness.=—If pulse is feeble and frequent, a general quieting
treatment should be given, including relaxation of the cervical area
and of the fourth and fifth dorsal segments. An ice bag in flannel
directly over the heart is often very useful. Gentle, careful spinal
extension is very restful and eases the spinal circulation.
=Delirium= is usually relieved, or prevented, by spinal extension,
the prolonged warm bath or the cold pack, if given when signs of
nervousness appear. Morphia or chloroform may be necessary in violent
and suicidal cases.
=Laryngeal Obstruction.=—Usually caused by edema and may require
tracheotomy.
=Bed-sores.=—These and abscesses may occur even under the best of care.
Place patient upon a water-bed or in a continued warm bath.
Convalescence is not complete until the skin is entirely free from
crusts and is perfectly smooth.
=Prognosis.=—Prognosis depends upon age of patient; complications; and
environment from which patient comes, as well as upon the nursing. In
varioloid the prognosis is recovery; in the discrete variety, good;
in the confluent type over 50% are fatal; in the malignant types
practically all die. In patients under five years old and over forty
years old the prognosis is very grave. A filthy environment predisposes
to complications. Recurrences seldom occur; second attacks are usually
varioloid.
=Prophylaxis.=—Usual rules of health authorities are: rigid quarantine
or isolation, vaccination, disinfection of the skin and all fomites,
and final fumigation. Quarantine of a suspected individual is sixteen
days after exposure. Isolation continued until every trace of eruption
has disappeared. The dead body is very dangerous and a public funeral
is not permitted. The clothes used by the patient must be steamed and
other articles must be washed with bichloride of mercury and fumigated
with formaldehyde vapor. Disinfection of the hands, face, beard and
hair of attendants with bichloride solution is imperative.
Vaccination
(VACCINIA; COW-POX)
=Definition.=—=Vaccinia= is an eruptive disease of the cow,
communicable only by inoculation and causing, when transmitted to the
human being, local reaction in the form of a pock and constitutional
disturbances which are followed by a more or less lasting immunity
against smallpox. =Vaccination= is the artificial inoculation of
vaccine virus for the purpose of producing an immunity against smallpox.
Arm to arm vaccination was formerly very generally practiced but has
been practically discontinued because of the possibility of infection
from syphilis and other infections. When it is necessary to use the
human lymph it should be taken upon the eighth day from a typical
unbroken vesicle in a perfectly healthy child at least three months
old. The vesicle must be pricked at several points, care being taken
not to draw blood. The bovine vaccine lymph is now in general use
because it practically eliminates the possibility of syphilis and other
infections. Also because it is more easily transported.
It is thought best by many authorities to vaccinate in infancy
after the sixth month, at the seventh and eighth year, at puberty,
and thereafter at intervals of about seven years, but depending
considerably on the prevalence of small pox. The virus is prepared
under sterile conditions from carefully selected and tested calves. It
is put up under aseptic conditions in hermetically sealed capillary
tubes or, in the old style, on ivory points.
There is a great variety of opinions as to the efficacy of vaccination
in producing immunity against small pox, this variety of opinion being
very prevalent among representatives of the medical schools. Dr. F.
P. Millard of Toronto says the lymphatic system is the keynote, and
that vaccine virus poisoning spreads through the lymphatics, causing
diphtheria and allied throat affections. Dr. A. T. Still said, “We are
opposed to vaccination.” He repeatedly emphasized the fact that “Nature
furnishes within the body all the remedies necessary to cure disease.”
In the recent Canadian epidemic (1919-1920) the medical authorities
have met with a most strenuous opposition. The Homeopathic profession,
almost to a man, went on record as opposed to compulsory vaccination.
The Illinois Supreme Court has ruled that compulsory vaccination is
unconstitutional.
=Technic.=—The area usually selected is the left arm at a point above
the insertion of the deltoid muscle. Some prefer the leg over the
junction of the two heads of the gastrocnemius muscle, because it is
more easily cared for, and, because of the style of wearing short
sleeves among women, it does not expose the scar which results from the
vaccination.
The surface must be washed, dried, with a soft towel, and then
sterilized with alcohol. With a sterilized needle or lance scratch
an area about a quarter of an inch in diameter, being careful not to
produce bleeding but merely an oozing of pinkish lymph. A drop of the
virus should be deposited upon the abraded surface, rubbed in with
the side of the needle and let dry. A thin layer of sterilized gauze
should be lightly applied and held by means of adhesive plaster, not
encircling the limb. This should be occasionally removed and redressed.
The pock should be kept dry and clean, and may be lightly dusted
with starch or toilet powder. “Persons exposed to the contagion of
small pox should be immediately revaccinated. The immunity conferred
diminishes with time.” It is the writer’s personal opinion that, with
the amount of complications that so frequently follow vaccination and
with the fact that “it is necessary to revaccinate during an epidemic
or after exposure,” it were better to defer vaccination, if parties are
favorably inclined to the practice, until such time as the presence of
small pox in the community make it apparently necessary.
=Typical Vaccination.=—The period of incubation varies from three to
five days. At the end of this time local reaction shows itself in the
form of reddish papules at the point of inoculation. In about five days
these develop into compound vesicles, which at first have clear and
then later opaque contents. About the eighth day the vesicle is fully
developed and is round or oval with prominent and well defined edges
and a depressed center. An erythematous areola usually appears about
the tenth day and the contents are purulent. The surrounding skin is
swollen and tender, and a scab now begins to form in the center of the
pock and rapidly extends toward its edges. About the end of the second
week the areola fades, and the pock is changed into a thick brownish
crust which becomes dry and hard, and comes off between the twentieth
and twenty-fifth days after vaccination. A dusky red scar is left and
this gradually becomes white and pitted. During the evolution of the
pock the glands through which lymphatic drainage takes place become
slightly enlarged and tender.
The constitutional reactions are usually moderate fever, restlessness
at night, irritability and loss of appetite. These symptoms usually
appear about the fourth day and continue about three to five days. At
any time during the vaccinia erythema, roseola or urticaria may appear.
The constitutional reaction in revaccination is sometimes very severe.
There are many atypical symptoms following vaccination as variation
in the number of the pocks, in the size, in the severity of the
constitutional symptoms, in the contents of the pock, in the healing
and formation of the scar and in the transmission of specific diseases
as syphilis, tuberculosis, leprosy, cancer and tetanus.
=Complications.=—All cases are not benign, as due to impurity of
vaccine, carelessness in technic, improper care in dressing, handling
of the wound by the patient himself, scratching it with the finger
nails, and other accidents of like nature, infections may set in
and very serious complications arise. These result in abscesses,
erysipelas, tetanus and various eruptions. Otitis media may leave
deafness.
The writer knows personally of a young man in the Army during the World
War who was vaccinated while in the Army and two abscesses developed
which ate entirely through the arm, one abscess passing through the arm
just anterior to the humerus and the other just posterior to it. It was
many, many months in healing, and nearly caused loss of the arm.
There are many cases of record where vaccination was followed, directly
or indirectly, by paralysis, deformities, and chronic constitutional
diseases. It is usually claimed these conditions were due to accidents
following the vaccination and not due to the vaccination itself.
However, it can not be denied that the vaccination was at least the
indirect cause of these deplorable conditions.
=General Vaccinia.=—(Vaccinal eruptive fever; Vaccinola). This consists
of a vaccine rash, developing usually from the fourth to the tenth day
following vaccination, and appearing in various parts of the body,
particularly about the wrists and on the back. The secondary pocks
usually develop about the eighth or tenth day after vaccination and are
usually more abundant on the vaccinated limb than on any other part of
the body. As the pocks appear in successive groups, all stages of the
disease may be seen at one time, and the condition may last for many
weeks. Fever may be absent or present, but is usually proportionate to
the extent of the eruption and the associated complications.
=Treatment.=—After vaccination, the patient should be told to return
in seven days, when the dressings should be removed, and if the
vaccination has been successful, a pearl-like vesicle will be present.
If the vesicle has been broken by accident or by rubbing of the gauze,
the free portions of the dressing should be cut away and the adherent
part left undisturbed. A new gauze should be applied in any case, and
in five or six days more, the dressing should be again changed, and
this changing continued at intervals until the crust falls, which is
usually during the third or fourth week.
If no vesicle forms by the tenth or twelfth day, the vaccination has
not been successful. It is suggested by the vaccination advocates that
another attempt should be immediately made.
=Prognosis.=—Uneventful recovery is to be usually expected. Pitting
from generalized vaccinia; various constitutional diseases; paralyses
and other maiming disabilities sometimes occur. While it is not
usually considered dangerous to life, there are nevertheless many
cases of record where death has resulted. It is not wholly unattended
with danger.
The best of care should always be taken following vaccination to
prevent the possibility of complications, though even then they do
occur.
Scarlet Fever
(SCARLATINA)
=Definition.=—Scarlet fever is an acute, specific, contagious,
infective disease of unknown origin, characterized by very sudden
onset, fever, vomiting, sore throat and diffuse exanthem.
=History.=—It was first recognized in the sixteenth century, but first
fully described and differentiated from measles by Sydenham in 1660. It
was introduced into America about 1735.
=Etiology.=—The causative organism or agent is unknown. The virus
of scarlet fever produces severe necrosis, but no suppuration. The
streptococcus is the most important factor in the production of
complications and in their mortality. It is claimed to be the cause
of the malignancy of the disease but not of the disease itself.
Susceptibility to the disease is by no means universal as only 38% of
children and but 5% of adults exposed to the infection acquire the
disease. Over 90% of the cases occur under ten years of age, and rarely
during the first year of life.
“Scarlet fever is a toxic superficial expression of internal
malnutritive conditions of the blood as a tissue. The cause of the
toxicity is usually overfeeding, or the feeding beyond the demands
of the proximate principles of the body, or the overfeeding under
unhygienic conditions.—J. MARTIN LITTLEJOHN.
“It was once held that the virus was disseminated during desquamation,
but oral, nasal and otitic discharges probably perpetuate the
infection, perhaps months after scaling is complete. In no other
disease is the virus so tenacious. It may persist ten years on clothes,
furniture, etc.”—A. R. EDWARDS.
The light forms are as contagious as the severe ones, and inoculations
have occurred from the living subjects as well as from autopsy cuts.
In degree of infectiousness smallpox ranks first, measles second and
scarlet fever third. The infection may be spread by any third person
or by articles coming in contact with the patient, and often the mode
is obscure. Sporadic cases apparently frequently appear. The reason
for the sporadic cases may easily be explained by the theory of J.
Martin Littlejohn, given above. One attack usually confers immunity,
but not always. This disease occurs more often in the autumn and
winter, and is more prevalent in cities than in the country. (Measles
is more prevalent in the country.) Scarlatina sometimes occurs with
other infections, such as diphtheria or measles, and more rarely with
varicella, pertussis, etc.
=Predisposing Factors.=—Age, one to ten years; lowered resistance from
overfeeding, unhygienic environments, exposure to sudden temperature
changes; lesions, both muscular and interosseous which interfere with
the distribution of the fluids and vital forces of the body; season of
the year (autumn and winter); puerperal women, and wounds.
=Pathology.=—No specific lesions are found. No trace of the rash shows
after death except in the hemorrhagic form. The anatomical changes in
cases coming to autopsy are those of simple inflammation, follicular
tonsillitis, or diphtheroid angina. Streptococci are abundantly found
in the glands and foci of suppuration.
=Symptomatology.=—Scarlet fever is divided into four stages: (1)
Incubation, (2) Invasion, (3) Exanthem, (4) Desquamation.
=Incubation Stage.=—Has no noticeable symptoms and lasts from two to
four days. Some authors claim as high as ten to fourteen days.
=Invasion.=—The invasion lasts one day. The onset is very sudden
beginning with a chill which is followed by a characteristic vomiting,
occurring in 75% of the cases, which is more frequent than in any other
disease of childhood except pneumonia.
The vomiting is followed by headache and the beginning evidence of sore
throat, which usually soon develops into a tonsillitis. The severity
of the sore throat is indicative of the severity of the scarlet fever
that follows. The temperature suddenly rises to 103° or more, the
pulse becomes unduly rapid for the temperature, 120 to 160 per minute,
and the respiration is increased. The skin begins to burn, there is
dysphagia and intumescence of the cervical glands. The muscles of
the back become hypersensitive to touch and to extremes of heat and
cold; and particularly sensitive spots are found over the transverse
processes of the first to 4th cervical vertebras, the 4th and 5th
dorsal and the 11th and 12th dorsal vertebras. At these points will be
found intensely contractured tissues which must be kept relaxed.
=Exanthem.=—The eruption appears at the end of the first day or early
the second day, showing first over the clavicles and on the neck, then
over the upper trunk, next the lower trunk and limbs. The eruption
on the extremities appears particularly over the flexor surfaces of
the joints. By the end of the second day the eruption has covered
practically the entire body, leaving a white circle about the eyes and
mouth. The eruption pales, or disappears on pressure, quickly returning
to the scarlet color on the removal of the pressure. Frequently, the
skin itches and is very uncomfortable.
A punctiform eruption in the arm-pits, over the groins, or on the roof
of the mouth is considered positive proof of scarlet fever.
The eruption at first consists of small red spots which fuse as the
skin swells and results in an intense lobster-colored erythema. This
lasts four to six days. The tongue, at first, is red at the tip and
margins with a greyish-yellow or whitish fur in the center through
which is often seen the swollen red papillæ, the “strawberry tongue.”
The “fur” desquamates on the third or fourth day, leaving a surface
intensely red with marked raised, swollen papillæ, the “raspberry
or cat tongue,” which lasts nearly a week. The breath has a heavy,
sweet odor. The pharynx, uvula and tonsils become swollen, and often
creamy-white patches cover the mouths of the tonsillar follicles.
Between the second and third day the eruption reaches its height, when
it has a vivid scarlet hue unlike any other eruption, and becomes
darker each day until it may be a bluish-red, when it gradually fades
and desquamation begins. By the seventh or eighth day the rash has
disappeared, together with the fever.
=Desquamation.=—Scaling begins on the face first, from the sixth to the
ninth day and lasts several weeks. The skin looks somewhat stained,
is a little rough like “goose-flesh” and gradually the upper layer
begins to separate, and the scaling begins in large lamellæ or flakes.
Casts of the fingers or toes may be shed. The swelling of the glands
disappears, and the fever falls by lysis, and convalescence begins,
unless complications intervene.
=Diagnosis.=—In typical cases diagnosis is easy, especially during
epidemics or when the eruption is accompanied by other criteria.
1. Sudden onset, with nausea and vomiting, sore throat, quick
appearance of fever and rapid development.
2. Punctate spots in the throat, swelling and dysphagia are usually
present. The severe sore throat symptoms with the above are always very
suspicious.
3. Strawberry tongue is constant.
4. Eruption, typical in character, appearing on second day, first
showing on the neck above the clavicles, intense on the body and
practically absent around the mouth. Eruption confluent, with no
intervening free areas of the skin, followed by desquamation.
5. Lymphadenitis much more pronounced in the inguinal and other glands
than in the cervical.
6. Desquamation, tender joints and albuminuria will force the
conclusion of scarlet fever, if former symptoms have been indefinite.
In the atypical cases we may have very light attacks with all the
symptoms present but very poorly developed; or some symptoms absent
as in cases with no temperature, or others with no rash. Some cases
are so atypical as to be impossible of diagnosis. The writer has very
recently had the experience of one case when there were absolutely
no typical symptoms present after being called on the case, but four
days after the invasion of the disease in the patient a sister of
the child developed typical scarlet fever, and not until the sixth
day did any eruption or sore throat appear, and then the eruption
was more characteristically measles than scarlet fever. Consultants
with the writer agreed with him that the case was one of an atypical,
non-eruptive scarlet fever.
=Differentiation.=—Scarlet fever is not always easily differentiated
from other diseases, such as a septic rash, drug rashes, diphtheria,
measles and German measles.
A. R. Edwards gives this differentiation between scarlet fever and
septic rash.
=Scarlet Fever= =Sepsis=.
Bright red erythema, with small A very deep purple-red rash,
red papules. sometimes spreading over the
entire body.
The eruption is much the same in
both diseases, the same places
being exempt.
Miliaria are rare. Miliaria are frequent.
Rather typical desquamation. Desquamation observed less
frequently.
CRITERIA: angina, tongue, onset, Etiology, chills, sweats, fever
glands, etc. irregularity, polymorphous
exanthems, etc.
=Diphtheria.=—Often difficult to differentiate. The simple erythema is
sometimes observed in diphtheria, but is darker, more on the trunk, and
more transitory than in scarlet fever.
=Drug Rashes.=—These rashes are caused by belladonna, iodoform,
quinine, iodide, chloral, copaiba or aspirin. They may be easily
differentiated if the cardinal symptoms of scarlet fever are considered
instead of the rash alone. At the present time, perhaps the most
frequent drug rash that we meet is that produced by aspirin. It is
sometimes hard to diagnose because the aspirin has been taken for a
sore throat or tonsillitis, which so resemble the early symptoms of
scarlet fever.
=Measles and German Measles.=—The symptoms of the invasion stage of
these diseases is sometimes quite similar, and even the rash may be
quite similar; the differentiation will be discussed under measles
(q.v.).
=Types and Forms.=—(a) Mild and abortive form (scarlatina sine
eruptione). In this the rash may be scarcely perceptible, while the
fever, sore throat and strawberry tongue are present. Desquamation may
be present and it may be followed with a severe nephritis.
(b) Malignant forms, (1) Atactic variety, violent intoxication, onset
of great severity, fever very high (107° to 108°), extreme headache,
delirium, and often convulsions. Initial delirium gives place to coma;
dyspnea may be urgent; pulse very rapid and feeble; and death occurs
before eruption appears. (2) Hemorrhagic variety: there are hemorrhages
into the skin, beginning with scattered petechiæ, becoming more
extensive and ultimately involving the whole skin. It is characterized
by severe fever and brain symptoms at the onset; incomplete exanthem,
necrosing angina, marked glandular and splenic swelling; subcutaneous,
serous and mucous membrane hemorrhages with ulceration. Death may take
place on the second or third day. This is more common in enfeebled
children, although it may attack adults in apparently full health.
(c) Anginose form (Scarlatina anginosa.) This form resembles septic
diphtheria, with marked toxemia, necrosis and adenitis. The throat
symptoms appear early and progress rapidly. Temperature high, cyanosis,
diarrhea, rapid weak irregular pulse, and stupor occur. The fauces and
tonsils are covered with a thick membranous exudate which may extend to
the posterior wall of the pharynx, forward into the mouth, upward into
the nasal chambers, and may occasionally reach the trachea and bronchi.
The Eustachian tubes and middle ear are usually involved. The glands of
the neck rapidly enlarge and become the seat of brawny induration, and
the inflammation extends beyond their limits. Necrosis occurs in the
tissues of the throat, fetor is extreme, the constitutional symptoms
are great and the child dies of toxemia. If he does not die, extensive
abscess formation in the tissues of the neck takes place with sloughing
and danger of hemorrhage from the opening of a large artery.
=Blood Pressure.=—Rises at first, thereafter it follows the pulse
and temperature. After the seventh or eighth day it may be below
normal. Cases of albuminuria show hyperextension and slowing of heart
action. With the subsidence of the kidney irritation the pulse-rate is
increased and the blood pressure returns to normal.
=Urine.=—Shows ordinary febrile character, being scanty and high
colored. Slight albuminuria is rather common after the stage of
eruption, even a few tube casts may be present without any serious
irritation of the kidneys. Urinalysis should be made daily.
=Blood.=—The red cells are moderately reduced to 3,000,000 or 4,000,000
per c. mm. during convalescence. There may be some poikilocytosis, and
normoblasts are occasionally seen. Leucocytosis is early, 15,000 to
30,000 per c. mm., falling with the decline of the fever usually by
the fourteenth day, but may persist for weeks after the temperature is
normal. The count runs roughly parallel to the temperature. Over 40,000
leucocytes per c. mm. are of bad prognostic omen. Polymorphonuclear
cells are increased to 80% or 90%; early returning to normal in
favorable cases.
Eosinophilia is present in all but malignant cases. It reaches its
maximum two or three days after the rash appears and returns to
normal after the leucocytosis has disappeared. The early presence of
eosinophilia excludes septic conditions. When these cells are absent in
scarlet fever, myelocytes are to be found.
=Treatment.=—Clinically scarlet fever represents, from the osteopathic
viewpoint, (a) a toxic condition due to internal malnutrition and
a decrease of the detoxinating function of the thyroid gland; (b)
secondarily associated with the sore throat is a type of toxic
tonsillitis, but it is due to the toxic elements in the blood; (c) in
the lesion field it is associated with extreme stiffness and muscular
tension in the upper cervical area and also in the entire dorsal
area, overlapping the upper lumbar. The eruption is a superficial
expression of the attempt of the body to eliminate the toxins, and
this elimination should be aided by enhancing the activity of all the
other eliminative functions. Cases are on record where patients have
been exposed to scarlet fever, have gone the usual incubation period
and developed the invasion symptoms, and by thorough, oft-repeated
osteopathic treatments, with the aid of enemata and copious hot water
drinking, have not gone beyond the invasion period and the disease
apparently aborted within two or three days. It is therefore well to
give thorough, oft-repeated attention to these cases during the very
early stages.
(1) In all cases where the first symptoms indicate the possibility of a
contagious disease, the patient should be immediately isolated and kept
isolated until all danger of contagion is past. In scarlet fever cases
get a competent nurse. Keep room light, quiet and thoroughly ventilated
with a constant temperature of as nearly 70° as is possible. (It were
better to have two rooms if possible, one for day and one for night:
have room or rooms on upper floor if in a house). Arrange suitable
means for thorough disinfection of all articles used in the sickroom.
These are very essential.
(2) Patient should be clothed in usual night wearing apparel. The bed
clothing should be warm, but not heavy. The physician should wear an
operating gown or a sheet which thoroughly covers his clothing, also
a cap. He should carefully wash his face and hands immediately after
leaving the sickroom. The quarantine should be maintained for the
legally required period, and even after if there continue discharges
from the nose, nasopharynx or the ear. Bichloride wrappings should be
placed about the body of the dead, and funeral must be private.
(3) Have enema given immediately to cleanse the lower bowel. Follow
this with frequent draughts of hot water, or better hot lemonade for
the first day. Place hot water bottles at feet. If eruption is slow in
coming out, it may be aided by a hot bath, followed by wrapping the
patient in warm blankets to prevent chilling.
(4) Thorough osteopathic treatment should be given along the entire
spinal area from the atlas to the sacrum, inclusive, to keep the
muscles well relaxed, giving special attention to the relationship of
the vertebræ and the tension of the muscles from the occiput to the
fourth cervical; the third to the sixth dorsal; and the tenth to the
twelfth dorsal areas. Also give special attention to the deep cervical
muscles, particularly those at the angle of the inferior maxilla, and
at the articulation of the inferior and superior maxillæ. Remember the
tendency of the kidneys to complication in scarlet fever, therefore
do not neglect the renal splanchnics, for here you not only control
the renal functions but also regulate the adrenal functions and
their internal secretions. Keep the clavicles properly adjusted and
articulate them by bringing them well forward to relieve any irritation
that may have started in that area. Careful direct treatment to the
abdomen should usually be given at each visit besides the work in the
splanchnic area to keep the bowels, kidneys and liver active.
=Diet.=—Water must be given freely. If fever is very high, pellets
of ice held in the mouth will give comfort. During the height of
the fever it is preferable to withhold all nourishment, but if in a
particular case it seems to be indicated, confine the nourishment to
fruit juices, especially oranges. Never force feeding during the fever.
For infants cut down their feeding to at least half, making the milk
very thin with water or gruel. After defervescence, carefully increase
to a light diet using sparingly of nitrogenous foods except milk. After
four weeks in the usual case, gradually return to the ordinary diet.
This is a good time to make corrections in the ordinary diet if any are
needed.
The =bowels= must be kept regulated. An enema is usually indicated
after the onset of the disease. During the time that food is permitted
it should be of a laxative character. During the fever stage the enema
should be given daily to help keep the bowel cleansed and to help
reduce the temperature. If bowels are persistently sluggish and the
fever is constantly high the abdominal heating compress (so-called
“cold compress”) will give much relief.
The =nose and throat= should be constantly looked after. The nose may
be cleansed by instillation by means of a medicine dropper, using
normal salt solution. If the throat symptoms are mild, a gargle of warm
normal salt solution is enough for cleanliness of the membrane. If the
throat symptoms are too severe to permit the use of the gargle, or if
the patient is too small to be taught the use of the gargle or to wash
the throat, irrigation may be employed. The use of raw lemon juice, or
of raw pineapple juice, on a cotton swab is of great value in cleansing
the tonsils and throat. The swabbing should be repeated several times
per day.
The =teeth= should be carefully and thoroughly cleansed twice per day.
The =skin= must be constantly cared for. During the fever it is well
to cover the skin with linen or soft cotton. Daily sponge baths of
carbolized water (1:40) of tepid temperature followed by applications
of cocoa-butter will give much comfort. Use only good toilet soap and
do not use the so-called antiseptic soaps because, authorities claim,
there is a chance of renal injury. During the period of desquamation
the use of the cocoa-butter will assist in limiting the source of
infection by preventing the diffusion of the dry scales which are
considered infectious by many physicians. A. R. Edwards says: “During
desquamation, oil-rubs were once employed to decrease the dissemination
of dry scales, but they decrease the function of the skin, which is
of great importance when the kidneys are involved; also, infection is
carried by means of throat secretions. Soap and water serve equally
well.” Some authorities suggest that during the desquamation, after
bathing the patient, the skin should be thoroughly rubbed and then the
oily application used, using cocoa-butter, unmedicated cold cream,
liquid albolene or the like. Olive oil and vaseline are usually
irritating. The writer inclines to the opinion that the soap and water
bathing is sufficient, except perhaps the use of cocoa-butter over the
areas that are desquamating severely.
The =temperature= can usually be controlled by the usual osteopathic
methods; steady deep pressure applied in the suboccipital region for
a few minutes, followed by relaxing the muscles of the back from the
first to the eighth dorsal, by raising and spreading the ribs in the
mid-dorsal area, and by light inhibition over the solar plexus. The
tepid enema will assist in lowering the temperature. If temperature
is high and patient is delirious and has other nervous symptoms the
cold pack is useful. The ice cap may be used almost constantly in high
fever. If glands are swollen treat by crowding the tissues toward the
gland =but never work upon the gland itself=.
If pain is felt in the =ear= immediate attention must be given it.
Correct any deviations of the atlas or other upper cervical vertebræ,
relax the deep muscles at the angle of the jaw, and relieve any
impingements in the lower cervical and upper dorsal regions. The
ear should also be treated with copious boric solution irrigations,
as hot as can be borne and at low pressure. The condition of the
ear drum membrane must be watched daily and if there is bulging and
congestion it is safer to puncture the drum under cocaine than to await
spontaneous rupture. Use small amount of boric powder after rupturing.
The =heart= must be examined daily. Vigorous treatment through the
thoracic region is indicated, if cardiac symptoms appear, and the
patient must be kept quiet and in bed. If heart seems feeble it may be
well supported by the cold packs directly over the heart.
=Nephritis= is most common in the second and third weeks of the
illness, but may develop later. In all cases where any symptoms of
nephritis appear, light or severe, the patient must be =confined to
bed= for at least four weeks, and kept on a milk diet. All irritants
must be absolutely avoided. Hot baths should be given twice daily to
increase the sweat and the urinary functions, the bath lasting half an
hour and the patient kept afterward between blankets. Treat thoroughly,
daily, the splanchnic and renal areas, paying particular attention to
the tissue conditions in the lower dorsal region.
In the milder cases, the urine contains albumin and a few tube casts,
very rarely blood, and edema is slight or transient. Though the
patient improves, he remains pale and there is a slight trace of
albumin in the urine for months. If recovery does not take place, then
chronic nephritis becomes established.
In the more severe cases there may be a puffy appearance of the
eyelids, slight edema of the feet, urine diminished in quantity, smoky,
containing albumin and tube casts. The kidney symptoms dominate, dropsy
persists and there may be effusion into the serous sacs. The condition
may become chronic, the patient may succumb to uremia, but in the
majority of cases recovery takes place.
The nephritis may be hemorrhagic, in which the urine is suppressed or
there may be a very small amount of bloody fluid laden with albumin and
casts; constant vomiting and convulsions follow and the patient dies
with symptoms of acute uremia.
Other =complications= are arthritis, malignant endocarditis,
severe toxic myocarditis and acute phlegmonous inflammation, the
last three of which are usually fatal. Chorea is a fairly frequent
nervous complication. The mental symptoms are mania and melancholia.
Progressive paralysis of the limbs with wasting, may simulate infantile
paralysis. The fever may persist after the eruption disappears and the
child remain in a septic state (scarlatinal typhoid).
=Relapses= are rare. Scarlatina may coexist with almost any other acute
infection. It lowers the resistance of the body to disease and is often
followed by other acute infections or by tuberculosis. Therefore the
necessity of care during the entire convalescent stage.
Measles
(RUBEOLA; MORBILLI)
=Definition.=—Measles is an acute infectious, contagious, erythematous
disease, occurring in epidemics, characterized by an initial coryza,
bronchial catarrh and an eruption of a general maculopapular type; also
by the presence of Koplik’s buccal spots.
=Etiology.=—=Predisposing Influences=: The chief predisposing factor in
measles, as in all other contagious diseases, is a lowered resistance
in which some structural or functional change has taken place that
reduces the functional activity of the body’s inherent protective
agencies. These predisposing factors may be classed under three heads,
namely; (a) structural, (b) environmental, (c) dietetic. Under the
first we find structural disturbances in the upper cervical area
affecting the functional control of the nose, throat and head, as
well affecting the thyroid and its internal secretions: structural
disturbances in the upper and mid-dorsal areas affecting the vasomotor
control to the head, neck, and chest, thereby perverting nutrition
to all these structures and rendering them more susceptible to the
infective organisms; also the dorsal lesions disturb the functional
integrity of the lungs and heart, with the result of disturbed
respiration and circulation, both of which are vital factors in body
resistance: we also find structural lesions in the lower dorsal region,
affecting the function of the kidneys and their elimination and the
function of the adrenals and their internal secretions. Under the
second or environmental, we have unsanitary and unhygienic conditions,
exposure to sudden changes of temperature, wet clothing, fatigue, etc.,
all of which produce secondary structural lesions and the effects above
mentioned. Under the third or dietetic classification, we have the
errors of diet so common in children and adults as well; such as too
much candies and other sugars, also too much starches, as well as over
eating and unbalanced diet.
Measles prevails in all climates and attacks all races, the Negroes
appearing to suffer more severely than the whites and to be more
subject to complications. Outbreaks are more common in winter and
spring, but occur at all seasons. The disease is particularly a
children’s disease but adults may contract it if not protected by an
attack in early life, and with adults the disease frequently manifests
the more aggravated forms. It is more common after puberty than scarlet
fever.
=Exciting Cause.=—While the disease is probably produced by a
micro-organism, it has not yet been demonstrated. Inoculation
experiments upon human beings have shown the presence of the infecting
principle in the blood, in the tears, in the secretions of the nasal,
pharyngeal and bronchial mucous membranes, and in the contents of
vesicles occasionally present. Inoculation with the epithelial scales
thrown off at the end of the disease has been unsuccessful. Ordinarily
the transmission of the disease takes place through the breath or
the nasal and bronchial secretions. The disease may be carried by
a third person or by fomites. The infecting principle is intensely
active, but not so tenacious nor persistent as scarlet fever. Measles
is communicable throughout its entire course from the earliest
appearance of the coryza. The individual predisposition toward measles
is apparently so general that few, upon exposure, escape it, though
we have observed cases where children have been directly exposed and
who were immediately thereafter put under osteopathic care and did
not develop the disease. Second, or even third, attacks may occur
at intervals of some years, but these are unusual. Sporadic cases
do occur and are often the starting points for epidemics. Extensive
outbreaks occur at intervals of five or six years.
The incubation period is from seven to eighteen days, usually about ten
days.
=Symptoms.=—Prodromes are common, usually consisting of loss of
appetite, restless sleep, fretfulness, and often feverishness. There
are three stages, (a) Invasion, (b) Eruption, (c) Desquamation.
(a) Stage of Invasion. The prodromal symptoms are intensified. There
is often chilliness but seldom distinct chills. The temperature rises,
often reaching 102 to 104 degrees, upon the first and second day. It
then falls one degree or more to rise again upon the appearance of the
eruption. Nausea, vomiting and headache are often present. The tongue
is furred. With these symptoms coryza has developed and is sometimes
intense, often simulating severe influenza. Irritation and smarting of
the eyelids, lachrymation, photophobia, persistent sneezing, running
of the nose, sore throat, discomfort in swallowing, hoarseness, and
cough, at first of a croupy character, appear in rapid succession
and with varying intensity. These initial catarrhal symptoms are
characteristic and occur in the mildest cases in which chilliness,
fever and the associated signs of the reaction of the organism to
general infection are not observed. The vessels of the conjunctivæ are
injected, the eyelids swollen, the nasal mucosa tumid and reddened. The
mucous membrane of the mouth and throat is erythematous, while upon
the soft palate and the roof of the mouth, and particularly upon the
buccal mucous membrane, are to be seen pin head or split pea sized,
circumscribed, round or irregularly shaped reddish blotches slightly
or scarcely at all raised above the surrounding tissues, usually
discrete, but sometimes confluent. This eruption also shows itself in
the larynx and is undoubtedly the cause of the croupy cough and other
throat symptoms. In a strong light there may be seen upon some of the
spots on the mucous membrane of the cheeks and lips minute bright
whitish, or bluish-white flecks which are called Koplik’s Spots. These
spots appear early and soon disappear, and as they are not found in
any other disease they are of value in the early diagnosis of measles.
The duration of this stage is usually three or four days; rarely it is
shorter or it may be as long as a week.
(b) Stage of Eruption. On about the fourth day the temperature again
rises, increasing as the rash develops, often to 104 or 105 degrees
and reaching its maximum about the sixth day when it usually falls by
crisis; followed on the seventh or eighth day by normal temperature.
The pulse-rate increases with the fever, often reaching 140 or higher.
The eruption usually appears on the fourth day, and shows first about
the hair line on the forehead, spreading to the face, chest, trunk and
the arms and legs. The eruption is attended by itching and burning, and
completely develops in from twelve to thirty-six hours, the catarrhal
symptoms persisting during this time. During this time, in the more
severe cases, delirium or stupor may be present, and the patient
complains of sore throat and general discomfort, and is restless and
wakeful. Usually upon the second or third day of the eruption, great
and rapid amelioration of all these symptoms takes place and the fever
falls to normal or subnormal. When the eruption is fully developed
the individual spots are irregularly circular or oval, and differ
greatly in size, averaging about the size of a split pea. The eruption
is unevenly set, but usually close together and sometimes confluent,
especially on the face, buttocks, hands and feet. Frequently they
take on a crescentic arrangement and the spots are circumscribed, the
intervening skin being normal or slightly hyperemic.
About the ninth day the rash begins to disappear, on the face first,
then the neck and the rest of the body in about the same order as the
eruption appeared. The skin takes on a yellowish discoloration and
the rash disappears in a bran-like desquamation which lasts several
days to a week. In the beginning of the stage of eruption, and in many
cases throughout its course, the skin is moist and often bathed in free
perspiration. At the height of the eruption the superficial lymphnodes
of the neck, and elsewhere, are often slightly swollen and tender.
(c) Stage of Desquamation. The fine branny scales of desquamation
are often so fine as to be easily overlooked. This process occupies
about a week. The catarrhal symptoms in uncomplicated cases gradually
disappear, so that, by the end of the second week from the initial
coryza, convalescence is fully established. The cough frequently
persists and is of a bronchial nature. Epistaxis is common at the
height of the attack. Relapses of measles are extremely rare. Diarrhea
is apt to occur at some time during the attack, without any particular
significance.
=Varieties.=—Atypical cases may occur but are not common. They are as
follows: (1) Morbilli Papulosi, development of distinct papules, hard
to the touch but not extending deeply into the skin. (2) M. Vesicular;
a vesicular form. (3) M. Sine Exanthema, cases in which the eruption
does not appear, but general symptoms and coryza are present. (4) M.
Sine Exanthema, in which the mucous membranes are not involved.
=Variations in constitutional symptoms.=—(1) M. Afebriles, rare cases
in which there is no rise of temperature. (2) M. Hemorrhagica. This
is the malignant form and in it the organism is unable to withstand
the intensity of the infection and death takes place in the course of
two or three days after sustained hyperpyrexia, profound adynamia, or
hemorrhages into the skin and mucous membranes. These malignant forms
are very rare in private practice, but they occasionally occur in
asylums and in the fierce epidemics of camps, and were common in the
first outbreaks among the natives of the Fiji Islands, where measles
prevailed as a scourge. Death may occur before the rash appears or a
few papules may show themselves upon the forehead and wrists. This is
also known as =black measles=, and it is characterized by convulsions,
delirium and coma, petechiæ, bleeding from the mucous surfaces and
profound constitutional depression. The patient is rapidly exhausted,
the pulse frequent and thready, the skin pale and cold, and death
occurs. (3) Adynamic measles is a serious type in which the symptoms
are grave from the onset but without hemorrhages and a typhoid status
is early present.
=Complications.=—In the absence of complications, measles is
comparatively a benign disease, but these complications are frequently
enough present to place measles among the more serious diseases of
childhood. The ordinary complications are due to the extension or
intensification of the catarrhal processes peculiar to the disease.
(1) Otitis media is quite common, and may result in perforation
of the tympanic membrane and permanent impairment of the hearing;
or lead to sinus thrombosis, meningitis, or abscess of the brain.
(2) Bronchopneumonia is the most common complication. (3) Purulent
conjunctivitis may occur and in neglected cases infiltration and
ulceration of the cornea. (4) Catarrhal laryngitis is a frequent
complication. (5) Pseudo-membranous type is very uncommon but very
dangerous. (6) Edema of the glottis is not common but does occur. (7)
Diphtheria is much less common in measles than in scarlet fever. The
high death rate of measles is due to the bronchopneumonia complication
in which the lesions become extensive, the symptoms become urgent and
a large proportion of these cases die. (8) Acute enterocolitis is a
frequent and serious complication. (9) Gangrenous stomatitis occurs in
young and debilitated children, and in girls gangrene of the pudenda
occur during convalescence with greater frequency than in other
infectious diseases.
=Sequelæ.=—The more common sequelæ are chronic local inflammations,
conjunctivitis, otitis, nasal catarrh, laryngitis, and bronchitis.
Tuberculosis is a common sequel.
=Diagnosis.=—During an epidemic, coryza, persistent sneezing and fever
are suspicious. The appearance of the eruption on the third or fourth
day upon the mucous membrane of the mouth and throat, and Koplik’s
spots are positive.
Measles is often confused with 1. Rubella or German measles, 2.
Variola, 3. Typhus Fever and 4. Scarlet Fever, which see. Occasionally
=drug exanthems= are confused with measles. These may be caused by
salicylates, antipyrin, quinine, turpentine or copaiba. These rashes
are not accompanied by fever or throat symptoms unless they have been
given to allay these very conditions.
=Treatment.=—Measles is so often a serious disease that it should
not be attended with carelessness as it so often is, but the best of
care and attention given. Parents should be informed of the danger
of complications and of the absolute necessity of proper care and
attention.
As soon as a susceptible individual is exposed to the measles, he
should be immediately isolated, watched and corrections made of any
dietetic errors, unsanitary conditions or structural lesions that may
exist. He should be protected from sudden atmospheric changes and
carefully watched for the first symptoms of the prodromal coryza.
On the appearance of the prodromal, or invasion symptoms the patient
should be put to bed in an isolated, well ventilated room of as nearly
constant temperature as is possible, from which all hangings, rugs and
unnecessary furniture have been removed. The windows must be shaded to
protect the eyes from direct or strong light, and any artificial lights
in the room must also be well shaded.
The cases can usually be easily handled by careful, well-directed
osteopathic treatments. In the manipulative treatment we must pay
especial attention to the muscular and other soft tissue conditions in
the suboccipital region, over the transverse processes of the upper
four or five cervical vertebræ, under the angle of the lower maxilla
and the lateral cervical tissues to remove any obstructions to the
circulation and nerve control of the head and throat; see that the
muscles in the lower cervical and upper dorsal areas are kept well
relaxed, and articulation of these vertebræ, the upper three ribs and
the clavicles are kept free; remove all lesions in the mid-dorsal area,
whether muscular or otherwise, to prevent involvement of the lungs
or heart, and to keep up function of the respiratory and circulatory
systems; treat and keep normal the tissues and the articulations at
the kidney and adrenal center, 11th and 12th dorsal; raise the ribs
and keep them freely movable, this especially for the bronchial cough.
Painful manipulations should be avoided and are not necessary. Dr.
Still said, “The arms must be raised and the axillary region freed and
kept so.” During the acute stage two or three treatments per day are
advisable. Do not treat severely or to cause discomfort to the patient.
Best results are obtained in the gentle, but thorough, treatments.
In the beginning of the case have the bowels cleansed with an enema,
and then careful attention must be constantly given to the bowels and
kidneys. The bowels can be kept open by manipulations and diet. The
diet should be light and easily digested; during the fever it is best
to withhold all food but give plenty of water. Follow fast with fruit
juices and then the light diet.
The temperature is usually controlled by treatment, but if it remains
high for some time and if the physician cannot reach the patient, the
nurse should be directed to give a tepid sponge bath of ten to twenty
minutes duration, and repeated at intervals of two or three hours. Also
the tepid enema will often reduce the temperature.
For the itching of the skin, a tepid bath with water at 100 degrees
given twice daily should be used, the patient dried carefully, and an
application of olive oil, cold cream, liquid albolene, or a two per
cent menthol salve, rubbed over the entire body will give relief.
The cough is best relieved by thorough treatment of the anterior
thoracic regions and the correction of any upper rib or clavicular
lesions. Keeping the air of the room moist with vapor is agreeable to
the mucous membranes. The dropping of a few drops of eucalyptus oil in
the boiling water produces a very soothing vapor.
If the eyes are much involved, they should be bathed every hour or two
with a three per cent solution of boric acid, using cotton which is
immediately destroyed after use. Dark glasses in a well ventilated room
is better than an unaired darkened room.
The nose and mouth should be carefully cleansed at regular intervals
and the cloths burned. The throat should be carefully examined daily
at first, and at least every other day later, until the case is
discharged. The conditions of the lungs must be observed by daily
examinations, and the lung and bronchial areas should be daily treated
to prevent the possibility of respiratory involvement.
If rash is slow in appearing and the temperature is high, a hot bath
(105 to 110 degrees) for three to five minutes will often bring out
the rash and relieve the more serious symptoms. During convalescence
the patient must be protected against cold. Recovery is hastened by
the continuation of treatment during convalescence and treatment given
should be indicated by the symptoms present.
=Prognosis.=—Practically all uncomplicated cases recover. In the
hemorrhagic and adynamic types, the majority succumb. One attack
usually confers immunity. Sequelæ are frequent under the “old school”
treatment, but are infrequent under careful, conscientious osteopathic
treatment and careful nursing.
“In and of itself measles is usually not particularly serious, but
the after effects are so far-reaching and so serious that students of
the history of medicine rank measles third among infectious diseases
for causing death. During recovery from measles the patient stands in
special danger from pneumonia, and pneumonia following measles is more
dangerous than uncomplicated pneumonia. There is a considerable length
of time during which he is particularly susceptible to tubercular
infection. This is so often insidious, and its evidences are so
obscure, that by the time the disease has fully developed, one may have
forgotten the mild attack of measles which really paved the way for the
serious malady.”—C. A. WHITING.
Rubella
(GERMAN MEASLES; RUBEOLA NOTHA; ROTHELN; EPIDEMIC ROSEOLA)
=Definition.=—A specific acute, contagious, infectious, eruptive
disease, characterized by a diffuse maculopapular eruption and swelling
of the superficial lymphatic glands. It is attended by a mild fever,
suffused eyes, mild cough, slight sore throat but no catarrh, a macular
rose-red eruption of the throat accompanied by the swelling of the
cervical lymph glands and by a rose-red eruption of irregular size and
shape appearing on the first day of the disease.
Rubella, in some ways, resembles scarlet fever and also measles and was
at one time considered a hybrid of the two. It is now known to be an
independent disease.
=Etiology.=—The exciting cause, or the infective principle, has not
yet been discovered. The disease is probably carried by fomites, is
readily transmissible, attacks children especially, and usually occurs
in epidemics, though sporadic cases are frequently found. The epidemics
usually occur at intervals with several years intervening, during
which time there are comparatively few cases. Persons of all ages are
susceptible unless having acquired an immunity through an attack of the
disease at some former time. Rubella does not confer immunity against
any other disease, as scarlet fever or measles, nor do these diseases
confer immunity against rubella. One attack of rubella confers immunity
against any succeeding attacks.
The incubation period is from five to twenty-one days and is without
symptoms.
The predisposing factors are the same as in measles or other infectious
or contagious diseases.
=Symptoms.=—=Invasion Period.= This stage is usually of very short
duration, lasting from a few hours to perhaps two days. The initial
symptoms are usually mild, being a sudden chilliness, but not chills;
mild fever of about 100 degrees; a slight headache; mild sore throat;
swollen cervical and post auricular lymphatic glands; little or no
coryza; sometimes slight pains in the back and legs; and the macular
rose-red eruption in the throat which is constantly present. Often the
initial symptoms are so mild that the presence of a disease is not
recognized until the eruption appears, which usually occurs on the
first day and rarely not until the fourth day.
=Eruption Period.=—The rash, which consists of round or oval reddish
spots about the size of a split pea, mostly discrete, but sometimes
confluent, and surrounded by areas of hyperemic skin, usually shows
first upon the face and follows a wavelike progression over the body
and limbs. The rash usually begins to fade upon the face before it
has appeared upon the last affected areas, and usually remains in one
region from a few hours to a half day. It extends over the entire
body in from twenty-four to thirty hours. Occasionally the skin is so
hyperemic in extensive tracts that the rash more resembles scarlet
fever rather than measles. The crescentic arrangement of the papules
usually seen in measles can not be made out in rubella. In the course
of two or three days the rash disappears with very fine desquamation,
leaving a faint pigmentation, which remains for a short time. Slight
etching usually accompanies the rash.
Relapses are rare and complications infrequent. There are no special
sequelæ, but albuminuria, bronchitis and pneumonia have been noted.
Although one attack usually confers immunity, second attacks have been
reported, which may have been real second attacks or the first attack
may have been an error in diagnosis.
=Diagnosis.=—Early or sporadic cases may present great difficulty in
diagnosis, but when an epidemic is present diagnosis becomes much
easier. The =direct= diagnosis of the disease rests upon the very mild
nature of the disease, its short initial onset, the character of the
eruptions and the early enlargement of the glands with the absence of
severe throat symptoms and coryza.
Rubella is frequently mistaken for mild cases of measles or scarlet
fever. Unlike measles, it does not have the prominent catarrhal
symptoms, the higher fever, the crescentic grouping of the eruption and
Koplik’s sign. In measles the adenitis is not so severe as in rubella,
and especially are the suboccipital and post-auricular glands involved
in rubella. Scarlet fever has a very sudden onset with severe symptoms,
a very sore throat, the characteristic tongue and the peculiar rash,
all of which are decidedly different from rubella. In the latter stages
the character of the desquamation is also a distinguishing feature.
=Treatment.=—Patient should be kept in a properly heated and well
ventilated room, being careful that no draughts chill the patient, and
should remain in bed for at least two days. Patient should be isolated.
Treatment should be directed to the upper cervical, mid-dorsal and
lower dorsal areas to keep normal the function of the internal
secreting mechanism, and to normalize and keep normal the respiratory
and circulatory systems. Treat carefully to upper lymphatics, working
around the enlarged glands and not directly over them. Watch the
excretory functions and keep them active by judicious measures. If
annoying itching occurs, the hot bath followed by being wrapped in a
soft warm blanket will usually relieve. Daily tepid sponging should
be given and if hot bath does not relieve itching an application of
olive oil or cold cream will often relieve. Diet should be reduced and
regulated according to age of patient and severity of the case. Usually
the above is all that is indicated, but if more severe symptoms present
themselves vary your treatment according to the symptoms present.
=Prognosis.=—Recovery is the general rule. Relapses sometimes occur,
and are usually much more severe than the initial attack. The symptoms
are often more severe in adults than in children. Like measles, this
disease seems to lower resistance to other infections, and therefore
especial care should be taken to protect the patient from exposure to
other diseases for some time after recovery from rubella. See that the
patient is built up constitutionally after recovery by plenty of fresh
air, suitable exercises and good food.
Varicella
(CHICKEN POX)
=Definition.=—Chicken pox is an acute, specific, contagious, slightly
febrile, eruptive disease, usually of childhood, affecting the whole
organism through the blood. It is an epidemic disease that spreads
rapidly, is highly contagious but not inoculable, and confers immunity.
=History.=—Varicella was first recognized about 1553 and was
distinguished from smallpox by Trousseau.
=Etiology.=—The agent that causes the disease is not known; the
disease usually affects children under ten years of age, but does
occasionally attack adults. It bears no relation to variola, except the
very slightly similar eruption. It is transferred by direct personal
contact, by the air or by a third person. It is infective from the
first symptoms until all the crusts have disappeared. Although the
disease usually occurs in epidemics, frequently we see sporadic cases.
As in all other contagious or infectious diseases the predisposing
causative factors are those conditions which lower the resistive
powers of the body, such as fatigue, improper diet, exposure to sudden
temperature changes and imperfect elimination of the body wastes. The
structural lesions found as predisposing factors are contractured
muscles of the neck and behind the jaw, and muscular and interosseous
lesions of the upper cervical, mid-dorsal and dorso-lumbar areas, also
of the clavicle and upper ribs.
=Symptoms and Diagnosis.=—There are three stages to the disease: (1)
Incubation, (2) Prodromal, (3) Eruptive.
1. Incubation Period.—This period lasts about fourteen days though it
may vary from seven to seventeen days. During this period there is
practically no symptomatology except perhaps the last two or three
days, when the child shows evidence of a little excitability and
irritability. Often on the day before the first noticeable symptoms the
child appears even more active than usual.
2. Prodromal Stage.—Prodromal symptoms are not common and usually
last but about twenty-four hours. The first noticeable symptom is
the irritability of the patient, which is followed by a temperature,
usually 99° to 101°, which temperature persists during the course of
the disease. There are sometimes thirst, anorexia, constipation, seldom
vomiting, and a furred tongue. Some cases have been observed to have
the following as prodromal symptoms, but these we believe are usually
due to concurrent conditions that exist at the time of the infection:
delirium, convulsions, angina, conjunctivitis, dysphagia, bloody
vomiting and stools, and an initial erythema, usually scarlatiniform.
3. Eruptive Stage.—The eruption comes within twenty-four hours and is
often the first symptom that is noticed. It appears first as hyperemic
macules and then rose colored papular spots, somewhat comparable to
the typhoid roseola and not hard. These papules rapidly become raised,
flattened, ovoid, pin-head to pea-sized vesicles containing a fluid at
first watery and then pearly. They disappear on pressure. The vesicles
mature within twenty-four hours, are very superficial, and leave a
slight areola about them, which is not inflammatory as in smallpox.
The eruption appears first on the chest and then on the neck, face,
scalp, and then trunk and limbs in the order named. The eruption is
most abundant upon the back, and over the entire body they may number
anywhere from eight to many hundred and are usually scattered.
The vesicles are not umbilicated, but some may have slightly depressed
centers, are discrete, and appear in successive crops which require
from three to six days to complete. Pustulation and hemorrhage into
the vesicle rarely occur. On the third or fourth day yellowish-brown
crusts form and gradually disappear. Scars may result from scratching
or infection. By the fifth day we may find all stages of the eruption
because of the appearance of the successive crops. There may be an
efflorescence upon the mucous membrane of the oral cavity and of the
pharynx causing slight difficulty in deglutition.
The itching may be more or less intense. As scratching may cause
pitting it should be guarded against. The fever which is usually
slight may persist during the entire eruptive stage, but if it is high
and persists as high temperature it suggests complications. Muscular
tension of the cervical muscles, especially those in front, and around
the angle of the inferior maxilla are usually found, and often the
clavicles are bound down, and relation of ribs is disturbed. Ulceration
sometimes follows scratching, and even gangrene may appear around the
vesicles in debilitated children, especially those who are tubercular
or congenitally syphilitic. It is apt to be fatal in these cases.
Complications of tubular nephritis, which occurs within two weeks;
cardiac hypertrophy; uremia; otitis media; and bronchial affections,
are sometimes met with.
=Treatment.=—Isolate patient so as not to come in contact with other
children. The younger children should be put to bed until the crusts
have formed; older children may be allowed to be up around the room if
their cases are light. Pay particular attention to the muscular lesions
of the neck, lower maxilla, mid-dorsal and dorso-lumbar regions,
keeping them relaxed by gentle relaxing treatments. A general systemic
treatment is soothing and helps to prevent complications.
“Be very careful and very thorough in your neck adjustments. Loosen the
atlas and axis and draw forward the inferior maxilla from its pressure
upon the vessels and nerves back of its angle. Draw the hyoid bone
forward and secure good circulation of blood throughout the entire
cervical area.”—A. T. STILL.
Give treatment at the 4th and 5th dorsals to stimulate the superficial
circulation and thus increase elimination through the eruption as well
as the sweat glands. Remember the eruption is the expression of the
body’s attempt to eliminate the toxins within.
Keep the bowels active by splanchnic and abdominal manipulations and
by laxative diet. If bowels are persistently inactive use enemata.
Diet should be bland and easily digested. During fever, diet should be
liquid or better restricted, giving only water in abundance.
During the eruptive stage do not use tub baths. Daily tepid sponges
with either plain water or boric acid solution answers both as an
antiseptic wash and bathing. After the daily sponging, and as often as
necessary to control itching, anoint with a 10% boric acid ointment
or with carbolized vaseline. If scratching can not be controlled, the
hands should be tied in muslin bags. As in smallpox the ultra-violet
rays seem to irritate the eruptions and to increase the tendency to
scarring, therefore the windows and lights should be screened with a
dull red material.
=Prognosis.=—Invariably favorable unless complications set in, which is
seldom. Recurrences are very rare.
=Prophylaxis.=—The child should be kept in quarantine for three weeks
or until the skin is entirely clean.
Epidemic Parotitis
(MUMPS; EPIDEMIC PAROTIDITIS)
=Definition.=—Mumps is an acute, infectious, contagious disease,
occurring in limited epidemics, and characterized by inflammation of
the salivary glands, particularly the parotid, swelling slight fever
and pain over the involved glands. There is special liability to
orchitis or to mastitis.
=Etiology.=—Predisposing Factors: Mumps is peculiarly a disease of
childhood and adolescence, not being common in infancy or after the
twentieth year. It affects boys nearly twice as often as girls.
Mandibular and upper cervical lesions, both of the interosseous and
soft tissue types, are undoubtedly potent predisposing factors, as
they obstruct and interfere with nerve and circulatory function to the
glands affected. Also any condition which lowers the child’s resistance
to infections makes them more susceptible to this disease than to any
other, these conditions being fatigue, exposure to dampness and sudden
weather changes, dietetic errors, etc. The cases are more numerous in
the spring and autumn seasons. Extensive epidemics are infrequent, but
do occur in reformatory institutions and children’s homes. It is much
more widespread in large cities than in the country or villages.
=Exciting Cause;= The specific cause has not been demonstrated. The
disease is usually transmitted by direct contact, but there are
instances where it has been transmitted by a third party or by fomites.
There are two views as to the mode of infection; the first being that
the active principle travels along the course of the salivary ducts
from the mouth to the glands, probably most often through the duct
of Stenson to the parotid gland. This is the most generally accepted
theory. The second is that the infection is a general one to which
certain structures are more susceptible, principally the salivary
glands, and the parotid in particular.
=Symptoms.=—The period of incubation is from fourteen to twenty-one
days. Prodromes are usually absent, though in the more severe cases
constitutional disturbances, with chilliness, vomiting and mild fever
may precede the local inflammation. In the milder cases the local
swelling may be the first manifestation of the disease. The temperature
is usually moderate but may rise to 103 or 104 degrees in the more
severe cases. The left side is more often affected than the right.
The disease is characterized by a feeling of tension with soreness
just below the ear. Soon a slight swelling may be observed directly
under the ear and in the course of forty-eight hours it reaches its
maximum size. The parotid gland becomes greatly enlarged and the
adjacent tissues of the neck and face become tense and edematous. The
skin becomes hard and glossy and usually white in color because of the
obstruction to the circulation from pressure. The swelling is between
the angle of the jaw and the mastoid process, pushing the ear upward
and its lobule is pushed sharply outward. In the majority of cases the
other side becomes affected in two or three days, but sometimes the
spread of the disease to the other side is delayed for several days,
and occasionally the other side escapes the infection. Frequently the
swelling of the other side is so slight that it is only recognized
by the closest scrutiny. Infrequently the submaxillary glands become
affected without involving the parotid glands, but these cases are
rather rare.
The patient is usually unable to open the mouth without considerable
pain; acids, and rarely sweets, produce spasms of the jaw muscles;
speech and even deglutition are difficult; the salivary secretions are
usually increased but quite frequently they are decreased. The breath
is foul and the tongue is furred. The mucous membrane of the cheek and
pharynx are reddened and there may be a slight angina.
The spine shows subluxations of the upper cervical area, particularly
of the atlas and axis, also upper rib lesions and upper dorsal lesions
are frequently found. The lesions of the second and third dorsal, and
their ribs, are most frequently found when the submaxillary gland is
involved.
The symptoms persist from six to fourteen days, when the swelling
disappears and the patient regains normal health. Orchitis occurs in
about one-third of the cases after puberty. In infancy and childhood
it is extremely rare. Usually one testicle is involved, and is
characterized by weight, swelling and pain in the scrotum. The testicle
may become greatly enlarged when the pain becomes intense. Atrophy may
result and if both testicles are affected the loss of reproductive
ability may result. In females, usually after puberty, the breasts may
become enlarged and tender, pain and tenderness of one or both ovaries,
hematoma of the labia, or a vulvovaginal discharge may occur. However
these complications are very rare. As a rule the patient is not very
sick and relapses are very uncommon. The attack confers immunity which
is practically permanent.
=Diagnosis.=—Under ordinary conditions, especially during an epidemic,
the diagnosis of mumps is very easy. The swelling in front of and
below the ear, with the displacement of the lobule outward is quite
indicative of mumps. The relative rapidity with which the swelling
appears, develops and subsides is characteristic of mumps. In acute
cervical adenitis the swelling is below the angle of the jaw and does
not at any time correspond with the outline of the parotid gland.
In Hodgkin’s disease, which is a chronic affection of the lymphatic
glands, the salivary glands are not involved.
=Treatment.=—The patient should be kept away from other children,
and should remain in a well lighted, well ventilated room of even
temperature, and if the temperature is high or moderately high he
should be kept in bed.
The correction of all interosseous lesions is indicated, especially of
the upper cervical area, though the second and third dorsal should be
given attention because of the influence of these dorsal nerves upon
the submaxillary glands. Also correct upper rib lesions that may exist.
As mumps is an infective disease the channels of elimination should be
watched and stimulated. Build up the body resistance by treatment at
the mid-dorsal area to affect circulation and respiration; and lower
dorsal area to affect kidney and adrenal function. Watch the bowels and
keep this avenue of elimination functioning freely, using enemata if
necessary.
The diet should be liquid, of fruit juices, thin gruels, milk and
plenty of water. Tepid sponging allays the fever and restlessness.
Relaxation of the deep muscles of the neck and shoulders will do much
to make the patient comfortable, also the muscles under the angle of
the jaw. A very gentle relaxing of the tissues around the gland itself,
by crowding them toward the gland, assists in relieving the tension by
securing a better venous and lymphatic drainage.
Hot applications to the swollen glands will give a considerable relief;
these may consist of hot fomentations, hot salt bag, electric heating
pad, hot water bottle, etc. The mouth is kept in good condition by the
use of a mild antiseptic mouth wash.
Orchitis should not occur if the boy is kept warm and in bed. If it
does occur the best treatment is relaxation of the lower dorsal and
upper lumbar spinal muscles, rest in bed, support and protection of the
scrotum with cotton wool, cold applications, correction of any bony
lesions affecting the pelvic viscera.
If mastitis occurs, rib lesions will be found and should be corrected,
as they are probably the predisposing factor to this complication.
Treatment would consist of correction of these lesions, if it can be
done without irritating the inflamed glands. The manipulation of the
surrounding tissues, with gentle crowding of the normal tissues toward
the inflamed glands, without exerting any pressure on the gland itself,
is helpful and comforting. Free tissues back to the axillary lymphatics.
=Prognosis.=—The outcome is usually favorable. In the rare fatal cases,
meningitis is the usual cause of death. Under osteopathic care the
duration of the swelling, fever and pain is usually greatly lessened.
Quarantine of twenty-four days is necessary.
Whooping Cough
(PERTUSSIS; TUSSIS CONVULSIVA)
=Definition.=—It is a specific, epidemic, infectious, contagious
disease affecting the respiratory organs, characterized by a cyclic
course, a severe convulsive cough, paroxysmal, with the characteristic
“whoop.”
=Etiology.=—It usually occurs in children, most frequently during
the fourth year, and extremely seldom after the twentieth year. It
appears to be slightly more frequent among girls, and most cases occur
in March and April. Pertussis is highly contagious, being carried by
direct contact and by fomites. The Bordet and Gengou bacillus is the
specific cause. This is found in the sputum most abundantly during the
first week, the most infectious period, and becomes gradually less. One
attack usually confers immunity.
The incubation period is from seven to ten days. The patient may be
considered non-infectious five weeks after the first whoop.
Lesions of the cervical and upper dorsal vertebræ and of the
first, second and third ribs, affecting the vagi, the phrenic, the
sympathetic, the recurrent laryngeal or the vasomotor nerves predispose
to the disease.
The bacteria were found by Mallory and Horner to be characteristically
between the cilia of the trachea and the bronchi. They interfere,
mechanically, with the movements of the cilia, preventing the normal
removal of secretions.
=Symptoms.=—The disease is divided into three stages: 1. The catarrhal
stage, which lasts one to two weeks; 2, the spasmodic stage, three to
six weeks; 3, the declining stage, three weeks.
=The Catarrhal Stage:= Characterized by headache, photophobia,
conjunctivitis, coryza and a cough which becomes drier and harder
toward the end of this stage. Often the invasion is insidious and
sometimes well marked with a temperature of 100° to 102°. Frequently
this stage cannot be differentiated from a “hard cold,” except toward
the end of the stage when the cough becomes worse instead of better,
and the child will seek some support to steady itself during the
coughing paroxysm. Also the eyes will water freely during the coughing
spell and the child will not be able to “get his breath” between
coughs, but will have a number of coughs without inhaling.
One to two weeks.
=The Spasmodic Stage:= This stage dates from the “first whoop.” The
fever now usually ceases, unless there are complications. The cough
becomes paroxysmal, consisting of a succession of fifteen or more
short, rapid expiratory puffs with no intervening inspirations,
immediately followed by a deep, loud inspiration, which is the
characteristic “whoop,” and is due to the partial closure of the
glottis. Each paroxysm is composed of three or more such spells, the
last one often followed by the expectoration of a small plug of mucus
or by vomiting. During the paroxysm the facies presents a swollen,
dusky appearance, eyeballs protruding, eyes reddened, and puffy,
pinkish lids. The child is well except for the paroxysm, which has
an aura, tickling in the larynx, thoracic constriction, a creeping
sensation, when the child attempts to brace himself, or runs in terror
for support. The “whoop” is a deep, singing or whistling inspiration
which is absolutely characteristic. During the cough the child’s body
is bent forward and he is perfectly helpless, often passing urine and
feces involuntarily. Cyanosis often occurs from the strain.
After the attack patient regains control of himself, the respiration
is fast, and there is fatigue, sweating and often pain in the abdomen
from the strain of coughing. During the severe cough petechiæ of the
forehead, ecchymosis of the conjunctivæ, epistaxis, bleeding of the
external auditory meatus or from the frenum of the tongue may occur.
Ulcer of the frenum of the tongue is quite common. The parosyxms vary
from four to a great many per day, averaging about twenty.
Three to six weeks, usually four weeks.
=The Terminal or Declining Stage:= This stage is longer in proportion
in the mild cases. The paroxysms occur at longer intervals, are of
shorter duration and of less intensity, the catarrhal symptoms are
more marked, the expectoration becomes thinner, fluid, mucopurulent,
and looser. The “habit cough” may follow. It is during this stage
that complications are most likely to occur, therefore it is the most
dangerous.
=Complications.=—Catarrhal inflammations are common in the initial
stage. =Bronchopneumonia= is the most frequent and severe complication.
Lobar pneumonia, exudative pleurisy, endocarditis, pericarditis,
meningitis and nephritis are infrequent complications. Spasms of the
glottis in nervous or scrofulous children is largely nocturnal, and
may cause death from asphyxia even in the lightest cases. Hemorrhages
may occur in the skin, conjunctivæ, nose, throat, ears or cerebrum.
The writer knows of one case where death was sudden from a cerebral
hemorrhage in an apparently mild case. Other complications are cardiac
dilatation, emphysema, bronchiectasis, pneumothorax, aneurysm hernias,
muscular ruptures, and visceral prolapses.
Spasmodic cough from diseased bronchial glands very closely resembles
whooping cough. Barthez and Sannee give the following differentiation:
=Whooping Cough vs Enlarged Glands=
1. Contagious, epidemic. Isolated, not contagious.
2. Three periods, 2nd parosyxmal. No distinct periods.
3. Paroxysmal cough with whoop, Paroxysms without whoop,
vomiting, viscid expectoration. expectoration or vomiting.
4. Respiratory sounds normal. Signs of enlarged glands sometimes
present.
5. Respiration normal in interval; Asthma in some cases, febrile
apyrexia if simple. movements, sweats, wasting, etc.
6. Voice natural. Voice sometimes changed.
7. Acute. Chronic.
=Treatment.=—Isolation of patient in well ventilated, sunny room where
there is plenty of fresh air day and night is essential. Children
exposed to infection should be disinfected and isolated for three
weeks, as the disease can not be diagnosed during the catarrhal stage.
If case is at all severe, patient should be put to bed.
Cases receiving early treatment are sometimes aborted. Treatment of the
whole respiratory tract with correction of vertebral and rib lesions,
and relaxation of the contracted muscles should be given. Treatments
for the first few days should be at least twice per day. Pay especial
attention to the vagi and phrenic nerves. Lesions of the first and
second ribs will affect the recurrent laryngeal nerves which will
aggravate the cough. The muscles of the shoulder girdle are always
very tense and should be kept well relaxed, as should the subscapular
muscles. Frequently after treatment the child will have a coughing
spasm and raise large quantities of mucus, after which there will be no
more spasms for several hours.
Children who play and live out of doors get along best. To support
the diaphragm and abdominal muscles from the strain of coughing a
muslin bandage tightly pinned about the trunk is very valuable, a pad
being placed over the stomach under the bandage. In a very young child
instruct the nurse to strongly flex thighs on abdomen during the severe
coughing. Inhalations of steam from water with a very few drops of
eucalyptus oil in it often relieves the first tickling sensations.
If cyanotic symptoms appear they may be relieved by raising the ribs,
especially those over the heart; by relaxing the subscapular muscles;
and by supporting the heart by application of cold cloth over the
heart. Elevating the abdominal viscera and diaphragm is, also, of
distinct benefit.
The diet should be nutritious and easily digested, restricted to
liquids during the fever. The child should be warmly clad and protected
from drafts. The excretory systems should be kept active by plenty
of water drinking and by diet. Treatment should be continued during
the terminal stage to prevent the possible complications. Irritants,
as beef-tea, stimulants, dry bread, cookies and overfeeding, provoke
coughing and vomiting. Food should be given at frequent intervals in
concentrated form—gruels, milk with lime water, zwieback in milk, eggs,
meat juice, etc. Older patients tolerate more solid food.
=Prognosis.=—With the complications, this is the most fatal of
the acute infections under five years of age. Infants and little
children should receive special care. Ordinary uncomplicated cases
are favorable for recovery. The prognosis depends upon the age and
strength of the patient, the severity and number of the paroxysms,
and the presence or absence of complications. No recurrence is to be
expected.
Death is due to spasm of the glottis or to extensive subdural
hemorrhage, occurring chiefly in the children of the poor and in
delicate infants.
Prophylaxis consists of isolation, disinfection of sputum and final
fumigation of the premises. Children should be protected from exposure
to infection from whooping cough. It must be realized that it is a very
serious disease.
CONSTITUTIONAL DISEASES
Rheumatic Fever
(INFLAMMATORY RHEUMATISM)
=Definition.=—An acute, febrile, non-contagious disease; it is
infectious, although there is some controversy as to its exact nature;
characterized by a multiple arthritis and a tendency to involve the
heart.
=Osteopathic Etiology= and =Pathology=.—The prevailing thought is that
the disease is an infection due to a diplococcus. This micro-organism
is called by others micrococcus rheumaticus and streptococcus
rheumaticus.
“Rheumatic fever occurs most frequently in the temperate zone, among
people who live under conditions which are unhealthful and which
especially induce focal infection. It is most prevalent in the young
and in the more exposed male of all ages. The excess of lymphoid tissue
in the pharynx and nose of the young explains the frequency of the
incidence of the focal infection and the subsequent rheumatism. The
frequent association of the onset of rheumatic fever with lowering of
the body temperature by exposure to cold and a wetting is explained by
the increased specific virulency of the bacterial cause acquired by a
low temperature and the coincident lessened resistance of the patient
due to the exposure. The frequent absence of evidence of acute focal
infection at the onset of the systemic disease is not an evidence
that no focus exists. The latent chronic streptococcus infection of
tonsillitis, pyorrhea alveolaris, sinusitis, etc., may suddenly acquire
increased virulence and specific pathogenic affinity with varying
degrees of focal tissue reaction. This transmutation of type and
pathogenicity certainly occurs in the focus of infection. The removal
of the tonsils and other sites of focal infection has been followed by
complete recovery of prolonged, subacute and chronic types of arthritis
and has unquestionably prevented recurrent attacks of rheumatic fever
to which the susceptibility is increased by one or more attacks. The
occurrence of rheumatic fever after the removal of an apparent focus
may be due to secondary systemic latent foci in lymph nodes proximal to
joints, in the neck or elsewhere. The streptococci of these secondary
foci may take on new virulence and specific pathogenicity, from the
same causes which induced like changes in the pathogenic bacteria of
the primary focus.[67]”
Osteopathic lesions play an important role, both in their relationship
or bearing upon the tissues of a possible site for a focal infection
and upon systemic conditions that derange general bodily tone. This has
been definitely confirmed in those cases of rheumatism where correction
of the osteopathic lesions, with attention to hygienic measures, have
resulted in recovery. This is a feature of osteopathic etiology and
therapy that can hardly be over-emphasized, for an intact innervation,
circulation and chemism of the organism is basic to both preventive and
curative therapy. Rheumatism, like most diseases, is of local origin
and if tissues and structures can be kept up to the normal, infectious
or the other pathologic processes can rarely become active.
=Pathologically=, the synovial membrane is hyperemic. The muscles and
ligaments are inflamed. The fluid is serous with more or less fibrin
and leucocytes. In severe cases slight erosion of the cartilages is
found. Acute rheumatism is rarely fatal; when death does occur it is
generally due to the complications which arise.
=Symptoms.=—The onset is usually sudden; although it may be preceded
by slight fever, aching in joints, chilliness, and sore throat. It
generally involves the larger joints and is almost always multiple;
it has a tendency to move from one joint to another. The pain in the
joints usually develops rapidly with slight chilliness and a rapid
rise in the temperature from 102 to 104 degrees F. The pulse is
frequent, often disproportionately to the fever. There are profuse
acid sweats, often causing sudamina. There is loss of appetite and
thirst is present. The urine is scanty, high colored, very acid, and
deposits urates upon standing. The tongue is coated and the bowels
are constipated. The joints are reddened, swollen, extremely painful
and tender to the touch. Every movement, jarring of the bed, or the
pressure of the bed clothes is agony to the patient. The blood is
greatly deranged, anemia develops rapidly and there is well marked
leucocytosis. The duration varies from a few days to several weeks.
=Complications.=—The temperature may rise to 106 or 109 degrees F.;
this is often associated with delirium, great prostration and a feeble,
frequent pulse. Endocarditis, pericarditis, myocarditis, pneumonia,
pleurisy, iritis, chorea, convulsions and meningitis may occur. Coma
may develop without preceding delirium or convulsions; this is very
serious and may prove fatal. Subcutaneous fibrous nodules attached to
tendons and fascia sometimes develop. They vary in size and are most
common in children and in young adults, occurring most frequently in
the fingers, hands and wrists. They are also sometimes seen about
the elbows, knees, scapulæ and spines of the vertebræ. They usually
last a few days, sometimes for months, and generally develop during
the decline of the fever. Cutaneous affections, such as urticaria,
erythema, nodosis, purpura and sweat vesicles sometimes appear.
=Diagnosis.=—This is seldom very difficult; there are, however,
several affections which resemble acute articular rheumatism. In
=septic arthritis= its association with some other septic process
and the tendency of the inflammation to end in suppuration with more
or less destruction of the joints, will determine the diagnosis.
Septic arthritis may develop during the course of pyemia, puerperal
fever, or acute osteomyelitis. =Gout= is rarely mistaken for acute
rheumatism. Gout occurs later in life and usually affects the greater
toe; history and mode of onset will usually render the diagnosis
easy. In =gonorrheal rheumatism= the history of recent infection, its
obstinate character and being generally connected with a single joint
from the start are diagnostic. It especially affects the knee. Heart
complications are rare. =Rheumatoid arthritis= begins in the small
joints; then attacks them all, leaving permanent deformity. There is
no fever or sweats and the heart is not affected. Acute arthritis of
infants usually attacks the hip or knee. The effusion becomes purulent.
=Prognosis.=—Recovery is the rule, but the prognosis nevertheless, must
be guarded. Relapses and recurrences are common.
=Subacute Rheumatism.=—In this form both the local and general symptoms
are of a milder type and are more prolonged than in the acute form. The
temperature seldom rises above 101 degrees F. The inflammation of the
joints is not so severe and fewer joints are involved. It may last for
weeks or months, and then it may pass into the chronic form. Usually
though, when the course is prolonged, the joints return to their normal
state.
=Treatment.=—Place the patient in a room that is well ventilated and
maintain a temperature of about 70 degrees F. Avoid draughts of air.
The bed should be soft and smooth and blankets should be used. The diet
should consist largely of milk, and let the patient drink freely of
water. Oatmeal, barley water, egg albumen and meat juices may also be
used.
Treatment should be given along the entire spine, especially if the
rheumatism changes from one joint to another; otherwise treat the
innervation directly to the affected joint. Correct any derangements
that may be found along the spinal column and carefully relax the deep
back muscles. Particular attention should be given to the bowels and
kidneys. Also, treat the liver most thoroughly during each treatment.
The liver is many times considerably enlarged and tender in rheumatism
and a thorough treatment of it seems to favor a more rapid cure.
Carefully treat the affected tissues. If you cannot treat over the
joint, then manipulate the tissues above and below the joint; and
usually after a few minutes’ manipulation the swelling is somewhat
relieved so that direct treatment of the joint can be given. It is best
to wrap the inflamed joints in flannel if the pain is severe. Besides
treatment of the innervation of the joint, hot applications will be
helpful. Some claim that cold compresses are of aid to the inflamed
joints.
=Complications= are to be treated separately. Besides the ordinary
fever treatment for the fever, the cold bath is very effectual. After
=convalescence= has been established, the patient should be carefully
protected for several days from cold and damp. For any stiffness that
may persist, manipulation and hot baths will be quite sufficient.
H. M. Still[68] writes “If the fever is not over 103 degrees I do not
try to reduce it.... After treatment in a majority of cases, the fever
is reduced within twenty-four hours unless complications have set in.
These are usually of the heart, so no matter how mild the attack, keep
this in mind. If the action is irregular and weak, stimulate it two or
three times a day. If it is rapid and high fever, go to the vasomotor
centers and reduce fever, then inhibit the heart action and keep the
excretions active. If the joints are affected I always move them gently
no matter how great the inflammation. As yet I have never had a case of
rheumatism in which cardiac lesions or ankylosed joints were a sequela.”
If the tonsils are evidently badly diseased and osteopathic treatment
does not clear them up do not hesitate to have them removed.
Chronic Articular Rheumatism
=Osteopathic Etiology= and =Pathology=.—This disorder should be studied
in connection with arthritis deformans owing to similar sources of
infection and various common factors. It usually develops slowly and
follows an acute or subacute attack and is common among the poor,
especially those exposed to damp and cold. Heredity, advanced years,
although the disease may appear at any age, and constant exposure to
cold and wet are predisposing causes. Chronic lesions to the spinal
column corresponding to the affected area are found. Too much stress
from an osteopathic point of view cannot be placed upon the importance
of lesions to both the digestive organs and to the joints especially
involved. Then, in addition, particular attention should be given
osteopathically or surgically, or both, to sites of focal infection.
=Pathologically=, the capsules and ligaments of the joints are
thickened also, the sheaths of the tendons around the joint, so that
in long standing cases the movements are impaired. In severe cases the
cartilages may be eroded. Atrophy of the muscles covering the joints
sometimes occurs, especially when there is neuritis; thus producing
marked deformity. This muscular atrophy is particularly marked when
the shoulders or hips are involved. The atrophy is caused partly from
disease; in cases where the joint is distended with effusion, the
wasting may be due to pressure upon the muscles or blood-vessels.
=Symptoms.=—Several joints are usually affected; but it may be limited
to one joint, particularly the knee, hip or shoulder. Pain and
stiffness are the most common symptoms. The pain is increased upon
motion, while the stiffness is often lessened by using the limbs. The
joints are slightly swollen, but seldom reddened and are usually tender
upon pressure. All the symptoms are aggravated on the approach of
stormy weather. There is fever but the general health is not greatly
impaired. There may be distortion of the joints and ankylosis may
occur. Arterial degeneration and chronic endocarditis may develop as
complications.
=Prognosis.=—This should be guarded so far as a complete cure is
concerned; although most cases are greatly benefited.
=Treatment.=—The treatment of chronic articular rheumatism is largely
correcting lesions of the spinal column, which affect the diseased
tissues as well as the digestive organs, local treatment of the joints,
and removal of focal infections. A certain percentage will respond to
osteopathic measures alone, though surgery has a definite place in
others. The joints and limbs should be thoroughly treated so as to
restore a better circulation and relieve the inflamed tissues. Wrapping
the affected joint with cold cloths and then covering the cloths with
flannel and oiled silk is often helpful. Due attention should be given
the general health, such as nourishing food, free elimination and
outdoor exercise.
Probably in some cases where the primary infection has been eliminated
secondary foci are present and a general treatment will arouse
sufficient reaction to cope with the condition.
Arthritis Deformans
(RHEUMATOID ARTHRITIS)
=Definition.=—A chronic affection of the joints, characterized by
progressive changes in the cartilages and synovial membranes, and by
new osseous formations restricting the motion of the joint and causing
deformity.
=Osteopathic Etiology= and =Pathology=.—It is due to lesions of the
spinal column affecting the spinal and sympathetic nerves as well as
disturbing the circulation to the cord. Lesions of the spinal column
and ribs are found corresponding to the innervation of the diseased
joints. The osteopath has been able in every case to demonstrate
clinically important osteopathic lesions. In addition the symmetry of
joint involvement, muscular atrophy, sweating, etc., point to nervous
lesions. Falli found upon autopsy that the anterior horns had undergone
atrophic changes. Nervous lesions are probably of a predisposing
character while some infection is the exciting cause. A thorough search
of the entire body should be made for foci of infection. Malnutrition,
traumatism, exposure to cold, and pelvic diseases are important
causative factors. In all cases lesions will be found disturbing the
organs of digestion. Females are more frequently affected than males.
The disease is frequently seen in women suffering from ovarian and
uterine troubles, especially at the menopause. Hereditary influence may
be a factor, also auto-intoxication. The disease is most common between
the ages of twenty and thirty. Mental worry, anxiety, grief and injury
are also predisposing factors.
=Pathologically=, in one class of cases, the cells of the cartilages
and of the synovial membrane proliferate. The cartilages undergo
atrophy, or may become soft, degenerate, and are absorbed, leaving the
ends of the bone bare. The bones naturally atrophy and become smooth.
In another class the edges of the cartilages where the pressure is
slight, thicken and form outgrowths which ossify and enlarge the heads
of the bones, forming osteophytes which greatly impair the motion;
true ankylosis is rare. The synovial membrane becomes thickened, also
the capsule and ligaments, thus greatly restricting the movements of
the joints. The muscles around the joints atrophy. In the spinal cord
atrophic and degenerative lesions are found. In Still’s disease there
is an enlarged spleen and marked changes in the joint.
=Symptoms.=—Pain and swelling of the joints and fever and enlargement
of the lymphatics near the joint are characteristic. The spleen
is congested and later on there is gastro-intestinal disturbance.
=Multiple arthritis deformans=, also known as Heberden’s nodosites,
is characterized by nodules developing at the sides of the distal
phalanges. It occurs most frequently in women between the ages of
thirty and forty, and gradually increases with age. At first the joints
are swollen, tender and painful and then apparently become better.
These attacks may appear at different intervals while the nodules at
the sides of the joints gradually increase in size. The larger joints
are rarely affected. The progressive form may be either acute or
chronic. The acute form at the onset may resemble articular rheumatism.
It is more common in women between the ages of twenty and thirty, but
may occur in children. Pregnancy, recent delivery, lactation, the
menopause, and rapid child bearing are common antecedents. There is
swelling and tenderness of the joints and slight fever. Several joints
are usually involved. The =chronic form= is most common. Symmetrical
joints are usually involved. The affected joints slowly enlarge and are
painful and red. Usually the hand is first affected; then the wrists,
knees, toes, jaws and spine; in extreme cases every joint is affected.
The vertebræ, =spondylitis deformans=, may be attacked. The cervical
spine may be alone involved, in which case the head cannot be moved
up or down, although rotation usually remains. In some instances the
entire spinal column is affected and may become perfectly rigid. In
some cases there is hardly if any pain, while in others the pain is
agonizing and is almost constant. The joints gradually become deformed,
stiff and creak when moved; later they become completely ankylosed.
This deformity is due partly to the thickening of the capsule, to
the presence of osteophytes, and to the contraction of the muscles.
These contractures flex the leg upon the thigh and the thigh upon the
abdomen. Muscular atrophy increases the deformity. Numbness, tingling,
pigmentation and glossiness of the skin, and local sweating may be
present and are of trophic origin.
The =monoarthritic form= affects old persons chiefly, and women more
frequently than men. It affects particularly the hips, the knees, the
shoulders, and the vertebral articulations. This is often caused by an
injury. The muscles waste away and the knee-jerk is usually increased
upon the affected side.
=Diagnosis.=—Care has to be taken in not confusing it with rheumatic
fever or gout. Radiographs should be made.
=Prognosis.=—If treated early there is a fair chance for curing
the disease. Advanced cases usually improve under treatment. The
osteopathic treatment should be persistent for at least several months.
=Treatment.=—Osteopathic treatment, if long continued in rheumatoid
arthritis, has given satisfactory results, although owing to the
extent of the deformity, a cure in advanced cases cannot be expected.
An important cause of the disease is probably a trophic or vasomotor
disturbance to the tissues of the joint. Osteopathically, there
is never any difficulty to locate disorders in the spinal column
corresponding to the innervation of the involved joints. The fact that
many of the joints are affected symmetrically indicates that the lesion
is a spinal one involving the nerve center. During the incipiency
marked improvement is the rule.
A thorough attempt should be made in every case to discover the source
of infection and remove it, though this does not preclude the essential
osteopathic adjustment.
The treatment consists of attempts to correct the spinal derangement
and careful manipulation of the diseased joints to restore vitality and
motion in them. The preceding simple, but effective treatment, must be
continued two or three times per week for months or even years in order
to be of particular value. Coupled with the specific treatment should
be a careful consideration of the general health. The emunctories
should be kept active and the food of the patient be nutritious. The
osteopath should require the patient to take considerable physical
exercise at regular intervals, warm baths and plenty of fresh air.
Massage and friction of the diseased joints will be of aid in absorbing
effusions and in restoring the tone of atrophied muscles. Hot
compresses are a help. The baths at various hot springs are sometimes
of benefit, and change of climate is invigorating.
O. J. Snyder[69] has this to say: “I must be very emphatic, however,
to here advise exceptional caution in your manipulative procedure.
* * * You cannot attempt to move the joint, for, if you do you will
cause excruciating pain and do irreparable harm in that you will cause
breaking down of the cartilage and cancellous bone tissue. Your first
endeavor should be to reduce inflammation and to mitigate pain. * * *
Osteopathically much comfort and reduction of pain can be accomplished
by inhibition in the proper spinal areas. A little friction and very
gentle extension or traction of the joint can be attempted as soon
as the condition of the joint, by the foregoing treatment, has been
made possible. At no time should rotation or sidebending, or any other
manipulation that produces irritation of tissue be attempted.”
In stout adult women a villous arthritis of the knees may develop owing
to faulty posture and poor elimination. These conditions are often
amenable to treatment.
Muscular Rheumatism
=Definition.=—A painful disease of the voluntary muscles and of their
fascia and the periosteum. It is regarded by many as a neuralgia of
these muscles. The pain is greatly increased by motion and pressure.
=Osteopathic Etiology= and =Pathology=.—Osteopathic experience with
cases of muscular rheumatism shows that the nerves, as they pass to
and from the spinal muscles, are affected. The lesion is caused,
principally, by subdislocations of the vertebræ, ribs or pelvis,
according to the region involved. A gouty or rheumatic diathesis,
heredity, exposure to cold and wet and previous attacks are
predisposing causes. Men are more often affected, owing to their more
frequent exposure. The disease affects persons of all ages. It occurs
in acute, subacute and chronic forms.
In cases of frequent recurrence focal infections and intestinal toxins
are often important factors. Vertebral and muscular lesions, septic
foci, intestinal stasis, exposure to cold and drafts are principal
causes.
=Pathologically=, there is swelling of the muscles of the nature of
myositis. In chronic cases there is often atrophy of the muscles, due
to interference of the trophic nerves.
=Symptoms.=—These are generally local and are never accompanied by
marked constitutional disturbances. There is seldom fever, and the
pulse is only slightly increased in frequency. Pain is the chief
symptom; it is increased by motion or pressure. Tenderness is generally
present and there may be swelling of the tissues. Rheumatic nodules
have been found. The duration is usually three or four days, though it
may last longer with frequent recurrences.
=Lumbago= is a painful affection of the muscles of the lumbar area and
their tendinous attachments. The onset is generally sudden. In severe
cases it sometimes renders the patient helpless. In =torticollis,= or
stiff neck, the muscles of the side and back of the neck are affected.
It is usually confined to one side of the head. Any attempt to turn the
head causes a sharp pain. In =pleurodynia= the intercostal muscles, and
sometimes the pectorals and serratus magnus, are affected. It usually
affects but one side, more frequently the left; it is the most painful
form of the disease, since the pain is aggravated by breathing. The
respiratory movements are consequently restricted on the affected
side. The absence of fever and physical signs will distinguish it from
pleurisy. In =intercostal neuralgia= the pain follows the distribution
of the nerves and there are tender spots along their courses.
=Cephalodynia= affects the muscles of the scalp. =Scapulodynia=,
=omodynia= and =dorsodynia= affect the muscles of the shoulder and
upper dorsal. =Abdominal rheumatism= affects the muscles of the abdomen.
=Prognosis.=—The prognosis is good. Favorable results are the general
rule under careful treatment.
=Treatment.=—Muscular rheumatism is usually an easy affection to cure.
The cause of the disturbance is generally found in the region involved,
and is due, in the majority of cases, to some dislocated tissue,
usually osseous, that irritates the nerves to the muscles. In addition
to correcting the lesions, removal of septic foci, free elimination,
lessened diet, stretching of the muscles, application of heat, ironing
and rest are beneficial.
In =lumbago= there is invariably found a slight lateral deviation of
some vertebræ along the lower dorsal or lumbar region. Occasionally
deformity of the vertebræ, asymmetry, or arthritis are factors. The
radiograph may be a diagnostic aid. Occasionally, a floating rib or
an innominate becomes displaced. Stretching the loins by placing the
patient upon his side or back and flexing the thighs on the abdomen is
very beneficial. Maintain the tension for three or four minutes. Hot
fomentations and rest are helpful.
=Torticollis=, or stiff neck, is generally due to a lesion of the
middle cervical vertebræ. The lesion is usually between the third,
fourth and fifth vertebræ, occasionally as low as the second dorsal.
A reduction of the subdislocation will often relieve the attack.
Stretching of the muscle and application of heat will also be of
aid. In some cases of torticollis (chronic) there is a curvature of
the cervical spine, and occasionally the muscles are more or less
fibrinous. Surgical measures may be instituted. In such instances a
cure cannot always be accomplished. The tonsils, nose and teeth should
be examined for sources of infection.
A few cases of acute torticollis are caused by some of the deep
muscular fibres becoming caught around a process of a vertebra. Severe
contraction of the muscles by cold or extensive rotary flexions of the
neck, may result in torticollis. Occasionally a case is found due to
injury at birth. The cervical vertebræ should be carefully examined.
The spinal accessory is the nerve generally involved. Lesions to
the spinal accessory occur commonly at the third, fourth and fifth
cervicals, or the atlas and axis. The muscles involved in torticollis
are the sternocleidomastoid, trapezius, splenius and scaleni.
Operations should not be performed until a thorough course of treatment
has failed to relieve.
=Pleurodynia= is often a neuralgia of the pleural nerves. It is
usually caused by subdislocations of the ribs exactly over the regions
involved. Occasionally, a lesion may exist to the corresponding
vertebra, but rarely. The rib is at times completely dislocated.
Applications of heat and rest of the part are of aid. Strapping of the
region will give considerable relief.
In =cephalodynia= the muscles of the scalp are generally involved
by lesions in the upper five cervical vertebræ. In =scapulodynia=,
=omodynia= and =dorsodynia= the muscles of the shoulder are usually
affected by displacements of the second and third ribs, although the
lesion may be found slightly lower in the ribs, or in the corresponding
vertebræ. The lower cervical vertebræ may also be at fault. In
recurring and chronic cases carefully examine for infectious sources.
Dislocations of the shoulder occur frequently; and muscular fibres may
slip out of the bicipital groove (rarely). In a few cases muscles may
become contracted about the coracoid process, or the acromial end of
the clavicle may become dislocated.
=Abdominal rheumatism= is generally caused by lesions in the lower six
dorsal vertebræ, which involve the innervation to the muscles. In some
cases lesions of the lower ribs are found, and in a few instances a
lesion may be discerned in the upper lumbar vertebræ.
=Myalgia= of the =upper extremity= is caused by lesions of the cervical
or upper dorsal vertebræ or upper ribs. Occasionally some trouble may
be found in the shoulder or elbow joints. In the =lower extremity=
lesions may be found in the lower dorsal or lumbar vertebræ, or there
may be derangements of the pelvic bones. Occasionally disorder is found
at the hip and knee joints.
Gout
=Definition.=—A nutritional disorder in which there is an abnormal
accumulation of uric acid and other purin bodies in the blood and
tissues; and arthritis, deformity of joints and visceral derangements
being the characteristic features.
=Osteopathic Etiology= and =Pathology=.—Hereditary influences are the
predisposing factors of about one-half of the cases of gout. Men are
more frequently affected than women. It rarely develops before the age
of thirty. Overeating, sedentary habits, drinking alcohol, especially
fermented drinks, and lead poisoning are predisposing factors.
Emotional disturbances may excite an attack. Gout is not confined to
the rich by any means; but there is also a “poor-man’s gout,” due to
poor food, unhygienic surroundings, and to an excessive use of malt
liquors. Uric acid seems to be a causative factor, but whether there is
an increased formation or a diminished excretion of the uric acid has
not yet been fully decided. The ultimate result is the same in either
case; there is an accumulation of uric acid and other purin bodies in
the blood, which is responsible for some of the effects of the disease.
Osteopathic experience with cases of gout shows that lesions affecting
the nervous system are important factors that control uric acid
accumulation or excretion. The nerve centers controlling the affected
portions of the body are almost invariably involved, as well as the
nerve control to the digestive and excretory organs. A neurosis of
these nerve centers probably occurs and is thus a predisposing cause
of gout. Considerable can be accomplished in the treatment of gout by
careful examination of the spinal column, in the region corresponding
to the innervation of the affected area, for vertebral lesions, and
correcting them. Usually, slight dislocations of the bones of the foot
are found, when that region of the body is involved. The most common
subdislocations of the foot are involvements of the astragalus with its
articulations and the metatarsals.
=Pathological= changes are those of the joints principally. There is
deposit of uric acid in cartilages, synovial membranes and ligaments.
The joint of the great toe is most frequently affected, then the
fingers, ankles, knees, hands and wrists. The exudates become hard and
are then called tophi. In severe cases the cartilages of the ears,
nose, eyelids and larynx are involved. Finally the joints become stiff,
deformed and ankylosed, and sometimes there is ulceration.
The kidneys are usually the seat of chronic interstitial inflammation
with a deposit of urates. The heart and blood-vessels almost always
present changes. Arterial sclerosis is quite a constant lesion; the
left ventricle of the heart is hypertrophied. Urate of sodium has been
found deposited upon the valves. There is an excess of uric acid in the
blood. Chronic bronchitis, emphysema and asthma are among the changes
in the respiratory system.
=Symptoms.=—In =acute gout=, before the attack, the patient may
complain of dyspeptic disorder, restlessness and twinges of pain in the
small joints. He is apt to have irritability of temper and depression
of spirits. The first symptom of the attack is great pain in the
metatarso-phalangeal joint of the great toe, which usually comes on
suddenly at night with swelling, heat and discoloration of the joint.
The temperature rises to 102 and 103 degrees F. Towards morning the
symptoms generally abate to recur again the next night. This lasts for
several days, the symptoms gradually abating. The urine is scanty,
high colored, of high specific gravity and acid in reaction. It
deposits urates and often contains a small quantity of albumin. There
may be gastro-intestinal symptoms—pain, vomiting, diarrhea, faintness
and a rapid, feeble pulse. Pharyngitis is an occasional symptom. The
cardiac symptoms are pain, shortness of breath and irregular action
of the heart. These attacks may appear with varying severity. In some
cases there may be severe cerebral symptoms.
=Chronic gout= follows repeated attacks of the acute form. The
articular symptoms continue for a longer time and the condition extends
to other joints. The chalk deposits slowly increase until the joint
becomes swollen and deformed. The morbid changes already described
are characteristic. The urine is increased in quantity, is of low
specific gravity and may contain albumin and hyalin and granular casts.
Involvement of the heart and blood-vessels gradually occurs.
=Irregular gout= or =lithemia= is seen in persons who have been gouty
or have a hereditary predisposition. It includes a set of symptoms that
are not alone distinctive, but when taken with this gouty tendency,
all forms of irregular gout can be recognized. There are various
gastro-intestinal disturbances; cutaneous eruptions; heart and blood
vessel changes; pains in the various muscles and joints; nervous
symptoms, as headache, neuralgia and neuritis; urinary symptoms, and
pulmonary and ocular disorders.
=Diagnosis.=—Only the irregular form of gout should be difficult to
diagnose. Differentiation is to be made from arthritis deformans and
acute and chronic rheumatism.
=Treatment.=—The hygienic treatment of gout is very essential. The
patient should live a quiet life, avoiding mental and physical strains.
Plenty of fresh air, exercise and regular hours should be insisted
upon. Alcoholic drinking should be avoided and the food taken in
moderate quantities. Keeping the skin active by the use of cold baths,
if the patient is strong, and warm baths should he be weak, is a
helpful measure. The dress of the patient should be warm and suitable
for the climate.
A regulated diet of nutritious food, taken at regular hours, is
necessary. Each patient should receive separate instructions as to
diet. The food given may be small amounts of beef, mutton and chicken,
with fresh vegetables; with the exception of strawberries, tomatoes
and bananas, fruits may be used; fats, milk and stale bread are also
suitable. The patient should avoid tea, coffee, pastry, hot breads,
highly seasoned dishes, and such articles. The free use of water is
beneficial.
The =osteopathic treatment= consists of careful correction of the
lesions of the spinal column in order to free the nerve force to
the affected region. The spinal treatment in gout is the most
essential treatment and is effective. A most thorough examination
should be made of the tissues about the diseased area; in the foot
the astragalus oftentimes is subdislocated from its articulations,
causing obstructions to the local vessels and nerves. The metatarsal
bones should receive due attention, as occasionally one of the
bones corresponding to the affected tissues is dislocated, usually
downward. All the joints between the diseased tissues and the spinal
nerve centers should be carefully manipulated so as to favor a better
circulation. During a severe attack of gout, besides careful treatment
of the blood supply to the diseased region, wrapping the joint in
cotton wool and applying warmth and moisture to the joint may be
helpful.
The kidneys, liver and bowels are to be kept active. A light treatment
to the kidneys and liver each time is very helpful in aiding the organs
to eliminate the waste material, and especially in controlling any
inflammation that may exist in the kidney. The essential treatment
in gout is to relieve the disorder of the nerve centers, to increase
the activities of the emunctories and to regulate the hygiene of the
patient.
Diabetes Mellitus
=Definition.=—A nutritional disorder in which there is an abnormal
amount of sugar in the blood, characterized by an excessive urinary
discharge, in which grape sugar is constantly present, and by a
progressive loss of flesh and strength.
=Osteopathic Etiology= and =Pathology=.—Almost invariably there will
be found a posterior dorso-lumbar curvature wherein the spinal column
tissues are much contractured. This condition probably involves the
sympathetics (vasomotor and trophic) to the pancreas, liver and
intestines. Important lesions may also be found as high as the occiput.
Tenderness and congestion over the abdomen, especially the liver, are
frequent. It affects men more frequently than women and is a disease
of adult life, ranging between the ages of thirty and sixty, though
cases have occurred in the very young. It is more serious in the young,
the very young seldom recovering. Hereditary influences are believed
to be a predisposing cause. It affects the better classes principally
and especially those of a neurotic temperament. The Hebrew race is
specially predisposed. The colored race is seldom affected.
Obesity, certain chronic diseases (malaria, gout, syphilis),
occupations taxing the mind, and pregnancy are predisposing influences.
Injury or disease of the spinal cord or brain frequently cause
diabetes, especially any irritation of Bernard’s diabetic center in
the medulla. Derangements of the endocrine system are important.
Injuries to the spine, chiefly in the dorso-lumbar and sacral regions,
and to the abdomen, and diseases of the pancreas or liver are, as
has been stated, oftentimes causes. Lesions to the spine may disturb
the glycogenic function of the liver, the glycolytic ferment of the
pancreas, or produce an alimentary glycosuria. Extirpation of the
pancreas is immediately followed by diabetes, but if a fragment of
the pancreas is left it is not always followed by diabetes. The
normal amount of sugar in the blood is 1-1000 while in diabetes the
amount of sugar is 3 to 4-1000 up to 7 or 8-1000. The healthy kidney
will not excrete sugar when it is at the normal ratio. Concerning
the presence of acetone-bodies von Noorden[70] says: “The excretion
of acetone-bodies may serve, like glycosuria, as a measure of the
intensity of the diabetic disease ... it will be at once understood
that in no other disease do the acetone-bodies occupy so important a
position as in diabetes.” Irritation of the centers of the vasomotor
nerves to the liver or direct stimulus to the liver cells is followed
by glycosuria. Interference with the pneumogastric nerve also
influences diabetes.
=Pathologically=, the liver is enlarged, firmer and darker in color
than normal. Often there is fatty degeneration of the organ. The
pancreas is diseased in about one-half of the cases of diabetes,
especially the islands of Langerhans. The lesions found are granular
atrophy, occlusion of the pancreatic duct, atrophy from pressure,
fat necrosis, and sometimes it is small, soft and anemic. The kidney
changes are those of catarrhal nephritis. In the fatty degeneration
hyalin changes take place. The heart is hypertrophied in a few cases.
Arterial sclerosis is frequently met with. In the lungs bronchitis,
pneumonia and tuberculosis occasionally develop. In the stomach and
intestines catarrh is common. The blood presents an increase of sugar.
In the nervous system are found many lesions, especially congestion,
extravasation and sclerosis of the brain; disturbances of the posterior
part of the cord, and congestion and sclerosis of the sympathetic
ganglia. The bony lesions, however, (almost invariably a posterior
lower dorsal and lumbar) must involve the sympathetics, via the
splanchnics, to the extent of profound metabolic disturbance, for in no
other way can the results of osteopathy be explained. The importance
of specific treatment at this point cannot be over estimated.
=Symptoms.=—The =onset= is gradual; thirst and frequent micturition
being the first symptoms noticed. After an injury or a sudden, severe
nervous shock, diabetes may set in abruptly. As the disease progresses
there will be marked thirst, polyuria, an abnormal appetite, wasting
and debility. The tongue is dry, red and coated. There is constipation
and the skin is dry and harsh. Temperature is often subnormal; pulse
frequent with increased tension.
In some cases the =urine= is not increased in quantity; usually
however, the amount varies from four to five pints to several quarts in
twenty-four hours. It is pale in color, of high specific gravity and
acid reaction. Sugar is present in variable quantities from one or two
per cent to five or ten per cent. Sugar in the urine must be constant
in order that the affection is a true diabetic one. Albumin is often
present; urea is increased and uric acid may be slightly increased.
Acetone-bodies are often found and usually indicate a more serious
condition.
=Diabetic Coma= is the most important and gravest complication.
There is either a sudden or gradual loss of consciousness. This may
occur after some form of exhausting exercise. There may be previous
headache or a feeling of intoxication. It may be preceded by nausea,
vomiting, colicky pains or some local affections, such as pharyngitis
or pulmonary complications. Peripheral neuritis, neuralgia, numbness,
are possible symptoms. Impairment of hearing, cataracts, strabismus,
diabetic retinitis and atrophy of the optic nerve may occur. The sexual
function is lost early in the disease. Eczema, with burning and itching
of the labia and vicinity, (and in men a balanitis), furuncles, boils
and carbuncles are common. Gangrene and edema are not uncommon. Acute
pneumonia, bronchitis and tuberculosis are possible complications.
=Progressive loss of flesh= is a serious indication.
=Diagnosis.=—The diagnosis is easy, as there is no other disease with
which it can be confounded. Careful urinalysis should always be made.
Examination for acetone, diacetic acid and oxybutyric acid is valuable.
=Prognosis.=—Many cases have been cured by osteopathic measures while
nearly all treated have been benefited. If the patient is put upon a
diet free from carbohydrates, in mild cases the sugar will disappear,
while in severe cases it will still be present. Mild cases usually
yield readily to treatment. In cases over forty years of age the
outlook is quite favorable, but in cases under forty, and especially
the young, the prognosis is not so favorable. In cases under puberty
the results are apt to be fatal. Stout persons bear diabetes better
than lean. All cases are liable to complications, which render the
prognosis more serious. It is a disease of long =duration=, although
death has occurred in a few weeks.
=Treatment.=—In nearly all cases of diabetes mellitus examined there
have been found posterior conditions of the lower dorsal and lumbar
regions. The posterior curve has always been fairly well marked and
generally is a symmetrical curve. By that is meant a spinal curve that
is not irregular and the relation of the various vertebræ, one to the
other, is not seriously deranged. Correction of this condition of the
spinal column has almost invariably given satisfactory results and
in the majority of cases the condition of the patient has improved
remarkably, and many entirely cured. To get the best results the
patient should be laid on his side on the operating table and the knees
drawn up so that the thighs are flexed upon the abdomen. The osteopath
standing in front of the patient throws his weight against the flexed
thighs and reaching over upon the spinal column springs the entire
weakened portion of the spine toward its normal position, stretching
the spinal column to separate each vertebra from its neighbor so that
the deranged nerves, as they pass through the intervertebral foramina,
may be released. Meeker[71] reports a case with a marked kyphosis which
was treated two years before enough motion could be had between the
vertebræ to produce any results, but after that they were favorable.
Direct treatment to the abdominal organs to correct liver congestion
and stimulate the pancreas and increase activity of the intestines is
essential.
The nerves affected by the posterior pathological curve of the spine,
mentioned above, and by separate lesions that may exist within the
pathological curvature, are probably the vasomotor nerves to the portal
system, pancreas and the intestines. The vasomotor nerves to the portal
system branches are given off principally from the fifth to the ninth
dorsal vertebræ, although fibres may escape from the cord as low as
the first lumbar vertebra. The nerves to the intestines are given off
principally from about the ninth dorsal to the lower lumbar vertebræ.
Possibly there are nerve fibres direct to the hepatic cell protoplasm.
How lesions in the dorso-lumbar region cause diabetes mellitus is an
important question and is hard to answer. An unnatural acceleration
of the portal circulation may cause an increased quantity of sugar to
pass to the liver, resulting in part of the sugar not being changed
into glycogen and thus passing into the circulation; or a paralysis
of the vasomotor nerves to the liver causes congestion and slowness of
the blood stream. Thus a disturbed circulation of the liver may cause
accumulation of sugar in the liver, so that the blood ferment has time
to act upon the glycogen and transform it into sugar; or there may be
a saccharinity of chyle or blood in the portal vein, due to an impeded
conversion of sugar in the intestines into lactic acid; or there may
be an accelerated absorption of sugar due to an abnormal state of the
intestines; or the nervous control to the pancreatic functions may
be disturbed. Hence, one or many pathological changes may occur and
influence a case of diabetes, due to a disordered dorso-lumbar region.
The center for the hepatic vasomotor nerves, “diabetic center,” is in
the floor of the fourth ventricle at the level of the origin of the
vagi nerves. A lesion of the “diabetic center” or an obstruction to the
pneumogastric anywhere along its course may cause diabetic symptoms;
hence, there may be lesions of the cervical region that would affect
reflexly the diabetic center, or lesions of the pneumogastric may
occur, particularly at the atlas or axis, and cause diabetic symptoms,
or, at least, these may influence the course of a case of diabetes
mellitus. Or the upper cervical lesions may disturb the pituitary gland
which is of importance in carbohydrate metabolism.
There are nerves from the superior and inferior cervical ganglia of
the sympathetic that have considerable influence upon the liver. These
nerves do not pass down the cord to the splanchnics, but pass in the
sympathetic to the celiac and hepatic plexuses and then to the liver.
Stimulation of these nerves causes the hepatic vessels at the periphery
of the liver lobules to become contracted. Possibly in a very few
cases, a stagnation of blood in other vascular regions of the body may
cause the blood ferment to accumulate in the blood to such an extent
that diabetic symptoms occur.
=Dietetic treatment= is essential, but is not so necessary as some
medical authors would have us believe. A regulated diet should be
insisted upon in all cases, but one should not go to extremes in
dieting. A complete elimination of the carbohydrates is no longer
considered the best treatment, as it withdraws too important an element
from the diet, producing weakness without any corresponding return for
good. A patient’s appetite is often inordinate and it will be necessary
to regulate the quantity and character of foods. Proctor[72] mentions a
case which recovered when carbohydrates were restored, as the patient
was too starved to build up. Under osteopathic treatment much more
liberty can be allowed in selection of foods. Von Noorden[73] reported
a number of cases in which excretions of sugar continued upon the
strict anti-diabetic diet, but which were sugar free when they received
a large amount of oatmeal along with some vegetable proteid or white of
egg and butter, other carbohydrates being excluded. It is suggested by
the editor of the Series that the oatmeal may be used alternately with
diabetic diet, and relieve the monotony greatly. It can also be used
as a test of the patient’s digestive and sugar destroying powers. The
following food may be included in the dietary:
Animal Foods.—Meats of every variety, except livers; game, poultry,
fish and eggs.
Vegetables.—Cabbage, cauliflower, celery, lettuce, green string beans,
the green ends of asparagus, tomatoes, spinach, mushrooms, cucumbers,
watercress, young onions, or any other green vegetable.
Bread and Cakes.—Made of gluten flour, bran flour or almond flour;
griddle cakes, biscuits, porridges, etc., may be made of these flours.
Beverages.—Skimmed milk, buttermilk, coffee and tea without sugar, and
carbonated water.
Relishes.—Pickles, cream cheese and nuts of all kinds except chestnuts.
Fruits.—Oranges, lemons, cranberries, cherries, strawberries, all in
moderate quantities.
Other foods may be used, but each case requires a thorough study in
order to determine what is best to do.
Various foods should be tested out and controlled by urinalysis.
The point is to increase metabolism so that the body can store up
considerable carbohydrates without the appearance of sugar in the urine.
In severe cases Allen’s fasting treatment to be followed by a low
diet should be instituted. However, it should be remembered that the
correction of dorsal and upper cervical lesions is invaluable.
Mental excitement and worry should be avoided as much as possible.
Frequent bathing and regulated exercise will be of considerable value.
The diabetic patient should have a well ventilated room and plenty
of rest and sleep; flannels are to be worn next to the skin the year
around.
Various symptoms and =complications= are liable to arise, which the
competent osteopath is prepared to meet by following general rules.
Keep the bowels open. And frequently examine for acetone and diacetic
acid. If there are any symptoms of =coma= fast the patient, and
neutralize the acid intoxication with bicarbonate of soda until the
urine is alkaline.
Diabetes Insipidus
(POLYURIA).
=Definition.=—A constitutional disorder in which there is a continued
excessive secretion of urine, free from albumin and sugar. There is
constant thirst.
=Osteopathic Etiology= and =Pathology=.—This disease is more frequent
in males than in females. It occurs most commonly between the ages of
twenty and thirty. It is due to chronic disturbances of the nerves.
The lesions usually found upon osteopathic examination are lateral
derangements of the vertebræ in the renal splanchnic region, (ninth to
twelfth dorsal inclusive) or a slight kyphosis in the same locality.
Such lesions probably affect the central nervous system in the region
of the sympathetic nerves to the kidneys, by a paralysis of the
muscular coat of the renal vessels. The disease may be associated
with other conditions, as injuries and diseases of the nervous system
elsewhere; exposure to cold; prolonged debility and fatigue; cerebral
diseases, as meningitis, paralysis of the sixth nerve, tumor of
the brain, and blows on the head; injuries of the cervical region;
sunstroke; cerebrospinal fever; malaria; syphilis; pregnancy; hysteria;
hereditary influences, and drinking too freely of cold water. There
are many diseases and conditions which may be associated with diabetes
insipidus; and which act as irritants, directly or reflexly, upon the
center in the medulla oblongata (which is just above the diabetic
center), or upon the sympathetic ganglia in the abdominal region. Thus,
there is a vasomotor neurosis, due either to central or reflex lesions.
Second in importance to lesions of the renal splanchnics are lesions
of the upper cervical region. Irritations in the cervical region may
act upon the center in the medulla or the lesions may affect some
of the sympathetic fibres as they pass from the brain to the renal
sympathetics. The pituitary gland may be disturbed. Probably axis and
atlas lesions are factors.
Lesions of the nerve centers and of the sympathetic ganglia have been
found upon post-mortem examination, but they are not constant. Nervous
lesions have been found in the region of the base of the brain. The
kidneys are sometimes congested and enlarged. The tubules may be
dilated.
=Symptoms.=—Great thirst and an enormous secretion of urine of a pale,
watery and slightly acid nature are the characteristic symptoms. The
skin is usually dry and harsh, the bowels are constipated, and the
appetite may be voracious. The health on the whole is quite perfect,
although if the affection is not arrested, considerable loss of flesh
and strength may result. There is a tendency for the disease to become
chronic.
The nervous lesion causing polyuria may be the outcome of a debilitated
condition of long standing or the symptoms may occur suddenly.
Preceding the large flow of urine such symptoms as nervousness,
irritability, headache, sleeplessness, failure of memory, and inability
to concentrate the mind commonly occur. Other symptoms may be present
in addition, as debility, diarrhea, epigastric and lumbar pains, and
impaired sexual function.
=Diagnosis=.—The diagnosis is not difficult. Thirst, polyuria and the
absence of albumin and sugar characterize the disease. In =diabetes
mellitus=, finding of grape sugar in the urine would at once exclude
polyuria. In =paroxysmal diuresis=, the increased amount of urine is
not permanent. In =interstitial nephritis=, there is albumin, casts,
etc.
=Prognosis.=—Depends upon the cause. The disease yields to treatment
much quicker than diabetes mellitus and is without doubt much less
serious. The disease, in a large majority of cases, can be cured. Under
osteopathic treatment most cases will yield good results or be cured in
from a few weeks to six months.
=Treatment.=—The treatment of the disease causing diabetes insipidus is
of first consequence, but frequently such a disease is undiscoverable.
There is often a tendency toward neurasthenia; consequently, habits,
environment, etc., should be carefully attended to. Examine for sexual,
rectal and other reflex irritations.
Correcting lesions of the renal splanchnics is important; in fact, in
a fair number of cases treatment of this locality will entirely cure
the disease. A very effective treatment, in addition to the ordinary
methods of treatment, is to have the patient lie flat upon the back
while the osteopath reaches around the patient on either side, placing
the fingers firmly upon the transverse processes of the lower dorsal
vertebræ and springing the spine forward by lifting upward on the
patient, enough even to raise the patient from the surface he is lying
on. This treatment is especially effective in lessening the increased
amount of urine. Attention should be given to the false ribs on either
side and to the condition of the spine below and above the renal
splanchnics. The cervical vertebræ should be examined carefully for
disorders, and if any are found they should be removed at once, if
possible.
=Hygienic treatment= is of as much importance as in diabetes mellitus.
The clothing should be warm, warm baths taken, and general friction
and care of the skin utilized so that the circulation may be somewhat
diverted from the kidneys. Restriction of water is not always
necessary, except in cases where excessive drinking has become a habit,
as the thirst is caused by the diuresis and not the diuresis by the
large ingestion of water. Regulate the diet and see that the bowels are
acting normally.
Rickets
RACHITIS
=Definition.=—A constitutional disease of children, characterized
by impaired nutrition and changes in the growing bones, causing
deformities. The physical growth is disturbed and the bone deformity is
due to an over growth of cartilages and delayed calcification.
=Etiology= and =Pathology=.—Rickets may occur in the new-born, but it
rarely begins before the child is six months old. It is a disease of
the first and second years of life. Heredity is probably not a factor
but certain races, especially the Negro and Italian, have a tendency to
be rickety. The disease is much more common in the large cities than
in rural districts; also it is more common in Europe than America. The
disease is most frequently met with among the ill-fed and badly housed
poor of the large cities, though it is not rare to find it among the
well-to-do. Lesions to the digestive organs predispose. Breast-fed
children seldom have the disorder. Improper or insufficient food (a
diet too low in fats and proteins) bad air, want of sunlight, prolonged
lactation, exposure to cold and dampness are predisposing factors.
=Pathologically=, the most marked changes are seen in the long
bones and the ribs. The cartilage between the epiphysis and shaft
is thickened and is soft and irregular in outline. Underneath the
periosteum the tissue is spongy. Microscopic examination shows
an increase of proliferation of the cartilage cells with scanty
calcification. The bones are soft and there is a diminution in the
calcareous salts. In a word ossification is delayed and the bones
are not perfectly developed. In the cranium the frontal and parietal
eminences are prominent, while the top of the head and the occiput are
flattened, giving the head a square appearance. The fontanelles remain
open until the second or third year of life. The ribs become affected
very early. At the point where the ribs join the costal cartilages,
bulging occurs, forming the so-called “rachitic rosary.” The normal
shape of the chest walls is markedly changed. Just outside the junction
of the ribs with the cartilages, the ribs fall in, producing a shallow
depression, while the sternum and cartilages are pushed forward. The
bones of the leg may be distorted. The normal curves of the spine are
occasionally disturbed. The liver and spleen are often increased in
size.
=Symptoms.=—The =onset= is slow. In many cases digestive disturbances,
with their usual effect upon the nutrition, precede the appearance of
the characteristic lesions. The child is irritable and restless, and
there is usually slight fever and profuse sweats. The child is often
languid, pale and feeble. The lymph gland are enlarged. The tissues are
soft and flabby and skeletal changes begin to make their appearance.
Among the first are changes in the ribs and head, already described
under pathology. Changes sometimes occur in the bones of the face,
particularly the maxillæ. Dentition is delayed. The spinal column is
frequently curved antero-posteriorly or laterally. The long bones are
curved and their extremities become thickened. The pelvis is distorted
and twisted and in women this may seriously complicate labor. “Chicken
breast” and “bow legs” are common, as well as muscular weakness, and
the child walks late. The abdomen is large and prominent, due to
flatulency and to the enlargement of the liver and spleen.
=Diagnosis= and =Prognosis=.—By observing the symptoms, diagnosis is
not difficult. Prognosis should be guarded, owing to danger from other
diseases; still, on the whole, prognosis is fairly favorable.
=Treatment.=—Rickets being a disease of malnutrition due to weakness
of the digestive organs, improper food, or to influences of disease,
the treatment must be principally following hygienic rules and good
dieting. The child under six months, if not nursed satisfactorily by
the mother, should be given diluted cow’s milk. Salts may be obtained
from barley gruel and whole wheat. Diluting the milk with barley water
is highly recommended. Fresh meat juice and cream are invaluable. If
curds are found in the stools, the digestion is not perfect and is
usually due to overfeeding the child. The child should be out doors as
much as possible. Fresh air is a necessity. The worst air outside is
better than the best air of the house as far as purity is concerned.
Protect the child carefully with warm clothes, and when sitting or
walking the child should be supported. Baths will be found beneficial.
In the older child, beef juice, light meats, yolks of eggs, green
vegetables and fruits may be given. Lessen the amount of carbohydrates.
Careful osteopathic treatment of the various affected tissues of the
child will aid a great deal in correcting deformities. Attention
to the lesions found will also aid in increasing the nutrition to
the involved tissues as well as correcting digestive disturbances.
This, also, is of distinct benefit in improving the assimilation
of lime salts. Possibly treatment of the “nutritional” centers,
(fourth dorsal and fourth lumbar) would be effectual. Carefully guard
against complications of the nervous and respiratory systems. After
ossification the deformities may be corrected by the orthopedic
surgeon, though in the young child considerable can be accomplished
by repeated attempts at straightening by bending and molding the long
bones. All those conditions which predispose to rickets should receive
attention; chief among these is the care of the nutrition of the mother
during pregnancy. Nursing should be regulated, and possibly future
pregnancies discouraged.
Obesity
=Definition.=—Obesity is essentially a nutritional disease and is an
inconvenient accumulation of adipose tissue in the body, sometimes
impairing the bodily function. With some individuals obesity is a
normal condition. In others it means impaired health, especially poor
elimination.
=Etiology= and =Pathology=.—Heredity, overeating, sedentary habits,
hot, moist climates are predisposing causes. Exciting causes are
especially the eating of fat-making food, excessive use of alcohol
and insufficient exercise. Obesity may follow the menopause or an
infectious disease. Osteopathic lesions are frequently found in
the upper and middle dorsal region. These probably are causes of a
disturbed metabolism. An excessive diet of starches and sugars will
indirectly act as a fat producer. In young people the possibility of
hypopituitarism should be considered. Lesions of the upper cervical, in
these cases, are frequent.
=Pathologically=, adipose tissue is deposited throughout most of
the tissues. Usually the abdomen is encumbered with a large amount.
Passive congestion probably favors the deposition of fat, for in cases
of pendulous abdomen, simply drawing the abdomen in and up and the
patient, through voluntary effort, keeping it up, will frequently cause
absorption of the fat in a few days or weeks. The fat is distributed
underneath the skin, throughout the viscera and about the heart. The
tissues may suffer from fatty infiltration, especially the heart,
arteries and veins; also the liver, kidneys and stomach. There is an
increase of specific gravity of the blood. Edema occurs from passive
congestion, due to weak heart.
=Symptoms.=—The round, fat face, double chin, hanging cheeks, large
waist, the thick, prominent, sometimes pendulous abdomen, and the
bulky extremities form characteristic features. At first obesity
presents no harmful symptoms. Usually the first troublesome symptom
is increased frequency in the breathing, due to a weak and overworked
heart, and to the fact that the motion of the lungs is hampered by
the heavy chest walls, and also by the interference with the descent
of the diaphragm on account of the enlarged liver. Dyspnea, passive
congestion, anemia, poor digestion, uterine disorders, and mental
inactivity are common. There is cardiac hypertrophy; later the heart is
overlaid with fat. The pulse is usually frequent, but may be irregular
and slow.
=Treatment.=—Obesity being a nutritional disease it seems but
reasonable that alterations of the anatomical structures will produce
a change in the proper balance of nutrition. Along osteopathic lines,
derangement of tissues affecting the nerves to the digestive and
lymphatic systems will produce obesity. In the majority of cases
examined have been found disturbances at the sixth and seventh
cervical, fourth and fifth dorsal and from the tenth dorsal to the
second lumbar. Lesions at these points could readily interfere with
the thoracic duct and the receptaculum chyli, as well as with the
processes of digestion, assimilation and elimination. It is claimed
that stimulation of the splanchnic nerves causes dilatation of the
receptaculum chyli. Direct treatment to the abdomen and to areas of
fatty deposit will aid very materially in absorption.
The =dietetic treatment= is essential, the principle being to furnish
less food to oxidize. Restrict fats, sugar and starches and limit the
amount of water. Alcohol should be prohibited. Another important point
in the treatment is exercise, which must be carried out in a systematic
way. Rules can be laid down only in individual cases and should be
governed by the osteopath in charge. The principal effect of general
mechanical treatment is to promote oxidation. Massage and baths are
beneficial. The patient can do much for the abdomen by keeping it in
and up, and walking erect.
Scurvy
=Definition.=—A constitutional disease, characterized by extreme
general weakness, anemia, spongy condition of the gums, disintegration
of tissue and a tendency to hemorrhages.
=Etiology= and =Pathology=.—In comparison with former times scurvy is
now a rare disease. Lack of fresh vegetables or their substitutes,
over-crowding, dampness, bad hygienic surroundings, and prolonged
fatigue under depressing influences are the predisposing causes. Arctic
explorers have shown that fresh bear’s meat and bear’s blood are a
preventative.
There are extravasations of blood into the skin, muscles and mucous
membranes. Hemorrhages may occur in the internal organs, especially
the kidneys and liver, and in the serous membranes. The gums are
swollen and spongy. The teeth decay. The spleen is soft and enlarged.
Parenchymatous degeneration of the heart, liver and kidney is frequent.
Ulcers occasionally occur in the skin and bowels. The blood is thin but
there is no leucocytosis.
=Symptoms.=—The disease is usually slow in development. The general
manifestations of anemia with debility are among the first symptoms.
The gums are swollen, soft and spongy, they bleed easily and in severe
cases there is ulceration. Petechial spots appear upon the body.
Subcutaneous ecchymosis occurs, first on the legs, then on the arms
and trunk. The eyes and face are swollen; the patient appears as if
he had been bruised. Hemorrhages from the mucous membrane frequently
occur. The temperature is usually normal. The pulse is small, feeble
and frequent; sometimes irregular and slow. The appetite is impaired
and constipation is present at first, as a rule, although this may be
followed by scorbutic dysentery.
=Diagnosis.=—The disease is readily recognized when several cases occur
together. It is somewhat hard to recognize in isolated cases, and to be
able to distinguish it from certain forms of =purpura=. The etiology,
the gingival changes and the hemorrhages usually decide the diagnosis.
=Prognosis.=—Scurvy being a disease due to malnutrition, it is
necessary to remedy such condition by attention and correction of the
faults producing it. Hygienic surroundings and a wholesome diet will do
more in curing the disease than anything else. An outdoor life and good
ventilation with anti-scorbutics, as fruit juices, especially lemons
and oranges, fresh vegetables, (onions, potatoes, etc.) and fresh milk,
are necessary.
It is held by Garrod that scurvy is caused by an absence of potash,
for a deficiency of potassium salts is found in the blood. The
anti-scorbutics named above contain potash. A careful treatment along
the splanchnics would help to improve the appetite and digestion. Treat
the gums and ulcers according to surgical indications.
Infantile Scurvy
SCORBUTUS
This form usually follows the prolonged use of condensed milk,
sterilized milk or proprietary foods for children. The disease occurs
during the first two years of life, but it is most common from the
seventh to the fourteenth month.
It develops rapidly. Joint pains, anemia and irritability are early
symptoms. The child is pale, has a muddy complexion and may show signs
of rickets. The gums may be soft and spongy. There is tenderness and
pain on motion. There may be hemorrhages under the skin. The lower
limbs are drawn up and motionless. The bones become thickened from
sub-periosteal hemorrhage, and there is apt to be softening between the
shaft and epiphysis. The back and legs become very weak. The lesions
are usually symmetrical. The temperature is variable.
=Treatment.=—The treatment of scurvy in children consists in, first,
omitting all proprietary foods and substituting fresh cow’s milk, meat
juice, strained gruel and a moderate quantity of fresh orange or lemon
juice. Under this treatment, cases that have not progressed too far
will promptly recover.
Northrop says: “It is a significant fact that the country which
furnishes most of the literature on scorbutus in children is the same
which is posted from end to end with advertisements of proprietary
foods.”
Purpura
=Purpura= is a symptom rather than a disease. It is characterized by
extravasation of blood into the skin and bleeding from the mucous
membranes, irrespective of direct injury. These extravasations do not
disappear upon pressure and vary greatly in size. They may be small,
(petechiæ) or large (ecchymoses). They are bright red and gradually
become darker. Clotting of normal blood requires three to five minutes,
purpuric blood, ten to fifteen minutes.
It is a symptom of =infectious diseases=, as in pyemia, septicemia,
mycotic endocarditis, typhus fever, smallpox, etc. =Toxic=, as produced
by venomous snake bites and by =certain medicines=, as copaiba,
mercury, quinine, iodides and others in overdoses. =Cachectic purpura=
may be observed in cancer, tuberculosis, Bright’s disease, scurvy,
etc. In =senile purpura= the spots are generally confined to the
extremities. In certain =nervous diseases=, bleeding spots appear on
the skin, as in tabes, myelitis and severe neuralgia. =Mechanical
purpura= is seen in venous stasis; this is rare.
=Purpura simplex= affects only the skin. It occasionally follows
attacks of infectious diseases. The spots are found upon the legs, more
rarely upon the trunk and arms. Articular pains may or may not occur.
Fever is seldom present. Loss of appetite, diarrhea and slight anemia
may be manifested. The duration is one to four weeks.
=Purpura rheumatica= is a much more serious affection, characterized
by multiple arthritis of rheumatism. Seldom seen under five years,
and lasts about two weeks. The joints are swollen and painful and the
temperature rises to 101 and 103 degrees F. The amount of edema varies
greatly and occasionally it is quite excessive. In addition to the
purpura there is usually urticaria. =Henoch’s purpura= is seen most
frequently in children and is characterized by severe gastro-intestinal
disturbances as pain, vomiting and diarrhea, hemorrhages from the
mucous membranes and acute enlargement of the spleen, in addition to
the symptoms already named under the foregoing form. There is some
danger of hemorrhage into the kidneys.
The disorder of =purpura hemorrhagica= is usually associated with
rheumatism, malaria and other infectious diseases. This is the most
serious form of purpura. It is most commonly met with in delicate girls
during early life; but it may occur at any age and in the most robust
of either sex. Fever, weakness, vomiting and diarrhea are the early
symptoms. After a couple of days of languor and weakness, purpuric
spots appear upon the skin; and bleeding occurs from the mucous
membranes and may cause profound anemia. Hemorrhages into the internal
organs occur. Favorable cases recover in ten days or two weeks. Others
may end fatally. Care should be taken not to confuse the disease with
scurvy.
=Treatment.=—In the treatment of purpura the disease from which it
develops should receive due attention. Occasionally there is danger
of overlooking the primary disease and treating some symptoms of the
disease, although it is true that sometimes an important symptom is
nearly all that is manifested. Outside of treating the conditions under
which purpura arises, general measures should be considered, as a
nutritious diet, rest, fresh air, and general treatment of the patient
so that normal circulation and strength may be restored. The treatment
of the purpura locally should be such as to restore normal circulation
of the part by removing any obstruction or irritation of the blood
supply that may be found, by careful manipulation of the tissues. As
stated the management of the disease under which it arises should be
embraced in the treatment. In cases of hemorrhage from various organs
see article under hemorrhage. Some cutaneous hemorrhages are best
relieved by local manipulation.
Hemophilia
(BLEEDER’S DISEASE).
Hemophilia is a hereditary condition manifested by a tendency to
uncontrollable hemorrhage with or without injury. The usual mode of
transmission is through the female line, rather than by the male. The
mother does not necessarily have to be a bleeder, but the daughter
of one, in order to transmit the disease to her offspring. Atavism
through the female alone is almost the rule. Not all the children of a
bleeding family are afflicted; the male children are more subject to
the condition than the female children. The tendency usually appears
within the first two years of life. The families of bleeders are often
large and are commonly healthy looking and have fine soft skins. It is
claimed blondes are most likely to be afflicted.
=Pathologically=, an unusual thinness of the blood-vessels with a
fatty degeneration of the intima has been noted. In many cases there
is deficient coagulability of the blood and a lessened number of
leucocytes. Hemorrhages have been found in and about the capsules
of the joints, and in a few instances inflammation of the synovial
surfaces. The arteries are situated superficially, but that does
not explain anything. The real nature of the disease has not been
determined. Emotional excitement is a factor, consequently vasomotor
disturbances may be important. The frailty of the blood-vessels and the
peculiar constitution of the blood preventing thrombotic formation are
the two facts of importance that have been recognized.
=Symptoms.=—Hemorrhages occur from the most trifling injuries. Blowing
the nose may cause severe epistaxis; the extraction of a tooth is a
frequent cause of hemorrhage; the prick of a pin, a slight cut, a
scratch, or a blow may result in profuse bleeding. The bleeding may
occur spontaneously from the mucous membrane of the mouth, nose,
lungs, intestines, etc.; or it may occur directly from the fingers,
toes, back of the hands, and lobes of the ears. The hemorrhages may
last several hours. As soon as checked the patients rapidly resume
natural appearance providing the bleeding is not often repeated,
thereby causing a permanent anemia. There may be attacks of arthritis
with fever, as with acquired hemorrhagic tendency, closely resembling
rheumatism.
=Diagnosis.=—Hereditary tendency and persistent hemorrhage from slight
injury.
=Prognosis.=—In a few cases the tendency to bleed gradually diminishes
until at last it entirely ceases. The younger the subject the more is
it liable to prove fatal. In the majority of cases death occurs between
the first and eighth years. After maturity the chances of an attack are
much lessened.
=Treatment.=—Members of the bleeder’s family, particularly the boys,
should be guarded against traumatic influences, and operations of
all kinds should be avoided. Outdoor exercise, fresh air, bathing and
plain nourishing food, in fact, the hygienic surroundings, and all food
should be carefully watched so that the threatened subject may become
strengthened and hardened. Marriage should be discouraged, especially
with the daughters, as it is through them the tendency is propagated.
Possibly, coupled with the foregoing prophylactic treatment, a
stimulation of the glands of elaboration of the blood will be of
service to build up the physical constitution of the patient. During
attacks absolute rest and the required symptomatic treatment should be
given. For resultant anemia the usual treatment is to be employed.
In severe cases direct transfusion should be considered.
FOOTNOTES:
[67] Billings, Focal Infection.
[68] Massachusetts Journal of Osteopathy, Jan. 1906.
[69] Journal of the American Osteopathic Association, November 1919.
[70] Diabetes, p. 90.
[71] Journal of the American Osteopathic Association, Oct., 1904.
[72] Journal of the American Osteopathic Association, Oct., 1904.
[73] Practical Medical Series, 1905.
DISEASES OF THE DIGESTIVE SYSTEM
Diseases of the Mouth
Stomatitis
=Definition.=—Inflammation of the mouth.
=Etiology.=—Chemical, mechanical, thermal or parasitic irritations;
secondary to disorders of the gastro-intestinal tract, scarlet fever,
measles and variola; cachexia, due to such diseases as cancer and
phthisis; dentition; artificial feeding; hot weather and poor hygienic
surroundings are the most common causes. Lesions to the innervation
and vascular supply of the mouth are found, principally, in the upper
cervical vertebræ, occasionally in the upper dorsal vertebræ and
corresponding ribs.
=Varieties.=—Catarrhal, aphthous, ulcerative, parasitic, gangrenous.
Catarrhal Stomatitis
=Etiology.=—Most common in infants and children. Hot and irritating
substances; secondary to diseases of the stomach, to measles, scarlet
fever and variola; difficult dentition; alcoholic or tobacco excesses.
Hazzard says in all cases of stomatitis “there is generally lesion to
the bony or other tissues in the cervical region (sometimes also in the
upper dorsal), which deranges vasomotor control of the tissues of the
mouth and tongue, obstructs venous return, weakens the tissues and lays
them liable to the effects of some particular irritant, local or in the
system, but there is, generally, lesion affecting the gastro-intestinal
tract which is the real underlying cause of the trouble.”
=Symptoms.=—Diffuse, red swelling of the mucous membrane, heat and pain
in the mouth, increased flow of saliva, fetor of breath, restlessness
and languor. In children there is a disinclination to nurse and a
slight fever may be present. The sense of taste is blunted and there is
commonly a bitter taste in the mouth. The neck glands are enlarged.
=Treatment.=—Removal of the exciting cause is the most important point
in the treatment. Good hygienic conditions must be enforced. The
mouth should be kept clean. Wipe it out at frequent intervals with a
soft piece of absorbent cotton and cold water. A borax solution is
frequently used. Attention should be paid to the diet and secretions.
Light but thorough treatment of the upper cervical region is to be
given, with careful attention to the tissues about and below the
angles of the jaw, so that the innervation, blood and lymphatic supply
may be equalized.
Aphthous Stomatitis
(CANKER)
This disease is characterized by little, painful, grayish-white spots
upon the superficial layer of the mucous membrane. They consist,
primarily, of an exudate of fibrin and wandered-out leucocytes. It
is principally a disease of childhood. Among the common causes are
difficult dentition, disorders of digestion and uncleanliness of the
mouth, such as neglect to cleanse the child’s mouth after nursing. It
may be a symptom of measles or of local diseases.
Probably the innervation to the region of the little grayish-white
spots or canker is obstructed at some points by a disordered tissue.
The lesion may be mechanical or it may arise from a disordered
digestion. If one is able to locate such a lesion and remove it, a cure
will be hastened. The seat of the infection is the internal surface of
the cheeks, gums, roof of the mouth, tongue and lips.
=Symptoms.=—There is redness of the mucous membrane of the mouth,
followed by the appearance of the vesicles with a red areola. Pain
in the mouth and an increased flow of saliva occur. Mastication,
deglutition, and even speaking, may be painful. This condition is
followed by sleeplessness, feverishness, diarrhea and fetor of the
breath.
=Treatment.=—Removal of the cause, as in other varieties of stomatitis,
is paramount. Give attention to the food. The milk should be
sterilized. The disordered digestion should be corrected at once. All
secretions must receive prompt attention. The child should be nursed at
regular intervals. Locally, keep the parts clean and carefully treat
the innervation.
Ulcerative Stomatitis
This is a disease of children, although it may not be limited to them,
as it occasionally occurs in epidemics and affects all ages. It occurs
chiefly in the families of the poor and in places where the hygienic
surroundings are bad, the food poor and personal cleanliness lacking.
It may begin as an aphthous stomatitis. Often sufferers from severe,
acute diseases are subjects of attack.
=Symptoms.=—The gums of the lower jaw are chiefly affected. They are
at first congested, swollen and bleed readily. Pain is increased by
mastication and deglutition, the mouth is hot, the breath fetid, the
saliva dribbles and the digestion and bowels are disordered. The ulcers
may appear at various points upon the cheeks, lips and tongue; the
deposit is yellowish-gray.
In the more severe cases the gums are spongy and the teeth are
loosened. In proportion to the constitutional disturbances, fever and
enlargement and tenderness of the submaxillary glands occur. Even
necrosis of the bone may follow.
Parasitic Stomatitis
(THRUSH)
The exciting cause is a fungus known as Laccharomyces albicans. It
is claimed that a catarrhal stomatitis is the soil upon which the
fungus develops. Parasitic stomatitis is chiefly a disease of nursing
children and is promoted by unhygienic conditions. It is seldom seen
after ten years of age, occurring in adults only in the last stages of
consumption, cancer, and severe chronic diseases.
=Symptoms.=—Upon inspection there are seen numerous milk-white
elevations. These appear first about the angles of the mouth, soon
extending to all parts of the mouth, and in a few cases, even to the
pharynx and to the esophagus. When removed bleeding points are left.
The general symptoms of stomatitis are present—pain upon mastication
and swallowing; fetid, hot breath; increased saliva; increased
temperature; restlessness; swollen lips and disordered digestion occur.
=Diagnosis.=—The microscope will remove all doubt as to the nature of
the affection. In aphthous stomatitis the ulcers are preceded by the
formation of vesicles.
=Prognosis.=—Is favorable in the majority of cases.
=Treatment.=—Hygienic measures, absolute cleanliness, correction of
the disorders of the gastro-intestinal tract and local treatment as
in other forms of stomatitis, is the required treatment. A boric acid
solution will be found beneficial.
SPINAL LESIONS AND THEIR RELATION TO DISEASES OF THE GASTRO-INTESTINAL
TRACT
Acute Gastritis, Chronic Gastritis, Gastric Neurosis, Gastric and
Duodenal Ulcer.
By CHARLES J. MUTTART
The instant relief that Osteopathy can give in acute indigestion is
one of its outstanding achievements. It impresses the patient and
his friends with a deep conviction of the superiority of osteopathic
therapy. The results in these cases are not, in any sense, a matter of
chance. They follow logically from the osteopathic viewpoint, teaching,
reasoning, and practice. In dealing with the manifestations of disease,
such as heredity, onset, course, duration, subjective and objective
symptoms, etc., and in the effort to differentiate cause from effect,
and to reconstruct a mental picture of the sequence of cause, effect
and sequelæ, the osteopath has the advantage of binocular vision in
that he recognizes two distinct pathologies cooperating to produce the
symptom complex, syndrome or disease which he is called upon to treat.
One pathology is to be found in one or more of the vertebral and rib
articulations and the immediately adjacent or corresponding segments
of the spinal cord. The other is in some one or more of the organs or
tissues connected with the pathological segment or segments of the cord.
=The function of the joint is MOTION.=—Unrestricted normal range
of motion is essential for the normal function of all parts of the
articulation as well as for the nutrition of the nerve mechanisms
immediately adjacent. When a spinal articulation ceases to perform
its function all of its parts are more or less impaired, muscles
atrophy, ligaments lose their tone, and circulation to and from the
spinal segment is interfered with because action is a large factor in
promoting the flow of blood and lymph and maintaining normal stimulus.
As a result of this spinal pathology, internal organs and tissues,
supplied by nerves arising in the segment that is in lesion, will be
variously disturbed in their function.
Dr. Carl P. McConnell says: “My observation of lesioned animals so
far as the digestive organs are concerned is that the lesion affects
the reflexes of and through spinal and sympathetic ganglia so that
the vasomotors are involved with a consequent hyperemia of the
submucous coat. This means involvement of the endothelial layer of the
blood-vessels, diapedesis, derangement of the secretory function and
disturbance of the motor mechanism, all of which lead to functional
upset and disturbance.”
The dominant part played by the osteopathic lesion as a causative
factor in acute and chronic diseases of the alimentary canal becomes
increasingly evident as clinical observation and laboratory research
permit a more thorough appreciation of the anatomy and physiology
of the parts involved. The abnormal stands out more clearly from
the normal. Finally, the task of restoring normality is becoming a
clear-cut problem to which the correction of the osteopathic lesions
furnishes an almost complete solution.
The normal alimentary canal transports food, macerating it, mixing
it, and treating it with various chemicals and enzymes on the way,
breaking it down physically and chemically, and absorbing from it
such end-products as are needed to maintain metabolism. The abnormal
alimentary tract may be at fault in any of these functions. This
delinquency is generally traceable to a mechanical origin. Correction
of the mechanical deviation is followed by restoration of normal
function except in cases where extensive tissue changes have occurred.
=Thorough mastication= is essential to good digestion. Any dental
defects or deficiencies should be corrected. =The temporo-mandibular
articulation= should be examined, and full free motion restored if
lacking. The muscles on the affected side are softer than on the sound
side. Tonic spasm rigidly closes the mouth. It may be due to tetanus,
caries of the lower teeth, cutting of the lower wisdom tooth, or other
irritations to the sensory branches of the inferior maxillary nerve.
There is enough space back of the wisdom teeth to pass a catheter to
administer food.
=The tongue= assists in mastication and deglutition and is the seat
of most of the nerves of taste. The hypoglossal nerve, which supplies
it, leaves the skull through the anterior condyloid foramen and may
be impinged there or lower in its course. =Lesions of the occiput and
upper cervical vertebræ= and obstructions to the lymphatic drainage
at the angle of the jaw may cause pressure on this nerve and cause
disturbances in the movements of the tongue, atrophy, swelling, etc.
Swelling may be due also to endocrine disturbance, constitutional
diseases, anemia, glossitis, local irritants, injuries, etc. Pressure
may be made on the hypoglossal nerve behind the angle of the jaw.
=The special sense of taste= plays an important role in normal
digestion. The lingual nerve supplies the anterior two-thirds of the
tongue with taste. The sense of taste may be lost, impaired, perverted
or otherwise abnormal.
The sense of smell plays an important part in our appreciation
of flavors, and when it is impaired by colds, adenoids, or other
affections of the nose or pharynx, the sense of taste is measurably
impaired. =Normalization of nose and pharynx= restores the sense of
taste in such cases. Impairment or loss may also be due to lesions
of the chorda tympani, or glosso-pharyngeal nerves. Lesions of the
mandible, hyoid, occiput or upper cervical nerves, parotid disease or
obstructed lymphatic drainage behind the angle of the jaw may cause
pressure directly or indirectly on the glosso-pharyngeal and chorda
tympani nerves. Perversion of taste occur in pregnancy, hysteria,
epilepsy and insanity.
=Foul taste=, fetororis in the mouth is frequent in pneumonia, typhoid
fever, peritonitis, septicemia and other severe fevers; also after
ingestion of pungent foods or strong drugs; in constitutional diseases;
as a result of inattention to oral hygiene, excessive smoking, mouth
breathing at night, furred tongue, etc. It clears up on removing the
cause.
=Furred tongue= occurs in gastritis, fevers, and a variety of other
conditions. The fur is composed of broken down epithelium which would
normally be removed by friction with solid food. When none is taken,
the fur accumulates. When blood or hematin becomes mixed with the
broken down epithelium, the fur is brown. Ordinarily it is white.
=A clean red tongue= is frequently found in hyperacidity. It is
probably due to vasodilatation due to hyperactivity of the autonomics
or inhibition of sympathetics. The sympathetic supply is from the
=superior cervical ganglion=. It may be affected by lesions of the
occiput, atlas, axis and third cervical vertebra, of the hyoid, by
anterior cervical muscular contractures, by obstruction to venous and
lymphatic drainage and blood supply. Correction of the lesions named
and normalization of the other structures involved will usually restore
the tongue to normal condition.
=The salivary glands= have a two-fold innervation. The thin, full,
watery, salty secretion is produced by activity of the cranial
autonomic fibers; the sparse, viscous secretion containing the organic
elements, ptyalin, etc., is produced by the sympathetics. =The
sympathetic nerve supply= is from the middle and superior cervical
ganglia and can be disturbed by lesions affecting them as mentioned
above. The secretion of ptyalin may be disturbed by any lesion from the
fifth dorsal up.
It must not be forgotten that a =posterior occiput= draws the superior
cervical ganglion back against the axis and third cervical with
just as much pressure as is exerted by an anterior atlas or third
cervical. This pressure or stretching tends to inhibit it, preventing
vaso-constriction and permitting vasodilatation of the internal
carotid artery and its branches and congestion of the parts supplied,
mid-brain, cerebrum, etc.
If, for any reason, the venous drainage from the lateral sinus into
the internal jugular vein, or the ebb and flow of the cerebrospinal
fluid between brain and cord, is reduced or hampered, an extra burden
is thrown on the cerebral veins and sinuses, and the intra-cranial
pressure is raised at each heart-beat, ultimately producing pressure
on the meninges and causing violent headache over the fifth and tenth
cranial nerves which supply the meninges with sensation. These nerves
are intimately connected with the digestive system. Any increase of
intra-cranial pressure causes increased irritability and hyperactivity
of the cranial nerves, many of which are concerned with various
functions of the digestive system. Moreover, the nuclei of these nerves
lie on the floor of the fourth ventricle which is supplied mainly by
the vertebral arteries and the basilar artery. Lesions of the cervical
vertebræ affecting the plexus on the vertebral artery or filaments to
it from the upper parts of the cervical gangliated sympathetic cord,
may impair the blood flow through the vertebral arteries and cause
similar increased irritability of the nerve cells in the medulla,
mid-brain and cerebellum. Such disturbance is reflected in awkward
movement, hyperesthesia, and symptoms due to increased irritability of
the autonomic nerves such as slow pulse and respiration, watering of
the mouth, hypersecretion and hypermotility of the gastro-intestinal
tract, rapid digestion and poor assimilation, vasodilatation,
impoverished blood, and so through a vicious cycle back to still
greater impairment of nutrition to the nerve cells within the cranium.
Until the lesions are corrected, the condition becomes progressively
worse till exhaustion occurs.
Ordinary medical hygiene can do little or nothing. The palliative
remedies employed simply mask the symptoms, or actually accelerate the
destructive process. Lesions that irritate the cervical sympathetics
would cause vaso-constriction and give rise to opposite symptoms,
namely, cerebral ischemia, decreased flow of saliva, atony of stomach,
lack of digestive juices, sluggish intestinal peristalsis, rapid
pulse and respiration, etc. Correction of the lesions and restoration
of normal blood supply and drainage to the brain and removal of any
lesions tending to inhibit the sympathetics from the fifth dorsal up,
will usually in a short time restore the activity of the salivary
glands to normal. The otic and sphenopalatine ganglia can be disturbed
by abnormal conditions within the pharynx. These must be corrected when
found.
=Deglutition=, or swallowing, is a very rapid, highly complex movement.
It takes not more than a second for the food to cross the pharynx. The
soft palate and larynx are raised to close off the air-way, making the
food-way practically continuous for the second needed to complete the
transfer of the food across the air-way. The tongue is pressed against
the roof of the mouth and the mylohyoid contracts vigorously and shoots
the bolus of food across the pharynx. Bolting the food leads to serious
digestive disturbances, not the least of which is the loss of the
normal reflex which prevents swallowing unprepared food. When lost,
this reflex can be restored by thorough mastication for three or four
months.
The voluntary part of swallowing is performed by the motor portion of
the fifth cranial and the hypoglossus. The involuntary part involves
afferent impulses over the superior laryngeal and efferent impulses
over the inferior laryngeal. The levator palati which raises the soft
palate is probably supplied by the spinal accessory nerve through
the pharyngeal plexus. This nerve can be affected by lesions of the
occiput, atlas, mandible and hyoid, and by any obstruction to lymphatic
drainage which increases pressure behind the angle of the jaw. In
paralysis of the levator palati, as =after diphtheria= or other
peripheral neuritis, fluids regurgitate through the nose during the act
of swallowing. The raising and closing of the larynx is accomplished by
the superior and recurrent laryngeal nerves by way of the pharyngeal
plexus. Pain in swallowing is generally due to some inflammation or
infection of the tonsil or pharynx. This does not occur when everything
is normal from the fifth dorsal up.
The second and third stages of swallowing occur in the =esophagus=.
The esophagus receives esophageal branches from the vagus, carrying
autonomic fibers which contract its longitudinal muscles and dilate
its arteries. It also receives sympathetic impulses from the plexus
on the arteries which supply it. These sympathetic impulses convey
vaso-constriction and constriction of the circular muscles of the
esophagus. Any lesion from seventh cervical to ninth dorsal might
affect the esophagus; probably fifth dorsal is the most nearly
specific, as the heartburn which results from regurgitation into the
esophagus is usually localized there.
Lesions of the upper six dorsal vertebræ interfere with digestion and
nutrition in another vital way by reducing the activity of the lungs
and consequent =intake of oxygen= into the system. If there is not
sufficient oxygen to oxidize the proteins to amino-acids there will be
harmful products left for the tissues to neutralize. Lesions of the
third, fourth and fifth cervical affecting the =phrenic= may have a
like effect. Sub-oxidation must be noted when present and treated by
removing lesions affecting respiration, by deep breathing exercises,
and by diet rich in the needed mineral salts, and properly balanced.
An improperly balanced diet changes the structure of the tissues and
amounts in effect to an osteopathic lesion which causes disturbed
function. It must be searched for, found if present, accounted for,
corrected and kept corrected to obtain maximum therapeutic results.
The stomach, intestines and rectum are intimately related with the
other abdominal viscera.
It will therefore be readily seen that any disturbance of the liver,
gall-bladder, pancreas, spleen, duodenum, pleura or peritoneum will
disturb the function of the stomach, and that any disturbance of any
organ will disturb the function of the intestine. In fact, clinically,
it would seem that the majority of cases can be accounted for by
the lesions found, the stomach or intestinal disturbances which are
regarded as reflex from some other organ, being in reality caused
by the same lesion as disturbed the organ which first manifested
disturbance.
Going more deeply into the nature of the mechanism whereby symptoms
of gastro-intestinal disturbance are produced, we find that the
alimentary tract has an ingenious conveyer mechanism with a number of
sphincters. These are operated by intrinsic sympathetic or myenteric
nerves, called plexuses of Meissner and Auerbach. In conveying food,
impulses are passed from one portion of the tract to the next over
these myenteric arcs. Normally the peristaltic movement is always
forward because the point of highest irritability is at the proximal
end. There is an exception to this rule in the ascending colon, where
antiperistalsis occurs normally. When the irritability of a distal
point of the alimentary tract becomes greater than the more proximal
points, an antiperistaltic wave is set up causing vomiting. The
myenteric activities are regulated by the autonomic impulses over the
vagus, and by the sympathetic impulses over the splanchnic nerves. The
autonomics contract the longitudinal muscles, dilating and shortening
the tube. They also stimulate secretion of digestive juices and fluids
and mucus and dilate the blood-vessels. The sympathetics contract
the circular fibers and sphincters, narrowing and lengthening the
tube, retarding the food, inhibiting the secretions and constricting
the blood-vessels. The myenteric reflexes can continue after the
vagi and splanchnics are cut. The vagi simply stimulate them and the
splanchnics inhibit them. The pathways are from the coeliac plexus
where the vagi and splanchnics meet with various other plexuses on
the arteries and following the courses of the arterial supply to
the minutest parts of each organ. Each cell is surrounded by nerve
fibers. Visceral-afferent fibers over both vagi and splanchnics convey
impulses to the cord segments and medulla which modify the systemic
blood supply, drawing blood from the head and surface by constricting
their arteries during digestion and filling the abdominal arteries.
If opposite impulses should be received drawing blood away from the
abdominal arteries, digestion would be interfered with. Any lesion or
other condition causing hyperirritability or overstimulation of the
vagus will result in overstimulation of the myenteric nerves, with
vasodilatation, hypersecretion, contraction of the longitudinal coat,
widening and shortening of the digestive tube, sluggish peristalsis but
rapid movement of food through the sphincters, incomplete digestion
and undernourishment. Inhibition of the splanchnic nerves will produce
a like result. The opposite condition would come about as a result of
inhibition of the impulses over the vagus to the myenteric nerves, or
of overstimulation of the splanchnic nerves.
Inhibition of the splanchnic nerves may be secured by extreme flexion
of the spinal column. This raises the cord in the spinal canal,
lengthens it, stretches or draws on the nerve roots and vessels,
squeezes the fluid out of the cord, and inhibits the splanchnics in two
ways, first by a partial anemia or ischemia of the cord, and secondly
by direct traction of the visceral afferent fibers in the posterior and
anterior roots.
Conversely, stimulation of the splanchnic nerves may be secured by
complete extension of the spinal column. This lowers the cord in
the spinal canal, shortens it, releases the strain on the nerve
roots and vessels, flushes the cord with blood, and tones up the
sympathetic impulses in two ways, first by increasing their relative
and absolute nutrition, through richer supply of richer blood, and
secondly by releasing the nerve roots from strain, permitting free
entry of afferent impulses over the posterior roots, and free exit of
visceral-efferent impulses over the anterior roots.
Any lesion, inasmuch as it limits or alters the normal motion in a
joint, produces an exaggeration or diminution of the normal spinal
curves, and more or less lateral curvature. The altered equilibrium
thus produced affects the viscera in three ways: 1. Mechanically, by
pressure, gravity, altered position of ribs, vertebræ, diaphragm, etc.;
2. Reflexly, influence on nerves to and from affected segment; 3.
Directly, by interference with nutrition of nerve cells by hyperemia or
ischemia.
There is always a functional kyphosis in visceroptosis or
splanchnoptosis. The nerves in the cord are inhibited. The skeletal
muscles are hypotonic, allowing the functional kyphosis to occur,
and the viscero-motor nerves are inhibited, allowing the abdominal
viscera to become hypotonic and sag out of place within the abdominal
cavity. The ribs are held up by the cervical fascia, and the abdominal
muscles are held up by the ribs. The hypotonic condition extends to
intercostals and abdominal muscles, with the result that the abdominal
muscles are unable to play their part in maintaining the viscera in
their proper places. The contraction or tonus of the abdominal muscles,
the external and internal oblique, transversalis, rectus abdominis,
diaphragm and levator ani, maintain the viscera firmly in position. It
is only when the muscles of the abdominal wall have lost their tone
that any strain or weight is thrown on the peritoneal and vascular
supports. The inhibition of the restraining sympathetic impulses via
the splanchnic nerves, allows hypersecretion and hypermotility of the
alimentary tubes and further complicates the clinical picture by a
colicky diarrhea or spastic constipation.
There are eight sphincters of circular unstriped muscle in the
alimentary tract. Inhibition of sympathetic supply or increased
autonomic supply causes sphincter insufficiency, overstimulation by
sympathetic impulses or an insufficient supply of balancing autonomic
impulses causes sphincter spasm, stasis, vomiting, fermentation,
putrefaction, auto-intoxication. At each of these sphincters food is
held back and controlled till the proper time has elapsed and the
proper chemical environment is prepared for it in the next portion
of the tract. Normal function of these sphincters is absolutely
essential to normal metabolism and nutrition. The upper esophageal
sphincter controls the entrance to the esophagus; the cardia controls
the entrance to the stomach, the pylorus controls the entrance to
the duodenum, the X-Ray shows a duodenal sphincter that controls the
entrance of food into the jejunum. Here the food enters the long
tract of the jejunum and ileum which measures twenty-five feet when
the longitudinal muscles are relaxed and the circular muscles tonic,
and which a short time later may measure only fifteen feet when the
longitudinal muscles are contracted and the circular are relaxed. This
section ends at the ileo-cecal valve, which controls the entrance
of food into the cecum. There is the mid-colic sphincter about the
junction of the proximal third with the distal two-thirds of the
transverse colon, and the recto-colic sphincter which controls the
passage from the sigmoid to the rectum. The rectum ends in the internal
sphincter ani. There is some evidence of a ninth sphincter, the
mid-gastric at the point where the peristaltic waves of the stomach
begin. Absorption takes place mostly from the ileum and jejunum and it
is worthy of note that four of these sphincters hold the food up on its
way into this part of the tract, and four of them hold it back on its
way out. Any lesion may affect one or other of these sphincters. It
is believed that antiperistalsis from the mid-colic sphincter to the
cecum during digestion is normal permitting more complete absorption of
nourishment. Yet here, after absorption is complete, and at all times
elsewhere in the alimentary tract, peristalsis is normally forward
because the point of highest irritability is at the upper esophageal
sphincter and the irritability decreases as the tract is further from
the esophagus.
When the splanchnics are inhibited and the vagus autonomic impulses are
normal or increased, the intestinal sphincters from the pylorus down
may all be incompetent, so that food passes along too rapidly to be
properly digested and absorbed. This results in undernourishment.
Any lesion anywhere in the body will affect =peristalsis=. It begins
at the lower third of the stomach where it joins the pyloric portion
and goes forward to the internal sphincter ani, being modified in its
course by local conditions. Compensation may be established. Many cases
of diarrhea and constipation are thus to be accounted for. =Diarrhea=
is a symptom due to vasodilatation, hypersecretion and relaxation of
the circular muscles especially at the sphincters. When these three
factors are cleared up by correction of the lesions and hyperextension
of the spine, the diarrhea stops unless some other factor is at
work to irritate the myenteric nerves or to excite the autonomics
or inhibit the splanchnics. Lesions from the sixth dorsal down are
usually accompanied at first by some diarrhea, which afterwards
becomes constipation, through loss of tone in the longitudinal muscles
especially in the distal part of the colon. In these cases, correction
of lesions, and extreme flexion of the lower dorsal and lumbar spine
will give relief while the body is returning to normal.
When gastric digestion begins, simultaneous action is set up in the
ileum. When disease of the cecum, appendix or ascending colon is
present, there is contraction of the ileo-cecal valve causing stasis
of the lower ileum and disturbed or retarded action of stomach and
duodenum. These reactions are brought about by impulses to and from the
myenteric plexus. The sympathetic and autonomic nerves affect the motor
system of the alimentary tract not directly but through the myenteric
or Auerbach’s plexus.
The =external sphincter ani= muscle is supplied by the pudendal
nerve from the third and fourth sacral segments. It is in a state
of tonic contraction, and having no opposing muscles keeps the anal
orifice closed. The autonomic supply to the longitudinal muscles in
the descending colon and rectum is from the second and fourth sacral.
Inhibition here will, therefore relax the longitudinal muscles and
external sphincter and permit free peristalsis in the descending colon
and rectum. Pelvic disturbances may affect these nerves, or pressure
due to visceroptosis, etc. The circular muscles of this section are
supplied from the lumbar cord. They may be affected in any lumbar
lesion, with the end result of spastic constipation by reason of a
shortened markedly distended descending colon, sigmoid and rectum, and
little peristalsis because of inhibition of the circular fibers, and
contraction of the external sphincter ani.
The fundus of the stomach, lying in the left dome of the diaphragm,
always contains a cushion of air which supports the left dome of the
diaphragm, as the convexity of the liver supports the right. Normally
the air is regulated and causes no symptoms. A lesion, usually of the
mid-dorsal or lower dorsal segments may inhibit the circular fibers
and permit distension, which becomes enormous when the pylorus is
obstructed. The shortness of breath, palpitation of the heart, etc.,
accompanying this distension are probably due to pressure on the heart
and lungs from which the stomach is separated only by the diaphragm.
Eighth, ninth and tenth dorsal lesions play a large part in peptic
ulcers by permitting hyperemia, hypersecretion, and lowered vitality
of the mucosa, and pyloric incompetence or spasm, because the pylorus,
pyloric end of the stomach and first part of the duodenum get their
chief sympathetic supply from the ninth and tenth dorsal segments of
the cord. The tenth vertebra is more freely movable than the higher
dorsal joints and is therefore more frequently in lesion, which helps
to account for the greater frequency of duodenal ulcer.
The main sympathetic supply to the appendix seems to be derived from
the eleventh dorsal segment. The appendix has the same motor and
secretory mechanism as the rest of the alimentary tract but is richly
supplied with lymphoid follicles. One of the twigs from the eleventh
dorsal nerve pierces the rectus muscle to supply the skin at McBurney’s
point, thus explaining the great frequency of pain and cutaneous
hyperalgesia at this situation in appendicitis. Lower dorsal and upper
lumbar lesions are unquestionably causes of many cases of appendicitis
and other obscure diseases traceable to appendicitis. Correction of
these lesions has restored the appendix and related structures to
normality in hundreds of cases.
Sensory reflexes are shown in hyperalgesia and pain or tenderness in
the abdominal skin and muscles and the parietal layer of the peritoneum
from the ensiform cartilage to the pubes in an area extending about two
inches on each side of the mid-line, corresponding to the distribution
of the twigs of the lower six thoracic nerves which supply sensation to
this region. =Esophageal= disturbance at the cardia causes pain in the
region supplied with sensation by the fifth and sixth dorsal, near the
ensiform. =Gastric derangement= causes pain midway between the ensiform
and umbilicus, which radiates to the left, in the area supplied by the
eighth dorsal. =Hepatic disturbance= causes pain on the right of the
median line, radiating to the right in the sensory distribution of the
ninth dorsal. =Intestinal pain= is located in the sensory distribution
of the tenth dorsal nerve in an oval area around the umbilicus. Pain
due to =duodenal ulcer= is sharply localized at a point about an inch
or two above and to the right of the umbilicus where twigs of the tenth
dorsal nerve come to the surface. This point corresponds closely to the
normal position of the underlying duodenum, though the duodenum may be
displaced, and the sensitive spot remain at the same point. The pain
from =fundal gastric ulcer= or =carcinoma= is usually localized sharply
about an inch or two to the right of the median line midway between
the ensiform and umbilicus, at the spot where the twigs from the
eighth dorsal nerve pierce the rectus and come to the surface. In the
disease of the =pylorus=, reflex pain is lower; of the =cardiac end=,
higher. The reflex pain at McBurney’s point in =appendicitis= has been
referred to, but it must be borne in mind that pain from disturbance
in the =colon= also shows in the sensory distribution of the eleventh
dorsal nerves midway between the umbilicus and pubes. Pain may also be
referred to areas supplied in the back by the corresponding segments.
These reflex pains can usually be stopped by inhibiting along the spine
corresponding to the sensory area affected. This reduces the impulses
entering the posterior roots and lowers the irritability of the segment.
The =motor reflexes= from gastro-intestinal disturbances result in
muscular contractures of spinal, abdominal and other muscles supplied
by motor nerves arising in the anterior horn of the segment which
innervates the part of the viscus that is affected. Stomach, liver,
gall-bladder, pyloric and duodenal disturbances cause increased tone,
contraction, contracture and rigidity of the rectus muscles above
the umbilicus, for instance, and the other viscera contract it in
lower portions. More important are the extreme contractures of the
musculature of the back which is supplied by the segments which supply
the affected part of the viscus. These contractures produce some
distortion and loss of motion in spinal joints and thereby produce the
same effects as primary lesions, causing widespread disturbance which
persists until the spinal musculature is normalized. In =colic=, the
lumbar segments being involved, there is marked contraction of the
ilio-psoas which causes the characteristic drawing up of the thighs
on the abdomen, while the extreme contraction of the rectus abdominis
draws the thorax down.
Most persistent vomiting may arise reflexly from other organs as
in so-called biliousness, jaundice, pregnancy, brain affections,
appendicitis, onset of acute infectious diseases, alcoholism,
sea-sickness, colic, hernia, intestinal obstruction, migraine,
shock, and anesthesia. Irritation of any sensory branch of the vagus
or of nerves which connect with it in the medulla, or reflexly
from consciousness via the cerebral cortex, as in the case of
nauseating sights, smells, tastes, as well as irritation from any
viscera innervated from the sixth dorsal down, may overstimulate
the corresponding efferent nerves going to parts of the alimentary
tract supplied by that segment, increase its irritability and start
antiperistalsis. Similarly disturbances in almost any viscus may
reflexly disturb the normal balance between sympathetic and vagal
autonomic stimuli resulting in hypersalivation, hyperchlorhydria,
pylorospasm, distension, gastric atony, gastrosulcorrhea,
enterocolitis, spastic constipation, achylia, or colicky diarrhea.
In these cases, the derangement of the viscus reflexly disturbs the
alimentary tract through central nerve connections. Correction of the
primary trouble is followed by removal of the reflex symptoms. In this
connection it is important to note that the visceral reflex symptoms
may arise from irritation of the alimentary tract by improper diet,
poor cooking, or wrong combinations. Carbohydrates digest quicker
than proteins, and these more rapidly than fats. Food is handled by
the fundus in the order in which it was swallowed. If the fats are
swallowed first, the starches may be held up for five or six hours,
subjected to the acid stomach secretions and allowed to ferment causing
distension, which reflexly produces a variety of symptoms.
Mental exertion, strong emotions, heavy physical exertion, interfere
with the function of the alimentary tract and set up disturbances in
the balance of sympathetic and vagal autonomic impulses, through the
nervous reflexes via the cortex, and through the demand for blood,
which impoverishes the abdominal circulation at a time when it needs
all the blood it can get. The ischemia produced in this way has about
the same effect as ischemia produced by a spinal lesion. Conversely,
disturbances of the alimentary tract produce profound changes in
character and personality, by reflexes to the cerebral cortex causing
dullness of perception, in all the senses, poor memory, sluggish
thought, erratic judgment, irritable disposition, fear, worry, lack
of ambition, indecision, lack of energy, vacillation, and finally a
psychosis in which manic depressive symptoms are balanced by paranoiac
symptoms.
The alimentary tract is so intimately bound up with the whole stream of
vital activity, whether vegetative, sensorimotor, or psychic, that any
disturbance of body or mind is likely to affect it in some part, and
conversely any disturbance of the alimentary tract is bound to affect
all the rest of the body and the mind. A satisfactory classification
of its diseases is therefore difficult to make, but the one here
adopted is probably the best for the purpose. The early stages of
gastro-intestinal diseases are often so similar that it is nearly
impossible to differentiate them with certainty; the classification
is therefore based on the clinical picture and pathology of advanced
stages. Fortunately, with the exception of cancer, diseases treated in
the early stages usually clear up when the lesions are corrected, and
the necessary attention given to the other causative factors present.
Acute Gastritis
Acute dyspepsia is one of the frequent disorders of the stomach. It
may occur as an early symptom of an infectious disease, but very often
it is due to some non-specific irritation. The usual exciting causes
are errors of diet, over-indulgence in improperly cooked and highly
seasoned food, or food that has been spoiled, such as meat, fish and
milk, or over or under ripe fruit. Food that is either too hot or too
cold may develop an attack. Alcohol is a common cause in those not
accustomed to its use. Overuse of tobacco may bring on an attack. Many
acute “bilious” attacks are brought about by some mental shock or
excitement at the time of taking food, for it has been shown by the
researches of Pawlow that both gastric motion and secretion are altered
by mental irritation during digestion.
Unquestionably osteopathic lesions of the splanchnics and vagi are
important predisposing factors. These lesions produce a lowered
resistance of the tissues, which will frequently explain why certain
exciting factors that will initiate an attack in one individual will
not do so in another. A healthy mucosa will not be so readily irritated
by either indigestible or partly decomposed food.
Osteopathic experimental work reveals that the vertebral and rib
lesions readily affect both the spinal nerves and the sympathetic
ganglia, which is followed by vasomotor and trophic disorder to the
mucous and submucous coats of the stomach, as shown by eccymosis and
hemorrhage of the submucosa and beginning parenchymatous degeneration
of the free ends of the glands of the mucosa. Upon the other hand
irritation of the muscles from dietetic errors always causes more or
less contraction of the muscles in the upper and middle dorsal, which,
in turn, may produce through imbalance of tension and fibrositic
changes, constant interosseous lesions and thus be the cause of the
catarrh becoming chronic. This vicious cycle phenomenon should not be
overlooked. Viscero-motor, viscerosensory and viscerotrophic reflexes
may be factors in the pathogenesis of the osteopathic lesion.
=Pathologically=, the mucous membrane is more or less covered with
mucus. Upon removal of the mucus the membrane is found red and swollen,
and the epithelial cells of the glands are granular. This is especially
noted in the pyloric area. There are minute extravasations of blood and
hemorrhages of the mucous coat, and infiltration of the submucous layer.
=Symptoms.=—Acute gastritis occurs at all ages, so particularly in
children care has to be taken that the attack is not the beginning
of some infectious disease. A careful inquiry into the history, and
examination of the vomitus will usually make the diagnosis clear.
The sudden onset of nausea, vomiting, pain in the epigastric region
referred to the back and head, vertigo in some cases, if the infections
can be ruled out should leave no doubt as to the nature of the disorder.
Other symptoms are weakness, and chilliness which later if the attack
is severe, is followed by fever. The tongue is coated, the lips dry,
and there may be herpes. Belching of gas, constipation in some and
diarrhea in others, and dark colored urine are noticeable. There is
tenderness on palpation over both the stomach and splanchnic areas.
Examination of the stomach contents show deficient hydrochloric
acid, the presence of organic acids, bile and undigested food, and
considerable mucus.
=Diagnosis.=—In young children acute gastric indigestion is common,
though a casual gastritis is rare. In the former prostration,
vomiting, and undigested, greenish stools are noted. In some cases
there is no fever, while in others it may range from 102 to 105
degrees. In all cases care should be taken, as has been stated,
that the attack is not the beginning of some infectious disease.
Appendicitis, acute bowel constriction, pregnancy, uremia, meningitis,
gall-stone colic, and gastric crises of tabes dorsalis should be
differentiated. Most attacks of acute dyspepsia are over in twenty-four
hours. The prognosis depends upon eliminating the cause. The X-ray may
be of value in protracted cases.
=Treatment.=—If the case is seen early, emptying the stomach by induced
vomiting or the stomach tube is the first indication. If several hours
have elapsed and much of the stomach contents have passed into the
intestine, emptying the colon with an enema will commonly give quick
relief. Withhold all food for from twelve to twenty-four hours, or
longer if necessary. In some cases the sipping of hot water will be
beneficial, while in others pellets of ice in the mouth will give some
relief.
Whether or not there existed previous spinal lesions there will always
be found muscular tension and spinal rigidness during an attack of
acute gastritis. These should be corrected for immediate relief, but
what is of greater importance, if these acute lesions are not corrected
the patient’s recuperative forces are interfered with and recovery is
delayed. Then, also, these lesions tend to chronicity and predispose
to future attacks. Treatment should be given daily, or oftener if
special indications arise. Though the most common area that demands
attention is from the fourth to tenth dorsals, still the vagi nerves,
especially the right, should not be neglected. Lesions of the upper
three cervicals are the most frequent disturbances of the vagi.
=Vomiting= is a common and distressing symptom. Pathologically, it is
due to an antiperistaltic contraction of the stomach and a spasmodic
contraction of the diaphragm and the abdominal muscles. It is caused,
usually, by irritation of the vagus in the stomach, or in the pharynx
by irritation along the spine (particularly in the cervical and upper
dorsal regions), or to the sympathetic nerves or to various parts of
the body, or by direct influence of the brain. Relief can usually
be given by inhibition of the vagus in the occipital region or by
inhibition at the fourth or fifth dorsal vertebra on the right side.
In a few instances, placing the patient in the knee-chest position and
gently raising the abdominal organs gives relief. If this does not
suffice the stomach and colon should be emptied, providing the vomiting
is protracted. A frequently effective measure for nausea and vomiting
that can be carried out by the attendant, is the application of hot
fomentations to the dorsal spine.
=Flatulency= may be very distressing. The spinal treatment may be
sufficient to control this condition, or careful direct pressure for a
few minutes over the pit of the stomach. Adjustment of the lower ribs,
especially of the left side, may be effective. Occasionally the gas
can be passed into the intestines by careful inhibitory treatment in
the region of the eighth and ninth dorsals. The inhibitory treatment
causes relaxation of the pyloric orifice; also, inhibition of the left
vagus relaxes the pylorus. Inhibition at the sixth and seventh dorsals
relaxes the cardiac orifice, thus favoring the passing of the gas from
the stomach out through the esophagus.
In all cases subject to gastritis the dorsal spine should receive
considerable attention in order that recovery may be complete. The
habits of the patient should be thoroughly regulated and overfatigue
guarded against. And, also of special importance in recurring attacks,
is the fact that a number of cases present some derangement of the
biliary tract, or duodenum, or the appendix region.
=Diet.=—After twenty-four or forty-eight hours, if the attack has been
severe, albumin water may be given in small quantities; also whey,
milk, bouillon, and chicken or lamb broth. If there is no return of
gastric distress, add junket, custard, cornstarch pudding, gelatine,
dropped eggs, scraped beef, and white meat of chicken; vegetables
purees made with cream or meat stock are usually well borne at this
time. Foods containing much cellulose, fats and sweets should be
withheld until all symptoms have subsided.
Chronic Gastritis
It is unnecessary here to repeat the causes of acute gastritis, any
one of which continued over a long period of time will cause chronic
catarrh of the stomach, as it is sometimes called.
Spinal and rib lesions anywhere from the occiput to the coccyx, but
more particularly from the fourth to the tenth dorsal, will predispose
to chronic gastritis, the particular type and degree of local pathology
depending upon the exciting factor.
A commonly found _en bloc_ lesion is a flattening of the normal
convexity in this region, with more or less immobilization, shown by
attempting to reestablish the normal convexity through flexion.
In addition there may be single spinal or rib lesion in the same area,
or cervical lesions affecting the pneumogastric, which is the secretory
nerve to the stomach. (See chapter on the “Lesion and Its Applied
Anatomy.”)
=Pathology.=—Chronic gastritis probably never develops as such without
going through several preliminary stages beginning with alimentary
hypersecretion, or hypersecretion occurring only during the active
period of digestion. These are the cases usually classified as
hyperchlorhydria. At this time no actual pathology can be demonstrated
in the glandularis.
If the condition is not treated intelligently at this time the next
step will be periodic attacks of what is known as “hypersecretion
periodica chronica” followed by “hypersecretion continua chronica.”
The stomach contains abnormal amounts of gastric juice even after a
night’s rest. At this stage there is a transition from the functional
to the organic condition. All stages are characterized by an abundant
secretion of mucus.
If allowed to go on there will finally result a destruction of the
secreting cells known as Atrophic Gastritis or Achylia Gastrica in
which the stomach presents a smooth functionless appearance.
=Secondary Chronic Gastritis.=—Portal obstruction from any cause
predisposes to chronic gastritis. The most common of these is failing
compensation in heart lesions, which through back pressure causes
portal stasis; the same thing may follow obstruction in the liver
itself. Chronic gastritis is also a late accompaniment of the nephritic
trinity, kidneys, heart and arteries. It may also be associated with
diabetes, gout, anemia and other constitutional disorders.
Tuberculosis is commonly ushered in by symptoms of chronic gastritis.
We should be constantly on the alert to avoid the mistake so commonly
made of treating the stomach as an entity and overlooking the real
trouble in some other part of the anatomy.
It is probably safe to say that there are only two primary diseases of
the stomach, ulcer and cancer. All others are suspiciously associated
with diseased processes elsewhere, and when the spinal lesion is given
its full significance even these will be found to be directly traceable
to anatomical perversions somewhere within the mechanism of local
nutrition.
=Symptoms.=—These are governed by the stage of progress in which the
patient is seen. During the stage of hypersecretion of acid gastric
juice there will be vague feelings of distress, fullness and burning
in the stomach, and “heartburn” during digestion. When the stomach is
empty all symptoms will subside. Later there will be periods of a few
days or weeks when there will be more or less continuous distress with
some vomiting of highly acid gastric juice containing mucus.
When the condition has progressed to the stage of continuous
hypersecretion there will be continuous symptoms as above, but with
nausea, vomiting becoming more frequent especially late at night or in
the morning, always accompanied by sticky mucus.
Appetite is variable, there is often a disagreeable taste in the mouth
(the “dark brown” taste of the chronic alcoholic). Heart palpitation
and vertigo and other vagus symptoms are common.
=Diagnosis.=—On physical examination the stomach is found distended,
and in some cases displaced (gastroptosis). There will be diffused
tenderness on pressure over the whole organ which should help to
distinguish it from gastric ulcer or cancer in which the tenderness is
quite localized.
Chronic gastritis cannot be =positively= diagnosed without making a
gastric analysis. Many cases are wrongly diagnosed through neglect of
this very important procedure.
The cases in which gastric analysis should be made are so well stated
by Lockwood that we will take the liberty of quoting them in their
entirety.
“(1) Gastric analysis should always be made in every case of dyspepsia,
no matter whether these symptoms be apparently gastric or intestinal,
unless passage of the tube is contraindicated.
“(2) Gastric analysis should be made in every case of chronic diarrhea
that is not due to evident disease of the colon or rectum.
“(3) Gastric analysis should always be made in all cases of intestinal
toxemia, or recurring headache of toxic origin, and in patients who
complain of the symptom complex which is spoken of by the laity as
‘biliousness’.
“(4) Gastric analysis should be made in all cases of anemia and general
physical wretchedness without known cause and which are rebellious to
treatment.”
The finding of excessive gastric mucus intimately mixed with food
remnants is the chief differential point in the diagnosis of chronic
gastritis.
=Differential Diagnosis.=—A complete statement of differential
diagnosis by Kemp cannot be well improved upon.
“CHRONIC GASTRITIS.—No severe pain, no circumscribed spot, painful to
pressure; no hematemesis; no cachexia; no marked emaciation, except in
severe cases of long duration; free hydrochloric diminished or absent;
gastric mucus present; slow course.
“ULCER OF THE STOMACH.—Hyperchlohydria present, but not invariably
so; severe pain in the epigastrium with intervals free from pain when
stomach is empty; local tenderness which is circumscribed; dorsal
pain; hematemesis, or occult blood in the stool or gastric contents;
microscopic pus; no mucus; patient has appearance of suffering; no true
cachexia.
“CANCER OF THE STOMACH.—Age usually over forty-five; rapid course;
free hydrochloric acid usually markedly diminished or absent; lactic
acid present; pain generally continuous, but not so acute as in ulcer;
Boas-Oppler bacillus; cachexia; tumor on physical examination; small
amount of visible or occult blood; hematemesis much less than ulcer;
foul odor to vomitus at times present.
“ACHYLIA GASTRICA.—Slow course; scarcely any gastric juice; acidity
very low or entirely absent; absence of pepsin and rennin; usually no
mucus or lactic acid.
“These differential considerations apply to typic cases, and
the observer must be on the qui vive for various gradations and
modifications of these clinical pictures.”
=Prognosis.=—The outcome of chronic gastritis depends upon our ability
to locate and remove every factor in the etiology, the willingness
of the patient to cooperate and the patience and resourcefulness
of the physician. At best the progress is slow and one must expect
temporary setbacks usually due to failure of the patient to carry out
instructions.
=Treatment.=—The most successful treatment is prophylactic, but until
the public has been educated up to this form of economy we must begin
with conditions as we find them.
First get the patient’s confidence by making an intelligent
examination, a scientific diagnosis, and a reliable prognosis based
upon your findings. All lesions, bony, ligamentous, muscular and
psychic must be intelligently and carefully removed.
Specific lesions which would directly or reflexly interfere with the
nerve and blood to the stomach must be corrected.
The rigidness commonly found in the vertebræ and ribs of the splanchnic
area must be overcome first by specific adjustment, and the normal
flexibility maintained by teaching the patient proper exercises for the
purpose. This should include deep breathing with the spine flexed to
the limit, and the ribs fixed, by the patient reaching around as far
as possible and grasping the ribs as described by Dr. Harry Forbes.
This will tend to overcome the flat dorsal so characteristic in all
gastro-intestinal conditions.
Direct manipulation over the stomach has no particular value and may be
even harmful.
Inasmuch as nausea and vomiting and excessive gas formation are only
the result of hypersecretion we cannot expect to give more than
temporary relief except by methods which remove causes. Much comfort
may be given by inhibition in the splanchnic area. In severe cases
it may be necessary at times to wash out the fermenting, irritating
mass by gastric lavage. Outdoor life, frequent vacations and change of
occupation are often of decided benefit.
=Diet.=—Indiscretions of diet must be avoided and this cannot be too
positively impressed upon the patient. It is always best to make a list
of foods to be taken for breakfast, lunch and dinner and insist that no
other foods be taken without further instruction.
Just what these foods shall be depends upon the gastric secretions as
shown by gastric analysis. They should always be nutritious and given
in quantities sufficient to maintain nutrition.
The stomach should have rest and yet is expected to do its part in
the process of digestion. All foods must be given in a finely divided
form and well masticated to spare the stomach the mechanical effort of
grinding.
In hyperacid gastritis all foods of an irritating nature must be
positively prohibited. The classical breakfast of grapefruit, oatmeal,
ham and eggs and coffee will not do. Starchy foods must be reduced
owing to their tendency to ferment in the presence of highly acid juice
and the delay in the stomach due to the high acidity.
In subacid gastritis advantage must be taken of the fact that
carbohydrates digest well and proteins do not.
=Diet for Hyperacid Gastritis.=—Before breakfast: Wash the stomach with
warm water and an ounce of Phillips Milk of Magnesia, allowing the
water to remain in the stomach 20 minutes or a half hour, lying down
and turning from side to side on the face in order that the water and
magnesia may be brought in contact with all parts of the stomach.
For breakfast: Prunes, allowed to simmer for four hours, without
boiling, and put through a colander, to remove the skins. Soft cereals,
such as farina, cream of wheat, or wheatlet, thoroughly cooked, and
served with middle heavy cream, no sugar. Two eggs, soft boiled, or
poached. Zweiback, thoroughly masticated, with a liberal quantity of
butter. Cocoa (Phillips).
Luncheon: Puree of peas, beans or lentils, made with cream. Asparagus,
green peas, boiled rice, spinach chopped very fine, creamed carrots,
boiled onions, baked potato, well done. Chicken, boiled lamb or beef,
ground; oysters in any form but fried; fresh fish. Desserts: Choice of
junket, cornstarch, custard, rice pudding, floating island, gelatine or
tapioca.
Evening meal: Same as luncheon except substituting eggs for meat.
Cup of hot water before luncheon and dinner.
If patient requires quick building up give milk between meals and at
bed-time.
Gastric Neuroses
Gastric neuroses include =motor=, =sensory= and =secretory=
derangements. Though the sensory disturbance is often the most marked,
still motor and secretory symptoms are usually present. In other words
there is commonly a complex of the different forms.
Where gastric neuroses can be positively diagnosed, by a process of
elimination, there is no more plausible explanation than that of the
spinal lesion. The success of osteopathic physicians in treating
so-called “stomach trouble” proves conclusively the superiority of the
osteopathic method. A note of warning should be sounded, however, for
as diagnostic methods have become more exact it is found that many
cases which were formerly diagnosed as neuroses prove to be referred
from some organic change, such as infected gall bladder, appendix, tube
or ovary, tonsil, tooth or sinus. It has been proven that many cases
of sensory and secretory disturbances have entirely cleared up when
these causes have been removed. Though infection may play an important
role, still in some instances, especially gall bladder, duodenum and
appendix, the gastric neurosis may be simply due to a nervous reflex.
Gastroptosis, atony, and in many cases splanchnoptosis, has been
found to be the underlying cause of many hitherto unaccountable
gastro-intestinal symptoms.
Gastric crisis of locomotor ataxia if not properly diagnosed by the
finding of the other well known symptoms may give us much trouble and
discouragement.
Ulcer and cancer have quite characteristic symptoms, yet it is well
known that they are often treated as neuroses in the early stages, much
to the detriment of the patient, especially if the case proves to be
cancer.
In the =sensory= disturbances, which are probably the most common,
hyperesthesia and =neuralgia= are the special features. In the former
a feeling of weight, fullness and burning are complained of, which are
frequently manifestations of a neurotic temperament. In fact, hysteria
and neurasthenia are very often basic conditions. The same is true
in gastrodynia, where the pain starts in the pit of the stomach and
extends around the lower chest and ribs. There may be other neurotic
symptoms such as excessive hunger and a constant desire for food.
Menstrual irregularities, the menopause, worry, constipation, and
anemia are important factors. Special care should be taken that there
is no organic disorder of the gastro-intestinal tract or of the nervous
system.
The =motor= neuroses comprise a variety of derangements. Excitation of
the motor functions of the stomach, as a direct result of irritated
nerves or of reflex stimuli, are not uncommon. Owing to this the food
may not remain in the stomach long enough or the stomach activity may
be too pronounced. There may be also more or less rapid vomiting of the
food, without any particular strain. Other motor neuroses may be spasms
of either the cardiac or pyloric sphincters, and in a few instances
there may be atony of the stomach walls. Although these conditions may
be of a neurotic character, still great care should be taken that some
organic disease is not basic.
The =secretory= derangements consist of hyperacidity, supersecretion,
and lessened amount of acid secretion or achylia gastrica. Many of
these cases are associated with hysteria and neurasthenia, though
in achylia gastrica, cancer may be the cause. Hyperacidity may be
associated with ulcer. Pelvic diseases, nervous reflexes from the
gastro-intestinal tract, constipation, and anemia are to be considered
as possible etiological factors.
=Diagnosis.=—These cases require the most painstaking inquiry into
the history, the most complete physical examination, and all findings
carefully checked up by laboratory tests.
Inquiry will often show that all symptoms subside when on a vacation
with a change of scene and climate.
Lockwood gives the following rules for arriving at a diagnosis of
“nervous indigestion.”
“(1) A diagnosis of nervous indigestion should not be made in the
presence of more than 30 c. c. of fluid in the fasting stomach, the
fluid giving a strong reaction for hydrochloric acid. Hypersecretion is
generally an expression of pyloric stenosis, organic or spasmodic, and
this is due to an organic cause.
“(2) A diagnosis of nervous indigestion should not be made in the
presence of persistent hyperacidity accompanied by epigastric pain.
Nervous hyperchlorhydria may occur, but is not accompanied by either
pyrosis or pain. The association of either of these latter symptoms
should suggest an organic origin for the complaint.
“(3) Achylia gastrica may be of nervous origin, but this is not
probable when serious motor error is in evidence. Achylia with
food-stagnation is strongly suggestive of cancer of the stomach.
“(4) Achylia gastrica, accompanied by pain or vomiting, indicates an
underlying organic cause.
“(5) The diagnosis of nervous indigestion should not be made when
recognizable food remains are repeatedly found in the fasting stomach.
Under the influence of fear, nervous shock, or vicissitudes of
temperament the motor functions may be temporarily interfered with, but
this would not be the case permanently.
“(6) The diagnosis of nervous indigestion should not be made when
epigastric distress or pain occurs regularly at a definite time after
eating. The very fact of this disturbance coming on at a definite time
argues against a neurosis.
“(7) The diagnosis of nervous indigestion should not be made when one
symptom alone persists, without other evidences of nervous instability.
The presence of one definite symptom in itself presupposes an organic
cause.
“(8) The physician should be on the qui vive for drug addictions, for
these habitues can sometimes present a syndrome of symptoms that will
puzzle the most experienced.
“(9) The diagnosis of nervous indigestion should not be made in persons
over forty or forty-five, in whom indigestion is a new symptom. Such
patients are usually developing a serious systemic or malignant
disorder.
“(10) Finally, digestive nervous neuroses and organic disease may be
concomitant, and the presence of either need not exclude the other.”
=Treatment.=—First get the patient’s confidence by making a most
complete examination. This desirable beginning is usually hastened by
the osteopathic physician, when after a few treatments symptoms are
greatly relieved. Correct all lesions wherever found, particularly
those anatomically connected with the stomach. When the symptoms are
sensory relief can always be given by inhibition over the splanchnic
area. Occasionally the ensiform process and the lower costal cartilages
are lesioned.
=Diet.=—When hyperchlorhydria is the chief symptom foods must be
selected which bind acidity or those which lessen its secretion, such
as milk, eggs, cream cheese, fats such as butter, cream, olive oil,
boiled or broiled fresh fish, =boiled= beef or lamb run through
a grinder, oysters in any form but fried, white meat of chicken,
vegetable puree made with cream or milk (no meat stock), gelatine,
custard, junket or =sponge cake=.
Many neurotic patients are under-nourished through fear of food.
They must be positively assured that if the food is well chosen and
carefully masticated there need be no fear of discomfort. Care should
be taken that the patient is not constipated.
Some cases can only be reached by a “rest cure” of four to six weeks,
which together with the treatment outlined above will prove most
satisfactory.
In all cases guard against worry and overfatigue. Build up the general
health as rapidly as possible. Outdoor life, sufficient sleep, frequent
vacations, and change of scene are specially beneficial.
Gastric and Duodenal Ulcer
Statistics show that peptic ulcer is far more prevalent than is
supposed by the casual observer. “In the combined statistics of 59,450
autopsies of various series evidence of healed or unhealed ulcer were
observed in 4.4 per cent.” (Bassler.)
The reason for this is that peptic ulcer may present very definite
symptoms which are readily interpreted or they may be so atypical as
to make definite diagnosis impossible. Like all gastro-intestinal
diseases, many of the symptoms are easily confused with so-called
indigestion or “stomach trouble.”
=Etiology.=—One characteristic of gastric and duodenal ulcer is that it
only occurs where the mucous membrane is subject to the influence of
hydrochloric acid and pepsin; lower end of esophagus, stomach and first
part of duodenum.
Similar ulcers are often found in the sigmoid and rectum where the
feces often become acid due to bacterial action, or on account of
slow movement, hydrochloric acid and pepsin which may have escaped
neutralization in the duodenum may attack the mucosa.
For the part played by spinal and rib lesions on the glandular layer
of the stomach, the reader is referred to a previous discussion of the
lesion.
Probable secondary causes of gastric ulcer are: (1) Embolism of an
artery (gastric arteries are terminal). These emboli are supposed to be
caused by toxic and infectious agencies which enter the circulation, as
sometimes occurs in pyemia and large burns of the skin.
(2) While hydrochloric acid associated with pepsin seems to be an
important factor, it is doubtful whether it can attack the mucosa
without there being a previous abrasion or other injury. It is said
that a normal secretion of mucus is nature’s protection against self
digestion.
The swallowing of substances of a coarse or irritating nature or those
chemically corrosive or at extremely high temperature may so injure the
mucous membrane as to permit an attack by HCl and pepsin.
Certain occupations seem to predispose to gastric ulcer, such as
cobblers, or others who in their work press various objects against the
stomach.
Sharp blows over the stomach have been followed by acute ulcer. A
frequently associated condition is gastroptosis, which seems to be
explained on the basis of narrowing of the blood vessels and their
more ready occlusion. Probably sagging of the duodenum is an important
predisposing factor.
Anemia and chlorosis should not be overlooked as predisposing causes.
And tuberculosis and syphilis are possible associated disorders.
Of all the theories advanced, the lowering of vitality, due to lesions
of the splanchnics and vagus nerves remains the most logical.
=Symptoms.=—The most characteristic symptom is pain, which in a typical
case comes on at a regular time after taking food. It may be a half
hour, an hour or two hours, and in the case of duodenal ulcer may be
as late as four hours. The distance beyond the cardia at which the
ulcer is located seems to govern the time; also the time at which the
secretion of hydrochloric acid reaches its height, which varies in
different individuals.
The pain is due to free acidity (that which is not combined with the
food) irritating the raw surface of the ulcer. Pain is often increased
or lessened by posture. If turning on the left side gives relief the
ulcer is probably at the pylorus; if worse when standing than reclining
the ulcer is probably on the greater curvature.
The pain is usually localized by the patient, and pressure at the given
spot increases the pain. In many cases there is referred pain in the
region of the 9th, 10th and 11th ribs on the left side.
At the height of pain vomiting may occur, due probably to pylorospasm
resulting from high acidity. Vomiting always gives relief. The taking
of protein food or alkali will usually relieve the pain of ulcer,
(hunger pain). Ulcer patients are usually well nourished owing to the
habit of relieving themselves by eating, or they may be thin due to
their fear of food.
In acute ulcer frank blood may show in the vomit, and may be the first
indication of trouble, whereas in the chronic type it may be occult, or
occult blood may be found in the feces. The hemorrhage of ulcer, unlike
that of cancer, is not constant.
=Diagnosis.=—Diagnosis of duodenal ulcer, as distinguished from
gastric, is made by finding the tender spot to the right and below the
pylorus, the pain coming on three or four hours after taking food, and
the finding of blood in the feces (tarry stool) and not in the stomach
contents. Repeated examinations may be necessary owing to the fact that
hemorrhage is not constant.
The large percentage of stomach ulcers are near the pylorus, and of the
duodenal ulcers the ascending portion is the area almost invariably
involved.
Ulcer is differentiated from functional disorders by a history of
real pain as distinguished from the vague disturbances of sensation
often called pain by neurotic patients. Also its regular appearance in
relation to food. The pain of “gastralgia” has no regular habit and is
not influenced by food.
Referred pain from cholecystitis, chronic appendicitis, etc. has no
relation to food and is not relieved by food or alkalies.
Ulcer is to be distinguished from cancer by the age of the patient (in
cancer usually over 40) with a previously good gastric history, except
in cases where cancer has been grafted on to a chronic ulcer. In these
cases a careful inquiry will bring out a characteristic ulcer history
up to a certain time, when all symptoms change; pain becomes constant;
is not relieved by food or alkali; vomit becomes dark in color and has
a characteristic odor, appetite fails, and signs of cachexia set in.
Gastric ulcer should be suspected in all cases of persistent gastric
symptoms which are not readily relieved by treatment and regulation
of diet, and in which there is found high acidity and continuous
hypersecretion not accompanied by mucus.
The X-ray and gastric analysis should never be neglected in suspected
cases, keeping in mind the possible injury from the tube in case of
recent hemorrhage.
=Treatment.=—Osteopathic treatment of gastric ulcer will be almost
uniformly successful if we will analyze all of the factors entering
into the problem.
It is obvious that in order to heal the ulcer we must remove all
factors which interfere in any way with nutrition. Then give the
stomach as near absolute rest as possible while at the same time
building up the nutrition by a generous but well chosen diet.
When acute hemorrhage has recently occurred, complete rest in bed with
a trained nurse in attendance is the first indication. Complete rest of
the stomach, all nourishment being given by nutrient enema. An ice bag
is to be placed over the stomach, and removed every three or four hours
to allow surface circulation to react. Warm applications should not be
used while there is any marked bleeding.
During this period no effort on the part of the patient should be
permitted, and no manipulative treatment which would tend to increase
blood pressure should be given.
After all evidence of hemorrhage has ceased for ten days, or at once
in case of chronic ulcer, we may carefully correct all spinal or rib
lesions in the splanchnic area especially the 6th dorsal, or cervical
lesions affecting the pneumogastric. Pain and pylorospasm may be
relieved by steady pressure at the 4th and 5th dorsal on the right side.
After spinal lesions have been corrected without unduly irritating the
stomach, careful relaxing treatment should be given with the patient on
the back, keeping in mind that all exertion will tend to irritate the
ulcer.
If special care is observed, frequently definite relief may be given
by placing patient in knee-chest position and gently raising the lower
portion of duodenum where it lies alongside of ascending 3rd and colon,
4th lumbar.
During this period a hot water bag or a thermal pad should be kept over
the stomach night and day.
In certain cases of perforation in a few obstinate conditions, and in a
few where mechanical obstruction is marked, surgery may be indicated.
The following diet will be found best during the first week:
7 A. M. A half glass of cooked milk, with the leathery substance which
rises on the top removed, and the yolk of one egg stirred into it and
sweetened, if desired; taken luke warm or cool, but never ice cold.
This amount to be increased on the second day to three-fourths of a
glass, and on the third to a full glass, which is to be continued for
a week. If the milk produces diarrhea, add two tablespoonfuls of lime
water to each portion.
9 A. M. A saucerful of gelatine (Knox’s or Crystal Rock) with 2
tablespoonfuls of cream and a teaspoonful of sugar.
12 M. A half to full glass of milk prepared as above.
3 P. M. A saucerful of gelatine, with cream (medium) and sugar as at 9
A. M.
6 P. M. A half to whole glass of milk, as before, with one egg stirred
in and sweetened. The egg yolks at 7 A. M. and 6 P. M. are to be
increased until six are taken daily at the end of the week.
8 P. M. A half to a full glass of milk.
The whites of the eggs are to be stirred up in the water in the
proportion of a white to a glass of water, 4 teaspoonfuls of sugar to
be added to every glass, this to be taken by the patient only when
thirsty. If the bowels do not move, no laxative can be taken, but an
injection of warm water or a little soap may be employed. If much
discomfort is produced by the food, a hot compress must be laid over
the stomach or above the navel.
During the second week the diet should remain much the same except for
the addition of one or two pieces of Zweiback three times a day.
During the third week, if pain and blood in the feces are lessening, we
may add soft, well cooked cereal like cream of wheat, cocoa, puree of
split pea made with cream.
Fifth week add minced chicken, coddled egg, =boiled= beef or lamb put
through a meat grinder, soft vegetables such as chopped spinach, squash
and mashed or baked potatoes with liberal quantities of butter.
During and after the sixth week we may add all vegetables which can be
served in puree form, fresh fish, oysters, apple sauce, inside of a
baked apple, prune whip, custard junket, corn starch pudding.
At this time also if all goes well the patient may sit up in bed and
gradually move about, being careful to avoid all sudden movements which
would put a strain on the epigastric region.
If necessary we may also increase our manipulative treatment at this
time.
The patient must be warned against the use of any article of diet which
will be chemically or mechanically irritating to the stomach, for a
period of months, and an examination of feces should be made from time
to time to make sure of no return of hemorrhage.
Dilatation of the Stomach
A dilated stomach is a stretched stomach having increased capacity, due
to nervo-muscular atony or to pyloric obstruction. Every stomach which
is not retracted when empty is a dilated stomach. A dilated stomach may
occur either as an acute or as a chronic condition, but it is to be
distinguished from temporary distention and a normally large stomach.
=Osteopathic Etiology= and =Pathology=.—The nervo-muscular atony
causing dilatation may be due to obstructive lesions in the stomach
splanchnics, or to a general debility of the spine in the dorsal region
(usually a kyphosis), or to continued overeating and improper food
causing a stasis and fermentation. It may also be due to overdrinking
and various diseases, as phthisis, liver and lung diseases, anemia,
chlorosis, acute fevers and kidney diseases, causing more or less
of a general nervo-muscular atony. Dilatation may result from a
mechanical obstruction, or narrowing of the pylorus or the duodenum,
by a cicatricial contraction of an ulcer; by hypertrophic thickening
due to various diseases, by adhesions and tumors. Occasionally the
pyloric obstruction is congenital. A floating kidney may fall upon the
horizontal portion of the duodenum and thus mechanically obstruct the
passage of food from the stomach, which consequently dilates. Tight
lacing might prevent the liver, when congested, from passing in front
of the kidney, thus luxating the kidney. Dilatation of the stomach
occurs at all ages, although most frequently in middle aged persons.
=Pathologically=, the muscular coat is thinner and paler than normal,
with more or less atrophy of the glandular tissues and an increase
in capacity of the stomach. When obstruction exists at the pylorus,
hypertrophy of the muscular coat may occur.
=Symptoms.=—The symptoms are those of the disease causing the
dilatation plus those of persistent chronic catarrh. The patient
complains of a sense of fullness in the epigastric region and there
is flatulency, eructations and vomiting. The cavity of the stomach
being much enlarged, great quantities which are usually considerably
decomposed are vomited each day or two. There is often lessened acidity
of the vomited mass, though in some cases it is increased. Passage of
the food from the stomach to the intestine is delayed and the bowels
are constipated, the fecal matter being dry and hard. The urine may be
scanty and the skin dry. Anemia, debility and emaciation are always
present to a greater or less extent, and on account of the absorption
of poisonous matter drowsiness may occur.
=Physical Signs.=—=Inspection.=—In some cases the outline of the
distended stomach can be plainly seen. There is prominence of the
epigastric region, the tumefaction being at the pyloric end of the
stomach. =Palpation.=—The resistance upon manipulation of a dilated
stomach is like that of an air cushion. If the patient is made to drink
a half tumbler of water, bimanual palpation will cause a splashing
sound to be heard along the circumference of the stomach at its lowest
point; and by moving the water about by changing the position of the
patient, the outline of the stomach can be made. If the sound is not
heard at the first manipulation, it must not be concluded that the
stomach is normal for the stomach may be so dilated and flabby that it
falls behind the abdominal wall like an apron. =Percussion.=—The note
is tympanitic over the greater part of the stomach until the lower
curvature is reached when the sound is dull (due to the liquid contents
of the stomach), followed by a tympanic sound again when the intestines
are reached. When percussion is made the patient should always be in a
standing position if possible.
When there is =pyloric obstruction= a tumor usually presents itself,
and vomiting is more severe and peristalsis more active than when
the dilatation is due to atony of the walls of the stomach from an
obstructed innervation.
=Diagnosis.=—This is usually easy if due care is taken in making the
examination. Goetz has shown by the use of his spinegraphometer that
in cases of visceral prolapse the spine is commonly posterior in the
dorso-lumbar region. The X-ray is of value in determining the size and
function of the organ.
=Prognosis.=—In a case of nervo-muscular atony the prognosis is
favorable. If due to a malignant disease recovery is usually
impossible. In hypertrophy of the pylorus or the duodenum, recovery is
probable by means of surgical interference.
=Treatment.=—When the dilatation is due to atony of the muscular walls
of the stomach from obstructed innervation at the spinal column,
treatment is usually successful. Attention should be given to the
condition of the spinal column in the splanchnic region (fourth dorsal
to twelfth dorsal), the spine being usually posterior. A thorough and
persistent course of treatment must be given, not only to restore the
normal activity of the nerves to the muscular coat and glands of the
stomach, but to build up and restore strength in the weakened spinal
column. Lesions in the spinal column, even higher than the fourth
dorsal, may affect the innervation of the stomach. There are cases
where lesions have been found at the fifth, sixth and seventh cervicals
that interfere considerably with the action of the stomach, causing
nausea, flatulency, eructations, and even vomiting. Such an affection
may be through the fibers of the splanchnic nerves or through fibers of
the vagi nerves.
The vagi nerves have an important bearing upon gastric dilatation as
paralysis of the gastric branches of the vagi arrests the peristalsis
of the stomach and thus tends to favor retention of food within its
cavity. The stomach in such cases becomes enlarged, mainly by the
weight of the food and the presence of gases due to decomposition of
the retained food. Thus lesions may be found higher than the lower
cervicals and cause obstruction and paralysis of the fibers of the vagi
to the stomach.
Direct stimulation over the stomach in the form of thorough
manipulation of the stomach walls causes contraction of the muscular
fibers of the stomach, mainly the circular fibers. This treatment,
with additional treatment of the splanchnic and the vagi nerves, will
tend to build up the weakened plexuses of the stomach. Much time can
be saved by putting the patient to bed and treating him every day for
several weeks. When the stomach is dilated or dilated and prolapsed,
to any extent, it usually requires three to five months treatment at
least; this time can be shortened one-half by keeping the patient in
bed, treating the spine three times a week, and the abdomen every
day. Light food at frequent intervals, upper thoracic breathing, and
frequent drawing up and in of the abdomen should be required. The
patient may also manipulate his own abdomen twice a day to advantage;
teach him to manipulate, draw and pull it upward. There is no danger of
too frequent treatment as long as there is no bruising of the parts;
this, however, does not apply to the spine. It is not an uncommon thing
to correct a dilated stomach or a dilated and prolapsed stomach that
is an inch and a half or two inches below the umbilicus. Care must
be taken in all cases that other viscera are not prolapsed. It is a
common experience to find enteroptosis, which can usually be readily
functionally corrected, with the stomach ptosis. But where the kidney,
or possibly both, is much prolapsed only fair results can be secured
until the kidney is replaced and kept there, and if necessary by
surgical means. Also, note whether the liver is enlarged. (See special
article on Prolapsed Organs).
When the disease is due to cancer and various growths of the pylorus
or the duodenum, nothing can be done but palliate. Such cases require
surgical attention. In all cases it is necessary that care and
preoccupation of the patient should be removed. Baths, changes of air,
a carefully regulated diet and caution in the use of liquids will be of
great aid to the general health of the patient, and thus the weakened
nervous system will be indirectly but greatly benefited. Too great care
cannot be taken of the patient, as there is created in the organism a
special aptitude for the tissues to become inflamed and thus weaknesses
at various parts of the body may occur. Phthisis, typhoid fever and
various diseases are apt to follow dilatation of the stomach, as the
nutritive and resistive process of the body are impaired.
The meals should be taken regularly and with great care, the patient
not eating too quickly nor too much. Solids should be used but little;
the artificially digested foods, such as peptonized milk and beef
peptonoids, probably being the best. Beef juice and scraped beef are
excellent foods, as they are easily digested. Fatty and starchy foods
should be avoided.
Washing out the stomach is useful, but it should not be
indiscriminately employed. Lavage will not be necessary in all cases
of mechanical obstruction. It relieves the distention, by removing the
weight and the fermenting and decomposing material.
In =acute dilatation=, which may be due to prolonged diseases, general
anesthesia, injuries of the spine, and to narrowing of the duodenum,
vomiting, pain and collapse occur. Empty the stomach, and place patient
in knee-chest position. Reach beneath the duodenum and raise this part
of bowel. Start well down, as low as third or fourth lumbar. If this
does not give quick relief stand patient on his head.
Gastroptosis and Enteroptosis[74]
(GLENARD’S DISEASE)
=Definition.=—A displacement of the stomach and intestines.
=Osteopathic Etiology= and =Pathology=.—A weakened, debilitated spine
is the common cause. A slight posterior curvature is a frequent
occurrence. A debilitated spine impairs the innervation to the
abdominal viscera and to the muscles of the abdomen. Many cases are
of congenital origin due to lack of complete development and weakness
of the supporting tissues. Other causes are muscular strain, repeated
pregnancies, tight lacing and malnutrition. A downward displacement
of the floating ribs, and a consequent prolapse of, and atony of the
diaphragm, is an important cause.
=Prolapses= of the stomach and intestines are of frequent occurrence
in both sexes, and very common in women. It is a condition oftentimes
overlooked, and when recognized, little has been done in the way of
a cure. It is the cause of much disturbance, not only to the stomach
and intestines, but to the various abdominal viscera and to the pelvic
organs, and it is the cause of a large percentage of prolapses of the
uterus, (excluding lacerations from childbirth) for not only is the
great suspensory ligament of the uterus (the peritoneum) prolapsed as a
consequence, but all of the abdominal viscera and the parietes of the
abdomen are also prolapsed and crowded down into the pelvis. The small
or large intestine or the stomach may be prolapsed singly. This is
frequently the case with the transverse portion of the colon, which may
be elongated and tortuous and prolapsed nearly to the symphysis pubis.
Prolapse of the liver, spleen and kidneys may occur singly or with a
general displacement of all the organs.
=Symptoms.=—The abdominal walls are weak, oftentimes flabby. The
viscera of the abdomen do not have normal resistance upon manipulation.
The spinal column presents lesions. There is dyspepsia, flatulency,
constipation, abdominal pains and various neurasthenic symptoms.
=Diagnosis.=—Is readily made by the lack of tone to the abdominal walls
and viscera and the general debility of the patient. Inflation of the
stomach with air will determine between gastroptosis and dilatation.
The X-ray is of special value in determining position, function,
spasms, kinks, etc. of the digestive tube. There are innumerable
gradations and phases of this condition.
=Treatment.=—To remove the cause is of primary importance. This is to
be followed by treatment of the spinal column, correcting its various
derangements and improving the innervation to the atonied viscera and
abdominal parietes. Direct treatment over the abdomen helps to give
tone to both the viscera and abdominal muscles. In many cases the
treatment will have to be a prolonged one in order that the tissues
may regain their normal condition. Usually a treatment from two months
to a year, or possibly more, is required. Exercises and manipulations
that tone the tissues, correct the posture, and raise the chest,
diaphragm, abdominal and pelvic viscera, and release spasms, kinks, and
adhesions, are indicated. The diet of the patient should be nutritious,
and sufficient in emaciated cases to increase his weight if possible.
A supporting bandage will often give some relief. A few cases will
require surgery.
Particular attention should be given to the colon, duodenum and
diaphragm.
Relative to the treatment of gastroptosis and enteroptosis, W. E.
Harris writes as follows: “I first set to work trying to correct the
spinal irregularities; coupled with this I give deep and careful
manipulation of the gastric and intestinal walls—treating my patient
two or more times per week for a period of one to three years. A lesser
period is not long enough to bring the desired result in such cases. I
also instruct the patient to knead his own bowels, which I prescribe
as a necessary proceeding, and to be performed twice daily on retiring
and before rising. Of equal importance with the osteopathic treatment,
come local, specific abdominal exercises. These are to be of the
resistive type, and must also be taken for the general musculature.
I have my patient retract the abdominal walls and voluntarily draw
the abdominal contents towards the diaphragm, in regular series.
These exercises must be faithfully performed and continued after the
treatment has ceased in order to be of real value. I do not find our
treatment, without the hearty cooperation of the patient in doing his
exercises conscientiously, to be sufficient in itself. Have the patient
avoid overloading the digestive tract. Use concentrated foods, in small
quantities, i. e., only sufficient to sustain strength, twice daily
and without taking fluids at meal times. Of course water, in small
quantities and at frequent intervals, may be taken between meals. To
summarize—First, corrective treatment. Second, resistive exercises.
Third, attention to diet.” (See Dilatation of the Stomach.)
DISEASES OF THE INTESTINES[75]
Acute Diarrhea
=Definition.=—A diffuse inflammation involving the entire intestinal
tract to a greater or less degree. Usually the seat of disease is found
in the small intestine and the upper part of the large bowel.
=Osteopathic Etiology= and =Pathology=.—Acute diarrhea may be caused
by overeating, drinking impure water, unripe fruits, and poisons
produced in decomposed and fermented milk and other articles of food.
This sometimes takes place in perfectly harmless substances in an
inexplicable manner. Milk and ice cream may produce intestinal catarrh.
Dr. Still often referred to the harm resulting from iced drinks.
Changes in the weather, tending to weaken the system, often cause
diarrhea; hot weather favors this, although a chilling of the system by
a sudden fall in the temperature may produce the disorder. Dr. Still
was of the opinion that sitting on the cold ground (a common habit of
children) is a frequent source of intestinal derangements. Changes in
the quantity and quality of the secretions also induce the disorder;
thus the bile, if in too great a quantity, increases the peristalsis
to such a degree that diarrhea is produced; if diminished, it favors
the fermentation and decomposition of the food. Pancreatic diseases may
be a cause of diarrhea. Infectious diseases, through their specific
poisons, such as cholera, dysentery and typhoid fever; inflammation,
extending into the bowels from adjacent parts; inflammation caused by
peritonitis and intestinal obstructions, as invagination and hernia;
hyperemia, secondary to diseases of the liver, heart and lungs;
cachectic states met with in Addison’s disease; the last stages of
Bright’s disease; cancer and marked anemia are all among the causes of
diarrhea.
As in constipation, diarrhea is oftentimes simply a symptom of various
disorders; still, it may be the only symptom manifested. Lesions are
found in various regions of the body, but chiefly in the lower dorsal
and lumbar vertebræ and the lower ribs at either side. Also lesions
may be found to the vagi, thus increasing the peristalsis or affecting
the blood supply of the intestines. The lesions to the splanchnics may
involve the motor, vasomotor or secretory fibers to the intestines.
Oftentimes the innervation to the liver is disturbed, affecting the
secretion of the bile. The left side of the spinal column is involved
more often that the right side, by vertebral, rib and muscular lesions.
=Nervous Diarrhea= frequently follows fright and other causes of
nervous excitement, and is often found in hysterical women. There is
simply an increase in the peristalsis and secretion of the bowel, due
to a vasomotor paresis of the intestinal vessels, producing an outflow
of the serum.
The intestinal condition is one of hyperemia. The secretory glands
are frequently inflamed. In decided cases the mucous membrane may be
red and injected, but more often it is pale and covered with a layer
of mucus. Sometimes the solitary follicles are considerably enlarged.
These enlargements may become filled with pus, forming abscesses which
rupture, leaving an ulcer. Peyer’s patches may also be involved.
=Symptoms.=—The diarrhea is the important, and often the only, symptom
of enteritis; the stools are frequent, varying from two or three to
fifteen or more a day; they are thin and watery, varying in color
according to the amount of bile they contain. They are usually of a
yellowish or greenish color. They contain undigested food, mucus,
columnar epithelium and mucous cells, micro-organisms and triple
phosphate. The reaction of the discharge is either acid or neutral.
There are colicky pains in the abdomen, rumbling noises or borborygmi,
intense thirst, dry and coated tongue, with loss of appetite, and,
rarely, a fever. When fever is pronounced care should be taken that
some infectious disease is not the cause. =Chronic catarrhal diarrhea=
may follow the acute form. If the stools contain much undigested food
the inflammation is in the upper bowel; if thin, watery and containing
mucus, the lower bowel is involved. In prolonged cases the general
health is affected. Definite tender areas along the spine and deep
muscular contractions are invariably important etiologic and diagnostic
clues.
=Diagnosis.=—This is ordinarily made easy by giving attention to the
above symptoms. In distinguishing as to whether the large or small
intestines are involved the following is important: In catarrh of the
=small intestines=, diarrhea is not so well marked; there is much
undigested food, but very little mucus; and there is usually pain of a
colicky nature in the middle or inferior part of the abdomen. When the
=large intestine= is involved there may be no pain; when present, it
is intense and usually in the upper and lateral parts of the abdomen;
there are borborygmi and thin, soupy stools, mixed with much mucus.
If the lower portion of the bowel is involved there may be marked
tenesmus, with marked contraction of the muscles over the sacral
foramina.
=Duodenitis= is often associated with acute gastritis. Placing the
patient in the knee-chest position one may be able to palpate the
duodenum. If the inflammation involves the bile duct, there is
jaundice; in these cases the urine may be bile-stained.
=Prognosis.=—Commonly favorable if early and prompt treatment is
employed; though it should be remembered that some infections, or
constitutional disease, or intestinal ulcer may be an underlying cause.
=Treatment.=—Many cases of acute diarrhea will recover by restricting
the diet, with rest. Where improper food and water are the causes, an
entire change of diet should be considered. Withdrawal of all food and
the substitution of boiled milk will be of great aid. The bowels should
never be confined if there is reason to suspect that all irritating
matters have not been removed; and when fermentation and irritation
exist in the lower bowel, an enema will often be beneficial. The spinal
column should be examined, especially on the left side, from the fifth
dorsal down to the coccyx. The vertebræ may become displaced and cause
diarrhea, by derangement of the vasomotor nerves.
Either an increased blood supply through the intestines, or an
affection of the motor nerves will produce an increased peristalsis.
An active condition of Meissner’s plexuses may be produced
sympathetically, resulting in increased secretion of intestinal juice
and thus in diarrhea. The ribs may become displaced and be a source of
irritation to the nerves of the intestines. The muscles of the spine
are apt to become contracted by colds, injuries, strains, etc., and
stimulate or inhibit the action of certain centers in the cord and
produce disordered intestines. Conversely the muscles of the back may
be thrown into a contracted condition by irritating substances in
the bowels acting as a stimulus to the centers in the cord, and thus
reflexly to the muscles. Trouble may arise in the colon and rectum by
lumbar lesions, the slipping of an innominate, a dislocated coccyx, or
contracted muscles over the sacrum. In a word, thorough inhibition,
relaxing contracted muscles and correcting abnormal vertebræ and ribs
are the osteopathic essentials of treatment for diarrhea. Inhibition
of the lower dorsal and lumbar is very effective; it dilates the
mesenteric vessels by way of vasomotor fibers, and thus controls
secretions and lessens peristalsis. This has been clearly proven in the
osteopathic experimental work of Burns and Pearce.
Hot fomentations over the dorsal and lumbar spine will frequently,
through the nervous reciprocal relationship, be of decided value.
Direct treatment over the mesenteric circulation, i. e., through the
abdomen anteriorly, will be helpful in some cases. It relaxes tissues,
removes irritations and frees the circulation generally about the
mesenteric vessels and intestines. When giving this treatment one
should be certain of the underlying pathology. The liver should be
kept active. Treatment of the vagus nerves is important, as they help
to control the blood supply and the motor nerve force through the
intestines. Daily hot baths and increased activity of the skin and
kidneys are beneficial.
Chronic Diarrhea, and Mucous Colitis
=Definition.=—A chronic inflammation of the mucous membrane of more or
less of the large intestines. There may be ulceration.
=Osteopathic Etiology= and =Pathology=.—Chronic diarrhea may be the
result of repeated attacks of the acute form or may be caused by
cancer, tuberculosis, Bright’s disease, typhus fever, disease of
the liver, organic disease of the heart and lungs, obstructions to
portal circulation or impactions of any nature that occasion passive
congestion. Frequently cases of long standing are due to chronic
lesions of the lower ribs or lower dorsal or lumbar vertebræ. The
lesions of the lower ribs usually consist of downward displacement
of the ribs, affecting the innervation to the intestines directly,
or possibly dragging the diaphragm downward to such an extent as to
interfere with the blood and lymph vessels as they pass through it,
thus causing congestion of the intestines by obstruction to the lumen
of the vessels.
In many cases the =pathological changes= are simply those of the acute
form. In more pronounced cases the mucous membrane becomes a brownish
red, livid gray or slate color; this discoloration being due to
hyperemia and blood extravasation. The mucous coat is also swollen and
thickened. Atrophy of the mucous membrane, and in some cases of all the
coats, with destruction of the glands, may be a result of the chronic
form. Ulcerative changes occur chiefly in the lower part of the ileum
and colon; these may be follicular or there may be large ulcers and
considerable areas of ulceration.
=Symptoms.=—Constipation and diarrhea frequently alternate; the stools
are thin, mixed with a large amount of slimy mucus; the small intestine
is most frequently involved, and the patient complains of pain in the
umbilical region; there is distention of the bowels with gas; the
health gradually declines; there is great pallor, and the patient
becomes emaciated, gloomy and irritable.
=Mucous Colitis= is a chronic form of colitis, characterized by
paroxysms of severe pain and the discharge of large masses of mucus,
forming gray translucent casts, which are not fibrinous but mucoid in
character. This disease occurs usually in women of nervous type, but
is occasionally seen in men and children. When there is no underlying
organic disease, it is probably largely a secretion neurosis. Mental
emotions and worry, sometimes errors in diet, or dyspepsia bring on
the attack. Overfatigue is often an exciting factor. The nutrition is
generally well maintained, but in other cases there may be a gradual
emaciation and ultimate death. This is undoubtedly one of the most
persistent and troublesome diseases that one will meet; still the
osteopath can do much for these cases and not infrequently bring about
a cure. But the treatment must be consistent and persistent.
Mucous colitis is not hard to diagnose, although many cases are treated
for simple indigestion. It is needless to say that a correct diagnosis
is paramount. In these cases there is almost invariably some visceral
prolapse, which undoubtedly is the underlying cause, by favoring venous
congestion of the bowels. The liver is usually congested; this alone
may cause the venous stagnation, but more often it is simply due to the
common cause. Back of the visceral prolapse and congestion will almost
invariably be found a posterior dorso-lumbar curvature; still there may
be a scoliosis or single lesions only, and a downward displacement and
constriction of the floating ribs.
The =treatment= requires most persistent and careful work for at least
three months, and probably six to nine months. Correction of the spine
and floating ribs should be of first consideration; then intelligent
treatment over the abdomen, by raising and toning the bowels, not
only the bowels as a whole, but especially in the ileo-cecal, hepatic
flexure, transverse colon, splenic flexure, sigmoid flexure, and rectal
regions. The direct treatment should be cautiously given when there
are indications of ulceration.
Have the patient help himself by manipulating his bowels night and
morning, drawing the abdomen up and in, and by thoracic breathing.
Prescribe plenty of drinking water and reduce starchy and saccharine
food to a minimum. Again emphasis is placed upon the necessity of
persistent treatment, two and three times per week, for several months.
The mucus is hard to remove. It is tenacious and frequently causes
colicky pains.
To the student Von Noorden’s[76] monograph on this subject is
especially instructive. He notes that almost without exception the
patients suffer for some weeks or months prior to the development of
colica mucosa from obstinate constipation. For acute attacks, among
other things, he advises rest in bed, hot applications, and high water
injections. He believes in massage of the large intestine (particularly
of the sigmoid flexure), in cases of atonic constipation and also in
spastic constipation, provided the patient has a diet that leaves a
large residue. “A coarse, laxative diet of Graham bread, leguminous
plants, including the husks, vegetables containing much cellulose;
fruit with small seeds and thick skins, like currants, gooseberries,
grapes; besides, large quantities of fat, particularly butter and
bacon.”
=Diagnosis.=—Diagnosis is always easy. The presence of blood, pus,
or fragments of tissue in the stool point to ulceration. Ulcers in
the rectum, and as high as the sigmoid flexure, will be recognized by
examination with the speculum.
=Prognosis.=—Osteopathy has undoubtedly changed the prognosis of
other treatment. Many cases can be cured and most other cases greatly
benefited. The deep seated ulcerations may cause circumscribed
peritonitis, or even abscess, and the prognosis becomes grave as these
complications arise.
=Treatment.=—As diarrhea may be caused by lesions anywhere from the
sixth dorsal to the coccyx, a most thorough examination is necessary.
On the one hand, diarrhea may be due to a marked lateral or posterior
spinal curvature, which is plainly seen upon inspection, but on the
other hand, it may be due to a slight twist or deviation from normal
of a vertebra which would require considerable osteopathic ability
to exactly locate. Diarrhea may result from subluxation in the lower
costal region, one or more of the three lower ribs on either side
being involved. Record of one case, in particular, of chronic diarrhea
is of interest as it was due to a rib dislocation. It was the case
of a man fifty years of age, who had suffered from chronic diarrhea,
several stools a day, for over thirty years. He was completely cured
in one treatment by correcting the dislocation of the vertebral end
of the tenth rib on the left side. This case is cited to impress upon
the student the necessity of precise diagnosis and treatment. Rarely
will diseases be cured by a single treatment, but when such happens
it exemplifies the potency of the osteopathic lesion. Treatment on
the left side is usually more effective in diarrhea than treatment
on the right side. When diarrhea is a symptom of some constitutional
disturbance, correction of dorsal, lumbar and rib lesions, with
thorough inhibition, careful dieting and rest, will commonly suffice
provided the primary disease is intelligently looked after.
=Chronic lesions= of the vagi nerves may exist and produce chronic
diarrhea in the same manner as in acute diarrhea. Rest and a liquid
diet, preferably boiled milk and albumin water, will be a helpful
treatment; the diet requirement is to have a minimum amount of waste,
so that the residue will cause the least possible irritation. Beef
peptonoids with the milk will be a nutritious addition to the diet, and
change of air and surroundings may be an aid to a more speedy cure.
The skin and kidneys should be kept in a healthy condition and, if
necessary, the bowels thoroughly emptied by injections.
Diarrhea of Children
Three forms of diarrhea are recognized in children: Acute dyspeptic
diarrhea, cholera infantum, acute enterocolitis.
Acute Dyspeptic Diarrhea
This disease is most frequently due to errors in diet; the mother’s
milk may be altered in quantity or quality from taking improper food;
the child may be over-nursed, or the foods given in place of the
mother’s milk are at fault. Too often a filthy bottle is the cause. The
predisposing causes are dentition and extreme heat; and these, combined
with constitutional weakness, bad hygiene and a weak spine, diminish
the resisting power of the infant. Hence, in artificially fed children
of the poorer classes, this disease is very prevalent.
=Pathologically=, there is catarrhal swelling of the mucosa of both the
small and large intestines. The amount of mucus is increased, and there
is more or less involvement of all the lymphoid tissue. The submucous
membrane is often infiltrated. If there is much inflammation ulcers may
occur.
=Symptoms.=—The child may seem to be in its usual health, with
slight restlessness at night and an increased number of stools.
This restlessness may be due to nausea and colicky pain. The stools
are copious and offensive, containing undigested food and curds. In
children over two years old these attacks may follow the eating of
unripe food or drinking tainted milk. In other cases the onset may
be sudden with vomiting, purging, and griping pains. The fever may
rise rapidly to 103 or 104 degrees or more, sometimes followed by
convulsions. The stools become more numerous—there may be twenty in the
twenty-four hours—gray or green in color, and sometimes containing much
mucus, rarely blood.
=Diagnosis.=—The sudden onset and the character of the stools, which
never have a watery, serous character, distinguish this from cholera
infantum. And the small amount of mucus which the stools contain
distinguishes them from those of ileo-colitis. This form often precedes
the onset of specific fevers.
=Prognosis.=—Among the better classes this is generally favorable,
but among the weak, half-starved children of the poor it is often
unfavorable, especially in hot weather.
=Treatment.=—The child should be clad warmly, kept absolutely clean
and given a change of diet and air if possible, with frequent baths.
Sterilized milk should be given at regular intervals; or if the
diarrhea continues, beef juice and egg albumin instead. The bowels
should be thoroughly cleansed by injections. The spine should be
thoroughly treated through the lower dorsal and lumbar regions, and if
the abdomen is not sensitive, a light treatment to the bowels directly
will aid recovery. Frequently it will be found that the muscles of the
neck and upper dorsals are considerably contracted, especially where
the child has fever and is very restless.
For =acute intestinal indigestion= Ruhrah gives the following dietetic
treatment: “Withhold all food for the first twenty-four hours, except
a little albumin water. This is best given in small doses at not too
great intervals. Plain boiled water may be used instead. Very weak tea
to which a little red wine has been added may be given if the child
is weak. On the second day the albumin or barley water may be given
with the addition of weak strained broth, and on the third day malted
milk may be added to the list. After four or five days cow’s milk
diluted and boiled or peptonized may be tried. It is best mixed with a
farinaceous gruel or with malted milk to start with. It may be given
every other feeding for a day or two if it agrees, and the former
feeding gradually resumed.
“In nursing infants withhold the breast twenty-four hours and feed as
above. After that the breast may be given once for a few minutes and
the feeding pieced out with albumin- or barley water. If it agrees the
breast may be given for three or four feedings, every other feeding
followed by albumin- or barley water. On the following day the breast
may be given at each feeding. The time of nursing should be increased
gradually until the child is back on its old schedule.”
Cholera Infantum
=Definition.=—An acute, catarrhal inflammation of the mucous membrane
of the stomach and intestines, with some disturbance of the sympathetic
ganglia. This is a disease of childhood during the first dentition.
=Etiology= and =Pathology=.—Probably due to the poisonous products
of decomposing and fermenting foods acting upon the system. The
predisposing causes are hot weather, dentition, bad hygiene, the
previous presence of some slight dyspeptic derangement, dyspeptic
diarrhea, and enterocolitis.
The =pathological= changes are similar to the morbid anatomy of
catarrhal gastritis and enteritis. The serous discharges and rapid
collapse are due to the intense irritation of the sympathetic system.
The kidneys and liver may become involved, and bronchopneumonia is a
possible complication.
=Symptoms.=—The disease is of sudden onset, setting in with severe
vomiting, which is increased by giving food or drink. The stools
are copious and frequent, at first containing some offensive fecal
matter, and later becoming watery, and odorless. There is decided
fever, reaching as high as 105 degrees. The pulse is rapid and feeble,
ranging from 130 to 160. Prostration, pinched features, hollow eyes,
depressed fontanelles and loss of weight are characteristic symptoms.
The tongue is coated at first, but soon becomes dry and red, and
thirst is intense. Even at this time a reaction may set in, but more
commonly death results with symptoms of collapse and high temperature.
In other cases there are restlessness, convulsions and coma. As there
is no cerebral lesion, this condition is probably due to toxic agents
absorbed from the intestines.
=Diagnosis.=—This is not difficult, as the toxic symptoms, the
severe vomiting, the profuse watery discharge, rapid emaciation and
prostration, and the hyperpyrexia are significant.
=Prognosis.=—Grave, even with the most favorable surroundings, although
in numerous instances osteopaths have successfully treated this
disorder. Much depends upon the promptness of treatment.
=Treatment.=—A change of air, complete rest, removal of all foods
for a short time, and absolute cleanliness are of great importance.
Thorough treatment should be given along the entire spine, particularly
to the splanchnics of the stomach and the intestines, and to the vagi
nerves in the cervical region. Frequent bathing with cool water, or
better still, wrapping the child in cold, wet sheets, will reduce the
hyperpyrexia.
Thorough cleansing of the stomach and intestines with warm water
occasionally gives excellent results. In =collapse= the use of a hot
bath is indicated, followed by wrapping the child warmly in blankets
and placing him in a horizontal position. The food of the child should
consist of peptonized milk, raw beef juice, diluted egg albumin, barley
water and chicken broth. Nourishment should be given gradually, and
=only= after the intense symptoms have subsided.
Acute Enterocolitis
In enterocolitis the ileum and colon are chiefly affected, especially
the lymphatic glands or lymph follicles.
=Osteopathic Etiology= and =Pathology=.—Warm weather, the artificial
feeding of children, dentition and bad hygiene are predisposing causes.
The disease usually occurs between the ages of six and eighteen months,
but it is not infrequent in the third or fourth year. This disease
is not confined to the warm weather, but may set in at any season of
the year. Previous light attacks of diarrhea are often a predisposing
factor. Lesions in the spine occur from the eleventh dorsal to the
fourth lumbar.
The mucous membrane is congested and swollen, and the solitary
follicles and Peyer’s patches are swollen and often ulcerated. The
changes may end here or the ulcers enlarge and extend into the muscular
coat with the separation of a slough. There may be infiltration and
thicking into the submucous and muscular coats, followed by induration
of the tissue, producing abnormal rigidity.
=Symptoms.=—The disease may be a sequel of dyspeptic diarrhea or
cholera infantum. The temperature increases and the stools change in
character, being at first yellow, and later green. They contain traces
of blood and mucus. Vomiting may be present, but is not a constant
symptom. The abdomen is distended and tender along the course of
the colon. The disease may abate here, recovery from the condition
being slow; or the symptoms may increase in severity with persistent,
small, painful stools, mainly of blood and mucus, tenesmus, and with
scanty urine. The child grows pale and emaciated, and assumes a senile
appearance. These cases last five or six weeks, death being preceded by
coma and convulsions; though a few recover. Relapses are not uncommon
and should be guarded against. =Ulcerative and membranous= forms may
occur. Pneumonia and nephritis are possible complications.
=Diagnosis.=—=Enterocolitis= is distinguished from dyspeptic diarrhea
by the greater severity, more fever, greater prostration, the stools
containing more mucus and even blood, and by the greater pain and
suffering. =Cholera infantum= may be recognized by the abrupt onset,
very high fever, constant vomiting, and early collapse. If typhoid
fever seems a possibility, the Widal test should be used.
=Prognosis.=—Grave; recovery follows prompt treatment with favorable
surroundings.
=Treatment.=—Attention should be given to the condition of the spine
from the eleventh dorsal to the fifth lumbar. An inhibitory relaxing
treatment over the sacral foramina will lessen the tenesmus. When
the ileum and colon are involved, disorder is usually present at the
third and fourth lumbar vertebræ, although the lesion may be higher.
Relaxation of all muscles in this region and correction of the
vertebral lesions are essential.
Irrigation of the bowels once a day with a pint of cold water is very
beneficial and even pieces of ice may be introduced into the rectum.
Fresh, pure air, rest and cleanliness, with a restricted diet and daily
warm baths are important. In a word, hygienic and dietetic treatment
similar to that for acute diarrhea should be employed.
In all forms of diarrheal diseases in children much depends upon
previous =osteopathic= attention, =diet=, =hygiene=, and =environment=.
Cholera Morbus
=Definition.=—An acute, gastro-intestinal catarrh of sudden onset,
characterized by violent abdominal pains, incessant vomiting and
purging.
=Etiology= and =Pathology=.—This disease greatly resembles Asiatic
cholera; so much so that one seems justified in suspecting that cholera
morbus, like true cholera, is due to a specific organism. No single
bacillus has yet been designated as the specific germ, although one
has been recognized resembling very much the common bacillus of true
cholera. Until this has been fully decided, cholera morbus must be
regarded as severe inflammation of the mucous membrane of the stomach
and intestines, due to some poison generated from the improper food,
which seems to be the cause of the disease, such as indigestible
fruits, cabbage and cucumbers. It is most prevalent in hot weather,
but is also caused by exposure to cold and damp. The condition of the
mucous lining of the intestines is the same as in acute diarrhea.
In fatal cases of cholera morbus there is the same shrunken, ashy
appearance of the skin that characterizes cholera.
=Symptoms.=—The onset is sudden, with intense cramps in the epigastrium
and frequently in the lower limbs; nausea; vomiting, and purging of
bilious material, which later becomes almost like water, and in severe
cases the discharge becomes serous, finally resembling the rice water
discharges of true cholera. There are also intense thirst, moderate
fever, rapid emaciation and loss of strength; the surface becomes cold
and covered with clammy sweat; the pulse is frequent and feeble. The
patient becomes restless and anxious.
=Diagnosis.=—=Asiatic Cholera.=—There is no way of distinguishing
between Asiatic cholera and cholera morbus, except by examination
of the discharges for the bacillus. Similar attacks are produced in
poisoning by arsenic, corrosive sublimate and certain fungi, and are
only discriminated from it by clinical history and cause.
=Prognosis.=—In the majority of cases the prognosis is favorable, death
rarely occurring. The duration is from twenty-four to forty-eight hours.
=Treatment.=—A strong inhibitory treatment to the gastro-intestinal
nerves is at once demanded. This relaxes the muscles of stomach and
intestines, dilates the blood-vessels and lessens peristalsis. The
treatment should be kept up until relief is given. In some cases,
gentle treatment over the stomach and intestines quiets the distress.
Inhibition at the occiput gives relief, especially to the nausea and
vomiting. Hot applications should be applied to dorsal and lumbar spine.
The vomiting is relieved principally at the fourth and fifth dorsal
vertebræ on the right side near the angle of the ribs. Cold carbonated
water and pieces of ice swallowed are useful. The diet must be
regulated, the further after treatment being symptomatic. Clear the
bowel by warm enema if any irritating matter is still present.
Inasmuch as food passes through the small intestine in 4 to 6 hours,
and requires 20 hours to pass through the colon, the colon should be
emptied by high irrigation in all acute intestinal disorders.
Intestinal Colic
This is a painful spasmodic contraction of the muscular layer of the
intestines.
=Osteopathic Etiology.=—Lesions of the splanchnics derange the
intestinal nervous mechanism, with a consequent upsetting of
circulatory equalization and chemical function of the intestines.
Thus irritations and obstructions of the reflex arc predispose to
lowered resistance, congestions, and disturbed chemism. Indigestible
food, flatulency and impaction of feces oftentimes produce intestinal
colic. Exposure to cold and emotional upsets may be factors. Foreign
bodies, intestinal worms, abnormal amounts of bile discharged into
the intestines, and reflex causes from diseases, as from the ovaries,
uterus, liver, kidneys, etc., will produce the disorder; also lead
poisoning, syphilis, rheumatism, locomotor ataxia, chronic malaria and
hysteria.
Kerley says: “Children who take too much milk, too strong milk, or who
take milk too frequently are the usual subjects of colic. Probably the
most frequent cause of colic is indigestion of the proteid of the milk;
either the proteid is in excess or the child has poor proteid capacity.
Not a few cases of colic are due secondarily to defective bowel action.”
=Symptoms.=—Severe paroxysms of pain, centering around the navel and
diffused throughout the entire abdomen. The pain is of a piercing,
cutting and twisting nature, relieved upon pressure. The abdomen
is distended and the patient restless and continually changing his
position. The attacks alternate with periods of complete quietude.
In severe attacks the features may be pinched and the surface cold,
with feeble pulse, vomiting and tense abdominal walls, all indicating
incipient collapse. The duration of the attack is from a few minutes to
several hours, eased at intervals and usually ending by a discharge of
flatus.
=Differential Diagnosis.=—In =lead colic= the history, the
slate-colored skin, blue line on the gums, sweetish metallic taste,
constipation, slow pulse, retracted abdominal walls, and lead in the
urine will designate this disease. =Biliary colic= presents pain in
the hepatic region, radiating to the back and right shoulder; also
jaundice, calculi in the stools and bile in the urine. Tenderness
over the gall bladder is important. =Nephritic colic= is accompanied
by pain radiating down one or both ureters to the inner side of the
thigh, with retraction of testicle of side affected, or the labia, and
blood, mucus, pus or calculi in the urine. In =uterine colic= there
is dysmenorrhea and pain in the pelvis. In =ovarian colic= there is
extreme pain upon pressure over the ovaries, and hysteria. =Abdominal
aneurism= presents tumor, pulsation, bruit. In =inflammatory= and
=ulcerative= disorders of the abdomen there is tenderness upon
pressure, and fever. The pain of acute appendicitis is at first
general, centering in the right iliac fossa in about 24 hours. The
X-ray may be of definite aid in renal and biliary conditions and
various disorders, such as intestinal adhesions, angulations, etc.
=Treatment.=—Relief of pain is the first indication and is best
accomplished by strong inhibition in the splanchnic region, which
relaxes the spasm of the intestinal muscles, by normalizing the
reflex arc. If disorders of the spinal column are located, it is of
primary importance that they be corrected. In cases of irritation of
the intestinal mucous membrane, a contraction of muscles of the spine
will be found according to the area of the intestines involved, e. g.,
irritation of the mucous coat of the jejunum causes contraction of
the muscles at the tenth and eleventh dorsals. It is a viscero-motor,
viscerosensory or viscerotrophic reflex sign. On the other hand, a
lesion at the tenth and eleventh dorsals may produce colic or other
disorders of the jejunum. The portion of the bowel affected, therefore,
can be often told by noticing the places of muscular contraction along
the spinal column. Generally the jejunum and ileum are the portions
of the bowel affected in intestinal colic. The pain can frequently
be controlled if in the jejunum, at the tenth and eleventh dorsals;
if in the ileum, at the twelfth dorsal; if in the ileo-cecal region,
including the vermiform appendix, at first to third lumbar; if in the
colon, at the third to the fifth lumbar; and if in the rectum, over
the sacral and coccygeal nerves. Occasionally the duodenum and jejunum
are reached by nerves as high as the fifth dorsal (usually vasomotor
nerves, not sensory), and the other portions of the bowel lower,
according to their respective positions. The relief is given by way
of the splanchnics and sympathetics to the mucous (sensory) coat of
the intestines, although inhibition relaxes intestinal muscles (motor
nerves) and dilates blood-vessels (vasomotor nerves). Though precisely
localized inhibition is of decided value, still if normal alignment,
through adjustment, can be secured results are usually quicker and more
satisfactory.
Anterior treatment to the abdomen helps to relieve the contracted
fascia of the mesentery, with a consequent freeing of the circulation.
It aids peristalsis of the intestines and expulsion of the irritating
material. This probably produces considerable effect by way of the
axone reflex. Direct treatment to the abdomen for the peristalsis
relieves also constipation, impactions and the enteralgia, the latter
principally by firm pressure. Peristalsis is also increased by
stimulation of the vagi and inhibition of the splanchnics. The latter
treatment, of course, is not given to relieve pain directly, but to
facilitate the removal of irritating substances if such are the source
of trouble. If this does not produce a movement of the bowels promptly,
a warm enema will assist greatly. The cecum and sigmoid should not be
overlooked.
=Flatulency= can be relieved by direct pressure upon the solar plexus,
which apparently removes obstructions to the abdominal nervous system
(particularly the nerves of the digestive glands, as fermentation and
flatulency are due to a disproportionate secretion of digestive juices)
and thus the gaseous formations are absorbed. Additional treatment to
the lower dorsal vertebræ and lower ribs to relieve nerve lesions and
increasing both thoracic and abdominal circulation may be indicated.
As stated in the etiology of intestinal colic, the splanchnic nerves
contain not only sensitive fibers, but motor and vasomotor fibers
as well. The same is true of the vagi nerves; they exert upon the
intestines not alone a motor influence, but also a blood control;
consequently, our work in a certain region can be for more than one
purpose. Hot applications to the abdomen may be of benefit. And hot
fomentations to the spine for 20 or 30 minutes (affecting reciprocal
innervation) is often of great benefit. The diet should always be
regulated for a few days at least.
Constipation[77]
=Constipation= is an unnatural retention of feces from any cause. The
following causes are frequently met with: A deficiency of the bile or
other secretions that aid peristalsis; many acute and chronic diseases
which lessen the secretions and impair peristalsis, such as anemia,
hysteria, chronic affections of the liver, stomach and intestines
and acute fevers; certain drugs and strong purgatives; strictures;
concentrated food; sedentary habits, overfatigue and neglect of the
calls of nature. Atony of the colon may be caused by chronic disease
of the mucosa and by general disease causing debility. There may be
weakness of the abdominal muscles, due to obesity and the distention
of frequent pregnancies, or obstructions, such as displaced uterus,
pregnancy, prolapsed cecum, sigmoid or rectum, and displaced coccyx.
Constipation is really a symptom, in most cases, of some disease; many
times it is about the only symptom observed. One has to take into
consideration the many causes that would produce constipation when the
treatment of a case is undertaken. A disordered structure may be found
in almost any region of a body, which would bear directly or indirectly
in the causation of constipation.
Irregular habits often bring on the most obstinate cases of
constipation in later life. There may also be local causes, such as
disturbances of the normal secretions, impairment of intestinal walls,
due to inflammation, and mechanical obstructions caused by tumors,
intussusception, twists, etc. Constipation in infants is usually caused
by errors in diet, but may be congenital.
In all obstinate cases the X-ray should be employed in diagnosis.
In the majority of cases lesions will be found in the vertebræ of
the lower dorsal and lumbar regions, or in the lower ribs of either
side. The lesions may affect the vascular supply and innervation of
the intestines directly, or the lesion may cause the constipation
by affecting some other digestive organ first. Lesions to the vagi
affecting the peristalsis of the intestines are common.
The usual =symptoms= are frequent stools, debility, lassitude,
headache, loss of appetite, anemia, furred tongue and fetid breath.
Serious symptoms may result in long continued cases, such as piles,
ulceration of the colon, perforation, enteritis and occlusion. The
fecal mass may become channeled and diarrhea may occur from the
irritation. In long standing cases of constipation, if the patient
suddenly develops diarrhea the rectum should be well examined to see if
there are impacted feces present. Neuralgia of the sacral nerves may
also be caused by impacted feces in the sigmoid flexure.
=Treatment.=—Naturally, owing to the numerous etiological factors, each
case is a special study and the treatment is necessarily varied. Many
cases will present slight impaction of the bowels, a sluggish liver,
spinal lesions and so on, which simply require a specific treatment and
all the symptoms will be removed. On the other hand, constipation may
be due to prolonged ill health and thus require a careful, systematic
treatment, not only of the bowels, but of the entire system. Of
primary importance in these cases is regulation of the diet, plenty of
exercise, sufficient sleep, and regularity in going to stool at a fixed
hour each day. The effect of attention to the latter point, in some
instances, will be sufficient to perform a cure. Too much cannot be
said in regard to the beneficial effect of systematic habits.
Lesions may be found in the spinal column producing constipation from
about the fifth dorsal to the coccyx, although principally the lower
three dorsal and upper two lumbar vertebræ are at fault. Constipation
may be caused by defects at any point in the intestines, and
consequently the sections of the spinal column sending nerves through
the intervertebral foramina to the several sections of the bowels
should be examined. At any point from the fifth dorsal to the coccyx,
certain vasomotor, motor and secretory nerves of the intestines may be
affected by various lesions. The vasomotor nerves keep up the vascular
tone of the bowels, the motor nerves the peristaltic action and the
secretory nerves attend to the intestinal juices. In constipation,
disorders of the spinal column are generally found on the right side.
There is no good reason offered as to why this is so.[78] In those
cases where the liver is impaired, the answer might be because most of
the nerves to the liver are on the right side, but the right side is
just as often affected when the lesions are in the lumbar region and
the nerve supply to the hepatic region intact. Dr. Still considered the
fifth dorsal of importance.
The =vagi nerves= have important bearing upon the motor apparatus of
the intestines. Lesions in the upper cervical, involving intestinal
fibers of the vagi, occur occasionally. Stimulation of these fibers
increases the peristalsis of the intestines. Mechanical stimulation of
the mid and lower dorsal region, as shown by osteopathic experiments,
increases peristaltic action and vaso-constriction in the stomach and
intestines.
The value of =direct treatment= over the intestines from the duodenum
to the rectum in most cases of constipation cannot be overestimated.
It aids peristaltic action, removes impactions, stretches adhesions,
strengthens weakened muscles of the intestines and abdomen, and in
general gives tone to all of the abdominal organs. The treatment should
not be given in a hap-hazard manner, but each effort should be for a
definite purpose. Care should be taken not to bruise the intestines or
other organs, as by gouging or severe punching; the flat surface and
the palms of the hands should be used. This means that the part of the
bowel involved should be treated intelligently, the osteopath reaching
underneath the section and the patient drawing the bowels up and in.
Obstructions and impactions of the gut, especially at the ileo-cecal
and sigmoid regions, should be carefully corrected. At all angles of
the gut, impactions and prolapses may occur.
J. H. Sullivan[79] makes the following observation concerning severe,
deep abdominal treatment: “I have noted that this often resulted in
the reverse of good effects. In constipation, naturally then, I am
chary about treating abdominally, confining my work principally to
the biliary regions, the ileo-cecal and left iliac regions and have
attained good results when a promiscuous working of the abdomen had not
so resulted.” This emphasizes the point that specific treatment is as
much indicated for the abdomen as it is for the spine.
Frequently there will be found a spastic condition of the pelvic colon,
often associated with congestion and adhesions. This probably sets
up a reversed peristalsis. Treatment by inhibitory relaxation, with
patient in knee-chest position, and adjustment of lumbar and innominate
lesions, is indicated.
Direct treatment to the liver and biliary ducts is necessary in many
cases, as the bile secretion is often defective; thus a slowness or
inactivity of the liver and bile ducts might cause costiveness.
Some cases result from anesthesia of the rectum, due to pressure of
the fecal matter collecting in the rectum. Simple dilatation of the
rectal sphincters and a stimulating treatment through the sacral nerves
will bring about a healthy activity of these parts. Occasionally the
coccyx becomes displaced and produces paresis of the rectal nerves; or
a displaced uterus or a tumor may produce the same result.
The use of =proper food= is essential. Coarse food leaves a great
amount of residue, and on the other hand, dainty food leaves but little
residue, both causing costiveness. As a rule increase the amount of
fruit and vegetables. The patient should drink considerable water, and
the time is of importance. Have a glass of cool, not iced, water taken
on arising and if breakfast is delayed sufficiently, another in half
an hour. Most people do not drink enough water. Unless contraindicated
eight or ten glasses daily should be insisted upon. An enema[80]
occasionally is indicated and is a great aid when used, particularly
in cases of paralysis of the intestines and in impactions. Correct
breathing and out door life are beneficial.
=Treatment of the Constipation of Infants.=—Repeated small enemata
at a fixed hour each day will often be satisfactory but be certain
that the tissue is not irritated. Two ounces of tepid water at a
time should be injected. Careful spinal treatment and massage to the
abdomen will be useful, as will slight dilation of the anus, which is
usually done with the little finger, but in obstinate cases a soap
stick may be used. When there has been continued straining at the
stool, the sigmoid and rectum will often be found prolapsed, causing
a mechanical obstruction. With the finger well lubricated this can be
corrected and often is all that is needed. These directions, with care
in the foods, are usually sufficient in any case not congenital. In
chronic constipation Ruhrah outlines dietetic treatment as follows: “In
infants see that they get sufficient fat and protein; well cooked and
sweetened oatmeal gruel is useful. Orange juice, baked apple, or prune
juice taken on an empty stomach is of service. Olive oil, the malted
foods, or malt extracts are useful. In older children fresh fruits,
vegetables, and oatmeal porridge are of value. Graham bread, dates,
figs, and prunes may be used.”
Intestinal Obstruction
(ILEUS)
This is due to a sudden or gradual closure of the intestinal canal
at any point. Closure of the gut may be caused by strangulation,
intussusception, twists and knots, abnormal contents, strictures,
tumors, kinks, spastic states, adhesions, etc.
=Strangulation.=—This is the most frequent cause of acute obstruction
of the bowels. There may be stricture of the bowels due to inflammatory
processes producing bands or adhesions, or due to the adhesion of a
bowel to an abdominal wound; a vitelline remnant, as a blood vessel,
may remain and act as a strangulating cord, or in Meckel’s diverticulum
one end may be attached to a mesentery or abdominal wall and thus form
a ring through which the gut may pass and become strangulated.
Strangulation may take place through the foramen of Winslow or the
foramen ovale, or between the pedicle of a tumor and the abdominal wall.
Peritoneal pouches, mesenteric and omental slits, adherent appendix
or Fallopian tubes and diaphragmatic hernia may be other causes.
An internal strangulation (hernia) may take place in the crural or
inguinal canal, in the umbilicus, in the sacro-sciatic notch or in the
opening through which the infra-pubic vessels pass. In strangulation
there is a constriction of a portion of the bowel causing an arrest of
the circulation of blood at that point, and more or less stoppage of
fecal matter of the intestine.
In ninety per cent of cases the strangulated part is in the lower
abdomen and sixty-seven per cent occur in the right iliac fossa,
according to Fitz.
=Intussusception or Invagination.=—Intussusception is a slipping of a
part of the intestine into another part immediately below it, as the
slipping of a part of a finger of a glove or a coat sleeve into another
part. The portion involved may be anywhere from half an inch to a
foot or more in length. This produces compression and inflammation of
the intestine, and obstruction to the intestinal contents. It occurs
principally in children and is more common in males.
Spasms of the intestinal muscles and perverted peristalsis are probably
the most common causes. One part of the bowel may be dilated and an
adjacent portion contracted, thus allowing an invagination. Diarrhea,
habitual constipation and intestinal polypi are important exciting
causes. Invaginations oftentimes occur just before death, probably due
to irregular peristalsis.
Following engorgement and inflammation of the invaginated portion,
a tumor is usually present, and lymph is exuded which may cause the
layers of gut to adhere, so that the invaginated portion is firmly
held. Necrosis and sloughing are then likely to take place.
Intussusception varies according to location and is named according
to the part of the bowel involved. There are commonly recognized (1)
Ileo-colic, when the ileo-cecal valve enters the colon. (2) Enteric,
of the small intestines. (3) Colic, of the large intestine. (4)
Colico-rectal, of the colon and rectum. (5) Rectal, of the rectum.
=Twists= and =Knots=.—These occur more frequently in males, usually
between the ages of thirty and forty. In nearly all cases the twist is
axial, accompanied by relaxed and lengthened mesentery. One portion of
the bowel may be twisted about another, or a loop of bowel twisted upon
its long axis. A bowel being impacted or overdistended by feces and
gas, is quite likely to roll on its axis or knot and become dislocated,
its weight and inactivity thus producing compression and obstruction
of the bowels. The volvulus commonly occurs in the large intestine,
at the sigmoid flexure and in the ileo-cecal and cecal regions. It
occasionally occurs in the small intestine.
=Abnormal Contents.=—Obstructions may be caused by gall-stones,
enteroliths, lumbricoid worms, certain medicines (such as magnesia
and bismuth), fruit stones, coins, needles, pins, buttons, etc., and
fecal matter. Foreign bodies usually lodge in the ileo-cecal region
and in the small intestine, while fecal impactions occur in the large
intestine, more frequently in the lower part. Females are more subject
to it than males.
Its causes are many and are similar to those of constipation. Spinal
lesions are very frequent, probably causing paresis or paralysis of
a segment of the bowel; or all the forces that maintain a normal
activity of the intestines may become impaired. Hemmeter[81] says it is
“more frequently the result of defective innervation of the intestine.”
=Impactions= are frequently met with and are easily overlooked
under any diagnosis which does not include thorough palpation of
the abdominal viscera. The impaction may be so large as to produce
dilation of the bowel. The obstructive mass becomes very hard and dry
and perhaps channeled, allowing some material to pass until, finally
a large piece of fecal matter will obstruct the passage completely.
In =diagnosis= it must not be confused with neoplasms, tumors, etc.
Impactions may occur at any point of the colon and the weight so drags
the bowel out of position as to be misleading. The principal points
are the ileo-cecal region, sigmoid flexure, and rectum. Tenderness is
usually present, as may be diarrhea which must not be taken as evidence
that the bowel is clear. Impaction gives rise to many reflex symptoms
and is often the real cause of many mistaken conditions.
Too much cannot be said on the importance of a thorough examination of
colon and its connections, which should be routine of every examination
as the large bowel is impacted much more often than suspected and may
be the seat of many reflex and direct disturbances. The heart may be
affected by weight upon the vessels, gastric disturbances and signs of
auto-intoxication from absorption may appear.
Dilatation of the sigmoid flexure, especially when it is congenitally
long, may even be so great as to crowd up and interfere with the liver
and diaphragm; in these cases the coats of the intestines are usually
hypertrophied.
=Strictures and Tumors.=—These usually occur in adults, more frequently
in women and generally involve the large intestine and lower part of
the abdomen, most of them occurring in the left iliac fossa. They
frequently result in chronic obstruction. Occasionally, a stricture may
be spastic, due to vertebral lesions, that is severe enough to cause
complete blockage of intestinal contents. These are usually of the
pelvic colon. There are cases where the opposite condition, paralysis
of a section, generally of the small intestine, occurs. This may be
due to injuries to the bowel, or to damage of the blood supply, or to
derangement of the innervation.
Scar tissue, following ulceration of the bowel; tumors of various
kinds; and congenital defects, are possible sources of intestinal
obstruction.
=Symptoms.=—=Acute Obstruction.=—There is constipation, nausea,
vomiting, and pain. The pain is of a colicky nature and may come on
abruptly. After the contents of the stomach have been vomited, the
material becomes colored with bile, and finally stercoraceous vomiting
occurs. Observing the contents vomited (gastric, bile-stained, and
fecal) will greatly aid in the diagnosis. The contents of the bowel,
below the obstruction, may be emptied or complete constipation may
remain. All the symptoms, as a rule, rapidly grow more pronounced. The
pain is more severe; tenderness occurs over the abdomen in limited
areas; there is slight tympany; the eyes are sunken; the skin is cold
and clammy; the pulse is quickened and feeble; there is rapid increase
of leucocytes; the urine highly colored; the tongue is dry and there
is incessant thirst; tenesmus and tumor may be marked, and fever
occasionally occurs. The above condition may continue from three days
to a week, when collapse and death may occur, if relief is not obtained.
=Chronic Obstruction.=—In fecal impactions constipation of long
standing is commonly observed. In some cases the fecal mass has
become channeled, allowing the bowels to remain open; the patient
possibly not knowing that there is any trouble. In fact, diarrhea may
be present, due to irritation above the impaction. Finally, however,
obstruction occurs; the breath is offensive, the appetite is poor, the
abdomen swells, and there is fullness and weight within the abdomen,
accompanied by pain and vomiting. Upon examination before complete
closure, the fecal impactions can easily be felt through the abdomen
externally. The tumor is a yielding mass. It has been mistaken for an
enlarged liver or gall-bladder, a kidney, or a tumor of the stomach
or duodenum. Other symptoms may be present as hiccough, jaundice,
tenesmus, tumultuous peristalsis, local peristalsis, local peritonitis
and collapse. In stricture caused by cicatrices that may have been
formed years before, complete obstruction takes place. Transient
attacks often occur. Usually the general health is greatly impaired
long before complete occlusion.
=Diagnosis.=—A diagnosis can usually be made by careful, thorough
examination through the abdominal wall, in connection with the
symptoms, and the physical signs. The region of intestinal trouble
is manifested by contracted muscles at certain points along the
spinal column, corresponding with the particular portion of the bowel
involved, as indicated under intestinal colic. Examining the patient in
the knee-chest position will often give a better opportunity to locate
and outline the obstruction. Rectal and vaginal examinations should not
be neglected. Intestinal obstruction may be confounded with tumors,
hernia, intestinal colic, enteritis, peritonitis, hepatic colic and
renal colic. =Peritonitis= may be differentiated by the history,
the early fever, diffused tenderness and absence of fecal vomiting.
When =invagination= occurs, besides the symptoms of obstruction, the
age, tenesmus, bloody discharges and the sausage-shaped tumor in the
line of the colon, will be diagnostic. In =stricture=, the history,
gradual onset, and ribbon-like and bloody stools will distinguish that
disorder. In =tumors= the gradual onset, age, bloody discharges, and
cachexia will be important symptoms. X-ray diagnosis may be of value in
certain cases.
=Treatment.=—Treatment of the bowels directly is required, and each
case must depend for its relief upon the ingenuity of the osteopath.
Rules to be followed cannot be given, as cases vary in manner of
involvement and in location, consequently the correction of the
disorder depends as much upon the ability of the osteopath as does the
determination of the diagnosis. Taxis is the method commonly used in
relieving intestinal obstructions, though other methods may be employed.
In =invagination=, raising the buttocks and lowering the chest, with
thorough injection of oil or tepid soapsuds, or an inflation of the
colon with air, may give relief. In addition to thorough but cautious
manipulation of the bowels as in =impaction=, irrigation of the lower
bowel with warm water, soapsuds, or glycerine and water, will usually
be of material aid. In =strangulation=, high injections of warm water,
and assuming the knee-elbow or lateral position, may straighten out
the acute obstruction. =Twists= and =knots= are best relieved by
direct treatment, although injections may be of aid. =Kinks= of the
pelvic colon, ileum, and duodenum are best treated with the patient
in the knee-chest position. =Tumors= and =strictures= will require,
sooner or later, surgical interference in most cases, but to treat as
in impaction will be effective for a short time at least. If there
is no indication of immediate =relief within three days, surgical
interference should be instituted=. Besides the ordinary treatment for
the nausea and vomiting, washing out the stomach will help allay such
disorder, quiet the peristalsis and relieve the abdominal distention
and pressure above the seat of obstruction. Strong thorough treatment
of the spinal nerves to the stomach and intestines will be of great
help in lessening pain, establishing normal peristaltic action and in
suppressing inflammation. The vagi also should be treated for perverted
peristalsis. Hot fomentations will be of service. The nutrition of the
patient is best retained by rectal injections of food.
=Spastic= states, particularly of the pelvic colon, frequently cause
constipation of various degrees of chronicity. Reaching beneath the
spastic area and inhibiting and raising (knee-chest position) the parts
will often give marked relief.
=Adhesions= can often be stretched sufficiently to restore normal
function of the bowels.
Treatment of =impactions= and =abnormal contents= requires an
additional word. The first step is to free the colon of the fecal mass.
The enema is of great assistance in this, for cases of long standing
present a hard, dry mass, often adherent, and the mucous membrane is
sensitive from inflammation. Much abdominal treatment must not be given
until the mass is softened by water. When in the sigmoid or rectum it
may, if not dislodged by repeated enemata, have to be removed by a
colon spoon, perhaps under anesthesia. Impaction of the small intestine
is rare and out of reach of the enema, although if taken as hot as
can be borne, it will exert considerable influence high up. In these
tendencies and in constipation, when the bowel must be kept open before
treatment has produced much effect, there should be an effort made to
break up any cathartic habit which may be formed. The enema is a most
valuable aid, but it must be given correctly. The patient should be
instructed that a fountain syringe is preferable, and that it must
never be taken standing. This merely fills and distends the rectum,
or lower sigmoid at the best, and is passed without any or with very
little effect. Lying on the right side is a very good position, as is
also on the back with hips elevated, but the knee and chest is best in
most cases. The water should be a little above body temperature and can
be saponified or used clear. The effect will be about the same. The
tube should be perfectly smooth and well lubricated and introduction
must be made with care so as not to bruise or irritate. The water,
having been allowed to run to expel the air, may be now started and
will separate the mucous folds and allow easy penetration. The rubber
tube should be held between the thumb and finger, so the flow can be
stopped as soon as it meets an obstruction. When this is passed the
flow can begin again and continue until the required amount (from one
to two quarts for an adult), has been taken, or until the feeling of
distention becomes too great. By following this method, much of the
distress and colicky pains which sometimes accompany an enema, may be
avoided. Water should be held for some minutes, to allow softening of
the fecal mass. In many impactions it is important to get the water
into the ascending colon. For that purpose nothing is better than a
Coles sigmoid irrigator. This is shaped somewhat like the letter S
and is about a foot long from tip to tip. Its introduction is not
difficult, but care must be used. Place the patient on the right side
and stand in front, having the bag suspended near. Introduce the tube
and with slow, gentle pressure let it follow the course of the bowel.
When the splenic flexure is reached, it will stop, but by letting a
little water flow, the bowel will distend and it will pass. When in the
full length, the end will be near the median line and in the transverse
colon. Now let the water flow slowly, stopping frequently, and with
one hand gently lift and work the abdomen. This will both soften the
contents and aid the water in reaching the farthest point. It is not
well to give more than a quart the first time, as there is apt to be
some prostration. The tube also has the mechanical effect of raising
and replacing the sigmoid, descending colon and splenic flexure. When
there is lack of tone to the bowel or when very little stimulus is
needed, a half pint of cold water taken in the morning, will often
act quickly. Appliances which force the water into the bowel when the
patient is sitting, are not recommended, as they tend to stretch the
muscular coat by pressure from lifting a column of water.
=Hernia.=—There are several methods of replacing a hernia. The first
endeavor, in every instance, must be to reduce it, whether it be
strangulated, incarcerated or simply protruded. One of the easiest and
commonest methods is to place the patient on his back, the buttocks
elevated, the legs flexed upon the thighs, the thighs flexed upon the
abdomen, and the limb on the affected side slightly rotated inward, so
that the columns of the ring about the hernia may be relaxed. After the
hernia is protruded a little more, so that its contents may be emptied
readily, a gentle pressure with the thumb and finger is made upon the
upper part of the tumor, when the rest will follow. A gurgling noise
is heard upon reduction. Cases that cannot be reduced and are causing
acute obstruction of the intestines, should be treated surgically.
Incomplete hernia, which does not show externally, may be present and
cause severe reflex symptoms. Considerable attention has been given to
this by some investigators. The patient is placed in the Trendelenburg
position and the bowel lifted out of the fossa. If any signs of
hernia are present a well fitting truss will often cause it to heal.
Exercises, in a few instances, will be beneficial.
Appendicitis
=Appendicitis= is an inflammation of the appendix vermiformis. In a
few cases the cecum and surrounding tissues are involved (typhlitis,
perityphlitis). The vasomotor nerve supply comes from the lower three
dorsals and upper two lumbars. The sensory nerves make their exit from
the three lower dorsals. Appendicitis is nearly always predisposed
by injury to the innervation of the vermiform appendix and immediate
region, vertebral derangements or subdislocations from the tenth dorsal
to the third lumbar. The vermiform appendix is a peculiarly constructed
organ, and its function has not been determined with positiveness. It
undoubtedly has a function and possibly a very useful one. Sir William
Macewen[82] does not share in the general belief that the appendix is
without function, but protests against its indiscriminate removal,
believing it has a powerful influence over the function of the colon.
“Yet thousands have been operated and show no ill effect.” This is in
keeping with the ideas of Dr. Still, who always maintained that the
appendix is of importance to the human economy. Although the organ has
been found in various localities of the abdomen, this fact and others
do not necessarily indicate that it is a functionless relic. It is
richly supplied with lymphatic and blood-vessels and has a peristaltic
action peculiar to itself. When the organ is in perfect condition,
foreign material probably would not find a lodging point in it, on
account of its peristalsis. Dr. Still[83] suggests that the appendix
has a sphincter, also the power to contract, dilate or shorten, should
any foreign substance enter, and he worked with this idea in view with
uniform success. The truth of this theory has been proved by Abrams[84]
who has demonstrated by the aid of the fluoroscope that peristalsis of
the appendix can be stimulated by percussion at the 10th dorsal and it
made to empty and fill itself. Abrams makes use of this fact in the
treatment of catarrhal appendicitis. Appendicitis may also be caused
by fecal impactions and foreign bodies in the bowel contiguous to the
appendix. In these cases there is usually an impaired innervation
from the spine, due to vertebral and lower rib lesions, resulting
in a weakened muscular coat and catarrhal congestion of the mucosa.
In a word, prolapse of the bowel at this point is a predisposing
common cause. In various instances abrasions of the coats of the
tube occur, or the innervation or vascular supply is impaired, and
pathogenic bacteria, as bacilli coli communis, streptococci pyogenes,
staphylococci pyogenes aureus, typhoid bacilli, tubercle bacilli and
others, find a favorable lodging point and determine the nature of
the disease. Injuries to the spinal column and displacements of the
vertebræ in the lower dorsal and lumbar regions, straining and lifting,
tight lacing, torsion of the appendix, traumatism, impaction of feces,
concretions and foreign bodies, acute indigestion, indigestible food,
overeating, exposure to wet and cold, and infectious diseases (as
typhoid fever, tuberculosis and influenza), are all in the list of
causes of appendicitis.
=Pathologically=, in most cases the inflammation is catarrhal. This
includes many of the mild attacks. The mucosa is inflamed similarly
to catarrhal processes elsewhere, although the inflammation may
rapidly spread to the deeper structures unless immediately cared
for. The inflammation may be so severe that the lumen becomes
closed. This is termed =obliterating appendicitis=. When this occurs
the attack may cease and danger from subsequent attacks are at an
end, but inflammation may go on to purulent involvement and even
to =ulceration=, =gangrene= and =perforation= or =peritonitis=. An
=abscess= may be within or without the appendix. =Adhesions= are likely
to form about the mass.
=Symptoms.=—A sudden, violent pain in the abdomen, usually localized in
the right iliac region, although at first this pain may be general. The
point of greatest tenderness is detected over McBurney’s point—a point
at the intersection of a line between the umbilicus and the anterior
iliac spine, with a second drawn along the outer edge of the right
rectus muscle. The patient usually lies on the back with the right leg
drawn up. The severity of pain is not indicative of the seriousness. If
the pain ceases suddenly, it is commonly a serious indication. There is
usually fever at the onset, the temperature being from 100 to 102 or
even 104 degrees F., and very rarely preceded by a chill. In favorable
cases the temperature gradually falls, reaching normal in from five
to seven days. If recovery has not begun by this time an abscess
is probably forming. If =suppuration= takes place the temperature
continues with but slight fall, although in some cases there is a rise,
or it may become almost normal. Pain in the right iliac fossa, without
fever, rarely points to an acute attack of appendicitis. Vomiting and
nausea are more or less frequent, and more commonly present in the
event of perforation or rupture of an abscess. In favorable cases
vomiting rarely lasts beyond the second day. In the majority of
cases constipation is present from the beginning of the attack, due
to paralysis of the bowels. There may be diarrhea, particularly in
children.
“=Urine= is febrile in character with large quantities of indican. The
=blood= shows leucocytosis. A leucocyte count of 20,000 is high and
indicates an acute appendicitis, with pus, gangrene or peritonitis.”
On =inspection= of the abdomen at the onset of the attack, the
sides look alike, but on =palpation= there is rigidity of the
rectus abdominis muscle and the other muscles overlying the seat of
inflammation. The whole abdomen may be slightly distended. In the
majority of cases there is a progressive development of a hard swelling
or tumor in the right iliac fossa. These tumors vary in size, but
are usually oval and the size of a hen’s egg, and generally situated
a little above Poupart’s ligament. =Fluctuation= of the tumor is
indicative of suppuration. There is often great irritability of the
bladder and frequent micturition. A sudden fall in the temperature
often indicates that a perforation has taken place, or that a small
abscess has ruptured into the intestines. In favorable cases the
temperature falls at the end of the third or fourth day, the pain
lessens, the tongue becomes clearer and the bowels are moved. If the
tumor persists, the patient is very liable to have a =recurrence= of
the condition.
Rapid growth of the tumor and aggravation of the several symptoms
point to suppuration, especially =extreme tenderness= over the point
of inflammation. If the appendicitis goes on to suppuration, there
is danger of rupture into the peritoneum. In a few cases the abscess
may rupture into the bowel, in which case the patient recovers. Other
terminations are lumbar abscess, hepatic abscess and perinephritic
abscess. Death may be caused by septicemia or pylephlebitis. These
events may be delayed a variable length of time, depending upon the
extent and strength of the adhesions that form about the abscess. “The
gravity of the appendix disease lies in the fact that from the very
outset the peritoneum may be infected; the initial symptoms of pain,
with nausea and vomiting, fever, and local tenderness, present in all
cases, may indicate a widespread infection of this membrane.” (Osler).
He also says local signs are not so trustworthy as the general symptoms.
There is liability to =relapse in appendicitis=. The attacks may
recur for years at different intervals. In some cases these intervals
are very short. In some cases perfect recovery may take place after
repeated attacks.
=Diagnosis.=—In many cases the diagnosis is easy, but other cases
require careful study and close observation. Sudden pain becoming
localized, tenderness and rigidity in the right iliac region are three
symptoms that together almost positively indicate appendicitis. The
leucocyte count is of particular value. A =pseudo-appendicitis=, with
all symptoms of true appendicitis in the initial stage, may be caused
by the downward dislocation of the twelfth rib on the right side, and
occasionally the eleventh rib on the same side. The rib lies obliquely
downward toward the crest of the ilium. In a few cases the obliquity
of the lower rib is so great as to very nearly touch the ilium. The
dislocated rib may produce severe irritation, pain, tenderness,
rigidity, and even inflammation, of the abdominal muscles. The patient
nearly always complains of the pain being deeply seated, thus possibly
confusing one. In =typhoid= there is a gradual development of the
fever, characteristic temperature curve, enlargement of the spleen,
epistaxis and diarrhea. The Widal test should be made. The absence of
fever and intermittent pain in the abdomen, with complete constipation,
fecal vomiting, general distention of the abdomen, bloody stools and
marked tenesmus would determine =intestinal obstruction=. In =tubal
disease= a gradual onset, a more dull and constant pain, the history,
and pelvic examination will usually differentiate this disorder from
appendicitis. Kelly[85] gives these points in differential diagnosis,
between acute salpingitis and appendicitis: “In the former it will
usually be found that there has been a yellowish vaginal discharge
for some period before the attack. The local pain and tenderness,
usually located deeper in the pelvis, is most intense on palpation in
the region of Poupart’s ligament. On vaginal examination exquisite
tenderness is felt on either side of the uterus.” In =biliary colic=
the pain is higher along the biliary ducts and gall-bladder, extending
even as high as the shoulder, and jaundice is generally present. In
=renal colic= the pain extends along the ureters down to the inner side
of thigh and testicle, and back into lumbar region. There is absence
of fever and rigidity. The pain in =perinephritic abscess= is downward
into groin, as in nephritic colic, and there is tenderness of the
lumbar region. Exploratory incision may be necessary.
=Prognosis.=—Naturally, the prognosis depends upon the character of
the appendicitis, but on the whole the prognosis is favorable. A
large proportion of cases recover. Surgical operations are many times
deferred until too late; undoubtedly on account of the uncertainty of
the condition. Still, on the other hand, many serious cases recover
under the proper treatment when an operation seemed almost absolutely
necessary; all going to prove the fact that very much depends upon
diagnosis of the true condition. The statement that there is “no
medical treatment for appendicitis,” seems rather broad in view of the
report of the medical inspector[86] of the French Army in Algeria.
Out of 668 patients suffering from appendicitis, 188 were operated
upon and 23 died, while 408 were treated medically and only three
died. He concluded that a meat diet tended to increase the number of
cases. “It is exceedingly common and the prognosis is, on the whole
favorable. Tafft, of Copenhagen, found adhesions in the neighborhood
of the appendix in 35 percent, of all bodies subjected to post-mortem
examinations[87].
=Treatment.=—Confine the patient in bed at once. Cases have undoubtedly
been lost by not enforcing this point. Attempts should be made to
correct the disordered condition of the dorsal and lumbar regions.
Thorough and careful treatment should be given at this point, and in
most instances the pain can be relieved by correction of the disordered
vertebræ. If the case is seen at the beginning of the attack, careful
manipulation that especially lifts the cecum and surrounding structures
and local application of ice are indicated. However, great care
should be exercised here, for some of the most severe cases show no
induration. Temperature, pulse, and blood picture are invaluable as
guides. When the case is advanced, extreme care should be used in
manipulating over the swollen and inflamed region. Hot applications
will be helpful in such instances.
When due to fecal impaction and foreign bodies, thorough, direct,
elevating treatment over the involved region, and high rectal
injections are indicated. This applies to the onset, for if the disease
has progressed to the point where pus may be present, the =bowel=
must be =absolutely= at =rest=. Do not give or allow to be given
purgatives at any stage of the disease. When =sure= that =there is
no pus=, direct, careful work over the cecum and appendix is allowed
and is of value. It should be a lifting of the colon and relaxing of
nearby tissues, to promote the circulation. Treatment of the spine
is necessary in all cases, to relieve pain, to correct the nerve and
vascular supply, and to increase peristalsis so as to remove irritating
bodies from the vermiform appendix. “Colitis follows appendectomy more
frequently than any other abdominal operation. The explanation for
this is that the appendicitis is seldom localized in the appendix but
is complicated by colitis, or rather the colitis is complicated by the
appendicitis. In such cases, removal of the appendix aggravates rather
than alleviates. A conclusion to be drawn is, to carefully palpate the
colon in all appendicitis cases and reserve diagnosis, prognosis and
advising of an operation until it can be definitely determined as to
the location, extent and degree of the disease. The formation of pus is
an indication requiring immediate evacuation.
“If good surgical advantages are available and the case begins with
considerable virulence and a surgeon can be had within the first twenty
four hours, it is in all probability best to operate; but if the case
begins slowly or no good hospital advantages are available, or if the
case is not seen until some forty-eight hours have elapsed after the
onset, in all probability it is strictly an osteopathic case and should
not be touched by surgery. Some advocate in all instances to wait until
pus is formed before operative procedure is resorted to. This is a
rather dangerous attitude to take, for I have seen hundreds of cases
operated and have operated upon a great many myself and I have never
seen a case die unless it was a pus case.”—S. L. TAYLOR.[88]
The case should be most carefully watched, and a surgeon should be
promptly called for consultation if the occasion demands it in the
least; and if thought advisable, operation should be resorted to before
too late. Do not assume too much responsibility in these cases. The
patient should be nourished on a restricted diet of milk and animal
broths. Asa Willard[89] strongly recommends no food by mouth, as it
is bound to set up peristalsis and cause increased irritation. He
sustains the strength by rectal feeding. This view is held by other
authorities, even to withholding water when the inflammation is at its
height. Tasker confirms the advisability of restricted feeding and
advises resting the bowel even to the point of discontinuance of food.
The course of the attack is usually so short that there is no danger of
starvation and little loss of strength results. This point is a highly
important one in cases of any degree of severity.
In =chronic cases= of a fibrotic character, no pus, carefully lifting
the parts and loosening adhesions in addition to spinal adjustment
will often restore normal circulation. These conditions aside from the
local disorder frequently cause hyperchloridia and other digestive
disturbances.
Diseases of the Liver and Bile Duct
Primary diseases of the liver will invariably present osteopathic
lesions from the fourth or fifth dorsals to the eleventh or
twelfth. The ribs on the right side are commonly involved. These
lesions probably disturb the liver by way of the vasomotor fibers.
Displacements of the duodenum, of the hepatic flexure and transverse
section of the colon and displacements of the right kidney are frequent
sources of liver disorders. Care should be taken in differentiating
primary from secondary diseases, for naturally the relative importance
of the various factors in treatment will vary. In many secondary
diseases there will be found predisposing osteopathic lesions, and
these secondary disorders and degenerations can at least be palliated
and occasionally the degeneration retarded or stopped by persistent
osteopathic treatment, diet, and hygienic measures.
Hyperemia of the Liver
This is an abnormal fullness of the blood-vessels of the liver,
followed by an enlargement of that organ. It is active when there is
abnormal pressure in the portal veins (afferent vessels); passive when
there is excessive pressure in the sublobular veins (efferent vessels).
=Osteopathic Etiology= and =Pathology.=—=Active hyperemia= is usually
due to indiscretions in diet. After each meal a physiological hyperemia
of the liver occurs, which is greatly increased by habitually
overeating and overdrinking. This condition may lead to functional
disturbance and possibly to organic change. Traumatism and lesions of
the vertebræ and ribs, irritating vasomotor nerves, are important.
Habitual constipation, malaria, heat, and arrested menstrual epoch, and
infectious fevers are also causes of the active form. Enteroptosis is
not a rare cause.
=Passive hyperemia= is due to obstructions of the efferent circulation.
Valvular heart disease is the most common cause. Lung diseases, as
emphysema or cirrhosis; obstruction to the vena cava or interference
with the flow of blood through the liver; and diseases of the pleura,
are among the causes.
Most cases of congestion of the liver present lesions to the vasomotor
nerves of the liver, fifth to ninth dorsal. Especially are the ribs
over the liver apt to become displaced and affect the organ.
=Pathologically=, the liver is enlarged and engorged with blood. The
appearance of the organ depends upon the duration of the hyperemia.
In passive hyperemia the central portion of the lobule and the area
of the hepatic vein are deeply colored. The periphery and the area of
the portal vein are pale. This alternation of the dark and light color
gives rise to the nutmeg liver, which is so noticeable upon section. In
cases of long standing, atrophy of the liver cells and overgrowth of
connective tissue result.
=Symptoms.=—=Active Hyperemia.=—Dull aching and a sense of fullness in
the right hypochondrium, aching of the limbs, coated tongue, nausea,
vomiting, constipation, highly colored urine, and slight jaundice.
In =passive hyperemia= the symptoms are the same, but less marked. The
onset is gradual and the liver may attain considerable size. In severe
cases following tricuspid regurgitation the liver may pulsate. In
severe cases dropsy takes place.
=Diagnosis.=—Active hyperemia is occasionally confounded with catarrhal
jaundice. Usually congestion of the liver is easily diagnosed.
=Prognosis.=—In active hyperemia the prognosis is good, unless repeated
attacks lead to atrophic degeneration. In passive hyperemia the
prognosis depends entirely upon the cause.
=Treatment.=—=Active hyperemia.=—The treatment consists of measures
which tend to diminish the congestion, principally a thorough, direct
manipulation over the liver by raising and spreading the ribs. Careful
and thorough treatment to the dorsal splanchnics of the liver is also
indicated. The substitution of a scanty for a heavy diet is essential.
The foods given should be such as are easily digested, as milk and
broths; fats and sugars are to be avoided.
In =passive hyperemia= the treatment consists of correcting the
disorder causing it. Often heart diseases are the cause. A thorough
depletion of the bowels will aid largely in relieving ascites that may
follow passive congestion (See ascites).
In liver congestions it is well to pay attention to the intestinal
condition in order that the circulatory mechanism here may be
thoroughly coordinated with the hepatic.
Simple Catarrhal Jaundice
=Definition.=—Jaundice due to inflammation of the terminal portion of
the common duct, not the result of impacted gall-stone. The disease
probably starts as a catarrhal inflammation of the stomach and upper
portion of the small intestine. The bile is retained and absorbed.
=Osteopathic Etiology= and =Pathology=.—A frequent predisposing
cause is the subdislocation of the tenth rib on the right side, thus
interfering with the innervation to the bile ducts, and causing
congestion of the mucous membrane of the common duct; although lesions
above and below this point may occur. Extension of gastro-duodenitis
into the common duct is a common source of the inflammation. Sagging of
the duodenum will disturb the bile-duct through its being a portion of
the duodeno-hepatic ligament. Duodenal catarrh usually follows errors
in diet, exposure, malaria, Bright’s disease, portal obstruction and
chronic heart disease. Infectious fevers, as pneumonia and typhoid
fever, and emotional disturbances are among the causes. Catarrhal
jaundice may occur in epidemic form.
=Pathologically=, the duodenal end of the duct is most commonly
involved. The mucous membrane is swollen and the orifice fills with
mucus. The inflammation may involve the common and cystic ducts and
even the hepatic. The liver is enlarged and the gall-bladder distended.
=Symptoms.=—The only symptom present may be simply the jaundice. There
is always tenderness upon pressure over the ducts. The patient many
times complains of a stabbing pain when pressure is exerted over the
duodenal opening. Usually the course of the bile duct can readily be
felt upon deep pressure, owing to the tumefaction. Accompanying this
condition may be general malaise, loss of appetite, nausea, vomiting,
constipation or irregular action of the bowels, pains in the back and
limbs and a slight fever.
=Diagnosis.=—Where jaundice is present without pain, it generally
indicates catarrhal jaundice. The absence of emaciation or of evidences
of cancer or cirrhosis usually makes the diagnosis easy. Good general
nutrition and a negative physical examination favor simple jaundice as
to the diagnosis.
=Prognosis.=—The prognosis of catarrhal jaundice is favorable, unless
accompanied with infectious diseases or hypertrophic cirrhosis. When
diseases are associated with jaundice the danger is usually from the
disease. The duration of the disease is generally given as from two to
eight weeks, but osteopathic treatment generally lessens that time at
least one-half.
=Treatment.=—The treatment is directed toward relieving the
inflammation of the bile ducts and increasing the flow of the bile into
the intestines. Great relief to the patient will be experienced from
thorough treatment over the bile ducts, especially at the duodenal end.
Press slowly but firmly over the region of the ducts, then execute a
downward motion with firm pressure over the course. This performance
should be repeated several times, until the tenderness in this region
is almost or entirely relieved. The idea of this treatment is, =first=,
to slowly but firmly bear down upon the abdominal muscles over the
congested tissues, so as to relax the tissues and get as close to
the ducts as possible, and =second=, with the downward movements to
reduce the congestion of the ducts and at the same time to remove any
mucus or other material from the orifice, thus allowing a freer flow
of bile. It will be recalled that the normal flow of bile is under
very low pressure. Care should be taken not to gouge or dig into the
tissues with the ends of the fingers, but to use the flat surface
of the fingers. Any gouging or severe treatment will not allow one
to accomplish his purpose, owing to the stimulus or irritation it
would give the abdominal muscles and thus cause them to contract; and
furthermore, it would more or less bruise the parts. An inhibitory
treatment should be given along the spine on the side affected to help
relax the abdominal muscles before this treatment is administered. In
all circulatory disturbances of the bile-duct and other hepatic tissues
lift the duodenum at about the second lumbar where it lies beside the
ascending colon. This tends to release portal vein, hepatic artery and
bile-duct, the duodeno-hepatic ligament.
=Direct treatment= is given to the liver by more or less kneading or
working the organ and also by raising and spreading the ribs. This
treatment is to stimulate the activity of the liver. Reaching under
the cartilages of the eighth and ninth ribs on the right side and
bearing inward and downward will empty the gall-bladder and thus be of
aid in relieving the tension in the biliary passages. It is probably
a stimulus to these cutaneous fibers that causes a relaxation of the
sphincter muscles of the gall-bladder and thus allows it to empty.
Stimulation of the tenth nerve contracts the gall-bladder. Then it
should also be noted that work over the duodenal end of the bile-duct
relaxes the orifice while through reciprocal relationship the fibers
of the gall-bladder contract. When all of the muscles of the hepatic
region have been carefully relaxed and softened, a thorough examination
can then be made of the vertebræ and ribs that might embarrass the
innervation or vascular supply of the liver. Lesions of the vertebræ
and ribs affecting the liver may occur from the sixth to the eleventh
dorsal. Lesions to the vagus and phrenic nerves may occasionally
involve the organ.
Irrigation of the large bowel with cold water may be employed. The cold
excites peristalsis of the gall-bladder and ducts. Drinking freely of
water will be helpful. A non-stimulating diet should be given. The
stomach may not be in a condition to bear solid food; and furthermore,
food on entering the duodenum will increase the local inflammation of
the common bile duct. Give diluted milk, buttermilk, light meat-broths,
clam-broth, egg albumin and pressed beef juice. After the pain,
vomiting and fever subside, the diet can be gradually increased.
Cholecystitis
=Cholecystitis= is an inflammation of the gall-bladder caused
by infection. Stagnation of bile due to obstruction (especially
gall-stones) of the bile ducts, or a slowing of the bile flow owing
to deranged innervation from osteopathic lesions or sagging bowel,
are predisposing factors. Fibrotic changes in the appendix are fairly
common sources that derange the nervous reflexes of the biliary
function. The disorder may be associated with specific fevers.
Exciting factors are the colon bacilli, streptococci, staphylococci,
typhoid bacilli, and pneumococci.
=Symptoms.=—The gall-bladder feels hard and full. There is inflammation
and thickening of the mucous membrane, with considerable increase of
mucus. Owing to the infection there may be ulceration and suppuration,
with possible perforation and peritonitis. When the inflammation
extends outside of the bladder there are usually adhesions.
The onset is commonly sudden, with pain and tenderness in the right
hypochondrium. Great care should be taken in deciding the location of
the inflammation, for the pain and tenderness may be over the stomach,
or along the duodenum or ascending colon as low as the cecum. Nausea,
fever, constipation, and possibly jaundice, are other symptoms.
=Treatment.=—Exercise special care in treating these cases. Although in
many instances the inflammation will rapidly subside, still owing to
suppuration there is danger of aggravating the condition. It is better,
in doubtful cases, to confine the treatment to spinal work, and to
influence drainage by placing the patient in knee-chest position and
carefully raise cecum, ascending colon and duodenum. Rest, restricted
diet, plenty of water, and hot fomentations will be beneficial. In
severe cases surgical interference is indicated.
Jaundice
(ICTERUS)
=Jaundice= is a symptom and not a disease. It consists of the
discoloration of the skin and other tissues by material derived from
the bile. The discoloration may vary from a mere paleness to a yellow
or brown olive hue.
=Toxic= jaundice occurs in acute yellow atrophy, pernicious anemia,
pyemia, specific fevers, and the action of poisons.
=Obstruction= by foreign bodies as gall-stones and parasites are
important causes. Inflammation and swelling of the biliary ducts and
duodenum are common causes as well as stricture of the duct by tumors
and various growths, either internal or external, to the biliary ducts.
In some instances pressure from without by the pancreas, stomach,
kidneys, enlarged glands, fecal matter, a pregnant uterus, etc., has
been the cause. Irritations and obstructions of the splanchnic nerves,
due to lesions in the lower dorsal vertebræ and the ribs from the sixth
to the eleventh, will often markedly affect the liver. Also lesions at
these points may predispose to inflammation and tumefaction of the bile
ducts.
=Symptoms.=—Besides the discoloration of the skin, there is itching
of the skin, on account of bile pigment deposits; even eruptions may
occur. The mucous membranes are often colored and a constant symptom
is the bright yellow discoloration of the sclerotic coat of the eye.
The secretions are colored. It may be first noticed in the urine. The
perspiration is colored, rarely the saliva and tears. There is frequent
sweating.
As very little bile passes into the intestine, the feces are pale
and gray, and sticky. The bowels are generally constipated, but
diarrhea may occur, owing to decomposition resulting from absence of
the normal ingredients. Other symptoms may be associated with the
gastro-intestinal derangements, as nausea, fetid breath and loss of
appetite. A slow pulse may occur, due probably to some stimulating
effect on the inhibitory action of the vagus nerve. Lesions are often
found at the atlas and axis, affecting the vagus. Pain back of the
right scapula is a symptom of liver trouble; it has been suggested that
it is due to a stimulus passing up the vagus to the spinal accessory,
and thence to the trapezius muscle.
Various cerebral symptoms may be present, as great depression,
irritability, headache and vertigo. In severe cases there may be
delirium and coma.
In =hemolytic= and =toxic jaundice= the destruction of blood is due to
some toxic agent. The feces are not clay colored and the urine is less
stained with bile. The general symptoms may be very severe depending
upon the underlying cause.
=Diagnosis.=—To mistake for jaundice the dirty yellowish discoloration
of the skin commonly termed sallowness is an error often made. This
condition indicates malaria, uterine disease or general ill health.
Very likely it is an anemia and is readily diagnosed from the jaundice
as the secretions and conjunctiva are not stained. Addison’s disease
somewhat resembles jaundice, but the feces are normal, the urine and
sclerotic coat are not colored, but exposed portions of the body and
flexures of the joints are deeply stained.
=Prognosis.=—Depends entirely on the cause producing it. Ordinary cases
run from two to six weeks, while others may not recover for several
months. Jaundice from impaction of the bile ducts may be manifest for
only a few days. Toxic form may terminate fatally, owing to the disease
causing it. The extent of resorption of bile and destruction of red
blood cells in the liver varies to a considerable degree.
=Treatment.=—The treatment for the different forms resulting
secondarily will be found under the diseases causing them. A simple
icterus, caused by disturbance through the innervation of the liver
and bile ducts directly, can be relieved readily by thorough treatment
of the liver and bile ducts as described under catarrhal jaundice.
Carefully raise the intestines if they are prolapsed, especially the
colon and duodenum.
Cirrhosis of the Liver
This is a chronic disease of the liver, characterized by hyperplasia of
the connective tissue with destruction of the liver cells, resulting in
the organ becoming hard and usually small.
=Etiology.=—The disease usually occurs in the male sex and in middle
life. When occurring in children, it is commonly of the syphilitic
form, though it may be due to other infections. The abuse of spirituous
liquors is a common cause. It follows chronic diseases, such as
syphilis, long continued malarial intoxication, gout and tuberculosis.
Passive congestion, due to chronic heart and lung disease, causes some
cases. A few cases are caused by inflammation of the bile ducts, due to
infection and obstructing calculi; others to a stimulating diet, while
some cases are inexplicable.
=Pathologically=, the =first stage= is hyperplasia of the connective
tissue and consequent enlargement of the organ. As this increases the
connective tissue destroys immense numbers of the hepatic cells, owing
to the pressure. Often the enlargement is accompanied by tenderness. In
the =later stage= the overgrowth of imperfectly developed tissue seems
to contract the hepatic cells that still remain, causing atrophy and
degeneration of most of them, and thus reducing the size of the organ,
which is followed by sclerosis. The portal and hepatic circulations
are greatly obstructed. An occasional form is termed =hypertrophic
sclerosis= in which sclerosis is found while the organ continues
enlarged.
There are two common and well defined varieties, atrophic cirrhosis and
hypertrophic cirrhosis; other forms (rare) are met with.
=Atrophic cirrhosis= is the common form, and is usually due to
alcoholic excess. The surface of the liver is rough and uneven in
addition to its hardness and reduction in size. It may also be greatly
deformed and covered with granulations (“hob-nails”). The normal weight
is four or five pounds, but it may be so reduced as to weigh no more
than one pound or a pound and one-half. Sometimes there is =fatty
infiltration=, which enlarges the liver to such an extent that the
contraction is not noticed. There is an overgrowth of the connective
tissue, which contracts and constricts the branches of the portal
vein, causes atrophy and degeneration of the hepatic cells, and even
sometimes obliterates the bile ducts. The new connective tissue is
well supplied with blood-vessels from the hepatic artery, thus aiding
greatly in the growth.
In the =hypertrophic form=, as well as in the atrophic cirrhosis, there
is an overgrowth of connective tissue, but in the hypertrophic form the
new form of tissue exhibits no disposition to contract. The enlargement
of the organ is largely due to hyperemia. As the tissue does not
contract there is no pressure on the portal vein and atrophy is
prevented. There is early jaundice (which is a characteristic symptom)
owing to obstruction of the biliary channels. The surface is smooth and
its color is greenish yellow.
=Symptoms.=—=Atrophic Form.=—There may be practically no symptoms.
As there is obstruction of the portal circulation, there may be
congestion of the stomach and intestines, resulting in chronic
gastric or intestinal catarrh having the following symptoms—anorexia,
distress after eating, distention, constipation and coated tongue.
Owing to the anastomotic communication between the portal and caval
circulations, as the portal circulation becomes more obstructed, the
superficial abdominal veins become greatly distended. Hemorrhoids
occur, owing to the communication of the superior hemorrhoidal,
which is a branch of the portal vein through the inferior middle
hemorrhoids, with the hypogastric vein and the vena cava; hence
hemorrhoids are a characteristic symptom. There is enlargement of the
spleen and hemorrhage from the stomach or bowels. Edema of the legs
and ascites are due to engorgement of the portal system. Ascites is
much more common than edema of the legs. There may be slight jaundice,
although this is a rare symptom in atrophic cirrhosis. There is
always decided emaciation. On examination there is a diminished area
of hepatic dullness, while the splenic dullness is enlarged. It is
often impossible to outline these organs, as the abdominal distention
prevents it. The urine is scanty, high colored and often loaded with
urates, but seldom bile-stained.
In the =hypertrophic form= slight jaundice appears at the onset, which
gradually deepens until it is intense and persistent. Occasionally
there is fever. The disease as a rule is decidedly chronic, though
acute symptoms may develop at any period. The urine is often
bile-stained, but of normal quantity. On examination the liver is
large, smooth and round and can be felt below the ribs. The spleen is
greatly enlarged.
=Diagnosis.=—In =atropic cirrhosis=.—With ascites without dropsy
elsewhere, history of alcoholism, hemorrhage from stomach or bowels and
reduction in size of liver, the diagnosis is absolute.
=Hypertrophic cirrhosis.=—In =cancer= of the liver the patient is
advanced in years, has no splenic enlargement, and more commonly
ascites is present; while in hypertrophic cirrhosis there is chronic
biliary obstruction, the liver is only moderately enlarged and hard,
marked jaundice, with causes leading to or evidence of hepatic
obstruction. This form of cirrhosis is also to be differentiated from
=amyloid liver= and =echinococcus cyst=.
=Prognosis.=—Unfavorable, although in some cases the disease can be
arrested during the early stage, provided the habits are regulated
and treatment is continuous and persistent. Death usually occurs from
one to two years after appearance of dropsy. Ascites is difficult to
contend with.
=Treatment.=—If the disease is recognized at the beginning and
persistent treatment given to the liver, the chances are that atrophy
of the cells and connective tissue formation will not take place. But
ordinarily cases of cirrhosis are incurable. The most that can be done
is to reestablish a compensatory circulation in the liver. Otherwise
it would be no more unreasonable to say that one could cure a chronic
valvular lesion of the heart. The patient should live a quiet outdoor
life. Alcoholic drinking should be stopped. The diet should be light
and nutritious, preferably a milk diet. The bowels should be kept open,
the skin active and the kidneys closely watched.
Fatty Liver
In fatty infiltration there is no loss of function. The fat infiltrates
the cell, crowding aside the protoplasm. This is largely a normal
process, though fatty degeneration may be associated.
In fatty degeneration the cell loses its structure and is changed into
fatty tissue. Chronic intoxication from infectious diseases, such as
phthisis puerperal fever, typhoid fever, pneumonia and syphilis are the
principal causes. Alcoholism and phosphorous poisoning are other causes.
Amyloid Liver
There is infiltration into the tissues of the liver, of the so-called
amyloid substance. The infiltration begins in the blood-vessels, the
hepatic artery first, then the central zone or periphery, and finally
all structures of the liver. This disorder should be viewed as a
disturbance of metabolism.
=Etiology= and =Pathology=.—This condition is usually found in cases of
prolonged suppuration, especially associated with tubercular disease
of the bones as in hip-disease, syphilis, rickets, malaria, cancer
and leukemia. It is believed by some to be the result of microbic
invasion, especially the tubercle bacillus and staphylococcus. Lesions
are frequently found from the fifth to the tenth dorsal vertebræ, which
probably act as predisposing factors.
The liver is considerably enlarged and rounded. It is pale or waxy in
appearance and is doughy in consistency. On section it is anemic and
whitish, partly due to infiltration into the walls of the blood-vessels
narrowing the lumen. The amyloid changes may be circumscribed and in
some cases fatty infiltration is present.
=Symptoms.=—There are no characteristic symptoms except the enlargement
of the liver, although the complexion may be waxy and there may be some
gastro-intestinal disturbances. Pain is absent, although occasionally
there is a dragging sensation, due to the weight of the organ. Jaundice
is not present, but the stools may become light colored, owing to a
diminished secretion of bile. The urine may be increased in amount and
contain some albumin if amyloid occur in the kidneys. Emaciation and
anemia are present and ascites seldom occurs. Amyloid changes involve
the spleen, kidneys, intestines and other organs.
=Diagnosis.=—The organ being large, hard and smooth, with absence of
jaundice and ascites, the presence of albuminuria and an enlarged
spleen and with the history of the case, mistakes are not likely to be
made.
=Prognosis.=—Depends upon the cause. The progress may be rapid or slow.
=Treatment.=—Careful attention to the primary disturbing factor and
direct treatment to the liver will, in some instances, reduce the
size of the organ. Nitrogenous food and hygienic measures should be
instituted. The vasomotor nerves of the portal system (fifth to last
dorsal) should be treated thoroughly.
Gall-Stones
=Gall-stones= are concretions that originate in the gall-bladder
and occasionally in the hepatic ducts. “The primary formation of
gall-stones is itself largely dependent upon =stagnation= of bile,
such as may arise in the gall-bladder if an intermittent or incomplete
closure of the cystic duct be brought about by such things as
tight lacing, pregnancy, or even unequal sagging of the abdominal
viscera.”—MacCallum. The stone is largely composed of cholesterin, and
may form without any inflammation of the gall-bladder, owing probably
to the stagnation affecting the bile salts so that the cholesterin is
precipitated instead of being held in solution.
More often there is inflammation of the wall of the gall-bladder due
to micro-organisms. This causes an exudate from which is derived the
calcium. The calcium with bilirubin is deposited in layers on the stone
which give it the various colors of yellow, brown or green.
A rare type is one formed in the hepatic ducts, which is soft, green,
and composed of calcium bilirubin concretions.
The stones “contain a great deal of organic material derived from
desquamated epithelial cells and coagulated albuminous matter, as well
as pigment.” The colon bacilli, staphylococci, streptococci, typhoid
bacilli, and pneumococci are the bacteria most frequently found. A
=cholecystitis= may be a predisposing factor or it may be secondary to
the concretion.
=Osteopathic Etiology= and =Pathology=.—This is a disease of middle
life and is more frequently found in women. Sedentary habits and
constipation combined with overeating, are other important factors.
It is found in stout subjects who are particularly fond of starchy
and saccharine food. Catarrhal jaundice is a predisposing factor.
Depressing mental influences may predispose. The thicker the bile the
more likely it is to deposit. Dr. Still’s theory is that lesions of the
ribs on the left side from the sixth to the tenth dorsal are factors
in the formation of the stones as they interfere with pancreatic
secretions. No matter how it comes about, the fact is that in all cases
of gall-stones the osteopath finds lesions to the eighth, ninth and
tenth ribs on the left side, as well as lesions from the fifth or sixth
to the tenth dorsal, deranging innervation to the liver and bile ducts.
It is possible that lesions over the spleen probably interfere with the
activities of the spleen and thus in some manner this organ does not
properly elaborate the blood before it passes to the liver. Sagging
of the duodenum may, through tension on the duodeno-hepatic ligament,
interfere with the flow of bile. This would cause derangement of the
nervous reciprocal relationship between opening at duodenal orifice and
gall-bladder. In carcinoma of the liver and stomach, gall-stones are
said to be frequent.
The stone itself is a brownish object, nearly spherical, faceted and
in some instances polygonal in shape, varying in size from a pea to a
hen’s egg.
The stones are found anywhere in the biliary tract from the duodenal
orifice to the ramification of the bile vessels. Usually there is more
or less of an accumulation in the gall-bladder. At any point the stone
may produce ulceration and suppuration. Perforation may occur into the
peritoneal cavity or adjacent organs.
=Symptoms.=—Gall-stones may be in the gall-bladder for years without
giving rise to any symptoms. Their presence is made known only by their
expulsion from the gall-bladder. If they lodge in the duct in transit
from the gall-bladder to the duodenum =biliary colic= is produced,
which is the characteristic symptom of an impacted gall-stone. Small
stones may pass into the intestine without producing symptoms. The
pain is very sudden, piercing and excruciating in the region of the
gall-bladder, when a stone attempts to pass. The pain radiates through
the abdomen, right chest and shoulder, and the patient writhes in agony
and occasionally faints. Downing[90] emphasizes the point that when a
patient comes in with a history of repeated attacks of biliary colic
and no stone found in the stools one should at once suspect that one of
considerable size obstructs the common duct.
There is always tenderness in the biliary region with more or less
contraction of the abdominal muscles. Nausea, vomiting and sweating
are usually present, followed by a weak pulse, cool skin and pale
and anxious face. Fever is soon present and a chill is common. The
paroxysms continue as long as the stone remains lodged, which may be
from an hour to several days. There are remissions of pain, entire
relief being given as soon as the stone reaches the duodenum. Jaundice
usually follows a prolonged attack. The liver is sometimes enlarged.
The spleen is enlarged. Should the stone become impacted, ulcerative
perforation, with consequent peritonitis and shock, follows.
=Diagnosis.=—The diagnosis is conclusive when the gall-stones are found
in the stools or when they can be felt in the gall-bladder. All the
above symptoms are characteristic. If a patient complains of severe
pain radiating from the hepatic region, and nausea and vomiting are
present, subsiding suddenly with a slight jaundice, the disease should
hardly be mistaken.
Tenderness over the gall-bladder frequently indicates infection or
gall-stones or both. Radiographic examination may be of aid.
=Nephritic colic= should never be confounded with hepatic colic
as in the former the pains start in the lumbar region and radiate
downward into the groin, the testicle and the inside of the thigh.
In =appendicitis=, jaundice and bile-stained urine are not found. A
=pseudo-biliary colic= is occasionally found in nervous individuals
especially when the eleventh and twelfth ribs (or ribs as high as the
seventh) on the right side are displaced downward.
=Prognosis.=—Is usually favorable. Ulceration, perforation, and
suppuration may prove fatal, although much depends upon surgical
interference.
=Treatment.=—During the attack of =biliary colic=, the osteopath should
usually be able to readily locate the position of the gall-stone in
its transit from the gall-bladder. He should usually proceed at once
to aid the stone in its downward passage by careful manipulation over
the duct. Still this treatment should be given with great caution,
for if there is suppuration or ulceration, perforation and resultant
peritonitis may occur.
Usually one will not have much difficulty in dislodging the stone
and relieving the sufferer in a few minutes. The recumbent position,
with the thighs flexed on the abdomen, is the position assumed for
treatment, and if the muscles in the hepatic region are very tense
and rigid, interfering with locating the gall-stone, an inhibitory
treatment to the posterior spinal nerves supplying the contracted
muscles will aid one materially. An inhibitory treatment of the nerves
of the biliary tract (the ninth and tenth dorsals), may be a helpful
measure in dilating the duct. Also, hot application over the affected
area and to the dorso-lumbar region will aid.
During remissions two or three treatments per week should be given
to correct the lesions at the eighth, ninth, tenth and eleventh
segments. Give particular attention to any enteroptosis that may be
found. Average cases should not require more than two or three months’
treatment. Hildreth, who has had many cases, is much opposed to
operation as his experience has been that where there is not complete
obstruction the correction of lesions will prevent further formation of
stones. While he finds the trouble ranges from the third to the eighth
dorsal, still, as a rule, it is between the fifth and sixth that best
results are obtained. Probably if the treatment is a rightly directed
one the stones already formed may be disintegrated. Willard[91] reports
393 cases.
Permanently impacted gall-stones require surgical treatment.
Prophylactic treatment, as a regulated diet, daily exercise and a
discontinuance of excesses, should be strongly urged. The patient
should not be allowed any fatty or saccharine food. Water freely taken
will be of aid.
Diseases of the Spleen
Diseases of the spleen are usually secondary to other disorders. The
following osteopathic treatment under Splenitis will, in addition to
the probably primary disturbance, be applicable to active and passive
splenic hyperemia and amyloid degeneration of the spleen. Surgical and
other measures are to be employed when indicated.
Owing to the role that the spleen plays in infections, the osteopath
pays considerable attention to stimulating the organ through its spinal
innervation in these cases.
Splenitis
In acute =splenitis= there is generally a blocking up of the smaller
splenic arteries by fibrous coagula (hemorrhagic infarct), which
have formed in the left ventricle of the heart in consequence of
endocarditis. Malarial infections, septicemia, typhus and acute
exanthematous fevers may cause coagula formation in the splenic veins.
Injuries to the vertebræ or ribs on the left side over the spleen
(ninth to eleventh ribs inclusive) are occasionally the predisposing
cause of primary inflammation of the spleen. Following the formation of
abscesses the entire organ may suppurate; it may produce pyemia, or it
may burst and the pus be discharged into the peritoneal sac, causing
peritonitis, or into the pleura, stomach or colon. =Chronic splenitis=
is induced by passive congestion, leukocythemia and splenic anemia.
=Symptoms.=—Tenderness and enlargement of the spleen are the principal
symptoms. The organ may be twice its normal size, but in a few cases
the tumefaction is so insignificant that it can hardly be found on
percussion. Dull pain generally exists if the enveloping membrane or
adjacent organs are involved, the pain being increased upon percussion
and deep inspiration. In a few cases the pain radiates to the left
shoulder and if the peritoneal covering is involved, a sharp pain will
be present. Fever and rigor follow if suppuration has taken place,
and peritonitis follows in case of rupture or perforation. Marked
hypertrophy and chronic inflammation may cause cough, nausea, vomiting
and dyspnea.
=Treatment.=—In the treatment of both the disease producing splenitis,
and of primary splenitis, a thorough treatment of the spine, eighth to
the eleventh dorsal, is necessary. The nerves (vasomotor) to the spleen
are from the left splanchnics, consequently treatment of the left side
is more effectual. Particular attention should be given the ribs over
the spleen—the ninth, tenth and eleventh—as disorders of these ribs
are a common cause of splenic disturbances. Careful and fairly firm
treatment is always indicated, care being taken not to add irritation
to an already inflamed organ, and especially beware that force is not
used where there is danger of rupture. Stimulation of the tenth nerve
contracts the spleen. In cases of suppurative splenitis the direct
treatment should not be given.
Stimulating treatment over the spleen, as over the liver and kidneys,
gives tone to the strong elastic capsule surrounding it, so that direct
manipulation over these organs, coupled with the power of the strong
elastic capsule and highly elastic tissue of the inner organ, will
greatly aid in lessening the engorgement and hyperemia. In a few cases
where the spleen is involved, lesions are found in the upper cervical
which affect the right pneumogastric nerve and thus impair the normal
activity of the gland.
FOOTNOTES:
[74] See special article, Prolapsed Organs, Part I.
[75] The student will receive many helpful suggestions by reading
Macleod, Physiology and Biochemistry in Modern Medicine; Cannon, The
Mechanical Factors of Digestion; Carlson, The Control of Hunger in
Health and Disease; Gaskell, The Involuntary Nervous System; Pottenger,
Symptoms of Nervous Disease.
[76] Von Noorden, Colitis, 1904.
[77] See Philosophy and Mechanical Principles of Osteopathy, p. 190.
[78] There are several possible suggestions. (1) Developmental (See
Mayo, Relation of the Development of the Gastro-intestinal Tract to
Abdominal Surgery. Jour. A. M. A. Feb. 7, 1920). (2) Owing to the
appendix, cecum, ascending colon, duodenum, and biliary tract being
frequently disordered. (3) Imbalance of muscular tension, owing to the
muscles of the right side being often the better developed. Muscular
lesions and lymphatic involvement of the cervical region seem to occur
oftener on the right side than on the left.
[79] Journal of Osteopathy, May, 1900.
[80] For points on enema, see treatment under Intestinal Obstruction.
[81] Diseases of the Intestines, Vol. I, p. 240.
[82] The Lancet, (London,) Oct., 1904.
[83] Philosophy of Osteopathy, p. 226.
[84] Medical Record.
[85] The Vermiform Appendix and Its Diseases, p. 711.
[86] Dr. Chauvel, 1902.
[87] Rose and Carless.
[88] Clinical Osteopathy.
[89] Journal of the American Osteopathic Association, Dec, 1902.
[90] Journal of American Osteopathic Association, March, 1905.
[91] Journal of American Osteopathic Association, March, 1905.
DISEASES OF THE RESPIRATORY SYSTEM
DISEASES OF THE LARYNX[92]
Acute Catarrhal Laryngitis
=Definition.=—An acute, catarrhal inflammation of the mucous membrane
of the larynx. This may be ushered in as an independent disease or it
may be associated with inflammation of the upper respiratory passages.
=Osteopathic Etiology= and =Pathology.=—One of the principal causes
of acute catarrhal laryngitis is exposure to cold and dampness, which
contracts the muscles of the neck region, especially about the larynx.
Lesions in the upper and middle cervical vertebræ are important
predisposing causes. Occasionally the first rib becomes luxated,
causing a greater or less congestion of the laryngeal mucous membrane
by contracting the lower antero-lateral muscles of the neck, and
affecting lymphatic drainage. Improper placing of tone, as well as too
constant use of the voice in speaking and singing, are common causes.
Inhalation of irritating gases or dust, and mechanical injuries to
the larynx are occasional causes. The disease may be associated with
certain infectious diseases, as measles, diphtheria, influenza and
whooping cough.
=Pathologically=, the mucous membrane is intensely reddened and
inflamed; this inflammation involves both the true and false vocal
cords and may extend into the trachea and about the epiglottis. The
membrane is covered slightly with mucous secretion. In rare instances
edema of the glottis may occur. The muscular contraction about
the larynx impedes blood and lymphatic drainage and thus induces
congestion. The contraction may be so severe as to slightly prolapse
the organ. The vertebral lesions impinge upon or affect vasomotor
fibers and thus bring about congestion.
=Symptoms=.—There is hoarseness and cough with a sensation of tickling
in the larynx; these are the most constant symptoms. The cough is
dry and the voice altered. At first the voice is husky, but some
attempts at speaking are attended with more or less pain and finally
the voice may be entirely lost. Deglutition is painful. At first the
expectoration is scanty, but later it becomes mucopurulent. There
is rarely much fever. When there is considerable edema, dyspnea and
asphyxia are prominent features.
=Prognosis.=—Simple catarrhal laryngitis never terminates fatally.
When there is dyspnea or asphyxia indicating edema of the larynx, the
prognosis is grave. The attack usually lasts from one week to ten days,
but this can be materially shortened by careful osteopathic treatment.
In severe infections it may be two or three weeks before the larynx
returns to its former condition.
=Treatment.=—In a few cases confinement of the patient to his room, and
possibly the bed, will be necessary; especially should the larynx have
rest from phonation, and the taking of food of an irritating character
should be avoided. Smoking is to be prohibited. The room should be
at an even temperature, from 70 to 75 degrees F., and the atmosphere
saturated with moisture by the generation of steam.
The tissues in the cervical region about the cervical sympathetic and
vagi nerves should be carefully adjusted. The deep posterior muscles
of the cervical spine are to be relaxed and direct treatment given
over and about the larynx. Relaxing tissues and raising the larynx
will be very effectual in relieving the =huskiness= of the voice
and in controlling the congestion and inflammation of the laryngeal
mucosa. Besides the treatment of the vagi nerves at the atlas and their
course down the lateral and anterior portion of the neck, the superior
laryngeal may be treated at the upper portion of the great cornu of
the hyoid bone and the inferior laryngeal at the inner side of the
cleido muscle near its sternal attachment. Adjust the tissues along
the course of the external carotid and subclavian arteries, chiefly
the first rib for the latter. Give careful treatment to the internal
jugular and innominate veins. Correct any tissues that may impinge upon
the lymphatics of the mucous and submucous coats of the larynx where
they are drained into the deep cervical glands. Release any immobility
of the upper chest, relax the pectoral, auxiliary and upper dorsal
muscles, and adjust the first four or five dorsal vertebræ.
Prompt action of the skin, freedom of the bowels, placing the feet
in a hot bath and continued local hot packs, or even an ice-bag in
severe cases, will be of special value at the onset; but due attention
should be given these throughout the entire course. The fever is easily
aborted by the cervical treatment and proper attention to the bowels
and sweat glands.
Chronic Catarrhal Laryngitis
=Definition.=—A chronic, catarrhal inflammation of the mucous membrane
of the larynx.
=Osteopathic Etiology= and =Pathology=.—The causes of chronic
laryngitis may be numerous, but lesions of the cervical vertebræ are
the most common. The contractured cervical muscles, especially the
deep vertebral ones, are usually the result of corresponding osseous
deviations.
Other causes given under the acute form, as overuse and abuse of the
voice, inhalation of irritating substances, excessive use of tobacco
and alcoholic drinks, tumors, etc., are important etiological factors.
Thus irritations inducing acute attacks, if repeated, will result in
chronic catarrh.
The =pathological= changes as revealed by the laryngoscope are swelling
of the mucous membrane, occasional superficial erosions, and rarely
ulceration.
=Symptoms.=—The voice is usually hoarse and rough, being due to a
thickening of the vocal organs. In severe cases the voice may be
lost. There is fatigue and pain after slight use of the voice, a
sense of tickling in the larynx which produces a desire to cough, and
expectorations of viscid mucus and mucopus.
=Prognosis.=—The prognosis is sometimes unfavorable, although many
cases are cured.
=Treatment.=—The patient must learn to take care of himself properly.
He should avoid overheated rooms and the use of tobacco and alcohol,
and the throat should not be protected too much. It is a good plan to
bathe the neck every morning and night with cold water. He should avoid
loud speaking; the sound should be expelled by the abdominal muscles
and diaphragm and not by the muscles of the throat. Examine the upper
air passages carefully for any obstructions and infections that might
exist which are a source of irritation to the larynx.
Special attention should be given to the atlas, axis and third
cervical. Lesions lower down the spine may be found, for other
laryngeal nerve fibers, other than those from the superior cervical
ganglion, may be at fault. Palpate the =hyoid= to see if it is tilted
by contracted muscles, as will often be the case.
=Aphonia= is commonly caused by a dislocated atlas. The aphonia may
also be caused by swelling of the vocal cords and tissues about them
and by serous effusions of the laryngeal muscles. The larynx may be
prolapsed slightly and if raised quickly relieved. Difficult breathing
and hoarseness are occasionally very troublesome symptoms. The former
is due to an inability of the glottis to dilate, on account of swelling
of the mucous membrane of the diseased parts and from drying of the
secretions on them, thus increasing the obstruction (this is sometimes
termed pseudocroup) but expiration is easy, the stridor is from the
inspiration; the latter is due to a collection of mucus on the vocal
cords or the cords may become relaxed, swollen or roughened.
Another annoying symptom sometimes presented is pain on deglutition,
which is due to swelling of the mucous membrane of the upper laryngeal
passages and the epiglottis. In all of these annoying symptoms,
persistent, thorough, direct treatment of the larynx is of value. On
the whole, careful, continued treatment of the cervical innervation and
vascular supply of the larynx, as in the acute form, is indicated.
In all laryngeal disorders, if condition permits, hyperextend the neck
while the patient is lying supine and thoroughly relax the soft tissues
about the organ and then carefully raise it.
Laryngismus Stridulus
(Spasm of the Glottis)
=Definition.=—A spasm of the muscles of the larynx that are supplied
by the inferior or recurrent laryngeal nerves. This is commonly not
excited by an inflammatory condition, but it is usually a purely
nervous condition.
=Osteopathic Etiology= and =Pathology=.—Spasm of the glottis is usually
found in children with =enlarged tonsils and adenoids=. It has been
observed that rickets and syphilis are probably frequent underlying
causes. The spasm is occasionally associated with tetany. The nervous
factor is the immediate and important consideration. Cervical lesions,
both vertebral and muscular, are invariably found. Then nasopharyngeal
and tracheal disorders and reflex digestive disturbance are exciting
causes. An elongated uvula or a deranged hyoid bone will occasionally
be exciting factors. Subluxation of the upper two or three ribs and of
the clavicle may also be exciting factors.
The affection is usually found in children under five years of age. All
cases are not of a distinct nervous type, for slight acute catarrhal
laryngitis may be present.
=Symptoms.=—There is a sudden onset and the spasm may occur on waking
from sleep, but it may come on either in the night or day. The disease
starts with a sudden arrest of breathing, the child struggles for
breath; there are tonic muscular spasms and the face becomes congested
in a few seconds. This is followed by sudden relaxation of the spasm
and the air is drawn through the glottis with a shrill, crowing sound.
Several spasms may occur in a day or they may be weeks apart. Death
rarely occurs.
=Diagnosis.=—The absence of fever, cough and hoarseness and its
distinctly intermittent nature will differentiate it from croup. Should
there be any question of diagnosis a bacteriological examination is
advisable.
=Prognosis.=—The prognosis is almost always favorable. In very young
children death from suffocation may occur, but rarely.
=Treatment.=—The treatment should be applied either centrally
or peripherally, depending altogether upon the location of the
irritation. If the irritation is of central origin, that is, through
the innervation from the brain and spine, a correction of the superior
and inferior laryngeal nerves is necessary; if the stridor is due to
peripherial irritations, a correction of the end-plates (muscles) over
and about the larynx is required in order that the spasms be relieved.
Thorough treatment should be applied to the upper part of the chest
and diaphragm, chiefly the phrenic nerves at the third, fourth and
fifth cervicals and over the eighth, ninth and tenth ribs anteriorly,
in order that the spasms may be prevented from extending to the
intercostal muscles and the diaphragm.
Placing the patient in a hot bath will be of service in some cases
when the spasms are severe. Alternating hot and cold packs about the
throat are of service. The air of the room should always be kept moist.
Care should be taken that the trouble is not due to gastro-intestinal
disorders or to dentition. Keep the child upon a fluid diet of milk,
meat broths and egg albumin.
In the more severe cases the well known osteopathic method of relaxing
and inhibiting the soft palate and contiguous tissues will stop the
spasm.
Spasmodic Laryngitis
(False Croup)
=Definition.=—A catarrhal inflammation of the mucous membrane of the
larynx with spasm of the glottis.
=Osteopathic Etiology= and =Pathology=.—This affection is practically
the same as laryngismus stridulus associated with catarrhal
inflammation of the mucous membrane. It is a disease of young children.
Derangements of the innervation and blood supply to the laryngeal
mucous membrane and muscles of the larynx are found in the same
locality as noted under acute catarrhal laryngitis and laryngismus
stridulus. There is acute catarrh causing a croupy cough, and
difficult breathing due to spasm of the glottis.
=Symptoms.=—These attacks generally occur during the night, the child
being suddenly awakened by severe paroxysms of suffocating and a dry,
hard cough, associated with evidences of dyspnea. In half an hour or
an hour or two the coughing ceases, perspiration follows and the child
falls asleep. If proper treatment is not given, these attacks may occur
for several successive nights, the child appearing almost or quite well
during the day.
=Diagnosis.=—The symptoms are so characteristic that the diagnosis is
easy. In all instances the prognosis is favorable.
=Treatment.=—The catarrhal inflammation of the mucous membrane of the
larynx should be treated in the same manner as simple inflammation of
the laryngeal mucosa, i. e., thorough treatment of the cervical spine
and direct treatment over the larynx.
During the paroxysm, if the patient cannot be relieved very shortly
by the cervical treatment, he should be placed in a hot bath of a
temperature from 98 to 110 degrees F. This will, in the majority of
cases, relieve the attack. In addition a hot compress may be placed
about the throat. Producing emesis by irritating the fauces with the
finger is necessary in a number of cases in order that the secretions
in the laryngeal region may be ejected, thus relieving suffocation and
labored breathing. Also, an overloaded stomach which is causing an
irritation, should be emptied at once by vomiting. The bowels should be
kept well open in all cases. Occasionally the epiglottis becomes wedged
in the chink of the glottis. Such a condition requires an introduction
of a finger into the fauces to release the disorder.
Care should be taken, especially following an attack, that the child
is not exposed to cold or rapid changes of temperature, so as to avoid
repetition of the spasms.
=Coughing.=—Coughing, not only in spasmodic laryngitis, but also in
various diseases where coughing is a prominent symptom, is a most
irritating and annoying feature. The osteopath is many times called
upon to relieve the cough, whether it is due to slight irritation of
a nerve fiber alone or is a symptom of a serious chronic disease. The
coughing center is located in the medulla oblongata; the afferent
nerves are sensory branches of the vagus; the efferent nerve fibers
are found in the nerves of expiration and in those that close the
glottis. Consequently, coughing may be caused by stimuli to various
sensory nerves, various cutaneous areas (chiefly the upper part of the
body), mucous membrane of the respiratory and digestive tracts, the
mammae, liver, spleen, ovaries, uterus, kidneys, etc. Perhaps the most
common cause of cough is contraction of some of the muscles of the
neck, irritating sensory fibers. Contraction of the omo-hyoid muscle
may produce an irritating cough by causing traction on the hyoid bone.
In a few cases the larynx may prolapse to some extent and thus be a
source of irritation. Lesions of the spinal cord between the seventh
and eighth dorsal, also at various points above in the dorsal vertebræ
and in the ribs (especially at the second and third ribs), are very
apt to produce a cough. Impaction of the sigmoid flexure is oftentimes
accompanied by coughing. Enlargement of the heart may cause pressure
upon the respiratory tract directly and cause a deep, dull cough.
Foreign bodies in the external meatus of the ear are occasionally a
source of irritation which is accompanied by coughing. Thus there are
innumerable sources of stimuli that may produce coughing. In all cases
it is necessary to make a careful diagnosis as to whether it is an
irritation to some fiber that can be corrected at once or whether it
is a symptom of a disease that can only be relieved by the cure of the
disease. In local congestions the cold pack will often be of service.
Tuberculous Laryngitis
=Definition.=—An inflammation of the laryngeal tissues of tuberculous
origin.
=Osteopathic Etiology= and =Pathology=.—Tuberculosis of the larynx
is commonly secondary to pulmonary tuberculosis. In a few cases the
laryngeal invasion may be of primary origin. In either instance there
will be found a disturbed innervation or altered blood supply of
the larynx that predisposes to the multiplication and growth of the
bacilli. The osteopathic lesions are similar to those found in other
involvements of the larynx.
=Pathologically=, the mucous membrane is inflamed and swollen,
and exhibits scattered tubercles, which are usually about the
blood-vessels. The tubercles cluster, caseate and leave shallow,
irregular ulcers. There is thickening of the mucosa about the ulcer,
and the ulcer is generally covered by a grayish exudate. They may erode
the true vocal cords, often destroying them completely. The ulcers
slowly involve the tissues in all directions, causing perichondritis
with necrosis of the cartilages. The mucous membrane of the pharynx,
esophagus, fauces, and tonsils may be involved, and the epiglottis may
be completely destroyed.
This disorder, strictly, should be discussed under pulmonary
tuberculosis for, as heretofore stated, it is generally a secondary
affection; the larynx being invaded by the tubercular bacilli in the
sputum arising from the bronchial tubes and lungs. The bacilli in
inspired air may primarily invade the laryngeal mucosa. However, in
either case the circulation of the mucosa is not normal and osteopathic
correction of the same is effective.
=Symptoms.=—Huskiness of the voice, followed by hoarseness, and in
advanced stages aphonia, are prominent symptoms. A hacking cough is
usually present and the patient complains of pain in the throat,
particularly on coughing, swallowing or speaking. The loss of voice,
painful speaking or whispering are quite characteristic. When the
ulceration of the tissues of the larynx has progressed to a later
stage, dysphagia, suffocation and distressing paroxysms of cough occur.
=Diagnosis.=—Is not difficult, as pulmonary phthisis is usually
associated with it. Examination of the sputum for the specific bacilli
will be conclusive.
=Prognosis.=—The prognosis is not of the best at any time. On the
whole, it is unfavorable.
=Treatment.=—In this disease osteopathic treatment has been quite
effectual. Cases of primary origin are more successfully treated than
when of secondary cause, although one will be surprised many times at
the results obtained when the disorder is not primary. The treatment
must necessarily be both constitutional and local. Care of the general
health as to hygiene and diet is absolutely necessary. The food must
be nutritious and non-irritating. Scraped beef, raw oysters, raw eggs,
soups and gruel are required. In cases where difficulty of deglutition
occurs, it may be largely overcome if the patient hangs his head over
the side of the bed and sucks through a tube liquid nourishment placed
in a dish upon the floor.
The local treatment required is careful, persistent work over the
larynx and adjacent tissues. The treatment is given to increase the
blood supply to the diseased tissues so that healing may take place,
and that the bacteria may be deprived of the conditions favorable to
their activity. Treatment along the cervical spine and upper dorsal
will aid in correcting the vasomotor disorders that exist. Local
application of hot water will assist in relieving the pain. When
pulmonary phthisis exists, attention and correction of it is important;
in fact, is of primary consideration in laryngeal affection.
Syphilitic Laryngitis
=Etiology.=—This disease is of frequent occurrence, due to inherited
syphilis, or to the secondary or tertiary stages of the acquired form.
=Symptoms.=—There is a hoarseness of the voice, a hacking cough,
difficulty in swallowing and the various symptoms of catarrhal
laryngitis. The secondary form may present superficial, whitish ulcers
on the cords or ventricular bands, while in a tertiary stage the
lesions are extensive and serious. Deep ulcers with raised edges are
present, gummata develop on the submucous coat of the epiglottis and
there may be necrosis and exfoliation of the cartilages. Deformity is
produced by the cicatrices following the healing of the ulcers and
sclerosis of the gummata. Edema of the larynx may suddenly prove fatal.
=Diagnosis.=—The history of the case, the presence of other symptoms of
the disease, the deep, symmetrical ulcers, the absence of tuberculosis
elsewhere and the absence of marked pain, will usually make a diagnosis
easy.
=Prognosis.=—Is somewhat favorable, more so at least than the
tubercular form of laryngitis. There is great danger of deformity and
permanent impairment of the voice.
=Treatment.=—The treatment should be both constitutional and local.
Active measures must be taken to rid the system of the virus of
syphilis, and thorough, direct treatment should be applied to the
larynx and to its innervation. If the cicatricial stenosis has
progressed so far that there is little hope from manipulative
treatment, tracheotomy or gradual dilatation should be performed. The
ulcerated portion is always to be kept clean.
Edematous Laryngitis
=Definition.=—An acute inflammation of the mucous membrane of the
larynx with infiltration of serous fluid into the submucous tissue.
=Etiology.=—This is a very serious affection. It may occur in
connection with acute laryngitis, though rarely, and occasionally with
chronic diseases of the larynx, as tuberculosis and syphilis. It may
be a complication of some acute infectious disease like diphtheria,
scarlet fever, or erysipelas of the face. It sometimes occurs suddenly
in the course of Bright’s disease. Lesions as in acute laryngitis are
predisposing factors.
=Pathologically=, there is marked swelling of the epiglottis. The
swelling can very easily be felt with the fingers. The mucous membrane
is tense and changed in color. There is infiltration of a serous or
sero-purulent fluid into the loose connective tissue of the larynx.
The arytenoepiglottic folds are greatly involved, and they may be
swollen to such a degree that they almost meet.
=Symptoms.=—Extreme dyspnea and stridulous respiration. Hoarseness of
the voice and later aphonia. There is a feeling of intense oppression
or suffocation. Evidence of dyspnea, anxious face, blue lips,
protruding eyes and retraction of the base of the chest occur. The
sternocleidomastoid muscle is very prominent.
=Diagnosis.=—This is not difficult. The history of the case,
laryngoscopic examination, and the swollen epiglottis which can be
easily felt with the fingers make diagnosis easy.
=Prognosis.=—Generally unfavorable. At any time it is extremely grave,
but with prompt and vigorous treatment recovery is possible.
The duration varies from a few hours to several days.
=Treatment.=—One must attend strictly and carefully to the laryngeal
innervation, as in acute catarrhal laryngitis. Obstruction to the
superior or inferior thyroid, facial, internal jugular or innominata
will cause tumefaction and edema of the larynx and adjacent tissues.
Also, enlargement of the lymphatics about the larynx and salivary
glands may produce edema of the laryngeal region; consequently,
particular care should be taken of the various tissues about these
vessels and of the innervation from the cervical spine, so the veins
are not obstructed or the lymphatic channels disordered, so that
infiltration of the tissues may be further prevented.
The most prominent symptom is laryngeal dyspnea and this depends
altogether upon the swelling of the soft parts. If the swelling is
great and the disorder cannot be removed, suffocation will follow.
In such cases, besides giving direct treatment over the larynx,
introducing a finger into the mouth, and reaching clear back under the
roof of the soft palate, with a firm, downward, outward and sweeping
movement on either side, relax the soft tissues. The persistent use of
small pellets of ice, held far back in the mouth, will be found very
beneficial; also, application of the ice-bag, provided the edema is of
inflammatory origin.
If one is not able to control the rapid infiltration of the larynx and
glottis when such cases arise, tracheotomy or intubation should be
performed at once. When edematous laryngitis is due to diseases of the
heart, lungs and kidneys, treatment of the primary disease should be
given in addition to the local treatment.
FOOTNOTES:
[92] For diseases of the nose see Deason, Part 1, Page 257.
DISEASES OF THE BRONCHI
Acute Bronchitis
=Definition.=—A catarrhal inflammation of part or whole of the mucous
membrane of the larynx, trachea and bronchial tubes, or it may extend
into the capillary tubes. This is bilateral, affecting more or less the
bronchial tree in both lungs.
=Osteopathic Etiology= and =Pathology=.—The most common cause of acute
bronchitis is “catching cold.” It is more prevalent in the winter, and
it often succeeds an ordinary cold in the head, coryza or laryngitis,
the inflammation extending downward from the upper air passages. A
case of acute bronchitis always presents a contracted condition of
the muscles on either side of the spine in the upper dorsal region.
The contracted muscles may extend as far down as the middle dorsal or
as high as the entire cervical. Occasionally, the ribs posteriorly
are drawn downward by the extreme contraction of the muscles, and
the upper anterior part of the chest may be somewhat constricted and
limited in its movements by the tensed muscles. Thus, in a few cases
the ribs and upper dorsal vertebræ are actually subdislocated by the
extreme contraction of the muscles. The principal points affected are
the second, third, fourth and fifth dorsal regions. In a few instances
cervical lesions disturbing the vagus and resulting in motor weakness
of the tubes, will be noted. The osteopathic control of the bronchial
vasomotor nerves is in this region (dorsal).
The disease is also associated with measles and it is usually a symptom
of influenza. One attack predisposes to another. It affects either
sex and especially children and the old, in whom it most frequently
involves the smaller bronchi. In adult life it involves the larger
bronchi. Micro-organisms, particularly the pneumococcus, influenza
bacillus, and micrococcus catarrhalis, act as exciting causes.
=Pathologically=, the mucous membrane of the portion of the trachea
and bronchi that are implicated become reddened, congested and more
or less covered with a tough mucus mingled with epithelial cells. The
hyperemia is most marked about the mucous glands. Some of the smaller
bronchial tubes are dilated. In severe cases there is desquamation
of the ciliated epithelium, swelling and edema of the submucosa, and
infiltration of the tissues with leucocytes. The affection involves
chiefly the vasomotor nerves. In cases on the verge of chronicity,
look well to the diet; especially lessen in amount the starchy and
saccharine foods.
=Symptoms.=—The onset of acute bronchitis is accompanied by the
symptoms of a common “cold.” In the beginning the cough is hard and dry
without expectoration; but later it is looser, the secretion becoming
mucopurulent and abundant and finally purulent. The scanty sputum
is at first glairy and mucoid, while later it becomes more abundant
and mucopurulent and contains pus cells and desquamated epithelium.
When the bronchial inflammation becomes fully established, there is a
feeling of tightness and rawness beneath the sternum and a sensation of
oppression in the chest, due to swelling of the mucous membrane and the
presence of secretions which cause stenosis of the bronchial lumina.
There is a slight fever, rarely exceeding 101 degrees F. The disease
lasts from four or five days to three weeks. There is either a complete
recovery or chronic bronchitis is developed.
=Physical Signs.=—There may be no physical signs in slight attacks of
acute bronchitis of the larger tubes. In severer cases the physical
signs are well marked. =Inspection= may recognize increased frequency
of breathing, and when the smaller tubes are involved there is dyspnea.
=Palpation.=—The bronchial fremitus may often be felt, providing there
is sufficient narrowing of the breathing tubes. =Percussion.=—Sounds
are normal as long as the bronchitis is uncomplicated.
=Auscultation.=—In the early stage piping, sibilant rales may be heard
on both sides. These rales are inconstant and appear and disappear with
coughing. There may be harshness of breathing added to these. When
resolution sets in, the rales change and become mucous and bubbling in
quality. Vocal resonance in bronchitis is normal, unless complications
occur.
=Diagnosis.=—This is generally easy. The absence of dullness and
blowing breathing and the bronchial character of the cough and
expectoration are usually sufficient to distinguish it from pneumonia
and pleurisy. If the physical signs are noticed carefully, the
diagnosis is rendered easy and positive in all cases.
=Prognosis.=—In the very young and the very old, the prognosis is
unfavorable, but in a previously healthy adult the most that can
happen to a case of acute bronchitis is to become chronic. Recovery is
the rule; even in the aged and feeble death is rare. If osteopathic
treatment can be instituted from the inception, the disease will
probably be aborted. The treatment almost invariably lessens the
severity and duration of an attack. For capillary bronchitis see
Bronchopneumonia.
=Treatment.=—Complete rest in a warm bed, and a hot foot bath would
cure a large majority of cases in a day or two if the patient would
only submit to such treatment. Most of them wish to be around and out
doors and very likely attending to their usual work, so that a cure in
some cases is hard to perform. They are very liable to take more “cold”
and in a few cases it will take great effort to prevent the bronchitis
from becoming chronic. One thorough treatment per day will usually be
sufficient.
The hyperemic condition of the bronchial tubes is due to a vasomotor
disturbance, generally caused by a severe contraction of the muscles
of the back in the region of the first to fourth dorsal; although the
vasomotor nerves to the mucous membrane of the bronchial tubes may
be affected anywhere from the first to the seventh dorsal inclusive.
Contraction of the muscles over the anterior part of the chest
corresponding to these regions and caused by the same influences
(chiefly atmospherical changes) is of quite common occurrence. In the
majority of cases the contraction of the chest and back muscles is
so severe that the ribs are partly displaced by the tension and thus
is added a complication to the disorder, and from this complication
chronic bronchitis is liable to occur. The ribs or even vertebræ to
the corresponding region oftentimes remain partly dislocated and are
a source of continued and permanent irritation to the innervation of
the bronchial tubes. So it is always necessary in treating any form of
bronchitis to see at each treatment that the ribs and vertebræ from the
first dorsal to the seventh dorsal, inclusive, are anatomically correct.
As has been stated, the disordered muscles or ribs may be affected
anteriorly as well as posteriorly; consequently, the treatment
applied is a thorough relaxation of the chest and back muscles and
the correction of the ribs and vertebræ in order that the vasomotor
disturbance of the bronchial mucosa may be corrected and the
inflammation relieved. An excellent method to release the immobilized
anterior upper chest is to place patient flat upon his back with
pillow beneath upper dorsal. This hyperextends spine, enlarges spinal
foramina, and tends to elevate ribs. Then by use of arms as levers,
moderate inspiration, and employment of one hand over anterior end of
ribs they may be easily released and raised. This treatment effects
circulation, innervation, lymph tissue, and rib bone marrow.
In addition to the dorsal spinal nerves, and the sympathetic, the vagi
are to be considered in the treatment of bronchitis, as all of these
nerves, sympathetic, spinal, and vagi, go to make up the anterior and
posterior pulmonary plexuses from which the bronchial mucosa receives
its innervation. The veins particularly involved in passive hyperemia
of the bronchial tubes are the superior intercostal and azygos
major; so raise and spread the ribs to give greater freedom to these
blood-vessels.
“The blood flow may be diverted from the bronchi to the abdomen by a
slow, deep, inhibitive treatment over it, including pressure over the
solar and hypogastric plexuses.” (Hazzard).
The excretory organs and the diet of the patient should be attended to.
Especially in children, the diet had best be a fluid one, as milk, egg
albumin, meat broths and meat juice. For those who are subject to the
disease an outdoor life is best.
Chronic Bronchitis
=Definition.=—A chronic inflammation of the mucous membrane of the
large and middle sized bronchial tubes.
=Osteopathic Etiology= and =Pathology=.—Chronic bronchitis may be
either primary or secondary. The primary form is the result of exposure
to wet and cold or to the daily inhalation of irritating vapors or
dust. This form is rare, the affection being almost always a secondary
one, and is most commonly met with in chronic lung affections, heart
disease, gout or renal disease. It may be caused by any disease which
favors congestion of the air tubes by obstruction of the circulation;
especially mitral diseases and Bright’s disease. It is also caused by
chronic alcoholism and may be the result of repeated attacks of the
acute form. Chronic vertebral and rib lesions are found from the first
to the seventh dorsal, inclusive. Elderly people are often subject to
the disorder.
=Pathologically=, the lesions of chronic bronchitis present great
variation, as to both their nature and extent. In some cases the
mucous membrane is atrophied, so that some of the elastic fibers are
noticeable. The epithelial layer is in great part missing. The muscular
coat and mucous glands are atrophied.
In certain cases the mucous membrane of the bronchi is thickened,
and there may be ulceration. In long standing bronchitis, there is
frequently dilation of the tubes (bronchiectasis) and emphysema.
=Symptoms.=—Pain is rarely present; there is merely a feeling of
constriction beneath the sternum. The cough varies with the weather and
season and there is often an absence of the cough during the summer.
It is apt to be worse at night than in the morning, and is frequently
paroxysmal. There is rarely any fever. As a rule, there is free
expectoration of mucopurulent or distinctly purulent matter. Sometimes
it is abundant, seromucous in character, and again there are severe
cases of dry cough in which there is almost no expectoration. Unless
associated with other diseases, the general health suffers but little,
if at all. The appetite, as a rule, is good and the body weight is well
maintained.
=Physical Signs.=—=Inspection.=—There is considerable immobility of the
chest and if emphysema is present there is distension. =Percussion= is
clear, and hyperresonant in emphysema. =Auscultation.=—The expiration
is prolonged and forcible. This is associated with sonorous and
sibilant rales and moist rales of all sizes.
=Special Varieties.=—Bronchorrhea, dry catarrh, putrid bronchitis or
fetid bronchitis.
=Bronchorrhea.=—In this form there may be an excessive bronchial
secretion. This may be liquid and watery, but more frequently it is
purulent, thin and containing greenish masses; or again it may be
thick. Dilation of the tubes and fetid bronchitis may be developed.
=Fetid Bronchitis.=—Fetid expectoration is associated with gangrene of
the lungs, abscesses, bronchiectasis, decomposition of matter within
phthisical cavities, or empyema with perforation of the lungs; or it
may occur independently. There is considerable expectoration that is
thin and offensive. When =putrefactive changes= take place during
the course of chronic bronchitis, as a rule, the following symptoms
immediately appear: fever, which may be septic; increase of cough; pain
in the side, and sometimes a chill. There is increased prostration. The
symptoms may abate followed by the usual course of bronchitis.
=Dry Catarrh.=—The cough is distressing and paroxysmal. It is usually
associated with emphysema and is a very troublesome form.
=Diagnosis.=—This is not usually difficult. Phthisis—the absence of
fever, of hemorrhage, of tubercle bacillus and the signs of localized
consolidation (usually at one or other apex) will serve to distinguish
between the two.
=Prognosis.=—Recovery is not always accomplished. The diseases being
generally a secondary affection, the prognosis must depend upon
the primary condition. The danger from development of emphysema,
bronchiectasis and dilatation of the right ventricle must be thought
of. Frequently cures will be obtained, even in old persons. Care must
be taken that there are no serious organic lesions. Deep treatment to
readjust the upper and middle dorsals is most essential.
=Treatment.=—In the first place there must be a careful regulation
of the hygiene of the patient. The diet should be a nutritious one,
care being taken to give food that is easily digested. A liberal diet
can easily be selected from the various meats, vegetables, cereals,
fruits, soups, broths, eggs and milk. The clothing should be carefully
selected. Flannel should be worn next the skin the year around, care
being taken that the sufferer is not too warmly clad. Due attention
should be given to bathing, exercising, etc. The patient should be
out in the open air a great deal, but be careful that it is not too
stormy. The air of the room should be kept at an even temperature and
not subject to abrupt changes. Two or three treatments per week will
be required, and when the condition is considerably aggravated, do not
hesitate to treat oftener, but be careful not to unduly irritate the
lesions.
Lesions will be found to the ribs and vertebræ from the first to the
seventh dorsal inclusive. Many cases present lesions in the vertebræ
from the second to fourth, usually of a lateral nature. Other lesions
of frequent occurrence are displacements of both vertebræ and ribs.
Correcting these deviations relieves the chronic inflammation of the
tubes. Also in those cases where dilatation of the bronchial tubes
occurs, the obstruction to the motor fibers is to be removed by the
correction of the vertebræ and by removing obstruction to fibers of
the pneumogastric; the fibers of the latter supplying the transverse
muscles of the bronchial tubes.
It generally requires a considerable course of treatment for the cure
of chronic bronchitis, and one of the hardest things to contend with in
the treatment is the likelihood of the patient “catching cold.” When a
fresh cold gets thoroughly started, it is almost impossible to prevent
the disease from extending down the bronchial tubes, as the innervation
is less rich in the smaller tubes.
Hazzard says: “The obese should be taught the habit of deep
respiration, as should all persons subject to the attacks of the
disease. This measure, together with the daily cold sponge or shower
bath, is a great aid in overcoming the chronic tendency.”
Those cases that are due to cardiac or nephritic diseases require the
treatment of the primary disease in addition to a light bronchial
treatment.
A lesion between the gladiolus and manubrium of the sternum may be
found, but it is of rare occurrence in these cases. The upper portion
of the sternum may be held very rigidly and slightly underneath the
middle portion of the sternum; or at the point of articulation of the
two portions a distinct ridge may be found, caused by the articular
ends being pushed anteriorly. Probably such lesions affect the
innervation to the bronchial tubes and lung tissues. Associated with
this condition the upper chest is considerably immobilized, affecting
the lymph and rib bone marrow function. Examine the first ribs and
clavicles carefully. Changes of climate are often beneficial.
Fibrinous Bronchitis
=Definition.=—A rare, acute or chronic inflammatory disease of the
bronchi, in which a fibrinous mould of the bronchus and its branches is
formed. These are expelled in paroxysms of cough and dyspnea. The casts
block the bronchial tubes. When these moulds are large or medium sized,
they are generally hollow, while those of the smaller bronchi are solid.
=Etiology= and =Pathology=.—The causes are unknown. Young men, between
the twentieth and fortieth years, are the usual subjects; but the
disease may occur at any period of life. Lesions occur as in other
forms of bronchitis. The attack occurs most frequently in the spring
months. In some cases there seems to be some hereditary influence.
Chronic pulmonary diseases, like phthisis, emphysema and pleurisy, are
occasionally predisposing causes. It is sometimes associated with skin
diseases, such as herpes, impetigo and pemphigus.
The =pathology= is not known. The masses that are expelled are usually
round and mixed with blood and mucus. The casts are more dense, but the
membrane is identical with that of croupous exudates. This affection,
however, is limited to certain bronchial tubes and recurs at stated or
irregular intervals, sometimes for a period of several years. There is
loss of epithelium in the affected bronchi and the submucous tissue is
often swollen and infiltrated with serum.
=Symptoms.=—Acute cases are rare. The attacks may set in with rigor,
high fever, pain in the side, soreness, severe paroxysms of cough and
sometimes a slight hemoptysis. The symptoms are those of an ordinary
acute bronchitis, but of severer character; aggravated cough and
dyspnea and fatal termination are not uncommon. Death occasionally
results from suffocation. There may be but one attack without any
recurrence, but in the chronic form the paroxysms recur at irregular
intervals, though they are less severe than in the acute form.
The disease may last for ten or even twenty years, the attacks
recurring weekly, or a period of a year or more may intervene. The
onset is marked by bronchial symptoms with or without fever. The cough
soon becomes distressing and paroxysmal in character. The sputum may
be blood-stained and occasionally there is profuse hemorrhage. The
expectoration is in the form of ball-like masses which, when unraveled
are found to be moulds of the bronchi. They may be hollow and laminated
or quite solid. When examined under the microscope they are seen to
consist of a fibrillated membrane in which are imbedded leucocytes,
mucus, corpuscles, fat drops and epithelial cells. Leyden’s crystals
and Curschmann’s spirals are occasionally found.
=Physical signs= are usually those of bronchitis. The weakened or
suppressed breath sounds in the affected territory may occasionally
be determined. There is sometimes a diminished expansion or even
retraction of the chest wall over the affected area. There is no
dullness on percussion, unless the portions of the lung supplied by the
affected tubes collapse. After dislodgement of the casts, the normal
respiratory murmur returns.
=Diagnosis.=—The fibrinous casts alone are sufficient for a positive
diagnosis.
=Prognosis.=—Generally favorable. In uncomplicated cases there is
rarely any danger, even though there may be severe paroxysms of cough
and dyspnea. In fatal cases the lesions of associated or preceding
affections have been found, such as chronic pleurisy, pneumonia and
phthisis. Although this is a rare disease, cases have been treated
with success by osteopathic means. If uncomplicated there should be a
fair chance for a cure, depending, of course, upon the constitutional
condition and the permanency of the lesions.
=Treatment.=—The treatment is largely that of acute bronchitis. The
disorder is more extensive than in acute bronchitis, consequently
severe subluxations of the ribs and vertebræ of the upper and middle
dorsals occur, besides extensive muscular contractions of the chest and
neck. The fibrinous casts are somewhat of the same nature of membranous
exudates elsewhere, therefore the treatment should be directed to a
correction of the hyperemia of the mucous membrane of the bronchial
tubes, thus loosening and disorganizing the exudate. The vagi nerves
supply a part of the innervation to the bronchial tubes and lungs. Any
disorder to them should be corrected when diseases of the bronchial
tubes and lungs exist. They contain motor fibers to these organs, and
to the bronchial tubes they supply, principally the transverse fibers.
In bronchitis of various forms, marked effect can be secured by close
attention and treatment to the inferior laryngeal nerve. This is best
treated at the inner side of the lower portion of the sternocleido
muscle.
The different forms of bronchitis illustrate the point so often noted
in osteopathic etiology and pathology, that the various affections
of the same region should not be studied so much as types of several
diseases or disease entities as different degrees of involvement,
depending on the severity of the causative lesion, the function of the
nerves disturbed, and the character of the tissues. It is straining
a point to diagnose and classify many diseases according to signs
and symptoms instead of studying the process from central causes,
for, at best, peripheral manifestations, micro-organisms, etc., are
really incidental to the importance of the primary source of disturbed
nutrition. Consequently, the same treatment, if scientific, is
frequently indicated for all of the disorders that may affect a given
locality. After all has been said and done, the therapy as well as the
pathology, must hinge upon the fundamental—uninterrupted blood channels
and nerve courses are essential to health. Whether a disease is of
primary or secondary origin, or whether or not it presents different
symptoms in various types, the above basic principle is invariably
applicable. This simplifies etiology, pathology and treatment and
furnishes a backbone to theory and practice, and some day rational
medicine will adopt it.
Bronchiectasis
=Bronchiectasis= is a dilatation of a part or the whole of the
bronchial tube. As a rule this affection is a secondary one, the most
common cause being chronic bronchitis. The inflammation weakens the
bronchial walls so that they are unable to resist the strain that is
put upon them during violent paroxysms of coughing. After dilatation
has once commenced, the weight of the secretion which accumulates tends
to further distend the weakened walls and the elasticity, becoming
impaired, is finally lost. Dilatation of the bronchi is also associated
with emphysema, compression of a bronchus, aneurism or mediastinal
tumor, bronchopneumonia, measles and whooping cough in children, and
also traction associated with fibroid induration. Hence the bronchial
dilatation is especially associated with bronchitis, interstitial
pneumonia, and sometimes chronic pleurisy. It is rarely a congenital
effect in such cases. It is commonly unilateral. The lesions presented
to the osteopath are largely like those found in chronic bronchitis,
i. e., derangement of the upper four or five dorsal vertebræ and ribs,
and lesions of the cervical vertebræ involving the vagi. These lesions
obstruct the nerve force to the bronchial tubes and thus cause the
dilatation.
=Pathologically=, the dilatation is usually either cylindrical or
saccular, which may occur in the same lung. The entire bronchial tree
may be converted into a series of sacs opening into each other. These
have smooth, shining walls in the most dependent parts which are
sometimes ulcerated. In extreme conditions the dilatations may form
large cysts immediately beneath the pleura; as a rule, the lung tissue
lying between the sacculi becomes cirrhotic. =Partial dilatation=
is more common. The bronchial mucous membrane is involved with an
occasional narrowing of the lumen. The narrowings are most commonly
cylindrical, sometimes saccular.
In all forms there is decided change in the bronchial wall. In the
large dilatations, the epithelium is changed. The elastic and muscular
layers are thin and atrophied. These dilatations frequently contain
fetid secretions and when these secretions are retained, the lining
membrane becomes ulcerated.
=Symptoms.=—There is always cough, which occurs in severe paroxysms. In
some cases a change of position will cause a paroxysm of coughing—very
likely due to the emptying of the contents of a dilated tube into
a normal one. The sputum is mucopurulent and is greenish brown in
color, is fluid, and has a sour, or more frequently, a fetid odor.
On standing, it separates into three layers; the upper is frothy and
thin, the middle mucoid, and the lower is a thick sediment of cells
and granular debris. Microscopically, the sediment consists of pus
corpuscles, fatty acid crystals which are arranged in the form of
bundles, and sometimes red blood discs and hematoidin crystals. Elastic
fibers may be found if ulcers are present.
=Physical Signs.=—When distinctly present, they are those of a cavity
in the lungs. When chronic pleurisy and interstitial pneumonia are
associated, there may be retraction of the chest wall. The percussion
resonance is impaired. On auscultation, bronchial, or even amphoric,
breathing is heard occasionally with metallic rales.
=Diagnosis.=—In a number of cases this was formerly impossible, where
the X-ray is now proving of great assistance. History, paroxysmal
cough, characteristic copious sputum and an absence of tubercle bacilli
with little impairment of the general health will serve to distinguish
bronchiectasis from pulmonary tuberculosis. Circumscribed empyema which
has ruptured into the lung may simulate bronchiectasis. This is of a
much more sudden onset, has a history of previous pleurisy, the health
is gradually impaired, and there is thoracic oppression and dyspnea on
the slightest exertion.
=Prognosis.=—Is generally unfavorable. However this largely depends
upon the cause.
=Treatment.=—Largely the same as in chronic bronchitis. Severe lesions
are found in the dorsal vertebræ about the region of the third, fourth
and fifth, and many times lesions of the pneumogastric at the upper
cervical vertebræ are also found. The lesions are much of the same
nature as those of bronchitis, but, as a rule, there is a much deeper
or more extensive lesion. These lesions weaken the motor innervation to
the muscular coats of the bronchial tubes, and in many instances the
extensive lesions involve the vasomotor nerves controlling the blood
supply to the bronchial tubes. In most cases marked lesions of the ribs
on either side will be found, usually in the region corresponding to
the affected vertebræ.
The position of the patient is important; the head should be low in
sleeping. In certain fetid cases surgery should be considered.
Care should be taken as to the hygienic surroundings of the patient.
The diet should be carefully regulated and nutritious, as in chronic
bronchitis.
Bronchial Asthma
=Bronchial= or =spasmodic asthma= is a chronic affection, characterized
by a paroxysmal dyspnea due to a spasmodic contraction of the muscles
of the bronchial tubes or to swelling of their mucous membrane.
=Osteopathic Etiology= and =Pathology.=—The majority of lesions causing
bronchial asthma are from the second to the seventh dorsal region,
inclusive, either in the ribs posteriorly or anteriorly, or in the
vertebræ. These lesions involve vasomotor nerves to the bronchioles
which produce the narrowing of the tubes and thus cause the dyspnea.
Usually the lesion is at the third, fourth or fifth rib on the right
side, although, as stated, a lesion may be found above or below this
point at the anterior or posterior ends of the ribs or in the vertebræ
corresponding to the same region. Probably lesions are found more on
the right side, because most people are right-handed; these muscles
being better developed would tend, when contracted, to draw the
ribs from their articulation. The third, fourth and fifth ribs are
usually found involved because it is the region of greatest vasomotor
innervation to the bronchial tubes.
In a number of cases there will be found a posterior curvature of the
dorso-lumbar region; and accompanying this condition will be catarrh
and dilatation of the stomach, congestion of the liver, and, perhaps,
intestinal indigestion and constipation. Careful attention should be
given to the digestive organs.
Lesions involving the pneumogastric at the atlas and axis are
fairly frequent. These irritate fibers of the pneumogastric to the
muscles of the bronchioles and thus produce narrowing of the tubes
and consequently the paroxysms. Other points to note are the costal
cartilages and hyoid bone, and probably, in a few instances, lesions to
the phrenic.
Attacks may be induced reflexly by various excitants, as dust, diseases
of the upper respiratory tract, etc., but the lesions to the vasomotor
and motor nerves are the predisposing causes. Laughlin[93] says: “It
is questionable whether reflex causes alone are sufficient to produce
genuine asthma without the existence of specific lesions affecting the
direct nerve connections of the part involved.” No doubt a neurotic
tendency is often a predisposing factor. Overeating, and particularly
certain foods will frequently excite an attack.
=Pathologically=, true asthma is a pure neurosis. There is more or
less chronic inflammation of the bronchial tubes, shown by injection
and thickening of the bronchial mucosa in the majority of cases.
There may be found the morbid states peculiar to chronic bronchitis
and emphysema. Whether the constriction of the tubes is due to spasms
of the bronchial muscles or to swelling of the mucosa, or to both,
the primary, predisposing and irritating influences are common to
both. These are vertebral and rib lesions affecting the spinal nerves
at their exit and the sympathetic chain along the head of the ribs;
irritating lesions to the vagi, constricting pulmonary vessels, and to
the cervical sympathetics, causing disturbance of the same, would be
factors in the pathological chain. Reflex irritations may be found in
various regions, but the principal osseous lesions, according to Dr.
Still, are on the right side from the second to the sixth dorsal.
=Symptoms.=—The attack may come on at any time, but usually it comes
on in the night during sleep. The onset may be sudden or the attack
may be preceded by premonitory sensations, such as tightness in the
chest, flatulence, sneezing, chilliness and a copious discharge of
pale urine. Nervous symptoms, headache, vertigo, neuralgia, and an
anxious, nervous, restless feeling may precede the attack. There is
a sense of oppression and anxiety, followed by dyspnea. Soon the
respiratory efforts become violent, the patient is obliged to sit up
or runs to the window for air. The shoulders are raised, the hands
are placed upon something firm to keep the shoulders fixed so that
the accessory muscles of respiration can be brought into play. The
contracted tubes resist the entrance of air. Expiration is prolonged
and wheezy. In severe cases the face becomes pale, the skin is covered
with perspiration, the extremities are cold, the lips, finger tips and
eyelids are livid, owing to defective oxygenation of the blood. The
pulse is small and quick and the temperature is normal or subnormal.
The attack may terminate suddenly, sometimes with a spell of coughing;
this is especially so of severe cases, as the cough is generally absent
in brief paroxysms.
The =cough= is at first very tight and dry and accompanied by a tough,
scanty expectoration which is expelled with great difficulty. The
=sputum= contains rounded masses of matter, the so-called “pearls” of
Lænnec. Microscopically, they are found to be of a spiral structure,
containing cells derived from the bronchial mucous membrane and fatty
degenerated pus cells. A second form is contained in the inside of the
coiled spiral of mucin, a filament of great clearness and translucency,
that is most probably composed of transformed mucin. Curschmann’s
spirals are found in the early stages of the attack and for a time
these were supposed, by their irritation, to excite the paroxysms.
Their spiral form is unexplained. Curschmann believes that these
spirals are found in the finer bronchioles and to be a product of
bronchiolitis.
=Physical Signs.=—=Inspection= shows enlargement of the chest which is
fixed and barrel-shaped. The breathing is labored and the chest moves
but slightly. The diaphragm is lowered and fixed. =Percussion= yields
hyperresonance, especially in cases which have had repeated attacks
or when the asthma is associated with emphysema. =Auscultation.=—With
inspiration and expiration are heard sonorous sibilant rales which are
more marked on expiration. As the secretion increases, which is later
in the attack, the rale becomes moist. The attack lasts for a variable
period, rarely less than an hour. In severe attacks the paroxysms recur
for three or four nights or more with spontaneous remissions during the
day. In some cases the relief seems to be absolute, but in the majority
of cases there is more or less oppression and cough for a day or two,
sometimes for many days.
=Diagnosis.=—The physical signs, examination of the sputum and the
history of the case makes the diagnosis easy.
=Prognosis.=—It is not a fatal disease and only dangerous when
complications arise. Under osteopathic treatment the prognosis is
usually favorable, unless there are serious complications, as this is
a disease that osteopathy has treated with signal success. In long
standing cases emphysema invariably develops.
=Treatment.=—Asthma, unless complicated with bronchial and lung
diseases, is usually readily relieved during the paroxysms. Cases of
many years’ standing have been cured in a few treatments. It should be
borne in mind that asthma is a respiratory neurosis.
To relieve an attack the osteopath should locate the lesion and, if
possible, correct it. Oium[94], in the acute attack, standing at the
head of his patient inserts the tips of both thumbs well under the
angles of the jaw and then brings direct pressure on both vagi as
they pass over the transverse processes of the axis. Pressure must be
brief and let up to be applied again. Immediate relief is given in many
cases. Adjust upper three cervicals if found deranged.
If the muscles are so severely contracted that it is impossible to
make out the nature of the lesion, then strong inhibition, with an
upward, outward movement over the angles of the ribs involved, will
be sufficient. The object to be gained in every case is to relieve
pressure or irritation to the vasomotor or motor nerves, so that the
narrowed tubes may be relaxed. Strong inhibition, such as placing the
knee in the patient’s back, at the same time pulling on the shoulders,
will have temporary effect, but it is always best to reduce the lesion
if possible. In severe cases dilatation of the rectum may relieve the
paroxysm, and in a few instances it will be necessary to treat the
uterus locally.
During the interval between the attacks is the time to remedy the
disease. Then one is able to locate exactly the position of the
disturbed tissues that are causing the paroxysms and apply treatment
in the regions given under etiology. Many cases of asthma are cured
in from one to three months’ treatment. One treatment a week is
sufficient, provided one is able each time to accomplish something
toward a correction of the lesion and that the patient does not suffer
during the meantime. Too frequent treatments may simply act as an
irritant to the nervous lesions.
Attention should always be given to the diet and hygiene. Gastric
digestion should be complete before retiring or it may induce an
attack. Complications are treated according to the disease. Examine the
upper respiratory tract, the digestive tract, and the pelvic organs
when there is reason to believe the paroxysm may be induced reflexly.
Laughlin sums up the treatment as follows: (1) Removal of specific
lesion; (2) removal of exciting causes; (3) removal of reflex causes;
and, (4) treatment of the patient to improve the condition of the
general nervous system.
FOOTNOTES:
[93] Laughlin—Asthma—Journal of the American Osteopathic Association,
Oct., 1914.
[94] Journal A. O. A. 1918.
DISEASES OF THE LUNGS
Emphysema
Used in a general way, emphysema is a term which implies the presence
of air in the interstitial tissue, but when applied to the lungs
there are two applications of the term, having widely different
significations, viz: Interlobular or interstitial emphysema and
vesicular emphysema.
=Interlobular Emphysema.=—This is caused by rupture of air vesicles,
deep in the lung structure, the air escaping into the interlobular
connective tissue. It is not a very serious condition, rarely produces
symptoms and affords no physical signs. It usually results from violent
acts of coughing in which the expiratory strain is very great, as in
whooping cough and in bronchial asthma; also, from wounds of the lung.
The air bubbles escape into the interlobular septa and are sometimes
seen like little rows of beads outlining the lobules. The pleura
may become detached and larger vesicles may form. In rare cases the
rupture may take place at the root of the lung and the air passes
along the trachea into the subcutaneous tissue of the neck and chest
wall, which gives rise to a very peculiar and distinctive crepitation
upon palpation. Rarely there is rupture of the superficial vesicles,
producing pneumothorax.
=Vesicular Emphysema.=—Dilatation of the infundibular passages and
alveoli or an increase in their size either symmetrical, involving both
lungs, or localized. Vesicular emphysema is divided into compensatory,
hypertrophic and atrophic forms.
=Compensatory.=—This occurs when a region of the lung has been disabled
from any cause and does not expand fully during inspiration; the
healthy portion of the lung must then distend and do vicarious work
or the chest wall will sink in to occupy the space. This happens with
portions of healthy lungs in the neighborhood of tubercular areas and
cicatrices, areas of collapsed lung or parts prevented from expansion
by pleuritic adhesions (in this case the compensatory emphysema
is chiefly at the anterior margins of the lungs). As a rule this
distention is physiologic and beneficial, the alveolar walls being
simply stretched. Later they may atrophy, the air cells becoming fused.
=Hypertrophic Emphysema.=—This is enlargement of the lung, due to
dilatation of the air vesicles and atrophy of the walls.
=Osteopathic Etiology= and =Pathology=.—An important predisposing cause
of emphysema is often found to be due to derangements of the tissues,
usually vertebræ and ribs, which affect the innervation to the lung
tissues. Such lesions are found in the vagi and spinal dorsal nerves.
The atlas may be involved, but it is generally the ribs and dorsal
vertebræ. Distinction should be made between cause and effect in the
skeletal changes. No doubt in many instances a vicious circle is thus
established. Congenital weakness of the lung tissues, probably due to
non-development of the elastic tissue, is a predisposing factor. This
disease has a markedly hereditary character and frequently starts
early in life. The heightened pressure within the air cells upon an
already weakened lung tissue produces emphysema. Hence, the obstinate
cough of chronic bronchitis and expiratory straining of asthma are
sometimes the immediate cause. In all attacks of severe coughing or
straining efforts, the glottis is closed and the air is forced into the
upper part of the lungs, forcibly expanding them, and here is where
emphysema is found to be most advanced. This disease is also found
in players of wind instruments, in glass blowers and in those whose
occupation necessitates heavy lifting or straining.
=Pathologically=, the thorax is barrel-shaped. The lungs are enlarged
and do not collapse when the thorax is opened, as they have lost their
elasticity. The organs are pale, soft and downy to the feeling and
pit on pressure. Enlarged air vesicles may readily be seen beneath
the pleura. Microscopically, there are seen atrophy of the vesicular
walls and a diminished amount of elastic tissue. There is more or less
obliteration of the capillaries, and the epithelium of the air cells
undergoes a fatty change. There is usually chronic inflammation of the
bronchial tubes, which may be roughened and thickened. The diaphragm
is lowered and the subjacent viscera are displaced. The most important
morbid changes are found in the heart, the right chamber being dilated
and hypertrophied. This is caused by the increased tension in the
pulmonary artery, which is enlarged and the seat of atheromatous
degeneration. In long standing cases the hypertrophy is general.
Changes in the liver, kidneys and other viscera are those associated
with prolonged venous engorgement.
=Symptoms.=—The onset of the disease is usually gradual. The first
symptom to be noticed is the shortness of breath. In rare cases it
may exhibit a more acute development, as after whooping cough, and
then the first symptom will be dyspnea. In some cases this persists
all the time, while in moderate emphysema the dyspnea is noticed
only on slight exertion, such as going up-stairs, running or walking
rapidly. The lungs are always filled with air which is charged with
carbon dioxid and does not change, as the patient is constantly making
ineffectual efforts to draw in air. The inspiration is shortened and
the expiration is greatly prolonged and is often harsh and wheezy. The
pulse-rate is accelerated; the temperature is usually normal. Cyanosis
is a characteristic symptom in well established cases and is of an
extreme grade not seen in any other affection. Bronchitis is frequently
found in combination, especially in winter. In this case there will be
the symptoms of the associated bronchitis, cough, expectoration and
sometimes oppression. As the patient advances in age and there are
successive attacks of bronchitis, the condition gets worse. In advanced
cases, the result of cardiac failures, there may be venous engorgement,
dropsy and effusions into the serous sacs.
=Physical Signs.=—=Inspection.=—There is a marked change in the shape
of the thorax. The chest is rounded with increased circumference,
giving the characteristic barrel-shaped chest. The sternum bulges,
as do also the costal cartilages. The intercostal spaces are wide,
especially in the hypochondriac region, and narrow above. The clavicles
and muscles of the neck stand out with great prominence and the neck
itself seems to be shortened on account of the elevation of the
thorax and sternum. The curve of the spine is increased and there is
a winged condition of the scapulæ. These changes give the patient a
stooping posture. The chest does not expand, but is raised up by the
scaleni and sternocleidomastoid muscles which stand out prominently
and are hypertrophied. The heart’s apex beat is invisible and there is
usually marked epigastric pulsation. On =palpation=, vocal fremitus
is found diminished, but not absent; the apex beat is rarely felt.
There is distinct shock over the ensiform cartilage. This is due to
the displacement of the heart and engorgement of the right ventricle.
There is marked pulsation in the epigastrium. On =percussion= there
is sometimes increased resonance, almost amounting to tympany. The
upper level of hepatic dullness is depressed. The heart dullness may
be obliterated and the upper limit of splenic dullness may also be
lowered. The =percussion= note is greatly extended. =Auscultation=
reveals that the inspiration is short and feeble while there is
prolonged expiration, the normal ratio being reversed. In associated
bronchitis rales are frequently heard.
=Diagnosis.=—Unless complicated the diagnosis is generally easily
made. The enlargement of the thorax, with dyspnea and hyperresonance
and a prolonged expiration will differentiate emphysema from =chronic
bronchitis=. =Pneumothorax= is of sudden development while emphysema is
of slow development. Pneumothorax is usually unilateral, and it gives a
tympanitic percussion note. In auscultation there is amphoric breathing
and metallic tinkling and absence of any vesicular murmur.
=Prognosis.=—The disease is rarely fatal, although death may result
from heart failure, dropsy or pneumonia. Thorough and persistent
treatment will generally relieve the primary condition. The disease, as
a rule, runs a long course but does not necessarily shorten life.
=Atrophic emphysema= is a senile change.
=Treatment.=—In cases of recent occurrence one may be able to build
up the altered lung tissue by treatment of the innervation to the
lung structure, viz.: the vasomotor nerves from the second to the
seventh dorsal, the vagi, and the cervical and dorsal sympathetics.
When a number of air vesicles have been converted into one sac, it is
impossible to restore the altered lung structure and a treatment to
relieve the symptoms and to prevent the further progress of the disease
is indicated. In all cases treatment should be applied to correct any
vertebræ or ribs of the upper dorsal region that may be displaced, and
to raise and spread the ribs so that the lung structure may be better
nourished and strengthened and that the aeration of the blood will
be more perfect. Treatment of the vagi nerves is important, as their
physiological action on the lungs is to increase their movement.
The general health of the patient is an important consideration
and everything should be done to promote as healthy a condition as
possible. The digestion should be carefully looked after and everything
done to restore a normal state of the blood. A change of climate may
prove beneficial.
Strengthening the cardiac action will be of service in relieving any
dropsical tendency that might occur on account of obstruction to the
pulmonary circulation. If bronchitis or asthma occurs, their respective
treatments are indicated. A general treatment of the splanchnic and
lung vascular areas should be given to prevent any disturbance in the
circulation which might cause congestion of the liver, congestion of
the hemorrhoidal veins, or catarrh of the stomach and bowels.
“Free evacuation of the bowels and measures to relieve any flatulent
distention are very needful in cases of emphysema to take off from the
diaphragm any pressure from below, and to allow it to descend as freely
as possible. With this view also the food should be concentrated,
nourishing, and not bulky.”[95]
It is a good plan to instruct the nurse or attendant to aid inspiration
by raising the arms strongly above the head during inspiration and to
compress the chest during expiration so as to coincide with natural
breathing, which will render the aeration of the blood greater and
increase the elasticity of the vesicles.
Acute Lobar Pneumonia
(CROUPOUS PNEUMONIA)
This is an acute, infectious disease wherein various vertebral, rib
and muscular lesions predispose to a lowered nutritive state of the
parenchyma of the lung, permitting the invasion of the diplococcus
pneumoniæ, with consequent local inflammation and pronounced
constitutional disturbances, chill, extreme prostration and fever,
which terminates abruptly by crisis. Secondary infective processes are
frequent.
In describing a typical case of pneumonia it is considered as a
self-limiting disease. By osteopathic treatment it is often aborted or,
at least, its course much shortened. In such a case it is not typical
pneumonia and could not be described as such.
=Osteopathic Etiology= and =Pathology=.—Pneumonia occurs more often in
the young up to the sixth year and in the aged. It is more frequent
during the winter and spring months. “Colds,” exposure and wetting are
predisposing influences that lower resistance. Climate exerts little
predisposing influence. Males are, on the whole, more frequently
attacked. Pneumonia may follow injuries of the chest. Various
derangements of the ribs and vertebræ are always found in pneumonia;
such derangements correspond with the regions of vasomotor, motor and
trophic fibers of the lungs, viz., second to seventh dorsal, inclusive,
and the upper cervical vertebræ, the latter region affecting the vagi.
The muscles of the chest region are always severed contracted. These
various disorders produce a lowered vitality of the bronchial and lung
tissues, thus favoring the existence of the micrococcus lanceolatus.
Unhygienic surroundings, alcoholism, any or all habits that tend to
depress the nervous system, or lowered vitality from some pre-existent
disease, like diabetes, Bright’s disease, organic heart affection
or one of the infectious fevers, favor its development. One attack
undoubtedly predisposes to another and repeated attacks may occur in
the same individual. The exciting cause is the invasion of the lung by
pathogenic bacteria, especially by diplococcus pneumoniæ. Pneumococci
are frequently found in the throat and mouth of the healthy.
=Pathologically=, the lung in croupous pneumonia exhibits three
distinct stages—congestion, red hepatization and gray hepatization. In
the =stage= of =engorgement= the tissue is red in color, firm and solid
and less crepitant than the healthy lung. The cut surface is bathed in
blood and stained serum. Microscopic examination shows the capillaries
to be dilated and tortuous. The alveolar epithelium is swollen and the
air cells filled with a variable number of red corpuscles, detached
alveolar cells and a few leucocytes. During the =stage= of =red
hepatization= the tissue is solid. It is reddish brown in color and of
a dry, mottled appearance. It is very friable and does not crepitate,
as the affected portion is airless. Its weight and specific gravity
are increased so that it sinks in water. The torn surface presents a
granular appearance, there being fibrinous plugs in the air cells. On
microscopic examination the air spaces are found filled with coagulated
fibrin. The tissue contains red blood-corpuscles and pus cells and the
walls of the air cells are infiltrated. In sections properly treated
the diplococcus is detected, and in some cases also the streptococcus
and staphylococcus. In the =stage= of =gray hepatization=, the lung is
still dense and heavy, but the surface is moister and softer, while the
lung tissue is even more friable and the red color gives place to a
mottled gray. The exudate loses its granular character and a yellowish
white purulent liquid flows from a cut surface. Microscopically, the
air cells are filled with leucocytes, while the red corpuscles and
fibrin filaments have disappeared. The stage of gray hepatization is
the stage of beginning =resolution=. The exudate is softened. The cell
elements are disintegrated and absorbed by the lymphatics and largely
eliminated through the kidneys. In unfavorable cases the consolidated
lung may become infiltrated with pus, and abscesses occur. In some
instances the tissue is gangrenous, or it may become the seat of
fibroid induration. These, however, are rare.
=Symptoms.=—The disease begins abruptly, usually with a severe chill,
lasting from half an hour to an hour, the fever rising rapidly. There
is a sharp pain in the side, the skin becomes harsh and dry, the
face is flushed, the eyes are bright and the expression anxious. A
short, dry, painful cough soon develops. The expectoration presents
a characteristic, rusty or blood tinged appearance and is extremely
tenacious. The temperature rises rapidly, frequently to 104 or 105
degrees F., and continues high for from five to ten days and generally
terminates by crisis. The pulse is full, but the pulse-respiration
ratio is not maintained. There is marked dyspnea, the respirations
ranging from forty to fifty per minute. There are many fine rales.
Headache, gastro-intestinal disturbances, sleeplessness, epistaxis,
rarely delirium except in drunkards, may also be present.
The symptoms given are those of a typical case of pneumonia, but all
are subject to modification. The onset may be gradual and the chill
absent. In all cases, and especially drunkards, the temperature may not
be high, while the pulse is often feeble and rapid instead of full and
strong, and the physical signs may not make their appearance until the
second or third day.
=Special Symptoms.=—The =fever= rises abruptly in the initial chill,
the temperature reaching 104 or 105 degrees F., and is continuous with
a variation of a degree or two. The fever terminates by =crisis= after
having continued from five to nine days. The temperature commonly
falls during the night and is accompanied by a profuse perspiration.
The temperature may fall from five to eight degrees in eight to twelve
hours. There is a wide range here depending upon promptness and
skillfulness of treatment, the reaction of the tissues, and previous
health. Early treatment is invaluable in modifying the course of the
disease.
The =sputum= at first is mucoid and frothy. About the second day it
becomes of a characteristic color, quite copious and consisting of
a frothy, fluid mucus, containing small viscid masses. It is very
viscid and glutinous, in some cases almost from the onset. In old
and previously weak persons, there may be no expectoration. Under
the microscope the sputum is seen to contain red blood-corpuscles,
leucocytes, alveolar epithelium, the micrococcus lanceolatus as well
as other micro-organisms, pus corpuscles and small fibrinous casts.
A stabbing =pain= is a common early symptom, as well as a dry, short
=cough=. The =urine= is febrile, scanty and high colored. Urea and
uric acid are increased. A trace of albumin is often present, and
there may be symptoms of acute nephritis. =Herpes= is common. The
nasolabial herpes appear from the second to the fifth day, and they
may occur upon the cheek, genitals and also upon mucosa of the tongue.
It is supposed to indicate a favorable prognosis. There is redness of
the cheek, usually on the affected side. The mucous membrane of the
mouth is dry. The tongue is white and furred. Anorexia and thirst are
present. The patient is usually constipated, but diarrhea may occur.
Vomiting is common. The spleen is usually enlarged, but the liver is
not perceptibly increased in size, unless there is extreme engorgement
of the right heart. The =pulse= is bounding. The average pulse-rate
is from 100 to 108 per minute. In consolidation the left ventricle
receives a lessened amount of blood and the pulse may become small. In
the aged and debilitated, a small, weak and rapid pulse may be present.
The =heart sounds= are loud and clear, and in favorable cases the
pulmonary second sound is accentuated, owing to the increased tension
in the pulmonary vessels. Upon distension of the right side of the
heart and partial failure of the right ventricle, the second sound
becomes less distinct which is a very unfavorable symptom, for very
much depends upon the strength of the right ventricle in pneumonia.
The =blood= usually exhibits leucocytosis which disappears with the
crisis. In malignant pneumonia this is absent and its continued absence
is an unfavorable sign. The proportion of fibrin is also greatly
increased. The diplococci can rarely be seen. Headache is common as an
initial symptom and may be persistent. The disease is often ushered
in by convulsions, especially in children; consciousness is usually
retained throughout the whole attack, even in severe cases, though in
some cases there is delirium. In drunkards delirium tremens may be
present from the onset. In these cases the patient often wanders about
until the preliminary excitement gives way to coma.
=Physical Signs.=—=Stage= of =Congestion.=—Diminished expansion, the
movements of the affected side are defective, the face is flushed and
the patient lies on the affected side. Tactile fremitus is slightly
increased. There may be tympany over the involved area from diminished
intrapulmonary tension. In the latter part of this stage there is
impairment of resonance. Fine crepitant rales are heard at the end of
forced inspiration. Great care has to be taken in examination when
there is deep seated consolidation.
=Stage= of =Red Hepatization=.—The breathing is markedly abnormal. Very
little or no expansive motion of the chest over the affected region.
Vocal fremitus is markedly exaggerated. The skin is hot and dry and
the pulse frequent. Dullness over the affected parts with an increased
sense of resistance is present. There is high-pitched, prolonged,
bronchial breathing when the lung becomes solidified. When the larger
bronchi are completely filled with exudate, tubular breathing is
absent. Crepitant rales may also be heard.
=Stage= of =Gray Hepatization=.—Largely the same physical signs
are repeated in this stage as in the second. The normal manner of
breathing returns, as does also the normal expansive movement of the
affected side. Crepitant rales reappear. The temperature of the skin is
lessened, breathing changes from bronchial to vesicular and bronchial
resonance continues for some time.
=Complications.=—=Pleurisy= is the most frequent complication.
Pneumonia on one side and pleurisy on the other is possible. The pain
is more acute and localized. The respiration is greatly affected and
the usual signs of effusion are present. Empyema may be a complication.
=Pericarditis= is more common in the pneumonia of children. Though
usually plastic it may be serofibrinous, but rarely the fluid is
purulent. There is increased dyspnea, the pulse becomes weaker,
and the heart sounds are gradually suppressed. =Endocarditis= is
a comparatively frequent complication. It is more liable to attack
patients with old valvular disease and to affect the left heart. The
physical signs are sometimes absent and even when present are liable
to be very deceptive. It may, however, be suspected in cases where the
fever is protracted; when septic manifestations, such as chills, sweats
or irregular temperature, develop; when embolic symptoms appear, or
when a rough, diastolic murmur develops. =Meningitis= is a complication
that comes on at the height of the fever. This complication is
rarely recognized unless the basilar meninges are involved. It is
frequently associated with ulcerated endocarditis. Cerebral embolism
causing hemiplegia has been observed. Other possible complications
are neuritis, arthritis, nephritis, parotitis and various digestive
disorders.
=Diagnosis.=—A typical case of pneumonia is easily recognized. The
abrupt onset with rigor, the rapidly developed fever, the sputum,
physical signs and abnormal pulse-respiration ratio, as a rule make
the diagnosis easy. Frequent examination of the lungs should be made
in Bright’s disease, diabetes, organic affections of the heart,
cancer and alcoholism, as all these affections are liable to become
complicated with acute pneumonia. =Pleurisy= is often confounded with
pneumonia. The resemblance between friction sounds and crepitant rales
is often very close. In pleurisy vocal resonance and vocal fremitus are
diminished; there is no “rusty” sputum; the percussion dullness may
change with the posture of the patient, and the breathing is distant
and weak. A typhoid state may be mistaken for typhoid fever. Hypostasis
occurs late in typhoid fever while dullness sets in early in pneumonia.
The history of the onset will be of aid, as pneumonia as a complication
sets in late in the disease. The Widal test will be of value. =Acute
phthisis= may begin with a chill and may resemble pneumonia very
closely, especially the physical signs. Examination of the sputum will
show the bacilli of tuberculosis. The X-ray will often be of aid as a
diagnostic measure.
=Prognosis.=—This largely depends upon the previous health of
the patient. At the extremes of life the prognosis is much more
unfavorable. It is especially fatal in drunkards. By competent
osteopathic treatment the mortality rate may be materially lessened and
this disease, dreaded by both physician and patient, need not seem so
fearful. The death rate from pneumonia during the past few years has
been appalling. In New York and Chicago nearly one-eighth of the deaths
the year around are due to pneumonia, and during certain months of the
year twenty-seven or eight per cent. of all deaths are due to this
disease. Drug medication is notoriously unreliable, the most competent
physicians freely admitting that they are practically powerless to stay
the ravages. Given a patient with a fair constitution, osteopathic
treatment will offer reasonable hope to the sufferer. There is no
question that osteopathy merits much commendation in the treatment
of pneumonia. Many severe cases have been cured and many more have
undoubtedly been aborted. The treatment is directly applicable and
specifically indicated, and coupled with good nursing and hygiene, the
mortality rate of the old schools is being markedly lessened.
=Treatment.=—The treatment of pneumonia must be both constitutional and
local. By this is meant that the systemic strength and vigor must be
maintained in addition to treatment of the chief lesion of the disease,
which is located in the lungs.
During the various stages of the disease, the treatment should
be directed to the nerves of direct innervation that control the
capillaries, and to the vasomotor nerves of the pulmonary circulation,
in order that the hyperemic and inflamed state of the pulmonary
capillaries and adjacent tissues may be lessened and the circulatory
system equalized. The disordered tissues that should be corrected
in order that the centers of the spinal cord and the nerves that
influence the function and structure of the lungs may be relieved, are:
contraction of the thoracic and dorsal muscles, subluxations of the
ribs and dorsal vertebræ from the second to the seventh, inclusive,
and the upper cervical vertebræ that may become disordered and impinge
upon the vagi nerves. However, owing to the fact that the vasomotors
are not especially abundant here, all increased chest mobility and deep
breathing and abdominal aid will materially assist the circulation.
Also, carefully treat the middle and inferior cervical regions for the
lymphatics of the lungs. Each of these regions should be carefully
examined and thoroughly treated whenever found involved. The specific
micro-organisms that influence the course of pneumonia are naturally
very important factors; but observing and improving the general health,
and establishing an unobstructed circulation through the diseased
lung tissues will hasten the crisis by favoring a rapid formation of
antidotal substances to neutralize the poisonous substance produced by
the micrococcus lanceolatus. Healthy tissues, which occur only where
there is uninterrupted freedom of vascular supply and nerve force,
are obtained by correction of any and all anatomical disorders. This
will rapidly decrease any lethal tendency in the patient and often
abort the disorder so that all that is needed is sufficient time
for nature to heal the diseased tissues. The principal predisposing
cause of many specific diseases, is some disorder of the anatomical
tissues that interferes with normal physiological functions; and the
determining of the different types of disease is often due to the
location of the lesion and the character of the micro-organism involved
in each disease. What is necessary in many cases is a correction of
the mechanical predisposing condition and the exciting and determining
influences will be rendered inactive.
The importance of close attention to both vagi can not be
overestimated. Any obstruction above or below the origin of the
superior laryngeal nerve is followed by loss of motor power of the
lungs, thus causing difficult and labored breathing. The lungs become
surcharged with blood, because the air pressure in the lungs is low
and the thorax is distended. This condition is followed by serous
exudation. Thus obstruction of the vagi may be one factor in the cause
of pneumonia. Obstruction of the vagi below the origin of the recurrent
laryngeal nerves affects the lower and middle lobes of the lungs,
and produces also a catarrhal inflammation of the upper lobes. The
recurrent laryngeal nerves may be obstructed by dilatation of the aorta
or subclavian artery as they wind about them; also by dislocations
of the first and second ribs, which may affect the nerves not only
directly, but by causing an obstruction to the subclavian vessels with
a consequent disturbance of the aorta and the heart. The recurrent
laryngeal nerves may be treated directly at the inner lower part of the
sternomastoid.
One of the chief objects of the treatment should be to prevent =heart
failure= and to lessen the pulse-respiration ratio. The average
pulse-rate in typical cases is from 100 to 110 per minute and when
it exceeds this to any extent, say 120, there is cause for alarm. At
first the pulse is full and bounding, later it is small on account of
a lessened amount of blood reaching the left ventricle and systemic
circulation, owing to the extensive consolidation. In treating heart
failure particular attention should be paid to the condition of the
ribs on the left side over the region of the heart, the second to the
fifth, inclusive. A correction of any disturbance to the inhibitory
nerves of the heart, (the vagi) and the accelerator fibers of the heart
(the cervical sympathetic) should be made. This means close attention
to probable derangements of the vertebræ from atlas to first dorsal.
General treatment of the entire system will relieve the heart of
some work and favor an equalization of the vascular system. Also by
the use of hydrotherapy the maintenance of the heart’s action may be
accomplished. Cold compresses, and not warm ones, should be used, as
the latter relax the vessel walls, producing more or less paresis of
the vessels, while the former stimulate the vaso-dilators, producing
dilatation and tone of the vessels, thereby causing a vigorous increase
in the flow of blood. This relieves the heart by increasing the
cutaneous circulation, besides increasing arterial tension. The right
heart is indirectly aided by the increase of the tension in the general
vascular system, and the vessels of the pulmonary circulation have more
force expended upon them and a greater contraction of their vessels
occurs on account of the dilatation of the cutaneous vessels. The
temperature of the water used should be 60 degrees F., and the compress
applied for thirty minutes or as long as necessary.
Attention to the abdominal area and diaphragm will have a definite
effect upon the circulation and elimination. It is beneficial in its
influence upon lungs and heart and in combatting toxemia. Carefully
graduated deep breathing is of distinct benefit.
In addition to the fever treatment in the cervical and dorsal regions,
the gradually cooled tub-bath will be of aid. The temperature at first
should be ninety degrees F. and then gradually cooled to eighty degrees
F. The duration should not be over ten or fifteen minutes. Care should
be taken that the patient does not exert himself. He should be lifted
in and out of the baths. These baths also have a marked effect upon the
respiratory and nervous centers. The ice-bag over the chest and spine
has a beneficial influence; still, with feeble children be exceedingly
careful when applying or using cold methods.
=During all stages of the disease=, the best possible care should be
taken of the patient. See the patient frequently, probably twice a day
or oftener. Each time thoroughly relax the dorsal muscles and readjust
the ribs, for as every osteopath of experience will note (and Dr.
Still particularly emphasizes) the contracted muscles frequently and
continually displace the ribs. The treatment should not be prolonged to
a point of overfatigue, but a definite reaction of tissues should be
secured but no further.
Carefully raise all the ribs and moderately hyperextend the spine.
Release the cervical, pectoral and axillary lymphatics, and stimulate
spleen and liver.
Experience has shown that the first treatment is of the greatest
importance and if the osteopath will control the predominant symptoms
at that time the result will be much simplified. For that reason it is
best not to leave the patient until the chest pain, fever, high pulse
or whatever may be present, are well in hand, although it may mean
a long visit with fairly frequent treatments. Treat the conditions
existing and wait; then treat again and the result will more than
repay. There is always more than a chance of aborting the disease, but
the first treatment is often the crucial test. F. E. Moore and many
others report numerous cases treated without a fatality and the average
duration of the disease not exceeding five days. The apartment should
be well aired and a temperature of 65 degrees F. maintained. In the
very young the temperature should be higher. The diet is exceedingly
important. Give a liquid, light and nutritious one, a milk diet being
preferable. Otherwise give meat juice, broths, egg albumin and whey.
Avoid starchy and saccharine foods, and give plenty of water. Good
nursing and complete rest of body and mind, with careful attention to
the activity of the bowels, kidneys and skin, will indirectly aid the
clogged up lung fascia to perform its function and hasten an early
recovery from the disease. In epidemic forms be particularly vigilant
in the employment of antiseptics.
Bronchopneumonia
(CATARRHAL PNEUMONIA)
=Definition.=—An inflammation of the minute bronchi and air vesicles.
The affection begins with an inflammation of the capillary bronchi,
which extends to the air vesicles. The micrococcus lanceolatus,
streptococcus pyogenes, influenza bacillus, and staphylococcus aureus
et albus are the principal exciting micro-organisms.
=Osteopathic Etiology= and =Pathology=.—The disease is most prevalent
among the very young and the old, and may be either primary or
secondary. It may occur as a sequence or in association with measles,
diphtheria, whooping cough and scarlet fever. Exposure to cold,
impure air, rickets and diarrhea are marked predisposing causes in
children. In the old, debilitating affections and chronic diseases
are predisposing causes. Bronchopneumonia occurs sometimes as a
complication in smallpox, erysipelas, typhoid fever and influenza.
The principal lesions found upon examination are subdislocated ribs
affecting the pulmonary vasomotor nerves. The third, fourth and fifth
ribs are especially apt to be subdislocated. The muscles throughout the
thoracic region are generally severely contracted.
Another group of cases, the so-called =aspiration or deglutition
pneumonia=, are caused by the inhalation of food particles or other
substances. A lessened sensitiveness of the larynx (as in comatose
states) may allow small particles of food to reach the smaller bronchi
and produce inflammation, which may even cause suppuration and
sometimes gangrene. Cases are liable to occur after operations about
the nose and mouth. It is often secondary to carcinoma of the larynx
and esophagus and after tracheotomy and glosso-pharyngeal palsy. A
serious form of bronchopneumonia is caused by the =tubercle bacillus=.
=Pathologically=, both lungs are usually involved and become heavy. On
the pleural surfaces, especially at the base, sunken purplish or slaty
patches are noticed, representing collapsed lung tissue. On section
small, projecting portions of consolidation are seen, separated from
each other by uninflamed and collapsed tissue. The section of lung
tissue is of a dark reddish color. The terminal bronchi are filled with
tenacious, purulent material. Microscopically, the terminal bronchi and
air cells are filled with a plug of exudation composed of leucocytes
and desquamated epithelium. The walls of the bronchi are swollen and
contain many leucocytes.
=Symptoms.=—The symptoms are frequently marked by those of the primary
affection. The onset may be either abrupt or gradual. The child becomes
feverish; there is increased frequency in respiration and there is
an aggravated cough. The temperature rises to 102 or 104 degrees
F.; respiration may rise as high as 60 or 80. The cough is hard,
distressing, frequently painful and accompanied by a mucopurulent
expectoration. The pulse is greatly accelerated—120 to 180 per minute.
As the disease advances, signs of deficient aeration of the blood are
noticed. At first there is a pale and anxious expression of the face,
the lips are blue and the child makes strenuous efforts to breathe.
The blood soon becomes highly charged with carbon dioxide and, by its
benumbing influence upon the nerve centers, sensibility is reduced and
the cough and suffering subside. The face becomes livid and death may
occur within twenty-four hours from paralysis of the heart.
At the beginning of the attack dullness is absent and subcrepitant
and sibilant rales are present. Areas of consolidation soon become
manifested. There is slight impairment of resonance and the breathing
is harsh. Upon inspection there is, in grave cases, retraction of the
sternum due to defective expansion.
=Diagnosis.=—This is usually easy, developing as it generally does in
the course or at the conclusion of another disease, with a gradual
onset as a rule, and irregular fever and a long duration, besides
usually occurring in children under five. If the areas of consolidation
are large, involving the greater part of a lobe, it is sometimes very
difficult to distinguish bronchial pneumonia from lobar pneumonia.
=Lobar pneumonia=, when occurring in children, is usually between
the ages of five and fifteen. The onset is abrupt in a child of
good health; it resolves rapidly; there is rusty colored sputum and
continued fever falling by crisis. =Tuberculous bronchopneumonia= is
very hard to differentiate from simple bronchopneumonia. A great many
cases can be correctly diagnosed only after the lapse of considerable
time. The presence of signs of softening, considerable disease of the
apices, and examination of the sputum, or in the case of a child,
of the vomited matter, would diagnose this form. If elastic fibers
and tubercle bacilli are found in the sputum or vomited matter, the
diagnosis is at once decided in favor of tuberculous bronchopneumonia.
X-ray diagnosis should be considered.
=Prognosis.=—The prognosis depends on the cause. In children that are
previously weak and debilitated the disease is very fatal. When the
disease follows measles and whooping cough, the fatality is not so
great. In adults the prognosis is about the same as in the croupous
form. The deglutition variety is apt to be fatal.
=Treatment.=—A great deal can be done to prevent the disease, by
careful attention to debilitated children in keeping them warm and
protected at all times. There is usually a preexisting bronchitis. In
measles and whooping cough and during convalescence, the child should
be well taken care of.
A thorough, persistent treatment, but not to a point of overfatigue,
of the dorsal vasomotor nerves posteriorly should be given. Gentle
work over the cervical and axillary lymphatics to free the edematous
barrier, correction of the tensed scaleni and deranged first ribs and
clavicles, and stimulation of spleen and liver, with sufficient general
treatment to start reaction, will be effective. Derangements to the
third, fourth and fifth dorsal nerves are most likely to be found; the
principal vasomotor innervation to the bronchials and air vesicles
is from this region. Treatment over the chest anteriorly is of great
aid, especially an upward and outward manipulation to release the ribs
should be given. Attention should be given the vagi nerves to increase
the activity of the lungs as well as for the effect gained upon the
circular fibers of the bronchi. Care should be taken, that the first
rib is not impinging upon the first thoracic ganglion, or interfering
with lymphatic drainage.
Ice-bags over the chest are helpful. The chest should be protected from
changes in temperature by a jacket of cotton batting. The diet should
consist of milk, egg albumin and broths. Keep the temperature at about
70 degrees F. and the air of the room moist and free from draughts.
When the fever is high, sponging or the wet pack is helpful. The
bowels from the beginning of the attack should be carefully watched.
There is danger of a =failing heart=; this is generally associated with
mucous rales and cyanosis. Douching alternately with hot and cold water
will usually excite coughing and overcome the difficulty. The gradually
cooled bath will have a marked effect in reducing the temperature,
quieting the nervous symptoms, increasing the respiratory power and
promoting sleep.
Raise and carefully stimulate the abdominal viscera, and elevate the
diaphragm. This is effective in both cyanosis and toxemia.
In the first stage of pneumonia, Hazzard[96] says, “There is better
opportunity to correct the specific lesion, as the patient’s strength
will allow of such treatment. The work is also aided by the fact that
the alveoli are still open, and lung action, stimulated by treatment,
may become a valuable aid in dispelling the engorgement.” This is a
most valuable suggestion, but be exceedingly careful in subsequent
treatments not to treat too hard and thus lame and bruise the patient.
Series I, II, III, and V of the American Osteopathic Association Case
Reports present several interesting cases of pneumonia which typify
the importance of immediate and direct correction of the osteopathic
lesions.
Herman[97] cites an interesting case of delayed resolution, due to a
depressed condition of all the ribs on the affected side with marked
luxation of the eighth. The lesion at the eighth was the cause of a
prolonged attack of hiccoughs which prevented resolution. It is pointed
out that there is an abundant intercostal nerve supply to the diaphragm
from the eighth and ninth intercostals. C. E. Achorn instances an
autopsy of patient dying of pneumonia, where a bony ankylosis was
found at the second dorsal; this lesion was probably an important
predisposing factor.
Broadly speaking, one should keep in mind the following: First,
early treatment will frequently abort what would ultimately be
pneumonia—still, in the preceding it is not these cases that are
especially referred to, but those following the course of a typical
pneumonic process; second, both specific and general treatment prior to
the crisis will materially lessen the severity of the disease; third,
the crisis corresponds to beginning resolution (during resolution
expectoration and liquefaction and absorption of the exudate are
paramount features) and must be met promptly and vigorously, special
attention being paid to the heart; and, fourth, during convalescence,
good, general attention and care of patient as to treatment, hygiene,
diet, and climate, are important.
Chronic Interstitial Pneumonia
(FIBROID INDURATION)
=Definition.=—A chronic, inflammatory disease of the lungs,
characterized by an overgrowth of fibrous or connective tissue.
=Etiology.=—With few exceptions chronic affections of the lungs cause
more or less fibroid overgrowth. This is especially frequent after
bronchial pneumonia and pulmonary tuberculosis. It is also excited by
abscesses, hydatids, syphilis, emphysema, sarcoma and old fibrinous
pleurisy. It may also be caused by compression, by aneurism or
neoplasms. It may arise as a primary affection, due to the inhalation
of irritating dusts (stone dust, coal dust and metal dust). There will
be found deeply seated osseous lesions of the upper and middle dorsal
region and corresponding ribs, and frequently of the cervical vertebræ.
=Pathologically=, as it involves limited or extensive areas, it is
recognized as =local= or =diffuse=. It is a unilateral affection. The
involved portion is shrunken and on section it is found to be tough,
firm, of a greenish color and containing an overgrowth of fibrous
tissue. If it affects the left side the heart may be displaced. The
unaffected lung is usually enlarged (compensatory emphysema). There is
hypertrophy of the right ventricle of the heart.
=Symptoms.=—There is a chronic cough, which varies greatly in its
severity; moderate dyspnea, and a variable expectoration. There is
no fever and the general health of the patient may be preserved for
a number of years. The expectoration is generally copious, muco- or
sero-purulent, rarely fetid. There is retraction of the affected
side, displacement of the apex beat and lateral curvature of the
spinal column. The unaffected side is enlarged. The intercostal spaces
disappear, the ribs sometimes even overlapping. The tactile fremitus
is generally increased, but if the pleural membrane is thickened the
fremitus may be decreased. There is generally impairment of resonance.
A tympanitic or amphoric note may be heard over a dilated bronchus.
On the sound side the percussion note is generally hyperresonant. The
breathing sounds may be feeble. They may be bronchial or cavernous, but
rather amphoric. Late in the disease cardiac murmurs are not uncommon.
=Diagnosis.=—This is never difficult. It is mainly to be distinguished
from =fibroid phthisis=. In the latter both lungs are involved
and there is fever and bacilli are found in the sputum. An X-ray
examination should be made.
=Prognosis.=—The disease is exceedingly chronic and may last for many
years. Death may result from gradual failure of the right heart,
hemorrhage or from intercurrent attacks of acute pneumonia involving
the other lung.
=Treatment.=—Little can be done for this condition. Intercurrent
bronchitis may be somewhat relieved by the treatment for chronic
bronchitis. The patient should dwell in a mild climate. Hygienic
surroundings and nutritious food are indicated. Something can be done
by attempting to correct the condition of the ribs and vertebræ, but
this measure, from the nature of the disease, is generally palliative
at best.
Congestion of the Lungs
=Congestion of the lungs= may be active, passive or hypostatic. The two
former have particular osteopathic significance, owing to the lesions
involved.
=Active congestion= may result from violent physical exertion,
excessive alcoholic indulgence, inhalation of hot air or as a symptom
in pneumonia and other pulmonary affections. There is dyspnea and cough
with rusty expectoration of a frothy nature. There may be absence of
fever. But generally a slight chill followed by moderate fever, pain in
side, and cough are the principal symptoms. On percussion, the note is
dull with increased tactile fremitus and bilateral involvement.
=Prognosis= is good under osteopathic treatment, but it must be
promptly met as it is usually a symptom of another disease.
=Treatment= is the same as in the beginning of pneumonia.
=Passive congestion=, when not hypostatic, is mechanical and due to
an impeded return of blood to the left heart from mitral stenosis, or
regurgitation, dilatation of the right ventricle and cerebral disease.
The lungs are large with distended pulmonary vessels with venous blood
in the air spaces. There is dyspnea and cough, with blood-streaked,
frothy expectorations.
The =treatment= is primarily of the condition causing the congestion,
but in addition the upper ribs should be raised and thorough treatment
of the abdomen and elevating the diaphragm are beneficial.
=Hypostatic congestion= results from a weakened heart in exhaustion,
infection or old age; also from continued dorsal decubitus. Rheumatic
fever, tuberculosis and other constitutional diseases, as well as
organic growths, may predispose. The condition gives rise to a mild
form of lobar pneumonia. =Symptoms= are not well defined and often are
not recognized. There may be slight dullness, increased fremitus, moist
rales and other signs of a venous engorgement.
In =treatment= the first move is to change position of the patient and
then look after any underlying cause. Osteopathically, follow treatment
of pneumonia. In all cases of circulatory involvement of the lungs,
treatment to relax muscles or to adjust vertebræ and rib lesions to
the vasomotor nerves of the lungs is very efficacious. Landois (1904)
says: “Irritation of sensory nerves, particularly if intense and long
continued, causes a dilatation of the vessels in the areas innervated
by them.”
Edema of the Lungs
There are two forms of =edema=, collateral and general, which follow
an intense congestion with transudation of serum into the air vesicles
and interstitial tissue. The =collateral form= is localized and
usually appears in connection with pneumonia, pulmonary infarction
or abscess. In =general edema= the base of the lung is involved to a
greater extent, but the whole structure is affected and hydrothorax is
generally present. The =cause= of edema is not well understood, but may
result from a long line of constitutional diseases. The =symptoms= are
dyspnea, cough with copious, blood-streaked sputum which is expelled
with difficulty. There may be fever in the inflammatory type with weak,
increased pulse. Dullness over the affected area, broncho-vesicular
breathing and small liquid rales are audible. The =diagnosis= must
largely be made upon the bilateral dullness at the base of each lung
and physical signs noted above. X-ray examination will usually be of
value. =Prognosis= depends on the condition causing the edema and
treatment should be directed to correcting it. Frequently edema is a
terminal affection. This should be followed by osteopathic treatment to
free the lungs of the effusion as outlined under pneumonia, especially
relaxation of the upper dorsal and cervical muscles, separation of the
upper ribs and stimulation of the heart.
FOOTNOTES:
[95] Yeo—A Manual of Medical Treatment or Clinical Therapeutics, Vol.
1, p. 597.
[96] Hazzard—Practice of Osteopathy p. 91.
[97] Herman—An Unusual Feature in a Case of Pneumonia—Journal of the
American Osteopathic Association, July 1906. (This refers to lobar
pneumonia.)
DISEASES OF THE PLEURA
Pleurisy
=Definition.=—An inflammation of one or both pleural membranes.
=Varieties.=—Etiologically, it may be divided into primary and
secondary pleurisy; also, into acute and chronic pleurisy.
Anatomically, the cases may be divided into dry pleurisy and pleurisy
with effusion (serofibrinous, purulent, hemorrhagic).
Acute Pleurisy
(FIBRINOUS OR PLASTIC PLEURISY)
The affection may be primary or secondary. As an independent affection
it is rare. It may follow exposure to wet and cold or it may be due to
mechanical injury. The disease may set in with pain in the side, slight
fever and the friction sound of pleurisy may be present. These symptoms
last a few days and then disappear and no exudation occurs. The pleural
surfaces become more or less united.
As a secondary process, dry =plastic pleurisy= arises from extension of
the inflammation in acute or chronic diseases of the lung, especially
pneumonia. Abscesses, gangrene and cancers are also causes. It
sometimes occurs in acute articular rheumatism, and in a large number
of cases is associated with =tuberculosis=. This condition may be a
complication in chronic Bright’s disease and in chronic alcoholism.
In the =fibrinous form of pleurisy= the serum is scant and the membrane
is covered with a sheathing of lymph, which finally organizes and
adhesion takes place between the opposing surfaces.
Serofibrinous Pleurisy
This form is known as pleurisy with effusion. There is little lymph,
the exudate being mainly composed of serum.
=Osteopathic Etiology and Pathology.=—Many cases rapidly follow
exposure to cold, wet or an injury to the thorax. Exposure to cold is
considered a mere predisposing agent, permitting the action of various
micro-organisms. The large majority of cases are due to =tuberculous=
infection of the pleura.
The osteopath finds that important predisposing causes of pleurisy are
injury to the chest wall, ribs and vertebræ, and exposure to cold,
causing contraction of the thoracic muscles. These injuries and strains
throughout the chest result in an interference with the intercostal
and phrenic nerves, and also with the intercostal and internal mammary
arteries; consequently, there is produced a lowered vitality of the
pleural tissues, which permits the attack of the micro-organisms. It
may be secondary to rheumatism, Bright’s disease, cancer and cirrhosis
of the liver.
=Pathologically=, there is an abundant exudation of serum. Fibrin is
found on the pleura, and is rarely abundant in the serous fluid in
the form of flocculi. The fluid is straw colored as a rule. It varies
greatly in quantity from one-half to four litres. Microscopically,
there are found leucocytes, red blood-corpuscles, shreds of fibrin and
occasionally cholesterin, uric acid and sugar. The composition of the
fluid resembles blood serum, and is rich in albumin.
Various displacements of the adjacent organs are caused by the
effusion. The lung is more or less compressed into the back part of
the pleural sac. The heart is displaced. The diaphragm may be crowded
downward. On the right side this lowers the liver; on the left it
displaces the stomach, transverse colon and sometimes the spleen.
=Symptoms.=—The onset may be abrupt with a chill, severe pain in the
side and fever. With few exceptions the disease comes on insidiously,
pain in the side being the first symptom. The pain is sharp and cutting
and is aggravated by breathing or coughing. There is moderate fever,
the temperature ranging from 102 to 103 degrees F. Dyspnea may be
present at the onset. This is due to the fever and pleuritic pain.
When the fluid is effused slowly, dyspnea may be absent except on
exertion. It is most marked when the effusion has developed rapidly. As
the effusion accumulates and the inflamed surfaces separate, the pain
diminishes and, as a rule, soon disappears.
=Physical Signs.=—Immobility and bulging of the affected side,
depending on the amount of exudation. The intercostal spaces are
obliterated. The apex beat of the heart is displaced. Upon =palpation=
the limited movement of the chest is more accurately determined.
Tactile fremitus is largely diminished. The position of the heart’s
impulse can be readily located by palpation. Displacements of the
liver and spleen can be felt through the abdominal walls. At first
the =percussion= notes are impaired and later there is dullness which
gradually rises as the fluid increases. The upper line of dullness
is not horizontal when the patient is in the erect posture, but is
higher behind than in front. Above the effusion in the sub-clavicular
region, percussion gives a tympanitic note, the so-called Skoda’s
resonance. In moderate effusions the level of dullness often changes
with the position of the patient. Early in the disease a friction rub
can usually be heard. As the fluid accumulates, the breath sounds
become weak, distant and may have a tubular or bronchial quality. Vocal
resonance is usually lessened. There may be bronchophony, or it may
manifest a nasal or metallic quality, resembling somewhat the bleating
of a goat (Lænnec’s egophony). X-ray examination should be made.
=Duration.=—The course is extremely variable. The fever is due to
inflammation and may last for two or three weeks, when it may subside.
The cough and pain disappear and the effusion, which is usually slight
in these cases, may be absorbed quickly. In cases where the effusion
is poured out rapidly it may be absorbed just as quickly. In cases
where the effusion is poured out slowly or where the effusion reaches
as high as the fourth rib, recovery is usually slower. Large effusions
may persist without change for months and finally the case may become
subacute or chronic. This is particularly true of tuberculous cases.
=Prognosis.=—This depends largely upon the cause; on the whole,
prognosis is favorable. Death is a rare termination of serofibrinous
effusion; death may, however, occur suddenly without sufficient lesions
to explain the cause. The exudate may become purulent.
Treatment of Acute Pleurisy
An early treatment and rest in bed with a liquid diet are the measures
to be employed at the beginning of the attack. Pay particular attention
to any primary disease and to the general health. Rarely is there any
difficulty in locating certain predisposing causes of the disturbance.
Then often a rib or corresponding vertebra is badly subdislocated
over the seat of the disease. The sympathetic and phrenic nerves
are involved through the intercostal and phrenic nerves. A careful
examination of the side of the affected chest should be made, as there
may be more or less obstruction of the intercostals and the internal
mammary arteries from their branching of the aorta and subclavian
vessels. A dislocation of the first or second rib may affect the
subclavian vessels and their branches markedly; although all the
upper ribs and the thoracic muscles should be examined carefully for
derangements which would affect these blood-vessels and produce an
exudation. Ice-bags upon the chest, as in pneumonia, may be used.
Limiting the movements of the chest with a bandage or adhesive strips
will give considerable relief.
When the effusion has taken place, carefully raising and spreading
the ribs with attention to special points of involvement, will at
times cause absorption of the fluid. The daily amount of liquid food
should be greatly lessened with a view of depleting the blood serum
from various tissues; thus the serum collecting in the pleura, which
is a lymph space, will also be absorbed. Treatment of the bowels,
kidneys and skin, so that they may be rendered active, will aid in the
depletion of the blood serum.
It may be necessary in some cases to aspirate, especially if other
methods fail and if the effusion is large. The points of operation
are in the mid-axillary line at the sixth interspace or at the angle
of the scapula at the eighth interspace. In puncturing, the needle
should be held close to the margin of the upper rib so as to avoid
the intercostal artery. Withdraw the fluid slowly and if faintness is
produced, desist.
Empyema should be treated surgically. Simply tapping is rarely
sufficient. A free incision, as in abscess, and thorough drainage
should be made. Care must be taken that the drainage tube is large
enough.
“In cases of pleurisy the axilla and the inner arm may be tender and
painful; this is due to the pleuritic inflammation being carried by the
way of the ‘nerve of Wrisburg.’
“The pleuritic pain in the costal muscles compels restricted movement
of the ribs and also limits the respiratory function of the diaphragm.
These painful cramps and stitches are independent of the pain arising
alone from the inflamed pleural surface, and the diminution of the
respiratory movements is due to a particularly contractured state
of the muscles of the chest as is demonstrated by the fact that the
patient can not draw a long breath; hence one may reasonably conclude
that nature has so distributed nerves to the pleura as to enable that
serous membrane to control the muscles which create movements of the
adjacent costal surfaces and thus insure its quietude during the stages
of inflammation or repair.” (Ranney).
Chronic Pleurisy
=Definition.=—Chronic inflammation of the pleural layers. There are two
forms, exudative and dry or plastic pleurisies.
=Chronic Pleurisy with Effusion.=—This may follow an acute
serofibrinous type. Some cases develop very slowly. In most cases in
children, the fluid changes to pus early in the disease. The fluid may
remain for months without changing to a purulent character. In such
cases the character and physical signs do not differ from those in
acute serofibrinous pleurisy.
=Chronic Dry Pleurisy.=—These cases originate in two ways:
=First=, this may succeed pleural effusion when the fluid portion of
the exudate is absorbed and the pleural layers are opposed. They are
separated only by fibrinous elements that become organized into firm
connective tissue. This process goes on at the base, principally,
which, if it follows the acute form, produces but slight flattening,
but if it succeeds the chronic form or empyema, the extent of
retraction and flattening will be marked. Calcification may occur in
these firm, fibrous membranes and occasionally little pouches of fluid
are found between the false bands.
=Second=, a large number of cases are dry from the onset. This
condition may follow directly =acute plastic pleurisy=. It may be of
=tuberculous= origin or it may set in without any acute symptoms. No
matter how slight the plastic exudate may be, it invariably tends
to become organized, thus producing adhesion of the layers. This is
undoubtedly the result when the pleurisy is primary or secondary.
The adhesions are generally circumscribed. When the adhesions are of
tuberculous origin they may be locally confined to one pleura or they
may be bilateral. In these cases both the parietal and costal layers
are thickened, and embodied in the thickened pleura are found firm
fibrin masses and small tubercles.
Occasionally, vasomotor symptoms arise in chronic pleurisy, especially
in cases of tuberculous origin, and are probably due to the involvement
of the first thoracic ganglion. These almost invariably mean that
there is a displacement of the first, second, or third rib. Unilateral
flushing or sweating of the face or dilatation of the pupil are
frequently noticeable.
=Symptoms.=—Definite symptoms are rarely present. In some cases the
physical signs are quite pronounced, while, on the other hand, they
may be entirely negative. In mild cases there may be slight immobility
of the affected side with feeble breath sounds. In other cases there
may be very full chest expansion while the breath sounds are feeble.
In a large number of instances the physical signs are quite distinct.
There is displacement of the viscera, retraction of the chest walls,
curvature of the spinal column and dropping of the shoulders. There are
feeble breathing and creaking, leathery friction sounds. Dullness is
found at the base.
=Treatment.=—The treatment of chronic pleurisy is largely that of
acute pleurisy. Gymnastic and methodical breathing exercises should be
employed in helping to correct the thoracic walls. Care must be taken
not to injure the chest and pleura if adhesions have formed. Surgical
work may be necessary in some cases.
The vasomotor symptoms that are sometimes manifested in chronic
pleurisy and are claimed to be due to involvement of the first thoracic
ganglion, are an interesting feature to the osteopath. Such cases would
probably present to the osteopath a marked lesion of the upper dorsal
vertebræ or the second or third rib. These vasomotor symptoms are also
found in pleurisy associated with tuberculosis of the apex of the lung.
The osteopath frequently treats these cases and he should be cautious
about over-treating or straining the chest wall. The adhesions are
persistent and often there is more or less pain, so care must be
exercised when attempting to structurally readjust. Do not expect to
completely relieve every case, but nevertheless there are few cases but
that can be benefited. Occasionally the pain alone is due simply to
pleurodynia.
DISEASES OF THE URINARY SYSTEM
Diseases of the Kidneys
(RENAL HYPEREMIA)
=Definition.=—An increase in the amount of blood to the vessels of
the kidney. It is active hyperemia when there is arterial congestion,
passive hyperemia when there is venous congestion.
=Osteopathic Etiology and Pathology.=—Active hyperemia may be caused
by injuries to the renal splanchnics, especially the tenth to twelfth
dorsal segments; injuries over and to the kidneys; exposure to cold
when the body is very warm; poison given, as diuretics; eruptive fevers
and pregnancy, or follow genito-urinary operations. Passive hyperemia
may be caused by obstructive diseases of the general circulation, as
chronic heart, lung and liver diseases, or by pressure on the renal
veins by tumors, growths and the pregnant uterus. Thrombosis of the
renal veins may produce passive hyperemia, but rarely.
=Pathologically=, in active hyperemia the kidney is swollen and
slightly enlarged. Upon removal of the capsule, the kidney is found to
be brown and mottled. On section the parts bleed freely, the Malpighian
bodies are distended, and microscopical examination shows a cloudy
swelling of the renal epithelium. In passive hyperemia the kidney
is swollen, hard, firm and of a bluish red color. Later there is an
overgrowth of connective tissue and some infiltration between the
tubules. The Malpighian bodies occasionally become shriveled and the
renal epithelium fatty.
=Symptoms.=—In =active hyperemia= the urine is scanty, of high specific
gravity and of high color, containing some albumin and casts. Pain is
experienced over the loins, following the course of the ureters, and
the bladder is irritable. There are headache, nausea and vomiting. When
from infection, fever may be present.
In =passive hyperemia= the symptoms are primarily those caused by the
disease producing the disorder. There is weight over the loins and
dropsy. The urine is diminished, of high specific gravity, highly
colored, albuminous and occasionally shows a few hyaline casts.
=Prognosis.=—=Active hyperemia.=—Usually favorable if it can be
treated in time. If prolonged, acute nephritis may develop. =Passive
hyperemia.=—Depends on the cause. If the disease is prolonged, it
terminates in interstitial nephritis.
=Treatment.=—=Active hyperemia.=—Absolute rest and thorough treatment
to the renal splanchnics and treatment over the abdomen to the kidneys
directly by carefully raising them. Adjust the lower ribs if found
lesioned. Water should be drunk liberally and the patient encouraged to
use vapor baths. Favorable hygienic surroundings, warmth and good food
are indispensable. Warm applications over the loins are helpful.
=Passive hyperemia=.—The treatment largely depends upon the cause, but
too much importance cannot be given to the treating of the vasomotor
fibers of the kidneys from the eighth dorsal to the first lumbar.
Textbooks state that the vasomotor fibers to the kidneys are from
the ninth to the twelfth dorsal vertebræ, inclusive, but osteopathic
experience shows we can affect vasomotor fibers slightly higher.
Treatment here has a distinct effect on the blood pressure within the
glomeruli. The renal epithelium is extremely sensitive to circulatory
changes. Even the compression of a renal artery for only a few minutes
causes marked disturbances. Hence any irritation or obstruction to the
vasomotor innervation of the renal blood-vessels may result in serious
conditions. The superior cervical ganglion of the sympathetic and the
sciatic center have important bearing on the secretions of the kidney,
through vasomotor fibers. Due attention should be paid to the bowels,
and the patient required to take plenty of rest and a light diet.
Acute Parenchymatous Nephritis
(ACUTE BRIGHT’S DISEASE)
=Definition.=—An acute, inflammatory process affecting the epithelium
of the uriniferous tubules and due to the action of cold or toxic
agents upon the kidneys, as well as to injuries to the renal
splanchnics; is characterized by certain nervous symptoms with fever,
dropsy, and scanty and highly colored urine. This inflammation involves
more or less the whole kidney.
=Osteopathic Etiology and Pathology.=—This disease is caused by
exposure to cold and wet while the body is warm and perspiring.
Excessive use of alcohol may be a factor. May be caused also by
infectious diseases, such as scarlet fever, diphtheria, measles,
smallpox, acute tuberculosis and others; also by certain specific
poisons which are eliminated by the kidneys, as turpentine, chlorate
of potash, carbolic acid, phosphorus, ginger, cantharides and oil of
mustard; also by pregnancy, as this is supposed to compress the renal
veins, or through toxic agents. Syphilis may be an underlying cause.
Blows and injuries to the back at the tenth, eleventh and twelfth
dorsals are frequently the cause. Lesions are found from the sixth
dorsal to the fourth lumbar. The lower three ribs may be at fault,
while the innominate and muscular contractions have been found to be
pathological factors. Lordosis may be a contributing cause. Loudon
places considerable importance on cervical lesions and McConnell
believes vasomotor disturbance plays an important causative role in the
disease.
=Pathologically=, at times the kidney alteration may be so slight
as not to be recognizable by the naked eye, the appearance varying
according to the stage and severity of the disease. The kidneys become
enlarged, engorged and of a bright red color, and later have a mottled
appearance; and when the capsule, which is non-adherent, is stripped
off, the kidney is found to be soft and inelastic. In most of the cases
in which the disease is due to toxic agents brought to the kidney
through the blood-vessels, the glomeruli suffer first. The epithelium
of the glomeruli and tubules is the seat of cloudy swelling and, in the
later stages, of fatty change and hyaline degeneration. The tubules
are clogged by altered cells, leucocytes and blood-corpuscles. In mild
cases the interstitial tissue is simply inflamed, but in all cases it
becomes more or less mixed with leucocytes and red blood-corpuscles.
Osteopathic lesions produced upon animals in the region of the ninth to
the twelfth dorsal, resulted in acute nephritis. The autopsy findings
were distinctly typical.
=Symptoms.=—The onset is usually sudden, with moderate fever, pain
in the back in the lumbar region and over the kidneys and following
the ureters. Nausea and vomiting may be present. Dropsy soon appears,
beginning with slight swelling or puffiness in the face below the eyes,
later showing itself in edema of the abdominal walls and extremities.
Uremic symptoms may develop. The urine is characteristic; is diminished
in quantity and of high specific gravity; at first the sediment is
copious and reddish brown in color, becoming less in amount and of
high color. This sediment contains casts of the uriniferous tubules,
free blood, epithelial cells, uric acid and urates. There are large
quantities of albumin in the urine.
The presence of albuminous matter in the urine, even in large
quantities, is not sufficient evidence to warrant a diagnosis of
Bright’s disease nor is the amount a guide as to the severity of the
case, for grave conditions often show a slight amount (Loudon).[98]
=Diagnosis.=—The general symptoms may be very slight, for the most
severe cases may manifest slight edema of the feet, or there may
be only the puffiness under the eyes and of the eyelids. In such
cases the diagnosis must depend upon examination of the urine. With
previous history, suddenness of the attack and character of the urine,
ordinarily the diagnosis will be quite easy.
=Prognosis.=—Although this disease is generally grave, the prognosis is
favorable and the majority of cases recover under judicious treatment.
=Treatment.=—Cases of acute nephritis require rest, quiet and warmth.
Many cases recover under these conditions alone. It is absolutely
necessary, however, that these conditions exist no matter what other
treatment is used. A thorough treatment to the renal splanchnics cannot
be overestimated for it is here (tenth to twelfth dorsal, inclusive)
that a majority of the lesions producing acute nephritis occur. Besides
correcting the vertebral and rib displacements in this region, a very
effective treatment is to have the patient lie flat upon the back and
then the osteopath, reaching around the patient with the fingers of
one hand on either side near the spines of the lower dorsal vertebræ,
raise the patient so that the entire body, except the shoulders and
the feet, are lifted clear of the bed. Thus the treatment springs the
spine anteriorly and produces a marked effect upon the kidneys through
the renal vasomotor nerves. Occasionally lesions in the upper cervical
region interfere with the normal activity of the renal nerve fibers
passing to the kidneys by way of the superior cervical ganglion of the
sympathetics.
Another very effectual treatment for the kidneys is treating them
through the abdomen by a careful pressure upon the kidneys through the
abdomen on either side of the umbilicus, thus lightly working each
kidney outward and upward. This treatment relaxes any tissues about the
blood-vessels, nerves and lymphatics to and from the kidneys that may
be contracted and thus aids in establishing a normal activity of the
involved organs. It also helps in relaxing tissues about the ureters
and prevents the clogging up of the latter with debris. Bandel and
Stearns report cases in which an impacted colon was an important factor
in this particular.
The above means have for their object the direct relief of the
congestion of the kidney. This is further aided by keeping the bowels
active, which supplements the action of the kidneys, and by increasing
the activity of the skin. This also aids in relieving dropsical
effusions. The hot pack, in which the patient is wrapped in a wet sheet
and then covered by a number of blankets, is an exceedingly good method
to relieve the kidneys of some of the work and lessen their congestion,
besides arresting uremic intoxication. This can be repeated daily if
necessary. Where there is dropsy and scanty urine, the indications
are to increase the secreting action of the kidney; besides treatment
through the renal splanchnics, which contain the vasomotor nerves of
the kidneys, stimulating treatment to the vagi will help to increase
the urinary secretion. Hot fomentations, placed directly over the
region of the renal splanchnics, is a valuable aid in cases which do
not respond quickly to osteopathic stimulation. Treatment of the liver
is important. Injections of cold water into the intestines will tend to
stimulate the secretion of the kidneys, but this should be used with
the greatest caution; in some cases tepid water would be better (see
uremia).
The diet of the patient with acute nephritis is important. Give food
that is easy of digestion and which contains a minimum amount of
nitrogen. The stomach is quite likely to be irritable, consequently
food that is adapted to it should be selected. Milk and weak animal
broths are undoubtedly the best foods. The return to a solid diet,
especially of meat, should be very slow. Suitable adjuvants to the
milk diet are rice and farinaceous preparations. Loudon[99] recommends
complete withdrawal of all foods for twenty-four to forty-eight hours
and the reducing of nitrogenous foods to a minimum; a diet of milk and
cream after the fast, followed by cereals and broths, then eggs and
fish until albumin disappears from the urine. Alkaline mineral waters
are useful to help maintain an alkaline urine, thus tending to withdraw
exudates. The patient should be treated daily at first and later on
every other day, for case reports show frequent treatments hasten
recovery.
For treatment of acute uremia in Bright’s disease, see uremia.
Complications should be treated as affections independent of the renal
disorder.
Chronic Parenchymatous Nephritis
=Definition.=—A chronic inflammation of the kidney, involving the
epithelium, glomeruli and interstitial tissue, characterized by dropsy,
increasing anemia, albuminous urine and acute uremia.
=Osteopathic Etiology and Pathology.=—It may be the result of acute
nephritis. It follows the same diseases as already mentioned in acute
nephritis. More often it follows the same diseases as already mentioned
in the acute form, syphilis, tuberculosis, purulent conditions,
focal infections (streptococcus), alcohol, scarlatina and pregnancy
contributing the greater number. It is more common in the male sex and
in early adult life. Habitual exposure to cold and dampness; chronic
lesions of the spine, chiefly in the lower dorsal region, are causative
factors.
=Pathologically=, the =large white or a yellowish white kidney= is the
most common kidney lesion. In this form the kidney is enlarged, often
to twice its normal size, is smooth, and the capsule very thin. The
tubes, on microscopic examination, are found to be choked with broken
down granulated epithelium and fibrinous casts. The capillaries show
hyaline changes. The interstitial tissue is increased everywhere, but
not to an extreme degree. Catarrhal swelling and hyperemia (to a slight
degree) are found in the pelvis of the kidney.
In the =second stage=—that of the =small white kidney=—there is a
reduction in the size of the organ, due to the destruction of the renal
epithelium and the contraction of the overgrown connective tissue.
Some hold that this may be a primary, independent form and not always
preceded by the large white kidney. The organ is pale in color, rough
and granular, the capsule being thickened and somewhat adherent. There
is an accumulation of fatty epithelium in the convoluted tubules,
constituting marked areas of fatty degeneration and giving the organ
a white or whitish yellow appearance. It is this which gives the name
of small granular fatty kidney to this form. There are extensive
interstitial changes, degeneration of tubules and destruction of great
numbers of the glomeruli.
=Chronic hemorrhagic nephritis= is a variety associated with this
stage. The organ is enlarged, and scattered throughout the cortex are
found brown hemorrhagic foci due to hemorrhages into and about the
tubes. Otherwise the changes are similar with those found in the first
form.
=Symptoms.=—It usually begins as a chronic affection and the symptoms
slowly become apparent. Failing health and loss of strength,
dyspepsia and anemia, waxy appearance with puffiness of the face,
dropsy and increased arterial tension with hypertrophy of the left
ventricle, gradually make their appearance. Uremic symptoms are
common, while dropsy is marked and persistent. Vomiting and sometimes
profuse diarrhea occur; in fatal cases there is sometimes found to
be ulceration of the colon. The urine, as a rule, is diminished in
quantity, is often very scanty, although it is frequently normal
in color and appearance. There is an abundance of albumin, heavy
sediment, hyaline and granular tube casts, epithelium from the kidneys
and pelvis, leukocytes and often red blood-corpuscles. If fatty
degeneration takes place, there will be fatty casts and oil globules.
In the later stages the urine is abundant, low specific gravity,
considerable albumin, and many casts.
=Diagnosis.=—In the inflammatory stage, where there is enlargement of
the kidney, extreme pallor, scanty urine, albumin, and tube casts,
history of infections, pregnancy, or exposure to cold and wet, and
lesions in the lower dorsal region, the diagnosis is clear.
=Prognosis.=—Always give a guarded prognosis; relapses are frequent,
but cases have been cured. There is always a tendency for the
subchronic forms to become chronic.
=Treatment.=—The treatment requires persistent work, especially over
the renal splanchnics, and strict attention on the part of the patient
to hygienic principles. The lower dorsal lesions are very apt to be
refractory owing to extensive fibrotic changes of the deep muscles and
capsular ligaments. But repeated effort will usually secure results.
Care should be taken as to exposure to cold and overexertion. The
quality of the blood should be improved, as it is anemic and contains
various toxic products. Strict attention should be paid to the diet.
Iron is largely used for anemic conditions, but this principle we hold
to be wrong. It is not more iron that is wanted, but an ability of the
system to assimilate the iron which it has. Relative to diuretics von
Noorden says: “It would be the greatest paradox to economize the renal
work to the utmost in one direction (diet, sweating, etc.) and on the
other hand excite them to increased activity by means of the strongest
stimulants we possess, (drugs). I regard such prescribing as radically
wrong.” The diet should be carefully selected and of minimum amount.
The pure milk diet is undoubtedly the best. The use of meat seems to
favor uremic convulsions.
The digestive organs should be kept in as good condition as possible,
particular attention being paid to the liver and bowels. The use
of suitable clothing is important; wool should be worn next to the
body. The skin is a powerful adjuvant to kidney elimination, and the
suppression of the action of the skin throws extra work on the kidneys.
Possibly stimulation of the lung function would aid in the elimination.
Rest, with a proper amount of fresh air and outdoor exercise, is
essential.
In conditions calling for attention to the skin and bowels the
treatment will be the same as in acute parenchymatous nephritis. There
is a ganglion on each side of the umbilicus within a radius of an inch
that sends fibers to the kidneys (Dr. Still). Just what is the function
of these ganglia is unknown. The treatment of the complications is
independent of that for the renal trouble. For direct treatment to the
kidneys see acute Bright’s disease.
Interstitial Nephritis
=Definition.=—A chronic inflammation of the kidney in which there is
reduction in its size due to an extensive destruction of the tubular
substance, with an overgrowth, and later a contraction, of the
connective tissue elements. Cardio-vascular changes, arteriosclerosis
and cardiac hypertrophy are usually associated.
=Osteopathic Etiology and Pathology.=—Osteopathic lesions to the
renal splanchnics are important predisposing causes. The disease may
follow parenchymatous nephritis; or it may be caused by a continued
passive congestion due to valvular heart disease. Gout; cystitis
(often following gonorrhea), the inflammation extending up the ureters
to the kidney; heredity; old age; long continued worry, anxiety or
grief; chronic alcoholism, overeating; syphilis; tuberculosis; focal
infections, especially of streptococci; chronic mineral poisoning (as
from lead), and alterations in the renal ganglionic centers are causes.
It chiefly occurs in males during middle life.
=Pathologically=, both kidneys are involved (although one may be more
affected than the other), and reduced in size, often to less than half
their normal size. After removing the capsule, which is thickened
and adherent, the surface is found to be uneven, or granular and
containing small cysts. The kidney is hard, tough and resistant, the
color varying from a darkish brown to a yellowish gray. The cortical
portion is especially reduced in size. On microscopic examination,
the connective tissue appears greatly increased; this contracts,
compressing the tubules and blood-vessels, causing their destruction.
There is general arterial sclerosis, and the left side of the heart is
hypertrophied. There are frequent nasal and retinal hemorrhages, due to
the brittleness of the arterial walls which predispose them to rupture;
hence, apoplexy is a frequent termination. The ganglionic centers,
being interfered with, undergo fatty degeneration and atrophy. There
are marked retinal changes—retinitis, fatty degeneration of the retinal
tissues and sclerosis of the nerve fiber layers.
=Symptoms.=—The onset is insidious. In most cases the symptoms
are latent. The general health is disturbed; there are frequent
micturition, gastric disturbances, tense and bounding pulse,
hypertrophy of the left ventricle, high blood pressure, disorders
of vision, sleeplessness, headache, furred tongue, slight swelling
of the feet, dry skin, scurvy and shortness of breath. The urine is
increased in quantity, of acid reaction, light in color, low specific
gravity, with a small amount of albumin, a few hyaline casts, and some
epithelial cells. There is increased thirst and the patient may have
to urinate two or three times during the night. There is well marked
mucous cloud, slight sediment, and as the disease advances the urine
may be diminished, the albumin increased and the casts become more
numerous, while occasionally blood cells will be found.
Much importance should be attached to the blood pressure condition.
=Diagnosis.=—The early stages are not always recognizable. Later, while
there is high arterial tension, thickening of the arterial walls and
marked hypertrophy of the heart, the urine should be examined very
carefully both night and morning, as the diagnosis will greatly depend
upon the condition of the urine, which is increased in quantity, of
low specific gravity, with a trace of albumin, narrow hyaline and pale
granular casts, making the diagnosis usually easy.
=Prognosis.=—It is generally incurable, but favorable so far as the
power to prolong life is concerned, provided the diagnosis be made
early in the case, and the patient lives a quiet life. The case usually
terminates with convulsions, coma and death. Apoplexy is frequently
associated with chronic nephritis. In all forms of chronic nephritis
some intercurrent infectious disease is quite possible, which is apt to
be serious owing to the cachectic state.
=Treatment.=—The dietetic and hygienic treatment is the same as in
chronic parenchymatous nephritis. The nerve and vascular supply to the
kidneys should be treated as in acute parenchymatous nephritis. Freedom
from worry and overwork, and if possible change of climate, should be
prescribed. Frequent bathing, with friction of the skin, should be
insisted upon and the bowels kept regular by a treatment of alkaline
water. In all kidney cases special attention should be given the liver.
The alkaline water is a good diuretic; besides it flushes the kidneys
and helps to remove the debris.
These cases invariably present a rigid spine which should be carefully
but thoroughly treated, traction being one of the methods that
give comparatively quick and excellent results. Overcoming spinal
immobility, correction of the dorsal area, attention to the chest
rigidness, and frequently raising the abdominal organs will often
considerably reduce the blood pressure.
The accidents and complications which so often endanger the patient,
must be treated as they arise.
Amyloid Kidney
=Definition.=—A pathological state of the kidney in which there is
a peculiar infiltration into the kidney structure of an albuminoid
material of a waxy appearance.
=Etiology and Pathology.=—This is associated with Bright’s disease
and other wasting diseases. It is most frequently caused by profuse
and long continued suppuration, especially of the bones, by syphilis,
tuberculosis, cancer, lead poisoning and gout.
=Pathologically=, the kidney is large and pale, but it may be normal in
size or even small, pale and granular. The capsule is not adherent, the
surface of the kidney, after removing the capsule, is pale and anemic.
On section the cortex is seen to be enlarged. It is homogeneous,
anemic, pale, waxy and resisting. On microscopic examination there is
found to be an infiltration of a homogeneous or wax-like material. This
progresses until all parts of the organ are infiltrated. As the result
of this pressure the structures of the kidney undergo an atrophic
degeneration, the kidney becoming contracted, smaller, rough and
even distorted in shape. The cortex becomes narrowed and the capsule
adherent. If a section of an amyloid kidney be stained with a solution
of iodine, numerous mahogany red points appear.
=Symptoms.=—There are similar changes in the liver, spleen and often
the intestinal canal. There is a profuse, watery diarrhea, due to
amyloid changes in the intestinal canal, with loss of flesh and
strength, edema of the lower extremities, and ascites. There is an
increased flow of pale, watery urine, of low specific gravity; albumin
is abundant and usually hyaline, often fatty or finally granular tube
casts occur.
=Prognosis.=—As a rule the prognosis is decidedly unfavorable and it
must be controlled by the disease with which it is associated.
=Treatment.=—The primary disease demands attention, otherwise the
measures of treatment indicated are those of chronic parenchymatous
nephritis, with special attention to the general health and
surroundings of the patient. Give a generous diet and be persistent
with the treatment.
Pyelitis
=Pyelitis= is inflammation of the pelvis of the kidney. When a
suppurative inflammation extends into the interstitial tissue of the
organ, it produces a condition called pyelonephritis. The inflammation
usually starts in the pelvis of the kidney, the infection being
carried there either by the circulation or the urinary tract, but it
soon involves the rest of the kidney. Pyelitis is usually secondary
to some other conditions such as urethritis, cystitis, or ureteritis.
“Infection of the kidney rarely takes place through the blood and only
when the vital membrane of the kidney is impaired.” It may start from
within the organ in the interstitial tissue, caused by infectious
embolism or traumatism, or the tubules may become obstructed by
concretions.
=Osteopathic Etiology and Pathology.=—Retained decomposed urine due
to pressure upon the ureters by tumors or bladder disease; calculus
concretion, kinked ureter, displaced kidney, traumatic agencies,
as falls, blows, strains, kicks or penetrating wounds; nephritis,
pregnancy, cold and wet, are causes. Pyelitis may follow cystitis,
the inflammation extending up the ureters to the pelvis of the kidney
and thence to the substance of the organ, inducing pyelonephritis.
Tuberculosis, focal infections, and intestinal disorders (colon
bacillus), are other causes. Lesions from the ninth dorsal to second
lumbar or lower, and malnutrition are predisposing factors.
=Pathologically=, the mucous membrane of the pelvis is usually the
first affected, the inflammation generally extending from below upward.
It is swollen and sometimes visibly congested and of a gray color. The
pelvis and calyces are more or less dilated, while the papillæ are
flattened. There is a gradual dilatation of the calyces and atrophy of
the kidney substance, until the whole organ may be converted into a pus
sac. If complete obstruction occurs, the fluid portion may be absorbed
and the pus become inspissated and cheesy. The ureter is often dilated.
In tuberculous pyelitis the apices of the pyramids are also invaded,
the kidney substance is broken down and the result is the same. In the
pyelitis caused by cystitis, the infection passes up the tubules or is
carried by the lymphatics. The abscesses extend along the pyramids,
burst through the papillæ and calyx into the pelvis of the kidney, and
thus also the kidney becomes a purulent sac.
=Symptoms.=—Pain and tenderness over the region of the kidney first
appear. In a few cases cystitis will be the only symptom. The
suppurative stage is marked by high fever and a chill or a succession
of chills. The general condition of the patient denotes prolonged
suppuration. There is failure of health and more or less wasting
and anemia. The urine is characteristic, contains pus, which varies
in quantity greatly, and where only one kidney is affected, may be
suppressed for a time and there will be a sudden outflow of the pus,
due to the breaking of the sac. Blood is also very constant, but hardly
ever of sufficient quantity to be seen by the naked eye. The urine is
usually diminished in quantity and the color pale; the specific gravity
is low on account of the small amount of urea present. The reaction of
the urine is acid. Pus and blood render the urine slightly albuminous.
Casts from the kidney, and even portions of the kidney, may be present.
=Diagnosis.=—From =nephritis= by the absence of much albumin, tube
casts and dropsy. From cystitis, by the history, lumbar pains and acid
urine. =In cystitis the urine is always alkaline.= From =perinephritic
abscess=, by the absence of edema over the lumbar region. The urine may
be normal and there are lumbar pains and hectic fever. In =tuberculous
pyelitis= there is a history of tuberculosis in other organs and there
are tubercles in the urine. =Malaria= or =typhoid= may be suspected.
The X-ray and cystoscope should be employed. An exploratory incision
may be necessary.
=Prognosis.=—Depends altogether on the cause and extent of kidney
involvement. In simple cases and some tubercular, recovery may occur,
although there is a tendency in all cases for the disease to become
chronic.
=Treatment.=—Depends upon the cause, but thorough treatment along the
lower dorsal, the lumbar and sacral regions will be of considerable
benefit in controlling the catarrhal process in the kidney, its pelvis,
the ureter and the bladder. If pathology permits, gently raising the
kidneys, ureters and neighboring organs, knee-chest position, will
materially assist circulation and drainage. Fresh spring waters for
diluents and restricting the diet to light food, preferably milk,
are indicated. Rest is important and warm applications locally are
sometimes helpful. The general health must be carefully watched as
there is always considerable drain upon the system. A timely operation
may materially lengthen the life in many cases. Attention to the
bladder, urethra and prostate is necessary.
Uremia
The name applied to a series of manifestations resulting from the
retention of poisonous materials in the blood, which should have been
removed by the kidneys. Uremic symptoms may occur any time during an
attack of nephritis. In chronic cases it seems likely that extensive
destruction of renal tissue is the principal factor that leads to the
toxemia. They may also occur when the circulation of the blood in the
kidneys is interfered with or the ureters are obstructed. They are not
due alone to the urea (which is found to be increased in the blood),
but more probably several poisons that are retained in the blood.
Traube’s theory is that acute cerebral edema with anemia accounts for
the symptoms. Halbert says: “A more recent and more plausible claim
is to the effect that a poison is developed in the body as the result
of nephritis,” for retention of effete matter or ligation of renal
arteries and ureters or impaired renal activity does not fully explain
the cause of the stupor, coma, convulsions, sometimes paralysis, and
gastro-intestinal disorders.
=Symptoms.=—Loss of appetite, nausea, vomiting, headache and drowsiness
are the initial symptoms. Headache is usually at the back of the head
and may extend down the neck. The next symptom is coma, alternating
with convulsions which may range from only a slight twitching to
violent epileptiform spasms. These spasms may occur without the
slightest warning and are often followed by blindness which may last
for several days. These attacks of coma and convulsions are sometimes
ascribed to localized edema of the brain.
Transient paralysis is also due to congestion or edema of the brain
and it may be of the cord. There may be mania which comes on abruptly,
although the delirium is not at all violent, while profound melancholia
may be found. There may be nervous symptoms develop, such as numbness
in the hands and fingers, itching of the skin and cramps in the
muscles—especially those of calves of the legs. Pulmonary symptoms are
sometimes continuous—dyspnea, paroxysmal dyspnea and Cheyne-Stokes’
breathing. These attacks of dyspnea may be as distressing as true
asthma. Cheyne-Stokes’ breathing may be present without coma.
Uncontrollable vomiting may set in with great abruptness, followed
by hiccough and purging. There may be a catarrhal or diphtheritic
inflammation of the colon with diarrhea. The breath has a urinous odor
and the tongue is often very foul. The pulse is slow and full, with a
temperature below the normal, although during convulsions the pulse may
become rapid and the temperature rise. Occasionally there are atypical
forms of uremia which may be very confusing and obscure.
=Diagnosis.=—The history, subnormal temperature, the urinous odor of
the breath, high arterial tension and increased second sound of the
heart will distinguish the condition. Feeling of numbness, palpitation,
headache, restlessness, mental wandering are not infrequently early
symptoms. The phenolsulphonephthalein test for the secreting power of
the kidney, and the examination of the urea in the blood are of great
aid in diagnosis.
=Prognosis.=—Extremely grave, but one should always be very careful in
his prognosis, for there is a possibility of recovery, even after the
most serious symptoms have been manifested.
=Treatment.=—As impermeability of the kidneys produces uremia, by not
allowing the various poisons to be eliminated by the renal path as
they should be, the treatment must be applied directly to the kidneys.
Elimination is demanded and if treatment through the abdomen to the
kidneys directly and to the renal splanchnics does not bring about
prompt and thorough elimination of the intoxicating properties, the
bowels and skin must be made active. The vapor or hot air bath or hot
pack should at once be used. An ice-bag to the head will be beneficial.
An increase in the quantity of urine may be brought about by the
displacement of a part of the mass of blood, which is in relative
stagnation in certain parts of the vascular system. Forcing it into the
main circulation in order to increase the pressure within the vessels
of the kidney, is the treatment indicated. This great stagnant mass of
blood is found in the arterial capillaries of the portal system in the
liver and splenic tissues and should be manipulated into the general
circulation in order to increase the arterial tension of the kidneys
and thus favor elimination. The treatment should mainly be applied to
the vasomotor nerves of the portal system, from the fifth to the ninth
dorsal, and directly over the abdomen, liver and spleen.
The introduction of water, from 110 degrees to 120 degrees, or even
150 degrees, into the colon by means of injections, is useful; warm
irrigations increase renal secretion, bowel action and sweating with
a decrease of tension. Cold drinks will stimulate the abdominal
vessels and induce absorption of a certain quantity of water to still
further increase diuresis. Cold irrigation increases blood pressure
temporarily, but later it lessens the pressure; it should be used
only with great caution. Milk is one of the best drinks to be used.
Secretions of the liver must not accumulate. The bile must be expelled
so that its toxicity will not be added to the other poisons.
The food of the patient is an important matter. A milk diet is best;
avoid meat and nitrogenous foods and any food that leaves much residue.
In this way the nutrition of the patient is kept up with a minimum
of urea formation and, besides, there will be very little intestinal
putrefaction. Emergency measures not mentioned above are repeated
high normal salt enemata (two to three pints), the alcohol sweat and
venesection (about one pint). When the attack is broken the condition
resolves itself into the renal disorder, generally acute Bright’s
disease.
This disease illustrates one phase of the uselessness of drugs; for
when the impermeability of the kidney has become such that it ceases to
have the power of eliminating toxic substances formed by the organism,
there is then retained the medicinal substances. The kidney is as
impermeable for therapeutic poisons as for the natural poisons and the
employment of toxic medicines in such cases has often no other effect
than to bring an association of medicinal intoxication with an uremic.
Renal Calculus
=Renal calculi= are concretions formed by precipitation of solids
derived from the urine, and are found in the kidney or its pelvis. If
large, they are called stones; the smaller masses are known as gravel
or sand, according to their size. When the stones attempt to pass
through the ureters, it brings on an attack of renal colic; rarely are
they voided without this symptom.
=Osteopathic Etiology and Pathology.=—The affection occurs at all ages,
more commonly, however, in children and in old people. The male sex is
more liable than the female. Sedentary habits, gout and excessive meat
eating are predisposing causes. Heredity seems to be a predisposing
cause in some families. Inflammation of the pelvis of the kidney,
caused by derangement of the ribs and vertebræ of the tenth, eleventh
and twelfth dorsals or first lumbar, is an important etiological factor.
=Pathologically=, the chemical varieties are:
(1) =Uric acid and urates= are the most common. The stones are usually
smooth or lobulated; are hard and of a reddish color. Usually in these
stones, both uric acid and urates are to be found. This material may
be passed in the form of sand or large stones. The sediment in the
urine may be the nuclei of the stones; as may foreign matters, such as
the mucus or desquamated epithelium caused by the inflammation of the
pelvis of the kidney, blood clots, or, in fact, any foreign matter that
may reach the urinary passages. Individuals passing a small amount of
urine, and old people are the principal subjects. “As a consequence of
concentration and high acidity of the urine, the uric acid and urates
are readily separated in solid form and held together by the albuminous
matrix.”
(2) =Phosphatic Calculi= are white in color, soft and mortarlike. They
are composed of phosphate of lime, ammonia and magnesium phosphate.
These are found more often in the bladder than the kidney. Disease of
the bladder is the cause.
(3) =Oxalate of Lime= are a mixture of oxalate of lime and uric acid.
They are dark in color, very hard and uneven, with hard, pointed
projections. On account of their uneven shape they have been named
mulberry calculi. These stones produce great pain as they pass through
the ureters.
There are other concretions of rare occurrence.
=Symptoms.=—There is pain in the back in the region of the kidneys
with more or less tenderness. The pain may be severe and paroxysmal.
There may be bleeding, which is seldom profuse; this will give the
urine a smoky hue, but may be present to such a small degree as to be
only apparent by the use of the microscope. The stone may obstruct
the ureter and cause pyonephrosis or hydronephrosis. Pyelitis of a
catarrhal character is common. In pyelitis there may be intermittent
fever of several degrees, then sweating. There may or may not be pus in
the urine.
=Renal Colic= is caused when the calculus attempts to pass through the
ureter so that ureteral spasms result. The stone, however, may become
lodged at the entrance to the ureter. There is a sudden onset and great
pain which starts in the back, radiating downward into the groin,
down the side of the thigh and into the testicle and glans penis. The
testicle is often retracted, the face pale, the features pinched, and
there is frequently vomiting. There are cold sweats and the pulse is
weak. The paroxysm may last only a few minutes or extend over several
hours. If uric acid is found, it points to uric acid or oxalate of
lime calculi and the urine is acid in reaction. If alkaline phosphatic
stones may be suspected, examination of the urine directly after the
attack aids greatly in diagnosis, for at other times the urine is
usually negative.
=Diagnosis.=—=Biliary Colic.=—The jaundice in biliary colic comes on
very soon after the obstruction begins. The stools are without bile
and the pain extends from the right hypochondriac region to the upper
abdomen and the right shoulder. The urine is negative and a stone may
be passed in the stools. =Renal colic= is often =simulated= when the
ureter is obstructed from any cause whatever. It may be compressed from
a floating kidney or tumor, or obstructed by a clot of blood, fragments
of hydatid cysts or plugs of mucus. =Lumbo-abdominal neuralgia=,
=intestinal colic=, =and renal tuberculosis= may simulate renal colic.
The X-ray plate is of decided value.
=Prognosis.=—As complications may arise, it is best to give a guarded
prognosis, but the prognosis is generally favorable. It is a disease
that is very apt to recur when strains or falls affect the innervation
to the kidney, but many cases have been permanently cured. If the stone
is large, its passage along the ureter may prove fatal unless surgical
interference is instituted at once, but if it is renal sand it may be
easily voided in the urine and thus the prognosis will be favorable.
=Treatment.=—Treatment should be given toward overcoming the cause
producing the calculi, which will often be found at the tenth rib.
Treat the kidneys thoroughly, both through the renal splanchnics
and directly through the abdomen, anteriorly. But direct abdominal
treatment should be given very cautiously. Treatment here corrects
disorders and seems to release some solvent that acts upon the various
forms of calculi and disintegrates the ones already formed and prevents
the formation of others. Possibly this solvent is an internal secretion
of some gland; possibly like the splenic secretion is to the biliary
calculi (Dr. Still.). Dr. Still held that one of the functions of the
suprarenal capsule was to prevent the formation of these concretions.
In the =uric acid tendency=, the free use of alkaline mineral waters
for the solution of uric acid may be helpful. Much may be done by
dieting. The amount of nitrogenous food should be limited, eating a
minimum amount of meat and using plenty of milk and vegetables. In the
=phosphatic tendency=, diluted drinks freely used are helpful. Meats
are indicated. Milk and vegetables should not be used freely as they
tend to make the urine alkaline. In all instances care of the general
health and avoidance of beer drinking and excessive meat eating are
demanded.
During an attack of =renal colic=, when a stone had lodged in a ureter,
one may be able, by very careful manipulation, to aid the stone in
its progress downward, (somewhat after the manner of manipulating
gall-stones), but do not delay surgical measures too long. By
inhibiting the nerve force of the spinal nerves along the lumbar and
sacral regions (chiefly tenth dorsal and first lumbar), relief may
be given. The nerves of the ureters are derived from the inferior
mesenteric, spermatic and pelvic plexuses. Employ the hot bath; this
may relax the spastic condition. Cloths wrung out of hot water and
applied locally are of aid. Occasionally a change of posture will
give relief. Even inversion of the patient is sometimes followed by
immediate cessation of the pain. The patient may drink freely of hot
lemonade or water. An anesthetic may be of aid in the manipulation
of a renal calculus in the ureter, as the anesthetic will relax the
tissues over the abdomen, making it much easier for one to get near
the impacted calculus, but =be cautious=. Morphine may be necessary.
During the intervals the patient should lead a quiet life and avoid
sudden exertions of any kind. It is important to keep the urine
abundant, consequently have the patient drink a large quantity of
distilled water. “Renal calculus is brought about by lesions affecting
the suprarenal capsule of the kidney, or spinal lesions from the tenth
dorsal to the first lumbar, affecting the lower ribs.”
Movable Kidney
This means a distinctly mobile condition of the kidney (almost always
acquired, but may be congenital), due to the lax condition of the
tissues which support it and to the elongation of the renal vessels
which allow the kidney to move in certain directions. Rapid loss
of tissue that absorbs the fat surrounding the kidney is a cause.
There are almost invariably lesions in the dorso-lumbar region that
predispose to an abnormal mobility of the kidney. These lesions
undoubtedly weaken the innervation to the surrounding and supporting
kidney structures. A posterior spine, with consequent downward and
constricting displacement of the floating ribs, is common, although
lateral and anterior spines (dorso-lumbar region) may be found.
Strains, heavy lifting, and various violent exertions are important
exciting factors. Tight lacing, pregnancies, an enlarged liver and
gastro— and enteroptosis are also important factors. This condition
is found more commonly in women, and undoubtedly is a frequent cause
of direct, gastro-intestinal, reflex, and obscure disturbances. There
are very different degrees of mobility in different cases. It may be
so slight as hardly to be recognized or so great that it can easily
be felt by the hand through the abdominal walls, resembling a movable
tumor in the abdomen.
=Symptoms.=—Often there are no noticeable symptoms. Sometimes when the
displacement and mobility of the kidney are most marked, the reflex
symptoms are not noticeable. The right kidney is the one usually
affected, on account of its relation to the liver which moves during
the respiratory act. Usually there is pain in the lumbar region and
the patient experiences a heavy, dragging pain in the abdomen, which
especially manifests itself while standing and walking. There may be
intercostal neuralgia. Various colicky and other gastro-intestinal
pains, and nervous symptoms as neurasthenia, melancholia, hysteria and
headache are common. There may be obstinate indigestion, palpitation
of the heart, flatulence and cardialgia; also, an irritable bladder,
due to pressure. At times the kidney becomes tender and swollen as
a result of twisting of the renal vessels or of the ureter (Dietl’s
crises), causing engorgement of the organ; this may be associated
with agonizing pain and symptoms of collapse. Hydronephrosis may be
manifested.
=Diagnosis.=—The shape of the tumor, marked mobility, and lessened
resistance on percussion of the renal region will make the diagnosis.
The disorder very rarely proves fatal. In doubtful cases utilize the
X-ray.
=Treatment.=—Many cases rarely give trouble directly, but may be a
source of reflex and obscure symptoms. Attention to the general health
of the patient and persistent treatment of the dorso-lumbar region
greatly strengthen the relaxed tissues about the kidney and cure a
number of cases. Having the patient attempt to replace the organ after
he goes to bed will be of value. Treatment of the abdomen to strengthen
the walls and lessen any liver congestion and to keep the bowels active
is very beneficial. Teach the patient how to stand and walk correctly,
especially holding the abdomen in and up. A liberal diet to the point
of increasing the weight is worthy of trial. The use of supports is
not always satisfactory. Surgical treatment for fixing the kidney is
of permanent value, but do not advise operation unless absolutely
indicated. (See Prolapsed Organs, Part I).
To =determine the presence of a movable kidney=, it is best to have
the patient in the dorsal position, the head slightly lowered and
the abdominal walls relaxed by flexing the thighs moderately upon
the abdomen. Then with the left hand in the lumbar region behind the
eleventh and twelfth ribs, and the right hand in the hypochondriac
region, the kidney can usually be detected after full inspiration
followed by complete expiration; or, have the patient in a standing
posture with the body bent slightly forward and the hands placed upon
a table, then perform bimanual palpation; or, perform the manipulation
in the knee-elbow position. When in this position (knee-elbow), if
the kidney has become dislodged, a resonant note will be obtained by
percussion over the normal location of the kidney.
FOOTNOTES:
[98] Journal of the American Osteopathic Association, July, 1904.
[99] Journal of the American Osteopathic Association, Dec., 1904.
DISEASES OF THE BLADDER
Cystitis
=Cystitis= is an inflammation of the mucous membrane of the bladder.
Retention of the urine; foreign bodies, such as stones, in the bladder;
the use of dirty catheters; exposure to wet and cold; injuries to the
bladder and over the pubes; irritations to the sacral nerves; spinal
lesions in the dorsal enlargement of the cord; innominate lesions;
irritating drugs; enlarged prostate and urethral strictures are the
principal causes of cystitis. The disease may be secondary to fevers,
infectious diseases and inflammation of adjacent organs. A displaced
uterus may produce a chronic irritation of the bladder.
=Pathologically=, there is hyperemia of the mucous membrane of part
or of the whole of the bladder, with redness, congestion and edema.
The secretion of mucus that covers the mucous membrane is of a dirty
gray color. If the congestion is very extensive, a bursting of the
capillaries may take place. In a few cases the neck of the bladder and
the urethra, where it passes through the prostate, is involved. In
chronic cases the mucous membrane becomes thickened and covered with
patches of false membrane. The muscular coat of the bladder becomes
hypertrophied and the veins tortuous.
=Symptoms.=—The onset may be sudden with rigors and fever, but in many
cases a frequent desire to micturate will be the first symptom. This
is followed by tenderness and pain over the bladder and contiguous
parts, loss of appetite, depression and sleeplessness. Tenesmus of the
bladder, caused by a spastic condition of its muscles, and a burning
along the urethra are usually present. The urine is alkaline in
reaction and contains pus, epithelium and blood.
=Diagnosis.=—The diagnosis is usually easy. =Pyelitis= causes pains in
the lumbar region and along the ureters and there is a frequent desire
to urinate. The bladder is not subject to spasms and the urine is of an
acid or neutral reaction.
=Prognosis.=—In many cases the prognosis is favorable, but in cases
of long standing and in hypertrophy of the bladder, prognosis must be
guarded.
=Treatment.=—Rest in bed with strict attention to diet is necessary.
Milk is the best food and avoid highly seasoned articles and acid
foods. The use of plenty of pure water is helpful to dilute the
urine, and if necessary the bladder should be washed out carefully.
If the case is severe, emptying the bladder several times a day with
a catheter will be necessary. Always be careful about the cleansing
of the instruments. Warm applications over the pelvic region will be
comforting to the patient. Lifting the abdominal viscera from the
bladder is of assistance. The patient may be placed in the knee and
chest position for this or the usual method employed.
Treatment to the second, third and fourth sacral nerves controls the
neck of the bladder, and strong inhibition will generally control
the spasms of the sphincter. The fundus of the organ is supplied by
sympathetic fibers from the pelvic plexus. Direct treatment over the
bladder, if applied carefully, will act on the terminal fibers of the
sympathetic. Lesions to the nerves of the sphincter of the bladder
oftentimes occur between the fifth lumbar and sacrum, also from a
displaced innominate. Such lesions are apt to be found in cases of
incontinence of urine. The lesion to the vertebra is usually a lateral
one.
Thorough treatment to the genito-urinary center (lower dorsal and upper
lumbar) will also be of aid. In males direct treatment of the prostate
gland is occasionally important as is also the plexus of nerves at the
trigone of the bladder. In =treating= the =prostate gland= introduce a
finger into the rectum and work about the base of the gland to relax
the tissues, and thus remove obstructions of the vascular, lymphatic
and nervous structures to the gland. Do not work too much upon the
gland itself (commonly once a week or ten days), as it may irritate,
but release surrounding edema. Also treat the innervation at the
eleventh and twelfth dorsals, fifth lumbar, and first, second and third
sacrals. Spreading the ischii will occasionally be beneficial; this
tends to release the anterior commissure where it is attached to the
symphysis.
Follow the above with a “general treatment” in order to secure a
general systemic reaction. This is of value in all infectious disorders.
It is important in =young boys= to examine the condition of the
penis in bladder diseases. The prepuce may become adherent or other
irritations may be found that are a source of disturbance to the
bladder, or even to the kidneys, on account of the intimate connection
of the sympathetic system in this region and the relation of one organ
to another.
An =irritable bladder= is usually due to disorders of nearby tissues,
especially the urethra, vagina, uterus and rectum.
=Enuresis=, exclusive of paralysis, is frequently due to some local
mechanical disturbance. =Nocturnal enuresis= or =bed wetting= is
caused by lower dorsal and lumbar lesions (especially the fifth
lumbar), displacements of the innominate, or phimosis, hooded clitoris,
contracted meatus, highly acid urine, worms, lack of discipline, etc.
The patient is usually =neurotic=, which demands attention to the
neuromuscular system of the entire body. Care of the general health and
habits is important. Constipation may be present.
DISEASES OF THE CIRCULATORY SYSTEM
DISEASES OF THE PERICARDIUM
Pericarditis
=Pericarditis= is an inflammation of the serous membrane covering the
heart and its reflection in front over the chest. Primary inflammation
of the pericardium is rare. Such cases usually result from cold and
exposure or injury or tuberculosis, and are most commonly met with in
children.
The exciting causes of =secondary pericarditis= are rheumatism,
Bright’s disease, tuberculosis, gout, diabetes, eruptive fevers,
various septic conditions and dyscrasia. Pericarditis may result by
extension of inflammation from contiguous organs, as the disease may
occur in pneumonia, pleuropneumonia, chronic valvular diseases, and
ulcerative diseases of the esophagus, bronchi, vertebræ, ribs, stomach,
etc.
Displacement of the ribs over the heart and involvement of the
corresponding vertebræ predispose to pericarditis, by weakening the
innervation of the pericardium and thus disturbing the circulation.
Lesions of the cervical region affecting the left phrenic are to
be considered. Upper rib lesions may disturb the internal mammary
artery and the lymphatics, which have important relationship with
the pericardium. The disease may occur at any age. Males are more
frequently attacked than females.
The morbid conditions vary with the stage. The stages are (1) acute,
plastic, or dry pericarditis; (2) pericarditis with effusion,
serofibrinous, hemorrhagic or purulent; (3) absorption or adhesive
pericarditis. These different stages or varieties commonly succeed one
another, although medical writers place so much importance in them that
each is described separately. =Acute pericarditis= is by far the most
common and often the inflammation subsides at this point instead of
going on to more serious involvement. There is a possibility that in
some cases the forms are independent of each other.
The changes are the same as in various serous membranes. Hyperemia
and alteration of the epithelium is most marked on the visceral
layer. This is followed by an exudation from the hyperemic vessels.
There is roughening and loosening of the epithelium and the fibrin is
precipitated upon the walls of the pericardium. More or less lymph is
exuded and sometimes injected capillaries burst and cause a bloody
exudation. From this stage the morbid appearances vary according to the
progress of the disease. The disease may undergo resolution and fatty
degeneration and absorption of the products in point take place. As
the stage of effusion occurs, the parietal and visceral layers of the
pericardium are separated by a serofibrinous exudate. This condition
may increase until the quantity of the exudation is considerable,
or the effusion may become absorbed. Rarely does the exudate become
purulent.
Adhesions may be formed between the layers of the pericardium, during
the last stage, by bands of various lengths or the layers are more or
less separable.
=Symptoms.=—Simple cases may not present any symptoms. Usually a chill
or cold feeling at the heart, followed by pains in the cardiac region,
ushers in the attack. Fever is commonly present, rarely exceeding 103
degrees F. Tenderness over the heart is noticeable. There is dyspnea
and the patient is restless.
In the =effusive stage= the symptoms depend largely upon the amount
of diffusion. The pain is sharp and stitch-like. Nausea, vomiting and
hiccough sometimes occur. The pulse is irregular and feeble. Insomnia,
headache and even delirium may occur. Distention of the veins of
the neck may cause dysphagia and a cough may be present, owing to
the irritation of the trachea. The recurrent laryngeal nerve may be
compressed as it winds about the aorta and thus cause aphonia.
The friction sound is a characteristic physical sign of the first
stage. In the effusive stage there may be precordial bulging. The
area of dullness is enlarged, the diaphragm and liver may be crowded
downward, causing an epigastric bulging. As the effusion increases, the
heart sounds become less distinct; the friction is not heard. In the
=third stage= there is usually a return to normal, although =adhesions=
may form and cause precordial retraction and permanently embarrass the
heart’s movements. The young are more subject to permanent disability.
Extension of heart impulse, which is undulatory; diastolic shock
to hand placed over heart; increased area of dullness; prominent
precordia; position of patient does not change apex beat; and when
pericardium is adherent to diaphragm a systolic tug is noted over
points of attachment, are essential signs and symptoms.
=Diagnosis.=—Pericarditis is frequently overlooked. It is a serious
disease and one should be especially careful. In cases of rheumatism
the osteopath must always be on his guard. Tonsillitis may be the
origin of the infection. Care has to be taken in distinguishing
between dilatation and cardiac hypertrophy and pericardial effusion.
Hydro-pericardium may be mistaken for pericardial effusion.
To distinguish between endocarditis and pericarditis should not be
a difficult task if one understands thoroughly the nature of each
disease. A large pericardial effusion may be confounded with a pleural
effusion. In doubtful cases utilize the X-ray.
=Prognosis.=—In mild cases of pericarditis the large majority rapidly
recover in two to three weeks. In cachectic subjects and where
adhesions have formed, the duration is longer. Relapses may occur. The
purulent effusions are always serious.
=Treatment.=—Demands prompt and effective measures. Absolute rest
mentally and physically, is necessary. Too much stress cannot be
laid upon this point, as death has occurred from neglect of this. To
quiet the heart’s action is the first necessary requisite, and then
give treatment to limit the inflammation. In the early stage relaxing
the upper dorsal musculature to control innervation, and raising and
freeing all the upper ribs and clavicles to promote lymphatic drainage
is effective. In the second stage prevention of cardiac failure and
promotion of absorption are the indications to be met. Too much
importance cannot be placed upon the point that general strength,
good nursing, dieting and free elimination are essential, not only in
securing a rapid subsidence of the inflammation, but to prevent further
complications.
Raising and separating the ribs over the heart will be of great aid
in lessening the inflammation and promoting absorption. In many cases
lesions to the ribs on the left side and subdislocations of the
vertebræ affecting the vasomotor nerves, the lymphatics and nerves to
the heart will be found. The first five ribs and corresponding vertebræ
is the region where one may expect to find the lesions. In addition to
absolute rest, an inhibiting treatment in the dorsal region between
the scapulæ will aid in slowing the heart’s action. Correcting any
lesion that may be found to the vagi nerves will also be a help in
controlling the heart’s action; besides, most of the vasomotor fibers
to the heart are in the vagi. These lesions are usually found at the
atlas. One should also examine carefully all the cervical vertebræ for
derangements that might affect the cervical sympathetic, especially
the superior and middle cervical ganglia. These ganglia are primarily
affected from the fifth cervical to the first dorsal. Inhibition for
a few minutes between the transverse process of the atlas and the
occipital bone to the posterior occipital nerves will be of great aid
in controlling the tumultuous action of the heart; also, inhibit in the
upper dorsal. The warm bath will quiet the heart, but care should be
taken not to weaken the patient. The general treatment has the effect
of lessening nervousness and quieting the heart.
The function of the phrenic nerve must be borne in mind when regarding
the pericardium. The phrenic is usually primarily affected at the
third, fourth and fifth cervicals, and occasionally there are
connecting fibers as low as the fourth and fifth dorsals. Ice-bags may
be found of value in retarding the progress of the effusion and in
lessening the heart’s action. Liquid food, as milk and broths, should
be given throughout the disease. If the effusion is very large the
services of a surgeon should be secured and tapping performed. If the
effusion is of a purulent nature, a free incision should be made with
antiseptic precautions.
In chronic cases carefully graduated breathing exercises and moderate
stretching of the adherent regions, if pathology permits, should be
considered.
Endocarditis
=Endocarditis= is an inflammation of the lining membrane of the heart.
The process is usually confined to the valves; the lining of the
cavity of the heart may also be affected, especially in severe cases.
Three forms are recognized: simple acute endocarditis, ulcerative
endocarditis, and chronic endocarditis.
=Simple Acute Endocarditis.=—This form usually results from acute
articular rheumatism. Tonsillitis may be associated with endocarditis.
It may also be caused by other infectious diseases, especially scarlet
fever, but rarely, by typhoid fever, measles, chicken-pox, diphtheria,
smallpox and erysipelas. Acute endocarditis is frequently found in
chorea. It is also met with in diseases attended with emaciation and
general weakness, as cancer, gout, Bright’s disease and diabetes. It
is not uncommon in phthisis. Micro-organisms play an exciting part,
but back of this the osteopath finds lesions of the heart innervation
important predisposing features. Prophylactic osteopathic treatment
is a potent factor in preventing endocardial changes in the above
diseases. Keeping the muscles relaxed and the osseous tissues intact is
of great value.
=Pathologically=, the left side of the heart is most commonly involved.
The disease is characterized by the presence of small vegetations on
the segments or on the lining membrane of the chambers, although in
mild cases there is simply swelling of the valves. The mitral valves
are more often affected than the aortic. The vegetations appear,
usually, on the auricular surface of the mitral and the ventricular
surface of the aortic valves, a little back of the valve edge. Their
seat corresponds to the point of maximum contact (Sibson). These
growths are liable to be broken off at any time and carried as emboli
by the blood current to distant organs, particularly the brain, spleen
and kidneys. This is not uncommon in acute endocarditis or chronic
valvulitis. In favorable cases the vegetation is ultimately absorbed
and the valve is but slightly altered beyond a simple sclerotic
thickening. This is often the starting point of sclerotic valvulitis.
Osteopathic measures undoubtedly lessen the liability of cardiac
involvement, prevent extensive changes and promote absorption of
disease products, by lowering heart tension and improving the cardiac
nutrition, as well as increasing free elimination of the toxins in the
blood.
During the fetal life, the right side of the heart is most commonly
involved. The chorda tendinæ are sometimes affected, but rarely alone.
The vegetations are composed of proliferated connective tissue cells.
The superficial elements undergo a coagulation-necrosis and fibrin
is deposited from the blood. Micro-organisms are found and are the
specific agent in causing acute endocarditis.
=Symptoms.=—A large number of cases are latent, the autopsy first
disclosing the lesion. In many cases there are slight fever, a
frequent, sometimes irregular, pulse, palpitation and dyspnea. There is
seldom any pain.
=Physical signs= are very uncertain. They may not be present in mild
cases and in those in which the valves are not affected. Usually
auscultation furnishes the only indication of endocarditis—a soft,
blowing, systolic murmur which is heard most frequently at the apex,
as the mitral valves are the ones generally involved. When the aortic
valves are affected, the murmur is heard at the second interspace at
the right edge of the sternum.
=Diagnosis.=—This depends entirely upon the etiology and physical
signs. The greatest danger is in the disease becoming chronic.
=Treatment.=—The patient should be kept as quiet as possible, so
that the work required of the heart may be reduced to a minimum. The
disturbed circulation can be controlled by careful attention to the
vasomotor nerves at the various centers along the spine. Attention
should be given the disease that is causing the endocarditis. Keep the
patient well protected by flannels and beware of damp rooms and sudden
changes of temperature.
Treatment should be given to correct any lesion found in the upper five
dorsal vertebræ or ribs and to raise and spread all of these ribs so
that the heart’s action will not be unduly disturbed by interferences
with its innervation. The vasomotor nerves to the heart’s vessels are
found in the vagi nerves, consequently care should be taken that
lesions to these nerves do not exist. An inhibitory treatment to the
suboccipital nerves acts reflexly on the vasomotor nerves and tends
to equalize the general vascular system. This treatment quiets the
heart’s action. Ice applied locally is advocated by many practitioners.
Flannels should be placed next to the skin and the ice-bag placed
over the flannel. This reduces the fever, lessens the pulse-rate and
quiets the heart action. The same points are obtained by the inhibitory
treatment at the suboccipital region. The ice-bag also relieves pain
and oppression. Be very careful in the use of ice when there is much
cardiac dilatation. Treatment of the middle and inferior cervical
regions may have some effect in controlling the heart’s action. A
general treatment to quiet the patient is effective. Do not allow any
overexertion. The patient should have nourishing liquid food.
Emery[100] says: “Many of us have been in the habit of saying, just
because we hear a decided murmur in the heart region, that the patient
has valvular heart trouble; that the patient has organic heart trouble.
This is a common error... When there is an anemic condition of the
body, apparently the cusps of the valve will be so weakened, and the
attachment will be so weakened that the blood will force its way
between the valves and back into the heart, causing regurgitation
murmur, when as an actual fact there is no deformity and no real
disease of the valves, and as soon as the general condition of the
anemia is improved, the valve will do its work fully and the murmur
entirely cease. So if you have the murmur without the hypertrophied
condition, which at once follows such a valvular lesion, you must
be guarded in your statements, for if an actual valvular lesion
existed, compensation would take place, and it would be the means of
corroborating such a valvular condition; if no hypertrophy is found,
then we are not justified in definitely stating that a valvular or
organic lesion exists, for such a weakened condition as has been
mentioned might be the only pathology present, and be the cause of the
murmur.”
=Ulcerative or malignant endocarditis.=—This is an acute, infectious or
septic disease, characterized locally by necrosis or ulceration of the
valve. It is generally a secondary affection to septicemia, pneumonia,
erysipelas, scarlet fever and acute rheumatism. Acute endocarditis
often precedes the ulcerative variety, the latter being simply an
increase in severity of the former.
=Etiology and Pathology.=—It is doubtful if there can be a primary
form of ulcerative endocarditis. Chronic valvular defects are the most
important predisposing causes. Pneumonia is most frequently, of all
the acute diseases, associated with severe endocarditis. It is rare
in tuberculosis, diphtheria, typhoid fever and chorea. It occurs in
association with erysipelas, gonorrhea and rheumatism. Septicemia,
pleurisy, meningitis and puerperal fever are other possible causes of
ulcerative endocarditis.
Deep seated lesions, which means firmly anchored lateral flexions
and rotations due to fibrotic changes, are important predisposing
local factors, while other lesions that disturb blood elaboration and
resistance and lessen elimination, are predisposing systemic causes.
=Pathologically=, the lesions are either vegetative, ulcerative or
suppurative. The vegetations are composed of granulation tissue,
granular and fibrillated fibrin, and colonies of micro-organisms. They
become necrotic and break down into ulcers. The ulcerative changes
may lead to perforations or produce valvular aneurisms. Of the valves
the mitral is the most frequently affected; then the aortic; then
the mitral and the aortic together; then the heart walls; then the
tricuspid; then the pulmonary. In a few cases the right heart alone
is involved. The lesion is not always confined to the valves, but may
involve the mural endocardium. The most common organisms found are the
pneumococcus, streptococci and staphylococci. The bacillus diphtheriæ,
bacillus coli, gonococcus, bacillus anthracis and other organisms have
been found. Associated pathological changes include the lesions of the
primary disease and the changes due to embolism. The spleen, kidneys,
brain, intestines and skin may be the seat of embolism. When found in
the lungs, they originate in the right heart.
=Symptoms.=—If in the course of any of the diseases previously named
under etiology, chills followed by fever and sweats occur, ulcerative
endocarditis should at once be suspected and a thorough examination
be made. The general symptoms are high, irregular fever, delirium,
sweating, great prostration, rapid pulse, hurried breathing and
sometimes jaundice and diarrhea occur.
The occurrence of delirium, coma or hemiplegia points to involvement of
the brain; pain in the region of the spleen, with increased dullness on
percussion, point to trouble in that organ; hematuria may occur from
involvement of the kidneys. More rarely there will be impaired vision
from retinal hemorrhage; and there may be suppuration and sometimes
gangrene in various locations, depending upon the position of the
embolism.
The =septic type= is secondary to suppurating external wounds,
puerperal sepsis or acute necrosis. Occasionally gonorrhea is the
cause. The symptoms presented are rigors, irregular fever, sweats and
exhaustion—the signs of septic infection. The symptoms may resemble a
quotidian or a tertian ague. The =typhoid type= is the most common.
The characteristic symptoms are irregular temperature, sweating,
prostration, delirium, drowsiness, diarrhea, petechial and other
rashes, distention of the abdomen and pain in the right iliac region.
The heart symptoms may be overlooked, as in the septic type. The
=cardiac type= are cases of chronic valvular diseases in which fever,
rigors and sweats, and the symptoms of embolism may develop. In the
=cerebral= cases the symptoms may simulate meningitis. Acute delirium
may be the distinctive symptom. Heart symptoms may be overlooked.
=Physical Signs.=—The heart symptoms may be latent. Even after a
careful examination, there may be no murmur present. When murmurs are
present it is often difficult to locate them.
=Diagnosis.=—The previous history should be considered and this,
together with the symptoms, makes a correct diagnosis possible, even
though physical signs are absent. The duration is from a few days to
several weeks.
=Treatment.=—The treatment of this form of endocarditis is likely to be
of little avail, although in a few cases where the source of infection
can be eradicated the condition may be considerably improved and life
prolonged. About the same treatment as in simple endocarditis should
be followed. Absolute rest is essential and this, coupled with the
local treatment of simple endocarditis and a nourishing liquid diet,
constitutes the principal treatment.
Chronic Endocarditis
This condition may begin as a chronic inflammation or follow the acute
form, which is more often the case. There is a =sclerosis= of the
valves which causes deformity, owing to the contractions. The onset is
usually insidious.
It is well known that the larger percentage of valvular lesions are the
result of either acute or chronic endocarditis. Thus rheumatism stands
foremost as a cause of valvular defects. Alcoholism and overeating
(through introducing irritating influences into the blood, or by
causing rheumatism, gout and allied diseases) are important etiological
considerations. Nephritis and syphilis are considered among the
causative factors. Infections and senility, when associated with high
blood pressure, is a phase not to be overlooked. Chronic endarteritis
extending from the aorta to the valves, resulting in thickening and
degeneration of the tissue, may be an insidious source of valve
disease. This is probably often of syphilitic origin.
A potent cause of special interest to the osteopath (for the reason
that his treatment is so effective), is continued =muscular strain= as
seen in athletes and laborers. The heart muscle itself may be strained,
particularly the valve leaflets and the tissues about the valve, which
effect often terminates in valvular leakage. In addition, the orifice
of the valve openings may become stretched and distorted through strain
superinduced by prolonged exertion, by flabbiness of heart tissue, and
by dilatation of the ventricles. In these latter cases it is seen that
the leaflets of the valves may remain intact, but still they are unable
to stretch completely across the opening.
With the above condition it is readily noted that thickening, curling
and adhesions will take place when inflammation attacks the valves and
contiguous tissues, and following these, limy infiltration and fatty
degeneration may be a consequence.
Predisposing osteopathic lesions as noted in acute endocarditis, are
not to be neglected.
=Thickening and hyperplasia= are immediate consequents of connective
tissue overgrowth; and especially is chronic endarteritis accompanied
with atheromatous and calcareous degeneration. Thickening, at times, is
only slight and the function of valves is not impaired.
In curling or =retraction=, there occurs a shrinkage of the
hypertrophic or hyperplastic tissues. This condition is very apt to
become permanent.
=Adhesions= of the valve leaflets is a self-evident condition. It is
well to note here that in acute and chronic endocarditis some part
of the fibrous valve ruptures or is lacerated or eroded from strong
and rapid heart action; the =laceration= or rupture or erosion always
occurs at the point of maximum contact. Thus the eroded surface allows
an opportunity for the rheumatic or septic micro-organisms to lodge,
multiply and grow, and adhesions result. Carefully applied osteopathic
methods are very efficacious in impending acute heart disturbances, and
this without doubt is the reason why so many of our rheumatic cases get
well without any heart affections. Keeping the heart quieted and slowed
prevents the strong and rapid action and thus lessens the probability
of lacerations, ruptures and erosions of the valve tissues. General
resistance is increased and elimination improved, which have a decided
effect in preventing complications.
=Calcification and atheroma=, as has been mentioned, may follow the
above diseased processes. The calcification is sometimes so marked as
to be of the character of a bony ring.
The question arises here, What effect have =osteopathic lesions= as
direct =causative factors= in valvulitis? It appears reasonable that
the heart is not exempt from the influences of the vertebral and rib
maladjustments. Furthermore, clinical experience has abundantly proven
that the heart tissues are affected by these lesions in the same manner
as any tissue or organ is affected. Again, osteopathic dissection
reveals direct nervous connection from the upper dorsal spinal ganglia
to the heart ganglia.
No one will question that the integrity of heart function and life
are dependent upon normal coronary artery supply, upon vasomotor
equilibrium, and upon motor control. All of these functions are
influenced by the status of cervical vertebræ, upper dorsal vertebræ,
and rib relations. Just what the pathological affection is when
these anatomical parts are disturbed is beyond us until more careful
dissection and experimentation have taken place. How cervical and
dorsal sympathetics, vasomotor and motor nerves with their spinal
connections, vagi and phrenic, are so disturbed as to involve valvular
parts and induce inflammation, is a problem for us to investigate.
Through analogous reasoning from other organic ailments and through
the fact that osteopathic therapeutics corrects heart lesions, we know
in a general way that the correction of osteopathic lesions decidedly
influences the heart.
Two well known =physiological facts= relative to the heart are: first,
the heart increases in size up to adult life, and, second, the heart
muscle can actually be increased in size. This latter fact occurs in
physical development and training. A heart that is weak and flabby can
be increased in strength, tone and size. This helps us to understand
how certain strains and distortions of the heart, with consequent
valvular lesions, may be corrected through rest, exercise and
treatment; somewhat analogous to the correction of an atonic, prolapsed
and dilated stomach. Then it also seems probable that disturbed
innervation and blood supply to heart areas or to the heart as a whole
would predispose to congestions, inflammations and degenerations
whereby rheumatism, septic states, etc., and muscular strains would act
only as exciting causes, not true causes.
No one is going to expect that thickened, retracted, adhered, or
ruptured valves are to be made anatomically correct; but the right
treatment will certainly reduce the morbid state to the minimum. Then
there are cases where osteopaths have eliminated all murmurs when
specialists stated the disease was incurable; showing that it is
impossible by signs and symptoms to always diagnose the morbid tissue
state. Only the resulting effects of size and of leakage are definitely
revealed by auscultation and percussion. Hence there is a class of
valvular diseases that can be successfully treated by osteopathic
measures, which, if left to terminate under drug medication, will
reveal (at post-mortem) the pathological signs of valvular heart
disease.
Downward displacement of the =first rib= may interfere directly with
the subclavian artery and thus cause constriction of that vessel and
a consequent regurgitation; also, cardiac fibers of the recurrent
laryngeal nerves may be impinged by a dislocation of this rib. Many
lesions which interfere with the right side of the heart occur at
the =second= and =third ribs= and lesions of the =third=, =fourth=
and =fifth ribs= may interfere with the valves. Lesions of the
=corresponding vertebræ= produce the same results as the ribs. These
lesions are probably to the sympathetic nerves along the dorsal region.
Lesions may be found anywhere along the cervical vertebræ which may
involve inhibitory (vagi) fibers or accelerator (sympathetic) fibers
to the heart. Also, in some cases the =floating ribs= are dislocated
downward and cause a prolapse of the diaphragm, and thus a constriction
of the aorta, which may result in regurgitation and valvular disorder.
=Mitral Regurgitation.=—Mitral regurgitation is a leakage of blood from
the left ventricle, through the mitral valves, into the left auricle.
The opening of the valve may be distorted, or the valve leaflets
thickened, rigid, or retracted, thus allowing an escape or reflux of
blood from ventricle into auricle. The tendinous cords may also be
thickened and adhered, with consequent prevention of free action.
By a forcing back of a portion of the blood from ventricle to auricle
at the same time the pulmonic veins are emptying into the auricle, an
overdistention of the auricle takes place. The auricle, then, from the
extra amount of work required, becomes hypertrophied and dilated. There
may be no noticeable symptoms at first. Later on shortness of breath,
cough, irregularity of heart’s action, indigestion, liver congestion,
and so on, occur.
The =apex beat= is forcible and downward to the left. Of course the
area of dullness is to the right and left. There is a =systolic murmur=
in the mitral area, which is transmitted to the left axilla.
Every osteopath should understand the mechanism of this most frequent
valvular lesion. Following hypertrophy and dilatation of the left
auricle, the reflux may be so excessive that a residue remains. The
auricle not being able to handle all the =blood=, stasis of the
pulmonary vessels takes place, and pulmonary edema and hydrothorax are
sequelæ. Then comes dilatation of the right ventricle and back pressure
on tricuspid valves and right auricle. The =veins= throughout the body
become turgescent, and the liver is apt to be indurated. It should be
emphasized, however, that “back pressure” is only an effect commonly
due to myocardial degeneration, caused by some infection, of which
auricular fibrillation is an important part of the pathology.
Before the breaking down of the left heart compensation, osteopathic
methods, as all know, are effective in maintaining balance. Even after
the lungs begin to be affected, careful and thorough treatment will
result in good, and in cases of general venous sluggishness treatment,
particularly to liver, diaphragm, bowels and limbs, will generally
materially help in slowing the downward course of the disease.
=Mitral Stenosis.=—In stenosis there is narrowing or constriction of
the valve opening. Thus in mitral stenosis the free flow of the blood
from left auricle to ventricle is hindered.
The =cusps= are usually thickened, rigid and adhered. The valve opening
may be so stenosed as to be but a narrow slit. In all cases stenosis
is a =structural defect=. It can occur by strains, as regurgitative
effects sometimes result.
The =symptoms= of mitral stenosis are practically the same as those of
mitral regurgitation, owing to similar effects upon the circulation.
Under =physical signs= we find the apex-beat is only slightly
displaced. Palpation will reveal, near the apex, a rough presystolic
thrill. The increased area of dullness is to the right. There is an
abruptly terminating, rough, presystolic murmur.
=Aortic Regurgitation.=—Aortic regurgitation is a reflux of blood
from aorta to left ventricle, following ventricular systole. This is
considered the =most serious= of the valvular diseases. The valve
opening is either too large, so the valve leaflets do not fit tightly,
or the segments themselves are thickened and retracted. Structural
defects of the aortic valves are largely of the same character as in
diseases of the mitral valves.
The =regurgitation= first causes dilatation of the left ventricle.
This is followed by hypertrophy. If the mitral valve holds intact, no
further effects result. But if the mitral valve is diseased or becomes
incompetent from the dilated ventricle, the same morbid states follow
as was noted under mitral regurgitation.
There is a forcible apex-beat, displaced downward to the left. The
increased dullness is to the left. There is a long, loud =diastolic
murmur=. The well known “water-hammer” pulse is felt.
=Aortic Stenosis.=—Aortic stenosis indicates a narrowing of the
aortic orifice. It is a structural defect. The free flow of blood is
obstructed from the left ventricle into the aorta.
Aortic stenosis is much less frequent than regurgitation. Aortic
stenosis and regurgitation are very apt to be associated. The beat is
commonly forcible, and the increased area of dullness is to the left.
There is a systolic murmur, heard best at the right second interspace,
which is conducted into both carotid arteries.
=Tricuspid Regurgitation.=—Tricuspid regurgitation is the most common
valvular lesion affecting the right heart. It is rare as a primary
lesion. The affection may be of a structural character, or functional.
Hypertrophy of the right ventricle occurs after the manner of left
ventricle hypertrophy in mitral regurgitation. The sequelæ of venous
turgescence follow, also, in the same way as was given under the mitral
lesions. Tricuspid regurgitation rarely exists independent of some
other cardiac or pulmonary ailments.
The apex-beat is diffused toward the epigastrium. Increased cardiac
dullness is toward the right. There is a systolic murmur, which is
heard best just above the xiphoid cartilage. The jugular vein pulsates;
in severe cases there is pulsation of the liver.
Osteopathic treatment is usually effective in relieving the engorgement
of the veins, and particularly in reducing liver congestion.
=Tricuspid Stenosis.=—This affection is said to be the =most rare=
of valvular lesions. Thickening, obstruction and adhesions from
endocarditis cause the stenosis. As in other lesions of the heart,
there is a congenital form. There is presystolic murmur, heard best at
the xiphoid cartilage. The pulse is small and weak.
=Pulmonary Regurgitation.=—This is another rare lesion, and is seldom
met with in a simple form.
There is forcible pulsation in the epigastrium. Increased cardiac
dullness is downward. There is a diastolic murmur, heard most
distinctly at the left second intercostal space.
=Pulmonary Stenosis.=—Another rare lesion. The effect of this lesion
on the right ventricle is the same as that of aortic stenosis on the
left. The congenital lesion is apt to occur with a patulous foramen
ovale.
There is a systolic murmur, heard best at the second intercostal space
on the left. =Many systolic murmurs= heard over the pulmonary opening
=are functional=.
=Combined Valvular Lesions.=—When two or more lesions occur at the same
time the terms, combined or associated, are employed. This is a very
common occurrence. Two, three or all of the valves may be affected at
the same time. =Stenosis= and =regurgitation= at the same orifice is
the most common association of any two valvular lesions. When there
is a joint affection of two or more valves, the =aortic= and =mitral=
are most commonly associated; then mitral and tricuspid; then aortic,
mitral and tricuspid.
=Prognosis and Treatment of Valvular Diseases.=—It is impossible
to outline with exactness either prognosis or treatment of heart
lesions. All will agree that the character of the lesion is the
first consideration, and before records of these cases can be of any
scientific benefit, we must look well to the nature of the valvular
leakage or obstruction and note precisely what effect our therapeutics
has. Perhaps of greatest consideration in the matter of prognosis
is, to what extent =compensation= has been maintained. We know that
compensation may be perfect; that hypertrophy and dilatation may
balance the valvular defect so thoroughly that even the patient is not
aware of a heart lesion. As soon as compensation begins to fail, when
palpitation, irregularity of pulse, dyspnea, edema, etc., appear, we
know that our treatment should pass from the realm of the defensive
to that of the offensive. Then when compensation fails still more,
prognosis and treatment must necessarily be changed according to the
increasing gravity.
In our osteopathic work we should never forget that the condition of
the lesion may be greatly influenced by environment. Habits, occupation
and general daily life may affect the heart ailment for good or
bad. Thus in =prognosis= we have =three features= in particular to
note: character of heart lesion, extent of systemic involvement, and
environment. In the immediate prognosis, the extent of general venous
stasis, if any, is of great importance. In other words, the gravity of
the complications is of first consideration.
Aortic regurgitation is ranked by heart specialists as the most serious
lesion. Aortic stenosis is a grave lesion, but not so serious as aortic
regurgitation. It is often stated that the character of the lesion is
not of so much consequence as the extent of involvement the lesion has
engendered. Mitral stenosis is more grave than mitral regurgitation.
Right side heart lesions are usually relative, and, naturally, when the
right heart is diseased from extension of the ailment from the left
side, the situation is serious.
It should be remembered that a heart normal in size and beating
regularly is usually in a fairly healthy condition even if a murmur is
present.
In our =treatment= the first point indicated is to improve, if
possible, the =integrity= of =heart muscle= and lessen the =valvular
defects=, if such can be done. Owing to a dearth of statistics, it is
impossible to state to what extent improvement in organic lesions has
been accomplished. Very likely if we had statistics and no post-mortem
findings, we would still be in the dark as to much of our work. This
much is positive: osteopaths have time and again apparently cured
grave valvular lesions; cases that eminent specialists diagnosed
as absolutely organic lesions. Our practitioners have eliminated
the murmurs, reduced the size of the heart, and removed any and all
systemic symptoms. These patients are well, have been well for years,
and are leading active lives. But were these cases suffering from
organic lesions? No doubt there was valvular leakage, hypertrophy and
dilatation, but was the valve defect a functional one? In other words,
was it due to strain and distortion? In all probability the patients’
days were numbered and post-mortems would have shown grave lesions and
quite likely more or less organic changes.
Does it not seem likely that some functional lesions may terminate
in organic lesions? Through continued stretching of the valves and
their immediate tissues, fatty degeneration may take place; the same
as fatty degeneration of the heart muscle, occurring in dilatation of
the chambers. If we can remedy functional lesions through specific
work upon nerve centers and fibers, why cannot we influence organic
lesions and at least reduce the gravity to a minimum? We know
functional diseases of the heart, as palpitation, rapid heart, slow
heart, etc., can be corrected, and from all indications, functional
valvular leakages are generally easily and quickly remedied; it is
only a step farther to affect truly organic lesions. The same valves,
the same nerves, and the same osteopathic lesions are noted. Then it
is only a continuation of the same process from functional disease to
organic disease. Indeed, no one is able to draw a line between the
two. Probably, as was intimated before, careful osteopathic treatment
in rheumatism and other diseases that are apt to predispose to heart
affections, will keep the heart so strong functionally and organically
that resulting valvular lesions are not nearly so likely to develop.
The heart can be treated and controlled as can any tissue or organ. It
certainly stands to reason that osteopathic therapeutics is rational
in both preventing and curing valvular lesions. The M. D. gives his
drugs with the hope of maintaining heart muscle integrity, of lessening
a too forceful beat, of increasing waning power, of promoting general
circulation, of preventing and lessening complications. We can do
the same thing with our methods, even more effectually, and with no
probability of harmful effects.
It would appear there are at least two ways in which organic lesions
may develop. =First=, as stated above, through =functional distortion=,
the normal heart muscle being strained from severe exercise, or a weak,
flabby, or disused heart muscle being overtaxed by ordinary exercise.
Here it will be seen that in the first instance immediate rest will
probably correct the weakness; in the second, rest and general
building up of the body if the atonic heart muscle resulted from some
debilitating disease. If from local causes correction of the specific
osteopathic lesion should be effective.
=Secondly=, through strong and rapid heart action the =valves= are
=ruptured= or =lacerated=, always at the point of =maximum contact=,
and thus present a favorable surface to micro-organisms.
Owing to the valves being a reduplication of the endocardium, they
have no muscles or blood-vessels, so that in =functional leakages=,
inflammation does not play a part, hence, a possibility of degeneration
occurring from excessive stretching.
The large majority of =osteopathic lesions= are unquestionably found
in the upper five dorsal vertebræ and the first five or six ribs on
the left side, although cervical lesions, in many instances, play an
important secondary, if not the primary, role. These maladjustments
affect vasomotor nerves to the heart, that is, to coronary vessels,
the dorsal and cervical sympathetics, the vagi, and the phrenic. We
are unable to state just how these lesions disturb nerve conductivity;
what present anatomy and physiology teach us does not fully explain.
Osteopathic dissection must be the means to the end of the explanation.
We have many clinical results, but not the physiological knowledge, as
yet, to support it.
The dropping down of the first rib, as well as the clavicle, interferes
with the large blood-vessels, especially the subclavian, and causes
increased resistance of the heart’s action and probably a certain
regurgitative effect. This regurgitative effect would also occur in
cases of obstruction to the aorta by constriction of the diaphragm
from dropping of the floating ribs. To what extent this latter
feature has been demonstrated is not known. In valvular diseases
it is practical to divide them for treatment into, =first=, where
the =lesion= is =compensated=; =second=, where =compensation= is
=incomplete=; =third=, where =compensation= is =lost=. With all cases
we should give consideration to environment, temperament, habits, food,
clothing, exercise, etc. Often these secondary matters are of vital
importance, especially when compensation is failing. The Schott method
of treatment may be of some avail; this treatment, which is composed of
a series of resistant exercises, tends to lessen peripheral resistance,
develop heart muscle, and remove heart stasis.
Speaking in general, =hypertrophy= and =dilatation= follow valvular
leakage, as a =secondary effect=. It is a compensatory condition, and
whenever compensation is failing, there is naturally a breaking down of
the structural tissues of the heart; that is, the muscular hypertrophy
is losing in integrity. Our primary aim, then, should be to keep up the
compensation, which is represented in the hypertrophy, although there
are cases that fail rapidly, especially in emphysema and cirrhosis
of the lungs. Generally, in hypertrophy and dilatation, there is a
=disproportion between= the =amount of work the heart has to do= and
its =ability= to do it. One of two things has occurred; there is an
increase in peripheral resistance or the volume of blood through the
heart is abnormal in quantity[101]. Loudon[102] says: “The treatment of
chronic disease of the heart requires a longer time, as a rule, than
the same disorder in the acute stage. Some cases cannot be materially
helped; a vast majority may be greatly benefited after a thorough
trial; while more than we might at first suppose, can be entirely
cured. We desire to quote at length from Hare relating to this point.
He says: ‘A chronic structural change in the heart resulting from an
acute process is not always synonymous with chronic heart disease.
Thus, acute endocarditis occasions a variety of changes of the mitral
and aortic valves which long may indicate their presence by their
characteristic murmurs, and yet in time these may wholly disappear.
That many such cases outgrow the valvular trouble, especially mitral
lesions, there can now be no doubt. The majority, even of those in
whom valvular murmurs permanently continue, do not have their health
unfavorably affected for years, and in many of these, the duration
of life is not appreciably shortened.’” This statement, from such an
author, gives the osteopath great encouragement; for add to those
above referred to, which recover in time from all valvular trouble,
the many cases of valvular insufficiency, due to dilatation, owing to
osteopathic lesions to the trophic nerves, and which may be cured by
removing such lesions, we find that quite a percentage of cases are
thus disposed of.
“It is doubtless true, also, that the cases above mentioned having
valvular thickening and vegetations, could have been cured in quicker
time and greater number had osteopathic treatment been given to
tone the heart, upbuild the general circulation and increase the
activities of the excretory organs. The importance of the lungs is
often overlooked in the treatment of cardiac diseases. The osteopath’s
ability to expand the chest and increase the capacity of the thorax
should be demonstrated in both cardiac and pulmonary troubles. It is
said to be a universal law throughout the animal kingdom ‘that muscular
power is directly proportional to the amount of oxygen consumed.’ Hence
give the power, and have your patient live as much out of doors as
practicable. =Exercise= should be =moderate= and always =stopped= short
of =fatigue=.”
Treatment of the abdominal organs should not be neglected, for improved
circulation here and thorough removal of effete products will influence
the heart. Freedom from worry, strains, etc. are essential. Tepid baths
are best.
A person may have a valvular leakage and not be aware of it. Probably
it is best to inform them, except in certain neurotic individuals. For
then they can take special care of themselves, as to overwork, strains
and intercurrent infections, and their life and usefulness be greatly
prolonged.
When compensation begins to break, certain symptoms are noticed,
as heart irregularity, difficult breathing, particularly at night,
shortness of breath, and more or less anemia. Later there is
disturbance of rhythm, cyanosis, dilatation of heart and dropsy.
Frequently, considerable can be accomplished through the upper dorsal
treatment, attention to the chest mobility, manipulation of the
abdominal organs and diaphragm, and special attention to the diet, rest
and some exercise. A light general treatment will assist the labored
circulation and improve assimilation, and a change of climate may be of
benefit.
Hypertrophy of the Heart
=Hypertrophy= of the heart is an enlargement of the heart, due to
an increase in the muscular tissue. It is usually associated with
dilatation. The ventricles are more often involved than the auricles,
and the left ventricle is more likely to be affected.
=Etiology.=—Valvular disease of the heart causing an obstruction to
the outflow of blood, as mitral insufficiency, diseases of the aortic
valve; increased intra-vascular pressure, caused by sclerotic changes
in the walls of the vessels; contraction of smaller arteries, due to
irritation of toxic substances in the blood, as in Bright’s disease.
Overeating or drinking and excessive physical exercise would also
induce hypertrophy of the left ventricle. Hypertrophy of the right
ventricle is caused by valvular lesions on the right side. Lesions
of the mitral valve causing an increased resistance in the pulmonary
vessels are etiologic factors; also diseases of the pulmonary vessels
in the lungs, as in cirrhosis and emphysema. There are conditions
affecting the heart, as the use of tea, alcohol and tobacco.
Disturbed innervation, as in exophthalmic goiter; derangements of the
vertebræ, and ribs corresponding to the upper five dorsals; downward
displacements of the floating ribs, causing a prolapse of the diaphragm
and a consequent retardation of blood through it to and from the heart,
will affect the heart’s action. Simple hypertrophy never occurs in
the auricles; it is always accompanied with dilatation. The condition
develops in the left auricle in mitral lesions; in the right auricle
when there are disturbances of the pulmonary circulation. The tricuspid
is rarely affected primarily.
=Pathologically=, the left side of the heart is more commonly enlarged
than the right; the ventricles than the auricles. The shape of the
heart varies when the left ventricle is hypertrophied, the conical
shape being more or less lost; it lies more horizontally and is
elongated. When both ventricles are enlarged the heart is round. When
the right ventricle is affected, it occupies the largest part of the
apex. The increase in the size of the heart is probably due to a
numerical increase in the muscle cells. The muscle is firm, of deep red
color and cuts with considerable resistance. Normally, the heart weighs
from eight to nine ounces. In general hypertrophy it may weigh from
fifteen to thirty ounces.
=Symptoms.=—Hypertrophy, being a conservative process or an act of
=compensation=, does not necessarily present any symptoms at first.
At the beginning there is rarely any pain, but a sense of fullness
and discomfort is present. As the hypertrophy increases, the arteries
become fuller, the veins less full and the circulation accelerated.
In hypertrophy associated with arteriosclerosis the blood pressure is
increased, and the pulse full and firm. Epistaxis may be of frequent
occurrence and the face congested. Pains occur in the precordial
region. There are nervousness, headache, hot flushes, palpitation,
cough and vertigo. In hypertrophy of the =left ventricle=, the apex
is lower and to the left. The carotids pulsate visibly and the radial
pulse is strong and tense. Percussion reveals enlargement to the left
and downward. The first sound is louder and prolonged. The aortic
second sound is intensified. In hypertrophy of the =right ventricle=
the enlargement is to the right edge of the sternum. The second
sound in the pulmonary area is increased. The apex-beat is displaced
outward. The pulse at the wrist is usually small. Hypertrophy of the
=auricles= always occurs with dilatation, which is most common in the
left auricle. The physical signs are characteristic. They are caused by
diseases of the mitral and tricuspid valves and diseases of the lungs,
as emphysema and cirrhosis.
=Diagnosis.=—If a careful examination is made, hypertrophy can hardly
be mistaken for any other condition. There may be a resemblance to
pericardial effusion, pleuritic effusion, aneurism or mediastinal
tumor, when near the heart. The X-ray will be of assistance.
=Prognosis.=—Depends largely upon the cause producing the hypertrophy.
Remember that hypertrophy is a compensatory act. The prognosis is more
or less unfavorable if resulting from emphysema, Bright’s disease or
in old age; also in degeneration of the vessels. In most cases of
functional overaction, persistent treatment can usually accomplish
considerable.
=Treatment.=—The treatment must be according to the cause of the
hypertrophy. There are many etiological factors, consequently the
treatment depends upon the influence of these factors. The principal
treatment will be found under endocarditis, as valvular diseases are
usually caused by endocarditis, and hypertrophy of the heart is a
conservative process of nature—an act of compensation secondary to
valvular and arterial lesions. The indications are to lessen the force
and number of pulsations of the heart and remove the cause if possible.
Dilatation of the Heart
There may be =dilatation= with thickening of the walls, and dilatation
with thinning of the walls, or they may be normal. It may be produced
by impaired nutrition of the cardiac muscle or increased endocardial
tension. More frequently the two conditions act jointly, although they
may act singly. Impaired nutrition of the cardiac muscle may diminish
the resisting power and thus cause dilatation. Weakening of the cardiac
walls may occur in scarlatina, typhoid, typhus, rheumatic fever, etc.
It is met with in chlorosis, anemia and leukemia. Increased endocardial
tension occurs in sudden, extreme exertions and in valvular diseases.
A normal heart through excessive exertion is rarely if ever dilated.
The important causes are considered under hypertrophy. Both impaired
nutrition and increased endocardial tension are influenced directly by
the extent and severity of the osteopathic lesion. This point has been
considered under chronic endocarditis.
=Pathologically=, the right side is more commonly affected than the
left. In advanced aortic incompetency, all the divisions may be
dilated. When one ventricle alone is dilated the septum may be seen
to bulge. In extensive dilatation, the auriculo-ventricular rings
are often dilated. Other orifices may also be dilated. The condition
is often associated with =hypertrophy= and =fatty degeneration=. The
muscle may be normal in appearance. The endocardium is often opaque,
and roughened in patches. There is degeneration of the ganglia of the
heart.
=Symptoms.=—Dilatation causes weakness of the walls of the heart, but
as long as the hypertrophied walls can compensate, no symptoms result.
When the hypertrophy weakens, greater dilatation occurs and symptoms
of venous stasis appear, as dropsy, feeble irregular pulse, dyspnea,
cough and scanty urine. In some instances there may be brief precordial
distress, faintness or palpitation.
=Physical Signs.=—On =inspection= the apex-beat is diffuse and feeble,
or it may not exist. As observed by Walsh, the impulse may be visible
and yet not palpable. =Palpation=—the impulse is diffuse, feeble and
fluttering. The pulse is small, rapid and irregular, rarely is it slow.
=Percussion=—the area of lateral dullness is increased to the right.
There is increase in the dullness downward to the sixth interspace and
upward to the second rib in many cases. =Auscultation=—the sounds are
weak and sharp. The first sound is shorter, lacks its muscular element
and becomes more like the second. The sounds are obscured, the cardiac
murmurs are present. In many cases the characteristic gallop rhythm is
present. When the right heart is chiefly dilated, the true apex-beat
cannot be felt, while an impulse may be felt below the xiphoid
cartilage, and a wavy impulse is seen in the fourth, fifth and sixth
interspaces to the left of the sternum.
=Diagnosis.=—When a clear history can be obtained, together with the
characteristic features, the diagnosis can be readily made. =Prognosis=
depends upon the cause.
=Treatment.=—The treatment of dilatation is that of valvular heart
disease. It is important that the patient should have plenty of rest,
suitable food and regulated exercises.
In acute dilatation absolute rest is necessary. Limit the fluid intake,
and open the bowels thoroughly. In serious cases, bleeding, a pint or
more, should be considered.
Myocarditis
=Myocarditis= is an acute or chronic inflammation of the heart muscle.
In many cases where the muscle substance of the heart is diseased,
there is no doubt that =osteopathic lesions= are potent underlying
factors. The lesions lessen nervous integrity and thus have a direct
bearing upon the muscular strength and the likelihood of inflammatory
invasion.
=Acute Interstitial Myocarditis.=—This affection is met with in fevers,
in connection with endocarditis and pericarditis. Of the infections
diphtheria and typhoid are the most frequent. Septic emboli may block
the coronary arteries in pyemia, septicemia and malignant endocarditis
and cause infarcts in the myocardium with abscess formation. It may be
a complication of gonorrhea. Males are affected more often than females.
=Pathologically=, in =acute interstitial myocarditis= the changes take
place in the intermuscular connective tissue. This becomes swollen
and round-cell infiltration takes place. The muscle substance is pale
and soft. =Acute parenchymatous degeneration= is characterized by
degeneration of the muscle fibers, which are infiltrated with granules.
The cardiac muscle throughout is pale and soft. =Acute suppurative
myocarditis= is a rare condition. In this form abscesses occur, which
vary in size from a pin’s head to a pea. They vary greatly in number
and are usually multiple. They may not cause any disturbance and may
not be recognized before death. On the other hand the abscess may
rupture into the heart cavities or the pericardium, or it may perforate
the intraventricular septum, thus allowing the venous and arterial
blood to intermingle. It may cause a cardiac aneurism.
=Symptoms.=—These are very uncertain. If during the course of any
of the causal diseases, the pulse suddenly becomes rapid, small and
irregular and compressible and palpitation and syncope develop, all of
which point to cardiac weakness, myocarditis may be suspected. Signs
of venous stasis develop later in the affection. The physical signs
are those of dilatation. This is extremely grave. Cases do, however,
recover.
=Treatment.=—The treatment is the same as that given under endocarditis
and pericarditis. Rest in bed is absolutely necessary. Pay particular
attention to the nourishment and to the hygienic surroundings of the
patient. Especially attention should be given to the upper dorsal area,
both to the muscles and the interosseous lesions, for this influences
cardiac muscle innervation and nutrition. Then lesions of the upper
cervical are important owing to their relationship to the vagi which
control muscular impulses of the heart muscle.
=Chronic Interstitial Myocarditis.=—Among the causes of this form
of myocarditis are the excessive use of tobacco or alcohol; gout,
rheumatism, malaria, diabetes, chronic nephritis, syphilis and lead
poisoning. Acute interstitial myocarditis may lead to the chronic
form. This form is “commonly caused by the narrowing of a coronary
branch in a process of obliterative endarteritis” (Osler). It may be
due to injuries of the anterior and lateral portions of the chest.
Unquestionably =osteopathic lesions= of the upper dorsal vertebræ and
ribs and cervical region affect the integrity of the heart muscle and
predispose to congestion, inflammation and debility of the tissue.
Males of middle life are more predisposed to chronic myocarditis.
The =pathological changes= occur most frequently in the left ventricle
and the septum, but they may occur in any portion. The patches and
streaks that are in the walls are sometimes only seen upon very careful
examination. They are of a gray or grayish-white color, and when fibers
that have undergone fatty degeneration are intermingled, they have a
grayish yellow tint. The condition may be associated with hypertrophy
and dilatation. A part of one of the heart cavities may become dilated,
producing what is known as cardiac aneurism. There is destruction of
the muscular fasciculi with subsequent development of new fibrous
tissue. Fatty degeneration is also seen.
=Symptoms.=—Advanced fibroid myocarditis may be present without any
symptoms. Slight degrees present no symptoms. The symptoms when present
are: a feeble, irregular, slow pulse; attacks of angina pectoris and
sometimes arhythmia. The blood pressure is increased. Upon exercising
there is more or less pain, cardiac distress and dyspnea. If fatty
degeneration is also present the pulse will be quickened and irregular.
=Diagnosis.=—This is often very difficult and it requires careful and
persistent study of a case to be able to make a correct diagnosis.
=Prognosis.=—This is grave, though unquestionably a number of cases
have been distinctly improved through osteopathic methods. Sudden
death is liable to occur at any time from complete obstruction to the
coronary arteries, as this condition is associated with sclerosis and
narrowing of these arteries or their branches.
=Treatment.=—The treatment of chronic myocarditis is largely included
in chronic endocarditis. The cause of the disease should be determined,
if possible. Careful treatment to the ribs of the left side, from the
first to the sixth, and the corresponding vertebræ, will be of great
aid in controlling the disease. The cervical region demands attention,
owing to the influence of the vagi on conduction of the heart impulse
and to vasomotor effect. Attention should be given to the diet and
hygiene of the patient. Outdoor life, bathing of the skin, and careful
treatment of the vasomotor nerves will be of great help.
Direct attention to the entire splanchnic region as vasomotor control
here materially lessens the work of the heart and assists generally in
maintaining the digestive and nutritive functions.
Degeneration of the Heart Muscle
In fatty degeneration, the sarcous substance of the fasciculi is
converted into fat. In fatty overgrowths there is an excess of fat in
and about the heart.
=Fatty degeneration= is very common and is due to an interference with
the nutrition of the cardiac muscles. It is found in the impaired
nutrition of old age, of cachectic states, of grave infectious diseases
and of wasting diseases. In poisoning by arsenic and phosphorus,
intense fatty degeneration is produced. Pericarditis may be associated
with changes in the superficial layers of the cardiac muscle. Lesions
of the coronary arteries will produce this condition; also impairment
of the oxygen-carrying power of the blood. It occurs most frequently
in men after forty years of age. The affection may be either general
or local. It is most commonly seen in the left ventricle. When the
condition is general the heart is dilated, flabby and relaxed.
Microscopically, the muscular fasciculi exhibit a loss of nuclei, and
oil drops and granules appear in the fibers. The affection may be
present without any noticeable symptoms. Slight degrees and localized
fatty degeneration are unrecognizable. =Dilatation= must be present to
produce =symptoms=. This is apt to occur early. Dyspnea; asthma; cough;
angina pectoris; dropsy; slow, weak pulse; palpitation, and toward
the end, Cheyne-Stokes breathing may appear. Mental symptoms, such as
maniacal delusions, may come on and last for weeks. =Prognosis= depends
upon the cause and extent of involvement.
The =treatment= is largely that of dilatation of the heart. An effort
must be made to determine the cause, and treatment should be applied
accordingly. Considerable can be done in improving the nutrition of the
tissues of the heart by hygienic and dietetic measures. Light exercises
will often be of aid, but care has to be taken that the exercises do
not tax the patient too severely. A general treatment of the body will
be a helpful measure in invigorating the system as a whole and toning
the cardiac tissues. The diet should be nutritious; largely nitrogenous.
Raising the ribs over the heart and increasing the chest expansion will
be of help in cases where there are attacks of dyspnea and angina. Many
cases present deep seated lesions in the upper dorsal region. When
there are attacks simulating apoplexy, lay the patient flat upon the
back with the head slightly elevated.
=Fatty overgrowth= is associated with general =obesity= and sooner
or later this infiltration impairs the nutrition of the cardiac
muscle and true fatty degeneration results. This form occurs more
frequently in men, and between the ages of forty and seventy years. The
characteristic changes consist of an increase in the normal fat. The
heart may be enclosed in a thick covering of fat. The fat may also be
deposited between the fasciculi, sometimes reaching the endocardium.
Fatty overgrowth is certain to exist in extreme obesity. No =symptoms=
are produced until the muscular fibers weaken so that =dilatation=
occurs. The presence of extreme obesity, combined with signs of
cardiac weakness, point to fatty overgrowth. The =treatment= of fatty
overgrowth of the heart is largely the same as that of obesity.
Oertel’s method of lessening the amount of liquids, proteid diet and
graduated exercises is effective in cases where heart compensation is
intact.
Neuroses of the Heart
=Palpitation= is a more or less rapid action of the heart, of which
the patient is conscious. There is usually an irregular or forcible
action of the heart, as well as a frequency of the heart-beat. There
is generally some local irritation to the cardiac nerves; especially
are =lesions= found to the third and fourth ribs, although a lesion
may be higher or lower in the dorsals or it may be in the cervical
area. Muscular lesions are frequent. These lesions predispose to
the disturbances of reflex stimuli, still the general health may be
so weakened or the reflex irritation so pronounced that palpitation
results independently of predisposing osteopathic lesions. Females are
more liable to be affected. The neurotic state is a common source of
the disorder. If palpitation is long continued it causes hypertrophy.
It often occurs at puberty, during menstruation and at the climacteric
period. Anemia, the acute infectious diseases, dyspepsia, disturbances
of the ovaries and other pelvic organs are common causes. The abuse
of coffee, tea, alcohol, tobacco; diseases of the stomach, overwork,
fright, grief, anxiety, and sexual excesses are causative factors.
Palpitation may be associated with organic diseases of the heart, but
as a rule it is a purely nervous affection.
The patient’s perception of the increased action and force of the heart
is the =essential element= in palpitation. The action of the heart
varies greatly and at times it may be a mere fluttering which lasts but
a few minutes. In severe cases the heart beats violently and the pulse
may be rapidly increased and reach 160 or more. The face is usually
pale, but may be flushed. The heart’s action is not increased in some
cases. The attack generally lasts only a few minutes.
The first consideration in =treatment= is to locate the disturbing
factor. Raising the ribs over the heart and lowering the first rib;
correcting the clavicle in a few instances, or inhibiting along the
upper dorsal region will usually quiet the heart’s action. Stimulation
of the vagi nerves, as they pass along the side of the neck, may be all
that is necessary; in some cases inhibition of the superior cervical
sympathetic or of the middle cervical region, acting on the depressor
nerve of the heart, will lessen the tumultuous action of the heart. It
will be recalled that either there is irritation of the accelerator
nerves of the heart or the vagus is inhibited.
All =reflex disturbances=, as a displaced uterus, indigestion, etc.,
must be removed before the palpitation can be permanently stopped.
Rest and confidence in the treatment are of great importance. A very
few cases will require a hot bath and a general treatment and possibly
an ice-bag over the heart to quiet the increased activity. In =anemic
cases= hygienic measures and a proper diet, coupled with the treatment
for anemia, are indicated. If the attack is severe, the patient should
rest in a recumbent posture and drink something warm, besides receiving
the indicated treatment. When the patient is not a decided neurasthenic
a rapid five or ten minute walk will often normalize the heart’s action.
=Tachycardia= is rapid action of the heart and commonly occurs in
paroxysms. There are no heart sensations, as in palpitation. Either
the sympathetics are stimulated or the vagus inhibited. It is not
generally related to lesions of the heart, but is in reality a
=disorder= of the =nervous system=. In some instances the condition
is physiologic. Nervous strain, in the form of =osteopathic lesions=
to the upper dorsal or cervicals irritating the sympathetic, is the
most common cause. Emotion, fright and severe exercise are other
causes. It is found in neurasthenia, anemia, hysteria and in those
using an excessive amount of tobacco, tea and coffee. =Reflex stimuli=
from abdominal or pelvic disorder, especially during the climacteric
may induce tachycardia. In exophthalmic goitre the sympathetics are
overstimulated, and in some instances the vagus inhibited, leading to
“heart hurry.” Tumors, hemorrhages, enlarged glands, etc., obstructing
the action of the vagus, are a source of rapid heart.
Sudden onset with rapid action of the heart, small weak pulse,
headache, flushed face and faintness are common =symptoms=.
The =treatment= is somewhat similar to that outlined under palpitation.
Locating the cause is the first essential. Besides removing local
osteopathic lesions, inhibition to the cervical and dorsal sympathetics
is effective. Raising the ribs over the heart will lessen the
pulse-rate.
Rest, diet and general care of the patient may be necessary. Outdoor
exercise and cold bathing are beneficial. In a few cases springing the
dorsal spine forward, raising the floating ribs, and slight traction of
the cervical spine are effective in slowing the heart’s activity. A few
cases are very refractory, especially in neurotics.
=Brachycardia=, or slow action of the heart, is the opposite of
tachycardia. In a few cases it is physiologic. It usually occurs
secondarily, following infectious diseases; accompanying nervous
disorders, as hysteria, melancholia and neurasthenia, and is associated
with diseases of the digestive organs, pulmonary disorders and toxic
effects of coffee, tea, tobacco, and drugs and the toxins of jaundice,
diabetes, uremia, etc. Obstructions to the cervical sympathetics and
irritations of the vagus, from osteopathic lesions, may be either
direct causes in themselves or predisposing factors in the above
diseases.
A =slow, weak pulse= is the characteristic symptom. The heart sounds
are feeble. When the pulse beat is below sixty per minute it is
diagnostic.
In the =treatment= of slow heart, as in the other neuroses of the
heart, the cause should be first determined. A stimulating treatment
to the cervical sympathetics and inhibition to the pneumogastric
will readily relieve many cases, at least temporarily. The lesion
may be directly to these nerves and of course removal of the same
is essential. Inhibition of the pneumogastric probably affects the
activity of the depressor nerve, and stimulation of the cervical
sympathetics, besides acting on the accelerator fibers of the heart
directly, influences the blood supply of the body and thus increases
arterial tension. Stimulation to the upper chest anteriorly and
posteriorly, over the cardiac region, will increase the rapidity of the
slow heart. Rest and care of the general health is necessary.
=Arhythmia=, or an irregularity of the heart’s action and pulse beat,
often due to lesions in the cervical region interfering with the
vagi, symis pathetic or vasomotor nerves to the heart. In a number
of cases the first, second or third rib on the left side is at fault
and a correction of it will relieve the irregularity immediately.
It is claimed that there are nerves at the fourth and fifth dorsals
that tend to control the rhythm of the heart-beat. Other causes are
organic diseases of the heart and nervous system, reflex disturbances,
excessive use of tobacco, coffee and tea.
“Normally, the contraction of the heart originates at the sinoauricular
node, at the mouth of the superior vena cava, is conducted to the
auricle, and thence to the ventricle by way of the auriculo-ventricular
bundle (bundle of His or Gaskell’s ridge). Under conditions of abnormal
stimulation, contractions may originate in the auriculo-ventricular
node in the wall of the right ventricle near the coronary sinus; or in
the auriculo-ventricular bundle on the ventricular side of the node; or
in the auricular tissue itself.”—Clinical Osteopathy.
Fibers from the right vagus pass to the sinoauricular node, and from
the vagus to the auriculo-ventricular bundle. Lesions of the upper
three cervicals may readily disturb the vagi through circulatory and
chemical sources as well as through the communicating branch of the
second spinal nerve. Thus the rhythmic power of the heart, rate and
strength, and conductivity of impulse may be readily influenced, which
is borne out by clinical experience.
There are several forms of irregular heart action. For a description of
same it is probably best to refer the student to special works.[103]
The more common forms are =Sinus= Irregularities, the =Extrasystole=,
=Paroxysmal Tachycardia=, =Auricular Fibrillation=, =Auricular
Flutter=, and =Heart-block=. =Pulsus Alternans= is a rare form, and is
of grave significance when the heart muscle is degenerated. A knowledge
of =auricular fibrillation= is of special value, for it is a common
form and often indicates a serious condition.
Most of the irregularities are not of special pathological importance,
providing the heart muscle is healthy. They are best studied through
instrumental means and require considerable experience in order to
determine the exact condition.
Frequently, unnecessary worry has been the result in discovering
irregularities in the young as well as in otherwise healthy adults.
Only when the cardiac muscle is diseased or degenerated through various
infections and toxic properties in the blood should they receive
unusual attention.
Dorsal and lower cervical lesions that affect the heart by way of the
sympathetics no doubt disturb nutrition of the heart tissues. And
lesions of the vagi, particularly of the upper three cervicals, will
disturb the rhythm, rate, strength, and conductivity of the impulse
through auricles and ventricles. In no other organ of the body will the
osteopath be better rewarded for careful and painstaking work than in
normalizing the stimuli from sympathetic and vagi that influence the
heart. Stimulatory and inhibitory efforts will frequently suffice, but
in our judgment it is always better to secure interosseous adjustment
if possible.
Though a number of individuals with heart irregularities are of a
neurotic type, that predisposes to nervous disturbances of various
kinds, still it would be an interesting study, especially in cases of
children, to note what percentage are the result of upper cervical
lesions caused by birth injury.
Angina Pectoris
=Angina pectoris= is characterized by pain in the cardiac region which
usually extends to the inner side of the upper arm and forearm. “This
region corresponds to the peripheral distribution of the lower cervical
nerves (6th and 7th in the arm) and the upper three or four dorsal
nerves (in the upper arm and the chest).”[104] Occasionally similar
areas of the right side are affected, and in a few there is pain in the
lower jaw and back of the ears. “The starting of the pain is usually
across the chest, about the level of the third ribs, or as low as the
fifth ribs,” although the inception may be anywhere in the left chest
or the arm. The duration of the pain is from a few seconds to several
minutes; sometimes it may remain for several hours.
Osteopathic lesions are invariably found in the upper dorsal, including
ribs, or lower cervical region, which are predisposing factors that
tend to exhaust and weaken the cardiac muscle, and disturb the coronary
circulation, so that resistance is lowered. Thus toxic agents and
infections may readily involve the cardiac tissues. Many cases present
more or less arteriosclerosis, which involves the heart and affects
its circulation. Inflammation of the root of the aorta from syphilis
is a frequent cause. Valvular heart disease and chronic nephritis
are other underlying factors. Worry, strenuous living, and continued
physical strain are to be considered. There are a group of cases, that
are comparatively mild and frequently found in women, that are of
toxic origin, due to intestinal stasis as a result of constipation,
adhesions, etc. The ileo-cecal section is commonly involved in these
instances. Focal infections may be an exciting cause.
The =osteopathic lesions= undoubtedly affect the cardiac innervation,
particularly vasomotor and trophic, thus leading to consequent
disturbances of cardiac circulation and resulting irritation to the
ganglia. Sclerosis and spasm of the coronaries, ischemia, cramping,
exhaustion, and degeneration of the heart muscle, and cardiac
neuralgia, are various results that may take place.
The =paroxysm= usually begins suddenly, often during exertion or
intense mental emotion. The pain is agonizing and of a grip-like
character, and there is a feeling of impending death. The intercostal
muscles are constricted and there may be a feeling of suffocation. The
pains radiate up the neck and down the arm, and may be accompanied by
numbness or tingling. There is usually extreme pallor, and the skin
is ashen. Sweating is not uncommon, and dyspnea may be present. The
attacks occur at intervals, varying from a few days to many years.
After the paroxysms there is instant relief.
Other cases may present less severe attacks.
In the =diagnosis= the only condition with which true angina pectoris
is liable to be confounded is pseudo-angina pectoris. =Pseudo-angina=
or hysterical angina occurs chiefly in women or in neurasthenic men.
These cases are often excited by toxemia. The attack usually occurs
at night and is unassociated with organic heart disease. There is a
feeling of cardiac =distention instead of constriction= as in true
angina. There is emotional excitement and the attack lasts one or
two hours, which is usually longer than that of true angina. The
=prognosis= is unfavorable, although many cases live for a number of
years. A few cases have recovered under a thorough course of treatment.
The =treatment= of angina pectoris consists in correcting the
disordered upper dorsal vertebræ, the upper left ribs over the heart,
and the lower cervicals. Invariably lesions are found in this region
and if the treatment is applied to correct these disorders, the attack
can frequently be relieved. By following up the treatment during the
intervals, a number of cases can be practically cured. A common lesion
found is a slight lateral curvature in the upper dorsal region. This
curvature is oftentimes great enough to cause a subdislocation of
several of the ribs, which certainly complicates the derangement, at
least as far as a quick cure is concerned.
=During= the =attack= raise the ribs over the heart at the point of
constriction so as to relieve the impinged nerve fibers. Hot drinks
are of value. The vagi and phrenic nerves may also be at fault in some
cases. The sensory nerves to the heart are from the first, second and
third dorsals.
Ice-bags or heat applied locally will be a helpful measure. In cases
where there is high arterial tension, an inhibitory treatment to
the upper and middle cervical regions will be of special aid, as it
relieves this tension by affecting the vasomotor nerves. This treatment
will at least overcome the =vasomotor form= of angina pectoris. Hot
foot-baths and friction will also be found of value. In many cases
under forty or forty-five syphilis is a cause. In cases past middle
life there is often organic disease of the circulatory organs.
The patient should at all times avoid any excitement and live a very
quiet life. He should take frequent vacations. He should take the best
of care of himself and his food should be nutritious. In pseudo-angina
the treatment is to relieve the irritation to the nerves affected as
well as the underlying affection.
FOOTNOTES:
[100] Journal of the American Osteopathic Association, April, 1906.
[101] Valvular Heart Diseases, A. O. A. Journal, March, 1905.
[102] Journal of Osteopathy, February, 1904.
[103] Mackenzie, Diseases of the Heart; Lewis, Mechanism of the Heart
Beat; Macleod, Physiology and Chemistry in Modern Medicine.
[104] Mackenzie, Oxford Medicine, Vol. II.
DISEASES OF THE ARTERIES
Arteriosclerosis
(ATHEROMA)
This is a thickening of the intima of the arteries, due to an
inflammatory increase of the connective tissue, associated with more or
less fatty degeneration and calcification.
Old age, alcohol, lead, gout, syphilis, rheumatism and other
infections, laborious work, overeating, nephritis, and calcareous water
tend to produce the condition. =Excessive eating= and =drinking= are
common causes of both atheroma and chronic renal diseases and should
always be regulated. Physical overwork, chronic intoxications, etc.,
produce hypertension of the vascular system and thus lead to changes
of the vessel walls. A rigid spine is invariably found; this may be
a causative factor in itself, or an associated condition. All of the
above list of causes are important.
=Pathologically=, the arteries are thickened, tortuous and rigid.
The intima may be occupied by rough, calcareous plates. In extreme
cases the sub-endothelial tissue undergoes degeneration and breaks
down in spots, forming “atheromatous abscesses.” The disease may be
=circumscribed= or =diffuse=; in the latter there is a widespread
distribution of the affection. Owing to the general effect, the
heart, liver and kidneys receive less blood and tend to atrophy.
Microscopically, there is found more or less fatty degeneration of the
different coats, and an overgrowth of connective tissue in the intima.
The arteries most frequently affected are the aorta and coronary.
=Symptoms.=—=Circulatory.=—There is a high tension pulse and
accentuation of the second aortic sound. There is also dyspnea, severe
pain in the left side, palpitation, pallor, and the left ventricle
is hypertrophied. =Cerebral.=—Such symptoms as headache, tinnitus,
aphasia, vertigo, syncopal or epileptiform attacks may be present.
=Renal.=—There is an increase in the quantity of urine, which is of a
pale color and low specific gravity; at times it is albuminous. The
disturbance leads to atrophic nephritis. There may be gastro-intestinal
symptoms, as constipation, pain, etc., due to hardening of the
splanchnic vessels. In some cases the peripheral arteries become
obliterated. The veins become hardened.
=Sequelæ= are cardiac dilatation, heart failure, paralysis, apoplexy,
fatty heart, aneurism, contracted or senile kidney, angina pectoris,
and in extreme cases, gangrene of the extremities.
=Diagnosis.=—The characteristic symptoms are hardened arteries,
high tension of the pulse, hypertrophy of the left ventricle and
accentuation of the aortic second sound. The average blood pressure is
from 160 to 180 mm. of mercury, though it may be considerably higher.
=Prognosis.=—Many cases can be greatly benefited by osteopathic
treatment, and at the incipiency the improvement is generally marked.
It usually runs a very chronic course.
=Treatment.=—The treatment must necessarily consist, principally, in
the removal of such conditions as are producing the degeneration.
The rigid spine should be carefully treated by methods (preferably
traction) that overcome the contractures and release the intervertebral
discs. The dorsal and lumbar areas, and the abdominal organs should
receive special attention. Outdoor life and plenty of rest are
important. Alcoholism, gout, rheumatism, syphilis, etc., must be
remedied before there can be much change in the arteries. Freeliving
and all excitement must be stopped. The patient’s cooperation is
invaluable. A milk diet is often beneficial. Besides treatment of
the primary disease, a general treatment will be of much avail in
equalizing and reducing arterial tension. Brunton[105] speaks of
cases of atheroma being cured by exercise and manual treatment to the
rheumatic joints themselves. One, apparently suffering from senile
dementia, was much improved after two years of this treatment applied
to the joints, and showed benefit to the cerebral circulation. The
bowels and kidneys should be kept active, and the general health of the
patient carefully watched. Keeping the skin active by daily baths is an
essential factor in the treatment. Very frequently the disease is not
only retarded, but improved. In high blood pressure venesection may be
of benefit.
FOOTNOTES:
[105] Lectures on the Action of Medicine, p. 343.
DISEASES OF THE BLOOD
BY EARL R. HOSKINS
=General Considerations:=—It has been said that each individual is
a part of all the generations which have preceded him. In the same
way it might be said that every drop of our blood is a part of every
other cell in our bodies. The other tissues are able to maintain their
existence only through the ministrations of the blood and in turn
the blood derives its own substance from tissues which it supplies.
We are accustomed to speak of certain organs as being those of blood
formation, yet it is true that every tissue furnishes its quota of
blood composition, making up the mass which we call blood.
It is in one way an algebraic sum of good and baneful substances,
without which there can be no normal function, and sometimes being of
itself a menace as well as an aid to other tissues, as in sepsis. There
can be no perverted function of any tissue without there being a direct
effect upon the blood. We may not always be able to measure this effect
with our present laboratory methods. We may not be able to detect
clinically the result of this alteration of the blood stream because of
compensatory influences, dilution, phagocytic action, enzymatic action,
oxidation, and the intricate processes of excretion. It must also be
remembered that normal blood is not of a certain definite chemical or
physical composition. It must vary from minute to minute according to
the normal metabolic phenomena which make up our succession of events
associated with life.
But comparatively little is known about this most important fluid. We
have accumulated data regarding morphology and relative numbers of
its formed elements and their behavior when sufficient abnormality is
present to upset their wonted balance of arrangement. We have an ever
widening field of investigation in the blood plasma in which we are
constantly being told of newly discovered complexities. Certainly the
field of the unknown is big enough to contain our unexplained blood
reactions.
It is probable that as our knowledge increases our number of diseases
really considered as true blood diseases will decrease and be shown to
be the effect of blood passing through certain pathologic tissues of
the body. We can measure the number and proportion of formed elements,
and the relative efficiency of the erythrocytes by the amount of
hemoglobin which they carry. The genesis of the formed elements is to
be kept in mind in considering therapy. The erythrocytes and granular
cells developing in adult life, principally from the red marrow, leads
our attention in decrease or increase of these particular cells to the
greatest aggregation of red bone marrow which happens to be in the
ribs. The anatomical relation of the ribs to the spine would seem to
render them very liable to disturbances of nutrition and nerve control
as a result of structural maladjustment and clinically this presumption
is verified. Limitation of the motion of the thoracic spine is perforce
accompanied by costal inactivity with disuse effects upon the red
marrow and eventually upon the relative content of the blood stream.
We can measure the efficiency of the erythrocytes in carrying oxygen
to the tissues by measuring the relative amount of hemoglobin which
a given volume of blood contains. The actual changes taking place in
blood character are often thus sufficiently indicated for us in terms
of our present methods of examination, to at least aid in the arrival
at a diagnosis. We sometimes have to remember that the adaptation to
abnormality may be efficient enough to keep the apparent significance
from telling the “whole truth.”
The Anemias
The class of diseases which are referred to as the Anemias are those in
which there is an actual, or apparent, decrease in the oxygen carrying
element or hemoglobin. This may not be due to an actual decrease in
amount of hemoglobin, but rather to a decrease in the ability of
the red cells to carry it. This decrease in ability may be due to
alteration in the erythrocytes themselves, or to effects of change in
the molecular concentration of the plasma in which they are suspended.
The plasma may also contain certain poisons probably protied, which
may make impossible the efficient carrying of hemoglobin by the
erythrocytes.
The simplest form of anemia is that due to removal of a large
percentage of erythrocytes from the body. This condition is fulfilled
in acute hemorrhage. If the amount of blood lost does not exceed the
amount necessary to maintain circulation, roughly fifty per cent of
the total quantity, the fluid portion lost is quickly replaced from
the fluids of the body and from material ingested. The formed elements
and proteids are less rapidly replaced by a compensatory increase in
function of the hematopoietic tissues so that there is a gradual return
to the original number and proportion.
A blood cell may be considered as passing through a life cycle of
infancy, adolescence, maturity, and senility before it is finally
destroyed. If the demand for new cells is not too great it will be met
with mature cells. If the call is more urgent, younger and older cells
will both be put into the conflict, while in a time of extreme stress
all types of cells, from the “school boys” to the “gray-beards”, will
have to be utilized to maintain life. So, roughly, we can judge the
severity of the anemic process by the reaction which the body makes to
it as indicated by the character of the cells in service.
The pigment, hemoglobin, is slowly regenerated even as compared to
erythrocytes, so that the color index is usually the last finding
to return to normal after a hemorrhage. The leucocytes are usually
increased after hemorrhage, probably as a protective mechanism, nature
having learned by hard experience that she has less resistance to
infection, when there is loss of a considerable quantity of blood.
To be considered, also, is the fact that constantly blood cells are
outliving their usefulness—some must be disposed of. The extra function
required of these older cells gives the same results as over work
upon an old man—hurries his time of demise so that there is a greater
percentage than usual to be sent to the salvage shops. The regeneration
of blood after hemorrhage depends upon the severity of the loss, the
nutrition, upon the treatment given, and indirectly the ability of
resistance developed by the patient.
In the chronic anemias we may have either defective development of
erythrocytes, or defective function of them, or a relatively too great
destruction of these same agents.
A bank account may be depleted either by too small deposits to account
for current expense, or by extravagant withdrawals. It is sometimes
difficult to determine on which side the fault lies. It seems to be
nature’s plan not to subject to active work an erythrocyte until after
the nucleus has disappeared, judged by ordinary methods of staining.
A sudden call for an increased number of erythrocytes may force the
organism to send in some with nuclei, but the circulation does not
receive those which have not been standardized, as to shape and
staining reaction, unless the crisis is of grave import. Evidence of
increased destruction of these cells is shown by broken forms—shadow
forms, and by an increased excretion of the pigments derived from the
breaking down of hemoglobin, namely bilirubin and urobilin. A great
deal of information can be obtained by a study of the other formed
elements of the blood.
In general the symptomatology of all the anemias will be that of
lessened metabolism because of deficient oxygenation. This is
accompanied by imperfect nutrition and general impairment of function.
Among the usual results are muscular weakness, malaise, headache,
dizziness, anorexia, and cutaneous and membranous pallor, with tendency
to local hemorrhages. The heart is often rapid, easily disturbed in
rhythm, may possess a hemic or functional murmur, and gives a soft
compressible pulse of low pressure. As a compensatory attempt the
respiration may be rapid, but is likely to be shallow, and dyspnea
results from disproportionately small exertions.
There may be either troublesome constipation, or diarrhea; often there
are alternating periods of each. In the severer forms convulsions,
coma, delirium, stupor, localized edema of the ankles or eyelids may be
seen.
In general the treatment of the secondary anemias will concern the
removal of the cause followed by measures tending to increase the
decreased element or elements in the blood stream. In the anemia
resulting from hemorrhage the thirst which follows is the body’s
method of calling for more fluid with which to maintain pressure in
the arteries and capillaries sufficient to develop new formed elements
to take the place of those lost. If the loss is severe enough to give
rise to shock, emergency measures are necessary of introducing into
the venous stream an artificial fluid to make up for the fluid part of
the blood lost. If the condition can be predicted and a suitable donor
obtained, blood transfusion is of greatest advantage to the patient.
More often the urgency of the condition will require an artificial
fluid to be given in haste. Probably the best so far devised solution
is Fischer’s physiological salt solution. In the anemias due to chronic
metal poisoning as from lead and mercury, or from systemic poisoning
such as syphilis or malaria, or from the retention of metabolic
products as in some of the diseases of the kidneys or of the liver,
the anemia can only be successfully treated by normalizing its primary
cause—as it occurs in the role of a symptom or result, and hence is
only indirectly a blood condition.
Costogenic Anemia
(BURNS’ ANEMIA)
Costogenic Anemia is a result of functional disuse-atrophy of
the hematopoietic organs, there being an insufficient supply of
erythrocytes to meet the demands of the metabolism of the body. It
results from insufficient opportunity for nutrition and drainage of the
red marrow of the ribs, and gives the clinical picture of an anemia due
to too slow production of erythrocytes.
=Etiology.=—The condition is predisposed to by any factor which tends
to limit the action and nutrition of the ribs. We are too prone to
forget that the function of the ribs is to produce erythrocytes; it
is really a matter of secondary importance that they make up part
of the thoracic wall. The change from the horizontal to the upright
position has tended to a drooping of the whole chest from gravity. The
human animal seldom develops the free hinge rib motion as often seen
in quadrupeds. The passage of both arterial and venous blood, is not
normally free and copious, and as a consequence the tissue supplied
functions less efficiently. This function of the red marrow is to
produce erythrocytes. Any structural lesion of the dorsal vertebral
column, or its costal articulations, which interferes with the free
motion of the rib thus interferes directly with the efficient function
of these particular ribs. The severity of the condition varies with the
number of ribs affected and the impedance to nutrition and drainage.
=Diagnosis.=—The condition may be of gradual onset, and may be
associated or coincident with some other condition leading to a loss
of tone or opportunity for free rib action. The systemic symptoms are
due to a deficient oxygenation of all tissues as a result of the above
disuse. The thorax is usually rigid—forced respiration requires unusual
effort without proportionate thorax expansion. The type of breathing
tends toward diaphragmatic. The quantities of tidal and supplemental
air are both markedly decreased. The lack of tissue oxidation renders
elimination less active, hence constipation. Gas accumulation,
weakness, insomnia, with slightly increased amount of urine, and low in
total solids, is the rule.
“The blood itself is rather characteristic. Coagulation time is
increased; specific gravity and viscidity diminished; red cell count
normal or only slightly diminished; hemoglobin 6 to 10 grams per
100 c. c. of blood (Meischer); 40% to 80% (Dare). The red cells are
small, pale, vacuolated, sometimes nucleated. The white cell count is
normal, slightly increased or slightly diminished. The hyaline cells
are normal, or slightly relatively increased. (These, being formed
in lymph nodes, tonsils, etc., are not affected by rib changes.) The
mononuclear neutrophiles are relatively increased. The nuclear average
of the polymorphonuclear neutrophile is low. Vacuolated and atypical
neutrophiles are often found. Basophiles, myelocytes and amphophiles
may be found in considerable numbers. Nuclei in all granular forms
present evidences of immaturity or degeneration—they may be swollen,
vacuolated, extruded, ragged, or with variable staining reaction”
(Clinical Osteopathy).
=Treatment.=—The treatment is to obtain a normal function in the
inactive tissues. This is done by getting better rib hygiene. Whatever
is interfering with rib function and metabolism is to be removed.
Breathing exercises are given not only to “ventilate the thorax, but to
exercise its walls”. Carefully selected horizontal bar work is often of
great value. The diet should be of such nature as to supply material
for manufacture of erythrocytes and for loading them with hemoglobin as
well. Hence the foods with high chlorophyl or hemoglobin content should
be emphasized.
=Prognosis.=—This depends on patient’s desire for improvement of his
condition. He can be improved by correction of whatever lesions there
may be interfering with his freedom of thoracic motion. He can be
benefited by manipulations which adjust the ribs, but his cooperation
is essential. Lack of cooperation on the part of the patient, which
would tend to increase the mobility and metabolism of the ribs, renders
him more liable to any of the intercurrent pulmonary infections, as a
result of his deficient thoracic ventilation.
Encourage free thoracic respiration especially when in school, or when
under conditions which ordinarily would tend to slovenly habits of
breathing.
Chlorosis
(GREEN SICKNESS)
An anemia characterized by great reduction in the amount of hemoglobin.
It most frequently occurs in adolescent girls. It seems to be
associated with neurotic manifestations and menstrual irregularities.
=Etiology.=—Its cause is not well understood. Poor hygienic conditions
may be a factor, but it is a condition found in all stations of
life. The age and sex have led to investigation as to probability of
lack of an ovarian internal secretion. The reports of workers are
contradictory. The name of the condition is derived from the color of
the skin, which usually ranges from a pale greenish tint to a slight
pallor. Occasionally there is localized vasodilation of the cheeks
giving brilliant color. Constipation accompanied by copremia seems to
be either a causative factor or result. In many cases it appears to act
in the dual role. Fixation of the middle and lower ribs accompanied by
osteopathic lesions from the mid to the lower dorsal spine seem to be
constant findings. The costal fixation leads to lessened respiratory
excursion and resulting diminished oxygenation.
=Diagnosis.=—Chlorosis may be suspected from the color of the skin,
perverted appetite, wandering neuralgias, heart palpitation, edematous
infiltration, and shallow type respiration, but the diagnosis is not to
be made without the aid of the blood count. The striking part of the
blood picture is the great reduction in amount of hemoglobin carried by
each erythrocyte. There is usually some reduction in the erythrocyte
percentage but not in proportion to the decrease in color index.
There are usually many pessary-shaped and shadow erythrocytes. These
are of all sizes, but seldom is the condition of such gravity as to
cause more than an occasional nucleated red cell, and when found
are most likely to be normoblasts. The staining reaction is of wide
limits. Cells of all degrees of relative alkalinity are found and often
there is a wide variation of staining reaction in the same cell. The
number of erythrocytes is usually slightly decreased but not in the
proportion that the hemoglobin percentage is, so that the color index
is therefore strikingly low. Probably, the average color index for a
typical case of chlorosis is 50, with an erythrocyte count of 4,000,000
and a hemoglobin of 40 per cent (Dare.) This drop in color index in
chlorosis is far out of proportion to the clinical symptoms which would
be expected from a similar reduction resulting from the ordinary causes
of secondary anemia. The blood plasma is increased and the specific
gravity is lowered, sometimes reduced from 1.055 to about 1.030.
=Treatment.=—The treatment of any malady in which the etiology may
be apparently of widely different natures will naturally rationally
vary with the apparent cause. If there is copremia, which seems to be
a definite causative factor, this should be at once corrected. These
patients form the cathartic habit readily, so physical and dietary
methods of returning the digestive motility to normal should logically
be given first trial. If it is a matter of lessened metabolism as
a result of insufficient exercise, or blood oxygenation, outdoor
gymnastics and breathing exercises may incite the stimulus to normal
erythrocyte hemoglobinization. The diet should be of such nature as
to furnish material both for erythrocyte formation and iron in form
for ready absorption by them. The organic iron compounds of animal
hemoglobin and vegetable chlorophyl are our most common and cheapest as
well as most effective sources.
The medical treatment of chlorosis is based on the empiric use of
inorganic iron. “The exact method in which iron exerts a favorable
influence upon chlorosis still remains unsettled. It is difficult to
understand why iron salts in the food which are sufficient for all
ordinary needs, are insufficient in chlorosis. It seems most probable
that iron cures chlorosis by acting as a stimulant to the =blood
forming organs=” (Beifeld, The Basis of Symptoms.)
Clinically, osteopaths are daily obtaining rationally the necessary
stimulus to the blood forming organs by removing all impedance from
these organs caused by vertebral and costal lesions and by obtaining
better digestive and respiratory hygiene.
=Prognosis.=—Recovery is to be expected and its rate will depend upon
the thoroughness of the osteopathic work and the patient’s ability to
respond to the stimulus. The blood may show chlorotic relapses with
concomitant symptoms if in later life secondary anemia develops from
hemorrhage, hook-worm infection, or other causes.
Pernicious Anemia
This anemia is of obscure etiology, characterized by progressive
destructive hemolysis of the erythrocytes, usually with fatal
termination. The cells retain their hemoglobin carrying ability,
so that while the hemoglobin is decreased in percentage, the
proportionately greater decrease in the number of erythrocytes leads
to a marked increase in the color index. The destructive influence
upon the red cells may be sufficient to allow only a small percentage
of the erythrocytes to appear normal and show the greater number to be
deformed, or in various stages of degeneration. Cells which in times
of health would have been sent to the “salvage station” are retained
to carry an over-load for them of hemoglobin to the needy tissues.
Immature nucleated cells of all types are drawn into the battle long
before they can be efficient carriers to help supply oxygen to the
tissues. Seldom will a secondary anemia be severe enough to produce
megaloblasts in the blood stream yet they are a rather constant finding
in pernicious anemia. With these cells of irregular carrying capacity
and development, anisocytosis and polychromatophilia are expected
findings.
=Symptoms.=—The condition must be regarded as a symptom complex or
a result of pathologic process or processes. A type of anemia very
similar in symptoms and blood findings to the pernicious anemia is
produced by the toxins of advanced malignancy, and by at least two
forms of intestinal parasites, the ankylostoma duodenale and the
bothriocephalus latus. In the true pernicious anemia we have similar
results but are not able to locate the primary pathology. There are
present synchronously, enormously increased destruction of erythrocytes
and enormously increased production of them but we are unable to
determine which is primarily at fault. The belief that the cells are
more fragile and too easily broken up has led to the removal of the
erythrocyte destroying spleen in the hope that destruction would be
delayed until regeneration of even imperfect cells would balance the
need. Occasionally, the algebraic sum of regeneration and destruction
may be apparently balanced and not tell the tremendous amount of
pathology both productive and destructive, that the body is going
through.
The first symptoms are of easily produced fatigue of all the body,
brain, muscles, diminished digestive secretion, and dyspnea. As a
result of poor tissue oxygenation, fatty degeneration takes place in
the more active organs as the heart, kidneys and liver. There may be
extensive degeneration of varying areas of the central nervous system.
Some of these areas are due to hemorrhages from the general tendency to
breaking down of vessel walls. Often these areas of destruction affect
the posterior horns of the spinal cord, and, occasionally, a blood
count differentiates between similar symptoms of pernicious anemia and
tabes dorsalis. There is seldom any emaciation; usually the patient
appears “puffy” with a “pasty” color. There is variable subcutaneous
edema. The symptoms being of such wide distribution and character, the
patient is usually treated for all sorts of supposed conditions until
some one makes a blood count at a time when there is enough disturbance
of equilibrium to give the findings of pernicious anemia.
=Treatment.=—The treatment of the form due to intestinal parasites
gives striking results on removal of the causative organisms. Some
advise treating all cases having these blood findings on the assumption
that the presence of these parasites is responsible for the condition.
The treatment of the idiopathic form resolves itself into building
up the ability of the body to resist disease and the removing of all
possible agents for depressing the vitality of the body. Rest in bed
coupled with the digestible and assimilable limit of nutrition often
gives temporary improvement. Removal of questionable teeth also often
aids for a time. Correction of troublesome osteopathic lesions is often
accompanied by the same result. The symptomatic osteopathic treatment
always makes the patient more comfortable, often gives temporary
improvement, and, occasionally, has given a return to normal that has
persisted for several years.
=Prognosis.=—It is nearly always possible to obtain transient
improvement, but the pernicious anemia patient is usually dead within
two years from the time the diagnosis is well established.
The Leucemias
As a result of any inflammatory process, there is a physiological
reaction or stimulus leading to an increase in the number of
neutrophilic leucocytes found in the peripheral circulation. As long
as this increase does not crowd out other cells, red and white,
sufficiently to interfere with their ability to function there is
nothing but gain to the body of the character of more efficient
bacterial destruction. After the need for these cells has passed,
their number is decreased by destruction and the lessening of their
production, until an equilibrium is reached which will be maintained.
This same process of making and destroying is constantly going on
for all of the different classes of cells found in the blood stream.
Over-production of any type will lead to actual increase of that sort
of cell in circulation, and, if unaccompanied by over-production of
other types, will lead to a relative decrease of the other elements.
It is very difficult for the body to furnish normal cells very much in
excess, relatively, of the normal number, so that when the stimulus
leading to immense over-production is at work immature cells in great
numbers are apt to be thrown into the blood stream. As an example, the
case of leucocytosis which has a white count of 60,000 is extreme and
the patient nearing death, yet it may not show many, if any, abnormal
types of cells. A case of myelogenous leucemia with a white count of
60,000 would not be proportionately sick, and would be a mild case—yet
the greater part of his white blood content would be made up of cells
not found in normal blood. The leucocytosis patient is suffering more
from the =cause= of his increase in number of cells, while usually the
leucemia patient suffers because =of= the increase of cells. In one,
the cause is usually extrinsic, and, in the other, it is intrinsic as
far as the blood is concerned.
In general, then, the symptoms of a leucemia parallel in intensity the
increase in cells. It takes energy to make these cells—other tissues
are made to suffer from lack of this energy. Erythrocytes and white
cells cannot occupy the same space at the same time. The increase
in white therefore crowds the red cells out of function. Disease in
relative and absolute content of erythrocytes decreases the oxygen
carrying capacity of the blood stream. Hence, metabolism of the whole
body suffers. Often, then, the whole apparent symptomatology of a
severe leucemia is that of a secondary anemia.
The primary pathology is of hyperplasia of the particular genetic
tissue of the type of cells which are in excess, and is proportionate
in amount to the excess developed.
Splenomedullary Leucemia
(MYELOID LEUCEMIA; MYELEMIA)
Myelemia is a disease characterized by an enormous increase in the
white cell content with proportionate changes in the spleen, liver, and
the blood marrow.
=Etiology.=—It is a disease occurring at all ages, but the majority of
cases are recognized in adult males.
Heredity, trauma to the spleen, malaria, syphilis, and rapid repetition
of pregnancies seem to be at least exciting factors. A few cases have
been reported in which tenth, eleventh, and twelfth rib lesions were
definite etiologic factors by pressure.
=Diagnosis.=—The patient goes through a period of vague, indefinite,
and wandering symptoms. General malaise, weakness often accompanied by
dyspnea, and emaciation similar in many ways to incipient pulmonary
tuberculosis, except that the slight temperature changes are not
typical. At the same time there may be digestive discomfort of
various kinds without typical pathology. Of these early symptoms the
most persistent is the =dyspnea= which is a structural result of the
increase in size of the spleen. As a direct pressure result of this
hyperplasia, there may develop dropsical infiltration of the lower
extremities and ascitic accumulation in the abdominal cavity.
With the changes in the blood itself, the blood vessel walls break down
more easily, and subcutaneous hemorrhages, epistaxis and hematemesis
are common.
In an attempt to destroy the excessive amount of white cells, the liver
may become enlarged. But this occurs later and of much less degree
than the enormous increase in size of spleen. There may be areas of
hemorrhage with resulting softening in the spinal cord. The most likely
areas to suffer are the posterior and lateral horns, with resulting
paraplegia, spastic or ataxic.
Usually, the course is slow, and the condition is truly chronic. But,
occasionally, the rapid increase and succession of symptoms, with
concomitant blood changes, change the diagnosis to acute myelogenous
leukemia.
The total cell count, red plus white, is diminished, for while there is
enormous relative increase of the white cells a greater actual decrease
takes place in the reds. This decrease in reds is partially relative
from crowding out of erythrocytes by leucocytes, but there is also
actual decrease in their formation, so that there is an actual anemia
present as well as a leukemia.
In some respects the red cells behave as in chlorosis, each carrying
a diminished percentage of hemoglobin, resulting in a low color
index. Atypical staining reactions and morphology, together with many
fractured forms, are the rule. Normoblasts are common throughout the
course of the disease, but megaloblasts seldom appear until near fatal
termination.
The changes in the white cells are enormous, both as to numbers and
character of cells found. The total white count often exceeds 350,000.
This, with the accompanying reduction in number of erythrocytes,
leads to a reduction of the ratio between reds and whites to as low
as 1 to 5 or 3, or occasionally 1 to 1. There is an actual increase
in number of all the white cells with the possible exception of the
lymphocytes. In the actual increase of polymorphonuclear neutrophiles
and eosinophiles is rendered a sharp relative decrease by the enormous
production of myelocytes. Basophiles are usually both relatively and
absolutely increased. In a white count of 350,000 it is not unusual to
have present 325,000 myelocytes, with 25,000 as the actual number of
ordinary leucocytes. There is, therefore, a =mild leucocytosis= coupled
with a =violent= leukemia. These two are combined with an =anemia= that
varies with the course of the disease.
=Treatment.=—The treatment is largely hygienic, including thorough
osteopathic attention to the lower dorsal and costal area. Symptomatic
treatment is often followed by temporary improvement both clinically
and in the blood picture, but complete recovery seldom takes place.
Occasionally, roentgen therapy has given a “cure” lasting several years.
=Prognosis= is not good. These patients are frequently carried away
quickly by some oftentimes slight intercurrent infection. Even if
carefully guarded from such, the course of the process usually leads to
death from exhaustion in two or three years.
Lymphatic Leucemia
Clinically, this is a parallel condition to myelogenous leucemia,
except that the hyperplasia of cells occurs in lymphoid tissue, and
leads to an enormous over-production of lymphocytes rather than
myelocytes. It is more readily divided into acute and chronic forms
than myelogenous leucemia from differences in symptomatology.
In the =acute form=, adolescents are usually affected, the condition
beginning with tumefaction of the lymph glands, first noted in the
cervical region, but usually a general involvement. Dyspnea results
from pressure upon trachea and bronchi by the enlarged glands of the
mediastinum. There is pyrexia of 103 to 105 degrees, intermittent in
character.
The pressure upon nerve trunks and plexuses in the thorax leads to
variable anginas distributed not only in regions actually imposed upon
but over all sorts of possible reflex paths. The blood vessels of the
skin are easily broken down so that slight injuries result in great
suggillation. The patient rapidly develops anemia, and later goes into
a syndrome similar to the cachexia of malignancy. In fact, the rapid
termination and clinical course of acute lymphatic leukemia is parallel
to the action of malignancy. Probably the condition will eventually be
properly classified as a neoplasm of the blood itself.
The =chronic form= occurs in later life, and, instead of being an
abrupt rapid process, is slow, progressive and painless. It has the
lymph gland hyperplasia, but the enlargement is so gradual that
compensation is established to a remarkable degree. It is usually a
generalized process, first noted in the cervical and axillary glands
because of their accessibility. Usually both the spleen and liver are
enlarged, but this also is a slow and later development.
There may be exacerbations of temperature, but they are not constant or
usually severe. Hemorrhages into the skin are not common, but pruritus
may be very troublesome.
The patient comes to a physician because of symptoms resulting from his
secondary anemia, dyspnea, dyspepsia, and palpitation.
The =diagnosis= cannot be made without the aid of a blood study.
The blood picture shows a severe anemia with both the number of
erythrocytes and the hemoglobin percentage very much lowered. Of the
two findings, the hemoglobin percentage is relatively more decreased,
so that the color index is markedly lowered.
In the acute form nucleated reds are common. Just before death these
may show various forms and sizes as well as the normoblasts. In the
chronic form normoblasts do not appear except as the case grows
decidedly worse. As compared to myelogenous leucemia the anemia of
lymphatic leukemia is of greater severity.
In the leucocyte count there is great increase in numbers, the greater
part being composed of the lymphocytes. The lymphocytes may be either
of the large or small variety, and occasionally are found in about
equal proportions. In contra-distinction to the myelogenous type, the
increased type of cells are of the mononuclear nongranular types. It is
not very unusual to find a well advanced case of lymphatic leucemia
without abnormal cells in the blood count, the expression of pathology
being in the shape of disturbance in number and proportion of cells
rather than in development of abnormal types. The actual number of
leucocytes does not go as high in proportion to the gravity of the
condition in lymphatic leukemia as it does in the myelogenous. In other
words, a patient with lymphoid leucemia showing a count of 90,000
leucocytes with 90% of these lymphocytes is a much sicker man than the
myelogenous case showing a 350,000 leucocyte count.
Usually there is an actual as well as relative decrease of all the
granular types of leucocytes with the polymorphonuclear neutrophiles
especially decreased.
The =treatment= is systemic and symptomatic. Recovery is not to be
expected, but these unfortunates can be made relatively comfortable and
given occasional respite by judicious osteopathic care.
Hodgkin’s Disease
(LYMPHADENOMA; PSEUDO-LEUCEMIA)
In a general way, the several conditions which are clinically
leucemia, yet do not possess leukemic blood, can be classified as
pseudo-leukemias. We do not definitely know the cause of leucemia as
yet and can but little more than speculate on the various etiologic
factors of the pseudo-leucemias.
Syphilis, malaria, tuberculosis, and malignancy are all considered as
factors, and probably certain cases can be definitely associated with
these conditions.
All of this group of pseudo-leucemias are characterized by early
swelling of cervical lymph glands, followed by general gland
enlargement, and by great destruction of the erythrocytes. There may
be metastatic-like growths of lymphoid tissue in other organs. The
enlargement of cervical glands usually begins on one side near the
angle of the jaw, and most commonly in young male adults. These glands
progressively increase in size, first are soft, then later become hard
through fibrous proliferation. Each gland tends to increase in size by
itself, not to coalesce with its neighbors, so that each separate gland
can be palpated. This is more readily done as there is little tendency
to fibrous adhesion formation to the overlying skin. These glands are
painless throughout the course of the disease, and tend neither to
caseate nor to suppurate.
The excised glands show a combined hyperplasia and connective tissue
proliferation. In the soft stage of the tumefaction, the lymphoid
hyperplasia is in preponderance, while, at the stage of hardening,
the fibrous tissue derived from the trabeculae and capsule of the
gland is in prominence. There is increase in the size of the spleen,
and occasionally of the liver, but these are never as marked as those
resulting from leucemia.
The =symptoms= are, first, those due to the glandular enlargement in
the order of: dyspnea, hydrothorax, dysphagia, ascites, swelling of the
extremities, and jaundice.
The destruction of red cells gives a resulting anemia which goes with
and exaggerates the pressure symptoms.
A process of this kind to induce such grave changes over as well
protected organs as make up the lymph system, must be virulent enough
to set up other symptoms, to be associated with those due to pressure
or to anemia. These are usually emaciation (giving greater prominence
to glandular tumefaction), cachexia, and the implantation of masses of
lymphatic tissue in organs where normally only traces of this tissue
exist.
Fever is dependent upon the disturbed thermic metabolism and may be
practically absent or subject to wide variations.
The erythrocyte count shows a progressive decrease with a greater
proportion of broken down cells and abnormal types as the condition
advances. The actual count is usually between 2,000,000 and 3,500,000
per cubic millimeter. The hemoglobin usually reduces in proportion to
the erythrocytes, so that there is little change in color index.
The leucocytes are not markedly changed in number (seldom over 10,000),
and this is often the =diagnostic= finding between leukemia and the
pseudo-leukemias. Hodgkin’s disease usually has a high percentage of
lymphocytes, so that there is an actual as well as relative decrease of
the granular leucocytes.
The =treatment= is unsatisfactory, and is in the main symptomatic.
Roentgen therapy has given temporary improvement, in some cases
lasting several years. In general the =prognosis= is hopeless, the end
occurring within four years of the time the condition is recognized.
DISEASES OF THE THYROID GLAND
Congestion
Physiological congestions of the thyroid gland are not uncommon during
puberty, painful menstruations, pregnancy, and the menopause. The
=premenstrual= congestion may persist after the menstrual function has
been established, but this is comparatively rare. When the enlargement
remains there is more or less hypertrophy, and it should receive
appropriate treatment. Upper dorsal and cervical lesions are common.
The congestion during =pregnancy= occurs in the majority of cases and
seems to be a physiological process, wherein there is more or less
hypertrophy and hyperplasia, which probably counteracts the waste
products especially caused by this state, or due to the inactivity of
the ovary. During =delivery= the gland may rapidly enlarge and remain
so for an indefinite time. It seems probable that the straining due
to labor may cause lesions of the upper dorsal and neck that will
derange the function of the organ. When the enlargement occurs during
the =menopause= special care should be taken that the goiter is not
malignant.
Other possible causes of congestion are overfatigue, particularly when
associated with heavy lifting; tight clothing about the neck; overuse
of the voice; and in a few cases it may be discovered in boys at
puberty.
The =symptoms= are congestion, the gland being very vascular, either
soft or tense, somewhat painful owing to the tension of the capsule,
and in persistent cases there may be hypertrophy and hyperplasia. The
treatment is the same as given under simple goiter.
Inflammation of the Thyroid
Inflammation of the thyroid is not of frequent occurrence. In the
several cases that the authors have seen there was some previous
enlargement of the organ, which probably caused a =lowered resistance=
of the local tissues. There is almost invariably some infection
elsewhere in the body. The exciting causes are usually streptococcus,
staphylococcus, or bacillus coli. The inflammation may follow
pneumonia, tonsillitis, rheumatism, typhoid, puerpal infections,
enteritis, diphtheria, influenza, mumps, etc. Trauma, carrying weights
on the head, and cold, may be etiological factors.
Commonly, one lobe is involved, though the entire gland may be
affected. There is swelling, the capsule is distended and painful, and
small hemorrhages occur which in the case of suppuration form the site
of the abscess. The swelling involves the parenchyma and interstitial
tissue.
The =onset= is usually sudden with chills, fever, and pain over the
glands. The patient keeps the head flexed to release the muscular
tension, swallowing is painful, and there is a sense of constriction.
A rapid heart may be a prominent symptom. Much depends at this period
on the =treatment= given. If the drainage can be freed, by lowering the
first ribs and raising the clavicles with attention to the dorsal and
cervical innervation, prompt subsidence of the condition commonly takes
place. This should be carefully accomplished in order not to bruise the
parts.
=Diagnosis= is not difficult as a rule. The symptoms and history of
infection will generally suffice. Hemorrhage may occur in a goiter and
somewhat simulate inflammation. A possibility of =malignancy= is to be
considered.
If the condition does not yield to treatment, surgical interference may
be necessary.
=Tuberculosis= and =syphilis= of the thyroid are rare conditions.
=Woody thyroiditis= may be mistaken for malignancy. The gland
is very fibrous, and when cut has a dry surface. The connective
tissue is hardened and crowds upon the parenchyma. This condition
is usually found in young men. It develops rapidly, with more or
less pain and dyspnea. =Adenocarcinoma=, =carcinoma=, and =sarcoma=
are rare diseases[106], still one should be on his guard as to
their possibility. They are most apt to occur after forty. A rapid
enlargement should be regarded with suspicion.
Simple Goiter
We employ the term simple goiter to designate chronic enlargement of
the thyroid gland not due to inflammation, exophthalmic goiter, or
malignancy, although the latter conditions are frequently associated
with or follow the former. There is usually an enlargement of the gland
in cretinism, and occasionally in myxedema, but the functional grade of
the gland is far different from that in other diseases of the thyroid.
The disease is very prevalent in certain regions of Europe and
Asia, although in the United States it is not so common, except
in the environs of the Great Lakes, the District of Columbia, and
the Northwest states. The second decade of life, probably owing to
adolescent changes, especially in girls, develop the greater number of
goiters. It is infrequently congenital, and occasionally a case will
develop as early as four or five years of age.
=Etiology.=—Disturbed innervation of the gland unquestionably seems
to be the predisposing cause of the deranged secretion and vascular
changes, which if continued finally lead to hypertrophy and hyperplasia
of the tissues. These lesions are found from the fifth dorsal to the
occiput and to the corresponding ribs. They probably involve secretory
fibers of the sympathetic that emerge from the upper dorsals, first to
fifth inclusive, maximum effect second, third and fourth. “Evidence is
presented that the impulses pass to outlying neurones whose cell bodies
are located close below the superior cervical ganglion and also in the
inferior cervical ganglion.”[107]. In both these ganglia impulses to
the thyroid pass from preganglionic fibers to the outlying neurones.
This also includes the area of vasomotor[108] innervation of the head
and neck.
In a number of cases cervical lesions alone will disturb the thyroid
innervation, especially from the second to fourth segments. These may
involve the superior cervical sympathetic, owing to its relationship
to the rectus capitis anticus major muscle. Then there are afferent
association fibers that pass down through the lateral horns and whose
connecting fibers emerge via the upper dorsal.
The lymphatic drainage of the thyroid should not be neglected.
Lesions of the upper ribs and clavicles are very prone to impede its
circulation, and thus predispose to secondary infections.
Infection from septic foci are important secondary factors. This is
particularly true of focal infections of the upper respiratory tract
and buccal cavity, although infections and toxins from various regions
may be exciting factors. Toxemia due to intestinal stasis is not rarely
an important consideration.
McCarrison insists that infection from certain waters is the cause of
goiter. He finds that boiling the water renders it harmless.
=Pathologically=, the first effect upon the gland is to lessen its
iodine content. The circulation is increased, with hyperplasia of
the epithelial tissue, and a lessened amount of colloid material.
If the condition continues, the alveoli will again become distended
with the colloid material so that the epithelial tissue cells are
almost flattened. This represents the so-termed =colloid goiter=. The
gland, commonly the whole organ, though one side may be involved, is
fairly uniform in size. In rare instances, the gland may surround the
trachea—the so-termed circular goiter. Hemorrhages may occur, and there
may be various alterations and degenerations. When the vessels are
much dilated, it is often called a vascular goiter, though the colloid
changes are present.
The =nodular goiter= is another form characterized by new formation of
gland tissue that is not diffuse but circumscribed. These cases are apt
to follow persistent involvement of the gland at puberty. The two forms
may occur together, and there may be various combinations and changes.
In the nodular goiter there is comparatively little colloid. There are
many blood-vessels, and small hemorrhages are frequent. This latter
point should be remembered by those who treat over the gland, which at
best is a doubtful procedure. Various changes may take place, as local
points of =necrosis=, =cystic= formation, and =calcification=, are not
uncommon.
=Symptoms.=—The essential feature in goiter is distension of the
alveoli and formation of new ones, associated with dilated vessels, and
usually degeneration of the colloid. Often the function of the gland
is not noticeably disturbed. Usually, it is for the pressure symptoms
or the unsightliness, due to the distension, that the patient seeks
relief. Pressure upon the windpipe, gullet, or blood-vessels is not
rare, and may cause more or less difficulty in breathing or swallowing.
Coughing and huskiness may be troublesome. The recurrent nerves and
vagus may be compressed. Disturbance of the heart, such as palpitation,
tachycardia, and hypertrophy may be caused by the effect of pressure
upon the blood-vessels, or to changes in the secretory function of the
gland.
=Treatment.=—Adjustment of the upper dorsal and cervical lesions will
be followed by recovery in the majority of cases. Dr. Still emphasized
the point that the vertebral ends of the first ribs are frequently
displaced upward and outward. This lesion is often found in cases
following confinement. The effect of the change here is probably to the
stellate ganglion, or to the lymphatic drainage of the gland. Treatment
over the gland should be cautiously given, if at all. Definite
correction of the lesioned vertebræ and ribs will be sufficient, but
muscular manipulation and halfway measures are practically useless.
Lesions of the lower spine may be the primary source of a compensatory
lesion of the upper dorsal, or they may derange the pelvic organs, or
be the predisposing factor of intestinal stasis. Attention to possible
focal infections, and thorough elimination, are to be considered. In
goitrous regions boiling the water is of value. In obstinate cases the
X-ray may be of service, and as a final resort surgery may be employed.
“Marine observed that the amount of iodine is inversely proportional
to the degree of hyperplasia of the gland, and when the hyperplastic
condition becomes fully developed, scarcely a trace of iodine is
contained in the gland. Later, when the hyperplasia gives place
to colloid goiter, the iodine increases again, both absolutely and
relatively. Moreover, it has been found that if iodine be administered
to an animal suffering from hyperplasia, the hyperplastic condition
very quickly disappears and the animal becomes normal.”[109]. His
viewpoint of the hyperplasia is that an effort is being made to
compensate for an “insufficiency due to inability to absorb or
assimilate sufficient iodine”, and thus the effect of the administered
iodine is to normalize the gland by stimulation.
No one can question that this may be effective under certain
conditions, particularly where there is deficient iodide in the water,
but it is an essential element of the body. But it does not necessarily
follow that because in thyroid disturbance the relationship between
thyroid functioning and the substance containing iodine is upset that
recovery depends upon furnishing more iodine to the body economy. It
may be somewhat parallel to giving iron in anemia, when often the
real difficulty is one of assimilation, and not insufficient iron
in the alimentary canal. Moreover, case after case of goiter has
recovered through osteopathic measures following a most thorough trial
of the iodine treatment. It is very obvious that the cause of the
goiter rested elsewhere. Dogs are susceptible to thyroid enlargement.
Lesioning of the cervical region has resulted in goiter formation,
and recovery has followed adjustment of the lesion. And dogs having
goiter without experimental lesions have frequently been normalized by
adjusting an abnormal cervical spine.
Exophthalmic Goiter
In exophthalmic goiter there is an excess of the thyroid secretion or
thyroid autacoid which passes into the circulation, due to hypertrophy
or hyperplasia of the secreting cells. The disease is characterized
clinically by nervousness and irritability, rapid pulse, flushed and
moist skin, tremor, and increased nitrogenous metabolism. A goiter
is usually present, but not always noticeable. There is apt to be
protrusion of the eyes, especially after the disorder is established,
though it may never appear. A disturbed coordination of the muscles of
the eyelid, eyeball, and orbit are frequent characteristic symptoms.
=Etiology.=—The essential factor in the cause of this disease is
probably osteopathic lesions that irritate the secretory fibers of the
thyroid tissue. These lesions are almost invariably found in the upper
dorsal, first to fifth, and most often localized at the second-third
or third-fourth segments. They are definite interosseous changes,
combined rotation and lateral flexion, and are generally very sensitive
upon palpation. The constant stimulus thus produced passes through
the sympathetic fibers to the cervical ganglia, and thence to thyroid
secreting tissue, which through vascular changes and hypertrophy and
hyperplasia increases the output of the thyroid hormone.
The sensitiveness of the lesions is probably of more than passing
interest. For this actual tenderness is not to be confused with a
neurasthenic state, which may be associated with the disease, or even
be a source of confusion in the diagnosis. The lesion is of such a
distinct character that there is considerable local irritation and
congestion. This constant stimulus is a cause of the increased number
of impulses carried to the sympathetic, and results in not only an
excess of thyroid secretion and the concomitant hypertrophic changes,
but also in the rapid removal of the colloid into the circulating
blood. This seems to be a very important link in the pathologic chain.
Other underlying lesions may be present, as outlined under simple
goiter, and do not require repetition here.
The mechanism of the thyroid gland may be further upset or deranged
by various exciting causes, such as focal infections, toxic states,
intestinal stasis, and occasionally an enlarged thymus is an important
factor. An inherited neuropathic tendency, excessive strain, worry, and
mental shocks may have more or less influence in either predisposing or
exciting the disorder.
The particular points for the practitioner to remember are that
exophthalmic goiter is due to a toxic state, of which there are many
gradations, from the excessive secretion of the thyroid gland; that the
normal resistance of the gland is lowered through definite lesions of
its innervation or circulatory channels, or occasionally of lesions of
the other organs of internal secretion which are closely associated;
that infections and toxins are often important considerations; and that
direct manipulation of the organ may increase the disorder.
=Pathology.=—The enlargement of the thyroid gland is commonly an
early symptom, occurring before the nervous, cardiac and exophthalmic
manifestations. There are instances where it follows a simple goiter,
although Graves’ disease does not seem to be any more prevalent in
regions where simple goiter is endemic than elsewhere. In these
particular instances intestinal toxemia is often present. There are
cases where the gland is very slightly enlarged, containing only small
areas of hyperplasia. There is usually very little colloid, though
there may be marked exceptions. It should be emphasized that there are
various degrees of changes found in the gland though fundamentally of
the same order. The blood supply is extensive, and the veins especially
are fragile. The alveoli are distorted, due to the increase of
epithelial cells. Lymphoid nodules are frequently noted through the
glandular tissue.
Research work of unusual interest to the osteopathic physician
pertaining to the etiology and pathology of exophthalmic goiter has
been carried out at the Mayo Clinic. An examination of cervical
sympathetic ganglia removed at operation from such cases and certain
animal experimentation has given definite results. The following is a
summary of their principal findings:
“Degree of hyperpigmentation, granular degeneration, and reduction in
the number of cells was in direct ratio to the continuance of symptoms
of hyperthyroidism. The increased amount of perivascular connective
tissue generally throughout the gland was similarly in direct ratio to
the time during which symptoms of hyperthyroidism had continued.
“Increase of connective tissue in the ganglia from the chronic cases
may be interpreted as due to the irritation from inflammation, or as
merely a replacement following the destruction of the ganglionic nerve
cells.
“Ganglia were intimately connected by firm adhesions to the surrounding
tissue.
“There were changes in the outer and middle coats of vessels, and in
the nerve fibers. There was an increase of connective tissue throughout
the ganglion.
“It appears that definite histologic changes do occur as (a)
hyper-chromatization, (b) hyperpigmentation, (c) chromatolysis, and
(d) atrophy, or (e) granular degeneration of the nerve cells. All of
these are but successive steps in degeneration which, if uninterrupted,
proceed to complete destruction of the ganglion cells affected. Not
all of the ganglion cells in any of the ganglia examined were so
completely destroyed as to render improbable their return to normal
under favorable conditions. There is some evidence that in ganglia from
cases clinically improved some of the cells have partially or wholly
recovered.”[110] They are inclined to the view that local infection
in the cervical sympathetic ganglia plays an important part in the
etiology.
The above pathologic changes of nerve fibers and ganglia support in
many ways the findings noted at the A. T. Still Research Institute, not
alone in the cervical region but in other regions of the body, that is,
they are changes common to interosseous lesion pathology of various
areas of the spine, and thus are predisposing factors that establish
lowered resistance of tissue and derangement of function.
An important feature of the pathology is hyperplasia of the thymus.
Simmonds finds it enlarged in three out of four cases. MacCallum[111]
has found it enlarged in all autopsies that he has seen. The lymphoid
structures of the spleen, liver, kidneys, intestines, and bone marrow
is increased, while the lymphatic glands of various regions of the body
may be enlarged, especially the cervical, bronchial, and axillary. This
is probably due to a toxic condition.
Dilatation and hypertrophy of the heart is common, and in advanced
cases myocardial degeneration is apt to take place.
=Symptoms.=—The outstanding feature of hyperthyroidism is the excessive
secretion of the gland. The symptoms seem to be largely dependent upon
the amount thrown into the blood stream; still there is a possibility
that there may be a certain perversion of the secretion, though if
such exists it has not been discovered. It should be kept in view
that in certain instances where the secreting activity of the gland
has been markedly curtailed, by surgical means, for instance, even
to hypo-functioning there may still exist some of the symptoms of
exophthalmic goiter, which goes to show that other factors may be of
decided importance. The thymus and other related organs, as well as the
sympathetic nerves, are not to be neglected.
Kendall and Plummer (Mayo Clinic) “believe that the location of the
active constituent of the thyroid, when it functions, is within the
cells not of any particular set of organs or portion of the body, but
that it is a constituent of cellular life and activity. Plummer states
that the active constituent of the thyroid determines the rate at which
any particular cell can produce energy, that is, it establishes the
quantum energy which any cell can produce when it is stimulated, either
from within itself or from without, so that the thyroid is directly
related to the production of energy within the body. He has shown that
one-third of one milligram of the active constituent of the thyroid
increases the basal metabolic rate one per cent in an adult weighing
approximately 150 pounds.” This shows how important the secretion is
not only to all related glands but to every cell of the body, and
assists in establishing a physiological basis in the correlation of the
symptoms of both hyper- and hypo-functioning of the organ.
As a rule the =thyroid= is not greatly =enlarged=. The size, shape, and
consistency varies. It may follow a simple goiter. Many of them are
soft and yielding, or cystic; others are hard, of a fibrous resistance,
or nodular. Probably in the instances where hypertrophy is not
discoverable there is hyperplastic tissue scattered through the gland.
Or it is possible there may be an intrathoracic thyroid, or =accessory=
tissue in other regions, varying from the root of the tongue to the
aortic arch, which has become diseased. Generally, both lobes are
enlarged, though the derangement may be confined to a portion. Often
there is pulsation and a thrill over the gland. Systolic murmurs are
frequent. In the early stage of goiter, tenderness is noticeable due to
the distension of the capsule.
The =eye symptoms= are: widened palpebral fissure or Dalrymple’s sign;
failure of the upper lid to follow the downward movement of the eyeball
or V. Graefe’s sign; insufficiency of convergence of the two eyes or
Moebius’ sign; exophthalmos, which may be unilateral (in about seventy
five percent of the cases); and rareness of involuntary winking, are
the principal eye signs.
=Rapid heart= action is an early and important symptom. This is given
by all observers as the most constant of all symptoms. Palpitation is
often disturbing. The pulse is forcible, especially in the vessels of
the neck. There is generally a low blood pressure. The heart is apt to
be dilated, and in chronic cases hypertrophy and degeneration are often
found.
A =fine tremor=, eight to ten times a second, is an important symptom.
This is usually present and is considered one of the cardinal
diagnostic points.
Profuse sweating, emaciation, muscular weakness, especially of the
legs, vomiting, diarrhea, a feeling of dyspnea, and polyuria are
frequent symptoms. Anxiety, apprehension, headache, irritability, and
fatigue are often early symptoms, but care should be taken that they
are not entirely dependent upon a neurasthenic state.
Pruritus may be a distressing symptom. There may be abnormal
pigmentation. Menstrual derangements are common, especially amenorrhea,
owing to the anemia. And there may be various sexual disturbances.
Exophthalmic goiter occurs oftener in women than in men.
The disease is commonly a chronic one lasting several years, unless the
morbid cycle can be broken; still there are cases where it appears very
suddenly and runs a rapid course.
McCarrison[112] says: “Our consideration of the morbid changes met
with in Graves’ disease will have brought into prominence the fact
that they are indicative of toxic action. The lymphocytosis, the
lymphatic hyperplasia, the lymphocytic infiltration of the thyroid,
the liver and other organs; the chronic toxic inflammatory changes in
the thyroid, liver and pancreas; the changes in the muscles, in the
nervous system and in the adrenals; all these point to a condition of
chronic irritation as the underlying factor in their production, and
to the gastro-intestinal tract as the most common source of the toxic
irritant.”
=Diagnosis.=—The diagnosis as a rule is not difficult. Difficulty
may arise where there is incomplete development of the disorder.
Irritation of the sympathetic nerves is of the greatest significance,
for the characteristic symptoms are dependent upon this condition.
Neurasthenia, hysteria, paralysis agitans, and tobacco poisoning and
alcoholism may mislead one. The enlarged and active gland, with murmur
in the majority of cases, loss of weight, excessive sweating, diarrhea,
tremor, and tachycardia, even without the eye symptoms, are specially
significant. The tenderness of the osteopathic lesions is very often
noticeable.
=Prognosis.=—A great deal depends upon the cooperation of the patient.
Rest and diet are such important features of the treatment, that if
the patient is not willing to follow instructions, great difficulty
will be encountered in securing satisfactory results. Adjustment of the
lesions and elimination of toxins are highly essential, but only in a
certain number of cases will this suffice. This, however, will usually
lessen the severity of the condition, and the patient gets along fairly
well, but this may be far from securing the possible maximum results.
The duration of the disease is often from five to twenty years, or
even longer. And the patient frequently dies from some intercurrent
disease, particularly pneumonia and tuberculosis. Weakness of the heart
is the most important cause of death. Severe vomiting and diarrhea may
so exhaust the patient that a fatal termination takes place. Surgical
interference should not be too long delayed if there is no indication
of improvement by other means.
=Treatment.=—Every case requires individual study, owing to the many
possible exciting causes, especially those where infections and toxins
play so important a role. The four cardinal features of treatment are:
adjustment of the osteopathic lesions, rest, diet, and elimination of
infectious and metabolic poisons.
=Specific adjustment= of the upper dorsal spine is primarily essential.
The work should be definitely and quickly accomplished. Soft tissue
manipulations amount to but little except as a preparation for the
interosseous adjustment. Do not tire the patient. Often, following
exact adjustment a definite lessening of the severe symptoms will be
noticed. The activity of the thyroid will be appreciably decreased; the
heart’s action slowed; the eye symptoms less noticeable; the tremor
lessened; and the strength of the patient improved. Do not treat too
often. Once a week is far better than every day. But usually twice a
week in the majority of cases will secure the best results. Then later
once in two weeks will be the best course to pursue. The tissues are
irritable, and require time to establish a physiological balance, that
if kept constantly excited by too frequent or too severe manipulation
will increase rather than lessen the condition. This, however, does
not apply to those cases where a certain amount of general treatment
is demanded to improve systemic tone and overcome intestinal stasis,
but even here do not unduly tire the patient, and keep away from the
thyroid innervation except at stated intervals. There is nothing more
important in osteopathic therapy, except definite adjustment, than not
over-treating.
The cervical region should be normalized, and the upper ribs and
clavicles carefully adjusted. But leave the gland alone, for
manipulation over it further stimulates its function and there is a
possibility of rupturing its fragile vessels. Normalization of the
entire spine is important, owing to its bearing upon interdependent
relationship, mechanically and physiologically, and the necessity of
correcting all metabolic irregularities.
Both =physical= and =mental rest= are essential. This tends to lessen
the excitability of the nerves, conserves the strength, increases the
metabolism, improves muscle tone, and rests the heart. At least several
extra hours in bed is always best. Lying down two or three hours during
the middle of the day will accomplish considerable. In severe cases
absolute rest in bed until the disorder is under control is imperative.
In mild and moderate cases all excessive fatigue should be avoided.
Unless such measures are followed the treatment otherwise may not
accomplish anything. Stopping short of fatigue is the rule that must be
followed.
The =diet= is important in order that the strength may be increased
and harmful foods eliminated. If the carbohydrates in the small
intestine are not sufficient, they may decompose into toxic substances
that are harmful when absorbed into the circulation. An abundance of
green vegetables and fresh fruit is best. Milk, fermented milk, butter
milk, butter and cream are allowable. The patient should drink freely
of water. Meat should be used sparingly, and avoid tea, coffee, and
condiments.
Free elimination and fresh air are also important. It is the aggregate
of details that counts so much, particularly in such a toxic and
excitable disease as exophthalmic goiter. The neutral bath (95 to 96
degrees) is better than either hot or cold baths. In such a nervous
disease as this, suggestion is unquestionably a valuable measure in
quieting the nerves and improving the mental viewpoint.
All focal =infections=, such as often found in the throat, nose, and
buccal cavity, in the appendix region, gall-bladder, etc., should be
eradicated.
If under carefully controlled treatment the patient does not definitely
respond within from two weeks to a month, surgical measures should be
seriously considered.
Myxedema
Myxedema is a chronic disease due to loss of thyroid function, and
characterized by markedly decreased metabolism, trophic disturbances
of the skin and subcutaneous tissues, and a cessation of mental
development corresponding to the time of the injury of the thyroid.
McCarrison restricts the term “cretinism” to those cases where there
is congenital thyroid deficiency. “After the first year of life, when
ossification has proceeded to the extent of closure of the fontanelles,
the case is only distinguishable from one of cretinism by this fact.”
In the =child=, all the functions are depressed, there is a low
temperature, the bones do not develop, and the child may become stout.
The mental development is retarded, and also the sex organs.
In the =adult= cases there is the same depressed metabolism. The skin
is sallow, dry, and increased in thickness. The tongue is enlarged,
the lips thick, and the feet and hands considerably changed in size.
The nails may be thickened, and the hair falls out. The abdomen is
apt to be pendulous. Heavy pads occur below the clavicles and on the
chest, neck, abdomen, and sexual organs. Usually the thyroid cannot be
palpated. In a few, the gland may be goitrous.
The =mental= faculties are sluggish. The speech is slow, and the voice
more or less changed. Physical exertion is an effort, and the patient
may have some difficulty in walking. And there is anemia, loss of
appetite, and poor digestion. The number and character of symptoms are
innumerable, depending upon the extent of thyroid insufficiency, and
often upon predisposing and associated disorders. But the essential
symptoms are those pertaining to the skin, and the mental apathy. In
children the retarded physical and mental growth is the outstanding
condition. Development of the disorder is slow.
=Etiology.=—Lesions of the thyroid innervation may cause a lessened
function of the gland, for correction of the lesions has been followed
by markedly definite improvement in a number of cases. The disorder
has followed operation on the gland. In other cases some form of
infection, primary or secondary, is probably the cause of the injury
and subsequent atrophy. In some instances there is evidently a family
tendency. It occurs more frequently in women, and in cold than in hot
climates. The menopause seems to be a predisposing factor. Overwork,
anxiety, poor nutrition, and conditions that lower tissue resistance,
are among the etiological considerations.
In well marked cases the =diagnosis= is easy. In others the disease
may be mistaken for nephritis or jaundice. X-ray examination of the
ossification centers is of decided value. The =prognosis=, in untreated
cases, is considered hopeless, the duration being from four to seven
years. The treatment with thyroid extract, or alpha-iodine, has
resulted in marked improvement, though in severe cases it must be kept
up continuously in order to supply the deficiency.
=Treatment.=—There have been several well marked cases that have
responded to the osteopathic treatment. Adjustment of the lesions
affecting the gland, and attention to the general health have been
the methods administered. The response in a number of children has
been most notable. In fact, to such an extent that all faculties and
functions were completely recovered. Even in cases where thyroid
extract had been administered with comparatively little results, the
adjustment of the upper dorsal and cervical lesions, with attention
to the diet, elimination, and general hygiene, was followed by
normalization.
That the thyroid function when deranged, hyperthyroidism,
hypothyroidism, or otherwise, can often be recovered through
osteopathic treatment, adds a very important therapeutic measure in
the treatment of this gland. But in view of the brilliant results
secured in hypothyroidism, through the administration of the thyroid
extract, one should not hesitate to use it if improvement is not
otherwise forthcoming. Nevertheless, the very important point remains
that thyroid extract is only supplying a necessary substance, however
essential, to the bodily metabolism, and does not strike at the
essential etiology of the disorder.
Cretinism
It should be kept in mind that there are many gradations and
alterations in both hyperthyroidism and hypothyroidism, and that a
“goiter” may present either picture, partly or wholly, or on the other
hand may be normally functioning.
MacCallum says: “Unlike the myxedema cases which occur anywhere and
everywhere, regardless of environment or hereditary taint, these
people, known as cretins, are found in regions where the condition
seems to be endemic or inherent in the environment, and we can usually
trace in their parents or ancestors some similar thyroid defect.”
This disease is found in various countries, particularly in certain
parts of Switzerland, Austria, and Italy. McCarrison presents an
interesting study of 203 cases of Endemic Cretinism found in Himalayan
India. He thinks it is due to infection. There are a few cases in North
America, probably mostly due to immigration. It is frequently confused
with myxedema.
Cretins are of short stature, flat-chested and pot-bellied. The face
is broad, low forehead, broad nose, prominent cheeks, thick lips, and
large nose. The development of the bones is retarded; the skin is
thickened and edematous; the hair is thin, and the nails brittle; the
sexual organs as a rule do not develop; and in most cases a goiter,
sometimes of huge size, is present. Most of them are stupid and
apathetic; others are distinct idiots. Deafness is common.
There are sporadic and endemic cases, but the same underlying cause is
probably present. It is claimed that most cases of the former should be
classed as congenital myxedema.
Early diagnosis is essential. Removal of the patient from the goiter
region, and thyroid substance is the treatment given, though results
are not so marked as in myxedema.
FOOTNOTES:
[106] Ewing, Neoplastic Diseases; Grotti, Thyroid and Thymus.
[107] Cannon and Cattell, The Secretory ennervation of the Thyroid
Gland, Am. Journal of Physiology, July, 1916.
[108] Gaskell, Involuntary Nervous System.
[109] Macleod, Physiology and Biochemistry in Modern Medicine.
[110] Collected Papers of the Mayo Clinic, 1916, ’17, ’18.
[111] MacCallum, A Text Book of Pathology.
[112] McCarrison, The Thyroid Gland.
DISEASES OF THE PARATHYROID GLANDS
Tetany
The clinical manifestations of the insufficiency of function of the
parathyroid glands is well understood. This came about through the
study of endemic tetany, and, especially, noting that tetany followed
operations when the entire thyroid gland was removed. Considerable
experimental work on animals was next in order, until the discovery
was made that the thyroid gland and parathyroids are anatomically
independent, and that tetany is entirely dependent upon the loss
of function of the parathyroid glands. =Operative tetany= is now
comparatively rare, since the surgeon is particularly careful not to
injure the parathyroids in his operations on goiters, though mild forms
may occur through damage of the tissues or extension of inflammatory
processes.
There are =other forms= of tetany aside from operative, that occur in
both adults and children, but instability and insufficiency of the
function of the glands are basic to all cases. This is the common
factor, which may be modified by tissue resistance and various hygienic
factors.
In tetany there are paroxysmal, and often painful, contractions of the
muscles of the extremities. Both sides are affected, and occasionally
the spasms may extend to other muscles of the body. This is due to an
abnormal excitability of the nervous system. Probably the secretion of
the parathyroids have normally a restraining effect upon the nervous
impulses, which when removed, or insufficient, or possibly perverted,
results in the tonic spasms.
Thus the =predisposing condition= of tetany may be either =acquired=
or =congenital=. Children may be born with defective parathyroids. In
such instances there is probably a hypoplasia of tissue, which may
markedly vary in a series of cases, and give rise to different degrees
of tetany. Other factors, nutritional and toxic, would, very likely, be
important exciting causes. Hemorrhages and fibrosis have been noted in
some cases, that add to the injury of the tissues.
The blood and nerve tissues in tetany show a decreased amount of
=calcium=. It is claimed by some that the abnormal excitability of the
nervous system is due to the lack of calcium. Noel Paton[113] believes
that, though this may bear some relationship, the parathyroids control
the metabolism of =guanidine=, and that guanidine intoxication is the
cause of the symptoms. Guanidine seems to regulate the tone of the
skeletal muscles, and is closely related to urea.
Tetany may occur under many conditions: during pregnancy and nursing,
the infectious and nutritional diseases, the diseases of the thyroid
and very often gastro-intestinal disorders. There are various exciting
causes, such as cold, worry, overfatigue, etc. Alcohol, ergot,
morphine, chloroform, and other poisoning may precipitate an attack.
But in all these cases the parathyroids are previously damaged.
The blood supply to the glands is from branches supplying the thyroid
organ. This intimacy implies that the same sympathetic nerves to the
thyroid vessels are in control. Probably there are distinct secretory
nerves, as well as vasomotors, that are connected with the upper dorsal
and cervical sympathetics. =Lesions= related to the corresponding
spinal areas probably affect the integrity of the parathyroid function.
Schafer says: “The parathyroids are amongst the most vascular organs
in the body. They are supplied each by a special branch of the
inferior thyroid artery. The sinus-like capillaries come into close
relationship with the epithelial cells of the gland. The nerves of the
parathyroids, like those of the thyroids, pass both to the vessels and
to the secreting cells. Some evidence has been adduced which seems to
show that the cell-activity is controlled by the nervous system.”
Hence it would seem that in many cases of tetany, aside from those
cases due to operative injury and possibly certain congenital
instances, =osteopathic lesions= affecting the nerve and vascular
supply of the organs may so lessen, or pervert, the secreting cells
that tetanic states may supervene, especially where lowered nutrition,
toxins, and infections are inciting factors.
=Symptoms.=—The tonic contraction of the muscles may last a few minutes
or may persist for several hours, and are usually confined to the hands
and feet. The fingers and toes are first affected by the spasm, which
extends upward toward elbows and knees. This is commonly preceded by
numbness and more or less pain in the parts. Occasionally there is a
general ill-feeling, depression, and headache. There may be rise of
temperature, and some edema of the affected parts. There are no mental
symptoms.
The fingers are partly flexed at the metacarpo-phalangeal joints and
rigidly extended at the inter-phalangeal joints, the thumb is markedly
adducted and the fingers drawn close together. The wrist may be flexed,
and in severe cases the elbows flexed and adducted. When the feet are
contracted the toes are drawn together, flexed, and may overlap, and
the feet are arched.
=Trousseau’s phenomenon.=—The spasm is increased by pressure over the
median or ulnar nerves, or blood-vessels supplying the parts. This may
also excite an attack. =Chvostek’s phenomenon.=—Percussion over the
facial nerve will cause quick contraction of the muscles innervated.
=Erb’s phenomenon.=—The electrical excitability of the motor nerves is
markedly increased.
=Diagnosis.=—The characteristic attitude, and the irritability of the
motor and sensory nerves, make diagnosis easy. It may be confused
with =meningitis=, but in tetany there are no brain symptoms, while
in meningitis there are no characteristic signs of tetany. Generally,
there is little probability of confusing the disease with =tetanus=, or
=hysteria=.
=Treatment.=—Most cases are of a mild type, and recovery is the rule.
A great deal depends upon the underlying cause. Malnutrition, if long
continued, is a very important factor that may readily predispose to
the disorder. Rickets in children is often a basic consideration.
Rest, warm baths, and careful inhibitory relaxation of the tissues
materially assist in controlling the spasms. Attention to the thyroid
innervation should not be neglected. In indicated cases thyroid feeding
may be of assistance. The diet is of special importance, for many cases
present some disorder of the gastro-intestinal tract. Meat should not
be given. Milk is of great value, owing to its calcium content. The
administration of calcium is highly recommended, for reasons stated
under etiology.
Diseases of the Thymus
There is little known relative to the functions of the thymus. It is
most active during the growth of the body, attaining its greatest
weight from the eleventh to fifteenth years, after which it gradually
atrophies, though a certain amount of the tissue remains throughout
life. There is usually a gradual atrophy of the organ after puberty,
associated with increase of connective and adipose tissues. In cases
where it does not atrophy, there is often hyperplasia of the entire
lymphatic system in the body.
There is some relationship between the thymus and sexual organs, and in
experiments where the organ has been removed, ossification is delayed,
muscular weakness and tremor occur, there is hyperplasia of the
thyroid, parathyroids, and adrenals, and general cachexia, acidosis,
and mental deterioration take place.
The inferior thyroid and internal mammary arteries from above, and
the pericardiophrenic from below, comprise its arterial supply. The
nerve supply is from the sympathetic, vagus, and possibly the phrenic.
In cases of exophthalmic goiter there is frequently an associated
enlargement of the thymus, which may be shown by the X-ray, due to
failure of normal involution or a renewal of growth, that may be
definitely influenced by adjustment of the osteopathic lesions.
In some of the acute infections as pneumonia the thymus may atrophy
with some fatty degeneration and increase of connective tissue. This
also occurs in starvation. If the condition is not of long standing
recovery will take place.
In =status lymphaticus= there is hyperplasia of the thymus and
enlargement of the lymphoid tissue of the body, and hypoplasia of the
cardiovascular system. This is a constitutional defect, so that slight
injuries or infections may prove fatal. It is found in some cases that
there is hypoplasia of the chromaffin system. Whether this latter
condition is primary or secondary has not been settled.
In males the secondary sexual characteristics are not fully developed.
The figure resembles the feminine type. The skin is pasty, and the
beard is lacking or but little developed. In females the distribution
of the hair may be somewhat similar to the male sex, slender limbs and
chest, and disturbances of the menstrual function are noticeable.
The thyroid, thymus and lymphatic tissues are usually enlarged, while
there is hypoplasia of the adrenals and chromaffin system.
The condition is met with in children who have a weak muscular system,
increased adipose tissue, pasty complexion, enlarged tonsils and
adenoids, and frequently are anemic. In children where the thymus is
enlarged there may be excessive lymphocytosis.
The enlarged thymus may compress the trachea, interfering with
breathing so that cyanosis and temporary loss of consciousness occur.
Young children may die in the attack, probably due to compression
of the trachea or to heart shock. Death in adults has occurred from
trifling injuries, shocks, infections, and anesthesia. The underlying
cause is probably a constitutional weakness.
=Diagnosis= is made from the clinical signs, percussion of the thymus
and the X-ray picture, although these may not be positive. An excessive
lymphocytosis is suggestive.
=Treatment= should consist of good general care of the patient,
avoidance of injuries and shocks as far as possible, and careful
attention to all lesions, especially of the upper chest and neck.
By following this plan the child may overcome the condition. X-ray
treatment is being employed with success in some cases. Operations
have been successful in thymic hyperplasia where it has complicated
exophthalmic goiter, and also in serious mechanical pressure in
children.
Diseases of the Adrenal Glands
Experimental work supports the view that the cortex and the medulla
have separate functions. The =medulla= of the adrenals is part of the
chromaffin system, which includes tissue of the same character in the
ganglia of the sympathetic, the carotid gland, and the accessory gland
called Zuckerkand’s organ. This system is derived from the same cells
as the sympathetic nerves. The medulla receives a richer blood supply
than any tissue in the body. The secretion of the chromaffin tissue is
called adrenalin or epinephrin. The blood receives a continuous supply
of the secretion, which acts upon the small blood-vessels and assists
in maintaining blood pressure. It also stimulates glandular tissue,
and has some effect upon voluntary muscle which tends to counteract
fatigue.
The =cortex= of the adrenal glands is of epithelial origin, and is part
of the so-called interrenal system, which comprises very small masses
of tissue in the sympathetic ganglia. These are located in the hilus of
the kidney, broad ligament, inguinal canal, prostate, epididymis, and
along the spermatic veins (Baker). The cortex is the chief glandular
tissue of the interrenal system. The amount of tissue is not so great
after puberty as before. The blood supply of the cortex is not so rich
as that of the medulla. Abnormal activity is claimed to be the cause of
certain sexual derangements, particularly sexual precocity.
Schafer states that the adrenals are very richly supplied with nerves.
Each receives no less than thirty-three nervous filaments (Kolliker),
derived in part directly from the splanchnic, in part from the
suprarenal plexus, which is itself constituted by branches from the
celiac, phrenic, and renal plexuses.
We have noted that in lesions (experimental) of the splanchnics a
few cases presented acute pathological changes, congestion with some
degeneration of cells, in the adrenals.
Macleod states that of the many functions of the adrenals that which is
most directly associated with epinephrin is the production of glucose
from glycogen. “When the nervous system is stimulated in such a way
as to excite the glycogenolytic process, two effects both operating
in the same direction with regard to the glycogenic function are
developed: the one, a hypersecretion of epinephrin, which activates the
sympathetic nerve endings, the other, the transmission of the nerve
impulse to the liver cell.”
Addison’s Disease
This is a rare, chronic disease, more often occurring in men, that
is characterized by muscular and vascular weakness, digestive
disturbances, and pigmentation. Tuberculosis of the adrenals has been
the most constant lesion found. In others, syphilis and atrophy have
been noted, while in a few the condition seemed to be functional. It
should be remembered that it is possible that lesions elsewhere in
the chromaffin system may be the cause in some cases, for all the
chromaffin tissues secrete adrenalin.
It is quite likely that in most cases there is some constitutional
defect of the chromaffin system which underlies a certain tendency to
the disorder. Infections, injuries, physical and mental strains may
lower resistance and predispose to the condition.
Osteopathic lesions of the splanchnics may congest the organs, or
derange the secretions, or be of such a character that hemorrhages
result, or fibrous changes follow, that would definitely incapacitate
the cells and lower resistance.
=Pathologically=, the most common change is tuberculosis. Next in
importance are atrophy and interstitial inflammation. Cancer of the
organs has been noted in a few. The adrenal ganglia, the semilunar
ganglia, and the solar plexus are often involved. The thyroid gland may
be altered, which, when affected, is usually decreased in size. Brown
atrophy of the heart is common.
=Symptoms.=—An insidious onset with muscular weakness, languor, and
weak action of the heart are generally the first symptoms. Digestive
derangements, such as nausea, hyperacidity, loss of appetite, may occur
at the same time, or shortly succeed the general debility. Headache,
insomnia, and depression frequently take place. Pigmentation, usually,
shortly follows, though there are cases where it is only slightly
noted. The disease is very chronic, of several years duration, with
periods of intermission. Occasionally, a case runs a very rapid course.
The general weakness is most noticeable. There is low blood pressure.
The derangement of the stomach and intestines is characteristic. And
the pigmentation, which at first is light yellow later assumes a dark
brown color. The pigmentation may be more or less general, but the
axillæ, nipples, genitals, the palms of the hands, and the neck, waist
or wherever the clothing presses upon the skin, are most pigmented. And
pigmentation of the mucous membrane may be noted.
=Diagnosis.=—In typical cases, where there is esthenia, pigmentation,
and gastro-intestinal disturbances, the diagnosis is not difficult.
Where the clinical picture is incomplete, the diagnosis may be very
difficult.
Pigmentation may occur in several other disorders, notably: in bronzed
diabetes, abdominal malignancy, tuberculosis of the peritoneum,
exophthalmic goiter, pellagra, marked intestinal stasis, stomach ulcer,
pernicious anemia, certain skin diseases, etc., so great care has to be
taken in atypical cases.
=Treatment.=—General treatment, with special attention to the adrenal
innervation, diet, rest, and fresh air will accomplish something. In
functional derangements, which are very few, recovery may follow.
But owing to the often constitutional defect, the probability of
tubercular, syphilitic, and other serious lesions, the prognosis is
unfavorable.
FOOTNOTES:
[113] Paton and Finlay, Jour. Exp. Phys., 1917.
DISEASES OF THE NERVOUS SYSTEM
DISEASES OF THE NERVES
Neuritis
=Neuritis= is an inflammation of the nerve fibers. It may be confined
to a single nerve, localized; or general, involving a large number of
nerves, when it is known as multiple neuritis. Osteopathically, there
are =invariably lesions= of the osseous or muscular tissues, that
correspond to the nerve fibers involved. The lesion either irritates
the nerve directly or disturbs the circulation to the nerve. In those
cases where the osteopathic lesion is not the immediate exciting cause,
there will be found anatomical irregularities that predispose to the
affection.
=Localized neuritis= may be due to: Local osteopathic lesions; Exposure
to cold; septic foci; traumatism; and inflammation of contiguous
tissues.
=Multiple Neuritis= may be due to: Osteopathic lesions, which are
associated with infectious diseases, as in diphtheria, typhoid, scarlet
fever, etc.; prolonged strain or exposure; metabolic poisons, as in
diabetes, anemia, tuberculosis, cancer, etc.; alcohol, lead, mercury
and arsenic poisoning; and =beri-beri=, which is probably due to lack
of vitamins, or possibly micro-organisms, or carbonic gas poisoning.
The inflammation may chiefly involve the connective tissue
surrounding the nerve—perineuritis—or it may involve the deeper
structure—interstitial neuritis. =Parenchymatous neuritis= is really
a degeneration, due to excessive or prolonged irritation or pressure
which cuts the nerves off from their centers. This is found in deeply
seated osteopathic lesions. In experimental osteopathic lesions
the first effect is degeneration of the medullary sheath. This is
followed by degeneration of the axis cylinder. The local circulation
is notably impaired. An acutely inflamed nerve is red and swollen.
In =perineuritis= there is an infiltration of the nerve sheath with
leucocytes. In the =interstitial form=, lymphoid cells are found
between the nerve bundles. In the parenchymatous form, inflammatory
signs are wanting. The muscles atrophy. Associated in all these forms
the =osteopathic lesion= plays either an exciting or predisposing role,
by disturbing nutrition to the tissue and thus setting up inflammation,
which may lead to Wallerian degeneration[114].
=Symptoms.—Localized Neuritis.=—In the case of a sensory nerve,
there is severe pain following the course of the affected nerve, with
tenderness upon pressure. This may be followed by loss of sensibility.
Trophic symptoms, such as glossiness of the skin and brittle nails,
arise in more chronic cases, while in advanced cases, there is wasting
of the muscles. Sweating, herpes, and occasionally effusion into the
joints, occur. When a motor nerve is principally affected, muscular
power is impaired, motion painful and muscular twitchings will occur.
Finally contractions, wasting of the muscles, and even reactions of
degeneration, may take place. A rare form is the so-called =ascending
neuritis=, in which the inflammation extends upward from the peripheral
nerves to the larger nerve trunks, or even the spinal cord, resulting
in =myelitis=. This occurs most commonly in traumatic neuritis. The
duration is variable. Many acute cases get well in a few days. Other
cases may persist for months and even years.
=Multiple Neuritis.=—Inflammation involving several nerves which are
affected simultaneously or in rapid succession. =Acute form.=—The
attack usually follows overexertion or exposure to cold and wet,
with probably some infection. This form is characterized by a chill,
followed by a rapid rise in temperature which may reach 103 or 104
degrees F.; headache; pains in the back and limbs. There is weakness
of the legs or arms, depending upon region involved, which may be so
severe that the muscles atrophy. Sensory symptoms are variable. Most
cases recover, though there are instances where the vagi, the nerves to
the bladder, rectum, or heart, may be involved.
=Alcoholic Neuritis= results from a moderate amount of alcoholic
drinking, continued over a long time. The first symptoms are usually
numbness and tingling in the fingers and toes. Loss of power soon
becomes marked, first in the lower, and then in the upper, extremities.
The extensor muscles are most affected, causing wrist and foot drop.
Occasionally there is paraplegia. There are hyperesthesia, tenderness
and pain, especially in the legs. The cutaneous reflexes are commonly
intact, and the deep reflexes, as a rule, are lost. Delirium is common,
and hallucinations or illusions occur.
Neuritis from =lead poisoning= usually present the “wrist drop” and
“foot drop”, with colic, and “blue line” on gums.
=Infectious Diseases= neuritis is due to an attack of some infectious
disease, and may be local or multiple. It is due to toxic materials
absorbed into the blood. It is most common after diphtheria. The
symptoms presented are those of neuritis due to any other cause.
=Senile neuritis= is probably due to arteriosclerosis.
=Diagnosis.=—As a rule, the diagnosis is not difficult. In the
alcoholic form in some instances, there may be difficulty, and in cases
with paralysis, care should be taken. The =prognosis= of neuritis is
generally favorable.
=Treatment.=—It is very evident that the successful treatment of
neuritis depends upon being able to ascertain the cause. Rest is
important in all cases. Rarely has one any difficulty in locating the
deranged structures that are predisposing to the attack; and usually
correction of these disturbances, which are in the region involved
will give considerable relief. If the parts are too sensitive to
handle insist on absolute rest and hot fomentations. The affected area
should be kept warm and protected. Attention to the diet, and free
elimination, are important. Metabolic disorders should be corrected,
if possible. Give particular attention to any septic foci. A change of
occupation may be necessary in some cases.
In alcoholic cases, the alcohol should be stopped as soon as possible.
Passive movements and massage are helpful, but of course bear no
comparison to specific osteopathic treatment. Relaxation of muscles
along the spinal column and along the course of the nerve will at least
give temporary relief.
If contractures and other changes remain after the acute attack,
persistent treatment will generally result in recovery. (See also
Painful Shoulders, Part I.)
=Sciatica= is usually a neuritis of the sciatic nerve, although all
painful affections of the nerve are termed sciatica. In some cases it
is a neuralgia when the nerve is swollen and presents an interstitial
neuritis.
=Osteopathic Etiology.=—This affection occurs more frequently in males
than in females. The usual period for sciatica is from the twentieth
to the fiftieth year and the principal causes are =vertebral lesions=
of the lower dorsal and lumbar vertebræ, especially lesions to the
fourth and fifth lumbar. Occasionally the lesion is a subdislocated
innominatum, a downward displacement of a floating rib or a partial
dislocation of the femur. Other causes are exposure to cold,
contraction of muscles, gout, rheumatism and syphilis. Contraction of
the pyriformis muscle may bring direct pressure on the nerve. Focal
infections, arthritis of the articular processes of the lower spine,
and sacro-iliac and hip-joint disease should not be overlooked. In a
few cases there are intrapelvic causes, such as uterine and ovarian
tumors, rectal accumulations and the fetal head during labor. Enlarged
prostate may be a factor. It is possible for the roughened edges of
the sacro-iliac joint, internally, to irritate the sacral plexus as it
passes over and thus keep up the pain. This may explain the occasional
failure of treatment.
=Symptoms.=—Pain in the nerve along its course is the most constant
symptom. The pain is most intense back of the thigh and above the
hip-joint. The pain radiates downward through the entire nerve; it is
of an annoying character and walking is especially painful. In rare
cases there is wasting of the muscles, cramps, herpes and edema. In a
few cases the neuritis may extend to the spinal cord.
=Diagnosis.=—The diagnosis of sciatica is usually easy. Care has
to be taken in the examination to determine whether the affection
is primary or secondary. It is difficult, in some cases, to locate
the origin of the disturbance, especially if it is in the lumbar
vertebræ, as frequently a very slight deviation of a vertebra will
cause the disease; or some focal infection may be difficult to locate;
or malformation of the fifth lumbar may be present; or asymmetry of
the legs or the body be a factor. Careful palpation, measurements,
and the X-ray are of diagnostic importance. =Hip-joint disease= and
=sacro-iliac disease= can generally be easily distinguished from this
affection. The lightning pains of =tabes= may simulate sciatica, but
then there are other well defined symptoms of the disease.
=Treatment.=—Sciatica rarely runs a very long course, though there are
cases that last for years. The treatment almost wholly depends upon the
cause. If the cause can be determined at once, the probabilities are
that severe cases may be relieved by a few treatments. Correction of
the vertebræ, to relieve impingements to the nerve fibers as they pass
through the intervertebral foramina, usually constitutes the primary
treatment. Carefully examine the pelvic organs for disturbances.
Occasionally deep treatment over the iliac vessels will be of great
help. The innominatum, if deranged, should be corrected and all
troubles of the hip-joint that are found must be corrected.
Cases of rheumatism and gout should receive their separate treatments,
besides careful manipulations of the affected leg. Rest in bed should
be insisted upon; this will usually markedly lessen the duration of
the inflammation. Adjustment of the special points found deranged and
a thorough treatment, if conditions permit, of the entire leg will be
beneficial. Hot fomentations applied along the course of the nerve,
and an inhibitory treatment back of the trochanter will at least give
temporary relief. Extension of the leg is effective. Placing a patient
upon his back and flexing the leg and thigh upon the abdomen, at the
same time keeping the leg straight and the foot flexed, is an effectual
stretching method. As a rule, sciatica readily responds to osteopathy.
Neuralgia
=Neuralgia= means simply “nerve pain.” The term neuralgia should be
restricted to such nerve pains as are not caused by structural changes
in the nerves. In cases where the pain is due to organic changes
in the nerves, the disease should not be classed as a neuralgia,
although it is practically impossible to draw an absolute line
between functional and organic disturbances for the one may gradually
progress (pathologically) into the other. In neuralgia there is always
=disturbance= of the =blood supply= to nervous tissue, which may be
of the character of congestive irritation, ischemia or altered states
of the blood wherein it contains toxic substances or is below normal
quality. It is well known that osteopathic lesions are very common
etiological factors.
=Osteopathic Etiology.=—Neuralgia is essentially a disease of adults.
It rarely occurs before puberty or late in life. Women are more prone
to neuralgia than men and the tendency may sometimes be hereditary.
Sufferers from neuralgia often present a peculiar “nervous temperament.”
The exciting causes of neuralgia are impairment of general health;
irritations of the nerve fiber or trunk by a displaced bone, ligament
or muscle, which may affect the nervous tissue directly by mechanical
irritation, or indirectly, by the disturbance of its blood supply,
or toxic agents; exposure to cold or damp; overwork and worry; toxic
influences of various diseases, as malaria, lead poisoning and
alcoholism; irritation from carious teeth, and various septic foci.
=Symptoms.=—Pain, which is spontaneous and paroxysmal, is the most
prominent symptom. It may be described as “darting,” “shooting,”
“burning,” “stabbing,” “boring,” etc. The pain is usually unilateral,
following the course of the sensory nerves, and there are generally
tender points along the course of the nerve. Especially are there
points of tenderness near the central end of the nerve, where the
displaced structures are irritating it. After the pain has continued
for some time the skin becomes tender, reddened and swollen. The
redness and edema are supposed to be due to vasomotor changes. Muscular
spasms, trophic disturbances, skin eruptions, herpes and grayness of
the hair are of rare occurrence. The duration of an attack varies from
a number of minutes to a few hours.
=Neuralgia of the Fifth Nerve.=—This is by far the most frequent
variety of neuralgia, and it is generally due to a displaced =atlas= or
=inferior maxilla=. The teeth sinuses, and other possible regions of
focal infections should be thoroughly investigated. Anemia and products
of metabolism may be underlying factors. All the branches of the fifth
nerve are rarely involved. The =ophthalmic division= is most often
affected; pain and tenderness being present about the supraorbital
notch or foramen, the palpebral branch at the outer part of the eyelid,
the nasal branch, and occasionally an ocular pain will be felt within
the eyeball. When the =infraorbital branch= is involved, pain and
tenderness are principally present at the infraorbital, nasal and malar
points. When the =third division= is affected, the chief tender places
are the inferior dental, temporal and parietal points. In nearly all
cases of neuralgia of the fifth nerve, there is extreme tenderness
in the region of the articulation of the atlas and the occipital,
particularly the side on which the fifth nerve is involved. This
tenderness in a few cases may be found as low as the second or third
cervical vertebra. The pain may be so severe as to cause edema along
the course of the affected nerve fibers, grayness of the eyebrows and
locks of hair chiefly in the temporal region, and convulsive twitching
of muscles.
=Tic Douloureux= is a vastly exaggerated neuralgia of the fifth nerve
and is supposed to be a primary affection of the Gasserian ganglion.
Starting in middle life from no apparent cause it increases in severity
until it becomes unbearable and suicide is not an infrequent result.
Many methods to relieve have been tried including destruction of the
ganglion but with various results.
Treatment should be the same as in the milder form of neuralgia but it
will require critical examination to determine the causes which are
liable to be obscure.
=Cervico-Occipital Neuralgia.=—This variety involves the =posterior
branches= of the =first four cervical= nerves, affecting the region of
the posterior part of the neck and head. The pain may extend as far
forward as the parietal eminence and the ear. The chief tender points
are about midway between the mastoid process and the spine, between
the sternomastoid and trapezius (branches of the cervical plexus), and
a point just above the parietal eminence. This form of neuralgia is
chiefly due to =subluxation= of the =upper four= or =five cervical=
vertebræ irritating the posterior branches of the spinal nerves. A
draught of air or exposure to cold are common exciting causes. The
pain is of a sharp lancinating nature or else it is heavy and tense.
Tuberculosis of the cervical spine may be an underlying cause.
=Cervico-Brachial and Brachial Neuralgia.=—In these forms of neuralgia
the pain is referred to the area supplied by the =four lower cervical=
and the =first dorsal= nerves. The tender points are in the axilla
along the course of the ulnar, the circumflex at the posterior part of
the deltoid and points at the lower and posterior part of the neck.
The =lesions= exciting this form of neuralgia are usually found in the
upper dorsal and upper cervical spines, but they may be as low as the
sixth dorsal or as high as the atlas. As far as neuralgia of the ulnar
nerve alone is concerned, it can be traced to the seventh and eighth
cervical and first dorsal, and the lesion may be found occasionally
at the fifth dorsal vertebra or rib. How a lesion as low as the fifth
dorsal affects the ulnar nerve, it is hard to say definitely. There
may be fibers directly to the ulnar nerve as low as this region, the
nerve may be reflexly affected, the vasomotor supply to the ulnar nerve
may be disturbed, or possibly the lesion interferes with fibers of the
deep layers of the back muscles and thus contraction of muscles for
some distance above the lesion would affect the ulnar and other nerves.
The scaleni may be affected and involve the plexus. A bursitis may be
present (See Painful Shoulders Part I). Focal infections are sometimes
factors.
=Trunk Neuralgia.=—This includes dorso-intercostal and lumbo-abdominal
neuralgia. The former, =dorso-intercostal= neuralgia, affects the
intercostal nerves from the =third= to =ninth dorsal=, and is
characterized by pain along the intercostal spaces, or in a few of
them. The pain may be bilateral and symmetrical, which usually shows
a vertebral lesion. Three points of tenderness are usually noted,
viz., near the median line in front, and midway between these two
points in the mid-axillary line. The pain is usually dull with acute
exacerbations. =Lesions= of the =vertebræ= and =ribs= in the locality
affected are by far the principal causes. Cold, exposure, strains,
etc., are exciting causes of every day occurrence. When the pain is
bilateral and symmetrical the lesion is usually in the vertebra; when
unilateral the rib alone may be involved. The most common lesion is
a crowding together of the ribs anteriorly at the fifth and sixth
interspaces. Carefully exclude a possible tuberculosis of the spine or
ribs, aneurism, etc.
The pain of =herpes zoster= is not neuralgic, but neuritic, involving
the posterior spinal ganglion. =Pleurodynia=, strictly speaking, is
neuralgia of the pleural nerves, and not of the intercostals, but a
deranged rib over the region of the pain is commonly the cause of the
pleurodynia.
=Lumbo-abdominal= neuralgia involves the posterior branches of the
=lumbar nerves=. Tender points are found near the vertebræ, middle
of the iliac crest, lower part of the rectus, and in the male
occassionally in the scrotum, in the female in the labia. These
are often bilateral and are usually of a constricting nature. The
ilioscrotal branch is the one most commonly affected.
=Subluxation= of the =vertebræ=, and other lesions, as contracted
muscles, are found along the lumbar vertebræ, and even as high as the
lower dorsal vertebræ. Also lesions are found at the lumbo-sacral
articulation. Pelvic disease is also a cause.
A downward displacement of the =lower ribs=, eleventh and twelfth, is a
common disorder and may be the cause of severe neuralgic pains in the
region of the iliac fossæ. It may simulate ovarian inflammation, renal
colic, or even appendicitis if on the right side. And septic kidney has
been wrongly diagnosed from these lesions. In fact it may be a cause of
inflammation of the deeper structures, such as the ovary and Fallopian
tube.
A subluxation of the vertebræ at the fourth and fifth dorsals may cause
severe neuralgic pains in the epigastrium.
=Neuralgia of the Spinal Column.=—According to medical writers this is
especially found in weakly women and after concussion of the spine;
that it is a troublesome symptom in hysteria, and in many cases it
is due to a reflex stimulus from diseased viscera. Most of this is
undoubtedly true, but they have not found out the real significance of
these neuralgic pains. The various =tender points= along the spinal
column are of paramount importance to the osteopath as a =guide= to his
=diagnosis=; not only in certain cases, but in nearly every case. The
tender points are not due, in nearly every instance, to reflex stimuli
from diseased organs, but these tender points are often the result of
a local lesion, and are many times the cause of the disorder to the
diseased viscus. The neuralgic pains are simply a symptom that a lesion
exists in the immediate locality.
=Neuralgia of the Sacral Region and Coccygodynia.=—This form involves
the nerves in the sacral and coccygeal regions. The nerves between the
bone and the skin are affected. The cause of the pain is generally due
to derangement of the articulation of the =lumbar= and =sacrum=, and
to severely contracted muscles over the sacral foramina; also to lower
lumbar lesions. It may be a reflex from various possible disorders
of the organs and tissues of the pelvis. In coccygeal neuralgia, the
=coccyx= is commonly displaced in any one of the various displacements
that are liable to occur. Special attention should be given to the
fibro-articulation of the coccyx, and to the status of the lumbo-sacral
and innominata. In adjusting the coccyx, place forefinger in rectum up
to proximal end of coccyx, and with thumb externally over the section,
exert traction until articulation is released; then adjust.
=Neuralgia of the Legs and Feet.=—This includes the =crural form=, in
which the front of the thigh is the seat of the pain; also the form
in which tender points are found along the course of the =sciatic=
nerve. The latter form is quite a common one, although sciatica
is rarely a neuralgia. It is a neuritis and will be found classed
under that heading. The tender points presented are the lumbar,
sacro-iliac, gluteal, peroneal, maleolar and external plantar. The
various neuralgic pains of the legs and feet are generally due to
=lesions= of the =lumbar=, =pelvic= and =thigh= regions, and to =weak
arches=. =Metatarsalgia= occurs when the fourth metatarso-phalangeal
articulation is partially dislocated. Neuralgia in the heel, ball of
the foot and toes may be due to local causes or to lesions higher up.
Aside from the above care should be taken that there are no toxic
factors that may be exciting causes.
=Visceral Neuralgia.=—This is a term applied to neuralgia of the
gastro-intestinal tract, the kidneys, and the various pelvic organs.
=Diagnosis and Prognosis of Neuralgia.=—Neuralgia is to be diagnosed
chiefly from neuritis, rheumatism, and the effects of severe pressure
upon the nerves. In =neuritis= there is oftentimes a symmetrical
affection, while in =neuralgia= there is a unilateral distribution and
there are many remissions and intermissions and a varying of the pain
from one place to another. In severe forms of neuritis, anesthesia
succeeds the hyperesthesia of the sensory nerves. In cases of severe
pressure upon nerves, the pain is continuous and neuritis will soon be
manifested. In =rheumatism= the pain is localized in muscles or groups
of muscles and does not follow the course of the nerve. The pain is
increased by motion.
The =prognosis= is generally favorable, no matter how severe the
attack. The prognosis is influenced only by the age of the patient and
the cause.
=Treatment of Neuralgia.=—Consists, first, in the control of the
paroxysm and, second, in the removal of its cause. In controlling
the paroxysm, frequently one will be able to remove the cause. In a
large majority of neuralgias the cause is directly due to a =displaced
tissue=, generally a bone or muscle in the locality affected; often
all that is necessary in order to perform a cure is to adjust the
disordered tissue and the pain will cease. This usually can be done
immediately, although there are cases which require several treatments
before an adjustment of the parts can be accomplished; besides, in
acute cases the involved region will be so tender that an attempt
to correct the tissues sufficiently to relieve the paroxysm will be
unbearable to the patient. In such instances when the cause cannot be
removed at once, firm pressure or inhibition over the involved nerves
for a few minutes and local application of hot packs generally disperse
the pain for the time being. The rules of hygiene should be observed in
all cases.
The best time to =remove= the =cause= of neuralgia is between the
attacks when the tissues are not as tender or contracted to such an
extent as during the paroxysm. A diagnosis can then be made much more
easily, and the tissues adjusted with less pain to the patient.
The details (as to the locality treated) for each form of neuralgia
will be found under the discussion of each variety. The general health
and diet should be considered. Peterson[115] says: “Morphine is,
among the alkaloids, the most frequent cause of insanity. It is a sad
commentary on the heedlessness of some medical men, but the family
physician is responsible, in almost every case, for the development
of the morphine habit and its far-reaching consequences. It should be
looked upon as a sin to give a dose of morphine for insomnia or for any
pain (such as neuralgia, dysmenorrhea, rheumatism) which is other than
extremely severe and transient.”
Diseases of the Cranial Nerves
=Olfactory Nerves.=—This nerve may be affected at various points from
its origin to distribution. The disturbances may produce hyperosmia, or
anosmia. The lesions may be tumors, injuries to the head and various
diseases of the brain, or diseases of the nasal mucous membrane.
The =treatment= of the nerve (beside treating the disease causing the
disturbance) is to the cervical region with a view to controlling the
blood supply.
=Optic Nerve and Tract.=[116]—The retina, optic nerve, chiasma and
optic tract may be affected by various lesions.
The affections of the =retina= are organic or functional. Under organic
there is hemorrhage and retinitis. Retinitis may be due to several
diseases, as syphilis, Bright’s disease, anemia, etc., Functional
includes toxic and hysterical amaurosis, tobacco amblyopia, nyctalopia,
hemeralopia and retinal hyperesthesia.
Included in the lesions of the =optic nerve=, are optic neuritis and
optic atrophy.
Under lesions of the =chiasma= and =tract= are diseases of the chiasma
and unilateral regions of the tract. Lesions of the tract and centers
may be found in the tract itself, in the optic thalamus and the
tubercula quadrigemina, in the fibers of the optic radiation, in the
cuneus, and in the angular gyrus.
A brief summary, only, has been given of the lesions found, it being
the idea not to dwell upon symptoms, morbid conditions, etc., but to
bring out essential osteopathic features in regard to the cranial
nerves. For the various effects of these lesions and points of
diagnosis, the reader is referred to the various works on nervous
diseases.
=Lesions= peculiar to =osteopathic= practice, that affect the optic
nerve and tract, are found chiefly in the upper and middle cervical
vertebræ. The disorders to these vertebræ may involve fibers of the
optic nerve directly—those that are supposed to originate in the
cervical spine; they involve the retina and optic nerve by way of the
fifth, as claimed by some; and the above lesions especially affect
the blood supply to the optic nerve and tract, either interfering
mechanically with the blood-vessels or obstructing and irritating
vasomotor nerves. The most common lesions are subdislocations of one or
all of the three upper cervical vertebræ. Still, lesions may be located
as low as the third or fourth dorsal vertebra, which may influence
vasomotor and sympathetic nerves, or the lymphatics. The three or four
upper ribs should also receive due consideration.
=Motor Oculi.=—Lesions of the third nerve may affect its center or the
course of the nerve. These lesions produce spasms or paralysis.
The only way that we can control the motor oculi is by way of the
superior cervical sympathetic; also, it has a connection with the
fourth, fifth and sixth nerves, and we can influence it to some extent
by direct treatment to the eyeball and orbital muscles. It should be
remembered by the osteopath that many of the lesions affecting the
cranial nerves, are found upon post-mortem examination, to be the
effect of lesions in the spinal region; that many predisposing lesions
are the disordered anatomical spinal tissues; as for instance in the
third nerve, derangements of the atlas or axis may affect the nerve
sympathetically (reflexly), or possibly by direct fibers, and produce
the secondary effect—the so-called primary lesions of other schools—at
the center or in the course of the nerve.
=Patheticus.=—This nerve may be involved by tumors at its nucleus,
or as it passes around the outer surface of the crus into the orbit.
Aneurisms or the exudation of meningitis may also compress its fibers.
This nerve is purely motor, although it receives a few recurrent
sensory fibers from the fifth nerve.
This nerve is controlled osteopathically, principally at the superior
cervical sympathetic. It has connections with the sympathetic by way of
the cavernous plexus.
=Trigeminus.=—Lesions of this nerve are found in its nucleus and in
the pons, and include sclerosis, hemorrhage, disease and injury at the
base of the skull, tumors, aneurisms, inflammation of the nerve, and
subdislocations of the =upper three cervical= vertebræ, or the inferior
maxillary.
This nerve is an extremely important one from an osteopathic point
of view, as it has a vasomotor influence over various vessels of the
head and face, and secretory fibers to the lachrymal, parotid and
submaxillary glands; also, it controls mastication, and to some extent
deglutition, and influences hearing (tensor tympanum muscle). Diseases
of the nasal mucous membrane and disease of the anterior portion of
the eyeballs are largely due to the =vertebral subdislocations= and
to derangements to the inferior maxilla. Our principal work upon this
nerve is at the upper cervical vertebræ, the inferior maxilla, and the
deeply contracted muscles in the upper cervical region. For the facial
points of treatment =see neuralgia of the fifth nerve=. This nerve is
closely related to the sixth, seventh, eighth, ninth, tenth, eleventh
and twelfth nerves. Particular emphasis is given to the importance
of treating this nerve in nasal catarrh and in eye diseases of the
anterior portion of the eyeball. It contains trophic fibers to the eye,
sensory fibers to the sclerotic coat and iris, and vasomotor fibers to
the choroid plexus.
=Abducens.=—This nerve is especially liable to be affected by tumors
and meningitis. It is controlled osteopathically at the superior
cervical sympathetic, being connected with the sympathetic at the
cavernous plexus.
=Facial.=—Lesions may occur in the cortical centers of the nerve, the
nucleus and the nerve trunk. Paralysis of the facial nerve occasionally
occurs (Bell’s paralysis); also facial spasm may occur. This nerve
is controlled at the stylomastoid foramen. =Lesions= to the =atlas=,
anteriorly or laterally, are commonly found. In the region of the
stylomastoid foramen, the nerve communicates with the great auricular
of the cervical plexus, the trifacial, the vagi, the glosso-pharyngeal
and the carotid plexus of the sympathetic. The facial nerve may be
affected directly as it passes above the angle of the jaw.
Nearly every case of =Bell’s paralysis= can be cured by osteopathic
treatment. There are usually lesions to the upper two or three
cervicals. Correction of the cervical vertebræ and massage of the
paralyzed muscles, with care of the general health, will suffice,
provided there is not an extensive central lesion. Although the
disease may be due to syphilis, meningitis, tumors, etc., the most
frequent causes are lesions of the =atlas=, =axis=, and =third
cervical= and =exposure= to =cold=. The cold produces a neuritis in the
Fallopian canal, and deep treatment beneath the angle of the jaw is
effective. The =prognosis= of Bell’s paralysis is favorable.
=Auditory.=—Lesions[117] affecting this nerve may occur anywhere from
its cortical center to its distribution in the cochlea and vestibule.
Disorders resulting from lesions to this nerve are nervous deafness,
auditory hyperesthesia, tinnitus aurium, and Meniere’s[118] disease.
The control of the nerve and the treatment of lesions affecting it, are
effected principally at the =first= and =second cervical= vertebræ.
The atlas is especially apt to be subdislocated anteriorly or in a
rotary manner. The condition of the =upper dorsal= region should also
be carefully examined, as vasomotor nerves to the ear may be impinged
at this point. The auditory connects with the fifth, sixth and seventh
nerves.
=Glosso-Pharyngeal.=—This nerve may be affected by tumors,
degenerations, meningitis and various lesions. It is often very hard to
determine exactly the pathology, on account of its various connections
with other nerves, the vagi, facial, spinal accessory, olfactory and
optic nerves.
This nerve is chiefly controlled at its exit at the jugular foramen.
Osteopathically, =lesions= of the =cervical= vertebræ and =upper
dorsal= vertebræ affect it. The deep muscles of the anterior and
lateral regions of the neck and subdislocations of the atlas especially
affect the nerve.
=Pneumogastric.=—On account of its extensive distribution, and the
importance of its functions this is one of the most important nerves
in the body. It distributes fibers to five vital organs—heart, lungs,
stomach, liver and intestines—and to other organs of secondary
importance. This nerve is associated with deglutition, phonation,
respiration, circulation and digestion.
Hemorrhages, softening, etc., may involve the nucleus of the nerve,
while the trunk may be impinged by tumors, thickened meninges, aneurism
of the vertebral artery and =subdislocation= of the =upper five= or
=six cervical= vertebræ, chiefly the atlas.
The nerve is most easily controlled at its exit from the foramen.
Inhibition of the suboccipital region, between the mastoid process
and transverse process of the atlas, will influence the nerve
markedly, probably reflexly; also direct treatment may be given
the nerve as it passes along the anterior part of the neck near the
trachea. The superior laryngeal branch may be treated below the
great cornu of the hyoid bone and attention is particularly called
to this in all affections of the throat where coughing is a feature;
the inferior laryngeal, at the inner side of the lower part of the
sternocleidomastoid muscle. The inferior laryngeal nerve may be
affected by dislocation of the first and second ribs, producing
pressure upon the nerve as it winds about the subclavian vessel. Fibers
of the nerve have been traced to the spinal accessory nerve, as low as
the sixth and seventh cervical vertebræ; consequently, lesions to the
vagi nerves may occur anywhere in the cervical region.
=Spinal Accessory.=—Lesions of this nerve may cause paralysis or spasms
to the structures to which it is distributed. The lesions consist of
=subdislocations= of =cervical= vertebræ, chiefly the upper three or
four. The nucleus may be involved by wounds, abscesses, caries of the
vertebræ, tumors and meningitis. These lesions may also involve fibers
of the trunk.
The special points of control of the nerve are at the jugular foramen,
the sixth and seventh cervicals and the second, third and fourth
cervicals.
=Torticollis= or =Wry-neck= is spasm of the muscles of the neck
supplied principally by this nerve. There will be found either
derangements of the =middle= or =lower cervical= vertebræ or the
muscles are swollen from exposure to cold or from a blow. Sometimes the
lesion is in the upper dorsal. The disorder is mainly a neurosis and,
unless it has become chronic, the =prognosis= is favorable, and even in
chronic cases, often considerable benefit can be obtained.
=Hypoglossal.=—This nerve may be affected by cortical, nuclear and
infra-nuclear diseases, as well as by subdislocations of the upper
cervical vertebræ. It communicates with the superior cervical ganglion,
the vagi, the upper cervical nerves and the gustatory branch of the
fifth nerve. We control the nerve at the anterior condyloid foramen and
at the superior cervical ganglion.
Diseases of the Spinal Nerves
=Cervical Nerves.=—The =great occipital= nerve may be controlled at a
point on the occiput between the mastoid process and the first cervical
vertebra. The =small occipital= and the =great auricular= nerves may
be controlled at a point just behind the mastoid process. The great
auricular nerve and the frontal branch of the trigeminus nerve meet
over the parietal protuberance. The preceding points are the places
where one may inhibit the nerves and control certain headaches or
neuralgic attacks, although subdislocations of the upper cervical
vertebræ, or contracted muscles between the atlas and occiput are
usually the cause of such disturbances. Adjustment of the lesion will
usually correct the disturbance. Carefully exclude possible caries or
tumors.
=Treatment= of the upper cervical region, by relaxing muscles and
correcting deranged vertebræ, constitutes the principal treatment of
an ordinary =headache=. It is best to have the patient flat upon his
back and the osteopath stand at the head of the patient, and, first,
thoroughly relax these contracted muscles or correct the derangement of
the vertebræ; then after the foregoing has been accomplished, give an
inhibitory treatment of the suboccipital region. In inhibiting, place
the fingers over the contracted and tender tissue; hold tightly for
several minutes, or at least until the tissues have thoroughly relaxed.
Many times one will be able to detect a slight twitching underneath
the fingers, and when such is felt, he knows at once that the headache
is relieved. In inhibiting at any point along the spine, seek the
contracted fibers and tender points and inhibit exactly over the area.
Headaches that are due to a disturbed circulation of the brain, may
be relieved by this inhibitory treatment in the suboccipital region.
The treatment tends to reestablish a normal circulation to the brain.
Although the large vascular areas such as the splanchnic, should,
if possible, be normalized. Headaches may also be due to lesions at
various points along the spine and ribs, and a correction of such
points is necessary in order to cure the affection. A place often found
involved is the upper dorsal region. =Reflex headaches= can be cured
only by relieving the irritation. The treatment to the head would only
be temporary. In headaches of the chronic type it is well to examine
the scalp and if not freely movable over occipital region it may be
adherent to the skull and cause pressure on the occipital nerves.
Lesions to the =phrenic nerve= usually occur in the region of the
third, fourth and fifth cervical vertebræ. The lesion may be due to a
deranged vertebra, or to disease of the membrane of the cord, or of the
anterior horn of the gray matter (See Hiccoughs).
Paralysis of diaphragm from the phrenic may be single or double. When
single it is not very noticeable. When double, respiration must be
carried on by the intercostals and accessory muscles. When quiet,
the patient may not notice it but on exertion there may be temporary
dyspnea. Bronchitis with its constant coughing is a bad complication.
Various disorders of the phrenic nerve are principally treated in the
area of the origin of the phrenic nerve. Tumors, aneurism, caries, and
neuritis are possible complications.
Lesions to the =brachial plexus= are usually derangements of the
cervical or upper dorsal vertebræ. Focal infections should not be
overlooked. Direct injuries, contraction of muscles, a deranged
clavicle, a cervical rib, or a dislocated shoulder are to be thought
of. (See, also, Painful Shoulders, Part I) The X-ray as a diagnostic
aid may be invaluable.
In obstructions to the =musculo-cutaneous= nerve, the power to flex the
forearm upon the arm is greatly impaired. The lesion is most likely to
be found between the fifth and sixth cervical vertebræ.
Clinically, the =median nerve= is of special interest from the fact
that atrophy of the muscles of the ball of the thumb, which is
pathognomonic of progressive muscular atrophy, may be caused by an
affection of this nerve. The lesion is usually from the third to the
seventh cervical vertebræ.
Lesions of the =ulnar nerve= may arise between the sixth and seventh
cervical vertebræ, but are oftentimes found as low as the fifth dorsal,
especially at the fifth rib on the side affected.
Lesions of the =circumflex nerve= may be found in the lower cervical
vertebræ, but are commonly caused by dislocations of the humerus and
clavicle.
Lesions of the =suprarscapular nerve= occur most frequently from the
fifth to sixth cervical vertebræ.
The =posterior thoracic= may be lesioned at the fifth or sixth
segments, or by pressure injuries to the serratus magnus.
=Dorsal Nerves.=—The essential osteopathic points of the dorsal nerves
have been considered under intercostal neuralgia. It might be stated
that the posterior fibers of the sixth and seventh dorsal nerves supply
the skin of the pit of the stomach. This is of value, clinically, as
severe pains in the epigastric region which may result from impingement
of these nerves, are supposed by the patient to be due to stomach
disorder.
Diseases of the =liver= may be manifested by =pains= in the region of
the right scapula. It has been suggested that the stimulus passes from
the liver up the pneumogastric to the spinal accessory and down the
spinal accessory to the trapezius muscle and thus causes the “liver
pain.”
=Intercostal neuralgia= is more common on the left side of the body.
The intercostal veins of the left side empty into the left superior
intercostal vein or the left azygos. Thus the blood, to reach the vena
cava, is obliged to take a circuitous route and stagnation is more
likely to occur than on the other side.
The glandular structure of the =mammary glands= is supplied by
intercostal nerves from the third to the sixth interspace. Lesions here
will cause various diseases of the breasts and adjustment will cure
many of them.
=Lumbar Nerves.=—The lumbar nerves may not only be deranged by various
growths, inflammatory processes and abscesses in the abdomen, but by
lesions, infections, parturition, and developmental defects of the
lumbar vertebræ. Tuberculosis of spine, sacro-iliac and hip joints, is
not rare. In doubtful cases utilize the X-ray plate.
Lesions in the region of the =first lumbar= may affect the
=iliohypogastric= and =ilio-inguinal= nerves and causes various
irritations of the penis, scrotum, labium and thigh. Also, the perineal
region may be involved, as well as connecting branches of these nerves
to various visceral nerves underneath.
The =genital organs= may be affected by lesions to the =genitocrural=
and =external cutaneous= nerves, caused by vertebral lesions of the
second and third lumbar vertebræ. The latter nerve may be irritated by
pressure underneath Poupart’s ligament.
Lesions at the third and fourth lumbar vertebræ and sacro-iliac
articulation may affect the =obturator nerve=.
=Sacral Nerves.=—Lesions to the sacral nerves are especially liable
to occur when an innominatum is subdislocated, as that changes the
relative position of the femur with the body and causes impingement to
the sacral nerves. Contraction of the pelvic and thigh muscles also
affect sacral nerves. Other lesions to the sacral nerves may be located
at the fifth lumbar and sacrum. It should be remembered that the
centers of the sacral nerves are in the lower dorsal and upper lumbar
region. Various lesions to the sacral nerves may be caused by pelvic
inflammation, compressions by growths, and injuries and contractions of
muscles within the pelvis. Sciatica has been described under neuritis.
FOOTNOTES:
[114] See Osteopathic Lesion—Journal of American Osteopathic
Association. May, 1906, and Deason’s Physiology.
[115] Nervous and Mental Diseases, p. 622.
[116] See Diseases of the Eye, Part I.
[117] See Ear Section, Part I.
[118] R. D. Emery reports a case of Meniere’s disease as cured. A. O.
A. Case Reports, Series IV.
GENERAL AND FUNCTIONAL DISEASES
Paralysis Agitans
(SHAKING PALSY)
=Definition.=—A chronic, nervous disease, characterized by tremors,
muscular weakness, muscular rigidity and alterations in the gait.
=Etiology.=—The disease usually commences after forty years of age,
but occasionally it occurs from the thirtieth to fortieth years. It
is more frequent in males than in females. Heredity seems to have but
little influence in the cause of the disease. Among the principal
causes are physical injuries, exposure to cold and wet, emotion, worry,
alcoholism, sexual excesses and acute diseases. Physical injury,
in conjunction with exposure to cold is the best determined cause.
Disorder of the vertebræ of the cervical or dorsal regions, or of the
upper and middle ribs, can generally be found. Traumatic influences
probably affect the nerve centers, causing a disturbed innervation,
either by the direct effect of the deranged structures upon the nervous
tissues or obstructing nutritive channels to the nervous tissues.
In most cases no changes have been observed in the central nervous
system or in the sympathetic ganglia. Some observers have noted
induration of the pons, medulla and cord, but these changes may be due
to senility or to the indirect consequences of the long disturbance
of function. In a few cases, interstitial sclerosis of the peripheral
nerves is observed; these are probably secondary changes. Osteopathic
experience regards paralysis agitans as an affection of the central
nervous system, due to a disordered structure in the locality affected.
=Symptoms.=—The onset is usually gradual, but may come on quite
suddenly after exertion. The =initial= symptoms are usually tremor,
stiffness or weakness in one hand. In rare cases, at first there may
be neuralgic pains, dizziness and symptoms of a rheumatoid nature. The
tremor can be controlled by the will at the onset of the disease. The
affection gradually extends until an entire side or the upper or lower
limbs are involved. At this =advanced stage= of the disease, a peculiar
muscular rigidity of the involved region takes place. Muscular weakness
comes on at about the same time as the rigidity, and the loss of power
varies much in degree. The condition is most marked in the fingers and
hands, whence it extends to the arms and legs. It commonly passes from
the right arm to the right leg, then to the left arm, and then to the
left leg. At this stage the movement between the thumb and fingers is
like that of crumbling bread. The writing is greatly affected and in
time it is impossible to write. The trembling may be so violent as to
prevent sleeping. There is occasionally an intermission of days in the
tremor.
On account of the rigidity of the muscles, the patient assumes a
characteristic =attitude= and =gait=. The position of the body is
that of a tendency to go forward, the head is bent forward, the back
curved outward, the arm bent at the elbow and held away from the body,
and the knees so close together that they rub in walking. The gait
is a “propulsive” one, and when once started in a forward walk, the
patient’s gait becomes more and more rapid and he cannot stop until
he comes against some object. The expression of the face is stiff and
mask-like, the speech slow and monotonous and the voice shrill. The
patient is generally restless and troubled with insomnia. The general
health is in fairly good condition. Reflexes are usually normal. The
intellect is generally retained, although the physical ailment may
cause mental depression.
=Diagnosis.=—Is usually easy and can oftentimes be made at a glance.
=Disseminated sclerosis= has a tremor, but is shown particularly in
voluntary movements. The speech is scanning and the gait ataxic. The
disease begins in the lower extremities, the attitude is different
from that of paralysis agitans, and there is nystagmus. In =chorea=
the movements are general, irregular and more intermittent, and it
particularly involves muscles of the face. Also chorea is a disease of
children and young adults.
The =tremors= of old age, hysteria, and certain toxic conditions due to
tobacco, alcohol, etc. are generally easily diagnosed.
=Prognosis.=—The disease does not necessarily shorten life; the patient
oftentimes dies with some intercurrent disease. Improvement usually
results from careful, prolonged treatment. Early treatment, of course,
will give the most satisfactory results, and occasionally, if taken
very early, the case can be cured.
=Treatment.=—A most careful examination of the physical structures of
the patient should be made, particular attention being paid to the
=cervical= and =dorsal vertebræ=, the upper and middle =ribs= and the
=muscles= along the spinal column. All irregularities found should be
corrected if possible, and strong, thorough treatment given to the
region of innervation of the affected parts. Traction of the rigid
areas is of some value. Treatment of the arms and legs will also be of
aid. All mental strain and physical exhaustion should be prevented if
possible. General =hygienic measures= are to be employed. The life of
the patient should be quiet and regular. Bathing, fresh air, massage
and outdoor life will aid in improving the general health. =Persistent=
treatment will retard the progress and frequently improve the general
condition. Simple and hysterical tremor must not be confounded with
that of paralysis agitans. E. Ashmore[119] reports an interesting case
which shows about what may be expected under treatment.
Acute Chorea
(ST. VITUS DANCE)
=Definition.=—A functional disorder of the nervous system, chiefly
affecting children, more than twice as frequent in females as males;
characterized by irregular involuntary muscular contractions, often
slight mental disturbance, and liability to endocarditis.
=Osteopathic Etiology.=—The disease affects children of all stations,
but is more common among the lower classes. The greater number of
cases occur before the age of twenty. It sometimes develops during the
early months of pregnancy, when it often assumes the maniacal type.
Chorea is frequently associated with endocarditis and rheumatism and
delayed menstruation. It occasionally follows infectious diseases of
childhood, especially scarlet fever. Fright, mental worry, sudden grief
and overstudy may bring on an attack. Children of neurotic stock are
more susceptible. Heredity plays some part as a predisposing cause.
Reflex irritation from worms or from genital irritation has a slight
influence upon the disease. Overwork in school is an important factor.
=Derangement= of the =anatomical structures=, involving the nervous
system along the spinal column, is the most common predisposing
cause. Most of the anatomical displacements are found in the cervical
vertebræ, although the upper dorsal may be involved.
=Pathologically=, as yet, no constant anatomical lesions have been
found. Emboli occur in some cases, but this might be expected, as
endocarditis so frequently occurs as an effect and not the cause of
chorea. “In cases not rheumatic, the most probable explanation of the
symptoms is to be found in vascular changes, having their origin in
disturbed nutrition.” (Holt) According to osteopathic theories and
investigations, the disease is due to various irritations to the spinal
centers and nerves of the affected region. The disordered nerve cells
may be the result of direct pressure, hyperemia, anemia, etc., and the
action upon the brain centers is possibly a reflex act. Of late acute
chorea is regarded by some as an infectious disease.
=Symptoms.=—In the majority of cases the muscular movement is
not severe. They are purposeless and the child appears awkward.
Restlessness, disturbed rest at night, crying spells, pain in the
limbs, headache and irritability, are some of the premonitory symptoms.
In =mild cases= one hand, or the hand and face, are involved.
Occasionally there is some difficulty in talking. The irregular, jerky
movements are characteristic of this disease. The child is anemic, and
the muscles are weak. In =severe cases= the movements are general,
the power of speech is lost, and the patient is unable to get about.
The condition usually occurs after one or more mild attacks, although
it may occur primarily. During an attack of chorea, the child’s
disposition changes, he becomes irritable, cannot concentrate his mind,
memory is affected and hallucinations may occur. The reflexes do not
usually differ from the normal. =Maniacal chorea= is most serious, and
often proves fatal, although recovery may occur. This form occurs most
frequently in pregnant women. Speech is greatly affected and insomnia,
fever and maniacal delirium develop. The =duration= is from six to ten
weeks, in the average case. Mild cases may recover in a month or less,
others last six or more months. There is a tendency of chorea to recur;
rheumatism seems to favor this tendency. In children recovery is the
rule.
=Diagnosis.=—In the majority of cases chorea is easily diagnosed. The
symptoms are generally very characteristic. In a few cases of hysteria
there may be difficulty of diagnosis, but history and rhythmical
movements will usually differentiate. In =hereditary ataxia= the slow,
irregular movements, the scolioses, scanning speech, talipes and the
existence of other cases in the family, will differentiate this from
chorea. =Cerebral sclerosis= usually occurs in infancy; impaired
mentality, exaggerated reflexes, rigidity and chronic course of the
disease, are points which render the diagnosis easy.
=Treatment.=—Nearly all cases can be cured.[120] The predisposing
causes of chorea, osteopathically, are usually found to be subluxations
of the vertebræ or ribs at any point, but particularly in the cervical
vertebræ. Chorea is one of the diseases of the nervous system, in which
constant morbid changes are not found upon the post-mortem examination.
Possibly the reason is because the lesions causing the diseased state
are not deeply seated enough to primarily affect motor centers; but
are lesions of the spinal column and ribs, affecting simply the nerve
fibers reflexly, as they pass through the intervertebral foramina.
There will be found well marked lesions, and upon their correction the
osteopath finds complete recovery largely depends.
The muscle, or group of muscles, involved, will give a =direct clue=
as to where the lesion will probably be found. In nearly all cases,
it is in the spinal region of innervation to the affected muscles.
Other cases may be due to cerebral lesions, as well as to intestinal
and uterine disturbances. Search should be made for possible =reflex=
irritation, such as intestinal parasites, adherent prepuce, eye strain,
nasal abnormalities, etc.
All cases should be taken from school, carefully guarded from
excitement, and placed under the most favorable =hygienic= conditions,
with a certain amount of discipline as to self control. The more
serious cases should be placed in bed, so that rest will be secured as
well as diminished liability to heart complications.
The =diet= must be carefully watched and the bowels attended to
regularly. A milk diet during the early stage is highly recommended.
Do everything possible to restore the general health. Mild gymnastics,
in most cases, will be found of service. Amusement should be given the
child, in the open air if possible. In severe cases where the skin is
harsh and dry, the hot air bath, providing the strength is good, will
give considerable relief from the intensity of the disease. A few cases
of acute chorea run into a =chronic form=, but the latter, as a rule,
yields to osteopathic treatment.
Choreiform Affections
=Myoclonia= is a sudden contraction of a few muscle fibers, a single
muscle or of a group of muscles. A neurotic tendency, infections and
toxic conditions are factors. Occasionally epilepsy may be associated
with it. Osteopathically there can be but little doubt that the
innervation to the muscles involved is interfered with.
The lower extremities are usually first affected and it may be sudden
or gradual in appearance. It is progressive and slowly involves the
arms and, rarely, the face. Usually the spasms cease during sleep.
=Prognosis= is rather favorable. Examination should show the cause of
the nerve interference and its correction bring relief.
=Dubini’s disease= is probably associated with certain diseases of the
cord and brain and is characterized by sudden, sharp pains in the head,
neck and lumbar muscles, extending to the lower extremities in the form
of a short, sharp spasm, usually at regular intervals. Later there may
be symptoms of hemiplegia. The disease is apt to progress and death may
occur during a convulsion.
=Habit spasm= usually results from overstudy and nerve exhaustion
with impairment of general health, and is incident to early life. The
child is usually a neurotic. The symptoms are twitching of the mouth
and eyelids, grimaces and jerking of the shoulders. =Treatment= for
the general condition, with correction of any spinal lesions, will
generally give relief.
=General tic= resembles habit spasms closely. In some cases the patient
is apparently healthy, while in others there is some brain disorder.
There are coordinate spasmodic movements of the head, face and upper
trunk, swallowing and abnormal vocal sounds. The movements are rapid
and frequently repeated. =Prognosis= is uncertain and will depend
largely on general conditions. In =convulsive tic= there is usually a
repetition of certain words or sounds with a convulsive twitching or
movement of certain muscles.
Infantile Convulsions
(ECLAMPSIA)
=Infantile convulsions= may be due to various causes. A neurotic
inheritance is an important predisposing factor. They may precede the
development of many diseases of the nervous system, and also occur as
the result of peripheral irritation. Dentition in association with
rickets, and intestinal parasites are common causes. They may be the
early symptoms of acute, infectious diseases. Scarlet fever, measles,
pneumonia and smallpox are very frequently preceded by convulsions.
They may be due to debility, resulting from gastro-intestinal
disorders. Malnutrition is a predisposing cause. Disease of the bones,
especially rickets, may be associated with convulsions. Lesions of the
brain are other causes. A protracted instrumental delivery may cause a
hemorrhage of the meninges.
=Symptoms.=—In severe cases the fit may be identical with epilepsy.
It is more often not so complete as true epilepsy. Convulsions vary
considerably, but there will be no difficulty in diagnosis. It may
come on suddenly, or be preceded by restlessness, twitching, sometimes
grinding of the teeth and fever. The spasms may be either of a tonic
or clonic type preceded by a cry and loss of consciousness. The attack
may be single, but the fits may follow each other with great rapidity
and terminate fatally. It is rare for the child to die during a
convulsion. Exhaustion and asphyxiation may cause a fatal termination.
As in epilepsy the temperature often rises during the fit. A transient
paresis sometimes follows, if the convulsions have been chiefly limited
to one side.
=Diagnosis.=—The diagnosis is generally easy. The attack is usually
due to the ingestion of some indigestible food or to some peripheral
irritation, or an acute disease. Convulsions, appearing immediately
after birth or injury, are probably due to meningeal hemorrhages or
serious injuries to the cortex; although a few of these cases will
present grave lesions of the cervical vertebræ, probably often due to
protracted instrumental delivery. Infantile convulsions usually occur
between the fifth and twentieth months. Convulsions occurring after
the second year are more likely to be true epilepsy. The =prognosis=
depends almost wholly upon the cause, severity and duration.
=Treatment.=—The =first step= in the treatment is to determine the
cause if possible. Treatment in the region of the sixth and seventh
dorsals will often give relief; thorough work along the lumbar region
and the sacrum will many times be sufficient, if the convulsion is due
to intestinal disorder. C. M. Proctor reports that in male infants he
has relieved convulsions quickly, in several cases, by pushing back
the foreskin and has always found, in such cases, either a phimosis
or an adherent prepuce. In female infants it might be well to examine
the clitoris. Dilatation of the rectal sphincter may be of aid. It may
be necessary to vomit the patient, when it is due to undigested food
in the stomach; and in some cases an enema should be used, when the
irritation is in the intestines. In a few cases, when the convulsions
are due to dentition, a lancet applied to the gums will be all that
is required. A thorough treatment to the cervical region, to control
the circulation, should always be given; at the same time apply ice to
the head. The patient should be put in a bath of 95 to 98 degrees F.,
should the preceding treatment not have the desired effect, or, better
still, use the bath at once and treat at the same time.
Owing to the neurotic tendency and the ofttimes trivial causes that
precipitate an attack everything possible should be done to build up
the general condition—adjustment of all lesions, regulated diet and
disciplined habits.
Epilepsy
=Definition.=—A chronic affection of the nervous system, characterized
by attacks of unconsciousness, which are usually accompanied by general
convulsions. When there is merely a momentary loss of consciousness it
is called =petit mal=. Loss of consciousness with convulsions is called
=grand mal=. When the convulsion is localized, with or without loss of
consciousness, it is called =Jacksonian epilepsy=. Certain cases of
temporary loss of consciousness are termed =psychic epilepsy=.
=Etiology.=—Epilepsy usually begins before puberty, and comparatively
seldom after the twenty-fifth year. Males suffer somewhat more
frequently than females. Heredity predisposes to the disease to some
extent, but probably not so greatly as many writers would claim.
Neuroses, as insanity and hysteria, and intermarriage of relatives,
are important elements to consider. When epilepsy is inherited, it is
almost always due to some morbid state of the nervous system. Other
predispositions to the disease may be caused from defective general
development of the brain, from impairment of the general health, and
from an exhausted nervous system.
Many =exciting causes= may be found: mental emotion, fright, excitement
and anxiety; blows and injuries to the head; infectious diseases;
syphilis; alcoholism; masturbation; ocular and aural irritation;
disturbed and delayed menstruation. Epilepsy may be excited by reflex
convulsions from intestinal worms, gastric irritation, etc. Also
thickening of the membranes of the brain, pressure from a tumor at the
periphery, uterine diseases and many other sources of irritation may be
found, that are the exciting causes of epilepsy.
Important exciting causes of epilepsy are, undoubtedly in many cases,
due to =lesions= of the =vertebræ= and =ribs= especially the vertebræ
of the cervical region, although in some cases the lesion is in the
lower splanchnic region or in the ribs (chiefly from the fourth to the
eighth). These lesions to the spinal tissues disturb the nutrition
to the vasomotor nerves. If the real seat of the disease is in the
cerebral cortex and the medulla, the cervical lesion, and in fact other
lesions, could readily affect the nerve force and circulation to and
from these regions. The vertebral artery circulation, where a cervical
lesion exists, may be involved and affect the brain. In cases where
lesions of the vertebræ and ribs exist in the upper and middle dorsal
region, the vasomotor innervation to the brain may be involved, for in
this region the vasomotor nerves to the cranium, etc., pass from the
cord into the sympathetics. Birth injuries may affect the brain tissue,
through cervical lesions, hemorrhages and asphyxiation.
Conklin attaches considerable importance to stasis of the sigmoid and
ascending colon. Lesions involving this region may result in toxins
entering the blood and affecting nervous tissue.
To illustrate a specific exciting lesion, the following is interesting.
The case was one of epilepsy that was evidently caused by a dislocated
right fifth rib. By producing an irritation in the region of this
rib, so that the lesion was increased, the patient could be made to
immediately suffer from an attack of epilepsy. By resetting the rib, at
once the sufferer would be entirely relieved. The case was cured after
three months’ treatment, the chief work being to keep the rib in place.
Rarely a subdislocated innominate bone, or some lesion remote from the
brain, is located and found to be causing epilepsy. Important lesions
in most cases will be readily located in the cervical region. Booth
reports: “I have records of seven fairly defined cases of epilepsy—such
as have been so pronounced by M. D.’s. I find in all of them =marked
lesions= in the =upper cervical= and in most of the cases the occiput
is posterior upon the atlas or twisted. In all cases there was a
thickening of the soft tissues, especially in the upper cervical. The
lower cervical was also much involved but not so noticeably. All of the
cases also presented marked disturbances in the upper dorsal; most were
decidedly anterior, and one very posterior. One was almost a confirmed
drunkard; notwithstanding the fact, he recovered to such an extent that
he went to work, and I understand has been holding his position for
more than three years. He had had to give up his work entirely. One
was a hopeless case in every particular and did not seem to receive
any benefit from the treatment. I think it was entirely beyond help
from any source. The others responded very well and the results were
definite and decided. The length of treatment in successful cases
ranges from about five weeks to a little over a year. But those that
were treated the greater length of time were not treated continuously.”
After one convulsion has occurred, others readily occur, owing to
the proneness to changes in the nerve centers. Very little is known
as to the pathology of this disease. Convulsions may be caused from
irritation of both the cortex cerebri and the medulla oblongata. From
a study of the character of the auræ, one is led to believe that
there is a disturbance, in most cases, in the centers of the cerebral
cortex; and that the lesions so generally found along the spinal column
are the true exciting causes of the disease. Perhaps in a few cases
the irritation may be to the medulla reflexly. The lesions found on
osteopathic examination may act reflexly, as has been stated, upon the
centers in the brain and excite them; or the circulation is deranged,
and consequently the nutrition to the brain and meninges, by vasomotor
control and the vertebral vessels, is impaired.
The splanchnic area and the cervical region should always receive
special attention. This in conjunction with all possible reflex
sources, and, not least, the general health, restoring a stable nervous
system if possible, are of greatest importance.
As a rule, =pathological= lesions are not found. To the naked eye the
appearance of the nerve centers is largely that of healthy organs. The
changes revealed by the microscope are most probably those of secondary
origin. Recent experiments seem to show that the motor zone of the
cortex is affected.
=Symptoms.=—These will be considered under the three varieties, known
as grand mal, petit mal and Jacksonian. =Grand mal.=—In most cases the
seizure is preceded by a pronounced sensation known as the =aura=. This
differs greatly in various individuals. It may begin in a finger or
toe and rise until it involves the head, when the patient screams and
falls to the floor unconscious. In other cases the sensation may start
from other parts of the body, as the epigastric region, where it may
simply be a slight discomfort; or other sensations may be felt, as that
of a ball rising from the stomach. The aura may start from any part of
the body as a numbness, tingling, chilliness, etc., and may, also, be
manifested through the optic, olfactory, auditory and gustatory nerves,
by flashes, smells, sounds and tastes. “Intellectual auræ” may also be
manifested. Some form of auræ is met with in nearly one-half the cases
of epilepsy. Others lose consciousness so early that the patient is not
aware of the onset. In cases not attacked suddenly and not preceded
by an aura, a prolonged prodrome may be present for several hours or
a day. The patient may feel irritable, dizzy or dispirited. Or he may
be quiet and calmly await the attack. In a few cases certain movements
may precede an attack, as running rapidly forward in a circle, or
standing on the toes and rotating rapidly. The attack proper is sudden.
The patient falls with a peculiar cry. The =convulsion= or fit may be
divided into =three stages=, that of =tonic= spasm, of =clonic= spasm
and of =coma=.
The =tonic spasm= succeeds the epileptic cry; there are loss of
consciousness, pallor of the face and the contraction of pupils. The
body assumes a position of tetanic rigidity, the head is retracted and
rotated, and the spine curved, owing to an unequal affection of the
muscles of the two sides. The jaws are fixed, the arms are flexed at
the elbow, the hands at the wrist, and the fingers are clinched. The
legs and feet are extended. The muscles of the chest are involved and
respiration is suspended. This stage lasts a few seconds. The =clonic
spasm= follows the tonic spasm. The muscular contractions become
intermittent. From slight vibratory motions, the intermittent muscular
contraction becomes general. The arms and legs are thrown about
violently, the muscles of the face are distorted, the eyes rolled, and
the lips open and close. The muscles of the jaw contract violently
and the tongue is apt to be bitten. The pupils are dilated, the face
cyanosed (though at first the face is pale and pupils contracted) and
blood-streaked, frothy saliva pours from the mouth. The feces and urine
may be discharged involuntarily. The temperature rises about one degree
F. This stage lasts about one or two minutes. The period of =coma= may
last from a few minutes to several hours. Usually if left alone, the
patient will awaken after a few hours. In a few cases mental confusion
follows the waking. During the stage of coma, the face is congested
but not cyanotic. The muscles are relaxed and the breathing is noisy.
Epileptic attacks during sleep, =nocturnal epilepsy=, are not rare.
This may continue for some time without the patient being aware of it.
=Petit Mal.=—In this variety of epilepsy, convulsions are absent. The
seizure consists of momentary unconsciousness with fixed, staring eyes,
dilated pupils and rarely any twitching of the muscles. After the
attack the patient resumes his work. There may be attacks of vertigo,
without unconsciousness, and the patient may fall. In a few instance
there may be auræ of various kinds. Petit mal may be a forerunner of
grand mal or the two may alternate. Between grand and petit mal there
are many grades of epilepsy varying in severity.
=Jacksonian Epilepsy.=—The affection is always symptomatic of lesion in
the motor area of the cortex. The lesion is quite apt to be a tumor,
though various injuries, inflammation, sclerosis, softening, hemorrhage
or an abscess may be the cause. Consciousness is retained and the
convulsions are limited in extent. Tonic and clonic spasms of the same
character as in general epilepsy occur. A slight numbness, tingling, or
twitching may precede the attack.
The =severity= of epilepsy =varies= extremely. The seizure may occur
but once a year or it may occur several times in a day. In many cases
a marked periodicity is observed. The mental functions are not, as a
rule, injured, but when the seizures are frequent, the health fails
and the mental capacity is reduced. Many sufferers from epilepsy are
subjects of chronic gastric catarrh, and have at the same time an
inordinate appetite. Quite frequently a fit may follow inordinate
eating.
When there is a =series= of =convulsions=, which follow one another in
rapid succession and which are associated with high fever, the term
“=status epilepticus=” is applied. The most =common form= of epilepsy
is the =major= form. About two-thirds of all attacks occur between
eight a. m. and eight p. m.
=Diagnosis.=—=Uremic convulsion= closely resembles an epileptic
convulsion. When the history of the case, analysis of the urine,
increased temperature and the general health of the patient are all
closely observed, error should be avoided. In =reflex convulsions= of
=children=, a careful search, and if necessary waiting a short time,
will readily determine the source of the attack. When =nocturnal
convulsions= take place without the knowledge of the patient the attack
is epileptic. In =hysterical convulsions= the patient rarely loses
consciousness. They rarely hurt themselves, never bite the tongue, the
temperature is normal, opisthotonos does not occur, and the duration
is usually longer. In =Jacksonian epilepsy=, the attack is limited to
some portion of the body, or it may gradually extend into a general
convulsion. Care should be taken to recognize petit mal.
=Prognosis.=[121]—Records show that many cases have been cured and a
much larger number have been benefited.
=Treatment.=—Osteopathic treatment has been especially successful in
epilepsy, as compared with other treatment. Although the osteopaths
do not claim a cure in every case, by any means, still about four out
of every ten have been cured, while one-half of the remaining have
been greatly helped in regard to the lessening of the severity of the
attack, and in rendering the attacks less frequent. Conklin through his
special treatment of fasting, dieting, enemata, spinal adjustment, and
particular attention to the large bowel, especially cecum and colon,
has increased this percentage. This is based on several hundred cases.
Important lesions are usually found in the cervical region, from the
third to the seventh vertebra, though they may be as high as the
atlas. These lesions may affect the brain in various ways; probably
in the manner described under the etiology. Lesions are also found in
the dorsal vertebræ and when occurring below the cervical region, the
lesions are generally found in the upper and middle dorsal regions,
though they may be located at any point along the spinal column.
The treatment is according to the rule that applies to all osteopathic
work: an individual correction of the lesions presented in the case at
hand. If any general movement or treatment might be given, it would
be strong traction of the head to stretch the cervical vertebræ, or
rather to separate them, so that the circulation to the brain may be
equalized. Another general measure is to hyperextend the neck with
fulcrum at juncture of atlas and occiput, thus releasing the upper
anterior tissues that may impede cerebral circulation.
If the lesions in such cases are in the cervical vertebræ, probably
they affect the cervical sympathetics. A =careful search= for a source
of excitation must be made throughout the entire body. An irritation
of the intestinal tract may be the exciting cause; or some irritation
of the genito-urinary tract may be found, as phimosis, masturbation,
etc., so that it is very necessary that great care be taken in the
examination. Subjects of masturbation usually present lesions along the
genito-urinary center in the spine. All possible reflex irritations
should be eradicated.
Proper =hygienic measures= should be added. Pay particular attention to
the bowels. Place the patient in the knee-chest position and thoroughly
raise the cecum and ascending colon in order to improve circulation
and promote elimination. Baths are important, and plenty of fresh air
and outdoor exercise are of much significance. The patient’s mind
should be occupied. The question of food is an important one; general
diet—carefully regulated as to the amount given—should be prescribed. A
vegetable diet is usually best. Reduction of salt seems to have a good
effect. The patient must not be allowed to eat too much at a time, nor
too often. If the bromides are being used, they should be withdrawn
gradually.
In most cases of true epilepsy a continued treatment of several months
is necessary. Unless the patient can follow out the treatment for
several months, or even years, in a number of cases it will be entirely
useless to take the treatment; although if the lesion present is very
apparent, and the patient is enjoying fair health otherwise, and has
not been affected long, a treatment for a few months, or even weeks,
might be all that is necessary.
=Surgical interference= may be indicated in Jacksonian epilepsy.
Trephining has been practiced successfully in a number of cases and
the risk from operation with modern surgery is so reduced that one is
frequently justified in advising an operation.
=During= an =attack=, a special treatment cannot be given to lessen the
severity of the fit in all cases; in fact, most patients prefer not to
have the seizure shortened as the after effects are more disagreeable.
In some cases, at the beginning of the seizure, exerting a firm
pressure upon the suboccipital will quiet the patient. This treatment
probably controls the circulation of the brain, by way of the superior
cervical ganglion. In cases where the exciting factor seems to be in
the intestines, and the peristaltic action of the bowels is reversed,
causing a reversion of the nerve current of the vagi, a rapid, firm
kneading over the abdomen, so as to establish normal peristalsis, will
suffice to prevent an attack, if one is notified of its approach. In
some cases a rapid, thorough stimulation of the solar plexus will
lessen an attack. Possibly it reduces the blood pressure in the brain,
by bringing blood to the splanchnic region.
In all cases during the convulsion the patient should be carefully
protected from injuring himself. A towel should be twisted and placed
in the mouth, so that the tongue cannot be bitten. Do not place small
articles as corks, etc., between the teeth, as they are liable to enter
the pharynx and cause suffocation. The patient should be watched to
protect him from any injury; otherwise the attack should usually be
allowed to spend itself.
Migraine
(SICK HEADACHE)
=Migraine= or sick headache is a neurosis, characterized by a
paroxysmal pain in the head, usually unilateral and periodical, with
nausea, frequently vomiting, and disorders of vision.
=Osteopathic Etiology.=—The disease usually begins in the first half
of life, rarely earlier than puberty and is slightly more frequent
in females. Some weakened or depressed condition of the nervous
system, due to lesions of the upper cervical vertebræ, lesions of the
inferior maxilla, anxiety, overfatigue, anemia, digestive derangements,
=eye strain= and menstrual disorders, is generally the cause. The
hereditary factor is very important. This is frequently associated with
derangement of the =large bowel=, especially cecum and ascending colon,
resulting in toxemia.
It is supposed by some to be a =vasomotor= disturbance, because
there are symptoms, as pallor and flushing of the skin, which show
an involvement of the sympathetic system. It is possible a spasm of
cerebral arteries, followed by vascular dilatation, takes place. The
seat of the pain is believed to be in the meninges of the brain.
Possibly in many cases where the atlas is found involved and causing
the affection, some meningeal fiber of the fifth nerve is impinged by
the lesion. Caries of the teeth and =nasal troubles= are causes of the
disease in children.
=Symptoms.=—A =paroxysmal= headache is the principal feature of
migraine. The attack may occur without warning, although there are
usually malaise, restlessness and a disturbed vision preceding the
headache. The =prodromal= symptoms vary to a great extent. Other
prodromal symptoms besides those given, may be vertigo, spots before
the eyes, tinnitus, chilliness, etc. The pain is of a sharp and
stabbing nature and is oftentimes limited to the temporal region of one
side. Others describe the pain as of a binding or of a boring nature.
It is continuous. It may be in the occiput instead of in the side of
the head.
=Hyperesthesia= of the surface is noticed, but the tender points of
neuralgia of the fifth nerve are absent. The patient is sensitive to
light and noise. Flashes of light occasionally attend the pain in
the head. Hemianopia is not infrequent. The temporal artery may be
contracted, the face pale and the pupil large. In others the eye is
dilated, the face flushed and the pupil small. Nausea and vomiting
are frequent, with loss of appetite. In some cases where the stomach
is full, vomiting the contents will relieve the attack. Should the
stomach be empty, vomiting of mucus may occur, and is later followed by
vomiting of bile. Tenderness is commonly found about the region of the
occipital and upper cervical muscles. Attacks rarely occur oftener than
once in ten or fifteen days. During the intervals the patient may be
quite well. The =duration= is anywhere from a few hours to several days.
=Diagnosis.=—The sensory symptoms, the paroxysmal character, the
severity and definite course, usually readily distinguish migraine.
=Growths= of the =brain= may be the cause of symptoms closely
simulating migraine. In such cases an ophthalmoscopic examination may
reveal a choked disc.
=Prognosis.=—Is usually favorable when the attacks are light and of
short duration. Cases of long standing and of great severity are not so
easily cured, although in most instances great relief can be given the
patient. There are very few cases in which the severity and frequency
of attacks cannot at least be lessened. Oftentimes attacks of migraine
cease after middle life.
=Treatment.=—The =atlas= or one of the =upper cervical= vertebræ is
almost invariably subluxated. This is not always the direct cause of
migraine, but it is an important factor in the causation. =During= the
=attack= many cases can be completely, or at least partially relieved,
by a careful treatment in the upper cervical region. But there are some
cases where treatment of the cervical region is entirely unsuccessful,
and, in fact, aggravates the attack. The details of treatment vary in
every case. If any defects in general health or any error in the mode
of living can be found, these of course must receive first attention.
Rest, diet (a vegetable diet is best) and regularity of meals are
usually to be specially considered. Anything that is known to induce
an attack must be carefully avoided. In some patients the attacks
cease so long as they remain free from mental work, but as soon as they
return to their studies the paroxysms occur.
Every case should be thoroughly examined before a course of treatment
is laid down. Causal conditions can generally be found, and the
correction of such usually results in a cure, or at least in great
relief. Errors in diet; digestive disturbances, as a disordered biliary
tract; disorders of the pelvic organs; eye strain; nasal disorders;
mental and physical fatigue, and affections of the nose may induce
attacks.
A beneficial treatment for many, aside from adjusting the spinal
lesions, especially the cervical and usually a rigid splanchnic area,
is to place the patient in the knee-chest position and thoroughly raise
the bowels of the right side beginning in the right iliac, loosening
possible adhesions, etc.
The earlier the treatment, the more likelihood of a cure. Cases of long
standing are generally harder to cure. Preceding a paroxysm, relief can
usually be given, but after the paroxysm has reached its height it is
harder to give relief. The patient should rest in a quiet room which
is darkened and well ventilated. Besides the indicated osteopathic
treatment (generally a cervical one), hot applications to the nape
of the neck and keeping the extremities warm are helpful. The nerves
involved are the vasomotor, occipital, frontal and temporal. A free
evacuation of the bowels will relieve a few cases, while washing out
the stomach will help others. Hot fomentations over the splanchnics
for thirty minutes may be beneficial. During the intervals, valuable
adjuncts will be found in the use of systematic exercises and frequent
bathing. Do not fail to have the eyes examined.
Occupation Neurosis
These are a group of maladies of the nervous system, due to excessive
use of certain muscles in some oft-repeated act, and characterized
by spasm of the muscles concerned. There are several varieties, as
writers’ cramp, telegraphers’ cramp, piano players’ cramp, violin
players’ cramp, typewriters’ cramp, etc.
Professional spasms, that involve muscles of the shoulder girdle, are
not rare among osteopathic practitioners, due to prolonged faulty
methods of technique.
=Osteopathic Etiology.=—A nervous temperament predisposes to the
development of the affection. Previous injuries and strains of the
involved parts are important factors. Faulty methods of writing, and
in the other disorders, strained or cramped positions of the affected
tissues, predispose to attacks. Slight =lesions= of the bones, joints,
ligaments and muscles are commonly found, involving the motor and
sensory nerves of the immediate locality. The majority of all cases
occur between twenty and fifty years of age.
Distinctive =pathological= changes have not been found. Each case
has particular lesions of its own. The details of the case are
characteristic of the one case only. The affection is often primarily a
spinal one, due to deranged action of the spinal centers concerned in
the various acts; though, no doubt, excessive use of a group of muscles
may result in contractions, spasms, contractures and nutritional
changes, that in turn will establish definite osteopathic lesions. This
is an illustration of a “vicious circle.”
=Symptoms.=—Symptoms of the various varieties of professional neuroses
develop slowly and gradually. A cramp or spasm affecting the used
member is an early symptom. Tremor, weakness, stiffness, fatigue and
heaviness of the affected part are present most of the time. In severe
cases neuritis may develop, and a glossiness of the skin be present.
Associated with the inability to perform the usual work, may be mental
worry and depression.
=Diagnosis.=—The history of the case and the limitation of the disease
to one member, usually make the diagnosis easy: =Cerebrospinal=
diseases, as hemiplegia; early =tabes=, affecting the arms; and
progressive =muscular atrophy=, have to be carefully excluded.
=Prognosis.=—As a rule is favorable. Osteopathic treatment, in the
majority of cases treated, has resulted in recovery.
=Treatment.=—Rest of the part, mental quiet and attention to the
nutrition of the patient, are the first essential considerations. A
change of occupation may be necessary if excessive use of parts and
faulty methods can not be corrected. The treatment consists of a
correction of the parts irritating or disturbing the spinal centers
or nerves affected. The ulnar, radial and median nerves all innervate
muscles employed in writing. Lesions of the cord affecting these
nerves may be found from the fifth cervical to the sixth dorsal. In a
few cases lesions occur as high as the atlas. When the =radial= and
=median= nerves are involved the lesions are principally found in the
upper dorsal vertebra. When the =ulnar= nerve is involved the lesions
are usually slightly lower. The lesions may affect the fibers of these
nerves directly (mechanically), but more probably the vasomotor nerves
are involved, as in this region the vasomotor fibers to the arm pass
from the cord to the sympathetic fibers. The brachial plexus originates
higher than the upper middle dorsal region, still some of its nerves
are frequently affected in the dorsal region by osteopathic lesions,
for removal of the same relieves the disorder.
Other lesions affecting the arms are oftentimes found in the ribs on
the side involved. Any of the first five ribs may become deranged and
affect the innervation of the arm. The clavicle in a few cases may
be abnormally low. A bursitis may be present. Occasionally slight
subdislocations of the shoulder joint (especially anterior) and elbow
joint are found. Gymnastic exercises of the arm and hand, coupled with
a general treatment of the shoulder, arm and hand, are beneficial.
Hydrotherapy, massage and friction of the involved member are useful.
In severe cases “breaking up” fibrotic tissue, and muscle training
frequently secures good results.
Hysteria
Oppenheim defines hysteria as “a psychosis, which does not express
itself by disorders of the intellect, but in defects of character and
emotional disturbances, whose real nature is hidden under an almost
unlimited and varied number of physical symptoms of disease.”
The affection is about equally divided between the two sexes. A
neurotic tendency, often inherited, is an important underlying factor.
This condition, when associated with lack of mental discipline, is very
apt to lead to the mental depression and outbreaks of hysteria. A large
number of cases are between the ages of puberty and twenty-five. After
forty-five the disorder is infrequent.
White, Osler’s System of Medicine, says: “The significance of
Freud’s theory is the tracing of every case to sexual traumata
during childhood. Sexual experiences differ, however, from ordinary
experiences—the latter have a tendency to fade out, while the idea
of the former grows with increasing sexual maturity. There results a
disproportionate capacity for increased reaction which takes place in
the subconscious. This is the cause of the mischief.” A distinction is
made between the sexual and the sensual.
Anders points out that lack of proper mental development, improper
hygienic surroundings and chronic toxemia are causes.
The =direct causes= of hysteria may be many, and include physical and
mental influence, or both. Traumatism of various regions of the body,
but especially of the spinal column, may excite hysteria. Some slight
lesion of the vertebra or rib may be all that is discoverable. A
correction of the same is occasionally all that is necessary to remove
the direct cause; still there is usually considerable disturbance
of the spinal tissues, especially slight curvatures and muscular
contractions. Prolonged emotional excitement, overwork, defective
education and many moral and mental influences are potent and frequent
causes. Masturbation or an adherent prepuce occasionally is the cause
of the affection in boys, or any excitation that produces exhaustion.
Disturbances of the sexual system in both sexes are responsible for
many cases. The menstrual period and the menopause are frequent periods
for the manifestation of the disease. The disease often affects
prostitutes. Disturbances of the digestive, nervous and circulatory
systems, and general diseases of an exhaustive kind are exciting causes
of hysteria. Dr. Still said that occasionally the colon is prolapsed
and crowded down upon the pelvic organs. Hazzard[122] is of the opinion
that “a majority of the cases show a depression of all the ribs,
narrowing the thorax and often causing enteroptosis.”
=Symptoms.=—The symptoms may be extremely varied, including any symptom
of the many nervous diseases. The =sensory symptoms= are numerous. The
most common is anesthesia, which may be found in certain parts of the
body, usually one side (the left) of the body. Geometrical areas that
bear no relation to the innervation is characteristic. The patient may
not know of the sensory derangements until discovered by the physician.
When there is =anesthesia= without other nervous symptoms, the case
is commonly hysterical. The most marked symptom is analgesia, where
the patient is insensible to painful impressions. A pin may be placed
deeply into the flesh, and not be felt by the patient. The anesthesia
may extend to the mucous surfaces, and even deeply down to the tissues
of the joints. Organic and tendon reflexes are not changed. There may
be other symptoms of disturbed sensation; as an absence of pressure,
temperature and muscular sensation.
=Hyperesthesia= may be present nearly as often as anesthesia.
Hyperesthetic areas may be found in various regions of the body,
but especially along the spinal column and in the ovarian region.
The “hysterical spinal irritability” is of special interest to the
osteopath. The spinal column may be affected as a whole, or in
segments, or confined to a single vertebra. Especially when a spinal
irritability is in segments, or confined to a single vertebra, are
local derangements of the spinal column apt to be found. Correction or
even =pressure= upon these areas will often relieve the patient. Severe
pain over the heart may simulate angina pectoris. =Globous hystericus=
is of quite common occurrence.
Charcot refers to the ovarian hyperesthesia as follows: “It is
indicated by pain in the lower part of the abdomen, usually felt on
one side, especially the left, but sometimes on both, and occupying
the extreme limits of the hyperesthetic region. It may be extremely
acute, the patient not tolerating the slightest touch; but in other
cases pressure is necessary to bring it out. The ovary may be felt to
be tumefied and enlarged. When the condition is unilateral, it may be
accompanied with hemianesthesia, paresis, or contracture on the same
side as the ovarialgia; if it is bilateral, these phenomena also become
bilateral. Pressure upon the ovary brings out certain sensations which
constitute the aura hysteria, but firm and systematic compression has
frequently a decisive effect upon the hysterical convulsive attack, the
intensity of which it can diminish, and even the cessation of which it
may sometimes determine, though it has no effect upon the permanent
symptoms of hysteria.”
The =special senses= may be disturbed, although these symptoms are
usually transient. There may be blindness; narrowing of the field of
vision, due to anesthesia of the periphery of the retina; loss of
hearing; loss of smell or loss of taste.
=Motor disorders= may be of different forms of paralysis, as
hemiplegia, paraplegia or monoplegia. In fact all forms of =paralysis=
may be found in hysterical patients. Osier says: “There is no type or
form of organic paralysis which may not be simulated in hysteria.” The
affected muscles do not atrophy. The paralysis is usually general, and
contractures are common. Local paralysis, as of the bladder, vocal
cords and other parts of the body, commonly occur.
=Contractures= and =spasms= may also occur. True epilepsy may even
be simulated by hysterical spasms, but on careful observation the
characteristic attack of epilepsy is found wanting. Firm pressure may
increase the severity of an attack as well as bring it on. The spasms
are of various parts of the body, as the diaphragm, bronchi, abdominal
muscles, bladder, etc.
Various =disturbances= of the =viscera= may occur. Of the digestive
tracts, the appetite may be disturbed or depraved. Diarrhea or
constipation may be present. Flatulency is a common symptom. The
respiratory tract may be another point of considerable disturbance
in many cases. Dyspnea, aphonia, hiccough, cough, and exaggerated
breathing, as when cold water is poured on one, are common
manifestations. Various =cardiac= vascular symptoms may be manifested,
especially a rapid heart. Various =vasomotor= derangements are common.
=Physical manifestations=, as amnesia, lack of will power and an
excitable nature—easily moved to laughter or tears—are frequent. The
moral tone may be lowered. Even delirium, catalepsy, ecstasy and
trance, may be mentioned among the psychical phenomena.
The =hysterogenous zones= are of more than passing interest to the
osteopath. Tyson writes as follows, in regard to the hysterogenous
zones: “These are hyperesthetic areas especially studied by Richet,
on which persistent pressure will sometimes excite a hysterical
attack. While the ovaries are favorite hysterogenous zones, the zones
may be in any part of the body; as for example, the sides of the
trunk. Such pressure may also cause an existing attack to subside.
Hysterical spasms may also be localized or limited to groups of
muscles.” Especially when zones along the spine and side of the trunk
are located, the attack of hysteria may be completely relieved by
correcting the localized deranged tissues.
=Convulsive seizures= are not uncommon and may follow various prodromal
symptoms. Some authors divide the symptoms of hysteria into convulsive
and non-convulsive forms.
These are part of the many manifestations that are presented by various
hysterical patients, and it is readily seen that an osteopath has to be
continually on his guard.
=Diagnosis.=—The diagnosis is generally quite easy. The characteristic
emotional symptoms, associated with any of the many other symptoms
which have no organic lesion, are characteristic of the disease. Care
has to be taken, though, in some cases where symptoms are presented
which have organic lesions. The history, the attack and neurotic
temperament, will largely decide the nature of the affection. After the
“outbreak” the patient often feels decidedly better.
=Prognosis.=—Death may occur from exhaustion, but such a termination
is rare. Recovery is the rule, although the duration may be long.
Recovery usually takes place rapidly, after the exciting cause has been
determined and removed.
=Treatment.=—First of all, the osteopath should have due appreciation
of the mental characteristics of the disease. Whatever is dominating
the patient mentally must be either changed or abolished. It is not
always necessary to be harsh and severe with the patient; but one
should be firm and unyielding. He can do a great deal by having
complete mental control of the hysterical patient.
A most careful examination should be made for an exciting cause,
and when found it should be removed. This naturally constitutes a
very important part of the treatment. A light general treatment is
commonly indicated. The general health, especially the bowels,
should be carefully attended to. The hygiene, exercise and amusement
of the patient should receive due consideration. One has to gain the
confidence of the patient, and then be firm but kind to him. Relative
to diet Yeo[123] says: “The diet should be simple, abundant, and
supplied regularly, and at not too long intervals as is frequently the
case in boarding schools. All strong stimulants are best avoided, and
the hysterical should not indulge in strong tea or coffee, or exciting
wines and liquors.”
The “rest cure” as introduced by Weir Mitchell, is applicable in
some cases. This method consists of plenty of food, especially milk,
absolute rest of the body and mind, massage and electricity with
isolation of the patient from friends and sympathetic relatives.
Doubtless a general osteopathic treatment would be much better than
massage. Yeo says that to the application of hypnotism and suggestion
“we look with little sympathy and less confidence.”
During the hysterical =convulsions=, the patient should be watched, but
extreme measures should not be practiced. There is little danger of
patients hurting themselves. Throwing cold water in the face, or a cold
bath may produce the necessary mental shock. Pressure over the ovary
as stated in hysterogenous zones, or some other zone of the body, or
pressure upon a large blood vessel, as a carotid, will oftentimes stop
an attack.
Neurasthenia
“Closely allied to, and in some cases almost inseparable from,
hysterical states are those morbid conditions to which, in modern
times, has been applied the term neurasthenia.” (Yeo). Neurasthenia
is a fatigue neurosis that is characterized by mental and physical
irritability and inefficiency. Headache, backache, insomnia, and
debility of the gastro-intestinal tract are common symptoms.
The affection is often found in that class of people who are
predisposed to hysteria. The disease is more common among men than
women, usually occurring after the twentieth year. The predisposition
may be inherited or acquired. Church states that “debilitating
conditions in the antecedents of neurasthenics,” and “defective
education that omits discipline and the cultivation of self control”
are important predisposing causes. Many of the exciting causes that
produce hysteria will cause neurasthenia. Various =lesions= along
the spinal column, chiefly in the cervical and upper dorsal regions,
include the predisposing causes of a large majority of cases. This
spinal irritation, taken in conjunction with overstrain of mind
and body, or probably in many cases the spinal irritation as the
predisposing cause of the over strain, results in nervous exhaustion.
Particularly overwork, associated with care and anxiety, is an exciting
cause of great significance.
The neurasthenic patient is generally of a =neurotic temperament=.
The affection may, also, result from various chronic diseases, toxic
conditions, sexual excesses, alcohol and tobacco. Thompson[124]
believes that improper sexual hygiene and perversion or abuse of the
marital relation are most important factors in the development of
neurasthenia in both sexes, and a regulation of this is imperative
for a cure. The symptoms are due, to a greater or less extent, upon
=spinal=, =cerebral=, =cardiac= and =gastric disturbances=, but all
of these conditions are usually dependent upon =vertebral= and =rib
lesions= of the upper dorsal and cervical regions. Care should be taken
whether the condition is secondary to organic lesions. The lesions
in the vertebræ are generally slight lateral deviations, in the ribs
upward displacements of the vertebral ends, followed by contraction
of the deep muscles in the neighborhood of the lesions. A posterior
condition of the atlas and a lateral lesion between the third and
fourth dorsal are especially apt to be found. As to spinal areas most
affected Stearns[125] says the predisposing irritations are located
particularly in the first two cervical, the first two dorsal and the
last two lumbar vertebræ.
These various lesions probably cause an impairment of nutrition in
the nerve centers of the cord and brain, or both. Definite =morbid
anatomical= changes have not been found resulting from nervous debility
or irritability. Still, it seems probable that certain changes in the
nerve cells may result from excessive functional activity. =Traumatism=
is a prominent causative factor in both =neurasthenia= and =hysteria=.
=Railway= and other =injuries= frequently produce osteopathic lesions
that result in nervous disorders. That there is a demonstrable
pathological basis resting in sympathetics and spinal nerves, there can
be no doubt.
=Symptoms.=—To enumerate the many symptoms of neurasthenia in detail
is hardly necessary. The nervous debility may affect any organ of the
body, owing to the exhaustion of the nervous energy, thus lessening the
functional activity of that organ.
The most noticeable symptoms are various =sensory disturbances= and
=muscular weakness=, dependent in part upon the spinal lesions. The
patient generally feels weak and tired. Headache, pains in the back
and sacrum, tender points along the spine, and various sensations of
numbness, tingling, etc., are felt.
The =mental faculties= are oftentimes irritable and weak. An inability
to concentrate the thoughts with depression, fear, vertigo, insomnia,
and many other mental symptoms, may be manifested.
=Palpitation=, irregular action of the heart and pain over the
precordia may be present. =Ocular= disturbances, particularly blurring
of letters and narrowing of the visual field, =visceral= symptoms
of many kinds, and =vasomotor= phenomena, as chilliness, flashes of
heat and sweating, are among the many symptoms of which the patient
complains.
=Genito-urinary= disorders in the male, and ovarian and uterine
irritation and painful menstruation in the female, are occasionally
symptoms dreaded by the sufferer. Polyuria is frequent.
The symptoms or signs of great importance to the osteopath in
neurasthenia, as in many other diseases, are the tender points along
the spinal column. They give direct clues as to where the lesion may be
found.
=Diagnosis.=—Error in diagnosis can usually be prevented by a study of
the history of the case and symptoms. Care must be taken in determining
between symptoms of organic diseases and the symptoms of a true nervous
exhaustion.
=Prognosis.=—Is almost invariably good. Only in cases where there is
a tendency to mental disorder should the prognosis be guarded. Much
depends upon the thorough cooperation of the patient. It usually takes
some time to perform a cure among the poorer class, as the requirements
demanded for a cure are oftentimes expensive.
=Treatment.=—Naturally the treatment, exclusive of the manipulation to
correct the various lesions found, is extremely varied, owing to the
many exciting causes and symptoms to contend with.
As has been stated, the lesions are usually found in the upper spinal
region; still lesions are occasionally located in the lower spinal
region, especially in female sufferers, when the pelvic organs are
disturbed. The many mental symptoms, as inability to concentrate the
mind, insomnia, vertigo, headache, etc., are best treated through the
cervical region, with attention to the heart’s action and the excretory
organs. Careful attention should be paid to the deep posterior muscles
between the atlas and occipital bones.
=Rest= is very necessary. Changes of scene and occupation, attention to
the surroundings, careful dieting, hydrotherapeutic measures, pleasant
companions, relief from responsibility, bathing, etc., should receive
careful attention and consideration by the osteopath. Set rules cannot
be given. The details of treatment that should be adopted are dependent
upon the individual case. Every well trained osteopath will be familiar
with such measures.
Careful attention must be given to the secretions, excretory organs
and the circulation. A study of each case will bring out the various
irregularities that may exist.
When the nervous involvement is extensive, a “general treatment” may be
given. Such a treatment would affect the entire nervous and muscular
system, and tend to equalize disturbed nerve force. Bringing the
muscular system into play and relaxing contracted muscles calls for
more blood and nerve force, and consequently a nutritious diet.
The “rest cure,” as introduced by Weir Mitchell, may be employed to
considerable advantage in many cases. Yeo says: “It is in certain cases
of this disease that the ‘rest cure,’ devised by Weir Mitchell, has
proved so remarkably successful. But there can be no sort of doubt
that it has been applied far too indiscriminately, and that for this,
as indeed for any special method of treatment, a careful selection of
suitable cases is needful.” The diet should consist principally of milk
at first, followed in a few days by soft boiled eggs, boiled rice, lamb
chops, graham bread, stewed fruits and butter, and a little later by
roast beef, vegetables and light puddings. Porter’s system of milk diet
has proved effective in many cases. Tea, coffee and alcohol should be
avoided.
During the entire course of the treatment, care should be taken
to correct any lesion that may bear directly upon the cervical
sympathetic, the solar plexus and the hypogastric plexus, as they are
the great reflex centers of the body.
FOOTNOTES:
[119] A. O. A. Case Reports, Series IV.
[120] See A. O. A. Case Reports, Series II., III., IV., V.
[121] See A. O. A. Case Reports, Series I., III., V.
[122] Practice of Osteopathy.
[123] Manual of Medical Treatment.
[124] Cosmopolitan Osteopath, October, 1903.
[125] Journal of Osteopathy, January, 1904.
DISEASES OF THE SPINAL CORD
Acute Myelitis
=Acute myelitis= is an acute inflammation, with softening of the
substance of the cord, giving rise to marked disturbances of motion,
sensation and nutrition. When the whole thickness of a section of the
cord is involved, the condition is termed =transverse myelitis=. When
an extensive area is involved, it is termed =diffuse myelitis=. When
the gray matter around the central canal is especially affected, it is
termed =central myelitis=.
=Etiology.=—There can be no doubt that osteopathic lesions are very
potent predisposing factors. Osteopathic lesions of the spine, even
of a muscular nature, readily disturb the cord circulation. It may
follow repeated exposure to wet, cold or exertion; or be a sequel to
the infectious diseases, as smallpox, typhoid fever, typhus, puerperal
fever or measles. It may be due to traumatism or disease of the
vertebræ, as caries or cancer. Syphilis is a frequent cause.
=Pathology.=—To the untrained, naked eye, the cord may present
little or no change. The nervous tissues are in various stages of
degeneration. On section the substance of the cord is red and soft,
the line of demarcation between the gray and white matter is lost or
extremely indistinct, and minute hemorrhages are sometimes seen. In
very acute cases, affecting the white and gray matter, after injury,
when the membranes are cut, the substance of the cord may flow out as a
reddish creamy fluid.
The nerve fibers are much swollen and the axis cylinders broken up.
Blood discs, leucocytes, and numerous granular fatty cells may also
be present. The blood-vessels are distended and dilated. There may be
thickening and hyaline degeneration of the vessel walls and hemorrhagic
extravasation.
=Symptoms.—Acute Transverse Myelitis.=—This is the type most frequently
met with. The symptoms differ with the situation of the lesion, which
is generally in the dorsal cord. At the onset there may be pain;
numbness and tingling in the back, radiating into the limbs. There
is usually moderate fever, malaise, chills, muscular pains, a coated
tongue and constipation. Symptoms of =motor paralysis= soon develop,
which may become more or less complete. Both motor and sensory symptoms
vary to a marked degree, depending upon the pathologic involvement. The
reflexes are lost at first. They may soon return and are exaggerated
below the lesion. Following this the muscles often become rigid and
contracted. Unless the lesion is in the lumbar or cervical cord,
reaction of degeneration or much wasting of the muscles, as a rule,
does not occur. A girdle sensation frequently occurs at the level of
the disease. At first there is retention of the urine and feces, later
incontinence. Bed-sores soon develop; also drying and hardening of
the skin. The nails become thick and brittle. Death may occur from
exhaustion, or heart or respiratory failure, but it is rare; segments
of the cord may be completely and permanently destroyed, causing
persistent paraplegia. H. A. Greene[126] reports a case, due to injury,
which was greatly benefited by treatment.
=Acute Diffuse Myelitis.=—In the acute forms the course of the disease
is rapid. The trophic disturbances are more marked than in the former
type. This form is likely to follow exposure to cold, injuries, tumors,
syphilis or one of the infectious diseases. There may be chills, fever,
malaise, pain in the back and limbs, and occasionally convulsions. The
reflexes are generally lost. The motor functions are rapidly lost.
There is incontinence of urine and feces, rapid wasting of the muscles
and bed-sores develop. The disease may prove fatal in from six to ten
days.
=Diagnosis.—Landry’s Disease.=—In this the bladder and rectum are
not affected. Trophic disturbances are absent. There is but slight
loss of sensation, no reactions of degeneration and no girdle pains.
=Multiple Neuritis.=—Both arms and legs involved, and slow onset. The
bladder and rectum are rarely involved; the girdle pain is absent.
=Acute Poliomyelitis.=—There are no sensory symptoms and the rectum and
bladder are not affected.
=Prognosis.=—In very acute cases death occurs in from three to ten
days. Milder cases generally recover with some loss of motor power,
although in a few cases treated by osteopathy recovery was complete,
due probably to the case being seen early and thus degeneration
prevented.
=Treatment.=—Lesions of the vertebræ are usually readily found in
cases of myelitis. Generally, deranged vertebræ are found in the upper
dorsal region, and occasionally lesions are located in the lumbar and
cervical vertebræ. The treatment of myelitis is chiefly to correct
these lesions, so that the normal circulation of the cord may be
reestablished. One has to be very =careful= when treating the lesions
not to cause additional injury to the cord. An inhibitory treatment
to the muscles about the lesion may be all the treatment that can be
given at first; nevertheless, it aids nature just so much in overcoming
the excessive irritation of the cord tissues. Nature has the curative
means, provided they may operate unobstructedly. In a few cases the
ribs in the region of the spinal lesion will be found deranged and
interfering with trophic fibers, blood-vessels and lymph vessels of the
cord. The patient should be kept in the prone posture at first.
Warm baths and massage will be found of additional value. The bowels
and bladder should receive special attention. An ice-bag to the spine
may be beneficial. If there is any danger of bed-sores, use alcohol to
stimulate and harden the skin. Rest, liquid diet and good nursing are
necessary. Later on careful exercising of the limbs will be beneficial.
=Chronic Myelitis.=—This defines the conditions when the inflammation
is subacute with the paraplegia and other symptoms which then naturally
appear, present, and also with the signs of both degeneration and
repair. The symptoms develop slowly as compared with the acute form. It
should not be confused with atrophy, pachymeningitis or tumors of the
cord. =Treatment= is practically the same as in acute form. Surgical
measures may be indicated. Loudon[127] reports a case due to injury
which was greatly benefited.
Poliomyelitis
(INFANTILE PARALYSIS)
=Definition.=—An acute infectious disease occurring most commonly in
young children, characterized by paralysis, rapid wasting of certain
muscles, and fever. It is an acute myelitis that affects the anterior
horns of the cord. There are no sensory symptoms.
=Etiology.=—It usually occurs in children under ten years of age,
and the majority of cases occur before the fourth year. It is more
common in summer than in winter. The infection seems to gain entrance
through the nasal mucous membrane. Traumatism, exposure to cold and
overexertion, are probably predisposing causes. It has occurred in
severe epidemic form.
=Morbid Anatomy.=—The disease is most frequently seen in either the
lumbar or cervical enlargement and is usually unilateral, though there
is considerable variation in the extent of the lesions. In very early
cases, the condition of acute hemorrhagic myelitis, with degeneration
and rapid destruction of the large ganglion cells, has been found. In
older lesions the anterior cornu in the affected region is atrophied
and there is destruction of the multipolar ganglion cells. The
anterior nerve roots are atrophied, the muscles are wasted and undergo
a fatty and sclerotic change.
=Symptoms.=—The child may have a slight fever, malaise, muscular
twitching, headache, some rigidity of the neck, and sometimes vomiting.
This may last a day or several days or only a few hours, when paralysis
sets in abruptly. The =paralysis= is rarely complete and groups of
muscles only may be affected. As a rule, the paralysis comes on
abruptly, but it may come on slowly, taking several days to develop.
In a few weeks, atrophy sets in and the limb becomes flaccid, soft and
wasted. The paralysis remains stationary for a time when improvement
takes place, but complete recovery is rare. Sometimes the growth of the
bone of the affected limb is impaired. Usually there are no sensory
disturbances and the bladder and rectum are not affected. The condition
of the reflexes is dependent upon the extent of involvement of the
cornual cells. Occasionally the bulbar muscles are affected.
=Diagnosis.=—This is not difficult except in the early stages. Careful
study of the case is commonly all that is necessary. Landry’s paralysis
and peripheral neuritis are to be differentiated.
=Prognosis.=—Complete recovery is rare. Improvement is the rule.
Ivie[128] tabulates sixteen cases, all showing good results. W. B.
Davis[129] reports a case cured by six months treatment and still well
after three years. T. M. King[129] one case cured and one greatly
benefited and A. S. Craig[129] one much helped. Florence Gair, F. P.
Millard, A. G. Walmsley and others report gratifying results in many
cases.
=Treatment.=—In the treatment of chronic cases, F. P. Millard[130]
says “Five minutes’ time is sufficiently long in treating a patient,
and sometimes too long. * * * Start in and move every spinal joint.
That takes about two minutes. Spring the sacro-iliac articulations
just enough to get motion. Then give a specific cervical treatment. Do
not stop to relax muscles in a child. Adjust as rapidly as possible.
Make every spinal joint yield to motion. Spend only one minute, or
possibly two, on the cervical vertebræ. So far we have consumed four
minutes. The last minute we loosen up the wrist or ankle, according
to the extremities that are involved.” This outline has been followed
with gratifying success by Gair, Green, Bush and others in many
chronic cases. The procedure in acute cases is condensed from A. G.
Walmsley[130]: “Isolate, keep cool and absolutely quiet. Stop all food
until the temperature drops to 100° F. or lower and until the pain
subsides when fruit juices may be given followed by heavier foods. Give
patient all the water he will drink. Where the spine is sensitive, and
it will be in many, use hot fomentations until a specific treatment can
be given. If the fever is running high cool compresses will be grateful
and help reduce temperature. Irrigate the colon twice daily with saline
water. Do this first thing when called. Later once daily will do and
then discontinue. Look carefully to the nose and throat and wash with
saline or boracic solution. Keep feet warm as they may be cold even
with high fever. Treat the case over a long period. See that he does
not overdo and observe all dietetic and hygienic measures.” Both these
men lay great stress on the importance of specific adjustments and
massage of muscle tissue has little place in their treatment. This,
with drill at home can be attended to by the mother.
Ivie[131], among other good ideas on treatment, gives the following:
“May I suggest that when such severe results (the acute stage) follow
a slight infection, that we may expect to find a lesion located at
such a point as will interfere with one or more of the anterior root
arteries which join and supply the anterior spinal plexuses. As there
are only five or ten of the anterior root arteries (Dana), the lesions
affecting them can be located throughout a wide range of the spine. In
a great many cases we find that the correction of lesions well up in
the dorsal and even in the cervical region have increased the amount
of the improvement well beyond that received in the correction of the
lumbar lesions alone. To =promote resolution=, correct the lesions,
both muscular and bony, and relax the muscles of the spine daily; move
every vertebra to the limit of all its possible motions; use flexion,
extension, rotation, and lateral flexion at least once every day for at
least a week; and help to overcome stasis by keeping the child off its
back, turning it from side to side, and letting it lie on its stomach
as much as possible. The limb, to be kept in its best condition, should
be kept warm; treated gently; held in a natural position by the use of
sand bags and clothes cradle, thus beginning early the =prevention= of
deformity; the paralyzed muscles should not be kept on a stretch, as
that will retard any possible improvement; stimulating rubs and baths
should be given frequently.” In the =chronic stage= he advocates: “Now
that the nerve cells have been given a chance to regenerate (removal of
lesions), the best thing to do is to force them to work if possible. To
do this, the so-called resistance exercises or educational movements
are to be strongly recommended; the idea being to place the limb in a
given position and then ask the child to fix all its attention on the
limb and to earnestly attempt to hold it there while you move it, or to
keep making the attempt while you move the limb through its whole range
of motion in that direction. These movements should be so calculated
that the resistance of the child will exercise the group of muscles
affected. The mother or nurse can give these exercises every night on
going to bed.”
Acute Ascending Paralysis
(LANDRY’S PARALYSIS)
=Definition.=—An acute disease, characterized by an advancing
paralysis, beginning in the legs, passing upward to the trunk and the
arms and finally it may involve the centers in the medulla. =Toxic= and
=infectious= influences that congest the nerve courses and ultimately
destroy the cells seem to be the important factor. The anterior gray
matter of the cord is involved, and it is probable that many cases are
a form of acute poliomyelitis. The spleen is congested and in some
instances the lymphatics.
=Etiology.=—A definite cause has not been found, although osteopathic
lesions are important predisposing factors. A toxic cause seems
probable. The disease is most common in males between twenty and
forty years of age. It may follow traumatism, exposure, cold or the
infectious fevers.
=Symptoms.=—Weakness of the lower extremities is generally the first
symptom, though the arms may be involved first. This is shortly
followed by paralysis. The paralysis then extends to the trunk and
within a few days the arms are also affected. The muscles of the neck
are next involved and finally those of respiration, deglutition and
articulation. The reflexes are abolished. The muscles are relaxed,
but generally do not waste or show electrical modification. Sensation
is usually not affected, but there may be tingling, numbness,
hyperesthesia and muscular tenderness. The sphincters are not
involved as a rule. The spleen is usually enlarged. The =course= is
variable. Death often occurs in from two days to a few weeks. When the
improvement takes place, the part last affected recovers first.
=Diagnosis.=—This is not always easy. It is sometimes impossible
to differentiate between this disease and =multiple neuritis=. The
history, the motor paralysis, the absence of wasting and of electrical
modification, as well as the absence of involvement of the sphincters,
will definitely aid in the diagnosis.
=Prognosis.=—The prognosis is unfavorable. A large majority of cases
prove fatal. In a few cases treated osteopathically, results were
favorable if the patient was seen early. The muscles of the spinal
column were markedly contracted.
=Treatment.=—The treatment of Landry’s disease consists principally
of thorough treatment of the spine, especially of the lower dorsal
and lumbar regions, and attention to the underlying toxic condition.
The treatment should be most thorough; the vertebræ and ribs found
disordered should be corrected and each vertebra should be carefully
separated (if conditions permit) from its neighbor. When the paralysis
has extended to the trunk and neck, a thorough treatment all along the
spinal column should be given with a view to relaxing the contracted
muscles and to render flexible the entire spinal column, so that the
cord may be properly nourished and the progress of the disease checked.
Careful relaxation of the contracted spinal muscles unquestionably has
a potent effect upon the cord circulation, which tends to check and
retard degenerative processes. Treatment of the limbs directly will be
found a help, as well as direct treatment of all tissues paralyzed. If
swallowing is impossible, the patient should be fed through the rectum,
or by the stomach or nasal tube. See that the patient is carefully
nursed. Massage is beneficial.
Locomotor Ataxia
(TABES DORSALIS)
=Locomotor Ataxia= is frequently met with. It is a disease of the
spinal cord wherein the ultimate effect is a sclerosis of a progressive
character of the nerve courses of the posterior column. It is claimed
that the origin is in the protoplasmic processes of the posterior
spinal ganglion. The characteristic symptoms are incoordination, Argyll
Robertson pupil, lightning pains and loss of knee-jerk.
=Osteopathic Etiology= and =Pathology=.—Most cases develop between
the ages of thirty and forty, although it is occasionally seen in
young men, and rarely in children from hereditary syphilis. Males
are much more frequently affected than females (10 to 1, Osler), and
the disease is much more frequent in cities. Predisposing causes are
given as syphilis, prolonged exposure to wet and cold, and sexual
excesses, although there is a disposition on the part of neurologists
to confine the cause of true tabes to syphilis, some records showing
as high as 90 per cent. of the cases from that cause. Tabetic symptoms
develop in from five to fifteen years after syphilitic infection.
There are no data to show the probable proportion of syphilitic cases
which later develop tabes, but it is undoubtedly small. As all cases
of tabes examined by osteopaths show spinal lesions, it is reasonable
to suppose that by interfering with the nutrition to the spinal cord,
they allow consequent degeneration. It is also quite probable that
osteopathic treatment for syphilis would, for the same reason, prevent
sclerosis and resultant tabes. That syphilis is not the only cause, is
also held by some authorities. Starr cites a true case from a severe
blow in the dorsal region. Osteopathic observation would lead to a
differentiation of tabes, according to the cause. Cases have been
recorded, which simulated true tabes in most symptoms, which did not
have a history of syphilis. J. Knowles makes the point that probably
certain cases simulating tabes have reached what might be called an
irritation stage (pathologically) of the nerves and their centers,
sclerotic changes not having taken place; and he believes these cases
would naturally yield to osteopathic treatment. Teall confirms this
view by being of the opinion that these cases are the ones largely due
to traumatism, exhaustion or exposure, and the probabilities are that
in time sclerotic changes would take place, resulting in true tabes. In
such cases there can be no question as to the osteopathic lesion, which
would be sufficient to materially interfere with the peripheral sensory
nerves and disturb the protoplasmic processes to the spinal ganglia
and sensory tract. As a rule they are in the lower dorsal and lumbar
regions. Cases are reported which had marked sacral and coccygeal
lesions.
=Pathologically=, Dana speaks of locomotor ataxia, “as a post-infective
degeneration, which first attacks the posterior spinal ganglia or
corresponding cells of the special senses, due to a prolonged poisoning
of these parts by the toxins of the infection.” The first change is
in the posterior roots. Without doubt osteopathic lesions can readily
affect the nutrition of these roots. This is shown upon examination
in cases where the vertebral lesions impinge the tissues surrounding
the spinal nerve at its exit, (or otherwise damage nervous stimuli
and circulation) and also where the displaced head of the rib crowds
upwards against the spinal nerve and again where the rib impinges the
corresponding sympathetic ganglion which lies anterior to the head
of the rib. Very likely in many cases the syphilitic infection is an
exciting factor, but it seems plausible that osteopathic lesions,
traumatism, cold, exposure and excesses predispose by disturbing the
circulation to involved areas. The changes are at first inflammatory,
followed by degenerative changes in the nerve courses which cause
connective and neuroglia overgrowths to take the place of fibers in the
sensory tract, and finally in the motor tract. Thus from the posterior
ganglia, a section between the columns of Goll and Burdach is involved,
and the progress of the sclerotic change is upward in the cord. The pia
mater and coats of the vessels are thickened. The principal changes in
the cord are in the lower dorsal and upper lumbar segments and the cord
may be changed in shape. In long standing cases there is degeneration
of the ascending antero-lateral tract, of the direct cerebellar tract,
and of the pyramidal tract. The cerebral changes in some cases consist
of sclerosis in the restiform bodies in the inferior peduncles of the
cerebellum, and of certain cranial nerves, especially the third, optic,
vagus and auditory nerves, and also cortical changes may occur.
=Symptoms.=—Authorities divide the symptoms into three stages—the
preataxic, ataxic and paralytic. This division is largely an arbitrary
one. =Motor symptoms= are usually the most prominent. There is
inability to coordinate the muscles. The patient first notices that
he cannot walk steadily when in the dark or when he has his eyes
closed. Later he finds that he cannot maintain his equilibrium even
in daylight; this is ascertained when the patient places his feet
together and the eyes are closed (sign of Romberg). As a rule this is
unaccompanied by muscular wasting, so there is no loss of motor power.
Soon the gait becomes characteristic; in walking the feet are lifted
high and are brought down heavily on the heel; the ball of the foot
comes down last, producing what is called the “double step;” the walk
is straddling: the limbs are thrown about, and there is staggering, due
to =incoordination=. Incoordination also develops in the hands, but
usually later in the disease. Sudden involuntary movements and palsies
are other motor symptoms. The latter occur in about twenty per cent
of cases and as a rule are of short duration. Paralysis and muscular
atrophy do not develop until after a few years.
=Pain= is an early symptom and always present; it is of a darting,
shooting or stabbing character and appears in paroxysms. It is most
common in the legs, lasting but a second or two, and often accompanied
by a hot, burning feeling. Herpes may appear along the course of the
nerve. Anesthesia and hyperesthesia of certain areas may occur. A
girdle sensation may be a noticeable symptom. The =muscular sense=
is more or less impaired; there is a feeling as if there were cotton
between the patient’s feet and the floor. Retardation of tactile
sensation is a common symptom. The power of localizing pain is often
lost. The =knee-jerk= is lost early in the disease. Occasionally,
however, cases are met where it is retained. The skin reflexes are
also impaired; in some cases they may be increased at first, but later
are sure to be involved with the deep reflexes. The =pupil= does not
respond to the light, but still accommodates for distance, constituting
the =Argyll Robertson= pupil. Ptosis may develop with or without
strabismus. Optic atrophy, which may lead to blindness, paresis of the
ocular muscle, and contracted pupils, may occur. The ocular symptoms
may appear early in the disease.
The =visceral pains= or =crises= are chiefly gastric and are sometimes
accompanied by obstinate vomiting. Laryngeal, rectal, urethral and
nephritic crises may occur, and at times are exceedingly severe.
Laryngeal crises may be manifested by intense dyspnea and noisy
breathing. Constipation is common. There may be retention of the urine
resulting in cystitis. Sexual power is generally lost early.
=Trophic changes= occur later in the disease. The so-called
arthropathies, or joint lesions, may occur at any period of the
disease. It consists of an enlargement of the joints, associated with
serous exudations, which rarely become purulent; atrophy of the heads
of the bones; destruction of the bones and cartilages; or spontaneous
fracture or dislocation may occur, owing to the brittleness of the
bones. There is no pain and the large joints are most frequently
affected; these may be excited by an injury. Herpes, skin ecchymoses,
edema, local sweating, alterations in the nails, perforating ulcer of
the foot, onychia, decay of the teeth and atrophy of the muscles may
occur. The auditory nerve is rarely affected, but in some cases there
may be deafness. There may be attacks of vertigo. Olfactory symptoms
are rarely met with. Cerebral symptoms are rare. =Paralysis= may
develop and the patient becomes bed-ridden. The disease itself does not
prove fatal; the patient may live for years until some intercurrent
disease causes death.
=Diagnosis.=—This is usually easy when the characteristic symptoms are
developed. The presence of lightning pains, absence of the knee-jerk,
early ocular palsies, a squint, ptosis and Argyll Robertson pupil make
the diagnosis conclusive. Care has to be taken in making diagnosis from
peripheral neuritis, paresis, ataxic paraplegia, cerebral disease and
some diseases in which the posterior columns are disturbed.
=Prognosis= will depend largely on the exciting cause, as it is least
hopeful from syphilis, but the earlier the case is treated the better
the chance. The progress of the disease can sometimes be arrested and
occasionally cases presenting symptoms of the first and second stage
are entirely relieved with persistent treatment.
=Treatment.=—Experience in the treatment of locomotor ataxia has been
that often the disease can be checked and the symptoms relieved; but
curing a case of locomotor ataxia, except in the early stages, is
seldom possible. When there is degeneration of nerve centers, there
is no hope for a cure. Those with a syphilitic history are by far the
hardest to relieve. Antisyphilitic treatment should be considered.
Cases with a syphilitic history presenting preataxic symptoms, Argyll
Robertson pupil, lightning pains and loss of patellar reflex have been
cured; unfortunately these cases are not always diagnosed.
The treatment consists of thorough correction of the spinal
derangements found, especially through the lumbar and lower dorsal
regions. If the disease has involved the arms or brain, thorough
treatment should be given the entire length of the spine with a view
to increasing the circulation in the spinal cord and brain, and thus
checking or preventing the tissue degeneration. “In the early stage,
deep massage to the muscles of the back promotes the flow of venous
blood through the spinal vessels and their anastomotic branches, and is
the best means of relieving the congestion which is supposed to exist.”
(Starr) The lower spine will be found to be rigid and should be well
sprung to get mobility.
Careful treatment of the limbs should be given, but be exceedingly
=cautious= in the treatment of the limbs of =advanced cases=, as there
is considerable danger of producing fractures. Stretching the thigh
muscles and internal and external rotation treatment of the legs should
be given. See that the bowels are moved daily and be positive that
there is no retention of the urine in the bladder. A catheter has to be
used in some cases. The patient should be careful about taking too much
food, and especially beware of indigestible food, as it irritates or
excites gastric crises.
During =painful attacks= the patient should rest in bed, and
with careful treatment the attack can generally be relieved. Hot
applications are of considerable aid.
At all times excesses should be avoided. Occupation of some character
should be given the sufferer. Do not promise to cure the patient, and
make it plain at the start that it will probably require a long time to
show much improvement. Systematic exercises to reestablish coordination
should not be neglected.
Hereditary Ataxia
(FRIEDREICH’S ATAXIA)
This is a rare hereditary disease, due to sclerosis of the columns of
Goll and Burdach and the pyramidal tracts. There are ataxia, muscular
weakness, nystagmus, speech disorders and loss of knee flex. Almost
invariably there will be found a neuropathic history. Alcoholism,
syphilis and insanity in the parents are predisposing causes.
Tuberculosis may be a factor. Acute diseases, especially infectious
fevers, dentition and injuries to the spine may be exciting causes.
It occurs most frequently in males about the seventh or eighth year
and very seldom after puberty. Several members of the same family are
apt to be affected. The disorder is transmitted by the female. “The
degeneration of the posterior and pyramidal columns seems to occur at
the time of cord development, when malnutrition or hereditary dyscrasia
would disturb it most.”
=Pathologically=, “the spinal cord is smaller throughout than normal;
we have also a combined disease of the posterior and lateral tracts
(Schultze), a degeneration of Goll’s tract in toto, of Burdach’s almost
entirely, and of the direct cerebellar, the crossed pyramidal (?), and
of Clarke’s columns, in which we find not only atrophy of fibers, but
also a degeneration of the ganglion cells. Gower’s tract may likewise
be involved.” (Oppenheim).
=Symptoms.=—Impaired coordination, beginning in the legs and later
extending to the arms, is the first marked symptom. The gait is
peculiar; it is swaying and irregular and it lacks the pronounced
stamping gait of locomotor ataxia. There is a loss of reflexes, while
no sensory symptoms are present as a rule. The sphincters are normal.
Nystagmus is present and is a characteristic symptom. The speech is
scanning. Talipes and lateral curvature of the spine are common. The
mind becomes sluggish in later stages. The course is always very slow.
=Diagnosis.=—This is not difficult as a rule, owing to the usual
family history presented. The spinal curvature, nystagmus,
incoordination, scanning speech, irregular gait, and deformity of the
feet are symptomatic. In =locomotor ataxia= the gait, sharp pains,
anesthesia and Argyll Robertson pupil will differentiate between the
two. Differentiation will also have to be made from chorea, ataxic
paraplegia and multiple sclerosis.
=Treatment.=—The same treatment as in locomotor ataxia is followed.
Lesions presented have been found at the tenth and eleventh dorsals,
and at the second and third cervicals, although, as a rule, the entire
spinal column is quite debilitated. Some improvement will be noted in
these cases, but not much can be expected from treatment; contractures
may be prevented.
Spastic Paraplegia
=Spastic paraplegia= begins as a stiffness in the legs, with no sensory
symptoms, but finally the muscles become rigid and slowly paralyzed.
The reflexes are exaggerated.
It may occur, in a few instances, as a primary disease, “being a
degeneration of the motor neurone, whose body lies in the brain cortex
and whose axone lies in the lateral pyramidal tract.” Usually it is
secondary to tumors, inflammation and softening of the brain. Multiple
sclerosis, hemorrhage, transverse myelitis, syringomyelia and other
diseases of the cord, injury, exposure and overexertion are exciting
causes. Syphilis may be a cause. It generally develops between the ages
of twenty and forty.
=Pathologically=, the degeneration involves the lateral pyramidal
columns of the cord. It begins at the periphery and extends upward
until finally the axones atrophy and neuroglia overgrowth takes place
and sclerosis of the motor tracts results.
=Symptoms.=—Muscular stiffness in one leg is usually the first symptom,
which gradually disturbs both sides. The muscular stiffness increases
to a rigidity, and even cramps, so that it is with considerable
difficulty that the patient moves about. The reflexes are exaggerated.
The joints, as well as the muscles are stiff, so that the toes are
dragged upon the ground and the legs are kept close together, abduction
of the limbs being difficult. On the whole, there is much tiredness,
stiffness, rigidity and hardness of the leg muscles, so that all
motions with them are performed with great effort. Sensory and trophic
symptoms are lacking; control of the bladder and rectum is usually
normal. The progress of the disease is slow. The upper extremities may
be involved in after years, but the common extensive disturbance is
with the legs, so that they may be entirely useless and the muscles
atrophy from disuse, although rigidity and contractures remain.
=Treatment.=—The prognosis is usually unfavorable, though frequently
the patient may be considerably benefited. A few cases that have
been =caused= by =traumatism=, cold or exposure have yielded to
osteopathic treatment and all symptoms disappeared. The treatment is
largely that of locomotor ataxia. The lesions are readily located in
the spinal column. In a few cases a slight posterior curvature of the
dorso-lumbar region is found, but the majority of the lesions are in
the lower dorsal region. Special care should be given to the bladder
and bowels. Prolonged warm baths are beneficial. Treatment of the legs
is always secondary to that of the spine. The diet should be nutritious
and one easily digested. Give the patient plenty of fresh air and
sunlight with cheerful surroundings. E. C. Link[132] reports two cases,
one of over one year’s standing, completely recovered, and another much
improved.
Ataxic Paraplegia
In =ataxic paraplegia= there are ataxic and spastic symptoms, due to
both posterior and lateral sclerosis. Traumatism, cold and exposure are
etiologic factors. It is found in diffuse myelitis, general paresis,
leptomeningitis and in toxic conditions as in pernicious anemia. The
posterior and lateral columns are degenerated, so that in the former
there is an ascending degeneration and in the latter a descending.
=Symptoms.=—These comprise those of =tabes= and =spastic paraplegia=.
Incoordination, ataxia, lightning pains, anesthesia, rigidness of
muscles and exaggerated reflexes are the principal symptoms. The
muscles easily fatigue; sensory symptoms are not so troublesome as in
tabes; there may be visceral crises, sometimes Argyll Robertson pupil;
and possibly spasms of the upper extremities and jaw. The course of the
disease is slow.
=Diagnosis.=—This is not difficult as a rule. First, there is ataxia;
then increased reflexes, fatigue of the muscles and paraplegia. =Tumor=
of the =cerebellum= may confuse the diagnosis.
=Treatment.=—There is frequently a chance to greatly benefit these
cases, and even in some instances a cure may be performed, provided
the case is seen early. Thorough treatment of the spine to relax
the muscles and to adjust the ribs and vertebræ is the indication.
Stretching the spine, if carefully done, is beneficial. Muscular
manipulation improves the spinal cord circulation, and osseous
correction removes probable impingements to nutrient channels and
nervous influences induced by cold, exposure, traumatism and secondary
disturbances. Care of the general health, hygiene, diet, etc., are
important.
Syringomyelia
=Definition.=—A chronic affection of the spinal cord in which there
is an embryonal neurogliar overgrowth about the central canal, with
cavity formation. It is characterized, clinically, by progressive
muscular atrophy, peculiar disturbances of sensation and various
trophic and vasomotor disorders. The onset generally takes place before
the thirtieth year. Males are much more commonly affected than females.
It is claimed by some that the disease is infectious. It frequently
follows trauma.
=Pathologically=, the condition begins with an overgrowth of embryonal
neurogliar tissue. This is followed by degeneration of the gliomatous
tissue with a formation of cavities, or this cavity formation may be
the result of hemorrhage. The disease, in most cases, involves only
the cervical or dorsal regions, and is usually in the posterior or
postero-lateral tracts. The cavity may prevail throughout the entire
cord, but usually only the cervical and dorsal regions are involved.
The cavities lie in the gray matter outside of the canal.
=Symptoms.=—The onset is slow. The symptoms depend upon the situation
and extent of the cavity. As the disease most frequently involves the
cervical region, the neck and arms are usually affected. At first
neuralgic pains may develop in the muscles. Later there is progressive
muscular atrophy and loss of painful and thermic sensations. Tactile
and muscular senses are usually intact. The reflexes are increased and
a spastic condition is present. The lower limbs usually escape, but
when they are involved the clinical picture may be that of =amyotrophic
lateral sclerosis=. A lateral curvature is present. When the disease
extends into the medulla, there will be various bulbar symptoms.
Trophic changes and vasomotor disorders are common.
A form of syringomyelia, known as =Morvan’s disease=, is characterized
by neuralgic pains, cutaneous anesthesia and painless felons.
=Diagnosis.=—The progressive muscular atrophy, the retention of
muscular and tactile senses, and the loss of thermic and painful
sensations are typical symptoms. The diseases with which it may be
confounded are: =Cervical Pachymeningitis.= The pain is usually
greater, the tactile sense is lost and it runs a more rapid course.
=Anesthetic Leprosy.= The trophic changes are more marked, tactile
sensation is lost and the phalanges often drop off. =Progressive
Muscular Atrophy= and =Amyotrophic Lateral Sclerosis=. Sensory symptoms
are wanting.
=Prognosis.=—The prognosis is unfavorable. Duration is from five to
twenty years.
=Treatment.=—Little can be done except attending to the diet and
hygiene of the patient and meeting urgent symptoms. Probably, continued
treatment along the spinal column would influence to some extent
the circulation of the cord in the region of the involvement. Hot
applications are of value in relieving pain and cramps. The X-ray has
proven of some benefit in checking the progress of the disease.
Amyotrophic Lateral Sclerosis
“This is a chronic, progressive form of spinal paralysis, characterized
by the symptoms of progressive muscular atrophy in the arms and by
lateral sclerosis or spastic paraplegia in the legs.” (Starr). It
is similar to progressive muscular atrophy, except, in addition,
there is sclerosis of the pyramidal tract. (See Progressive Muscular
Atrophy.) Osler classes progressive muscular atrophy of spinal origin,
amyotrophic lateral sclerosis and progressive bulbar paralysis as
diseases of the whole efferent or motor tract, wherein these disorders
may simply be various stages in the same case. He says, “A slow,
atrophic change in the motor neurones is the anatomical basis, and the
disease is one of the whole motor path, involving, in many cases, the
cortical, bulbar, and spinal centers.” There can be no question that
for the student, a classification of spinal cord diseases according
to the whole motor tract, the upper motor segment, the lower motor
segment, etc., is a scientific classification from our present
knowledge of the histology and physiology of the neurone, but for
clinical purposes the usual classification is given. Osteopathically,
we are greatly in need of a new nosology, either according to the cause
of the disorder or to the physiological disturbance.
=Amyotrophic lateral sclerosis= does not occur so frequently as
progressive muscular atrophy. Heredity plays a part, and it affects
older people. =Injury= to the =spinal column= is undoubtedly an
important factor. Exposure and cold may be exciting causes. Infectious
diseases and syphilis are probably important causes.
=Pathologically=, there are atrophy in the anterior cornu and sclerosis
of the crossed and direct pyramidal tracts. There is sclerosis of
centers in the medulla.
=Symptoms.=—Atonic atrophy, muscular weakness and fibrillary
contractions, of varying degrees, are characteristic. The reflexes are
exaggerated; the arm and leg muscles become weak and finally rigid and
atrophied. This results in deformity. Disturbances of sensation are not
pronounced. The sphincters may be slightly affected.
=Diagnosis.=—The disease is not so prolonged as progressive muscular
atrophy. Differentiation has to be made from multiple arthritis and
transverse myelitis and syringomyelia.
=Treatment.=—The same treatment as outlined for progressive muscular
atrophy is indicated. The disease may be retarded and life prolonged.
Progressive Muscular Atrophy
A disease characterized by a slow, but progressive, loss of power
and by muscular atrophy. Anatomically, it is characterized by
degeneration of the ganglion cells of the gray matter in the cord.
This atrophic affection develops just opposite to that of chronic
anterior poliomyelitis. It is commonly a disease of males in middle
life. Syphilis, rheumatism and lead poisoning predispose. It sometimes
follows cold, wet, exposure, traumatism, mental worries, overuse
of certain muscles, or prolonged emotional excitement. Hereditary
influences are present in some cases. In all cases =lesions= are
detected in the =vertebræ= and =ribs=, corresponding to the innervation
of the diseased areas. Very likely these lesions are the starting
point of the disease, by impairing nutrition to the motor cells of the
anterior cornu, and thus resulting in atrophy.
=Pathologically=, the muscles are wasted, the fibers undergo fatty
degeneration and there is an overgrowth of connective tissue. The
peripheral motor fibers are degenerated. The anterior nerve roots
leading to the horns are atrophied. The large ganglion cells of the
anterior horns are atrophied, or even entirely removed. The neurogliar
tissue is increased. There is sclerosis of the anterior and lateral
pyramidal tracts of the cord in the majority of cases. (See Amyotrophic
Lateral Sclerosis). The pyramidal tracts have been found degenerated
through the pons and internal capsule, even up to the motor cortex.
When bulbar symptoms are present, there is degeneration of the motor
nuclei of the medulla. The posterior columns are not involved.
=Symptoms.=—Irregular pains, numbness or exhaustion are usually felt
in the region that is soon to become wasted. The upper extremities
are first affected. The muscles of the ball of the thumb waste first,
then the interossei. From atrophy of the interossei and lumbricales
and contraction of the long extensor and flexor muscles, the deformity
known as “claw hand” results. The wasting creeps up from the forearm,
arm and shoulder. The muscles of the trunk are gradually affected.
The muscles of the lower extremity may escape entirely. The platysma
myoides does not waste and is often hypertrophied. The face muscles
are attacked late or not at all. The affected muscles often twitch.
Deformities and contractures develop, notably lordosis. Sensation
is not impaired although the patient may complain of numbness and
coldness. The bladder and rectum are not affected, but sexual power
may be lost. The paralysis is flaccid and the reflexes absent in the
so-called =atonic cases=. In =atonic= atrophy there is more or less
spasm, the reflexes are greatly increased, there are often contractures
and the wasting is usually trifling.
=Diagnosis.=—Differential diagnosis has to be made from syringomyelia,
chronic anterior poliomyelitis, lead palsy and muscular dystrophies.
=Prognosis.=—The prognosis of progressive muscular atrophy is not
favorable, although a number of cases have been greatly helped by an
extended course of treatment.
=Treatment.=—The treatment consists of a thorough, stimulating
treatment of the innervation of the affected regions, with manipulation
of the muscles and parts diseased. =Correction= of the =lesions= to
the =vertebræ= and =ribs=, which are involving the innervation to
the diseased tissues, is of primary importance. A cure cannot be
expected when degeneration of the nerve centers has occurred; still,
the progress of the disease may be checked in many cases, and the
patient occasionally gain considerable strength. When atrophy starts
in the muscles of the ball of the thumb, the lesion is to the median
nerve, and derangements of the cervical vertebræ, from the fifth to the
seventh, may be found. Attention to the general health is important.
Outdoor life is preferable and gymnastic exercises are of value, but do
not overtax the strength.
Bulbar Paralysis
(LABIOGLOSSOLARYNGEAL PARALYSIS)
A progressive atrophy and paralysis, invading the lips, tongue, pharynx
and larynx, due to involvement (sclerosis) of the motor nuclei of the
medulla oblongata that supply these tissues. It is rarely primary,
more =frequently secondary= to tabes, amyotrophic lateral sclerosis
and diseases involving the motor nuclei of the medulla. Diphtheria,
syphilis and lead poisoning are said to predispose. =Osteopathic
lesions= of the upper cervical are also important factors in many
cases. Halbert says: “The nuclei of the hypoglossal, the spinal
accessory, the facial and the motor part of the trifacial nerves suffer
most decidedly from the sclerotic degeneration. The nerve trunks and
the muscles which they supply gradually show the effects of a similar
degeneration.”
The =acute form= results from hemorrhage, embolism or inflammatory
softening. The onset is usually sudden. The speech is difficult or
entirely lost. There are dribbling of saliva, difficult swallowing,
flabbiness and flaccidity of the lips and frequent choking spells
occur. These cases may prove rapidly fatal.
The =chronic form= may result from progressive muscular atrophy,
insular sclerosis, amyotrophic lateral sclerosis, acute ascending
paralysis or chronic poliomyelitis. The paralysis starts in the tongue,
the first symptom being a slight defect in the speech. When the lips
become involved, the patient cannot whistle and speech is rendered
still more difficult. The lips are prominent and the lower one drops.
The saliva is increased in amount and there is drooling. Mastication
of the food becomes difficult. The tongue becomes atrophied and the
mucous membrane wrinkled. Fibrillary tremors of the lips and tongue are
present. Sensory symptoms are not present. Taste is normal. Paralysis
of the larynx is not so pronounced as of the other parts.
=Diagnosis.=—This is generally easy as the symptoms are well marked.
The =prognosis= is unfavorable.
=Treatment.=—Little can be done in the majority of cases. Only in those
cases where the paralysis is caused by =cervical lesions= can much hope
be given. Derangements of the cervical vertebræ, especially the atlas
and axis, occasionally influence the circulation in the medulla to such
an extent that the motor nuclei are greatly involved. The subluxated
vertebras may interfere with the blood-vessels directly or through
the vasomotor and trophic nerves. When the onset is not abrupt, the
prognosis is more favorable. When deglutition is impaired, the stomach
tube should be used in feeding the patient to prevent the food passing
into the trachea.
FOOTNOTES:
[126] A. O. A. Case Reports, Series V.
[127] A. O. A. Case Reports, Series II.
[128] A. O. A. Case Reports, Series V.
[129] A. O. O. Case Reports, Series I.
[130] Millard, Poliomyelitis.
[131] Journal of the American Osteopathic Association, February 1906.
[132] Journal of Osteopathy, Oct. 1904.
ORTHOPEDIC SURGERY
By H. S. HAIN
Orthopedic surgery deals with the mechanical or surgical prevention
and correction of all deformities, especially those of children. It
is not alone justifiable, but imperative, that orthopedic surgery be
given a prominent position in any up-to-date text on the Principles
and Practice of Osteopathy. The justification is threefold: though
orthopedics was practiced to a limited extent before the Science of
Osteopathy was developed, it has always been considered to be outside
the realms of true surgery, in that it is practically bloodless, and
those engaged in such practice have sought to establish it upon a
platform of its own.
The basis of the practice of orthopedic surgery and osteopathy is
similar, if not identical, in that it deals almost entirely with bony
abnormalities. It is recognized by the whole osteopathic profession,
and unconsciously by some adherents of medical science, that the
maintainance and restoration of normal function are alike dependent on
a force inherent in bioplasm and that function perverted beyond the
limits of self-adjustment, is dependent upon a condition of structure
perverted beyond those limits. This, then is the platform upon which
the two sciences of osteopathy and orthopedic surgery are erected.
The technique of osteopathic practice consists of passive manipulative
measures, designed to render to the organism such aid as will enable it
to overcome or adapt itself to the disturbed structure; and does not
seek, in itself, the aid of any instrument, mechanical appliance or
plaster of Paris cast.
Surely it is but a short step from our osteopathic therapeutics to
a system of therapeutics where we find all sorts of mechanical and
plaster of paris appliances, etc., to help our passive manipulation in
rendering to the human organism such aid as will enable it to overcome
or adapt itself to a disturbed structure. This latter, of course, is
the modern science of orthopedic surgery, and because of the shortness
of this step, I insist that it is one of the most valuable adjuncts
of the science of osteopathy. It is frequently necessary for the
osteopathic practitioner to take this step as conditions are met with
that have progressed beyond the possibilities of passive manipulations
and again other conditions of perverted structure can be much more
quickly reduced by the aid of each.
It is then indisputable that the therapist who approaches disease from
the osteopathic standpoint, above enunciated, is far more competent
to deal with the mechanical problems of orthopedic surgery than any
other known therapist. Secondly, in many conditions originally treated
by orthopedic methods, subsequent ordinary osteopathic manipulations
obtain a much more satisfactory and more lasting result than if it is
withheld. Thirdly, in order to avoid possible error, it is of extreme
importance that all osteopathic practitioners be particularly familiar
with the conditions hereinafter described, more especially tubercular
conditions of the spine, bones and joints, primary spinal curvatures
and others.
It is reasonable and furthermore true that osteopathic physicians are
confronted in practice with an unusually large percentage of cases
indicated above, and the early recognition of such conditions is of
fundamental importance in order that osteopathic manipulations be
withheld and supplemented or replaced by orthopedic methods.
Space of course will not permit of the entire discussion of this vast
subject but the most important and serious conditions met with in
general practice are fully discussed in the following pages of this
chapter.
Perhaps the commonest condition coming under this line of therapeutics,
and one in which we, as osteopaths, are most vitally interested is
rotary lateral curvature of the spine. From my personal observation
and from experiences of some of the most prominent members of our
profession, I am led to believe that this is one of our most difficult
lesions to overcome osteopathically, hence my desire to go further
into this condition than most of us might expect. I had opportunity
to obtain personally some very valuable information from Dr. Joachim
Stahl in the King’s Charity Hospital in Berlin, and to him I am
deeply grateful for many of the ideas of treatment presented in the
following article. I believe that I have an accurate conception of the
pathological condition that exists in connection with this deformity,
and I believe that my treatment of it has been more successful than
any that I have seen under other methods, in that I have gotten most
excellent results, in selected cases, in a comparatively short time,
entirely because osteopathic manipulations and exercises were used in
connection with the modified Abbott method.
Scoliosis or Rotary Lateral Curvature
Scoliosis or Lateral Curvature of the Spine is a deformity where the
spine is deviated in whole or in part to one or the other side of the
median line, which deviation is accompanied by an element of rotation.
Though usually considered as a spinal deformity its =effects= are
obvious outside the spinal area in so much as it will cause deformity
of the pelvis, legs, ribs, sternum, scapulæ, and in severe cases, of
the thoracic and abdominal viscera.
Curvatures of the spine are the result of one of two distinct factors:
first where there is a primary disease of the bone causing more or less
destruction of the bone and spinal articulations, and resulting in
permanent spinal curvature. The most common example of this condition
is seen in the angular curvature of Pott’s disease. =Rickets= is
usually responsible for a general long posterior curvature of the whole
spine, as is osteomalacia with the superimposition of some lateral
deviation. Further, any type of inflammation or trauma is capable
of producing curvatures of various types. Second, where there is no
primary disease of the bone, joints, or ligaments, and where the
curvature is due to external forces acting constantly or at frequently
recurring intervals on the spine.
Scoliosis or lateral curvature belongs to the second class. It is
unfortunately necessary to further subdivide scoliosis into two
classes; one where the curvature is a position permanently maintained
but capable of being reproduced by extreme physiological movement of a
normal spine, and secondly, a position which no normal spine can assume
and which necessarily implies a change in the normal shape of the bones
and intervertebral discs. The first may be described as a functional or
postural lateral curvature, and the second as an organic or structural
lateral curvature. Further, I might say that the first type may
progress until it becomes the organic type.
=Pathology.=—In scoliosis the spine undergoes not only curvature or
lateral deviation but also rotation of the vertebral bodies which you
will note always takes place towards the convexity of the curve.
=Changes in the Individual Vertebræ.=—The bodies may be either
wedge shaped or lozenge shaped. In wedge shaped vertebræ, the bodies
are compressed on the concave side and extended on the convex side,
the intervertebral discs being atrophied on the shortened side. In the
lozenge shaped type, the change in the bodies is most marked at the
junction of the opposite curves, and is thus more commonly observed in
compound curvatures. The pedicles are directed more antero-posteriorly
on the convex side and more transversely on the concave side. The
transverse processes on the convex side are more antero-posterior
than normal, causing the vertical furrow between them and the spine
to be narrower on this side. The spines point towards the concavity
in structural curvatures and toward the convexity in the functional
type. The vertebral foramen is rounded in the convexity and pointed in
the concavity. The edge of the anterior common ligament toward the
convexity is greatly thinned while it has a well marked edge on the
concave border. A fibrous degeneration occurs in the muscles on the
convexity owing to stretching, while atrophy from disuse takes place in
those on the concave side.
=Associated changes in the Viscera.=—The =dorso-lumbar= curvature
decrease in the volume of the lower thorax on the dorso-convex side
tends to cause pleural adhesions with obliteration of the pleural
sac and consequent collapse. Tuberculosis of the =lung= is common in
patients who suffer from scoliosis. The =heart= is often overworked
but the above lessening of the pulmonary area in turn results in
hypertrophy and dilatation of the right ventricle and subsequent
general venous stasis. The =kidney= on the convex side is compressed,
and as a result degenerative changes are prone to occur. The =spleen=
is frequently displaced upward and is liable to pathological changes.
Organs such as the stomach, transverse colon, esophagus and trachea are
frequently displaced owing to the bony deformity and are thereby more
prone to pathological change.
=Etiology.=—The essential factor in the production of scoliosis is
spinal insufficiency, which includes spinal muscles and ligaments as
well as the bones. In many instances, however, the following factors
have an important augmenting or predisposing effect.
=1. Occupational Deformity.=—Primarily under this classification, I
have found faulty positions adopted by school children as being the
most comfortable, to be perhaps most important. Occupations such as
those of nurse-maids, hod carriers, or stone cutters, are apt to induce
scoliosis.
=2. Diseases of the Central Nervous System.=—Unilateral weakness or
paralysis of the muscles of the trunk are common causes of scoliosis.
Anterior poliomyelitis plays a particularly important part as it
may induce deformity by distortion of the lower extremity or by any
inequality in the length of the limbs due to retardation of growth, as
well as inducing general weakness of the muscles of the trunk. Other
nervous disorders that should be considered are spastic paralysis,
locomotor ataxia, syringomyelia and Friedreich’s ataxia.
=3. Incidental Deformity.=—Scoliosis may be caused by direct injury or
by fracture, Pott’s Disease, or organic affections of the spine. Marked
deformity caused by Sciatica or lumbar neuritis, if persistent may
finally induce permanent deformity.
=4. Deformities Due to Diseases of the Chest.=—In =empyema= or
=pleurisy= one side of the chest is retracted and it will be noticed
that the curvature occurs toward the healthy side. Chronic pulmonary
tuberculosis producing fibrosis of the lung gives the same result as
empyema and pleurisy.
=5. Deformity due to obliquity of the pelvis.=—This type may be due to
any inequality of the limbs, such as equinus of the foot. Congenital
dislocation of the hip may play a part while one naturally lays stress
on pelvic and lower lumbar lesions.
=6. Deformity due to Distortion of Other Parts.=—Unequal visions,
unequal hearing, and torticollis by causing malposition are etiological
factors especially in school children. The loss of an arm will tend to
cause an asymmetrical position of the trunk.
=7. Congenital Deformity.=—Congenital scoliosis occurs, but is usually
associated with other congenital deformities of the spine, such as the
reduction or increase of the vertebræ, cervical rib, elevation of the
scapula, etc. The deformity is usually not apparent until later years,
though it may occur at birth.
=8. Spinal Lesions.=—Any osteopathic lesion predisposes to curvature
because it interferes with the nerve supply and tonicity of the spinal
muscles and could readily cause the faulty position.
Functional or Postural Lateral Curvature
This is a condition where there is a gradual curve to one side
unaccompanied by any marked rotation. The maximum deviation may be no
more than one inch and a half from the middle line, which point is
generally found about the tenth dorsal vertebra. In the vast majority
of cases deviation is to the left and in such the following alterations
will be noticed: a general convex curve to the left; elevation, and
anterior displacement of the left shoulder; posterior displacement
of the right shoulder; in extension, the right side of the back will
be higher than the left and in addition some torsion to the concave
side, which is easily understood if one recalls the exact changes that
take place during side movement of the normal spine. It is important
to remember that functional scoliosis disappears when the patient is
suspended or assumes the recumbent position.
Organic or Structural Scoliosis
This term is applied to cases where definite change has taken place
in the vertebræ. Organic curves may be simple when the deviation
is unaccompanied by any compensatory curve, or compound when a
compensatory curve is present. We shall consider the deformities as
they present themselves in the various regions of the spine.
=Cervico-Dorsal Curvature.=—This condition is comparatively rare and
according to Lovett occurs in only three and six tenths per cent of
cases. The head is slightly deviated towards the concave side, the
shoulder on the concave side is lowered, while on the opposite side or
the side of the convexity it is naturally at a higher level. The angles
of the upper ribs are prominent due to the co-existing rotation.
=The Dorsal Curvature.=—The shoulder is raised on the convex side, and
the rotation of the vertebræ is very marked, causing a very definite
projection of the angles of the ribs on the convexity. This rotation
also projects the scapula backwards on the convex side. On the concave
side the scapula is flat and sunken, and the inferior angle rotated
inwards and at a higher level than the opposite side. Viewed from the
front the thorax may not be displaced at all, or it may be displaced
toward the convex side, and if the latter is the case it is, of course
more prominent on the concave side. In severe cases the lower end
of the sternum is deviated towards the convexity and you will find
that usually the arm hangs further from the convex side than from the
opposite one.
=The Lumbar Curvature.=—Here we find the trunk displaced toward the
side of the convexity, and the waist retracted on the opposite side.
The difference in the level of the hips is the most prominent deformity
in this region, and it will be found that the hips are raised on the
concave side. Rotation in this region is much less evident than in the
dorsal region, but can be demonstrated by a fullness on the convex side
of the curve, due to the projection of the transverse processes.
=Dorso-Lumbar Curvatures.=—This condition is similar to a certain
extent, to a severe functional scoliosis. The findings observed in the
last two regions above described will naturally be present in this type
of curvature. It is not so frequently associated with compensatory
curves as in the other types described.
=Compound Structural Curves.=—The appearance in this type of scoliosis
will, of course, be a combination of those described above according
to the types of curvature in combination, that is to say right dorsal
and left lumbar, etc. If one type predominates the appearance will be
chiefly that found in that particular type of curvature. The relative
frequency of the common type, as given by Schaltless, in eleven hundred
and thirty seven cases is as follows; functional scoliosis, 15.39%;
lumbar, 11.7%; dorsal, 19%; dorso-lumbar, 20%; cervico-dorsal, 3.6%;
compound, 30%.
=Diagnosis.=—To the osteopathic physician the diagnosis of scoliosis
is not difficult. Let me caution you that true scoliosis must be
distinguished from the lateral curvatures caused by Pott’s disease.
Vertebral rotation, the absence of pain, the extreme rigidity, the
characteristic appearance of the ribs and thorax should, however, make
the diagnosis of scoliosis easy.
=Treatment.=—In general the treatment of scoliosis is difficult to
present, because every case is considerably different, and the amount
of correcting force used in any form is almost entirely a matter of
judgment, as is also the time when corrective pressure should be
discontinued. Continual practice in the treatment of these conditions
is most essential to your success with them. I have had most gratifying
results in a comparatively short time simply because I used osteopathic
treatment and exercises along with a modified Abbott method.
Functional or False Scoliosis
The functional or false scoliosis might be regarded as a habitual
inability to stand correctly, simply a postural malposition and lack
of muscle tone without marked structural change, which is maintained
for a considerable length of time or where the position is repeated
several times daily. The treatment of selected types of this deformity
is most successful and may well be divided into three procedures:
first, the substitution of a correct attitude for the faulty one, that
is careful investigation should be made to ascertain the condition
which might be the cause of the incorrect position such as poor school
desks which might cause the child to reach either up or down to write,
poorly fitting clothing which causes a pulling on the shoulder, eye
strain which would cause tilting or twisting of the neck, congenital
shortening of one limb or too rapid growth, should all be looked for
and removed; second, regular osteopathic manipulation, at least three
times per week to increase the tonicity of the already weakened spinal
muscles and aid correction, are highly essential and shortens the time
required for a complete cure; third, supervised gymnastic exercises of
various kinds are very beneficial to develop and bring the musculature
back to normal. Such simple exercises as crawling on the hands and
knees in a small circle towards the side of the convexity, and the
hanging from a horizontal bar by the arm on the side of the concavity
will prove to be helpful. Some authors recommend the regular army
setting up exercises for some cases or a frame by means of which the
hips are fixed, and rotating and side bending exercises of the head
and trunk given. These last two exercises are indeed very reasonable
procedures but I have found them unnecessary mainly because I used
osteopathic manipulations instead.
In advising and supervising exercises it is best to have the patient’s
back bared so that the effect of each movement can be noticed and the
exercises directed accordingly. Care and judgment should be used as to
the number and severity of the exercises and would depend of course on
the vigor of the child. Treatment should continue until the condition
has been overcome, and the patient should be under observation for a
couple of months afterwards so that any recurrence of the deformity
would be noticed and attended.
Organic or Structural Scoliosis
The treatment of organic or structural scoliosis is more complicated
for it must be remembered there are two elements of the deformity
demanding correction; one, the lateral curve to be corrected by a side
force, and the other, the rotation of the vertebræ to be corrected by
a twisting force. I find both osteopathic manipulation and gymnastic
exercises are of great value in the correction of this deformity as
they help to loosen the curve and develop the musculature but used
alone good results can rarely be obtained especially in obstinate
curvatures. I believe that I have improved nutrition and probably
prevented further deformity by treatments and exercises, but I am
quite positive that it is not possible to correct an organic scoliosis
without the forcible correction used in the Abbott method.
As the details of treatment are tedious to follow, we will take for
example a case of right dorsal curvature presenting a marked hump
deformity, with a compensatory curve to the left in the lumbar region,
as this is the most common type. I might say here that whether or not
a compensatory curve is present, makes no difference, as treatment
is directed entirely to the primary curve on the assumption that
overcorrection of it will cause a secondary curve to disappear by
compensation.
The patient is prepared by putting on a snug fitting undershirt and
sewing pads of saddler’s felt over all bony prominences, especially
the crest of the ileum and anterior superior spine. Sometimes I take a
piece of felt of four or five inches wide and long enough to go around
the entire pelvis, just high enough to cover the brim, and fasten it in
front with adhesive. Next I make a bunch of pads two or three inches in
thickness and large enough to fill up the concavity of the left side,
and first sew them together, and then with a few stitches fasten them
to the undershirt thereby filling up the space on the concave side.
The edges of the pads should, of course, be trimmed down to conform
with the general contour of the body, the main thickness being in the
middle. I then sew a single pad on the right side of the thorax in
front and a little to the right side.
[Illustration: Patient suspended on canvas hammock in regular Abbott
frame ready to apply cast for a right dorsal curvature. Notice manner
of applying the correcting canvas straps.]
The patient is now ready for the Abbott frame and is placed on a
canvas hammock about twelve inches wide, which is cut on the bias so
the right side is three inches shorter than the left. The hammock
can be adjusted to the desired degree of flexion by a ratchet at the
foot of the regular Abbott frame. The limbs of the patient should be
elevated to increase the flexion as this has a tendency to unlock the
articulation and thereby help in overcoming the rotation. Next a canvas
bandage four inches wide is passed around the patient under the axilla
of the concave side and fastened to the frame on the opposite side, and
another one is placed around the pelvis and fastened to the same side
of the frame, both on a level with the body plane. A third bandage is
next placed around the point of greatest convexity and fastened to the
opposite side of the frame in such a way that it can be tightened and
a direct pull be made on the curve. Before tightening the last bandage
the left arm and shoulder should be brought up high beside the face and
pulled backward toward the floor as it is this twisting force that
produces some rotation of the thorax. The correcting bandage is now
tightened being careful not to cause the patient too much discomfort.
[Illustration: Cross section sketch of a right dorsal curvature showing
deformity in the thorax and rotation of the vertebræ, also windows
which are cut in the cast to allow expansion in these two directions
and the directing force of the pads. These are placed over the angles
of the ribs. Arrows show directions of the various forces.]
I always use ordinary absorbent cotton for padding, which is held in
place by the regular gauze bandage. The plaster of Paris bandages
should be applied high up under the left shoulder and well down over
the sacrum and innominate bones and should be of a uniform thickness
of half an inch. Sometimes I carry the plaster over the right shoulder
to hold it down and back, though not always. I always let the cast set
pretty well before removing the patient from the frame and if it has
been applied in the morning I find it best to wait until afternoon
before trimming and cutting the windows because there is less danger of
breaking it. In trimming I always smooth up the edges, lower the right
shoulder, but keep the left well up, trim off enough at the bottom in
front to allow the thighs to be readily flexed without obstruction,
and leave it low behind so as to maintain the flexion. Next, two holes
or windows are cut in the cast, one over each area where the pads
were inserted, and remove them. The hole in the back on the left or
concave side permits expansion of the chest to the back, while the
hole on the right side in front allows the ribs, which are posterior,
to move forward under pressure or the pads to be inserted at the
posterior angle or backward prominence of the ribs of the convexity.
The canvas bandages or straps around both the axilla and pelvis are
removed, but the one about the convexity of the curve is left in place
so as to assist in the after treatment. The patient usually suffers
some discomfort such as difficulty in breathing and the inability to
move the body freely, and should remain in bed a day or two after the
cast has been applied. Usually they sleep very poorly the first few
nights, but the spine soon gives under the pressure and they become
comfortable. When the cast has become quite comfortable an assistant
pulls on the canvas bandage which was left around the convexity, while
pads are inserted so that the greatest pressure is exerted on the angle
of the ribs to further overcome the rotation and decrease the lateral
deformity. Also heavy felt pad may be inserted over the bulging ribs
in front of the left side to push them back. Care should be taken that
too much pressure is not brought to bear on the side of the convexity
because if more pressure is exerted here than on the angles of the
ribs, it will tend to increase rather than decrease.
Casts should be worn for different periods, some being changed in a
month while others can be worn for three months. It is entirely a
matter of judgment. My best results have been secured by only slightly
correcting the curvature at the time the cast was applied, and relying
more on the proper insertion of the pads. Often at the end of a month
or six weeks, in selected cases, I have split the cast down the front
and removed it by springing it apart, and administered osteopathic
manipulations to the spine freely in all directions, thoroughly
loosening up the muscles. Then I replace the cast and hold it together
in front with moleskin adhesive and insert the pads as before. I repeat
this procedure three times per week for another month, together with
daily exercises each morning and evening of drawing the left shoulder
up and forward while in the cast to develop the muscles of the left
shoulder girdle. The treatments and exercises certainly do build up
the spinal muscles for it must be realized that they have suffered in
nutrition to a great extent as a result of wearing the cast. Next the
cast can be worn during the day and removed at night, and gradually
it can be left off several hours at a time. If no bad results occur
it can be left off for longer periods until finally its use can be
discontinued. However, the patient should still be under observation
once a week for a couple of months to determine any recurrence of the
deformity. The resumption of active corrective treatment, or increasing
relaxation in gymnastic work, will, of course, depend upon the progress
of the case.
In the more obstinate cases, casts should be applied as long as further
correction can be obtained. The procedure is entirely the same, only
the time required for correction is longer, sometimes a year or year
and a half, and when overcorrection has been maintained, it is better
to use a removable jacket made of celluloid or light stiffened leather,
with large windows cut over the region where pressure is to be avoided,
than the removable cast described above.
In closing let me say that this method of correcting lateral curvature
is best adapted to patients during their growing period and though it
may be employed in older cases you will usually be disappointed in the
final result. The only reason I can see for treating older cases is
purely mercenary.
Congenital Dislocation of the Hip
Unilateral
Undoubtedly as far back as 1829, the actual recognition of this
condition was due to the pathological research of a French surgeon
Dupuytren, who described this deformity with great accuracy and
insisted that there was no possible chance of correction. From then
on until 1886 nothing was done by medical science to overcome the
deformity, though it is claimed some were made. It was in this year
that the famous Bavarian surgeon, Hoffa, gave to the medical profession
the results of his successful attempts at reduction by opening the hip
joint from behind and enlarging the acetabulum to a size sufficient to
hold the head of the femur.
Orthopedic surgery has to thank the irritating effects on the skin,
of antiseptics necessary in preparing his hands for ordinary surgery,
as it was due to this triviality that Lorenz, a promising surgeon of
Vienna, transferred his energies to the field of bloodless surgery and
gave to us the most valuable early work and present day technique in
the bloodless reduction of congenital dislocation of the hip.
The name, of course, is applied to a congenital deformity which
involves one or both hip joints, resulting in lameness, due to a
misplacement of the head of the femur from the acetabulum. Of all
congenital dislocations the hip joint is by far the most common and
most important. The misplacement is far more often unilateral than
bilateral and far more frequent in females than in males, the cause for
the latter probably being the difference which exists in aspect and
position of the acetabulum as well as the disproportionate laxity of
the capsule in the two sexes. It must be remembered that normally at
birth, the acetabulum covers only about one-third of the head of the
femur, and our most accepted theory as to the cause of this deformity,
is a defective development of the acetabulum or its posterior margin,
which may be primary or secondary to an abnormally prolonged fixation
of the limb in a position of flexion or adduction while in utero. At
birth it is quite probable that the dislocation is a subluxation only,
which becomes complete by muscular action and the use of the limb in
standing and walking.
The pathology of this disease is clearly established, and varies, of
course, with the age of the patient in strain and friction to which
the misplaced parts have been subjected. In children over two and
one-half years of age the acetabulum is usually shallow and small, and
filled with a deposit of fat and fibrous tissue. It is covered with
normal hyaline cartilage and nearly always the ligamentum teres is
present, but is so badly stretched and ribbon-like that ultimately the
artery accompanying it fails to function, resulting in a malformation
of the head of the femur. The capsular ligament is elongated and
thickened to accommodate the upper displacement of the femur, and the
anterior wall of it is stretched tight across the acetabulum like an
hour glass. The interior of the capsule is always partly lined with
synovial membrane. Usually a secondary acetabulum is found upon the
ileum, formed by the direct pressure of the head of the femur through
the capsule and the result of irritation of the periosteum of the
ileum, but it is as a rule, not deep enough to form a secure support
for the head of the bone. The neck of the femur is usually shorter
than normal and the upper extremity of the bone is somewhat atrophied.
The pelvis is usually slightly atrophied on the affected side, and
a lateral inclination of the spine may be present. The long muscles
of the thigh are shortened; while those attached to the pelvis and
trochanter are changed in direction and are usually lengthened.
[Illustration: Typical congenital dislocation of the hip, showing the
“hour glass” constriction of the capsular ligament.]
=Symptoms.=—As a rule congenital dislocation of the hip is not
accompanied by the defective development or deformity elsewhere, and
the symptoms are so diagnostic that there is little difficulty in
recognizing this condition even without the X-ray which is, of course,
a positive diagnosis.
Rarely does the displacement attract attention until the child begins
to walk. Often the child does not walk as early as it should. Sometimes
it may be delayed until the eighteenth month or second year and then
it walks with a limp which becomes more pronounced as the child grows
older until at the fourth or fifth year it is very decided. The limp
is peculiar and its character is explained by its cause; for the
shortened limb, owing to the elasticity of the capsule, becomes still
shorter when the weight is borne upon it, thus causing a peculiar lunge
of the body towards the short side like the normal motion of walking
downstairs. In compensation, of course, the pelvis is tilted towards
the short limb and its inclination is thereby increased, so that the
anterior superior spine lies at a lower level and in advance of the
opposite side. Usually the affected limb is about an inch shorter than
the sound one, and in adult life it is considerably more. The range
of abduction is much diminished, but flexion, extension and adduction
are quite normal, and the trochanter will be found elevated about
an inch above Nelaton’s line. If the thigh be flexed and adducted
to its extreme limit, the neck and head of the femur can be easily
distinguished moving under the gluteal muscles when the limb is
rotated, or the head can usually be readily palpated in front when the
limb is extended. Then, too, by fixing the pelvis and using traction
and upward pressure on the limb, the abnormal mobility or telescopic
motion is easily demonstrated and this, I might add, is a very
important test.
[Illustration: Outline of a radiograph following reduction and removal
of the first cast in unilateral dislocation of the hip. Notice the head
in the socket and the thigh still flexed and abducted.]
Rarely do we find a unilateral anterior dislocation, in which the
head of the bone lies beneath the anterior superior spine, but when
this position is present, the symptoms are much less marked than in
the ordinary form because the relation of the pelvis to the femur is
more nearly normal. The limp and the shortening of the limb are less
noticeable because the tissues attached to the anterior superior spine
form a relatively secure support.
The X-ray, of course, makes the diagnosis complete. Even though the
clinical diagnosis is certain, a radiograph is indispensable in every
case, particularly for the purpose of ascertaining the exact position
of the head and condition of the acetabulum and femur. The acetabulum
is usually shallow and poorly developed, more particularly the iliac
portion of its rim. After the reduction of the dislocation, an X-ray
picture should always be taken within the first few weeks, and before
the plaster of paris cast has been removed, to ascertain whether the
head of the femur is still in place.
[Illustration: Outline of the same case following removal of the second
cast. The head of the femur is firmly fixed in the acetabulum and the
position of the limb is nearly normal.]
As to bilateral dislocation of the hip, the pathology, of course, is
the same as in the unilateral type. The shortening of the limbs is
as a rule equal or nearly so, and when both femurs are displaced
backward, the pelvis is tilted forward thus presenting a marked lumbar
lordosis and protruding abdomen. The pelvis seems to be abnormally
wide, both buttocks are flattened and the thighs are separated by a
considerable space. The characteristic limp in this condition is an
exaggerated waddle, often spoken of as “sailor gait.” Again in this
condition rarely do we find an anterior dislocation, but when such
is the case, the entire body is swayed entirely backward, though the
lumbar lordosis is not increased, in fact usually presents a peculiarly
flattened appearance. Other symptoms differ only in a slight degree
from those of the ordinary posterior displacement. The physical signs
are the same as the unilateral displacement and are even more readily
recognized by the peculiar appearance and distinctive gait of the
patient. The swaggering gait of lumbar Pott’s Disease is somewhat
similar, but this is an acquired clinical condition of the spine in
which the hip joints are normal in appearance and nearly so in function.
Before taking up the usual procedure for the correction of congenital
dislocation of the hip, it might be interesting to touch on several
cases of this deformity in young children that I have reduced without
an anesthetic. If future experience proves as successful as these
cases it will entirely revolutionize the treatment of this condition
especially in children under twenty months of age. To begin with,
these children had just started to walk and it must be remembered that
at this stage the acetabula are nearly normal and there has been no
muscular or ligamentous contraction because very little weight has been
borne on the limb.
First the pelvis is held fixed by the assistant, and the thighs
completely flexed on the abdomen. Next firm pressure is made on the
knee to force the head of the femur beneath the acetabulum and as the
limb is abducted in the flexed position, the head is raised into the
acetabulum with the thumb of the operator’s other hand. The whole
procedure takes but a moment’s time and the child should be placed
at once upon the floor and allowed to walk. Time will tell if the
reduction has been successful, and if failure of retention develops,
the Lorenz method followed by plaster of Paris fixation can still be
used. I should always recommend the trial of this method in children
who have walked not longer than six months, before resorting to the
following Lorenz treatment.
=Treatment by the Lorenz Operation.=—This treatment is based on the
fact that there is normally present an acetabulum of sufficient size
and capacity to retain the head of the femur, providing the limb can be
fixed in a favorable attitude, and as soon as possible weight borne
upon it to deepen the rudimentary acetabulum. The typical operation
of today is best divided into four distinct steps; first, to overcome
the resistance of the tissues surrounding the joint; second, to reduce
the dislocation, or rather to force the head of the femur over the
posterior border of the acetabulum; third, to increase the security
of the articulation by stretching the anterior border of the capsule;
fourth, to fix the parts in a plaster of Paris bandage.
The child is completely anesthetized, and an assistant firmly fixes the
pelvis on the table with his hand. The operator first flexes the thigh
to a right angle with the body and forcibly abducts, at the same time
kneading and stretching the tense adductor muscles and if necessary
rupturing the adductor tendons in order to bring the limb down to the
plane with the body. Next to overcome the contraction of the posterior
tissues, the limb fully extended is flexed upon the trunk and gradually
forced downward until the toes touch the patient’s face. To overcome
the resistance of the tissues on the front of the joint, it is best
to move the patient to the edge of the table and forcibly extend the
thigh downward behind the plane of the body. It is also well to apply
direct traction in the line of the body. This preliminary stretching
is absolutely necessary, because all the tissues about the joint are
so shortened, and it will now be noted that with slight traction the
trochanter can be drawn down to Nelaton’s line.
Next reduction is attempted by grasping the limb with one hand at the
knee and strongly abducting it while the palm of the other hand is
placed on the anterior spine of the ilium with the thumb placed beneath
the great trochanter to act as fulcrum. As the limb is gradually forced
downward to and behind the body plane, the head of the femur is forced
upward until it finally slips over the posterior and inferior border of
the acetabulum. In the more resistant cases a padded wedge-shaped block
placed behind the trochanter will be an aid in pushing the head forward
and upward while the patient’s knee is forced downward. A successful
reduction is usually accompanied by a distinct jar and audible thud,
and it would be observed that the tension upon the ham string muscles
causes fixed flexion of the leg. After reduction has been made, the
limb should be brought down carefully into a straight position to test
the security of the re-position. If dislocation appears during this
manipulation, the tissues must be still further stretched and the
displacement further reduced. If displacement occurs readily due to a
shallowness of the acetabulum the prognosis is not so good as where
the stability remains when the limb is brought down into a straight
position, and one must be more particular in the fixation of it. I have
also observed that the more difficult the reduction the more stable
the end results. The easy replacements are usually just as easily
displaced. Sometimes the head slips into the socket quietly without the
distinct jar or thud but the results in these cases are just as good
provided they are properly cast.
[Illustration: Patient in position for the first cast in a left
unilateral dislocation. The thigh should be a little past a right angle
in relation to the trunk, with about 80° abduction.]
The application of the plaster spica is by far the most important part
of the treatment, as the reduction is usually quite easily accomplished
in children under six years of age. If the cast is improperly applied,
the hip will slip out of the socket and the case is a failure. A pair
of soft knitted cotton drawers are put on and the patient is placed
upon a pelvic rest with the limb held in the position of greatest
stability at a right angle with the trunk, or even slightly more and
about eighty degrees abduction. In a case where the socket is very
shallow, the position to be cast should be about one hundred degrees
flexion, and in abduction the limb should lie slightly behind the plane
of the body to secure the best results.
[Illustration: Correct position and proper application of cast for
double congenital dislocation of the hips.]
The limb and pelvis are covered with ordinary absorbent cotton which
is held in place with a roller gauze bandage. A snug fitting plaster
of Paris cast is now applied around the pelvis and well down over the
knee. I leave this over the knee for five or six days or until the
child ceases to be fretful, then I cut it away just back of the knee
joint to permit motion there. The ends of the drawers are drawn back
smoothly over the cast and are sewed to each other. For about a week
following the operation the adductor region is swollen and discolored
and more or less painful due to rupturing and stretching of those
tendons. After this discomfort has passed away, walking is encouraged
on the theory that the weight bearing and the stimulation of functional
activity will increase the stability of the joint by deepening the
acetabulum.
[Illustration: Proper position of the limb in the second cast for
unilateral dislocation.]
The first cast should remain from three to six months according to
the stability of the joint at the time of reduction. If in young
children the cast becomes offensive, it must be changed as often as is
necessary. When the first cast is removed, the limb is pulled down to
about thirty degrees abduction and the same amount of flexion, without
an anesthetic, and a second cast is applied, which extends only to
the knee, to be worn from three to six months longer. After removal
of second cast, the child is permitted to get about carefully. The
limb will be everted and slightly flexed, which position invariably
causes much concern among the relatives of the patient, but this
abnormal condition disappears after a few months’ time. Sometimes for
even a year following removal of the second cast there will also be a
noticeable hitch in the walk of the child; but this, too, disappears
and in the course of two years’ time one could never tell that such
an operation had been performed. Massage of the posterior and lateral
muscles of the hip always helps considerably towards the relief of any
stiffness or lameness.
Reduction by Open Incision
In the more resistant older cases, where manipulative reduction has
failed, reduction by incision can be employed with success, but this
procedure requires the exercise of care in order to do as little injury
to the muscles as possible. A crucial incision of the capsule is made
and the capsular constriction and ilio-psoas tendon divided. With a
little traction, the head of the femur slips easily into its socket.
The capsule is stretched firmly around the neck and the incision into
the capsule is then closed by suture, and the limb fixed in a plaster
of Paris spica in the fully abducted position. The operation should of
course be done under the strictest asepsis.
Talipes or Club Foot
The word talipes signifies some deformity of the foot and is quite
common in orthopedic practice, being found in nearly ten per cent
of the cases coming under this branch of the science. Club foot may
be classified into two types—the congenital and the acquired. The
congenital type is the most common and is due probably to abnormal
intrauterine pressure or to a perversion of normal intrauterine
development. The acquired type is due usually to injury or infantile
paralysis, but either joint disease or cerebral paralysis may be
the cause. The deformity presents six different forms with most
characteristic clinical pictures which, with the exception of talipes
planus I have taken up in the order of frequency.
[Illustration: Illustrating the more common types of talipes. A
combination of any may be present.]
=Talipes Equinovarus= is usually congenital and is the most common
type. It is characterized by inversion and torsion of the foot with
elevation of the heel. The weight is borne on the outer side of the
foot and in extreme cases upon the dorsum as well. Calluses are always
present which are red and painful upon the point where the greatest
weight is borne. The most common method of treating this condition
is to divide the tendo Achilles at a level with the malleoli. The
operation should be done aseptically and under complete anesthesia.
As an assistant raises the end of the foot so as to stretch the tendo
Achilles the surgeon enters the knife parallel to the border of the
tendon through the skin and tendon sheath into the tendon itself. Next
with a tenotome inserted into the incision and turned at right angles
to the tendon, the tendon is divided first on one-half then on the
other. Care should be taken to disturb the tendon sheath as little
as possible for it serves an important purpose in repair. When the
division is complete as indicated by the separation of the divided
ends, the tenotome is withdrawn and the minute opening in the skin,
from which there is only slight bleeding, is covered with aseptic
gauze. The foot is forced into dorsal flexion and if in severe cases
the deformity is not then corrected, the tendons on the outer side
of the foot may be shortened, while those on the inner side may be
lengthened in the same manner as the tendo Achilles. A plaster of Paris
cast is then applied well up to the knee with the foot in the over
corrected position, care being taken that no undue pressure is brought
upon the seat of operation, as this might interfere with the effusion
of plastic material. Personally I believe that functional use of the
limb and foot stimulate repair, and I always encourage the patient to
stand and walk after the discomfort of the operation has passed. At the
end of four weeks the space between the two cut ends will be filled
with new material and the cast can be removed, and in another month the
splice, which is somewhat larger and thicker than normal, should be
strong enough for use. In the course of a year the lengthened tendon is
perfectly normal.
=Talipes Equinus.=—In this type the patient walks on his toes with the
heel highly elevated, in the same position as the horse, and it will
be noticed that the foot has no dorsal flexion whatsoever. Infantile
paralysis affecting the anterior muscles of the leg is usually the
cause of this condition, though sometimes shortening of the leg
following knee joint disease, or fracture may lead to an adaptive
equinus which serves to make the limb of equal length for walking.
This type is by far the easiest to remedy, and the results following
operations are perfect. A simple division of the tendo Achilles is
made under anesthesia and a cast applied as above, in a position of
exaggerated dorsal flexion. Functional use of the limb after the cast
has been removed overcomes any stiffness that might occur and perfect
results are obtained in a short time, compared with the other types.
=Talipes Calcaneous.=—This is a condition in which the foot is held in
a position of dorsal flexion. The patient walks on the heel with an
inelastic gait because the spring of the foot is absent and the whole
weight is borne upon the os calcis. The best procedure in this type is
manipulative treatment into a position of plantar flexion to overcome
the contraction of the anterior muscles of the foot and leg, and bring
about contraction and shortening of the posterior muscles. A tenotomy
of the anterior tendons or an anesthetic is rarely indicated, though in
severe cases, a series of casts holding the foot in position of plantar
flexion may be necessary to secure good results. I have found it a help
to have a shoe with a heel prolongated backward, or a steel splint
laced to the leg to prevent the foot from upward motion.
=Talipes Valgus.=—This is a very uncommon type of deformity,
characterized by eversion of the foot. The patient walks on the inside
of the foot and, as a rule, experiences very little trouble. I find a
manipulative treatment is best for this condition, aided by braces.
=Talipes Cavus.=—This form is sometimes called “=hollow foot=” and is
very uncommon in this country. It is characterized by a markedly high
arch sometimes as in Chinese women to the extent that the anterior
part of the foot is approximated to the heel. The plantar fascia is
badly contracted and one can distinctly palpate the bands beneath the
skin. This condition is practically the same as the ordinary so-called
“=contracted foot=” except that it is much more exaggerated. The
ordinary high arch of today is usually the result of wearing too short
a shoe, and if painful, long last shoes, aided by manipulations, will
usually correct the trouble. In severe cases of contracted foot the
plantar fascia may be divided, under anesthesia and the arch brought
down and put in a cast, though this procedure is not very successful.
In case it is done the patient should be made to walk in two or three
weeks, as this helps materially to overcome the deformity and hasten
repair of the fascia.
=Talipes Planus.=—This condition is commonly known as “=flat foot=” and
is taken up in another part of this text. However, it is one of the
classifications of “club foot” and is far the most common type.
=Prognosis.=—These conditions never correct themselves and if
uncorrected usually get worse and the more severe types certainly
become obstinate malformations. In general the tendency to relapse
is strong, though if properly treated the results are excellent. In
infantile cases the time required for correction is relatively short,
but retentive appliances are needed for a longer time. The older
the cases and larger the foot the more difficult, of course, the
correction, but usually there is less danger of relapse. A perfect
correction, that is when the gait and attitude are normal, will never
relapse. I find it better to leave the fixation appliance on too long
than not long enough. Never remove a cast under four weeks except in
the cavus type, then apply a brace such as can be obtained from any
supply house for any type of case, for from one to three months longer.
The tendons involved in these conditions are so apparent that it is
almost impossible to make a mistake in the division of them. About
the only precaution necessary is to be assured that the tendon itself
is completely divided, but that the tendon sheath is only slightly
disturbed.
Tuberculous Disease of the Bones and Joints
Perhaps no bony lesion has caused so much difference of opinion in
this profession as tubercular conditions of the spine, bones and
joints and I wish it understood that in the following discussion, it
is not my desire to reopen the argument. My observations have been
of cases treated both osteopathically and by fixation, in private
practice and institutional work. And I have come to the conclusion that
the fixation method of treatment is absolutely always indicated. In
general the pathology and etiology of all tubercular bone conditions
is the same. It begins as a tubercular infection of the spongy tissue
of the epiphysis, the first change being a local hyperemia of the
portion involved, followed by one of three courses: the diseased focus
being absorbed and a spontaneous cure resulting; it may extend to
the periphery of the bone and break through the periositum and empty
itself there by abscess formation; or most commonly it may extend to
the joint, which becomes involved through attendant injury. Repair is
brought about by the formation of fibrous tissue probably arising from
the layer of non-tuberculous granulation tissue which grows in and
replaces the tuberculous tissue. Also the replacing material may become
calcified and encapsulated. A fibrous or bony ankylosis may result from
this process of repair.
The vulnerability of growing bone accounts for the frequency of
tubercular bone disease in children as compared with adult life.
Injury not only causes a local predisposition to the disease, but it
favors its progress when it is once established. About seven-eighths
of the cases of this trouble occur under fourteen years of age, more
especially when the vertebræ or hip-joint are involved. The knee and
ankle joints as well as the elbow and shoulder joints are more often
diseased in later life. While the inherited predisposition is very
direct and positive in twenty-five percent of the cases, the acquired
predisposition is of most importance since it includes lessened
vitality due to poor food and imperfect hygienic surroundings. As
to the distribution of the disease the vertebræ are most commonly
affected, followed closely by the hip and knee joints, and then in the
order of frequency the ankle, elbow, shoulder and wrist joints.
Tubercular Disease of the Spine
This condition is commonly called =Pott’s Disease= or =Caries=. It is
a chronic destructive process of the bodies of the vertebræ. The spine
bends at the weakest point and the compression and collapse of the
affected parts cause the characteristic posterior angular projection
at the seat of the disease. If one vertebral body is destroyed, the
projection will be sharp; if several are involved it will be less
angular and if one side breaks down before the other, there may be a
lateral as well as posterior distortion. The size of the deformity and
its effect upon the patient depend upon its situation; that is, if
either end of the spine is involved the angular projection is slight
because the area of the spine directly involved in the deformity is
small compared with that which is free from the disease. If the middle
of the spine is affected, the deformity is great, because the entire
spinal column may enter into the angular projection. In the latter area
the internal organs are compressed and, of course, the effect upon the
vital organisms of the body is disastrous.
=Pathology.=—The first indication of tubercular disease of the spine
is usually found in the anterior part of a vertebral body just beneath
the fibro-periosteal layer of the anterior longitudinal ligament. From
this point the foci may advance along the front of the spine following
the course of the blood vessels and invading the adjacent vertebral
bodies. The destruction may begin in the interior of the body itself,
more often in several minute foci near the upper or lower epiphysis,
which coalesce, gradually enlarge and form a cavity surrounded, for a
time, by unbroken cortical substances which finally collapse under the
pressure of the weight above. The intervertebral discs seem to offer
some resistance to the extension of the disease from one vertebra to
another but once the bone is destroyed on either side, they too quickly
disintegrate and disappear. Pedicles and articulations which come into
direct contact with the disease may become involved. Originally the
disease is confined to one or two adjacent vertebræ and may extend
in either direction, and the final area of deformity and rigidity
shows that from three to six bodies may be involved before a cure is
established. The infected granulations advance rapidly with the usual
retrograde change of shape and structure to a cheesy degeneration and
frequently liquefaction and abscess formation may follow.
=Symptoms of Pott’s Disease.=—There are three main symptoms of Pott’s
disease, namely the peculiarity of attitude and gait, limitation
of motion or muscular stiffness and the pain and referred pains.
In the cervical region, the chin is held somewhat raised and the
patient may have somewhat the same appearance as in wry-neck. In the
mid-dorsal region one will always find an elevation of the shoulder
besides the deformity. In the lumbar region, the patient nearly always
leans backward and has a sort of sidling gait or waddle due to the
contraction of the psoas and iliacus muscles. The patient in walking,
stooping, or lying down most carefully guards the spine against any jar
or motion, and always assumes attitudes which will relieve the strain
on the involved vertebræ. There is always present an unnatural mode
of standing or walking, especially when the dorsal and lumbar regions
are involved, as the patient walks more on his toes and with the knees
slightly bent, because in this posture all possible strain of the step
may be brought into play to diminish jarring of the spine. The child
becomes tired very easily and lies down or rests on the arms of a chair
or seat. The pain rarely occurs in the back, but is usually referred
to the peripheral end of the nerves and is thus felt in the chest,
abdomen or limbs. The abdominal pain passes sometimes as a stomach
ache and often times in the limbs, as rheumatism or “growing pains”.
I have noticed also a peculiar grunting respiration and sometimes
cough especially when the mid-dorsal region is involved. Muscular
stiffness is always present, all mobility being lost. The temperature
is not at all diagnostic, though sometimes in the afternoon it will
be one or two degrees higher than normal and does occur independently
of abscesses. About the only complication that occurs is paralysis or
abscess formations. Paralysis is given as a frequent complication,
though I have never seen it. It is usually flaccid and bilateral and
may exist from a mere muscular weakness to a complete loss of power.
It is certainly uncommon under proper treatment, and the prognosis is
favorable. Abscesses, though a very distressing complication, are very
uncommon in my experience and are certainly an evidence of improper or
incomplete treatment. They may subside in any region and be absorbed
without detriment to the patient, though if they increase in size there
is no tendency towards absorption. It is best to incise them and secure
complete drainage. It is hard, of course, to do this on account of the
depth. Abscesses occur always in close proximity to the disease.
=Treatment.=—Some authors recommend a brace for the treatment of this
condition, while others recommend a frame to which the patient is
strapped, and rest in bed. I have found nothing that gets results like
a plaster of Paris jacket applied with the patient suspended by the
neck and shoulders. I make no attempt at correction of the deformity
present other than the traction of the weight of the body at the time
the cast is applied. The spine is, of course, fully extended by this
and any undue pressure on the cord relieved. The cast should extend
over the shoulders and well down over the pelvis and sacrum. If the
disease is in the neck the cast should include the head as well. A
large window is cut in front and one must be cut over the involved area
of the spine behind. Ordinary absorbent cotton is used for padding
with, of course, extra padding over all bony prominences. From two to
five years’ time is required for a complete recovery. The X-ray is
invaluable in diagnosing this trouble, and each time a cast is removed
to see how much progress has been made. The casts should be changed as
often as they become soiled.
Tuberculosis of the Hip
This is a chronic tubercular condition of the head of the femur or of
the acetabulum commonly known as =hip-joint disease=.
=Pathology.=—Primarily the head of the femur is the seat of the
disease, the epiphysis being attacked in seventy-five per cent of
the cases and the acetabulum in twenty-five per cent. The irritated
pelvic femoral muscles which are in a state of chronic contraction
crowd the head of the femur against the upper and back border of the
acetabulum. Under this continual pressure, absorption of that portion
of the rim takes place with actual enlargement of the acetabulum from
below upwards. This is spoken of “migration of the acetabulum” and is
one cause for the shortening of the limb. Changes in the head of the
femur are the result of inflammation and pressure. Partial destruction
of the head also helps shortening of the limb and elevation of the
trochanter above its proper level the same as the wearing away of the
acetabulum. The synovial membrane is found to be reddened and thickened
and granulation tissue is present, and usually the cartilage is gone
from the head of the femur. Rarely does perforation of the floor of the
acetabulum take place, but if such is the case a dense wall of fibrous
tissue and thickened periosteum shuts off the head of the femur from
the pelvic cavity. A natural cure results in two ways,—by absorption
or calcification of the tubercular tissue, or by the evacuation and
discharge by an external opening. This latter suppuration seems to
be nature’s effort to eliminate the disease, and when a cure is
established this way it is usually characterized by malpositions and
shortening of the limb, and, of course, an ankylosed joint.
=Early Symptoms.=—The most characteristic symptoms of the disease
are the ‘night cries’, stiffness and limping, shortening of the leg,
atrophy of the muscles of the hip, leg, and thigh, and the unconscious
protection of the joint. A referred pain is usually present to the
inside and front of the thigh near the knee or directly at the knee
joint itself, due to the intimate relations and anastamosis of sciatic,
obturator, and anterior crural nerves.
=Diagnosis.=—The chief diagnostic sign is muscular spasms or the
presence of stiffness of the joints and limitations of its proper arc
of motion, due to the tonic contraction of the muscles controlling the
joint. If there is no limitation of motion it is almost safe to say
there is no hip-joint disease. The lameness may be intermittent. The
attitudes or abnormal positions of the diseased limb are caused by the
action of muscles holding the limb stiffly in a distorted position.
The pelvis is usually tilted and always one will find the patient
assuming attitudes which will favor the diseased limb. Atrophy is
very significant and a comparison of the two limbs should be made by
measuring at the middle of the thigh and the middle of the calf. Nearly
always one will find a deep thickening over the front of the hip joint
and behind the trochanter.
=Physical Examination.=—1. Observe the general condition of the patient.
2. Note the attitude in standing.
3. Note character of the limp.
4. Note shortening of the limb.
5. Remove the clothing and lay patient on the back.
6. Test the function of the groin. Always begin on the sound side
for comparison in order that the patient may become accustomed to
the manipulation before the limb suspected of disease is tested.
Tuberculosis in a joint is always accompanied by muscular spasms that
positively limit motion in every direction, while in other affections
only one or more limitations are observed, but never in all directions.
Compare closely the motions of the sound and affected limbs while the
patient is on the back. Turn patient on face and test for extension by
holding pelvis flat on table with one hand and gently elevating thigh
with the other. The normal range in a child is about twenty degrees
backward from the line of the body and limitation of this range is
perhaps the earliest indication of hip-joint disease. It is due to
psoas contraction. If this range of motion is unrestricted hip disease
can be practically excluded.
The X-ray completes the diagnosis when used with a thorough knowledge
of the physical signs. It must be remembered that in early life a
larger part of the extremity of the femur is cartilaginous and does
not show well in a radiograph. The X-ray picture shows clearly the
destructive effect of the disease on the femur and acetabulum and gives
a clear conception of the actual condition of the joint.
=Treatment.=—The object of treatment of this condition is threefold:
first, to relieve the pain that depresses the vitality of the patient;
second, to relieve the muscular spasms that induce distortion of the
limb and which stimulates the destructive process by increasing
pressure and friction of the diseased surfaces of the opposing bones;
third, to correct and prevent deformity by lessening pressure and by
restraining motion, thereby keeping the femur from upward displacement.
Rest and protection are the two cardinal features of treatment of
this condition. Sunshine, fresh air and good nutritious diet are very
important.
Complete rest of the joint offers the most favorable opportunity for
nature to repair this disease. The recumbent period of the treatment
necessitates rest in bed for the reduction of the deformity and
subsidence of acute symptoms. By the aid of traction, which is applied
to the length of the legs by means of a Buck’s extension. As much
weight should be applied as can be borne without discomfort to the
patient.
As soon as the deformity and acute symptoms have subsided, the
ambulatory treatment should be substituted to keep up the general
health of the patient. This merely consists of the application of a
long plaster of Paris spica of the hip which should reach well up to
the thorax and extend down and include the foot. All bony prominences
should be well padded, and a moderate amount of traction with about
twenty degrees abduction should be used while applying the plaster
bandage. Though various forms of apparatus have been devised for
fixation and traction, I believe that the plaster of Paris spica is
far the most effective and should always be used, changing the cast
as often as it becomes soiled. Locomotion is possible with crutches
providing the shoe on the well side is stilted by an iron patten which
is high enough to allow the casted limb to clear the floor.
The earlier treatment is begun, the better the outlook. Recovery with
perfect motion occurs in about twenty-five percent of hospital cases;
fifty per cent will obtain useful motion and the other twenty-five per
cent will obtain practical fixation, but it must be remembered that
results will range entirely according to the thoroughness of treatment,
the severity of the disease in the individual case, and the natural
resistance of the child. In general, the hip should be fixed as long as
it is sensitive, it should be protected and distracted as long as there
is muscular spasm, and protected until the congested and inflamed bone
of the epiphysis is replaced by firm healthy bone.
Tuberculosis of the Knee Joint
Tuberculous disease of the knee is next to the hip in frequency. It is
a chronic destructive process of the epiphysis of the femur or tibia,
or it may start in the patella, head of the fibula, or primarily in
the synovial membrane of the knee joint. The condition presents two
distinct types; one, the adult type beginning as a chronic synovitis,
of which the early symptoms are subacute; and the other, the childhood
or most common class, in which the symptoms of pain, muscular spasms
and deformity seem to indicate clearly a primary disease of the bone.
=Symptoms.=—This disease is commonly known as “white swelling” and
the symptoms as a rule are quite characteristic. The affection begins
with a limp and limitation of motion, and is usually slow in progress
with periods of severe pain. There is usually much swelling and
this together with the distortion of the limb by muscular spasm and
atrophy of the muscles both above and below the joint, gives a most
characteristic knock-kneed appearance. The affected limb is usually
longer at first, owing to the congestion of the epiphysis of the knee.
Local heat is always present in the more acute stages and the lameness
is usually a constant symptom. The differential diagnosis from other
joint troubles is easy because of the slow insidious onset.
=Treatment.=—Like other tubercular bone conditions the fixation
treatment is best. Rest in bed with a Buck’s extension to overcome
the deformity and the local application of hot packs until the acute
symptoms have subsided, is the best preliminary treatment of this
condition. Five- to ten-second exposures to the X-ray each day for ten
days seems to relieve the pain and in most instances causes less marked
infiltration of tissues.
When the acute stage has subsided, the ambulatory treatment by fixation
in a plaster of Paris cast extending from the groin to the ankle, with
about 10 degrees flexion, is most efficient.
The patient is allowed to walk about with the aid of crutches, having
the shoe on the sound side stilted enough so that the diseased limb
clears the floor. The functional results after conservative treatment
are in the average case excellent, that is providing proper treatment
is begun at an early stage. Useful motion is obtained in fifty per cent
of these cases, perfect motion is restored in twenty-five per cent, and
complete rigidity results in the other twenty-five per cent of cases.
Any chronic, painful inflammation confined to a single joint, in which
motion is limited by muscular spasm, and in which there is a tendency
towards deformity, is almost always tubercular in character.
The Plaster of Paris Bandage
The plaster of Paris bandage was perhaps first applied by Kluge of
Berlin in 1829, but to the Dutch physicians Mathysen and Vander Loo
belongs the credit of the modern bandage.
It is imperative to give, in this chapter, a detailed and complete
description of what constitutes a properly made plaster of Paris
bandage and the application of it, in order that the general
practitioner may become familiar with its use. Even though one
cares not to treat the conditions heretofore enumerated, I have
found that for fractures of almost every bone in the body requiring
immobilization, the plaster bandage properly applied is far superior
and rather to be preferred to any other form of splints.
It has been used very little in the past in private practice because
the ordinary commercial bandage found in any supply house does not come
up to requirements, in that it is usually air slaked or the plaster has
been shaken from it by the time it is received. Then too the mesh is
too closely woven and the plaster lies on the bandage instead of in the
meshes and there is, in consequence, an excess of plaster; also as a
rule the bandages are rolled so tightly that the water does not reach
the deeper layers.
The ordinary plaster of Paris bandage made in your own office can
always be successfully applied because the right quantity of plaster
can be incorporated in the bandage and it can readily be made into
the desired widths. The plaster of Paris to be used should be of the
superior quality used by dentists and should be of the quick setting
kind. It can be procured at almost any drug store but the surest place
for quality will be your dentist.
Absolutely, the only kind of gauze to be successfully used is white
crinoline of the ordinary variety used by dressmakers and obtainable
at any dry goods store in twenty-four yard bolts. It is especially
desirable to get a kind not too rich in starch or dextrin and of a mesh
running about one hundred holes to the square inch.
The bandages should be made in six yard lengths, and of widths ranging
from three to five inches according to the part that is to be cast;
for instance the three inch widths are most suitable for casts for the
extremities, while the larger ones serve best for conditions of the
spine. After the length had been measured and cut the desired widths
can be torn the full length without trouble. The edge of the crinoline
nearly always frays out and naturally will become so entangled as to
prevent rolling in the plaster or as to hinder the free unrolling of
the bandage when applying it. To prevent this, three threads should be
plucked from each side of each strip before starting to roll in the
plaster.
A hard surface of, at least, two feet in width should be used on which
to roll in the plaster. Starting at one end, a handful of plaster of
Paris is rubbed into the crinoline with the palmar surface of the hand,
bearing down hard, so that all excessive plaster passes to either edge
of the bandage. No more plaster should be rubbed into the crinoline
than the meshes will hold, and as each successive yard is incorporated
with the necessary amount of plaster, it is loosely rolled in such
manner that in the center of the bandage there is a hollow cylinder of
the thickness of the index finger, and the concentric layers are easily
movable on one another. This manner of rolling permits of the rapid and
uniform spread of water through the bandage when it is to be applied,
and prevents parts of the bandage from being insufficiently moistened.
The general practitioner should always keep on hand about two dozen
completed bandages that he is most accustomed to using in his daily
practice. These should be corded as it were, to prevent unrolling, in
an air tight container, either of glass or tin in the bottom of which
is placed a small quantity of plaster of Paris, and should always be
kept in a dry place. I have never found either a nurse or an office
girl who could not make these bandages successfully so that in the
future there is no excuse for a practitioner not using this superior
form of splints.
The Immediate Use of the Bandage
While plaster of Paris is in no way harmful to either garments or
surroundings, both the operator and the assistants should be properly
gowned and the floor covered with newspapers to prevent unnecessary
soiling. It should be borne in mind that if a properly made bandage is
used, which is squeezed to the extent of ridding it of an excess of
water, very few drippings will be scattered and the whole procedure of
the application of the plaster differs in no way from simple roller
bandaging.
The number of bandages intended for use should be taken from the
container and placed in a pan near the pail holding the water, in
which they are to be immersed, in a position in relation to the pail
that will guard against water being splashed upon the dry bandages,
which would render them unfit for subsequent use. Water as hot as the
hand will tolerate, as opposed to cold, facilitates setting. I do not
recommend any chemicals to hasten setting, because a properly made
bandage, prepared as above, of quick setting plaster sets in remarkably
fast time.
The area to be cast should be encased in ordinary absorbent cotton of
the thickness in which it comes rolled, putting an extra pad over all
marked bony prominences, and a roller gauze bandage applied to hold
it in place and snug to the part. Under no consideration do I advise
the use of flannel bandage or the ordinary sheet wadding cotton that
are recommended by some authors, because padding with these materials
is always conducive to applying a cast far too tightly, especially
in fractures where the swelling increases after application thereby
causing constriction of the limb and interference with circulation. The
regular absorbent cotton as padding beneath a cast is always best for
it is almost impossible to apply a cast too tightly when it is used.
The bandage should be completely submerged on its side, and should
remain so until the bubbles cease to come off, which time takes place
most readily in the properly rolled dressing. When the bubbling has
ceased, the bandage is lifted out of the pail and squeezed with the
hands merely to free it of the excessive water, the end is found and
handed to the operator ready to apply. No undue traction should be
made in applying the successive turns of the bandage, though it must
be remembered the cast should fit snugly to the part, and the ordinary
rules of simple roller bandaging followed, except that the reverse
spirals are unnecessary. The assistant should constantly rub the layers
as they are applied by the operator, as this not only helps the cast to
fit more snugly, but also makes the rough edges of the bandage adhere
more firmly to the layer beneath, thereby making a smoother cast.
As a rule there need be no dread of an increased swelling beneath the
bandage because usually several hours have elapsed after the injury
before the physician has arrived and made preparations to apply the
plaster. Indeed, one of the best means of limiting swelling after a
fracture is the prompt application of a plaster of Paris bandage. If
there is any concern that the cast is too tight, while the plaster is
still soft it can be easily cut through the entire length with a knife,
and thus relieve the pressure existing. Also it is a good plan to cut a
window or opening over the sight of injury, which would in no way harm
the object of the cast and would allow a gentle massage to the part. A
neat finish may be given to the edges of a plaster cast by turning over
the ends of the cotton, in cuff-like fashion and held in the grasp of
the last few turns of the plaster at either end.
On clothing you will find it best to allow the plaster to dry before
removing, while on furniture or the hands it is readily removed by
washing off in warm water. The water in which the bandages were
immersed contains, of course, considerable plaster, and under no
circumstances should this be emptied into a sink or waste pipe for
it will certainly demand the services of a plumber. The water may be
poured out on the ground and the paste shaken into a refuse barrel or
ash pile. The best way to remove a cast is to moisten it with water or
vinegar along the path of the knife. I might add that all patients are
in constant fear of being cut either while you are trimming, cutting
windows, or removing the cast, but because of the cotton padding
underneath you will find that it is almost an impossibility. Care, of
course, should be taken that the knife does not slip in any of these
procedures and come in contact with the unprotected parts.
In general, for fractures of the extremities it is best to apply the
plaster with the patient in the recumbent position to secure complete
muscular relaxation, and the part to be cast should be supported by an
assistant. It is also a general rule that in fractures of the shaft
of the long bones, especially of the lower extremities, the plaster
bandage should be applied to include the adjacent articulation and
extend well beyond the joints.
INDEX
A
Abbott treatment, 98, 774, 778.
Abdomen pendulous, 127.
Abdominal examination, 51.
rheumatism, 466, 467.
technic, 77, 536, 539.
dangers of, 87, 540.
Abducens nerve, lesions affecting, 717.
Abscess of rectum, 174.
perinephritic, differentiate pyelitis, 628.
peritonsillar, 278.
Achylia gastrica, differential diagnosis, 508.
Acne, 150.
Accommodation in the eye, 192.
Acetabulum, migration of, 791.
Addison’s disease, 704.
differentiated from jaundice, 559.
Adenitis, tubercular, 384.
Adenoids, 273.
Adhesions, broken up after sprains, 108.
Adjustment, osteopathic, 90.
Adrenal glands, diseases of, 703.
Aged, spine of the, 101.
Agitans, paralysis, 723.
Agitata, melancholia, 297.
Ague, 347.
Alcohol in post-operative pneumonia, 319.
Amentia, 290, 307.
Amyloid kidney, 626.
liver, 562.
Amyotrophic lateral sclerosis, 762.
Angina pectoris, 666.
differential diagnosis, 667.
pathology in, 308.
Anemias, the, 672.
Anemia, costogenic, 673.
Burns, 673.
pernicious, 678.
Aneurism, cardiac, 660.
Animal experiments, 91, 490.
parasites, 151.
Ankle, 56.
sprain, 112.
Ankylostomiasis, 155.
Anterior dorsal lesions technic, 76.
Antidotes may be necessary, 62.
Antiseptics may be necessary, 62.
Aortic regurgitation, 649.
stenosis, 551.
Aphonia, 571.
Aphthous stomatitis, 488.
Appendectomy, colitis following, 552.
Appendicitis, 547.
differential diagnosis, 550.
Appendicitis from ileo-cecal trouble, 141.
pseudo, 550.
Appendix innervation, 498.
Arch supporters, 114.
Arhythmia, 665.
Arm affected by rib lesions, 740.
Arm examination, 56.
technic, 80.
vasomotor nerves to, 94.
Arteries, diseases of, 669.
Arteriosclerosis, 669.
Artery complications from typhoid, 332.
Arthritis deformans, 462.
rheumatoid, 462.
differentiated from inflammatory rheumatism, 459.
septic, differentiated from inflammatory rheumatism, 459.
Articular rheumatism, acute, 460.
Ascaris lumbricoides, 153.
Aspiration pneumonia, 605.
Asthenopia, 232.
Asthma bronchial, 589.
caused by rib lesions, 94.
Ataxia, Friedreich’s, 759.
hereditary, 759.
differentiate chorea, 726.
locomotor, 754.
Ataxic paraplegia, 761.
Atheroma, 669.
in heart, 647.
Atlas examination, 44.
lesions, 44.
Atrophy of optic nerve, 231.
progressive muscular, 762, 764.
Auditory—See also ear.
Auditory meatus, diseases of, 236.
nerve degeneration, 256.
nerve lesions affecting, 718.
Auerbach’s plexus, 494.
Auto-intoxication in nose diseases, 268.
Axis lesions, 45.
B
Backache, post-operative, 313.
Bandage, abdominal, for floating kidney, 137.
liver, 139.
sprain, 106.
Barbadoes leg, 158.
Baths, hot, in skin diseases, 147.
Bee sting near eye, 199.
Bell’s paralysis, 717.
Belt—See bandage; also brace.
Biceps, long tendon dislocated, 114.
Bile duct, diseases of the liver and, 553.
Biliary colic, 565.
differentiate, 551, 565, 632.
Binocular vision of osteopath (two pathologies), 489.
Birth injuries, causes of heart irregularities, 666.
Black eye, 199.
Blackwater fever, 351.
Bladder, diseases of, 635.
hemorrhage, 164.
sensory nerves to, 95.
Bleeders disease, 484.
Blennorrhea, acute, 209.
Blepharitis, 200.
Blood flow directed to abdomen, 582.
Blood, diseases of, 671.
Bones and joints, tuberculous disease, 788.
Bothriocephalus latus, 151.
Bowel—See intestine.
Brace in Pott’s disease, 103, 131.
in prolapse, 133.
in spinal curvature, 99, 103, 122.
Brachial neuralgia, 711.
neuritis, 123.
differential diagnosis, 125.
plexus, lesions affecting, 721.
Brachycardia, 664.
Brain, pathology of, 307.
its relation to mind, 307.
physiology of, 306.
tumors, differentiate migraine, 737.
Brand bath, 329, 343.
Breakbone fever, 356.
Bright’s disease, 618.
Bronchi, diseases of the, 579.
Bronchial asthma, 589.
Bronchiolectasis, 587.
Bronchitis, 579.
Bronchopneumonia, 605.
caused by tubercle bacillus, 606.
Broncho-pulmonary hemorrhage, 160.
Bulbar paralysis, 765.
Bunions, cause of, 112.
Bursitis, 123.
differentiate from neuritis, 125.
C
Calcification in heart, 647.
Calculus, renal, 631.
Cancer of liver, 562.
of stomach, differential diagnosis, 508.
Canker, 488.
Carcinoma, location of reflex pain in, 499.
Cardiac—See heart.
Caries—See Pott’s disease.
Catalonia, 286.
Cataract, 229.
Catarrh
dry, 583.
of conjunctiva, vernal, 216.
stomach, chronic, 505.
Catarrhal deafness, 246.
pneumonia, 605.
stomatitis, 487.
Center, diabetic, 474.
Centers, osteopathic, 88.
nutritional, 480.
Cephalodynia, 465, 467.
Cerebrospinal fluid interfered with, affects digestion, 492.
meningitis, 358.
Cerumen, inspissated, 236.
Cervical—See also neck.
examination, 41.
glands, examination of, 47.
lesions affect eye, 93, 86.
region, caution in treating, 66.
treatment for vasomotor effects, 92.
Cervico-occipital and cervico-brachial neuralgia, 711.
Chalazion, 200.
Character and disposition affected by alimentary disturbances, 502.
Chest examination, 51.
Chiasma, diseases of, 715.
Chicken-pox, 446.
differentiate from smallpox, 417.
Childbirth resulting in pendulous abdomen, 128.
Children—See also infants.
defective, 303.
diarrhea of, 529.
Chlorosis, 676.
Cholecystitis, 557.
Cholera infantum, 531.
morbus, 532.
Chorea, 725.
differential diagnosis, 726.
differentiate paralysis agitans, 724.
Choreiform affections, 727.
Choroid, diseases of, 226.
Choroiditis, 226.
Chromaffin system, 702, 703.
Chronic lesions, reduce gradually, 66.
Chvostek’s phenomenon, 701.
Chyluria, chylocele, chylous ascitis, 158.
Ciliary injection in keratitis, 221.
body, diseases of the, 225.
Ciliospinal center, 187.
Circulatory system, disease of, 638.
Circumflex nerve, lesions affecting, 721.
Cirrhosis of liver, 560.
Clavicle examination, 49.
“Claw hand,” 764.
Club foot, 784.
Coccygodynia, 713.
Coccyx examination, 55, 81.
fractured, 81.
technic, 81, 713.
“Cold in the head,” 257.
Cold in treating sprain, 106.
“Colds” inadvertently cured, 90.
Cole’s irrigator for high enema, 170, 546.
Colic, biliary, 565.
differentiation of, 535, 566.
intestinal, 535.
renal, 631.
differential diagnosis, 632.
Colitis following appendectomy, 552.
Colitis, mucous, 526.
Coma, diabetic, 472.
Confusion and stupor, delirium, 289.
Congestion of the lungs, 610.
thyroid, 686.
Conjunctiva, diseases of, 202.
Conjunctivitis, 202.
catarrhal, 204.
corneal ulcers complicating, 204.
follicular, 207.
differentiated from trachoma, 208.
gonorrheal, 209.
granular, 212.
phlyctenular, 214.
vernal, 216.
Constipation, causes and technic, 497, 537.
from pendulous abdomen, 127.
resulting in diarrhea, 538.
Constitutional diseases, 457.
Contracted muscles relieved by inhibition, 89.
Convulsions, infantile, 728.
Cornea, anatomy of, 217.
diseases of, 217, 219.
examination of, 219.
ulcer of, 219, 221.
Coughing, 573.
Coughing (superior laryngeal nerve), 719.
Cow-pox, 424.
Cramp, constitutional, 738.
Cranial nerves, diseases of, 715.
Cretinism, 698.
Croup treatment, 68.
differentiate from spasm of glottis, 573.
false, 574.
Croupous pneumonia, 597.
Curschmann’s spirals, 586.
Curvatures, spinal, 96, 99, 103, 122, 768.
See Abbott treatment,
braces for, 99, 131.
cervico-dorsal, 772.
complicated by innominate lesion, 99.
differentiate organic and functional, 769.
dorsal, 772.
dorso-lumbar, 772.
Cophosis, 97.
lateral, 98, 177.
lumbar, 772.
other organs affected, 770.
pathological, 96.
rotary lateral, 768.
postural, 128.
(scoliosis), 96, 768.
differentiated from Pott’s disease, 773.
false, 773.
structural, 774.
technic for, 98.
treatment for rotation and sidebending, 76.
Cystitis, 635.
Cystitis, differentiate pyelitis, 628, 636.
D
Dalrymple’s sign, 694.
Deafness, catarrhal, 246.
nerve, 255, 718.
Defective children, 303.
Deformans, spondylitis, 463.
Degeneration of heart muscle, 661.
Deglutition, 493.
Deglutition pneumonia, 605.
Delirium, confusion and stupor, 289.
senile, 300.
Dementia, arteriosclerotic, 300.
defined, 306, 307.
praecox, 287.
senile, 297.
Dengue, 356.
Dental troubles should be corrected, 490.
Descemetitis, 226.
DeSchweinitz, Dr., 215.
Diabetes, differential diagnosis, 477.
insipidus, 476.
mellitus, 470.
Diabetic coma, 472.
Diagnosis, osteopathic, 38.
see also under lesion.
reliable, osteopathic, 21.
sight, 38.
Diaphragm, paralysis of, 720.
Diarrhea, causes and technic, 497.
acute, 523.
dyspeptic, 529.
caused by constipation, 538.
of children, 529.
chronic, 529.
catarrhal, 524.
differential diagnosis of, 530, 533.
nervous, 524.
through impactions, 538, 544.
Diet and osteopathy, 22, 62.
Diet, diabetic, 475.
Dietl’s crisis, 137, 635.
Digestion, relation of lungs to, 494.
Digestive disturbances affect character, 502.
system, diseases of, 487.
trouble due to intra-cranial conditions, 492.
Digital surgery in hay fever, 226.
treatment in tonsillitis, 281.
Dilatation of heart, 657.
of sigmoid, 543.
of stomach, 153, 517.
Diopter defined, 192.
Diphtheria, 362.
differentiated from scarlet fever, 431.
laryngeal, 364.
nasal, 364.
neuritis following, 707.
pharyngeal, 364.
Disease should be studied by regions, 586.
constitutional, 457.
general and functional, 723.
Dislocation, differentiated from neuritis, 125.
Disposition and character affected by digestive disturbances, 501.
Diuresis, Paroxysmal, differentiated from diabetes insipidus, 477.
Dorsal spine examination, 49.
technic, 74.
Dorsodynia, 466, 467.
Drugs not useful in nose and throat work, 262.
Why medics give, 21.
Dubini’s disease, 727.
Duodenal ulcer, Gastric and, 512.
Duodenitis, 524.
Dupuytren’s contraction, 115.
Dysentery, 368.
Dysentery, a word on treatment, 170
amebic, 370.
bacillary, 368.
chronic, 371.
treatment, a word on, 170.
tropical, 370.
Dysmenorrhea caused by lumbar curvature, 126.
Dyspepsia, acute, 501.
Dystrichiasis, 201.
E
Ear—See also auditory
Ear, Diseases of, 236.
of inner, 254
of middle, 239.
foreign bodies in, cause cough, 575.
normal hearing, 249.
nose and throat, diseases of, 236.
pain in diagnosis of diseases of, 238.
test for hearing, 249.
vasomotor nerves to, 92.
wax, hardened, 236.
Eccymosis, 199.
Eclampsia, 728.
Ectropion, 201.
Eczema, 147.
in ear, 230.
Edema of the lungs, 611.
Edwards finger treatment in hay fever, 267.
trachoma treatment, 213.
turbinate adjuster, 197.
Egophony, Lænnec’s, 613.
Elbow, 56.
sprains, 114.
Elephantiasis, 158.
Emboli in endocarditis, 642, 641.
Emphysema, 592.
compensatory, 609.
differential diagnosis, 595.
Endocarditis, 641.
complicating pneumonia, 601.
Enema, directions for, 546.
Enteric fever, 329.
Enterocolitis, acute, 532.
Enteroptosis, 521.
Entropion, 201.
Enuresis, 637.
Epididymis sensory nerves to, 95.
Epilepsy, 729.
differential diagnosis, 734.
nocturnal, 733, 734.
grand mal, 732.
Jacksonian, 733.
petit mal, 733.
Epilepticus, status, 734.
Epistaxis, 160, 271.
differential diagnosis of, 161.
Erb’s phenomenon, 701.
Erysipelas, 372.
Esophagus, 493.
location of reflex pain from, 499.
Estivo-autumnal fever, 350.
Etiological factors, 25.
Etiology, osteopathic, 25.
Examination—See under various structures and regions.
thorough, essential, 38.
Exercise and postural defects, 120, 129, 131.
cannot take place of osteopathy, 120.
in treatment of ptosis, 521.
of false scoliosis, 773.
to reduce abdomen, 128, 139, 480.
External cutaneous nerve, lesions affecting, 722.
Eye, accommodation in the, 192.
affected by osseous lesions, 93, 185, and under individual
diseases.
Eye diseases, 183, 713.
Eye diseases, osteopathic manipulation in, 196, 223, 716.
examination by special methods, 191.
how to examine, 183.
lesions affecting certain nerves of, 716.
osteopathic, 184.
neuralgia, 197.
restored by osteopathy, A case history, 185.
schematic, 194.
strain and its reflexes, 231.
trouble, nose and throat in, 191.
vasomotor nerves, 92.
Eyelids, diseases of, 199.
F
Face examination, 46.
technic, 68.
Facial nerve, lesions affecting, 117.
Fatty degeneration of heart, 661.
liver, 561.
Fecal impactions palpated, 52, 543.
with diarrhea, 538, 544.
Feet, neuralgia of, 714.
Fetor oris, 491.
Fever, 325.
acute eruptive, mumps and whooping cough, 411.
enteric, 329.
estivo-autumnal, 350.
malarial, 347.
paratyphoid, 344.
remittent, 350.
rheumatic, 457.
simple continued, 379.
treatment, 325.
Brand method, 329.
usually beneficial, 327.
typhoid, 329.
typhus, 344.
yellow, 374.
Fibroid phthisis, 393.
induration, 609.
Fifth nerve, neuralgia of, 710.
Filaria, 158.
Fingers, sprains of, 114.
surgery in hay fever, 266.
treatment in catarrhal deafness, 252.
in tonsillitis, 281.
trigger, 115.
First rib—see rib.
Fissures of rectum, 174.
Fistulae, rectal, 174.
Flat foot, 112, 787.
Flatulency, technic for, 505, 537.
Focus of infection—see infection.
Foot, club, 784
neuralgias, some causes of, 112.
sprains of, 112.
Fractures, 115.
and sprains, 104.
summary of massage and immobilization in, 118.
of treatment of, 119.
Frequency of treatments—see treatments.
Friedreich’s ataxia—See ataxia.
Functional and general diseases, 723.
Furunculosis of ear, 238.
G
Gall bladder, sensory nerves to, 95.
Gall-stones, 563.
easily diagnosed by osteopath, 52.
Ganglion (weeping sinew), 115.
Gas in stomach, technic for, 505, 537.
Gastritis, acute, 502.
chronic, 505.
due to portal disturbance, 506.
gastric analysis essential to diagnose, 507.
Gastric—see also indigestion.
Gastric derangement, location of reflex pain from, 499.
and duodenal ulcer, 513.
neuralgia, 510.
neuroses, 510.
trouble often reflex, 510.
General treatment—see treatment.
Generative organs, vasomotor nerves to, 94.
Genitocrural nerve, lesions affecting, 722.
Genito-urinary system, 175.
Germ theory—its relation to osteopathy, 26.
German measles, 444.
differentiate measles and scarlet fever, 446.
Glands enlarged, differentiate from whooping cough, 454.
examination of thyroid and cervical, 47.
Glaucoma, 227.
Glenard’s disease, 521.
Glosso-pharyngeal nerve, lesions affecting, 718.
Glottis, spasm of, 572.
Goiter, do not treat direct, 691, 696.
exophthalmic, 690.
findings at Mayo clinic, 692.
parathyroid glands in, 699.
simple, 687.
Gonorrhea germs in prostate, 176.
Gonorrheal conjunctivitis, 209.
rheumatism, 459.
Gout, 467.
differentiated from rheumatic fever, 459.
Grand mal, 730, 732.
Grattage, 213.
Great occipital nerve, point of control, 719.
Great auricular nerve, point of control, 719.
Green Sickness, 676.
H
Habit spasm, 728.
Hammer toe, 112.
Hand, sprain of, 114.
Hay fever, 263.
relation of focal infection to, 266.
treatment, 68.
Head examination, 41.
technic, 64.
vasomotor nerves to, 92.
Headache, from eye strain, 188.
post-operative, 313.
sick, 736.
technic, 720.
Hearing—see also ear.
test, 249.
Heart, affected by stomach pressure, 498.
aneurism, 660.
changes in goiter, 693.
complications in typhoid, 332.
crowded by round shoulders, 121.
contraction mechanism, 665.
dilatation, 657.
diseases, 638.
due to ribs, 47.
causing hyperemia of liver, 554.
enlargement causing cough, 575.
failure in pneumonia, 603.
hypertrophy, 655.
hypertrophy and dilatation often recover, 654.
irregularities due to birth injury, 666.
muscle degeneration, 661.
neuroses of, 662.
palpitation of, 662.
sensory nerves to, 95.
stimulated through rectum, 169, 170.
trouble and osteopathy, 647, 648, 652.
Heat in treating ear, 238, 240, 241.
in treating sprain, 106.
prostration, 181.
stroke, 180.
Hebephrenia, 286.
Hematemesis, 162.
differential diagnosis of, 161.
Hematuria, 163.
Hemophilia, 484.
Hemoptysis, 160.
differential diagnosis of, 161.
Hemorrhages, 160.
in feces, 163, 174.
of intestines, 163, 174.
of lungs, 160.
of nose, 160.
of stomach, 162, 516.
of urinary tract, 163.
of uterus, 164.
Hemorrhoids, 171.
acute, 173.
due to portal obstruction, 560.
treatment briefly discussed, 170.
Hemorrhagia subdermalis, 199.
Hepatic colic. See biliary colic.
flexure prolapse, 140.
Heredity, See Inherited.
Hernia, 141.
treatment, 546.
Herpes, 149.
conjunctivæ, 214.
zoster, 712.
zoster ophthalmia, 199.
Hiccoughs, 165.
Hip, 56.
congenital dislocation, 778.
Lorenz operation, 781.
open operation, 784.
lesion affecting knee, 112.
the prominent, description and treatment, 125.
sprains of, 111.
treatment following intracapsular fracture, 111.
tuberculosis of, 791.
Hip-joint disease, 791.
treatment following, 111.
Hives, 149.
Hobnailed liver, 559.
Hodgkin’s disease, 684.
differentiate from mumps, 451.
Holmes electric auroscope, 236.
Homatropine, 194.
Hook-worm disease, 155.
Hordeolum, 200.
Hospital—See post-operative treatment.
Hot fomentations to relieve and relax, 95.
Hydrophobia differentiated from tetanus, 378.
Hydrotherapy in fever, 327.
bronchial asthma, 589.
often necessary with osteopathy, 62.
Hygiene necessary with osteopathy, 62.
Hyoid examination, 47.
lesion affecting sense of taste, 491.
causing cough, 46, 574.
furred tongue, 491.
in bronchial asthma, 589.
in laryngismus stridulus, 572.
in laryngitis, 571.
Hyperemia renal, 617.
Hypertrophy of heart, 655.
Hypoglossal nerve, lesions affecting, 719.
Hypopyon in keratitis, 221.
Hysteria, 740.
Hysterical convulsions, differentiated from epilepsy, 734.
spine, 101.
Hysterogenous zones, 743.
I
Icterus, 557.
Idiots, 305.
Ileocolitis, acute, 368.
Ileus, 540.
Iliohypogastric and ilio-inguinal nerves, lesions affecting, 722.
Imbeciles, 305.
Immobilization in relation to tuberculosis, 115.
See also under sprains.
Impacted lesions, 92.
Impactions, fecal, palpated, 52.
of intestines, 543.
of small intestine, 546.
Impotency, 177.
Indigestion—see also gastric.
and asthma, 590.
caused by pendulous abdomen, 127.
by round shoulders, 121.
nervous, 521.
Infantile convulsions, 728.
paralysis—see poliomyelitis.
Infants—see children.
constipation treatment, 539.
Infection differentiated from neuritis, 125.
foci of, look out for, 131.
Infectious diseases, 325.
Inflammatory rheumatism, 457.
Influenza, Spanish or epidemic, 399.
causes bronchitis, 79.
Inherited tendencies in defective children, 303.
Inhibition, Osteopathic, 89, 94.
Insanity, See also Mental diseases.
acute confusional, 290.
Circular, 293.
defined, 306.
(Physiology of brain), 305.
Innominate examination, 52, 54.
lesions preventing knee recovery, 112.
sprains, 111.
technic, 79.
dangerous, 87.
Insect bites and stings, 199.
Insipidus, diabetes, 476.
Interrenal system, 704.
Intestinal colic, 535.
diseases, 523.
relation of spinal lesions to gastro-, 489.
obstruction, 541.
differential diagnosis, 545.
strangulation, 541.
Intestine, examination of, 52.
foreign substances in, 542.
impactions of, 52, 543.
treatment, 545, 546.
with diarrhea, 538, 544.
knots of, 542.
treatment, 541, 545.
location of reflex pain from, 499.
obstruction of, 52, 78, 545, 546.
differentiate from appendicitis, 551.
prolapsed, 52, 139.
sensory nerves to, 95.
strictures of, 543.
treatment of, 545.
technic, 78.
tumors of, 543.
treatment, 545,
twists, 542.
treatment, 545.
vasomotor nerves to, 94.
Intranasal surgery, 266.
Introduction, 17.
Intercostal neuralgia, 712, 721.
Intussusception, 541.
Invagination, 541.
treatment, 545.
Iridocyclitis in keratitis, 221.
Iris, diseases of, 225.
Iritis complicating conjunctivitis, 204.
in keratitis, 221.
Iron not indicated in anemic conditions, 623.
J
Jaundice, 558.
differentiate from Addison’s disease, 559.
simple catarrhal, 555.
Jacksonian epilepsy, 730, 733.
Jaw, full motion essential, 490.
lesions, 46, 491.
technic, 68.
Joints and bones, tuberculosis of, 788.
function is motion, 489.
K
Keratoconus, 218.
Keratitis, 219.
cornea-phlyctenular, 214.
neuroparalytica, 223.
parenchymatous or interstitial, 224.
Keratitis, phlyctenular, 224.
Keratomalacia, 219, 223.
Kidney, amyloid, 626.
complications in typhoid, 331.
diseases of, 617.
examination, 52
hemorrhage, 164.
movable, 634.
prolapsed, 136.
belt for, 137.
sensory nerves to, 95.
stones, 631.
treatment, 78, 620, 623.
vasomotor nerves to, 94.
Knee, tuberculosis of, 793.
Kraepelin’s classification of dementia praecox, 283.
Kyphosis—See curvatures.
L
Labioglossopharyngeal paralysis, 765.
Laboratory experiments on animals (Lesions), 91.
Labyrinthitis, 254.
Lachrymal apparatus, Diseases of, 202.
Laennac’s egophony, 613.
pearls, 586.
Landmarks of spine, 39.
Landry’s disease differentiated from myelitis, 749.
paralysis, 753.
Laryngeal nerve technic, 719.
lesions affecting superior and inferior, 719.
Laryngismus stridulus, 572.
differentiated from croup, 573.
Laryngitis, acute catarrhal, 569.
chronic catarrhal, 570.
edematous, 577.
spasmodic, 573.
syphilitic, 577.
tuberculous, 575.
Larynx complications in typhoid, 332.
diseases of, 569.
examination, 47.
technic, 67.
Lateral curvature, 98.
Lead colic differentiated from intestinal colic, 535.
poisoning, Neuritis from, 707.
Leg examination, 56.
neuralgia of, 714.
technic, 80.
vasomotor nerves to, 91.
Lens, diseases of, 229.
opacity, 229.
Lenses explained, 191.
Leprosy, anesthetic, differentiated from syringomyelitis, 762.
Lesions of each part or organ indexed under respective names of
parts, but not under all diseases in which they may be found
Lesion affecting one viscus affects others also, 494.
caused by visceral disturbance, 501, 503.
chronic, reduce gradually, 66.
composite, 30.
dominant in causing gastro-intestinal disease, Osteopathic, 489, 490.
effects of, 33.
effects in heart cases, Osteopathic, 647, 648.
impacted, 92.
is absence of motion, 489.
ligamentous, 28.
muscular, 27, 41, 45.
caused by visceral disturbances, 500.
of various structures and regions, considered in connection with
osseous lesions of same.
osseous, 26.
also listed under various bones, organs and regions.
pathognomonic signs of, 39.
results stated by McConnell, 490.
to diagnose, 38, 30, 91.
visceral, 29.
Leyden’s crystals, 586.
Leukemia, 680.
acute myelogenous, 681.
lymphatic, 682.
splenomedullary, 681.
Lithemia, 469.
Liver, amyloid, 562.
and bile duct, diseases of, 553.
cancer of, 562.
(cholecystitis), 557.
cirrhosis of, 560.
complications in typhoid, 332.
examination, 51.
fatty, 562.
(gall-stones), 564.
hyperemia of, 554.
inactivity from pendulous abdomen, 127.
innervation, 474.
involved in rheumatism, 460.
(jaundice), 558.
location of reflex pain from, 499.
nutmeg, 553.
pain reflex to scapula, 721.
(simple catarrhal jaundice), 555.
prolapse, 138.
sensory nerves to, 95.
technic, 77.
vasomotor nerves to, 94.
Lobar pneumonia, acute, 597.
Lock-jaw, 377.
Locomotor ataxia, 754.
differentiated from Friedreich’s ataxia, 759.
Lordosis, 97.
Lorenz operation, 781.
Lumbago, 465, 466.
Lumbar curve and prolapsed uterus, 143.
prominent hip, 125.
examination, 49, 52.
lumbar nerves, lesions affecting, 722.
technic, 74.
Lumbo-abdominal neuralgia, 713.
Lungs affected by stomach pressure, 498.
complications in typhoid, 332.
congestion, 610.
crowded by round shoulders, 121.
diseases, 592.
due to ribs, 47.
causing hyperemia of liver, 554.
edema of, 611.
relation to digestion, 494.
sensory nerves to, 95.
stimulated through rectum, 169, 170.
vasomotor nerves to, 93.
Lymphatic leukemia, 682.
Lymphadenoma, 684.
M
McBurney’s point, 549.
why pain in appendicitis, 499.
Macula lutea, 195.
Maddox rod, 193.
Mal, grand, 730, 732.
petit, 730, 733.
Malaria associated with typhoid, 337.
Malarial cachexia, 351.
fever, 347.
pernicious, 350.
hematuria, 351.
Mammary gland innervation, 722.
Manic depressive psychoses, 291.
Massage following hip joint disease, 111.
intracapsular fracture of hip, 111.
of fractures, 116.
of sprains, 109.
not osteopathy, 19.
Mastoiditis, 240.
Mayo clinic’s goiter findings, 692.
Measles, 437.
a cause of bronchitis, 579.
differentiate German measles, 446.
scarlet fever, 432.
German, 444.
Meatus of ear, atrophic, 237.
infection of, 238.
Medulla contains vasomotor center, 92.
Meibomian cyst, 200.
Meissner’s plexus, 494.
Melancholia agitata, 297.
Mellitus, Diabetes, 470.
Meniere’s disease, 254, 718.
symptom complex, 253.
Meningeal tuberculosis, 387.
Meningitis, cerebrospinal, 358.
complicating pneumonia, 601.
tubercular, 360.
Menopause, thyroid enlargement during, 686.
Mental deficiency, 305.
diseases, 282.
osteopathic lesions in, 289.
Microcephalous, 308.
Migraine, 736.
Milk leg, 167.
Mind, relation to brain, 307.
Miner’s anemia, 155.
Mitral regurgitation, 648.
stenosis, 649.
Moebius’ sign, 694.
Morbilli, 437.
Mongolian amentia, 309.
Morons, 305.
Morphine habit, physicians responsible, 715.
Morton’s disease, 112.
Morvan’s disease, 762.
Mosquito carrier of filaria, 158.
Motion is function of joint, 489.
Motor oculi nerve, lesions affecting, 716.
Mouth, diseases of, 487.
Mucous colitis, 526.
Mumps, 449.
whooping cough and acute eruptive fevers, 410.
differential diagnosis, 451.
Murmurs, Heart, 642, 643.
Muscle contractions caused by visceral disturbances, how, 500.
relieved by inhibition, 89.
Muscular lesions, 27, 41, 45. Also considered in connection with
osseous lesions of various parts.
rheumatism, 465.
Musculacutaneous nerve, lesions affecting, and results, 721.
Myalgia, 467.
Mydriatic, 194.
Myelemia, 681.
Myelitis, 707.
acute, 748.
chronic, 750.
diffuse, 749.
transverse, 748.
Myelogenous leukemia, acute, 681.
Myeloid leukemia, 681.
Myocarditis, 659.
Myoclonia, 727.
Myxedema, 697.
N
Nasal—See nose.
Nasopharyngitis, 272.
Nasopharynx, diseases of, 272.
Neck—See also cervical.
Neck examination, 47.
muscle lesions, 46.
stiff, 465, 466.
technic, 64, 66.
dangers of, 66, 86.
Nephritis differentiated from pyelitis, 628.
hemorrhagic, chronic, 622.
interstitial, 624.
differentiated from diabetes insipidus, 477.
parenchymatous, acute, 618.
chronic, 621.
post-operative, 314.
Nerve centers (osteopathic), 88.
deafness, 255, 718.
degeneration, auditory, 256.
diseases of, 706.
cranial, diseases of, 715.
spinal, diseases of, 719.
sensory, 94.
vasomotor, 92.
Nervous indigestion, 511.
prostration from prolapse, 128.
system, diseases of, 706.
Neuralgia, 710.
cervico-brachial and brachial, 711.
cervico-occipital, 711.
differential diagnosis, 714.
intercostal, 721.
of eye, 197.
of fifth nerve, 710.
of foot, some causes, 112.
of legs and feet, 714.
of sacral nerve from impacted feces, 537.
of sacral region, 713.
of spinal column, 713.
of trunk, 712.
relieved by inhibition, 89.
Neurasthenia, 744.
Neuritis, 706.
brachial, 123.
differentiated from neuralgia, 714.
multiple, differentiated from Landry’s paralysis, 753.
from myelitis, 749.
optic, 230.
post-operative, 313.
retrobulbar, 231.
Neuroses of heart, 662.
gastric, 510.
Neurosis, occupation, 738.
“Neurotic spine,” 101.
Nocturnal epilepsy, 733, 734.
Nose and throat in eye troubles, 191, 196, 225, 229.
antiseptic sprays etc., 258, 262.
conditions in torticollis, 466.
diseases of, 257.
intranasal treatment, 260.
packing, 267, 268.
pharmacodynamics of, 262.
syphilis of, 270.
throat and ear, diseases, 236.
nosebleed, 161, 271.
differential diagnosis, 161.
Nursing necessary to osteopathy, 62.
Nutmeg liver, 554.
O
Obesity, 480.
exercises to reduce abdomen, 128, 139, 480.
Obstetric cases, innominate leosin in, 168.
Obstruction, intestinal—see intestinal.
Obturator nerve, lesions affecting, 722.
Occipito-atlantal examination and lesions, 45.
technic, 67.
Occupation neurosis, 738.
Olfactory nerve, diseases of, 715.
Omodynia, 466, 467.
Ophthalmia neonatorum, 210.
purulent, 209.
sympathetic, 227.
Ophthalmology, 183.
Ophthalmoscope, 193.
Optic disc, 195.
nerve atrophy, 231.
probably connection with third, 234.
neuritis, 230.
tract, diseases of, 715.
Oropharynx, diseases of, 274.
Orthopedic Surgery, 767.
Osteopathic centers—see centers.
diagnosis and prognosis, 38.
etiology and pathology, 24.
examination of eye, 184.
inhibition, 89.
lesion defined, 24.
manipulation in eye diseases, 196, 213.
readjustment, 90.
stimulation, 88.
theory, proof of, 34.
scientific demonstration, 89.
treatment, general directions, 58.
Osteopathy, definitions of, 18.
includes many measures, 62.
not massage, 19.
not passive exercise, 129.
not Swedish movements, 19, 63, 68.
Otitis media, acute suppurative, 239.
chronic suppurative, 243.
differential diagnosis, 244.
non-suppurative, 246.
Ovarian examination, 56.
Ovary, prolapse of, 144.
sensory nerves to, 95.
Oxyuris vermicularis, 154.
P
Pachymeningitis, cervical, differentiated from syringomyelia, 762.
Packing, nasal, 267, 268.
Pains, location of reflex, 499.
Palpation, educated, 60.
practice in, 87.
Palpitation, 662.
Pannus, 224.
Panophthalmitis, 227.
Papillae in rectum, 174.
Paralysis, acute ascending, 753.
Paralysis agitans, 723.
differential diagnosis, 724.
bulbar, 765.
Paralysis, infantile, 750.
Paranephritic abscess differentiated from pyelitis, 628.
Paranoia, 287.
Paraplegia, ataxic, 761.
spastic, 760.
Parasites, animal, 151.
Parathyroid glands, diseases of, 699.
Paratyphoid fever, 344.
Paris, plaster of, 795.
Parotiditis, epidemic, 449.
differential diagnosis of, 451.
Parotitis, epidemic, 449.
Patheticus nerves, lesions affecting, 716.
Pathologies, osteopathy recognizes two distinct, 489.
Pathology, osteopathic, 31.
Patient’s receptivity to treatment, 61.
Pearls, Lænnec’s, 591.
Pelvic examination, 52.
prolapse caused by abdominal prolapse, 128.
technic, 78.
Pendulous abdomen, 127.
Pericarditis, 638.
complicating pneumonia, 600.
Pericardium, diseases of, 638.
Peristalsis explained, 494.
reversed, normal in parts of colon, 497.
technic to affect, 495.
Peritonsillar abscess, 278.
Pernicious anemia, 678.
Pertussis, 452.
Petit mal, 730, 733.
Pharyngitis, 274.
Pharynx complications in typhoid, 332.
technic, 67.
Phenol-glycerine formula, 263.
Phlebitis, 167.
post-operative, 313.
Phlegmasia alba dolens, 167.
Phlyctenular keratitis, 224.
Phrenic nerve, lesions affecting, 720.
Phthisis, see tuberculosis.
Piles, 171.
Pin-worm, 154.
Plaster of Paris, 795.
Pleura, diseases of, 611.
Pleurisy, 611.
complicating pneumonia, 600.
differentiated from pneumonia, 601.
post-operative, 314.
Pleurodynia, 465, 466, 712.
Pneumogastric nerve, lesions affecting, 718.
Pneumonia, acute lobar, 597.
aspiration, 605.
alcohol not indicated in, 319.
associated with endocarditis, 644.
bronchial, 605.
caused by tubercle bacillus, 606.
catarrhal, 605.
complication of typhoid, 332.
chronic interstitial, 609.
croupous, 597.
differential diagnosis of, 609.
deglutition, 605.
differential diagnosis of, 601.
post-operative, 314.
Pneumonia, strychnine not indicated in, 320.
Pneumonic phthisis, 388.
Poliomyelitis, 750.
causing scoliosis, 770.
differentiated from myelitis, 749.
Polyuria, 476.
Portal system, vasomotors to, 94.
Posterior spine technic, 101.
thoracic nerve, lesions affecting, 721.
Post-operative treatment, 312.
Postural curves of spine, 128.
defects, 120.
Posture, correct, 127, 128.
Pott’s disease, 102, 788.
differentiated from kyphosis, 97.
from scoliosis, 773.
treatment, 102.
Proctitis, 170.
Prognosis and diagnosis, osteopathic, 38.
osteopathic, 56.
Progressive muscular atrophy, 764.
differentiated from syringomyelitis, 762.
Prolapse—See also ptosis.
Prolapsed hepatic flexure, 139.
intestines, 139, 170.
kidney, 136.
liver, 138.
organs, 127, 133, 521.
ovaries, 144.
rectum, 171.
sigmoid flexure, 141, 170.
stomach, 134.
uterus, 143.
Prominent hip, 125.
Prostate gland, 175.
technic, 637.
sensory nerves to, 95.
Prostatitis, 175.
Prostatorrhea, 176.
Pseudo-angina pectoris, 667.
appendicitis, 550.
croup, 572.
leukemia, 684.
Psychalgia, 293, 296.
Psychosis, involutional, 295.
Ptosis—See also prolapse.
of abdominal organs, 127.
of eyelids, 201.
Pulmonary regurgitation, 650.
stenosis, 650.
Punctum proximum, 192.
remotum, 192.
Purpura, 483.
variolosa, 420.
Pyelitis, 627.
differential diagnosis, 628, 636.
Pyelonephritis, 627.
Pyemia, 356.
Q
Quinsy, 278.
R
Radial nerve, lesions affecting, 739.
Rash, differentiate scarlet fever from drug or septic, 431.
Receptaculum chyli, vasomotor nerves to, 94.
Rectal conditions requiring surgery, 174.
disorders, brief discussion, 141.
examination, 55, 56, 169.
Rectum, 169.
to dilate, 170.
technic, 169.
Reflex gastric troubles, 509.
pains, location of various, 499.
Reflexes, somatic, Burns experiments, 189.
Regions of body should form basis of disease classification, 586.
Regurgitation, aortic, 649.
mitral, 648.
pulmonary, 650.
tricuspid, 650.
Remittent fever, 350.
differentiate from yellow fever, 375.
Renal calculus, 631.
Renal colic—see colic.
differentiate from appendicitis, 551.
Respiratory diseases, 569.
reflex inefficiency, 264.
Retina, diseases of, 230, 715.
Retinitis, 230.
Retrobulbar neuritis, 231.
Rheumatic fever, 457.
Rheumatism, abdominal, 466, 467.
cause of heart valve defects, 645.
chronic articular, 460.
differential diagnosis, 459.
and brachial neuritis, 125.
gonorrheal, 459.
inflammatory, 457.
muscular, 465.
subacute, 459.
Rheumatoid arthritis, 462.
differentiated from rheumatic fever, 459.
Rhinitis, acute, 257.
atrophic, 261.
chronic hypertrophic, 259.
hyperesthetic, 263.
purulent, 259.
Ribs, danger in elderly patients, 87.
examination, 47.
false, technic, 74.
first, examination, 49.
technic, 72.
floating, 49.
technic, 73.
lesions cause heart trouble, 648, 653.
described, 48.
sprains, 111.
technic, 69.
Rickets, 478.
Rose spots, 334.
Round shoulders, 121, 130.
worm, 151.
Rubella, 444.
differentiated from measles and scarlet fever, 446.
Rubeola, 437.
Ruddy nasal third finger, 197.
third finger eye instrument, 214, 229.
treatment of tonsillitis, 281.
S
St. Vitus’ dance, 725.
Saccules in rectum, 174.
Sacral nerves, lesions affecting, 722.
neuralgia, 713.
caused by impacted feces, 538.
Sacro-iliac—see innominate.
Sacrum examination, 55.
technic, 82.
Salivary glands, 491.
Sallow skin, 559.
Scalp, 46.
technic, 68.
Scapula, technic, 68.
Scapulodynia, 466, 467.
Scarlatina, 428.
differentiate diphtheria, 432.
drug rash, 431.
German measles, 432, 446.
measles, 432.
septic rash, 431.
types and forms, 432.
Scarlet fever—see scarlatina.
Schematic eye, 194.
Sciatica, 708, 714.
“Scissors” technic dangerous, 86.
Sclerosis, amyotrophic lateral, 762, 763.
differentiate from syringomyelia, 762.
cerebral, differentiate from chorea, 726.
disseminated, differentiate from paralysis agitans, 724.
Scoliosis—See curvatures.
Scrofula, 384, 396.
Scrofulous ophthalmia, 214.
Scurvy, 481.
Seminal vesicles, 176.
Senile delirium, 300.
dementia, 297.
Sensory nerves to various viscera, 94. See also under various viscera.
Septic rash, differentiate scarlatina, 431.
Septicemia, 355.
“Setting up” exercises for pendulous abdomen, 128.
Shaking palsy, 723.
Shoulder, 56, 80.
painful, 122.
round, 121.
sprain of, 114.
Sight—see eye.
diagnosis, 38.
Sigmoid impaction causing cough, 575.
prolapse, 141.
Sinusitis, 269.
vacuum, 270.
Skin diseases, 147.
Small occipital nerve, point to control, 719.
Smallpox, 412.
black, 420.
differentiate from chicken-pox, 417.
Smell, sense of, 491.
Snellin’s test type, 191.
Solar plexus inhibition, 582.
Somatic reflexes—Burns experiments, 188.
Spasm—see convulsions.
habit, 728.
Spastic paraplegia, 760.
Sphincters, alimentary, 496.
ani, external, 498.
Spinal accessory nerve, lesions affecting, 719.
centers (osteopathic), 88.
column, neuralgia of, 713.
postural curvatures of, 128.
cord, diseases of, 748.
curvature, pathological, 96.
technic, 97.
examination, importance of, 41.
landmarks, 39.
lesions—see lesions.
nerves, diseases of, 719.
stretching, dangers of, 86.
Spine the center of osteopathic interest, 38.
hysterical, description and technic, 101.
neurotic, description and technic, 101.
of the aged, description and technic, 101.
posterior, technic, 101.
sprains of, 110.
straight, 99.
technic, 100.
tubercular disease of, 788, 102.
typhoid, description and technic, 100.
Splanchnic technic, 495.
Spleen complications in typhoid, 332.
diseases of, 567.
examination, 52.
treatment, 78.
vasomotor nerves to, 94.
Splenitis, 567.
Splenomedullary leukemia, 681.
Spondylitis deformans, 463.
Sprains and fractures, 104.
bandaging not always good, 107.
heat and cold in treatment, 106.
immobilization and rest, 106, 115.
massage, 109, 116.
of ankle, 112.
of elbow, 114.
of fingers, 114.
of foot, 112.
of hip, 111.
of innominate, 111.
of knee, 112.
of ribs, 111.
of shoulder, 114.
of spinal column, 110.
of wrist and hand, 114.
passive movement, 107.
summary of treatment, 110.
Stand erect, how to, 127.
Status epilepticus, 734.
lymphaticus, 702.
Stenosis, aortic, 650.
mitral, 649.
pulmonary, 650.
tricuspid, 650.
Sternum examination, 49.
technic, 73.
Still, early struggles of Dr. A. T., 17.
Still-Hildreth Sanitarium 280, 291.
Several times in chapter on mental and nervous diseases.
Stimulation, osteopathic, 88.
Stomach,—see also digestive system.
cardiac relaxation by inhibition, 89.
conditions in bronchial asthma, 589.
dilatation, 134.
differentiate from gastroptosia, 134.
distention, 498.
examination, 52.
hemorrhage, 162, 516.
pain over pit of, due to cutaneous sensory nerves, 721.
prolapse, 134.
sensory nerves to, 95.
technic, 78.
ulcer, spinal causes of, 498.
Stomatitis, 487.
Stones, gall, 563.
kidney, 631.
“Straight spine,” 99, 130.
technic for, 100.
Strangulation of intestines, 541.
Stretching, indiscriminate, 86.
Strychnine not indicated in post-operative pneumonia, 320.
poisoning differentiated from tetanus, 378.
Stupor, delirium and confusion, 289.
Sty, 200.
Sunstroke, 180.
Supports, arch, 114.
in prolapse, 133, 142.
Suprarenal capsule, Dr. Still’s theory, 633.
Surgery, relation to osteopathy, 22.
in various conditions, taken up in connection with treatment.
orthopedic, 767.
Swallowing, 492.
Swedish movements not osteopathy, 19, 63, 68.
Synechiae in keratitis, 221.
Syphilis of nose, 270.
of thyroid, 687.
Syphilitic laryngitis, 577.
Syringomyelia, 761.
differential diagnosis, 762.
T
Tabes dorsalis, 754.
Tachycardia, 663.
Taenia flavo-punctata, 151.
saginata, 151.
solium, 151.
Talipes, 784.
Tape-worm, 151.
Taste, bad, in mouth, 492.
sense of, 491.
Technic, see under osteopathic treatment; also under various regions,
and organs.
dangerous, 86.
osteopathic, 60.
Teeth conditions in torticollis, 466.
defects should be corrected, 490.
Temporo-mandibular—see jaw.
Tenesmus treatment, 170.
Testes, sensory nerves to, 95.
Tetanus, 377.
differentiated from hydrophobia, 378.
strychnine poisoning, 378.
Tetany, 699.
Thorax examination, 51.
Thread-worm, 154.
Throat and nose in eye trouble, 191, 196, 225, 229.
Throat, diseases of the ear, nose and, 236.
(Edwards’ turbinate adjuster), 197.
irritation due to hyoid, 47.
(Ruddy’s nasal third finger), 197.
technic, 67.
Thrombosis from typhoid, 332.
Thrush, 488.
Thyroid gland, direct manipulation dangerous, 696.
diseases of, 686.
Thymus gland enlarged in goiter, 691, 693.
diseases of, 702.
Tic, convulsive, 728.
douloureux, 711.
general, 728.
Tongue, 490.
furred, 491.
vasomotor nerves to, 92.
Tonsils, 67.
function of, 276.
in rheumatism, 457, 460.
in torticollis, 466.
palpated, 47.
(peritonsillar abscess), 278.
trouble in eye disease, 196.
Tonsillectomy, 278.
summary of indications for, 280.
Tonsillitis, 276.
technic, 68, 279, 280.
Torticollis, 129, 465, 466, 719.
Touch, educated sense of, 60.
Trachoma, 208, 212.
differentiated from follicular conjunctivitis, 208.
Traction, reasons for, 62.
Transillumination in diagnosing sinuitis, 269.
Treating (over-treating), 84.
in influenza, 404.
Treatment—see also technic.
after a meal, 83.
frequency of, 83, 84.
general, 62, 68, 90.
should be given when, 63.
inhibition to begin, 89.
length of, 84.
misapplied, 85, 87.
position of physician and patient, 63.
receptivity of patient to, 61.
resulting in some motion, leave lesion for that time, 76.
to be avoided, 86.
value of vacation from, 85.
Tremors, differentiate from paralysis agitans, 724.
Trichiniasis, 156.
Trichiasis, 201.
Tricuspid regurgitation, 650.
stenosis, 650.
Trigeminus nerve, lesions affecting, 717.
Trigger-finger, 115.
Trousseau’s phenomenon, 701.
Tubal disease, differentiated from appendicitis, 551.
Tubercle bacillus may cause bronchopneumonia, 606.
Tuberculosis, 380.
and joint immobilization, 115.
of alimentary tract, 393.
acute, 386.
begins as chronic gastritis, 506.
bones and joints, 788.
bronchopneumonic, 388.
cerebral, 387.
deformities predisposing factors, 389.
differentiate from brachial neuritis, 125.
pneumonia, 601.
(fibroid phthisis), 393.
differentiate from chronic interstitial pneumonia, 609.
of genito-urinary tract, 394.
of hip, 791.
of knee, 793.
of lymph glands, 384.
of miliary, 386, 394.
pneumonic, 386.
pulmonary, 387, 389.
of spine, 102, 788.
orthopedic surgery necessary in, 767.
of thyroid, 687.
Tuberculous laryngitis, 575.
Tumor, brain, differentiate from migraine, 737.
Tuning fork tests, 294.
Turbinates, to clean around in rhinitis, 200.
Tussis convulsiva, 452.
Typhoid fever, 329.
afebrile, 334.
fever associated with malaria, 387.
do not manipulate abdomen, 163.
differentiated from appendicitis, 551.
spine, 100.
Typhus fever, 344.
U
Ulcer of cornea, 219, 221.
gastric and duodenal, 512.
location of reflex pain in gastric or duodenal, 499.
of stomach, spinal causes of, 498.
differential diagnosis, 508, 515.
Ulcerative stomatitis, 164.
Ulnar nerve, lesions affecting, 726, 739.
Uncinariasis, 155.
Uremia, 628.
Uremic convulsions, differentiated from epilepsy, 734.
Ureter, sensory nerves to, 95.
hemorrhage, 164.
Urethra hemorrhage, 164.
Urinary system, diseases of, 617.
Urine, blood in, 163.
massage prostate for retention of, 176.
Urticaria, 149.
Uterine examination, 56.
hemorrhage, 164.
Uterus, prolapsed, 143.
sensory nerves to, 95.
V
Vaccination, 424.
Vaccinia, 424.
Valve diseases, heart, 642, 644, 645, 649, 651.
Varicella, 424, 446.
differentiated from variola, 417.
Varicocele, 176.
Varicose veins, 166.
Variola, 412.
cornea, 421.
differentiated from varicella, 417.
hemorrhagica pustulosa, 420.
vera, 418.
verucosa, 420.
Varioloid, 420.
Variolosa purpura, 420.
sine exanthemate, 420.
Vasomotor nerves, 92.
Venereal disease and eye trouble, 184.
Vertebræ, landmarks for distinguishing, 39.
Vision explained, 230.
Volvulus, 541.
Vomiting, persistent, mostly reflex, 501.
post-operative, 312.
technic to relieve, 504.
von Graefe’s sign, 694.
W
Water, drink plenty, 540.
White swelling, 793.
Whooping cough, 452.
Whooping cough, mumps, and acute eruptive fevers, 411.
differentiate enlarged glands, 454.
Worms, intestinal, 151.
Wrist, 56.
sprain, 114.
Wry-neck—see torticollis.
Y
Yellow Fever, 374.
differentiate from remittent fever, 375.
Z
Zuckerkand’s organ, 703.
Transcriber’s Notes
pg 48 Changed: resistance is a helpful guide in dignosis
to: resistance is a helpful guide in diagnosis
pg 71 Changed: Still another method of adjustfng ribs
to: Still another method of adjusting ribs
pg 79 Changed: slip one hand bteween the thighs
to: slip one hand between the thighs
pg 91 Changed: In other words pathogological changes are just as real
to: In other words pathological changes are just as real
pg 111 Changed: Diagnosis, Etiology, and Tecnhique, and the general
to: Diagnosis, Etiology, and Technique, and the general
pg 112 Changed: Another joint frequent overlooked is the innominate.
to: Another joint frequently overlooked is the innominate.
pg 112 Changed: of the innominate that is preventing revovery
to: of the innominate that is preventing recovery
pg 130 Changed: There is often a shortning of the anterior structures
to: There is often a shortening of the anterior structures
pg 140 Changed: Of particular local interest to the osteopth
to: Of particular local interest to the osteopath
pg 186 Changed: goins then to the innominates
to: going then to the innominates
pg 214 Changed: The exact cause of ocular lesions, or phlycentular
to: The exact cause of ocular lesions, or phlyctenular
pg 215 Changed: diathesis and the exanthemata play their roll
to: diathesis and the exanthemata play their role
pg 220 Changed: progressive ulcer (second sage.)
to: progressive ulcer (second stage.)
pg 228 Changed: which begins by contration of the field
to: which begins by contraction of the field
pg 238 Changed: paraffin oil and the heat applied continusously
to: paraffin oil and the heat applied continuously
pg 254 Changed: Labyrinthitis is of several forms but in gerneral
to: Labyrinthitis is of several forms but in general
pg 261 Changed: mucopurulent discharge, accompanied by a bad ordor
to: mucopurulent discharge, accompanied by a bad odor
pg 271 Changed: The constitutioual causes of epistaxis
to: The constitutional causes of epistaxis
pg 275 Changed: treatment consists of throrough cleansing
to: treatment consists of thorough cleansing
pg 288 Changed: nearly always refers to the patinet’s exterior
to: nearly always refers to the patient’s exterior
pg 288 Changed: and hence before detrioroation has set in
to: and hence before deterioration has set in
pg 290 Changed: the term “acute confusional insantiy”
to: the term “acute confusional insanity”
pg 296 Changed: fears, particulary of impending danger
to: fears, particularly of impending danger
pg 306 Changed: mental capacity in man lie betweeen:
to: mental capacity in man lie between:
pg 311 Changed: gain is shown treatment is discontinuted
to: gain is shown treatment is discontinued
pg 314 Changed: if necessary completely elimination of the operation
to: if necessary complete elimination of the operation
pg 317 Changed: tried to cross the railraod track
to: tried to cross the railroad track
pg 340 Changed: care being taken that it is thoroghly digested
to: care being taken that it is thoroughly digested
pg 340 Changed: lymphoid elements of the inteatines
to: lymphoid elements of the intestines
pg 345 Changed: and maybe bronchial symptms.
to: and maybe bronchial symptoms.
pg 349 Changed: If there are two parosyxms in the same day
to: If there are two paroxysms in the same day
pg 350 Changed: twelve to twenty-four hours when consciouness
to: twelve to twenty-four hours when consciousness
pg 362 Changed: A derangement of the veretbral articulation
to: A derangement of the vertebral articulation
pg 369 Changed: for unsually this gives only temporary relief
to: for unusually this gives only temporary relief
pg 376 Changed: Let the patient drink freely of tater
to: Let the patient drink freely of water
pg 377 Changed: Esposure to damp cold is one of the recognized causes
to: Exposure to damp cold is one of the recognized causes
pg 382 Changed: artery increase the susceptiblility to infection
to: artery increase the susceptibility to infection
pg 411 Changed: blood and lympathic supply to the lungs
to: blood and lymphatic supply to the lungs
pg 423 Changed: During convalenscence a full, well-regulated,
to: During convalescence a full, well-regulated,
pg 433 Changed: fever usually by the fourteeneth day
to: fever usually by the fourteenth day
pg 436 Changed: temperature is high and patient is delirius
to: temperature is high and patient is delirious
pg 437 Changed: may simulate infantile paraylsis
to: may simulate infantile paralysis
pg 437 Changed: Measles is an acute infectious, congatious
to: Measles is an acute infectious, contagious
pg 438 Changed: functional integrety of the lungs and heart
to: functional integrity of the lungs and heart
pg 441 Changed: greater frequency than in other infectiouss diseases
to: greater frequency than in other infectious diseases
pg 442 Changed: rugs and unnecessary funiture have been removed
to: rugs and unnecessary furniture have been removed
pg 444 Changed: is readily transmissable, attacks children especially
to: is readily transmissible, attacks children especially
pg 448 Changed: stratching may cause pitting
to: scratching may cause pitting
pg 449 Changed: are undoubtedly potent presisposing factors
to: are undoubtedly potent predisposing factors
pg 457 Changed: tonsillitis, pyorrhea alveolaris, sinuitis, etc.
to: tonsillitis, pyorrhea alveolaris, sinusitis, etc.
pg 478 Changed: cold and dampness are presisposing factors
to: cold and dampness are predisposing factors
pg 487 Changed: Removal of the exciting cause is the most improtant
to: Removal of the exciting cause is the most important
pg 492 Changed: result of inattention to oral hygience
to: result of inattention to oral hygiene
pg 493 Changed: the ebb and flow of the crebrospinal fluid
to: the ebb and flow of the cerebrospinal fluid
pg 497 Changed: further complicacates the clinical picture
to: further complicates the clinical picture
pg 500 Changed: Stomach, liver, gall-gladder, pyloric and duodenal
to: Stomach, liver, gall-bladder, pyloric and duodenal
pg 508 Changed: confidence by making an intellegent examination
to: confidence by making an intelligent examination
pg 515 Changed: Referred pain from cholesystitis, chronic appendicitis
to: Referred pain from cholecystitis, chronic appendicitis
pg 522 Changed: There is dypspesia, flatulency, constipation
to: There is dyspepsia, flatulency, constipation
pg 527 Changed: The nurtition is generally well maintained
to: The nutrition is generally well maintained
pg 537 Changed: (affecting reciprocal inneravtion)
to: (affecting reciprocal innervation)
pg 539 Changed: peristaltic action and the secertory nerves
to: peristaltic action and the secretory nerves
pg 545 Changed: Kinks of the pelivc colon, ileum
to: Kinks of the pelvic colon, ileum
pg 546 Changed: stretched sufficiently to resore normal function
to: stretched sufficiently to restore normal function
pg 548 Changed: appendix can be stimulated by purcussion
to: appendix can be stimulated by percussion
pg 548 Changed: pyogenes aureus, typhoid baccilli, tubercle bacilli
to: pyogenes aureus, typhoid bacilli, tubercle bacilli
pg 551 Changed: large proportion of cases revover
to: large proportion of cases recover
pg 555 Changed: tenth rib on the right side, thus interferring
to: tenth rib on the right side, thus interfering
pg 564 Changed: particularly fond of starchy and saccahrine food
to: particularly fond of starchy and saccharine food
pg 571 Changed: mucous membrane, osccaional superficial erosions
to: mucous membrane, occasional superficial erosions
pg 572 Changed: On the whole, careful, continued treament
to: On the whole, careful, continued treatment
pg 582 Changed: The primary form is the result of expossure
to: The primary form is the result of exposure
pg 583 Changed: lungs, abscesses, bronchiestasis
to: lungs, abscesses, bronchiectasis
pg 585 Changed: Death occassionally results from suffocation
to: Death occasionally results from suffocation
pg 597 Changed: especially by diploccocus pneumoniæ.
to: especially by diplococcus pneumoniæ.
pg 634 Changed: symptoms as neuresthenia, melancholia
to: symptoms as neurasthenia, melancholia
pg 645 Changed: stands foremost as a cuase of valvular defects
to: stands foremost as a cause of valvular defects
pg 647 Changed: Through analagous reasoning from other organic
to: Through analogous reasoning from other organic
pg 648 Changed: involve inhibitory (vagi) fibers or accellerator
to: involve inhibitory (vagi) fibers or accelerator
pg 656 Changed: process or an act of compenation
to: process or an act of compensation
pg 666 Changed: discovering irregulartities in the young
to: discovering irregularities in the young
pg 675 Changed: The mononuclear neurtophiles are relatively increased.
to: The mononuclear neutrophiles are relatively increased.
pg 681 Changed: It is a disease occuring at all ages
to: It is a disease occurring at all ages
pg 691 Changed: supply is estensive, and the veins expecially
to: supply is extensive, and the veins especially
pg 692 Changed: due to the incresee of epithelial cells
to: due to the increase of epithelial cells
pg 703 Changed: Death in adults has ocurred from trifling injuries
to: Death in adults has occurred from trifling injuries
pg 708 Changed: In a few cases there are intraplevic causes
to: In a few cases there are intrapelvic causes
pg 720 Changed: he knows at once that the headadche is relieved
to: he knows at once that the headache is relieved
pg 724 Changed: kness so close together that they rub in walking
to: knees so close together that they rub in walking
pg 742 Changed: these phemomena also become bilateral
to: these phenomena also become bilateral
pg 770 Changed: curvavature decrease in the volume of the lower
to: curvature decrease in the volume of the lower
pg 770 Changed: that should be considered are spastic parlaysis
to: that should be considered are spastic paralysis
pg 788 Changed: arising from the layer of non-tuberculus granulation
to: arising from the layer of non-tuberculous granulation
pg 790 Changed: flacid and bilateral and may exist
to: flaccid and bilateral and may exist
pg 790 Changed: must be cut over the invoved area
to: must be cut over the involved area
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