INFECTIOUS DISEASES (continued 2)

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.