Chapter XVII: Introduction (2)

=2. The Acquired Tendency.=—In this the second great class are those conditions arising subsequent to conception where germ plasm is healthy but growth is arrested by some external factor either intra- or extra-uterine. Thus the acquired tendency may be given to the fetus in utero and not be considered congenital as in case of injury affecting health and growth of otherwise healthy conception. In short, the acquired has its beginning at conception or subsequent to it while the congenital is previous to conception or already inherent in the germ plasm leading to conception.

Any influence which retards the

1. Inherent capacity of cell for growth or,

2. Adequate blood supply either in quantity or quality results in enfeebled offspring and these causes are enhanced by

(a) Traumatism or Injury
(b) Drink or Abuse
(c) Dirt or Unhygienic surroundings
(d) Depravity or Ignorance

Factors entering into acquired tendencies affecting offspring direct are divided into three classes, those:

I. Before Birth such as

(a) Abnormal condition of mother’s health during pregnancy as in
disease of any nature, mental or physical or

(b) Injury to fetus direct by blow, fall of parent, or instrument.

II. During Birth from:

(a) Abnormal labor from any cause.

(b) Primogeniture.

(c) Premature birth.

III. After Birth.

(a) Traumatism.

(b) Toxic causes such as scarlet fever, whooping cough, meningitis,
measles, mumps and exanthemata.

(c) Convulsions.

(d) Nutritional disturbances.

Consanguinity or intermarrying of blood relations, or in-breeding results in:

1. Instability of the nervous system.

2. Intensifying of constitutional defects.

3. Decrease in size of offspring.

4. Predisposition to disease through lowered vitality.

5. Impairment of reproductive function.

Immediate consanguinous offspring may manifest a high degree of intellectual or physical attainment but successive processes tend to neurotic types and are prone to physical weaknesses and insanity. This practice is found among Quakers and Jewish peoples, inhabitants of the Islands north of Scotland, in isolated rural localities, and among African tribes.

Mental Deficiency in Children

=Synonyms.=—Amentia; feeble-mindedness.

There are three grades of amentia:

=1. Morons:= those whose mental age corresponds closely to their chronological age or is nearly normal.

=2. Imbeciles:= those in whom there is a wide disparity between the mental age and the chronological age.

=3. Idiots:= the lowest form of arrested mentality or those whom it is impossible to teach.

=Definition.=—Mental deficiency is a pathological stage in which the mind has failed to attain normal development.

=Various degrees of intelligence= or mental capacity in man lie between:

(=1=) =Genius= such as Bacon, Newton, Plato, Galileo, Shakespeare.

(=2=) =Lesser Ability= but still conspicuous in development such as our great leaders in science, literature, reform and the arts and medicine, furthering, each their respective causes. These merge easily into

(=3=) =Average= mass of mankind.

(=4=) =Dullards= or those of inferior intelligence.

(=5=) =Feeble minded=, merging imperceptibly into

(=6=) =Imbeciles= and by insensible gradation into

(=7=) =Idiots= and gross idiots.

The mentally defective is wholly incapable at maturity of adapting himself to his environment or local conditions in order to maintain existence independent of any external support.

=Dementia= is a disease of the mind or that which was once possessed, and by some neuronic disturbance is lost totally or partially.

=Insanity= is a disturbance of neuronic function which may or may not end in degeneration of brain tissue.

=Physiology.=—The normal brain begins its development shortly after fertilization of the germ cell, by the expansion of the anterior end of the rudimentary spinal cord into four primary cerebral vesicles. These develop into a series of elaborate infoldings, each with multiple cells around them. At or about the sixth month of fetal life this embryonic brain assumes the shape of the adult brain, minus the secondary fissures and convolutions which are characteristic of full development.

At birth there are sometimes many convolutions and the brain weighs from 280 to 330 grams. Growth is then rapid and at six months it weighs from 560 to 680 grams;

At one year, 750 grams. It continues to increase until

At 12 to 14 years it weighs 1150 grams in the female, and 1300 in the male;

At 20 to 21 years the weight is 1244 grams in the female and 1374 in the male.

Growth is slow from this time until at 25 to 35 years the average weight of the brain is 1269 grams (45 oz.) in the female, 1421 grams (50 oz.) in the male.

This growth of the brain is due, first to the rapid multiplication of nerve cells and, secondly, to the individual enlargement of each nerve cell. These cells arise from the floor of the four primary vesicles and are each similar to its fellow. They finally show differences in feature and become characteristic in size and shape which process continues throughout life. This process of differentiation of nerve cells results in the peculiar laminated appearance of the brain cortex. At the period of lamination, the nerve cells throw out delicate processes which pursue definite directions throughout the brain mass constituting a system of association fibers which link together in a most complicated manner all parts of the brain, and are called the association fibers of Flechsig. Projections from these cells form the various pathways by which the brain is connected to the various parts of the body.

Nerve cells in the different parts of the brain mature at different periods, those areas which have to do with the highest intellectual functions, viz., the frontal and parietal regions, maturing last.

At the seventh month of intrauterine life the brain cell is a small round type of neuroblast, undifferentiated, lying in a matrix. The cells increase in size until about the second week (extra-uterine) of life, tiny processes begin to develop. At the third to fifth year these cells are mature and possess axons, dendrons and geminules. These communicate, forming the above named association system conveying impulses to and from all parts of the cerebrospinal system. They multiply and elaborate after puberty into a complicated system up into middle life after which growth ceases and they slowly diminish.

=Greatest Growth= is between the first appearance of the primitive brain and the end of the sixth month of life (extra-uterine), hence it is during this period that any adverse conditions relative to development of nerve cells may cause the greatest damage.

=Mind and Brain.=—Whatever may be the connection between these two, we know that the former develops with the growth of brain cells and fails with their decay. =Amentia= is associated with the incomplete development of brain cells and =Dementia= is coincident with their degeneration and death.

=Pathology=—=Brain.=—Structural abnormality of the brain tissue may exist without variation of mentality or defect. Early observers gave these gross defects as a cause for amentia. However, it has been demonstrated beyond doubt by microscopic examination of cerebral neurosis that cellular changes occur and that imperfect and arrested development exists and is an essential basis of amentia.

=Histology=—=Blood Cells.=—Cortical blood cells in the ament are

1. Numerically fewer.

2. Irregular in arrangement.

3. Imperfectly developed.

4. Microscope reveals changes proportionate to the deficiency during life.

=Blood-vessels in Amentia= show no marked changes from those of the normal brain. Hyaline degeneration may be present; also pigmentation. These conditions are not constant in amentia hence cannot be considered causal.

=Neuroglia in Amentia.=—Sclerosis and hypertrophy occur in a large proportion of cases. This is diffuse throughout the brain, with here and there certain circumscribed areas forming nodules.

=Nerve Fibres of Cortex in Amentia.=—Association system fibres are always diminished in number and not so complicated.

=Clinical Varieties of Amentia.=—There are two varieties of amentia and conventionally for sake of study we must arrange them into those from

(1) Congenital causes and (2) acquired causes.

Among those which arise from congenital causes we have the microcephalous and Mongolian types. In both cases there exist constitutional taints through successive or immediately forgoing generations of such diseases as syphilis, tuberculosis, epilepsy, and acute alcoholism affecting proper collaboration of germ cells previous to fertilization and hence impaired germinal endowment through a weakened nervous system.

Those arising from acquired causes are from injury to mother or fetus.

=Macrocephalus.=—A person whose skull measures less than seventeen inches in its greatest circumference. This class comprises less than 10% of all aments.

=Cause.=—The type is neither a freak reversion of the species to a lower grade of development nor accidental, but due to an inherited blight on the nervous system arising from constitutional disease, alcoholic and sexual excesses, consanguinous unions and too numerous latter-life pregnancies in undermined health states. They come entirely from neuropathic stock and their brothers and sisters are degenerates. Many dwarfs exhibit this type.

=Characteristics of Microcephaly.=—(1) Circumference of skull diminished; (2) Brain smaller; (3) Stature small (5 feet); (4) Rarely live to advanced age; (5) Die of tuberculosis; (6) Mostly imbeciles and idiots (few morons).

They have their sensory impressions intact and are generally vivacious and muscularly active, even restless. They have good sight and hearing and are highly initiative but have not the ability to any sustained effort. They are actively observant and the majority are affectionate and well behaved. Some are unsteady in walking, others are helpless, and about one-half are subject to epileptic fits.

=Mongolian Amentia= (Mongolism).—This type (Kalunk or Tartar variety) received its name from Dr. J. Langdon Down from their facial resemblance to members of the Mongolian race. They number about 5% of all aments including the semi-mongols who have only a few of the characteristics of this type.

=Cause.=—Eleven out of twenty-five are from syphilitic origin. Glandular or nutritional defects are suggested as a cause. They will show negative Wassermann test and positive tuberculin tests. Uterine exhaustion and ill health of mother during gestation are factors suspected of entering into this condition. The latter-born of large families are frequently affected.

=Pathology of Mongolian Idiocy.=—The brain of the Mongolian ament is considerably under-sized and has less convolutions and is more shallow. The pons, medulla, and cerebellum are about half the size of ordinary feeble minded types. The cells by microscopic examination show an immature condition. This lack of brain development results in deficient expansion of base of skull, hence the characteristic physiognomy. There is no glandular abnormality.

=Description of the Mongol Type.=—This type is distinguished by characteristics of skull, eyes and tongue and is usually observed at birth.

1. The skull (Brachycephalous) is rounded and diminished in size particularly through the antero-posterior diameter. The face is flattened, there being no recession of frontal and supra-occipital regions.

=Eyes.=—The palpebral fissures are narrow and slope obliquely downward and inward. Lids inflamed.

=Tongue= protrudes, is large and marked by large papillæ and scored by transverse fissures due probably to tongue sucking, predisposing to inflammation of the mucous membranes.

=Ears= are small and round and have poorly developed and irregular lobules.

=Nose= is short and flat and has triangular nostrils.

=Teeth= are soft and ill formed and tend to decay.

=Hair= is usually scanty and wiry and very dry.

=Cheeks= are flushed. Palate is high and narrow and mouth is open, and lips are cracked. Adenoids exist in all cases.

=Hands and Feet= are broad and clumsy. Flat foot and knock-knees are common. Skin is rough, coarse and dry.

=Abdomen= is large and mushy. Umbilical hernia often present.

=Circulation= is rarely good, causing blueness and coldness of extremities, with sores and chilblains. Heart lesions are frequent. Lesions of a chronic inflammatory nature in respiratory and digestive tracts exist. Nasal and bronchial catarrh and diarrhea are common. Mongols die early (about 14 years) usually of phthisis.

Available statistics show the various types and variations of these conditions in great detail; however, the above will enable the reader to classify and properly diagnose in given cases. It is not the writer’s intention to portray here what is easily a treatise by itself.

=Osteopathic Consideration of Amentia.=—During a period of five years, observation of the various types has led me to believe that much can be done to correct circulation to cerebral structure with consequent development of brain tissue and function, where discoverable trauma exists. From all available sources there is traumatic interference in from 15 to 45% of these cases, according to different authors. Where history involves constitutional findings (syphilis, tubercular, glandular and chronic alcoholism) I have treated them with the intent of relieving only until the next phase of the condition would appear. Where trauma alone exists and the family history is good, I know the case is in the field of osteopathy alone, and can be developed to a degree limited only by the intelligent care of those having the case in charge. Especial attention should be given to discipline, housing, sanitation, personal hygiene and general environment.

=Lesions.=—Atlas, generally rotated. Rarely posterior but frequently resting beneath a posterior occiput. Lateral mass on the posteriorly resting portion of misplaced atlas will become interlocked with transverse process of axis in a few instances, combining the amentia with a progressive inflammatory tendency to the middle ear which by successive abscesses ultimately destroys structure and function; possibly traumatic epilepsy, and surely catarrhal inflammations in all mucous membranes of the head.

Many bony and ligamentous irregularities exist in the various types of mental defective where the cause is inherited weakness, nutritional diseases or kindred sources. Spinal luxations exist singly and in series, causing various palsies, spastic muscles, and deformity. Postural defects, particularly of ribs and costal cartilages cause functional disturbance throughout the thorax and abdomen.

=Treatment.=—Invariably the care of aments entails wisdom of procedure. Reconstruction is the prime object in every instance, hence time and number of treatments must not be considered. Treat to =correct structure; teach= as far as possible; =train= always.

Deft and intelligently applied technique are certainly required in the correction of these cervical lesions. Treatment should be given thrice weekly (never less than twice for progress) with definitely established mental tests before, to discern the mental level, and at succeeding periods of three months each, noting progress, if any. The Binet-Simon scale or some other available mental test should always be made and record carefully kept of each case for your own benefit as well as the patient’s. After six months, if no appreciable gain is shown treatment is discontinued and the case must be cared for in another manner as beyond your special field of effort. Usually it is apparent by the end of the third month if anything can be done to improve the mentality. The physical advantages, in some cases warrant continued treatment where there is no appreciable mental gain. Institutional care of these types is the only practical means of handling them properly from an osteopathic standpoint, as it requires some one properly equipped to make your tests and keep your record;—it is sufficient for the doctor to do the work demanded. They can thus be classified and progress systematically shown. The higher grades must be taught and though self dependence may never be attained they can in many cases by training be capable of useful pursuits and quite frequently remunerative work. It makes for happiness at least to keep them busy and forestalls the mischief that would otherwise result. Even imbeciles can help in routine work of an institution or home, and idiots may, by training, gain some power of self help and cleanliness. Training depends on the individual capacity for such in each case—his habits, and general character of his propensities. Prevention of their marriage should be positive and for prevention of their propagation this and their sterilization by operation are the only two measures at hand. Sterilization, however, is repugnant to some elements of society and could be abused, hence the segregation of aments would appear to be our only solution at present. The ultimate intention of treating any case is to use any measure tending to stabilize the nervous system. Corrective effort alone is not sufficient but these osteopathic endeavors in conjunction with proper discipline, good food, regular rest and personal hygiene both mental and physical and a scrutinizing restriction tending to any kind of excess is rendering the osteopathic procedure in such cases rapidly indispensable for the treatment of amentia.

POST-OPERATIVE TREATMENT

By GEORGE A. STILL

At the convention of the American Osteopathic Association held in Boston in 1918, I gave a short talk on the above subject, and during the day after I had given the lecture, two women and one man, graduate osteopaths, asked me if I really meant to convey the impression that we actually gave osteopathic treatments to recent surgical cases. I do not know whether I convinced them or not, but I do know that they convinced me that there are people practicing osteopathy who have absolutely no concept of its merits and underlying principles.

To my surprise I have found that a great many osteopaths who consider themselves absolutely “pure” are just a bit startled at the thought of handling post-operative complications by treatment. These are invariably fellows who have had most of their experience in office work, and who do not come in contact with acute cases. Still it is difficult to conceive how a man can believe that osteopathy is specific for certain diseased conditions and not for others. As a matter of fact osteopathic treatment has not proved itself more satisfactory in any field of therapeutics than it has in post-operative conditions.

The common post-operative conditions are pneumonia, pleurisy, backache and headache, nephritis, vomiting, neuritis, phlebitis.

Taking up these subjects and discussing the least serious first we would of necessity discuss pneumonia last, as it is the most serious, and is less influenced by other conditions. It will also serve to illustrate many of the details in treatment.

We will therefore briefly take up the other conditions and then discuss pneumonia more fully.

Vomiting

We believe there is no question that a good part of the prevention of anesthetic vomiting is in the preparation of the patient, including a good cleaning out of the bowels without debilitating cathartics. In other words, the vomiting is increased if the alimentary tract is loaded, or if on the other hand it has been irritated to the extent of losing its tone. Combining a careful preparation with a straight ether anesthesia and osteopathic treatment to the neck and splanchnics we have been able to eliminate any serious post-operative nausea. I do not recall a case in the last few years that vomited on the following day unless the condition for which they were operated was one that essentially in itself would cause vomiting; for instance if the patient had peritonitis and had been vomiting due to the toxic ileus. They might even vomit after the abdomen had been opened. This could hardly be called “post-operative” vomiting.

The improvement in our records in post-operative vomiting is in proportion to our increased faith and use of the osteopathic treatment. Time and again patients have told us that they had taken anesthetics before and were sick from three to five days and even a week. Invariably we have been able to surprise these patients by the fact that they were sick less than a day.

The usual treatment with bismuth sub-nitrate, cerium oxylate, sour wine and the other usual remedies were not used in any case or in any amount. No drugs whatever were employed.

Backache and Headache

There is practically no difference in the post-operative headache and the office headache. There is of course the usual multiplicity of causes, and as a matter of fact in this condition treatment can more nearly approach the ordinary office treatment, and the results are about the same. As for backache, we find that speed of operating and not keeping the patient under the ether too long has a marked influence. Also we have a four inch Seely mattress on the operating table which helps some. Treatment does the rest and does it effectively. For this complication even the ordinary nurse knows enough to give a treatment of some sort.

Neuritis

Nine times out of ten the post-operative neuritis is really a local osseous lesion, a slipped innominate, rib, vertebra, clavicle, biceps tendon or something of the sort, and responds quickly to a specific treatment.

Phlebitis

This complication usually comes on quite late after an operation and at first it is sometimes hard to differentiate it from a neuritis. Absolute rest of the involved part with lower spinal treatment gives relief, but under no circumstances should the affected part be freely moved while there is active inflammation. The reason for treatment of the lower spinal area is that practically always one of the saphenous veins is involved.

Nephritis

This complication is to a very big extent eliminated by a careful urinalysis prior to the operation, and careful preliminary treatment in indicated cases, and in other cases the postponement or if necessary complete elimination of the operation where it is not a case of life and death. Where the condition does appear we have found it the hardest of the post-operative complications to control. Indeed it is the only one that we have not found very easy to manage.

We do not vary the treatment for a post-operative nephritis from what we would use in any ordinary case of nephritis. We have observed treatment of this condition in many cases under medical management, and while we are satisfied with the osteopathic treatment comparatively we are not yet satisfied that we have it developed to its greatest efficiency.

Pleurisy

This condition in nearly every instance can be corrected with one or two treatments of a twisted rib unless it is the pleurisy of a beginning pneumonia. As far as the pain is concerned the simpler type hurts as much as the one that is going to develop a real complication. For this reason relief obtained by a single treatment often seems little short of miraculous to the patient.

Pneumonia

When I took charge of the surgical work at Kirksville, osteopathy was not used in post-surgical treatment. Post-operative vomiting was treated medically, as were other post-operative conditions, including pneumonia. Cases of a real major surgical nature rarely got an osteopathic treatment.

The idea seemed to be that osteopathic post-operative treatment had to be along the same lines as it would be for such an illness as lumbago, brachial neuritis, or ordinary pneumonia, and other non-surgical conditions where the patient could be placed for giving a treatment in a position that was not permissible following an operation, as it would work great harm to the wound.

It seemed to me that if osteopathy was effective in a case of ordinary non-surgical pneumonia, it should certainly be good for a case of pneumonia that was post-operative and that all we had to do to handle the condition was to apply a new technique of treatment that could be used on a patient who had a surgical wound. All we had to do was to so manipulate the spine that we would get the results locally, and yet handle it in such a manner as not to affect the wound.

Many laymen, and even some physicians of our own school, express surprise at the suggestion that we do much osteopathic work in the after care of surgical patients. But the fact is we have worked it out so that now, except for pain, during the immediate after effects of the operation drugs are absolutely not used in our hospital for any of the post-operative complications. The opiate immediately following the operation, is really a follow up of the anesthetic, and we use that as rarely as possible. Needless to say, there are cases such as un-united fractures, extensive adhesions, etc., where the emergency conditions positively call for some relief of the pain for a short while, but that is the only condition that we cannot control with mechanical treatment.

I am very glad that I had the confidence to give this an early trial and a thorough trial, without being afraid to leave off the drugs. The big field, however, where osteopathic treatment has won the most impressive success and proved itself a most absolute specific, is in the field of post-operative pneumonia with which I am proud to announce a one hundred per cent. success for combined osteopathic treatment in my fourteen years continuous surgical work. Not to have lost a single case is partly due to luck. In other words, with any series of serious cases, it is impossible but that there be some fatality finally.

Post-operative cases have one advantage along with their disadvantage. While they have the shock of the operation to contend with, and the weakened condition from the disease for which they were operated, still except in extreme emergency they would not have been operated on unless they had a good heart and good kidneys and a good blood pressure, so that in cases in which we are most concerned in combatting pneumonia, we usually start with a patient who has those organs in a healthy condition.

=First Post-operative Pneumonia Cases Treated Osteopathically.=—At the Chicago Convention in 1911, I reported the first post-operative pneumonia cases that had been treated osteopathically. I believe at that time that there had been only three cases. At that meeting I mentioned the fact that some of the doctors and some of the internes who treated those cases felt sure that they were not treating them properly because they could not get away from the idea that pneumonia needed strychnin and other drugs. One of these cases got well in three days from the developed lobar pneumonia symptoms. The results were so miraculous that the young man treating it began to doubt whether it could have been pneumonia. He could not understand how he, a senior student, could overcome this dreaded disease by merely working on the spine. He could not believe that osteopathy, a science that he had been able to learn himself, so easily could cure a condition that he had thought must be almost necessarily fatal.

One of the weaknesses of osteopathy is the fact that there is no mysticism about it. It is so simple that any person with ordinary intelligence can learn to use it, and yet it is so simple that it takes an unusual intelligence to be able to grasp the fact that it is the therapeutic discovery of the age. Many, many times I have had young internes and students cure genuine lobar pneumonia and do it with such obvious ease that it caused them to wonder, in a way, if it really could be pneumonia. It is bred in our very tissues to look for some mysticism, something impossible to understand, something supernatural, something connected with the Unknown associated with the treatment of disease and accordingly it is just human nature to find it difficult to believe, even when we see it, that a simple method of treatment can actually effect a cure.

Real pneumonia, as we understand it, is a consolidation of the lung tissues characterized by fibrosanguinous exudate into the pulmonary tissues and spaces, associated with one or more particular germs as exciting factors and proved by the physical tests and the character of the expectoration. How many cases have been cured that had not entered consolidation I do not know because up until the time of actual consolidation there may be a question as to whether or not they would have had pneumonia. I know that many cases with marked symptoms of pneumonia have failed to develop under treatment or the case has been aborted.

Pneumonia lacks a great deal of being a self limited disease. The number of cases with beginning symptoms that fail to develop is too great to be ascribed to coincidence. Of course I know that some of these might have been only pleuritis, some only neuritis, etc. However, in giving the statistics of pneumonia cures we will give only those in which pneumonia developed and showed a hardening or consolidation of the lung tissue. In these cases there can be no argument as to whether there was pneumonia.

When we have an acute condition associated with the symptoms of consolidation, we can hardly be confused as to the diagnosis. We may make a mistake in our physical findings, but hardly after a little experience, and certainly when we are sure of the physical findings there will be no trouble in naming the disease.

=The Clinical Findings.=—Post-operative pneumonia is a little different from the common pneumonia. It always comes on a little more insidiously. One has to watch for post-operative pneumonia more closely than he would for the attack that we may meet in ordinary practice. A patient may have considerable pain from his wound, may have some pain in the back from the position he is in; there may be headache, and an upset feeling from ether; and the pain comes in the chest. All these symptoms are forerunners of pneumonia, but the pain in the chest is not noticed until it gets quite severe. In other words, there are other things to annoy the patient as well as the attendant, and at first, this condition does not cause complaint. A strong and healthy individual who feels a pain in his pleura, which is the forerunner of pneumonia, knows it at once, because that is the only distress he has. His entire attention is attracted and he asks for a physician’s help. But in the post-operative case, the physician has to keep a look out in order to prevent a case from getting well under way before it is recognized.

As an example of this I had a case of a man who was with a party driving an automobile and they tried to cross the railroad track in front of a train. This patient I speak of was one of the survivors. He had a fracture of the femur, fracture of the skull, fracture of three ribs, and otherwise more or less bruised up. Naturally the preliminary work consisted in getting the ribs and legs attended to as well as possible and looking out for cerebral hemorrhage or meningitis.

This patient developed consolidation in both lungs in spite of regular treatment, and it precipitated on him very rapidly, partly masked by the disturbed breathing from other sources of irritation. We put him on hourly treatment, but after a few hours his condition from the injuries and the pneumonia was such that his wife asked us not to treat him any more. She put it this way, that she knew he would die in spite of all that could be done and as long as he was going to die he might as well die easy. Every time he was treated it had the effect of bringing him out of his stupor, and he would complain, and she thought it would be a kind act to let him slide off into the next world uncomplaining.

Pneumonia in a case of this sort cannot be handled with kid gloves if we wish to save the patient. We must give firm, strong treatment. Light treatment in this condition will do no good. Indeed light treatments in any sort of pneumonia are of little avail. Many times I have changed internes in a pneumonic case that was not responding and the results were immediate. That is, the turn for the better was obvious from the beginning of the good strong treatment.

The case above mentioned was treated a good part of each hour for twelve hours. He had no strychnin, no oxygen, nothing but treatments, but he got well and is now living, and aside from a limp has no evidence of either his injury or his illness.

Some cases, in private practice, may get well on a treatment a day, but I would hate to handle the kind of cases we get in that manner. I have had severe cases, especially hemorrhagic cases, where the treatment was almost continuous for hours preceding the crisis. Of course, after the crisis we can ease up. On the other hand, it is not infrequent that a few good strong early treatments, given at the beginning of a case absolutely stop it. I have seen cases where a consolidation area of the apex of the lower right lobe as large as the palm was easily outlined, and this together with the clinical symptoms would be cleared up in two or three days.

There is no possible medical method by which this can be done. Medical authorities agree that under their treatment pneumonia runs an unshortened course; in other words, a course in the individual case that has not been affected by the medication. Medically, even where the crisis occurs early, the consolidation persists for some time, but I have seen it cleared up time and again under osteopathic treatment in the length of time that could have been brought about only by osteopathic treatment.

I have previously called attention to the fact that many of the medical text books on physical diagnosis mention a point that is a very practical and very plain demonstration of the efficiency of osteopathy in pulmonary conditions. These books only mention this fact without pointing any moral or drawing any conclusions. The point is this: that frequently when a professor is having a class or a section of a class examining a case of pneumonia, they will outline the size of the consolidation at the beginning, the instructor marking it off when he makes the first examination; then after the students have examined it, by percussion, palpation, etc., possibly a dozen or twenty of them, the later students will find that the area has shrunken perhaps an inch. This fact has been frequently noted. It is said, indeed, that if careful examination is made it will always be noted.

How Manipulative Treatment Benefits

Doubtless this proved that accidental manipulations of the ribs helps clear up the congestion about the real consolidation and reduces some of the dull area. Very likely this explains some of the cases of partial or real results from spondylotherapy. Naturally, scientific osteopathic treatment would necessarily magnify such results very much.

It is a great wonder with the obvious failure of medical treatment in pneumonia, that at least some crude from of manipulative treatment has not been devised by those practitioners. We have already mentioned that the treatment of post-operative cases varies mainly in the manner of applying it. In other words, when we raise the ribs we keep the patient on his back, in treating the spinal centers we treat with patient on his back, and the physician who has no grip in his hands will not be able to treat a post-operative pneumonia to any advantage.

In these cases one has to get at the patient’s back by reaching under and the weight of the patient helps to give the treatment, but a strong grip is necessary. It is much safer for the wound to handle the patient in this way but not infrequently beginners wear their knuckles pretty nearly off before they get the finer technique; after which it is easy. In raising the ribs there is no more difficulty in treating in this position than there is with a patient who can sit up or turn from side to side and in some cases a patient can, of course, be partially turned.

Theory is all right but in these cases practice has been added to it in something over three hundred cases treated in this manner, and in this manner only. I have had no case die. None of my cases had oxygen and none of them had strychnin or alcohol unless it was a person who had used alcohol constantly or daily and in these cases I consider that the system has become sufficiently used to it that it is practically a food and that sudden withdrawal is apt to bring on delirium. It is not necessary in those cases that indulge deeply now and then, but it is advisable in those that take a small amount regularly, just as they take food. These patients are used to a constant heart stimulant and its withdrawal is also apt to be reflected in the heart action. These are the only cases in which I have ever authorized anything in the way of a chemical stimulant of the heart during pneumonia.

You will undoubtedly recall that in reading the newspaper accounts of men who are big enough and prominent enough to have bulletins in the newspapers when they are dying, that almost universally the next to the last bulletin was that oxygen is being administered. The last bulletin announces the time of death. You will also note that in case the patient lives that oxygen then is not mentioned, and a few days later the patient is all right. My observation is that the use of oxygen may attract the attention of the family, it may attract the attention of the patient, but as for any actual benefit on the patient I do not believe it is in the least helpful, and that the only treatment for pneumonia is osteopathic. I am so convinced of it that I am using only that method.

As to strychnin, some say strychnin must be given. Some say it must be given at the crisis, and others say it must be given from the inception of the disease. I do not believe the majority of cases will do as well under strychnin. I know they will not do as well under strychnin as under osteopathic treatment. I will not say they will not do as well as if under no treatment. It is possible that there would be an occasion for its use at the crisis, and I have seen such cases, and I have used it while studying medicine. I used it at the crisis, and I used it in cases where I am convinced that it helped them over the crisis, but I am also convinced now that by osteopathic treatment they would have done still better and the crisis would not have been so acute. In other words what strychnin does in favorable cases, osteopathic treatment does better in all cases.

In our post-operative cases study the charts and you will see that they do not have the acutely violent crisis that usually occurs under other treatment. They are under better control and if we can get them near the beginning, as we usually do, we can keep up the resistance so that where they would otherwise have a hard crisis they have an easy one. Instead of having a temperature of 105, pulse 165, respiration 70, or such a condition, they are more apt to run a temperature of 102, pulse 120, respiration 35 or 40 and they go through it without that suddenness and acuteness that is common under other methods of treatment.

In several instances, as an example of showing how this resistance is kept up, I had letters from boys in the camps. One letter told of a wide epidemic of severe tonsillitis. In one group of soldiers there were three osteopaths who treated all the men and this was the only group that was not sent to quarantine. This group developed sore throat and was treated osteopathically and the sore throats checked so that quarantine was unnecessary.

Among the detailed reports in the A. M. A. Journal there will be nothing about this, nor about many other instances where osteopathic treatment, given by men forced to remain in the ranks, has done things that medicine cannot do. These examples are too frequent to be coincidents. If I had had three cases of post-operative pneumonia and they had all got well, it would not be surprising. If I had ten cases and they all got well, there are medical hospitals that have been this lucky. But there are no medical hospitals in the world that can report one hundred cases or two hundred cases or three hundred with developed pneumonia and all lived. The percentage of pneumonia cases that die now in medical hospitals, is much less than formerly. But the cause of this is not vaccine, antitoxin or drugs. It is due to the fact that pneumonia cases now, like typhoid, are given very little medicine and are turned over to general nursing treatment; that is, in the best medical hospitals.

The mortality is in inverse ratio to the drugs given. The advance medical teaching is against so much drugs in pneumonia, though of course the hick doctors use it because they are practicing medicine of the by-gone age, before Andrew Taylor Still forced on the world the idea partly started by homeopathy, that the less drugs the better. Homeopathy failed in not quite discarding drugs and in not having a substitute that reproved drugs.

As a matter of interest I wish to mention that while in medical college I had the advantage of being taught surgery by the greatest surgeon that ever lived, John B. Murphy. I only wish that circumstances could have permitted me to have shown him what osteopathy could do in post-operative conditions, because Murphy was a broad minded man and no man living ever thought less of orthodox medicine and old fashioned drug treatment than Murphy.

He and the Old Doctor would have been great friends had they ever met. Murphy, whom I considered a most wonderful surgeon, and whose skill I never hope to approach, stated to me many times while a student that he lost more cases from post-operative pneumonia than any other condition and that in upper abdominal conditions like gall bladder, stomach, and similar operations, post-operative pneumonia constituted the most of his mortality.

This great man was afraid of post-operative pneumonia, while I, a much less skilled surgeon, am no more afraid of post-operative pneumonia than I am of something occurring in a distant state because with osteopathic treatment, we have eliminated post-operative pneumonia as a fatal condition.

PART SECOND

INFECTIOUS DISEASES

Fever

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

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

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

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

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

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

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

=Two points= should always be remembered relative to fever:

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

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

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

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

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

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

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

Typhoid Fever

(ENTERIC FEVER)

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

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