Chapter XXI: Introduction (6)

=Treatment of Tuberculosis.=—The =prophylactic treatment= of tuberculosis should receive first consideration. The sputum should be thoroughly disinfected and care taken that the patient does not spit about carelessly. A spit-cup should be provided and the sputum collected and destroyed by burning and the cup sterilized. The patient should be well taken care of and given a separate apartment, so that the danger of conveying the disease to others is reduced to a minimum. He should occupy a single bed. All unnecessary furnishings of the room should be removed and the objects that remain in the room should be frequently aired and disinfected. The general and sanitary environment of the patient should be as favorable as possible to hygienic living. Many times a change of residence is of great benefit. When possible the patient should be out of doors and light exercise taken. The body should be well protected by flannels, the year around.

Keene[61] would carry prophylaxis to careful examination of the pregnant woman to avert a sudden development of tuberculosis after parturition; also of the child, after birth, to remove any predisposing lesions. The mother with a tubercular tendency should, under no circumstance, nurse the child and should be instructed to observe any disposition on the part of the child to acquire malpositions in sitting, standing or walking.

Another important consideration in the prophylactic treatment is the inspection of dairies and slaughter houses. The disease may be transmitted by infected milk. There is less danger of infection through meat; although all animals that present distinct lesions should be confiscated. Sanatoria and other special arrangements for the care of patients should be encouraged.

The =Treatment of the disease= consists primarily in locating the cause of the devitalized condition of the cellular tissue. This is the vital point to be considered and requires a thorough examination of anatomical structures in the region involved. There is a reason why the tissues are in a depraved state and it is our work to examine thoroughly the structures that might become deranged anatomically and cause an obstructed innervation or vascular supply. The disease is not primarily due to the bacilli; the bacilli would not have infected the system had it been in a healthy state. Hence, the object of the treatment in tuberculosis is to favor a building up of normal, well-nourished tissues so that it is impossible for the bacilli to infect the region. Of course, destruction of the bacilli is important, but we cannot expect to do much by the use of a parasiticide, for we are not then influencing or affecting the real cause of the disease. If we can improve the arterial circulation to the diseased tissues, we will be striking at the root of the disease and the healthy blood will be the only parasiticide necessary. This is where the osteopathic theory of the cause of disease differs from that of other schools of medicine. At the local points of infection there is a decided malnutrition of the tissues, due to a lack of proper blood to the parts, thus favoring the lodging of micro-organisms; by reestablishing normal nutrition nature will repair the tissues if the condition is curable. Hence, it can be seen at once that if the case is curable osteopathic treatment will meet the demands scientifically.

The preceding is the keynote of osteopathic therapeutics; not only in the treatment of tuberculosis, but in all diseases where micro-organisms play an important part. In =tuberculosis of any part of the body=, it is the duty of the osteopath to carefully examine the structures that may become anatomically deranged, from any cause, affecting the nerve, blood and lymphatic supply to the tissues or organs diseased. Correction of anatomically deranged tissues and attention to the hygiene, diet and general health of the patient constitute the treatment.

On the subject of Pulmonary Tuberculosis, W. Banks Meacham says:

“In cases of =pulmonary tuberculosis= it should be remembered that the pathological lesion in the lung is a result of a general systemic interference—an interference so great that the body as a whole loses its stored-up heat in excessive temperature, loses its reserve nutrition, as manifested by early and continuous loss of weight.

“Therefore the causative osteopathic lesion should not be sought alone over the site of the pathological lung lesion but rather in that area where general nutrition is osteopathically affected.

“A few general considerations of =osteopathic mechanics= involved in nutrition should be ever present with the searcher for the cause of pulmonary tuberculosis. For instance we know that ingested fat is acted upon by the pancreatic enzymes; that the invertin of the intestine is an endocrine secretion. In diet we seek to administer an excess of fats to take the place of fat-loss in this disease, often losing sight of the fact that some mechanical maladjustment prevents fat-splitting into a form suitable for tissue assimilation.

“It is common osteopathic knowledge that lesions of the upper dorsal area have a profound influence on general nutrition. Consequently it is to this area that we must look for the causative osteopathic lesion in this disease. The influence of this area is due to the fact that the nervous mechanism of the secretory glands gets its most direct disturbance in this area where the nerves leave the spinal cord to become distinct innervation to these organs.

“Apart from the nutritive and general circulatory influence of upper dorsal lesions we must consider the germicidal action of the endocrinous secretions in devitalizing the specific bacterial agent in tuberculosis. Undoubtedly these internal secretions have marked effect in agglutinating the bacilli, thus enabling the phagocytes to perform a larger duty.

“The correction of upper dorsal lesions, with due regard for the pathological condition within the thoracic cavity gives a scientific physiological and bacteriological therapeutic action in tuberculosis.

“=Other lesions= may and do demand attention and correction when possible. But we must not lose sight of the fact that our specific action comes from a corrected relation of the upper dorsals. In the cloud of unproved theories and guesses in the literature of pulmonary tuberculosis nothing seems nearer an established truth than that it is a disease contracted in infancy, that it develops, later, in those persons who retain the infantile type of chest—thorax of large antero-posterior diameter in contrast with the lateral diameter.

“In the progress of the disease we do get a costal malformation giving the ‘horse-collar’ thorax, with an apparent lesion of the osseous walls of the thoracic cavity. But these lesions are the result of nutritive changes brought on by the active infection already present; and are not in any true sense, causative factors in the establishment of pathological areas within the lung.

“The =osteopathic treatment=, then, of this disease is, manifestly, a correction of a plastic posterior upper dorsal lesion. And where the pathological lesion of the lung contraindicates forceful correction, mobility of the area should be sought.

“The =general care= of the case should look to the normal functioning of all organs, with emphasis on ease to the patient. The =diet= should be what the patient can assimilate properly even though it be much less than the amount a normally active person should ingest. =Altitude= has a favorable effect in selected cases only. It is remarkable that many cases recover in the extremes of the Rockies and the coasts of California and Florida.

“No violent =exercise= should be undertaken on account of the possible embarrassment of an already overworked heart and in consideration of the possibly engorged pulmonary vessels. For these reasons, too, rest in bed is advisable with temperature above 99° F. and pulse above 85.”

In =scrofula=, lesions will be found to the lymphatic glands, impairing their innervation and function. The treatment is not to be applied over the glands directly. First, it is necessary to locate the lesions of the bones, ligaments and muscles or such tissues that would cause disturbances to the glands, then readjust the parts. The object of the treatment is to modify the soil conditions on which the bacilli multiply, by correcting the local derangement of the tissues. The entire body is not in such a depraved state that the bacilli will grow and multiply wherever they happen to come in contact with the body; tissues of any organ favor a receptivity for the bacillus only when these local tissues are in a morbid condition. It is then our work to aid nature in relieving obstructed forces that are causing such an effect.

There are =general measures= which influence the tubercular process. The diet of the patient should be nutritious. A diet of milk, buttermilk, egg albumen and meat juice will probably be found best, although many will be able to take ordinary food. The patient should be out of doors as much as possible. Meacham[62] says “Fresh, pure air, wherever found, is essential; elevation is an individual requirement, an even temperature is not necessary and sunshine is important only as it allows the patient to be out of doors. Exercise should not be taken when the patient has a temperature above 99 degrees.” The dry, even climate of the Southwest certainly tempts the patient to be out of doors more than one with opposite conditions. Even when the patient is greatly debilitated and weakened, insist upon his taking outdoor exercises or rides. Gymnastic and methodical breathing exercises are essential in widening and strengthening the chest. Bolles[63] believes that the appetite should control the diet and forced feeding be not insisted upon. Fasting, to test the sense of food desires, has points well worth looking into, as gastric disturbances with a loss of strength follow overfeeding. He also recommends deep breathing and physical culture to elevate the ribs and increase thoracic expansion. Outdoor sanatoria are being established over the country, in many cases by state appropriation as, “the treatment of tuberculosis itself has not been a satisfactory procedure except by climatic changes or the outdoor treatment persistently applied.” (Halbert). The fresh air treatment may be taken at home by sleeping in the open air or by appliances fitted to the window of the room so only the head is exposed to the air. The only factor is to get the air. The skin, as well as the excretory organs, should be kept active. Always make it as comfortable for the patient as possible.

The =fever= is indicative of the activity of the disease, so that treatment to influence the process and to promote elimination is best. Sponging with either cold or tepid water will be helpful. The =cough= is a troublesome symptom. Attention to the underlying irritation is demanded, although one cannot hope to influence, to any great extent, the cough dependent on cavity formation. Catarrhal processes in the respiratory tract can be lessened. Lesions that are acting as a cause of irritation, will frequently be found in subluxated ribs or vertebræ. The seventh and eighth dorsals are frequent sources of cough. The tissues about the pharynx and larynx, and the hyoid bone, disturbing the vagus and other nerves, should be carefully watched, also possible reflex irritation from the abdomen and pelvis. =Night sweats= are due to tubercular processes weakening the system and particularly lessening nervous control. These will subside as the body is strengthened. Sponging will be of service. Disorders of the =stomach= and =intestines=, such as nausea, vomiting and diarrhea, require treatment of the splanchnic area and regulation of diet. Considerable can be done to relieve =tubercular laryngitis= by careful treatment of the larynx and contiguous tissues. =Hemorrhage= is likely to be self-limiting. Attention to the upper dorsal vertebræ and ribs and muscles will tend to equalize the circulation. Rest and use of ice upon the chest, as well as internally, will be beneficial.

McIntyre, in an article on “Fat Food in Consumption,” sums up the treatment for tuberculosis in the following words: “The treatment, then, for consumption should include rich, stimulating diet, proportioned to the digestive power of the patient, containing an excess of fats in most digestible form, of which sweet cream, fresh butter and well-cured bacon are the best examples, and the free use of pure drinking water, coupled with the promotion of blood flow, respiration and elimination of waste by osteopathic means.”

Surgical measures may be necessary where glandular or other tissue has broken down and is a menace to recovery.

Spanish or Epidemic Influenza[64]

By GEORGE M. MCCOLE

The epidemic of influenza which swept over the world and reached the United States in August 1918, starting in at the Atlantic sea-board cities, developed rapidly there and passed westward over the country. It reappeared the following winter.

=Epidemiology.=—In the United States it was called Spanish influenza, as it was at its worst in Spain at the time it broke out here and was thought to have been brought from that country.

In Europe it was called the Ukrainian influenza and in southern Russia it was said to have emanated from the Orient. No country in the world was exempt. It was at one time thought to be a type of the pneumonic plague and while plague is the severest toxemia known many cases of Spanish influenza were equally as prostrating and fatal as the ordinary type of pneumonic plague. The bacillus pestis was never proved to be the cause of this pandemic of influenza but the clinical analogy was very evident.

A study of European conditions of health and hygiene shows how reasonable it is to believe that some disease would develop and sweep a world lowered in vitality and immunity by the abnormal conditions of war. Every known communicable disease was raging in Europe and Asia where millions of people existed under exceedingly poor hygienic conditions.

The period of incubation of influenza was extremely short, averaging about two days. All ages were attacked, although persons over 60 rarely. Those between 25 and 35 seemed to be the most susceptible but it was, perhaps, because they were in active life and more exposed. There is considerable evidence that the disease was not air-borne but conveyed by contact with active cases. The secretions of the mouth, nose and eyes were considered the active carriers. Masks, made of several layers of gauze fastened over the face, have been worn by many people but experience taught that their use did not avail against infection.

=Mortality.=—The mortality under drug medication as shown in a statement by Henry S. Bunting was as follows: “New York City 9.8%; Chicago 14.5%; Boston 27%. Osteopathy’s influenza salvage represents the difference between these figures and the low score of one fourth of 1%.” He gives the following statistics on pneumonia following influenza under drug medication. “Reports from 148 health commissioners show an estimate (called conservative) of 33% of fatalities in epidemic pneumonia under medical care. In some large centers it ran as high as 68% to 73%. As officially compiled to date, the fatalities in epidemic =pneumonia= in our army and navy cantonment hospitals amounted to 34½. Osteopathy’s fatalities were only 10% which included all those eleventh-hour appeals to Osteopathy.

“The Chicago and New York departments of health figures, each show total death losses of 18% in all of their epidemic cases. Osteopathy’s remarkable salvage of life is best measured from this point of comparison. Its total death rate from both influenza and pneumonia has been actually less than one percent.” And this is based on 110,000 cases reported to the American Osteopathic Association.

=Pathology.=—The pathology of Spanish influenza is practically a study of lung involvement. There we find an exudative pneumonia of a rapidly confluent type, a transudate of blood serum and red cells appearing in the lower lobes of both lungs and rapidly flooding the entire space. Air bubbles were scattered through the serum soaked lungs, giving a frothy appearance to some parts. At times some parts of the lungs showed drops of liquid pus.

Where pneumonia did not develop there was no typical pathology. The toxins left an irritated bronchial tube, intestine or kidney just as in any other severe toxemia.

Bronchial and the old type of lobar pneumonia also appeared as a complication of Spanish influenza, making three types of pneumonia which were to be guarded against.

=Symptoms.=—The attack is usually ushered in by a chill or prolonged chilly sensations, sometimes lasting for two or three hours; fever 103° to 105° F.; if it does not fall in three days or if it comes up after once falling, pneumonia is to be suspected; pulse, full and bounding with a varying rate; headache usually general in type and in severity from slight discomfort to a most violent type; intense pain in the back and legs; tenderness the whole length of the spine but especially distressing in the upper dorsal, lower lumbar and sometimes the upper cervical; a dyspnea which is best described as being a constricted feeling of the chest with air hunger; often the bronchial tubes are raw and dry, the patient feeling as if the breathed-in air were hot to the bronchial tubes, an active exudative bronchitis developing; sometimes there is an active bronchitis with distressing cough; nose bleed is a frequent symptom (and is often a sign of threatening pneumonia); most cases sweat more or less, some have drenching sweats; sleeplessness; albuminuria frequent.

When the temperature breaks it practically always falls below normal during the course of that day. A typical case of severe character often presents all of the above symptoms; the lighter cases perhaps only two or three of them, of which the chilly sensations, fever and bounding pulse are the most common encountered.

A severe case is impossible to differentiate from the first symptoms of smallpox. Where a case of this type is encountered, it is always advisable to get history of vaccination or smallpox.

=Examination.=—The successful treatment of disease calls for attention to little things. Some little thing properly cared for very often gives us our margin over adverse conditions and spells success in the care of our patient.

During the epidemic I found a few cases which ran a temperature much below normal, sometimes as much as three or four degrees, and still with enough symptoms to be easily diagnosed as influenza.

=Pulse= was taken at the time the thermometer was in the mouth. Pulse was practically always bounding and hard. Its rate varied widely, being influenced by many other conditions. I often, early in the attack and where other symptoms were indefinite, made a diagnosis principally from the pulse.

=Respiration= was taken while holding the watch and with the finger on the pulse so that patient would not know that breathing was being watched.

Many patients complained of a sensation of weight on the chest and difficult breathing—hardly what one would term true =dyspnea= yet a real air hunger and sensation of constriction in the chest. The breath was often tainted with the odor of acetone, indicating a high degree of acidosis and giving an important diagnostic point.

The =heart= was then examined, both by auscultation and percussion.

The examination was then extended over the lungs and pleural rub listened for.

Patient was questioned as to having had a chill, general health, occupation, undue exposure, fatigue, what physic if any, had been taken or other drugs used, bowel movements and bloody stools, food taken, sleep the night before, and dreams, headache and backache.

The full examination could not be given at each call and not all of it to each patient, as time would not permit during the height of the epidemic.

Throat was always examined. This is an important point.

The urine was examined in a great many cases and often albumin and sometimes casts were found.

=Treatment.=—I consider it advisable to give a strong deep treatment if the patient is seen before the attack has gained full headway; after that I give short light treatments.

If the disease has not developed much at the time of the first visit vigorous treatment with adjustment of the deep-lying and tightened-up ligaments over the spinal cord is indicated. Subsequent treatments are given to overcome the invariable and recurring contractions along the spinal cord. The spine is gently sprung and the muscles pulled away from the intervertebral foramina so that arteries, veins and nerves of the spinal cord are free to function.

I might note here that I consider Spanish Influenza does its damage through the attack of its peculiar and virulent toxin and the accompanying acidosis, on the body’s reservoir of energy—the spinal cord and related structures, the vegetative glands and nerves.

If the patient is in a serious condition he is often treated in the position in which found, so as not to disturb him. Care is particularly taken to keep a patient who is moist with sweat from taking cold or being exposed. An extra covering is thrown across the neck and shoulders, and pulled down as the bed covers are moved to get to the area to be treated.

The musculature of the upper dorsal and cervical region is given special attention, the region of the first and second cervical and the first to sixth dorsal being special seats of trouble. The region between the spine and scapula on the left side, first to sixth ribs left, and the region of the suprascapular notch on the left side are given specific treatment to free them of contractions. The tissues of the suprascapular notch are in direct connection with the nerve supply of the heart muscle and treatment here is astonishingly effective.

This treatment for the heart is best given with the patient lying on the right side, leaning a little forward, with his left forearm against the chest, hand at neck or chin. Stand then at the patient’s head and with the thumbs give all the region on the left side at the base of the neck and around the suprascapular notch thorough muscular adjustment for circulation and removal of contractions which disturb the heart’s vitality. Treat first to sixth dorsal region.

I consider this treatment specific for the heart debility of influenza and many other heart conditions, as well. I have found it especially effective in the weakened and nervous states following influenza and in so-called “run down conditions” generally.

Vibration with the tips of the fingers on the anterior chest wall is often used. Tender and contracted tissues are often found along the anterior ends of the ribs which are involved at their spinal ends. These are gently treated. Children are often given vibration, holding their chests with my hands under their arms.

If the patient is stout and not easy to treat I have him sit up in bed and give the upper dorsal thorough percussion with the side of the hand[65]. About 100 strokes at each treatment are usually given. I remember one very fat patient in the eighth month of pregnancy to whom I could give hardly any other treatment. It was especially valuable here and we saved the mother after a hard fight, though the child was still-born.

When nature is meeting the emergency and holding her own in the battle against infection we have a moderate fever—a benign fever. When the body is overworked with other duties and irritations the fever may rise dangerously high. Here it is that the physician must give further aid. Here it is that osteopathic treatment further aids by giving rest to the patient, easing pain and promoting general circulation (this in itself often quickly reduces fever). Here it is that the attention we give to clothing, diet, ventilation, quietness, good nursing, etc., comes in. The body is relieved of all duties but the one. Its functions are all turned to one end—the destruction of the invading infection. The osteopathic physician adjusts. Nature cures. It is all a matter of adjustment.

For labored breathing, an effective treatment is to have the patient with hands clasped and arms raised above the head, patient being in bed, face up. Stand directly at head of patient. Reach over patient’s arms and under the upper dorsal and lift up against the heads of the ribs with your fingers, thus raising the chest, beginning as far down the spine as you can and working up as you treat. Relax the muscles at the same time.

=Frequency and Amount of Treatment.=—Frequency and extent of treatment depend upon the condition of the patient. In influenza the patient is approached with the idea of a daily visit. If then there is any doubt about his being entirely safe for 24 hours he is seen in 12 hours or as often as the condition indicates. Patients are usually seen more than once a day.

The average time which the patients are confined to the bed is about five days. Some are free from fever in three days; some not for six or seven days. According to conditions they are then kept in bed from one to three days longer.

As to the amount and length of treatment, I agree with James M. Fraser, who says adjustment of the soft tissues should be made and made with as little disturbance to the patient as possible. He says[66]: “The ill effects of too long-drawn-out general treatments, or in short, over-treatment, I consider one of the most important questions for osteopaths because I incline to the belief that in many acute infections more harm may be done by such fatiguing over-treating than if the patient were really not treated at all. A “flu” or pneumonia patient should never be treated over fifteen minutes at the longest in one treatment. It is much better to treat often and not treat so long, as over-treatment may result from a desire to be thorough. If we always would stop and think what we are doing and just what we are trying to prevent we would be more careful when we treat these infectious cases. A patient’s resistance may really be lowered, his bowels inhibited, his heart overstimulated, his muscles fatigued and his nerve force depleted by treating overtime. When the reaction begins, stop.”

Congestions and contractions should be removed wherever they are found, be it in the region of the throat, spine, ribs, liver or spleen. I order a daily enema and give positive instructions—after having had one or two almost fatal cases from this cause—to use no physics. Purging killed more people here than any one other thing. If a heavy physic be given two or three times and the patient comes to a crisis, so much vitality has been taken out of the blood that he does not have enough strength to carry him over and he dies.

If the patient comes to pneumonia I find it good and effective to use the “constipation treatment.” It is best to let the bowel take care of itself. Nature can do many things, and caring for the bowel in a crisis is one of them, providing the correct diet has been given the patient. If the patient is getting nothing but fruit juices there may be a natural bowel movement and even if he has been getting other food it is better to leave the bowel alone until after the crisis and then give the enema.

A patient with a frank pneumonia following influenza has but little chance of living if his strength is being drained from the blood stream through the bowel every few hours.

I see to it that no draft blows on the patient’s bed. In a windy location a cold draft can appear suddenly and do great damage in a short time. The patient should not breathe cold air. Fresh air is all right but it must not be cold air. I order extra covering for the neck, arms, shoulders, back and chest. I like a wool workshirt best but use pneumonia jackets, extra undershirts, sweaters, etc., when the wool shirt is not to be had. In fact continued warmth seems to be an almost necessary condition to the proper handling of influenza. It is because heat, even the heat of the fever itself seems to aid the nervous system in building up antitoxins.

The patient is instructed that if a sweat comes on, either from a hot bath, hot drink or as a result of the disease, to lie and take it, for throwing off the covers is a sure way of taking cold and inviting pneumonia.

If the house is cold or the patient weak or very sick the urinal and bed pan are used. In fact I prefer their use even when those conditions are not present, as the less the exposure the less chance of pneumonia and the quicker recovery. =Rest= lying in bed is absolutely necessary to a satisfactory course and quick recovery.

For lung congestions and bronchial irritation, in addition to osteopathic treatment along the spinal cord, raising the ribs and chest, and vibration of the chest wall, I sometimes use the old fashioned mustard plaster (made with one teaspoon each of flour and mustard, mixed with olive oil or with water and white of egg), keeping it on about ten to thirty minutes or until a good, red reaction is brought about. The feet must be kept warm with hot water jugs. A hot mustard foot bath is excellent when the feet persist in staying cold.

At first I did not use the hot tub-bath. I am now ordering it if I see the patient early in the attack and where there is no contraindication, such as a dangerous heart condition. I do not use it unless it can be given properly and without undue exposure to the patient. I never give it late in the disease.

A good method is to get the patient into the tub, lay two canes or sticks across the tub, and cover all with a blanket or rug. Place a bath towel for the head to rest on and pull the blanket around the neck. The patient can then take a good hot sweat in comfort. His arms and shoulders, his knees and legs will not be exposed to chill. When he gets up the blanket can be drawn about him if desired. He then goes back to bed for a good rest and sweat. A cold towel is placed on the head and water given to drink.

Every patient should have a good sweat early in the attack. Another good method is to cover with a blanket and place outside fruit jars or jugs filled with hot water, cold towel to the head and several glasses of water or lemonade to drink.

The use of cold compresses on the chest I do not favor. They are used by some osteopathic physicians, but I believe the result is better with other methods. Applied in a hospital where the technique is well in hand they might be successful, but personally I fear them. I am even careful about putting an ice bag on the heart. Cold packs are sometimes used in my practice but only on the head for pain or delirium. Chill must be avoided. Warmth must be conserved, even the fever is benign.

Neither do I favor “rub-on” of camphor, turpentine or onions when they irritate the patient. If the patient has been used to them or has faith in them and wants them I order them. I also order something of the kind where “something must be done”. When a family calls a doctor they “want something done,” and it is best to do something; ever keeping in mind, however, that our patient’s strength must be conserved.

I do favor “rub-ons” in that I think it is well to keep the skin soft with some oil. It helps to keep an even temperature and the skin active. The skin should be wiped dry often, however, to remove the skin secretions which if left on become stale.

I remember being called to see one little girl who could not get her breath, and found she was holding her nose with the bed clothes. She told me that the smell and stickiness of the lard and turpentine and the onions made her so sick and uncomfortable that she felt she could stand it no longer. When she was cleaned up, and clothed in nice clean white cotton she showed a wonderful improvement, and it was real as well as apparent.

As to =baths= in influenza, I instruct the nurse to bathe the patient only as necessary for cleanliness and his comfort. Dabbling around in water is not a safe procedure in a disease where pneumonia is so easily contracted.

I do not use alcohol rubs where the patient is in anything like a serious condition, as alcohol closes the pores and dries out the skin. A rubbing or massage by the nurse is good for a restless, nervous patient, but it had better be done with olive oil or some other good oil. In influenza we do not want the pores closed. We need elimination, and all we can get. A small saving of vitality or a little elimination of toxins may be the margin that saves a patient for us. I do not favor the use of turpentine, for if it is absorbed it irritates an already sick kidney; if it is not absorbed it is useless. Why disturb the patient?

For the bronchial irritation, in addition to osteopathic treatment, and the accessory mustard plasters, inhalation of steam is often used. A pan of boiling water is set by the bed and the patient leans over the edge of the bed with a bed-sheet or paper over the head and steam vessel, breathing the steam as long as it lasts.

For the =throat= most any cleansing gargle can be used but I prefer the use of the common baking soda gargle. I have about one-half teaspoonful of soda placed in a glass and boiling hot water poured over it. As soon as this is cool enough to use I have the patient gargle thoroughly. The idea is to get the mouth, pharynx and tonsillar area clean and free from accumulations. Lemon-water gargle is often gratefully accepted.

If a very sick patient breathes through a dirty and dried-out mouth, all the stage is set for him to draw into the devitalized lung large quantities of infectious material. For this reason if not for the comfort of the patient it is necessary that the mouth be kept clean and also moist.

It is not possible to kill this germ life with any antiseptic. The field must be made and kept clean.

The =nasal passage= also should be looked after, to keep it clean as possible and also to allow the patient to breathe through the nose.

For the nasal passage any good non-irritating oil is effective but I like best 2½ iodine in oil. It is a good lubricant and as far as possible we do get the germicical action of the iodine.

Patients asking me what to do to avoid influenza are advised to keep the mouth clean and closed and to use the oily solution of iodine in the nasal passages.

And when treating the respiratory tract we must keep in mind the fact that all healing comes from the blood side of a membrane. No healing ever comes to a membrane from its exposed surface. Local treatment to a membrane must be a treatment which removes irritation, not one which adds more. Healing must come from within. “The rule of the artery is supreme.”

=Diet.=—The diet used is liquid, so that the digestive functions will be taxed as little as possible, for they are weak at this time. Fruit and vegetable juices only are used.

The influenza germ propagates largely in the intestine and if the intestine has in it the products of a full diet the bacterial growth soon overpowers the patient. Germ life cannot develop on fruit and vegetable juices.

Another reason for using the liquid and fruit diet is that influenza is a disease running a short course and feeding is not necessary. If it were a disease such as typhoid, running a fever for several weeks, we would then give a more liberal diet, but the patient’s strength will not be lost on a liquid and fruit-juice diet in three or even eight days.

The frequency with which the urine contains albumin in this disease shows us what a heavy load the kidneys are carrying. This makes a salt-free diet advisable and again brings fruit juice to our favorable attention.

To activate the kidneys and thus relieve the headache we give always plenty of water and often hot lemonade. Orange juice and lemonade are used frequently as are blackberry, raspberry, pineapple, loganberry and grape juices. When the acid juices are not well borne we use non-acid juices, such as pear and raspberry juice. A ripe, cooked pear mashed with a fork and mixed with one or two different fruit juices makes a satisfying dish.

Bottled sweet cider is also a most valuable food and a good beverage. We use it in almost every case and find it the most acceptable to the patient of any food offered. I am of the opinion that apple cider has been neglected as an article of diet, both in disease and health, but especially in fevers. It contains considerable iron for the blood, as well as having considerable food value. It has the added virtue of being pleasing to the patient.

In addition to these juices we often use spinach juice. I have the nurse get a can of the best grade spinach and serve the juice hot, as a broth, with a little salt and pepper and perhaps celery salt and a piece of bacon in it to flavor it and to appeal to the patient. Spinach juice contains much iron and iodine in a form readily absorbable by the blood. It also is useful in maintaining the alkalinity of the blood and body fluids, thus counteracting the acidosis of the disease. It renders the urine alkaline and thus relieves the kidneys of the irritation of acidosis and of an acid urine. Where the kidneys are or are likely to be involved the spinach juice must be served without salt.

All the mentioned fruit juices tend to counteract acidosis and produce alkalinity, but are not so effective as the spinach juice. They have the advantage, however, of being used in larger quantities. The spinach juice has considerable food value and has the added value of appealing to the patient’s reason, when the iron and iodine content is explained to him. It is especially useful when treating those patients who are wondering if they should not be getting some sort of “tonic.”

The juice taken from ground fresh lettuce is also valuable. It contains more iron, iodine and phosphates than the spinach but it is not so easy to prepare. I have used it in the cases of several anemic and quite sick babies and consider it well worth all the expense and effort it took to secure it.

The breaking down of the alkaline reserve of the body and the consequent acidosis, comes early in the disease and is disastrous, and all the attention given to the diet is amply repaid in results. Careful attention to the diet is the only way the acidosis can be overcome.

Raw fruit and vegetable juices also supply that most valuable element, vitamines. For this one thing alone is the raw fruit juice most valuable. I do not believe too much attention can be given to securing a liberal supply of vitamines for the body, especially during an attack of fever.

Some especially interesting points are brought out by contributors to the Journal of the American Osteopathic Association in the March, 1919 number. I wish here to add a discussion of these points. The contributors are physicians and good representatives of our profession and they report uniform and excellent success in handling the recent epidemic.

It seems to be the consensus of opinion that the treatment should be specific and light to avoid fatigue, with the possible exception of the first treatment, which often should be general and vigorous.

All are agreed that the patient should be kept in bed, not even leaving it to go to the bath room. The patient must be protected in every way from fatigue and exposure. The enema was used by all. A number of writers state plainly their opposition to the use of physics and laxatives. A hot tub-bath is recommended by several, but there is opposition to much bathing.

Practically all the writers used the fruit-juice diet. However, a few gave a heavier diet and were successful with their patients, which is one more proof that the osteopathic treatment is the deciding factor in bringing about a cure.

J. R. Thornton wrote after having had about 100 cases. He speaks especially of his cases of pneumonia. They resolved by crisis. There were no deaths. He says: “All cases were, preceding the first treatment, given a generous plain water enema. Orders were left for two enemas per day until told to discontinue, and in most cases the patient got the enema. A few cases, with the highest fever, the stationary fever, were given tap-water enemas, one each hour until the temperature dropped two or three degrees.

“Sponge baths were given to reduce fever in every case. Diet was liquid until the temperature was normal.

“The osteopathic treatment of the usual spinal work, paying special attention to cervical and dorsal areas, and strong inhibition.

“Pneumonia cases were treated three to five times a day and had as much time as they required at each visit. They required action. Heating compresses were used on each case, except the ice bag to the heart when rapid. One case of delirium was treated with ice caps to the head and neck. Normal salt solution per rectum. Murphy drip was given in each case. Diet, liquid consisting of egg-nog, milk, strained soup and broth.”

Mary Alexander Patton: “Treatment should be quick, every motion significant so as not to tire the patient, for exhaustion is always present. Each patient was treated two or three times a day until temperature became normal. The nasal douche was given twice a day followed by K-Y jelly. Hot soap bath followed by soap enema and enteroclysis when fever persisted.”

W. Curtis Brigham ordered “Hot packs the full length of the spine twenty to thirty minutes, three times a day. This will produce profuse sweating and often put the patient to sleep.”

I have used this same treatment, especially in nervous cases, and hold it in high esteem. I have the patient put a bath robe on backwards so that the arms and legs are well protected but the spine easily accessible. The hot packs can then be used and covered over and the patient not exposed.

R. H. Nuckles maintains that lung and ear trouble will not follow influenza where osteopathic treatment has been given to adjust the cervical and upper dorsal circulation.

H. A. Price: “We have kept particularly in mind, first, the nerve, blood and lymphatic supply to the lungs; second, the circulation to the spine (meaning spinal cord); third, the internal secretory functions and to the general excretion.”

Ralph M. Crane says: “A great deal of my work is among the Italians. It was necessary to give quick specific treatment that I might do as much good as possible to the greatest number. I did not treat them as often as I would like to, and because of this fact I learned that osteopathy got control of the ‘flu’ immediately, the first treatment sufficing to start them on the road to recovery; in fact, many of them got no more than one treatment.”

FOOTNOTES:

[51] Hinckle—The Scientific Basis of Osteopathy.

[52] Clinical Osteopathy.

[53] Journal of Osteopathy—Prize Article July, 1906.

[54] A. O. A. Case Reports—Series I.

[55] E. Link, Diphtheria—The Bulletin, 1905.

[56] A. M. Willard, Membranous Croup—Journal of Osteopathy, March, 1904

[57] See Dr. Still—Philosophy and Mechanical Principles of Osteopathy.

[58] Journal of Osteopathy, October 1905.

[59] Journal of Osteopathy, October 1905.

[60] Journal of the American Osteopathic Association, March 1906.

[61] Journal American Osteopathic Association, December 1904.

[62] Journal American Osteopathic Association, May, 1905.

[63] Journal American Osteopathic Association, May, 1905.

[64] Rewritten from article in Osteopathic Physician, June 1919.

[65] This treatment was described by Henry M. Stovel, in The Osteopathic Physician of January 1917.

[66] O. P. June 1919.

ACUTE ERUPTIVE FEVERS, MUMPS AND WHOOPING COUGH

By EDGAR S. COMSTOCK

GENERAL CONSIDERATION

In the consideration of these diseases, it is well to bear in mind that lowered resistance is the primary condition that has made the infections possible, and that lowered resistance implies an imbalance of or obstruction to the vital fluids and forces of the body, thereby interfering with the functional activity of the body’s normal protective mechanism.

The imbalance of or the obstruction to these vital fluids and forces, which is structural in nature, is produced by many conditions, as fatigue, exposure, sudden changes of heat and cold, emotions, dietetic errors, physical force or violence, etc. These conditions, because of the response of the tissues of the body to environmental changes, produce contractures of the elastic tissues, such as muscle, fascia, etc., which disturbs the structural integrity of the body and thus produces obstructions, irritations or interference with the media of exchange of these vital fluids (blood and lymph) and forces (nervous energy) of the body.

It is evident, then, that the most potent curative factor in the treatment of these diseases, as in all others, is the removal, whenever possible, of the obstructions and interferences that pervert the activity of these protective forces. It is necessary, therefore, to remove the exciting causes (fatigue, dietetic error, etc.) and by such physiological means as may seem necessary to readjust the structures of the body so as to remove the above mentioned obstructions and interferences.

The structural lesions most frequently found in the infectious diseases are of the muscular and fascial type and are very evident to the careful observer. The interosseous lesions are probably often the predisposing factors to the susceptibility of the softer tissues to reaction to environmental changes, but it has been the experience of the writer that the adjustment of the softer tissues was of greater primary importance in the acute stages of these diseases. The interosseous lesions may be easily adjusted in the very early stages of these diseases, that is before the severe symptoms have appeared, but after the more severe conditions have appeared it has been our experience that the soft tissue work was sufficient unless the interosseous lesions were very easily adjusted.

It is the writer’s desire to impress upon the reader the necessity of careful attention to the structural lesions that are always constant in these diseases, using whatever physiological means seem necessary to adjust these lesions and keep them adjusted, and to insist upon carefully restricted diet; continuous, thorough elimination of the waste products of the body; hygienic surroundings and well-regulated environments both mental and physical. Then Nature, which has given the body its own protective mechanism, may have full control of the situation and all of the normal protective chemicals and forces in the body organism are utilized in the battle with the invading infective forces: the glands secrete the chemicals of protection; the antibodies are rapidly developed and thrown into the battle area; metabolism begins to return to normal; elimination becomes increased because of the stimulating action of foreign substances in the body structures; and the work of repair and recuperation begins.

If reliance is placed upon the inherent protective forces of the body, the knowledge of the special type or character of the invading organism is of little importance from the standpoint of the treatment of the disease after it has become established. The value of the knowledge of the specific organisms is in preventive medicine, in seeking out the habitat and breeding ground of the organism and its mode of transmigration. Knowing these, effective measures may be adopted to prevent their propagation and spread. Examples of this are Yellow Fever and Malaria.

Variola

(SMALLPOX)

=Definition.=—=Variola= is an acute, specific, highly infectious and contagious, epidemic disease. Its beginning is sudden with a chill, vomiting, severe headache and lumbo-sacral pains. It has a typical fever curve and a typical eruption on the skin and mucosæ of macules, papules, pustules and crusts successively.

=History.=—Prevailed in China and India at least 1000 years before the Christian era. Epidemics occurred in the sixth century and during the crusades. Its first clinical description was given in Arabia during the ninth century. It was brought into Mexico about 1520 by the Spaniards and between three and four million people contracted the disease. In 1718 preventive inoculation was introduced into England and in 1796 Jenner discovered vaccination.

=Etiology.=—The specific agent which is the cause of this disease is unknown, but the virulence of the agents is retained for a long period and is the most virulent found in all diseases. There is no period from the initial fever to the final desquamation that the disease is not contagious, although the stage of suppuration is the most violent. Although the disease is so highly contagious and the entrance of this particular poison into the system produces this disease, still no one has yet been able to discover a germ nor what the nature of the infective agent is. To contract the disease it is not necessary to touch an individual already afflicted, not to even approach the sick room. It may be only necessary to touch a garment that has once been in contact with a smallpox patient, or which has simply hung in his vicinity.

The blood is infectious at a very early stage. As smallpox is contagious without eruption it seems that the secretions and excretions convey the virus. The dried pustules seem to have the greatest infectiousness. Cadavers of smallpox (Variola) victims are very dangerous and relatives of them should be carefully warned. The disease often persists in infected communities for years. The disease is evidently spread by fomites, contact with the pustular contents, and crusts or scales of the desquamating skin. It attacks all classes, ages and conditions of people, which is unlike other erythematous diseases.

A previous attack usually confers immunity. Vaccination is claimed to confer immunity but apparently in not all instances, for there are records of “successfully vaccinated” individuals having severe attacks of the disease.

The susceptibility to smallpox, as to all other infectious diseases, varies in different individuals, in different races, and under the influence of conditions as yet unknown. Some persons are not susceptible to the disease, nor are they to vaccination, and yet others have been known to have had the disease as much as three times. The Negro and Indian races seem to be more susceptible than the Caucasian. Then again at intervals of a few years, the general susceptibility of the people seems to be increased so that cases of smallpox become far more numerous than usual.

A point of considerable interest is the fact that the child, while in the mother’s womb, may experience the disease along with the mother and thereby acquire, before birth, the usual immunity conferred by one attack of the disease. In most cases of smallpox in pregnant women, abortion or miscarriage occurs, yet a sufficient number of instances are on record in which healthy children have been born, exhibiting the characteristic pitting of smallpox, and possessing no susceptibility to vaccination. Again there are other cases in which pregnant women have smallpox and the babes in the wombs have escaped entirely; while the most singular fact is that while the fetus may experience the disease, the mother through whom the exposure was effected, escapes, either because of a previous attack or possibly because of vaccination.

While there seems to be no reason for believing that an attack of smallpox can be, or ever has been, aborted by artificial means, yet there is a prevalent belief that this process occurred during certain epidemics of smallpox, cases having been known in which individuals presented all the symptoms indicating the invasion of smallpox, and yet no eruption occurred, and yet such individuals were thereafter insusceptible to smallpox or vaccination.

The mortality of smallpox varies like the susceptibility of it—with the age of the patient and with some unknown conditions of the atmosphere or soil which favor the occurrence of the epidemics. The average in scattered cases—sporadic—is probably not greater than one in nine or ten. A fatal result occurs more frequently in the second week of the disease than at any other time.

=Pathology.=—Granular and fatty degeneration occurs in the liver, spleen, kidneys and heart. Infiltration is found in the adrenal glands and testicles. During the papular stage, there is local hyperemia of the papillæ, with interstitial exudation and colliquative necrosis of rete cells, so that a vesicle is formed, peculiar in that it is traversed by delicate bands of epithelial cells. This, with the fact that coagulation-necrosis occurs mainly in the center, gives it the umbilicated, or depressed appearance. The contents of the vesicle are plasma, fibrin and cell detritus. Leucocytic invasion converts vesicles into pustules. This has a more globular, elevated appearance than the umbilicated vesicle. Pyogenic organisms are found in the pus. When the inflammation injures the corium, scars are apt to result; this occurs when the skin is scratched. The actinic light rays increase the danger.

=Diagnosis.=—Mistakes in the diagnosis of the first cases of smallpox in an epidemic are almost inevitable. Hemorrhagic scarlatina or measles sometimes cause confusion; in the hemorrhagic scarlatina the mucous membrane hemorrhages are less frequent than in smallpox. The prodromal eruptions plus purpura are very suggestive. The invasion stage lasts about three days.