During the chilly stage thorough treatment of the vasomotor nerves in the upper cervical, the upper dorsal, the lower dorsal and the lumbar regions is indicated; this treatment is given to equalize the vascular system.
During the hot stage the same treatment as in the chilly stage should be given to control the vascular system; besides a thorough treatment of the spleen and liver is necessary. Sponging the body with water will be of some aid in reducing the temperature.
During the sweat stage thorough inhibition at the superior cervical ganglion to control the sweat center of the medulla, and treatment at the upper dorsal and first lumbar to control auxiliary sweat centers are indicated.
The bowels should be kept active. When in a comatose form and when internal temperature is high, place the patient in a bath. In chronic cases, change of climate with thorough systematic treatment will usually result in recovery.
Tete[53], of Louisiana, makes the following interesting statement: “A specific osteopathic treatment given within an hour before the expected chill is a specific cure for malaria.” He follows this up by treating on the third, fifth, seventh, fourteenth, and twenty-first days, on account of the tendency of the return of an attack on those days. His observation of the value of treatment just before the attack is borne out by a report by Teall[54] where the case was cured in one treatment, but the lesion was as high as the fourth dorsal. N. Chapman confirms this as being her experience in many cases. The spleen has been observed by Bandel to become engorged and upon emptying there would follow a rise of temperature of one fourth to half a degree. This has also been spoken of by Tucker as the “splenic wave.” Ligon makes the statement that where the osteopathic lesion (the predisposing cause) has been of long standing prior to the attack, and as a consequence hard to correct, it is difficult to shorten the malarial attack.
This would emphasize the point that the essential treatment must be a thoroughly readjustive one, and that stimulatory and inhibitory work can only palliate. This is borne out by several practitioners who have had considerable experience. Very satisfactory results follow adjustment of the seventh to tenth dorsals.
Quinine has been accepted by medical authorities as a specific for malaria. It is supposed to act directly upon the intracorpuscular hematozoa. That it is not infallible is shown by the numerous cases which come to the osteopath, suffering from both the disease and the quinine. And even drug authorities state that other treatment is also required. It has remained for Dr. Still to demonstrate that excellent results follow osteopathic treatment in malaria. Frequently a single treatment has been sufficient to free and regulate the body fluids and forces so that the parasite was rendered inert, and this treatment was directed chiefly to the fourth and twelfth dorsals. Whereas the osteopath recognizes and appreciates the importance of micro-organisms as exciting and determining factors in many diseases, still he values them as secondary factors only and relies primarily upon removing the predisposing and true etiologic factors, so that nature’s forces may not be obstructed and thus predominate. Osteopathic etiology and pathology has shown so conclusively, in a large number of cases, that the existence of micro-organisms is dependent upon devitalized tissue, whether the tissue is a local one or a circulating one, as the blood; and just so soon as the anatomical is adjusted the physiological will function and antitoxic and antimicrobic substances are secreted.
“When the patient has the quartan parasite, as soon as the temperature begins to fall I give him from two to six ounces of red meat juice, extracted from rare beefsteak, sometimes as much as five pounds in the first twenty-four hours following the chill. In almost all cases of quartan malaria the blood is built up sufficiently by the time they reach the second cycle to pass without the paroxysm, or chill. By the time for the third cycle, which is the seventh day, I always have built up the patient’s resistance so as to enable him to pass by this cycle without any symptoms of malaria whatever. In cases of double or triple I find the same treatment causes about the same results. I do not give any other diet, except dry toast if they eat the beef instead of taking the juice. If they can take the steak I prefer their taking it, but almost all cases prefer the juice. * * * The treatment for the tertian type of malaria is practically the same as the treatment for the quartan.
“The estivo-autumnal type of malaria differs from the quartan and tertian types; first, in that the paroxysms are, as a rule, much more irregular; second, they are much longer in duration; third, the chills are more frequently absent; fourth, the fever is often irregular, intermittent, remittent, or continuous in character. This type very often takes the form of blackwater or hemoglobinuric type with hemorrhagic symptoms, with hemorrhage from nose, gums, and bowels. The first thing to do in a case of hemorrhagic malaria is to put an ice bag on the abdomen, which will tend to control the hemorrhage from the kidneys. Give the patient all the red beef juice you can get him to take, provided he has not developed a very sick stomach; if so, give him high saline enemas and in one-half hour give him four ounces red beef juice per rectum. Repeat the feeding per rectum in four hours. As soon as he can retain anything on stomach give him all the juice he can take comfortably. Treat the liver thoroughly—at least three times in the first twenty-four hours. At the end of thirty-six hours the yellow cast will be very much lighter, which is a sure sign that the patient is getting better. Watch the urine closely. The third day there may occur a suppression. If so, give strong stimulation to the renal plexus through the abdomen, and be sure there is a thorough relaxation of the dorsal and lumbar muscles.
“It is an established fact that people in the malarial districts eat very little beef. I find that ninety-nine per cent of the cases of malaria never eat it, or when they on rare occasion do, it has been so overcooked that all the blood-building substances have been destroyed. The beef raw would be better in my opinion; although, the possible chance of getting a tape-worm or animal parasite is so considerable that I would advise that the beef should be heated to 250 degrees.”—E. C. Armstrong, Clinical Osteopathy.
Septicemia
This term is applied to any toxic condition caused by the invasion of the blood by pathogenic micro-organisms, with or without any visible site of infection.
Etiologically, the micrococci, streptococci, pneumococci, or staphylococci, as to frequency, in order named, are the cause. The infection is usually introduced by a wound, of any degree of severity. The uterus is a frequent seat following miscarriage, parturition or operation. The virus may be absorbed by the mucous membrane. It may also arise from infection of the deeper tissues. Pathologically, the changes are not marked, but consist in brownish color of the muscles, ecchymotic spots in the pia mater and dark appearance of the blood, which is also less coagulable. Spleen, liver and lymphatics are enlarged with some changes in the other organs.
Symptoms.—The incubation period is from four to six days and the onset is gradual, though often announced by a distinctive chill, followed by a profuse sweat. The most common type is the continuous form of fever, which may, in morning remissions, become subnormal. Pulse is rapid at the beginning, but as cardiac failure comes on, it becomes weaker. In the earlier stages there may be vomiting with diarrhea later. There are punctiform hemorrhages of the skin and possibly other eruptions. Blood examination will settle any doubt as to diagnosis.
Prognosis is good in large percent of cases and depends upon the general health of the patient.
Treatment.—“Incise and drain the infected part; if possible, apply hot boracic acid compresses or keep part suspended in hot boracic acid solution. Osteopathic treatment will aid materially in stimulating and strengthening the patient. Bowels, kidneys and skin must be kept active. Normal salt solution, hypodermically or per rectum is of value. Diet should be liquid, fruit juices, broths, soups until temperature has remained normal twenty-four hours then milk, eggs etc., in gradually increasing amounts until general diet is restored. Amputation of the part may be necessary.”—L. E. Browne.
Pyemia
A febrile disease arising from an invasion of the blood by pathogenic bacteria, wherein sepsis and multiple abscesses occur from absorption and metastasis.
Etiologically, the cause may be traced to various specific organisms which enter the blood stream and produce thrombophlebitis. From these points and from other bacteria, new foci are established. Occasionally the lymphatics carry the germs. The disease may also start from ulcerative endocarditis or when the appendix is infected.
Pathologically, thrombosis of the vein may take place in any region. Abscesses may form in the lungs, liver, spleen or other internal organs. The small abscesses may unite and form a large one. The skin presents eruptions and hemorrhagic extravasations, while there may be ulcers of the mucous membrane, also the serous surfaces may be purulently inflamed. The muscles, subcutaneous and osseous tissue occasionally have abscesses. Ulcerative and suppurative heart lesions occur.
Symptoms.—The incubation period is short. There may be slight fever, but commonly a chill is the first symptom, which may reoccur for some time. The fever is either remittent or intermittent and when the temperature is low, sweating is a feature. The pulse becomes rapid and weak, when the disease is severe; breathing becomes difficult. Skin symptoms, such as eruptions and pustules, generally occur. In a word, there is a general intoxication. There is a lessened number of red blood corpuscles and leucocytosis is a characteristic. In grave cases, delirium and coma are present.
Diagnosis.—The history of the case and symptoms will usually render diagnosis easy, although care is necessary to determine from septicemia. Malaria, typhoid and acute tuberculosis must be excluded.
Prognosis.—Much depends on asepsis and surgery but on the whole it is unfavorable.
Treatment.—Surgical interference and treatment as outlined under septicemia is the only hope.
Dengue
(Breakbone Fever)
Definition.—An acute infectious disease; characterized by a double febrile paroxysm, severe pains in the muscles and joints and sometimes a skin eruption.
Etiology.—It is a disease of tropical and subtropical regions. Unhygienic conditions predispose to an attack. During an epidemic a single attack is the rule. The disease spreads from place to place along the lines of travel, attacking both sexes, and all ages. It occurs in epidemics, practically affecting every one. The specific germ has never been isolated as it is probably ultra-microscopic but there is no doubt but that it is carried by the mosquito Culex fatigans.
Symptoms.—The incubation period lasts about four days. The onset is abrupt with a slight chill, headache, and extreme pain in the joints and muscles, of a boring or breaking character. The joints become red, swollen and painful. The fever rises gradually to 103 or 106 degrees F., or over. The pulse is rapid and full and the respirations are much quickened. The face is flushed, the tongue coated, the appetite is lost, and slight nausea occurs. “Black vomit,” similar to that of yellow fever, has been observed in this disease. Hemorrhages from various organs may occur and the lymphatic glands are swollen. The urine is scanty and the bowels constipated. Febrile albuminuria and delirium are rare.
At the end of three or four days the temperature falls and there is a period of remission; the patient is free from pain, but profoundly prostrated. During this time the eruption generally appears, but is never constant in character. After a remission of two or three days, the symptoms reappear and a second febrile paroxysm sets in. This is usually milder and shorter than the first, lasting two or three days, when convalescence begins. The duration is, according to medical writers, from seven to ten days, and convalescence slow. Death seldom occurs, so practically no pathological changes have been recorded. By osteopathic treatment, E. B. Ligon has been able to confine the attack to four or five days duration; this is confirmed by the experience of N. Chapman.
Diagnosis.—During an epidemic the disease attacks all classes alike, and the distinct remission renders the diagnosis comparatively easy. An occasional case might be mistaken for acute rheumatism, but the absence of any glandular swelling or eruption, while the pain is more closely limited to the joints, will aid in the diagnosis. Care has to be taken that yellow fever is not mistaken for dengue.
Treatment.—The indications of the treatment are to maintain the patient’s strength and to treat the leading symptoms as they arise. The severity of an attack can probably be lessened at the start by strong and thorough treatment of the suboccipital, upper dorsal, lower dorsal and lower lumbar regions, respectively, so as to control the large vascular areas by means of the vasomotor nerves of the cranial region, of the lungs, of the splanchnic region, and of the lower limbs, thus equalizing the entire vascular system. Elimination should be pushed and the excretory organs stimulated. Ligon has observed that the cervical and lumbar regions are especially tender on the second day and the lower dorsal region on the third day. The most severe symptoms disappeared within a few hours after treatment and the attack was markedly shortened.
The high fever may be treated by the usual methods and by the external application of cold water. The pain is to be controlled, according to the region affected, by a correction of parts impinging upon the nerve tissues and by strong inhibition. The entire spinal region should be kept constantly in a relaxed condition, as far as muscular contractions are concerned. Particularly should the treatment be extensive along the spine during prostration. N. Chapman, in addition to the osteopathic treatment, has the patient drink considerable hot water; also employs the hot bath. The treatment frequently shortened the attack. During the entire attack of the disease, the patient should be kept in bed and a carefully regulated diet administered. Relapses are not infrequent. A suitable change of air may hasten convalescence.
Cerebrospinal Meningitis
Definition.—A specific, infectious disease caused by the diplococcus intracellularis meningitidis, occurring sporadically and in epidemics. It is characterized by inflammation of the membranes of the brain and spinal cord and an irregular course.
Osteopathic Etiology and Pathology.—The specific exciting cause of the cerebrospinal meningitis is due to the diplococcus intracellularis meningitidis of Weichselbaum. Lesions are found in the vertebræ corresponding to the cervical and dorsal enlargement of the cord, as well as in corresponding deep muscles; also, as is well known, the muscles of the entire back are severely contracted, especially of the cervical, upper and lower dorsal regions. More commonly it attacks the young, although it may occur at any age. Overexertion, exposure, overcrowded and illy-ventilated buildings, barracks and tenements, and depressing mental influences are predisposing causes. Many times the disease occurs among the poorer classes. Sometimes the disease prevails in the country rather than in the city.
In cases that prove speedily fatal there may be no characteristic changes; simply marked congestion. Other cases in which death occurs after the disease has been fully developed, there is found every degree of inflammation from slight hyperemia to suppurative changes. There can be no doubt that the osteopathic lesion, as vertebral and rib lesions and deep muscular contractions, affects the circulation of the meninges of the brain and cord and thus favors the invasion of the specific micro-organism. The arteries, veins and sinuses are greatly engorged. The walls of the ventricles soften and the ventricles contain serous exudate. The brain matter may be congested and softened in spots. In the spinal membranes similar changes take place and at times there is extravasation of blood. The changes are more marked on the posterior than the anterior surface of the cord. Abscesses sometimes form. The exudate may follow the lymph sheaths of the cranial nerves, especially the auditory and optic. In long standing cases the membranes become thick and adherent and areas of softening or atrophy of the cortex develop. The thickening and adhesions of the membranes may cause various symptoms for months or even years after recovery from the acute disorder.
The spleen may be normal in size, but when the fever has been intense, it is apt to be slightly enlarged. Bronchitis, pneumonia, endocarditis and pleurisy may occur. The liver may become hyperemic and the kidneys congested.
Symptoms.—The prodromes vary, although the onset is apt to be sudden with a decided chill; headache; vomiting, and pain in the neck and back, which is usually severe, but may be so slight as not to be noticed by the patient. The temperature rises to 101 to 102 degrees F., in most cases. However, it may rise to 105 degrees or 106 degrees and even to 108 degrees in fatal cases, and the pulse is full. Hyperesthesia, photophobia, and dread of noise are apt to be prominent symptoms. The muscles of the neck and back become rigid, and there are pains in the limbs. Orthotonos occurs more frequently than opisthotonos. Convulsions are common in children. There may be paralysis, especially of the muscles of the face and eyes. Delirium usually appears early; it may be mild, but it is often maniacal. The bowels are usually confined, though there may be diarrhea. There is moderate and constant leucocytosis and jaundice has been met with.
The urine is sometimes albuminous, and sugar has been noted in rare cases. The urine may be increased, but more often it is lessened as in other infectious diseases.
Herpes facialis occurs shortly after the onset in more than half the cases. The contents of the vesicles may be purulent and one or two may coalesce. The petechial eruptions are occasionally numerous and cover the entire skin; they do not disappear upon pressure and the number of spots varies greatly. Other eruptions as sudamina, ecthyma, pemphigus, urticaria, erysipelas, rose colored spots, and gangrene of the skin (rarely) have been met with.
In cases that are rapidly fatal, the onset is sudden, usually with violent chills, headache, depression, and in a few hours coma and collapse, which are soon followed by a fatal termination. The temperature may rise slightly, but it is often subnormal. The pulse is feeble; breathing is labored. These cases occur more frequently at the beginning of an epidemic. They occasionally occur sporadically.
The abortive form terminates abruptly after the development of one or more pronounced, characteristic symptoms.
The mild form can only be recognized during the prevalence of an epidemic. The symptoms are very mild; slight vomiting, little or no fever, headache and slight pain in the back and limbs.
The intermittent form is characterized by increase in the fever every day or second day. The strict periodicity seen in malaria is not observed; the fever resembles that of pyemia.
In the chronic form the condition may persist for weeks or months.
Complications.—Pneumonia (lobar and lobular) is a frequent complication. Pleurisy, pericarditis, parotitis, arthritis, enteritis, optic neuritis and otitis media may be other complications.
Sequelæ.—Blindness, deafness, keratitis (rarely), persistent headache, chronic hydrocephalus, abscess of the brain, mental feebleness, defective articulation, aphasia, and paralysis of certain cranial nerves or of the lower extremities have occurred.
Diagnosis.—Typhoid fever begins slowly and is unaccompanied by vomiting, muscular spasms or rigidity, or hyperesthesia. In typhoid the fever is higher and there is a characteristic temperature curve. Widal’s test will confirm.
Tubercular meningitis is not epidemic and has no characteristic eruption. It is usually less sudden in its development and is invariably fatal. Retraction of the neck, muscular spasms of the legs and arms are not so marked as in spinal meningitis.
Pneumonia may be complicated with meningitis, especially when the meningitis is confined to the cerebrum. If the case is not seen early, it is almost impossible to say which is the primary affection, as pneumonia may have meningeal complications or cerebrospinal meningitis may be associated with pneumonia. There will be motor spasms and tremors, but the head is rarely retracted, and there is less myalgiac pain than in cerebrospinal meningitis.
Prognosis.—This varies according to the severity of the type. It is a grave disease. Cases have been treated successfully by several osteopaths. The duration is very variable—from two or three days to weeks or even months, but probably in all cases this time can be materially shortened by judicious osteopathic treatment. Convalescence is very slow and relapses are prone to occur.
Treatment.—The osteopathic treatment of cerebrospinal meningitis requires most thorough, but very careful, work along the spinal column, especially the cervical region and the region of the dorsal enlargement of the spinal cord, in relaxing and keeping relaxed the deep muscles on either side of the spine and correcting the derangements of the vertebræ, particularly in the upper cervical spine. Such treatment has a marked effect on the circulation of the spinal cord and brain. Probably, a large amount of the work along the spine, in all cases where muscles are relaxed, has a direct effect upon the circulation of the spinal cord. This treatment constitutes the primary osteopathic work in cerebrospinal fever and should be frequently applied until a cure is obtained. Even in chronic cases where limbs have been greatly affected by pressure upon the nerve centers, due to a thickened membrane, continued osteopathic treatment along the spine has had a marked effect in absorbing the pathological condition and restoring strength.
The preceding spinal treatment is also a very great safeguard in keeping the various viscera healthy and thus preventing complications. In all constitutional diseases of an acute nature, it is a wise precaution to thoroughly examine the entire length of the spinal column at each visit; and if such precaution is taken many serious complications will never occur that might otherwise have taken place.
The patient should be isolated in a somewhat darkened room, and care taken that the disease is not allowed to spread. Keep the patient upon his sides as much as possible. The diet should be a nutritious one of milk and broths. They should drink freely of water. Cold to the head and spine will be of service in controlling the inflammation; it should be applied with an ice-cap and a spinal ice-bag. Sponging the body should be employed if the temperature is above 102° F. The general bath, as in typhoid fever, may be employed if practicable. Direct treatment to the bowels, kidneys, liver and spleen should be given at each treatment.
Lumbar puncture and the Flexner-Jobling serum are considered of value by those who have had an extensive experience.
Diphtheria
Definition.—An acute, infectious disease, caused by the Klebs-Loeffler bacillus, and characterized by a membranous exudation on the mucous membrane of the fauces, larynx or nose, and by constitutional symptoms. The presence of the Klebs-Loeffler bacillus distinguishes true diphtheria from any other form of membranous inflammation. The term diphtheroid is applied to all such forms as are not due to the Klebs-Loeffler bacillus.
Osteopathic Etiology and Pathology.—The exciting cause is the Klebs-Loeffler bacillus. The predisposing cause is obstruction to the circulation of the pharynx and tonsils by subdislocations of upper cervical vertebræ, and even the lower cervical and upper dorsal, and severely contracted deep muscles of the neck. The stasis of blood favors the growth of the bacillus.
Link[55] says: “The cause of nasal, pharyngeal or laryngeal diphtheria is obstruction of the blood and lymph through the neck and the obstruction occurs as a result of lesions in the cervical region, affecting the cervical sympathetics, or lesions in the upper thoracic region whence the vasomotor fibers arise. A derangement of the vertebral articulation of the first rib is usually found. (This affects the stellate ganglion and fibers of the sympathetic chain). These lesions cause a condition of lowered vitality of the mucosa of the nose and throat; the abnormal secretion favoring the rapid multiplication of the Klebs-Loeffler bacillus—the exciting cause of the disease.”
Dr. Still believed that, among other lesions, contracting of tissues involving the scaleni and disturbing the relations of the first rib with the clavicle and vertebra are causative factors. The constitutional symptoms are produced by the toxins generated by the bacillus and absorbed from the diseased spots by the lymphatics and blood-vessels. The bacillus is non-motile and does not usually penetrate the mucosa, but remains very near the site of the local changes although there are instances where it may enter the blood and other tissues. The bacillus is very resistant and can maintain an existence for months outside of the body. There is great variation in the virulence of the Klebs-Loeffler bacillus; it has been found in healthy throats, and sometimes the bacillus may exist in the throat after an attack of diphtheria for months after all the membrane has disappeared. It has also been found in cases of simple catarrhal angina without membrane, and in simple tonsillitis Of the bacteria associated with the bacillus of diphtheria, the streptococcus pyogenes is the most common and probably the most active. The staphylococcus, micrococcus lanceolatus and bacillus coli communis are also found.
The contagion is communicated, as a rule, through the air, by means of fomites from the membranous exudate or discharges from the diphtheritic patients, or during convalescence, from secretions of the nose and throat. Infected milk may cause the disease. Most cases occur in childhood, between the second and seventh year. The disease is most prevalent in the cold autumn and spring months. It is most frequently met with in temperate and cold climates. Defective drainage, catarrhal conditions of the throat, enlarged tonsils, general weakness, and feeble resisting power are predisposing factors. One attack does not confer immunity from another, but rather predisposes to a second.
The false membrane is usually found on the tonsils, the pillars of the fauces and the pharynx, and in fatal cases it may be extensive and involve the uvula, the soft palate and the posterior nares, and even the trachea and bronchi. At first this membrane is yellowish white, but later may become gray; it is more or less adherent and when torn off leaves a raw surface. The diphtheritic poison coming in contact with the throat leads to, first, a necrosis or death of the epithelial cells, especially the more superficial, and the leucocytes. The second change is the hyaline transformation, and simultaneously coagulation; hence the term coagulation-necrosis. The irritation produced by the bacilli causes a migration of leucocytes and these are destroyed and undergo hyaline transformation. This process proceeds from without inward and is usually superficial, and the necrosis may be extensive, involving the deeper tissues, causing ulceration and a gangrenous condition of the parts. The erosion of the tonsils may be so severe as to attack the carotid artery. The lymphatic glands are considerably swollen. The spleen is commonly enlarged. The kidneys show parenchymatous changes. The blood is dark and fluid. Fatty degeneration of the heart is not infrequent. Sometimes fibrinous coagula are found in the heart. Capillary bronchitis, catarrhal pneumonia and areas of collapse are almost constantly found on examination of the lungs in fatal cases. The urine is typically febrile with early albumin and often tube casts and renal epithelium. The blood shows an excess of red blood cells which may reach 7,500,000. Hemoglobin is slightly reduced. There is considerable anemia during convalescence depending upon severity of toxemia.
Symptoms.—The incubation period varies from one to ten days, usually two or three days. According to the location, diphtheria may be divided into pharyngeal, laryngeal and nasal forms.
In Pharyngeal Diphtheria, which is most common, there is first a slight chill or chilliness, followed by fever and sore throat, both of which increase rapidly. The throat is swollen and red and the patient complains of difficult swallowing. The membrane begins on the tonsils in the form of grayish-white patches; it then spreads from the tonsils to the soft palate, sometimes covering the uvula. The cervical glands are swollen and tender. The neck muscles are contracted and somewhat difficult to relax. The temperature rises to 102 or 104 degrees F. The pulse is rapid and feeble, ranging from 120 to 140. There is loss of appetite. There is more or less prostration depending upon the gravity of the constitutional symptoms. The average duration is from one to two weeks.
Laryngeal Diphtheria (Membranous Croup) may be secondary to extension from the fauces or it may be primary. At first there is slight hoarseness and a harsh, metallic, ringing cough. These symptoms may persist for a day or two, when the child suddenly becomes worse; there is marked dyspnea and the lips and finger tips become livid. The child soon becomes very restless. The temperature may be slightly above normal and the pulse increased in frequency. In favorable cases the dyspnea is not very marked and the child probably will have only one or two paroxysms, when it will fall asleep and wake in the morning feeling very comfortable. The next night, however, the attack may be more pronounced. In extreme cases death may result from suffocation. In some cases the suffocation is slower and results from extension of the membrane downward into the bronchi. Dr. Still found same conditions as in diphtheria, but also the hyoid is involved with the superior laryngeal nerve. The sacral and lumbar nerves are also involved. He always emphasized chilling of gluteal region as a cause for croup and that heat should be applied at the inception of the disease.
Nasal Diphtheria is generally secondary, but it may be a primary affection. In many cases no membrane is found; in others there may be a pseudo-membrane formed in the nose, but there is absence of any systemic disturbance. The Klebs-Loeffler bacillus is sometimes present in these membranes. Nasal diphtheria may be a very grave disease—the constitutional symptoms being great prostration, high fever, marked glandular swelling, irritating and offensive discharges from the nose, and epistaxis. Inflammation occasionally extends through the tear duct to the conjunctiva.
A diphtheritic membrane may grow where the skin has been cut or bruised, but the bacillus cannot live on normal skin. It nourishes on a raw, moist surface and membranes have grown on the lips, tongue, vulva, glans penis, and on ulcerative surfaces and wounds. Diphtheria occurs occasionally in the conjunctiva and the external auditory meatus.
It should be remembered that there are many atypical forms of diphtheria. Bacteriological examination should always be made in suspicious and puzzling cases.
The complications of diphtheria are nephritis, hemorrhages, rashes, capillary bronchitis, pulmonary collapse, catarrhal pneumonia, myocarditis, arthritis, otitis media, and paralysis.
Diagnosis.—The presence of the Klebs-Loeffler bacillus will at once decide the diagnosis of diphtheria.
Prognosis.—The prognosis should always be guarded. The nasal and laryngeal forms are always grave. The causes of death are involvement of the larynx, septic infection, heart failure, bronchopneumonia during convalescence, and rarely, uremia.
Treatment.—Hygienic and prophylactic measures are important. A room should be selected that is ventilated and exposed to the sunlight. All unnecessary articles of furniture should be removed. Great care must be taken against the spread of the disease. Always isolate the patient and disinfect everything that has come in contact with him. The greatest danger lies in the spread of the disease during convalescence and in the ambulatory form, when patients are about and coming in contact with individuals, especially children with catarrhal conditions of the nose and throat. The physician should be careful about disinfecting himself.
In view of the fact that many osteopaths have treated successfully numerous cases of diphtheria and that the osteopathic treatment is peculiarly indicated and effective, the probable requirement of antitoxin (the use of which we do not feel called upon to discuss) would be lessened. Relative to the antitoxin Osier says: “The principle of action depends on the circumstance that the blood serum of an animal rendered immune, when introduced into another animal, protects it from infection with the diphtheria bacilli, and has also an important curative influence upon diphtheria, whether artificially given to animals, or spontaneously acquired by man.”
“The treatment of diphtheria by osteopathic methods is often a pleasure rather than a trial because of the success which rewards us for our efforts. There has been considerable discussion by the members of our profession regarding the methods to be employed in successfully overcoming this disease, and many have expressed the view that since antitoxic serum is a physiological remedy, which naturally belongs to all schools of healing, it should be employed by the osteopathic physician in cases of diphtheria. I have no objections to the use of the serum therapy by members of the profession who conscientiously feel that they need it in their practice to secure the highest success. However, I feel, on the other hand, that if they were well acquainted with the technique of the methods * * * they would not feel it to their advantage, from the standpoint of success, to use injections in a single case.”—R. D. Emery, Clinical Osteopathy.
The local treatment should be carefully, but vigorously, given. By proper treatment of the throat the extension of the disease may be prevented. The muscles about the throat, especially the deep ones, should be thoroughly relaxed and the cervical vertebra; corrected if displaced. The vasomotor nerves to the blood vessels of the affected region require careful treatment at the superior cervical ganglion, and the cervical lymphatics from the atlas to the first rib should be closely watched. The nerves to control are the vagi, glosso-pharyngeal, spinal accessory, and sympathetic nerves to the pharyngeal plexus, and in cases of nasal diphtheria the fifth nerve has to be carefully treated. An external treatment to the pharynx will have the greatest effect on these nerves. An internal treatment to the nerves of the soft palate will be of considerable service. The parts diseased should be disinfected and kept as clean as possible. Bichloride of mercury (1 : 4000) used as a spray will be found satisfactory, although there are several other disinfectants and germicides that may be used. Pellets of ice in the mouth will be a comfort to the patient. Cold applied externally will be found best for the adult; heat externally is better for the child.
Every possible means should be used to prevent the disease from spreading. One of the chief dangers of diphtheria is the spread of the disease to the larynx, trachea and bronchi. When the disease has extended to these parts it presents all the symptoms of true croup. The deep cervical muscles should be thoroughly relaxed to aid in relieving the passive hyperemia and with a view of disorganizing the exudate. Attention should be given to the upper ribs, as interferences with the vasomotor nerves of the mucous membrane of the trachea and bronchial tubes usually occur. Direct treatment over the larynx and local treatment through the mouth upon the soft palate will be of aid. A thorough relaxation of all the dorsal muscles, even as low as the tenth dorsal, should be given. Inhalations of slaked, freshly burnt lime may be useful in loosening the exudation. In desperate cases tracheotomy or intubation of the larynx should be performed. Willard[56] says, relative to membranous croup: “It matters not whether or not the laryngeal inflammation was immediately caused by a germ; it would not, nor could not, have been produced by such had there not been an unnatural condition of the circulation of and about the larynx.”
A constitutional treatment should always be given with a view of preventing the spread of the disease from one organ to another and to prevent complications. The heart’s action should be carefully watched throughout the entire course of the disease. Treatment of the spinal cord will guard against paralysis that sometimes follows the venous hyperemia of the vascular linings and substance of the brain and spinal cord. Pay particular attention to the upper dorsal region to prevent possible heart involvement. Post-diphtheritic paralysis seldom if ever occurs in cases that are treated osteopathically. This is a common sequela and is present in from 10 percent to 30 per cent of cases, appearing within three weeks of apparent recovery. Sometimes it is the only result to show diphtheria was present. It seems to follow use of antitoxin rather frequently. Attention to the splanchnics and to the abdomen directly will tend to keep the stomach, liver, kidneys, and intestines in a healthy state. The diet of the patient should consist of liquid food—milk, broths, meat juice, raw eggs and barley water. Let the patient drink freely of water. Treatment of the rectum may be employed with benefit when the pharynx is greatly disturbed.
Various sequelæ and complications are best relieved or prevented, according to Link, as follows: “First, limiting the production of toxins by a most thorough relaxation of the muscles of the neck, thereby favoring the unobstructed circulation of the blood and lymph; second, by the correction of lesions which affect the vasomotor of the head and neck; third, by spinal treatment affecting the vasomotor to the areas involved; fourth, by increasing the activity of the excretory organs, by treatment in the splanchnic and lumbar areas, that the toxins may be more rapidly eliminated. In cases where laryngeal stenosis is marked and suffocation is imminent, intubation should not be delayed.” Post-diphtheritic paralysis usually yields to osteopathic treatment. Apply treatment according to location.
Dysentery
(Bloody Flux).
Dysentery is an infectious disease wherein the large intestine is inflamed, with ulceration of the mucous membrane; is characterized, clinically, by frequent stools containing blood and mucus; fever and exhaustion. Osteopathic lesions of an osseous character and deep muscular contractions of the lumbar region are always present. These involve the vasomotor nerves to blood vessels and lymph channels. Catarrh of the intestinal tract is an important predisposing cause. The disease usually occurs in the summer and autumn, and is more common in hot, malarial regions, although it is found in various climates. Unhygienic conditions are also important predisposing factors. In no disease more than dysentery does specific correction of the osseous lesion effect quick and satisfactory results.
Acute Ileocolitis
(Bacillary Dysentery)
This is the variety most frequently found in temperate climates. It occurs either sporadically or endemically. The Flexner bacillus is frequently found, as well as pus micro-organisms. There are various strains of the bacillus. There is a catarrhal inflammation of part or the whole of the large bowel. Other forms may occur, as ulcerative and membranous.
Osteopathic Etiology and Pathology.—Sudden atmospheric changes and simple irritants, such as unripe and indigestible food, are usually the immediate causes. The predisposing cause of acute catarrhal dysentery is always found by the osteopath to be due to spinal derangements in the lumbar region. The lesion is generally a slight lateral deviation of a vertebra. It is generally found at the second or third lumbar; still, the trouble may be found at any point in the lumbar section. The lesion involves vasomotor nerves to the intestinal mucous membrane, thus causing the inflammation. The drinking of impure water in itself may not be the cause of the disease, but is a favorable medium for the development of the organisms which may excite it. Dyspeptic conditions and constipation seem to predispose to the disease.
The mucous membrane is injected and swollen and often covered with bloody mucus. The follicles of Lieberkuhn are enlarged from retention of their contents, the result of the swelling; the follicles are often ruptured and the mucous membrane sloughs off in patches, forming ulcers. These may extend along the whole colon and frequently into the ileum.
Symptoms.—Diarrhea is the most common initial symptom; the stools being copious and painless. The stools soon become small and frequent, covered with mucus and streaked with blood. These are passed with straining and tenesmus, accompanied by colicky abdominal pains of a griping character. Chills are rare. The tongue is furred and moist: later it becomes dry. Nausea and vomiting may be present, but not as a rule. There is fever and often excessive thirst. Later the stools become green in color, due to the bile which causes a burning sensation in the rectum.
On examination there are found red blood-corpuscles and leucocytes, and large, round and oval epithelioid cells containing fat drops and vacuoles. In mild cases, the course is about eight days; severe cases subside within four weeks, but if the osteopathic treatment is careful and specific, the usual duration can generally be reduced one-half.
Prognosis.—The prognosis is generally favorable in the catarrhal form when the disease is treated properly. The previous general health, hygienic conditions, and sanitary surroundings are of great importance. When there is ulceration or membranes the prognosis should be guarded. The condition may become chronic.
Treatment.—The bowel should be thoroughly washed out by warm water enema, several times, if necessary, to remove irritating material. Invariably a lesion of the spinal column is found at the third and fourth lumbars or near by. It is generally a subluxation, of a lateral nature, between these vertebræ: rarely is the lesion above or below this point. The treatment should be applied immediately and directly to this region. Time is valuable in these cases and one should go to work at once to correct the irritation. An attempt should be made at each treatment to correct the disorder. This should not be delayed by wasting time in relaxing muscles and inhibiting, for unusually this gives only temporary relief. When a slight movement has been accomplished between disordered vertebræ, treatment should be stopped and results watched, because the adjustment may have released all obstructions or irritations causing the disease. In many cases, to get an anatomically correct spine is an impossibility, from the fact that the displacements may be of long standing and naturally the subluxated vertebræ have conformed themselves to some extent to their unnatural position. In other words, what has been lost in the position and relation of a vertebra may have been compensated by reducing the effect of the lesion to a minimum. A lesion of this nature at the third lumbar impairs the innervation to the colon and consequently produces a stasis of blood in the mesenteric circulation, followed by inflammation, bloody discharges, cramps, etc. A single treatment is usually quite sufficient in milder cases. Other cases require treatment every few hours or thereabouts, until recovery.
Treatment directly over the abdomen through the mesenteric circulation and glands is an effective treatment in most cases and especially when the attack is severe. It relaxes the tissues about the mesentery, thereby relieving the stasis and freeing the circulation. The greatest care, however should be exercised in giving this treatment.
The constant desire to defecate, that is common to many cases, is a very annoying symptom. Strong, thorough treatment over the sacral region, by inhibition over the sacral foramina and by relaxing the tense muscles of the sacrum, will relieve this condition. In relaxing these muscles, place the whole hand against the muscles and push upward toward the occiput. This treatment inhibits the nerves to the rectum and lessens the tenesmus.
Attention should be paid to the liver to keep it active. Washing out the large bowel with tepid water produces a soothing effect, besides having a tendency to allay inflammation. The blandest of liquid foods, as peptonized or boiled milk, broths, beef juice, barley and rice, should be given. The patient should remain in bed until completely cured.
Amebic or Tropical Dysentery
This form prevails in the tropical and subtropical countries for the most part, and is caused by an animal parasite, the ameba dysenteriae. This is constantly found in the stools, the tissue of the intestine and also in the pus of the liver abscesses, which are secondary to dysentery. Amebae are sometimes found in the stools of healthy men, having probably entered the system through the drinking water or uncooked food.
Pathologically, the mucous membrane of part or whole of the large intestine is swollen. Round or irregular ulcers which undermine the mucous membrane, especially of cecum, ascending and pelvic colon, are found. In later stages there is infiltration of the connective tissue followed by necrosis. In some cases false membranes and sloughs are formed.
Symptoms.—The onset may be either sudden or gradual, with a very irregular diarrhea, moderate fever, and copious, liquid stools, abounding with the amebae coli. The straining may be less severe and persistent than in catarrhal dysentery and may be absent. Sometimes there is nausea and vomiting.
Abscess of the liver is the most common complication, which may be single or multiple. When single it usually involves the right lobe. Multiple abscesses are small. The more recent abscess walls are necrotic; the older have whitish, smooth, fibrous walls. These abscesses do not contain pure pus, but a fatty and granular debris containing the amebae and a few cellular elements. Sometimes they extend into the lung.
Diagnosis.—This depends upon severity of attack and general condition of the patient. Relapses often occur and the case may become chronic. Cases have been treated osteopathically with success.
Treatment.—In this form of dysentery the treatment is largely the same as in acute ileo-colitis. The spinal lesions affect the innervation to the intestine, thus producing a stasis in the circulation; this condition favoring, and in fact, inviting the retention of the ameba coli in the system at this point.
The diet is the same as in other forms of dysentery. Rectal injections and hot applications to the abdomen are useful. In all cases where strong treatment has been given to the spinal column, a quieting treatment to the nervous system and an inhibitory treatment to the heart will be gratefully received by the sufferer. Both of these effects can be accomplished at the same time by simple inhibition to the occipital nerves. The stools should be taken care of immediately and disinfected. Ice water enemas given frequently are reported as giving good results. For the tenesmus, inhibit strongly at 3d, and 4th, sacrals.
Chronic Dysentery
This is generally resultant from an acute attack, though the amebic form may be subacute from the onset.
Pathologically, the coats are generally thickened, especially the submucosa and the muscular coats being hypertrophied. Ulcers are usually present, although there are cases in which there are no ulcers. Cicatricial contractions sometimes follow and the calibre of the bowels is reduced, strictures being rare.
Symptoms.—There is a progressive loss of flesh and strength, little or no tenesmus, slight, colicky pain and extreme anemia. The stools contain mucus, at times blood, and the bowels move from two to twelve times a day.
Diagnosis.—The history of the initial symptoms will establish the diagnosis. It is not always possible to distinguish between chronic dysentery and chronic diarrhea. The duration is from a few months to several years, although osteopathic treatment has proven very efficient in many instances.
Treatment.—Rest and a liquid diet are most essential. Foods that are easily assimilable and nourishing, with a minimum amount of residue, are required. Beef juice, beef peptonoids and peptonized milk are the types of food. Change of air, hygienic measures and environment are important.
In cases that become chronic, the spinal column oftentimes exhibits lesions above and below the lumbar region. Undoubtedly they are lesions of secondary importance in comparison to the lumbar lesions, but it is important that they be corrected. The treatment requires thorough, careful work of the disordered spinal column and lower ribs. Occasionally a slight kyphosis is present in the dorso-lumbar region that demands persistent work in order to correct it. An occasional rectal injection is beneficial, especially in cases that have slight ulceration of the sigmoid flexure or rectum causing colicky pains and a few loose stools in the morning, the patient being fairly comfortable during the rest of the day.
Erysipelas
Definition.—An acute, infectious, specific disease, characterized by a peculiar inflammation of the skin, due to the streptococcus erysipelatis, with a tendency to spread.
Osteopathic Etiology and Pathology.—Osteopathically, lesions are found to the vasomotor nerves and lymphatics of the affected area. Dr. Still gives lesions of the “inferior maxilla, the cervical vertebræ, the clavicles or the upper ribs” as specially important factors. These lead to congestion and predispose to infection. It occurs in epidemic form, especially in the late winter and spring. One attack predisposes to a second. Family predisposition exercises a slight influence. Abrasions, lacerated wounds, especially of the scalp, may be the starting point of an attack. Persons having skin diseases and wounds, and women who have been recently delivered are liable to be affected. Chronic Bright’s disease, chronic alcoholism, syphilis, debility, phthisis, organic heart disease and unhygienic surroundings are predisposing causes.
The specific virus is the streptococcus erysipelatis, which acts as a local irritant producing the dermatitis. These are found in the lymph vessels and cutaneous connective tissue. The fever and constitutional symptoms are due to toxic agents.
It is an inflammation of the skin, and if uncomplicated, no other structures are involved. Subcutaneous and mucous tissues may be involved, but rarely; if so, there is apt to be suppuration. Visceral complications are of a septic character. Endocarditis, pericarditis, pleuritis-pneumonia, and nephritis are possible complications.
Symptoms.—The incubation period varies from two to seven days. The onset is generally sudden with chill, followed by fever, 104 or 105 degrees F. There may be nausea, headache, and pain in the back and limbs. The local inflammation of the skin follows, usually on cheeks and bridge of nose, or at site of an abraded surface. The area is red, smooth, and edematous. It spreads rapidly, the patch being elevated above the surrounding tissue and tense. The swelling may be so great as to close the eyes and distort the features. The cervical glands are swollen. The temperature continues high for four or five days and falls by crisis. The eruption begins to subside and a moderate desquamation occurs. If the disease takes a fresh start the fever again rises and continues as long as the disease spreads. There is usually headache and sometimes delirium. The tongue is furred, and bowels constipated and the urine scanty. As a result of intense infiltration the part may become gangrenous. Suppuration frequently occurs in facial erysipelas. The inflammation may extend to the mucous membrane of the throat and mouth.
Diagnosis.—This is not difficult. The fever, the acuteness of the disease, the rapidily spreading eruption, and the constitutional disturbances will serve to distinguish it from all others.
Prognosis.—This is usually favorable; healthy persons rarely die. Convalescence may be slow.
Treatment.—Isolate the patient for the disease is contagious, and a third person may convey the virus. The poison may cling to clothing, furniture, etc. The physician should not take care of confinement cases.
A number of cases of erysipelas have been cured by correcting disorders in the region of the second, third, fourth and fifth dorsals. The lesions are principally subluxations of the ribs and severely contracted muscles. The disorder at the points named interferes with the vasomotor nerves to the face, thus predisposing to an attack of erysipelas by allowing the micro-organism congenial tissue for its devastations. In many other cases derangements have been found higher than the upper dorsal, principally through the middle and upper cervical vertebræ. Lesions in these regions would also interfere with vasomotor fibres, especially through the fifth nerve directly.
The treatments on the whole are to examine for lesions to the innervation of the affected region and remove them, besides giving special attention to the bowels, a nutritious diet, and absolute rest. In cases where there is much restlessness and insomnia, treat the upper cervical region, especially the deep posterior muscles[57]. Locally, use cold water applications; adhesive strips applied near the inflamed area or tincture of iodine, may prevent the disease spreading.
Yellow Fever
Definition.—An acute, infectious disease, characterized by a febrile paroxysm followed by short remission and then relapse, jaundice, toxemia, suppression of the urine, and gastric hemorrhage.
Osteopathic Etiology and Pathology.—While a specific germ is the cause of yellow fever, it has not as yet been isolated. Extended tests by United States Army surgeons in Cuba show conclusively that the infection is alone carried by the stegomyia fasciata, but “It remains somewhat uncertain whether the mosquito is the sole means of transmission.” (Anders). Season is the chief predisposing cause as the outbreak is usually in summer and a frost ends its spread. Immunity is generally conferred by one attack. Tucker[58] noted that all cases examined had liver lesions and that most of the patients were of the malarial or bilious type. Spinal lesions were not marked in some cases, but when present were in the liver and renal areas. Tete[59] believes it to be a virus secreted in the human organism under certain atmospheric and other conditions in certain types, i. e. people subject to hepatic and renal disturbances. He also says the vagus is an important factor.
Pathologically, there is more or less jaundice and hemorrhagic extravasations under the skin. The blood serum is red-tinted, owing to the destruction of the red cells. The liver is pale and presents extensive fatty degeneration, with necrotic masses in and between the cells. The gastro-intestinal mucous membrane is swollen, congested and presents numerous minute hemorrhages. The kidneys show parenchymatous inflammation. The spleen is not enlarged. The heart sometimes shows fatty degeneration. The stomach contains more or less of the “black vomit,” which is a mixture of transuded serum and transformed blood pigment.
Symptoms.—The incubation period varies from one to five days. The attack generally begins with a chill, fever, 102 to 105 degrees, headache and pains in the loins and legs. The pulse is accelerated, the face is flushed, the tongue is coated, the throat sore, the bowels constipated and the urine scanty and albuminous. Recent observers state that bile is present in most cases before the albumin is noted. Nausea and vomiting may be present at the onset, but become more severe about the second or third day when the black vomit appears. The febrile stage or stage of invasion, lasts from a few hours to several days and is followed by a decline in the fever when the severity of the other symptoms abates. This is called the stage of remission and in favorable cases convalescence sets in or the patient may pass into the second febrile paroxysm. The temperature rises again, jaundice appears rapidly, nausea and vomiting return. The tongue becomes dry and coated. The stools are black and offensive, the urine is albuminous, scanty and may be suppressed; there may also be hematuria. Death may occur from exhaustion or from uremia. Recovery may follow the gravest symptoms, even when there has been black vomit. The duration of the entire attack covers about one week. Relapses sometimes occur.
Price says there is a point in differential diagnosis in yellow fever and it is a symptom not met with in any other febrile affection. It is the progressive fall of the pulse-rate during the congestive stage of the first sixty or seventy hours, i. e., a variation of from five to ten beats less each morning and evening. He adds, “As long as the kidneys are active there is but little to fear.”
Diagnosis.—Remittent fever has not the deep jaundice, the clear mind, the black vomit, or the albuminuria of yellow fever. The enlarged spleen and the presence of the organism of Laveran in the blood in remittent fever will decide the diagnosis. Dengue is sometimes confused with yellow fever.
Prognosis.—This is always a grave disease, and in its severe forms very fatal. Recovery, however, may occur after the severest symptoms have been manifested. Black vomit is not always a fatal sign. Enough cases have been treated osteopathically to state that osteopathy is particularly effective. Improved sanitation is doing much to reduce mortality.
Treatment.—Prophylactic treatment should be carefully carried out. All patients should be quarantined and carefully screened so they cannot be bitten by the mosquito and the disease spread further. People that are not acclimated should keep away from infected districts. All pools, cisterns and other places which can breed mosquitoes should be drained or screened. A systematic warfare should be waged against them. The patient must be put to bed at once and plentifully supplied with fresh air. Everything must be scrupulously clean—body and bed linen. Use a tube for nourishment and a bed-pan for excretions as the patient must not make the slightest exertion.
Spinal lesions may or may not be found. They have been observed in the cervical, eighth dorsal and second lumbar.
The treatment on the whole is symptomatic. The chills and fever of the first stage should be controlled by thorough work at the upper cervical, upper dorsal, lower dorsal and lower lumbar regions. Treatment at these points controls the superficial and deep vascular areas of the body through the vasomotor nerves. The irritable stomach, delirium and severe neuralgic pains of the head, back, epigastrium and limbs are to be treated according to the conditions and severity of the symptoms. The kidneys and bowels should be watched carefully, and at the onset should be freely opened and control of the kidneys never lost. Let the patient drink freely of water, which will aid. Hydrotherapeutic measures, as a cold bath or sponging, may be employed to aid in controlling the fever, the nervous symptoms, and the eliminative power of the excretory organs. Discontinue the use of hydrotherapy when a spontaneous fall of temperature occurs.
At the beginning of the first stage and during the stage of remission are the periods that the osteopath should do very effectual work by paying particular attention to the four large vascular areas of the body, viz.: head, lungs, abdomen and legs. Treat the vasomotor nerves to these regions, thoroughly, as given in the treatment of the first stage. During the third stage everything should be done that is possible to support the system. Ice slowly dissolved in the mouth will be of aid to an irritable stomach. Hemorrhages and the various symptoms are to be treated as they arise.
Good nursing, dieting, ventilation and keeping the skin, kidneys and bowels active are the primary points to consider. During the period of depression, the heart must be closely watched. The diet should be a light, liquid one, of the nature of peptonized milk or light broths. No food is recommended by some at the onset nor until the crisis is passed. Others feed during the stage of remission and give stimulants. During the last stage rectal feeding is suggested if gastric irritability is pronounced.
Tetanus
(Lock-jaw)
Definition.—An infectious disease, caused by Nicolaier’s tetanus bacillus, characterized by persistent, tonic spasms of the muscles with violent exacerbations.
Etiology and Pathology.—The exciting cause of tetanus is a specific bacillus which usually gains access to the system through some wound. The site of infection is the only place the germs are found.
The disease is much more prevalent in some localities than in others. It is found in hot countries, as in India and the West Indies, far more commonly than in temperate regions. Exposure to damp cold is one of the recognized causes, also those localities where there are rapid changes from cold. Such regions seem to produce conditions favorable to the existence and growth of the bacilli.
Earth mould, particularly where putrefaction is taking place, as in soil that has been manured, is especially favorable to the existence of the bacillus. It is frequently found in the intestinal tract of the horse, so that the soil about stables is apt to contain the germs. The highly fertilized soil of France and Belgium rendered it a special menace to the wounded of the Great War. Antitetanic serum, according to all reports, was particularly efficacious.
Wounds and abrasions of various kinds, particularly contused and punctured wounds of the hands and feet, favor the excitation of tetanus. When an open wound is present, the term traumatic tetanus is given to the disease; idiopathic tetanus when no wound is discoverable; tetanus neonatorum when it attacks infants—this form is usually due to insanitary conditions, especially the improper care of the umbilical cord; lock-jaw or trismus when the jaw alone is affected; cephalic tetanus when the throat and face is involved.
Characteristic lesions have not been found in the cord or the brain. The bacilli develop at the site of the wound where the toxin is manufactured. The bacilli do not invade the blood and organs. The toxalbumin is one of the most virulent poisons known.
Congestion occurs in various organs, due to obstruction of the movement of the blood during a spasm. The brain, cord, lungs and muscles are congested. The nerves are often found swollen.
Symptoms.—The period of incubation is from one to twenty days. This is time required for the poison “to be absorbed by the end plates in the muscles and to pass up the motor nerves to the spinal cord.” In most cases the incubation is from five to ten days. A chill precedes other symptoms in a few cases. The onset is quite sudden, with stiffness in the neck, jaw and tongue. There are headache, stomach disturbance and languor. Opening the mouth is difficult, but is not painful. Deglutition is difficult. The stiffness increases and extends to the spinal muscles, abdomen and legs which are held in a firm spasm. Thus, the trunk and legs are inflexible.
These symptoms vary in degree of severity, dependent upon the extent of involvement. The jaws may be firmly locked or they may yield to forced extension—“lock-jaw.” The muscles of the face may be involved, the angle of the mouth drawn out, and the eyebrows raised—“risus sardonicus.” The neck and trunk muscles affected produce opisthotonos. Spasms of the pharynx and esophagus may occur, especially when there are injuries to the fifth nerve.
Associated with these tonic convulsions is intense pain. The distress of the patient is extreme when the chest muscles are affected. All symptoms are increased during the paroxysm. A foot fall, the slamming of a door, a draught of air or any slight sensory impression may excite a paroxysm. The paroxysm may relax and during the interval the patient may walk about. The spasms vary in frequency from a few minutes to one in several hours. During spontaneous or induced sleep the spasm usually ceases. The febrile reaction is generally slight and apparently of nervous origin; in many cases 102 degrees F. In severe cases the temperature may be considerably higher. Perspiration is excessive. The urine is scanty and high colored. The bowels are usually constipated. The mind remains clear throughout. Death is generally caused by exhaustion. Chronic tetanus presents similar symptoms, but less marked, and it develops slowly.
Diagnosis.—The history of a wound followed by the characteristic symptoms would rarely occasion an error. Strychnine poisoning differs from tetanus in the history, in the more rapid development of the symptoms, no trismus at the beginning, marked involvement of the extremities, and absence of rigidity between the paroxysms. In tetany the extremities are chiefly affected by the spasms, the muscles are relaxed during intervals, and trismus is a late or very rare condition. In hydrophobia trismus does not occur and the respiratory spasm is caused by attempts at swallowing. The mental symptoms increase.
Prognosis.—The prognosis is unfavorable. Eighty per cent of traumatic and fifty per cent of the idiopathic cases prove fatal. Cases that are fatal usually die within six days. Cases where there is slight elevation of temperature, and where the spasm is localized to the muscles of the face, neck and jaw, or where muscle stiffness is late in appearing, are more likely to recover.
Treatment.—Free incision and thorough disinfection with hydrogen peroxide and cauterization with pure carbolic acid, of the wound are necessary. The patient should be put in a dark room and there remain as quietly as possible. Avoid all sources of peripheral irritation. Liquid food is to be given, and if the jaws are firmly set, rectal feeding may be employed or food may be passed through the nose with a catheter.
For the spasms, strong inhibition of the nerve centers controlling the affected muscles may be of use. Probably the most effectual treatment for the paroxysms would be strong, thorough treatment of the upper cervical region. Hot baths give relief to the spasms. All the excretory organs should be greatly stimulated, particularly the kidneys, lungs and bowels. Other symptoms are to be treated as they arise. Tetanus antitoxin is highly commended by surgeons who used it during the Great War. As death is at a two to one ratio any method of treatment is justified. A few cases have been treated osteopathically with fair success, following antiseptic measures.