The practice of osteopathy

By Edgar S. Comstock

GENERAL CONSIDERATION

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

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

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

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

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

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

Variola

(Smallpox)

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

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

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

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

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

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

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

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

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

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

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

Smallpox is characterized by sudden onset with violent chill and shivering; agonizing pain in the back and legs; intense headache, mostly frontal; temperature rapidly reaching 102 to 104 degrees F.; full, strong, rapid pulse, going to 100 to 140; uncontrollable vomiting; pharyngitis; red face, bright eyes, coated tongue; anorexia; constipation; sleeplessness; delirium; often copious perspiration and extreme prostration.

An “initial exanthem,” clearing within 24 to 48 hours, appears. It is either hemorrhagic or erythematous. About the third day the true eruption appears, first upon the forehead and in the scalp, then the rest of the face, the backs of the wrists, trunk, arms, and lastly the legs, most abundant upon the parts exposed to the atmosphere. With the appearance of the eruption, all symptoms abate, the temperature falls, and the patient may feel quite comfortable. The eruption consists of coarse, red spots upon the body, like flea-bites, rapidly becoming, within 24 hours, slightly raised red papules, feeling hard and shotty to the touch, and each surrounded by a broad red inflammatory band, the areola. Usually by the sixth day the papules become converted into umbilicated vesicles, at first clear, then turbid. They are hard and indurated to the touch, and on the eighth or ninth day they become pustular. The areola becomes much darker, the temperature rises to 103 to 105 degrees F., and the pulse to 110 to 120. The other symptoms all reappear, with salivation and delirium. Marked edema of the skin renders the skin unrecognizable. The pustules are painful, especially in places where the skin is thickened. The maturation lasts about three days, when the fever falls by lysis. If fatal, death usually takes place about the tenth day, preceded by feeble and more rapid pulse, marked delirium, subsultus and sometimes diarrhea. About the eleventh day, desiccation begins, the pustules begin to dry, forming tight scabs which are closely adherent. The fever and other symptoms subside but itching becomes annoying. The odor from the pustular stage on is a peculiar greasy one.

After the rupture of large pustules the centers frequently dry and sink in, often in the shape of the Maltese cross. This is most typically seen on the backs of the hands and is pathognomonic. Toward the end of the third week the scabs fall, leaving red glistening pits which disappear or change into deep white striated scars. The hair falls but may grow again. The diagnosis is not certain until the eruption is seen. In the smallpox without eruption the diagnosis must be made from the history of exposure, the presence of an epidemic, fever, lumbar and head pains, delirium, and possibly the initial rash.

Mistakes in diagnosis may be made even by smallpox experts, but attention to the history, somatic findings and the course of the disease, rather than to the eruption, will prevent disastrous results. Always isolate any and all suspected patients.

Varicella Compared with Variola

The Secondary Toxic or Septic Rash appears during the stage of decrustation, sometimes with a mild fever. It may be either scarlatiniform, morbilliform, or hemorrhagic. The skin immediately surrounding the drying pocks is often exempt leaving an anemic halo. The rash lasts about three days and fades or desquamates. With the development of the skin eruption, an exanthem appears upon the mucous membranes of the body cavities, developing into ulcers. This may develop before the dermal rash and be of diagnostic importance.

Forms or Varieties

Discrete Variola Vera.—Incubation symptomless and averages 12 days.

Prodromal stage, from first symptom to eruption. Averages three days. The longer the stage the more severe the infection. Intensity bears little if any relation to prognosis; however, if onset is mild, disease will not be confluent or hemorrhagic.

Invasion begins with severe chill, often repeated. Initial fever rises suddenly to 103° or 104°, and reaches maximum on second or third day. Pulse is rapid and full. Skin is red, hot and dry. There may be sweating in the discrete form and in the favorable cases. The headache appears with the chill and is usually frontal. When severe and accompanied with neckache and vomiting it may suggest meningitis. The backache appears with the chill and lasts about two days. It is a lumbar pain, very like lumbago; it occurs slightly less frequently than the headache and vomiting. This pain is rare in other fevers likely to be confused with smallpox. Vomiting is constant in children and usual in adults. The initial eruptions, which are present in about 10 to 12 per cent, are of considerable diagnostic importance. They are usually limited to the lower abdomen, inner side of the thighs, axillæ, and sometimes on the extensor surfaces of the knees and elbows.

The Eruptive stage consists of the following sub-stages: macules and papules; vesicles, and pustules.

The macules and papules occur on the fourth day and progress for about three days. They begin on the forehead, near the hair, with itching and burning and resemble flea-bites. These soon become papules, which are reddish, elevated, circular, hard or shotty and discrete. On second day of this stage they appear on the body, and on the next day on the extensor surfaces of the extremities. If the eruption appears on the second day the confluent type may be anticipated; if on the third day of the disease, the discrete type.

The vesicles which occur on about the seventh day of the disease, contain lymph. Umbilication occurs in the centers of many of the vesicles, and it is suggestive of smallpox.

The suppurative stage begins about the ninth day with clouding of the vesicles and inflammation around them. This continues for three days. The pustules become opaque, then yellow, and a thick pus obliterates the umbilication. The inflammatory “halo” becomes more vivid and edema may follow around these haloes. This edema causes increased tension and deformity, particularly of the face, and produces great tenderness and pain. The pustulation follows in the order of eruption, from the face downward, and are the thickest on the extremities and head. The pustules evacuate spontaneously, or may dry up without rupture. The skin gives off a peculiar, offensive odor. Bed-sores are now most likely to develop.

The eruptions also may occur in the mucous membranes, particularly in the mouth and nasopharynx. These pass through the successive stages as do those of the skin, but less typically. With the pustulation there is usually a gradually rising secondary fever. In the discrete type the secondary fever does not remain high more than twenty-four to thirty-six hours, with morning remissions. A marked leucocytosis occurs with the secondary fever and its extent depends upon the severity of the infection. Delirium, albuminuria, acute exhaustion and heart paralysis are to be guarded against during this stage.

The state of involution, or decrustation, begins about the twelfth day. It follows the order of eruption, and is accompanied with a decrease in edema, redness and pain, but is attended with intolerable itching. Crusts form, the hair falls out and by the end of the second week the temperature returns to normal. If fever persists during this stage it indicates some complications. Scars occur when the true skin is involved and lasts three or four weeks. Complete convalescence follows the disappearance of the last crust.

Confluent Variola Vera.—This is a malignant type and used to be more prevalent than now. The initial stage is violent, and the headache and backache very agonizing. The fever remission is very slight or absent, and attended with hardly any improvement in symptoms. The earlier the exanthem occurs in variola the more likely it will be of the confluent type. The confluent eruptions occur especially upon the face and head, sometimes on the hands and feet. It is largely discrete on the body and extremities. Great edema appears with the fusion of the eruption, with the swelling and erosion of the mucous membrane, the eyes close and the nostrils become obstructed. The fever is high, pulse high and rapid (often irregular), dilirium, albuminuria, persistent nausea and vomiting, great thirst, husky voice, enlarged cervical glands, salivation in adults and diarrhea in children are symptoms present. Death occurs from acute toxemia, usually within a week, but may last a little longer. Recovery from confluent variola is very infrequent.

Purpura Variolosa.—This is “Black Smallpox.” That is, smallpox with primary hemorrhage in the initial stages. It is the worst type and results almost invariably in death. It is very important because it is so difficult to diagnose. Its incubation period is short (6 to 8 days), invasion very severe, lumbar pains almost unbearable, prostration great, pulse soft, small and rapid and respiration unusually high. The initial pains and vomiting may last until death.

On the first or second day a plum colored eruption appears, with brick-red, purple or inky ecchymoses particularly about the eyes. The condition is desperate. Hemorrhages may occur from any cavity of the body, sometimes accompanied by gangrene of the pharynx. The disease does not usually reach the period of real eruption, because death usually occurs within four or five days. The diagnosis of this condition is by history of exposure to smallpox and the characteristic prodromes.

Variola Hemorrhagica Pustulosa.—This is the type with the secondary hemorrhage, or the hemorrhage after the eruption appears, and is more common than primary hemorrhage. It occurs in weakly and alcoholic subjects. The initial stage is severe, and the hemorrhages occur into the vesicles or pustules. There may be epistaxis, hematuria and metrorrhagia. The outcome is almost always fatal, though the hemorrhage at the vesicular stage may be followed by rapid abortion of the rash and recovery.

Varioloid.—This is modified or mitigated smallpox; also known as variola benigna. Persons exposed to smallpox sometimes suffer from varioloid, and persons who have had smallpox may suffer from varioloid at subsequent exposure to smallpox. Vaccination appears to initiate an attack in persons peculiarly susceptible, or as a result of improperly performed vaccination. The lesions remain in the epidermis, the course of the eruption is shorter, the papules vesicate by the fifth day, the process of suppuration is abridged, decrustation occurs rapidly with little or no scarring, and all symptoms are milder. There are many modifications.

Other varieties are (1) Variola sine exanthemate, which has the usual symptoms without the eruption; (2) Variola verrucosa, which has large, solid, conical papules with small vesicles at their apices, which rapidly desicate and form crusts, and finally disappear without scars; (3) Variola cornea (horn pox) which is known by the large mahogany crusts.

Complications and Sequelæ.—Variola is often accompanied by many complications and sequalæ which are an early severe toxemia and a later secondary infection. During the secondary fever, there may be bronchopneumonia, pleurisy, dysentery, hemorrhages of all kinds, ulcerative eye, ear or laryngeal conditions, purulent arthritis, orchitis, gangrene when the swelling is great and subcutaneous abscesses form, often attacking the penis and scrotum, erysipelas attacking the face, and rarely nephritis.

During convalescence, carbuncles, boils and other subcutaneous abscesses are very common. Disturbances of the peripheral nervous system as neuritis, paralyses especially of the palatal muscles, neuroretinitis, and otitis media are less common. The sequalæ most common are boils, abscesses, deep pitting, otitis media, blindness and permanent baldness.

The urine has the usual febrile changes. White blood cells reach 10,000 to 20,000 or more. Lymphocytosis occurs during pustulation; polymorphonuclear cells are decreased to 40%, sometimes to 12%; myelocytes and irritation forms are found. During the febrile stage there is a polycythemia followed by an anemia to 3,000,000 or less during the pustular stage. Regeneration is slow, lasting about fourteen days. Normoblasts are rare except in hemorrhagic forms. Exudate taken from the pustules show streptococci, staphylococci, and pseudodiphtheria bacilli.

Treatment.—The imperative demands of treatment are isolation, ventilation, cleanliness and disinfection.

If symptoms are suspicious of smallpox, notify the proper authorities at once and isolate patient. When diagnosis is made, cut hair and beard very short.

1. Isolate patient in room free from draperies, rugs, carpets, curtains, pictures, etc.

2. Disinfect all vessels used in room of the patient in carbolic acid solution or in bichloride of mercury solution.

3. Family of patient should be isolated for from sixteen to twenty days.

4. Room should be well ventilated, with windows screened and slightly darkened with red curtains to exclude the ultra-violet rays of light. Temperature should be maintained at 65 degrees. Door-way may be protected by a sheet dampened with a 1:60 carbolic solution.

5. Nurse must be robust, perfectly immune and not afraid. If male nurse, hair must be very short and must have no beard; if female, hair must be short and must wear close fitting cap.

6. Absolute cleanliness is secured by plenty of baths, clean bed and personal linen, and careful nursing. Physician must put on special suit with cap and gloves which are kept in the house, but not in the sickroom.

The first symptoms being the headache, nausea and vomiting and the lumbar pains, the first points of attack in the treatment would be the relief of these pains in the head and back by thorough relaxation of the spinal muscles, paying particular attention to the suboccipital, mid-dorsal and lumbar areas. The headache may be partially relieved by steady pressure between the frontal and occipital regions. No interosseous adjustments requiring painful or difficult technique should be given after the more severe symptoms have appeared. Patient should be visited from one to three times per day, and the reflex contractures of the muscles must be relieved as often as they occur.

Dysentery and diarrhea are controlled by strong inhibitory pressure in the sacral and lumbar regions. Give vasomotor treatment to the superior cervical ganglion. Stimulate the anterior aspect of the solar plexus to stir up its acid function, the blood being alkaline in smallpox.

During all the stages up to the stage of pustulation, the patient responds very readily and successfully to osteopathic treatment. The headache, the backache and the aching joints respond to treatment as readily as, if not more readily than, the headache and backache of influenza do to osteopathic care. The constipation is usually quite readily relieved. It has been the experience of those who have handled smallpox cases, that the tendency to the confluent type is greatly reduced by this treatment and that the response of the patient to osteopathic treatment is very gratifying. Indeed, those of experience have less fear of the outcome of their smallpox cases than do they have of scarlet fever or pneumonia.

After the pustules have formed, each pustule is treated with iodine painted on the pustule with a camel’s hair brush. During the pustular stage it is not necessary to give manipulative treatment, and indeed it is sometimes impractical because of the tenderness of the skin. However, about all that is needed during this period is good hygienic treatment and good nursing. During convalescence constitutional treatment should be given.

Diet.—During period of vomiting, pellets of ice in the mouth are comforting. During periods of fever give plenty of water with, preferably, lemon juice. As the fever declines begin with barley and oatmeal water with lemon juice; then follow with easily digested and nutritious diet of milk, eggs, broths, beef juice and gruels. Feed every three hours during that period but not large quantities. During convalescence a full, well-regulated, nutritious diet should be ordered.

Hygienic Care.—Keep nose cleansed with glycerine, cold cream or olive oil, which keeps the crusts soft. The mouth and nasopharynx may be cleansed with any mild antiseptic. The eyes are washed with warm boric acid solution. Cold compresses applied over the eyelids assist in reducing the edema. A daily tepid sponge bath is necessary. Bath may be given with bichloride of mercury solution (1:20,000) or creolin (1:500).

Headache.—Deep, steady digital pressure in the suboccipital fossa and at eighth thoracic spine; ice bag to the head; or a mustard plaster at the back of the neck may relieve.

Vomiting.—Thorough relaxation and adjustment of the great splanchnic and cervical areas, with deep, steady digital pressure in the occipital triangles, and at the fourth and fifth dorsal vertebræ on the right side will usually control the condition.

Fever.—Relaxation of the upper dorsal area, relaxation of the cervical area, and deep, steady pressure in the suboccipital region often reduce temperature. Warm sponging in lower grades of fever, bath at 70° F., and cold pack may be needed. If temperature goes very high give a continuous cool colonic irrigation.

Pitting.—Cold wet dressings of lint soaked in any comfortable mildly antiseptic solution, or of ice water and glycerine, are to be used on the hands and face to prevent pitting. Hot water dressings are more comfortable to some patients. It is well to protect the skin from the light, especially from the ultra-violet rays. This, however, must not lead to any lack of ventilation. When crusts are forming keep them moist with vaseline, oil, glycerine, or carbolic acid in lanolin or vaseline.

Odor.—Baths, the daily toilet and the use of dusting powder or 5% iodoform powder, an open bottle of smelling salts or of weak ammonia are good. Plenty of fresh air is best of all.

Cardiac Weakness.—If pulse is feeble and frequent, a general quieting treatment should be given, including relaxation of the cervical area and of the fourth and fifth dorsal segments. An ice bag in flannel directly over the heart is often very useful. Gentle, careful spinal extension is very restful and eases the spinal circulation.

Delirium is usually relieved, or prevented, by spinal extension, the prolonged warm bath or the cold pack, if given when signs of nervousness appear. Morphia or chloroform may be necessary in violent and suicidal cases.

Laryngeal Obstruction.—Usually caused by edema and may require tracheotomy.

Bed-sores.—These and abscesses may occur even under the best of care. Place patient upon a water-bed or in a continued warm bath.

Convalescence is not complete until the skin is entirely free from crusts and is perfectly smooth.

Prognosis.—Prognosis depends upon age of patient; complications; and environment from which patient comes, as well as upon the nursing. In varioloid the prognosis is recovery; in the discrete variety, good; in the confluent type over 50% are fatal; in the malignant types practically all die. In patients under five years old and over forty years old the prognosis is very grave. A filthy environment predisposes to complications. Recurrences seldom occur; second attacks are usually varioloid.

Prophylaxis.—Usual rules of health authorities are: rigid quarantine or isolation, vaccination, disinfection of the skin and all fomites, and final fumigation. Quarantine of a suspected individual is sixteen days after exposure. Isolation continued until every trace of eruption has disappeared. The dead body is very dangerous and a public funeral is not permitted. The clothes used by the patient must be steamed and other articles must be washed with bichloride of mercury and fumigated with formaldehyde vapor. Disinfection of the hands, face, beard and hair of attendants with bichloride solution is imperative.

Vaccination

(Vaccinia; Cow-pox)

Definition.—Vaccinia is an eruptive disease of the cow, communicable only by inoculation and causing, when transmitted to the human being, local reaction in the form of a pock and constitutional disturbances which are followed by a more or less lasting immunity against smallpox. Vaccination is the artificial inoculation of vaccine virus for the purpose of producing an immunity against smallpox.

Arm to arm vaccination was formerly very generally practiced but has been practically discontinued because of the possibility of infection from syphilis and other infections. When it is necessary to use the human lymph it should be taken upon the eighth day from a typical unbroken vesicle in a perfectly healthy child at least three months old. The vesicle must be pricked at several points, care being taken not to draw blood. The bovine vaccine lymph is now in general use because it practically eliminates the possibility of syphilis and other infections. Also because it is more easily transported.

It is thought best by many authorities to vaccinate in infancy after the sixth month, at the seventh and eighth year, at puberty, and thereafter at intervals of about seven years, but depending considerably on the prevalence of small pox. The virus is prepared under sterile conditions from carefully selected and tested calves. It is put up under aseptic conditions in hermetically sealed capillary tubes or, in the old style, on ivory points.

There is a great variety of opinions as to the efficacy of vaccination in producing immunity against small pox, this variety of opinion being very prevalent among representatives of the medical schools. Dr. F. P. Millard of Toronto says the lymphatic system is the keynote, and that vaccine virus poisoning spreads through the lymphatics, causing diphtheria and allied throat affections. Dr. A. T. Still said, “We are opposed to vaccination.” He repeatedly emphasized the fact that “Nature furnishes within the body all the remedies necessary to cure disease.” In the recent Canadian epidemic (1919-1920) the medical authorities have met with a most strenuous opposition. The Homeopathic profession, almost to a man, went on record as opposed to compulsory vaccination. The Illinois Supreme Court has ruled that compulsory vaccination is unconstitutional.

Technic.—The area usually selected is the left arm at a point above the insertion of the deltoid muscle. Some prefer the leg over the junction of the two heads of the gastrocnemius muscle, because it is more easily cared for, and, because of the style of wearing short sleeves among women, it does not expose the scar which results from the vaccination.

The surface must be washed, dried, with a soft towel, and then sterilized with alcohol. With a sterilized needle or lance scratch an area about a quarter of an inch in diameter, being careful not to produce bleeding but merely an oozing of pinkish lymph. A drop of the virus should be deposited upon the abraded surface, rubbed in with the side of the needle and let dry. A thin layer of sterilized gauze should be lightly applied and held by means of adhesive plaster, not encircling the limb. This should be occasionally removed and redressed. The pock should be kept dry and clean, and may be lightly dusted with starch or toilet powder. “Persons exposed to the contagion of small pox should be immediately revaccinated. The immunity conferred diminishes with time.” It is the writer’s personal opinion that, with the amount of complications that so frequently follow vaccination and with the fact that “it is necessary to revaccinate during an epidemic or after exposure,” it were better to defer vaccination, if parties are favorably inclined to the practice, until such time as the presence of small pox in the community make it apparently necessary.

Typical Vaccination.—The period of incubation varies from three to five days. At the end of this time local reaction shows itself in the form of reddish papules at the point of inoculation. In about five days these develop into compound vesicles, which at first have clear and then later opaque contents. About the eighth day the vesicle is fully developed and is round or oval with prominent and well defined edges and a depressed center. An erythematous areola usually appears about the tenth day and the contents are purulent. The surrounding skin is swollen and tender, and a scab now begins to form in the center of the pock and rapidly extends toward its edges. About the end of the second week the areola fades, and the pock is changed into a thick brownish crust which becomes dry and hard, and comes off between the twentieth and twenty-fifth days after vaccination. A dusky red scar is left and this gradually becomes white and pitted. During the evolution of the pock the glands through which lymphatic drainage takes place become slightly enlarged and tender.

The constitutional reactions are usually moderate fever, restlessness at night, irritability and loss of appetite. These symptoms usually appear about the fourth day and continue about three to five days. At any time during the vaccinia erythema, roseola or urticaria may appear. The constitutional reaction in revaccination is sometimes very severe.

There are many atypical symptoms following vaccination as variation in the number of the pocks, in the size, in the severity of the constitutional symptoms, in the contents of the pock, in the healing and formation of the scar and in the transmission of specific diseases as syphilis, tuberculosis, leprosy, cancer and tetanus.

Complications.—All cases are not benign, as due to impurity of vaccine, carelessness in technic, improper care in dressing, handling of the wound by the patient himself, scratching it with the finger nails, and other accidents of like nature, infections may set in and very serious complications arise. These result in abscesses, erysipelas, tetanus and various eruptions. Otitis media may leave deafness.

The writer knows personally of a young man in the Army during the World War who was vaccinated while in the Army and two abscesses developed which ate entirely through the arm, one abscess passing through the arm just anterior to the humerus and the other just posterior to it. It was many, many months in healing, and nearly caused loss of the arm.

There are many cases of record where vaccination was followed, directly or indirectly, by paralysis, deformities, and chronic constitutional diseases. It is usually claimed these conditions were due to accidents following the vaccination and not due to the vaccination itself. However, it can not be denied that the vaccination was at least the indirect cause of these deplorable conditions.

General Vaccinia.—(Vaccinal eruptive fever; Vaccinola). This consists of a vaccine rash, developing usually from the fourth to the tenth day following vaccination, and appearing in various parts of the body, particularly about the wrists and on the back. The secondary pocks usually develop about the eighth or tenth day after vaccination and are usually more abundant on the vaccinated limb than on any other part of the body. As the pocks appear in successive groups, all stages of the disease may be seen at one time, and the condition may last for many weeks. Fever may be absent or present, but is usually proportionate to the extent of the eruption and the associated complications.

Treatment.—After vaccination, the patient should be told to return in seven days, when the dressings should be removed, and if the vaccination has been successful, a pearl-like vesicle will be present. If the vesicle has been broken by accident or by rubbing of the gauze, the free portions of the dressing should be cut away and the adherent part left undisturbed. A new gauze should be applied in any case, and in five or six days more, the dressing should be again changed, and this changing continued at intervals until the crust falls, which is usually during the third or fourth week.

If no vesicle forms by the tenth or twelfth day, the vaccination has not been successful. It is suggested by the vaccination advocates that another attempt should be immediately made.

Prognosis.—Uneventful recovery is to be usually expected. Pitting from generalized vaccinia; various constitutional diseases; paralyses and other maiming disabilities sometimes occur. While it is not usually considered dangerous to life, there are nevertheless many cases of record where death has resulted. It is not wholly unattended with danger.

The best of care should always be taken following vaccination to prevent the possibility of complications, though even then they do occur.

Scarlet Fever

(Scarlatina)

Definition.—Scarlet fever is an acute, specific, contagious, infective disease of unknown origin, characterized by very sudden onset, fever, vomiting, sore throat and diffuse exanthem.

History.—It was first recognized in the sixteenth century, but first fully described and differentiated from measles by Sydenham in 1660. It was introduced into America about 1735.

Etiology.—The causative organism or agent is unknown. The virus of scarlet fever produces severe necrosis, but no suppuration. The streptococcus is the most important factor in the production of complications and in their mortality. It is claimed to be the cause of the malignancy of the disease but not of the disease itself. Susceptibility to the disease is by no means universal as only 38% of children and but 5% of adults exposed to the infection acquire the disease. Over 90% of the cases occur under ten years of age, and rarely during the first year of life.

“Scarlet fever is a toxic superficial expression of internal malnutritive conditions of the blood as a tissue. The cause of the toxicity is usually overfeeding, or the feeding beyond the demands of the proximate principles of the body, or the overfeeding under unhygienic conditions.—J. Martin Littlejohn.

“It was once held that the virus was disseminated during desquamation, but oral, nasal and otitic discharges probably perpetuate the infection, perhaps months after scaling is complete. In no other disease is the virus so tenacious. It may persist ten years on clothes, furniture, etc.”—A. R. Edwards.

The light forms are as contagious as the severe ones, and inoculations have occurred from the living subjects as well as from autopsy cuts. In degree of infectiousness smallpox ranks first, measles second and scarlet fever third. The infection may be spread by any third person or by articles coming in contact with the patient, and often the mode is obscure. Sporadic cases apparently frequently appear. The reason for the sporadic cases may easily be explained by the theory of J. Martin Littlejohn, given above. One attack usually confers immunity, but not always. This disease occurs more often in the autumn and winter, and is more prevalent in cities than in the country. (Measles is more prevalent in the country.) Scarlatina sometimes occurs with other infections, such as diphtheria or measles, and more rarely with varicella, pertussis, etc.

Predisposing Factors.—Age, one to ten years; lowered resistance from overfeeding, unhygienic environments, exposure to sudden temperature changes; lesions, both muscular and interosseous which interfere with the distribution of the fluids and vital forces of the body; season of the year (autumn and winter); puerperal women, and wounds.

Pathology.—No specific lesions are found. No trace of the rash shows after death except in the hemorrhagic form. The anatomical changes in cases coming to autopsy are those of simple inflammation, follicular tonsillitis, or diphtheroid angina. Streptococci are abundantly found in the glands and foci of suppuration.

Symptomatology.—Scarlet fever is divided into four stages: (1) Incubation, (2) Invasion, (3) Exanthem, (4) Desquamation.

Incubation Stage.—Has no noticeable symptoms and lasts from two to four days. Some authors claim as high as ten to fourteen days.

Invasion.—The invasion lasts one day. The onset is very sudden beginning with a chill which is followed by a characteristic vomiting, occurring in 75% of the cases, which is more frequent than in any other disease of childhood except pneumonia.

The vomiting is followed by headache and the beginning evidence of sore throat, which usually soon develops into a tonsillitis. The severity of the sore throat is indicative of the severity of the scarlet fever that follows. The temperature suddenly rises to 103° or more, the pulse becomes unduly rapid for the temperature, 120 to 160 per minute, and the respiration is increased. The skin begins to burn, there is dysphagia and intumescence of the cervical glands. The muscles of the back become hypersensitive to touch and to extremes of heat and cold; and particularly sensitive spots are found over the transverse processes of the first to 4th cervical vertebras, the 4th and 5th dorsal and the 11th and 12th dorsal vertebras. At these points will be found intensely contractured tissues which must be kept relaxed.

Exanthem.—The eruption appears at the end of the first day or early the second day, showing first over the clavicles and on the neck, then over the upper trunk, next the lower trunk and limbs. The eruption on the extremities appears particularly over the flexor surfaces of the joints. By the end of the second day the eruption has covered practically the entire body, leaving a white circle about the eyes and mouth. The eruption pales, or disappears on pressure, quickly returning to the scarlet color on the removal of the pressure. Frequently, the skin itches and is very uncomfortable.

A punctiform eruption in the arm-pits, over the groins, or on the roof of the mouth is considered positive proof of scarlet fever.

The eruption at first consists of small red spots which fuse as the skin swells and results in an intense lobster-colored erythema. This lasts four to six days. The tongue, at first, is red at the tip and margins with a greyish-yellow or whitish fur in the center through which is often seen the swollen red papillæ, the “strawberry tongue.” The “fur” desquamates on the third or fourth day, leaving a surface intensely red with marked raised, swollen papillæ, the “raspberry or cat tongue,” which lasts nearly a week. The breath has a heavy, sweet odor. The pharynx, uvula and tonsils become swollen, and often creamy-white patches cover the mouths of the tonsillar follicles.

Between the second and third day the eruption reaches its height, when it has a vivid scarlet hue unlike any other eruption, and becomes darker each day until it may be a bluish-red, when it gradually fades and desquamation begins. By the seventh or eighth day the rash has disappeared, together with the fever.

Desquamation.—Scaling begins on the face first, from the sixth to the ninth day and lasts several weeks. The skin looks somewhat stained, is a little rough like “goose-flesh” and gradually the upper layer begins to separate, and the scaling begins in large lamellæ or flakes. Casts of the fingers or toes may be shed. The swelling of the glands disappears, and the fever falls by lysis, and convalescence begins, unless complications intervene.

Diagnosis.—In typical cases diagnosis is easy, especially during epidemics or when the eruption is accompanied by other criteria.

1. Sudden onset, with nausea and vomiting, sore throat, quick appearance of fever and rapid development.

2. Punctate spots in the throat, swelling and dysphagia are usually present. The severe sore throat symptoms with the above are always very suspicious.

3. Strawberry tongue is constant.

4. Eruption, typical in character, appearing on second day, first showing on the neck above the clavicles, intense on the body and practically absent around the mouth. Eruption confluent, with no intervening free areas of the skin, followed by desquamation.

5. Lymphadenitis much more pronounced in the inguinal and other glands than in the cervical.

6. Desquamation, tender joints and albuminuria will force the conclusion of scarlet fever, if former symptoms have been indefinite.

In the atypical cases we may have very light attacks with all the symptoms present but very poorly developed; or some symptoms absent as in cases with no temperature, or others with no rash. Some cases are so atypical as to be impossible of diagnosis. The writer has very recently had the experience of one case when there were absolutely no typical symptoms present after being called on the case, but four days after the invasion of the disease in the patient a sister of the child developed typical scarlet fever, and not until the sixth day did any eruption or sore throat appear, and then the eruption was more characteristically measles than scarlet fever. Consultants with the writer agreed with him that the case was one of an atypical, non-eruptive scarlet fever.

Differentiation.—Scarlet fever is not always easily differentiated from other diseases, such as a septic rash, drug rashes, diphtheria, measles and German measles.

A. R. Edwards gives this differentiation between scarlet fever and septic rash.

Diphtheria.—Often difficult to differentiate. The simple erythema is sometimes observed in diphtheria, but is darker, more on the trunk, and more transitory than in scarlet fever.

Drug Rashes.—These rashes are caused by belladonna, iodoform, quinine, iodide, chloral, copaiba or aspirin. They may be easily differentiated if the cardinal symptoms of scarlet fever are considered instead of the rash alone. At the present time, perhaps the most frequent drug rash that we meet is that produced by aspirin. It is sometimes hard to diagnose because the aspirin has been taken for a sore throat or tonsillitis, which so resemble the early symptoms of scarlet fever.

Measles and German Measles.—The symptoms of the invasion stage of these diseases is sometimes quite similar, and even the rash may be quite similar; the differentiation will be discussed under measles (q.v.).

Types and Forms.—(a) Mild and abortive form (scarlatina sine eruptione). In this the rash may be scarcely perceptible, while the fever, sore throat and strawberry tongue are present. Desquamation may be present and it may be followed with a severe nephritis.

(b) Malignant forms, (1) Atactic variety, violent intoxication, onset of great severity, fever very high (107° to 108°), extreme headache, delirium, and often convulsions. Initial delirium gives place to coma; dyspnea may be urgent; pulse very rapid and feeble; and death occurs before eruption appears. (2) Hemorrhagic variety: there are hemorrhages into the skin, beginning with scattered petechiæ, becoming more extensive and ultimately involving the whole skin. It is characterized by severe fever and brain symptoms at the onset; incomplete exanthem, necrosing angina, marked glandular and splenic swelling; subcutaneous, serous and mucous membrane hemorrhages with ulceration. Death may take place on the second or third day. This is more common in enfeebled children, although it may attack adults in apparently full health.

(c) Anginose form (Scarlatina anginosa.) This form resembles septic diphtheria, with marked toxemia, necrosis and adenitis. The throat symptoms appear early and progress rapidly. Temperature high, cyanosis, diarrhea, rapid weak irregular pulse, and stupor occur. The fauces and tonsils are covered with a thick membranous exudate which may extend to the posterior wall of the pharynx, forward into the mouth, upward into the nasal chambers, and may occasionally reach the trachea and bronchi. The Eustachian tubes and middle ear are usually involved. The glands of the neck rapidly enlarge and become the seat of brawny induration, and the inflammation extends beyond their limits. Necrosis occurs in the tissues of the throat, fetor is extreme, the constitutional symptoms are great and the child dies of toxemia. If he does not die, extensive abscess formation in the tissues of the neck takes place with sloughing and danger of hemorrhage from the opening of a large artery.

Blood Pressure.—Rises at first, thereafter it follows the pulse and temperature. After the seventh or eighth day it may be below normal. Cases of albuminuria show hyperextension and slowing of heart action. With the subsidence of the kidney irritation the pulse-rate is increased and the blood pressure returns to normal.

Urine.—Shows ordinary febrile character, being scanty and high colored. Slight albuminuria is rather common after the stage of eruption, even a few tube casts may be present without any serious irritation of the kidneys. Urinalysis should be made daily.

Blood.—The red cells are moderately reduced to 3,000,000 or 4,000,000 per c. mm. during convalescence. There may be some poikilocytosis, and normoblasts are occasionally seen. Leucocytosis is early, 15,000 to 30,000 per c. mm., falling with the decline of the fever usually by the fourteenth day, but may persist for weeks after the temperature is normal. The count runs roughly parallel to the temperature. Over 40,000 leucocytes per c. mm. are of bad prognostic omen. Polymorphonuclear cells are increased to 80% or 90%; early returning to normal in favorable cases.

Eosinophilia is present in all but malignant cases. It reaches its maximum two or three days after the rash appears and returns to normal after the leucocytosis has disappeared. The early presence of eosinophilia excludes septic conditions. When these cells are absent in scarlet fever, myelocytes are to be found.

Treatment.—Clinically scarlet fever represents, from the osteopathic viewpoint, (a) a toxic condition due to internal malnutrition and a decrease of the detoxinating function of the thyroid gland; (b) secondarily associated with the sore throat is a type of toxic tonsillitis, but it is due to the toxic elements in the blood; (c) in the lesion field it is associated with extreme stiffness and muscular tension in the upper cervical area and also in the entire dorsal area, overlapping the upper lumbar. The eruption is a superficial expression of the attempt of the body to eliminate the toxins, and this elimination should be aided by enhancing the activity of all the other eliminative functions. Cases are on record where patients have been exposed to scarlet fever, have gone the usual incubation period and developed the invasion symptoms, and by thorough, oft-repeated osteopathic treatments, with the aid of enemata and copious hot water drinking, have not gone beyond the invasion period and the disease apparently aborted within two or three days. It is therefore well to give thorough, oft-repeated attention to these cases during the very early stages.

(1) In all cases where the first symptoms indicate the possibility of a contagious disease, the patient should be immediately isolated and kept isolated until all danger of contagion is past. In scarlet fever cases get a competent nurse. Keep room light, quiet and thoroughly ventilated with a constant temperature of as nearly 70° as is possible. (It were better to have two rooms if possible, one for day and one for night: have room or rooms on upper floor if in a house). Arrange suitable means for thorough disinfection of all articles used in the sickroom. These are very essential.

(2) Patient should be clothed in usual night wearing apparel. The bed clothing should be warm, but not heavy. The physician should wear an operating gown or a sheet which thoroughly covers his clothing, also a cap. He should carefully wash his face and hands immediately after leaving the sickroom. The quarantine should be maintained for the legally required period, and even after if there continue discharges from the nose, nasopharynx or the ear. Bichloride wrappings should be placed about the body of the dead, and funeral must be private.

(3) Have enema given immediately to cleanse the lower bowel. Follow this with frequent draughts of hot water, or better hot lemonade for the first day. Place hot water bottles at feet. If eruption is slow in coming out, it may be aided by a hot bath, followed by wrapping the patient in warm blankets to prevent chilling.

(4) Thorough osteopathic treatment should be given along the entire spinal area from the atlas to the sacrum, inclusive, to keep the muscles well relaxed, giving special attention to the relationship of the vertebræ and the tension of the muscles from the occiput to the fourth cervical; the third to the sixth dorsal; and the tenth to the twelfth dorsal areas. Also give special attention to the deep cervical muscles, particularly those at the angle of the inferior maxilla, and at the articulation of the inferior and superior maxillæ. Remember the tendency of the kidneys to complication in scarlet fever, therefore do not neglect the renal splanchnics, for here you not only control the renal functions but also regulate the adrenal functions and their internal secretions. Keep the clavicles properly adjusted and articulate them by bringing them well forward to relieve any irritation that may have started in that area. Careful direct treatment to the abdomen should usually be given at each visit besides the work in the splanchnic area to keep the bowels, kidneys and liver active.

Diet.—Water must be given freely. If fever is very high, pellets of ice held in the mouth will give comfort. During the height of the fever it is preferable to withhold all nourishment, but if in a particular case it seems to be indicated, confine the nourishment to fruit juices, especially oranges. Never force feeding during the fever. For infants cut down their feeding to at least half, making the milk very thin with water or gruel. After defervescence, carefully increase to a light diet using sparingly of nitrogenous foods except milk. After four weeks in the usual case, gradually return to the ordinary diet. This is a good time to make corrections in the ordinary diet if any are needed.

The bowels must be kept regulated. An enema is usually indicated after the onset of the disease. During the time that food is permitted it should be of a laxative character. During the fever stage the enema should be given daily to help keep the bowel cleansed and to help reduce the temperature. If bowels are persistently sluggish and the fever is constantly high the abdominal heating compress (so-called “cold compress”) will give much relief.

The nose and throat should be constantly looked after. The nose may be cleansed by instillation by means of a medicine dropper, using normal salt solution. If the throat symptoms are mild, a gargle of warm normal salt solution is enough for cleanliness of the membrane. If the throat symptoms are too severe to permit the use of the gargle, or if the patient is too small to be taught the use of the gargle or to wash the throat, irrigation may be employed. The use of raw lemon juice, or of raw pineapple juice, on a cotton swab is of great value in cleansing the tonsils and throat. The swabbing should be repeated several times per day.

The teeth should be carefully and thoroughly cleansed twice per day.

The skin must be constantly cared for. During the fever it is well to cover the skin with linen or soft cotton. Daily sponge baths of carbolized water (1:40) of tepid temperature followed by applications of cocoa-butter will give much comfort. Use only good toilet soap and do not use the so-called antiseptic soaps because, authorities claim, there is a chance of renal injury. During the period of desquamation the use of the cocoa-butter will assist in limiting the source of infection by preventing the diffusion of the dry scales which are considered infectious by many physicians. A. R. Edwards says: “During desquamation, oil-rubs were once employed to decrease the dissemination of dry scales, but they decrease the function of the skin, which is of great importance when the kidneys are involved; also, infection is carried by means of throat secretions. Soap and water serve equally well.” Some authorities suggest that during the desquamation, after bathing the patient, the skin should be thoroughly rubbed and then the oily application used, using cocoa-butter, unmedicated cold cream, liquid albolene or the like. Olive oil and vaseline are usually irritating. The writer inclines to the opinion that the soap and water bathing is sufficient, except perhaps the use of cocoa-butter over the areas that are desquamating severely.

The temperature can usually be controlled by the usual osteopathic methods; steady deep pressure applied in the suboccipital region for a few minutes, followed by relaxing the muscles of the back from the first to the eighth dorsal, by raising and spreading the ribs in the mid-dorsal area, and by light inhibition over the solar plexus. The tepid enema will assist in lowering the temperature. If temperature is high and patient is delirious and has other nervous symptoms the cold pack is useful. The ice cap may be used almost constantly in high fever. If glands are swollen treat by crowding the tissues toward the gland but never work upon the gland itself.

If pain is felt in the ear immediate attention must be given it. Correct any deviations of the atlas or other upper cervical vertebræ, relax the deep muscles at the angle of the jaw, and relieve any impingements in the lower cervical and upper dorsal regions. The ear should also be treated with copious boric solution irrigations, as hot as can be borne and at low pressure. The condition of the ear drum membrane must be watched daily and if there is bulging and congestion it is safer to puncture the drum under cocaine than to await spontaneous rupture. Use small amount of boric powder after rupturing.

The heart must be examined daily. Vigorous treatment through the thoracic region is indicated, if cardiac symptoms appear, and the patient must be kept quiet and in bed. If heart seems feeble it may be well supported by the cold packs directly over the heart.

Nephritis is most common in the second and third weeks of the illness, but may develop later. In all cases where any symptoms of nephritis appear, light or severe, the patient must be confined to bed for at least four weeks, and kept on a milk diet. All irritants must be absolutely avoided. Hot baths should be given twice daily to increase the sweat and the urinary functions, the bath lasting half an hour and the patient kept afterward between blankets. Treat thoroughly, daily, the splanchnic and renal areas, paying particular attention to the tissue conditions in the lower dorsal region.

In the milder cases, the urine contains albumin and a few tube casts, very rarely blood, and edema is slight or transient. Though the patient improves, he remains pale and there is a slight trace of albumin in the urine for months. If recovery does not take place, then chronic nephritis becomes established.

In the more severe cases there may be a puffy appearance of the eyelids, slight edema of the feet, urine diminished in quantity, smoky, containing albumin and tube casts. The kidney symptoms dominate, dropsy persists and there may be effusion into the serous sacs. The condition may become chronic, the patient may succumb to uremia, but in the majority of cases recovery takes place.

The nephritis may be hemorrhagic, in which the urine is suppressed or there may be a very small amount of bloody fluid laden with albumin and casts; constant vomiting and convulsions follow and the patient dies with symptoms of acute uremia.

Other complications are arthritis, malignant endocarditis, severe toxic myocarditis and acute phlegmonous inflammation, the last three of which are usually fatal. Chorea is a fairly frequent nervous complication. The mental symptoms are mania and melancholia. Progressive paralysis of the limbs with wasting, may simulate infantile paralysis. The fever may persist after the eruption disappears and the child remain in a septic state (scarlatinal typhoid).

Relapses are rare. Scarlatina may coexist with almost any other acute infection. It lowers the resistance of the body to disease and is often followed by other acute infections or by tuberculosis. Therefore the necessity of care during the entire convalescent stage.

Measles

(Rubeola; Morbilli)

Definition.—Measles is an acute infectious, contagious, erythematous disease, occurring in epidemics, characterized by an initial coryza, bronchial catarrh and an eruption of a general maculopapular type; also by the presence of Koplik’s buccal spots.

Etiology.—Predisposing Influences: The chief predisposing factor in measles, as in all other contagious diseases, is a lowered resistance in which some structural or functional change has taken place that reduces the functional activity of the body’s inherent protective agencies. These predisposing factors may be classed under three heads, namely; (a) structural, (b) environmental, (c) dietetic. Under the first we find structural disturbances in the upper cervical area affecting the functional control of the nose, throat and head, as well affecting the thyroid and its internal secretions: structural disturbances in the upper and mid-dorsal areas affecting the vasomotor control to the head, neck, and chest, thereby perverting nutrition to all these structures and rendering them more susceptible to the infective organisms; also the dorsal lesions disturb the functional integrity of the lungs and heart, with the result of disturbed respiration and circulation, both of which are vital factors in body resistance: we also find structural lesions in the lower dorsal region, affecting the function of the kidneys and their elimination and the function of the adrenals and their internal secretions. Under the second or environmental, we have unsanitary and unhygienic conditions, exposure to sudden changes of temperature, wet clothing, fatigue, etc., all of which produce secondary structural lesions and the effects above mentioned. Under the third or dietetic classification, we have the errors of diet so common in children and adults as well; such as too much candies and other sugars, also too much starches, as well as over eating and unbalanced diet.

Measles prevails in all climates and attacks all races, the Negroes appearing to suffer more severely than the whites and to be more subject to complications. Outbreaks are more common in winter and spring, but occur at all seasons. The disease is particularly a children’s disease but adults may contract it if not protected by an attack in early life, and with adults the disease frequently manifests the more aggravated forms. It is more common after puberty than scarlet fever.

Exciting Cause.—While the disease is probably produced by a micro-organism, it has not yet been demonstrated. Inoculation experiments upon human beings have shown the presence of the infecting principle in the blood, in the tears, in the secretions of the nasal, pharyngeal and bronchial mucous membranes, and in the contents of vesicles occasionally present. Inoculation with the epithelial scales thrown off at the end of the disease has been unsuccessful. Ordinarily the transmission of the disease takes place through the breath or the nasal and bronchial secretions. The disease may be carried by a third person or by fomites. The infecting principle is intensely active, but not so tenacious nor persistent as scarlet fever. Measles is communicable throughout its entire course from the earliest appearance of the coryza. The individual predisposition toward measles is apparently so general that few, upon exposure, escape it, though we have observed cases where children have been directly exposed and who were immediately thereafter put under osteopathic care and did not develop the disease. Second, or even third, attacks may occur at intervals of some years, but these are unusual. Sporadic cases do occur and are often the starting points for epidemics. Extensive outbreaks occur at intervals of five or six years.

The incubation period is from seven to eighteen days, usually about ten days.

Symptoms.—Prodromes are common, usually consisting of loss of appetite, restless sleep, fretfulness, and often feverishness. There are three stages, (a) Invasion, (b) Eruption, (c) Desquamation.

(a) Stage of Invasion. The prodromal symptoms are intensified. There is often chilliness but seldom distinct chills. The temperature rises, often reaching 102 to 104 degrees, upon the first and second day. It then falls one degree or more to rise again upon the appearance of the eruption. Nausea, vomiting and headache are often present. The tongue is furred. With these symptoms coryza has developed and is sometimes intense, often simulating severe influenza. Irritation and smarting of the eyelids, lachrymation, photophobia, persistent sneezing, running of the nose, sore throat, discomfort in swallowing, hoarseness, and cough, at first of a croupy character, appear in rapid succession and with varying intensity. These initial catarrhal symptoms are characteristic and occur in the mildest cases in which chilliness, fever and the associated signs of the reaction of the organism to general infection are not observed. The vessels of the conjunctivæ are injected, the eyelids swollen, the nasal mucosa tumid and reddened. The mucous membrane of the mouth and throat is erythematous, while upon the soft palate and the roof of the mouth, and particularly upon the buccal mucous membrane, are to be seen pin head or split pea sized, circumscribed, round or irregularly shaped reddish blotches slightly or scarcely at all raised above the surrounding tissues, usually discrete, but sometimes confluent. This eruption also shows itself in the larynx and is undoubtedly the cause of the croupy cough and other throat symptoms. In a strong light there may be seen upon some of the spots on the mucous membrane of the cheeks and lips minute bright whitish, or bluish-white flecks which are called Koplik’s Spots. These spots appear early and soon disappear, and as they are not found in any other disease they are of value in the early diagnosis of measles. The duration of this stage is usually three or four days; rarely it is shorter or it may be as long as a week.