The practice of osteopathy

(b) Stage of Eruption. On about the fourth day the temperature again rises, increasing as the rash develops, often to 104 or 105 degrees and reaching its maximum about the sixth day when it usually falls by crisis; followed on the seventh or eighth day by normal temperature. The pulse-rate increases with the fever, often reaching 140 or higher. The eruption usually appears on the fourth day, and shows first about the hair line on the forehead, spreading to the face, chest, trunk and the arms and legs. The eruption is attended by itching and burning, and completely develops in from twelve to thirty-six hours, the catarrhal symptoms persisting during this time. During this time, in the more severe cases, delirium or stupor may be present, and the patient complains of sore throat and general discomfort, and is restless and wakeful. Usually upon the second or third day of the eruption, great and rapid amelioration of all these symptoms takes place and the fever falls to normal or subnormal. When the eruption is fully developed the individual spots are irregularly circular or oval, and differ greatly in size, averaging about the size of a split pea. The eruption is unevenly set, but usually close together and sometimes confluent, especially on the face, buttocks, hands and feet. Frequently they take on a crescentic arrangement and the spots are circumscribed, the intervening skin being normal or slightly hyperemic.

About the ninth day the rash begins to disappear, on the face first, then the neck and the rest of the body in about the same order as the eruption appeared. The skin takes on a yellowish discoloration and the rash disappears in a bran-like desquamation which lasts several days to a week. In the beginning of the stage of eruption, and in many cases throughout its course, the skin is moist and often bathed in free perspiration. At the height of the eruption the superficial lymphnodes of the neck, and elsewhere, are often slightly swollen and tender.

(c) Stage of Desquamation. The fine branny scales of desquamation are often so fine as to be easily overlooked. This process occupies about a week. The catarrhal symptoms in uncomplicated cases gradually disappear, so that, by the end of the second week from the initial coryza, convalescence is fully established. The cough frequently persists and is of a bronchial nature. Epistaxis is common at the height of the attack. Relapses of measles are extremely rare. Diarrhea is apt to occur at some time during the attack, without any particular significance.

Varieties.—Atypical cases may occur but are not common. They are as follows: (1) Morbilli Papulosi, development of distinct papules, hard to the touch but not extending deeply into the skin. (2) M. Vesicular; a vesicular form. (3) M. Sine Exanthema, cases in which the eruption does not appear, but general symptoms and coryza are present. (4) M. Sine Exanthema, in which the mucous membranes are not involved.

Variations in constitutional symptoms.—(1) M. Afebriles, rare cases in which there is no rise of temperature. (2) M. Hemorrhagica. This is the malignant form and in it the organism is unable to withstand the intensity of the infection and death takes place in the course of two or three days after sustained hyperpyrexia, profound adynamia, or hemorrhages into the skin and mucous membranes. These malignant forms are very rare in private practice, but they occasionally occur in asylums and in the fierce epidemics of camps, and were common in the first outbreaks among the natives of the Fiji Islands, where measles prevailed as a scourge. Death may occur before the rash appears or a few papules may show themselves upon the forehead and wrists. This is also known as black measles, and it is characterized by convulsions, delirium and coma, petechiæ, bleeding from the mucous surfaces and profound constitutional depression. The patient is rapidly exhausted, the pulse frequent and thready, the skin pale and cold, and death occurs. (3) Adynamic measles is a serious type in which the symptoms are grave from the onset but without hemorrhages and a typhoid status is early present.

Complications.—In the absence of complications, measles is comparatively a benign disease, but these complications are frequently enough present to place measles among the more serious diseases of childhood. The ordinary complications are due to the extension or intensification of the catarrhal processes peculiar to the disease.

(1) Otitis media is quite common, and may result in perforation of the tympanic membrane and permanent impairment of the hearing; or lead to sinus thrombosis, meningitis, or abscess of the brain. (2) Bronchopneumonia is the most common complication. (3) Purulent conjunctivitis may occur and in neglected cases infiltration and ulceration of the cornea. (4) Catarrhal laryngitis is a frequent complication. (5) Pseudo-membranous type is very uncommon but very dangerous. (6) Edema of the glottis is not common but does occur. (7) Diphtheria is much less common in measles than in scarlet fever. The high death rate of measles is due to the bronchopneumonia complication in which the lesions become extensive, the symptoms become urgent and a large proportion of these cases die. (8) Acute enterocolitis is a frequent and serious complication. (9) Gangrenous stomatitis occurs in young and debilitated children, and in girls gangrene of the pudenda occur during convalescence with greater frequency than in other infectious diseases.

Sequelæ.—The more common sequelæ are chronic local inflammations, conjunctivitis, otitis, nasal catarrh, laryngitis, and bronchitis. Tuberculosis is a common sequel.

Diagnosis.—During an epidemic, coryza, persistent sneezing and fever are suspicious. The appearance of the eruption on the third or fourth day upon the mucous membrane of the mouth and throat, and Koplik’s spots are positive.

Measles is often confused with 1. Rubella or German measles, 2. Variola, 3. Typhus Fever and 4. Scarlet Fever, which see. Occasionally drug exanthems are confused with measles. These may be caused by salicylates, antipyrin, quinine, turpentine or copaiba. These rashes are not accompanied by fever or throat symptoms unless they have been given to allay these very conditions.

Treatment.—Measles is so often a serious disease that it should not be attended with carelessness as it so often is, but the best of care and attention given. Parents should be informed of the danger of complications and of the absolute necessity of proper care and attention.

As soon as a susceptible individual is exposed to the measles, he should be immediately isolated, watched and corrections made of any dietetic errors, unsanitary conditions or structural lesions that may exist. He should be protected from sudden atmospheric changes and carefully watched for the first symptoms of the prodromal coryza.

On the appearance of the prodromal, or invasion symptoms the patient should be put to bed in an isolated, well ventilated room of as nearly constant temperature as is possible, from which all hangings, rugs and unnecessary furniture have been removed. The windows must be shaded to protect the eyes from direct or strong light, and any artificial lights in the room must also be well shaded.

The cases can usually be easily handled by careful, well-directed osteopathic treatments. In the manipulative treatment we must pay especial attention to the muscular and other soft tissue conditions in the suboccipital region, over the transverse processes of the upper four or five cervical vertebræ, under the angle of the lower maxilla and the lateral cervical tissues to remove any obstructions to the circulation and nerve control of the head and throat; see that the muscles in the lower cervical and upper dorsal areas are kept well relaxed, and articulation of these vertebræ, the upper three ribs and the clavicles are kept free; remove all lesions in the mid-dorsal area, whether muscular or otherwise, to prevent involvement of the lungs or heart, and to keep up function of the respiratory and circulatory systems; treat and keep normal the tissues and the articulations at the kidney and adrenal center, 11th and 12th dorsal; raise the ribs and keep them freely movable, this especially for the bronchial cough. Painful manipulations should be avoided and are not necessary. Dr. Still said, “The arms must be raised and the axillary region freed and kept so.” During the acute stage two or three treatments per day are advisable. Do not treat severely or to cause discomfort to the patient. Best results are obtained in the gentle, but thorough, treatments.

In the beginning of the case have the bowels cleansed with an enema, and then careful attention must be constantly given to the bowels and kidneys. The bowels can be kept open by manipulations and diet. The diet should be light and easily digested; during the fever it is best to withhold all food but give plenty of water. Follow fast with fruit juices and then the light diet.

The temperature is usually controlled by treatment, but if it remains high for some time and if the physician cannot reach the patient, the nurse should be directed to give a tepid sponge bath of ten to twenty minutes duration, and repeated at intervals of two or three hours. Also the tepid enema will often reduce the temperature.

For the itching of the skin, a tepid bath with water at 100 degrees given twice daily should be used, the patient dried carefully, and an application of olive oil, cold cream, liquid albolene, or a two per cent menthol salve, rubbed over the entire body will give relief.

The cough is best relieved by thorough treatment of the anterior thoracic regions and the correction of any upper rib or clavicular lesions. Keeping the air of the room moist with vapor is agreeable to the mucous membranes. The dropping of a few drops of eucalyptus oil in the boiling water produces a very soothing vapor.

If the eyes are much involved, they should be bathed every hour or two with a three per cent solution of boric acid, using cotton which is immediately destroyed after use. Dark glasses in a well ventilated room is better than an unaired darkened room.

The nose and mouth should be carefully cleansed at regular intervals and the cloths burned. The throat should be carefully examined daily at first, and at least every other day later, until the case is discharged. The conditions of the lungs must be observed by daily examinations, and the lung and bronchial areas should be daily treated to prevent the possibility of respiratory involvement.

If rash is slow in appearing and the temperature is high, a hot bath (105 to 110 degrees) for three to five minutes will often bring out the rash and relieve the more serious symptoms. During convalescence the patient must be protected against cold. Recovery is hastened by the continuation of treatment during convalescence and treatment given should be indicated by the symptoms present.

Prognosis.—Practically all uncomplicated cases recover. In the hemorrhagic and adynamic types, the majority succumb. One attack usually confers immunity. Sequelæ are frequent under the “old school” treatment, but are infrequent under careful, conscientious osteopathic treatment and careful nursing.

“In and of itself measles is usually not particularly serious, but the after effects are so far-reaching and so serious that students of the history of medicine rank measles third among infectious diseases for causing death. During recovery from measles the patient stands in special danger from pneumonia, and pneumonia following measles is more dangerous than uncomplicated pneumonia. There is a considerable length of time during which he is particularly susceptible to tubercular infection. This is so often insidious, and its evidences are so obscure, that by the time the disease has fully developed, one may have forgotten the mild attack of measles which really paved the way for the serious malady.”—C. A. Whiting.

Rubella

(German Measles; Rubeola notha; Rotheln; Epidemic Roseola)

Definition.—A specific acute, contagious, infectious, eruptive disease, characterized by a diffuse maculopapular eruption and swelling of the superficial lymphatic glands. It is attended by a mild fever, suffused eyes, mild cough, slight sore throat but no catarrh, a macular rose-red eruption of the throat accompanied by the swelling of the cervical lymph glands and by a rose-red eruption of irregular size and shape appearing on the first day of the disease.

Rubella, in some ways, resembles scarlet fever and also measles and was at one time considered a hybrid of the two. It is now known to be an independent disease.

Etiology.—The exciting cause, or the infective principle, has not yet been discovered. The disease is probably carried by fomites, is readily transmissible, attacks children especially, and usually occurs in epidemics, though sporadic cases are frequently found. The epidemics usually occur at intervals with several years intervening, during which time there are comparatively few cases. Persons of all ages are susceptible unless having acquired an immunity through an attack of the disease at some former time. Rubella does not confer immunity against any other disease, as scarlet fever or measles, nor do these diseases confer immunity against rubella. One attack of rubella confers immunity against any succeeding attacks.

The incubation period is from five to twenty-one days and is without symptoms.

The predisposing factors are the same as in measles or other infectious or contagious diseases.

Symptoms.—Invasion Period. This stage is usually of very short duration, lasting from a few hours to perhaps two days. The initial symptoms are usually mild, being a sudden chilliness, but not chills; mild fever of about 100 degrees; a slight headache; mild sore throat; swollen cervical and post auricular lymphatic glands; little or no coryza; sometimes slight pains in the back and legs; and the macular rose-red eruption in the throat which is constantly present. Often the initial symptoms are so mild that the presence of a disease is not recognized until the eruption appears, which usually occurs on the first day and rarely not until the fourth day.

Eruption Period.—The rash, which consists of round or oval reddish spots about the size of a split pea, mostly discrete, but sometimes confluent, and surrounded by areas of hyperemic skin, usually shows first upon the face and follows a wavelike progression over the body and limbs. The rash usually begins to fade upon the face before it has appeared upon the last affected areas, and usually remains in one region from a few hours to a half day. It extends over the entire body in from twenty-four to thirty hours. Occasionally the skin is so hyperemic in extensive tracts that the rash more resembles scarlet fever rather than measles. The crescentic arrangement of the papules usually seen in measles can not be made out in rubella. In the course of two or three days the rash disappears with very fine desquamation, leaving a faint pigmentation, which remains for a short time. Slight etching usually accompanies the rash.

Relapses are rare and complications infrequent. There are no special sequelæ, but albuminuria, bronchitis and pneumonia have been noted. Although one attack usually confers immunity, second attacks have been reported, which may have been real second attacks or the first attack may have been an error in diagnosis.

Diagnosis.—Early or sporadic cases may present great difficulty in diagnosis, but when an epidemic is present diagnosis becomes much easier. The direct diagnosis of the disease rests upon the very mild nature of the disease, its short initial onset, the character of the eruptions and the early enlargement of the glands with the absence of severe throat symptoms and coryza.

Rubella is frequently mistaken for mild cases of measles or scarlet fever. Unlike measles, it does not have the prominent catarrhal symptoms, the higher fever, the crescentic grouping of the eruption and Koplik’s sign. In measles the adenitis is not so severe as in rubella, and especially are the suboccipital and post-auricular glands involved in rubella. Scarlet fever has a very sudden onset with severe symptoms, a very sore throat, the characteristic tongue and the peculiar rash, all of which are decidedly different from rubella. In the latter stages the character of the desquamation is also a distinguishing feature.

Treatment.—Patient should be kept in a properly heated and well ventilated room, being careful that no draughts chill the patient, and should remain in bed for at least two days. Patient should be isolated. Treatment should be directed to the upper cervical, mid-dorsal and lower dorsal areas to keep normal the function of the internal secreting mechanism, and to normalize and keep normal the respiratory and circulatory systems. Treat carefully to upper lymphatics, working around the enlarged glands and not directly over them. Watch the excretory functions and keep them active by judicious measures. If annoying itching occurs, the hot bath followed by being wrapped in a soft warm blanket will usually relieve. Daily tepid sponging should be given and if hot bath does not relieve itching an application of olive oil or cold cream will often relieve. Diet should be reduced and regulated according to age of patient and severity of the case. Usually the above is all that is indicated, but if more severe symptoms present themselves vary your treatment according to the symptoms present.

Prognosis.—Recovery is the general rule. Relapses sometimes occur, and are usually much more severe than the initial attack. The symptoms are often more severe in adults than in children. Like measles, this disease seems to lower resistance to other infections, and therefore especial care should be taken to protect the patient from exposure to other diseases for some time after recovery from rubella. See that the patient is built up constitutionally after recovery by plenty of fresh air, suitable exercises and good food.

Varicella

(Chicken Pox)

Definition.—Chicken pox is an acute, specific, contagious, slightly febrile, eruptive disease, usually of childhood, affecting the whole organism through the blood. It is an epidemic disease that spreads rapidly, is highly contagious but not inoculable, and confers immunity.

History.—Varicella was first recognized about 1553 and was distinguished from smallpox by Trousseau.

Etiology.—The agent that causes the disease is not known; the disease usually affects children under ten years of age, but does occasionally attack adults. It bears no relation to variola, except the very slightly similar eruption. It is transferred by direct personal contact, by the air or by a third person. It is infective from the first symptoms until all the crusts have disappeared. Although the disease usually occurs in epidemics, frequently we see sporadic cases.

As in all other contagious or infectious diseases the predisposing causative factors are those conditions which lower the resistive powers of the body, such as fatigue, improper diet, exposure to sudden temperature changes and imperfect elimination of the body wastes. The structural lesions found as predisposing factors are contractured muscles of the neck and behind the jaw, and muscular and interosseous lesions of the upper cervical, mid-dorsal and dorso-lumbar areas, also of the clavicle and upper ribs.

Symptoms and Diagnosis.—There are three stages to the disease: (1) Incubation, (2) Prodromal, (3) Eruptive.

1. Incubation Period.—This period lasts about fourteen days though it may vary from seven to seventeen days. During this period there is practically no symptomatology except perhaps the last two or three days, when the child shows evidence of a little excitability and irritability. Often on the day before the first noticeable symptoms the child appears even more active than usual.

2. Prodromal Stage.—Prodromal symptoms are not common and usually last but about twenty-four hours. The first noticeable symptom is the irritability of the patient, which is followed by a temperature, usually 99° to 101°, which temperature persists during the course of the disease. There are sometimes thirst, anorexia, constipation, seldom vomiting, and a furred tongue. Some cases have been observed to have the following as prodromal symptoms, but these we believe are usually due to concurrent conditions that exist at the time of the infection: delirium, convulsions, angina, conjunctivitis, dysphagia, bloody vomiting and stools, and an initial erythema, usually scarlatiniform.

3. Eruptive Stage.—The eruption comes within twenty-four hours and is often the first symptom that is noticed. It appears first as hyperemic macules and then rose colored papular spots, somewhat comparable to the typhoid roseola and not hard. These papules rapidly become raised, flattened, ovoid, pin-head to pea-sized vesicles containing a fluid at first watery and then pearly. They disappear on pressure. The vesicles mature within twenty-four hours, are very superficial, and leave a slight areola about them, which is not inflammatory as in smallpox. The eruption appears first on the chest and then on the neck, face, scalp, and then trunk and limbs in the order named. The eruption is most abundant upon the back, and over the entire body they may number anywhere from eight to many hundred and are usually scattered.

The vesicles are not umbilicated, but some may have slightly depressed centers, are discrete, and appear in successive crops which require from three to six days to complete. Pustulation and hemorrhage into the vesicle rarely occur. On the third or fourth day yellowish-brown crusts form and gradually disappear. Scars may result from scratching or infection. By the fifth day we may find all stages of the eruption because of the appearance of the successive crops. There may be an efflorescence upon the mucous membrane of the oral cavity and of the pharynx causing slight difficulty in deglutition.

The itching may be more or less intense. As scratching may cause pitting it should be guarded against. The fever which is usually slight may persist during the entire eruptive stage, but if it is high and persists as high temperature it suggests complications. Muscular tension of the cervical muscles, especially those in front, and around the angle of the inferior maxilla are usually found, and often the clavicles are bound down, and relation of ribs is disturbed. Ulceration sometimes follows scratching, and even gangrene may appear around the vesicles in debilitated children, especially those who are tubercular or congenitally syphilitic. It is apt to be fatal in these cases. Complications of tubular nephritis, which occurs within two weeks; cardiac hypertrophy; uremia; otitis media; and bronchial affections, are sometimes met with.

Treatment.—Isolate patient so as not to come in contact with other children. The younger children should be put to bed until the crusts have formed; older children may be allowed to be up around the room if their cases are light. Pay particular attention to the muscular lesions of the neck, lower maxilla, mid-dorsal and dorso-lumbar regions, keeping them relaxed by gentle relaxing treatments. A general systemic treatment is soothing and helps to prevent complications.

“Be very careful and very thorough in your neck adjustments. Loosen the atlas and axis and draw forward the inferior maxilla from its pressure upon the vessels and nerves back of its angle. Draw the hyoid bone forward and secure good circulation of blood throughout the entire cervical area.”—A. T. Still.

Give treatment at the 4th and 5th dorsals to stimulate the superficial circulation and thus increase elimination through the eruption as well as the sweat glands. Remember the eruption is the expression of the body’s attempt to eliminate the toxins within.

Keep the bowels active by splanchnic and abdominal manipulations and by laxative diet. If bowels are persistently inactive use enemata. Diet should be bland and easily digested. During fever, diet should be liquid or better restricted, giving only water in abundance.

During the eruptive stage do not use tub baths. Daily tepid sponges with either plain water or boric acid solution answers both as an antiseptic wash and bathing. After the daily sponging, and as often as necessary to control itching, anoint with a 10% boric acid ointment or with carbolized vaseline. If scratching can not be controlled, the hands should be tied in muslin bags. As in smallpox the ultra-violet rays seem to irritate the eruptions and to increase the tendency to scarring, therefore the windows and lights should be screened with a dull red material.

Prognosis.—Invariably favorable unless complications set in, which is seldom. Recurrences are very rare.

Prophylaxis.—The child should be kept in quarantine for three weeks or until the skin is entirely clean.

Epidemic Parotitis

(Mumps; Epidemic Parotiditis)

Definition.—Mumps is an acute, infectious, contagious disease, occurring in limited epidemics, and characterized by inflammation of the salivary glands, particularly the parotid, swelling slight fever and pain over the involved glands. There is special liability to orchitis or to mastitis.

Etiology.—Predisposing Factors: Mumps is peculiarly a disease of childhood and adolescence, not being common in infancy or after the twentieth year. It affects boys nearly twice as often as girls. Mandibular and upper cervical lesions, both of the interosseous and soft tissue types, are undoubtedly potent predisposing factors, as they obstruct and interfere with nerve and circulatory function to the glands affected. Also any condition which lowers the child’s resistance to infections makes them more susceptible to this disease than to any other, these conditions being fatigue, exposure to dampness and sudden weather changes, dietetic errors, etc. The cases are more numerous in the spring and autumn seasons. Extensive epidemics are infrequent, but do occur in reformatory institutions and children’s homes. It is much more widespread in large cities than in the country or villages.

Exciting Cause; The specific cause has not been demonstrated. The disease is usually transmitted by direct contact, but there are instances where it has been transmitted by a third party or by fomites. There are two views as to the mode of infection; the first being that the active principle travels along the course of the salivary ducts from the mouth to the glands, probably most often through the duct of Stenson to the parotid gland. This is the most generally accepted theory. The second is that the infection is a general one to which certain structures are more susceptible, principally the salivary glands, and the parotid in particular.

Symptoms.—The period of incubation is from fourteen to twenty-one days. Prodromes are usually absent, though in the more severe cases constitutional disturbances, with chilliness, vomiting and mild fever may precede the local inflammation. In the milder cases the local swelling may be the first manifestation of the disease. The temperature is usually moderate but may rise to 103 or 104 degrees in the more severe cases. The left side is more often affected than the right. The disease is characterized by a feeling of tension with soreness just below the ear. Soon a slight swelling may be observed directly under the ear and in the course of forty-eight hours it reaches its maximum size. The parotid gland becomes greatly enlarged and the adjacent tissues of the neck and face become tense and edematous. The skin becomes hard and glossy and usually white in color because of the obstruction to the circulation from pressure. The swelling is between the angle of the jaw and the mastoid process, pushing the ear upward and its lobule is pushed sharply outward. In the majority of cases the other side becomes affected in two or three days, but sometimes the spread of the disease to the other side is delayed for several days, and occasionally the other side escapes the infection. Frequently the swelling of the other side is so slight that it is only recognized by the closest scrutiny. Infrequently the submaxillary glands become affected without involving the parotid glands, but these cases are rather rare.

The patient is usually unable to open the mouth without considerable pain; acids, and rarely sweets, produce spasms of the jaw muscles; speech and even deglutition are difficult; the salivary secretions are usually increased but quite frequently they are decreased. The breath is foul and the tongue is furred. The mucous membrane of the cheek and pharynx are reddened and there may be a slight angina.

The spine shows subluxations of the upper cervical area, particularly of the atlas and axis, also upper rib lesions and upper dorsal lesions are frequently found. The lesions of the second and third dorsal, and their ribs, are most frequently found when the submaxillary gland is involved.

The symptoms persist from six to fourteen days, when the swelling disappears and the patient regains normal health. Orchitis occurs in about one-third of the cases after puberty. In infancy and childhood it is extremely rare. Usually one testicle is involved, and is characterized by weight, swelling and pain in the scrotum. The testicle may become greatly enlarged when the pain becomes intense. Atrophy may result and if both testicles are affected the loss of reproductive ability may result. In females, usually after puberty, the breasts may become enlarged and tender, pain and tenderness of one or both ovaries, hematoma of the labia, or a vulvovaginal discharge may occur. However these complications are very rare. As a rule the patient is not very sick and relapses are very uncommon. The attack confers immunity which is practically permanent.

Diagnosis.—Under ordinary conditions, especially during an epidemic, the diagnosis of mumps is very easy. The swelling in front of and below the ear, with the displacement of the lobule outward is quite indicative of mumps. The relative rapidity with which the swelling appears, develops and subsides is characteristic of mumps. In acute cervical adenitis the swelling is below the angle of the jaw and does not at any time correspond with the outline of the parotid gland. In Hodgkin’s disease, which is a chronic affection of the lymphatic glands, the salivary glands are not involved.

Treatment.—The patient should be kept away from other children, and should remain in a well lighted, well ventilated room of even temperature, and if the temperature is high or moderately high he should be kept in bed.

The correction of all interosseous lesions is indicated, especially of the upper cervical area, though the second and third dorsal should be given attention because of the influence of these dorsal nerves upon the submaxillary glands. Also correct upper rib lesions that may exist. As mumps is an infective disease the channels of elimination should be watched and stimulated. Build up the body resistance by treatment at the mid-dorsal area to affect circulation and respiration; and lower dorsal area to affect kidney and adrenal function. Watch the bowels and keep this avenue of elimination functioning freely, using enemata if necessary.

The diet should be liquid, of fruit juices, thin gruels, milk and plenty of water. Tepid sponging allays the fever and restlessness. Relaxation of the deep muscles of the neck and shoulders will do much to make the patient comfortable, also the muscles under the angle of the jaw. A very gentle relaxing of the tissues around the gland itself, by crowding them toward the gland, assists in relieving the tension by securing a better venous and lymphatic drainage.

Hot applications to the swollen glands will give a considerable relief; these may consist of hot fomentations, hot salt bag, electric heating pad, hot water bottle, etc. The mouth is kept in good condition by the use of a mild antiseptic mouth wash.

Orchitis should not occur if the boy is kept warm and in bed. If it does occur the best treatment is relaxation of the lower dorsal and upper lumbar spinal muscles, rest in bed, support and protection of the scrotum with cotton wool, cold applications, correction of any bony lesions affecting the pelvic viscera.

If mastitis occurs, rib lesions will be found and should be corrected, as they are probably the predisposing factor to this complication. Treatment would consist of correction of these lesions, if it can be done without irritating the inflamed glands. The manipulation of the surrounding tissues, with gentle crowding of the normal tissues toward the inflamed glands, without exerting any pressure on the gland itself, is helpful and comforting. Free tissues back to the axillary lymphatics.

Prognosis.—The outcome is usually favorable. In the rare fatal cases, meningitis is the usual cause of death. Under osteopathic care the duration of the swelling, fever and pain is usually greatly lessened.

Quarantine of twenty-four days is necessary.

Whooping Cough

(Pertussis; tussis convulsiva)

Definition.—It is a specific, epidemic, infectious, contagious disease affecting the respiratory organs, characterized by a cyclic course, a severe convulsive cough, paroxysmal, with the characteristic “whoop.”

Etiology.—It usually occurs in children, most frequently during the fourth year, and extremely seldom after the twentieth year. It appears to be slightly more frequent among girls, and most cases occur in March and April. Pertussis is highly contagious, being carried by direct contact and by fomites. The Bordet and Gengou bacillus is the specific cause. This is found in the sputum most abundantly during the first week, the most infectious period, and becomes gradually less. One attack usually confers immunity.

The incubation period is from seven to ten days. The patient may be considered non-infectious five weeks after the first whoop.

Lesions of the cervical and upper dorsal vertebræ and of the first, second and third ribs, affecting the vagi, the phrenic, the sympathetic, the recurrent laryngeal or the vasomotor nerves predispose to the disease.

The bacteria were found by Mallory and Horner to be characteristically between the cilia of the trachea and the bronchi. They interfere, mechanically, with the movements of the cilia, preventing the normal removal of secretions.

Symptoms.—The disease is divided into three stages: 1. The catarrhal stage, which lasts one to two weeks; 2, the spasmodic stage, three to six weeks; 3, the declining stage, three weeks.

The Catarrhal Stage: Characterized by headache, photophobia, conjunctivitis, coryza and a cough which becomes drier and harder toward the end of this stage. Often the invasion is insidious and sometimes well marked with a temperature of 100° to 102°. Frequently this stage cannot be differentiated from a “hard cold,” except toward the end of the stage when the cough becomes worse instead of better, and the child will seek some support to steady itself during the coughing paroxysm. Also the eyes will water freely during the coughing spell and the child will not be able to “get his breath” between coughs, but will have a number of coughs without inhaling.

One to two weeks.

The Spasmodic Stage: This stage dates from the “first whoop.” The fever now usually ceases, unless there are complications. The cough becomes paroxysmal, consisting of a succession of fifteen or more short, rapid expiratory puffs with no intervening inspirations, immediately followed by a deep, loud inspiration, which is the characteristic “whoop,” and is due to the partial closure of the glottis. Each paroxysm is composed of three or more such spells, the last one often followed by the expectoration of a small plug of mucus or by vomiting. During the paroxysm the facies presents a swollen, dusky appearance, eyeballs protruding, eyes reddened, and puffy, pinkish lids. The child is well except for the paroxysm, which has an aura, tickling in the larynx, thoracic constriction, a creeping sensation, when the child attempts to brace himself, or runs in terror for support. The “whoop” is a deep, singing or whistling inspiration which is absolutely characteristic. During the cough the child’s body is bent forward and he is perfectly helpless, often passing urine and feces involuntarily. Cyanosis often occurs from the strain.

After the attack patient regains control of himself, the respiration is fast, and there is fatigue, sweating and often pain in the abdomen from the strain of coughing. During the severe cough petechiæ of the forehead, ecchymosis of the conjunctivæ, epistaxis, bleeding of the external auditory meatus or from the frenum of the tongue may occur. Ulcer of the frenum of the tongue is quite common. The parosyxms vary from four to a great many per day, averaging about twenty.

Three to six weeks, usually four weeks.

The Terminal or Declining Stage: This stage is longer in proportion in the mild cases. The paroxysms occur at longer intervals, are of shorter duration and of less intensity, the catarrhal symptoms are more marked, the expectoration becomes thinner, fluid, mucopurulent, and looser. The “habit cough” may follow. It is during this stage that complications are most likely to occur, therefore it is the most dangerous.

Complications.—Catarrhal inflammations are common in the initial stage. Bronchopneumonia is the most frequent and severe complication. Lobar pneumonia, exudative pleurisy, endocarditis, pericarditis, meningitis and nephritis are infrequent complications. Spasms of the glottis in nervous or scrofulous children is largely nocturnal, and may cause death from asphyxia even in the lightest cases. Hemorrhages may occur in the skin, conjunctivæ, nose, throat, ears or cerebrum. The writer knows of one case where death was sudden from a cerebral hemorrhage in an apparently mild case. Other complications are cardiac dilatation, emphysema, bronchiectasis, pneumothorax, aneurysm hernias, muscular ruptures, and visceral prolapses.

Spasmodic cough from diseased bronchial glands very closely resembles whooping cough. Barthez and Sannee give the following differentiation:

Treatment.—Isolation of patient in well ventilated, sunny room where there is plenty of fresh air day and night is essential. Children exposed to infection should be disinfected and isolated for three weeks, as the disease can not be diagnosed during the catarrhal stage. If case is at all severe, patient should be put to bed.

Cases receiving early treatment are sometimes aborted. Treatment of the whole respiratory tract with correction of vertebral and rib lesions, and relaxation of the contracted muscles should be given. Treatments for the first few days should be at least twice per day. Pay especial attention to the vagi and phrenic nerves. Lesions of the first and second ribs will affect the recurrent laryngeal nerves which will aggravate the cough. The muscles of the shoulder girdle are always very tense and should be kept well relaxed, as should the subscapular muscles. Frequently after treatment the child will have a coughing spasm and raise large quantities of mucus, after which there will be no more spasms for several hours.

Children who play and live out of doors get along best. To support the diaphragm and abdominal muscles from the strain of coughing a muslin bandage tightly pinned about the trunk is very valuable, a pad being placed over the stomach under the bandage. In a very young child instruct the nurse to strongly flex thighs on abdomen during the severe coughing. Inhalations of steam from water with a very few drops of eucalyptus oil in it often relieves the first tickling sensations.

If cyanotic symptoms appear they may be relieved by raising the ribs, especially those over the heart; by relaxing the subscapular muscles; and by supporting the heart by application of cold cloth over the heart. Elevating the abdominal viscera and diaphragm is, also, of distinct benefit.

The diet should be nutritious and easily digested, restricted to liquids during the fever. The child should be warmly clad and protected from drafts. The excretory systems should be kept active by plenty of water drinking and by diet. Treatment should be continued during the terminal stage to prevent the possible complications. Irritants, as beef-tea, stimulants, dry bread, cookies and overfeeding, provoke coughing and vomiting. Food should be given at frequent intervals in concentrated form—gruels, milk with lime water, zwieback in milk, eggs, meat juice, etc. Older patients tolerate more solid food.

Prognosis.—With the complications, this is the most fatal of the acute infections under five years of age. Infants and little children should receive special care. Ordinary uncomplicated cases are favorable for recovery. The prognosis depends upon the age and strength of the patient, the severity and number of the paroxysms, and the presence or absence of complications. No recurrence is to be expected.

Death is due to spasm of the glottis or to extensive subdural hemorrhage, occurring chiefly in the children of the poor and in delicate infants.

Prophylaxis consists of isolation, disinfection of sputum and final fumigation of the premises. Children should be protected from exposure to infection from whooping cough. It must be realized that it is a very serious disease.