CONSTITUTIONAL DISEASES
Rheumatic Fever
(Inflammatory Rheumatism)
Definition.—An acute, febrile, non-contagious disease; it is infectious, although there is some controversy as to its exact nature; characterized by a multiple arthritis and a tendency to involve the heart.
Osteopathic Etiology and Pathology.—The prevailing thought is that the disease is an infection due to a diplococcus. This micro-organism is called by others micrococcus rheumaticus and streptococcus rheumaticus.
“Rheumatic fever occurs most frequently in the temperate zone, among people who live under conditions which are unhealthful and which especially induce focal infection. It is most prevalent in the young and in the more exposed male of all ages. The excess of lymphoid tissue in the pharynx and nose of the young explains the frequency of the incidence of the focal infection and the subsequent rheumatism. The frequent association of the onset of rheumatic fever with lowering of the body temperature by exposure to cold and a wetting is explained by the increased specific virulency of the bacterial cause acquired by a low temperature and the coincident lessened resistance of the patient due to the exposure. The frequent absence of evidence of acute focal infection at the onset of the systemic disease is not an evidence that no focus exists. The latent chronic streptococcus infection of tonsillitis, pyorrhea alveolaris, sinusitis, etc., may suddenly acquire increased virulence and specific pathogenic affinity with varying degrees of focal tissue reaction. This transmutation of type and pathogenicity certainly occurs in the focus of infection. The removal of the tonsils and other sites of focal infection has been followed by complete recovery of prolonged, subacute and chronic types of arthritis and has unquestionably prevented recurrent attacks of rheumatic fever to which the susceptibility is increased by one or more attacks. The occurrence of rheumatic fever after the removal of an apparent focus may be due to secondary systemic latent foci in lymph nodes proximal to joints, in the neck or elsewhere. The streptococci of these secondary foci may take on new virulence and specific pathogenicity, from the same causes which induced like changes in the pathogenic bacteria of the primary focus.[67]”
Osteopathic lesions play an important role, both in their relationship or bearing upon the tissues of a possible site for a focal infection and upon systemic conditions that derange general bodily tone. This has been definitely confirmed in those cases of rheumatism where correction of the osteopathic lesions, with attention to hygienic measures, have resulted in recovery. This is a feature of osteopathic etiology and therapy that can hardly be over-emphasized, for an intact innervation, circulation and chemism of the organism is basic to both preventive and curative therapy. Rheumatism, like most diseases, is of local origin and if tissues and structures can be kept up to the normal, infectious or the other pathologic processes can rarely become active.
Pathologically, the synovial membrane is hyperemic. The muscles and ligaments are inflamed. The fluid is serous with more or less fibrin and leucocytes. In severe cases slight erosion of the cartilages is found. Acute rheumatism is rarely fatal; when death does occur it is generally due to the complications which arise.
Symptoms.—The onset is usually sudden; although it may be preceded by slight fever, aching in joints, chilliness, and sore throat. It generally involves the larger joints and is almost always multiple; it has a tendency to move from one joint to another. The pain in the joints usually develops rapidly with slight chilliness and a rapid rise in the temperature from 102 to 104 degrees F. The pulse is frequent, often disproportionately to the fever. There are profuse acid sweats, often causing sudamina. There is loss of appetite and thirst is present. The urine is scanty, high colored, very acid, and deposits urates upon standing. The tongue is coated and the bowels are constipated. The joints are reddened, swollen, extremely painful and tender to the touch. Every movement, jarring of the bed, or the pressure of the bed clothes is agony to the patient. The blood is greatly deranged, anemia develops rapidly and there is well marked leucocytosis. The duration varies from a few days to several weeks.
Complications.—The temperature may rise to 106 or 109 degrees F.; this is often associated with delirium, great prostration and a feeble, frequent pulse. Endocarditis, pericarditis, myocarditis, pneumonia, pleurisy, iritis, chorea, convulsions and meningitis may occur. Coma may develop without preceding delirium or convulsions; this is very serious and may prove fatal. Subcutaneous fibrous nodules attached to tendons and fascia sometimes develop. They vary in size and are most common in children and in young adults, occurring most frequently in the fingers, hands and wrists. They are also sometimes seen about the elbows, knees, scapulæ and spines of the vertebræ. They usually last a few days, sometimes for months, and generally develop during the decline of the fever. Cutaneous affections, such as urticaria, erythema, nodosis, purpura and sweat vesicles sometimes appear.
Diagnosis.—This is seldom very difficult; there are, however, several affections which resemble acute articular rheumatism. In septic arthritis its association with some other septic process and the tendency of the inflammation to end in suppuration with more or less destruction of the joints, will determine the diagnosis. Septic arthritis may develop during the course of pyemia, puerperal fever, or acute osteomyelitis. Gout is rarely mistaken for acute rheumatism. Gout occurs later in life and usually affects the greater toe; history and mode of onset will usually render the diagnosis easy. In gonorrheal rheumatism the history of recent infection, its obstinate character and being generally connected with a single joint from the start are diagnostic. It especially affects the knee. Heart complications are rare. Rheumatoid arthritis begins in the small joints; then attacks them all, leaving permanent deformity. There is no fever or sweats and the heart is not affected. Acute arthritis of infants usually attacks the hip or knee. The effusion becomes purulent.
Prognosis.—Recovery is the rule, but the prognosis nevertheless, must be guarded. Relapses and recurrences are common.
Subacute Rheumatism.—In this form both the local and general symptoms are of a milder type and are more prolonged than in the acute form. The temperature seldom rises above 101 degrees F. The inflammation of the joints is not so severe and fewer joints are involved. It may last for weeks or months, and then it may pass into the chronic form. Usually though, when the course is prolonged, the joints return to their normal state.
Treatment.—Place the patient in a room that is well ventilated and maintain a temperature of about 70 degrees F. Avoid draughts of air. The bed should be soft and smooth and blankets should be used. The diet should consist largely of milk, and let the patient drink freely of water. Oatmeal, barley water, egg albumen and meat juices may also be used.
Treatment should be given along the entire spine, especially if the rheumatism changes from one joint to another; otherwise treat the innervation directly to the affected joint. Correct any derangements that may be found along the spinal column and carefully relax the deep back muscles. Particular attention should be given to the bowels and kidneys. Also, treat the liver most thoroughly during each treatment. The liver is many times considerably enlarged and tender in rheumatism and a thorough treatment of it seems to favor a more rapid cure.
Carefully treat the affected tissues. If you cannot treat over the joint, then manipulate the tissues above and below the joint; and usually after a few minutes’ manipulation the swelling is somewhat relieved so that direct treatment of the joint can be given. It is best to wrap the inflamed joints in flannel if the pain is severe. Besides treatment of the innervation of the joint, hot applications will be helpful. Some claim that cold compresses are of aid to the inflamed joints.
Complications are to be treated separately. Besides the ordinary fever treatment for the fever, the cold bath is very effectual. After convalescence has been established, the patient should be carefully protected for several days from cold and damp. For any stiffness that may persist, manipulation and hot baths will be quite sufficient.
H. M. Still[68] writes “If the fever is not over 103 degrees I do not try to reduce it.... After treatment in a majority of cases, the fever is reduced within twenty-four hours unless complications have set in. These are usually of the heart, so no matter how mild the attack, keep this in mind. If the action is irregular and weak, stimulate it two or three times a day. If it is rapid and high fever, go to the vasomotor centers and reduce fever, then inhibit the heart action and keep the excretions active. If the joints are affected I always move them gently no matter how great the inflammation. As yet I have never had a case of rheumatism in which cardiac lesions or ankylosed joints were a sequela.”
If the tonsils are evidently badly diseased and osteopathic treatment does not clear them up do not hesitate to have them removed.
Chronic Articular Rheumatism
Osteopathic Etiology and Pathology.—This disorder should be studied in connection with arthritis deformans owing to similar sources of infection and various common factors. It usually develops slowly and follows an acute or subacute attack and is common among the poor, especially those exposed to damp and cold. Heredity, advanced years, although the disease may appear at any age, and constant exposure to cold and wet are predisposing causes. Chronic lesions to the spinal column corresponding to the affected area are found. Too much stress from an osteopathic point of view cannot be placed upon the importance of lesions to both the digestive organs and to the joints especially involved. Then, in addition, particular attention should be given osteopathically or surgically, or both, to sites of focal infection.
Pathologically, the capsules and ligaments of the joints are thickened also, the sheaths of the tendons around the joint, so that in long standing cases the movements are impaired. In severe cases the cartilages may be eroded. Atrophy of the muscles covering the joints sometimes occurs, especially when there is neuritis; thus producing marked deformity. This muscular atrophy is particularly marked when the shoulders or hips are involved. The atrophy is caused partly from disease; in cases where the joint is distended with effusion, the wasting may be due to pressure upon the muscles or blood-vessels.
Symptoms.—Several joints are usually affected; but it may be limited to one joint, particularly the knee, hip or shoulder. Pain and stiffness are the most common symptoms. The pain is increased upon motion, while the stiffness is often lessened by using the limbs. The joints are slightly swollen, but seldom reddened and are usually tender upon pressure. All the symptoms are aggravated on the approach of stormy weather. There is fever but the general health is not greatly impaired. There may be distortion of the joints and ankylosis may occur. Arterial degeneration and chronic endocarditis may develop as complications.
Prognosis.—This should be guarded so far as a complete cure is concerned; although most cases are greatly benefited.
Treatment.—The treatment of chronic articular rheumatism is largely correcting lesions of the spinal column, which affect the diseased tissues as well as the digestive organs, local treatment of the joints, and removal of focal infections. A certain percentage will respond to osteopathic measures alone, though surgery has a definite place in others. The joints and limbs should be thoroughly treated so as to restore a better circulation and relieve the inflamed tissues. Wrapping the affected joint with cold cloths and then covering the cloths with flannel and oiled silk is often helpful. Due attention should be given the general health, such as nourishing food, free elimination and outdoor exercise.
Probably in some cases where the primary infection has been eliminated secondary foci are present and a general treatment will arouse sufficient reaction to cope with the condition.
Arthritis Deformans
(Rheumatoid Arthritis)
Definition.—A chronic affection of the joints, characterized by progressive changes in the cartilages and synovial membranes, and by new osseous formations restricting the motion of the joint and causing deformity.
Osteopathic Etiology and Pathology.—It is due to lesions of the spinal column affecting the spinal and sympathetic nerves as well as disturbing the circulation to the cord. Lesions of the spinal column and ribs are found corresponding to the innervation of the diseased joints. The osteopath has been able in every case to demonstrate clinically important osteopathic lesions. In addition the symmetry of joint involvement, muscular atrophy, sweating, etc., point to nervous lesions. Falli found upon autopsy that the anterior horns had undergone atrophic changes. Nervous lesions are probably of a predisposing character while some infection is the exciting cause. A thorough search of the entire body should be made for foci of infection. Malnutrition, traumatism, exposure to cold, and pelvic diseases are important causative factors. In all cases lesions will be found disturbing the organs of digestion. Females are more frequently affected than males. The disease is frequently seen in women suffering from ovarian and uterine troubles, especially at the menopause. Hereditary influence may be a factor, also auto-intoxication. The disease is most common between the ages of twenty and thirty. Mental worry, anxiety, grief and injury are also predisposing factors.
Pathologically, in one class of cases, the cells of the cartilages and of the synovial membrane proliferate. The cartilages undergo atrophy, or may become soft, degenerate, and are absorbed, leaving the ends of the bone bare. The bones naturally atrophy and become smooth. In another class the edges of the cartilages where the pressure is slight, thicken and form outgrowths which ossify and enlarge the heads of the bones, forming osteophytes which greatly impair the motion; true ankylosis is rare. The synovial membrane becomes thickened, also the capsule and ligaments, thus greatly restricting the movements of the joints. The muscles around the joints atrophy. In the spinal cord atrophic and degenerative lesions are found. In Still’s disease there is an enlarged spleen and marked changes in the joint.
Symptoms.—Pain and swelling of the joints and fever and enlargement of the lymphatics near the joint are characteristic. The spleen is congested and later on there is gastro-intestinal disturbance. Multiple arthritis deformans, also known as Heberden’s nodosites, is characterized by nodules developing at the sides of the distal phalanges. It occurs most frequently in women between the ages of thirty and forty, and gradually increases with age. At first the joints are swollen, tender and painful and then apparently become better. These attacks may appear at different intervals while the nodules at the sides of the joints gradually increase in size. The larger joints are rarely affected. The progressive form may be either acute or chronic. The acute form at the onset may resemble articular rheumatism. It is more common in women between the ages of twenty and thirty, but may occur in children. Pregnancy, recent delivery, lactation, the menopause, and rapid child bearing are common antecedents. There is swelling and tenderness of the joints and slight fever. Several joints are usually involved. The chronic form is most common. Symmetrical joints are usually involved. The affected joints slowly enlarge and are painful and red. Usually the hand is first affected; then the wrists, knees, toes, jaws and spine; in extreme cases every joint is affected. The vertebræ, spondylitis deformans, may be attacked. The cervical spine may be alone involved, in which case the head cannot be moved up or down, although rotation usually remains. In some instances the entire spinal column is affected and may become perfectly rigid. In some cases there is hardly if any pain, while in others the pain is agonizing and is almost constant. The joints gradually become deformed, stiff and creak when moved; later they become completely ankylosed. This deformity is due partly to the thickening of the capsule, to the presence of osteophytes, and to the contraction of the muscles. These contractures flex the leg upon the thigh and the thigh upon the abdomen. Muscular atrophy increases the deformity. Numbness, tingling, pigmentation and glossiness of the skin, and local sweating may be present and are of trophic origin.
The monoarthritic form affects old persons chiefly, and women more frequently than men. It affects particularly the hips, the knees, the shoulders, and the vertebral articulations. This is often caused by an injury. The muscles waste away and the knee-jerk is usually increased upon the affected side.
Diagnosis.—Care has to be taken in not confusing it with rheumatic fever or gout. Radiographs should be made.
Prognosis.—If treated early there is a fair chance for curing the disease. Advanced cases usually improve under treatment. The osteopathic treatment should be persistent for at least several months.
Treatment.—Osteopathic treatment, if long continued in rheumatoid arthritis, has given satisfactory results, although owing to the extent of the deformity, a cure in advanced cases cannot be expected. An important cause of the disease is probably a trophic or vasomotor disturbance to the tissues of the joint. Osteopathically, there is never any difficulty to locate disorders in the spinal column corresponding to the innervation of the involved joints. The fact that many of the joints are affected symmetrically indicates that the lesion is a spinal one involving the nerve center. During the incipiency marked improvement is the rule.
A thorough attempt should be made in every case to discover the source of infection and remove it, though this does not preclude the essential osteopathic adjustment.
The treatment consists of attempts to correct the spinal derangement and careful manipulation of the diseased joints to restore vitality and motion in them. The preceding simple, but effective treatment, must be continued two or three times per week for months or even years in order to be of particular value. Coupled with the specific treatment should be a careful consideration of the general health. The emunctories should be kept active and the food of the patient be nutritious. The osteopath should require the patient to take considerable physical exercise at regular intervals, warm baths and plenty of fresh air. Massage and friction of the diseased joints will be of aid in absorbing effusions and in restoring the tone of atrophied muscles. Hot compresses are a help. The baths at various hot springs are sometimes of benefit, and change of climate is invigorating.
O. J. Snyder[69] has this to say: “I must be very emphatic, however, to here advise exceptional caution in your manipulative procedure. * * * You cannot attempt to move the joint, for, if you do you will cause excruciating pain and do irreparable harm in that you will cause breaking down of the cartilage and cancellous bone tissue. Your first endeavor should be to reduce inflammation and to mitigate pain. * * * Osteopathically much comfort and reduction of pain can be accomplished by inhibition in the proper spinal areas. A little friction and very gentle extension or traction of the joint can be attempted as soon as the condition of the joint, by the foregoing treatment, has been made possible. At no time should rotation or sidebending, or any other manipulation that produces irritation of tissue be attempted.”
In stout adult women a villous arthritis of the knees may develop owing to faulty posture and poor elimination. These conditions are often amenable to treatment.
Muscular Rheumatism
Definition.—A painful disease of the voluntary muscles and of their fascia and the periosteum. It is regarded by many as a neuralgia of these muscles. The pain is greatly increased by motion and pressure.
Osteopathic Etiology and Pathology.—Osteopathic experience with cases of muscular rheumatism shows that the nerves, as they pass to and from the spinal muscles, are affected. The lesion is caused, principally, by subdislocations of the vertebræ, ribs or pelvis, according to the region involved. A gouty or rheumatic diathesis, heredity, exposure to cold and wet and previous attacks are predisposing causes. Men are more often affected, owing to their more frequent exposure. The disease affects persons of all ages. It occurs in acute, subacute and chronic forms.
In cases of frequent recurrence focal infections and intestinal toxins are often important factors. Vertebral and muscular lesions, septic foci, intestinal stasis, exposure to cold and drafts are principal causes.
Pathologically, there is swelling of the muscles of the nature of myositis. In chronic cases there is often atrophy of the muscles, due to interference of the trophic nerves.
Symptoms.—These are generally local and are never accompanied by marked constitutional disturbances. There is seldom fever, and the pulse is only slightly increased in frequency. Pain is the chief symptom; it is increased by motion or pressure. Tenderness is generally present and there may be swelling of the tissues. Rheumatic nodules have been found. The duration is usually three or four days, though it may last longer with frequent recurrences.
Lumbago is a painful affection of the muscles of the lumbar area and their tendinous attachments. The onset is generally sudden. In severe cases it sometimes renders the patient helpless. In torticollis, or stiff neck, the muscles of the side and back of the neck are affected. It is usually confined to one side of the head. Any attempt to turn the head causes a sharp pain. In pleurodynia the intercostal muscles, and sometimes the pectorals and serratus magnus, are affected. It usually affects but one side, more frequently the left; it is the most painful form of the disease, since the pain is aggravated by breathing. The respiratory movements are consequently restricted on the affected side. The absence of fever and physical signs will distinguish it from pleurisy. In intercostal neuralgia the pain follows the distribution of the nerves and there are tender spots along their courses. Cephalodynia affects the muscles of the scalp. Scapulodynia, omodynia and dorsodynia affect the muscles of the shoulder and upper dorsal. Abdominal rheumatism affects the muscles of the abdomen.
Prognosis.—The prognosis is good. Favorable results are the general rule under careful treatment.
Treatment.—Muscular rheumatism is usually an easy affection to cure. The cause of the disturbance is generally found in the region involved, and is due, in the majority of cases, to some dislocated tissue, usually osseous, that irritates the nerves to the muscles. In addition to correcting the lesions, removal of septic foci, free elimination, lessened diet, stretching of the muscles, application of heat, ironing and rest are beneficial.
In lumbago there is invariably found a slight lateral deviation of some vertebræ along the lower dorsal or lumbar region. Occasionally deformity of the vertebræ, asymmetry, or arthritis are factors. The radiograph may be a diagnostic aid. Occasionally, a floating rib or an innominate becomes displaced. Stretching the loins by placing the patient upon his side or back and flexing the thighs on the abdomen is very beneficial. Maintain the tension for three or four minutes. Hot fomentations and rest are helpful.
Torticollis, or stiff neck, is generally due to a lesion of the middle cervical vertebræ. The lesion is usually between the third, fourth and fifth vertebræ, occasionally as low as the second dorsal. A reduction of the subdislocation will often relieve the attack. Stretching of the muscle and application of heat will also be of aid. In some cases of torticollis (chronic) there is a curvature of the cervical spine, and occasionally the muscles are more or less fibrinous. Surgical measures may be instituted. In such instances a cure cannot always be accomplished. The tonsils, nose and teeth should be examined for sources of infection.
A few cases of acute torticollis are caused by some of the deep muscular fibres becoming caught around a process of a vertebra. Severe contraction of the muscles by cold or extensive rotary flexions of the neck, may result in torticollis. Occasionally a case is found due to injury at birth. The cervical vertebræ should be carefully examined. The spinal accessory is the nerve generally involved. Lesions to the spinal accessory occur commonly at the third, fourth and fifth cervicals, or the atlas and axis. The muscles involved in torticollis are the sternocleidomastoid, trapezius, splenius and scaleni. Operations should not be performed until a thorough course of treatment has failed to relieve.
Pleurodynia is often a neuralgia of the pleural nerves. It is usually caused by subdislocations of the ribs exactly over the regions involved. Occasionally, a lesion may exist to the corresponding vertebra, but rarely. The rib is at times completely dislocated. Applications of heat and rest of the part are of aid. Strapping of the region will give considerable relief.
In cephalodynia the muscles of the scalp are generally involved by lesions in the upper five cervical vertebræ. In scapulodynia, omodynia and dorsodynia the muscles of the shoulder are usually affected by displacements of the second and third ribs, although the lesion may be found slightly lower in the ribs, or in the corresponding vertebræ. The lower cervical vertebræ may also be at fault. In recurring and chronic cases carefully examine for infectious sources. Dislocations of the shoulder occur frequently; and muscular fibres may slip out of the bicipital groove (rarely). In a few cases muscles may become contracted about the coracoid process, or the acromial end of the clavicle may become dislocated.
Abdominal rheumatism is generally caused by lesions in the lower six dorsal vertebræ, which involve the innervation to the muscles. In some cases lesions of the lower ribs are found, and in a few instances a lesion may be discerned in the upper lumbar vertebræ.
Myalgia of the upper extremity is caused by lesions of the cervical or upper dorsal vertebræ or upper ribs. Occasionally some trouble may be found in the shoulder or elbow joints. In the lower extremity lesions may be found in the lower dorsal or lumbar vertebræ, or there may be derangements of the pelvic bones. Occasionally disorder is found at the hip and knee joints.
Gout
Definition.—A nutritional disorder in which there is an abnormal accumulation of uric acid and other purin bodies in the blood and tissues; and arthritis, deformity of joints and visceral derangements being the characteristic features.
Osteopathic Etiology and Pathology.—Hereditary influences are the predisposing factors of about one-half of the cases of gout. Men are more frequently affected than women. It rarely develops before the age of thirty. Overeating, sedentary habits, drinking alcohol, especially fermented drinks, and lead poisoning are predisposing factors. Emotional disturbances may excite an attack. Gout is not confined to the rich by any means; but there is also a “poor-man’s gout,” due to poor food, unhygienic surroundings, and to an excessive use of malt liquors. Uric acid seems to be a causative factor, but whether there is an increased formation or a diminished excretion of the uric acid has not yet been fully decided. The ultimate result is the same in either case; there is an accumulation of uric acid and other purin bodies in the blood, which is responsible for some of the effects of the disease.
Osteopathic experience with cases of gout shows that lesions affecting the nervous system are important factors that control uric acid accumulation or excretion. The nerve centers controlling the affected portions of the body are almost invariably involved, as well as the nerve control to the digestive and excretory organs. A neurosis of these nerve centers probably occurs and is thus a predisposing cause of gout. Considerable can be accomplished in the treatment of gout by careful examination of the spinal column, in the region corresponding to the innervation of the affected area, for vertebral lesions, and correcting them. Usually, slight dislocations of the bones of the foot are found, when that region of the body is involved. The most common subdislocations of the foot are involvements of the astragalus with its articulations and the metatarsals.
Pathological changes are those of the joints principally. There is deposit of uric acid in cartilages, synovial membranes and ligaments. The joint of the great toe is most frequently affected, then the fingers, ankles, knees, hands and wrists. The exudates become hard and are then called tophi. In severe cases the cartilages of the ears, nose, eyelids and larynx are involved. Finally the joints become stiff, deformed and ankylosed, and sometimes there is ulceration.
The kidneys are usually the seat of chronic interstitial inflammation with a deposit of urates. The heart and blood-vessels almost always present changes. Arterial sclerosis is quite a constant lesion; the left ventricle of the heart is hypertrophied. Urate of sodium has been found deposited upon the valves. There is an excess of uric acid in the blood. Chronic bronchitis, emphysema and asthma are among the changes in the respiratory system.
Symptoms.—In acute gout, before the attack, the patient may complain of dyspeptic disorder, restlessness and twinges of pain in the small joints. He is apt to have irritability of temper and depression of spirits. The first symptom of the attack is great pain in the metatarso-phalangeal joint of the great toe, which usually comes on suddenly at night with swelling, heat and discoloration of the joint. The temperature rises to 102 and 103 degrees F. Towards morning the symptoms generally abate to recur again the next night. This lasts for several days, the symptoms gradually abating. The urine is scanty, high colored, of high specific gravity and acid in reaction. It deposits urates and often contains a small quantity of albumin. There may be gastro-intestinal symptoms—pain, vomiting, diarrhea, faintness and a rapid, feeble pulse. Pharyngitis is an occasional symptom. The cardiac symptoms are pain, shortness of breath and irregular action of the heart. These attacks may appear with varying severity. In some cases there may be severe cerebral symptoms.
Chronic gout follows repeated attacks of the acute form. The articular symptoms continue for a longer time and the condition extends to other joints. The chalk deposits slowly increase until the joint becomes swollen and deformed. The morbid changes already described are characteristic. The urine is increased in quantity, is of low specific gravity and may contain albumin and hyalin and granular casts. Involvement of the heart and blood-vessels gradually occurs.
Irregular gout or lithemia is seen in persons who have been gouty or have a hereditary predisposition. It includes a set of symptoms that are not alone distinctive, but when taken with this gouty tendency, all forms of irregular gout can be recognized. There are various gastro-intestinal disturbances; cutaneous eruptions; heart and blood vessel changes; pains in the various muscles and joints; nervous symptoms, as headache, neuralgia and neuritis; urinary symptoms, and pulmonary and ocular disorders.
Diagnosis.—Only the irregular form of gout should be difficult to diagnose. Differentiation is to be made from arthritis deformans and acute and chronic rheumatism.
Treatment.—The hygienic treatment of gout is very essential. The patient should live a quiet life, avoiding mental and physical strains. Plenty of fresh air, exercise and regular hours should be insisted upon. Alcoholic drinking should be avoided and the food taken in moderate quantities. Keeping the skin active by the use of cold baths, if the patient is strong, and warm baths should he be weak, is a helpful measure. The dress of the patient should be warm and suitable for the climate.
A regulated diet of nutritious food, taken at regular hours, is necessary. Each patient should receive separate instructions as to diet. The food given may be small amounts of beef, mutton and chicken, with fresh vegetables; with the exception of strawberries, tomatoes and bananas, fruits may be used; fats, milk and stale bread are also suitable. The patient should avoid tea, coffee, pastry, hot breads, highly seasoned dishes, and such articles. The free use of water is beneficial.
The osteopathic treatment consists of careful correction of the lesions of the spinal column in order to free the nerve force to the affected region. The spinal treatment in gout is the most essential treatment and is effective. A most thorough examination should be made of the tissues about the diseased area; in the foot the astragalus oftentimes is subdislocated from its articulations, causing obstructions to the local vessels and nerves. The metatarsal bones should receive due attention, as occasionally one of the bones corresponding to the affected tissues is dislocated, usually downward. All the joints between the diseased tissues and the spinal nerve centers should be carefully manipulated so as to favor a better circulation. During a severe attack of gout, besides careful treatment of the blood supply to the diseased region, wrapping the joint in cotton wool and applying warmth and moisture to the joint may be helpful.
The kidneys, liver and bowels are to be kept active. A light treatment to the kidneys and liver each time is very helpful in aiding the organs to eliminate the waste material, and especially in controlling any inflammation that may exist in the kidney. The essential treatment in gout is to relieve the disorder of the nerve centers, to increase the activities of the emunctories and to regulate the hygiene of the patient.
Diabetes Mellitus
Definition.—A nutritional disorder in which there is an abnormal amount of sugar in the blood, characterized by an excessive urinary discharge, in which grape sugar is constantly present, and by a progressive loss of flesh and strength.
Osteopathic Etiology and Pathology.—Almost invariably there will be found a posterior dorso-lumbar curvature wherein the spinal column tissues are much contractured. This condition probably involves the sympathetics (vasomotor and trophic) to the pancreas, liver and intestines. Important lesions may also be found as high as the occiput. Tenderness and congestion over the abdomen, especially the liver, are frequent. It affects men more frequently than women and is a disease of adult life, ranging between the ages of thirty and sixty, though cases have occurred in the very young. It is more serious in the young, the very young seldom recovering. Hereditary influences are believed to be a predisposing cause. It affects the better classes principally and especially those of a neurotic temperament. The Hebrew race is specially predisposed. The colored race is seldom affected.
Obesity, certain chronic diseases (malaria, gout, syphilis), occupations taxing the mind, and pregnancy are predisposing influences. Injury or disease of the spinal cord or brain frequently cause diabetes, especially any irritation of Bernard’s diabetic center in the medulla. Derangements of the endocrine system are important. Injuries to the spine, chiefly in the dorso-lumbar and sacral regions, and to the abdomen, and diseases of the pancreas or liver are, as has been stated, oftentimes causes. Lesions to the spine may disturb the glycogenic function of the liver, the glycolytic ferment of the pancreas, or produce an alimentary glycosuria. Extirpation of the pancreas is immediately followed by diabetes, but if a fragment of the pancreas is left it is not always followed by diabetes. The normal amount of sugar in the blood is 1-1000 while in diabetes the amount of sugar is 3 to 4-1000 up to 7 or 8-1000. The healthy kidney will not excrete sugar when it is at the normal ratio. Concerning the presence of acetone-bodies von Noorden[70] says: “The excretion of acetone-bodies may serve, like glycosuria, as a measure of the intensity of the diabetic disease ... it will be at once understood that in no other disease do the acetone-bodies occupy so important a position as in diabetes.” Irritation of the centers of the vasomotor nerves to the liver or direct stimulus to the liver cells is followed by glycosuria. Interference with the pneumogastric nerve also influences diabetes.
Pathologically, the liver is enlarged, firmer and darker in color than normal. Often there is fatty degeneration of the organ. The pancreas is diseased in about one-half of the cases of diabetes, especially the islands of Langerhans. The lesions found are granular atrophy, occlusion of the pancreatic duct, atrophy from pressure, fat necrosis, and sometimes it is small, soft and anemic. The kidney changes are those of catarrhal nephritis. In the fatty degeneration hyalin changes take place. The heart is hypertrophied in a few cases. Arterial sclerosis is frequently met with. In the lungs bronchitis, pneumonia and tuberculosis occasionally develop. In the stomach and intestines catarrh is common. The blood presents an increase of sugar. In the nervous system are found many lesions, especially congestion, extravasation and sclerosis of the brain; disturbances of the posterior part of the cord, and congestion and sclerosis of the sympathetic ganglia. The bony lesions, however, (almost invariably a posterior lower dorsal and lumbar) must involve the sympathetics, via the splanchnics, to the extent of profound metabolic disturbance, for in no other way can the results of osteopathy be explained. The importance of specific treatment at this point cannot be over estimated.
Symptoms.—The onset is gradual; thirst and frequent micturition being the first symptoms noticed. After an injury or a sudden, severe nervous shock, diabetes may set in abruptly. As the disease progresses there will be marked thirst, polyuria, an abnormal appetite, wasting and debility. The tongue is dry, red and coated. There is constipation and the skin is dry and harsh. Temperature is often subnormal; pulse frequent with increased tension.
In some cases the urine is not increased in quantity; usually however, the amount varies from four to five pints to several quarts in twenty-four hours. It is pale in color, of high specific gravity and acid reaction. Sugar is present in variable quantities from one or two per cent to five or ten per cent. Sugar in the urine must be constant in order that the affection is a true diabetic one. Albumin is often present; urea is increased and uric acid may be slightly increased. Acetone-bodies are often found and usually indicate a more serious condition.
Diabetic Coma is the most important and gravest complication. There is either a sudden or gradual loss of consciousness. This may occur after some form of exhausting exercise. There may be previous headache or a feeling of intoxication. It may be preceded by nausea, vomiting, colicky pains or some local affections, such as pharyngitis or pulmonary complications. Peripheral neuritis, neuralgia, numbness, are possible symptoms. Impairment of hearing, cataracts, strabismus, diabetic retinitis and atrophy of the optic nerve may occur. The sexual function is lost early in the disease. Eczema, with burning and itching of the labia and vicinity, (and in men a balanitis), furuncles, boils and carbuncles are common. Gangrene and edema are not uncommon. Acute pneumonia, bronchitis and tuberculosis are possible complications. Progressive loss of flesh is a serious indication.
Diagnosis.—The diagnosis is easy, as there is no other disease with which it can be confounded. Careful urinalysis should always be made. Examination for acetone, diacetic acid and oxybutyric acid is valuable.
Prognosis.—Many cases have been cured by osteopathic measures while nearly all treated have been benefited. If the patient is put upon a diet free from carbohydrates, in mild cases the sugar will disappear, while in severe cases it will still be present. Mild cases usually yield readily to treatment. In cases over forty years of age the outlook is quite favorable, but in cases under forty, and especially the young, the prognosis is not so favorable. In cases under puberty the results are apt to be fatal. Stout persons bear diabetes better than lean. All cases are liable to complications, which render the prognosis more serious. It is a disease of long duration, although death has occurred in a few weeks.
Treatment.—In nearly all cases of diabetes mellitus examined there have been found posterior conditions of the lower dorsal and lumbar regions. The posterior curve has always been fairly well marked and generally is a symmetrical curve. By that is meant a spinal curve that is not irregular and the relation of the various vertebræ, one to the other, is not seriously deranged. Correction of this condition of the spinal column has almost invariably given satisfactory results and in the majority of cases the condition of the patient has improved remarkably, and many entirely cured. To get the best results the patient should be laid on his side on the operating table and the knees drawn up so that the thighs are flexed upon the abdomen. The osteopath standing in front of the patient throws his weight against the flexed thighs and reaching over upon the spinal column springs the entire weakened portion of the spine toward its normal position, stretching the spinal column to separate each vertebra from its neighbor so that the deranged nerves, as they pass through the intervertebral foramina, may be released. Meeker[71] reports a case with a marked kyphosis which was treated two years before enough motion could be had between the vertebræ to produce any results, but after that they were favorable. Direct treatment to the abdominal organs to correct liver congestion and stimulate the pancreas and increase activity of the intestines is essential.
The nerves affected by the posterior pathological curve of the spine, mentioned above, and by separate lesions that may exist within the pathological curvature, are probably the vasomotor nerves to the portal system, pancreas and the intestines. The vasomotor nerves to the portal system branches are given off principally from the fifth to the ninth dorsal vertebræ, although fibres may escape from the cord as low as the first lumbar vertebra. The nerves to the intestines are given off principally from about the ninth dorsal to the lower lumbar vertebræ. Possibly there are nerve fibres direct to the hepatic cell protoplasm.
How lesions in the dorso-lumbar region cause diabetes mellitus is an important question and is hard to answer. An unnatural acceleration of the portal circulation may cause an increased quantity of sugar to pass to the liver, resulting in part of the sugar not being changed into glycogen and thus passing into the circulation; or a paralysis of the vasomotor nerves to the liver causes congestion and slowness of the blood stream. Thus a disturbed circulation of the liver may cause accumulation of sugar in the liver, so that the blood ferment has time to act upon the glycogen and transform it into sugar; or there may be a saccharinity of chyle or blood in the portal vein, due to an impeded conversion of sugar in the intestines into lactic acid; or there may be an accelerated absorption of sugar due to an abnormal state of the intestines; or the nervous control to the pancreatic functions may be disturbed. Hence, one or many pathological changes may occur and influence a case of diabetes, due to a disordered dorso-lumbar region.
The center for the hepatic vasomotor nerves, “diabetic center,” is in the floor of the fourth ventricle at the level of the origin of the vagi nerves. A lesion of the “diabetic center” or an obstruction to the pneumogastric anywhere along its course may cause diabetic symptoms; hence, there may be lesions of the cervical region that would affect reflexly the diabetic center, or lesions of the pneumogastric may occur, particularly at the atlas or axis, and cause diabetic symptoms, or, at least, these may influence the course of a case of diabetes mellitus. Or the upper cervical lesions may disturb the pituitary gland which is of importance in carbohydrate metabolism.
There are nerves from the superior and inferior cervical ganglia of the sympathetic that have considerable influence upon the liver. These nerves do not pass down the cord to the splanchnics, but pass in the sympathetic to the celiac and hepatic plexuses and then to the liver. Stimulation of these nerves causes the hepatic vessels at the periphery of the liver lobules to become contracted. Possibly in a very few cases, a stagnation of blood in other vascular regions of the body may cause the blood ferment to accumulate in the blood to such an extent that diabetic symptoms occur.
Dietetic treatment is essential, but is not so necessary as some medical authors would have us believe. A regulated diet should be insisted upon in all cases, but one should not go to extremes in dieting. A complete elimination of the carbohydrates is no longer considered the best treatment, as it withdraws too important an element from the diet, producing weakness without any corresponding return for good. A patient’s appetite is often inordinate and it will be necessary to regulate the quantity and character of foods. Proctor[72] mentions a case which recovered when carbohydrates were restored, as the patient was too starved to build up. Under osteopathic treatment much more liberty can be allowed in selection of foods. Von Noorden[73] reported a number of cases in which excretions of sugar continued upon the strict anti-diabetic diet, but which were sugar free when they received a large amount of oatmeal along with some vegetable proteid or white of egg and butter, other carbohydrates being excluded. It is suggested by the editor of the Series that the oatmeal may be used alternately with diabetic diet, and relieve the monotony greatly. It can also be used as a test of the patient’s digestive and sugar destroying powers. The following food may be included in the dietary:
Animal Foods.—Meats of every variety, except livers; game, poultry, fish and eggs.
Vegetables.—Cabbage, cauliflower, celery, lettuce, green string beans, the green ends of asparagus, tomatoes, spinach, mushrooms, cucumbers, watercress, young onions, or any other green vegetable.
Bread and Cakes.—Made of gluten flour, bran flour or almond flour; griddle cakes, biscuits, porridges, etc., may be made of these flours.
Beverages.—Skimmed milk, buttermilk, coffee and tea without sugar, and carbonated water.
Relishes.—Pickles, cream cheese and nuts of all kinds except chestnuts.
Fruits.—Oranges, lemons, cranberries, cherries, strawberries, all in moderate quantities.
Other foods may be used, but each case requires a thorough study in order to determine what is best to do.
Various foods should be tested out and controlled by urinalysis. The point is to increase metabolism so that the body can store up considerable carbohydrates without the appearance of sugar in the urine.
In severe cases Allen’s fasting treatment to be followed by a low diet should be instituted. However, it should be remembered that the correction of dorsal and upper cervical lesions is invaluable.
Mental excitement and worry should be avoided as much as possible. Frequent bathing and regulated exercise will be of considerable value. The diabetic patient should have a well ventilated room and plenty of rest and sleep; flannels are to be worn next to the skin the year around.
Various symptoms and complications are liable to arise, which the competent osteopath is prepared to meet by following general rules.
Keep the bowels open. And frequently examine for acetone and diacetic acid. If there are any symptoms of coma fast the patient, and neutralize the acid intoxication with bicarbonate of soda until the urine is alkaline.
Diabetes Insipidus
(Polyuria).
Definition.—A constitutional disorder in which there is a continued excessive secretion of urine, free from albumin and sugar. There is constant thirst.
Osteopathic Etiology and Pathology.—This disease is more frequent in males than in females. It occurs most commonly between the ages of twenty and thirty. It is due to chronic disturbances of the nerves. The lesions usually found upon osteopathic examination are lateral derangements of the vertebræ in the renal splanchnic region, (ninth to twelfth dorsal inclusive) or a slight kyphosis in the same locality. Such lesions probably affect the central nervous system in the region of the sympathetic nerves to the kidneys, by a paralysis of the muscular coat of the renal vessels. The disease may be associated with other conditions, as injuries and diseases of the nervous system elsewhere; exposure to cold; prolonged debility and fatigue; cerebral diseases, as meningitis, paralysis of the sixth nerve, tumor of the brain, and blows on the head; injuries of the cervical region; sunstroke; cerebrospinal fever; malaria; syphilis; pregnancy; hysteria; hereditary influences, and drinking too freely of cold water. There are many diseases and conditions which may be associated with diabetes insipidus; and which act as irritants, directly or reflexly, upon the center in the medulla oblongata (which is just above the diabetic center), or upon the sympathetic ganglia in the abdominal region. Thus, there is a vasomotor neurosis, due either to central or reflex lesions.
Second in importance to lesions of the renal splanchnics are lesions of the upper cervical region. Irritations in the cervical region may act upon the center in the medulla or the lesions may affect some of the sympathetic fibres as they pass from the brain to the renal sympathetics. The pituitary gland may be disturbed. Probably axis and atlas lesions are factors.
Lesions of the nerve centers and of the sympathetic ganglia have been found upon post-mortem examination, but they are not constant. Nervous lesions have been found in the region of the base of the brain. The kidneys are sometimes congested and enlarged. The tubules may be dilated.
Symptoms.—Great thirst and an enormous secretion of urine of a pale, watery and slightly acid nature are the characteristic symptoms. The skin is usually dry and harsh, the bowels are constipated, and the appetite may be voracious. The health on the whole is quite perfect, although if the affection is not arrested, considerable loss of flesh and strength may result. There is a tendency for the disease to become chronic.
The nervous lesion causing polyuria may be the outcome of a debilitated condition of long standing or the symptoms may occur suddenly. Preceding the large flow of urine such symptoms as nervousness, irritability, headache, sleeplessness, failure of memory, and inability to concentrate the mind commonly occur. Other symptoms may be present in addition, as debility, diarrhea, epigastric and lumbar pains, and impaired sexual function.
Diagnosis.—The diagnosis is not difficult. Thirst, polyuria and the absence of albumin and sugar characterize the disease. In diabetes mellitus, finding of grape sugar in the urine would at once exclude polyuria. In paroxysmal diuresis, the increased amount of urine is not permanent. In interstitial nephritis, there is albumin, casts, etc.
Prognosis.—Depends upon the cause. The disease yields to treatment much quicker than diabetes mellitus and is without doubt much less serious. The disease, in a large majority of cases, can be cured. Under osteopathic treatment most cases will yield good results or be cured in from a few weeks to six months.
Treatment.—The treatment of the disease causing diabetes insipidus is of first consequence, but frequently such a disease is undiscoverable. There is often a tendency toward neurasthenia; consequently, habits, environment, etc., should be carefully attended to. Examine for sexual, rectal and other reflex irritations.
Correcting lesions of the renal splanchnics is important; in fact, in a fair number of cases treatment of this locality will entirely cure the disease. A very effective treatment, in addition to the ordinary methods of treatment, is to have the patient lie flat upon the back while the osteopath reaches around the patient on either side, placing the fingers firmly upon the transverse processes of the lower dorsal vertebræ and springing the spine forward by lifting upward on the patient, enough even to raise the patient from the surface he is lying on. This treatment is especially effective in lessening the increased amount of urine. Attention should be given to the false ribs on either side and to the condition of the spine below and above the renal splanchnics. The cervical vertebræ should be examined carefully for disorders, and if any are found they should be removed at once, if possible.
Hygienic treatment is of as much importance as in diabetes mellitus. The clothing should be warm, warm baths taken, and general friction and care of the skin utilized so that the circulation may be somewhat diverted from the kidneys. Restriction of water is not always necessary, except in cases where excessive drinking has become a habit, as the thirst is caused by the diuresis and not the diuresis by the large ingestion of water. Regulate the diet and see that the bowels are acting normally.
Rickets
Rachitis
Definition.—A constitutional disease of children, characterized by impaired nutrition and changes in the growing bones, causing deformities. The physical growth is disturbed and the bone deformity is due to an over growth of cartilages and delayed calcification.
Etiology and Pathology.—Rickets may occur in the new-born, but it rarely begins before the child is six months old. It is a disease of the first and second years of life. Heredity is probably not a factor but certain races, especially the Negro and Italian, have a tendency to be rickety. The disease is much more common in the large cities than in rural districts; also it is more common in Europe than America. The disease is most frequently met with among the ill-fed and badly housed poor of the large cities, though it is not rare to find it among the well-to-do. Lesions to the digestive organs predispose. Breast-fed children seldom have the disorder. Improper or insufficient food (a diet too low in fats and proteins) bad air, want of sunlight, prolonged lactation, exposure to cold and dampness are predisposing factors.
Pathologically, the most marked changes are seen in the long bones and the ribs. The cartilage between the epiphysis and shaft is thickened and is soft and irregular in outline. Underneath the periosteum the tissue is spongy. Microscopic examination shows an increase of proliferation of the cartilage cells with scanty calcification. The bones are soft and there is a diminution in the calcareous salts. In a word ossification is delayed and the bones are not perfectly developed. In the cranium the frontal and parietal eminences are prominent, while the top of the head and the occiput are flattened, giving the head a square appearance. The fontanelles remain open until the second or third year of life. The ribs become affected very early. At the point where the ribs join the costal cartilages, bulging occurs, forming the so-called “rachitic rosary.” The normal shape of the chest walls is markedly changed. Just outside the junction of the ribs with the cartilages, the ribs fall in, producing a shallow depression, while the sternum and cartilages are pushed forward. The bones of the leg may be distorted. The normal curves of the spine are occasionally disturbed. The liver and spleen are often increased in size.
Symptoms.—The onset is slow. In many cases digestive disturbances, with their usual effect upon the nutrition, precede the appearance of the characteristic lesions. The child is irritable and restless, and there is usually slight fever and profuse sweats. The child is often languid, pale and feeble. The lymph gland are enlarged. The tissues are soft and flabby and skeletal changes begin to make their appearance. Among the first are changes in the ribs and head, already described under pathology. Changes sometimes occur in the bones of the face, particularly the maxillæ. Dentition is delayed. The spinal column is frequently curved antero-posteriorly or laterally. The long bones are curved and their extremities become thickened. The pelvis is distorted and twisted and in women this may seriously complicate labor. “Chicken breast” and “bow legs” are common, as well as muscular weakness, and the child walks late. The abdomen is large and prominent, due to flatulency and to the enlargement of the liver and spleen.
Diagnosis and Prognosis.—By observing the symptoms, diagnosis is not difficult. Prognosis should be guarded, owing to danger from other diseases; still, on the whole, prognosis is fairly favorable.
Treatment.—Rickets being a disease of malnutrition due to weakness of the digestive organs, improper food, or to influences of disease, the treatment must be principally following hygienic rules and good dieting. The child under six months, if not nursed satisfactorily by the mother, should be given diluted cow’s milk. Salts may be obtained from barley gruel and whole wheat. Diluting the milk with barley water is highly recommended. Fresh meat juice and cream are invaluable. If curds are found in the stools, the digestion is not perfect and is usually due to overfeeding the child. The child should be out doors as much as possible. Fresh air is a necessity. The worst air outside is better than the best air of the house as far as purity is concerned. Protect the child carefully with warm clothes, and when sitting or walking the child should be supported. Baths will be found beneficial.
In the older child, beef juice, light meats, yolks of eggs, green vegetables and fruits may be given. Lessen the amount of carbohydrates. Careful osteopathic treatment of the various affected tissues of the child will aid a great deal in correcting deformities. Attention to the lesions found will also aid in increasing the nutrition to the involved tissues as well as correcting digestive disturbances. This, also, is of distinct benefit in improving the assimilation of lime salts. Possibly treatment of the “nutritional” centers, (fourth dorsal and fourth lumbar) would be effectual. Carefully guard against complications of the nervous and respiratory systems. After ossification the deformities may be corrected by the orthopedic surgeon, though in the young child considerable can be accomplished by repeated attempts at straightening by bending and molding the long bones. All those conditions which predispose to rickets should receive attention; chief among these is the care of the nutrition of the mother during pregnancy. Nursing should be regulated, and possibly future pregnancies discouraged.
Obesity
Definition.—Obesity is essentially a nutritional disease and is an inconvenient accumulation of adipose tissue in the body, sometimes impairing the bodily function. With some individuals obesity is a normal condition. In others it means impaired health, especially poor elimination.
Etiology and Pathology.—Heredity, overeating, sedentary habits, hot, moist climates are predisposing causes. Exciting causes are especially the eating of fat-making food, excessive use of alcohol and insufficient exercise. Obesity may follow the menopause or an infectious disease. Osteopathic lesions are frequently found in the upper and middle dorsal region. These probably are causes of a disturbed metabolism. An excessive diet of starches and sugars will indirectly act as a fat producer. In young people the possibility of hypopituitarism should be considered. Lesions of the upper cervical, in these cases, are frequent.
Pathologically, adipose tissue is deposited throughout most of the tissues. Usually the abdomen is encumbered with a large amount. Passive congestion probably favors the deposition of fat, for in cases of pendulous abdomen, simply drawing the abdomen in and up and the patient, through voluntary effort, keeping it up, will frequently cause absorption of the fat in a few days or weeks. The fat is distributed underneath the skin, throughout the viscera and about the heart. The tissues may suffer from fatty infiltration, especially the heart, arteries and veins; also the liver, kidneys and stomach. There is an increase of specific gravity of the blood. Edema occurs from passive congestion, due to weak heart.
Symptoms.—The round, fat face, double chin, hanging cheeks, large waist, the thick, prominent, sometimes pendulous abdomen, and the bulky extremities form characteristic features. At first obesity presents no harmful symptoms. Usually the first troublesome symptom is increased frequency in the breathing, due to a weak and overworked heart, and to the fact that the motion of the lungs is hampered by the heavy chest walls, and also by the interference with the descent of the diaphragm on account of the enlarged liver. Dyspnea, passive congestion, anemia, poor digestion, uterine disorders, and mental inactivity are common. There is cardiac hypertrophy; later the heart is overlaid with fat. The pulse is usually frequent, but may be irregular and slow.
Treatment.—Obesity being a nutritional disease it seems but reasonable that alterations of the anatomical structures will produce a change in the proper balance of nutrition. Along osteopathic lines, derangement of tissues affecting the nerves to the digestive and lymphatic systems will produce obesity. In the majority of cases examined have been found disturbances at the sixth and seventh cervical, fourth and fifth dorsal and from the tenth dorsal to the second lumbar. Lesions at these points could readily interfere with the thoracic duct and the receptaculum chyli, as well as with the processes of digestion, assimilation and elimination. It is claimed that stimulation of the splanchnic nerves causes dilatation of the receptaculum chyli. Direct treatment to the abdomen and to areas of fatty deposit will aid very materially in absorption.
The dietetic treatment is essential, the principle being to furnish less food to oxidize. Restrict fats, sugar and starches and limit the amount of water. Alcohol should be prohibited. Another important point in the treatment is exercise, which must be carried out in a systematic way. Rules can be laid down only in individual cases and should be governed by the osteopath in charge. The principal effect of general mechanical treatment is to promote oxidation. Massage and baths are beneficial. The patient can do much for the abdomen by keeping it in and up, and walking erect.
Scurvy
Definition.—A constitutional disease, characterized by extreme general weakness, anemia, spongy condition of the gums, disintegration of tissue and a tendency to hemorrhages.
Etiology and Pathology.—In comparison with former times scurvy is now a rare disease. Lack of fresh vegetables or their substitutes, over-crowding, dampness, bad hygienic surroundings, and prolonged fatigue under depressing influences are the predisposing causes. Arctic explorers have shown that fresh bear’s meat and bear’s blood are a preventative.
There are extravasations of blood into the skin, muscles and mucous membranes. Hemorrhages may occur in the internal organs, especially the kidneys and liver, and in the serous membranes. The gums are swollen and spongy. The teeth decay. The spleen is soft and enlarged. Parenchymatous degeneration of the heart, liver and kidney is frequent. Ulcers occasionally occur in the skin and bowels. The blood is thin but there is no leucocytosis.
Symptoms.—The disease is usually slow in development. The general manifestations of anemia with debility are among the first symptoms. The gums are swollen, soft and spongy, they bleed easily and in severe cases there is ulceration. Petechial spots appear upon the body. Subcutaneous ecchymosis occurs, first on the legs, then on the arms and trunk. The eyes and face are swollen; the patient appears as if he had been bruised. Hemorrhages from the mucous membrane frequently occur. The temperature is usually normal. The pulse is small, feeble and frequent; sometimes irregular and slow. The appetite is impaired and constipation is present at first, as a rule, although this may be followed by scorbutic dysentery.
Diagnosis.—The disease is readily recognized when several cases occur together. It is somewhat hard to recognize in isolated cases, and to be able to distinguish it from certain forms of purpura. The etiology, the gingival changes and the hemorrhages usually decide the diagnosis.
Prognosis.—Scurvy being a disease due to malnutrition, it is necessary to remedy such condition by attention and correction of the faults producing it. Hygienic surroundings and a wholesome diet will do more in curing the disease than anything else. An outdoor life and good ventilation with anti-scorbutics, as fruit juices, especially lemons and oranges, fresh vegetables, (onions, potatoes, etc.) and fresh milk, are necessary.
It is held by Garrod that scurvy is caused by an absence of potash, for a deficiency of potassium salts is found in the blood. The anti-scorbutics named above contain potash. A careful treatment along the splanchnics would help to improve the appetite and digestion. Treat the gums and ulcers according to surgical indications.