The practice of osteopathy

Infantile Scurvy

Scorbutus

This form usually follows the prolonged use of condensed milk, sterilized milk or proprietary foods for children. The disease occurs during the first two years of life, but it is most common from the seventh to the fourteenth month.

It develops rapidly. Joint pains, anemia and irritability are early symptoms. The child is pale, has a muddy complexion and may show signs of rickets. The gums may be soft and spongy. There is tenderness and pain on motion. There may be hemorrhages under the skin. The lower limbs are drawn up and motionless. The bones become thickened from sub-periosteal hemorrhage, and there is apt to be softening between the shaft and epiphysis. The back and legs become very weak. The lesions are usually symmetrical. The temperature is variable.

Treatment.—The treatment of scurvy in children consists in, first, omitting all proprietary foods and substituting fresh cow’s milk, meat juice, strained gruel and a moderate quantity of fresh orange or lemon juice. Under this treatment, cases that have not progressed too far will promptly recover.

Northrop says: “It is a significant fact that the country which furnishes most of the literature on scorbutus in children is the same which is posted from end to end with advertisements of proprietary foods.”

Purpura

Purpura is a symptom rather than a disease. It is characterized by extravasation of blood into the skin and bleeding from the mucous membranes, irrespective of direct injury. These extravasations do not disappear upon pressure and vary greatly in size. They may be small, (petechiæ) or large (ecchymoses). They are bright red and gradually become darker. Clotting of normal blood requires three to five minutes, purpuric blood, ten to fifteen minutes.

It is a symptom of infectious diseases, as in pyemia, septicemia, mycotic endocarditis, typhus fever, smallpox, etc. Toxic, as produced by venomous snake bites and by certain medicines, as copaiba, mercury, quinine, iodides and others in overdoses. Cachectic purpura may be observed in cancer, tuberculosis, Bright’s disease, scurvy, etc. In senile purpura the spots are generally confined to the extremities. In certain nervous diseases, bleeding spots appear on the skin, as in tabes, myelitis and severe neuralgia. Mechanical purpura is seen in venous stasis; this is rare.

Purpura simplex affects only the skin. It occasionally follows attacks of infectious diseases. The spots are found upon the legs, more rarely upon the trunk and arms. Articular pains may or may not occur. Fever is seldom present. Loss of appetite, diarrhea and slight anemia may be manifested. The duration is one to four weeks.

Purpura rheumatica is a much more serious affection, characterized by multiple arthritis of rheumatism. Seldom seen under five years, and lasts about two weeks. The joints are swollen and painful and the temperature rises to 101 and 103 degrees F. The amount of edema varies greatly and occasionally it is quite excessive. In addition to the purpura there is usually urticaria. Henoch’s purpura is seen most frequently in children and is characterized by severe gastro-intestinal disturbances as pain, vomiting and diarrhea, hemorrhages from the mucous membranes and acute enlargement of the spleen, in addition to the symptoms already named under the foregoing form. There is some danger of hemorrhage into the kidneys.

The disorder of purpura hemorrhagica is usually associated with rheumatism, malaria and other infectious diseases. This is the most serious form of purpura. It is most commonly met with in delicate girls during early life; but it may occur at any age and in the most robust of either sex. Fever, weakness, vomiting and diarrhea are the early symptoms. After a couple of days of languor and weakness, purpuric spots appear upon the skin; and bleeding occurs from the mucous membranes and may cause profound anemia. Hemorrhages into the internal organs occur. Favorable cases recover in ten days or two weeks. Others may end fatally. Care should be taken not to confuse the disease with scurvy.

Treatment.—In the treatment of purpura the disease from which it develops should receive due attention. Occasionally there is danger of overlooking the primary disease and treating some symptoms of the disease, although it is true that sometimes an important symptom is nearly all that is manifested. Outside of treating the conditions under which purpura arises, general measures should be considered, as a nutritious diet, rest, fresh air, and general treatment of the patient so that normal circulation and strength may be restored. The treatment of the purpura locally should be such as to restore normal circulation of the part by removing any obstruction or irritation of the blood supply that may be found, by careful manipulation of the tissues. As stated the management of the disease under which it arises should be embraced in the treatment. In cases of hemorrhage from various organs see article under hemorrhage. Some cutaneous hemorrhages are best relieved by local manipulation.

Hemophilia

(Bleeder’s Disease).

Hemophilia is a hereditary condition manifested by a tendency to uncontrollable hemorrhage with or without injury. The usual mode of transmission is through the female line, rather than by the male. The mother does not necessarily have to be a bleeder, but the daughter of one, in order to transmit the disease to her offspring. Atavism through the female alone is almost the rule. Not all the children of a bleeding family are afflicted; the male children are more subject to the condition than the female children. The tendency usually appears within the first two years of life. The families of bleeders are often large and are commonly healthy looking and have fine soft skins. It is claimed blondes are most likely to be afflicted.

Pathologically, an unusual thinness of the blood-vessels with a fatty degeneration of the intima has been noted. In many cases there is deficient coagulability of the blood and a lessened number of leucocytes. Hemorrhages have been found in and about the capsules of the joints, and in a few instances inflammation of the synovial surfaces. The arteries are situated superficially, but that does not explain anything. The real nature of the disease has not been determined. Emotional excitement is a factor, consequently vasomotor disturbances may be important. The frailty of the blood-vessels and the peculiar constitution of the blood preventing thrombotic formation are the two facts of importance that have been recognized.

Symptoms.—Hemorrhages occur from the most trifling injuries. Blowing the nose may cause severe epistaxis; the extraction of a tooth is a frequent cause of hemorrhage; the prick of a pin, a slight cut, a scratch, or a blow may result in profuse bleeding. The bleeding may occur spontaneously from the mucous membrane of the mouth, nose, lungs, intestines, etc.; or it may occur directly from the fingers, toes, back of the hands, and lobes of the ears. The hemorrhages may last several hours. As soon as checked the patients rapidly resume natural appearance providing the bleeding is not often repeated, thereby causing a permanent anemia. There may be attacks of arthritis with fever, as with acquired hemorrhagic tendency, closely resembling rheumatism.

Diagnosis.—Hereditary tendency and persistent hemorrhage from slight injury.

Prognosis.—In a few cases the tendency to bleed gradually diminishes until at last it entirely ceases. The younger the subject the more is it liable to prove fatal. In the majority of cases death occurs between the first and eighth years. After maturity the chances of an attack are much lessened.

Treatment.—Members of the bleeder’s family, particularly the boys, should be guarded against traumatic influences, and operations of all kinds should be avoided. Outdoor exercise, fresh air, bathing and plain nourishing food, in fact, the hygienic surroundings, and all food should be carefully watched so that the threatened subject may become strengthened and hardened. Marriage should be discouraged, especially with the daughters, as it is through them the tendency is propagated. Possibly, coupled with the foregoing prophylactic treatment, a stimulation of the glands of elaboration of the blood will be of service to build up the physical constitution of the patient. During attacks absolute rest and the required symptomatic treatment should be given. For resultant anemia the usual treatment is to be employed.

In severe cases direct transfusion should be considered.