,transcriber's ,note ,italic text displayed as3 italic ,bold text displayed as3 bold ,,the ,,practice ,,of ,,osteopathy ,illustration ,,carl ,,philip ,mc,c,o,n,n,e,l,l ,president ,american ,osteopathic ,association1 #aijd-je4 ,formerly of the ,faculty ,american ,school of ,osteopathy4 ,member of the ,faculty ,chicago ,college of ,osteopathy ,,charles ,,clayton ,,teall ,president ,american ,osteopathic ,association1 #aijb-jc4 ,dean of the ,faculty and ,professor of ,practice and ,clinical ,osteopathy ,american ,school of ,osteopathy4 ,editor ,journal of ,osteopathy ,,fourth ,,edition ,rewritten in collaboration with osteopathic specialists of note with much new and original matter #aibj ,,journal ,,printing ,,co4 ,,kirksville1 ,,mo4 ,,copyright #aibj ,,carl ,,philip ,,mcconnell ,,and ,,charles ,,clayton ,,teall ,,dedicated ,,to ,,the ,,memory ,,of ,,andrew ,,taylor ,,still ,,first ,,edition #ahii ,,second ,,edition #aijb ,,third ,,edition #aijf ,,fourth ,,edition #aibj ,,preface ,,to ,,the ,,fourth ,,edition ,a science is said to be known by its literature and1 if that be true1 ,osteopathy is backward for there are few available books on the subject for the student and investigator although there is a vast amount of unclassified journalistic matter4 ,a pretentious start was made and1 for a time1 it appeared that we should have texts on all subjects for the teaching of ,osteopathy but1 for reasons not necessary to give here1 these books did not live although their value and need was never questioned4 ,the third edition of the ,practice of ,osteopathy was exhausted very soon after publication and there have been insistent calls for a fourth which is now presented with the hope that it will find as friendly a reception as was accorded the previous editions4 ,close attention to current literature has been given and reports from experienced practitioners in the field has been sought and this material made use of wherever possible4 ,besides this1 certain sections have been written by specialists in their several lines whose signed articles we confidently present4 ,the subject of osteopathic practice has been handled to avoid undue optimism in the light of experience but1 also1 not to lose sight of the fact that osteopathy won its way by performing the so-called impossible in a multitude of cases4 ,therefore1 it has been thought best not to draw a hard and fast line on our limitations4 ,the border line between osteopathy and surgery has been demonstrated as well as can be done on paper without the actual patient in hand4 ,medical literature has been called upon to give its store of knowledge wherever our needs have appeared and all osteopathic prints have1 also1 given from their accumulated wisdom and experience4 ,the authors acknowledge1 with thanks1 this information from the many writers for osteopathic journals who have created a great fund of knowledge on osteopathic subjects and particularly those who have contributed special sections4 ,,carl ,,philip ,,mcconnell4 ,,charles ,,clayton ,,teall4 #aibj4 8,osteopathy is not so much a question of books as it is of intelligence4 ,a successful osteopath is in all cases1 or should be1 a person of individuality with a mechanical eye behind all motions or efforts to readjust any part of the body to its original normality1 because unguided force is dangerous1 often doing harm and failing to give relief that should be the reward of well directed skill40--,a4 ,t4 ,,still4 ,,list ,,of ,,contributors ,,raymond ,w4 ,,bailey1 ,d4 ,o4 ,former member of the faculty1 ,philadelphia ,college of ,osteopathy4 7,defective ,children7 ,,edgar ,s4 ,,comstock1 ,d4 ,o4 ,professor of ,principles of ,osteopathy1 and of ,respiratory and ,infectious ,diseases1 ,chicago ,college of ,osteopathy4 7,infectious ,diseases7 ,j4 ,,deason1 ,m4,s41 ,ph4 ,g41 ,d4 ,o4 ,professor of ,rhinology1 ,laryngology and ,otology1 ,chicago ,college of ,osteopathy4 7,ear1 ,nose and ,throat7 ,l4 ,,van ,,horn ,,gerdine1 ,a4 ,m41 ,m4 ,d41 ,d4 ,o4 ,neurologist1 ,still-,hildreth ,sanatorium4 7,mental ,diseases7 ,a4 ,g4 ,,hildreth1 ,d4 ,o4 ,superintendent1 ,still-,hildreth ,sanatorium4 7,mental ,diseases7 ,h4 ,s4 ,,hain1 ,d4 ,o4 ,professor of ,orthopedics1 ,american ,school of ,osteopathy1 ,orthopedic ,surgeon1 ,a4 ,s4 ,o4 ,hospitals4 7,deformities7 ,,earl ,r4 ,,hoskins1 ,sc4 ,b41 ,d4 ,o4 ,professor of ,clinical ,osteopathy1 ,x-,radiance and ,diagnosis1 ,chicago ,college of ,osteopathy4 7,diseases of the ,blood7 ,,charles ,j4 ,,muttart1 ,d4 ,o4 ,professor of ,diagnosis and ,technique and of ,gastroenterology1 ,philadelphia ,college of ,osteopathy4 7,diseases of the ,stomach7 ,,george ,m4 ,,mccole1 ,d4 ,o4 ,osteopathic ,practitioner and ,writer4 7,influenza7 ,,charles ,c4 ,,reid1 ,m4 ,d41 ,d4 ,o4 ,president1 ,denver ,polyclinic and ,post-,graduate ,college4 7,ophthalmology7 ,,george ,a4 ,,still1 ,m4 ,s41 ,m4 ,d41 ,d4 ,o4 ,professor of ,surgery1 ,american ,school of ,osteopathy1 ,surgeon in ,chief1 ,a4 ,s4 ,o4 ,hospitals4 7,post-,operative ,treatment7 ,,table ,,of ,,contents ,,part ,i4 ,,introduction #ag ,,osteopathic ,,etiology ,,and ,,pathology #bd ,osteopathic lesion2 ,etiological factors2 ,osseous lesion2 ,muscular lesion2 ,ligamentous lesion2 ,visceral lesion2 ,composite lesion2 ,pathology2 ,spinal lesions2 ,proof4 ,,osteopathic ,,diagnosis ,,and ,,prognosis #ch ,the ,spine2 ,examination2 ,vertebr2 ,position in examination2 ,neck1 ,head and ,face1 ,atlas1 ,axis1 ,skull1 ,third ,cervical1 ,muscles of the ,neck1 ,temporo-,maxillary ,articulation1 ,scalp1 ,ribs1 ,clavicle1 ,sternum1 ,dorso-,lumbar1 ,thorax1 ,abdomen1 ,gall ,bladder1 ,spleen1 ,stomach1 ,intestines1 ,kidneys1 ,lumbar1 ,pelvis1 ,coccyx1 ,arms1 ,legs4 ,,osteopathic ,,prognosis #ef ,,osteopathic ,,technique #fj ,sense of touch1 ,definite principles1 ,general treatment1 ,position1 ,neck1 ,head1 ,ribs1 ,dorsal1 ,lumbar1 ,abdomen1 ,pelvis1 ,legs1 ,arms1 ,how often to treat1 ,length of treatment1 ,over-treatment1 ,misapplied treatment4 ,,osteopathic ,,centers1 ,,stimulation1 ,,inhibition1 ,,readjustment1 ,,vasomotor ,,and ,,sensory ,,nerves #hh ,,spinal ,,curvature #if ,,pott',s ,,disease #ajb ,,sprains #ajd ,,flat ,,foot #aab ,,fractures #aae ,,postural ,,defects #abj ,round ,shoulders1 ,painful ,shoulders1 ,pendulous ,abdomen1 ,postural ,curvature of the ,spinal ,column4 ,,prolapsed ,,organs #acc ,prolapsed and ,dilated ,stomach1 ,prolapsed ,kidney1 ,liver ,prolapse1 ,prolapsed ,intestines1 ,prolapsed ,uterus1 ,ovarian ,displacements4 ,,skin ,,diseases #adg ,eczema1 ,herpes ,simplex1 ,herpes ,zoster1 ,urticaria1 ,acne4 ,,animal ,,parasites #aea ,tape ,worm1 ,round ,worm1 ,pin ,worm1 ,hook ,worm1 ,trichiniasis1 ,filaria4 ,,hemorrhages #afj ,epistaxis1 ,hemoptysis1 ,hematemesis1 ,intestinal ,hemorrhage1 ,hematuria1 ,uterine ,hemorrhage4 ,,hiccoughs #afe ,,varicose ,,veins #aff ,,phlebitis #afh ,,the ,,rectum #afi ,local ,treatment1 ,proctitis1 ,hemorrhoids1 ,rectal ,conditions4 ,,genito-,,urinary #age ,prostate ,gland1 ,acute ,prostatitis1 ,chronic ,prostatitis1 ,seminal ,vesicles1 ,varicocele1 ,impotency4 ,,heat ,,stroke #ahj ,,department ,,of ,,ophthalmology #ahc ,examination of the ,eye1 ,ciliospinal ,center1 ,somatic ,reflexes1 ,accommodation in the ,eye1 ,the ,ophthalmoscope1 ,diseases of the ,eye1 ,neuralgia1 ,diseases of the ,eyelids1 ,lachrymal ,apparatus1 ,conjunctiva1 ,ophthalmia ,neonatorum1 ,trachoma1 ,phlyctenular ,conjunctivitis1 ,vernal ,conjunctivitis1 ,diseases of the ,cornea1 ,examination1 ,ulcer1 ,xerosis1 ,keratitis ,neuropatalytica1 ,pannus1 ,phlyctenular ,keratitis1 ,interstitial ,keratitis1 ,diseases of the ,iris and ,ciliary ,body1 ,diseases of the ,choroid1 ,glaucoma1 ,diseases of the ,lens1 ,cataract1 ,diseases of the ,retina1 ,optic ,neuritis1 ,optic ,atrophy1 ,asthenopia4 ,,diseases ,,of ,,the ,,ear1 ,,nose ,,and ,,throat #bcf ,examination1 ,diseases of the ,auditory ,meatus1 ,diseases of the ,middle ,ear1 ,acute ,mastoiditis1 ,chronic ,mastoiditis1 ,otitis ,media1 ,catarrhal ,deafness1 ,normal ,hearing1 ,diseases of the ,middle ,ear1 ,diseases of the ,nose1 ,rhinitis1 ,hay ,fever1 ,sinuitis1 ,epistaxis1 ,diseases of the ,nasopharynx1 ,adenoids1 ,diseases of the ,oropharynx1 ,tonsillitis1 ,tonsillectomy1 ,quinsy4 ,,mental ,,diseases #bhb ,dementia ,praecox1 ,delirium1 ,confusion and ,stupor1 ,manic ,depressive ,psychosis1 ,involutional ,psychosis1 ,senile ,dementia4 ,,defective ,,children #cjc ,tendencies1 ,amentia1 ,treatment4 ,,post-,,operative ,,treatment #cab ,vomiting1 ,backache and ,headache1 ,neuritis1 ,phlebitis1 ,nephritis1 ,pleurisy1 ,pneumonia4 ,,part ,,ii4 ,,infectious ,,diseases ,fever #cbe ,typhoid ,fever #cbi ,typhus ,fever #cdd ,malarial ,fever #cdg ,septicemia #cee ,pyemia #cef ,dengue #cef ,cerebrospinal ,meningitis #ceh ,diphtheria #cfb ,dysentery #cfh ,acute ,ileocolitis #cfh ,amebic ,dysentery #cgj ,chronic ,dysentery #cga ,erysipelas #cgb ,yellow ,fever #cgd ,tetanus #cgg ,simple ,continued ,fever #cgi ,tuberculosis #chj ,influenza #cii ,,acute ,,eruptive ,,fevers #dab ,smallpox #dac ,varioloid #dbj ,vaccination #dbd ,scarlet ,fever #dbh ,measles #dcg ,rubella #ddd ,varicella #ddf ,mumps #ddi ,whooping ,cough #deb ,,constitutional ,,diseases ,rheumatic ,fever #deg ,chronic ,articular ,rheumatism #dfj ,arthritis ,deformans #dfb ,muscular ,rheumatism #dfe ,gout #dfg ,diabetes ,mellitus #dgj ,diabetes ,insipidus #dgf ,rickets #dgh ,obesity #dhj ,scurvy #dha ,infantile ,scurvy #dhb ,purpura #dhc ,hemophilia #dhd ,,diseases ,,of ,,the ,,digestive ,,system ,stomatitis #dhg ,catarrhal ,stomatitis #dhg ,aphthous ,stomatitis #dhh ,ulcerative ,stomatitis #dhh ,parasitic ,stomatitis #dhi ,diseases of the ,gastro-intestinal ,tract ,applied ,anatomy #dij ,acute ,gastritis #ejb ,chronic ,gastritis #eje ,gastric ,neuroses #eaj ,gastric and ,duodenal ,ulcer #eac ,dilatation of the ,stomach #eag ,gastroptosis and ,enteroptosis #eba ,diseases of the ,intestines ,acute ,diarrhea #ebc ,chronic ,diarrhea and ,mucous ,colitis #ebf ,diarrhea in ,children #ebi ,acute ,dyspeptic ,diarrhea #ebi ,cholera ,infantum #eca ,acute ,enterocolitis #ecb ,cholera ,morbus #ecc ,intestinal ,colic #ece ,constipation #ecg ,intestinal ,obstruction #eda ,hernia #edg ,appendicitis #edg ,diseases of the ,liver and ,bile ,duct ,hyperemia of the ,liver #eed ,simple ,catarrhal ,jaundice #eee ,cholecystitis #eeg ,jaundice #eeh ,cirrhosis of the ,liver #efj ,fatty ,liver #efb ,amyloid ,liver #efb ,gall-stones #efc ,diseases of the ,spleen ,splenitis #efg ,,diseases ,,of ,,the ,,respiratory ,,tract ,acute ,laryngitis #efi ,chronic ,catarrhal ,laryngitis #egj ,laryngismus ,stridulus #egb ,spasmodic ,laryngitis #egc ,tuberculous ,laryngitis #ege ,syphilitic ,laryngitis #egg ,edematous ,laryngitis #egg ,diseases of the ,bronchi ,acute ,bronchitis #egi ,chronic ,bronchitis #ehb ,fibrinous ,bronchitis #ehe ,bronchiectasis #ehg ,bronchial ,asthma #ehi ,diseases of the ,lungs ,emphysema #eib ,acute ,lobar ,pneumonia #eig ,bronchopneumonia #fje ,chronic ,interstitial ,pneumonia #fji ,congestion of the ,lungs #faj ,edema of the ,lungs #faa ,diseases of the ,pleura ,pleurisy #faa ,acute ,pleurisy #fab ,serofibrinous ,pleurisy #fab ,chronic ,pleurisy #fae ,,diseases ,,of ,,the ,,urinary ,,system ,diseases of the ,kidneys ,renal ,hyperemia #fag ,acute ,parenchymatous ,nephritis #fah ,chronic ,parenchymatous ,nephritis #fba ,interstitial ,nephritis #fbd ,amyloid ,kidney #fbf ,pyelitis #fbg ,uremia #fbh ,renal ,calculus #fca ,diseases of the ,bladder ,cystitis #fce ,,diseases ,,of ,,the ,,circulatory ,,system ,diseases of the ,pericardium ,pericarditis #fch ,endocarditis #fda ,chronic ,endocarditis #fde ,hypertrophy of the ,heart #fee ,dilatation of the ,heart #feg ,myocarditis #fei ,degeneration of the ,heart ,muscle #ffa ,neuroses of the ,heart #ffb ,angina ,pectoris #fff ,diseases of the ,arteries ,arteriosclerosis #ffi ,,diseases ,,of ,,the ,,blood ,general ,consideration #fga ,the ,anemias #fgb ,costogenic ,anemia #fgd ,chlorosis #fgf ,pernicious ,anemia #fgh ,the ,leucemias #fhj ,splenomedullary ,leucemia #fha ,lymphatic ,leucemia #fhb ,hodgkin's ,disease #fhd ,,diseases ,,of ,,the ,,thyroid ,,gland ,congestion #fhf ,inflammation of the ,thyroid #fhf ,simple ,goiter #fhg ,exophthalmic ,goiter #fij ,myxedema #fig ,cretinism #fih ,,diseases ,,of ,,the ,,parathyroid ,,gland ,tetany #fii ,diseases of the ,thymus #gjb ,diseases of the ,adrenal ,glands #gjc ,addison's ,disease #gjd ,,diseases ,,of ,,the ,,nervous ,,system ,diseases of the ,nerves ,neuritis #gjf ,neuralgia #gaj ,diseases of the ,cranial ,nerves ,olfactory #gae ,optic #gae ,motor ,oculi #gaf ,patheticus #gaf ,trigeminus #gag ,facial #gag ,auditory #gah ,glosso-,pharyngeal #gah ,pneumogastric #gah ,spinal ,accessory #gai ,hypoglossal #gai ,diseases of the ,spinal ,nerves ,cervical ,nerves #gai ,phrenic ,nerve #gbj ,brachial ,plexus #gba ,dorsal ,nerves #gba ,lumbar ,nerves #gbb ,sacral ,nerves #gbb ,,general ,,and ,,functional ,,diseases ,paralysis ,agitans #gbc ,acute ,chorea #gbe ,choreiform ,affections #gbg ,infantile ,convulsions #gbh ,epilepsy #gbi ,migraine #gcf ,occupation ,neurosis #gch ,hysteria #gdj ,neurasthenia #gdd ,,diseases ,,of ,,the ,,spinal ,,cord ,acute ,myelitis #gdh ,poliomyelitis #gej ,acute ,ascending ,paralysis #gec ,locomotor ,ataxia #ged ,friedreich's ,ataxia #gei ,spastic ,paraplegia #gfj ,ataxic ,paraplegia #gfa ,syringomyelia #gfa ,amyotrophic ,lateral ,sclerosis #gfc ,progressive ,muscular ,atrophy #gfd ,bulbar ,paralysis #gfe ,,orthopedic ,,surgery ,scoliosis #gfg ,functional ,curvature #ggc ,organic ,curvature #ggd ,congenital ,dislocation of the ,hip #ggh ,talipes #ghd ,pott's ,disease #ghh ,hip-,joint ,disease #gia ,tuberculosis of the ,knee ,joint #gic ,the ,plaster ,cast ,bandage #gie ,index #gii ,,part ,,first ,,introduction ,what ,hippocrates was to the ,allopath1 what ,hahnemann was to the ,homeopath1 ,andrew ,taylor ,still is to the ,osteopath1 and it is safe to say that when another century shall have rolled away1 his fame will be equal to that of either4 ,that he is a maker of history1 even the most skeptical will admit4 ,his teachings are revolutionary but are borne out in fact1 and on that as a foundation1 is built the superstructure of the young therapeutic giant--,osteopathy4 ,it would be of great interest to trace the history of the first inception of the thought that drugs were not only unnecessary but harmful1 then view the struggle to grasp something tangible to take their place1 then see the development of the idea that the human body has within it all that is needed for its upbuilding and repair until he came to this fundamental3 8,the power of the artery must be absolute1 universal and unobstructed or disease will result4 ,the moment of its disturbance means the period when disease begins to sow the seeds of destruction in the human body2 and in no case can it be done without a broken or suspended current of arterial blood10 capped by the epoch-making discovery of the cause for this interrupted flow of the blood stream--the theory of obstruction by anatomical displacement4 ,it is the only theory of the etiology of disease that will stand the test of science and its acceptance and practice means a revolution in the field of therapeutics4 ,as it is1 he sets the exact date1 ,june #bb1 #ahgd1 when the light dawned and he saw the outline of his great philosophy--,osteopathy4 ,then came the years of adversity and struggle4 ,with the eye of a prophet he saw the future of that philosophy1 and with the firmness of a ,spartan has defended it since birth4 ,it must be a separate1 distinct system4 ,outside the fact that it was to heal the sick and was founded on a knowledge of anatomy and physiology it had nothing in common with existing schools1 and if it were ever to grow it must be alone1 for his brother practitioners would have none of it and if left to their tender mercies it would have 8died a-borning40 ,even had it been taken up the result would have been the same for they would never have fully developed it4 ,and so through the lean1 terrible years he struggled1 buoyed by the faith of a discoverer1 urged on by love of this child of his brain1 fanatical in his determination to win4 ,and win he did for it was vouchsafed to him in his vigorous old age to sit on his hearthstone and see the results of his work1 his struggle and his faith4 ,it is something to know that his fame has circled the earth1 to be honored and sung by millions2 a boon not accorded many a sage or philosopher4 ,not only has the public accepted it but the medical profession is making tardy but forced recognition of certain cardinal principles of osteopathy by using them1 but1 of course1 without credit4 ,osteopathy has been defined as 8that science or system of healing which emphasizes1 7a7 the diagnosis of disease by physical methods with the view of discovering1 not the symptoms but the cause of disease in connection with misplacements of tissue1 obstruction of the fluids and interference with the forces of the organism2 7b7 the treatment of disease by scientific manipulations in connection with which the operating physician mechanically uses and applies the inherent resources of the organism to overcome disease and establish health1 either by removing or correcting mechanical disorders and thus permitting nature to recuperate the diseased parts1 or by producing and establishing antitoxic and antiseptic conditions to counteract toxic and septic conditions of the organism or its parts2 7c7 the application of mechanical and operative surgery in setting fractures or dislocated bones1 repairing lacerations and removing abnormal tissue growths or tissue elements when these become dangerous to organic life40#a ,in a word1 osteopathy is adjustment and the osteopath is an anatomical engineer who knows what is wrong and has the ability to correct it4 ,dr4 ,still changed diagnosis from guess work to fact and on it his fame may well stand1 for when the cause of the disease was found1 treatment was easy4 ,he has ever emphasized the necessity of thorough examination and correct diagnosis4 ,all treatment must be based on the definite1 specific object to accomplish certain definite1 specific things4 8,osteopathy would expound and apply the true philosophy of manipulation4 ,while the hands are used1 it is not this alone and chiefly that distinguishes its method of operation1 but the idea and purpose that lie behind manipulation40#b ,all manipulators are not osteopaths any more than all butchers are surgeons4 ,the need for deep study of the subject is apparent from this characteristic statement of ,dr4 ,still's3 8,osteopathy is a science2 not what we know of it1 but the subject we are working is deep as eternity4 ,we know but little of it4 ,i have worked and worried here in ,kirksville for twenty-two long years1 and ,i intend to study for twenty-three thousand years yet40#c ,this brings us to the point of the relations of osteopathy with other manipulative forms of treatment4 ,they are not many1 for ,gerdine1#d in closing a long article on the 8,physiological ,effects of ,mechanical ,therapeutics0 says3 8,i have striven to show that in no way is ,osteopathy similar to massage either in theory or practice if ,osteopathy is conceived of1 according to its founder1 ,dr4 ,a4 ,t4 ,still1 as a system of healing in which a definite lesion in form of a bony displacement is the causative factor and a removal of the same1 the curative factor in disease40 ,the fact that use is made of the hands to the extent it is by both osteopaths and masseurs or ,swedish movement operators gives rise to the mistaken idea of similarity in treatment4 8,the essential distinction10 says ,g4 ,d4 ,hulett1 8between ,osteopathy and all other systems of healing based on manipulation1 clusters around the etiology of disease4 ,while these other systems1 as indicated at least by their practice1 look at disease from a peripheral standpoint1 osteopathy views it from a central standpoint40#e ,massage is a small branch of manipulative therapeutics1 but conceding that it is perfect and scientific it can only resemble osteopathic treatment in one ramification of osteopathic practice1 viz3 relaxation of muscles4 ,the fact that massage is often employed by osteopaths in connection with their work shows the limitations of that form of treatment4 ,says ,mc,connell#f3 8,in the human body1 as in any delicate1 complicated mechanism1 there is mechanism within mechanism2 and1 in order to obtain certain mechanical effects1 many times there is required a series of complicated movements1 all of which bear a ratio one to the other according to the energy utilized and the mechanical principle involved40 ,no other form of manual treatment takes this principle of mechanics into consideration4 ,it is possible1 as ,gerdine points out1 for an undeveloped osteopath to practice massage under another name4 ,that the two should be confounded before the public is due to his ignorance and not from any fault of the system4 ,massage is a valuable aid in the treatment of disease but it is not ,osteopathy4 8,in the bright lexicon of osteopathy there is no such word as rub#g40 ,osteopathy in its relation with medicine has little in common4 ,from the beginning1 its founder realized their paths should run divergently1 so the first step1 its teaching1 must be considered from a different viewpoint4 ,to quote from an address by ,teall#h3 8,but to adequately teach osteopathy a vast amount of original work must be done4 ,anatomy is anatomy but there is a vast difference in its application4 ,physiology must be taught to mean something more than an interesting phenomenon4 ,pathology has an unfilled gap between cause and effect which must be bridged4 ,the post-mortem has a great story to tell but an osteopath must tell it4 ,a slide of degenerated tissue under the microscope is of interest1 but why the degeneration8 ,it is described at length by the authorities1 but the reason for the causes and morbific changes are not carried out4 ,obstetrics along strictly natural and physiological lines insuring both mother and babe against injury2 gynecology1 minus the knife and plus common sense2 all these1 and more must be put into shape to teach the osteopathic student4 ,the archives of osteopathy were empty ten years ago4 ,there was no precedent to follow and the ideas in teaching which had prevailed for centuries dominated4 ,all this is changed4 ,the colleges teach the science along strictly osteopathic lines1 making the application of the truths which have escaped the notice of centuries of investigation40 ,all schools recognize the wonderful recuperative power of nature1 as this from the introduction of a standard allopathic text book will show#i3 8,there is no scientific dogma better established than this3 that the living organism is in itself adequate to the cure of all its curable disorders4 ,this natural law sustains the medical skeptic in his infidelity1 enables the homeopath to report his sugar cures1 and helps all physicians out of more close places than they are generally willing to acknowledge40 ,but at times1 as all will agree1 nature is not able to overcome its maladies and assistance is needed4 ,here1 again1 is a divergence as to the method and character of that assistance4 ,there is no system so trivial or absurd which cannot point to its cures1 but a school of medicine should have a settled system with established methods of procedure4 ,this is not true of any school employing drugs as its principal therapy4 ,in the ,president's annual address at ,cleveland he says#aj3 8,the observant reader of the progressive medical press is struck at once by the unsettled condition in the field of modern therapeutics4 ,the trend is emphatically away from drugs4 ,but1 in the effort to get away from medicine1 the medical investigator has wandered far afield1 cutting loose from nature and resorting to the artificial40 ,it is the last paragraph of the extract quoted which particularly emphasizes the point of divergence1 natural versus unnatural methods4 ,it must be understood at once that the osteopath admits the reality of drug action for 8there is no doubt that the pharmacopeia records many drugs whose action is rapid and effective so far as securing activity or decrease of secretion is concerned1 but the element of danger1 i4 e41 their destructive power is great4 ,oftentimes their power does not stop at the point desired or limit its effect to the therapeutic action sought#aa40 ,this point of unreliability of the drug is emphasized by the following from recognized medical authority#ab3 8,we give drugs for two purposes3 7#a7 ,to restore health directly by removing the sum of the conditions which constitute disease4 ,here we act empirically with no definite knowledge--often indeed with little idea of the action of our drugs1 but on the ground that in our hands or in the hands of others they have restored health in like cases4 7#b7 ,to influence one or more of the several tissues and organs which are in an abnormal state so as to restore them to or toward the normal2 with the hope that if we succeed in our purpose recovery will take place4 ,the purpose we effect by means of the influence which the chemical properties or drugs exert on the structure and function of the several tissues and organs4 ,minute information1 therefore1 of the nature of drugs and their action is essential for their proper employment40 ,osteopathy brings into action the latent or stagnant forces of nature by specific methods which are usually reliable4 ,naturally there being such a wide difference in theory of the cause of disease it would be also shown in diagnosis as well as treatment4 ,the most striking points to the layman in medical procedure are3 first1 wide difference in the system of diagnosis and in its findings by physicians of the same school2 second1 the great variance in remedies employed by different physicians of the same school for the same disease4 ,osteopathic diagnosis is so physical in its character1 depending upon actual conditions found and not upon the subjective symptoms alone1 that the same patient examined by a number of experienced osteopaths will be given the same diagnosis1 and he will also be able to detect in each the same effort to correct in all their technique4 ,all the methods of physical diagnosis are used plus the distinctive osteopathic procedure4 ,results wherever used bear out the effectiveness of the system4 ,the osteopath must and does consider the necessity of surgery1 but his effort is always to prevent the operation if possible4 ,there can be no doubt that surgery is carried to extremes and there is a strong sentiment growing that much of it is unnecessary4 ,says ,homer ,wakefield1 ,m4 ,d4#ac3 8,it is to the everlasting disgrace and mortification of the medical man that the wealthy classes who are continually under the observation and direction of eminent men1 in dietary1 and all life habits1 in health as well as in sickness1 are not only the very ones who develop appendicitis and most largely go to operation1 but are almost exclusively those who attain to this distinction40 ,the operations of today are wonderful and the surgeon shows great skill and genius in their performance1 but great as he is in these matters how infinitely greater is the man who can prevent them4 ,the need of the osteopath today is to be trained to recognize surgical conditions and neither allow surgery unnecessarily nor make the more terrible error of not acting soon enough4 ,where surgery is a necessity there is always an etiological factor to be considered4 ,the cause of the manifestation not always being removed what is to prevent a recurrence or serious sequela in spite of the operation8 8,the specialist 444 if he has wit enough to read the lesson presented to him1 that it is not sufficient to remove an ovarian tumor1 e4 g41 and that if nothing is said at the same time or subsequently as to the causes which induced it1 a positive damage may be done to the woman1 who may1 therefore1 while considering herself cured1 proceed to manufacture one on the other side1 or may find herself in a few years suffering from cancer in the stump of the previous one#ad40 ,and so the combination of osteopathy with surgery may be necessary that the cause shall be removed4 ,osteopathic treatment before operations in reducing congestions and inflammations1 also in toning the nervous system1 is particularly efficacious while the after treatment gives gratifying results4 ,in fact1 the two go hand in hand when conservatism rules both4 ,that diet should receive particular attention from the osteopath is not strange1 for his veneration of nature peculiarly fits him to realize the necessity of correct feeding4 ,probably no subject is more discussed or presents a wider range of opinion than diet4 ,there is overfeeding and underfeeding2 long intervals and short between feedings4 ,there is the no breakfast and no supper plan1 mixed diet and the vegetarian1 uncooked foods1 and one exclusively of milk1 anything you want so long as you are hungry but chew it well1 etc41 ad4 lib4 ,all are represented by osteopaths in their following as they are from other professions1 but probably this would more nearly represent the views of them as a school4 ,in health1 first1 most people eat too much and do not thoroughly masticate and insalivate4 ,this applies to all stations of society4 ,second1 meat forms too large an item in the daily dietary4 ,third1 there is not enough variety and the ration is not well balanced as to elements4 ,fourth1 not enough care is used in preparation of foods4 ,in illness1 first1 the stopping1 complete or partial1 of food until the system can take care of it2 second1 the giving of easily digested foods4 ,the man who avoids violent extremes in diet as well as in other habits of life will usually last longest4 ,it is to be hoped that some rational system can be evolved on which all factions may agree1 for the present confusion of authorities is bewildering4 ,the osteopath gives attention to hygiene1 sanitation1 exercise1 environment1 mental attitude1 etc41 as they may affect the welfare of his patient4 ,osteopathy can cure all curable diseases1 for the same forces which will overcome one malady will overcome another when set in motion4 ,forces that produce a diseased condition will it normalized restore the established type4 ,,footnotes3 #a ,littlejohn1 7,j4 ,m47--,journal of the ,science of ,osteopathy4 #b ,encyclopedia ,americana4 #c ,booth--,history of ,osteopathy4 #d ,journal of ,osteopathy1 ,may1 #aije4 #e ,principles of ,osteopathy1 p4 #aij4 #f ,journal of the ,science of ,osteopathy1 ,dec4 #ae1 #aijj4 #g ,osteopathic ,calendar1 #aijj4 #h ,reported1 ,portland1 7,me471 ,advertiser1 ,feb4 #bg1 #aije4 #i ,potter's ,materia ,medica4 #aj ,teall--,journal of the ,american ,osteopathic ,association1 ,aug41 #aijc4 #aa ,tasker--,principles of ,osteopathy1 p4 #aaj4 #ab ,allbutt's ,system of ,medicine4 #ac ,cyclopdia of ,practical ,medicine1 ,june1 #aijf4 #ad ,rabagliati--,air1 ,food and ,exercise1 p4 #abi4 ,,osteopathic ,,etiology ,,and ,,pathology ,osteopathic ,etiology ,osteopathic etiology and pathology constitutes the most interesting chapter of osteopathic science4 ,the primal divergence of the osteopathic schools from previous systems is to be found in the osteopathic interpretation of disease causes and processes1 and not in osteopathic therapy as some may think4 ,osteopathy makes claim to an independent school because it possesses a distinct etiology1 pathology1 diagnosis and treatment4 ,thus osteopathic practice is not a mere method1 but instead a system1 a school1 a science4 ,at no period of medical history have physicians of the older schools felt more keenly the futility of medical methods and the lack of an all-embracing principle of medicine than at the present4 ,a recent writer#ae who claims to have discovered a principle that encompasses the entire field of medicine1 says3 8,we found1 we may say1 that the backbone of medicine was the absent factor1 and that if the patient labors of so many great minds had not proven as useful in the development of practical medicine as they should1 it was because they lacked such a fundamental framework to afford a fixed nidus for each discovery1 wherein its true relation to other discoveries would at once become evident40 ,since the conception of osteopathy its fundamental framework has not changed one iota as to principle1 although the application of the principle has been greatly elaborated4 ,when ,dr4 ,still proclaimed that 8the rule of the artery is supreme0 he gave utterance to a basic physiological truth4 ,but when he demonstrated that osseous and other anatamo-mechanical lesions disturbed the artery and caused disease1 and that readjustment of the anatomical cured the disorder1 thus allowing the physiological to potentiate and revealing that the living body contains all the attributes of a vital and physical mechanism1 did his teaching contain the germ of a comprehensive philosophy2 this gave osteopathic science a 8backbone0 with a consequent fixed nidus for all existing facts and future discoveries4 ,and thus1 it should always be emphasized that mechanical readjustment of the component parts of the vital body is the eternal keynote of the osteopathic school of healing4 ,the ,osteopathic ,lesion4--,broadly speaking a lesion is 8any morbid alteration in a tissue whether attended by a recognizable structural change or not2 but especially a change in which the continuity of some of the tissue elements is broken in upon4#af0 ,there are several kinds of lesions expressing the tissue involved1 character of degeneration1 locality of same1 etc4 ,but upon analyzing the medley of arbitrarily defined lesions the fact will be evident that much of medical etiology and pathology has not been logically and consistently sifted and arranged2 and moreover1 it will be found the cause of causes of many diseases is unknown4 ,herein1 arises the great significance of the osteopathic lesion1 for the lesion alters the very governing and controlling tissues of the body1 viz41 the nervous tissue and the vascular channels4 ,hulett#ag defined the osteopathic lesion as 8any structural perversion which by pressure produces or maintains functional disorder40 ,the constant maintenance of the structural perversion will1 also1 cause organic disease1 although it is granted that functional disorder must necessarily result prior to any organic change4 ,the osteopathic conception of a lesion1 functional and organic disorder caused by pressure from disturbed structures1 does not bring us into an absolute new field4 ,medical literature of all ages contains references to diseases caused by pressure of tissues on nerves1 blood vessels1 or other channels4 ,but the osteopathic idea is an absolutely new one in the application of this principle universally4 ,it simplifies and makes uniform the arbitrariness of present semeiology4 ,thus the osteopathic idea that many diseases originate1 primarily1 from anatomically malaligned1 malpositioned1 or malrelated tissues causing a blockage of vital processes1 immediate or remote1 is a theory inclusive of disturbances to all tissues4 ,this principle is fundamental and is supported by the physiological truth that uninterrupted vital channels preserve health2 moreover clinical and experimental data1 as will be shown later1 substantiate this fundamental4 ,it at once places interpretation of a lesion in an entirely new light from preconceived concepts1 and is analogous to and co-extensive with etiology and pathology4 ,etiological ,factors4--,the osteopath believes in the potency of inherited and environmental influences4 ,there can be no question that a few diseases and certain disease tendencies may be inherited1 the principle feature1 however1 from the standpoint of heredity is1 various organs and tissues have less vital resistance4 ,these should not be confounded with congenital weaknesses and diathetic tendencies4 ,environmental influences are very important factors4 ,one's surroundings and daily habits in the home1 shop1 or office count for much in the aggregate4 ,food1 drink1 air1 rest1 sleep1 clothing1 exercise1 mental attitude1 etc41 are all factors in the sum total of health1 and consequently ill health may be traceable to their abuse4 ,in fact1 all hygienic and sanitary measures are duly considered by the osteopath4 ,various abuses1 over use1 and disuse of the functions will certainly be followed by physiological discord4 ,the germ theory contains much truth1 but in the very large percentage of cases where the micro-organism is a factor its significance is only of secondary consideration4 ,immunity and resistance comprise an important part of the health problem1 of which the intact anatomical is of first consideration4 ,usually the micro-organism plays the role of an exciting and determining factor2 before it can multiply and grow there must be a field that is first nutritionally disturbed4 ,nutrition of the tissue is the one great point always to be considered4 ,the constitution of an individual is the pivot about which predisposing1 environmental1 and exciting factors of disease center4 ,health represents the integrity of the artery as well as a maintenance of that master tissue1 the nervous system1 and anything that produces or influences1 directly or indirectly1 a disturbance of physiological functioning borders on the pathological4 ,hence the osteopath recognizes many of the common medical causes of disease1 but reserves the privilege of rearranging their relative positions1 for the osteopathic cause of disease greatly modifies their value4 ,osteopathic ,etiology distinctively emphasizes structural derangements and perversions4 ,of first importance1 owing to static requirements1 is the osseous lesion4 ,this lesion is represented by any abnormal change of position or relation of the many bony constituents of the body4 ,the framework of the body is subject to not only any and every physical violence of any mechanism1 but moreover being the corporeal foundation of a vital mechanism is subject to both direct and indirect biochemic changes and influences4 ,thus the osseous lesion is caused 7a7 by traumatism1 e4 g41 strains1 falls1 blows1 etc42 7b7 indirectly by atmospheric changes1 over and violent exercise1 the slumped posture1 debilitating habits1 etc41 through the media of muscle changes and imbalance2 7c7 by nutritional effects disturbing the elements of bony tissue2 7d7 by ligamentous change such as thickening of a capsular ligament2 7e7 by infections2 7f7 compensatorily and reflexly through the media of body distortions and muscular irritability or debility1 e4 g41 an innominate lesion may be compensatory to a lumbar curvature1 dietetic errors may cause dorsal muscular irritation and contraction produce a constant osseous lesion which in turn may result in chronic indigestion4 ,the pathological changes in the osseous lesion are commonly one of structural derangement1 deviation or complete displacement4 ,the vertebral segments are of primary consideration owing to their important relations to the spinal nerves1 spinal cord centers and sympathetics2 the ribs owing to the close sympathetic and spinal nervous relations2 and then other osseous tissues1 as the innominata1 clavicles1 etc41 depending upon their importance to contiguous vessels1 nerves and organs4 ,it should always be remembered and emphasized that mechanical changes of the anatomical structures is the primary essential in osteopathic etiology2 this is the one great inception of pathological variations from the distinctively osteopathic conception1 which the osseous lesion typifies4 ,consequently the osseous lesion factor is actually a luxation 7complete1 or partial1 even to a very slight degree71 or malalignment of the bony constituents1 which by virtue of their physical malposition impinge or irritate contiguous tissues4 ,the essential test is the functional one1 movement4 ,the degree of involvement may be one of many gradations ranging from a slight malposition or impaction to a marked deviation or firm anchorage4 ,second in importance from the static requirement of support is the muscular lesion though from the standpoints of movement and dynamics it is often of the first consideration etiologically4 ,many interosseous lesions are the result of spastic involvement of deep seated spinal muscles1 of fibrotic changes and of tensions and weaknesses that either establish a rigidness of the segments1 compromising nervous stimulus or vascular channel1 or produce an imbalance of muscular tone and tension4 ,in the latter instance some type of sidebending-rotation osseous lesion occurs1 commonly anchored within the physiologic movements of the spine4 ,the muscular lesion may be an actual dislocation of either muscle or tendon1 but rarely4 ,commonly it is a contracted1 or tensed1 or contractured muscle4 ,the muscle1 also1 may be diseased either from primary or secondary causes through nutritional and infectious sources and thus be an etiological feature4 ,the muscular lesion is caused1 7a7 by direct or indirect violence the same as the osseous lesion2 7b7 by atmospheric influences2 7c7 by slumped posture1 debilitating habits and various errors of living2 7d7 infections2 7e7 by reflex irritations2 7f7 by compensatory changes2 7g7 by disease causing hypertrophy or atrophy2 and1 7h7 secondary to osseous lesions1 being the result of impingement to the muscles' nervous control4 ,the tensed or stretched muscle may result from a separation of the points of origin and insertion4 ,herein the fundamental osteopathic concept is the resulting affection due to the physical encroachment1 directly or indirectly1 of the muscle tissue upon vascular channel or nerve fibre1 or the effect upon the movement or alignment of the osseous tissue4 ,muscular contractions1 displacements1 and tensions play a most important part in acute disorders1 although muscular lesions that are secondary to other lesions are usually taken into account when treatment is given4 ,muscular lesions affect1 7a7 blood and lymph vessels2 7b7 nerve fibres4 ,muscular contractions1 especially1 impede mechanically the return of the venous blood to the heart4 ,the lesions to the nerves may be manifested in innumerable ways1 depending upon the location of the muscle and the function and distribution of the nerve affected4 ,then there is the relaxed1 overstretched1 and atonied muscle4 ,this condition results as a secondary effect to mechanical strains1 these being so severe and constant as to cause direct stretching and possibly tearing of the muscle fibres4 ,this should be distinguished from the exhausted or debilitated muscle1 e4 g41 as found in neurasthenia and anemia4 ,diagnostically there are1 7a7 contractions of more or less area1 due to atmospherical changes2 7b7 the deeply seated contractions involving a very small area1 caused by vertebral and rib lesions2 7c7 contractions due to reflex disturbances2 7d7 contractions caused by postural effects and deformities2 7e7 contractions from spasms of the blood vessels as a result of nervous irritations2 7f7 contractions due to toxicity of the blood4 ,all of these characteristic muscular lesions give a direct hint as to both etiology and prognosis4 ,third1 the ligamentous lesion1 as a lesion per se1 is usually of secondary importance to the osseous lesion4 ,in chronic cases affections of the capsular ligament and muscular fibrosis commonly maintain malalignment or rigidness4 ,there are two features that should be noted in particular when considering this lesion2 first1 thickenings and adhesions2 and1 second1 relaxations4 ,the tone and integrity of the ligaments cannot but be of vital concern to the stability1 suppleness1 and adaptability of the bony framework in all physical movements4 ,no matter how slight the osseous lesion may be the ligament must of necessity be involved4 ,the osseous derangements are either a source of irritation to the ligamentous tissue1 resulting in congestion and inflammation and hence thickening and adhesions1 or else the ligaments are so strained and tensed that in time atony may occur4 ,probably1 in a fair percentage of atonied cases the first disturbance to the ligament is one of irritation and congestion1 and from long continued involvement irritation is supplanted by debility4 ,consequently the primary consideration of the ligamentous lesion from the etiological standpoint is the character of the tissue 7ligament7 changes4 ,this1 also1 gives us a direct hint that is of the utmost value in prognosis4 ,the independent displacement of a ligament is rare1 thus ligamentous lesions from the viewpoint of purely physical displacements are secondary to if not an actual part of the osseous lesion4 ,ligaments1 when displaced or tensed1 readily impinge or irritate contiguous tissues1 but the original cause of the structural perversion is commonly either the osseous or muscular lesion4 ,hence1 whatever factors enter into the production of these lesions will at least indirectly produce the ligamentous lesion4 ,fourth1 the visceral lesion is frequently overlooked as being of much moment as an osteopathic lesion4 ,visceral displacements acting as a source of functional and organic annoyance on the physical plane 7structural perversion which produces and maintains pressure7 alone are not in the least uncommon4 ,any or all of the abdominal viscera1 or even the organs of the thorax1 may be displaced 7physically7 pathologically4 ,actual displacement of the viscus is a prolific source of distinct disorders and many obscure symptoms4 ,true it is the organs are most frequently displaced from indirect causes1 but nevertheless the actual physical malposition is in turn a primary cause of still another train of symptoms and diseases4 ,visceral lesions are caused by1 7a7 vertebral lesions2 7b7 postural defects2 7c7 direct violence2 7d7 nutritional disorders2 7e7 childbirth2 7f7 unhygienic measures 7tight lacing1 heavy skirts1 etc472 7g7 congenital weakness4 ,from the displaced heart due to valvular and debilitating influences to the displaced liver1 the stomach1 the kidneys1 the intestines1 the ovaries1 and the uterus1 may arise a source of direct or indirect irritations1 a train of apparent or masked symptoms1 or a group of nutritional disturbances that include an extremely important chapter in etiology4 ,moreover not only may one organ alone be involved but several may be displaced or prolapsed as a whole as in splanchnoptosis2 and even these in turn may be the direct cause of further organic displacements as the abdominal viscera prolapsing upon the pelvic organs4 ,here is a very fruitful field for the diagnostician1 for to separate cause from effect requires keen perception1 an acute sense of touch1 and above all1 most careful weighing of all the factors that enter into the maze4 ,fifth1 the composite lesion is not always recognized as an extremely important osteopathic factor4 ,by composite lesion is meant a structural lesion that primarily includes the osseous1 muscular1 and ligamentous tissues as a whole4 ,this may be termed a lesion en bloc or en masse4 ,composite lesions are of exceedingly frequent occurrence4 ,indeed1 many composite lesions are overlooked and instead of treating the en bloc disturbance as a consistent whole the component factors are treated separately with no concern or attention to the whole4 ,postural defects are excellent types of the composite lesion4 ,the various curvatures1 the tilted pelvis1 etc41 are representative of the composite lesion4 ,etiologically1 pathologically1 diagnostically1 and therapeutically the contour of the spine and ribs1 the relation of the innominata to the sacrum and spine1 and the symmetry of the body generally should be recognized and appreciated4 ,the relation of the part to the whole and of the whole to the part are of vital etiological concern4 ,an incipient curvature may be easily overlooked1 a pendulous abdomen neglected1 and a slipped innominatum passed unnoticed wherein as a result the entire vertebral column is malaligned in relation to the physiological curves or to the perpendicular line of gravity4 ,frequently attempts are made to correct individual lesions when attention should be directed to the composite lesion and vice versa1 e4 g41 a displaced rib is usually dependent upon a corresponding vertebral lesion1 and thus the transverse plane or section of the body should be considered as a whole4 ,a single lesion may be dependent upon a composite lesion or a composite lesion dependent upon one or more single lesions4 ,a slipped innominatum or a disordered hip joint may bring about a strain to a greater or less section of the spinal column1 or a twisted vertebra may cause a curvature1 whereas on the other hand postural defects may cause a strain at its maximum focal point resulting in over-stretching and relaxing of ligaments so that an osseous lesion results1 or a spinal curvature cause an innominatum displacement4 ,thus there is a constant establishing of equilibrium1 physically and physiologically1 through the medium of compensation1 but at some phase of the change there are apt to be pathological phenomena resulting1 and very frequently physiological harmony is not reestablished but instead irritation1 debility and other disease symptoms are constant effects until relieved4 ,consequently osteopathic etiology is many sided and complicated4 ,to know whether an osseous1 ligamentous1 muscular1 visceral1 or composite lesion is primary or secondary1 compensatory1 reflex1 predisposing1 or exciting1 requires a command of theoretical knowledge backed by much actual clinical experience4 ,in noting the above distinctive osteopathic etiologic features the student should not lose sight of the constitutional status of the patient which may be modified by inherited1 congenital1 diathetic1 and environmental influences1 all of which go to make up the predisposition of the individual and have an important relation to osteopathic factors4 ,then it should be recalled that disease processes may be of insidious progress1 and the products and effects of pathologic changes accumulative4 ,osteopathic ,pathology ,in the etiologic study the osteopathic characteristics have been designated structural maladjustment1 although at the same time not losing sight of the angle that the body is not only a physical mechanism but also a vital organism4 ,structural perversions characterize the osteopathic distinction when dealing with the physical body1 and remembering the vital or biochemic mechanism1 mental attitude1 diet1 hygiene1 etc41 are not forgotten4 ,to retain or attain health1 thorough appreciation of both the physical and vital mechanisms should be kept in view1 for there is both an independent and dependent interaction on the part of each4 ,the living body being an entity premises a system of therapeutics both physical and vital1 that acts in direct accord and harmony with physical laws and physiological functioning4 ,osteopathic pathology deals with the distinctive osteopathic lesion as a factor in production and maintenance of disease4 ,then the province of pathology is1 first1 to determine whether the lesion is in reality an etiologic factor2 second1 the immediate character of the lesion disturbance2 and1 third1 how organic life becomes involved4 ,inspection1 palpation1 clinical results1 dissection and laboratory experimentation include the methods employed to prove that the lesion is of practical consequence4 ,that the lesion is an etiological factor can be known only through clinical and experimental proof2 the immediate character of the lesion disturbance can be determined by dissection2 and how organic life becomes involved requires the summation of histological1 physiological and pathological data4 ,the following outline assumes that the reader is familiar with anatomy1 physiology and pathology4 ,osteopathic pathology does not add to medical pathology an absolutely new pathology in all of the present known numerous details1 but instead interprets much of clinical pathology anew1 and furthermore it presents absolutely new data that is exclusive1 but germane to the present general medical and surgical fields4 ,nervous tissue and arterial blood are the master tissues1 the controlling and governing factors in health1 and disturbances of these tissues are necessarily the cause of ill health4 ,the rule of the artery and the control of the nerve must continue uninterruptedly in order that physiological functioning remains intact4 ,the body should be looked upon as a being complete1 no more or less1 each tissue and organ essential to the whole and the organism as a whole essential to every part4 ,this is fundamental and germane to a living structure1 and hence disturbance to the governing and controlling tissues1 the nerves and vascular channels1 must necessarily cause a break in the concatenation and disease must logically follow4 ,thus in the osteopathic pathology we look to those influences that primarily disturb the nerve or artery1 study the disease process or extension from inception to effect and from primary lesion to morbid results1 and note action and interaction of tissue upon organ and organ upon organ4 ,that all parts of the body are in intimate and dependent relations each with the other through the media of the nervous and endocrine systems is a well known fact based upon histological and physiological grounds4 ,the neurone being the physiological unit implies that any disturbance to the cell quickly disturbs any or all of its processes4 ,it may be said that 8nervous tissue is dependent for its integrity upon two things1 blood supply and trophic influences4 ,the nerve cell is solely dependent on a proper supply of blood1 and dies when this is withdrawn4 ,but the nerve fiber is more dependent on the trophic influence of the cell of which it is a prolongation4 ,it dies when cut off from the cell but it can get along for a time with but little direct blood supply4 ,on the other hand1 if the nerve fiber is injured it reacts on the cell1 leading to a partial but curable degeneration of the cell body40#ah ,here is the immediate pathologic key to many diseases4 ,whatever cuts off or obstructs the artery leading to the cell is a primary etiologic factor2 this then leads to degeneration of protoplasmic processes and axone4 ,it should be carefully noted that if the obstructed blood vessel is one to the nerve fiber only the resultant partial injury to the cell is curable4 8,when an axone degenerates the retrogressive process involves not only the main axone1 but also its terminals1 together with the collaterals belonging to it with their terminals40#ai ,this is an exceedingly important link in the explanation of osteopathic pathology1 that distant organs may be affected by the osteopathic lesion4 ,moreover1 8degenerations of a secondary character may occur in those systems of neurones which are more or less dependent upon the peripheral sensory neurone system for their impulses40#bj ,this is equally true with the central motor neurone1 or any neurone4 ,it shows how far-reaching a degenerative process and its effects may be4 ,it further makes clear that nerve intactness is directly and absolutely dependent upon a normal circulation1 and that it is self-evident any blockage either to blood vessels or to neurones will vitally affect those tissues that govern and control the life processes of the body4 ,the integrative action of the nervous system is one of the outstanding facts of physiology4 ,the above is presented so the student may see how osteopathic spinal lesions1 if deeply seated and effective enough1 can involve remote tissues and organs4 ,no one will doubt that fractures and complete dislocations of the spinal column will seriously affect visceral life1 or a prolapsed kidney will be a cause of nutritive disturbance1 or a displaced uterus the cause of ovarian congestion1 or a dislocated hip the cause of atrophy of the leg muscles1 but it has remained for the osteopath to offer proof that slight misplacements of the vertebr or ribs1 incipient curvatures1 postural defects1 slight deformities1 and unsymmetrical bodies are of sufficient etiological importance on the physical plane to affect neurone integrity and obstruct artery courses1 and thus organic life4 ,the question at once arises1 what is the immediate or direct effect upon blood vessel or nerve of the osseous1 ligamentous1 muscular1 visceral or composite lesion8 ,the osseous lesion will be taken as a type4 ,the direct effect is usually one of hyperemia or ischemia1 generally the former1 for as physiologists and clinicians observe irritation commonly precedes debility4 ,in the vertebral and rib lesions there may be direct pressure upon the spinal nerve at its spinal foramen exit or on the sympathetic chain directly contiguous to the heads of the ribs4 ,this causes congestion1 inflammation1 ecchymosis1 and degeneration of the nerve fiber1 followed by macroscopic and microscopic changes as connective tissue proliferations1 arterial scleroses1 etc4 ,or1 as seems probable in experimental work1 the inception of the pathology may be frequently the result of blockage to nervous stimuli1 which when maintained affects the efferent vasomotor1 secretory1 trophic and other fibers so that circulation and nutrition are definitely involved4 ,thus the cells so sensitive to altered vascular changes are directly and remotely affected1 and disease characteristics dependent upon structure and function of tissue1 and degree of irritant are evident4 ,this can vary1 in degree only1 with the muscular lesion that involves collateral spinal cord circulation1 the visceral lesion that irritates sympathetic life1 or the composite lesion that deforms or perverts structure en masse4 ,but is the physical noxa as potent an etiologic factor as the chemical or bacteriologic8 ,adami#ba informs us whether an irritant is physical1 bacterial or chemical1 no satisfactory distinction can be founded on the duration of the irritation2 that a local irritation of the nervous system may lead apart from 8direct reflex action1 to changes of nervous origin1 in the region of the injury and in the reflexes affecting associated regions1 the higher centers2 and through them the system at large1 may become affected by paths that it is not always easy to trace40 ,again he says that 8centrifugal impulses alone1 apart from any local injury1 may originate a succession of phenomena of inflammation in a part40 ,and 8in all probability a nervous and central origin must be ascribed to some1 at least1 of the sympathetic inflammations seen to occur in areas supplied by the other branches of a nerve supplying a part primarily inflamed2 and again in areas supplied from the same region of the brain or cord as the inflamed organ40 ,other inflammatory changes1 of course1 may occur independently of centrifugal nervous influences1 and the vessels react independently of central influences4 ,this1 then1 presents a situation postulated thus3 #a4 ,the body follows definite structural relations and is influenced by mechanical arrangements in its morphology4 #b4 ,the integrity of tissue depends upon structural freedom of nutritive courses4 #c4 ,the above predicates a structural etiology as exact and precise as structural relations are important to nutrition4 ,what proof1 then1 of the foregoing have we to offer8 ,first1 the clinical proof4 ,clinical results have been obtained in tens of thousands of cases that include disease of various types and lesions1 and of all sections and organs of the body4 ,the art of osteopathy has been perfected in many of its details1 based upon actual experience and splendid results4 ,the cure of the patient is paramount to all other consideration1 and whereas the osteopathic school has been shown a superior system it logically follows on a priori grounds that relief and cure of suffering is of the first and final importance4#bb ,were it not for clinical results no new system of therapeutics could withstand criticism and calumny and finally triumph and be publicly1 legislatively1 and scientifically recognized4 ,second1 the autopsy proof4 ,many dissections have been made and autopsies held with the view of discovering the character and the potency of the osteopathic lesion4 ,this very important work has borne out the osteopathic theory of disease4 ,vertebral and rib displacements have been noted1 corresponding ligamentous tissues thickened1 associated nerve tracts and vascular channels disturbed1 and finally the related organ found diseased4#bc ,third1 the experimental proof4 ,experimental proof appeals1 logically1 to the scientific mind4 ,this proof#bd is being gradually developed4 ,experimental investigation has been successfully carried out upon numerous animals4 ,the experiments conclusively prove that not only spinal inhibitory and stimulatory manipulations 7mechanical7 are productive of immediate physiological changes in the viscera1 but that the structural anatomical lesion or noxa is an important factor in the etiologic field4 ,pathological changes in several organs directly follow the artificially produced vertebral and rib lesions1 showing beyond doubt the reality and effectiveness of the osteopathic lesion4 ,this emphasizes the point that centrifugal impulses originate an inflammation in a previously healthy and uninjured tissue or viscus4 ,and as 8inflammatory phenomena may be sympathetically developed in regions innervated from the same area in the brain or spinal cord0 it remains to prove the actuality of vertebral and rib lesions1 i4 e41 structural perversions really affect contiguous nerve courses and vascular channels2 and this has been demonstrated in laboratory experiments and at the autopsy4 ,consequently the vertebral1 rib1 or other lesion may be an important etiologic factor either to the nerve strand from cord or brain to viscus or from viscus to cord or brain4 ,dr4 ,still says in his ,autobiography that 8all nerves depend wholly on the arterial system for their qualities1 such as sensation1 nutrition and motion1 even though by the law of reciprocity they furnish force1 nutrition and sensation to the artery itself40 ,it matters little in this outline whether obstruction to nervous integrity is by way of an impinged artery or by direct pressure1 or both1 or otherwise1 for the primary consideration is the noting that the osteopathic lesion is a real and potent factor of disease4 ,sajous#be informs us that 8a neurone is directly connected with the circulation 7via neuroglia-fibril7 by one or more of its dendrites1 which serve as channels for blood plasma10 that a neurone receives its nutrition directly from the general circulation1 and that from the axone the blood passes into a lymph space connected with a vein4 ,thus in reality a part of the circulatory system is that of the entire cerebrospinal system4 ,the student is referred to the various publications of the ,research ,institute and ,deason's ,physiology for experimental data confirming the validity of the osteopathic theory1 although it should be emphasized that clinical evidence is quite conclusive4 ,malalignment injuries of the vertebral articulations1 for example1 ranging from imbalance of muscular tension to infections1 is certain to result in some type of rotation and sidebending of the segments to an extent that apposition is compromised and abnormal anchorage supervenes4 ,there are many factors of the pathology3 muscular tension and fibrosis2 damaged ligaments1 particularly the capsular2 interference of nervous stimuli1 blockage of impulse directly and reflexly as shown by pathologic involvement in cord centers and sympathetic ganglia1 and in certain cases direct obstruction of nerve fibers as revealed by ,wallerian degeneration2 involvement of circulation as shown by damage to blood-vessels1 local edema and local acidosis1 and effect upon local tissue respiration and drainage4 ,through a combination of these various factors circulation1 nervous equilibrium and chemism of related parts are involved1 both anatomical and physiologic balance is upset1 and resistance of corresponding viscera affected4 ,reciprocal innervation and the axone reflex are also disturbed1 all of which are important predisposing causes that disturb resistance of tissues and organs1 upset their correlated mechanisms and render active various possible infections and toxins that otherwise a normal circulation1 nervous and endocrine systems1 and oxygen supply would rapidly and successfully combat and restore the organism to normal4 ,thus from the practitioner's standpoint there are three points to always keep in mind3 readjustment of the lesion2 correction of the forces1 habits1 environment1 etc4 that produce the lesion2 and hygienic attention of the body after lesion adjustment in order that normal condition may be maintained4 ,a thorough study of the physiologic movements of the spine is a prerequisite to an understanding of the various possible abnormal appositions1 though it should be appreciated that these movements are not consonant or applicable to many abnormal conditions4 ,pathology reveals many gradations and combinations not found in normal conditions4 ,frequently the key of a successful technique rests upon an understanding of the individual make up of the interosseous lesion4 ,it has not been the purpose of this section to go into details but rather to follow logically an outline of osteopathic etiology and pathology4 ,the various details will be found in the osteopathic works on ,principles as well as in the experimental articles referred to4 ,it should be understood that the osteopath believes thoroughly in vis medicatrix naturae whether the indications are for stimulation or inhibition or for the basic readjustment4 ,generally speaking1 however1 therapeutic philosophy resolves itself 7ultimately7 into the principle that a cure depends upon giving an impetus to impaired1 habitual and latent forces1 which in the osteopathic field implies fundamentally adjustive manipulation whereby the resultant impetus or physiological stimulus is initiated4 ,in a word1 osteopathy premises that the body is a vital and physical mechanism subject to derangements1 structural alterations1 and functional changes1 as results of violence on the mechanical plane1 as well as disturbances on the psychic and biochemic planes4 ,hence1 osteopathic philosophy is inclusive of preventive1 palliative and curative measure4 ,,footnotes3 #ae ,sajous--,the ,internal ,secretions and the ,principles of ,medicine4 #af ,foster--,medical ,dictionary4 #ag ,hulett--,principles of ,osteopathy4 #ah ,dana--,text ,book of ,nervous ,diseases4 #ai ,barker--,reference ,hand ,book of the ,medical ,sciences4 #bj ,delafield ,prudden--,hand ,book of ,pathological ,anatomy and ,histology4 #ba ,adami--,inflammation1 ,allbutt's ,system of ,medicine4 #bb ,see ,case ,reports1 ,american ,osteopathic ,association4 #bc ,clark--,applied ,anatomy4 #bd ,mc,connell--,numerous articles ,journal ,a4 ,o4 ,a4 #aije-ai1 ,bulletins ,research ,institute2 ,deason1 ,bulletins ,research ,institute1 ,deason's ,physiology2 ,burns' ,osteop4 ,world1 ,aug4 #aije2 ,basic ,sciences1 ,bulletins ,research ,institute2 ,pearce1 ,osteopathic ,physician1 ,nov4 #aije4 #be ,sajous--,internal ,secretions and the ,principles of ,medicine4 ,,osteopathic ,,diagnosis ,,and ,,prognosis ,osteopathic ,diagnosis ,in osteopathic diagnosis the spine is the first and greatest object of interest1 for on the result of its examination will depend the treatment to be given which is in turn hoped to bring about recovery4 ,as it is the structure on which rests the weight of the body the practiced eye is able to detect at a glance1 by the poise and gait of the patient1 if there is an abnormal condition affecting any considerable area of the spinal column4 ,it is well to observe these points1 especially in the female1 before having them prepare for examination1 as it will often give a clue to sources of trouble through faulty carriage1 improper dress1 particularly corset and shoes4 ,slight changes of gait1 unnoticed by the patient may be of great aid in determining the beginning of disease in the spinal cord4 ,no osteopath is justified in accepting a patient who will not permit every examination deemed necessary1 as remote and obscure lesions are frequently the cause of disease1 so preparation of the patient for the first scrutiny is of importance4 ,this cannot be made with the patient fully clothed1 as visual observation is second only to the touch in making one's deductions4 ,neither can palpation be made through more than one thickness of clothing with accuracy1 and examination next to the skin is always preferable4 ,this need in no way ever cause complaint1 for with the use of a loose fitting short kimono1 with all outer clothing removed except the knit undergarment1 and with skirt bands loosed1 a complete survey of the whole dorsum from occiput to coccyx can be had without the slightest unnecessary exposure4 ,it is well to remember that the patient has come for help and the osteopath is not justified in sacrificing thoroughness for any exaggerated feelings of modesty4 ,with tact and care in the use of the garments the most sensitive ones need feel no hesitation in coming for treatment4 ,a complete history of the case should be taken before the examination begins1 former methods of treatment1 symptoms1 environment1 etc41 as it will aid in the final conclusions4 ,it is well to have blanks for keeping records of all cases4 ,probably the most comfortable manner to begin physical examination is to seat the patient on a table squarely with hands placed upon the knees1 then raise the garment and expose the whole back4 ,begin by noting the texture of the skin1 if it is clear1 pigmented1 blotched1 or has eruptions4 ,try the capillary reflex by pinching or stroking quickly with the finger tips or the blunt end of a pencil4 ,find if it is moist or dry and also outline the areas of changed temperature1 if any4 ,then observe the general contour of the spine with the patient sitting upright1 to find how near it is to the normal body curve4 ,occasionally having the patient alternately sit and stand will1 by comparison1 throw light upon the condition4 ,with the patient bending forward place the hands on the crest of the ilia and see if they are of equal height4 ,occupation may result in over development of one side or there may be congenital asymmetry#bf4 ,note position of the scapul and habit of posture in sitting and standing4 ,before taking up the subject of a critical examination of each vertebra there are certain points it will be well to consider4 ,it is easy to know instantly1 without counting1 the number of the vertebra causing the lesion if these landmarks are remembered3 ,first1 the spine of the third dorsal is on a level with the spine of the scapula4 ,second1 the spine of the seventh dorsal is on a level with the inferior angle of the scapula4 ,third1 the spine of the last dorsal is on a level with the head of the last rib4 ,it will save much time for the busy osteopath to have these well in mind4 ,the pathognomonic symptoms of the osteopathic lesion are3 7a7 maladjustment2 7b7 contracted muscles2 7c7 tenderness2 7d7 limited movement4 ,to these might be added changes in local temperature and disturbance of function1 but the former is not constant and the latter may be remote4 ,here the primary lesion is considered1 for an osteopathic lesion may be1 also1 secondary or compensatory4 ,forbes speaks of compensatory changes as being an important diagnostic sign4 ,diagnosis of the position of a vertebra is sometimes difficult to the beginner from its having longer or shorter spines than normal4 ,horsley speaks of the occasional congenital absence of a spinous process4 ,they may be bent laterally1 upward or downward and thus have all the appearances of a marked displacement1 while occasionally the body itself seems much at fault4 ,these present what might be termed normal abnormalities and make it necessary for the osteopath to be very sure of his diagnosis before attempting to correct what is not abnormal1 for disappointment1 at least1 and injury1 perhaps1 may follow4 ,to avoid mistake1 carefully palpate the transverse processes and determine if they are at right angles with the adjoining normal spine4 ,in the cervical and lumbar vertebr it is possible to reach the tips of the transverse processes1 and on moderate pressure1 if a lesion exists1 pain will be elicited4 ,further1 where tenderness is associated with other diagnostic points it can be safely assumed that a lesion exists1 and by outlining the suspected vertebra with the finger and localizing the sensitive spot one can be sure of the point of greatest irritation and the character of the displacement4 ,associated also with these signs will probably be evidence of congestion1 such as thickened tissues1 contracted muscles1 etc4 ,after having examined the condition of the spinal column thoroughly by inspection1 begin at the first dorsal and examine the spinal column down to the sacrum4 ,place the middle and ring fingers over the spinous processes and stand directly back of the patient and draw the flat surfaces of these two fingers over the spinous processes from the upper dorsal to the sacrum in such a manner that the spines of the vertebr pass tightly between the two fingers1 thus leaving a red streak where the cutaneous vessels press upon the spines of the vertebr4 ,in this manner slight deviations of the vertebr laterally can be noted with the greatest accuracy by observing the red line4 ,when a vertebra or a section of vertebr are too posterior a heavy red streak is noticed and when a vertebra or vertebr are anterior the streak is not so noticeable4 ,thus when suspicious points are noticed a special examination of the localized point can be given4 ,this examination simply takes into consideration the contour and superficial condition of disordered portions of the spinal column4 ,in a few cases such an examination will not be necessary1 for the symptoms and signs of the disease will be so clearly manifested that one's attention will be called directly to the cause4 ,still1 great care should be taken in the majority of cases1 as the osteopath finds causes of disease remote from the seat of complaint4 ,we must always bear in mind the significance of reflex stimuli and sympathetic radiation4 ,in making a critical and exhaustive diagnosis of the spinal condition after the foregoing general examination has been made1 it will be best to have the patient lie on the side upon the operating table4 ,when the patient is in this position a more thorough examination can be made1 as then the spinal muscles are not contracted unless abnormally so1 for when a person is in the upright position muscles are continually contracting first on one side and then on the other1 as one of their functions is to act as a support in keeping the spinal column erect4 ,the patient lying on his side1 the physician should then stand in front of him and reach over upon the back and make a thorough examination of the affected portions of the spinal column1 chiefly through the dorsal and lumbar regions4 ,consideration should be given the contraction of the muscles along the back1 chiefly the deeper layers of muscles4 ,it may even be necessary to relax some of the muscles before a thorough examination of the vertebr can be made4 ,from a pathological point of view too much stress should not be put upon the contracted state of the muscles2 although in a number of instances the contracted muscles may be the primary cause of the patient's trouble2 especially so when the affection is due to atmospheric and other changes4 ,contraction of the muscles may be secondary to the lesions presented in the bony frame work4 ,for instance1 a dislocated vertebra may be the cause of an irritation to the innervation of certain muscles along the spinal column and thus cause them to contract4 ,still1 we must not lose sight of the importance of the contracted muscles from a diagnostic point of view4 ,they are oftentimes prominent signs that a lesion exists in the immediate region and are thus faithful guides in locating the cause of diseases4 ,in closing the general consideration of the spinal column it is well to emphasize the importance of training the faculties to grasp at a glance the story told by the back as a region1 instinctively placing the proper value on each physical sign and weaving them into a composite whole so that the patient's condition stands out a vivid picture on the osteopath's mind4 ,when this is accomplished the more detailed observations are but incidental4 ,relative to the examination of the spinal column ,clark#bg says3 8,to the osteopathic physician1 the most important part of the human body is the spinal column4 ,by its changes in contour and condition the various visceral diseases can be diagnosed1 in most cases4 ,i believe that every disease is characterized by extreme changes or signs1 and ,i further believe that every chronic visceral disorder is manifest by changes in the spinal column that can be1 by the practical eye and touch1 readily interpreted4 ,in short1 there are various signs along the spinal column that point out the weakened or diseased parts of the body4 ,this method of diagnosing disease1 that is by noting these spinal changes1 is distinctly osteopathic1 and ,i believe the time will come when it will become such an exact science that the character of the spinal change or lesion is diagnostic not only of the viscus affected1 but the way it is affected40 ,regional examinations and diagnosis will now be taken up4 ,neck1 ,head and ,face4--,to make a thorough diagnosis of the condition of the cervical vertebr probably requires more skill and a more acute sense of touch than of any other region of the body4 ,the irregularities and variations of the cervical vertebr1 the numerous muscles and the passage of many vessels through the neck are very liable to mislead one4 ,one may examine the cervical vertebr by having the patient either lying down or in a sitting posture4 ,the former position is preferable1 as then the muscles of the neck are passive1 and besides it is much easier to relax the muscles if such should be necessary4 ,also one has better control of the field of examination4 ,it is undoubtedly best for the student when learning to examine the cervical vertebr to first examine along the base of the skull the condition of the occipital muscles 7after the patient has assumed the dorsal position upon the treating table7 for any contractions2 for if disorder exists in the upper five cervical vertebr the condition will be manifested by contraction of muscular fibres along the base of the occipital bone4 ,the muscles of the occiput are supplied by fibres from the posterior branches of the upper five pairs of spinal nerves1 and if lesions exist to these upper nerves a contracted state of more or less extent of the occipital muscles will occur1 no matter how slight the lesion4 ,thus the examiner after locating contracted fibres under the occiput has a direct clue to lesions existing somewhere in the upper five cervical vertebr4 ,after locating these contracted fibres of the occipital region and then still keeping the finger upon the contracted muscular fibres and following them downward until the contractions are lost and seem to enter the spinal cord1 one has then located the exact point of disorder that is causing the irritation to the muscular fibres involved1 and most probably the cause of the affection from which the patient is suffering1 i4 e41 provided one has reason to suspect the trouble is in the cervical vertebr4 ,simply follow the contracted muscular fibre downward until it seems to enter the spinal cord and there one will find a lesion4 ,after the osteopath has become expert in diagnosis this will not be necessary unless he has to make a very fine diagnosis or unless he is examining a stout neck where it is hard to examine through the heavy muscles4 ,with this method one has a firm1 flat1 broad surface to work on 7the occipital bone7 making it very easy first to locate contracted muscles and second to trace the course of contracted muscles and thus find the disorder4 ,otherwise the beginner is apt to get confused by trying to examine the condition of the cervical vertebr4 ,later1 when a student becomes more expert such a procedure will rarely be necessary only in cases that require special work in the examination4 ,when the point of disorder has been located the diagnosis as to the exact character of the maladjustment has to be determined4 ,the abnormal position of the vertebra1 tenderness at the point involved1 local contracted muscles1 and limited motion are the four diagnostic points1 although the temperature of the affected part as compared with the general cutaneous temperature and the state of the local vascular channels 7blood and lymphatics7 will occasionally be of aid4 ,owing to the irregularity of the spinous processes of the cervical vertebr in regard to their length1 great care has to be taken in the examination4 ,probably there is no other region of the body that will tax the patience of the osteopathic student so much in his practical work as making a diagnosis of disorders in the cervical spine4 ,it requires patient and persistent work to become a fair diagnostician of the cervical region1 and it will take much experience to become expert in both the examination and treatment4 ,one can depend that lateral deviations of the spinous processes are abnormal in most instances4 ,placing the finger upon the spinous processes of two consecutive vertebras the student can readily tell whether or not there is any lateral displacement2 but telling as to other features is impossible as the spinous processes vary greatly in length4 ,when a vertebra is lateral1 a slightly twisted condition will be felt by the finger when placed upon and between the two spinous processes4 ,to elicit the various degrees and combinations of rotation and sidebending one should depend upon the symmetry of the transverse processes4 ,reaching anterior to the sternocleidomastoid muscle1 or better still1 pushing the cleido muscles forward and reaching posterior to them upon the transverse processes1 a very fair examination can then be given the vertebras4 ,when the vertebras are deranged1 especially anteriorly or posteriorly1 that is the apposition of the articular facets1 a slight elevation will be felt1 possibly not any larger than a very small pea1 either the anterior or posterior aspects of the transverse processes1 depending upon which way the vertebr are deranged4 ,remember that accompanying this slight elevation will be degrees of sensitiveness of the vertebra at the point deranged4 ,in cases where the vertebra is lateral a slight eminence will be noted along the outside of the process4 ,commonly disordered vertebr are not entirely deranged in one direction but are oftentimes slightly rotated1 so we may find them dislocated antero-laterally or in various combinations of sidebending-rotation4 ,several consecutive vertebras may be deranged in like manner of direction2 this condition is chiefly found in pathological curves of the spinal column4 ,probably the most common general lesion is a strained condition of several consecutive vertebr1 each one being nearly intact but all of them as a whole somewhat strained or twisted4 ,thus there are many pathological states to take into consideration1 although it is not surprising to the osteopath when he realizes that many of our pains and aches are due to anatomical derangement4 ,frequently bending the head strongly forward and downward1 or downward pressure with slight rotation will produce pain at the point of lesion4 ,subdislocations of the atlas are probably among the most common lesions presented to the osteopath4 ,owing to the articulation of the atlas and occipital bone being an anatomically weak point and the neck muscles being exposed constantly to atmospheric changes1 besides the articulation between the head and neck receiving the brunt of many jars1 falls and strains1 the atlas is especially susceptible to derangements4 ,on account of the intimate relation of the atlas to the superior cervical ganglion of the sympathetic and to the vertebral blood vessels it is certainly very necessary that the atlas should be well taken care of4 ,no other tissue maintains such a significant position in relation to the blood and nerve supply to and from the brain4 ,to diagnose correctly the position of an atlas and to be able to correct it is undoubtedly one of the most essential achievements of the practitioner of osteopathy4 ,the most common disorders of the atlas are anterior and lateral displacements4 ,next in order come 8rotary0 lesions of the atlas1 i4 e41 where the atlas has been deranged diagonally or simply twisted4 ,it may also be luxated anteriorly and laterally1 or posteriorly and laterally1 etc4 ,a posterior derangement of the atlas is comparatively a rare disorder1 although owing to the many lesions that are found in atlases one has1 during the course of a year's practice1 several to correct4 ,the atlas may occasionally be slightly tipped laterally1 anteriorly1 or posteriorly1 and in a few cases it may be somewhat impacted against the occipital bone4 ,many times when the atlas is displaced the axis is also deranged on account of the close relation between the atlas and axis by the odontoid process of the axis4 ,to examine the atlas the patient may be either in the sitting or dorsal posture2 it matters but little which position is taken4 ,possibly the dorsal position is better1 as then the neck muscles are more relaxed and if necessary an examination of the cervical spine1 below the atlas1 can easily be made4 ,by placing the middle finger of either hand on the transverse processes of the atlas when the patient is in the sitting posture1 or the thumbs on the transverse processes when the patient is in the dorsal posture and comparing the two sides1 undue prominence of one side or the other can easily be noted4 ,remember the transverse processes of the atlas are slightly above and posterior to the angle of the inferior maxilla4 ,always1 in examining one side of the patient1 compare it with the other2 it may save considerable embarrassment4 ,one side may seem abnormal when by comparing it with the other side1 both sides may be found the same and still be normal4 ,with the fingers still on the transverse processes note the distance between the process and angle of the jaw1 besides take into consideration the tenderness of the locality1 and1 also1 what is of essential importance in all interosseous lesions1 its articular range of movements4 ,there should be room enough 7approximately7 to just comfortably wedge the end of a medium sized middle finger between the transverse process of the atlas and the angle of the inferior maxilla when both are normal4 ,thus with the fingers on the transverse processes an expert will be able to readily determine whether or not an atlas is lateral or anterior4 ,if an atlas is posterior the distance between the angles of the jaw and the transverse process will be increased1 besides the atlas will be quite prominent posteriorly4 ,in conjunction with the abnormality of the tissues 7prominence or depression of the bone and state of the muscles7 the sensitiveness of the locality is extremely significant4 ,outside of displacements of the atlas1 a lesion between the axis and third cervical is most common2 following next in frequency are lesions of the skull and atlas4 ,by that is meant where all the cervical vertebr are intact as far as their individual relation is concerned1 but the skull is forward1 backward or lateral upon the spinal column4 ,this condition occurs quite frequently4 ,to determine its condition the same methods are employed as in diagnosing a deranged atlas2 for if the dislocations exist between the atlas and skull the same diagnostic points are presented as far as the skull is concerned as when the atlas1 or atlas and axis1 are dislocated from the occipital bone or from the axis or third cervical4 ,following the preceding examinations1 additional examination will have to be made to see whether or not the atlas is intact with the vertebr below4 ,if the atlas is found to be intact with the vertebr below and lesions are presented between the atlas and the skull1 then the disorder must be between the atlas and the skull and nowhere else4 ,occasionally there are cases where the skull is so far posterior upon the spinal column that the angles of the jaw strike against the transverse processes of the atlas when the jaw is opened widely4 ,derangement of the muscles of the anterior and lateral regions of the neck are common4 ,especially are contractions of the muscles on either side of the larynx liable to occur4 ,in examining the cervical region do not pay too much attention to the superficial muscles1 but examine carefully the deeper muscles4 ,it is from these that impingements of nerves and constrictions of vessels are likely to take place in the contracted fibres4 ,also1 imbalance of muscular tension may be the source of the resulting malalignment4 ,in examining for contracted muscles do not gouge into the muscle nor grasp the muscle roughly1 but bear down lightly 7inhibitory7 upon the muscles and then gradually exert firmer pressure4 ,by carefully and firmly exerting pressure over muscular areas the deep muscles can then be felt beneath the superficial ones4 ,otherwise when the muscles are manipulated severely the superficial ones will contract to such an extent that the deeper ones cannot be felt4 ,the muscles contracting on either side of the larynx tend to draw the larynx downward and thus there may arise a source of irritation4 ,the various muscles contracting in the antero-lateral region of the neck are very often the source of chronic irritations of the pharynx or throat4 ,the omo-hyoid muscle may become contracted and cause slight traction on the hyoid bone and thus produce an irritating cough4 ,to examine the muscles of the neck thoroughly it is best to have the patient flat upon the back1 for then all the normal muscles are relaxed4 ,lesions quite frequently occur in the temporo-inferior maxillary articulation4 ,the lesion may be either unilateral or bilateral1 more commonly the former4 ,the disorder usually consists of a relaxation of the muscles and ligaments about the articulation which allows a slight but perceptible dropping of the inferior maxilla on the side involved4 ,in other cases there may be presented a spasticity of tissue1 while in still others some degree of joint infection may be found4 ,lesions of this articulation particularly impinge upon fibres of the fifth cranial nerve4 ,the points of diagnosis are clicking and tenderness at the articulation4 ,these two points are the symptoms of which the patient complains2 those noticed by the osteopath are a slight deviation of the jaw to one side or the other when the jaw is opened and a flinching of the patient due to tenderness when pressure is exerted over the articulation of the jaw4 ,when the physician places his fingers around the jaw1 anterior to the angles1 and the thumbs over the bridge of the nose1 having patient open the mouth1 at the same time exerting pressure with the fingers and thumb1 a sharp click may be elicited by the return of the jaw into its articulation4 ,in disease of the scalp the condition of the muscles of the scalp should be taken into consideration4 ,the muscles are usually found contracted4 ,the contraction of the muscles is generally due1 as well as the disease of the scalp1 to derangement existing in the posterior branches of the upper five pairs of the cervical spinal nerves4 ,in the neck1 anteriorly the hyoid is the only bone to consider4 ,it is easily palpated by standing at the head of the table and with the second finger of each hand outline both ends to ascertain its relation with the thyroid cartilage4 ,note carefully any contracted tissue or glandular enlargements which might cause undue tension4 ,the tilting of either end of the hyoid from these contractions is productive of much throat irritation4 ,at the same time the larynx may be examined4 ,it may be prolapsed1 causing irritation of the laryngeal group of nerves4 ,the thyroid and cervical glands should be palpated for enlargements1 and all the muscles and ligaments for contractions4 ,externally the tonsil may be felt by deep pressure in front of the angle of the inferior maxilla4 ,the ,ribs4--,under the osteopathic diagnosis of the ribs will be included the examination of the clavicle and sternum4 ,to be able to diagnose intelligently1 the position of the ribs in detail is very necessary to the osteopath4 ,many of the diseases of the heart and lungs1 besides a large number of the diseases of the digestive tract1 may be traced to a deranged rib2 also1 occasionally diseases of different regions of the head and neck may be due to dislocated ribs4 ,in making a thorough examination of the ribs each rib should be carefully noted as to its position4 ,the ribs may be examined when the patient is sitting up2 but it is better to have the patient flat upon the back and especially so if the floating ribs are to be carefully examined1 because the muscular tissues of the side if contracted will interfere with the diagnosis4 ,in many instances the rib lesion is secondary to a vertebral subluxation4 ,an expert osteopathic diagnostician will be able to detect at once by a single passage of the hands down over the ribs if there are any disorders of them4 ,in passing the flat of the hand1 especially the flat part of the fingers over the ribs1 carefully observe if the intercostal spaces are too narrow or too wide1 and if any of the ribs are unduly prominent or depressed4 ,if an intercostal space is too narrow it shows that the ribs on either side of the intercostal space are too close together4 ,then the question arises1 which one of the ribs is crowding upon the intercostal space1 or whether both of the ribs are crowded together4 ,usually when the sternal end of the rib is displaced upward1 the involved rib is prominent and when displaced downward the rib is depressed4 ,thus it is commonly easy to diagnose which is the involved rib4 ,besides finding an abnormal position of the rib there will be more or less tenderness over the rib4 ,finding a rib prominent or depressed and tender is generally quite conclusive that the rib is displaced4 ,then the range of movement as expressed through the sense of resistance is a helpful guide in diagnosis4 ,if a typical rib is placed upon a flat surface and one end of it is depressed the other end will be elevated and vice versa4 ,this peculiarity holds true as well when the ribs 7typical7 are dislocated in the living body4 ,if the anterior end is elevated the posterior end is commonly depressed and vice versa4 ,care should be taken in examining the first rib and the false ribs1 for in these ribs this peculiarity is not found4 ,as a whole a very complete diagnosis can be made of the condition of the ribs by examining the anterior part of the thorax1 although it is always best to examine along the angles of the ribs if for nothing more than to confirm the diagnosis made at the sternal ends4 ,still it must be remembered that the preceding only holds good when the entire rib is dislocated4 ,many times simply one end of the rib is deranged and the other end is practically intact4 ,besides careful examination of the sternal end of the rib1 attention should be paid to the condition of the costal cartilages4 ,the costal cartilages may become deranged at either the articulation with the rib or with the sternum4 ,the same rule holds good when the costal cartilages are dislocated as when the ribs are dislocated1 i4 e41 when the cartilages are prominent1 they are usually displaced upward and when depressed the cartilage is displaced downward toward its neighbor4 ,one is apt to think that a rib is only dislocated at its vertebral end4 ,although lesions of the vertebral end are generally of greater significance as far as the etiological factors are concerned1 still the sternal end of the rib must not be overlooked4 ,in examining the vertebral end of a rib attention should be paid the angles of the ribs1 for at the angles a better opportunity for examination is given on account of the prominence4 ,it will be necessary in many cases to find out whether or not the vertebral end of the rib is lying between the transverse processes instead of in front of them4 ,in many severe lesions of the ribs the vertebral end of the rib is dislocated upward or downward from the transverse process of the vertebra and lies between the transverse processes of the vertebr above and below its attachment4 ,this certainly requires considerable skill in the diagnosis1 for oftentimes the point to be found is barely an eighth of an inch in diameter4 ,it is usually best before making such a close examination to relax the tissues well over the field of examination4 ,the ribs as a whole may be too transverse or too oblique upon one side4 ,this is chiefly found in pathological curves of the spine1 but still such conditions may exist where there are severely contracted muscles1 especially in some cases of paralysis4 ,thus the contour of the ribs must be taken into consideration by comparing one side with the other4 ,in examining the first rib an examination somewhat different from the other ribs should be given4 ,it is best to have the patient assume a sitting posture2 then place the middle fingers of each hand upon the first ribs near their centers and compare one with the other4 ,also note the difference of the spaces between the ribs and clavicles4 ,generally the first rib is dislocated upward1 rarely downward4 ,besides finding an abnormal prominence or depression of the rib at its center considerable tenderness will be noticed4 ,examinations of this region are every day experiences with the osteopath4 ,when diagnosing the position of the floating ribs it is best to have the patient lie flat upon the back with the thighs flexed upon the abdomen1 so that the tissues about the lower ribs may be entirely relaxed4 ,then by placing the flat of the fingers carefully over the ribs the outline and position of them can be easily discerned4 ,the floating ribs are oftentimes found deranged and are the source of a great deal of suffering through the iliac regions4 ,these ribs may become dislocated from the vertebral ends and drop down obliquely toward the iliac crest1 or else the free end may become locked beneath the rib above4 ,occasionally both ends of the rib drop down quite perceptibly and consequently is the cause of considerable distress4 ,in such instances the rib is depressed inward so that the normal contour of the lower thorax is lost4 ,an examination of the clavicle should be carefully made4 ,always compare the clavicle with its fellow and examine thoroughly its articulation with the sternum as well as at the acromial prominence4 ,often the sternal end of the clavicle is slightly dislocated posteriorly to the sternum2 although it may become completely luxated4 ,the acromial end may be dislocated upward or downward4 ,in examining the sternum special attention should be given the articulation of the manubrium and gladiolus4 ,this is due to the crowding anteriorly of the articulation of the sternal parts4 ,normally until well along in adult life there should be some movement here due to its membranous attachment4 ,occasionally the ensiform cartilage is turned inward1 producing a tender point1 but this rarely occurs4 ,also the articulation of the cartilages in the region of the eighth1 ninth1 and tenth ribs may be found considerably deranged1 causing local tenderness and even stomach trouble4 ,dorsal and ,lumbar ,spinal ,region4--,with the patient sitting on the table abnormal deviations can be readily noted4 ,there may be lateral swerves1 from muscular weakness1 or unilateral tension1 involving the whole spine or less1 or a reversal of natural curves1 i4 e41 the spine depressed anteriorly between the shoulders and posteriorly in the lumbar making the straight spine4 ,there may be1 also1 an exaggerated normal curve in the dorsal region producing a kyphosis with a compensatory lordosis in the lumbar region sufficiently great to change its relations with the pelvis4 ,by the method previously given1 now outline the spinal column for lateral and bilateral scoliosis4 ,these1 frequently1 are at their incipiency1 and to the casual observer would pass unnoticed4 ,it is well to make an outline of the spine before beginning treatment1 and at times following1 that progress may be observed4 ,a simple method is lead tape which can be had from any plumber shop and can be molded to the deformity and traced on paper together with date of examination4 ,h4 ,f4 ,goetz has perfected an appliance for outlining and recording these deviations4 ,observe well the ligaments1 as well as extent of joint movement1 under deep palpation2 from irritation they may become thickened and more or less fill the spaces about the spines and transverse processes1 causing a rigid1 smooth spine4 ,to make a detailed examination the patient should be stretched out on one side upon a treating table1 although the general examination may be sufficient4 ,then1 standing in front of the patient and reaching over him1 a most careful diagnosis can be made4 ,do not stand back of the patient as the flat of the fingers can not be used to advantage in outlining the different vertebr4 ,the various contracted muscles that may be found along the spinal column will be of valuable aid in locating derangements of the vertebr and vertebral ends of the ribs4 ,by using contracted muscles along the spinal column as a guide for locating lesions1 reference to the large superficial muscles is not made1 but to the small areas of contracted fibres of the deep muscles4 ,it is the deep muscles that become more or less contracted1 and even fibrotic1 when lesions of the vertebr and ribs exist4 ,the superficial muscles are generally contracted by atmospheric changes1 slumped postures1 wrong habits1 etc41 and are not generally the result of disorders in the osseous system4 ,the preceding points in regard to contracted muscles cannot be too carefully observed for there is a tendency among many osteopaths to treat the contracted deep muscles as primary lesions in nearly every case4 ,remember that if they are not due to the motor nerve fibres of the muscles being irritated by the spinal lesion1 or to a reflex stimulus1 or to a compensatory change1 that although the muscular tension may be the inception of the almost certain interosseous lesion1 still the leverages secured through bony adjusting are very essential not only in correcting the osseous malposition but in loosening and releasing fibrous muscles and thickened ligaments4 ,thorax4--,examination of the thorax as a region has been largely gone over in speaking of the ribs and their sternal attachment1 cartilages1 sternum and the clavicles1 but its appearance as a whole should be carefully noted for it will be a valuable aid in diagnosis4 ,deviations from the normal1 such as the emphysematous or barrel-shaped chest in asthmatic affections1 or chronic cough1 or accompanying kyphosis1 the flat chest and its association with phthisis1 the rachitic1 etc41 should be considered4 ,spinal deformities are reflected in the thorax by marked changes in contour1 such as elevations and depressions corresponding to the spinal changes4 ,these result in marked interference with the thoracic organs and in young subjects are of particular interest4 ,rib changes are frequently the result of vertebral deviations4 ,abdomen4--,the position for examination of the abdominal viscera is usually with the patient supine1 head slightly elevated1 knees drawn up partially and supported to relieve any muscular strain1 and with the hands at the sides4 ,in this position complete relaxation is obtained4 ,observe any enlargements from gas1 fluid1 or tumor1 muscular changes1 color1 etc4 ,the patient may1 also1 be placed upon the side1 and in the knee-chest position for further verification of the diagnosis4 ,where the abdominal wall is much relaxed1 or there is a pendulous abdomen with enteroptosis1 there will be found a change of relations of the viscera by these different positions1 allowing them to be palpated in another position4 ,when there is marked tenderness it is often possible to go deeper with less discomfort with the patient in the knee-chest position4 ,the ,trendelenburg position may also be utilized4 ,where ascites is suspected palpation should be made with the patient in various positions in order to note changes of location of the fluid4 ,frequently much can be learned by inspection with the patient standing4 ,clues to visceral disturbance can often be had by tracing the nerve connection from the spinal lesions to the suspected part4 ,in examining the liver care must be taken that any gouging or severe bruising of the organ does not take place4 ,the liver can be outlined by percussion and also by palpation of its lower and inner borders ,congestions1 atrophy1 enlargement or hardening should be noted1 also any change in position4 ,a rather complete examination can be given the biliary tract from the gall-bladder to the duodenal orifice of the biliary duct4 ,by a careful inhibitory pressure over the duct the outline of the tract can be discerned providing the patient is not too stout4 ,when the tract is swollen considerable tenderness will be present4 ,the patient will complain of a stabbing or piercing pain upon pressure and manipulation if the duct is inflamed4 ,usually the tenderness is greatest nearer the duodenal orifice4 ,the duodenal orifice is about one and one-half inches diagonally downward to the right from the umbilicus4 ,in cases of impacted gall-stones the osteopath as a rule has very little trouble in locating the stone4 ,the spleen may be percussed and when in a markedly enlarged condition its lower border can be palpated4 ,great care must be used in the latter condition as there is danger of rupture4 ,in examining the stomach the usual methods of inspection1 palpation1 percussion1 analysis of the contents1 etc41 are employed4 ,palpation and manipulation over the intestines are practiced a great deal by the osteopath in various intestinal diseases4 ,by his educated sense of touch he is usually able to locate at once any impactions of fecal matter4 ,such impactions are generally found in the ilio-cecal and sigmoid regions4 ,in the various acute obstructions from invagination1 tumors1 twists1 adhesions1 spasticity1 knots1 etc41 many times one is able to readily locate the seat of the disturbance4 ,there is one point to specially emphasize2 that is1 do not overlook prolapsed regions of the intestines2 such occur frequently and are a source of considerable distress1 especially constipation4 ,simple manipulation will never do much good1 neither will spinal treatment or injections1 as a rule4 ,a specific treatment must be given and1 that is1 after locating the exact point of prolapse1 to reach carefully beneath the fold and replace it4 ,in emaciated subjects the kidneys can be readily located1 and in a few instances when they are diseased one can feel the contracted tissues about them4 ,be very careful not to injure the capsule about the kidney4 ,do not punch or gouge them in the least2 but locate the kidneys by a careful inhibitory palpation4 ,lumbar and ,pelvis4--,the intimate relation between the lumbar spine and pelvis make a consideration of them as a region necessary4 ,outside of ordinary curvatures involving both the dorsal and lumbar regions there are certain conditions which involve but one structure and require careful differential diagnosis to determine whether the lumbar or pelvis is at fault4 ,in the former the fifth vertebra is a weak point and is most frequently at fault4 ,the deviations are usually a sidebending and frequently accompanied with some rotation4 ,occasionally a malstructure of the lower lumbar or pathologically relaxed ligaments will approximate the spines and be misleading as to the real condition4 ,a rotation or lateral tilting of the fifth lumbar may have the effect of elevating the crest of the ilium so that the innominatum would appear involved4 ,there will be a difference in the length of the legs1 angles of feet when patient is lying on the back1 anterior spines out of line and tenderness of the muscles attached near them4 ,however1 other diagnostic points of innominate lesions1 i4 e41 tenderness of symphysis and sacro-iliac articulation1 and prominence of the posterior spine1 will be lacking4 ,marked deviation of other lumbar vertebr may produce practically the same effect1 but the lesion will be so apparent that there will be no doubt as to the cause4 ,to be able to diagnose accurately and intelligently the pelvic region requires nearly as much skill as in examining the cervical region4 ,the pelvic bones are liable to many subdislocations1 especially in the female4 ,however1 it should be remembered that many apparent innominate lesions are secondary or compensatory changes due to lumbar lesions4 ,the pelvis as a whole may be tipped anteriorly or posteriorly upon the spinal column4 ,it also may be twisted or rotated laterally upon the spinal column4 ,the most common lesions are subluxations of an innominatum forward1 backward1 upward1 or downward1 or various combinations of these displacements1 such as a tipping forward and downward of an innominatum1 or a tipping backward and upward1 but these combinations do not always exist in the manner given4 ,as a rule when the ilium is anterior1 the ischium posterior1 then the innominatum as a whole is downward2 when the ilium is posterior1 the ischium anterior1 then the innominatum as a whole is upward4 ,this is only a rule1 there are exceptions to it2 for in some few cases when the ilium is anterior1 the ischium posterior1 the innominatum may be higher1 and when the ilium is posterior and the ischium anterior the innominatum may be lower4 ,to be able to diagnose such derangements will require skill and practice2 still there are symptoms and signs that are characteristic of such disorders4 ,in examining the pelvic bones have the patient flat upon the back at first4 ,be sure he is flat upon the back for a very slight variation may make considerable difference in the relation of the pelvic bones1 one to the other1 so far as the diagnostic points are concerned4 ,then go to the feet of the patient and grasp the ankles firmly1 rotate laterally both legs1 first to one side and then to the other1 as well as pull and push both limbs slightly1 and then bring the heels together directly in the median fine of the body and compare the length of the limbs at the heels4 ,if there is any disorder whatever in one innominatum1 and the thigh muscles have been relaxed thoroughly by the preceding movements and the heels are brought together in the median line of the body1 a difference in the length of the limbs will readily be observed at the inner malleoli or the heels4 ,for if the ilium is forward the ischium must be backward and as a rule the innominatum is thrown downward1 thus causing an apparent lengthening of the limb which will be noticed by comparing the heels2 if the ilium is backward the ischium must be forward and as a rule the innominatum is then upward1 causing an apparent shortening of the limb on the affected side4 ,a very slight variation in the pelvis will make considerable difference in an apparent lengthening or shortening of the limbs4 ,such conditions are generally met with several times a day by osteopaths4 ,the object of the lateral rotary movement and the pushing and pulling of the limbs is to make sure that all the thigh muscles are thoroughly relaxed1 for it is a very easy matter for contracted muscles in one thigh to produce an apparent shortening of the limb4 ,also be very careful in comparing the length of the two limbs at the heels where they come together that they are exactly in the median line of the body1 for if they should be to one side or the other1 however slightly1 there would be an apparent lengthening of the outer limb as compared with the limb near the median line4 ,while the patient remains flat upon the back it is a good plan to compare the anterior spines of the ilia4 ,it may be readily noticed that one is higher or more depressed than the other1 which will help to confirm the diagnosis4 ,it is a good plan also to have the patient sit up squarely upon the table and compare the crests and posterior spines of the ilia2 thus one may be seen to be higher than the other4 ,then1 also1 note the angles of the feet when patient is supine2 an everted foot usually means that the limb is shorter due to the tilted pelvis2 the opposite is commonly true when the foot is inverted4 ,however1 this is not an absolute rule4 ,care should be taken in differential diagnosis of possible old fracture of leg1 of infantile paralysis1 of asymmetry1 etc4 ,there are three diagnostic points exclusive of all other signs that are quite conclusive when coupled with the preceding examination4 ,if an innominatum is dislocated or subdislocated there will be tenderness over the symphysis pubis on the side affected1 tenderness over the ilio-sacral articulation on the side affected1 and tenderness along the crest of ilium where the abdominal muscles are attached4 ,when tenderness is found at these three points it is quite conclusive that the innominatum is deranged1 for at the symphysis pubis and ilio-sacral articulation tenderness must exist if the innominatum is disturbed1 and by a change in the crest of the ilium the abdominal parietes will be affected1 provided they are not too much debilitated4 ,marked tenderness of the external cutaneous nerve as it passes over the crest of the ilium below the anterior spine will be noticed on the unaffected side 7,dr4 ,still74 ,there will be1 on rectal examination1 marked tension of the tissues on the affected side4 ,possibly the patient may complain of pain exclusively in one side along the pelvis and limb which will be a leading symptom telling which side is affected4 ,additional diagnostic signs will be rigidity of muscles along the ilio-sacral articulation and abnormal prominence or depression of the ilium at its articulation with the sacrum1 depending upon which way the innominatum has slipped4 ,considerable deviation of the pubic bones may be noticed4 ,the pubic bone on the side affected may be either thrown upward or downward4 ,radiographs have repeatedly revealed subluxations of the innominate bones in many instances4 ,this is certainly quite conclusive in confirmation of the osteopathic ideas in regard to the pelvic bones becoming dislocated4 ,sacrum4--,examination of the sacrum is best made with the patient lying on the side1 with the osteopath standing in front and with the hand palpate its posterior surface4 ,in the sitting posture its relation with both innominates can be determined4 ,it is displaced posteriorly but seldom1 the most frequent being anterior1 downward1 and a combination of the two4 ,in the anterior conditions tenderness at the sacro-iliac articulations is a good point1 but it must not be confounded with an innominate lesion4 ,the downward displacement is shown by comparison with the lower lumbar vertebr4 ,observe the relation between the two1 as a change in contour of the spine will also change the angle of the sacrum and vice versa4 ,coccyx4--,with the patient and operator in same position as for the sacral examination outline the coccyx1 as to first1 contour2 second1 rigidity2 third1 sensitiveness4 ,if abnormalities are detected go to the other side of the table and with a well lubricated index finger palpate its anterior surface4 ,changed contour1 displacements1 and old fractures can be readily determined4 ,the most common deviation is anterior at its union with the sacrum4 ,the lateral form generally resulting from muscular contraction is next1 with posterior but seldom4 8,if the lower part of the sacrum is rotated backward1 the sacro-coccygeal articulation or angle is affected or becomes more acute1 since the tip of the coccyx is not displaced1 but held in position by structures attached to it4 ,if the sacrum is displaced downward the effect is about the same4 ,often this sort of sacral lesion is mistaken for an anterior luxation of the coccyx40#bh ,remember that normally there should be some movement of the coccyx4 ,it has a fibro-membranous articulation4 ,uterine1 ovarian and rectal examinations are largely of the same nature as those given by other practitioners1 although osteopaths find that oftentimes other practitioners are mistaken in regard to the etiology of many diseases to which these organs are subject4 ,arms and ,legs4--,there is comparatively little that is exclusively osteopathic in regard to the diagnosis of disorders of the arms and legs4 ,one important feature that the osteopath finds in examining the arms and legs is that many of the disorders supposed to originate in the affected member are found to be caused from vertebral or rib dislocations4 ,innominate and lumbar lesions are particularly fruitful sources of trouble in the legs and feet4 ,always carefully examine the spine in the region of innervation to the arms and legs when they are affected4 ,the shoulder and hip joints1 as well as all joints1 are subject to partial dislocations4 ,many times when pain or other symptoms are presented in the arms or legs the trouble is at the shoulder or hip joint or in the spinal column4 ,there are two regions that are very apt to be overlooked in the examinations of the arms and legs and they are the elbow joint and the fibula4 ,the small bones of the ankle and wrist as well as of the foot and hand are subject to many dislocations which are easily discerned upon examination and often overlooked4 ,special emphasis should be given in regard to many supposed diseases of the knee joints which are really caused by lesions in the spine or at the hip joint4 ,osteopathic ,prognosis ,everyone is of the opinion that to forecast the probable result of a disease is one of the most difficult problems the physician has to meet4 ,to state the duration1 course1 and termination of an attack of disease as presented by its nature and symptoms implies an accurate knowledge of both disease processes and changes1 and an insight into the individual's idiosyncrasies backed by ripe clinical experience4 ,and after each of these factors has been carefully considered to balance one against the other1 nothing short of superhuman knowledge may present a sufficient insight in order to render an accurate prognosis4 ,a prognosis represents the culmination of one's learning1 an understanding of disease characteristics1 and an insight into temperament4 ,c4 ,m4 ,t4 ,hulett#bi says3 8,only when we can know all the conditions1 causative and sequential1 with their possible complications and terminations1 together with a full history of therapeutic results in a large number of similar cases1 and carefully analyzing and weighing these various elements1 are we prepared to really make a prognosis40 ,nettie ,h4 ,bolles#cj writes as follows3 8,the prognosis depends upon the cause of the disease1 the possibility of removing the cause1 or the likelihood of recurrence of causes1 and the chances of avoiding such recurrence4 ,the circumstances to modify the outlook are various and deserve careful consideration40 ,it is not the purpose here to go into the many essential details1 for that would mean an outline and forecast of all disease processes1 and the effect of numerous extenuating circumstances4 ,the medical profession have been gathering data for these three thousand years and prognosis with them is still inaccurate and incomplete4 ,osteopathic science will add just so much to the accuracy of prognosis as the sum total of the knowledge displayed in the fields of osteopathic etiology1 diagnosis1 pathology and therapeutics4 ,suffice it to give here a few salient practical hints as noted in the osteopathic treating room and at the bedside4 ,osteopathically it may be said that prognosis depends1 first1 upon the true conception of osteopathy2 second1 upon the relative value of all factors pertaining to health and disease2 and1 third1 upon the skill 7technique and native ability7 of the osteopath4 ,the first and second being granted1 the third includes a remarkably practical and pregnant field1 for in no school does the physician get into as close touch and understanding of the actual condition of the patient's disorder as in the osteopathic4 ,although the fundamentals and principles of the osteopathic conception of diseases are really broad1 liberal1 and all-inclusive1 still owing to the fact that each individual 7and thus each disease7 is more or less a law unto himself should there not be absolute tables and prescriptions to be governed by2 remember1 however1 this does not imply our fundamentals are not basic or our principles are not truths1 but rather the application and execution of the same are as varied as the individual's constitution1 temperament1 and disease4 ,herein rests the really difficult practical consideration of etiology1 pathology1 diagnosis1 treatment1 and prognosis4 ,in other words1 if the diagnosis and treatment are accurate the result rests entirely with the patient4 ,first1 too much emphasis cannot be placed upon the fact that prognosis is dependent upon the osteopath--his education1 training1 ability1 experience1 and technique4 ,one's fitness is most important4 ,and fitness and personality complement each other4 ,an osteopath may know theory and still not be practical2 still one cannot be practical unless he knows theory4 ,second1 osteopathic treatment frequently changes the usual course of acute disease4 ,it is well known that many diseases have a certain regular course in their history4 ,many times the osteopath will be able to abort1 lessen the severity1 or cut short the ailment1 thus changing the recognized symptoms and termination4 ,third1 the knack of treatment1 or knowing how to treat1 not only one region of the body but all regions1 not only one temperament but all temperaments4 ,fourth1 the preparatory treatment before correcting the lesion4 ,prevention1 palliation1 or cure1 and thus prognosis1 may be dependent upon a necessary preparatory treatment4 ,here is where a study of the patient's temperament is very essential4 ,fifth1 a prolonged treatment may defeat one's purpose4 ,as a rule a comparatively short1 thoroughly indicated1 specific treatment is best4 ,sixth1 much1 relative to prognosis1 can be told by the tone of the vertebral ligaments4 ,when a lesion corrects too easily or does not remain well in place it shows a lack of tonicity on the part of the ligaments and muscles4 ,improvement is in direct ration to the increase of tonicity4 ,seventh1 special care should be taken with the irritable spine4 ,this spine commonly precedes the debilitated spine4 ,unless precaution is taken to apply inhibition before treating specifically a cure may be prevented or at least the disorder prolonged4 ,eighth1 relaxation of muscles is not always essential1 although the lack of it may prevent the correction of primary lesions4 ,the relaxation should be carried out with care in order that all shock and irritation may be kept at a minimum4 ,ninth1 needless stretching1 traction1 extending1 rotation1 and snapping of the neck is not only useless but may be positively dangerous4 ,rarely is it necessary to go through the above 8movements0 as many are accustomed to do4 ,tenth1 it may be necessary1 but not always1 to give as additional treatment1 after the anatomical defect has been specifically treated1 a certain amount of stretching and moulding of the parts4 ,eleventh1 owing to the close personal relations of physician and patient1 personality has a powerful influence on prognosis4 ,twelfth1 too much emphasis cannot be placed upon the uselessness and injurious effects of over and misapplied treatment4 ,all of the above have a positive bearing on prognosis4 ,the osteopath should study his technique well4 ,he will find that it gradually changes and improves from year to year4 ,in a word1 as he gains in experience he will become more skillful by giving careful attention to the development of the sense of touch1 by noting the resistance of the tissues1 and a score of details that are very hard to describe but the sum total of which determines and indicates the successful osteopath4 ,another practical point that bears upon prognosis as well as upon the health of the osteopath is the manner of giving treatment4 ,first1 the height of the treating table should correspond to the height of the practitioner4 ,the table should be made for the practitioner and not the practitioner fitted and warped according to a certain table4 ,second1 give part of the treatments on a treating stool4 ,here there is greater freedom of movement on the part of the patient1 hence greater and more effective leverage can be obtained4 ,suit your treatment to the patient1 not your patient to the treatment4 ,third1 make your weight count for energy expended in the treatment4 ,as soon as one set of muscles become tired substitute another set1 e4 g41 the back muscles and the arms1 the arms and the hands4 ,fourth1 whenever possible substitute the weight of the patient for expended energy4 ,fifth1 when lifting keep the spinal column straight2 do the bending of the body at the knees4 ,hence a better treatment and a more favorable prognosis1 and besides that new occupation neurosis1 the 8osteopathic back10 will be materially lessened in both severity and frequency4 ,,footnotes3 #bf ,see ,tubby1 ,deformities4 #bg ,clark's ,applied ,anatomy1 p4 #ccd4 #bh ,clark's ,applied ,anatomy1 p4 #cca4 #bi ,prognosis--,journal of the ,american ,osteopathic ,association1 ,jan41 #aijf4 #cj ,prognosis--,journal of the ,american ,osteopathic ,association1 ,nov41 #aijb4 ,,osteopathic ,,technique ,the technique of treatment is1 in a sense1 a personal factor1 for it is a well known fact no two osteopaths treat just alike4 ,nevertheless1 the principles of technique are constant and universally applicable1 and he who applies them with specificity manifestly secures the best results1 and exhibits a technique that is finished and characteristically osteopathic4 ,general manipulations are not essentially osteopathic1 although by employing them a few definite results may be obtained2 still such technique should not be classed as distinctive osteopathic therapy4 ,every case is a law unto itself and must be studied individually in order to be able to understand it perfectly4 ,so much depends upon the ability of the osteopath in the treating of a case1 that in order to meet the indications intelligently he must have command of the various anatomical details of the body1 not only in his mind but upon his finger tips4#ca ,the sense of touch should be very acutely developed and this requires months of persistent1 practical experience4 ,a carefully educated sense of touch is the keynote to both osteopathic diagnosis and operative technique4 ,from the very nature of the osteopathic conception--the physical body viewed as a mechanism whose disordered or diseased conditions demand anatomical readjustment--it is imperative that a delicate and educated sense of touch be acquired in order to logically and successfully apply its tenets4 ,proficiency means not only being able to note certain small physical irregularities1 and various degrees and areas of muscular contractions1 and variations in body temperature1 but the extent and state of vital resistance1 that is1 tissue condition1 and the feeling of organic resistance1 e4 g41 the heart1 lungs1 liver4 ,these are the special features wherein osteopathic fingers detect disease causes and traces4 ,to know the difference between normal and abnormal structural deviations and distortions1 as well as organic changes1 requires an accurate1 detailed knowledge of anatomy and pathology with a systematic daily education of the sense of touch2 but to realize1 appreciate and know by tissue resistance feeling that nutritional condition is improving requires much more practical experience4 ,thus two very practical points should be taught to and thoroughly impressed upon every osteopathic student3 ,first1 the sense of resistance of the tissues4 ,this gives us an absolute clue to the vitality of the patient4 ,as has been stated1 there is a vast difference between the feel1 the sense of resistance1 of normal and abnormal tissues2 for instance1 a normal muscle and a contractured muscle1 a normal liver and a congested liver1 a normal intestine and a prolapsed intestine and these differences comprise innumerable gradations4 ,second1 the receptivity of the patient to treatment4 ,this is dependent upon the vitality of the tissues4 ,the sense of resistance to touch gives us an important diagnostic clue2 the receptivity of the patient to treatment tells us much as to prognosis4 ,after a few treatments the receptiveness will be positive or negative2 that is1 the patient is1 or is not1 responding to treatment4 ,consequently the receptivity of the patient usually tells much as to the state of nutrition4 ,definite principles should be followed when applying the technique1 for the osteopathic lesion is a 8structural perversion10 thus indicating mechanical readjustment for its correction4 ,the time is coming when the technique will be taught graphically and mathematically4 ,this would not be a difficult thing to do1 and it could not but prove invaluable aid to the student4 ,he can then the more readily and comprehensively grasp the principles involved4 ,to resolve and illustrate manipulative readjustment to and by the principles of mechanics would add considerable to osteopathic development4 ,for example1 how nicely the correction of certain innominata maladjustments illustrates the principle of the wheel and axle4 ,vertebral and rib displacements when readjusted make application of the principles of the simple machines4 ,we are gradually approaching a more comprehensive understanding of the physiologic movements of the spine and of the etiologic role of muscle tension4 ,this is part of the foundation work4 ,great care must be exercised in correlating this data with the individual case1 for in therapy we are dealing with abnormalities--not alone normal physiologic changes4 ,if our distinctive dynamics and therapeutics were taught in this manner the average osteopath would be more specific and comprehensive in his work and as a consequence more scientific4 ,and consequently the principles involved in each and every case would stand out clearly4 ,hence diagnosis would be more exact1 routine pommeling discarded1 and better all around technique executed4 ,two general rules are applicable to all dislocations1 whether partial or complete3 #a4 ,exaggerate or increase the dislocation4 ,this is to relax the tissues about the dislocated articulation and to disengage the articular points that have become locked4 #b4 ,reduce the dislocation by retracing the path along which the parts were dislocated4 ,hence to correct a lesion1 for example1 a vertebral lesion3 7#a7 ,exaggerate the lesion4 7#b7 ,place the fingers of the hand that are not employed in exaggerating the lesion over the extended portion of the lesion4 7#c7 ,extend the region that is flexed when the lesion was exaggerated4 7#d7 ,when the lesion is being extended produce traction and slight rotation of the region4 7#e7 ,at the same time extension1 traction and rotation is being produced push in upon the extended portion of the lesion4 ,to this might be added for sake of clearness and greater assurance of success3 7a7 ,be positive the focal point absolutely corresponds to the lesion1 or else most if not all of your effort will be useless4 7b7 ,just before reaching the maximum of exaggeration have your fingers correctly placed for the readjustment1 and at the very moment of maximum exaggeration or just a fraction of a second prior begin to correct or readjust1 or else you will lose the vantage gained and the operation will probably be a failure4 7c7 ,the general traction and rotation are to aid in unlocking the lesion1 not to readjust as some may think4 ,inhibiting and releasing the soft tissues1 such as spasms1 contractions and contractures of muscles1 and stretching thickened and adherent ligaments is very important preliminary work4 ,then1 next to securing exact leverages an essential point is to maintain the release or exaggeration until the readjusting step is incepted4 ,in other words1 coordination of all factors is the desideratum4 ,the lack of this is the cause of many failures4 ,hot fomentations frequently assist in relaxing irritable and spastic soft tissues4 ,this1 however1 is but a preliminary measure4 ,all rough handling1 needless snapping of parts1 and excessive rotation and stretching are not only apt to tighten the lesion more1 shock the system and irritate the parts1 but it may be absolutely dangerous4 ,it should not be forgotten that the osteopath includes many measures in his treatment of various diseases1 as nursing1 dieting1 hygiene1 sanitation1 hydrotherapy1 antidotes1 antiseptics1 etc41 and does not depend upon readjustive manipulation alone1 although correcting disordered anatomical structures and perversions are paramount in the treatment4 ,the ,general ,treatment4--,a general treatment but accentuates the ignorance1 in a majority of cases1 of many so-termed osteopaths4 ,it is a deplorable fact that there is a tendency among some osteopaths to give general treatments in every case presented4 ,the only explanation of such a procedure that one can think of is a lack of conception as to what osteopathy really is4 ,to give a general treatment in every case is not only actually detrimental to the patient but it is the height of folly on the osteopath's part1 for it gets him into a slovenly habit of procedure from both scientific and curative points of view1 besides giving the outside world an impression that osteopathy is but little different from massage and ,swedish movements instead of skillful1 mechanical engineering of the human body4 ,but a 8general treatment0 is not to be confused with definite attention to be a series of more or less interrelated lesions4 ,the essential point is to normalize the body when and where distinctly indicated and after a skillful manner4 ,a general treatment1 broadly speaking1 should be given only under three conditions3 7#a7 ,constitutional diseases that are to be treated symptomatically4 7#b7 ,certain anemic cases4 7#c7 ,when one is ignorant of the real cause of the disease4 ,each of these conditions is self-evident why a general treatment should be given4 ,a fourth might be added1 for those individuals who think they are not getting value received unless they are treated from head to foot4 ,such patients are usually ignorant of the philosophy of osteopathy and it is the osteopath's duty to teach them differently4 ,the general treatment consists in stretching the spinal column from the atlas to the coccyx and relaxing all contracted muscles along both sides of the spinal column1 besides giving special treatment to the cervical region1 between the scapul1 the splanchnics and internal and external rotation of the legs4 ,it is no wonder that fake osteopaths do cure a case occasionally4 ,they are quite certain to correct some disorder by pulling and hauling a patient around in such a manner4 ,still on the other hand they are very likely to do injury to the patient4 ,those who claim that no injury can come from osteopathic treatment are mistaken4 ,one can injure a person by treatment if he is not careful4 ,it does not stand to reason that the most delicately constructed mechanism should stand any amount of manipulation and misdirected force that may be given it4 ,positions of the ,patient and ,physician in ,treating4--,the position of the patient when a treatment is given depends altogether upon the affection to be treated4 ,probably about one-half of the cases can be treated to advantage upon a table1 the remainder sitting on a stool4 ,many osteopaths treat nearly all their patients upon a table4 ,it is much better to change back and forth1 because to correct a certain disorder may be hard upon the table1 but will be comparatively easy when the patient is on a stool1 and vice versa4 ,besides1 constantly changing back and forth rests a physician greatly4 ,learn to treat in various positions1 because it will be impossible to have all cases assume a certain position when being treated2 and especially in treating acute cases one is obliged to suit his treatment to the patient and not the patient to the treatment4 ,there is also a tendency for one to get into slovenly habits of treating when patients are all placed practically in one position1 and certainly one cannot treat all cases in one position to equal advantage4 ,also learn to treat as well with one hand as the other4 ,many times one will be in such positions that equal use of either hand will be required4 ,carefully educate the sense of touch in both hands4 ,another point should receive consideration3 learn to shift the strength exerted in treating from one set of muscles to others4 ,for example1 when one is standing for a long time he will continually shift his weight from one limb to the other4 ,in the same manner in treating use the strength of the hands awhile1 then the arms1 then the muscles of the back1 then the weight of the body1 etc42 all in such a manner that there is a constant change by utilizing certain groups of muscles for the same work1 as well as utilizing the weight of the body of both physician and patient to advantage4 ,it rests a physician greatly and thus allows him to perform a maximum amount of work with a minimum amount of strength and labor4 ,it is frequently an advantage to the physician to treat upon the nude skin1 thus preventing the fingers from becoming tender4 ,gowns can be easily made that open down the back so that the patient does not have to disrobe4 ,the ,neck and ,head4--,in the treatment of the neck the patient may assume the sitting posture or lie flat upon the back4 ,the latter is preferable1 as then one has complete control of the neck and head4 ,absolute control of a part is always necessary and when this is secured the dangers are reduced to a minimum1 provided always that reasonable discretion as to the amount of strength1 is used4 ,before correcting the various deviations of the cervical vertebr it is usually best to thoroughly relax all the muscles1 superficial and deep1 about the field of operation4 ,in relaxing muscles three methods may be employed4 ,the muscle may be firmly grasped and manipulated until relaxed1 or a firm pressure may be exerted upon the muscle and thus inhibit its nerve force until the muscle relaxes1 or the muscle may be longitudinally stretched4 ,the second method is comparatively slow and is usually given in acute cases where the patients are so weak and exhausted that they cannot stand any severe manipulation4 ,this method1 however1 has certain advantages when employed as a preparatory step in interosseous adjustments1 though steady traction accompanied with slight rotation1 if precisely localized1 has many advocates4 ,in relaxing muscles by manipulation1 grasp firmly the belly of the muscle and draw outward on the muscle several times until it relaxes4 ,if the patient is sitting1 place one hand upon the head of the patient or about the chin in such a manner that complete control of the head is maintained throughout the procedure2 then with the fingers of the other hand upon the contracted muscular fibres a manipulating or kneading of the muscle can be given4 ,it is best to flex the neck and head to the side where the contracted muscles are1 so that a better hold of the muscle may be maintained2 then by a series of flexions and extensions with manipulation of the contracted muscles outward1 results can be readily obtained4 ,when the patient is lying on the back the physician may stand to one side of the patient's head and with one hand on the forehead of the patient and the other hand around the opposite side of the neck1 a rotary motion of the head and neck1 which is equal to flexion and extension in the sitting posture1 may be given by the hand on the frontal region while the other hand relaxes the muscles2 or the osteopath may stand at the head of the patient and with either hand on the side of the head and neck of the patient a series of rotary movements of the head and neck may be given with manipulation of first one side of the neck and then the other2 the hands and fingers being placed in such a manner that when the fingers of one hand are relaxing the muscles on its side the other hand is executing the movements of the head and neck1 each hand continually alternating in the work4 ,this latter method requires some practice in order to do the work readily and successfully1 for quite a variety of movements are required4 ,in the former method after one has worked on one side he is obliged to change to the other side and go through the same process4 ,movements may also be given to stretch the contracted muscles1 thus overcoming the contraction and producing relaxation of the muscles4 ,after having relaxed the muscles over the field of operation1 correcting the vertebr will generally be easier to accomplish4 ,in readjusting an atlas it matters but little whether the patient is sitting up or lying down4 ,a firm hold of the atlas can be gotten in either instance4 ,in correcting the middle and lower cervical vertebr it is best to place the patient upon the back4 ,in correcting dislocations1 as heretofore suggested1 two general rules should be followed3 7#a7 ,exaggerate or increase the dislocation4 ,this is to relax the tissues about the dislocated articulation and to disengage the articular points that have become locked4 7#b7 ,reduce the lesion by retracing the path along which the parts were dislocated4 ,one can readily see that a dislocated ball and socket joint could be reduced only by the dislocated bone retracing the path by which it left its socket1 for the capsular ligament would at once prevent its returning to the socket by any path other than that taken when dislocated4 ,this applies to all dislocations to a greater or less extent4 ,after locating the exact position of the abnormal vertebra the first rule is applied1 i4 e41 exaggerating the lesion by flexing the head in the opposite direction to which the vertebra is dislocated4 ,then with one or two fingers placed firmly upon the side of the vertebra in the direction dislocated1 so that when the proper time comes the vertebra may be pushed or slightly rotated back into its normal position1 with the other hand produce flexion of the neck1 so that the angle of flexion is exactly over the involved vertebra2 next produce slight traction1 so as to be sure that the articular points will be disengaged2 and then with rotation and extension of the head to a normal or upright posture1 at the same time pushing in on the disordered vertebra1 are the movements to be executed in reducing a dislocated vertebra4 ,it takes considerable practice to be able to correct a vertebra and to know when it is corrected4 ,the amount of force applied varies greatly in different cases4 ,cases of recent subdislocation require but little force unless there is marked spasticity of tissue1 while in long standing cases many times the amount of force required is about all that one wishes to exert4 ,as a rule in many chronic cases it is better to give a series of preparatory treatments in order to reduce muscle fibrosis and thickening of capsular ligament4 ,remember that often it is a slight rotary movement or twist given that aids the most in executing rule second4 ,no matter to what position a vertebra is rotated or side-bent the principles applied are the same in each case4 ,be very careful when flexing1 extending or rotating the neck that too much strain is not brought to bear upon the ligaments4 ,some osteopaths seem to take delight in rotating and flexing the neck to a great degree4 ,it is a dangerous procedure and moreover does not accomplish anything in particular4 ,it should be kept in mind that osteopathic treatment is scientific and not a number of general movements of various regions of the body4 ,locate the lesions exactly and then a specific treatment can be given in every instance4 ,to illustrate the treatment according to the preceding rules we will assume that a certain cervical vertebra is anterior1 say the fourth cervical4 ,this means that there is an interosseous lesion between the fourth and fifth4 ,the inferior articular processes and facets of the fourth have slipped upward and forward on the opposing facets of the fifth4 ,first1 hyperextend the head in such a manner that the fulcrum comes exactly over the displaced articulating planes1 thus throwing the fourth vertebra still more anterior1 or in other words1 exaggerating the lesion or increasing the space anteriorly between the fourth and fifth cervicals1 so that when the head is flexed forward and pressure is exerted upon the anterior part of the vertebra 7body or transverse process7 the vertebra will have room and release enough to occupy its normal position4 ,second1 when the head is hyperextended place a finger anterior to the transverse process of the dislocated vertebra and with the other hand around the head1 that is producing the hyperextension1 throw the head forward with slight traction and rotation and at the same time push posteriorly quite strongly upon the dislocated vertebra4 ,follow out the same principles in all cases1 no matter in which way the vertebr are deranged4 ,there are several methods of applying the underlying principles of adjustment4 ,relaxation and leverages may be secured in various ways4 ,preciseness1 expeditiousness and skillfulness can be attained only by considerable personal experience4 ,in cases where the lesion is between the skull and atlas have the patient sit on a stool with the back part of his head against your chest1 and reach around the head with one hand under the chin2 then with the other hand around the transverse processes of three or four upper cervical vertebr pull the spinal column toward the median line1 while at the same time lifting up on the skull with the other hand and throwing the skull toward the median line4 ,the object of lifting up on the skull is to relax and disengage the articulations1 by inhibition1 traction and rotation1 between the occipital bone and atlas4 ,this is one method applicable to the various lesions of the occiput1 which are of frequent occurrence4 ,in treating the pharynx1 tonsils and larynx1 outside of correcting spinal lesions1 an anterior treatment to these organs is very effective4 ,examine the deep muscles beneath the angle of the jaw when the pharynx and tonsils are involved2 and when the larynx is affected note the condition of the muscles on either side of the larynx4 ,after locating deeply seated contracted muscles in the region of the angle of the inferior maxilla place the fingers over the contracted tissues1 and then by a downward1 inward sweeping motion toward the median line the muscles may be readily relaxed4 ,when treating the larynx relax the tissues on both sides by an upward1 inward movement4 ,these treatments are very effectual when applied directly to the disordered tissues4 ,attention should also be given to the lymphatics4 ,in simple infections treat the glands very lightly but attempt to break down the surrounding edematous barrier4 ,release all the tissues down to and including clavicles1 first ribs and pectoral and axillary regions4 ,to treat slight lesions of the inferior maxillary articulation1 stand at the head of the patient when he is lying down and hook the fingers about the jaw just in front of the angles1 and with the thumbs over the bridge of the nose have the patient open the mouth while considerable force is exerted against his effort4 ,this reduces any slight dislocation of the inferior maxilla4 ,when the jaw is completely dislocated place a piece of wood or hard substance between the molars and exert pressure upward and backward on the chin4 ,if the dislocation is bilateral work on one side at a time4 ,the object of treatment to the face is to stimulate or inhibit points of the fifth nerve that come near the surface 7see neuralgia of fifth nerve74 ,while the patient is lying flat upon the back carefully stimulate these various points1 especially the supraorbital and nasal1 with a downward and outward movement1 or inhibit as indicated4 ,in treating the scalp relax the muscles over the scalp thoroughly4 ,this is secondary treatment to correcting the innervation to the scalp at the upper four or five cervical vertebr4 ,in cases of pharyngitis1 tonsillitis1 croup1 hay fever1 etc41 an effective local treatment may be given through the mouth upon the soft and hard palate4 ,introducing a finger into the mouth clear back upon the roof of the soft palate1 and with a downward and backward sweeping movement from the median line on either side toward the tonsils1 considerable relief can be given the patient4 ,this treatment relaxes the tissues1 relieves the congestion1 and gives a stimulating treatment to the local nerves4 ,a treatment of the same nature may be given over the hard palate to affect the palatine nerves1 especially in hay fever1 when the itching of the palate and sneezing are extreme4 ,in cases of young children it is best to protect the finger by wrapping a piece of cloth around it4 ,an osteopath should never give a manipulation or movement unless he understands why4 ,just as soon as one gives general imitating movements1 from that moment his work is not that of a scientific osteopath1 but of a ,swedish movement curist and masseur and a poor one at that4 ,the osteopath's work is to locate the anatomical derangement and correct it1 as a mechanic would adjust any disordered mechanism4 ,general treatment amounts largely to naught1 although in some few instances it is of benefit4 ,to give a detailed description of the treatment of all lesions that may be found in the cervical vertebr would be impossible in this sketch2 only a general survey of the work can be given4 ,each case calls for special treatment1 but the same general principles are applicable in each case4 ,if there is any one thing that should be eliminated from osteopathic treatment it is those mechanical routine movements of rotating1 flexing1 extending1 and various ,swedish-movement-massage-like manipulations that certain osteopaths give in each and every case4 ,it shows that they are imitators and do not have a correct conception of osteopathic therapeutics4 ,true it is1 that routine movements will have stimulating and other effects upon the system4 ,but does the body require such treatment8 ,is it lack of exercise on the part of the patient8 ,if it is1 then let the patient exercise himself4 ,you do not want to lower yourself to be a mere 8engine wiper10 or an exerciser4 ,if it is not the lack of exercise and the system is in need of certain treatment1 then seek the cause and apply a specific treatment4 ,do not hide behind generalities4 ,the ,ribs4--,in correcting dislocated ribs many methods may be employed1 but all are subject to the same principles as given under the treatment of the neck and head4 ,one of the best methods to correct typical ribs is to have the patient upon the side with the side of the affected ribs upward4 ,find out exactly the nature of the dislocation1 i4 e41 what is the relation of the dislocated rib to the other tissues4 ,note whether the rib is upward1 downward1 inward or forward1 locate exactly the dislocated rib4 ,then1 while standing back of the patient1 place your fingers upon both ends of the rib4 ,place your fingers in such a manner that when the proper time in the procedure arrives1 all that will be necessary will be to push the ends of the rib into their articulations4 ,for instance1 if the rib is raised anteriorly and lowered posteriorly1 you will place the fingers on the sternal end1 above the affected rib and the fingers on the vertebral end1 below the rib1 so that when the rib has been released from its abnormal position it may be slipped into normal position4 ,after having placed the fingers in the exact position necessary1 have an assistant take the arm and draw it obliquely across the face1 while at the same time the patient takes a forced inhalation4 ,the object of drawing the arm across the face and the deep inhalation is to exaggerate the lesion--to draw the ribs out of their locked position--so that the fingers upon either end of the rib may push the rib into normal position4 ,drawing upon the arm raises all the upper ribs as well as the dislocated typical rib1 principally by the use of the serratus magnus2 also inhalation has an effect to throw the rib outward and upward and thus away from its articulation4 ,thus after the lesion has been increased sufficiently to loosen the rib from its abnormal position1 the arm is relaxed1 the patient exhales1 and the fingers upon the ends of the rib correct the dislocation4 ,this treatment is used to the greatest advantage when there is a dislocation of a typical rib2 it can be given while the patient is lying down or sitting up1 although the former position is preferable4 ,an excellent method1 when the sternal end of the rib is dislocated is to have the patient sit upon a stool with his back toward the physician2 then by placing the knee in the back 7while standing up1 or easier still for the physician to sit upon an operating table back of the patient7 over the vertebral end of the rib so that the rib may be held rigid posteriorly1 reach around with one hand over the dislocated end of the rib and place the fingers upon the rib in the direction dislocated2 so that when the rib is sufficiently released from its abnormal position it can be readily pushed into place2 then with the other hand under the axilla of the arm on the affected side1 pull up and back on the shoulder1 so that the rib may be pulled away from its sternal articulation2 and at the same time have the patient take a deep inhalation so as to aid in throwing the rib outward1 upward and away from its sternal attachment2 then when the end of the rib has been released sufficiently1 relax the hold underneath the axilla1 have the patient exhale1 and slip the rib into its normal position by the fingers over the end of the rib4 ,this is an excellent method4 ,it is easy to give and does the work admirably4 ,practically the same procedure may be gone through when the vertebral end is dislocated1 by changing your position to the front of the patient1 but there is danger of the knee slipping off from the sternum during the operation and injuring the ribs4 ,several other treatments may be given to correct dislocations of the vertebral ends of the ribs4 ,for example1 while the patient remains sitting the osteopath stands in front of the patient and reaches around both sides upon the angle of the ribs2 then with an outward and upward movement of the fingers upon the angle of the ribs1 they are pulled away from their locked position and allowed to slip into normal articulation4 ,this treatment is applicable only when the ribs are dislocated downward1 but it is one of the best treatments for such cases4 ,another method oftentimes employed in correcting dislocations of the vertebral end of the ribs is to have the patient lie flat upon the side with the affected side upward2 then by flexing the arm on the forearm and placing the elbow against the chest or abdomen reach over the patient upon the angle of the dislocated rib and pull it away from the vertebra2 when it is pulled away from the spinal column sufficiently1 push upward or downward on the angle of the ribs1 as the case may demand4 ,the elbow placed against you gives complete control of the patient and aids1 by your weight1 in throwing the rib upward or downward4 ,a treatment somewhat like the preceding one which is commonly employed1 is to reach underneath the patient's upper arm1 when he is lying upon his side1 with the arm extended upward across the face2 then by placing the fingers of the hand underneath the patient's arm over the angles of the affected rib or ribs and reinforcing the hand by the fingers of the other hand an upward1 outward and rotary movement can be given the ribs1 which pulls them out of their abnormal position and allows them to return to their normal articulations4 ,an effectual treatment to spread and raise the upper ribs is to have the patient flat upon the back1 and with the fingers of one hand underneath the angles of the ribs and the other hand upon the elbow of the patient's arm of the same side throw the patient's arm across the chest transversely and bear down upon the elbow1 at the same time spring upward and outward on the angles of the ribs with the other hand4 ,by throwing the arm across the chest and bearing down upon the elbow a strong leverage can be obtained upon the upper ribs1 especially those between the scapul4 ,this treatment is very efficacious in certain lung and heart diseases4 ,still another method of adjusting ribs is to have the patient flat on his face upon an operating table with the arms hanging down on both sides of the table and a small pillow or folded blanket beneath the upper part of the chest2 then standing beside the table1 or better still1 with one foot upon a low stool and the knee of the other limb upon the table in such a manner that one is directly over the patient's dorsal region one is then in a position to have full control of the vertebral end of the ribs4 ,if the ends of the ribs are displaced downward1 placing the thumbs over the angles of the ribs and pushing upward and outward on the angles1 the ribs can be very readily crowded into position4 ,if the ribs1 especially between the scapul1 are dislocated in any direction1 they may be quite readily corrected by placing the hand over the shoulder posteriorly and throwing it outward and upward and away from the spinal column in such a manner that the ribs are pulled away from the abnormal position2 then upon relaxing the hold upon the shoulder with the one hand1 the fingers of the unemployed hand may push upward or downward1 as the occasion requires1 on the angles of the affected side so that the ribs may be slipped into place4 ,many times one is obliged to treat the ribs of one side as a whole4 ,in such instances the ribs are almost invariably thrown downward except on one side of scoliosis of the dorsal region4 ,several methods may be employed to raise the ribs4 ,probably the best method is to have the patient upon the side and with one hand upon the angles of the ribs and the other hand holding the wrist of the upper arm of the patient1 an upward lifting movement is given both upon the angles of the ribs and upon the arm of the patient while the patient inhales4 ,the work upon the angles of the ribs is to raise the ribs directly2 the work upon the arm is to raise the ribs indirectly1 principally by the use of the serratus magnus4 ,another effective treatment is to have the patient upon the back and with one hand over the anterior ends of the ribs and the other hand over the angles of the ribs an upward movement is given them by springing the ends of the ribs toward each other and by strong inhalation on the part of the patient4 ,this treatment is most effective where the false ribs are at fault and especially in case of hemiplegia4 ,while the patient is upon the back an assistant may take hold of the arm and draw it upward over the head of the patient1 producing considerable additional upward tendency of the ribs1 and the physician giving the same treatment of the ends of the ribs as before2 or the physician may take an arm in one hand and raise it above the head of the patient and with his other hand around the angles of the ribs1 and the patient inhaling deeply1 the ribs may be raised4 ,a treatment used a great deal in raising the ribs as a whole is to have the patient sit upon a stool1 and reaching around the patient from the front1 place the fingers upon the angles of the ribs and raise them upward on both sides at the same time4 ,this treatment can also be given by standing behind the patient and reaching around upon the anterior ends of the ribs and lifting upward while the patient aids you by deep inhalation4 ,remember that many times the ribs are drawn downward by contraction of the muscles1 due to atmospherical changes and slumped postures4 ,one should begin at the upper ribs in all treatments where the ribs are to be raised1 as a whole1 and work downward4 ,to correct the first and the floating ribs a different treatment has to be given than the foregoing4 ,an upward displacement is the most common lesion of the first rib4 ,to correct such a dislocation1 have the patient sit upon a stool and with one hand pull the head to the opposite side in order that the lesion may be exaggerated by traction of the lateral muscles of the neck 7principally the scaleni7 upon the rib2 this disengages the rib from its abnormal position2 then with the fingers of the other hand upon a point midway of the ends of the rib1 exert a downward pressure at the moment the extended head is relaxed describing a short arc4 ,but don't relax head until readjusting pressure is exerted upon rib4 ,if the patient is unable to sit up1 and it is not best to give the foregoing treatment1 have the patient flat upon the back1 with one hand take hold of the arm on the affected side and pull down and out upon the shoulder so that the rib may be somewhat drawn away from its articulation and released from its position2 then with the fingers of the other hand upon the center of the rib1 or its highest point1 press downward when the hold upon the arm is being relaxed4 ,correction of an upper displacement of the first rib is an every day occurrence4 ,downward dislocation of the first rib1 is rare4 ,to reduce this dislocation1 place the thumb beneath the vertebral end of the rib1 and with the other hand lift up strongly on the shoulder from beneath the axilla1 at the same time exerting pressure upward with the thumb on the end of the rib4 ,the floating ribs may be dislocated obliquely downward1 or the free end of the rib may be caught underneath the end of the rib above4 ,in either case1 in order to correct the displacement1 place the patient upon the back with the thigh on the affected side flexed upon the abdomen so that the tissues about the field of operation are relaxed2 then bear down carefully but firmly over the free end of the rib with the fingers until one finger can be hooked underneath the end of the rib2 then with the other hand over the vertebral end of the rib1 have the patient take a deep breath1 at the same time springing the ends of the rib toward each other1 thus relaxing the rib from its locked position2 then have the patient exhale quickly and at the same time spring the rib into its normal position4 ,it oftentimes requires repeated trials1 especially in stout persons1 and quite often the operation is painful to the patient4 ,it is necessary that one should understand this operation thoroughly1 as it is one of the most common treatments in osteopathic practice4 ,the floating ribs are very liable to dislocations and may be the cause of many pains in the side1 disturbances of the vessels as they pass through the diaphragm and inflammation in the iliac region4 ,a palliative treatment may be given the floating ribs by having the patient lie flat either on the back or on the side2 then place the hand near the vertebral end of the ribs and raise them upward while the patient takes a deep breath4 ,treatment of lesions between the manubrium and gladiolus are best given by placing the patient with the face downward upon the operating table1 and having the articulation of the manubrium and gladiolus just over the edge of the table4 ,an assistant should hold the patient firmly upon the table while hyperextension or flexion1 as the case may require1 with traction1 is exerted upon the head1 neck and shoulders1 and manipulation of the articular points is given to reduce the dislocation4 ,the same principles are employed here as in correcting lesions elsewhere4 ,correction of the cartilages along the sternum is very easily accomplished by having the patient sit upon a stool and the osteopath standing behind the patient places a knee in the back2 then reaching around with one hand over the cartilages and the other hand underneath the axilla1 execute the same movement as given in correcting dislocations of the sternal ends of the ribs4 ,a treatment sometimes used to release a depressed condition of the cartilages of the false ribs is to stand behind the patient while he sits upon a stool and reach around him with fingers underneath the cartilages and raise them upward as he inhales4 ,by having the patient take a deep breath and then exhale quickly while the fingers are over the cartilages a much better grasp of them can be obtained4 ,this treatment should be carefully given1 as there is danger of tearing the cartilages loose from the ribs4 ,the ,dorsal and ,lumbar ,spinal ,regions4--,here1 as in other regions of the body1 before an attempt is made to correct the vertebr the muscles should be thoroughly relaxed4 ,one of the easiest methods to relax the muscles is to have the patient lie upon the side1 and then by standing in front of the patient and reaching over him with the fingers upon the contracted muscles an upward and outward rotary manipulation is given2 or the patient may sit upon a stool while the physician stands in front with the arms around the patient and the fingers over the contracted muscles manipulating them upward and outward4 ,another very easy method is to stand behind the patient while he sits upon a stool and place a thumb over the contracted fibres1 with the other hand underneath the axilla lifting the shoulder upward and backward so as to favor a relaxation of the muscles1 while the thumb manipulates them4 ,in relaxing the muscles of the lumbar region have the patient on the side upon the table2 then flex the thighs upon the abdomen with your weight against the knees so as to control all movements of the patient2 reach over the patient with the fingers upon the contracted tissues and manipulate them outward and upward on either side until they are relaxed4 ,a method sometimes employed to relax the muscles of the dorsal1 lumbar and sacral regions is to place the patient flat on his face upon the table2 then by pushing up on the muscles from above downward with the flat of the hand they are easily relaxed4 ,this treatment should be especially given when the patient's muscles are contracted by atmospherical changes and from standing in one position for a long time4 ,when the muscles of the back are contracting they draw downward and many times draw the ribs with them1 as well as tensing the tissues over the sacral foramina and obstructing or irritating the sacral nerves4 ,by using the modern table longitudinally relaxing1 or stretching1 the lumbar and dorsal musculature saves considerable strength and effort of the physician4 ,to correct vertebral lesions of the dorsal region the same rules should be followed as in treating lesions of the cervical vertebr4 ,treatments may be given with almost equal ease whether the patient is lying on the side or sitting up4 ,to illustrate the treatment of the dorsal region when the patient is lying down1 assume that there exists a lateral lesion1 combined rotation and sidebending1 between two vertebr2 if the lesion is below the seventh dorsal use the legs as a lever1 and if the lesion is above the seventh dorsal use the head and neck as the lever4 ,have the patient lie upon the side toward which the lesion is pronounced1 either reach under the neck or around the limbs with one hand1 and with the other hand upon the lesion bend the head and neck or the thighs in such a manner that the angle of the flexion is directly over the break in the spinal column2 this is to exaggerate the lesion2 then by lightly lifting up on the neck or limbs and with a slight rotation of this lever the flexed parts should be extended1 at the same time exerting pressure with the hand over the lesion in such a manner that the vertebra is pushed forward toward its normal position4 ,practically1 the same treatment is given when a patient is sitting up1 with the exception1 of course1 that the limbs cannot be used as levers4 ,lesions of the dorsal region or even the lumbar region can be corrected while the patient is sitting up4 ,by this method considerable lifting is done away with4 ,in fact1 the weight of the patient can be used to great advantage by substituting it for one's strength4 ,no matter in what direction the lesion is1 the physician reaches around the patient's shoulders so that he just holds the weight of the patient from falling to one side or the other2 thus with one hand manipulating the lesion the other arm is around the patient guiding the weight of the body in flexion1 rotation and extension4 ,it is not always necessary to lift up on the patient but just let the weight of the patient act as strength applied to the power arm4 ,always make it a point when working upon dislocated vertebr in any region that just as soon as one has obtained a slight movement in the lesion do not attempt to correct it any more for the time being4 ,a slight movement toward the right direction may be all that is necessary to relieve the ill effects of the lesion4 ,in fact it might be impossible to get the lesion anatomically correct as the shape of the vertebra may have conformed in a greater or less extent to its abnormal position4 ,an excellent method to correct the various combinations of rotation and sidebending of the third to ninth dorsals is to have the patient sit up with the physician either sitting or standing1 depending upon height of seat1 back of the patient4 ,have the patient lean back until head is supported upon shoulder of physician1 and the anterior and posterior musculature of torso1 abdomen and pelvis are thoroughly relaxed4 ,reach around the patient's chest with one arm1 the hand of which is placed beneath the axilla4 ,the thenar eminence of the other hand is placed upon the posteriorly prominent transverse process of the lesioned segment4 ,then with careful hyperextension1 traction1 and rotation and1 sidebending of the torso1 the anchorage is released1 care being taken that localization is exact2 this moment of coordination is accompanied with a thrust of the thenar eminence upon the transverse process4 ,relaxation1 leverages and thrust must be precise and thoroughly coordinated4 ,to reduce vertebr that are deviated anteriorly in the dorsal region1 especially between the scapul1 is often a hard matter4 ,a satisfactory method is to stand behind the patient1 while he is sitting upon a stool1 and reach around both sides of him upon the sternal ends of the ribs corresponding to the anterior vertebr2 then have the patient relax with the head upon the chest1 and at the same time take a full inhalation while pressure is exerted posteriorly upon the sternal ends of the ribs4 ,the object of this method is to pull back the rigid ribs 7the lungs being filled with air7 which are attached to the anterior surfaces of the transverse processes of the vertebr1 and thus upon the anterior vertebr pushing them posteriorly2 all of the muscles of the body being quite passive and the head relaxed on the body1 a separation of the vertebr is accomplished1 thus favoring a crowding posteriorly of the subdislocated vertebr4 ,to correct vertebr of the lumbar region is on the whole much easier than in the dorsal region4 ,here the legs can be used as levers to great advantage4 ,by the same method of flexion1 rotation1 and extension1 as employed in the dorsal region when the patient is lying on the side1 the result can generally be obtained4 ,sidebending is the most common single lesion of the lumbar vertebr1 though there may be some rotation at the lumbo-sacral juncture4 ,occasionally malformation is found at the fifth4 ,to correct the lumbar lesions the following method is often used3 place the patient upon the side of the rotation or sidebending with knees flexed1 buttocks well back and entire spinal column straight4 ,next bring torso and head1 with spine straight1 well forward to edge of table4 ,then with hand upon ilium tilt it slightly forward1 and with other hand upon shoulder rotate entire spine1 including head1 so that spine is locked and the point of localization exactly corresponds to the lesions4 ,this brings the spine back to nearly a straight position4 ,next1 after a moment or two of tension-relaxation1 either thrust back upon the shoulder or forward upon the ilium4 ,again exactly coordinating localization1 relaxation and leverages is the key of the method4 ,the ,abdomen4--,direct treatment of the abdomen is given in many diseases of its organs4 ,the patient should lie flat upon the back1 the legs flexed upon the thighs and the thighs flexed upon the abdomen1 so that the abdominal muscles will be thoroughly relaxed2 and then the various organs of the abdomen can usually be manipulated with ease4 ,remember that in many diseases of the abdominal viscera the treatment of the splanchnics and vagi will be the primary treatment rather than direct abdominal treatments4 ,in treating the liver directly1 the ribs over the liver should be raised and separated1 and the lower border of the liver manipulated directly1 as considerable therapeutic results can be obtained1 particularly when the liver is congested and enlarged4 ,manipulation of the bile ducts is very essential in many liver diseases4 ,the treatment relieves congestion of the ducts and removes any collections of mucus in the ducts due to the congestion1 as well as freeing obstructed flow of bile4 ,the manipulation should be a deep1 downward one1 directly over the path of the ducts 7from about the cartilage of the ninth rib to the duodenal orifice of the biliary tract1 the latter being about one and one-half inches diagonally downward and to the right of the umbilicus74 ,be very careful when first manipulating1 and bear down lightly over the duct so that the structures superficial to it may be relaxed as the duct is deep below the surface of the abdomen4 ,usually the gall-gladder can be emptied by light pressure over the skin above the cartilages of the eighth1 ninth and tenth ribs4 ,the light manipulation acts1 probably1 by way of the spinal segment1 as a stimulus to the dilators of the sphincters of the gall-bladder4 ,very likely through reciprocal innervation relaxing the sphincter of the bile duct will contract fibres of the gall bladder4 ,manipulation of the stomach has considerable effect in strengthening its circular fibres and toning up the coats in general4 ,in cases of gas formation1 the gas in some instances may by manipulating over the stomach1 be forced through the cardiac or pyloric orifices4 ,direct treatment over the spleen by raising the eighth1 ninth1 tenth and eleventh ribs of the left side is effectual in congestion and enlargement of the organ4 ,in thin subjects the kidneys can be treated directly by pressing down carefully but deeply over the kidneys1 and lightly crowding them upward and outward4 ,this treatment also has some effect in relieving contracted tissues about the renal vessels and kidneys4 ,treatment to the intestines through the abdomen is an effective treatment4 ,in the various obstructions to the intestines1 constipation1 etc41 the direct work is essential4 ,treatment of the intestines is to correct any abnormal position that they may have assumed1 to relieve constrictions of the gut caused by contracted tissues1 to relieve impactions and adhesions1 to increase peristalsis and to tone up the intestinal coats in general4 ,the treatment consists in a manipulation of the intestines1 especially in the right and left iliac foss1 and the pelvic colon1 ascending colon and duodenum1 as impactions and prolapses of the gut are more liable to occur at these points than in any other locality4 ,in manipulating the intestines1 work for a definite purpose and not give a general kneading treatment unless the walls of the abdomen and the coats of the intestines are weakened2 in the latter case the spinal treatment is the primary one4 ,in treating over the iliac region1 draw upward and inward on the folds of the gut4 ,it is claimed by some authorities that nerves pass from the cutaneous surface of the abdomen directly to the intestine by way of the peritoneum2 if such is the case1 manipulation of the abdominal walls would have direct effect upon these nerve fibres4 ,the abdomen may be treated when the patient is sitting up1 but the treatment is not satisfactory4 7,see ,prolapsed ,organs74 ,the ,pelvis4--,the treatment of the pelvis is easy1 but the difficult work is in making a diagnosis of the position of the pelvic bones4 ,the pelvis is especially apt to become deranged by jars and falls4 ,some of the most successful osteopathic results have been obtained in correcting the pelvic region4 ,to relax the muscles over the pelvis1 the patient should be on the side or upon the face2 then relax the muscles by manipulating them upward1 chiefly those over the sacral foramina4 ,it is a good rule to adjust the lumbar first owing to release secured to the nerves supplying pelvic muscles and also to the fact that many pelvic distortions are secondary or compensatory to lumbar lesions4 ,the easiest method to correct the innominata is to have the patient lie upon his side2 then by standing in front of the patient slip one hand between the thighs and grasp around the tuberosity of the ischium1 and with the other hand upon the crest of the ilium1 the innominatum can be moved upward or downward and forward or backward 7wheel and axle principle74 ,simply pulling or pushing upon these two points in whatever direction necessary is all that is required providing the soft tissues are thoroughly relaxed4 ,by having the patient flat upon the back practically the same treatment can be given1 but not to so great an advantage4 ,in cases where the ilium is posterior and the ischium anterior1 the physician may stand back of the patient1 while he is lying upon his side1 and place one knee against the sacrum and with one hand upon the ilium1 with the other take hold of the ankle of the affected side 7the involved side being uppermost in all cases where the patient is lying upon his side72 pressure can be exerted upon the ilium and the limb pulled backward1 thus correcting the derangement4 ,this treatment should be avoided as much as possible1 as there is considerable danger of pulling back too severely and injuring the patient2 the lever is long and the amount of force exerted upon it cannot be judged precisely4 ,another method is1 with the patient on the back1 flex and evert the knee to the side so the side of the foot lies flat on the table4 ,grasp the ankle with one hand and with the other on the crest of the ilium of the opposite side then1 by pushing down firmly on the knee the articulation is gaped and at the same time the operator pushes with his body against the knee with a sharp thrust4 ,this may have to be repeated a few times before the articulation is released and if one is keen he will easily detect the slight concussion carried down the femur as the adjustment takes place4 ,this will correct a forward and downward innominate4 ,for an upward and backward one1 place the patient in exactly the same position and go through the same motions except that the knee is pulled toward the operator4 ,if the desired 8chug0 is not felt and adjustment is not definite1 the leg may be pulled down rather smartly by the ankle to a parallel with the other4 ,this is a technique that is easy1 both for the patient and operator1 and will correct any but the most stubborn4 ,in the case of a greatly relaxed and atonic condition of the ligaments of the pelvis much trouble is experienced1 often1 in making the adjustment permanent4 ,many suggestions have been made and most of them useless but1 probably the use of a belt of non-elastic webbing about two inches in width buckled tightly around the pelvis just below the anterior spines will do as much as anything and is a procedure well to follow in all such cases4 ,where there is a pendulous abdomen a support in the shape of a simple belt which should be so fitted as to act as a sling will transfer the weight of the abdominal viscera from the muscles1 already stretched and atonic1 to the belt and put the burden over the sacrum4 ,this prevents the pulling of the innominatum in lesion again4 ,overcorrection is suggested as a means on the ground that it sets up irritation and induces fibrous ankylosis and for the same reason ,w4 ,w4 ,howard places his patient prone and with thumb works the ligaments associated with the joint until they are thoroughly inflamed4 ,the patient is then put in bed a few days and after the inflammation has cleared up the ligaments will be found to have shortened4 ,to correct a rotary lesion between the pelvis and fifth lumbar the patient should be placed upon the side1 and with the body held firmly1 the pelvis can be forced backward or forward as the occasion demands4 7,see ,coccyx74 ,the ,legs4--,the origin of many symptoms manifested in the legs1 as in the arms1 are due to spinal lesions corresponding to the region of innervation to the affected tissues4 ,the derangements of the pelvic bones are a frequent source of symptoms that are referred to the legs and feet4 ,the osteopath finds that a slight dislocation of the hip may occur which is especially likely to affect the knee4 ,this partial dislocation is apt to be an upward-posterior one2 the head of the femur resting in the upper and posterior part of the acetabulum4 ,many diseases of the legs and feet are due to local displacement of the bones4 ,the method of treatment is the same as given in surgical works4 7,see ,sprains74 ,a general treatment of the legs and thighs is oftentimes necessary2 it consists of flexing the thighs quite firmly upon the abdomen1 and executing thorough external and internal rotary movements of the thighs and legs4 ,in a few cases both limbs are flexed strongly at the same time upon the abdomen4 ,after giving these movements manipulation over the saphenous opening and beneath the popliteal space is performed4 ,this general treatment tends to increase the circulation of the entire limb and to relax thoroughly all contracted fibres4 ,the ,arms4--,in treating the arms1 care has to be taken that the affection is not due to spinal derangements2 otherwise the arms are manipulated according to the disorder4 ,complete dislocations of the shoulder comes under the province of surgery4 ,many times the osteopath locates slight or incomplete dislocations of the shoulder4 ,partial dislocations of the shoulder are generally anterior4 7,see ,sprains74 ,in cases where pain exists in the shoulder or arm1 outside of locating the cause in the shoulder joint1 the affection may be due to fibres contracting over the coracoid process1 or a dislocation of the second or third rib1 and in some instances the clavicle is deranged4 ,special care should be given to a possible bursitis and tendo-synovitis4 ,occasionally muscular fibres may slip out of the bicipital groove4 ,dislocations of the bones of the arm are treated according to surgical methods4 ,the pains and various troublesome symptoms that may be manifested in the fingers or the hands are oftentimes caused by slight dislocations of the elbow1 shoulder1 ribs1 or vertebr1 as low as the sixth to eighth dorsals4 ,the coccyx4--,the coccyx1 owing to its exposed position and rather unstable attachment1 is subject to many injuries2 more indeed than come to notice4 ,its injury results in many local and general disturbances owing to its close relation to the sympathetics4 ,successful treatment of deviations often bring startling results4 ,they may be divided into fractures and displacements4 ,in complete or partial fracture of the coccyx1 as well as in dislocation1 if the patient can be seen with reasonable promptness after the accident much can be done for relief of the pain and the prognosis is good for complete recovery4 ,examination should be made externally and internally and after the condition is diagnosed about the same procedure is indicated for any of the conditions4 ,with the patient on the left side introduce the right index finger1 well lubricated1 into the rectum and carefully relax all tissue within reach of the tip4 ,if there are spasms of the coccygeal muscles1 inhibition of the anterior nerves will quiet them4 ,when this has been done place the left index finger externally along the body of the coccyx and holding it firmly both within and without release it longitudinally and then adjust4 ,after this has been done it is well to hold it there until all danger of returning spasm1 which might displace it again1 is over1 when the finger can be withdrawn4 ,the pain following will depend on the severity of the injury1 but will keep up more or less constantly for several days4 ,when severe1 relief is often given by introducing the finger and relaxing contracted tissue which is pulling it from its position4 ,hot water bags placed next to the part will be of benefit4 ,the bowels should be kept confined for forty-eight hours if possible in cases of fracture4 ,watch carefully the progress of union that the bones are in situ so there will not be deformity4 ,in diagnosing the first injury be sure that there is no splitting of the first segment or splinters which may require surgical interference4 ,in old cases of fracture where there is complete bony ankylosis it is not justifiable to attempt any change1 but where there is motion and a fibrous union1 after preparatory treatments about one week apart1 it can usually be replaced4 ,look well to any muscular contractions which might interfere with it4 ,force must never be used nor any attempt to replace until it has been first released from its articular attachment4 ,in the various forms of displacement the same technique applies as in fractures1 or the finger and thumb of one hand may be used1 the tip of the finger internally at the sacro-coccygeal articulation and the thumb externally at the same point4 ,complete control of the part is secured in this manner4 ,great care must always be used in treatment of any displacement of the coccyx4 ,contractions of its muscular attachments will often cause deviations in contour4 ,removal of the irritation and relaxation will allow it to assume its normal position4 ,the sacrum4--,adjustments of the sacrum as distinguished from the ilium in strictly innominate lesions are not many4 ,when posterior with the patient on a stool the knee of the osteopath coveted by a pillow and placed against the sacrum and both hands grasping the anterior borders of the ilia1 strong traction will move it into position4 ,in a downward displacement with the aid of an assistant from behind holding the crests of the ilia firmly as the patient sits on the table1 the osteopath in front clasping both arms about the patient and with a rocking motion from side disengages the sacrum and at the same time lifts it into position4 ,for anterior displacements use the technique described in replacing upward and backward innominate dislocation first right side and then left1 which will result in correcting the lesion4 ,the preceding osteopathic technique includes a few of the treatments given by the osteopath4 ,although many osteopaths use methods not given here1 those outlined are sufficient for illustrative purposes4 ,a point which cannot be too thoroughly impressed upon the student is that osteopathic treatment is in reality constructive work1 that is1 readjustive1 not only in detail1 but in viewing the body structure as a whole4 ,detailed readjustment is an essential1 still do not lose sight of the relation of the part to the whole4 ,in our distinctive work anatomical construction is the basis of physiological function1 although physiological stimulus is essential to anatomical development4 ,how often to treat4--,how often to treat a case depends entirely upon the nature of the disease from which the patient is suffering4 ,just as in giving drugs the frequency of treatment is entirely dependent upon the seat of the disease and its severity4 ,acute cases require a thorough treatment at least once daily1 and many times in severe cases the treatment has to be repeated several times daily4 ,in subacute and chronic cases1 as a rule1 treatment should not be given as often as in acute cases2 possibly once a day1 but usually alternate days is better4 ,in office practice cases are commonly treated two or three times weekly4 ,still it is better not to treat some cases oftener than once a week4 ,there is more danger in treating too often and too long than in not treating often enough4 ,the distinctive work of an osteopath is to correct disordered anatomical structures2 and when a certain derangement has been corrected the tissues should have rest and plenty of time for repair4 ,when treatments are given often1 it simply keeps the tissues in an irritated state and nature does not have time to heal the diseased tissues4 ,always make it a point at each treatment to correct some definite lesion1 and when the work is accomplished let the parts alone until the tissues have recovered as much as possible from the effects of the previous treatment before another treatment is attempted4 ,the reason why some cases do not get cured under osteopathic treatment is simply because the osteopath keeps the diseased tissues in an aggravated state by the constant treatment so that they do not have the least chance to heal2 the physician is thus adding irritation to the disease4 ,it is only by experience that one can tell how often to treat4 ,each case is a special study2 what would be quite sufficient for a certain individual with a given disease would not be at all suitable for a second individual with the same disease4 ,as in drugs what is suitable for one person would not be adapted to another1 because the make up of each individual is entirely different2 but here the parallelism diverges1 for in drugs there is a foreign agent introduced into the system1 while in osteopathic treatment the curative agent is entirely harmonious with the idiosyncrasies of the individual4 ,it is for this reason that experience in practice is so essential4 ,most cases should not be treated1 as a rule1 after a meal unless the patient is suffering from some digestive disturbance2 for treating other regions of the body outside of the digestive tract causes more or less stimulation of the parts treated and thereby draws blood away from the organs of digestion4 ,cases of disordered brain circulation1 where the patient is unable to rest or sleep at night1 should be treated at about their retiring time so that the circulation of the body may be equalized1 thus giving the patient undisturbed rest4 ,to show in a practical way the methods of experienced osteopaths in this matter ,g4 ,j4 ,helmer#cb is quoted3 8,i submit the following table to illustrate the frequency of treatment in one hundred cases taken from my practice3 one case three times per week1 sixty-three cases two times per week1 twenty-two cases one time per week1 nine cases once every two weeks1 five cases once every four weeks4 ,comparing the present with the past1 ,i find ,i am lengthening the time between treatments with much better results40 ,another very practical side of the question and one which will be greatly appreciated by the patient1 is the lessened cost for the same result in the less frequent treatments1 as well as the saving in time4 ,with the loss in going to the office1 rest after treatment1 not to mention possible wait while there1 three times weekly represents more time than the average person can well spare and not infrequently will deter him from continuing4 ,more especially is this true of those coming from a distance4 ,length of ,treatment and ,overtreatment4--,naturally the length of treatment depends upon the case at issue and nothing more4 ,there is no reason why any two cases should be treated for the same length of time unless they present identical lesions and then the personal equation of the two might present such a wide difference of aspect as to forbid such a proceeding4 ,the question of time has no place in the matter1 save that it must not exceed physiological limits and be sufficient for the needs of the case4 ,the patient should understand at once that it is to accomplish a specific purpose that the treatment is given1 just as definite as a surgical or dental operation1 and when the work is done it is time to stop4 ,he would hardly be attracted to the dentist who guaranteed to use forty-five minutes in extracting a tooth4 ,good judgment is required in this as in all matters pertaining to osteopathy4 ,there is a generally expressed opinion among the older osteopaths1 based on experience1 that3 first1 a short specific treatment is productive of best results and1 second1 treatments given under high tension when quick work is necessary are most satisfactory4 ,long treatments are debilitating and over stimulation amounts to inhibition4 ,further1 in a long treatment it is necessary to go over the whole body1 thus dispersing the vital forces 7which have been stimulated for healing and upbuilding the pathological area7 to parts not involved1 thus defeating the very purposes intended4 ,dr4 ,still always advocated and gave the short1 specific treatment4 ,the point always to be considered is the individual characteristics of the patient1 and effects of the first treatment should be carefully observed4 ,after a patient has been under treatment for any considerable time it is well to give him a vacation from treatment1 and it is remarkable what improvement will be shown at times by such a measure and how seldom he will lose ground4 ,dr4 ,still presented this subject vividly as follows3 8,to treat the spine more than once or twice a week and thereby irritate the spinal cord1 will cause the vital assimilation to be perverted and become death producing by effecting an absorption of the living molecules of life before they are fully matured and while they are in the cellular system1 lying immediately under the lymphatics4 ,if you will allow yourself to think for a moment of the possible irritation of the spinal cord and what effect it will have on the uterus1 for example1 you will realize that ,i have told you a truth4 ,many of your patients are well six months before they are discharged4 ,they continue treatment because they are weak1 and they are weak because you keep them so by irritating the spinal cord40 ,it is not a rare experience for a patient to leave apparently with little or no improvement only to report a complete recovery a little later4 ,misapplied ,treatment4--,probably in spinal treatment more risks are taken than in any other region of the body4 ,to us as a school it is by far the most important and interesting area we have to treat1 consequently it is not surprising that various general treatments and methods have been devised with the idea of getting quicker and easier results4 ,herein lies the danger outside of mistaken diagnosis1 for short cut treatments can never take the place of time and skill4 ,technically speaking1 if one thoroughly understands the philosophy of osteopathy and is conversant with the underlying principles of its therapeutics1 there is absolutely no danger of even the slightest injury4 ,it is the one who takes chances by not properly diagnosing and by not being cautious enough with delicate persons when applying his treatments that is apt to overstrain some tissue or organ and otherwise do bodily harm4 ,of the treatments considered dangerous not one of them is without merit if judiciously applied1 but unfortunately in many cases they are in general and indiscriminate use4 ,it is well to remember that we are moving structures which have never been moved before and that time enough has not elapsed to observe what the ultimate result may be4 ,again1 in adjusting a subluxation of the spine do not forget that the force necessary for that adjustment1 if misapplied1 is sufficient to produce a lesion1 and there is no doubt that this has happened4 ,your patient's interests are above everything and must never be sacrificed for any reason whatever1 so if at any time there is uncertainty always give the patient the benefit of the doubt4 ,on the other hand the osteopath must have the courage of his convictions and fortunately when these are coupled with good judgment the results are all that could be desired4 ,the following should be used with great caution if used at all3 ,first1 ,indiscriminate stretching of the spinal column with the aid of an assistant4 ,it is not good osteopathy although there are some cases where it may be beneficial4 ,while not specially dangerous1 generally1 in delicate patients1 elderly people1 arteriosclerotic conditions1 and in some stages of ,pott's disease it is absolutely contraindicated4 ,moreover in most spinal cases except impacted vertebr and symmetrical curvatures the stretching of the vertebral ligaments locks the lesion firmer4 ,second1 ,extreme rotating of the cervical region4 ,this cannot be considered good treatment in any case with the exception of the muscle stretching4 ,on the contrary it is dangerous2 first1 it is not osteopathy for it is not specific2 second1 the nervous shock is severe1 an important consideration in delicate people2 third1 the cervical ligaments become stretched and the vertebr are easily displaced1 while damage to a diseased vertebra1 an aneurism or in arteriosclerosis would be irreparable4 ,no other region of the body should have greater care in treatment than the neck4 ,third1 ,hyperextension of the spine with the patient on his face4 ,this treatment is rarely indicated4 ,in fact1 it is barbarous and a relic of an early day4 ,possibly more cases have been injured by this treatment than all others combined4 ,fourth1 ,rough separating of the vertebr and ribs while the patient is on his face4 ,this is a most excellent treatment in many cases1 but great judgment is necessary4 ,delicate patients1 heart disease1 and necrosed vertebr and ribs should be carefully excluded4 ,fifth1 ,innominate adjustments such as placing the patient on the side and putting the knee against the sacrum while grasping the leg at the knee4 ,or1 the placing of the patient face down with one hand on the sacrum and the other holding the knee4 ,in both these there is a tremendous leverage and in the latter the strain is at the lumbar rather than where needed4 ,there are other unnecessarily risky methods for this operation1 while it is easy to perform in most cases and without danger4 ,sixth1 ,abdominal treatment gives wonderful results when intelligently applied1 but it may be productive of great harm in conditions of tumors1 malignancy1 and pus formations4 ,misapplied treatment is always dangerous1 no matter to what part of the body given1 and it is proof of wrong diagnosis when given4 ,as a rule treatment is given without proper diagnosis in such cases1 so a misapplied treatment has two interpretations--first1 ignorance2 second1 laziness4 ,in the former lies the greater danger for ignorance coupled with force and lack of skill is an appalling combination4 ,cases are frequently reported where tumors have passed from the vagina1 rectum1 nose1 etc41 the osteopath thinking it was the result of good treatment1 without considering that it was simply the breaking of a long pedicle with great danger from hemorrhage4 ,the greatest care should be exercised in treating cases where aneurism1 osteomalacia1 and arteriosclerosis are present1 also in the leg treatment of tabes dorsalis and in the weak1 thin ribs of elderly people and those with a gouty or rheumatic diathesis4 ,imagine treating an abscess directly1 yet it has been done1 as have varicose veins with the terrible danger of rupture and embolism4 ,aneurisms have been ruptured in the same way4 ,one could go on indefinitely with this subject1 but to sum up3 if the osteopath is not familiar with the feel of the living anatomy in its giving and resisting under treatment both in health and disease and does not know his osteopathy1 nothing can prevent him doing harm4 ,a successful practitioner means an understanding of pathology1 then experience plus common sense4 ,,footnotes3 #ca ,see ,ashmore's ,osteopathic ,mechanics4 #cb ,journal of the ,american ,osteopathic ,association1 ,dec41 #aijc4 ,,osteopathic ,,centers 8,osteopathic spinal centers0 was a term commonly used in the early period of osteopathic development4 ,from the facts1 first1 that a few centers have been actually determined in the cord1 viz41 genito-urinary1 vasomotor1 etc42 second1 that the innervation from the spinal segment to various thoracic1 abdominal and pelvic viscera correspond with a considerable degree of accuracy to certain vertebral sections1 and third1 displacements of tissues of the spinal column affect viscus integrity1 depending upon the locality of the structural perversion as to the organ involved and is a clinical observation of great import1 arose the misnomer 8osteopathic centers40 ,for one to ask what 8centers0 should be 8treated0 in this or that disease shows a lack of the conception of osteopathy as if he asked what 8movements0 to give when 8treating0 a certain disorder4 ,it is as unosteopathic1 as it is unscientific1 broadly speaking1 to suppose osteopathic technique implies the application of movements to certain nerve centers4 ,osteopathic ,stimulation 8,osteopathic stimulation0 is another term loosely used without extensive clinical experience to support it4 ,mechanical stimulation is frequently utilized in the physiological laboratory4 ,but to employ it extensively and comprehensively in the treating room or at the bedside the therapeutic potency of it will be found wanting2 that is1 to employ it to the exclusion of that most important basic treatment1 readjustment1 is a great mistake4 ,clinically1 the pathologically slowed heart may be stimulated by a stimulus to the cervical sympathies1 the gall-bladder emptied by a stimulus near the costal cartilages of the ninth and tenth ribs 7this is probably via the spinal segments71 etc4 ,normally1 these organs and others may be temporarily stimulated4 ,experimentally1 ,burns#cc of ,los ,angeles and ,pearce#cd of ,san ,francisco have shown the potency of osteopathic mechanical stimulation4 ,for example1 stimulation 7mechanical7 in the middle and lower dorsal regions irritates and increases peristaltic action and vaso-constriction in the stomach and intestines4 ,osteopathic ,inhibition ,likewise the term 8osteopathic inhibition0 has not always been scientifically employed4 ,mechanical inhibition is probably used less frequently than stimulation but still it is of more importance4 ,probably the true interpretation of considerable of so-termed stimulatory and inhibitory efforts1 is simply one of normalization of tissues1 physiologic equilibrium resulting from such changes4 ,clinically1 to relax contracted muscles by inhibition1 to relieve neuralgia by impinging nerve courses1 to relax the cardiac orifice of the stomach by pressure at the ninth or tenth dorsal vertebra on the left side1 etc41 are excellent examples of the therapeutic value of inhibition4 ,experimentally ,pearce and ,burns produced the opposite results to that of stimulation4 ,inhibition in the middle and lower dorsal region caused relaxation of the muscles of both the stomach and intestines1 decreased peristalsis1 and caused dilatation of the blood vessels4 ,the employment of stimulation and inhibition rounds out to a certain extent our therapeutics1 that is1 makes it more practical and specific4 ,we should not1 however1 over-rate the relative value of stimulatory and inhibitory treatment as compared with the readjustive treatment4 ,not but what the former is of considerable practical importance1 but the point to be emphasized is that it gives a scientific demonstration of how pathological effects result1 if long continued1 from the various osteopathic lesions4 ,in a word1 it shows the physiological process from cause to effect1 or rather a step in the beginning pathological 7perverted physiological7 in many disturbances4 ,therapeutically1 all will agree with ,cherry#ce that 8stimulation and inhibition should be employed in all forms of acute disease as palliative measures until such time as the primary lesion may be removed40 ,as a preparation for adjustment of any bony lesion there is no question but that simple inhibition for a brief time in the area will bring about relaxation of soft tissues in a much more satisfactory manner than the usual massage like method4 ,mc,pherson1 ,montreal1 has developed a technique of sacral pressure which he uses exclusively in his practice4 ,without going into the merits of his theory there is no doubt that inhibition at the second and third sacral will bring about relaxation of the muscles of the lower trunk in a most gratifying manner4 ,another thing1 if there is difficulty in introducing the finger in making either a vaginal or rectal examination1 a minute's pressure at these points will1 in most cases1 cause the sphincter to relax so as to cause no discomfort to the patient4 ,this pressure will1 also1 have a great effect on the hypogastric plexus and the pelvic organs4 ,osteopathic ,readjustment ,readjustment or adjustment is many times particularly emphasized in this work as the key to osteopathic therapeutics4 ,if the theory of readjustment can not stand the most searching tests of science osteopathy will have to be relegated to a most subservient place1 on a par with massage1 ,swedish movements1 and various medical gymnastics4 ,consequently the readjustment theory is again referred to1 and especially so when the subjects of osteopathic centers1 stimulation and inhibition are outlined4 ,no doubt many stimulatory 7so-called7 and general treatments exert their greatest influence by inadvertently readjusting tissues4 ,then how much more effective would the readjustment treatment be if applied intelligently4 ,in certain acute disorders1 e4 g41 8colds10 immediate relief is often obtained by relaxing muscles through either stimulation or inhibition2 in reality the final result1 as far as the muscle is concerned1 is one of readjustment4 ,likewise in stretching and rotation of tissues and sections of the body the effect may either be stimulatory or inhibitory1 and still it may be1 also1 readjustive4 ,after all has been said the ultimate physiological effect of any of these treatments1 if of any therapeutic value1 must be one of stimulation to a part or to the body generally4 ,but there is a vast difference between physiological stimulation and the one method of obtaining the same termed mechanical stimulation4 ,it is not the purpose here to enter into anything like an exhaustive survey of stimulation and inhibition but simply to outline a few practical hints on the relative values4 ,everyone is aware that overstimulation is equal to inhibition1 and even applying it to very delicate subjects the therapeutic end we may wish to obtain may be lost and as a consequence the patient exhausted2 whereas at the same time readjustment possibly could have been employed and real permanent effects secured4 ,so we should whenever possible utilize the basic principle of our therapeutics1 readjustment1 for this represents in the majority of cases1 first1 permanent results2 second1 a saving of much time1 and third1 less exhaustion on the part of both patient and physician4 ,mc,connell#cf has shown in his series of laboratory experiments on animals the reality and potency of the readjustment fundamental4 ,the effect of malaligned vertebr and ribs upon contiguous vascular channels and nervous tissues1 not only affects immediate skeletal muscles by simple contractions but even produces interstitial myositis4 ,through narrowing of the intervertebral foramina and tension upon the fibrous tissue anchoring the spinal nerve in its exit1 and through pressure and strain on the sympathetics in contact with the heads of the ribs1 which are secured there by the parietal layer of the pleura1 organs in corresponding cavities become diseased4 ,some of the diseases produced in the series of experiments were catarrhal and parenchymatous changes in the stomach and intestines1 congestion of the liver and spleen1 acute nephritis1 goitre1 inflammation of the lymphatics1 edema of the cornea1 and degenerations of nervous tissues4 ,still too much emphasis should not be placed upon the narrowing of the foramen for certain pathologic changes are shown to be due to other conditions than ,wallerian4 ,the osteopath1 as stated1 may inadvertently correct osteopathic lesions4 ,vis medicatrix naturae undoubtedly corrects many osteopathic lesions2 this is evident from the fact that many bodily strains1 sprains1 and injuries are overcome naturally or involuntarily1 that is1 without any voluntary assistance from an osteopath4 ,on the other hand all osteopathic lesions are not due to outside influences or forces1 e4 g41 in pneumonia the severely contracted dorsal muscles often partially dislocate the vertebral ends of the ribs and thus increase the seriousness of the disease2 and this is true in many acute conditions wherein visceral changes will reflexly contract spinal muscles and also through these contractions produce osseous lesions4 ,here is where osteopathic treatment in acute diseases will not only correct the primary lesion but also these secondary ones and thus abort1 or shorten1 or lessen severity1 or prevent complications of the disease4 ,but it should always be borne in mind that when certain disease processes occur it will take a definite time at best for curative changes to predominate4 ,in other words pathological changes are just as real and potent as physiological facts or anatomical data and the character of the same should always be considered4 ,consequently in readjustment work a distinctive etiology and pathology has to be taken into account4 ,the color1 contour 7whether the lesion is simply a local one or there is a composite or group lesion71 condition 7irritation1 debility1 contractions1 and tenderness71 and movement of the several regions1 and the spine as a whole should be noted4 ,and the student should always keep in mind that the osseous vertebral lesion may be1 7a7 a twist between two vertebr 7this generally means a rotation of one section of the spine on another section71 7b7 malalignment of several vertebr 7the composite or group lesion71 or 7c7 the impacted or strained lesion1 7this is a lesion that ,clark attaches considerable significance to1 wherein there is injury to the articular surfaces and ligaments without osseous derangement1 followed by exudation and other inflammatory products1 limited motion1 etc474 ,vaso,motor ,nerves ,it is extremely important that the osteopath should be thoroughly conversant with the regions where he may affect the vasomotor nerves to various tissues and organs4 ,many anatomical derangements undoubtedly involve the vasomotor nerves1 and it is therefore necessary to know where they may be affected4 ,the following table is taken mostly from the physiology of ,landois and ,stirling1 but many of the statements have been noted at various times2 it is1 therefore1 impossible to give full credit4#cg ,the vasomotor center is in the medulla1 consequently the osteopath gives cervical treatment to influence this center4 ,treatment of the upper cervical region has undoubtedly a marked effect in tending to equalize the vascular system of the body1 when it is disturbed4 ,head4--,the cervical sympathetic for the same side of the face1 eye1 ear1 salivary glands1 tongue1 etc41 and possibly the brain4 ,lesions are found in all the tissues about the cervical region1 but usually in the vertebr1 which influence these nerves4 ,deep contracted muscles oftentimes involve them4 ,the spinal vaso-constrictors for the vessels of the head are from the first five or six thoracics4 ,many lesions are located in the upper five or six dorsal vertebr1 or corresponding ribs1 that have apparently a direct influence upon the vessels of the head4 ,not only congestive headache and congestion of the brain tissues are influenced by lesions in this region1 but disease of the eye1 ear and face occasionally arise from such derangements4 ,it is always best when the head1 neck or even the arms are involved1 to examine carefully this region4 ,vaso-dilator fibres for the face and mouth are found from the second to the fifth dorsals2 these fibres unite almost entirely with the trigeminus1 and pass from the superior cervical ganglion of the sympathetic1 to the ganglion of ,gasser4 ,this fact is of great importance to the osteopath1 for oftentimes when inflammation of the face and mouth occurs1 lesions may be located along the upper dorsal vertebr or ribs1 or in the deeply contracted muscles of this region4 ,observation revealed in several cases of erysipelas that the causative lesion was located in the upper dorsal region2 and the cases were cured by correcting these lesions1 thus showing that probably the vasomotor nerves were the seat of the trouble4 ,other dilator fibres arise apparently in the trigeminus1 for stimulation of this nerve between the brain and ,gasser's ganglion causes dilatation of the vessels of the face4 ,the lingual and glosso-pharyngeal nerves are the dilators of the lingual vessels4 ,the sympathetic and hypo glossal are the constrictors2 these arise in the sympathetic and reach the nerves by way of the superior cervical ganglion4 ,stimulation of the cervical sympathetic causes constriction of the retinal vessels4 ,this point is extremely interesting to the osteopath1 because diseases of the retina and optic nerve are oftentimes due to subluxated cervical vertebr1 usually the atlas or third cervical4 ,the retinal fibres leave the sympathetic at the superior cervical ganglion and pass along the communicating ramus to the ganglion of ,gasser1 from whence they reach the eye through the ophthalmic branch of the fifth nerve1 the gray root of the ophthalmic1 the ganglion and the ciliary nerves4 ,almost all the fibres to the anterior part of the eye are found in the fifth nerve2 this1 also1 is another important point for the osteopath's consideration4 ,cases of conjunctivitis1 keratitis1 corneal astigmatism and diseases about the eyelids and tear ducts are usually caused by lesions to the fifth nerve1 due to a deranged atlas or third cervical4 ,the vaso-dilators for the anterior part of the eye1 and also dilating fibres to the iris may be affected at the first and second dorsals4 ,this point is also taken advantage of by the osteopath1 for lesions of these fibres occur oftentimes at the upper dorsal4 ,it is claimed that important fibres that aid in the control of the metabolism of the retina1 may be affected at the fourth and fifth dorsals4 ,lungs4--,reflex constriction by stimulation of the intercostals1 central end of the sciatic1 abdominal pneumogastric and abdominal sympathetic4 ,there is not a rich vasomotor supply4#ch ,the essential feature to the osteopath is that the vaso-constrictors to the lungs and bronchial tubes are very likely to be interfered with by rib and vertebral dislocations1 from the second to the seventh dorsals1 inclusive1 but chiefly at the third1 fourth and fifth4 ,the heaviest innervation being from the third1 fourth and fifth spaces1 probably explains why asthma is often due to a dislocation of the third1 fourth or fifth rib4 ,heart4--,first to fifth thoracic via ganglion stellatum and inferior cervical ganglion4 ,vasomotor fibres to the coronary arteries are found in the vagi4 ,intestines4--,sympathetic1 chiefly through the splanchnic nerves4 ,vaso-constrictors of the jejunum from the fifth dorsal down1 for the ileum slightly lower and for the colon still lower4 ,there are none below the second lumbar4 ,dilators are present in the same sheath1 but more abundant in the last three dorsals and the upper two lumbars2 all probably end in the solar and renal plexuses4 ,receptaculum ,chyli4--,stimulation of the splanclinics causes dilatation4 ,liver4--,the splanchnics chiefly on the right side4 ,the vagus contains vaso-dilators4 ,there are also fibres from the inferior cervical ganglia of the sympathetic4 ,kidneys4--,vasomotor nerves from the sixth dorsal to the second lumbar1 but principally from the ninth to twelfth dorsals1 inclusive4 ,in the large majority of kidney diseases1 lesions are found from the tenth to the twelfth dorsals4 ,stimulation of the sciatic centers causes contraction4 ,there are also fibres from the superior cervical ganglion4 ,spleen4--,vasomotor fibres are in the splanchnics1 third dorsal to third lumbar1 principally1 on the left side4 ,there are some fibres direct from the brain4 ,stimulation of the vagi contracts the spleen4 ,portal ,system4--,fifth to ninth dorsal4 ,generative ,organs4--,for ,fallopian tubes1 uterus1 vagina1 vas deferens and seminal vesicles1 vasomotor fibres are found in the lower dorsal1 and the second1 third1 fourth and fifth lumbar nerves1 principally4 ,coccyx and ,immediate ,region4--,third lumbar down4 ,back ,muscles4--,dorsal ,posterior branches of the lumbar nerves and intercostal nerves4 ,these nerves arise from the gray ramus of the corresponding sympathetic ganglia4 ,arm4--,from the brachial plexus1 the sympathetic1 inferior cervical ganglion and first thoracic ganglion1 and sometimes lower4 ,leg4--,second dorsal down1 the sciatic and crural nerves1 and the abdominal sympathetics4 ,sensory ,nerves ,inhibition of various regions along the spinal column is frequently given by the osteopath to lessen pain4 ,it is only a temporary or palliative treatment1 but many times gives great relief4 ,one should inhibit usually over tender points and contracted muscles4 ,these 7tender points and contracted muscles7 are signs to the osteopath that disturbances exist at these points4 ,the following table is taken from ,quain1 which is ,head's classification3 ,heart4--,first1 second and third dorsals4 ,lungs4--,first1 second1 third1 fourth and fifth dorsals4 ,stomach4--,sixth1 seventh1 eighth and ninth dorsals4 ,cardiac end from sixth and seventh4 ,pyloric end from ninth4 ,intestines4--7a7 ,down to upper part of rectum1 ninth1 tenth1 eleventh and twelfth dorsals4 7b7 ,rectum1 second1 third and fourth sacrals4 ,liver and ,gall-bladder4--,sixth1 seventh1 eighth1 ninth and tenth dorsals4 ,kidney and ,ureter4--,tenth1 eleventh and twelfth dorsals4 ,upper part of ureter1 tenth dorsal4 ,at lower end of ureter1 first lumbar tends to appear4 ,bladder4--7a7 ,mucous membrane and neck of bladder2 7first7 second1 third and fourth sacrals2 7b7 over distension and ineffectual contraction1 eleventh and twelfth dorsals1 and first lumbar4 ,prostate4--,tenth1 eleventh 7twelfth7 dorsals4 ,first1 second and third sacrals1 and fifth lumbar4 ,epididymis4--,eleventh and twelfth dorsals and first lumbar4 ,testis4--,tenth dorsal4 ,ovary4--,tenth dorsal4 ,appendages1 etc4--,eleventh and twelfth dorsals1 first lumbar4 ,uterus4--7a7 ,in contraction1 tenth1 eleventh and twelfth dorsals1 and first lumbar4 7b7 ,os uteri2 7first7 second1 third and fourth sacrals 7fifth lumbar very rarely74 ,other points are used by the osteopath to relieve pain of certain regions1 for such the reader is referred to the article on neuralgia2 besides many tender points are found along the spine by the osteopath1 where inhibition gives relief to the patient1 provided such points have a connection with the case in question4 ,hot fomentations if property applied1 through reciprocal relationship of the nervous system1 are of value in relieving pain1 releasing spastic musculature and normalizing visceral function4 ,frequently1 in both acute and chronic cases1 this is an excellent preparatory measure1 to be followed by careful adjustment4 ,it will be recalled that the functional test1 movement of a vertebral lesion is of primary consideration4#ci ,,footnotes3 #cc ,burns--,partial ,report of ,experiments upon ,visceral ,reflexes4 ,the ,osteopathic ,world1 ,aug41 #aije4 #cd ,pearce--,some ,laboratory ,demonstrations of ,osteopathic ,principles4 ,the ,osteopathic ,physician1 ,nov41 #aije4 #ce ,stimulation--,leslie ,e4 ,cherry1 ,journal of the ,american ,osteopathic ,association1 ,feb41 #aije4 #cf ,mc,connell--,the ,osteopathic ,lesion1--,journal of the ,american ,osteopathic ,association4 #cg ,see also ,gaskell1 ,the ,involuntary ,nervous ,system2 ,pattenger1 ,symptoms of ,visceral ,disease2 ,mackenzie1 ,symptoms and ,their ,interpretation4 #ch ,mac,leod1 ,physiology and ,biochemistry in ,modern ,medicine4 #ci ,see ,luciani1 ,human ,physiology1 ,vol4 ,,iii2 ,mac,leod1 ,physiology and ,biochemistry in ,modern ,medicine4 ,,pathological ,,spinal ,,curvatures ,,spinal ,,curvatures ,any deviation of two or more consecutive vertebr from the normal curves of the spinal column is usually termed by the osteopath a pathological curvature4 ,of the common pathological curvatures of the spinal column there are found3 7#a7 scoliosis or lateral curvature1 7#b7 kyphosis1 or excurvation1 an antero-posterior curve with the convexity backward1 and1 7#c7 lordosis1 or incurvation1 an antero-posterior curve with the convexity forward4 ,osteopathic ,etiology4--,of primary importance in the causation of pathological curvatures of the spinal column1 are injuries to the spine1 such as strains1 falls1 blows1 and various physical forces1 acting directly or indirectly1 as injuries to the chest1 pelvis and limbs4 ,the osteopath in his daily work finds more curvatures1 as well as acute and chronic diseases1 resulting from some simple injury to the spine1 as a slip1 strain or twist1 than from any other cause4 ,the dire effects of any violence to the spinal column cannot be overestimated4 ,among predisposing causes may be mentioned1 continued ill health1 general weakness1 rapid growth1 rachitis1 tuberculosis1 etc4 ,any habitual one-sided position may result in a curvature4 ,an injury to the chest1 adhesions from pleuritis1 chronic liver disease1 obliquity of the pelvis producing unequal length of the legs1 carrying heavy weights on one side1 and various morbid growths of the chest and abdomen1 may all produce curvatures4 ,many cases are found in school children who are growing rapidly1 and whose muscular strength and development do not keep pace with their growth4 ,unilateral atrophy of the muscles1 due to central changes or overuse1 may be the cause of deviations of the spinal column4 ,sacro-iliac disease in some instances is a potent factor4 ,thus there may be a great variety of causes productive of the incipiency1 and the spine being strained or irritated at a single point and in a certain way gradually develops a curvature4 ,every spinal and innominate lesion should be considered as a potential cause for a curvature4 ,scoliosis4--,this is the most common spinal deformity and is characterized by lateral deviation from the median line4 ,in most cases the curve is to the right in the upper dorsal region1 with a compensatory curve in the opposite direction in the lumbar region4 ,the curve being to the right in the majority of cases1 is probably due to the fact that most people are right-handed4 ,morbid ,anatomy4--,the vertebr in the region involved are rotated so that their spinous processes point toward the concavity of the lateral curve4 ,the bodies of the vertebr on the side next to the concavity are thinner1 due to absorption2 the intervertebral discs are made thin on the same side by pressure and absorption4 ,the ribs are considerably distorted1 depressed on the concave side and prominent on the convex side4 ,the ligaments on the concave side are contracted1 and stretched on the convex side4 ,the muscles on the concave side are more or less contracted1 and on the convex side they are stretched1 causing atrophy and fatty infiltration of their tissues4 ,kyphosis4--,this may be a slight posterior curve really amounting to nothing1 or it may be a very grave pathological condition as in ,pott's disease4 ,therefore it is very necessary that one should make a most careful diagnosis 7see ,pott's disease74 ,the most common causes of kyphosis are ,pott's disease1 rachitis1 occupation1 general weakness1 rheumatism and old age4 ,in ,pott's disease1 the posterior curve is characterized by a sharp angle1 and by the spine being very rigid4 ,this1 taken in conjunction with the history and other symptoms should be sufficient to enable one to make a diagnosis4 ,radiographic examination should be made4 ,the condition of round shoulders1 which in time produces marked kyphosis1 is rarely a habit as it is usually termed4 ,in nearly every case it indicates either a weakness of the back muscles or1 what is more apt to be the cause1 a strained posterior condition of the dorsal vertebr1 commonly of the lower dorsal region4 ,morbid ,anatomy4--,in mild cases there is simply a relaxation of the ligaments of the vertebr and a separation of the lamin and spinous processes4 ,in severe forms there may be absorption of the anterior portion of the intervertebral discs and the bodies of the vertebr 7,pott's disease74 ,lordosis4--,this may be a congenital condition1 especially when occurring in the lumbar region4 ,anterior curves of the spine are generally found in the lumbar or cervical regions1 but occasionally occur in the dorsal region1 causing the spinal column to be more or less straight1 and thus weakening the individual4 ,this curve is commonly compensatory to kyphosis1 hip-joint disease and congenital dislocations of the hip4 ,treatment of ,spinal ,curvatures4--,the treatment of pathological curves of the spinal column1 by osteopathic methods1 has been highly satisfactory to both osteopath and patient4 ,the success of the osteopath in these cases has been due to his comprehensive and exact knowledge of each vertebra1 and of the spinal column in general4 ,he recognizes curvatures that the ordinary practitioner1 and it is safe to say the orthopaedic specialist1 would not even notice or recognize4 ,on account of the highly developed sense of touch of the osteopath1 he is capable of detecting the slightest deviation of one vertebra from another1 and of the spine in general from the normal4 ,thus by the uniqueness and peculiarity of his work he is capable1 not only of discovering a curvature1 but also of reducing a curve when found4 ,the work consists of1 first1 relaxing any muscles that may have become rigid over the seat of the curve4 ,then follows a treatment to each vertebra involved1 by attempting to replace it1 and treatment to the curve in general by springing it toward its normal position4 ,at each treatment effort should be made to accomplish something toward correcting the spine2 too many treatments are given in a 8general0 way1 and being unspecialized amount to nothing4 ,one must become familiar with the exact location of each vertebra involved1 to attempt a correction of a curvature intelligently4 ,upon this one point it is impossible to speak too strongly1 for a great many treatments have been wasted and improvement of cases retarded by not paying enough attention to the details of the diagnosis1 either from pure slothfulness or from an imperfect conception of osteopathy4 ,corrective exercises are always of value in addition to treatment4 ,these remarks refer to incipient and certain moderate curvatures4 ,in other cases radical measures 7,abbott7 should be employed if age and conditions permit4 ,remember1 however1 that the practitioner in his daily work of adjusting the many combinations of rotation and sidebending lesions corrects innumerable actual and impending curves4 ,lateral curvature in the dorsal region is undoubtedly the hardest to correct on account of the ribs1 which complicate the condition4 ,a marked curve in the dorsal region is sure to be accompanied by a dislocation of the vertebral end of one or more ribs4 ,treat each distinct lesion separately1 follow by general stretching1 replacing and molding of the tissues4 ,a good method to stretch tissues and adjust a moderate lateral curve is to utilize the swing1 or in lieu of this have the patient stand just at arm's length from the wall with concave side toward the wall with straight arm at right angles and palm resting against the wall4 ,stand in front of patient whose feet are firmly on the floor and reach around with both hands upon the spine4 ,as the patient sidebends toward the wall it tends to correct the deformity1 so if the operator coordinates his adjustment with that lateral movement of the patient1 precise fulcra can be obtained and a certain1 definite correction secured4 ,the significance rests with the stretching of tissues and the definite fulcra obtained1 thereby securing a maximum sidebending and rotation toward correction4 ,the dislocation of an innominate sometimes complicates matters1 but is a simple point to remedy1 and should not be overlooked4 ,the correction of a curvature presents a special study to the osteopath1 whether it be scoliosis1 kyphosis or lordosis1 and special rules cannot be laid down for treatment4 ,cases of rare occurrence are what might be termed 8symmetrical0 curves2 i4 e41 no vertebra presents separately a marked lesion1 the column on the whole being simply bowed4 ,such cases can be treated by springing back the spinal column1 and by the use of methodical exercises4 ,unfortunately most curvatures are characterized by various lesions between the vertebr1 and thus each lesion requires special work4 ,in simple curves the use of braces1 jackets1 and the various mechanical appliances are of very little use to the osteopath1 in fact1 more harmful on the whole1 than beneficial4 ,naturally they would apply to a 8symmetrical0 curve1 or where the patient is too weak to sit or walk1 but they can be of very little use to the average patient1 in place of correct osteopathic treatment4 ,mechanical appliances confine the movements of the patient1 interfere with the development of the muscles1 and impinge to a greater or less extent the spinal nerves4 ,due attention to hygienic surroundings and diet are certainly of aid4 ,proper exercises and occupation for the sufferer should be advised4 ,special care should be taken in examining 7radiographic7 for infectious lesions 7arthritis74 ,straight ,spine is a term used particularly by osteopaths for a condition seldom recognized by orthopedic surgeons4 ,the following is from ,h4 ,w4 ,forbes#dj3 ,straight spine is 8a departure from the normal in the conformation of the chest2 characterized anatomically by bilateral diminution in size1 decrease in the antero-posterior diameter1 relative increase in the transverse diameter and flattening of the anterior and posterior walls2 characterized clinically by diminution of respiratory capacity1 lowered lung and heart resistance1 impaired general nutrition and predisposition to neurosis4 8,of the many possible manipulations that may be used to lift and overcome the morbid bend of the ribs ,i will attempt the description of but one4 8,relax the musculature of the back and chest4 ,rotate1 flex and extend the dorsal spine4 ,examine all the ribs on each side and loosen any that do not move freely4 ,having done this1 the patient is prepared for the specific treatment4 ,have the patient sit on a stool and lean forward on a table4 ,have him separate the elbows1 flex the forearms1 place one hand over the other and his forehead on the hands4 ,tell him to relax all the muscles of the shoulders and arms and to breathe deeply without using the muscles4 ,after a few trials he is able to fully expand his chest without contracting the muscles connecting the upper extremity with the trunk4 ,the physician then takes a position at side 7either side7 of the patient and places the weight of his trunk on the ribs of the side he is on1 a little external to their angles4 ,he passes his arms around the patient's body2 the arms passing across the front of the chest are carried around far enough to allow the hand to be placed on the ribs just external to their angles4 ,the other hand is placed on the top of this one4 ,in this position the physician's body on one side1 and his hands on the opposite1 occupy similar positions4 ,the patient is now told to inspire deeply and at the same time to relax the shoulder muscles1 as before instructed4 ,as the chest expands drop the weight of the trunk on one side and make pressure forward 7forward meaning toward the anterior surface of patient's body7 with the hands on the other side4 ,this lifts the ribs to a greater extent than the patient unassisted could lift them4 ,at the end of inspiration and during the first third of expiration the chest is compressed laterally4 ,the compressing force1 if applied correctly1 will fix the ribs in a position of less obliquity and will also correct the increased lateral bending of them4 ,the dorsal spine becomes more convex posteriorly at the moment of lateral compression of the thorax1 if correctly made4 ,great force should not be used at the beginning4 ,repeat the manipulation five to twenty times each treatment4 ,give treatment three times a week4 ,a similar movement may be given on the table4 8,the greater number of flat chests in patients under thirty years of age may be corrected4 ,if the patient is above thirty1 although complete correction may not always be accomplished1 the results are satisfactory4 ,two to six months treatment is required40 ,a 8typhoid spine0 comes as a sequel to typhoid fever4 ,there is constant pain1 tenderness along the lumbar region and rise of temperature4 ,the pain is generally increased when the spine is moved forward or sidewise4 ,such a condition is clearly understood by the osteopath4 ,there are always found distinct vertebral lesions along the region that is tender on pressure4 ,in fact these very lesions may have been the predisposing cause of the attack of typhoid fever4 ,the treatment is rest and the indicated manipulation to correct the derangements4 ,it is of great interest to note that where the typhoid patient is treated osteopathically the condition just described seldom results4 ,observations by ,c4 ,m4 ,t4 ,hulett confirm this statement4 ,the ,neurotic ,spine may be the result of injury but the subject is usually of a nervous1 neurasthenic type4 ,it occurs from the age of puberty to adult1 much more often in females than males4 ,the patient has dull pain in the back of the neck or in the lumbar or sacral region1 complains of a constant tired feeling and often of a sharp neuralgic pain in certain parts of the spine4 ,generally there is a drooping posture in the upper dorsal with shoulders thrown forward1 which is a sign of weakness4 ,there is extreme tenderness along the spine and usually the pain is confined to the sensitive places4 ,treatment consists of a constitutional toning up1 and increasing muscular strength through judicious exercise4 ,the posterior curve may be pushed toward the median line by laying the patient on the face2 also with the knee in the back and the flat of both hands on the sternal ends raise the ribs2 or by the arms making use of the pectoral muscles accomplish the same result4 ,deep breathing is also effective4 ,relief can usually be given and a cure will depend upon the patient's general condition4 ,the ,hysterical ,spine is usually considered the same as the neurotic spine1 but there are many cases which have the sensitive spine without being hysterical4 ,there is more deformity usually present1 particularly in the lumbar region4 ,probably there will be a history of some injury4 ,the treatment is to correct the curvature and build up the general health4 ,these conditions are stubborn and progress is slow4 ,in both the neurotic and hysterical spines the ligaments of certain areas will be found atonied and relaxed4 ,this is especially noticed upon attempting to spring a group of vertebr when all of a sudden the section relaxes4 ,in either of these spines the lesions will irritate or obstruct nervous courses1 produce venous stagnation or arterial starvation1 and disturb lymph channels4 ,h4 ,f4 ,goetz has observed that in functional nervous diseases the dorsal spine is flat1 while in visceral displacement the dorso-lumbar spine is posterior4 ,the ,spine of the ,aged wherein is found stooped shoulders and a rigid spinal structure1 can be distinctly improved by slow1 cautious traction4 ,this tones weakened muscles1 releases contractures1 separates the compressed intervertebral discs1 and definitely tones the viscera4 ,careful work is imperative4 ,,footnotes3 #dj ,journal of the ,american ,osteopathic ,association4 ,,pott',s ,,disease ,an article on ,pott's disease does not really come within the province of a practice of medicine4 ,still it will be acceptable to the practitioners and students of osteopathy1 as one of the objects of osteopathic work is to improve1 not only medical and obstetrical practice1 but also surgical practice1 and besides the osteopath will have many cases of spondylitis to treat4 8,pott's disease1 or caries of vertebral bodies1 was first described by ,percival ,pott in #aggi4 ,it consists of a destructive ostitis affecting the spongy tissue of one or more of the bodies of the vertebr4 ,the ostitis is tuberculous1 and is similar in character to tubercular ostitis seen in the epiphysis of the long bones4 ,owing to the superincumbent weight of the head and shoulders pressing upon the carious vertebral bodies1 the spine and trunk become peculiarly and characteristically distorted4 ,the morbid process is limited1 as a rule1 to the bodies2 the transverse1 articular1 and spinous processes are rarely primarily affected40 7,park74 ,the first consideration in the treatment of ,pott's disease is rest4 ,if the disease is a progressive one1 rest in bed in the recumbent position is necessary4 ,naturally1 the object of the treatment is to secure resolution of the tubercular ostitis as soon as possible4 ,to do this1 careful manipulative treatment should be applied to the diseased vertebr4 ,the treatment must not be harsh1 for there would be danger of greater irritation to the parts1 and possibly infected particles from the destroyed tissue might gain entrance to the vascular system4 ,the osteopath must be extremely careful how he manipulates the spinal column in ,pott's disease4 ,the object of the manipulation is not primarily to overcome the deformity1 as some may think such an act possible1 but to separate the vertebr enough to allow a freedom of the circulation1 and to remove impingements of the nerve tissue4 ,it is impossible to overcome the deformity to any extent when part of the body of the vertebra is destroyed2 but if one could treat the case at the incipiency1 most probably deformity would be prevented4 ,there is another danger in treating cases too severely1 and that is causing exhaustion of the patient4 ,treat the spinal column not only to separate each articulation slightly1 but to carefully crowd the diseased vertebr toward their normal position4 ,when the disease is in the dorsal region1 considerable attention has to be paid to the ribs1 as they are invariably involved when the spinal curvature is great4 ,hence it is necessary to treat each rib separately1 and try to correct them at least1 and remove any obstruction to nerve fibres or vessels that may be found4 ,one of the strongest arguments against the indiscriminate use of braces1 jackets and various mechanical appliances in spinal deformities1 is that they tend to straighten the spine1 by simply crowding the vertebr and ribs as a whole into place1 besides interfering with the cutaneous circulation4 ,the osteopath should realize that each vertebra and rib has to receive special treatment1 in order to correct the spinal column1 and that mechanically exerting pressure upon all the vertebr at one time tends to lock the vertebr and ribs all the more securely4 ,it is like trying to correct a certain subdislocation of the cervical vertebr by pulling and twisting the neck instead of applying specific treatment--the lesion is all the more firmly fastened4 ,young1 in his ,surgery1 makes this observation3 8,like chronic abscess or chronic bone disease1 this affection has its origin in the fact that the tissues of the anterior parts of the bodies of the vertebr have been partly deprived of their nutrition because of luxated ribs or subluxated or twisted vertebr40 ,after the tissue destruction has been limited1 and the deformity corrected as much as can be1 an ankylosis should be secured if possible4 ,promotion of ankylosis depends altogether upon the preceding treatment--rest and an improved nutrition of the parts4 ,a truss or brace1 if correctly applied1 is often beneficial in such cases4 ,the treatment of spinal abscesses is entirely in accordance with surgical treatment4 ,in all cases the general health of the patient has to be well taken care of4 ,the osteopath must not be over zealous for quick results4 ,it takes many months to perform a cure2 however1 there is always a tendency toward a cure4 ,treatment of the spinal muscles and of the limbs1 and pure air1 sunlight1 massage and good food are very necessary4 ,,sprains ,,and ,,fractures ,,sprains ,the osteopath is often called upon to treat sprains of various sections of the body as well as to relieve after effects of fractures and restore function to the part4 ,the osteopathic treatment is very effectual2 therefore1 an outline of the purpose and method is given4 ,sprain is defined by ,dorland as 8the wrenching of a joint with partial rupture or other injury of its attachments1 and without luxation of bones40 ,from an osteopathic viewpoint the above definition is not fully explanatory1 for there is in most cases a partial luxation of the bones4 ,the most common cause of a sprain becoming chronic is the presence of partial bony displacements4 ,rupture of tissues may be the cause of a chronic state but is not nearly so frequent as the bony dislocation4 ,in most sprains1 the wrenching causes a displacement of the bony tissues1 which may or may not return to normal position and relation4 ,the function of the muscles is not primarily to hold the bones in place2 this is left to the ligaments1 so when a wrench of a joint is so severe as to cause rupture of muscles or tearing of ligaments1 partial luxation of the bones is almost certain to follow2 and even where such damage does not occur a change in the relation of the bones is a frequent occurrence4 ,unless a sprain can be seen very early it may be difficult to detect just what has happened2 whether it rests with a rupture of the areolar and connective tissues1 a displaced cartilage1 tendon1 or bone1 a torn ligament1 or ruptured muscle4 ,hemorrhage and swelling take place so rapidly that no time should be lost in critically examining the joint4 ,when in doubt as to the structural disturbances1 particularly in acute cases if there is a possibility of a fracture1 and in chronic cases any supposition that tubercular involvement is present1 have a radiographic examination4 ,there is comparatively little to be found in medical literature relative to the pathology of sprains4 ,probably ,moullin in his excellent monograph on ,sprains has given as good an outline as can be found#da4 ,he says that 8generally speaking1 the tissues on one side of a joint are overstretched and torn2 those on the other compressed and crushed together2 but there is always so much twisting1 and such a difference in the strength and power of resistance of various structures1 that unless the part is examined with the greatest care it is almost impossible to say what actually has given way40 ,hemorrhage due to torn vessels is the cause of most of the swelling within the first few hours4 ,later on1 there is considerable lymph mixed with the blood4 ,there is not only extravasation of blood into the surrounding tissues but also into the synovial wall and cavity4 ,this causes considerable irritation and pain owing to the roughening of the membrane1 and the joint becomes inflexible4 ,and if the joint or any strained tissue is kept too long at rest the mass becomes organized and is the cause of much discomfort and annoyance4 ,similar changes may occur in the burs due to the extravasated blood4 ,strong ligaments may be torn across1 but not frequently4 ,the tear is usually a separation from the bone4 ,occasionally interosseous ligaments1 as for instance in the knee1 may be injured4 ,the muscles may be severely torn1 but more often they are 8hurt by their own sudden and spasmodic effort at recovery than by anything else40 ,in a few cases the tendons and muscles will be found bruised1 lacerated1 and dislocated4 ,the veins occasionally rupture and thus results more or less effusion1 so that rigidity and edema may persist for a long time4 ,the bones are very frequently damaged4 ,this may be a simple bruising of the tissue but more often1 as osteopathic diagnosis shows1 there is partial displacement of the bony structure4 ,a point of great importance that every experienced osteopath will agree to is the following from ,moullin3 8,diseases of the spine1 hip1 and other joints in children may be due1 in great measure1 to some constitutional taint1 though it is open to question whether the influence of this is not overrated2 but it is quite certain that the immediate starting point in nine cases out of ten is some chance sprain1 often so slight as scarcely to have been noticed at the time40 ,before treating a sprain there are one or two points the osteopath should carefully note3 first1 that there is no complicative fracture2 second1 in children that there is not an epiphysial separation2 and1 third1 note peculiarities of a constitutional character that would complicate matters4 ,whatever is done1 always give the patient the benefit of the doubt4 ,if the patient can be seen early1 before swelling has reached the maximum1 many times a very quick cure can be secured4 ,do not at once put the part at rest and apply cold1 but examine the sprain most carefully and thoroughly and readjust first of all any bony defects2 then replace the softer tissues if displaced1 and next relax contractions2 follow this by light massage and passive movements to reduce and combat hemorrhage and swelling4 ,this treatment alone in a fair percentage of cases will be all that is necessary provided frequent subsequent treatments of massage and passive movements are continued to reduce and counteract inflammation and to prevent rigidity and stiffness of the softer tissues4 ,where the osteopathic treatment is distinctly indicated is in the readjustive manipulation4 ,this is the reason why the treatment is so efficacious1 and the patient is cured in a fraction of the usual time1 and few sprains result in complications and become chronic4 ,in sprains that have become chronic there will be found almost invariably some osseous tissue slightly displaced4 ,after correcting this1 apply careful and thorough manipulation and massage and movements to break up adhesions1 to remove effusions and extravasations1 to relax muscles1 and to promote normal circulation4 ,care should be taken that there are no displaced cartilages1 ligaments1 tendons1 or muscles4 ,it is well to keep in mind that the osteopathic readjustive manipulation is not an exercise or movement1 but definite1 specific correction of the tissues anatomically4 ,do not treat the displacement by any general 8pommelling10 but apply the mechanical principles indicated as in any dislocation4 ,this will mean much to the patient in more ways than one1 and especially so should the sprain be so severe and complicated as to demand anesthesia for correction4 ,there is no objection to the employment of cold and heat2 in fact1 both are beneficial4 ,cold to prevent extravasation and swelling1 and heat to remove and relieve the same1 is a sound and practical method4 ,but do not apply a wet bandage4 ,pouring cold water over the sprain is the best method2 even better than immersing the part4 ,an ice bag is another good way to apply cold4 ,when the skin begins to look blanched and dull the maximum amount of benefit has been secured4 ,heat at the very first may be employed instead of cold1 for it has a tendency to prevent bleeding and inflammation1 but the temperature of the application must be hot as can be borne or else the desired effect will not be obtained4 ,later on to relieve pain and rigidity1 and to relax the muscles so that a better circulation will be secured1 moderate heat will be beneficial4 ,then the application of heat and cold alternately will be of service1 employed as a douche for a tonic effect1 when the part is weak1 inactive1 and powerless after the elapse of several days4 ,it should always be remembered that the employment of heat and cold is only of temporary benefit1 so if used too long opposite effects to those desired will result4 ,bandaging the sprain may be helpful1 but not always4 ,great care should be taken as to how pressure is applied4 ,bandaging from periphery toward the trunk1 seeing that the bandage is smooth1 and padding all depressions so that the bandage does not touch bony prominences only1 are necessary4 ,unless the bandage is applied so that an even pressure is secured1 the material used not too warm1 and the bandage attended to each day1 the effectiveness will amount to but little4 ,next1 do not make the mistake of resting the injured joint too much4 ,the function of a joint is movement1 and it has been observed that prolonged rest of a healthy joint may result in rigidity1 stiffness1 and distension of the soft part1 and even serious organic changes in the ligaments1 synovial membrane1 and cartilages have occurred4 ,consequently continued passive movements should be kept up from the inception of the injury1 although it must not be carried to extremes so that inflammation1 hemorrhage1 or laceration will be aggravated4 ,moullin says3 8,as a rule1 passive movement may be commenced from the second day with the certainty of preventing adhesions1 and without the least fear40 ,osteopathically1 with due attention to readjustive manipulation1 and care as to correct position and rest1 passive motion will be allowable usually from the first day4 ,there is much corroborative evidence in current medical literature that bears in a general way upon part of the foregoing4 ,the ,international ,text ,book of ,surgery says3 8,massage should begin early1 in order to avoid1 as far as possible1 weakness of the muscles1 and to ensure security to the position of the joints by the retention of a proper tone in them20 besides1 early movement tends to reduce the effusion into the tendon sheaths around the articulation1 which in some cases1 particularly the ankle and wrist1 may be a very prominent feature4 ,the ,reference ,hand ,book of the ,medical ,sciences voices the same opinion2 and ,mumford is referred to as follows3 8,immobilization for more than a few days1 as under the older methods1 is objectionable because adhesions are apt to form1 thus causing impairment of function1 and because when there is a tubercular taint1 proper conditions for a localized tuberculosis are established40 ,among other statements ,holder ,sneve in the ,journal of the ,american ,medical ,association of ,june #a1 #aija1 says3 8,immobilization of muscles is not rest4 ,on the contrary1 in all sprains the muscles should have passive exercise the first few hours and days1 and active exercise after that4 ,in the majority of cases active exercise should be instituted from the beginning4 ,the plaster cast should not be used at all1 even in cases where we have a fracture1 unless it be impossible to maintain a proper position of the joint40#db ,again quotation is made from ,moullin4 ,these quotations are taken from the chapters on ,manipulation and ,massage4 ,it will be observed he makes a distinction between the two methods4 ,and the osteopath should carefully keep in mind not only the difference between the two1 but beyond these the more fundamental treatment1 readjustment4 ,the characteristic feature of osteopathy is anatomical readjustment1 and this in sprains should be supplemented by massage 7superficial work71 and also manipulation 7deep and more or less forcible work7 in order to remove stiffness1 rigidity1 and fibrous ankylosis4 ,the following is relative to forcible manipulation3 8,manipulation is much more useful than division2 it can be employed for such a variety of purposes4 ,in the early stages it prevents the occurrence of stiffness or the formation of adhesions4 ,later1 when the swelling and heat have disappeared1 it is no less successful in restoring freedom and ease of movement1 and afterward1 when all mechanical obstructions have been cleared away by its use1 it is one of the most effectual methods known for bringing back the circulation and nutrition of the part1 and giving again to the muscles and nerves the energy which has so long been wanting4444 8,to carry this out effectively two things are needed beyond all others4 ,the one is a sense of touch so delicate that it can appreciate the least resistance or irregularity of movement2 the other an accurate knowledge1 not merely of the ordinary anatomy of the part1 but of the different degrees of tension that fall on the ligaments in every position of the limb4 8,each joint requires a different kind of manipulation according to its construction4444 8,there should be no jerking4 ,the movements must be vigorous and forcible1 but perfectly smooth2 and they must be carried out thoroughly1 the joint being moved to its full extent in all directions that are natural to it4 ,each kind of action should be combined successively with the rest1 one by one1 so that the tension may fall in turn upon all the different parts of the capsule4 8,movements which are especially restricted or painful1 of course require most attention1 but the others1 though they may not be affected to the same extent1 are not to be neglected4 ,it sometimes happens if these are dealt with first1 that a considerable proportion of the main obstruction is cleared away1 as it were1 by side attacks1 so that when its turn comes it yields more readily than it otherwise would4 8,recent slight adhesions give away at once without a sound1 though the sensation is generally conveyed to the hand4 ,when they are older the noise may be as loud and clear as when a bone is broken4444 8,the after treatment of these cases 7cases where there has been tearing and breaking of adhesions7 should be in all respects the same as that of a recent sprain1 only if passive motion at an early date is advisable to prevent the occurrence of stiffness in the one1 it is absolutely necessary in the other40 ,the following pertains to massage of sprains3 8,massage1 in the strict sense of the term1 is a great deal more efficacious1 especially with older sprains4 ,its action is not limited to the skin and superficial structures4 ,these undergo immense changes1 it is true2 they become softer and finer while under manipulation2 their strength and elasticity increase1 the extreme tenderness diminishes1 and the natural appearance and texture return4 ,the surface loses its dry1 harsh character and becomes warm and moist again2 the livid bluish color gives away to a brighter hue1 and the deeper layers of fibrous tissue yield and stretch1 so that the hide-bound1 shrunken condition that is often present after long disuse gradually passes off4 ,but the good effect is not by any means limited to1 or even most conspicuously shown by1 this4 ,when properly carried out1 massage exerts a simultaneous influence on muscles1 nerves1 and vessels2 in fact1 on all the tissues within its reach4 8,the circulation is the first thing to feel its power4 ,it has already been explained how1 after prolonged rest1 the blood1 as it were1 lies almost stagnant in the tissues1 slowly circulating through them1 and neither giving them sufficient for their nutrition1 nor removing from them the waste products of their action4 ,this is changed at once4 ,the life of the part is quickened4 ,the veins and absorbents are emptied first1 and the fluid they contain driven out into the heart1 which fills more rapidly1 and contracts more vigorously and firmly4 ,then the pressure falls in the smaller vessels1 and the tiny irregular spaces1 full of lymph1 which extend in all directions through the tissues4 ,these1 in their turn1 are compressed and mechanically emptied1 their contents being driven on into the empty vessels1 from which any backward flow is prevented by the valves4 ,the circulation becomes more rapid2 nutrition is carried on with greater energy1 and the actual amount of the blood in the tissues at any one time so much increased that they become full and soft to the touch and regain the even and rounded contour of active health4444 8,it is most essential to commence as gradually and as gently as possible1 working on the deeper tissues only after the more superficial ones have become thoroughly accustomed1 and have been unloaded of their surplus fluid4 ,the skin1 the soft subcutaneous tissue1 the muscles1 and the deeper layers1 must all be worked in turn4 ,nor should the manipulation be confined to the injured part4 ,in a sprain of any standing1 the whole of the limb is affected more or less4 ,it is usually better to devote attention first to the parts nearer the trunk than to deal with those around the injured area1 and only afterward1 when the circulation is thoroughly reestablished1 to manipulate the joint itself4 8,the tendency is to make the sittings last too long4 ,deep manipulation itself rarely requires more than five minutes2 but in dealing with a recent injury it may be advisable to spend a longer time than this over the friction and other preparatory measures1 so that a quarter of an hour soon passes by4 ,when the tenderness is very great1 and the amount of swelling excessive1 much longer than this may be necessary1 but short1 frequently repeated sittings are of greater benefit than one long one4 ,a skillful operator1 too1 will often effect more in a few minutes than an ordinary rubber will in as many sittings40 ,a summary of the general treatments of sprains would be as follows3 #a4 ,readjustment of parts and removal of obstructions4 ,osteopathy is especially adapted in these cases1 for two of the primal therapeutic factors in all cases from an osteopathic viewpoint are to readjust the anatomical and to remove obstructions4 ,one should constantly keep in mind1 8a temporary displacement followed immediately by a return to place1 constitutes a sprain40 ,the osteopath often finds that a perfect returning does not take place1 and even remote lesions may affect a joint4 #b4 ,manipulation1 and massage of soft tissues1 to restore circulation and to prevent and remove debris from rupture of vessels and inflammatory products4 #c4 ,the employment of cold1 heat and pressure1 and a certain amount of rest4 #d4 ,anatomical readjustment and manipulation in chronic cases to break up adhesions1 remove exudates1 overcome the organized products of inflammation1 and cure synovitis4 #e4 ,movements both passive and active to stimulate and exercise functions of the joint4 ,the ,spinal ,column4--,the osteopath is especially cognizant of the fact that many sprains occur to the spinal column4 ,these may affect a single joint1 or more or less of a section may be involved4 ,the bones1 ligaments1 tendons1 muscles1 or spinal cord may be found injured4 ,even distant organs1 through involvement of the circulation to the cord1 or through irritation or impingement of spinal nerves and sympathetics1 are frequently disordered4 ,it is not necessary to go into detailed description1 for the points bearing upon this will be found under ,osteopathic ,diagnosis1 ,etiology1 and ,technique1 and the general description will1 also1 apply4 ,readjustment1 strapping1 heat1 massage1 manipulation1 ironing1 stretching of muscles1 fomentation1 etc41 have their place4 ,there is no doubt that sprains1 strains1 and blows to the spinal column are the cause of many spinal disorders and consequent visceral disturbances4 ,the ,ribs4--,sprains of the vertebral ends frequently occur1 resulting in a partial luxation1 stretching of ligaments1 contraction of muscles1 and exudative formation in the joint structures1 which often is the cause of irritation to the sympathetic nerves4 ,the costal cartilages are frequently strained1 and may so irritate the intercostal nerve as to cause considerable pain both locally and reflexly4 ,the treatment is essentially one of replacement1 and relaxation of the softer tissues4 ,adhesive strips to limit movement due to respiration may be helpful4 ,the ,innominata4--,sprains of the innominata are also commonly met with4 ,besides being a source of discomfort to the patient they are an important cause of pelvic disorders and leg affections4 ,partial displacements are the rule1 the correction of which gives quick relief4 ,where there is considerable spasm of muscles1 examine carefully the lumbar alignment4 ,in chronic cases fibrosis of muscles and adhesions may complicate matters4 ,the ,hip ,joint4--,sprains involving the hip joint may be readily corrected1 and again may be the exciting cause of serious involvement4 ,previous tubercular disease can be aggravated in this manner1 or syphilitic changes in the joint disturbed4 ,care should be taken that there are no complicating displacements of the innominata or irritations to the spinal nerves4 ,possibly the hip may be so strained as to cause a twist of the femur in the socket and thus simulate a partial dislocation2 this1 in fact1 would probably be termed a partial dislocation4 ,strain of one set of muscles about the hip joint is somewhat rare1 and spinal lesions may disturb the innervation to one set of muscles4 ,in cases of intracapsular fracture considerable can be done by careful massage and manipulation after union has taken place1 to secure greater freedom of movement and strength of the limb4 ,likewise in hip-joint disease1 after the disease is healed1 massage and manipulation will be very beneficial4 ,care must be taken if the treatment causes spasticity of the muscles2 this shows the treatment is irritative and should be stopped until the spasticity has ceased4 ,where the limb is shortened from either hip-joint disease or intracapsular fracture apparent lengthening may be secured by careful abductive and hyperextensive stretching4 ,the ,knee4--,the knee is the most complicated joint1 and sprains are apt to be very serious4 ,the usual treatment for sprains is employed4 ,occasionally the semilunar cartilages are displaced and may be a source of difficulty in diagnosis2 likewise injuries to the patellar tendon and lateral ligaments4 ,another joint frequently overlooked is the innominate4 ,in a number of knee cases that terminate in chronic synovitis there will be found a displacement of the innominate that is preventing recovery4 ,a villous synovitis may arise in strains from faulty posture1 especially in the obese4 ,injury to the hip-joint1 also1 may cause strain or irritation at the knee4 ,occasionally tender points about the knee1 especially at the inner side1 are due to irritation at the hip1 or possibly from the spine4 ,referred pain of the knee joint is of frequent occurrence4 ,the ,ankle and ,foot4--,the ankle is often sprained4 ,one should examine carefully for a possible fracture of the malleolus1 and for fracture of the tibia4 ,there may be a dislocation of the fibula1 also a separating of the tibia and fibula at the ankle4 ,the common bony displacement takes place between the astragalus and os calcis4 ,then the cuboid is frequently displaced1 and occasionally the navicular4 ,the treatment should first of all be directed to correction of the osseous lesions4 ,the arch of the instep may be weakened from the ligamentous strain and be an immediate step in the production of flat foot4 ,teall is of the opinion that lumbar and innominate displacement are common predisposing causes4 ,faulty position of the foot in walking may be an underlying factor4 ,bunions result from a malposition of the joint4 ,morton's disease due to a pinching of the metatarsal nerve will often yield to osteopathic treatment alone4 ,there is generally displacement of the metatarsal bone4 ,a pad worn directly under the painful point will be of benefit4 ,in many of the local neuralgias1 some anatomical displacement will be found as the exciting cause4 ,hammer-toe if not complicated with gout1 rheumatism1 etc41 will yield to treatment if kept at persistently1 otherwise surgical interference will be necessary4 ,likewise various deformities of the foot and resulting neuralgias may be traced to local sprains1 ill-fitting shoes1 or anatomical maladjustments higher up of such a character as to affect the pedal circulation4 ,flat ,foot ,flat foot or weak foot is one of the common disorders that the osteopath is constantly called upon to treat4 ,in the first place the patient should be taught to walk correctly4 ,the feet should be parallel in walking so that the weakened muscles may be developed and strengthened4 ,this will be difficult at first1 but recovery depends upon this important point4 ,in addition to this1 special exercises1 like turning the toes under and tip toe exercises1 should be persisted in for a few minutes two or three times daily4 ,upon the other hand1 do not overdo the exercises but always carry them to a point of fatigue4 ,these two features1 walking correctly and exercising1 are essential complementary measures to the adjusting treatment4 ,in conjunction with the above1 the ,scotch douche at the end of the day will prove of considerable benefit4 ,in the technique work1 first make certain that there are no innominate or spinal lesions that bear upon the circulation and innervation of the feet4 ,then frequently faulty walking is due to these lesions4 ,in recent cases1 simply remolding the arches of the foot will be all that is necessary1 providing correct walking and foot exercising is maintained4 ,but in the more chronic cases considerable adjusting and remolding of the tissues1 bones1 ligaments1 muscles and fascia1 are demanded4 ,perfect apposition between the astragalus and navicular bones1 the highest point of the longitudinal arch1 should be first secured4 ,attention should also be given the other articulating structures down to the metatarsal bones4 ,this reestablishes the arch and overcomes the everted tendency4 ,considerable repeated force is often demanded to release the fibrotic tissues1 but it is the important part of this technique4 ,with the patient on the table1 supine1 place your thumb firmly at the articulation of the navicular and astragalus4 ,then with the other hand around the metatarsals to be used as a lever in extending1 rotating and inverting the foot with the fulcrum at the thumb of the first hand1 spring1 thrust and adjust the arch4 ,this requires considerable strength and exactness of application4 ,the tissues must give freely before the result can be secured4 ,this is often painful to the patient but should be continued and repeated to the furthest point of motion until recovery is complete4 ,treat as often as the condition permits4 ,substituting the crotch of the thumb and forefinger or the knee for the thumb will give added advantage4 ,follow this with thorough springing of the plantar tissues by thumb and fingers4 ,if this is kept up with suitable exercises and correct walking1 and proper shoes 7,munson last71 excellent results will be obtained in the great majority of cases4 ,same pair of shoes should not be worn two days in succession4 ,many times the anterior arch is involved1 jointly or separately4 ,persistent adjusting and remolding of the arch tissues will secure satisfactory results unless the bones are markedly deformed and the weight of the body is relatively too great4 ,in this disorder1 aside from paying special attention to the metatarsal articulations1 the great toe requires a particular technique4 ,for this grasp the toe firmly1 exert traction until the tissue gives slightly and rotate it inward1 toward the median line of the body1 on its longitudinal axis4 ,have the patient frequently turn the toes under1 or attempt to do it until the exercise can be easily accomplished4 ,do not employ arch supporters except in hopeless cases4 ,they simply splint the foot and thus further weaken the foot muscles4 ,if the above methods are persistently followed to the point of actual adjustment1 accompanied by releasing of fibrous tissue and actual strengthening of muscles through exercise1 a very large percentage of cases will recover4 ,in a few cases adhesive strips will be of benefit4 ,the ,shoulder4--,exclusive of muscular and other strains there may be a partial dislocation4 ,in these cases the acromial end of the clavicle is frequently dislocated1 and owing to a general lack of muscular tone may be very hard to keep in place4 ,the lower and inner part of the capsule is often affected1 so that freedom of function is lacking and there is considerable pain4 ,this is due to the thinness of the capsule and the large amount of soft tissue1 so that when the arm hangs at the side the tissue is thrown into folds2 and being very vascular is easily injured1 so that the vascular lymph readily organizes and the part becomes stiff and unyielding4 ,it requires patient1 laborious treatment to break up and absorb this fibrous tissue4 ,then the long tendon of the biceps in some shoulder sprains is dislocated1 but rarely4 ,in shoulder injuries1 examine also1 the upper ribs4 ,the ,elbow4--,the elbow is another complicated joint4 ,one should be careful that there is no fracture1 and in children that there is not epiphysial separation4 ,extending1 flexing1 pronating and supinating the arm will aid much in the diagnosis4 ,examine well the rotation of the radius at the elbow joint1 and be positive that the olecranon process drops normally into its fossa at the end of the humerus4 ,the ,wrist and ,hand4--,the wrist is another joint commonly sprained4 ,here1 also1 care should be taken that a fracture does not exist4 ,colle's fracture is frequent4 ,the bursal and tendon sheaths are usually markedly involved4 ,the scaphoid and semilunar are apt to be displaced2 also1 the os magnum and the unciform4 ,sprains of the fingers are often met with4 ,outside of strains to the muscles1 ligaments1 and other tissues the joint is apt to be somewhat impacted4 ,traction will correct the latter4 ,care should be taken that a fracture is not present4 ,dupuytren's contraction occurs from sprains or injuries1 as the result of contraction of the fascia4 ,the ring and index fingers are members usually affected4 ,in some cases the affection will be found in both hands 7symmetrical71 and a spinal lesion will be the predisposing factor4 ,treatment every day1 by straightening the fingers and stretching the tissue will at least retard the deformity1 but in a number of cases surgery will have to be resorted to4 ,a ganglion or 8weeping sinew0 is a swelling in connection with the tendon sheath4 ,it presents a round1 firm outline1 usually upon the back of the wrist4 ,there is generally found a displacement of one or more of the wrist bones4 ,if treatment of the joint and tendon sheath does not remove the ganglion1 surgery may be utilized4 ,trigger-finger is a rare disorder4 ,there is usually a history of local strain1 which probably resulted in some thickening of the tendon4 ,manipulation and passive motion if continued will generally give relief4 ,fractures ,immobilization and rest have been the paramount points with most physicians in the treatment of fractures and sprains4 ,they have claimed that a sprain should be manipulated but rarely1 much less a fractured bone4 ,rest1 quiet1 and fixation of an injured joint or bone have been rules that should not be violated under any consideration4 ,in cases of sprain the great cry has been to let the joint alone for fear of spreading a possible tubercular infection4 ,it is well to recall ,mumford's statement that if immobilization is too long continued1 should there be a tubercular taint1 proper conditions for a localized tuberculosis is established4 ,and still a word of caution here1 that an osteopath should not be over zealous and should carefully weigh all possible factors1 both local and constitutional1 may not be amiss4 ,in previous tubercular1 syphilitic1 and other diseased states discretion should be employed4 ,reducing rest and immobilization to a minimum means much to the patient1 not only in the loss of valuable time but in annoying and serious after effects4 ,many cases of sprains and fractures come to the osteopath4 ,in sprains that have become chronic through too much rest of the part and improper treatment1 almost invariably there is found displacements of bone and adhesions that should never have existed2 then has followed organized exudates and chronic synovitis4 ,in fractures and even in complete dislocations the osteopath continually observes that too much rest has been given the part1 resulting in unnecessary adhesions1 contractions1 atrophy of muscles1 and impairment of function4 ,treatment almost always cures the condition1 or at least materially relieves4 ,how much better if the proper treatment had been first instituted and thus a large percentage of cases prevented from becoming chronic4 ,of particular interest to the osteopath is the paper prepared by ,eisendrath on 8,early ,massage and ,movements in the ,treatment of ,fractures and ,sprains10 and the discussion that followed before the ,chicago ,medical ,society4 ,the ,illinois ,medical ,journal1 ,december1 #aijc1 contains a report4 ,eisendrath said in part3 8,the former routine of immobilizing all fractures and the adjacent joints for a period of four to six weeks must1 ,i feel1 be subject to slight modification in the light of recent experience1 and it shall be the aim of this paper to show what these changes are4 ,when we are called to a case of fracture1 it should be one's first duty after its reduction to consider how can ,i best aid the patient in recovering the usefulness of his or her limbs8 ,can we shorten the long convalescence with its resultant loss of valuable time and earning capacity8 ,how can we most rapidly restore to the limb its normal joint functions and prevent an atrophy of muscles and an ankylosis which will require many months to overcome8444 8,the use of massage and of active and passive movements in the treatment of fractures and of severe sprains has been gradually gaining in the number of its advocates through the writings of ,lucas-,championniere of ,paris4 ,we owe him a great debt for calling the attention of the profession to the employment of these methods in order to prevent atrophy and ankylosis as well as to promote healing4444 8,before taking up my subject in detail permit me to recall a few salient points in the surgical pathology of fracture4 ,soon after the injury the blood clot around and between the ends of the fragments is absorbed and replaced by a jelly-like mass of young connective tissue cells called the callus4 ,it corresponds to the solder which the plumber places over the ends of two pipes he desires to join4 ,bone begins to form at the periphery of the callus about the tenth day and advances toward the center rapidly1 forming a ring of bone around the ends of the fragments so that by the end of the third week there is but slight abnormal motion at the point of fracture 7exception to this is the femur74 ,this entirely disappears by the end of the fourth week1 especially in young people1 and the union is firm4 ,in the case of the femur it requires six or eight weeks4 ,the greater the displacement of the ends of the fragment1 the larger the callus and the slower the healing of the fracture4 8,during these changes 7callus formation7 the muscles which supply the immobilized joints atrophy and the circulation in the skin and neighboring tissues is sluggish1 resulting in swelling1 etc41 of the limb4 ,the enforced rest causes more or less fluid to accumulate in the tendon sheaths and joints4 ,this becomes organized and results in fibrous ankylosis of the joints and great impediment to the free action of the tendons within their sheaths4 ,it is this atrophy1 fibrous ankylosis and tenovaginitis which interfere with the restoration of the normal functions of the limb4444 8,can we decrease the amount of wasting of muscles and control the stiffness of joints and tendons after fractures8 8,it is the belief of the writer1 based on a large experience1 that the earlier use of massage1 active and passive motions1 will to a great extent eliminate the above conditions1 which retard convalescence and in some cases cause permanent disability4 8,massage of an injured limb increases the amount of blood supplied to it1 promotes the absorption of the swelling and prevents atrophy of muscles4 ,in the case of a joint injury the exudate rapidly disappears and the articular surfaces can be again approximated so that movement is facilitated4 ,by the cautious use of active and passive movements1 either with or without the aid of apparatus1 the normal functions of a joint can be rapidly restored4444 8,the active and passive movements of the limbs can be carried out immediately after the massage1 but should only be permitted for a period of five minutes at first and the time then gradually increased4 ,when a severe sprain1 say the elbow or ankle1 is first massaged1 the pain seems to be almost unbearable1 but this discomfort as well as the swelling rapidly disappears1 and it is surprising to those who have never applied this treatment how quickly the normal function of the joint reappears4 ,the same applies to the synovitis which accompanies fractures in close proximity or even into joints40 ,the relief given these cases by massage1 movements and manipulations by the osteopath is a daily experience1 and results to him are not surprising4 ,then in addition to what the surgeon would do1 the osteopath applies his principles of careful detail readjustment4 ,eisendrath continues his paper by referring to the principal varieties of fractures and giving the treatment for each4 ,he says that if correct treatment is carried out with proper massage and movements in fractures of one or both bones of the leg1 the patient will be at work in six or seven weeks instead of three or four months1 that in ,colle's fracture some surgeons do not employ a splint1 and that in fractures of the olecranon1 massage from the first week on is of the greatest use4 ,this part is very interesting but space forbids giving it4 ,he then concludes his article with citation of several very interesting cases of fractures and severe sprains4 ,these cases are exceptionally interesting to the osteopath1 but still the same good treatment and results are duplicated every day in the osteopathic school4 ,the doctor's contraindications to the use of early massage in fractures or sprains are the following3 8#a4 ,tendency to displacement of fragments in oblique fractures4 ,under such conditions it is best not to begin either massage or movements until the union is firm 7fourth to fifth week74 8#b4 ,in compound fractures until the wound is healed4 8#c4 ,whenever the condition of the skin is such as to permit of infection2 for example1 the presence of blebs1 or extensive abrasions4 8#d4 ,the presence of fragments which project but do not penetrate the skin40 ,his conclusions are3 8#a4 ,massage1 active and passive motions prevent atrophy of muscles1 tenovaginitis and ankylosis so frequently accompanying and following fractures1 especially those close to the shoulder1 elbow1 wrist1 knee and ankle joints4 8#b4 ,they give far better results than complete immobilization in the majority of fractures40 ,in the discussion that followed ,henrotin said that for some time1 8,i have never put a restraining apparatus of any kind1 nor have ,i used any lotions on any sprain1 no matter how severe4444 8,it has taken many years to bring this subject before the profession4 ,it is a method that is absolutely effective as regards sprains and some forms of fractures4 ,i have treated several hundred such cases with the greatest success40 ,he also said that1 8,in treating an inflamed joint it is improper to use a restraining apparatus of any kind4 ,i consider that the plaster cast is the bane of all inflamed joints unless there is a specific form of infection1 a traumatic condition40 ,neither does he believe that an inflamed joint should be put at rest4 ,he says the patient is a good judge as to the amount of quiet the joint needs4 ,he has treated ,colle's fractures and fractured clavicles without bandages or apparatus4 ,to sum up1 the osteopathic procedure in the treatment of fractures would be as follows3 #a4 ,immobilization in those cases especially demanding it1 from the character of the fracture1 until formation assures solid and firm union4 #b4 ,manipulation and massage and movements of parts at an early period1 compatible with the above1 to render soft tissues pliable1 to remove stiffness and adhesions1 to restore a normal circulation1 and to exercise and function the parts4 #c4 ,in cases of laceration of soft tissues1 abrasions1 etc41 great care should be taken so as not to infect the parts4 #d4 ,great care should be taken where fracture is compound1 and where fragments exist4 #e4 ,in all cases1 both acute and chronic1 critically examine for slight anatomical deviations locally and remotely4 ,in dislocations the fundamentals of the above are applicable4 ,do not let chronic stiffness1 or rigidity1 adhesions1 or synovitis supervene if possible to prevent4 ,an important consideration in all cases of sprains1 fractures1 and dislocations that become chronic is the probable effect upon dependent tissues by way of nerve impairment and vascular obstruction2 for examples1 the sprained back may readily impair organic life1 the fractured elbow prevent use of the arm1 the injured leg predispose to flat foot4 7,see ,j4 ,b4 ,littlejohn--,osteopathic ,surgery1 including ,treatment of ,fractures1 ,journal of the ,american ,osteopathic ,association1 ,nov41 #aije47 ,,footnotes3 #da ,see also ,jones' latest work1 ,injuries to ,joints4 #db ,see also ,wharton ,hood1 ,sprains and ,fractures4 ,,postural ,,defects ,a postural defect is any abnormal position1 congenital or acquired1 of the body1 assumed in sitting1 standing or walking4 ,this leads to a symmetrical development1 causes structural changes1 and as a sequel1 disturbance of function and organic life results4 ,defects in posture are of very common occurrence4 ,a perfect posture1 in fact1 is somewhat rare4 ,considerable is being accomplished1 especially of late years1 by the laity through various physical methods and exercises to correct the many defects of position in sitting1 standing and walking4 ,the originators of the many so-termed systems of exercises have gone so far as to even advertise to cure various diseases of the body as well as attempting to improve the normal tissues and structure4 ,exercises1 undoubtedly1 have their place1 particularly in the life of those of sedentary habits4 ,most of us do not exercise enough1 neither do we as a rule get enough fresh air and pure water4 ,but there are many defects of the anatomical that mere gymnastics can not adjust4 ,and there are still other defects that gymnastics may decidedly aggravate4 ,in these cases the mechanism of the body has become so deranged and disturbed that nothing short of actual readjustment can be effective4 ,in the consideration of postural defects there are a few points that should be particularly emphasized4 ,first1 these defects may not only be the result of laziness or carelessness1 but of more frequent occurrence is some previous strain or injury to the spinal column or other parts of the body framework4 ,some defect of position or symmetry of the body may easily follow as a result4 ,here gymnastic work may reduce the defect to a minimum1 but rarely can the compensatory forces of nature entirely obliterate the structural disorder1 unless assisted by actual1 specific readjustment4 ,second1 in the examination and treatment of the patient due attention should be given the symmetry and figure of the body as a whole so that relation of the part to the whole and vice versa may be rightly proportioned4 ,remember that the spinal column is only one part of the body outline1 thus one should consider the transverse section of the body in relation to the spinal column and not the spinal column alone4 ,in a word1 correction of postural defects implies both structural rearrangement and molding of the contour4 ,do not make the mistake1 for example1 when correcting a deformity that involves the chest1 of paying attention to the spine alone1 but take into consideration the thorax as a whole of which the spine is only a part4 ,round ,shoulders ,round ,shoulders are a defective posture with which everyone is familiar4 ,how many children have escaped the parents' criticism to sit1 stand1 and walk erect8 ,and not a few of the afflicted have not succeeded after persistently doing their best4 ,round shoulders or stoop shoulders are commonly attributed to indifference4 ,probably a few cases are due simply to laziness and indifference1 and others may be carelessness1 and usually when they arrive at an age where pride of their physical demeanor and powers enters as a life factor1 the child soon overcomes the postural weakness4 ,with still others the correct1 persistent physical training1 as exemplified in military schools1 will readjust the defect4 ,but there is a class1 and by far the largest1 where round shoulders are a very real and active weakness of the physical body4 ,and the weakness is not primarily in the shoulders as nearly everyone thinks4 ,the stoop is a result4 ,the origin is in the lower dorsal spinal column4 ,here will be found a posterior curvature that involves nearly the entire dorsal and lumbar areas4 ,this is the real1 the original cause of the larger number of round shoulders4 ,this backward curve of the spinal column1 instead of the forward curve as it should normally be at the waist1 obliterates the brace or truss of the spinal column that is so essential in maintaining an erect posture of the shoulders4 ,it allows the individual to 8fall into his stomach10 to drop the shoulders1 and as a consequence the chest cavity is depressed4 ,the spine is one continuous backward bow1 and when he does try to sit straight1 and it is always with a constant effort1 the normal1 the physiological curves of the spine are not apparent4 ,first1 then1 there is a spinal weakness in the region of the innervation to the digestive organs4 ,indigestion of various forms is a common accompaniment4 ,second1 there is lessened lung and heart capacity4 ,the ribs are depressed1 interfering with perfect aeration and elimination on the part of the lungs and with normal activity and tone of the heart muscles4 ,phthisis is predisposed4 ,is it any wonder the child's blood is impoverished and anemia results from the insufficient aeration and poor digestion and assimilation8 ,costogenic anemia may also be a result4 ,and1 third1 the shoulders are 8round0 from the spinal weakness and flattened chest1 really an effect2 but while the most noticeable1 it is the least serious4 ,it is evident from careful observation and study of these cases that the treatment resolves itself into the treatment of a posterior spinal curvature4 ,shoulder braces1 steel braces and jackets1 and casts have very little place1 if any1 although there may be diseased bone of such character and severity that a cast will be necessary2 this1 however1 would refer to treatment of ,pott's disease and similar conditions4 ,hence1 the treatment is1 first to replace and readjust the malaligned vertebr4 ,there must be an actual physical manipulation in order to correct the vertebr at fault4 ,this is the essential1 and by far the primal1 treatment for the key to the truss or brace that holds and retains the body in an erect position is then replaced4 ,second1 raising the depressed ribs4 ,remember the depressed ribs are dependent upon the spinal condition4 ,the thorax should be treated as a comprehensive whole1 not the spinal column alone4 ,third1 exercises are a valuable aid4 ,the individual's part is as necessary1 in a way1 as the physician's1 for in order to accomplish the maximum there should be consistent and appreciative work on the part of the patient4 ,holding the shoulders back1 the head erect and the chin in1 drawing the abdomen in and up1 all with deep breathing by the use of the chest muscles1 the patient will be able to retain the correction obtained during treatments4 8,setting up0 exercises are helpful4 ,developing the muscles of forced expiration is excellent4 ,thus the patient must be conscious of the work required of him and act in concert with the physician4 ,minute instruction on the requirements of each case is demanded4 ,good food1 pure water1 and fresh air are necessary1 particularly in the anemic4 ,right living and correct environment are always in order4 ,painful ,shoulders ,under this heading may come a variety of conditions affecting one or both shoulders causing much distress and1 at times1 total disability4 ,the conditions may be the result of direct injury to the joint1 systemic1 or from spinal lesions4 ,anatomically the shoulder offers frequent opportunity to injury as it has the greatest range of motion of any joint1 is least secure in its articulation1 and is most vulnerable from location4 ,once the shoulder has been dislocated it is rarely back to normal functioning again as this injury tears the capsular ligament and stretches the structures in relation4 ,many times there is only a subluxation in which the head of the humerus is driven upwards in the fossa1 usually from a fall or blow on the point of the elbow4 ,as a rule1 after such an accident1 the only thing done is to rest the joint and apply a liniment and1 after a time1 begin the use of the arm4 ,it is1 however1 painful and to save himself1 the patient each time restricts movement until he reaches a point where he is unable to dress without assistance4 ,it is then found that normal motion is reduced fully one-half and even this will be accompanied by pain on movement and in bed4 ,a radiograph will1 usually1 show the condition4 ,articular crepitus and fibrous adhesions are present while the adjoining structures have undergone changes so that a reduction is impossible without certain preparation4 ,very often a trivial cause will disable a joint2 a sudden movement which finds the muscles about the shoulder unprepared and the resulting lesion is so slight as to1 often1 defy detection4 ,at first there will be swelling and pain but1 in time1 it settles down to a limited motion with more or less distress4 ,bursitis4--,this is a condition in which the subdeltoid bursa is involved or where there have been a number of burs formed from overuse of the joint4 ,one authority reports as many as twenty-five in a shoulder4 ,there may be1 also1 tenosynovitis primarily or from extension4 ,these conditions may not be easily diagnosed at first4 ,brachial neuritis 7chronic7 beginning with or without an acute attack is usually from a cervical lesion involving the brachial plexus but most frequently it is the #eth and #fth cervicals at the origin of the circumflex nerve4 ,from this the deltoid is particularly affected and its contraction leads to pressure on the nerve and subsequent partial or complete paralysis4 ,brachial neuritis is found in an increasing number of osteopathic practicians and is the result of overwork of the arms and to strain of the upper dorsals and lower cervicals4 ,there are contractions of structures about the joint constantly limiting motion and pain when a strain is put on them4 ,many methods for the treatment of the conditions described have been employed1 all involving the same principle but none of them systematized4 ,c4 ,h4 ,spencer has worked out a technique which1 while originally intended for bursitis1 has been found well adapted to all conditions described4 ,it gives a stretching of all structures and gradually breaks up adhesions1 both in the joint and in the tendon sheaths1 so there is no resulting irritation which could easily result if suddenly done4 ,his technique is#dc3 8,first3 ,the patient on the side1 the affected shoulder up2 operator facing the patient1 places one hand on the top of the shoulder1 does nothing more than fixing it2 with the hand grasping the forearm above the wrist1 push the elbow backward1 the arm parallel to and almost in contact with the body1 then pull forward in the same plane4 ,second3 ,elevate the elbow with the hands of the operator in the same position as before1 carry the elbow in as wide a circle as possible4 ,third3 ,with the hands still in the same position1 extend the forearm with traction2 carry it as high in front of the patient as possible4 ,the foregoing are designed to relieve the congestion about the shoulder1 bring pressure to bear on the subdeltoid bursa and moderate traction on the supraspinatus1 infraspinatus1 subscapularis1 teres minor and major1 latissimus dorsi and the tendon of the biceps4 ,these manipulations will be all that is possible in the more aggravated cases for some considerable period of time4 ,as the tenderness subsides1 the second group may be cautiously started1 the hands in the same position as above noted1 with the arm extended as nearly as possible at right angles with the body1 carry the arm in as wide a circle as the pain will permit4 ,again1 with the arm flexed at the elbow1 one hand of the operator on the point of the shoulder and the forearm of the patient across the forearm of the operator1 the other hand of the operator resting on the point of the patient's elbow1 push down toward the middle line of the body and carry the elbow toward the head4 ,then flex the arm and place the back of the hand behind the patient1 flexing the shoulder in front with one hand grasping the point of the elbow and pull forward4 ,this group of movements accomplishes with greater force the same ends obtained in the previous1 and the first in this group is the most effective in overcoming swelling of the subdeltoid bursa4 ,direct manipulation of the muscle masses and this bursa is desirable from the first40 ,it will be noticed in all these movements that the joint is protected by one hand of the operator while the other is grasping the arm of the patient4 ,this is desirable as it makes the technique absolutely safe4 ,an additional treatment will be found very effective1 especially where the deltoid is involved4 ,with the patient on the well side1 facing the operator1 locate the quadrilateral space which is bounded by the subscapularis above1 the teres minor below and the long head of the biceps medially and the surgical neck of the humerus externally1 and the circumflex nerve can be easily palpated along with the artery4 ,if these structures are stretched and the deltoid lifted from the shoulder it will be found to free the action of both nerve and artery1 one supplying the joint with nutrition and the other innervating it4 ,certain conditions for which these movements are contraindicated arise and the following differential points by ,h4 ,glasscock are well to remember#dd3 8,rheumatism3 ,fever in the joint1 with redness1 swelling and other joints involved4 ,tuberculosis3 ,daily temperature and other tubercular foci4 ,neuritis3 ,pain in the neck and shoulder muscles1 also near insertion of deltoid and in the forearm1 particularly musculo spiral4 ,pain worse at night4 ,no pain on movement4 ,no swelling4 ,bursitis3 ,no pain in neck4 ,pain in anterior and posterior part of joint and on motion4 ,pain near insertion of deltoid4 ,arm held close to the body1 motionless4 ,infection3 ,chill1 limited motion1 severe pain with temperature4 ,dislocation3 ,deformity with preternatural mobility4 ,dislocation of acromio-clavicular joint3 ,tenderness over articulation4 ,arm cannot be raised beyond right angle with the body1 but elbow may be brought across the chest with external rotation of arm and raised perpendicular with the body without pain40 ,the infected joint should never be manipulated and all conditions showing swelling1 redness and pain on touch should be viewed with suspicion4 ,remember that all other conditions will almost invariably have vertebral lesions1 primary or secondary and a permanent result will depend upon their correction4 ,the ,prominent ,hip ,a hip that is prominent and larger than its fellow is of frequent occurrence4 ,it may not be necessarily conducive to a defect in posture1 but it often is4 ,the female is more frequently afflicted with this anatomical irregularity than the male4 ,in the first place1 the female pelvis is not so stable and rugged as the male pelvis1 i4 e41 a mechanical wrench or fall will more easily displace the relative position of the tissues in the female4 ,then1 in the second place1 the dress of the woman accentuates irregularities of the figure1 so that possibly in some instances the defect1 from a diseased or deformed point of view1 is more apparent than real4 ,but of still more importance is the fact that many cases of a prominent hip are due to a lateral curvature of the lumbar spinal column4 ,lumbar curvatures are of common occurrence in the woman2 first1 the spinal column is not so strong as in man1 simply on account of the physique not being so robust2 second1 modern dress constricts the waist by the use of corsets and many waist bands1 and the weight of heavy skirts upon the waist1 hips and abdomen2 and1 third1 severe strains from childbirth4 ,care should be taken that there is no congenital abnormalities of the lumbar spine1 or that congenital asymmetry of one-half of body1 or trunk or leg is not present4 ,thus the principal cause of a prominent hip is the lateral lumbar curvature4 ,this1 through compensatory action1 renders the hip on the concave side prominent and high1 while the hip on the convex side is depressed and less pronounced in appearance4 ,dressmakers and tailors are all too familiar with this feature of the irregularly outlined figure1 and1 consequently1 have to resort to 8padding0 to round out the symmetry of the body4 ,the mere irregularity of the figure1 unfortunately1 is by far the less serious part of the defect4 ,many ailments and diseases can be readily and directly traced to this4 ,not that the prominent hip itself necessarily always plays a leading part1 but rather the lumbar curvature is the cause of very much suffering and misery4 ,to enumerate the many disorders that arise from malaligned lumbar vertebr may be unnecessary but a few will be given4 ,a point to be emphasized is that the prominent hip often plays the role of a sign or symptom1 or an effect1 that an ailment or disease may be elsewhere4 ,in the female one of the most common causes1 if not the most common cause by far1 of disorders of menstruation1 whether painful1 profuse1 or irregular1 is irritation or obstruction of the lumbar spinal nerves due to lumbar curvatures4 ,it is well known the lumbar spinal nerves control1 to a large extent1 the pelvic organs2 consequently the osteopath pays particular attention to this area4 ,then certain intestinal disorders1 such as appendicitis1 typhoid fever1 dysentery1 rectal diseases1 owe their origin to predisposing lesions here2 also1 bladder ailments1 and sexual diseases of men1 and many affections of the legs1 as sciatica1 varicose veins1 etc4 ,in a number of instances the prominent hip will be due to a displaced innominatum4 ,then a lumbar curvature will result as a compensatory condition4 ,this reverses the compensatory act as heretofore referred to2 the prominent hip1 in this instance1 is the cause and not the effect4 ,to diagnose which is cause and which is effect will frequently require considerable technical knowledge and experience4 ,the slipped innominatum then produces symptoms and disorders directly from its changed anatomical relations2 the points of diagnosis are given in the chapter on ,diagnosis4 ,the prominent hip can easily be detected when the subject sits down upon an even1 firm surface1 or stands up1 and the one side is compared with the other4 ,in some cases where the prominent hip is due to a lumbar curvature1 and the prominence is a secondary feature1 the legs will be found uneven in length1 but not always1 for the lumbar curvature may straighten out when the patient lies flat upon the back4 ,to diagnose the cause from effect and to differentiate the maze of signs and symptoms that may be present is not always easy even for the skilled practitioner4 ,the correction of a prominent hip is not ordinarily a difficult matter4 ,in the cases where lumbar vertebr are principally at fault1 and these include the greater number1 the problem is one of correcting the spinal curvature4 ,lumbar curvatures are the easiest of any of the curvatures to correct1 for one is not hampered by the rib articulations1 and the lumbar section presents an area where a leverage can readily be obtained4 ,where the innominatum is primarily at fault it is simply a matter of readjusting this1 with probably some attention to the lumbar region4 ,care should be taken that the prominent hip is not caused by a tubercular sacro-iliac disease1 by hip-joint disease1 by a dislocated hip1 or by an overlapping of thigh or leg bones from fracture4 ,standing erect will1 of course1 be a valuable help1 for standing with the weight on one foot will tend to make the hip on that side more prominent4 ,but generally the reason why one favors a certain side is because the other side is weaker2 a weak back1 a slipped innominatum1 or an injured leg are common causes4 ,there are many cases where the skirts will have to be considerably altered after the hips have been made symmetrical4 ,pendulous ,abdomen ,the pendulous abdomen is another defect that is all too common4 ,a great many people have prominent abdomens because they do not stand properly1 but a pendulous or prominent abdomen is not necessarily synonymous with a stout abdomen4 ,they attempt to stand erect by drawing the shoulders back and extending the abdomen4 ,if they would hold the head erect and the chin in1 with the shoulders back and the chest forward1 and draw the abdomen inward and upward1 their figures and physiques would undergo shortly a wonderful transformation4 ,these directions also apply to pregnant women4 ,drawing the abdomen upward and inward will at first require considerable effort4 ,it certainly will not be an involuntary act for the first few days4 ,the sagging of the abdomen not only causes an unsightly appearance but results in great relaxation of the abdominal muscles1 interferes with digestive functions1 displaces the pelvic organs1 and weakens the action of the lungs and heart4 ,the laxity of the abdominal muscles allows the abdominal organs--the intestines1 stomach1 kidneys1 etc4--to displace downward4 ,this tends to indigestion1 constipation1 inactivity of the liver1 etc41 and causes a score of reflex symptoms4 ,the organs become simply weakened from a lack of proper tone4 ,this is a frequent cause of nervous prostration4 ,also it is one of the common causes of prolapsed and displaced pelvic organs1 because the abdominal organs sag down upon them and the pelvic organs thus receive the brunt of the gravitative effect4 ,internal local treatment of the pelvic organs can only be a makeshift in these cases4 ,the lungs and heart are weakened because the abdominal organs are dragging on the chest1 the lungs can not aerate the blood freely owing to the abdominal weight and to the blood being obstructed in passing from the abdominal organs through the liver to the heart and lungs4 ,the heart is handicapped in its work through lessened chest capacity and obstructed circulation4 ,just 8suck0 up the abdominal organs and see how much easier it is to expand the chest and to breathe4 ,there are other causes for a pendulous abdomen1 such as a weakened spinal nerve supply to the abdominal muscles and organs4 ,the weakened nerve supply may cause a loss of tone to the abdominal organs themselves1 so that certain organs1 as the stomach and intestines1 become dilated and prolapsed2 to the ligaments1 and to the tissues and organs as a whole so that they become gravitated4 ,through childbirth muscular fibres of the abdominal walls often rupture1 leaving scars and a relaxed condition4 ,actual ruptures1 hernia1 of the abdominal muscles occur and cause a pendulous abdomen4 ,then there are cases of obesity where the pendulous abdomen is a symptom4 ,much can be done with all of these conditions through osteopathic work2 the patient must also help himself4 ,the center of gravity of the body must be changed1 and kept changed2 correct posture and a constant effort will accomplish considerable4 ,the 8setting up0 military exercises are excellent4 ,even in some cases of obesity the abdominal prominence can be markedly lessened by careful exercising and keeping the abdomen drawn in so that the abdominal muscles1 the diaphragm1 and the chest may be strengthened4 ,for the relaxed1 flabby abdomen1 self manipulation of the weak muscles when lying on the back will materially aid4 ,postural ,curvatures of the ,spinal ,column ,undoubtedly1 the great percentage of postural defects1 or slumped states1 are dependent1 directly or indirectly1 upon weaknesses in the spinal column4 ,as was seen1 round shoulders1 the prominent hip1 or the pendulous abdomen1 are often initiated by spinal deviations and deformities1 so naturally spinal column curvatures are a most fruitful source of direct defects of posture4 ,it is somewhat uncommon to find an anatomically true spinal column1 although this does not preclude that one's posture is defective1 for often through pride and effort one may consciously overcome a defective posture4 ,it is the purpose here to offer a few suggestions relative to the development of a greater symmetry of the body4 ,nearly every one is more or less interested in physical exercises and development4 ,and especially to those of sedentary habits do means and methods of exercise appeal4 ,curiously enough1 in a way1 nearly every layman looks upon defects in posture1 symmetry and stature as an effect arising from lack of1 or improper1 exercise4 ,he seems to be imbued with the idea that the body in most instances is practically permanent in construction and when irregularities in figure occur certain exercises will correct the defect4 ,thus have individuals been prone to look upon osteopathy as a method of passive exercises4 ,osteopaths should believe most thoroughly in exercising1 personal hygiene1 etc41 but the idea of osteopathic manipulation is primarily one of anatomical reconstruction1 and not muscular development alone4 ,the work of the osteopath is to readjust or to re-mold the body framework and the many tissues that clothe it so that normality of function may predominate4 ,the manipulation is not routinism but mechanical rebuilding of the tissues so that perfect freedom of vital forces may be forthcoming4 ,the spinal column presents the most frequent as well as many extremely interesting phases for re-correcting work4 ,the number of abnormalities as to contour to which it is subject are many and varied4 ,emphasis should be placed upon possible congenital abnormalities and developmental defects as sources of certain derangements4 ,any variation or combination of variations with the normal or physiological curves constitutes an abnormality or pathological curve4 ,and as a consequence defective posture1 unless thoroughly compensated1 is readily initiated4 ,not only may the normal curves be exaggerated1 lessened1 eliminated or reversed1 but lateral and rotary curvatures are of frequent occurrence4 ,curvatures involving the cervical region to the extent of producing noticeable defects of posture are principally lateral deviations of several vertebr4 ,wry-neck is probably the most noticeable disturbance4 ,the head and neck being drawn and slightly twisted to one side is a defect that is both noticeable and painful4 ,another common source of postural affection is an exaggerated forward curving of the neck vertebr4 ,this produces a stooped appearance of the neck4 ,the dorsal vertebr are often curved backward too far4 ,this produces roundness with too decided a fullness of the upper back and shoulders4 ,the chest may be somewhat flattened as a secondary effect but not necessarily so4 ,neither are the shoulders what may be termed 8round shoulders10 still such a condition may occur1 for 8round shoulders0 are more often caused by a backward swerve of the column at the waist line4 ,there is often a shortening of the anterior structures which pull the point of the shoulders forward4 ,forcing them backward will aid in correcting the fault4 ,the dorsal vertebr may be forward from what is termed a 8straight0 spine2 this results in an exaggerated 8braced0 back position4 ,then lateral curvatures of the dorsal spine are common1 which in time may develop into a rotary curvature2 that is1 the vertebr are actually rotated on their axes4 ,lateral curvatures of the dorsal spine are slow and difficult to correct1 for the ribs complicate matters very materially4 ,then1 also1 the vertebr are apt to be deformed4 ,curvatures of the lumbar spine1 whether posterior1 lateral or anterior1 are common4 ,both dorsal and lumbar curvatures1 as any one can readily see1 are extremely common sources of postural defects4 ,erect positions of the body are maintained through the support of the dorsal and lumbar vertebr4 ,stooped shoulders1 one shoulder lower than its fellow1 sitting humped over1 sitting on the sacrum instead of squarely on the buttocks1 the prominent hip1 standing first on one foot and then on the other in order to rest the back1 and the many allied variations of incorrect postures are largely dependent on the condition of the lumbar and dorsal spines4 ,it is not to be supposed that the above defects are the only ailments and disturbances that spinal curvatures cause1 for1 indeed1 the defective posture may be by far a minor consideration4 ,disorders of body functions and affection of organic life itself are very often traced to the malaligned vertebr4 ,the causes of spinal curvatures are many1 but without question one of the most common causes is mechanical wrenching or twisting of the column from falls1 jars1 etc4 ,often the strain or sprain of the sections are readjusted through the inherent powers of the body1 but there is a point where vis medicatrix naturae requires extraneous help to correct the perversion2 and1 naturally1 such aid1 by virtue of the cause of the disturbance1 should be physical force mechanically applied4 ,other causes of spinal curvatures are contractions of muscles on one side of the column or paralysis of the muscles on one side2 in either instance1 muscular action is greater on one side than the other1 which easily results in a curvature4 ,this imbalance of muscular tension1 whether due to the above or other sources such as overfatigue or various deleterious habits1 is a prolific source of lesions4 ,and among still other causes may be noted1 bone diseases of the spinal column1 compensatory deformities1 and constitutional weakening and irritating diseases4 ,also1 some occupations predispose to certain curvatures4 ,one can readily see that the treatment which is directed specifically to the cause of the vertebral deviation would be the most scientific4 ,this is just what osteopathic work implies1 direct readjustment of the sections at fault--not exercises1 or routine stretching1 or braces2 although these latter methods may in some cases have their place as secondary aids4 ,of course exercises are usually physiological and may be employed1 in many instances1 as an auxiliary4 ,care should be taken to eradicate infectious foci when present4 ,where curvatures are extreme1 complicating and deforming the ribs1 and absorbing the bodies of the vertebr so they become wedge-shaped1 and resulting from abscesses1 no one can expect within reason to absolutely correct the posture4 ,some aggressive work can be accomplished1 but a perfect symmetry will not be forthcoming4 ,it may be well to emphasize again that where the ribs are involved the osteopath is not contending with the deformity of the spinal column alone1 but in addition the entire transverse area of the body4 7,see also ,spinal ,curvatures74 ,conclusion4--,in concluding this rapid survey of a number of postural defects the principal lesson to be drawn is not one of developing the physique and thus perfecting a better posture1 so much as curtailing and eliminating insidious beginnings of disease4 ,these little ailments and deformities1 of which postural defects may be the most noticeable1 are so often the inception of more serious disorders4 ,the anatomical structure being maladjusted1 -aligned1 or -positioned1 easily and readily leads to consequences that require much time and patience to overcome4 ,poise of body represents much to every one4 ,poise or correct posture coupled with careful and methodical exercise and correct breathing are material aids in constructive development1 as well as in eliminating disease1 for not alone may abdominal1 pelvic and thoracic integrity be benefited1 but the upper respiratory tract may be toned4 ,the most important goal that osteopathic science and art is striving for is that of a fully developed and rounded out prophylaxis or preventive treatment4 ,when the public realizes that the proverbial ounce of prevention is an established medical reality then it can truly be said our science has reached its ultimate good4 ,to those who are familiar with osteopathic theory1 facts1 and development1 it is an open secret that this school holds the key to successful preventive treatment4 ,the time is rapidly approaching when the actual lessening of diseases will be an established fact4 ,then will be the universal practice of the layman going periodically to his osteopath to see if there are any small or insidious beginnings of disorder or disease4 ,not only must the many deleterious habits and errors of the daily regimen be corrected1 but after environmental1 physiological and structural adjustment1 in so far as possible1 has been attained1 a daily regimen to maintain the normal should be instituted4 ,,footnotes3 #dc ,journal ,american ,osteopathic ,association1 ,jan4 #aiaf4 #dd ,osteopathic ,physician1 ,nov4 #aiai4 ,,prolapsed ,,organs ,prolapse of various organs or tissues are among the very common ailments that afflict all classes4 ,prolapse of the stomach1 a kidney1 the uterus1 or the rectum is a familiar term to every one4 ,but this condition may also rest with the intestines1 the liver1 an ovary1 or even the heart4 ,outside of injuries1 congenital weaknesses1 and so-termed surgical disorders1 there are commonly two constant forces predisposing to prolapsed organs1 viz3 gravitation and weakened innervation2 the one1 of course1 is a constant factor in either health or ill health1 the other is dependent upon acquirement4 ,here the latter1 or acquired nervous weakness1 will especially demand our attention4 ,where tissues are torn or lacerated1 or congenital malformations are present1 or tissues are weakened from ulceration and with a resultant scar tissue1 or certain tumors are present1 the disorder must be amenable largely to surgical measures if at all4 ,the perpendicular position of the body favors a decided gravitation of the abdominal and pelvic organs4 ,this gravitative effect being a constant one1 many methods1 both surgical and mechanical1 have been devised to hold in approximate and relative position certain organs and tissues that may be prolapsed4 ,but it is well known that outside of a certain few instances where surgical measures are clearly indicated the prevalent use of braces1 bandages1 supports and the like are usually poor makeshifts4 ,the one great feature in these cases is that tonicity to organs and supporting muscles and tissues is more or less impaired4 ,the tissue atony may vary from mere weakness to actual tearing and separating of the fibres4 ,the indications in the cases about to be described are to stimulate a lowered nerve supply and to increase a lessened blood supply2 if this can be accomplished1 supporting muscles1 ligaments and other tissues will be able to restore the prolapsed organs to normal positions1 thus improving functions and eliminating disease symptoms4 ,in discussing the prolapse of the following organs1 perhaps it should be noted here that all of the abdominal organs may be prolapsed as a whole4 ,the intestines1 stomach1 liver1 kidneys1 etc41 may actually prolapse together4 ,this is more apt to occur in persons whose abdominal walls are thin and flabby4 ,in women pregnancy is a common cause4 ,when the abdominal organs have gravitated1 the pelvic organs1 also1 are very likely to be disturbed and displaced2 in fact1 the pelvic organs are frequently disordered this way4 ,prolapse and ,dilatation of the ,stomach ,dilatation of the stomach is a much more common and serious affection than prolapse of the stomach1 although usually the two are associated4 ,prolapse1 or ptosis1 of the stomach means simply a downward displacement of the organ4 ,this is apt to take place in those cases where all of the abdominal organs have gravitated4 ,there is invariably some dilatation of the organ as well4 ,weakness of the abdominal walls and of the supports of the stomach constitute the principal causes of the prolapse4 ,spinal deviations that impinge or obstruct the nerve strands 7or obstruct the blood and lymph supply to these strands7 to the supporting stomach tissues is the most frequent cause of the ailment4 ,general debilitating diseases1 as anemia1 cancer1 etc41 are indirect causes of weakened organs with consequent displacements4 ,in dilatation of the stomach the condition may be either acute or chronic4 ,the former is found where immense amounts of food or drink have been introduced4 ,one of the principal causes of chronic dilatation is some obstruction to the opening from the stomach into the intestine1 so that the stomach contents do not pass readily into the bowel4 ,this leads to chronic disturbances of the stomach walls1 and the food remaining in the stomach somewhat indefinitely weights down and stretches the walls of the stomach4 ,the obstruction may be a tumor1 or some stricture or adhesion from scar tissue resulting from ulceration or inflammation4 ,the treatment of these cases comes within the province of surgical interference rather than other methods4 ,the second important cause of chronic dilatation is muscular weakness of the walls from poor nerve supply4 ,this is a common cause and osteopathy is very successful in curing these cases4 ,the splanchnic nerves are below normal1 usually from a slight lateral or posterior spinal curvature4 ,the nerve force to the walls of the stomach not being normal causes atony of the muscles and dilatation results4 ,this nervo-muscular atony1 also1 results from a chronic catarrh1 or from a general nutritional disorder as tuberculosis or anemia4 ,the treatment of the former would imply direct correction of nerve and blood supply with attention to diet2 the latter can be cured only through relieving the nutritional disorder of which the stomach condition is a symptom4 ,dilatation of the stomach is most common in people of middle age or older4 ,the disease is usually easily diagnosed4 ,the symptoms may not be indicative of the trouble beyond showing that the stomach is disturbed4 ,indigestion1 uneasiness1 and nausea are common4 ,vomiting of large quantities of material from the stomach is likely to occur4 ,the patient is generally emaciated1 the skin is dry1 the bowels constipated1 and the urine scanty4 ,the diagnosis1 as a rule1 is not hard to make4 ,through the media of inspection1 palpation and percussion1 the careful osteopath will have little trouble to determine the size of the stomach4 ,kemp's#de distinction between gastroptosia and dilatation of the stomach is as follows3 8,in dilatation the lesser curvature retains its relation to the diaphragm4 ,the distance between the lesser and the greater curvature is increased1 but the lesser curvature still maintains its relation to the diaphragm1 with the exception that the pyloric end may extend farther over and somewhat farther down40 ,another instructive point relative to diagnosis the above authors make is the importance of the splashing sound4 ,owing to the fact that the stomach in health closes concentrically about its contents and thus adapts itself to the volume of ingesta1 no splashing sound can be elicited4 ,three different degrees of relaxation are diagnosticated as follows3 8,splashing sound1 which can be elicited only during the normal period of digestion1 means simple atony2 splashing sound produced after the legitimate time of digestion has expired means motor insufficiency2 and splashing sound produced in the morning1 after the night's fasting1 before liquid or food has been introduced1 may mean stagnation1 dilatation of the stomach1 as understood by most writers40 7,for a more complete outline see ,dilatation of the ,stomach4 ,the object of this section is to present an outline of prolapsed organs as a whole1 and to refer especially to the effectiveness of osteopathic treatment in this condition74 ,this is a disease where osteopathy has been particularly successful in not only relieving distressing symptoms1 but in actually curing the disorder4 ,this refers to the nervo-muscular atony type1 for where there is obstruction due to stricture or tumor of the pylorus1 resulting in stomach dilatation1 the treatment1 from the very nature of things1 must be largely surgical4 ,stomachs that have been dilated and prolapsed several inches have been entirely restored to function and organic integrity4 ,to cure these cases is a matter of stimulating nerve control and blood supply to the stomach tissues1 and1 often of greater importance1 removing spinal impingements to the stomach nerve fibers1 thus allowing nature to fully assert herself4 ,in reality1 outside of so-termed surgical cases and other cases where the stomach dilatation is merely a symptom of general nutritional disorder1 the primary treatment1 by far1 is the spinal one4 ,treatment over the stomach is a decidedly beneficial treatment2 it aids materially in toning both abdominal and stomach muscles2 still this is mostly a secondary treatment4 ,dieting is essential4 ,careful dieting lessens the tendency to catarrhal inflammation and reduces the work of the stomach to a minimum4 ,still1 nourishing food is necessary and the dieting can easily be carried to an extreme4 ,liquids should not be taken freely4 ,fatty and starchy foods should be eliminated4 ,give the patient food at short intervals4 ,various nutritious meats are excellent4 ,in dilatation1 and also general abdominal relaxation1 daily abdominal treatments may be indicated4 ,if the relaxation is pronounced1 keeping the patient in bed with thorough spinal treatment two or three times a week1 daily abdominal treatment1 having the patient exercise abdominal parietes by drawing the walls in and up1 upper thoracic breathing1 and frequent feeding will accomplish comparatively quick results4 ,the progress of each case depends very materially upon the general health1 the physical status of other tissues1 constitution1 inheritance1 environment1 age1 etc4 ,some cases will yield in two or three months1 others will require two or three years in order to obtain the greatest possible benefit4 ,the ,prolapsed ,kidney ,a prolapsed kidney is often termed a floating kidney1 or movable kidney1 or dislocated kidney4 ,it is of common occurrence1 especially in thin persons4 ,some authorities state that one woman out of every four has a floating kidney4 ,it is more common in women than in men1 and among the working class than other classes4 ,the condition is usually an acquired one1 following severe strains from lifting1 falls1 injuries1 etc4 ,it is claimed by some that a floating kidney arises from congenitally weakened and relaxed tissues about the kidney1 that is1 the tissues that keep the kidney normally at anchorage4 ,thus a congenital looseness of the kidney would easily be a predisposing cause whence mechanical violence1 repeated pregnancies1 an enlarged liver1 or tight lacing would act as an exciting cause4 ,undoubtedly in some instances there is a congenital predisposition1 the peritoneal fold attaching the kidney to the spine being loose and the capsule of fat retaining the kidney being scanty1 but osteopathic experience has amply demonstrated that the tissues anchoring the kidney may in many case become atonied and relaxed from lower dorsal spinal lesions4 ,rarely is a case presented to an osteopath that does not exhibit two apparently characteristic causative features1 viz3 spinal irregularity in the lower dorsal spine1 and constriction of the zone about the waist1 i4 e41 dropping and constricting of the floating ribs4 ,furthermore1 correction of these lesions will almost invariably lessen the mobility of the palpable kidney4 ,the symptoms of a floating kidney are many and variable4 ,the kidney may be slightly movable or it may be so loose that one can easily grasp it through the walls of the abdomen4 ,most of the symptoms are of a nervous reflex nature4 ,indigestion1 which is likely to be very persistent1 flatulency1 heart palpitation1 painful menstruation1 irritable bladder1 etc41 are the most common symptoms4 ,still1 blueness1 depression and morbidness are frequently present4 ,the most distressing direct disturbance is the feeling of weight in the abdomen1 especially on standing1 running or lifting4 ,sometimes the ureter becomes twisted and severe pain1 colic and even collapse occurs4 7,dietl's crisis47 ,the diagnosis of a dislocated kidney is not a particularly difficult matter4 ,a little experience coupled with a delicate sense of touch will usually readily detect abnormal mobility of the kidney4 ,a point to always remember is that the kidney normally descends about one-half an inch with each inspiration4 ,care should be taken not to mistake a floating kidney for a movable spleen1 although this is not likely1 as the shape of the spleen is different4 ,the treatment of a movable kidney under osteopathic measures is usually successful4 ,in the first place a number of cases require but little attention1 simply toning up the general health1 and especially directing attention to the abdominal walls and organs4 ,there are a number of cases where the kidney prolapse is incidental to general abdominal laxness and weakness4 ,in more severe cases1 treating the spine1 raising the floating ribs1 carefully manipulating over the abdomen1 keeping the bowels open1 and lessening liver congestion should it arise1 will suffice2 in fact1 will remedy a good percentage of the cases4 ,with others1 a well fitting1 medium width1 elastic bandage with pad underneath will be beneficial4 ,in these cases the patient should be taught how to treat the abdominal organs1 to manipulate the abdominal walls1 and to replace the prolapsed kidney2 particularly after going to bed this can be done successfully by the patient and will prove a decided help in obstinate cases4 ,surgical measures for fixing the kidney should seldom be resorted to4 ,if the patient will live a careful life1 avoid unduly straining himself1 keep the bowels normal1 and have the anatomical lesions corrected1 he will come very near being entirely relieved1 if not absolutely4 ,surgical measures are not always a success4 ,surgeons are not operating for this disorder so often as in past years4 7,see ,movable ,kidney--,diseases of the ,kidney47 ,liver ,prolapse ,this is commonly termed a floating liver4 ,there is prolapse of the organ as well as its being abnormally movable4 ,it is not of frequent occurrence2 women suffer from it much oftener than men4 ,normally1 the liver is partially held in place1 in the concavity of the diaphragm1 by a number of peritoneal folds4 ,the attachment of these ligaments is to the spine and the diaphragm2 their principal function is to prevent extended lateral movements4 ,of greater importance in supporting the liver in a normal position is the integrity of the abdominal walls1 and the position of the stomach and intestines4 ,if the abdominal walls are of normal tone the liver is very apt to be in correct position4 ,and the rest of the abdominal organs1 especially intestines and stomach1 act as a cushion support4 ,often when the liver is displaced the remaining abdominal organs are1 also1 out of normal position and relation to each other2 in fact1 general prolapse of the abdominal viscera is a frequent cause of liver prolapse4 ,an additional support of the liver is a certain cohesion of the liver and diaphragm1 and the elastic traction of the lungs4 ,foremost among the causes that predispose to inelastic and atonied abdominal walls are spinal irregularities1 deviations1 and curvatures1 which impinge nerve force and obstruct blood supply4 ,these same lesions weaken ligamentous supports of the liver and lessen tonicity of the other abdominal organs1 so that local or general displacements are readily forthcoming4 ,strains1 injuries1 frequent pregnancies1 etc41 also act as causes that weaken the supports of abdominal tissues and organs4 ,in a word it is very often the pendulous abdomen that is the immediate cause of a floating liver4 ,it is very rare to find the liver displaced to the lower region of the abdomen4 ,the ptosis is usually somewhat slight4 ,the organ generally rotates on descent1 the right lobe being the lowest portion1 owing to the attachment of a ligament1 the ligamentum teres1 to the umbilicus4 ,probably in some cases there is a congenital tendency to relaxation of the ligaments1 and1 thus violent exertions and atonic and flabby abdominal walls and diaphragm are secondary but important factors4 ,the principal symptom of a floating liver is a tumor in the right side1 which may be low down4 ,palpation will usually determine this4 ,then the abdominal walls are flabby4 ,pain and bearing down of the right side are common4 ,there is apt to be considerable indigestion4 ,various reflex symptoms are often present4 ,the floating liver will seem larger than normal1 as the liver is below the costal arch and much of it can be felt4 ,percussion will be of value in determining the extent of the disorder4 ,much can be accomplished by treatment1 especially where the displacement is of a lesser degree4 ,correcting the spinal lesions1 toning up the abdominal walls and diaphragm1 and replacing the displaced organs will be extremely effectual4 ,the abdominal bandage may be of service4 ,certainly abdominal exercises will be beneficial4 ,a point to remember is1 stimulation over the abdomen beneath the right costal arch will cause the liver to contract and retract4 ,this is of considerable osteopathic note4 ,the liver will often recede at least a half an inch4 ,this is a liver reflex 7,abrams74 ,prolapsed ,intestines ,prolapse of the bowels1 as a whole1 or1 more frequent still1 of a part1 is undoubtedly the most common form of organ prolapse4 ,the intestines are so situated that they readily feel the effect of gravitative influences1 of atonic and anemic states1 and of weaknesses and disorders of other abdominal organs4 ,spinal irregularities come first as potent causes of bowel prolapse4 ,the spinal nerves to the supports of the intestines1 to the muscular coats of the intestines1 and to the abdominal walls1 are obstructed in their normal activity1 and consequently those tissues to which these nerves are distributed are affected4 ,wasting diseases1 as anemia1 consumption1 cancer and the like predispose to intestinal atony4 ,the severe mechanical wrenches1 strains1 frequent pregnancies1 tight lacing1 heavy skirts1 large abdominal tumors1 obesity1 cause more or less general or local weakness4 ,the pendulous abdomen1 from wrong or careless posture1 and exclusive of other causes1 is a common source of general bowel displacement4 ,this form of disorder1 besides being unsightly1 favors abdominal stoutness4 ,there are a number of instances where simply voluntarily holding or 8sucking0 the abdomen into place1 until it becomes strong enough to support itself1 has reduced one's weight by five1 ten or fifteen pounds4 ,these were cases where most of the adipose tissue was about the abdomen4 ,thus exercising and toning the abdominal organs by keeping them in normal position rectified a dormant blood and lymph circulation1 which was followed by absorption of the abdominal stoutness4 ,congenital weaknesses are to be considered in many cases4 ,the muscular ligaments may not be developed1 the mesenteric attachments may be too long1 and various other abnormalities may result from congenital disturbances4 ,of particular local interest to the osteopath1 outside of the bowels dislocating as a whole1 are3 first1 the hepatic flexure2 second1 the ileo-cecal region2 third1 the sigmoid flexure2 fourth1 the rectum2 and fifth1 hernias4 ,each of these sections are of separate interest and will be considered presently4 ,the symptoms are extremely variable4 ,constipation1 a feeling of discomfort in the bowels1 nervousness1 depression1 lassitude and anemia are frequent4 ,colicky pains in the intestines1 indigestion1 hysteria at times1 are also among the symptoms4 ,in reality a great variety of symptoms may be present4 ,the patient is likely to be emaciated4 ,in some cases exhaustion is marked4 ,diagnosis1 as a rule1 is not a difficult matter4 ,the various neurasthenic symptoms in a lean patient with constipation1 indigestion1 and stomach and intestinal distress would lead one to suspect intestinal displacement4 ,the outline or contour of the abdomen will often reveal the character of the trouble4 ,the atonic1 thin and relaxed walls of the abdomen may readily give view of the displaced organs4 ,then careful examination by palpation and percussion will help very materially in the diagnosis4 ,radiographic examination is a decidedly helpful diagnostic method4 ,the hepatic flexure is frequently prolapsed4 ,the bowel 7colon7 ascends from below upward to beneath the costal arch and then angles sharply into the transverse colon1 which extends directly across the abdomen to the left side4 ,the ligaments that support this flexure are apt to become weakened or stretched and allow a descent of this section of the bowel1 which is followed by constipation1 indigestion1 etc4 ,the ligament especially involved is the colo-hepatic ligament4 ,the duodenum may require attention4 ,this can be raised by getting beneath it where the organ descends alongside of the ascending colon4 ,the effect of treatment is to release tension of the duodeno-hepatic ligament which is closely associated with the portal vein1 hepatic artery and bile-duct4 ,the ileo-cecal region is an area that readily becomes congested and catarrhally inflamed1 especially from constipation or impaction at this point4 ,the section often becomes atonic and prolapsed with resultant clogging of fecal matter4 ,owing to the close proximity of the vermiform appendix1 appendicitis frequently results from the above condition4 ,the osteopath can do much in these cases of appendicitis4 ,lesions are invariably found in the lumbar vertebr or the floating ribs are depressed4 ,the sigmoid flexure is also frequently prolapsed4 ,the fecal mass often becomes impacted here1 owing to a settling or prolapse of this part4 ,in some cases the prolapse is so marked that it extends to the rectum below and drags on the splenic flexure above4 ,lumbar and innominate lesions are the usual causes1 although1 it seems in a number of instances1 that relaxed walls of the abdomen cause a 8contraction of the diaphragm resulting in kidney displacement and followed by intestinal prolapse40 ,the vertebral lesions1 probably1 first weaken the muscular coat of the bowel1 then1 second1 the bowel supports 7other than its own inherent tonicity7 and the abdominal walls4 ,prolapse of the rectum is of such separate importance that it will be but partly outlined here4 ,as stated above1 a source of rectal displacement arises from the section of the bowel above settling downward and ultimately causing invagination of one or more coats of the rectum4 ,dislocation of the coccyx is a potent cause of rectal disorders4 ,lumbar lesions1 especially twists between the fourth and fifth1 and fifth and sacrum are common causes of rectal weaknesses4 ,slips of the innominata are other causes of prolapse4 ,osteopathy has had marked success in these cases4 ,cures may result from a single treatment to readjust the coccygeal displacement or temporarily relieve excessive physiological activity by dilating the rectal sphincter1 or the treatment may demand a number of months' work in correcting general abdominal prolapse4 ,raising the sigmoid is effectual4 ,a hernia is 8the protrusion of a loop or knuckle of an organ or tissue through an abdominal opening40 ,two of the common hernias of the intestines are inguinal and femoral4 ,these conditions are most often acquired from severe straining1 so that a loop of the bowel protrudes through a weakened and stretched area of the abdominal walls1 though there is reason to suspect that congenital defects are often predisposing factors4 ,mention of the hernia is here made because1 in a way1 it is a form of bowel prolapse2 that is1 a limited form1 and osteopathy contains certain possibilities for a successful treatment4 ,hernia has always been looked upon as purely a surgical disorder2 i4 e41 remediable by surgical measures only4 ,where a truss has failed to give relief surgery has been resorted to4 ,this is true in most instances1 but where the hernia is in the incipiency careful abdominal exercises 7this should be carried out with great care1 for severe exercise may produce a hernia or increase one already existing71 massage to the tissues about the hernia1 attention to the bowels1 and spinal stimulation corresponding to the weakened tissue1 and avoidance of strains may strengthen the tissues materially about the hernia4 ,occasionally a loop of the intestine will prolapse into the cul-de-sac back of the uterus4 ,a heavy dragging pain low down in the center of the abdomen and constipation or complete obstruction are the pronounced symptoms4 ,careful lifting of the loop of bowel by pressure within the vagina and traction from above with a hand outside1 with the patient1 on her back1 with buttocks elevated1 gives speedy relief4 ,the treatment of the prolapsed bowels represents those measures that will replace and keep in position the displaced organs4 ,naturally1 the spinal and abdominal treatment comes first2 this strengthens intestinal ligaments1 tones intestinal muscles1 and contracts the abdominal parietes1 and at the same time the bowels are regulated1 digestion and nutrition improved1 and the general health built up4 ,in some cases abdominal supporters will be of value4 ,in a number of instances attention to chest mobility and diaphragm tonicity will be of value4 ,right living1 which is represented by proper diet1 sufficient outdoor exercise and regular habits1 is invaluable4 ,the really specific treatment is to correct spinal1 rib and innominate deviations and abnormalities4 ,but direct local work will be1 in many instances1 necessary4 ,general abdominal manipulation is good1 but this should be supplemented by careful local treatment4 ,the hepatic flexure requires a direct stimulating and replacing treatment4 ,the ileo-cecal section should be raised1 stimulated and emptied of the fecal mass4 ,direct upward manipulation of the sigmoid flexure in the left iliac fossa and of the splenic flexure beneath the left costal arch is extremely efficacious4 ,care must be taken not to bruise the parts4 ,getting beneath the prolapsed area and gently and intelligently raising the bowel so that it is emptied1 toned up1 and vascular congestion relieved1 are the indications4 ,this requires careful work and the necessity of gentleness can not be emphasized too much4 ,still in all of this treatment we should never forget the absolutely essential spinal readjustment4 ,rectal prolapse requires lacol internal treatment1 external tissue correction1 especially of the coccyx1 an innominatum or the lumbar spine1 and1 of much importance1 deep1 careful and thorough work over the sigmoid section4 ,cases of bowel prolapse are every day experiences with the osteopath4 ,the osteopathic treatment is of great value in these and a successful issue is very often the result4 ,cases of pendulous abdomen1 of obstinate constipation1 of chronic indigestion1 of many nutritional disorders1 of feeling pain1 weight or dragging1 locally or generally1 in the abdomen1 are very apt to be in persons suffering from prolapsed intestines4 ,a number of cases of bowel prolapse are associated with general prolapse of abdominal organs2 that is1 displacement of the stomach1 kidneys1 liver1 spleen1 etc4 ,this general condition is termed enteroptosis or ,glenard's disease4 ,it usually requires several months to treat it successfully4 ,these patients are neurasthenic1 malnourished1 and often hysteriacs4 ,the symptoms from which they suffer are innumerable4 ,mechanical weaknesses1 lowered vitality1 poor innervation and blood supply1 and auto-intoxication are causative factors4 ,the ,prolapsed ,uterus ,prolapse of the uterus is of common occurrence4 ,the prolapse may be incomplete or complete2 the latter when the organ is presented to the external world4 ,of special interest are those affections exclusive of surgical cases4 ,ptosis of the abdominal organs upon the pelvic organs is a common cause of uterine prolapse4 ,the abdominal prolapse crowds uterine space1 congests the uterus1 weakens the ligaments1 and drives the uterus downward as a wedge4 ,lumbar spinal curvatures are frequent causes of prolapse1 as well as other displacements of the uterus4 ,in this region vasomotor nerves to the pelvic organs make their exit1 and1 consequently congestions1 inflammations1 and weaknesses of supports are results4 ,also1 slips of the innominata disturb the pelvic circulatory balance4 ,weakness of the uterine support from below1 the vaginal walls and perineum1 most often arises from lacerations at childbirth4 ,still1 the vaginal walls may become relaxed through other causes4 ,tumors and extreme congestions are causes of prolapse4 ,heavy lifting is quite a frequent source of uterine displacements4 ,osteopathy is very successful in uterine prolapses2 that is1 any displacement of the uterus not of a surgical character4 ,correction of the external causes comes first4 ,then local treatment to replace1 tone1 and relieve congestion1 and break up adhesions is necessary4 ,the external treatment is usually the primary treatment4 ,local work is not always necessary4 ,lacerations and other surgical indications1 of course1 require surgery4 ,ovarian ,displacements ,the ovaries may be prolapsed1 the left much oftener than the right4 ,when prolapsed1 it drops backward1 downward and inward4 ,ovarian congestion1 tumor1 retroverted or retroflexed uterus1 tubal disease1 and pregnancy are among the principal causes4 ,back of these congestions1 tumors and uterine displacements1 are the osteopathic causes1 particularly spinal and rib lesions from the ninth dorsal downward4 ,specific lesions at the ninth and tenth dorsals and corresponding ribs1 affecting directly ovarian tissues1 and lumbar and innominate lesions and abdominal prolapse disturbing uterine and tubal tissues1 are the most frequent osteopathic causes4 ,a retroverted or retroflexed uterus is often found4 ,uterine displacements bear down upon the ovary and cause its descent1 and also disturb ovarian circulation4 ,as has been stated1 the left ovary is more apt to be displaced than the right4 ,this is owing to the absence of a valve in the ovarian vein on the left side1 and also1 this vein opens at a right angle into the renal vein2 this anatomical feature easily leads to passive congestion of the ovary1 and thus to diseases of the organ4 ,then the rectum is on the left side and large fecal masses are apt to crowd against the ovary1 which tends to its displacement4 ,thus it is readily seen that osteopathic treatment is very applicable to ovarian displacement unless the indications are surgical4 ,a more or less constant burning or sharp pain in the ovarian region1 with probably some feeling of weight1 profuse and painful menstruation1 depression1 irritability1 etc41 are diagnostic4 ,however1 a local examination will reveal the status of the ovarian position and congestion4 ,the same treatment as in other organ prolapse is indicated3 toning weakened tissues1 relieving congestions1 replacing organ1 with careful attention to the bowels and the general health4 ,there are no tissue disorders of any part of the body wherein osteopathy is more thoroughly indicated and the results more generally satisfactory than in prolapse4 ,and especially should it be remembered that in prolapse of various organs many vague intestinal and pelvic disorders and even ureteral and bladder disturbances may be traced to bowel dislocations and excessive kidney mobility in which osteopathic measures are often successful4 ,conclusion4--,the purpose of this section on ,prolapsed ,organs has been to supplement the various articles on ,dilatation of the ,stomach1 ,movable ,kidney1 etc41 with an outline that may include relaxation of a part or of the whole of the abdominal viscera4 ,the physician is all too prone to simply note the most offending or conspicuously disturbed organ instead of carefully analyzing all the features1 great and trivial1 that may be either apparent or marked4 ,a general relaxation of the abdominal and pelvic organs may be found1 and a nearly complete restoration take place under treatment1 but still a lacerated perineum may have to be repaired before a cure is completed4 ,or it may be in a general abdominal ptosis that a floating kidney will resist all measures for restoration1 short of surgery1 and before much improvement can be obtained the kidney will have to be stitched into place4 ,an enlarged liver may crowd the kidney out of place or a transverse colon may prolapse and drag on contiguous tissues and still the annoying symptoms be referred elsewhere4 ,then the primal point of general relaxation may not be in one organ1 but there may be a simultaneous displacement of several4 ,the thorax itself may be distorted from various diseases so that the chest is narrowed1 the diaphragm displaced with consequent descension of the abdominal organs1 and from the latter a displacement of the pelvic4 8,far down displacement1 marked changes of form1 and real disfigurements of the stomach are found in some cases of kyphosis and scolio-kyphosis40#df ,the osteopath will not only find this true in some cases1 but in many cases1 although he recognizes as causative factors injuries to the spine causing curvatures and postural defects as prolific sources of abdominal relaxation4 8,glenard's whole theory of splanchnoptosia is based on the relaxation of the suspensory ligaments of the intestines1 especially that of the transverse colon2 and ,stiller1 the discoverer of the floating tenth rib1 says that splanchnoptosia is a descent of the atonic stomach1 of the colon 7especially the transverse portion71 of the kidney 7the right or both kidneys71 exceptionally of the liver or the spleen4 ,a descent which has been developed mostly in tender age1 in consequence of general relaxation1 especially of the peritoneal suspensory ligaments in individuals with congenital general dyspeptic neurasthenia1 tender muscles1 lean habit1 and slender bone structure1 manifested in a higher degree by a floating tenth rib40 ,stiller observed that when there is a floating tenth rib there is a displaced stomach and a floating kidney1 although it is not found in every case1 but never missing if the case is pronounced4 ,the tenth ribs in these cases have only a ligamentous fastening and are as freely movable as the eleventh and twelfth4 ,that abdominal relaxation plays a very important part in many diseases of the abdominal and pelvic organs1 in cardiac and pulmonary affections1 disturbs the circulation in the legs1 and is the source of many reflex affections no one can gainsay4 ,the osteopath should always pay particular attention to tonic condition of the abdominal viscera1 for relaxation of the suspensory tissues and walls1 and atony and sluggishness of the organs are frequently paramount etiological factors4 ,and the osteopathic treatment is the remedy par excellence4 ,,footnotes3 #de ,rose and ,kemp--,atonia ,gastricia4 #df ,rose and ,kemp--,atonia ,gastricia4 ,,skin ,,diseases ,various skin diseases have been treated osteopathically with varying success4 ,so much depends upon the cause of the disturbance and its removal1 in skin diseases1 that the cure does not rest so much with the mere treatment1 as with the necessary skill in locating the disturbing factor4 ,one has to be continually on his guard to locate external irritations and disorders of the digestive and genito-urinary tracts4 ,a great deal depends upon the avoidance of external influences2 eating nutritious food and having an unobstructed circulation4 ,the leading object of osteopathic treatment is to free the circulation and thus promote a healthy and unobstructed flow of blood2 in no other class of diseases is this more essential than in skin diseases4 ,after the removal of cutaneous irritations and the correction of internal disorders1 the cure of the case depends upon the removal of constrictions to the cutaneous blood-vessels4 ,the osteopath corrects the lesions found1 relaxes the muscles thoroughly and stimulates the circulation to the parts involved1 and promotes a healthy activity of all the excretory organs4 ,when the upper part of the body is affected1 lesions are generally found at the atlas and axis1 and when the lower part of the body is affected1 lesions at the fifth lumbar are of common occurrence1 although lesions may be located at various points corresponding with the seat of disturbance4 ,the constant use of hot baths will be found a helpful measure in many skin diseases4 ,but use of soap must be considered as too much alkali will neutralize the oil of the skin and cause undue dryness1 but bran may be substituted to advantage4 ,cleanliness is necessary but the result sought is1 also1 flushing the cutaneous vessels4 ,there are many cases where a specific vertebral lesion will cause1 through the peripheral nerves1 a cutaneous irritation with intense itching and discomfort4 ,this1 in turn1 produces an exudate with or without a crust and a condition results which is not amenable to any local or constitutional treatment but an adjustment of the lesion will in most cases bring immediate relief4 ,application of this principle will aid greatly in treatment of any skin disease4 ,in no disturbance of health is it more necessary to find the cause than in skin disease and once found to apply specific treatment4 ,eczema is frequently met in osteopathic practice4 ,it is the most common form of skin disease1 comprising nearly one-third of all these disorders4 ,for a differential diagnosis of the several varieties the student is referred to special texts4 ,it is well to remember that the same underlying causes may be basic to the various forms1 for several varieties may occur at the same time or one variety pass into another1 though commonly one form is more prevalent4 ,the limbs1 face and genitalia are the most common sites1 though the eruption may occur on various parts of the body4 ,etiology includes a number of factors1 constitutional and local4 ,dietetic errors1 indigestion and faulty elimination comprise the principal underlying causes1 often manifested through absorption of toxins and leucomains4 ,in fact any disorder of the abdominal viscera1 organic or functional1 may be a predisposing factor1 likewise various disorders of the pelvis1 tuberculosis1 diabetes1 anemia1 etc4 should be considered4 ,so-called gouty and rheumatic tendencies may be the constitutional basis4 ,the many osteopathic lesions play a very important role in lowering not only systemic resistance but of local tissue as well4 ,this feature can not be over-emphasized4 ,then local irritants1 mechanical1 chemical and thermal1 are not to be neglected4 ,these are usually of secondary importance4 ,micro-organisms are probably a complicating factor after the lowered resistance has been established4 ,vasomotor neurosis1 through constitutional defects1 toxins and the very significant osteopathic lesion1 is probably an essential part of the pathogenesis4 ,treatment is usually successful if the various etiologic factors are eradicated4 ,early treatment is very important4 ,if the disorder is of more than local significance change the entire daily regimen of the patient4 ,diet1 outdoor exercise and sufficient sleep should be definitely regulated4 ,a certain amount of general treatment to improve digestion1 assimilation and elimination is imperative4 ,an unbalanced diet and over eating must be corrected4 ,in certain moist types1 eliminating fatty foods will be helpful1 while in dry forms the starches and sugars should be reduced4 ,if there is an underlying disease this should be remedied if possible4 ,particular attention should be paid to constipation4 ,common sense in diet1 rest1 change of environment and free elimination1 coupled with due attention to the osteopathic lesions1 will cure the vast majority of cases4 ,the greatest difficulty arises where there is some underlying disease4 ,the parts should be protected against irritation such as dirt1 cold1 soap1 and too much water4 ,meddlesome local treatment is to be guarded against4 ,a simple application is boric acid1 rice-flour or cornstarch1 or where there is much itching add carbolic acid to the saturated solution of boric acid4 ,substitute bran for soap for cleansing purposes4 ,herpes ,simplex1 fever-blister1 or 8cold sore0 comprise two principal varieties3 herpes facialis and herpes genitalis4 ,the first occurs upon or near the lips1 face1 neck or ears4 ,when the herpes is on the tongue or the mucous membrane within the mouth it is commonly termed 8canker sores40 ,herpes genitalis is located on the prepuce1 glans penis or farther back upon the penis4 ,in the female the labia majora and minora and vestibule are the usual locations4 ,lack of cleanliness1 sexual excitement and adherent prepuce are causative factors1 though predisposing factors such as faulty circulation and disturbed innervation are to be considered4 ,in 8cold sores0 there is often some gastro-intestinal disturbance1 especially intestinal stasis1 cold in the head and other infections that supply toxins which irritate the nerves4 ,no doubt there are underlying osteopathic lesions that lower the local nerve resistance or block the impulses such as vertebral and inferior maxillary lesions4 ,the predisposing disturbance is probably due to the ,gasserian ganglion4 ,cold winds and excessive exposure to the sun's rays will effect the tissues over the mental and infraorbital foramina1 tensing the muscles and irritating the nerves at these points4 ,on palpation they will be found sensitive4 ,frequent rotary motion by tip of finger over foramina will open them and allow congestion to drain4 ,herpes ,zoster1 or shingles1 is an acute inflammatory disease characterized by groups of small vesicles1 usually along the course of the intercostal nerves on one side of the body4 ,before the vesicles appear there is more or less severe neuralgia4 ,the eruption is unilateral1 very rarely bilateral4 ,the nearby lymphatics are usually enlarged4 ,though the intercostal nerves are the ones most frequently involved1 still the lumbar1 thigh1 trifacial and other cutaneous nerves may be affected4 ,the most common lesion is an inflammation of the posterior spinal ganglion which usually involves the fibers of the entire nerve4 ,inflammation of the nerve outside of the ganglion will cause the disorder4 ,toxins from various infectious sources are often exciting causes4 ,vertebral and rib lesions are always found2 and where the ,gasserian ganglion is involved lesions of the inferior maxilla and upper cervical vertebr are predisposing factors4 ,thus osteopathic lesions from traumatism1 cold and wet1 and imbalance of muscular tension are important4 ,exudates1 tumors1 pleuritic and pulmonary affections are to be considered as possible sources4 ,treatment4--,adjust vertebral lesions and carefully raise and separate ribs if intercostals are affected4 ,look after vertebral origin of any other nerve or nerves if otherwise4 ,local application of talcum or starch or boric acid will generally be sufficient4 ,urticaria1 hives or nettle rash is a common affection often due to some derangement of the digestive tract4 ,this may be a mechanical irritation or of a toxic nature4 ,every one is familiar with the various foods that are apt to cause the hives1 shell fish1 strawberries1 cheese1 pork1 oatmeal1 mushrooms1 etc4 ,the irritation may be a reflex one from the visceral disturbance2 also1 there may be irritation of the pelvic organs that would give rise to the trouble4 ,it is well known that certain drugs will produce urticarial eruptions4 ,there are cases where the irritation is simply local due to the nettle1 mosquito bites and wasp stings4 ,in chronic cases intestinal stasis1 nervous exhaustion and nephritic diseases are important4 ,no doubt osteopathic lesions frequently determine the location of the wheals4 ,these lesions affect the innervation and thus establish a basis for the reflex vasomotor effect4 ,this is in the nature of spasm of the cutaneous vessels quickly followed by dilatation with exudation of serum4 ,the irritant probably acts on the walls of the blood vessels4 ,treatment consists of thoroughly emptying the bowels by warm water enema1 correcting the diet1 toning the viscera and adjusting the osteopathic lesions4 ,thorough attention to the patient's environment1 daily habits and occupation are of value4 ,warm soda baths will relieve the itching4 ,acne is a common skin disorder that is characterized by an inflammation of the sebaceous glands of the nature of papules1 tubercles or pustules4 ,the face1 shoulders1 chest and back are the regions usually involved4 ,it generally1 appears about puberty4 ,blackheads is the starting point2 these are accompanied with greasy skin and dust1 and influenced by micro-organisms and more or less intestinal disorder4 ,the general or systemic health no doubt affects the local disorder1 as in many skin diseases2 for various intestinal derangements as indigestion1 constipation1 etc42 pelvic and menstrual irregularities2 general ill health2 anemia1 etc4 affect circulatory1 glandular and nervous integrity4 ,any disturbance of normal elimination is important4 ,the treatment consists of careful attention to the general health and to the local innervation of the face or region involved4 ,measures that tone the bodily organs such as outdoor life1 regular habits1 plenty of sleep and correct diet are important4 ,in some cases the ,x-ray is of value4 ,,animal ,,parasites ,tape ,worms ,varieties4--,taenia solium2 taenia saginata2 bothriocephalus latus4 ,the larv of tape-worms are introduced into the intestinal canal by food and drink4 ,the parasite reaches adult growth in the intestines4 ,the larval forms are then found again in the muscles and solid organs4 ,taenia ,solium4--,this is derived from the hog1 and is the most common form in this country4 ,when mature it is from two to four yards in length4 ,the head is small1 about the size of a pin1 and provided with four cup-like suckers surrounded by a double row of hooklets1 hence it is called the armed tape-worm4 ,the head is fastened to the body by a thread-like neck1 and following the neck1 the body occurs in segments4 ,the sexual organs1 both male and female1 occur in the center of the broad surface of the segment4 ,the segments are about one millimeter in length and seven or eight millimeters in breadth4 ,there are thousands of ova in each mature segment4 ,the worm attains its growth in about twelve to fifteen weeks1 after which time the segments are shed and passed4 ,for further development the ova must gain entrance to the stomach of a pig or of man1 and passing from the stomach they may reach the muscles and organs and develop into larv or cysticerci4 ,taenia ,saginata4--,this is derived from beef1 and is much longer and larger than the taenia solium4 ,it is from five to six yards in length2 the head is over two millimeters in breadth1 is square shaped1 and has four large sucking discs1 without hooklets2 hence it is called the unarmed tape-worm1 in contra-distinction to the hooked variety4 ,the segments are thicker and the ova larger1 and they are passed and ingested in the same manner as the taenia solium4 ,bothriocephalus ,latus4--,this is found especially in ,europe and is very long1 measuring from eight to ten yards2 it is derived from fish1 is not provided with hooklets1 but has two lateral grooves4 ,the segments are short and wide1 the sexual organs being on the narrow side of the segment4 ,etiology4--,unhealthy condition of the stomach and intestines is the predisposing1 and uncleanliness an important1 factor in the occurrence of tape-worm4 ,those eating imperfectly cooked beef1 pork1 fish or other meats1 and those handling fresh meats1 are liable to be affected with tape-worm4 ,when the ovum is taken into the stomach the capsule is dissolved and the embryo passes into the small intestines1 fastening itself into the mucous membrane1 by its hooklets and suckers and grooves4 ,symptoms4--,tape-worms occur in the human being at all ages4 ,oftentimes symptoms are absent1 the expulsion of segments being noticed and thus the worms accidentally discovered4 ,the tape-worm is seldom dangerous1 but if a worm is known to exist it is always a source of considerable anxiety on the part of the patient4 ,severe anemia may result and be wrongly diagnosed4 ,there are dyspeptic symptoms1 colicky pains1 nausea and occasionally diarrhea4 ,the appetite is variable1 sometimes ravenous4 ,this condition is followed by loss of flesh and various reflex phenomena1 as vertigo1 headache1 convulsions1 palpitation1 choreic movements1 itching of the nose and anus1 paralysis1 and rarely1 insanity4 ,in addition to these symptoms there may be a wrinkled countenance1 sensation of a cold stream winding itself toward the back immediately after a meal1 pain in various parts of the body and ringing in the ears4 ,the decisive diagnostic symptom is to find segments of the worm in the stools4 ,diagnosis4--,discovery of the ova or segments in the passages of the bowels is the only proof of the presence of a tape-worm4 ,prognosis4--,favorable in all cases4 ,treatment4--,prophylactic treatment is necessary4 ,meats should be thoroughly cooked so that the larv will be destroyed2 and all segments of tape-worms passed in the stools should be burned--by no means should they be thrown outside or in the water-closet4 ,the immediate expulsion of a tape-worm is not a necessity4 ,first of all the mode of living1 and then the general state of health should be corrected4 ,tape-worms invariably result from a general state of unhealthiness1 and with improved health and corrected digestive processes the worms cannot exist1 and in a short time will be expelled4 ,expulsion of the head is necessary before the case will be cured1 for if the head is not expelled new segments will continue to grow4 ,stimulating the liver to increase the amount of bile1 and increasing the activity of the digestive glands of the stomach and intestines1 by a thorough treatment of the splanchnic region and direct treatment over the abdomen1 will usually be sufficient for the cure of intestinal parasites4 ,the treatment will probably have to be repeated several times1 in order that the intestines may regain a healthy tone1 so that the parasite will not find favorable conditions for its existence within the intestines1 and that the bile may be secreted in sufficient quantities to dislodge the worm4 ,hahnemann claimed1 8that during a period of comparative health tape-worms do not inhabit the intestines proper1 but rather the remnants of food and fecal matter contained in the intestines1 living quietly as in a world of their own without the least inconvenience to the patient and finding their sustenance in the contents of the bowels4 ,during this state they do not come in contact with intestinal walls1 and remain harmless4 ,but when from any cause a person is attacked by an acute disease the contents of the bowels become offensive to the parasite1 which in its writhing and distress touches and irritates the sensitive intestinal lining1 thus increasing the complaints of the patient considerably by a peculiar kind of cramp-like colic4 7,in similar manner the human foetus in the womb becomes restless1 twists its body and moves whenever the mother is sick1 but floats quietly in the liquor amnii1 without distressing her while she is well470 ,this but harmonizes with the osteopathic theory and practice with regard to tape-worm1 that there is an unhealthy condition of the intestines which predisposes to the affection1 and consequently the cure must be a correction of such a disordered state4 ,during the treatment1 if a light diet of milk and broths is given1 it will favor an earlier removal of the parasite1 by helping to remove the mucus in which the head is embedded4 ,if this fails extract of male fern is suggested4 ,ascaris ,lumbricoides 7,round ,worm7 ,this is the most common parasite1 and is found principally in children2 it is also found in cattle and hogs4 ,it is of a yellowish brown color and in form resembles earth worms4 ,the worm is cylindrical1 pointed at both ends2 the female is from seven to twelve inches in length1 and the male from four to eight inches4 ,they are probably introduced into the stomach by food and drink4 ,they occupy the upper part of the small intestine1 and are usually one or two in number1 though they may be numerous4 ,occasionally they migrate into the stomach and are ejected by vomiting1 or into the trachea and produce suffocation1 or into the larynx or ,eustachian tube1 or they may pass downward to the anus1 or into the bile ducts4 ,symptoms4--,oftentimes symptoms are absent4 ,there may be dyspepsia1 colicky pains1 mucous stools1 meteorism1 vertigo1 fretfulness1 voracious appetite1 anemia1 sallow complexion1 headache1 chorea and convulsions4 ,other symptoms may be present1 as grinding of the teeth and itching of the nose and anus4 ,obstruction of the bowels has occurred4 ,if a worm enters the bile duct obstructive jaundice occurs4 ,a decisive diagnosis can be given only when the worm is seen4 ,treatment4--,particular attention should be paid the liver1 for it is here that we must seek the natural remedy in the form of bile1 in order to eject and cleanse the system from nematodes4 ,modes of improper living should be corrected2 cleanliness is essential1 and there should be attention to the general health of the patient4 ,thorough correction of all defects of the spinal column in the region of the splanchnics1 and careful direct treatment of the bowels is indicated4 ,the child may be put to bed and fasted twenty-four hours1 then the liver strongly stimulated to increase flow of bile4 ,if the above treatment is not successful oil of wormwood may be employed4 ,oxyuris ,vermicularis 7,thread-worm2 ,pin-worm7 ,this small parasite1 commonly seen in children1 is from three to five millimeters long in the male and about twenty millimeters in the female1 is blunt at one end and sharp at the other1 and occupies the colon and rectum4 ,they are probably introduced into the intestines in the ova1 by uncooked fruits and vegetables1 or by the dirty hands of mothers and nurses of the infants4 ,they vary greatly in number2 migrate to the rectum where they deposit their eggs1 and are often discharged in the feces1 where they appear like pieces of ordinary white thread4 ,symptoms4--,loss of appetite1 anemia1 restlessness and irritability are marked4 ,the itching becomes intolerable when the worms come down in the rectum to the anus and within the folds about the anal orifice4 ,in the female the worms may wander into the vagina where they become particularly distressing1 and thus may produce excessive sexual excitement and cause nymphomania and masturbation4 ,treatment4--,cleanliness of the most scrupulous kind should be demanded in every instance4 ,injections of cold salt water 7repeated for at least ten days7 and other agents within the rectum will destroy the eggs as soon as they are deposited1 besides relieving the terrible itching4 ,in obstinate cases use quassia decoction4 ,attention to the general health of the patient and great care of the intestines and other digestive organs are absolutely necessary4 ,the spinal treatment to the intestines and other digestive organs1 as well as thorough direct treatment over the abdomen1 is indicated4 ,uncinariasis 7,european hook-worm disease2 ,miner's anemia2 ,ankylostomiasis2 ,hook-worm disease7 ,this disease results from infection by the hook-worm of any of the various types4 ,in ,europe it is found in ,italy1 ,belgium1 ,germany1 ,france and ,switzerland4 ,in ,america it seems to be of ,africo-,asiatic origin but was first discovered in the ,southern states and abounds chiefly in ,texas1 ,florida1 ,georgia1 ,north and ,south ,carolina as well as in the ,west ,indies4 ,infection comes from unprotected feces that are allowed to be spread where the feet or hands may come in contact as it is without doubt that the contagion occurs through the skin4 ,one authority states that hook-worm is rarely found except in cases where ground itch has occurred within a period of eight years4 ,negroes harbor the parasite and transmit it but seem immune to its effects while the poorer whites are afflicted to a large degree4 ,the worms are carried from some abrasion of the skin1 by the blood to the heart and lungs1 thence to the pharynx and swallowed1 thence to the duodenum and jejunum where they attach themselves to the lining walls4 ,here they not only feed upon the blood but develop a toxin4 ,the female worm is about twice the size of the male1 #aj to #ah mm4 as against #f to #aa mm4 and there is slight difference between the old and new world varieties4 ,the head is provided with four hook shaped teeth which form the attachment to the intestine and it is very secure4 ,diagnosis4--,for years the languid1 dull1 expressionless1 lack-luster of eye and general unambitious characteristics of the inhabitants of the great sand belt of the ,united ,states attracted attention and was attributed to laziness but the discovery of the hook-worm explained the cause4 ,children are stunted in mind and body and have a muddy1 dirty white complexion4 ,at the beginning there must be a very considerable colony of the parasites to cause symptoms but as the disease advances there is a distention of the abdomen from enlargement of the spleen and liver and from flatulency4 ,there is palpitation1 shortness of breath1 cardiac bruits from the severe anemia while edema of the feet and legs is rather common4 ,the blood shows a severe secondary anemia with its coagulation time much increased4 ,leucocytosis is not common2 hemoglobin is from one-tenth to one-half normal with erythrocytes about half normal4 ,treatment4--,the removal of the worms with the least possible harm to the body is indicated4 ,thymol is a poison which is not absorbed by the body1 when carefully given1 and which is very toxic to the parasite4 ,the dose varies from eight grains for a child under five years of age1 to forty-five for an adult4 ,thymol is soluble in fats and in alcohol1 so that for a day or so before the thymol is given1 and from one to four days after1 no fats or alcohol should be taken4 ,the best way to avoid poisoning by thymol is to give the patient charcoal1 then no fats or alcohol is permitted until the treatment is completed4 ,when the stools become black1 the thymol is given on an empty stomach4 ,a purgative is given a few hours later4 ,enemas should be used very freely in order to facilitate the removal of the injured or poisoned worms4 ,another dose of charcoal is given1 and when the stools are black again1 the patient may return to his ordinary diet4 ,the denial of fats to the person so thoroughly accustomed to bacon three times a day is a factor met with difficulty in dealing with patients of the ordinary class with the disease4 7,clinical ,osteopathy47 ,prophylaxis4--,after treatment it is imperative to prevent reinfection and to do that the most rigorous sanitary measures must be instituted4 ,all feces must be disposed of and habits of cleanliness in defecation insisted upon while negroes1 who harbor the worm without showing symptoms1 must be looked after as well as the actual victims4 ,care of the feet is important and shoes should be worn in infected regions and all abrasions of the skin protected4 ,drinking water must be uncontaminated which presents a problem as wells and springs are usually unprotected4 ,absolute and persistent cleanliness is the answer to the question of prevention4 ,trichiniasis ,trichiniasis is a name given to a disease produced by the embryos of the trichina spiralis4 ,in the adult condition the trichina spiralis lives in the small intestines4 ,the embryos migrate into the muscles where they finally become encapsulated4 ,man is infected by eating insufficiently cooked pork containing the encapsulated worm1 which is set free during the digestive process4 ,about the third day they attain their full growth and become sexually mature4 ,each one discharges large numbers of embryos4 ,as soon as born the young brood is carried away from the bowel and invade the muscles through various channels--principally by means of the blood stream and along the connective tissue routes4 ,the female trichina may bring forth several broods of embryos in succession4 ,in nine or ten days after infection the first brood reaches its destination4 ,they attain to maturity in about two weeks after entering the muscular tissue4 ,in this process an interstitial myositis is excited and a fibrous capsule is formed in four to six weeks4 ,the capsule gradually becomes thicker and finally calcareous infiltration may take place4 ,thorough cooking destroys the parasite4 ,the disease is most frequent among the ,germans who eat raw ham and sausages4 ,symptoms4--,these are sometimes absent1 especially when only a few are eaten4 ,if large numbers have been ingested1 gastro-intestinal symptoms develop in the course of a few days4 ,vomiting1 diarrhea1 and pain in the abdomen may be present4 ,in from one to two weeks muscular symptoms develop4 ,there is fever1 muscular pain1 especially during motion1 and the muscles are stiff1 tense and sometimes swollen4 ,when the respiratory muscles are involved dyspnea is produced1 which may prove fatal4 ,eosinophilia is a helpful diagnostic point4 ,edema1 especially of the face1 is an important symptom4 ,profuse sweats1 itching and tingling of the skin have been observed4 ,diagnosis4--,epidemics of this disease are more easily diagnosed than an isolated case4 ,among the ,germans1 if cases of apparent typhoid fever occur after a picnic or other feasting occasion1 where raw ham or sausages have been indulged in1 this disease should be suspected4 ,examination of the stools and of the muscles will be of aid4 ,the worms may be discovered in the pork1 a portion of which has been eaten by the patient4 ,prognosis4--,this depends upon the number of worms ingested4 ,the prognosis should always be guarded4 ,early1 marked diarrhea is favorable4 ,treatment4--,prophylactic treatment is of great importance in trichiniasis4 ,inspection of the meat supply1 is doing much to prevent trichiniasis2 although the most practical way to prevent the disease is to thoroughly cook all pork and sausages4 ,the central portions of the meat should be well cooked4 ,in the feeding of hogs care should be taken that they do not receive any offal1 but only milk1 grain1 vegetables1 etc4 ,when a person is infected with trichiniasis1 thorough and prompt evacuation of the bowels should be performed at once1 so that the embryos will not have time to pass into the muscles1 but will be ejected from the body4 ,this should be followed by a thorough and persistent treatment for several days of the liver and intestines2 treat both the liver and intestines directly and through the spine4 ,the object of this treatment is to render all the digestive juices active1 so that they may dislodge the animal parasite1 and to prevent their passing into the muscles4 ,also keep the bowels active for several days4 ,when the larval parasites have entered the muscles1 a treatment cannot be applied to affect them directly1 but the health of the body should be maintained if possible1 and the severer symptoms1 as the muscular pains1 weakness and insomnia combated4 ,thorough manipulation1 massage and hot baths will be of special aid in relieving the stiffness and weakness of the muscles4 ,filaria 7,filaria ,sanguinis-,hominis7 ,there are two varieties4 ,one is a thread-like worm with tapering1 blunt ends1 appearing in the blood at night1 hence called nocturna1 while the other is of slightly different form1 appearing in the blood only by day and is called diurna4 ,the mosquito is the communicating host of the parasite4 ,during the night1 or should the patient sleep during the day1 the nocturna appears in the peripheral circulation1 while during the other interval they are probably in the other vessels1 particularly the lungs4 ,after the mosquito has taken blood from an affected patient it requires from six to seven days for the metamorphosis of the minute filaria which are then lodged in the probosis of the mosquito and introduced into the blood of the next victim4 ,the adult parasite is from three to four inches long and the thickness of a coarse hair1 with clear sexual distinction4 ,pathologically there are no distinct lesions1 as the parent worm must establish one4 ,lymphatic engorgement may result from plugging of the thoracic duct or of a large lymphatic with consequent engorgement which may develop symptoms in the inguinal glands1 pelvic and lumbar lymphatic trunks4 ,as these varicosities develop rupture may occur2 if into the genito-urinary tract chyluria or chylocele may result1 or if in the abdominal cavity chylous ascites4 ,lymphangitis follows a lymph stasis1 which later results in elephantiasis4 7,barbadoes leg47 ,symptoms4--,elephantiasis affects the legs1 but the arms rarely2 the labia of the female and scrotum of the male2 occasionally the breasts and other parts of the body4 ,fever is present on account of the lymphangitis1 accompanied by rigors and delirium and there is marked local inflammation4 ,the attack terminates in a pronounced sweat4 ,in deeper parts there is deep seated pain and signs of sepsis1 while abscesses may develop over the inflamed area4 ,the varicose inguinal glands are doughy1 soft and painless1 with both sides affected alike4 ,the scrotum is affected by the extension1 and at times the testes4 ,treatment is surgical1 as the tumors must be removed4 ,unless the female worm is also removed this is1 however1 only palliative4 ,methylene blue is said to be destructive to the filaria and it is practically harmless to the human body4 ,the only treatment is one that will aid in building up the general health4 ,,hemorrhages ,nasal ,hemorrhage 7,nose bleed2 ,epistaxis7 ,osteopathic ,etiology and ,pathology4--,traumatism1 such as picking the nose1 blows1 and surgical operations2 straining when coughing2 nasal tumors and ulcerations2 lesions of the atlas1 or any lesion of the upper cervical vertebr1 that would interfere with the vasomotor distribution to the nose and cause local congestion or weakness of the blood vessels2 obstructions to the general circulation2 irregularities or suppression of the menstrual flow may result in nose bleed1 as a vicarious menstruation2 suppression of a habitual hemorrhoidal discharge4 ,pathologically the great frequency of nasal hemorrhage is due to the great vascularity of the nasal mucous membrane4 ,usually in cases of spontaneous origin1 bleeding is from the region of the septal artery4 ,spontaneous bleeding may also occur from posterior hypertrophies or adenoid vegetations4 ,the blood flowing downward into the fauces1 is expectorated in such cases1 and may be mistaken for a hemorrhage from the lungs4 ,treatment4--,the position of the individual is important4 ,he should assume a sitting posture1 or as nearly so as possible4 ,holding the nostrils tightly1 or plugging them with a piece of cotton1 will favor the formation and retention of a clot1 so that the hemorrhage may be controlled4 ,pressure upon the carotid artery1 or upon the facial artery at the angle of the inferior maxilla1 will slow the blood current and favor the formation of a clot1 also pressure on the sides of the bridge of the nose may influence it4 ,correcting any lesions that may exist in the superior cervical region1 as derangement of the vertebr or contracted muscles1 will remove obstructions or irritations to the vasomotor system of the affected region1 and thus equalize the vascular system4 ,holding the arms above the head1 and the application of ice to the nose are of aid in some cases4 ,also1 injection of cold or hot water into the nostrils4 ,in serious and obstinate cases1 where other methods fail1 a plugging of the anterior and posterior nares should be resorted to1 using absorbent cotton or gauze4 ,broncho-pulmonary ,hemorrhage 7,hemoptysis7 ,osteopathic ,etiology and ,pathology4--,pulmonary congestion2 croupous pneumonia2 tuberculosis2 hemorrhagic infarction2 ulcers of the larynx1 trachea or bronchi2 gangrene of the lung2 fibrinous bronchitis1 carcinoma of the lung2 lesions of the ribs or vertebr from the second to the seventh dorsal inclusive1 may cause diseases of the bronchial tubes or lungs1 that result in hemoptysis1 or the hemorrhage may be caused directly by extreme congestion resulting from the disordered vasomotor nerves2 diseases of the heart1 such as mitral disease1 causing pulmonary congestion2 aneurism of the branches of the pulmonary artery2 vicarious menstruation from deranged menstrual functions2 diseases of the vessel walls1 or blood1 as scurvy1 anemia1 hemophilia1 etc4 ,pathologically in many cases1 the lesions are microscopic1 consisting of ruptured capillaries4 ,in other cases larger vessels may be ruptured1 or are the seat of erosion4 ,many other lesions may be observed4 ,after death the bronchial mucosa is occasionally found inflamed and the lung tissues paler than normal4 ,diagnosis4--,a differential diagnosis must be made between epistaxis1 hemoptysis and hematemesis4 ,in epistaxis the blood may flow from the posterior nares into the pharynx2 it causes coughing and a discharge of the blood may occur the same as in hemoptysis4 ,a careful examination of the nasal region alone can determine the source of the bleeding4 ,in hemoptysis the history of the case as to pulmonary or cardiac diseases is to be considered4 ,there is a feeling of weight and of uneasiness in the chest4 ,a salty taste and a tickling of the throat precedes the bleeding4 ,the blood is ejected by coughing and is bright red1 frothy1 very little coagula1 and is alkaline in reaction4 ,in hematemesis the history would indicate disease of the stomach1 spleen1 liver or heart4 ,uneasiness1 and occasionally nausea and faintness1 precedes the bleeding4 ,the blood is ejected by vomiting1 and is dark1 clotted or fluid1 mixed with food1 and is of acid reaction4 ,in a few instances the blood due to hemoptysis may be swallowed1 and vomited4 ,treatment4--,in all these cases of hemoptysis the patient should be placed in bed and absolute rest demanded4 ,an attempt should at once be made to correct any lesion that may be found influencing the cause of the bleeding4 ,correcting lesions to the vasomotor nerves of the lungs and bronchial tubes1 and equalizing the disturbed vascular area1 may be sufficient in a number of cases4 ,these lesions will be found principally in the upper dorsal region4 ,in some cases1 perhaps1 there is an impairment of the trophic nerves by the same lesions1 thus interfering with the tone of the vessel walls and pulmonary tissues4 ,the diet should be light1 nutritious and non-stimulating4 ,the use of hot drinks is to be avoided4 ,the rapidity of the heart's action should be reduced4 ,this is best performed by thorough treatment of the dorsal spinal nerves of the left side over the heart1 and by inhibition in the suboccipital region4 ,the ice-bag to the precordia is also helpful4 ,iced drinks and the eating of ice is of aid4 ,stimulation of the systemic circulation will be of value in helping to relieve the pulmonary congestion1 although the two systems are somewhat independent of each other4 ,also1 hot foot baths and the evacuation of the bowels may be of additional value4 ,in cases due to organic disease of the heart1 the mind and body should receive absolute rest1 so that the diseased areas may be strengthened as much as possible2 besides a tonic treatment for the heart's action is necessary4 ,after the hemorrhage has subsided care should be taken that bleeding does not occur again4 ,all irritations of the respiratory tract should be avoided4 ,a stimulating diet1 tobacco and alcohol should be avoided4 ,nutritious food and a moderate amount of exercise is indicated4 ,hemorrhage of the ,stomach 7,hematemesis7 ,osteopathic ,etiology4--,injuries to the stomach2 local diseases1 as congestion1 ulcers and cancer2 vicarious menstruation2 a mechanical obstruction to the portal circulation2 spinal lesions to the vasomotor nerves of the stomach2 alterations in the blood2 perforation of the stomach walls1 involving a blood vessel2 disease of some neighboring organ4 ,diagnosis4--,a careful examination of the case and of the blood ejected will be necessary to determine the nature of the cause4 ,the differential diagnosis as to the source of the blood1 whether from the stomach or lungs1 was given under hemoptysis4 ,treatment4--,correction of any lesions that may influence the blood pressure in the region of the stomach1 is the first requisite4 ,treatment of the splanchnics has the greatest influence upon the vasomotor nerves to the stomach4 ,treatment of the vagi nerves and of the fourth and fifth dorsals1 will quiet the violent movements of the stomach1 and thus aid in controlling the hemorrhage4 ,stimulation of the cervical sympathetics and heat applied to the feet will tend to equalize the vascular system1 and thus lessen the gastric congestion4 ,the application of a broad flat ice-bag over the stomach will be of great value4 ,keep the patient quiet in bed4 ,surgical interference may be necessary4 ,intestinal ,hemorrhage ,osteopathic ,etiology4--,an obstructed circulation of the blood through the venaporta1 as in diseases of the heart1 lungs and liver2 lesions of the vertebr deranging spinal nerves to the intestinal blood supply2 injuries caused by corroding or cutting substances2 mechanical injuries to the intestines2 degeneration or erosions of the blood-vessels from ulcers of the intestines1 as from typhoid fever1 typhus1 dysentery1 etc42 disordered menstrual or hemorrhoidal discharges4 ,diagnosis4--,the locality of the intestines affected can be approximately determined by an examination of the discharged blood4 ,when the blood comes from the upper part of the intestines1 it is generally dark and mixed with the intestinal contents1 which gives it a tarry appearance4 ,it is generally red and fluid when it comes from the lower portion of the bowels4 ,if from the stomach1 the blood is thoroughly mixed with fecal matter4 ,throwing the passage into water1 the water is colored red when it contains blood1 and if the contents contain bile the water is colored green or yellow4 ,also1 noting the areas of contracted muscles1 as in intestinal colic1 will aid in the regional diagnosis4 ,treatment4--,absolute rest in all cases is necessary1 the patient remaining as quiet as possible4 ,food1 in severe cases1 should not be given for ten or twelve hours4 ,the bed-pan should be used in caring for the evacuations4 ,correction of the lesions along the spinal region1 chiefly of the lower dorsal and lumbar regions1 that are impeding the innervation to the intestines1 should be attended to at once4 ,this treatment tends to relieve any hyperemic condition of the intestinal mucosa and influences the whole vasomotor area of the mesentery4 ,direct treatment of the abdomen in a few cases is of great value to relieve obstructed and contracted vessels in the mesentery1 but in certain pathological conditions1 e4 g41 typhoid fever1 leave the abdomen alone4 ,treatment 7inhibition7 along the spinal column from the sixth dorsal to the coccyx is helpful in all cases to quiet the peristalsis of the intestines4 ,in severe cases cold drinks1 eating of ice and an ice pack to the abdomen are of aid4 ,in a few instances surgical measures will be necessary4 ,hematuria ,osteopathic ,etiology4--,congestion and acute inflammation of the kidneys1 exacerbations of pyelitis1 renal calculi1 chronic nephritis1 traumatism1 tuberculosis1 etc42 affections of the urinary tract1 as calculi or lacerations of the ureter2 calculi1 cystitis1 ulcerations1 etc41 of the bladder2 calculi1 gonorrhoea1 parasites1 etc41 of the urethra2 general diseases1 chiefly the acute specific fevers and blood diseases2 blows1 wounds and traumatic influences1 external to the kidneys2 lesions of the renal splanchnics4 ,diagnosis of the locality of the hemorrhage in the urinary tract3 ,in hemorrhage from the kidney the blood is thoroughly mixed with the urine1 giving a uniform color4 ,blood casts and leucocytes are present4 ,in hemorrhage from the ureters the blood is usually molded in clots which conform to the shape of the ureter4 ,the clots appear like small dark worms4 ,in hemorrhage from the bladder the blood is not thoroughly mixed with the urine and large clots form upon standing4 ,in hemorrhage from the urethra the blood often discharges without micturition4 ,when urine is passed the blood precedes the passage of urine4 ,treatment4--,rest is essential4 ,a correction of the lesions to the renal splanchnics is necessary to control the congestion and inflammation of the kidneys4 ,when the ureters1 bladder or urethra is involved1 attention must be given to the condition of the spinal column below the renal splanchnics4 ,in all cases the inhibitory treatment to the lower spinal column and ice to the loins are of value4 ,if surgery is indicated1 do not delay operation4 ,uterine ,hemorrhage ,most of the causes of uterine hemorrhage come under the subject of obstetrics2 others under menorrhagia and metrorrhagia4 ,such will be found in obstetrical and gynecological works4 ,treatment4--,the patient should assume the dorsal position with the buttocks raised4 ,if any displacement of the uterus is present or if there is any foreign material in the uterus1 usually such should be corrected or removed at once4 ,stimulation of the clitoris is a most effectual means to control uterine hemorrhage2 it contracts the circular fibres of the uterus4 ,stimulation of the uterus directly through the vagina1 and over the abdomen1 and stimulation of the upper wall of the vagina1 will aid in contracting the uterus4 ,a quick1 unexpected pull of the hair on the mons veneris will have the effect of closing the capillaries by shock to the nervous control 7,dr4 ,still74 ,before closing the os1 however1 it is well to know that there is no irritating foreign material within the body of the uterus4 ,correction of obstructions of the vasomotor nerves of the uterus through the splanchnic and lumbar region is important4 ,compression of the abdominal aorta1 and vaginal injections of hot water may be of aid1 as will also a hot water bag at the lumbar region and ice water bag over symphysis4 ,in severe cases inversion of the body1 if it can be done with safety1 may be performed4 ,packing the vagina is a method resorted to occasionally in severe cases4 ,hiccoughs ,occasionally there is a case of hiccoughs that has been continuous for hours or even days and that all efforts have failed to stop4 ,they are caused by an irritation to the peripheral distribution of the phrenic nerve from some gastric disturbance or a local irritant acting upon the center in the medulla4 ,it may follow fright or great emotion and be associated in persistent form in rheumatism1 typhoid fever and other febrile diseases4 ,it follows abdominal operations at times and is very distressing4 ,when occurring in elderly people with pneumonia and in peritonitis with distention it usually marks the end4 ,the same may be said in case of carcinoma of the stomach and bowels4 ,treatment4--,go first to the origin of the phrenic nerve at the third1 fourth and fifth cervical and1 if there is a lesion as there will probably be1 adjust it and note results4 ,this will be sufficient in many cases4 ,failing1 bring direct pressure on the nerve just above the clavicle and anterior to the sternomastoid muscle and release the scaleni muscles4 ,after this examine and treat at the fifth and twelfth dorsals4 ,correct any lesions but best results will be had from inhibition at these points4 ,another method is to stand beside the patient and insert the fingers of both hands under the costal end of the ribs and lightly pull4 ,firm pressure over the solar plexus with flat of the hand is sometimes beneficial4 ,in hysterical cases1 drawing out the tongue will often be effective and it has been suggested that standing the patient on the head will stop them in short order4 ,tickling the nose to produce violent sneezing is an ancient remedy4 ,some one of these will cure the case1 as osteopathy has never failed so far as recorded4 ,the stomach should be emptied of all irritating matter to prevent recurrence4 ,,varicose ,,veins ,in varicose veins there is a dilatation of the calibre of the veins and their valves are insufficient4 ,the walls are irregularly thinned1 lengthened and tortuous4 ,osteopathic ,etiology and ,pathology4--,the internal saphenous is the vein most frequently affected1 although any vein throughout the body may become varicose4 ,commonly1 varicose veins occur in the lower extremities and occasionally in the arms4 ,the valvular insufficiency is caused by stretching of the wall of the vein1 thus separating the thin1 free edges and leaving an interspace that allows regurgitation of the blood4 ,the valves becoming insufficient1 the column of blood in the veins has no support against gravity1 and being interrupted in its course does not flow normally into collateral channels4 ,the walls of the veins become thin1 as does also the adjacent skin1 thus increasing the danger of a rupture1 either external or subcutaneous4 ,varicose veins are most frequently found in females1 following uterine enlargements4 ,the condition may be due to any obstruction or constriction that prevents the free return of blood from the veins1 such as dislocations of the hip1 either slight or complete1 dislocations of innominata1 contractions of adductor magnus muscle affecting femoral vein1 prolapse of diaphragm obstructing vena cava1 tissue constrictions about the saphenous opening1 garters1 and1 in fact1 anything that might impede the free venous flow4 ,the tendency to varicose veins increases as age advances1 and many cases are found among people of middle life who have been accustomed to standing a great deal4 ,injuries to the pelvis1 thigh or leg1 lessening the nutrition to the leg1 or injuries to the nerves1 as vertebral dislocations in the lower dorsal or lumbar regions 7the fourth lumbar especially7 may be causes of varicose veins4 ,pregnancy or tumors in the abdomen or pelvis1 causing pressure upon the iliac veins1 are occasionally causes4 ,distention of the sigmoid flexure1 causing pressure upon the left iliac vein1 or distention of the cecum2 pressing upon the right iliac vein1 are fruitful sources1 as are also diseases of the heart and lungs4 ,varicose veins of the upper extremities are due to occupations requiring overuse of the arms4 ,complications4--,varicocele1 hemorrhoids1 labial varix in the female1 varix over pubes1 ulceration and eczema due to disturbances of nutrition1 edema and thrombus4 ,symptoms4--,lower ,extremities4--,cramping pains in the limbs upon rising4 ,fullness and heaviness of the limbs4 ,inspection may reveal superficial varicose veins near the saphenous opening1 upon the external thigh1 in the popliteal space1 upon the external leg or behind the ankles4 ,edema and congestion of the foot and ankles occur in a few cases4 ,pain is quite a prominent symptom1 due to pressure upon the nerve fibres4 ,eczema and itching are due to disturbed innervation and blood supply to the skin4 ,ulceration may occur1 due to the bursting of a vein4 ,upper ,extremities4--,before the varicosity appears there is usually pain or a feeling as of a sprain in the involved region of the arm4 ,the pain is usually confined to a muscle or group of muscles4 ,treatment4--,the majority of cases are due to disorders about the pelvis1 hip or thigh1 and the treatment resolves itself into the removal of these obstructions or constrictions4 ,occasionally cases are caused by partial dislocations of the hip joint1 which can be easily overlooked during a hurried examination4 ,the slipping of an innominatum is an important factor4 ,rest in a recumbent position1 attention to the general health1 and especial attention to the bowels and liver1 are essential in acute attacks4 ,occasionally the heart and lungs are at fault4 ,treatment twice per week should consist of removing any of the numerous causes of the condition1 and spinal treatment as well2 then the leg should receive special attention4 ,remember1 thrombi may form and the vein must1 under no circumstances1 be touched in the treatment4 ,begin by carefully rotating the leg to stretch contracted tissue about the saphenous opening1 then separate the tendons of the popliteal space and follow the course of the vein to the abdomen and relax tissue about it4 ,keep patient off the feet as much as possible and elevate the leg when sitting4 ,in rupture of varicose veins the hemorrhage can be arrested by elevating the limb and applying pressure with the fingers1 above and below the wound1 until a compress and bandage can be applied4 ,the support of the varicose veins by elastic stockings will ease the pain and prevent edema in many cases1 but1 as a rule1 it is a direct hindrance to the circulation on account of the necessity of having the stocking fit closely4 ,surgical operations are rarely indicated4 ,phlebitis 7,phlegmasia alba dolens2 milk leg7 ,an inflammation of a vein4 ,in the condition described here it is a puerperal septic inflammation of the femoral vein4 ,about the third week after confinement there is a swelling of the leg with or without redness4 ,great pain accompanies the condition and the temperature gradually rises to #ajb-c4 ,as understood by osteopaths1 this is the result of a partial closing of the saphenous opening during parturition so that the venous flow is partly stopped4 ,treatment consists in carefully rotating the leg at the hip so that the fascia lata is spread1 opening the lumen of the vein so the congestion will drain out4 ,there will1 also1 probably be found innominate or lumbar lesions which must be adjusted with the result that almost immediate relief is given as a rule4 ,chronic ,phlebitis ,the chronic form shows considerable inflammation along the line of the vein marked by tenderness1 edema and thickening of tissue4 ,the entire leg may be more or less involved through circulatory injury4 ,in these cases will be found definite innominate lesions of a primary type or the distortion is superinduced by lumbar lesions4 ,a few cases are quickly cleared up through adjustment that is readily secured4 ,however1 in others1 there being considerable thickening of the sacro-iliac articulating tissues1 some time may be required to get complete adjustment and consequent restoration of femoral circulation4 ,in addition to this1 careful abduction1 flexion1 hyperextension and circumduction is indicated4 ,this last technique should be executed with great care and with due regard to pathology4 ,if ,dr4 ,still's emphatic command were followed1 that all maternity patients should have both legs rotated and innominates inspected1 there would be no phlebitis cases1 acute or chronic4 ,,the ,,rectum ,to treat the rectum intelligently and thoroughly1 requires special knowledge on the part of the osteopath4 ,a speculum should be used in many cases when making an examination1 and all abnormal conditions carefully inspected with the eye2 although much can usually be noted by the examination with the finger alone4 ,the best position in which to give an examination and treatment is to have the patient on the side1 with thighs flexed upon the abdomen4 ,in a few cases the patient may lean over an operating table4 ,the objects of rectal treatment are many--to relieve hemorrhoids1 etc41 of the mucous membrane2 to correct a dislocated coccyx2 to treat an enlarged prostate gland2 to replace a prolapsed rectum2 to tone the lower bowel in cases of constipation2 to give reflex stimuli to the heart and lungs1 in cases of fainting1 paroxysms1 etc42 to relieve severe pains in the rectum at the time of the menstrual period1 and to relieve congestion1 inflammation1 contracted tissues1 etc41 of local sources2 to relax spasms in croup1 and to remove tension to the nervous system in some forms of insomnia4 ,in fact1 so many diseases are affected by reflex irritations from the rectum that its examination is a necessity in many cases4 ,the phrase 8when in doubt treat the rectum0 was coined by a progressive student and there is an element of truth in it4 ,surgical assistance to treatment will be considered under hemorrhoids4 ,the principal need of osteopathic internal rectal treatment1 is3 7#a7 ,to relax all contracted and constricted fibres about the walls of the rectum and between the sacrum and coccyx4 7#b7 ,to correct a dislocated coccyx4 7#c7 ,to dilate the sphincters thoroughly1 in order to relieve irritations about the sphincters1 and to stimulate the sympathetic nerves4 ,work through the rectum to treat an enlarged prostate gland1 to correct a displaced uterus1 and to make a more thorough examination of the uterine tissues1 the ,fallopian tubes and the ovaries1 is a frequent occurrence4 ,in giving local treatment1 cleanse the fingers and oil the index finger2 then1 after introducing it into the rectum relax the contracted tissues by an upward sweeping motion on all sides4 ,this treatment relieves all obstructions to vessels and nerves caused by contracted fibres1 and tones the rectal walls4 ,in prolapsed sigmoid1 causing obstructive constipation1 the finger can be used to separate the folds of mucous membrane and open the lumen of the bowel4 ,frequently there will be enough tone to the muscular coat so that the irritation will set up slight peristalsis and cause the bowel to draw up to a considerable degree4 ,in children where there is much straining at the stool1 the sigmoid will often be found down and by using the little finger the same results can be accomplished and much relief given4 ,to dilate and stretch the sphincters thoroughly a speculum or dilator should be used under anesthesia2 still1 considerable can be done by one or two fingers4 ,the sphincter should be thoroughly stretched in all directions1 care being taken when an instrument is used that too much force is not applied4 ,secure as much voluntary relaxation of the sphincter as possible4 ,inhibition at #b;d and #c;d sacral will aid4 ,this treatment is of aid in cases of hemorrhoids and prolapse of the rectum1 in constipation due to the loss of tonicity of the lower bowels1 in tightness of the sphincters1 in pain of the rectum1 and in stimulating the heart and lungs4 ,in cases of a prolapsed rectum1 due to irritation about the sphincters1 causing tenesmus1 this treatment is of special value1 as it gives the sphincter a physiological rest4 ,frequency of treatment per rectum must depend entirely on the patient and disease4 ,it can be given daily in many cases and is frequently so indicated in acute hemorrhoids1 prostatic troubles1 etc4 ,according to ,quain1 the sensory nerves to the rectum are from the second1 third and fourth sacrals4 ,some of the motor fibres of the circular muscles of the rectum are from the lower dorsal and upper two lumbar nerves2 these pass by the aortic plexus to the inferior mesenteric ganglion4 ,associated with these fibres1 are the inhibitory fibres of the longitudinal muscles of the rectum4 ,the sacral nerves contain motor fibres to the longitudinal muscles1 and inhibitory fibres to the circular muscles of the rectum4 ,in all cases of rectal trouble1 the lower dorsal and upper lumbar vertebr may be found deranged1 and thus interfere with the rectal nerves4 ,relaxation of the sacral muscles over the sacral foramina has a marked effect in relieving tenesmus4 ,in dysentery1 where there is a constant desire to defecate1 a thorough upward relaxation of the sacral muscles will give great relief4 ,proctitis or inflammation of the rectum is not an uncommon disorder4 ,the disease has been divided into acute1 chronic1 gonorrheal1 dysenteric1 and diphtheritic4 ,foreign bodies1 impacted feces1 cold1 purgatives1 prolapse of the sigmoid1 and lumbar1 coccygeal and innominate lesions are the most important causative factors4 ,the acute form is more frequently found in older people4 ,the symptoms are tenesmus1 frequent evacuations of blood and mucus 7possibly pus71 prolapse of the mucous membrane1 feeling of fullness1 and radiating pains4 ,the gonorrheal1 diphtheritic and dysenteric forms are of rare occurrence1 with the exception that the dysenteric may be somewhat frequent4 ,the treatment is to remove all local irritations1 cleanse the bowels1 and put the patient in bed4 ,all irritating foods are to be prohibited4 ,use milk1 soups1 beef juice1 soft boiled eggs and similar foods4 ,correct all osteopathic lesions2 especially will inhibition over the sacral foramina relieve the tenesmus4 ,cold water in the rectum and applied to the anus will be beneficial4 ,if abscesses occur1 employ surgical measures4 ,prolapse of the rectum is another common rectal disorder4 ,acute cases are especially found in children1 due to straining at stool4 ,the sacrum is more straight1 and thus violent straining1 coughing1 etc41 the more readily produces prolapse4 ,prolapse of the mucous membrane is the most common1 although all of the rectal coats may be involved4 ,prolapse of the upper part of the rectum into the lower or invagination is frequently met with by osteopaths4 ,the sigmoid may prolapse and also affect the rectum4 ,the treatment is to return the mass1 using an anesthetic if necessary4 ,if it is not retained1 place straps across the buttocks4 ,then with attention to lesions that may be disturbing and weakening the rectal walls1 and thorough local toning treatment1 the prognosis should be favorable4 ,in high rectal prolapse local attention is necessary as well as deep treatment through the abdominal walls to the sigmoid and upper rectum4 ,the use of ,cole's irrigator for high enema will replace and elevate both the upper rectum and sigmoid and greatly aid in a cure4 ,regularity of habits and proper food are essentials4 ,hemorrhoids ,definition4--,a dilated or varicose condition of the plexus of veins lying in the submucous tissue of the lower part of the rectum4 ,the dilatation of these hemorrhoidal veins may extend into the adjoining subcutaneous tissues and mucous membrane1 and the perirectal plexus and adjoining venous plexuses of the bladder1 uterus1 vagina and sacral canal may become involved4 ,osteopathic ,etiology and ,pathology4--,the chief predisposing cause of piles is man's erect position and the absence of valves in the hemorrhoidal veins4 ,thus a retardation or stagnation of the portal vein would cause a backward movement of the entire column4 ,it is evident that such a downward pressure of the blood in the portal system would dilate and extend the blood vessels1 to the very capillaries in the rectal region4 ,this retardation may arise from several causes3 obstruction of the portal vein1 from diseases of the liver2 diseases of the heart2 obstruction or destruction of the capillaries of the lungs2 pressure from a gravid uterus1 tumor1 etc42 a general loss of tonicity of the abdominal walls1 as in persons who take but little exercise2 the excessive use of wine1 tea and coffee2 injuries to the spinal column1 especially in the lumbar1 sacral and coccygeal regions2 a dislocation of an innominate bone2 lifting2 constipation2 straining at stool2 carelessness of the calls of nature1 etc4 ,catarrh of the bowels may cause a congestion of the mucous membrane and consequently piles4 ,hereditary influence may be a factor in a few cases4 ,hemorrhoids are divided into two classes1 external and internal4 ,an external pile is one that arises from the margin of the anus outside of the external sphincter muscle4 ,it differs from the internal pile from the fact that it is always composed either of skin or hypertrophied connective tissue1 forming a mere cutaneous tag1 or else it is composed of a small cutaneous vein enlarged by a clot of blood4 ,the internal hemorrhoids are composed mostly of enlarged veins and are connected by hypertrophied connective tissue4 ,they have a free arterial supply and are covered by the mucous membrane of the rectum4 ,they are due1 usually1 to an affection of the middle hemorrhoidal blood supply1 thereby being a part of the visceral vascular system4 ,internal hemorrhoids1 when protruding1 can be returned within the rectum1 while the external ones cannot4 ,the venous turgescence varies in size from a pea to a walnut4 ,they may be single or may surround the entire anal opening like a bunch of grapes4 ,repeated attacks of engorgement of the veins involved1 will in time change the mucous membrane or the submucous tissue1 and cause catarrhal swelling of the mucous membrane1 or hyperplasia of the connective tissue4 ,at first the hemorrhoid is usually a blood tumor1 but in chronic cases it is oftentimes made up largely of connective tissue4 ,owing to pressure of the varicose veins1 atrophy of the mucous and submucous tissue may occur4 ,the white or slimy hemorrhoids occur when these roughened parts of the mucous membrane become inflamed and thickened1 resulting in suppuration4 ,symptoms4--,the symptoms are quite diagnostic and need not be mistaken4 ,besides the appearance of tumors1 there may be constipation1 pain during stools1 indigestion1 headache and pain in the back4 ,hemorrhages frequently occur1 and if suddenly checked1 as by cold1 other disturbances may occur1 as congestion of the head1 lungs1 stomach1 liver1 kidneys1 etc41 which may result in hemorrhages from these organs4 ,fissures of the anus1 contraction of the rectal sphincters and prolapse of the rectum may occur4 ,occasionally in old people there is a varicose state of the veins of the neck of the bladder1 and in females1 of the uterus and vagina1 which causes hemorrhages of these organs4 ,the communicating plexus of the spinal canal may be affected1 causing weight1 numbness and pain1 so as to simulate a lesion of the cord4 ,the patient may have a hypochondriacal disposition and be disinclined to work1 especially at mental labor4 ,prognosis4--,depends upon the predisposing and immediate causes1 but a large majority of cases can be cured4 ,treatment4--,a thorough examination of the patient should be made1 not only to ascertain the extent of the local trouble1 but to understand thoroughly the general health of the sufferer1 especially the state of the heart1 lungs and liver4 ,many cases of hemorrhoids are caused by lesions in the lumbar and sacral regions1 and especially dislocations of the coccyx 7usually anterior7 and the innominata4 ,correcting these lesions will oftentimes cure the hemorrhoidal disorder4 ,simple dilatation of the rectum once a week1 in addition to other treatment1 is of great aid in curing hemorrhoids1 not a few of the cases being cured by dilatation alone4 ,it relaxes the tissues about the tumefied vessels4 ,treatment is rarely necessary above the second lumbar1 7unless there is more or less of a constitutional disorder7 as the superior hemorrhoidal blood vessel of the inferior mesenteric is given off about opposite the second lumbar4 ,in cases where the abdominal walls have become relaxed1 a treatment should be given to strengthen the abdominal muscles and viscera4 ,particular attention should be given the liver4 ,treatment should be given over the abdominal muscles directly1 and also to the spinal nerves of the same region4 ,the diet should be strictly regulated and the bowels kept loose1 and stimulants1 indigestible food1 full meals and too much meat should be avoided4 ,injection of cold water before stools is a good prophylactic1 and applications of cold water to the protruding pile will be of some help in relieving the congestion4 ,a squatting position during defecation will relieve considerable strain4 ,hemorrhoids in the acute state1 within twelve or twenty-four hours from the engorgement1 yield quickly to treatment4 ,the local technique is to relax the tissues about the tumor1 especially above and along the line of the vein1 then with pressure at its base carefully force out the engorged blood4 ,follow this up by another treatment the next day and continue until normal4 ,the vein wall1 not being permanently stretched1 will contract and if the irritating cause is found1 there is little danger of return4 ,remember1 in a case like this1 the danger of embolism and be sure a clot has not formed4 ,cases of hemorrhage at stool1 during or immediately following evacuation1 when not from a bleeding pile1 may be of considerable quantity and the source difficult to locate4 ,it may be due to ulcerations or easily ruptured capillaries of the mucosa1 but the cause will in many cases be found in the innominata and a reduction of the lesion give relief4 ,rectal conditions1 associated with piles1 and requiring surgery after treatment has failed1 are3 hemorrhoids1 which are of such long standing as to become organized tissue1 7these will keep up continual irritation and cannot be absorbed72 saccules or pocket1 formed by folds of mucous membrane catching and holding particles of feces1 gradually enlarging and ending with considerable reflex symptoms2 fistulae1 complete or incomplete1 may frequently be healed by adjusting coccygeal or innominate lesions1 but are apt to recur from the tract not being clean in the center or bottom2 abscesses in or about the anus or rectum are usually traced to coccygeal1 innominate1 or local interference to circulation2 fissure1 complete dilatation under anesthesia to insure physiological rest of parts1 is probably the best treatment4 ,it is suggested that a fissure may be healed by making surgically clean1 touching with iodine and coating with collodium4 ,papillae are small1 hard black-capped papules in the lower rectum1 each one involving a nerve terminal and causing much distress4 ,all these conditions give rise to much discomfort and with surgical assistance can be cured without much trouble4 ,it is not necessary to make them a major operation and do uncalled-for things4 ,the less surgery about the rectal sphincter the better4 ,care of the anus and rectum after operation or successful treatment is a factor in preventing return4 ,first1 there should be soluble1 non-irritating stools1 which do not tend to bring about prolapse from straining4 ,diet and regularity contribute to this4 ,second1 absolute cleanliness4 ,this can only be obtained by following the stool with an enema of four or five ounces of cool water and immediately passing it4 ,it will bring forth a considerable quantity of feces which would otherwise have been retained for another twenty-four hours4 ,this procedure following1 as it does1 the stool does not in any way interfere with the normal function or create a habit4 ,the anus should then be thoroughly washed in cool water and as thoroughly dried4 ,dusting with borated talcum powder1 starch1 etc41 will prevent chafing4 ,,genito-,,urinary ,,the ,,prostate ,,gland ,this gland is subject to several painful and annoying diseases1 controlling1 as it does1 the flow of urine and exerting such a profound influence over the sexual functions4 ,the nerves to the prostate pass between the gland and the levator ani muscle1 and the secretory branches are from the sacral nerves1 while ,quain gives the sensory as from the tenth1 eleventh 7twelfth7 dorsal1 first1 second and third sacral and fifth lumbar4 ,lesions affecting the prostate are occasionally found at the tenth and eleventh dorsal and fifth lumbar1 while the innominate lesions are common causes of trouble4 ,these should be corrected1 if present1 and local treatment given to the gland4 8,massage of the prostate10 says ,lydston1#dg 8properly performed1 is one of the most valuable advances in genito-urinary therapeutics that has been developed in many years40 ,osteopathic technique is to place the patient on the side1 knees flexed1 and standing in front insert the index finger4 ,care must be used not to bruise the gland and it must be touched lightly when sensitive4 ,relax tissue about the gland1 and1 then1 from the median line with an outward movement1 massage the surface of each lobe4 ,this influences the blood and nerve supply1 while the pressure will tend to relieve congestion4 ,length of treatment1 as well as frequency1 depends entirely upon conditions4 ,do not make the mistake of treating the perineum instead of the gland and do not gouge it with the finger4 ,remember it is sensitive tissue4 ,hypertrophy is most commonly met with in practice1 as twenty per cent of men past middle life are said to be afflicted4 ,it is probably not a sequence of old age1 but due to chronic1 congestive and inflammatory conditions4 ,anything which would produce these conditions--spinal lesions1 excessive venery1 masturbation1 or other more innocent causes--would in time bring about enlargement4 ,as the length of catheter life is estimated at six years it is of great importance that the condition be early recognized1 for in advanced stages surgery is the last resort4 ,in early stages the prognosis is good1 either for a cure or to stop further enlargement1 while many enlarged ones at the catheter stage have been greatly benefited or cured4 ,treatment of the gland once per week is usually enough1 but in older cases can be given semi-weekly4 ,look well to nerve and blood supply4 ,acute ,prostatitis is a serious and painful inflammation1 causing urinary retention usually4 ,it results from trauma1 horseback riding1 over exertion1 gonorrhea and its maltreatment1 etc4 ,lower dorsal and lumbar lesions are frequent4 ,this condition must be closely watched4 ,inhibition of the sacral nerves will help control pain and stop any spasm of the sphincter4 ,cold applications to the gland externally at the perineum will aid in reducing inflammation4 ,local treatment should at first be given to the adjacent tissues as the gland will be very sensitive4 ,later direct massage will be of great benefit4 ,chronic ,prostatitis may follow an acute attack or it may originate as a chronic or subacute affection4 ,frequent micturition and dull pain1 referred to the perineum and rectum1 with the local examination1 make diagnosis sure4 ,the spinal lesions should be corrected and the gland massaged4 ,this will induce absorption1 by squeezing out the inflammatory products and do much toward preventing future hypertrophy4 8,massage is done by the finger4 ,the patient is placed in the knee-elbow position and massage employed for four minutes daily4 ,the value of massage in chronic prostatitis is very great1 but should be employed with much caution and never in cases of suppuration40#dh ,prostatorrhea is often taken for spermatorrhea and any irritation of anterior sacral nerves would cause undue activity to the secretory nerves to the gland4 ,this is easily determined4 ,the ,seminal ,vesicles can be reached just above the prostate1 and if inflamed and tender or if engorged by inspissated seminal fluid1 local treatment will be of benefit4 ,frequent massage1 daily in some cases1 to the gland and treatment to the sympathetic nerves above the trigone of the bladder1 to the nerve fibres passing along the spermatic cord1 and to the arteries directly1 will be of the greatest aid in impotency4 ,in ,chronic ,gonorrhea1 where the gonococcus has found lodgement in and about the gland1 it can be more readily dislodged by massage than by any other form of treatment4 ,retention of urine from nervous excitement or other minor causes1 can often be overcome by local massage of the prostate4 ,spastic stricture can usually be cured by work about the prostate and its innervation4 ,varicocele ,a varicose enlargement of the veins of the spermatic cord1 epididymis and testicle4 ,in varicocele the pampiniform plexus is usually enlarged1 but all the veins of the cord may be involved4 ,the swelling gets smaller under compression or in a horizontal position and enlarges again on standing erect4 ,it is almost invariably found on the left side1 and the testicle on the affected side is generally smaller and softer than its fellow4 ,the predisposing causes are a longer and tortuous spermatic vein on the left side2 the absence of support of the veins from surrounding muscles2 the imperfect valves2 the entry of the left spermatic vein into the renal vein at a right angle1 instead of at an acute angle like the right vein2 the more liability of compression of the left spermatic vein by accumulation of feces in the sigmoid flexure2 the lack of normal exercise of the sexual functions in young1 unmarried adults4 ,lesions in lower dorsal and upper lumbar affect the condition2 the eleventh dorsal particularly4 ,a lesion at the second lumbar may cause neuralgia of the testicle with engorgement of the vein4 ,the exciting causes are straining during stool1 heavy lifting1 excessive sexual indulgence or anything that would determine more blood to the testicles4 ,varicocele is similar to the varicose state of the hemorrhoidal veins and may have like causes4 ,the diagnosis is easily made4 ,the feeling of the veins between the fingers like a convolution of earth worms2 dull1 aching1 dragging sensation1 and possibly prostration1 weakness and dejectedness of spirits1 are characteristic symptoms4 8,the condition is devoid of danger1 except that it often begets morbid fears on the part of the patient1 usually the result of suggestion40#di ,the treatment consists of regulation of the bowels1 removal of such predisposing and exciting causes as may be found1 treatment of the vessels along the spermatic cord1 and treatment to the lower dorsal and lumbar regions4 ,in severe cases a suspensory bandage will give temporary relief4 ,surgical interference may be necessary in some cases in order to effect a cure4 ,impotency ,results from treatment in these conditions are particularly gratifying and offer a great field of activity in this day of sensational medical advertising4 ,this condition can well be classed under four heads1 ,exhaustive1 ,traumatic1 ,psychic and ,organic4 ,exhaustive ,impotency is the result of functional abuse1 masturbation in early life1 excessive venery1 coupled with intemperate use of alcohol and improper diet without sufficient sleep4 ,it can be symptomatic in neurasthenia4 ,there is at first irritation of the spinal centers1 which causes exaggerated sexual activity1 and later this is followed by complete or partial loss of function4 ,the first step is for a radical reform in habits2 regulation of the bowels1 as they will likely be constipated2 direction of the mind into wholesome channels1 and then skillfully directed spinal treatment4 ,where there has been masturbation1 look well for sources of irritation to the parts2 a long foreskin or adherent prepuce indicates surgical aid1 or there may be a lesion at the sacrals involving the nervi erigentes or1 of greater importance1 the pudic nerve4 ,the innominatum can be at fault in this4 ,the lower dorsal1 ribs and upper lumbar are of importance4 ,kraft-,ebing says3 8,conditions of absolute impotency are1 however1 rare1 and are caused only by severe vertebral and nervous diseases40 ,nerve irritation undoubtedly is the cause of sexual perversion 7outside of heredity and malformation7 so their relief is as necessary to bring about reform of habits as to effect a cure4 ,where the general health is affected constitutional treatment should follow4 ,motschutkovsky uses suspension in treating these cases with good results4 ,the effect is to separate the vertebr1 freeing spinal nerve and blood channels4 ,the prostate will probably be found in an irritated1 sensitive condition1 as well as the seminal vesicles4 ,treat as outlined under the prostate gland4 ,ligation of the dorsal vein of the penis is recommended by some authorities as tending to aid turgescence of the organ4 ,prognosis is so dependent on how well the patient follows directions1 age1 environment and general condition that it is hard to give1 but as a rule is rather favorable4 ,traumatic ,impotency is a strictly osteopathic classification1 for the reason that sexual weakness is often traced to lesions resulting from remote injuries4 ,these injuries may be to the spine1 ribs or sacrum4 ,the lower spine may be impacted from a fall or the result of long continued riding on rough streets or the railway4 ,this inhibits the nerve supply to the extent of often seriously impairing the sexual functions4 ,if the cord is injured to any extent the results are more serious4 ,treatment in these cases has given uniformly good results4 ,it will always be due to a specific lesion1 so the examination must be thorough4 ,psychic ,impotency is the form most frequently met with and generally the most difficult to cure1 yet it should not be if the patient's confidence can be secured1 for in many cases sexual power is but slightly impaired1 but owing to the suggestions given by the medical advertisers the victim diagnoses his own case as hopeless4 8,it is not uncommon that virility returns with the peace of mind40#ej ,observe all the procedure given and then inspire hope where it can be honestly given1 and if the patient is progressing favorably1 other things being equal1 advise early marriage under strict rules of conduct4 ,if already married1 conjugal relations should be most carefully investigated and the wife taken into your confidence4 ,her cooperation in correcting very possible errors in sexual matters1 as well as sympathetic aid in easing the patient's anxiety and chagrin1 will be invaluable4 ,nothing but the frankest understanding between all parties is permissible and the osteopath must be in absolute control4 ,organic ,impotency is the result of a cortical injury or disease4 ,the latter is the most common1 as it follows tabes dorsalis1 paralysis affecting the lumbar cord1 some cases of diabetes1 etc4 ,also1 any congenital malformations or absence of all or part of the organs4 ,prognosis in these cases is bad1 as cure is seldom possible4 ,in no other class of cases will honesty1 tact and good judgment count for so much or the rewards be greater4 ,,footnotes3 #dg ,twentieth ,century ,practice of ,medicine1 ,vol4 ,,xxi4 #dh ,c4 ,kruger1 ,munch ,med4 ,woch4 #di ,deaver's ,surgical ,anatomy1 ,vol4 ,,ii1 p4 #feb4 #ej ,vecki1 ,sexual ,impotence4 ,,heat ,,stroke 7,heat ,exhaustion3 ,sunstroke7 ,an affection produced by exposure to excessive heat4 ,two varieties are recognized2 heat exhaustion and thermic fever4 ,heat ,exhaustion4--,this is caused by prolonged exposure to high temperatures1 combined with physical exertion4 ,fatigue1 overeating1 alcoholic drinking1 and poor sanitation predispose4 ,this may occur without exposure to the direct rays of the sun1 the heat being artificial1 or in mid-summer1 in close1 confined rooms the same result will be produced4 ,there is vasomotor paralysis1 the surface of the body is usually cool1 the temperature may be as low as #ie degrees ,f41 while the pulse is small and rapid4 ,sunstroke or ,thermic ,fever4--,this is usually caused by prolonged work under the direct rays of the sun in a humid1 very hot and sultry atmosphere4 ,this is caused by the action of the heat upon the heart centers producing a paralysis of those centers4 ,pathologically1 rigor mortis develops early and is marked4 ,putrefactive changes appear early1 owing to the high temperature of the cadaver4 ,the various organs are deeply congested1 the venous engorgement is extreme in the cerebrum4 ,there is rigid contraction of the left ventricle2 while the right is dilated and filled with blood4 ,the blood is fluid and dark4 ,parenchymatous changes take place in the liver and kidneys4 ,in heat exhaustion with lowered temperature there is a paralysis of the vasomotor center in the medulla1 and the heat is dissipated more rapidly than it is produced4 ,in thermic fever the heat regulating centers become paralyzed by the action of the excessive temperature and more heat is produced1 and less dissipated than normal4 ,symptoms4--,heat ,exhaustion4--,this may occur gradually or suddenly with a severe attack of faintness1 pallor1 dizziness1 headache1 cold perspiration and sometimes blindness as the first symptoms4 ,consciousness is rarely entirely lost4 ,in severe cases there is more permanent collapse4 ,the pulse is rapid and feeble and there is great restlessness and delirium4 ,under prompt treatment mild cases may recover in a few hours1 while in extreme cases death may occur almost at once from heart failure4 ,thermic ,fever4--,in some cases the patient is struck down1 becomes quickly unconscious1 and may die within an hour1 or death may be almost instantaneous4 ,in other cases there is pain in the head1 oppression1 dizziness1 nausea1 vomiting and sometimes diarrhea or frequent micturition4 ,soon unconsciousness sets in1 the face is flushed1 the eyes injected1 the breathing labored and there is a temperature of from #aje to #aaj ,f4 ,the pulse is full and rapid1 the skin hot and dry and the pupils are contracted4 ,there is usually complete relaxation of the muscles1 and in some cases there is twitching and jactitation4 ,epileptiform convulsions are rare4 ,in fatal cases the coma deepens1 the pulse becomes feeble1 rapid and irregular1 the breathing hurried and shallow and death occurs in a few hours4 ,favorable cases are indicated by a fall in the temperature and by the return of consciousness4 ,in these cases recovery may be complete4 ,in some cases the patient may never be able to stand even moderate degrees of temperature1 which often produce excitement1 headache and pain in the cervical region4 ,failure of the memory1 and the loss of power to concentrate the mind are sometimes sequel4 ,meningitis1 epilepsy and insanity are also sequel4 ,diagnosis4--,this presents little difficulty4 ,the history and circumstances preceding the attack are very important in making the diagnosis4 ,the diagnosis between heat exhaustion and sunstroke fever is readily made4 ,in heat exhaustion the temperature is lowered1 the pulse is feeble1 consciousness is rarely completely lost2 in sunstroke fever the temperature is extremely high1 there is usually complete unconsciousness1 and the pulse is full and rapid4 ,prognosis4--,this should be guarded1 depending upon the severity of the case4 ,treatment4--,in cases of heat exhaustion remove the patient to a shady place and apply water to the face1 chest and spine4 ,thoroughly treat the upper cervical region1 in order to control the impaired vasomotor centers and nerves4 ,if the temperature is below normal a hot bath should be given4 ,keep the heart and lungs stimulated4 ,in sunstroke1 place the patient in a recumbent position and loosen all constricted clothing1 and stimulate the heart's action4 ,the high fever is to be met promptly4 ,place the patient in a bath of water1 to which add ice freely4 ,the patient may also be rubbed with ice1 and ice water enemata may be employed4 ,the muscles of the neck will be found contracted1 probably due to cerebral hyperemia4 ,a thorough relaxation of these muscles will be of great aid in equalizing the vascular system4 ,it is a good plan to thoroughly relax all the muscles along the spinal column for the same purpose4 ,when the temperature nears normal the baths should be stopped4 ,after the temperature has been reduced place the patient upon a cot with ice to the head4 ,the cervical treatment should be repeated as often as necessary4 ,the diet of the patient should be liquid for a few days4 ,plenty of water and stimulation of the kidneys and bowels will be found beneficial4 ,the sequel are to be treated according to the condition4 ,much can be done for the sequel of heat exhaustion and sunstroke4 ,lesions will be found corresponding to the regions involved4 ,deep contracted muscles are common4 ,,department ,,of ,,ophthalmology ,by ,c4 ,c4 ,,reid ,it is the desire to make this discussion on the eye the most useful possible to the whole profession4 ,let it be plainly understood that there is no effort to cover every phase of eye pathology but to elaborate eye diseases and therapeutics strictly from the standpoint of osteopathy4 ,there are many very elaborate and extensive text books and even encyclopedi written on the eye by the medical profession4 ,the world of ophthalmic literature is extensive and profound4 ,just so are the elaborations on the general field of medicine4 ,such things as hereditary influences1 congenital deformities1 amblyopias1 albinism1 coloboma and the field of ophthalmic surgery does not concern us at the present time in an osteopathic text book4 ,this department is dedicated to a scientific development of ophthalmic therapeutics along osteopathic lines of thought4 ,some things in the therapeutics of the eye concern all schools alike4 ,for instance1 proper cleanliness and antiseptic precautions in regard to the eye1 dietetics1 hygiene and the care of the general health4 ,the same anatomy and many of the same methods of examination and diagnosis obtain in all schools4 ,it is the intention to go into the opthhalmic therapeutic field in these discussions where osteopathy has a different outlook with a definite distinct reform to offer in the viewpoint of the anatomy1 methods of diagnosis and the system of treatment4 ,how to ,examine an ,eye ,it has been said that one should be a good general man in order to be a competent specialist4 ,this is especially true in regard to ophthalmic therapeutics4 ,many systemic diseases have eye symptoms and pathology4 ,the same blood and lymph that nourishes and bathes different parts of the body1 also circulates in the structures of the eye4 ,in the examination of the eye1 heredity1 occupation and environment are to be taken into consideration4 ,osteopathic lesions may exist from falls1 strains1 twists1 blows1 colds and exposure and impair the integrity of the metabolic processes of the eye through the nerve connections and blood supply and lay the foundation for a great variety of eye diseases4 ,with these lesions existing about the neck and upper dorsal1 it is only required to have some insignificant local irritant to start symptoms and cause pathology apparently out of all proportion to the etiology4 ,it is important then that one understand the nerve centers and reflexes and the osteopathic logic underlying these conditions or else he must frequently work without a satisfactory explanation of the etiology and consequently be more or less unscientific in his treatment4 ,the eye examination should consist of the case history1 the family history1 inspection1 osteopathic examination1 especially from the fourth dorsal vertebra to the occiput and especial examination of the eye by inspection and other methods4 #a4 ,the ,case ,history4--,thoroughness of the doctor1 or the lack of it1 will be readily displayed at this point4 ,every little thing1 as far as possible1 that has a bearing on the case should be observed and uncovered in the case history4 ,the physician should want to know every fact that helps him to better understand his case4 ,patience in hearing the history will often be of great assistance4 ,it gives light on the physical and mental condition of the patient4 ,much can be gained by being careful and attentive4 ,notice carefully what he emphasizes and what he thinks is the most important4 ,inquire in regard to headaches1 nervous symptoms1 previous eye trouble and past illnesses4 ,get a venereal history if present1 as many eye diseases are complicated or caused by syphilis or gonorrhea4 #b4 ,the ,family ,history4--,inquire as to blindness in the family and about the age it occurred1 if any4 ,get a venereal history if possible4 #c4 ,inspection4--,much inspection can go on while the history is being taken4 ,observe the countenance1 whether there is strabismus or frowning due to eye strain1 photophobia as suggested by the effort to avoid the light2 note symmetry4 ,look closely at the lashes1 lids1 conjunctiva1 cornea and iris4 ,note any scales or crusts on the lids at the root of the lashes4 ,turn the lids for further inspection4 ,note the size and relation of the eyes4 ,exophthalmos may be due to an enlarged globe in high myopia1 to ,graves' disease1 orbital tumor and paralysis of the extrinsic muscles1 or staphyloma4 ,in blepharospasm there may be a corneal ulcer or a rupture of the eyeball4 ,an exact examination must be made at the first visit in order for a diagnosis to institute the best treatment possible4 ,study the conjunctival sac for congestions1 hypertrophy1 swelling1 tumors1 foreign bodies1 trachoma bodies and secretions4 ,in all forms of conjunctivitis the congestion is most marked in the fornix and decreases toward the sclerocorneal junction4 ,in iritis and cyclitis there is a circumcorneal injection1 a pink or red color radiating from the cornea4 ,note any corneal pathology in the way of ulcers or abrasions and foreign bodies4 ,compare the tension of the eyes4 #d4 ,the ,osteopathic ,examination of the ,eye4--,this heading is put here in order to show what osteopathy has to offer that is distinct as belonging to our system and not practiced by any other school4 ,osteopathic research so far has shown that osteopathic science has much to offer on etiology and diagnosis and treatment in eye diseases4 ,the case history1 family history and inspection should require but a few minutes but they are essential to a proper examination and may aid us in what to expect osteopathically4 ,weak nerves will cause asthenopia4 ,a broken arch1 an innominate lesion or a slipped axis may cause weak nerves4 ,the osteopathic eye examination then should consider the whole mechanism of the body4 ,in case glasses are being worn for asthenopia they may readily be made unnecessary by osteopathic treatment in the correction of the lesions and building up the system4 ,some time ago some parents sent their daughter to me to have her eyes fitted for glasses4 ,they stated that she had been to different doctors and opticians and no one had ever given satisfaction4 ,they said she was all right every other way if her eyes were properly fitted with glasses4 ,they did not want her examined or treated otherwise because she would be well every other way with correct glasses4 ,her vision was right eye #e-bj1 left eye #e-ae or about one fourth vision in each eye4 ,a plus 4#hg diopter sphere combined with a plus #c diopter cylinder in axis #ij gave her perfectly normal #e-e vision in each eye4 ,this gave her perfect satisfaction until she started to school in ,september1 a couple of months later4 ,before the end of the first month she was having trouble with her eyes and was again sent to me by her parents4 ,her vision was reduced to #f-ae in each eye with her glasses on4 ,she wondered and no doubt the parents did1 if it was not another case of a misfit in glasses similar to all her previous experiences4 ,this time ,i insisted upon a thorough physical examination against all protest4 ,the following lesions were discovered3 the left innominate was up and back or tilted posteriorly1 first lumbar anterior and to the right1 sixth and first dorsals to the right4 ,the case was not refracted again4 ,i took particular care the first time and ,i was quite sure the refractive error was corrected4 ,it was all explained to the parents and regular osteopathic treatment was begun4 ,in less than a month practically every lesion was corrected1 her vision returned to normal and she also was cured of an annoying backache with which she had been bothered for years4 ,her nerves were depleted a great deal4 ,she got benefit in ways that she had not dreamed of4 ,this approach to the eye is not considered by physicians in general1 even the oculists4 ,i have had about ten special courses in medical colleges and hospitals on the eye1 ear1 nose and throat1 and ,i have never heard anything mentioned that would indicate any ideas of the logic involved in this case4 ,surely osteopathy has much to offer in eye troubles that is new and unique4 ,the osteopathic examination of the eye then should begin with the feet1 going then to the innominates1 lumbar1 dorsal1 ribs and cervical regions4 ,oculists are too prone to rely upon crutches 7glasses7 in the treatment of asthenopia4 ,it is easy for the osteopath to conceive how lesions of the upper dorsal and cervical regions may occur and disturb the nerve and blood supply to the eye4 ,this is why asthenopia appears so frequently with ordinary use of the eyes1 even without abuse or refractive errors4 ,the ,lumbar ,region ,the lumbar region should be carefully examined1 especially for any curvature which might cause a disturbance of the equilibrium above4 ,compensatory curves or individual lesions would be the result with a consequent interference with the integrity of the nervous reflexes to the eye4 ,the ,dorsal ,region ,the same may be said of the dorsal region as of the lumbar in regard to curvatures4 ,there is one individual lesion in this region that very frequently exists with eye troubles1 i4 e41 the #bnd dorsal vertebra lateral4 ,any of the upper four dorsals in lesion may be a causative factor in predisposing to disease of the eye but it has been my observation that the #bnd is involved most often4 ,in severe headaches due to eye strain from refractive error1 a good diagnostic symptom is tenderness and contraction at the #bnd dorsal even when there is no subluxation4 ,the ,cervical ,region ,this region should have particular care in search for individual lesions4 ,it is quite easy to pass over some small cervical lesion that may be causing serious disturbance1 especially if the neck happens to be fleshy4 ,i have corrected cervical lesions and stopped twitching of the eyelids 7orbicularis palpebrarum7 and other muscles about the face4 ,the first case ,i ever saw was twenty-two years ago when ,i was a junior at ,kirksville4 ,dr4 ,f4 ,p4 ,millard1 now of ,toronto1 was a room mate of mine4 ,he was constantly annoyed by a twitching of an eyelid4 ,i did not find any lesion for it4 ,we went one day to see ,dr4 ,still at his home and told him of our difficulty4 ,he said without examination that the #crd cervical was in lesion4 ,there was a senior student present whom the 8,old ,doctor0 directed how to use the proper technique4 ,there was a sharp pop1 the vertebra evidently went into right relation1 the twitching stopped4 ,i understand the patient has had very little trouble since4 ,injuries1 exposure and strains to the spine may have antedated an innominate lesion and caused weak joints1 muscular and ligamentous tension1 local inflammations and partial immobilization of joints4 ,all this would have its modifying effects upon the manifestation of secondary lesions from the innominate abnormality4 ,this makes the study of the bony relations very complex and the effect upon the numerous blood vessels1 nerves and other soft tissues still more complicated4 ,the ,ciliospinal ,center ,following osteopathic examination and giving proper importance to lesions below the fourth dorsal vertebra1 we must remember a special significance to be attached to lesions of the upper dorsal in relation to the eye4 ,almost any author on nervous diseases or diagnosis will discuss this center4 ,many of us have it not sufficiently impressed1 hence ,i repeat some known relations4 ,the ciliospinal center consists of a nuclear group of cells in the lateral horn of the last cervical and two upper dorsal segments of the spinal cord4 ,from this nucleus fibers pass to the anterior division of the eighth cervical and first and second dorsal nerves and become the white rami communicantes which are efferent in their function4 ,these fibers pass to the inferior cervical sympathetic ganglion1 thence upward with the sympathetic trunk through the middle and superior cervical sympathetic ganglia1 along the carotid plexus to the vessels of the face and eye1 to the glands of that region1 to the unstriped muscular fibers of the levator palpebr superioris and to the dilator pupillae muscle4 ,any strong feeling or emotion 7which of course is perceived and interpreted by the brain cortex7 will cause a dilatation of the pupil of the eye4 ,the cervical sympathetic being cut1 dilatation does not take place4 ,the rami of the cervical1 first and second dorsal cut1 the phenomenon stops4 ,it is evident the ciliospinal center is under the influence of a center or centers in the brain4 ,bing says 8,there is even an idiomotor mydriasis1 which may be brought about by a very vivid mental conception of darkness40 ,it has been noted that paralyzing lesions of the cervical sympathetic1 of the last cervical and two upper dorsal segments of the cord1 and of the anterior roots and rami communicantes of the same1 will result in myosis4 ,the efferent rami are also vasomotor1 secretory and trophic4 ,it must necessarily follow that congestive and inflammatory conditions1 secretory perversion of the lachrymal1 ,meibomian1 ,zeissian and perspiratory glands1 and disturbance of the normal nutrition of any of the orbital tissues may result from lesions of the lower cervical and upper dorsal vertebr4 ,osteopathically we know that such a lesion may not be sufficient to be paralytic in its effect1 but stimulatory4 ,in this case we may note a pupil habitually too wide and more or less photophobia from a superabundance of light4 ,the unstriped muscle fibers in the levator palpebr superioris may be unduly contracted making an appearance of a slightly bulging eyeball when it is only a wide open eye4 ,one who has eye strain from a refractive error1 overuse of the eyes1 or unbalanced muscles will as a rule have tenderness at some spot in the region of the ciliospinal center4 ,a mechanical lesion at that part of the spine may or may not exist in such conditions1 but ,i believe the soreness is there every time4 ,this is one of the diagnostic points in differentiating headache of eye strain from other conditions4 ,white rami are only in the dorsal region and to the second lumbar and from the second1 third and fourth sacral4 ,it has been noted that lesions of the cervical vertebr do not have as profound an effect upon the eyes as do lesions of the first three dorsal vertebr4 ,the plausible explanation of that is that the cervical vertebr have no white rami from their corresponding nerves in the bulbo-spino-sympathetic-ciliary arc as have the upper dorsal4 ,from all the foregoing statements one can readily contemplate the intricate complexity of our osteopathic problems in relation to the eye4 ,combine this logic of the lesions outlined and the ramifications of the structures with their normal and perverted functions and combine it with contributing causes1 such as infection1 exposure1 irritants1 etc41 and amidst the great diversity we reduce much miscellaneous1 unclassified material to a degree of simplicity4 ,many otherwise unexplainable conditions become reasonably clear4 ,dr4 ,louisa ,burns under 8,the ,experimental ,demonstration of ,osteopathic ,centers0 has this to say3 8,somatic ,reflexes0 8,in the first series of experiments1 the electrodes were placed upon the nasal mucous membrane of animals under anesthesia4 ,the muscles near the third thoracic vertebra were at once strongly contracted4444 8,the electrodes were then placed upon the conjunctiv4 ,the muscles near the second vertebra were then contracted4 ,there were also slight and inconstant contractions of the cervical muscles4444 8,the electrodes were placed upon the eye ball4 ,the muscular contractions were sometimes noted near the second thoracic vertebra1 but the reaction was not constant4 ,the cervical muscles were scarcely contracted at all4 8,the electrodes were placed upon the outer surface of the eye lids4 ,the facial muscles were contracted very quickly and forcibly1 but no contraction of the muscles of the upper dorsal region were noted4444 8,the superior cervical ganglion was exposed to view1 and the electrodes placed upon it4 ,the pupils became greatly dilated1 the conjunctiv became lighter in color1 and the mucous membranes of the nose and throat were also lightened4444 8,the ,gasserian ganglion was exposed to view4 ,the ganglion was stimulated directly4 ,the upper thoracic muscles were very strongly contracted1 and the blood vessels in the area of the distribution of the fifth nerve were immediately and strongly contracted4 ,some of the sympathetic fibers are carried by way of the fifth nerve4 ,in order to exclude the effect of the direct stimulation of these fibers1 the fifth nerve was cut1 and the central end was stimulated by the electrodes4 ,the muscles of the upper thoracic region were contracted1 as before4 ,the vessels in the area of distribution of the fifth nerve were contracted after latent period of a minute or so4444 8,the stimulation of the central end of the cut fifth nerve caused strong muscular contractions in the upper thoracic region1 and also constriction of the vessels in the area of distribution of the fifth4 ,direct stimulation of the superior cervical ganglion produced effects identical with those produced before the mutilation4 8,the spinal cord was cut above and below the superior cervical ganglion4 ,this cut was made from behind1 and the sympathetic chain was uninjured4 ,the effects noted after both operations were the same1 and can be described as one4 8,the stimulation of any cranial structure failed to cause reflex contraction of the muscles in the upper dorsal or the cervical region4 8,stimulation of the cranial structures did not produce any vascular changes except those which might be referred to the direct effects of the electricity upon the vessel walls4 8,direct stimulation of the superior cervical ganglion produced the effects noted before mutilation4 8,therefore the cervical portion of the spinal cord is an essential element of the reflex arc by way of which sensory impulses from the cranial structures are able to affect the condition of the upper dorsal muscles1 and also in the path by which these impulses are able to affect the size of the blood vessels of the cranial structures themselves4444 8,mechanical stimulation of the tissues near the second thoracic spine was followed by a contraction of the blood vessels of the cranial mucous membranes and the conjunctiv1 by a dilatation of the pupils1 and an increased secretion of saliva4 ,these effects were practically invariable4444 8,the superior cervical ganglion was subjected to mechanical stimulation by the manipulation of the tissues over it4 ,in animals1 this maneuver was followed by dilatation of the pupils and by a contraction of the cranial vessels1 which was soon followed1 if the stimulation continued1 by a dilatation which was rather persistent4 8,after the extirpation of the ,gasserian ganglion without the injury of the sympathetic nerves1 the mechanical stimulation of the tissues near the second and third thoracic vertebr caused the same vaso-constriction and pupilo-dilation as was observed in the animal before mutilation4 8,after the destruction of the cervical portion of the sympathetic chain1 and after the extirpation of the ,gasserian ganglion in most animals1 the mechanical stimulation of the tissues in the upper dorsal region did not produce any perceptible effects4444 8,mechanical stimulation of the tissues near the second and third thoracic spines caused dilatation of the pupils and contraction of the vessels of the cranial mucous membranes4 8,inhibition1 or the maintenance of an artificial lesion1 caused dilatation of the vessels of the nasal mucous membranes and of the conjunctiv4 ,the eye ball was also somewhat congested4 ,the pupils were dilated in this case also40 ,the ,nose and ,throat in ,eye ,trouble ,an examination of the eye would not be complete without a careful inspection of the nose and throat4 ,the same nerve and blood supply that go to the eye is tied up so definitely with the nose and throat that when there are lesions of the nose and throat the eye is often affected secondarily4 ,just recently a case of dacryocystitis came into my office4 ,after ,i had carefully examined her eye1 spine1 nose and throat1 she informed me that she had been to three eye specialists before and not one of them had ever looked at her nose and throat1 not to mention the spine4 ,she had cervical and dorsal lesions1 and diseased tonsils4 ,the inferior turbinate on the side of the dacryocystitis was curled out so that it lay against the external wall of the nose almost if not altogether blocking the entrance of the lacrymal duct to the inferior meatus4 ,this was evidently the predisposing cause of her dacryocystitis4 ,in neuralgia of the eye1 blepharitis1 obscure pain1 conjunctivitis and often deeper troubles you will find a bad condition of the nasopharynx1 such as adenoids1 vegetations1 pus pockets1 adhesions in the fossa of ,rosenmuller1 contraction of the soft palate1 disturbed relations of the septum and turbinates1 sinus trouble1 poor drainage1 exostoses and polyps4 ,in eye disease all these things should be discovered if they are present1 in order to get best results and in order to make a careful diagnosis4 ,examination of the ,eye by ,special ,methods ,the first thing after the family history1 personal history1 inspection of the eye and the osteopathic examination1 is to find out how well the patient can see4 ,to test the acuteness of vision certain test letters are used4 ,snellen's ,test ,letters are good4 ,the normal eye can read #c-h inch letters at twenty feet4 ,the test letters on the cards usually range in size to be read at #aj1 #ae1 #bj1 #cj1 #dj1 #ej1 #gj1 #ajj and #bjj feet4 ,the most desirable distance is #bj feet4 ,if at the distance of twenty feet he reads the #c-h inch letters his acuteness of vision would be marked #bj-bj or normal4 ,always use the distance between patient and chart as the numerator of the fraction and the number above the letters which he reads as the denominator4 ,if he is twenty feet away1 the numerator remains twenty and the denominator changes according to the line of letters seen on the test cards thus3 #bj-ae1 #bj-cj1 #bj-gj1 or #bj-bjj may express the vision4 ,if the patient could not see the #bjj feet letters at #bj feet he must be brought nearer1 say #aj feet1 for him to see the large letters2 his vision would be #aj-bjj4 ,these fractions representing the acuteness of vision may be expressed in meters4 ,some charts have letters numbered that way4 ,if the vision is good enough for small objects to be clear1 the near point should be taken4 ,this would show the amount of accommodation of the eye4 ,this is expressed in diopters4 ,a diopter is the unit of measurement of the refractive power of lenses4 ,lenses are numbered by their refractive power in diopters4 ,a lens that has a curvature that will refract parallel rays of light and bring them to a focus at one meter distance is said to be a one diopter lens4 ,this unit of measurement for the refractive power of lenses was proposed by ,nagel in #ahff4 ,it soon became quite generally used4 ,the focal distance of a lens decreases as the strength of a lens increases4 ,one diopter lens 7written #a ,d7 has a focus of one meter 7#a ,m7 or #ajj cm distance4 ,a #b ,d lens has a focal distance of ,m or #ej cm4 ,a #d ,d lens has #be cm focal distance and a ,d lens has #ajj cm #bjj cm distance or #b ,m4 ,trial cases have in them lenses varying in strength from 4#ab ,d or 4#be ,d to #bj ,d of the spheric form4 ,we will not discuss the trial case here4 ,accommodation in the ,eye ,accommodation in the eye is the ability of the eye to vary its focal point4 ,when the normal eye 7emmetropic7 is at rest its focal point is at infinity so far as parallel rays are concerned4 ,this is called the far-point or the 8punctum remotum0 7,p4 ,r474 ,when the eye looks at letters twenty feet away it scarcely accommodates at all to get a focus1 or so little that it may be disregarded in ordinary practice4 ,now if one brings fine print close to the eye he will find a point so close that it becomes indistinct4 ,this point is the near-point of focus or the 8punctum proximum0 7,p4 ,p474 ,the range of accommodation is the difference between the refractive power of the eye when it is at rest and when the accommodation is exerted to the utmost1 the difference between the ,p4 ,r4 and the ,p4 ,p4 ,if one must accommodate one diopter to get a focus at one meter or forty inches distance1 at thirteen inches or reading distance one must accommodate at least #c ,d in order to see the letters clearly4 ,if #c ,d were the total of his accommodation he could not read at that distance but a few minutes2 because the accommodation could not be held at its maximum for long at a time4 ,eye strain with its train of symptoms would result4 ,hence it is quite important to find the near-point or punctum proximum in order to judge in regard to eye strain in an emmetropic eye4 ,if there is a refractive error1 allowance for it must be made accordingly4 ,as a person gets older the accommodation in the eye becomes less and less until at #de years of age he can only use #d to #e ,d of accommodation4 ,this is so close to the amount required for reading that he has some eye strain4 ,he begins to hold his paper farther away from him so he requires less accommodation4 ,this condition we call 8old sight0 or presbyopia4 ,an emmetropic eye at forty-five to fifty years of age requires a plus glass to make up for some accommodation in reading4 ,frequently there are latent disturbances of equilibrium of the extrinsic muscles of the eye4 ,this is heterophoria4 ,if it is a latent convergence it is esophoria2 if a latent divergence it is exophoria4 ,the latter is more frequent4 ,hyper- and hypophoria are used for upward or downward tendencies4 ,normal muscular balance is orthophoria4 ,cause the patient to fix on an object about thirteen inches away with both eyes2 push a sheet of paper in front of one eye and watch behind the paper1 the eye thus covered4 ,if heterophoria exists the eye will move slightly from its point of fixation since it no longer sees the object4 ,in orthophoria it will remain fixed as long as the other eye sees the object2 the innervation to the different muscles is properly distributed4 ,a ,maddox rod found in any complete trial case may be placed before one eye4 ,have the patient fix on a candle flame1 say twenty feet away4 ,the flame appears drawn out into a luminous line4 ,this line can not be fused with the candle flame as the other eye sees it if there is heterophoria4 ,the amount and kind of disturbance is somewhat indicated by the distance and direction of the luminous line and the flame4 ,the exact amount can be measured by the use of a prism that will cause them to fuse4 ,next the patient should be taken to the dark room and a careful inspection of the anterior segment of the eye should be made with oblique illumination4 ,first use the unaided eye1 then use a lens that magnifies4 ,the #bj ,d plus lens from your trial case will suffice for the magnification4 ,note the transparency or lack of it in the cornea and crystalline lens2 the depth of the anterior chamber and the appearance of the pupil and iris4 ,now we are ready for the ophthalmoscopic examination4 ,the ,ophthalmoscope4--,this is an instrument that commands great respect4 ,any one who is interested in eye troubles must have and use the ophthalmoscope if he expects to be efficient in diagnosis1 upon which1 of course1 intelligent treatment must forever depend4 ,one must try and try again in order to become proficient in the use of the ophthalmoscope4 ,a ,schematic ,eye is of great assistance to a beginner who does not have clinics or patients on whom to practice4 ,such an eye with full directions can be obtained at almost any optical goods store4 ,it will make the study of ophthalmoscopy easy and interesting4 ,the pupil can be regulated to any size and the eye can be made short 7hyperopic71 long 7myopic7 or normal 7emmetropic7 for study4 ,the efficient use of the ophthalmoscope makes the diagnosis of internal diseases of the eye as easy as the diagnosis of external diseases of the eye4 ,only some rare conditions will puzzle1 and that is true of any part of the anatomy4 ,the ophthalmoscope is a simple instrument2 its chief function is to illuminate the interior of the eye4 ,the value of ophthalmoscopic findings depends on their correct interpretation by the examiner4 ,the ophthalmoscope has a mirror to reflect the light into the eye4 ,it has two discs on which are mounted convex 7plus7 and concave 7minus7 lenses4 ,the larger disc has seven plus and eight minus lenses4 ,to these may be added the lenses in the smaller disc making many combinations4 ,a drop of a #b solution of cocaine or homatropine may be used as a mydriatic where one can not otherwise see clearly the fundus4 ,if no mydriatic is used a somewhat weak illumination should be employed in order not to arouse the accommodation to much activity and make the pupil small4 ,if there is any opacity in the media a strong illumination should be used4 ,the room should be dark2 the darker the better4 ,there are two methods of using the ophthalmoscope4 ,the indirect and the direct methods4 ,one is more useful at one time and the other at another time4 ,by the indirect method we view the whole field of the fundus more readily but less in detail4 ,with the ophthalmoscope before his eye the examiner's face is twelve to fifteen inches from that of the patient4 ,when the 8red reflex0 of the eye is seen a plus #ac or #af ,d lens is interposed near the patient's eye4 ,this magnifies the field4 ,the image is inverted4 ,as a rule it is best seen with a #d ,d lens in the aperture of the ophthalmoscope4 ,this method is especially more satisfactory in high degrees of myopia and astigmatism4 ,the optic disc is the objective point4 ,one may see a retinal vessel first2 this should be followed to its emergence from the disc4 ,from this point view all parts of the fundus by having the patient look in different directions4 ,this is better by the indirect method than for the examiner to vary his position4 ,the direct method of ophthalmoscopy is better for detail work and in all cases except high degrees of myopia and astigmatism4 ,it is also better in determining errors of refraction4 ,the patient looks straight across the room4 ,for a beginner it may be essential to dilate the pupil1 hence the schematic eye as suggested4 ,if the examiner has a refractive error1 he should wear his own glasses or correct by throwing in front of his eye proper lenses in the ophthalmoscope4 ,face the patient and sit on the side of the eye to be examined4 ,use left eye to examine the patient's left eye and right eye for the patient's right4 ,examiner and patient keep both eyes open4 ,the examiner may not be able to suppress the image of his other eye and may have to close it part of the time4 ,catch the 8red reflex0 some #ae to #ah inches away and move close to the patient's eye4 ,the 8red reflex0 color varies with the error of refraction1 the transparency of the media1 the degree of pigmentation and the size of the pupil4 ,a blood clot will make it redder1 some exudates will make it gray or yellow4 ,the examiner may approach as close as half an inch from the eye to be examined4 ,find the optic disc and examine all points of the fundus from it4 ,rotate in glasses to correct the patient's refractive error if he has any4 ,the strongest plus glass with which the fine retinal vessels can be clearly seen will represent the hyperopia of the eye4 ,this is true only if the examiner's accommodation is at rest4 ,the weakest minus glass with which the fine retinal vessels can be clearly seen represents the myopia4 ,a ,normal ,fundus4--,the color of the fundus is due to the blood vessels of the retina and choroid and the connective tissue of the choroid and sclera4 ,variation is due to the pigment4 ,in the albino it is light pink4 ,in the negro it is dark reddish4 ,there are all gradations between the two4 ,the optic disc is the end of the optic nerve as it comes into the eye2 it is circular in shape1 pink in color1 and sharply defined4 ,it is about #a-afth of an inch in diameter2 about #ae to the nasal side of the pole of the eye and slightly above the horizontal4 ,there may be a dark choroidal ring around the disc or part way around4 ,there may also be a white ring caused by the sclera4 ,as a rule there is a depression in the center of the disc out of which the retinal vessels emerge and spread out over the fundus4 ,the fovea centralis or point of clearest vision is located two and a half disc diameters to the temporal side of the disc4 ,around this is a circular area of light yellow1 the macula lutea4 ,the subject of ophthalmoscopy has been touched upon somewhat in detail because of its great importance to the general practitioner4 ,every osteopathic physician should know the ophthalmoscope well enough to recognize the ordinary lesions inside the eye4 ,when we take up pathological conditions of the eye we will have occasion frequently to refer to the ophthalmoscopic appearance4 ,without the use of this instrument all of our clinical field research on internal diseases of the eye is valueless4 ,many have told me they have cured cataract with osteopathic treatment1 some say they have cured specific neuroretinitis with no sequel1 others testify to opacities and blindness from various causes4 ,invariably we ask if they used the ophthalmoscope in their diagnosis and with it watched the progress of the case4 ,almost invariably the answer is 8no1 it looked like it10 8the symptoms indicated it10 or 8,dr4 so and so1 an oculist diagnosed it as such40 ,fellow ,osteopaths6 we can not base our claims on this kind of data4 ,with a little study and practice the ophthalmoscope can be mastered4 ,not till then can we get reliable statistics on internal diseases of the eye in our case reports4 ,osteopathy has much to reveal to us in this field and for the sake of the science and our patients we appeal to every one to do the work here set forth4 ,diseases of the ,eye ,,osteopathic ,,manipulation ,,for ,,eye ,,diseases ,a general correction of lesions should be made in order to give perfect alignment and equilibrium4 ,lesions that affect the nerve and blood supply will be found from the fourth thoracic to the occiput2 more often at the occiput1 atlas and axis in the cervical region and the second and third thoracic in the dorsal region including the ribs4 ,correction of these lesions must have specific attention in every case of eye disease that shows any tendency to chronicity or in repeated eye disease and exacerbations4 ,a thorough upper spinal treatment to insure good mobility of all joints and establish freedom of fluids and forces is recommended4 ,the nose1 throat and sinuses should be examined for pathology4 ,if the tonsils and pharynx are not normal the cotted index finger should be introduced into the mouth until the anterior pillar of the fauces is reached4 ,a mouth gag may or may not be used4 ,massage the tonsil through the anterior pillar then move to the top and press down on the tonsil with a pumping motion4 ,repeat this from below the tonsil and posteriorly4 ,slip the finger under the soft palate and stretch it thoroughly4 ,clean out any adhesions and vegetations in the vault of the nasopharynx and fossa of ,rosenmuller4 ,stretch the pillars of the fauces by pressing down on each side at the root of the tongue4 ,if the sinuses are diseased they should be drained4 ,if the nose is diseased and has abundance of secretion1 first use irrigation for cleanliness4 ,manipulation in the nose will be of great benefit in some eye diseases as pathology there frequently has an important bearing on diseases of the eye4 ,the nose is often too narrow and contracted4 ,the first inch of the nose is muscular and cartilaginous2 it is of even more importance to dilate the nose in contractured conditions than it is the sphincters at the lower end of the rectum4 ,the great benefit derived from rectal dilatation has been recognized for years4 ,in dilating the contracted nose a wide blade nasal speculum may be used4 ,the cotted and oiled little finger may be used where it is properly adapted in size4 ,the dilating can be done with practically no pain and no damage to membranes or other tissues4 ,it should not be extended beyond the cartilaginous and muscular part4 ,manipulation of the turbinates and tissue further back may be done if needed1 by the use of instruments4 ,the ,edwards turbinate adjuster instrument 7,aloe ,co41 ,st4 ,louis7 or the ,ruddy ,nasal ,third ,finger 7,sharp and ,smith1 ,chicago7 are the best instruments so far devised for this operation4 ,a thorough stretching of the eyelids1 manipulation of the eye ball and the points of the fifth nerve are indicated in many diseases4 ,the lids may be stretched by pulling them from side to side4 ,the cotted forefinger well oiled 7sterile vaseline7 may be slipped into the conjunctival sac back of either lid and with the thumb on the outside the lid may be massaged or stretched in any direction4 ,the points of the fifth nerve may readily be influenced at their respective exits about the orbit4 ,the eye ball and deeper contents of the orbit can be profoundly treated by pressing the finger into the orbit above1 below and at the sides of the bulb and pushing it in all directions as far as possible4 ,the ,ruddy eye finger instrument was devised for this deep manipulation of the orbital and bulbar structures4 ,it is of high value4 ,one finger may be laid on the closed eye and with a tapping motion with the other hand a vibration or oscillation of the orbital structures may be had4 ,this is a useful treatment4 ,the wise selection and skillful use of these various methods of treatment for the eye will solve most of our difficulties4 ,this short survey of osteopathic methods will aid us in the more specific discussions to follow4 ,neuralgia ,a considerable number of people seem to be subject to attacks of pain in one or both eyes4 ,these attacks of pain come at varying intervals2 in some cases several times a day1 in others as far apart as one or two weeks4 ,the pain will suddenly start almost without warning and with very little provocation1 and last from one to twenty-four hours4 ,it is very severe and the patient frequently thinks something terrible is wrong4 ,something terrible is wrong so far as his comfort is concerned4 ,but in these cases to which ,i am referring there is no organic trouble with the eye4 ,the patient does not need glasses4 ,there is no sign of inflammation4 ,vision is not disturbed4 ,local examination of the eye with the ophthalmoscope reveals that the fundus of the eye is normal4 ,there is no symptom connected with the eye except pain1 occasionally accompanied by a slight redness4 ,i have had several cases in my own practice and my attention has been directed to cases of other physicians4 ,these cases differ from tic douloureux in that there is no muscular spasm4 ,in fact1 motor nerves do not seem to be involved4 ,the involvement seems to be largely in the fifth cranial nerve1 usually the supraorbital1 or other smaller branches of the ophthalmic division of the fifth cranial4 ,sometimes we note slight dilatation of the pupil with more or less congestion4 ,this would indicate an involvement of the sympathetic branch to the eye4 ,the lesions discovered in these cases have been a subluxation of the occiput upon the atlas or an upper cervical lesion and frequently some involvement at the second dorsal4 ,there has been noted also trouble in the nasopharynx such as contractures of the muscles of the soft palate and adhesions in the fossa of ,rosenmuller4 ,misplacements of the uterus have also been found in some cases4 ,treatment ,nearly all these cases are curable with from one week to six weeks treatment4 ,of course the treatment must be intelligently directed after a correct diagnosis as to the cause4 ,the cause can usually be removed4 ,one case to which my attention has been directed was that of a woman about forty years of age who had very severe pains4 ,with all the local treatment of the eye and otherwise she got practically no results until she had replacement of the uterus1 which brought immediate relief4 ,other cases have no trouble on that kind but have lesions of the cervical region and on correction of these lesions the neuralgia disappears4 ,other cases have had the nasopharynx cleaned out by the finger operation and the stretching of the soft palate which relieved the neuralgia immediately or in a few days4 ,numbers of cases have been to medical physicians and had various eye remedies administered locally with no permanent benefit4 ,of course the treatment was administered at the wrong place4 ,the ramifications of the sympathetic and fifth cranial nerves are so complex and far-reaching that we must keep in mind that one or more of many causes for the trouble may exist and be quite remote from the seat of the pain4 ,diseases of the ,eyelids ,occasional factors are bee stings or insect bites1 which completely occlude the palpebral fissure4 ,we may have some palpebral edema from lid abscesses1 chalazion1 hordeolum1 dacryocystitis1 panophthalmia and so forth4 ,in hemorrhagia subdermalis there is so much spongy tissue beneath the skin about the eye that the blood extends easily and far4 ,the red tint will soon change to a reddish blue and then become dark1 what is known as a black eye 7ecchymosis74 ,this frequently results from a blow4 ,the skin is sharply attached around the orbital margin by tense connective tissue so the area of the hemorrhage is limited to the region of the orbit4 ,there may be spontaneous rupture of some of the vessels by hard sneezing or coughing1 especially in young children4 ,in older people it may indicate a fragile condition of the vessels1 arteriosclerosis or some trouble with the kidneys4 ,the diagnosis of the eye condition is not difficult but the cause of the hemorrhage in that region might be investigated further4 ,local treatment is of some value in these conditions4 ,they may be soothed by cold compresses4 ,in bee stings and insect bites use an alkaline compress4 ,manipulation about the eye and osteopathic treatment of the neck with a view to directing a better circulation to that region will aid much4 ,herpes ,zoster ,ophthalmia ,this affection of the supraorbital branch of the fifth cranial nerve may extend to the eyelids4 ,it may not go beyond the stage of blistering and redness with some edema4 ,however1 it is possible for it to become gangrenous and even extend to the conjunctiva and cornea4 ,i had one case of herpes zoster gangrenosa of this region4 ,there were several gangrenous spots as large as a dime on the forehead and extending down in the region of the eyelid4 ,the process extended to some extent on the cornea and in healing left a condition of irregular astigmatism4 ,treatment4--,the prognosis in herpes zoster is always favorable under osteopathic treatment4 ,lesions of the cervical region will almost invariably be found interfering with the sympathetic connections of the fifth cranial nerve causing the trophic disturbance to the region4 ,osteopathic treatment applied to these conditions will always hasten normalization4 ,the affected part might be kept covered with some soothing lotion to keep the skin soft4 ,hordeolum ,this is commonly known as a sty4 ,it is due to suppuration of the glands of ,zeiss4 ,it is a harmless affection but causes pain and inconvenience4 ,diagnosis4--,swelling and pain with a small inflammed nodule in the palpebral margin is quite diagnostic4 ,treatment4--,the circulation is obstructed in this region4 ,the effort should be made to open the circulation before pus has formed4 ,this can frequently be done and the hordeolum aborted by carefully picking up the eyelid and rolling the nodule between the fingers4 ,this will cause some pain but if it is kept up for a moment or two about every hour through the day with an occasional thorough treatment of the neck the sty will usually be aborted4 ,if pus forms it should be opened as soon as it points and then the squeezing and rolling process may be employed again1 which will aid rapidly in the freeing of the circulation4 ,chalazion ,this is a ,meibomian cyst in the eyelid4 ,it shows as a circumscribed swelling on the inner side of the lid4 ,it frequently becomes large enough to produce some deformity of the lid4 ,a chalazion is movable on the tarsal cartilage4 ,it is a chronic condition and the cyst may become as large as a bean4 ,there may be more than one in the same lid4 ,treatment4--,when a chalazion is small and not of long standing it can frequently be cured by osteopathic treatment4 ,introduce the finger into the conjunctival sac under the lid1 and with the thumb externally1 grasp the chalazion between the finger and thumb2 roll it thoroughly4 ,squeeze and massage it two or three times a week for awhile4 ,this1 combined with a thorough treatment of the neck1 will result in a cure4 ,if at the end of six weeks the condition has not disappeared surgery should be resorted to4 ,blepharitis ,this is an inflammation of the eyelid4 ,it is either acute or chronic according to the cause4 ,acute blepharitis may be due to heat or injury4 ,chronic blepharitis affects the glands of the lid causing a perversion of the secretions4 ,there is usually the formation of crusts and scales4 ,this condition is known as blepharitis sicca4 ,in some cases infection will form little pustules at the roots of the cilia4 ,there is soreness and aching4 ,there may be photophobia4 ,the nasal region may be involved4 ,osseous lesions of the cervical region are usually present4 ,refractive errors frequently exist in these cases4 ,occupation or environment may expose to dust or wind sufficient to keep up the irritation4 ,treatment4--,change environment4 ,see that there is thorough cleanliness of the lid4 ,rub or pick away all scales4 ,use a bland ointment4 ,correct any cervical or upper dorsal lesions4 ,ptosis ,this is congenital or acquired4 ,in congenital ptosis operation seems to be the only treatment4 ,acquired ptosis is amenable to treatment frequently4 ,the cause is some lesion interfering with the passage of proper nerve force to the levator muscle of the lid4 ,the lesion may be at the origin of the third nerve1 at the cortical nucleus in the sigmoid gyrus or in the trunk of the third nerve1 or a lesion of the muscle itself4 ,tumor1 trauma1 syphilis1 sclerosis1 hemorrhage1 gout or rheumatism1 or anything that will produce a peripheral neuritis are causative factors4 ,lesions of the cervical and upper dorsal by reflecting back upon the nerve centers may produce a ptosis4 ,treatment4--,remedial measures according to indications4 ,cases due to osteopathic lesions as indicated will usually yield readily to treatment4 ,where there are other factors treatment must be varied accordingly4 ,trichiasis ,this is a condition in which part or all of the eye lashes turn inward and touch the eye ball1 due to cicatricial contractions in the conjunctiva and tarsus4 ,many of the cilia are so small in these conditions that it is very difficult to see them4 ,a loupe or a magnifying glass must be used in order to discover them4 ,dystrichiasis is a condition where the cilia come in irregularly growing in all directions1 some of them turning in toward the eye ball and causing irritation4 ,treatment4--,an epilatory should be used to extract all of the wild hairs4 ,care should be taken to get out the finest ones as they will frequently cause irritation if not removed4 ,entropion and ,ectropion ,entropion is a turning in of the eyelid and ectropion is a turning out4 ,these conditions may be spasmodic and temporary4 ,entropion is more often due to cicatricial contraction in old blepharitis or trachoma conditions4 ,in some cases the condition may be corrected by the use of strips of adhesive plaster4 ,in cicatricial conditions operation is the rule4 ,spasmodic ectropion may be corrected sometimes by curing the conjunctivitis4 ,bandaging may be resorted to4 ,in paralytic ectropion osteopathic treatment may serve to produce a complete cure4 ,operative procedure should be a last resort4 ,diseases of the ,lachrymal ,apparatus ,dacryocystitis ,dacryocystitis is an inflammation of the lacrymal sac4 ,it is due to some lesion in the nose1 malposition of the inferior turbinate or a poor blood and nerve supply to the lacrymal region as determined by cervical lesions4 ,the sac becomes infected and we have a dacryocystoblennorrhea4 ,pus and tears are regurgitated into the eye through the puncta4 ,there is irritation and the conjunctiva may become infected at any time1 also the cornea4 ,it is a dangerous and annoying affection4 ,treatment4--,osteopathic measures have something to offer along this line4 ,the medical idea seems to be completely surgical in recent years4 ,the first and only thing to be done surgically is to obliterate the sac or dissect it out and curette the nasal duct1 completely destroying the apparatus4 ,lancing does not affect a cure4 ,by treating for a good nerve and blood supply to that region1 the irrigation of the nose and a thorough squeezing of the sac each time with a view to forcing the solution in the sac down through the nasal duct into the nose1 a cure may be effected in many cases4 ,if these cases can be gotten before infection has taken place1 in the state of epiphora or the backing up of the tears into the eye1 thorough treatment along the lines just indicated will in nearly all cases result in a cure4 ,boric acid solution should be used to wash out the sac when pus is present4 ,the attempt should be made to force it into the nose4 ,probing properly done is of value in many cases4 ,these cases should be followed up with great care4 ,treat the neck thoroughly and spring the inferior maxilla4 ,diseases of the ,conjunctiva ,conjunctivitis ,the conjunctiva is a mucous membrane that coats the posterior surface of the eyelids and the anterior surface of the eyeball4 ,it forms a sac1 which is slit open in front in the line of the palpebral fissure4 ,the conjunctiva consists of three parts 7#a7 the conjunctiva tarsi1 the part on the lids2 7#b7 the conjunctiva bulbi1 the part on the eyeball1 and 7#c7 the conjunctiva fornicis1 the part connecting the first and second2 it is the retrotarsal fold or the region of transition1 often called the fornix4 ,the first part can be seen by everting the lids4 ,it is adherent to the tarsus4 ,it is covered with a laminated cylindrical epithelium4 ,the membrane contains an abundance of lymphocytes similar to adenoid tissue4 ,this increases with every inflammation of the conjunctiva4 ,this is why chronic conjunctivitis often results in thickened lids4 ,the blood supply of the conjunctiva of the lids is from the muscular branches of the ophthalmic artery4 ,the nerve supply is from the ophthalmic division of the #eth cranial and the sympathetic4 ,the bulbar conjunctiva continues over the cornea4 ,it is covered with layers of pavement epithelium4 ,its blood supply comes from the posterior conjunctival vessels about the retrotarsal fold1 and the anterior ciliary arteries which accompany the tendons of recti muscles2 these two systems anastomose in the conjunctiva4 ,conjunctival injection or congestion shows a superficial net work of larger or smaller vessels that move with the conjunctiva4 ,the color is scarlet or brick red4 ,ciliary injection occurs as a rose-red or pale violet zone around the cornea1 spoken of as peri-or circumcorneal injection4 ,it does not move with the conjunctiva and occurs more with diseases of the cornea1 iris and ciliary body4 ,in the etiology of conjunctivitis a great variety of germs are considered by different writers4 ,collins and ,mayo give a report of 8germs found in normal conjunctiva40 ,bacillus ,xerosis in #id of normal conjunctiv2 ,staphylococcus ,albus in #gi2 ,pneumococcus in #i2 ,diplobacillus in #f2 ,staphylococcus ,aureus in #f2 ,streptococcus in #e4 ,if this be true1 and ,i do not doubt their statement1 we are practically compelled to say that these germs at least are only secondary in the etiology of conjunctivitis4 ,just at this point osteopathy comes with its flood of light and makes it easily explainable why some conjunctiv become inflamed while others do not1 when all have germs present4 ,the lesion disturbing the integrity of blood supply and nerve force to the eye is the primary cause while the presence of germs may be the aggravating cause4 ,the lesion prepares the soil in which the germs thrive sufficiently to become an irritant4 ,there are all gradations of this soil preparation4 ,the more fertile the field 7i4 e4 the more profound the effect of the lesion7 the more virulent germ life may become2 the resistance is proportionately less4 ,conjunctivitis is classified for convenience in study1 diagnosis and treatment as follows3 7#a7 ,catarrhal1 7a7 acute1 7b7 chronic1 7c7 follicular2 7#b7 gonorrhoeal2 7#c7 ophthalmia neonatorum2 7#d7 trachoma2 7#e7 diphtheritic2 7#f7 eczematosa 7phlyctenulosa72 7#g7 vernalis2 7#h7 tubercular2 7#i7 traumatic4 ,this is the clinical classification after ,fuch4 ,treatment of ,conjunctivitis ,in order to give the best care in these cases it is quite essential that both the primary and secondary causes be given attention4 ,some good germicide or antiseptic is to be used with intelligence4 ,this is in harmony with the great principles of antisepsis and cleanliness taught by osteopathy from its inception4 ,the use of the microscope in the bacteriology of conjunctivitis aids in more definite diagnosis and the selection of a proper germicide4 ,for the ,koch-,weeks bacillus1 the pneumococcus and the influenza bacillus silver nitrate #a or a #be solution of argyrol is used2 for the diplo bacillus 7,morax-,axenfeld7 zinc sulphate #a gr4 to the ounce is almost a specific4 ,a good way to prepare the zinc prescription would be3 ,boracic acid and water oz4 #a4 ,zinc sulphate gr4 #a4 ,the boric acid and water of course being a saturated solution4 ,apply one drop to each eye about four times a day4 ,if one can not have the use of the microscope to make specific the diagnosis1 the zinc solution may be alternated with the argyrol as the germicide4 ,ice cold applications are good in many of these cases4 ,catarrhal ,conjunctivitis ,acute4--mostly affects the conjunctiva of the lids in the light form4 ,if severe it invades the bulbar conjunctiva4 ,there is redness and swelling and increased secretion which dries at night upon the edges of the lids and glues them together4 ,the eyes are better in the morning and worse toward evening4 ,corneal ulcers and iritis may arise as complications4 ,chronic inflammation may result4 ,etiology4--,textbooks on the eye give bacteria as the chief cause2 some scarcely mention anything else4 ,after discussing how the bacteria get there and multiply1 they usually bring in some statement to indicate that in many cases no bacteria can be found in the secretions from the conjunctiva4 ,these latter are unaccounted for in the etiology4 ,catarrhal conjunctivitis is non-specific in its origin4 ,the great science of osteopathy will fill in the missing links to works otherwise very exhaustive on the eye4 ,if the cause is due only to a passing irritant as dust1 smoke1 pollen or wind the disturbance may vary from hyperemia only1 to a severe attack of conjunctivitis4 ,fuch says the majority of cases are produced by bacteria1 but ,,that ,,in ,,not ,a ,,few ,,cases ,,of ,,conjunctival ,,catarrh ,,the ,,examination ,,of ,,the ,,secretions ,,for ,,bacteria ,,proves ,,negative4 ,he also says that the usual course of the disease is from eight to fourteen days1 but ,,not ,,infrequently ,,there ,,remains ,a ,,condition ,,of ,,chronic ,,catarrh ,,protracted ,,over ,a ,,long ,,time2 ,,that ,,not ,,infrequently ,,the ,,normal ,,conjunctival ,,sac ,,contains ,,pathogenic ,,germs4 ,some authors divide the etiology into 7#a7 specific1 7#b7 non-specific4 ,the first they account for by irritants due to dust1 heat1 smoke1 metal1 pollen1 cold1 wind1 glare of light1 eye strain from overwork of the eyes1 ametropia and chronic alcoholism4 ,the second they account for by germ life1 most often the ,morax-,axenfeld diplobacillus or the ,koch-,weeks bacillus1 the latter germ being found in the so-called 8pink-eye40 ,it is contagious4 ,this is one condition for which the zinc sulphate 7 to #b solution7 is almost a specific4 ,no doubt the irritants and the bacteria mentioned1 with others1 do cause much of our catarrhal conjunctivitis and that one who fails to consider properly the local conditions in practice will be sadly lacking in best results4 ,on the other hand many cases1 treated for local conditions only by very competent men who used the best antiseptics and germicides1 have very indifferent results4 ,the acute condition would continue and gradually become chronic4 ,from observation1 study and experience there are causes aside from local irritants1 ametropia1 bacteria1 syphilis1 rheumatism or measles4 ,there is some disturbance to the integrity of the spinociliary sympathetic arc4 ,in many cases of eye disease note lesion and tenderness at the upper dorsal1 the removal of which will cause improvement of the eyes4 ,many cases of eye strain can be relieved by correction of the first1 second or third dorsal1 and the use of glasses made unnecessary4 ,irritation of the eye will cause more or less tension of the muscles at the second and third dorsal1 and stimulation of the tissues near the second and third dorsal spines will cause dilatation of the pupils and contraction of vessels of the cranial mucous membranes2 which means vasomotor1 secretory and trophic disturbances4 ,it follows then that an osteopathic lesion at the second or third dorsal will cause or tend to cause disease of the eye4 ,there may be all gradations in the effect produced1 the lighter being mere tendency1 while again it may be enough to set up profound vasomotor1 secretory and trophic changes in and about the eye4 ,the first effect of the lesion may be stimulatory1 and later1 inhibitory4 ,the normal resistance of the eye would be lowered and naturally1 local irritants1 bacteria and ametropia would have a more profound effect4 ,this will explain how one can develop conjunctivitis in the absence of a local irritant with no bacteria present1 and no eye strain4 ,all of these causes1 or any number of them1 may be acting together1 and each more virulent because of the influence of the other4 ,lesions of the occipito-atlantal joint or any of the cervical articulations may cause eye disturbance4 ,there are no efferent ramicommunicantes in that region and the course of the physical disturbance must be greater in proportion to the eye trouble produced1 than at the upper dorsal4 ,it is important however to make a close examination of the entire cervical region in eye trouble4 ,what has been said on the osteopathic causes of acute catarrhal conjunctivitis applies with equal force to chronic and follicular concatarrhal conjunctivitis4 ,what has been said on the osteopathic causes of acute catarrhal conjunctivitis applies with even greater force to the chronic form4 ,the great variety of local irritants may account for acute conjunctivitis1 and does in most instances2 but in chronic conjunctivitis local irritants are more often secondary or incidental while the osteopathic lesion with its effect upon the bulbo-spino-sympathetic ciliary arc is the fundamental cause4 ,of course some continuous local irritant1 e4 g41 an uncorrected refractive error1 excessive light1 heat1 dust or germ life in the environment may cause a chronic conjunctivitis4 ,other causes may be retracted lids 7lagophthalmus7 leaving the eyeballs too prominently exposed2 turning in of the cilia 7entropion1 trichiasis or dystrichiasis7 which impinge upon and irritate the bulbar conjunctiva4 ,chronic blepharitis may spread to the palpebral conjunctiva and then the bulbar4 ,foreign bodies in the eye1 or infarction of ,meibomian glands may be causes4 ,the diplobacillus 7,morax-,axenfeld7 is the most common germ in chronic catarrhal conjunctivitis4 ,symptoms and ,course4--,in mild cases the redness is only moderate4 ,the conjunctiva is smooth and not swollen4 ,old cases have hypertrophy with thickening4 ,there was a small girl who came into the office recently who had the conjunctiva of the lids decidedly swollen with some hypertrophy4 ,her eyes were glued shut with pus every morning4 ,pus pockets were forming along the follicles of the cilia and on the direct edge of the lid4 ,her troubles started a year ago and got gradually worse4 ,a few osteopathic treatments were given during three months 7she was irregular in coming7 and argyrol1 #bj1 used locally4 ,all pus and debris were cleared off the lids and conjunctiva each time4 ,the swelling all left and the thickening became inconsiderable2 the eyes looked almost clear4 ,on pressure there was tenderness at the right side of the second dorsal4 ,no mechanical lesion was apparent there but in treatment that region was thoroughly loosened4 ,the subjective symptoms are usually worse at night2 pain1 heaviness of the lids2 feeling of a foreign body in the eye2 burning2 itching and dryness in many cases4 ,this condition is one of the most frequent of eye diseases in adults2 may be senile catarrh in advanced age4 ,it is frequently complicated with blepharitis1 ectropion1 epiphora and ulcerations of the cornea4 ,treatment4--,the osteopathic treatment depends on the findings in the osteopathic examination4 ,no case of chronic catarrhal conjunctivitis should be treated without a thorough examination of the whole spinal1 rib and innominate mechanism4 ,careful and detailed adjustment should be made of any lesions that might disturb the ciliary arc1 the other nerve connections1 the blood supply or the body equilibrium4 ,this does not mean that local treatment of the eye should be neglected in any way4 ,any measure that will aid in getting rid of local pathology as quickly as possible should be ours4 ,where there is abundant secretion1 silver nitrate #a to #b solution put on the conjunctiva with a brush when the lids are turned1 or argyrol #bj to #be dropped into the eye are among the best antiseptics for local use4 ,if the diplobacillus is present zinc sulphate solution is indicated4 ,the nose1 nasopharynx and pharynx should never be overlooked in this disease4 ,follicular ,conjunctivitis ,follicular conjunctivitis is of catarrhal origin4 ,it is characterized by the presence of follicles4 ,there may be only a few or a great many4 ,if numerous they are often in rows on the palpebral conjunctiva4 ,microscopically they show as circumscribed masses of adenoid tissue4 ,in this they resemble the granules of trachoma4 ,sometimes cases persist for years with little or no inflammatory symptoms4 ,on account of the follicles this disease is frequently confused with trachoma4 ,we have heard numbers of well meaning conscientious osteopathic physicians testify to curing cases of trachoma with a short course of osteopathic treatment with no pathology remaining4 ,we are absolute believers in the effectiveness of osteopathic treatment and want to give it full credit for doing all it will2 but here we want to enter a plea to the profession that we need more discrimination and definiteness in our diagnosis4 ,technique is being emphasized and we say ,amen6 ,it is proper for us to be thoroughly competent in technique but diagnosis should be made just as emphatic because scientific technique depends upon diagnosis for each individual case4 ,differentiation of follicular conjunctivitis from trachoma4 ,follicular conjunctivitis occurs 7#a7 chiefly in the young2 7#b7 the follicles are smaller1 more sharply limited1 project more above the conjunctiva1 are often in rows1 and oval in shape2 7#c7 the disease clears up with no bad after effects often without any treatment and the tendency is to ultimately get well2 7#d7 it never leads to shrinking of the conjunctiva1 to pannus or other destructive sequel2 7#e7 it can arise without contagion and is not considered contagious although1 like trachoma1 it does attack large numbers of people who are confined in a small place4 ,trachoma4--7#a7 ,it seldom occurs in children2 7#b7 the follicles are larger1 do not have sharp outlines1 are less prominent under the conjunctiva1 are round in shape and never in rows2 7#c7 tends to lead to more or less pathology and seldom recovers spontaneously2 7#d7 scar tissue becomes a product of the inflammation in the conjunctiva and leads to shrinking of the conjunctiva1 causing in turn entropion and trichiasis4 ,pannus is the sure result of unarrested cases as there is a tendency to infection of the cornea from the infected conjunctiva moving over it and remaining in contact2 7#e7 trachoma has been proved to be contagious4 ,trachoma bodies which are considered the infective agent have been isolated4 ,the use of atropine in some instances will cause a follicular catarrh which clears up on stopping the use of the poison4 ,parinauds 8,infectious conjunctivitis0 has granulations but almost always occurs in only one eye and is accompanied with constitutional symptoms4 ,treatment of ,follicular ,conjunctivitis4--,the treatment should be directed against the inflammation4 ,the trophicity of the nerve terminals to the conjunctiva may be altered by osteopathic lesions4 ,suggestions under chronic catarrhal conjunctivitis apply here4 ,if there is no inflammation the follicles tend to disappear1 leaving no trace of pathology1 hence a few osteopathic treatments of the lids and the cervical region will hasten normalization4 ,gonorrheal ,conjunctivitis ,this disease is sometimes called purulent ophthalmia or acute blennorrhea1 ,it is caused from an infection of the conjunctival sac with the gonococcus of ,neisser4 ,contact with soiled fingers or linen may transfer the germ4 ,symptoms4--,within #ab-dh hours after inoculation the first symptoms of redness and irritation occur4 ,this is soon followed by much swelling and tension of the lids and chemosis of the conjunctiva4 ,there is much pain and a copious discharge of pus coming from beneath the lids4 ,at first the pus is yellow or yellowish green4 ,later the symptoms begin to subside2 there is less tenseness and heat2 the lids can be more readily everted and the discharge ceases after #f or #h weeks4 ,the puckered conjunctiva becomes rough and granular4 ,in these cases the prognosis is always grave2 more so than in ophthalmia neonatorum4 ,the eye is almost always marred in some way4 ,one of the great dangers is involvement and destruction of the cornea4 ,if the cornea becomes hazy soon after symptoms begin it is not a good omen4 ,ulcers will likely form and then there is a tendency to puncture the cornea4 ,in mild cases the cornea may escape without injury4 ,in severe cases it is likely to ulcerate4 ,if it perforates1 the anterior chamber is emptied and the iris prolapses into the perforation2 adhesions take place and there is healing with reformation partially of the anterior chamber4 ,an adherent leucoma is the result with practical loss of vision4 ,there may be a bulging of the cornea known as anterior staphyloma4 ,the iris and ciliary body may become involved1 causing iritis and cyclitis1 or the whole inner structures may be affected making a panophthalmitis with atrophy of the eyeball4 ,the cornea is affected by the infective material direct or the nutrient vessels to the cornea at the limbus may be obstructed by the extreme swelling and pressure4 ,complications of arthritis1 rhinitis1 septicemia and endocarditis may arise4 ,if there is none of these1 at least there is a general debilitated condition which needs attention4 ,treatment4--,the treatment should be local and constitutional1 ,the diagnosis should be made quickly from the history1 symptoms microscopically1 and local cleansing begun at once and followed diligently4 ,excessive discharge should be wiped away with cotton4 ,the conjunctival sac should be thoroughly irrigated every hour or oftener if necessary to keep it clean4 ,this is to be done day and night4 ,a saturated solution of boric acid may be used1 or corrosive sublimate one grain to the pint1 or permanganate of potassium solution #a-ejjj4 ,the irrigation should be followed by the free use of argyrol #be4 ,this procedure will keep the eye clean and be the means often of saving the cornea from destruction and the eye from blindness4 ,if there should be ulceration of the cornea a drop of atropine should be used in the eye often enough to keep the pupil dilated and the ciliary body at rest4 ,osteopathic physicians no less than other physicians should not neglect this local1 careful1 persistent1 antiseptic cleansing of the eye in such cases4 ,the osteopathist can do more4 ,he is not limited to antisepsis even in this kind of work1 however important it might be4 ,the unaffected eye should be carefully protected4 ,buller's shield should be used4 ,the osteopath should give thorough treatments to the neck and the fifth nerve4 ,supporting treatment to the system according to indications should be given e4 g41 bowels1 kidneys1 nerves1 muscles1 joints as in constipation1 nephritis1 neurosis1 rheumatism1 arthritis1 endocarditis1 septicemia1 rhinitis etc4 ,ophthalmia ,neonatorum ,this is an acute purulent conjunctivitis in the new-born4 ,neonatorum comes from a junction of the ,greek word ,neos--new1 to the ,latin word natus--born2 new-born4 ,this disease is the bugbear to the obstetrician4 ,he must always be on the lookout for it and act promptly in order to save sight4 ,every general practician should make a careful study of this disease if he expects to treat children4 ,sixty to seventy percent of conjunctivitis neonatorum is due to the infection with the gonococcus of ,neisser4 ,it usually comes from a gonorrheal discharge from the genitals of the mother4 ,the nurse or anyone who handles the baby might be the agent in the transmission of the infection4 ,the disease is not always of gonorrheal origin4 ,some cases are due to the pneumococcus1 streptococcus1 diplobacillus or one variety of staphylococci4 ,thus there are two varieties or types of ophthalmia neonatorum2 a severe type which is gonorrheal or specific and a mild type which is non-specific4 ,in some states there is a law which requires the use of silver nitrate in the eyes of all babies at birth4 ,every baby's eyes should be thoroughly washed at birth1 with boric acid and where there is the least suspicion of gonorrhea silver nitrate #a or argyrol #be should be used4 ,a routine use of one of the silver salts would be good practice4 ,symptoms4--,gonorrheal cases begin usually the third day after birth1 non-gonorrheal1 on the fifth or sixth day4 ,both eyes are usually involved1 one worse than the other4 ,the lids swell much4 ,there is chemosis of the conjunctiva which may put the cornea in a pit4 ,the discharge is abundant4 ,it is yellow or greenish yellow4 ,the disease gradually declines and the discharge ceases in six to eight weeks4 ,the conjunctiva is thickened and looks granular4 ,may be some cicatricial changes4 ,the chief danger is to the cornea1 more so if it becomes hazy the first two days4 ,corneal lesions seldom occur in non-specific forms4 ,if the cornea is involved perforation is likely1 with a general inflammation of the eyeball 7panophthalmitis7 followed by atrophy 7phthisis bulbi74 ,complications such as rhinitis1 meningitis1 endocarditis and general septicemia may occur4 ,diagnosis is made from the onset1 character1 symptoms and course with the use of the microscope4 ,prognosis4--,delayed or improper treatment in these cases will likely be fatal to sight as sloughing of the cornea will occur4 ,with prompt and proper care the prognosis is favorable4 ,treatment4--,mild cases 7non-specific7 are treated in the same manner as simple conjunctivitis4 ,in severe cases 7specific7 clean the eye carefully and apply cold compresses of gauze #ae to #bj minutes at a time every hour or two4 ,keep the gauze on a block of ice and change every few minutes4 ,if the cornea is involved heat may prove more satisfactory4 ,there must be constant removal of the discharge4 ,wipe away the excess and irrigate freely with boric acid at least every hour day and night and more often if necessary4 ,after each washing use a solution of argyrol #be4 ,once a day silver nitrate #a solution may be used and washed out with a salt solution4 ,if the cornea should ulcerate the treatment need not be altered4 ,the attendants should be carefully instructed as to the importance of the care and the contagious nature of the pus4 ,antisepsis and cleanliness here is more essential1 effective and exclusive than in any other disease of the eye4 ,wisdom in the use of antiseptics is a strong point in the armamentarium of every progressive osteopath4 ,trachoma ,this disease is known as granular lids or granular conjunctivitis4 ,although the germ has not been discovered1 we know this is an infectious disease4 ,a roughness and hypertrophy of the conjunctiva develops4 ,there is development of follicles or granulations4 ,later these products are absorbed and cicatrization of the tissues follows4 ,cause4--,trachoma is found most common in ,egypt and ,arabia4 ,it spreads easily in crowded institutions4 ,it is in many instances a mixed infection with the ,morax-,axenfeld bacillus1 ,koch-,weeks bacillus and the gonococcus4 8,trachoma bodies0 have been discovered which are claimed by some to be a causative factor in the disease4 ,these small bodies are not found in all cases however4 ,spinal lesions of the cervical and upper four thoracic vertebr will disturb the blood and nerve supply to the eye which will predispose to the disease should some of the virus or germs of trachoma be present4 ,in practically all these cases there is tenderness if not an actual twist at the second and third thoracic4 ,symptoms4--,a small boy came to our clinics complaining that his left eye was smaller than the right4 ,no inflammation or swelling was prominent4 ,the eye looked normal except slightly smaller than the right4 ,on turning the lid granules in the fornix of that eye were readily noticed4 ,trachoma had a good start4 ,the tissues were so hypertrophied in that region that the eye could not be opened quite as wide as the other one1 hence the impression that that eyeball was smaller4 ,the granulation often develops so insidiously that the victim may have the disease for months before he realizes he has a bad eye4 ,when symptoms appear there may be photophobia1 lachrymation1 gluing of the lids from a scanty secretion1 pain1 and blurring of vision4 ,the granules are gray1 translucent and roundish under the conjunctiva4 ,hypertrophy increases to a certain height when cicatrization and contraction begin4 ,the duration may be years4 ,the more the hypertrophy the longer the duration and the greater the contraction4 7,note here that treatment should be directed toward combatting the hypertrophy by establishing circulation74 ,sequel4 ,i merely mention the sequel here3 pannus1 ulceration of the cornea1 trichiasis1 dystrichiasis1 entropion1 ectropion1 symblepharon1 xerosis1 corneal opacities4 ,for the explanation1 pathology and treatment of these sequel not covered in this treatise1 see any good works on diseases of the eye as ,weeks1 ,fuchs or ,de ,schweinitz4 ,treatment of ,trachoma4--,in reporting cases of trachoma treated and cured by osteopathy we should be sure of our diagnosis4 ,the treatment is antiseptic1 hydrotherapeutical1 osteopathic and operative4 ,a saturated solution of boric acid should be used4 ,argyrol #bj is good if there is much secretion4 ,nitrate of silver #b and copper sulphate are still used in some cases to advantage as claimed by some physicians4 ,the osteopath should count on careful cleanliness4 ,hot compresses over the eyes are often very agreeable4 ,operations are often performed for trachoma4 ,the granules are rolled out with ,knapp's roller forceps1 and other methods4 ,grattage is practiced with some wonderful results4 ,it is done as follows3 ,get some fine sand paper and cut it in strips about one-half inch wide by three or four inches long4 ,put it in alcohol in a vessel for ten to fifteen minutes4 ,pour off all the alcohol except a few drops that will cling to the vessel by capillary attraction4 ,touch a match to the residue4 ,this will burn just enough to make the sand paper absolutely sterile without burning the latter4 ,put the patient under somnoform4 ,use a small artery forceps to grasp the edge of the eyelid1 roll the lid back over the artery forceps to expose all granulations clear to the fornix4 ,use a protector to the eyeball4 ,now with the sandpaper quickly scrape or curette away all of the trachoma bodies and granulations4 ,repeat the process on the other eye if it is involved4 ,wash out well with a saturated solution of boric acid and bandage the eyes for a few hours4 ,this will cause considerable swelling and inflammation4 ,use cold applications and keep the eyes disinfected4 ,i have seen some very good results from this method4 ,osteopathic4--,following the sand paper operation a thorough treatment of the cervical and upper dorsal region would add considerably to the rapidity of the patient's recovery and sense of well being4 ,general tonic treatment is of special benefit in nearly all trachoma cases as they are subnormal in their general health4 ,one form of technique which has been used by myself and others to advantage in these cases is as follows3 ,sterilize the fingers carefully1 lubricate with vaseline or ,k4 ,y4 the forefinger of the right hand4 ,with the left hand raise the upper lid and introduce the forefinger of the right hand with the thumb above4 ,catching the lid between the thumb and finger squeeze and massage the whole structure clear to the fornix as thoroughly as possible4 ,repeat the process on the other eye4 ,a technique used by ,dr4 ,edwards of ,st4 ,louis is as follows3 ,after sterilizing and lubricating the forefinger lift the lid and introduce the finger as far as possible into the orbit pushing the fornix back into the orbit4 ,this stretches all the tissues around the fornix1 opening up a better conjunctival and palpebral circulation4 ,the ciliary vessels and nerves are stretched and stimulated4 ,it is rather surprising to one who has not tried it1 how far the finger can be introduced into the orbit4 ,one set of nerves that should be especially studied and considered in trachomatous conditions is the cere-brobulbo-spino-sympathetic-ciliary arc4 ,this has already been elaborated4 ,all spinal lesions should be carefully diagnosed and corrected4 ,dr4 ,t4 ,j4 ,ruddy's third finger eye instrument is very useful in these conditions in restoring normal circulation about the orbit4 ,see that the nose and throat are normal4 ,phlyctenular ,conjunctivitis ,by some this disease is considered an eczema of the conjunctiva4 ,this will at least enable us to get an idea of the conjunctival pathology4 ,what is said of phlyctenular conjunctivitis applies largely to its corresponding disease of the cornea-phlyctenular keratitis4 ,scrofulous ophthalmia is applied by some because so many of these phlyctenular patients have scrofula4 ,herpes conjunctiv is used as a name because of the small blisters or blebs that form in the beginning stage4 ,little red eminences develop near the limbus 7sclerocorneal junction74 ,they are cone shaped1 slightly elevated about the surrounding tissue4 ,there may be one or several1 usually not more than one or two4 ,after a few days the cone breaks and on top appears a small gray ulcer4 ,there is further breaking down and the cone disappears leaving an ulcer on level with the conjunctiva4 ,vessels are congested about it4 ,there may often be noted an area of small vessels1 fan like in shape1 running from the outer region of the conjunctiva to the ulcer or phlyctenule4 ,etiology4--,this is a disease of frequent occurrence in children1 mostly among the poor classes4 ,such things as eczema1 dirt1 adenoids1 scrofula1 rhinitis1 malnutrition1 abuse of tea and coffee and exanthematous disease are mentioned by oculists as causes4 ,i have no doubt any or all these conditions predispose to phlyctenular conjunctivitis4 ,de ,schweinitz in 8,diseases of the ,eye10 #aiaf edition1 p4 #bdb1 says3 8,the exact cause of ocular lesions1 or phlyctenular eruption1 has not been determined40 ,i have met ,dr4 ,de ,schweinitz and heard him lecture on the eye4 ,i consider him one of the best eye specialists in the country4 ,his experience and study with the eye dates over many years and his book has gone through eight editions4 ,he is professor of ophthalmology in the ,university of ,pennsylvania2 ,ophthalmic ,surgeon to the ,philadelphia ,polyclinic ,hospital1 the ,philadelphia ,general ,hospital etc41 etc4 ,his opinion represents the summary of the investigation of the ophthalmic profession the world over and through all the past down to the present time4 8,the cause of phlyctenular conjunctivitis is not known40 ,bacteriology4--,at times in the ulcers have been found the staphylococcus pyogenes aureus and albus4 ,they are also found in a normal conjunctival sac4 ,they could not with logic be taken as a causative factor2 at least they would be only secondary4 ,if oculists and other students of the eye all had a good deep osteopathic vision to throw light upon these problems many causative factors would take on a new meaning4 ,such supposed causes as have been mentioned1 e4 g4 eczema1 adenoids1 rhinitis and malnutrition may easily be secondary to the osteopathic lesions4 ,micro-organisms may be enabled to act because of trophic and circulatory disturbances to the conjunctiva through disturbed nerve connections from lesions in the cervical and upper dorsal regions4 ,herpes zoster is purely a trophic nerve disturbance manifestation on the skin as blebs or blisters with more or less neuritis4 ,any lesion that would affect the integrity of the function of the fifth cranial nerve might easily manifest itself as herpes of the conjunctiva4 ,we believe the osteopathic lesion is primary and fundamental in the causation of most of our phlyctenular conjunctivitis4 ,of course insanitation1 scrofulous diathesis and the exanthemata play their role4 ,a good diagnostician should figure out the relative importance4 ,the history1 onset and examination will usually eliminate these conditions4 ,symptoms4--,lachrymation1 photophobia1 blepharospasm and injected vessels are the chief symptoms4 ,there is pain as well as fear of light4 ,the child fights examination4 ,the attack subsides in ten to fourteen days unless there is multiplicity of blebs4 ,some patients have repeated attacks for months or years4 ,many of these cases in medical clinics keep coming for months with repeated attacks4 ,never leave out careful osteopathic treatment4 ,prognosis4--,this is favorable for a final cure4 ,if there should be multiple blebs and frequent recurrence and the cornea is invaded1 the prognosis is not good for perfect sight4 ,the pathology goes deep enough to affect ,bowman's membrane of the cornea disturbing the substantia propria4 ,this causes a macular condition of the cornea which impairs sight4 ,therapy4--,diet should be bland2 the eyes should be protected from irritants2 yellow oxide ointment should be used in the eye once a day or #aj argyrol4 ,the ointment is preferred4 ,moist warm compresses on the eye are comforting4 ,a boric acid wash in almost all conjunctival trouble is good4 ,if there is much irritation giving a suspicion of iris involvement a drop of atropine should be used4 ,the general regimes of living should be regulated4 ,osteopathic treatment should be directed toward building up the general health and correcting all lesions1 especially that may have a specific bearing on the eye trouble4 ,such lesions will be found more often at the first1 second and third thoracic1 but may be anywhere from there to the occiput4 ,vernal ,conjunctivitis ,this disease is known by many as vernal catarrh or spring catarrh of the conjunctiva4 ,it is a chronic inflammation which sets up changes in the conjunctiva and tarsus4 ,this disease may be confused with trachoma unless one observes closely4 ,there are broad flat papill on the conjunctiva4 ,these papill may readily be taken for granulations4 ,they are larger than the granules in trachoma4 ,they somewhat resemble the arrangement of cobble stones4 ,the conjunctiva has a bluish-white filmy appearance called by some1 milky shimmer4 ,the disease was thought at first to appear only in the spring1 hence the name vernal4 ,many cases continue through the year with exacerbations in the spring4 ,it occurs more often in boys4 ,both eyes are attacked4 ,it may heal and leave no trace4 ,it may last from four to twenty years4 ,causes4--,almost all works on the eye say the cause is not known4 ,de ,schweinitz says1 8,definite information in regard to the cause of this disease is lacking40 ,there may be a micro-organism which has not been discovered4 ,i wish to call the attention of the osteopathic profession to the great fact that there are numbers of diseases of the eye as well as of other parts of the body about which the medical profession are entirely 8at sea40 ,this gives valuable ground for scientific research by our profession4 ,my experience with this disease is not sufficient for me to speak with any positiveness or finality as to its cause4 ,the altered trophic parts and the very chronic condition existing leads me to the firm belief that we will ultimately find the cause as a mechanical lesion affecting the trigeminal or sympathetic 7or both7 nerve connections4 ,glare of light and local irritants act only as secondary causes4 ,nasal disease may be associated and act as a cause4 ,symptoms4--,there is photophobia1 some mucus1 slight pericorneal injection1 redness of the conjunctiva of both the bulb and lids2 that of the lids is thickened and of dull pale color due to sub-epithelial hyaline thickening4 ,the fact that there is no pannus1 and flat granulations and recurrence with spring1 marks it from trachoma4 ,prognosis4--,under medical treatment it is unfavorable2 may last twenty years4 ,slight opacity of the cornea may develop4 ,treatment4--,the eyes should be protected with dark glasses4 ,cold compresses give some relief4 ,boric acid is good as a wash4 ,yellow oxide of mercury ointment may be of service as an antiseptic and alternative4 ,if nasal disease exists1 it1 of course1 should be treated according to indications4 ,fundamentally the lesions in the spine in the cervical and upper dorsal regions should be specifically corrected4 ,when enough cases of vernal catarrh have been observed and treated osteopathically much light and benefit will be brought to bear upon this obscure and intractable disease of the conjunctiva4 ,diseases of the ,cornea ,anatomy ,the cornea with the sclera forms the outer coat or tunic of the eye ball4 ,the cornea is in front and forms one-sixth of the envelope4 ,it is a segment of a smaller globe than that of the sclera4 ,it is about #ab mm4 horizontally and #aa mm4 in the vertical diameter4 ,its thickest part is at its junction with the sclera where it is about #a mm4 ,this junction is called the limbus4 ,the cornea is inserted into and rests on the sclera like a watch crystal4 ,the fibers of the cornea pass continuously into the sclera1 however4 ,the normal cornea is transparent4 ,most morbid changes of the cornea cause a diminution in this transparency4 ,in old age a narrow gray line near the corneal margin makes its appearance4 ,this is known as the arcus senilis4 ,there is a little strip of perfectly clear cornea between the arcus senilis and the limbus4 ,the cornea has five layers4 ,these layers should be noted with care1 as in wounds of the eye1 foreign bodies in the cornea and ulcerations1 the results depend much upon which layers are affected4 #a4 ,the anterior epithelium consists of pavement cells of several layers4 ,this layer of the cornea may be damaged or scratched off in large patches and still it will heal readily leaving no trace of the injury4 #b4 ,the anterior elastic lamina or ,bowman's membrane is very thin and homogeneous2 it is just beneath the epithelial layer and forms a resisting sheath to prevent damage to the next layer4 #c4 ,the stroma or substantia propria4 ,this layer composes about nine-tenths of the cornea4 ,it is composed of minute connective tissue fibers between which lie some stroma cells or corneal corpuscles4 ,some of these cells are fixed while others are motile4 ,the motile ones are the white blood-corpuscles which move about in the lymph passages of the stroma4 ,they increase in any irritation of the cornea4 #d4 ,descemet's membrane4 ,this is a tough homogeneous hyaloid membrane back of the stroma4 ,when the stroma is diseased and breaks down ,descemet's membrane may be sufficient to prevent a puncture of the cornea4 #e4 ,the ,endothelial layer is a single layer of flattened cells which coat the posterior surface of ,descemet's membrane4 ,the margin of the cornea is in relation with three membranes1 the conjunctiva1 the sclera and the uvea 7iris and ciliary body74 ,in a disease of the cornea1 a conjunctivitis1 an iritis or a cyclitis is easily started4 ,the cornea contains no vessels4 ,it is nourished by imbibition4 ,at the limbus there is a rich network of marginal loops supplied by the anterior ciliary vessels4 ,from these loops the blood plasma passes into the stroma of the cornea4 ,the nerves of the cornea come from the ciliary nerves and the nerves of the bulbar conjunctiva4 ,these are from the trigeminus and the sympathetic4 ,the nerves extend numerously in the stroma passing forward through ,bowman's membrane into the epithelial layer4 ,this makes the cornea very sensitive to the touch4 ,examination of the ,cornea ,note the size and form4 ,both may be modified by morbid processes4 ,note the surface with regard to curvature1 evenness and smoothness4 ,in keratoconus the curvature is greatly increased4 ,noting the reflex images in the cornea and comparing these with those of a normal cornea will show any variation in curvature4 ,also any unevenness of the surface may be noted by the irregularity or distortion of the images4 ,uneven spots on the cornea may be depressions or elevations from loss of substance2 wrinkles or collapse from lowered tension4 ,if the smoothness or polish of the cornea is lost it looks like glass that has been breathed upon or greased4 ,it is lusterless and dull4 ,note also the transparency of the cornea and determine the form1 extent and density of the opacity2 whether it is diffuse or in spots2 in the deep or superficial layers4 ,a magnifying glass should be used in the study of opacities4 ,according to the density of the opacity of the cornea it is known as a nebula or a nebulous opacity1 a macula or a leucoma4 ,the nebula is the least noticeable and the leucoma is the densest opacity4 ,a leucoma is a condition of complete opacity4 ,the cornea looks white4 ,defects in the corneal epithelium may be made to show clearly by the use of a #b solution of fluorescein which stains them green4 ,note the sensitiveness of the cornea by touching it with the end of a thread1 a little cotton or a shred of paper4 ,the sensitiveness is diminished or lost in glaucoma and some other diseases4 ,diseases of the ,cornea ,almost all diseases of the cornea have some form or degree of inflammation4 ,keratitis is the word generally used for inflammation of the cornea4 ,in order to aid clearness in discussion there are various subdivisions of keratitis made by different writers4 ,suppurative and non-suppurative are the principal types4 ,in suppurative keratitis there is always some destruction of corneal tissue which on healing leaves an opacity with partial loss of vision4 ,germs gain entrance into the tissues usually from the exterior and some form of ulceration results4 ,the following classification is taken from ,fuchs3 ,suppurative ,keratitis4--7#a7 ,ulcer of the cornea2 7#b7 ,serpiginous ulcer2 7#c7 ,keratomalacia or ,xerosis2 7#d7 ,keratitis neuroparalytica4 ,non-suppurative ,keratitis4--7,a7 ,,superficial3 7#a7 ,pannus1 or keratitis with blood vessels2 7#b7 ,phlyctenular1 or keratitis with vesicles4 7,b7 ,,deep3 7#a7 ,parenchymatous or interstitial4 ,in keratitis there is first an infiltration or the increase of cells in the substantia propria or the parenchyma of the cornea4 ,this is the exudate of the inflammation4 ,it causes the cornea to look more or less dull or cloudy4 ,the disease may clear up at this point or go on to suppuration4 ,if it clears up it is known as resorption4 ,if the lamell of the substantia propria are not destroyed by the process1 resorption takes place with no loss of substance4 ,the exudate disappears and there is perfect transparency of the cornea again4 ,there may be slight damage of the stroma preventing perfect transparency4 ,resorption of the exudate may not be quite complete which may become partly organized and left permanently fixed in the cornea4 ,cases resorbing without destruction of the stroma are forms of the non-suppurative keratitis group4 ,if the stroma breaks1 suppuration occurs4 ,this is the second stage and is associated with a localized destruction of the cornea4 ,these cases are known as suppurative keratitis or ulceration of the cornea4 ,the disintegration begins in the most anterior layers of the cornea4 ,a slight depression in the cornea can be noticed4 ,the infiltration is all about the ulcer1 getting less as it is more remote from it4 ,if the floor and walls of the ulcer are foul with the infiltrate it is known as a progressive ulcer4 ,sloughing may continue to spread the ulcer4 ,if the cloudiness around it disappears and the ulcer acquires a smooth transparent base and edges it is known as a retrogressive or clean ulcer4 ,the disintegrated areas of the cornea may be replaced by newly formed tissue4 ,this is the third stage or that of cicatrization4 ,this new tissue is connective tissue4 ,it is opaque1 leaving a permanent opacity4 ,stages of keratitis3 ,suppurative4--7#a7 ,infiltration2 7#b7 ,suppuration and 7#c7 ,cicatrization or ,reparation4 ,the suppuration is progressive or retrogressive4 ,non-suppurative4--7#a7 ,infiltration2 7#b7 ,resorption4 ,in the diagnosis of a keratitis one should look at it very carefully4 ,a loupe which has thick plus sphere lenses will magnify the field and may be of great assistance in observing closely the condition4 ,if the cornea is clouded and dull the trouble is recent and if there is no loss of substance it is an infiltrate 7first stage74 ,if there is loss of substance it is a progressive ulcer 7second stage47 ,if the surface is lustrous but cloudy the trouble is an old one and if there is loss of substance it is a retrogressive ulcer2 if no loss of substance it is a cicatrix4 ,frequently blood vessels grow in from the margin in ulcerations of the cornea4 ,this is usually a process of healing of the corneal ulcer4 ,the advent of the blood vessels is favorable4 ,after healing the blood vessels gradually disappear4 ,they never entirely disappear from large cicatrices4 ,in some cases new vessels accompany the inflammatory process and like the exudate are a part of the clinical picture of the disease as in parenchymatous or interstitial keratitis4 ,pannus also has vessels4 ,they are not in the cornea but are in new tissue deposited upon it4 ,symptoms appearing in keratitis3 #a4 ,ciliary injection or a red area encircling the cornea4 ,if the keratitis is severe there will be considerable inflammation of the conjunctiva which may hide to some extent the ciliary injection4 #b4 ,iritis or iridocyclitis may set in4 ,the iris and ciliary body are in such intimate relation with the cornea that these structures are very subject to involvement in any severe keratitis4 ,with iritis would come danger of synechiae or adherence of the iris to the anterior surface of the lens4 #c4 ,hypopyon4--,in suppurative keratitis there is some exudate into the anterior chamber of the eye4 ,this exudate drops to the bottom of the chamber and looks like pus had gathered in the bottom of the aqueous4 ,this condition is called hypopyon4 #d4 ,other symptoms which are frequently prominent are diminished vision1 pain1 photophobia1 excessive lachrymation and blepharospasm4 ,edema of the lids and conjunctiva may occur4 ,intelligent treatment of keratitis of course is based upon the exact conditions present4 ,great care in diagnosis and treatment should be exercised4 ,ulcer of the ,cornea ,inflammation of the cornea sets in from some cause4 ,there is an infiltrate into the substantia propria4 ,a spot becomes cloudy and the surface over it becomes dull2 at this point the epithelium breaks down or exfoliates and the loss of substance in the parenchyma is the beginning of an ulcer4 ,cause4--,the cause may be constitutional or local4 ,the causes usually thought of from the medical standpoint may be noted in such books as 8,diseases of the ,eye0 by ,de ,schweinitz or ,weeks4 ,i wish especially to call attention to the fact that there is frequently a primary and underlying cause of corneal ulcers not mentioned in any medical texts1 i4 e4 the osteopathic lesion4 ,by this ,i mean more than the spinal lesion although the subluxation lesions that result from the occiput to the fourth dorsal are of most importance4 ,any tension or change of tissue in the cervical region that may interfere with perfect freedom of circulation of blood to the tracts and centers in the cord1 is to be considered4 ,the osteopath of course should take into consideration all causes primary and secondary and govern himself accordingly4 ,symptoms and ,course4--,there is a gray area surrounding the ulcer at first1 also the floor is grayish in color4 ,in this condition it is known as a progressive ulcer or a foul or unclean ulcer4 ,this cloudiness or gray area may increase in size and the ulcer keep spreading1 or it may go deeper even to perforation of the cornea4 ,some ulcers advance or spread on one side and heal on the opposite side so that they creep along on the cornea--these are the so-called serpiginous ulcers4 ,with corneal ulcers there is irritation1 pain1 photophobia and increased lachrymation4 ,there is usually some ciliary injection which is an indication of involvement of the iris and ciliary body4 ,if iritis occurs there is contraction of the pupil with slow reaction4 ,hypopyon may develop4 ,with iritis and the exudate there is likely to be adhesions between the iris and the lens known as posterior synechia4 ,a few corneal ulcers are asthenic and do not have irritative symptoms and yet are dangerous4 ,when the ulcer begins to heal it is called retrogressive4 ,dead tissue is cast off2 other tissue becomes transparent from resorption4 ,we have a clean ulcer4 ,symptoms disappear and cicatrization begins4 ,vessels extend to the ulcers and soon it is leveled up with the corneal surface4 ,cicatrization may leave it slightly below the corneal level or above it4 ,if there should be perforation of the cornea from the ulcer there may be complications1 e4 g4 keratocele1 loss of aqueous1 dislocation and expulsion of the lens1 intra-ocular hemorrhage1 flattening of the cornea1 fistula of the cornea1 glaucoma1 intra-ocular suppuration1 prolapse of the iris into the opening1 etc4 ,these complications and sequel that occur occasionally will not be considered here4 ,after healing is complete by cicatrization there is opacity of the cornea in proportion to the depth and size of the ulcer4 ,in months and years of time there is some clearing of the opacity so that small superficial opacities may become invisible4 ,treatment of ,corneal ,ulcers4--,most ulcers of the cornea are quite amenable to proper treatment and the prognosis is favorable4 ,neglect or wrong treatment is very dangerous4 ,the treatment is local and constitutional4 ,often the ulcer is kept going by unwholesome constitutional conditions4 ,local ,treatment4--,this varies according to the stage of the ulcer1 whether progressive or retrogressive4 ,in a progressive or foul ulcer if due to trauma any foreign bodies should be removed4 ,if the ulcer is a result of pathology of the conjunctiva it is of primary importance to treat the conjunctival condition4 ,in mild cases of ulcer a dressing over the eye with atropine to keep the pupil dilated is sufficient local treatment4 ,the bandage protects the eye from bright light and other environment and the atropine puts the iris and ciliary body at rest preventing complications and giving nature her best chance to work4 ,if the ulcer is rapidly progressive1 warm compresses an hour or two a day are good2 iodoform sprinkled on the ulcer or actual cautery may be used4 ,in the retrogressive stage 7clean ulcer7 healing has begun and we desire to get as near as possible a resistant transparent cicatrix4 ,yellow oxide ointment is useful at this stage4 ,osteopathic4--,the local measures just mentioned are not incompatible with osteopathic theory or practice4 ,they are merely adjunctive in getting nature's reaction toward normalization1 as also are hot and cold applications4 ,osteopathy comes in now in a most important and fundamental way with the constitutional and specific lesion treatment4 ,the bulbo-spino-sympathetic-ciliary arc has been mentioned and explained4 ,through this important nerve connection with the eye1 profound and wholesome effects on the eye may be gotten by osteopathic treatment4 ,frequently lesions of the occiput1 cervicals and upper dorsals will affect the integrity of the ocular structures through disturbances of nerve and blood supply4 ,the stomach1 bowels1 liver and kidneys should be carefully noted in corneal ulcers4 ,poor circulation1 indigestion1 constipation and auto-intoxication may have an important bearing on the recovery of the ulcer4 ,xerosis or ,keratomalacia ,this is a disease of the eye in children due to insufficient nutrition of the cornea4 ,hereditary influences1 depleting diseases and lesions affecting the trophic nerves to the eye are causes4 ,treatment consists of building up the nourishment of the child1 correction of lesions and careful dieting4 ,hot applications to the palpebral region helps to bring the blood supply to the eye for local effects4 ,keratitis ,neuroparalytica ,this disease is due to a paralysis of the #eth cranial nerve4 ,the cornea becomes slightly cloudy4 ,the epithelium gradually sloughs away4 ,an ulcer may or may not form4 ,pain and lachrymation are absent because of paralysis of the trigeminus4 ,there is usually ciliary injection4 ,treatment4--,the most important treatment for this unfortunate condition is manipulation to restore the integrity of the #eth cranial nerve and the blood supply to the eye4 ,cervical1 spinal1 nasal1 nasopharynx treatment should be given4 ,spring the inferior maxilla4 ,a drop of atropine 7#a7 should be used locally because of the ciliary injection4 ,warm compresses used locally will help4 ,the healing usually leaves some opacity of the cornea4 ,keep the eye bandaged to protect the cornea4 ,pannus ,this form of keratitis is superficial and is characterized by the formation of blood vessels in the cornea4 ,it is caused by some irritative influence4 ,most often it is a complication of trachoma4 ,if the irritation can be removed the vascularity gradually recedes1 leaving a clear cornea unless the deeper structures of the cornea have been involved4 ,phlyctenular ,keratitis ,this disease is an involvement of the cornea with an eczematous process similar to phlyctenular conjunctivitis4 ,there is more likely to be ciliary injection and iritis1 in which case atropine should be used4 ,the treatment is the same otherwise as for phlyctenular conjunctivitis4 ,parenchymatous or ,interstitial ,keratitis ,this is shown by a diffuse inflammatory infiltration of the substantia propria of the cornea4 ,part or whole of the cornea of one or both eyes may be involved4 ,very fine blood vessels may invade the deep structures of the cornea4 ,cause4--,syphilis1 tuberculosis1 rheumatism1 diabetes and rachitis are systemic diseases found back of this trouble4 ,symptoms4--,irritation1 lachrymation1 photophobia with ciliary injection are the chief symptoms4 ,treatment must be local and constitutional4 ,locally atropine should be used4 ,dark glasses should be worn or the patient must be kept in a dark room4 ,treatment to the trigeminal nerve and tissues of the orbit should be given4 ,constitutional treatment should be spinal with the idea of arousing all the forces of the body to greater activity4 ,careful dieting should be followed according to indications4 ,the infiltration and blood vessels will ultimately disappear4 ,sometimes enough may remain to cloud the vision4 ,diseases of the ,iris and ,ciliary ,body ,the iris and ciliary body have the same blood and nerve supply4 ,that is1 they are supplied by the same set of vessels and nerves4 ,for this reason it is practically impossible to have an iritis absolutely independent of a cyclitis or some inflammation of the ciliary body4 ,if the iris is the primary seat of the trouble there are certain symptoms that may indicate such a state4 ,however1 when we are treating the iris or diagnosing conditions of the iris we must remember that the ciliary body is very likely more or less involved and may be the primary seat of the trouble4 ,in iritis there are some symptoms which are caused from the hyperemic condition of the eye1 such as a slight change in color4 ,the pupil becomes rather inactive1 there is some ciliary injection with photophobia1 lacrymation and pain4 ,in case of an exudate in the iris there may be thickening1 and the exudate in the anterior chamber of the eye will form a hypopyon4 ,sometimes the small vessels will break and there will be a little bleeding which will be mixed with the debris in the bottom of the anterior chamber4 ,this is known as hyphemia4 ,there are likely to be adhesions between the iris and the anterior capsule of the lens known as posterior synechia4 ,the pupil is more or less irregular4 ,if atropine is dropped into the eye to dilate the pupil1 parts of the edge of the pupil will be adhered while the other parts dilate making it very irregular4 ,in case of cyclitis there is an exudate from the ciliary body into the posterior chamber4 ,this may cause a total adherence of the iris to the crystalline lens4 ,with the ophthalmoscope1 opacities in the vitreous may be noticed4 ,these are exudates4 ,the tension of the eye is liable to increase a little at first but as the exudates absorb there is more or less softening4 ,vision is low4 ,also in cyclitis there is ciliary injection1 photophobia1 lacrymation and pain1 similar to that of iritis4 ,pressure on the eye ball will reveal a very tender condition around the sclerocorneal junction or over the area of ciliary injection4 ,the causes of iritis1 cyclitis or iridocyclitis frequently are systemic conditions and infection such as syphilis1 rheumatism1 gonorrhea1 tuberculosis1 infectious diseases and metabolic changes1 it may be of traumatic origin or sympathetic4 ,fuchs says 8,there are many cases of iritis for which no cause can be discovered and therefore which cannot be placed under these causes40 ,we agree with him and advance the theory of cervical and upper dorsal lesions or trouble in the sinuses1 nose1 nasopharynx or throat4 ,no doubt osteopathy can throw some important light on the causes of diseases of the iris and ciliary body4 ,the nose and throat should be examined in all these cases4 ,treatment4--,atropine must be used in the sore eye to put the iris and ciliary body at rest and dilate the pupil to draw it back from the lens so that adhesions may not form4 ,warm compresses will give much comfort4 ,sweating should be brought about4 ,all fluid should be reduced to a minimum4 ,diet should be very moderate and the bowels kept unusually free4 ,the eye should be protected by dark goggles4 ,thorough treatment of the neck and upper dorsal region with attention to the nose and throat should be given4 ,constitutional treatment should be given according to the indications mentioned under causes4 ,if annular synechia or total posterior synechia form or there is atrophy of the eyeball operative work may be needed4 ,also for injuries1 tumors1 anomalies and so forth of the iris see the latest medical works on this subject4 ,diseases of the ,choroid ,the choroid is the vascular tunic of the eye4 ,with the iris and ciliary body it forms the uvea4 ,the iris and ciliary body are rich in nerve terminals and when inflamed2 pain is a prominent symptom4 ,the choroid has no sensory nerve terminals4 ,when it is involved alone2 pain is not present however severe the pathology4 ,embryologically ,descemet's membrane is a part of the uvea4 ,when the uveal tract is diseased we frequently note symptoms of a descemetitis as a turbidity of the anterior chamber and spots on ,descemet's membrane4 ,when one part of the uvea is inflamed the tendency is to pass to the other parts because of the intimate blood supply4 ,choroiditis ,there are many forms of choroiditis given by writers according to the clinical picture and the pathology4 ,symptoms4--,no pain is experienced unless there are complications4 ,vision is altered in some degree4 ,the use of the ophthalmoscope may reveal opacities in the vitreous4 ,pigmentation spots and exudation may be noted in the fundus4 ,in disseminated choroiditis spots of exudate appear in the fundus which go on to atrophy1 leaving irregular circular light patches4 ,treatment4--,in all forms of choroiditis careful diagnosis of constitutional conditions should be made and treatment given according to indications4 ,nasopharynx and orbital treatment as outlined under manipulation for diseases of the eye should be given4 ,rest and protect the eyes4 ,secure free elimination4 ,panophthalmitis ,by injury or otherwise pathogenic germs are introduced into the eye4 ,the trouble begins as a suppurative choroiditis and rapidly spreads to all the eye structures4 ,the vitreous chamber becomes filled with pus4 ,symptoms4--,pain is severe and sight is lost early4 ,the conjunctiva and lids are much swollen4 ,there is a mucopurulent discharge4 ,the cornea becomes gray and may slough4 ,in about two weeks the inflammation subsides and the globe passes into atrophy4 ,treatment4--,elimination must be thorough4 ,spinal treatment for keeping up strength4 ,cervical1 upper dorsal and nasopharynx treatment for the eye4 ,moist hot compresses to the eye4 ,operation1 incision for drainage1 or evisceration may have to be performed4 ,sympathetic ,ophthalmia ,the other eye may become inflamed by the process from the panophthalmitis passing around through the circulation or the continuous structures4 ,all symptoms of a general inflammation appear and vision gradually diminishes4 ,treatment4--,in panophthalmitis of one eye always watch the other eye closely4 ,if it becomes irritable or shows any signs of being affected the diseased eye should be promptly removed1 especially if vision is lost in that eye4 ,if no irritation occurs1 continued conservative treatment of the panophthalmitis may result in a subsidence of the disease without the well eye becoming affected4 ,sympathetic inflammation rarely develops earlier than a month after injury to the exciting eye4 ,sooner than that or even a few minutes after injury there may be some signs of sympathetic irritation and the symptoms continue with no evidence except a slight circumcorneal injection4 ,it should be treated like iritis4 ,a thorough toning of the system by spinal treatment should be given4 ,order a limited diet4 ,secure free elimination4 ,glaucoma ,glaucoma is essentially an increase in the intra-ocular pressure4 ,all other symptoms of the trouble may be traced to this condition4 ,in ,primary ,glaucoma the increase in pressure sets in without any discoverable antecedent disease of the eye4 ,in ,secondary ,glaucoma the increase in pressure is due to some other disease of the eye4 ,it is a symptom1 a complication or accessory and is confined to the eye diseased4 ,primary glaucoma affects both eyes1 but not always at the same time4 ,fuchs says primary glaucoma constitutes about #a of all eye diseases4 ,it is often mistaken for iritis or iridocyclitis and treated with atropine which is contraindicated4 ,it may be regarded as beginning cataract and time lost in expecting it to become ripe4 ,these delays and wrong treatment have caused much blindness4 ,palpation with the finger or the use of the tonometer may readily detect any increase in tension4 ,a correct diagnosis must be made early and proper treatment instituted if vision is to be saved4 ,primary glaucoma may or may not have signs of inflammation4 ,if the tension rises suddenly inflammatory symptoms develop 7acute7 while if the increase in tension develops gradually these symptoms are lacking 7simple74 ,acute primary glaucoma--,symptoms4--,first stage1 rise in tension1 vision obscured1 sees a colored ring around lights1 cornea dull1 pupil dilated and sluggish1 some ciliary injection4 ,the attack may clear up for a day or for weeks4 ,gradually the symptoms become permanent after repeated attacks4 ,second stage1 when the attack comes there is much pain1 visual power fails rapidly1 may be edema of the lids and chemosis of the conjunctiva1 all symptoms become much exaggerated1 the cornea becomes cloudy4 ,after a violent attack the vision is more or less permanently damaged4 ,third stage1 after many attacks the optic nerve becomes excavated and atrophy takes place4 ,simple ,primary ,glaucoma ,symptoms4--,tension comes gradually2 no inflammatory signs2 pupil somewhat dilated and sluggish1 the cornea may look slightly smoky4 ,with the ophthalmoscope a cupped disc may be noted4 ,there is gradual diminution of sight1 which begins by contraction of the field4 ,there are many theories advanced as to the cause of intra-ocular tension in glaucoma4 7,fuchs1 ,weeks1 ,de ,schweinitz74 ,treatment4--,eserine is used instead of atropine4 ,the object is to contract the pupil and draw it away from the side wall of the eye ball so the sinus 7,schlemm's canal7 and the pectinate ligament 7the filtering angle7 may become free4 ,the good effect of this is more marked in inflammatory glaucoma4 ,in simple primary glaucoma miotics do little good4 ,reports from osteopathic treatment of this condition have been favorable in a number of cases4 ,careful manipulation of the structures of the orbit with the finger or with ,dr4 ,ruddy's third finger eye instrument is good in restoring better circulation of the lymph and blood4 ,special attention to the venous drainage should be given4 ,treat the points of the fifth nerve1 the nasopharynx and cervical region1 spring the jaw4 ,treat second dorsal4 ,have the patient avoid strong emotions or excitement4 ,keep the bowels free and use only a very bland diet4 ,iridectomy is considered the best operation in glaucoma4 ,in the treatment of secondary glaucoma the other diseases or complications must be considered in conjunction with the foregoing treatment4 ,diseases of the ,lens ,opacities or ,cataract ,symptoms4--,beginning opacities can best be recognized with the ophthalmoscope4 ,advance opacities can be seen at a glance with the naked eye4 ,vision is disturbed according to degree and location of the opacity4 ,if the opacity is in the center of the lens and the periphery is transparent they see better when the pupil is dilated4 ,when the opacities are in the periphery of the lens they see better by day4 ,musc volitantes and polyopia are present until increasing opacity closes up all clear areas shutting out these visual perversions4 ,there are many clinical varieties of cataracts which may be studied in works on ophthalmology4 ,causes4--,some interference with the nutrition of the lens accounts for the condition4 ,heredity is supposed to play a part in some cataracts4 ,rickets1 convulsions1 traumatism1 old age1 some drugs 7ergot71 inflammation of iris1 ciliary body and choroid are given as causes4 ,cervical and upper dorsal lesions and disease of the throat1 nasopharynx and nose will interfere with perfect circulation and drainage of the orbit1 and may well have much to do with many idiopathic cataracts4 ,treatment4--,many cases have been reported cured by osteopathic measures4 ,correct lesions and treat to establish free nerve force and circulation of blood and lymph to the orbit4 ,manipulation of the orbital tissues and mild vibration of the bulb are measures of value4 ,more hope may be held in symptomatic1 toxic1 secondary and progressive cataracts4 ,the process may be stopped and in many cases there is hope of a clearing4 ,diseases of the ,retina ,the retina lines the back part of the eye ball4 ,it comes forward to the ora serrata4 ,it consists of ten layers which have been demonstrated microscopically4 ,one layer of it passes over the ciliary body and back part of the iris to the pupil4 ,the fibers of the optic nerve spread out over the retina4 ,the point of entrance of the optic nerve is the papilla4 ,it is to the inner side of the posterior pole of the eye4 ,the retinal vessels emanate there4 ,the macula lutea is the yellow sensitive spot at the posterior pole of the eye4 ,the fovea is the center of the macula4 ,the rods and cones constitute the external layer of the retina4 ,this layer is the light perceiving stratum4 ,for vision to be perfect all the other layers must be perfectly transparent4 ,the visual purple is a chemical substance in the rods that gives the retina a purplish-red color4 ,the light shining into the eye forms images which are converted into nervous stimuli by chemical action of the visual purple and by physical changes and fibrillations in the rods and cones4 ,retinitis ,symptoms4--,the ophthalmoscope must be used in diagnosis4 ,there is at first cloudiness of the retina2 the outlines of the papilla become indistinct4 ,we may note light patches of exudates4 ,the vessels are more tortuous and often there are hemorrhagic spots4 ,opacities in the vitreous due to the exudate may be seen4 ,vision is disturbed in proportion to the inflammation4 ,weeks or months are required for recovery4 ,atrophy may set in and cause blindness4 ,cause4--,many general diseases are found back of this trouble1 e4 g4 albuminuria1 diabetes1 leukemia1 syphilis1 gout and arteriosclerosis4 ,idiopathic cases occur with none of these diseases present1 which gives a field for osteopathic research4 ,treatment should be directed against the general disease when present4 ,for local effects treatment should be given to all the centers and localities that affect the trophism1 nerve supply and circulation to the eye4 ,protect the eye by dark glass or confinement to a dark room and complete rest4 ,keep the bowels free and produce diaphoresis4 ,optic ,neuritis ,this disease when manifest in the eye ball is called papillitis4 ,if back of the bulb it is retrobulbar neuritis4 ,symptoms of papillitis4--,pupils are dilated and sight diminishes4 ,the color of the papilla is altered to a white1 reddish or gray and may show extravasation of blood4 ,the papilla is swollen 7choked disc71 the arteries are thin and the veins are engorged4 ,it takes months for the inflammation to clear4 ,atrophy is likely to occur4 ,causes4--,brain diseases are the most frequent cause1 e4 g4 tumors4 ,syphilis1 febrile diseases1 nutritive disturbances1 lead poisoning1 heredity and growths in the orbit are cited as causes4 ,symptoms of ,retrobulbar ,neuritis4--,there is little or no change in the papilla4 ,the diagnosis must be made mostly from the way the vision is affected4 ,the rule is a central scotoma in the field of vision4 ,the first colors to disappear are red and green4 ,in the acute form there is quick disturbance of vision4 ,the eye looks normal outside and shows practically no change inside4 ,cause4--,toxemia1 cold1 influenza2 nasal1 nasopharyngeal and sinus disease 7ethmoids71 and infectious diseases are causes4 ,idiopathic inflammation of the optic nerve is noted by most oculists4 ,here the profound effects of spinal lesions upon the eye adds some important light4 ,treatment of ,papillitis and ,retrobulbar ,neuritis4--,in each individual case the treatment requires consideration of the causal factor4 ,there may be required constitutional treatment in many cases4 ,in others the cause may be found in the nose1 nasopharynx1 or spine4 ,effort should be made to remove the lesion in each case4 ,diaphoresis will aid in acute stages4 ,atrophy of the ,optic ,nerve ,there are many causes for this condition such as optic neuritis1 meningitis1 acute infectious diseases1 locomotor ataxia1 arteriosclerosis1 nasal disease1 syphilis1 traumatism1 alcoholism1 exposure1 embolism of the central retinal artery1 diabetes and poisoning4 ,diagnosis must determine the original cause4 ,treatment4--,i have mentioned conditions in the nose as frequently accounting for various eye troubles4 ,if these atrophies of the optic nerve can be gotten early1 many of them will be influenced very favorably by osteopathic treatment4 ,spinal treatment to direct the circulation to the area of the orbit at the base of the brain is beneficial4 ,regulation of the patient's diet1 habits1 methods of living and so forth is important4 ,excessive mental strain1 excessive sexual intercourse and stresses of every kind should be prohibited4 ,special treatment should then be given according to the causal factors entering into the case4 ,eye ,strain and ,its ,reflexes ,for the subject of refraction and refractive errors such as the different forms of hypermetropia1 myopia and astigmatism the reader is referred to the many excellent works on ophthalmology which cover these subjects quite thoroughly4 ,they are only used here in the relation to eye strain and its reflexes4 ,the osteopathic logic here given should be combined with a reading of the refractive errors in such works as ,fuchs1 ,weeks1 ,de ,schweinitz and others4 ,asthenopia ,eye strain1 weak sight or asthenopia embraces the group of symptoms dependent upon fatigue of the ciliary muscles or of the extraocular muscles4 ,there are three varieties of asthenopia4 7#a7 ,retinal or nervous1 7#b7 muscular and 7#c7 accommodative4 ,the symptoms are headache--frontal1 fronto-temporal or fronto-occipital4 ,it may extend into the neck between the shoulders4 ,eye balls may be tender1 diplopia at times1 may be photophobia1 lachrymation1 congestion of the eye1 itching and burning of the lids4 ,accommodative ,asthenopia4--,in this form the ciliary muscle is fatigued4 ,the cause is usually overuse of the eye when hyperopia and astigmatism exist2 sometimes in myopia or presbyopia4 ,treatment4--,in this form the treatment is the proper fitting of glasses and improvement of the general health4 ,muscular ,asthenopia is due to tiring of the extraocular muscles1 usually the internal rectus4 ,this may result in a phoria or a non-paralytic squint4 ,ametropia may exist but asthenopia may come even in emmetropia due to overuse of the eye4 ,treatment4--,correct ametropia if present1 with glasses4 ,exercise the weakened muscle4 ,correct the nerve supply to the weak muscle4 ,treat cervical and upper dorsal4 ,manipulate tissues of the orbit4 ,spring the jaw4 ,correct any nose and throat pathology4 ,nervous1 ,neurasthenic or ,reflex ,asthenopia4--,the cause is supposed to be some functional disorder1 more often found in females4 ,may be due to too dim or too bright light1 overuse of the eyes4 ,hysteria may follow ametropia4 ,treatment4--,often the treatment is troublesome and the case is very obstinate according to old school methods4 ,rest1 hygiene1 general health and habits are looked after4 ,the cause must be found or the treatment cannot be specific4 ,these are the different forms of eye strain as ordinarily classified4 ,now as we study the reflex symptoms from these and attempt to trace out the reflexes from an osteopathic point of view1 we may find some more definite causes of these conditions and consequently some methods of treatment not found in standard text books might naturally suggest themselves4 ,reflex symptoms that have been traced to eye strain by ophthalmologists are as follows3 ,constipation1 indigestion1 heartburn1 nausea1 vomiting1 nervous attacks1 fear of impending calamity1 irritability1 despondency1 insomnia1 restless sleep1 epilepsy1 nervous twitchings and enuresis4 ,all these symptoms have been seen to disappear after eye strain was corrected4 ,there is no absolute way of proving that all these symptoms have existed because of eye strain4 ,the existence and disappearance of some of them at the time of treatment for eye strain may be a coincidence4 ,it is evident that eye strain in varying degrees may produce a train of symptoms similar to many above mentioned4 ,a patient1 nervous1 anxious1 uneasy1 and despondent1 constipated1 and having some indigestion1 showed on examination contractures and tenderness at the third dorsal4 ,it was found he was suffering from eye strain from overuse of glasses that were too strong for him4 ,the eyes were refitted4 ,he was wearing a 7,r7#d4ej ,d4 ,s4 4#ej cyl4 ,ax4 #ahj4 7,l7#d4ej ,d4 ,s4 4#ej cyl4 ,ax4 #ij for close work and a 7,r7#b4jj ,d4 ,s4 4#ej cyl4 ,ax4 #ahj 7,l7#b4ej ,d4 ,s4 4#be cyl4 ,ax4 #ij for distance4 ,the new glasses were--,reading-- 7,r7#c4jj ,d4 ,s4 4#be cyl4 ,ax4 #ahj 7,l7#c4jj ,d4 ,s4 4#be cyl4 ,ax4 #ahj ,distance3 7,r7 #a4ej ,d4 ,s4 4#be cyl4 ,ax4 #ahj 7,l7 #a4ej ,d4 ,s4 4#be cyl4 ,ax4 #ahj ,he was fitted two years previously4 ,at that time the stronger glasses were correct4 ,eyes change more or less constantly1 especially between the ages thirty-five to fifty-five years4 ,when glasses are fitted1 a weak ciliary muscle after a rest may become stronger and allow weaker glasses to be worn4 ,if a young person is fitted for myopia1 in a few years he may discard his glasses as presbyopia develops4 ,a person fitted correctly1 who has a strong ciliary muscle may not be able for awhile to see as well with the glasses as without them4 ,after they are worn awhile the ciliary muscle will cease its efforts to accommodate so much and the glasses give the desired effect4 ,in some cases the doctor's reputation to fit glasses properly may suffer at the hands of such people who sometimes refuse to take glasses1 or after getting them refuse to wear them4 ,in the case of the man just mentioned a refitting quieted the nervous symptoms--he became more cheerful and ceased to worry4 ,indigestion and constipation improved4 ,the soreness and contractures were overcome in a few treatments4 ,now let us ask the question1 why is it that eye strain will cause nausea and vomiting8 ,also why will indigestion affect the eyes by causing 8spools0 in the vision8 ,a little osteopathic logic1 based as it always is or should be1 upon anatomy and physiology1 may throw some light on this subject4 ,no doubt every one of us has demonstrated many times clinically that indigestion from overeating will cause soreness and contractures at the third and fourth dorsal1 the nerve center in the spine for the stomach4 ,the reflexes between the viscera and the eye are complex and difficult to follow4 ,in giving the probable course of the nerve reflexes from the optic nerve to the third nerve ,dr4 ,louisa ,burns suggests the following3 8,the nerve elements of the retina start the impulse2 it passes over that portion of the optic nerves which enter the anterior quadrigeminates1 the cells of the quadrigeminates where the impulses are coordinated1 then by axons of these cells to the lateral or viscero-motor nucleus of the third nerve1 thence to the cells of the ciliary ganglion1 and by the non-medulated 7sympathetic7 fibers of these1 the short ciliary nerves to the non-striated muscles concerned1 viz3 the ciliary muscle1 some fibers of the levator palpebral and the sphincter of the iris40 ,the third nerve arises in the floor of the aqueduct of ,sylvius from two nuclei2 a lateral nucleus which is a viscero-motor group of nerve cells1 and a central nucleus or a somato-motor group of cells4 ,the somato-motor nucleus supplies all the extrinsic muscles of the eye except the external rectus and superior oblique which are supplied by the sixth and fourth respectively4 ,the nasal branch of the ophthalmic division of the #eth sends fibers to the ciliary muscle4 ,association fibers connect the nuclei of the #crd1 #dth1 #fth and #gth4 ,the evidence is in favor of the #ajth or pneumogastric having such association fibers4 ,we noted four places in the brain to which the optic tracts go before the radiations reached the center of sight in the occipital lobe4 ,if we cannot follow all the reflexes through the brain and cord at least with the facts we have it is not difficult to imagine abnormal impulses coming over the third nerve from a straining of the ciliary nucleus1 thence over viscero-motor fibers in the lateral horn of the cord1 over the white ramicommunicantes1 through the sympathetic ganglia1 over the splanchnics to the stomach1 producing abnormal peristalsis1 nausea and vomiting4 ,in turn we would have the somato-motor nerves to the muscles affected as before described1 contraction and congestion of muscles of the spine4 ,when we have patients consult us and describe a train of symptoms like nausea1 vomiting1 nervousness1 frontal and occipital headache1 we should have eye strain in mind and inquire for lachrymation1 photophobia1 itching and burning lids and congestion of the eye4 ,any of these things should make us think of testing for ametropia in its various refractive errors1 as well as a careful spinal and a nose and throat examination4 ,general physical and laboratory diagnosis should not be neglected4 ,references ,fuchs's ,text ,book of ,ophthalmology1 ,duane4 ,headaches and ,eye ,disorders of ,nasal ,origin1 ,sluder4 ,external ,diseases of the ,eye1 ,greeff4 ,vol4 ,,iii ,practical ,medicine ,series3 ,the ,eye1 ,ear1 ,nose and ,throat by ,casey ,a4 ,wood1 ,albert ,h4 ,andrews1 ,geo4 ,e4 ,shambaugh4 ,diseases of the ,eye1 ,weeks4 ,diseases of the ,eye1 ,ear1 ,nose and ,throat1 ,posy and ,wright4 ,diseases of the ,eye1 ,de ,schweinitz4 ,diseases of the ,eye1 ,may4 ,text ,book of ,ophthalmology1 ,roemer and ,foster4 ,diseases of the ,eye1 ,jackson4 ,ophthalmic ,surgery1 ,meller4 ,,diseases ,,of ,,the ,,ear1 ,,nose ,,and ,,throat ,by ,j4 ,,deason ,diseases of the ,ear ,methods and ,technic of ,examination4--,the external ear may be examined by direct inspection with or without the aid of artificial light4 ,the external auditory meatus may be examined by means of a simple conical ear speculum and reflected light from a head mirror4 ,this method requires considerable practice but efficiency can and should be attained because it can be used under all conditions and therefore is a reliable method4 ,the ,holmes electric auroscope which we use and recommend for examining the meatus and ear drum1 is very efficient but like other electrical equipment is not always dependable4 ,there are many electrical equipments for examining the ear1 but so far ,i have found none other than the one above mentioned that is worth space in an instrument cabinet4 ,to examine the meatus1 grasp the pinna and draw it firmly upward and backward4 ,this tends to straighten the canal so that the aural speculum may be inserted well into the external canal4 ,it must be remembered that the auditory canal is always sensitive and while there is really little danger of doing any harm by exercising ordinary care1 the patient is always afraid of being hurt and one can accomplish better results by practicing careful technic4 ,if the electric auroscope is used1 the eye should be placed very close to the lens and every part of the canal1 walls and drum membrane carefully examined4 ,the ,holmes auroscope has a small tube and bulb1 pressure upon which will vary the air pressure in the meatus and cause the drum to move4 ,this must be done very carefully because in very thin1 atrophic membranes there is some danger of rupturing the drum4 ,diseases of the ,auditory ,meatus ,inspissated ,cerumen1 or hardened ear wax is one of the most common affections of the meatus4 ,the cause in some cases can be traced to lesions of the mandible1 but in many cases the cause is unknown4 ,treatment4--,protect the clothing by means of a towel or rubber neck piece4 ,by means of a soft rubber ear syringe1 wash the canal thoroughly by forcing warm soap solution into it4 ,i prefer concentrated liquid castile soap 7any good soap will do7 diluted about one to four in water as warm as the patient can bear it4 ,the soap solution is contained in a pus bowl held tightly against the neck under the ear4 ,there is little danger of using too much force with the soft rubber syringe4 ,in most cases the hardened cerumen will be dislodged by the syringing only4 ,if this cannot be done1 it may be well to discontinue the treatment until the following day4 ,the solvent action of the soap solution will further reduce the hardened mass and it usually can be removed by syringing the following day4 ,this method is preferable in many cases because patients dislike the pain which usually accompanies the use of a curet4 ,the dull loop curet is the most efficient and safest instrument for removing hardened cerumen that the syringe may fail to dislodge4 ,this instrument must be used with great care because the membranes1 long protected by the covering of cerumen are hypersensitive and bleed easily4 ,after removing the cerumen1 the canal should be thoroughly dried and lubricated with some non-irritating lubricant4 ,it is also well to place a small pledget of absorbent cotton into the external opening to protect the sensitive membranes from the cold1 air and dust4 ,in drying the canal ,i prefer to use a small aluminum applicator1 twisting a small piece of absorbent cotton on the end in such a way as to cover the tip well1 thus making any injury from its use impossible4 ,atrophic ,meatus ,sensitive or itching ears as the patient commonly describes it1 is a very common disease caused by any atrophic condition of the membranes of the auditory meati and frequently found in common with auditory or other cranial nerve deficiency or degeneration4 ,the direct cause of the irritation is the collection of particles of dry cerumen4 ,treatment4--,the local treatment consists of syringing with warm 7#aah to #abj;,f7 soap solution until all of the scaly cerumen has been removed4 ,the canal is then dried and lubricated as described above4 ,several such treatments may be required after which ,i prefer the use of the continuous irrigating ear cup1 using salt mixture instead of the soap4 ,the same salt mixture as is recommended for nose and throat irrigation is satisfactory4 ,after such irrigations the application of phenol-glycerine 7#aj phenol in glycerine7 seems to be an efficient treatment4 ,the local treatment must1 of course1 be accompanied by corrective treatment to the mandible and upper cervicals4 ,furunculosis ,there are three acute affections of the ear which may usually be diagnosed from their points of tenderness or pain4 ,pain upon moving the lobe or pinna indicates furunculosis4 ,pain on pressure posterior to the angle of the jaw or externally in front of the ear indicates middle ear infection and pain on pressure over the mastoid region suggests mastoiditis4 ,probably the most common of the painful diseases of the external meatus is furunculosis1 which is a subcutaneous infection of the lining membrane of the meatus4 ,the point of swelling may usually be seen but in some cases the entire canal is closed4 ,treatment4--,in all cases of occluded pus1 drainage must be obtained1 but in the early stages of furunculosis1 it is not always possible to determine the place of 8pointing0 or the most desirable point to lance4 ,as soon as the place of 8pointing0 can be located it is advisable to lance deeply by means of a curved paracentesis knife4 ,the parts are thoroughly cleansed and anesthetized by applying phenol and neutralizing with alcohol4 ,the external parts are first painted with alcohol to prevent 8burning0 from any phenol which may be dropped upon them4 ,a small cotton applicator is used1 applying the concentrated solution of phenol or the crystals 7using only a small amount of phenol7 to the affected parts and immediately neutralizing with alcohol4 ,care must be observed not to apply any phenol to the drum membrane and the operator must be sure that the action of the carbolic acid is completely neutralized by a liberal application of alcohol4 ,the knife blade is placed beyond the furuncle1 its curved point turned outward and quickly drawn forward through the furuncle1 cutting deeply4 ,the canal is then packed with a pledget of cotton dipped into phenol-glycerine4 ,if the place of pointing cannot be seen1 palliative treatment may be applied by thoroughly cleaning the meatus1 drying and applying a phenol-glycerine pack4 ,heat may be applied by means of a therapeutic lamp4 ,any electric light bulb or the dry electric pack will do4 ,the external parts are well lubricated with paraffin oil and the heat applied continuously or intermittently until the pain is relieved4 ,infection of the ,meatus ,infections of the meatus are frequently secondary to1 or accompanied by furunculosis4 ,the treatment1 therefore1 is similar to that of furunculosis4 ,always try to locate the point of infection1 lance or curet1 apply phenol or other chemical germicide1 neutralize1 dry and pack with phenol-glycerine4 ,after the point of infection has been thoroughly drained1 cleanliness and protection from dust or further infection is all that is necessary4 ,in all cases of infection of the external meatus1 suspect middle ear abscess as a cause4 ,there may be a pin-point opening through the drum1 from which the infection has originated and is being maintained4 ,otomycosis or fungus infection of the auditory meatus is rare4 ,it usually resembles other infections symptomatically1 but often without pus4 ,a microscopic examination will serve to diagnose the condition4 ,the treatment consists of thorough cleansing1 drying and the free application of alcohol4 ,alcohol is dropped into the ear until the canal is full and a pledget of cotton applied to retain it4 ,usually two or three applications are sufficient to effect a cure4 ,eczema of the auricle and meatus is of two types1 the squamous or scaly form and the sclerotic form4 ,both forms are chronic and may be readily diagnosed by the appearance4 ,treatment4--,some cases are very difficult to cure but we have had excellent results with the following treatment3 ,careful adjustment of cervical and mandibular lesions2 thorough treatment of any local infections of head or neck2 direct application of phenol-glycerine1 local cleanliness and protection from irritation4 ,diseases of the ,middle ,ear ,clinically the middle ear consists of the tympanic cavity and its contents1 the ,eustachian tube and the mastoid cells4 ,acute ,suppurative ,otitis ,media ,acute infections of the middle ear result from acute nasopharyngeal affections such as colds1 influenza1 measles1 mumps1 whooping cough1 etc4 ,bathing in contaminated water often results in infection to the middle ear through the ,eustachian tube4 ,diagnosis4--,earache1 pain on pressure under the angle of the jaw and sudden deafness are the symptoms4 7,there are also the common febrile symptoms47 ,the chief physical signs are3 redness and bulging of drum membrane1 and contraction and tenderness of upper cervical muscles4 ,treatment4--,if the patient is seen before the drum has ruptured it is seldom necessary to lance the drum if the proper treatment is given promptly4 ,drainage must be obtained and maintained by catheter aspiration through the tube irrigation of the nasopharyngeal cavity1 irrigation of the meatus by means of the continuous ear irrigator and application of dry heat over the affected part4 ,heat is best applied by means of a therapeutic lamp4 7,any lamp with reflector that will furnish proper heat is efficient as there is no virtue in colored light47 ,the skin surface over the ear1 side of face and mastoid region is first well lubricated with some mineral oil to prevent blistering and the heat is applied either constantly or intermittently4 ,a pledget of absorbent cotton dipped into phenol-glycerine is placed in the meatus and forced loosely against the drum4 ,this should be removed every few hours and a fresh pledget put in4 ,the neck and upper dorsal muscles should be kept relaxed and adjustive treatment given frequently4 ,under this treatment the pain should be relieved and the bulging of the drum should disappear in from two to twelve hours4 ,if this is not accomplished or if the condition grows worse1 the drum should be lanced4 ,see some text on otology for technique4 ,in my experience1 very few cases have required paracentesis4 ,it must be remembered that treatment should be continued regularly and for some time after the pain and other symptoms have been relieved or a recurrence is probable4 ,patients should have daily treatment until the physician is sure that no complication or recurrence is likely to result4 ,if the patient is not seen until after the drum has ruptured1 the same treatment may be applied except the irrigation or syringing of the meatus4 ,this1 in case of ruptured drum1 may force pus into the mastoid cells resulting in mastoiditis4 ,instead of syringing1 the auditory meatus is cleaned by means of a cotton applicator or by aspirating with a catheter4 ,at all times drainage through the meatus must be maintained until the drum begins to heal4 ,acute ,mastoiditis ,acute mastoiditis results from acute or chronic otitis media4 ,in some cases the otitis media may have been only a mild attack4 ,diagnosis4--,there is no one symptom that is positively diagnostic but a number of signs and symptoms must be considered as follows3 #a4 ,always suspect mastoid complications in acute otitis media and watch for this complication daily4 ,most cases have some mastoid inflammation4 #b4 ,pain or swelling over mastoid4 ,pain may not be present1 but usually is1 sometimes radiating over temples and eye on affected side4 #c4 ,tenderness on pressure not always present4 ,may be very marked4 ,tenderness extending to tip or above ear means extension of infection4 ,if persistent tenderness over tips with marked swelling and discoloration--operation is indicated4 #d4 ,swelling1 not always present1 but sometimes very marked4 ,if extreme swelling and bluish discoloration--usually means operation4 #e4 ,temperature varies from normal to #ajd or #aje ,f4 ,temperature of more than one or two degrees means systemic absorption and suggests surgical drainage4 ,streptococcus or staphylococcus infections cause higher temperatures and require drainage earlier than other infections4 #f4 ,transillumination not positive1 but of some value4 ,like ,x-ray1 usually shows dark1 because of inflammation1 but must rely upon symptoms1 as above4 #g4 ,microscopic4--,stain for pus1 bacteria and bone debris4 ,hematoxylin stain shows dark bone particles if there is bone disintegration4 #h4 ,blood ,count4--,if absorption1 there will be some variation in proportions of leucocytes4 ,any high leucocytosis shows systemic absorption and the natural attempt to overcome the infection4 ,non-,surgical ,treatment4--#a4 ,drainage must be maintained from middle ear through tube or drum or both4 ,catheter aspiration through tube4 ,sometimes gentle inflation to clear the tube1 followed by aspiration is effective4 #b4 ,if drum is ruptured1 aspirate middle ear by catheter or by ,moore's method or both4 ,this is very important4 ,if no aspirating machine1 use syringe and pump meatus and tube persistently4 ,dry meatus and keep well open4 #c4 ,patient should be kept in bed if symptoms are marked1 with light diet and bowels well open4 #d4 ,heat4--,apply oil or other lubricant over whole side of face and head and apply heat by means of 8therapeutic0 lamp intermittently4 ,thirty minutes light on and fifteen minutes light off4 ,the light-heat 7any electric lamp with reflecting shade will do7 is much better than hot water bottle or electric pad or sand bag4 ,the heat must be kept going day and night if symptoms are marked until the pain has entirely subsided4 ,heat is most efficient in the early stages4 ,after symptoms are well marked1 the ice pack is more desirable4 #e4 ,if drum is not ruptured1 heat may be applied by means of ,deason's continuous irrigating cup4 ,start at #aaf ,f4 and gradually increase to #abc ,f4 if patient can bear it4 ,surgical4--,if drum has not ruptured and symptoms continue1 it is best to make free incision of drum1--keep open and apply 7#b7 above4 ,indications for ,mastoid ,operation4--,there are no definite signs1 symptoms or tests that will determine positively when operation should be done4 ,if the above non-surgical methods are practiced1 few cases will require operation1 but many will develop into chronic mastoiditis and so it is very difficult to decide whether a mastoid operation should or should not be done4 ,it is best to explain thoroughly the possible complications to the patient and relatives and request them to assume responsibility4 ,mastoid operations are attended by very little danger when properly done4 ,signs and ,symptoms ,suggesting ,operation4--,acute otitis media with mastoiditis4 7#a7 ,persistent pain and swelling not relieved by non-surgical treatment4 7#b7 ,marked protruding of posterior wall or meatus4 7#c7 ,marked tenderness1 swelling and discoloration above ear or over tip of mastoid4 ,these with temperature of more than #ajb usually are enough to demand immediate drainage4 7#d7 ,any evidence of extension of pus under skin of neck below tip4 ,a positive indication for drainage4 7#e7 ,any indications of brain or meningeal involvement such as very marked and persistent headache1 partial or total loss of consciousness1 etc4 7#f7 ,indications of labyrinthine involvement such as marked vertigo1 etc4 7#g7 ,sudden cessation of discharge means obstructed drainage from middle ear or from mastoid into middle ear and if drainage cannot be restored by aspiration1 this means operation4 7#h7 ,the whole clinical picture must be carefully considered at all times4 ,take no chances4 ,advise operation before someone else finds it too late4 ,chronic ,mastoiditis ,cause4--,always from unsuccessfully treated acute form or from chronic suppurative otitis media4 ,non-surgical treatment4--,see chronic suppurative otitis media4 ,we have had a few cases that were seemingly permanently cured by non-surgical treatment1 but believe they are rare4 ,indications for ,operation4--#a4 ,recurrent exacerbation of acute or chronic otitis media4 #b4 ,constant discharge which resists treatment for chronic suppurative otitis media4 #c4 ,continued pain or recurrent pain and swelling following acute otitis media4 #d4 ,open sinus into mastoid either external or through meatus4 #e4 ,cholesteatoma4 #f4 ,symptoms of labyrinthine or brain involvement following acute otitis media4 #g4 ,definite evidence of bone disintegration in mastoid4 ,as stated above1 none of these are definite indications4 ,the whole group of signs and symptoms are to be considered4 ,chronic ,suppurative ,otitis ,media ,etiology4--,chronic suppurative otitis media usually results from an unsuccessfully treated acute otitis media4 ,if in acute otitis media there has been bone erosion or extensive destruction of the mucous membrane by a virulent infection1 chronic suppuration is likely to result4 ,a persistent mastoid infection following otitis media is likely to result in chronic otitis media and this is strong argument for early mastoid operation4 #a4 ,otitis media resulting from some virulent infection such as the recent influenza pandemic or scarlet fever is always more likely to result in mastoiditis and chronic suppuration of the middle ear4 #b4 ,such infectious agents as streptococcus1 staphylococcus1 long-chain pneumococcus or bacillus influenz are likely to result in chronic suppurations4 #c4 ,lowered vitality from any cause4 #d4 ,inefficient drainage from failure to aspirate the ,eustachian tube1 delayed perforation or failure to lance drum sufficiently early4 #e4 ,mastoid necrosis1 which maintains drainage into the tympanic cavity4 #f4 ,abnormal granulations1 polypi1 etc4 in tympanic cavity4 #g4 ,chronic inflammation with suppuration of the epipharynx or ,eustachian tubes4 #h4 ,cholesteatoma resulting from perforated drum and growths of epithelium extending into the middle ear cavity4 ,diagnosis4--,the diagnosis is easy because nearly every case of discharging ear without pain is chronic suppurative otitis media4 ,the determination of the exact nature of the condition present is not only very important but very difficult4 ,differential diagnosis consists in determining the nature of the infecting organism and the nature and extent of the pathology4 #a4 ,direct examination of the external meatus after drying with cotton applicator usually determines the location and extent of perforation of the drum and the general nature of the discharge1 whether purulent or mucopurulent4 ,very rarely one finds a serious discharge which means a very slight infection or discharge from non-infective inflammation4 ,the presence of whitish or greyish pus1 mucoid and stringy1 usually means pneumococcus infection4 ,greyish1 purulent non-mucoid discharge usually indicates streptococcus or bacillus influenz infection4 ,yellow1 purulent discharge suggests staphylococcus infection4 ,the general appearance of the discharge1 however1 cannot be considered of important diagnostic value because most chronic suppurations are mixed infections1 because of long exposure to external contamination4 #b4 ,after cleaning the meatus1 several smears should be made directly from the opening in the drum4 ,by staining with methylin blue or gentian violet1 the nature of the bacterial infection can be determined and this is very important4 ,by staining another smear with hematoxylin and washing in water1 any dark irregular particles1 bone debris1 may be found1 which means bone disintegration4 ,this too1 is very important4 #c4 ,transillumination is sometimes of value4 ,the mastoid may be transilluminated by placing a good rubber covered transilluminating lamp over the mastoid and observing the external meatus through an aural speculum4 ,if the mastoid is free from infection the light will pass through and illuminate the meatus4 #d4 ,the ,x-ray plate is1 of course1 the best means of determining the nature and extent of mastoid involvement4 ,treatment4--,this is certainly one of the most difficult diseases of the ear that one is ever called upon to treat and the physician should be cautioned against offering a favorable prognosis4 ,perhaps the most difficult thing about its treatment that the doctor has to learn is that practically none of the so-called antiseptic washes do any good1 but on the other hand they often do harm4 ,certain general principles are important and the treatment must depend upon the nature and extent of the infection and pathology present in each case4 ,the constitutional treatment consists of everything that will increase the patient's general resistance and certainly all lesions of the cervical1 upper dorsal and mandibles must be properly adjusted1 but this is not enough4 ,all spinal lesions that may exert an influence on metabolism and elimination are of important consideration4 ,the diet1 habits and environment of the patient must be considered4 ,a careful examination of the nasopharyngeal tract may reveal some other focal infection1 such as chronic tonsillitis1 pharyngitis or sinuitis1 which is maintaining the infection through the ,eustachian tube4 ,there may be a focal or general infection of some other part of the body1 which is reducing resistance or causing a hematogenous infection of the tympanic cavity or mastoid cells4 ,drainage must be maintained in all cases1 both through the ,eustachian tube by catheter aspiration and through the drum by aspirating and drying4 ,if the perforation in the drum is small or in the middle or upper part1 it should be opened down to the floor so that the contents may be more easily removed and better drainage established4 ,it is well first to thoroughly cleanse the meatus and tympanic cavity by syringing with salt mixture 7salt #c parts1 borax #b parts and soda #a part1 a teaspoonful to a half pus bowl of water7 at from #aaf to #aah ,f4 ,after syringing1 the meatus is carefully dried1 and the middle ear cavity aspirated through the tube and drum opening4 ,the advantage of this simple treatment is thorough cleanliness and drainage with the minimum of irritation4 ,this treatment given daily or thrice weekly will often cure the case4 ,staphylococcus and streptococcus infections usually respond to the following treatment3 ,after thoroughly cleansing as above1 the meatus and tympanic cavity is syringed with a one to four or one to five dilution of ,dakin-,carrel solution 7,hyclorite may be used instead7 followed by aspiration1 the fluid being drawn through the tube1 thus preventing reinfection from that source4 ,pneumococcus infections do not respond to either of these methods of treatment4 ,the pneumococcus1 because of its capsule1 is not affected by antiseptics1 but on the other hand the irritation of the tissues caused by their use1 only gives the infective agent a better opportunity for growth4 ,in pneumococcus infections we have found the following method efficient3 ,thoroughly cleanse the meatus and middle ear cavity by salt mixture syringing1 aspiration and drying4 ,the meatus and tympanic cavity is then filled with a neutral mineral oil4 ,the oil is also pumped through the ,eustachian tube4 ,it is the purpose to fill the entire cavity and its openings so thoroughly that no air can enter4 ,in some cases we have used bismuth paste after the oiling with excellent results4 ,the pneumococcus is aerobic and if all air can be kept away for a considerable time1 it furnishes an unfavorable culture environment with little irritation to the membranes4 ,surgical treatment4--,the presence of bone debris indicates bone disintegration in the tympanic cavity or mastoid cells4 ,if the mastoid cells are thus involved there is little chance for direct treatment4 ,if such cases do not respond in a short time to any of the above methods of local treatment1 ossiculectomy or mastoid operation may be necessary4 ,some specialist surgeons claim from #hj to #ij favorable results from mastoid operation in such cases4 ,non-,suppurative ,otitis ,media--,catarrhal ,deafness ,deafness is any impairment of normal hearing and is that symptom next to pain and chronic discharge that causes the patient to visit the doctor4 ,if acute diseases of the ear1 nose and throat could always be successfully treated1 there would be little trouble from the symptoms of chronic pathology4 ,it must be understood that catarrhal deafness is a symptom of chronic otitis media and is1 therefore1 seldom of recent origin4 ,etiology4--,chronic otitis media is nearly always the result of the extension of infection through the ,eustachian tube and has come from some acute or chronic nasopharyngeal infection4 ,chronic colds1 pharyngitis1 tonsillitis1 sinuitis1 etc41 resulting in acute or chronic otitis media either with or without suppuration1 constitutes the beginning of catarrhal deafness4 ,symptoms4--,there is seldom any pain with this disease4 ,some cases have an occasional acute attack with pain and other symptoms of acute otitis media4 ,deafness1 varying with the progress of the pathologic changes1 is always present4 ,the patient in the early stages will seldom admit that he suffers from deafness and often he is honest because he may not realize that he cannot hear normally until his otitis media has progressed to the second or third stage4 ,most patients1 in fact1 do not become alarmed about their hearing until it is too late to restore normal hearing4 ,for this reason1 physicians should be on the lookout for such conditions and should advise special treatment early4 ,the human species in its present environment1 depends much less upon the organs of special sensation than do the animals of the wild1 and they may therefore be very deficient in sight1 hearing1 smell1 etc4 without actually realizing this loss4 ,in addition to deafness there are other symptoms such as occasional or constant fullness or feeling of 8stuffiness0 as the patients express it1 due to partial or complete occlusion of the ,eustachian tubes4 ,tinnitus aurium or head noises is very common and often the most annoying symptom4 ,autophony1 or the loud sound of the patient's voice to himself1 which often causes him to speak low and indistinctly1 occurs in the later stages4 ,presbyacusia1 or the inability to adjust the hearing apparatus to variations in pitch1 commonly occurs in the second stage and is evidenced by the fact that the patient does not hear when more than one person is talking4 ,paracousis or perverted phenomena of hearing1 such as the better hearing of some persons in a noisy environment1 is a symptom of the third stage of otitis media and often means an unfavorable prognosis1 so far as marked improvement in hearing is concerned4 ,pathologic ,stages4--,for convenience of discussion we may consider chronic otitis media in three stages4 ,the ,first ,stage4--,the active pathology is limited to the pharyngeal portion of the ,eustachian tube with some inflammation of the membranes of the tympanic cavity4 ,closure of the tube followed by absorption of the oxygen causes a decreased pressure in the tympanic cavity and thus a retraction of the drum1 decreased movement of the ossicles and a general decrease in function of all tympanic structures4 ,deafness in this stage may be very marked1 especially if the ,eustachian occlusion has occurred from some nasopharyngeal acute inflammation4 ,there may be pain but there is always a characteristic 8fullness0 and sometimes dizziness4 ,deafness in these cases varies with weather changes4 ,if proper treatment is had in time1 the progress of the pathology can be stopped and every case can be restored to normal hearing4 ,the ,second ,stage4--,the active pathology has extended throughout the ,eustachian tube causing marked occlusion and some stenosis4 ,there is further inflammation of the tympanic structures with an increase in the symptoms of the first stage4 ,the drum membrane is less movable but there is no fixation of the ossicles4 ,pressure upon the bulb of the auroscope causes movement of that part of the drum to which the malleus is attached4 ,the drum is thicker1 more retracted1 and less movable than in the first stage4 ,presbyacusia is common and often marked1 but there is no paracousis4 ,more than #ij of these cases can be materially improved and many can be made to hear normally if proper treatment is given in due time4 ,the ,third ,stage4--,the active pathology in the third stage consists of an involvement of the entire mucous membrane lining the ,eustachian tube and tympanic cavity4 ,these membranes are all chronically hypertrophied4 ,the ,eustachian tube1 however1 is sometimes fairly well open1 but the ossicular attachments are more or less fixed by hypertrophied tissue and adhesions and the drum is markedly retracted1 thickened and usually very immovable4 ,the deafness is usually quite marked1 head noises are commonly present and often very annoying4 ,patients usually do not notice a variation in their hearing from weather changes4 ,presbyacusia is present in #hj of cases and their hearing for low tones is much reduced4 ,unless there is a complicating nerve affection these cases hear well by telephone1 which means that they can also use an electric hearing instrument to advantage4 ,these cases can never be restored to normal hearing1 but many of them 7#cj of my cases7 can have some improvement and in most cases ,i believe the progress of the pathology can be stopped1 and this is always well worth while because their hearing is likely to be entirely lost if something is not done4 ,psychologic ,stages4--,there are three rather distinct psychologic stages in catarrhal deafness4 ,the first1 the period in which most patients refuse absolutely to admit that they are deaf even to the aurist upon whom they call for treatment4 ,they insist that they hear perfectly if people would only speak distinctly4 ,this is partially true1 because up to the third stage of deafness the voice can be fairly well heard if people would only articulate clearly4 ,in the second stage patients admit that they don't hear well1 but insist that they are going to recover normal hearing and often resort to various kinds of injurious treatment4 ,in the third stage they give up all hope of ever regaining their hearing1 become morose1 and avoid company4 ,these psychic stages do not always correspond with the pathologic stages given above4 ,diagnosis4--,the external auditory meatus1 drum membrane and ossicular chain1 constitute the apparatus whose function is that of conduction of sound waves to the perception apparatus of the inner ear4 ,the function of the conduction apparatus varies inversely with the progress of pathologic change in these structures4 ,the perception apparatus1 the structures of the inner ear1 are not necessarily affected by middle ear pathology1 but on the other hand1 sounds transmitted by bone conduction not only seem louder but they last longer because the 8escape of the excess0 of sound thus transmitted is hindered by deficient conductive mechanism4 ,this explains why such persons hear well by telephone and why the tuning fork1 whose base is held to the mastoid 7provided there is no nerve affection7 may be heard for a greater time than normal4 ,likewise the prong of the vibrating tuning fork when held near the concha is heard for a shorter time than normal1 because of the deficient function of the conduction mechanism4 ,tuning forks are known by their number of vibrations per second1 such as #af1 #cb1 #fd1 #abh1 etc4 ,three or more forks are required to make an accurate measurement of the conduction and perception functions--a low fork about a #cb1 for the low tones1 #abh or a #eab for the medium tones and a #bjdh for the high tones4 ,a good set of forks should be selected and standardized1 i4 e41 the normal bone and air conduction of each fork determined by testing it on a number of persons whose hearing is known to be normal4 ,for the general practitioner who cares only to get a general idea of the extent of the pathology1 one fork of medium pitch such as a #abh or #eab will be sufficient4 ,to measure the function of hearing1 the fork is set into maximum vibration1 its base held against the mastoid and the patient is asked to state when he no longer hears it4 ,this length of time in seconds is recorded as 8bone conduction40 ,the fork is then held near the concha and the patient again states when he does not hear it4 ,this length of time in seconds is recorded as air conduction4 ,normal ,hearing ,tuning ,fork ,test4--,the normal time rate in seconds set of forks is as follows3 ,fork #cb #fd #abh #eab #bjdh #djif ,b4 ,c4 #be #cj #cj #bj #aj ,a4 ,c4 tone #gj #ij #ij #dj #bj ,the tuning fork test1 carefully made1 is the only known method of measuring the functions of the various structures concerned in audition4 ,the ,whisper ,test is made by producing a clear whisper from residual air only1 which should be heard about twenty feet by a normal ear4 ,the ,watch ,test is made by using some loud ticking watch 7,i prefer an ,ingersoll71 holding it first near the ear until the patient recognizes the tone1 and then taking it beyond the hearing distance and approaching the ear until it is heard4 ,i prefer also to move away from the ear until the limit is reached and strike an average of this with the above results4 ,the average eighteen size ,ingersoll watch can be heard for from #ajj to #aej inches by the normal ear4 ,the practical test for the patient is his hearing from the spoken voice1 and is the most reliable so far as permanent results are concerned4 ,low ,tone ,limit4--,the lowest limit of hearing is about sixteen double vibrations per second1 but the lowest practical limit is about thirty-two4 ,there are few people with normal hearing and with musically trained ears who can recognize a definite tone lower than this1 so ,i consider the thirty-two fork sufficiently low for all practical tests4 ,conduction ,deafness4--,low tones are lost in tympanic involvement or conduction deafness1 and are diagnostic in such cases1 but are of no particular value in nerve deafness except when that is complicated by catarrhal deafness4 ,practical ,hearing ,limits4--,the human voice varies from about #fj to #aej double vibrations per second1 and most sounds that we really need to hear are less than #gjj vibrations per second4 ,this is the reason for using the low forks1 #fd1 #abh and #eab4 ,measurement of ,nerve ,force4--,to measure auditory nerve force1 the fork 7say the #abh1 whose normal ,b4 ,c4 is #cj seconds7 is set into vibration and held gently and with even pressure against the mastoid and the patient is asked to tell or signal the doctor when he ceases to hear the tone4 ,two or more tests may be made to determine the patient's personal equation1 but the use of control forks 7the #fd and #eab7 will show any such error4 ,granting that there is no complicating pathology1 tympanic or labyrinthine1 the number of seconds of hearing over #cj will be the patient's auditory nerve force4 ,for example1 if he hears the fork #cj seconds his hearing will be thirty-thirtieths or normal4 ,if his hearing is #be1 #bj1 #ae or #aj seconds1 his auditory nerve force will be respectively #be-cj1 #bj-cj1 #ae-cj or #aj-cj4 ,by means of this method an accurate measurement of the functions of hearing can be made and a definite prognosis can be given4 ,i never use any of the various named qualitative fork tests for hearing1 because they have no value to one who employs this system4 ,,foot ,,note--,in the chart ,t is used1 meaning that tone is heard1 while ,s indicates sound but no tone4 ,,foot ,,note--,it is not the purpose to give any detailed or differential methods of diagnosis because if one cares to treat these diseases he will of course1 study a special text on this subject4 ,the methods here given are only for the general practician who wishes a general idea of the condition present4 ,summary of ,diagnosis of ,different ,stages of ,catarrhal ,deafness ,first ,stage4 #a4 ,fork #cb #abh #bjdh ,b4 ,c4 #ce #bj ,a4 ,c4 ,t #gj #dj #b4 ,the drum is only slightly retracted but freely movable4 #c4 ,whisper heard from five to twenty feet4 #d4 ,ingersoll watch heard from #cj to #aej inches4 ,second ,stage4 #a4 ,fork #cb #abh #bjdh ,b4 ,c4 #dj #bj ,a4 ,c4 ,t #fj #dj ,note that the tone of the #cb fork is heard1 the #abh fork has increased in bone conduction and reduced in air conduction but that the bone-air ratio is direct1 that is the patient hears longer by air than by bone conduction4 ,note also that the high fork is still normal4 #b4 ,the drum will be found retracted but that part to which the malleus is attached is still movable when tested with the auroscope4 #c4 ,the whisper is heard from two to ten feet4 #d4 ,the ,ingersoll watch is heard from six to sixty inches4 #e4 ,presbyacusia but not paracousia is present4 ,third ,stage4 #a4 ,fork #cb #abh #bjdh ,b4 ,c4 #de #ae ,a4 ,c4 ,s #bj #cj ,the typical diagnostic points in third stage catarrhal deafness are3 #a4 ,tone for the #cb fork is lost4 #b4 ,there is an inverted bone-air ratio for the medium fork4 ,the drum is retracted and the malleus fixed4 #d4 ,the whisper may be heard at less than one foot or not at all4 #e4 ,the ,ingersoll watch is heard less than six inches from the mastoid4 #f4 ,paracousis ,willisiani is present4 ,for the general practician this is important because he can make a rather definite prognosis4 ,treatment4--,the treatment will be given briefly because space would not permit of lengthy discussions of details of methods and technic4 ,,foot ,,note--,note that the patient hears the tone of the low fork1 that the #abh fork has its bone conduction slightly increased 7#cj to #ce7 that the air conduction is slightly decreased 7#ij to #gj7 and that the high fork remains normal4 ,a careful examination should be made for some source of focal infection about the nasopharyngeal tract4 ,chronic or subacute tonsillitis1 pharyngitis or sinuitis or root abscess are often a cause1 and not much will be accomplished in improving the otitis media until these focal infections are found and properly treated4 ,the original cause of these focal infections may have been some bony lesion1 but to successfully correct such lesion now does not mean that the source of infection will be removed4 ,auto-intoxication from gastro-intestinal disease is common4 ,in my cases1 #hj of the third stage have chronic constipation or other chronic gastro-intestinal affection4 ,in many severe acute affections of the nasopharynx the inflammatory process has left the ,eustachian tube occluded or stenosed and the pharyngeal fossa filled with adhesive bands4 ,it is not uncommon to find the epipharynx and pharyngeal fossa filled with partially atrophied adenoid tissue or if the curet method has been used for removing adenoids1 there is often connective tissue adhesions and any or all of these may prevent the normal ventilation of the tympanic cavity by way of the ,eustachian tube4 ,in such cases surgical removal of these obstructions and dilation of the tube is necessary4 ,my practice has been to give a general anesthetic 7nitrous oxide or somnoform will be sufficient in many cases7 and by means of an adenotome 7,la ,force or ,cradle1 ,i never use a curet7 remove all adenoid tissue4 ,then by means of the finger ,i carefully remove any adenoid tissue in the posterior nares and pharyngeal foss that the adenotome may have failed to get and also dilate the pharyngeal portion of the tube by inserting the finger4 ,this operation if carefully and thoroughly done and if preceded and followed by the proper surgical cleanliness and supportive treatment1 will when indicated1 accomplish excellent results4 ,the after treatment is even more important because if this is not well done1 no results or even unfavorable results may occur4 ,the after treatment consists of daily irrigations of the nasopharynx1 thorough attention to upper thoracic1 cervical and mandibular lesions1 aspiration of the ,eustachian tubes and other local treatment to the nasopharyngeal membranes4 ,after the operation has been done it is best to do no digital manipulation of the pharynx for from three to six days4 ,after this time digital treatment1 gentle dilation of the ,eustachian orifice to maintain its patency1 stretching of the soft palate to reestablish proper nerve function and the application of deep pressure in the pharyngeal foss to stimulate the otic ganglion is important4 ,this treatment is not massage in any sense but definite1 purposeful1 manipulation and if carefully done will be followed by excellent results4 ,since the origin of this method of treatment1 there has been much comment on its value and many have tried or at least they thought they tried it with unfavorable results4 ,the causes of failure are1 attempting treatment in cases impossible of cure1 or poor diagnosis1 improper technic of operator or incomplete operative procedure and inefficient supportive treatment4 ,it must be understood that not all cases of otitis media even in the beginning stages require the above method of treatment or will be benefited by it4 ,those cases which have resulted from other causes than acute pharyngitis seldom require such radical methods of treatment4 ,in every case1 the cause must be found and consistent treatment given4 ,in my experience1 the radical method of treatment has not been found necessary in more than twenty per cent of cases of chronic otitis media4 ,in the other cases the treatment consists of removing sources of focal infection 7about forty per cent7 and normalizing nasopharyngeal reflexes by osteopathic and local treatment 7about forty per cent74 ,in all cases1 the treatment must be complete4 ,to remove thoroughly all obstruction from the epipharynx and leave a source of focal infection in the tonsils will accomplish little1 or to remove carefully all pharyngeal obstruction and all sources of focal infection will not restore normal functions of the middle ear structures if the osteopathic lesions and gastro-intestinal perversions are neglected4 ,surgery in itself1 even though carefully and thoroughly done1 is not efficient treatment and this is why the medical specialists fail in this disease4 ,after the necessary surgery has been done1 then normal tone must be restored to the various tissues involved4 ,normal reflex mechanisms must be reestablished and this can be done by thorough and efficient osteopathic corrective work and the proper local treatment directly to the structures affected4 ,meniere's ,symptom ,complex ,this is a form of catarrhal deafness with all the characteristic pathology of the first or second stage1 but in which1 due probably to sudden tubal occlusion1 there results a marked variation in the intralabyrinthine pressure and there are1 therefore1 the symptoms of conduction deafness combined with labyrinthine involvement somewhat resembling ,meniere's disease4 ,there is dizziness or even vertigo1 with head noises1 but not the marked prostration and nausea which characterizes ,meniere's disease4 ,treatment4--,the treatment is the same as in the first stages of catarrhal deafness and the prognosis is always good4 ,the labyrinthine symptoms are usually completely relieved as soon as the middle ear is ventilated4 ,diseases of the ,inner ,ear ,acute ,suppurations4--,acute suppurative diseases of the labyrinth occasionally result from the extension of infection from the tympanum but they are certainly very rare4 ,such conditions may result from acute suppurative otitis media in which there has been an excessive collection of pus without rupture of the drum or drainage through the tube but this very rarely occurs and after drainage has been established1 labyrinthine infection is hardly possible4 ,diagnosis4--,labyrinthitis is of several forms but in general1 there are the symptoms of labyrinthine involvement such as3 nystagmus1 vertigo1 nausea1 vomiting1 headache1 earache1 deafness and febrile symptoms4 ,when labyrinthitis is suspected1 an aurist of much experience should be called into consultation at once4 ,treatment4--,suppurative labyrinthitis is not in itself a fatal disease but dangerous complications may result because of the close proximity to so many delicate structures4 ,threatened meningeal infection requires surgical drainage1 but unless meningeal infection is imminent1 surgery is contraindicated4 ,since the mortality1 considering dangers of complications1 is not high 7about #aj7 and since such operations are very complicated and require great surgical skill1 we may conclude that surgery is generally contraindicated4 ,non-surgical treatment consists of keeping the patient quiet in bed1 liquid diet1 and good elimination4 ,drainage through the middle ear or ,eustachian tube must be maintained4 ,deep manipulation of the cervical structures will help to maintain lymphatic drainage but any treatment which necessitates much movement of the head should be avoided until the symptoms of vestibular irritation have ceased4 ,non-,suppurative ,labyrinthine ,diseases ,meniere's ,disease4--,this disease is caused by hemorrhage into the labyrinth with the following symptoms3 ,there is sudden and intense vestibular irritation such as vertigo1 marked tinnitus1 nausea1 vomiting and complete deafness on the affected side4 ,there may also be cerebral disturbances and loss of consciousness4 ,the ,prognosis depends upon the extent and severity of the pathology4 ,it is probable that those cases in which recovery occurs quickly are not true cases of ,meniere's disease but have some causes other than labyrinthine hemorrhage4 ,such cases are perhaps ,meniere's ,symptom ,complex4 ,the ,treatment consists of complete rest in bed1 light diet1 and good elimination until the marked irritation has passed4 ,it has been my practice to carry out further treatment similar to that of the treatment of nerve deafness to be given later4 ,many of these cases will make complete recovery4 ,nerve ,deafness ,the term 8nerve deafness0 is generally used very carelessly to apply to any chronic or non-suppurative process of the labyrinthine structures other than those mentioned above1 which cause impaired hearing4 ,nerve deafness is not an uncommon disease4 ,in my cases of deafness there has been some involvement of the labyrinthine structures or auditory nerve in #bg of the cases examined4 ,i think the reason for most authors putting the percentage of nerve deafness much lower than this is because of inexact methods of diagnosis4 ,the above percentage is based upon the actual measurement of nerve force4 ,see measurement of nerve force under non-suppurative otitis media above4 ,a careful study of cases by the method of actual measurement of nerve force1 shows that there are two distinct forms of nerve deafness4 ,in one there is only a deficient function of the structures of the labyrinth1 due perhaps to some perverted physiologic function1 and this form we may call auditory nerve deficiency4 ,the other form of nerve deafness1 due probably to an actual degeneration of the nerve or its end organs in the labyrinth1 may be properly known as auditory nerve degeneration4 ,auditory ,nerve ,deficiency4--,a study of our case reports shows that in #fd of the cases in which the nerve force was #af-cj or higher 7more than half7 favorable results were obtained1 provided that there was no complicating labyrinthine affection4 ,these cases have been classed as 8nerve deficiency0 and the pathology as functional4 ,a favorable prognosis 7#fd7 may be offered4 ,example of tuning fork findings3 ,fork #cb #fd #abh #eab #bjdh #djif ,b4 ,c4 #ah #bj #bj #bj #aj ,a4 ,c4 ,t #ej #fj #fj #dj #bj ,in addition to the tuning fork findings the voice and watch test will be reduced to from one-tenth to two-thirds normal4 ,the patient often complains of itching meati and dry nares4 ,there are usually no signs or symptoms of labyrinthine affection4 ,treatment4--,the treatment consists of local treatment to the nasopharynx1 tubes and meati as described under the treatment of chronic otitis media4 ,everything should be done to build up the patient's general health and improve the local nutrition4 ,it is highly essential to search the entire system for sources of focal and general infection4 ,auto-intoxication from chronic gastro-intestinal disease was found in #ij of our cases4 ,any treatment therefore that will restore normal gastro-intestinal function is indicated4 ,recently we have had some excellent results from colonic irrigation and the proper adjustment of diet in such cases4 ,any source of focal infection must of course receive proper attention4 ,the osteopathic corrective treatment consists largely of careful attention to lesions of the splanchnic area because of the importance of normal digestion1 metabolism and elimination4 ,this is certainly a most important part of the treatment and should never be neglected4 ,upper cervical and mandibular lesions have much to do with the local nutrition to the ear structures and these must not be neglected4 ,the fact that we almost constantly find evidence of deficient nutrition to the meati and drums in this disease together with lesions of the mandible1 suggests a local osteopathic cause4 ,auditory ,nerve ,degeneration4--,in those cases in which there is a measurable deficiency of nerve function of less than half the normal we have found that very few respond to treatment4 7,see table above47 ,the cause has therefore been attributed to a structural pathology and the condition called auditory degeneration4 ,example ,table3 ,fork #cb #fd #abh #eab #bjdh #djif ,b4 ,c4 #aj #ab #h #e #b ,a4 ,c4 ,s #bj #be #ae #g #e ,there is usually very marked impairment of hearing for voice and all other sounds4 ,the ,ingersoll watch may be heard five or ten inches1 but usually not at all1 and the whispered voice heard only a few inches or not at all4 ,there are nearly always signs and symptoms of labyrinthine deafness and evidence of tone islands4 ,the deafness in these cases is usually progressive regardless of any treatment4 ,in this disease there is nearly always an associated affection of the labyrinth as shown by the high forks4 ,the fractions represented by the high forks will agree in proportion provided there is no labyrinthine involvement4 ,our results in auditory nerve degeneration have been measurable improvement in only #b of the cases treated4 ,the prognosis is therefore very poor and ,i believe we should always tell our patients frankly that there is almost no chance for improving their hearing in such cases4 ,the treatment is the same as that given for nerve deficiency and because of the general good that may be had from treatment1 that is1 the improvement of the general resistance1 it is often well for the patient to have such treatment to stop the progress of further special sensory degeneration4 ,it should always be our purpose to treat the patient rather than to treat some particular organ only and if this method is followed1 our general results will surely be much higher4 ,diseases of the ,nose ,method of ,examination4--,for use in nasal examinations and treatment1 a suitable chair with adjustable headrest is of much value because if the patient is not comfortable and in a convenient position1 the work is very difficult4 ,a few instruments1 such as the following1 are very essential3 ,a sterilizer for instruments1 head mirror and reflecting lamp1 nasal speculum1 tongue depressor1 tonsil pillar-retractor1 a nasal packing forceps and a few aluminum cotton applicators4 ,these instruments are few and comparatively inexpensive1 but are of more practical value than a lifetime collection of electrical apparatus4 ,any physician can readily learn the use of these instruments and the methods of examination by attending the clinical sessions of our conventions4 ,methods and technic of treatment1 however1 require much practice and experience to develop efficiency4 ,acute ,rhinitis ,this disease1 commonly known as a 8cold in the head0 is one of the most common1 and because of the complications which so commonly result1 a disease which really requires careful consideration4 ,etiology4--,the predisposing cause is reduced resistance and individual susceptibility to air-borne irritants and infective organisms4 ,direct exposure of some insufficiently protected part of the body such as the feet in cold1 damp weather1 exposure of some unprotected part of the body to draughts or exposure of the whole body to slightly reduced temperature for a considerable time1 are the common causes4 ,in cold weather1 it is very important that the proper indoor humidity be maintained1 because the drying of the mucous membranes renders them susceptible to infection4 ,this disease is not only contagious at times but may even become endemic from some specific and virulent organism4 ,the complications which may and often do follow such infections are laryngitis1 bronchitis1 pneumonia1 etc4 and any one or more of the focal infections1 such as sinuitis1 tonsillitis1 or middle ear infection4 ,a focal infection thus caused may become chronic and render the patient constantly susceptible to head colds4 ,in fact in those persons who suffer from chronic head colds1 there may nearly always be found some focal infection1 such as the above named1 and it is often impossible to get permanent relief until such sources of focal infection have been properly treated4 ,the influence of gross structural lesions1 osteopathic lesions of the cervical and upper thoracic region1 vertebr and ribs must not be overlooked because they exert a powerful influence upon the blood supply1 particularly the venous and lymphatic drainage and upon the autonomic nervous mechanism1 which regulates the physiologic control of such functions4 ,gross structural abnormalities of the intranasal chambers1 such as deflected septum1 enlarged turbinates or cellular turbinates1 which cause deficient or abnormal breathing space1 may cause and maintain head colds4 ,diagnosis4--,the diagnosis is usually easy4 ,nasal congestion with the usual 8stuffy0 feeling of the head1 sneezing1 headache1 etc4 are well known symptoms4 ,on direct examination the nares are congested1 there is a watery discharge and all of the membranes of the nasopharyngeal tract are congested4 ,treatment4--,if there is ever a demand for good1 thorough and specific osteopathic work1 certainly it is demanded in such cases4 ,i am an advocate of thorough1 deep relaxing treatment followed by specific adjustment in such cases4 ,complete rest in bed with light diet and careful attention to the elimination are very essential4 ,perhaps the most difficult problem is to convince the patient that a head cold is really a serious disease and demands thorough and prompt treatment4 ,every ear1 nose and throat specialist has had ample opportunity to know that most of the really serious complications of the head and neck result from the lack of prompt and proper attention to head colds4 ,the local treatment consists of irrigation of the nasopharynx followed by oil spray to protect from further irritation and the maintenance of proper drainage from the sinuses and middle ears4 ,i am not an advocate of the so-called 8antiseptic sprays0 because they neither destroy bacteria sufficiently to be effective nor do they maintain drainage4 ,in all cases1 the physician should be ever watchful for the complications and should not hesitate to call consultation of a specialist when such symptoms develop4 ,purulent ,rhinitis ,persistent inflammations of the nasal membranes are usually of a purulent nature or at least have had such a cause in the beginning4 ,etiology4--,purulent rhinitis may be a result of an unsuccessfully treated infection of the nose or throat following some disease of childhood or early life4 ,it may be due to infection at birth4 ,commonly there is a subacute or chronic sinus infection that maintains the infection of the nasal mucosa4 ,polyps1 enlarged or cellular turbinates1 adenoids or adhesions in the epipharynx1 often retain the secretions and cause chronic rhinitis4 ,in many cases ,i have found that osteopathic lesions of the cervical or upper thoracic region are effective causes of chronic rhinitis4 ,the ,pathology consists of hyperemia1 hypertrophy and exfoliation of the cellular membrane4 ,the turbinates and all membranes become enlarged and thickened and the breathing space is usually greatly decreased4 ,the ,symptoms are nasal obstruction1 and mucous or mucopurulent discharge with usually hypersensitiveness1 which causes sneezing and other symptoms common to 8head colds40 ,treatment4--,the same treatment as given above for acute rhinitis applies here4 ,a thorough examination should be made for all of the various causes given above and the proper corrective treatment given for any or all such causes4 ,chronic ,hypertrophic ,rhinitis ,etiology4--,chronic rhinitis is usually a result of an infective rhinitis and has for its cause any one or more of the various causes given above under purulent rhinitis4 ,pathology4--,the pathology in chronic rhinitis varies with the cause1 but is usually characterized by a series of changes beginning with infection and hyperemia and followed by an actual and usually marked hypertrophy of the interstitial tissue4 ,the posterior ends of the inferior or1 less often1 the middle turbinates are usually enlarged and extend backward into the pharynx4 ,the ,symptoms are much the same as in purulent rhinitis1 except that the purulent discharge is often not present4 ,these cases usually suffer from chronic head colds1 headaches and persistent nasal obstruction4 ,the senses of smell and taste are usually impaired and there is a nasal twang to the voice4 ,treatment4--,in these cases1 it is common to find osteopathic causes which prevent proper drainage from the head and neck and this is important because1 if all the local causes are properly corrected1 this is not sufficient to effect a cure4 ,surgical treatment for the removal of polyps1 synechia1 adenoids1 adhesions1 correction of septum1 or hypertrophied or cellular middle turbinates is often essential and certainly infected sinuses must be properly drained4 ,we have had cases in which root abscesses seemed to be active causes1 but it must not be thought that surgery and surgery alone is likely to cure chronic rhinitis1 and ,i want to caution against the wholesale removal of turbinates for such conditions4 ,the mere fact that the turbinates are enlarged is not sufficient reason for their removal4 ,there has been a cause for this enlargement and turbinotomy or turbinectomy does not remove this cause4 ,cautery is worse1 because it seldom accomplishes more than very temporary results and often leaves the membranes worse than before4 ,cautery destroys mucous membrane1 leaving a dry and easily irritated surface which is often impossible to normalize4 ,the proper surgery1 carefully done1 followed by efficient osteopathic corrective work and thorough irrigation of the nasopharyngeal tract with the necessary oil spray protection after irrigation1 will constitute efficient treatment4 ,treatment1 thorough and long continued1 will in due time restore nutrition1 drainage and normal reflex nerve control to the tissues4 ,treatment after surgery is essential4 ,intranasal ,treatment4--,many cases are caused by the retention of secretions under the turbinates and in the superior vault4 ,in all cases1 therefore1 it is essential to thoroughly free all possible retention cavities by means of a small cotton-wound probe before irrigation4 ,the intranasal membranes are adrenalized and anesthetized and a thorough examination is made using a good reflecting lamp1 nasal speculum and cotton tipped probe4 ,every part of the intranasal region is inspected for sources of purulent discharge1 mucus collections1 synechia and for hypersensitive areas4 ,the probe is curved at the end and passed under each turbinate and drawn forward and backward with considerable pressure to insure that any collection of foreign matter is thoroughly removed4 ,every part of the intranasal region should be thoroughly treated in this way4 ,the hiatus semilunaris must be kept well open to permit free antrum drainage and all other sinus openings should be kept free from any obstruction that may block the drainage4 ,this particular technic requires great care and practice1 but it is very effective and so commonly we have found that this work thoroughly done will reduce much and in some cases all of the turbinate hypertrophy rendering surgery unnecessary4 ,atrophic ,rhinitis ,as the term suggests1 this disease is just the opposite from hypertrophic rhinitis in that the membranes are shrunken1 the nares are wide open and usually the membranes are coated with a mucopurulent discharge1 accompanied by a bad odor4 ,it is a chronic disease and progressive in nature4 ,etiology4--,deficient nutrition1 systemic or local1 or some degenerative infective process constitutes the cause4 ,some cases may be traced to syphilis1 but this is certainly not always the cause4 ,chronic sinuitis1 the cause of which is some virulent infection1 is often the cause4 ,too much or incorrect surgery and cautery is certainly a cause in many cases4 ,pathology4--,the marked atrophic appearance1 the retracted turbinates1 the excessive purulent or mucopurulent foul discharge are characteristic and diagnostic4 ,the tissues underlying the mucous membranes are shrunken1 and atrophic and this tissue has usually been replaced1 sometimes almost completely1 by connective tissue1 and thus the blood supply is markedly deficient4 ,treatment4--,in chronic cases1 those in which the atrophy is well progressed1 there is no hope of restoration to normal conditions1 but ,i believe that the progress of practically every case can be stopped and that1 in most cases1 a permanent cure can be effected under proper treatment4 ,every possible source of focal infection1 such as sinuitis1 pharyngitis1 tonsillitis1 etc4 should receive proper attention promptly4 ,after this has been done and sufficient time allowed for normalization1 a blood count may reveal some other source of focal or general infection1 which may be reducing the general resistance4 ,auto-intoxication from some gastro-intestinal affection is commonly a cause and must receive proper attention4 ,the general health of the patient must be restored and maintained4 ,thorough osteopathic treatment must be given for any cause of lowered nutrition1 local or general4 ,the failure1 ,i believe1 in medical practice 7,they admit failure in this disease7 is due to the lack of attention to the restoration of normal nutrition4 ,why drain a sinus and leave an atlas or upper thoracic lesion which decreases the local nutrition and leaves these membranes susceptible to further infection8 ,before and after surgical drainage1 irrigation of the nasopharyngeal tract4 ,thorough irrigation to cleanse every part4 ,hot irrigation 7one gallon of salt mixture solution1 salt #c parts1 borax #b parts1 and soda #a part1 a tablespoonful to the gallon at #aah;,f4 to #abc;,f47 to cleanse1 to free all parts from infection and to restore blood supply to the affected parts4 ,frequent irrigation1 daily for a sufficient time to thoroughly sterilize and restore circulation4 ,after each irrigation1 an oil spray 7any non-irritating petroleum oil7 is applied freely to protect the membranes from irritation and further infection4 ,before each irrigation a thorough probe treatment1 as described under hypertrophic rhinitis1 should be given that the membranes may be thoroughly freed from all retained secretions4 ,after the membranes are once clean1 the sinuses free from infection and the blood supply reestablished1 the treatment may be reduced in frequency to three times weekly1 but the treatment must be continued for months or even years to effect a permanent cure4 ,the patient can be taught to do his own irrigation after the disease is well under control4 ,all irritating sprays1 chemical cauteries1 etc4 must be avoided4 ,the so-called 8antiseptic sprays0 do harm by irritating the membranes and certainly do no good1 because they do not cleanse the parts4 ,they only serve to deodorize1 but actually accomplish nothing in the way of cure4 ,it has been my experience that iodine and the silver salts in any of their various preparations are not efficient but that they actually do harm4 ,my experience indicates that practically every case can be cured if the proper treatment is given for sufficient time4 ,pharmacodynamics ,if ,i may be pardoned for discussing things pharmacological in a text on practice1 ,i want to urge that chemicals as such1 are usually a failure in treatment4 ,my results from various series of experimental work both laboratory and clinical1 show quite conclusively that there are very few1 if any1 chemical substances that have actual value by virtue of their chemical properties alone4 ,there are1 however1 cases in which chemical agents may be used to advantage to obtain desirable physical results and physiologic reactions4 ,the salt mixture mentioned above increases the solvent power of the water for mucus1 pus1 and other collected material and it also renders the water less irritating to the mucous membranes4 ,other than this1 it has no value so far as ,i know4 ,this solution is certainly not antiseptic or germicidal1 further than that cleanliness may be considered an antiseptic procedure4 ,the phenol-glycerine 7#aj phenol and #ij glycerine7 which we have recommended1 is somewhat germicidal1 non-irritating1 except to the nasal mucosa1 is a protectant to inflamed membranes in some instances and is also somewhat hygroscopic4 ,these virtues to the limited extent that they may be of advantage1 depend chiefly upon physical qualities4 ,adrenalin in high dilutions 7#a to #ejjj to #a to #aj1jjj7 is of value in retracting the erectile tissues of the nares for purposes of examination and for obtaining better drainage1 etc4 ,it also constricts the small blood vessels and thus reduces the chances for hemorrhage or absorption of narcotic drugs which may necessarily be used as local anesthetics4 ,the effects of adrenalin are very temporary and it is1 therefore1 of little value in treatment4 ,following irrigation ,i have used the petroleum oils 7liquid petrolatum7 to advantage as a protection to the mucous membrane4 ,one-half gram each of menthol and camphor and two or three drops of cinnamon oil to the pint of this oil1 is readily dissolved and produces a pleasant1 soothing effect to inflamed membranes1 but further than this1 the added substances have no particular value4 ,the above named chemical agents constitute1 except in rare instances1 my stock of 8drugs0 for treatment purposes4 ,hyperesthetic ,rhinitis--,hay ,fever ,there is perhaps no disease in which there has been more speculation concerning the etiology than in hay fever1 and while osteopathy has accomplished a wonderful advance in the treatment of this disease1 ,i am not sure that the cause or causes are yet thoroughly understood4 ,etiology4--,the theoretic causes of this disease may be expressed in the various names which have been given to it as follows3 ,the term ,hay ,fever suggests that it is a febrile condition caused by hay pollen irritation4 ,peach cold1 ,rose cold1 ,rose fever1 ,rose catarrh1 ,rye fever and ,ragweed fever suggest similar specific causes4 ,idiosyncratic coryza means nothing and this probably expresses what the theorists know about its cause better than any other name4 ,hysteric rhinitis suggests a probable psychic cause1 which certainly does exist in some cases4 ,if ,i may be pardoned1 and ,i know ,i never will be1 let me suggest just one more name--8,respiratory ,reflex ,inefficiency40 ,intoxications4--,auto-intoxication from focal infections or from gastro-intestinal perversions certainly have an important influence either directly or as predisposing factors and should always be carefully considered in treatment4 ,osteopathic ,lesions4--,osteopathic lesions1 such as interosseous1 muscular and ligamentous1 seem to function as predisposing causes by their general effects upon the system4 ,it seems probable that their effects upon the organs of metabolism and elimination are of greater importance than any direct or specific effect in causing the immediate symptoms4 ,in practically all cases lesions of the upper thoracic vertebr and ribs and of the cervical region are present4 ,it is my opinion that such lesions are more often secondary than primary4 ,respiratory ,reflex ,inefficiency4--,measurement of nerve force in these cases shows that none are really possessed with 8an excess of nerve force10 but that practically all vary from two-thirds to four-fifths normal1 showing that probably all cases are deficient in nerve force4 ,this instability of the nervous system can be explained1 ,i believe1 in the theory of peripheral reflex insufficiency4 ,as evidence of this the following facts may be cited3 #a4 ,it is known that peripheral irritation of almost any nature1 to the mucous membranes of the nasopharyngeal tract1 will excite an attack in susceptible individuals4 #b4 ,that any treatment which tends to increase the resistance of these membranes will prevent or relieve an attack4 #c4 ,that peripheral inhibition to these surfaces will temporarily relieve an attack4 #d4 ,that complete normalization of these membranes will make the patient resistive to the so-called specific irritants1 such as pollen1 dust1 etc4 #e4 ,that the mucous membranes of the entire respiratory and gastro-intestinal tract react to irritants to bring about 8the hay fever state0 and that any treatment which tends to normalize these membranes1 renders the patient more resistive to hay fever attacks4 ,exciting ,causes4--,there is no doubt that various air-borne irritants1 such as pollen1 dust1 chemical fumes1 emanations from animals1 etc41 act as exciting causes of acute attacks1 and yet there are cases that develop acute attacks out of season or at a time when it seems that there could be no air-borne irritation4 ,from evidence which will be offered later 7see prognosis7 ,i am led to believe that probably all susceptible cases can be made entirely resistive to the air-borne irritants4 ,pathology ,functional ,pathology4--,certainly in this disease there is ample evidence of marked perversions of function or functional pathology4 ,kyle believes that in many cases the cause of local irritation lies in 8some chemical change in the constituents of the mucus-secreting glands10 and 8it is a well known fact that in many cases of hay fever the irritation is not limited to the nasal mucous membrane4 ,the eyes and mucous membrane of the stomach and bladder1 and even the intestines may be markedly irritated40 ,these chemical changes in the secretion of the mucous membranes1 together with the excess of uric acid would seem to point either to a general perversion of the secretory mechanism or to a deficient elimination1 or to both4 ,the periodic occurrence may be accounted for by assuming that the systemic strain is sufficient to initiate the symptoms4 ,the fact that the attack is actually delayed or hastened in susceptible individuals by the late or early beginning of hot weather1 and that these cases get relief by going to a more moderate climate is further evidence of this4 ,again we are reminded of ,dr4 ,still's teaching1 that the body maintains its own chemical laboratory which adjusts or tends to adjust its work to the needs of that body1 but under abnormal strain this adjustive mechanism may fail to meet all of the demands of function4 ,it seems here that the osteopathic concept may easily include all environmental causes as well as internal causes in the predisposition to deficient function or disease4 ,structural ,pathology4--,during the attack there is a general catarrhal inflammation of all nasopharyngeal membranes1 accompanied by a watery discharge and marked swelling of the turbinates4 ,sensitive areas may be found on the middle turbinate and opposite wall of the septum4 ,probably it is this hypersusceptibility to irritation that causes the attack from the air-borne irritants4 ,the pseudo-membrane which may be found covering a part or all of the mucous membranes of the nares probably results from this irritation and is formed for the purpose of protection4 ,clinical ,types4--,clinically1 three rather indefinite types of hay fever may be recognized1 viz43 ,vernal1 those cases which have their attack sometime during ,may1 ,june or ,july2 ,autumnal1 in which the attack occurs in ,august or ,september and usually lasts until the beginning of cold weather1 and an indefinite or pseudo form occurring at any time of the year1 with no characteristic attack1 as in the other forms1 but with indefinite symptoms resembling hay fever4 ,symptoms and ,diagnosis4--,patients usually go to the physician self diagnosed4 ,the characteristic sneezing1 the watery discharge from the nose1 and the irritation of all membranes of the nasopharynx and conjunctiva will serve to make a diagnosis in most cases4 ,direct examination will reveal the nasal congestion and other characteristic pathology as described above4 ,termination4--,most cases of the autumnal form1 unless successfully treated1 continue with equal or increased severity until after the first or second frost1 when they usually terminate in asthma1 bronchitis or sinuitis1 which lasts for several weeks or months4 ,each year the attack lasts longer and is more severe and the asthma occurs earlier and is more severe4 ,treatment ,intranasal ,surgery4--,intranasal abnormalities1 such as deflected septum1 spurs on the septum1 hypertrophied turbinates1 polypi1 etc41 which materially reduce the breathing space1 usually demand surgery4 ,nasal surgery1 carefully and properly done1 is always a great aid and often absolutely essential to the successful treatment of hay fever and asthma1 but nasal surgery carelessly done frequently does more harm than good4 ,the correction of a deflected septum or the removal of a spur on the septum by submucous operation often aids materially in the prevention of pressure irritation1 increases the breathing space and normalizes drainage from the sinuses4 ,surgery is therefore very essential in many cases of hay fever1 but surgery is never the all essential part of the treatment1 because if the proper after treatment is not given1 the surgery alone will seldom result in either temporary relief or cure4 ,focal ,infection4--,the importance of focal infection of the sinuses1 tonsils1 teeth and occasionally other parts1 such as the nasal cavities1 epipharynx1 middle ear and mastoid cavities cannot be overestimated4 ,such conditions may be effective in causing hay fever1 by causing direct infection of the membranes of the nasopharyngeal tract or by auto-intoxication4 ,digital ,surgery1 for the removal of adhesions in the posterior nares and pharynx1 is in my opinion1 very essential1 and this work should be done thoroughly4 ,massage of the soft palate or pharyngeal walls is of no particular value4 ,all adhesions and adenoid tissue must be removed because this removes an effective source of constant irritation and focal infection and tends to normalize the direct and reflex nerve mechanism4 ,the practice of the radical intranasal technique as originated by ,j4 ,d4 ,edwards1 ,d4 ,o41 is indicated1 ,i believe1 in some cases in which the crushing of cellular middle turbinates1 or the breaking of adhesions is indicated1 but ,i am not yet ready to accept this theory of 8curetting0 the mucous membrane by radical digital technique4 ,the fracture of the turbinates is not necessarily a bad technique provided they are properly readjusted as ,dr4 ,edwards does it1 but to fracture and not readjust is a dangerous practice4 ,the efficiency and safety of any method depends upon the operator's definite knowledge of what needs to be accomplished and how it is to be done4 ,there are contraindications to digital1 as well as any other kind of nasopharyngeal surgery1 such as3 7#a7 ,acute infection of any part of the nasopharyngeal tract2 7#b7 evidence of sinus involvement2 7#c7 septal deflections1 spurs and hypertrophied turbinates1 which would not permit such work without undue trauma4 ,there are certain other precautions such as thorough cleanliness of the parts to be treated2 aspiration of the sinuses before and afterward1 and the use of a finger of sufficient size which will not produce undue trauma4 ,in my opinion very few doctors have such fingers4 ,failure in accomplishing results is due to three things1 viz41 7#a7 ,insufficient knowledge of diagnosis and prognosis2 7#b7 insufficient knowledge of what should be accomplished and the technique of doing it1 and 7#c7 the necessary additional or supportive treatment4 ,it is a great mistake to think that the removal of adhesions in the pharynx or nares is sufficient1 because if this is not followed by the proper supportive treatment1 no results or even bad results will frequently occur4 ,this treatment is not a massage in any sense1 but a definite operative procedure and requires as much care and skill as the removal of adenoids or tonsils4 ,space will not permit an explanation of the digital technique and the radical treatment should not be attempted without some definite knowledge of the methods and technique4 ,intranasal ,treatment4--,the intranasal method of treatment as explained above under hypertrophic rhinitis is very effective and if carefully and thoroughly done is in most cases just as efficient as intranasal digital surgery4 ,this treatment followed by irrigation and oil spray and nasal packing will be found effective in most cases if the treatment is properly done4 ,nasal ,packing4--,thorough packing of the nasal cavities after all sources of focal infection have been removed and after thorough cleansing has been done1 by means of long strips of absorbent cotton is effective in reducing the swelling and irritation4 ,the ,radical ,packing ,method4--,this method can be done best in a hospital4 ,the nares are prepared as for surgical operation1 by complete retraction of all erectile tissue1 thorough cleansing by irrigation and the application of a local anesthetic4 ,anesthesia need not be complete4 ,a careful examination is then made for any synechia1 or focal infections4 ,packing should never be done until the doctor is sure there is no sinus involvement4 ,the entire nasal cavity is then packed very firmly with sterile gauze4 ,this is best done by means of a special packing instrument or long nasal packing forceps1 using narrow gauze contained in tubes4 ,in some cases the nasal cavity is lubricated before packing4 ,the packing should be done early in the morning and removed just before bed-time1 so that the patient may sleep4 ,this treatment is repeated daily until all signs and symptoms of nasal irritation are gone and then replaced by irrigation and oil spray4 ,if this treatment is properly done1 there will be a complete sloughing of the pseudo-membrane followed by a restoration of normal and resistive tissue4 ,the results of our two years' experience 7we have tried this on only a few patients each year7 are very encouraging4 ,relief from the symptoms are very prompt and seemingly more permanent than from other methods4 ,treatment of ,auto-intoxication4--,all sources of focal infection are thoroughly treated4 ,sinus infection is very common and must receive proper attention before any other treatment can be effective4 ,our experience shows that many cases have auto-intoxication of gastro-intestinal origin4 ,the hospital care of such cases makes possible the thorough cleansing of the colon by irrigation and the reestablishment of an acid producing flora which seems to prevent fermentation4 ,osteopathic ,corrective ,work4--,thoroughness of treatment for the removal of all causes is the secret of success4 ,to successfully remove the immediate sources of auto-intoxication by treating a sinus infection or by thoroughly freeing the colon from fermentation products means only temporary results if the underlying causes are not corrected4 ,a thorough osteopathic examination is necessary to determine such causes and certainly such treatment should not be neglected4 ,correction of all cervical and upper thoracic lesions and particularly the clavicles and ribs is important4 ,these lesions seem to be the result rather than the cause1 but normal respiratory functions seemingly cannot be maintained unless such treatment is done4 ,sinuitis ,acute or chronic inflammatory disease of the nasal accessory sinuses with or without suppuration is more common1 ,i believe1 and is responsible for more complications and chronic affections of the nose and throat than is generally known4 ,etiology4--,the cause in most cases lies in unsuccessfully treated acute infections involving the nose and throat4 ,abnormalities of the nasal respiratory passages such as deflected septum1 enlarged or cellular turbinates1 adhesions resulting from cautery or careless surgery1 causing deficient drainage1 constitute the local causes4 ,underlying some of these direct causes1 lesions of the cervical region which impair the nutrition to and drainage from the head are to be considered4 ,symptoms and ,diagnosis4--,acute or chronic headaches and neuralgic pains of the head are common symptoms4 ,acute sinuitis of the frontal sinuses is accompanied by marked and persistent frontal headache and pain in the eyes4 ,in infections of the maxillary sinus there is usually pain over the affected part1 but there is often referred pain to other parts of the head4 ,sphenoidal sinuitis usually causes general headache with no definite location4 ,by direct examination of the nasal cavities a purulent or mucopurulent discharge may be seen and the source determined4 ,in many cases1 however1 the pus may be retained or insufficient in amount to detect by direct examination4 ,transillumination in a dark room by means of a good transilluminator will usually show a darkened area over the affected part4 ,the average battery equipments commonly sold for this purpose are of little value4 ,the ,x-ray plate when properly done1 is more dependable than the transilluminator4 ,in some cases1 all of these methods fail to locate the affected sinus and the cause can be found only by opening into the sinuses1 aspirating with a catheter and making microscopic examination of the aspirated material4 ,the microscope is indispensable for this work4 ,every suspicious discharge should be stained until pus is found and except in well defined cases1 this is the only practical method of positive diagnosis4 ,treatment4--,local treatment of the nasal cavities by retracting the turbinates and irrigation will be successful in many cases1 but unless there is a large normal opening the pus will not drain sufficiently and probe treatment is required4 ,in acute cases in which the pain is marked1 osteopathic treatment of the cervical region1 deep relaxation of the submaxillary structures and the application of heat over the affected part1 together with the local nasal treatment should be given1 but if this does not relieve the pain within twenty-four hours1 the sinus should be opened and thoroughly drained4 ,if efficient drainage is not established early the symptoms will usually increase until the pain is almost unbearable and serious complications may result4 ,in practically every case of acute sinuitis1 ,i believe it is best to make a good1 free opening into the affected sinus first and secure complete drainage by catheter aspiration4 ,if this is properly done every case will recover much more quickly and without complications or danger of chronic infection4 ,non-,suppurative ,sinuitis ,cases of non-suppurative sinus involvement are not at all uncommon4 ,the so-called 8,vacuum sinuitis0 which results from a closure of the normal opening1 resulting in inflammation without pus formation1 is responsible for many of the complicated cases of referred pain1 which are so often improperly diagnosed4 ,chronic headaches and the various symptoms of fifth nerve affections1 the neuralgias of the head1 are frequently caused by non-suppurative sinus involvement4 ,treatment4--,the treatment consists of establishing good drainage and proper ventilation of the affected sinus or sinuses followed by thorough intranasal treatment as explained above4 ,the osteopathic corrective work must not be neglected4 ,syphilis of the ,nose ,in osteopathic practice syphilis is not a common disease4 ,the occurrence of syphilis of the nose is still more rare but certainly should be recognized4 ,diagnosis4--,the local lesions of the nose are of two types1 those of acquired syphilis and of congenital syphilis4 ,there are three characteristic manifestations of acquired syphilis as follows4 ,the primary lesion or hard chancre is a firm1 indurated ulcerated mass with only slight discharge4 ,chancre of the nose is exceedingly rare4 ,in secondary syphilis there is the mucous patch1 the result of mucous membrane necrosis4 ,in tertiary syphilis the local lesion is the gumma or more commonly1 the ulceration left from necrosis of the gumma4 ,these lesions may appear from a few to many years after the initial infection1 but they never follow immediately4 ,the lesions may appear on almost any part of the intranasal structures4 ,they resemble the lesions of atrophic rhinitis but in atrophic rhinitis there is never the extent of destruction that so frequently results from tertiary syphilis4 ,treatment4--,it has been my practice to refer all suspected cases to ,dr4 ,f4 ,j4 ,stewart for differential diagnosis and treatment and his method of the use of salvarsan has proven efficient4 ,epistaxis--,nose ,bleed ,the causes of nose bleed may be divided into two general groups1 local and constitutional4 ,the first group consists of trauma directly to the nose either external or internal1 from nasal operations and other causes4 ,the presence of a cluster of thin-walled veins on the anterior part of the septum which readily rupture from slight cause1 constitutes perhaps the most common cause of nose bleed4 ,the ulcers of atrophic rhinitis or syphilis occasionally cause bleeding4 ,malignant growths of the nose may cause frequent and profuse hemorrhage4 ,the constitutional causes of epistaxis are1 the acute fevers1 cardiac and arterial diseases1 which cause excessive tension2 and cases of altered composition of the blood such as the anemias1 malaria1 purpura1 chlorosis1 hemophilia1 etc4 ,diagnosis4--,direct examination of the nose will usually reveal the cause4 ,if there are no signs of trauma or rupture of the anterior group of vessels and the bleeding does not respond quickly to packing of the affected side1 there is either a rupture of a large vessel1 which requires long continued packing1 or it belongs to the class of constitutional disease4 ,if there is evidence of some necrotic disease of the nose or if there are areas of exposed bone or cartilage from careless surgery1 these may usually be seen and the point of bleeding located4 ,treatment4--,cold applications1 irrigation of the nares with cold normal salt solution and the application of an absorbent cotton or gauze pack is usually sufficient to stop the average case of epistaxis from any cause4 ,the direct application of cold to the lower cervical region will cause capillary restriction4 ,there are many cases in which the membranes of the nose have lost their tone due to various irritants or from deficient nutrition to the parts4 ,these are cases of a wholly different type from that of the well known necrotic diseases such as atrophic rhinitis and syphilis4 ,hay fever is a result of such a cause4 ,the treatment in such cases consists of removing any local causes or osteopathic lesions and then normalizing the resistance of the membranes by the methods described under the treatment for hay fever4 ,the treatment for those cases of epistaxis due to constitutional disease depends wholly upon the causative factors and the proper treatment of these4 ,any local treatment in such cases will be expected to produce only temporary results4 ,diseases of the ,nasopharynx ,the nasopharynx may be the location of acute or chronic inflammations1 neoplasms1 malignant or nonmalignant1 processes of atrophy or hypertrophy1 adhesions1 etc4 ,it is important to remember that the nasopharynx admits the ,eustachian tubes and supports four superficially located ganglia of the fifth nerve4 ,acute ,nasopharyngitis4--,acute inflammatory processes of this region may result from rhinitis1 infections of the lower pharynx1 focal infections of these parts or from direct involvement of its own structures4 ,the symptoms are post nasal tenderness and mucus dropping4 ,some patients experience the sensation of a foreign body in that location4 ,the thick1 adherent collections of mucus are difficult to dislodge and sometimes are so persistent that they cause nausea4 ,there is usually occlusion of the ,eustachian tubes1 resulting in partial deafness1 tinnitus and often dizziness4 ,the ,treatment consists of thorough cleanliness by irrigation and osteopathic corrective work to the cervical region4 ,it is also essential to keep the anterior neck structures particularly those of the submaxillary region1 thoroughly relaxed to maintain efficient drainage4 ,chronic ,nasopharyngitis ,this is one of most common diseases of the nasopharyngeal tract1 causative of many complications and yet perhaps the least recognized in proportion to its significance4 ,the frequent occurrence of adhesions of the pharyngeal foss1 hypertrophied membranes1 enlarged spongy extensions of the inferior and middle turbinates 7the posterior turbinate bodies7 occlusion of the orifice of the ,eustachian tubes and chronic1 excessive secretion of thick mucus all show that this disease has either gone unrecognized or at least has not received proper treatment4 ,treatment4--,complete surgical removal of all abnormal growths1 adhesions1 etc4 as described under the treatment of chronic non-suppurative otitis media and this followed by thorough irrigation and other methods of local treatment described above are efficient4 ,the successful treatment of this disease requires time4 ,there has been a partial or1 in some cases1 almost a complete loss of the normal functions of the nerve reflex mechanism of these parts1 peripheral reflex inefficiency and this must be restored4 ,efficient and long continued treatment of the lesions commonly found in the cervical and upper thoracic regions will do much to restore these normal functions1 but this alone without the surgical treatment will never effect a permanent cure4 ,neither will the surgery and local treatment alone effect a cure4 ,the whole treatment is required4 ,adenoids ,adenoids are the hypertrophied lymphoid tissue of the nasopharynx4 ,they occur commonly in children1 as a result of acute inflammations4 ,possibly the suckling process of the child produces a partial vacuum of the epipharynx and thus causes excessive blood supply to the part and therefore excessive growth of these soft tissues4 ,adenoids1 however1 are not confined to children but frequently occur in adults4 ,in all cases they are a source of much annoyance and often the cause of acute and chronic disease4 ,symptoms and ,diagnosis4--,mouth breathing1 head colds1 partial deafness1 etc4 are the common symptoms4 ,the flattened nose1 the high arch of the hard palate and the stupid appearance of the face are diagnostic4 ,by direct palpation to the nasopharynx the nature and extent of the adenoid mass can be determined and this is the best method of diagnosis4 ,treatment4--,many methods of non-surgical treatment have been employed1 but there is nothing as satisfactory as complete surgical removal4 ,adenoid tissue has no known function different from that of other lymphoid tissue and there is always sufficient to perform any necessary function without excess of adenoid growth4 ,the excessive adenoid growth is in every case a detriment to normal development1 because it impairs nasal respiration and usually causes chronic nasopharyngitis and thus reduces resistance against all diseases of childhood4 ,there is therefore1 no excuse1 much less a reason1 why excessive adenoid growths should not be removed surgically1 provided it is properly and thoroughly done4 ,the operation for removing adenoids requires in children1 a general anesthetic4 ,in adults1 a local anesthetic is used by some operators4 ,i have found it best to first break the adenoid mass away from the side walls of the pharynx digitally4 ,a ,la,force or ,gradle adenotome is then used to remove the adenoid mass4 ,if either of these instruments is properly used it will always remove the greater part of the adenoid mass without undue trauma or injury to any of the pharyngeal structures4 ,curets should never be used because they almost never remove the adenoid mass properly1 but they usually do injure the pharynx4 ,many cases of pharyngeal adhesions1 ,eustachian tube occlusion and nasopharyngitis result from direct injury caused by curets4 ,after the adenoid mass has been removed the finger is inserted into the pharynx and any adenoid growths in the posterior nares are removed4 ,the pharyngeal foss are also thoroughly freed from adenoid tissue and adhesions and the orifices of the pharyngeal portions of the tubes are gently dilated4 ,this method insures complete removal of all excessive adenoid tissue1 and normal functions of the nasopharynx4 ,adenoids thus removed do not return4 ,after the surgical work has been completed the nasopharyngeal tract should be thoroughly irrigated with hot salt mixture solution4 ,this thoroughly cleanses the membranes1 hastens healing1 prevents hemorrhage and avoids post-operative infection4 ,irrigation of the nasopharynx should be continued for some days or until all evidences of inflammation have ceased4 ,the pharynx should then be examined to be sure that no adhesions have developed from inflammation1 but if the operation is carefully done1 complications will never result4 ,diseases of the ,oropharynx ,acute ,pharyngitis ,acute inflammations of the pharynx alone or in common with inflammations of other parts of the nasopharyngeal tract are common4 ,this disease is most common as a result of the acute infections affecting the nose and throat4 ,etiology4--,the predisposing causes are focal infections of the nasopharynx1 such as tonsillitis1 sinuitis1 etc4 ,deficient nutrition or anemia of the pharynx or systemic anemia are common causes4 ,lesions of the cervical1 upper thoracic and hyoid are common predisposing causes4 ,undue exposure of the neck in susceptible persons or too much or too tight clothing about the neck may also predispose to inflammations of the pharynx4 ,the exciting causes are the acute infections1 colds and focal infections4 ,perhaps the most common exciting cause is tonsillitis1 acute or chronic4 ,symptoms and ,diagnosis4--,the characteristic dryness of the pharynx1 pain and persistent coughing are diagnostic4 ,upon direct examination1 the reddened1 swollen appearance of the pharynx and posterior pillars can be seen4 ,treatment4--,the treatment should be general and local and should be determined by the causes and conditions present4 ,this disease is usually an acute infection and like other acute infections1 the usual systemic treatment should be applied4 ,the local treatment consists of thorough cleansing of the nasopharynx 7by irrigation if the patient can permit7 and the frequent 7or occasional as required7 use of some gargle until the inflammation has subsided4 ,any cleansing nonirritative solution may be used for a gargle4 ,equal parts of peroxide1 alcohol and glycerine1 a tablespoonful to a half glass of very warm water or ten to fifteen drops of phenol-glycerine to a half glass of warm water will make a good cleansing gargle4 ,the osteopathic treatment consists of corrective work to the cervical1 upper thoracic and hyoid and thorough relaxation of the submaxillary musculature to obtain good venous and lymphatic drainage4 ,if sufficient care be taken to avoid trauma1 digital stretching of the soft palate and pharyngeal muscles by the use of the finger internally1 is very efficacious4 ,chronic ,pharyngitis ,chronic pharyngitis may be hypertrophic1 atrophic or granular4 ,in hypertrophic pharyngitis the pathologic changes have passed beyond the stage of hyperemia and there is always hypertrophy or hyperplasia1 usually the latter1 of the pharyngeal membranes4 ,these changes in most cases1 have extended to and involved all of the nasopharyngeal membranes4 ,chronic granular pharyngitis1 or so-called clergyman's sore throat1 has a similar pathology to that described above1 but with swollen and inflamed lymph follicles4 ,this condition seems to be a result of excessive use of the voice4 ,chronic atrophic pharyngitis has a similar etiology and the diagnostic signs are also similar to atrophic nasopharyngitis with which it is usually associated4 ,etiology4--,the causative factors are similar or the same as those of nasopharyngitis4 ,lesions of the cervical and upper thoracic and chronic focal infections such as tonsillitis1 sinuitis1 etc4 are the common causes4 ,treatment4--,the nature of the treatment should be determined by the causes found4 ,the nature of the pathology requires long continued treatment and careful attention to all causes4 ,thorough osteopathic corrective work1 the removal of all sources of focal infection1 proper attention to any gastro-intestinal perversions which may be causing auto-intoxication and thorough cleanliness of the parts by gargling with some cleansing1 non-irritating solution and by irrigation4 ,in most cases there is a considerable collection of adhesions in the nasopharynx or posterior nares or in both4 ,enlarged 8posterior turbinate bodies0 and the extension of the inferior turbinates into the pharynx are also common results of the hypertrophic process4 ,complete surgical removal of this excess tissue and the after treatment as described above under chronic nasopharyngitis are frequently required to obtain complete and permanent results4 ,these cases can be successfully treated if the proper attention is given to all possible causes in each individual case4 ,it is the individualization1 the specific and detailed attention to the cause or causes1 and such treatment continued for sufficient time1 that will obtain results4 ,in atrophic pharyngitis1 normal nutrition to the parts and usually to the entire system must be restored4 ,many such cases are secondary to systemic anemia or to rheumatic intoxication4 ,a careful examination should be made for evidence of systemic causes4 ,in many cases1 ,i believe that thorough osteopathic corrective work applied to the mid and lower spine is the most essential part of the treatment4 ,other than this the local treatment as described under atrophic rhinitis applies here4 ,tonsillitis ,there is perhaps no other organ of the body1 diseases of which have caused a greater variance of opinion relative to treatment than the tonsils4 ,there are those who believe that every hypertrophied1 atrophied1 or infected tonsil together with its fellow of the opposite side should be removed4 ,there are also those who believe that no tonsils1 regardless of their pathology1 should ever be removed4 ,these are the radicals and their views are not at all in keeping with present day facts4 ,those physicians and surgeons who have tried to arrive at some safe conclusion on this subject1 believe that there are certain methods of non-surgical treatment which are effective in many cases and they also believe that in other cases1 tonsillectomy is imperative4 ,functions of the ,tonsils4--,many and varied functions for the tonsils have been held by various theorists such as3 the absorption of the products of salivary digestion2 the secretion of an amylolytic ferment2 that they are atavistic structures and therefore have no function2 that they eliminate systemic toxins2 that they serve as culture tubes for the production of vaccines2 that they protect the deeper cervical tissues from bacterial invasion2 the theory of internal secretion and a score of other theories which so far1 have never been substantiated by either clinical or experimental evidence4 ,the hematopoietic theory or the theory of blood formation has a rather definite basis because such a function would be possible from the histologic structure4 ,the formation of small lymphocytes has been attributed to tonsil tissue 7,flemming7 and this view has been generally accepted4 ,some of the lymphocytes however1 find their way through the epithelial walls into the crypts and are discharged as 8mucous plugs01 while others are carried by the efferent lymphatics into the circulatory system4 ,in this respect1 the tonsils1 like other lymphoid tissue1 produce lymphocytes which are essential constituents of the blood4 ,this function is particularly marked during the growing period1 but this function is also highly developed in all lymph nodules during this period1 and in the growing child there is an abundance of such tissue and thus it seems that the tonsils1 while important to the growing child1 would not be at all indispensable structures4 ,some physicians claim to have observed deficiencies in growth and development of children whose tonsils had been removed during the first ten or fifteen years of life1 but this is not commonly accepted4 ,the tonsils have their greatest cellular activity during the growing period and unless chronically hypertrophied they atrophy during adult life4 ,tonsillectomy ,we may safely conclude from this evidence1 that in the growing child1 it may be well to retain the tonsils providing they are not directly affected in such a way as to endanger the general health of the child1 but that there is little1 if any1 danger in their early removal4 ,in adults1 there seems to be no reason why they should not be removed in cases in which there is evidence of involvement beyond restoration by treatment or those cases in which there is evidence of toxic absorption4 ,when surgical removal of the tonsils is indicated1 the complete removal or tonsillectomy should always be done4 ,a careful and complete enucleation of the tonsils when properly done will never be followed by any untoward results other than the temporary surgical sore throat4 ,there is never any excuse1 much less a reason1 for partial removal of the tonsils or tonsillotomy1 because such operations never accomplish the desired result and they nearly always require tonsillectomy later4 ,in association with a reputable vocal teacher ,i have studied the results of tonsillectomy on the voice4 ,in none of the twenty cases studied was there any impairment following the operation1 but on the other hand sixty per cent were improved either in range of pitch1 quality or endurance1 in addition to their being more free from laryngitis1 pharyngitis1 etc4 for which the operation was done4 ,doctors ,ruddy1 ,edwards and ,reid of our profession have told me of similar experiences1 so ,i am certain that tonsillectomy properly done will in selected cases1 improve the voice4 ,acute ,tonsillitis ,acute tonsillitis is an acute infectious and often a contagious disease characterized pathologically by inflammation of the tonsils4 ,some authors differentiate between follicular tonsillitis in which the crypts or lacun are involved1 and parenchymatous tonsillitis in which the parenchyma is involved4 ,etiology4--,the predisposing and exciting causes are the same as in other acute infections of the upper air passages except that there is usually a chronic tonsillitis as a result of some previous attack4 ,symptoms and ,diagnosis4--,the symptoms also are similar to other acute infections of the nasopharyngeal tract1 with sore throat1 variable temperature1 headache1 etc4 ,by direct examination of the pharynx1 the protruding masses with white or yellow patches are readily seen4 ,treatment4--,infection1 drainage and elimination are three words inseparable in the therapeutics4 ,the local treatment 7,i doubt if many will agree7 in either acute or chronic tonsillitis is essentially the same--radical aspiration drainage4 ,in all cases1 except young children who will not permit it1 ,i place a vacuum cup directly over the tonsil and apply as much vacuum as can be obtained4 ,this treatment will1 when properly done1 empty the crypts of all pus4 ,this accomplished1 each crypt is probed with a cotton applicator dipped into phenol-glycerine4 ,cervical and upper thoracic treatment and deep relaxation of the sub-tonsil tissues to increase the normal blood supply and to decrease congestion by drainage elimination are essential4 ,the lower thoracic and lumbar should receive due attention for the purpose of increasing general elimination4 ,the diet and other treatment are no different from that in other infectious fevers4 ,peritonsillar ,abscess 7,quinsy ,sore ,throat47 ,peritonsillar abscess results from the collection of pyogenic bacteria and pus formation between the tonsil and the pillars of the fauces4 ,it is perhaps a result of the closing of an infected crypt causing deep penetration of the pus4 ,diagnosis4--,the symptoms are those of acute tonsillitis but usually more marked and with one tonsil decidedly more protruding than the other4 ,in some cases the location of the abscess can be seen and it is comparatively easy to open with a knife or probe1 but in many cases the abscess is so situated that it cannot be located except by exploratory probing4 ,treatment4--,drainage by direct incision of the abscess pocket is indicated as early as a definite diagnosis can be made4 ,there is no definite technic to be followed except to observe certain general principles4 ,if the 8pointing0 of the abscess can be located1 it is comparatively easy to make a good1 free1 direct incision and accomplish complete drainage4 ,in many cases the only way to locate the pocket is to employ a probe or small1 long1 scalpel and explore between the pillar and tonsil until the pus pocket is found4 ,as soon as this is located the pus pours out around the probe and this gives the location4 ,free drainage by means of a liberal incision should then be made4 ,aspiration of the pus pocket and filling with phenol-glycerine is effective after drainage has been obtained1 but a liberal drainage must be maintained4 ,the non-surgical treatment as described under acute tonsillitis is to be applied here4 ,chronic ,tonsillitis ,chronic tonsillitis usually is the result of one or many attacks of acute infections of the tonsils4 ,occasionally cases of marked chronic tonsillitis occur in which the patient denies ever having had an acute attack4 ,the pathology consists of hypertrophy of the lymphoid tissue and connective tissue4 ,diagnosis4--,the purpose in diagnosis is not to determine whether the tonsil is hypertrophied but to determine whether the tonsil is causing any local or general physiological perversions and if so1 whether local treatment or surgery should be applied4 ,the direct examination should be made very carefully1 because otherwise a bad tonsil may be readily overlooked4 ,the mere fact that a tonsil is large or has open crypts from which a whitish mass may be expressed does not mean that such a tonsil is directly responsible for local or systemic physiologic perversions4 ,the examination should be made by means of a tongue depressor1 tonsil retractor and a good head mirror and reflecting lamp4 ,every part of the tonsil and surrounding pillars should be carefully examined4 ,firm pressure applied against the tonsil from in front and behind will often force material from the crypts or out around the capsular margin4 ,any such material thus expressed should be examined microscopically4 ,by probing the crypts with a small pointed cotton-wound probe and staining the material obtained1 the condition of the deep parts of the tonsil can be determined4 ,the symptoms in every case1 are to be considered with the microscopic findings1 but there are cases in which either of these1 together with appearance on direct examination1 is sufficient to determine the advisability of tonsillectomy4 ,in general1 we may say that the following factors would indicate tonsillectomy4 #a4 ,chronic1 recurrent tonsillitis with or without complications1 which does not respond to non-surgical treatment4 #b4 ,positive evidence of arthritis of any form with microscopic evidence of some virulent organism1 such as staphylococcus1 streptococcus or long-chain pneumococcus1 present deep in the tonsillar tissue4 #c4 ,any persistent discharge of pus from the tonsil in which the microscope shows the presence of virulent bacteria and which will not be relieved by treatment4 #d4 ,markedly hypertrophied tonsils which directly interfere with the voice1 deglutition or respiration and which do not respond to treatment4 #e4 ,persistent focal infections of the middle ears1 or sinuses or root abscesses which do not respond to treatment and in which case there is a virulent infection of the deep parts of the tonsil1 shown by microscopic examination4 ,the above are only general conditions and there are probably many other indications or groups of symptoms that would indicate tonsillectomy4 ,in most cases1 unless the findings show positively that tonsillectomy should not be delayed1 we advise treatment4 ,if treatment does not restore to normal1 it will probably reduce the time of the surgical sore throat following the operation4 ,non-surgical treatment4--,the local direct treatment1 as we practice it1 consists of3 #a4 ,direct aspiration by means of the tonsil cup1 applying from fifteen to twenty inches of vacuum4 #b4 ,application of phenol-glycerine by means of cotton applicator to the full depth of each crypt4 #c4 ,irrigation of the crypts by means of a catheter and hot salt mixture solution4 #d4 ,syringing of the crypts by means of the catheter and phenol #aj1 alcohol #bj and glycerine #gj4 ,the digital treatment of the tonsil consists of3 #a4 ,applying pressure against the anterior pillar thus forcing the contents out of the tonsil1 the ,ruddy method4 #b4 ,by the bidigital technic1 the front finger of one hand inside1 posterior and inferior to the tonsil and the fingers of the other hand outside exerting deep pressure and opposing the finger inside4 ,in this way the tonsil can be lifted forward and upward and its contents expressed4 ,the digital treatment is not as effective as that described above4 ,the osteopathic corrective treatment consists of adjustment of the atlas and axis and the mandibular articulation and the obtaining of free movement of the hyoid and the relaxation of the submaxillary musculature and other deep structures4 ,this treatment1 if followed persistently1 will relieve the local symptoms of a very high percentage of cases of chronic tonsillitis1 and in many cases even the systemic complications will be relieved4 ,whether in cases of systemic absorption this is the preferable treatment ,i am not sure1 because1 once the local condition is improved the patient will usually refuse operation and even if the physician finds definite evidence of toxic absorption he cannot convince the patient that his tonsils require surgery4 ,,mental ,,diseases ,,by ,l4 ,,van ,h4 ,,gerdine ,,and ,a4 ,g4 ,,hildreth4 ,,introduction ,the subjects herewith presented1 while including certain of the most important sections of mental disease1 make no claim to completeness either in the subject matter presented or in the attempt to cover the entire field of the psychoses4 ,they cover those portions1 however1 with which we have come in closest touch at the ,still-,hildreth ,sanatorium1 and in which we have the most complete records4 ,i have been aided in the compilation of the essential facts and statistics by the able staff of the institution and wish to acknowledge especially the valuable cooperation of ,dr4 ,c4 ,m4 ,van,duzer in the ,dementia ,praecox group1 ,dr4 ,h4 ,p4 ,hoyle in the ,manic ,depressive group1 ,dr4 ,b4 ,l4 ,jemmette in the group entitled ,delirium1 ,confusion and ,stupor1 ,dr4 ,j4 ,c4 ,snyder in the ,senile ,dementia group and ,dr4 ,g4 ,s4 ,elkins in the ,involutional group4 ,the opinions concerning each type held by ,dr4 ,a4 ,g4 ,hildreth are appended under its appropriate heading4 ,i wish to state emphatically that the sole treatment carried out in the ,macon ,institution is specific corrective work upon spinal lesions1 and it is upon this treatment that the statistics are based which are to be found throughout the text4 ,these records cover more than #gjj cases1 including complete histories of the patients with the physical and mental findings on examination2 these represent1 therefore1 by far the largest body of statistics ever accumulated in the study of osteopathic results in mental disorders4 ,while the results naturally vary in different types of mental disease the grand total shows that more than one-half of all patients admitted recovered4 ,details for each group will be mentioned under its appropriate heading4 ,while adjuncts such as diet and hydrotherapy have been utilized2 we certainly cannot attribute any curative value to their influence4 ,it should be further emphasized that in no case whatsoever has medicine been used as a curative agent4 ,and the same may be said of surgery4 ,it has indeed been conclusively proved even in the medical world that medicines and surgical procedures are absolutely ineffective2 from the osteopathic viewpoint this of course is perfectly reasonable since the theory calls for definite lesions as causative factors and these lesions can hardly be reached other than by the osteopathic method of correction4 ,the results obtained1 therefore1 could only be attributed to the genuine osteopathic principle enunciated by ,dr4 ,a4 ,t4 ,still who kept in close touch with the work and gave it his approval up to the time of his death4 ,he had always maintained that the osteopathic principle could accomplish remarkable results in this field and considering the previous inefficiency of any other method his confidence has been fully justified4 ,dementia ,praecox ,this condition refers to mental disorders arising usually during the period of puberty or adolescence1 therefore1 between the ages of fourteen and twenty-five for the most part1 although apparently similar cases may arise in later years4 ,the term dementia refers to mental deterioration and enfeeblement1 while 8praecox0 signifies adolescence1 though some writers infer that the term praecox may be used to indicate the early or precocious development of the mental enfeeblement4 ,certain it is that in most cases deterioration1 with its resulting symptoms of mental enfeeblement giving rise to the term dementia1 usually occurs in time1 though by no means always early4 ,it is a chronic progressive disease which may terminate in a complete loss of mentality2 in other cases it may become arrested in any stage and remain so permanently2 in still others it may recover1 though this is rare4 ,by reason of the variability of the symptoms1 three groups are generally recognized1 first suggested by ,kraepelin4 ,each is differentiated by more or less characteristic symptoms and referred to under the head of the ,hebephrenic1 ,catatonic and ,paranoid types1 although all have certain symptoms in common and there are mixed types4 ,etiology4--,according to the authorities some form of hereditary factor can be found in some fifty per cent or more of all cases2 this is supposed to create a predisposition1 a natural weakness of the nervous system1 which renders it unable to bear the ordinary storm and stress of life1 so that the mechanism becomes according to the ,french expression1 8wrecked upon the rock of puberty or adolescence20 in other words1 a premature giving way of the nervous system1 being inherently unable to stand the strain of life4 ,another suggestion is that it represents the outcome of abnormal types or reactions of the individual to the environment1 with a failure of proper adjustment to surroundings and the formation consequently of mental problems which to the patient are incapable of solution4 ,this may be called the psychological theory4 ,the most commonly accepted idea1 however1 is the physical causation4 ,according to this the disease results from auto-intoxication1 the intoxicant arising from the disturbances of the glands with internal secretions1 more particularly the sexual glands4 ,this endocrine theory is supposed to be supported by the fact of the appearance of this disease most commonly at the time of puberty and shortly thereafter4 ,the osteopathic conception fits in very well with this latter view1 inasmuch as the spinal lesions are quite capable of explaining not only a disturbance of innervation to the glands with the resultant interference in their normal secretion1 but also could produce disorder of the circulation and nutrition to the brain4 ,symptomatology4--,although each variety of ,dementia ,praecox has special symptoms characteristic of the type there are certain symptoms common to all forms1 and these will be first considered4 ,all the functions of the mind in the course of time tend to become disturbed and to be weakened1 but in the earlier stages we find marked differences as regards the disturbance of different functions1 thus memory and orientation in most cases seem good2 on the contrary1 attention and association of ideas somewhat poor4 ,emotional life is almost always markedly affected1 even in the beginning4 ,very commonly at first there is depression to be followed later by expansive feelings and then by apathy in general4 ,the will power is altered early and the conduct is apt to be peculiar4 ,the judgment becomes impaired4 ,all of these symptoms mentioned are deviations from the normal in the patient and therefore presuppose that the patient was formerly normal4 ,this should sharply differentiate the praecox group from cases of defective development 7imbecility or idiocy74 ,in this latter group there is an arrest of development of the mind1 whereas in praecox there is a loss in a developed intellect4 ,we see a young patient1 for example1 who has lost interest in things about him1 neglects his work at school or at home1 remains alone for long periods of time and seems unwilling to mingle with other people4 ,he gives the impression of one depressed and worried about something he is trying to solve1 perhaps he mutters to himself or gives way to unprovoked laughter1 he may refuse to eat1 or to talk unless questioned and may even then not answer4 ,when he does talk it will be discovered that he knows perfectly well where he is1 and knows people around him and understands everything that is going on2 his memory will be found good1 he can usually recall past incidents and tell what he has been doing recently4 ,as the condition progresses1 however1 while the patient may still for a long time retain fair orientation and memory for past events1 his accumulation of recent ideas will be found poor1 so that he will recall them with difficulty4 ,we notice that it is difficult to get the patient's attention and concentration seems to be impossible1 he may answer a direct question1 but immediately seems to be occupied with other thoughts and it takes some little effort to gain his attention again4 ,if he continues to talk it is plain that the association of ideas is poor1 giving rise to disconnected phrases which usually come forth sluggishly and without show of emotion4 ,dissociation of ideas occurs2 that is1 different ideas expressed may practically contradict themselves4 ,for example1 the patient may say he is a king and yet when asked to sweep the floor will do it perhaps without hesitation1 not considering that is hardly the kind of work a king would do4 ,the dissociation is also marked in the contradiction found between the content of the thought and its associated emotional idea1 for example1 the patient may speak of a near relative as dying recently1 yet with no show of emotion1 even with a meaningless laugh4 ,this dissociation may ultimately result in complete incoherence1 in which no sense can be found whatsoever in his speech4 ,emotional indifference is noticeable early and sluggishness of reactions to stimuli1 even failure of such reactions2 the patient will neglect himself1 stay away from meals1 express no desires and make no complaints4 ,in the earlier stages1 however1 the patient who may have been for some little time apathetic1 suddenly without apparent cause becomes angry1 noisy1 and possibly violent and destructive1 again gradually relapsing into his quiet1 apathetic state4 ,the thought content is commonly associated with delusions1 that is obviously false ideas1 but which the patient is unable to perceive are false4 ,delusions of persecution are most common1 the patient feeling in a dim way that everything is not right2 and in attempting to explain to himself the reason1 often attributes causes to people or forces outside of himself1 and on account of the feeling of bodily discomfort1 also by reason of the depression1 he explains the external forces as unfriendly to himself4 ,hallucinations may be present and furnish the material around which the delusions form2 on the other hand hallucinations may result from the delusions4 ,by hallucination is meant a false sense perception1 as the patient may state he sees someone before him who is not there1 or that he hears voices from individuals who are not around him2 he may also complain of receiving electrical shocks1 or wireless messages1 which he usually states come from his persecutors4 ,symptoms of this nature form a good example of the so-called split personality1 or 8schizophrenia10 wherein certain idea complexes are split off from the main personality and address themselves to the main portion1 the patient attributing these noises 7voices71 sensations 7visceral and tactile71 tastes and smells to an objective rather than a subjective source and subsequently forming delusions4 ,however1 unless we are dealing with the paranoid form the delusions are fragmentary1 transient and absurd4 ,hebephrenia4--,this is a progressing mental enfeeblement1 terminating usually in deterioration1 and without showing marked peculiarities in thought or action aside from the progressing deficiency4 ,the patient appears in general inactive1 lacking in energy and ambition1 indifferent1 depressed1 incapable of much concentration and hence the efficiency becomes progressively impaired until he is unable to accomplish anything4 ,from time to time there may be periods of confusion1 depression1 passivity1 at other times periods of excitement4 ,catatonia4--,in this form the general symptoms are similar to those of the simple type above described with the addition of the special symptoms referred to as catatonic excitement and catatonic stupor4 ,the excitement period is manifested by an unrest and monotonous activity1 stereotyped actions and speech1 the patient constantly repeating some act1 such as moving the hand1 foot or head over and over again in the same way1 or repeating the same word or phrase indefinitely4 ,this occurs apparently involuntarily1 the actions being automatic in character4 ,the patient who has been in a semistuporous state may pick up a glass or chair and without show of emotion break it against the wall4 ,in catatonic stupor the patient may show in the lighter degrees a simple loss of interest and feeling with sluggish reaction to stimuli1 or a profound inactivity and stupor in which state he cannot apparently be reached by any stimuli2 nevertheless1 he apparently retains consciousness4 ,in this type we observe the interesting symptom of negativism in which the patient always does the opposite of what he is requested1 or refuses outright to obey any command4 ,there may be a refusal of food so that the patient has to be fed by a tube1 mutism may be present1 the patient may go for weeks or months without saying a word2 stereotype of attitude results in cataleptic poses and rigidity1 in which the patient may maintain any particular pose for a prolonged period of time1 and if placed in some other attitude may similarly retain the new attitude for a long time4 ,this constitutes the so-called wax like rigidity1 the patient reminding one of a wax figure4 ,pathologic suggestibility occurs in which the patient imitates movements1 or repeats words and phrases that are spoken or performed before him4 ,paranoiac ,form4--,in this type delusions predominate and are characterized by variability1 inconsistency1 illogicality and transitoriness on the one hand1 with many gradations to the opposite extreme where they become more or less fixed1 and often dovetail into each other forming apparently a systematic whole4 ,they tend to be usually of a persecutory and hypochondriacal character and in later stages when the mind is distinctly weakened are often of a grandiose type4 ,sometimes the patients have some kind of explanations for them and at other times none whatsoever1 and they are often curiously dissociated from the emotional accompaniment4 ,the patient may state there is poison in his food1 in an indifferent tone of voice or even with a laugh2 he may claim that his teeth are all set in wrong and offer no explanations to these obviously false ideas4 ,the patient commonly thinks that somebody 8has it in for him10 someone will do him mischief1 will kill him1 that people are talking about him and criticizing him1 everything that he hears or reads he thinks has some bearing on himself1 so-called 8delusions of reference40 ,hallucinations may be present1 the patient hearing voices1 or receiving impressions or ideas which he claims come from without4 ,these external impressions he misinterprets as voices or forces which are accusing1 threatening and slandering him4 ,later on1 the patient tends to change from the depressed persecutory stage to an expansive one1 when he claims he is some celebrated person1 king or president1 or pope4 ,the impairment of the judgment is clearly demonstrated in these cases since the patient who may claim to be the king of ,england may beg the attendant to change his place at the table or for a postage stamp4 ,pathologic ,anatomy4--,this is obscure4 ,since a certain proportion of cases recover1 there can evidently be no degenerative changes at the outset1 though some cases deteriorate fairly early1 others only after several years4 ,in some chronic cases there have been observed degenerative changes in the cortical cells4 ,diagnosis4--,first1 the common age of onset during puberty and adolescence1 fourteen to twenty-four in the vast majority of cases1 this being the only common mental disease occurring during this age period4 ,second1 the progressive character terminating in mental enfeeblement or deterioration1 that is 8dementia0 proper4 ,third1 the evidence of defect or deficiency symptoms indicating that the patient's mind has altered in the sense of deterioration from its former normal condition1 whereas1 in imbeciles or idiots the mind has failed to develop in the first place4 ,fourth1 in the earlier stages particularly the marked dissociation of the brain powers1 some being well maintained as memory and orientation 7that is knowledge of time and space71 others being weakened1 such as judgment1 power of attention and the like4 ,fifth1 the early appearance of the emotional defect1 a remarkable indifference and apathy of the patient to people and surroundings1 the patient being unsocial and taking no interest in anything4 ,sixth1 all the peculiar motor reactions1 which are mentioned above under the catatonic head1 and which very rarely occur in any other mental disorder4 ,seventh1 the delusional content nearly always refers to the patient's exterior1 forces outside of him1 people or things which are exerting an unfavorable influence upon him1 delusions of persecution and reference4 ,the patient practically never accuses himself1 as is the rule in cases of true melancholia1 never blames himself1 but always the other party or the other force outside of him4 ,eighth1 the delusions of grandeur are usually indicative of a stage of deterioration4 ,prognosis4--,some authorities are inclined to doubt if any case ever completely recovers1 claiming that in apparent recovery it may have been a question of mistaken diagnosis1 or that the recovery is more apparent than real1 that the patient is not truly well1 or will have a relapse1 so that a permanent cure will be impossible4 ,other authorities admit the possibility of recovery though in a very small minority of cases4 ,the statistics of the ,still-,hildreth ,sanatorium1 covering more than two-hundred fifty cases show total recoveries of at least one-third4 ,this includes all types and all stages of progress1 many being advanced on entrance4 ,of the less advanced cases and those of not more than two or three years' standing there have been some fifty per cent recovery4 ,many cases make improvement or become stationary in greatly improved condition1 but are not included in the thirty per cent4 ,of the three types1 the catatonic offers the best prognosis1 the hebeprhenic the poorest1 while the paranoiac occupies an intermediate position4 ,treatment4--,of the etiologic factors above mentioned1 that of auto-intoxication1 resulting possibly from endocrine disturbances or other sources1 is most generally accepted in the medical world and agrees excellently with the osteopathic point of view4 ,spinal lesions are regularly found more particularly in the dorsal region1 which are quite capable of disturbing the innervation to the glands2 therefore1 their nutrition and activity4 ,a correction of these before the disturbance has continued too long1 and hence before deterioration has set in1 should theoretically normalize the glandular condition and therefore prevent deterioration and enable the patient to recover4 ,such is the probable explanation of the results1 and in many cases the recoveries were obtained in patients previously considered hopeless4 ,remarks by ,dr4 ,hildreth ,in a great majority of the cases the cause lies in the interference between the fourth dorsal vertebra and the eighth1 which analyzed means a disturbance of the great splanchnic nerves1 through whose interference would be caused the toxic condition and even the sexual disturbance described in so many cases from standard authorities4 ,the same lesion1 if deep seated enough1 could produce an interference with the vasomotors and reflexly interfere with the circulation to the brain4 ,in many we also find a first1 second or third cervical lesion4 ,the effects of these lesions on the equilibrium of the circulation to the brain are easily traced through the superior cervical sympathetic ganglia4 ,these lesions1 namely1 the mid-dorsal and upper cervical1 especially when corrected in the earlier stages1 have thus far proven to produce successful results4 ,in a lesser number of cases we find the cause to be from the first to the fourth dorsal vertebr2 our reasoning here being that the interference or the physical disturbance must be so deep that it reaches and interferes with the deeper nerve currents1 both downward and upward1 thus disturbing the equilibrium of the circulation to the brain4 ,we have found this class to be the hardest to respond to treatment2 however1 that may be due to the fact that the physical defects at that point are harder to correct4 ,osteopathic treatment applied to the lesions above described without question offers therapeutics of intrinsic value to this class of patients4 ,delirium1 ,confusion and ,stupor ,this clinical group has become well established1 not only in its recognition from the dominant symptoms as indicated above1 but also from rather definite causes4 ,the immediate cause seems to be an abnormal blood state1 or so-called toxemia1 which may result from infectious diseases1 or states of exhaustion1 or autointoxications1 or foreign poisons2 the poison acts as an irritant to the brain4 ,in states of exhaustion so-called 8fatigue bodies0 are formed and are apparently toxic in character4 ,the autointoxicants may have various sources1 such as chronic kidney disease1 or diabetes1 and the like4 ,the most important of the foreign poisons are alcohol and morphine4 ,this morbid group is further characterized not only by a toxic cause and dominant symptom complex of delirium1 or confusion1 or stupor1 but by a similar onset and course4 ,the onset is usually acute and the course somewhat wave like1 gradually reaching a climax and subsiding1 or resulting in death or becoming chronic4 ,to emphasize the clinical symptoms of confusion which is so important the term 8acute confusional insanity0 has often been used1 or 8amentia10 according to the common ,german terminology4 ,hallucinations also play a prominent part1 particularly those of vision2 hence1 another common appellation1 8acute hallucinatory confusion40 ,heredity is mentioned at most as creating a predisposition1 though often the personal and family histories show no such evidence whatsoever4 ,intellectually there is a definite lack of orientation1 the patient is unable to identify himself or his surroundings in time and space4 ,he cannot clearly understand what goes on around him1 that is1 consciousness is 8clouded20 the clouding may be of such extreme degree the patient's mind becomes blank1 due to complete psychic inhibition4 ,this is referred to as stupor4 ,the emotional life plays a secondary role subordinate to the intellectual content4 ,the patient may be greatly excited for example1 resulting from a frightful hallucination4 ,the hallucinations are mainly of the visual type and are almost always present4 ,the patient lives in a perpetual state of sense deception as if he were constantly dreaming2 the hallucinations for the most part are of distressing1 disagreeable or even frightful character4 ,these may give rise to delusions1 which are manifold1 often fantastic and usually transitory4 ,physical changes are always found associated with the disturbed mental status4 ,if it arises during the active stage of an infectious process there is of course the high temperature and all other physical signs of fever4 ,in a certain number of cases with temperature no definite signs can be found indicative of any of the well known fevers1 hence has been called by various names1 such as 8,bell's ,delirium10 8,acute ,mania ,gravis10 or 8,acute ,febrile ,delirium40 ,this ordinarily runs an acute rapid course with very high temperature1 very marked delirium1 followed by stupor and usually death from exhaustion4 ,even though no temperature be present the physical condition reminds one very much of that found in fever diseases4 ,there is the lost appetite1 resulting emaciation and malnutrition1 insomnia1 exhaustion1 etc4 ,osteopathic ,theory4--,while it may be admitted that the various factors mentioned above may take part as exciting or predisposing causes1 it is obvious that in numerous instances mental disorders do not arise whatsoever1 even when the patient is subjected to these factors4 ,there must necessarily be other elements essential to produce the psychosis4 ,the osteopathic theory comes in at this point to fill in and complete the chain of causes and to initiate the onset by the introduction of the idea of nutritional and circulatory disturbances resulting from the spinal lesions4 ,the records of the ,still-,hildreth ,institution show #ah of the toxic type1 in which the poison is derived from without1 who were treated1 with #ag recoveries4 ,there were #be cases connected with the infection and exhaustion group1 with #bj recoveries4 ,remarks by ,dr4 ,hildreth ,in this group we have to do with blood disorders1 resulting from the infections1 conditions producing exhaustion1 and the various toxins1 or poisons1 whether originating within the body or derived from without4 ,these disorders are largely functional in character1 resulting from brain irritation due to the toxemia or disturbance to the centers of nutrition4 ,the main object of the osteopathic treatment1 therefore1 is to aid elimination and regulate and build up the nutrition4 ,in most of the patients the physical lesions are found in the mid-dorsal area1 chiefly from the #dth to the #gth1 and in the cervical region1 the #ast to the #c;d4 ,in aiding the kidneys in elimination the #ajth and #aath dorsal vertebr must be looked after4 ,these conditions commonly respond very rapidly to the treatment and represent one of our most successful groups so far as results are concerned4 ,manic ,depressive ,psychoses ,the psychoses which are brought together under this classification include mental disorders which at first glance would appear to be of very wide variation1 namely1 conditions of maniacal excitement and those of depression4 ,further consideration1 however1 reveals the very evident reasons why they should be united as sub groups under the one head4 ,the fact that these two mental states of seemingly opposite characteristics often appear alternately in the same individual1 that in certain cases of each type there is a wave like feature in the nature of the attack and the frequency with which they tend to recur1 together with other points of similarity in respect to duration1 prognosis1 etc41 tend to point to their very close relationship4 ,kraepelin was the first to draw attention to these facts and advocate the present convenient and widely accepted classification of these disorders4 ,the outstanding feature is the disturbed emotional state which dominates and overshadows all other symptoms and is fundamentally the same whether expressed through the excitement of mania or the depression of melancholia4 ,etiology4--,heredity is considered an important factor4 ,various authorities claim to have demonstrated direct hereditary influences in as many as eighty per cent and more of cases4 ,individual predisposition resolves itself into a matter of constitution and temperament in which there seems to be a greater tendency among those who are subject to the emotional extremes4 ,early adult life is by far its most frequent period of onset1 though it may arise also somewhat later4 ,in certain cases the beginning of the disorder dates from some psychic or emotional shock4 ,just what importance these factors have as causes is little known since other cases develop in which the constitutional element alone seems responsible and no immediate exciting cause can be demonstrated4 ,the osteopathic viewpoint emphasizes the all important influence of spinal lesions as exciting factors4 ,in individuals who have a tendency to this reaction their presence disturbing the cerebral circulation and nutrition may act as the direct causative factor4 ,manic ,phase4--,the manifestation of this condition is brought about by the release of the inhibiting influences which normally govern all psychic function4 ,various terms as hypomania1 acute mania1 delirious mania1 etc41 have been used to differentiate the different degrees in which the symptoms appear4 ,in the milder types we find the following symptoms present4 ,there is a marked feeling of well being4 ,the patient1 having lost sight of his personal limitations1 feels a consequent exalted opinion of himself4 ,his conduct is often rather boisterous1 he talks a great deal1 often swearing and using obscene language4 ,he is inconsiderate of others and tries to impose his will upon those about him4 ,there goes with this a certain unstability of the emotional tone as manifested by the quickly changing feeling of good humor1 irritability and anger4 ,there is a rapid flow of ideas with a marked loss in the ability to concentrate and direct thought4 ,the ideas which pass through the mind do not coordinate themselves toward a definite goal1 but deviate from the course of consecutive thinking by any passing association4 ,again there is a restlessness and activity beyond all normal bounds4 ,the individual feels strong physically and mentally4 ,the appetite is unusually good and if activity is not too extreme there may be a gain in weight4 ,the period of sleep is diminished and the feeling of fatigue is reduced4 ,in the more exaggerated cases the flight of ideas becomes more marked1 the associations are more rapid and superficial and the attention is focused but momentarily4 ,illusions and delusions may be present due to the imperfect preceptions from inability to concentrate attention and from abnormal associations4 ,rhyming speech1 disconnection of phrases and even apparent incoherence are often present4 ,the state of mind may be such that the patient tears his clothing1 breaks up furniture1 jumps1 dances and shouts and often will not take time to eat4 ,the most extreme cases which refuse food over some period of time progress rapidly to exhaustion and measures to conserve strength become imperative4 ,depressive ,phase4--,in this phase of the disorder are encountered manifestations which are in direct contrast to those presented in the manic phase4 ,in place of the exalted emotional state there is a depression4 ,there is a tendency to worry over trivial matters of the daily routine and of instances in past life4 ,introspection is the predominant mental attitude and the whole outer world is colored by the inner feeling of worry and uncertainty4 ,replacing the rapidity of thought in the manic phase there is a distinct slowing of mental processes in the depressive phase4 ,thinking is more difficult and labored1 questions are answered slowly and with an apparent effort and there is usually a tendency to avoid social life4 ,again replacing the excessive activity in mania the depressions show a retarded action4 ,there is disinclination or disability toward any effort either motor or mental4 ,the patient feels weak and incapable of effort1 the body assumes a bent attitude and the facial expression is one of despondency4 ,the appetite is usually impaired with resultant loss of weight1 the bowels are sluggish1 the period of sleep reduced4 ,in the more exaggerated cases the retardation may be complete4 ,introspection is carried to the degree where the patient tries to take unto himself the responsibility for all the sin in the world4 ,he himself is the arch sinner and he feels himself the subject of punishment by divine wrath in a manner in which no other individual was ever punished4 ,also the introspection tends to produce various hypochondriacal ideas4 ,the patient may feel that he has contracted some incurable disease and that certain bodily functions have ceased operating4 ,mental processes become not only retarded and difficult1 but actually painful1 a symptom which has been termed psychalgia4 ,suicidal tendencies are also quite frequently present4 ,in extreme conditions the patient may become so retarded in thought and activity that he apparently receives no stimulus from the outer world4 ,he lives in a more or less stuporous state1 even requiring that food be administered by tube4 ,circular ,insanity and ,mixed ,forms4--,in addition to the conditions in which simply mania or melancholia are manifest there are certain cases which show variations and combinations of these forms4 ,a common type is that in which there is an alternation of the manic and depressed conditions4 ,the patient may pass directly from one state into the other1 or there may be an intervening period of lucidity4 ,the term circular insanity has been applied to this type4 ,other variations are those in which there are recurrences of the manic or depressive attacks often at more or less regular intervals1 each recurrence being a practical repetition of the preceding4 ,there is also possible a considerable intermingling of the characteristics of the two types4 ,in the manias may occur difficulty of thinking1 passing feelings of depression and even almost stuporous conditions4 ,in depressions there can exist a marked degree of restlessness and activity and a rapidity in the flow of ideas4 ,prognosis4--,the outlook for recovery from the individual attack is good4 ,the attack may last from a period of days to one of a number of months and recovery comes with rarely any evidence of mental deterioration4 ,there is a tendency to recurrence of the trouble4 ,in fact recurrence is the rule rather than the exception4 ,in the osteopathic handling of these cases it has been the endeavor to demonstrate that the correction of lesions had a tendency to lessen the duration of the individual attack and reduce the tendency to recurrence4 ,judging from the experience thus far gained in the observation of cases under treatment during the attack and the comparative few recurrences reported both of these aims have been attained4 ,treatment4--,the osteopathic measures are aimed at the correction of the spinal lesions1 especially those located in the upper dorsal and the cervical regions4 ,some reflex effects from lesions in more remote areas may have their influence so that it is wise to look to the correction of any other structural variations when present4 ,remarks by ,dr4 ,hildreth ,the mental disorders of this type are purely functional and may cover a broad scope as to causes2 however1 from the osteopathic viewpoint a great majority of them seem to have as their specific exciting cause1 lesions in the upper dorsal and upper cervical regions4 ,the treatment should be applied specifically to the cause which may range anywhere from the #ast to the #hth dorsal1 or from the #ast to the #c;d cervical1 covering the nutritional and circulatory centers and thus controlling the nutrition and circulation to the brain4 ,there can be no question but what the osteopathic theory of adjustment of physical defects forms the basis of permanent cure1 since many of our recoveries had been previously under other methods of treatment without results4 ,our records cover over #bjj cases with recovery in more than two-thirds1 and very few recurrences up to the present4 ,involutional ,psychosis ,in the mid years of life1 between forty and sixty1 a decline begins1 which in the older years results in decay2 it is especially true at this period of the sexual life and the organs underlying it4 ,while these organs undergo a very definite change constituting the so-called climacteric period in women1 it is not at first sight so evident in men2 however1 the evidence is that a somewhat similar process1 though much slower1 tends to occur in the male4 ,associated with the decay of the sexual organs is a disturbance presumably of the internal secretions2 if this latter disturbance takes place slowly and evenly the body may not notice any marked changes2 on the other hand1 if it takes place more quickly1 or unevenly1 it may give rise to distinct symptoms which indicate a disturbance of the nervous system in general and often even of the mentality4 ,hence1 the significance of the term1 ,involutional ,psychosis4 ,in a large majority of cases the mental disorder is marked by the dominance of depression and is frequently referred to as melancholia4 ,for a long time it was considered that this represented a special mental disorder having little or nothing in common with other psychoses4 ,in recent times ,dumas has studied this group very carefully and shown that it in reality has very much in common with the depressed phases of the ,manic ,depressive ,group of psychoses4 ,kraepelin himself1 who was the first to demonstrate the unity of the ,manic ,depressive ,group1 has accepted the conclusions of ,dumas and incorporated the ,involutional ,depressions as a sub type of his ,manic ,depressive ,psychosis4 ,among etiologic factors have been mentioned hereditary elements1 which have been claimed to have been found in at least fifty per cent of all cases1 forming presumably a predisposition2 it is also stated that a predisposition may be acquired through various debilitating causes4 ,exciting factors are claimed to be present1 such as mental shock1 grief1 worry and the like4 ,the disease would then seem to occur when we have a combination of exciting factors and predisposition4 ,careful consideration will show1 however1 that no such mental disturbance occurs at this age in many people who show evidences of such predisposition and of exciting factors1 therefore it would seem that still other causes were necessary2 if we consider the suggestion above mentioned that there are atrophic processes taking place in the sexual glands leading to a loss of the internal secretions and if we further consider that this may take place unevenly and in an unbalanced way1 thus aiding in giving rise to the symptoms1 we will find a definite point of contact for the osteopathic conception4 ,osteopathically considered1 we may say that the spinal lesions lead to a disturbance of innervation and nutrition to the ductless glands1 and therefore produce disordered secretions in those patients developing the disease1 whereas such a condition may not be present in others who at the same age period do not develop the psychosis4 ,symptomatology ,the emotional tone of depression dominates the picture4 ,associated symptoms are anxiety1 fears1 particularly of impending danger1 the loss of interest in the external world1 with a concentration of attention upon self2 psychic distress is usually present1 often to an extreme degree1 leading apparently to real mental pain1 so-called psychalgia4 ,delusions are usually present and manifold in variety2 they mainly refer to the patient himself and are of a self-accusatory nature2 they frequently refer to notions of sins having been committed1 also unworthiness of the patient1 of poverty1 nihilistic ideas1 either about his own body or external things4 ,he may claim for example that he has no stomach or kidney1 or heart1 that the external world is unreal and the like4 ,his motor reactions become retarded1 or even in the more extreme cases inhibited1 producing a form of stupor4 ,the inefficiency which results along with the psychic pain and distress may determine suicidal tendencies which are very frequent4 ,orientation is usually good1 the patient remaining aware of his own identity and that of his surroundings2 the judgment of course is impaired so that the patient is unable to appreciate the unreality of his delusions2 as a result he sees no hope in the future and on account of present sufferings prefers death to life4 ,the patient may remain in a perfectly passive mood1 giving the appearance of extreme depression1 paying no attention to the surroundings1 possibly mute1 giving no regard to the necessity of the toilet1 paying no attention to his clothing and the like4 ,this may continue for hours or days4 ,food often has to be forced on him1 possibly even by the tube2 the result is usually more or less emaciation and may result in marked malnutrition2 similarly the sleep may be seriously interfered with1 even though the patient is quiet4 ,the resulting loss of sleep and malnutrition sometimes lead to the death of the patient4 ,on the other hand1 the patient may moan and wring his hands in anguish1 walking up and down1 crying out that he is a sinner and that he wants to die and the like4 ,this is the so-called melancholia agitata4 ,the physical symptoms of importance are sleep disturbances1 poor appetite1 with emaciation1 cyanosis1 often a subnormal temperature1 low blood pressure1 slowed heart action and weakened circulation4 ,the hair may become gray1 the skin dry and harsh and indeed any of the signs of senile decay may appear4 ,diagnosis and ,prognosis4--,these depend partly upon the mental symptoms1 partly upon the physical4 ,on the mental side is to be emphasized marked depression1 with the relatively clear orientation1 resembling the depressed phase of ,manic ,depressive insanity2 also the dominance of the self-accusatory delusions4 ,on the physical side the age period1 and the evidence of previous attacks1 even though very slight4 ,the prognosis from the study of the mental symptoms depends on the presence or absence of signs of defect1 or deterioration1 as for example foolish and silly delusions4 ,on the physical side the presence or absence of conditions like kidney or arterial disease2 in general1 it may be said if the physical findings are negative and the mental symptoms show no deterioration there should be a good outlook1 particularly if the condition has not become too chronic4 ,a favorable outlook is always possible if the disease is treated early and the lesions disturbing the activities of the glands and of nutrition and the circulation are corrected and if the other physical findings are negative and signs of deterioration absent4 ,since this is probably only a sub-group of the ,manic ,depressive ,psychoses1 as has been mentioned above1 the results obtained under osteopathic treatment are noted under the ,manic ,depressive group4 ,remarks by ,dr4 ,hildreth ,our experience with this class of cases invariably lead us to the nerve centers which regulate and control the process of nutrition and circulation2 it is a matter of keeping up normal equilibrium of all organic life and especially the circulation to the brain4 ,the basis of the treatment therefore is to be found in the nutritive centers1 as well as those centers which control the circulation to the brain1 the ductless glands1 etc4 ,senile ,dementia ,senile ,dementia may be defined as an abnormal weakening of the mind arising in old age4 ,as the word dementia implies1 the intellectual change is quantitative rather than qualitative1 the prime characteristic of the disease being mental loss rather than mental perversion4 ,it is commonly stated that a most important cause of the disease is the general malnutrition incident to age4 ,since only a small proportion of the aged develop dementia1 this is probably only a cooperating factor4 ,other causes mentioned are overwork1 emotional strain1 traumatisms1 intoxications 7especially alcoholism71 cerebral arteriosclerosis and perhaps heredity4 ,pathologic ,anatomy4--,the disease is organic1 the brain exhibiting definite pathological tissue changes4 ,there is an atrophy of many nerve cells and a proliferation of neuroglia fibers1 so that the cerebrum becomes shrunken and hard1 with thickened meninges and thinned cortex1 and shows a loss of weight4 ,the cerebral arteries may or may not exhibit sclerosis1 thrombosis1 or miliary aneurisms1 with resultant areas of softening4 ,the cells show pigmentary degeneration and many of the association fibers have disappeared4 ,onset4--,the onset of this dementia is usually very gradual1 the condition not being recognized until rather marked4 ,it occurs mainly in the seventies and later and in the late sixties1 being rare before sixty4 ,it often follows financial reverses1 emotional shock1 or various diseases4 ,the earliest symptoms are a change in the person's disposition1 slight disorders of memory1 and trivial lapses of various sorts4 ,as the disease progresses the symptoms become more marked and fundamental1 involving not only the intellectual but also the emotional and volitional phases of consciousness4 ,interest in the outside world begins to flag1 attention to wander1 perception to be incomplete and inaccurate1 association of ideas to be slow1 memory to weaken and judgment to be impaired4 ,memory of the most recent incidents is the first to be lost1 of recent years next1 and then of middle age so that the patient may not recognize his own children or know1 for example1 that his wife is dead2 finally the memory even of youth is lost and the patient is to all intents and purposes a child1 his condition being an exaggeration and aggravation of that commonly known as 8second childhood40 ,several forms of ,senile ,dementia exist1 of which the most common is probably the simple or non-delusional type4 ,other forms are fundamentally the same as the simple1 but with certain superimposed symptoms4 ,fairly early in this type it becomes unsafe for the patient to continue in business4 ,due to impairment of memory and judgment he is apt to lose his property4 ,soon his work is poorly done or neglected entirely4 ,he becomes garrulous and annoys his associates with tiresome repetitions of childish reminiscences1 continually wandering from one subject to another4 ,his speech becomes incoherent and his sentences fragmentary4 ,he grows untidy and indifferent to the ordinary niceties and conventions of life4 ,his appetite is either poor or voracious2 in the latter case the weight may keep up fairly well4 ,he may be either apathetic or turbulent4 ,if the former1 he seems stupid1 indifferent1 and sleepy4 ,he is credulous1 docile1 and very suggestible4 ,patients of the turbulent type are restless and always moving about1 either depressed or elated1 giving unreasonable orders and then contradicting them4 ,sleeping poorly1 they are apt to get up and wander about the house at night4 ,in men1 prostatic disease may cause a recrudescence of sexual feeling4 ,patients of either type eventually become filthy1 soiling their clothing1 etc4 ,even in well advanced cases1 however1 senile dements are often able to perform well certain habitual activities1 such as signing their names1 or playing certain games1 such as checkers or dominoes4 ,confusional ,type4--,another form of ,senile ,dementia1 which may in severe cases usher in the attack1 but which usually1 when present1 is sequent to the simple form1 of which it is a more severe grade1 is the confusional4 ,the additional symptoms of this type are probably due to defective elimination and the consequent toxicity4 ,usually unsystematized delusions1 and sometimes hallucinations are present4 ,except for a possible occasional period of remission the confusion is continuous4 ,it varies greatly in degree1 now being mild and passive and again active1 perhaps developing into delirium4 ,orientation as to both time and place may be lacking4 ,such patients may ask for dinner a few minutes after a meal1 go to bed at noon1 be unable to find their own room1 or to recognize their own children4 ,they are apt to be obstinate and peevish4 ,delusions vary in type but both these and the hallucinations are usually painful and1 being referred to the patient's associates1 give rise to the thought that they are trying to kill or otherwise harm him4 ,delusional ,type4--,a third type of ,senile ,dementia is the paranoid form4 ,dements of this type1 owing to delusions of persecution and auditory hallucinations are sensitive and suspicious4 ,such cases may sometimes show good orientation1 apparently unclouded minds1 and little evidence of senility1 requiring careful study to differentiate the condition from true paranoia4 ,a patient may1 on account of hallucinations of taste and smell1 refuse food in the belief that it is poisoned4 ,members of his family who are devotedly caring for him are suspected of designs on his money1 and this suspicious attitude frequently leads to unjust wills4 ,the delusions and suspicions may be entirely concealed from the family4 ,wealthy paranoid elements are peculiarly apt to become the prey of scheming adventuresses1 particularly in case of the above mentioned sexual recrudescence1 and marry them4 ,opposition of the family is regarded as part of their general persecution or as due merely to their desire to get the estate4 ,some patients merely appear odd1 suspicious1 untidy1 peevish1 and childish4 ,some have expansive delusions and exhibit the euphoria so frequently found in syphilitic dements4 ,senile ,delirium4--,a fourth type has been described by some psychiatrists under the title of senile delirium4 ,this may appear as the initial form of the disease or as an acute attack in one of the above forms4 ,it is characterized by great incoherence and restlessness1 entire absence of orientation1 and numerous rapidly changing delusions and hallucinations1 the condition resembling delirium tremens4 ,it is probably due to some somatic cause1 such as nephritis1 pneumonia1 or cystitis1 which is often fatal4 ,complications may arise in ,senile ,dementia1 such as apoplectic strokes1 hemiplegia1 epileptiform seizures and aphasias4 ,prognosis4--,it is evident from the pathology of the conditions that the prognosis is not at all good when the disease is well advanced4 ,it is a chronic disease and usually progressive until death1 which is due to one of the complications1 malnutrition1 or especially pneumonia4 ,however1 many cases have shown improvement1 and in incipient stages recovery4 ,a cure of advanced cases being impossible1 the important consideration is prevention or arrest in its incipiency4 ,it is evident that this can be done only by preventing1 or removing as far as possible1 the predisposing causes4 ,a glance at the list of these shows that much depends upon the cooperation of the patient by regulating his habits of life4 ,physical and mental overstrain must be avoided1 deleterious habits1 such as the use of intoxicants or narcotics given up4 ,much can be done by osteopathy to eliminate the effects of these upon the organism4 ,cardio-vascular and renal symptoms are very important and should be watched for in order that early treatment may check the process initiated4 ,to this end the patient's habits and diet must be regulated and treatment instituted to relieve toxicity and promote elimination4 ,lesions must be corrected1 special attention being given to the lower dorsal that affect the kidneys1 the upper dorsal that affect blood pressure1 and both the upper cervical and upper dorsal that affect the blood supply and nutrition of the brain4 ,arteriosclerotic ,dementia4--,this is a mental enfeeblement arising sometimes in the fourth1 but chiefly in the fifth1 decade of life1 and associated with symptoms of arterial hardening4 ,the cause is arteriosclerosis1 which may be secondary to some form of nephritis4 ,the arterial hardening may be general or may be confined to the arteries of the cerebrum4 ,it is likely that the arterioles supplying the cortical cells are especially involved in an atheromatous condition4 ,the disease is organic1 chronic and progressive4 ,hemorrhage1 embolism1 or thrombosis may occur1 producing focal lesions and areas of softening1 with hemiplegia1 aphasia1 etc4 ,the earliest symptoms may be headaches and dizziness4 ,the blood pressure is usually found to be high but not invariably4 ,an atheromatosis may be present in some one of the palpable peripheral arteries1 such as the radials4 ,further symptoms on the physical side are quick fatigue1 loss of energy1 numbness and paresthesias of the extremities1 and somnolence in the daytime or perhaps insomnia at night4 ,strokes may occur1 usually slight and temporary1 probably due to spasm in a degenerating artery or perhaps to serous effusion4 ,toxic symptoms appear1 due to disorder in kidneys1 liver1 and other organs4 ,epileptiform seizures are possible4 ,mentally the patient shows impairment of memory1 and perhaps some confusion and hallucinations4 ,rarely stupor occurs4 ,he may be agitated and irritable or melancholy and depressed4 ,suspicious and persecutory ideas of the paranoid type may appear2 also hypochondriacal ideas4 ,osteopathic ,theory4--,in these psychoses of the older years of life the termination is usually dementia1 which means mental enfeeblement1 and which results from degenerative changes in the brain substance4 ,as has been shown it is largely a nutritional question and the nutritional condition varies tremendously in different elderly people2 it is well known that many old people preserve their brain powers fairly well to the end2 on the other hand others fail relatively early1 some even in the fifties2 these cases of earlier failure are referred to as the 8presenile type40 ,the osteopathic conception would be to find out the source productive of the nutritional disorder and correct it at the very outset1 therefore making it quite possible to prevent the disease process from taking place4 ,the prognosis then in the earlier stages is very good4 ,remarks by ,dr4 ,hildreth ,while many cooperating factors may be found in the causation of the mental disorder of elderly people1 our experience shows there is always very definite disturbance of nutrition and the nutritional centers4 ,we find chief physical interference between the #c;d and #hth dorsal vertebr1 most definite as a rule at the #dth1 #eth and #fth1 with the corresponding ribs on the right side4 ,contributing causes may be found in other areas1 associated with the disturbances of the heart and circulation and of the kidney4 ,in the cardio circulatory disorders we find abnormal spinal conditions in the upper dorsal region and especially the #eth rib on the left side4 ,in the kidney disorders we find the lesions usually at the #ajth1 #aath and #abth dorsal4 ,the above mentioned areas in general represent the centers of control of the splanchnic nerves and therefore the important processes of digestion1 metabolism and assimilation4 ,specific treatment applied to these points is very helpful and results in marked improvement and indeed in relieving the patient's symptoms completely when in the earlier stages of the disease4 ,,defective ,,children ,by ,,raymond ,w4 ,,bailey ,it is our purpose here to impress on osteopaths the almost unlimited possibilities in the study and treatment of mental conditions of children1 which heretofore have been considered hopeless4 ,osteopathy has demonstrated that it has much to offer to this class of defectives but the profession has not thoroughly appreciated its great possibilities4 ,it has been the custom to send these children to institutions where they have received care with some attempt toward education but with absolutely no effort being made through physical treatment to overcome their debility4 ,we shall show that the osteopathic lesion is of prime importance in these cases1 and that we have been slow to realize the efficacy of osteopathic treatment for such seemingly hopeless children4 ,we cannot emphasize too strongly the importance of accepting and treating these cases wherever possible4 ,the mental diseases are considered under two general heads3 7#a7 ,inherited1 and 7#b7 ,acquired ,tendencies4 #a4 ,inherited ,tendencies4--,in this class are those cases arising from poor endowment of the protoplasmic structure through lowered vitality of the parents or other progenitors4 ,these taints may come from either parent1 or both1 and may exist in the offspring from some preceding generation4 ,such diseases are constitutional and are amenable to supporting treatment in direct proportion to the amount of endowed energy inherent in any given organism4 ,of the inherited tendencies1 we have two kinds3 #a4 ,congenital ,diseases4 7a7 ,from any influence of an inherited nature not directly acting on the environment of the parent while the fetus is in utero1 and 7b7 ,from any influence which directly affects the development of the ovum through imperfect fertilization coming through either parent or both4 #b4 ,general ,impairment4--,this condition exists 7a7 ,where a similar defect has existed in foregoing generations and is strictly hereditary2 7b7 ,where general vitality is diminished from such causes as neuropathic parents1 or where there have existed constitutional defects1 such as tuberculosis1 syphilis1 epilepsy1 alcoholism1 abuse1 overwork1 strain1 acute inflammatory diseases1 and poor health of the mother during gestation2 also consanguinity4 7c7 ,premature birth tends to impairment physically and mentally of growth of organism and frequently leaves its manifestations of marasmus1 rachitis and other nutritional disturbances4 7d7 ,prolonged labor may leave its mark on the child where more or less asphyxia has occurred resulting in obstruction to cerebral circulation4 ,causes acting after birth to the already impaired germ cell and resulting in many of the afflictions of early life1 both mentally and physically1 are #a4 ,traumatism4 #b4 ,convulsions4 #c4 ,rachitis4 #d4 ,infectious fevers4 #e4 ,meningitis4 ,all of these seriously affect the metabolism within the newly-born1 a process which is begun1 doubtless with difficulty1 and susceptible to easy derangement1 and the same effect magnified with growth into its subsequent mental and physical deformity4 #b4 ,the ,acquired ,tendency4--,in this the second great class are those conditions arising subsequent to conception where germ plasm is healthy but growth is arrested by some external factor either intra- or extra-uterine4 ,thus the acquired tendency may be given to the fetus in utero and not be considered congenital as in case of injury affecting health and growth of otherwise healthy conception4 ,in short1 the acquired has its beginning at conception or subsequent to it while the congenital is previous to conception or already inherent in the germ plasm leading to conception4 ,any influence which retards the #a4 ,inherent capacity of cell for growth or1 #b4 ,adequate blood supply either in quantity or quality results in enfeebled offspring and these causes are enhanced by 7a7 ,traumatism or ,injury 7b7 ,drink or ,abuse 7c7 ,dirt or ,unhygienic surroundings 7d7 ,depravity or ,ignorance ,factors entering into acquired tendencies affecting offspring direct are divided into three classes1 those3 ,i4 ,before ,birth such as 7a7 ,abnormal condition of mother's health during pregnancy as in disease of any nature1 mental or physical or 7b7 ,injury to fetus direct by blow1 fall of parent1 or instrument4 ,,ii4 ,during ,birth from3 7a7 ,abnormal labor from any cause4 7b7 ,primogeniture4 7c7 ,premature birth4 ,,iii4 ,after ,birth4 7a7 ,traumatism4 7b7 ,toxic causes such as scarlet fever1 whooping cough1 meningitis1 measles1 mumps and exanthemata4 7c7 ,convulsions4 7d7 ,nutritional disturbances4 ,consanguinity or intermarrying of blood relations1 or in-breeding results in3 #a4 ,instability of the nervous system4 #b4 ,intensifying of constitutional defects4 #c4 ,decrease in size of offspring4 #d4 ,predisposition to disease through lowered vitality4 #e4 ,impairment of reproductive function4 ,immediate consanguinous offspring may manifest a high degree of intellectual or physical attainment but successive processes tend to neurotic types and are prone to physical weaknesses and insanity4 ,this practice is found among ,quakers and ,jewish peoples1 inhabitants of the ,islands north of ,scotland1 in isolated rural localities1 and among ,african tribes4 ,mental ,deficiency in ,children ,synonyms4--,amentia2 feeble-mindedness4 ,there are three grades of amentia3 #a4 ,morons3 those whose mental age corresponds closely to their chronological age or is nearly normal4 #b4 ,imbeciles3 those in whom there is a wide disparity between the mental age and the chronological age4 #c4 ,idiots3 the lowest form of arrested mentality or those whom it is impossible to teach4 ,definition4--,mental deficiency is a pathological stage in which the mind has failed to attain normal development4 ,various degrees of intelligence or mental capacity in man lie between3 7#a7 ,genius such as ,bacon1 ,newton1 ,plato1 ,galileo1 ,shakespeare4 7#b7 ,lesser ,ability but still conspicuous in development such as our great leaders in science1 literature1 reform and the arts and medicine1 furthering1 each their respective causes4 ,these merge easily into 7#c7 ,average mass of mankind4 7#d7 ,dullards or those of inferior intelligence4 7#e7 ,feeble minded1 merging imperceptibly into 7#f7 ,imbeciles and by insensible gradation into 7#g7 ,idiots and gross idiots4 ,the mentally defective is wholly incapable at maturity of adapting himself to his environment or local conditions in order to maintain existence independent of any external support4 ,dementia is a disease of the mind or that which was once possessed1 and by some neuronic disturbance is lost totally or partially4 ,insanity is a disturbance of neuronic function which may or may not end in degeneration of brain tissue4 ,physiology4--,the normal brain begins its development shortly after fertilization of the germ cell1 by the expansion of the anterior end of the rudimentary spinal cord into four primary cerebral vesicles4 ,these develop into a series of elaborate infoldings1 each with multiple cells around them4 ,at or about the sixth month of fetal life this embryonic brain assumes the shape of the adult brain1 minus the secondary fissures and convolutions which are characteristic of full development4 ,at birth there are sometimes many convolutions and the brain weighs from #bhj to #ccj grams4 ,growth is then rapid and at six months it weighs from #efj to #fhj grams2 ,at one year1 #gej grams4 ,it continues to increase until ,at #ab to #ad years it weighs #aaej grams in the female1 and #acjj in the male2 ,at #bj to #ba years the weight is #abdd grams in the female and #acgd in the male4 ,growth is slow from this time until at #be to #ce years the average weight of the brain is #abfi grams 7#de oz47 in the female1 #adba grams 7#ej oz47 in the male4 ,this growth of the brain is due1 first to the rapid multiplication of nerve cells and1 secondly1 to the individual enlargement of each nerve cell4 ,these cells arise from the floor of the four primary vesicles and are each similar to its fellow4 ,they finally show differences in feature and become characteristic in size and shape which process continues throughout life4 ,this process of differentiation of nerve cells results in the peculiar laminated appearance of the brain cortex4 ,at the period of lamination1 the nerve cells throw out delicate processes which pursue definite directions throughout the brain mass constituting a system of association fibers which link together in a most complicated manner all parts of the brain1 and are called the association fibers of ,flechsig4 ,projections from these cells form the various pathways by which the brain is connected to the various parts of the body4 ,nerve cells in the different parts of the brain mature at different periods1 those areas which have to do with the highest intellectual functions1 viz41 the frontal and parietal regions1 maturing last4 ,at the seventh month of intrauterine life the brain cell is a small round type of neuroblast1 undifferentiated1 lying in a matrix4 ,the cells increase in size until about the second week 7extra-uterine7 of life1 tiny processes begin to develop4 ,at the third to fifth year these cells are mature and possess axons1 dendrons and geminules4 ,these communicate1 forming the above named association system conveying impulses to and from all parts of the cerebrospinal system4 ,they multiply and elaborate after puberty into a complicated system up into middle life after which growth ceases and they slowly diminish4 ,greatest ,growth is between the first appearance of the primitive brain and the end of the sixth month of life 7extra-uterine71 hence it is during this period that any adverse conditions relative to development of nerve cells may cause the greatest damage4 ,mind and ,brain4--,whatever may be the connection between these two1 we know that the former develops with the growth of brain cells and fails with their decay4 ,amentia is associated with the incomplete development of brain cells and ,dementia is coincident with their degeneration and death4 ,pathology--,brain4--,structural abnormality of the brain tissue may exist without variation of mentality or defect4 ,early observers gave these gross defects as a cause for amentia4 ,however1 it has been demonstrated beyond doubt by microscopic examination of cerebral neurosis that cellular changes occur and that imperfect and arrested development exists and is an essential basis of amentia4 ,histology--,blood ,cells4--,cortical blood cells in the ament are #a4 ,numerically fewer4 #b4 ,irregular in arrangement4 #c4 ,imperfectly developed4 #d4 ,microscope reveals changes proportionate to the deficiency during life4 ,blood-vessels in ,amentia show no marked changes from those of the normal brain4 ,hyaline degeneration may be present2 also pigmentation4 ,these conditions are not constant in amentia hence cannot be considered causal4 ,neuroglia in ,amentia4--,sclerosis and hypertrophy occur in a large proportion of cases4 ,this is diffuse throughout the brain1 with here and there certain circumscribed areas forming nodules4 ,nerve ,fibres of ,cortex in ,amentia4--,association system fibres are always diminished in number and not so complicated4 ,clinical ,varieties of ,amentia4--,there are two varieties of amentia and conventionally for sake of study we must arrange them into those from 7#a7 ,congenital causes and 7#b7 acquired causes4 ,among those which arise from congenital causes we have the microcephalous and ,mongolian types4 ,in both cases there exist constitutional taints through successive or immediately forgoing generations of such diseases as syphilis1 tuberculosis1 epilepsy1 and acute alcoholism affecting proper collaboration of germ cells previous to fertilization and hence impaired germinal endowment through a weakened nervous system4 ,those arising from acquired causes are from injury to mother or fetus4 ,macrocephalus4--,a person whose skull measures less than seventeen inches in its greatest circumference4 ,this class comprises less than #aj of all aments4 ,cause4--,the type is neither a freak reversion of the species to a lower grade of development nor accidental1 but due to an inherited blight on the nervous system arising from constitutional disease1 alcoholic and sexual excesses1 consanguinous unions and too numerous latter-life pregnancies in undermined health states4 ,they come entirely from neuropathic stock and their brothers and sisters are degenerates4 ,many dwarfs exhibit this type4 ,characteristics of ,microcephaly4--7#a7 ,circumference of skull diminished2 7#b7 ,brain smaller2 7#c7 ,stature small 7#e feet72 7#d7 ,rarely live to advanced age2 7#e7 ,die of tuberculosis2 7#f7 ,mostly imbeciles and idiots 7few morons74 ,they have their sensory impressions intact and are generally vivacious and muscularly active1 even restless4 ,they have good sight and hearing and are highly initiative but have not the ability to any sustained effort4 ,they are actively observant and the majority are affectionate and well behaved4 ,some are unsteady in walking1 others are helpless1 and about one-half are subject to epileptic fits4 ,mongolian ,amentia 7,mongolism74--,this type 7,kalunk or ,tartar variety7 received its name from ,dr4 ,j4 ,langdon ,down from their facial resemblance to members of the ,mongolian race4 ,they number about #e of all aments including the semi-mongols who have only a few of the characteristics of this type4 ,cause4--,eleven out of twenty-five are from syphilitic origin4 ,glandular or nutritional defects are suggested as a cause4 ,they will show negative ,wassermann test and positive tuberculin tests4 ,uterine exhaustion and ill health of mother during gestation are factors suspected of entering into this condition4 ,the latter-born of large families are frequently affected4 ,pathology of ,mongolian ,idiocy4--,the brain of the ,mongolian ament is considerably under-sized and has less convolutions and is more shallow4 ,the pons1 medulla1 and cerebellum are about half the size of ordinary feeble minded types4 ,the cells by microscopic examination show an immature condition4 ,this lack of brain development results in deficient expansion of base of skull1 hence the characteristic physiognomy4 ,there is no glandular abnormality4 ,description of the ,mongol ,type4--,this type is distinguished by characteristics of skull1 eyes and tongue and is usually observed at birth4 #a4 ,the skull 7,brachycephalous7 is rounded and diminished in size particularly through the antero-posterior diameter4 ,the face is flattened1 there being no recession of frontal and supra-occipital regions4 ,eyes4--,the palpebral fissures are narrow and slope obliquely downward and inward4 ,lids inflamed4 ,tongue protrudes1 is large and marked by large papill and scored by transverse fissures due probably to tongue sucking1 predisposing to inflammation of the mucous membranes4 ,ears are small and round and have poorly developed and irregular lobules4 ,nose is short and flat and has triangular nostrils4 ,teeth are soft and ill formed and tend to decay4 ,hair is usually scanty and wiry and very dry4 ,cheeks are flushed4 ,palate is high and narrow and mouth is open1 and lips are cracked4 ,adenoids exist in all cases4 ,hands and ,feet are broad and clumsy4 ,flat foot and knock-knees are common4 ,skin is rough1 coarse and dry4 ,abdomen is large and mushy4 ,umbilical hernia often present4 ,circulation is rarely good1 causing blueness and coldness of extremities1 with sores and chilblains4 ,heart lesions are frequent4 ,lesions of a chronic inflammatory nature in respiratory and digestive tracts exist4 ,nasal and bronchial catarrh and diarrhea are common4 ,mongols die early 7about #ad years7 usually of phthisis4 ,available statistics show the various types and variations of these conditions in great detail2 however1 the above will enable the reader to classify and properly diagnose in given cases4 ,it is not the writer's intention to portray here what is easily a treatise by itself4 ,osteopathic ,consideration of ,amentia4--,during a period of five years1 observation of the various types has led me to believe that much can be done to correct circulation to cerebral structure with consequent development of brain tissue and function1 where discoverable trauma exists4 ,from all available sources there is traumatic interference in from #ae to #de of these cases1 according to different authors4 ,where history involves constitutional findings 7syphilis1 tubercular1 glandular and chronic alcoholism7 ,i have treated them with the intent of relieving only until the next phase of the condition would appear4 ,where trauma alone exists and the family history is good1 ,i know the case is in the field of osteopathy alone1 and can be developed to a degree limited only by the intelligent care of those having the case in charge4 ,especial attention should be given to discipline1 housing1 sanitation1 personal hygiene and general environment4 ,lesions4--,atlas1 generally rotated4 ,rarely posterior but frequently resting beneath a posterior occiput4 ,lateral mass on the posteriorly resting portion of misplaced atlas will become interlocked with transverse process of axis in a few instances1 combining the amentia with a progressive inflammatory tendency to the middle ear which by successive abscesses ultimately destroys structure and function2 possibly traumatic epilepsy1 and surely catarrhal inflammations in all mucous membranes of the head4 ,many bony and ligamentous irregularities exist in the various types of mental defective where the cause is inherited weakness1 nutritional diseases or kindred sources4 ,spinal luxations exist singly and in series1 causing various palsies1 spastic muscles1 and deformity4 ,postural defects1 particularly of ribs and costal cartilages cause functional disturbance throughout the thorax and abdomen4 ,treatment4--,invariably the care of aments entails wisdom of procedure4 ,reconstruction is the prime object in every instance1 hence time and number of treatments must not be considered4 ,treat to correct structure2 teach as far as possible2 train always4 ,deft and intelligently applied technique are certainly required in the correction of these cervical lesions4 ,treatment should be given thrice weekly 7never less than twice for progress7 with definitely established mental tests before1 to discern the mental level1 and at succeeding periods of three months each1 noting progress1 if any4 ,the ,binet-,simon scale or some other available mental test should always be made and record carefully kept of each case for your own benefit as well as the patient's4 ,after six months1 if no appreciable gain is shown treatment is discontinued and the case must be cared for in another manner as beyond your special field of effort4 ,usually it is apparent by the end of the third month if anything can be done to improve the mentality4 ,the physical advantages1 in some cases warrant continued treatment where there is no appreciable mental gain4 ,institutional care of these types is the only practical means of handling them properly from an osteopathic standpoint1 as it requires some one properly equipped to make your tests and keep your record2--it is sufficient for the doctor to do the work demanded4 ,they can thus be classified and progress systematically shown4 ,the higher grades must be taught and though self dependence may never be attained they can in many cases by training be capable of useful pursuits and quite frequently remunerative work4 ,it makes for happiness at least to keep them busy and forestalls the mischief that would otherwise result4 ,even imbeciles can help in routine work of an institution or home1 and idiots may1 by training1 gain some power of self help and cleanliness4 ,training depends on the individual capacity for such in each case--his habits1 and general character of his propensities4 ,prevention of their marriage should be positive and for prevention of their propagation this and their sterilization by operation are the only two measures at hand4 ,sterilization1 however1 is repugnant to some elements of society and could be abused1 hence the segregation of aments would appear to be our only solution at present4 ,the ultimate intention of treating any case is to use any measure tending to stabilize the nervous system4 ,corrective effort alone is not sufficient but these osteopathic endeavors in conjunction with proper discipline1 good food1 regular rest and personal hygiene both mental and physical and a scrutinizing restriction tending to any kind of excess is rendering the osteopathic procedure in such cases rapidly indispensable for the treatment of amentia4 ,,post-,,operative ,,treatment ,by ,,george ,a4 ,,still ,at the convention of the ,american ,osteopathic ,association held in ,boston in #aiah1 ,i gave a short talk on the above subject1 and during the day after ,i had given the lecture1 two women and one man1 graduate osteopaths1 asked me if ,i really meant to convey the impression that we actually gave osteopathic treatments to recent surgical cases4 ,i do not know whether ,i convinced them or not1 but ,i do know that they convinced me that there are people practicing osteopathy who have absolutely no concept of its merits and underlying principles4 ,to my surprise ,i have found that a great many osteopaths who consider themselves absolutely 8pure0 are just a bit startled at the thought of handling post-operative complications by treatment4 ,these are invariably fellows who have had most of their experience in office work1 and who do not come in contact with acute cases4 ,still it is difficult to conceive how a man can believe that osteopathy is specific for certain diseased conditions and not for others4 ,as a matter of fact osteopathic treatment has not proved itself more satisfactory in any field of therapeutics than it has in post-operative conditions4 ,the common post-operative conditions are pneumonia1 pleurisy1 backache and headache1 nephritis1 vomiting1 neuritis1 phlebitis4 ,taking up these subjects and discussing the least serious first we would of necessity discuss pneumonia last1 as it is the most serious1 and is less influenced by other conditions4 ,it will also serve to illustrate many of the details in treatment4 ,we will therefore briefly take up the other conditions and then discuss pneumonia more fully4 ,vomiting ,we believe there is no question that a good part of the prevention of anesthetic vomiting is in the preparation of the patient1 including a good cleaning out of the bowels without debilitating cathartics4 ,in other words1 the vomiting is increased if the alimentary tract is loaded1 or if on the other hand it has been irritated to the extent of losing its tone4 ,combining a careful preparation with a straight ether anesthesia and osteopathic treatment to the neck and splanchnics we have been able to eliminate any serious post-operative nausea4 ,i do not recall a case in the last few years that vomited on the following day unless the condition for which they were operated was one that essentially in itself would cause vomiting2 for instance if the patient had peritonitis and had been vomiting due to the toxic ileus4 ,they might even vomit after the abdomen had been opened4 ,this could hardly be called 8post-operative0 vomiting4 ,the improvement in our records in post-operative vomiting is in proportion to our increased faith and use of the osteopathic treatment4 ,time and again patients have told us that they had taken anesthetics before and were sick from three to five days and even a week4 ,invariably we have been able to surprise these patients by the fact that they were sick less than a day4 ,the usual treatment with bismuth sub-nitrate1 cerium oxylate1 sour wine and the other usual remedies were not used in any case or in any amount4 ,no drugs whatever were employed4 ,backache and ,headache ,there is practically no difference in the post-operative headache and the office headache4 ,there is of course the usual multiplicity of causes1 and as a matter of fact in this condition treatment can more nearly approach the ordinary office treatment1 and the results are about the same4 ,as for backache1 we find that speed of operating and not keeping the patient under the ether too long has a marked influence4 ,also we have a four inch ,seely mattress on the operating table which helps some4 ,treatment does the rest and does it effectively4 ,for this complication even the ordinary nurse knows enough to give a treatment of some sort4 ,neuritis ,nine times out of ten the post-operative neuritis is really a local osseous lesion1 a slipped innominate1 rib1 vertebra1 clavicle1 biceps tendon or something of the sort1 and responds quickly to a specific treatment4 ,phlebitis ,this complication usually comes on quite late after an operation and at first it is sometimes hard to differentiate it from a neuritis4 ,absolute rest of the involved part with lower spinal treatment gives relief1 but under no circumstances should the affected part be freely moved while there is active inflammation4 ,the reason for treatment of the lower spinal area is that practically always one of the saphenous veins is involved4 ,nephritis ,this complication is to a very big extent eliminated by a careful urinalysis prior to the operation1 and careful preliminary treatment in indicated cases1 and in other cases the postponement or if necessary complete elimination of the operation where it is not a case of life and death4 ,where the condition does appear we have found it the hardest of the post-operative complications to control4 ,indeed it is the only one that we have not found very easy to manage4 ,we do not vary the treatment for a post-operative nephritis from what we would use in any ordinary case of nephritis4 ,we have observed treatment of this condition in many cases under medical management1 and while we are satisfied with the osteopathic treatment comparatively we are not yet satisfied that we have it developed to its greatest efficiency4 ,pleurisy ,this condition in nearly every instance can be corrected with one or two treatments of a twisted rib unless it is the pleurisy of a beginning pneumonia4 ,as far as the pain is concerned the simpler type hurts as much as the one that is going to develop a real complication4 ,for this reason relief obtained by a single treatment often seems little short of miraculous to the patient4 ,pneumonia ,when ,i took charge of the surgical work at ,kirksville1 osteopathy was not used in post-surgical treatment4 ,post-operative vomiting was treated medically1 as were other post-operative conditions1 including pneumonia4 ,cases of a real major surgical nature rarely got an osteopathic treatment4 ,the idea seemed to be that osteopathic post-operative treatment had to be along the same lines as it would be for such an illness as lumbago1 brachial neuritis1 or ordinary pneumonia1 and other non-surgical conditions where the patient could be placed for giving a treatment in a position that was not permissible following an operation1 as it would work great harm to the wound4 ,it seemed to me that if osteopathy was effective in a case of ordinary non-surgical pneumonia1 it should certainly be good for a case of pneumonia that was post-operative and that all we had to do to handle the condition was to apply a new technique of treatment that could be used on a patient who had a surgical wound4 ,all we had to do was to so manipulate the spine that we would get the results locally1 and yet handle it in such a manner as not to affect the wound4 ,many laymen1 and even some physicians of our own school1 express surprise at the suggestion that we do much osteopathic work in the after care of surgical patients4 ,but the fact is we have worked it out so that now1 except for pain1 during the immediate after effects of the operation drugs are absolutely not used in our hospital for any of the post-operative complications4 ,the opiate immediately following the operation1 is really a follow up of the anesthetic1 and we use that as rarely as possible4 ,needless to say1 there are cases such as un-united fractures1 extensive adhesions1 etc41 where the emergency conditions positively call for some relief of the pain for a short while1 but that is the only condition that we cannot control with mechanical treatment4 ,i am very glad that ,i had the confidence to give this an early trial and a thorough trial1 without being afraid to leave off the drugs4 ,the big field1 however1 where osteopathic treatment has won the most impressive success and proved itself a most absolute specific1 is in the field of post-operative pneumonia with which ,i am proud to announce a one hundred per cent4 success for combined osteopathic treatment in my fourteen years continuous surgical work4 ,not to have lost a single case is partly due to luck4 ,in other words1 with any series of serious cases1 it is impossible but that there be some fatality finally4 ,post-operative cases have one advantage along with their disadvantage4 ,while they have the shock of the operation to contend with1 and the weakened condition from the disease for which they were operated1 still except in extreme emergency they would not have been operated on unless they had a good heart and good kidneys and a good blood pressure1 so that in cases in which we are most concerned in combatting pneumonia1 we usually start with a patient who has those organs in a healthy condition4 ,first ,post-operative ,pneumonia ,cases ,treated ,osteopathically4--,at the ,chicago ,convention in #aiaa1 ,i reported the first post-operative pneumonia cases that had been treated osteopathically4 ,i believe at that time that there had been only three cases4 ,at that meeting ,i mentioned the fact that some of the doctors and some of the internes who treated those cases felt sure that they were not treating them properly because they could not get away from the idea that pneumonia needed strychnin and other drugs4 ,one of these cases got well in three days from the developed lobar pneumonia symptoms4 ,the results were so miraculous that the young man treating it began to doubt whether it could have been pneumonia4 ,he could not understand how he1 a senior student1 could overcome this dreaded disease by merely working on the spine4 ,he could not believe that osteopathy1 a science that he had been able to learn himself1 so easily could cure a condition that he had thought must be almost necessarily fatal4 ,one of the weaknesses of osteopathy is the fact that there is no mysticism about it4 ,it is so simple that any person with ordinary intelligence can learn to use it1 and yet it is so simple that it takes an unusual intelligence to be able to grasp the fact that it is the therapeutic discovery of the age4 ,many1 many times ,i have had young internes and students cure genuine lobar pneumonia and do it with such obvious ease that it caused them to wonder1 in a way1 if it really could be pneumonia4 ,it is bred in our very tissues to look for some mysticism1 something impossible to understand1 something supernatural1 something connected with the ,unknown associated with the treatment of disease and accordingly it is just human nature to find it difficult to believe1 even when we see it1 that a simple method of treatment can actually effect a cure4 ,real pneumonia1 as we understand it1 is a consolidation of the lung tissues characterized by fibrosanguinous exudate into the pulmonary tissues and spaces1 associated with one or more particular germs as exciting factors and proved by the physical tests and the character of the expectoration4 ,how many cases have been cured that had not entered consolidation ,i do not know because up until the time of actual consolidation there may be a question as to whether or not they would have had pneumonia4 ,i know that many cases with marked symptoms of pneumonia have failed to develop under treatment or the case has been aborted4 ,pneumonia lacks a great deal of being a self limited disease4 ,the number of cases with beginning symptoms that fail to develop is too great to be ascribed to coincidence4 ,of course ,i know that some of these might have been only pleuritis1 some only neuritis1 etc4 ,however1 in giving the statistics of pneumonia cures we will give only those in which pneumonia developed and showed a hardening or consolidation of the lung tissue4 ,in these cases there can be no argument as to whether there was pneumonia4 ,when we have an acute condition associated with the symptoms of consolidation1 we can hardly be confused as to the diagnosis4 ,we may make a mistake in our physical findings1 but hardly after a little experience1 and certainly when we are sure of the physical findings there will be no trouble in naming the disease4 ,the ,clinical ,findings4--,post-operative pneumonia is a little different from the common pneumonia4 ,it always comes on a little more insidiously4 ,one has to watch for post-operative pneumonia more closely than he would for the attack that we may meet in ordinary practice4 ,a patient may have considerable pain from his wound1 may have some pain in the back from the position he is in2 there may be headache1 and an upset feeling from ether2 and the pain comes in the chest4 ,all these symptoms are forerunners of pneumonia1 but the pain in the chest is not noticed until it gets quite severe4 ,in other words1 there are other things to annoy the patient as well as the attendant1 and at first1 this condition does not cause complaint4 ,a strong and healthy individual who feels a pain in his pleura1 which is the forerunner of pneumonia1 knows it at once1 because that is the only distress he has4 ,his entire attention is attracted and he asks for a physician's help4 ,but in the post-operative case1 the physician has to keep a look out in order to prevent a case from getting well under way before it is recognized4 ,as an example of this ,i had a case of a man who was with a party driving an automobile and they tried to cross the railroad track in front of a train4 ,this patient ,i speak of was one of the survivors4 ,he had a fracture of the femur1 fracture of the skull1 fracture of three ribs1 and otherwise more or less bruised up4 ,naturally the preliminary work consisted in getting the ribs and legs attended to as well as possible and looking out for cerebral hemorrhage or meningitis4 ,this patient developed consolidation in both lungs in spite of regular treatment1 and it precipitated on him very rapidly1 partly masked by the disturbed breathing from other sources of irritation4 ,we put him on hourly treatment1 but after a few hours his condition from the injuries and the pneumonia was such that his wife asked us not to treat him any more4 ,she put it this way1 that she knew he would die in spite of all that could be done and as long as he was going to die he might as well die easy4 ,every time he was treated it had the effect of bringing him out of his stupor1 and he would complain1 and she thought it would be a kind act to let him slide off into the next world uncomplaining4 ,pneumonia in a case of this sort cannot be handled with kid gloves if we wish to save the patient4 ,we must give firm1 strong treatment4 ,light treatment in this condition will do no good4 ,indeed light treatments in any sort of pneumonia are of little avail4 ,many times ,i have changed internes in a pneumonic case that was not responding and the results were immediate4 ,that is1 the turn for the better was obvious from the beginning of the good strong treatment4 ,the case above mentioned was treated a good part of each hour for twelve hours4 ,he had no strychnin1 no oxygen1 nothing but treatments1 but he got well and is now living1 and aside from a limp has no evidence of either his injury or his illness4 ,some cases1 in private practice1 may get well on a treatment a day1 but ,i would hate to handle the kind of cases we get in that manner4 ,i have had severe cases1 especially hemorrhagic cases1 where the treatment was almost continuous for hours preceding the crisis4 ,of course1 after the crisis we can ease up4 ,on the other hand1 it is not infrequent that a few good strong early treatments1 given at the beginning of a case absolutely stop it4 ,i have seen cases where a consolidation area of the apex of the lower right lobe as large as the palm was easily outlined1 and this together with the clinical symptoms would be cleared up in two or three days4 ,there is no possible medical method by which this can be done4 ,medical authorities agree that under their treatment pneumonia runs an unshortened course2 in other words1 a course in the individual case that has not been affected by the medication4 ,medically1 even where the crisis occurs early1 the consolidation persists for some time1 but ,i have seen it cleared up time and again under osteopathic treatment in the length of time that could have been brought about only by osteopathic treatment4 ,i have previously called attention to the fact that many of the medical text books on physical diagnosis mention a point that is a very practical and very plain demonstration of the efficiency of osteopathy in pulmonary conditions4 ,these books only mention this fact without pointing any moral or drawing any conclusions4 ,the point is this3 that frequently when a professor is having a class or a section of a class examining a case of pneumonia1 they will outline the size of the consolidation at the beginning1 the instructor marking it off when he makes the first examination2 then after the students have examined it1 by percussion1 palpation1 etc41 possibly a dozen or twenty of them1 the later students will find that the area has shrunken perhaps an inch4 ,this fact has been frequently noted4 ,it is said1 indeed1 that if careful examination is made it will always be noted4 ,how ,manipulative ,treatment ,benefits ,doubtless this proved that accidental manipulations of the ribs helps clear up the congestion about the real consolidation and reduces some of the dull area4 ,very likely this explains some of the cases of partial or real results from spondylotherapy4 ,naturally1 scientific osteopathic treatment would necessarily magnify such results very much4 ,it is a great wonder with the obvious failure of medical treatment in pneumonia1 that at least some crude from of manipulative treatment has not been devised by those practitioners4 ,we have already mentioned that the treatment of post-operative cases varies mainly in the manner of applying it4 ,in other words1 when we raise the ribs we keep the patient on his back1 in treating the spinal centers we treat with patient on his back1 and the physician who has no grip in his hands will not be able to treat a post-operative pneumonia to any advantage4 ,in these cases one has to get at the patient's back by reaching under and the weight of the patient helps to give the treatment1 but a strong grip is necessary4 ,it is much safer for the wound to handle the patient in this way but not infrequently beginners wear their knuckles pretty nearly off before they get the finer technique2 after which it is easy4 ,in raising the ribs there is no more difficulty in treating in this position than there is with a patient who can sit up or turn from side to side and in some cases a patient can1 of course1 be partially turned4 ,theory is all right but in these cases practice has been added to it in something over three hundred cases treated in this manner1 and in this manner only4 ,i have had no case die4 ,none of my cases had oxygen and none of them had strychnin or alcohol unless it was a person who had used alcohol constantly or daily and in these cases ,i consider that the system has become sufficiently used to it that it is practically a food and that sudden withdrawal is apt to bring on delirium4 ,it is not necessary in those cases that indulge deeply now and then1 but it is advisable in those that take a small amount regularly1 just as they take food4 ,these patients are used to a constant heart stimulant and its withdrawal is also apt to be reflected in the heart action4 ,these are the only cases in which ,i have ever authorized anything in the way of a chemical stimulant of the heart during pneumonia4 ,you will undoubtedly recall that in reading the newspaper accounts of men who are big enough and prominent enough to have bulletins in the newspapers when they are dying1 that almost universally the next to the last bulletin was that oxygen is being administered4 ,the last bulletin announces the time of death4 ,you will also note that in case the patient lives that oxygen then is not mentioned1 and a few days later the patient is all right4 ,my observation is that the use of oxygen may attract the attention of the family1 it may attract the attention of the patient1 but as for any actual benefit on the patient ,i do not believe it is in the least helpful1 and that the only treatment for pneumonia is osteopathic4 ,i am so convinced of it that ,i am using only that method4 ,as to strychnin1 some say strychnin must be given4 ,some say it must be given at the crisis1 and others say it must be given from the inception of the disease4 ,i do not believe the majority of cases will do as well under strychnin4 ,i know they will not do as well under strychnin as under osteopathic treatment4 ,i will not say they will not do as well as if under no treatment4 ,it is possible that there would be an occasion for its use at the crisis1 and ,i have seen such cases1 and ,i have used it while studying medicine4 ,i used it at the crisis1 and ,i used it in cases where ,i am convinced that it helped them over the crisis1 but ,i am also convinced now that by osteopathic treatment they would have done still better and the crisis would not have been so acute4 ,in other words what strychnin does in favorable cases1 osteopathic treatment does better in all cases4 ,in our post-operative cases study the charts and you will see that they do not have the acutely violent crisis that usually occurs under other treatment4 ,they are under better control and if we can get them near the beginning1 as we usually do1 we can keep up the resistance so that where they would otherwise have a hard crisis they have an easy one4 ,instead of having a temperature of #aje1 pulse #afe1 respiration #gj1 or such a condition1 they are more apt to run a temperature of #ajb1 pulse #abj1 respiration #ce or #dj and they go through it without that suddenness and acuteness that is common under other methods of treatment4 ,in several instances1 as an example of showing how this resistance is kept up1 ,i had letters from boys in the camps4 ,one letter told of a wide epidemic of severe tonsillitis4 ,in one group of soldiers there were three osteopaths who treated all the men and this was the only group that was not sent to quarantine4 ,this group developed sore throat and was treated osteopathically and the sore throats checked so that quarantine was unnecessary4 ,among the detailed reports in the ,a4 ,m4 ,a4 ,journal there will be nothing about this1 nor about many other instances where osteopathic treatment1 given by men forced to remain in the ranks1 has done things that medicine cannot do4 ,these examples are too frequent to be coincidents4 ,if ,i had had three cases of post-operative pneumonia and they had all got well1 it would not be surprising4 ,if ,i had ten cases and they all got well1 there are medical hospitals that have been this lucky4 ,but there are no medical hospitals in the world that can report one hundred cases or two hundred cases or three hundred with developed pneumonia and all lived4 ,the percentage of pneumonia cases that die now in medical hospitals1 is much less than formerly4 ,but the cause of this is not vaccine1 antitoxin or drugs4 ,it is due to the fact that pneumonia cases now1 like typhoid1 are given very little medicine and are turned over to general nursing treatment2 that is1 in the best medical hospitals4 ,the mortality is in inverse ratio to the drugs given4 ,the advance medical teaching is against so much drugs in pneumonia1 though of course the hick doctors use it because they are practicing medicine of the by-gone age1 before ,andrew ,taylor ,still forced on the world the idea partly started by homeopathy1 that the less drugs the better4 ,homeopathy failed in not quite discarding drugs and in not having a substitute that reproved drugs4 ,as a matter of interest ,i wish to mention that while in medical college ,i had the advantage of being taught surgery by the greatest surgeon that ever lived1 ,john ,b4 ,murphy4 ,i only wish that circumstances could have permitted me to have shown him what osteopathy could do in post-operative conditions1 because ,murphy was a broad minded man and no man living ever thought less of orthodox medicine and old fashioned drug treatment than ,murphy4 ,he and the ,old ,doctor would have been great friends had they ever met4 ,murphy1 whom ,i considered a most wonderful surgeon1 and whose skill ,i never hope to approach1 stated to me many times while a student that he lost more cases from post-operative pneumonia than any other condition and that in upper abdominal conditions like gall bladder1 stomach1 and similar operations1 post-operative pneumonia constituted the most of his mortality4 ,this great man was afraid of post-operative pneumonia1 while ,i1 a much less skilled surgeon1 am no more afraid of post-operative pneumonia than ,i am of something occurring in a distant state because with osteopathic treatment1 we have eliminated post-operative pneumonia as a fatal condition4 ,,part ,,second ,,infectious ,,diseases ,fever ,fever is due to various causes1 so that a definite statement cannot always be given as to the cause of fever in every disease4 ,each fever case1 like all other disorders1 is a law unto itself2 different causes are found in different cases4 ,moreover1 often only theories1 and not absolute facts1 can be given4 ,fever may be present when a local disease assumes a constitutional character or when the constitutional character is manifested from the beginning of the disease4 ,fever may be a systemic disorder or a symptom of disease1 and is characterized by an increase of body temperature4 ,other symptoms are usually present1 as an accelerated pulse1 disturbances of distribution of the blood1 increased catabolism1 and disordered secretions4 ,etiology4--,in infectious diseases fever is due chiefly to the action of various toxic or harmful agents1 produced by the disease1 upon the fluids of the body and upon the nervous system4 ,disturbances of the thermogenic centers and nerves of the brain or cord by harmful agents1 or by lesions of the anatomical structures affecting these nerves1 are sources of fever4 ,also disturbances of the vasomotor centers 7in the medulla and auxiliary centers along the cord7 and nerves are causes of fever in many instances4 ,a disturbed or lessened function of the nerves controlling sweating is an important factor4 ,the multiplication of micro-organisms in the body1 acting directly on the tissues or by producing toxic substances which affect the nervous system1 is a fruitful source of fever4 ,a few cases may be caused by direct affection of the nervous system1 as is shown by appearance of fever in epileptic attacks1 or by the passage of a catheter into the bladder4 ,in a large number of all cases a demonstrable cause can be found upon careful examination1 whether the fever be due to a necrosed mass of tissue1 the introduction into the system of decomposed food1 infectious diseases1 a lesion of some anatomical structure affecting a thermogenic1 vasomotor or sweat center1 a lesion to the innervation to the heart 7vagi and cervical sympathetic7 causing a rapid heart1 or a lesion to the lymphatic system4 ,treatment4--,the treatment of fevers in a general way consists principally of thorough inhibition to the posterior spinal nerves of the upper cervical region in order that the center of the vasomotor system in the medulla may be affected1 probably by the way of the superior cervical ganglion of the sympathetic4 ,thus the entire vascular system is equalized1 for there is always a disturbance in the distribution of the blood in fever and if the center controlling the nerves that govern the lumen of the blood-vessels can be brought under control1 there will result an equalization of the vascular system2 if such occurs1 health must ensue4 ,besides the vasomotor nerves to the blood-vessels being affected by this treatment1 the nerves governing the lymphatics and the sweat glands will also be controlled4 ,the sweat glands as a rule are rendered active by affecting directly the innervation of the glands1 also the glands are controlled indirectly by the blood supply2 this aids materially in lessening the temperature of the body4 ,treatment for a few minutes to the upper posterior cervical region would also affect the thermogenic centers and nerves of the brain reflexly in the same manner as the vasomotor and sweat centers and nerves are affected1 thus tending to equalize the mechanism of the thermogenic system4 ,besides this action on the vasomotor1 sweat1 and the thermogenic nerves1 there is produced an increased exhalation of moisture from the lungs1 on account of an increase of vascular area in the lungs through vasomotor action4 ,also the large vascular area in the abdomen1 under control of the splanchnic nerves1 becomes constricted4 ,thus there is brought about a lessening temperature by evaporation1 heat radiation1 and perspiration2 and an increased action of the general nervous system1 a stronger cardiac force1 an equalization of the vascular system1 and a more perfect elimination of toxic properties by the skin1 kidneys and lungs2 consequently a reduction of the fever4 ,the foregoing treatment is successful to a limited extent1 only in such cases where causative factors of the fever are involving the predominating centers controlling the heat production or dispersion and the vasomotor system directly2 for if the lesion that is causing the disorder should be affecting an auxiliary center along the spinal cord instead of the predominating center1 as is oftentimes the case1 treatment of the predominating center would be useless as far as any permanent benefit is considered2 although a temporary effect will be gained by lessening the fever at that point4 ,consequently1 in many cases1 the lesion lies within the jurisdiction of auxiliary centers which are situated at various points along the spinal cord4 ,when such is the case1 it will be of little benefit to give the cervical treatment4 ,in such instances the lesion to the auxiliary center would have to be removed in order to cure4 ,one cannot depend upon a set rule to reduce a fever2 determine the cause1 as in any other disease or symptom1 and remove it4 ,in addition to the treatment to the cervical region and along the spinal column1 as are indicated upon an examination1 attention should be given to the heart's action4 ,the equilibrium between the accelerator and inhibitory nerves 7cervical sympathetic and vagi7 should be maintained4 ,the interchange of gases in the lungs should be rendered as nearly normal as possible2 this is best accomplished by raising and spreading of the ribs from the second to the seventh dorsals1 particularly in the region of the fifth and sixth4 ,also stimulation of the vagi will aid by increasing the motor power of the lungs4 ,the kidneys and bowels should be kept active so as to favor a rapid elimination of various toxic properties2 besides they have control over large vascular areas4 ,treatment over the ureters will prevent any clogging that might occur in them from a condensation of the urine4 ,attention1 also1 should be given the tissues at the fifth lumbar and over the iliac vessels to influence the circulation in the pelvis4 ,the food of the patient should be liquid--milk1 soup1 broths1 etc41 and almost any quantity of water allowed if called for1 given little at a time and at frequent intervals4 ,the room should be well lighted1 ventilated1 clean and kept at an even temperature4 ,two points should always be remembered relative to fever3 ,first--,that there are many causes of fever2 and in order to reduce the fever the cause must be determined and removed1 the same as in any disorder4 ,a definite fever treatment cannot be given any more than a definite constipation treatment2 the case must be seen in order to determine the cause4 ,second--,the reduction of fever is not necessary2 the fever should be treated only as a symptom of disease when it exists as such4 ,in fact1 fever is beneficial1 for it is one of nature's methods to relieve an over-burdened system from harmful agents1 unless the temperature is excessive and continuous and is likely to cause more harm than the primary trouble4 ,absolute rest in bed always is of decided benefit in lessening the temperature4 ,hydrotherapy is of immense value in reducing a fever4 ,it is an agent that has been greatly used1 and if applied intelligently cannot but be of aid4 ,there is much ignorance in regard to the principles and practice of hydrotherapy1 not only among all classes of people1 but among well informed practitioners in medicine4 ,the most important function of the skin is as a heat regulator4 ,knowing this fact1 the osteopath treats the vasomotor nerves that control the cutaneous circulation and the nerves that control the excretion of the skin2 the nerve supply being from the cerebrospinal and sympathetic nerves4 ,in many difficult and obstinate cases hydrotherapeutic measures should be used to aid the skin in regulating the temperature1 as well as to enhance system functions for the same reason that osteopathic manipulations are given4 ,maintaining an equilibrium in heat production and heat dispersion is necessary in order that the standard of the body temperature may be kept2 and the amount of the arterial blood circulating within a tissue determines its temperature4 ,the principal effect of water as a thermic agent when applied externally is due to the influence of the action of the water upon the cutaneous circulation4 ,lesser effects would be the mere extraction of heat from the body by evaporation and the equalization of temperatures of two bodies coming into contact4 ,as the body is endowed with compensatory powers1 this latter means would apply only to a limited extent4 ,the temperature of the water used is important1 as the colder the bath the less effective would its power be in reducing internal temperature4 ,when a cold bath is used there is a driving of the blood away from the surface on account of the contraction of the peripheral vessels2 consequently increasing the cutaneous circulation and cooling by radiation is prevented and less heat is lost4 ,a collateral hyperemia occurs in the underlying parts which acts as a protection to the deeper tissues4 ,the cold also inhibits the vasomotor nerves controlling the abdominal splanchnics1 and thus a larger amount of blood passes to this immense vascular area4 ,on the other hand1 when a warmer bath is used the effect is opposite1 and a lowering of the temperature is the result4 ,the cutaneous vessels being dilated1 the superficial blood is rapidly replaced by blood from the deeper vessels1 thus allowing a cooling of the body to a large degree4 ,in the various fevers where hydrotherapeutic measures are employed1 the object to be gained by such methods is not primarily an anti-thermic one but an anti-febrile reaction2 consequently the use of cold water is employed4 ,in mere heat reduction the warmer water would be more effective2 but by the aid of the colder water the cause of the increased temperature1 as in infectious fevers1 is lessened2 besides a refreshing and stimulating effect upon the entire system is gained4 ,thus the aim of the cold bath and friction1 is not primarily to subdue the temperature by heat radiation or evaporation1 but to correct disturbances governing the formation and the dissipation of heat caused by infectious fevers1 and1 moreover1 to stimulate the nervous system1 prevent heart failure1 increase the eliminating power of the skin1 kidneys and lungs1 and to influence the corpuscular and chemical constituents of the blood to a more normal condition4 ,the full cold bath and friction 7,brand ,method7 is commonly employed in infectious fevers4 ,the half bath1 wet pack1 or sponging may be used4 ,the modus operandi of each is given under the hydrotherapeutic treatment of typhoid fever4 ,typhoid ,fever 7,,enteric ,,fever7 ,in writing of these acute diseases which are self-limiting1 it is understood that osteopathy aborts1 overcomes symptoms and otherwise changes conditions frequently4 ,when this occurs the case is not typical and it is a typical case which is here described4 ,definition4--,an acute1 infectious disease caused by the bacillus typhosus4 ,it is characterized anatomically by hyperplasia and definite lesions of ,peyer's patches and mesenteric glands1 and enlargement of the spleen1 and clinically by its slow onset1 often diarrhea1 abdominal tenderness1 tympanites1 fever1 headache1 and rose colored spots on the abdomen4 ,osteopathic ,etiology and ,pathology4--,lesions to the lower dorsal and lumbar regions are always found1 which impair the innervation and vascular supply of the intestines and cause defective nutrition4 ,this is the most important predisposing cause1 although general lowered vitality from overwork1 improper food1 unhygienic environment1 and insanitary surroundings1 are also of great importance4 ,it is possible that one's vitality may be so lowered that the bacillus of ,eberth1 if of sufficient numbers or virulency1 will find a suitable medium wherein to multiply and grow1 and thus the spinal lesions found in these cases are the result of reflex irritation4 ,but the most probable underlying cause is the spinal lesion1 and given two individuals with equal likelihood to infection1 one with the spinal lesions and the other not1 the former within all probability will be the more likely to suffer an attack4 ,the severity and extent of the osteopathic lesion undoubtedly bears a direct ratio to the probability of attack from an infectious disease4 ,typhoid fever usually occurs between the ages of fifteen and thirty years4 ,some families are more susceptible than others4 ,the autumn months1 especially after a dry1 hot summer1 favor the disease4 ,one may be reasonably certain that whenever there is a case of typhoid the individual has not been careful as to diet1 or drinking water1 or some rule of health1 and wherever there is an epidemic it can always be traced to insanitary surroundings1 the water supply1 contaminated garden truck or other food1 sewage1 etc42 although this does not preclude the probability that the osteopathic lesion or lowered vitality of ,peyer's patches and mesenteric glands from other causes are important and many times primal etiological factors4 ,the specific poison may be so virulent that practically no one escapes and again those of lowered vitality only will succumb to an attack4 ,the exciting cause is a special micro-organism1 the bacillus of ,eberth4 ,the contagion may be carried through the air from one person to another1 but this is rarely the case4 ,though the water is the most common mode of conveyance1 the bacillus has been found during epidemics in both water and milk4 ,the water may be contaminated by the intestinal discharges which have not been properly disinfected4 ,extreme cold does not destroy the typhoid germs4 ,milk may be infected from the milk-can being washed with the contaminated water or the unclean hands of the milker4 ,in fresh milk the germs multiply rapidly4 ,salads1 celery1 ice and fruits may be contaminated4 ,oysters have become infected while being fattened or freshened4 ,it is thought by some that the poison is not eliminated from the sick in a condition capable of transferring disease to a healthy person1 but must undergo changes in the soil before it is able to cause the disease in another4 ,typhoid fever may be caused1 however1 by direct contact with the stools4 ,filth1 sewers1 or cesspools do not directly cause the disease1 but they form a suitable medium for the preservation of the typhoid germs4 ,pathologically1 the characteristic lesions in typhoid fever consist of changes in the lymphoid elements of the bowels4 ,these changes are most striking in the solitary glands and ,peyer's patches4 ,the alterations which occur may be divided into four well defined stages3 7#a7 ,infiltration--the glands are enlarged from infiltration and there is marked cell proliferation1 particularly ,peyer's glands in the jejunum and ileum and to a lesser extent those in the large intestine4 ,the glands become pale and prominent4 ,occasionally the solitary glands1 which are usually deeply imbedded in the submucosa1 become prominent also4 ,microscopically1 the capillary blood-vessels are at first considerably dilated1 but later become more or less contracted1 giving an anemic appearance to the follicles4 ,the adjacent mucosa and muscularis may become infiltrated4 ,the cells have the character of lymph corpuscles1 some of which are larger1 epithelioid in character1 containing several nuclei4 ,from the eighth to the tenth day this medullary infiltration reaches its height and then undergoes either resolution or necrosis4 7#a7 ,resolution takes place by a granular or fatty infiltration of the cells4 ,this produces pitting of the swollen follicles1 which may cause small hemorrhages4 7#b7 ,necrosis4--,with all the severe cases of cell infiltration1 hyperplasia of lymph follicles reaches a stage where resolution is impossible and necrosis occurs4 ,the necrosis is partly due to the choking of the blood-vessels and partly to the direct action of the bacilli4 ,the necrosis may involve only the superficial layers of the mucosa or it may extend deep into the muscular coat and even perforate the outer or serous coat4 ,usually1 however1 this does not extend below the submucosa1 mucosa1 or muscularis4 ,not all of the patches necessarily slough1 but as a rule it is always more intense toward the ilio-cecal valve4 7#c7 ,ulceration4--,the extent and depth of the ulcers depend upon the amount of the necrosis4 ,large ulcers are sometimes formed1 especially in the lower end of the bowel1 by the union of several4 ,the edges are swollen and undermined4 ,the base is usually smooth and formed of submucosa4 ,perforation of the bowel occurs in a small percentage of cases2 more commonly the ulcers heal4 ,the perforations may be multiple1 but rarely exceed two in number4 7#d7 ,healing4--,cicatrization begins about the fourth week4 ,this granulation tissue covers the floor4 ,it is sometimes formed with connective tissue and a new growth of epithelium results4 ,the gland is ultimately replaced by a depressed scar with a smooth1 pigmented surface4 ,the majority of deaths occur before this stage is reached4 ,the gland structure is never regenerated4 ,the mesenteric glands show intense hyperemia and later become enlarged and softened1 but rarely ruptured4 ,the glands at the lower end of the ileum are markedly involved4 ,the spleen is enlarged1 softened1 and diffluent4 ,occasionally rupture occurs4 ,infarction is not a rare occurrence4 ,the liver shows parenchymatous and granular degeneration1 and the cells are found to contain much fat4 ,infarction abscesses and acute yellow atrophy occur in rare instances4 ,diphtheritic inflammation of the gall-bladder sometimes occurs and the bile is thinner and paler than normal4 ,the kidneys also show parenchymatous degeneration4 ,they are pale in appearance1 with slight cloudy swelling4 ,microscopically1 there are seen granular and fatty infiltration of the cells of the convoluted tubules4 ,rarely1 there is acute nephritis which may be hemorrhagic4 ,there may be miliary abscesses in which typhoid bacilli have been found by some observers4 ,diphtheritic1 but more frequently catarrhal1 inflammation of the pelvis of the kidney may occur4 ,catarrh of the bladder is not infrequent and even sometimes diphtheritic inflammation is present4 ,rarely orchitis is encountered4 ,hypostatic congestion of the lungs is not uncommon4 ,gangrene and hemorrhagic infarction are sometimes present4 ,lobar pneumonia may be a complication4 ,in the larynx ulceration is sometimes met with bacilli1 however1 have not yet been found in these ulcers4 ,diphtheritis of the pharynx and larynx may occur4 ,catarrhal or croupous pharyngitis may occur2 while swelling of the follicles of the pharynx and base of the tongue is frequently noticed4 ,peritonitis is always present in fatal cases in which perforation of the bowel has taken place4 ,the perforation may occur in ulcers from which the sloughs have already separated1 or it may be caused by a necrosis of all the coats4 ,extensive peritonitis may occur without perforation1 and is probably due to extension of the inflammation to the peritoneum4 ,the heart may be affected4 ,endocarditis is rare1 while pericarditis is much more frequent4 ,myocarditis is frequently met with1 the cardiac muscles presenting parenchymatous and rarely hyaline degeneration4 ,the arteries are frequently found to be involved4 ,these conditions 7obliterating arteritis and partial arteritis7 may affect the smaller vessels1 especially those of the heart1 but more commonly affect the arteries of the lower extremities4 ,thrombosis of the veins1 especially of the femoral1 and more rarely of the cerebral veins and sinuses1 occurs4 ,granular and hyaline changes in the voluntary muscles may occur4 ,this degeneration does not affect the whole muscle but involves only certain fibres4 ,regeneration takes place during convalescence4 ,with the nervous system meningitis is rare4 ,the peripheral nerves are frequently the seat of parenchymatous changes4 ,the ganglia of the trunks of the vagi present an inflammatory change4 ,the blood presents little change4 ,during the first two weeks the red corpuscles gradually decrease in number until the first week of convalescence1 after which they gradually increase in number4 ,there is often a marked decrease in the number of leucocytes4 ,leucocytosis is absent4 ,the hemoglobin is always reduced4 ,symptoms and ,course4--,the incubation period varies from a few days to two weeks or longer4 ,during this time the patient may feel in his usual health1 but more often there is a feeling of languor and indisposition to exertion1 loss of appetite1 slight coating of the tongue1 nausea1 headache1 chilliness1 but seldom a decided rigor1 pains in the back or legs and nose-bleeding4 ,any of these symptoms may be present and last usually from a few days to a week or more4 ,these symptoms increase in severity and the patient takes to his bed4 ,the invasion as a rule is gradual4 ,the first week dates from the onset of the fever which generally 7but by no means in all cases7 rises steadily during the first week a degree or a degree and one-half each day1 reaching #ajc or #ajd degrees ,f4 ,the pulse is quickened to #ij to #aaj per minute and is full1 of low tension and sometimes dicrotic4 ,there is great thirst1 also a coated tongue4 ,the skin is hot and dry and there is rather intense headache4 ,unless the fever is high there is no delirium4 ,the sleep is disturbed and there may be mental confusion and wandering4 ,cough with some thoracic oppression is not uncommon at the onset4 ,the abdomen is slightly distended and tender4 ,there may be either constipation or diarrhea4 ,the spleen is somewhat swollen and a rose colored rash appears on the skin of the abdomen and chest4 ,during the second week the fever remains high and exhibits the continued type1 the morning remission being slight4 ,the pulse is accelerated4 ,the headache disappears1 but there is marked mental dullness and slowness and there may be a mild delirium at night4 ,the tongue is coated and the lips are dry4 ,the abdomen is tympanitic and tender4 ,diarrhea replaces constipation4 ,the case may prove fatal during this week from the result of nervous or pulmonary symptoms1 hemorrhage1 or perforation4 ,the fever changes in the third week from a continuous to a remittent type4 ,the pulse ranges from #aaj to #acj4 ,the patient is very weak4 ,complications may arise1 as pulmonary symptoms1 feebleness of heart1 intestinal hemorrhage1 perforation1 and peritonitis4 ,in favorable cases during the fourth week the fever begins to decline and the general and local symptoms gradually disappear4 ,in protracted cases the fourth and fifth weeks may present the symptoms of the third week4 ,frequently the following aggravated symptoms are added3 stupor1 delirium1 increased weakness1 rapid1 feeble pulse1 and distended abdomen4 ,heart failure and inflammatory complications increase the danger4 ,during the fifth and sixth weeks a few cases will show irregular fever4 ,great care should be taken that complications do not occur4 ,the fever is the most important and characteristic symptom and from the temperature alone a diagnosis may be made4 ,during these stages of development1 which is the first four or five days1 the temperature rises steadily2 the evening temperature being about a degree or a degree and one-half higher than the morning remissions1 reaching #ajd or #aje degrees ,f4 at the end of the first week4 ,when the fastigium is reached the fever persists with slight morning remissions4 ,at the end of the second and throughout the third week the temperature becomes more remittent and there may be a difference of three or four degrees between the morning and evening temperature4 ,during the last stage the fever falls by lysis1 forming a more or less regular step-like line of descent4 ,the stage lasts from one week to ten days4 ,when the disease sets in with a severe rigor the fever frequently rises at once to #ajc or #ajd degrees ,f4 ,in the lightest forms the fastigium may be almost absent2 defervescence setting in upon the first day of the fastigium and in many cases defervescence occurs at the end of the second week and the temperature may fall rapidly1 becoming normal in ten or twenty hours4 ,this fall in the temperature may take place without any apparent cause or it may follow an intestinal hemorrhage4 ,the temperature often falls many hours before the blood appears in the evacuations4 ,the occurrence of peritonitis is also marked by a sudden fall in the temperature4 ,hyperpyrexia in typhoid fever is not very common except just before death4 ,after the temperature has been normal for several days there may be a sudden rise of the temperature to #ajb or #ajc degrees ,f4 ,this may persist for a couple of days and then return rapidly to the normal4 ,these recrudescences1 as they are called1 are quite common and are caused most frequently by errors in the diet1 constipation1 excitement or mental emotion4 ,these elevations in the temperature are found most frequently in children and persons of a nervous temperament4 ,afebrile ,typhoid is of very rare occurrence4 ,the patient has all the characteristic symptoms of typhoid fever with the exception of a fever4 ,the rash is highly characteristic4 ,it appears about the eighth or tenth day1 usually upon the skin of the abdomen or chest1 rarely found elsewhere on the body4 ,it consists of a variable number of rose colored spots distinctly elevated1 and disappear on pressure4 ,these spots last three or four days and appear in successive crops4 ,vivid red erythematous eruptions upon the chest and abdomen are commonly seen during the first week of typhoid fever4 ,urticaria is rarely seen4 ,sweating characterizes some cases of typhoid fever1 but generally the skin is dry4 ,this may occur with or without chilly sensations or actual rigors4 ,in some cases there may be recurring paroxysms of chills1 fever1 and sweats and they may be mistaken for intermittent fever4 ,edema of the skin may occur and is usually due to anemia or cachexia and sometimes to nephritis4 ,local edema may occur as the result of vascular obstruction1 particularly thrombosis of the femoral vein4 ,there is a peculiar musty odor exhaled from the skin in typhoid fever1 particularly if the skin has been neglected4 ,in all protracted cases bed-sores are likely to develop4 ,the hair is apt to fall out but is generally renewed4 ,the nails also suffer and ridges can usually be observed upon them4 ,intestinal symptoms are very inconstant4 ,usually there is constipation at the onset and this may persist throughout the disease although a moderate diarrhea may occur throughout the disease4 ,the severity of the diarrhea is due most probably to the degree of the catarrh rather than to the extent of the ulcers4 ,it is probable that the discharges are more frequent when the catarrh involves the large intestine4 ,the number of discharges average1 as a rule1 from two to four or more daily4 ,the stools are either fluid or of the consistency of jelly1 of a grayish-yellow color1 alkaline in reaction and are very offensive4 ,hemorrhage is a serious symptom1 but by no means always fatal4 ,this usually occurs in cases of considerable severity and it generally occurs at the time of the separation of the sloughs during the third week4 ,when it occurs quite early in the disease it is generally the result of hyperemia4 ,it may be so slight as not to be noticed by the eye or it may be from one to three pints4 ,intestinal hemorrhage1 however slight1 is always a grave symptom4 ,there may be symptoms of collapse and fall of temperature1 or it may occur without any symptoms4 ,meteorism is an almost constant symptom1 and when excessive adds to the seriousness of the case and corresponds generally with the extent of local lesions4 ,abdominal tenderness and gurgling upon pressure in the right iliac fossa may be present2 pain is generally absent1 and when present is usually slight4 ,perforation almost invariably causes fatal diffuse peritonitis and is the most serious complication4 ,it may occur at any time but is most common between the second and fourth weeks4 ,it is usually indicated by sudden acute pains in the abdomen and symptoms of collapse4 ,as a rule symptoms of peritonitis appear at once2 distension of the abdomen1 great tenderness1 and rigid abdominal walls4 ,vomiting1 pinched features1 and rapid1 small pulse shows general collapse of the circulatory system4 ,bronchitis is almost invariably present as an initial symptom4 ,it is indicated by the existence of sibilant rales4 ,the cough is generally slight4 ,hypostatic congestion of the lungs and edema1 due to enfeeblement of the cardio-pulmonary circulation1 in the latter part of the disease are not infrequent4 ,the pulse as a rule is not very frequent and is generally not in proportion to the fever until late in the disease2 #ij to #abj is the usual range4 ,during the first week it is about #ajj1 full1 and frequently dicrotic2 later it becomes more rapid1 feeble and small4 ,in severe cases during the extreme debility of the third week the pulse may reach #aej or more 7the so-called running pulse74 ,during convalescence the pulse occasionally becomes subnormal and bradycardia is met with more frequently than after any other acute fever4 ,the blood presents definite changes1 some of which are important4 ,in cases where there is profuse sweating or copious diarrhea1 the red corpuscles may be relatively increased2 this is due to the loss of water4 ,in most cases there is little change until the end of the second week4 ,during the third week there is generally a decrease in the number of corpuscles and of the hemoglobin1 which is always reduced4 ,leucocytosis is always absent4 ,the white corpuscles are slightly diminished especially toward the end of convalescence4 ,during the first week there is generally persistent headache1 sometimes neuralgia4 ,there are a few cases in which the effects of the typhoid bacilli or their poison is manifested in the nervous system from the very onset4 ,there are violent headaches1 retraction of the head1 rigidity1 photophobia1 twitching of the muscles1 rarely convulsions1 all indicating meningitis as which it is occasionally diagnosed4 ,it must be remembered however1 that all nervous symptoms may occur independently of a lesion of the nervous system4 ,delirium may exist from the onset1 but it usually is not present until the second or third week and only in the severer cases4 ,as a rule it is most marked at night4 ,it is generally of the low1 muttering type1 very seldom maniacal4 ,when the patient picks at the bed clothes or grasps at imaginary objects there is indication of danger1 as it is a serious symptom4 ,convulsions are rare4 ,the urine is diminished in quantity1 high specific gravity1 and of dark hue4 ,both urea and uric acid are increased and the chlorids are diminished during the first stages4 ,about the stage of decline the urine becomes light in color and greater in quantity than normal4 ,the specific gravity is lowered1 urea and uric acid are diminished1 and the chlorids are increased4 ,febrile albuminuria is very common but of no special significance4 ,acute nephritis may develop as a complication4 ,pyuria is not an uncommon complication and post-typhoid pyelitis may also develop4 ,malarial fever may be associated with typhoid1 especially in malarial districts4 ,persons with tuberculosis1 epilepsy1 chorea1 and other forms of chronic nervous diseases are liable to typhoid fever4 ,in epilepsy and chorea the movements and fits usually cease during the attack of typhoid fever4 ,varieties of ,typhoid are numerous and are named with reference to the degree of severity which varies from extreme mildness to extreme severity4 ,the mild or abortive form is of frequent occurrence4 ,the onset is usually sudden4 ,the symptoms are similar to those of a typical case but much milder and appear earlier than in the usual type4 ,this form runs its course in about two weeks4 ,the fever usually reaches #ajd degrees ,f4 ,in the severe or grave form there is high fever and the nervous symptoms show a profound intoxication of the system4 ,the grave types are those associated with serious complications or those cases which set in with pneumonia1 ,bright's disease1 or cerebrospinal symptoms4 ,in the latent or ambulatory form 7walking typhoid7 the symptoms are very slight1 the patient being hardly sick enough to go to bed4 ,the symptoms may be of this character throughout the attack1 and the patient may be able to be up and about4 ,in other cases the first symptoms are very mild1 but later they may develop symptoms of the severest type4 ,the ,afebrile form is rare4 ,hemorrhagic typhoid is a very fatal but rare form4 ,in this type there are cutaneous and mucous hemorrhages4 ,diagnosis4--,as a general rule typhoid fever is easily recognized4 ,the ,widal test should be made4 ,at times the diagnosis may have to be delayed until the distinctive signs appear1 especially in those cases which come on with severe headache1 delirium1 twitching of the muscles1 and retraction of the head4 ,in these cases the diagnosis of cerebrospinal meningitis is invariably made1 until the appearance of the colored spots on the abdomen1 which must decide the diagnosis2 cerebrospinal meningitis being a rare disease and typhoid fever with severe nervous symptoms quite frequent1 it is more probable that it is typhoid4 ,at least one-half of the cases termed brain fever belong to this class of nervous typhoid4 ,prognosis4--,a positive prognosis can not be made1 as even the mildest cases are liable to have severe complications develop at any stage of the disease4 ,under osteopathic treatment the prognosis is undoubtedly more favorable than with the treatment of the older schools4 ,if the osteopath can see the case early1 the first week1 there is always a chance to abort the attack4 ,in all cases there is the probability that the attack will be shortened2 this is a common experience4 ,price of ,mississippi1 has treated many cases1 and invariably when the patient is seen early the attack has been shortened to thirteen or fourteen days1 whereas under other treatment the disease runs the usual course4 ,adsit of ,kentucky1 ,white of ,new ,york1 and the staff of the ,american ,school of ,osteopathy 7,kirksville71 as well as many others1 have had the same experience4 ,and if the attack cannot be aborted or shortened there is the further probability that the severity will be lessened and complications prevented4 ,the prognosis is always more favorable in winter than in summer1 and especially favorable in children4 ,more women die than men1 and fat persons stand the disease badly4 ,treatment4--,typhoid fever is one of the diseases that practitioners of all the schools are agreed that drug therapeutics avail but little in its treatment4 ,the treatment of the older schools consists of prophylaxis1 good nursing1 attention to hygienic principles1 dieting1 and hydrotherapy4 ,all of these have their places and are recognized by the osteopathic school4 ,but the above methods are of the defensive only--allowing the disease to run its usual course and reducing the likelihood of complications4 ,on the other hand the above treatment coupled with osteopathy1 not only attacks the ravages of the disease defensively1 but of more importance1 the disorder is attacked offensively4 ,herein is where attacks are aborted1 or shortened1 or severity lessened1 or complications prevented4 ,the efficacy of osteopathy is due to the ability of the osteopath to treat disease1 not only prophylactically and palliatively1 but of more consequence1 aggressively4 ,the correction of the spinal lesions in typhoid fever is of first importance4 ,this treatment effects a tendency toward equalized circulation of the intestines4 ,the vasomotor nerves are disturbed by the above lesions which in turn produces stasis in ,peyer's patches and the mesenteric glands4 ,reversely some of the spinal lesions may be due to reflex stimuli1 for 8,kirk 444 states that muscular contractions produced by reflex activity are often more sustained than those produced by direct stimulation of the motor nerves themselves40#ea ,prophylactic treatment is very essential1 for typhoid fever as a rule is a preventable affection4 ,modern hygienic and sanitary resources enable a community to reduce the number of cases to a minimum4 ,the number of cases in a locality depends almost directly upon the condition of the water supply and drainage4 ,care should always be taken in regard to the source of drinking water and milk4 ,during an epidemic the water should be boiled for half an hour before being used4 ,the patient should be isolated4 ,in hospitals they should have special wards2 in families a special apartment should be given them4 ,hygienic principles should be followed as in other infectious diseases4 ,the methods of disinfection must be rigid to prevent the spread of an infection4 ,the excreta 7stools1 urine1 vomitus1 and sputum7 are to be received into a bed-pan or any appropriate receptacle containing half a pint of carbolic acid 7one to twenty74 ,three or four pints of the carbolic acid 7one to twenty7 should then be added to the bed-pan and the contents mixed carefully before emptying4 ,all utensils used in handling the excreta are to be carefully disinfected by the same material1 and dried4 ,after every stool the nates of the patient should be cleansed by a cloth compress1 wet with a solution of carbolic acid 7one to forty7 and the cloth burned4 ,the sick room should be thoroughly ventilated each day4 ,all utensils used about the patient in feeding should be boiled in water immediately after using4 ,the bed and body linen is to be changed as soon as soiled and these1 with all changed bath towels1 blankets and rubber sheets1 should be received in a sheet rinsed in carbolic acid 7one to forty7 and placed where they may be soaked in the solution for four or five hours4 ,the clothes are to be boiled for half an hour4 ,the rubber blanket is to be washed in the solution1 dried and aired4 ,the ,general ,management1 careful nursing and a regulated diet1 is of paramount importance in the treatment of typhoid fever4 ,the patient should be placed in bed as soon as the disease is determined and there remain until the end of the attack4 ,the room should be well ventilated and have a sunny exposure if possible4 ,the single woven wire bed with soft hair mattress and two folds of blankets is best4 ,a rubber cloth should be placed smoothly under the sheet4 ,when a good nurse cannot be had1 the attending osteopath should write out directions regarding diet1 bed linen1 and utensils1 and the disinfection of the excreta4 ,a liquid diet should be administered4 ,milk is most commonly used2 care being taken that it is thoroughly digested4 ,if milk is not borne well by the patient1 other foods1 as whey1 sour milk1 buttermilk1 and broths may be substituted4 ,give food that is easily digested and which leaves but little residue4 ,when milk is used alone1 three pints at least may be given to an adult in the course of twenty-four hours2 and it should always be diluted1 preferably with plain water4 ,beef juice1 mutton or chicken broth may also be used when milk is not agreeable4 ,albumin water1 prepared by straining the white of eggs through a cloth and adding an equal amount of water1 is an excellent food4 ,well strained1 thin barley gruel is considered by many an excellent food for typhoid fever patients4 ,cases not able to take nourishment into the stomach1 on account of vomiting and other causes1 should be fed rectally to support life4 ,do not force feeding to an unwarranted degree4 ,recently a number of new diets have received commendation4 ,these include the 8high calory0 diet1 which includes three pints of milk with one of cream1 two to eight ounces of milk sugar1 eggs1 butter2 sometimes cereals1 toast1 potato1 and other soft foods are given4 ,a full sugar diet1 as of candy alone1 is based upon the immediate absorption of sugar1 its value as a source of energy1 and the fact that a plentiful carbohydrate supply lessens the danger of acidosis4#eb ,the best drink for fever patients is pure1 cold water and they should be encouraged to drink freely of it4 ,barley water1 ice tea1 lemonade1 or even moderate quantities of coffee or cocoa1 may be given4 ,by ,osteopathic ,treatment many cases of typhoid fever may be aborted1 if treated correctly1 during the first week4 ,if the stage of necrosis of ,peyer's patches has set in1 one can either lessen the severity of the attack or1 at least1 shorten the usual course4 ,during the stage of infiltration1 treatment to the intestinal splanchnics 7chiefly from the ninth to twelfth dorsal1 the innervation to the jejunum and ileum7 and careful treatment over the abdomen is indicated4 ,this treatment will tend to lessen the intestinal catarrh and diminish the infiltration and cell proliferation of the lymphoid elements of the intestines1 and thus produce unfavorable the conditions for the bacillus of ,eberth4 ,in other words1 increase the tone and activity of the intestines so that the micro-organisms of typhoid fever will not find the proper tissue-soil in order to grow and multiply4 ,all cases of typhoid fever present lesions in the dorsal or lumbar spine and this is really the great predisposing cause of typhoid fever4 ,correcting these lesions is absolutely necessary in order to abort the disease4 ,some patients may have such a lowered vitality to begin with that the recuperative powers of the body cannot be rendered forceful enough in a short time to combat the effects of the micro-organism4 ,carefully raising the cecum is very effective 7,a4 ,t4 ,still71 but this must be done with the greatest of caution and judgment4 ,dr4 ,still considers a posterior condition of the third1 fourth and fifth lumbars as typical in typhoid and that it inhibits the lymphatics to the intestines4 ,r4 ,l4 ,price has had excellent success in shortening the usual typhoid course4 ,his first treatment is to thoroughly empty the bowels by enemata4 ,this is followed by spinal1 liver and splenic treatment1 and a liquid diet4 ,e4 ,c4 ,white has also treated a large number of typhoid cases with marked success4 ,he prefers to employ the ,brand method 7and it must be properly used7 from the start4 ,he is1 also1 a thorough advocate of the spinal treatment4 ,in cases of constipation give a very light treatment over the left iliac fossa4 ,with all patients observe careful dieting4 ,white believes that many lesions of the spine arise from reflex irritations during acute attacks4 ,careful1 frequent attention to the spine is demanded4 ,hildreth1 relative to abdominal and spinal treatment1 writes as follows3 8,in the abdominal treatment of typhoid fever1 too much care cannot be exercised2 or in the spinal treatment1 too much judgment used in giving just the right kind of manipulation4 ,there can be no question relative to the seat of the disease1 and consequently there should be no trouble in knowing where or how to affect the nerves to control the same4 ,that ,peyer's patches or the right iliac region is always involved1 we all know4 ,the spinal treatment should be applied from the eighth dorsal to the first lumbar inclusive2 this affects all the lesser splanchnics and thus controls the circulation of the entire bowel4 ,and this treatment should be given1 according to the symptoms indicated1 in each and every case4 ,if the patient is constipated1 then the treatment should be more of a stimulative character1 but if diarrhea is present1 as is commonly the case1 the treatment should be an inhibitory one4 ,in the above ,i always finish with a very careful treatment of the floating ribs on the left side2 this affects the lesser splanchnic nerves4 ,in all cases ,i always carefully treat the lower two or three lumbar vertebr1 which directly affects the hypogastric plexus of nerves1 and thus controls the circulation to the lower bowel4 8,in all cases ,i always treat the bowels directly1 more or less1 but this treatment must be given with the very greatest care and the best judgment1 always governed by the condition of the bowel4 ,by no means manipulate the bowel1 but just lay your hands flat on the abdomen1 and with the most gentle pressure inhibit the peripheral nerves1 thus either quieting an excited peristalsis or equalizing a disturbed circulation4 ,and with this treatment remember that the two specific points in typhoid fever are the lower dorsal and lower lumbar nerves4 8,the above treatment is used1 of course1 in connection with all the other necessary treatments1 such as dieting1 nursing1 sponging1 relieving the headaches1 etc4 ,i am unalterably opposed to ice-packs for the bowels in typhoid1 for the reason it is too much of a shock4 ,cold cloths are good and much better than ice1 and should always be used instead of ice40 ,after the disease has become thoroughly established always make it a point during each visit to examine the entire length of the spinal column carefully and readjust any tissue1 whether it be vertebra1 rib1 or muscle1 that may be found disordered4 ,the bowels are to be watched carefully and if constipated1 they should be moved with a light enema4 ,great care must be taken not to treat the abdomen roughly1 if at all1 after the first week4 ,the treatment might be very injurious to the structures diseased4 ,a light treatment over the liver and kidneys each time is a wise precaution4 ,the heart's action1 should be watched carefully4 ,in addition to the hydrotherapeutic treatment1 the general fever treatment should be employed4 ,the patient should usually be seen twice a day4 ,abdominal pain is best relieved by light treatment over the abdomen and by thorough treatment of the lower dorsal or lumbar region4 ,applications of hot water will be helpful4 ,meteorism can be relieved by raising the lower ribs and by direct treatment to the abdomen4 ,a change of diet may be beneficial4 ,when gas is in the large bowel an enema may be given to remove it4 ,diarrhea and constipation are best controlled by the usual treatment given the spine in such cases1 and over the abdomen and the liver4 ,light enemata may be given for constipation4 ,the stools should be examined when diarrhea occurs1 as the presence of curds may cause the aggravation4 ,hemorrhage from the bowels demands absolute rest4 ,it is probably better to have the patient use the draw sheet for the evacuation4 ,immediate and thorough treatment must be given to the spinal column in the region of the intestinal nerves to the diseased area1 so that existing lesions may be corrected and the vascular area of the mesentery equalized4 ,ice should be given freely and an ice pack placed over the abdomen4 ,food should be restricted for ten or twelve hours4 ,if the peristalsis of the intestines is increased1 an effort should be made to control it through the vagi and splanchnic nerves4 ,in perforation hot applications1 rest and thorough treatment of the innervation to the peritoneum are of value1 but immediate operation is usually advisable4 ,insomnia is best relieved by attention to the cervical region4 ,relaxation of the muscles in this region and a quieting treatment to the posterior occipital nerves1 coupled with cold sponge baths1 will usually induce sleep4 ,in delirium attention to the circulation of the brain1 by careful treatment of the vasomotor system1 and the ,brand method of baths will relieve this distressing symptom4 ,during convalescence the patient should be restricted from any mental or physical exercise for a week or ten days and then should move about with care4 ,solid food should not be given for ten days or two weeks4 ,if the temperature has been normal for ten days1 it is then safe to allow such food as eggs1 milk puddings1 and milk toast4 ,if diarrhea should persist1 being due to ulceration1 the diet should be restricted and the patient confined to the bed4 ,if constipation is troublesome relieve it by enemata4 ,there are several beneficial effects obtained by hydrotherapeutic measures that should receive careful consideration4 ,probably it is of the least significance to lower the temperature2 other beneficial effects being of greater importance4 ,when the baths are systematically carried out1 7#a7 there is obtained a general improvement of the nervous system1 the mind is rendered clear1 muscular twitchings are lessened1 sleep is induced and the heart's action strengthened2 7#b7 the respiration is stimulated1 thus diminishing the liability of lung complications2 7#c7 the activity of the renal function is increased1 consequently allowing more rapid elimination of toxic matter2 7#d7 reduction of the temperature1 and overcoming ill effects of high fever4 ,a cold water bath1 or what is generally termed the ,brand method1 is commonly employed4 ,the following plan is usually followed4 ,when the temperature is above #ajb4e degrees ,f41 rectally1 a bath of #gj degrees ,f4 is wheeled to the patient's bedside and he is placed into it for ten or fifteen minutes4 ,the patient should be lowered into the bath by means of a sheet4 ,enough water is used to cover the body and neck of the patient4 ,the head is sponged and the limbs and trunk are rubbed thoroughly during the entire procedure4 ,when the patient is taken out he is wrapped in a dry sheet and covered with a blanket4 ,this procedure is gone through with every three hours if the case is severe1 otherwise once every seven or eight hours will be sufficient4 ,the luke-warm bath is occasionally used in private practice when one is unable to use the ,brand method4 ,a bath of #ij degrees ,f4 is employed1 which is gradually cooled ten or twelve degrees1 after the patient has been placed in it1 by pouring cold water on the patient4 ,this bath is found very helpful4 ,also in private practice the cold pack is found satisfactory4 ,the patient is wrapped in a sheet wrung out of water at #fe degrees ,f4 and cold water is sprinkled over him4 ,whenever there is objection to any of these methods the body may be sponged off with tepid or cold water when the temperature rises above #ajb4e degrees ,f41 rectally4 ,one limb should be taken at a time and then the trunk1 occupying altogether some twenty or thirty minutes4 ,the ,great ,war brought the subject of typhoid vaccination before the world with emphasis but its results are not1 as yet1 in shape so an unbiased opinion can be formed4 ,the army medical department will tell us that it was an unqualified success but we do know that there were serious outbreaks among inoculated troops who were living under most hygienic surroundings in ,america4 ,there were1 also1 outbreaks among protected troops in ,france to the extent that the medical authorities felt called upon to warn all medical officers that vaccination should not be considered as protecting against unsanitary surroundings and that great precaution must be observed1 the same as under non-vaccination conditions4 ,this does not imply implicit confidence4 ,it is1 also1 a historical fact that the ,japanese army1 during the ,russo-,japanese war had as low a rate of typhoid without vaccination as can1 probably1 be shown with it in this war4 ,at that time they depended entirely upon pure water and sanitation4 ,see reports of typhoid fever in ,a4 ,o4 ,a4 ,case ,reports as follows3 ,c4 ,m4 ,t4 ,hulett1 ,series ,i1 p4 #g1 ,j4 ,h4 ,wilson1 ,series ,,iii1 p4 #c1 ,f4 ,e4 and ,h4 ,p4 ,moore1 and ,f4 ,a4 and ,e4 ,s4 ,cave1 ,series ,,iv1 pp4 #d and #e4 ,in paratyphoid fever1 an acute infectious disease caused by the paratyphoid bacillus1 the treatment is the same as for typhoid fever4 ,it is milder and similar to typhoid fever4 ,typhus ,fever ,definition4--,an acute1 infectious disease2 characterized by sudden invasion1 high fever1 marked nervous symptoms1 a peculiar maculated and petechial eruption and a termination by crisis about the fourteenth day4 ,etiology and ,pathology4--,typhus fever is becoming less frequent than formerly and is rarely seen in this country4 ,it was very destructive during the ,great ,war1 particularly in the ,balkan states4 ,filth1 over-crowding1 famine1 intemperance and bad food are the predisposing causes4 ,typhus fever is highly contagious and is transmitted by the pediculus corporis 7cootie7 as was first discovered by the ,american ,red ,cross workers in ,serbia4 ,probably infection may come by contact and fomites4 ,the specific organism is the bacillus typhi exanthematici 7,platz74 ,pathologically1 there are no constant lesions4 ,there is a general hyperplasia of the lymph follicles1 but no ulceration4 ,the blood is dark1 thin and lessened in fibrin4 ,hypostatic congestion of the lungs and bronchial catarrh are frequently met with4 ,the liver1 kidneys and spleen are found to be somewhat enlarged and softened4 ,the petechial rash remains after death4 ,symptoms4--,the incubation period is about twelve days4 ,the onset is usually sudden1 ushered in by chills4 ,the temperature quickly rises to #ajd or #aje degrees ,f4 ,there is headache1 pains in the muscles1 especially of the back1 and early1 profound prostration4 ,the pulse is at first full and strong1 #ajj to #adj1 but soon becomes weak and frequent4 ,there may be distressing vomiting4 ,the face is flushed1 the eyes injected1 the expression stupid1 and there is generally low1 muttering delirium4 ,the tongue is furred and white1 soon becoming dry4 ,the bowels are constipated and the urine is usually scanty and of high specific gravity4 ,there is great thirst4 ,conjunctiva injected2 pupils contracted2 early prostration4 ,the eruption appears about the fifth or seventh day4 ,it first makes its appearance upon the abdomen and chest4 ,it rapidly extends all over the body with the exception of the face4 ,the eruption is of two kinds--rose spots1 which disappear upon pressure1 and those which become hemorrhagic 7petechial72 pressure has no effect upon them4 ,during the second week the symptoms are increased4 ,the tongue is dry1 brown and fissured1 and sordes appear on the teeth4 ,retention of the urine1 due to paralysis of the bladder1 is common4 ,the breathing becomes more rapid and the heart's action more feeble2 the patient may die from exhaustion4 ,this ushers in the typhoid state with low1 muttering delirium1 ataxic symptoms1 subsultus1 tremors1 and maybe bronchial symptoms4 ,in favorable cases the crisis occurs at the end of the second week4 ,patient sinks into a sound sleep1 the temperature falls rapidly1 there is profuse sweating and a critical diarrhea but the patient now gains rapidly4 ,convalescence is usually rapid2 relapses rarely occur4 ,the urine is scanty1 high colored and frequently albuminous4 ,bed-sores are common4 ,the temperature continues high1 reaching #ajf degrees ,f41 or more1 with slight nocturnal remissions4 ,in fatal cases the fever often rises to #ajh or #aji degrees ,f4 just before death4 ,diagnosis4--,the sudden onset1 frequent chills1 early profound prostration1 character of the rash1 history of exposure to the poison and unhygienic surroundings decide the diagnosis4 ,during an epidemic there is usually no doubt1 but in sporadic cases the diagnosis is sometimes extremely difficult4 ,prognosis4--,this is usually grave1 but the mortality rate is being greatly reduced in consequence of the better sanitary arrangements4 ,treatment4--,typhus fever is highly contagious and great care should be taken in controlling the disease4 ,isolation1 disinfection and extermination is imperative4 ,so far as known none of the osteopaths have had experience in the treating of typhus fever osteopathically1 but there is no reason why the disease should not be treated with the same success as is met with by osteopathic treatment in other diseases4 ,it is claimed that the disease should be treated in the open air1 in tents1 as the recovery of the patient and the safety of the attendants are greatly favored4 ,for high temperature1 besides the treatment given to remove any disorder that may be found1 the general fever treatment is indicated1 and hydrotherapy would also be of aid--sponging the surface of the body1 or the use of the bath4 ,asthenia is wherein the greatest danger lies1 and a stimulating treatment along the spine and to the heart should be given2 although correction of the primary trouble may be sufficient4 ,hydrotherapeutic measures1 the systematic use of the cold bath1 would be of service the same as in typhoid fever4 ,headache and delirium which are apt to arise1 caused by too much blood in the head1 may be relieved by treatment of the cervical spine4 ,also cold applied to the head will aid4 ,the bowels should be watched carefully2 treat the splanchnics thoroughly and the intestines and liver directly4 ,nourish the patient as in typhoid fever by nutritious liquids--milk1 broths1 etc4 ,although typhus is now a comparatively rare disease1 an outline has been given to emphasize what correction of unhygienic conditions and insanitary surroundings will accomplish4 ,it is particularly a disease of filth4 ,malarial ,fever 7,,ague7 ,definition4--,an infectious disease caused by the hemocytozoon of ,laveran4 8,it is characterized by paroxysms of intermittent fever of the quotidian1 tertian or quartan type1 a continued fever with marked remissions1 a pernicious or rapidly fatal form1 and a chronic cachexia with anemia and enlarged spleen40 7,halbert74 ,the varieties of malarial fever are3 intermittent fever2 pernicious intermittent2 remittent fever2 malarial cachexia2 masked intermittent2 malarial hematuria4 ,osteopathic ,etiology and ,pathology4--,malarial fevers are caused by a parasite known as the hematozoon of ,laveran4 ,three varieties of the parasite have been separated1 corresponding with the three leading forms of the affection4 ,the parasite of tertian fever is about as large as a normal red blood-corpuscle1 beginning as a small hyaline ameba in the red blood-corpuscles4 ,the parasite of quartan fever is very similar in its appearance to the tertian parasite but smaller2 its ameboid movements are slower and the red blood-corpuscle embracing it shrinks about the parasite1 assuming a deeper greenish color4 ,the parasite of the estivo-autumnal fevers is still smaller4 8,if only one group of parasites exists the paroxysms--quartan intermittent--will occur every fourth day4 ,double quartan infection will result in paroxysms on two successive days with an intermission of one day4 ,infection by three groups of parasites will create daily paroxysms--the quotidian intermittent4 ,infection by more than three groups is rare40 7,anders74 ,only in the earlier stages of development1 small hyaline bodies are to be found in the peripheral circulation2 being1 in the later stages1 in the blood of certain internal viscera1 spleen1 and bone marrow1 particularly4 ,it is an accepted fact among medical observers that to the mosquito1 anopheles1 is due the spread of malaria and it has been the subject of much investigation in all parts of the world4 ,the mosquito becomes infected from biting an individual whose blood contains the malarial parasite1 this is then developed in the mosquito to maturity and later is transmitted to the next subject bitten4 ,this explanation would show why certain localities favorable for the breeding of mosquitoes are particularly given to malarial outbreaks4 ,low1 marshy grounds1 banks of rivers1 small ponds1 etc41 as well as warm weather1 are needed to produce the conditions for the development of the anopheles4 ,as the country has developed the intensity and extent of malaria has diminished until it is now confined largely to the southern states4 ,it is practically unknown in the northwest and in the ,st4 ,lawrence basin4 ,regions which have never had cases1 however1 have developed them when the anopheles has appeared4 ,whiting notes cases in ,southern ,california1 the result of the insect being brought in by ships from ,mexican or ,central ,american ports4 ,in certain regions the anopheles is present but has not apparently come in contact with a malarial victim1 so is incapable of spreading the disease4 ,also in colder climates this species is harmless4 ,by draining the lands and preventing the breeding places1 the number of the pests is reduced1 while the screening of houses and care against exposure to the bites make it possible to live in malarial sections and not become infected4 ,naturally the resisting power of a patient is called into account when bitten by the mosquito4 ,where it is epidemic the inhabitants will be found1 generally1 poorly nourished or debilitated from climatic or other conditions4 ,this renders infection easy1 for immunity must come from the ability of the blood to combat the invading parasite4 ,the osteopathic predisposing causes for malaria are usually interference with the vasomotor nerves to the spleen and liver1 as these two organs are so concerned in maintaining the stability of the blood tissue4 ,ligon1 of ,alabama1 notes that most cases have lesions between the ninth and twelfth dorsal on the right side4 ,the chief morbid changes are clue to the direct effect of the malarial parasite upon the blood4 ,there are also changes in the liver1 kidneys1 and spleen1 which changes usually vary with the duration and intensity of the disease4 ,the disintegration of the red blood-corpuscles1 accumulation of the pigment thus formed1 and the toxin engendered by the malarial parasite are responsible for the morbid lesions of the disease4 ,in pernicious malaria the blood is more or less hydremic1 and the discs are seen in all stages of destruction4 ,the spleen is enlarged and soft and the pulp dark from the accumulation of the pigment1 and spontaneous rupture has occurred in a number of cases4 ,the liver is swollen and turbid2 pigmentation occurs1 but is generally only visible by means of the microscope4 ,by the aid of the microscope all the tissues of the body1 even the brain1 may be found to be pigmented4 ,the spleen in chronic malaria is greatly enlarged1 firm1 pigmented and the capsule thickened4 ,the liver is enlarged1 the color varying from a slight gray to a deep slate gray1 according to the amount of pigment4 ,the kidneys may be enlarged and deeply pigmented1 as is also the mucous membrane of the stomach and intestines4 ,r4 ,w4 ,connor observes that the kidneys and liver are most noticeably involved1 vasomotor obstructions the rule1 the spleen in the majority of cases shows engorgement and that special attention to these centers will give the best results4 ,he invariably finds spinal lesions from the seventh dorsal to the first and second lumbar1 most frequently the eighth1 ninth and tenth dorsals4 ,a lowered vitality predisposes to infection from the bite of the mosquito4 ,symptoms4--,intermittent ,fever4--,this form is what is known as fever and ague1 in which chills1 fever and sweat follow each other4 ,the period of incubation varies from six to fifteen days1 but it may be months after exposure before the first paroxysms set in4 ,the paroxysm is usually preceded by a feeling of uneasiness and discomfort1 sometimes by nausea or headache4 ,the paroxysm consists of three stages1 cold1 heat and sweating4 ,in the cold stage the chill usually begins gradually2 it is generally intense1 the teeth chatter and the body shakes violently4 ,the skin is cool and pale1 the lips are blue1 the face is pinched and the patient looks very cold4 ,during the chill the temperature rises rapidly4 ,nausea1 vomiting and headache are common4 ,the pulse is frequent1 small and hard4 ,the urine is increased in quantity and of low specific gravity4 ,the chill lasts from a few minutes to a couple of hours4 ,the hot stage succeeds the chill4 ,the skin gradually loses its coldness and becomes hot4 ,the face is flushed1 there is great thirst1 the mouth is dry1 and the tongue is coated4 ,usually at the termination of the chill the temperature has reached its maximum level1 from #ajd to #ajf degrees ,f4 ,the pulse is full1 and there may be a throbbing headache4 ,the duration of this stage is from half an hour to three or four hours4 ,during the sweating stage drops of perspiration appear upon the face2 the perspiration soon becomes profuse1 extending all over the body4 ,the temperature soon falls1 the headache disappears and in a couple of hours the paroxysm is over4 ,the entire duration of the paroxysm is from eight to twelve hours2 the patient usually feeling perfectly well between the paroxysms4 ,the spleen is enlarged4 ,if the paroxysms of fever occur daily at the same hour they are called quotidian intermittent fever2 if every other day they are known as tertian intermittent2 and if every third day they are called quartan intermittent4 ,if there are two paroxysms in the same day the term double quotidian is used2 if the paroxysms occur a couple of hours later each successive day they are called 8retarding20 if a couple of hours earlier they are named 8anticipating40 ,remittent ,fever4--7,estivo-,autumnal ,fever74--,this is characterized by a continued fever with paroxysmal exacerbations and remissions4 ,it occurs especially in warm and tropical climates4 ,in temperate climates it usually occurs in the late summer and fall4 ,it is also termed bilious remittent fever on account of the intensity of the gastro-intestinal manifestation4 ,the estivo-autumnal parasite is the exciting cause4 ,it is very often preceded by malaise1 headache1 nausea and vomiting4 ,the onset is usually gradual and the chill may be wholly absent4 ,as a rule1 however1 a chill generally occurs at the onset1 but it is less severe than that of intermittent fever4 ,after the chill the temperature rises rapidly to #ajb or #ajd degrees ,f4 or even higher4 ,the pulse is full1 rising to #ajj or #abj4 ,there is violent headache1 flushed face1 pains in the limbs and loins1 nausea and vomiting1 and delirium when the temperature is very high4 ,the urine is scanty or even suppressed1 slightly albuminous1 sometimes bloody1 high colored1 and deposits a sediment of urates4 ,jaundice is not infrequent2 the spleen is enlarged and herpes labialis is quite common4 ,after six to twenty-four hours the symptoms abate and slight sweating occurs4 ,the temperature usually drops to #ajj degrees ,f41 the headache disappears and vomiting ceases2 this is followed by a new exacerbation of fever at the end of about twelve hours1 generally without the chill2 and this hot stage is in turn again followed by the remission4 ,these attacks may last three or four weeks4 ,pernicious ,malarial ,fever4--,this is rare in temperate climates and is always associated with the estivo-autumnal parasite4 ,the principal types are the cerebral and algid4 ,the cerebral type usually begins with a severe chill2 sometimes1 however1 the chill is absent4 ,the patient is violently seized with grave cerebral symptoms1 as acute delirium or sudden coma4 ,the comatose condition lasts from twelve to twenty-four hours when consciousness usually returns1 the primary paroxysm rarely proving fatal2 it is1 however1 often followed in a short time by fatal relapse4 ,the ,algid variety is characterized by intense prostration and extreme coolness of the surface with the internal temperature high4 ,the gastric symptoms are extreme nausea and vomiting4 ,the pulse is feeble2 the breathing frequent and shallow4 ,there is intense thirst4 ,the voice is feeble and indistinct4 ,the mind is clear4 ,the urine is suppressed4 ,in this type the parasites gain entrance to the gastro-intestinal mucosa1 sometimes forming distinct thromboses of the smaller vessels4 ,this form may be confused with yellow fever4 ,malarial ,cachexia4--,this is a chronic condition which often occurs in cases that have not been properly treated or in persons that live in malarial districts and are constantly exposed to the infection4 ,the two most striking symptoms of this condition are anemia and an enlarged spleen or 8ague cake40 ,there is fever at intervals1 but chills rarely occur4 ,the skin is of a dirty yellow color4 ,the spleen is greatly enlarged and the blood is profoundly anemic4 ,there is debility1 and frequent sweating1 and the hands and feet are cold4 ,the digestion may be deranged and there may be slight jaundice4 ,sometimes there is edema of the feet and even dropsy occurs4 ,hemorrhages of the various mucous surfaces are common4 ,paraplegia and orchitis are rare symptoms4 ,these cases usually do well under proper treatment1 and if the patient can be moved from the malarial district4 ,masked ,intermittent4--,malarial neuralgia most frequently involves the supraorbital branch of the trigeminus2 also the occipital1 the intercostals1 sciatic and brachial nerves may be affected4 ,such forms of malaria are called 8masked malaria40 ,in this form there is no fever and as a rule it is very hard to diagnose4 ,a blood analysis should be made to confirm the diagnosis4 ,in some cases one or more stages in the paroxysm of intermittent fever is omitted2 this is especially true with the chill1 in which case it is termed 8dumb ague40 ,malarial cachexia is also sometimes called 8dumb ague0 and both are found among the older inhabitants of malarial districts4 ,persons living in malarial districts are sometimes affected with constipation1 headache1 loss of appetite1 nausea1 vomiting and a languid feeling2 this is called 8latent intermittent fever40 ,frequently 8bilious attacks0 are of a malarial origin4 ,malarial ,hematuria4--,hemorrhages may occur from the mucous membrane in all severe and persistent types of malarial infection4 ,it is a frequent symptom of the pernicious variety4 ,the parasites destroy the red blood-corpuscles2 this is the cause of the hemoglobinuria4 ,prostration and anemia are marked4 ,in blackwater fever1 a tropical disorder1 acute hemolysis1 is the cause of the hemoglobinuria4 ,diagnosis4--,this is usually easy4 ,the characteristic stages of the paroxysms1 the periodicity1 residence in malarial districts and the alterations in the blood will usually remove every doubt as to the diagnosis4 ,typhoid ,fever may simulate malarial fever1 but a careful analysis of symptoms and blood examination will differentiate4 ,prognosis4--,this is almost always favorable under early and persistent treatment4 ,the unfavorable symptoms are uremia1 hemorrhage and marked jaundice4 ,treatment4--,attention should first be given to prophylactic measures4 ,environment1 isolation of the patient1 and destruction of the mosquito are important considerations4 ,cases of malarial fever present distinct lesions in the vertebr and ribs corresponding to the vasomotor nerve supply of the spleen and liver4 ,the most common lesion found is a marked lateral deviation between the ninth and tenth dorsal vertebr and a consequent downward displacement of the tenth ribs4 ,a disturbance will always be found in the region of the eighth to the eleventh dorsal vertebra1 inclusive1 or in the corresponding ribs on either side4 ,these lesions undoubtedly derange the vasomotor nerves to the spleen and liver2 thus permitting a weakness or lowered resistance of the system1 especially of the blood4 ,the blood resisting powers are lessened1 probably on account of the spleen being affected1 as it is an elaborating gland of the blood2 and the liver's action is somewhat dependent upon the action of the spleen2 besides1 the liver is a secretory and excretory organ4 ,the principal osteopathic treatment given in cases of malarial fever is correction of these subdislocations1 and thorough treatment to the liver and spleen directly4 ,ligon observes that when the case does not respond quickly to treatment it is very liable to be of considerable duration1 although in the majority of cases the disease is controlled from the third to seventh day2 the most constant lesions found are from the eighth to tenth dorsal and also the fourth lumbar4 ,during the chilly stage thorough treatment of the vasomotor nerves in the upper cervical1 the upper dorsal1 the lower dorsal and the lumbar regions is indicated2 this treatment is given to equalize the vascular system4 ,during the hot stage the same treatment as in the chilly stage should be given to control the vascular system2 besides a thorough treatment of the spleen and liver is necessary4 ,sponging the body with water will be of some aid in reducing the temperature4 ,during the sweat stage thorough inhibition at the superior cervical ganglion to control the sweat center of the medulla1 and treatment at the upper dorsal and first lumbar to control auxiliary sweat centers are indicated4 ,the bowels should be kept active4 ,when in a comatose form and when internal temperature is high1 place the patient in a bath4 ,in chronic cases1 change of climate with thorough systematic treatment will usually result in recovery4 ,tete#ec1 of ,louisiana1 makes the following interesting statement3 8,a specific osteopathic treatment given within an hour before the expected chill is a specific cure for malaria40 ,he follows this up by treating on the third1 fifth1 seventh1 fourteenth1 and twenty-first days1 on account of the tendency of the return of an attack on those days4 ,his observation of the value of treatment just before the attack is borne out by a report by ,teall#ed where the case was cured in one treatment1 but the lesion was as high as the fourth dorsal4 ,n4 ,chapman confirms this as being her experience in many cases4 ,the spleen has been observed by ,bandel to become engorged and upon emptying there would follow a rise of temperature of one fourth to half a degree4 ,this has also been spoken of by ,tucker as the 8splenic wave40 ,ligon makes the statement that where the osteopathic lesion 7the predisposing cause7 has been of long standing prior to the attack1 and as a consequence hard to correct1 it is difficult to shorten the malarial attack4 ,this would emphasize the point that the essential treatment must be a thoroughly readjustive one1 and that stimulatory and inhibitory work can only palliate4 ,this is borne out by several practitioners who have had considerable experience4 ,very satisfactory results follow adjustment of the seventh to tenth dorsals4 ,quinine has been accepted by medical authorities as a specific for malaria4 ,it is supposed to act directly upon the intracorpuscular hematozoa4 ,that it is not infallible is shown by the numerous cases which come to the osteopath1 suffering from both the disease and the quinine4 ,and even drug authorities state that other treatment is also required4 ,it has remained for ,dr4 ,still to demonstrate that excellent results follow osteopathic treatment in malaria4 ,frequently a single treatment has been sufficient to free and regulate the body fluids and forces so that the parasite was rendered inert1 and this treatment was directed chiefly to the fourth and twelfth dorsals4 ,whereas the osteopath recognizes and appreciates the importance of micro-organisms as exciting and determining factors in many diseases1 still he values them as secondary factors only and relies primarily upon removing the predisposing and true etiologic factors1 so that nature's forces may not be obstructed and thus predominate4 ,osteopathic etiology and pathology has shown so conclusively1 in a large number of cases1 that the existence of micro-organisms is dependent upon devitalized tissue1 whether the tissue is a local one or a circulating one1 as the blood2 and just so soon as the anatomical is adjusted the physiological will function and antitoxic and antimicrobic substances are secreted4 8,when the patient has the quartan parasite1 as soon as the temperature begins to fall ,i give him from two to six ounces of red meat juice1 extracted from rare beefsteak1 sometimes as much as five pounds in the first twenty-four hours following the chill4 ,in almost all cases of quartan malaria the blood is built up sufficiently by the time they reach the second cycle to pass without the paroxysm1 or chill4 ,by the time for the third cycle1 which is the seventh day1 ,i always have built up the patient's resistance so as to enable him to pass by this cycle without any symptoms of malaria whatever4 ,in cases of double or triple ,i find the same treatment causes about the same results4 ,i do not give any other diet1 except dry toast if they eat the beef instead of taking the juice4 ,if they can take the steak ,i prefer their taking it1 but almost all cases prefer the juice4 99 99 99 ,the treatment for the tertian type of malaria is practically the same as the treatment for the quartan4 8,the estivo-autumnal type of malaria differs from the quartan and tertian types2 first1 in that the paroxysms are1 as a rule1 much more irregular2 second1 they are much longer in duration2 third1 the chills are more frequently absent2 fourth1 the fever is often irregular1 intermittent1 remittent1 or continuous in character4 ,this type very often takes the form of blackwater or hemoglobinuric type with hemorrhagic symptoms1 with hemorrhage from nose1 gums1 and bowels4 ,the first thing to do in a case of hemorrhagic malaria is to put an ice bag on the abdomen1 which will tend to control the hemorrhage from the kidneys4 ,give the patient all the red beef juice you can get him to take1 provided he has not developed a very sick stomach2 if so1 give him high saline enemas and in one-half hour give him four ounces red beef juice per rectum4 ,repeat the feeding per rectum in four hours4 ,as soon as he can retain anything on stomach give him all the juice he can take comfortably4 ,treat the liver thoroughly--at least three times in the first twenty-four hours4 ,at the end of thirty-six hours the yellow cast will be very much lighter1 which is a sure sign that the patient is getting better4 ,watch the urine closely4 ,the third day there may occur a suppression4 ,if so1 give strong stimulation to the renal plexus through the abdomen1 and be sure there is a thorough relaxation of the dorsal and lumbar muscles4 8,it is an established fact that people in the malarial districts eat very little beef4 ,i find that ninety-nine per cent of the cases of malaria never eat it1 or when they on rare occasion do1 it has been so overcooked that all the blood-building substances have been destroyed4 ,the beef raw would be better in my opinion2 although1 the possible chance of getting a tape-worm or animal parasite is so considerable that ,i would advise that the beef should be heated to #bej degrees40--,e4 ,c4 ,,armstrong1 ,clinical ,osteopathy4 ,septicemia ,this term is applied to any toxic condition caused by the invasion of the blood by pathogenic micro-organisms1 with or without any visible site of infection4 ,etiologically1 the micrococci1 streptococci1 pneumococci1 or staphylococci1 as to frequency1 in order named1 are the cause4 ,the infection is usually introduced by a wound1 of any degree of severity4 ,the uterus is a frequent seat following miscarriage1 parturition or operation4 ,the virus may be absorbed by the mucous membrane4 ,it may also arise from infection of the deeper tissues4 ,pathologically1 the changes are not marked1 but consist in brownish color of the muscles1 ecchymotic spots in the pia mater and dark appearance of the blood1 which is also less coagulable4 ,spleen1 liver and lymphatics are enlarged with some changes in the other organs4 ,symptoms4--,the incubation period is from four to six days and the onset is gradual1 though often announced by a distinctive chill1 followed by a profuse sweat4 ,the most common type is the continuous form of fever1 which may1 in morning remissions1 become subnormal4 ,pulse is rapid at the beginning1 but as cardiac failure comes on1 it becomes weaker4 ,in the earlier stages there may be vomiting with diarrhea later4 ,there are punctiform hemorrhages of the skin and possibly other eruptions4 ,blood examination will settle any doubt as to diagnosis4 ,prognosis is good in large percent of cases and depends upon the general health of the patient4 ,treatment4--8,incise and drain the infected part2 if possible1 apply hot boracic acid compresses or keep part suspended in hot boracic acid solution4 ,osteopathic treatment will aid materially in stimulating and strengthening the patient4 ,bowels1 kidneys and skin must be kept active4 ,normal salt solution1 hypodermically or per rectum is of value4 ,diet should be liquid1 fruit juices1 broths1 soups until temperature has remained normal twenty-four hours then milk1 eggs etc41 in gradually increasing amounts until general diet is restored4 ,amputation of the part may be necessary40--,l4 ,e4 ,,browne4 ,pyemia ,a febrile disease arising from an invasion of the blood by pathogenic bacteria1 wherein sepsis and multiple abscesses occur from absorption and metastasis4 ,etiologically1 the cause may be traced to various specific organisms which enter the blood stream and produce thrombophlebitis4 ,from these points and from other bacteria1 new foci are established4 ,occasionally the lymphatics carry the germs4 ,the disease may also start from ulcerative endocarditis or when the appendix is infected4 ,pathologically1 thrombosis of the vein may take place in any region4 ,abscesses may form in the lungs1 liver1 spleen or other internal organs4 ,the small abscesses may unite and form a large one4 ,the skin presents eruptions and hemorrhagic extravasations1 while there may be ulcers of the mucous membrane1 also the serous surfaces may be purulently inflamed4 ,the muscles1 subcutaneous and osseous tissue occasionally have abscesses4 ,ulcerative and suppurative heart lesions occur4 ,symptoms4--,the incubation period is short4 ,there may be slight fever1 but commonly a chill is the first symptom1 which may reoccur for some time4 ,the fever is either remittent or intermittent and when the temperature is low1 sweating is a feature4 ,the pulse becomes rapid and weak1 when the disease is severe2 breathing becomes difficult4 ,skin symptoms1 such as eruptions and pustules1 generally occur4 ,in a word1 there is a general intoxication4 ,there is a lessened number of red blood corpuscles and leucocytosis is a characteristic4 ,in grave cases1 delirium and coma are present4 ,diagnosis4--,the history of the case and symptoms will usually render diagnosis easy1 although care is necessary to determine from septicemia4 ,malaria1 typhoid and acute tuberculosis must be excluded4 ,prognosis4--,much depends on asepsis and surgery but on the whole it is unfavorable4 ,treatment4--,surgical interference and treatment as outlined under septicemia is the only hope4 ,dengue 7,,breakbone ,,fever7 ,definition4--,an acute infectious disease2 characterized by a double febrile paroxysm1 severe pains in the muscles and joints and sometimes a skin eruption4 ,etiology4--,it is a disease of tropical and subtropical regions4 ,unhygienic conditions predispose to an attack4 ,during an epidemic a single attack is the rule4 ,the disease spreads from place to place along the lines of travel1 attacking both sexes1 and all ages4 ,it occurs in epidemics1 practically affecting every one4 ,the specific germ has never been isolated as it is probably ultra-microscopic but there is no doubt but that it is carried by the mosquito ,culex fatigans4 ,symptoms4--,the incubation period lasts about four days4 ,the onset is abrupt with a slight chill1 headache1 and extreme pain in the joints and muscles1 of a boring or breaking character4 ,the joints become red1 swollen and painful4 ,the fever rises gradually to #ajc or #ajf degrees ,f41 or over4 ,the pulse is rapid and full and the respirations are much quickened4 ,the face is flushed1 the tongue coated1 the appetite is lost1 and slight nausea occurs4 8,black vomit10 similar to that of yellow fever1 has been observed in this disease4 ,hemorrhages from various organs may occur and the lymphatic glands are swollen4 ,the urine is scanty and the bowels constipated4 ,febrile albuminuria and delirium are rare4 ,at the end of three or four days the temperature falls and there is a period of remission2 the patient is free from pain1 but profoundly prostrated4 ,during this time the eruption generally appears1 but is never constant in character4 ,after a remission of two or three days1 the symptoms reappear and a second febrile paroxysm sets in4 ,this is usually milder and shorter than the first1 lasting two or three days1 when convalescence begins4 ,the duration is1 according to medical writers1 from seven to ten days1 and convalescence slow4 ,death seldom occurs1 so practically no pathological changes have been recorded4 ,by osteopathic treatment1 ,e4 ,b4 ,ligon has been able to confine the attack to four or five days duration2 this is confirmed by the experience of ,n4 ,chapman4 ,diagnosis4--,during an epidemic the disease attacks all classes alike1 and the distinct remission renders the diagnosis comparatively easy4 ,an occasional case might be mistaken for acute rheumatism1 but the absence of any glandular swelling or eruption1 while the pain is more closely limited to the joints1 will aid in the diagnosis4 ,care has to be taken that yellow fever is not mistaken for dengue4 ,treatment4--,the indications of the treatment are to maintain the patient's strength and to treat the leading symptoms as they arise4 ,the severity of an attack can probably be lessened at the start by strong and thorough treatment of the suboccipital1 upper dorsal1 lower dorsal and lower lumbar regions1 respectively1 so as to control the large vascular areas by means of the vasomotor nerves of the cranial region1 of the lungs1 of the splanchnic region1 and of the lower limbs1 thus equalizing the entire vascular system4 ,elimination should be pushed and the excretory organs stimulated4 ,ligon has observed that the cervical and lumbar regions are especially tender on the second day and the lower dorsal region on the third day4 ,the most severe symptoms disappeared within a few hours after treatment and the attack was markedly shortened4 ,the high fever may be treated by the usual methods and by the external application of cold water4 ,the pain is to be controlled1 according to the region affected1 by a correction of parts impinging upon the nerve tissues and by strong inhibition4 ,the entire spinal region should be kept constantly in a relaxed condition1 as far as muscular contractions are concerned4 ,particularly should the treatment be extensive along the spine during prostration4 ,n4 ,chapman1 in addition to the osteopathic treatment1 has the patient drink considerable hot water2 also employs the hot bath4 ,the treatment frequently shortened the attack4 ,during the entire attack of the disease1 the patient should be kept in bed and a carefully regulated diet administered4 ,relapses are not infrequent4 ,a suitable change of air may hasten convalescence4 ,cerebrospinal ,meningitis ,definition4--,a specific1 infectious disease caused by the diplococcus intracellularis meningitidis1 occurring sporadically and in epidemics4 ,it is characterized by inflammation of the membranes of the brain and spinal cord and an irregular course4 ,osteopathic ,etiology and ,pathology4--,the specific exciting cause of the cerebrospinal meningitis is due to the diplococcus intracellularis meningitidis of ,weichselbaum4 ,lesions are found in the vertebr corresponding to the cervical and dorsal enlargement of the cord1 as well as in corresponding deep muscles2 also1 as is well known1 the muscles of the entire back are severely contracted1 especially of the cervical1 upper and lower dorsal regions4 ,more commonly it attacks the young1 although it may occur at any age4 ,overexertion1 exposure1 overcrowded and illy-ventilated buildings1 barracks and tenements1 and depressing mental influences are predisposing causes4 ,many times the disease occurs among the poorer classes4 ,sometimes the disease prevails in the country rather than in the city4 ,in cases that prove speedily fatal there may be no characteristic changes2 simply marked congestion4 ,other cases in which death occurs after the disease has been fully developed1 there is found every degree of inflammation from slight hyperemia to suppurative changes4 ,there can be no doubt that the osteopathic lesion1 as vertebral and rib lesions and deep muscular contractions1 affects the circulation of the meninges of the brain and cord and thus favors the invasion of the specific micro-organism4 ,the arteries1 veins and sinuses are greatly engorged4 ,the walls of the ventricles soften and the ventricles contain serous exudate4 ,the brain matter may be congested and softened in spots4 ,in the spinal membranes similar changes take place and at times there is extravasation of blood4 ,the changes are more marked on the posterior than the anterior surface of the cord4 ,abscesses sometimes form4 ,the exudate may follow the lymph sheaths of the cranial nerves1 especially the auditory and optic4 ,in long standing cases the membranes become thick and adherent and areas of softening or atrophy of the cortex develop4 ,the thickening and adhesions of the membranes may cause various symptoms for months or even years after recovery from the acute disorder4 ,the spleen may be normal in size1 but when the fever has been intense1 it is apt to be slightly enlarged4 ,bronchitis1 pneumonia1 endocarditis and pleurisy may occur4 ,the liver may become hyperemic and the kidneys congested4 ,symptoms4--,the prodromes vary1 although the onset is apt to be sudden with a decided chill2 headache2 vomiting1 and pain in the neck and back1 which is usually severe1 but may be so slight as not to be noticed by the patient4 ,the temperature rises to #aja to #ajb degrees ,f41 in most cases4 ,however1 it may rise to #aje degrees or #ajf degrees and even to #ajh degrees in fatal cases1 and the pulse is full4 ,hyperesthesia1 photophobia1 and dread of noise are apt to be prominent symptoms4 ,the muscles of the neck and back become rigid1 and there are pains in the limbs4 ,orthotonos occurs more frequently than opisthotonos4 ,convulsions are common in children4 ,there may be paralysis1 especially of the muscles of the face and eyes4 ,delirium usually appears early2 it may be mild1 but it is often maniacal4 ,the bowels are usually confined1 though there may be diarrhea4 ,there is moderate and constant leucocytosis and jaundice has been met with4 ,the urine is sometimes albuminous1 and sugar has been noted in rare cases4 ,the urine may be increased1 but more often it is lessened as in other infectious diseases4 ,herpes facialis occurs shortly after the onset in more than half the cases4 ,the contents of the vesicles may be purulent and one or two may coalesce4 ,the petechial eruptions are occasionally numerous and cover the entire skin2 they do not disappear upon pressure and the number of spots varies greatly4 ,other eruptions as sudamina1 ecthyma1 pemphigus1 urticaria1 erysipelas1 rose colored spots1 and gangrene of the skin 7rarely7 have been met with4 ,in cases that are rapidly fatal1 the onset is sudden1 usually with violent chills1 headache1 depression1 and in a few hours coma and collapse1 which are soon followed by a fatal termination4 ,the temperature may rise slightly1 but it is often subnormal4 ,the pulse is feeble2 breathing is labored4 ,these cases occur more frequently at the beginning of an epidemic4 ,they occasionally occur sporadically4 ,the abortive form terminates abruptly after the development of one or more pronounced1 characteristic symptoms4 ,the mild form can only be recognized during the prevalence of an epidemic4 ,the symptoms are very mild2 slight vomiting1 little or no fever1 headache and slight pain in the back and limbs4 ,the intermittent form is characterized by increase in the fever every day or second day4 ,the strict periodicity seen in malaria is not observed2 the fever resembles that of pyemia4 ,in the chronic form the condition may persist for weeks or months4 ,complications4--,pneumonia 7lobar and lobular7 is a frequent complication4 ,pleurisy1 pericarditis1 parotitis1 arthritis1 enteritis1 optic neuritis and otitis media may be other complications4 ,sequel4--,blindness1 deafness1 keratitis 7rarely71 persistent headache1 chronic hydrocephalus1 abscess of the brain1 mental feebleness1 defective articulation1 aphasia1 and paralysis of certain cranial nerves or of the lower extremities have occurred4 ,diagnosis4--,typhoid fever begins slowly and is unaccompanied by vomiting1 muscular spasms or rigidity1 or hyperesthesia4 ,in typhoid the fever is higher and there is a characteristic temperature curve4 ,widal's test will confirm4 ,tubercular meningitis is not epidemic and has no characteristic eruption4 ,it is usually less sudden in its development and is invariably fatal4 ,retraction of the neck1 muscular spasms of the legs and arms are not so marked as in spinal meningitis4 ,pneumonia may be complicated with meningitis1 especially when the meningitis is confined to the cerebrum4 ,if the case is not seen early1 it is almost impossible to say which is the primary affection1 as pneumonia may have meningeal complications or cerebrospinal meningitis may be associated with pneumonia4 ,there will be motor spasms and tremors1 but the head is rarely retracted1 and there is less myalgiac pain than in cerebrospinal meningitis4 ,prognosis4--,this varies according to the severity of the type4 ,it is a grave disease4 ,cases have been treated successfully by several osteopaths4 ,the duration is very variable--from two or three days to weeks or even months1 but probably in all cases this time can be materially shortened by judicious osteopathic treatment4 ,convalescence is very slow and relapses are prone to occur4 ,treatment4--,the osteopathic treatment of cerebrospinal meningitis requires most thorough1 but very careful1 work along the spinal column1 especially the cervical region and the region of the dorsal enlargement of the spinal cord1 in relaxing and keeping relaxed the deep muscles on either side of the spine and correcting the derangements of the vertebr1 particularly in the upper cervical spine4 ,such treatment has a marked effect on the circulation of the spinal cord and brain4 ,probably1 a large amount of the work along the spine1 in all cases where muscles are relaxed1 has a direct effect upon the circulation of the spinal cord4 ,this treatment constitutes the primary osteopathic work in cerebrospinal fever and should be frequently applied until a cure is obtained4 ,even in chronic cases where limbs have been greatly affected by pressure upon the nerve centers1 due to a thickened membrane1 continued osteopathic treatment along the spine has had a marked effect in absorbing the pathological condition and restoring strength4 ,the preceding spinal treatment is also a very great safeguard in keeping the various viscera healthy and thus preventing complications4 ,in all constitutional diseases of an acute nature1 it is a wise precaution to thoroughly examine the entire length of the spinal column at each visit2 and if such precaution is taken many serious complications will never occur that might otherwise have taken place4 ,the patient should be isolated in a somewhat darkened room1 and care taken that the disease is not allowed to spread4 ,keep the patient upon his sides as much as possible4 ,the diet should be a nutritious one of milk and broths4 ,they should drink freely of water4 ,cold to the head and spine will be of service in controlling the inflammation2 it should be applied with an ice-cap and a spinal ice-bag4 ,sponging the body should be employed if the temperature is above #ajb ,f4 ,the general bath1 as in typhoid fever1 may be employed if practicable4 ,direct treatment to the bowels1 kidneys1 liver and spleen should be given at each treatment4 ,lumbar puncture and the ,flexner-,jobling serum are considered of value by those who have had an extensive experience4 ,diphtheria ,definition4--,an acute1 infectious disease1 caused by the ,klebs-,loeffler bacillus1 and characterized by a membranous exudation on the mucous membrane of the fauces1 larynx or nose1 and by constitutional symptoms4 ,the presence of the ,klebs-,loeffler bacillus distinguishes true diphtheria from any other form of membranous inflammation4 ,the term diphtheroid is applied to all such forms as are not due to the ,klebs-,loeffler bacillus4 ,osteopathic ,etiology and ,pathology4--,the exciting cause is the ,klebs-,loeffler bacillus4 ,the predisposing cause is obstruction to the circulation of the pharynx and tonsils by subdislocations of upper cervical vertebr1 and even the lower cervical and upper dorsal1 and severely contracted deep muscles of the neck4 ,the stasis of blood favors the growth of the bacillus4 ,link#ee says3 8,the cause of nasal1 pharyngeal or laryngeal diphtheria is obstruction of the blood and lymph through the neck and the obstruction occurs as a result of lesions in the cervical region1 affecting the cervical sympathetics1 or lesions in the upper thoracic region whence the vasomotor fibers arise4 ,a derangement of the vertebral articulation of the first rib is usually found4 7,this affects the stellate ganglion and fibers of the sympathetic chain74 ,these lesions cause a condition of lowered vitality of the mucosa of the nose and throat2 the abnormal secretion favoring the rapid multiplication of the ,klebs-,loeffler bacillus--the exciting cause of the disease40 ,dr4 ,still believed that1 among other lesions1 contracting of tissues involving the scaleni and disturbing the relations of the first rib with the clavicle and vertebra are causative factors4 ,the constitutional symptoms are produced by the toxins generated by the bacillus and absorbed from the diseased spots by the lymphatics and blood-vessels4 ,the bacillus is non-motile and does not usually penetrate the mucosa1 but remains very near the site of the local changes although there are instances where it may enter the blood and other tissues4 ,the bacillus is very resistant and can maintain an existence for months outside of the body4 ,there is great variation in the virulence of the ,klebs-,loeffler bacillus2 it has been found in healthy throats1 and sometimes the bacillus may exist in the throat after an attack of diphtheria for months after all the membrane has disappeared4 ,it has also been found in cases of simple catarrhal angina without membrane1 and in simple tonsillitis ,of the bacteria associated with the bacillus of diphtheria1 the streptococcus pyogenes is the most common and probably the most active4 ,the staphylococcus1 micrococcus lanceolatus and bacillus coli communis are also found4 ,the contagion is communicated1 as a rule1 through the air1 by means of fomites from the membranous exudate or discharges from the diphtheritic patients1 or during convalescence1 from secretions of the nose and throat4 ,infected milk may cause the disease4 ,most cases occur in childhood1 between the second and seventh year4 ,the disease is most prevalent in the cold autumn and spring months4 ,it is most frequently met with in temperate and cold climates4 ,defective drainage1 catarrhal conditions of the throat1 enlarged tonsils1 general weakness1 and feeble resisting power are predisposing factors4 ,one attack does not confer immunity from another1 but rather predisposes to a second4 ,the false membrane is usually found on the tonsils1 the pillars of the fauces and the pharynx1 and in fatal cases it may be extensive and involve the uvula1 the soft palate and the posterior nares1 and even the trachea and bronchi4 ,at first this membrane is yellowish white1 but later may become gray2 it is more or less adherent and when torn off leaves a raw surface4 ,the diphtheritic poison coming in contact with the throat leads to1 first1 a necrosis or death of the epithelial cells1 especially the more superficial1 and the leucocytes4 ,the second change is the hyaline transformation1 and simultaneously coagulation2 hence the term coagulation-necrosis4 ,the irritation produced by the bacilli causes a migration of leucocytes and these are destroyed and undergo hyaline transformation4 ,this process proceeds from without inward and is usually superficial1 and the necrosis may be extensive1 involving the deeper tissues1 causing ulceration and a gangrenous condition of the parts4 ,the erosion of the tonsils may be so severe as to attack the carotid artery4 ,the lymphatic glands are considerably swollen4 ,the spleen is commonly enlarged4 ,the kidneys show parenchymatous changes4 ,the blood is dark and fluid4 ,fatty degeneration of the heart is not infrequent4 ,sometimes fibrinous coagula are found in the heart4 ,capillary bronchitis1 catarrhal pneumonia and areas of collapse are almost constantly found on examination of the lungs in fatal cases4 ,the urine is typically febrile with early albumin and often tube casts and renal epithelium4 ,the blood shows an excess of red blood cells which may reach #g1ejj1jjj4 ,hemoglobin is slightly reduced4 ,there is considerable anemia during convalescence depending upon severity of toxemia4 ,symptoms4--,the incubation period varies from one to ten days1 usually two or three days4 ,according to the location1 diphtheria may be divided into pharyngeal1 laryngeal and nasal forms4 ,in ,pharyngeal ,diphtheria1 which is most common1 there is first a slight chill or chilliness1 followed by fever and sore throat1 both of which increase rapidly4 ,the throat is swollen and red and the patient complains of difficult swallowing4 ,the membrane begins on the tonsils in the form of grayish-white patches2 it then spreads from the tonsils to the soft palate1 sometimes covering the uvula4 ,the cervical glands are swollen and tender4 ,the neck muscles are contracted and somewhat difficult to relax4 ,the temperature rises to #ajb or #ajd degrees ,f4 ,the pulse is rapid and feeble1 ranging from #abj to #adj4 ,there is loss of appetite4 ,there is more or less prostration depending upon the gravity of the constitutional symptoms4 ,the average duration is from one to two weeks4 ,laryngeal ,diphtheria 7,membranous ,croup7 may be secondary to extension from the fauces or it may be primary4 ,at first there is slight hoarseness and a harsh1 metallic1 ringing cough4 ,these symptoms may persist for a day or two1 when the child suddenly becomes worse2 there is marked dyspnea and the lips and finger tips become livid4 ,the child soon becomes very restless4 ,the temperature may be slightly above normal and the pulse increased in frequency4 ,in favorable cases the dyspnea is not very marked and the child probably will have only one or two paroxysms1 when it will fall asleep and wake in the morning feeling very comfortable4 ,the next night1 however1 the attack may be more pronounced4 ,in extreme cases death may result from suffocation4 ,in some cases the suffocation is slower and results from extension of the membrane downward into the bronchi4 ,dr4 ,still found same conditions as in diphtheria1 but also the hyoid is involved with the superior laryngeal nerve4 ,the sacral and lumbar nerves are also involved4 ,he always emphasized chilling of gluteal region as a cause for croup and that heat should be applied at the inception of the disease4 ,nasal ,diphtheria is generally secondary1 but it may be a primary affection4 ,in many cases no membrane is found2 in others there may be a pseudo-membrane formed in the nose1 but there is absence of any systemic disturbance4 ,the ,klebs-,loeffler bacillus is sometimes present in these membranes4 ,nasal diphtheria may be a very grave disease--the constitutional symptoms being great prostration1 high fever1 marked glandular swelling1 irritating and offensive discharges from the nose1 and epistaxis4 ,inflammation occasionally extends through the tear duct to the conjunctiva4 ,a diphtheritic membrane may grow where the skin has been cut or bruised1 but the bacillus cannot live on normal skin4 ,it nourishes on a raw1 moist surface and membranes have grown on the lips1 tongue1 vulva1 glans penis1 and on ulcerative surfaces and wounds4 ,diphtheria occurs occasionally in the conjunctiva and the external auditory meatus4 ,it should be remembered that there are many atypical forms of diphtheria4 ,bacteriological examination should always be made in suspicious and puzzling cases4 ,the complications of diphtheria are nephritis1 hemorrhages1 rashes1 capillary bronchitis1 pulmonary collapse1 catarrhal pneumonia1 myocarditis1 arthritis1 otitis media1 and paralysis4 ,diagnosis4--,the presence of the ,klebs-,loeffler bacillus will at once decide the diagnosis of diphtheria4 ,prognosis4--,the prognosis should always be guarded4 ,the nasal and laryngeal forms are always grave4 ,the causes of death are involvement of the larynx1 septic infection1 heart failure1 bronchopneumonia during convalescence1 and rarely1 uremia4 ,treatment4--,hygienic and prophylactic measures are important4 ,a room should be selected that is ventilated and exposed to the sunlight4 ,all unnecessary articles of furniture should be removed4 ,great care must be taken against the spread of the disease4 ,always isolate the patient and disinfect everything that has come in contact with him4 ,the greatest danger lies in the spread of the disease during convalescence and in the ambulatory form1 when patients are about and coming in contact with individuals1 especially children with catarrhal conditions of the nose and throat4 ,the physician should be careful about disinfecting himself4 ,in view of the fact that many osteopaths have treated successfully numerous cases of diphtheria and that the osteopathic treatment is peculiarly indicated and effective1 the probable requirement of antitoxin 7the use of which we do not feel called upon to discuss7 would be lessened4 ,relative to the antitoxin ,osier says3 8,the principle of action depends on the circumstance that the blood serum of an animal rendered immune1 when introduced into another animal1 protects it from infection with the diphtheria bacilli1 and has also an important curative influence upon diphtheria1 whether artificially given to animals1 or spontaneously acquired by man40 8,the treatment of diphtheria by osteopathic methods is often a pleasure rather than a trial because of the success which rewards us for our efforts4 ,there has been considerable discussion by the members of our profession regarding the methods to be employed in successfully overcoming this disease1 and many have expressed the view that since antitoxic serum is a physiological remedy1 which naturally belongs to all schools of healing1 it should be employed by the osteopathic physician in cases of diphtheria4 ,i have no objections to the use of the serum therapy by members of the profession who conscientiously feel that they need it in their practice to secure the highest success4 ,however1 ,i feel1 on the other hand1 that if they were well acquainted with the technique of the methods 99 99 99 they would not feel it to their advantage1 from the standpoint of success1 to use injections in a single case40--,r4 ,d4 ,,emery1 ,clinical ,osteopathy4 ,the local treatment should be carefully1 but vigorously1 given4 ,by proper treatment of the throat the extension of the disease may be prevented4 ,the muscles about the throat1 especially the deep ones1 should be thoroughly relaxed and the cervical vertebra2 corrected if displaced4 ,the vasomotor nerves to the blood vessels of the affected region require careful treatment at the superior cervical ganglion1 and the cervical lymphatics from the atlas to the first rib should be closely watched4 ,the nerves to control are the vagi1 glosso-pharyngeal1 spinal accessory1 and sympathetic nerves to the pharyngeal plexus1 and in cases of nasal diphtheria the fifth nerve has to be carefully treated4 ,an external treatment to the pharynx will have the greatest effect on these nerves4 ,an internal treatment to the nerves of the soft palate will be of considerable service4 ,the parts diseased should be disinfected and kept as clean as possible4 ,bichloride of mercury 7#a 3 #djjj7 used as a spray will be found satisfactory1 although there are several other disinfectants and germicides that may be used4 ,pellets of ice in the mouth will be a comfort to the patient4 ,cold applied externally will be found best for the adult2 heat externally is better for the child4 ,every possible means should be used to prevent the disease from spreading4 ,one of the chief dangers of diphtheria is the spread of the disease to the larynx1 trachea and bronchi4 ,when the disease has extended to these parts it presents all the symptoms of true croup4 ,the deep cervical muscles should be thoroughly relaxed to aid in relieving the passive hyperemia and with a view of disorganizing the exudate4 ,attention should be given to the upper ribs1 as interferences with the vasomotor nerves of the mucous membrane of the trachea and bronchial tubes usually occur4 ,direct treatment over the larynx and local treatment through the mouth upon the soft palate will be of aid4 ,a thorough relaxation of all the dorsal muscles1 even as low as the tenth dorsal1 should be given4 ,inhalations of slaked1 freshly burnt lime may be useful in loosening the exudation4 ,in desperate cases tracheotomy or intubation of the larynx should be performed4 ,willard#ef says1 relative to membranous croup3 8,it matters not whether or not the laryngeal inflammation was immediately caused by a germ2 it would not1 nor could not1 have been produced by such had there not been an unnatural condition of the circulation of and about the larynx40 ,a constitutional treatment should always be given with a view of preventing the spread of the disease from one organ to another and to prevent complications4 ,the heart's action should be carefully watched throughout the entire course of the disease4 ,treatment of the spinal cord will guard against paralysis that sometimes follows the venous hyperemia of the vascular linings and substance of the brain and spinal cord4 ,pay particular attention to the upper dorsal region to prevent possible heart involvement4 ,post-diphtheritic paralysis seldom if ever occurs in cases that are treated osteopathically4 ,this is a common sequela and is present in from #aj percent to #cj per cent of cases1 appearing within three weeks of apparent recovery4 ,sometimes it is the only result to show diphtheria was present4 ,it seems to follow use of antitoxin rather frequently4 ,attention to the splanchnics and to the abdomen directly will tend to keep the stomach1 liver1 kidneys1 and intestines in a healthy state4 ,the diet of the patient should consist of liquid food--milk1 broths1 meat juice1 raw eggs and barley water4 ,let the patient drink freely of water4 ,treatment of the rectum may be employed with benefit when the pharynx is greatly disturbed4 ,various sequel and complications are best relieved or prevented1 according to ,link1 as follows3 8,first1 limiting the production of toxins by a most thorough relaxation of the muscles of the neck1 thereby favoring the unobstructed circulation of the blood and lymph2 second1 by the correction of lesions which affect the vasomotor of the head and neck2 third1 by spinal treatment affecting the vasomotor to the areas involved2 fourth1 by increasing the activity of the excretory organs1 by treatment in the splanchnic and lumbar areas1 that the toxins may be more rapidly eliminated4 ,in cases where laryngeal stenosis is marked and suffocation is imminent1 intubation should not be delayed40 ,post-diphtheritic paralysis usually yields to osteopathic treatment4 ,apply treatment according to location4 ,dysentery 7,,bloody ,,flux74 ,dysentery is an infectious disease wherein the large intestine is inflamed1 with ulceration of the mucous membrane2 is characterized1 clinically1 by frequent stools containing blood and mucus2 fever and exhaustion4 ,osteopathic lesions of an osseous character and deep muscular contractions of the lumbar region are always present4 ,these involve the vasomotor nerves to blood vessels and lymph channels4 ,catarrh of the intestinal tract is an important predisposing cause4 ,the disease usually occurs in the summer and autumn1 and is more common in hot1 malarial regions1 although it is found in various climates4 ,unhygienic conditions are also important predisposing factors4 ,in no disease more than dysentery does specific correction of the osseous lesion effect quick and satisfactory results4 ,acute ,ileocolitis 7,,bacillary ,,dysentery7 ,this is the variety most frequently found in temperate climates4 ,it occurs either sporadically or endemically4 ,the ,flexner bacillus is frequently found1 as well as pus micro-organisms4 ,there are various strains of the bacillus4 ,there is a catarrhal inflammation of part or the whole of the large bowel4 ,other forms may occur1 as ulcerative and membranous4 ,osteopathic ,etiology and ,pathology4--,sudden atmospheric changes and simple irritants1 such as unripe and indigestible food1 are usually the immediate causes4 ,the predisposing cause of acute catarrhal dysentery is always found by the osteopath to be due to spinal derangements in the lumbar region4 ,the lesion is generally a slight lateral deviation of a vertebra4 ,it is generally found at the second or third lumbar2 still1 the trouble may be found at any point in the lumbar section4 ,the lesion involves vasomotor nerves to the intestinal mucous membrane1 thus causing the inflammation4 ,the drinking of impure water in itself may not be the cause of the disease1 but is a favorable medium for the development of the organisms which may excite it4 ,dyspeptic conditions and constipation seem to predispose to the disease4 ,the mucous membrane is injected and swollen and often covered with bloody mucus4 ,the follicles of ,lieberkuhn are enlarged from retention of their contents1 the result of the swelling2 the follicles are often ruptured and the mucous membrane sloughs off in patches1 forming ulcers4 ,these may extend along the whole colon and frequently into the ileum4 ,symptoms4--,diarrhea is the most common initial symptom2 the stools being copious and painless4 ,the stools soon become small and frequent1 covered with mucus and streaked with blood4 ,these are passed with straining and tenesmus1 accompanied by colicky abdominal pains of a griping character4 ,chills are rare4 ,the tongue is furred and moist3 later it becomes dry4 ,nausea and vomiting may be present1 but not as a rule4 ,there is fever and often excessive thirst4 ,later the stools become green in color1 due to the bile which causes a burning sensation in the rectum4 ,on examination there are found red blood-corpuscles and leucocytes1 and large1 round and oval epithelioid cells containing fat drops and vacuoles4 ,in mild cases1 the course is about eight days2 severe cases subside within four weeks1 but if the osteopathic treatment is careful and specific1 the usual duration can generally be reduced one-half4 ,prognosis4--,the prognosis is generally favorable in the catarrhal form when the disease is treated properly4 ,the previous general health1 hygienic conditions1 and sanitary surroundings are of great importance4 ,when there is ulceration or membranes the prognosis should be guarded4 ,the condition may become chronic4 ,treatment4--,the bowel should be thoroughly washed out by warm water enema1 several times1 if necessary1 to remove irritating material4 ,invariably a lesion of the spinal column is found at the third and fourth lumbars or near by4 ,it is generally a subluxation1 of a lateral nature1 between these vertebr3 rarely is the lesion above or below this point4 ,the treatment should be applied immediately and directly to this region4 ,time is valuable in these cases and one should go to work at once to correct the irritation4 ,an attempt should be made at each treatment to correct the disorder4 ,this should not be delayed by wasting time in relaxing muscles and inhibiting1 for unusually this gives only temporary relief4 ,when a slight movement has been accomplished between disordered vertebr1 treatment should be stopped and results watched1 because the adjustment may have released all obstructions or irritations causing the disease4 ,in many cases1 to get an anatomically correct spine is an impossibility1 from the fact that the displacements may be of long standing and naturally the subluxated vertebr have conformed themselves to some extent to their unnatural position4 ,in other words1 what has been lost in the position and relation of a vertebra may have been compensated by reducing the effect of the lesion to a minimum4 ,a lesion of this nature at the third lumbar impairs the innervation to the colon and consequently produces a stasis of blood in the mesenteric circulation1 followed by inflammation1 bloody discharges1 cramps1 etc4 ,a single treatment is usually quite sufficient in milder cases4 ,other cases require treatment every few hours or thereabouts1 until recovery4 ,treatment directly over the abdomen through the mesenteric circulation and glands is an effective treatment in most cases and especially when the attack is severe4 ,it relaxes the tissues about the mesentery1 thereby relieving the stasis and freeing the circulation4 ,the greatest care1 however should be exercised in giving this treatment4 ,the constant desire to defecate1 that is common to many cases1 is a very annoying symptom4 ,strong1 thorough treatment over the sacral region1 by inhibition over the sacral foramina and by relaxing the tense muscles of the sacrum1 will relieve this condition4 ,in relaxing these muscles1 place the whole hand against the muscles and push upward toward the occiput4 ,this treatment inhibits the nerves to the rectum and lessens the tenesmus4 ,attention should be paid to the liver to keep it active4 ,washing out the large bowel with tepid water produces a soothing effect1 besides having a tendency to allay inflammation4 ,the blandest of liquid foods1 as peptonized or boiled milk1 broths1 beef juice1 barley and rice1 should be given4 ,the patient should remain in bed until completely cured4 ,amebic or ,tropical ,dysentery ,this form prevails in the tropical and subtropical countries for the most part1 and is caused by an animal parasite1 the ameba dysenteriae4 ,this is constantly found in the stools1 the tissue of the intestine and also in the pus of the liver abscesses1 which are secondary to dysentery4 ,amebae are sometimes found in the stools of healthy men1 having probably entered the system through the drinking water or uncooked food4 ,pathologically1 the mucous membrane of part or whole of the large intestine is swollen4 ,round or irregular ulcers which undermine the mucous membrane1 especially of cecum1 ascending and pelvic colon1 are found4 ,in later stages there is infiltration of the connective tissue followed by necrosis4 ,in some cases false membranes and sloughs are formed4 ,symptoms4--,the onset may be either sudden or gradual1 with a very irregular diarrhea1 moderate fever1 and copious1 liquid stools1 abounding with the amebae coli4 ,the straining may be less severe and persistent than in catarrhal dysentery and may be absent4 ,sometimes there is nausea and vomiting4 ,abscess of the liver is the most common complication1 which may be single or multiple4 ,when single it usually involves the right lobe4 ,multiple abscesses are small4 ,the more recent abscess walls are necrotic2 the older have whitish1 smooth1 fibrous walls4 ,these abscesses do not contain pure pus1 but a fatty and granular debris containing the amebae and a few cellular elements4 ,sometimes they extend into the lung4 ,diagnosis4--,this depends upon severity of attack and general condition of the patient4 ,relapses often occur and the case may become chronic4 ,cases have been treated osteopathically with success4 ,treatment4--,in this form of dysentery the treatment is largely the same as in acute ileo-colitis4 ,the spinal lesions affect the innervation to the intestine1 thus producing a stasis in the circulation2 this condition favoring1 and in fact1 inviting the retention of the ameba coli in the system at this point4 ,the diet is the same as in other forms of dysentery4 ,rectal injections and hot applications to the abdomen are useful4 ,in all cases where strong treatment has been given to the spinal column1 a quieting treatment to the nervous system and an inhibitory treatment to the heart will be gratefully received by the sufferer4 ,both of these effects can be accomplished at the same time by simple inhibition to the occipital nerves4 ,the stools should be taken care of immediately and disinfected4 ,ice water enemas given frequently are reported as giving good results4 ,for the tenesmus1 inhibit strongly at #c;d1 and #dth1 sacrals4 ,chronic ,dysentery ,this is generally resultant from an acute attack1 though the amebic form may be subacute from the onset4 ,pathologically1 the coats are generally thickened1 especially the submucosa and the muscular coats being hypertrophied4 ,ulcers are usually present1 although there are cases in which there are no ulcers4 ,cicatricial contractions sometimes follow and the calibre of the bowels is reduced1 strictures being rare4 ,symptoms4--,there is a progressive loss of flesh and strength1 little or no tenesmus1 slight1 colicky pain and extreme anemia4 ,the stools contain mucus1 at times blood1 and the bowels move from two to twelve times a day4 ,diagnosis4--,the history of the initial symptoms will establish the diagnosis4 ,it is not always possible to distinguish between chronic dysentery and chronic diarrhea4 ,the duration is from a few months to several years1 although osteopathic treatment has proven very efficient in many instances4 ,treatment4--,rest and a liquid diet are most essential4 ,foods that are easily assimilable and nourishing1 with a minimum amount of residue1 are required4 ,beef juice1 beef peptonoids and peptonized milk are the types of food4 ,change of air1 hygienic measures and environment are important4 ,in cases that become chronic1 the spinal column oftentimes exhibits lesions above and below the lumbar region4 ,undoubtedly they are lesions of secondary importance in comparison to the lumbar lesions1 but it is important that they be corrected4 ,the treatment requires thorough1 careful work of the disordered spinal column and lower ribs4 ,occasionally a slight kyphosis is present in the dorso-lumbar region that demands persistent work in order to correct it4 ,an occasional rectal injection is beneficial1 especially in cases that have slight ulceration of the sigmoid flexure or rectum causing colicky pains and a few loose stools in the morning1 the patient being fairly comfortable during the rest of the day4 ,erysipelas ,definition4--,an acute1 infectious1 specific disease1 characterized by a peculiar inflammation of the skin1 due to the streptococcus erysipelatis1 with a tendency to spread4 ,osteopathic ,etiology and ,pathology4--,osteopathically1 lesions are found to the vasomotor nerves and lymphatics of the affected area4 ,dr4 ,still gives lesions of the 8inferior maxilla1 the cervical vertebr1 the clavicles or the upper ribs0 as specially important factors4 ,these lead to congestion and predispose to infection4 ,it occurs in epidemic form1 especially in the late winter and spring4 ,one attack predisposes to a second4 ,family predisposition exercises a slight influence4 ,abrasions1 lacerated wounds1 especially of the scalp1 may be the starting point of an attack4 ,persons having skin diseases and wounds1 and women who have been recently delivered are liable to be affected4 ,chronic ,bright's disease1 chronic alcoholism1 syphilis1 debility1 phthisis1 organic heart disease and unhygienic surroundings are predisposing causes4 ,the specific virus is the streptococcus erysipelatis1 which acts as a local irritant producing the dermatitis4 ,these are found in the lymph vessels and cutaneous connective tissue4 ,the fever and constitutional symptoms are due to toxic agents4 ,it is an inflammation of the skin1 and if uncomplicated1 no other structures are involved4 ,subcutaneous and mucous tissues may be involved1 but rarely2 if so1 there is apt to be suppuration4 ,visceral complications are of a septic character4 ,endocarditis1 pericarditis1 pleuritis-pneumonia1 and nephritis are possible complications4 ,symptoms4--,the incubation period varies from two to seven days4 ,the onset is generally sudden with chill1 followed by fever1 #ajd or #aje degrees ,f4 ,there may be nausea1 headache1 and pain in the back and limbs4 ,the local inflammation of the skin follows1 usually on cheeks and bridge of nose1 or at site of an abraded surface4 ,the area is red1 smooth1 and edematous4 ,it spreads rapidly1 the patch being elevated above the surrounding tissue and tense4 ,the swelling may be so great as to close the eyes and distort the features4 ,the cervical glands are swollen4 ,the temperature continues high for four or five days and falls by crisis4 ,the eruption begins to subside and a moderate desquamation occurs4 ,if the disease takes a fresh start the fever again rises and continues as long as the disease spreads4 ,there is usually headache and sometimes delirium4 ,the tongue is furred1 and bowels constipated and the urine scanty4 ,as a result of intense infiltration the part may become gangrenous4 ,suppuration frequently occurs in facial erysipelas4 ,the inflammation may extend to the mucous membrane of the throat and mouth4 ,diagnosis4--,this is not difficult4 ,the fever1 the acuteness of the disease1 the rapidily spreading eruption1 and the constitutional disturbances will serve to distinguish it from all others4 ,prognosis4--,this is usually favorable2 healthy persons rarely die4 ,convalescence may be slow4 ,treatment4--,isolate the patient for the disease is contagious1 and a third person may convey the virus4 ,the poison may cling to clothing1 furniture1 etc4 ,the physician should not take care of confinement cases4 ,a number of cases of erysipelas have been cured by correcting disorders in the region of the second1 third1 fourth and fifth dorsals4 ,the lesions are principally subluxations of the ribs and severely contracted muscles4 ,the disorder at the points named interferes with the vasomotor nerves to the face1 thus predisposing to an attack of erysipelas by allowing the micro-organism congenial tissue for its devastations4 ,in many other cases derangements have been found higher than the upper dorsal1 principally through the middle and upper cervical vertebr4 ,lesions in these regions would also interfere with vasomotor fibres1 especially through the fifth nerve directly4 ,the treatments on the whole are to examine for lesions to the innervation of the affected region and remove them1 besides giving special attention to the bowels1 a nutritious diet1 and absolute rest4 ,in cases where there is much restlessness and insomnia1 treat the upper cervical region1 especially the deep posterior muscles#eg4 ,locally1 use cold water applications2 adhesive strips applied near the inflamed area or tincture of iodine1 may prevent the disease spreading4 ,yellow ,fever ,definition4--,an acute1 infectious disease1 characterized by a febrile paroxysm followed by short remission and then relapse1 jaundice1 toxemia1 suppression of the urine1 and gastric hemorrhage4 ,osteopathic ,etiology and ,pathology4--,while a specific germ is the cause of yellow fever1 it has not as yet been isolated4 ,extended tests by ,united ,states ,army surgeons in ,cuba show conclusively that the infection is alone carried by the stegomyia fasciata1 but 8,it remains somewhat uncertain whether the mosquito is the sole means of transmission40 7,anders74 ,season is the chief predisposing cause as the outbreak is usually in summer and a frost ends its spread4 ,immunity is generally conferred by one attack4 ,tucker#eh noted that all cases examined had liver lesions and that most of the patients were of the malarial or bilious type4 ,spinal lesions were not marked in some cases1 but when present were in the liver and renal areas4 ,tete#ei believes it to be a virus secreted in the human organism under certain atmospheric and other conditions in certain types1 i4 e4 people subject to hepatic and renal disturbances4 ,he also says the vagus is an important factor4 ,pathologically1 there is more or less jaundice and hemorrhagic extravasations under the skin4 ,the blood serum is red-tinted1 owing to the destruction of the red cells4 ,the liver is pale and presents extensive fatty degeneration1 with necrotic masses in and between the cells4 ,the gastro-intestinal mucous membrane is swollen1 congested and presents numerous minute hemorrhages4 ,the kidneys show parenchymatous inflammation4 ,the spleen is not enlarged4 ,the heart sometimes shows fatty degeneration4 ,the stomach contains more or less of the 8black vomit10 which is a mixture of transuded serum and transformed blood pigment4 ,symptoms4--,the incubation period varies from one to five days4 ,the attack generally begins with a chill1 fever1 #ajb to #aje degrees1 headache and pains in the loins and legs4 ,the pulse is accelerated1 the face is flushed1 the tongue is coated1 the throat sore1 the bowels constipated and the urine scanty and albuminous4 ,recent observers state that bile is present in most cases before the albumin is noted4 ,nausea and vomiting may be present at the onset1 but become more severe about the second or third day when the black vomit appears4 ,the febrile stage or stage of invasion1 lasts from a few hours to several days and is followed by a decline in the fever when the severity of the other symptoms abates4 ,this is called the stage of remission and in favorable cases convalescence sets in or the patient may pass into the second febrile paroxysm4 ,the temperature rises again1 jaundice appears rapidly1 nausea and vomiting return4 ,the tongue becomes dry and coated4 ,the stools are black and offensive1 the urine is albuminous1 scanty and may be suppressed2 there may also be hematuria4 ,death may occur from exhaustion or from uremia4 ,recovery may follow the gravest symptoms1 even when there has been black vomit4 ,the duration of the entire attack covers about one week4 ,relapses sometimes occur4 ,price says there is a point in differential diagnosis in yellow fever and it is a symptom not met with in any other febrile affection4 ,it is the progressive fall of the pulse-rate during the congestive stage of the first sixty or seventy hours1 i4 e41 a variation of from five to ten beats less each morning and evening4 ,he adds1 8,as long as the kidneys are active there is but little to fear40 ,diagnosis4--,remittent fever has not the deep jaundice1 the clear mind1 the black vomit1 or the albuminuria of yellow fever4 ,the enlarged spleen and the presence of the organism of ,laveran in the blood in remittent fever will decide the diagnosis4 ,dengue is sometimes confused with yellow fever4 ,prognosis4--,this is always a grave disease1 and in its severe forms very fatal4 ,recovery1 however1 may occur after the severest symptoms have been manifested4 ,black vomit is not always a fatal sign4 ,enough cases have been treated osteopathically to state that osteopathy is particularly effective4 ,improved sanitation is doing much to reduce mortality4 ,treatment4--,prophylactic treatment should be carefully carried out4 ,all patients should be quarantined and carefully screened so they cannot be bitten by the mosquito and the disease spread further4 ,people that are not acclimated should keep away from infected districts4 ,all pools1 cisterns and other places which can breed mosquitoes should be drained or screened4 ,a systematic warfare should be waged against them4 ,the patient must be put to bed at once and plentifully supplied with fresh air4 ,everything must be scrupulously clean--body and bed linen4 ,use a tube for nourishment and a bed-pan for excretions as the patient must not make the slightest exertion4 ,spinal lesions may or may not be found4 ,they have been observed in the cervical1 eighth dorsal and second lumbar4 ,the treatment on the whole is symptomatic4 ,the chills and fever of the first stage should be controlled by thorough work at the upper cervical1 upper dorsal1 lower dorsal and lower lumbar regions4 ,treatment at these points controls the superficial and deep vascular areas of the body through the vasomotor nerves4 ,the irritable stomach1 delirium and severe neuralgic pains of the head1 back1 epigastrium and limbs are to be treated according to the conditions and severity of the symptoms4 ,the kidneys and bowels should be watched carefully1 and at the onset should be freely opened and control of the kidneys never lost4 ,let the patient drink freely of water1 which will aid4 ,hydrotherapeutic measures1 as a cold bath or sponging1 may be employed to aid in controlling the fever1 the nervous symptoms1 and the eliminative power of the excretory organs4 ,discontinue the use of hydrotherapy when a spontaneous fall of temperature occurs4 ,at the beginning of the first stage and during the stage of remission are the periods that the osteopath should do very effectual work by paying particular attention to the four large vascular areas of the body1 viz43 head1 lungs1 abdomen and legs4 ,treat the vasomotor nerves to these regions1 thoroughly1 as given in the treatment of the first stage4 ,during the third stage everything should be done that is possible to support the system4 ,ice slowly dissolved in the mouth will be of aid to an irritable stomach4 ,hemorrhages and the various symptoms are to be treated as they arise4 ,good nursing1 dieting1 ventilation and keeping the skin1 kidneys and bowels active are the primary points to consider4 ,during the period of depression1 the heart must be closely watched4 ,the diet should be a light1 liquid one1 of the nature of peptonized milk or light broths4 ,no food is recommended by some at the onset nor until the crisis is passed4 ,others feed during the stage of remission and give stimulants4 ,during the last stage rectal feeding is suggested if gastric irritability is pronounced4 ,tetanus 7,,lock-,,jaw7 ,definition4--,an infectious disease1 caused by ,nicolaier's tetanus bacillus1 characterized by persistent1 tonic spasms of the muscles with violent exacerbations4 ,etiology and ,pathology4--,the exciting cause of tetanus is a specific bacillus which usually gains access to the system through some wound4 ,the site of infection is the only place the germs are found4 ,the disease is much more prevalent in some localities than in others4 ,it is found in hot countries1 as in ,india and the ,west ,indies1 far more commonly than in temperate regions4 ,exposure to damp cold is one of the recognized causes1 also those localities where there are rapid changes from cold4 ,such regions seem to produce conditions favorable to the existence and growth of the bacilli4 ,earth mould1 particularly where putrefaction is taking place1 as in soil that has been manured1 is especially favorable to the existence of the bacillus4 ,it is frequently found in the intestinal tract of the horse1 so that the soil about stables is apt to contain the germs4 ,the highly fertilized soil of ,france and ,belgium rendered it a special menace to the wounded of the ,great ,war4 ,antitetanic serum1 according to all reports1 was particularly efficacious4 ,wounds and abrasions of various kinds1 particularly contused and punctured wounds of the hands and feet1 favor the excitation of tetanus4 ,when an open wound is present1 the term traumatic tetanus is given to the disease2 idiopathic tetanus when no wound is discoverable2 tetanus neonatorum when it attacks infants--this form is usually due to insanitary conditions1 especially the improper care of the umbilical cord2 lock-jaw or trismus when the jaw alone is affected2 cephalic tetanus when the throat and face is involved4 ,characteristic lesions have not been found in the cord or the brain4 ,the bacilli develop at the site of the wound where the toxin is manufactured4 ,the bacilli do not invade the blood and organs4 ,the toxalbumin is one of the most virulent poisons known4 ,congestion occurs in various organs1 due to obstruction of the movement of the blood during a spasm4 ,the brain1 cord1 lungs and muscles are congested4 ,the nerves are often found swollen4 ,symptoms4--,the period of incubation is from one to twenty days4 ,this is time required for the poison 8to be absorbed by the end plates in the muscles and to pass up the motor nerves to the spinal cord40 ,in most cases the incubation is from five to ten days4 ,a chill precedes other symptoms in a few cases4 ,the onset is quite sudden1 with stiffness in the neck1 jaw and tongue4 ,there are headache1 stomach disturbance and languor4 ,opening the mouth is difficult1 but is not painful4 ,deglutition is difficult4 ,the stiffness increases and extends to the spinal muscles1 abdomen and legs which are held in a firm spasm4 ,thus1 the trunk and legs are inflexible4 ,these symptoms vary in degree of severity1 dependent upon the extent of involvement4 ,the jaws may be firmly locked or they may yield to forced extension--8lock-jaw40 ,the muscles of the face may be involved1 the angle of the mouth drawn out1 and the eyebrows raised--8risus sardonicus40 ,the neck and trunk muscles affected produce opisthotonos4 ,spasms of the pharynx and esophagus may occur1 especially when there are injuries to the fifth nerve4 ,associated with these tonic convulsions is intense pain4 ,the distress of the patient is extreme when the chest muscles are affected4 ,all symptoms are increased during the paroxysm4 ,a foot fall1 the slamming of a door1 a draught of air or any slight sensory impression may excite a paroxysm4 ,the paroxysm may relax and during the interval the patient may walk about4 ,the spasms vary in frequency from a few minutes to one in several hours4 ,during spontaneous or induced sleep the spasm usually ceases4 ,the febrile reaction is generally slight and apparently of nervous origin2 in many cases #ajb degrees ,f4 ,in severe cases the temperature may be considerably higher4 ,perspiration is excessive4 ,the urine is scanty and high colored4 ,the bowels are usually constipated4 ,the mind remains clear throughout4 ,death is generally caused by exhaustion4 ,chronic tetanus presents similar symptoms1 but less marked1 and it develops slowly4 ,diagnosis4--,the history of a wound followed by the characteristic symptoms would rarely occasion an error4 ,strychnine poisoning differs from tetanus in the history1 in the more rapid development of the symptoms1 no trismus at the beginning1 marked involvement of the extremities1 and absence of rigidity between the paroxysms4 ,in tetany the extremities are chiefly affected by the spasms1 the muscles are relaxed during intervals1 and trismus is a late or very rare condition4 ,in hydrophobia trismus does not occur and the respiratory spasm is caused by attempts at swallowing4 ,the mental symptoms increase4 ,prognosis4--,the prognosis is unfavorable4 ,eighty per cent of traumatic and fifty per cent of the idiopathic cases prove fatal4 ,cases that are fatal usually die within six days4 ,cases where there is slight elevation of temperature1 and where the spasm is localized to the muscles of the face1 neck and jaw1 or where muscle stiffness is late in appearing1 are more likely to recover4 ,treatment4--,free incision and thorough disinfection with hydrogen peroxide and cauterization with pure carbolic acid1 of the wound are necessary4 ,the patient should be put in a dark room and there remain as quietly as possible4 ,avoid all sources of peripheral irritation4 ,liquid food is to be given1 and if the jaws are firmly set1 rectal feeding may be employed or food may be passed through the nose with a catheter4 ,for the spasms1 strong inhibition of the nerve centers controlling the affected muscles may be of use4 ,probably the most effectual treatment for the paroxysms would be strong1 thorough treatment of the upper cervical region4 ,hot baths give relief to the spasms4 ,all the excretory organs should be greatly stimulated1 particularly the kidneys1 lungs and bowels4 ,other symptoms are to be treated as they arise4 ,tetanus antitoxin is highly commended by surgeons who used it during the ,great ,war4 ,as death is at a two to one ratio any method of treatment is justified4 ,a few cases have been treated osteopathically with fair success1 following antiseptic measures4 ,simple ,continued ,fever ,definition4--,an acute1 febrile disease1 mild in character1 of short duration1 not excited by any special organism and depending on a variety of irritating causes4 ,osteopathic ,etiology4--,the most frequent cause of this form of fever is probably gastro-intestinal disturbance4 ,in children it may be due to gastro-intestinal derangement1 or to the eating of decomposing food or to exposure to wet and cold4 ,it may be caused by exposure to the sun or great heat1 or mental or physical fatigue4 ,it may be the result of exposure to cold sufficient to produce a slight bronchitis1 tonsillitis or other affection producing an unnoticed localized inflammation4 ,it may follow a prolonged exposure to noxious odors or gas4 ,lesions1 osseous or muscular1 are always present1 corresponding to the tissues and organs disturbed4 ,muscular lesions1 especially1 are prominent4 ,symptoms4--,the onset is usually sudden with a feeling of lassitude1 weariness1 chilliness1 and headache4 ,the temperature rises quickly to #ajb or #ajc degrees ,f4 or over1 and is usually apt to terminate suddenly by crisis on the third or fourth day4 ,the pulse is frequent and the face is flushed4 ,the child is often irritable4 ,mild delirium may occur4 ,anorexia is present1 and the bowels are constipated4 ,convalescence is rapid4 ,diagnosis4--,this depends upon excluding other probable diseases4 ,if the fever cannot be attributed to some of the causes already referred to1 there may be a doubt as to its character for the first twenty-four hours1 but1 if after a careful examination1 one finds no other cause and no symptoms develop of any of the recognized diseases1 acute continued fever can hardly be mistaken for any other disease4 ,prognosis4--,always favorable1 recovery without sequel being the rule4 ,treatment4--,it is necessary to find out the irritative cause in order for one to be able to treat intelligently4 ,rest in bed with treatment of the disturbing factor of the disease1 whatever that may be1 is the principal treatment to be given4 ,careful examination of all the organs1 with due consideration of the symptoms1 will generally leave no doubt as to the cause1 and treatment applied accordingly will be sufficient4 ,if there is any gastro-intestinal disorder1 thorough treatment of the splanchnics1 anterior treatment to the abdomen and thorough evacuation of the bowels are indicated4 ,use an enema if necessary4 ,besides the usual fever treatment1 sponging the body with tepid water at the time of day when the fever is highest will aid in lessening the temperature and render the patient more comfortable4 ,in cases where nervous symptoms are prominent1 care should be taken against any excitement and1 if insomnia results1 a quieting treatment in the cervical region is usually sufficient4 ,use plenty of water internally1 which is not only necessary for the tissues on account of the fever1 but is of great aid in keeping the skin and kidneys active1 and thus a great help in the elimination of waste material4 ,a liquid1 nutritious diet is best4 ,milk1 broths and soups will be enough4 ,the demands on the digestive tract are not great when a light diet is administered1 besides not exciting the nervous and vascular systems unduly4 ,tuberculosis ,definition4--,a general or local infectious disease caused by the bacillus tuberculosis of ,koch4 ,the bacillus produces specific lesions of the form of nodular bodies called tubercles that undergo caseous necrosis with a tendency to involve neighboring tissue4 ,there may be a diffusion of the infection by way of the lymph and blood vessels to various tissues and organs4 ,osteopathic ,etiology and ,pathology4--,tuberculosis exists in all countries4 ,it generally prevails more extensively in warm than in cold climates1 and is of more frequent occurrence in the city than in the country4 ,altitude1 however1 exerts more influence than latitude4 ,the disease rarely occurs in mountainous countries1 owing to the purity of the atmosphere4 ,the disease is very prevalent in the ,west ,indies and the ,south ,sea ,islands4 ,tuberculosis is frequently met with in ,canada among the ,french ,canadians and the ,english4 ,all races are subject to tuberculosis1 but the ,indians of this continent1 the ,south ,sea ,islanders and the colored race are very susceptible to the disease4 ,it is estimated that from seven to ten percent of the present death rate in the ,united ,states is due to tuberculosis4 ,the tubercle bacillus was discovered by ,koch in #ahha4 ,it is a short1 straight or slightly bent1 rod4 ,this bacillus has an exceedingly tenacious hold on life and is found in greater or less numbers in all tuberculous lesions4 ,it can live almost indefinitely outside the body4 ,the bacilli are found in great numbers in the sputum1 which dries and flies in the atmosphere in the form of dust4 ,the organism is thus widely spread in regions frequented by phthisical patients4 ,the bacillus gains entrance into the body by way of the respiratory tract in the vast majority of cases4 ,milk from tuberculous cows will produce the disease1 especially in children1 causing intestinal and mesenteric tuberculosis4 ,the meat of tuberculous animals is not necessarily infectious1 although there is a possibility of infection by this means4 ,tuberculosis may be transmitted by direct inoculation2 this does not often occur in man1 but when it does1 the disease usually remains local1 although general infection may occur4 ,persons who follow certain occupations1 as butchers1 dissectors of dead bodies1 and handlers of hides1 are more or less subject to local tubercles of the skin4 ,the virus may enter the body through any fissure or excoriation on the skin2 thus by washing the clothes or bed linen of phthisical patients1 by the bite of a consumptive1 or by a cut from a broken sputum glass of a consumptive1 one may become infected4 ,it is stated that there may be hereditary transmission4 ,in some cases the virus may be transmitted and the disease may not appear for many years4 ,predisposing ,causes4--,hereditary predisposition1 which renders the person more liable to accidental infection2 delicate constitution2 scrofulous tendency2 previous infectious diseases1 as influenza1 whooping cough1 measles1 typhoid fever2 diabetes mellitus1 etc4 ,in young children meningeal1 mesenteric and lymphatic forms of tuberculosis are the most frequent4 ,pulmonary tuberculosis is usually met with in adults1 especially between twenty and thirty years or age4 ,the development of tuberculosis is favored by damp localities2 by improper and insufficient food2 constant inhalation of impure air2 injuries to the chest1 with or without laceration of the lungs1 and various osteopathic lesions that weaken the tissue through faulty nutrition4 ,corresponding to the innervation of the organ or tissue diseased will always be found anatomical derangements4 8,every case has a defective spine and thorax40 7,hayden#fj74 ,bronchial catarrh1 tonsillitis1 diseases of the stomach and intestines1 especially enterocolitis1 tubercular pneumonia1 pleurisy 7rarely71 intrathoracic tumors and congenital or acquired contraction of the orifice of the pulmonary artery increase the susceptibility to infection4 ,lessened vitality of the tissues1 whether inherited or acquired1 is necessary before the germ can become implanted and proliferate1 producing tuberculosis of the tissues and organs4 ,in nearly every instance1 when the lungs are involved1 lesions are found at the second1 third1 or fourth ribs4 ,these lesions undoubtedly predispose to the tubercular infection1 by lessening the vitality of the lung tissues through interference with the innervation or vascular supply4 ,possibly a lesion at the second rib or second dorsal vertebra would interfere directly with the vasomotor nerves of the upper thoracic ganglia4 ,the condition of the middle and lower cervical vertebr should be carefully examined1 for lesions at that point would involve the lymphatics of the lungs4 ,the lowered vitality caused by the lesion is the predisposing cause and the tubercular bacillus is the exciting cause which determine the character of the affection4 ,c4 ,a4 ,whiting in ,clinical ,osteopathy says3 8,the spinal outline characteristic of tuberculosis and of the pretubercular stages presents the following peculiarities3 ,the cervical spine presents various abnormalities1 usually lesions involving single vertebr and associated with irregular muscular tensions4 ,the upper thoracic spine is anterior1 the ribs drooping and rather more freely movable than normal2 the vertebral articulations are less movable than normal2 the tissues in the neighborhood of the upper two or three dorsal spines are abnormally sensitive and the muscles innervated from these segments are contracted irregularly when the disease involves the apices4 ,the lower interscapular region is found sensitive and these muscles are contracted when the lower lobes of the lung are involved1 and the location of these sensitive areas may be employed in the localization of the lung area infected4 8,in every case recorded in this clinic1 lesions involving the area of the origin of the upper and middle splanchnic nerves have been found4 ,the typical tuberculosis spine must include lesions of the lower dorsal area4 ,probably these lesions are predisposing factors in tuberculosis1 partly because of the effects produced upon nutrition thereby1 but doubtless the lack of the normal mobility of this part of the spine prevents the normal stimulation of the liver1 the spleen1 perhaps the pancreas1 thus the normal opsonic index is lost1 and immunity broken4 ,the treatment of tubercular cases should include careful attention to the splanchnic area1 the maintenance of the normal mobility and structural relationship of the entire spinal column1 and such stimulating movements to the ninth and tenth thoracic neighborhood as is indicated in each individual case40 ,pathology4--,in adults the most common site of tubercles is the lungs2 in children it is the lymphatic glands1 joints and bones4 ,no organ is exempt2 the salivary glands and pancreas are the least frequently involved4 ,the military tubercle is the beginning of tubercular deposits4 ,this may develop in any tissue where the tubercle bacillus is found and it is only distinguished by the presence of a tubercle bacillus1 as similar conditions are produced by the aspergillus glaucus and actinomyces4 ,in the development of a tubercle there is proliferation of the fixed tissue cells1 particularly those of the connective tissue and the endothelium of the capillaries1 due to the irritation of the bacillus1 producing the epithelioid cells and in some instances the giant cells1 in both of which bacilli may be found4 ,the epithelioid cells vary in shape4 ,the giant cells are formed by enlargements of the epithelioid cells and a repeated division of their nuclei or possibly by fusion of several cells4 ,on account of the inflammation produced by the bacillus1 there is migration of leucocytes from the adjacent vessels and lymphoid cells4 ,the leucocytes are largely polynuclear and are rapidly destroyed1 but later mononuclear leucocytes appear1 which are able to resist the action of the bacilli so that they are not so readily destroyed4 ,a reticulum of connective tissue is formed around the various cells4 ,the tubercles are non-vascular and when once formed undergo caseation and sclerosis4 ,caseation is a process of coagulation-necrosis or destructive change1 beginning at the central part of the growth1 due to the action of the bacilli4 ,the primarily transparent tubercular tissue may become a gray gelatinous body containing bacilli4 ,frequently the caseation is followed by softening2 less frequently1 calcification1 or it may be surrounded by fibrous tissue4 ,during the time the cell destruction is going on at the center of the tubercle1 hyaline and fibrous changes may render the tissues sclerotic4 ,these changes1 caseation1 the destruction of forces1 which are dangerous to the patient1 or sclerosis1 which is a healing process1 depend upon the power of the body to produce an antitoxin to overcome the effects of the special toxin produced by the bacilli4 ,there may be a widespread tuberculous involvement4 ,this is the result of fusion of the new foci of infection or of miliary tubercles4 ,the lungs are the usual site of infection1 varying from a small area1 to a lobe or a still greater area4 ,the irritation of the bacilli is capable of producing associated inflammatory processes in its own neighborhood4 ,there may be an overgrowth of interstitial tissue4 ,in other instances1 changes to catarrhal or croupous pneumonia may occur4 ,suppuration is associated with tuberculosis1 especially of the lungs1 and is due to a mixed infection or the presence of pus organisms4 ,some authorities claim that the tubercle bacilli alone are able to produce suppuration2 it is1 however1 more probable that suppuration is due to a mixed infection4 ,the constitutional features in tuberculosis are more dependent upon this secondary infection1 especially by the streptococci1 than upon the primary infection4 ,tuberculosis of the ,lymph ,glands 7,,scrofula7 ,scrofula is a true tuberculosis of the lymphatic glands4 ,the virus is less virulent than that from other sources1 which accounts for the slow development and milder course of tuberculosis of the glandular system4 ,tuberculous ,adenitis may occur at all ages1 but is most common in children and young adults4 ,it is rarely congenital4 ,catarrhal inflammation of the mucous tissues weakens the resisting power of the lymph tissue1 thus allowing the bacilli to develop1 and is an important predisposing cause4 ,the glands most frequently affected are those of the neck2 more rarely there is involvement of all the lymphatic glands of the body4 ,invariably lesions of the upper and middle cervical vertebr and upper dorsals and corresponding ribs are found1 as well as lesions to the lymphatics at various points along the spinal column and ribs4 ,these lesions affect the innervation to the lymph glands1 as well as mucous membranes1 and thus predispose to the disease4 ,in all cases anatomical derangements are found in the region of the innervation to the involved gland4 ,in general tuberculous adenitis all the lymph glands of the body are more or less involved1 while the other organs and tissues are rarely affected4 ,all the visible glands are found to be swollen1 tender and painful4 ,there is more or less protracted fever1 with wasting and debility4 ,this is a rare affection4 ,in local adenitis the glands of the neck are most frequently affected and this is especially the case with children4 ,negroes are more frequently affected than whites4 ,it is seen especially among those living in an unsanitary environment4 ,measles1 whooping cough and an hereditary tendency are predisposing factors4 ,the submaxillary glands are usually the first affected4 ,at first they are swollen to various degrees and are tender2 later they suppurate and rupture if one is not able to cure them4 ,there may be fever4 ,the skin over the glands is usually freely movable2 it may1 however1 be adherent4 ,the glands above the clavicle1 those in the posterior cervical triangle1 and the axillary glands may all be affected4 ,in such cases it is likely that the bronchial glands are also involved and may infect the living tissue4 ,lesions of the upper and middle cervicals and deep muscles are always found and undoubtedly are the underlying causes4 ,lesions of the lower cervical1 upper dorsal1 ribs and clavicle1 are of frequent occurrence4 ,infection may gain entrance by way of the pharynx and tonsils4 ,the affection often runs a slow course4 ,the bronchial glands may be affected primarily1 but usually secondarily to infection of the lungs4 ,the primary form is seen most commonly in children and is apt to be associated with suppuration4 ,lesions of the upper and middle dorsals and of the cervicals will be found4 ,catarrh of the bronchial tubes is a predisposing cause4 ,the ,x-ray is of great value in the diagnosis4 ,the most noticeable symptoms are those due to pressure or irritation4 ,systemic infection may follow rupture into a vessel4 ,local infection of the lung may occur and the pericardium become infected4 ,mesenteric cases occur among children and may be primary or secondary4 ,the primary form is rare4 ,swallowed sputum is a frequent cause4 ,the trunk and limbs are puny4 ,the child is anemic1 and often the abdomen is tympanitic4 ,diarrhea is marked and there is pain and indigestion4 ,fever is almost constantly present and of an intermittent type4 ,the disease is most frequently met with among poor children in unhygienic1 poorly ventilated houses4 ,there may be an associated tuberculosis of the peritoneum4 ,acute ,tuberculosis ,this shows best the truly infectious nature of tuberculosis4 ,in it miliary tubercles develop in many and various parts of the body4 ,in some cases these growths seem to be uniformly distributed throughout all the viscera4 ,in other instances they are localized in the lungs or in the meninges of the brain4 ,in nearly every instance it is an auto-infection1 arising from an old tuberculous focus1 which may be latent and quite unsuspected4 ,general infection1 in most instances1 arises from the rupture of a nodule into a vein1 from tuberculous lymph glands1 tuberculosis of the bones1 joints1 or even the skin4 ,general ,miliary ,tuberculosis or ,typhoid ,form4--,this is similar to a general infection of the body and resembles1 to a marked degree1 the symptoms of typhoid fever4 ,the onset is rarely rapid4 ,in most cases there is a period of incubation1 during which the health fails1 the appetite is lost1 headache occurs1 and the patient soon becomes feverish1 with increased debility4 ,the temperature rises and the pulse is rapid and feeble4 ,the tongue is dry4 ,the respirations are increased4 ,delirium may be present4 ,in rare cases1 there may be little or no fever4 ,the temperature ranges from #aja to #ajc or even #aje degrees ,f4 ,it is irregular and marked by evening exacerbations and morning remissions4 ,occasionally there is an inverse type of temperature in which it rises in the morning and falls in the evening4 ,in some cases the pulmonary symptoms are marked1 while in others the meningeal symptoms are more prominent4 ,tubercle bacilli are rarely found in the sputum4 ,the spleen is usually enlarged4 ,constipation is present1 as a rule1 but there may be diarrhea1 and hemorrhage from the bowels may occur4 ,the urine may contain traces of albumin4 ,there may be excessive sweating1 and herpes is often present4 ,choroid tuberculosis is frequently met with4 ,in doubtful cases the blood should be examined for tubercle bacilli1 although they are not always present4 ,the duration is from two to four weeks1 the disease usually terminating unfavorably4 ,diagnosis4--,it is often very hard to differentiate between this form of tuberculosis and typhoid fever4 ,in typhoid fever epistaxis is a common1 early symptom4 ,the temperature curve of the continued type is quite diagnostic4 ,the ,widal test should be made4 ,the respirations are moderately hurried and the pulse is often dicrotic4 ,diarrhea is frequent4 ,typhoid rash is diagnostic4 ,no tubercles are found on the choroid4 ,no tubercle bacilli are found in the blood4 ,hemorrhages from the bowels are common4 ,pulmonary ,form4--,when the lungs are chiefly affected the pulmonary symptoms are marked from the onset4 ,it may develop suddenly or there may be a long period during which the general health fails markedly4 ,in children the disease may follow measles or whooping cough4 ,there is dyspnea1 cough and the expectoration is mucopurulent4 ,there is broncho-vesicular breathing with sibilant and subcrepitant rales4 ,the temperature is high1 ranging from #ajc to #aje degrees ,f41 or higher4 ,respiration and pulse are rapid4 ,the disease may last from several weeks to months1 or1 on the other hand1 it may prove fatal within a few days4 ,as the end draws near the signs of suffocation become intensified4 ,diagnosis4--,the history and general symptoms1 together with the dyspnea and cyanosis1 will generally decide the diagnosis4 ,the blood should be examined for malarial parasites4 ,the ,widal test will differentiate typhoid4 ,cerebral or ,meningeal 7,tuberculous ,meningitis74--,this form which is sometimes called acute hydrocephalus1 occurs quite frequently and is an infection of the pia mater of the brain or cord4 ,it occurs most frequently in the first two years of life1 although it may occur later4 ,it is usually tuberculous in some other region1 especially in the bronchial glands4 ,rarely does the disease involve the meninges primarily4 ,the meninges at the base of the cerebrum is the principal involvement4 ,there is more or less inflammation1 with fibrous purulent exudation4 ,there are tubercles along the blood vessels4 ,the ventricles may be distended4 ,symptoms4--,the onset is slow1 lasting one or more weeks4 ,headache1 constipation1 vomiting and chills1 followed by a fever1 are the initial symptoms4 ,when the onset is sudden1 the disease is generally ushered in with a convulsion4 ,the fever rarely rises above #ajb or #ajc degrees ,f4 ,the pain is often severe1 causing the child to give a sudden cry--the hydrocephalic cry4 ,during sleep the child is restless and there are slight muscular twitchings4 ,the irritative symptoms now abate4 ,the child becomes quiet and is dull and apathetic4 ,constipation still persists4 ,the abdomen is boat-shaped1 and the neck may be retracted4 ,the pupils are dilated4 ,convulsions and other cerebral symptoms may occur4 ,the temperature ranges from #ajj to #ajc degrees ,f4 ,the respiration is irregular and sighing4 ,following this1 the mental faculties are lost and coma occurs4 ,convulsions or spasmodic contractions of the muscles of the neck1 back and limbs may occur4 ,the pupils are dilated and do not respond to light4 ,the pulse is frequent1 irregular and small4 ,the temperature rises to #ajc to #aje degrees ,f41 or it may be subnormal4 ,the duration is from two to five weeks2 chronic cases may last for a number of months4 ,prognosis4--,generally very unfavorable4 ,acute ,pneumonic ,phthisis ,the infection of the lungs is rapid and may be primary or secondary4 ,this form is met with most frequently in children and young adults1 but may occur at any age4 ,the ,pneumonic form is more rare than the bronchopneumonic form and may be very rapid in its course4 ,the attack sets in abruptly with a chill and the temperature rises rapidly4 ,there is pain in the side2 cough2 dyspnea and mucous and rusty sputum1 which may contain tubercle bacilli4 ,there is impairment of resonance1 increased fremitus1 and bronchial breathing4 ,the whole or part of the lung may show signs of consolidation and dullness1 all the symptoms of pneumonia being present4 ,the patient rapidly loses flesh4 ,this attack may come on a person in good health after exposure to cold2 but there may have been a debilitated condition1 or a predisposition to phthisis4 ,death may occur in the second or third week or the case may continue from three to four months4 ,one or both lungs may be involved4 ,the lung is heavy and airless1 sinking quickly in water4 ,there is destruction of lung tissue and upon section1 cavities are found4 ,the cavities are generally small and are surrounded by tubercles4 ,older caseous areas of a yellowish white color may be visible4 ,miliary tubercles are found upon careful examination4 ,the bronchopneumonic form is the most common and occurs most frequently in children4 ,it often follows the infectious diseases1 especially measles and whooping cough4 ,the child may be taken ill suddenly with what seems to be an ordinary bronchitis1 the temperature rises1 the cough is severe1 and there may be consolidation with submucous and subcrepitant rales4 ,rapid respiration and sweating are often marked4 ,the course of the disease varies4 ,there is rapid loss of flesh1 and in many cases the disease develops into chronic phthisis4 ,in other instances death occurs in from three to eight weeks4 ,the disease may attack the adult whose resistance is impaired4 ,chills1 fever1 pain in the chest1 hemorrhages1 wasting are most noticeable symptoms2 these are the various signs of bronchopneumonia4 ,tubercle bacilli are often found in the sputum4 ,the course is usually from three to eight weeks1 while a number pass into a chronic stage4 ,areas of caseous tubercles are found1 which later suppurate1 break down and form cavities4 ,the bronchial lymph nodes are found enlarged1 and usually there is acute tuberculous pleurisy4 ,diagnosis4--,in the pneumonic form it may be impossible to make a diagnosis early in the disease4 ,tuberculosis may be suspected if the patient has been in bad health1 has a predisposition to phthisis1 or has had any pulmonary disorder4 ,pneumonia will present the typical symptoms1 but if fever continues1 tuberculosis will be suspected4 ,examination of the sputum will probably decide4 ,in the bronchopneumonic form it is very difficult1 in the early stages1 to distinguish it from simple bronchitis and bronchopneumonia4 ,the irregular fever and rapid loss of flesh are important signs4 ,the sputum will show elastic tissue and tubercle bacilli early in the disease and should be carefully examined4 ,chronic ,pulmonary ,tuberculosis ,the chronic form of the disease is more common than the acute4 ,it seems probable that many cases of pulmonary tuberculosis are due to inhalation of the tubercle bacillus1 though no doubt1 particularly in children the bacillus frequently gains entrance to the system through the intestinal tract from infected milk and food4 ,deformities of the chest1 especially where there is constriction and rigidness of the upper part1 with more or less immobility of the first1 second and third ribs and the junction of the manubrium and gladiolus1 associated with weak muscles and a stooped posture are definite predisposing factors4 ,this condition may be congenital or acquired4 ,the local innervation1 blood supply and lymphatic drainage is involved1 so that the individual is less resistant and consequently susceptible to infection4 ,the bronchi are thus weakened1 favoring the infectious process so that the disease may advance and involve the neighboring tissues1 or if infection has gained entrance to the lymph or blood stream elsewhere1 the susceptible pulmonary organs may become diseased4 ,owing to the above predisposing factors the primary lesion of the lungs is often in the bronchus a little below the apex near to the posterior and external borders4 ,a lower lobe may be involved1 or several lesions may occur at the same time1 involving one or both lungs4 ,frequently the other lung is infected from the lesion or lesions of the first4 ,in the acute cases the exudative process involves the lung tissue1 becomes caseous and softened1 and later necrotic with cavity formation4 ,in the chronic type the exudative process is slower1 with thickening of the walls of the air vesicles and increase of fibrous tissue4 ,cavities1 the result of caseation1 are of various size1 ragged1 often coalesce and open into the bronchus4 ,fibrous tissue forms about them and frequently arrest the process4 ,in the necrotic involvement blood vessels are often injured causing hemorrhages4 ,pleurisy1 empyema1 catarrhal bronchitis1 and bronchiectasis are often associated involvements4 ,in addition to the tubercle bacillus1 other micro-organisms1 streptococcus and staphylococcus pyogenes1 influenza bacillus1 and diplococcus pneumoni1 are often found1 and no doubt are important exciting factors4 ,the bronchial glands are swollen1 and contain tubercles4 ,they may undergo purulent disintegration4 ,tuberculosis of the larynx is common4 ,in severe cases there may be amyloid changes of liver1 kidneys1 spleen1 and mucous membrane of the intestines4 ,tuberculous lesions are found in the intestines1 spleen1 kidneys1 and brain in nearly equal proportions2 then come the liver and pericardium4 ,symptoms4--,the onset of the disease is either abrupt or gradual4 ,frequently it succeeds influenza1 measles1 or bronchitis4 ,there is a cough1 expectoration1 loss of weight1 afternoon temperature and probably night sweats4 ,the disease is likely to develop slowly4 ,in other cases gastro-intestinal disorders are the first symptoms1 especially with weakness and debility4 ,again1 the disease may follow pleurisy4 ,when the attack is abrupt1 pneumonia is simulated4 ,however1 the apex of the lung1 instead of the middle or lower lobe1 is involved2 expectoration is considerable and the fever is not so high and pronounced4 ,hemoptysis frequently occurs4 ,the local symptoms are important4 ,pain is an early either moderate or severe1 symptom1 although there are cases where it is absent4 ,when associated with pleurisy1 it is severe4 ,the pain is usually situated at the base1 anteriorly or laterally1 of the scapul1 but may be between them4 ,cough is present1 in the majority of cases1 throughout the entire course4 ,it usually grows worse1 and is dry and hacking at the beginning but looser and paroxysmal and accompanied by a mucopurulent expectoration later on4 ,the expectoration1 at first1 is slight and there may be more or less blood mixed with it1 or even hemorrhage may occur4 ,with the formation of cavities1 the expectoration increases and is of a greenish-gray or greenish yellow color4 ,in some instance the sputum is more or less fetid4 ,the expectoration is composed of pus cells1 blood1 elastic tissue1 fat globules and tubercle bacilli4 ,hemoptysis is present in a majority of cases4 ,early hemorrhages are usually slight1 due to rupture of weakened vessels4 ,when there is softening or cavity formation1 erosion of vessels may be pronounced and hemorrhage considerable4 ,dyspnea is a variable symptom1 but is characteristic of lung changes4 ,fever is a characteristic symptom4 ,it is probably always present at the beginning and the afternoon increase of temperature is common4 ,where there is softening and formation of cavities1 a remittent or intermittent type is present4 ,the pulse is frequent1 regular and compressible4 ,sweats may occur at any time1 but especially during sleep4 ,they indicate fever activity1 and are increased during cavity formation4 ,emaciation is a prominent symptom4 ,this is due to gastro-intestinal disorders and prolonged fever4 ,loss of weight is gradual1 especially if the disease is advancing4 ,where the lung is considerably diseased1 heart disturbances are common4 ,other disorders1 as of the gastro-intestinal tract1 genito-urinary1 cutaneous1 and nervous systems1 are frequent1 especially in long standing cases4 ,the gastro-intestinal disturbances are gastric catarrh1 vomiting1 loss of appetite1 coated tongue1 constipation1 and later on1 diarrhea4 ,among genito-urinary symptoms1 albuminuria is frequent4 ,the kidney involvement may be either of an acute or chronic character4 ,pyelitis and cystitis are present in some cases1 and amyloid degenerations are not uncommon4 ,with the cutaneous symptoms1 the skin is frequently dry and scaly1 and the hair of the head dry4 ,the hectic flush is common4 ,upon the chest and back there may be pigmentary stains4 ,the nervous symptoms vary according to the involvement4 ,tuberculous meningitis is rare4 ,the mind usually is clear and even in advanced stages the patient is always hopeful4 ,physical ,signs4--,inspection reveals that the shape of the chest is often characteristic4 ,a phthisical thorax is flat1 especially the thoracic opening with wide intercostal spaces1 prominent costal cartilages1 and depressed sternum4 ,sometimes the lower sternum forms a deep concavity 7funnel breast74 ,another type of thorax is long and narrow1 with very oblique ribs1 and little expansion4 ,in other instances the chest is of apparently normal build4 ,defective expansion is observed early1 especially at the apex of the affected side4 ,the clavicle of the affected side often stands out more prominently4 ,palpation shows there is decreased expansion and increased fremitus4 ,normally1 the fremitus is stronger at the right than at the left apex4 ,if the pleura is thickened1 the fremitus is decreased1 but increased in lung involvement4 ,on percussion1 if the diseased areas are minute1 the percussion note may not be changed4 ,always compare the two sides of the chest4 ,dullness is first noted1 as a rule1 above1 on or below the clavicle4 ,as the disease progresses1 the dull sound increases4 ,the size of the cavity1 its walls and the amount of secretion modify the note4 ,large1 thin-walled cavities elicit the 8cracked-pot0 sound4 ,consolidation1 thickened pleura1 large amount of material in a cavity and a connecting bronchus impair resonance4 ,on auscultation the breathing is harsh and the expiration is prolonged and high-pitched 7bronchial74 ,early in the disease crackling rales may be heard4 ,after consolidation takes place there is bronchial breathing and crepitant rales4 ,when softening occurs they become moist1 louder and sometimes bubbling4 ,these may be heard upon inspiration and expiration4 ,pleuritic friction sounds1 as in case of pleurisy1 may be heard at any stage4 ,vocal resonance is increased4 ,the signs of cavity are3 ,percussion4--,there is more or less defective resonance or tympany4 ,over large cavities a 8cracked-pot0 resonance is obtained4 ,this is best obtained when the patient has his mouth open4 ,there may be normal resonance if the cavities are covered with a considerable thickness of unaffected air cells4 ,auscultation may detect cavernous or amphoric breathing1 pectoriloquy and coarse1 bubbling rales4 ,metallic tinkling may be heard over large cavities4 ,vocal resonance is increased4 ,complications4--,the larynx and trachea frequently undergo tubercular inflammation1 due to invasion from the lung tissue4 ,pneumonia is of common occurrence4 ,gangrene1 pleurisy and endocarditis are other complications4 ,diagnosis4--,bacilli may be found in the sputum before the physical signs are well developed4 ,it may be necessary to examine the sputum several times before the tubercle bacilli are detected4 ,the presence of bacilli will set the diagnosis at rest1 provided clinical symptoms are present4 ,fever1 hemoptysis1 cough1 emaciation and a continuous1 local induration are diagnostic4 ,the ,x-ray should be employed as an aid in diagnosis4 ,prognosis4--,the prognosis of pulmonary tuberculosis varies greatly in different cases4 ,undoubtedly a number of cases have been cured2 many arrested2 even spontaneous cures have occurred4 ,a great deal can be done to prolong life and to make the patient comfortable4 ,the average duration is about three years1 although by careful treatment this time is probably being increased4 ,fibroid ,phthisis ,this term is applied to a form in which there is induration1 followed by contraction of the affected lung tissue1 due to an overgrowth of fibroid tissue4 ,the greater number of cases are primarily tubercular1 but have run a fibroid course4 ,other cases are primarily fibroid1 followed by tuberculous infections4 ,it may begin as an ordinary ulcerative phthisis1 or it may begin as an inhalation bronchitis4 ,in other instances it may follow a chronic tuberculous bronchial pneumonia or pleurisy4 ,the onset is extremely insidious4 ,there is persistent cough1 often paroxysmal in character4 ,dyspnea is marked1 especially on exertion1 but little or no fever is present4 ,the expectoration is profuse and mucopurulent4 ,there is slight loss of weight4 ,in the later stages edema is marked4 ,it is a disease of long duration1 lasting from ten to twenty years4 ,the patient is often able to pursue some occupation and may have fair health4 ,there is marked dullness over the affected side1 which is commonly much depressed4 ,there is distinct bronchial breathing at the base1 while at the apex there may be cavernous sounds4 ,the heart is frequently displaced and the right ventricle hypertrophied4 ,the bronchi are dilated4 ,the clinical history is identical with that of simple cirrhosis of the lung from which it is often separated with difficulty4 ,both lungs may become the seat of tuberculous disease4 ,prolonged suppuration results in amyloid changes in the liver1 spleen1 kidneys and intestines4 ,x-ray plates are of value in diagnosis4 ,tuberculosis of ,other ,tissues ,the alimentary tract is frequently the seat of tubercular inflammation4 ,the intestines may be involved primarily or else secondarily from the lungs or peritoneum4 ,the primary form is most common in children4 ,there is slight fever1 pains of a colicky nature1 irregular and persistent diarrhea4 ,the disorder is commonly unrecognized1 being mistaken for appendicitis or other intestinal disorders1 until emaciation1 sweats1 the continued fever or lung involvement are manifested4 ,the stomach1 esophagus1 pharynx1 tonsils1 palate1 tongue and lips may be the seat of a tubercular lesion4 ,the serous membranes are usually secondarily involved4 ,the peritoneum is generally invaded from contiguous organs1 especially the intestines1 although the pleurae may be the starting point 7and in the female the generative tract is a source74 ,the disease may be either acute or chronic4 ,in the former it starts abruptly with vomiting1 pain in the abdomen1 fever1 and possibly diarrhea4 ,in the chronic form there are fever1 pains1 emaciation1 weakness and the abdomen is distended4 ,the enlarged glands may be felt through the walls4 ,there may be ascites1 or the walls of the peritoneum are adherent1 or the tubercles may ulcerate4 ,the endocardium is occasionally the seat of acute or chronic tuberculosis4 ,it is usually secondary4 ,likewise the pleurae are sometimes involved4 ,the chronic form is more common4 ,the genito-urinary system is subject to tuberculosis4 ,the bladder1 ureters and pelvis of the kidney are attacked1 and from these the kidney2 or possibly the kidney involvement is part of a general tuberculosis4 7,see pyelitis74 ,the ovaries1 ,fallopian tubes and uterus are also subject to tubercular invasion4 ,the diagnosis depends upon finding the bacilli1 the symptoms indicating1 oftentimes1 an inflammation only4 ,also the prostate1 testicles and seminal vesicles are attacked4 ,tuberculosis of the mammary glands is rare4 ,in miliary tuberculosis the liver is commonly affected1 often secondary to other tissues1 especially the peritoneum1 lymphatics and lungs4 ,the blood-vessels and heart are sometimes involved from nearby organs or from miliary tuberculosis4 ,the brain and cord are also at times invaded4 ,this has been described under meningeal tuberculosis4 ,diagnosis and ,prognosis of ,tuberculosis4--,the osteopath should be familiar with the various forms of the disease4 ,an understanding of the pathology and clinical symptoms is essential4 ,the finding of the bacillus1 provided there are symptoms of inflammation1 is diagnostic4 ,much depends upon the patient's constitution1 hygiene1 sanitation1 food1 fresh air and general management4 ,the osteopathic lesion is decidedly an important factor1 but the treatment must be balanced from both the distinctive osteopathic view and that of general management4 ,then the patient's part is as necessary as the osteopath's4 ,under proper care and treatment1 unless the disease has progressed to a marked degree1 there is always a tendency toward recovery1 but1 to emphasize again1 the osteopathic treatment1 the environment and general hygiene should be thoroughly understood and appreciated1 for at best1 the disease is treacherous4 ,even after an apparent recovery is made1 the patient should be under observation2 there is always danger of recurrence4 ,tuberculosis can often be treated successfully1 or arrested1 provided the disease has not progressed to a late stage2 although many times1 in the later stages1 life can be considerably prolonged by careful treatment4 ,treatment of ,tuberculosis4--,the prophylactic treatment of tuberculosis should receive first consideration4 ,the sputum should be thoroughly disinfected and care taken that the patient does not spit about carelessly4 ,a spit-cup should be provided and the sputum collected and destroyed by burning and the cup sterilized4 ,the patient should be well taken care of and given a separate apartment1 so that the danger of conveying the disease to others is reduced to a minimum4 ,he should occupy a single bed4 ,all unnecessary furnishings of the room should be removed and the objects that remain in the room should be frequently aired and disinfected4 ,the general and sanitary environment of the patient should be as favorable as possible to hygienic living4 ,many times a change of residence is of great benefit4 ,when possible the patient should be out of doors and light exercise taken4 ,the body should be well protected by flannels1 the year around4 ,keene#fa would carry prophylaxis to careful examination of the pregnant woman to avert a sudden development of tuberculosis after parturition2 also of the child1 after birth1 to remove any predisposing lesions4 ,the mother with a tubercular tendency should1 under no circumstance1 nurse the child and should be instructed to observe any disposition on the part of the child to acquire malpositions in sitting1 standing or walking4 ,another important consideration in the prophylactic treatment is the inspection of dairies and slaughter houses4 ,the disease may be transmitted by infected milk4 ,there is less danger of infection through meat2 although all animals that present distinct lesions should be confiscated4 ,sanatoria and other special arrangements for the care of patients should be encouraged4 ,the ,treatment of the disease consists primarily in locating the cause of the devitalized condition of the cellular tissue4 ,this is the vital point to be considered and requires a thorough examination of anatomical structures in the region involved4 ,there is a reason why the tissues are in a depraved state and it is our work to examine thoroughly the structures that might become deranged anatomically and cause an obstructed innervation or vascular supply4 ,the disease is not primarily due to the bacilli2 the bacilli would not have infected the system had it been in a healthy state4 ,hence1 the object of the treatment in tuberculosis is to favor a building up of normal1 well-nourished tissues so that it is impossible for the bacilli to infect the region4 ,of course1 destruction of the bacilli is important1 but we cannot expect to do much by the use of a parasiticide1 for we are not then influencing or affecting the real cause of the disease4 ,if we can improve the arterial circulation to the diseased tissues1 we will be striking at the root of the disease and the healthy blood will be the only parasiticide necessary4 ,this is where the osteopathic theory of the cause of disease differs from that of other schools of medicine4 ,at the local points of infection there is a decided malnutrition of the tissues1 due to a lack of proper blood to the parts1 thus favoring the lodging of micro-organisms2 by reestablishing normal nutrition nature will repair the tissues if the condition is curable4 ,hence1 it can be seen at once that if the case is curable osteopathic treatment will meet the demands scientifically4 ,the preceding is the keynote of osteopathic therapeutics2 not only in the treatment of tuberculosis1 but in all diseases where micro-organisms play an important part4 ,in tuberculosis of any part of the body1 it is the duty of the osteopath to carefully examine the structures that may become anatomically deranged1 from any cause1 affecting the nerve1 blood and lymphatic supply to the tissues or organs diseased4 ,correction of anatomically deranged tissues and attention to the hygiene1 diet and general health of the patient constitute the treatment4 ,on the subject of ,pulmonary ,tuberculosis1 ,w4 ,banks ,meacham says3 8,in cases of pulmonary tuberculosis it should be remembered that the pathological lesion in the lung is a result of a general systemic interference--an interference so great that the body as a whole loses its stored-up heat in excessive temperature1 loses its reserve nutrition1 as manifested by early and continuous loss of weight4 8,therefore the causative osteopathic lesion should not be sought alone over the site of the pathological lung lesion but rather in that area where general nutrition is osteopathically affected4 8,a few general considerations of osteopathic mechanics involved in nutrition should be ever present with the searcher for the cause of pulmonary tuberculosis4 ,for instance we know that ingested fat is acted upon by the pancreatic enzymes2 that the invertin of the intestine is an endocrine secretion4 ,in diet we seek to administer an excess of fats to take the place of fat-loss in this disease1 often losing sight of the fact that some mechanical maladjustment prevents fat-splitting into a form suitable for tissue assimilation4 8,it is common osteopathic knowledge that lesions of the upper dorsal area have a profound influence on general nutrition4 ,consequently it is to this area that we must look for the causative osteopathic lesion in this disease4 ,the influence of this area is due to the fact that the nervous mechanism of the secretory glands gets its most direct disturbance in this area where the nerves leave the spinal cord to become distinct innervation to these organs4 8,apart from the nutritive and general circulatory influence of upper dorsal lesions we must consider the germicidal action of the endocrinous secretions in devitalizing the specific bacterial agent in tuberculosis4 ,undoubtedly these internal secretions have marked effect in agglutinating the bacilli1 thus enabling the phagocytes to perform a larger duty4 8,the correction of upper dorsal lesions1 with due regard for the pathological condition within the thoracic cavity gives a scientific physiological and bacteriological therapeutic action in tuberculosis4 8,other lesions may and do demand attention and correction when possible4 ,but we must not lose sight of the fact that our specific action comes from a corrected relation of the upper dorsals4 ,in the cloud of unproved theories and guesses in the literature of pulmonary tuberculosis nothing seems nearer an established truth than that it is a disease contracted in infancy1 that it develops1 later1 in those persons who retain the infantile type of chest--thorax of large antero-posterior diameter in contrast with the lateral diameter4 8,in the progress of the disease we do get a costal malformation giving the #8horse-collar' thorax1 with an apparent lesion of the osseous walls of the thoracic cavity4 ,but these lesions are the result of nutritive changes brought on by the active infection already present2 and are not in any true sense1 causative factors in the establishment of pathological areas within the lung4 8,the osteopathic treatment1 then1 of this disease is1 manifestly1 a correction of a plastic posterior upper dorsal lesion4 ,and where the pathological lesion of the lung contraindicates forceful correction1 mobility of the area should be sought4 8,the general care of the case should look to the normal functioning of all organs1 with emphasis on ease to the patient4 ,the diet should be what the patient can assimilate properly even though it be much less than the amount a normally active person should ingest4 ,altitude has a favorable effect in selected cases only4 ,it is remarkable that many cases recover in the extremes of the ,rockies and the coasts of ,california and ,florida4 8,no violent exercise should be undertaken on account of the possible embarrassment of an already overworked heart and in consideration of the possibly engorged pulmonary vessels4 ,for these reasons1 too1 rest in bed is advisable with temperature above #ii ,f4 and pulse above #he40 ,in scrofula1 lesions will be found to the lymphatic glands1 impairing their innervation and function4 ,the treatment is not to be applied over the glands directly4 ,first1 it is necessary to locate the lesions of the bones1 ligaments and muscles or such tissues that would cause disturbances to the glands1 then readjust the parts4 ,the object of the treatment is to modify the soil conditions on which the bacilli multiply1 by correcting the local derangement of the tissues4 ,the entire body is not in such a depraved state that the bacilli will grow and multiply wherever they happen to come in contact with the body2 tissues of any organ favor a receptivity for the bacillus only when these local tissues are in a morbid condition4 ,it is then our work to aid nature in relieving obstructed forces that are causing such an effect4 ,there are general measures which influence the tubercular process4 ,the diet of the patient should be nutritious4 ,a diet of milk1 buttermilk1 egg albumen and meat juice will probably be found best1 although many will be able to take ordinary food4 ,the patient should be out of doors as much as possible4 ,meacham#fb says 8,fresh1 pure air1 wherever found1 is essential2 elevation is an individual requirement1 an even temperature is not necessary and sunshine is important only as it allows the patient to be out of doors4 ,exercise should not be taken when the patient has a temperature above #ii degrees40 ,the dry1 even climate of the ,southwest certainly tempts the patient to be out of doors more than one with opposite conditions4 ,even when the patient is greatly debilitated and weakened1 insist upon his taking outdoor exercises or rides4 ,gymnastic and methodical breathing exercises are essential in widening and strengthening the chest4 ,bolles#fc believes that the appetite should control the diet and forced feeding be not insisted upon4 ,fasting1 to test the sense of food desires1 has points well worth looking into1 as gastric disturbances with a loss of strength follow overfeeding4 ,he also recommends deep breathing and physical culture to elevate the ribs and increase thoracic expansion4 ,outdoor sanatoria are being established over the country1 in many cases by state appropriation as1 8the treatment of tuberculosis itself has not been a satisfactory procedure except by climatic changes or the outdoor treatment persistently applied40 7,halbert74 ,the fresh air treatment may be taken at home by sleeping in the open air or by appliances fitted to the window of the room so only the head is exposed to the air4 ,the only factor is to get the air4 ,the skin1 as well as the excretory organs1 should be kept active4 ,always make it as comfortable for the patient as possible4 ,the fever is indicative of the activity of the disease1 so that treatment to influence the process and to promote elimination is best4 ,sponging with either cold or tepid water will be helpful4 ,the cough is a troublesome symptom4 ,attention to the underlying irritation is demanded1 although one cannot hope to influence1 to any great extent1 the cough dependent on cavity formation4 ,catarrhal processes in the respiratory tract can be lessened4 ,lesions that are acting as a cause of irritation1 will frequently be found in subluxated ribs or vertebr4 ,the seventh and eighth dorsals are frequent sources of cough4 ,the tissues about the pharynx and larynx1 and the hyoid bone1 disturbing the vagus and other nerves1 should be carefully watched1 also possible reflex irritation from the abdomen and pelvis4 ,night sweats are due to tubercular processes weakening the system and particularly lessening nervous control4 ,these will subside as the body is strengthened4 ,sponging will be of service4 ,disorders of the stomach and intestines1 such as nausea1 vomiting and diarrhea1 require treatment of the splanchnic area and regulation of diet4 ,considerable can be done to relieve tubercular laryngitis by careful treatment of the larynx and contiguous tissues4 ,hemorrhage is likely to be self-limiting4 ,attention to the upper dorsal vertebr and ribs and muscles will tend to equalize the circulation4 ,rest and use of ice upon the chest1 as well as internally1 will be beneficial4 ,mc,intyre1 in an article on 8,fat ,food in ,consumption10 sums up the treatment for tuberculosis in the following words3 8,the treatment1 then1 for consumption should include rich1 stimulating diet1 proportioned to the digestive power of the patient1 containing an excess of fats in most digestible form1 of which sweet cream1 fresh butter and well-cured bacon are the best examples1 and the free use of pure drinking water1 coupled with the promotion of blood flow1 respiration and elimination of waste by osteopathic means40 ,surgical measures may be necessary where glandular or other tissue has broken down and is a menace to recovery4 ,spanish or ,epidemic ,influenza#fd ,by ,,george ,m4 ,,mccole ,the epidemic of influenza which swept over the world and reached the ,united ,states in ,august #aiah1 starting in at the ,atlantic sea-board cities1 developed rapidly there and passed westward over the country4 ,it reappeared the following winter4 ,epidemiology4--,in the ,united ,states it was called ,spanish influenza1 as it was at its worst in ,spain at the time it broke out here and was thought to have been brought from that country4 ,in ,europe it was called the ,ukrainian influenza and in southern ,russia it was said to have emanated from the ,orient4 ,no country in the world was exempt4 ,it was at one time thought to be a type of the pneumonic plague and while plague is the severest toxemia known many cases of ,spanish influenza were equally as prostrating and fatal as the ordinary type of pneumonic plague4 ,the bacillus pestis was never proved to be the cause of this pandemic of influenza but the clinical analogy was very evident4 ,a study of ,european conditions of health and hygiene shows how reasonable it is to believe that some disease would develop and sweep a world lowered in vitality and immunity by the abnormal conditions of war4 ,every known communicable disease was raging in ,europe and ,asia where millions of people existed under exceedingly poor hygienic conditions4 ,the period of incubation of influenza was extremely short1 averaging about two days4 ,all ages were attacked1 although persons over #fj rarely4 ,those between #be and #ce seemed to be the most susceptible but it was1 perhaps1 because they were in active life and more exposed4 ,there is considerable evidence that the disease was not air-borne but conveyed by contact with active cases4 ,the secretions of the mouth1 nose and eyes were considered the active carriers4 ,masks1 made of several layers of gauze fastened over the face1 have been worn by many people but experience taught that their use did not avail against infection4 ,mortality4--,the mortality under drug medication as shown in a statement by ,henry ,s4 ,bunting was as follows3 8,new ,york ,city #i4h2 ,chicago #ad4e2 ,boston #bg4 ,osteopathy's influenza salvage represents the difference between these figures and the low score of one fourth of #a40 ,he gives the following statistics on pneumonia following influenza under drug medication4 8,reports from #adh health commissioners show an estimate 7called conservative7 of #cc of fatalities in epidemic pneumonia under medical care4 ,in some large centers it ran as high as #fh to #gc4 ,as officially compiled to date1 the fatalities in epidemic pneumonia in our army and navy cantonment hospitals amounted to #cd4 ,osteopathy's fatalities were only #aj which included all those eleventh-hour appeals to ,osteopathy4 8,the ,chicago and ,new ,york departments of health figures1 each show total death losses of #ah in all of their epidemic cases4 ,osteopathy's remarkable salvage of life is best measured from this point of comparison4 ,its total death rate from both influenza and pneumonia has been actually less than one percent40 ,and this is based on #aaj1jjj cases reported to the ,american ,osteopathic ,association4 ,pathology4--,the pathology of ,spanish influenza is practically a study of lung involvement4 ,there we find an exudative pneumonia of a rapidly confluent type1 a transudate of blood serum and red cells appearing in the lower lobes of both lungs and rapidly flooding the entire space4 ,air bubbles were scattered through the serum soaked lungs1 giving a frothy appearance to some parts4 ,at times some parts of the lungs showed drops of liquid pus4 ,where pneumonia did not develop there was no typical pathology4 ,the toxins left an irritated bronchial tube1 intestine or kidney just as in any other severe toxemia4 ,bronchial and the old type of lobar pneumonia also appeared as a complication of ,spanish influenza1 making three types of pneumonia which were to be guarded against4 ,symptoms4--,the attack is usually ushered in by a chill or prolonged chilly sensations1 sometimes lasting for two or three hours2 fever #ajc to #aje ,f42 if it does not fall in three days or if it comes up after once falling1 pneumonia is to be suspected2 pulse1 full and bounding with a varying rate2 headache usually general in type and in severity from slight discomfort to a most violent type2 intense pain in the back and legs2 tenderness the whole length of the spine but especially distressing in the upper dorsal1 lower lumbar and sometimes the upper cervical2 a dyspnea which is best described as being a constricted feeling of the chest with air hunger2 often the bronchial tubes are raw and dry1 the patient feeling as if the breathed-in air were hot to the bronchial tubes1 an active exudative bronchitis developing2 sometimes there is an active bronchitis with distressing cough2 nose bleed is a frequent symptom 7and is often a sign of threatening pneumonia72 most cases sweat more or less1 some have drenching sweats2 sleeplessness2 albuminuria frequent4 ,when the temperature breaks it practically always falls below normal during the course of that day4 ,a typical case of severe character often presents all of the above symptoms2 the lighter cases perhaps only two or three of them1 of which the chilly sensations1 fever and bounding pulse are the most common encountered4 ,a severe case is impossible to differentiate from the first symptoms of smallpox4 ,where a case of this type is encountered1 it is always advisable to get history of vaccination or smallpox4 ,examination4--,the successful treatment of disease calls for attention to little things4 ,some little thing properly cared for very often gives us our margin over adverse conditions and spells success in the care of our patient4 ,during the epidemic ,i found a few cases which ran a temperature much below normal1 sometimes as much as three or four degrees1 and still with enough symptoms to be easily diagnosed as influenza4 ,pulse was taken at the time the thermometer was in the mouth4 ,pulse was practically always bounding and hard4 ,its rate varied widely1 being influenced by many other conditions4 ,i often1 early in the attack and where other symptoms were indefinite1 made a diagnosis principally from the pulse4 ,respiration was taken while holding the watch and with the finger on the pulse so that patient would not know that breathing was being watched4 ,many patients complained of a sensation of weight on the chest and difficult breathing--hardly what one would term true dyspnea yet a real air hunger and sensation of constriction in the chest4 ,the breath was often tainted with the odor of acetone1 indicating a high degree of acidosis and giving an important diagnostic point4 ,the heart was then examined1 both by auscultation and percussion4 ,the examination was then extended over the lungs and pleural rub listened for4 ,patient was questioned as to having had a chill1 general health1 occupation1 undue exposure1 fatigue1 what physic if any1 had been taken or other drugs used1 bowel movements and bloody stools1 food taken1 sleep the night before1 and dreams1 headache and backache4 ,the full examination could not be given at each call and not all of it to each patient1 as time would not permit during the height of the epidemic4 ,throat was always examined4 ,this is an important point4 ,the urine was examined in a great many cases and often albumin and sometimes casts were found4 ,treatment4--,i consider it advisable to give a strong deep treatment if the patient is seen before the attack has gained full headway2 after that ,i give short light treatments4 ,if the disease has not developed much at the time of the first visit vigorous treatment with adjustment of the deep-lying and tightened-up ligaments over the spinal cord is indicated4 ,subsequent treatments are given to overcome the invariable and recurring contractions along the spinal cord4 ,the spine is gently sprung and the muscles pulled away from the intervertebral foramina so that arteries1 veins and nerves of the spinal cord are free to function4 ,i might note here that ,i consider ,spanish ,influenza does its damage through the attack of its peculiar and virulent toxin and the accompanying acidosis1 on the body's reservoir of energy--the spinal cord and related structures1 the vegetative glands and nerves4 ,if the patient is in a serious condition he is often treated in the position in which found1 so as not to disturb him4 ,care is particularly taken to keep a patient who is moist with sweat from taking cold or being exposed4 ,an extra covering is thrown across the neck and shoulders1 and pulled down as the bed covers are moved to get to the area to be treated4 ,the musculature of the upper dorsal and cervical region is given special attention1 the region of the first and second cervical and the first to sixth dorsal being special seats of trouble4 ,the region between the spine and scapula on the left side1 first to sixth ribs left1 and the region of the suprascapular notch on the left side are given specific treatment to free them of contractions4 ,the tissues of the suprascapular notch are in direct connection with the nerve supply of the heart muscle and treatment here is astonishingly effective4 ,this treatment for the heart is best given with the patient lying on the right side1 leaning a little forward1 with his left forearm against the chest1 hand at neck or chin4 ,stand then at the patient's head and with the thumbs give all the region on the left side at the base of the neck and around the suprascapular notch thorough muscular adjustment for circulation and removal of contractions which disturb the heart's vitality4 ,treat first to sixth dorsal region4 ,i consider this treatment specific for the heart debility of influenza and many other heart conditions1 as well4 ,i have found it especially effective in the weakened and nervous states following influenza and in so-called 8run down conditions0 generally4 ,vibration with the tips of the fingers on the anterior chest wall is often used4 ,tender and contracted tissues are often found along the anterior ends of the ribs which are involved at their spinal ends4 ,these are gently treated4 ,children are often given vibration1 holding their chests with my hands under their arms4 ,if the patient is stout and not easy to treat ,i have him sit up in bed and give the upper dorsal thorough percussion with the side of the hand#fe4 ,about #ajj strokes at each treatment are usually given4 ,i remember one very fat patient in the eighth month of pregnancy to whom ,i could give hardly any other treatment4 ,it was especially valuable here and we saved the mother after a hard fight1 though the child was still-born4 ,when nature is meeting the emergency and holding her own in the battle against infection we have a moderate fever--a benign fever4 ,when the body is overworked with other duties and irritations the fever may rise dangerously high4 ,here it is that the physician must give further aid4 ,here it is that osteopathic treatment further aids by giving rest to the patient1 easing pain and promoting general circulation 7this in itself often quickly reduces fever74 ,here it is that the attention we give to clothing1 diet1 ventilation1 quietness1 good nursing1 etc41 comes in4 ,the body is relieved of all duties but the one4 ,its functions are all turned to one end--the destruction of the invading infection4 ,the osteopathic physician adjusts4 ,nature cures4 ,it is all a matter of adjustment4 ,for labored breathing1 an effective treatment is to have the patient with hands clasped and arms raised above the head1 patient being in bed1 face up4 ,stand directly at head of patient4 ,reach over patient's arms and under the upper dorsal and lift up against the heads of the ribs with your fingers1 thus raising the chest1 beginning as far down the spine as you can and working up as you treat4 ,relax the muscles at the same time4 ,frequency and ,amount of ,treatment4--,frequency and extent of treatment depend upon the condition of the patient4 ,in influenza the patient is approached with the idea of a daily visit4 ,if then there is any doubt about his being entirely safe for #bd hours he is seen in #ab hours or as often as the condition indicates4 ,patients are usually seen more than once a day4 ,the average time which the patients are confined to the bed is about five days4 ,some are free from fever in three days2 some not for six or seven days4 ,according to conditions they are then kept in bed from one to three days longer4 ,as to the amount and length of treatment1 ,i agree with ,james ,m4 ,fraser1 who says adjustment of the soft tissues should be made and made with as little disturbance to the patient as possible4 ,he says#ff3 8,the ill effects of too long-drawn-out general treatments1 or in short1 over-treatment1 ,i consider one of the most important questions for osteopaths because ,i incline to the belief that in many acute infections more harm may be done by such fatiguing over-treating than if the patient were really not treated at all4 ,a 8flu0 or pneumonia patient should never be treated over fifteen minutes at the longest in one treatment4 ,it is much better to treat often and not treat so long1 as over-treatment may result from a desire to be thorough4 ,if we always would stop and think what we are doing and just what we are trying to prevent we would be more careful when we treat these infectious cases4 ,a patient's resistance may really be lowered1 his bowels inhibited1 his heart overstimulated1 his muscles fatigued and his nerve force depleted by treating overtime4 ,when the reaction begins1 stop40 ,congestions and contractions should be removed wherever they are found1 be it in the region of the throat1 spine1 ribs1 liver or spleen4 ,i order a daily enema and give positive instructions--after having had one or two almost fatal cases from this cause--to use no physics4 ,purging killed more people here than any one other thing4 ,if a heavy physic be given two or three times and the patient comes to a crisis1 so much vitality has been taken out of the blood that he does not have enough strength to carry him over and he dies4 ,if the patient comes to pneumonia ,i find it good and effective to use the 8constipation treatment40 ,it is best to let the bowel take care of itself4 ,nature can do many things1 and caring for the bowel in a crisis is one of them1 providing the correct diet has been given the patient4 ,if the patient is getting nothing but fruit juices there may be a natural bowel movement and even if he has been getting other food it is better to leave the bowel alone until after the crisis and then give the enema4 ,a patient with a frank pneumonia following influenza has but little chance of living if his strength is being drained from the blood stream through the bowel every few hours4 ,i see to it that no draft blows on the patient's bed4 ,in a windy location a cold draft can appear suddenly and do great damage in a short time4 ,the patient should not breathe cold air4 ,fresh air is all right but it must not be cold air4 ,i order extra covering for the neck1 arms1 shoulders1 back and chest4 ,i like a wool workshirt best but use pneumonia jackets1 extra undershirts1 sweaters1 etc41 when the wool shirt is not to be had4 ,in fact continued warmth seems to be an almost necessary condition to the proper handling of influenza4 ,it is because heat1 even the heat of the fever itself seems to aid the nervous system in building up antitoxins4 ,the patient is instructed that if a sweat comes on1 either from a hot bath1 hot drink or as a result of the disease1 to lie and take it1 for throwing off the covers is a sure way of taking cold and inviting pneumonia4 ,if the house is cold or the patient weak or very sick the urinal and bed pan are used4 ,in fact ,i prefer their use even when those conditions are not present1 as the less the exposure the less chance of pneumonia and the quicker recovery4 ,rest lying in bed is absolutely necessary to a satisfactory course and quick recovery4 ,for lung congestions and bronchial irritation1 in addition to osteopathic treatment along the spinal cord1 raising the ribs and chest1 and vibration of the chest wall1 ,i sometimes use the old fashioned mustard plaster 7made with one teaspoon each of flour and mustard1 mixed with olive oil or with water and white of egg71 keeping it on about ten to thirty minutes or until a good1 red reaction is brought about4 ,the feet must be kept warm with hot water jugs4 ,a hot mustard foot bath is excellent when the feet persist in staying cold4 ,at first ,i did not use the hot tub-bath4 ,i am now ordering it if ,i see the patient early in the attack and where there is no contraindication1 such as a dangerous heart condition4 ,i do not use it unless it can be given properly and without undue exposure to the patient4 ,i never give it late in the disease4 ,a good method is to get the patient into the tub1 lay two canes or sticks across the tub1 and cover all with a blanket or rug4 ,place a bath towel for the head to rest on and pull the blanket around the neck4 ,the patient can then take a good hot sweat in comfort4 ,his arms and shoulders1 his knees and legs will not be exposed to chill4 ,when he gets up the blanket can be drawn about him if desired4 ,he then goes back to bed for a good rest and sweat4 ,a cold towel is placed on the head and water given to drink4 ,every patient should have a good sweat early in the attack4 ,another good method is to cover with a blanket and place outside fruit jars or jugs filled with hot water1 cold towel to the head and several glasses of water or lemonade to drink4 ,the use of cold compresses on the chest ,i do not favor4 ,they are used by some osteopathic physicians1 but ,i believe the result is better with other methods4 ,applied in a hospital where the technique is well in hand they might be successful1 but personally ,i fear them4 ,i am even careful about putting an ice bag on the heart4 ,cold packs are sometimes used in my practice but only on the head for pain or delirium4 ,chill must be avoided4 ,warmth must be conserved1 even the fever is benign4 ,neither do ,i favor 8rub-on0 of camphor1 turpentine or onions when they irritate the patient4 ,if the patient has been used to them or has faith in them and wants them ,i order them4 ,i also order something of the kind where 8something must be done04 ,when a family calls a doctor they 8want something done10 and it is best to do something2 ever keeping in mind1 however1 that our patient's strength must be conserved4 ,i do favor 8rub-ons0 in that ,i think it is well to keep the skin soft with some oil4 ,it helps to keep an even temperature and the skin active4 ,the skin should be wiped dry often1 however1 to remove the skin secretions which if left on become stale4 ,i remember being called to see one little girl who could not get her breath1 and found she was holding her nose with the bed clothes4 ,she told me that the smell and stickiness of the lard and turpentine and the onions made her so sick and uncomfortable that she felt she could stand it no longer4 ,when she was cleaned up1 and clothed in nice clean white cotton she showed a wonderful improvement1 and it was real as well as apparent4 ,as to baths in influenza1 ,i instruct the nurse to bathe the patient only as necessary for cleanliness and his comfort4 ,dabbling around in water is not a safe procedure in a disease where pneumonia is so easily contracted4 ,i do not use alcohol rubs where the patient is in anything like a serious condition1 as alcohol closes the pores and dries out the skin4 ,a rubbing or massage by the nurse is good for a restless1 nervous patient1 but it had better be done with olive oil or some other good oil4 ,in influenza we do not want the pores closed4 ,we need elimination1 and all we can get4 ,a small saving of vitality or a little elimination of toxins may be the margin that saves a patient for us4 ,i do not favor the use of turpentine1 for if it is absorbed it irritates an already sick kidney2 if it is not absorbed it is useless4 ,why disturb the patient8 ,for the bronchial irritation1 in addition to osteopathic treatment1 and the accessory mustard plasters1 inhalation of steam is often used4 ,a pan of boiling water is set by the bed and the patient leans over the edge of the bed with a bed-sheet or paper over the head and steam vessel1 breathing the steam as long as it lasts4 ,for the throat most any cleansing gargle can be used but ,i prefer the use of the common baking soda gargle4 ,i have about one-half teaspoonful of soda placed in a glass and boiling hot water poured over it4 ,as soon as this is cool enough to use ,i have the patient gargle thoroughly4 ,the idea is to get the mouth1 pharynx and tonsillar area clean and free from accumulations4 ,lemon-water gargle is often gratefully accepted4 ,if a very sick patient breathes through a dirty and dried-out mouth1 all the stage is set for him to draw into the devitalized lung large quantities of infectious material4 ,for this reason if not for the comfort of the patient it is necessary that the mouth be kept clean and also moist4 ,it is not possible to kill this germ life with any antiseptic4 ,the field must be made and kept clean4 ,the nasal passage also should be looked after1 to keep it clean as possible and also to allow the patient to breathe through the nose4 ,for the nasal passage any good non-irritating oil is effective but ,i like best #b iodine in oil4 ,it is a good lubricant and as far as possible we do get the germicical action of the iodine4 ,patients asking me what to do to avoid influenza are advised to keep the mouth clean and closed and to use the oily solution of iodine in the nasal passages4 ,and when treating the respiratory tract we must keep in mind the fact that all healing comes from the blood side of a membrane4 ,no healing ever comes to a membrane from its exposed surface4 ,local treatment to a membrane must be a treatment which removes irritation1 not one which adds more4 ,healing must come from within4 8,the rule of the artery is supreme40 ,diet4--,the diet used is liquid1 so that the digestive functions will be taxed as little as possible1 for they are weak at this time4 ,fruit and vegetable juices only are used4 ,the influenza germ propagates largely in the intestine and if the intestine has in it the products of a full diet the bacterial growth soon overpowers the patient4 ,germ life cannot develop on fruit and vegetable juices4 ,another reason for using the liquid and fruit diet is that influenza is a disease running a short course and feeding is not necessary4 ,if it were a disease such as typhoid1 running a fever for several weeks1 we would then give a more liberal diet1 but the patient's strength will not be lost on a liquid and fruit-juice diet in three or even eight days4 ,the frequency with which the urine contains albumin in this disease shows us what a heavy load the kidneys are carrying4 ,this makes a salt-free diet advisable and again brings fruit juice to our favorable attention4 ,to activate the kidneys and thus relieve the headache we give always plenty of water and often hot lemonade4 ,orange juice and lemonade are used frequently as are blackberry1 raspberry1 pineapple1 loganberry and grape juices4 ,when the acid juices are not well borne we use non-acid juices1 such as pear and raspberry juice4 ,a ripe1 cooked pear mashed with a fork and mixed with one or two different fruit juices makes a satisfying dish4 ,bottled sweet cider is also a most valuable food and a good beverage4 ,we use it in almost every case and find it the most acceptable to the patient of any food offered4 ,i am of the opinion that apple cider has been neglected as an article of diet1 both in disease and health1 but especially in fevers4 ,it contains considerable iron for the blood1 as well as having considerable food value4 ,it has the added virtue of being pleasing to the patient4 ,in addition to these juices we often use spinach juice4 ,i have the nurse get a can of the best grade spinach and serve the juice hot1 as a broth1 with a little salt and pepper and perhaps celery salt and a piece of bacon in it to flavor it and to appeal to the patient4 ,spinach juice contains much iron and iodine in a form readily absorbable by the blood4 ,it also is useful in maintaining the alkalinity of the blood and body fluids1 thus counteracting the acidosis of the disease4 ,it renders the urine alkaline and thus relieves the kidneys of the irritation of acidosis and of an acid urine4 ,where the kidneys are or are likely to be involved the spinach juice must be served without salt4 ,all the mentioned fruit juices tend to counteract acidosis and produce alkalinity1 but are not so effective as the spinach juice4 ,they have the advantage1 however1 of being used in larger quantities4 ,the spinach juice has considerable food value and has the added value of appealing to the patient's reason1 when the iron and iodine content is explained to him4 ,it is especially useful when treating those patients who are wondering if they should not be getting some sort of 8tonic40 ,the juice taken from ground fresh lettuce is also valuable4 ,it contains more iron1 iodine and phosphates than the spinach but it is not so easy to prepare4 ,i have used it in the cases of several anemic and quite sick babies and consider it well worth all the expense and effort it took to secure it4 ,the breaking down of the alkaline reserve of the body and the consequent acidosis1 comes early in the disease and is disastrous1 and all the attention given to the diet is amply repaid in results4 ,careful attention to the diet is the only way the acidosis can be overcome4 ,raw fruit and vegetable juices also supply that most valuable element1 vitamines4 ,for this one thing alone is the raw fruit juice most valuable4 ,i do not believe too much attention can be given to securing a liberal supply of vitamines for the body1 especially during an attack of fever4 ,some especially interesting points are brought out by contributors to the ,journal of the ,american ,osteopathic ,association in the ,march1 #aiai number4 ,i wish here to add a discussion of these points4 ,the contributors are physicians and good representatives of our profession and they report uniform and excellent success in handling the recent epidemic4 ,it seems to be the consensus of opinion that the treatment should be specific and light to avoid fatigue1 with the possible exception of the first treatment1 which often should be general and vigorous4 ,all are agreed that the patient should be kept in bed1 not even leaving it to go to the bath room4 ,the patient must be protected in every way from fatigue and exposure4 ,the enema was used by all4 ,a number of writers state plainly their opposition to the use of physics and laxatives4 ,a hot tub-bath is recommended by several1 but there is opposition to much bathing4 ,practically all the writers used the fruit-juice diet4 ,however1 a few gave a heavier diet and were successful with their patients1 which is one more proof that the osteopathic treatment is the deciding factor in bringing about a cure4 ,j4 ,r4 ,thornton wrote after having had about #ajj cases4 ,he speaks especially of his cases of pneumonia4 ,they resolved by crisis4 ,there were no deaths4 ,he says3 8,all cases were1 preceding the first treatment1 given a generous plain water enema4 ,orders were left for two enemas per day until told to discontinue1 and in most cases the patient got the enema4 ,a few cases1 with the highest fever1 the stationary fever1 were given tap-water enemas1 one each hour until the temperature dropped two or three degrees4 8,sponge baths were given to reduce fever in every case4 ,diet was liquid until the temperature was normal4 8,the osteopathic treatment of the usual spinal work1 paying special attention to cervical and dorsal areas1 and strong inhibition4 8,pneumonia cases were treated three to five times a day and had as much time as they required at each visit4 ,they required action4 ,heating compresses were used on each case1 except the ice bag to the heart when rapid4 ,one case of delirium was treated with ice caps to the head and neck4 ,normal salt solution per rectum4 ,murphy drip was given in each case4 ,diet1 liquid consisting of egg-nog1 milk1 strained soup and broth40 ,mary ,alexander ,patton3 8,treatment should be quick1 every motion significant so as not to tire the patient1 for exhaustion is always present4 ,each patient was treated two or three times a day until temperature became normal4 ,the nasal douche was given twice a day followed by ,k-,y jelly4 ,hot soap bath followed by soap enema and enteroclysis when fever persisted40 ,w4 ,curtis ,brigham ordered 8,hot packs the full length of the spine twenty to thirty minutes1 three times a day4 ,this will produce profuse sweating and often put the patient to sleep40 ,i have used this same treatment1 especially in nervous cases1 and hold it in high esteem4 ,i have the patient put a bath robe on backwards so that the arms and legs are well protected but the spine easily accessible4 ,the hot packs can then be used and covered over and the patient not exposed4 ,r4 ,h4 ,nuckles maintains that lung and ear trouble will not follow influenza where osteopathic treatment has been given to adjust the cervical and upper dorsal circulation4 ,h4 ,a4 ,price3 8,we have kept particularly in mind1 first1 the nerve1 blood and lymphatic supply to the lungs2 second1 the circulation to the spine 7meaning spinal cord72 third1 the internal secretory functions and to the general excretion40 ,ralph ,m4 ,crane says3 8,a great deal of my work is among the ,italians4 ,it was necessary to give quick specific treatment that ,i might do as much good as possible to the greatest number4 ,i did not treat them as often as ,i would like to1 and because of this fact ,i learned that osteopathy got control of the #8flu' immediately1 the first treatment sufficing to start them on the road to recovery2 in fact1 many of them got no more than one treatment40 ,,footnotes3 #ea ,hinckle--,the ,scientific ,basis of ,osteopathy4 #eb ,clinical ,osteopathy4 #ec ,journal of ,osteopathy--,prize ,article ,july1 #aijf4 #ed ,a4 ,o4 ,a4 ,case ,reports--,series ,i4 #ee ,e4 ,link1 ,diphtheria--,the ,bulletin1 #aije4 #ef ,a4 ,m4 ,willard1 ,membranous ,croup--,journal of ,osteopathy1 ,march1 #aijd #eg ,see ,dr4 ,still--,philosophy and ,mechanical ,principles of ,osteopathy4 #eh ,journal of ,osteopathy1 ,october #aije4 #ei ,journal of ,osteopathy1 ,october #aije4 #fj ,journal of the ,american ,osteopathic ,association1 ,march #aijf4 #fa ,journal ,american ,osteopathic ,association1 ,december #aijd4 #fb ,journal ,american ,osteopathic ,association1 ,may1 #aije4 #fc ,journal ,american ,osteopathic ,association1 ,may1 #aije4 #fd ,rewritten from article in ,osteopathic ,physician1 ,june #aiai4 #fe ,this treatment was described by ,henry ,m4 ,stovel1 in ,the ,osteopathic ,physician of ,january #aiag4 #ff ,o4 ,p4 ,june #aiai4 ,,acute ,,eruptive ,,fevers1 ,,mumps ,,and ,,whooping ,,cough ,by ,,edgar ,s4 ,,comstock ,,general ,,consideration ,in the consideration of these diseases1 it is well to bear in mind that lowered resistance is the primary condition that has made the infections possible1 and that lowered resistance implies an imbalance of or obstruction to the vital fluids and forces of the body1 thereby interfering with the functional activity of the body's normal protective mechanism4 ,the imbalance of or the obstruction to these vital fluids and forces1 which is structural in nature1 is produced by many conditions1 as fatigue1 exposure1 sudden changes of heat and cold1 emotions1 dietetic errors1 physical force or violence1 etc4 ,these conditions1 because of the response of the tissues of the body to environmental changes1 produce contractures of the elastic tissues1 such as muscle1 fascia1 etc41 which disturbs the structural integrity of the body and thus produces obstructions1 irritations or interference with the media of exchange of these vital fluids 7blood and lymph7 and forces 7nervous energy7 of the body4 ,it is evident1 then1 that the most potent curative factor in the treatment of these diseases1 as in all others1 is the removal1 whenever possible1 of the obstructions and interferences that pervert the activity of these protective forces4 ,it is necessary1 therefore1 to remove the exciting causes 7fatigue1 dietetic error1 etc47 and by such physiological means as may seem necessary to readjust the structures of the body so as to remove the above mentioned obstructions and interferences4 ,the structural lesions most frequently found in the infectious diseases are of the muscular and fascial type and are very evident to the careful observer4 ,the interosseous lesions are probably often the predisposing factors to the susceptibility of the softer tissues to reaction to environmental changes1 but it has been the experience of the writer that the adjustment of the softer tissues was of greater primary importance in the acute stages of these diseases4 ,the interosseous lesions may be easily adjusted in the very early stages of these diseases1 that is before the severe symptoms have appeared1 but after the more severe conditions have appeared it has been our experience that the soft tissue work was sufficient unless the interosseous lesions were very easily adjusted4 ,it is the writer's desire to impress upon the reader the necessity of careful attention to the structural lesions that are always constant in these diseases1 using whatever physiological means seem necessary to adjust these lesions and keep them adjusted1 and to insist upon carefully restricted diet2 continuous1 thorough elimination of the waste products of the body2 hygienic surroundings and well-regulated environments both mental and physical4 ,then ,nature1 which has given the body its own protective mechanism1 may have full control of the situation and all of the normal protective chemicals and forces in the body organism are utilized in the battle with the invading infective forces3 the glands secrete the chemicals of protection2 the antibodies are rapidly developed and thrown into the battle area2 metabolism begins to return to normal2 elimination becomes increased because of the stimulating action of foreign substances in the body structures2 and the work of repair and recuperation begins4 ,if reliance is placed upon the inherent protective forces of the body1 the knowledge of the special type or character of the invading organism is of little importance from the standpoint of the treatment of the disease after it has become established4 ,the value of the knowledge of the specific organisms is in preventive medicine1 in seeking out the habitat and breeding ground of the organism and its mode of transmigration4 ,knowing these1 effective measures may be adopted to prevent their propagation and spread4 ,examples of this are ,yellow ,fever and ,malaria4 ,variola 7,,smallpox7 ,definition4--,variola is an acute1 specific1 highly infectious and contagious1 epidemic disease4 ,its beginning is sudden with a chill1 vomiting1 severe headache and lumbo-sacral pains4 ,it has a typical fever curve and a typical eruption on the skin and mucos of macules1 papules1 pustules and crusts successively4 ,history4--,prevailed in ,china and ,india at least #ajjj years before the ,christian era4 ,epidemics occurred in the sixth century and during the crusades4 ,its first clinical description was given in ,arabia during the ninth century4 ,it was brought into ,mexico about #aebj by the ,spaniards and between three and four million people contracted the disease4 ,in #agah preventive inoculation was introduced into ,england and in #agif ,jenner discovered vaccination4 ,etiology4--,the specific agent which is the cause of this disease is unknown1 but the virulence of the agents is retained for a long period and is the most virulent found in all diseases4 ,there is no period from the initial fever to the final desquamation that the disease is not contagious1 although the stage of suppuration is the most violent4 ,although the disease is so highly contagious and the entrance of this particular poison into the system produces this disease1 still no one has yet been able to discover a germ nor what the nature of the infective agent is4 ,to contract the disease it is not necessary to touch an individual already afflicted1 not to even approach the sick room4 ,it may be only necessary to touch a garment that has once been in contact with a smallpox patient1 or which has simply hung in his vicinity4 ,the blood is infectious at a very early stage4 ,as smallpox is contagious without eruption it seems that the secretions and excretions convey the virus4 ,the dried pustules seem to have the greatest infectiousness4 ,cadavers of smallpox 7,variola7 victims are very dangerous and relatives of them should be carefully warned4 ,the disease often persists in infected communities for years4 ,the disease is evidently spread by fomites1 contact with the pustular contents1 and crusts or scales of the desquamating skin4 ,it attacks all classes1 ages and conditions of people1 which is unlike other erythematous diseases4 ,a previous attack usually confers immunity4 ,vaccination is claimed to confer immunity but apparently in not all instances1 for there are records of 8successfully vaccinated0 individuals having severe attacks of the disease4 ,the susceptibility to smallpox1 as to all other infectious diseases1 varies in different individuals1 in different races1 and under the influence of conditions as yet unknown4 ,some persons are not susceptible to the disease1 nor are they to vaccination1 and yet others have been known to have had the disease as much as three times4 ,the ,negro and ,indian races seem to be more susceptible than the ,caucasian4 ,then again at intervals of a few years1 the general susceptibility of the people seems to be increased so that cases of smallpox become far more numerous than usual4 ,a point of considerable interest is the fact that the child1 while in the mother's womb1 may experience the disease along with the mother and thereby acquire1 before birth1 the usual immunity conferred by one attack of the disease4 ,in most cases of smallpox in pregnant women1 abortion or miscarriage occurs1 yet a sufficient number of instances are on record in which healthy children have been born1 exhibiting the characteristic pitting of smallpox1 and possessing no susceptibility to vaccination4 ,again there are other cases in which pregnant women have smallpox and the babes in the wombs have escaped entirely2 while the most singular fact is that while the fetus may experience the disease1 the mother through whom the exposure was effected1 escapes1 either because of a previous attack or possibly because of vaccination4 ,while there seems to be no reason for believing that an attack of smallpox can be1 or ever has been1 aborted by artificial means1 yet there is a prevalent belief that this process occurred during certain epidemics of smallpox1 cases having been known in which individuals presented all the symptoms indicating the invasion of smallpox1 and yet no eruption occurred1 and yet such individuals were thereafter insusceptible to smallpox or vaccination4 ,the mortality of smallpox varies like the susceptibility of it--with the age of the patient and with some unknown conditions of the atmosphere or soil which favor the occurrence of the epidemics4 ,the average in scattered cases--sporadic--is probably not greater than one in nine or ten4 ,a fatal result occurs more frequently in the second week of the disease than at any other time4 ,pathology4--,granular and fatty degeneration occurs in the liver1 spleen1 kidneys and heart4 ,infiltration is found in the adrenal glands and testicles4 ,during the papular stage1 there is local hyperemia of the papill1 with interstitial exudation and colliquative necrosis of rete cells1 so that a vesicle is formed1 peculiar in that it is traversed by delicate bands of epithelial cells4 ,this1 with the fact that coagulation-necrosis occurs mainly in the center1 gives it the umbilicated1 or depressed appearance4 ,the contents of the vesicle are plasma1 fibrin and cell detritus4 ,leucocytic invasion converts vesicles into pustules4 ,this has a more globular1 elevated appearance than the umbilicated vesicle4 ,pyogenic organisms are found in the pus4 ,when the inflammation injures the corium1 scars are apt to result2 this occurs when the skin is scratched4 ,the actinic light rays increase the danger4 ,diagnosis4--,mistakes in the diagnosis of the first cases of smallpox in an epidemic are almost inevitable4 ,hemorrhagic scarlatina or measles sometimes cause confusion2 in the hemorrhagic scarlatina the mucous membrane hemorrhages are less frequent than in smallpox4 ,the prodromal eruptions plus purpura are very suggestive4 ,the invasion stage lasts about three days4 ,smallpox is characterized by sudden onset with violent chill and shivering2 agonizing pain in the back and legs2 intense headache1 mostly frontal2 temperature rapidly reaching #ajb to #ajd degrees ,f42 full1 strong1 rapid pulse1 going to #ajj to #adj2 uncontrollable vomiting2 pharyngitis2 red face1 bright eyes1 coated tongue2 anorexia2 constipation2 sleeplessness2 delirium2 often copious perspiration and extreme prostration4 ,an 8initial exanthem10 clearing within #bd to #dh hours1 appears4 ,it is either hemorrhagic or erythematous4 ,about the third day the true eruption appears1 first upon the forehead and in the scalp1 then the rest of the face1 the backs of the wrists1 trunk1 arms1 and lastly the legs1 most abundant upon the parts exposed to the atmosphere4 ,with the appearance of the eruption1 all symptoms abate1 the temperature falls1 and the patient may feel quite comfortable4 ,the eruption consists of coarse1 red spots upon the body1 like flea-bites1 rapidly becoming1 within #bd hours1 slightly raised red papules1 feeling hard and shotty to the touch1 and each surrounded by a broad red inflammatory band1 the areola4 ,usually by the sixth day the papules become converted into umbilicated vesicles1 at first clear1 then turbid4 ,they are hard and indurated to the touch1 and on the eighth or ninth day they become pustular4 ,the areola becomes much darker1 the temperature rises to #ajc to #aje degrees ,f41 and the pulse to #aaj to #abj4 ,the other symptoms all reappear1 with salivation and delirium4 ,marked edema of the skin renders the skin unrecognizable4 ,the pustules are painful1 especially in places where the skin is thickened4 ,the maturation lasts about three days1 when the fever falls by lysis4 ,if fatal1 death usually takes place about the tenth day1 preceded by feeble and more rapid pulse1 marked delirium1 subsultus and sometimes diarrhea4 ,about the eleventh day1 desiccation begins1 the pustules begin to dry1 forming tight scabs which are closely adherent4 ,the fever and other symptoms subside but itching becomes annoying4 ,the odor from the pustular stage on is a peculiar greasy one4 ,after the rupture of large pustules the centers frequently dry and sink in1 often in the shape of the ,maltese cross4 ,this is most typically seen on the backs of the hands and is pathognomonic4 ,toward the end of the third week the scabs fall1 leaving red glistening pits which disappear or change into deep white striated scars4 ,the hair falls but may grow again4 ,the diagnosis is not certain until the eruption is seen4 ,in the smallpox without eruption the diagnosis must be made from the history of exposure1 the presence of an epidemic1 fever1 lumbar and head pains1 delirium1 and possibly the initial rash4 ,mistakes in diagnosis may be made even by smallpox experts1 but attention to the history1 somatic findings and the course of the disease1 rather than to the eruption1 will prevent disastrous results4 ,always isolate any and all suspected patients4 ,varicella ,compared with ,variola ,vaccination and smallpox never ,smallpox may closely resemble prevent4 chicken pox2 especially mild cases4 ,,age--usually before puberty1 may ,usually after puberty 7many occur in adults4 exceptions47 ,initial stage practically absent4 ,initial stage severe1 even in mild cases4 ,,temperature1--no remission on ,typical remission and secondary onset of rash4 fever4 ,white cells normal or decreased4 ,leukocytosis4 ,prodromal rash very exceptional4 ,prodromal rash quite frequent4 ,vesicles in crops4 ,vesicles never in crops4 ,vesicles rarely shotty4 ,vesicles1 following macules1 are hard and shotty4 ,,rash ,,evolution1-- ,,rash ,,evolution1-- ,very rapid1 vesicles on first or ,much slower1 vesicles on seventh second day4 day4 ,eruption is universal1 successive ,development progresses downward1 crops1 most abundant on back1 face first1 then wrists1 begins on body1 less on face1 trunk1 arms and lastly legs4 ,less scalp1 hands and feet4 on trunk4 ,vesicle is superficial and fluid ,fluid pearl-colored and ,,not transparent4 transparent4 ,thicker covering4 ,halo 7areola7 usually absent4 ,areola is marked4 ,involution is quite rapid4 ,involution is slow4 ,the ,secondary ,toxic or ,septic ,rash appears during the stage of decrustation1 sometimes with a mild fever4 ,it may be either scarlatiniform1 morbilliform1 or hemorrhagic4 ,the skin immediately surrounding the drying pocks is often exempt leaving an anemic halo4 ,the rash lasts about three days and fades or desquamates4 ,with the development of the skin eruption1 an exanthem appears upon the mucous membranes of the body cavities1 developing into ulcers4 ,this may develop before the dermal rash and be of diagnostic importance4 ,forms or ,varieties ,i4 ,variola ,vera4 a4 ,discrete4 b4 ,confluent4 c4 ,purpura variolosa ,,ii4 ,variola ,hemorrhagica4 7black smallpox7 d4 ,variola hemorrhagica pustulosa4 ,,iii4 ,varioloid4 e4 ,smallpox modified by vaccination or partial immunity4 ,discrete ,variola ,vera4--,incubation symptomless and averages #ab days4 ,prodromal stage1 from first symptom to eruption4 ,averages three days4 ,the longer the stage the more severe the infection4 ,intensity bears little if any relation to prognosis2 however1 if onset is mild1 disease will not be confluent or hemorrhagic4 ,invasion begins with severe chill1 often repeated4 ,initial fever rises suddenly to #ajc or #ajd1 and reaches maximum on second or third day4 ,pulse is rapid and full4 ,skin is red1 hot and dry4 ,there may be sweating in the discrete form and in the favorable cases4 ,the headache appears with the chill and is usually frontal4 ,when severe and accompanied with neckache and vomiting it may suggest meningitis4 ,the backache appears with the chill and lasts about two days4 ,it is a lumbar pain1 very like lumbago2 it occurs slightly less frequently than the headache and vomiting4 ,this pain is rare in other fevers likely to be confused with smallpox4 ,vomiting is constant in children and usual in adults4 ,the initial eruptions1 which are present in about #aj to #ab per cent1 are of considerable diagnostic importance4 ,they are usually limited to the lower abdomen1 inner side of the thighs1 axill1 and sometimes on the extensor surfaces of the knees and elbows4 ,the ,eruptive stage consists of the following sub-stages3 macules and papules2 vesicles1 and pustules4 ,the macules and papules occur on the fourth day and progress for about three days4 ,they begin on the forehead1 near the hair1 with itching and burning and resemble flea-bites4 ,these soon become papules1 which are reddish1 elevated1 circular1 hard or shotty and discrete4 ,on second day of this stage they appear on the body1 and on the next day on the extensor surfaces of the extremities4 ,if the eruption appears on the second day the confluent type may be anticipated2 if on the third day of the disease1 the discrete type4 ,the vesicles which occur on about the seventh day of the disease1 contain lymph4 ,umbilication occurs in the centers of many of the vesicles1 and it is suggestive of smallpox4 ,the suppurative stage begins about the ninth day with clouding of the vesicles and inflammation around them4 ,this continues for three days4 ,the pustules become opaque1 then yellow1 and a thick pus obliterates the umbilication4 ,the inflammatory 8halo0 becomes more vivid and edema may follow around these haloes4 ,this edema causes increased tension and deformity1 particularly of the face1 and produces great tenderness and pain4 ,the pustulation follows in the order of eruption1 from the face downward1 and are the thickest on the extremities and head4 ,the pustules evacuate spontaneously1 or may dry up without rupture4 ,the skin gives off a peculiar1 offensive odor4 ,bed-sores are now most likely to develop4 ,the eruptions also may occur in the mucous membranes1 particularly in the mouth and nasopharynx4 ,these pass through the successive stages as do those of the skin1 but less typically4 ,with the pustulation there is usually a gradually rising secondary fever4 ,in the discrete type the secondary fever does not remain high more than twenty-four to thirty-six hours1 with morning remissions4 ,a marked leucocytosis occurs with the secondary fever and its extent depends upon the severity of the infection4 ,delirium1 albuminuria1 acute exhaustion and heart paralysis are to be guarded against during this stage4 ,the state of involution1 or decrustation1 begins about the twelfth day4 ,it follows the order of eruption1 and is accompanied with a decrease in edema1 redness and pain1 but is attended with intolerable itching4 ,crusts form1 the hair falls out and by the end of the second week the temperature returns to normal4 ,if fever persists during this stage it indicates some complications4 ,scars occur when the true skin is involved and lasts three or four weeks4 ,complete convalescence follows the disappearance of the last crust4 ,confluent ,variola ,vera4--,this is a malignant type and used to be more prevalent than now4 ,the initial stage is violent1 and the headache and backache very agonizing4 ,the fever remission is very slight or absent1 and attended with hardly any improvement in symptoms4 ,the earlier the exanthem occurs in variola the more likely it will be of the confluent type4 ,the confluent eruptions occur especially upon the face and head1 sometimes on the hands and feet4 ,it is largely discrete on the body and extremities4 ,great edema appears with the fusion of the eruption1 with the swelling and erosion of the mucous membrane1 the eyes close and the nostrils become obstructed4 ,the fever is high1 pulse high and rapid 7often irregular71 dilirium1 albuminuria1 persistent nausea and vomiting1 great thirst1 husky voice1 enlarged cervical glands1 salivation in adults and diarrhea in children are symptoms present4 ,death occurs from acute toxemia1 usually within a week1 but may last a little longer4 ,recovery from confluent variola is very infrequent4 ,purpura ,variolosa4--,this is 8,black ,smallpox40 ,that is1 smallpox with primary hemorrhage in the initial stages4 ,it is the worst type and results almost invariably in death4 ,it is very important because it is so difficult to diagnose4 ,its incubation period is short 7#f to #h days71 invasion very severe1 lumbar pains almost unbearable1 prostration great1 pulse soft1 small and rapid and respiration unusually high4 ,the initial pains and vomiting may last until death4 ,on the first or second day a plum colored eruption appears1 with brick-red1 purple or inky ecchymoses particularly about the eyes4 ,the condition is desperate4 ,hemorrhages may occur from any cavity of the body1 sometimes accompanied by gangrene of the pharynx4 ,the disease does not usually reach the period of real eruption1 because death usually occurs within four or five days4 ,the diagnosis of this condition is by history of exposure to smallpox and the characteristic prodromes4 ,variola ,hemorrhagica ,pustulosa4--,this is the type with the secondary hemorrhage1 or the hemorrhage after the eruption appears1 and is more common than primary hemorrhage4 ,it occurs in weakly and alcoholic subjects4 ,the initial stage is severe1 and the hemorrhages occur into the vesicles or pustules4 ,there may be epistaxis1 hematuria and metrorrhagia4 ,the outcome is almost always fatal1 though the hemorrhage at the vesicular stage may be followed by rapid abortion of the rash and recovery4 ,varioloid4--,this is modified or mitigated smallpox2 also known as variola benigna4 ,persons exposed to smallpox sometimes suffer from varioloid1 and persons who have had smallpox may suffer from varioloid at subsequent exposure to smallpox4 ,vaccination appears to initiate an attack in persons peculiarly susceptible1 or as a result of improperly performed vaccination4 ,the lesions remain in the epidermis1 the course of the eruption is shorter1 the papules vesicate by the fifth day1 the process of suppuration is abridged1 decrustation occurs rapidly with little or no scarring1 and all symptoms are milder4 ,there are many modifications4 ,other varieties are 7#a7 ,variola sine exanthemate1 which has the usual symptoms without the eruption2 7#b7 ,variola verrucosa1 which has large1 solid1 conical papules with small vesicles at their apices1 which rapidly desicate and form crusts1 and finally disappear without scars2 7#c7 ,variola cornea 7horn pox7 which is known by the large mahogany crusts4 ,complications and ,sequel4--,variola is often accompanied by many complications and sequal which are an early severe toxemia and a later secondary infection4 ,during the secondary fever1 there may be bronchopneumonia1 pleurisy1 dysentery1 hemorrhages of all kinds1 ulcerative eye1 ear or laryngeal conditions1 purulent arthritis1 orchitis1 gangrene when the swelling is great and subcutaneous abscesses form1 often attacking the penis and scrotum1 erysipelas attacking the face1 and rarely nephritis4 ,during convalescence1 carbuncles1 boils and other subcutaneous abscesses are very common4 ,disturbances of the peripheral nervous system as neuritis1 paralyses especially of the palatal muscles1 neuroretinitis1 and otitis media are less common4 ,the sequal most common are boils1 abscesses1 deep pitting1 otitis media1 blindness and permanent baldness4 ,the urine has the usual febrile changes4 ,white blood cells reach #aj1jjj to #bj1jjj or more4 ,lymphocytosis occurs during pustulation2 polymorphonuclear cells are decreased to #dj1 sometimes to #ab2 myelocytes and irritation forms are found4 ,during the febrile stage there is a polycythemia followed by an anemia to #c1jjj1jjj or less during the pustular stage4 ,regeneration is slow1 lasting about fourteen days4 ,normoblasts are rare except in hemorrhagic forms4 ,exudate taken from the pustules show streptococci1 staphylococci1 and pseudodiphtheria bacilli4 ,treatment4--,the imperative demands of treatment are isolation1 ventilation1 cleanliness and disinfection4 ,if symptoms are suspicious of smallpox1 notify the proper authorities at once and isolate patient4 ,when diagnosis is made1 cut hair and beard very short4 #a4 ,isolate patient in room free from draperies1 rugs1 carpets1 curtains1 pictures1 etc4 #b4 ,disinfect all vessels used in room of the patient in carbolic acid solution or in bichloride of mercury solution4 #c4 ,family of patient should be isolated for from sixteen to twenty days4 #d4 ,room should be well ventilated1 with windows screened and slightly darkened with red curtains to exclude the ultra-violet rays of light4 ,temperature should be maintained at #fe degrees4 ,door-way may be protected by a sheet dampened with a #a3fj carbolic solution4 #e4 ,nurse must be robust1 perfectly immune and not afraid4 ,if male nurse1 hair must be very short and must have no beard2 if female1 hair must be short and must wear close fitting cap4 #f4 ,absolute cleanliness is secured by plenty of baths1 clean bed and personal linen1 and careful nursing4 ,physician must put on special suit with cap and gloves which are kept in the house1 but not in the sickroom4 ,the first symptoms being the headache1 nausea and vomiting and the lumbar pains1 the first points of attack in the treatment would be the relief of these pains in the head and back by thorough relaxation of the spinal muscles1 paying particular attention to the suboccipital1 mid-dorsal and lumbar areas4 ,the headache may be partially relieved by steady pressure between the frontal and occipital regions4 ,no interosseous adjustments requiring painful or difficult technique should be given after the more severe symptoms have appeared4 ,patient should be visited from one to three times per day1 and the reflex contractures of the muscles must be relieved as often as they occur4 ,dysentery and diarrhea are controlled by strong inhibitory pressure in the sacral and lumbar regions4 ,give vasomotor treatment to the superior cervical ganglion4 ,stimulate the anterior aspect of the solar plexus to stir up its acid function1 the blood being alkaline in smallpox4 ,during all the stages up to the stage of pustulation1 the patient responds very readily and successfully to osteopathic treatment4 ,the headache1 the backache and the aching joints respond to treatment as readily as1 if not more readily than1 the headache and backache of influenza do to osteopathic care4 ,the constipation is usually quite readily relieved4 ,it has been the experience of those who have handled smallpox cases1 that the tendency to the confluent type is greatly reduced by this treatment and that the response of the patient to osteopathic treatment is very gratifying4 ,indeed1 those of experience have less fear of the outcome of their smallpox cases than do they have of scarlet fever or pneumonia4 ,after the pustules have formed1 each pustule is treated with iodine painted on the pustule with a camel's hair brush4 ,during the pustular stage it is not necessary to give manipulative treatment1 and indeed it is sometimes impractical because of the tenderness of the skin4 ,however1 about all that is needed during this period is good hygienic treatment and good nursing4 ,during convalescence constitutional treatment should be given4 ,diet4--,during period of vomiting1 pellets of ice in the mouth are comforting4 ,during periods of fever give plenty of water with1 preferably1 lemon juice4 ,as the fever declines begin with barley and oatmeal water with lemon juice2 then follow with easily digested and nutritious diet of milk1 eggs1 broths1 beef juice and gruels4 ,feed every three hours during that period but not large quantities4 ,during convalescence a full1 well-regulated1 nutritious diet should be ordered4 ,hygienic ,care4--,keep nose cleansed with glycerine1 cold cream or olive oil1 which keeps the crusts soft4 ,the mouth and nasopharynx may be cleansed with any mild antiseptic4 ,the eyes are washed with warm boric acid solution4 ,cold compresses applied over the eyelids assist in reducing the edema4 ,a daily tepid sponge bath is necessary4 ,bath may be given with bichloride of mercury solution 7#a3bj1jjj7 or creolin 7#a3ejj74 ,headache4--,deep1 steady digital pressure in the suboccipital fossa and at eighth thoracic spine2 ice bag to the head2 or a mustard plaster at the back of the neck may relieve4 ,vomiting4--,thorough relaxation and adjustment of the great splanchnic and cervical areas1 with deep1 steady digital pressure in the occipital triangles1 and at the fourth and fifth dorsal vertebr on the right side will usually control the condition4 ,fever4--,relaxation of the upper dorsal area1 relaxation of the cervical area1 and deep1 steady pressure in the suboccipital region often reduce temperature4 ,warm sponging in lower grades of fever1 bath at #gj ,f41 and cold pack may be needed4 ,if temperature goes very high give a continuous cool colonic irrigation4 ,pitting4--,cold wet dressings of lint soaked in any comfortable mildly antiseptic solution1 or of ice water and glycerine1 are to be used on the hands and face to prevent pitting4 ,hot water dressings are more comfortable to some patients4 ,it is well to protect the skin from the light1 especially from the ultra-violet rays4 ,this1 however1 must not lead to any lack of ventilation4 ,when crusts are forming keep them moist with vaseline1 oil1 glycerine1 or carbolic acid in lanolin or vaseline4 ,odor4--,baths1 the daily toilet and the use of dusting powder or #e iodoform powder1 an open bottle of smelling salts or of weak ammonia are good4 ,plenty of fresh air is best of all4 ,cardiac ,weakness4--,if pulse is feeble and frequent1 a general quieting treatment should be given1 including relaxation of the cervical area and of the fourth and fifth dorsal segments4 ,an ice bag in flannel directly over the heart is often very useful4 ,gentle1 careful spinal extension is very restful and eases the spinal circulation4 ,delirium is usually relieved1 or prevented1 by spinal extension1 the prolonged warm bath or the cold pack1 if given when signs of nervousness appear4 ,morphia or chloroform may be necessary in violent and suicidal cases4 ,laryngeal ,obstruction4--,usually caused by edema and may require tracheotomy4 ,bed-sores4--,these and abscesses may occur even under the best of care4 ,place patient upon a water-bed or in a continued warm bath4 ,convalescence is not complete until the skin is entirely free from crusts and is perfectly smooth4 ,prognosis4--,prognosis depends upon age of patient2 complications2 and environment from which patient comes1 as well as upon the nursing4 ,in varioloid the prognosis is recovery2 in the discrete variety1 good2 in the confluent type over #ej are fatal2 in the malignant types practically all die4 ,in patients under five years old and over forty years old the prognosis is very grave4 ,a filthy environment predisposes to complications4 ,recurrences seldom occur2 second attacks are usually varioloid4 ,prophylaxis4--,usual rules of health authorities are3 rigid quarantine or isolation1 vaccination1 disinfection of the skin and all fomites1 and final fumigation4 ,quarantine of a suspected individual is sixteen days after exposure4 ,isolation continued until every trace of eruption has disappeared4 ,the dead body is very dangerous and a public funeral is not permitted4 ,the clothes used by the patient must be steamed and other articles must be washed with bichloride of mercury and fumigated with formaldehyde vapor4 ,disinfection of the hands1 face1 beard and hair of attendants with bichloride solution is imperative4 ,vaccination 7,,vaccinia2 ,,cow-,,pox7 ,definition4--,vaccinia is an eruptive disease of the cow1 communicable only by inoculation and causing1 when transmitted to the human being1 local reaction in the form of a pock and constitutional disturbances which are followed by a more or less lasting immunity against smallpox4 ,vaccination is the artificial inoculation of vaccine virus for the purpose of producing an immunity against smallpox4 ,arm to arm vaccination was formerly very generally practiced but has been practically discontinued because of the possibility of infection from syphilis and other infections4 ,when it is necessary to use the human lymph it should be taken upon the eighth day from a typical unbroken vesicle in a perfectly healthy child at least three months old4 ,the vesicle must be pricked at several points1 care being taken not to draw blood4 ,the bovine vaccine lymph is now in general use because it practically eliminates the possibility of syphilis and other infections4 ,also because it is more easily transported4 ,it is thought best by many authorities to vaccinate in infancy after the sixth month1 at the seventh and eighth year1 at puberty1 and thereafter at intervals of about seven years1 but depending considerably on the prevalence of small pox4 ,the virus is prepared under sterile conditions from carefully selected and tested calves4 ,it is put up under aseptic conditions in hermetically sealed capillary tubes or1 in the old style1 on ivory points4 ,there is a great variety of opinions as to the efficacy of vaccination in producing immunity against small pox1 this variety of opinion being very prevalent among representatives of the medical schools4 ,dr4 ,f4 ,p4 ,millard of ,toronto says the lymphatic system is the keynote1 and that vaccine virus poisoning spreads through the lymphatics1 causing diphtheria and allied throat affections4 ,dr4 ,a4 ,t4 ,still said1 8,we are opposed to vaccination40 ,he repeatedly emphasized the fact that 8,nature furnishes within the body all the remedies necessary to cure disease40 ,in the recent ,canadian epidemic 7#aiai-aibj7 the medical authorities have met with a most strenuous opposition4 ,the ,homeopathic profession1 almost to a man1 went on record as opposed to compulsory vaccination4 ,the ,illinois ,supreme ,court has ruled that compulsory vaccination is unconstitutional4 ,technic4--,the area usually selected is the left arm at a point above the insertion of the deltoid muscle4 ,some prefer the leg over the junction of the two heads of the gastrocnemius muscle1 because it is more easily cared for1 and1 because of the style of wearing short sleeves among women1 it does not expose the scar which results from the vaccination4 ,the surface must be washed1 dried1 with a soft towel1 and then sterilized with alcohol4 ,with a sterilized needle or lance scratch an area about a quarter of an inch in diameter1 being careful not to produce bleeding but merely an oozing of pinkish lymph4 ,a drop of the virus should be deposited upon the abraded surface1 rubbed in with the side of the needle and let dry4 ,a thin layer of sterilized gauze should be lightly applied and held by means of adhesive plaster1 not encircling the limb4 ,this should be occasionally removed and redressed4 ,the pock should be kept dry and clean1 and may be lightly dusted with starch or toilet powder4 8,persons exposed to the contagion of small pox should be immediately revaccinated4 ,the immunity conferred diminishes with time40 ,it is the writer's personal opinion that1 with the amount of complications that so frequently follow vaccination and with the fact that 8it is necessary to revaccinate during an epidemic or after exposure10 it were better to defer vaccination1 if parties are favorably inclined to the practice1 until such time as the presence of small pox in the community make it apparently necessary4 ,typical ,vaccination4--,the period of incubation varies from three to five days4 ,at the end of this time local reaction shows itself in the form of reddish papules at the point of inoculation4 ,in about five days these develop into compound vesicles1 which at first have clear and then later opaque contents4 ,about the eighth day the vesicle is fully developed and is round or oval with prominent and well defined edges and a depressed center4 ,an erythematous areola usually appears about the tenth day and the contents are purulent4 ,the surrounding skin is swollen and tender1 and a scab now begins to form in the center of the pock and rapidly extends toward its edges4 ,about the end of the second week the areola fades1 and the pock is changed into a thick brownish crust which becomes dry and hard1 and comes off between the twentieth and twenty-fifth days after vaccination4 ,a dusky red scar is left and this gradually becomes white and pitted4 ,during the evolution of the pock the glands through which lymphatic drainage takes place become slightly enlarged and tender4 ,the constitutional reactions are usually moderate fever1 restlessness at night1 irritability and loss of appetite4 ,these symptoms usually appear about the fourth day and continue about three to five days4 ,at any time during the vaccinia erythema1 roseola or urticaria may appear4 ,the constitutional reaction in revaccination is sometimes very severe4 ,there are many atypical symptoms following vaccination as variation in the number of the pocks1 in the size1 in the severity of the constitutional symptoms1 in the contents of the pock1 in the healing and formation of the scar and in the transmission of specific diseases as syphilis1 tuberculosis1 leprosy1 cancer and tetanus4 ,complications4--,all cases are not benign1 as due to impurity of vaccine1 carelessness in technic1 improper care in dressing1 handling of the wound by the patient himself1 scratching it with the finger nails1 and other accidents of like nature1 infections may set in and very serious complications arise4 ,these result in abscesses1 erysipelas1 tetanus and various eruptions4 ,otitis media may leave deafness4 ,the writer knows personally of a young man in the ,army during the ,world ,war who was vaccinated while in the ,army and two abscesses developed which ate entirely through the arm1 one abscess passing through the arm just anterior to the humerus and the other just posterior to it4 ,it was many1 many months in healing1 and nearly caused loss of the arm4 ,there are many cases of record where vaccination was followed1 directly or indirectly1 by paralysis1 deformities1 and chronic constitutional diseases4 ,it is usually claimed these conditions were due to accidents following the vaccination and not due to the vaccination itself4 ,however1 it can not be denied that the vaccination was at least the indirect cause of these deplorable conditions4 ,general ,vaccinia4--7,vaccinal eruptive fever2 ,vaccinola74 ,this consists of a vaccine rash1 developing usually from the fourth to the tenth day following vaccination1 and appearing in various parts of the body1 particularly about the wrists and on the back4 ,the secondary pocks usually develop about the eighth or tenth day after vaccination and are usually more abundant on the vaccinated limb than on any other part of the body4 ,as the pocks appear in successive groups1 all stages of the disease may be seen at one time1 and the condition may last for many weeks4 ,fever may be absent or present1 but is usually proportionate to the extent of the eruption and the associated complications4 ,treatment4--,after vaccination1 the patient should be told to return in seven days1 when the dressings should be removed1 and if the vaccination has been successful1 a pearl-like vesicle will be present4 ,if the vesicle has been broken by accident or by rubbing of the gauze1 the free portions of the dressing should be cut away and the adherent part left undisturbed4 ,a new gauze should be applied in any case1 and in five or six days more1 the dressing should be again changed1 and this changing continued at intervals until the crust falls1 which is usually during the third or fourth week4 ,if no vesicle forms by the tenth or twelfth day1 the vaccination has not been successful4 ,it is suggested by the vaccination advocates that another attempt should be immediately made4 ,prognosis4--,uneventful recovery is to be usually expected4 ,pitting from generalized vaccinia2 various constitutional diseases2 paralyses and other maiming disabilities sometimes occur4 ,while it is not usually considered dangerous to life1 there are nevertheless many cases of record where death has resulted4 ,it is not wholly unattended with danger4 ,the best of care should always be taken following vaccination to prevent the possibility of complications1 though even then they do occur4 ,scarlet ,fever 7,,scarlatina7 ,definition4--,scarlet fever is an acute1 specific1 contagious1 infective disease of unknown origin1 characterized by very sudden onset1 fever1 vomiting1 sore throat and diffuse exanthem4 ,history4--,it was first recognized in the sixteenth century1 but first fully described and differentiated from measles by ,sydenham in #affj4 ,it was introduced into ,america about #agce4 ,etiology4--,the causative organism or agent is unknown4 ,the virus of scarlet fever produces severe necrosis1 but no suppuration4 ,the streptococcus is the most important factor in the production of complications and in their mortality4 ,it is claimed to be the cause of the malignancy of the disease but not of the disease itself4 ,susceptibility to the disease is by no means universal as only #ch of children and but #e of adults exposed to the infection acquire the disease4 ,over #ij of the cases occur under ten years of age1 and rarely during the first year of life4 8,scarlet fever is a toxic superficial expression of internal malnutritive conditions of the blood as a tissue4 ,the cause of the toxicity is usually overfeeding1 or the feeding beyond the demands of the proximate principles of the body1 or the overfeeding under unhygienic conditions4--,j4 ,,martin ,,littlejohn4 8,it was once held that the virus was disseminated during desquamation1 but oral1 nasal and otitic discharges probably perpetuate the infection1 perhaps months after scaling is complete4 ,in no other disease is the virus so tenacious4 ,it may persist ten years on clothes1 furniture1 etc40--,a4 ,r4 ,,edwards4 ,the light forms are as contagious as the severe ones1 and inoculations have occurred from the living subjects as well as from autopsy cuts4 ,in degree of infectiousness smallpox ranks first1 measles second and scarlet fever third4 ,the infection may be spread by any third person or by articles coming in contact with the patient1 and often the mode is obscure4 ,sporadic cases apparently frequently appear4 ,the reason for the sporadic cases may easily be explained by the theory of ,j4 ,martin ,littlejohn1 given above4 ,one attack usually confers immunity1 but not always4 ,this disease occurs more often in the autumn and winter1 and is more prevalent in cities than in the country4 7,measles is more prevalent in the country47 ,scarlatina sometimes occurs with other infections1 such as diphtheria or measles1 and more rarely with varicella1 pertussis1 etc4 ,predisposing ,factors4--,age1 one to ten years2 lowered resistance from overfeeding1 unhygienic environments1 exposure to sudden temperature changes2 lesions1 both muscular and interosseous which interfere with the distribution of the fluids and vital forces of the body2 season of the year 7autumn and winter72 puerperal women1 and wounds4 ,pathology4--,no specific lesions are found4 ,no trace of the rash shows after death except in the hemorrhagic form4 ,the anatomical changes in cases coming to autopsy are those of simple inflammation1 follicular tonsillitis1 or diphtheroid angina4 ,streptococci are abundantly found in the glands and foci of suppuration4 ,symptomatology4--,scarlet fever is divided into four stages3 7#a7 ,incubation1 7#b7 ,invasion1 7#c7 ,exanthem1 7#d7 ,desquamation4 ,incubation ,stage4--,has no noticeable symptoms and lasts from two to four days4 ,some authors claim as high as ten to fourteen days4 ,invasion4--,the invasion lasts one day4 ,the onset is very sudden beginning with a chill which is followed by a characteristic vomiting1 occurring in #ge of the cases1 which is more frequent than in any other disease of childhood except pneumonia4 ,the vomiting is followed by headache and the beginning evidence of sore throat1 which usually soon develops into a tonsillitis4 ,the severity of the sore throat is indicative of the severity of the scarlet fever that follows4 ,the temperature suddenly rises to #ajc or more1 the pulse becomes unduly rapid for the temperature1 #abj to #afj per minute1 and the respiration is increased4 ,the skin begins to burn1 there is dysphagia and intumescence of the cervical glands4 ,the muscles of the back become hypersensitive to touch and to extremes of heat and cold2 and particularly sensitive spots are found over the transverse processes of the first to #dth cervical vertebras1 the #dth and #eth dorsal and the #aath and #abth dorsal vertebras4 ,at these points will be found intensely contractured tissues which must be kept relaxed4 ,exanthem4--,the eruption appears at the end of the first day or early the second day1 showing first over the clavicles and on the neck1 then over the upper trunk1 next the lower trunk and limbs4 ,the eruption on the extremities appears particularly over the flexor surfaces of the joints4 ,by the end of the second day the eruption has covered practically the entire body1 leaving a white circle about the eyes and mouth4 ,the eruption pales1 or disappears on pressure1 quickly returning to the scarlet color on the removal of the pressure4 ,frequently1 the skin itches and is very uncomfortable4 ,a punctiform eruption in the arm-pits1 over the groins1 or on the roof of the mouth is considered positive proof of scarlet fever4 ,the eruption at first consists of small red spots which fuse as the skin swells and results in an intense lobster-colored erythema4 ,this lasts four to six days4 ,the tongue1 at first1 is red at the tip and margins with a greyish-yellow or whitish fur in the center through which is often seen the swollen red papill1 the 8strawberry tongue40 ,the 8fur0 desquamates on the third or fourth day1 leaving a surface intensely red with marked raised1 swollen papill1 the 8raspberry or cat tongue10 which lasts nearly a week4 ,the breath has a heavy1 sweet odor4 ,the pharynx1 uvula and tonsils become swollen1 and often creamy-white patches cover the mouths of the tonsillar follicles4 ,between the second and third day the eruption reaches its height1 when it has a vivid scarlet hue unlike any other eruption1 and becomes darker each day until it may be a bluish-red1 when it gradually fades and desquamation begins4 ,by the seventh or eighth day the rash has disappeared1 together with the fever4 ,desquamation4--,scaling begins on the face first1 from the sixth to the ninth day and lasts several weeks4 ,the skin looks somewhat stained1 is a little rough like 8goose-flesh0 and gradually the upper layer begins to separate1 and the scaling begins in large lamell or flakes4 ,casts of the fingers or toes may be shed4 ,the swelling of the glands disappears1 and the fever falls by lysis1 and convalescence begins1 unless complications intervene4 ,diagnosis4--,in typical cases diagnosis is easy1 especially during epidemics or when the eruption is accompanied by other criteria4 #a4 ,sudden onset1 with nausea and vomiting1 sore throat1 quick appearance of fever and rapid development4 #b4 ,punctate spots in the throat1 swelling and dysphagia are usually present4 ,the severe sore throat symptoms with the above are always very suspicious4 #c4 ,strawberry tongue is constant4 #d4 ,eruption1 typical in character1 appearing on second day1 first showing on the neck above the clavicles1 intense on the body and practically absent around the mouth4 ,eruption confluent1 with no intervening free areas of the skin1 followed by desquamation4 #e4 ,lymphadenitis much more pronounced in the inguinal and other glands than in the cervical4 #f4 ,desquamation1 tender joints and albuminuria will force the conclusion of scarlet fever1 if former symptoms have been indefinite4 ,in the atypical cases we may have very light attacks with all the symptoms present but very poorly developed2 or some symptoms absent as in cases with no temperature1 or others with no rash4 ,some cases are so atypical as to be impossible of diagnosis4 ,the writer has very recently had the experience of one case when there were absolutely no typical symptoms present after being called on the case1 but four days after the invasion of the disease in the patient a sister of the child developed typical scarlet fever1 and not until the sixth day did any eruption or sore throat appear1 and then the eruption was more characteristically measles than scarlet fever4 ,consultants with the writer agreed with him that the case was one of an atypical1 non-eruptive scarlet fever4 ,differentiation4--,scarlet fever is not always easily differentiated from other diseases1 such as a septic rash1 drug rashes1 diphtheria1 measles and ,german measles4 ,a4 ,r4 ,edwards gives this differentiation between scarlet fever and septic rash4 ,scarlet ,fever ,sepsis4 ,bright red erythema1 with small ,a very deep purple-red rash1 red papules4 sometimes spreading over the entire body4 ,the eruption is much the same in both diseases1 the same places being exempt4 ,miliaria are rare4 ,miliaria are frequent4 ,rather typical desquamation4 ,desquamation observed less frequently4 ,,criteria3 angina1 tongue1 onset1 ,etiology1 chills1 sweats1 fever glands1 etc4 irregularity1 polymorphous exanthems1 etc4 ,diphtheria4--,often difficult to differentiate4 ,the simple erythema is sometimes observed in diphtheria1 but is darker1 more on the trunk1 and more transitory than in scarlet fever4 ,drug ,rashes4--,these rashes are caused by belladonna1 iodoform1 quinine1 iodide1 chloral1 copaiba or aspirin4 ,they may be easily differentiated if the cardinal symptoms of scarlet fever are considered instead of the rash alone4 ,at the present time1 perhaps the most frequent drug rash that we meet is that produced by aspirin4 ,it is sometimes hard to diagnose because the aspirin has been taken for a sore throat or tonsillitis1 which so resemble the early symptoms of scarlet fever4 ,measles and ,german ,measles4--,the symptoms of the invasion stage of these diseases is sometimes quite similar1 and even the rash may be quite similar2 the differentiation will be discussed under measles 7q4v474 ,types and ,forms4--7a7 ,mild and abortive form 7scarlatina sine eruptione74 ,in this the rash may be scarcely perceptible1 while the fever1 sore throat and strawberry tongue are present4 ,desquamation may be present and it may be followed with a severe nephritis4 7b7 ,malignant forms1 7#a7 ,atactic variety1 violent intoxication1 onset of great severity1 fever very high 7#ajg to #ajh71 extreme headache1 delirium1 and often convulsions4 ,initial delirium gives place to coma2 dyspnea may be urgent2 pulse very rapid and feeble2 and death occurs before eruption appears4 7#b7 ,hemorrhagic variety3 there are hemorrhages into the skin1 beginning with scattered petechi1 becoming more extensive and ultimately involving the whole skin4 ,it is characterized by severe fever and brain symptoms at the onset2 incomplete exanthem1 necrosing angina1 marked glandular and splenic swelling2 subcutaneous1 serous and mucous membrane hemorrhages with ulceration4 ,death may take place on the second or third day4 ,this is more common in enfeebled children1 although it may attack adults in apparently full health4 7c7 ,anginose form 7,scarlatina anginosa47 ,this form resembles septic diphtheria1 with marked toxemia1 necrosis and adenitis4 ,the throat symptoms appear early and progress rapidly4 ,temperature high1 cyanosis1 diarrhea1 rapid weak irregular pulse1 and stupor occur4 ,the fauces and tonsils are covered with a thick membranous exudate which may extend to the posterior wall of the pharynx1 forward into the mouth1 upward into the nasal chambers1 and may occasionally reach the trachea and bronchi4 ,the ,eustachian tubes and middle ear are usually involved4 ,the glands of the neck rapidly enlarge and become the seat of brawny induration1 and the inflammation extends beyond their limits4 ,necrosis occurs in the tissues of the throat1 fetor is extreme1 the constitutional symptoms are great and the child dies of toxemia4 ,if he does not die1 extensive abscess formation in the tissues of the neck takes place with sloughing and danger of hemorrhage from the opening of a large artery4 ,blood ,pressure4--,rises at first1 thereafter it follows the pulse and temperature4 ,after the seventh or eighth day it may be below normal4 ,cases of albuminuria show hyperextension and slowing of heart action4 ,with the subsidence of the kidney irritation the pulse-rate is increased and the blood pressure returns to normal4 ,urine4--,shows ordinary febrile character1 being scanty and high colored4 ,slight albuminuria is rather common after the stage of eruption1 even a few tube casts may be present without any serious irritation of the kidneys4 ,urinalysis should be made daily4 ,blood4--,the red cells are moderately reduced to #c1jjj1jjj or #d1jjj1jjj per c4 mm4 during convalescence4 ,there may be some poikilocytosis1 and normoblasts are occasionally seen4 ,leucocytosis is early1 #ae1jjj to #cj1jjj per c4 mm41 falling with the decline of the fever usually by the fourteenth day1 but may persist for weeks after the temperature is normal4 ,the count runs roughly parallel to the temperature4 ,over #dj1jjj leucocytes per c4 mm4 are of bad prognostic omen4 ,polymorphonuclear cells are increased to #hj or #ij2 early returning to normal in favorable cases4 ,eosinophilia is present in all but malignant cases4 ,it reaches its maximum two or three days after the rash appears and returns to normal after the leucocytosis has disappeared4 ,the early presence of eosinophilia excludes septic conditions4 ,when these cells are absent in scarlet fever1 myelocytes are to be found4 ,treatment4--,clinically scarlet fever represents1 from the osteopathic viewpoint1 7a7 a toxic condition due to internal malnutrition and a decrease of the detoxinating function of the thyroid gland2 7b7 secondarily associated with the sore throat is a type of toxic tonsillitis1 but it is due to the toxic elements in the blood2 7c7 in the lesion field it is associated with extreme stiffness and muscular tension in the upper cervical area and also in the entire dorsal area1 overlapping the upper lumbar4 ,the eruption is a superficial expression of the attempt of the body to eliminate the toxins1 and this elimination should be aided by enhancing the activity of all the other eliminative functions4 ,cases are on record where patients have been exposed to scarlet fever1 have gone the usual incubation period and developed the invasion symptoms1 and by thorough1 oft-repeated osteopathic treatments1 with the aid of enemata and copious hot water drinking1 have not gone beyond the invasion period and the disease apparently aborted within two or three days4 ,it is therefore well to give thorough1 oft-repeated attention to these cases during the very early stages4 7#a7 ,in all cases where the first symptoms indicate the possibility of a contagious disease1 the patient should be immediately isolated and kept isolated until all danger of contagion is past4 ,in scarlet fever cases get a competent nurse4 ,keep room light1 quiet and thoroughly ventilated with a constant temperature of as nearly #gj as is possible4 7,it were better to have two rooms if possible1 one for day and one for night3 have room or rooms on upper floor if in a house74 ,arrange suitable means for thorough disinfection of all articles used in the sickroom4 ,these are very essential4 7#b7 ,patient should be clothed in usual night wearing apparel4 ,the bed clothing should be warm1 but not heavy4 ,the physician should wear an operating gown or a sheet which thoroughly covers his clothing1 also a cap4 ,he should carefully wash his face and hands immediately after leaving the sickroom4 ,the quarantine should be maintained for the legally required period1 and even after if there continue discharges from the nose1 nasopharynx or the ear4 ,bichloride wrappings should be placed about the body of the dead1 and funeral must be private4 7#c7 ,have enema given immediately to cleanse the lower bowel4 ,follow this with frequent draughts of hot water1 or better hot lemonade for the first day4 ,place hot water bottles at feet4 ,if eruption is slow in coming out1 it may be aided by a hot bath1 followed by wrapping the patient in warm blankets to prevent chilling4 7#d7 ,thorough osteopathic treatment should be given along the entire spinal area from the atlas to the sacrum1 inclusive1 to keep the muscles well relaxed1 giving special attention to the relationship of the vertebr and the tension of the muscles from the occiput to the fourth cervical2 the third to the sixth dorsal2 and the tenth to the twelfth dorsal areas4 ,also give special attention to the deep cervical muscles1 particularly those at the angle of the inferior maxilla1 and at the articulation of the inferior and superior maxill4 ,remember the tendency of the kidneys to complication in scarlet fever1 therefore do not neglect the renal splanchnics1 for here you not only control the renal functions but also regulate the adrenal functions and their internal secretions4 ,keep the clavicles properly adjusted and articulate them by bringing them well forward to relieve any irritation that may have started in that area4 ,careful direct treatment to the abdomen should usually be given at each visit besides the work in the splanchnic area to keep the bowels1 kidneys and liver active4 ,diet4--,water must be given freely4 ,if fever is very high1 pellets of ice held in the mouth will give comfort4 ,during the height of the fever it is preferable to withhold all nourishment1 but if in a particular case it seems to be indicated1 confine the nourishment to fruit juices1 especially oranges4 ,never force feeding during the fever4 ,for infants cut down their feeding to at least half1 making the milk very thin with water or gruel4 ,after defervescence1 carefully increase to a light diet using sparingly of nitrogenous foods except milk4 ,after four weeks in the usual case1 gradually return to the ordinary diet4 ,this is a good time to make corrections in the ordinary diet if any are needed4 ,the bowels must be kept regulated4 ,an enema is usually indicated after the onset of the disease4 ,during the time that food is permitted it should be of a laxative character4 ,during the fever stage the enema should be given daily to help keep the bowel cleansed and to help reduce the temperature4 ,if bowels are persistently sluggish and the fever is constantly high the abdominal heating compress 7so-called 8cold compress07 will give much relief4 ,the nose and throat should be constantly looked after4 ,the nose may be cleansed by instillation by means of a medicine dropper1 using normal salt solution4 ,if the throat symptoms are mild1 a gargle of warm normal salt solution is enough for cleanliness of the membrane4 ,if the throat symptoms are too severe to permit the use of the gargle1 or if the patient is too small to be taught the use of the gargle or to wash the throat1 irrigation may be employed4 ,the use of raw lemon juice1 or of raw pineapple juice1 on a cotton swab is of great value in cleansing the tonsils and throat4 ,the swabbing should be repeated several times per day4 ,the teeth should be carefully and thoroughly cleansed twice per day4 ,the skin must be constantly cared for4 ,during the fever it is well to cover the skin with linen or soft cotton4 ,daily sponge baths of carbolized water 7#a3dj7 of tepid temperature followed by applications of cocoa-butter will give much comfort4 ,use only good toilet soap and do not use the so-called antiseptic soaps because1 authorities claim1 there is a chance of renal injury4 ,during the period of desquamation the use of the cocoa-butter will assist in limiting the source of infection by preventing the diffusion of the dry scales which are considered infectious by many physicians4 ,a4 ,r4 ,edwards says3 8,during desquamation1 oil-rubs were once employed to decrease the dissemination of dry scales1 but they decrease the function of the skin1 which is of great importance when the kidneys are involved2 also1 infection is carried by means of throat secretions4 ,soap and water serve equally well40 ,some authorities suggest that during the desquamation1 after bathing the patient1 the skin should be thoroughly rubbed and then the oily application used1 using cocoa-butter1 unmedicated cold cream1 liquid albolene or the like4 ,olive oil and vaseline are usually irritating4 ,the writer inclines to the opinion that the soap and water bathing is sufficient1 except perhaps the use of cocoa-butter over the areas that are desquamating severely4 ,the temperature can usually be controlled by the usual osteopathic methods2 steady deep pressure applied in the suboccipital region for a few minutes1 followed by relaxing the muscles of the back from the first to the eighth dorsal1 by raising and spreading the ribs in the mid-dorsal area1 and by light inhibition over the solar plexus4 ,the tepid enema will assist in lowering the temperature4 ,if temperature is high and patient is delirious and has other nervous symptoms the cold pack is useful4 ,the ice cap may be used almost constantly in high fever4 ,if glands are swollen treat by crowding the tissues toward the gland but never work upon the gland itself4 ,if pain is felt in the ear immediate attention must be given it4 ,correct any deviations of the atlas or other upper cervical vertebr1 relax the deep muscles at the angle of the jaw1 and relieve any impingements in the lower cervical and upper dorsal regions4 ,the ear should also be treated with copious boric solution irrigations1 as hot as can be borne and at low pressure4 ,the condition of the ear drum membrane must be watched daily and if there is bulging and congestion it is safer to puncture the drum under cocaine than to await spontaneous rupture4 ,use small amount of boric powder after rupturing4 ,the heart must be examined daily4 ,vigorous treatment through the thoracic region is indicated1 if cardiac symptoms appear1 and the patient must be kept quiet and in bed4 ,if heart seems feeble it may be well supported by the cold packs directly over the heart4 ,nephritis is most common in the second and third weeks of the illness1 but may develop later4 ,in all cases where any symptoms of nephritis appear1 light or severe1 the patient must be confined to bed for at least four weeks1 and kept on a milk diet4 ,all irritants must be absolutely avoided4 ,hot baths should be given twice daily to increase the sweat and the urinary functions1 the bath lasting half an hour and the patient kept afterward between blankets4 ,treat thoroughly1 daily1 the splanchnic and renal areas1 paying particular attention to the tissue conditions in the lower dorsal region4 ,in the milder cases1 the urine contains albumin and a few tube casts1 very rarely blood1 and edema is slight or transient4 ,though the patient improves1 he remains pale and there is a slight trace of albumin in the urine for months4 ,if recovery does not take place1 then chronic nephritis becomes established4 ,in the more severe cases there may be a puffy appearance of the eyelids1 slight edema of the feet1 urine diminished in quantity1 smoky1 containing albumin and tube casts4 ,the kidney symptoms dominate1 dropsy persists and there may be effusion into the serous sacs4 ,the condition may become chronic1 the patient may succumb to uremia1 but in the majority of cases recovery takes place4 ,the nephritis may be hemorrhagic1 in which the urine is suppressed or there may be a very small amount of bloody fluid laden with albumin and casts2 constant vomiting and convulsions follow and the patient dies with symptoms of acute uremia4 ,other complications are arthritis1 malignant endocarditis1 severe toxic myocarditis and acute phlegmonous inflammation1 the last three of which are usually fatal4 ,chorea is a fairly frequent nervous complication4 ,the mental symptoms are mania and melancholia4 ,progressive paralysis of the limbs with wasting1 may simulate infantile paralysis4 ,the fever may persist after the eruption disappears and the child remain in a septic state 7scarlatinal typhoid74 ,relapses are rare4 ,scarlatina may coexist with almost any other acute infection4 ,it lowers the resistance of the body to disease and is often followed by other acute infections or by tuberculosis4 ,therefore the necessity of care during the entire convalescent stage4 ,measles 7,,rubeola2 ,,morbilli7 ,definition4--,measles is an acute infectious1 contagious1 erythematous disease1 occurring in epidemics1 characterized by an initial coryza1 bronchial catarrh and an eruption of a general maculopapular type2 also by the presence of ,koplik's buccal spots4 ,etiology4--,predisposing ,influences3 ,the chief predisposing factor in measles1 as in all other contagious diseases1 is a lowered resistance in which some structural or functional change has taken place that reduces the functional activity of the body's inherent protective agencies4 ,these predisposing factors may be classed under three heads1 namely2 7a7 structural1 7b7 environmental1 7c7 dietetic4 ,under the first we find structural disturbances in the upper cervical area affecting the functional control of the nose1 throat and head1 as well affecting the thyroid and its internal secretions3 structural disturbances in the upper and mid-dorsal areas affecting the vasomotor control to the head1 neck1 and chest1 thereby perverting nutrition to all these structures and rendering them more susceptible to the infective organisms2 also the dorsal lesions disturb the functional integrity of the lungs and heart1 with the result of disturbed respiration and circulation1 both of which are vital factors in body resistance3 we also find structural lesions in the lower dorsal region1 affecting the function of the kidneys and their elimination and the function of the adrenals and their internal secretions4 ,under the second or environmental1 we have unsanitary and unhygienic conditions1 exposure to sudden changes of temperature1 wet clothing1 fatigue1 etc41 all of which produce secondary structural lesions and the effects above mentioned4 ,under the third or dietetic classification1 we have the errors of diet so common in children and adults as well2 such as too much candies and other sugars1 also too much starches1 as well as over eating and unbalanced diet4 ,measles prevails in all climates and attacks all races1 the ,negroes appearing to suffer more severely than the whites and to be more subject to complications4 ,outbreaks are more common in winter and spring1 but occur at all seasons4 ,the disease is particularly a children's disease but adults may contract it if not protected by an attack in early life1 and with adults the disease frequently manifests the more aggravated forms4 ,it is more common after puberty than scarlet fever4 ,exciting ,cause4--,while the disease is probably produced by a micro-organism1 it has not yet been demonstrated4 ,inoculation experiments upon human beings have shown the presence of the infecting principle in the blood1 in the tears1 in the secretions of the nasal1 pharyngeal and bronchial mucous membranes1 and in the contents of vesicles occasionally present4 ,inoculation with the epithelial scales thrown off at the end of the disease has been unsuccessful4 ,ordinarily the transmission of the disease takes place through the breath or the nasal and bronchial secretions4 ,the disease may be carried by a third person or by fomites4 ,the infecting principle is intensely active1 but not so tenacious nor persistent as scarlet fever4 ,measles is communicable throughout its entire course from the earliest appearance of the coryza4 ,the individual predisposition toward measles is apparently so general that few1 upon exposure1 escape it1 though we have observed cases where children have been directly exposed and who were immediately thereafter put under osteopathic care and did not develop the disease4 ,second1 or even third1 attacks may occur at intervals of some years1 but these are unusual4 ,sporadic cases do occur and are often the starting points for epidemics4 ,extensive outbreaks occur at intervals of five or six years4 ,the incubation period is from seven to eighteen days1 usually about ten days4 ,symptoms4--,prodromes are common1 usually consisting of loss of appetite1 restless sleep1 fretfulness1 and often feverishness4 ,there are three stages1 7a7 ,invasion1 7b7 ,eruption1 7c7 ,desquamation4 7a7 ,stage of ,invasion4 ,the prodromal symptoms are intensified4 ,there is often chilliness but seldom distinct chills4 ,the temperature rises1 often reaching #ajb to #ajd degrees1 upon the first and second day4 ,it then falls one degree or more to rise again upon the appearance of the eruption4 ,nausea1 vomiting and headache are often present4 ,the tongue is furred4 ,with these symptoms coryza has developed and is sometimes intense1 often simulating severe influenza4 ,irritation and smarting of the eyelids1 lachrymation1 photophobia1 persistent sneezing1 running of the nose1 sore throat1 discomfort in swallowing1 hoarseness1 and cough1 at first of a croupy character1 appear in rapid succession and with varying intensity4 ,these initial catarrhal symptoms are characteristic and occur in the mildest cases in which chilliness1 fever and the associated signs of the reaction of the organism to general infection are not observed4 ,the vessels of the conjunctiv are injected1 the eyelids swollen1 the nasal mucosa tumid and reddened4 ,the mucous membrane of the mouth and throat is erythematous1 while upon the soft palate and the roof of the mouth1 and particularly upon the buccal mucous membrane1 are to be seen pin head or split pea sized1 circumscribed1 round or irregularly shaped reddish blotches slightly or scarcely at all raised above the surrounding tissues1 usually discrete1 but sometimes confluent4 ,this eruption also shows itself in the larynx and is undoubtedly the cause of the croupy cough and other throat symptoms4 ,in a strong light there may be seen upon some of the spots on the mucous membrane of the cheeks and lips minute bright whitish1 or bluish-white flecks which are called ,koplik's ,spots4 ,these spots appear early and soon disappear1 and as they are not found in any other disease they are of value in the early diagnosis of measles4 ,the duration of this stage is usually three or four days2 rarely it is shorter or it may be as long as a week4 7b7 ,stage of ,eruption4 ,on about the fourth day the temperature again rises1 increasing as the rash develops1 often to #ajd or #aje degrees and reaching its maximum about the sixth day when it usually falls by crisis2 followed on the seventh or eighth day by normal temperature4 ,the pulse-rate increases with the fever1 often reaching #adj or higher4 ,the eruption usually appears on the fourth day1 and shows first about the hair line on the forehead1 spreading to the face1 chest1 trunk and the arms and legs4 ,the eruption is attended by itching and burning1 and completely develops in from twelve to thirty-six hours1 the catarrhal symptoms persisting during this time4 ,during this time1 in the more severe cases1 delirium or stupor may be present1 and the patient complains of sore throat and general discomfort1 and is restless and wakeful4 ,usually upon the second or third day of the eruption1 great and rapid amelioration of all these symptoms takes place and the fever falls to normal or subnormal4 ,when the eruption is fully developed the individual spots are irregularly circular or oval1 and differ greatly in size1 averaging about the size of a split pea4 ,the eruption is unevenly set1 but usually close together and sometimes confluent1 especially on the face1 buttocks1 hands and feet4 ,frequently they take on a crescentic arrangement and the spots are circumscribed1 the intervening skin being normal or slightly hyperemic4 ,about the ninth day the rash begins to disappear1 on the face first1 then the neck and the rest of the body in about the same order as the eruption appeared4 ,the skin takes on a yellowish discoloration and the rash disappears in a bran-like desquamation which lasts several days to a week4 ,in the beginning of the stage of eruption1 and in many cases throughout its course1 the skin is moist and often bathed in free perspiration4 ,at the height of the eruption the superficial lymphnodes of the neck1 and elsewhere1 are often slightly swollen and tender4 7c7 ,stage of ,desquamation4 ,the fine branny scales of desquamation are often so fine as to be easily overlooked4 ,this process occupies about a week4 ,the catarrhal symptoms in uncomplicated cases gradually disappear1 so that1 by the end of the second week from the initial coryza1 convalescence is fully established4 ,the cough frequently persists and is of a bronchial nature4 ,epistaxis is common at the height of the attack4 ,relapses of measles are extremely rare4 ,diarrhea is apt to occur at some time during the attack1 without any particular significance4 ,varieties4--,atypical cases may occur but are not common4 ,they are as follows3 7#a7 ,morbilli ,papulosi1 development of distinct papules1 hard to the touch but not extending deeply into the skin4 7#b7 ,m4 ,vesicular2 a vesicular form4 7#c7 ,m4 ,sine ,exanthema1 cases in which the eruption does not appear1 but general symptoms and coryza are present4 7#d7 ,m4 ,sine ,exanthema1 in which the mucous membranes are not involved4 ,variations in constitutional symptoms4--7#a7 ,m4 ,afebriles1 rare cases in which there is no rise of temperature4 7#b7 ,m4 ,hemorrhagica4 ,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 hyperpyrexia1 profound adynamia1 or hemorrhages into the skin and mucous membranes4 ,these malignant forms are very rare in private practice1 but they occasionally occur in asylums and in the fierce epidemics of camps1 and were common in the first outbreaks among the natives of the ,fiji ,islands1 where measles prevailed as a scourge4 ,death may occur before the rash appears or a few papules may show themselves upon the forehead and wrists4 ,this is also known as black measles1 and it is characterized by convulsions1 delirium and coma1 petechi1 bleeding from the mucous surfaces and profound constitutional depression4 ,the patient is rapidly exhausted1 the pulse frequent and thready1 the skin pale and cold1 and death occurs4 7#c7 ,adynamic measles is a serious type in which the symptoms are grave from the onset but without hemorrhages and a typhoid status is early present4 ,complications4--,in the absence of complications1 measles is comparatively a benign disease1 but these complications are frequently enough present to place measles among the more serious diseases of childhood4 ,the ordinary complications are due to the extension or intensification of the catarrhal processes peculiar to the disease4 7#a7 ,otitis media is quite common1 and may result in perforation of the tympanic membrane and permanent impairment of the hearing2 or lead to sinus thrombosis1 meningitis1 or abscess of the brain4 7#b7 ,bronchopneumonia is the most common complication4 7#c7 ,purulent conjunctivitis may occur and in neglected cases infiltration and ulceration of the cornea4 7#d7 ,catarrhal laryngitis is a frequent complication4 7#e7 ,pseudo-membranous type is very uncommon but very dangerous4 7#f7 ,edema of the glottis is not common but does occur4 7#g7 ,diphtheria is much less common in measles than in scarlet fever4 ,the high death rate of measles is due to the bronchopneumonia complication in which the lesions become extensive1 the symptoms become urgent and a large proportion of these cases die4 7#h7 ,acute enterocolitis is a frequent and serious complication4 7#i7 ,gangrenous stomatitis occurs in young and debilitated children1 and in girls gangrene of the pudenda occur during convalescence with greater frequency than in other infectious diseases4 ,sequel4--,the more common sequel are chronic local inflammations1 conjunctivitis1 otitis1 nasal catarrh1 laryngitis1 and bronchitis4 ,tuberculosis is a common sequel4 ,diagnosis4--,during an epidemic1 coryza1 persistent sneezing and fever are suspicious4 ,the appearance of the eruption on the third or fourth day upon the mucous membrane of the mouth and throat1 and ,koplik's spots are positive4 ,measles is often confused with #a4 ,rubella or ,german measles1 #b4 ,variola1 #c4 ,typhus ,fever and #d4 ,scarlet ,fever1 which see4 ,occasionally drug exanthems are confused with measles4 ,these may be caused by salicylates1 antipyrin1 quinine1 turpentine or copaiba4 ,these rashes are not accompanied by fever or throat symptoms unless they have been given to allay these very conditions4 ,treatment4--,measles is so often a serious disease that it should not be attended with carelessness as it so often is1 but the best of care and attention given4 ,parents should be informed of the danger of complications and of the absolute necessity of proper care and attention4 ,as soon as a susceptible individual is exposed to the measles1 he should be immediately isolated1 watched and corrections made of any dietetic errors1 unsanitary conditions or structural lesions that may exist4 ,he should be protected from sudden atmospheric changes and carefully watched for the first symptoms of the prodromal coryza4 ,on the appearance of the prodromal1 or invasion symptoms the patient should be put to bed in an isolated1 well ventilated room of as nearly constant temperature as is possible1 from which all hangings1 rugs and unnecessary furniture have been removed4 ,the windows must be shaded to protect the eyes from direct or strong light1 and any artificial lights in the room must also be well shaded4 ,the cases can usually be easily handled by careful1 well-directed osteopathic treatments4 ,in the manipulative treatment we must pay especial attention to the muscular and other soft tissue conditions in the suboccipital region1 over the transverse processes of the upper four or five cervical vertebr1 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 throat2 see that the muscles in the lower cervical and upper dorsal areas are kept well relaxed1 and articulation of these vertebr1 the upper three ribs and the clavicles are kept free2 remove all lesions in the mid-dorsal area1 whether muscular or otherwise1 to prevent involvement of the lungs or heart1 and to keep up function of the respiratory and circulatory systems2 treat and keep normal the tissues and the articulations at the kidney and adrenal center1 #aath and #abth dorsal2 raise the ribs and keep them freely movable1 this especially for the bronchial cough4 ,painful manipulations should be avoided and are not necessary4 ,dr4 ,still said1 8,the arms must be raised and the axillary region freed and kept so40 ,during the acute stage two or three treatments per day are advisable4 ,do not treat severely or to cause discomfort to the patient4 ,best results are obtained in the gentle1 but thorough1 treatments4 ,in the beginning of the case have the bowels cleansed with an enema1 and then careful attention must be constantly given to the bowels and kidneys4 ,the bowels can be kept open by manipulations and diet4 ,the diet should be light and easily digested2 during the fever it is best to withhold all food but give plenty of water4 ,follow fast with fruit juices and then the light diet4 ,the temperature is usually controlled by treatment1 but if it remains high for some time and if the physician cannot reach the patient1 the nurse should be directed to give a tepid sponge bath of ten to twenty minutes duration1 and repeated at intervals of two or three hours4 ,also the tepid enema will often reduce the temperature4 ,for the itching of the skin1 a tepid bath with water at #ajj degrees given twice daily should be used1 the patient dried carefully1 and an application of olive oil1 cold cream1 liquid albolene1 or a two per cent menthol salve1 rubbed over the entire body will give relief4 ,the cough is best relieved by thorough treatment of the anterior thoracic regions and the correction of any upper rib or clavicular lesions4 ,keeping the air of the room moist with vapor is agreeable to the mucous membranes4 ,the dropping of a few drops of eucalyptus oil in the boiling water produces a very soothing vapor4 ,if the eyes are much involved1 they should be bathed every hour or two with a three per cent solution of boric acid1 using cotton which is immediately destroyed after use4 ,dark glasses in a well ventilated room is better than an unaired darkened room4 ,the nose and mouth should be carefully cleansed at regular intervals and the cloths burned4 ,the throat should be carefully examined daily at first1 and at least every other day later1 until the case is discharged4 ,the conditions of the lungs must be observed by daily examinations1 and the lung and bronchial areas should be daily treated to prevent the possibility of respiratory involvement4 ,if rash is slow in appearing and the temperature is high1 a hot bath 7#aje to #aaj degrees7 for three to five minutes will often bring out the rash and relieve the more serious symptoms4 ,during convalescence the patient must be protected against cold4 ,recovery is hastened by the continuation of treatment during convalescence and treatment given should be indicated by the symptoms present4 ,prognosis4--,practically all uncomplicated cases recover4 ,in the hemorrhagic and adynamic types1 the majority succumb4 ,one attack usually confers immunity4 ,sequel are frequent under the 8old school0 treatment1 but are infrequent under careful1 conscientious osteopathic treatment and careful nursing4 8,in and of itself measles is usually not particularly serious1 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 death4 ,during recovery from measles the patient stands in special danger from pneumonia1 and pneumonia following measles is more dangerous than uncomplicated pneumonia4 ,there is a considerable length of time during which he is particularly susceptible to tubercular infection4 ,this is so often insidious1 and its evidences are so obscure1 that by the time the disease has fully developed1 one may have forgotten the mild attack of measles which really paved the way for the serious malady40--,c4 ,a4 ,,whiting4 ,rubella 7,,german ,,measles2 ,,rubeola ,,notha2 ,,rotheln2 ,,epidemic ,,roseola7 ,definition4--,a specific acute1 contagious1 infectious1 eruptive disease1 characterized by a diffuse maculopapular eruption and swelling of the superficial lymphatic glands4 ,it is attended by a mild fever1 suffused eyes1 mild cough1 slight sore throat but no catarrh1 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 disease4 ,rubella1 in some ways1 resembles scarlet fever and also measles and was at one time considered a hybrid of the two4 ,it is now known to be an independent disease4 ,etiology4--,the exciting cause1 or the infective principle1 has not yet been discovered4 ,the disease is probably carried by fomites1 is readily transmissible1 attacks children especially1 and usually occurs in epidemics1 though sporadic cases are frequently found4 ,the epidemics usually occur at intervals with several years intervening1 during which time there are comparatively few cases4 ,persons of all ages are susceptible unless having acquired an immunity through an attack of the disease at some former time4 ,rubella does not confer immunity against any other disease1 as scarlet fever or measles1 nor do these diseases confer immunity against rubella4 ,one attack of rubella confers immunity against any succeeding attacks4 ,the incubation period is from five to twenty-one days and is without symptoms4 ,the predisposing factors are the same as in measles or other infectious or contagious diseases4 ,symptoms4--,invasion ,period4 ,this stage is usually of very short duration1 lasting from a few hours to perhaps two days4 ,the initial symptoms are usually mild1 being a sudden chilliness1 but not chills2 mild fever of about #ajj degrees2 a slight headache2 mild sore throat2 swollen cervical and post auricular lymphatic glands2 little or no coryza2 sometimes slight pains in the back and legs2 and the macular rose-red eruption in the throat which is constantly present4 ,often the initial symptoms are so mild that the presence of a disease is not recognized until the eruption appears1 which usually occurs on the first day and rarely not until the fourth day4 ,eruption ,period4--,the rash1 which consists of round or oval reddish spots about the size of a split pea1 mostly discrete1 but sometimes confluent1 and surrounded by areas of hyperemic skin1 usually shows first upon the face and follows a wavelike progression over the body and limbs4 ,the rash usually begins to fade upon the face before it has appeared upon the last affected areas1 and usually remains in one region from a few hours to a half day4 ,it extends over the entire body in from twenty-four to thirty hours4 ,occasionally the skin is so hyperemic in extensive tracts that the rash more resembles scarlet fever rather than measles4 ,the crescentic arrangement of the papules usually seen in measles can not be made out in rubella4 ,in the course of two or three days the rash disappears with very fine desquamation1 leaving a faint pigmentation1 which remains for a short time4 ,slight etching usually accompanies the rash4 ,relapses are rare and complications infrequent4 ,there are no special sequel1 but albuminuria1 bronchitis and pneumonia have been noted4 ,although one attack usually confers immunity1 second attacks have been reported1 which may have been real second attacks or the first attack may have been an error in diagnosis4 ,diagnosis4--,early or sporadic cases may present great difficulty in diagnosis1 but when an epidemic is present diagnosis becomes much easier4 ,the direct diagnosis of the disease rests upon the very mild nature of the disease1 its short initial onset1 the character of the eruptions and the early enlargement of the glands with the absence of severe throat symptoms and coryza4 ,rubella is frequently mistaken for mild cases of measles or scarlet fever4 ,unlike measles1 it does not have the prominent catarrhal symptoms1 the higher fever1 the crescentic grouping of the eruption and ,koplik's sign4 ,in measles the adenitis is not so severe as in rubella1 and especially are the suboccipital and post-auricular glands involved in rubella4 ,scarlet fever has a very sudden onset with severe symptoms1 a very sore throat1 the characteristic tongue and the peculiar rash1 all of which are decidedly different from rubella4 ,in the latter stages the character of the desquamation is also a distinguishing feature4 ,treatment4--,patient should be kept in a properly heated and well ventilated room1 being careful that no draughts chill the patient1 and should remain in bed for at least two days4 ,patient should be isolated4 ,treatment should be directed to the upper cervical1 mid-dorsal and lower dorsal areas to keep normal the function of the internal secreting mechanism1 and to normalize and keep normal the respiratory and circulatory systems4 ,treat carefully to upper lymphatics1 working around the enlarged glands and not directly over them4 ,watch the excretory functions and keep them active by judicious measures4 ,if annoying itching occurs1 the hot bath followed by being wrapped in a soft warm blanket will usually relieve4 ,daily tepid sponging should be given and if hot bath does not relieve itching an application of olive oil or cold cream will often relieve4 ,diet should be reduced and regulated according to age of patient and severity of the case4 ,usually the above is all that is indicated1 but if more severe symptoms present themselves vary your treatment according to the symptoms present4 ,prognosis4--,recovery is the general rule4 ,relapses sometimes occur1 and are usually much more severe than the initial attack4 ,the symptoms are often more severe in adults than in children4 ,like measles1 this disease seems to lower resistance to other infections1 and therefore especial care should be taken to protect the patient from exposure to other diseases for some time after recovery from rubella4 ,see that the patient is built up constitutionally after recovery by plenty of fresh air1 suitable exercises and good food4 ,varicella 7,,chicken ,,pox7 ,definition4--,chicken pox is an acute1 specific1 contagious1 slightly febrile1 eruptive disease1 usually of childhood1 affecting the whole organism through the blood4 ,it is an epidemic disease that spreads rapidly1 is highly contagious but not inoculable1 and confers immunity4 ,history4--,varicella was first recognized about #aeec and was distinguished from smallpox by ,trousseau4 ,etiology4--,the agent that causes the disease is not known2 the disease usually affects children under ten years of age1 but does occasionally attack adults4 ,it bears no relation to variola1 except the very slightly similar eruption4 ,it is transferred by direct personal contact1 by the air or by a third person4 ,it is infective from the first symptoms until all the crusts have disappeared4 ,although the disease usually occurs in epidemics1 frequently we see sporadic cases4 ,as in all other contagious or infectious diseases the predisposing causative factors are those conditions which lower the resistive powers of the body1 such as fatigue1 improper diet1 exposure to sudden temperature changes and imperfect elimination of the body wastes4 ,the structural lesions found as predisposing factors are contractured muscles of the neck and behind the jaw1 and muscular and interosseous lesions of the upper cervical1 mid-dorsal and dorso-lumbar areas1 also of the clavicle and upper ribs4 ,symptoms and ,diagnosis4--,there are three stages to the disease3 7#a7 ,incubation1 7#b7 ,prodromal1 7#c7 ,eruptive4 #a4 ,incubation ,period4--,this period lasts about fourteen days though it may vary from seven to seventeen days4 ,during this period there is practically no symptomatology except perhaps the last two or three days1 when the child shows evidence of a little excitability and irritability4 ,often on the day before the first noticeable symptoms the child appears even more active than usual4 #b4 ,prodromal ,stage4--,prodromal symptoms are not common and usually last but about twenty-four hours4 ,the first noticeable symptom is the irritability of the patient1 which is followed by a temperature1 usually #ii to #aja1 which temperature persists during the course of the disease4 ,there are sometimes thirst1 anorexia1 constipation1 seldom vomiting1 and a furred tongue4 ,some cases have been observed to have the following as prodromal symptoms1 but these we believe are usually due to concurrent conditions that exist at the time of the infection3 delirium1 convulsions1 angina1 conjunctivitis1 dysphagia1 bloody vomiting and stools1 and an initial erythema1 usually scarlatiniform4 #c4 ,eruptive ,stage4--,the eruption comes within twenty-four hours and is often the first symptom that is noticed4 ,it appears first as hyperemic macules and then rose colored papular spots1 somewhat comparable to the typhoid roseola and not hard4 ,these papules rapidly become raised1 flattened1 ovoid1 pin-head to pea-sized vesicles containing a fluid at first watery and then pearly4 ,they disappear on pressure4 ,the vesicles mature within twenty-four hours1 are very superficial1 and leave a slight areola about them1 which is not inflammatory as in smallpox4 ,the eruption appears first on the chest and then on the neck1 face1 scalp1 and then trunk and limbs in the order named4 ,the eruption is most abundant upon the back1 and over the entire body they may number anywhere from eight to many hundred and are usually scattered4 ,the vesicles are not umbilicated1 but some may have slightly depressed centers1 are discrete1 and appear in successive crops which require from three to six days to complete4 ,pustulation and hemorrhage into the vesicle rarely occur4 ,on the third or fourth day yellowish-brown crusts form and gradually disappear4 ,scars may result from scratching or infection4 ,by the fifth day we may find all stages of the eruption because of the appearance of the successive crops4 ,there may be an efflorescence upon the mucous membrane of the oral cavity and of the pharynx causing slight difficulty in deglutition4 ,the itching may be more or less intense4 ,as scratching may cause pitting it should be guarded against4 ,the fever which is usually slight may persist during the entire eruptive stage1 but if it is high and persists as high temperature it suggests complications4 ,muscular tension of the cervical muscles1 especially those in front1 and around the angle of the inferior maxilla are usually found1 and often the clavicles are bound down1 and relation of ribs is disturbed4 ,ulceration sometimes follows scratching1 and even gangrene may appear around the vesicles in debilitated children1 especially those who are tubercular or congenitally syphilitic4 ,it is apt to be fatal in these cases4 ,complications of tubular nephritis1 which occurs within two weeks2 cardiac hypertrophy2 uremia2 otitis media2 and bronchial affections1 are sometimes met with4 ,treatment4--,isolate patient so as not to come in contact with other children4 ,the younger children should be put to bed until the crusts have formed2 older children may be allowed to be up around the room if their cases are light4 ,pay particular attention to the muscular lesions of the neck1 lower maxilla1 mid-dorsal and dorso-lumbar regions1 keeping them relaxed by gentle relaxing treatments4 ,a general systemic treatment is soothing and helps to prevent complications4 8,be very careful and very thorough in your neck adjustments4 ,loosen the atlas and axis and draw forward the inferior maxilla from its pressure upon the vessels and nerves back of its angle4 ,draw the hyoid bone forward and secure good circulation of blood throughout the entire cervical area40--,a4 ,t4 ,,still4 ,give treatment at the #dth and #eth dorsals to stimulate the superficial circulation and thus increase elimination through the eruption as well as the sweat glands4 ,remember the eruption is the expression of the body's attempt to eliminate the toxins within4 ,keep the bowels active by splanchnic and abdominal manipulations and by laxative diet4 ,if bowels are persistently inactive use enemata4 ,diet should be bland and easily digested4 ,during fever1 diet should be liquid or better restricted1 giving only water in abundance4 ,during the eruptive stage do not use tub baths4 ,daily tepid sponges with either plain water or boric acid solution answers both as an antiseptic wash and bathing4 ,after the daily sponging1 and as often as necessary to control itching1 anoint with a #aj boric acid ointment or with carbolized vaseline4 ,if scratching can not be controlled1 the hands should be tied in muslin bags4 ,as in smallpox the ultra-violet rays seem to irritate the eruptions and to increase the tendency to scarring1 therefore the windows and lights should be screened with a dull red material4 ,prognosis4--,invariably favorable unless complications set in1 which is seldom4 ,recurrences are very rare4 ,prophylaxis4--,the child should be kept in quarantine for three weeks or until the skin is entirely clean4 ,epidemic ,parotitis 7,,mumps2 ,,epidemic ,,parotiditis7 ,definition4--,mumps is an acute1 infectious1 contagious disease1 occurring in limited epidemics1 and characterized by inflammation of the salivary glands1 particularly the parotid1 swelling slight fever and pain over the involved glands4 ,there is special liability to orchitis or to mastitis4 ,etiology4--,predisposing ,factors3 ,mumps is peculiarly a disease of childhood and adolescence1 not being common in infancy or after the twentieth year4 ,it affects boys nearly twice as often as girls4 ,mandibular and upper cervical lesions1 both of the interosseous and soft tissue types1 are undoubtedly potent predisposing factors1 as they obstruct and interfere with nerve and circulatory function to the glands affected4 ,also any condition which lowers the child's resistance to infections makes them more susceptible to this disease than to any other1 these conditions being fatigue1 exposure to dampness and sudden weather changes1 dietetic errors1 etc4 ,the cases are more numerous in the spring and autumn seasons4 ,extensive epidemics are infrequent1 but do occur in reformatory institutions and children's homes4 ,it is much more widespread in large cities than in the country or villages4 ,exciting ,cause2 ,the specific cause has not been demonstrated4 ,the disease is usually transmitted by direct contact1 but there are instances where it has been transmitted by a third party or by fomites4 ,there are two views as to the mode of infection2 the first being that the active principle travels along the course of the salivary ducts from the mouth to the glands1 probably most often through the duct of ,stenson to the parotid gland4 ,this is the most generally accepted theory4 ,the second is that the infection is a general one to which certain structures are more susceptible1 principally the salivary glands1 and the parotid in particular4 ,symptoms4--,the period of incubation is from fourteen to twenty-one days4 ,prodromes are usually absent1 though in the more severe cases constitutional disturbances1 with chilliness1 vomiting and mild fever may precede the local inflammation4 ,in the milder cases the local swelling may be the first manifestation of the disease4 ,the temperature is usually moderate but may rise to #ajc or #ajd degrees in the more severe cases4 ,the left side is more often affected than the right4 ,the disease is characterized by a feeling of tension with soreness just below the ear4 ,soon a slight swelling may be observed directly under the ear and in the course of forty-eight hours it reaches its maximum size4 ,the parotid gland becomes greatly enlarged and the adjacent tissues of the neck and face become tense and edematous4 ,the skin becomes hard and glossy and usually white in color because of the obstruction to the circulation from pressure4 ,the swelling is between the angle of the jaw and the mastoid process1 pushing the ear upward and its lobule is pushed sharply outward4 ,in the majority of cases the other side becomes affected in two or three days1 but sometimes the spread of the disease to the other side is delayed for several days1 and occasionally the other side escapes the infection4 ,frequently the swelling of the other side is so slight that it is only recognized by the closest scrutiny4 ,infrequently the submaxillary glands become affected without involving the parotid glands1 but these cases are rather rare4 ,the patient is usually unable to open the mouth without considerable pain2 acids1 and rarely sweets1 produce spasms of the jaw muscles2 speech and even deglutition are difficult2 the salivary secretions are usually increased but quite frequently they are decreased4 ,the breath is foul and the tongue is furred4 ,the mucous membrane of the cheek and pharynx are reddened and there may be a slight angina4 ,the spine shows subluxations of the upper cervical area1 particularly of the atlas and axis1 also upper rib lesions and upper dorsal lesions are frequently found4 ,the lesions of the second and third dorsal1 and their ribs1 are most frequently found when the submaxillary gland is involved4 ,the symptoms persist from six to fourteen days1 when the swelling disappears and the patient regains normal health4 ,orchitis occurs in about one-third of the cases after puberty4 ,in infancy and childhood it is extremely rare4 ,usually one testicle is involved1 and is characterized by weight1 swelling and pain in the scrotum4 ,the testicle may become greatly enlarged when the pain becomes intense4 ,atrophy may result and if both testicles are affected the loss of reproductive ability may result4 ,in females1 usually after puberty1 the breasts may become enlarged and tender1 pain and tenderness of one or both ovaries1 hematoma of the labia1 or a vulvovaginal discharge may occur4 ,however these complications are very rare4 ,as a rule the patient is not very sick and relapses are very uncommon4 ,the attack confers immunity which is practically permanent4 ,diagnosis4--,under ordinary conditions1 especially during an epidemic1 the diagnosis of mumps is very easy4 ,the swelling in front of and below the ear1 with the displacement of the lobule outward is quite indicative of mumps4 ,the relative rapidity with which the swelling appears1 develops and subsides is characteristic of mumps4 ,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 gland4 ,in ,hodgkin's disease1 which is a chronic affection of the lymphatic glands1 the salivary glands are not involved4 ,treatment4--,the patient should be kept away from other children1 and should remain in a well lighted1 well ventilated room of even temperature1 and if the temperature is high or moderately high he should be kept in bed4 ,the correction of all interosseous lesions is indicated1 especially of the upper cervical area1 though the second and third dorsal should be given attention because of the influence of these dorsal nerves upon the submaxillary glands4 ,also correct upper rib lesions that may exist4 ,as mumps is an infective disease the channels of elimination should be watched and stimulated4 ,build up the body resistance by treatment at the mid-dorsal area to affect circulation and respiration2 and lower dorsal area to affect kidney and adrenal function4 ,watch the bowels and keep this avenue of elimination functioning freely1 using enemata if necessary4 ,the diet should be liquid1 of fruit juices1 thin gruels1 milk and plenty of water4 ,tepid sponging allays the fever and restlessness4 ,relaxation of the deep muscles of the neck and shoulders will do much to make the patient comfortable1 also the muscles under the angle of the jaw4 ,a very gentle relaxing of the tissues around the gland itself1 by crowding them toward the gland1 assists in relieving the tension by securing a better venous and lymphatic drainage4 ,hot applications to the swollen glands will give a considerable relief2 these may consist of hot fomentations1 hot salt bag1 electric heating pad1 hot water bottle1 etc4 ,the mouth is kept in good condition by the use of a mild antiseptic mouth wash4 ,orchitis should not occur if the boy is kept warm and in bed4 ,if it does occur the best treatment is relaxation of the lower dorsal and upper lumbar spinal muscles1 rest in bed1 support and protection of the scrotum with cotton wool1 cold applications1 correction of any bony lesions affecting the pelvic viscera4 ,if mastitis occurs1 rib lesions will be found and should be corrected1 as they are probably the predisposing factor to this complication4 ,treatment would consist of correction of these lesions1 if it can be done without irritating the inflamed glands4 ,the manipulation of the surrounding tissues1 with gentle crowding of the normal tissues toward the inflamed glands1 without exerting any pressure on the gland itself1 is helpful and comforting4 ,free tissues back to the axillary lymphatics4 ,prognosis4--,the outcome is usually favorable4 ,in the rare fatal cases1 meningitis is the usual cause of death4 ,under osteopathic care the duration of the swelling1 fever and pain is usually greatly lessened4 ,quarantine of twenty-four days is necessary4 ,whooping ,cough 7,,pertussis2 ,,tussis ,,convulsiva7 ,definition4--,it is a specific1 epidemic1 infectious1 contagious disease affecting the respiratory organs1 characterized by a cyclic course1 a severe convulsive cough1 paroxysmal1 with the characteristic 8whoop40 ,etiology4--,it usually occurs in children1 most frequently during the fourth year1 and extremely seldom after the twentieth year4 ,it appears to be slightly more frequent among girls1 and most cases occur in ,march and ,april4 ,pertussis is highly contagious1 being carried by direct contact and by fomites4 ,the ,bordet and ,gengou bacillus is the specific cause4 ,this is found in the sputum most abundantly during the first week1 the most infectious period1 and becomes gradually less4 ,one attack usually confers immunity4 ,the incubation period is from seven to ten days4 ,the patient may be considered non-infectious five weeks after the first whoop4 ,lesions of the cervical and upper dorsal vertebr and of the first1 second and third ribs1 affecting the vagi1 the phrenic1 the sympathetic1 the recurrent laryngeal or the vasomotor nerves predispose to the disease4 ,the bacteria were found by ,mallory and ,horner to be characteristically between the cilia of the trachea and the bronchi4 ,they interfere1 mechanically1 with the movements of the cilia1 preventing the normal removal of secretions4 ,symptoms4--,the disease is divided into three stages3 #a4 ,the catarrhal stage1 which lasts one to two weeks2 #b1 the spasmodic stage1 three to six weeks2 #c1 the declining stage1 three weeks4 ,the ,catarrhal ,stage3 ,characterized by headache1 photophobia1 conjunctivitis1 coryza and a cough which becomes drier and harder toward the end of this stage4 ,often the invasion is insidious and sometimes well marked with a temperature of #ajj to #ajb4 ,frequently this stage cannot be differentiated from a 8hard cold10 except toward the end of the stage when the cough becomes worse instead of better1 and the child will seek some support to steady itself during the coughing paroxysm4 ,also the eyes will water freely during the coughing spell and the child will not be able to 8get his breath0 between coughs1 but will have a number of coughs without inhaling4 ,one to two weeks4 ,the ,spasmodic ,stage3 ,this stage dates from the 8first whoop40 ,the fever now usually ceases1 unless there are complications4 ,the cough becomes paroxysmal1 consisting of a succession of fifteen or more short1 rapid expiratory puffs with no intervening inspirations1 immediately followed by a deep1 loud inspiration1 which is the characteristic 8whoop10 and is due to the partial closure of the glottis4 ,each paroxysm is composed of three or more such spells1 the last one often followed by the expectoration of a small plug of mucus or by vomiting4 ,during the paroxysm the facies presents a swollen1 dusky appearance1 eyeballs protruding1 eyes reddened1 and puffy1 pinkish lids4 ,the child is well except for the paroxysm1 which has an aura1 tickling in the larynx1 thoracic constriction1 a creeping sensation1 when the child attempts to brace himself1 or runs in terror for support4 ,the 8whoop0 is a deep1 singing or whistling inspiration which is absolutely characteristic4 ,during the cough the child's body is bent forward and he is perfectly helpless1 often passing urine and feces involuntarily4 ,cyanosis often occurs from the strain4 ,after the attack patient regains control of himself1 the respiration is fast1 and there is fatigue1 sweating and often pain in the abdomen from the strain of coughing4 ,during the severe cough petechi of the forehead1 ecchymosis of the conjunctiv1 epistaxis1 bleeding of the external auditory meatus or from the frenum of the tongue may occur4 ,ulcer of the frenum of the tongue is quite common4 ,the parosyxms vary from four to a great many per day1 averaging about twenty4 ,three to six weeks1 usually four weeks4 ,the ,terminal or ,declining ,stage3 ,this stage is longer in proportion in the mild cases4 ,the paroxysms occur at longer intervals1 are of shorter duration and of less intensity1 the catarrhal symptoms are more marked1 the expectoration becomes thinner1 fluid1 mucopurulent1 and looser4 ,the 8habit cough0 may follow4 ,it is during this stage that complications are most likely to occur1 therefore it is the most dangerous4 ,complications4--,catarrhal inflammations are common in the initial stage4 ,bronchopneumonia is the most frequent and severe complication4 ,lobar pneumonia1 exudative pleurisy1 endocarditis1 pericarditis1 meningitis and nephritis are infrequent complications4 ,spasms of the glottis in nervous or scrofulous children is largely nocturnal1 and may cause death from asphyxia even in the lightest cases4 ,hemorrhages may occur in the skin1 conjunctiv1 nose1 throat1 ears or cerebrum4 ,the writer knows of one case where death was sudden from a cerebral hemorrhage in an apparently mild case4 ,other complications are cardiac dilatation1 emphysema1 bronchiectasis1 pneumothorax1 aneurysm hernias1 muscular ruptures1 and visceral prolapses4 ,spasmodic cough from diseased bronchial glands very closely resembles whooping cough4 ,barthez and ,sannee give the following differentiation3 ,whooping ,cough vs ,enlarged ,glands #a4 ,contagious1 epidemic4 ,isolated1 not contagious4 #b4 ,three periods1 #bnd parosyxmal4 ,no distinct periods4 #c4 ,paroxysmal cough with whoop1 ,paroxysms without whoop1 vomiting1 viscid expectoration4 expectoration or vomiting4 #d4 ,respiratory sounds normal4 ,signs of enlarged glands sometimes present4 #e4 ,respiration normal in interval2 ,asthma in some cases1 febrile apyrexia if simple4 movements1 sweats1 wasting1 etc4 #f4 ,voice natural4 ,voice sometimes changed4 #g4 ,acute4 ,chronic4 ,treatment4--,isolation of patient in well ventilated1 sunny room where there is plenty of fresh air day and night is essential4 ,children exposed to infection should be disinfected and isolated for three weeks1 as the disease can not be diagnosed during the catarrhal stage4 ,if case is at all severe1 patient should be put to bed4 ,cases receiving early treatment are sometimes aborted4 ,treatment of the whole respiratory tract with correction of vertebral and rib lesions1 and relaxation of the contracted muscles should be given4 ,treatments for the first few days should be at least twice per day4 ,pay especial attention to the vagi and phrenic nerves4 ,lesions of the first and second ribs will affect the recurrent laryngeal nerves which will aggravate the cough4 ,the muscles of the shoulder girdle are always very tense and should be kept well relaxed1 as should the subscapular muscles4 ,frequently after treatment the child will have a coughing spasm and raise large quantities of mucus1 after which there will be no more spasms for several hours4 ,children who play and live out of doors get along best4 ,to support the diaphragm and abdominal muscles from the strain of coughing a muslin bandage tightly pinned about the trunk is very valuable1 a pad being placed over the stomach under the bandage4 ,in a very young child instruct the nurse to strongly flex thighs on abdomen during the severe coughing4 ,inhalations of steam from water with a very few drops of eucalyptus oil in it often relieves the first tickling sensations4 ,if cyanotic symptoms appear they may be relieved by raising the ribs1 especially those over the heart2 by relaxing the subscapular muscles2 and by supporting the heart by application of cold cloth over the heart4 ,elevating the abdominal viscera and diaphragm is1 also1 of distinct benefit4 ,the diet should be nutritious and easily digested1 restricted to liquids during the fever4 ,the child should be warmly clad and protected from drafts4 ,the excretory systems should be kept active by plenty of water drinking and by diet4 ,treatment should be continued during the terminal stage to prevent the possible complications4 ,irritants1 as beef-tea1 stimulants1 dry bread1 cookies and overfeeding1 provoke coughing and vomiting4 ,food should be given at frequent intervals in concentrated form--gruels1 milk with lime water1 zwieback in milk1 eggs1 meat juice1 etc4 ,older patients tolerate more solid food4 ,prognosis4--,with the complications1 this is the most fatal of the acute infections under five years of age4 ,infants and little children should receive special care4 ,ordinary uncomplicated cases are favorable for recovery4 ,the prognosis depends upon the age and strength of the patient1 the severity and number of the paroxysms1 and the presence or absence of complications4 ,no recurrence is to be expected4 ,death is due to spasm of the glottis or to extensive subdural hemorrhage1 occurring chiefly in the children of the poor and in delicate infants4 ,prophylaxis consists of isolation1 disinfection of sputum and final fumigation of the premises4 ,children should be protected from exposure to infection from whooping cough4 ,it must be realized that it is a very serious disease4 ,,constitutional ,,diseases ,rheumatic ,fever 7,,inflammatory ,,rheumatism7 ,definition4--,an acute1 febrile1 non-contagious disease2 it is infectious1 although there is some controversy as to its exact nature2 characterized by a multiple arthritis and a tendency to involve the heart4 ,osteopathic ,etiology and ,pathology4--,the prevailing thought is that the disease is an infection due to a diplococcus4 ,this micro-organism is called by others micrococcus rheumaticus and streptococcus rheumaticus4 8,rheumatic fever occurs most frequently in the temperate zone1 among people who live under conditions which are unhealthful and which especially induce focal infection4 ,it is most prevalent in the young and in the more exposed male of all ages4 ,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 rheumatism4 ,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 exposure4 ,the frequent absence of evidence of acute focal infection at the onset of the systemic disease is not an evidence that no focus exists4 ,the latent chronic streptococcus infection of tonsillitis1 pyorrhea alveolaris1 sinusitis1 etc41 may suddenly acquire increased virulence and specific pathogenic affinity with varying degrees of focal tissue reaction4 ,this transmutation of type and pathogenicity certainly occurs in the focus of infection4 ,the removal of the tonsils and other sites of focal infection has been followed by complete recovery of prolonged1 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 attacks4 ,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 joints1 in the neck or elsewhere4 ,the streptococci of these secondary foci may take on new virulence and specific pathogenicity1 from the same causes which induced like changes in the pathogenic bacteria of the primary focus4#fg0 ,osteopathic lesions play an important role1 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 tone4 ,this has been definitely confirmed in those cases of rheumatism where correction of the osteopathic lesions1 with attention to hygienic measures1 have resulted in recovery4 ,this is a feature of osteopathic etiology and therapy that can hardly be over-emphasized1 for an intact innervation1 circulation and chemism of the organism is basic to both preventive and curative therapy4 ,rheumatism1 like most diseases1 is of local origin and if tissues and structures can be kept up to the normal1 infectious or the other pathologic processes can rarely become active4 ,pathologically1 the synovial membrane is hyperemic4 ,the muscles and ligaments are inflamed4 ,the fluid is serous with more or less fibrin and leucocytes4 ,in severe cases slight erosion of the cartilages is found4 ,acute rheumatism is rarely fatal2 when death does occur it is generally due to the complications which arise4 ,symptoms4--,the onset is usually sudden2 although it may be preceded by slight fever1 aching in joints1 chilliness1 and sore throat4 ,it generally involves the larger joints and is almost always multiple2 it has a tendency to move from one joint to another4 ,the pain in the joints usually develops rapidly with slight chilliness and a rapid rise in the temperature from #ajb to #ajd degrees ,f4 ,the pulse is frequent1 often disproportionately to the fever4 ,there are profuse acid sweats1 often causing sudamina4 ,there is loss of appetite and thirst is present4 ,the urine is scanty1 high colored1 very acid1 and deposits urates upon standing4 ,the tongue is coated and the bowels are constipated4 ,the joints are reddened1 swollen1 extremely painful and tender to the touch4 ,every movement1 jarring of the bed1 or the pressure of the bed clothes is agony to the patient4 ,the blood is greatly deranged1 anemia develops rapidly and there is well marked leucocytosis4 ,the duration varies from a few days to several weeks4 ,complications4--,the temperature may rise to #ajf or #aji degrees ,f42 this is often associated with delirium1 great prostration and a feeble1 frequent pulse4 ,endocarditis1 pericarditis1 myocarditis1 pneumonia1 pleurisy1 iritis1 chorea1 convulsions and meningitis may occur4 ,coma may develop without preceding delirium or convulsions2 this is very serious and may prove fatal4 ,subcutaneous fibrous nodules attached to tendons and fascia sometimes develop4 ,they vary in size and are most common in children and in young adults1 occurring most frequently in the fingers1 hands and wrists4 ,they are also sometimes seen about the elbows1 knees1 scapul and spines of the vertebr4 ,they usually last a few days1 sometimes for months1 and generally develop during the decline of the fever4 ,cutaneous affections1 such as urticaria1 erythema1 nodosis1 purpura and sweat vesicles sometimes appear4 ,diagnosis4--,this is seldom very difficult2 there are1 however1 several affections which resemble acute articular rheumatism4 ,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 joints1 will determine the diagnosis4 ,septic arthritis may develop during the course of pyemia1 puerperal fever1 or acute osteomyelitis4 ,gout is rarely mistaken for acute rheumatism4 ,gout occurs later in life and usually affects the greater toe2 history and mode of onset will usually render the diagnosis easy4 ,in gonorrheal rheumatism the history of recent infection1 its obstinate character and being generally connected with a single joint from the start are diagnostic4 ,it especially affects the knee4 ,heart complications are rare4 ,rheumatoid arthritis begins in the small joints2 then attacks them all1 leaving permanent deformity4 ,there is no fever or sweats and the heart is not affected4 ,acute arthritis of infants usually attacks the hip or knee4 ,the effusion becomes purulent4 ,prognosis4--,recovery is the rule1 but the prognosis nevertheless1 must be guarded4 ,relapses and recurrences are common4 ,subacute ,rheumatism4--,in this form both the local and general symptoms are of a milder type and are more prolonged than in the acute form4 ,the temperature seldom rises above #aja degrees ,f4 ,the inflammation of the joints is not so severe and fewer joints are involved4 ,it may last for weeks or months1 and then it may pass into the chronic form4 ,usually though1 when the course is prolonged1 the joints return to their normal state4 ,treatment4--,place the patient in a room that is well ventilated and maintain a temperature of about #gj degrees ,f4 ,avoid draughts of air4 ,the bed should be soft and smooth and blankets should be used4 ,the diet should consist largely of milk1 and let the patient drink freely of water4 ,oatmeal1 barley water1 egg albumen and meat juices may also be used4 ,treatment should be given along the entire spine1 especially if the rheumatism changes from one joint to another2 otherwise treat the innervation directly to the affected joint4 ,correct any derangements that may be found along the spinal column and carefully relax the deep back muscles4 ,particular attention should be given to the bowels and kidneys4 ,also1 treat the liver most thoroughly during each treatment4 ,the liver is many times considerably enlarged and tender in rheumatism and a thorough treatment of it seems to favor a more rapid cure4 ,carefully treat the affected tissues4 ,if you cannot treat over the joint1 then manipulate the tissues above and below the joint2 and usually after a few minutes' manipulation the swelling is somewhat relieved so that direct treatment of the joint can be given4 ,it is best to wrap the inflamed joints in flannel if the pain is severe4 ,besides treatment of the innervation of the joint1 hot applications will be helpful4 ,some claim that cold compresses are of aid to the inflamed joints4 ,complications are to be treated separately4 ,besides the ordinary fever treatment for the fever1 the cold bath is very effectual4 ,after convalescence has been established1 the patient should be carefully protected for several days from cold and damp4 ,for any stiffness that may persist1 manipulation and hot baths will be quite sufficient4 ,h4 ,m4 ,still#fh writes 8,if the fever is not over #ajc degrees ,i do not try to reduce it4444 ,after treatment in a majority of cases1 the fever is reduced within twenty-four hours unless complications have set in4 ,these are usually of the heart1 so no matter how mild the attack1 keep this in mind4 ,if the action is irregular and weak1 stimulate it two or three times a day4 ,if it is rapid and high fever1 go to the vasomotor centers and reduce fever1 then inhibit the heart action and keep the excretions active4 ,if the joints are affected ,i always move them gently no matter how great the inflammation4 ,as yet ,i have never had a case of rheumatism in which cardiac lesions or ankylosed joints were a sequela40 ,if the tonsils are evidently badly diseased and osteopathic treatment does not clear them up do not hesitate to have them removed4 ,chronic ,articular ,rheumatism ,osteopathic ,etiology and ,pathology4--,this disorder should be studied in connection with arthritis deformans owing to similar sources of infection and various common factors4 ,it usually develops slowly and follows an acute or subacute attack and is common among the poor1 especially those exposed to damp and cold4 ,heredity1 advanced years1 although the disease may appear at any age1 and constant exposure to cold and wet are predisposing causes4 ,chronic lesions to the spinal column corresponding to the affected area are found4 ,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 involved4 ,then1 in addition1 particular attention should be given osteopathically or surgically1 or both1 to sites of focal infection4 ,pathologically1 the capsules and ligaments of the joints are thickened also1 the sheaths of the tendons around the joint1 so that in long standing cases the movements are impaired4 ,in severe cases the cartilages may be eroded4 ,atrophy of the muscles covering the joints sometimes occurs1 especially when there is neuritis2 thus producing marked deformity4 ,this muscular atrophy is particularly marked when the shoulders or hips are involved4 ,the atrophy is caused partly from disease2 in cases where the joint is distended with effusion1 the wasting may be due to pressure upon the muscles or blood-vessels4 ,symptoms4--,several joints are usually affected2 but it may be limited to one joint1 particularly the knee1 hip or shoulder4 ,pain and stiffness are the most common symptoms4 ,the pain is increased upon motion1 while the stiffness is often lessened by using the limbs4 ,the joints are slightly swollen1 but seldom reddened and are usually tender upon pressure4 ,all the symptoms are aggravated on the approach of stormy weather4 ,there is fever but the general health is not greatly impaired4 ,there may be distortion of the joints and ankylosis may occur4 ,arterial degeneration and chronic endocarditis may develop as complications4 ,prognosis4--,this should be guarded so far as a complete cure is concerned2 although most cases are greatly benefited4 ,treatment4--,the treatment of chronic articular rheumatism is largely correcting lesions of the spinal column1 which affect the diseased tissues as well as the digestive organs1 local treatment of the joints1 and removal of focal infections4 ,a certain percentage will respond to osteopathic measures alone1 though surgery has a definite place in others4 ,the joints and limbs should be thoroughly treated so as to restore a better circulation and relieve the inflamed tissues4 ,wrapping the affected joint with cold cloths and then covering the cloths with flannel and oiled silk is often helpful4 ,due attention should be given the general health1 such as nourishing food1 free elimination and outdoor exercise4 ,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 condition4 ,arthritis ,deformans 7,,rheumatoid ,,arthritis7 ,definition4--,a chronic affection of the joints1 characterized by progressive changes in the cartilages and synovial membranes1 and by new osseous formations restricting the motion of the joint and causing deformity4 ,osteopathic ,etiology and ,pathology4--,it is due to lesions of the spinal column affecting the spinal and sympathetic nerves as well as disturbing the circulation to the cord4 ,lesions of the spinal column and ribs are found corresponding to the innervation of the diseased joints4 ,the osteopath has been able in every case to demonstrate clinically important osteopathic lesions4 ,in addition the symmetry of joint involvement1 muscular atrophy1 sweating1 etc41 point to nervous lesions4 ,falli found upon autopsy that the anterior horns had undergone atrophic changes4 ,nervous lesions are probably of a predisposing character while some infection is the exciting cause4 ,a thorough search of the entire body should be made for foci of infection4 ,malnutrition1 traumatism1 exposure to cold1 and pelvic diseases are important causative factors4 ,in all cases lesions will be found disturbing the organs of digestion4 ,females are more frequently affected than males4 ,the disease is frequently seen in women suffering from ovarian and uterine troubles1 especially at the menopause4 ,hereditary influence may be a factor1 also auto-intoxication4 ,the disease is most common between the ages of twenty and thirty4 ,mental worry1 anxiety1 grief and injury are also predisposing factors4 ,pathologically1 in one class of cases1 the cells of the cartilages and of the synovial membrane proliferate4 ,the cartilages undergo atrophy1 or may become soft1 degenerate1 and are absorbed1 leaving the ends of the bone bare4 ,the bones naturally atrophy and become smooth4 ,in another class the edges of the cartilages where the pressure is slight1 thicken and form outgrowths which ossify and enlarge the heads of the bones1 forming osteophytes which greatly impair the motion2 true ankylosis is rare4 ,the synovial membrane becomes thickened1 also the capsule and ligaments1 thus greatly restricting the movements of the joints4 ,the muscles around the joints atrophy4 ,in the spinal cord atrophic and degenerative lesions are found4 ,in ,still's disease there is an enlarged spleen and marked changes in the joint4 ,symptoms4--,pain and swelling of the joints and fever and enlargement of the lymphatics near the joint are characteristic4 ,the spleen is congested and later on there is gastro-intestinal disturbance4 ,multiple arthritis deformans1 also known as ,heberden's nodosites1 is characterized by nodules developing at the sides of the distal phalanges4 ,it occurs most frequently in women between the ages of thirty and forty1 and gradually increases with age4 ,at first the joints are swollen1 tender and painful and then apparently become better4 ,these attacks may appear at different intervals while the nodules at the sides of the joints gradually increase in size4 ,the larger joints are rarely affected4 ,the progressive form may be either acute or chronic4 ,the acute form at the onset may resemble articular rheumatism4 ,it is more common in women between the ages of twenty and thirty1 but may occur in children4 ,pregnancy1 recent delivery1 lactation1 the menopause1 and rapid child bearing are common antecedents4 ,there is swelling and tenderness of the joints and slight fever4 ,several joints are usually involved4 ,the chronic form is most common4 ,symmetrical joints are usually involved4 ,the affected joints slowly enlarge and are painful and red4 ,usually the hand is first affected2 then the wrists1 knees1 toes1 jaws and spine2 in extreme cases every joint is affected4 ,the vertebr1 spondylitis deformans1 may be attacked4 ,the cervical spine may be alone involved1 in which case the head cannot be moved up or down1 although rotation usually remains4 ,in some instances the entire spinal column is affected and may become perfectly rigid4 ,in some cases there is hardly if any pain1 while in others the pain is agonizing and is almost constant4 ,the joints gradually become deformed1 stiff and creak when moved2 later they become completely ankylosed4 ,this deformity is due partly to the thickening of the capsule1 to the presence of osteophytes1 and to the contraction of the muscles4 ,these contractures flex the leg upon the thigh and the thigh upon the abdomen4 ,muscular atrophy increases the deformity4 ,numbness1 tingling1 pigmentation and glossiness of the skin1 and local sweating may be present and are of trophic origin4 ,the monoarthritic form affects old persons chiefly1 and women more frequently than men4 ,it affects particularly the hips1 the knees1 the shoulders1 and the vertebral articulations4 ,this is often caused by an injury4 ,the muscles waste away and the knee-jerk is usually increased upon the affected side4 ,diagnosis4--,care has to be taken in not confusing it with rheumatic fever or gout4 ,radiographs should be made4 ,prognosis4--,if treated early there is a fair chance for curing the disease4 ,advanced cases usually improve under treatment4 ,the osteopathic treatment should be persistent for at least several months4 ,treatment4--,osteopathic treatment1 if long continued in rheumatoid arthritis1 has given satisfactory results1 although owing to the extent of the deformity1 a cure in advanced cases cannot be expected4 ,an important cause of the disease is probably a trophic or vasomotor disturbance to the tissues of the joint4 ,osteopathically1 there is never any difficulty to locate disorders in the spinal column corresponding to the innervation of the involved joints4 ,the fact that many of the joints are affected symmetrically indicates that the lesion is a spinal one involving the nerve center4 ,during the incipiency marked improvement is the rule4 ,a thorough attempt should be made in every case to discover the source of infection and remove it1 though this does not preclude the essential osteopathic adjustment4 ,the treatment consists of attempts to correct the spinal derangement and careful manipulation of the diseased joints to restore vitality and motion in them4 ,the preceding simple1 but effective treatment1 must be continued two or three times per week for months or even years in order to be of particular value4 ,coupled with the specific treatment should be a careful consideration of the general health4 ,the emunctories should be kept active and the food of the patient be nutritious4 ,the osteopath should require the patient to take considerable physical exercise at regular intervals1 warm baths and plenty of fresh air4 ,massage and friction of the diseased joints will be of aid in absorbing effusions and in restoring the tone of atrophied muscles4 ,hot compresses are a help4 ,the baths at various hot springs are sometimes of benefit1 and change of climate is invigorating4 ,o4 ,j4 ,snyder#fi has this to say3 8,i must be very emphatic1 however1 to here advise exceptional caution in your manipulative procedure4 99 99 99 ,you cannot attempt to move the joint1 for1 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 tissue4 ,your first endeavor should be to reduce inflammation and to mitigate pain4 99 99 99 ,osteopathically much comfort and reduction of pain can be accomplished by inhibition in the proper spinal areas4 ,a little friction and very gentle extension or traction of the joint can be attempted as soon as the condition of the joint1 by the foregoing treatment1 has been made possible4 ,at no time should rotation or sidebending1 or any other manipulation that produces irritation of tissue be attempted40 ,in stout adult women a villous arthritis of the knees may develop owing to faulty posture and poor elimination4 ,these conditions are often amenable to treatment4 ,muscular ,rheumatism ,definition4--,a painful disease of the voluntary muscles and of their fascia and the periosteum4 ,it is regarded by many as a neuralgia of these muscles4 ,the pain is greatly increased by motion and pressure4 ,osteopathic ,etiology and ,pathology4--,osteopathic experience with cases of muscular rheumatism shows that the nerves1 as they pass to and from the spinal muscles1 are affected4 ,the lesion is caused1 principally1 by subdislocations of the vertebr1 ribs or pelvis1 according to the region involved4 ,a gouty or rheumatic diathesis1 heredity1 exposure to cold and wet and previous attacks are predisposing causes4 ,men are more often affected1 owing to their more frequent exposure4 ,the disease affects persons of all ages4 ,it occurs in acute1 subacute and chronic forms4 ,in cases of frequent recurrence focal infections and intestinal toxins are often important factors4 ,vertebral and muscular lesions1 septic foci1 intestinal stasis1 exposure to cold and drafts are principal causes4 ,pathologically1 there is swelling of the muscles of the nature of myositis4 ,in chronic cases there is often atrophy of the muscles1 due to interference of the trophic nerves4 ,symptoms4--,these are generally local and are never accompanied by marked constitutional disturbances4 ,there is seldom fever1 and the pulse is only slightly increased in frequency4 ,pain is the chief symptom2 it is increased by motion or pressure4 ,tenderness is generally present and there may be swelling of the tissues4 ,rheumatic nodules have been found4 ,the duration is usually three or four days1 though it may last longer with frequent recurrences4 ,lumbago is a painful affection of the muscles of the lumbar area and their tendinous attachments4 ,the onset is generally sudden4 ,in severe cases it sometimes renders the patient helpless4 ,in torticollis1 or stiff neck1 the muscles of the side and back of the neck are affected4 ,it is usually confined to one side of the head4 ,any attempt to turn the head causes a sharp pain4 ,in pleurodynia the intercostal muscles1 and sometimes the pectorals and serratus magnus1 are affected4 ,it usually affects but one side1 more frequently the left2 it is the most painful form of the disease1 since the pain is aggravated by breathing4 ,the respiratory movements are consequently restricted on the affected side4 ,the absence of fever and physical signs will distinguish it from pleurisy4 ,in intercostal neuralgia the pain follows the distribution of the nerves and there are tender spots along their courses4 ,cephalodynia affects the muscles of the scalp4 ,scapulodynia1 omodynia and dorsodynia affect the muscles of the shoulder and upper dorsal4 ,abdominal rheumatism affects the muscles of the abdomen4 ,prognosis4--,the prognosis is good4 ,favorable results are the general rule under careful treatment4 ,treatment4--,muscular rheumatism is usually an easy affection to cure4 ,the cause of the disturbance is generally found in the region involved1 and is due1 in the majority of cases1 to some dislocated tissue1 usually osseous1 that irritates the nerves to the muscles4 ,in addition to correcting the lesions1 removal of septic foci1 free elimination1 lessened diet1 stretching of the muscles1 application of heat1 ironing and rest are beneficial4 ,in lumbago there is invariably found a slight lateral deviation of some vertebr along the lower dorsal or lumbar region4 ,occasionally deformity of the vertebr1 asymmetry1 or arthritis are factors4 ,the radiograph may be a diagnostic aid4 ,occasionally1 a floating rib or an innominate becomes displaced4 ,stretching the loins by placing the patient upon his side or back and flexing the thighs on the abdomen is very beneficial4 ,maintain the tension for three or four minutes4 ,hot fomentations and rest are helpful4 ,torticollis1 or stiff neck1 is generally due to a lesion of the middle cervical vertebr4 ,the lesion is usually between the third1 fourth and fifth vertebr1 occasionally as low as the second dorsal4 ,a reduction of the subdislocation will often relieve the attack4 ,stretching of the muscle and application of heat will also be of aid4 ,in some cases of torticollis 7chronic7 there is a curvature of the cervical spine1 and occasionally the muscles are more or less fibrinous4 ,surgical measures may be instituted4 ,in such instances a cure cannot always be accomplished4 ,the tonsils1 nose and teeth should be examined for sources of infection4 ,a few cases of acute torticollis are caused by some of the deep muscular fibres becoming caught around a process of a vertebra4 ,severe contraction of the muscles by cold or extensive rotary flexions of the neck1 may result in torticollis4 ,occasionally a case is found due to injury at birth4 ,the cervical vertebr should be carefully examined4 ,the spinal accessory is the nerve generally involved4 ,lesions to the spinal accessory occur commonly at the third1 fourth and fifth cervicals1 or the atlas and axis4 ,the muscles involved in torticollis are the sternocleidomastoid1 trapezius1 splenius and scaleni4 ,operations should not be performed until a thorough course of treatment has failed to relieve4 ,pleurodynia is often a neuralgia of the pleural nerves4 ,it is usually caused by subdislocations of the ribs exactly over the regions involved4 ,occasionally1 a lesion may exist to the corresponding vertebra1 but rarely4 ,the rib is at times completely dislocated4 ,applications of heat and rest of the part are of aid4 ,strapping of the region will give considerable relief4 ,in cephalodynia the muscles of the scalp are generally involved by lesions in the upper five cervical vertebr4 ,in scapulodynia1 omodynia and dorsodynia the muscles of the shoulder are usually affected by displacements of the second and third ribs1 although the lesion may be found slightly lower in the ribs1 or in the corresponding vertebr4 ,the lower cervical vertebr may also be at fault4 ,in recurring and chronic cases carefully examine for infectious sources4 ,dislocations of the shoulder occur frequently2 and muscular fibres may slip out of the bicipital groove 7rarely74 ,in a few cases muscles may become contracted about the coracoid process1 or the acromial end of the clavicle may become dislocated4 ,abdominal rheumatism is generally caused by lesions in the lower six dorsal vertebr1 which involve the innervation to the muscles4 ,in some cases lesions of the lower ribs are found1 and in a few instances a lesion may be discerned in the upper lumbar vertebr4 ,myalgia of the upper extremity is caused by lesions of the cervical or upper dorsal vertebr or upper ribs4 ,occasionally some trouble may be found in the shoulder or elbow joints4 ,in the lower extremity lesions may be found in the lower dorsal or lumbar vertebr1 or there may be derangements of the pelvic bones4 ,occasionally disorder is found at the hip and knee joints4 ,gout ,definition4--,a nutritional disorder in which there is an abnormal accumulation of uric acid and other purin bodies in the blood and tissues2 and arthritis1 deformity of joints and visceral derangements being the characteristic features4 ,osteopathic ,etiology and ,pathology4--,hereditary influences are the predisposing factors of about one-half of the cases of gout4 ,men are more frequently affected than women4 ,it rarely develops before the age of thirty4 ,overeating1 sedentary habits1 drinking alcohol1 especially fermented drinks1 and lead poisoning are predisposing factors4 ,emotional disturbances may excite an attack4 ,gout is not confined to the rich by any means2 but there is also a 8poor-man's gout10 due to poor food1 unhygienic surroundings1 and to an excessive use of malt liquors4 ,uric acid seems to be a causative factor1 but whether there is an increased formation or a diminished excretion of the uric acid has not yet been fully decided4 ,the ultimate result is the same in either case2 there is an accumulation of uric acid and other purin bodies in the blood1 which is responsible for some of the effects of the disease4 ,osteopathic experience with cases of gout shows that lesions affecting the nervous system are important factors that control uric acid accumulation or excretion4 ,the nerve centers controlling the affected portions of the body are almost invariably involved1 as well as the nerve control to the digestive and excretory organs4 ,a neurosis of these nerve centers probably occurs and is thus a predisposing cause of gout4 ,considerable can be accomplished in the treatment of gout by careful examination of the spinal column1 in the region corresponding to the innervation of the affected area1 for vertebral lesions1 and correcting them4 ,usually1 slight dislocations of the bones of the foot are found1 when that region of the body is involved4 ,the most common subdislocations of the foot are involvements of the astragalus with its articulations and the metatarsals4 ,pathological changes are those of the joints principally4 ,there is deposit of uric acid in cartilages1 synovial membranes and ligaments4 ,the joint of the great toe is most frequently affected1 then the fingers1 ankles1 knees1 hands and wrists4 ,the exudates become hard and are then called tophi4 ,in severe cases the cartilages of the ears1 nose1 eyelids and larynx are involved4 ,finally the joints become stiff1 deformed and ankylosed1 and sometimes there is ulceration4 ,the kidneys are usually the seat of chronic interstitial inflammation with a deposit of urates4 ,the heart and blood-vessels almost always present changes4 ,arterial sclerosis is quite a constant lesion2 the left ventricle of the heart is hypertrophied4 ,urate of sodium has been found deposited upon the valves4 ,there is an excess of uric acid in the blood4 ,chronic bronchitis1 emphysema and asthma are among the changes in the respiratory system4 ,symptoms4--,in acute gout1 before the attack1 the patient may complain of dyspeptic disorder1 restlessness and twinges of pain in the small joints4 ,he is apt to have irritability of temper and depression of spirits4 ,the first symptom of the attack is great pain in the metatarso-phalangeal joint of the great toe1 which usually comes on suddenly at night with swelling1 heat and discoloration of the joint4 ,the temperature rises to #ajb and #ajc degrees ,f4 ,towards morning the symptoms generally abate to recur again the next night4 ,this lasts for several days1 the symptoms gradually abating4 ,the urine is scanty1 high colored1 of high specific gravity and acid in reaction4 ,it deposits urates and often contains a small quantity of albumin4 ,there may be gastro-intestinal symptoms--pain1 vomiting1 diarrhea1 faintness and a rapid1 feeble pulse4 ,pharyngitis is an occasional symptom4 ,the cardiac symptoms are pain1 shortness of breath and irregular action of the heart4 ,these attacks may appear with varying severity4 ,in some cases there may be severe cerebral symptoms4 ,chronic gout follows repeated attacks of the acute form4 ,the articular symptoms continue for a longer time and the condition extends to other joints4 ,the chalk deposits slowly increase until the joint becomes swollen and deformed4 ,the morbid changes already described are characteristic4 ,the urine is increased in quantity1 is of low specific gravity and may contain albumin and hyalin and granular casts4 ,involvement of the heart and blood-vessels gradually occurs4 ,irregular gout or lithemia is seen in persons who have been gouty or have a hereditary predisposition4 ,it includes a set of symptoms that are not alone distinctive1 but when taken with this gouty tendency1 all forms of irregular gout can be recognized4 ,there are various gastro-intestinal disturbances2 cutaneous eruptions2 heart and blood vessel changes2 pains in the various muscles and joints2 nervous symptoms1 as headache1 neuralgia and neuritis2 urinary symptoms1 and pulmonary and ocular disorders4 ,diagnosis4--,only the irregular form of gout should be difficult to diagnose4 ,differentiation is to be made from arthritis deformans and acute and chronic rheumatism4 ,treatment4--,the hygienic treatment of gout is very essential4 ,the patient should live a quiet life1 avoiding mental and physical strains4 ,plenty of fresh air1 exercise and regular hours should be insisted upon4 ,alcoholic drinking should be avoided and the food taken in moderate quantities4 ,keeping the skin active by the use of cold baths1 if the patient is strong1 and warm baths should he be weak1 is a helpful measure4 ,the dress of the patient should be warm and suitable for the climate4 ,a regulated diet of nutritious food1 taken at regular hours1 is necessary4 ,each patient should receive separate instructions as to diet4 ,the food given may be small amounts of beef1 mutton and chicken1 with fresh vegetables2 with the exception of strawberries1 tomatoes and bananas1 fruits may be used2 fats1 milk and stale bread are also suitable4 ,the patient should avoid tea1 coffee1 pastry1 hot breads1 highly seasoned dishes1 and such articles4 ,the free use of water is beneficial4 ,the osteopathic treatment consists of careful correction of the lesions of the spinal column in order to free the nerve force to the affected region4 ,the spinal treatment in gout is the most essential treatment and is effective4 ,a most thorough examination should be made of the tissues about the diseased area2 in the foot the astragalus oftentimes is subdislocated from its articulations1 causing obstructions to the local vessels and nerves4 ,the metatarsal bones should receive due attention1 as occasionally one of the bones corresponding to the affected tissues is dislocated1 usually downward4 ,all the joints between the diseased tissues and the spinal nerve centers should be carefully manipulated so as to favor a better circulation4 ,during a severe attack of gout1 besides careful treatment of the blood supply to the diseased region1 wrapping the joint in cotton wool and applying warmth and moisture to the joint may be helpful4 ,the kidneys1 liver and bowels are to be kept active4 ,a light treatment to the kidneys and liver each time is very helpful in aiding the organs to eliminate the waste material1 and especially in controlling any inflammation that may exist in the kidney4 ,the essential treatment in gout is to relieve the disorder of the nerve centers1 to increase the activities of the emunctories and to regulate the hygiene of the patient4 ,diabetes ,mellitus ,definition4--,a nutritional disorder in which there is an abnormal amount of sugar in the blood1 characterized by an excessive urinary discharge1 in which grape sugar is constantly present1 and by a progressive loss of flesh and strength4 ,osteopathic ,etiology and ,pathology4--,almost invariably there will be found a posterior dorso-lumbar curvature wherein the spinal column tissues are much contractured4 ,this condition probably involves the sympathetics 7vasomotor and trophic7 to the pancreas1 liver and intestines4 ,important lesions may also be found as high as the occiput4 ,tenderness and congestion over the abdomen1 especially the liver1 are frequent4 ,it affects men more frequently than women and is a disease of adult life1 ranging between the ages of thirty and sixty1 though cases have occurred in the very young4 ,it is more serious in the young1 the very young seldom recovering4 ,hereditary influences are believed to be a predisposing cause4 ,it affects the better classes principally and especially those of a neurotic temperament4 ,the ,hebrew race is specially predisposed4 ,the colored race is seldom affected4 ,obesity1 certain chronic diseases 7malaria1 gout1 syphilis71 occupations taxing the mind1 and pregnancy are predisposing influences4 ,injury or disease of the spinal cord or brain frequently cause diabetes1 especially any irritation of ,bernard's diabetic center in the medulla4 ,derangements of the endocrine system are important4 ,injuries to the spine1 chiefly in the dorso-lumbar and sacral regions1 and to the abdomen1 and diseases of the pancreas or liver are1 as has been stated1 oftentimes causes4 ,lesions to the spine may disturb the glycogenic function of the liver1 the glycolytic ferment of the pancreas1 or produce an alimentary glycosuria4 ,extirpation of the pancreas is immediately followed by diabetes1 but if a fragment of the pancreas is left it is not always followed by diabetes4 ,the normal amount of sugar in the blood is #a-ajjj while in diabetes the amount of sugar is #c to #d-ajjj up to #g or #h-ajjj4 ,the healthy kidney will not excrete sugar when it is at the normal ratio4 ,concerning the presence of acetone-bodies von ,noorden#gj says3 8,the excretion of acetone-bodies may serve1 like glycosuria1 as a measure of the intensity of the diabetic disease 444 it will be at once understood that in no other disease do the acetone-bodies occupy so important a position as in diabetes40 ,irritation of the centers of the vasomotor nerves to the liver or direct stimulus to the liver cells is followed by glycosuria4 ,interference with the pneumogastric nerve also influences diabetes4 ,pathologically1 the liver is enlarged1 firmer and darker in color than normal4 ,often there is fatty degeneration of the organ4 ,the pancreas is diseased in about one-half of the cases of diabetes1 especially the islands of ,langerhans4 ,the lesions found are granular atrophy1 occlusion of the pancreatic duct1 atrophy from pressure1 fat necrosis1 and sometimes it is small1 soft and anemic4 ,the kidney changes are those of catarrhal nephritis4 ,in the fatty degeneration hyalin changes take place4 ,the heart is hypertrophied in a few cases4 ,arterial sclerosis is frequently met with4 ,in the lungs bronchitis1 pneumonia and tuberculosis occasionally develop4 ,in the stomach and intestines catarrh is common4 ,the blood presents an increase of sugar4 ,in the nervous system are found many lesions1 especially congestion1 extravasation and sclerosis of the brain2 disturbances of the posterior part of the cord1 and congestion and sclerosis of the sympathetic ganglia4 ,the bony lesions1 however1 7almost invariably a posterior lower dorsal and lumbar7 must involve the sympathetics1 via the splanchnics1 to the extent of profound metabolic disturbance1 for in no other way can the results of osteopathy be explained4 ,the importance of specific treatment at this point cannot be over estimated4 ,symptoms4--,the onset is gradual2 thirst and frequent micturition being the first symptoms noticed4 ,after an injury or a sudden1 severe nervous shock1 diabetes may set in abruptly4 ,as the disease progresses there will be marked thirst1 polyuria1 an abnormal appetite1 wasting and debility4 ,the tongue is dry1 red and coated4 ,there is constipation and the skin is dry and harsh4 ,temperature is often subnormal2 pulse frequent with increased tension4 ,in some cases the urine is not increased in quantity2 usually however1 the amount varies from four to five pints to several quarts in twenty-four hours4 ,it is pale in color1 of high specific gravity and acid reaction4 ,sugar is present in variable quantities from one or two per cent to five or ten per cent4 ,sugar in the urine must be constant in order that the affection is a true diabetic one4 ,albumin is often present2 urea is increased and uric acid may be slightly increased4 ,acetone-bodies are often found and usually indicate a more serious condition4 ,diabetic ,coma is the most important and gravest complication4 ,there is either a sudden or gradual loss of consciousness4 ,this may occur after some form of exhausting exercise4 ,there may be previous headache or a feeling of intoxication4 ,it may be preceded by nausea1 vomiting1 colicky pains or some local affections1 such as pharyngitis or pulmonary complications4 ,peripheral neuritis1 neuralgia1 numbness1 are possible symptoms4 ,impairment of hearing1 cataracts1 strabismus1 diabetic retinitis and atrophy of the optic nerve may occur4 ,the sexual function is lost early in the disease4 ,eczema1 with burning and itching of the labia and vicinity1 7and in men a balanitis71 furuncles1 boils and carbuncles are common4 ,gangrene and edema are not uncommon4 ,acute pneumonia1 bronchitis and tuberculosis are possible complications4 ,progressive loss of flesh is a serious indication4 ,diagnosis4--,the diagnosis is easy1 as there is no other disease with which it can be confounded4 ,careful urinalysis should always be made4 ,examination for acetone1 diacetic acid and oxybutyric acid is valuable4 ,prognosis4--,many cases have been cured by osteopathic measures while nearly all treated have been benefited4 ,if the patient is put upon a diet free from carbohydrates1 in mild cases the sugar will disappear1 while in severe cases it will still be present4 ,mild cases usually yield readily to treatment4 ,in cases over forty years of age the outlook is quite favorable1 but in cases under forty1 and especially the young1 the prognosis is not so favorable4 ,in cases under puberty the results are apt to be fatal4 ,stout persons bear diabetes better than lean4 ,all cases are liable to complications1 which render the prognosis more serious4 ,it is a disease of long duration1 although death has occurred in a few weeks4 ,treatment4--,in nearly all cases of diabetes mellitus examined there have been found posterior conditions of the lower dorsal and lumbar regions4 ,the posterior curve has always been fairly well marked and generally is a symmetrical curve4 ,by that is meant a spinal curve that is not irregular and the relation of the various vertebr1 one to the other1 is not seriously deranged4 ,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 remarkably1 and many entirely cured4 ,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 abdomen4 ,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 position1 stretching the spinal column to separate each vertebra from its neighbor so that the deranged nerves1 as they pass through the intervertebral foramina1 may be released4 ,meeker#ga reports a case with a marked kyphosis which was treated two years before enough motion could be had between the vertebr to produce any results1 but after that they were favorable4 ,direct treatment to the abdominal organs to correct liver congestion and stimulate the pancreas and increase activity of the intestines is essential4 ,the nerves affected by the posterior pathological curve of the spine1 mentioned above1 and by separate lesions that may exist within the pathological curvature1 are probably the vasomotor nerves to the portal system1 pancreas and the intestines4 ,the vasomotor nerves to the portal system branches are given off principally from the fifth to the ninth dorsal vertebr1 although fibres may escape from the cord as low as the first lumbar vertebra4 ,the nerves to the intestines are given off principally from about the ninth dorsal to the lower lumbar vertebr4 ,possibly there are nerve fibres direct to the hepatic cell protoplasm4 ,how lesions in the dorso-lumbar region cause diabetes mellitus is an important question and is hard to answer4 ,an unnatural acceleration of the portal circulation may cause an increased quantity of sugar to pass to the liver1 resulting in part of the sugar not being changed into glycogen and thus passing into the circulation2 or a paralysis of the vasomotor nerves to the liver causes congestion and slowness of the blood stream4 ,thus a disturbed circulation of the liver may cause accumulation of sugar in the liver1 so that the blood ferment has time to act upon the glycogen and transform it into sugar2 or there may be a saccharinity of chyle or blood in the portal vein1 due to an impeded conversion of sugar in the intestines into lactic acid2 or there may be an accelerated absorption of sugar due to an abnormal state of the intestines2 or the nervous control to the pancreatic functions may be disturbed4 ,hence1 one or many pathological changes may occur and influence a case of diabetes1 due to a disordered dorso-lumbar region4 ,the center for the hepatic vasomotor nerves1 8diabetic center10 is in the floor of the fourth ventricle at the level of the origin of the vagi nerves4 ,a lesion of the 8diabetic center0 or an obstruction to the pneumogastric anywhere along its course may cause diabetic symptoms2 hence1 there may be lesions of the cervical region that would affect reflexly the diabetic center1 or lesions of the pneumogastric may occur1 particularly at the atlas or axis1 and cause diabetic symptoms1 or1 at least1 these may influence the course of a case of diabetes mellitus4 ,or the upper cervical lesions may disturb the pituitary gland which is of importance in carbohydrate metabolism4 ,there are nerves from the superior and inferior cervical ganglia of the sympathetic that have considerable influence upon the liver4 ,these nerves do not pass down the cord to the splanchnics1 but pass in the sympathetic to the celiac and hepatic plexuses and then to the liver4 ,stimulation of these nerves causes the hepatic vessels at the periphery of the liver lobules to become contracted4 ,possibly in a very few cases1 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 occur4 ,dietetic treatment is essential1 but is not so necessary as some medical authors would have us believe4 ,a regulated diet should be insisted upon in all cases1 but one should not go to extremes in dieting4 ,a complete elimination of the carbohydrates is no longer considered the best treatment1 as it withdraws too important an element from the diet1 producing weakness without any corresponding return for good4 ,a patient's appetite is often inordinate and it will be necessary to regulate the quantity and character of foods4 ,proctor#gb mentions a case which recovered when carbohydrates were restored1 as the patient was too starved to build up4 ,under osteopathic treatment much more liberty can be allowed in selection of foods4 ,von ,noorden#gc reported a number of cases in which excretions of sugar continued upon the strict anti-diabetic diet1 but which were sugar free when they received a large amount of oatmeal along with some vegetable proteid or white of egg and butter1 other carbohydrates being excluded4 ,it is suggested by the editor of the ,series that the oatmeal may be used alternately with diabetic diet1 and relieve the monotony greatly4 ,it can also be used as a test of the patient's digestive and sugar destroying powers4 ,the following food may be included in the dietary3 ,animal ,foods4--,meats of every variety1 except livers2 game1 poultry1 fish and eggs4 ,vegetables4--,cabbage1 cauliflower1 celery1 lettuce1 green string beans1 the green ends of asparagus1 tomatoes1 spinach1 mushrooms1 cucumbers1 watercress1 young onions1 or any other green vegetable4 ,bread and ,cakes4--,made of gluten flour1 bran flour or almond flour2 griddle cakes1 biscuits1 porridges1 etc41 may be made of these flours4 ,beverages4--,skimmed milk1 buttermilk1 coffee and tea without sugar1 and carbonated water4 ,relishes4--,pickles1 cream cheese and nuts of all kinds except chestnuts4 ,fruits4--,oranges1 lemons1 cranberries1 cherries1 strawberries1 all in moderate quantities4 ,other foods may be used1 but each case requires a thorough study in order to determine what is best to do4 ,various foods should be tested out and controlled by urinalysis4 ,the point is to increase metabolism so that the body can store up considerable carbohydrates without the appearance of sugar in the urine4 ,in severe cases ,allen's fasting treatment to be followed by a low diet should be instituted4 ,however1 it should be remembered that the correction of dorsal and upper cervical lesions is invaluable4 ,mental excitement and worry should be avoided as much as possible4 ,frequent bathing and regulated exercise will be of considerable value4 ,the diabetic patient should have a well ventilated room and plenty of rest and sleep2 flannels are to be worn next to the skin the year around4 ,various symptoms and complications are liable to arise1 which the competent osteopath is prepared to meet by following general rules4 ,keep the bowels open4 ,and frequently examine for acetone and diacetic acid4 ,if there are any symptoms of coma fast the patient1 and neutralize the acid intoxication with bicarbonate of soda until the urine is alkaline4 ,diabetes ,insipidus 7,,polyuria74 ,definition4--,a constitutional disorder in which there is a continued excessive secretion of urine1 free from albumin and sugar4 ,there is constant thirst4 ,osteopathic ,etiology and ,pathology4--,this disease is more frequent in males than in females4 ,it occurs most commonly between the ages of twenty and thirty4 ,it is due to chronic disturbances of the nerves4 ,the lesions usually found upon osteopathic examination are lateral derangements of the vertebr in the renal splanchnic region1 7ninth to twelfth dorsal inclusive7 or a slight kyphosis in the same locality4 ,such lesions probably affect the central nervous system in the region of the sympathetic nerves to the kidneys1 by a paralysis of the muscular coat of the renal vessels4 ,the disease may be associated with other conditions1 as injuries and diseases of the nervous system elsewhere2 exposure to cold2 prolonged debility and fatigue2 cerebral diseases1 as meningitis1 paralysis of the sixth nerve1 tumor of the brain1 and blows on the head2 injuries of the cervical region2 sunstroke2 cerebrospinal fever2 malaria2 syphilis2 pregnancy2 hysteria2 hereditary influences1 and drinking too freely of cold water4 ,there are many diseases and conditions which may be associated with diabetes insipidus2 and which act as irritants1 directly or reflexly1 upon the center in the medulla oblongata 7which is just above the diabetic center71 or upon the sympathetic ganglia in the abdominal region4 ,thus1 there is a vasomotor neurosis1 due either to central or reflex lesions4 ,second in importance to lesions of the renal splanchnics are lesions of the upper cervical region4 ,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 sympathetics4 ,the pituitary gland may be disturbed4 ,probably axis and atlas lesions are factors4 ,lesions of the nerve centers and of the sympathetic ganglia have been found upon post-mortem examination1 but they are not constant4 ,nervous lesions have been found in the region of the base of the brain4 ,the kidneys are sometimes congested and enlarged4 ,the tubules may be dilated4 ,symptoms4--,great thirst and an enormous secretion of urine of a pale1 watery and slightly acid nature are the characteristic symptoms4 ,the skin is usually dry and harsh1 the bowels are constipated1 and the appetite may be voracious4 ,the health on the whole is quite perfect1 although if the affection is not arrested1 considerable loss of flesh and strength may result4 ,there is a tendency for the disease to become chronic4 ,the nervous lesion causing polyuria may be the outcome of a debilitated condition of long standing or the symptoms may occur suddenly4 ,preceding the large flow of urine such symptoms as nervousness1 irritability1 headache1 sleeplessness1 failure of memory1 and inability to concentrate the mind commonly occur4 ,other symptoms may be present in addition1 as debility1 diarrhea1 epigastric and lumbar pains1 and impaired sexual function4 ,diagnosis4--,the diagnosis is not difficult4 ,thirst1 polyuria and the absence of albumin and sugar characterize the disease4 ,in diabetes mellitus1 finding of grape sugar in the urine would at once exclude polyuria4 ,in paroxysmal diuresis1 the increased amount of urine is not permanent4 ,in interstitial nephritis1 there is albumin1 casts1 etc4 ,prognosis4--,depends upon the cause4 ,the disease yields to treatment much quicker than diabetes mellitus and is without doubt much less serious4 ,the disease1 in a large majority of cases1 can be cured4 ,under osteopathic treatment most cases will yield good results or be cured in from a few weeks to six months4 ,treatment4--,the treatment of the disease causing diabetes insipidus is of first consequence1 but frequently such a disease is undiscoverable4 ,there is often a tendency toward neurasthenia2 consequently1 habits1 environment1 etc41 should be carefully attended to4 ,examine for sexual1 rectal and other reflex irritations4 ,correcting lesions of the renal splanchnics is important2 in fact1 in a fair number of cases treatment of this locality will entirely cure the disease4 ,a very effective treatment1 in addition to the ordinary methods of treatment1 is to have the patient lie flat upon the back while the osteopath reaches around the patient on either side1 placing the fingers firmly upon the transverse processes of the lower dorsal vertebr and springing the spine forward by lifting upward on the patient1 enough even to raise the patient from the surface he is lying on4 ,this treatment is especially effective in lessening the increased amount of urine4 ,attention should be given to the false ribs on either side and to the condition of the spine below and above the renal splanchnics4 ,the cervical vertebr should be examined carefully for disorders1 and if any are found they should be removed at once1 if possible4 ,hygienic treatment is of as much importance as in diabetes mellitus4 ,the clothing should be warm1 warm baths taken1 and general friction and care of the skin utilized so that the circulation may be somewhat diverted from the kidneys4 ,restriction of water is not always necessary1 except in cases where excessive drinking has become a habit1 as the thirst is caused by the diuresis and not the diuresis by the large ingestion of water4 ,regulate the diet and see that the bowels are acting normally4 ,rickets ,,rachitis ,definition4--,a constitutional disease of children1 characterized by impaired nutrition and changes in the growing bones1 causing deformities4 ,the physical growth is disturbed and the bone deformity is due to an over growth of cartilages and delayed calcification4 ,etiology and ,pathology4--,rickets may occur in the new-born1 but it rarely begins before the child is six months old4 ,it is a disease of the first and second years of life4 ,heredity is probably not a factor but certain races1 especially the ,negro and ,italian1 have a tendency to be rickety4 ,the disease is much more common in the large cities than in rural districts2 also it is more common in ,europe than ,america4 ,the disease is most frequently met with among the ill-fed and badly housed poor of the large cities1 though it is not rare to find it among the well-to-do4 ,lesions to the digestive organs predispose4 ,breast-fed children seldom have the disorder4 ,improper or insufficient food 7a diet too low in fats and proteins7 bad air1 want of sunlight1 prolonged lactation1 exposure to cold and dampness are predisposing factors4 ,pathologically1 the most marked changes are seen in the long bones and the ribs4 ,the cartilage between the epiphysis and shaft is thickened and is soft and irregular in outline4 ,underneath the periosteum the tissue is spongy4 ,microscopic examination shows an increase of proliferation of the cartilage cells with scanty calcification4 ,the bones are soft and there is a diminution in the calcareous salts4 ,in a word ossification is delayed and the bones are not perfectly developed4 ,in the cranium the frontal and parietal eminences are prominent1 while the top of the head and the occiput are flattened1 giving the head a square appearance4 ,the fontanelles remain open until the second or third year of life4 ,the ribs become affected very early4 ,at the point where the ribs join the costal cartilages1 bulging occurs1 forming the so-called 8rachitic rosary40 ,the normal shape of the chest walls is markedly changed4 ,just outside the junction of the ribs with the cartilages1 the ribs fall in1 producing a shallow depression1 while the sternum and cartilages are pushed forward4 ,the bones of the leg may be distorted4 ,the normal curves of the spine are occasionally disturbed4 ,the liver and spleen are often increased in size4 ,symptoms4--,the onset is slow4 ,in many cases digestive disturbances1 with their usual effect upon the nutrition1 precede the appearance of the characteristic lesions4 ,the child is irritable and restless1 and there is usually slight fever and profuse sweats4 ,the child is often languid1 pale and feeble4 ,the lymph gland are enlarged4 ,the tissues are soft and flabby and skeletal changes begin to make their appearance4 ,among the first are changes in the ribs and head1 already described under pathology4 ,changes sometimes occur in the bones of the face1 particularly the maxill4 ,dentition is delayed4 ,the spinal column is frequently curved antero-posteriorly or laterally4 ,the long bones are curved and their extremities become thickened4 ,the pelvis is distorted and twisted and in women this may seriously complicate labor4 8,chicken breast0 and 8bow legs0 are common1 as well as muscular weakness1 and the child walks late4 ,the abdomen is large and prominent1 due to flatulency and to the enlargement of the liver and spleen4 ,diagnosis and ,prognosis4--,by observing the symptoms1 diagnosis is not difficult4 ,prognosis should be guarded1 owing to danger from other diseases2 still1 on the whole1 prognosis is fairly favorable4 ,treatment4--,rickets being a disease of malnutrition due to weakness of the digestive organs1 improper food1 or to influences of disease1 the treatment must be principally following hygienic rules and good dieting4 ,the child under six months1 if not nursed satisfactorily by the mother1 should be given diluted cow's milk4 ,salts may be obtained from barley gruel and whole wheat4 ,diluting the milk with barley water is highly recommended4 ,fresh meat juice and cream are invaluable4 ,if curds are found in the stools1 the digestion is not perfect and is usually due to overfeeding the child4 ,the child should be out doors as much as possible4 ,fresh air is a necessity4 ,the worst air outside is better than the best air of the house as far as purity is concerned4 ,protect the child carefully with warm clothes1 and when sitting or walking the child should be supported4 ,baths will be found beneficial4 ,in the older child1 beef juice1 light meats1 yolks of eggs1 green vegetables and fruits may be given4 ,lessen the amount of carbohydrates4 ,careful osteopathic treatment of the various affected tissues of the child will aid a great deal in correcting deformities4 ,attention to the lesions found will also aid in increasing the nutrition to the involved tissues as well as correcting digestive disturbances4 ,this1 also1 is of distinct benefit in improving the assimilation of lime salts4 ,possibly treatment of the 8nutritional0 centers1 7fourth dorsal and fourth lumbar7 would be effectual4 ,carefully guard against complications of the nervous and respiratory systems4 ,after ossification the deformities may be corrected by the orthopedic surgeon1 though in the young child considerable can be accomplished by repeated attempts at straightening by bending and molding the long bones4 ,all those conditions which predispose to rickets should receive attention2 chief among these is the care of the nutrition of the mother during pregnancy4 ,nursing should be regulated1 and possibly future pregnancies discouraged4 ,obesity ,definition4--,obesity is essentially a nutritional disease and is an inconvenient accumulation of adipose tissue in the body1 sometimes impairing the bodily function4 ,with some individuals obesity is a normal condition4 ,in others it means impaired health1 especially poor elimination4 ,etiology and ,pathology4--,heredity1 overeating1 sedentary habits1 hot1 moist climates are predisposing causes4 ,exciting causes are especially the eating of fat-making food1 excessive use of alcohol and insufficient exercise4 ,obesity may follow the menopause or an infectious disease4 ,osteopathic lesions are frequently found in the upper and middle dorsal region4 ,these probably are causes of a disturbed metabolism4 ,an excessive diet of starches and sugars will indirectly act as a fat producer4 ,in young people the possibility of hypopituitarism should be considered4 ,lesions of the upper cervical1 in these cases1 are frequent4 ,pathologically1 adipose tissue is deposited throughout most of the tissues4 ,usually the abdomen is encumbered with a large amount4 ,passive congestion probably favors the deposition of fat1 for in cases of pendulous abdomen1 simply drawing the abdomen in and up and the patient1 through voluntary effort1 keeping it up1 will frequently cause absorption of the fat in a few days or weeks4 ,the fat is distributed underneath the skin1 throughout the viscera and about the heart4 ,the tissues may suffer from fatty infiltration1 especially the heart1 arteries and veins2 also the liver1 kidneys and stomach4 ,there is an increase of specific gravity of the blood4 ,edema occurs from passive congestion1 due to weak heart4 ,symptoms4--,the round1 fat face1 double chin1 hanging cheeks1 large waist1 the thick1 prominent1 sometimes pendulous abdomen1 and the bulky extremities form characteristic features4 ,at first obesity presents no harmful symptoms4 ,usually the first troublesome symptom is increased frequency in the breathing1 due to a weak and overworked heart1 and to the fact that the motion of the lungs is hampered by the heavy chest walls1 and also by the interference with the descent of the diaphragm on account of the enlarged liver4 ,dyspnea1 passive congestion1 anemia1 poor digestion1 uterine disorders1 and mental inactivity are common4 ,there is cardiac hypertrophy2 later the heart is overlaid with fat4 ,the pulse is usually frequent1 but may be irregular and slow4 ,treatment4--,obesity being a nutritional disease it seems but reasonable that alterations of the anatomical structures will produce a change in the proper balance of nutrition4 ,along osteopathic lines1 derangement of tissues affecting the nerves to the digestive and lymphatic systems will produce obesity4 ,in the majority of cases examined have been found disturbances at the sixth and seventh cervical1 fourth and fifth dorsal and from the tenth dorsal to the second lumbar4 ,lesions at these points could readily interfere with the thoracic duct and the receptaculum chyli1 as well as with the processes of digestion1 assimilation and elimination4 ,it is claimed that stimulation of the splanchnic nerves causes dilatation of the receptaculum chyli4 ,direct treatment to the abdomen and to areas of fatty deposit will aid very materially in absorption4 ,the dietetic treatment is essential1 the principle being to furnish less food to oxidize4 ,restrict fats1 sugar and starches and limit the amount of water4 ,alcohol should be prohibited4 ,another important point in the treatment is exercise1 which must be carried out in a systematic way4 ,rules can be laid down only in individual cases and should be governed by the osteopath in charge4 ,the principal effect of general mechanical treatment is to promote oxidation4 ,massage and baths are beneficial4 ,the patient can do much for the abdomen by keeping it in and up1 and walking erect4 ,scurvy ,definition4--,a constitutional disease1 characterized by extreme general weakness1 anemia1 spongy condition of the gums1 disintegration of tissue and a tendency to hemorrhages4 ,etiology and ,pathology4--,in comparison with former times scurvy is now a rare disease4 ,lack of fresh vegetables or their substitutes1 over-crowding1 dampness1 bad hygienic surroundings1 and prolonged fatigue under depressing influences are the predisposing causes4 ,arctic explorers have shown that fresh bear's meat and bear's blood are a preventative4 ,there are extravasations of blood into the skin1 muscles and mucous membranes4 ,hemorrhages may occur in the internal organs1 especially the kidneys and liver1 and in the serous membranes4 ,the gums are swollen and spongy4 ,the teeth decay4 ,the spleen is soft and enlarged4 ,parenchymatous degeneration of the heart1 liver and kidney is frequent4 ,ulcers occasionally occur in the skin and bowels4 ,the blood is thin but there is no leucocytosis4 ,symptoms4--,the disease is usually slow in development4 ,the general manifestations of anemia with debility are among the first symptoms4 ,the gums are swollen1 soft and spongy1 they bleed easily and in severe cases there is ulceration4 ,petechial spots appear upon the body4 ,subcutaneous ecchymosis occurs1 first on the legs1 then on the arms and trunk4 ,the eyes and face are swollen2 the patient appears as if he had been bruised4 ,hemorrhages from the mucous membrane frequently occur4 ,the temperature is usually normal4 ,the pulse is small1 feeble and frequent2 sometimes irregular and slow4 ,the appetite is impaired and constipation is present at first1 as a rule1 although this may be followed by scorbutic dysentery4 ,diagnosis4--,the disease is readily recognized when several cases occur together4 ,it is somewhat hard to recognize in isolated cases1 and to be able to distinguish it from certain forms of purpura4 ,the etiology1 the gingival changes and the hemorrhages usually decide the diagnosis4 ,prognosis4--,scurvy being a disease due to malnutrition1 it is necessary to remedy such condition by attention and correction of the faults producing it4 ,hygienic surroundings and a wholesome diet will do more in curing the disease than anything else4 ,an outdoor life and good ventilation with anti-scorbutics1 as fruit juices1 especially lemons and oranges1 fresh vegetables1 7onions1 potatoes1 etc47 and fresh milk1 are necessary4 ,it is held by ,garrod that scurvy is caused by an absence of potash1 for a deficiency of potassium salts is found in the blood4 ,the anti-scorbutics named above contain potash4 ,a careful treatment along the splanchnics would help to improve the appetite and digestion4 ,treat the gums and ulcers according to surgical indications4 ,infantile ,scurvy ,,scorbutus ,this form usually follows the prolonged use of condensed milk1 sterilized milk or proprietary foods for children4 ,the disease occurs during the first two years of life1 but it is most common from the seventh to the fourteenth month4 ,it develops rapidly4 ,joint pains1 anemia and irritability are early symptoms4 ,the child is pale1 has a muddy complexion and may show signs of rickets4 ,the gums may be soft and spongy4 ,there is tenderness and pain on motion4 ,there may be hemorrhages under the skin4 ,the lower limbs are drawn up and motionless4 ,the bones become thickened from sub-periosteal hemorrhage1 and there is apt to be softening between the shaft and epiphysis4 ,the back and legs become very weak4 ,the lesions are usually symmetrical4 ,the temperature is variable4 ,treatment4--,the treatment of scurvy in children consists in1 first1 omitting all proprietary foods and substituting fresh cow's milk1 meat juice1 strained gruel and a moderate quantity of fresh orange or lemon juice4 ,under this treatment1 cases that have not progressed too far will promptly recover4 ,northrop says3 8,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 foods40 ,purpura ,purpura is a symptom rather than a disease4 ,it is characterized by extravasation of blood into the skin and bleeding from the mucous membranes1 irrespective of direct injury4 ,these extravasations do not disappear upon pressure and vary greatly in size4 ,they may be small1 7petechi7 or large 7ecchymoses74 ,they are bright red and gradually become darker4 ,clotting of normal blood requires three to five minutes1 purpuric blood1 ten to fifteen minutes4 ,it is a symptom of infectious diseases1 as in pyemia1 septicemia1 mycotic endocarditis1 typhus fever1 smallpox1 etc4 ,toxic1 as produced by venomous snake bites and by certain medicines1 as copaiba1 mercury1 quinine1 iodides and others in overdoses4 ,cachectic purpura may be observed in cancer1 tuberculosis1 ,bright's disease1 scurvy1 etc4 ,in senile purpura the spots are generally confined to the extremities4 ,in certain nervous diseases1 bleeding spots appear on the skin1 as in tabes1 myelitis and severe neuralgia4 ,mechanical purpura is seen in venous stasis2 this is rare4 ,purpura simplex affects only the skin4 ,it occasionally follows attacks of infectious diseases4 ,the spots are found upon the legs1 more rarely upon the trunk and arms4 ,articular pains may or may not occur4 ,fever is seldom present4 ,loss of appetite1 diarrhea and slight anemia may be manifested4 ,the duration is one to four weeks4 ,purpura rheumatica is a much more serious affection1 characterized by multiple arthritis of rheumatism4 ,seldom seen under five years1 and lasts about two weeks4 ,the joints are swollen and painful and the temperature rises to #aja and #ajc degrees ,f4 ,the amount of edema varies greatly and occasionally it is quite excessive4 ,in addition to the purpura there is usually urticaria4 ,henoch's purpura is seen most frequently in children and is characterized by severe gastro-intestinal disturbances as pain1 vomiting and diarrhea1 hemorrhages from the mucous membranes and acute enlargement of the spleen1 in addition to the symptoms already named under the foregoing form4 ,there is some danger of hemorrhage into the kidneys4 ,the disorder of purpura hemorrhagica is usually associated with rheumatism1 malaria and other infectious diseases4 ,this is the most serious form of purpura4 ,it is most commonly met with in delicate girls during early life2 but it may occur at any age and in the most robust of either sex4 ,fever1 weakness1 vomiting and diarrhea are the early symptoms4 ,after a couple of days of languor and weakness1 purpuric spots appear upon the skin2 and bleeding occurs from the mucous membranes and may cause profound anemia4 ,hemorrhages into the internal organs occur4 ,favorable cases recover in ten days or two weeks4 ,others may end fatally4 ,care should be taken not to confuse the disease with scurvy4 ,treatment4--,in the treatment of purpura the disease from which it develops should receive due attention4 ,occasionally there is danger of overlooking the primary disease and treating some symptoms of the disease1 although it is true that sometimes an important symptom is nearly all that is manifested4 ,outside of treating the conditions under which purpura arises1 general measures should be considered1 as a nutritious diet1 rest1 fresh air1 and general treatment of the patient so that normal circulation and strength may be restored4 ,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 found1 by careful manipulation of the tissues4 ,as stated the management of the disease under which it arises should be embraced in the treatment4 ,in cases of hemorrhage from various organs see article under hemorrhage4 ,some cutaneous hemorrhages are best relieved by local manipulation4 ,hemophilia 7,,bleeder',s ,,disease74 ,hemophilia is a hereditary condition manifested by a tendency to uncontrollable hemorrhage with or without injury4 ,the usual mode of transmission is through the female line1 rather than by the male4 ,the mother does not necessarily have to be a bleeder1 but the daughter of one1 in order to transmit the disease to her offspring4 ,atavism through the female alone is almost the rule4 ,not all the children of a bleeding family are afflicted2 the male children are more subject to the condition than the female children4 ,the tendency usually appears within the first two years of life4 ,the families of bleeders are often large and are commonly healthy looking and have fine soft skins4 ,it is claimed blondes are most likely to be afflicted4 ,pathologically1 an unusual thinness of the blood-vessels with a fatty degeneration of the intima has been noted4 ,in many cases there is deficient coagulability of the blood and a lessened number of leucocytes4 ,hemorrhages have been found in and about the capsules of the joints1 and in a few instances inflammation of the synovial surfaces4 ,the arteries are situated superficially1 but that does not explain anything4 ,the real nature of the disease has not been determined4 ,emotional excitement is a factor1 consequently vasomotor disturbances may be important4 ,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 recognized4 ,symptoms4--,hemorrhages occur from the most trifling injuries4 ,blowing the nose may cause severe epistaxis2 the extraction of a tooth is a frequent cause of hemorrhage2 the prick of a pin1 a slight cut1 a scratch1 or a blow may result in profuse bleeding4 ,the bleeding may occur spontaneously from the mucous membrane of the mouth1 nose1 lungs1 intestines1 etc42 or it may occur directly from the fingers1 toes1 back of the hands1 and lobes of the ears4 ,the hemorrhages may last several hours4 ,as soon as checked the patients rapidly resume natural appearance providing the bleeding is not often repeated1 thereby causing a permanent anemia4 ,there may be attacks of arthritis with fever1 as with acquired hemorrhagic tendency1 closely resembling rheumatism4 ,diagnosis4--,hereditary tendency and persistent hemorrhage from slight injury4 ,prognosis4--,in a few cases the tendency to bleed gradually diminishes until at last it entirely ceases4 ,the younger the subject the more is it liable to prove fatal4 ,in the majority of cases death occurs between the first and eighth years4 ,after maturity the chances of an attack are much lessened4 ,treatment4--,members of the bleeder's family1 particularly the boys1 should be guarded against traumatic influences1 and operations of all kinds should be avoided4 ,outdoor exercise1 fresh air1 bathing and plain nourishing food1 in fact1 the hygienic surroundings1 and all food should be carefully watched so that the threatened subject may become strengthened and hardened4 ,marriage should be discouraged1 especially with the daughters1 as it is through them the tendency is propagated4 ,possibly1 coupled with the foregoing prophylactic treatment1 a stimulation of the glands of elaboration of the blood will be of service to build up the physical constitution of the patient4 ,during attacks absolute rest and the required symptomatic treatment should be given4 ,for resultant anemia the usual treatment is to be employed4 ,in severe cases direct transfusion should be considered4 ,,footnotes3 #fg ,billings1 ,focal ,infection4 #fh ,massachusetts ,journal of ,osteopathy1 ,jan4 #aijf4 #fi ,journal of the ,american ,osteopathic ,association1 ,november #aiai4 #gj ,diabetes1 p4 #ij4 #ga ,journal of the ,american ,osteopathic ,association1 ,oct41 #aijd4 #gb ,journal of the ,american ,osteopathic ,association1 ,oct41 #aijd4 #gc ,practical ,medical ,series1 #aije4 ,,diseases ,,of ,,the ,,digestive ,,system ,diseases of the ,mouth ,stomatitis ,definition4--,inflammation of the mouth4 ,etiology4--,chemical1 mechanical1 thermal or parasitic irritations2 secondary to disorders of the gastro-intestinal tract1 scarlet fever1 measles and variola2 cachexia1 due to such diseases as cancer and phthisis2 dentition2 artificial feeding2 hot weather and poor hygienic surroundings are the most common causes4 ,lesions to the innervation and vascular supply of the mouth are found1 principally1 in the upper cervical vertebr1 occasionally in the upper dorsal vertebr and corresponding ribs4 ,varieties4--,catarrhal1 aphthous1 ulcerative1 parasitic1 gangrenous4 ,catarrhal ,stomatitis ,etiology4--,most common in infants and children4 ,hot and irritating substances2 secondary to diseases of the stomach1 to measles1 scarlet fever and variola2 difficult dentition2 alcoholic or tobacco excesses4 ,hazzard says in all cases of stomatitis 8there is generally lesion to the bony or other tissues in the cervical region 7sometimes also in the upper dorsal71 which deranges vasomotor control of the tissues of the mouth and tongue1 obstructs venous return1 weakens the tissues and lays them liable to the effects of some particular irritant1 local or in the system1 but there is1 generally1 lesion affecting the gastro-intestinal tract which is the real underlying cause of the trouble40 ,symptoms4--,diffuse1 red swelling of the mucous membrane1 heat and pain in the mouth1 increased flow of saliva1 fetor of breath1 restlessness and languor4 ,in children there is a disinclination to nurse and a slight fever may be present4 ,the sense of taste is blunted and there is commonly a bitter taste in the mouth4 ,the neck glands are enlarged4 ,treatment4--,removal of the exciting cause is the most important point in the treatment4 ,good hygienic conditions must be enforced4 ,the mouth should be kept clean4 ,wipe it out at frequent intervals with a soft piece of absorbent cotton and cold water4 ,a borax solution is frequently used4 ,attention should be paid to the diet and secretions4 ,light but thorough treatment of the upper cervical region is to be given1 with careful attention to the tissues about and below the angles of the jaw1 so that the innervation1 blood and lymphatic supply may be equalized4 ,aphthous ,stomatitis 7,,canker7 ,this disease is characterized by little1 painful1 grayish-white spots upon the superficial layer of the mucous membrane4 ,they consist1 primarily1 of an exudate of fibrin and wandered-out leucocytes4 ,it is principally a disease of childhood4 ,among the common causes are difficult dentition1 disorders of digestion and uncleanliness of the mouth1 such as neglect to cleanse the child's mouth after nursing4 ,it may be a symptom of measles or of local diseases4 ,probably the innervation to the region of the little grayish-white spots or canker is obstructed at some points by a disordered tissue4 ,the lesion may be mechanical or it may arise from a disordered digestion4 ,if one is able to locate such a lesion and remove it1 a cure will be hastened4 ,the seat of the infection is the internal surface of the cheeks1 gums1 roof of the mouth1 tongue and lips4 ,symptoms4--,there is redness of the mucous membrane of the mouth1 followed by the appearance of the vesicles with a red areola4 ,pain in the mouth and an increased flow of saliva occur4 ,mastication1 deglutition1 and even speaking1 may be painful4 ,this condition is followed by sleeplessness1 feverishness1 diarrhea and fetor of the breath4 ,treatment4--,removal of the cause1 as in other varieties of stomatitis1 is paramount4 ,give attention to the food4 ,the milk should be sterilized4 ,the disordered digestion should be corrected at once4 ,all secretions must receive prompt attention4 ,the child should be nursed at regular intervals4 ,locally1 keep the parts clean and carefully treat the innervation4 ,ulcerative ,stomatitis ,this is a disease of children1 although it may not be limited to them1 as it occasionally occurs in epidemics and affects all ages4 ,it occurs chiefly in the families of the poor and in places where the hygienic surroundings are bad1 the food poor and personal cleanliness lacking4 ,it may begin as an aphthous stomatitis4 ,often sufferers from severe1 acute diseases are subjects of attack4 ,symptoms4--,the gums of the lower jaw are chiefly affected4 ,they are at first congested1 swollen and bleed readily4 ,pain is increased by mastication and deglutition1 the mouth is hot1 the breath fetid1 the saliva dribbles and the digestion and bowels are disordered4 ,the ulcers may appear at various points upon the cheeks1 lips and tongue2 the deposit is yellowish-gray4 ,in the more severe cases the gums are spongy and the teeth are loosened4 ,in proportion to the constitutional disturbances1 fever and enlargement and tenderness of the submaxillary glands occur4 ,even necrosis of the bone may follow4 ,parasitic ,stomatitis 7,,thrush7 ,the exciting cause is a fungus known as ,laccharomyces albicans4 ,it is claimed that a catarrhal stomatitis is the soil upon which the fungus develops4 ,parasitic stomatitis is chiefly a disease of nursing children and is promoted by unhygienic conditions4 ,it is seldom seen after ten years of age1 occurring in adults only in the last stages of consumption1 cancer1 and severe chronic diseases4 ,symptoms4--,upon inspection there are seen numerous milk-white elevations4 ,these appear first about the angles of the mouth1 soon extending to all parts of the mouth1 and in a few cases1 even to the pharynx and to the esophagus4 ,when removed bleeding points are left4 ,the general symptoms of stomatitis are present--pain upon mastication and swallowing2 fetid1 hot breath2 increased saliva2 increased temperature2 restlessness2 swollen lips and disordered digestion occur4 ,diagnosis4--,the microscope will remove all doubt as to the nature of the affection4 ,in aphthous stomatitis the ulcers are preceded by the formation of vesicles4 ,prognosis4--,is favorable in the majority of cases4 ,treatment4--,hygienic measures1 absolute cleanliness1 correction of the disorders of the gastro-intestinal tract and local treatment as in other forms of stomatitis1 is the required treatment4 ,a boric acid solution will be found beneficial4 ,,spinal ,,lesions ,,and ,,their ,,relation ,,to ,,diseases ,,of ,,the ,,gastro-,,intestinal ,,tract ,acute ,gastritis1 ,chronic ,gastritis1 ,gastric ,neurosis1 ,gastric and ,duodenal ,ulcer4 ,by ,,charles ,j4 ,,muttart ,the instant relief that ,osteopathy can give in acute indigestion is one of its outstanding achievements4 ,it impresses the patient and his friends with a deep conviction of the superiority of osteopathic therapy4 ,the results in these cases are not1 in any sense1 a matter of chance4 ,they follow logically from the osteopathic viewpoint1 teaching1 reasoning1 and practice4 ,in dealing with the manifestations of disease1 such as heredity1 onset1 course1 duration1 subjective and objective symptoms1 etc41 and in the effort to differentiate cause from effect1 and to reconstruct a mental picture of the sequence of cause1 effect and sequel1 the osteopath has the advantage of binocular vision in that he recognizes two distinct pathologies cooperating to produce the symptom complex1 syndrome or disease which he is called upon to treat4 ,one pathology is to be found in one or more of the vertebral and rib articulations and the immediately adjacent or corresponding segments of the spinal cord4 ,the other is in some one or more of the organs or tissues connected with the pathological segment or segments of the cord4 ,the function of the joint is ,,motion4--,unrestricted normal range of motion is essential for the normal function of all parts of the articulation as well as for the nutrition of the nerve mechanisms immediately adjacent4 ,when a spinal articulation ceases to perform its function all of its parts are more or less impaired1 muscles atrophy1 ligaments lose their tone1 and circulation to and from the spinal segment is interfered with because action is a large factor in promoting the flow of blood and lymph and maintaining normal stimulus4 ,as a result of this spinal pathology1 internal organs and tissues1 supplied by nerves arising in the segment that is in lesion1 will be variously disturbed in their function4 ,dr4 ,carl ,p4 ,mc,connell says3 8,my observation of lesioned animals so far as the digestive organs are concerned is that the lesion affects the reflexes of and through spinal and sympathetic ganglia so that the vasomotors are involved with a consequent hyperemia of the submucous coat4 ,this means involvement of the endothelial layer of the blood-vessels1 diapedesis1 derangement of the secretory function and disturbance of the motor mechanism1 all of which lead to functional upset and disturbance40 ,the dominant part played by the osteopathic lesion as a causative factor in acute and chronic diseases of the alimentary canal becomes increasingly evident as clinical observation and laboratory research permit a more thorough appreciation of the anatomy and physiology of the parts involved4 ,the abnormal stands out more clearly from the normal4 ,finally1 the task of restoring normality is becoming a clear-cut problem to which the correction of the osteopathic lesions furnishes an almost complete solution4 ,the normal alimentary canal transports food1 macerating it1 mixing it1 and treating it with various chemicals and enzymes on the way1 breaking it down physically and chemically1 and absorbing from it such end-products as are needed to maintain metabolism4 ,the abnormal alimentary tract may be at fault in any of these functions4 ,this delinquency is generally traceable to a mechanical origin4 ,correction of the mechanical deviation is followed by restoration of normal function except in cases where extensive tissue changes have occurred4 ,thorough mastication is essential to good digestion4 ,any dental defects or deficiencies should be corrected4 ,the temporo-mandibular articulation should be examined1 and full free motion restored if lacking4 ,the muscles on the affected side are softer than on the sound side4 ,tonic spasm rigidly closes the mouth4 ,it may be due to tetanus1 caries of the lower teeth1 cutting of the lower wisdom tooth1 or other irritations to the sensory branches of the inferior maxillary nerve4 ,there is enough space back of the wisdom teeth to pass a catheter to administer food4 ,the tongue assists in mastication and deglutition and is the seat of most of the nerves of taste4 ,the hypoglossal nerve1 which supplies it1 leaves the skull through the anterior condyloid foramen and may be impinged there or lower in its course4 ,lesions of the occiput and upper cervical vertebr and obstructions to the lymphatic drainage at the angle of the jaw may cause pressure on this nerve and cause disturbances in the movements of the tongue1 atrophy1 swelling1 etc4 ,swelling may be due also to endocrine disturbance1 constitutional diseases1 anemia1 glossitis1 local irritants1 injuries1 etc4 ,pressure may be made on the hypoglossal nerve behind the angle of the jaw4 ,the special sense of taste plays an important role in normal digestion4 ,the lingual nerve supplies the anterior two-thirds of the tongue with taste4 ,the sense of taste may be lost1 impaired1 perverted or otherwise abnormal4 ,the sense of smell plays an important part in our appreciation of flavors1 and when it is impaired by colds1 adenoids1 or other affections of the nose or pharynx1 the sense of taste is measurably impaired4 ,normalization of nose and pharynx restores the sense of taste in such cases4 ,impairment or loss may also be due to lesions of the chorda tympani1 or glosso-pharyngeal nerves4 ,lesions of the mandible1 hyoid1 occiput or upper cervical nerves1 parotid disease or obstructed lymphatic drainage behind the angle of the jaw may cause pressure directly or indirectly on the glosso-pharyngeal and chorda tympani nerves4 ,perversion of taste occur in pregnancy1 hysteria1 epilepsy and insanity4 ,foul taste1 fetororis in the mouth is frequent in pneumonia1 typhoid fever1 peritonitis1 septicemia and other severe fevers2 also after ingestion of pungent foods or strong drugs2 in constitutional diseases2 as a result of inattention to oral hygiene1 excessive smoking1 mouth breathing at night1 furred tongue1 etc4 ,it clears up on removing the cause4 ,furred tongue occurs in gastritis1 fevers1 and a variety of other conditions4 ,the fur is composed of broken down epithelium which would normally be removed by friction with solid food4 ,when none is taken1 the fur accumulates4 ,when blood or hematin becomes mixed with the broken down epithelium1 the fur is brown4 ,ordinarily it is white4 ,a clean red tongue is frequently found in hyperacidity4 ,it is probably due to vasodilatation due to hyperactivity of the autonomics or inhibition of sympathetics4 ,the sympathetic supply is from the superior cervical ganglion4 ,it may be affected by lesions of the occiput1 atlas1 axis and third cervical vertebra1 of the hyoid1 by anterior cervical muscular contractures1 by obstruction to venous and lymphatic drainage and blood supply4 ,correction of the lesions named and normalization of the other structures involved will usually restore the tongue to normal condition4 ,the salivary glands have a two-fold innervation4 ,the thin1 full1 watery1 salty secretion is produced by activity of the cranial autonomic fibers2 the sparse1 viscous secretion containing the organic elements1 ptyalin1 etc41 is produced by the sympathetics4 ,the sympathetic nerve supply is from the middle and superior cervical ganglia and can be disturbed by lesions affecting them as mentioned above4 ,the secretion of ptyalin may be disturbed by any lesion from the fifth dorsal up4 ,it must not be forgotten that a posterior occiput draws the superior cervical ganglion back against the axis and third cervical with just as much pressure as is exerted by an anterior atlas or third cervical4 ,this pressure or stretching tends to inhibit it1 preventing vaso-constriction and permitting vasodilatation of the internal carotid artery and its branches and congestion of the parts supplied1 mid-brain1 cerebrum1 etc4 ,if1 for any reason1 the venous drainage from the lateral sinus into the internal jugular vein1 or the ebb and flow of the cerebrospinal fluid between brain and cord1 is reduced or hampered1 an extra burden is thrown on the cerebral veins and sinuses1 and the intra-cranial pressure is raised at each heart-beat1 ultimately producing pressure on the meninges and causing violent headache over the fifth and tenth cranial nerves which supply the meninges with sensation4 ,these nerves are intimately connected with the digestive system4 ,any increase of intra-cranial pressure causes increased irritability and hyperactivity of the cranial nerves1 many of which are concerned with various functions of the digestive system4 ,moreover1 the nuclei of these nerves lie on the floor of the fourth ventricle which is supplied mainly by the vertebral arteries and the basilar artery4 ,lesions of the cervical vertebr affecting the plexus on the vertebral artery or filaments to it from the upper parts of the cervical gangliated sympathetic cord1 may impair the blood flow through the vertebral arteries and cause similar increased irritability of the nerve cells in the medulla1 mid-brain and cerebellum4 ,such disturbance is reflected in awkward movement1 hyperesthesia1 and symptoms due to increased irritability of the autonomic nerves such as slow pulse and respiration1 watering of the mouth1 hypersecretion and hypermotility of the gastro-intestinal tract1 rapid digestion and poor assimilation1 vasodilatation1 impoverished blood1 and so through a vicious cycle back to still greater impairment of nutrition to the nerve cells within the cranium4 ,until the lesions are corrected1 the condition becomes progressively worse till exhaustion occurs4 ,ordinary medical hygiene can do little or nothing4 ,the palliative remedies employed simply mask the symptoms1 or actually accelerate the destructive process4 ,lesions that irritate the cervical sympathetics would cause vaso-constriction and give rise to opposite symptoms1 namely1 cerebral ischemia1 decreased flow of saliva1 atony of stomach1 lack of digestive juices1 sluggish intestinal peristalsis1 rapid pulse and respiration1 etc4 ,correction of the lesions and restoration of normal blood supply and drainage to the brain and removal of any lesions tending to inhibit the sympathetics from the fifth dorsal up1 will usually in a short time restore the activity of the salivary glands to normal4 ,the otic and sphenopalatine ganglia can be disturbed by abnormal conditions within the pharynx4 ,these must be corrected when found4 ,deglutition1 or swallowing1 is a very rapid1 highly complex movement4 ,it takes not more than a second for the food to cross the pharynx4 ,the soft palate and larynx are raised to close off the air-way1 making the food-way practically continuous for the second needed to complete the transfer of the food across the air-way4 ,the tongue is pressed against the roof of the mouth and the mylohyoid contracts vigorously and shoots the bolus of food across the pharynx4 ,bolting the food leads to serious digestive disturbances1 not the least of which is the loss of the normal reflex which prevents swallowing unprepared food4 ,when lost1 this reflex can be restored by thorough mastication for three or four months4 ,the voluntary part of swallowing is performed by the motor portion of the fifth cranial and the hypoglossus4 ,the involuntary part involves afferent impulses over the superior laryngeal and efferent impulses over the inferior laryngeal4 ,the levator palati which raises the soft palate is probably supplied by the spinal accessory nerve through the pharyngeal plexus4 ,this nerve can be affected by lesions of the occiput1 atlas1 mandible and hyoid1 and by any obstruction to lymphatic drainage which increases pressure behind the angle of the jaw4 ,in paralysis of the levator palati1 as after diphtheria or other peripheral neuritis1 fluids regurgitate through the nose during the act of swallowing4 ,the raising and closing of the larynx is accomplished by the superior and recurrent laryngeal nerves by way of the pharyngeal plexus4 ,pain in swallowing is generally due to some inflammation or infection of the tonsil or pharynx4 ,this does not occur when everything is normal from the fifth dorsal up4 ,the second and third stages of swallowing occur in the esophagus4 ,the esophagus receives esophageal branches from the vagus1 carrying autonomic fibers which contract its longitudinal muscles and dilate its arteries4 ,it also receives sympathetic impulses from the plexus on the arteries which supply it4 ,these sympathetic impulses convey vaso-constriction and constriction of the circular muscles of the esophagus4 ,any lesion from seventh cervical to ninth dorsal might affect the esophagus2 probably fifth dorsal is the most nearly specific1 as the heartburn which results from regurgitation into the esophagus is usually localized there4 ,lesions of the upper six dorsal vertebr interfere with digestion and nutrition in another vital way by reducing the activity of the lungs and consequent intake of oxygen into the system4 ,if there is not sufficient oxygen to oxidize the proteins to amino-acids there will be harmful products left for the tissues to neutralize4 ,lesions of the third1 fourth and fifth cervical affecting the phrenic may have a like effect4 ,sub-oxidation must be noted when present and treated by removing lesions affecting respiration1 by deep breathing exercises1 and by diet rich in the needed mineral salts1 and properly balanced4 ,an improperly balanced diet changes the structure of the tissues and amounts in effect to an osteopathic lesion which causes disturbed function4 ,it must be searched for1 found if present1 accounted for1 corrected and kept corrected to obtain maximum therapeutic results4 ,the stomach1 intestines and rectum are intimately related with the other abdominal viscera4 ,it will therefore be readily seen that any disturbance of the liver1 gall-bladder1 pancreas1 spleen1 duodenum1 pleura or peritoneum will disturb the function of the stomach1 and that any disturbance of any organ will disturb the function of the intestine4 ,in fact1 clinically1 it would seem that the majority of cases can be accounted for by the lesions found1 the stomach or intestinal disturbances which are regarded as reflex from some other organ1 being in reality caused by the same lesion as disturbed the organ which first manifested disturbance4 ,going more deeply into the nature of the mechanism whereby symptoms of gastro-intestinal disturbance are produced1 we find that the alimentary tract has an ingenious conveyer mechanism with a number of sphincters4 ,these are operated by intrinsic sympathetic or myenteric nerves1 called plexuses of ,meissner and ,auerbach4 ,in conveying food1 impulses are passed from one portion of the tract to the next over these myenteric arcs4 ,normally the peristaltic movement is always forward because the point of highest irritability is at the proximal end4 ,there is an exception to this rule in the ascending colon1 where antiperistalsis occurs normally4 ,when the irritability of a distal point of the alimentary tract becomes greater than the more proximal points1 an antiperistaltic wave is set up causing vomiting4 ,the myenteric activities are regulated by the autonomic impulses over the vagus1 and by the sympathetic impulses over the splanchnic nerves4 ,the autonomics contract the longitudinal muscles1 dilating and shortening the tube4 ,they also stimulate secretion of digestive juices and fluids and mucus and dilate the blood-vessels4 ,the sympathetics contract the circular fibers and sphincters1 narrowing and lengthening the tube1 retarding the food1 inhibiting the secretions and constricting the blood-vessels4 ,the myenteric reflexes can continue after the vagi and splanchnics are cut4 ,the vagi simply stimulate them and the splanchnics inhibit them4 ,the pathways are from the coeliac plexus where the vagi and splanchnics meet with various other plexuses on the arteries and following the courses of the arterial supply to the minutest parts of each organ4 ,each cell is surrounded by nerve fibers4 ,visceral-afferent fibers over both vagi and splanchnics convey impulses to the cord segments and medulla which modify the systemic blood supply1 drawing blood from the head and surface by constricting their arteries during digestion and filling the abdominal arteries4 ,if opposite impulses should be received drawing blood away from the abdominal arteries1 digestion would be interfered with4 ,any lesion or other condition causing hyperirritability or overstimulation of the vagus will result in overstimulation of the myenteric nerves1 with vasodilatation1 hypersecretion1 contraction of the longitudinal coat1 widening and shortening of the digestive tube1 sluggish peristalsis but rapid movement of food through the sphincters1 incomplete digestion and undernourishment4 ,inhibition of the splanchnic nerves will produce a like result4 ,the opposite condition would come about as a result of inhibition of the impulses over the vagus to the myenteric nerves1 or of overstimulation of the splanchnic nerves4 ,inhibition of the splanchnic nerves may be secured by extreme flexion of the spinal column4 ,this raises the cord in the spinal canal1 lengthens it1 stretches or draws on the nerve roots and vessels1 squeezes the fluid out of the cord1 and inhibits the splanchnics in two ways1 first by a partial anemia or ischemia of the cord1 and secondly by direct traction of the visceral afferent fibers in the posterior and anterior roots4 ,conversely1 stimulation of the splanchnic nerves may be secured by complete extension of the spinal column4 ,this lowers the cord in the spinal canal1 shortens it1 releases the strain on the nerve roots and vessels1 flushes the cord with blood1 and tones up the sympathetic impulses in two ways1 first by increasing their relative and absolute nutrition1 through richer supply of richer blood1 and secondly by releasing the nerve roots from strain1 permitting free entry of afferent impulses over the posterior roots1 and free exit of visceral-efferent impulses over the anterior roots4 ,any lesion1 inasmuch as it limits or alters the normal motion in a joint1 produces an exaggeration or diminution of the normal spinal curves1 and more or less lateral curvature4 ,the altered equilibrium thus produced affects the viscera in three ways3 #a4 ,mechanically1 by pressure1 gravity1 altered position of ribs1 vertebr1 diaphragm1 etc42 #b4 ,reflexly1 influence on nerves to and from affected segment2 #c4 ,directly1 by interference with nutrition of nerve cells by hyperemia or ischemia4 ,there is always a functional kyphosis in visceroptosis or splanchnoptosis4 ,the nerves in the cord are inhibited4 ,the skeletal muscles are hypotonic1 allowing the functional kyphosis to occur1 and the viscero-motor nerves are inhibited1 allowing the abdominal viscera to become hypotonic and sag out of place within the abdominal cavity4 ,the ribs are held up by the cervical fascia1 and the abdominal muscles are held up by the ribs4 ,the hypotonic condition extends to intercostals and abdominal muscles1 with the result that the abdominal muscles are unable to play their part in maintaining the viscera in their proper places4 ,the contraction or tonus of the abdominal muscles1 the external and internal oblique1 transversalis1 rectus abdominis1 diaphragm and levator ani1 maintain the viscera firmly in position4 ,it is only when the muscles of the abdominal wall have lost their tone that any strain or weight is thrown on the peritoneal and vascular supports4 ,the inhibition of the restraining sympathetic impulses via the splanchnic nerves1 allows hypersecretion and hypermotility of the alimentary tubes and further complicates the clinical picture by a colicky diarrhea or spastic constipation4 ,there are eight sphincters of circular unstriped muscle in the alimentary tract4 ,inhibition of sympathetic supply or increased autonomic supply causes sphincter insufficiency1 overstimulation by sympathetic impulses or an insufficient supply of balancing autonomic impulses causes sphincter spasm1 stasis1 vomiting1 fermentation1 putrefaction1 auto-intoxication4 ,at each of these sphincters food is held back and controlled till the proper time has elapsed and the proper chemical environment is prepared for it in the next portion of the tract4 ,normal function of these sphincters is absolutely essential to normal metabolism and nutrition4 ,the upper esophageal sphincter controls the entrance to the esophagus2 the cardia controls the entrance to the stomach1 the pylorus controls the entrance to the duodenum1 the ,x-,ray shows a duodenal sphincter that controls the entrance of food into the jejunum4 ,here the food enters the long tract of the jejunum and ileum which measures twenty-five feet when the longitudinal muscles are relaxed and the circular muscles tonic1 and which a short time later may measure only fifteen feet when the longitudinal muscles are contracted and the circular are relaxed4 ,this section ends at the ileo-cecal valve1 which controls the entrance of food into the cecum4 ,there is the mid-colic sphincter about the junction of the proximal third with the distal two-thirds of the transverse colon1 and the recto-colic sphincter which controls the passage from the sigmoid to the rectum4 ,the rectum ends in the internal sphincter ani4 ,there is some evidence of a ninth sphincter1 the mid-gastric at the point where the peristaltic waves of the stomach begin4 ,absorption takes place mostly from the ileum and jejunum and it is worthy of note that four of these sphincters hold the food up on its way into this part of the tract1 and four of them hold it back on its way out4 ,any lesion may affect one or other of these sphincters4 ,it is believed that antiperistalsis from the mid-colic sphincter to the cecum during digestion is normal permitting more complete absorption of nourishment4 ,yet here1 after absorption is complete1 and at all times elsewhere in the alimentary tract1 peristalsis is normally forward because the point of highest irritability is at the upper esophageal sphincter and the irritability decreases as the tract is further from the esophagus4 ,when the splanchnics are inhibited and the vagus autonomic impulses are normal or increased1 the intestinal sphincters from the pylorus down may all be incompetent1 so that food passes along too rapidly to be properly digested and absorbed4 ,this results in undernourishment4 ,any lesion anywhere in the body will affect peristalsis4 ,it begins at the lower third of the stomach where it joins the pyloric portion and goes forward to the internal sphincter ani1 being modified in its course by local conditions4 ,compensation may be established4 ,many cases of diarrhea and constipation are thus to be accounted for4 ,diarrhea is a symptom due to vasodilatation1 hypersecretion and relaxation of the circular muscles especially at the sphincters4 ,when these three factors are cleared up by correction of the lesions and hyperextension of the spine1 the diarrhea stops unless some other factor is at work to irritate the myenteric nerves or to excite the autonomics or inhibit the splanchnics4 ,lesions from the sixth dorsal down are usually accompanied at first by some diarrhea1 which afterwards becomes constipation1 through loss of tone in the longitudinal muscles especially in the distal part of the colon4 ,in these cases1 correction of lesions1 and extreme flexion of the lower dorsal and lumbar spine will give relief while the body is returning to normal4 ,when gastric digestion begins1 simultaneous action is set up in the ileum4 ,when disease of the cecum1 appendix or ascending colon is present1 there is contraction of the ileo-cecal valve causing stasis of the lower ileum and disturbed or retarded action of stomach and duodenum4 ,these reactions are brought about by impulses to and from the myenteric plexus4 ,the sympathetic and autonomic nerves affect the motor system of the alimentary tract not directly but through the myenteric or ,auerbach's plexus4 ,the external sphincter ani muscle is supplied by the pudendal nerve from the third and fourth sacral segments4 ,it is in a state of tonic contraction1 and having no opposing muscles keeps the anal orifice closed4 ,the autonomic supply to the longitudinal muscles in the descending colon and rectum is from the second and fourth sacral4 ,inhibition here will1 therefore relax the longitudinal muscles and external sphincter and permit free peristalsis in the descending colon and rectum4 ,pelvic disturbances may affect these nerves1 or pressure due to visceroptosis1 etc4 ,the circular muscles of this section are supplied from the lumbar cord4 ,they may be affected in any lumbar lesion1 with the end result of spastic constipation by reason of a shortened markedly distended descending colon1 sigmoid and rectum1 and little peristalsis because of inhibition of the circular fibers1 and contraction of the external sphincter ani4 ,the fundus of the stomach1 lying in the left dome of the diaphragm1 always contains a cushion of air which supports the left dome of the diaphragm1 as the convexity of the liver supports the right4 ,normally the air is regulated and causes no symptoms4 ,a lesion1 usually of the mid-dorsal or lower dorsal segments may inhibit the circular fibers and permit distension1 which becomes enormous when the pylorus is obstructed4 ,the shortness of breath1 palpitation of the heart1 etc41 accompanying this distension are probably due to pressure on the heart and lungs from which the stomach is separated only by the diaphragm4 ,eighth1 ninth and tenth dorsal lesions play a large part in peptic ulcers by permitting hyperemia1 hypersecretion1 and lowered vitality of the mucosa1 and pyloric incompetence or spasm1 because the pylorus1 pyloric end of the stomach and first part of the duodenum get their chief sympathetic supply from the ninth and tenth dorsal segments of the cord4 ,the tenth vertebra is more freely movable than the higher dorsal joints and is therefore more frequently in lesion1 which helps to account for the greater frequency of duodenal ulcer4 ,the main sympathetic supply to the appendix seems to be derived from the eleventh dorsal segment4 ,the appendix has the same motor and secretory mechanism as the rest of the alimentary tract but is richly supplied with lymphoid follicles4 ,one of the twigs from the eleventh dorsal nerve pierces the rectus muscle to supply the skin at ,mc,burney's point1 thus explaining the great frequency of pain and cutaneous hyperalgesia at this situation in appendicitis4 ,lower dorsal and upper lumbar lesions are unquestionably causes of many cases of appendicitis and other obscure diseases traceable to appendicitis4 ,correction of these lesions has restored the appendix and related structures to normality in hundreds of cases4 ,sensory reflexes are shown in hyperalgesia and pain or tenderness in the abdominal skin and muscles and the parietal layer of the peritoneum from the ensiform cartilage to the pubes in an area extending about two inches on each side of the mid-line1 corresponding to the distribution of the twigs of the lower six thoracic nerves which supply sensation to this region4 ,esophageal disturbance at the cardia causes pain in the region supplied with sensation by the fifth and sixth dorsal1 near the ensiform4 ,gastric derangement causes pain midway between the ensiform and umbilicus1 which radiates to the left1 in the area supplied by the eighth dorsal4 ,hepatic disturbance causes pain on the right of the median line1 radiating to the right in the sensory distribution of the ninth dorsal4 ,intestinal pain is located in the sensory distribution of the tenth dorsal nerve in an oval area around the umbilicus4 ,pain due to duodenal ulcer is sharply localized at a point about an inch or two above and to the right of the umbilicus where twigs of the tenth dorsal nerve come to the surface4 ,this point corresponds closely to the normal position of the underlying duodenum1 though the duodenum may be displaced1 and the sensitive spot remain at the same point4 ,the pain from fundal gastric ulcer or carcinoma is usually localized sharply about an inch or two to the right of the median line midway between the ensiform and umbilicus1 at the spot where the twigs from the eighth dorsal nerve pierce the rectus and come to the surface4 ,in the disease of the pylorus1 reflex pain is lower2 of the cardiac end1 higher4 ,the reflex pain at ,mc,burney's point in appendicitis has been referred to1 but it must be borne in mind that pain from disturbance in the colon also shows in the sensory distribution of the eleventh dorsal nerves midway between the umbilicus and pubes4 ,pain may also be referred to areas supplied in the back by the corresponding segments4 ,these reflex pains can usually be stopped by inhibiting along the spine corresponding to the sensory area affected4 ,this reduces the impulses entering the posterior roots and lowers the irritability of the segment4 ,the motor reflexes from gastro-intestinal disturbances result in muscular contractures of spinal1 abdominal and other muscles supplied by motor nerves arising in the anterior horn of the segment which innervates the part of the viscus that is affected4 ,stomach1 liver1 gall-bladder1 pyloric and duodenal disturbances cause increased tone1 contraction1 contracture and rigidity of the rectus muscles above the umbilicus1 for instance1 and the other viscera contract it in lower portions4 ,more important are the extreme contractures of the musculature of the back which is supplied by the segments which supply the affected part of the viscus4 ,these contractures produce some distortion and loss of motion in spinal joints and thereby produce the same effects as primary lesions1 causing widespread disturbance which persists until the spinal musculature is normalized4 ,in colic1 the lumbar segments being involved1 there is marked contraction of the ilio-psoas which causes the characteristic drawing up of the thighs on the abdomen1 while the extreme contraction of the rectus abdominis draws the thorax down4 ,most persistent vomiting may arise reflexly from other organs as in so-called biliousness1 jaundice1 pregnancy1 brain affections1 appendicitis1 onset of acute infectious diseases1 alcoholism1 sea-sickness1 colic1 hernia1 intestinal obstruction1 migraine1 shock1 and anesthesia4 ,irritation of any sensory branch of the vagus or of nerves which connect with it in the medulla1 or reflexly from consciousness via the cerebral cortex1 as in the case of nauseating sights1 smells1 tastes1 as well as irritation from any viscera innervated from the sixth dorsal down1 may overstimulate the corresponding efferent nerves going to parts of the alimentary tract supplied by that segment1 increase its irritability and start antiperistalsis4 ,similarly disturbances in almost any viscus may reflexly disturb the normal balance between sympathetic and vagal autonomic stimuli resulting in hypersalivation1 hyperchlorhydria1 pylorospasm1 distension1 gastric atony1 gastrosulcorrhea1 enterocolitis1 spastic constipation1 achylia1 or colicky diarrhea4 ,in these cases1 the derangement of the viscus reflexly disturbs the alimentary tract through central nerve connections4 ,correction of the primary trouble is followed by removal of the reflex symptoms4 ,in this connection it is important to note that the visceral reflex symptoms may arise from irritation of the alimentary tract by improper diet1 poor cooking1 or wrong combinations4 ,carbohydrates digest quicker than proteins1 and these more rapidly than fats4 ,food is handled by the fundus in the order in which it was swallowed4 ,if the fats are swallowed first1 the starches may be held up for five or six hours1 subjected to the acid stomach secretions and allowed to ferment causing distension1 which reflexly produces a variety of symptoms4 ,mental exertion1 strong emotions1 heavy physical exertion1 interfere with the function of the alimentary tract and set up disturbances in the balance of sympathetic and vagal autonomic impulses1 through the nervous reflexes via the cortex1 and through the demand for blood1 which impoverishes the abdominal circulation at a time when it needs all the blood it can get4 ,the ischemia produced in this way has about the same effect as ischemia produced by a spinal lesion4 ,conversely1 disturbances of the alimentary tract produce profound changes in character and personality1 by reflexes to the cerebral cortex causing dullness of perception1 in all the senses1 poor memory1 sluggish thought1 erratic judgment1 irritable disposition1 fear1 worry1 lack of ambition1 indecision1 lack of energy1 vacillation1 and finally a psychosis in which manic depressive symptoms are balanced by paranoiac symptoms4 ,the alimentary tract is so intimately bound up with the whole stream of vital activity1 whether vegetative1 sensorimotor1 or psychic1 that any disturbance of body or mind is likely to affect it in some part1 and conversely any disturbance of the alimentary tract is bound to affect all the rest of the body and the mind4 ,a satisfactory classification of its diseases is therefore difficult to make1 but the one here adopted is probably the best for the purpose4 ,the early stages of gastro-intestinal diseases are often so similar that it is nearly impossible to differentiate them with certainty2 the classification is therefore based on the clinical picture and pathology of advanced stages4 ,fortunately1 with the exception of cancer1 diseases treated in the early stages usually clear up when the lesions are corrected1 and the necessary attention given to the other causative factors present4 ,acute ,gastritis ,acute dyspepsia is one of the frequent disorders of the stomach4 ,it may occur as an early symptom of an infectious disease1 but very often it is due to some non-specific irritation4 ,the usual exciting causes are errors of diet1 over-indulgence in improperly cooked and highly seasoned food1 or food that has been spoiled1 such as meat1 fish and milk1 or over or under ripe fruit4 ,food that is either too hot or too cold may develop an attack4 ,alcohol is a common cause in those not accustomed to its use4 ,overuse of tobacco may bring on an attack4 ,many acute 8bilious0 attacks are brought about by some mental shock or excitement at the time of taking food1 for it has been shown by the researches of ,pawlow that both gastric motion and secretion are altered by mental irritation during digestion4 ,unquestionably osteopathic lesions of the splanchnics and vagi are important predisposing factors4 ,these lesions produce a lowered resistance of the tissues1 which will frequently explain why certain exciting factors that will initiate an attack in one individual will not do so in another4 ,a healthy mucosa will not be so readily irritated by either indigestible or partly decomposed food4 ,osteopathic experimental work reveals that the vertebral and rib lesions readily affect both the spinal nerves and the sympathetic ganglia1 which is followed by vasomotor and trophic disorder to the mucous and submucous coats of the stomach1 as shown by eccymosis and hemorrhage of the submucosa and beginning parenchymatous degeneration of the free ends of the glands of the mucosa4 ,upon the other hand irritation of the muscles from dietetic errors always causes more or less contraction of the muscles in the upper and middle dorsal1 which1 in turn1 may produce through imbalance of tension and fibrositic changes1 constant interosseous lesions and thus be the cause of the catarrh becoming chronic4 ,this vicious cycle phenomenon should not be overlooked4 ,viscero-motor1 viscerosensory and viscerotrophic reflexes may be factors in the pathogenesis of the osteopathic lesion4 ,pathologically1 the mucous membrane is more or less covered with mucus4 ,upon removal of the mucus the membrane is found red and swollen1 and the epithelial cells of the glands are granular4 ,this is especially noted in the pyloric area4 ,there are minute extravasations of blood and hemorrhages of the mucous coat1 and infiltration of the submucous layer4 ,symptoms4--,acute gastritis occurs at all ages1 so particularly in children care has to be taken that the attack is not the beginning of some infectious disease4 ,a careful inquiry into the history1 and examination of the vomitus will usually make the diagnosis clear4 ,the sudden onset of nausea1 vomiting1 pain in the epigastric region referred to the back and head1 vertigo in some cases1 if the infections can be ruled out should leave no doubt as to the nature of the disorder4 ,other symptoms are weakness1 and chilliness which later if the attack is severe1 is followed by fever4 ,the tongue is coated1 the lips dry1 and there may be herpes4 ,belching of gas1 constipation in some and diarrhea in others1 and dark colored urine are noticeable4 ,there is tenderness on palpation over both the stomach and splanchnic areas4 ,examination of the stomach contents show deficient hydrochloric acid1 the presence of organic acids1 bile and undigested food1 and considerable mucus4 ,diagnosis4--,in young children acute gastric indigestion is common1 though a casual gastritis is rare4 ,in the former prostration1 vomiting1 and undigested1 greenish stools are noted4 ,in some cases there is no fever1 while in others it may range from #ajb to #aje degrees4 ,in all cases care should be taken1 as has been stated1 that the attack is not the beginning of some infectious disease4 ,appendicitis1 acute bowel constriction1 pregnancy1 uremia1 meningitis1 gall-stone colic1 and gastric crises of tabes dorsalis should be differentiated4 ,most attacks of acute dyspepsia are over in twenty-four hours4 ,the prognosis depends upon eliminating the cause4 ,the ,x-ray may be of value in protracted cases4 ,treatment4--,if the case is seen early1 emptying the stomach by induced vomiting or the stomach tube is the first indication4 ,if several hours have elapsed and much of the stomach contents have passed into the intestine1 emptying the colon with an enema will commonly give quick relief4 ,withhold all food for from twelve to twenty-four hours1 or longer if necessary4 ,in some cases the sipping of hot water will be beneficial1 while in others pellets of ice in the mouth will give some relief4 ,whether or not there existed previous spinal lesions there will always be found muscular tension and spinal rigidness during an attack of acute gastritis4 ,these should be corrected for immediate relief1 but what is of greater importance1 if these acute lesions are not corrected the patient's recuperative forces are interfered with and recovery is delayed4 ,then1 also1 these lesions tend to chronicity and predispose to future attacks4 ,treatment should be given daily1 or oftener if special indications arise4 ,though the most common area that demands attention is from the fourth to tenth dorsals1 still the vagi nerves1 especially the right1 should not be neglected4 ,lesions of the upper three cervicals are the most frequent disturbances of the vagi4 ,vomiting is a common and distressing symptom4 ,pathologically1 it is due to an antiperistaltic contraction of the stomach and a spasmodic contraction of the diaphragm and the abdominal muscles4 ,it is caused1 usually1 by irritation of the vagus in the stomach1 or in the pharynx by irritation along the spine 7particularly in the cervical and upper dorsal regions71 or to the sympathetic nerves or to various parts of the body1 or by direct influence of the brain4 ,relief can usually be given by inhibition of the vagus in the occipital region or by inhibition at the fourth or fifth dorsal vertebra on the right side4 ,in a few instances1 placing the patient in the knee-chest position and gently raising the abdominal organs gives relief4 ,if this does not suffice the stomach and colon should be emptied1 providing the vomiting is protracted4 ,a frequently effective measure for nausea and vomiting that can be carried out by the attendant1 is the application of hot fomentations to the dorsal spine4 ,flatulency may be very distressing4 ,the spinal treatment may be sufficient to control this condition1 or careful direct pressure for a few minutes over the pit of the stomach4 ,adjustment of the lower ribs1 especially of the left side1 may be effective4 ,occasionally the gas can be passed into the intestines by careful inhibitory treatment in the region of the eighth and ninth dorsals4 ,the inhibitory treatment causes relaxation of the pyloric orifice2 also1 inhibition of the left vagus relaxes the pylorus4 ,inhibition at the sixth and seventh dorsals relaxes the cardiac orifice1 thus favoring the passing of the gas from the stomach out through the esophagus4 ,in all cases subject to gastritis the dorsal spine should receive considerable attention in order that recovery may be complete4 ,the habits of the patient should be thoroughly regulated and overfatigue guarded against4 ,and1 also of special importance in recurring attacks1 is the fact that a number of cases present some derangement of the biliary tract1 or duodenum1 or the appendix region4 ,diet4--,after twenty-four or forty-eight hours1 if the attack has been severe1 albumin water may be given in small quantities2 also whey1 milk1 bouillon1 and chicken or lamb broth4 ,if there is no return of gastric distress1 add junket1 custard1 cornstarch pudding1 gelatine1 dropped eggs1 scraped beef1 and white meat of chicken2 vegetables purees made with cream or meat stock are usually well borne at this time4 ,foods containing much cellulose1 fats and sweets should be withheld until all symptoms have subsided4 ,chronic ,gastritis ,it is unnecessary here to repeat the causes of acute gastritis1 any one of which continued over a long period of time will cause chronic catarrh of the stomach1 as it is sometimes called4 ,spinal and rib lesions anywhere from the occiput to the coccyx1 but more particularly from the fourth to the tenth dorsal1 will predispose to chronic gastritis1 the particular type and degree of local pathology depending upon the exciting factor4 ,a commonly found en bloc lesion is a flattening of the normal convexity in this region1 with more or less immobilization1 shown by attempting to reestablish the normal convexity through flexion4 ,in addition there may be single spinal or rib lesion in the same area1 or cervical lesions affecting the pneumogastric1 which is the secretory nerve to the stomach4 7,see chapter on the 8,lesion and ,its ,applied ,anatomy407 ,pathology4--,chronic gastritis probably never develops as such without going through several preliminary stages beginning with alimentary hypersecretion1 or hypersecretion occurring only during the active period of digestion4 ,these are the cases usually classified as hyperchlorhydria4 ,at this time no actual pathology can be demonstrated in the glandularis4 ,if the condition is not treated intelligently at this time the next step will be periodic attacks of what is known as 8hypersecretion periodica chronica0 followed by 8hypersecretion continua chronica40 ,the stomach contains abnormal amounts of gastric juice even after a night's rest4 ,at this stage there is a transition from the functional to the organic condition4 ,all stages are characterized by an abundant secretion of mucus4 ,if allowed to go on there will finally result a destruction of the secreting cells known as ,atrophic ,gastritis or ,achylia ,gastrica in which the stomach presents a smooth functionless appearance4 ,secondary ,chronic ,gastritis4--,portal obstruction from any cause predisposes to chronic gastritis4 ,the most common of these is failing compensation in heart lesions1 which through back pressure causes portal stasis2 the same thing may follow obstruction in the liver itself4 ,chronic gastritis is also a late accompaniment of the nephritic trinity1 kidneys1 heart and arteries4 ,it may also be associated with diabetes1 gout1 anemia and other constitutional disorders4 ,tuberculosis is commonly ushered in by symptoms of chronic gastritis4 ,we should be constantly on the alert to avoid the mistake so commonly made of treating the stomach as an entity and overlooking the real trouble in some other part of the anatomy4 ,it is probably safe to say that there are only two primary diseases of the stomach1 ulcer and cancer4 ,all others are suspiciously associated with diseased processes elsewhere1 and when the spinal lesion is given its full significance even these will be found to be directly traceable to anatomical perversions somewhere within the mechanism of local nutrition4 ,symptoms4--,these are governed by the stage of progress in which the patient is seen4 ,during the stage of hypersecretion of acid gastric juice there will be vague feelings of distress1 fullness and burning in the stomach1 and 8heartburn0 during digestion4 ,when the stomach is empty all symptoms will subside4 ,later there will be periods of a few days or weeks when there will be more or less continuous distress with some vomiting of highly acid gastric juice containing mucus4 ,when the condition has progressed to the stage of continuous hypersecretion there will be continuous symptoms as above1 but with nausea1 vomiting becoming more frequent especially late at night or in the morning1 always accompanied by sticky mucus4 ,appetite is variable1 there is often a disagreeable taste in the mouth 7the 8dark brown0 taste of the chronic alcoholic74 ,heart palpitation and vertigo and other vagus symptoms are common4 ,diagnosis4--,on physical examination the stomach is found distended1 and in some cases displaced 7gastroptosis74 ,there will be diffused tenderness on pressure over the whole organ which should help to distinguish it from gastric ulcer or cancer in which the tenderness is quite localized4 ,chronic gastritis cannot be positively diagnosed without making a gastric analysis4 ,many cases are wrongly diagnosed through neglect of this very important procedure4 ,the cases in which gastric analysis should be made are so well stated by ,lockwood that we will take the liberty of quoting them in their entirety4 87#a7 ,gastric analysis should always be made in every case of dyspepsia1 no matter whether these symptoms be apparently gastric or intestinal1 unless passage of the tube is contraindicated4 87#b7 ,gastric analysis should be made in every case of chronic diarrhea that is not due to evident disease of the colon or rectum4 87#c7 ,gastric analysis should always be made in all cases of intestinal toxemia1 or recurring headache of toxic origin1 and in patients who complain of the symptom complex which is spoken of by the laity as #8biliousness'4 87#d7 ,gastric analysis should be made in all cases of anemia and general physical wretchedness without known cause and which are rebellious to treatment40 ,the finding of excessive gastric mucus intimately mixed with food remnants is the chief differential point in the diagnosis of chronic gastritis4 ,differential ,diagnosis4--,a complete statement of differential diagnosis by ,kemp cannot be well improved upon4 8,,chronic ,,gastritis4--,no severe pain1 no circumscribed spot1 painful to pressure2 no hematemesis2 no cachexia2 no marked emaciation1 except in severe cases of long duration2 free hydrochloric diminished or absent2 gastric mucus present2 slow course4 8,,ulcer ,,of ,,the ,,stomach4--,hyperchlohydria present1 but not invariably so2 severe pain in the epigastrium with intervals free from pain when stomach is empty2 local tenderness which is circumscribed2 dorsal pain2 hematemesis1 or occult blood in the stool or gastric contents2 microscopic pus2 no mucus2 patient has appearance of suffering2 no true cachexia4 8,,cancer ,,of ,,the ,,stomach4--,age usually over forty-five2 rapid course2 free hydrochloric acid usually markedly diminished or absent2 lactic acid present2 pain generally continuous1 but not so acute as in ulcer2 ,boas-,oppler bacillus2 cachexia2 tumor on physical examination2 small amount of visible or occult blood2 hematemesis much less than ulcer2 foul odor to vomitus at times present4 8,,achylia ,,gastrica4--,slow course2 scarcely any gastric juice2 acidity very low or entirely absent2 absence of pepsin and rennin2 usually no mucus or lactic acid4 8,these differential considerations apply to typic cases1 and the observer must be on the qui vive for various gradations and modifications of these clinical pictures40 ,prognosis4--,the outcome of chronic gastritis depends upon our ability to locate and remove every factor in the etiology1 the willingness of the patient to cooperate and the patience and resourcefulness of the physician4 ,at best the progress is slow and one must expect temporary setbacks usually due to failure of the patient to carry out instructions4 ,treatment4--,the most successful treatment is prophylactic1 but until the public has been educated up to this form of economy we must begin with conditions as we find them4 ,first get the patient's confidence by making an intelligent examination1 a scientific diagnosis1 and a reliable prognosis based upon your findings4 ,all lesions1 bony1 ligamentous1 muscular and psychic must be intelligently and carefully removed4 ,specific lesions which would directly or reflexly interfere with the nerve and blood to the stomach must be corrected4 ,the rigidness commonly found in the vertebr and ribs of the splanchnic area must be overcome first by specific adjustment1 and the normal flexibility maintained by teaching the patient proper exercises for the purpose4 ,this should include deep breathing with the spine flexed to the limit1 and the ribs fixed1 by the patient reaching around as far as possible and grasping the ribs as described by ,dr4 ,harry ,forbes4 ,this will tend to overcome the flat dorsal so characteristic in all gastro-intestinal conditions4 ,direct manipulation over the stomach has no particular value and may be even harmful4 ,inasmuch as nausea and vomiting and excessive gas formation are only the result of hypersecretion we cannot expect to give more than temporary relief except by methods which remove causes4 ,much comfort may be given by inhibition in the splanchnic area4 ,in severe cases it may be necessary at times to wash out the fermenting1 irritating mass by gastric lavage4 ,outdoor life1 frequent vacations and change of occupation are often of decided benefit4 ,diet4--,indiscretions of diet must be avoided and this cannot be too positively impressed upon the patient4 ,it is always best to make a list of foods to be taken for breakfast1 lunch and dinner and insist that no other foods be taken without further instruction4 ,just what these foods shall be depends upon the gastric secretions as shown by gastric analysis4 ,they should always be nutritious and given in quantities sufficient to maintain nutrition4 ,the stomach should have rest and yet is expected to do its part in the process of digestion4 ,all foods must be given in a finely divided form and well masticated to spare the stomach the mechanical effort of grinding4 ,in hyperacid gastritis all foods of an irritating nature must be positively prohibited4 ,the classical breakfast of grapefruit1 oatmeal1 ham and eggs and coffee will not do4 ,starchy foods must be reduced owing to their tendency to ferment in the presence of highly acid juice and the delay in the stomach due to the high acidity4 ,in subacid gastritis advantage must be taken of the fact that carbohydrates digest well and proteins do not4 ,diet for ,hyperacid ,gastritis4--,before breakfast3 ,wash the stomach with warm water and an ounce of ,phillips ,milk of ,magnesia1 allowing the water to remain in the stomach #bj minutes or a half hour1 lying down and turning from side to side on the face in order that the water and magnesia may be brought in contact with all parts of the stomach4 ,for breakfast3 ,prunes1 allowed to simmer for four hours1 without boiling1 and put through a colander1 to remove the skins4 ,soft cereals1 such as farina1 cream of wheat1 or wheatlet1 thoroughly cooked1 and served with middle heavy cream1 no sugar4 ,two eggs1 soft boiled1 or poached4 ,zweiback1 thoroughly masticated1 with a liberal quantity of butter4 ,cocoa 7,phillips74 ,luncheon3 ,puree of peas1 beans or lentils1 made with cream4 ,asparagus1 green peas1 boiled rice1 spinach chopped very fine1 creamed carrots1 boiled onions1 baked potato1 well done4 ,chicken1 boiled lamb or beef1 ground2 oysters in any form but fried2 fresh fish4 ,desserts3 ,choice of junket1 cornstarch1 custard1 rice pudding1 floating island1 gelatine or tapioca4 ,evening meal3 ,same as luncheon except substituting eggs for meat4 ,cup of hot water before luncheon and dinner4 ,if patient requires quick building up give milk between meals and at bed-time4 ,gastric ,neuroses ,gastric neuroses include motor1 sensory and secretory derangements4 ,though the sensory disturbance is often the most marked1 still motor and secretory symptoms are usually present4 ,in other words there is commonly a complex of the different forms4 ,where gastric neuroses can be positively diagnosed1 by a process of elimination1 there is no more plausible explanation than that of the spinal lesion4 ,the success of osteopathic physicians in treating so-called 8stomach trouble0 proves conclusively the superiority of the osteopathic method4 ,a note of warning should be sounded1 however1 for as diagnostic methods have become more exact it is found that many cases which were formerly diagnosed as neuroses prove to be referred from some organic change1 such as infected gall bladder1 appendix1 tube or ovary1 tonsil1 tooth or sinus4 ,it has been proven that many cases of sensory and secretory disturbances have entirely cleared up when these causes have been removed4 ,though infection may play an important role1 still in some instances1 especially gall bladder1 duodenum and appendix1 the gastric neurosis may be simply due to a nervous reflex4 ,gastroptosis1 atony1 and in many cases splanchnoptosis1 has been found to be the underlying cause of many hitherto unaccountable gastro-intestinal symptoms4 ,gastric crisis of locomotor ataxia if not properly diagnosed by the finding of the other well known symptoms may give us much trouble and discouragement4 ,ulcer and cancer have quite characteristic symptoms1 yet it is well known that they are often treated as neuroses in the early stages1 much to the detriment of the patient1 especially if the case proves to be cancer4 ,in the sensory disturbances1 which are probably the most common1 hyperesthesia and neuralgia are the special features4 ,in the former a feeling of weight1 fullness and burning are complained of1 which are frequently manifestations of a neurotic temperament4 ,in fact1 hysteria and neurasthenia are very often basic conditions4 ,the same is true in gastrodynia1 where the pain starts in the pit of the stomach and extends around the lower chest and ribs4 ,there may be other neurotic symptoms such as excessive hunger and a constant desire for food4 ,menstrual irregularities1 the menopause1 worry1 constipation1 and anemia are important factors4 ,special care should be taken that there is no organic disorder of the gastro-intestinal tract or of the nervous system4 ,the motor neuroses comprise a variety of derangements4 ,excitation of the motor functions of the stomach1 as a direct result of irritated nerves or of reflex stimuli1 are not uncommon4 ,owing to this the food may not remain in the stomach long enough or the stomach activity may be too pronounced4 ,there may be also more or less rapid vomiting of the food1 without any particular strain4 ,other motor neuroses may be spasms of either the cardiac or pyloric sphincters1 and in a few instances there may be atony of the stomach walls4 ,although these conditions may be of a neurotic character1 still great care should be taken that some organic disease is not basic4 ,the secretory derangements consist of hyperacidity1 supersecretion1 and lessened amount of acid secretion or achylia gastrica4 ,many of these cases are associated with hysteria and neurasthenia1 though in achylia gastrica1 cancer may be the cause4 ,hyperacidity may be associated with ulcer4 ,pelvic diseases1 nervous reflexes from the gastro-intestinal tract1 constipation1 and anemia are to be considered as possible etiological factors4 ,diagnosis4--,these cases require the most painstaking inquiry into the history1 the most complete physical examination1 and all findings carefully checked up by laboratory tests4 ,inquiry will often show that all symptoms subside when on a vacation with a change of scene and climate4 ,lockwood gives the following rules for arriving at a diagnosis of 8nervous indigestion40 87#a7 ,a diagnosis of nervous indigestion should not be made in the presence of more than #cj c4 c4 of fluid in the fasting stomach1 the fluid giving a strong reaction for hydrochloric acid4 ,hypersecretion is generally an expression of pyloric stenosis1 organic or spasmodic1 and this is due to an organic cause4 87#b7 ,a diagnosis of nervous indigestion should not be made in the presence of persistent hyperacidity accompanied by epigastric pain4 ,nervous hyperchlorhydria may occur1 but is not accompanied by either pyrosis or pain4 ,the association of either of these latter symptoms should suggest an organic origin for the complaint4 87#c7 ,achylia gastrica may be of nervous origin1 but this is not probable when serious motor error is in evidence4 ,achylia with food-stagnation is strongly suggestive of cancer of the stomach4 87#d7 ,achylia gastrica1 accompanied by pain or vomiting1 indicates an underlying organic cause4 87#e7 ,the diagnosis of nervous indigestion should not be made when recognizable food remains are repeatedly found in the fasting stomach4 ,under the influence of fear1 nervous shock1 or vicissitudes of temperament the motor functions may be temporarily interfered with1 but this would not be the case permanently4 87#f7 ,the diagnosis of nervous indigestion should not be made when epigastric distress or pain occurs regularly at a definite time after eating4 ,the very fact of this disturbance coming on at a definite time argues against a neurosis4 87#g7 ,the diagnosis of nervous indigestion should not be made when one symptom alone persists1 without other evidences of nervous instability4 ,the presence of one definite symptom in itself presupposes an organic cause4 87#h7 ,the physician should be on the qui vive for drug addictions1 for these habitues can sometimes present a syndrome of symptoms that will puzzle the most experienced4 87#i7 ,the diagnosis of nervous indigestion should not be made in persons over forty or forty-five1 in whom indigestion is a new symptom4 ,such patients are usually developing a serious systemic or malignant disorder4 87#aj7 ,finally1 digestive nervous neuroses and organic disease may be concomitant1 and the presence of either need not exclude the other40 ,treatment4--,first get the patient's confidence by making a most complete examination4 ,this desirable beginning is usually hastened by the osteopathic physician1 when after a few treatments symptoms are greatly relieved4 ,correct all lesions wherever found1 particularly those anatomically connected with the stomach4 ,when the symptoms are sensory relief can always be given by inhibition over the splanchnic area4 ,occasionally the ensiform process and the lower costal cartilages are lesioned4 ,diet4--,when hyperchlorhydria is the chief symptom foods must be selected which bind acidity or those which lessen its secretion1 such as milk1 eggs1 cream cheese1 fats such as butter1 cream1 olive oil1 boiled or broiled fresh fish1 boiled beef or lamb run through a grinder1 oysters in any form but fried1 white meat of chicken1 vegetable puree made with cream or milk 7no meat stock71 gelatine1 custard1 junket or sponge cake4 ,many neurotic patients are under-nourished through fear of food4 ,they must be positively assured that if the food is well chosen and carefully masticated there need be no fear of discomfort4 ,care should be taken that the patient is not constipated4 ,some cases can only be reached by a 8rest cure0 of four to six weeks1 which together with the treatment outlined above will prove most satisfactory4 ,in all cases guard against worry and overfatigue4 ,build up the general health as rapidly as possible4 ,outdoor life1 sufficient sleep1 frequent vacations1 and change of scene are specially beneficial4 ,gastric and ,duodenal ,ulcer ,statistics show that peptic ulcer is far more prevalent than is supposed by the casual observer4 8,in the combined statistics of #ei1dej autopsies of various series evidence of healed or unhealed ulcer were observed in #d4d per cent40 7,bassler47 ,the reason for this is that peptic ulcer may present very definite symptoms which are readily interpreted or they may be so atypical as to make definite diagnosis impossible4 ,like all gastro-intestinal diseases1 many of the symptoms are easily confused with so-called indigestion or 8stomach trouble40 ,etiology4--,one characteristic of gastric and duodenal ulcer is that it only occurs where the mucous membrane is subject to the influence of hydrochloric acid and pepsin2 lower end of esophagus1 stomach and first part of duodenum4 ,similar ulcers are often found in the sigmoid and rectum where the feces often become acid due to bacterial action1 or on account of slow movement1 hydrochloric acid and pepsin which may have escaped neutralization in the duodenum may attack the mucosa4 ,for the part played by spinal and rib lesions on the glandular layer of the stomach1 the reader is referred to a previous discussion of the lesion4 ,probable secondary causes of gastric ulcer are3 7#a7 ,embolism of an artery 7gastric arteries are terminal74 ,these emboli are supposed to be caused by toxic and infectious agencies which enter the circulation1 as sometimes occurs in pyemia and large burns of the skin4 7#b7 ,while hydrochloric acid associated with pepsin seems to be an important factor1 it is doubtful whether it can attack the mucosa without there being a previous abrasion or other injury4 ,it is said that a normal secretion of mucus is nature's protection against self digestion4 ,the swallowing of substances of a coarse or irritating nature or those chemically corrosive or at extremely high temperature may so injure the mucous membrane as to permit an attack by ,h,cl and pepsin4 ,certain occupations seem to predispose to gastric ulcer1 such as cobblers1 or others who in their work press various objects against the stomach4 ,sharp blows over the stomach have been followed by acute ulcer4 ,a frequently associated condition is gastroptosis1 which seems to be explained on the basis of narrowing of the blood vessels and their more ready occlusion4 ,probably sagging of the duodenum is an important predisposing factor4 ,anemia and chlorosis should not be overlooked as predisposing causes4 ,and tuberculosis and syphilis are possible associated disorders4 ,of all the theories advanced1 the lowering of vitality1 due to lesions of the splanchnics and vagus nerves remains the most logical4 ,symptoms4--,the most characteristic symptom is pain1 which in a typical case comes on at a regular time after taking food4 ,it may be a half hour1 an hour or two hours1 and in the case of duodenal ulcer may be as late as four hours4 ,the distance beyond the cardia at which the ulcer is located seems to govern the time2 also the time at which the secretion of hydrochloric acid reaches its height1 which varies in different individuals4 ,the pain is due to free acidity 7that which is not combined with the food7 irritating the raw surface of the ulcer4 ,pain is often increased or lessened by posture4 ,if turning on the left side gives relief the ulcer is probably at the pylorus2 if worse when standing than reclining the ulcer is probably on the greater curvature4 ,the pain is usually localized by the patient1 and pressure at the given spot increases the pain4 ,in many cases there is referred pain in the region of the #ith1 #ajth and #aath ribs on the left side4 ,at the height of pain vomiting may occur1 due probably to pylorospasm resulting from high acidity4 ,vomiting always gives relief4 ,the taking of protein food or alkali will usually relieve the pain of ulcer1 7hunger pain74 ,ulcer patients are usually well nourished owing to the habit of relieving themselves by eating1 or they may be thin due to their fear of food4 ,in acute ulcer frank blood may show in the vomit1 and may be the first indication of trouble1 whereas in the chronic type it may be occult1 or occult blood may be found in the feces4 ,the hemorrhage of ulcer1 unlike that of cancer1 is not constant4 ,diagnosis4--,diagnosis of duodenal ulcer1 as distinguished from gastric1 is made by finding the tender spot to the right and below the pylorus1 the pain coming on three or four hours after taking food1 and the finding of blood in the feces 7tarry stool7 and not in the stomach contents4 ,repeated examinations may be necessary owing to the fact that hemorrhage is not constant4 ,the large percentage of stomach ulcers are near the pylorus1 and of the duodenal ulcers the ascending portion is the area almost invariably involved4 ,ulcer is differentiated from functional disorders by a history of real pain as distinguished from the vague disturbances of sensation often called pain by neurotic patients4 ,also its regular appearance in relation to food4 ,the pain of 8gastralgia0 has no regular habit and is not influenced by food4 ,referred pain from cholecystitis1 chronic appendicitis1 etc4 has no relation to food and is not relieved by food or alkalies4 ,ulcer is to be distinguished from cancer by the age of the patient 7in cancer usually over #dj7 with a previously good gastric history1 except in cases where cancer has been grafted on to a chronic ulcer4 ,in these cases a careful inquiry will bring out a characteristic ulcer history up to a certain time1 when all symptoms change2 pain becomes constant2 is not relieved by food or alkali2 vomit becomes dark in color and has a characteristic odor1 appetite fails1 and signs of cachexia set in4 ,gastric ulcer should be suspected in all cases of persistent gastric symptoms which are not readily relieved by treatment and regulation of diet1 and in which there is found high acidity and continuous hypersecretion not accompanied by mucus4 ,the ,x-ray and gastric analysis should never be neglected in suspected cases1 keeping in mind the possible injury from the tube in case of recent hemorrhage4 ,treatment4--,osteopathic treatment of gastric ulcer will be almost uniformly successful if we will analyze all of the factors entering into the problem4 ,it is obvious that in order to heal the ulcer we must remove all factors which interfere in any way with nutrition4 ,then give the stomach as near absolute rest as possible while at the same time building up the nutrition by a generous but well chosen diet4 ,when acute hemorrhage has recently occurred1 complete rest in bed with a trained nurse in attendance is the first indication4 ,complete rest of the stomach1 all nourishment being given by nutrient enema4 ,an ice bag is to be placed over the stomach1 and removed every three or four hours to allow surface circulation to react4 ,warm applications should not be used while there is any marked bleeding4 ,during this period no effort on the part of the patient should be permitted1 and no manipulative treatment which would tend to increase blood pressure should be given4 ,after all evidence of hemorrhage has ceased for ten days1 or at once in case of chronic ulcer1 we may carefully correct all spinal or rib lesions in the splanchnic area especially the #fth dorsal1 or cervical lesions affecting the pneumogastric4 ,pain and pylorospasm may be relieved by steady pressure at the #dth and #eth dorsal on the right side4 ,after spinal lesions have been corrected without unduly irritating the stomach1 careful relaxing treatment should be given with the patient on the back1 keeping in mind that all exertion will tend to irritate the ulcer4 ,if special care is observed1 frequently definite relief may be given by placing patient in knee-chest position and gently raising the lower portion of duodenum where it lies alongside of ascending #crd and colon1 #dth lumbar4 ,during this period a hot water bag or a thermal pad should be kept over the stomach night and day4 ,in certain cases of perforation in a few obstinate conditions1 and in a few where mechanical obstruction is marked1 surgery may be indicated4 ,the following diet will be found best during the first week3 #g ,a4 ,m4 ,a half glass of cooked milk1 with the leathery substance which rises on the top removed1 and the yolk of one egg stirred into it and sweetened1 if desired2 taken luke warm or cool1 but never ice cold4 ,this amount to be increased on the second day to three-fourths of a glass1 and on the third to a full glass1 which is to be continued for a week4 ,if the milk produces diarrhea1 add two tablespoonfuls of lime water to each portion4 #i ,a4 ,m4 ,a saucerful of gelatine 7,knox's or ,crystal ,rock7 with #b tablespoonfuls of cream and a teaspoonful of sugar4 #ab ,m4 ,a half to full glass of milk prepared as above4 #c ,p4 ,m4 ,a saucerful of gelatine1 with cream 7medium7 and sugar as at #i ,a4 ,m4 #f ,p4 ,m4 ,a half to whole glass of milk1 as before1 with one egg stirred in and sweetened4 ,the egg yolks at #g ,a4 ,m4 and #f ,p4 ,m4 are to be increased until six are taken daily at the end of the week4 #h ,p4 ,m4 ,a half to a full glass of milk4 ,the whites of the eggs are to be stirred up in the water in the proportion of a white to a glass of water1 #d teaspoonfuls of sugar to be added to every glass1 this to be taken by the patient only when thirsty4 ,if the bowels do not move1 no laxative can be taken1 but an injection of warm water or a little soap may be employed4 ,if much discomfort is produced by the food1 a hot compress must be laid over the stomach or above the navel4 ,during the second week the diet should remain much the same except for the addition of one or two pieces of ,zweiback three times a day4 ,during the third week1 if pain and blood in the feces are lessening1 we may add soft1 well cooked cereal like cream of wheat1 cocoa1 puree of split pea made with cream4 ,fifth week add minced chicken1 coddled egg1 boiled beef or lamb put through a meat grinder1 soft vegetables such as chopped spinach1 squash and mashed or baked potatoes with liberal quantities of butter4 ,during and after the sixth week we may add all vegetables which can be served in puree form1 fresh fish1 oysters1 apple sauce1 inside of a baked apple1 prune whip1 custard junket1 corn starch pudding4 ,at this time also if all goes well the patient may sit up in bed and gradually move about1 being careful to avoid all sudden movements which would put a strain on the epigastric region4 ,if necessary we may also increase our manipulative treatment at this time4 ,the patient must be warned against the use of any article of diet which will be chemically or mechanically irritating to the stomach1 for a period of months1 and an examination of feces should be made from time to time to make sure of no return of hemorrhage4 ,dilatation of the ,stomach ,a dilated stomach is a stretched stomach having increased capacity1 due to nervo-muscular atony or to pyloric obstruction4 ,every stomach which is not retracted when empty is a dilated stomach4 ,a dilated stomach may occur either as an acute or as a chronic condition1 but it is to be distinguished from temporary distention and a normally large stomach4 ,osteopathic ,etiology and ,pathology4--,the nervo-muscular atony causing dilatation may be due to obstructive lesions in the stomach splanchnics1 or to a general debility of the spine in the dorsal region 7usually a kyphosis71 or to continued overeating and improper food causing a stasis and fermentation4 ,it may also be due to overdrinking and various diseases1 as phthisis1 liver and lung diseases1 anemia1 chlorosis1 acute fevers and kidney diseases1 causing more or less of a general nervo-muscular atony4 ,dilatation may result from a mechanical obstruction1 or narrowing of the pylorus or the duodenum1 by a cicatricial contraction of an ulcer2 by hypertrophic thickening due to various diseases1 by adhesions and tumors4 ,occasionally the pyloric obstruction is congenital4 ,a floating kidney may fall upon the horizontal portion of the duodenum and thus mechanically obstruct the passage of food from the stomach1 which consequently dilates4 ,tight lacing might prevent the liver1 when congested1 from passing in front of the kidney1 thus luxating the kidney4 ,dilatation of the stomach occurs at all ages1 although most frequently in middle aged persons4 ,pathologically1 the muscular coat is thinner and paler than normal1 with more or less atrophy of the glandular tissues and an increase in capacity of the stomach4 ,when obstruction exists at the pylorus1 hypertrophy of the muscular coat may occur4 ,symptoms4--,the symptoms are those of the disease causing the dilatation plus those of persistent chronic catarrh4 ,the patient complains of a sense of fullness in the epigastric region and there is flatulency1 eructations and vomiting4 ,the cavity of the stomach being much enlarged1 great quantities which are usually considerably decomposed are vomited each day or two4 ,there is often lessened acidity of the vomited mass1 though in some cases it is increased4 ,passage of the food from the stomach to the intestine is delayed and the bowels are constipated1 the fecal matter being dry and hard4 ,the urine may be scanty and the skin dry4 ,anemia1 debility and emaciation are always present to a greater or less extent1 and on account of the absorption of poisonous matter drowsiness may occur4 ,physical ,signs4--,inspection4--,in some cases the outline of the distended stomach can be plainly seen4 ,there is prominence of the epigastric region1 the tumefaction being at the pyloric end of the stomach4 ,palpation4--,the resistance upon manipulation of a dilated stomach is like that of an air cushion4 ,if the patient is made to drink a half tumbler of water1 bimanual palpation will cause a splashing sound to be heard along the circumference of the stomach at its lowest point2 and by moving the water about by changing the position of the patient1 the outline of the stomach can be made4 ,if the sound is not heard at the first manipulation1 it must not be concluded that the stomach is normal for the stomach may be so dilated and flabby that it falls behind the abdominal wall like an apron4 ,percussion4--,the note is tympanitic over the greater part of the stomach until the lower curvature is reached when the sound is dull 7due to the liquid contents of the stomach71 followed by a tympanic sound again when the intestines are reached4 ,when percussion is made the patient should always be in a standing position if possible4 ,when there is pyloric obstruction a tumor usually presents itself1 and vomiting is more severe and peristalsis more active than when the dilatation is due to atony of the walls of the stomach from an obstructed innervation4 ,diagnosis4--,this is usually easy if due care is taken in making the examination4 ,goetz has shown by the use of his spinegraphometer that in cases of visceral prolapse the spine is commonly posterior in the dorso-lumbar region4 ,the ,x-ray is of value in determining the size and function of the organ4 ,prognosis4--,in a case of nervo-muscular atony the prognosis is favorable4 ,if due to a malignant disease recovery is usually impossible4 ,in hypertrophy of the pylorus or the duodenum1 recovery is probable by means of surgical interference4 ,treatment4--,when the dilatation is due to atony of the muscular walls of the stomach from obstructed innervation at the spinal column1 treatment is usually successful4 ,attention should be given to the condition of the spinal column in the splanchnic region 7fourth dorsal to twelfth dorsal71 the spine being usually posterior4 ,a thorough and persistent course of treatment must be given1 not only to restore the normal activity of the nerves to the muscular coat and glands of the stomach1 but to build up and restore strength in the weakened spinal column4 ,lesions in the spinal column1 even higher than the fourth dorsal1 may affect the innervation of the stomach4 ,there are cases where lesions have been found at the fifth1 sixth and seventh cervicals that interfere considerably with the action of the stomach1 causing nausea1 flatulency1 eructations1 and even vomiting4 ,such an affection may be through the fibers of the splanchnic nerves or through fibers of the vagi nerves4 ,the vagi nerves have an important bearing upon gastric dilatation as paralysis of the gastric branches of the vagi arrests the peristalsis of the stomach and thus tends to favor retention of food within its cavity4 ,the stomach in such cases becomes enlarged1 mainly by the weight of the food and the presence of gases due to decomposition of the retained food4 ,thus lesions may be found higher than the lower cervicals and cause obstruction and paralysis of the fibers of the vagi to the stomach4 ,direct stimulation over the stomach in the form of thorough manipulation of the stomach walls causes contraction of the muscular fibers of the stomach1 mainly the circular fibers4 ,this treatment1 with additional treatment of the splanchnic and the vagi nerves1 will tend to build up the weakened plexuses of the stomach4 ,much time can be saved by putting the patient to bed and treating him every day for several weeks4 ,when the stomach is dilated or dilated and prolapsed1 to any extent1 it usually requires three to five months treatment at least2 this time can be shortened one-half by keeping the patient in bed1 treating the spine three times a week1 and the abdomen every day4 ,light food at frequent intervals1 upper thoracic breathing1 and frequent drawing up and in of the abdomen should be required4 ,the patient may also manipulate his own abdomen twice a day to advantage2 teach him to manipulate1 draw and pull it upward4 ,there is no danger of too frequent treatment as long as there is no bruising of the parts2 this1 however1 does not apply to the spine4 ,it is not an uncommon thing to correct a dilated stomach or a dilated and prolapsed stomach that is an inch and a half or two inches below the umbilicus4 ,care must be taken in all cases that other viscera are not prolapsed4 ,it is a common experience to find enteroptosis1 which can usually be readily functionally corrected1 with the stomach ptosis4 ,but where the kidney1 or possibly both1 is much prolapsed only fair results can be secured until the kidney is replaced and kept there1 and if necessary by surgical means4 ,also1 note whether the liver is enlarged4 7,see special article on ,prolapsed ,organs74 ,when the disease is due to cancer and various growths of the pylorus or the duodenum1 nothing can be done but palliate4 ,such cases require surgical attention4 ,in all cases it is necessary that care and preoccupation of the patient should be removed4 ,baths1 changes of air1 a carefully regulated diet and caution in the use of liquids will be of great aid to the general health of the patient1 and thus the weakened nervous system will be indirectly but greatly benefited4 ,too great care cannot be taken of the patient1 as there is created in the organism a special aptitude for the tissues to become inflamed and thus weaknesses at various parts of the body may occur4 ,phthisis1 typhoid fever and various diseases are apt to follow dilatation of the stomach1 as the nutritive and resistive process of the body are impaired4 ,the meals should be taken regularly and with great care1 the patient not eating too quickly nor too much4 ,solids should be used but little2 the artificially digested foods1 such as peptonized milk and beef peptonoids1 probably being the best4 ,beef juice and scraped beef are excellent foods1 as they are easily digested4 ,fatty and starchy foods should be avoided4 ,washing out the stomach is useful1 but it should not be indiscriminately employed4 ,lavage will not be necessary in all cases of mechanical obstruction4 ,it relieves the distention1 by removing the weight and the fermenting and decomposing material4 ,in acute dilatation1 which may be due to prolonged diseases1 general anesthesia1 injuries of the spine1 and to narrowing of the duodenum1 vomiting1 pain and collapse occur4 ,empty the stomach1 and place patient in knee-chest position4 ,reach beneath the duodenum and raise this part of bowel4 ,start well down1 as low as third or fourth lumbar4 ,if this does not give quick relief stand patient on his head4 ,gastroptosis and ,enteroptosis#gd 7,,glenard',s ,,disease7 ,definition4--,a displacement of the stomach and intestines4 ,osteopathic ,etiology and ,pathology4--,a weakened1 debilitated spine is the common cause4 ,a slight posterior curvature is a frequent occurrence4 ,a debilitated spine impairs the innervation to the abdominal viscera and to the muscles of the abdomen4 ,many cases are of congenital origin due to lack of complete development and weakness of the supporting tissues4 ,other causes are muscular strain1 repeated pregnancies1 tight lacing and malnutrition4 ,a downward displacement of the floating ribs1 and a consequent prolapse of1 and atony of the diaphragm1 is an important cause4 ,prolapses of the stomach and intestines are of frequent occurrence in both sexes1 and very common in women4 ,it is a condition oftentimes overlooked1 and when recognized1 little has been done in the way of a cure4 ,it is the cause of much disturbance1 not only to the stomach and intestines1 but to the various abdominal viscera and to the pelvic organs1 and it is the cause of a large percentage of prolapses of the uterus1 7excluding lacerations from childbirth7 for not only is the great suspensory ligament of the uterus 7the peritoneum7 prolapsed as a consequence1 but all of the abdominal viscera and the parietes of the abdomen are also prolapsed and crowded down into the pelvis4 ,the small or large intestine or the stomach may be prolapsed singly4 ,this is frequently the case with the transverse portion of the colon1 which may be elongated and tortuous and prolapsed nearly to the symphysis pubis4 ,prolapse of the liver1 spleen and kidneys may occur singly or with a general displacement of all the organs4 ,symptoms4--,the abdominal walls are weak1 oftentimes flabby4 ,the viscera of the abdomen do not have normal resistance upon manipulation4 ,the spinal column presents lesions4 ,there is dyspepsia1 flatulency1 constipation1 abdominal pains and various neurasthenic symptoms4 ,diagnosis4--,is readily made by the lack of tone to the abdominal walls and viscera and the general debility of the patient4 ,inflation of the stomach with air will determine between gastroptosis and dilatation4 ,the ,x-ray is of special value in determining position1 function1 spasms1 kinks1 etc4 of the digestive tube4 ,there are innumerable gradations and phases of this condition4 ,treatment4--,to remove the cause is of primary importance4 ,this is to be followed by treatment of the spinal column1 correcting its various derangements and improving the innervation to the atonied viscera and abdominal parietes4 ,direct treatment over the abdomen helps to give tone to both the viscera and abdominal muscles4 ,in many cases the treatment will have to be a prolonged one in order that the tissues may regain their normal condition4 ,usually a treatment from two months to a year1 or possibly more1 is required4 ,exercises and manipulations that tone the tissues1 correct the posture1 and raise the chest1 diaphragm1 abdominal and pelvic viscera1 and release spasms1 kinks1 and adhesions1 are indicated4 ,the diet of the patient should be nutritious1 and sufficient in emaciated cases to increase his weight if possible4 ,a supporting bandage will often give some relief4 ,a few cases will require surgery4 ,particular attention should be given to the colon1 duodenum and diaphragm4 ,relative to the treatment of gastroptosis and enteroptosis1 ,w4 ,e4 ,harris writes as follows3 8,i first set to work trying to correct the spinal irregularities2 coupled with this ,i give deep and careful manipulation of the gastric and intestinal walls--treating my patient two or more times per week for a period of one to three years4 ,a lesser period is not long enough to bring the desired result in such cases4 ,i also instruct the patient to knead his own bowels1 which ,i prescribe as a necessary proceeding1 and to be performed twice daily on retiring and before rising4 ,of equal importance with the osteopathic treatment1 come local1 specific abdominal exercises4 ,these are to be of the resistive type1 and must also be taken for the general musculature4 ,i have my patient retract the abdominal walls and voluntarily draw the abdominal contents towards the diaphragm1 in regular series4 ,these exercises must be faithfully performed and continued after the treatment has ceased in order to be of real value4 ,i do not find our treatment1 without the hearty cooperation of the patient in doing his exercises conscientiously1 to be sufficient in itself4 ,have the patient avoid overloading the digestive tract4 ,use concentrated foods1 in small quantities1 i4 e41 only sufficient to sustain strength1 twice daily and without taking fluids at meal times4 ,of course water1 in small quantities and at frequent intervals1 may be taken between meals4 ,to summarize--,first1 corrective treatment4 ,second1 resistive exercises4 ,third1 attention to diet40 7,see ,dilatation of the ,stomach47 ,,diseases ,,of ,,the ,,intestines#ge ,acute ,diarrhea ,definition4--,a diffuse inflammation involving the entire intestinal tract to a greater or less degree4 ,usually the seat of disease is found in the small intestine and the upper part of the large bowel4 ,osteopathic ,etiology and ,pathology4--,acute diarrhea may be caused by overeating1 drinking impure water1 unripe fruits1 and poisons produced in decomposed and fermented milk and other articles of food4 ,this sometimes takes place in perfectly harmless substances in an inexplicable manner4 ,milk and ice cream may produce intestinal catarrh4 ,dr4 ,still often referred to the harm resulting from iced drinks4 ,changes in the weather1 tending to weaken the system1 often cause diarrhea2 hot weather favors this1 although a chilling of the system by a sudden fall in the temperature may produce the disorder4 ,dr4 ,still was of the opinion that sitting on the cold ground 7a common habit of children7 is a frequent source of intestinal derangements4 ,changes in the quantity and quality of the secretions also induce the disorder2 thus the bile1 if in too great a quantity1 increases the peristalsis to such a degree that diarrhea is produced2 if diminished1 it favors the fermentation and decomposition of the food4 ,pancreatic diseases may be a cause of diarrhea4 ,infectious diseases1 through their specific poisons1 such as cholera1 dysentery and typhoid fever2 inflammation1 extending into the bowels from adjacent parts2 inflammation caused by peritonitis and intestinal obstructions1 as invagination and hernia2 hyperemia1 secondary to diseases of the liver1 heart and lungs2 cachectic states met with in ,addison's disease2 the last stages of ,bright's disease2 cancer and marked anemia are all among the causes of diarrhea4 ,as in constipation1 diarrhea is oftentimes simply a symptom of various disorders2 still1 it may be the only symptom manifested4 ,lesions are found in various regions of the body1 but chiefly in the lower dorsal and lumbar vertebr and the lower ribs at either side4 ,also lesions may be found to the vagi1 thus increasing the peristalsis or affecting the blood supply of the intestines4 ,the lesions to the splanchnics may involve the motor1 vasomotor or secretory fibers to the intestines4 ,oftentimes the innervation to the liver is disturbed1 affecting the secretion of the bile4 ,the left side of the spinal column is involved more often that the right side1 by vertebral1 rib and muscular lesions4 ,nervous ,diarrhea frequently follows fright and other causes of nervous excitement1 and is often found in hysterical women4 ,there is simply an increase in the peristalsis and secretion of the bowel1 due to a vasomotor paresis of the intestinal vessels1 producing an outflow of the serum4 ,the intestinal condition is one of hyperemia4 ,the secretory glands are frequently inflamed4 ,in decided cases the mucous membrane may be red and injected1 but more often it is pale and covered with a layer of mucus4 ,sometimes the solitary follicles are considerably enlarged4 ,these enlargements may become filled with pus1 forming abscesses which rupture1 leaving an ulcer4 ,peyer's patches may also be involved4 ,symptoms4--,the diarrhea is the important1 and often the only1 symptom of enteritis2 the stools are frequent1 varying from two or three to fifteen or more a day2 they are thin and watery1 varying in color according to the amount of bile they contain4 ,they are usually of a yellowish or greenish color4 ,they contain undigested food1 mucus1 columnar epithelium and mucous cells1 micro-organisms and triple phosphate4 ,the reaction of the discharge is either acid or neutral4 ,there are colicky pains in the abdomen1 rumbling noises or borborygmi1 intense thirst1 dry and coated tongue1 with loss of appetite1 and1 rarely1 a fever4 ,when fever is pronounced care should be taken that some infectious disease is not the cause4 ,chronic catarrhal diarrhea may follow the acute form4 ,if the stools contain much undigested food the inflammation is in the upper bowel2 if thin1 watery and containing mucus1 the lower bowel is involved4 ,in prolonged cases the general health is affected4 ,definite tender areas along the spine and deep muscular contractions are invariably important etiologic and diagnostic clues4 ,diagnosis4--,this is ordinarily made easy by giving attention to the above symptoms4 ,in distinguishing as to whether the large or small intestines are involved the following is important3 ,in catarrh of the small intestines1 diarrhea is not so well marked2 there is much undigested food1 but very little mucus2 and there is usually pain of a colicky nature in the middle or inferior part of the abdomen4 ,when the large intestine is involved there may be no pain2 when present1 it is intense and usually in the upper and lateral parts of the abdomen2 there are borborygmi and thin1 soupy stools1 mixed with much mucus4 ,if the lower portion of the bowel is involved there may be marked tenesmus1 with marked contraction of the muscles over the sacral foramina4 ,duodenitis is often associated with acute gastritis4 ,placing the patient in the knee-chest position one may be able to palpate the duodenum4 ,if the inflammation involves the bile duct1 there is jaundice2 in these cases the urine may be bile-stained4 ,prognosis4--,commonly favorable if early and prompt treatment is employed2 though it should be remembered that some infections1 or constitutional disease1 or intestinal ulcer may be an underlying cause4 ,treatment4--,many cases of acute diarrhea will recover by restricting the diet1 with rest4 ,where improper food and water are the causes1 an entire change of diet should be considered4 ,withdrawal of all food and the substitution of boiled milk will be of great aid4 ,the bowels should never be confined if there is reason to suspect that all irritating matters have not been removed2 and when fermentation and irritation exist in the lower bowel1 an enema will often be beneficial4 ,the spinal column should be examined1 especially on the left side1 from the fifth dorsal down to the coccyx4 ,the vertebr may become displaced and cause diarrhea1 by derangement of the vasomotor nerves4 ,either an increased blood supply through the intestines1 or an affection of the motor nerves will produce an increased peristalsis4 ,an active condition of ,meissner's plexuses may be produced sympathetically1 resulting in increased secretion of intestinal juice and thus in diarrhea4 ,the ribs may become displaced and be a source of irritation to the nerves of the intestines4 ,the muscles of the spine are apt to become contracted by colds1 injuries1 strains1 etc41 and stimulate or inhibit the action of certain centers in the cord and produce disordered intestines4 ,conversely the muscles of the back may be thrown into a contracted condition by irritating substances in the bowels acting as a stimulus to the centers in the cord1 and thus reflexly to the muscles4 ,trouble may arise in the colon and rectum by lumbar lesions1 the slipping of an innominate1 a dislocated coccyx1 or contracted muscles over the sacrum4 ,in a word1 thorough inhibition1 relaxing contracted muscles and correcting abnormal vertebr and ribs are the osteopathic essentials of treatment for diarrhea4 ,inhibition of the lower dorsal and lumbar is very effective2 it dilates the mesenteric vessels by way of vasomotor fibers1 and thus controls secretions and lessens peristalsis4 ,this has been clearly proven in the osteopathic experimental work of ,burns and ,pearce4 ,hot fomentations over the dorsal and lumbar spine will frequently1 through the nervous reciprocal relationship1 be of decided value4 ,direct treatment over the mesenteric circulation1 i4 e41 through the abdomen anteriorly1 will be helpful in some cases4 ,it relaxes tissues1 removes irritations and frees the circulation generally about the mesenteric vessels and intestines4 ,when giving this treatment one should be certain of the underlying pathology4 ,the liver should be kept active4 ,treatment of the vagus nerves is important1 as they help to control the blood supply and the motor nerve force through the intestines4 ,daily hot baths and increased activity of the skin and kidneys are beneficial4 ,chronic ,diarrhea1 and ,mucous ,colitis ,definition4--,a chronic inflammation of the mucous membrane of more or less of the large intestines4 ,there may be ulceration4 ,osteopathic ,etiology and ,pathology4--,chronic diarrhea may be the result of repeated attacks of the acute form or may be caused by cancer1 tuberculosis1 ,bright's disease1 typhus fever1 disease of the liver1 organic disease of the heart and lungs1 obstructions to portal circulation or impactions of any nature that occasion passive congestion4 ,frequently cases of long standing are due to chronic lesions of the lower ribs or lower dorsal or lumbar vertebr4 ,the lesions of the lower ribs usually consist of downward displacement of the ribs1 affecting the innervation to the intestines directly1 or possibly dragging the diaphragm downward to such an extent as to interfere with the blood and lymph vessels as they pass through it1 thus causing congestion of the intestines by obstruction to the lumen of the vessels4 ,in many cases the pathological changes are simply those of the acute form4 ,in more pronounced cases the mucous membrane becomes a brownish red1 livid gray or slate color2 this discoloration being due to hyperemia and blood extravasation4 ,the mucous coat is also swollen and thickened4 ,atrophy of the mucous membrane1 and in some cases of all the coats1 with destruction of the glands1 may be a result of the chronic form4 ,ulcerative changes occur chiefly in the lower part of the ileum and colon2 these may be follicular or there may be large ulcers and considerable areas of ulceration4 ,symptoms4--,constipation and diarrhea frequently alternate2 the stools are thin1 mixed with a large amount of slimy mucus2 the small intestine is most frequently involved1 and the patient complains of pain in the umbilical region2 there is distention of the bowels with gas2 the health gradually declines2 there is great pallor1 and the patient becomes emaciated1 gloomy and irritable4 ,mucous ,colitis is a chronic form of colitis1 characterized by paroxysms of severe pain and the discharge of large masses of mucus1 forming gray translucent casts1 which are not fibrinous but mucoid in character4 ,this disease occurs usually in women of nervous type1 but is occasionally seen in men and children4 ,when there is no underlying organic disease1 it is probably largely a secretion neurosis4 ,mental emotions and worry1 sometimes errors in diet1 or dyspepsia bring on the attack4 ,overfatigue is often an exciting factor4 ,the nutrition is generally well maintained1 but in other cases there may be a gradual emaciation and ultimate death4 ,this is undoubtedly one of the most persistent and troublesome diseases that one will meet2 still the osteopath can do much for these cases and not infrequently bring about a cure4 ,but the treatment must be consistent and persistent4 ,mucous colitis is not hard to diagnose1 although many cases are treated for simple indigestion4 ,it is needless to say that a correct diagnosis is paramount4 ,in these cases there is almost invariably some visceral prolapse1 which undoubtedly is the underlying cause1 by favoring venous congestion of the bowels4 ,the liver is usually congested2 this alone may cause the venous stagnation1 but more often it is simply due to the common cause4 ,back of the visceral prolapse and congestion will almost invariably be found a posterior dorso-lumbar curvature2 still there may be a scoliosis or single lesions only1 and a downward displacement and constriction of the floating ribs4 ,the treatment requires most persistent and careful work for at least three months1 and probably six to nine months4 ,correction of the spine and floating ribs should be of first consideration2 then intelligent treatment over the abdomen1 by raising and toning the bowels1 not only the bowels as a whole1 but especially in the ileo-cecal1 hepatic flexure1 transverse colon1 splenic flexure1 sigmoid flexure1 and rectal regions4 ,the direct treatment should be cautiously given when there are indications of ulceration4 ,have the patient help himself by manipulating his bowels night and morning1 drawing the abdomen up and in1 and by thoracic breathing4 ,prescribe plenty of drinking water and reduce starchy and saccharine food to a minimum4 ,again emphasis is placed upon the necessity of persistent treatment1 two and three times per week1 for several months4 ,the mucus is hard to remove4 ,it is tenacious and frequently causes colicky pains4 ,to the student ,von ,noorden's#gf monograph on this subject is especially instructive4 ,he notes that almost without exception the patients suffer for some weeks or months prior to the development of colica mucosa from obstinate constipation4 ,for acute attacks1 among other things1 he advises rest in bed1 hot applications1 and high water injections4 ,he believes in massage of the large intestine 7particularly of the sigmoid flexure71 in cases of atonic constipation and also in spastic constipation1 provided the patient has a diet that leaves a large residue4 8,a coarse1 laxative diet of ,graham bread1 leguminous plants1 including the husks1 vegetables containing much cellulose2 fruit with small seeds and thick skins1 like currants1 gooseberries1 grapes2 besides1 large quantities of fat1 particularly butter and bacon40 ,diagnosis4--,diagnosis is always easy4 ,the presence of blood1 pus1 or fragments of tissue in the stool point to ulceration4 ,ulcers in the rectum1 and as high as the sigmoid flexure1 will be recognized by examination with the speculum4 ,prognosis4--,osteopathy has undoubtedly changed the prognosis of other treatment4 ,many cases can be cured and most other cases greatly benefited4 ,the deep seated ulcerations may cause circumscribed peritonitis1 or even abscess1 and the prognosis becomes grave as these complications arise4 ,treatment4--,as diarrhea may be caused by lesions anywhere from the sixth dorsal to the coccyx1 a most thorough examination is necessary4 ,on the one hand1 diarrhea may be due to a marked lateral or posterior spinal curvature1 which is plainly seen upon inspection1 but on the other hand1 it may be due to a slight twist or deviation from normal of a vertebra which would require considerable osteopathic ability to exactly locate4 ,diarrhea may result from subluxation in the lower costal region1 one or more of the three lower ribs on either side being involved4 ,record of one case1 in particular1 of chronic diarrhea is of interest as it was due to a rib dislocation4 ,it was the case of a man fifty years of age1 who had suffered from chronic diarrhea1 several stools a day1 for over thirty years4 ,he was completely cured in one treatment by correcting the dislocation of the vertebral end of the tenth rib on the left side4 ,this case is cited to impress upon the student the necessity of precise diagnosis and treatment4 ,rarely will diseases be cured by a single treatment1 but when such happens it exemplifies the potency of the osteopathic lesion4 ,treatment on the left side is usually more effective in diarrhea than treatment on the right side4 ,when diarrhea is a symptom of some constitutional disturbance1 correction of dorsal1 lumbar and rib lesions1 with thorough inhibition1 careful dieting and rest1 will commonly suffice provided the primary disease is intelligently looked after4 ,chronic lesions of the vagi nerves may exist and produce chronic diarrhea in the same manner as in acute diarrhea4 ,rest and a liquid diet1 preferably boiled milk and albumin water1 will be a helpful treatment2 the diet requirement is to have a minimum amount of waste1 so that the residue will cause the least possible irritation4 ,beef peptonoids with the milk will be a nutritious addition to the diet1 and change of air and surroundings may be an aid to a more speedy cure4 ,the skin and kidneys should be kept in a healthy condition and1 if necessary1 the bowels thoroughly emptied by injections4 ,diarrhea of ,children ,three forms of diarrhea are recognized in children3 ,acute dyspeptic diarrhea1 cholera infantum1 acute enterocolitis4 ,acute ,dyspeptic ,diarrhea ,this disease is most frequently due to errors in diet2 the mother's milk may be altered in quantity or quality from taking improper food2 the child may be over-nursed1 or the foods given in place of the mother's milk are at fault4 ,too often a filthy bottle is the cause4 ,the predisposing causes are dentition and extreme heat2 and these1 combined with constitutional weakness1 bad hygiene and a weak spine1 diminish the resisting power of the infant4 ,hence1 in artificially fed children of the poorer classes1 this disease is very prevalent4 ,pathologically1 there is catarrhal swelling of the mucosa of both the small and large intestines4 ,the amount of mucus is increased1 and there is more or less involvement of all the lymphoid tissue4 ,the submucous membrane is often infiltrated4 ,if there is much inflammation ulcers may occur4 ,symptoms4--,the child may seem to be in its usual health1 with slight restlessness at night and an increased number of stools4 ,this restlessness may be due to nausea and colicky pain4 ,the stools are copious and offensive1 containing undigested food and curds4 ,in children over two years old these attacks may follow the eating of unripe food or drinking tainted milk4 ,in other cases the onset may be sudden with vomiting1 purging1 and griping pains4 ,the fever may rise rapidly to #ajc or #ajd degrees or more1 sometimes followed by convulsions4 ,the stools become more numerous--there may be twenty in the twenty-four hours--gray or green in color1 and sometimes containing much mucus1 rarely blood4 ,diagnosis4--,the sudden onset and the character of the stools1 which never have a watery1 serous character1 distinguish this from cholera infantum4 ,and the small amount of mucus which the stools contain distinguishes them from those of ileo-colitis4 ,this form often precedes the onset of specific fevers4 ,prognosis4--,among the better classes this is generally favorable1 but among the weak1 half-starved children of the poor it is often unfavorable1 especially in hot weather4 ,treatment4--,the child should be clad warmly1 kept absolutely clean and given a change of diet and air if possible1 with frequent baths4 ,sterilized milk should be given at regular intervals2 or if the diarrhea continues1 beef juice and egg albumin instead4 ,the bowels should be thoroughly cleansed by injections4 ,the spine should be thoroughly treated through the lower dorsal and lumbar regions1 and if the abdomen is not sensitive1 a light treatment to the bowels directly will aid recovery4 ,frequently it will be found that the muscles of the neck and upper dorsals are considerably contracted1 especially where the child has fever and is very restless4 ,for acute intestinal indigestion ,ruhrah gives the following dietetic treatment3 8,withhold all food for the first twenty-four hours1 except a little albumin water4 ,this is best given in small doses at not too great intervals4 ,plain boiled water may be used instead4 ,very weak tea to which a little red wine has been added may be given if the child is weak4 ,on the second day the albumin or barley water may be given with the addition of weak strained broth1 and on the third day malted milk may be added to the list4 ,after four or five days cow's milk diluted and boiled or peptonized may be tried4 ,it is best mixed with a farinaceous gruel or with malted milk to start with4 ,it may be given every other feeding for a day or two if it agrees1 and the former feeding gradually resumed4 8,in nursing infants withhold the breast twenty-four hours and feed as above4 ,after that the breast may be given once for a few minutes and the feeding pieced out with albumin- or barley water4 ,if it agrees the breast may be given for three or four feedings1 every other feeding followed by albumin- or barley water4 ,on the following day the breast may be given at each feeding4 ,the time of nursing should be increased gradually until the child is back on its old schedule40 ,cholera ,infantum ,definition4--,an acute1 catarrhal inflammation of the mucous membrane of the stomach and intestines1 with some disturbance of the sympathetic ganglia4 ,this is a disease of childhood during the first dentition4 ,etiology and ,pathology4--,probably due to the poisonous products of decomposing and fermenting foods acting upon the system4 ,the predisposing causes are hot weather1 dentition1 bad hygiene1 the previous presence of some slight dyspeptic derangement1 dyspeptic diarrhea1 and enterocolitis4 ,the pathological changes are similar to the morbid anatomy of catarrhal gastritis and enteritis4 ,the serous discharges and rapid collapse are due to the intense irritation of the sympathetic system4 ,the kidneys and liver may become involved1 and bronchopneumonia is a possible complication4 ,symptoms4--,the disease is of sudden onset1 setting in with severe vomiting1 which is increased by giving food or drink4 ,the stools are copious and frequent1 at first containing some offensive fecal matter1 and later becoming watery1 and odorless4 ,there is decided fever1 reaching as high as #aje degrees4 ,the pulse is rapid and feeble1 ranging from #acj to #afj4 ,prostration1 pinched features1 hollow eyes1 depressed fontanelles and loss of weight are characteristic symptoms4 ,the tongue is coated at first1 but soon becomes dry and red1 and thirst is intense4 ,even at this time a reaction may set in1 but more commonly death results with symptoms of collapse and high temperature4 ,in other cases there are restlessness1 convulsions and coma4 ,as there is no cerebral lesion1 this condition is probably due to toxic agents absorbed from the intestines4 ,diagnosis4--,this is not difficult1 as the toxic symptoms1 the severe vomiting1 the profuse watery discharge1 rapid emaciation and prostration1 and the hyperpyrexia are significant4 ,prognosis4--,grave1 even with the most favorable surroundings1 although in numerous instances osteopaths have successfully treated this disorder4 ,much depends upon the promptness of treatment4 ,treatment4--,a change of air1 complete rest1 removal of all foods for a short time1 and absolute cleanliness are of great importance4 ,thorough treatment should be given along the entire spine1 particularly to the splanchnics of the stomach and the intestines1 and to the vagi nerves in the cervical region4 ,frequent bathing with cool water1 or better still1 wrapping the child in cold1 wet sheets1 will reduce the hyperpyrexia4 ,thorough cleansing of the stomach and intestines with warm water occasionally gives excellent results4 ,in collapse the use of a hot bath is indicated1 followed by wrapping the child warmly in blankets and placing him in a horizontal position4 ,the food of the child should consist of peptonized milk1 raw beef juice1 diluted egg albumin1 barley water and chicken broth4 ,nourishment should be given gradually1 and only after the intense symptoms have subsided4 ,acute ,enterocolitis ,in enterocolitis the ileum and colon are chiefly affected1 especially the lymphatic glands or lymph follicles4 ,osteopathic ,etiology and ,pathology4--,warm weather1 the artificial feeding of children1 dentition and bad hygiene are predisposing causes4 ,the disease usually occurs between the ages of six and eighteen months1 but it is not infrequent in the third or fourth year4 ,this disease is not confined to the warm weather1 but may set in at any season of the year4 ,previous light attacks of diarrhea are often a predisposing factor4 ,lesions in the spine occur from the eleventh dorsal to the fourth lumbar4 ,the mucous membrane is congested and swollen1 and the solitary follicles and ,peyer's patches are swollen and often ulcerated4 ,the changes may end here or the ulcers enlarge and extend into the muscular coat with the separation of a slough4 ,there may be infiltration and thicking into the submucous and muscular coats1 followed by induration of the tissue1 producing abnormal rigidity4 ,symptoms4--,the disease may be a sequel of dyspeptic diarrhea or cholera infantum4 ,the temperature increases and the stools change in character1 being at first yellow1 and later green4 ,they contain traces of blood and mucus4 ,vomiting may be present1 but is not a constant symptom4 ,the abdomen is distended and tender along the course of the colon4 ,the disease may abate here1 recovery from the condition being slow2 or the symptoms may increase in severity with persistent1 small1 painful stools1 mainly of blood and mucus1 tenesmus1 and with scanty urine4 ,the child grows pale and emaciated1 and assumes a senile appearance4 ,these cases last five or six weeks1 death being preceded by coma and convulsions2 though a few recover4 ,relapses are not uncommon and should be guarded against4 ,ulcerative and membranous forms may occur4 ,pneumonia and nephritis are possible complications4 ,diagnosis4--,enterocolitis is distinguished from dyspeptic diarrhea by the greater severity1 more fever1 greater prostration1 the stools containing more mucus and even blood1 and by the greater pain and suffering4 ,cholera infantum may be recognized by the abrupt onset1 very high fever1 constant vomiting1 and early collapse4 ,if typhoid fever seems a possibility1 the ,widal test should be used4 ,prognosis4--,grave2 recovery follows prompt treatment with favorable surroundings4 ,treatment4--,attention should be given to the condition of the spine from the eleventh dorsal to the fifth lumbar4 ,an inhibitory relaxing treatment over the sacral foramina will lessen the tenesmus4 ,when the ileum and colon are involved1 disorder is usually present at the third and fourth lumbar vertebr1 although the lesion may be higher4 ,relaxation of all muscles in this region and correction of the vertebral lesions are essential4 ,irrigation of the bowels once a day with a pint of cold water is very beneficial and even pieces of ice may be introduced into the rectum4 ,fresh1 pure air1 rest and cleanliness1 with a restricted diet and daily warm baths are important4 ,in a word1 hygienic and dietetic treatment similar to that for acute diarrhea should be employed4 ,in all forms of diarrheal diseases in children much depends upon previous osteopathic attention1 diet1 hygiene1 and environment4 ,cholera ,morbus ,definition4--,an acute1 gastro-intestinal catarrh of sudden onset1 characterized by violent abdominal pains1 incessant vomiting and purging4 ,etiology and ,pathology4--,this disease greatly resembles ,asiatic cholera2 so much so that one seems justified in suspecting that cholera morbus1 like true cholera1 is due to a specific organism4 ,no single bacillus has yet been designated as the specific germ1 although one has been recognized resembling very much the common bacillus of true cholera4 ,until this has been fully decided1 cholera morbus must be regarded as severe inflammation of the mucous membrane of the stomach and intestines1 due to some poison generated from the improper food1 which seems to be the cause of the disease1 such as indigestible fruits1 cabbage and cucumbers4 ,it is most prevalent in hot weather1 but is also caused by exposure to cold and damp4 ,the condition of the mucous lining of the intestines is the same as in acute diarrhea4 ,in fatal cases of cholera morbus there is the same shrunken1 ashy appearance of the skin that characterizes cholera4 ,symptoms4--,the onset is sudden1 with intense cramps in the epigastrium and frequently in the lower limbs2 nausea2 vomiting1 and purging of bilious material1 which later becomes almost like water1 and in severe cases the discharge becomes serous1 finally resembling the rice water discharges of true cholera4 ,there are also intense thirst1 moderate fever1 rapid emaciation and loss of strength2 the surface becomes cold and covered with clammy sweat2 the pulse is frequent and feeble4 ,the patient becomes restless and anxious4 ,diagnosis4--,asiatic ,cholera4--,there is no way of distinguishing between ,asiatic cholera and cholera morbus1 except by examination of the discharges for the bacillus4 ,similar attacks are produced in poisoning by arsenic1 corrosive sublimate and certain fungi1 and are only discriminated from it by clinical history and cause4 ,prognosis4--,in the majority of cases the prognosis is favorable1 death rarely occurring4 ,the duration is from twenty-four to forty-eight hours4 ,treatment4--,a strong inhibitory treatment to the gastro-intestinal nerves is at once demanded4 ,this relaxes the muscles of stomach and intestines1 dilates the blood-vessels and lessens peristalsis4 ,the treatment should be kept up until relief is given4 ,in some cases1 gentle treatment over the stomach and intestines quiets the distress4 ,inhibition at the occiput gives relief1 especially to the nausea and vomiting4 ,hot applications should be applied to dorsal and lumbar spine4 ,the vomiting is relieved principally at the fourth and fifth dorsal vertebr on the right side near the angle of the ribs4 ,cold carbonated water and pieces of ice swallowed are useful4 ,the diet must be regulated1 the further after treatment being symptomatic4 ,clear the bowel by warm enema if any irritating matter is still present4 ,inasmuch as food passes through the small intestine in #d to #f hours1 and requires #bj hours to pass through the colon1 the colon should be emptied by high irrigation in all acute intestinal disorders4 ,intestinal ,colic ,this is a painful spasmodic contraction of the muscular layer of the intestines4 ,osteopathic ,etiology4--,lesions of the splanchnics derange the intestinal nervous mechanism1 with a consequent upsetting of circulatory equalization and chemical function of the intestines4 ,thus irritations and obstructions of the reflex arc predispose to lowered resistance1 congestions1 and disturbed chemism4 ,indigestible food1 flatulency and impaction of feces oftentimes produce intestinal colic4 ,exposure to cold and emotional upsets may be factors4 ,foreign bodies1 intestinal worms1 abnormal amounts of bile discharged into the intestines1 and reflex causes from diseases1 as from the ovaries1 uterus1 liver1 kidneys1 etc41 will produce the disorder2 also lead poisoning1 syphilis1 rheumatism1 locomotor ataxia1 chronic malaria and hysteria4 ,kerley says3 8,children who take too much milk1 too strong milk1 or who take milk too frequently are the usual subjects of colic4 ,probably the most frequent cause of colic is indigestion of the proteid of the milk2 either the proteid is in excess or the child has poor proteid capacity4 ,not a few cases of colic are due secondarily to defective bowel action40 ,symptoms4--,severe paroxysms of pain1 centering around the navel and diffused throughout the entire abdomen4 ,the pain is of a piercing1 cutting and twisting nature1 relieved upon pressure4 ,the abdomen is distended and the patient restless and continually changing his position4 ,the attacks alternate with periods of complete quietude4 ,in severe attacks the features may be pinched and the surface cold1 with feeble pulse1 vomiting and tense abdominal walls1 all indicating incipient collapse4 ,the duration of the attack is from a few minutes to several hours1 eased at intervals and usually ending by a discharge of flatus4 ,differential ,diagnosis4--,in lead colic the history1 the slate-colored skin1 blue line on the gums1 sweetish metallic taste1 constipation1 slow pulse1 retracted abdominal walls1 and lead in the urine will designate this disease4 ,biliary colic presents pain in the hepatic region1 radiating to the back and right shoulder2 also jaundice1 calculi in the stools and bile in the urine4 ,tenderness over the gall bladder is important4 ,nephritic colic is accompanied by pain radiating down one or both ureters to the inner side of the thigh1 with retraction of testicle of side affected1 or the labia1 and blood1 mucus1 pus or calculi in the urine4 ,in uterine colic there is dysmenorrhea and pain in the pelvis4 ,in ovarian colic there is extreme pain upon pressure over the ovaries1 and hysteria4 ,abdominal aneurism presents tumor1 pulsation1 bruit4 ,in inflammatory and ulcerative disorders of the abdomen there is tenderness upon pressure1 and fever4 ,the pain of acute appendicitis is at first general1 centering in the right iliac fossa in about #bd hours4 ,the ,x-ray may be of definite aid in renal and biliary conditions and various disorders1 such as intestinal adhesions1 angulations1 etc4 ,treatment4--,relief of pain is the first indication and is best accomplished by strong inhibition in the splanchnic region1 which relaxes the spasm of the intestinal muscles1 by normalizing the reflex arc4 ,if disorders of the spinal column are located1 it is of primary importance that they be corrected4 ,in cases of irritation of the intestinal mucous membrane1 a contraction of muscles of the spine will be found according to the area of the intestines involved1 e4 g41 irritation of the mucous coat of the jejunum causes contraction of the muscles at the tenth and eleventh dorsals4 ,it is a viscero-motor1 viscerosensory or viscerotrophic reflex sign4 ,on the other hand1 a lesion at the tenth and eleventh dorsals may produce colic or other disorders of the jejunum4 ,the portion of the bowel affected1 therefore1 can be often told by noticing the places of muscular contraction along the spinal column4 ,generally the jejunum and ileum are the portions of the bowel affected in intestinal colic4 ,the pain can frequently be controlled if in the jejunum1 at the tenth and eleventh dorsals2 if in the ileum1 at the twelfth dorsal2 if in the ileo-cecal region1 including the vermiform appendix1 at first to third lumbar2 if in the colon1 at the third to the fifth lumbar2 and if in the rectum1 over the sacral and coccygeal nerves4 ,occasionally the duodenum and jejunum are reached by nerves as high as the fifth dorsal 7usually vasomotor nerves1 not sensory71 and the other portions of the bowel lower1 according to their respective positions4 ,the relief is given by way of the splanchnics and sympathetics to the mucous 7sensory7 coat of the intestines1 although inhibition relaxes intestinal muscles 7motor nerves7 and dilates blood-vessels 7vasomotor nerves74 ,though precisely localized inhibition is of decided value1 still if normal alignment1 through adjustment1 can be secured results are usually quicker and more satisfactory4 ,anterior treatment to the abdomen helps to relieve the contracted fascia of the mesentery1 with a consequent freeing of the circulation4 ,it aids peristalsis of the intestines and expulsion of the irritating material4 ,this probably produces considerable effect by way of the axone reflex4 ,direct treatment to the abdomen for the peristalsis relieves also constipation1 impactions and the enteralgia1 the latter principally by firm pressure4 ,peristalsis is also increased by stimulation of the vagi and inhibition of the splanchnics4 ,the latter treatment1 of course1 is not given to relieve pain directly1 but to facilitate the removal of irritating substances if such are the source of trouble4 ,if this does not produce a movement of the bowels promptly1 a warm enema will assist greatly4 ,the cecum and sigmoid should not be overlooked4 ,flatulency can be relieved by direct pressure upon the solar plexus1 which apparently removes obstructions to the abdominal nervous system 7particularly the nerves of the digestive glands1 as fermentation and flatulency are due to a disproportionate secretion of digestive juices7 and thus the gaseous formations are absorbed4 ,additional treatment to the lower dorsal vertebr and lower ribs to relieve nerve lesions and increasing both thoracic and abdominal circulation may be indicated4 ,as stated in the etiology of intestinal colic1 the splanchnic nerves contain not only sensitive fibers1 but motor and vasomotor fibers as well4 ,the same is true of the vagi nerves2 they exert upon the intestines not alone a motor influence1 but also a blood control2 consequently1 our work in a certain region can be for more than one purpose4 ,hot applications to the abdomen may be of benefit4 ,and hot fomentations to the spine for #bj or #cj minutes 7affecting reciprocal innervation7 is often of great benefit4 ,the diet should always be regulated for a few days at least4 ,constipation#gg ,constipation is an unnatural retention of feces from any cause4 ,the following causes are frequently met with3 ,a deficiency of the bile or other secretions that aid peristalsis2 many acute and chronic diseases which lessen the secretions and impair peristalsis1 such as anemia1 hysteria1 chronic affections of the liver1 stomach and intestines and acute fevers2 certain drugs and strong purgatives2 strictures2 concentrated food2 sedentary habits1 overfatigue and neglect of the calls of nature4 ,atony of the colon may be caused by chronic disease of the mucosa and by general disease causing debility4 ,there may be weakness of the abdominal muscles1 due to obesity and the distention of frequent pregnancies1 or obstructions1 such as displaced uterus1 pregnancy1 prolapsed cecum1 sigmoid or rectum1 and displaced coccyx4 ,constipation is really a symptom1 in most cases1 of some disease2 many times it is about the only symptom observed4 ,one has to take into consideration the many causes that would produce constipation when the treatment of a case is undertaken4 ,a disordered structure may be found in almost any region of a body1 which would bear directly or indirectly in the causation of constipation4 ,irregular habits often bring on the most obstinate cases of constipation in later life4 ,there may also be local causes1 such as disturbances of the normal secretions1 impairment of intestinal walls1 due to inflammation1 and mechanical obstructions caused by tumors1 intussusception1 twists1 etc4 ,constipation in infants is usually caused by errors in diet1 but may be congenital4 ,in all obstinate cases the ,x-ray should be employed in diagnosis4 ,in the majority of cases lesions will be found in the vertebr of the lower dorsal and lumbar regions1 or in the lower ribs of either side4 ,the lesions may affect the vascular supply and innervation of the intestines directly1 or the lesion may cause the constipation by affecting some other digestive organ first4 ,lesions to the vagi affecting the peristalsis of the intestines are common4 ,the usual symptoms are frequent stools1 debility1 lassitude1 headache1 loss of appetite1 anemia1 furred tongue and fetid breath4 ,serious symptoms may result in long continued cases1 such as piles1 ulceration of the colon1 perforation1 enteritis and occlusion4 ,the fecal mass may become channeled and diarrhea may occur from the irritation4 ,in long standing cases of constipation1 if the patient suddenly develops diarrhea the rectum should be well examined to see if there are impacted feces present4 ,neuralgia of the sacral nerves may also be caused by impacted feces in the sigmoid flexure4 ,treatment4--,naturally1 owing to the numerous etiological factors1 each case is a special study and the treatment is necessarily varied4 ,many cases will present slight impaction of the bowels1 a sluggish liver1 spinal lesions and so on1 which simply require a specific treatment and all the symptoms will be removed4 ,on the other hand1 constipation may be due to prolonged ill health and thus require a careful1 systematic treatment1 not only of the bowels1 but of the entire system4 ,of primary importance in these cases is regulation of the diet1 plenty of exercise1 sufficient sleep1 and regularity in going to stool at a fixed hour each day4 ,the effect of attention to the latter point1 in some instances1 will be sufficient to perform a cure4 ,too much cannot be said in regard to the beneficial effect of systematic habits4 ,lesions may be found in the spinal column producing constipation from about the fifth dorsal to the coccyx1 although principally the lower three dorsal and upper two lumbar vertebr are at fault4 ,constipation may be caused by defects at any point in the intestines1 and consequently the sections of the spinal column sending nerves through the intervertebral foramina to the several sections of the bowels should be examined4 ,at any point from the fifth dorsal to the coccyx1 certain vasomotor1 motor and secretory nerves of the intestines may be affected by various lesions4 ,the vasomotor nerves keep up the vascular tone of the bowels1 the motor nerves the peristaltic action and the secretory nerves attend to the intestinal juices4 ,in constipation1 disorders of the spinal column are generally found on the right side4 ,there is no good reason offered as to why this is so4#gh ,in those cases where the liver is impaired1 the answer might be because most of the nerves to the liver are on the right side1 but the right side is just as often affected when the lesions are in the lumbar region and the nerve supply to the hepatic region intact4 ,dr4 ,still considered the fifth dorsal of importance4 ,the vagi nerves have important bearing upon the motor apparatus of the intestines4 ,lesions in the upper cervical1 involving intestinal fibers of the vagi1 occur occasionally4 ,stimulation of these fibers increases the peristalsis of the intestines4 ,mechanical stimulation of the mid and lower dorsal region1 as shown by osteopathic experiments1 increases peristaltic action and vaso-constriction in the stomach and intestines4 ,the value of direct treatment over the intestines from the duodenum to the rectum in most cases of constipation cannot be overestimated4 ,it aids peristaltic action1 removes impactions1 stretches adhesions1 strengthens weakened muscles of the intestines and abdomen1 and in general gives tone to all of the abdominal organs4 ,the treatment should not be given in a hap-hazard manner1 but each effort should be for a definite purpose4 ,care should be taken not to bruise the intestines or other organs1 as by gouging or severe punching2 the flat surface and the palms of the hands should be used4 ,this means that the part of the bowel involved should be treated intelligently1 the osteopath reaching underneath the section and the patient drawing the bowels up and in4 ,obstructions and impactions of the gut1 especially at the ileo-cecal and sigmoid regions1 should be carefully corrected4 ,at all angles of the gut1 impactions and prolapses may occur4 ,j4 ,h4 ,sullivan#gi makes the following observation concerning severe1 deep abdominal treatment3 8,i have noted that this often resulted in the reverse of good effects4 ,in constipation1 naturally then1 ,i am chary about treating abdominally1 confining my work principally to the biliary regions1 the ileo-cecal and left iliac regions and have attained good results when a promiscuous working of the abdomen had not so resulted40 ,this emphasizes the point that specific treatment is as much indicated for the abdomen as it is for the spine4 ,frequently there will be found a spastic condition of the pelvic colon1 often associated with congestion and adhesions4 ,this probably sets up a reversed peristalsis4 ,treatment by inhibitory relaxation1 with patient in knee-chest position1 and adjustment of lumbar and innominate lesions1 is indicated4 ,direct treatment to the liver and biliary ducts is necessary in many cases1 as the bile secretion is often defective2 thus a slowness or inactivity of the liver and bile ducts might cause costiveness4 ,some cases result from anesthesia of the rectum1 due to pressure of the fecal matter collecting in the rectum4 ,simple dilatation of the rectal sphincters and a stimulating treatment through the sacral nerves will bring about a healthy activity of these parts4 ,occasionally the coccyx becomes displaced and produces paresis of the rectal nerves2 or a displaced uterus or a tumor may produce the same result4 ,the use of proper food is essential4 ,coarse food leaves a great amount of residue1 and on the other hand1 dainty food leaves but little residue1 both causing costiveness4 ,as a rule increase the amount of fruit and vegetables4 ,the patient should drink considerable water1 and the time is of importance4 ,have a glass of cool1 not iced1 water taken on arising and if breakfast is delayed sufficiently1 another in half an hour4 ,most people do not drink enough water4 ,unless contraindicated eight or ten glasses daily should be insisted upon4 ,an enema#hj occasionally is indicated and is a great aid when used1 particularly in cases of paralysis of the intestines and in impactions4 ,correct breathing and out door life are beneficial4 ,treatment of the ,constipation of ,infants4--,repeated small enemata at a fixed hour each day will often be satisfactory but be certain that the tissue is not irritated4 ,two ounces of tepid water at a time should be injected4 ,careful spinal treatment and massage to the abdomen will be useful1 as will slight dilation of the anus1 which is usually done with the little finger1 but in obstinate cases a soap stick may be used4 ,when there has been continued straining at the stool1 the sigmoid and rectum will often be found prolapsed1 causing a mechanical obstruction4 ,with the finger well lubricated this can be corrected and often is all that is needed4 ,these directions1 with care in the foods1 are usually sufficient in any case not congenital4 ,in chronic constipation ,ruhrah outlines dietetic treatment as follows3 8,in infants see that they get sufficient fat and protein2 well cooked and sweetened oatmeal gruel is useful4 ,orange juice1 baked apple1 or prune juice taken on an empty stomach is of service4 ,olive oil1 the malted foods1 or malt extracts are useful4 ,in older children fresh fruits1 vegetables1 and oatmeal porridge are of value4 ,graham bread1 dates1 figs1 and prunes may be used40 ,intestinal ,obstruction 7,,ileus7 ,this is due to a sudden or gradual closure of the intestinal canal at any point4 ,closure of the gut may be caused by strangulation1 intussusception1 twists and knots1 abnormal contents1 strictures1 tumors1 kinks1 spastic states1 adhesions1 etc4 ,strangulation4--,this is the most frequent cause of acute obstruction of the bowels4 ,there may be stricture of the bowels due to inflammatory processes producing bands or adhesions1 or due to the adhesion of a bowel to an abdominal wound2 a vitelline remnant1 as a blood vessel1 may remain and act as a strangulating cord1 or in ,meckel's diverticulum one end may be attached to a mesentery or abdominal wall and thus form a ring through which the gut may pass and become strangulated4 ,strangulation may take place through the foramen of ,winslow or the foramen ovale1 or between the pedicle of a tumor and the abdominal wall4 ,peritoneal pouches1 mesenteric and omental slits1 adherent appendix or ,fallopian tubes and diaphragmatic hernia may be other causes4 ,an internal strangulation 7hernia7 may take place in the crural or inguinal canal1 in the umbilicus1 in the sacro-sciatic notch or in the opening through which the infra-pubic vessels pass4 ,in strangulation there is a constriction of a portion of the bowel causing an arrest of the circulation of blood at that point1 and more or less stoppage of fecal matter of the intestine4 ,in ninety per cent of cases the strangulated part is in the lower abdomen and sixty-seven per cent occur in the right iliac fossa1 according to ,fitz4 ,intussusception or ,invagination4--,intussusception is a slipping of a part of the intestine into another part immediately below it1 as the slipping of a part of a finger of a glove or a coat sleeve into another part4 ,the portion involved may be anywhere from half an inch to a foot or more in length4 ,this produces compression and inflammation of the intestine1 and obstruction to the intestinal contents4 ,it occurs principally in children and is more common in males4 ,spasms of the intestinal muscles and perverted peristalsis are probably the most common causes4 ,one part of the bowel may be dilated and an adjacent portion contracted1 thus allowing an invagination4 ,diarrhea1 habitual constipation and intestinal polypi are important exciting causes4 ,invaginations oftentimes occur just before death1 probably due to irregular peristalsis4 ,following engorgement and inflammation of the invaginated portion1 a tumor is usually present1 and lymph is exuded which may cause the layers of gut to adhere1 so that the invaginated portion is firmly held4 ,necrosis and sloughing are then likely to take place4 ,intussusception varies according to location and is named according to the part of the bowel involved4 ,there are commonly recognized 7#a7 ,ileo-colic1 when the ileo-cecal valve enters the colon4 7#b7 ,enteric1 of the small intestines4 7#c7 ,colic1 of the large intestine4 7#d7 ,colico-rectal1 of the colon and rectum4 7#e7 ,rectal1 of the rectum4 ,twists and ,knots4--,these occur more frequently in males1 usually between the ages of thirty and forty4 ,in nearly all cases the twist is axial1 accompanied by relaxed and lengthened mesentery4 ,one portion of the bowel may be twisted about another1 or a loop of bowel twisted upon its long axis4 ,a bowel being impacted or overdistended by feces and gas1 is quite likely to roll on its axis or knot and become dislocated1 its weight and inactivity thus producing compression and obstruction of the bowels4 ,the volvulus commonly occurs in the large intestine1 at the sigmoid flexure and in the ileo-cecal and cecal regions4 ,it occasionally occurs in the small intestine4 ,abnormal ,contents4--,obstructions may be caused by gall-stones1 enteroliths1 lumbricoid worms1 certain medicines 7such as magnesia and bismuth71 fruit stones1 coins1 needles1 pins1 buttons1 etc41 and fecal matter4 ,foreign bodies usually lodge in the ileo-cecal region and in the small intestine1 while fecal impactions occur in the large intestine1 more frequently in the lower part4 ,females are more subject to it than males4 ,its causes are many and are similar to those of constipation4 ,spinal lesions are very frequent1 probably causing paresis or paralysis of a segment of the bowel2 or all the forces that maintain a normal activity of the intestines may become impaired4 ,hemmeter#ha says it is 8more frequently the result of defective innervation of the intestine40 ,impactions are frequently met with and are easily overlooked under any diagnosis which does not include thorough palpation of the abdominal viscera4 ,the impaction may be so large as to produce dilation of the bowel4 ,the obstructive mass becomes very hard and dry and perhaps channeled1 allowing some material to pass until1 finally a large piece of fecal matter will obstruct the passage completely4 ,in diagnosis it must not be confused with neoplasms1 tumors1 etc4 ,impactions may occur at any point of the colon and the weight so drags the bowel out of position as to be misleading4 ,the principal points are the ileo-cecal region1 sigmoid flexure1 and rectum4 ,tenderness is usually present1 as may be diarrhea which must not be taken as evidence that the bowel is clear4 ,impaction gives rise to many reflex symptoms and is often the real cause of many mistaken conditions4 ,too much cannot be said on the importance of a thorough examination of colon and its connections1 which should be routine of every examination as the large bowel is impacted much more often than suspected and may be the seat of many reflex and direct disturbances4 ,the heart may be affected by weight upon the vessels1 gastric disturbances and signs of auto-intoxication from absorption may appear4 ,dilatation of the sigmoid flexure1 especially when it is congenitally long1 may even be so great as to crowd up and interfere with the liver and diaphragm2 in these cases the coats of the intestines are usually hypertrophied4 ,strictures and ,tumors4--,these usually occur in adults1 more frequently in women and generally involve the large intestine and lower part of the abdomen1 most of them occurring in the left iliac fossa4 ,they frequently result in chronic obstruction4 ,occasionally1 a stricture may be spastic1 due to vertebral lesions1 that is severe enough to cause complete blockage of intestinal contents4 ,these are usually of the pelvic colon4 ,there are cases where the opposite condition1 paralysis of a section1 generally of the small intestine1 occurs4 ,this may be due to injuries to the bowel1 or to damage of the blood supply1 or to derangement of the innervation4 ,scar tissue1 following ulceration of the bowel2 tumors of various kinds2 and congenital defects1 are possible sources of intestinal obstruction4 ,symptoms4--,acute ,obstruction4--,there is constipation1 nausea1 vomiting1 and pain4 ,the pain is of a colicky nature and may come on abruptly4 ,after the contents of the stomach have been vomited1 the material becomes colored with bile1 and finally stercoraceous vomiting occurs4 ,observing the contents vomited 7gastric1 bile-stained1 and fecal7 will greatly aid in the diagnosis4 ,the contents of the bowel1 below the obstruction1 may be emptied or complete constipation may remain4 ,all the symptoms1 as a rule1 rapidly grow more pronounced4 ,the pain is more severe2 tenderness occurs over the abdomen in limited areas2 there is slight tympany2 the eyes are sunken2 the skin is cold and clammy2 the pulse is quickened and feeble2 there is rapid increase of leucocytes2 the urine highly colored2 the tongue is dry and there is incessant thirst2 tenesmus and tumor may be marked1 and fever occasionally occurs4 ,the above condition may continue from three days to a week1 when collapse and death may occur1 if relief is not obtained4 ,chronic ,obstruction4--,in fecal impactions constipation of long standing is commonly observed4 ,in some cases the fecal mass has become channeled1 allowing the bowels to remain open2 the patient possibly not knowing that there is any trouble4 ,in fact1 diarrhea may be present1 due to irritation above the impaction4 ,finally1 however1 obstruction occurs2 the breath is offensive1 the appetite is poor1 the abdomen swells1 and there is fullness and weight within the abdomen1 accompanied by pain and vomiting4 ,upon examination before complete closure1 the fecal impactions can easily be felt through the abdomen externally4 ,the tumor is a yielding mass4 ,it has been mistaken for an enlarged liver or gall-bladder1 a kidney1 or a tumor of the stomach or duodenum4 ,other symptoms may be present as hiccough1 jaundice1 tenesmus1 tumultuous peristalsis1 local peristalsis1 local peritonitis and collapse4 ,in stricture caused by cicatrices that may have been formed years before1 complete obstruction takes place4 ,transient attacks often occur4 ,usually the general health is greatly impaired long before complete occlusion4 ,diagnosis4--,a diagnosis can usually be made by careful1 thorough examination through the abdominal wall1 in connection with the symptoms1 and the physical signs4 ,the region of intestinal trouble is manifested by contracted muscles at certain points along the spinal column1 corresponding with the particular portion of the bowel involved1 as indicated under intestinal colic4 ,examining the patient in the knee-chest position will often give a better opportunity to locate and outline the obstruction4 ,rectal and vaginal examinations should not be neglected4 ,intestinal obstruction may be confounded with tumors1 hernia1 intestinal colic1 enteritis1 peritonitis1 hepatic colic and renal colic4 ,peritonitis may be differentiated by the history1 the early fever1 diffused tenderness and absence of fecal vomiting4 ,when invagination occurs1 besides the symptoms of obstruction1 the age1 tenesmus1 bloody discharges and the sausage-shaped tumor in the line of the colon1 will be diagnostic4 ,in stricture1 the history1 gradual onset1 and ribbon-like and bloody stools will distinguish that disorder4 ,in tumors the gradual onset1 age1 bloody discharges1 and cachexia will be important symptoms4 ,x-ray diagnosis may be of value in certain cases4 ,treatment4--,treatment of the bowels directly is required1 and each case must depend for its relief upon the ingenuity of the osteopath4 ,rules to be followed cannot be given1 as cases vary in manner of involvement and in location1 consequently the correction of the disorder depends as much upon the ability of the osteopath as does the determination of the diagnosis4 ,taxis is the method commonly used in relieving intestinal obstructions1 though other methods may be employed4 ,in invagination1 raising the buttocks and lowering the chest1 with thorough injection of oil or tepid soapsuds1 or an inflation of the colon with air1 may give relief4 ,in addition to thorough but cautious manipulation of the bowels as in impaction1 irrigation of the lower bowel with warm water1 soapsuds1 or glycerine and water1 will usually be of material aid4 ,in strangulation1 high injections of warm water1 and assuming the knee-elbow or lateral position1 may straighten out the acute obstruction4 ,twists and knots are best relieved by direct treatment1 although injections may be of aid4 ,kinks of the pelvic colon1 ileum1 and duodenum are best treated with the patient in the knee-chest position4 ,tumors and strictures will require1 sooner or later1 surgical interference in most cases1 but to treat as in impaction will be effective for a short time at least4 ,if there is no indication of immediate relief within three days1 surgical interference should be instituted4 ,besides the ordinary treatment for the nausea and vomiting1 washing out the stomach will help allay such disorder1 quiet the peristalsis and relieve the abdominal distention and pressure above the seat of obstruction4 ,strong thorough treatment of the spinal nerves to the stomach and intestines will be of great help in lessening pain1 establishing normal peristaltic action and in suppressing inflammation4 ,the vagi also should be treated for perverted peristalsis4 ,hot fomentations will be of service4 ,the nutrition of the patient is best retained by rectal injections of food4 ,spastic states1 particularly of the pelvic colon1 frequently cause constipation of various degrees of chronicity4 ,reaching beneath the spastic area and inhibiting and raising 7knee-chest position7 the parts will often give marked relief4 ,adhesions can often be stretched sufficiently to restore normal function of the bowels4 ,treatment of impactions and abnormal contents requires an additional word4 ,the first step is to free the colon of the fecal mass4 ,the enema is of great assistance in this1 for cases of long standing present a hard1 dry mass1 often adherent1 and the mucous membrane is sensitive from inflammation4 ,much abdominal treatment must not be given until the mass is softened by water4 ,when in the sigmoid or rectum it may1 if not dislodged by repeated enemata1 have to be removed by a colon spoon1 perhaps under anesthesia4 ,impaction of the small intestine is rare and out of reach of the enema1 although if taken as hot as can be borne1 it will exert considerable influence high up4 ,in these tendencies and in constipation1 when the bowel must be kept open before treatment has produced much effect1 there should be an effort made to break up any cathartic habit which may be formed4 ,the enema is a most valuable aid1 but it must be given correctly4 ,the patient should be instructed that a fountain syringe is preferable1 and that it must never be taken standing4 ,this merely fills and distends the rectum1 or lower sigmoid at the best1 and is passed without any or with very little effect4 ,lying on the right side is a very good position1 as is also on the back with hips elevated1 but the knee and chest is best in most cases4 ,the water should be a little above body temperature and can be saponified or used clear4 ,the effect will be about the same4 ,the tube should be perfectly smooth and well lubricated and introduction must be made with care so as not to bruise or irritate4 ,the water1 having been allowed to run to expel the air1 may be now started and will separate the mucous folds and allow easy penetration4 ,the rubber tube should be held between the thumb and finger1 so the flow can be stopped as soon as it meets an obstruction4 ,when this is passed the flow can begin again and continue until the required amount 7from one to two quarts for an adult71 has been taken1 or until the feeling of distention becomes too great4 ,by following this method1 much of the distress and colicky pains which sometimes accompany an enema1 may be avoided4 ,water should be held for some minutes1 to allow softening of the fecal mass4 ,in many impactions it is important to get the water into the ascending colon4 ,for that purpose nothing is better than a ,coles sigmoid irrigator4 ,this is shaped somewhat like the letter ,s and is about a foot long from tip to tip4 ,its introduction is not difficult1 but care must be used4 ,place the patient on the right side and stand in front1 having the bag suspended near4 ,introduce the tube and with slow1 gentle pressure let it follow the course of the bowel4 ,when the splenic flexure is reached1 it will stop1 but by letting a little water flow1 the bowel will distend and it will pass4 ,when in the full length1 the end will be near the median line and in the transverse colon4 ,now let the water flow slowly1 stopping frequently1 and with one hand gently lift and work the abdomen4 ,this will both soften the contents and aid the water in reaching the farthest point4 ,it is not well to give more than a quart the first time1 as there is apt to be some prostration4 ,the tube also has the mechanical effect of raising and replacing the sigmoid1 descending colon and splenic flexure4 ,when there is lack of tone to the bowel or when very little stimulus is needed1 a half pint of cold water taken in the morning1 will often act quickly4 ,appliances which force the water into the bowel when the patient is sitting1 are not recommended1 as they tend to stretch the muscular coat by pressure from lifting a column of water4 ,hernia4--,there are several methods of replacing a hernia4 ,the first endeavor1 in every instance1 must be to reduce it1 whether it be strangulated1 incarcerated or simply protruded4 ,one of the easiest and commonest methods is to place the patient on his back1 the buttocks elevated1 the legs flexed upon the thighs1 the thighs flexed upon the abdomen1 and the limb on the affected side slightly rotated inward1 so that the columns of the ring about the hernia may be relaxed4 ,after the hernia is protruded a little more1 so that its contents may be emptied readily1 a gentle pressure with the thumb and finger is made upon the upper part of the tumor1 when the rest will follow4 ,a gurgling noise is heard upon reduction4 ,cases that cannot be reduced and are causing acute obstruction of the intestines1 should be treated surgically4 ,incomplete hernia1 which does not show externally1 may be present and cause severe reflex symptoms4 ,considerable attention has been given to this by some investigators4 ,the patient is placed in the ,trendelenburg position and the bowel lifted out of the fossa4 ,if any signs of hernia are present a well fitting truss will often cause it to heal4 ,exercises1 in a few instances1 will be beneficial4 ,appendicitis ,appendicitis is an inflammation of the appendix vermiformis4 ,in a few cases the cecum and surrounding tissues are involved 7typhlitis1 perityphlitis74 ,the vasomotor nerve supply comes from the lower three dorsals and upper two lumbars4 ,the sensory nerves make their exit from the three lower dorsals4 ,appendicitis is nearly always predisposed by injury to the innervation of the vermiform appendix and immediate region1 vertebral derangements or subdislocations from the tenth dorsal to the third lumbar4 ,the vermiform appendix is a peculiarly constructed organ1 and its function has not been determined with positiveness4 ,it undoubtedly has a function and possibly a very useful one4 ,sir ,william ,macewen#hb does not share in the general belief that the appendix is without function1 but protests against its indiscriminate removal1 believing it has a powerful influence over the function of the colon4 8,yet thousands have been operated and show no ill effect40 ,this is in keeping with the ideas of ,dr4 ,still1 who always maintained that the appendix is of importance to the human economy4 ,although the organ has been found in various localities of the abdomen1 this fact and others do not necessarily indicate that it is a functionless relic4 ,it is richly supplied with lymphatic and blood-vessels and has a peristaltic action peculiar to itself4 ,when the organ is in perfect condition1 foreign material probably would not find a lodging point in it1 on account of its peristalsis4 ,dr4 ,still#hc suggests that the appendix has a sphincter1 also the power to contract1 dilate or shorten1 should any foreign substance enter1 and he worked with this idea in view with uniform success4 ,the truth of this theory has been proved by ,abrams#hd who has demonstrated by the aid of the fluoroscope that peristalsis of the appendix can be stimulated by percussion at the #ajth dorsal and it made to empty and fill itself4 ,abrams makes use of this fact in the treatment of catarrhal appendicitis4 ,appendicitis may also be caused by fecal impactions and foreign bodies in the bowel contiguous to the appendix4 ,in these cases there is usually an impaired innervation from the spine1 due to vertebral and lower rib lesions1 resulting in a weakened muscular coat and catarrhal congestion of the mucosa4 ,in a word1 prolapse of the bowel at this point is a predisposing common cause4 ,in various instances abrasions of the coats of the tube occur1 or the innervation or vascular supply is impaired1 and pathogenic bacteria1 as bacilli coli communis1 streptococci pyogenes1 staphylococci pyogenes aureus1 typhoid bacilli1 tubercle bacilli and others1 find a favorable lodging point and determine the nature of the disease4 ,injuries to the spinal column and displacements of the vertebr in the lower dorsal and lumbar regions1 straining and lifting1 tight lacing1 torsion of the appendix1 traumatism1 impaction of feces1 concretions and foreign bodies1 acute indigestion1 indigestible food1 overeating1 exposure to wet and cold1 and infectious diseases 7as typhoid fever1 tuberculosis and influenza71 are all in the list of causes of appendicitis4 ,pathologically1 in most cases the inflammation is catarrhal4 ,this includes many of the mild attacks4 ,the mucosa is inflamed similarly to catarrhal processes elsewhere1 although the inflammation may rapidly spread to the deeper structures unless immediately cared for4 ,the inflammation may be so severe that the lumen becomes closed4 ,this is termed obliterating appendicitis4 ,when this occurs the attack may cease and danger from subsequent attacks are at an end1 but inflammation may go on to purulent involvement and even to ulceration1 gangrene and perforation or peritonitis4 ,an abscess may be within or without the appendix4 ,adhesions are likely to form about the mass4 ,symptoms4--,a sudden1 violent pain in the abdomen1 usually localized in the right iliac region1 although at first this pain may be general4 ,the point of greatest tenderness is detected over ,mc,burney's point--a point at the intersection of a line between the umbilicus and the anterior iliac spine1 with a second drawn along the outer edge of the right rectus muscle4 ,the patient usually lies on the back with the right leg drawn up4 ,the severity of pain is not indicative of the seriousness4 ,if the pain ceases suddenly1 it is commonly a serious indication4 ,there is usually fever at the onset1 the temperature being from #ajj to #ajb or even #ajd degrees ,f41 and very rarely preceded by a chill4 ,in favorable cases the temperature gradually falls1 reaching normal in from five to seven days4 ,if recovery has not begun by this time an abscess is probably forming4 ,if suppuration takes place the temperature continues with but slight fall1 although in some cases there is a rise1 or it may become almost normal4 ,pain in the right iliac fossa1 without fever1 rarely points to an acute attack of appendicitis4 ,vomiting and nausea are more or less frequent1 and more commonly present in the event of perforation or rupture of an abscess4 ,in favorable cases vomiting rarely lasts beyond the second day4 ,in the majority of cases constipation is present from the beginning of the attack1 due to paralysis of the bowels4 ,there may be diarrhea1 particularly in children4 8,urine is febrile in character with large quantities of indican4 ,the blood shows leucocytosis4 ,a leucocyte count of #bj1jjj is high and indicates an acute appendicitis1 with pus1 gangrene or peritonitis40 ,on inspection of the abdomen at the onset of the attack1 the sides look alike1 but on palpation there is rigidity of the rectus abdominis muscle and the other muscles overlying the seat of inflammation4 ,the whole abdomen may be slightly distended4 ,in the majority of cases there is a progressive development of a hard swelling or tumor in the right iliac fossa4 ,these tumors vary in size1 but are usually oval and the size of a hen's egg1 and generally situated a little above ,poupart's ligament4 ,fluctuation of the tumor is indicative of suppuration4 ,there is often great irritability of the bladder and frequent micturition4 ,a sudden fall in the temperature often indicates that a perforation has taken place1 or that a small abscess has ruptured into the intestines4 ,in favorable cases the temperature falls at the end of the third or fourth day1 the pain lessens1 the tongue becomes clearer and the bowels are moved4 ,if the tumor persists1 the patient is very liable to have a recurrence of the condition4 ,rapid growth of the tumor and aggravation of the several symptoms point to suppuration1 especially extreme tenderness over the point of inflammation4 ,if the appendicitis goes on to suppuration1 there is danger of rupture into the peritoneum4 ,in a few cases the abscess may rupture into the bowel1 in which case the patient recovers4 ,other terminations are lumbar abscess1 hepatic abscess and perinephritic abscess4 ,death may be caused by septicemia or pylephlebitis4 ,these events may be delayed a variable length of time1 depending upon the extent and strength of the adhesions that form about the abscess4 8,the gravity of the appendix disease lies in the fact that from the very outset the peritoneum may be infected2 the initial symptoms of pain1 with nausea and vomiting1 fever1 and local tenderness1 present in all cases1 may indicate a widespread infection of this membrane40 7,osler74 ,he also says local signs are not so trustworthy as the general symptoms4 ,there is liability to relapse in appendicitis4 ,the attacks may recur for years at different intervals4 ,in some cases these intervals are very short4 ,in some cases perfect recovery may take place after repeated attacks4 ,diagnosis4--,in many cases the diagnosis is easy1 but other cases require careful study and close observation4 ,sudden pain becoming localized1 tenderness and rigidity in the right iliac region are three symptoms that together almost positively indicate appendicitis4 ,the leucocyte count is of particular value4 ,a pseudo-appendicitis1 with all symptoms of true appendicitis in the initial stage1 may be caused by the downward dislocation of the twelfth rib on the right side1 and occasionally the eleventh rib on the same side4 ,the rib lies obliquely downward toward the crest of the ilium4 ,in a few cases the obliquity of the lower rib is so great as to very nearly touch the ilium4 ,the dislocated rib may produce severe irritation1 pain1 tenderness1 rigidity1 and even inflammation1 of the abdominal muscles4 ,the patient nearly always complains of the pain being deeply seated1 thus possibly confusing one4 ,in typhoid there is a gradual development of the fever1 characteristic temperature curve1 enlargement of the spleen1 epistaxis and diarrhea4 ,the ,widal test should be made4 ,the absence of fever and intermittent pain in the abdomen1 with complete constipation1 fecal vomiting1 general distention of the abdomen1 bloody stools and marked tenesmus would determine intestinal obstruction4 ,in tubal disease a gradual onset1 a more dull and constant pain1 the history1 and pelvic examination will usually differentiate this disorder from appendicitis4 ,kelly#he gives these points in differential diagnosis1 between acute salpingitis and appendicitis3 8,in the former it will usually be found that there has been a yellowish vaginal discharge for some period before the attack4 ,the local pain and tenderness1 usually located deeper in the pelvis1 is most intense on palpation in the region of ,poupart's ligament4 ,on vaginal examination exquisite tenderness is felt on either side of the uterus40 ,in biliary colic the pain is higher along the biliary ducts and gall-bladder1 extending even as high as the shoulder1 and jaundice is generally present4 ,in renal colic the pain extends along the ureters down to the inner side of thigh and testicle1 and back into lumbar region4 ,there is absence of fever and rigidity4 ,the pain in perinephritic abscess is downward into groin1 as in nephritic colic1 and there is tenderness of the lumbar region4 ,exploratory incision may be necessary4 ,prognosis4--,naturally1 the prognosis depends upon the character of the appendicitis1 but on the whole the prognosis is favorable4 ,a large proportion of cases recover4 ,surgical operations are many times deferred until too late2 undoubtedly on account of the uncertainty of the condition4 ,still1 on the other hand1 many serious cases recover under the proper treatment when an operation seemed almost absolutely necessary2 all going to prove the fact that very much depends upon diagnosis of the true condition4 ,the statement that there is 8no medical treatment for appendicitis10 seems rather broad in view of the report of the medical inspector#hf of the ,french ,army in ,algeria4 ,out of #ffh patients suffering from appendicitis1 #ahh were operated upon and #bc died1 while #djh were treated medically and only three died4 ,he concluded that a meat diet tended to increase the number of cases4 8,it is exceedingly common and the prognosis is1 on the whole favorable4 ,tafft1 of ,copenhagen1 found adhesions in the neighborhood of the appendix in #ce percent1 of all bodies subjected to post-mortem examinations#hg4 ,treatment4--,confine the patient in bed at once4 ,cases have undoubtedly been lost by not enforcing this point4 ,attempts should be made to correct the disordered condition of the dorsal and lumbar regions4 ,thorough and careful treatment should be given at this point1 and in most instances the pain can be relieved by correction of the disordered vertebr4 ,if the case is seen at the beginning of the attack1 careful manipulation that especially lifts the cecum and surrounding structures and local application of ice are indicated4 ,however1 great care should be exercised here1 for some of the most severe cases show no induration4 ,temperature1 pulse1 and blood picture are invaluable as guides4 ,when the case is advanced1 extreme care should be used in manipulating over the swollen and inflamed region4 ,hot applications will be helpful in such instances4 ,when due to fecal impaction and foreign bodies1 thorough1 direct1 elevating treatment over the involved region1 and high rectal injections are indicated4 ,this applies to the onset1 for if the disease has progressed to the point where pus may be present1 the bowel must be absolutely at rest4 ,do not give or allow to be given purgatives at any stage of the disease4 ,when sure that there is no pus1 direct1 careful work over the cecum and appendix is allowed and is of value4 ,it should be a lifting of the colon and relaxing of nearby tissues1 to promote the circulation4 ,treatment of the spine is necessary in all cases1 to relieve pain1 to correct the nerve and vascular supply1 and to increase peristalsis so as to remove irritating bodies from the vermiform appendix4 8,colitis follows appendectomy more frequently than any other abdominal operation4 ,the explanation for this is that the appendicitis is seldom localized in the appendix but is complicated by colitis1 or rather the colitis is complicated by the appendicitis4 ,in such cases1 removal of the appendix aggravates rather than alleviates4 ,a conclusion to be drawn is1 to carefully palpate the colon in all appendicitis cases and reserve diagnosis1 prognosis and advising of an operation until it can be definitely determined as to the location1 extent and degree of the disease4 ,the formation of pus is an indication requiring immediate evacuation4 8,if good surgical advantages are available and the case begins with considerable virulence and a surgeon can be had within the first twenty four hours1 it is in all probability best to operate2 but if the case begins slowly or no good hospital advantages are available1 or if the case is not seen until some forty-eight hours have elapsed after the onset1 in all probability it is strictly an osteopathic case and should not be touched by surgery4 ,some advocate in all instances to wait until pus is formed before operative procedure is resorted to4 ,this is a rather dangerous attitude to take1 for ,i have seen hundreds of cases operated and have operated upon a great many myself and ,i have never seen a case die unless it was a pus case40--,s4 ,l4 ,,taylor4#hh ,the case should be most carefully watched1 and a surgeon should be promptly called for consultation if the occasion demands it in the least2 and if thought advisable1 operation should be resorted to before too late4 ,do not assume too much responsibility in these cases4 ,the patient should be nourished on a restricted diet of milk and animal broths4 ,asa ,willard#hi strongly recommends no food by mouth1 as it is bound to set up peristalsis and cause increased irritation4 ,he sustains the strength by rectal feeding4 ,this view is held by other authorities1 even to withholding water when the inflammation is at its height4 ,tasker confirms the advisability of restricted feeding and advises resting the bowel even to the point of discontinuance of food4 ,the course of the attack is usually so short that there is no danger of starvation and little loss of strength results4 ,this point is a highly important one in cases of any degree of severity4 ,in chronic cases of a fibrotic character1 no pus1 carefully lifting the parts and loosening adhesions in addition to spinal adjustment will often restore normal circulation4 ,these conditions aside from the local disorder frequently cause hyperchloridia and other digestive disturbances4 ,diseases of the ,liver and ,bile ,duct ,primary diseases of the liver will invariably present osteopathic lesions from the fourth or fifth dorsals to the eleventh or twelfth4 ,the ribs on the right side are commonly involved4 ,these lesions probably disturb the liver by way of the vasomotor fibers4 ,displacements of the duodenum1 of the hepatic flexure and transverse section of the colon and displacements of the right kidney are frequent sources of liver disorders4 ,care should be taken in differentiating primary from secondary diseases1 for naturally the relative importance of the various factors in treatment will vary4 ,in many secondary diseases there will be found predisposing osteopathic lesions1 and these secondary disorders and degenerations can at least be palliated and occasionally the degeneration retarded or stopped by persistent osteopathic treatment1 diet1 and hygienic measures4 ,hyperemia of the ,liver ,this is an abnormal fullness of the blood-vessels of the liver1 followed by an enlargement of that organ4 ,it is active when there is abnormal pressure in the portal veins 7afferent vessels72 passive when there is excessive pressure in the sublobular veins 7efferent vessels74 ,osteopathic ,etiology and ,pathology4--,active hyperemia is usually due to indiscretions in diet4 ,after each meal a physiological hyperemia of the liver occurs1 which is greatly increased by habitually overeating and overdrinking4 ,this condition may lead to functional disturbance and possibly to organic change4 ,traumatism and lesions of the vertebr and ribs1 irritating vasomotor nerves1 are important4 ,habitual constipation1 malaria1 heat1 and arrested menstrual epoch1 and infectious fevers are also causes of the active form4 ,enteroptosis is not a rare cause4 ,passive hyperemia is due to obstructions of the efferent circulation4 ,valvular heart disease is the most common cause4 ,lung diseases1 as emphysema or cirrhosis2 obstruction to the vena cava or interference with the flow of blood through the liver2 and diseases of the pleura1 are among the causes4 ,most cases of congestion of the liver present lesions to the vasomotor nerves of the liver1 fifth to ninth dorsal4 ,especially are the ribs over the liver apt to become displaced and affect the organ4 ,pathologically1 the liver is enlarged and engorged with blood4 ,the appearance of the organ depends upon the duration of the hyperemia4 ,in passive hyperemia the central portion of the lobule and the area of the hepatic vein are deeply colored4 ,the periphery and the area of the portal vein are pale4 ,this alternation of the dark and light color gives rise to the nutmeg liver1 which is so noticeable upon section4 ,in cases of long standing1 atrophy of the liver cells and overgrowth of connective tissue result4 ,symptoms4--,active ,hyperemia4--,dull aching and a sense of fullness in the right hypochondrium1 aching of the limbs1 coated tongue1 nausea1 vomiting1 constipation1 highly colored urine1 and slight jaundice4 ,in passive hyperemia the symptoms are the same1 but less marked4 ,the onset is gradual and the liver may attain considerable size4 ,in severe cases following tricuspid regurgitation the liver may pulsate4 ,in severe cases dropsy takes place4 ,diagnosis4--,active hyperemia is occasionally confounded with catarrhal jaundice4 ,usually congestion of the liver is easily diagnosed4 ,prognosis4--,in active hyperemia the prognosis is good1 unless repeated attacks lead to atrophic degeneration4 ,in passive hyperemia the prognosis depends entirely upon the cause4 ,treatment4--,active hyperemia4--,the treatment consists of measures which tend to diminish the congestion1 principally a thorough1 direct manipulation over the liver by raising and spreading the ribs4 ,careful and thorough treatment to the dorsal splanchnics of the liver is also indicated4 ,the substitution of a scanty for a heavy diet is essential4 ,the foods given should be such as are easily digested1 as milk and broths2 fats and sugars are to be avoided4 ,in passive hyperemia the treatment consists of correcting the disorder causing it4 ,often heart diseases are the cause4 ,a thorough depletion of the bowels will aid largely in relieving ascites that may follow passive congestion 7,see ascites74 ,in liver congestions it is well to pay attention to the intestinal condition in order that the circulatory mechanism here may be thoroughly coordinated with the hepatic4 ,simple ,catarrhal ,jaundice ,definition4--,jaundice due to inflammation of the terminal portion of the common duct1 not the result of impacted gall-stone4 ,the disease probably starts as a catarrhal inflammation of the stomach and upper portion of the small intestine4 ,the bile is retained and absorbed4 ,osteopathic ,etiology and ,pathology4--,a frequent predisposing cause is the subdislocation of the tenth rib on the right side1 thus interfering with the innervation to the bile ducts1 and causing congestion of the mucous membrane of the common duct2 although lesions above and below this point may occur4 ,extension of gastro-duodenitis into the common duct is a common source of the inflammation4 ,sagging of the duodenum will disturb the bile-duct through its being a portion of the duodeno-hepatic ligament4 ,duodenal catarrh usually follows errors in diet1 exposure1 malaria1 ,bright's disease1 portal obstruction and chronic heart disease4 ,infectious fevers1 as pneumonia and typhoid fever1 and emotional disturbances are among the causes4 ,catarrhal jaundice may occur in epidemic form4 ,pathologically1 the duodenal end of the duct is most commonly involved4 ,the mucous membrane is swollen and the orifice fills with mucus4 ,the inflammation may involve the common and cystic ducts and even the hepatic4 ,the liver is enlarged and the gall-bladder distended4 ,symptoms4--,the only symptom present may be simply the jaundice4 ,there is always tenderness upon pressure over the ducts4 ,the patient many times complains of a stabbing pain when pressure is exerted over the duodenal opening4 ,usually the course of the bile duct can readily be felt upon deep pressure1 owing to the tumefaction4 ,accompanying this condition may be general malaise1 loss of appetite1 nausea1 vomiting1 constipation or irregular action of the bowels1 pains in the back and limbs and a slight fever4 ,diagnosis4--,where jaundice is present without pain1 it generally indicates catarrhal jaundice4 ,the absence of emaciation or of evidences of cancer or cirrhosis usually makes the diagnosis easy4 ,good general nutrition and a negative physical examination favor simple jaundice as to the diagnosis4 ,prognosis4--,the prognosis of catarrhal jaundice is favorable1 unless accompanied with infectious diseases or hypertrophic cirrhosis4 ,when diseases are associated with jaundice the danger is usually from the disease4 ,the duration of the disease is generally given as from two to eight weeks1 but osteopathic treatment generally lessens that time at least one-half4 ,treatment4--,the treatment is directed toward relieving the inflammation of the bile ducts and increasing the flow of the bile into the intestines4 ,great relief to the patient will be experienced from thorough treatment over the bile ducts1 especially at the duodenal end4 ,press slowly but firmly over the region of the ducts1 then execute a downward motion with firm pressure over the course4 ,this performance should be repeated several times1 until the tenderness in this region is almost or entirely relieved4 ,the idea of this treatment is1 first1 to slowly but firmly bear down upon the abdominal muscles over the congested tissues1 so as to relax the tissues and get as close to the ducts as possible1 and second1 with the downward movements to reduce the congestion of the ducts and at the same time to remove any mucus or other material from the orifice1 thus allowing a freer flow of bile4 ,it will be recalled that the normal flow of bile is under very low pressure4 ,care should be taken not to gouge or dig into the tissues with the ends of the fingers1 but to use the flat surface of the fingers4 ,any gouging or severe treatment will not allow one to accomplish his purpose1 owing to the stimulus or irritation it would give the abdominal muscles and thus cause them to contract2 and furthermore1 it would more or less bruise the parts4 ,an inhibitory treatment should be given along the spine on the side affected to help relax the abdominal muscles before this treatment is administered4 ,in all circulatory disturbances of the bile-duct and other hepatic tissues lift the duodenum at about the second lumbar where it lies beside the ascending colon4 ,this tends to release portal vein1 hepatic artery and bile-duct1 the duodeno-hepatic ligament4 ,direct treatment is given to the liver by more or less kneading or working the organ and also by raising and spreading the ribs4 ,this treatment is to stimulate the activity of the liver4 ,reaching under the cartilages of the eighth and ninth ribs on the right side and bearing inward and downward will empty the gall-bladder and thus be of aid in relieving the tension in the biliary passages4 ,it is probably a stimulus to these cutaneous fibers that causes a relaxation of the sphincter muscles of the gall-bladder and thus allows it to empty4 ,stimulation of the tenth nerve contracts the gall-bladder4 ,then it should also be noted that work over the duodenal end of the bile-duct relaxes the orifice while through reciprocal relationship the fibers of the gall-bladder contract4 ,when all of the muscles of the hepatic region have been carefully relaxed and softened1 a thorough examination can then be made of the vertebr and ribs that might embarrass the innervation or vascular supply of the liver4 ,lesions of the vertebr and ribs affecting the liver may occur from the sixth to the eleventh dorsal4 ,lesions to the vagus and phrenic nerves may occasionally involve the organ4 ,irrigation of the large bowel with cold water may be employed4 ,the cold excites peristalsis of the gall-bladder and ducts4 ,drinking freely of water will be helpful4 ,a non-stimulating diet should be given4 ,the stomach may not be in a condition to bear solid food2 and furthermore1 food on entering the duodenum will increase the local inflammation of the common bile duct4 ,give diluted milk1 buttermilk1 light meat-broths1 clam-broth1 egg albumin and pressed beef juice4 ,after the pain1 vomiting and fever subside1 the diet can be gradually increased4 ,cholecystitis ,cholecystitis is an inflammation of the gall-bladder caused by infection4 ,stagnation of bile due to obstruction 7especially gall-stones7 of the bile ducts1 or a slowing of the bile flow owing to deranged innervation from osteopathic lesions or sagging bowel1 are predisposing factors4 ,fibrotic changes in the appendix are fairly common sources that derange the nervous reflexes of the biliary function4 ,the disorder may be associated with specific fevers4 ,exciting factors are the colon bacilli1 streptococci1 staphylococci1 typhoid bacilli1 and pneumococci4 ,symptoms4--,the gall-bladder feels hard and full4 ,there is inflammation and thickening of the mucous membrane1 with considerable increase of mucus4 ,owing to the infection there may be ulceration and suppuration1 with possible perforation and peritonitis4 ,when the inflammation extends outside of the bladder there are usually adhesions4 ,the onset is commonly sudden1 with pain and tenderness in the right hypochondrium4 ,great care should be taken in deciding the location of the inflammation1 for the pain and tenderness may be over the stomach1 or along the duodenum or ascending colon as low as the cecum4 ,nausea1 fever1 constipation1 and possibly jaundice1 are other symptoms4 ,treatment4--,exercise special care in treating these cases4 ,although in many instances the inflammation will rapidly subside1 still owing to suppuration there is danger of aggravating the condition4 ,it is better1 in doubtful cases1 to confine the treatment to spinal work1 and to influence drainage by placing the patient in knee-chest position and carefully raise cecum1 ascending colon and duodenum4 ,rest1 restricted diet1 plenty of water1 and hot fomentations will be beneficial4 ,in severe cases surgical interference is indicated4 ,jaundice 7,,icterus7 ,jaundice is a symptom and not a disease4 ,it consists of the discoloration of the skin and other tissues by material derived from the bile4 ,the discoloration may vary from a mere paleness to a yellow or brown olive hue4 ,toxic jaundice occurs in acute yellow atrophy1 pernicious anemia1 pyemia1 specific fevers1 and the action of poisons4 ,obstruction by foreign bodies as gall-stones and parasites are important causes4 ,inflammation and swelling of the biliary ducts and duodenum are common causes as well as stricture of the duct by tumors and various growths1 either internal or external1 to the biliary ducts4 ,in some instances pressure from without by the pancreas1 stomach1 kidneys1 enlarged glands1 fecal matter1 a pregnant uterus1 etc41 has been the cause4 ,irritations and obstructions of the splanchnic nerves1 due to lesions in the lower dorsal vertebr and the ribs from the sixth to the eleventh1 will often markedly affect the liver4 ,also lesions at these points may predispose to inflammation and tumefaction of the bile ducts4 ,symptoms4--,besides the discoloration of the skin1 there is itching of the skin1 on account of bile pigment deposits2 even eruptions may occur4 ,the mucous membranes are often colored and a constant symptom is the bright yellow discoloration of the sclerotic coat of the eye4 ,the secretions are colored4 ,it may be first noticed in the urine4 ,the perspiration is colored1 rarely the saliva and tears4 ,there is frequent sweating4 ,as very little bile passes into the intestine1 the feces are pale and gray1 and sticky4 ,the bowels are generally constipated1 but diarrhea may occur1 owing to decomposition resulting from absence of the normal ingredients4 ,other symptoms may be associated with the gastro-intestinal derangements1 as nausea1 fetid breath and loss of appetite4 ,a slow pulse may occur1 due probably to some stimulating effect on the inhibitory action of the vagus nerve4 ,lesions are often found at the atlas and axis1 affecting the vagus4 ,pain back of the right scapula is a symptom of liver trouble2 it has been suggested that it is due to a stimulus passing up the vagus to the spinal accessory1 and thence to the trapezius muscle4 ,various cerebral symptoms may be present1 as great depression1 irritability1 headache and vertigo4 ,in severe cases there may be delirium and coma4 ,in hemolytic and toxic jaundice the destruction of blood is due to some toxic agent4 ,the feces are not clay colored and the urine is less stained with bile4 ,the general symptoms may be very severe depending upon the underlying cause4 ,diagnosis4--,to mistake for jaundice the dirty yellowish discoloration of the skin commonly termed sallowness is an error often made4 ,this condition indicates malaria1 uterine disease or general ill health4 ,very likely it is an anemia and is readily diagnosed from the jaundice as the secretions and conjunctiva are not stained4 ,addison's disease somewhat resembles jaundice1 but the feces are normal1 the urine and sclerotic coat are not colored1 but exposed portions of the body and flexures of the joints are deeply stained4 ,prognosis4--,depends entirely on the cause producing it4 ,ordinary cases run from two to six weeks1 while others may not recover for several months4 ,jaundice from impaction of the bile ducts may be manifest for only a few days4 ,toxic form may terminate fatally1 owing to the disease causing it4 ,the extent of resorption of bile and destruction of red blood cells in the liver varies to a considerable degree4 ,treatment4--,the treatment for the different forms resulting secondarily will be found under the diseases causing them4 ,a simple icterus1 caused by disturbance through the innervation of the liver and bile ducts directly1 can be relieved readily by thorough treatment of the liver and bile ducts as described under catarrhal jaundice4 ,carefully raise the intestines if they are prolapsed1 especially the colon and duodenum4 ,cirrhosis of the ,liver ,this is a chronic disease of the liver1 characterized by hyperplasia of the connective tissue with destruction of the liver cells1 resulting in the organ becoming hard and usually small4 ,etiology4--,the disease usually occurs in the male sex and in middle life4 ,when occurring in children1 it is commonly of the syphilitic form1 though it may be due to other infections4 ,the abuse of spirituous liquors is a common cause4 ,it follows chronic diseases1 such as syphilis1 long continued malarial intoxication1 gout and tuberculosis4 ,passive congestion1 due to chronic heart and lung disease1 causes some cases4 ,a few cases are caused by inflammation of the bile ducts1 due to infection and obstructing calculi2 others to a stimulating diet1 while some cases are inexplicable4 ,pathologically1 the first stage is hyperplasia of the connective tissue and consequent enlargement of the organ4 ,as this increases the connective tissue destroys immense numbers of the hepatic cells1 owing to the pressure4 ,often the enlargement is accompanied by tenderness4 ,in the later stage the overgrowth of imperfectly developed tissue seems to contract the hepatic cells that still remain1 causing atrophy and degeneration of most of them1 and thus reducing the size of the organ1 which is followed by sclerosis4 ,the portal and hepatic circulations are greatly obstructed4 ,an occasional form is termed hypertrophic sclerosis in which sclerosis is found while the organ continues enlarged4 ,there are two common and well defined varieties1 atrophic cirrhosis and hypertrophic cirrhosis2 other forms 7rare7 are met with4 ,atrophic cirrhosis is the common form1 and is usually due to alcoholic excess4 ,the surface of the liver is rough and uneven in addition to its hardness and reduction in size4 ,it may also be greatly deformed and covered with granulations 78hob-nails074 ,the normal weight is four or five pounds1 but it may be so reduced as to weigh no more than one pound or a pound and one-half4 ,sometimes there is fatty infiltration1 which enlarges the liver to such an extent that the contraction is not noticed4 ,there is an overgrowth of the connective tissue1 which contracts and constricts the branches of the portal vein1 causes atrophy and degeneration of the hepatic cells1 and even sometimes obliterates the bile ducts4 ,the new connective tissue is well supplied with blood-vessels from the hepatic artery1 thus aiding greatly in the growth4 ,in the hypertrophic form1 as well as in the atrophic cirrhosis1 there is an overgrowth of connective tissue1 but in the hypertrophic form the new form of tissue exhibits no disposition to contract4 ,the enlargement of the organ is largely due to hyperemia4 ,as the tissue does not contract there is no pressure on the portal vein and atrophy is prevented4 ,there is early jaundice 7which is a characteristic symptom7 owing to obstruction of the biliary channels4 ,the surface is smooth and its color is greenish yellow4 ,symptoms4--,atrophic ,form4--,there may be practically no symptoms4 ,as there is obstruction of the portal circulation1 there may be congestion of the stomach and intestines1 resulting in chronic gastric or intestinal catarrh having the following symptoms--anorexia1 distress after eating1 distention1 constipation and coated tongue4 ,owing to the anastomotic communication between the portal and caval circulations1 as the portal circulation becomes more obstructed1 the superficial abdominal veins become greatly distended4 ,hemorrhoids occur1 owing to the communication of the superior hemorrhoidal1 which is a branch of the portal vein through the inferior middle hemorrhoids1 with the hypogastric vein and the vena cava2 hence hemorrhoids are a characteristic symptom4 ,there is enlargement of the spleen and hemorrhage from the stomach or bowels4 ,edema of the legs and ascites are due to engorgement of the portal system4 ,ascites is much more common than edema of the legs4 ,there may be slight jaundice1 although this is a rare symptom in atrophic cirrhosis4 ,there is always decided emaciation4 ,on examination there is a diminished area of hepatic dullness1 while the splenic dullness is enlarged4 ,it is often impossible to outline these organs1 as the abdominal distention prevents it4 ,the urine is scanty1 high colored and often loaded with urates1 but seldom bile-stained4 ,in the hypertrophic form slight jaundice appears at the onset1 which gradually deepens until it is intense and persistent4 ,occasionally there is fever4 ,the disease as a rule is decidedly chronic1 though acute symptoms may develop at any period4 ,the urine is often bile-stained1 but of normal quantity4 ,on examination the liver is large1 smooth and round and can be felt below the ribs4 ,the spleen is greatly enlarged4 ,diagnosis4--,in atropic cirrhosis4--,with ascites without dropsy elsewhere1 history of alcoholism1 hemorrhage from stomach or bowels and reduction in size of liver1 the diagnosis is absolute4 ,hypertrophic cirrhosis4--,in cancer of the liver the patient is advanced in years1 has no splenic enlargement1 and more commonly ascites is present2 while in hypertrophic cirrhosis there is chronic biliary obstruction1 the liver is only moderately enlarged and hard1 marked jaundice1 with causes leading to or evidence of hepatic obstruction4 ,this form of cirrhosis is also to be differentiated from amyloid liver and echinococcus cyst4 ,prognosis4--,unfavorable1 although in some cases the disease can be arrested during the early stage1 provided the habits are regulated and treatment is continuous and persistent4 ,death usually occurs from one to two years after appearance of dropsy4 ,ascites is difficult to contend with4 ,treatment4--,if the disease is recognized at the beginning and persistent treatment given to the liver1 the chances are that atrophy of the cells and connective tissue formation will not take place4 ,but ordinarily cases of cirrhosis are incurable4 ,the most that can be done is to reestablish a compensatory circulation in the liver4 ,otherwise it would be no more unreasonable to say that one could cure a chronic valvular lesion of the heart4 ,the patient should live a quiet outdoor life4 ,alcoholic drinking should be stopped4 ,the diet should be light and nutritious1 preferably a milk diet4 ,the bowels should be kept open1 the skin active and the kidneys closely watched4 ,fatty ,liver ,in fatty infiltration there is no loss of function4 ,the fat infiltrates the cell1 crowding aside the protoplasm4 ,this is largely a normal process1 though fatty degeneration may be associated4 ,in fatty degeneration the cell loses its structure and is changed into fatty tissue4 ,chronic intoxication from infectious diseases1 such as phthisis puerperal fever1 typhoid fever1 pneumonia and syphilis are the principal causes4 ,alcoholism and phosphorous poisoning are other causes4 ,amyloid ,liver ,there is infiltration into the tissues of the liver1 of the so-called amyloid substance4 ,the infiltration begins in the blood-vessels1 the hepatic artery first1 then the central zone or periphery1 and finally all structures of the liver4 ,this disorder should be viewed as a disturbance of metabolism4 ,etiology and ,pathology4--,this condition is usually found in cases of prolonged suppuration1 especially associated with tubercular disease of the bones as in hip-disease1 syphilis1 rickets1 malaria1 cancer and leukemia4 ,it is believed by some to be the result of microbic invasion1 especially the tubercle bacillus and staphylococcus4 ,lesions are frequently found from the fifth to the tenth dorsal vertebr1 which probably act as predisposing factors4 ,the liver is considerably enlarged and rounded4 ,it is pale or waxy in appearance and is doughy in consistency4 ,on section it is anemic and whitish1 partly due to infiltration into the walls of the blood-vessels narrowing the lumen4 ,the amyloid changes may be circumscribed and in some cases fatty infiltration is present4 ,symptoms4--,there are no characteristic symptoms except the enlargement of the liver1 although the complexion may be waxy and there may be some gastro-intestinal disturbances4 ,pain is absent1 although occasionally there is a dragging sensation1 due to the weight of the organ4 ,jaundice is not present1 but the stools may become light colored1 owing to a diminished secretion of bile4 ,the urine may be increased in amount and contain some albumin if amyloid occur in the kidneys4 ,emaciation and anemia are present and ascites seldom occurs4 ,amyloid changes involve the spleen1 kidneys1 intestines and other organs4 ,diagnosis4--,the organ being large1 hard and smooth1 with absence of jaundice and ascites1 the presence of albuminuria and an enlarged spleen and with the history of the case1 mistakes are not likely to be made4 ,prognosis4--,depends upon the cause4 ,the progress may be rapid or slow4 ,treatment4--,careful attention to the primary disturbing factor and direct treatment to the liver will1 in some instances1 reduce the size of the organ4 ,nitrogenous food and hygienic measures should be instituted4 ,the vasomotor nerves of the portal system 7fifth to last dorsal7 should be treated thoroughly4 ,gall-,stones ,gall-stones are concretions that originate in the gall-bladder and occasionally in the hepatic ducts4 8,the primary formation of gall-stones is itself largely dependent upon stagnation of bile1 such as may arise in the gall-bladder if an intermittent or incomplete closure of the cystic duct be brought about by such things as tight lacing1 pregnancy1 or even unequal sagging of the abdominal viscera40--,mac,callum4 ,the stone is largely composed of cholesterin1 and may form without any inflammation of the gall-bladder1 owing probably to the stagnation affecting the bile salts so that the cholesterin is precipitated instead of being held in solution4 ,more often there is inflammation of the wall of the gall-bladder due to micro-organisms4 ,this causes an exudate from which is derived the calcium4 ,the calcium with bilirubin is deposited in layers on the stone which give it the various colors of yellow1 brown or green4 ,a rare type is one formed in the hepatic ducts1 which is soft1 green1 and composed of calcium bilirubin concretions4 ,the stones 8contain a great deal of organic material derived from desquamated epithelial cells and coagulated albuminous matter1 as well as pigment40 ,the colon bacilli1 staphylococci1 streptococci1 typhoid bacilli1 and pneumococci are the bacteria most frequently found4 ,a cholecystitis may be a predisposing factor or it may be secondary to the concretion4 ,osteopathic ,etiology and ,pathology4--,this is a disease of middle life and is more frequently found in women4 ,sedentary habits and constipation combined with overeating1 are other important factors4 ,it is found in stout subjects who are particularly fond of starchy and saccharine food4 ,catarrhal jaundice is a predisposing factor4 ,depressing mental influences may predispose4 ,the thicker the bile the more likely it is to deposit4 ,dr4 ,still's theory is that lesions of the ribs on the left side from the sixth to the tenth dorsal are factors in the formation of the stones as they interfere with pancreatic secretions4 ,no matter how it comes about1 the fact is that in all cases of gall-stones the osteopath finds lesions to the eighth1 ninth and tenth ribs on the left side1 as well as lesions from the fifth or sixth to the tenth dorsal1 deranging innervation to the liver and bile ducts4 ,it is possible that lesions over the spleen probably interfere with the activities of the spleen and thus in some manner this organ does not properly elaborate the blood before it passes to the liver4 ,sagging of the duodenum may1 through tension on the duodeno-hepatic ligament1 interfere with the flow of bile4 ,this would cause derangement of the nervous reciprocal relationship between opening at duodenal orifice and gall-bladder4 ,in carcinoma of the liver and stomach1 gall-stones are said to be frequent4 ,the stone itself is a brownish object1 nearly spherical1 faceted and in some instances polygonal in shape1 varying in size from a pea to a hen's egg4 ,the stones are found anywhere in the biliary tract from the duodenal orifice to the ramification of the bile vessels4 ,usually there is more or less of an accumulation in the gall-bladder4 ,at any point the stone may produce ulceration and suppuration4 ,perforation may occur into the peritoneal cavity or adjacent organs4 ,symptoms4--,gall-stones may be in the gall-bladder for years without giving rise to any symptoms4 ,their presence is made known only by their expulsion from the gall-bladder4 ,if they lodge in the duct in transit from the gall-bladder to the duodenum biliary colic is produced1 which is the characteristic symptom of an impacted gall-stone4 ,small stones may pass into the intestine without producing symptoms4 ,the pain is very sudden1 piercing and excruciating in the region of the gall-bladder1 when a stone attempts to pass4 ,the pain radiates through the abdomen1 right chest and shoulder1 and the patient writhes in agony and occasionally faints4 ,downing#ij emphasizes the point that when a patient comes in with a history of repeated attacks of biliary colic and no stone found in the stools one should at once suspect that one of considerable size obstructs the common duct4 ,there is always tenderness in the biliary region with more or less contraction of the abdominal muscles4 ,nausea1 vomiting and sweating are usually present1 followed by a weak pulse1 cool skin and pale and anxious face4 ,fever is soon present and a chill is common4 ,the paroxysms continue as long as the stone remains lodged1 which may be from an hour to several days4 ,there are remissions of pain1 entire relief being given as soon as the stone reaches the duodenum4 ,jaundice usually follows a prolonged attack4 ,the liver is sometimes enlarged4 ,the spleen is enlarged4 ,should the stone become impacted1 ulcerative perforation1 with consequent peritonitis and shock1 follows4 ,diagnosis4--,the diagnosis is conclusive when the gall-stones are found in the stools or when they can be felt in the gall-bladder4 ,all the above symptoms are characteristic4 ,if a patient complains of severe pain radiating from the hepatic region1 and nausea and vomiting are present1 subsiding suddenly with a slight jaundice1 the disease should hardly be mistaken4 ,tenderness over the gall-bladder frequently indicates infection or gall-stones or both4 ,radiographic examination may be of aid4 ,nephritic colic should never be confounded with hepatic colic as in the former the pains start in the lumbar region and radiate downward into the groin1 the testicle and the inside of the thigh4 ,in appendicitis1 jaundice and bile-stained urine are not found4 ,a pseudo-biliary colic is occasionally found in nervous individuals especially when the eleventh and twelfth ribs 7or ribs as high as the seventh7 on the right side are displaced downward4 ,prognosis4--,is usually favorable4 ,ulceration1 perforation1 and suppuration may prove fatal1 although much depends upon surgical interference4 ,treatment4--,during the attack of biliary colic1 the osteopath should usually be able to readily locate the position of the gall-stone in its transit from the gall-bladder4 ,he should usually proceed at once to aid the stone in its downward passage by careful manipulation over the duct4 ,still this treatment should be given with great caution1 for if there is suppuration or ulceration1 perforation and resultant peritonitis may occur4 ,usually one will not have much difficulty in dislodging the stone and relieving the sufferer in a few minutes4 ,the recumbent position1 with the thighs flexed on the abdomen1 is the position assumed for treatment1 and if the muscles in the hepatic region are very tense and rigid1 interfering with locating the gall-stone1 an inhibitory treatment to the posterior spinal nerves supplying the contracted muscles will aid one materially4 ,an inhibitory treatment of the nerves of the biliary tract 7the ninth and tenth dorsals71 may be a helpful measure in dilating the duct4 ,also1 hot application over the affected area and to the dorso-lumbar region will aid4 ,during remissions two or three treatments per week should be given to correct the lesions at the eighth1 ninth1 tenth and eleventh segments4 ,give particular attention to any enteroptosis that may be found4 ,average cases should not require more than two or three months' treatment4 ,hildreth1 who has had many cases1 is much opposed to operation as his experience has been that where there is not complete obstruction the correction of lesions will prevent further formation of stones4 ,while he finds the trouble ranges from the third to the eighth dorsal1 still1 as a rule1 it is between the fifth and sixth that best results are obtained4 ,probably if the treatment is a rightly directed one the stones already formed may be disintegrated4 ,willard#ia reports #cic cases4 ,permanently impacted gall-stones require surgical treatment4 ,prophylactic treatment1 as a regulated diet1 daily exercise and a discontinuance of excesses1 should be strongly urged4 ,the patient should not be allowed any fatty or saccharine food4 ,water freely taken will be of aid4 ,diseases of the ,spleen ,diseases of the spleen are usually secondary to other disorders4 ,the following osteopathic treatment under ,splenitis will1 in addition to the probably primary disturbance1 be applicable to active and passive splenic hyperemia and amyloid degeneration of the spleen4 ,surgical and other measures are to be employed when indicated4 ,owing to the role that the spleen plays in infections1 the osteopath pays considerable attention to stimulating the organ through its spinal innervation in these cases4 ,splenitis ,in acute splenitis there is generally a blocking up of the smaller splenic arteries by fibrous coagula 7hemorrhagic infarct71 which have formed in the left ventricle of the heart in consequence of endocarditis4 ,malarial infections1 septicemia1 typhus and acute exanthematous fevers may cause coagula formation in the splenic veins4 ,injuries to the vertebr or ribs on the left side over the spleen 7ninth to eleventh ribs inclusive7 are occasionally the predisposing cause of primary inflammation of the spleen4 ,following the formation of abscesses the entire organ may suppurate2 it may produce pyemia1 or it may burst and the pus be discharged into the peritoneal sac1 causing peritonitis1 or into the pleura1 stomach or colon4 ,chronic splenitis is induced by passive congestion1 leukocythemia and splenic anemia4 ,symptoms4--,tenderness and enlargement of the spleen are the principal symptoms4 ,the organ may be twice its normal size1 but in a few cases the tumefaction is so insignificant that it can hardly be found on percussion4 ,dull pain generally exists if the enveloping membrane or adjacent organs are involved1 the pain being increased upon percussion and deep inspiration4 ,in a few cases the pain radiates to the left shoulder and if the peritoneal covering is involved1 a sharp pain will be present4 ,fever and rigor follow if suppuration has taken place1 and peritonitis follows in case of rupture or perforation4 ,marked hypertrophy and chronic inflammation may cause cough1 nausea1 vomiting and dyspnea4 ,treatment4--,in the treatment of both the disease producing splenitis1 and of primary splenitis1 a thorough treatment of the spine1 eighth to the eleventh dorsal1 is necessary4 ,the nerves 7vasomotor7 to the spleen are from the left splanchnics1 consequently treatment of the left side is more effectual4 ,particular attention should be given the ribs over the spleen--the ninth1 tenth and eleventh--as disorders of these ribs are a common cause of splenic disturbances4 ,careful and fairly firm treatment is always indicated1 care being taken not to add irritation to an already inflamed organ1 and especially beware that force is not used where there is danger of rupture4 ,stimulation of the tenth nerve contracts the spleen4 ,in cases of suppurative splenitis the direct treatment should not be given4 ,stimulating treatment over the spleen1 as over the liver and kidneys1 gives tone to the strong elastic capsule surrounding it1 so that direct manipulation over these organs1 coupled with the power of the strong elastic capsule and highly elastic tissue of the inner organ1 will greatly aid in lessening the engorgement and hyperemia4 ,in a few cases where the spleen is involved1 lesions are found in the upper cervical which affect the right pneumogastric nerve and thus impair the normal activity of the gland4 ,,footnotes3 #gd ,see special article1 ,prolapsed ,organs1 ,part ,i4 #ge ,the student will receive many helpful suggestions by reading ,macleod1 ,physiology and ,biochemistry in ,modern ,medicine2 ,cannon1 ,the ,mechanical ,factors of ,digestion2 ,carlson1 ,the ,control of ,hunger in ,health and ,disease2 ,gaskell1 ,the ,involuntary ,nervous ,system2 ,pottenger1 ,symptoms of ,nervous ,disease4 #gf ,von ,noorden1 ,colitis1 #aijd4 #gg ,see ,philosophy and ,mechanical ,principles of ,osteopathy1 p4 #aij4 #gh ,there are several possible suggestions4 7#a7 ,developmental 7,see ,mayo1 ,relation of the ,development of the ,gastro-intestinal ,tract to ,abdominal ,surgery4 ,jour4 ,a4 ,m4 ,a4 ,feb4 #g1 #aibj74 7#b7 ,owing to the appendix1 cecum1 ascending colon1 duodenum1 and biliary tract being frequently disordered4 7#c7 ,imbalance of muscular tension1 owing to the muscles of the right side being often the better developed4 ,muscular lesions and lymphatic involvement of the cervical region seem to occur oftener on the right side than on the left4 #gi ,journal of ,osteopathy1 ,may1 #aijj4 #hj ,for points on enema1 see treatment under ,intestinal ,obstruction4 #ha ,diseases of the ,intestines1 ,vol4 ,i1 p4 #bdj4 #hb ,the ,lancet1 7,london17 ,oct41 #aijd4 #hc ,philosophy of ,osteopathy1 p4 #bbf4 #hd ,medical ,record4 #he ,the ,vermiform ,appendix and ,its ,diseases1 p4 #gaa4 #hf ,dr4 ,chauvel1 #aijb4 #hg ,rose and ,carless4 #hh ,clinical ,osteopathy4 #hi ,journal of the ,american ,osteopathic ,association1 ,dec1 #aijb4 #ij ,journal of ,american ,osteopathic ,association1 ,march1 #aije4 #ia ,journal of ,american ,osteopathic ,association1 ,march1 #aije4 ,,diseases ,,of ,,the ,,respiratory ,,system ,,diseases ,,of ,,the ,,larynx#ib ,acute ,catarrhal ,laryngitis ,definition4--,an acute1 catarrhal inflammation of the mucous membrane of the larynx4 ,this may be ushered in as an independent disease or it may be associated with inflammation of the upper respiratory passages4 ,osteopathic ,etiology and ,pathology4--,one of the principal causes of acute catarrhal laryngitis is exposure to cold and dampness1 which contracts the muscles of the neck region1 especially about the larynx4 ,lesions in the upper and middle cervical vertebr are important predisposing causes4 ,occasionally the first rib becomes luxated1 causing a greater or less congestion of the laryngeal mucous membrane by contracting the lower antero-lateral muscles of the neck1 and affecting lymphatic drainage4 ,improper placing of tone1 as well as too constant use of the voice in speaking and singing1 are common causes4 ,inhalation of irritating gases or dust1 and mechanical injuries to the larynx are occasional causes4 ,the disease may be associated with certain infectious diseases1 as measles1 diphtheria1 influenza and whooping cough4 ,pathologically1 the mucous membrane is intensely reddened and inflamed2 this inflammation involves both the true and false vocal cords and may extend into the trachea and about the epiglottis4 ,the membrane is covered slightly with mucous secretion4 ,in rare instances edema of the glottis may occur4 ,the muscular contraction about the larynx impedes blood and lymphatic drainage and thus induces congestion4 ,the contraction may be so severe as to slightly prolapse the organ4 ,the vertebral lesions impinge upon or affect vasomotor fibers and thus bring about congestion4 ,symptoms4--,there is hoarseness and cough with a sensation of tickling in the larynx2 these are the most constant symptoms4 ,the cough is dry and the voice altered4 ,at first the voice is husky1 but some attempts at speaking are attended with more or less pain and finally the voice may be entirely lost4 ,deglutition is painful4 ,at first the expectoration is scanty1 but later it becomes mucopurulent4 ,there is rarely much fever4 ,when there is considerable edema1 dyspnea and asphyxia are prominent features4 ,prognosis4--,simple catarrhal laryngitis never terminates fatally4 ,when there is dyspnea or asphyxia indicating edema of the larynx1 the prognosis is grave4 ,the attack usually lasts from one week to ten days1 but this can be materially shortened by careful osteopathic treatment4 ,in severe infections it may be two or three weeks before the larynx returns to its former condition4 ,treatment4--,in a few cases confinement of the patient to his room1 and possibly the bed1 will be necessary2 especially should the larynx have rest from phonation1 and the taking of food of an irritating character should be avoided4 ,smoking is to be prohibited4 ,the room should be at an even temperature1 from #gj to #ge degrees ,f41 and the atmosphere saturated with moisture by the generation of steam4 ,the tissues in the cervical region about the cervical sympathetic and vagi nerves should be carefully adjusted4 ,the deep posterior muscles of the cervical spine are to be relaxed and direct treatment given over and about the larynx4 ,relaxing tissues and raising the larynx will be very effectual in relieving the huskiness of the voice and in controlling the congestion and inflammation of the laryngeal mucosa4 ,besides the treatment of the vagi nerves at the atlas and their course down the lateral and anterior portion of the neck1 the superior laryngeal may be treated at the upper portion of the great cornu of the hyoid bone and the inferior laryngeal at the inner side of the cleido muscle near its sternal attachment4 ,adjust the tissues along the course of the external carotid and subclavian arteries1 chiefly the first rib for the latter4 ,give careful treatment to the internal jugular and innominate veins4 ,correct any tissues that may impinge upon the lymphatics of the mucous and submucous coats of the larynx where they are drained into the deep cervical glands4 ,release any immobility of the upper chest1 relax the pectoral1 auxiliary and upper dorsal muscles1 and adjust the first four or five dorsal vertebr4 ,prompt action of the skin1 freedom of the bowels1 placing the feet in a hot bath and continued local hot packs1 or even an ice-bag in severe cases1 will be of special value at the onset2 but due attention should be given these throughout the entire course4 ,the fever is easily aborted by the cervical treatment and proper attention to the bowels and sweat glands4 ,chronic ,catarrhal ,laryngitis ,definition4--,a chronic1 catarrhal inflammation of the mucous membrane of the larynx4 ,osteopathic ,etiology and ,pathology4--,the causes of chronic laryngitis may be numerous1 but lesions of the cervical vertebr are the most common4 ,the contractured cervical muscles1 especially the deep vertebral ones1 are usually the result of corresponding osseous deviations4 ,other causes given under the acute form1 as overuse and abuse of the voice1 inhalation of irritating substances1 excessive use of tobacco and alcoholic drinks1 tumors1 etc41 are important etiological factors4 ,thus irritations inducing acute attacks1 if repeated1 will result in chronic catarrh4 ,the pathological changes as revealed by the laryngoscope are swelling of the mucous membrane1 occasional superficial erosions1 and rarely ulceration4 ,symptoms4--,the voice is usually hoarse and rough1 being due to a thickening of the vocal organs4 ,in severe cases the voice may be lost4 ,there is fatigue and pain after slight use of the voice1 a sense of tickling in the larynx which produces a desire to cough1 and expectorations of viscid mucus and mucopus4 ,prognosis4--,the prognosis is sometimes unfavorable1 although many cases are cured4 ,treatment4--,the patient must learn to take care of himself properly4 ,he should avoid overheated rooms and the use of tobacco and alcohol1 and the throat should not be protected too much4 ,it is a good plan to bathe the neck every morning and night with cold water4 ,he should avoid loud speaking2 the sound should be expelled by the abdominal muscles and diaphragm and not by the muscles of the throat4 ,examine the upper air passages carefully for any obstructions and infections that might exist which are a source of irritation to the larynx4 ,special attention should be given to the atlas1 axis and third cervical4 ,lesions lower down the spine may be found1 for other laryngeal nerve fibers1 other than those from the superior cervical ganglion1 may be at fault4 ,palpate the hyoid to see if it is tilted by contracted muscles1 as will often be the case4 ,aphonia is commonly caused by a dislocated atlas4 ,the aphonia may also be caused by swelling of the vocal cords and tissues about them and by serous effusions of the laryngeal muscles4 ,the larynx may be prolapsed slightly and if raised quickly relieved4 ,difficult breathing and hoarseness are occasionally very troublesome symptoms4 ,the former is due to an inability of the glottis to dilate1 on account of swelling of the mucous membrane of the diseased parts and from drying of the secretions on them1 thus increasing the obstruction 7this is sometimes termed pseudocroup7 but expiration is easy1 the stridor is from the inspiration2 the latter is due to a collection of mucus on the vocal cords or the cords may become relaxed1 swollen or roughened4 ,another annoying symptom sometimes presented is pain on deglutition1 which is due to swelling of the mucous membrane of the upper laryngeal passages and the epiglottis4 ,in all of these annoying symptoms1 persistent1 thorough1 direct treatment of the larynx is of value4 ,on the whole1 careful1 continued treatment of the cervical innervation and vascular supply of the larynx1 as in the acute form1 is indicated4 ,in all laryngeal disorders1 if condition permits1 hyperextend the neck while the patient is lying supine and thoroughly relax the soft tissues about the organ and then carefully raise it4 ,laryngismus ,stridulus 7,spasm of the ,glottis7 ,definition4--,a spasm of the muscles of the larynx that are supplied by the inferior or recurrent laryngeal nerves4 ,this is commonly not excited by an inflammatory condition1 but it is usually a purely nervous condition4 ,osteopathic ,etiology and ,pathology4--,spasm of the glottis is usually found in children with enlarged tonsils and adenoids4 ,it has been observed that rickets and syphilis are probably frequent underlying causes4 ,the spasm is occasionally associated with tetany4 ,the nervous factor is the immediate and important consideration4 ,cervical lesions1 both vertebral and muscular1 are invariably found4 ,then nasopharyngeal and tracheal disorders and reflex digestive disturbance are exciting causes4 ,an elongated uvula or a deranged hyoid bone will occasionally be exciting factors4 ,subluxation of the upper two or three ribs and of the clavicle may also be exciting factors4 ,the affection is usually found in children under five years of age4 ,all cases are not of a distinct nervous type1 for slight acute catarrhal laryngitis may be present4 ,symptoms4--,there is a sudden onset and the spasm may occur on waking from sleep1 but it may come on either in the night or day4 ,the disease starts with a sudden arrest of breathing1 the child struggles for breath2 there are tonic muscular spasms and the face becomes congested in a few seconds4 ,this is followed by sudden relaxation of the spasm and the air is drawn through the glottis with a shrill1 crowing sound4 ,several spasms may occur in a day or they may be weeks apart4 ,death rarely occurs4 ,diagnosis4--,the absence of fever1 cough and hoarseness and its distinctly intermittent nature will differentiate it from croup4 ,should there be any question of diagnosis a bacteriological examination is advisable4 ,prognosis4--,the prognosis is almost always favorable4 ,in very young children death from suffocation may occur1 but rarely4 ,treatment4--,the treatment should be applied either centrally or peripherally1 depending altogether upon the location of the irritation4 ,if the irritation is of central origin1 that is1 through the innervation from the brain and spine1 a correction of the superior and inferior laryngeal nerves is necessary2 if the stridor is due to peripherial irritations1 a correction of the end-plates 7muscles7 over and about the larynx is required in order that the spasms be relieved4 ,thorough treatment should be applied to the upper part of the chest and diaphragm1 chiefly the phrenic nerves at the third1 fourth and fifth cervicals and over the eighth1 ninth and tenth ribs anteriorly1 in order that the spasms may be prevented from extending to the intercostal muscles and the diaphragm4 ,placing the patient in a hot bath will be of service in some cases when the spasms are severe4 ,alternating hot and cold packs about the throat are of service4 ,the air of the room should always be kept moist4 ,care should be taken that the trouble is not due to gastro-intestinal disorders or to dentition4 ,keep the child upon a fluid diet of milk1 meat broths and egg albumin4 ,in the more severe cases the well known osteopathic method of relaxing and inhibiting the soft palate and contiguous tissues will stop the spasm4 ,spasmodic ,laryngitis 7,false ,croup7 ,definition4--,a catarrhal inflammation of the mucous membrane of the larynx with spasm of the glottis4 ,osteopathic ,etiology and ,pathology4--,this affection is practically the same as laryngismus stridulus associated with catarrhal inflammation of the mucous membrane4 ,it is a disease of young children4 ,derangements of the innervation and blood supply to the laryngeal mucous membrane and muscles of the larynx are found in the same locality as noted under acute catarrhal laryngitis and laryngismus stridulus4 ,there is acute catarrh causing a croupy cough1 and difficult breathing due to spasm of the glottis4 ,symptoms4--,these attacks generally occur during the night1 the child being suddenly awakened by severe paroxysms of suffocating and a dry1 hard cough1 associated with evidences of dyspnea4 ,in half an hour or an hour or two the coughing ceases1 perspiration follows and the child falls asleep4 ,if proper treatment is not given1 these attacks may occur for several successive nights1 the child appearing almost or quite well during the day4 ,diagnosis4--,the symptoms are so characteristic that the diagnosis is easy4 ,in all instances the prognosis is favorable4 ,treatment4--,the catarrhal inflammation of the mucous membrane of the larynx should be treated in the same manner as simple inflammation of the laryngeal mucosa1 i4 e41 thorough treatment of the cervical spine and direct treatment over the larynx4 ,during the paroxysm1 if the patient cannot be relieved very shortly by the cervical treatment1 he should be placed in a hot bath of a temperature from #ih to #aaj degrees ,f4 ,this will1 in the majority of cases1 relieve the attack4 ,in addition a hot compress may be placed about the throat4 ,producing emesis by irritating the fauces with the finger is necessary in a number of cases in order that the secretions in the laryngeal region may be ejected1 thus relieving suffocation and labored breathing4 ,also1 an overloaded stomach which is causing an irritation1 should be emptied at once by vomiting4 ,the bowels should be kept well open in all cases4 ,occasionally the epiglottis becomes wedged in the chink of the glottis4 ,such a condition requires an introduction of a finger into the fauces to release the disorder4 ,care should be taken1 especially following an attack1 that the child is not exposed to cold or rapid changes of temperature1 so as to avoid repetition of the spasms4 ,coughing4--,coughing1 not only in spasmodic laryngitis1 but also in various diseases where coughing is a prominent symptom1 is a most irritating and annoying feature4 ,the osteopath is many times called upon to relieve the cough1 whether it is due to slight irritation of a nerve fiber alone or is a symptom of a serious chronic disease4 ,the coughing center is located in the medulla oblongata2 the afferent nerves are sensory branches of the vagus2 the efferent nerve fibers are found in the nerves of expiration and in those that close the glottis4 ,consequently1 coughing may be caused by stimuli to various sensory nerves1 various cutaneous areas 7chiefly the upper part of the body71 mucous membrane of the respiratory and digestive tracts1 the mammae1 liver1 spleen1 ovaries1 uterus1 kidneys1 etc4 ,perhaps the most common cause of cough is contraction of some of the muscles of the neck1 irritating sensory fibers4 ,contraction of the omo-hyoid muscle may produce an irritating cough by causing traction on the hyoid bone4 ,in a few cases the larynx may prolapse to some extent and thus be a source of irritation4 ,lesions of the spinal cord between the seventh and eighth dorsal1 also at various points above in the dorsal vertebr and in the ribs 7especially at the second and third ribs71 are very apt to produce a cough4 ,impaction of the sigmoid flexure is oftentimes accompanied by coughing4 ,enlargement of the heart may cause pressure upon the respiratory tract directly and cause a deep1 dull cough4 ,foreign bodies in the external meatus of the ear are occasionally a source of irritation which is accompanied by coughing4 ,thus there are innumerable sources of stimuli that may produce coughing4 ,in all cases it is necessary to make a careful diagnosis as to whether it is an irritation to some fiber that can be corrected at once or whether it is a symptom of a disease that can only be relieved by the cure of the disease4 ,in local congestions the cold pack will often be of service4 ,tuberculous ,laryngitis ,definition4--,an inflammation of the laryngeal tissues of tuberculous origin4 ,osteopathic ,etiology and ,pathology4--,tuberculosis of the larynx is commonly secondary to pulmonary tuberculosis4 ,in a few cases the laryngeal invasion may be of primary origin4 ,in either instance there will be found a disturbed innervation or altered blood supply of the larynx that predisposes to the multiplication and growth of the bacilli4 ,the osteopathic lesions are similar to those found in other involvements of the larynx4 ,pathologically1 the mucous membrane is inflamed and swollen1 and exhibits scattered tubercles1 which are usually about the blood-vessels4 ,the tubercles cluster1 caseate and leave shallow1 irregular ulcers4 ,there is thickening of the mucosa about the ulcer1 and the ulcer is generally covered by a grayish exudate4 ,they may erode the true vocal cords1 often destroying them completely4 ,the ulcers slowly involve the tissues in all directions1 causing perichondritis with necrosis of the cartilages4 ,the mucous membrane of the pharynx1 esophagus1 fauces1 and tonsils may be involved1 and the epiglottis may be completely destroyed4 ,this disorder1 strictly1 should be discussed under pulmonary tuberculosis for1 as heretofore stated1 it is generally a secondary affection2 the larynx being invaded by the tubercular bacilli in the sputum arising from the bronchial tubes and lungs4 ,the bacilli in inspired air may primarily invade the laryngeal mucosa4 ,however1 in either case the circulation of the mucosa is not normal and osteopathic correction of the same is effective4 ,symptoms4--,huskiness of the voice1 followed by hoarseness1 and in advanced stages aphonia1 are prominent symptoms4 ,a hacking cough is usually present and the patient complains of pain in the throat1 particularly on coughing1 swallowing or speaking4 ,the loss of voice1 painful speaking or whispering are quite characteristic4 ,when the ulceration of the tissues of the larynx has progressed to a later stage1 dysphagia1 suffocation and distressing paroxysms of cough occur4 ,diagnosis4--,is not difficult1 as pulmonary phthisis is usually associated with it4 ,examination of the sputum for the specific bacilli will be conclusive4 ,prognosis4--,the prognosis is not of the best at any time4 ,on the whole1 it is unfavorable4 ,treatment4--,in this disease osteopathic treatment has been quite effectual4 ,cases of primary origin are more successfully treated than when of secondary cause1 although one will be surprised many times at the results obtained when the disorder is not primary4 ,the treatment must necessarily be both constitutional and local4 ,care of the general health as to hygiene and diet is absolutely necessary4 ,the food must be nutritious and non-irritating4 ,scraped beef1 raw oysters1 raw eggs1 soups and gruel are required4 ,in cases where difficulty of deglutition occurs1 it may be largely overcome if the patient hangs his head over the side of the bed and sucks through a tube liquid nourishment placed in a dish upon the floor4 ,the local treatment required is careful1 persistent work over the larynx and adjacent tissues4 ,the treatment is given to increase the blood supply to the diseased tissues so that healing may take place1 and that the bacteria may be deprived of the conditions favorable to their activity4 ,treatment along the cervical spine and upper dorsal will aid in correcting the vasomotor disorders that exist4 ,local application of hot water will assist in relieving the pain4 ,when pulmonary phthisis exists1 attention and correction of it is important2 in fact1 is of primary consideration in laryngeal affection4 ,syphilitic ,laryngitis ,etiology4--,this disease is of frequent occurrence1 due to inherited syphilis1 or to the secondary or tertiary stages of the acquired form4 ,symptoms4--,there is a hoarseness of the voice1 a hacking cough1 difficulty in swallowing and the various symptoms of catarrhal laryngitis4 ,the secondary form may present superficial1 whitish ulcers on the cords or ventricular bands1 while in a tertiary stage the lesions are extensive and serious4 ,deep ulcers with raised edges are present1 gummata develop on the submucous coat of the epiglottis and there may be necrosis and exfoliation of the cartilages4 ,deformity is produced by the cicatrices following the healing of the ulcers and sclerosis of the gummata4 ,edema of the larynx may suddenly prove fatal4 ,diagnosis4--,the history of the case1 the presence of other symptoms of the disease1 the deep1 symmetrical ulcers1 the absence of tuberculosis elsewhere and the absence of marked pain1 will usually make a diagnosis easy4 ,prognosis4--,is somewhat favorable1 more so at least than the tubercular form of laryngitis4 ,there is great danger of deformity and permanent impairment of the voice4 ,treatment4--,the treatment should be both constitutional and local4 ,active measures must be taken to rid the system of the virus of syphilis1 and thorough1 direct treatment should be applied to the larynx and to its innervation4 ,if the cicatricial stenosis has progressed so far that there is little hope from manipulative treatment1 tracheotomy or gradual dilatation should be performed4 ,the ulcerated portion is always to be kept clean4 ,edematous ,laryngitis ,definition4--,an acute inflammation of the mucous membrane of the larynx with infiltration of serous fluid into the submucous tissue4 ,etiology4--,this is a very serious affection4 ,it may occur in connection with acute laryngitis1 though rarely1 and occasionally with chronic diseases of the larynx1 as tuberculosis and syphilis4 ,it may be a complication of some acute infectious disease like diphtheria1 scarlet fever1 or erysipelas of the face4 ,it sometimes occurs suddenly in the course of ,bright's disease4 ,lesions as in acute laryngitis are predisposing factors4 ,pathologically1 there is marked swelling of the epiglottis4 ,the swelling can very easily be felt with the fingers4 ,the mucous membrane is tense and changed in color4 ,there is infiltration of a serous or sero-purulent fluid into the loose connective tissue of the larynx4 ,the arytenoepiglottic folds are greatly involved1 and they may be swollen to such a degree that they almost meet4 ,symptoms4--,extreme dyspnea and stridulous respiration4 ,hoarseness of the voice and later aphonia4 ,there is a feeling of intense oppression or suffocation4 ,evidence of dyspnea1 anxious face1 blue lips1 protruding eyes and retraction of the base of the chest occur4 ,the sternocleidomastoid muscle is very prominent4 ,diagnosis4--,this is not difficult4 ,the history of the case1 laryngoscopic examination1 and the swollen epiglottis which can be easily felt with the fingers make diagnosis easy4 ,prognosis4--,generally unfavorable4 ,at any time it is extremely grave1 but with prompt and vigorous treatment recovery is possible4 ,the duration varies from a few hours to several days4 ,treatment4--,one must attend strictly and carefully to the laryngeal innervation1 as in acute catarrhal laryngitis4 ,obstruction to the superior or inferior thyroid1 facial1 internal jugular or innominata will cause tumefaction and edema of the larynx and adjacent tissues4 ,also1 enlargement of the lymphatics about the larynx and salivary glands may produce edema of the laryngeal region2 consequently1 particular care should be taken of the various tissues about these vessels and of the innervation from the cervical spine1 so the veins are not obstructed or the lymphatic channels disordered1 so that infiltration of the tissues may be further prevented4 ,the most prominent symptom is laryngeal dyspnea and this depends altogether upon the swelling of the soft parts4 ,if the swelling is great and the disorder cannot be removed1 suffocation will follow4 ,in such cases1 besides giving direct treatment over the larynx1 introducing a finger into the mouth1 and reaching clear back under the roof of the soft palate1 with a firm1 downward1 outward and sweeping movement on either side1 relax the soft tissues4 ,the persistent use of small pellets of ice1 held far back in the mouth1 will be found very beneficial2 also1 application of the ice-bag1 provided the edema is of inflammatory origin4 ,if one is not able to control the rapid infiltration of the larynx and glottis when such cases arise1 tracheotomy or intubation should be performed at once4 ,when edematous laryngitis is due to diseases of the heart1 lungs and kidneys1 treatment of the primary disease should be given in addition to the local treatment4 ,,footnotes3 #ib ,for diseases of the nose see ,deason1 ,part #a1 ,page #beg4 ,,diseases ,,of ,,the ,,bronchi ,acute ,bronchitis ,definition4--,a catarrhal inflammation of part or whole of the mucous membrane of the larynx1 trachea and bronchial tubes1 or it may extend into the capillary tubes4 ,this is bilateral1 affecting more or less the bronchial tree in both lungs4 ,osteopathic ,etiology and ,pathology4--,the most common cause of acute bronchitis is 8catching cold40 ,it is more prevalent in the winter1 and it often succeeds an ordinary cold in the head1 coryza or laryngitis1 the inflammation extending downward from the upper air passages4 ,a case of acute bronchitis always presents a contracted condition of the muscles on either side of the spine in the upper dorsal region4 ,the contracted muscles may extend as far down as the middle dorsal or as high as the entire cervical4 ,occasionally1 the ribs posteriorly are drawn downward by the extreme contraction of the muscles1 and the upper anterior part of the chest may be somewhat constricted and limited in its movements by the tensed muscles4 ,thus1 in a few cases the ribs and upper dorsal vertebr are actually subdislocated by the extreme contraction of the muscles4 ,the principal points affected are the second1 third1 fourth and fifth dorsal regions4 ,in a few instances cervical lesions disturbing the vagus and resulting in motor weakness of the tubes1 will be noted4 ,the osteopathic control of the bronchial vasomotor nerves is in this region 7dorsal74 ,the disease is also associated with measles and it is usually a symptom of influenza4 ,one attack predisposes to another4 ,it affects either sex and especially children and the old1 in whom it most frequently involves the smaller bronchi4 ,in adult life it involves the larger bronchi4 ,micro-organisms1 particularly the pneumococcus1 influenza bacillus1 and micrococcus catarrhalis1 act as exciting causes4 ,pathologically1 the mucous membrane of the portion of the trachea and bronchi that are implicated become reddened1 congested and more or less covered with a tough mucus mingled with epithelial cells4 ,the hyperemia is most marked about the mucous glands4 ,some of the smaller bronchial tubes are dilated4 ,in severe cases there is desquamation of the ciliated epithelium1 swelling and edema of the submucosa1 and infiltration of the tissues with leucocytes4 ,the affection involves chiefly the vasomotor nerves4 ,in cases on the verge of chronicity1 look well to the diet2 especially lessen in amount the starchy and saccharine foods4 ,symptoms4--,the onset of acute bronchitis is accompanied by the symptoms of a common 8cold40 ,in the beginning the cough is hard and dry without expectoration2 but later it is looser1 the secretion becoming mucopurulent and abundant and finally purulent4 ,the scanty sputum is at first glairy and mucoid1 while later it becomes more abundant and mucopurulent and contains pus cells and desquamated epithelium4 ,when the bronchial inflammation becomes fully established1 there is a feeling of tightness and rawness beneath the sternum and a sensation of oppression in the chest1 due to swelling of the mucous membrane and the presence of secretions which cause stenosis of the bronchial lumina4 ,there is a slight fever1 rarely exceeding #aja degrees ,f4 ,the disease lasts from four or five days to three weeks4 ,there is either a complete recovery or chronic bronchitis is developed4 ,physical ,signs4--,there may be no physical signs in slight attacks of acute bronchitis of the larger tubes4 ,in severer cases the physical signs are well marked4 ,inspection may recognize increased frequency of breathing1 and when the smaller tubes are involved there is dyspnea4 ,palpation4--,the bronchial fremitus may often be felt1 providing there is sufficient narrowing of the breathing tubes4 ,percussion4--,sounds are normal as long as the bronchitis is uncomplicated4 ,auscultation4--,in the early stage piping1 sibilant rales may be heard on both sides4 ,these rales are inconstant and appear and disappear with coughing4 ,there may be harshness of breathing added to these4 ,when resolution sets in1 the rales change and become mucous and bubbling in quality4 ,vocal resonance in bronchitis is normal1 unless complications occur4 ,diagnosis4--,this is generally easy4 ,the absence of dullness and blowing breathing and the bronchial character of the cough and expectoration are usually sufficient to distinguish it from pneumonia and pleurisy4 ,if the physical signs are noticed carefully1 the diagnosis is rendered easy and positive in all cases4 ,prognosis4--,in the very young and the very old1 the prognosis is unfavorable1 but in a previously healthy adult the most that can happen to a case of acute bronchitis is to become chronic4 ,recovery is the rule2 even in the aged and feeble death is rare4 ,if osteopathic treatment can be instituted from the inception1 the disease will probably be aborted4 ,the treatment almost invariably lessens the severity and duration of an attack4 ,for capillary bronchitis see ,bronchopneumonia4 ,treatment4--,complete rest in a warm bed1 and a hot foot bath would cure a large majority of cases in a day or two if the patient would only submit to such treatment4 ,most of them wish to be around and out doors and very likely attending to their usual work1 so that a cure in some cases is hard to perform4 ,they are very liable to take more 8cold0 and in a few cases it will take great effort to prevent the bronchitis from becoming chronic4 ,one thorough treatment per day will usually be sufficient4 ,the hyperemic condition of the bronchial tubes is due to a vasomotor disturbance1 generally caused by a severe contraction of the muscles of the back in the region of the first to fourth dorsal2 although the vasomotor nerves to the mucous membrane of the bronchial tubes may be affected anywhere from the first to the seventh dorsal inclusive4 ,contraction of the muscles over the anterior part of the chest corresponding to these regions and caused by the same influences 7chiefly atmospherical changes7 is of quite common occurrence4 ,in the majority of cases the contraction of the chest and back muscles is so severe that the ribs are partly displaced by the tension and thus is added a complication to the disorder1 and from this complication chronic bronchitis is liable to occur4 ,the ribs or even vertebr to the corresponding region oftentimes remain partly dislocated and are a source of continued and permanent irritation to the innervation of the bronchial tubes4 ,so it is always necessary in treating any form of bronchitis to see at each treatment that the ribs and vertebr from the first dorsal to the seventh dorsal1 inclusive1 are anatomically correct4 ,as has been stated1 the disordered muscles or ribs may be affected anteriorly as well as posteriorly2 consequently1 the treatment applied is a thorough relaxation of the chest and back muscles and the correction of the ribs and vertebr in order that the vasomotor disturbance of the bronchial mucosa may be corrected and the inflammation relieved4 ,an excellent method to release the immobilized anterior upper chest is to place patient flat upon his back with pillow beneath upper dorsal4 ,this hyperextends spine1 enlarges spinal foramina1 and tends to elevate ribs4 ,then by use of arms as levers1 moderate inspiration1 and employment of one hand over anterior end of ribs they may be easily released and raised4 ,this treatment effects circulation1 innervation1 lymph tissue1 and rib bone marrow4 ,in addition to the dorsal spinal nerves1 and the sympathetic1 the vagi are to be considered in the treatment of bronchitis1 as all of these nerves1 sympathetic1 spinal1 and vagi1 go to make up the anterior and posterior pulmonary plexuses from which the bronchial mucosa receives its innervation4 ,the veins particularly involved in passive hyperemia of the bronchial tubes are the superior intercostal and azygos major2 so raise and spread the ribs to give greater freedom to these blood-vessels4 8,the blood flow may be diverted from the bronchi to the abdomen by a slow1 deep1 inhibitive treatment over it1 including pressure over the solar and hypogastric plexuses40 7,hazzard74 ,the excretory organs and the diet of the patient should be attended to4 ,especially in children1 the diet had best be a fluid one1 as milk1 egg albumin1 meat broths and meat juice4 ,for those who are subject to the disease an outdoor life is best4 ,chronic ,bronchitis ,definition4--,a chronic inflammation of the mucous membrane of the large and middle sized bronchial tubes4 ,osteopathic ,etiology and ,pathology4--,chronic bronchitis may be either primary or secondary4 ,the primary form is the result of exposure to wet and cold or to the daily inhalation of irritating vapors or dust4 ,this form is rare1 the affection being almost always a secondary one1 and is most commonly met with in chronic lung affections1 heart disease1 gout or renal disease4 ,it may be caused by any disease which favors congestion of the air tubes by obstruction of the circulation2 especially mitral diseases and ,bright's disease4 ,it is also caused by chronic alcoholism and may be the result of repeated attacks of the acute form4 ,chronic vertebral and rib lesions are found from the first to the seventh dorsal1 inclusive4 ,elderly people are often subject to the disorder4 ,pathologically1 the lesions of chronic bronchitis present great variation1 as to both their nature and extent4 ,in some cases the mucous membrane is atrophied1 so that some of the elastic fibers are noticeable4 ,the epithelial layer is in great part missing4 ,the muscular coat and mucous glands are atrophied4 ,in certain cases the mucous membrane of the bronchi is thickened1 and there may be ulceration4 ,in long standing bronchitis1 there is frequently dilation of the tubes 7bronchiectasis7 and emphysema4 ,symptoms4--,pain is rarely present2 there is merely a feeling of constriction beneath the sternum4 ,the cough varies with the weather and season and there is often an absence of the cough during the summer4 ,it is apt to be worse at night than in the morning1 and is frequently paroxysmal4 ,there is rarely any fever4 ,as a rule1 there is free expectoration of mucopurulent or distinctly purulent matter4 ,sometimes it is abundant1 seromucous in character1 and again there are severe cases of dry cough in which there is almost no expectoration4 ,unless associated with other diseases1 the general health suffers but little1 if at all4 ,the appetite1 as a rule1 is good and the body weight is well maintained4 ,physical ,signs4--,inspection4--,there is considerable immobility of the chest and if emphysema is present there is distension4 ,percussion is clear1 and hyperresonant in emphysema4 ,auscultation4--,the expiration is prolonged and forcible4 ,this is associated with sonorous and sibilant rales and moist rales of all sizes4 ,special ,varieties4--,bronchorrhea1 dry catarrh1 putrid bronchitis or fetid bronchitis4 ,bronchorrhea4--,in this form there may be an excessive bronchial secretion4 ,this may be liquid and watery1 but more frequently it is purulent1 thin and containing greenish masses2 or again it may be thick4 ,dilation of the tubes and fetid bronchitis may be developed4 ,fetid ,bronchitis4--,fetid expectoration is associated with gangrene of the lungs1 abscesses1 bronchiectasis1 decomposition of matter within phthisical cavities1 or empyema with perforation of the lungs2 or it may occur independently4 ,there is considerable expectoration that is thin and offensive4 ,when putrefactive changes take place during the course of chronic bronchitis1 as a rule1 the following symptoms immediately appear3 fever1 which may be septic2 increase of cough2 pain in the side1 and sometimes a chill4 ,there is increased prostration4 ,the symptoms may abate followed by the usual course of bronchitis4 ,dry ,catarrh4--,the cough is distressing and paroxysmal4 ,it is usually associated with emphysema and is a very troublesome form4 ,diagnosis4--,this is not usually difficult4 ,phthisis--the absence of fever1 of hemorrhage1 of tubercle bacillus and the signs of localized consolidation 7usually at one or other apex7 will serve to distinguish between the two4 ,prognosis4--,recovery is not always accomplished4 ,the diseases being generally a secondary affection1 the prognosis must depend upon the primary condition4 ,the danger from development of emphysema1 bronchiectasis and dilatation of the right ventricle must be thought of4 ,frequently cures will be obtained1 even in old persons4 ,care must be taken that there are no serious organic lesions4 ,deep treatment to readjust the upper and middle dorsals is most essential4 ,treatment4--,in the first place there must be a careful regulation of the hygiene of the patient4 ,the diet should be a nutritious one1 care being taken to give food that is easily digested4 ,a liberal diet can easily be selected from the various meats1 vegetables1 cereals1 fruits1 soups1 broths1 eggs and milk4 ,the clothing should be carefully selected4 ,flannel should be worn next the skin the year around1 care being taken that the sufferer is not too warmly clad4 ,due attention should be given to bathing1 exercising1 etc4 ,the patient should be out in the open air a great deal1 but be careful that it is not too stormy4 ,the air of the room should be kept at an even temperature and not subject to abrupt changes4 ,two or three treatments per week will be required1 and when the condition is considerably aggravated1 do not hesitate to treat oftener1 but be careful not to unduly irritate the lesions4 ,lesions will be found to the ribs and vertebr from the first to the seventh dorsal inclusive4 ,many cases present lesions in the vertebr from the second to fourth1 usually of a lateral nature4 ,other lesions of frequent occurrence are displacements of both vertebr and ribs4 ,correcting these deviations relieves the chronic inflammation of the tubes4 ,also in those cases where dilatation of the bronchial tubes occurs1 the obstruction to the motor fibers is to be removed by the correction of the vertebr and by removing obstruction to fibers of the pneumogastric2 the fibers of the latter supplying the transverse muscles of the bronchial tubes4 ,it generally requires a considerable course of treatment for the cure of chronic bronchitis1 and one of the hardest things to contend with in the treatment is the likelihood of the patient 8catching cold40 ,when a fresh cold gets thoroughly started1 it is almost impossible to prevent the disease from extending down the bronchial tubes1 as the innervation is less rich in the smaller tubes4 ,hazzard says3 8,the obese should be taught the habit of deep respiration1 as should all persons subject to the attacks of the disease4 ,this measure1 together with the daily cold sponge or shower bath1 is a great aid in overcoming the chronic tendency40 ,those cases that are due to cardiac or nephritic diseases require the treatment of the primary disease in addition to a light bronchial treatment4 ,a lesion between the gladiolus and manubrium of the sternum may be found1 but it is of rare occurrence in these cases4 ,the upper portion of the sternum may be held very rigidly and slightly underneath the middle portion of the sternum2 or at the point of articulation of the two portions a distinct ridge may be found1 caused by the articular ends being pushed anteriorly4 ,probably such lesions affect the innervation to the bronchial tubes and lung tissues4 ,associated with this condition the upper chest is considerably immobilized1 affecting the lymph and rib bone marrow function4 ,examine the first ribs and clavicles carefully4 ,changes of climate are often beneficial4 ,fibrinous ,bronchitis ,definition4--,a rare1 acute or chronic inflammatory disease of the bronchi1 in which a fibrinous mould of the bronchus and its branches is formed4 ,these are expelled in paroxysms of cough and dyspnea4 ,the casts block the bronchial tubes4 ,when these moulds are large or medium sized1 they are generally hollow1 while those of the smaller bronchi are solid4 ,etiology and ,pathology4--,the causes are unknown4 ,young men1 between the twentieth and fortieth years1 are the usual subjects2 but the disease may occur at any period of life4 ,lesions occur as in other forms of bronchitis4 ,the attack occurs most frequently in the spring months4 ,in some cases there seems to be some hereditary influence4 ,chronic pulmonary diseases1 like phthisis1 emphysema and pleurisy1 are occasionally predisposing causes4 ,it is sometimes associated with skin diseases1 such as herpes1 impetigo and pemphigus4 ,the pathology is not known4 ,the masses that are expelled are usually round and mixed with blood and mucus4 ,the casts are more dense1 but the membrane is identical with that of croupous exudates4 ,this affection1 however1 is limited to certain bronchial tubes and recurs at stated or irregular intervals1 sometimes for a period of several years4 ,there is loss of epithelium in the affected bronchi and the submucous tissue is often swollen and infiltrated with serum4 ,symptoms4--,acute cases are rare4 ,the attacks may set in with rigor1 high fever1 pain in the side1 soreness1 severe paroxysms of cough and sometimes a slight hemoptysis4 ,the symptoms are those of an ordinary acute bronchitis1 but of severer character2 aggravated cough and dyspnea and fatal termination are not uncommon4 ,death occasionally results from suffocation4 ,there may be but one attack without any recurrence1 but in the chronic form the paroxysms recur at irregular intervals1 though they are less severe than in the acute form4 ,the disease may last for ten or even twenty years1 the attacks recurring weekly1 or a period of a year or more may intervene4 ,the onset is marked by bronchial symptoms with or without fever4 ,the cough soon becomes distressing and paroxysmal in character4 ,the sputum may be blood-stained and occasionally there is profuse hemorrhage4 ,the expectoration is in the form of ball-like masses which1 when unraveled are found to be moulds of the bronchi4 ,they may be hollow and laminated or quite solid4 ,when examined under the microscope they are seen to consist of a fibrillated membrane in which are imbedded leucocytes1 mucus1 corpuscles1 fat drops and epithelial cells4 ,leyden's crystals and ,curschmann's spirals are occasionally found4 ,physical signs are usually those of bronchitis4 ,the weakened or suppressed breath sounds in the affected territory may occasionally be determined4 ,there is sometimes a diminished expansion or even retraction of the chest wall over the affected area4 ,there is no dullness on percussion1 unless the portions of the lung supplied by the affected tubes collapse4 ,after dislodgement of the casts1 the normal respiratory murmur returns4 ,diagnosis4--,the fibrinous casts alone are sufficient for a positive diagnosis4 ,prognosis4--,generally favorable4 ,in uncomplicated cases there is rarely any danger1 even though there may be severe paroxysms of cough and dyspnea4 ,in fatal cases the lesions of associated or preceding affections have been found1 such as chronic pleurisy1 pneumonia and phthisis4 ,although this is a rare disease1 cases have been treated with success by osteopathic means4 ,if uncomplicated there should be a fair chance for a cure1 depending1 of course1 upon the constitutional condition and the permanency of the lesions4 ,treatment4--,the treatment is largely that of acute bronchitis4 ,the disorder is more extensive than in acute bronchitis1 consequently severe subluxations of the ribs and vertebr of the upper and middle dorsals occur1 besides extensive muscular contractions of the chest and neck4 ,the fibrinous casts are somewhat of the same nature of membranous exudates elsewhere1 therefore the treatment should be directed to a correction of the hyperemia of the mucous membrane of the bronchial tubes1 thus loosening and disorganizing the exudate4 ,the vagi nerves supply a part of the innervation to the bronchial tubes and lungs4 ,any disorder to them should be corrected when diseases of the bronchial tubes and lungs exist4 ,they contain motor fibers to these organs1 and to the bronchial tubes they supply1 principally the transverse fibers4 ,in bronchitis of various forms1 marked effect can be secured by close attention and treatment to the inferior laryngeal nerve4 ,this is best treated at the inner side of the lower portion of the sternocleido muscle4 ,the different forms of bronchitis illustrate the point so often noted in osteopathic etiology and pathology1 that the various affections of the same region should not be studied so much as types of several diseases or disease entities as different degrees of involvement1 depending on the severity of the causative lesion1 the function of the nerves disturbed1 and the character of the tissues4 ,it is straining a point to diagnose and classify many diseases according to signs and symptoms instead of studying the process from central causes1 for1 at best1 peripheral manifestations1 micro-organisms1 etc41 are really incidental to the importance of the primary source of disturbed nutrition4 ,consequently1 the same treatment1 if scientific1 is frequently indicated for all of the disorders that may affect a given locality4 ,after all has been said and done1 the therapy as well as the pathology1 must hinge upon the fundamental--uninterrupted blood channels and nerve courses are essential to health4 ,whether a disease is of primary or secondary origin1 or whether or not it presents different symptoms in various types1 the above basic principle is invariably applicable4 ,this simplifies etiology1 pathology and treatment and furnishes a backbone to theory and practice1 and some day rational medicine will adopt it4 ,bronchiectasis ,bronchiectasis is a dilatation of a part or the whole of the bronchial tube4 ,as a rule this affection is a secondary one1 the most common cause being chronic bronchitis4 ,the inflammation weakens the bronchial walls so that they are unable to resist the strain that is put upon them during violent paroxysms of coughing4 ,after dilatation has once commenced1 the weight of the secretion which accumulates tends to further distend the weakened walls and the elasticity1 becoming impaired1 is finally lost4 ,dilatation of the bronchi is also associated with emphysema1 compression of a bronchus1 aneurism or mediastinal tumor1 bronchopneumonia1 measles and whooping cough in children1 and also traction associated with fibroid induration4 ,hence the bronchial dilatation is especially associated with bronchitis1 interstitial pneumonia1 and sometimes chronic pleurisy4 ,it is rarely a congenital effect in such cases4 ,it is commonly unilateral4 ,the lesions presented to the osteopath are largely like those found in chronic bronchitis1 i4 e41 derangement of the upper four or five dorsal vertebr and ribs1 and lesions of the cervical vertebr involving the vagi4 ,these lesions obstruct the nerve force to the bronchial tubes and thus cause the dilatation4 ,pathologically1 the dilatation is usually either cylindrical or saccular1 which may occur in the same lung4 ,the entire bronchial tree may be converted into a series of sacs opening into each other4 ,these have smooth1 shining walls in the most dependent parts which are sometimes ulcerated4 ,in extreme conditions the dilatations may form large cysts immediately beneath the pleura2 as a rule1 the lung tissue lying between the sacculi becomes cirrhotic4 ,partial dilatation is more common4 ,the bronchial mucous membrane is involved with an occasional narrowing of the lumen4 ,the narrowings are most commonly cylindrical1 sometimes saccular4 ,in all forms there is decided change in the bronchial wall4 ,in the large dilatations1 the epithelium is changed4 ,the elastic and muscular layers are thin and atrophied4 ,these dilatations frequently contain fetid secretions and when these secretions are retained1 the lining membrane becomes ulcerated4 ,symptoms4--,there is always cough1 which occurs in severe paroxysms4 ,in some cases a change of position will cause a paroxysm of coughing--very likely due to the emptying of the contents of a dilated tube into a normal one4 ,the sputum is mucopurulent and is greenish brown in color1 is fluid1 and has a sour1 or more frequently1 a fetid odor4 ,on standing1 it separates into three layers2 the upper is frothy and thin1 the middle mucoid1 and the lower is a thick sediment of cells and granular debris4 ,microscopically1 the sediment consists of pus corpuscles1 fatty acid crystals which are arranged in the form of bundles1 and sometimes red blood discs and hematoidin crystals4 ,elastic fibers may be found if ulcers are present4 ,physical ,signs4--,when distinctly present1 they are those of a cavity in the lungs4 ,when chronic pleurisy and interstitial pneumonia are associated1 there may be retraction of the chest wall4 ,the percussion resonance is impaired4 ,on auscultation1 bronchial1 or even amphoric1 breathing is heard occasionally with metallic rales4 ,diagnosis4--,in a number of cases this was formerly impossible1 where the ,x-ray is now proving of great assistance4 ,history1 paroxysmal cough1 characteristic copious sputum and an absence of tubercle bacilli with little impairment of the general health will serve to distinguish bronchiectasis from pulmonary tuberculosis4 ,circumscribed empyema which has ruptured into the lung may simulate bronchiectasis4 ,this is of a much more sudden onset1 has a history of previous pleurisy1 the health is gradually impaired1 and there is thoracic oppression and dyspnea on the slightest exertion4 ,prognosis4--,is generally unfavorable4 ,however this largely depends upon the cause4 ,treatment4--,largely the same as in chronic bronchitis4 ,severe lesions are found in the dorsal vertebr about the region of the third1 fourth and fifth1 and many times lesions of the pneumogastric at the upper cervical vertebr are also found4 ,the lesions are much of the same nature as those of bronchitis1 but1 as a rule1 there is a much deeper or more extensive lesion4 ,these lesions weaken the motor innervation to the muscular coats of the bronchial tubes1 and in many instances the extensive lesions involve the vasomotor nerves controlling the blood supply to the bronchial tubes4 ,in most cases marked lesions of the ribs on either side will be found1 usually in the region corresponding to the affected vertebr4 ,the position of the patient is important2 the head should be low in sleeping4 ,in certain fetid cases surgery should be considered4 ,care should be taken as to the hygienic surroundings of the patient4 ,the diet should be carefully regulated and nutritious1 as in chronic bronchitis4 ,bronchial ,asthma ,bronchial or spasmodic asthma is a chronic affection1 characterized by a paroxysmal dyspnea due to a spasmodic contraction of the muscles of the bronchial tubes or to swelling of their mucous membrane4 ,osteopathic ,etiology and ,pathology4--,the majority of lesions causing bronchial asthma are from the second to the seventh dorsal region1 inclusive1 either in the ribs posteriorly or anteriorly1 or in the vertebr4 ,these lesions involve vasomotor nerves to the bronchioles which produce the narrowing of the tubes and thus cause the dyspnea4 ,usually the lesion is at the third1 fourth or fifth rib on the right side1 although1 as stated1 a lesion may be found above or below this point at the anterior or posterior ends of the ribs or in the vertebr corresponding to the same region4 ,probably lesions are found more on the right side1 because most people are right-handed2 these muscles being better developed would tend1 when contracted1 to draw the ribs from their articulation4 ,the third1 fourth and fifth ribs are usually found involved because it is the region of greatest vasomotor innervation to the bronchial tubes4 ,in a number of cases there will be found a posterior curvature of the dorso-lumbar region2 and accompanying this condition will be catarrh and dilatation of the stomach1 congestion of the liver1 and1 perhaps1 intestinal indigestion and constipation4 ,careful attention should be given to the digestive organs4 ,lesions involving the pneumogastric at the atlas and axis are fairly frequent4 ,these irritate fibers of the pneumogastric to the muscles of the bronchioles and thus produce narrowing of the tubes and consequently the paroxysms4 ,other points to note are the costal cartilages and hyoid bone1 and probably1 in a few instances1 lesions to the phrenic4 ,attacks may be induced reflexly by various excitants1 as dust1 diseases of the upper respiratory tract1 etc41 but the lesions to the vasomotor and motor nerves are the predisposing causes4 ,laughlin#ic says3 8,it is questionable whether reflex causes alone are sufficient to produce genuine asthma without the existence of specific lesions affecting the direct nerve connections of the part involved40 ,no doubt a neurotic tendency is often a predisposing factor4 ,overeating1 and particularly certain foods will frequently excite an attack4 ,pathologically1 true asthma is a pure neurosis4 ,there is more or less chronic inflammation of the bronchial tubes1 shown by injection and thickening of the bronchial mucosa in the majority of cases4 ,there may be found the morbid states peculiar to chronic bronchitis and emphysema4 ,whether the constriction of the tubes is due to spasms of the bronchial muscles or to swelling of the mucosa1 or to both1 the primary1 predisposing and irritating influences are common to both4 ,these are vertebral and rib lesions affecting the spinal nerves at their exit and the sympathetic chain along the head of the ribs2 irritating lesions to the vagi1 constricting pulmonary vessels1 and to the cervical sympathetics1 causing disturbance of the same1 would be factors in the pathological chain4 ,reflex irritations may be found in various regions1 but the principal osseous lesions1 according to ,dr4 ,still1 are on the right side from the second to the sixth dorsal4 ,symptoms4--,the attack may come on at any time1 but usually it comes on in the night during sleep4 ,the onset may be sudden or the attack may be preceded by premonitory sensations1 such as tightness in the chest1 flatulence1 sneezing1 chilliness and a copious discharge of pale urine4 ,nervous symptoms1 headache1 vertigo1 neuralgia1 and an anxious1 nervous1 restless feeling may precede the attack4 ,there is a sense of oppression and anxiety1 followed by dyspnea4 ,soon the respiratory efforts become violent1 the patient is obliged to sit up or runs to the window for air4 ,the shoulders are raised1 the hands are placed upon something firm to keep the shoulders fixed so that the accessory muscles of respiration can be brought into play4 ,the contracted tubes resist the entrance of air4 ,expiration is prolonged and wheezy4 ,in severe cases the face becomes pale1 the skin is covered with perspiration1 the extremities are cold1 the lips1 finger tips and eyelids are livid1 owing to defective oxygenation of the blood4 ,the pulse is small and quick and the temperature is normal or subnormal4 ,the attack may terminate suddenly1 sometimes with a spell of coughing2 this is especially so of severe cases1 as the cough is generally absent in brief paroxysms4 ,the cough is at first very tight and dry and accompanied by a tough1 scanty expectoration which is expelled with great difficulty4 ,the sputum contains rounded masses of matter1 the so-called 8pearls0 of ,lnnec4 ,microscopically1 they are found to be of a spiral structure1 containing cells derived from the bronchial mucous membrane and fatty degenerated pus cells4 ,a second form is contained in the inside of the coiled spiral of mucin1 a filament of great clearness and translucency1 that is most probably composed of transformed mucin4 ,curschmann's spirals are found in the early stages of the attack and for a time these were supposed1 by their irritation1 to excite the paroxysms4 ,their spiral form is unexplained4 ,curschmann believes that these spirals are found in the finer bronchioles and to be a product of bronchiolitis4 ,physical ,signs4--,inspection shows enlargement of the chest which is fixed and barrel-shaped4 ,the breathing is labored and the chest moves but slightly4 ,the diaphragm is lowered and fixed4 ,percussion yields hyperresonance1 especially in cases which have had repeated attacks or when the asthma is associated with emphysema4 ,auscultation4--,with inspiration and expiration are heard sonorous sibilant rales which are more marked on expiration4 ,as the secretion increases1 which is later in the attack1 the rale becomes moist4 ,the attack lasts for a variable period1 rarely less than an hour4 ,in severe attacks the paroxysms recur for three or four nights or more with spontaneous remissions during the day4 ,in some cases the relief seems to be absolute1 but in the majority of cases there is more or less oppression and cough for a day or two1 sometimes for many days4 ,diagnosis4--,the physical signs1 examination of the sputum and the history of the case makes the diagnosis easy4 ,prognosis4--,it is not a fatal disease and only dangerous when complications arise4 ,under osteopathic treatment the prognosis is usually favorable1 unless there are serious complications1 as this is a disease that osteopathy has treated with signal success4 ,in long standing cases emphysema invariably develops4 ,treatment4--,asthma1 unless complicated with bronchial and lung diseases1 is usually readily relieved during the paroxysms4 ,cases of many years' standing have been cured in a few treatments4 ,it should be borne in mind that asthma is a respiratory neurosis4 ,to relieve an attack the osteopath should locate the lesion and1 if possible1 correct it4 ,oium#id1 in the acute attack1 standing at the head of his patient inserts the tips of both thumbs well under the angles of the jaw and then brings direct pressure on both vagi as they pass over the transverse processes of the axis4 ,pressure must be brief and let up to be applied again4 ,immediate relief is given in many cases4 ,adjust upper three cervicals if found deranged4 ,if the muscles are so severely contracted that it is impossible to make out the nature of the lesion1 then strong inhibition1 with an upward1 outward movement over the angles of the ribs involved1 will be sufficient4 ,the object to be gained in every case is to relieve pressure or irritation to the vasomotor or motor nerves1 so that the narrowed tubes may be relaxed4 ,strong inhibition1 such as placing the knee in the patient's back1 at the same time pulling on the shoulders1 will have temporary effect1 but it is always best to reduce the lesion if possible4 ,in severe cases dilatation of the rectum may relieve the paroxysm1 and in a few instances it will be necessary to treat the uterus locally4 ,during the interval between the attacks is the time to remedy the disease4 ,then one is able to locate exactly the position of the disturbed tissues that are causing the paroxysms and apply treatment in the regions given under etiology4 ,many cases of asthma are cured in from one to three months' treatment4 ,one treatment a week is sufficient1 provided one is able each time to accomplish something toward a correction of the lesion and that the patient does not suffer during the meantime4 ,too frequent treatments may simply act as an irritant to the nervous lesions4 ,attention should always be given to the diet and hygiene4 ,gastric digestion should be complete before retiring or it may induce an attack4 ,complications are treated according to the disease4 ,examine the upper respiratory tract1 the digestive tract1 and the pelvic organs when there is reason to believe the paroxysm may be induced reflexly4 ,laughlin sums up the treatment as follows3 7#a7 ,removal of specific lesion2 7#b7 removal of exciting causes2 7#c7 removal of reflex causes2 and1 7#d7 treatment of the patient to improve the condition of the general nervous system4 ,,footnotes3 #ic ,laughlin--,asthma--,journal of the ,american ,osteopathic ,association1 ,oct41 #aiad4 #id ,journal ,a4 ,o4 ,a4 #aiah4 ,,diseases ,,of ,,the ,,lungs ,emphysema ,used in a general way1 emphysema is a term which implies the presence of air in the interstitial tissue1 but when applied to the lungs there are two applications of the term1 having widely different significations1 viz3 ,interlobular or interstitial emphysema and vesicular emphysema4 ,interlobular ,emphysema4--,this is caused by rupture of air vesicles1 deep in the lung structure1 the air escaping into the interlobular connective tissue4 ,it is not a very serious condition1 rarely produces symptoms and affords no physical signs4 ,it usually results from violent acts of coughing in which the expiratory strain is very great1 as in whooping cough and in bronchial asthma2 also1 from wounds of the lung4 ,the air bubbles escape into the interlobular septa and are sometimes seen like little rows of beads outlining the lobules4 ,the pleura may become detached and larger vesicles may form4 ,in rare cases the rupture may take place at the root of the lung and the air passes along the trachea into the subcutaneous tissue of the neck and chest wall1 which gives rise to a very peculiar and distinctive crepitation upon palpation4 ,rarely there is rupture of the superficial vesicles1 producing pneumothorax4 ,vesicular ,emphysema4--,dilatation of the infundibular passages and alveoli or an increase in their size either symmetrical1 involving both lungs1 or localized4 ,vesicular emphysema is divided into compensatory1 hypertrophic and atrophic forms4 ,compensatory4--,this occurs when a region of the lung has been disabled from any cause and does not expand fully during inspiration2 the healthy portion of the lung must then distend and do vicarious work or the chest wall will sink in to occupy the space4 ,this happens with portions of healthy lungs in the neighborhood of tubercular areas and cicatrices1 areas of collapsed lung or parts prevented from expansion by pleuritic adhesions 7in this case the compensatory emphysema is chiefly at the anterior margins of the lungs74 ,as a rule this distention is physiologic and beneficial1 the alveolar walls being simply stretched4 ,later they may atrophy1 the air cells becoming fused4 ,hypertrophic ,emphysema4--,this is enlargement of the lung1 due to dilatation of the air vesicles and atrophy of the walls4 ,osteopathic ,etiology and ,pathology4--,an important predisposing cause of emphysema is often found to be due to derangements of the tissues1 usually vertebr and ribs1 which affect the innervation to the lung tissues4 ,such lesions are found in the vagi and spinal dorsal nerves4 ,the atlas may be involved1 but it is generally the ribs and dorsal vertebr4 ,distinction should be made between cause and effect in the skeletal changes4 ,no doubt in many instances a vicious circle is thus established4 ,congenital weakness of the lung tissues1 probably due to non-development of the elastic tissue1 is a predisposing factor4 ,this disease has a markedly hereditary character and frequently starts early in life4 ,the heightened pressure within the air cells upon an already weakened lung tissue produces emphysema4 ,hence1 the obstinate cough of chronic bronchitis and expiratory straining of asthma are sometimes the immediate cause4 ,in all attacks of severe coughing or straining efforts1 the glottis is closed and the air is forced into the upper part of the lungs1 forcibly expanding them1 and here is where emphysema is found to be most advanced4 ,this disease is also found in players of wind instruments1 in glass blowers and in those whose occupation necessitates heavy lifting or straining4 ,pathologically1 the thorax is barrel-shaped4 ,the lungs are enlarged and do not collapse when the thorax is opened1 as they have lost their elasticity4 ,the organs are pale1 soft and downy to the feeling and pit on pressure4 ,enlarged air vesicles may readily be seen beneath the pleura4 ,microscopically1 there are seen atrophy of the vesicular walls and a diminished amount of elastic tissue4 ,there is more or less obliteration of the capillaries1 and the epithelium of the air cells undergoes a fatty change4 ,there is usually chronic inflammation of the bronchial tubes1 which may be roughened and thickened4 ,the diaphragm is lowered and the subjacent viscera are displaced4 ,the most important morbid changes are found in the heart1 the right chamber being dilated and hypertrophied4 ,this is caused by the increased tension in the pulmonary artery1 which is enlarged and the seat of atheromatous degeneration4 ,in long standing cases the hypertrophy is general4 ,changes in the liver1 kidneys and other viscera are those associated with prolonged venous engorgement4 ,symptoms4--,the onset of the disease is usually gradual4 ,the first symptom to be noticed is the shortness of breath4 ,in rare cases it may exhibit a more acute development1 as after whooping cough1 and then the first symptom will be dyspnea4 ,in some cases this persists all the time1 while in moderate emphysema the dyspnea is noticed only on slight exertion1 such as going up-stairs1 running or walking rapidly4 ,the lungs are always filled with air which is charged with carbon dioxid and does not change1 as the patient is constantly making ineffectual efforts to draw in air4 ,the inspiration is shortened and the expiration is greatly prolonged and is often harsh and wheezy4 ,the pulse-rate is accelerated2 the temperature is usually normal4 ,cyanosis is a characteristic symptom in well established cases and is of an extreme grade not seen in any other affection4 ,bronchitis is frequently found in combination1 especially in winter4 ,in this case there will be the symptoms of the associated bronchitis1 cough1 expectoration and sometimes oppression4 ,as the patient advances in age and there are successive attacks of bronchitis1 the condition gets worse4 ,in advanced cases1 the result of cardiac failures1 there may be venous engorgement1 dropsy and effusions into the serous sacs4 ,physical ,signs4--,inspection4--,there is a marked change in the shape of the thorax4 ,the chest is rounded with increased circumference1 giving the characteristic barrel-shaped chest4 ,the sternum bulges1 as do also the costal cartilages4 ,the intercostal spaces are wide1 especially in the hypochondriac region1 and narrow above4 ,the clavicles and muscles of the neck stand out with great prominence and the neck itself seems to be shortened on account of the elevation of the thorax and sternum4 ,the curve of the spine is increased and there is a winged condition of the scapul4 ,these changes give the patient a stooping posture4 ,the chest does not expand1 but is raised up by the scaleni and sternocleidomastoid muscles which stand out prominently and are hypertrophied4 ,the heart's apex beat is invisible and there is usually marked epigastric pulsation4 ,on palpation1 vocal fremitus is found diminished1 but not absent2 the apex beat is rarely felt4 ,there is distinct shock over the ensiform cartilage4 ,this is due to the displacement of the heart and engorgement of the right ventricle4 ,there is marked pulsation in the epigastrium4 ,on percussion there is sometimes increased resonance1 almost amounting to tympany4 ,the upper level of hepatic dullness is depressed4 ,the heart dullness may be obliterated and the upper limit of splenic dullness may also be lowered4 ,the percussion note is greatly extended4 ,auscultation reveals that the inspiration is short and feeble while there is prolonged expiration1 the normal ratio being reversed4 ,in associated bronchitis rales are frequently heard4 ,diagnosis4--,unless complicated the diagnosis is generally easily made4 ,the enlargement of the thorax1 with dyspnea and hyperresonance and a prolonged expiration will differentiate emphysema from chronic bronchitis4 ,pneumothorax is of sudden development while emphysema is of slow development4 ,pneumothorax is usually unilateral1 and it gives a tympanitic percussion note4 ,in auscultation there is amphoric breathing and metallic tinkling and absence of any vesicular murmur4 ,prognosis4--,the disease is rarely fatal1 although death may result from heart failure1 dropsy or pneumonia4 ,thorough and persistent treatment will generally relieve the primary condition4 ,the disease1 as a rule1 runs a long course but does not necessarily shorten life4 ,atrophic emphysema is a senile change4 ,treatment4--,in cases of recent occurrence one may be able to build up the altered lung tissue by treatment of the innervation to the lung structure1 viz43 the vasomotor nerves from the second to the seventh dorsal1 the vagi1 and the cervical and dorsal sympathetics4 ,when a number of air vesicles have been converted into one sac1 it is impossible to restore the altered lung structure and a treatment to relieve the symptoms and to prevent the further progress of the disease is indicated4 ,in all cases treatment should be applied to correct any vertebr or ribs of the upper dorsal region that may be displaced1 and to raise and spread the ribs so that the lung structure may be better nourished and strengthened and that the aeration of the blood will be more perfect4 ,treatment of the vagi nerves is important1 as their physiological action on the lungs is to increase their movement4 ,the general health of the patient is an important consideration and everything should be done to promote as healthy a condition as possible4 ,the digestion should be carefully looked after and everything done to restore a normal state of the blood4 ,a change of climate may prove beneficial4 ,strengthening the cardiac action will be of service in relieving any dropsical tendency that might occur on account of obstruction to the pulmonary circulation4 ,if bronchitis or asthma occurs1 their respective treatments are indicated4 ,a general treatment of the splanchnic and lung vascular areas should be given to prevent any disturbance in the circulation which might cause congestion of the liver1 congestion of the hemorrhoidal veins1 or catarrh of the stomach and bowels4 8,free evacuation of the bowels and measures to relieve any flatulent distention are very needful in cases of emphysema to take off from the diaphragm any pressure from below1 and to allow it to descend as freely as possible4 ,with this view also the food should be concentrated1 nourishing1 and not bulky40#ie ,it is a good plan to instruct the nurse or attendant to aid inspiration by raising the arms strongly above the head during inspiration and to compress the chest during expiration so as to coincide with natural breathing1 which will render the aeration of the blood greater and increase the elasticity of the vesicles4 ,acute ,lobar ,pneumonia 7,,croupous ,,pneumonia7 ,this is an acute1 infectious disease wherein various vertebral1 rib and muscular lesions predispose to a lowered nutritive state of the parenchyma of the lung1 permitting the invasion of the diplococcus pneumoni1 with consequent local inflammation and pronounced constitutional disturbances1 chill1 extreme prostration and fever1 which terminates abruptly by crisis4 ,secondary infective processes are frequent4 ,in describing a typical case of pneumonia it is considered as a self-limiting disease4 ,by osteopathic treatment it is often aborted or1 at least1 its course much shortened4 ,in such a case it is not typical pneumonia and could not be described as such4 ,osteopathic ,etiology and ,pathology4--,pneumonia occurs more often in the young up to the sixth year and in the aged4 ,it is more frequent during the winter and spring months4 8,colds10 exposure and wetting are predisposing influences that lower resistance4 ,climate exerts little predisposing influence4 ,males are1 on the whole1 more frequently attacked4 ,pneumonia may follow injuries of the chest4 ,various derangements of the ribs and vertebr are always found in pneumonia2 such derangements correspond with the regions of vasomotor1 motor and trophic fibers of the lungs1 viz41 second to seventh dorsal1 inclusive1 and the upper cervical vertebr1 the latter region affecting the vagi4 ,the muscles of the chest region are always severed contracted4 ,these various disorders produce a lowered vitality of the bronchial and lung tissues1 thus favoring the existence of the micrococcus lanceolatus4 ,unhygienic surroundings1 alcoholism1 any or all habits that tend to depress the nervous system1 or lowered vitality from some pre-existent disease1 like diabetes1 ,bright's disease1 organic heart affection or one of the infectious fevers1 favor its development4 ,one attack undoubtedly predisposes to another and repeated attacks may occur in the same individual4 ,the exciting cause is the invasion of the lung by pathogenic bacteria1 especially by diplococcus pneumoni4 ,pneumococci are frequently found in the throat and mouth of the healthy4 ,pathologically1 the lung in croupous pneumonia exhibits three distinct stages--congestion1 red hepatization and gray hepatization4 ,in the stage of engorgement the tissue is red in color1 firm and solid and less crepitant than the healthy lung4 ,the cut surface is bathed in blood and stained serum4 ,microscopic examination shows the capillaries to be dilated and tortuous4 ,the alveolar epithelium is swollen and the air cells filled with a variable number of red corpuscles1 detached alveolar cells and a few leucocytes4 ,during the stage of red hepatization the tissue is solid4 ,it is reddish brown in color and of a dry1 mottled appearance4 ,it is very friable and does not crepitate1 as the affected portion is airless4 ,its weight and specific gravity are increased so that it sinks in water4 ,the torn surface presents a granular appearance1 there being fibrinous plugs in the air cells4 ,on microscopic examination the air spaces are found filled with coagulated fibrin4 ,the tissue contains red blood-corpuscles and pus cells and the walls of the air cells are infiltrated4 ,in sections properly treated the diplococcus is detected1 and in some cases also the streptococcus and staphylococcus4 ,in the stage of gray hepatization1 the lung is still dense and heavy1 but the surface is moister and softer1 while the lung tissue is even more friable and the red color gives place to a mottled gray4 ,the exudate loses its granular character and a yellowish white purulent liquid flows from a cut surface4 ,microscopically1 the air cells are filled with leucocytes1 while the red corpuscles and fibrin filaments have disappeared4 ,the stage of gray hepatization is the stage of beginning resolution4 ,the exudate is softened4 ,the cell elements are disintegrated and absorbed by the lymphatics and largely eliminated through the kidneys4 ,in unfavorable cases the consolidated lung may become infiltrated with pus1 and abscesses occur4 ,in some instances the tissue is gangrenous1 or it may become the seat of fibroid induration4 ,these1 however1 are rare4 ,symptoms4--,the disease begins abruptly1 usually with a severe chill1 lasting from half an hour to an hour1 the fever rising rapidly4 ,there is a sharp pain in the side1 the skin becomes harsh and dry1 the face is flushed1 the eyes are bright and the expression anxious4 ,a short1 dry1 painful cough soon develops4 ,the expectoration presents a characteristic1 rusty or blood tinged appearance and is extremely tenacious4 ,the temperature rises rapidly1 frequently to #ajd or #aje degrees ,f41 and continues high for from five to ten days and generally terminates by crisis4 ,the pulse is full1 but the pulse-respiration ratio is not maintained4 ,there is marked dyspnea1 the respirations ranging from forty to fifty per minute4 ,there are many fine rales4 ,headache1 gastro-intestinal disturbances1 sleeplessness1 epistaxis1 rarely delirium except in drunkards1 may also be present4 ,the symptoms given are those of a typical case of pneumonia1 but all are subject to modification4 ,the onset may be gradual and the chill absent4 ,in all cases1 and especially drunkards1 the temperature may not be high1 while the pulse is often feeble and rapid instead of full and strong1 and the physical signs may not make their appearance until the second or third day4 ,special ,symptoms4--,the fever rises abruptly in the initial chill1 the temperature reaching #ajd or #aje degrees ,f41 and is continuous with a variation of a degree or two4 ,the fever terminates by crisis after having continued from five to nine days4 ,the temperature commonly falls during the night and is accompanied by a profuse perspiration4 ,the temperature may fall from five to eight degrees in eight to twelve hours4 ,there is a wide range here depending upon promptness and skillfulness of treatment1 the reaction of the tissues1 and previous health4 ,early treatment is invaluable in modifying the course of the disease4 ,the sputum at first is mucoid and frothy4 ,about the second day it becomes of a characteristic color1 quite copious and consisting of a frothy1 fluid mucus1 containing small viscid masses4 ,it is very viscid and glutinous1 in some cases almost from the onset4 ,in old and previously weak persons1 there may be no expectoration4 ,under the microscope the sputum is seen to contain red blood-corpuscles1 leucocytes1 alveolar epithelium1 the micrococcus lanceolatus as well as other micro-organisms1 pus corpuscles and small fibrinous casts4 ,a stabbing pain is a common early symptom1 as well as a dry1 short cough4 ,the urine is febrile1 scanty and high colored4 ,urea and uric acid are increased4 ,a trace of albumin is often present1 and there may be symptoms of acute nephritis4 ,herpes is common4 ,the nasolabial herpes appear from the second to the fifth day1 and they may occur upon the cheek1 genitals and also upon mucosa of the tongue4 ,it is supposed to indicate a favorable prognosis4 ,there is redness of the cheek1 usually on the affected side4 ,the mucous membrane of the mouth is dry4 ,the tongue is white and furred4 ,anorexia and thirst are present4 ,the patient is usually constipated1 but diarrhea may occur4 ,vomiting is common4 ,the spleen is usually enlarged1 but the liver is not perceptibly increased in size1 unless there is extreme engorgement of the right heart4 ,the pulse is bounding4 ,the average pulse-rate is from #ajj to #ajh per minute4 ,in consolidation the left ventricle receives a lessened amount of blood and the pulse may become small4 ,in the aged and debilitated1 a small1 weak and rapid pulse may be present4 ,the heart sounds are loud and clear1 and in favorable cases the pulmonary second sound is accentuated1 owing to the increased tension in the pulmonary vessels4 ,upon distension of the right side of the heart and partial failure of the right ventricle1 the second sound becomes less distinct which is a very unfavorable symptom1 for very much depends upon the strength of the right ventricle in pneumonia4 ,the blood usually exhibits leucocytosis which disappears with the crisis4 ,in malignant pneumonia this is absent and its continued absence is an unfavorable sign4 ,the proportion of fibrin is also greatly increased4 ,the diplococci can rarely be seen4 ,headache is common as an initial symptom and may be persistent4 ,the disease is often ushered in by convulsions1 especially in children2 consciousness is usually retained throughout the whole attack1 even in severe cases1 though in some cases there is delirium4 ,in drunkards delirium tremens may be present from the onset4 ,in these cases the patient often wanders about until the preliminary excitement gives way to coma4 ,physical ,signs4--,stage of ,congestion4--,diminished expansion1 the movements of the affected side are defective1 the face is flushed and the patient lies on the affected side4 ,tactile fremitus is slightly increased4 ,there may be tympany over the involved area from diminished intrapulmonary tension4 ,in the latter part of this stage there is impairment of resonance4 ,fine crepitant rales are heard at the end of forced inspiration4 ,great care has to be taken in examination when there is deep seated consolidation4 ,stage of ,red ,hepatization4--,the breathing is markedly abnormal4 ,very little or no expansive motion of the chest over the affected region4 ,vocal fremitus is markedly exaggerated4 ,the skin is hot and dry and the pulse frequent4 ,dullness over the affected parts with an increased sense of resistance is present4 ,there is high-pitched1 prolonged1 bronchial breathing when the lung becomes solidified4 ,when the larger bronchi are completely filled with exudate1 tubular breathing is absent4 ,crepitant rales may also be heard4 ,stage of ,gray ,hepatization4--,largely the same physical signs are repeated in this stage as in the second4 ,the normal manner of breathing returns1 as does also the normal expansive movement of the affected side4 ,crepitant rales reappear4 ,the temperature of the skin is lessened1 breathing changes from bronchial to vesicular and bronchial resonance continues for some time4 ,complications4--,pleurisy is the most frequent complication4 ,pneumonia on one side and pleurisy on the other is possible4 ,the pain is more acute and localized4 ,the respiration is greatly affected and the usual signs of effusion are present4 ,empyema may be a complication4 ,pericarditis is more common in the pneumonia of children4 ,though usually plastic it may be serofibrinous1 but rarely the fluid is purulent4 ,there is increased dyspnea1 the pulse becomes weaker1 and the heart sounds are gradually suppressed4 ,endocarditis is a comparatively frequent complication4 ,it is more liable to attack patients with old valvular disease and to affect the left heart4 ,the physical signs are sometimes absent and even when present are liable to be very deceptive4 ,it may1 however1 be suspected in cases where the fever is protracted2 when septic manifestations1 such as chills1 sweats or irregular temperature1 develop2 when embolic symptoms appear1 or when a rough1 diastolic murmur develops4 ,meningitis is a complication that comes on at the height of the fever4 ,this complication is rarely recognized unless the basilar meninges are involved4 ,it is frequently associated with ulcerated endocarditis4 ,cerebral embolism causing hemiplegia has been observed4 ,other possible complications are neuritis1 arthritis1 nephritis1 parotitis and various digestive disorders4 ,diagnosis4--,a typical case of pneumonia is easily recognized4 ,the abrupt onset with rigor1 the rapidly developed fever1 the sputum1 physical signs and abnormal pulse-respiration ratio1 as a rule make the diagnosis easy4 ,frequent examination of the lungs should be made in ,bright's disease1 diabetes1 organic affections of the heart1 cancer and alcoholism1 as all these affections are liable to become complicated with acute pneumonia4 ,pleurisy is often confounded with pneumonia4 ,the resemblance between friction sounds and crepitant rales is often very close4 ,in pleurisy vocal resonance and vocal fremitus are diminished2 there is no 8rusty0 sputum2 the percussion dullness may change with the posture of the patient1 and the breathing is distant and weak4 ,a typhoid state may be mistaken for typhoid fever4 ,hypostasis occurs late in typhoid fever while dullness sets in early in pneumonia4 ,the history of the onset will be of aid1 as pneumonia as a complication sets in late in the disease4 ,the ,widal test will be of value4 ,acute phthisis may begin with a chill and may resemble pneumonia very closely1 especially the physical signs4 ,examination of the sputum will show the bacilli of tuberculosis4 ,the ,x-ray will often be of aid as a diagnostic measure4 ,prognosis4--,this largely depends upon the previous health of the patient4 ,at the extremes of life the prognosis is much more unfavorable4 ,it is especially fatal in drunkards4 ,by competent osteopathic treatment the mortality rate may be materially lessened and this disease1 dreaded by both physician and patient1 need not seem so fearful4 ,the death rate from pneumonia during the past few years has been appalling4 ,in ,new ,york and ,chicago nearly one-eighth of the deaths the year around are due to pneumonia1 and during certain months of the year twenty-seven or eight per cent4 of all deaths are due to this disease4 ,drug medication is notoriously unreliable1 the most competent physicians freely admitting that they are practically powerless to stay the ravages4 ,given a patient with a fair constitution1 osteopathic treatment will offer reasonable hope to the sufferer4 ,there is no question that osteopathy merits much commendation in the treatment of pneumonia4 ,many severe cases have been cured and many more have undoubtedly been aborted4 ,the treatment is directly applicable and specifically indicated1 and coupled with good nursing and hygiene1 the mortality rate of the old schools is being markedly lessened4 ,treatment4--,the treatment of pneumonia must be both constitutional and local4 ,by this is meant that the systemic strength and vigor must be maintained in addition to treatment of the chief lesion of the disease1 which is located in the lungs4 ,during the various stages of the disease1 the treatment should be directed to the nerves of direct innervation that control the capillaries1 and to the vasomotor nerves of the pulmonary circulation1 in order that the hyperemic and inflamed state of the pulmonary capillaries and adjacent tissues may be lessened and the circulatory system equalized4 ,the disordered tissues that should be corrected in order that the centers of the spinal cord and the nerves that influence the function and structure of the lungs may be relieved1 are3 contraction of the thoracic and dorsal muscles1 subluxations of the ribs and dorsal vertebr from the second to the seventh1 inclusive1 and the upper cervical vertebr that may become disordered and impinge upon the vagi nerves4 ,however1 owing to the fact that the vasomotors are not especially abundant here1 all increased chest mobility and deep breathing and abdominal aid will materially assist the circulation4 ,also1 carefully treat the middle and inferior cervical regions for the lymphatics of the lungs4 ,each of these regions should be carefully examined and thoroughly treated whenever found involved4 ,the specific micro-organisms that influence the course of pneumonia are naturally very important factors2 but observing and improving the general health1 and establishing an unobstructed circulation through the diseased lung tissues will hasten the crisis by favoring a rapid formation of antidotal substances to neutralize the poisonous substance produced by the micrococcus lanceolatus4 ,healthy tissues1 which occur only where there is uninterrupted freedom of vascular supply and nerve force1 are obtained by correction of any and all anatomical disorders4 ,this will rapidly decrease any lethal tendency in the patient and often abort the disorder so that all that is needed is sufficient time for nature to heal the diseased tissues4 ,the principal predisposing cause of many specific diseases1 is some disorder of the anatomical tissues that interferes with normal physiological functions2 and the determining of the different types of disease is often due to the location of the lesion and the character of the micro-organism involved in each disease4 ,what is necessary in many cases is a correction of the mechanical predisposing condition and the exciting and determining influences will be rendered inactive4 ,the importance of close attention to both vagi can not be overestimated4 ,any obstruction above or below the origin of the superior laryngeal nerve is followed by loss of motor power of the lungs1 thus causing difficult and labored breathing4 ,the lungs become surcharged with blood1 because the air pressure in the lungs is low and the thorax is distended4 ,this condition is followed by serous exudation4 ,thus obstruction of the vagi may be one factor in the cause of pneumonia4 ,obstruction of the vagi below the origin of the recurrent laryngeal nerves affects the lower and middle lobes of the lungs1 and produces also a catarrhal inflammation of the upper lobes4 ,the recurrent laryngeal nerves may be obstructed by dilatation of the aorta or subclavian artery as they wind about them2 also by dislocations of the first and second ribs1 which may affect the nerves not only directly1 but by causing an obstruction to the subclavian vessels with a consequent disturbance of the aorta and the heart4 ,the recurrent laryngeal nerves may be treated directly at the inner lower part of the sternomastoid4 ,one of the chief objects of the treatment should be to prevent heart failure and to lessen the pulse-respiration ratio4 ,the average pulse-rate in typical cases is from #ajj to #aaj per minute and when it exceeds this to any extent1 say #abj1 there is cause for alarm4 ,at first the pulse is full and bounding1 later it is small on account of a lessened amount of blood reaching the left ventricle and systemic circulation1 owing to the extensive consolidation4 ,in treating heart failure particular attention should be paid to the condition of the ribs on the left side over the region of the heart1 the second to the fifth1 inclusive4 ,a correction of any disturbance to the inhibitory nerves of the heart1 7the vagi7 and the accelerator fibers of the heart 7the cervical sympathetic7 should be made4 ,this means close attention to probable derangements of the vertebr from atlas to first dorsal4 ,general treatment of the entire system will relieve the heart of some work and favor an equalization of the vascular system4 ,also by the use of hydrotherapy the maintenance of the heart's action may be accomplished4 ,cold compresses1 and not warm ones1 should be used1 as the latter relax the vessel walls1 producing more or less paresis of the vessels1 while the former stimulate the vaso-dilators1 producing dilatation and tone of the vessels1 thereby causing a vigorous increase in the flow of blood4 ,this relieves the heart by increasing the cutaneous circulation1 besides increasing arterial tension4 ,the right heart is indirectly aided by the increase of the tension in the general vascular system1 and the vessels of the pulmonary circulation have more force expended upon them and a greater contraction of their vessels occurs on account of the dilatation of the cutaneous vessels4 ,the temperature of the water used should be #fj degrees ,f41 and the compress applied for thirty minutes or as long as necessary4 ,attention to the abdominal area and diaphragm will have a definite effect upon the circulation and elimination4 ,it is beneficial in its influence upon lungs and heart and in combatting toxemia4 ,carefully graduated deep breathing is of distinct benefit4 ,in addition to the fever treatment in the cervical and dorsal regions1 the gradually cooled tub-bath will be of aid4 ,the temperature at first should be ninety degrees ,f4 and then gradually cooled to eighty degrees ,f4 ,the duration should not be over ten or fifteen minutes4 ,care should be taken that the patient does not exert himself4 ,he should be lifted in and out of the baths4 ,these baths also have a marked effect upon the respiratory and nervous centers4 ,the ice-bag over the chest and spine has a beneficial influence2 still1 with feeble children be exceedingly careful when applying or using cold methods4 ,during all stages of the disease1 the best possible care should be taken of the patient4 ,see the patient frequently1 probably twice a day or oftener4 ,each time thoroughly relax the dorsal muscles and readjust the ribs1 for as every osteopath of experience will note 7and ,dr4 ,still particularly emphasizes7 the contracted muscles frequently and continually displace the ribs4 ,the treatment should not be prolonged to a point of overfatigue1 but a definite reaction of tissues should be secured but no further4 ,carefully raise all the ribs and moderately hyperextend the spine4 ,release the cervical1 pectoral and axillary lymphatics1 and stimulate spleen and liver4 ,experience has shown that the first treatment is of the greatest importance and if the osteopath will control the predominant symptoms at that time the result will be much simplified4 ,for that reason it is best not to leave the patient until the chest pain1 fever1 high pulse or whatever may be present1 are well in hand1 although it may mean a long visit with fairly frequent treatments4 ,treat the conditions existing and wait2 then treat again and the result will more than repay4 ,there is always more than a chance of aborting the disease1 but the first treatment is often the crucial test4 ,f4 ,e4 ,moore and many others report numerous cases treated without a fatality and the average duration of the disease not exceeding five days4 ,the apartment should be well aired and a temperature of #fe degrees ,f4 maintained4 ,in the very young the temperature should be higher4 ,the diet is exceedingly important4 ,give a liquid1 light and nutritious one1 a milk diet being preferable4 ,otherwise give meat juice1 broths1 egg albumin and whey4 ,avoid starchy and saccharine foods1 and give plenty of water4 ,good nursing and complete rest of body and mind1 with careful attention to the activity of the bowels1 kidneys and skin1 will indirectly aid the clogged up lung fascia to perform its function and hasten an early recovery from the disease4 ,in epidemic forms be particularly vigilant in the employment of antiseptics4 ,bronchopneumonia 7,,catarrhal ,,pneumonia7 ,definition4--,an inflammation of the minute bronchi and air vesicles4 ,the affection begins with an inflammation of the capillary bronchi1 which extends to the air vesicles4 ,the micrococcus lanceolatus1 streptococcus pyogenes1 influenza bacillus1 and staphylococcus aureus et albus are the principal exciting micro-organisms4 ,osteopathic ,etiology and ,pathology4--,the disease is most prevalent among the very young and the old1 and may be either primary or secondary4 ,it may occur as a sequence or in association with measles1 diphtheria1 whooping cough and scarlet fever4 ,exposure to cold1 impure air1 rickets and diarrhea are marked predisposing causes in children4 ,in the old1 debilitating affections and chronic diseases are predisposing causes4 ,bronchopneumonia occurs sometimes as a complication in smallpox1 erysipelas1 typhoid fever and influenza4 ,the principal lesions found upon examination are subdislocated ribs affecting the pulmonary vasomotor nerves4 ,the third1 fourth and fifth ribs are especially apt to be subdislocated4 ,the muscles throughout the thoracic region are generally severely contracted4 ,another group of cases1 the so-called aspiration or deglutition pneumonia1 are caused by the inhalation of food particles or other substances4 ,a lessened sensitiveness of the larynx 7as in comatose states7 may allow small particles of food to reach the smaller bronchi and produce inflammation1 which may even cause suppuration and sometimes gangrene4 ,cases are liable to occur after operations about the nose and mouth4 ,it is often secondary to carcinoma of the larynx and esophagus and after tracheotomy and glosso-pharyngeal palsy4 ,a serious form of bronchopneumonia is caused by the tubercle bacillus4 ,pathologically1 both lungs are usually involved and become heavy4 ,on the pleural surfaces1 especially at the base1 sunken purplish or slaty patches are noticed1 representing collapsed lung tissue4 ,on section small1 projecting portions of consolidation are seen1 separated from each other by uninflamed and collapsed tissue4 ,the section of lung tissue is of a dark reddish color4 ,the terminal bronchi are filled with tenacious1 purulent material4 ,microscopically1 the terminal bronchi and air cells are filled with a plug of exudation composed of leucocytes and desquamated epithelium4 ,the walls of the bronchi are swollen and contain many leucocytes4 ,symptoms4--,the symptoms are frequently marked by those of the primary affection4 ,the onset may be either abrupt or gradual4 ,the child becomes feverish2 there is increased frequency in respiration and there is an aggravated cough4 ,the temperature rises to #ajb or #ajd degrees ,f42 respiration may rise as high as #fj or #hj4 ,the cough is hard1 distressing1 frequently painful and accompanied by a mucopurulent expectoration4 ,the pulse is greatly accelerated--#abj to #ahj per minute4 ,as the disease advances1 signs of deficient aeration of the blood are noticed4 ,at first there is a pale and anxious expression of the face1 the lips are blue and the child makes strenuous efforts to breathe4 ,the blood soon becomes highly charged with carbon dioxide and1 by its benumbing influence upon the nerve centers1 sensibility is reduced and the cough and suffering subside4 ,the face becomes livid and death may occur within twenty-four hours from paralysis of the heart4 ,at the beginning of the attack dullness is absent and subcrepitant and sibilant rales are present4 ,areas of consolidation soon become manifested4 ,there is slight impairment of resonance and the breathing is harsh4 ,upon inspection there is1 in grave cases1 retraction of the sternum due to defective expansion4 ,diagnosis4--,this is usually easy1 developing as it generally does in the course or at the conclusion of another disease1 with a gradual onset as a rule1 and irregular fever and a long duration1 besides usually occurring in children under five4 ,if the areas of consolidation are large1 involving the greater part of a lobe1 it is sometimes very difficult to distinguish bronchial pneumonia from lobar pneumonia4 ,lobar pneumonia1 when occurring in children1 is usually between the ages of five and fifteen4 ,the onset is abrupt in a child of good health2 it resolves rapidly2 there is rusty colored sputum and continued fever falling by crisis4 ,tuberculous bronchopneumonia is very hard to differentiate from simple bronchopneumonia4 ,a great many cases can be correctly diagnosed only after the lapse of considerable time4 ,the presence of signs of softening1 considerable disease of the apices1 and examination of the sputum1 or in the case of a child1 of the vomited matter1 would diagnose this form4 ,if elastic fibers and tubercle bacilli are found in the sputum or vomited matter1 the diagnosis is at once decided in favor of tuberculous bronchopneumonia4 ,x-ray diagnosis should be considered4 ,prognosis4--,the prognosis depends on the cause4 ,in children that are previously weak and debilitated the disease is very fatal4 ,when the disease follows measles and whooping cough1 the fatality is not so great4 ,in adults the prognosis is about the same as in the croupous form4 ,the deglutition variety is apt to be fatal4 ,treatment4--,a great deal can be done to prevent the disease1 by careful attention to debilitated children in keeping them warm and protected at all times4 ,there is usually a preexisting bronchitis4 ,in measles and whooping cough and during convalescence1 the child should be well taken care of4 ,a thorough1 persistent treatment1 but not to a point of overfatigue1 of the dorsal vasomotor nerves posteriorly should be given4 ,gentle work over the cervical and axillary lymphatics to free the edematous barrier1 correction of the tensed scaleni and deranged first ribs and clavicles1 and stimulation of spleen and liver1 with sufficient general treatment to start reaction1 will be effective4 ,derangements to the third1 fourth and fifth dorsal nerves are most likely to be found2 the principal vasomotor innervation to the bronchials and air vesicles is from this region4 ,treatment over the chest anteriorly is of great aid1 especially an upward and outward manipulation to release the ribs should be given4 ,attention should be given the vagi nerves to increase the activity of the lungs as well as for the effect gained upon the circular fibers of the bronchi4 ,care should be taken1 that the first rib is not impinging upon the first thoracic ganglion1 or interfering with lymphatic drainage4 ,ice-bags over the chest are helpful4 ,the chest should be protected from changes in temperature by a jacket of cotton batting4 ,the diet should consist of milk1 egg albumin and broths4 ,keep the temperature at about #gj degrees ,f4 and the air of the room moist and free from draughts4 ,when the fever is high1 sponging or the wet pack is helpful4 ,the bowels from the beginning of the attack should be carefully watched4 ,there is danger of a failing heart2 this is generally associated with mucous rales and cyanosis4 ,douching alternately with hot and cold water will usually excite coughing and overcome the difficulty4 ,the gradually cooled bath will have a marked effect in reducing the temperature1 quieting the nervous symptoms1 increasing the respiratory power and promoting sleep4 ,raise and carefully stimulate the abdominal viscera1 and elevate the diaphragm4 ,this is effective in both cyanosis and toxemia4 ,in the first stage of pneumonia1 ,hazzard#if says1 8,there is better opportunity to correct the specific lesion1 as the patient's strength will allow of such treatment4 ,the work is also aided by the fact that the alveoli are still open1 and lung action1 stimulated by treatment1 may become a valuable aid in dispelling the engorgement40 ,this is a most valuable suggestion1 but be exceedingly careful in subsequent treatments not to treat too hard and thus lame and bruise the patient4 ,series ,i1 ,,ii1 ,,iii1 and ,v of the ,american ,osteopathic ,association ,case ,reports present several interesting cases of pneumonia which typify the importance of immediate and direct correction of the osteopathic lesions4 ,herman#ig cites an interesting case of delayed resolution1 due to a depressed condition of all the ribs on the affected side with marked luxation of the eighth4 ,the lesion at the eighth was the cause of a prolonged attack of hiccoughs which prevented resolution4 ,it is pointed out that there is an abundant intercostal nerve supply to the diaphragm from the eighth and ninth intercostals4 ,c4 ,e4 ,achorn instances an autopsy of patient dying of pneumonia1 where a bony ankylosis was found at the second dorsal2 this lesion was probably an important predisposing factor4 ,broadly speaking1 one should keep in mind the following3 ,first1 early treatment will frequently abort what would ultimately be pneumonia--still1 in the preceding it is not these cases that are especially referred to1 but those following the course of a typical pneumonic process2 second1 both specific and general treatment prior to the crisis will materially lessen the severity of the disease2 third1 the crisis corresponds to beginning resolution 7during resolution expectoration and liquefaction and absorption of the exudate are paramount features7 and must be met promptly and vigorously1 special attention being paid to the heart2 and1 fourth1 during convalescence1 good1 general attention and care of patient as to treatment1 hygiene1 diet1 and climate1 are important4 ,chronic ,interstitial ,pneumonia 7,,fibroid ,,induration7 ,definition4--,a chronic1 inflammatory disease of the lungs1 characterized by an overgrowth of fibrous or connective tissue4 ,etiology4--,with few exceptions chronic affections of the lungs cause more or less fibroid overgrowth4 ,this is especially frequent after bronchial pneumonia and pulmonary tuberculosis4 ,it is also excited by abscesses1 hydatids1 syphilis1 emphysema1 sarcoma and old fibrinous pleurisy4 ,it may also be caused by compression1 by aneurism or neoplasms4 ,it may arise as a primary affection1 due to the inhalation of irritating dusts 7stone dust1 coal dust and metal dust74 ,there will be found deeply seated osseous lesions of the upper and middle dorsal region and corresponding ribs1 and frequently of the cervical vertebr4 ,pathologically1 as it involves limited or extensive areas1 it is recognized as local or diffuse4 ,it is a unilateral affection4 ,the involved portion is shrunken and on section it is found to be tough1 firm1 of a greenish color and containing an overgrowth of fibrous tissue4 ,if it affects the left side the heart may be displaced4 ,the unaffected lung is usually enlarged 7compensatory emphysema74 ,there is hypertrophy of the right ventricle of the heart4 ,symptoms4--,there is a chronic cough1 which varies greatly in its severity2 moderate dyspnea1 and a variable expectoration4 ,there is no fever and the general health of the patient may be preserved for a number of years4 ,the expectoration is generally copious1 muco- or sero-purulent1 rarely fetid4 ,there is retraction of the affected side1 displacement of the apex beat and lateral curvature of the spinal column4 ,the unaffected side is enlarged4 ,the intercostal spaces disappear1 the ribs sometimes even overlapping4 ,the tactile fremitus is generally increased1 but if the pleural membrane is thickened the fremitus may be decreased4 ,there is generally impairment of resonance4 ,a tympanitic or amphoric note may be heard over a dilated bronchus4 ,on the sound side the percussion note is generally hyperresonant4 ,the breathing sounds may be feeble4 ,they may be bronchial or cavernous1 but rather amphoric4 ,late in the disease cardiac murmurs are not uncommon4 ,diagnosis4--,this is never difficult4 ,it is mainly to be distinguished from fibroid phthisis4 ,in the latter both lungs are involved and there is fever and bacilli are found in the sputum4 ,an ,x-ray examination should be made4 ,prognosis4--,the disease is exceedingly chronic and may last for many years4 ,death may result from gradual failure of the right heart1 hemorrhage or from intercurrent attacks of acute pneumonia involving the other lung4 ,treatment4--,little can be done for this condition4 ,intercurrent bronchitis may be somewhat relieved by the treatment for chronic bronchitis4 ,the patient should dwell in a mild climate4 ,hygienic surroundings and nutritious food are indicated4 ,something can be done by attempting to correct the condition of the ribs and vertebr1 but this measure1 from the nature of the disease1 is generally palliative at best4 ,congestion of the ,lungs ,congestion of the lungs may be active1 passive or hypostatic4 ,the two former have particular osteopathic significance1 owing to the lesions involved4 ,active congestion may result from violent physical exertion1 excessive alcoholic indulgence1 inhalation of hot air or as a symptom in pneumonia and other pulmonary affections4 ,there is dyspnea and cough with rusty expectoration of a frothy nature4 ,there may be absence of fever4 ,but generally a slight chill followed by moderate fever1 pain in side1 and cough are the principal symptoms4 ,on percussion1 the note is dull with increased tactile fremitus and bilateral involvement4 ,prognosis is good under osteopathic treatment1 but it must be promptly met as it is usually a symptom of another disease4 ,treatment is the same as in the beginning of pneumonia4 ,passive congestion1 when not hypostatic1 is mechanical and due to an impeded return of blood to the left heart from mitral stenosis1 or regurgitation1 dilatation of the right ventricle and cerebral disease4 ,the lungs are large with distended pulmonary vessels with venous blood in the air spaces4 ,there is dyspnea and cough1 with blood-streaked1 frothy expectorations4 ,the treatment is primarily of the condition causing the congestion1 but in addition the upper ribs should be raised and thorough treatment of the abdomen and elevating the diaphragm are beneficial4 ,hypostatic congestion results from a weakened heart in exhaustion1 infection or old age2 also from continued dorsal decubitus4 ,rheumatic fever1 tuberculosis and other constitutional diseases1 as well as organic growths1 may predispose4 ,the condition gives rise to a mild form of lobar pneumonia4 ,symptoms are not well defined and often are not recognized4 ,there may be slight dullness1 increased fremitus1 moist rales and other signs of a venous engorgement4 ,in treatment the first move is to change position of the patient and then look after any underlying cause4 ,osteopathically1 follow treatment of pneumonia4 ,in all cases of circulatory involvement of the lungs1 treatment to relax muscles or to adjust vertebr and rib lesions to the vasomotor nerves of the lungs is very efficacious4 ,landois 7#aijd7 says3 8,irritation of sensory nerves1 particularly if intense and long continued1 causes a dilatation of the vessels in the areas innervated by them40 ,edema of the ,lungs ,there are two forms of edema1 collateral and general1 which follow an intense congestion with transudation of serum into the air vesicles and interstitial tissue4 ,the collateral form is localized and usually appears in connection with pneumonia1 pulmonary infarction or abscess4 ,in general edema the base of the lung is involved to a greater extent1 but the whole structure is affected and hydrothorax is generally present4 ,the cause of edema is not well understood1 but may result from a long line of constitutional diseases4 ,the symptoms are dyspnea1 cough with copious1 blood-streaked sputum which is expelled with difficulty4 ,there may be fever in the inflammatory type with weak1 increased pulse4 ,dullness over the affected area1 broncho-vesicular breathing and small liquid rales are audible4 ,the diagnosis must largely be made upon the bilateral dullness at the base of each lung and physical signs noted above4 ,x-ray examination will usually be of value4 ,prognosis depends on the condition causing the edema and treatment should be directed to correcting it4 ,frequently edema is a terminal affection4 ,this should be followed by osteopathic treatment to free the lungs of the effusion as outlined under pneumonia1 especially relaxation of the upper dorsal and cervical muscles1 separation of the upper ribs and stimulation of the heart4 ,,footnotes3 #ie ,yeo--,a ,manual of ,medical ,treatment or ,clinical ,therapeutics1 ,vol4 #a1 p4 #eig4 #if ,hazzard--,practice of ,osteopathy p4 #ia4 #ig ,herman--,an ,unusual ,feature in a ,case of ,pneumonia--,journal of the ,american ,osteopathic ,association1 ,july #aijf4 7,this refers to lobar pneumonia47 ,,diseases ,,of ,,the ,,pleura ,pleurisy ,definition4--,an inflammation of one or both pleural membranes4 ,varieties4--,etiologically1 it may be divided into primary and secondary pleurisy2 also1 into acute and chronic pleurisy4 ,anatomically1 the cases may be divided into dry pleurisy and pleurisy with effusion 7serofibrinous1 purulent1 hemorrhagic74 ,acute ,pleurisy 7,,fibrinous ,,or ,,plastic ,,pleurisy7 ,the affection may be primary or secondary4 ,as an independent affection it is rare4 ,it may follow exposure to wet and cold or it may be due to mechanical injury4 ,the disease may set in with pain in the side1 slight fever and the friction sound of pleurisy may be present4 ,these symptoms last a few days and then disappear and no exudation occurs4 ,the pleural surfaces become more or less united4 ,as a secondary process1 dry plastic pleurisy arises from extension of the inflammation in acute or chronic diseases of the lung1 especially pneumonia4 ,abscesses1 gangrene and cancers are also causes4 ,it sometimes occurs in acute articular rheumatism1 and in a large number of cases is associated with tuberculosis4 ,this condition may be a complication in chronic ,bright's disease and in chronic alcoholism4 ,in the fibrinous form of pleurisy the serum is scant and the membrane is covered with a sheathing of lymph1 which finally organizes and adhesion takes place between the opposing surfaces4 ,serofibrinous ,pleurisy ,this form is known as pleurisy with effusion4 ,there is little lymph1 the exudate being mainly composed of serum4 ,osteopathic ,etiology and ,pathology4--,many cases rapidly follow exposure to cold1 wet or an injury to the thorax4 ,exposure to cold is considered a mere predisposing agent1 permitting the action of various micro-organisms4 ,the large majority of cases are due to tuberculous infection of the pleura4 ,the osteopath finds that important predisposing causes of pleurisy are injury to the chest wall1 ribs and vertebr1 and exposure to cold1 causing contraction of the thoracic muscles4 ,these injuries and strains throughout the chest result in an interference with the intercostal and phrenic nerves1 and also with the intercostal and internal mammary arteries2 consequently1 there is produced a lowered vitality of the pleural tissues1 which permits the attack of the micro-organisms4 ,it may be secondary to rheumatism1 ,bright's disease1 cancer and cirrhosis of the liver4 ,pathologically1 there is an abundant exudation of serum4 ,fibrin is found on the pleura1 and is rarely abundant in the serous fluid in the form of flocculi4 ,the fluid is straw colored as a rule4 ,it varies greatly in quantity from one-half to four litres4 ,microscopically1 there are found leucocytes1 red blood-corpuscles1 shreds of fibrin and occasionally cholesterin1 uric acid and sugar4 ,the composition of the fluid resembles blood serum1 and is rich in albumin4 ,various displacements of the adjacent organs are caused by the effusion4 ,the lung is more or less compressed into the back part of the pleural sac4 ,the heart is displaced4 ,the diaphragm may be crowded downward4 ,on the right side this lowers the liver2 on the left it displaces the stomach1 transverse colon and sometimes the spleen4 ,symptoms4--,the onset may be abrupt with a chill1 severe pain in the side and fever4 ,with few exceptions the disease comes on insidiously1 pain in the side being the first symptom4 ,the pain is sharp and cutting and is aggravated by breathing or coughing4 ,there is moderate fever1 the temperature ranging from #ajb to #ajc degrees ,f4 ,dyspnea may be present at the onset4 ,this is due to the fever and pleuritic pain4 ,when the fluid is effused slowly1 dyspnea may be absent except on exertion4 ,it is most marked when the effusion has developed rapidly4 ,as the effusion accumulates and the inflamed surfaces separate1 the pain diminishes and1 as a rule1 soon disappears4 ,physical ,signs4--,immobility and bulging of the affected side1 depending on the amount of exudation4 ,the intercostal spaces are obliterated4 ,the apex beat of the heart is displaced4 ,upon palpation the limited movement of the chest is more accurately determined4 ,tactile fremitus is largely diminished4 ,the position of the heart's impulse can be readily located by palpation4 ,displacements of the liver and spleen can be felt through the abdominal walls4 ,at first the percussion notes are impaired and later there is dullness which gradually rises as the fluid increases4 ,the upper line of dullness is not horizontal when the patient is in the erect posture1 but is higher behind than in front4 ,above the effusion in the sub-clavicular region1 percussion gives a tympanitic note1 the so-called ,skoda's resonance4 ,in moderate effusions the level of dullness often changes with the position of the patient4 ,early in the disease a friction rub can usually be heard4 ,as the fluid accumulates1 the breath sounds become weak1 distant and may have a tubular or bronchial quality4 ,vocal resonance is usually lessened4 ,there may be bronchophony1 or it may manifest a nasal or metallic quality1 resembling somewhat the bleating of a goat 7,lnnec's egophony74 ,x-ray examination should be made4 ,duration4--,the course is extremely variable4 ,the fever is due to inflammation and may last for two or three weeks1 when it may subside4 ,the cough and pain disappear and the effusion1 which is usually slight in these cases1 may be absorbed quickly4 ,in cases where the effusion is poured out rapidly it may be absorbed just as quickly4 ,in cases where the effusion is poured out slowly or where the effusion reaches as high as the fourth rib1 recovery is usually slower4 ,large effusions may persist without change for months and finally the case may become subacute or chronic4 ,this is particularly true of tuberculous cases4 ,prognosis4--,this depends largely upon the cause2 on the whole1 prognosis is favorable4 ,death is a rare termination of serofibrinous effusion2 death may1 however1 occur suddenly without sufficient lesions to explain the cause4 ,the exudate may become purulent4 ,treatment of ,acute ,pleurisy ,an early treatment and rest in bed with a liquid diet are the measures to be employed at the beginning of the attack4 ,pay particular attention to any primary disease and to the general health4 ,rarely is there any difficulty in locating certain predisposing causes of the disturbance4 ,then often a rib or corresponding vertebra is badly subdislocated over the seat of the disease4 ,the sympathetic and phrenic nerves are involved through the intercostal and phrenic nerves4 ,a careful examination of the side of the affected chest should be made1 as there may be more or less obstruction of the intercostals and the internal mammary arteries from their branching of the aorta and subclavian vessels4 ,a dislocation of the first or second rib may affect the subclavian vessels and their branches markedly2 although all the upper ribs and the thoracic muscles should be examined carefully for derangements which would affect these blood-vessels and produce an exudation4 ,ice-bags upon the chest1 as in pneumonia1 may be used4 ,limiting the movements of the chest with a bandage or adhesive strips will give considerable relief4 ,when the effusion has taken place1 carefully raising and spreading the ribs with attention to special points of involvement1 will at times cause absorption of the fluid4 ,the daily amount of liquid food should be greatly lessened with a view of depleting the blood serum from various tissues2 thus the serum collecting in the pleura1 which is a lymph space1 will also be absorbed4 ,treatment of the bowels1 kidneys and skin1 so that they may be rendered active1 will aid in the depletion of the blood serum4 ,it may be necessary in some cases to aspirate1 especially if other methods fail and if the effusion is large4 ,the points of operation are in the mid-axillary line at the sixth interspace or at the angle of the scapula at the eighth interspace4 ,in puncturing1 the needle should be held close to the margin of the upper rib so as to avoid the intercostal artery4 ,withdraw the fluid slowly and if faintness is produced1 desist4 ,empyema should be treated surgically4 ,simply tapping is rarely sufficient4 ,a free incision1 as in abscess1 and thorough drainage should be made4 ,care must be taken that the drainage tube is large enough4 8,in cases of pleurisy the axilla and the inner arm may be tender and painful2 this is due to the pleuritic inflammation being carried by the way of the #8nerve of ,wrisburg4' 8,the pleuritic pain in the costal muscles compels restricted movement of the ribs and also limits the respiratory function of the diaphragm4 ,these painful cramps and stitches are independent of the pain arising alone from the inflamed pleural surface1 and the diminution of the respiratory movements is due to a particularly contractured state of the muscles of the chest as is demonstrated by the fact that the patient can not draw a long breath2 hence one may reasonably conclude that nature has so distributed nerves to the pleura as to enable that serous membrane to control the muscles which create movements of the adjacent costal surfaces and thus insure its quietude during the stages of inflammation or repair40 7,ranney74 ,chronic ,pleurisy ,definition4--,chronic inflammation of the pleural layers4 ,there are two forms1 exudative and dry or plastic pleurisies4 ,chronic ,pleurisy with ,effusion4--,this may follow an acute serofibrinous type4 ,some cases develop very slowly4 ,in most cases in children1 the fluid changes to pus early in the disease4 ,the fluid may remain for months without changing to a purulent character4 ,in such cases the character and physical signs do not differ from those in acute serofibrinous pleurisy4 ,chronic ,dry ,pleurisy4--,these cases originate in two ways3 ,first1 this may succeed pleural effusion when the fluid portion of the exudate is absorbed and the pleural layers are opposed4 ,they are separated only by fibrinous elements that become organized into firm connective tissue4 ,this process goes on at the base1 principally1 which1 if it follows the acute form1 produces but slight flattening1 but if it succeeds the chronic form or empyema1 the extent of retraction and flattening will be marked4 ,calcification may occur in these firm1 fibrous membranes and occasionally little pouches of fluid are found between the false bands4 ,second1 a large number of cases are dry from the onset4 ,this condition may follow directly acute plastic pleurisy4 ,it may be of tuberculous origin or it may set in without any acute symptoms4 ,no matter how slight the plastic exudate may be1 it invariably tends to become organized1 thus producing adhesion of the layers4 ,this is undoubtedly the result when the pleurisy is primary or secondary4 ,the adhesions are generally circumscribed4 ,when the adhesions are of tuberculous origin they may be locally confined to one pleura or they may be bilateral4 ,in these cases both the parietal and costal layers are thickened1 and embodied in the thickened pleura are found firm fibrin masses and small tubercles4 ,occasionally1 vasomotor symptoms arise in chronic pleurisy1 especially in cases of tuberculous origin1 and are probably due to the involvement of the first thoracic ganglion4 ,these almost invariably mean that there is a displacement of the first1 second1 or third rib4 ,unilateral flushing or sweating of the face or dilatation of the pupil are frequently noticeable4 ,symptoms4--,definite symptoms are rarely present4 ,in some cases the physical signs are quite pronounced1 while1 on the other hand1 they may be entirely negative4 ,in mild cases there may be slight immobility of the affected side with feeble breath sounds4 ,in other cases there may be very full chest expansion while the breath sounds are feeble4 ,in a large number of instances the physical signs are quite distinct4 ,there is displacement of the viscera1 retraction of the chest walls1 curvature of the spinal column and dropping of the shoulders4 ,there are feeble breathing and creaking1 leathery friction sounds4 ,dullness is found at the base4 ,treatment4--,the treatment of chronic pleurisy is largely that of acute pleurisy4 ,gymnastic and methodical breathing exercises should be employed in helping to correct the thoracic walls4 ,care must be taken not to injure the chest and pleura if adhesions have formed4 ,surgical work may be necessary in some cases4 ,the vasomotor symptoms that are sometimes manifested in chronic pleurisy and are claimed to be due to involvement of the first thoracic ganglion1 are an interesting feature to the osteopath4 ,such cases would probably present to the osteopath a marked lesion of the upper dorsal vertebr or the second or third rib4 ,these vasomotor symptoms are also found in pleurisy associated with tuberculosis of the apex of the lung4 ,the osteopath frequently treats these cases and he should be cautious about over-treating or straining the chest wall4 ,the adhesions are persistent and often there is more or less pain1 so care must be exercised when attempting to structurally readjust4 ,do not expect to completely relieve every case1 but nevertheless there are few cases but that can be benefited4 ,occasionally the pain alone is due simply to pleurodynia4 ,,diseases ,,of ,,the ,,urinary ,,system ,diseases of the ,kidneys 7,,renal ,,hyperemia7 ,definition4--,an increase in the amount of blood to the vessels of the kidney4 ,it is active hyperemia when there is arterial congestion1 passive hyperemia when there is venous congestion4 ,osteopathic ,etiology and ,pathology4--,active hyperemia may be caused by injuries to the renal splanchnics1 especially the tenth to twelfth dorsal segments2 injuries over and to the kidneys2 exposure to cold when the body is very warm2 poison given1 as diuretics2 eruptive fevers and pregnancy1 or follow genito-urinary operations4 ,passive hyperemia may be caused by obstructive diseases of the general circulation1 as chronic heart1 lung and liver diseases1 or by pressure on the renal veins by tumors1 growths and the pregnant uterus4 ,thrombosis of the renal veins may produce passive hyperemia1 but rarely4 ,pathologically1 in active hyperemia the kidney is swollen and slightly enlarged4 ,upon removal of the capsule1 the kidney is found to be brown and mottled4 ,on section the parts bleed freely1 the ,malpighian bodies are distended1 and microscopical examination shows a cloudy swelling of the renal epithelium4 ,in passive hyperemia the kidney is swollen1 hard1 firm and of a bluish red color4 ,later there is an overgrowth of connective tissue and some infiltration between the tubules4 ,the ,malpighian bodies occasionally become shriveled and the renal epithelium fatty4 ,symptoms4--,in active hyperemia the urine is scanty1 of high specific gravity and of high color1 containing some albumin and casts4 ,pain is experienced over the loins1 following the course of the ureters1 and the bladder is irritable4 ,there are headache1 nausea and vomiting4 ,when from infection1 fever may be present4 ,in passive hyperemia the symptoms are primarily those caused by the disease producing the disorder4 ,there is weight over the loins and dropsy4 ,the urine is diminished1 of high specific gravity1 highly colored1 albuminous and occasionally shows a few hyaline casts4 ,prognosis4--,active hyperemia4--,usually favorable if it can be treated in time4 ,if prolonged1 acute nephritis may develop4 ,passive hyperemia4--,depends on the cause4 ,if the disease is prolonged1 it terminates in interstitial nephritis4 ,treatment4--,active hyperemia4--,absolute rest and thorough treatment to the renal splanchnics and treatment over the abdomen to the kidneys directly by carefully raising them4 ,adjust the lower ribs if found lesioned4 ,water should be drunk liberally and the patient encouraged to use vapor baths4 ,favorable hygienic surroundings1 warmth and good food are indispensable4 ,warm applications over the loins are helpful4 ,passive hyperemia4--,the treatment largely depends upon the cause1 but too much importance cannot be given to the treating of the vasomotor fibers of the kidneys from the eighth dorsal to the first lumbar4 ,textbooks state that the vasomotor fibers to the kidneys are from the ninth to the twelfth dorsal vertebr1 inclusive1 but osteopathic experience shows we can affect vasomotor fibers slightly higher4 ,treatment here has a distinct effect on the blood pressure within the glomeruli4 ,the renal epithelium is extremely sensitive to circulatory changes4 ,even the compression of a renal artery for only a few minutes causes marked disturbances4 ,hence any irritation or obstruction to the vasomotor innervation of the renal blood-vessels may result in serious conditions4 ,the superior cervical ganglion of the sympathetic and the sciatic center have important bearing on the secretions of the kidney1 through vasomotor fibers4 ,due attention should be paid to the bowels1 and the patient required to take plenty of rest and a light diet4 ,acute ,parenchymatous ,nephritis 7,,acute ,,bright',s ,,disease7 ,definition4--,an acute1 inflammatory process affecting the epithelium of the uriniferous tubules and due to the action of cold or toxic agents upon the kidneys1 as well as to injuries to the renal splanchnics2 is characterized by certain nervous symptoms with fever1 dropsy1 and scanty and highly colored urine4 ,this inflammation involves more or less the whole kidney4 ,osteopathic ,etiology and ,pathology4--,this disease is caused by exposure to cold and wet while the body is warm and perspiring4 ,excessive use of alcohol may be a factor4 ,may be caused also by infectious diseases1 such as scarlet fever1 diphtheria1 measles1 smallpox1 acute tuberculosis and others2 also by certain specific poisons which are eliminated by the kidneys1 as turpentine1 chlorate of potash1 carbolic acid1 phosphorus1 ginger1 cantharides and oil of mustard2 also by pregnancy1 as this is supposed to compress the renal veins1 or through toxic agents4 ,syphilis may be an underlying cause4 ,blows and injuries to the back at the tenth1 eleventh and twelfth dorsals are frequently the cause4 ,lesions are found from the sixth dorsal to the fourth lumbar4 ,the lower three ribs may be at fault1 while the innominate and muscular contractions have been found to be pathological factors4 ,lordosis may be a contributing cause4 ,loudon places considerable importance on cervical lesions and ,mc,connell believes vasomotor disturbance plays an important causative role in the disease4 ,pathologically1 at times the kidney alteration may be so slight as not to be recognizable by the naked eye1 the appearance varying according to the stage and severity of the disease4 ,the kidneys become enlarged1 engorged and of a bright red color1 and later have a mottled appearance2 and when the capsule1 which is non-adherent1 is stripped off1 the kidney is found to be soft and inelastic4 ,in most of the cases in which the disease is due to toxic agents brought to the kidney through the blood-vessels1 the glomeruli suffer first4 ,the epithelium of the glomeruli and tubules is the seat of cloudy swelling and1 in the later stages1 of fatty change and hyaline degeneration4 ,the tubules are clogged by altered cells1 leucocytes and blood-corpuscles4 ,in mild cases the interstitial tissue is simply inflamed1 but in all cases it becomes more or less mixed with leucocytes and red blood-corpuscles4 ,osteopathic lesions produced upon animals in the region of the ninth to the twelfth dorsal1 resulted in acute nephritis4 ,the autopsy findings were distinctly typical4 ,symptoms4--,the onset is usually sudden1 with moderate fever1 pain in the back in the lumbar region and over the kidneys and following the ureters4 ,nausea and vomiting may be present4 ,dropsy soon appears1 beginning with slight swelling or puffiness in the face below the eyes1 later showing itself in edema of the abdominal walls and extremities4 ,uremic symptoms may develop4 ,the urine is characteristic2 is diminished in quantity and of high specific gravity2 at first the sediment is copious and reddish brown in color1 becoming less in amount and of high color4 ,this sediment contains casts of the uriniferous tubules1 free blood1 epithelial cells1 uric acid and urates4 ,there are large quantities of albumin in the urine4 ,the presence of albuminous matter in the urine1 even in large quantities1 is not sufficient evidence to warrant a diagnosis of ,bright's disease nor is the amount a guide as to the severity of the case1 for grave conditions often show a slight amount 7,loudon74#ih ,diagnosis4--,the general symptoms may be very slight1 for the most severe cases may manifest slight edema of the feet1 or there may be only the puffiness under the eyes and of the eyelids4 ,in such cases the diagnosis must depend upon examination of the urine4 ,with previous history1 suddenness of the attack and character of the urine1 ordinarily the diagnosis will be quite easy4 ,prognosis4--,although this disease is generally grave1 the prognosis is favorable and the majority of cases recover under judicious treatment4 ,treatment4--,cases of acute nephritis require rest1 quiet and warmth4 ,many cases recover under these conditions alone4 ,it is absolutely necessary1 however1 that these conditions exist no matter what other treatment is used4 ,a thorough treatment to the renal splanchnics cannot be overestimated for it is here 7tenth to twelfth dorsal1 inclusive7 that a majority of the lesions producing acute nephritis occur4 ,besides correcting the vertebral and rib displacements in this region1 a very effective treatment is to have the patient lie flat upon the back and then the osteopath1 reaching around the patient with the fingers of one hand on either side near the spines of the lower dorsal vertebr1 raise the patient so that the entire body1 except the shoulders and the feet1 are lifted clear of the bed4 ,thus the treatment springs the spine anteriorly and produces a marked effect upon the kidneys through the renal vasomotor nerves4 ,occasionally lesions in the upper cervical region interfere with the normal activity of the renal nerve fibers passing to the kidneys by way of the superior cervical ganglion of the sympathetics4 ,another very effectual treatment for the kidneys is treating them through the abdomen by a careful pressure upon the kidneys through the abdomen on either side of the umbilicus1 thus lightly working each kidney outward and upward4 ,this treatment relaxes any tissues about the blood-vessels1 nerves and lymphatics to and from the kidneys that may be contracted and thus aids in establishing a normal activity of the involved organs4 ,it also helps in relaxing tissues about the ureters and prevents the clogging up of the latter with debris4 ,bandel and ,stearns report cases in which an impacted colon was an important factor in this particular4 ,the above means have for their object the direct relief of the congestion of the kidney4 ,this is further aided by keeping the bowels active1 which supplements the action of the kidneys1 and by increasing the activity of the skin4 ,this also aids in relieving dropsical effusions4 ,the hot pack1 in which the patient is wrapped in a wet sheet and then covered by a number of blankets1 is an exceedingly good method to relieve the kidneys of some of the work and lessen their congestion1 besides arresting uremic intoxication4 ,this can be repeated daily if necessary4 ,where there is dropsy and scanty urine1 the indications are to increase the secreting action of the kidney2 besides treatment through the renal splanchnics1 which contain the vasomotor nerves of the kidneys1 stimulating treatment to the vagi will help to increase the urinary secretion4 ,hot fomentations1 placed directly over the region of the renal splanchnics1 is a valuable aid in cases which do not respond quickly to osteopathic stimulation4 ,treatment of the liver is important4 ,injections of cold water into the intestines will tend to stimulate the secretion of the kidneys1 but this should be used with the greatest caution2 in some cases tepid water would be better 7see uremia74 ,the diet of the patient with acute nephritis is important4 ,give food that is easy of digestion and which contains a minimum amount of nitrogen4 ,the stomach is quite likely to be irritable1 consequently food that is adapted to it should be selected4 ,milk and weak animal broths are undoubtedly the best foods4 ,the return to a solid diet1 especially of meat1 should be very slow4 ,suitable adjuvants to the milk diet are rice and farinaceous preparations4 ,loudon#ii recommends complete withdrawal of all foods for twenty-four to forty-eight hours and the reducing of nitrogenous foods to a minimum2 a diet of milk and cream after the fast1 followed by cereals and broths1 then eggs and fish until albumin disappears from the urine4 ,alkaline mineral waters are useful to help maintain an alkaline urine1 thus tending to withdraw exudates4 ,the patient should be treated daily at first and later on every other day1 for case reports show frequent treatments hasten recovery4 ,for treatment of acute uremia in ,bright's disease1 see uremia4 ,complications should be treated as affections independent of the renal disorder4 ,chronic ,parenchymatous ,nephritis ,definition4--,a chronic inflammation of the kidney1 involving the epithelium1 glomeruli and interstitial tissue1 characterized by dropsy1 increasing anemia1 albuminous urine and acute uremia4 ,osteopathic ,etiology and ,pathology4--,it may be the result of acute nephritis4 ,it follows the same diseases as already mentioned in acute nephritis4 ,more often it follows the same diseases as already mentioned in the acute form1 syphilis1 tuberculosis1 purulent conditions1 focal infections 7streptococcus71 alcohol1 scarlatina and pregnancy contributing the greater number4 ,it is more common in the male sex and in early adult life4 ,habitual exposure to cold and dampness2 chronic lesions of the spine1 chiefly in the lower dorsal region1 are causative factors4 ,pathologically1 the large white or a yellowish white kidney is the most common kidney lesion4 ,in this form the kidney is enlarged1 often to twice its normal size1 is smooth1 and the capsule very thin4 ,the tubes1 on microscopic examination1 are found to be choked with broken down granulated epithelium and fibrinous casts4 ,the capillaries show hyaline changes4 ,the interstitial tissue is increased everywhere1 but not to an extreme degree4 ,catarrhal swelling and hyperemia 7to a slight degree7 are found in the pelvis of the kidney4 ,in the second stage--that of the small white kidney--there is a reduction in the size of the organ1 due to the destruction of the renal epithelium and the contraction of the overgrown connective tissue4 ,some hold that this may be a primary1 independent form and not always preceded by the large white kidney4 ,the organ is pale in color1 rough and granular1 the capsule being thickened and somewhat adherent4 ,there is an accumulation of fatty epithelium in the convoluted tubules1 constituting marked areas of fatty degeneration and giving the organ a white or whitish yellow appearance4 ,it is this which gives the name of small granular fatty kidney to this form4 ,there are extensive interstitial changes1 degeneration of tubules and destruction of great numbers of the glomeruli4 ,chronic hemorrhagic nephritis is a variety associated with this stage4 ,the organ is enlarged1 and scattered throughout the cortex are found brown hemorrhagic foci due to hemorrhages into and about the tubes4 ,otherwise the changes are similar with those found in the first form4 ,symptoms4--,it usually begins as a chronic affection and the symptoms slowly become apparent4 ,failing health and loss of strength1 dyspepsia and anemia1 waxy appearance with puffiness of the face1 dropsy and increased arterial tension with hypertrophy of the left ventricle1 gradually make their appearance4 ,uremic symptoms are common1 while dropsy is marked and persistent4 ,vomiting and sometimes profuse diarrhea occur2 in fatal cases there is sometimes found to be ulceration of the colon4 ,the urine1 as a rule1 is diminished in quantity1 is often very scanty1 although it is frequently normal in color and appearance4 ,there is an abundance of albumin1 heavy sediment1 hyaline and granular tube casts1 epithelium from the kidneys and pelvis1 leukocytes and often red blood-corpuscles4 ,if fatty degeneration takes place1 there will be fatty casts and oil globules4 ,in the later stages the urine is abundant1 low specific gravity1 considerable albumin1 and many casts4 ,diagnosis4--,in the inflammatory stage1 where there is enlargement of the kidney1 extreme pallor1 scanty urine1 albumin1 and tube casts1 history of infections1 pregnancy1 or exposure to cold and wet1 and lesions in the lower dorsal region1 the diagnosis is clear4 ,prognosis4--,always give a guarded prognosis2 relapses are frequent1 but cases have been cured4 ,there is always a tendency for the subchronic forms to become chronic4 ,treatment4--,the treatment requires persistent work1 especially over the renal splanchnics1 and strict attention on the part of the patient to hygienic principles4 ,the lower dorsal lesions are very apt to be refractory owing to extensive fibrotic changes of the deep muscles and capsular ligaments4 ,but repeated effort will usually secure results4 ,care should be taken as to exposure to cold and overexertion4 ,the quality of the blood should be improved1 as it is anemic and contains various toxic products4 ,strict attention should be paid to the diet4 ,iron is largely used for anemic conditions1 but this principle we hold to be wrong4 ,it is not more iron that is wanted1 but an ability of the system to assimilate the iron which it has4 ,relative to diuretics von ,noorden says3 8,it would be the greatest paradox to economize the renal work to the utmost in one direction 7diet1 sweating1 etc47 and on the other hand excite them to increased activity by means of the strongest stimulants we possess1 7drugs74 ,i regard such prescribing as radically wrong40 ,the diet should be carefully selected and of minimum amount4 ,the pure milk diet is undoubtedly the best4 ,the use of meat seems to favor uremic convulsions4 ,the digestive organs should be kept in as good condition as possible1 particular attention being paid to the liver and bowels4 ,the use of suitable clothing is important2 wool should be worn next to the body4 ,the skin is a powerful adjuvant to kidney elimination1 and the suppression of the action of the skin throws extra work on the kidneys4 ,possibly stimulation of the lung function would aid in the elimination4 ,rest1 with a proper amount of fresh air and outdoor exercise1 is essential4 ,in conditions calling for attention to the skin and bowels the treatment will be the same as in acute parenchymatous nephritis4 ,there is a ganglion on each side of the umbilicus within a radius of an inch that sends fibers to the kidneys 7,dr4 ,still74 ,just what is the function of these ganglia is unknown4 ,the treatment of the complications is independent of that for the renal trouble4 ,for direct treatment to the kidneys see acute ,bright's disease4 ,interstitial ,nephritis ,definition4--,a chronic inflammation of the kidney in which there is reduction in its size due to an extensive destruction of the tubular substance1 with an overgrowth1 and later a contraction1 of the connective tissue elements4 ,cardio-vascular changes1 arteriosclerosis and cardiac hypertrophy are usually associated4 ,osteopathic ,etiology and ,pathology4--,osteopathic lesions to the renal splanchnics are important predisposing causes4 ,the disease may follow parenchymatous nephritis2 or it may be caused by a continued passive congestion due to valvular heart disease4 ,gout2 cystitis 7often following gonorrhea71 the inflammation extending up the ureters to the kidney2 heredity2 old age2 long continued worry1 anxiety or grief2 chronic alcoholism1 overeating2 syphilis2 tuberculosis2 focal infections1 especially of streptococci2 chronic mineral poisoning 7as from lead71 and alterations in the renal ganglionic centers are causes4 ,it chiefly occurs in males during middle life4 ,pathologically1 both kidneys are involved 7although one may be more affected than the other71 and reduced in size1 often to less than half their normal size4 ,after removing the capsule1 which is thickened and adherent1 the surface is found to be uneven1 or granular and containing small cysts4 ,the kidney is hard1 tough and resistant1 the color varying from a darkish brown to a yellowish gray4 ,the cortical portion is especially reduced in size4 ,on microscopic examination1 the connective tissue appears greatly increased2 this contracts1 compressing the tubules and blood-vessels1 causing their destruction4 ,there is general arterial sclerosis1 and the left side of the heart is hypertrophied4 ,there are frequent nasal and retinal hemorrhages1 due to the brittleness of the arterial walls which predispose them to rupture2 hence1 apoplexy is a frequent termination4 ,the ganglionic centers1 being interfered with1 undergo fatty degeneration and atrophy4 ,there are marked retinal changes--retinitis1 fatty degeneration of the retinal tissues and sclerosis of the nerve fiber layers4 ,symptoms4--,the onset is insidious4 ,in most cases the symptoms are latent4 ,the general health is disturbed2 there are frequent micturition1 gastric disturbances1 tense and bounding pulse1 hypertrophy of the left ventricle1 high blood pressure1 disorders of vision1 sleeplessness1 headache1 furred tongue1 slight swelling of the feet1 dry skin1 scurvy and shortness of breath4 ,the urine is increased in quantity1 of acid reaction1 light in color1 low specific gravity1 with a small amount of albumin1 a few hyaline casts1 and some epithelial cells4 ,there is increased thirst and the patient may have to urinate two or three times during the night4 ,there is well marked mucous cloud1 slight sediment1 and as the disease advances the urine may be diminished1 the albumin increased and the casts become more numerous1 while occasionally blood cells will be found4 ,much importance should be attached to the blood pressure condition4 ,diagnosis4--,the early stages are not always recognizable4 ,later1 while there is high arterial tension1 thickening of the arterial walls and marked hypertrophy of the heart1 the urine should be examined very carefully both night and morning1 as the diagnosis will greatly depend upon the condition of the urine1 which is increased in quantity1 of low specific gravity1 with a trace of albumin1 narrow hyaline and pale granular casts1 making the diagnosis usually easy4 ,prognosis4--,it is generally incurable1 but favorable so far as the power to prolong life is concerned1 provided the diagnosis be made early in the case1 and the patient lives a quiet life4 ,the case usually terminates with convulsions1 coma and death4 ,apoplexy is frequently associated with chronic nephritis4 ,in all forms of chronic nephritis some intercurrent infectious disease is quite possible1 which is apt to be serious owing to the cachectic state4 ,treatment4--,the dietetic and hygienic treatment is the same as in chronic parenchymatous nephritis4 ,the nerve and vascular supply to the kidneys should be treated as in acute parenchymatous nephritis4 ,freedom from worry and overwork1 and if possible change of climate1 should be prescribed4 ,frequent bathing1 with friction of the skin1 should be insisted upon and the bowels kept regular by a treatment of alkaline water4 ,in all kidney cases special attention should be given the liver4 ,the alkaline water is a good diuretic2 besides it flushes the kidneys and helps to remove the debris4 ,these cases invariably present a rigid spine which should be carefully but thoroughly treated1 traction being one of the methods that give comparatively quick and excellent results4 ,overcoming spinal immobility1 correction of the dorsal area1 attention to the chest rigidness1 and frequently raising the abdominal organs will often considerably reduce the blood pressure4 ,the accidents and complications which so often endanger the patient1 must be treated as they arise4 ,amyloid ,kidney ,definition4--,a pathological state of the kidney in which there is a peculiar infiltration into the kidney structure of an albuminoid material of a waxy appearance4 ,etiology and ,pathology4--,this is associated with ,bright's disease and other wasting diseases4 ,it is most frequently caused by profuse and long continued suppuration1 especially of the bones1 by syphilis1 tuberculosis1 cancer1 lead poisoning and gout4 ,pathologically1 the kidney is large and pale1 but it may be normal in size or even small1 pale and granular4 ,the capsule is not adherent1 the surface of the kidney1 after removing the capsule1 is pale and anemic4 ,on section the cortex is seen to be enlarged4 ,it is homogeneous1 anemic1 pale1 waxy and resisting4 ,on microscopic examination there is found to be an infiltration of a homogeneous or wax-like material4 ,this progresses until all parts of the organ are infiltrated4 ,as the result of this pressure the structures of the kidney undergo an atrophic degeneration1 the kidney becoming contracted1 smaller1 rough and even distorted in shape4 ,the cortex becomes narrowed and the capsule adherent4 ,if a section of an amyloid kidney be stained with a solution of iodine1 numerous mahogany red points appear4 ,symptoms4--,there are similar changes in the liver1 spleen and often the intestinal canal4 ,there is a profuse1 watery diarrhea1 due to amyloid changes in the intestinal canal1 with loss of flesh and strength1 edema of the lower extremities1 and ascites4 ,there is an increased flow of pale1 watery urine1 of low specific gravity2 albumin is abundant and usually hyaline1 often fatty or finally granular tube casts occur4 ,prognosis4--,as a rule the prognosis is decidedly unfavorable and it must be controlled by the disease with which it is associated4 ,treatment4--,the primary disease demands attention1 otherwise the measures of treatment indicated are those of chronic parenchymatous nephritis1 with special attention to the general health and surroundings of the patient4 ,give a generous diet and be persistent with the treatment4 ,pyelitis ,pyelitis is inflammation of the pelvis of the kidney4 ,when a suppurative inflammation extends into the interstitial tissue of the organ1 it produces a condition called pyelonephritis4 ,the inflammation usually starts in the pelvis of the kidney1 the infection being carried there either by the circulation or the urinary tract1 but it soon involves the rest of the kidney4 ,pyelitis is usually secondary to some other conditions such as urethritis1 cystitis1 or ureteritis4 8,infection of the kidney rarely takes place through the blood and only when the vital membrane of the kidney is impaired40 ,it may start from within the organ in the interstitial tissue1 caused by infectious embolism or traumatism1 or the tubules may become obstructed by concretions4 ,osteopathic ,etiology and ,pathology4--,retained decomposed urine due to pressure upon the ureters by tumors or bladder disease2 calculus concretion1 kinked ureter1 displaced kidney1 traumatic agencies1 as falls1 blows1 strains1 kicks or penetrating wounds2 nephritis1 pregnancy1 cold and wet1 are causes4 ,pyelitis may follow cystitis1 the inflammation extending up the ureters to the pelvis of the kidney and thence to the substance of the organ1 inducing pyelonephritis4 ,tuberculosis1 focal infections1 and intestinal disorders 7colon bacillus71 are other causes4 ,lesions from the ninth dorsal to second lumbar or lower1 and malnutrition are predisposing factors4 ,pathologically1 the mucous membrane of the pelvis is usually the first affected1 the inflammation generally extending from below upward4 ,it is swollen and sometimes visibly congested and of a gray color4 ,the pelvis and calyces are more or less dilated1 while the papill are flattened4 ,there is a gradual dilatation of the calyces and atrophy of the kidney substance1 until the whole organ may be converted into a pus sac4 ,if complete obstruction occurs1 the fluid portion may be absorbed and the pus become inspissated and cheesy4 ,the ureter is often dilated4 ,in tuberculous pyelitis the apices of the pyramids are also invaded1 the kidney substance is broken down and the result is the same4 ,in the pyelitis caused by cystitis1 the infection passes up the tubules or is carried by the lymphatics4 ,the abscesses extend along the pyramids1 burst through the papill and calyx into the pelvis of the kidney1 and thus also the kidney becomes a purulent sac4 ,symptoms4--,pain and tenderness over the region of the kidney first appear4 ,in a few cases cystitis will be the only symptom4 ,the suppurative stage is marked by high fever and a chill or a succession of chills4 ,the general condition of the patient denotes prolonged suppuration4 ,there is failure of health and more or less wasting and anemia4 ,the urine is characteristic1 contains pus1 which varies in quantity greatly1 and where only one kidney is affected1 may be suppressed for a time and there will be a sudden outflow of the pus1 due to the breaking of the sac4 ,blood is also very constant1 but hardly ever of sufficient quantity to be seen by the naked eye4 ,the urine is usually diminished in quantity and the color pale2 the specific gravity is low on account of the small amount of urea present4 ,the reaction of the urine is acid4 ,pus and blood render the urine slightly albuminous4 ,casts from the kidney1 and even portions of the kidney1 may be present4 ,diagnosis4--,from nephritis by the absence of much albumin1 tube casts and dropsy4 ,from cystitis1 by the history1 lumbar pains and acid urine4 ,in cystitis the urine is always alkaline4 ,from perinephritic abscess1 by the absence of edema over the lumbar region4 ,the urine may be normal and there are lumbar pains and hectic fever4 ,in tuberculous pyelitis there is a history of tuberculosis in other organs and there are tubercles in the urine4 ,malaria or typhoid may be suspected4 ,the ,x-ray and cystoscope should be employed4 ,an exploratory incision may be necessary4 ,prognosis4--,depends altogether on the cause and extent of kidney involvement4 ,in simple cases and some tubercular1 recovery may occur1 although there is a tendency in all cases for the disease to become chronic4 ,treatment4--,depends upon the cause1 but thorough treatment along the lower dorsal1 the lumbar and sacral regions will be of considerable benefit in controlling the catarrhal process in the kidney1 its pelvis1 the ureter and the bladder4 ,if pathology permits1 gently raising the kidneys1 ureters and neighboring organs1 knee-chest position1 will materially assist circulation and drainage4 ,fresh spring waters for diluents and restricting the diet to light food1 preferably milk1 are indicated4 ,rest is important and warm applications locally are sometimes helpful4 ,the general health must be carefully watched as there is always considerable drain upon the system4 ,a timely operation may materially lengthen the life in many cases4 ,attention to the bladder1 urethra and prostate is necessary4 ,uremia ,the name applied to a series of manifestations resulting from the retention of poisonous materials in the blood1 which should have been removed by the kidneys4 ,uremic symptoms may occur any time during an attack of nephritis4 ,in chronic cases it seems likely that extensive destruction of renal tissue is the principal factor that leads to the toxemia4 ,they may also occur when the circulation of the blood in the kidneys is interfered with or the ureters are obstructed4 ,they are not due alone to the urea 7which is found to be increased in the blood71 but more probably several poisons that are retained in the blood4 ,traube's theory is that acute cerebral edema with anemia accounts for the symptoms4 ,halbert says3 8,a more recent and more plausible claim is to the effect that a poison is developed in the body as the result of nephritis10 for retention of effete matter or ligation of renal arteries and ureters or impaired renal activity does not fully explain the cause of the stupor1 coma1 convulsions1 sometimes paralysis1 and gastro-intestinal disorders4 ,symptoms4--,loss of appetite1 nausea1 vomiting1 headache and drowsiness are the initial symptoms4 ,headache is usually at the back of the head and may extend down the neck4 ,the next symptom is coma1 alternating with convulsions which may range from only a slight twitching to violent epileptiform spasms4 ,these spasms may occur without the slightest warning and are often followed by blindness which may last for several days4 ,these attacks of coma and convulsions are sometimes ascribed to localized edema of the brain4 ,transient paralysis is also due to congestion or edema of the brain and it may be of the cord4 ,there may be mania which comes on abruptly1 although the delirium is not at all violent1 while profound melancholia may be found4 ,there may be nervous symptoms develop1 such as numbness in the hands and fingers1 itching of the skin and cramps in the muscles--especially those of calves of the legs4 ,pulmonary symptoms are sometimes continuous--dyspnea1 paroxysmal dyspnea and ,cheyne-,stokes' breathing4 ,these attacks of dyspnea may be as distressing as true asthma4 ,cheyne-,stokes' breathing may be present without coma4 ,uncontrollable vomiting may set in with great abruptness1 followed by hiccough and purging4 ,there may be a catarrhal or diphtheritic inflammation of the colon with diarrhea4 ,the breath has a urinous odor and the tongue is often very foul4 ,the pulse is slow and full1 with a temperature below the normal1 although during convulsions the pulse may become rapid and the temperature rise4 ,occasionally there are atypical forms of uremia which may be very confusing and obscure4 ,diagnosis4--,the history1 subnormal temperature1 the urinous odor of the breath1 high arterial tension and increased second sound of the heart will distinguish the condition4 ,feeling of numbness1 palpitation1 headache1 restlessness1 mental wandering are not infrequently early symptoms4 ,the phenolsulphonephthalein test for the secreting power of the kidney1 and the examination of the urea in the blood are of great aid in diagnosis4 ,prognosis4--,extremely grave1 but one should always be very careful in his prognosis1 for there is a possibility of recovery1 even after the most serious symptoms have been manifested4 ,treatment4--,as impermeability of the kidneys produces uremia1 by not allowing the various poisons to be eliminated by the renal path as they should be1 the treatment must be applied directly to the kidneys4 ,elimination is demanded and if treatment through the abdomen to the kidneys directly and to the renal splanchnics does not bring about prompt and thorough elimination of the intoxicating properties1 the bowels and skin must be made active4 ,the vapor or hot air bath or hot pack should at once be used4 ,an ice-bag to the head will be beneficial4 ,an increase in the quantity of urine may be brought about by the displacement of a part of the mass of blood1 which is in relative stagnation in certain parts of the vascular system4 ,forcing it into the main circulation in order to increase the pressure within the vessels of the kidney1 is the treatment indicated4 ,this great stagnant mass of blood is found in the arterial capillaries of the portal system in the liver and splenic tissues and should be manipulated into the general circulation in order to increase the arterial tension of the kidneys and thus favor elimination4 ,the treatment should mainly be applied to the vasomotor nerves of the portal system1 from the fifth to the ninth dorsal1 and directly over the abdomen1 liver and spleen4 ,the introduction of water1 from #aaj degrees to #abj degrees1 or even #aej degrees1 into the colon by means of injections1 is useful2 warm irrigations increase renal secretion1 bowel action and sweating with a decrease of tension4 ,cold drinks will stimulate the abdominal vessels and induce absorption of a certain quantity of water to still further increase diuresis4 ,cold irrigation increases blood pressure temporarily1 but later it lessens the pressure2 it should be used only with great caution4 ,milk is one of the best drinks to be used4 ,secretions of the liver must not accumulate4 ,the bile must be expelled so that its toxicity will not be added to the other poisons4 ,the food of the patient is an important matter4 ,a milk diet is best2 avoid meat and nitrogenous foods and any food that leaves much residue4 ,in this way the nutrition of the patient is kept up with a minimum of urea formation and1 besides1 there will be very little intestinal putrefaction4 ,emergency measures not mentioned above are repeated high normal salt enemata 7two to three pints71 the alcohol sweat and venesection 7about one pint74 ,when the attack is broken the condition resolves itself into the renal disorder1 generally acute ,bright's disease4 ,this disease illustrates one phase of the uselessness of drugs2 for when the impermeability of the kidney has become such that it ceases to have the power of eliminating toxic substances formed by the organism1 there is then retained the medicinal substances4 ,the kidney is as impermeable for therapeutic poisons as for the natural poisons and the employment of toxic medicines in such cases has often no other effect than to bring an association of medicinal intoxication with an uremic4 ,renal ,calculus ,renal calculi are concretions formed by precipitation of solids derived from the urine1 and are found in the kidney or its pelvis4 ,if large1 they are called stones2 the smaller masses are known as gravel or sand1 according to their size4 ,when the stones attempt to pass through the ureters1 it brings on an attack of renal colic2 rarely are they voided without this symptom4 ,osteopathic ,etiology and ,pathology4--,the affection occurs at all ages1 more commonly1 however1 in children and in old people4 ,the male sex is more liable than the female4 ,sedentary habits1 gout and excessive meat eating are predisposing causes4 ,heredity seems to be a predisposing cause in some families4 ,inflammation of the pelvis of the kidney1 caused by derangement of the ribs and vertebr of the tenth1 eleventh and twelfth dorsals or first lumbar1 is an important etiological factor4 ,pathologically1 the chemical varieties are3 7#a7 ,uric acid and urates are the most common4 ,the stones are usually smooth or lobulated2 are hard and of a reddish color4 ,usually in these stones1 both uric acid and urates are to be found4 ,this material may be passed in the form of sand or large stones4 ,the sediment in the urine may be the nuclei of the stones2 as may foreign matters1 such as the mucus or desquamated epithelium caused by the inflammation of the pelvis of the kidney1 blood clots1 or1 in fact1 any foreign matter that may reach the urinary passages4 ,individuals passing a small amount of urine1 and old people are the principal subjects4 8,as a consequence of concentration and high acidity of the urine1 the uric acid and urates are readily separated in solid form and held together by the albuminous matrix40 7#b7 ,phosphatic ,calculi are white in color1 soft and mortarlike4 ,they are composed of phosphate of lime1 ammonia and magnesium phosphate4 ,these are found more often in the bladder than the kidney4 ,disease of the bladder is the cause4 7#c7 ,oxalate of ,lime are a mixture of oxalate of lime and uric acid4 ,they are dark in color1 very hard and uneven1 with hard1 pointed projections4 ,on account of their uneven shape they have been named mulberry calculi4 ,these stones produce great pain as they pass through the ureters4 ,there are other concretions of rare occurrence4 ,symptoms4--,there is pain in the back in the region of the kidneys with more or less tenderness4 ,the pain may be severe and paroxysmal4 ,there may be bleeding1 which is seldom profuse2 this will give the urine a smoky hue1 but may be present to such a small degree as to be only apparent by the use of the microscope4 ,the stone may obstruct the ureter and cause pyonephrosis or hydronephrosis4 ,pyelitis of a catarrhal character is common4 ,in pyelitis there may be intermittent fever of several degrees1 then sweating4 ,there may or may not be pus in the urine4 ,renal ,colic is caused when the calculus attempts to pass through the ureter so that ureteral spasms result4 ,the stone1 however1 may become lodged at the entrance to the ureter4 ,there is a sudden onset and great pain which starts in the back1 radiating downward into the groin1 down the side of the thigh and into the testicle and glans penis4 ,the testicle is often retracted1 the face pale1 the features pinched1 and there is frequently vomiting4 ,there are cold sweats and the pulse is weak4 ,the paroxysm may last only a few minutes or extend over several hours4 ,if uric acid is found1 it points to uric acid or oxalate of lime calculi and the urine is acid in reaction4 ,if alkaline phosphatic stones may be suspected1 examination of the urine directly after the attack aids greatly in diagnosis1 for at other times the urine is usually negative4 ,diagnosis4--,biliary ,colic4--,the jaundice in biliary colic comes on very soon after the obstruction begins4 ,the stools are without bile and the pain extends from the right hypochondriac region to the upper abdomen and the right shoulder4 ,the urine is negative and a stone may be passed in the stools4 ,renal colic is often simulated when the ureter is obstructed from any cause whatever4 ,it may be compressed from a floating kidney or tumor1 or obstructed by a clot of blood1 fragments of hydatid cysts or plugs of mucus4 ,lumbo-abdominal neuralgia1 intestinal colic1 and renal tuberculosis may simulate renal colic4 ,the ,x-ray plate is of decided value4 ,prognosis4--,as complications may arise1 it is best to give a guarded prognosis1 but the prognosis is generally favorable4 ,it is a disease that is very apt to recur when strains or falls affect the innervation to the kidney1 but many cases have been permanently cured4 ,if the stone is large1 its passage along the ureter may prove fatal unless surgical interference is instituted at once1 but if it is renal sand it may be easily voided in the urine and thus the prognosis will be favorable4 ,treatment4--,treatment should be given toward overcoming the cause producing the calculi1 which will often be found at the tenth rib4 ,treat the kidneys thoroughly1 both through the renal splanchnics and directly through the abdomen1 anteriorly4 ,but direct abdominal treatment should be given very cautiously4 ,treatment here corrects disorders and seems to release some solvent that acts upon the various forms of calculi and disintegrates the ones already formed and prevents the formation of others4 ,possibly this solvent is an internal secretion of some gland2 possibly like the splenic secretion is to the biliary calculi 7,dr4 ,still474 ,dr4 ,still held that one of the functions of the suprarenal capsule was to prevent the formation of these concretions4 ,in the uric acid tendency1 the free use of alkaline mineral waters for the solution of uric acid may be helpful4 ,much may be done by dieting4 ,the amount of nitrogenous food should be limited1 eating a minimum amount of meat and using plenty of milk and vegetables4 ,in the phosphatic tendency1 diluted drinks freely used are helpful4 ,meats are indicated4 ,milk and vegetables should not be used freely as they tend to make the urine alkaline4 ,in all instances care of the general health and avoidance of beer drinking and excessive meat eating are demanded4 ,during an attack of renal colic1 when a stone had lodged in a ureter1 one may be able1 by very careful manipulation1 to aid the stone in its progress downward1 7somewhat after the manner of manipulating gall-stones71 but do not delay surgical measures too long4 ,by inhibiting the nerve force of the spinal nerves along the lumbar and sacral regions 7chiefly tenth dorsal and first lumbar71 relief may be given4 ,the nerves of the ureters are derived from the inferior mesenteric1 spermatic and pelvic plexuses4 ,employ the hot bath2 this may relax the spastic condition4 ,cloths wrung out of hot water and applied locally are of aid4 ,occasionally a change of posture will give relief4 ,even inversion of the patient is sometimes followed by immediate cessation of the pain4 ,the patient may drink freely of hot lemonade or water4 ,an anesthetic may be of aid in the manipulation of a renal calculus in the ureter1 as the anesthetic will relax the tissues over the abdomen1 making it much easier for one to get near the impacted calculus1 but be cautious4 ,morphine may be necessary4 ,during the intervals the patient should lead a quiet life and avoid sudden exertions of any kind4 ,it is important to keep the urine abundant1 consequently have the patient drink a large quantity of distilled water4 8,renal calculus is brought about by lesions affecting the suprarenal capsule of the kidney1 or spinal lesions from the tenth dorsal to the first lumbar1 affecting the lower ribs40 ,movable ,kidney ,this means a distinctly mobile condition of the kidney 7almost always acquired1 but may be congenital71 due to the lax condition of the tissues which support it and to the elongation of the renal vessels which allow the kidney to move in certain directions4 ,rapid loss of tissue that absorbs the fat surrounding the kidney is a cause4 ,there are almost invariably lesions in the dorso-lumbar region that predispose to an abnormal mobility of the kidney4 ,these lesions undoubtedly weaken the innervation to the surrounding and supporting kidney structures4 ,a posterior spine1 with consequent downward and constricting displacement of the floating ribs1 is common1 although lateral and anterior spines 7dorso-lumbar region7 may be found4 ,strains1 heavy lifting1 and various violent exertions are important exciting factors4 ,tight lacing1 pregnancies1 an enlarged liver and gastro-- and enteroptosis are also important factors4 ,this condition is found more commonly in women1 and undoubtedly is a frequent cause of direct1 gastro-intestinal1 reflex1 and obscure disturbances4 ,there are very different degrees of mobility in different cases4 ,it may be so slight as hardly to be recognized or so great that it can easily be felt by the hand through the abdominal walls1 resembling a movable tumor in the abdomen4 ,symptoms4--,often there are no noticeable symptoms4 ,sometimes when the displacement and mobility of the kidney are most marked1 the reflex symptoms are not noticeable4 ,the right kidney is the one usually affected1 on account of its relation to the liver which moves during the respiratory act4 ,usually there is pain in the lumbar region and the patient experiences a heavy1 dragging pain in the abdomen1 which especially manifests itself while standing and walking4 ,there may be intercostal neuralgia4 ,various colicky and other gastro-intestinal pains1 and nervous symptoms as neurasthenia1 melancholia1 hysteria and headache are common4 ,there may be obstinate indigestion1 palpitation of the heart1 flatulence and cardialgia2 also1 an irritable bladder1 due to pressure4 ,at times the kidney becomes tender and swollen as a result of twisting of the renal vessels or of the ureter 7,dietl's crises71 causing engorgement of the organ2 this may be associated with agonizing pain and symptoms of collapse4 ,hydronephrosis may be manifested4 ,diagnosis4--,the shape of the tumor1 marked mobility1 and lessened resistance on percussion of the renal region will make the diagnosis4 ,the disorder very rarely proves fatal4 ,in doubtful cases utilize the ,x-ray4 ,treatment4--,many cases rarely give trouble directly1 but may be a source of reflex and obscure symptoms4 ,attention to the general health of the patient and persistent treatment of the dorso-lumbar region greatly strengthen the relaxed tissues about the kidney and cure a number of cases4 ,having the patient attempt to replace the organ after he goes to bed will be of value4 ,treatment of the abdomen to strengthen the walls and lessen any liver congestion and to keep the bowels active is very beneficial4 ,teach the patient how to stand and walk correctly1 especially holding the abdomen in and up4 ,a liberal diet to the point of increasing the weight is worthy of trial4 ,the use of supports is not always satisfactory4 ,surgical treatment for fixing the kidney is of permanent value1 but do not advise operation unless absolutely indicated4 7,see ,prolapsed ,organs1 ,part ,i74 ,to determine the presence of a movable kidney1 it is best to have the patient in the dorsal position1 the head slightly lowered and the abdominal walls relaxed by flexing the thighs moderately upon the abdomen4 ,then with the left hand in the lumbar region behind the eleventh and twelfth ribs1 and the right hand in the hypochondriac region1 the kidney can usually be detected after full inspiration followed by complete expiration2 or1 have the patient in a standing posture with the body bent slightly forward and the hands placed upon a table1 then perform bimanual palpation2 or1 perform the manipulation in the knee-elbow position4 ,when in this position 7knee-elbow71 if the kidney has become dislodged1 a resonant note will be obtained by percussion over the normal location of the kidney4 ,,footnotes3 #ih ,journal of the ,american ,osteopathic ,association1 ,july1 #aijd4 #ii ,journal of the ,american ,osteopathic ,association1 ,dec41 #aijd4 ,,diseases ,,of ,,the ,,bladder ,cystitis ,cystitis is an inflammation of the mucous membrane of the bladder4 ,retention of the urine2 foreign bodies1 such as stones1 in the bladder2 the use of dirty catheters2 exposure to wet and cold2 injuries to the bladder and over the pubes2 irritations to the sacral nerves2 spinal lesions in the dorsal enlargement of the cord2 innominate lesions2 irritating drugs2 enlarged prostate and urethral strictures are the principal causes of cystitis4 ,the disease may be secondary to fevers1 infectious diseases and inflammation of adjacent organs4 ,a displaced uterus may produce a chronic irritation of the bladder4 ,pathologically1 there is hyperemia of the mucous membrane of part or of the whole of the bladder1 with redness1 congestion and edema4 ,the secretion of mucus that covers the mucous membrane is of a dirty gray color4 ,if the congestion is very extensive1 a bursting of the capillaries may take place4 ,in a few cases the neck of the bladder and the urethra1 where it passes through the prostate1 is involved4 ,in chronic cases the mucous membrane becomes thickened and covered with patches of false membrane4 ,the muscular coat of the bladder becomes hypertrophied and the veins tortuous4 ,symptoms4--,the onset may be sudden with rigors and fever1 but in many cases a frequent desire to micturate will be the first symptom4 ,this is followed by tenderness and pain over the bladder and contiguous parts1 loss of appetite1 depression and sleeplessness4 ,tenesmus of the bladder1 caused by a spastic condition of its muscles1 and a burning along the urethra are usually present4 ,the urine is alkaline in reaction and contains pus1 epithelium and blood4 ,diagnosis4--,the diagnosis is usually easy4 ,pyelitis causes pains in the lumbar region and along the ureters and there is a frequent desire to urinate4 ,the bladder is not subject to spasms and the urine is of an acid or neutral reaction4 ,prognosis4--,in many cases the prognosis is favorable1 but in cases of long standing and in hypertrophy of the bladder1 prognosis must be guarded4 ,treatment4--,rest in bed with strict attention to diet is necessary4 ,milk is the best food and avoid highly seasoned articles and acid foods4 ,the use of plenty of pure water is helpful to dilute the urine1 and if necessary the bladder should be washed out carefully4 ,if the case is severe1 emptying the bladder several times a day with a catheter will be necessary4 ,always be careful about the cleansing of the instruments4 ,warm applications over the pelvic region will be comforting to the patient4 ,lifting the abdominal viscera from the bladder is of assistance4 ,the patient may be placed in the knee and chest position for this or the usual method employed4 ,treatment to the second1 third and fourth sacral nerves controls the neck of the bladder1 and strong inhibition will generally control the spasms of the sphincter4 ,the fundus of the organ is supplied by sympathetic fibers from the pelvic plexus4 ,direct treatment over the bladder1 if applied carefully1 will act on the terminal fibers of the sympathetic4 ,lesions to the nerves of the sphincter of the bladder oftentimes occur between the fifth lumbar and sacrum1 also from a displaced innominate4 ,such lesions are apt to be found in cases of incontinence of urine4 ,the lesion to the vertebra is usually a lateral one4 ,thorough treatment to the genito-urinary center 7lower dorsal and upper lumbar7 will also be of aid4 ,in males direct treatment of the prostate gland is occasionally important as is also the plexus of nerves at the trigone of the bladder4 ,in treating the prostate gland introduce a finger into the rectum and work about the base of the gland to relax the tissues1 and thus remove obstructions of the vascular1 lymphatic and nervous structures to the gland4 ,do not work too much upon the gland itself 7commonly once a week or ten days71 as it may irritate1 but release surrounding edema4 ,also treat the innervation at the eleventh and twelfth dorsals1 fifth lumbar1 and first1 second and third sacrals4 ,spreading the ischii will occasionally be beneficial2 this tends to release the anterior commissure where it is attached to the symphysis4 ,follow the above with a 8general treatment0 in order to secure a general systemic reaction4 ,this is of value in all infectious disorders4 ,it is important in young boys to examine the condition of the penis in bladder diseases4 ,the prepuce may become adherent or other irritations may be found that are a source of disturbance to the bladder1 or even to the kidneys1 on account of the intimate connection of the sympathetic system in this region and the relation of one organ to another4 ,an irritable bladder is usually due to disorders of nearby tissues1 especially the urethra1 vagina1 uterus and rectum4 ,enuresis1 exclusive of paralysis1 is frequently due to some local mechanical disturbance4 ,nocturnal enuresis or bed wetting is caused by lower dorsal and lumbar lesions 7especially the fifth lumbar71 displacements of the innominate1 or phimosis1 hooded clitoris1 contracted meatus1 highly acid urine1 worms1 lack of discipline1 etc4 ,the patient is usually neurotic1 which demands attention to the neuromuscular system of the entire body4 ,care of the general health and habits is important4 ,constipation may be present4 ,,diseases ,,of ,,the ,,circulatory ,,system ,,diseases ,,of ,,the ,,pericardium ,pericarditis ,pericarditis is an inflammation of the serous membrane covering the heart and its reflection in front over the chest4 ,primary inflammation of the pericardium is rare4 ,such cases usually result from cold and exposure or injury or tuberculosis1 and are most commonly met with in children4 ,the exciting causes of secondary pericarditis are rheumatism1 ,bright's disease1 tuberculosis1 gout1 diabetes1 eruptive fevers1 various septic conditions and dyscrasia4 ,pericarditis may result by extension of inflammation from contiguous organs1 as the disease may occur in pneumonia1 pleuropneumonia1 chronic valvular diseases1 and ulcerative diseases of the esophagus1 bronchi1 vertebr1 ribs1 stomach1 etc4 ,displacement of the ribs over the heart and involvement of the corresponding vertebr predispose to pericarditis1 by weakening the innervation of the pericardium and thus disturbing the circulation4 ,lesions of the cervical region affecting the left phrenic are to be considered4 ,upper rib lesions may disturb the internal mammary artery and the lymphatics1 which have important relationship with the pericardium4 ,the disease may occur at any age4 ,males are more frequently attacked than females4 ,the morbid conditions vary with the stage4 ,the stages are 7#a7 acute1 plastic1 or dry pericarditis2 7#b7 pericarditis with effusion1 serofibrinous1 hemorrhagic or purulent2 7#c7 absorption or adhesive pericarditis4 ,these different stages or varieties commonly succeed one another1 although medical writers place so much importance in them that each is described separately4 ,acute pericarditis is by far the most common and often the inflammation subsides at this point instead of going on to more serious involvement4 ,there is a possibility that in some cases the forms are independent of each other4 ,the changes are the same as in various serous membranes4 ,hyperemia and alteration of the epithelium is most marked on the visceral layer4 ,this is followed by an exudation from the hyperemic vessels4 ,there is roughening and loosening of the epithelium and the fibrin is precipitated upon the walls of the pericardium4 ,more or less lymph is exuded and sometimes injected capillaries burst and cause a bloody exudation4 ,from this stage the morbid appearances vary according to the progress of the disease4 ,the disease may undergo resolution and fatty degeneration and absorption of the products in point take place4 ,as the stage of effusion occurs1 the parietal and visceral layers of the pericardium are separated by a serofibrinous exudate4 ,this condition may increase until the quantity of the exudation is considerable1 or the effusion may become absorbed4 ,rarely does the exudate become purulent4 ,adhesions may be formed between the layers of the pericardium1 during the last stage1 by bands of various lengths or the layers are more or less separable4 ,symptoms4--,simple cases may not present any symptoms4 ,usually a chill or cold feeling at the heart1 followed by pains in the cardiac region1 ushers in the attack4 ,fever is commonly present1 rarely exceeding #ajc degrees ,f4 ,tenderness over the heart is noticeable4 ,there is dyspnea and the patient is restless4 ,in the effusive stage the symptoms depend largely upon the amount of diffusion4 ,the pain is sharp and stitch-like4 ,nausea1 vomiting and hiccough sometimes occur4 ,the pulse is irregular and feeble4 ,insomnia1 headache and even delirium may occur4 ,distention of the veins of the neck may cause dysphagia and a cough may be present1 owing to the irritation of the trachea4 ,the recurrent laryngeal nerve may be compressed as it winds about the aorta and thus cause aphonia4 ,the friction sound is a characteristic physical sign of the first stage4 ,in the effusive stage there may be precordial bulging4 ,the area of dullness is enlarged1 the diaphragm and liver may be crowded downward1 causing an epigastric bulging4 ,as the effusion increases1 the heart sounds become less distinct2 the friction is not heard4 ,in the third stage there is usually a return to normal1 although adhesions may form and cause precordial retraction and permanently embarrass the heart's movements4 ,the young are more subject to permanent disability4 ,extension of heart impulse1 which is undulatory2 diastolic shock to hand placed over heart2 increased area of dullness2 prominent precordia2 position of patient does not change apex beat2 and when pericardium is adherent to diaphragm a systolic tug is noted over points of attachment1 are essential signs and symptoms4 ,diagnosis4--,pericarditis is frequently overlooked4 ,it is a serious disease and one should be especially careful4 ,in cases of rheumatism the osteopath must always be on his guard4 ,tonsillitis may be the origin of the infection4 ,care has to be taken in distinguishing between dilatation and cardiac hypertrophy and pericardial effusion4 ,hydro-pericardium may be mistaken for pericardial effusion4 ,to distinguish between endocarditis and pericarditis should not be a difficult task if one understands thoroughly the nature of each disease4 ,a large pericardial effusion may be confounded with a pleural effusion4 ,in doubtful cases utilize the ,x-ray4 ,prognosis4--,in mild cases of pericarditis the large majority rapidly recover in two to three weeks4 ,in cachectic subjects and where adhesions have formed1 the duration is longer4 ,relapses may occur4 ,the purulent effusions are always serious4 ,treatment4--,demands prompt and effective measures4 ,absolute rest mentally and physically1 is necessary4 ,too much stress cannot be laid upon this point1 as death has occurred from neglect of this4 ,to quiet the heart's action is the first necessary requisite1 and then give treatment to limit the inflammation4 ,in the early stage relaxing the upper dorsal musculature to control innervation1 and raising and freeing all the upper ribs and clavicles to promote lymphatic drainage is effective4 ,in the second stage prevention of cardiac failure and promotion of absorption are the indications to be met4 ,too much importance cannot be placed upon the point that general strength1 good nursing1 dieting and free elimination are essential1 not only in securing a rapid subsidence of the inflammation1 but to prevent further complications4 ,raising and separating the ribs over the heart will be of great aid in lessening the inflammation and promoting absorption4 ,in many cases lesions to the ribs on the left side and subdislocations of the vertebr affecting the vasomotor nerves1 the lymphatics and nerves to the heart will be found4 ,the first five ribs and corresponding vertebr is the region where one may expect to find the lesions4 ,in addition to absolute rest1 an inhibiting treatment in the dorsal region between the scapul will aid in slowing the heart's action4 ,correcting any lesion that may be found to the vagi nerves will also be a help in controlling the heart's action2 besides1 most of the vasomotor fibers to the heart are in the vagi4 ,these lesions are usually found at the atlas4 ,one should also examine carefully all the cervical vertebr for derangements that might affect the cervical sympathetic1 especially the superior and middle cervical ganglia4 ,these ganglia are primarily affected from the fifth cervical to the first dorsal4 ,inhibition for a few minutes between the transverse process of the atlas and the occipital bone to the posterior occipital nerves will be of great aid in controlling the tumultuous action of the heart2 also1 inhibit in the upper dorsal4 ,the warm bath will quiet the heart1 but care should be taken not to weaken the patient4 ,the general treatment has the effect of lessening nervousness and quieting the heart4 ,the function of the phrenic nerve must be borne in mind when regarding the pericardium4 ,the phrenic is usually primarily affected at the third1 fourth and fifth cervicals1 and occasionally there are connecting fibers as low as the fourth and fifth dorsals4 ,ice-bags may be found of value in retarding the progress of the effusion and in lessening the heart's action4 ,liquid food1 as milk and broths1 should be given throughout the disease4 ,if the effusion is very large the services of a surgeon should be secured and tapping performed4 ,if the effusion is of a purulent nature1 a free incision should be made with antiseptic precautions4 ,in chronic cases carefully graduated breathing exercises and moderate stretching of the adherent regions1 if pathology permits1 should be considered4 ,endocarditis ,endocarditis is an inflammation of the lining membrane of the heart4 ,the process is usually confined to the valves2 the lining of the cavity of the heart may also be affected1 especially in severe cases4 ,three forms are recognized3 simple acute endocarditis1 ulcerative endocarditis1 and chronic endocarditis4 ,simple ,acute ,endocarditis4--,this form usually results from acute articular rheumatism4 ,tonsillitis may be associated with endocarditis4 ,it may also be caused by other infectious diseases1 especially scarlet fever1 but rarely1 by typhoid fever1 measles1 chicken-pox1 diphtheria1 smallpox and erysipelas4 ,acute endocarditis is frequently found in chorea4 ,it is also met with in diseases attended with emaciation and general weakness1 as cancer1 gout1 ,bright's disease and diabetes4 ,it is not uncommon in phthisis4 ,micro-organisms play an exciting part1 but back of this the osteopath finds lesions of the heart innervation important predisposing features4 ,prophylactic osteopathic treatment is a potent factor in preventing endocardial changes in the above diseases4 ,keeping the muscles relaxed and the osseous tissues intact is of great value4 ,pathologically1 the left side of the heart is most commonly involved4 ,the disease is characterized by the presence of small vegetations on the segments or on the lining membrane of the chambers1 although in mild cases there is simply swelling of the valves4 ,the mitral valves are more often affected than the aortic4 ,the vegetations appear1 usually1 on the auricular surface of the mitral and the ventricular surface of the aortic valves1 a little back of the valve edge4 ,their seat corresponds to the point of maximum contact 7,sibson74 ,these growths are liable to be broken off at any time and carried as emboli by the blood current to distant organs1 particularly the brain1 spleen and kidneys4 ,this is not uncommon in acute endocarditis or chronic valvulitis4 ,in favorable cases the vegetation is ultimately absorbed and the valve is but slightly altered beyond a simple sclerotic thickening4 ,this is often the starting point of sclerotic valvulitis4 ,osteopathic measures undoubtedly lessen the liability of cardiac involvement1 prevent extensive changes and promote absorption of disease products1 by lowering heart tension and improving the cardiac nutrition1 as well as increasing free elimination of the toxins in the blood4 ,during the fetal life1 the right side of the heart is most commonly involved4 ,the chorda tendin are sometimes affected1 but rarely alone4 ,the vegetations are composed of proliferated connective tissue cells4 ,the superficial elements undergo a coagulation-necrosis and fibrin is deposited from the blood4 ,micro-organisms are found and are the specific agent in causing acute endocarditis4 ,symptoms4--,a large number of cases are latent1 the autopsy first disclosing the lesion4 ,in many cases there are slight fever1 a frequent1 sometimes irregular1 pulse1 palpitation and dyspnea4 ,there is seldom any pain4 ,physical signs are very uncertain4 ,they may not be present in mild cases and in those in which the valves are not affected4 ,usually auscultation furnishes the only indication of endocarditis--a soft1 blowing1 systolic murmur which is heard most frequently at the apex1 as the mitral valves are the ones generally involved4 ,when the aortic valves are affected1 the murmur is heard at the second interspace at the right edge of the sternum4 ,diagnosis4--,this depends entirely upon the etiology and physical signs4 ,the greatest danger is in the disease becoming chronic4 ,treatment4--,the patient should be kept as quiet as possible1 so that the work required of the heart may be reduced to a minimum4 ,the disturbed circulation can be controlled by careful attention to the vasomotor nerves at the various centers along the spine4 ,attention should be given the disease that is causing the endocarditis4 ,keep the patient well protected by flannels and beware of damp rooms and sudden changes of temperature4 ,treatment should be given to correct any lesion found in the upper five dorsal vertebr or ribs and to raise and spread all of these ribs so that the heart's action will not be unduly disturbed by interferences with its innervation4 ,the vasomotor nerves to the heart's vessels are found in the vagi nerves1 consequently care should be taken that lesions to these nerves do not exist4 ,an inhibitory treatment to the suboccipital nerves acts reflexly on the vasomotor nerves and tends to equalize the general vascular system4 ,this treatment quiets the heart's action4 ,ice applied locally is advocated by many practitioners4 ,flannels should be placed next to the skin and the ice-bag placed over the flannel4 ,this reduces the fever1 lessens the pulse-rate and quiets the heart action4 ,the same points are obtained by the inhibitory treatment at the suboccipital region4 ,the ice-bag also relieves pain and oppression4 ,be very careful in the use of ice when there is much cardiac dilatation4 ,treatment of the middle and inferior cervical regions may have some effect in controlling the heart's action4 ,a general treatment to quiet the patient is effective4 ,do not allow any overexertion4 ,the patient should have nourishing liquid food4 ,emery#ajj says3 8,many of us have been in the habit of saying1 just because we hear a decided murmur in the heart region1 that the patient has valvular heart trouble2 that the patient has organic heart trouble4 ,this is a common error444 ,when there is an anemic condition of the body1 apparently the cusps of the valve will be so weakened1 and the attachment will be so weakened that the blood will force its way between the valves and back into the heart1 causing regurgitation murmur1 when as an actual fact there is no deformity and no real disease of the valves1 and as soon as the general condition of the anemia is improved1 the valve will do its work fully and the murmur entirely cease4 ,so if you have the murmur without the hypertrophied condition1 which at once follows such a valvular lesion1 you must be guarded in your statements1 for if an actual valvular lesion existed1 compensation would take place1 and it would be the means of corroborating such a valvular condition2 if no hypertrophy is found1 then we are not justified in definitely stating that a valvular or organic lesion exists1 for such a weakened condition as has been mentioned might be the only pathology present1 and be the cause of the murmur40 ,ulcerative or malignant endocarditis4--,this is an acute1 infectious or septic disease1 characterized locally by necrosis or ulceration of the valve4 ,it is generally a secondary affection to septicemia1 pneumonia1 erysipelas1 scarlet fever and acute rheumatism4 ,acute endocarditis often precedes the ulcerative variety1 the latter being simply an increase in severity of the former4 ,etiology and ,pathology4--,it is doubtful if there can be a primary form of ulcerative endocarditis4 ,chronic valvular defects are the most important predisposing causes4 ,pneumonia is most frequently1 of all the acute diseases1 associated with severe endocarditis4 ,it is rare in tuberculosis1 diphtheria1 typhoid fever and chorea4 ,it occurs in association with erysipelas1 gonorrhea and rheumatism4 ,septicemia1 pleurisy1 meningitis and puerperal fever are other possible causes of ulcerative endocarditis4 ,deep seated lesions1 which means firmly anchored lateral flexions and rotations due to fibrotic changes1 are important predisposing local factors1 while other lesions that disturb blood elaboration and resistance and lessen elimination1 are predisposing systemic causes4 ,pathologically1 the lesions are either vegetative1 ulcerative or suppurative4 ,the vegetations are composed of granulation tissue1 granular and fibrillated fibrin1 and colonies of micro-organisms4 ,they become necrotic and break down into ulcers4 ,the ulcerative changes may lead to perforations or produce valvular aneurisms4 ,of the valves the mitral is the most frequently affected2 then the aortic2 then the mitral and the aortic together2 then the heart walls2 then the tricuspid2 then the pulmonary4 ,in a few cases the right heart alone is involved4 ,the lesion is not always confined to the valves1 but may involve the mural endocardium4 ,the most common organisms found are the pneumococcus1 streptococci and staphylococci4 ,the bacillus diphtheri1 bacillus coli1 gonococcus1 bacillus anthracis and other organisms have been found4 ,associated pathological changes include the lesions of the primary disease and the changes due to embolism4 ,the spleen1 kidneys1 brain1 intestines and skin may be the seat of embolism4 ,when found in the lungs1 they originate in the right heart4 ,symptoms4--,if in the course of any of the diseases previously named under etiology1 chills followed by fever and sweats occur1 ulcerative endocarditis should at once be suspected and a thorough examination be made4 ,the general symptoms are high1 irregular fever1 delirium1 sweating1 great prostration1 rapid pulse1 hurried breathing and sometimes jaundice and diarrhea occur4 ,the occurrence of delirium1 coma or hemiplegia points to involvement of the brain2 pain in the region of the spleen1 with increased dullness on percussion1 point to trouble in that organ2 hematuria may occur from involvement of the kidneys4 ,more rarely there will be impaired vision from retinal hemorrhage2 and there may be suppuration and sometimes gangrene in various locations1 depending upon the position of the embolism4 ,the septic type is secondary to suppurating external wounds1 puerperal sepsis or acute necrosis4 ,occasionally gonorrhea is the cause4 ,the symptoms presented are rigors1 irregular fever1 sweats and exhaustion--the signs of septic infection4 ,the symptoms may resemble a quotidian or a tertian ague4 ,the typhoid type is the most common4 ,the characteristic symptoms are irregular temperature1 sweating1 prostration1 delirium1 drowsiness1 diarrhea1 petechial and other rashes1 distention of the abdomen and pain in the right iliac region4 ,the heart symptoms may be overlooked1 as in the septic type4 ,the cardiac type are cases of chronic valvular diseases in which fever1 rigors and sweats1 and the symptoms of embolism may develop4 ,in the cerebral cases the symptoms may simulate meningitis4 ,acute delirium may be the distinctive symptom4 ,heart symptoms may be overlooked4 ,physical ,signs4--,the heart symptoms may be latent4 ,even after a careful examination1 there may be no murmur present4 ,when murmurs are present it is often difficult to locate them4 ,diagnosis4--,the previous history should be considered and this1 together with the symptoms1 makes a correct diagnosis possible1 even though physical signs are absent4 ,the duration is from a few days to several weeks4 ,treatment4--,the treatment of this form of endocarditis is likely to be of little avail1 although in a few cases where the source of infection can be eradicated the condition may be considerably improved and life prolonged4 ,about the same treatment as in simple endocarditis should be followed4 ,absolute rest is essential and this1 coupled with the local treatment of simple endocarditis and a nourishing liquid diet1 constitutes the principal treatment4 ,chronic ,endocarditis ,this condition may begin as a chronic inflammation or follow the acute form1 which is more often the case4 ,there is a sclerosis of the valves which causes deformity1 owing to the contractions4 ,the onset is usually insidious4 ,it is well known that the larger percentage of valvular lesions are the result of either acute or chronic endocarditis4 ,thus rheumatism stands foremost as a cause of valvular defects4 ,alcoholism and overeating 7through introducing irritating influences into the blood1 or by causing rheumatism1 gout and allied diseases7 are important etiological considerations4 ,nephritis and syphilis are considered among the causative factors4 ,infections and senility1 when associated with high blood pressure1 is a phase not to be overlooked4 ,chronic endarteritis extending from the aorta to the valves1 resulting in thickening and degeneration of the tissue1 may be an insidious source of valve disease4 ,this is probably often of syphilitic origin4 ,a potent cause of special interest to the osteopath 7for the reason that his treatment is so effective71 is continued muscular strain as seen in athletes and laborers4 ,the heart muscle itself may be strained1 particularly the valve leaflets and the tissues about the valve1 which effect often terminates in valvular leakage4 ,in addition1 the orifice of the valve openings may become stretched and distorted through strain superinduced by prolonged exertion1 by flabbiness of heart tissue1 and by dilatation of the ventricles4 ,in these latter cases it is seen that the leaflets of the valves may remain intact1 but still they are unable to stretch completely across the opening4 ,with the above condition it is readily noted that thickening1 curling and adhesions will take place when inflammation attacks the valves and contiguous tissues1 and following these1 limy infiltration and fatty degeneration may be a consequence4 ,predisposing osteopathic lesions as noted in acute endocarditis1 are not to be neglected4 ,thickening and hyperplasia are immediate consequents of connective tissue overgrowth2 and especially is chronic endarteritis accompanied with atheromatous and calcareous degeneration4 ,thickening1 at times1 is only slight and the function of valves is not impaired4 ,in curling or retraction1 there occurs a shrinkage of the hypertrophic or hyperplastic tissues4 ,this condition is very apt to become permanent4 ,adhesions of the valve leaflets is a self-evident condition4 ,it is well to note here that in acute and chronic endocarditis some part of the fibrous valve ruptures or is lacerated or eroded from strong and rapid heart action2 the laceration or rupture or erosion always occurs at the point of maximum contact4 ,thus the eroded surface allows an opportunity for the rheumatic or septic micro-organisms to lodge1 multiply and grow1 and adhesions result4 ,carefully applied osteopathic methods are very efficacious in impending acute heart disturbances1 and this without doubt is the reason why so many of our rheumatic cases get well without any heart affections4 ,keeping the heart quieted and slowed prevents the strong and rapid action and thus lessens the probability of lacerations1 ruptures and erosions of the valve tissues4 ,general resistance is increased and elimination improved1 which have a decided effect in preventing complications4 ,calcification and atheroma1 as has been mentioned1 may follow the above diseased processes4 ,the calcification is sometimes so marked as to be of the character of a bony ring4 ,the question arises here1 ,what effect have osteopathic lesions as direct causative factors in valvulitis8 ,it appears reasonable that the heart is not exempt from the influences of the vertebral and rib maladjustments4 ,furthermore1 clinical experience has abundantly proven that the heart tissues are affected by these lesions in the same manner as any tissue or organ is affected4 ,again1 osteopathic dissection reveals direct nervous connection from the upper dorsal spinal ganglia to the heart ganglia4 ,no one will question that the integrity of heart function and life are dependent upon normal coronary artery supply1 upon vasomotor equilibrium1 and upon motor control4 ,all of these functions are influenced by the status of cervical vertebr1 upper dorsal vertebr1 and rib relations4 ,just what the pathological affection is when these anatomical parts are disturbed is beyond us until more careful dissection and experimentation have taken place4 ,how cervical and dorsal sympathetics1 vasomotor and motor nerves with their spinal connections1 vagi and phrenic1 are so disturbed as to involve valvular parts and induce inflammation1 is a problem for us to investigate4 ,through analogous reasoning from other organic ailments and through the fact that osteopathic therapeutics corrects heart lesions1 we know in a general way that the correction of osteopathic lesions decidedly influences the heart4 ,two well known physiological facts relative to the heart are3 first1 the heart increases in size up to adult life1 and1 second1 the heart muscle can actually be increased in size4 ,this latter fact occurs in physical development and training4 ,a heart that is weak and flabby can be increased in strength1 tone and size4 ,this helps us to understand how certain strains and distortions of the heart1 with consequent valvular lesions1 may be corrected through rest1 exercise and treatment2 somewhat analogous to the correction of an atonic1 prolapsed and dilated stomach4 ,then it also seems probable that disturbed innervation and blood supply to heart areas or to the heart as a whole would predispose to congestions1 inflammations and degenerations whereby rheumatism1 septic states1 etc41 and muscular strains would act only as exciting causes1 not true causes4 ,no one is going to expect that thickened1 retracted1 adhered1 or ruptured valves are to be made anatomically correct2 but the right treatment will certainly reduce the morbid state to the minimum4 ,then there are cases where osteopaths have eliminated all murmurs when specialists stated the disease was incurable2 showing that it is impossible by signs and symptoms to always diagnose the morbid tissue state4 ,only the resulting effects of size and of leakage are definitely revealed by auscultation and percussion4 ,hence there is a class of valvular diseases that can be successfully treated by osteopathic measures1 which1 if left to terminate under drug medication1 will reveal 7at post-mortem7 the pathological signs of valvular heart disease4 ,downward displacement of the first rib may interfere directly with the subclavian artery and thus cause constriction of that vessel and a consequent regurgitation2 also1 cardiac fibers of the recurrent laryngeal nerves may be impinged by a dislocation of this rib4 ,many lesions which interfere with the right side of the heart occur at the second and third ribs and lesions of the third1 fourth and fifth ribs may interfere with the valves4 ,lesions of the corresponding vertebr produce the same results as the ribs4 ,these lesions are probably to the sympathetic nerves along the dorsal region4 ,lesions may be found anywhere along the cervical vertebr which may involve inhibitory 7vagi7 fibers or accelerator 7sympathetic7 fibers to the heart4 ,also1 in some cases the floating ribs are dislocated downward and cause a prolapse of the diaphragm1 and thus a constriction of the aorta1 which may result in regurgitation and valvular disorder4 ,mitral ,regurgitation4--,mitral regurgitation is a leakage of blood from the left ventricle1 through the mitral valves1 into the left auricle4 ,the opening of the valve may be distorted1 or the valve leaflets thickened1 rigid1 or retracted1 thus allowing an escape or reflux of blood from ventricle into auricle4 ,the tendinous cords may also be thickened and adhered1 with consequent prevention of free action4 ,by a forcing back of a portion of the blood from ventricle to auricle at the same time the pulmonic veins are emptying into the auricle1 an overdistention of the auricle takes place4 ,the auricle1 then1 from the extra amount of work required1 becomes hypertrophied and dilated4 ,there may be no noticeable symptoms at first4 ,later on shortness of breath1 cough1 irregularity of heart's action1 indigestion1 liver congestion1 and so on1 occur4 ,the apex beat is forcible and downward to the left4 ,of course the area of dullness is to the right and left4 ,there is a systolic murmur in the mitral area1 which is transmitted to the left axilla4 ,every osteopath should understand the mechanism of this most frequent valvular lesion4 ,following hypertrophy and dilatation of the left auricle1 the reflux may be so excessive that a residue remains4 ,the auricle not being able to handle all the blood1 stasis of the pulmonary vessels takes place1 and pulmonary edema and hydrothorax are sequel4 ,then comes dilatation of the right ventricle and back pressure on tricuspid valves and right auricle4 ,the veins throughout the body become turgescent1 and the liver is apt to be indurated4 ,it should be emphasized1 however1 that 8back pressure0 is only an effect commonly due to myocardial degeneration1 caused by some infection1 of which auricular fibrillation is an important part of the pathology4 ,before the breaking down of the left heart compensation1 osteopathic methods1 as all know1 are effective in maintaining balance4 ,even after the lungs begin to be affected1 careful and thorough treatment will result in good1 and in cases of general venous sluggishness treatment1 particularly to liver1 diaphragm1 bowels and limbs1 will generally materially help in slowing the downward course of the disease4 ,mitral ,stenosis4--,in stenosis there is narrowing or constriction of the valve opening4 ,thus in mitral stenosis the free flow of the blood from left auricle to ventricle is hindered4 ,the cusps are usually thickened1 rigid and adhered4 ,the valve opening may be so stenosed as to be but a narrow slit4 ,in all cases stenosis is a structural defect4 ,it can occur by strains1 as regurgitative effects sometimes result4 ,the symptoms of mitral stenosis are practically the same as those of mitral regurgitation1 owing to similar effects upon the circulation4 ,under physical signs we find the apex-beat is only slightly displaced4 ,palpation will reveal1 near the apex1 a rough presystolic thrill4 ,the increased area of dullness is to the right4 ,there is an abruptly terminating1 rough1 presystolic murmur4 ,aortic ,regurgitation4--,aortic regurgitation is a reflux of blood from aorta to left ventricle1 following ventricular systole4 ,this is considered the most serious of the valvular diseases4 ,the valve opening is either too large1 so the valve leaflets do not fit tightly1 or the segments themselves are thickened and retracted4 ,structural defects of the aortic valves are largely of the same character as in diseases of the mitral valves4 ,the regurgitation first causes dilatation of the left ventricle4 ,this is followed by hypertrophy4 ,if the mitral valve holds intact1 no further effects result4 ,but if the mitral valve is diseased or becomes incompetent from the dilated ventricle1 the same morbid states follow as was noted under mitral regurgitation4 ,there is a forcible apex-beat1 displaced downward to the left4 ,the increased dullness is to the left4 ,there is a long1 loud diastolic murmur4 ,the well known 8water-hammer0 pulse is felt4 ,aortic ,stenosis4--,aortic stenosis indicates a narrowing of the aortic orifice4 ,it is a structural defect4 ,the free flow of blood is obstructed from the left ventricle into the aorta4 ,aortic stenosis is much less frequent than regurgitation4 ,aortic stenosis and regurgitation are very apt to be associated4 ,the beat is commonly forcible1 and the increased area of dullness is to the left4 ,there is a systolic murmur1 heard best at the right second interspace1 which is conducted into both carotid arteries4 ,tricuspid ,regurgitation4--,tricuspid regurgitation is the most common valvular lesion affecting the right heart4 ,it is rare as a primary lesion4 ,the affection may be of a structural character1 or functional4 ,hypertrophy of the right ventricle occurs after the manner of left ventricle hypertrophy in mitral regurgitation4 ,the sequel of venous turgescence follow1 also1 in the same way as was given under the mitral lesions4 ,tricuspid regurgitation rarely exists independent of some other cardiac or pulmonary ailments4 ,the apex-beat is diffused toward the epigastrium4 ,increased cardiac dullness is toward the right4 ,there is a systolic murmur1 which is heard best just above the xiphoid cartilage4 ,the jugular vein pulsates2 in severe cases there is pulsation of the liver4 ,osteopathic treatment is usually effective in relieving the engorgement of the veins1 and particularly in reducing liver congestion4 ,tricuspid ,stenosis4--,this affection is said to be the most rare of valvular lesions4 ,thickening1 obstruction and adhesions from endocarditis cause the stenosis4 ,as in other lesions of the heart1 there is a congenital form4 ,there is presystolic murmur1 heard best at the xiphoid cartilage4 ,the pulse is small and weak4 ,pulmonary ,regurgitation4--,this is another rare lesion1 and is seldom met with in a simple form4 ,there is forcible pulsation in the epigastrium4 ,increased cardiac dullness is downward4 ,there is a diastolic murmur1 heard most distinctly at the left second intercostal space4 ,pulmonary ,stenosis4--,another rare lesion4 ,the effect of this lesion on the right ventricle is the same as that of aortic stenosis on the left4 ,the congenital lesion is apt to occur with a patulous foramen ovale4 ,there is a systolic murmur1 heard best at the second intercostal space on the left4 ,many systolic murmurs heard over the pulmonary opening are functional4 ,combined ,valvular ,lesions4--,when two or more lesions occur at the same time the terms1 combined or associated1 are employed4 ,this is a very common occurrence4 ,two1 three or all of the valves may be affected at the same time4 ,stenosis and regurgitation at the same orifice is the most common association of any two valvular lesions4 ,when there is a joint affection of two or more valves1 the aortic and mitral are most commonly associated2 then mitral and tricuspid2 then aortic1 mitral and tricuspid4 ,prognosis and ,treatment of ,valvular ,diseases4--,it is impossible to outline with exactness either prognosis or treatment of heart lesions4 ,all will agree that the character of the lesion is the first consideration1 and before records of these cases can be of any scientific benefit1 we must look well to the nature of the valvular leakage or obstruction and note precisely what effect our therapeutics has4 ,perhaps of greatest consideration in the matter of prognosis is1 to what extent compensation has been maintained4 ,we know that compensation may be perfect2 that hypertrophy and dilatation may balance the valvular defect so thoroughly that even the patient is not aware of a heart lesion4 ,as soon as compensation begins to fail1 when palpitation1 irregularity of pulse1 dyspnea1 edema1 etc41 appear1 we know that our treatment should pass from the realm of the defensive to that of the offensive4 ,then when compensation fails still more1 prognosis and treatment must necessarily be changed according to the increasing gravity4 ,in our osteopathic work we should never forget that the condition of the lesion may be greatly influenced by environment4 ,habits1 occupation and general daily life may affect the heart ailment for good or bad4 ,thus in prognosis we have three features in particular to note3 character of heart lesion1 extent of systemic involvement1 and environment4 ,in the immediate prognosis1 the extent of general venous stasis1 if any1 is of great importance4 ,in other words1 the gravity of the complications is of first consideration4 ,aortic regurgitation is ranked by heart specialists as the most serious lesion4 ,aortic stenosis is a grave lesion1 but not so serious as aortic regurgitation4 ,it is often stated that the character of the lesion is not of so much consequence as the extent of involvement the lesion has engendered4 ,mitral stenosis is more grave than mitral regurgitation4 ,right side heart lesions are usually relative1 and1 naturally1 when the right heart is diseased from extension of the ailment from the left side1 the situation is serious4 ,it should be remembered that a heart normal in size and beating regularly is usually in a fairly healthy condition even if a murmur is present4 ,in our treatment the first point indicated is to improve1 if possible1 the integrity of heart muscle and lessen the valvular defects1 if such can be done4 ,owing to a dearth of statistics1 it is impossible to state to what extent improvement in organic lesions has been accomplished4 ,very likely if we had statistics and no post-mortem findings1 we would still be in the dark as to much of our work4 ,this much is positive3 osteopaths have time and again apparently cured grave valvular lesions2 cases that eminent specialists diagnosed as absolutely organic lesions4 ,our practitioners have eliminated the murmurs1 reduced the size of the heart1 and removed any and all systemic symptoms4 ,these patients are well1 have been well for years1 and are leading active lives4 ,but were these cases suffering from organic lesions8 ,no doubt there was valvular leakage1 hypertrophy and dilatation1 but was the valve defect a functional one8 ,in other words1 was it due to strain and distortion8 ,in all probability the patients' days were numbered and post-mortems would have shown grave lesions and quite likely more or less organic changes4 ,does it not seem likely that some functional lesions may terminate in organic lesions8 ,through continued stretching of the valves and their immediate tissues1 fatty degeneration may take place2 the same as fatty degeneration of the heart muscle1 occurring in dilatation of the chambers4 ,if we can remedy functional lesions through specific work upon nerve centers and fibers1 why cannot we influence organic lesions and at least reduce the gravity to a minimum8 ,we know functional diseases of the heart1 as palpitation1 rapid heart1 slow heart1 etc41 can be corrected1 and from all indications1 functional valvular leakages are generally easily and quickly remedied2 it is only a step farther to affect truly organic lesions4 ,the same valves1 the same nerves1 and the same osteopathic lesions are noted4 ,then it is only a continuation of the same process from functional disease to organic disease4 ,indeed1 no one is able to draw a line between the two4 ,probably1 as was intimated before1 careful osteopathic treatment in rheumatism and other diseases that are apt to predispose to heart affections1 will keep the heart so strong functionally and organically that resulting valvular lesions are not nearly so likely to develop4 ,the heart can be treated and controlled as can any tissue or organ4 ,it certainly stands to reason that osteopathic therapeutics is rational in both preventing and curing valvular lesions4 ,the ,m4 ,d4 gives his drugs with the hope of maintaining heart muscle integrity1 of lessening a too forceful beat1 of increasing waning power1 of promoting general circulation1 of preventing and lessening complications4 ,we can do the same thing with our methods1 even more effectually1 and with no probability of harmful effects4 ,it would appear there are at least two ways in which organic lesions may develop4 ,first1 as stated above1 through functional distortion1 the normal heart muscle being strained from severe exercise1 or a weak1 flabby1 or disused heart muscle being overtaxed by ordinary exercise4 ,here it will be seen that in the first instance immediate rest will probably correct the weakness2 in the second1 rest and general building up of the body if the atonic heart muscle resulted from some debilitating disease4 ,if from local causes correction of the specific osteopathic lesion should be effective4 ,secondly1 through strong and rapid heart action the valves are ruptured or lacerated1 always at the point of maximum contact1 and thus present a favorable surface to micro-organisms4 ,owing to the valves being a reduplication of the endocardium1 they have no muscles or blood-vessels1 so that in functional leakages1 inflammation does not play a part1 hence1 a possibility of degeneration occurring from excessive stretching4 ,the large majority of osteopathic lesions are unquestionably found in the upper five dorsal vertebr and the first five or six ribs on the left side1 although cervical lesions1 in many instances1 play an important secondary1 if not the primary1 role4 ,these maladjustments affect vasomotor nerves to the heart1 that is1 to coronary vessels1 the dorsal and cervical sympathetics1 the vagi1 and the phrenic4 ,we are unable to state just how these lesions disturb nerve conductivity2 what present anatomy and physiology teach us does not fully explain4 ,osteopathic dissection must be the means to the end of the explanation4 ,we have many clinical results1 but not the physiological knowledge1 as yet1 to support it4 ,the dropping down of the first rib1 as well as the clavicle1 interferes with the large blood-vessels1 especially the subclavian1 and causes increased resistance of the heart's action and probably a certain regurgitative effect4 ,this regurgitative effect would also occur in cases of obstruction to the aorta by constriction of the diaphragm from dropping of the floating ribs4 ,to what extent this latter feature has been demonstrated is not known4 ,in valvular diseases it is practical to divide them for treatment into1 first1 where the lesion is compensated2 second1 where compensation is incomplete2 third1 where compensation is lost4 ,with all cases we should give consideration to environment1 temperament1 habits1 food1 clothing1 exercise1 etc4 ,often these secondary matters are of vital importance1 especially when compensation is failing4 ,the ,schott method of treatment may be of some avail2 this treatment1 which is composed of a series of resistant exercises1 tends to lessen peripheral resistance1 develop heart muscle1 and remove heart stasis4 ,speaking in general1 hypertrophy and dilatation follow valvular leakage1 as a secondary effect4 ,it is a compensatory condition1 and whenever compensation is failing1 there is naturally a breaking down of the structural tissues of the heart2 that is1 the muscular hypertrophy is losing in integrity4 ,our primary aim1 then1 should be to keep up the compensation1 which is represented in the hypertrophy1 although there are cases that fail rapidly1 especially in emphysema and cirrhosis of the lungs4 ,generally1 in hypertrophy and dilatation1 there is a disproportion between the amount of work the heart has to do and its ability to do it4 ,one of two things has occurred2 there is an increase in peripheral resistance or the volume of blood through the heart is abnormal in quantity#aja4 ,loudon#ajb says3 8,the treatment of chronic disease of the heart requires a longer time1 as a rule1 than the same disorder in the acute stage4 ,some cases cannot be materially helped2 a vast majority may be greatly benefited after a thorough trial2 while more than we might at first suppose1 can be entirely cured4 ,we desire to quote at length from ,hare relating to this point4 ,he says3 #8,a chronic structural change in the heart resulting from an acute process is not always synonymous with chronic heart disease4 ,thus1 acute endocarditis occasions a variety of changes of the mitral and aortic valves which long may indicate their presence by their characteristic murmurs1 and yet in time these may wholly disappear4 ,that many such cases outgrow the valvular trouble1 especially mitral lesions1 there can now be no doubt4 ,the majority1 even of those in whom valvular murmurs permanently continue1 do not have their health unfavorably affected for years1 and in many of these1 the duration of life is not appreciably shortened4'0 ,this statement1 from such an author1 gives the osteopath great encouragement2 for add to those above referred to1 which recover in time from all valvular trouble1 the many cases of valvular insufficiency1 due to dilatation1 owing to osteopathic lesions to the trophic nerves1 and which may be cured by removing such lesions1 we find that quite a percentage of cases are thus disposed of4 8,it is doubtless true1 also1 that the cases above mentioned having valvular thickening and vegetations1 could have been cured in quicker time and greater number had osteopathic treatment been given to tone the heart1 upbuild the general circulation and increase the activities of the excretory organs4 ,the importance of the lungs is often overlooked in the treatment of cardiac diseases4 ,the osteopath's ability to expand the chest and increase the capacity of the thorax should be demonstrated in both cardiac and pulmonary troubles4 ,it is said to be a universal law throughout the animal kingdom #8that muscular power is directly proportional to the amount of oxygen consumed4' ,hence give the power1 and have your patient live as much out of doors as practicable4 ,exercise should be moderate and always stopped short of fatigue40 ,treatment of the abdominal organs should not be neglected1 for improved circulation here and thorough removal of effete products will influence the heart4 ,freedom from worry1 strains1 etc4 are essential4 ,tepid baths are best4 ,a person may have a valvular leakage and not be aware of it4 ,probably it is best to inform them1 except in certain neurotic individuals4 ,for then they can take special care of themselves1 as to overwork1 strains and intercurrent infections1 and their life and usefulness be greatly prolonged4 ,when compensation begins to break1 certain symptoms are noticed1 as heart irregularity1 difficult breathing1 particularly at night1 shortness of breath1 and more or less anemia4 ,later there is disturbance of rhythm1 cyanosis1 dilatation of heart and dropsy4 ,frequently1 considerable can be accomplished through the upper dorsal treatment1 attention to the chest mobility1 manipulation of the abdominal organs and diaphragm1 and special attention to the diet1 rest and some exercise4 ,a light general treatment will assist the labored circulation and improve assimilation1 and a change of climate may be of benefit4 ,hypertrophy of the ,heart ,hypertrophy of the heart is an enlargement of the heart1 due to an increase in the muscular tissue4 ,it is usually associated with dilatation4 ,the ventricles are more often involved than the auricles1 and the left ventricle is more likely to be affected4 ,etiology4--,valvular disease of the heart causing an obstruction to the outflow of blood1 as mitral insufficiency1 diseases of the aortic valve2 increased intra-vascular pressure1 caused by sclerotic changes in the walls of the vessels2 contraction of smaller arteries1 due to irritation of toxic substances in the blood1 as in ,bright's disease4 ,overeating or drinking and excessive physical exercise would also induce hypertrophy of the left ventricle4 ,hypertrophy of the right ventricle is caused by valvular lesions on the right side4 ,lesions of the mitral valve causing an increased resistance in the pulmonary vessels are etiologic factors2 also diseases of the pulmonary vessels in the lungs1 as in cirrhosis and emphysema4 ,there are conditions affecting the heart1 as the use of tea1 alcohol and tobacco4 ,disturbed innervation1 as in exophthalmic goiter2 derangements of the vertebr1 and ribs corresponding to the upper five dorsals2 downward displacements of the floating ribs1 causing a prolapse of the diaphragm and a consequent retardation of blood through it to and from the heart1 will affect the heart's action4 ,simple hypertrophy never occurs in the auricles2 it is always accompanied with dilatation4 ,the condition develops in the left auricle in mitral lesions2 in the right auricle when there are disturbances of the pulmonary circulation4 ,the tricuspid is rarely affected primarily4 ,pathologically1 the left side of the heart is more commonly enlarged than the right2 the ventricles than the auricles4 ,the shape of the heart varies when the left ventricle is hypertrophied1 the conical shape being more or less lost2 it lies more horizontally and is elongated4 ,when both ventricles are enlarged the heart is round4 ,when the right ventricle is affected1 it occupies the largest part of the apex4 ,the increase in the size of the heart is probably due to a numerical increase in the muscle cells4 ,the muscle is firm1 of deep red color and cuts with considerable resistance4 ,normally1 the heart weighs from eight to nine ounces4 ,in general hypertrophy it may weigh from fifteen to thirty ounces4 ,symptoms4--,hypertrophy1 being a conservative process or an act of compensation1 does not necessarily present any symptoms at first4 ,at the beginning there is rarely any pain1 but a sense of fullness and discomfort is present4 ,as the hypertrophy increases1 the arteries become fuller1 the veins less full and the circulation accelerated4 ,in hypertrophy associated with arteriosclerosis the blood pressure is increased1 and the pulse full and firm4 ,epistaxis may be of frequent occurrence and the face congested4 ,pains occur in the precordial region4 ,there are nervousness1 headache1 hot flushes1 palpitation1 cough and vertigo4 ,in hypertrophy of the left ventricle1 the apex is lower and to the left4 ,the carotids pulsate visibly and the radial pulse is strong and tense4 ,percussion reveals enlargement to the left and downward4 ,the first sound is louder and prolonged4 ,the aortic second sound is intensified4 ,in hypertrophy of the right ventricle the enlargement is to the right edge of the sternum4 ,the second sound in the pulmonary area is increased4 ,the apex-beat is displaced outward4 ,the pulse at the wrist is usually small4 ,hypertrophy of the auricles always occurs with dilatation1 which is most common in the left auricle4 ,the physical signs are characteristic4 ,they are caused by diseases of the mitral and tricuspid valves and diseases of the lungs1 as emphysema and cirrhosis4 ,diagnosis4--,if a careful examination is made1 hypertrophy can hardly be mistaken for any other condition4 ,there may be a resemblance to pericardial effusion1 pleuritic effusion1 aneurism or mediastinal tumor1 when near the heart4 ,the ,x-ray will be of assistance4 ,prognosis4--,depends largely upon the cause producing the hypertrophy4 ,remember that hypertrophy is a compensatory act4 ,the prognosis is more or less unfavorable if resulting from emphysema1 ,bright's disease or in old age2 also in degeneration of the vessels4 ,in most cases of functional overaction1 persistent treatment can usually accomplish considerable4 ,treatment4--,the treatment must be according to the cause of the hypertrophy4 ,there are many etiological factors1 consequently the treatment depends upon the influence of these factors4 ,the principal treatment will be found under endocarditis1 as valvular diseases are usually caused by endocarditis1 and hypertrophy of the heart is a conservative process of nature--an act of compensation secondary to valvular and arterial lesions4 ,the indications are to lessen the force and number of pulsations of the heart and remove the cause if possible4 ,dilatation of the ,heart ,there may be dilatation with thickening of the walls1 and dilatation with thinning of the walls1 or they may be normal4 ,it may be produced by impaired nutrition of the cardiac muscle or increased endocardial tension4 ,more frequently the two conditions act jointly1 although they may act singly4 ,impaired nutrition of the cardiac muscle may diminish the resisting power and thus cause dilatation4 ,weakening of the cardiac walls may occur in scarlatina1 typhoid1 typhus1 rheumatic fever1 etc4 ,it is met with in chlorosis1 anemia and leukemia4 ,increased endocardial tension occurs in sudden1 extreme exertions and in valvular diseases4 ,a normal heart through excessive exertion is rarely if ever dilated4 ,the important causes are considered under hypertrophy4 ,both impaired nutrition and increased endocardial tension are influenced directly by the extent and severity of the osteopathic lesion4 ,this point has been considered under chronic endocarditis4 ,pathologically1 the right side is more commonly affected than the left4 ,in advanced aortic incompetency1 all the divisions may be dilated4 ,when one ventricle alone is dilated the septum may be seen to bulge4 ,in extensive dilatation1 the auriculo-ventricular rings are often dilated4 ,other orifices may also be dilated4 ,the condition is often associated with hypertrophy and fatty degeneration4 ,the muscle may be normal in appearance4 ,the endocardium is often opaque1 and roughened in patches4 ,there is degeneration of the ganglia of the heart4 ,symptoms4--,dilatation causes weakness of the walls of the heart1 but as long as the hypertrophied walls can compensate1 no symptoms result4 ,when the hypertrophy weakens1 greater dilatation occurs and symptoms of venous stasis appear1 as dropsy1 feeble irregular pulse1 dyspnea1 cough and scanty urine4 ,in some instances there may be brief precordial distress1 faintness or palpitation4 ,physical ,signs4--,on inspection the apex-beat is diffuse and feeble1 or it may not exist4 ,as observed by ,walsh1 the impulse may be visible and yet not palpable4 ,palpation--the impulse is diffuse1 feeble and fluttering4 ,the pulse is small1 rapid and irregular1 rarely is it slow4 ,percussion--the area of lateral dullness is increased to the right4 ,there is increase in the dullness downward to the sixth interspace and upward to the second rib in many cases4 ,auscultation--the sounds are weak and sharp4 ,the first sound is shorter1 lacks its muscular element and becomes more like the second4 ,the sounds are obscured1 the cardiac murmurs are present4 ,in many cases the characteristic gallop rhythm is present4 ,when the right heart is chiefly dilated1 the true apex-beat cannot be felt1 while an impulse may be felt below the xiphoid cartilage1 and a wavy impulse is seen in the fourth1 fifth and sixth interspaces to the left of the sternum4 ,diagnosis4--,when a clear history can be obtained1 together with the characteristic features1 the diagnosis can be readily made4 ,prognosis depends upon the cause4 ,treatment4--,the treatment of dilatation is that of valvular heart disease4 ,it is important that the patient should have plenty of rest1 suitable food and regulated exercises4 ,in acute dilatation absolute rest is necessary4 ,limit the fluid intake1 and open the bowels thoroughly4 ,in serious cases1 bleeding1 a pint or more1 should be considered4 ,myocarditis ,myocarditis is an acute or chronic inflammation of the heart muscle4 ,in many cases where the muscle substance of the heart is diseased1 there is no doubt that osteopathic lesions are potent underlying factors4 ,the lesions lessen nervous integrity and thus have a direct bearing upon the muscular strength and the likelihood of inflammatory invasion4 ,acute ,interstitial ,myocarditis4--,this affection is met with in fevers1 in connection with endocarditis and pericarditis4 ,of the infections diphtheria and typhoid are the most frequent4 ,septic emboli may block the coronary arteries in pyemia1 septicemia and malignant endocarditis and cause infarcts in the myocardium with abscess formation4 ,it may be a complication of gonorrhea4 ,males are affected more often than females4 ,pathologically1 in acute interstitial myocarditis the changes take place in the intermuscular connective tissue4 ,this becomes swollen and round-cell infiltration takes place4 ,the muscle substance is pale and soft4 ,acute parenchymatous degeneration is characterized by degeneration of the muscle fibers1 which are infiltrated with granules4 ,the cardiac muscle throughout is pale and soft4 ,acute suppurative myocarditis is a rare condition4 ,in this form abscesses occur1 which vary in size from a pin's head to a pea4 ,they vary greatly in number and are usually multiple4 ,they may not cause any disturbance and may not be recognized before death4 ,on the other hand the abscess may rupture into the heart cavities or the pericardium1 or it may perforate the intraventricular septum1 thus allowing the venous and arterial blood to intermingle4 ,it may cause a cardiac aneurism4 ,symptoms4--,these are very uncertain4 ,if during the course of any of the causal diseases1 the pulse suddenly becomes rapid1 small and irregular and compressible and palpitation and syncope develop1 all of which point to cardiac weakness1 myocarditis may be suspected4 ,signs of venous stasis develop later in the affection4 ,the physical signs are those of dilatation4 ,this is extremely grave4 ,cases do1 however1 recover4 ,treatment4--,the treatment is the same as that given under endocarditis and pericarditis4 ,rest in bed is absolutely necessary4 ,pay particular attention to the nourishment and to the hygienic surroundings of the patient4 ,especially attention should be given to the upper dorsal area1 both to the muscles and the interosseous lesions1 for this influences cardiac muscle innervation and nutrition4 ,then lesions of the upper cervical are important owing to their relationship to the vagi which control muscular impulses of the heart muscle4 ,chronic ,interstitial ,myocarditis4--,among the causes of this form of myocarditis are the excessive use of tobacco or alcohol2 gout1 rheumatism1 malaria1 diabetes1 chronic nephritis1 syphilis and lead poisoning4 ,acute interstitial myocarditis may lead to the chronic form4 ,this form is 8commonly caused by the narrowing of a coronary branch in a process of obliterative endarteritis0 7,osler74 ,it may be due to injuries of the anterior and lateral portions of the chest4 ,unquestionably osteopathic lesions of the upper dorsal vertebr and ribs and cervical region affect the integrity of the heart muscle and predispose to congestion1 inflammation and debility of the tissue4 ,males of middle life are more predisposed to chronic myocarditis4 ,the pathological changes occur most frequently in the left ventricle and the septum1 but they may occur in any portion4 ,the patches and streaks that are in the walls are sometimes only seen upon very careful examination4 ,they are of a gray or grayish-white color1 and when fibers that have undergone fatty degeneration are intermingled1 they have a grayish yellow tint4 ,the condition may be associated with hypertrophy and dilatation4 ,a part of one of the heart cavities may become dilated1 producing what is known as cardiac aneurism4 ,there is destruction of the muscular fasciculi with subsequent development of new fibrous tissue4 ,fatty degeneration is also seen4 ,symptoms4--,advanced fibroid myocarditis may be present without any symptoms4 ,slight degrees present no symptoms4 ,the symptoms when present are3 a feeble1 irregular1 slow pulse2 attacks of angina pectoris and sometimes arhythmia4 ,the blood pressure is increased4 ,upon exercising there is more or less pain1 cardiac distress and dyspnea4 ,if fatty degeneration is also present the pulse will be quickened and irregular4 ,diagnosis4--,this is often very difficult and it requires careful and persistent study of a case to be able to make a correct diagnosis4 ,prognosis4--,this is grave1 though unquestionably a number of cases have been distinctly improved through osteopathic methods4 ,sudden death is liable to occur at any time from complete obstruction to the coronary arteries1 as this condition is associated with sclerosis and narrowing of these arteries or their branches4 ,treatment4--,the treatment of chronic myocarditis is largely included in chronic endocarditis4 ,the cause of the disease should be determined1 if possible4 ,careful treatment to the ribs of the left side1 from the first to the sixth1 and the corresponding vertebr1 will be of great aid in controlling the disease4 ,the cervical region demands attention1 owing to the influence of the vagi on conduction of the heart impulse and to vasomotor effect4 ,attention should be given to the diet and hygiene of the patient4 ,outdoor life1 bathing of the skin1 and careful treatment of the vasomotor nerves will be of great help4 ,direct attention to the entire splanchnic region as vasomotor control here materially lessens the work of the heart and assists generally in maintaining the digestive and nutritive functions4 ,degeneration of the ,heart ,muscle ,in fatty degeneration1 the sarcous substance of the fasciculi is converted into fat4 ,in fatty overgrowths there is an excess of fat in and about the heart4 ,fatty degeneration is very common and is due to an interference with the nutrition of the cardiac muscles4 ,it is found in the impaired nutrition of old age1 of cachectic states1 of grave infectious diseases and of wasting diseases4 ,in poisoning by arsenic and phosphorus1 intense fatty degeneration is produced4 ,pericarditis may be associated with changes in the superficial layers of the cardiac muscle4 ,lesions of the coronary arteries will produce this condition2 also impairment of the oxygen-carrying power of the blood4 ,it occurs most frequently in men after forty years of age4 ,the affection may be either general or local4 ,it is most commonly seen in the left ventricle4 ,when the condition is general the heart is dilated1 flabby and relaxed4 ,microscopically1 the muscular fasciculi exhibit a loss of nuclei1 and oil drops and granules appear in the fibers4 ,the affection may be present without any noticeable symptoms4 ,slight degrees and localized fatty degeneration are unrecognizable4 ,dilatation must be present to produce symptoms4 ,this is apt to occur early4 ,dyspnea2 asthma2 cough2 angina pectoris2 dropsy2 slow1 weak pulse2 palpitation1 and toward the end1 ,cheyne-,stokes breathing may appear4 ,mental symptoms1 such as maniacal delusions1 may come on and last for weeks4 ,prognosis depends upon the cause and extent of involvement4 ,the treatment is largely that of dilatation of the heart4 ,an effort must be made to determine the cause1 and treatment should be applied accordingly4 ,considerable can be done in improving the nutrition of the tissues of the heart by hygienic and dietetic measures4 ,light exercises will often be of aid1 but care has to be taken that the exercises do not tax the patient too severely4 ,a general treatment of the body will be a helpful measure in invigorating the system as a whole and toning the cardiac tissues4 ,the diet should be nutritious2 largely nitrogenous4 ,raising the ribs over the heart and increasing the chest expansion will be of help in cases where there are attacks of dyspnea and angina4 ,many cases present deep seated lesions in the upper dorsal region4 ,when there are attacks simulating apoplexy1 lay the patient flat upon the back with the head slightly elevated4 ,fatty overgrowth is associated with general obesity and sooner or later this infiltration impairs the nutrition of the cardiac muscle and true fatty degeneration results4 ,this form occurs more frequently in men1 and between the ages of forty and seventy years4 ,the characteristic changes consist of an increase in the normal fat4 ,the heart may be enclosed in a thick covering of fat4 ,the fat may also be deposited between the fasciculi1 sometimes reaching the endocardium4 ,fatty overgrowth is certain to exist in extreme obesity4 ,no symptoms are produced until the muscular fibers weaken so that dilatation occurs4 ,the presence of extreme obesity1 combined with signs of cardiac weakness1 point to fatty overgrowth4 ,the treatment of fatty overgrowth of the heart is largely the same as that of obesity4 ,oertel's method of lessening the amount of liquids1 proteid diet and graduated exercises is effective in cases where heart compensation is intact4 ,neuroses of the ,heart ,palpitation is a more or less rapid action of the heart1 of which the patient is conscious4 ,there is usually an irregular or forcible action of the heart1 as well as a frequency of the heart-beat4 ,there is generally some local irritation to the cardiac nerves2 especially are lesions found to the third and fourth ribs1 although a lesion may be higher or lower in the dorsals or it may be in the cervical area4 ,muscular lesions are frequent4 ,these lesions predispose to the disturbances of reflex stimuli1 still the general health may be so weakened or the reflex irritation so pronounced that palpitation results independently of predisposing osteopathic lesions4 ,females are more liable to be affected4 ,the neurotic state is a common source of the disorder4 ,if palpitation is long continued it causes hypertrophy4 ,it often occurs at puberty1 during menstruation and at the climacteric period4 ,anemia1 the acute infectious diseases1 dyspepsia1 disturbances of the ovaries and other pelvic organs are common causes4 ,the abuse of coffee1 tea1 alcohol1 tobacco2 diseases of the stomach1 overwork1 fright1 grief1 anxiety1 and sexual excesses are causative factors4 ,palpitation may be associated with organic diseases of the heart1 but as a rule it is a purely nervous affection4 ,the patient's perception of the increased action and force of the heart is the essential element in palpitation4 ,the action of the heart varies greatly and at times it may be a mere fluttering which lasts but a few minutes4 ,in severe cases the heart beats violently and the pulse may be rapidly increased and reach #afj or more4 ,the face is usually pale1 but may be flushed4 ,the heart's action is not increased in some cases4 ,the attack generally lasts only a few minutes4 ,the first consideration in treatment is to locate the disturbing factor4 ,raising the ribs over the heart and lowering the first rib2 correcting the clavicle in a few instances1 or inhibiting along the upper dorsal region will usually quiet the heart's action4 ,stimulation of the vagi nerves1 as they pass along the side of the neck1 may be all that is necessary2 in some cases inhibition of the superior cervical sympathetic or of the middle cervical region1 acting on the depressor nerve of the heart1 will lessen the tumultuous action of the heart4 ,it will be recalled that either there is irritation of the accelerator nerves of the heart or the vagus is inhibited4 ,all reflex disturbances1 as a displaced uterus1 indigestion1 etc41 must be removed before the palpitation can be permanently stopped4 ,rest and confidence in the treatment are of great importance4 ,a very few cases will require a hot bath and a general treatment and possibly an ice-bag over the heart to quiet the increased activity4 ,in anemic cases hygienic measures and a proper diet1 coupled with the treatment for anemia1 are indicated4 ,if the attack is severe1 the patient should rest in a recumbent posture and drink something warm1 besides receiving the indicated treatment4 ,when the patient is not a decided neurasthenic a rapid five or ten minute walk will often normalize the heart's action4 ,tachycardia is rapid action of the heart and commonly occurs in paroxysms4 ,there are no heart sensations1 as in palpitation4 ,either the sympathetics are stimulated or the vagus inhibited4 ,it is not generally related to lesions of the heart1 but is in reality a disorder of the nervous system4 ,in some instances the condition is physiologic4 ,nervous strain1 in the form of osteopathic lesions to the upper dorsal or cervicals irritating the sympathetic1 is the most common cause4 ,emotion1 fright and severe exercise are other causes4 ,it is found in neurasthenia1 anemia1 hysteria and in those using an excessive amount of tobacco1 tea and coffee4 ,reflex stimuli from abdominal or pelvic disorder1 especially during the climacteric may induce tachycardia4 ,in exophthalmic goitre the sympathetics are overstimulated1 and in some instances the vagus inhibited1 leading to 8heart hurry40 ,tumors1 hemorrhages1 enlarged glands1 etc41 obstructing the action of the vagus1 are a source of rapid heart4 ,sudden onset with rapid action of the heart1 small weak pulse1 headache1 flushed face and faintness are common symptoms4 ,the treatment is somewhat similar to that outlined under palpitation4 ,locating the cause is the first essential4 ,besides removing local osteopathic lesions1 inhibition to the cervical and dorsal sympathetics is effective4 ,raising the ribs over the heart will lessen the pulse-rate4 ,rest1 diet and general care of the patient may be necessary4 ,outdoor exercise and cold bathing are beneficial4 ,in a few cases springing the dorsal spine forward1 raising the floating ribs1 and slight traction of the cervical spine are effective in slowing the heart's activity4 ,a few cases are very refractory1 especially in neurotics4 ,brachycardia1 or slow action of the heart1 is the opposite of tachycardia4 ,in a few cases it is physiologic4 ,it usually occurs secondarily1 following infectious diseases2 accompanying nervous disorders1 as hysteria1 melancholia and neurasthenia1 and is associated with diseases of the digestive organs1 pulmonary disorders and toxic effects of coffee1 tea1 tobacco1 and drugs and the toxins of jaundice1 diabetes1 uremia1 etc4 ,obstructions to the cervical sympathetics and irritations of the vagus1 from osteopathic lesions1 may be either direct causes in themselves or predisposing factors in the above diseases4 ,a slow1 weak pulse is the characteristic symptom4 ,the heart sounds are feeble4 ,when the pulse beat is below sixty per minute it is diagnostic4 ,in the treatment of slow heart1 as in the other neuroses of the heart1 the cause should be first determined4 ,a stimulating treatment to the cervical sympathetics and inhibition to the pneumogastric will readily relieve many cases1 at least temporarily4 ,the lesion may be directly to these nerves and of course removal of the same is essential4 ,inhibition of the pneumogastric probably affects the activity of the depressor nerve1 and stimulation of the cervical sympathetics1 besides acting on the accelerator fibers of the heart directly1 influences the blood supply of the body and thus increases arterial tension4 ,stimulation to the upper chest anteriorly and posteriorly1 over the cardiac region1 will increase the rapidity of the slow heart4 ,rest and care of the general health is necessary4 ,arhythmia1 or an irregularity of the heart's action and pulse beat1 often due to lesions in the cervical region interfering with the vagi1 symis pathetic or vasomotor nerves to the heart4 ,in a number of cases the first1 second or third rib on the left side is at fault and a correction of it will relieve the irregularity immediately4 ,it is claimed that there are nerves at the fourth and fifth dorsals that tend to control the rhythm of the heart-beat4 ,other causes are organic diseases of the heart and nervous system1 reflex disturbances1 excessive use of tobacco1 coffee and tea4 8,normally1 the contraction of the heart originates at the sinoauricular node1 at the mouth of the superior vena cava1 is conducted to the auricle1 and thence to the ventricle by way of the auriculo-ventricular bundle 7bundle of ,his or ,gaskell's ridge74 ,under conditions of abnormal stimulation1 contractions may originate in the auriculo-ventricular node in the wall of the right ventricle near the coronary sinus2 or in the auriculo-ventricular bundle on the ventricular side of the node2 or in the auricular tissue itself40--,clinical ,osteopathy4 ,fibers from the right vagus pass to the sinoauricular node1 and from the vagus to the auriculo-ventricular bundle4 ,lesions of the upper three cervicals may readily disturb the vagi through circulatory and chemical sources as well as through the communicating branch of the second spinal nerve4 ,thus the rhythmic power of the heart1 rate and strength1 and conductivity of impulse may be readily influenced1 which is borne out by clinical experience4 ,there are several forms of irregular heart action4 ,for a description of same it is probably best to refer the student to special works4#ajc ,the more common forms are ,sinus ,irregularities1 the ,extrasystole1 ,paroxysmal ,tachycardia1 ,auricular ,fibrillation1 ,auricular ,flutter1 and ,heart-block4 ,pulsus ,alternans is a rare form1 and is of grave significance when the heart muscle is degenerated4 ,a knowledge of auricular fibrillation is of special value1 for it is a common form and often indicates a serious condition4 ,most of the irregularities are not of special pathological importance1 providing the heart muscle is healthy4 ,they are best studied through instrumental means and require considerable experience in order to determine the exact condition4 ,frequently1 unnecessary worry has been the result in discovering irregularities in the young as well as in otherwise healthy adults4 ,only when the cardiac muscle is diseased or degenerated through various infections and toxic properties in the blood should they receive unusual attention4 ,dorsal and lower cervical lesions that affect the heart by way of the sympathetics no doubt disturb nutrition of the heart tissues4 ,and lesions of the vagi1 particularly of the upper three cervicals1 will disturb the rhythm1 rate1 strength1 and conductivity of the impulse through auricles and ventricles4 ,in no other organ of the body will the osteopath be better rewarded for careful and painstaking work than in normalizing the stimuli from sympathetic and vagi that influence the heart4 ,stimulatory and inhibitory efforts will frequently suffice1 but in our judgment it is always better to secure interosseous adjustment if possible4 ,though a number of individuals with heart irregularities are of a neurotic type1 that predisposes to nervous disturbances of various kinds1 still it would be an interesting study1 especially in cases of children1 to note what percentage are the result of upper cervical lesions caused by birth injury4 ,angina ,pectoris ,angina pectoris is characterized by pain in the cardiac region which usually extends to the inner side of the upper arm and forearm4 8,this region corresponds to the peripheral distribution of the lower cervical nerves 7#fth and #gth in the arm7 and the upper three or four dorsal nerves 7in the upper arm and the chest740#ajd ,occasionally similar areas of the right side are affected1 and in a few there is pain in the lower jaw and back of the ears4 8,the starting of the pain is usually across the chest1 about the level of the third ribs1 or as low as the fifth ribs10 although the inception may be anywhere in the left chest or the arm4 ,the duration of the pain is from a few seconds to several minutes2 sometimes it may remain for several hours4 ,osteopathic lesions are invariably found in the upper dorsal1 including ribs1 or lower cervical region1 which are predisposing factors that tend to exhaust and weaken the cardiac muscle1 and disturb the coronary circulation1 so that resistance is lowered4 ,thus toxic agents and infections may readily involve the cardiac tissues4 ,many cases present more or less arteriosclerosis1 which involves the heart and affects its circulation4 ,inflammation of the root of the aorta from syphilis is a frequent cause4 ,valvular heart disease and chronic nephritis are other underlying factors4 ,worry1 strenuous living1 and continued physical strain are to be considered4 ,there are a group of cases1 that are comparatively mild and frequently found in women1 that are of toxic origin1 due to intestinal stasis as a result of constipation1 adhesions1 etc4 ,the ileo-cecal section is commonly involved in these instances4 ,focal infections may be an exciting cause4 ,the osteopathic lesions undoubtedly affect the cardiac innervation1 particularly vasomotor and trophic1 thus leading to consequent disturbances of cardiac circulation and resulting irritation to the ganglia4 ,sclerosis and spasm of the coronaries1 ischemia1 cramping1 exhaustion1 and degeneration of the heart muscle1 and cardiac neuralgia1 are various results that may take place4 ,the paroxysm usually begins suddenly1 often during exertion or intense mental emotion4 ,the pain is agonizing and of a grip-like character1 and there is a feeling of impending death4 ,the intercostal muscles are constricted and there may be a feeling of suffocation4 ,the pains radiate up the neck and down the arm1 and may be accompanied by numbness or tingling4 ,there is usually extreme pallor1 and the skin is ashen4 ,sweating is not uncommon1 and dyspnea may be present4 ,the attacks occur at intervals1 varying from a few days to many years4 ,after the paroxysms there is instant relief4 ,other cases may present less severe attacks4 ,in the diagnosis the only condition with which true angina pectoris is liable to be confounded is pseudo-angina pectoris4 ,pseudo-angina or hysterical angina occurs chiefly in women or in neurasthenic men4 ,these cases are often excited by toxemia4 ,the attack usually occurs at night and is unassociated with organic heart disease4 ,there is a feeling of cardiac distention instead of constriction as in true angina4 ,there is emotional excitement and the attack lasts one or two hours1 which is usually longer than that of true angina4 ,the prognosis is unfavorable1 although many cases live for a number of years4 ,a few cases have recovered under a thorough course of treatment4 ,the treatment of angina pectoris consists in correcting the disordered upper dorsal vertebr1 the upper left ribs over the heart1 and the lower cervicals4 ,invariably lesions are found in this region and if the treatment is applied to correct these disorders1 the attack can frequently be relieved4 ,by following up the treatment during the intervals1 a number of cases can be practically cured4 ,a common lesion found is a slight lateral curvature in the upper dorsal region4 ,this curvature is oftentimes great enough to cause a subdislocation of several of the ribs1 which certainly complicates the derangement1 at least as far as a quick cure is concerned4 ,during the attack raise the ribs over the heart at the point of constriction so as to relieve the impinged nerve fibers4 ,hot drinks are of value4 ,the vagi and phrenic nerves may also be at fault in some cases4 ,the sensory nerves to the heart are from the first1 second and third dorsals4 ,ice-bags or heat applied locally will be a helpful measure4 ,in cases where there is high arterial tension1 an inhibitory treatment to the upper and middle cervical regions will be of special aid1 as it relieves this tension by affecting the vasomotor nerves4 ,this treatment will at least overcome the vasomotor form of angina pectoris4 ,hot foot-baths and friction will also be found of value4 ,in many cases under forty or forty-five syphilis is a cause4 ,in cases past middle life there is often organic disease of the circulatory organs4 ,the patient should at all times avoid any excitement and live a very quiet life4 ,he should take frequent vacations4 ,he should take the best of care of himself and his food should be nutritious4 ,in pseudo-angina the treatment is to relieve the irritation to the nerves affected as well as the underlying affection4 ,,footnotes3 #ajj ,journal of the ,american ,osteopathic ,association1 ,april1 #aijf4 #aja ,valvular ,heart ,diseases1 ,a4 ,o4 ,a4 ,journal1 ,march1 #aije4 #ajb ,journal of ,osteopathy1 ,february1 #aijd4 #ajc ,mackenzie1 ,diseases of the ,heart2 ,lewis1 ,mechanism of the ,heart ,beat2 ,macleod1 ,physiology and ,chemistry in ,modern ,medicine4 #ajd ,mackenzie1 ,oxford ,medicine1 ,vol4 ,,ii4 ,,diseases ,,of ,,the ,,arteries ,arteriosclerosis 7,,atheroma7 ,this is a thickening of the intima of the arteries1 due to an inflammatory increase of the connective tissue1 associated with more or less fatty degeneration and calcification4 ,old age1 alcohol1 lead1 gout1 syphilis1 rheumatism and other infections1 laborious work1 overeating1 nephritis1 and calcareous water tend to produce the condition4 ,excessive eating and drinking are common causes of both atheroma and chronic renal diseases and should always be regulated4 ,physical overwork1 chronic intoxications1 etc41 produce hypertension of the vascular system and thus lead to changes of the vessel walls4 ,a rigid spine is invariably found2 this may be a causative factor in itself1 or an associated condition4 ,all of the above list of causes are important4 ,pathologically1 the arteries are thickened1 tortuous and rigid4 ,the intima may be occupied by rough1 calcareous plates4 ,in extreme cases the sub-endothelial tissue undergoes degeneration and breaks down in spots1 forming 8atheromatous abscesses40 ,the disease may be circumscribed or diffuse2 in the latter there is a widespread distribution of the affection4 ,owing to the general effect1 the heart1 liver and kidneys receive less blood and tend to atrophy4 ,microscopically1 there is found more or less fatty degeneration of the different coats1 and an overgrowth of connective tissue in the intima4 ,the arteries most frequently affected are the aorta and coronary4 ,symptoms4--,circulatory4--,there is a high tension pulse and accentuation of the second aortic sound4 ,there is also dyspnea1 severe pain in the left side1 palpitation1 pallor1 and the left ventricle is hypertrophied4 ,cerebral4--,such symptoms as headache1 tinnitus1 aphasia1 vertigo1 syncopal or epileptiform attacks may be present4 ,renal4--,there is an increase in the quantity of urine1 which is of a pale color and low specific gravity2 at times it is albuminous4 ,the disturbance leads to atrophic nephritis4 ,there may be gastro-intestinal symptoms1 as constipation1 pain1 etc41 due to hardening of the splanchnic vessels4 ,in some cases the peripheral arteries become obliterated4 ,the veins become hardened4 ,sequel are cardiac dilatation1 heart failure1 paralysis1 apoplexy1 fatty heart1 aneurism1 contracted or senile kidney1 angina pectoris1 and in extreme cases1 gangrene of the extremities4 ,diagnosis4--,the characteristic symptoms are hardened arteries1 high tension of the pulse1 hypertrophy of the left ventricle and accentuation of the aortic second sound4 ,the average blood pressure is from #afj to #ahj mm4 of mercury1 though it may be considerably higher4 ,prognosis4--,many cases can be greatly benefited by osteopathic treatment1 and at the incipiency the improvement is generally marked4 ,it usually runs a very chronic course4 ,treatment4--,the treatment must necessarily consist1 principally1 in the removal of such conditions as are producing the degeneration4 ,the rigid spine should be carefully treated by methods 7preferably traction7 that overcome the contractures and release the intervertebral discs4 ,the dorsal and lumbar areas1 and the abdominal organs should receive special attention4 ,outdoor life and plenty of rest are important4 ,alcoholism1 gout1 rheumatism1 syphilis1 etc41 must be remedied before there can be much change in the arteries4 ,freeliving and all excitement must be stopped4 ,the patient's cooperation is invaluable4 ,a milk diet is often beneficial4 ,besides treatment of the primary disease1 a general treatment will be of much avail in equalizing and reducing arterial tension4 ,brunton#aje speaks of cases of atheroma being cured by exercise and manual treatment to the rheumatic joints themselves4 ,one1 apparently suffering from senile dementia1 was much improved after two years of this treatment applied to the joints1 and showed benefit to the cerebral circulation4 ,the bowels and kidneys should be kept active1 and the general health of the patient carefully watched4 ,keeping the skin active by daily baths is an essential factor in the treatment4 ,very frequently the disease is not only retarded1 but improved4 ,in high blood pressure venesection may be of benefit4 ,,footnotes3 #aje ,lectures on the ,action of ,medicine1 p4 #cdc4 ,,diseases ,,of ,,the ,,blood ,,by ,,earl ,r4 ,,hoskins ,general ,considerations3--,it has been said that each individual is a part of all the generations which have preceded him4 ,in the same way it might be said that every drop of our blood is a part of every other cell in our bodies4 ,the other tissues are able to maintain their existence only through the ministrations of the blood and in turn the blood derives its own substance from tissues which it supplies4 ,we are accustomed to speak of certain organs as being those of blood formation1 yet it is true that every tissue furnishes its quota of blood composition1 making up the mass which we call blood4 ,it is in one way an algebraic sum of good and baneful substances1 without which there can be no normal function1 and sometimes being of itself a menace as well as an aid to other tissues1 as in sepsis4 ,there can be no perverted function of any tissue without there being a direct effect upon the blood4 ,we may not always be able to measure this effect with our present laboratory methods4 ,we may not be able to detect clinically the result of this alteration of the blood stream because of compensatory influences1 dilution1 phagocytic action1 enzymatic action1 oxidation1 and the intricate processes of excretion4 ,it must also be remembered that normal blood is not of a certain definite chemical or physical composition4 ,it must vary from minute to minute according to the normal metabolic phenomena which make up our succession of events associated with life4 ,but comparatively little is known about this most important fluid4 ,we have accumulated data regarding morphology and relative numbers of its formed elements and their behavior when sufficient abnormality is present to upset their wonted balance of arrangement4 ,we have an ever widening field of investigation in the blood plasma in which we are constantly being told of newly discovered complexities4 ,certainly the field of the unknown is big enough to contain our unexplained blood reactions4 ,it is probable that as our knowledge increases our number of diseases really considered as true blood diseases will decrease and be shown to be the effect of blood passing through certain pathologic tissues of the body4 ,we can measure the number and proportion of formed elements1 and the relative efficiency of the erythrocytes by the amount of hemoglobin which they carry4 ,the genesis of the formed elements is to be kept in mind in considering therapy4 ,the erythrocytes and granular cells developing in adult life1 principally from the red marrow1 leads our attention in decrease or increase of these particular cells to the greatest aggregation of red bone marrow which happens to be in the ribs4 ,the anatomical relation of the ribs to the spine would seem to render them very liable to disturbances of nutrition and nerve control as a result of structural maladjustment and clinically this presumption is verified4 ,limitation of the motion of the thoracic spine is perforce accompanied by costal inactivity with disuse effects upon the red marrow and eventually upon the relative content of the blood stream4 ,we can measure the efficiency of the erythrocytes in carrying oxygen to the tissues by measuring the relative amount of hemoglobin which a given volume of blood contains4 ,the actual changes taking place in blood character are often thus sufficiently indicated for us in terms of our present methods of examination1 to at least aid in the arrival at a diagnosis4 ,we sometimes have to remember that the adaptation to abnormality may be efficient enough to keep the apparent significance from telling the 8whole truth40 ,the ,anemias ,the class of diseases which are referred to as the ,anemias are those in which there is an actual1 or apparent1 decrease in the oxygen carrying element or hemoglobin4 ,this may not be due to an actual decrease in amount of hemoglobin1 but rather to a decrease in the ability of the red cells to carry it4 ,this decrease in ability may be due to alteration in the erythrocytes themselves1 or to effects of change in the molecular concentration of the plasma in which they are suspended4 ,the plasma may also contain certain poisons probably protied1 which may make impossible the efficient carrying of hemoglobin by the erythrocytes4 ,the simplest form of anemia is that due to removal of a large percentage of erythrocytes from the body4 ,this condition is fulfilled in acute hemorrhage4 ,if the amount of blood lost does not exceed the amount necessary to maintain circulation1 roughly fifty per cent of the total quantity1 the fluid portion lost is quickly replaced from the fluids of the body and from material ingested4 ,the formed elements and proteids are less rapidly replaced by a compensatory increase in function of the hematopoietic tissues so that there is a gradual return to the original number and proportion4 ,a blood cell may be considered as passing through a life cycle of infancy1 adolescence1 maturity1 and senility before it is finally destroyed4 ,if the demand for new cells is not too great it will be met with mature cells4 ,if the call is more urgent1 younger and older cells will both be put into the conflict1 while in a time of extreme stress all types of cells1 from the 8school boys0 to the 8gray-beards01 will have to be utilized to maintain life4 ,so1 roughly1 we can judge the severity of the anemic process by the reaction which the body makes to it as indicated by the character of the cells in service4 ,the pigment1 hemoglobin1 is slowly regenerated even as compared to erythrocytes1 so that the color index is usually the last finding to return to normal after a hemorrhage4 ,the leucocytes are usually increased after hemorrhage1 probably as a protective mechanism1 nature having learned by hard experience that she has less resistance to infection1 when there is loss of a considerable quantity of blood4 ,to be considered1 also1 is the fact that constantly blood cells are outliving their usefulness--some must be disposed of4 ,the extra function required of these older cells gives the same results as over work upon an old man--hurries his time of demise so that there is a greater percentage than usual to be sent to the salvage shops4 ,the regeneration of blood after hemorrhage depends upon the severity of the loss1 the nutrition1 upon the treatment given1 and indirectly the ability of resistance developed by the patient4 ,in the chronic anemias we may have either defective development of erythrocytes1 or defective function of them1 or a relatively too great destruction of these same agents4 ,a bank account may be depleted either by too small deposits to account for current expense1 or by extravagant withdrawals4 ,it is sometimes difficult to determine on which side the fault lies4 ,it seems to be nature's plan not to subject to active work an erythrocyte until after the nucleus has disappeared1 judged by ordinary methods of staining4 ,a sudden call for an increased number of erythrocytes may force the organism to send in some with nuclei1 but the circulation does not receive those which have not been standardized1 as to shape and staining reaction1 unless the crisis is of grave import4 ,evidence of increased destruction of these cells is shown by broken forms--shadow forms1 and by an increased excretion of the pigments derived from the breaking down of hemoglobin1 namely bilirubin and urobilin4 ,a great deal of information can be obtained by a study of the other formed elements of the blood4 ,in general the symptomatology of all the anemias will be that of lessened metabolism because of deficient oxygenation4 ,this is accompanied by imperfect nutrition and general impairment of function4 ,among the usual results are muscular weakness1 malaise1 headache1 dizziness1 anorexia1 and cutaneous and membranous pallor1 with tendency to local hemorrhages4 ,the heart is often rapid1 easily disturbed in rhythm1 may possess a hemic or functional murmur1 and gives a soft compressible pulse of low pressure4 ,as a compensatory attempt the respiration may be rapid1 but is likely to be shallow1 and dyspnea results from disproportionately small exertions4 ,there may be either troublesome constipation1 or diarrhea2 often there are alternating periods of each4 ,in the severer forms convulsions1 coma1 delirium1 stupor1 localized edema of the ankles or eyelids may be seen4 ,in general the treatment of the secondary anemias will concern the removal of the cause followed by measures tending to increase the decreased element or elements in the blood stream4 ,in the anemia resulting from hemorrhage the thirst which follows is the body's method of calling for more fluid with which to maintain pressure in the arteries and capillaries sufficient to develop new formed elements to take the place of those lost4 ,if the loss is severe enough to give rise to shock1 emergency measures are necessary of introducing into the venous stream an artificial fluid to make up for the fluid part of the blood lost4 ,if the condition can be predicted and a suitable donor obtained1 blood transfusion is of greatest advantage to the patient4 ,more often the urgency of the condition will require an artificial fluid to be given in haste4 ,probably the best so far devised solution is ,fischer's physiological salt solution4 ,in the anemias due to chronic metal poisoning as from lead and mercury1 or from systemic poisoning such as syphilis or malaria1 or from the retention of metabolic products as in some of the diseases of the kidneys or of the liver1 the anemia can only be successfully treated by normalizing its primary cause--as it occurs in the role of a symptom or result1 and hence is only indirectly a blood condition4 ,costogenic ,anemia 7,,burns' ,,anemia7 ,costogenic ,anemia is a result of functional disuse-atrophy of the hematopoietic organs1 there being an insufficient supply of erythrocytes to meet the demands of the metabolism of the body4 ,it results from insufficient opportunity for nutrition and drainage of the red marrow of the ribs1 and gives the clinical picture of an anemia due to too slow production of erythrocytes4 ,etiology4--,the condition is predisposed to by any factor which tends to limit the action and nutrition of the ribs4 ,we are too prone to forget that the function of the ribs is to produce erythrocytes2 it is really a matter of secondary importance that they make up part of the thoracic wall4 ,the change from the horizontal to the upright position has tended to a drooping of the whole chest from gravity4 ,the human animal seldom develops the free hinge rib motion as often seen in quadrupeds4 ,the passage of both arterial and venous blood1 is not normally free and copious1 and as a consequence the tissue supplied functions less efficiently4 ,this function of the red marrow is to produce erythrocytes4 ,any structural lesion of the dorsal vertebral column1 or its costal articulations1 which interferes with the free motion of the rib thus interferes directly with the efficient function of these particular ribs4 ,the severity of the condition varies with the number of ribs affected and the impedance to nutrition and drainage4 ,diagnosis4--,the condition may be of gradual onset1 and may be associated or coincident with some other condition leading to a loss of tone or opportunity for free rib action4 ,the systemic symptoms are due to a deficient oxygenation of all tissues as a result of the above disuse4 ,the thorax is usually rigid--forced respiration requires unusual effort without proportionate thorax expansion4 ,the type of breathing tends toward diaphragmatic4 ,the quantities of tidal and supplemental air are both markedly decreased4 ,the lack of tissue oxidation renders elimination less active1 hence constipation4 ,gas accumulation1 weakness1 insomnia1 with slightly increased amount of urine1 and low in total solids1 is the rule4 8,the blood itself is rather characteristic4 ,coagulation time is increased2 specific gravity and viscidity diminished2 red cell count normal or only slightly diminished2 hemoglobin #f to #aj grams per #ajj c4 c4 of blood 7,meischer72 #dj to #hj 7,dare74 ,the red cells are small1 pale1 vacuolated1 sometimes nucleated4 ,the white cell count is normal1 slightly increased or slightly diminished4 ,the hyaline cells are normal1 or slightly relatively increased4 7,these1 being formed in lymph nodes1 tonsils1 etc41 are not affected by rib changes47 ,the mononuclear neutrophiles are relatively increased4 ,the nuclear average of the polymorphonuclear neutrophile is low4 ,vacuolated and atypical neutrophiles are often found4 ,basophiles1 myelocytes and amphophiles may be found in considerable numbers4 ,nuclei in all granular forms present evidences of immaturity or degeneration--they may be swollen1 vacuolated1 extruded1 ragged1 or with variable staining reaction0 7,clinical ,osteopathy74 ,treatment4--,the treatment is to obtain a normal function in the inactive tissues4 ,this is done by getting better rib hygiene4 ,whatever is interfering with rib function and metabolism is to be removed4 ,breathing exercises are given not only to 8ventilate the thorax1 but to exercise its walls04 ,carefully selected horizontal bar work is often of great value4 ,the diet should be of such nature as to supply material for manufacture of erythrocytes and for loading them with hemoglobin as well4 ,hence the foods with high chlorophyl or hemoglobin content should be emphasized4 ,prognosis4--,this depends on patient's desire for improvement of his condition4 ,he can be improved by correction of whatever lesions there may be interfering with his freedom of thoracic motion4 ,he can be benefited by manipulations which adjust the ribs1 but his cooperation is essential4 ,lack of cooperation on the part of the patient1 which would tend to increase the mobility and metabolism of the ribs1 renders him more liable to any of the intercurrent pulmonary infections1 as a result of his deficient thoracic ventilation4 ,encourage free thoracic respiration especially when in school1 or when under conditions which ordinarily would tend to slovenly habits of breathing4 ,chlorosis 7,,green ,,sickness7 ,an anemia characterized by great reduction in the amount of hemoglobin4 ,it most frequently occurs in adolescent girls4 ,it seems to be associated with neurotic manifestations and menstrual irregularities4 ,etiology4--,its cause is not well understood4 ,poor hygienic conditions may be a factor1 but it is a condition found in all stations of life4 ,the age and sex have led to investigation as to probability of lack of an ovarian internal secretion4 ,the reports of workers are contradictory4 ,the name of the condition is derived from the color of the skin1 which usually ranges from a pale greenish tint to a slight pallor4 ,occasionally there is localized vasodilation of the cheeks giving brilliant color4 ,constipation accompanied by copremia seems to be either a causative factor or result4 ,in many cases it appears to act in the dual role4 ,fixation of the middle and lower ribs accompanied by osteopathic lesions from the mid to the lower dorsal spine seem to be constant findings4 ,the costal fixation leads to lessened respiratory excursion and resulting diminished oxygenation4 ,diagnosis4--,chlorosis may be suspected from the color of the skin1 perverted appetite1 wandering neuralgias1 heart palpitation1 edematous infiltration1 and shallow type respiration1 but the diagnosis is not to be made without the aid of the blood count4 ,the striking part of the blood picture is the great reduction in amount of hemoglobin carried by each erythrocyte4 ,there is usually some reduction in the erythrocyte percentage but not in proportion to the decrease in color index4 ,there are usually many pessary-shaped and shadow erythrocytes4 ,these are of all sizes1 but seldom is the condition of such gravity as to cause more than an occasional nucleated red cell1 and when found are most likely to be normoblasts4 ,the staining reaction is of wide limits4 ,cells of all degrees of relative alkalinity are found and often there is a wide variation of staining reaction in the same cell4 ,the number of erythrocytes is usually slightly decreased but not in the proportion that the hemoglobin percentage is1 so that the color index is therefore strikingly low4 ,probably1 the average color index for a typical case of chlorosis is #ej1 with an erythrocyte count of #d1jjj1jjj and a hemoglobin of #dj per cent 7,dare47 ,this drop in color index in chlorosis is far out of proportion to the clinical symptoms which would be expected from a similar reduction resulting from the ordinary causes of secondary anemia4 ,the blood plasma is increased and the specific gravity is lowered1 sometimes reduced from #a4jee to about #a4jcj4 ,treatment4--,the treatment of any malady in which the etiology may be apparently of widely different natures will naturally rationally vary with the apparent cause4 ,if there is copremia1 which seems to be a definite causative factor1 this should be at once corrected4 ,these patients form the cathartic habit readily1 so physical and dietary methods of returning the digestive motility to normal should logically be given first trial4 ,if it is a matter of lessened metabolism as a result of insufficient exercise1 or blood oxygenation1 outdoor gymnastics and breathing exercises may incite the stimulus to normal erythrocyte hemoglobinization4 ,the diet should be of such nature as to furnish material both for erythrocyte formation and iron in form for ready absorption by them4 ,the organic iron compounds of animal hemoglobin and vegetable chlorophyl are our most common and cheapest as well as most effective sources4 ,the medical treatment of chlorosis is based on the empiric use of inorganic iron4 8,the exact method in which iron exerts a favorable influence upon chlorosis still remains unsettled4 ,it is difficult to understand why iron salts in the food which are sufficient for all ordinary needs1 are insufficient in chlorosis4 ,it seems most probable that iron cures chlorosis by acting as a stimulant to the blood forming organs0 7,beifeld1 ,the ,basis of ,symptoms47 ,clinically1 osteopaths are daily obtaining rationally the necessary stimulus to the blood forming organs by removing all impedance from these organs caused by vertebral and costal lesions and by obtaining better digestive and respiratory hygiene4 ,prognosis4--,recovery is to be expected and its rate will depend upon the thoroughness of the osteopathic work and the patient's ability to respond to the stimulus4 ,the blood may show chlorotic relapses with concomitant symptoms if in later life secondary anemia develops from hemorrhage1 hook-worm infection1 or other causes4 ,pernicious ,anemia ,this anemia is of obscure etiology1 characterized by progressive destructive hemolysis of the erythrocytes1 usually with fatal termination4 ,the cells retain their hemoglobin carrying ability1 so that while the hemoglobin is decreased in percentage1 the proportionately greater decrease in the number of erythrocytes leads to a marked increase in the color index4 ,the destructive influence upon the red cells may be sufficient to allow only a small percentage of the erythrocytes to appear normal and show the greater number to be deformed1 or in various stages of degeneration4 ,cells which in times of health would have been sent to the 8salvage station0 are retained to carry an over-load for them of hemoglobin to the needy tissues4 ,immature nucleated cells of all types are drawn into the battle long before they can be efficient carriers to help supply oxygen to the tissues4 ,seldom will a secondary anemia be severe enough to produce megaloblasts in the blood stream yet they are a rather constant finding in pernicious anemia4 ,with these cells of irregular carrying capacity and development1 anisocytosis and polychromatophilia are expected findings4 ,symptoms4--,the condition must be regarded as a symptom complex or a result of pathologic process or processes4 ,a type of anemia very similar in symptoms and blood findings to the pernicious anemia is produced by the toxins of advanced malignancy1 and by at least two forms of intestinal parasites1 the ankylostoma duodenale and the bothriocephalus latus4 ,in the true pernicious anemia we have similar results but are not able to locate the primary pathology4 ,there are present synchronously1 enormously increased destruction of erythrocytes and enormously increased production of them but we are unable to determine which is primarily at fault4 ,the belief that the cells are more fragile and too easily broken up has led to the removal of the erythrocyte destroying spleen in the hope that destruction would be delayed until regeneration of even imperfect cells would balance the need4 ,occasionally1 the algebraic sum of regeneration and destruction may be apparently balanced and not tell the tremendous amount of pathology both productive and destructive1 that the body is going through4 ,the first symptoms are of easily produced fatigue of all the body1 brain1 muscles1 diminished digestive secretion1 and dyspnea4 ,as a result of poor tissue oxygenation1 fatty degeneration takes place in the more active organs as the heart1 kidneys and liver4 ,there may be extensive degeneration of varying areas of the central nervous system4 ,some of these areas are due to hemorrhages from the general tendency to breaking down of vessel walls4 ,often these areas of destruction affect the posterior horns of the spinal cord1 and1 occasionally1 a blood count differentiates between similar symptoms of pernicious anemia and tabes dorsalis4 ,there is seldom any emaciation2 usually the patient appears 8puffy0 with a 8pasty0 color4 ,there is variable subcutaneous edema4 ,the symptoms being of such wide distribution and character1 the patient is usually treated for all sorts of supposed conditions until some one makes a blood count at a time when there is enough disturbance of equilibrium to give the findings of pernicious anemia4 ,treatment4--,the treatment of the form due to intestinal parasites gives striking results on removal of the causative organisms4 ,some advise treating all cases having these blood findings on the assumption that the presence of these parasites is responsible for the condition4 ,the treatment of the idiopathic form resolves itself into building up the ability of the body to resist disease and the removing of all possible agents for depressing the vitality of the body4 ,rest in bed coupled with the digestible and assimilable limit of nutrition often gives temporary improvement4 ,removal of questionable teeth also often aids for a time4 ,correction of troublesome osteopathic lesions is often accompanied by the same result4 ,the symptomatic osteopathic treatment always makes the patient more comfortable1 often gives temporary improvement1 and1 occasionally1 has given a return to normal that has persisted for several years4 ,prognosis4--,it is nearly always possible to obtain transient improvement1 but the pernicious anemia patient is usually dead within two years from the time the diagnosis is well established4 ,the ,leucemias ,as a result of any inflammatory process1 there is a physiological reaction or stimulus leading to an increase in the number of neutrophilic leucocytes found in the peripheral circulation4 ,as long as this increase does not crowd out other cells1 red and white1 sufficiently to interfere with their ability to function there is nothing but gain to the body of the character of more efficient bacterial destruction4 ,after the need for these cells has passed1 their number is decreased by destruction and the lessening of their production1 until an equilibrium is reached which will be maintained4 ,this same process of making and destroying is constantly going on for all of the different classes of cells found in the blood stream4 ,over-production of any type will lead to actual increase of that sort of cell in circulation1 and1 if unaccompanied by over-production of other types1 will lead to a relative decrease of the other elements4 ,it is very difficult for the body to furnish normal cells very much in excess1 relatively1 of the normal number1 so that when the stimulus leading to immense over-production is at work immature cells in great numbers are apt to be thrown into the blood stream4 ,as an example1 the case of leucocytosis which has a white count of #fj1jjj is extreme and the patient nearing death1 yet it may not show many1 if any1 abnormal types of cells4 ,a case of myelogenous leucemia with a white count of #fj1jjj would not be proportionately sick1 and would be a mild case--yet the greater part of his white blood content would be made up of cells not found in normal blood4 ,the leucocytosis patient is suffering more from the cause of his increase in number of cells1 while usually the leucemia patient suffers because of the increase of cells4 ,in one1 the cause is usually extrinsic1 and1 in the other1 it is intrinsic as far as the blood is concerned4 ,in general1 then1 the symptoms of a leucemia parallel in intensity the increase in cells4 ,it takes energy to make these cells--other tissues are made to suffer from lack of this energy4 ,erythrocytes and white cells cannot occupy the same space at the same time4 ,the increase in white therefore crowds the red cells out of function4 ,disease in relative and absolute content of erythrocytes decreases the oxygen carrying capacity of the blood stream4 ,hence1 metabolism of the whole body suffers4 ,often1 then1 the whole apparent symptomatology of a severe leucemia is that of a secondary anemia4 ,the primary pathology is of hyperplasia of the particular genetic tissue of the type of cells which are in excess1 and is proportionate in amount to the excess developed4 ,splenomedullary ,leucemia 7,,myeloid ,,leucemia2 ,,myelemia7 ,myelemia is a disease characterized by an enormous increase in the white cell content with proportionate changes in the spleen1 liver1 and the blood marrow4 ,etiology4--,it is a disease occurring at all ages1 but the majority of cases are recognized in adult males4 ,heredity1 trauma to the spleen1 malaria1 syphilis1 and rapid repetition of pregnancies seem to be at least exciting factors4 ,a few cases have been reported in which tenth1 eleventh1 and twelfth rib lesions were definite etiologic factors by pressure4 ,diagnosis4--,the patient goes through a period of vague1 indefinite1 and wandering symptoms4 ,general malaise1 weakness often accompanied by dyspnea1 and emaciation similar in many ways to incipient pulmonary tuberculosis1 except that the slight temperature changes are not typical4 ,at the same time there may be digestive discomfort of various kinds without typical pathology4 ,of these early symptoms the most persistent is the dyspnea which is a structural result of the increase in size of the spleen4 ,as a direct pressure result of this hyperplasia1 there may develop dropsical infiltration of the lower extremities and ascitic accumulation in the abdominal cavity4 ,with the changes in the blood itself1 the blood vessel walls break down more easily1 and subcutaneous hemorrhages1 epistaxis and hematemesis are common4 ,in an attempt to destroy the excessive amount of white cells1 the liver may become enlarged4 ,but this occurs later and of much less degree than the enormous increase in size of spleen4 ,there may be areas of hemorrhage with resulting softening in the spinal cord4 ,the most likely areas to suffer are the posterior and lateral horns1 with resulting paraplegia1 spastic or ataxic4 ,usually1 the course is slow1 and the condition is truly chronic4 ,but1 occasionally1 the rapid increase and succession of symptoms1 with concomitant blood changes1 change the diagnosis to acute myelogenous leukemia4 ,the total cell count1 red plus white1 is diminished1 for while there is enormous relative increase of the white cells a greater actual decrease takes place in the reds4 ,this decrease in reds is partially relative from crowding out of erythrocytes by leucocytes1 but there is also actual decrease in their formation1 so that there is an actual anemia present as well as a leukemia4 ,in some respects the red cells behave as in chlorosis1 each carrying a diminished percentage of hemoglobin1 resulting in a low color index4 ,atypical staining reactions and morphology1 together with many fractured forms1 are the rule4 ,normoblasts are common throughout the course of the disease1 but megaloblasts seldom appear until near fatal termination4 ,the changes in the white cells are enormous1 both as to numbers and character of cells found4 ,the total white count often exceeds #cej1jjj4 ,this1 with the accompanying reduction in number of erythrocytes1 leads to a reduction of the ratio between reds and whites to as low as #a to #e or #c1 or occasionally #a to #a4 ,there is an actual increase in number of all the white cells with the possible exception of the lymphocytes4 ,in the actual increase of polymorphonuclear neutrophiles and eosinophiles is rendered a sharp relative decrease by the enormous production of myelocytes4 ,basophiles are usually both relatively and absolutely increased4 ,in a white count of #cej1jjj it is not unusual to have present #cbe1jjj myelocytes1 with #be1jjj as the actual number of ordinary leucocytes4 ,there is1 therefore1 a mild leucocytosis coupled with a violent leukemia4 ,these two are combined with an anemia that varies with the course of the disease4 ,treatment4--,the treatment is largely hygienic1 including thorough osteopathic attention to the lower dorsal and costal area4 ,symptomatic treatment is often followed by temporary improvement both clinically and in the blood picture1 but complete recovery seldom takes place4 ,occasionally1 roentgen therapy has given a 8cure0 lasting several years4 ,prognosis is not good4 ,these patients are frequently carried away quickly by some oftentimes slight intercurrent infection4 ,even if carefully guarded from such1 the course of the process usually leads to death from exhaustion in two or three years4 ,lymphatic ,leucemia ,clinically1 this is a parallel condition to myelogenous leucemia1 except that the hyperplasia of cells occurs in lymphoid tissue1 and leads to an enormous over-production of lymphocytes rather than myelocytes4 ,it is more readily divided into acute and chronic forms than myelogenous leucemia from differences in symptomatology4 ,in the acute form1 adolescents are usually affected1 the condition beginning with tumefaction of the lymph glands1 first noted in the cervical region1 but usually a general involvement4 ,dyspnea results from pressure upon trachea and bronchi by the enlarged glands of the mediastinum4 ,there is pyrexia of #ajc to #aje degrees1 intermittent in character4 ,the pressure upon nerve trunks and plexuses in the thorax leads to variable anginas distributed not only in regions actually imposed upon but over all sorts of possible reflex paths4 ,the blood vessels of the skin are easily broken down so that slight injuries result in great suggillation4 ,the patient rapidly develops anemia1 and later goes into a syndrome similar to the cachexia of malignancy4 ,in fact1 the rapid termination and clinical course of acute lymphatic leukemia is parallel to the action of malignancy4 ,probably the condition will eventually be properly classified as a neoplasm of the blood itself4 ,the chronic form occurs in later life1 and1 instead of being an abrupt rapid process1 is slow1 progressive and painless4 ,it has the lymph gland hyperplasia1 but the enlargement is so gradual that compensation is established to a remarkable degree4 ,it is usually a generalized process1 first noted in the cervical and axillary glands because of their accessibility4 ,usually both the spleen and liver are enlarged1 but this also is a slow and later development4 ,there may be exacerbations of temperature1 but they are not constant or usually severe4 ,hemorrhages into the skin are not common1 but pruritus may be very troublesome4 ,the patient comes to a physician because of symptoms resulting from his secondary anemia1 dyspnea1 dyspepsia1 and palpitation4 ,the diagnosis cannot be made without the aid of a blood study4 ,the blood picture shows a severe anemia with both the number of erythrocytes and the hemoglobin percentage very much lowered4 ,of the two findings1 the hemoglobin percentage is relatively more decreased1 so that the color index is markedly lowered4 ,in the acute form nucleated reds are common4 ,just before death these may show various forms and sizes as well as the normoblasts4 ,in the chronic form normoblasts do not appear except as the case grows decidedly worse4 ,as compared to myelogenous leucemia the anemia of lymphatic leukemia is of greater severity4 ,in the leucocyte count there is great increase in numbers1 the greater part being composed of the lymphocytes4 ,the lymphocytes may be either of the large or small variety1 and occasionally are found in about equal proportions4 ,in contra-distinction to the myelogenous type1 the increased type of cells are of the mononuclear nongranular types4 ,it is not very unusual to find a well advanced case of lymphatic leucemia without abnormal cells in the blood count1 the expression of pathology being in the shape of disturbance in number and proportion of cells rather than in development of abnormal types4 ,the actual number of leucocytes does not go as high in proportion to the gravity of the condition in lymphatic leukemia as it does in the myelogenous4 ,in other words1 a patient with lymphoid leucemia showing a count of #ij1jjj leucocytes with #ij of these lymphocytes is a much sicker man than the myelogenous case showing a #cej1jjj leucocyte count4 ,usually there is an actual as well as relative decrease of all the granular types of leucocytes with the polymorphonuclear neutrophiles especially decreased4 ,the treatment is systemic and symptomatic4 ,recovery is not to be expected1 but these unfortunates can be made relatively comfortable and given occasional respite by judicious osteopathic care4 ,hodgkin's ,disease 7,,lymphadenoma2 ,,pseudo-,,leucemia7 ,in a general way1 the several conditions which are clinically leucemia1 yet do not possess leukemic blood1 can be classified as pseudo-leukemias4 ,we do not definitely know the cause of leucemia as yet and can but little more than speculate on the various etiologic factors of the pseudo-leucemias4 ,syphilis1 malaria1 tuberculosis1 and malignancy are all considered as factors1 and probably certain cases can be definitely associated with these conditions4 ,all of this group of pseudo-leucemias are characterized by early swelling of cervical lymph glands1 followed by general gland enlargement1 and by great destruction of the erythrocytes4 ,there may be metastatic-like growths of lymphoid tissue in other organs4 ,the enlargement of cervical glands usually begins on one side near the angle of the jaw1 and most commonly in young male adults4 ,these glands progressively increase in size1 first are soft1 then later become hard through fibrous proliferation4 ,each gland tends to increase in size by itself1 not to coalesce with its neighbors1 so that each separate gland can be palpated4 ,this is more readily done as there is little tendency to fibrous adhesion formation to the overlying skin4 ,these glands are painless throughout the course of the disease1 and tend neither to caseate nor to suppurate4 ,the excised glands show a combined hyperplasia and connective tissue proliferation4 ,in the soft stage of the tumefaction1 the lymphoid hyperplasia is in preponderance1 while1 at the stage of hardening1 the fibrous tissue derived from the trabeculae and capsule of the gland is in prominence4 ,there is increase in the size of the spleen1 and occasionally of the liver1 but these are never as marked as those resulting from leucemia4 ,the symptoms are1 first1 those due to the glandular enlargement in the order of3 dyspnea1 hydrothorax1 dysphagia1 ascites1 swelling of the extremities1 and jaundice4 ,the destruction of red cells gives a resulting anemia which goes with and exaggerates the pressure symptoms4 ,a process of this kind to induce such grave changes over as well protected organs as make up the lymph system1 must be virulent enough to set up other symptoms1 to be associated with those due to pressure or to anemia4 ,these are usually emaciation 7giving greater prominence to glandular tumefaction71 cachexia1 and the implantation of masses of lymphatic tissue in organs where normally only traces of this tissue exist4 ,fever is dependent upon the disturbed thermic metabolism and may be practically absent or subject to wide variations4 ,the erythrocyte count shows a progressive decrease with a greater proportion of broken down cells and abnormal types as the condition advances4 ,the actual count is usually between #b1jjj1jjj and #c1ejj1jjj per cubic millimeter4 ,the hemoglobin usually reduces in proportion to the erythrocytes1 so that there is little change in color index4 ,the leucocytes are not markedly changed in number 7seldom over #aj1jjj71 and this is often the diagnostic finding between leukemia and the pseudo-leukemias4 ,hodgkin's disease usually has a high percentage of lymphocytes1 so that there is an actual as well as relative decrease of the granular leucocytes4 ,the treatment is unsatisfactory1 and is in the main symptomatic4 ,roentgen therapy has given temporary improvement1 in some cases lasting several years4 ,in general the prognosis is hopeless1 the end occurring within four years of the time the condition is recognized4 ,,diseases ,,of ,,the ,,thyroid ,,gland ,congestion ,physiological congestions of the thyroid gland are not uncommon during puberty1 painful menstruations1 pregnancy1 and the menopause4 ,the premenstrual congestion may persist after the menstrual function has been established1 but this is comparatively rare4 ,when the enlargement remains there is more or less hypertrophy1 and it should receive appropriate treatment4 ,upper dorsal and cervical lesions are common4 ,the congestion during pregnancy occurs in the majority of cases and seems to be a physiological process1 wherein there is more or less hypertrophy and hyperplasia1 which probably counteracts the waste products especially caused by this state1 or due to the inactivity of the ovary4 ,during delivery the gland may rapidly enlarge and remain so for an indefinite time4 ,it seems probable that the straining due to labor may cause lesions of the upper dorsal and neck that will derange the function of the organ4 ,when the enlargement occurs during the menopause special care should be taken that the goiter is not malignant4 ,other possible causes of congestion are overfatigue1 particularly when associated with heavy lifting2 tight clothing about the neck2 overuse of the voice2 and in a few cases it may be discovered in boys at puberty4 ,the symptoms are congestion1 the gland being very vascular1 either soft or tense1 somewhat painful owing to the tension of the capsule1 and in persistent cases there may be hypertrophy and hyperplasia4 ,the treatment is the same as given under simple goiter4 ,inflammation of the ,thyroid ,inflammation of the thyroid is not of frequent occurrence4 ,in the several cases that the authors have seen there was some previous enlargement of the organ1 which probably caused a lowered resistance of the local tissues4 ,there is almost invariably some infection elsewhere in the body4 ,the exciting causes are usually streptococcus1 staphylococcus1 or bacillus coli4 ,the inflammation may follow pneumonia1 tonsillitis1 rheumatism1 typhoid1 puerpal infections1 enteritis1 diphtheria1 influenza1 mumps1 etc4 ,trauma1 carrying weights on the head1 and cold1 may be etiological factors4 ,commonly1 one lobe is involved1 though the entire gland may be affected4 ,there is swelling1 the capsule is distended and painful1 and small hemorrhages occur which in the case of suppuration form the site of the abscess4 ,the swelling involves the parenchyma and interstitial tissue4 ,the onset is usually sudden with chills1 fever1 and pain over the glands4 ,the patient keeps the head flexed to release the muscular tension1 swallowing is painful1 and there is a sense of constriction4 ,a rapid heart may be a prominent symptom4 ,much depends at this period on the treatment given4 ,if the drainage can be freed1 by lowering the first ribs and raising the clavicles with attention to the dorsal and cervical innervation1 prompt subsidence of the condition commonly takes place4 ,this should be carefully accomplished in order not to bruise the parts4 ,diagnosis is not difficult as a rule4 ,the symptoms and history of infection will generally suffice4 ,hemorrhage may occur in a goiter and somewhat simulate inflammation4 ,a possibility of malignancy is to be considered4 ,if the condition does not yield to treatment1 surgical interference may be necessary4 ,tuberculosis and syphilis of the thyroid are rare conditions4 ,woody thyroiditis may be mistaken for malignancy4 ,the gland is very fibrous1 and when cut has a dry surface4 ,the connective tissue is hardened and crowds upon the parenchyma4 ,this condition is usually found in young men4 ,it develops rapidly1 with more or less pain and dyspnea4 ,adenocarcinoma1 carcinoma1 and sarcoma are rare diseases#ajf1 still one should be on his guard as to their possibility4 ,they are most apt to occur after forty4 ,a rapid enlargement should be regarded with suspicion4 ,simple ,goiter ,we employ the term simple goiter to designate chronic enlargement of the thyroid gland not due to inflammation1 exophthalmic goiter1 or malignancy1 although the latter conditions are frequently associated with or follow the former4 ,there is usually an enlargement of the gland in cretinism1 and occasionally in myxedema1 but the functional grade of the gland is far different from that in other diseases of the thyroid4 ,the disease is very prevalent in certain regions of ,europe and ,asia1 although in the ,united ,states it is not so common1 except in the environs of the ,great ,lakes1 the ,district of ,columbia1 and the ,northwest states4 ,the second decade of life1 probably owing to adolescent changes1 especially in girls1 develop the greater number of goiters4 ,it is infrequently congenital1 and occasionally a case will develop as early as four or five years of age4 ,etiology4--,disturbed innervation of the gland unquestionably seems to be the predisposing cause of the deranged secretion and vascular changes1 which if continued finally lead to hypertrophy and hyperplasia of the tissues4 ,these lesions are found from the fifth dorsal to the occiput and to the corresponding ribs4 ,they probably involve secretory fibers of the sympathetic that emerge from the upper dorsals1 first to fifth inclusive1 maximum effect second1 third and fourth4 8,evidence is presented that the impulses pass to outlying neurones whose cell bodies are located close below the superior cervical ganglion and also in the inferior cervical ganglion40#ajg4 ,in both these ganglia impulses to the thyroid pass from preganglionic fibers to the outlying neurones4 ,this also includes the area of vasomotor#ajh innervation of the head and neck4 ,in a number of cases cervical lesions alone will disturb the thyroid innervation1 especially from the second to fourth segments4 ,these may involve the superior cervical sympathetic1 owing to its relationship to the rectus capitis anticus major muscle4 ,then there are afferent association fibers that pass down through the lateral horns and whose connecting fibers emerge via the upper dorsal4 ,the lymphatic drainage of the thyroid should not be neglected4 ,lesions of the upper ribs and clavicles are very prone to impede its circulation1 and thus predispose to secondary infections4 ,infection from septic foci are important secondary factors4 ,this is particularly true of focal infections of the upper respiratory tract and buccal cavity1 although infections and toxins from various regions may be exciting factors4 ,toxemia due to intestinal stasis is not rarely an important consideration4 ,mc,carrison insists that infection from certain waters is the cause of goiter4 ,he finds that boiling the water renders it harmless4 ,pathologically1 the first effect upon the gland is to lessen its iodine content4 ,the circulation is increased1 with hyperplasia of the epithelial tissue1 and a lessened amount of colloid material4 ,if the condition continues1 the alveoli will again become distended with the colloid material so that the epithelial tissue cells are almost flattened4 ,this represents the so-termed colloid goiter4 ,the gland1 commonly the whole organ1 though one side may be involved1 is fairly uniform in size4 ,in rare instances1 the gland may surround the trachea--the so-termed circular goiter4 ,hemorrhages may occur1 and there may be various alterations and degenerations4 ,when the vessels are much dilated1 it is often called a vascular goiter1 though the colloid changes are present4 ,the nodular goiter is another form characterized by new formation of gland tissue that is not diffuse but circumscribed4 ,these cases are apt to follow persistent involvement of the gland at puberty4 ,the two forms may occur together1 and there may be various combinations and changes4 ,in the nodular goiter there is comparatively little colloid4 ,there are many blood-vessels1 and small hemorrhages are frequent4 ,this latter point should be remembered by those who treat over the gland1 which at best is a doubtful procedure4 ,various changes may take place1 as local points of necrosis1 cystic formation1 and calcification1 are not uncommon4 ,symptoms4--,the essential feature in goiter is distension of the alveoli and formation of new ones1 associated with dilated vessels1 and usually degeneration of the colloid4 ,often the function of the gland is not noticeably disturbed4 ,usually1 it is for the pressure symptoms or the unsightliness1 due to the distension1 that the patient seeks relief4 ,pressure upon the windpipe1 gullet1 or blood-vessels is not rare1 and may cause more or less difficulty in breathing or swallowing4 ,coughing and huskiness may be troublesome4 ,the recurrent nerves and vagus may be compressed4 ,disturbance of the heart1 such as palpitation1 tachycardia1 and hypertrophy may be caused by the effect of pressure upon the blood-vessels1 or to changes in the secretory function of the gland4 ,treatment4--,adjustment of the upper dorsal and cervical lesions will be followed by recovery in the majority of cases4 ,dr4 ,still emphasized the point that the vertebral ends of the first ribs are frequently displaced upward and outward4 ,this lesion is often found in cases following confinement4 ,the effect of the change here is probably to the stellate ganglion1 or to the lymphatic drainage of the gland4 ,treatment over the gland should be cautiously given1 if at all4 ,definite correction of the lesioned vertebr and ribs will be sufficient1 but muscular manipulation and halfway measures are practically useless4 ,lesions of the lower spine may be the primary source of a compensatory lesion of the upper dorsal1 or they may derange the pelvic organs1 or be the predisposing factor of intestinal stasis4 ,attention to possible focal infections1 and thorough elimination1 are to be considered4 ,in goitrous regions boiling the water is of value4 ,in obstinate cases the ,x-ray may be of service1 and as a final resort surgery may be employed4 8,marine observed that the amount of iodine is inversely proportional to the degree of hyperplasia of the gland1 and when the hyperplastic condition becomes fully developed1 scarcely a trace of iodine is contained in the gland4 ,later1 when the hyperplasia gives place to colloid goiter1 the iodine increases again1 both absolutely and relatively4 ,moreover1 it has been found that if iodine be administered to an animal suffering from hyperplasia1 the hyperplastic condition very quickly disappears and the animal becomes normal40#aji4 ,his viewpoint of the hyperplasia is that an effort is being made to compensate for an 8insufficiency due to inability to absorb or assimilate sufficient iodine01 and thus the effect of the administered iodine is to normalize the gland by stimulation4 ,no one can question that this may be effective under certain conditions1 particularly where there is deficient iodide in the water1 but it is an essential element of the body4 ,but it does not necessarily follow that because in thyroid disturbance the relationship between thyroid functioning and the substance containing iodine is upset that recovery depends upon furnishing more iodine to the body economy4 ,it may be somewhat parallel to giving iron in anemia1 when often the real difficulty is one of assimilation1 and not insufficient iron in the alimentary canal4 ,moreover1 case after case of goiter has recovered through osteopathic measures following a most thorough trial of the iodine treatment4 ,it is very obvious that the cause of the goiter rested elsewhere4 ,dogs are susceptible to thyroid enlargement4 ,lesioning of the cervical region has resulted in goiter formation1 and recovery has followed adjustment of the lesion4 ,and dogs having goiter without experimental lesions have frequently been normalized by adjusting an abnormal cervical spine4 ,exophthalmic ,goiter ,in exophthalmic goiter there is an excess of the thyroid secretion or thyroid autacoid which passes into the circulation1 due to hypertrophy or hyperplasia of the secreting cells4 ,the disease is characterized clinically by nervousness and irritability1 rapid pulse1 flushed and moist skin1 tremor1 and increased nitrogenous metabolism4 ,a goiter is usually present1 but not always noticeable4 ,there is apt to be protrusion of the eyes1 especially after the disorder is established1 though it may never appear4 ,a disturbed coordination of the muscles of the eyelid1 eyeball1 and orbit are frequent characteristic symptoms4 ,etiology4--,the essential factor in the cause of this disease is probably osteopathic lesions that irritate the secretory fibers of the thyroid tissue4 ,these lesions are almost invariably found in the upper dorsal1 first to fifth1 and most often localized at the second-third or third-fourth segments4 ,they are definite interosseous changes1 combined rotation and lateral flexion1 and are generally very sensitive upon palpation4 ,the constant stimulus thus produced passes through the sympathetic fibers to the cervical ganglia1 and thence to thyroid secreting tissue1 which through vascular changes and hypertrophy and hyperplasia increases the output of the thyroid hormone4 ,the sensitiveness of the lesions is probably of more than passing interest4 ,for this actual tenderness is not to be confused with a neurasthenic state1 which may be associated with the disease1 or even be a source of confusion in the diagnosis4 ,the lesion is of such a distinct character that there is considerable local irritation and congestion4 ,this constant stimulus is a cause of the increased number of impulses carried to the sympathetic1 and results in not only an excess of thyroid secretion and the concomitant hypertrophic changes1 but also in the rapid removal of the colloid into the circulating blood4 ,this seems to be a very important link in the pathologic chain4 ,other underlying lesions may be present1 as outlined under simple goiter1 and do not require repetition here4 ,the mechanism of the thyroid gland may be further upset or deranged by various exciting causes1 such as focal infections1 toxic states1 intestinal stasis1 and occasionally an enlarged thymus is an important factor4 ,an inherited neuropathic tendency1 excessive strain1 worry1 and mental shocks may have more or less influence in either predisposing or exciting the disorder4 ,the particular points for the practitioner to remember are that exophthalmic goiter is due to a toxic state1 of which there are many gradations1 from the excessive secretion of the thyroid gland2 that the normal resistance of the gland is lowered through definite lesions of its innervation or circulatory channels1 or occasionally of lesions of the other organs of internal secretion which are closely associated2 that infections and toxins are often important considerations2 and that direct manipulation of the organ may increase the disorder4 ,pathology4--,the enlargement of the thyroid gland is commonly an early symptom1 occurring before the nervous1 cardiac and exophthalmic manifestations4 ,there are instances where it follows a simple goiter1 although ,graves' disease does not seem to be any more prevalent in regions where simple goiter is endemic than elsewhere4 ,in these particular instances intestinal toxemia is often present4 ,there are cases where the gland is very slightly enlarged1 containing only small areas of hyperplasia4 ,there is usually very little colloid1 though there may be marked exceptions4 ,it should be emphasized that there are various degrees of changes found in the gland though fundamentally of the same order4 ,the blood supply is extensive1 and the veins especially are fragile4 ,the alveoli are distorted1 due to the increase of epithelial cells4 ,lymphoid nodules are frequently noted through the glandular tissue4 ,research work of unusual interest to the osteopathic physician pertaining to the etiology and pathology of exophthalmic goiter has been carried out at the ,mayo ,clinic4 ,an examination of cervical sympathetic ganglia removed at operation from such cases and certain animal experimentation has given definite results4 ,the following is a summary of their principal findings3 8,degree of hyperpigmentation1 granular degeneration1 and reduction in the number of cells was in direct ratio to the continuance of symptoms of hyperthyroidism4 ,the increased amount of perivascular connective tissue generally throughout the gland was similarly in direct ratio to the time during which symptoms of hyperthyroidism had continued4 8,increase of connective tissue in the ganglia from the chronic cases may be interpreted as due to the irritation from inflammation1 or as merely a replacement following the destruction of the ganglionic nerve cells4 8,ganglia were intimately connected by firm adhesions to the surrounding tissue4 8,there were changes in the outer and middle coats of vessels1 and in the nerve fibers4 ,there was an increase of connective tissue throughout the ganglion4 8,it appears that definite histologic changes do occur as 7a7 hyper-chromatization1 7b7 hyperpigmentation1 7c7 chromatolysis1 and 7d7 atrophy1 or 7e7 granular degeneration of the nerve cells4 ,all of these are but successive steps in degeneration which1 if uninterrupted1 proceed to complete destruction of the ganglion cells affected4 ,not all of the ganglion cells in any of the ganglia examined were so completely destroyed as to render improbable their return to normal under favorable conditions4 ,there is some evidence that in ganglia from cases clinically improved some of the cells have partially or wholly recovered40#aaj ,they are inclined to the view that local infection in the cervical sympathetic ganglia plays an important part in the etiology4 ,the above pathologic changes of nerve fibers and ganglia support in many ways the findings noted at the ,a4 ,t4 ,still ,research ,institute1 not alone in the cervical region but in other regions of the body1 that is1 they are changes common to interosseous lesion pathology of various areas of the spine1 and thus are predisposing factors that establish lowered resistance of tissue and derangement of function4 ,an important feature of the pathology is hyperplasia of the thymus4 ,simmonds finds it enlarged in three out of four cases4 ,mac,callum#aaa has found it enlarged in all autopsies that he has seen4 ,the lymphoid structures of the spleen1 liver1 kidneys1 intestines1 and bone marrow is increased1 while the lymphatic glands of various regions of the body may be enlarged1 especially the cervical1 bronchial1 and axillary4 ,this is probably due to a toxic condition4 ,dilatation and hypertrophy of the heart is common1 and in advanced cases myocardial degeneration is apt to take place4 ,symptoms4--,the outstanding feature of hyperthyroidism is the excessive secretion of the gland4 ,the symptoms seem to be largely dependent upon the amount thrown into the blood stream2 still there is a possibility that there may be a certain perversion of the secretion1 though if such exists it has not been discovered4 ,it should be kept in view that in certain instances where the secreting activity of the gland has been markedly curtailed1 by surgical means1 for instance1 even to hypo-functioning there may still exist some of the symptoms of exophthalmic goiter1 which goes to show that other factors may be of decided importance4 ,the thymus and other related organs1 as well as the sympathetic nerves1 are not to be neglected4 ,kendall and ,plummer 7,mayo ,clinic7 8believe that the location of the active constituent of the thyroid1 when it functions1 is within the cells not of any particular set of organs or portion of the body1 but that it is a constituent of cellular life and activity4 ,plummer states that the active constituent of the thyroid determines the rate at which any particular cell can produce energy1 that is1 it establishes the quantum energy which any cell can produce when it is stimulated1 either from within itself or from without1 so that the thyroid is directly related to the production of energy within the body4 ,he has shown that one-third of one milligram of the active constituent of the thyroid increases the basal metabolic rate one per cent in an adult weighing approximately #aej pounds40 ,this shows how important the secretion is not only to all related glands but to every cell of the body1 and assists in establishing a physiological basis in the correlation of the symptoms of both hyper- and hypo-functioning of the organ4 ,as a rule the thyroid is not greatly enlarged4 ,the size1 shape1 and consistency varies4 ,it may follow a simple goiter4 ,many of them are soft and yielding1 or cystic2 others are hard1 of a fibrous resistance1 or nodular4 ,probably in the instances where hypertrophy is not discoverable there is hyperplastic tissue scattered through the gland4 ,or it is possible there may be an intrathoracic thyroid1 or accessory tissue in other regions1 varying from the root of the tongue to the aortic arch1 which has become diseased4 ,generally1 both lobes are enlarged1 though the derangement may be confined to a portion4 ,often there is pulsation and a thrill over the gland4 ,systolic murmurs are frequent4 ,in the early stage of goiter1 tenderness is noticeable due to the distension of the capsule4 ,the eye symptoms are3 widened palpebral fissure or ,dalrymple's sign2 failure of the upper lid to follow the downward movement of the eyeball or ,v4 ,graefe's sign2 insufficiency of convergence of the two eyes or ,moebius' sign2 exophthalmos1 which may be unilateral 7in about seventy five percent of the cases72 and rareness of involuntary winking1 are the principal eye signs4 ,rapid heart action is an early and important symptom4 ,this is given by all observers as the most constant of all symptoms4 ,palpitation is often disturbing4 ,the pulse is forcible1 especially in the vessels of the neck4 ,there is generally a low blood pressure4 ,the heart is apt to be dilated1 and in chronic cases hypertrophy and degeneration are often found4 ,a fine tremor1 eight to ten times a second1 is an important symptom4 ,this is usually present and is considered one of the cardinal diagnostic points4 ,profuse sweating1 emaciation1 muscular weakness1 especially of the legs1 vomiting1 diarrhea1 a feeling of dyspnea1 and polyuria are frequent symptoms4 ,anxiety1 apprehension1 headache1 irritability1 and fatigue are often early symptoms1 but care should be taken that they are not entirely dependent upon a neurasthenic state4 ,pruritus may be a distressing symptom4 ,there may be abnormal pigmentation4 ,menstrual derangements are common1 especially amenorrhea1 owing to the anemia4 ,and there may be various sexual disturbances4 ,exophthalmic goiter occurs oftener in women than in men4 ,the disease is commonly a chronic one lasting several years1 unless the morbid cycle can be broken2 still there are cases where it appears very suddenly and runs a rapid course4 ,mc,carrison#aab says3 8,our consideration of the morbid changes met with in ,graves' disease will have brought into prominence the fact that they are indicative of toxic action4 ,the lymphocytosis1 the lymphatic hyperplasia1 the lymphocytic infiltration of the thyroid1 the liver and other organs2 the chronic toxic inflammatory changes in the thyroid1 liver and pancreas2 the changes in the muscles1 in the nervous system and in the adrenals2 all these point to a condition of chronic irritation as the underlying factor in their production1 and to the gastro-intestinal tract as the most common source of the toxic irritant40 ,diagnosis4--,the diagnosis as a rule is not difficult4 ,difficulty may arise where there is incomplete development of the disorder4 ,irritation of the sympathetic nerves is of the greatest significance1 for the characteristic symptoms are dependent upon this condition4 ,neurasthenia1 hysteria1 paralysis agitans1 and tobacco poisoning and alcoholism may mislead one4 ,the enlarged and active gland1 with murmur in the majority of cases1 loss of weight1 excessive sweating1 diarrhea1 tremor1 and tachycardia1 even without the eye symptoms1 are specially significant4 ,the tenderness of the osteopathic lesions is very often noticeable4 ,prognosis4--,a great deal depends upon the cooperation of the patient4 ,rest and diet are such important features of the treatment1 that if the patient is not willing to follow instructions1 great difficulty will be encountered in securing satisfactory results4 ,adjustment of the lesions and elimination of toxins are highly essential1 but only in a certain number of cases will this suffice4 ,this1 however1 will usually lessen the severity of the condition1 and the patient gets along fairly well1 but this may be far from securing the possible maximum results4 ,the duration of the disease is often from five to twenty years1 or even longer4 ,and the patient frequently dies from some intercurrent disease1 particularly pneumonia and tuberculosis4 ,weakness of the heart is the most important cause of death4 ,severe vomiting and diarrhea may so exhaust the patient that a fatal termination takes place4 ,surgical interference should not be too long delayed if there is no indication of improvement by other means4 ,treatment4--,every case requires individual study1 owing to the many possible exciting causes1 especially those where infections and toxins play so important a role4 ,the four cardinal features of treatment are3 adjustment of the osteopathic lesions1 rest1 diet1 and elimination of infectious and metabolic poisons4 ,specific adjustment of the upper dorsal spine is primarily essential4 ,the work should be definitely and quickly accomplished4 ,soft tissue manipulations amount to but little except as a preparation for the interosseous adjustment4 ,do not tire the patient4 ,often1 following exact adjustment a definite lessening of the severe symptoms will be noticed4 ,the activity of the thyroid will be appreciably decreased2 the heart's action slowed2 the eye symptoms less noticeable2 the tremor lessened2 and the strength of the patient improved4 ,do not treat too often4 ,once a week is far better than every day4 ,but usually twice a week in the majority of cases will secure the best results4 ,then later once in two weeks will be the best course to pursue4 ,the tissues are irritable1 and require time to establish a physiological balance1 that if kept constantly excited by too frequent or too severe manipulation will increase rather than lessen the condition4 ,this1 however1 does not apply to those cases where a certain amount of general treatment is demanded to improve systemic tone and overcome intestinal stasis1 but even here do not unduly tire the patient1 and keep away from the thyroid innervation except at stated intervals4 ,there is nothing more important in osteopathic therapy1 except definite adjustment1 than not over-treating4 ,the cervical region should be normalized1 and the upper ribs and clavicles carefully adjusted4 ,but leave the gland alone1 for manipulation over it further stimulates its function and there is a possibility of rupturing its fragile vessels4 ,normalization of the entire spine is important1 owing to its bearing upon interdependent relationship1 mechanically and physiologically1 and the necessity of correcting all metabolic irregularities4 ,both physical and mental rest are essential4 ,this tends to lessen the excitability of the nerves1 conserves the strength1 increases the metabolism1 improves muscle tone1 and rests the heart4 ,at least several extra hours in bed is always best4 ,lying down two or three hours during the middle of the day will accomplish considerable4 ,in severe cases absolute rest in bed until the disorder is under control is imperative4 ,in mild and moderate cases all excessive fatigue should be avoided4 ,unless such measures are followed the treatment otherwise may not accomplish anything4 ,stopping short of fatigue is the rule that must be followed4 ,the diet is important in order that the strength may be increased and harmful foods eliminated4 ,if the carbohydrates in the small intestine are not sufficient1 they may decompose into toxic substances that are harmful when absorbed into the circulation4 ,an abundance of green vegetables and fresh fruit is best4 ,milk1 fermented milk1 butter milk1 butter and cream are allowable4 ,the patient should drink freely of water4 ,meat should be used sparingly1 and avoid tea1 coffee1 and condiments4 ,free elimination and fresh air are also important4 ,it is the aggregate of details that counts so much1 particularly in such a toxic and excitable disease as exophthalmic goiter4 ,the neutral bath 7#ie to #if degrees7 is better than either hot or cold baths4 ,in such a nervous disease as this1 suggestion is unquestionably a valuable measure in quieting the nerves and improving the mental viewpoint4 ,all focal infections1 such as often found in the throat1 nose1 and buccal cavity1 in the appendix region1 gall-bladder1 etc41 should be eradicated4 ,if under carefully controlled treatment the patient does not definitely respond within from two weeks to a month1 surgical measures should be seriously considered4 ,myxedema ,myxedema is a chronic disease due to loss of thyroid function1 and characterized by markedly decreased metabolism1 trophic disturbances of the skin and subcutaneous tissues1 and a cessation of mental development corresponding to the time of the injury of the thyroid4 ,mc,carrison restricts the term 8cretinism0 to those cases where there is congenital thyroid deficiency4 8,after the first year of life1 when ossification has proceeded to the extent of closure of the fontanelles1 the case is only distinguishable from one of cretinism by this fact40 ,in the child1 all the functions are depressed1 there is a low temperature1 the bones do not develop1 and the child may become stout4 ,the mental development is retarded1 and also the sex organs4 ,in the adult cases there is the same depressed metabolism4 ,the skin is sallow1 dry1 and increased in thickness4 ,the tongue is enlarged1 the lips thick1 and the feet and hands considerably changed in size4 ,the nails may be thickened1 and the hair falls out4 ,the abdomen is apt to be pendulous4 ,heavy pads occur below the clavicles and on the chest1 neck1 abdomen1 and sexual organs4 ,usually the thyroid cannot be palpated4 ,in a few1 the gland may be goitrous4 ,the mental faculties are sluggish4 ,the speech is slow1 and the voice more or less changed4 ,physical exertion is an effort1 and the patient may have some difficulty in walking4 ,and there is anemia1 loss of appetite1 and poor digestion4 ,the number and character of symptoms are innumerable1 depending upon the extent of thyroid insufficiency1 and often upon predisposing and associated disorders4 ,but the essential symptoms are those pertaining to the skin1 and the mental apathy4 ,in children the retarded physical and mental growth is the outstanding condition4 ,development of the disorder is slow4 ,etiology4--,lesions of the thyroid innervation may cause a lessened function of the gland1 for correction of the lesions has been followed by markedly definite improvement in a number of cases4 ,the disorder has followed operation on the gland4 ,in other cases some form of infection1 primary or secondary1 is probably the cause of the injury and subsequent atrophy4 ,in some instances there is evidently a family tendency4 ,it occurs more frequently in women1 and in cold than in hot climates4 ,the menopause seems to be a predisposing factor4 ,overwork1 anxiety1 poor nutrition1 and conditions that lower tissue resistance1 are among the etiological considerations4 ,in well marked cases the diagnosis is easy4 ,in others the disease may be mistaken for nephritis or jaundice4 ,x-ray examination of the ossification centers is of decided value4 ,the prognosis1 in untreated cases1 is considered hopeless1 the duration being from four to seven years4 ,the treatment with thyroid extract1 or alpha-iodine1 has resulted in marked improvement1 though in severe cases it must be kept up continuously in order to supply the deficiency4 ,treatment4--,there have been several well marked cases that have responded to the osteopathic treatment4 ,adjustment of the lesions affecting the gland1 and attention to the general health have been the methods administered4 ,the response in a number of children has been most notable4 ,in fact1 to such an extent that all faculties and functions were completely recovered4 ,even in cases where thyroid extract had been administered with comparatively little results1 the adjustment of the upper dorsal and cervical lesions1 with attention to the diet1 elimination1 and general hygiene1 was followed by normalization4 ,that the thyroid function when deranged1 hyperthyroidism1 hypothyroidism1 or otherwise1 can often be recovered through osteopathic treatment1 adds a very important therapeutic measure in the treatment of this gland4 ,but in view of the brilliant results secured in hypothyroidism1 through the administration of the thyroid extract1 one should not hesitate to use it if improvement is not otherwise forthcoming4 ,nevertheless1 the very important point remains that thyroid extract is only supplying a necessary substance1 however essential1 to the bodily metabolism1 and does not strike at the essential etiology of the disorder4 ,cretinism ,it should be kept in mind that there are many gradations and alterations in both hyperthyroidism and hypothyroidism1 and that a 8goiter0 may present either picture1 partly or wholly1 or on the other hand may be normally functioning4 ,mac,callum says3 8,unlike the myxedema cases which occur anywhere and everywhere1 regardless of environment or hereditary taint1 these people1 known as cretins1 are found in regions where the condition seems to be endemic or inherent in the environment1 and we can usually trace in their parents or ancestors some similar thyroid defect40 ,this disease is found in various countries1 particularly in certain parts of ,switzerland1 ,austria1 and ,italy4 ,mc,carrison presents an interesting study of #bjc cases of ,endemic ,cretinism found in ,himalayan ,india4 ,he thinks it is due to infection4 ,there are a few cases in ,north ,america1 probably mostly due to immigration4 ,it is frequently confused with myxedema4 ,cretins are of short stature1 flat-chested and pot-bellied4 ,the face is broad1 low forehead1 broad nose1 prominent cheeks1 thick lips1 and large nose4 ,the development of the bones is retarded2 the skin is thickened and edematous2 the hair is thin1 and the nails brittle2 the sexual organs as a rule do not develop2 and in most cases a goiter1 sometimes of huge size1 is present4 ,most of them are stupid and apathetic2 others are distinct idiots4 ,deafness is common4 ,there are sporadic and endemic cases1 but the same underlying cause is probably present4 ,it is claimed that most cases of the former should be classed as congenital myxedema4 ,early diagnosis is essential4 ,removal of the patient from the goiter region1 and thyroid substance is the treatment given1 though results are not so marked as in myxedema4 ,,footnotes3 #ajf ,ewing1 ,neoplastic ,diseases2 ,grotti1 ,thyroid and ,thymus4 #ajg ,cannon and ,cattell1 ,the ,secretory ennervation of the ,thyroid ,gland1 ,am4 ,journal of ,physiology1 ,july1 #aiaf4 #ajh ,gaskell1 ,involuntary ,nervous ,system4 #aji ,macleod1 ,physiology and ,biochemistry in ,modern ,medicine4 #aaj ,collected ,papers of the ,mayo ,clinic1 #aiaf1 '#ag1 '#ah4 #aaa ,mac,callum1 ,a ,text ,book of ,pathology4 #aab ,mc,carrison1 ,the ,thyroid ,gland4 ,,diseases ,,of ,,the ,,parathyroid ,,glands ,tetany ,the clinical manifestations of the insufficiency of function of the parathyroid glands is well understood4 ,this came about through the study of endemic tetany1 and1 especially1 noting that tetany followed operations when the entire thyroid gland was removed4 ,considerable experimental work on animals was next in order1 until the discovery was made that the thyroid gland and parathyroids are anatomically independent1 and that tetany is entirely dependent upon the loss of function of the parathyroid glands4 ,operative tetany is now comparatively rare1 since the surgeon is particularly careful not to injure the parathyroids in his operations on goiters1 though mild forms may occur through damage of the tissues or extension of inflammatory processes4 ,there are other forms of tetany aside from operative1 that occur in both adults and children1 but instability and insufficiency of the function of the glands are basic to all cases4 ,this is the common factor1 which may be modified by tissue resistance and various hygienic factors4 ,in tetany there are paroxysmal1 and often painful1 contractions of the muscles of the extremities4 ,both sides are affected1 and occasionally the spasms may extend to other muscles of the body4 ,this is due to an abnormal excitability of the nervous system4 ,probably the secretion of the parathyroids have normally a restraining effect upon the nervous impulses1 which when removed1 or insufficient1 or possibly perverted1 results in the tonic spasms4 ,thus the predisposing condition of tetany may be either acquired or congenital4 ,children may be born with defective parathyroids4 ,in such instances there is probably a hypoplasia of tissue1 which may markedly vary in a series of cases1 and give rise to different degrees of tetany4 ,other factors1 nutritional and toxic1 would1 very likely1 be important exciting causes4 ,hemorrhages and fibrosis have been noted in some cases1 that add to the injury of the tissues4 ,the blood and nerve tissues in tetany show a decreased amount of calcium4 ,it is claimed by some that the abnormal excitability of the nervous system is due to the lack of calcium4 ,noel ,paton#aac believes that1 though this may bear some relationship1 the parathyroids control the metabolism of guanidine1 and that guanidine intoxication is the cause of the symptoms4 ,guanidine seems to regulate the tone of the skeletal muscles1 and is closely related to urea4 ,tetany may occur under many conditions3 during pregnancy and nursing1 the infectious and nutritional diseases1 the diseases of the thyroid and very often gastro-intestinal disorders4 ,there are various exciting causes1 such as cold1 worry1 overfatigue1 etc4 ,alcohol1 ergot1 morphine1 chloroform1 and other poisoning may precipitate an attack4 ,but in all these cases the parathyroids are previously damaged4 ,the blood supply to the glands is from branches supplying the thyroid organ4 ,this intimacy implies that the same sympathetic nerves to the thyroid vessels are in control4 ,probably there are distinct secretory nerves1 as well as vasomotors1 that are connected with the upper dorsal and cervical sympathetics4 ,lesions related to the corresponding spinal areas probably affect the integrity of the parathyroid function4 ,schafer says3 8,the parathyroids are amongst the most vascular organs in the body4 ,they are supplied each by a special branch of the inferior thyroid artery4 ,the sinus-like capillaries come into close relationship with the epithelial cells of the gland4 ,the nerves of the parathyroids1 like those of the thyroids1 pass both to the vessels and to the secreting cells4 ,some evidence has been adduced which seems to show that the cell-activity is controlled by the nervous system40 ,hence it would seem that in many cases of tetany1 aside from those cases due to operative injury and possibly certain congenital instances1 osteopathic lesions affecting the nerve and vascular supply of the organs may so lessen1 or pervert1 the secreting cells that tetanic states may supervene1 especially where lowered nutrition1 toxins1 and infections are inciting factors4 ,symptoms4--,the tonic contraction of the muscles may last a few minutes or may persist for several hours1 and are usually confined to the hands and feet4 ,the fingers and toes are first affected by the spasm1 which extends upward toward elbows and knees4 ,this is commonly preceded by numbness and more or less pain in the parts4 ,occasionally there is a general ill-feeling1 depression1 and headache4 ,there may be rise of temperature1 and some edema of the affected parts4 ,there are no mental symptoms4 ,the fingers are partly flexed at the metacarpo-phalangeal joints and rigidly extended at the inter-phalangeal joints1 the thumb is markedly adducted and the fingers drawn close together4 ,the wrist may be flexed1 and in severe cases the elbows flexed and adducted4 ,when the feet are contracted the toes are drawn together1 flexed1 and may overlap1 and the feet are arched4 ,trousseau's phenomenon4--,the spasm is increased by pressure over the median or ulnar nerves1 or blood-vessels supplying the parts4 ,this may also excite an attack4 ,chvostek's phenomenon4--,percussion over the facial nerve will cause quick contraction of the muscles innervated4 ,erb's phenomenon4--,the electrical excitability of the motor nerves is markedly increased4 ,diagnosis4--,the characteristic attitude1 and the irritability of the motor and sensory nerves1 make diagnosis easy4 ,it may be confused with meningitis1 but in tetany there are no brain symptoms1 while in meningitis there are no characteristic signs of tetany4 ,generally1 there is little probability of confusing the disease with tetanus1 or hysteria4 ,treatment4--,most cases are of a mild type1 and recovery is the rule4 ,a great deal depends upon the underlying cause4 ,malnutrition1 if long continued1 is a very important factor that may readily predispose to the disorder4 ,rickets in children is often a basic consideration4 ,rest1 warm baths1 and careful inhibitory relaxation of the tissues materially assist in controlling the spasms4 ,attention to the thyroid innervation should not be neglected4 ,in indicated cases thyroid feeding may be of assistance4 ,the diet is of special importance1 for many cases present some disorder of the gastro-intestinal tract4 ,meat should not be given4 ,milk is of great value1 owing to its calcium content4 ,the administration of calcium is highly recommended1 for reasons stated under etiology4 ,diseases of the ,thymus ,there is little known relative to the functions of the thymus4 ,it is most active during the growth of the body1 attaining its greatest weight from the eleventh to fifteenth years1 after which it gradually atrophies1 though a certain amount of the tissue remains throughout life4 ,there is usually a gradual atrophy of the organ after puberty1 associated with increase of connective and adipose tissues4 ,in cases where it does not atrophy1 there is often hyperplasia of the entire lymphatic system in the body4 ,there is some relationship between the thymus and sexual organs1 and in experiments where the organ has been removed1 ossification is delayed1 muscular weakness and tremor occur1 there is hyperplasia of the thyroid1 parathyroids1 and adrenals1 and general cachexia1 acidosis1 and mental deterioration take place4 ,the inferior thyroid and internal mammary arteries from above1 and the pericardiophrenic from below1 comprise its arterial supply4 ,the nerve supply is from the sympathetic1 vagus1 and possibly the phrenic4 ,in cases of exophthalmic goiter there is frequently an associated enlargement of the thymus1 which may be shown by the ,x-ray1 due to failure of normal involution or a renewal of growth1 that may be definitely influenced by adjustment of the osteopathic lesions4 ,in some of the acute infections as pneumonia the thymus may atrophy with some fatty degeneration and increase of connective tissue4 ,this also occurs in starvation4 ,if the condition is not of long standing recovery will take place4 ,in status lymphaticus there is hyperplasia of the thymus and enlargement of the lymphoid tissue of the body1 and hypoplasia of the cardiovascular system4 ,this is a constitutional defect1 so that slight injuries or infections may prove fatal4 ,it is found in some cases that there is hypoplasia of the chromaffin system4 ,whether this latter condition is primary or secondary has not been settled4 ,in males the secondary sexual characteristics are not fully developed4 ,the figure resembles the feminine type4 ,the skin is pasty1 and the beard is lacking or but little developed4 ,in females the distribution of the hair may be somewhat similar to the male sex1 slender limbs and chest1 and disturbances of the menstrual function are noticeable4 ,the thyroid1 thymus and lymphatic tissues are usually enlarged1 while there is hypoplasia of the adrenals and chromaffin system4 ,the condition is met with in children who have a weak muscular system1 increased adipose tissue1 pasty complexion1 enlarged tonsils and adenoids1 and frequently are anemic4 ,in children where the thymus is enlarged there may be excessive lymphocytosis4 ,the enlarged thymus may compress the trachea1 interfering with breathing so that cyanosis and temporary loss of consciousness occur4 ,young children may die in the attack1 probably due to compression of the trachea or to heart shock4 ,death in adults has occurred from trifling injuries1 shocks1 infections1 and anesthesia4 ,the underlying cause is probably a constitutional weakness4 ,diagnosis is made from the clinical signs1 percussion of the thymus and the ,x-ray picture1 although these may not be positive4 ,an excessive lymphocytosis is suggestive4 ,treatment should consist of good general care of the patient1 avoidance of injuries and shocks as far as possible1 and careful attention to all lesions1 especially of the upper chest and neck4 ,by following this plan the child may overcome the condition4 ,x-ray treatment is being employed with success in some cases4 ,operations have been successful in thymic hyperplasia where it has complicated exophthalmic goiter1 and also in serious mechanical pressure in children4 ,diseases of the ,adrenal ,glands ,experimental work supports the view that the cortex and the medulla have separate functions4 ,the medulla of the adrenals is part of the chromaffin system1 which includes tissue of the same character in the ganglia of the sympathetic1 the carotid gland1 and the accessory gland called ,zuckerkand's organ4 ,this system is derived from the same cells as the sympathetic nerves4 ,the medulla receives a richer blood supply than any tissue in the body4 ,the secretion of the chromaffin tissue is called adrenalin or epinephrin4 ,the blood receives a continuous supply of the secretion1 which acts upon the small blood-vessels and assists in maintaining blood pressure4 ,it also stimulates glandular tissue1 and has some effect upon voluntary muscle which tends to counteract fatigue4 ,the cortex of the adrenal glands is of epithelial origin1 and is part of the so-called interrenal system1 which comprises very small masses of tissue in the sympathetic ganglia4 ,these are located in the hilus of the kidney1 broad ligament1 inguinal canal1 prostate1 epididymis1 and along the spermatic veins 7,baker74 ,the cortex is the chief glandular tissue of the interrenal system4 ,the amount of tissue is not so great after puberty as before4 ,the blood supply of the cortex is not so rich as that of the medulla4 ,abnormal activity is claimed to be the cause of certain sexual derangements1 particularly sexual precocity4 ,schafer states that the adrenals are very richly supplied with nerves4 ,each receives no less than thirty-three nervous filaments 7,kolliker71 derived in part directly from the splanchnic1 in part from the suprarenal plexus1 which is itself constituted by branches from the celiac1 phrenic1 and renal plexuses4 ,we have noted that in lesions 7experimental7 of the splanchnics a few cases presented acute pathological changes1 congestion with some degeneration of cells1 in the adrenals4 ,macleod states that of the many functions of the adrenals that which is most directly associated with epinephrin is the production of glucose from glycogen4 8,when the nervous system is stimulated in such a way as to excite the glycogenolytic process1 two effects both operating in the same direction with regard to the glycogenic function are developed3 the one1 a hypersecretion of epinephrin1 which activates the sympathetic nerve endings1 the other1 the transmission of the nerve impulse to the liver cell40 ,addison's ,disease ,this is a rare1 chronic disease1 more often occurring in men1 that is characterized by muscular and vascular weakness1 digestive disturbances1 and pigmentation4 ,tuberculosis of the adrenals has been the most constant lesion found4 ,in others1 syphilis and atrophy have been noted1 while in a few the condition seemed to be functional4 ,it should be remembered that it is possible that lesions elsewhere in the chromaffin system may be the cause in some cases1 for all the chromaffin tissues secrete adrenalin4 ,it is quite likely that in most cases there is some constitutional defect of the chromaffin system which underlies a certain tendency to the disorder4 ,infections1 injuries1 physical and mental strains may lower resistance and predispose to the condition4 ,osteopathic lesions of the splanchnics may congest the organs1 or derange the secretions1 or be of such a character that hemorrhages result1 or fibrous changes follow1 that would definitely incapacitate the cells and lower resistance4 ,pathologically1 the most common change is tuberculosis4 ,next in importance are atrophy and interstitial inflammation4 ,cancer of the organs has been noted in a few4 ,the adrenal ganglia1 the semilunar ganglia1 and the solar plexus are often involved4 ,the thyroid gland may be altered1 which1 when affected1 is usually decreased in size4 ,brown atrophy of the heart is common4 ,symptoms4--,an insidious onset with muscular weakness1 languor1 and weak action of the heart are generally the first symptoms4 ,digestive derangements1 such as nausea1 hyperacidity1 loss of appetite1 may occur at the same time1 or shortly succeed the general debility4 ,headache1 insomnia1 and depression frequently take place4 ,pigmentation1 usually1 shortly follows1 though there are cases where it is only slightly noted4 ,the disease is very chronic1 of several years duration1 with periods of intermission4 ,occasionally1 a case runs a very rapid course4 ,the general weakness is most noticeable4 ,there is low blood pressure4 ,the derangement of the stomach and intestines is characteristic4 ,and the pigmentation1 which at first is light yellow later assumes a dark brown color4 ,the pigmentation may be more or less general1 but the axill1 nipples1 genitals1 the palms of the hands1 and the neck1 waist or wherever the clothing presses upon the skin1 are most pigmented4 ,and pigmentation of the mucous membrane may be noted4 ,diagnosis4--,in typical cases1 where there is esthenia1 pigmentation1 and gastro-intestinal disturbances1 the diagnosis is not difficult4 ,where the clinical picture is incomplete1 the diagnosis may be very difficult4 ,pigmentation may occur in several other disorders1 notably3 in bronzed diabetes1 abdominal malignancy1 tuberculosis of the peritoneum1 exophthalmic goiter1 pellagra1 marked intestinal stasis1 stomach ulcer1 pernicious anemia1 certain skin diseases1 etc41 so great care has to be taken in atypical cases4 ,treatment4--,general treatment1 with special attention to the adrenal innervation1 diet1 rest1 and fresh air will accomplish something4 ,in functional derangements1 which are very few1 recovery may follow4 ,but owing to the often constitutional defect1 the probability of tubercular1 syphilitic1 and other serious lesions1 the prognosis is unfavorable4 ,,footnotes3 #aac ,paton and ,finlay1 ,jour4 ,exp4 ,phys41 #aiag4 ,,diseases ,,of ,,the ,,nervous ,,system ,,diseases ,,of ,,the ,,nerves ,neuritis ,neuritis is an inflammation of the nerve fibers4 ,it may be confined to a single nerve1 localized2 or general1 involving a large number of nerves1 when it is known as multiple neuritis4 ,osteopathically1 there are invariably lesions of the osseous or muscular tissues1 that correspond to the nerve fibers involved4 ,the lesion either irritates the nerve directly or disturbs the circulation to the nerve4 ,in those cases where the osteopathic lesion is not the immediate exciting cause1 there will be found anatomical irregularities that predispose to the affection4 ,localized neuritis may be due to3 ,local osteopathic lesions2 ,exposure to cold2 septic foci2 traumatism2 and inflammation of contiguous tissues4 ,multiple ,neuritis may be due to3 ,osteopathic lesions1 which are associated with infectious diseases1 as in diphtheria1 typhoid1 scarlet fever1 etc42 prolonged strain or exposure2 metabolic poisons1 as in diabetes1 anemia1 tuberculosis1 cancer1 etc42 alcohol1 lead1 mercury and arsenic poisoning2 and beri-beri1 which is probably due to lack of vitamins1 or possibly micro-organisms1 or carbonic gas poisoning4 ,the inflammation may chiefly involve the connective tissue surrounding the nerve--perineuritis--or it may involve the deeper structure--interstitial neuritis4 ,parenchymatous neuritis is really a degeneration1 due to excessive or prolonged irritation or pressure which cuts the nerves off from their centers4 ,this is found in deeply seated osteopathic lesions4 ,in experimental osteopathic lesions the first effect is degeneration of the medullary sheath4 ,this is followed by degeneration of the axis cylinder4 ,the local circulation is notably impaired4 ,an acutely inflamed nerve is red and swollen4 ,in perineuritis there is an infiltration of the nerve sheath with leucocytes4 ,in the interstitial form1 lymphoid cells are found between the nerve bundles4 ,in the parenchymatous form1 inflammatory signs are wanting4 ,the muscles atrophy4 ,associated in all these forms the osteopathic lesion plays either an exciting or predisposing role1 by disturbing nutrition to the tissue and thus setting up inflammation1 which may lead to ,wallerian degeneration#aad4 ,symptoms4--,localized ,neuritis4--,in the case of a sensory nerve1 there is severe pain following the course of the affected nerve1 with tenderness upon pressure4 ,this may be followed by loss of sensibility4 ,trophic symptoms1 such as glossiness of the skin and brittle nails1 arise in more chronic cases1 while in advanced cases1 there is wasting of the muscles4 ,sweating1 herpes1 and occasionally effusion into the joints1 occur4 ,when a motor nerve is principally affected1 muscular power is impaired1 motion painful and muscular twitchings will occur4 ,finally contractions1 wasting of the muscles1 and even reactions of degeneration1 may take place4 ,a rare form is the so-called ascending neuritis1 in which the inflammation extends upward from the peripheral nerves to the larger nerve trunks1 or even the spinal cord1 resulting in myelitis4 ,this occurs most commonly in traumatic neuritis4 ,the duration is variable4 ,many acute cases get well in a few days4 ,other cases may persist for months and even years4 ,multiple ,neuritis4--,inflammation involving several nerves which are affected simultaneously or in rapid succession4 ,acute form4--,the attack usually follows overexertion or exposure to cold and wet1 with probably some infection4 ,this form is characterized by a chill1 followed by a rapid rise in temperature which may reach #ajc or #ajd degrees ,f42 headache2 pains in the back and limbs4 ,there is weakness of the legs or arms1 depending upon region involved1 which may be so severe that the muscles atrophy4 ,sensory symptoms are variable4 ,most cases recover1 though there are instances where the vagi1 the nerves to the bladder1 rectum1 or heart1 may be involved4 ,alcoholic ,neuritis results from a moderate amount of alcoholic drinking1 continued over a long time4 ,the first symptoms are usually numbness and tingling in the fingers and toes4 ,loss of power soon becomes marked1 first in the lower1 and then in the upper1 extremities4 ,the extensor muscles are most affected1 causing wrist and foot drop4 ,occasionally there is paraplegia4 ,there are hyperesthesia1 tenderness and pain1 especially in the legs4 ,the cutaneous reflexes are commonly intact1 and the deep reflexes1 as a rule1 are lost4 ,delirium is common1 and hallucinations or illusions occur4 ,neuritis from lead poisoning usually present the 8wrist drop0 and 8foot drop01 with colic1 and 8blue line0 on gums4 ,infectious ,diseases neuritis is due to an attack of some infectious disease1 and may be local or multiple4 ,it is due to toxic materials absorbed into the blood4 ,it is most common after diphtheria4 ,the symptoms presented are those of neuritis due to any other cause4 ,senile neuritis is probably due to arteriosclerosis4 ,diagnosis4--,as a rule1 the diagnosis is not difficult4 ,in the alcoholic form in some instances1 there may be difficulty1 and in cases with paralysis1 care should be taken4 ,the prognosis of neuritis is generally favorable4 ,treatment4--,it is very evident that the successful treatment of neuritis depends upon being able to ascertain the cause4 ,rest is important in all cases4 ,rarely has one any difficulty in locating the deranged structures that are predisposing to the attack2 and usually correction of these disturbances1 which are in the region involved will give considerable relief4 ,if the parts are too sensitive to handle insist on absolute rest and hot fomentations4 ,the affected area should be kept warm and protected4 ,attention to the diet1 and free elimination1 are important4 ,metabolic disorders should be corrected1 if possible4 ,give particular attention to any septic foci4 ,a change of occupation may be necessary in some cases4 ,in alcoholic cases1 the alcohol should be stopped as soon as possible4 ,passive movements and massage are helpful1 but of course bear no comparison to specific osteopathic treatment4 ,relaxation of muscles along the spinal column and along the course of the nerve will at least give temporary relief4 ,if contractures and other changes remain after the acute attack1 persistent treatment will generally result in recovery4 7,see also ,painful ,shoulders1 ,part ,i47 ,sciatica is usually a neuritis of the sciatic nerve1 although all painful affections of the nerve are termed sciatica4 ,in some cases it is a neuralgia when the nerve is swollen and presents an interstitial neuritis4 ,osteopathic ,etiology4--,this affection occurs more frequently in males than in females4 ,the usual period for sciatica is from the twentieth to the fiftieth year and the principal causes are vertebral lesions of the lower dorsal and lumbar vertebr1 especially lesions to the fourth and fifth lumbar4 ,occasionally the lesion is a subdislocated innominatum1 a downward displacement of a floating rib or a partial dislocation of the femur4 ,other causes are exposure to cold1 contraction of muscles1 gout1 rheumatism and syphilis4 ,contraction of the pyriformis muscle may bring direct pressure on the nerve4 ,focal infections1 arthritis of the articular processes of the lower spine1 and sacro-iliac and hip-joint disease should not be overlooked4 ,in a few cases there are intrapelvic causes1 such as uterine and ovarian tumors1 rectal accumulations and the fetal head during labor4 ,enlarged prostate may be a factor4 ,it is possible for the roughened edges of the sacro-iliac joint1 internally1 to irritate the sacral plexus as it passes over and thus keep up the pain4 ,this may explain the occasional failure of treatment4 ,symptoms4--,pain in the nerve along its course is the most constant symptom4 ,the pain is most intense back of the thigh and above the hip-joint4 ,the pain radiates downward through the entire nerve2 it is of an annoying character and walking is especially painful4 ,in rare cases there is wasting of the muscles1 cramps1 herpes and edema4 ,in a few cases the neuritis may extend to the spinal cord4 ,diagnosis4--,the diagnosis of sciatica is usually easy4 ,care has to be taken in the examination to determine whether the affection is primary or secondary4 ,it is difficult1 in some cases1 to locate the origin of the disturbance1 especially if it is in the lumbar vertebr1 as frequently a very slight deviation of a vertebra will cause the disease2 or some focal infection may be difficult to locate2 or malformation of the fifth lumbar may be present2 or asymmetry of the legs or the body be a factor4 ,careful palpation1 measurements1 and the ,x-ray are of diagnostic importance4 ,hip-joint disease and sacro-iliac disease can generally be easily distinguished from this affection4 ,the lightning pains of tabes may simulate sciatica1 but then there are other well defined symptoms of the disease4 ,treatment4--,sciatica rarely runs a very long course1 though there are cases that last for years4 ,the treatment almost wholly depends upon the cause4 ,if the cause can be determined at once1 the probabilities are that severe cases may be relieved by a few treatments4 ,correction of the vertebr1 to relieve impingements to the nerve fibers as they pass through the intervertebral foramina1 usually constitutes the primary treatment4 ,carefully examine the pelvic organs for disturbances4 ,occasionally deep treatment over the iliac vessels will be of great help4 ,the innominatum1 if deranged1 should be corrected and all troubles of the hip-joint that are found must be corrected4 ,cases of rheumatism and gout should receive their separate treatments1 besides careful manipulations of the affected leg4 ,rest in bed should be insisted upon2 this will usually markedly lessen the duration of the inflammation4 ,adjustment of the special points found deranged and a thorough treatment1 if conditions permit1 of the entire leg will be beneficial4 ,hot fomentations applied along the course of the nerve1 and an inhibitory treatment back of the trochanter will at least give temporary relief4 ,extension of the leg is effective4 ,placing a patient upon his back and flexing the leg and thigh upon the abdomen1 at the same time keeping the leg straight and the foot flexed1 is an effectual stretching method4 ,as a rule1 sciatica readily responds to osteopathy4 ,neuralgia ,neuralgia means simply 8nerve pain40 ,the term neuralgia should be restricted to such nerve pains as are not caused by structural changes in the nerves4 ,in cases where the pain is due to organic changes in the nerves1 the disease should not be classed as a neuralgia1 although it is practically impossible to draw an absolute line between functional and organic disturbances for the one may gradually progress 7pathologically7 into the other4 ,in neuralgia there is always disturbance of the blood supply to nervous tissue1 which may be of the character of congestive irritation1 ischemia or altered states of the blood wherein it contains toxic substances or is below normal quality4 ,it is well known that osteopathic lesions are very common etiological factors4 ,osteopathic ,etiology4--,neuralgia is essentially a disease of adults4 ,it rarely occurs before puberty or late in life4 ,women are more prone to neuralgia than men and the tendency may sometimes be hereditary4 ,sufferers from neuralgia often present a peculiar 8nervous temperament40 ,the exciting causes of neuralgia are impairment of general health2 irritations of the nerve fiber or trunk by a displaced bone1 ligament or muscle1 which may affect the nervous tissue directly by mechanical irritation1 or indirectly1 by the disturbance of its blood supply1 or toxic agents2 exposure to cold or damp2 overwork and worry2 toxic influences of various diseases1 as malaria1 lead poisoning and alcoholism2 irritation from carious teeth1 and various septic foci4 ,symptoms4--,pain1 which is spontaneous and paroxysmal1 is the most prominent symptom4 ,it may be described as 8darting10 8shooting10 8burning10 8stabbing10 8boring10 etc4 ,the pain is usually unilateral1 following the course of the sensory nerves1 and there are generally tender points along the course of the nerve4 ,especially are there points of tenderness near the central end of the nerve1 where the displaced structures are irritating it4 ,after the pain has continued for some time the skin becomes tender1 reddened and swollen4 ,the redness and edema are supposed to be due to vasomotor changes4 ,muscular spasms1 trophic disturbances1 skin eruptions1 herpes and grayness of the hair are of rare occurrence4 ,the duration of an attack varies from a number of minutes to a few hours4 ,neuralgia of the ,fifth ,nerve4--,this is by far the most frequent variety of neuralgia1 and it is generally due to a displaced atlas or inferior maxilla4 ,the teeth sinuses1 and other possible regions of focal infections should be thoroughly investigated4 ,anemia and products of metabolism may be underlying factors4 ,all the branches of the fifth nerve are rarely involved4 ,the ophthalmic division is most often affected2 pain and tenderness being present about the supraorbital notch or foramen1 the palpebral branch at the outer part of the eyelid1 the nasal branch1 and occasionally an ocular pain will be felt within the eyeball4 ,when the infraorbital branch is involved1 pain and tenderness are principally present at the infraorbital1 nasal and malar points4 ,when the third division is affected1 the chief tender places are the inferior dental1 temporal and parietal points4 ,in nearly all cases of neuralgia of the fifth nerve1 there is extreme tenderness in the region of the articulation of the atlas and the occipital1 particularly the side on which the fifth nerve is involved4 ,this tenderness in a few cases may be found as low as the second or third cervical vertebra4 ,the pain may be so severe as to cause edema along the course of the affected nerve fibers1 grayness of the eyebrows and locks of hair chiefly in the temporal region1 and convulsive twitching of muscles4 ,tic ,douloureux is a vastly exaggerated neuralgia of the fifth nerve and is supposed to be a primary affection of the ,gasserian ganglion4 ,starting in middle life from no apparent cause it increases in severity until it becomes unbearable and suicide is not an infrequent result4 ,many methods to relieve have been tried including destruction of the ganglion but with various results4 ,treatment should be the same as in the milder form of neuralgia but it will require critical examination to determine the causes which are liable to be obscure4 ,cervico-,occipital ,neuralgia4--,this variety involves the posterior branches of the first four cervical nerves1 affecting the region of the posterior part of the neck and head4 ,the pain may extend as far forward as the parietal eminence and the ear4 ,the chief tender points are about midway between the mastoid process and the spine1 between the sternomastoid and trapezius 7branches of the cervical plexus71 and a point just above the parietal eminence4 ,this form of neuralgia is chiefly due to subluxation of the upper four or five cervical vertebr irritating the posterior branches of the spinal nerves4 ,a draught of air or exposure to cold are common exciting causes4 ,the pain is of a sharp lancinating nature or else it is heavy and tense4 ,tuberculosis of the cervical spine may be an underlying cause4 ,cervico-,brachial and ,brachial ,neuralgia4--,in these forms of neuralgia the pain is referred to the area supplied by the four lower cervical and the first dorsal nerves4 ,the tender points are in the axilla along the course of the ulnar1 the circumflex at the posterior part of the deltoid and points at the lower and posterior part of the neck4 ,the lesions exciting this form of neuralgia are usually found in the upper dorsal and upper cervical spines1 but they may be as low as the sixth dorsal or as high as the atlas4 ,as far as neuralgia of the ulnar nerve alone is concerned1 it can be traced to the seventh and eighth cervical and first dorsal1 and the lesion may be found occasionally at the fifth dorsal vertebra or rib4 ,how a lesion as low as the fifth dorsal affects the ulnar nerve1 it is hard to say definitely4 ,there may be fibers directly to the ulnar nerve as low as this region1 the nerve may be reflexly affected1 the vasomotor supply to the ulnar nerve may be disturbed1 or possibly the lesion interferes with fibers of the deep layers of the back muscles and thus contraction of muscles for some distance above the lesion would affect the ulnar and other nerves4 ,the scaleni may be affected and involve the plexus4 ,a bursitis may be present 7,see ,painful ,shoulders ,part ,i74 ,focal infections are sometimes factors4 ,trunk ,neuralgia4--,this includes dorso-intercostal and lumbo-abdominal neuralgia4 ,the former1 dorso-intercostal neuralgia1 affects the intercostal nerves from the third to ninth dorsal1 and is characterized by pain along the intercostal spaces1 or in a few of them4 ,the pain may be bilateral and symmetrical1 which usually shows a vertebral lesion4 ,three points of tenderness are usually noted1 viz41 near the median line in front1 and midway between these two points in the mid-axillary line4 ,the pain is usually dull with acute exacerbations4 ,lesions of the vertebr and ribs in the locality affected are by far the principal causes4 ,cold1 exposure1 strains1 etc41 are exciting causes of every day occurrence4 ,when the pain is bilateral and symmetrical the lesion is usually in the vertebra2 when unilateral the rib alone may be involved4 ,the most common lesion is a crowding together of the ribs anteriorly at the fifth and sixth interspaces4 ,carefully exclude a possible tuberculosis of the spine or ribs1 aneurism1 etc4 ,the pain of herpes zoster is not neuralgic1 but neuritic1 involving the posterior spinal ganglion4 ,pleurodynia1 strictly speaking1 is neuralgia of the pleural nerves1 and not of the intercostals1 but a deranged rib over the region of the pain is commonly the cause of the pleurodynia4 ,lumbo-abdominal neuralgia involves the posterior branches of the lumbar nerves4 ,tender points are found near the vertebr1 middle of the iliac crest1 lower part of the rectus1 and in the male occassionally in the scrotum1 in the female in the labia4 ,these are often bilateral and are usually of a constricting nature4 ,the ilioscrotal branch is the one most commonly affected4 ,subluxation of the vertebr1 and other lesions1 as contracted muscles1 are found along the lumbar vertebr1 and even as high as the lower dorsal vertebr4 ,also lesions are found at the lumbo-sacral articulation4 ,pelvic disease is also a cause4 ,a downward displacement of the lower ribs1 eleventh and twelfth1 is a common disorder and may be the cause of severe neuralgic pains in the region of the iliac foss4 ,it may simulate ovarian inflammation1 renal colic1 or even appendicitis if on the right side4 ,and septic kidney has been wrongly diagnosed from these lesions4 ,in fact it may be a cause of inflammation of the deeper structures1 such as the ovary and ,fallopian tube4 ,a subluxation of the vertebr at the fourth and fifth dorsals may cause severe neuralgic pains in the epigastrium4 ,neuralgia of the ,spinal ,column4--,according to medical writers this is especially found in weakly women and after concussion of the spine2 that it is a troublesome symptom in hysteria1 and in many cases it is due to a reflex stimulus from diseased viscera4 ,most of this is undoubtedly true1 but they have not found out the real significance of these neuralgic pains4 ,the various tender points along the spinal column are of paramount importance to the osteopath as a guide to his diagnosis2 not only in certain cases1 but in nearly every case4 ,the tender points are not due1 in nearly every instance1 to reflex stimuli from diseased organs1 but these tender points are often the result of a local lesion1 and are many times the cause of the disorder to the diseased viscus4 ,the neuralgic pains are simply a symptom that a lesion exists in the immediate locality4 ,neuralgia of the ,sacral ,region and ,coccygodynia4--,this form involves the nerves in the sacral and coccygeal regions4 ,the nerves between the bone and the skin are affected4 ,the cause of the pain is generally due to derangement of the articulation of the lumbar and sacrum1 and to severely contracted muscles over the sacral foramina2 also to lower lumbar lesions4 ,it may be a reflex from various possible disorders of the organs and tissues of the pelvis4 ,in coccygeal neuralgia1 the coccyx is commonly displaced in any one of the various displacements that are liable to occur4 ,special attention should be given to the fibro-articulation of the coccyx1 and to the status of the lumbo-sacral and innominata4 ,in adjusting the coccyx1 place forefinger in rectum up to proximal end of coccyx1 and with thumb externally over the section1 exert traction until articulation is released2 then adjust4 ,neuralgia of the ,legs and ,feet4--,this includes the crural form1 in which the front of the thigh is the seat of the pain2 also the form in which tender points are found along the course of the sciatic nerve4 ,the latter form is quite a common one1 although sciatica is rarely a neuralgia4 ,it is a neuritis and will be found classed under that heading4 ,the tender points presented are the lumbar1 sacro-iliac1 gluteal1 peroneal1 maleolar and external plantar4 ,the various neuralgic pains of the legs and feet are generally due to lesions of the lumbar1 pelvic and thigh regions1 and to weak arches4 ,metatarsalgia occurs when the fourth metatarso-phalangeal articulation is partially dislocated4 ,neuralgia in the heel1 ball of the foot and toes may be due to local causes or to lesions higher up4 ,aside from the above care should be taken that there are no toxic factors that may be exciting causes4 ,visceral ,neuralgia4--,this is a term applied to neuralgia of the gastro-intestinal tract1 the kidneys1 and the various pelvic organs4 ,diagnosis and ,prognosis of ,neuralgia4--,neuralgia is to be diagnosed chiefly from neuritis1 rheumatism1 and the effects of severe pressure upon the nerves4 ,in neuritis there is oftentimes a symmetrical affection1 while in neuralgia there is a unilateral distribution and there are many remissions and intermissions and a varying of the pain from one place to another4 ,in severe forms of neuritis1 anesthesia succeeds the hyperesthesia of the sensory nerves4 ,in cases of severe pressure upon nerves1 the pain is continuous and neuritis will soon be manifested4 ,in rheumatism the pain is localized in muscles or groups of muscles and does not follow the course of the nerve4 ,the pain is increased by motion4 ,the prognosis is generally favorable1 no matter how severe the attack4 ,the prognosis is influenced only by the age of the patient and the cause4 ,treatment of ,neuralgia4--,consists1 first1 in the control of the paroxysm and1 second1 in the removal of its cause4 ,in controlling the paroxysm1 frequently one will be able to remove the cause4 ,in a large majority of neuralgias the cause is directly due to a displaced tissue1 generally a bone or muscle in the locality affected2 often all that is necessary in order to perform a cure is to adjust the disordered tissue and the pain will cease4 ,this usually can be done immediately1 although there are cases which require several treatments before an adjustment of the parts can be accomplished2 besides1 in acute cases the involved region will be so tender that an attempt to correct the tissues sufficiently to relieve the paroxysm will be unbearable to the patient4 ,in such instances when the cause cannot be removed at once1 firm pressure or inhibition over the involved nerves for a few minutes and local application of hot packs generally disperse the pain for the time being4 ,the rules of hygiene should be observed in all cases4 ,the best time to remove the cause of neuralgia is between the attacks when the tissues are not as tender or contracted to such an extent as during the paroxysm4 ,a diagnosis can then be made much more easily1 and the tissues adjusted with less pain to the patient4 ,the details 7as to the locality treated7 for each form of neuralgia will be found under the discussion of each variety4 ,the general health and diet should be considered4 ,peterson#aae says3 8,morphine is1 among the alkaloids1 the most frequent cause of insanity4 ,it is a sad commentary on the heedlessness of some medical men1 but the family physician is responsible1 in almost every case1 for the development of the morphine habit and its far-reaching consequences4 ,it should be looked upon as a sin to give a dose of morphine for insomnia or for any pain 7such as neuralgia1 dysmenorrhea1 rheumatism7 which is other than extremely severe and transient40 ,diseases of the ,cranial ,nerves ,olfactory ,nerves4--,this nerve may be affected at various points from its origin to distribution4 ,the disturbances may produce hyperosmia1 or anosmia4 ,the lesions may be tumors1 injuries to the head and various diseases of the brain1 or diseases of the nasal mucous membrane4 ,the treatment of the nerve 7beside treating the disease causing the disturbance7 is to the cervical region with a view to controlling the blood supply4 ,optic ,nerve and ,tract4#aaf--,the retina1 optic nerve1 chiasma and optic tract may be affected by various lesions4 ,the affections of the retina are organic or functional4 ,under organic there is hemorrhage and retinitis4 ,retinitis may be due to several diseases1 as syphilis1 ,bright's disease1 anemia1 etc41 ,functional includes toxic and hysterical amaurosis1 tobacco amblyopia1 nyctalopia1 hemeralopia and retinal hyperesthesia4 ,included in the lesions of the optic nerve1 are optic neuritis and optic atrophy4 ,under lesions of the chiasma and tract are diseases of the chiasma and unilateral regions of the tract4 ,lesions of the tract and centers may be found in the tract itself1 in the optic thalamus and the tubercula quadrigemina1 in the fibers of the optic radiation1 in the cuneus1 and in the angular gyrus4 ,a brief summary1 only1 has been given of the lesions found1 it being the idea not to dwell upon symptoms1 morbid conditions1 etc41 but to bring out essential osteopathic features in regard to the cranial nerves4 ,for the various effects of these lesions and points of diagnosis1 the reader is referred to the various works on nervous diseases4 ,lesions peculiar to osteopathic practice1 that affect the optic nerve and tract1 are found chiefly in the upper and middle cervical vertebr4 ,the disorders to these vertebr may involve fibers of the optic nerve directly--those that are supposed to originate in the cervical spine2 they involve the retina and optic nerve by way of the fifth1 as claimed by some2 and the above lesions especially affect the blood supply to the optic nerve and tract1 either interfering mechanically with the blood-vessels or obstructing and irritating vasomotor nerves4 ,the most common lesions are subdislocations of one or all of the three upper cervical vertebr4 ,still1 lesions may be located as low as the third or fourth dorsal vertebra1 which may influence vasomotor and sympathetic nerves1 or the lymphatics4 ,the three or four upper ribs should also receive due consideration4 ,motor ,oculi4--,lesions of the third nerve may affect its center or the course of the nerve4 ,these lesions produce spasms or paralysis4 ,the only way that we can control the motor oculi is by way of the superior cervical sympathetic2 also1 it has a connection with the fourth1 fifth and sixth nerves1 and we can influence it to some extent by direct treatment to the eyeball and orbital muscles4 ,it should be remembered by the osteopath that many of the lesions affecting the cranial nerves1 are found upon post-mortem examination1 to be the effect of lesions in the spinal region2 that many predisposing lesions are the disordered anatomical spinal tissues2 as for instance in the third nerve1 derangements of the atlas or axis may affect the nerve sympathetically 7reflexly71 or possibly by direct fibers1 and produce the secondary effect--the so-called primary lesions of other schools--at the center or in the course of the nerve4 ,patheticus4--,this nerve may be involved by tumors at its nucleus1 or as it passes around the outer surface of the crus into the orbit4 ,aneurisms or the exudation of meningitis may also compress its fibers4 ,this nerve is purely motor1 although it receives a few recurrent sensory fibers from the fifth nerve4 ,this nerve is controlled osteopathically1 principally at the superior cervical sympathetic4 ,it has connections with the sympathetic by way of the cavernous plexus4 ,trigeminus4--,lesions of this nerve are found in its nucleus and in the pons1 and include sclerosis1 hemorrhage1 disease and injury at the base of the skull1 tumors1 aneurisms1 inflammation of the nerve1 and subdislocations of the upper three cervical vertebr1 or the inferior maxillary4 ,this nerve is an extremely important one from an osteopathic point of view1 as it has a vasomotor influence over various vessels of the head and face1 and secretory fibers to the lachrymal1 parotid and submaxillary glands2 also1 it controls mastication1 and to some extent deglutition1 and influences hearing 7tensor tympanum muscle74 ,diseases of the nasal mucous membrane and disease of the anterior portion of the eyeballs are largely due to the vertebral subdislocations and to derangements to the inferior maxilla4 ,our principal work upon this nerve is at the upper cervical vertebr1 the inferior maxilla1 and the deeply contracted muscles in the upper cervical region4 ,for the facial points of treatment see neuralgia of the fifth nerve4 ,this nerve is closely related to the sixth1 seventh1 eighth1 ninth1 tenth1 eleventh and twelfth nerves4 ,particular emphasis is given to the importance of treating this nerve in nasal catarrh and in eye diseases of the anterior portion of the eyeball4 ,it contains trophic fibers to the eye1 sensory fibers to the sclerotic coat and iris1 and vasomotor fibers to the choroid plexus4 ,abducens4--,this nerve is especially liable to be affected by tumors and meningitis4 ,it is controlled osteopathically at the superior cervical sympathetic1 being connected with the sympathetic at the cavernous plexus4 ,facial4--,lesions may occur in the cortical centers of the nerve1 the nucleus and the nerve trunk4 ,paralysis of the facial nerve occasionally occurs 7,bell's paralysis72 also facial spasm may occur4 ,this nerve is controlled at the stylomastoid foramen4 ,lesions to the atlas1 anteriorly or laterally1 are commonly found4 ,in the region of the stylomastoid foramen1 the nerve communicates with the great auricular of the cervical plexus1 the trifacial1 the vagi1 the glosso-pharyngeal and the carotid plexus of the sympathetic4 ,the facial nerve may be affected directly as it passes above the angle of the jaw4 ,nearly every case of ,bell's paralysis can be cured by osteopathic treatment4 ,there are usually lesions to the upper two or three cervicals4 ,correction of the cervical vertebr and massage of the paralyzed muscles1 with care of the general health1 will suffice1 provided there is not an extensive central lesion4 ,although the disease may be due to syphilis1 meningitis1 tumors1 etc41 the most frequent causes are lesions of the atlas1 axis1 and third cervical and exposure to cold4 ,the cold produces a neuritis in the ,fallopian canal1 and deep treatment beneath the angle of the jaw is effective4 ,the prognosis of ,bell's paralysis is favorable4 ,auditory4--,lesions#aag affecting this nerve may occur anywhere from its cortical center to its distribution in the cochlea and vestibule4 ,disorders resulting from lesions to this nerve are nervous deafness1 auditory hyperesthesia1 tinnitus aurium1 and ,meniere's#aah disease4 ,the control of the nerve and the treatment of lesions affecting it1 are effected principally at the first and second cervical vertebr4 ,the atlas is especially apt to be subdislocated anteriorly or in a rotary manner4 ,the condition of the upper dorsal region should also be carefully examined1 as vasomotor nerves to the ear may be impinged at this point4 ,the auditory connects with the fifth1 sixth and seventh nerves4 ,glosso-,pharyngeal4--,this nerve may be affected by tumors1 degenerations1 meningitis and various lesions4 ,it is often very hard to determine exactly the pathology1 on account of its various connections with other nerves1 the vagi1 facial1 spinal accessory1 olfactory and optic nerves4 ,this nerve is chiefly controlled at its exit at the jugular foramen4 ,osteopathically1 lesions of the cervical vertebr and upper dorsal vertebr affect it4 ,the deep muscles of the anterior and lateral regions of the neck and subdislocations of the atlas especially affect the nerve4 ,pneumogastric4--,on account of its extensive distribution1 and the importance of its functions this is one of the most important nerves in the body4 ,it distributes fibers to five vital organs--heart1 lungs1 stomach1 liver and intestines--and to other organs of secondary importance4 ,this nerve is associated with deglutition1 phonation1 respiration1 circulation and digestion4 ,hemorrhages1 softening1 etc41 may involve the nucleus of the nerve1 while the trunk may be impinged by tumors1 thickened meninges1 aneurism of the vertebral artery and subdislocation of the upper five or six cervical vertebr1 chiefly the atlas4 ,the nerve is most easily controlled at its exit from the foramen4 ,inhibition of the suboccipital region1 between the mastoid process and transverse process of the atlas1 will influence the nerve markedly1 probably reflexly2 also direct treatment may be given the nerve as it passes along the anterior part of the neck near the trachea4 ,the superior laryngeal branch may be treated below the great cornu of the hyoid bone and attention is particularly called to this in all affections of the throat where coughing is a feature2 the inferior laryngeal1 at the inner side of the lower part of the sternocleidomastoid muscle4 ,the inferior laryngeal nerve may be affected by dislocation of the first and second ribs1 producing pressure upon the nerve as it winds about the subclavian vessel4 ,fibers of the nerve have been traced to the spinal accessory nerve1 as low as the sixth and seventh cervical vertebr2 consequently1 lesions to the vagi nerves may occur anywhere in the cervical region4 ,spinal ,accessory4--,lesions of this nerve may cause paralysis or spasms to the structures to which it is distributed4 ,the lesions consist of subdislocations of cervical vertebr1 chiefly the upper three or four4 ,the nucleus may be involved by wounds1 abscesses1 caries of the vertebr1 tumors and meningitis4 ,these lesions may also involve fibers of the trunk4 ,the special points of control of the nerve are at the jugular foramen1 the sixth and seventh cervicals and the second1 third and fourth cervicals4 ,torticollis or ,wry-neck is spasm of the muscles of the neck supplied principally by this nerve4 ,there will be found either derangements of the middle or lower cervical vertebr or the muscles are swollen from exposure to cold or from a blow4 ,sometimes the lesion is in the upper dorsal4 ,the disorder is mainly a neurosis and1 unless it has become chronic1 the prognosis is favorable1 and even in chronic cases1 often considerable benefit can be obtained4 ,hypoglossal4--,this nerve may be affected by cortical1 nuclear and infra-nuclear diseases1 as well as by subdislocations of the upper cervical vertebr4 ,it communicates with the superior cervical ganglion1 the vagi1 the upper cervical nerves and the gustatory branch of the fifth nerve4 ,we control the nerve at the anterior condyloid foramen and at the superior cervical ganglion4 ,diseases of the ,spinal ,nerves ,cervical ,nerves4--,the great occipital nerve may be controlled at a point on the occiput between the mastoid process and the first cervical vertebra4 ,the small occipital and the great auricular nerves may be controlled at a point just behind the mastoid process4 ,the great auricular nerve and the frontal branch of the trigeminus nerve meet over the parietal protuberance4 ,the preceding points are the places where one may inhibit the nerves and control certain headaches or neuralgic attacks1 although subdislocations of the upper cervical vertebr1 or contracted muscles between the atlas and occiput are usually the cause of such disturbances4 ,adjustment of the lesion will usually correct the disturbance4 ,carefully exclude possible caries or tumors4 ,treatment of the upper cervical region1 by relaxing muscles and correcting deranged vertebr1 constitutes the principal treatment of an ordinary headache4 ,it is best to have the patient flat upon his back and the osteopath stand at the head of the patient1 and1 first1 thoroughly relax these contracted muscles or correct the derangement of the vertebr2 then after the foregoing has been accomplished1 give an inhibitory treatment of the suboccipital region4 ,in inhibiting1 place the fingers over the contracted and tender tissue2 hold tightly for several minutes1 or at least until the tissues have thoroughly relaxed4 ,many times one will be able to detect a slight twitching underneath the fingers1 and when such is felt1 he knows at once that the headache is relieved4 ,in inhibiting at any point along the spine1 seek the contracted fibers and tender points and inhibit exactly over the area4 ,headaches that are due to a disturbed circulation of the brain1 may be relieved by this inhibitory treatment in the suboccipital region4 ,the treatment tends to reestablish a normal circulation to the brain4 ,although the large vascular areas such as the splanchnic1 should1 if possible1 be normalized4 ,headaches may also be due to lesions at various points along the spine and ribs1 and a correction of such points is necessary in order to cure the affection4 ,a place often found involved is the upper dorsal region4 ,reflex headaches can be cured only by relieving the irritation4 ,the treatment to the head would only be temporary4 ,in headaches of the chronic type it is well to examine the scalp and if not freely movable over occipital region it may be adherent to the skull and cause pressure on the occipital nerves4 ,lesions to the phrenic nerve usually occur in the region of the third1 fourth and fifth cervical vertebr4 ,the lesion may be due to a deranged vertebra1 or to disease of the membrane of the cord1 or of the anterior horn of the gray matter 7,see ,hiccoughs74 ,paralysis of diaphragm from the phrenic may be single or double4 ,when single it is not very noticeable4 ,when double1 respiration must be carried on by the intercostals and accessory muscles4 ,when quiet1 the patient may not notice it but on exertion there may be temporary dyspnea4 ,bronchitis with its constant coughing is a bad complication4 ,various disorders of the phrenic nerve are principally treated in the area of the origin of the phrenic nerve4 ,tumors1 aneurism1 caries1 and neuritis are possible complications4 ,lesions to the brachial plexus are usually derangements of the cervical or upper dorsal vertebr4 ,focal infections should not be overlooked4 ,direct injuries1 contraction of muscles1 a deranged clavicle1 a cervical rib1 or a dislocated shoulder are to be thought of4 7,see1 also1 ,painful ,shoulders1 ,part ,i7 ,the ,x-ray as a diagnostic aid may be invaluable4 ,in obstructions to the musculo-cutaneous nerve1 the power to flex the forearm upon the arm is greatly impaired4 ,the lesion is most likely to be found between the fifth and sixth cervical vertebr4 ,clinically1 the median nerve is of special interest from the fact that atrophy of the muscles of the ball of the thumb1 which is pathognomonic of progressive muscular atrophy1 may be caused by an affection of this nerve4 ,the lesion is usually from the third to the seventh cervical vertebr4 ,lesions of the ulnar nerve may arise between the sixth and seventh cervical vertebr1 but are oftentimes found as low as the fifth dorsal1 especially at the fifth rib on the side affected4 ,lesions of the circumflex nerve may be found in the lower cervical vertebr1 but are commonly caused by dislocations of the humerus and clavicle4 ,lesions of the suprarscapular nerve occur most frequently from the fifth to sixth cervical vertebr4 ,the posterior thoracic may be lesioned at the fifth or sixth segments1 or by pressure injuries to the serratus magnus4 ,dorsal ,nerves4--,the essential osteopathic points of the dorsal nerves have been considered under intercostal neuralgia4 ,it might be stated that the posterior fibers of the sixth and seventh dorsal nerves supply the skin of the pit of the stomach4 ,this is of value1 clinically1 as severe pains in the epigastric region which may result from impingement of these nerves1 are supposed by the patient to be due to stomach disorder4 ,diseases of the liver may be manifested by pains in the region of the right scapula4 ,it has been suggested that the stimulus passes from the liver up the pneumogastric to the spinal accessory and down the spinal accessory to the trapezius muscle and thus causes the 8liver pain40 ,intercostal neuralgia is more common on the left side of the body4 ,the intercostal veins of the left side empty into the left superior intercostal vein or the left azygos4 ,thus the blood1 to reach the vena cava1 is obliged to take a circuitous route and stagnation is more likely to occur than on the other side4 ,the glandular structure of the mammary glands is supplied by intercostal nerves from the third to the sixth interspace4 ,lesions here will cause various diseases of the breasts and adjustment will cure many of them4 ,lumbar ,nerves4--,the lumbar nerves may not only be deranged by various growths1 inflammatory processes and abscesses in the abdomen1 but by lesions1 infections1 parturition1 and developmental defects of the lumbar vertebr4 ,tuberculosis of spine1 sacro-iliac and hip joints1 is not rare4 ,in doubtful cases utilize the ,x-ray plate4 ,lesions in the region of the first lumbar may affect the iliohypogastric and ilio-inguinal nerves and causes various irritations of the penis1 scrotum1 labium and thigh4 ,also1 the perineal region may be involved1 as well as connecting branches of these nerves to various visceral nerves underneath4 ,the genital organs may be affected by lesions to the genitocrural and external cutaneous nerves1 caused by vertebral lesions of the second and third lumbar vertebr4 ,the latter nerve may be irritated by pressure underneath ,poupart's ligament4 ,lesions at the third and fourth lumbar vertebr and sacro-iliac articulation may affect the obturator nerve4 ,sacral ,nerves4--,lesions to the sacral nerves are especially liable to occur when an innominatum is subdislocated1 as that changes the relative position of the femur with the body and causes impingement to the sacral nerves4 ,contraction of the pelvic and thigh muscles also affect sacral nerves4 ,other lesions to the sacral nerves may be located at the fifth lumbar and sacrum4 ,it should be remembered that the centers of the sacral nerves are in the lower dorsal and upper lumbar region4 ,various lesions to the sacral nerves may be caused by pelvic inflammation1 compressions by growths1 and injuries and contractions of muscles within the pelvis4 ,sciatica has been described under neuritis4 ,,footnotes3 #aad ,see ,osteopathic ,lesion--,journal of ,american ,osteopathic ,association4 ,may1 #aijf1 and ,deason's ,physiology4 #aae ,nervous and ,mental ,diseases1 p4 #fbb4 #aaf ,see ,diseases of the ,eye1 ,part ,i4 #aag ,see ,ear ,section1 ,part ,i4 #aah ,r4 ,d4 ,emery reports a case of ,meniere's disease as cured4 ,a4 ,o4 ,a4 ,case ,reports1 ,series ,,iv4 ,,general ,,and ,,functional ,,diseases ,paralysis ,agitans 7,,shaking ,,palsy7 ,definition4--,a chronic1 nervous disease1 characterized by tremors1 muscular weakness1 muscular rigidity and alterations in the gait4 ,etiology4--,the disease usually commences after forty years of age1 but occasionally it occurs from the thirtieth to fortieth years4 ,it is more frequent in males than in females4 ,heredity seems to have but little influence in the cause of the disease4 ,among the principal causes are physical injuries1 exposure to cold and wet1 emotion1 worry1 alcoholism1 sexual excesses and acute diseases4 ,physical injury1 in conjunction with exposure to cold is the best determined cause4 ,disorder of the vertebr of the cervical or dorsal regions1 or of the upper and middle ribs1 can generally be found4 ,traumatic influences probably affect the nerve centers1 causing a disturbed innervation1 either by the direct effect of the deranged structures upon the nervous tissues or obstructing nutritive channels to the nervous tissues4 ,in most cases no changes have been observed in the central nervous system or in the sympathetic ganglia4 ,some observers have noted induration of the pons1 medulla and cord1 but these changes may be due to senility or to the indirect consequences of the long disturbance of function4 ,in a few cases1 interstitial sclerosis of the peripheral nerves is observed2 these are probably secondary changes4 ,osteopathic experience regards paralysis agitans as an affection of the central nervous system1 due to a disordered structure in the locality affected4 ,symptoms4--,the onset is usually gradual1 but may come on quite suddenly after exertion4 ,the initial symptoms are usually tremor1 stiffness or weakness in one hand4 ,in rare cases1 at first there may be neuralgic pains1 dizziness and symptoms of a rheumatoid nature4 ,the tremor can be controlled by the will at the onset of the disease4 ,the affection gradually extends until an entire side or the upper or lower limbs are involved4 ,at this advanced stage of the disease1 a peculiar muscular rigidity of the involved region takes place4 ,muscular weakness comes on at about the same time as the rigidity1 and the loss of power varies much in degree4 ,the condition is most marked in the fingers and hands1 whence it extends to the arms and legs4 ,it commonly passes from the right arm to the right leg1 then to the left arm1 and then to the left leg4 ,at this stage the movement between the thumb and fingers is like that of crumbling bread4 ,the writing is greatly affected and in time it is impossible to write4 ,the trembling may be so violent as to prevent sleeping4 ,there is occasionally an intermission of days in the tremor4 ,on account of the rigidity of the muscles1 the patient assumes a characteristic attitude and gait4 ,the position of the body is that of a tendency to go forward1 the head is bent forward1 the back curved outward1 the arm bent at the elbow and held away from the body1 and the knees so close together that they rub in walking4 ,the gait is a 8propulsive0 one1 and when once started in a forward walk1 the patient's gait becomes more and more rapid and he cannot stop until he comes against some object4 ,the expression of the face is stiff and mask-like1 the speech slow and monotonous and the voice shrill4 ,the patient is generally restless and troubled with insomnia4 ,the general health is in fairly good condition4 ,reflexes are usually normal4 ,the intellect is generally retained1 although the physical ailment may cause mental depression4 ,diagnosis4--,is usually easy and can oftentimes be made at a glance4 ,disseminated sclerosis has a tremor1 but is shown particularly in voluntary movements4 ,the speech is scanning and the gait ataxic4 ,the disease begins in the lower extremities1 the attitude is different from that of paralysis agitans1 and there is nystagmus4 ,in chorea the movements are general1 irregular and more intermittent1 and it particularly involves muscles of the face4 ,also chorea is a disease of children and young adults4 ,the tremors of old age1 hysteria1 and certain toxic conditions due to tobacco1 alcohol1 etc4 are generally easily diagnosed4 ,prognosis4--,the disease does not necessarily shorten life2 the patient oftentimes dies with some intercurrent disease4 ,improvement usually results from careful1 prolonged treatment4 ,early treatment1 of course1 will give the most satisfactory results1 and occasionally1 if taken very early1 the case can be cured4 ,treatment4--,a most careful examination of the physical structures of the patient should be made1 particular attention being paid to the cervical and dorsal vertebr1 the upper and middle ribs and the muscles along the spinal column4 ,all irregularities found should be corrected if possible1 and strong1 thorough treatment given to the region of innervation of the affected parts4 ,traction of the rigid areas is of some value4 ,treatment of the arms and legs will also be of aid4 ,all mental strain and physical exhaustion should be prevented if possible4 ,general hygienic measures are to be employed4 ,the life of the patient should be quiet and regular4 ,bathing1 fresh air1 massage and outdoor life will aid in improving the general health4 ,persistent treatment will retard the progress and frequently improve the general condition4 ,simple and hysterical tremor must not be confounded with that of paralysis agitans4 ,e4 ,ashmore#aai reports an interesting case which shows about what may be expected under treatment4 ,acute ,chorea 7,,st4 ,,vitus ,,dance7 ,definition4--,a functional disorder of the nervous system1 chiefly affecting children1 more than twice as frequent in females as males2 characterized by irregular involuntary muscular contractions1 often slight mental disturbance1 and liability to endocarditis4 ,osteopathic ,etiology4--,the disease affects children of all stations1 but is more common among the lower classes4 ,the greater number of cases occur before the age of twenty4 ,it sometimes develops during the early months of pregnancy1 when it often assumes the maniacal type4 ,chorea is frequently associated with endocarditis and rheumatism and delayed menstruation4 ,it occasionally follows infectious diseases of childhood1 especially scarlet fever4 ,fright1 mental worry1 sudden grief and overstudy may bring on an attack4 ,children of neurotic stock are more susceptible4 ,heredity plays some part as a predisposing cause4 ,reflex irritation from worms or from genital irritation has a slight influence upon the disease4 ,overwork in school is an important factor4 ,derangement of the anatomical structures1 involving the nervous system along the spinal column1 is the most common predisposing cause4 ,most of the anatomical displacements are found in the cervical vertebr1 although the upper dorsal may be involved4 ,pathologically1 as yet1 no constant anatomical lesions have been found4 ,emboli occur in some cases1 but this might be expected1 as endocarditis so frequently occurs as an effect and not the cause of chorea4 8,in cases not rheumatic1 the most probable explanation of the symptoms is to be found in vascular changes1 having their origin in disturbed nutrition40 7,holt7 ,according to osteopathic theories and investigations1 the disease is due to various irritations to the spinal centers and nerves of the affected region4 ,the disordered nerve cells may be the result of direct pressure1 hyperemia1 anemia1 etc41 and the action upon the brain centers is possibly a reflex act4 ,of late acute chorea is regarded by some as an infectious disease4 ,symptoms4--,in the majority of cases the muscular movement is not severe4 ,they are purposeless and the child appears awkward4 ,restlessness1 disturbed rest at night1 crying spells1 pain in the limbs1 headache and irritability1 are some of the premonitory symptoms4 ,in mild cases one hand1 or the hand and face1 are involved4 ,occasionally there is some difficulty in talking4 ,the irregular1 jerky movements are characteristic of this disease4 ,the child is anemic1 and the muscles are weak4 ,in severe cases the movements are general1 the power of speech is lost1 and the patient is unable to get about4 ,the condition usually occurs after one or more mild attacks1 although it may occur primarily4 ,during an attack of chorea1 the child's disposition changes1 he becomes irritable1 cannot concentrate his mind1 memory is affected and hallucinations may occur4 ,the reflexes do not usually differ from the normal4 ,maniacal chorea is most serious1 and often proves fatal1 although recovery may occur4 ,this form occurs most frequently in pregnant women4 ,speech is greatly affected and insomnia1 fever and maniacal delirium develop4 ,the duration is from six to ten weeks1 in the average case4 ,mild cases may recover in a month or less1 others last six or more months4 ,there is a tendency of chorea to recur2 rheumatism seems to favor this tendency4 ,in children recovery is the rule4 ,diagnosis4--,in the majority of cases chorea is easily diagnosed4 ,the symptoms are generally very characteristic4 ,in a few cases of hysteria there may be difficulty of diagnosis1 but history and rhythmical movements will usually differentiate4 ,in hereditary ataxia the slow1 irregular movements1 the scolioses1 scanning speech1 talipes and the existence of other cases in the family1 will differentiate this from chorea4 ,cerebral sclerosis usually occurs in infancy2 impaired mentality1 exaggerated reflexes1 rigidity and chronic course of the disease1 are points which render the diagnosis easy4 ,treatment4--,nearly all cases can be cured4#abj ,the predisposing causes of chorea1 osteopathically1 are usually found to be subluxations of the vertebr or ribs at any point1 but particularly in the cervical vertebr4 ,chorea is one of the diseases of the nervous system1 in which constant morbid changes are not found upon the post-mortem examination4 ,possibly the reason is because the lesions causing the diseased state are not deeply seated enough to primarily affect motor centers2 but are lesions of the spinal column and ribs1 affecting simply the nerve fibers reflexly1 as they pass through the intervertebral foramina4 ,there will be found well marked lesions1 and upon their correction the osteopath finds complete recovery largely depends4 ,the muscle1 or group of muscles1 involved1 will give a direct clue as to where the lesion will probably be found4 ,in nearly all cases1 it is in the spinal region of innervation to the affected muscles4 ,other cases may be due to cerebral lesions1 as well as to intestinal and uterine disturbances4 ,search should be made for possible reflex irritation1 such as intestinal parasites1 adherent prepuce1 eye strain1 nasal abnormalities1 etc4 ,all cases should be taken from school1 carefully guarded from excitement1 and placed under the most favorable hygienic conditions1 with a certain amount of discipline as to self control4 ,the more serious cases should be placed in bed1 so that rest will be secured as well as diminished liability to heart complications4 ,the diet must be carefully watched and the bowels attended to regularly4 ,a milk diet during the early stage is highly recommended4 ,do everything possible to restore the general health4 ,mild gymnastics1 in most cases1 will be found of service4 ,amusement should be given the child1 in the open air if possible4 ,in severe cases where the skin is harsh and dry1 the hot air bath1 providing the strength is good1 will give considerable relief from the intensity of the disease4 ,a few cases of acute chorea run into a chronic form1 but the latter1 as a rule1 yields to osteopathic treatment4 ,choreiform ,affections ,myoclonia is a sudden contraction of a few muscle fibers1 a single muscle or of a group of muscles4 ,a neurotic tendency1 infections and toxic conditions are factors4 ,occasionally epilepsy may be associated with it4 ,osteopathically there can be but little doubt that the innervation to the muscles involved is interfered with4 ,the lower extremities are usually first affected and it may be sudden or gradual in appearance4 ,it is progressive and slowly involves the arms and1 rarely1 the face4 ,usually the spasms cease during sleep4 ,prognosis is rather favorable4 ,examination should show the cause of the nerve interference and its correction bring relief4 ,dubini's disease is probably associated with certain diseases of the cord and brain and is characterized by sudden1 sharp pains in the head1 neck and lumbar muscles1 extending to the lower extremities in the form of a short1 sharp spasm1 usually at regular intervals4 ,later there may be symptoms of hemiplegia4 ,the disease is apt to progress and death may occur during a convulsion4 ,habit spasm usually results from overstudy and nerve exhaustion with impairment of general health1 and is incident to early life4 ,the child is usually a neurotic4 ,the symptoms are twitching of the mouth and eyelids1 grimaces and jerking of the shoulders4 ,treatment for the general condition1 with correction of any spinal lesions1 will generally give relief4 ,general tic resembles habit spasms closely4 ,in some cases the patient is apparently healthy1 while in others there is some brain disorder4 ,there are coordinate spasmodic movements of the head1 face and upper trunk1 swallowing and abnormal vocal sounds4 ,the movements are rapid and frequently repeated4 ,prognosis is uncertain and will depend largely on general conditions4 ,in convulsive tic there is usually a repetition of certain words or sounds with a convulsive twitching or movement of certain muscles4 ,infantile ,convulsions 7,,eclampsia7 ,infantile convulsions may be due to various causes4 ,a neurotic inheritance is an important predisposing factor4 ,they may precede the development of many diseases of the nervous system1 and also occur as the result of peripheral irritation4 ,dentition in association with rickets1 and intestinal parasites are common causes4 ,they may be the early symptoms of acute1 infectious diseases4 ,scarlet fever1 measles1 pneumonia and smallpox are very frequently preceded by convulsions4 ,they may be due to debility1 resulting from gastro-intestinal disorders4 ,malnutrition is a predisposing cause4 ,disease of the bones1 especially rickets1 may be associated with convulsions4 ,lesions of the brain are other causes4 ,a protracted instrumental delivery may cause a hemorrhage of the meninges4 ,symptoms4--,in severe cases the fit may be identical with epilepsy4 ,it is more often not so complete as true epilepsy4 ,convulsions vary considerably1 but there will be no difficulty in diagnosis4 ,it may come on suddenly1 or be preceded by restlessness1 twitching1 sometimes grinding of the teeth and fever4 ,the spasms may be either of a tonic or clonic type preceded by a cry and loss of consciousness4 ,the attack may be single1 but the fits may follow each other with great rapidity and terminate fatally4 ,it is rare for the child to die during a convulsion4 ,exhaustion and asphyxiation may cause a fatal termination4 ,as in epilepsy the temperature often rises during the fit4 ,a transient paresis sometimes follows1 if the convulsions have been chiefly limited to one side4 ,diagnosis4--,the diagnosis is generally easy4 ,the attack is usually due to the ingestion of some indigestible food or to some peripheral irritation1 or an acute disease4 ,convulsions1 appearing immediately after birth or injury1 are probably due to meningeal hemorrhages or serious injuries to the cortex2 although a few of these cases will present grave lesions of the cervical vertebr1 probably often due to protracted instrumental delivery4 ,infantile convulsions usually occur between the fifth and twentieth months4 ,convulsions occurring after the second year are more likely to be true epilepsy4 ,the prognosis depends almost wholly upon the cause1 severity and duration4 ,treatment4--,the first step in the treatment is to determine the cause if possible4 ,treatment in the region of the sixth and seventh dorsals will often give relief2 thorough work along the lumbar region and the sacrum will many times be sufficient1 if the convulsion is due to intestinal disorder4 ,c4 ,m4 ,proctor reports that in male infants he has relieved convulsions quickly1 in several cases1 by pushing back the foreskin and has always found1 in such cases1 either a phimosis or an adherent prepuce4 ,in female infants it might be well to examine the clitoris4 ,dilatation of the rectal sphincter may be of aid4 ,it may be necessary to vomit the patient1 when it is due to undigested food in the stomach2 and in some cases an enema should be used1 when the irritation is in the intestines4 ,in a few cases1 when the convulsions are due to dentition1 a lancet applied to the gums will be all that is required4 ,a thorough treatment to the cervical region1 to control the circulation1 should always be given2 at the same time apply ice to the head4 ,the patient should be put in a bath of #ie to #ih degrees ,f41 should the preceding treatment not have the desired effect1 or1 better still1 use the bath at once and treat at the same time4 ,owing to the neurotic tendency and the ofttimes trivial causes that precipitate an attack everything possible should be done to build up the general condition--adjustment of all lesions1 regulated diet and disciplined habits4 ,epilepsy ,definition4--,a chronic affection of the nervous system1 characterized by attacks of unconsciousness1 which are usually accompanied by general convulsions4 ,when there is merely a momentary loss of consciousness it is called petit mal4 ,loss of consciousness with convulsions is called grand mal4 ,when the convulsion is localized1 with or without loss of consciousness1 it is called ,jacksonian epilepsy4 ,certain cases of temporary loss of consciousness are termed psychic epilepsy4 ,etiology4--,epilepsy usually begins before puberty1 and comparatively seldom after the twenty-fifth year4 ,males suffer somewhat more frequently than females4 ,heredity predisposes to the disease to some extent1 but probably not so greatly as many writers would claim4 ,neuroses1 as insanity and hysteria1 and intermarriage of relatives1 are important elements to consider4 ,when epilepsy is inherited1 it is almost always due to some morbid state of the nervous system4 ,other predispositions to the disease may be caused from defective general development of the brain1 from impairment of the general health1 and from an exhausted nervous system4 ,many exciting causes may be found3 mental emotion1 fright1 excitement and anxiety2 blows and injuries to the head2 infectious diseases2 syphilis2 alcoholism2 masturbation2 ocular and aural irritation2 disturbed and delayed menstruation4 ,epilepsy may be excited by reflex convulsions from intestinal worms1 gastric irritation1 etc4 ,also thickening of the membranes of the brain1 pressure from a tumor at the periphery1 uterine diseases and many other sources of irritation may be found1 that are the exciting causes of epilepsy4 ,important exciting causes of epilepsy are1 undoubtedly in many cases1 due to lesions of the vertebr and ribs especially the vertebr of the cervical region1 although in some cases the lesion is in the lower splanchnic region or in the ribs 7chiefly from the fourth to the eighth74 ,these lesions to the spinal tissues disturb the nutrition to the vasomotor nerves4 ,if the real seat of the disease is in the cerebral cortex and the medulla1 the cervical lesion1 and in fact other lesions1 could readily affect the nerve force and circulation to and from these regions4 ,the vertebral artery circulation1 where a cervical lesion exists1 may be involved and affect the brain4 ,in cases where lesions of the vertebr and ribs exist in the upper and middle dorsal region1 the vasomotor innervation to the brain may be involved1 for in this region the vasomotor nerves to the cranium1 etc41 pass from the cord into the sympathetics4 ,birth injuries may affect the brain tissue1 through cervical lesions1 hemorrhages and asphyxiation4 ,conklin attaches considerable importance to stasis of the sigmoid and ascending colon4 ,lesions involving this region may result in toxins entering the blood and affecting nervous tissue4 ,to illustrate a specific exciting lesion1 the following is interesting4 ,the case was one of epilepsy that was evidently caused by a dislocated right fifth rib4 ,by producing an irritation in the region of this rib1 so that the lesion was increased1 the patient could be made to immediately suffer from an attack of epilepsy4 ,by resetting the rib1 at once the sufferer would be entirely relieved4 ,the case was cured after three months' treatment1 the chief work being to keep the rib in place4 ,rarely a subdislocated innominate bone1 or some lesion remote from the brain1 is located and found to be causing epilepsy4 ,important lesions in most cases will be readily located in the cervical region4 ,booth reports3 8,i have records of seven fairly defined cases of epilepsy--such as have been so pronounced by ,m4 ,d4's4 ,i find in all of them marked lesions in the upper cervical and in most of the cases the occiput is posterior upon the atlas or twisted4 ,in all cases there was a thickening of the soft tissues1 especially in the upper cervical4 ,the lower cervical was also much involved but not so noticeably4 ,all of the cases also presented marked disturbances in the upper dorsal2 most were decidedly anterior1 and one very posterior4 ,one was almost a confirmed drunkard2 notwithstanding the fact1 he recovered to such an extent that he went to work1 and ,i understand has been holding his position for more than three years4 ,he had had to give up his work entirely4 ,one was a hopeless case in every particular and did not seem to receive any benefit from the treatment4 ,i think it was entirely beyond help from any source4 ,the others responded very well and the results were definite and decided4 ,the length of treatment in successful cases ranges from about five weeks to a little over a year4 ,but those that were treated the greater length of time were not treated continuously40 ,after one convulsion has occurred1 others readily occur1 owing to the proneness to changes in the nerve centers4 ,very little is known as to the pathology of this disease4 ,convulsions may be caused from irritation of both the cortex cerebri and the medulla oblongata4 ,from a study of the character of the aur1 one is led to believe that there is a disturbance1 in most cases1 in the centers of the cerebral cortex2 and that the lesions so generally found along the spinal column are the true exciting causes of the disease4 ,perhaps in a few cases the irritation may be to the medulla reflexly4 ,the lesions found on osteopathic examination may act reflexly1 as has been stated1 upon the centers in the brain and excite them2 or the circulation is deranged1 and consequently the nutrition to the brain and meninges1 by vasomotor control and the vertebral vessels1 is impaired4 ,the splanchnic area and the cervical region should always receive special attention4 ,this in conjunction with all possible reflex sources1 and1 not least1 the general health1 restoring a stable nervous system if possible1 are of greatest importance4 ,as a rule1 pathological lesions are not found4 ,to the naked eye the appearance of the nerve centers is largely that of healthy organs4 ,the changes revealed by the microscope are most probably those of secondary origin4 ,recent experiments seem to show that the motor zone of the cortex is affected4 ,symptoms4--,these will be considered under the three varieties1 known as grand mal1 petit mal and ,jacksonian4 ,grand mal4--,in most cases the seizure is preceded by a pronounced sensation known as the aura4 ,this differs greatly in various individuals4 ,it may begin in a finger or toe and rise until it involves the head1 when the patient screams and falls to the floor unconscious4 ,in other cases the sensation may start from other parts of the body1 as the epigastric region1 where it may simply be a slight discomfort2 or other sensations may be felt1 as that of a ball rising from the stomach4 ,the aura may start from any part of the body as a numbness1 tingling1 chilliness1 etc41 and may1 also1 be manifested through the optic1 olfactory1 auditory and gustatory nerves1 by flashes1 smells1 sounds and tastes4 8,intellectual aur0 may also be manifested4 ,some form of aur is met with in nearly one-half the cases of epilepsy4 ,others lose consciousness so early that the patient is not aware of the onset4 ,in cases not attacked suddenly and not preceded by an aura1 a prolonged prodrome may be present for several hours or a day4 ,the patient may feel irritable1 dizzy or dispirited4 ,or he may be quiet and calmly await the attack4 ,in a few cases certain movements may precede an attack1 as running rapidly forward in a circle1 or standing on the toes and rotating rapidly4 ,the attack proper is sudden4 ,the patient falls with a peculiar cry4 ,the convulsion or fit may be divided into three stages1 that of tonic spasm1 of clonic spasm and of coma4 ,the tonic spasm succeeds the epileptic cry2 there are loss of consciousness1 pallor of the face and the contraction of pupils4 ,the body assumes a position of tetanic rigidity1 the head is retracted and rotated1 and the spine curved1 owing to an unequal affection of the muscles of the two sides4 ,the jaws are fixed1 the arms are flexed at the elbow1 the hands at the wrist1 and the fingers are clinched4 ,the legs and feet are extended4 ,the muscles of the chest are involved and respiration is suspended4 ,this stage lasts a few seconds4 ,the clonic spasm follows the tonic spasm4 ,the muscular contractions become intermittent4 ,from slight vibratory motions1 the intermittent muscular contraction becomes general4 ,the arms and legs are thrown about violently1 the muscles of the face are distorted1 the eyes rolled1 and the lips open and close4 ,the muscles of the jaw contract violently and the tongue is apt to be bitten4 ,the pupils are dilated1 the face cyanosed 7though at first the face is pale and pupils contracted7 and blood-streaked1 frothy saliva pours from the mouth4 ,the feces and urine may be discharged involuntarily4 ,the temperature rises about one degree ,f4 ,this stage lasts about one or two minutes4 ,the period of coma may last from a few minutes to several hours4 ,usually if left alone1 the patient will awaken after a few hours4 ,in a few cases mental confusion follows the waking4 ,during the stage of coma1 the face is congested but not cyanotic4 ,the muscles are relaxed and the breathing is noisy4 ,epileptic attacks during sleep1 nocturnal epilepsy1 are not rare4 ,this may continue for some time without the patient being aware of it4 ,petit ,mal4--,in this variety of epilepsy1 convulsions are absent4 ,the seizure consists of momentary unconsciousness with fixed1 staring eyes1 dilated pupils and rarely any twitching of the muscles4 ,after the attack the patient resumes his work4 ,there may be attacks of vertigo1 without unconsciousness1 and the patient may fall4 ,in a few instance there may be aur of various kinds4 ,petit mal may be a forerunner of grand mal or the two may alternate4 ,between grand and petit mal there are many grades of epilepsy varying in severity4 ,jacksonian ,epilepsy4--,the affection is always symptomatic of lesion in the motor area of the cortex4 ,the lesion is quite apt to be a tumor1 though various injuries1 inflammation1 sclerosis1 softening1 hemorrhage or an abscess may be the cause4 ,consciousness is retained and the convulsions are limited in extent4 ,tonic and clonic spasms of the same character as in general epilepsy occur4 ,a slight numbness1 tingling1 or twitching may precede the attack4 ,the severity of epilepsy varies extremely4 ,the seizure may occur but once a year or it may occur several times in a day4 ,in many cases a marked periodicity is observed4 ,the mental functions are not1 as a rule1 injured1 but when the seizures are frequent1 the health fails and the mental capacity is reduced4 ,many sufferers from epilepsy are subjects of chronic gastric catarrh1 and have at the same time an inordinate appetite4 ,quite frequently a fit may follow inordinate eating4 ,when there is a series of convulsions1 which follow one another in rapid succession and which are associated with high fever1 the term 8status epilepticus0 is applied4 ,the most common form of epilepsy is the major form4 ,about two-thirds of all attacks occur between eight a4 m4 and eight p4 m4 ,diagnosis4--,uremic convulsion closely resembles an epileptic convulsion4 ,when the history of the case1 analysis of the urine1 increased temperature and the general health of the patient are all closely observed1 error should be avoided4 ,in reflex convulsions of children1 a careful search1 and if necessary waiting a short time1 will readily determine the source of the attack4 ,when nocturnal convulsions take place without the knowledge of the patient the attack is epileptic4 ,in hysterical convulsions the patient rarely loses consciousness4 ,they rarely hurt themselves1 never bite the tongue1 the temperature is normal1 opisthotonos does not occur1 and the duration is usually longer4 ,in ,jacksonian epilepsy1 the attack is limited to some portion of the body1 or it may gradually extend into a general convulsion4 ,care should be taken to recognize petit mal4 ,prognosis4#aba--,records show that many cases have been cured and a much larger number have been benefited4 ,treatment4--,osteopathic treatment has been especially successful in epilepsy1 as compared with other treatment4 ,although the osteopaths do not claim a cure in every case1 by any means1 still about four out of every ten have been cured1 while one-half of the remaining have been greatly helped in regard to the lessening of the severity of the attack1 and in rendering the attacks less frequent4 ,conklin through his special treatment of fasting1 dieting1 enemata1 spinal adjustment1 and particular attention to the large bowel1 especially cecum and colon1 has increased this percentage4 ,this is based on several hundred cases4 ,important lesions are usually found in the cervical region1 from the third to the seventh vertebra1 though they may be as high as the atlas4 ,these lesions may affect the brain in various ways2 probably in the manner described under the etiology4 ,lesions are also found in the dorsal vertebr and when occurring below the cervical region1 the lesions are generally found in the upper and middle dorsal regions1 though they may be located at any point along the spinal column4 ,the treatment is according to the rule that applies to all osteopathic work3 an individual correction of the lesions presented in the case at hand4 ,if any general movement or treatment might be given1 it would be strong traction of the head to stretch the cervical vertebr1 or rather to separate them1 so that the circulation to the brain may be equalized4 ,another general measure is to hyperextend the neck with fulcrum at juncture of atlas and occiput1 thus releasing the upper anterior tissues that may impede cerebral circulation4 ,if the lesions in such cases are in the cervical vertebr1 probably they affect the cervical sympathetics4 ,a careful search for a source of excitation must be made throughout the entire body4 ,an irritation of the intestinal tract may be the exciting cause2 or some irritation of the genito-urinary tract may be found1 as phimosis1 masturbation1 etc41 so that it is very necessary that great care be taken in the examination4 ,subjects of masturbation usually present lesions along the genito-urinary center in the spine4 ,all possible reflex irritations should be eradicated4 ,proper hygienic measures should be added4 ,pay particular attention to the bowels4 ,place the patient in the knee-chest position and thoroughly raise the cecum and ascending colon in order to improve circulation and promote elimination4 ,baths are important1 and plenty of fresh air and outdoor exercise are of much significance4 ,the patient's mind should be occupied4 ,the question of food is an important one2 general diet--carefully regulated as to the amount given--should be prescribed4 ,a vegetable diet is usually best4 ,reduction of salt seems to have a good effect4 ,the patient must not be allowed to eat too much at a time1 nor too often4 ,if the bromides are being used1 they should be withdrawn gradually4 ,in most cases of true epilepsy a continued treatment of several months is necessary4 ,unless the patient can follow out the treatment for several months1 or even years1 in a number of cases it will be entirely useless to take the treatment2 although if the lesion present is very apparent1 and the patient is enjoying fair health otherwise1 and has not been affected long1 a treatment for a few months1 or even weeks1 might be all that is necessary4 ,surgical interference may be indicated in ,jacksonian epilepsy4 ,trephining has been practiced successfully in a number of cases and the risk from operation with modern surgery is so reduced that one is frequently justified in advising an operation4 ,during an attack1 a special treatment cannot be given to lessen the severity of the fit in all cases2 in fact1 most patients prefer not to have the seizure shortened as the after effects are more disagreeable4 ,in some cases1 at the beginning of the seizure1 exerting a firm pressure upon the suboccipital will quiet the patient4 ,this treatment probably controls the circulation of the brain1 by way of the superior cervical ganglion4 ,in cases where the exciting factor seems to be in the intestines1 and the peristaltic action of the bowels is reversed1 causing a reversion of the nerve current of the vagi1 a rapid1 firm kneading over the abdomen1 so as to establish normal peristalsis1 will suffice to prevent an attack1 if one is notified of its approach4 ,in some cases a rapid1 thorough stimulation of the solar plexus will lessen an attack4 ,possibly it reduces the blood pressure in the brain1 by bringing blood to the splanchnic region4 ,in all cases during the convulsion the patient should be carefully protected from injuring himself4 ,a towel should be twisted and placed in the mouth1 so that the tongue cannot be bitten4 ,do not place small articles as corks1 etc41 between the teeth1 as they are liable to enter the pharynx and cause suffocation4 ,the patient should be watched to protect him from any injury2 otherwise the attack should usually be allowed to spend itself4 ,migraine 7,,sick ,,headache7 ,migraine or sick headache is a neurosis1 characterized by a paroxysmal pain in the head1 usually unilateral and periodical1 with nausea1 frequently vomiting1 and disorders of vision4 ,osteopathic ,etiology4--,the disease usually begins in the first half of life1 rarely earlier than puberty and is slightly more frequent in females4 ,some weakened or depressed condition of the nervous system1 due to lesions of the upper cervical vertebr1 lesions of the inferior maxilla1 anxiety1 overfatigue1 anemia1 digestive derangements1 eye strain and menstrual disorders1 is generally the cause4 ,the hereditary factor is very important4 ,this is frequently associated with derangement of the large bowel1 especially cecum and ascending colon1 resulting in toxemia4 ,it is supposed by some to be a vasomotor disturbance1 because there are symptoms1 as pallor and flushing of the skin1 which show an involvement of the sympathetic system4 ,it is possible a spasm of cerebral arteries1 followed by vascular dilatation1 takes place4 ,the seat of the pain is believed to be in the meninges of the brain4 ,possibly in many cases where the atlas is found involved and causing the affection1 some meningeal fiber of the fifth nerve is impinged by the lesion4 ,caries of the teeth and nasal troubles are causes of the disease in children4 ,symptoms4--,a paroxysmal headache is the principal feature of migraine4 ,the attack may occur without warning1 although there are usually malaise1 restlessness and a disturbed vision preceding the headache4 ,the prodromal symptoms vary to a great extent4 ,other prodromal symptoms besides those given1 may be vertigo1 spots before the eyes1 tinnitus1 chilliness1 etc4 ,the pain is of a sharp and stabbing nature and is oftentimes limited to the temporal region of one side4 ,others describe the pain as of a binding or of a boring nature4 ,it is continuous4 ,it may be in the occiput instead of in the side of the head4 ,hyperesthesia of the surface is noticed1 but the tender points of neuralgia of the fifth nerve are absent4 ,the patient is sensitive to light and noise4 ,flashes of light occasionally attend the pain in the head4 ,hemianopia is not infrequent4 ,the temporal artery may be contracted1 the face pale and the pupil large4 ,in others the eye is dilated1 the face flushed and the pupil small4 ,nausea and vomiting are frequent1 with loss of appetite4 ,in some cases where the stomach is full1 vomiting the contents will relieve the attack4 ,should the stomach be empty1 vomiting of mucus may occur1 and is later followed by vomiting of bile4 ,tenderness is commonly found about the region of the occipital and upper cervical muscles4 ,attacks rarely occur oftener than once in ten or fifteen days4 ,during the intervals the patient may be quite well4 ,the duration is anywhere from a few hours to several days4 ,diagnosis4--,the sensory symptoms1 the paroxysmal character1 the severity and definite course1 usually readily distinguish migraine4 ,growths of the brain may be the cause of symptoms closely simulating migraine4 ,in such cases an ophthalmoscopic examination may reveal a choked disc4 ,prognosis4--,is usually favorable when the attacks are light and of short duration4 ,cases of long standing and of great severity are not so easily cured1 although in most instances great relief can be given the patient4 ,there are very few cases in which the severity and frequency of attacks cannot at least be lessened4 ,oftentimes attacks of migraine cease after middle life4 ,treatment4--,the atlas or one of the upper cervical vertebr is almost invariably subluxated4 ,this is not always the direct cause of migraine1 but it is an important factor in the causation4 ,during the attack many cases can be completely1 or at least partially relieved1 by a careful treatment in the upper cervical region4 ,but there are some cases where treatment of the cervical region is entirely unsuccessful1 and1 in fact1 aggravates the attack4 ,the details of treatment vary in every case4 ,if any defects in general health or any error in the mode of living can be found1 these of course must receive first attention4 ,rest1 diet 7a vegetable diet is best7 and regularity of meals are usually to be specially considered4 ,anything that is known to induce an attack must be carefully avoided4 ,in some patients the attacks cease so long as they remain free from mental work1 but as soon as they return to their studies the paroxysms occur4 ,every case should be thoroughly examined before a course of treatment is laid down4 ,causal conditions can generally be found1 and the correction of such usually results in a cure1 or at least in great relief4 ,errors in diet2 digestive disturbances1 as a disordered biliary tract2 disorders of the pelvic organs2 eye strain2 nasal disorders2 mental and physical fatigue1 and affections of the nose may induce attacks4 ,a beneficial treatment for many1 aside from adjusting the spinal lesions1 especially the cervical and usually a rigid splanchnic area1 is to place the patient in the knee-chest position and thoroughly raise the bowels of the right side beginning in the right iliac1 loosening possible adhesions1 etc4 ,the earlier the treatment1 the more likelihood of a cure4 ,cases of long standing are generally harder to cure4 ,preceding a paroxysm1 relief can usually be given1 but after the paroxysm has reached its height it is harder to give relief4 ,the patient should rest in a quiet room which is darkened and well ventilated4 ,besides the indicated osteopathic treatment 7generally a cervical one71 hot applications to the nape of the neck and keeping the extremities warm are helpful4 ,the nerves involved are the vasomotor1 occipital1 frontal and temporal4 ,a free evacuation of the bowels will relieve a few cases1 while washing out the stomach will help others4 ,hot fomentations over the splanchnics for thirty minutes may be beneficial4 ,during the intervals1 valuable adjuncts will be found in the use of systematic exercises and frequent bathing4 ,do not fail to have the eyes examined4 ,occupation ,neurosis ,these are a group of maladies of the nervous system1 due to excessive use of certain muscles in some oft-repeated act1 and characterized by spasm of the muscles concerned4 ,there are several varieties1 as writers' cramp1 telegraphers' cramp1 piano players' cramp1 violin players' cramp1 typewriters' cramp1 etc4 ,professional spasms1 that involve muscles of the shoulder girdle1 are not rare among osteopathic practitioners1 due to prolonged faulty methods of technique4 ,osteopathic ,etiology4--,a nervous temperament predisposes to the development of the affection4 ,previous injuries and strains of the involved parts are important factors4 ,faulty methods of writing1 and in the other disorders1 strained or cramped positions of the affected tissues1 predispose to attacks4 ,slight lesions of the bones1 joints1 ligaments and muscles are commonly found1 involving the motor and sensory nerves of the immediate locality4 ,the majority of all cases occur between twenty and fifty years of age4 ,distinctive pathological changes have not been found4 ,each case has particular lesions of its own4 ,the details of the case are characteristic of the one case only4 ,the affection is often primarily a spinal one1 due to deranged action of the spinal centers concerned in the various acts2 though1 no doubt1 excessive use of a group of muscles may result in contractions1 spasms1 contractures and nutritional changes1 that in turn will establish definite osteopathic lesions4 ,this is an illustration of a 8vicious circle40 ,symptoms4--,symptoms of the various varieties of professional neuroses develop slowly and gradually4 ,a cramp or spasm affecting the used member is an early symptom4 ,tremor1 weakness1 stiffness1 fatigue and heaviness of the affected part are present most of the time4 ,in severe cases neuritis may develop1 and a glossiness of the skin be present4 ,associated with the inability to perform the usual work1 may be mental worry and depression4 ,diagnosis4--,the history of the case and the limitation of the disease to one member1 usually make the diagnosis easy3 ,cerebrospinal diseases1 as hemiplegia2 early tabes1 affecting the arms2 and progressive muscular atrophy1 have to be carefully excluded4 ,prognosis4--,as a rule is favorable4 ,osteopathic treatment1 in the majority of cases treated1 has resulted in recovery4 ,treatment4--,rest of the part1 mental quiet and attention to the nutrition of the patient1 are the first essential considerations4 ,a change of occupation may be necessary if excessive use of parts and faulty methods can not be corrected4 ,the treatment consists of a correction of the parts irritating or disturbing the spinal centers or nerves affected4 ,the ulnar1 radial and median nerves all innervate muscles employed in writing4 ,lesions of the cord affecting these nerves may be found from the fifth cervical to the sixth dorsal4 ,in a few cases lesions occur as high as the atlas4 ,when the radial and median nerves are involved the lesions are principally found in the upper dorsal vertebra4 ,when the ulnar nerve is involved the lesions are usually slightly lower4 ,the lesions may affect the fibers of these nerves directly 7mechanically71 but more probably the vasomotor nerves are involved1 as in this region the vasomotor fibers to the arm pass from the cord to the sympathetic fibers4 ,the brachial plexus originates higher than the upper middle dorsal region1 still some of its nerves are frequently affected in the dorsal region by osteopathic lesions1 for removal of the same relieves the disorder4 ,other lesions affecting the arms are oftentimes found in the ribs on the side involved4 ,any of the first five ribs may become deranged and affect the innervation of the arm4 ,the clavicle in a few cases may be abnormally low4 ,a bursitis may be present4 ,occasionally slight subdislocations of the shoulder joint 7especially anterior7 and elbow joint are found4 ,gymnastic exercises of the arm and hand1 coupled with a general treatment of the shoulder1 arm and hand1 are beneficial4 ,hydrotherapy1 massage and friction of the involved member are useful4 ,in severe cases 8breaking up0 fibrotic tissue1 and muscle training frequently secures good results4 ,hysteria ,oppenheim defines hysteria as 8a psychosis1 which does not express itself by disorders of the intellect1 but in defects of character and emotional disturbances1 whose real nature is hidden under an almost unlimited and varied number of physical symptoms of disease40 ,the affection is about equally divided between the two sexes4 ,a neurotic tendency1 often inherited1 is an important underlying factor4 ,this condition1 when associated with lack of mental discipline1 is very apt to lead to the mental depression and outbreaks of hysteria4 ,a large number of cases are between the ages of puberty and twenty-five4 ,after forty-five the disorder is infrequent4 ,white1 ,osler's ,system of ,medicine1 says3 8,the significance of ,freud's theory is the tracing of every case to sexual traumata during childhood4 ,sexual experiences differ1 however1 from ordinary experiences--the latter have a tendency to fade out1 while the idea of the former grows with increasing sexual maturity4 ,there results a disproportionate capacity for increased reaction which takes place in the subconscious4 ,this is the cause of the mischief40 ,a distinction is made between the sexual and the sensual4 ,anders points out that lack of proper mental development1 improper hygienic surroundings and chronic toxemia are causes4 ,the direct causes of hysteria may be many1 and include physical and mental influence1 or both4 ,traumatism of various regions of the body1 but especially of the spinal column1 may excite hysteria4 ,some slight lesion of the vertebra or rib may be all that is discoverable4 ,a correction of the same is occasionally all that is necessary to remove the direct cause2 still there is usually considerable disturbance of the spinal tissues1 especially slight curvatures and muscular contractions4 ,prolonged emotional excitement1 overwork1 defective education and many moral and mental influences are potent and frequent causes4 ,masturbation or an adherent prepuce occasionally is the cause of the affection in boys1 or any excitation that produces exhaustion4 ,disturbances of the sexual system in both sexes are responsible for many cases4 ,the menstrual period and the menopause are frequent periods for the manifestation of the disease4 ,the disease often affects prostitutes4 ,disturbances of the digestive1 nervous and circulatory systems1 and general diseases of an exhaustive kind are exciting causes of hysteria4 ,dr4 ,still said that occasionally the colon is prolapsed and crowded down upon the pelvic organs4 ,hazzard#abb is of the opinion that 8a majority of the cases show a depression of all the ribs1 narrowing the thorax and often causing enteroptosis40 ,symptoms4--,the symptoms may be extremely varied1 including any symptom of the many nervous diseases4 ,the sensory symptoms are numerous4 ,the most common is anesthesia1 which may be found in certain parts of the body1 usually one side 7the left7 of the body4 ,geometrical areas that bear no relation to the innervation is characteristic4 ,the patient may not know of the sensory derangements until discovered by the physician4 ,when there is anesthesia without other nervous symptoms1 the case is commonly hysterical4 ,the most marked symptom is analgesia1 where the patient is insensible to painful impressions4 ,a pin may be placed deeply into the flesh1 and not be felt by the patient4 ,the anesthesia may extend to the mucous surfaces1 and even deeply down to the tissues of the joints4 ,organic and tendon reflexes are not changed4 ,there may be other symptoms of disturbed sensation2 as an absence of pressure1 temperature and muscular sensation4 ,hyperesthesia may be present nearly as often as anesthesia4 ,hyperesthetic areas may be found in various regions of the body1 but especially along the spinal column and in the ovarian region4 ,the 8hysterical spinal irritability0 is of special interest to the osteopath4 ,the spinal column may be affected as a whole1 or in segments1 or confined to a single vertebra4 ,especially when a spinal irritability is in segments1 or confined to a single vertebra1 are local derangements of the spinal column apt to be found4 ,correction or even pressure upon these areas will often relieve the patient4 ,severe pain over the heart may simulate angina pectoris4 ,globous hystericus is of quite common occurrence4 ,charcot refers to the ovarian hyperesthesia as follows3 8,it is indicated by pain in the lower part of the abdomen1 usually felt on one side1 especially the left1 but sometimes on both1 and occupying the extreme limits of the hyperesthetic region4 ,it may be extremely acute1 the patient not tolerating the slightest touch2 but in other cases pressure is necessary to bring it out4 ,the ovary may be felt to be tumefied and enlarged4 ,when the condition is unilateral1 it may be accompanied with hemianesthesia1 paresis1 or contracture on the same side as the ovarialgia2 if it is bilateral1 these phenomena also become bilateral4 ,pressure upon the ovary brings out certain sensations which constitute the aura hysteria1 but firm and systematic compression has frequently a decisive effect upon the hysterical convulsive attack1 the intensity of which it can diminish1 and even the cessation of which it may sometimes determine1 though it has no effect upon the permanent symptoms of hysteria40 ,the special senses may be disturbed1 although these symptoms are usually transient4 ,there may be blindness2 narrowing of the field of vision1 due to anesthesia of the periphery of the retina2 loss of hearing2 loss of smell or loss of taste4 ,motor disorders may be of different forms of paralysis1 as hemiplegia1 paraplegia or monoplegia4 ,in fact all forms of paralysis may be found in hysterical patients4 ,osier says3 8,there is no type or form of organic paralysis which may not be simulated in hysteria40 ,the affected muscles do not atrophy4 ,the paralysis is usually general1 and contractures are common4 ,local paralysis1 as of the bladder1 vocal cords and other parts of the body1 commonly occur4 ,contractures and spasms may also occur4 ,true epilepsy may even be simulated by hysterical spasms1 but on careful observation the characteristic attack of epilepsy is found wanting4 ,firm pressure may increase the severity of an attack as well as bring it on4 ,the spasms are of various parts of the body1 as the diaphragm1 bronchi1 abdominal muscles1 bladder1 etc4 ,various disturbances of the viscera may occur4 ,of the digestive tracts1 the appetite may be disturbed or depraved4 ,diarrhea or constipation may be present4 ,flatulency is a common symptom4 ,the respiratory tract may be another point of considerable disturbance in many cases4 ,dyspnea1 aphonia1 hiccough1 cough1 and exaggerated breathing1 as when cold water is poured on one1 are common manifestations4 ,various cardiac vascular symptoms may be manifested1 especially a rapid heart4 ,various vasomotor derangements are common4 ,physical manifestations1 as amnesia1 lack of will power and an excitable nature--easily moved to laughter or tears--are frequent4 ,the moral tone may be lowered4 ,even delirium1 catalepsy1 ecstasy and trance1 may be mentioned among the psychical phenomena4 ,the hysterogenous zones are of more than passing interest to the osteopath4 ,tyson writes as follows1 in regard to the hysterogenous zones3 8,these are hyperesthetic areas especially studied by ,richet1 on which persistent pressure will sometimes excite a hysterical attack4 ,while the ovaries are favorite hysterogenous zones1 the zones may be in any part of the body2 as for example1 the sides of the trunk4 ,such pressure may also cause an existing attack to subside4 ,hysterical spasms may also be localized or limited to groups of muscles40 ,especially when zones along the spine and side of the trunk are located1 the attack of hysteria may be completely relieved by correcting the localized deranged tissues4 ,convulsive seizures are not uncommon and may follow various prodromal symptoms4 ,some authors divide the symptoms of hysteria into convulsive and non-convulsive forms4 ,these are part of the many manifestations that are presented by various hysterical patients1 and it is readily seen that an osteopath has to be continually on his guard4 ,diagnosis4--,the diagnosis is generally quite easy4 ,the characteristic emotional symptoms1 associated with any of the many other symptoms which have no organic lesion1 are characteristic of the disease4 ,care has to be taken1 though1 in some cases where symptoms are presented which have organic lesions4 ,the history1 the attack and neurotic temperament1 will largely decide the nature of the affection4 ,after the 8outbreak0 the patient often feels decidedly better4 ,prognosis4--,death may occur from exhaustion1 but such a termination is rare4 ,recovery is the rule1 although the duration may be long4 ,recovery usually takes place rapidly1 after the exciting cause has been determined and removed4 ,treatment4--,first of all1 the osteopath should have due appreciation of the mental characteristics of the disease4 ,whatever is dominating the patient mentally must be either changed or abolished4 ,it is not always necessary to be harsh and severe with the patient2 but one should be firm and unyielding4 ,he can do a great deal by having complete mental control of the hysterical patient4 ,a most careful examination should be made for an exciting cause1 and when found it should be removed4 ,this naturally constitutes a very important part of the treatment4 ,a light general treatment is commonly indicated4 ,the general health1 especially the bowels1 should be carefully attended to4 ,the hygiene1 exercise and amusement of the patient should receive due consideration4 ,one has to gain the confidence of the patient1 and then be firm but kind to him4 ,relative to diet ,yeo#abc says3 8,the diet should be simple1 abundant1 and supplied regularly1 and at not too long intervals as is frequently the case in boarding schools4 ,all strong stimulants are best avoided1 and the hysterical should not indulge in strong tea or coffee1 or exciting wines and liquors40 ,the 8rest cure0 as introduced by ,weir ,mitchell1 is applicable in some cases4 ,this method consists of plenty of food1 especially milk1 absolute rest of the body and mind1 massage and electricity with isolation of the patient from friends and sympathetic relatives4 ,doubtless a general osteopathic treatment would be much better than massage4 ,yeo says that to the application of hypnotism and suggestion 8we look with little sympathy and less confidence40 ,during the hysterical convulsions1 the patient should be watched1 but extreme measures should not be practiced4 ,there is little danger of patients hurting themselves4 ,throwing cold water in the face1 or a cold bath may produce the necessary mental shock4 ,pressure over the ovary as stated in hysterogenous zones1 or some other zone of the body1 or pressure upon a large blood vessel1 as a carotid1 will oftentimes stop an attack4 ,neurasthenia 8,closely allied to1 and in some cases almost inseparable from1 hysterical states are those morbid conditions to which1 in modern times1 has been applied the term neurasthenia40 7,yeo74 ,neurasthenia is a fatigue neurosis that is characterized by mental and physical irritability and inefficiency4 ,headache1 backache1 insomnia1 and debility of the gastro-intestinal tract are common symptoms4 ,the affection is often found in that class of people who are predisposed to hysteria4 ,the disease is more common among men than women1 usually occurring after the twentieth year4 ,the predisposition may be inherited or acquired4 ,church states that 8debilitating conditions in the antecedents of neurasthenics10 and 8defective education that omits discipline and the cultivation of self control0 are important predisposing causes4 ,many of the exciting causes that produce hysteria will cause neurasthenia4 ,various lesions along the spinal column1 chiefly in the cervical and upper dorsal regions1 include the predisposing causes of a large majority of cases4 ,this spinal irritation1 taken in conjunction with overstrain of mind and body1 or probably in many cases the spinal irritation as the predisposing cause of the over strain1 results in nervous exhaustion4 ,particularly overwork1 associated with care and anxiety1 is an exciting cause of great significance4 ,the neurasthenic patient is generally of a neurotic temperament4 ,the affection may1 also1 result from various chronic diseases1 toxic conditions1 sexual excesses1 alcohol and tobacco4 ,thompson#abd believes that improper sexual hygiene and perversion or abuse of the marital relation are most important factors in the development of neurasthenia in both sexes1 and a regulation of this is imperative for a cure4 ,the symptoms are due1 to a greater or less extent1 upon spinal1 cerebral1 cardiac and gastric disturbances1 but all of these conditions are usually dependent upon vertebral and rib lesions of the upper dorsal and cervical regions4 ,care should be taken whether the condition is secondary to organic lesions4 ,the lesions in the vertebr are generally slight lateral deviations1 in the ribs upward displacements of the vertebral ends1 followed by contraction of the deep muscles in the neighborhood of the lesions4 ,a posterior condition of the atlas and a lateral lesion between the third and fourth dorsal are especially apt to be found4 ,as to spinal areas most affected ,stearns#abe says the predisposing irritations are located particularly in the first two cervical1 the first two dorsal and the last two lumbar vertebr4 ,these various lesions probably cause an impairment of nutrition in the nerve centers of the cord and brain1 or both4 ,definite morbid anatomical changes have not been found resulting from nervous debility or irritability4 ,still1 it seems probable that certain changes in the nerve cells may result from excessive functional activity4 ,traumatism is a prominent causative factor in both neurasthenia and hysteria4 ,railway and other injuries frequently produce osteopathic lesions that result in nervous disorders4 ,that there is a demonstrable pathological basis resting in sympathetics and spinal nerves1 there can be no doubt4 ,symptoms4--,to enumerate the many symptoms of neurasthenia in detail is hardly necessary4 ,the nervous debility may affect any organ of the body1 owing to the exhaustion of the nervous energy1 thus lessening the functional activity of that organ4 ,the most noticeable symptoms are various sensory disturbances and muscular weakness1 dependent in part upon the spinal lesions4 ,the patient generally feels weak and tired4 ,headache1 pains in the back and sacrum1 tender points along the spine1 and various sensations of numbness1 tingling1 etc41 are felt4 ,the mental faculties are oftentimes irritable and weak4 ,an inability to concentrate the thoughts with depression1 fear1 vertigo1 insomnia1 and many other mental symptoms1 may be manifested4 ,palpitation1 irregular action of the heart and pain over the precordia may be present4 ,ocular disturbances1 particularly blurring of letters and narrowing of the visual field1 visceral symptoms of many kinds1 and vasomotor phenomena1 as chilliness1 flashes of heat and sweating1 are among the many symptoms of which the patient complains4 ,genito-urinary disorders in the male1 and ovarian and uterine irritation and painful menstruation in the female1 are occasionally symptoms dreaded by the sufferer4 ,polyuria is frequent4 ,the symptoms or signs of great importance to the osteopath in neurasthenia1 as in many other diseases1 are the tender points along the spinal column4 ,they give direct clues as to where the lesion may be found4 ,diagnosis4--,error in diagnosis can usually be prevented by a study of the history of the case and symptoms4 ,care must be taken in determining between symptoms of organic diseases and the symptoms of a true nervous exhaustion4 ,prognosis4--,is almost invariably good4 ,only in cases where there is a tendency to mental disorder should the prognosis be guarded4 ,much depends upon the thorough cooperation of the patient4 ,it usually takes some time to perform a cure among the poorer class1 as the requirements demanded for a cure are oftentimes expensive4 ,treatment4--,naturally the treatment1 exclusive of the manipulation to correct the various lesions found1 is extremely varied1 owing to the many exciting causes and symptoms to contend with4 ,as has been stated1 the lesions are usually found in the upper spinal region2 still lesions are occasionally located in the lower spinal region1 especially in female sufferers1 when the pelvic organs are disturbed4 ,the many mental symptoms1 as inability to concentrate the mind1 insomnia1 vertigo1 headache1 etc41 are best treated through the cervical region1 with attention to the heart's action and the excretory organs4 ,careful attention should be paid to the deep posterior muscles between the atlas and occipital bones4 ,rest is very necessary4 ,changes of scene and occupation1 attention to the surroundings1 careful dieting1 hydrotherapeutic measures1 pleasant companions1 relief from responsibility1 bathing1 etc41 should receive careful attention and consideration by the osteopath4 ,set rules cannot be given4 ,the details of treatment that should be adopted are dependent upon the individual case4 ,every well trained osteopath will be familiar with such measures4 ,careful attention must be given to the secretions1 excretory organs and the circulation4 ,a study of each case will bring out the various irregularities that may exist4 ,when the nervous involvement is extensive1 a 8general treatment0 may be given4 ,such a treatment would affect the entire nervous and muscular system1 and tend to equalize disturbed nerve force4 ,bringing the muscular system into play and relaxing contracted muscles calls for more blood and nerve force1 and consequently a nutritious diet4 ,the 8rest cure10 as introduced by ,weir ,mitchell1 may be employed to considerable advantage in many cases4 ,yeo says3 8,it is in certain cases of this disease that the #8rest cure1' devised by ,weir ,mitchell1 has proved so remarkably successful4 ,but there can be no sort of doubt that it has been applied far too indiscriminately1 and that for this1 as indeed for any special method of treatment1 a careful selection of suitable cases is needful40 ,the diet should consist principally of milk at first1 followed in a few days by soft boiled eggs1 boiled rice1 lamb chops1 graham bread1 stewed fruits and butter1 and a little later by roast beef1 vegetables and light puddings4 ,porter's system of milk diet has proved effective in many cases4 ,tea1 coffee and alcohol should be avoided4 ,during the entire course of the treatment1 care should be taken to correct any lesion that may bear directly upon the cervical sympathetic1 the solar plexus and the hypogastric plexus1 as they are the great reflex centers of the body4 ,,footnotes3 #aai ,a4 ,o4 ,a4 ,case ,reports1 ,series ,,iv4 #abj ,see ,a4 ,o4 ,a4 ,case ,reports1 ,series ,,ii41 ,,iii41 ,,iv41 ,v4 #aba ,see ,a4 ,o4 ,a4 ,case ,reports1 ,series ,i41 ,,iii41 ,v4 #abb ,practice of ,osteopathy4 #abc ,manual of ,medical ,treatment4 #abd ,cosmopolitan ,osteopath1 ,october1 #aijc4 #abe ,journal of ,osteopathy1 ,january1 #aijd4 ,,diseases ,,of ,,the ,,spinal ,,cord ,acute ,myelitis ,acute myelitis is an acute inflammation1 with softening of the substance of the cord1 giving rise to marked disturbances of motion1 sensation and nutrition4 ,when the whole thickness of a section of the cord is involved1 the condition is termed transverse myelitis4 ,when an extensive area is involved1 it is termed diffuse myelitis4 ,when the gray matter around the central canal is especially affected1 it is termed central myelitis4 ,etiology4--,there can be no doubt that osteopathic lesions are very potent predisposing factors4 ,osteopathic lesions of the spine1 even of a muscular nature1 readily disturb the cord circulation4 ,it may follow repeated exposure to wet1 cold or exertion2 or be a sequel to the infectious diseases1 as smallpox1 typhoid fever1 typhus1 puerperal fever or measles4 ,it may be due to traumatism or disease of the vertebr1 as caries or cancer4 ,syphilis is a frequent cause4 ,pathology4--,to the untrained1 naked eye1 the cord may present little or no change4 ,the nervous tissues are in various stages of degeneration4 ,on section the substance of the cord is red and soft1 the line of demarcation between the gray and white matter is lost or extremely indistinct1 and minute hemorrhages are sometimes seen4 ,in very acute cases1 affecting the white and gray matter1 after injury1 when the membranes are cut1 the substance of the cord may flow out as a reddish creamy fluid4 ,the nerve fibers are much swollen and the axis cylinders broken up4 ,blood discs1 leucocytes1 and numerous granular fatty cells may also be present4 ,the blood-vessels are distended and dilated4 ,there may be thickening and hyaline degeneration of the vessel walls and hemorrhagic extravasation4 ,symptoms4--,acute ,transverse ,myelitis4--,this is the type most frequently met with4 ,the symptoms differ with the situation of the lesion1 which is generally in the dorsal cord4 ,at the onset there may be pain2 numbness and tingling in the back1 radiating into the limbs4 ,there is usually moderate fever1 malaise1 chills1 muscular pains1 a coated tongue and constipation4 ,symptoms of motor paralysis soon develop1 which may become more or less complete4 ,both motor and sensory symptoms vary to a marked degree1 depending upon the pathologic involvement4 ,the reflexes are lost at first4 ,they may soon return and are exaggerated below the lesion4 ,following this the muscles often become rigid and contracted4 ,unless the lesion is in the lumbar or cervical cord1 reaction of degeneration or much wasting of the muscles1 as a rule1 does not occur4 ,a girdle sensation frequently occurs at the level of the disease4 ,at first there is retention of the urine and feces1 later incontinence4 ,bed-sores soon develop2 also drying and hardening of the skin4 ,the nails become thick and brittle4 ,death may occur from exhaustion1 or heart or respiratory failure1 but it is rare2 segments of the cord may be completely and permanently destroyed1 causing persistent paraplegia4 ,h4 ,a4 ,greene#abf reports a case1 due to injury1 which was greatly benefited by treatment4 ,acute ,diffuse ,myelitis4--,in the acute forms the course of the disease is rapid4 ,the trophic disturbances are more marked than in the former type4 ,this form is likely to follow exposure to cold1 injuries1 tumors1 syphilis or one of the infectious diseases4 ,there may be chills1 fever1 malaise1 pain in the back and limbs1 and occasionally convulsions4 ,the reflexes are generally lost4 ,the motor functions are rapidly lost4 ,there is incontinence of urine and feces1 rapid wasting of the muscles and bed-sores develop4 ,the disease may prove fatal in from six to ten days4 ,diagnosis4--,landry's ,disease4--,in this the bladder and rectum are not affected4 ,trophic disturbances are absent4 ,there is but slight loss of sensation1 no reactions of degeneration and no girdle pains4 ,multiple ,neuritis4--,both arms and legs involved1 and slow onset4 ,the bladder and rectum are rarely involved2 the girdle pain is absent4 ,acute ,poliomyelitis4--,there are no sensory symptoms and the rectum and bladder are not affected4 ,prognosis4--,in very acute cases death occurs in from three to ten days4 ,milder cases generally recover with some loss of motor power1 although in a few cases treated by osteopathy recovery was complete1 due probably to the case being seen early and thus degeneration prevented4 ,treatment4--,lesions of the vertebr are usually readily found in cases of myelitis4 ,generally1 deranged vertebr are found in the upper dorsal region1 and occasionally lesions are located in the lumbar and cervical vertebr4 ,the treatment of myelitis is chiefly to correct these lesions1 so that the normal circulation of the cord may be reestablished4 ,one has to be very careful when treating the lesions not to cause additional injury to the cord4 ,an inhibitory treatment to the muscles about the lesion may be all the treatment that can be given at first2 nevertheless1 it aids nature just so much in overcoming the excessive irritation of the cord tissues4 ,nature has the curative means1 provided they may operate unobstructedly4 ,in a few cases the ribs in the region of the spinal lesion will be found deranged and interfering with trophic fibers1 blood-vessels and lymph vessels of the cord4 ,the patient should be kept in the prone posture at first4 ,warm baths and massage will be found of additional value4 ,the bowels and bladder should receive special attention4 ,an ice-bag to the spine may be beneficial4 ,if there is any danger of bed-sores1 use alcohol to stimulate and harden the skin4 ,rest1 liquid diet and good nursing are necessary4 ,later on careful exercising of the limbs will be beneficial4 ,chronic ,myelitis4--,this defines the conditions when the inflammation is subacute with the paraplegia and other symptoms which then naturally appear1 present1 and also with the signs of both degeneration and repair4 ,the symptoms develop slowly as compared with the acute form4 ,it should not be confused with atrophy1 pachymeningitis or tumors of the cord4 ,treatment is practically the same as in acute form4 ,surgical measures may be indicated4 ,loudon#abg reports a case due to injury which was greatly benefited4 ,poliomyelitis 7,,infantile ,,paralysis7 ,definition4--,an acute infectious disease occurring most commonly in young children1 characterized by paralysis1 rapid wasting of certain muscles1 and fever4 ,it is an acute myelitis that affects the anterior horns of the cord4 ,there are no sensory symptoms4 ,etiology4--,it usually occurs in children under ten years of age1 and the majority of cases occur before the fourth year4 ,it is more common in summer than in winter4 ,the infection seems to gain entrance through the nasal mucous membrane4 ,traumatism1 exposure to cold and overexertion1 are probably predisposing causes4 ,it has occurred in severe epidemic form4 ,morbid ,anatomy4--,the disease is most frequently seen in either the lumbar or cervical enlargement and is usually unilateral1 though there is considerable variation in the extent of the lesions4 ,in very early cases1 the condition of acute hemorrhagic myelitis1 with degeneration and rapid destruction of the large ganglion cells1 has been found4 ,in older lesions the anterior cornu in the affected region is atrophied and there is destruction of the multipolar ganglion cells4 ,the anterior nerve roots are atrophied1 the muscles are wasted and undergo a fatty and sclerotic change4 ,symptoms4--,the child may have a slight fever1 malaise1 muscular twitching1 headache1 some rigidity of the neck1 and sometimes vomiting4 ,this may last a day or several days or only a few hours1 when paralysis sets in abruptly4 ,the paralysis is rarely complete and groups of muscles only may be affected4 ,as a rule1 the paralysis comes on abruptly1 but it may come on slowly1 taking several days to develop4 ,in a few weeks1 atrophy sets in and the limb becomes flaccid1 soft and wasted4 ,the paralysis remains stationary for a time when improvement takes place1 but complete recovery is rare4 ,sometimes the growth of the bone of the affected limb is impaired4 ,usually there are no sensory disturbances and the bladder and rectum are not affected4 ,the condition of the reflexes is dependent upon the extent of involvement of the cornual cells4 ,occasionally the bulbar muscles are affected4 ,diagnosis4--,this is not difficult except in the early stages4 ,careful study of the case is commonly all that is necessary4 ,landry's paralysis and peripheral neuritis are to be differentiated4 ,prognosis4--,complete recovery is rare4 ,improvement is the rule4 ,ivie#abh tabulates sixteen cases1 all showing good results4 ,w4 ,b4 ,davis#abi reports a case cured by six months treatment and still well after three years4 ,t4 ,m4 ,king#abi one case cured and one greatly benefited and ,a4 ,s4 ,craig#abi one much helped4 ,florence ,gair1 ,f4 ,p4 ,millard1 ,a4 ,g4 ,walmsley and others report gratifying results in many cases4 ,treatment4--,in the treatment of chronic cases1 ,f4 ,p4 ,millard#acj says 8,five minutes' time is sufficiently long in treating a patient1 and sometimes too long4 99 99 99 ,start in and move every spinal joint4 ,that takes about two minutes4 ,spring the sacro-iliac articulations just enough to get motion4 ,then give a specific cervical treatment4 ,do not stop to relax muscles in a child4 ,adjust as rapidly as possible4 ,make every spinal joint yield to motion4 ,spend only one minute1 or possibly two1 on the cervical vertebr4 ,so far we have consumed four minutes4 ,the last minute we loosen up the wrist or ankle1 according to the extremities that are involved40 ,this outline has been followed with gratifying success by ,gair1 ,green1 ,bush and others in many chronic cases4 ,the procedure in acute cases is condensed from ,a4 ,g4 ,walmsley#acj3 8,isolate1 keep cool and absolutely quiet4 ,stop all food until the temperature drops to #ajj ,f4 or lower and until the pain subsides when fruit juices may be given followed by heavier foods4 ,give patient all the water he will drink4 ,where the spine is sensitive1 and it will be in many1 use hot fomentations until a specific treatment can be given4 ,if the fever is running high cool compresses will be grateful and help reduce temperature4 ,irrigate the colon twice daily with saline water4 ,do this first thing when called4 ,later once daily will do and then discontinue4 ,look carefully to the nose and throat and wash with saline or boracic solution4 ,keep feet warm as they may be cold even with high fever4 ,treat the case over a long period4 ,see that he does not overdo and observe all dietetic and hygienic measures40 ,both these men lay great stress on the importance of specific adjustments and massage of muscle tissue has little place in their treatment4 ,this1 with drill at home can be attended to by the mother4 ,ivie#aca1 among other good ideas on treatment1 gives the following3 8,may ,i suggest that when such severe results 7the acute stage7 follow a slight infection1 that we may expect to find a lesion located at such a point as will interfere with one or more of the anterior root arteries which join and supply the anterior spinal plexuses4 ,as there are only five or ten of the anterior root arteries 7,dana71 the lesions affecting them can be located throughout a wide range of the spine4 ,in a great many cases we find that the correction of lesions well up in the dorsal and even in the cervical region have increased the amount of the improvement well beyond that received in the correction of the lumbar lesions alone4 ,to promote resolution1 correct the lesions1 both muscular and bony1 and relax the muscles of the spine daily2 move every vertebra to the limit of all its possible motions2 use flexion1 extension1 rotation1 and lateral flexion at least once every day for at least a week2 and help to overcome stasis by keeping the child off its back1 turning it from side to side1 and letting it lie on its stomach as much as possible4 ,the limb1 to be kept in its best condition1 should be kept warm2 treated gently2 held in a natural position by the use of sand bags and clothes cradle1 thus beginning early the prevention of deformity2 the paralyzed muscles should not be kept on a stretch1 as that will retard any possible improvement2 stimulating rubs and baths should be given frequently40 ,in the chronic stage he advocates3 8,now that the nerve cells have been given a chance to regenerate 7removal of lesions71 the best thing to do is to force them to work if possible4 ,to do this1 the so-called resistance exercises or educational movements are to be strongly recommended2 the idea being to place the limb in a given position and then ask the child to fix all its attention on the limb and to earnestly attempt to hold it there while you move it1 or to keep making the attempt while you move the limb through its whole range of motion in that direction4 ,these movements should be so calculated that the resistance of the child will exercise the group of muscles affected4 ,the mother or nurse can give these exercises every night on going to bed40 ,acute ,ascending ,paralysis 7,,landry',s ,,paralysis7 ,definition4--,an acute disease1 characterized by an advancing paralysis1 beginning in the legs1 passing upward to the trunk and the arms and finally it may involve the centers in the medulla4 ,toxic and infectious influences that congest the nerve courses and ultimately destroy the cells seem to be the important factor4 ,the anterior gray matter of the cord is involved1 and it is probable that many cases are a form of acute poliomyelitis4 ,the spleen is congested and in some instances the lymphatics4 ,etiology4--,a definite cause has not been found1 although osteopathic lesions are important predisposing factors4 ,a toxic cause seems probable4 ,the disease is most common in males between twenty and forty years of age4 ,it may follow traumatism1 exposure1 cold or the infectious fevers4 ,symptoms4--,weakness of the lower extremities is generally the first symptom1 though the arms may be involved first4 ,this is shortly followed by paralysis4 ,the paralysis then extends to the trunk and within a few days the arms are also affected4 ,the muscles of the neck are next involved and finally those of respiration1 deglutition and articulation4 ,the reflexes are abolished4 ,the muscles are relaxed1 but generally do not waste or show electrical modification4 ,sensation is usually not affected1 but there may be tingling1 numbness1 hyperesthesia and muscular tenderness4 ,the sphincters are not involved as a rule4 ,the spleen is usually enlarged4 ,the course is variable4 ,death often occurs in from two days to a few weeks4 ,when the improvement takes place1 the part last affected recovers first4 ,diagnosis4--,this is not always easy4 ,it is sometimes impossible to differentiate between this disease and multiple neuritis4 ,the history1 the motor paralysis1 the absence of wasting and of electrical modification1 as well as the absence of involvement of the sphincters1 will definitely aid in the diagnosis4 ,prognosis4--,the prognosis is unfavorable4 ,a large majority of cases prove fatal4 ,in a few cases treated osteopathically1 results were favorable if the patient was seen early4 ,the muscles of the spinal column were markedly contracted4 ,treatment4--,the treatment of ,landry's disease consists principally of thorough treatment of the spine1 especially of the lower dorsal and lumbar regions1 and attention to the underlying toxic condition4 ,the treatment should be most thorough2 the vertebr and ribs found disordered should be corrected and each vertebra should be carefully separated 7if conditions permit7 from its neighbor4 ,when the paralysis has extended to the trunk and neck1 a thorough treatment all along the spinal column should be given with a view to relaxing the contracted muscles and to render flexible the entire spinal column1 so that the cord may be properly nourished and the progress of the disease checked4 ,careful relaxation of the contracted spinal muscles unquestionably has a potent effect upon the cord circulation1 which tends to check and retard degenerative processes4 ,treatment of the limbs directly will be found a help1 as well as direct treatment of all tissues paralyzed4 ,if swallowing is impossible1 the patient should be fed through the rectum1 or by the stomach or nasal tube4 ,see that the patient is carefully nursed4 ,massage is beneficial4 ,locomotor ,ataxia 7,,tabes ,,dorsalis7 ,locomotor ,ataxia is frequently met with4 ,it is a disease of the spinal cord wherein the ultimate effect is a sclerosis of a progressive character of the nerve courses of the posterior column4 ,it is claimed that the origin is in the protoplasmic processes of the posterior spinal ganglion4 ,the characteristic symptoms are incoordination1 ,argyll ,robertson pupil1 lightning pains and loss of knee-jerk4 ,osteopathic ,etiology and ,pathology4--,most cases develop between the ages of thirty and forty1 although it is occasionally seen in young men1 and rarely in children from hereditary syphilis4 ,males are much more frequently affected than females 7#aj to #a1 ,osler71 and the disease is much more frequent in cities4 ,predisposing causes are given as syphilis1 prolonged exposure to wet and cold1 and sexual excesses1 although there is a disposition on the part of neurologists to confine the cause of true tabes to syphilis1 some records showing as high as #ij per cent4 of the cases from that cause4 ,tabetic symptoms develop in from five to fifteen years after syphilitic infection4 ,there are no data to show the probable proportion of syphilitic cases which later develop tabes1 but it is undoubtedly small4 ,as all cases of tabes examined by osteopaths show spinal lesions1 it is reasonable to suppose that by interfering with the nutrition to the spinal cord1 they allow consequent degeneration4 ,it is also quite probable that osteopathic treatment for syphilis would1 for the same reason1 prevent sclerosis and resultant tabes4 ,that syphilis is not the only cause1 is also held by some authorities4 ,starr cites a true case from a severe blow in the dorsal region4 ,osteopathic observation would lead to a differentiation of tabes1 according to the cause4 ,cases have been recorded1 which simulated true tabes in most symptoms1 which did not have a history of syphilis4 ,j4 ,knowles makes the point that probably certain cases simulating tabes have reached what might be called an irritation stage 7pathologically7 of the nerves and their centers1 sclerotic changes not having taken place2 and he believes these cases would naturally yield to osteopathic treatment4 ,teall confirms this view by being of the opinion that these cases are the ones largely due to traumatism1 exhaustion or exposure1 and the probabilities are that in time sclerotic changes would take place1 resulting in true tabes4 ,in such cases there can be no question as to the osteopathic lesion1 which would be sufficient to materially interfere with the peripheral sensory nerves and disturb the protoplasmic processes to the spinal ganglia and sensory tract4 ,as a rule they are in the lower dorsal and lumbar regions4 ,cases are reported which had marked sacral and coccygeal lesions4 ,pathologically1 ,dana speaks of locomotor ataxia1 8as a post-infective degeneration1 which first attacks the posterior spinal ganglia or corresponding cells of the special senses1 due to a prolonged poisoning of these parts by the toxins of the infection40 ,the first change is in the posterior roots4 ,without doubt osteopathic lesions can readily affect the nutrition of these roots4 ,this is shown upon examination in cases where the vertebral lesions impinge the tissues surrounding the spinal nerve at its exit1 7or otherwise damage nervous stimuli and circulation7 and also where the displaced head of the rib crowds upwards against the spinal nerve and again where the rib impinges the corresponding sympathetic ganglion which lies anterior to the head of the rib4 ,very likely in many cases the syphilitic infection is an exciting factor1 but it seems plausible that osteopathic lesions1 traumatism1 cold1 exposure and excesses predispose by disturbing the circulation to involved areas4 ,the changes are at first inflammatory1 followed by degenerative changes in the nerve courses which cause connective and neuroglia overgrowths to take the place of fibers in the sensory tract1 and finally in the motor tract4 ,thus from the posterior ganglia1 a section between the columns of ,goll and ,burdach is involved1 and the progress of the sclerotic change is upward in the cord4 ,the pia mater and coats of the vessels are thickened4 ,the principal changes in the cord are in the lower dorsal and upper lumbar segments and the cord may be changed in shape4 ,in long standing cases there is degeneration of the ascending antero-lateral tract1 of the direct cerebellar tract1 and of the pyramidal tract4 ,the cerebral changes in some cases consist of sclerosis in the restiform bodies in the inferior peduncles of the cerebellum1 and of certain cranial nerves1 especially the third1 optic1 vagus and auditory nerves1 and also cortical changes may occur4 ,symptoms4--,authorities divide the symptoms into three stages--the preataxic1 ataxic and paralytic4 ,this division is largely an arbitrary one4 ,motor symptoms are usually the most prominent4 ,there is inability to coordinate the muscles4 ,the patient first notices that he cannot walk steadily when in the dark or when he has his eyes closed4 ,later he finds that he cannot maintain his equilibrium even in daylight2 this is ascertained when the patient places his feet together and the eyes are closed 7sign of ,romberg74 ,as a rule this is unaccompanied by muscular wasting1 so there is no loss of motor power4 ,soon the gait becomes characteristic2 in walking the feet are lifted high and are brought down heavily on the heel2 the ball of the foot comes down last1 producing what is called the 8double step20 the walk is straddling3 the limbs are thrown about1 and there is staggering1 due to incoordination4 ,incoordination also develops in the hands1 but usually later in the disease4 ,sudden involuntary movements and palsies are other motor symptoms4 ,the latter occur in about twenty per cent of cases and as a rule are of short duration4 ,paralysis and muscular atrophy do not develop until after a few years4 ,pain is an early symptom and always present2 it is of a darting1 shooting or stabbing character and appears in paroxysms4 ,it is most common in the legs1 lasting but a second or two1 and often accompanied by a hot1 burning feeling4 ,herpes may appear along the course of the nerve4 ,anesthesia and hyperesthesia of certain areas may occur4 ,a girdle sensation may be a noticeable symptom4 ,the muscular sense is more or less impaired2 there is a feeling as if there were cotton between the patient's feet and the floor4 ,retardation of tactile sensation is a common symptom4 ,the power of localizing pain is often lost4 ,the knee-jerk is lost early in the disease4 ,occasionally1 however1 cases are met where it is retained4 ,the skin reflexes are also impaired2 in some cases they may be increased at first1 but later are sure to be involved with the deep reflexes4 ,the pupil does not respond to the light1 but still accommodates for distance1 constituting the ,argyll ,robertson pupil4 ,ptosis may develop with or without strabismus4 ,optic atrophy1 which may lead to blindness1 paresis of the ocular muscle1 and contracted pupils1 may occur4 ,the ocular symptoms may appear early in the disease4 ,the visceral pains or crises are chiefly gastric and are sometimes accompanied by obstinate vomiting4 ,laryngeal1 rectal1 urethral and nephritic crises may occur1 and at times are exceedingly severe4 ,laryngeal crises may be manifested by intense dyspnea and noisy breathing4 ,constipation is common4 ,there may be retention of the urine resulting in cystitis4 ,sexual power is generally lost early4 ,trophic changes occur later in the disease4 ,the so-called arthropathies1 or joint lesions1 may occur at any period of the disease4 ,it consists of an enlargement of the joints1 associated with serous exudations1 which rarely become purulent2 atrophy of the heads of the bones2 destruction of the bones and cartilages2 or spontaneous fracture or dislocation may occur1 owing to the brittleness of the bones4 ,there is no pain and the large joints are most frequently affected2 these may be excited by an injury4 ,herpes1 skin ecchymoses1 edema1 local sweating1 alterations in the nails1 perforating ulcer of the foot1 onychia1 decay of the teeth and atrophy of the muscles may occur4 ,the auditory nerve is rarely affected1 but in some cases there may be deafness4 ,there may be attacks of vertigo4 ,olfactory symptoms are rarely met with4 ,cerebral symptoms are rare4 ,paralysis may develop and the patient becomes bed-ridden4 ,the disease itself does not prove fatal2 the patient may live for years until some intercurrent disease causes death4 ,diagnosis4--,this is usually easy when the characteristic symptoms are developed4 ,the presence of lightning pains1 absence of the knee-jerk1 early ocular palsies1 a squint1 ptosis and ,argyll ,robertson pupil make the diagnosis conclusive4 ,care has to be taken in making diagnosis from peripheral neuritis1 paresis1 ataxic paraplegia1 cerebral disease and some diseases in which the posterior columns are disturbed4 ,prognosis will depend largely on the exciting cause1 as it is least hopeful from syphilis1 but the earlier the case is treated the better the chance4 ,the progress of the disease can sometimes be arrested and occasionally cases presenting symptoms of the first and second stage are entirely relieved with persistent treatment4 ,treatment4--,experience in the treatment of locomotor ataxia has been that often the disease can be checked and the symptoms relieved2 but curing a case of locomotor ataxia1 except in the early stages1 is seldom possible4 ,when there is degeneration of nerve centers1 there is no hope for a cure4 ,those with a syphilitic history are by far the hardest to relieve4 ,antisyphilitic treatment should be considered4 ,cases with a syphilitic history presenting preataxic symptoms1 ,argyll ,robertson pupil1 lightning pains and loss of patellar reflex have been cured2 unfortunately these cases are not always diagnosed4 ,the treatment consists of thorough correction of the spinal derangements found1 especially through the lumbar and lower dorsal regions4 ,if the disease has involved the arms or brain1 thorough treatment should be given the entire length of the spine with a view to increasing the circulation in the spinal cord and brain1 and thus checking or preventing the tissue degeneration4 8,in the early stage1 deep massage to the muscles of the back promotes the flow of venous blood through the spinal vessels and their anastomotic branches1 and is the best means of relieving the congestion which is supposed to exist40 7,starr7 ,the lower spine will be found to be rigid and should be well sprung to get mobility4 ,careful treatment of the limbs should be given1 but be exceedingly cautious in the treatment of the limbs of advanced cases1 as there is considerable danger of producing fractures4 ,stretching the thigh muscles and internal and external rotation treatment of the legs should be given4 ,see that the bowels are moved daily and be positive that there is no retention of the urine in the bladder4 ,a catheter has to be used in some cases4 ,the patient should be careful about taking too much food1 and especially beware of indigestible food1 as it irritates or excites gastric crises4 ,during painful attacks the patient should rest in bed1 and with careful treatment the attack can generally be relieved4 ,hot applications are of considerable aid4 ,at all times excesses should be avoided4 ,occupation of some character should be given the sufferer4 ,do not promise to cure the patient1 and make it plain at the start that it will probably require a long time to show much improvement4 ,systematic exercises to reestablish coordination should not be neglected4 ,hereditary ,ataxia 7,,friedreich',s ,,ataxia7 ,this is a rare hereditary disease1 due to sclerosis of the columns of ,goll and ,burdach and the pyramidal tracts4 ,there are ataxia1 muscular weakness1 nystagmus1 speech disorders and loss of knee flex4 ,almost invariably there will be found a neuropathic history4 ,alcoholism1 syphilis and insanity in the parents are predisposing causes4 ,tuberculosis may be a factor4 ,acute diseases1 especially infectious fevers1 dentition and injuries to the spine may be exciting causes4 ,it occurs most frequently in males about the seventh or eighth year and very seldom after puberty4 ,several members of the same family are apt to be affected4 ,the disorder is transmitted by the female4 8,the degeneration of the posterior and pyramidal columns seems to occur at the time of cord development1 when malnutrition or hereditary dyscrasia would disturb it most40 ,pathologically1 8the spinal cord is smaller throughout than normal2 we have also a combined disease of the posterior and lateral tracts 7,schultze71 a degeneration of ,goll's tract in toto1 of ,burdach's almost entirely1 and of the direct cerebellar1 the crossed pyramidal 7871 and of ,clarke's columns1 in which we find not only atrophy of fibers1 but also a degeneration of the ganglion cells4 ,gower's tract may likewise be involved40 7,oppenheim74 ,symptoms4--,impaired coordination1 beginning in the legs and later extending to the arms1 is the first marked symptom4 ,the gait is peculiar2 it is swaying and irregular and it lacks the pronounced stamping gait of locomotor ataxia4 ,there is a loss of reflexes1 while no sensory symptoms are present as a rule4 ,the sphincters are normal4 ,nystagmus is present and is a characteristic symptom4 ,the speech is scanning4 ,talipes and lateral curvature of the spine are common4 ,the mind becomes sluggish in later stages4 ,the course is always very slow4 ,diagnosis4--,this is not difficult as a rule1 owing to the usual family history presented4 ,the spinal curvature1 nystagmus1 incoordination1 scanning speech1 irregular gait1 and deformity of the feet are symptomatic4 ,in locomotor ataxia the gait1 sharp pains1 anesthesia and ,argyll ,robertson pupil will differentiate between the two4 ,differentiation will also have to be made from chorea1 ataxic paraplegia and multiple sclerosis4 ,treatment4--,the same treatment as in locomotor ataxia is followed4 ,lesions presented have been found at the tenth and eleventh dorsals1 and at the second and third cervicals1 although1 as a rule1 the entire spinal column is quite debilitated4 ,some improvement will be noted in these cases1 but not much can be expected from treatment2 contractures may be prevented4 ,spastic ,paraplegia ,spastic paraplegia begins as a stiffness in the legs1 with no sensory symptoms1 but finally the muscles become rigid and slowly paralyzed4 ,the reflexes are exaggerated4 ,it may occur1 in a few instances1 as a primary disease1 8being a degeneration of the motor neurone1 whose body lies in the brain cortex and whose axone lies in the lateral pyramidal tract40 ,usually it is secondary to tumors1 inflammation and softening of the brain4 ,multiple sclerosis1 hemorrhage1 transverse myelitis1 syringomyelia and other diseases of the cord1 injury1 exposure and overexertion are exciting causes4 ,syphilis may be a cause4 ,it generally develops between the ages of twenty and forty4 ,pathologically1 the degeneration involves the lateral pyramidal columns of the cord4 ,it begins at the periphery and extends upward until finally the axones atrophy and neuroglia overgrowth takes place and sclerosis of the motor tracts results4 ,symptoms4--,muscular stiffness in one leg is usually the first symptom1 which gradually disturbs both sides4 ,the muscular stiffness increases to a rigidity1 and even cramps1 so that it is with considerable difficulty that the patient moves about4 ,the reflexes are exaggerated4 ,the joints1 as well as the muscles are stiff1 so that the toes are dragged upon the ground and the legs are kept close together1 abduction of the limbs being difficult4 ,on the whole1 there is much tiredness1 stiffness1 rigidity and hardness of the leg muscles1 so that all motions with them are performed with great effort4 ,sensory and trophic symptoms are lacking2 control of the bladder and rectum is usually normal4 ,the progress of the disease is slow4 ,the upper extremities may be involved in after years1 but the common extensive disturbance is with the legs1 so that they may be entirely useless and the muscles atrophy from disuse1 although rigidity and contractures remain4 ,treatment4--,the prognosis is usually unfavorable1 though frequently the patient may be considerably benefited4 ,a few cases that have been caused by traumatism1 cold or exposure have yielded to osteopathic treatment and all symptoms disappeared4 ,the treatment is largely that of locomotor ataxia4 ,the lesions are readily located in the spinal column4 ,in a few cases a slight posterior curvature of the dorso-lumbar region is found1 but the majority of the lesions are in the lower dorsal region4 ,special care should be given to the bladder and bowels4 ,prolonged warm baths are beneficial4 ,treatment of the legs is always secondary to that of the spine4 ,the diet should be nutritious and one easily digested4 ,give the patient plenty of fresh air and sunlight with cheerful surroundings4 ,e4 ,c4 ,link#acb reports two cases1 one of over one year's standing1 completely recovered1 and another much improved4 ,ataxic ,paraplegia ,in ataxic paraplegia there are ataxic and spastic symptoms1 due to both posterior and lateral sclerosis4 ,traumatism1 cold and exposure are etiologic factors4 ,it is found in diffuse myelitis1 general paresis1 leptomeningitis and in toxic conditions as in pernicious anemia4 ,the posterior and lateral columns are degenerated1 so that in the former there is an ascending degeneration and in the latter a descending4 ,symptoms4--,these comprise those of tabes and spastic paraplegia4 ,incoordination1 ataxia1 lightning pains1 anesthesia1 rigidness of muscles and exaggerated reflexes are the principal symptoms4 ,the muscles easily fatigue2 sensory symptoms are not so troublesome as in tabes2 there may be visceral crises1 sometimes ,argyll ,robertson pupil2 and possibly spasms of the upper extremities and jaw4 ,the course of the disease is slow4 ,diagnosis4--,this is not difficult as a rule4 ,first1 there is ataxia2 then increased reflexes1 fatigue of the muscles and paraplegia4 ,tumor of the cerebellum may confuse the diagnosis4 ,treatment4--,there is frequently a chance to greatly benefit these cases1 and even in some instances a cure may be performed1 provided the case is seen early4 ,thorough treatment of the spine to relax the muscles and to adjust the ribs and vertebr is the indication4 ,stretching the spine1 if carefully done1 is beneficial4 ,muscular manipulation improves the spinal cord circulation1 and osseous correction removes probable impingements to nutrient channels and nervous influences induced by cold1 exposure1 traumatism and secondary disturbances4 ,care of the general health1 hygiene1 diet1 etc41 are important4 ,syringomyelia ,definition4--,a chronic affection of the spinal cord in which there is an embryonal neurogliar overgrowth about the central canal1 with cavity formation4 ,it is characterized1 clinically1 by progressive muscular atrophy1 peculiar disturbances of sensation and various trophic and vasomotor disorders4 ,the onset generally takes place before the thirtieth year4 ,males are much more commonly affected than females4 ,it is claimed by some that the disease is infectious4 ,it frequently follows trauma4 ,pathologically1 the condition begins with an overgrowth of embryonal neurogliar tissue4 ,this is followed by degeneration of the gliomatous tissue with a formation of cavities1 or this cavity formation may be the result of hemorrhage4 ,the disease1 in most cases1 involves only the cervical or dorsal regions1 and is usually in the posterior or postero-lateral tracts4 ,the cavity may prevail throughout the entire cord1 but usually only the cervical and dorsal regions are involved4 ,the cavities lie in the gray matter outside of the canal4 ,symptoms4--,the onset is slow4 ,the symptoms depend upon the situation and extent of the cavity4 ,as the disease most frequently involves the cervical region1 the neck and arms are usually affected4 ,at first neuralgic pains may develop in the muscles4 ,later there is progressive muscular atrophy and loss of painful and thermic sensations4 ,tactile and muscular senses are usually intact4 ,the reflexes are increased and a spastic condition is present4 ,the lower limbs usually escape1 but when they are involved the clinical picture may be that of amyotrophic lateral sclerosis4 ,a lateral curvature is present4 ,when the disease extends into the medulla1 there will be various bulbar symptoms4 ,trophic changes and vasomotor disorders are common4 ,a form of syringomyelia1 known as ,morvan's disease1 is characterized by neuralgic pains1 cutaneous anesthesia and painless felons4 ,diagnosis4--,the progressive muscular atrophy1 the retention of muscular and tactile senses1 and the loss of thermic and painful sensations are typical symptoms4 ,the diseases with which it may be confounded are3 ,cervical ,pachymeningitis4 ,the pain is usually greater1 the tactile sense is lost and it runs a more rapid course4 ,anesthetic ,leprosy4 ,the trophic changes are more marked1 tactile sensation is lost and the phalanges often drop off4 ,progressive ,muscular ,atrophy and ,amyotrophic ,lateral ,sclerosis4 ,sensory symptoms are wanting4 ,prognosis4--,the prognosis is unfavorable4 ,duration is from five to twenty years4 ,treatment4--,little can be done except attending to the diet and hygiene of the patient and meeting urgent symptoms4 ,probably1 continued treatment along the spinal column would influence to some extent the circulation of the cord in the region of the involvement4 ,hot applications are of value in relieving pain and cramps4 ,the ,x-ray has proven of some benefit in checking the progress of the disease4 ,amyotrophic ,lateral ,sclerosis 8,this is a chronic1 progressive form of spinal paralysis1 characterized by the symptoms of progressive muscular atrophy in the arms and by lateral sclerosis or spastic paraplegia in the legs40 7,starr74 ,it is similar to progressive muscular atrophy1 except1 in addition1 there is sclerosis of the pyramidal tract4 7,see ,progressive ,muscular ,atrophy47 ,osler classes progressive muscular atrophy of spinal origin1 amyotrophic lateral sclerosis and progressive bulbar paralysis as diseases of the whole efferent or motor tract1 wherein these disorders may simply be various stages in the same case4 ,he says1 8,a slow1 atrophic change in the motor neurones is the anatomical basis1 and the disease is one of the whole motor path1 involving1 in many cases1 the cortical1 bulbar1 and spinal centers40 ,there can be no question that for the student1 a classification of spinal cord diseases according to the whole motor tract1 the upper motor segment1 the lower motor segment1 etc41 is a scientific classification from our present knowledge of the histology and physiology of the neurone1 but for clinical purposes the usual classification is given4 ,osteopathically1 we are greatly in need of a new nosology1 either according to the cause of the disorder or to the physiological disturbance4 ,amyotrophic lateral sclerosis does not occur so frequently as progressive muscular atrophy4 ,heredity plays a part1 and it affects older people4 ,injury to the spinal column is undoubtedly an important factor4 ,exposure and cold may be exciting causes4 ,infectious diseases and syphilis are probably important causes4 ,pathologically1 there are atrophy in the anterior cornu and sclerosis of the crossed and direct pyramidal tracts4 ,there is sclerosis of centers in the medulla4 ,symptoms4--,atonic atrophy1 muscular weakness and fibrillary contractions1 of varying degrees1 are characteristic4 ,the reflexes are exaggerated2 the arm and leg muscles become weak and finally rigid and atrophied4 ,this results in deformity4 ,disturbances of sensation are not pronounced4 ,the sphincters may be slightly affected4 ,diagnosis4--,the disease is not so prolonged as progressive muscular atrophy4 ,differentiation has to be made from multiple arthritis and transverse myelitis and syringomyelia4 ,treatment4--,the same treatment as outlined for progressive muscular atrophy is indicated4 ,the disease may be retarded and life prolonged4 ,progressive ,muscular ,atrophy ,a disease characterized by a slow1 but progressive1 loss of power and by muscular atrophy4 ,anatomically1 it is characterized by degeneration of the ganglion cells of the gray matter in the cord4 ,this atrophic affection develops just opposite to that of chronic anterior poliomyelitis4 ,it is commonly a disease of males in middle life4 ,syphilis1 rheumatism and lead poisoning predispose4 ,it sometimes follows cold1 wet1 exposure1 traumatism1 mental worries1 overuse of certain muscles1 or prolonged emotional excitement4 ,hereditary influences are present in some cases4 ,in all cases lesions are detected in the vertebr and ribs1 corresponding to the innervation of the diseased areas4 ,very likely these lesions are the starting point of the disease1 by impairing nutrition to the motor cells of the anterior cornu1 and thus resulting in atrophy4 ,pathologically1 the muscles are wasted1 the fibers undergo fatty degeneration and there is an overgrowth of connective tissue4 ,the peripheral motor fibers are degenerated4 ,the anterior nerve roots leading to the horns are atrophied4 ,the large ganglion cells of the anterior horns are atrophied1 or even entirely removed4 ,the neurogliar tissue is increased4 ,there is sclerosis of the anterior and lateral pyramidal tracts of the cord in the majority of cases4 7,see ,amyotrophic ,lateral ,sclerosis74 ,the pyramidal tracts have been found degenerated through the pons and internal capsule1 even up to the motor cortex4 ,when bulbar symptoms are present1 there is degeneration of the motor nuclei of the medulla4 ,the posterior columns are not involved4 ,symptoms4--,irregular pains1 numbness or exhaustion are usually felt in the region that is soon to become wasted4 ,the upper extremities are first affected4 ,the muscles of the ball of the thumb waste first1 then the interossei4 ,from atrophy of the interossei and lumbricales and contraction of the long extensor and flexor muscles1 the deformity known as 8claw hand0 results4 ,the wasting creeps up from the forearm1 arm and shoulder4 ,the muscles of the trunk are gradually affected4 ,the muscles of the lower extremity may escape entirely4 ,the platysma myoides does not waste and is often hypertrophied4 ,the face muscles are attacked late or not at all4 ,the affected muscles often twitch4 ,deformities and contractures develop1 notably lordosis4 ,sensation is not impaired although the patient may complain of numbness and coldness4 ,the bladder and rectum are not affected1 but sexual power may be lost4 ,the paralysis is flaccid and the reflexes absent in the so-called atonic cases4 ,in atonic atrophy there is more or less spasm1 the reflexes are greatly increased1 there are often contractures and the wasting is usually trifling4 ,diagnosis4--,differential diagnosis has to be made from syringomyelia1 chronic anterior poliomyelitis1 lead palsy and muscular dystrophies4 ,prognosis4--,the prognosis of progressive muscular atrophy is not favorable1 although a number of cases have been greatly helped by an extended course of treatment4 ,treatment4--,the treatment consists of a thorough1 stimulating treatment of the innervation of the affected regions1 with manipulation of the muscles and parts diseased4 ,correction of the lesions to the vertebr and ribs1 which are involving the innervation to the diseased tissues1 is of primary importance4 ,a cure cannot be expected when degeneration of the nerve centers has occurred2 still1 the progress of the disease may be checked in many cases1 and the patient occasionally gain considerable strength4 ,when atrophy starts in the muscles of the ball of the thumb1 the lesion is to the median nerve1 and derangements of the cervical vertebr1 from the fifth to the seventh1 may be found4 ,attention to the general health is important4 ,outdoor life is preferable and gymnastic exercises are of value1 but do not overtax the strength4 ,bulbar ,paralysis 7,,labioglossolaryngeal ,,paralysis7 ,a progressive atrophy and paralysis1 invading the lips1 tongue1 pharynx and larynx1 due to involvement 7sclerosis7 of the motor nuclei of the medulla oblongata that supply these tissues4 ,it is rarely primary1 more frequently secondary to tabes1 amyotrophic lateral sclerosis and diseases involving the motor nuclei of the medulla4 ,diphtheria1 syphilis and lead poisoning are said to predispose4 ,osteopathic lesions of the upper cervical are also important factors in many cases4 ,halbert says3 8,the nuclei of the hypoglossal1 the spinal accessory1 the facial and the motor part of the trifacial nerves suffer most decidedly from the sclerotic degeneration4 ,the nerve trunks and the muscles which they supply gradually show the effects of a similar degeneration40 ,the acute form results from hemorrhage1 embolism or inflammatory softening4 ,the onset is usually sudden4 ,the speech is difficult or entirely lost4 ,there are dribbling of saliva1 difficult swallowing1 flabbiness and flaccidity of the lips and frequent choking spells occur4 ,these cases may prove rapidly fatal4 ,the chronic form may result from progressive muscular atrophy1 insular sclerosis1 amyotrophic lateral sclerosis1 acute ascending paralysis or chronic poliomyelitis4 ,the paralysis starts in the tongue1 the first symptom being a slight defect in the speech4 ,when the lips become involved1 the patient cannot whistle and speech is rendered still more difficult4 ,the lips are prominent and the lower one drops4 ,the saliva is increased in amount and there is drooling4 ,mastication of the food becomes difficult4 ,the tongue becomes atrophied and the mucous membrane wrinkled4 ,fibrillary tremors of the lips and tongue are present4 ,sensory symptoms are not present4 ,taste is normal4 ,paralysis of the larynx is not so pronounced as of the other parts4 ,diagnosis4--,this is generally easy as the symptoms are well marked4 ,the prognosis is unfavorable4 ,treatment4--,little can be done in the majority of cases4 ,only in those cases where the paralysis is caused by cervical lesions can much hope be given4 ,derangements of the cervical vertebr1 especially the atlas and axis1 occasionally influence the circulation in the medulla to such an extent that the motor nuclei are greatly involved4 ,the subluxated vertebras may interfere with the blood-vessels directly or through the vasomotor and trophic nerves4 ,when the onset is not abrupt1 the prognosis is more favorable4 ,when deglutition is impaired1 the stomach tube should be used in feeding the patient to prevent the food passing into the trachea4 ,,footnotes3 #abf ,a4 ,o4 ,a4 ,case ,reports1 ,series ,v4 #abg ,a4 ,o4 ,a4 ,case ,reports1 ,series ,,ii4 #abh ,a4 ,o4 ,a4 ,case ,reports1 ,series ,v4 #abi ,a4 ,o4 ,o4 ,case ,reports1 ,series ,i4 #acj ,millard1 ,poliomyelitis4 #aca ,journal of the ,american ,osteopathic ,association1 ,february #aijf4 #acb ,journal of ,osteopathy1 ,oct4 #aijd4 ,,orthopedic ,,surgery ,by ,h4 ,s4 ,,hain ,orthopedic surgery deals with the mechanical or surgical prevention and correction of all deformities1 especially those of children4 ,it is not alone justifiable1 but imperative1 that orthopedic surgery be given a prominent position in any up-to-date text on the ,principles and ,practice of ,osteopathy4 ,the justification is threefold3 though orthopedics was practiced to a limited extent before the ,science of ,osteopathy was developed1 it has always been considered to be outside the realms of true surgery1 in that it is practically bloodless1 and those engaged in such practice have sought to establish it upon a platform of its own4 ,the basis of the practice of orthopedic surgery and osteopathy is similar1 if not identical1 in that it deals almost entirely with bony abnormalities4 ,it is recognized by the whole osteopathic profession1 and unconsciously by some adherents of medical science1 that the maintainance and restoration of normal function are alike dependent on a force inherent in bioplasm and that function perverted beyond the limits of self-adjustment1 is dependent upon a condition of structure perverted beyond those limits4 ,this1 then is the platform upon which the two sciences of osteopathy and orthopedic surgery are erected4 ,the technique of osteopathic practice consists of passive manipulative measures1 designed to render to the organism such aid as will enable it to overcome or adapt itself to the disturbed structure2 and does not seek1 in itself1 the aid of any instrument1 mechanical appliance or plaster of ,paris cast4 ,surely it is but a short step from our osteopathic therapeutics to a system of therapeutics where we find all sorts of mechanical and plaster of paris appliances1 etc41 to help our passive manipulation in rendering to the human organism such aid as will enable it to overcome or adapt itself to a disturbed structure4 ,this latter1 of course1 is the modern science of orthopedic surgery1 and because of the shortness of this step1 ,i insist that it is one of the most valuable adjuncts of the science of osteopathy4 ,it is frequently necessary for the osteopathic practitioner to take this step as conditions are met with that have progressed beyond the possibilities of passive manipulations and again other conditions of perverted structure can be much more quickly reduced by the aid of each4 ,it is then indisputable that the therapist who approaches disease from the osteopathic standpoint1 above enunciated1 is far more competent to deal with the mechanical problems of orthopedic surgery than any other known therapist4 ,secondly1 in many conditions originally treated by orthopedic methods1 subsequent ordinary osteopathic manipulations obtain a much more satisfactory and more lasting result than if it is withheld4 ,thirdly1 in order to avoid possible error1 it is of extreme importance that all osteopathic practitioners be particularly familiar with the conditions hereinafter described1 more especially tubercular conditions of the spine1 bones and joints1 primary spinal curvatures and others4 ,it is reasonable and furthermore true that osteopathic physicians are confronted in practice with an unusually large percentage of cases indicated above1 and the early recognition of such conditions is of fundamental importance in order that osteopathic manipulations be withheld and supplemented or replaced by orthopedic methods4 ,space of course will not permit of the entire discussion of this vast subject but the most important and serious conditions met with in general practice are fully discussed in the following pages of this chapter4 ,perhaps the commonest condition coming under this line of therapeutics1 and one in which we1 as osteopaths1 are most vitally interested is rotary lateral curvature of the spine4 ,from my personal observation and from experiences of some of the most prominent members of our profession1 ,i am led to believe that this is one of our most difficult lesions to overcome osteopathically1 hence my desire to go further into this condition than most of us might expect4 ,i had opportunity to obtain personally some very valuable information from ,dr4 ,joachim ,stahl in the ,king's ,charity ,hospital in ,berlin1 and to him ,i am deeply grateful for many of the ideas of treatment presented in the following article4 ,i believe that ,i have an accurate conception of the pathological condition that exists in connection with this deformity1 and ,i believe that my treatment of it has been more successful than any that ,i have seen under other methods1 in that ,i have gotten most excellent results1 in selected cases1 in a comparatively short time1 entirely because osteopathic manipulations and exercises were used in connection with the modified ,abbott method4 ,scoliosis or ,rotary ,lateral ,curvature ,scoliosis or ,lateral ,curvature of the ,spine is a deformity where the spine is deviated in whole or in part to one or the other side of the median line1 which deviation is accompanied by an element of rotation4 ,though usually considered as a spinal deformity its effects are obvious outside the spinal area in so much as it will cause deformity of the pelvis1 legs1 ribs1 sternum1 scapul1 and in severe cases1 of the thoracic and abdominal viscera4 ,curvatures of the spine are the result of one of two distinct factors3 first where there is a primary disease of the bone causing more or less destruction of the bone and spinal articulations1 and resulting in permanent spinal curvature4 ,the most common example of this condition is seen in the angular curvature of ,pott's disease4 ,rickets is usually responsible for a general long posterior curvature of the whole spine1 as is osteomalacia with the superimposition of some lateral deviation4 ,further1 any type of inflammation or trauma is capable of producing curvatures of various types4 ,second1 where there is no primary disease of the bone1 joints1 or ligaments1 and where the curvature is due to external forces acting constantly or at frequently recurring intervals on the spine4 ,scoliosis or lateral curvature belongs to the second class4 ,it is unfortunately necessary to further subdivide scoliosis into two classes2 one where the curvature is a position permanently maintained but capable of being reproduced by extreme physiological movement of a normal spine1 and secondly1 a position which no normal spine can assume and which necessarily implies a change in the normal shape of the bones and intervertebral discs4 ,the first may be described as a functional or postural lateral curvature1 and the second as an organic or structural lateral curvature4 ,further1 ,i might say that the first type may progress until it becomes the organic type4 ,pathology4--,in scoliosis the spine undergoes not only curvature or lateral deviation but also rotation of the vertebral bodies which you will note always takes place towards the convexity of the curve4 ,changes in the ,individual ,vertebr4--,the bodies may be either wedge shaped or lozenge shaped4 ,in wedge shaped vertebr1 the bodies are compressed on the concave side and extended on the convex side1 the intervertebral discs being atrophied on the shortened side4 ,in the lozenge shaped type1 the change in the bodies is most marked at the junction of the opposite curves1 and is thus more commonly observed in compound curvatures4 ,the pedicles are directed more antero-posteriorly on the convex side and more transversely on the concave side4 ,the transverse processes on the convex side are more antero-posterior than normal1 causing the vertical furrow between them and the spine to be narrower on this side4 ,the spines point towards the concavity in structural curvatures and toward the convexity in the functional type4 ,the vertebral foramen is rounded in the convexity and pointed in the concavity4 ,the edge of the anterior common ligament toward the convexity is greatly thinned while it has a well marked edge on the concave border4 ,a fibrous degeneration occurs in the muscles on the convexity owing to stretching1 while atrophy from disuse takes place in those on the concave side4 ,associated changes in the ,viscera4--,the dorso-lumbar curvature decrease in the volume of the lower thorax on the dorso-convex side tends to cause pleural adhesions with obliteration of the pleural sac and consequent collapse4 ,tuberculosis of the lung is common in patients who suffer from scoliosis4 ,the heart is often overworked but the above lessening of the pulmonary area in turn results in hypertrophy and dilatation of the right ventricle and subsequent general venous stasis4 ,the kidney on the convex side is compressed1 and as a result degenerative changes are prone to occur4 ,the spleen is frequently displaced upward and is liable to pathological changes4 ,organs such as the stomach1 transverse colon1 esophagus and trachea are frequently displaced owing to the bony deformity and are thereby more prone to pathological change4 ,etiology4--,the essential factor in the production of scoliosis is spinal insufficiency1 which includes spinal muscles and ligaments as well as the bones4 ,in many instances1 however1 the following factors have an important augmenting or predisposing effect4 #a4 ,occupational ,deformity4--,primarily under this classification1 ,i have found faulty positions adopted by school children as being the most comfortable1 to be perhaps most important4 ,occupations such as those of nurse-maids1 hod carriers1 or stone cutters1 are apt to induce scoliosis4 #b4 ,diseases of the ,central ,nervous ,system4--,unilateral weakness or paralysis of the muscles of the trunk are common causes of scoliosis4 ,anterior poliomyelitis plays a particularly important part as it may induce deformity by distortion of the lower extremity or by any inequality in the length of the limbs due to retardation of growth1 as well as inducing general weakness of the muscles of the trunk4 ,other nervous disorders that should be considered are spastic paralysis1 locomotor ataxia1 syringomyelia and ,friedreich's ataxia4 #c4 ,incidental ,deformity4--,scoliosis may be caused by direct injury or by fracture1 ,pott's ,disease1 or organic affections of the spine4 ,marked deformity caused by ,sciatica or lumbar neuritis1 if persistent may finally induce permanent deformity4 #d4 ,deformities ,due to ,diseases of the ,chest4--,in empyema or pleurisy one side of the chest is retracted and it will be noticed that the curvature occurs toward the healthy side4 ,chronic pulmonary tuberculosis producing fibrosis of the lung gives the same result as empyema and pleurisy4 #e4 ,deformity due to obliquity of the pelvis4--,this type may be due to any inequality of the limbs1 such as equinus of the foot4 ,congenital dislocation of the hip may play a part while one naturally lays stress on pelvic and lower lumbar lesions4 #f4 ,deformity due to ,distortion of ,other ,parts4--,unequal visions1 unequal hearing1 and torticollis by causing malposition are etiological factors especially in school children4 ,the loss of an arm will tend to cause an asymmetrical position of the trunk4 #g4 ,congenital ,deformity4--,congenital scoliosis occurs1 but is usually associated with other congenital deformities of the spine1 such as the reduction or increase of the vertebr1 cervical rib1 elevation of the scapula1 etc4 ,the deformity is usually not apparent until later years1 though it may occur at birth4 #h4 ,spinal ,lesions4--,any osteopathic lesion predisposes to curvature because it interferes with the nerve supply and tonicity of the spinal muscles and could readily cause the faulty position4 ,functional or ,postural ,lateral ,curvature ,this is a condition where there is a gradual curve to one side unaccompanied by any marked rotation4 ,the maximum deviation may be no more than one inch and a half from the middle line1 which point is generally found about the tenth dorsal vertebra4 ,in the vast majority of cases deviation is to the left and in such the following alterations will be noticed3 a general convex curve to the left2 elevation1 and anterior displacement of the left shoulder2 posterior displacement of the right shoulder2 in extension1 the right side of the back will be higher than the left and in addition some torsion to the concave side1 which is easily understood if one recalls the exact changes that take place during side movement of the normal spine4 ,it is important to remember that functional scoliosis disappears when the patient is suspended or assumes the recumbent position4 ,organic or ,structural ,scoliosis ,this term is applied to cases where definite change has taken place in the vertebr4 ,organic curves may be simple when the deviation is unaccompanied by any compensatory curve1 or compound when a compensatory curve is present4 ,we shall consider the deformities as they present themselves in the various regions of the spine4 ,cervico-,dorsal ,curvature4--,this condition is comparatively rare and according to ,lovett occurs in only three and six tenths per cent of cases4 ,the head is slightly deviated towards the concave side1 the shoulder on the concave side is lowered1 while on the opposite side or the side of the convexity it is naturally at a higher level4 ,the angles of the upper ribs are prominent due to the co-existing rotation4 ,the ,dorsal ,curvature4--,the shoulder is raised on the convex side1 and the rotation of the vertebr is very marked1 causing a very definite projection of the angles of the ribs on the convexity4 ,this rotation also projects the scapula backwards on the convex side4 ,on the concave side the scapula is flat and sunken1 and the inferior angle rotated inwards and at a higher level than the opposite side4 ,viewed from the front the thorax may not be displaced at all1 or it may be displaced toward the convex side1 and if the latter is the case it is1 of course more prominent on the concave side4 ,in severe cases the lower end of the sternum is deviated towards the convexity and you will find that usually the arm hangs further from the convex side than from the opposite one4 ,the ,lumbar ,curvature4--,here we find the trunk displaced toward the side of the convexity1 and the waist retracted on the opposite side4 ,the difference in the level of the hips is the most prominent deformity in this region1 and it will be found that the hips are raised on the concave side4 ,rotation in this region is much less evident than in the dorsal region1 but can be demonstrated by a fullness on the convex side of the curve1 due to the projection of the transverse processes4 ,dorso-,lumbar ,curvatures4--,this condition is similar to a certain extent1 to a severe functional scoliosis4 ,the findings observed in the last two regions above described will naturally be present in this type of curvature4 ,it is not so frequently associated with compensatory curves as in the other types described4 ,compound ,structural ,curves4--,the appearance in this type of scoliosis will1 of course1 be a combination of those described above according to the types of curvature in combination1 that is to say right dorsal and left lumbar1 etc4 ,if one type predominates the appearance will be chiefly that found in that particular type of curvature4 ,the relative frequency of the common type1 as given by ,schaltless1 in eleven hundred and thirty seven cases is as follows2 functional scoliosis1 #ae4ci2 lumbar1 #aa4g2 dorsal1 #ai2 dorso-lumbar1 #bj2 cervico-dorsal1 #c4f2 compound1 #cj4 ,diagnosis4--,to the osteopathic physician the diagnosis of scoliosis is not difficult4 ,let me caution you that true scoliosis must be distinguished from the lateral curvatures caused by ,pott's disease4 ,vertebral rotation1 the absence of pain1 the extreme rigidity1 the characteristic appearance of the ribs and thorax should1 however1 make the diagnosis of scoliosis easy4 ,treatment4--,in general the treatment of scoliosis is difficult to present1 because every case is considerably different1 and the amount of correcting force used in any form is almost entirely a matter of judgment1 as is also the time when corrective pressure should be discontinued4 ,continual practice in the treatment of these conditions is most essential to your success with them4 ,i have had most gratifying results in a comparatively short time simply because ,i used osteopathic treatment and exercises along with a modified ,abbott method4 ,functional or ,false ,scoliosis ,the functional or false scoliosis might be regarded as a habitual inability to stand correctly1 simply a postural malposition and lack of muscle tone without marked structural change1 which is maintained for a considerable length of time or where the position is repeated several times daily4 ,the treatment of selected types of this deformity is most successful and may well be divided into three procedures3 first1 the substitution of a correct attitude for the faulty one1 that is careful investigation should be made to ascertain the condition which might be the cause of the incorrect position such as poor school desks which might cause the child to reach either up or down to write1 poorly fitting clothing which causes a pulling on the shoulder1 eye strain which would cause tilting or twisting of the neck1 congenital shortening of one limb or too rapid growth1 should all be looked for and removed2 second1 regular osteopathic manipulation1 at least three times per week to increase the tonicity of the already weakened spinal muscles and aid correction1 are highly essential and shortens the time required for a complete cure2 third1 supervised gymnastic exercises of various kinds are very beneficial to develop and bring the musculature back to normal4 ,such simple exercises as crawling on the hands and knees in a small circle towards the side of the convexity1 and the hanging from a horizontal bar by the arm on the side of the concavity will prove to be helpful4 ,some authors recommend the regular army setting up exercises for some cases or a frame by means of which the hips are fixed1 and rotating and side bending exercises of the head and trunk given4 ,these last two exercises are indeed very reasonable procedures but ,i have found them unnecessary mainly because ,i used osteopathic manipulations instead4 ,in advising and supervising exercises it is best to have the patient's back bared so that the effect of each movement can be noticed and the exercises directed accordingly4 ,care and judgment should be used as to the number and severity of the exercises and would depend of course on the vigor of the child4 ,treatment should continue until the condition has been overcome1 and the patient should be under observation for a couple of months afterwards so that any recurrence of the deformity would be noticed and attended4 ,organic or ,structural ,scoliosis ,the treatment of organic or structural scoliosis is more complicated for it must be remembered there are two elements of the deformity demanding correction2 one1 the lateral curve to be corrected by a side force1 and the other1 the rotation of the vertebr to be corrected by a twisting force4 ,i find both osteopathic manipulation and gymnastic exercises are of great value in the correction of this deformity as they help to loosen the curve and develop the musculature but used alone good results can rarely be obtained especially in obstinate curvatures4 ,i believe that ,i have improved nutrition and probably prevented further deformity by treatments and exercises1 but ,i am quite positive that it is not possible to correct an organic scoliosis without the forcible correction used in the ,abbott method4 ,as the details of treatment are tedious to follow1 we will take for example a case of right dorsal curvature presenting a marked hump deformity1 with a compensatory curve to the left in the lumbar region1 as this is the most common type4 ,i might say here that whether or not a compensatory curve is present1 makes no difference1 as treatment is directed entirely to the primary curve on the assumption that overcorrection of it will cause a secondary curve to disappear by compensation4 ,the patient is prepared by putting on a snug fitting undershirt and sewing pads of saddler's felt over all bony prominences1 especially the crest of the ileum and anterior superior spine4 ,sometimes ,i take a piece of felt of four or five inches wide and long enough to go around the entire pelvis1 just high enough to cover the brim1 and fasten it in front with adhesive4 ,next ,i make a bunch of pads two or three inches in thickness and large enough to fill up the concavity of the left side1 and first sew them together1 and then with a few stitches fasten them to the undershirt thereby filling up the space on the concave side4 ,the edges of the pads should1 of course1 be trimmed down to conform with the general contour of the body1 the main thickness being in the middle4 ,i then sew a single pad on the right side of the thorax in front and a little to the right side4 ,illustration3 ,patient suspended on canvas hammock in regular ,abbott frame ready to apply cast for a right dorsal curvature4 ,notice manner of applying the correcting canvas straps4 ,the patient is now ready for the ,abbott frame and is placed on a canvas hammock about twelve inches wide1 which is cut on the bias so the right side is three inches shorter than the left4 ,the hammock can be adjusted to the desired degree of flexion by a ratchet at the foot of the regular ,abbott frame4 ,the limbs of the patient should be elevated to increase the flexion as this has a tendency to unlock the articulation and thereby help in overcoming the rotation4 ,next a canvas bandage four inches wide is passed around the patient under the axilla of the concave side and fastened to the frame on the opposite side1 and another one is placed around the pelvis and fastened to the same side of the frame1 both on a level with the body plane4 ,a third bandage is next placed around the point of greatest convexity and fastened to the opposite side of the frame in such a way that it can be tightened and a direct pull be made on the curve4 ,before tightening the last bandage the left arm and shoulder should be brought up high beside the face and pulled backward toward the floor as it is this twisting force that produces some rotation of the thorax4 ,the correcting bandage is now tightened being careful not to cause the patient too much discomfort4 ,illustration3 ,cross section sketch of a right dorsal curvature showing deformity in the thorax and rotation of the vertebr1 also windows which are cut in the cast to allow expansion in these two directions and the directing force of the pads4 ,these are placed over the angles of the ribs4 ,arrows show directions of the various forces4 ,i always use ordinary absorbent cotton for padding1 which is held in place by the regular gauze bandage4 ,the plaster of ,paris bandages should be applied high up under the left shoulder and well down over the sacrum and innominate bones and should be of a uniform thickness of half an inch4 ,sometimes ,i carry the plaster over the right shoulder to hold it down and back1 though not always4 ,i always let the cast set pretty well before removing the patient from the frame and if it has been applied in the morning ,i find it best to wait until afternoon before trimming and cutting the windows because there is less danger of breaking it4 ,in trimming ,i always smooth up the edges1 lower the right shoulder1 but keep the left well up1 trim off enough at the bottom in front to allow the thighs to be readily flexed without obstruction1 and leave it low behind so as to maintain the flexion4 ,next1 two holes or windows are cut in the cast1 one over each area where the pads were inserted1 and remove them4 ,the hole in the back on the left or concave side permits expansion of the chest to the back1 while the hole on the right side in front allows the ribs1 which are posterior1 to move forward under pressure or the pads to be inserted at the posterior angle or backward prominence of the ribs of the convexity4 ,the canvas bandages or straps around both the axilla and pelvis are removed1 but the one about the convexity of the curve is left in place so as to assist in the after treatment4 ,the patient usually suffers some discomfort such as difficulty in breathing and the inability to move the body freely1 and should remain in bed a day or two after the cast has been applied4 ,usually they sleep very poorly the first few nights1 but the spine soon gives under the pressure and they become comfortable4 ,when the cast has become quite comfortable an assistant pulls on the canvas bandage which was left around the convexity1 while pads are inserted so that the greatest pressure is exerted on the angle of the ribs to further overcome the rotation and decrease the lateral deformity4 ,also heavy felt pad may be inserted over the bulging ribs in front of the left side to push them back4 ,care should be taken that too much pressure is not brought to bear on the side of the convexity because if more pressure is exerted here than on the angles of the ribs1 it will tend to increase rather than decrease4 ,casts should be worn for different periods1 some being changed in a month while others can be worn for three months4 ,it is entirely a matter of judgment4 ,my best results have been secured by only slightly correcting the curvature at the time the cast was applied1 and relying more on the proper insertion of the pads4 ,often at the end of a month or six weeks1 in selected cases1 ,i have split the cast down the front and removed it by springing it apart1 and administered osteopathic manipulations to the spine freely in all directions1 thoroughly loosening up the muscles4 ,then ,i replace the cast and hold it together in front with moleskin adhesive and insert the pads as before4 ,i repeat this procedure three times per week for another month1 together with daily exercises each morning and evening of drawing the left shoulder up and forward while in the cast to develop the muscles of the left shoulder girdle4 ,the treatments and exercises certainly do build up the spinal muscles for it must be realized that they have suffered in nutrition to a great extent as a result of wearing the cast4 ,next the cast can be worn during the day and removed at night1 and gradually it can be left off several hours at a time4 ,if no bad results occur it can be left off for longer periods until finally its use can be discontinued4 ,however1 the patient should still be under observation once a week for a couple of months to determine any recurrence of the deformity4 ,the resumption of active corrective treatment1 or increasing relaxation in gymnastic work1 will1 of course1 depend upon the progress of the case4 ,in the more obstinate cases1 casts should be applied as long as further correction can be obtained4 ,the procedure is entirely the same1 only the time required for correction is longer1 sometimes a year or year and a half1 and when overcorrection has been maintained1 it is better to use a removable jacket made of celluloid or light stiffened leather1 with large windows cut over the region where pressure is to be avoided1 than the removable cast described above4 ,in closing let me say that this method of correcting lateral curvature is best adapted to patients during their growing period and though it may be employed in older cases you will usually be disappointed in the final result4 ,the only reason ,i can see for treating older cases is purely mercenary4 ,congenital ,dislocation of the ,hip ,unilateral ,undoubtedly as far back as #ahbi1 the actual recognition of this condition was due to the pathological research of a ,french surgeon ,dupuytren1 who described this deformity with great accuracy and insisted that there was no possible chance of correction4 ,from then on until #ahhf nothing was done by medical science to overcome the deformity1 though it is claimed some were made4 ,it was in this year that the famous ,bavarian surgeon1 ,hoffa1 gave to the medical profession the results of his successful attempts at reduction by opening the hip joint from behind and enlarging the acetabulum to a size sufficient to hold the head of the femur4 ,orthopedic surgery has to thank the irritating effects on the skin1 of antiseptics necessary in preparing his hands for ordinary surgery1 as it was due to this triviality that ,lorenz1 a promising surgeon of ,vienna1 transferred his energies to the field of bloodless surgery and gave to us the most valuable early work and present day technique in the bloodless reduction of congenital dislocation of the hip4 ,the name1 of course1 is applied to a congenital deformity which involves one or both hip joints1 resulting in lameness1 due to a misplacement of the head of the femur from the acetabulum4 ,of all congenital dislocations the hip joint is by far the most common and most important4 ,the misplacement is far more often unilateral than bilateral and far more frequent in females than in males1 the cause for the latter probably being the difference which exists in aspect and position of the acetabulum as well as the disproportionate laxity of the capsule in the two sexes4 ,it must be remembered that normally at birth1 the acetabulum covers only about one-third of the head of the femur1 and our most accepted theory as to the cause of this deformity1 is a defective development of the acetabulum or its posterior margin1 which may be primary or secondary to an abnormally prolonged fixation of the limb in a position of flexion or adduction while in utero4 ,at birth it is quite probable that the dislocation is a subluxation only1 which becomes complete by muscular action and the use of the limb in standing and walking4 ,the pathology of this disease is clearly established1 and varies1 of course1 with the age of the patient in strain and friction to which the misplaced parts have been subjected4 ,in children over two and one-half years of age the acetabulum is usually shallow and small1 and filled with a deposit of fat and fibrous tissue4 ,it is covered with normal hyaline cartilage and nearly always the ligamentum teres is present1 but is so badly stretched and ribbon-like that ultimately the artery accompanying it fails to function1 resulting in a malformation of the head of the femur4 ,the capsular ligament is elongated and thickened to accommodate the upper displacement of the femur1 and the anterior wall of it is stretched tight across the acetabulum like an hour glass4 ,the interior of the capsule is always partly lined with synovial membrane4 ,usually a secondary acetabulum is found upon the ileum1 formed by the direct pressure of the head of the femur through the capsule and the result of irritation of the periosteum of the ileum1 but it is as a rule1 not deep enough to form a secure support for the head of the bone4 ,the neck of the femur is usually shorter than normal and the upper extremity of the bone is somewhat atrophied4 ,the pelvis is usually slightly atrophied on the affected side1 and a lateral inclination of the spine may be present4 ,the long muscles of the thigh are shortened2 while those attached to the pelvis and trochanter are changed in direction and are usually lengthened4 ,illustration3 ,typical congenital dislocation of the hip1 showing the 8hour glass0 constriction of the capsular ligament4 ,symptoms4--,as a rule congenital dislocation of the hip is not accompanied by the defective development or deformity elsewhere1 and the symptoms are so diagnostic that there is little difficulty in recognizing this condition even without the ,x-ray which is1 of course1 a positive diagnosis4 ,rarely does the displacement attract attention until the child begins to walk4 ,often the child does not walk as early as it should4 ,sometimes it may be delayed until the eighteenth month or second year and then it walks with a limp which becomes more pronounced as the child grows older until at the fourth or fifth year it is very decided4 ,the limp is peculiar and its character is explained by its cause2 for the shortened limb1 owing to the elasticity of the capsule1 becomes still shorter when the weight is borne upon it1 thus causing a peculiar lunge of the body towards the short side like the normal motion of walking downstairs4 ,in compensation1 of course1 the pelvis is tilted towards the short limb and its inclination is thereby increased1 so that the anterior superior spine lies at a lower level and in advance of the opposite side4 ,usually the affected limb is about an inch shorter than the sound one1 and in adult life it is considerably more4 ,the range of abduction is much diminished1 but flexion1 extension and adduction are quite normal1 and the trochanter will be found elevated about an inch above ,nelaton's line4 ,if the thigh be flexed and adducted to its extreme limit1 the neck and head of the femur can be easily distinguished moving under the gluteal muscles when the limb is rotated1 or the head can usually be readily palpated in front when the limb is extended4 ,then1 too1 by fixing the pelvis and using traction and upward pressure on the limb1 the abnormal mobility or telescopic motion is easily demonstrated and this1 ,i might add1 is a very important test4 ,illustration3 ,outline of a radiograph following reduction and removal of the first cast in unilateral dislocation of the hip4 ,notice the head in the socket and the thigh still flexed and abducted4 ,rarely do we find a unilateral anterior dislocation1 in which the head of the bone lies beneath the anterior superior spine1 but when this position is present1 the symptoms are much less marked than in the ordinary form because the relation of the pelvis to the femur is more nearly normal4 ,the limp and the shortening of the limb are less noticeable because the tissues attached to the anterior superior spine form a relatively secure support4 ,the ,x-ray1 of course1 makes the diagnosis complete4 ,even though the clinical diagnosis is certain1 a radiograph is indispensable in every case1 particularly for the purpose of ascertaining the exact position of the head and condition of the acetabulum and femur4 ,the acetabulum is usually shallow and poorly developed1 more particularly the iliac portion of its rim4 ,after the reduction of the dislocation1 an ,x-ray picture should always be taken within the first few weeks1 and before the plaster of paris cast has been removed1 to ascertain whether the head of the femur is still in place4 ,illustration3 ,outline of the same case following removal of the second cast4 ,the head of the femur is firmly fixed in the acetabulum and the position of the limb is nearly normal4 ,as to bilateral dislocation of the hip1 the pathology1 of course1 is the same as in the unilateral type4 ,the shortening of the limbs is as a rule equal or nearly so1 and when both femurs are displaced backward1 the pelvis is tilted forward thus presenting a marked lumbar lordosis and protruding abdomen4 ,the pelvis seems to be abnormally wide1 both buttocks are flattened and the thighs are separated by a considerable space4 ,the characteristic limp in this condition is an exaggerated waddle1 often spoken of as 8sailor gait40 ,again in this condition rarely do we find an anterior dislocation1 but when such is the case1 the entire body is swayed entirely backward1 though the lumbar lordosis is not increased1 in fact usually presents a peculiarly flattened appearance4 ,other symptoms differ only in a slight degree from those of the ordinary posterior displacement4 ,the physical signs are the same as the unilateral displacement and are even more readily recognized by the peculiar appearance and distinctive gait of the patient4 ,the swaggering gait of lumbar ,pott's ,disease is somewhat similar1 but this is an acquired clinical condition of the spine in which the hip joints are normal in appearance and nearly so in function4 ,before taking up the usual procedure for the correction of congenital dislocation of the hip1 it might be interesting to touch on several cases of this deformity in young children that ,i have reduced without an anesthetic4 ,if future experience proves as successful as these cases it will entirely revolutionize the treatment of this condition especially in children under twenty months of age4 ,to begin with1 these children had just started to walk and it must be remembered that at this stage the acetabula are nearly normal and there has been no muscular or ligamentous contraction because very little weight has been borne on the limb4 ,first the pelvis is held fixed by the assistant1 and the thighs completely flexed on the abdomen4 ,next firm pressure is made on the knee to force the head of the femur beneath the acetabulum and as the limb is abducted in the flexed position1 the head is raised into the acetabulum with the thumb of the operator's other hand4 ,the whole procedure takes but a moment's time and the child should be placed at once upon the floor and allowed to walk4 ,time will tell if the reduction has been successful1 and if failure of retention develops1 the ,lorenz method followed by plaster of ,paris fixation can still be used4 ,i should always recommend the trial of this method in children who have walked not longer than six months1 before resorting to the following ,lorenz treatment4 ,treatment by the ,lorenz ,operation4--,this treatment is based on the fact that there is normally present an acetabulum of sufficient size and capacity to retain the head of the femur1 providing the limb can be fixed in a favorable attitude1 and as soon as possible weight borne upon it to deepen the rudimentary acetabulum4 ,the typical operation of today is best divided into four distinct steps2 first1 to overcome the resistance of the tissues surrounding the joint2 second1 to reduce the dislocation1 or rather to force the head of the femur over the posterior border of the acetabulum2 third1 to increase the security of the articulation by stretching the anterior border of the capsule2 fourth1 to fix the parts in a plaster of ,paris bandage4 ,the child is completely anesthetized1 and an assistant firmly fixes the pelvis on the table with his hand4 ,the operator first flexes the thigh to a right angle with the body and forcibly abducts1 at the same time kneading and stretching the tense adductor muscles and if necessary rupturing the adductor tendons in order to bring the limb down to the plane with the body4 ,next to overcome the contraction of the posterior tissues1 the limb fully extended is flexed upon the trunk and gradually forced downward until the toes touch the patient's face4 ,to overcome the resistance of the tissues on the front of the joint1 it is best to move the patient to the edge of the table and forcibly extend the thigh downward behind the plane of the body4 ,it is also well to apply direct traction in the line of the body4 ,this preliminary stretching is absolutely necessary1 because all the tissues about the joint are so shortened1 and it will now be noted that with slight traction the trochanter can be drawn down to ,nelaton's line4 ,next reduction is attempted by grasping the limb with one hand at the knee and strongly abducting it while the palm of the other hand is placed on the anterior spine of the ilium with the thumb placed beneath the great trochanter to act as fulcrum4 ,as the limb is gradually forced downward to and behind the body plane1 the head of the femur is forced upward until it finally slips over the posterior and inferior border of the acetabulum4 ,in the more resistant cases a padded wedge-shaped block placed behind the trochanter will be an aid in pushing the head forward and upward while the patient's knee is forced downward4 ,a successful reduction is usually accompanied by a distinct jar and audible thud1 and it would be observed that the tension upon the ham string muscles causes fixed flexion of the leg4 ,after reduction has been made1 the limb should be brought down carefully into a straight position to test the security of the re-position4 ,if dislocation appears during this manipulation1 the tissues must be still further stretched and the displacement further reduced4 ,if displacement occurs readily due to a shallowness of the acetabulum the prognosis is not so good as where the stability remains when the limb is brought down into a straight position1 and one must be more particular in the fixation of it4 ,i have also observed that the more difficult the reduction the more stable the end results4 ,the easy replacements are usually just as easily displaced4 ,sometimes the head slips into the socket quietly without the distinct jar or thud but the results in these cases are just as good provided they are properly cast4 ,illustration3 ,patient in position for the first cast in a left unilateral dislocation4 ,the thigh should be a little past a right angle in relation to the trunk1 with about #hj abduction4 ,the application of the plaster spica is by far the most important part of the treatment1 as the reduction is usually quite easily accomplished in children under six years of age4 ,if the cast is improperly applied1 the hip will slip out of the socket and the case is a failure4 ,a pair of soft knitted cotton drawers are put on and the patient is placed upon a pelvic rest with the limb held in the position of greatest stability at a right angle with the trunk1 or even slightly more and about eighty degrees abduction4 ,in a case where the socket is very shallow1 the position to be cast should be about one hundred degrees flexion1 and in abduction the limb should lie slightly behind the plane of the body to secure the best results4 ,illustration3 ,correct position and proper application of cast for double congenital dislocation of the hips4 ,the limb and pelvis are covered with ordinary absorbent cotton which is held in place with a roller gauze bandage4 ,a snug fitting plaster of ,paris cast is now applied around the pelvis and well down over the knee4 ,i leave this over the knee for five or six days or until the child ceases to be fretful1 then ,i cut it away just back of the knee joint to permit motion there4 ,the ends of the drawers are drawn back smoothly over the cast and are sewed to each other4 ,for about a week following the operation the adductor region is swollen and discolored and more or less painful due to rupturing and stretching of those tendons4 ,after this discomfort has passed away1 walking is encouraged on the theory that the weight bearing and the stimulation of functional activity will increase the stability of the joint by deepening the acetabulum4 ,illustration3 ,proper position of the limb in the second cast for unilateral dislocation4 ,the first cast should remain from three to six months according to the stability of the joint at the time of reduction4 ,if in young children the cast becomes offensive1 it must be changed as often as is necessary4 ,when the first cast is removed1 the limb is pulled down to about thirty degrees abduction and the same amount of flexion1 without an anesthetic1 and a second cast is applied1 which extends only to the knee1 to be worn from three to six months longer4 ,after removal of second cast1 the child is permitted to get about carefully4 ,the limb will be everted and slightly flexed1 which position invariably causes much concern among the relatives of the patient1 but this abnormal condition disappears after a few months' time4 ,sometimes for even a year following removal of the second cast there will also be a noticeable hitch in the walk of the child2 but this1 too1 disappears and in the course of two years' time one could never tell that such an operation had been performed4 ,massage of the posterior and lateral muscles of the hip always helps considerably towards the relief of any stiffness or lameness4 ,reduction by ,open ,incision ,in the more resistant older cases1 where manipulative reduction has failed1 reduction by incision can be employed with success1 but this procedure requires the exercise of care in order to do as little injury to the muscles as possible4 ,a crucial incision of the capsule is made and the capsular constriction and ilio-psoas tendon divided4 ,with a little traction1 the head of the femur slips easily into its socket4 ,the capsule is stretched firmly around the neck and the incision into the capsule is then closed by suture1 and the limb fixed in a plaster of ,paris spica in the fully abducted position4 ,the operation should of course be done under the strictest asepsis4 ,talipes or ,club ,foot ,the word talipes signifies some deformity of the foot and is quite common in orthopedic practice1 being found in nearly ten per cent of the cases coming under this branch of the science4 ,club foot may be classified into two types--the congenital and the acquired4 ,the congenital type is the most common and is due probably to abnormal intrauterine pressure or to a perversion of normal intrauterine development4 ,the acquired type is due usually to injury or infantile paralysis1 but either joint disease or cerebral paralysis may be the cause4 ,the deformity presents six different forms with most characteristic clinical pictures which1 with the exception of talipes planus ,i have taken up in the order of frequency4 ,illustration3 ,illustrating the more common types of talipes4 ,a combination of any may be present4 ,talipes ,equinovarus is usually congenital and is the most common type4 ,it is characterized by inversion and torsion of the foot with elevation of the heel4 ,the weight is borne on the outer side of the foot and in extreme cases upon the dorsum as well4 ,calluses are always present which are red and painful upon the point where the greatest weight is borne4 ,the most common method of treating this condition is to divide the tendo ,achilles at a level with the malleoli4 ,the operation should be done aseptically and under complete anesthesia4 ,as an assistant raises the end of the foot so as to stretch the tendo ,achilles the surgeon enters the knife parallel to the border of the tendon through the skin and tendon sheath into the tendon itself4 ,next with a tenotome inserted into the incision and turned at right angles to the tendon1 the tendon is divided first on one-half then on the other4 ,care should be taken to disturb the tendon sheath as little as possible for it serves an important purpose in repair4 ,when the division is complete as indicated by the separation of the divided ends1 the tenotome is withdrawn and the minute opening in the skin1 from which there is only slight bleeding1 is covered with aseptic gauze4 ,the foot is forced into dorsal flexion and if in severe cases the deformity is not then corrected1 the tendons on the outer side of the foot may be shortened1 while those on the inner side may be lengthened in the same manner as the tendo ,achilles4 ,a plaster of ,paris cast is then applied well up to the knee with the foot in the over corrected position1 care being taken that no undue pressure is brought upon the seat of operation1 as this might interfere with the effusion of plastic material4 ,personally ,i believe that functional use of the limb and foot stimulate repair1 and ,i always encourage the patient to stand and walk after the discomfort of the operation has passed4 ,at the end of four weeks the space between the two cut ends will be filled with new material and the cast can be removed1 and in another month the splice1 which is somewhat larger and thicker than normal1 should be strong enough for use4 ,in the course of a year the lengthened tendon is perfectly normal4 ,talipes ,equinus4--,in this type the patient walks on his toes with the heel highly elevated1 in the same position as the horse1 and it will be noticed that the foot has no dorsal flexion whatsoever4 ,infantile paralysis affecting the anterior muscles of the leg is usually the cause of this condition1 though sometimes shortening of the leg following knee joint disease1 or fracture may lead to an adaptive equinus which serves to make the limb of equal length for walking4 ,this type is by far the easiest to remedy1 and the results following operations are perfect4 ,a simple division of the tendo ,achilles is made under anesthesia and a cast applied as above1 in a position of exaggerated dorsal flexion4 ,functional use of the limb after the cast has been removed overcomes any stiffness that might occur and perfect results are obtained in a short time1 compared with the other types4 ,talipes ,calcaneous4--,this is a condition in which the foot is held in a position of dorsal flexion4 ,the patient walks on the heel with an inelastic gait because the spring of the foot is absent and the whole weight is borne upon the os calcis4 ,the best procedure in this type is manipulative treatment into a position of plantar flexion to overcome the contraction of the anterior muscles of the foot and leg1 and bring about contraction and shortening of the posterior muscles4 ,a tenotomy of the anterior tendons or an anesthetic is rarely indicated1 though in severe cases1 a series of casts holding the foot in position of plantar flexion may be necessary to secure good results4 ,i have found it a help to have a shoe with a heel prolongated backward1 or a steel splint laced to the leg to prevent the foot from upward motion4 ,talipes ,valgus4--,this is a very uncommon type of deformity1 characterized by eversion of the foot4 ,the patient walks on the inside of the foot and1 as a rule1 experiences very little trouble4 ,i find a manipulative treatment is best for this condition1 aided by braces4 ,talipes ,cavus4--,this form is sometimes called 8hollow foot0 and is very uncommon in this country4 ,it is characterized by a markedly high arch sometimes as in ,chinese women to the extent that the anterior part of the foot is approximated to the heel4 ,the plantar fascia is badly contracted and one can distinctly palpate the bands beneath the skin4 ,this condition is practically the same as the ordinary so-called 8contracted foot0 except that it is much more exaggerated4 ,the ordinary high arch of today is usually the result of wearing too short a shoe1 and if painful1 long last shoes1 aided by manipulations1 will usually correct the trouble4 ,in severe cases of contracted foot the plantar fascia may be divided1 under anesthesia and the arch brought down and put in a cast1 though this procedure is not very successful4 ,in case it is done the patient should be made to walk in two or three weeks1 as this helps materially to overcome the deformity and hasten repair of the fascia4 ,talipes ,planus4--,this condition is commonly known as 8flat foot0 and is taken up in another part of this text4 ,however1 it is one of the classifications of 8club foot0 and is far the most common type4 ,prognosis4--,these conditions never correct themselves and if uncorrected usually get worse and the more severe types certainly become obstinate malformations4 ,in general the tendency to relapse is strong1 though if properly treated the results are excellent4 ,in infantile cases the time required for correction is relatively short1 but retentive appliances are needed for a longer time4 ,the older the cases and larger the foot the more difficult1 of course1 the correction1 but usually there is less danger of relapse4 ,a perfect correction1 that is when the gait and attitude are normal1 will never relapse4 ,i find it better to leave the fixation appliance on too long than not long enough4 ,never remove a cast under four weeks except in the cavus type1 then apply a brace such as can be obtained from any supply house for any type of case1 for from one to three months longer4 ,the tendons involved in these conditions are so apparent that it is almost impossible to make a mistake in the division of them4 ,about the only precaution necessary is to be assured that the tendon itself is completely divided1 but that the tendon sheath is only slightly disturbed4 ,tuberculous ,disease of the ,bones and ,joints ,perhaps no bony lesion has caused so much difference of opinion in this profession as tubercular conditions of the spine1 bones and joints and ,i wish it understood that in the following discussion1 it is not my desire to reopen the argument4 ,my observations have been of cases treated both osteopathically and by fixation1 in private practice and institutional work4 ,and ,i have come to the conclusion that the fixation method of treatment is absolutely always indicated4 ,in general the pathology and etiology of all tubercular bone conditions is the same4 ,it begins as a tubercular infection of the spongy tissue of the epiphysis1 the first change being a local hyperemia of the portion involved1 followed by one of three courses3 the diseased focus being absorbed and a spontaneous cure resulting2 it may extend to the periphery of the bone and break through the periositum and empty itself there by abscess formation2 or most commonly it may extend to the joint1 which becomes involved through attendant injury4 ,repair is brought about by the formation of fibrous tissue probably arising from the layer of non-tuberculous granulation tissue which grows in and replaces the tuberculous tissue4 ,also the replacing material may become calcified and encapsulated4 ,a fibrous or bony ankylosis may result from this process of repair4 ,the vulnerability of growing bone accounts for the frequency of tubercular bone disease in children as compared with adult life4 ,injury not only causes a local predisposition to the disease1 but it favors its progress when it is once established4 ,about seven-eighths of the cases of this trouble occur under fourteen years of age1 more especially when the vertebr or hip-joint are involved4 ,the knee and ankle joints as well as the elbow and shoulder joints are more often diseased in later life4 ,while the inherited predisposition is very direct and positive in twenty-five percent of the cases1 the acquired predisposition is of most importance since it includes lessened vitality due to poor food and imperfect hygienic surroundings4 ,as to the distribution of the disease the vertebr are most commonly affected1 followed closely by the hip and knee joints1 and then in the order of frequency the ankle1 elbow1 shoulder and wrist joints4 ,tubercular ,disease of the ,spine ,this condition is commonly called ,pott's ,disease or ,caries4 ,it is a chronic destructive process of the bodies of the vertebr4 ,the spine bends at the weakest point and the compression and collapse of the affected parts cause the characteristic posterior angular projection at the seat of the disease4 ,if one vertebral body is destroyed1 the projection will be sharp2 if several are involved it will be less angular and if one side breaks down before the other1 there may be a lateral as well as posterior distortion4 ,the size of the deformity and its effect upon the patient depend upon its situation2 that is1 if either end of the spine is involved the angular projection is slight because the area of the spine directly involved in the deformity is small compared with that which is free from the disease4 ,if the middle of the spine is affected1 the deformity is great1 because the entire spinal column may enter into the angular projection4 ,in the latter area the internal organs are compressed and1 of course1 the effect upon the vital organisms of the body is disastrous4 ,pathology4--,the first indication of tubercular disease of the spine is usually found in the anterior part of a vertebral body just beneath the fibro-periosteal layer of the anterior longitudinal ligament4 ,from this point the foci may advance along the front of the spine following the course of the blood vessels and invading the adjacent vertebral bodies4 ,the destruction may begin in the interior of the body itself1 more often in several minute foci near the upper or lower epiphysis1 which coalesce1 gradually enlarge and form a cavity surrounded1 for a time1 by unbroken cortical substances which finally collapse under the pressure of the weight above4 ,the intervertebral discs seem to offer some resistance to the extension of the disease from one vertebra to another but once the bone is destroyed on either side1 they too quickly disintegrate and disappear4 ,pedicles and articulations which come into direct contact with the disease may become involved4 ,originally the disease is confined to one or two adjacent vertebr and may extend in either direction1 and the final area of deformity and rigidity shows that from three to six bodies may be involved before a cure is established4 ,the infected granulations advance rapidly with the usual retrograde change of shape and structure to a cheesy degeneration and frequently liquefaction and abscess formation may follow4 ,symptoms of ,pott's ,disease4--,there are three main symptoms of ,pott's disease1 namely the peculiarity of attitude and gait1 limitation of motion or muscular stiffness and the pain and referred pains4 ,in the cervical region1 the chin is held somewhat raised and the patient may have somewhat the same appearance as in wry-neck4 ,in the mid-dorsal region one will always find an elevation of the shoulder besides the deformity4 ,in the lumbar region1 the patient nearly always leans backward and has a sort of sidling gait or waddle due to the contraction of the psoas and iliacus muscles4 ,the patient in walking1 stooping1 or lying down most carefully guards the spine against any jar or motion1 and always assumes attitudes which will relieve the strain on the involved vertebr4 ,there is always present an unnatural mode of standing or walking1 especially when the dorsal and lumbar regions are involved1 as the patient walks more on his toes and with the knees slightly bent1 because in this posture all possible strain of the step may be brought into play to diminish jarring of the spine4 ,the child becomes tired very easily and lies down or rests on the arms of a chair or seat4 ,the pain rarely occurs in the back1 but is usually referred to the peripheral end of the nerves and is thus felt in the chest1 abdomen or limbs4 ,the abdominal pain passes sometimes as a stomach ache and often times in the limbs1 as rheumatism or 8growing pains04 ,i have noticed also a peculiar grunting respiration and sometimes cough especially when the mid-dorsal region is involved4 ,muscular stiffness is always present1 all mobility being lost4 ,the temperature is not at all diagnostic1 though sometimes in the afternoon it will be one or two degrees higher than normal and does occur independently of abscesses4 ,about the only complication that occurs is paralysis or abscess formations4 ,paralysis is given as a frequent complication1 though ,i have never seen it4 ,it is usually flaccid and bilateral and may exist from a mere muscular weakness to a complete loss of power4 ,it is certainly uncommon under proper treatment1 and the prognosis is favorable4 ,abscesses1 though a very distressing complication1 are very uncommon in my experience and are certainly an evidence of improper or incomplete treatment4 ,they may subside in any region and be absorbed without detriment to the patient1 though if they increase in size there is no tendency towards absorption4 ,it is best to incise them and secure complete drainage4 ,it is hard1 of course1 to do this on account of the depth4 ,abscesses occur always in close proximity to the disease4 ,treatment4--,some authors recommend a brace for the treatment of this condition1 while others recommend a frame to which the patient is strapped1 and rest in bed4 ,i have found nothing that gets results like a plaster of ,paris jacket applied with the patient suspended by the neck and shoulders4 ,i make no attempt at correction of the deformity present other than the traction of the weight of the body at the time the cast is applied4 ,the spine is1 of course1 fully extended by this and any undue pressure on the cord relieved4 ,the cast should extend over the shoulders and well down over the pelvis and sacrum4 ,if the disease is in the neck the cast should include the head as well4 ,a large window is cut in front and one must be cut over the involved area of the spine behind4 ,ordinary absorbent cotton is used for padding with1 of course1 extra padding over all bony prominences4 ,from two to five years' time is required for a complete recovery4 ,the ,x-ray is invaluable in diagnosing this trouble1 and each time a cast is removed to see how much progress has been made4 ,the casts should be changed as often as they become soiled4 ,tuberculosis of the ,hip ,this is a chronic tubercular condition of the head of the femur or of the acetabulum commonly known as hip-joint disease4 ,pathology4--,primarily the head of the femur is the seat of the disease1 the epiphysis being attacked in seventy-five per cent of the cases and the acetabulum in twenty-five per cent4 ,the irritated pelvic femoral muscles which are in a state of chronic contraction crowd the head of the femur against the upper and back border of the acetabulum4 ,under this continual pressure1 absorption of that portion of the rim takes place with actual enlargement of the acetabulum from below upwards4 ,this is spoken of 8migration of the acetabulum0 and is one cause for the shortening of the limb4 ,changes in the head of the femur are the result of inflammation and pressure4 ,partial destruction of the head also helps shortening of the limb and elevation of the trochanter above its proper level the same as the wearing away of the acetabulum4 ,the synovial membrane is found to be reddened and thickened and granulation tissue is present1 and usually the cartilage is gone from the head of the femur4 ,rarely does perforation of the floor of the acetabulum take place1 but if such is the case a dense wall of fibrous tissue and thickened periosteum shuts off the head of the femur from the pelvic cavity4 ,a natural cure results in two ways1--by absorption or calcification of the tubercular tissue1 or by the evacuation and discharge by an external opening4 ,this latter suppuration seems to be nature's effort to eliminate the disease1 and when a cure is established this way it is usually characterized by malpositions and shortening of the limb1 and1 of course1 an ankylosed joint4 ,early ,symptoms4--,the most characteristic symptoms of the disease are the #8night cries'1 stiffness and limping1 shortening of the leg1 atrophy of the muscles of the hip1 leg1 and thigh1 and the unconscious protection of the joint4 ,a referred pain is usually present to the inside and front of the thigh near the knee or directly at the knee joint itself1 due to the intimate relations and anastamosis of sciatic1 obturator1 and anterior crural nerves4 ,diagnosis4--,the chief diagnostic sign is muscular spasms or the presence of stiffness of the joints and limitations of its proper arc of motion1 due to the tonic contraction of the muscles controlling the joint4 ,if there is no limitation of motion it is almost safe to say there is no hip-joint disease4 ,the lameness may be intermittent4 ,the attitudes or abnormal positions of the diseased limb are caused by the action of muscles holding the limb stiffly in a distorted position4 ,the pelvis is usually tilted and always one will find the patient assuming attitudes which will favor the diseased limb4 ,atrophy is very significant and a comparison of the two limbs should be made by measuring at the middle of the thigh and the middle of the calf4 ,nearly always one will find a deep thickening over the front of the hip joint and behind the trochanter4 ,physical ,examination4--#a4 ,observe the general condition of the patient4 #b4 ,note the attitude in standing4 #c4 ,note character of the limp4 #d4 ,note shortening of the limb4 #e4 ,remove the clothing and lay patient on the back4 #f4 ,test the function of the groin4 ,always begin on the sound side for comparison in order that the patient may become accustomed to the manipulation before the limb suspected of disease is tested4 ,tuberculosis in a joint is always accompanied by muscular spasms that positively limit motion in every direction1 while in other affections only one or more limitations are observed1 but never in all directions4 ,compare closely the motions of the sound and affected limbs while the patient is on the back4 ,turn patient on face and test for extension by holding pelvis flat on table with one hand and gently elevating thigh with the other4 ,the normal range in a child is about twenty degrees backward from the line of the body and limitation of this range is perhaps the earliest indication of hip-joint disease4 ,it is due to psoas contraction4 ,if this range of motion is unrestricted hip disease can be practically excluded4 ,the ,x-ray completes the diagnosis when used with a thorough knowledge of the physical signs4 ,it must be remembered that in early life a larger part of the extremity of the femur is cartilaginous and does not show well in a radiograph4 ,the ,x-ray picture shows clearly the destructive effect of the disease on the femur and acetabulum and gives a clear conception of the actual condition of the joint4 ,treatment4--,the object of treatment of this condition is threefold3 first1 to relieve the pain that depresses the vitality of the patient2 second1 to relieve the muscular spasms that induce distortion of the limb and which stimulates the destructive process by increasing pressure and friction of the diseased surfaces of the opposing bones2 third1 to correct and prevent deformity by lessening pressure and by restraining motion1 thereby keeping the femur from upward displacement4 ,rest and protection are the two cardinal features of treatment of this condition4 ,sunshine1 fresh air and good nutritious diet are very important4 ,complete rest of the joint offers the most favorable opportunity for nature to repair this disease4 ,the recumbent period of the treatment necessitates rest in bed for the reduction of the deformity and subsidence of acute symptoms4 ,by the aid of traction1 which is applied to the length of the legs by means of a ,buck's extension4 ,as much weight should be applied as can be borne without discomfort to the patient4 ,as soon as the deformity and acute symptoms have subsided1 the ambulatory treatment should be substituted to keep up the general health of the patient4 ,this merely consists of the application of a long plaster of ,paris spica of the hip which should reach well up to the thorax and extend down and include the foot4 ,all bony prominences should be well padded1 and a moderate amount of traction with about twenty degrees abduction should be used while applying the plaster bandage4 ,though various forms of apparatus have been devised for fixation and traction1 ,i believe that the plaster of ,paris spica is far the most effective and should always be used1 changing the cast as often as it becomes soiled4 ,locomotion is possible with crutches providing the shoe on the well side is stilted by an iron patten which is high enough to allow the casted limb to clear the floor4 ,the earlier treatment is begun1 the better the outlook4 ,recovery with perfect motion occurs in about twenty-five percent of hospital cases2 fifty per cent will obtain useful motion and the other twenty-five per cent will obtain practical fixation1 but it must be remembered that results will range entirely according to the thoroughness of treatment1 the severity of the disease in the individual case1 and the natural resistance of the child4 ,in general1 the hip should be fixed as long as it is sensitive1 it should be protected and distracted as long as there is muscular spasm1 and protected until the congested and inflamed bone of the epiphysis is replaced by firm healthy bone4 ,tuberculosis of the ,knee ,joint ,tuberculous disease of the knee is next to the hip in frequency4 ,it is a chronic destructive process of the epiphysis of the femur or tibia1 or it may start in the patella1 head of the fibula1 or primarily in the synovial membrane of the knee joint4 ,the condition presents two distinct types2 one1 the adult type beginning as a chronic synovitis1 of which the early symptoms are subacute2 and the other1 the childhood or most common class1 in which the symptoms of pain1 muscular spasms and deformity seem to indicate clearly a primary disease of the bone4 ,symptoms4--,this disease is commonly known as 8white swelling0 and the symptoms as a rule are quite characteristic4 ,the affection begins with a limp and limitation of motion1 and is usually slow in progress with periods of severe pain4 ,there is usually much swelling and this together with the distortion of the limb by muscular spasm and atrophy of the muscles both above and below the joint1 gives a most characteristic knock-kneed appearance4 ,the affected limb is usually longer at first1 owing to the congestion of the epiphysis of the knee4 ,local heat is always present in the more acute stages and the lameness is usually a constant symptom4 ,the differential diagnosis from other joint troubles is easy because of the slow insidious onset4 ,treatment4--,like other tubercular bone conditions the fixation treatment is best4 ,rest in bed with a ,buck's extension to overcome the deformity and the local application of hot packs until the acute symptoms have subsided1 is the best preliminary treatment of this condition4 ,five- to ten-second exposures to the ,x-ray each day for ten days seems to relieve the pain and in most instances causes less marked infiltration of tissues4 ,when the acute stage has subsided1 the ambulatory treatment by fixation in a plaster of ,paris cast extending from the groin to the ankle1 with about #aj degrees flexion1 is most efficient4 ,the patient is allowed to walk about with the aid of crutches1 having the shoe on the sound side stilted enough so that the diseased limb clears the floor4 ,the functional results after conservative treatment are in the average case excellent1 that is providing proper treatment is begun at an early stage4 ,useful motion is obtained in fifty per cent of these cases1 perfect motion is restored in twenty-five per cent1 and complete rigidity results in the other twenty-five per cent of cases4 ,any chronic1 painful inflammation confined to a single joint1 in which motion is limited by muscular spasm1 and in which there is a tendency towards deformity1 is almost always tubercular in character4 ,the ,plaster of ,paris ,bandage ,the plaster of ,paris bandage was perhaps first applied by ,kluge of ,berlin in #ahbi1 but to the ,dutch physicians ,mathysen and ,vander ,loo belongs the credit of the modern bandage4 ,it is imperative to give1 in this chapter1 a detailed and complete description of what constitutes a properly made plaster of ,paris bandage and the application of it1 in order that the general practitioner may become familiar with its use4 ,even though one cares not to treat the conditions heretofore enumerated1 ,i have found that for fractures of almost every bone in the body requiring immobilization1 the plaster bandage properly applied is far superior and rather to be preferred to any other form of splints4 ,it has been used very little in the past in private practice because the ordinary commercial bandage found in any supply house does not come up to requirements1 in that it is usually air slaked or the plaster has been shaken from it by the time it is received4 ,then too the mesh is too closely woven and the plaster lies on the bandage instead of in the meshes and there is1 in consequence1 an excess of plaster2 also as a rule the bandages are rolled so tightly that the water does not reach the deeper layers4 ,the ordinary plaster of ,paris bandage made in your own office can always be successfully applied because the right quantity of plaster can be incorporated in the bandage and it can readily be made into the desired widths4 ,the plaster of ,paris to be used should be of the superior quality used by dentists and should be of the quick setting kind4 ,it can be procured at almost any drug store but the surest place for quality will be your dentist4 ,absolutely1 the only kind of gauze to be successfully used is white crinoline of the ordinary variety used by dressmakers and obtainable at any dry goods store in twenty-four yard bolts4 ,it is especially desirable to get a kind not too rich in starch or dextrin and of a mesh running about one hundred holes to the square inch4 ,the bandages should be made in six yard lengths1 and of widths ranging from three to five inches according to the part that is to be cast2 for instance the three inch widths are most suitable for casts for the extremities1 while the larger ones serve best for conditions of the spine4 ,after the length had been measured and cut the desired widths can be torn the full length without trouble4 ,the edge of the crinoline nearly always frays out and naturally will become so entangled as to prevent rolling in the plaster or as to hinder the free unrolling of the bandage when applying it4 ,to prevent this1 three threads should be plucked from each side of each strip before starting to roll in the plaster4 ,a hard surface of1 at least1 two feet in width should be used on which to roll in the plaster4 ,starting at one end1 a handful of plaster of ,paris is rubbed into the crinoline with the palmar surface of the hand1 bearing down hard1 so that all excessive plaster passes to either edge of the bandage4 ,no more plaster should be rubbed into the crinoline than the meshes will hold1 and as each successive yard is incorporated with the necessary amount of plaster1 it is loosely rolled in such manner that in the center of the bandage there is a hollow cylinder of the thickness of the index finger1 and the concentric layers are easily movable on one another4 ,this manner of rolling permits of the rapid and uniform spread of water through the bandage when it is to be applied1 and prevents parts of the bandage from being insufficiently moistened4 ,the general practitioner should always keep on hand about two dozen completed bandages that he is most accustomed to using in his daily practice4 ,these should be corded as it were1 to prevent unrolling1 in an air tight container1 either of glass or tin in the bottom of which is placed a small quantity of plaster of ,paris1 and should always be kept in a dry place4 ,i have never found either a nurse or an office girl who could not make these bandages successfully so that in the future there is no excuse for a practitioner not using this superior form of splints4 ,the ,immediate ,use of the ,bandage ,while plaster of ,paris is in no way harmful to either garments or surroundings1 both the operator and the assistants should be properly gowned and the floor covered with newspapers to prevent unnecessary soiling4 ,it should be borne in mind that if a properly made bandage is used1 which is squeezed to the extent of ridding it of an excess of water1 very few drippings will be scattered and the whole procedure of the application of the plaster differs in no way from simple roller bandaging4 ,the number of bandages intended for use should be taken from the container and placed in a pan near the pail holding the water1 in which they are to be immersed1 in a position in relation to the pail that will guard against water being splashed upon the dry bandages1 which would render them unfit for subsequent use4 ,water as hot as the hand will tolerate1 as opposed to cold1 facilitates setting4 ,i do not recommend any chemicals to hasten setting1 because a properly made bandage1 prepared as above1 of quick setting plaster sets in remarkably fast time4 ,the area to be cast should be encased in ordinary absorbent cotton of the thickness in which it comes rolled1 putting an extra pad over all marked bony prominences1 and a roller gauze bandage applied to hold it in place and snug to the part4 ,under no consideration do ,i advise the use of flannel bandage or the ordinary sheet wadding cotton that are recommended by some authors1 because padding with these materials is always conducive to applying a cast far too tightly1 especially in fractures where the swelling increases after application thereby causing constriction of the limb and interference with circulation4 ,the regular absorbent cotton as padding beneath a cast is always best for it is almost impossible to apply a cast too tightly when it is used4 ,the bandage should be completely submerged on its side1 and should remain so until the bubbles cease to come off1 which time takes place most readily in the properly rolled dressing4 ,when the bubbling has ceased1 the bandage is lifted out of the pail and squeezed with the hands merely to free it of the excessive water1 the end is found and handed to the operator ready to apply4 ,no undue traction should be made in applying the successive turns of the bandage1 though it must be remembered the cast should fit snugly to the part1 and the ordinary rules of simple roller bandaging followed1 except that the reverse spirals are unnecessary4 ,the assistant should constantly rub the layers as they are applied by the operator1 as this not only helps the cast to fit more snugly1 but also makes the rough edges of the bandage adhere more firmly to the layer beneath1 thereby making a smoother cast4 ,as a rule there need be no dread of an increased swelling beneath the bandage because usually several hours have elapsed after the injury before the physician has arrived and made preparations to apply the plaster4 ,indeed1 one of the best means of limiting swelling after a fracture is the prompt application of a plaster of ,paris bandage4 ,if there is any concern that the cast is too tight1 while the plaster is still soft it can be easily cut through the entire length with a knife1 and thus relieve the pressure existing4 ,also it is a good plan to cut a window or opening over the sight of injury1 which would in no way harm the object of the cast and would allow a gentle massage to the part4 ,a neat finish may be given to the edges of a plaster cast by turning over the ends of the cotton1 in cuff-like fashion and held in the grasp of the last few turns of the plaster at either end4 ,on clothing you will find it best to allow the plaster to dry before removing1 while on furniture or the hands it is readily removed by washing off in warm water4 ,the water in which the bandages were immersed contains1 of course1 considerable plaster1 and under no circumstances should this be emptied into a sink or waste pipe for it will certainly demand the services of a plumber4 ,the water may be poured out on the ground and the paste shaken into a refuse barrel or ash pile4 ,the best way to remove a cast is to moisten it with water or vinegar along the path of the knife4 ,i might add that all patients are in constant fear of being cut either while you are trimming1 cutting windows1 or removing the cast1 but because of the cotton padding underneath you will find that it is almost an impossibility4 ,care1 of course1 should be taken that the knife does not slip in any of these procedures and come in contact with the unprotected parts4 ,in general1 for fractures of the extremities it is best to apply the plaster with the patient in the recumbent position to secure complete muscular relaxation1 and the part to be cast should be supported by an assistant4 ,it is also a general rule that in fractures of the shaft of the long bones1 especially of the lower extremities1 the plaster bandage should be applied to include the adjacent articulation and extend well beyond the joints4 ,,index ,a ,abbott treatment1 #ih1 #ggd1 #ggh4 ,abdomen pendulous1 #abg4 ,abdominal examination1 #ea4 rheumatism1 #dff1 #dfg4 technic1 #gg1 #ecf1 #eci4 dangers of1 #hg1 #edj4 ,abducens nerve1 lesions affecting1 #gag4 ,abscess of rectum1 #agd4 perinephritic1 differentiate pyelitis1 #fbh4 peritonsillar1 #bgh4 ,achylia gastrica1 differential diagnosis1 #ejh4 ,acne1 #aej4 ,accommodation in the eye1 #aib4 ,acetabulum1 migration of1 #gia4 ,addison's disease1 #gjd4 differentiated from jaundice1 #eei4 ,adenitis1 tubercular1 #chd4 ,adenoids1 #bgc4 ,adhesions1 broken up after sprains1 #ajh4 ,adjustment1 osteopathic1 #ij4 ,adrenal glands1 diseases of1 #gjc4 ,aged1 spine of the1 #aja4 ,agitans1 paralysis1 #gbc4 ,agitata1 melancholia1 #big4 ,ague1 #cdg4 ,alcohol in post-operative pneumonia1 #cai4 ,amentia1 #bij1 #cjg4 ,amyloid kidney1 #fbf4 liver1 #efb4 ,amyotrophic lateral sclerosis1 #gfb4 ,angina pectoris1 #fff4 differential diagnosis1 #ffg4 pathology in1 #cjh4 ,anemias1 the1 #fgb4 ,anemia1 costogenic1 #fgc4 ,burns1 #fgc4 pernicious1 #fgh4 ,aneurism1 cardiac1 #ffj4 ,animal experiments1 #ia1 #dij4 parasites1 #aea4 ,ankle1 #ef4 sprain1 #aab4 ,ankylostomiasis1 #aee4 ,anterior dorsal lesions technic1 #gf4 ,antidotes may be necessary1 #fb4 ,antiseptics may be necessary1 #fb4 ,aortic regurgitation1 #fdi4 stenosis1 #eea4 ,aphonia1 #ega4 ,aphthous stomatitis1 #dhh4 ,appendectomy1 colitis following1 #eeb4 ,appendicitis1 #edg4 differential diagnosis1 #eej4 ,appendicitis from ileo-cecal trouble1 #ada4 pseudo1 #eej4 ,appendix innervation1 #dih4 ,arch supporters1 #aad4 ,arhythmia1 #ffe4 ,arm affected by rib lesions1 #gdj4 ,arm examination1 #ef4 technic1 #hj4 vasomotor nerves to1 #id4 ,arteries1 diseases of1 #ffi4 ,arteriosclerosis1 #ffi4 ,artery complications from typhoid1 #ccb4 ,arthritis deformans1 #dfb4 rheumatoid1 #dfb4 differentiated from inflammatory rheumatism1 #dei4 septic1 differentiated from inflammatory rheumatism1 #dei4 ,articular rheumatism1 acute1 #dfj4 ,ascaris lumbricoides1 #aec4 ,aspiration pneumonia1 #fje4 ,asthenopia1 #bcb4 ,asthma bronchial1 #ehi4 caused by rib lesions1 #id4 ,ataxia1 ,friedreich's1 #gei4 hereditary1 #gei4 differentiate chorea1 #gbf4 locomotor1 #ged4 ,ataxic paraplegia1 #gfa4 ,atheroma1 #ffi4 in heart1 #fdg4 ,atlas examination1 #dd4 lesions1 #dd4 ,atrophy of optic nerve1 #bca4 progressive muscular1 #gfb1 #gfd4 ,auditory--,see also ear4 ,auditory meatus1 diseases of1 #bcf4 nerve degeneration1 #bef4 nerve lesions affecting1 #gah4 ,auerbach's plexus1 #did4 ,auto-intoxication in nose diseases1 #bfh4 ,axis lesions1 #de4 ,b ,backache1 post-operative1 #cac4 ,bandage1 abdominal1 for floating kidney1 #acg4 liver1 #aci4 sprain1 #ajf4 ,barbadoes leg1 #aeh4 ,baths1 hot1 in skin diseases1 #adg4 ,bee sting near eye1 #aii4 ,bell's paralysis1 #gag4 ,belt--,see bandage2 also brace4 ,biceps1 long tendon dislocated1 #aad4 ,bile duct1 diseases of the liver and1 #eec4 ,biliary colic1 #efe4 differentiate1 #eea1 #efe1 #fcb4 ,binocular vision of osteopath 7two pathologies71 #dhi4 ,birth injuries1 causes of heart irregularities1 #fff4 ,black eye1 #aii4 ,blackwater fever1 #cea4 ,bladder1 diseases of1 #fce4 hemorrhage1 #afd4 sensory nerves to1 #ie4 ,bleeders disease1 #dhd4 ,blennorrhea1 acute1 #bji4 ,blepharitis1 #bjj4 ,blood flow directed to abdomen1 #ehb4 ,blood1 diseases of1 #fga4 ,bones and joints1 tuberculous disease1 #ghh4 ,bothriocephalus latus1 #aea4 ,bowel--,see intestine4 ,brace in ,pott's disease1 #ajc1 #aca4 in prolapse1 #acc4 in spinal curvature1 #ii1 #ajc1 #abb4 ,brachial neuralgia1 #gaa4 neuritis1 #abc4 differential diagnosis1 #abe4 plexus1 lesions affecting1 #gba4 ,brachycardia1 #ffd4 ,brain1 pathology of1 #cjg4 its relation to mind1 #cjg4 physiology of1 #cjf4 tumors1 differentiate migraine1 #gcg4 ,brand bath1 #cbi1 #cdc4 ,breakbone fever1 #cef4 ,bright's disease1 #fah4 ,bronchi1 diseases of the1 #egi4 ,bronchial asthma1 #ehi4 ,bronchiolectasis1 #ehg4 ,bronchitis1 #egi4 ,bronchopneumonia1 #fje4 caused by tubercle bacillus1 #fjf4 ,broncho-pulmonary hemorrhage1 #afj4 ,bulbar paralysis1 #gfe4 ,bunions1 cause of1 #aab4 ,bursitis1 #abc4 differentiate from neuritis1 #abe4 ,c ,calcification in heart1 #fdg4 ,calculus1 renal1 #fca4 ,cancer of liver1 #efb4 of stomach1 differential diagnosis1 #ejh4 ,canker1 #dhh4 ,carcinoma1 location of reflex pain in1 #dii4 ,cardiac--,see heart4 ,caries--,see ,pott's disease4 ,catalonia1 #bhf4 ,cataract1 #bbi4 ,catarrh dry1 #ehc4 of conjunctiva1 vernal1 #baf4 stomach1 chronic1 #eje4 ,catarrhal deafness1 #bdf4 pneumonia1 #fje4 stomatitis1 #dhg4 ,center1 diabetic1 #dgd4 ,centers1 osteopathic1 #hh4 nutritional1 #dhj4 ,cephalodynia1 #dfe1 #dfg4 ,cerebrospinal fluid interfered with1 affects digestion1 #dib4 meningitis1 #ceh4 ,cerumen1 inspissated1 #bcf4 ,cervical--,see also neck4 examination1 #da4 glands1 examination of1 #dg4 lesions affect eye1 #ic1 #hf4 region1 caution in treating1 #ff4 treatment for vasomotor effects1 #ib4 ,cervico-occipital and cervico-brachial neuralgia1 #gaa4 ,chalazion1 #bjj4 ,character and disposition affected by alimentary disturbances1 #ejb4 ,chest examination1 #ea4 ,chiasma1 diseases of1 #gae4 ,chicken-pox1 #ddf4 differentiate from smallpox1 #dag4 ,childbirth resulting in pendulous abdomen1 #abh4 ,children--,see also infants4 defective1 #cjc4 diarrhea of1 #ebi4 ,chlorosis1 #fgf4 ,cholecystitis1 #eeg4 ,cholera infantum1 #eca4 morbus1 #ecb4 ,chorea1 #gbe4 differential diagnosis1 #gbf4 differentiate paralysis agitans1 #gbd4 ,choreiform affections1 #gbg4 ,choroid1 diseases of1 #bbf4 ,choroiditis1 #bbf4 ,chromaffin system1 #gjb1 #gjc4 ,chronic lesions1 reduce gradually1 #ff4 ,chvostek's phenomenon1 #gja4 ,chyluria1 chylocele1 chylous ascitis1 #aeh4 ,ciliary injection in keratitis1 #bba4 body1 diseases of the1 #bbe4 ,ciliospinal center1 #ahg4 ,circulatory system1 disease of1 #fch4 ,circumflex nerve1 lesions affecting1 #gba4 ,cirrhosis of liver1 #efj4 ,clavicle examination1 #di4 8,claw hand10 #gfd4 ,club foot1 #ghd4 ,coccygodynia1 #gac4 ,coccyx examination1 #ee1 #ha4 fractured1 #ha4 technic1 #ha1 #gac4 8,cold in the head10 #beg4 ,cold in treating sprain1 #ajf4 8,colds0 inadvertently cured1 #ij4 ,cole's irrigator for high enema1 #agj1 #edf4 ,colic1 biliary1 #efe4 differentiation of1 #ece1 #eff4 intestinal1 #ece4 renal1 #fca4 differential diagnosis1 #fcb4 ,colitis following appendectomy1 #eeb4 ,colitis1 mucous1 #ebf4 ,coma1 diabetic1 #dgb4 ,confusion and stupor1 delirium1 #bhi4 ,congestion of the lungs1 #faj4 thyroid1 #fhf4 ,conjunctiva1 diseases of1 #bjb4 ,conjunctivitis1 #bjb4 catarrhal1 #bjd4 corneal ulcers complicating1 #bjd4 follicular1 #bjg4 differentiated from trachoma1 #bjh4 gonorrheal1 #bji4 granular1 #bab4 phlyctenular1 #bad4 vernal1 #baf4 ,constipation1 causes and technic1 #dig1 #ecg4 from pendulous abdomen1 #abg4 resulting in diarrhea1 #ech4 ,constitutional diseases1 #deg4 ,contracted muscles relieved by inhibition1 #hi4 ,convulsions1 infantile1 #gbh4 ,cornea1 anatomy of1 #bag4 diseases of1 #bag1 #bai4 examination of1 #bai4 ulcer of1 #bai1 #bba4 ,coughing1 #egc4 ,coughing 7superior laryngeal nerve71 #gai4 ,cow-pox1 #dbd4 ,cramp1 constitutional1 #gch4 ,cranial nerves1 diseases of1 #gae4 ,cretinism1 #fih4 ,croup treatment1 #fh4 differentiate from spasm of glottis1 #egc4 false1 #egd4 ,croupous pneumonia1 #eig4 ,curschmann's spirals1 #ehf4 ,curvatures1 spinal1 #if1 #ii1 #ajc1 #abb1 #gfh4 ,see ,abbott treatment1 braces for1 #ii1 #aca4 cervico-dorsal1 #ggb4 complicated by innominate lesion1 #ii4 differentiate organic and functional1 #gfi4 dorsal1 #ggb4 dorso-lumbar1 #ggb4 ,cophosis1 #ig4 lateral1 #ih1 #agg4 lumbar1 #ggb4 other organs affected1 #ggj4 pathological1 #if4 rotary lateral1 #gfh4 postural1 #abh4 7scoliosis71 #if1 #gfh4 differentiated from ,pott's disease1 #ggc4 false1 #ggc4 structural1 #ggd4 technic for1 #ih4 treatment for rotation and sidebending1 #gf4 ,cystitis1 #fce4 ,cystitis1 differentiate pyelitis1 #fbh1 #fcf4 ,d ,dalrymple's sign1 #fid4 ,deafness1 catarrhal1 #bdf4 nerve1 #bee1 #gah4 ,defective children1 #cjc4 ,deformans1 spondylitis1 #dfc4 ,degeneration of heart muscle1 #ffa4 ,deglutition1 #dic4 ,deglutition pneumonia1 #fje4 ,delirium1 confusion and stupor1 #bhi4 senile1 #cjj4 ,dementia1 arteriosclerotic1 #cjj4 defined1 #cjf1 #cjg4 praecox1 #bhg4 senile1 #big4 ,dengue1 #cef4 ,dental troubles should be corrected1 #dij4 ,descemetitis1 #bbf4 ,de,schweinitz1 ,dr41 #bae4 ,diabetes1 differential diagnosis1 #dgg4 insipidus1 #dgf4 mellitus1 #dgj4 ,diabetic coma1 #dgb4 ,diagnosis1 osteopathic1 #ch4 see also under lesion4 reliable1 osteopathic1 #ba4 sight1 #ch4 ,diaphragm1 paralysis of1 #gbj4 ,diarrhea1 causes and technic1 #dig4 acute1 #ebc4 dyspeptic1 #ebi4 caused by constipation1 #ech4 of children1 #ebi4 chronic1 #ebi4 catarrhal1 #ebd4 differential diagnosis of1 #ecj1 #ecc4 nervous1 #ebd4 through impactions1 #ech1 #edd4 ,diet and osteopathy1 #bb1 #fb4 ,diet1 diabetic1 #dge4 ,dietl's crisis1 #acg1 #fce4 ,digestion1 relation of lungs to1 #did4 ,digestive disturbances affect character1 #ejb4 system1 diseases of1 #dhg4 trouble due to intra-cranial conditions1 #dib4 ,digital surgery in hay fever1 #bbf4 treatment in tonsillitis1 #bha4 ,dilatation of heart1 #feg4 of sigmoid1 #edc4 of stomach1 #aec1 #eag4 ,diopter defined1 #aib4 ,diphtheria1 #cfb4 differentiated from scarlet fever1 #dca4 laryngeal1 #cfd4 nasal1 #cfd4 neuritis following1 #gjg4 pharyngeal1 #cfd4 ,disease should be studied by regions1 #ehf4 constitutional1 #deg4 general and functional1 #gbc4 ,dislocation1 differentiated from neuritis1 #abe4 ,disposition and character affected by digestive disturbances1 #eja4 ,diuresis1 ,paroxysmal1 differentiated from diabetes insipidus1 #dgg4 ,dorsal spine examination1 #di4 technic1 #gd4 ,dorsodynia1 #dff1 #dfg4 ,drugs not useful in nose and throat work1 #bfb4 ,why medics give1 #ba4 ,dubini's disease1 #gbg4 ,duodenal ulcer1 ,gastric and1 #eab4 ,duodenitis1 #ebd4 ,dupuytren's contraction1 #aae4 ,dysentery1 #cfh4 ,dysentery1 a word on treatment1 #agj amebic1 #cgj4 bacillary1 #cfh4 chronic1 #cga4 treatment1 a word on1 #agj4 tropical1 #cgj4 ,dysmenorrhea caused by lumbar curvature1 #abf4 ,dyspepsia1 acute1 #eja4 ,dystrichiasis1 #bja4 ,e ,ear--,see also auditory ,ear1 ,diseases of1 #bcf4 of inner1 #bed of middle1 #bci4 foreign bodies in1 cause cough1 #ege4 normal hearing1 #bdi4 nose and throat1 diseases of1 #bcf4 pain in diagnosis of diseases of1 #bch4 test for hearing1 #bdi4 vasomotor nerves to1 #ib4 wax1 hardened1 #bcf4 ,eccymosis1 #aii4 ,eclampsia1 #gbh4 ,ectropion1 #bja4 ,eczema1 #adg4 in ear1 #bcj4 ,edema of the lungs1 #faa4 ,edwards finger treatment in hay fever1 #bfg4 trachoma treatment1 #bac4 turbinate adjuster1 #aig4 ,egophony1 ,lnnec's1 #fac4 ,elbow1 #ef4 sprains1 #aad4 ,elephantiasis1 #aeh4 ,emboli in endocarditis1 #fdb1 #fda4 ,emphysema1 #eib4 compensatory1 #fji4 differential diagnosis1 #eie4 ,endocarditis1 #fda4 complicating pneumonia1 #fja4 ,enema1 directions for1 #edf4 ,enteric fever1 #cbi4 ,enterocolitis1 acute1 #ecb4 ,enteroptosis1 #eba4 ,entropion1 #bja4 ,enuresis1 #fcg4 ,epididymis sensory nerves to1 #ie4 ,epilepsy1 #gbi4 differential diagnosis1 #gcd4 nocturnal1 #gcc1 #gcd4 grand mal1 #gcb4 ,jacksonian1 #gcc4 petit mal1 #gcc4 ,epilepticus1 status1 #gcd4 ,epistaxis1 #afj1 #bga4 differential diagnosis of1 #afa4 ,erb's phenomenon1 #gja4 ,erysipelas1 #cgb4 ,esophagus1 #dic4 location of reflex pain from1 #dii4 ,estivo-autumnal fever1 #cej4 ,etiological factors1 #be4 ,etiology1 osteopathic1 #be4 ,examination--,see under various structures and regions4 thorough1 essential1 #ch4 ,exercise and postural defects1 #abj1 #abi1 #aca4 cannot take place of osteopathy1 #abj4 in treatment of ptosis1 #eba4 of false scoliosis1 #ggc4 to reduce abdomen1 #abh1 #aci1 #dhj4 ,external cutaneous nerve1 lesions affecting1 #gbb4 ,eye1 accommodation in the1 #aib4 affected by osseous lesions1 #ic1 #ahe1 and under individual diseases4 ,eye diseases1 #ahc1 #gac4 ,eye diseases1 osteopathic manipulation in1 #aif1 #bbc1 #gaf4 examination by special methods1 #aia4 how to examine1 #ahc4 lesions affecting certain nerves of1 #gaf4 osteopathic1 #ahd4 neuralgia1 #aig4 restored by osteopathy1 ,a case history1 #ahe4 schematic1 #aid4 strain and its reflexes1 #bca4 trouble1 nose and throat in1 #aia4 vasomotor nerves1 #ib4 ,eyelids1 diseases of1 #aii4 ,f ,face examination1 #df4 technic1 #fh4 ,facial nerve1 lesions affecting1 #aag4 ,fatty degeneration of heart1 #ffa4 liver1 #efa4 ,fecal impactions palpated1 #eb1 #edc4 with diarrhea1 #ech1 #edd4 ,feet1 neuralgia of1 #gad4 ,fetor oris1 #dia4 ,fever1 #cbe4 acute eruptive1 mumps and whooping cough1 #daa4 enteric1 #cbi4 estivo-autumnal1 #cej4 malarial1 #cdg4 paratyphoid1 #cdd4 remittent1 #cej4 rheumatic1 #deg4 simple continued1 #cgi4 treatment1 #cbe4 ,brand method1 #cbi4 usually beneficial1 #cbg4 typhoid1 #cbi4 typhus1 #cdd4 yellow1 #cgd4 ,fibroid phthisis1 #cic4 induration1 #fji4 ,fifth nerve1 neuralgia of1 #gaj4 ,filaria1 #aeh4 ,fingers1 sprains of1 #aad4 surgery in hay fever1 #bff4 treatment in catarrhal deafness1 #beb4 in tonsillitis1 #bha4 trigger1 #aae4 ,first rib--see rib4 ,fissures of rectum1 #agd4 ,fistulae1 rectal1 #agd4 ,flat foot1 #aab1 #ghg4 ,flatulency1 technic for1 #eje1 #ecg4 ,focus of infection--see infection4 ,foot1 club1 #ghd neuralgias1 some causes of1 #aab4 sprains of1 #aab4 ,fractures1 #aae4 and sprains1 #ajd4 summary of massage and immobilization in1 #aah4 of treatment of1 #aai4 ,frequency of treatments--see treatments4 ,friedreich's ataxia--,see ataxia4 ,functional and general diseases1 #gbc4 ,furunculosis of ear1 #bch4 ,g ,gall bladder1 sensory nerves to1 #ie4 ,gall-stones1 #efc4 easily diagnosed by osteopath1 #eb4 ,ganglion 7weeping sinew71 #aae4 ,gas in stomach1 technic for1 #eje1 #ecg4 ,gastritis1 acute1 #ejb4 chronic1 #eje4 due to portal disturbance1 #ejf4 gastric analysis essential to diagnose1 #ejg4 ,gastric--see also indigestion4 ,gastric derangement1 location of reflex pain from1 #dii4 and duodenal ulcer1 #eac4 neuralgia1 #eaj4 neuroses1 #eaj4 trouble often reflex1 #eaj4 ,general treatment--see treatment4 ,generative organs1 vasomotor nerves to1 #id4 ,genitocrural nerve1 lesions affecting1 #gbb4 ,genito-urinary system1 #age4 ,germ theory--its relation to osteopathy1 #bf4 ,german measles1 #ddd4 differentiate measles and scarlet fever1 #ddf4 ,glands enlarged1 differentiate from whooping cough1 #ded4 examination of thyroid and cervical1 #dg4 ,glaucoma1 #bbg4 ,glenard's disease1 #eba4 ,glosso-pharyngeal nerve1 lesions affecting1 #gah4 ,glottis1 spasm of1 #egb4 ,goiter1 do not treat direct1 #fia1 #fif4 exophthalmic1 #fij4 findings at ,mayo clinic1 #fib4 parathyroid glands in1 #fii4 simple1 #fhg4 ,gonorrhea germs in prostate1 #agf4 ,gonorrheal conjunctivitis1 #bji4 rheumatism1 #dei4 ,gout1 #dfg4 differentiated from rheumatic fever1 #dei4 ,grand mal1 #gcj1 #gcb4 ,grattage1 #bac4 ,great occipital nerve1 point of control1 #gai4 ,great auricular nerve1 point of control1 #gai4 ,green ,sickness1 #fgf4 ,h ,habit spasm1 #gbh4 ,hammer toe1 #aab4 ,hand1 sprain of1 #aad4 ,hay fever1 #bfc4 relation of focal infection to1 #bff4 treatment1 #fh4 ,head examination1 #da4 technic1 #fd4 vasomotor nerves to1 #ib4 ,headache1 from eye strain1 #ahh4 post-operative1 #cac4 sick1 #gcf4 technic1 #gbj4 ,hearing--see also ear4 test1 #bdi4 ,heart1 affected by stomach pressure1 #dih4 aneurism1 #ffj4 changes in goiter1 #fic4 complications in typhoid1 #ccb4 crowded by round shoulders1 #aba4 contraction mechanism1 #ffe4 dilatation1 #feg4 diseases1 #fch4 due to ribs1 #dg4 causing hyperemia of liver1 #eed4 enlargement causing cough1 #ege4 failure in pneumonia1 #fjc4 hypertrophy1 #fee4 hypertrophy and dilatation often recover1 #fed4 irregularities due to birth injury1 #fff4 muscle degeneration1 #ffa4 neuroses of1 #ffb4 palpitation of1 #ffb4 sensory nerves to1 #ie4 stimulated through rectum1 #afi1 #agj4 trouble and osteopathy1 #fdg1 #fdh1 #feb4 ,heat in treating ear1 #bch1 #bdj1 #bda4 in treating sprain1 #ajf4 prostration1 #aha4 stroke1 #ahj4 ,hebephrenia1 #bhf4 ,hematemesis1 #afb4 differential diagnosis of1 #afa4 ,hematuria1 #afc4 ,hemophilia1 #dhd4 ,hemoptysis1 #afj4 differential diagnosis of1 #afa4 ,hemorrhages1 #afj4 in feces1 #afc1 #agd4 of intestines1 #afc1 #agd4 of lungs1 #afj4 of nose1 #afj4 of stomach1 #afb1 #eaf4 of urinary tract1 #afc4 of uterus1 #afd4 ,hemorrhoids1 #aga4 acute1 #agc4 due to portal obstruction1 #efj4 treatment briefly discussed1 #agj4 ,hemorrhagia subdermalis1 #aii4 ,hepatic colic4 ,see biliary colic4 flexure prolapse1 #adj4 ,heredity1 ,see ,inherited4 ,hernia1 #ada4 treatment1 #edf4 ,herpes1 #adi4 conjunctiv1 #bad4 zoster1 #gab4 zoster ophthalmia1 #aii4 ,hiccoughs1 #afe4 ,hip1 #ef4 congenital dislocation1 #ggh4 ,lorenz operation1 #gha4 open operation1 #ghd4 lesion affecting knee1 #aab4 the prominent1 description and treatment1 #abe4 sprains of1 #aaa4 treatment following intracapsular fracture1 #aaa4 tuberculosis of1 #gia4 ,hip-joint disease1 #gia4 treatment following1 #aaa4 ,hives1 #adi4 ,hobnailed liver1 #eei4 ,hodgkin's disease1 #fhd4 differentiate from mumps1 #dea4 ,holmes electric auroscope1 #bcf4 ,homatropine1 #aid4 ,hook-worm disease1 #aee4 ,hordeolum1 #bjj4 ,hospital--,see post-operative treatment4 ,hot fomentations to relieve and relax1 #ie4 ,hydrophobia differentiated from tetanus1 #cgh4 ,hydrotherapy in fever1 #cbg4 bronchial asthma1 #ehi4 often necessary with osteopathy1 #fb4 ,hygiene necessary with osteopathy1 #fb4 ,hyoid examination1 #dg4 lesion affecting sense of taste1 #dia4 causing cough1 #df1 #egd4 furred tongue1 #dia4 in bronchial asthma1 #ehi4 in laryngismus stridulus1 #egb4 in laryngitis1 #ega4 ,hyperemia renal1 #fag4 ,hypertrophy of heart1 #fee4 ,hypoglossal nerve1 lesions affecting1 #gai4 ,hypopyon in keratitis1 #bba4 ,hysteria1 #gdj4 ,hysterical convulsions1 differentiated from epilepsy1 #gcd4 spine1 #aja4 ,hysterogenous zones1 #gdc4 ,i ,icterus1 #eeg4 ,idiots1 #cje4 ,ileocolitis1 acute1 #cfh4 ,ileus1 #edj4 ,iliohypogastric and ilio-inguinal nerves1 lesions affecting1 #gbb4 ,imbeciles1 #cje4 ,immobilization in relation to tuberculosis1 #aae4 ,see also under sprains4 ,impacted lesions1 #ib4 ,impactions1 fecal1 palpated1 #eb4 of intestines1 #edc4 of small intestine1 #edf4 ,impotency1 #agg4 ,indigestion--see also gastric4 and asthma1 #eij4 caused by pendulous abdomen1 #abg4 by round shoulders1 #aba4 nervous1 #eba4 ,infantile convulsions1 #gbh4 paralysis--see poliomyelitis4 ,infants--see children4 constipation treatment1 #eci4 ,infection differentiated from neuritis1 #abe4 foci of1 look out for1 #aca4 ,infectious diseases1 #cbe4 ,inflammatory rheumatism1 #deg4 ,influenza1 ,spanish or epidemic1 #cii4 causes bronchitis1 #gi4 ,inherited tendencies in defective children1 #cjc4 ,inhibition1 ,osteopathic1 #hi1 #id4 ,insanity1 ,see also ,mental diseases4 acute confusional1 #bij4 ,circular1 #bic4 defined1 #cjf4 7,physiology of brain71 #cje4 ,innominate examination1 #eb1 #ed4 lesions preventing knee recovery1 #aab4 sprains1 #aaa4 technic1 #gi4 dangerous1 #hg4 ,insect bites and stings1 #aii4 ,insipidus1 diabetes1 #dgf4 ,interrenal system1 #gjd4 ,intestinal colic1 #ece4 diseases1 #ebc4 relation of spinal lesions to gastro-1 #dhi4 obstruction1 #eda4 differential diagnosis1 #ede4 strangulation1 #eda4 ,intestine1 examination of1 #eb4 foreign substances in1 #edb4 impactions of1 #eb1 #edc4 treatment1 #ede1 #edf4 with diarrhea1 #ech1 #edd4 knots of1 #edb4 treatment1 #eda1 #ede4 location of reflex pain from1 #dii4 obstruction of1 #eb1 #gh1 #ede1 #edf4 differentiate from appendicitis1 #eea4 prolapsed1 #eb1 #aci4 sensory nerves to1 #ie4 strictures of1 #edc4 treatment of1 #ede4 technic1 #gh4 tumors of1 #edc4 treatment1 #ede1 twists1 #edb4 treatment1 #ede4 vasomotor nerves to1 #id4 ,intranasal surgery1 #bff4 ,introduction1 #ag4 ,intercostal neuralgia1 #gab1 #gba4 ,intussusception1 #eda4 ,invagination1 #eda4 treatment1 #ede4 ,iridocyclitis in keratitis1 #bba4 ,iris1 diseases of1 #bbe4 ,iritis complicating conjunctivitis1 #bjd4 in keratitis1 #bba4 ,iron not indicated in anemic conditions1 #fbc4 ,j ,jaundice1 #eeh4 differentiate from ,addison's disease1 #eei4 simple catarrhal1 #eee4 ,jacksonian epilepsy1 #gcj1 #gcc4 ,jaw1 full motion essential1 #dij4 lesions1 #df1 #dia4 technic1 #fh4 ,joints and bones1 tuberculosis of1 #ghh4 function is motion1 #dhi4 ,k ,keratoconus1 #bah4 ,keratitis1 #bai4 cornea-phlyctenular1 #bad4 neuroparalytica1 #bbc4 parenchymatous or interstitial1 #bbd4 ,keratitis1 phlyctenular1 #bbd4 ,keratomalacia1 #bai1 #bbc4 ,kidney1 amyloid1 #fbf4 complications in typhoid1 #cca4 diseases of1 #fag4 examination1 #eb hemorrhage1 #afd4 movable1 #fcd4 prolapsed1 #acf4 belt for1 #acg4 sensory nerves to1 #ie4 stones1 #fca4 treatment1 #gh1 #fbj1 #fbc4 vasomotor nerves to1 #id4 ,knee1 tuberculosis of1 #gic4 ,kraepelin's classification of dementia praecox1 #bhc4 ,kyphosis--,see curvatures4 ,l ,labioglossopharyngeal paralysis1 #gfe4 ,laboratory experiments on animals 7,lesions71 #ia4 ,labyrinthitis1 #bed4 ,lachrymal apparatus1 ,diseases of1 #bjb4 ,laennac's egophony1 #fac4 pearls1 #ehf4 ,landmarks of spine1 #ci4 ,landry's disease differentiated from myelitis1 #gdi4 paralysis1 #gec4 ,laryngeal nerve technic1 #gai4 lesions affecting superior and inferior1 #gai4 ,laryngismus stridulus1 #egb4 differentiated from croup1 #egc4 ,laryngitis1 acute catarrhal1 #efi4 chronic catarrhal1 #egj4 edematous1 #egg4 spasmodic1 #egc4 syphilitic1 #egg4 tuberculous1 #ege4 ,larynx complications in typhoid1 #ccb4 diseases of1 #efi4 examination1 #dg4 technic1 #fg4 ,lateral curvature1 #ih4 ,lead colic differentiated from intestinal colic1 #ece4 poisoning1 ,neuritis from1 #gjg4 ,leg examination1 #ef4 neuralgia of1 #gad4 technic1 #hj4 vasomotor nerves to1 #ia4 ,lens1 diseases of1 #bbi4 opacity1 #bbi4 ,lenses explained1 #aia4 ,leprosy1 anesthetic1 differentiated from syringomyelitis1 #gfb4 ,lesions of each part or organ indexed under respective names of parts1 but not under all diseases in which they may be found ,lesion affecting one viscus affects others also1 #did4 caused by visceral disturbance1 #eja1 #ejc4 chronic1 reduce gradually1 #ff4 composite1 #cj4 dominant in causing gastro-intestinal disease1 ,osteopathic1 #dhi1 #dij4 effects of1 #cc4 effects in heart cases1 ,osteopathic1 #fdg1 #fdh4 impacted1 #ib4 is absence of motion1 #dhi4 ligamentous1 #bh4 muscular1 #bg1 #da1 #de4 caused by visceral disturbances1 #ejj4 of various structures and regions1 considered in connection with osseous lesions of same4 osseous1 #bf4 also listed under various bones1 organs and regions4 pathognomonic signs of1 #ci4 results stated by ,mc,connell1 #dij4 to diagnose1 #ch1 #cj1 #ia4 visceral1 #bi4 ,leyden's crystals1 #ehf4 ,leukemia1 #fhj4 acute myelogenous1 #fha4 lymphatic1 #fhb4 splenomedullary1 #fha4 ,lithemia1 #dfi4 ,liver1 amyloid1 #efb4 and bile duct1 diseases of1 #eec4 cancer of1 #efb4 7cholecystitis71 #eeg4 cirrhosis of1 #efj4 complications in typhoid1 #ccb4 examination1 #ea4 fatty1 #efb4 7gall-stones71 #efd4 hyperemia of1 #eed4 inactivity from pendulous abdomen1 #abg4 innervation1 #dgd4 involved in rheumatism1 #dfj4 7jaundice71 #eeh4 location of reflex pain from1 #dii4 nutmeg1 #eec4 pain reflex to scapula1 #gba4 7simple catarrhal jaundice71 #eee4 prolapse1 #ach4 sensory nerves to1 #ie4 technic1 #gg4 vasomotor nerves to1 #id4 ,lobar pneumonia1 acute1 #eig4 ,lock-jaw1 #cgg4 ,locomotor ataxia1 #ged4 differentiated from ,friedreich's ataxia1 #gei4 ,lordosis1 #ig4 ,lorenz operation1 #gha4 ,lumbago1 #dfe1 #dff4 ,lumbar curve and prolapsed uterus1 #adc4 prominent hip1 #abe4 examination1 #di1 #eb4 lumbar nerves1 lesions affecting1 #gbb4 technic1 #gd4 ,lumbo-abdominal neuralgia1 #gac4 ,lungs affected by stomach pressure1 #dih4 complications in typhoid1 #ccb4 congestion1 #faj4 crowded by round shoulders1 #aba4 diseases1 #eib4 due to ribs1 #dg4 causing hyperemia of liver1 #eed4 edema of1 #faa4 relation to digestion1 #did4 sensory nerves to1 #ie4 stimulated through rectum1 #afi1 #agj4 vasomotor nerves to1 #ic4 ,lymphatic leukemia1 #fhb4 ,lymphadenoma1 #fhd4 ,m ,mc,burney's point1 #edi4 why pain in appendicitis1 #dii4 ,macula lutea1 #aie4 ,maddox rod1 #aic4 ,mal1 grand1 #gcj1 #gcb4 petit1 #gcj1 #gcc4 ,malaria associated with typhoid1 #ccg4 ,malarial cachexia1 #cea4 fever1 #cdg4 pernicious1 #cej4 hematuria1 #cea4 ,mammary gland innervation1 #gbb4 ,manic depressive psychoses1 #bia4 ,massage following hip joint disease1 #aaa4 intracapsular fracture of hip1 #aaa4 of fractures1 #aaf4 of sprains1 #aji4 not osteopathy1 #ai4 ,mastoiditis1 #bdj4 ,mayo clinic's goiter findings1 #fib4 ,measles1 #dcg4 a cause of bronchitis1 #egi4 differentiate ,german measles1 #ddf4 scarlet fever1 #dcb4 ,german1 #ddd4 ,meatus of ear1 atrophic1 #bcg4 infection of1 #bch4 ,medulla contains vasomotor center1 #ib4 ,meibomian cyst1 #bjj4 ,meissner's plexus1 #did4 ,melancholia agitata1 #big4 ,mellitus1 ,diabetes1 #dgj4 ,meniere's disease1 #bed1 #gah4 symptom complex1 #bec4 ,meningeal tuberculosis1 #chg4 ,meningitis1 cerebrospinal1 #ceh4 complicating pneumonia1 #fja4 tubercular1 #cfj4 ,menopause1 thyroid enlargement during1 #fhf4 ,mental deficiency1 #cje4 diseases1 #bhb4 osteopathic lesions in1 #bhi4 ,microcephalous1 #cjh4 ,migraine1 #gcf4 ,milk leg1 #afg4 ,mind1 relation to brain1 #cjg4 ,miner's anemia1 #aee4 ,mitral regurgitation1 #fdh4 stenosis1 #fdi4 ,moebius' sign1 #fid4 ,morbilli1 #dcg4 ,mongolian amentia1 #cji4 ,morons1 #cje4 ,morphine habit1 physicians responsible1 #gae4 ,morton's disease1 #aab4 ,morvan's disease1 #gfb4 ,mosquito carrier of filaria1 #aeh4 ,motion is function of joint1 #dhi4 ,motor oculi nerve1 lesions affecting1 #gaf4 ,mouth1 diseases of1 #dhg4 ,mucous colitis1 #ebf4 ,mumps1 #ddi4 whooping cough and acute eruptive fevers1 #daj4 differential diagnosis1 #dea4 ,murmurs1 ,heart1 #fdb1 #fdc4 ,muscle contractions caused by visceral disturbances1 how1 #ejj4 relieved by inhibition1 #hi4 ,muscular lesions1 #bg1 #da1 #de4 ,also considered in connection with osseous lesions of various parts4 rheumatism1 #dfe4 ,musculacutaneous nerve1 lesions affecting1 and results1 #gba4 ,myalgia1 #dfg4 ,mydriatic1 #aid4 ,myelemia1 #fha4 ,myelitis1 #gjg4 acute1 #gdh4 chronic1 #gej4 diffuse1 #gdi4 transverse1 #gdh4 ,myelogenous leukemia1 acute1 #fha4 ,myeloid leukemia1 #fha4 ,myocarditis1 #fei4 ,myoclonia1 #gbg4 ,myxedema1 #fig4 ,n ,nasal--,see nose4 ,nasopharyngitis1 #bgb4 ,nasopharynx1 diseases of1 #bgb4 ,neck--,see also cervical4 ,neck examination1 #dg4 muscle lesions1 #df4 stiff1 #dfe1 #dff4 technic1 #fd1 #ff4 dangers of1 #ff1 #hf4 ,nephritis differentiated from pyelitis1 #fbh4 hemorrhagic1 chronic1 #fbb4 interstitial1 #fbd4 differentiated from diabetes insipidus1 #dgg4 parenchymatous1 acute1 #fah4 chronic1 #fba4 post-operative1 #cad4 ,nerve centers 7osteopathic71 #hh4 deafness1 #bee1 #gah4 degeneration1 auditory1 #bef4 diseases of1 #gjf4 cranial1 diseases of1 #gae4 spinal1 diseases of1 #gai4 sensory1 #id4 vasomotor1 #ib4 ,nervous indigestion1 #eaa4 prostration from prolapse1 #abh4 system1 diseases of1 #gjf4 ,neuralgia1 #gaj4 cervico-brachial and brachial1 #gaa4 cervico-occipital1 #gaa4 differential diagnosis1 #gad4 intercostal1 #gba4 of eye1 #aig4 of fifth nerve1 #gaj4 of foot1 some causes1 #aab4 of legs and feet1 #gad4 of sacral nerve from impacted feces1 #ecg4 of sacral region1 #gac4 of spinal column1 #gac4 of trunk1 #gab4 relieved by inhibition1 #hi4 ,neurasthenia1 #gdd4 ,neuritis1 #gjf4 brachial1 #abc4 differentiated from neuralgia1 #gad4 multiple1 differentiated from ,landry's paralysis1 #gec4 from myelitis1 #gdi4 optic1 #bcj4 post-operative1 #cac4 retrobulbar1 #bca4 ,neuroses of heart1 #ffb4 gastric1 #eaj4 ,neurosis1 occupation1 #gch4 8,neurotic spine10 #aja4 ,nocturnal epilepsy1 #gcc1 #gcd4 ,nose and throat in eye troubles1 #aia1 #aif1 #bbe1 #bbi4 antiseptic sprays etc41 #beh1 #bfb4 conditions in torticollis1 #dff4 diseases of1 #beg4 intranasal treatment1 #bfj4 packing1 #bfg1 #bfh4 pharmacodynamics of1 #bfb4 syphilis of1 #bgj4 throat and ear1 diseases1 #bcf4 nosebleed1 #afa1 #bga4 differential diagnosis1 #afa4 ,nursing necessary to osteopathy1 #fb4 ,nutmeg liver1 #eed4 ,o ,obesity1 #dhj4 exercises to reduce abdomen1 #abh1 #aci1 #dhj4 ,obstetric cases1 innominate leosin in1 #afh4 ,obstruction1 intestinal--see intestinal4 ,obturator nerve1 lesions affecting1 #gbb4 ,occipito-atlantal examination and lesions1 #de4 technic1 #fg4 ,occupation neurosis1 #gch4 ,olfactory nerve1 diseases of1 #gae4 ,omodynia1 #dff1 #dfg4 ,ophthalmia neonatorum1 #baj4 purulent1 #bji4 sympathetic1 #bbg4 ,ophthalmology1 #ahc4 ,ophthalmoscope1 #aic4 ,optic disc1 #aie4 nerve atrophy1 #bca4 probably connection with third1 #bcd4 neuritis1 #bcj4 tract1 diseases of1 #gae4 ,oropharynx1 diseases of1 #bgd4 ,orthopedic ,surgery1 #gfg4 ,osteopathic centers--see centers4 diagnosis and prognosis1 #ch4 etiology and pathology1 #bd4 examination of eye1 #ahd4 inhibition1 #hi4 lesion defined1 #bd4 manipulation in eye diseases1 #aif1 #bac4 readjustment1 #ij4 stimulation1 #hh4 theory1 proof of1 #cd4 scientific demonstration1 #hi4 treatment1 general directions1 #eh4 ,osteopathy1 definitions of1 #ah4 includes many measures1 #fb4 not massage1 #ai4 not passive exercise1 #abi4 not ,swedish movements1 #ai1 #fc1 #fh4 ,otitis media1 acute suppurative1 #bci4 chronic suppurative1 #bdc4 differential diagnosis1 #bdd4 non-suppurative1 #bdf4 ,ovarian examination1 #ef4 ,ovary1 prolapse of1 #add4 sensory nerves to1 #ie4 ,oxyuris vermicularis1 #aed4 ,p ,pachymeningitis1 cervical1 differentiated from syringomyelia1 #gfb4 ,packing1 nasal1 #bfg1 #bfh4 ,pains1 location of reflex1 #dii4 ,palpation1 educated1 #fj4 practice in1 #hg4 ,palpitation1 #ffb4 ,pannus1 #bbd4 ,panophthalmitis1 #bbg4 ,papillae in rectum1 #agd4 ,paralysis1 acute ascending1 #gec4 ,paralysis agitans1 #gbc4 differential diagnosis1 #gbd4 bulbar1 #gfe4 ,paralysis1 infantile1 #gej4 ,paranephritic abscess differentiated from pyelitis1 #fbh4 ,paranoia1 #bhg4 ,paraplegia1 ataxic1 #gfa4 spastic1 #gfj4 ,parasites1 animal1 #aea4 ,parathyroid glands1 diseases of1 #fii4 ,paratyphoid fever1 #cdd4 ,paris1 plaster of1 #gie4 ,parotiditis1 epidemic1 #ddi4 differential diagnosis of1 #dea4 ,parotitis1 epidemic1 #ddi4 ,patheticus nerves1 lesions affecting1 #gaf4 ,pathologies1 osteopathy recognizes two distinct1 #dhi4 ,pathology1 osteopathic1 #ca4 ,patient's receptivity to treatment1 #fa4 ,pearls1 ,lnnec's1 #eia4 ,pelvic examination1 #eb4 prolapse caused by abdominal prolapse1 #abh4 technic1 #gh4 ,pendulous abdomen1 #abg4 ,pericarditis1 #fch4 complicating pneumonia1 #fjj4 ,pericardium1 diseases of1 #fch4 ,peristalsis explained1 #did4 reversed1 normal in parts of colon1 #dig4 technic to affect1 #die4 ,peritonsillar abscess1 #bgh4 ,pernicious anemia1 #fgh4 ,pertussis1 #deb4 ,petit mal1 #gcj1 #gcc4 ,pharyngitis1 #bgd4 ,pharynx complications in typhoid1 #ccb4 technic1 #fg4 ,phenol-glycerine formula1 #bfc4 ,phlebitis1 #afg4 post-operative1 #cac4 ,phlegmasia alba dolens1 #afg4 ,phlyctenular keratitis1 #bbd4 ,phrenic nerve1 lesions affecting1 #gbj4 ,phthisis1 see tuberculosis4 ,piles1 #aga4 ,pin-worm1 #aed4 ,plaster of ,paris1 #gie4 ,pleura1 diseases of1 #faa4 ,pleurisy1 #faa4 complicating pneumonia1 #fjj4 differentiated from pneumonia1 #fja4 post-operative1 #cad4 ,pleurodynia1 #dfe1 #dff1 #gab4 ,pneumogastric nerve1 lesions affecting1 #gah4 ,pneumonia1 acute lobar1 #eig4 aspiration1 #fje4 alcohol not indicated in1 #cai4 associated with endocarditis1 #fdd4 bronchial1 #fje4 caused by tubercle bacillus1 #fjf4 catarrhal1 #fje4 complication of typhoid1 #ccb4 chronic interstitial1 #fji4 croupous1 #eig4 differential diagnosis of1 #fji4 deglutition1 #fje4 differential diagnosis of1 #fja4 post-operative1 #cad4 ,pneumonia1 strychnine not indicated in1 #cbj4 ,pneumonic phthisis1 #chh4 ,poliomyelitis1 #gej4 causing scoliosis1 #ggj4 differentiated from myelitis1 #gdi4 ,polyuria1 #dgf4 ,portal system1 vasomotors to1 #id4 ,posterior spine technic1 #aja4 thoracic nerve1 lesions affecting1 #gba4 ,post-operative treatment1 #cab4 ,postural curves of spine1 #abh4 defects1 #abj4 ,posture1 correct1 #abg1 #abh4 ,pott's disease1 #ajb1 #ghh4 differentiated from kyphosis1 #ig4 from scoliosis1 #ggc4 treatment1 #ajb4 ,proctitis1 #agj4 ,prognosis and diagnosis1 osteopathic1 #ch4 osteopathic1 #ef4 ,progressive muscular atrophy1 #gfd4 differentiated from syringomyelitis1 #gfb4 ,prolapse--,see also ptosis4 ,prolapsed hepatic flexure1 #aci4 intestines1 #aci1 #agj4 kidney1 #acf4 liver1 #ach4 organs1 #abg1 #acc1 #eba4 ovaries1 #add4 rectum1 #aga4 sigmoid flexure1 #ada1 #agj4 stomach1 #acd4 uterus1 #adc4 ,prominent hip1 #abe4 ,prostate gland1 #age4 technic1 #fcg4 sensory nerves to1 #ie4 ,prostatitis1 #age4 ,prostatorrhea1 #agf4 ,pseudo-angina pectoris1 #ffg4 appendicitis1 #eej4 croup1 #egb4 leukemia1 #fhd4 ,psychalgia1 #bic1 #bif4 ,psychosis1 involutional1 #bie4 ,ptosis--,see also prolapse4 of abdominal organs1 #abg4 of eyelids1 #bja4 ,pulmonary regurgitation1 #fej4 stenosis1 #fej4 ,punctum proximum1 #aib4 remotum1 #aib4 ,purpura1 #dhc4 variolosa1 #dbj4 ,pyelitis1 #fbg4 differential diagnosis1 #fbh1 #fcf4 ,pyelonephritis1 #fbg4 ,pyemia1 #cef4 ,q ,quinsy1 #bgh4 ,r ,radial nerve1 lesions affecting1 #gci4 ,rash1 differentiate scarlet fever from drug or septic1 #dca4 ,receptaculum chyli1 vasomotor nerves to1 #id4 ,rectal conditions requiring surgery1 #agd4 disorders1 brief discussion1 #ada4 examination1 #ee1 #ef1 #afi4 ,rectum1 #afi4 to dilate1 #agj4 technic1 #afi4 ,reflex gastric troubles1 #eji4 pains1 location of various1 #dii4 ,reflexes1 somatic1 ,burns experiments1 #ahi4 ,regions of body should form basis of disease classification1 #ehf4 ,regurgitation1 aortic1 #fdi4 mitral1 #fdh4 pulmonary1 #fej4 tricuspid1 #fej4 ,remittent fever1 #cej4 differentiate from yellow fever1 #cge4 ,renal calculus1 #fca4 ,renal colic--see colic4 differentiate from appendicitis1 #eea4 ,respiratory diseases1 #efi4 reflex inefficiency1 #bfd4 ,retina1 diseases of1 #bcj1 #gae4 ,retinitis1 #bcj4 ,retrobulbar neuritis1 #bca4 ,rheumatic fever1 #deg4 ,rheumatism1 abdominal1 #dff1 #dfg4 cause of heart valve defects1 #fde4 chronic articular1 #dfj4 differential diagnosis1 #dei4 and brachial neuritis1 #abe4 gonorrheal1 #dei4 inflammatory1 #deg4 muscular1 #dfe4 subacute1 #dei4 ,rheumatoid arthritis1 #dfb4 differentiated from rheumatic fever1 #dei4 ,rhinitis1 acute1 #beg4 atrophic1 #bfa4 chronic hypertrophic1 #bei4 hyperesthetic1 #bfc4 purulent1 #bei4 ,ribs1 danger in elderly patients1 #hg4 examination1 #dg4 false1 technic1 #gd4 first1 examination1 #di4 technic1 #gb4 floating1 #di4 technic1 #gc4 lesions cause heart trouble1 #fdh1 #fec4 described1 #dh4 sprains1 #aaa4 technic1 #fi4 ,rickets1 #dgh4 ,rose spots1 #ccd4 ,round shoulders1 #aba1 #acj4 worm1 #aea4 ,rubella1 #ddd4 differentiated from measles and scarlet fever1 #ddf4 ,rubeola1 #dcg4 ,ruddy nasal third finger1 #aig4 third finger eye instrument1 #bad1 #bbi4 treatment of tonsillitis1 #bha4 ,s ,st4 ,vitus' dance1 #gbe4 ,saccules in rectum1 #agd4 ,sacral nerves1 lesions affecting1 #gbb4 neuralgia1 #gac4 caused by impacted feces1 #ech4 ,sacro-iliac--see innominate4 ,sacrum examination1 #ee4 technic1 #hb4 ,salivary glands1 #dia4 ,sallow skin1 #eei4 ,scalp1 #df4 technic1 #fh4 ,scapula1 technic1 #fh4 ,scapulodynia1 #dff1 #dfg4 ,scarlatina1 #dbh4 differentiate diphtheria1 #dcb4 drug rash1 #dca4 ,german measles1 #dcb1 #ddf4 measles1 #dcb4 septic rash1 #dca4 types and forms1 #dcb4 ,scarlet fever--see scarlatina4 ,schematic eye1 #aid4 ,sciatica1 #gjh1 #gad4 8,scissors0 technic dangerous1 #hf4 ,sclerosis1 amyotrophic lateral1 #gfb1 #gfc4 differentiate from syringomyelia1 #gfb4 cerebral1 differentiate from chorea1 #gbf4 disseminated1 differentiate from paralysis agitans1 #gbd4 ,scoliosis--,see curvatures4 ,scrofula1 #chd1 #cif4 ,scrofulous ophthalmia1 #bad4 ,scurvy1 #dha4 ,seminal vesicles1 #agf4 ,senile delirium1 #cjj4 dementia1 #big4 ,sensory nerves to various viscera1 #id4 ,see also under various viscera4 ,septic rash1 differentiate scarlatina1 #dca4 ,septicemia1 #cee4 8,setting up0 exercises for pendulous abdomen1 #abh4 ,shaking palsy1 #gbc4 ,shoulder1 #ef1 #hj4 painful1 #abb4 round1 #aba4 sprain of1 #aad4 ,sight--see eye4 diagnosis1 #ch4 ,sigmoid impaction causing cough1 #ege4 prolapse1 #ada4 ,sinusitis1 #bfi4 vacuum1 #bgj4 ,skin diseases1 #adg4 ,small occipital nerve1 point to control1 #gai4 ,smallpox1 #dab4 black1 #dbj4 differentiate from chicken-pox1 #dag4 ,smell1 sense of1 #dia4 ,snellin's test type1 #aia4 ,solar plexus inhibition1 #ehb4 ,somatic reflexes--,burns experiments1 #ahh4 ,spasm--see convulsions4 habit1 #gbh4 ,spastic paraplegia1 #gfj4 ,sphincters1 alimentary1 #dif4 ani1 external1 #dih4 ,spinal accessory nerve1 lesions affecting1 #gai4 centers 7osteopathic71 #hh4 column1 neuralgia of1 #gac4 postural curvatures of1 #abh4 cord1 diseases of1 #gdh4 curvature1 pathological1 #if4 technic1 #ig4 examination1 importance of1 #da4 landmarks1 #ci4 lesions--see lesions4 nerves1 diseases of1 #gai4 stretching1 dangers of1 #hf4 ,spine the center of osteopathic interest1 #ch4 hysterical1 description and technic1 #aja4 neurotic1 description and technic1 #aja4 of the aged1 description and technic1 #aja4 posterior1 technic1 #aja4 sprains of1 #aaj4 straight1 #ii4 technic1 #ajj4 tubercular disease of1 #ghh1 #ajb4 typhoid1 description and technic1 #ajj4 ,splanchnic technic1 #die4 ,spleen complications in typhoid1 #ccb4 diseases of1 #efg4 examination1 #eb4 treatment1 #gh4 vasomotor nerves to1 #id4 ,splenitis1 #efg4 ,splenomedullary leukemia1 #fha4 ,spondylitis deformans1 #dfc4 ,sprains and fractures1 #ajd4 bandaging not always good1 #ajg4 heat and cold in treatment1 #ajf4 immobilization and rest1 #ajf1 #aae4 massage1 #aji1 #aaf4 of ankle1 #aab4 of elbow1 #aad4 of fingers1 #aad4 of foot1 #aab4 of hip1 #aaa4 of innominate1 #aaa4 of knee1 #aab4 of ribs1 #aaa4 of shoulder1 #aad4 of spinal column1 #aaj4 of wrist and hand1 #aad4 passive movement1 #ajg4 summary of treatment1 #aaj4 ,stand erect1 how to1 #abg4 ,status epilepticus1 #gcd4 lymphaticus1 #gjb4 ,stenosis1 aortic1 #fej4 mitral1 #fdi4 pulmonary1 #fej4 tricuspid1 #fej4 ,sternum examination1 #di4 technic1 #gc4 ,still1 early struggles of ,dr4 ,a4 ,t41 #ag4 ,still-,hildreth ,sanitarium #bhj1 #bia4 ,several times in chapter on mental and nervous diseases4 ,stimulation1 osteopathic1 #hh4 ,stomach1--see also digestive system4 cardiac relaxation by inhibition1 #hi4 conditions in bronchial asthma1 #ehi4 dilatation1 #acd4 differentiate from gastroptosia1 #acd4 distention1 #dih4 examination1 #eb4 hemorrhage1 #afb1 #eaf4 pain over pit of1 due to cutaneous sensory nerves1 #gba4 prolapse1 #acd4 sensory nerves to1 #ie4 technic1 #gh4 ulcer1 spinal causes of1 #dih4 ,stomatitis1 #dhg4 ,stones1 gall1 #efc4 kidney1 #fca4 8,straight spine10 #ii1 #acj4 technic for1 #ajj4 ,strangulation of intestines1 #eda4 ,stretching1 indiscriminate1 #hf4 ,strychnine not indicated in post-operative pneumonia1 #cbj4 poisoning differentiated from tetanus1 #cgh4 ,stupor1 delirium and confusion1 #bhi4 ,sty1 #bjj4 ,sunstroke1 #ahj4 ,supports1 arch1 #aad4 in prolapse1 #acc1 #adb4 ,suprarenal capsule1 ,dr4 ,still's theory1 #fcc4 ,surgery1 relation to osteopathy1 #bb4 in various conditions1 taken up in connection with treatment4 orthopedic1 #gfg4 ,swallowing1 #dib4 ,swedish movements not osteopathy1 #ai1 #fc1 #fh4 ,synechiae in keratitis1 #bba4 ,syphilis of nose1 #bgj4 of thyroid1 #fhg4 ,syphilitic laryngitis1 #egg4 ,syringomyelia1 #gfa4 differential diagnosis1 #gfb4 ,t ,tabes dorsalis1 #ged4 ,tachycardia1 #ffc4 ,taenia flavo-punctata1 #aea4 saginata1 #aea4 solium1 #aea4 ,talipes1 #ghd4 ,tape-worm1 #aea4 ,taste1 bad1 in mouth1 #dib4 sense of1 #dia4 ,technic1 see under osteopathic treatment2 also under various regions1 and organs4 dangerous1 #hf4 osteopathic1 #fj4 ,teeth conditions in torticollis1 #dff4 defects should be corrected1 #dij4 ,temporo-mandibular--see jaw4 ,tenesmus treatment1 #agj4 ,testes1 sensory nerves to1 #ie4 ,tetanus1 #cgg4 differentiated from hydrophobia1 #cgh4 strychnine poisoning1 #cgh4 ,tetany1 #fii4 ,thorax examination1 #ea4 ,thread-worm1 #aed4 ,throat and nose in eye trouble1 #aia1 #aif1 #bbe1 #bbi4 ,throat1 diseases of the ear1 nose and1 #bcf4 7,edwards' turbinate adjuster71 #aig4 irritation due to hyoid1 #dg4 7,ruddy's nasal third finger71 #aig4 technic1 #fg4 ,thrombosis from typhoid1 #ccb4 ,thrush1 #dhh4 ,thyroid gland1 direct manipulation dangerous1 #fif4 diseases of1 #fhf4 ,thymus gland enlarged in goiter1 #fia1 #fic4 diseases of1 #gjb4 ,tic1 convulsive1 #gbh4 douloureux1 #gaa4 general1 #gbh4 ,tongue1 #dij4 furred1 #dia4 vasomotor nerves to1 #ib4 ,tonsils1 #fg4 function of1 #bgf4 in rheumatism1 #deg1 #dfj4 in torticollis1 #dff4 palpated1 #dg4 7peritonsillar abscess71 #bgh4 trouble in eye disease1 #aif4 ,tonsillectomy1 #bgh4 summary of indications for1 #bhj4 ,tonsillitis1 #bgf4 technic1 #fh1 #bgi1 #bhj4 ,torticollis1 #abi1 #dfe1 #dff1 #gai4 ,touch1 educated sense of1 #fj4 ,trachoma1 #bjh1 #bab4 differentiated from follicular conjunctivitis1 #bjh4 ,traction1 reasons for1 #fb4 ,transillumination in diagnosing sinuitis1 #bfi4 ,treating 7over-treating71 #hd4 in influenza1 #djd4 ,treatment--see also technic4 after a meal1 #hc4 frequency of1 #hc1 #hd4 general1 #fb1 #fh1 #ij4 should be given when1 #fc4 inhibition to begin1 #hi4 length of1 #hd4 misapplied1 #he1 #hg4 position of physician and patient1 #fc4 receptivity of patient to1 #fa4 resulting in some motion1 leave lesion for that time1 #gf4 to be avoided1 #hf4 value of vacation from1 #he4 ,tremors1 differentiate from paralysis agitans1 #gbd4 ,trichiniasis1 #aef4 ,trichiasis1 #bja4 ,tricuspid regurgitation1 #fej4 stenosis1 #fej4 ,trigeminus nerve1 lesions affecting1 #gag4 ,trigger-finger1 #aae4 ,trousseau's phenomenon1 #gja4 ,tubal disease1 differentiated from appendicitis1 #eea4 ,tubercle bacillus may cause bronchopneumonia1 #fjf4 ,tuberculosis1 #chj4 and joint immobilization1 #aae4 of alimentary tract1 #cic4 acute1 #chf4 begins as chronic gastritis1 #ejf4 bones and joints1 #ghh4 bronchopneumonic1 #chh4 cerebral1 #chg4 deformities predisposing factors1 #chi4 differentiate from brachial neuritis1 #abe4 pneumonia1 #fja4 7fibroid phthisis71 #cic4 differentiate from chronic interstitial pneumonia1 #fji4 of genito-urinary tract1 #cid4 of hip1 #gia4 of knee1 #gic4 of lymph glands1 #chd4 of miliary1 #chf1 #cid4 pneumonic1 #chf4 pulmonary1 #chg1 #chi4 of spine1 #ajb1 #ghh4 orthopedic surgery necessary in1 #gfg4 of thyroid1 #fhg4 ,tuberculous laryngitis1 #ege4 ,tumor1 brain1 differentiate from migraine1 #gcg4 ,tuning fork tests1 #bid4 ,turbinates1 to clean around in rhinitis1 #bjj4 ,tussis convulsiva1 #deb4 ,typhoid fever1 #cbi4 afebrile1 #ccd4 fever associated with malaria1 #chg4 do not manipulate abdomen1 #afc4 differentiated from appendicitis1 #eea4 spine1 #ajj4 ,typhus fever1 #cdd4 ,u ,ulcer of cornea1 #bai1 #bba4 gastric and duodenal1 #eab4 location of reflex pain in gastric or duodenal1 #dii4 of stomach1 spinal causes of1 #dih4 differential diagnosis1 #ejh1 #eae4 ,ulcerative stomatitis1 #afd4 ,ulnar nerve1 lesions affecting1 #gbf1 #gci4 ,uncinariasis1 #aee4 ,uremia1 #fbh4 ,uremic convulsions1 differentiated from epilepsy1 #gcd4 ,ureter1 sensory nerves to1 #ie4 hemorrhage1 #afd4 ,urethra hemorrhage1 #afd4 ,urinary system1 diseases of1 #fag4 ,urine1 blood in1 #afc4 massage prostate for retention of1 #agf4 ,urticaria1 #adi4 ,uterine examination1 #ef4 hemorrhage1 #afd4 ,uterus1 prolapsed1 #adc4 sensory nerves to1 #ie4 ,v ,vaccination1 #dbd4 ,vaccinia1 #dbd4 ,valve diseases1 heart1 #fdb1 #fdd1 #fde1 #fdi1 #fea4 ,varicella1 #dbd1 #ddf4 differentiated from variola1 #dag4 ,varicocele1 #agf4 ,varicose veins1 #aff4 ,variola1 #dab4 cornea1 #dba4 differentiated from varicella1 #dag4 hemorrhagica pustulosa1 #dbj4 vera1 #dah4 verucosa1 #dbj4 ,varioloid1 #dbj4 ,variolosa purpura1 #dbj4 sine exanthemate1 #dbj4 ,vasomotor nerves1 #ib4 ,venereal disease and eye trouble1 #ahd4 ,vertebr1 landmarks for distinguishing1 #ci4 ,vision explained1 #bcj4 ,volvulus1 #eda4 ,vomiting1 persistent1 mostly reflex1 #eja4 post-operative1 #cab4 technic to relieve1 #ejd4 von ,graefe's sign1 #fid4 ,w ,water1 drink plenty1 #edj4 ,white swelling1 #gic4 ,whooping cough1 #deb4 ,whooping cough1 mumps1 and acute eruptive fevers1 #daa4 differentiate enlarged glands1 #ded4 ,worms1 intestinal1 #aea4 ,wrist1 #ef4 sprain1 #aad4 ,wry-neck--see torticollis4 ,y ,yellow ,fever1 #cgd4 differentiate from remittent fever1 #cge4 ,z ,zuckerkand's organ1 #gjc4 ,transcriber's ,notes pg #dh ,changed3 resistance is a helpful guide in dignosis to3 resistance is a helpful guide in diagnosis pg #ga ,changed3 ,still another method of adjustfng ribs to3 ,still another method of adjusting ribs pg #gi ,changed3 slip one hand bteween the thighs to3 slip one hand between the thighs pg #ia ,changed3 ,in other words pathogological changes are just as real to3 ,in other words pathological changes are just as real pg #aaa ,changed3 ,diagnosis1 ,etiology1 and ,tecnhique1 and the general to3 ,diagnosis1 ,etiology1 and ,technique1 and the general pg #aab ,changed3 ,another joint frequent overlooked is the innominate4 to3 ,another joint frequently overlooked is the innominate4 pg #aab ,changed3 of the innominate that is preventing revovery to3 of the innominate that is preventing recovery pg #acj ,changed3 ,there is often a shortning of the anterior structures to3 ,there is often a shortening of the anterior structures pg #adj ,changed3 ,of particular local interest to the osteopth to3 ,of particular local interest to the osteopath pg #ahf ,changed3 goins then to the innominates to3 going then to the innominates pg #bad ,changed3 ,the exact cause of ocular lesions1 or phlycentular to3 ,the exact cause of ocular lesions1 or phlyctenular pg #bae ,changed3 diathesis and the exanthemata play their roll to3 diathesis and the exanthemata play their role pg #bbj ,changed3 progressive ulcer 7second sage47 to3 progressive ulcer 7second stage47 pg #bbh ,changed3 which begins by contration of the field to3 which begins by contraction of the field pg #bch ,changed3 paraffin oil and the heat applied continusously to3 paraffin oil and the heat applied continuously pg #bed ,changed3 ,labyrinthitis is of several forms but in gerneral to3 ,labyrinthitis is of several forms but in general pg #bfa ,changed3 mucopurulent discharge1 accompanied by a bad ordor to3 mucopurulent discharge1 accompanied by a bad odor pg #bga ,changed3 ,the constitutioual causes of epistaxis to3 ,the constitutional causes of epistaxis pg #bge ,changed3 treatment consists of throrough cleansing to3 treatment consists of thorough cleansing pg #bhh ,changed3 nearly always refers to the patinet's exterior to3 nearly always refers to the patient's exterior pg #bhh ,changed3 and hence before detrioroation has set in to3 and hence before deterioration has set in pg #bij ,changed3 the term 8acute confusional insantiy0 to3 the term 8acute confusional insanity0 pg #bif ,changed3 fears1 particulary of impending danger to3 fears1 particularly of impending danger pg #cjf ,changed3 mental capacity in man lie betweeen3 to3 mental capacity in man lie between3 pg #caa ,changed3 gain is shown treatment is discontinuted to3 gain is shown treatment is discontinued pg #cad ,changed3 if necessary completely elimination of the operation to3 if necessary complete elimination of the operation pg #cag ,changed3 tried to cross the railraod track to3 tried to cross the railroad track pg #cdj ,changed3 care being taken that it is thoroghly digested to3 care being taken that it is thoroughly digested pg #cdj ,changed3 lymphoid elements of the inteatines to3 lymphoid elements of the intestines pg #cde ,changed3 and maybe bronchial symptms4 to3 and maybe bronchial symptoms4 pg #cdi ,changed3 ,if there are two parosyxms in the same day to3 ,if there are two paroxysms in the same day pg #cej ,changed3 twelve to twenty-four hours when consciouness to3 twelve to twenty-four hours when consciousness pg #cfb ,changed3 ,a derangement of the veretbral articulation to3 ,a derangement of the vertebral articulation pg #cfi ,changed3 for unsually this gives only temporary relief to3 for unusually this gives only temporary relief pg #cgf ,changed3 ,let the patient drink freely of tater to3 ,let the patient drink freely of water pg #cgg ,changed3 ,esposure to damp cold is one of the recognized causes to3 ,exposure to damp cold is one of the recognized causes pg #chb ,changed3 artery increase the susceptiblility to infection to3 artery increase the susceptibility to infection pg #daa ,changed3 blood and lympathic supply to the lungs to3 blood and lymphatic supply to the lungs pg #dbc ,changed3 ,during convalenscence a full1 well-regulated1 to3 ,during convalescence a full1 well-regulated1 pg #dcc ,changed3 fever usually by the fourteeneth day to3 fever usually by the fourteenth day pg #dcf ,changed3 temperature is high and patient is delirius to3 temperature is high and patient is delirious pg #dcg ,changed3 may simulate infantile paraylsis to3 may simulate infantile paralysis pg #dcg ,changed3 ,measles is an acute infectious1 congatious to3 ,measles is an acute infectious1 contagious pg #dch ,changed3 functional integrety of the lungs and heart to3 functional integrity of the lungs and heart pg #dda ,changed3 greater frequency than in other infectiouss diseases to3 greater frequency than in other infectious diseases pg #ddb ,changed3 rugs and unnecessary funiture have been removed to3 rugs and unnecessary furniture have been removed pg #ddd ,changed3 is readily transmissable1 attacks children especially to3 is readily transmissible1 attacks children especially pg #ddh ,changed3 stratching may cause pitting to3 scratching may cause pitting pg #ddi ,changed3 are undoubtedly potent presisposing factors to3 are undoubtedly potent predisposing factors pg #deg ,changed3 tonsillitis1 pyorrhea alveolaris1 sinuitis1 etc4 to3 tonsillitis1 pyorrhea alveolaris1 sinusitis1 etc4 pg #dgh ,changed3 cold and dampness are presisposing factors to3 cold and dampness are predisposing factors pg #dhg ,changed3 ,removal of the exciting cause is the most improtant to3 ,removal of the exciting cause is the most important pg #dib ,changed3 result of inattention to oral hygience to3 result of inattention to oral hygiene pg #dic ,changed3 the ebb and flow of the crebrospinal fluid to3 the ebb and flow of the cerebrospinal fluid pg #dig ,changed3 further complicacates the clinical picture to3 further complicates the clinical picture pg #ejj ,changed3 ,stomach1 liver1 gall-gladder1 pyloric and duodenal to3 ,stomach1 liver1 gall-bladder1 pyloric and duodenal pg #ejh ,changed3 confidence by making an intellegent examination to3 confidence by making an intelligent examination pg #eae ,changed3 ,referred pain from cholesystitis1 chronic appendicitis to3 ,referred pain from cholecystitis1 chronic appendicitis pg #ebb ,changed3 ,there is dypspesia1 flatulency1 constipation to3 ,there is dyspepsia1 flatulency1 constipation pg #ebg ,changed3 ,the nurtition is generally well maintained to3 ,the nutrition is generally well maintained pg #ecg ,changed3 7affecting reciprocal inneravtion7 to3 7affecting reciprocal innervation7 pg #eci ,changed3 peristaltic action and the secertory nerves to3 peristaltic action and the secretory nerves pg #ede ,changed3 ,kinks of the pelivc colon1 ileum to3 ,kinks of the pelvic colon1 ileum pg #edf ,changed3 stretched sufficiently to resore normal function to3 stretched sufficiently to restore normal function pg #edh ,changed3 appendix can be stimulated by purcussion to3 appendix can be stimulated by percussion pg #edh ,changed3 pyogenes aureus1 typhoid baccilli1 tubercle bacilli to3 pyogenes aureus1 typhoid bacilli1 tubercle bacilli pg #eea ,changed3 large proportion of cases revover to3 large proportion of cases recover pg #eee ,changed3 tenth rib on the right side1 thus interferring to3 tenth rib on the right side1 thus interfering pg #efd ,changed3 particularly fond of starchy and saccahrine food to3 particularly fond of starchy and saccharine food pg #ega ,changed3 mucous membrane1 osccaional superficial erosions to3 mucous membrane1 occasional superficial erosions pg #egb ,changed3 ,on the whole1 careful1 continued treament to3 ,on the whole1 careful1 continued treatment pg #ehb ,changed3 ,the primary form is the result of expossure to3 ,the primary form is the result of exposure pg #ehc ,changed3 lungs1 abscesses1 bronchiestasis to3 lungs1 abscesses1 bronchiectasis pg #ehe ,changed3 ,death occassionally results from suffocation to3 ,death occasionally results from suffocation pg #eig ,changed3 especially by diploccocus pneumoni4 to3 especially by diplococcus pneumoni4 pg #fcd ,changed3 symptoms as neuresthenia1 melancholia to3 symptoms as neurasthenia1 melancholia pg #fde ,changed3 stands foremost as a cuase of valvular defects to3 stands foremost as a cause of valvular defects pg #fdg ,changed3 ,through analagous reasoning from other organic to3 ,through analogous reasoning from other organic pg #fdh ,changed3 involve inhibitory 7vagi7 fibers or accellerator to3 involve inhibitory 7vagi7 fibers or accelerator pg #fef ,changed3 process or an act of compenation to3 process or an act of compensation pg #fff ,changed3 discovering irregulartities in the young to3 discovering irregularities in the young pg #fge ,changed3 ,the mononuclear neurtophiles are relatively increased4 to3 ,the mononuclear neutrophiles are relatively increased4 pg #fha ,changed3 ,it is a disease occuring at all ages to3 ,it is a disease occurring at all ages pg #fia ,changed3 supply is estensive1 and the veins expecially to3 supply is extensive1 and the veins especially pg #fib ,changed3 due to the incresee of epithelial cells to3 due to the increase of epithelial cells pg #gjc ,changed3 ,death in adults has ocurred from trifling injuries to3 ,death in adults has occurred from trifling injuries pg #gjh ,changed3 ,in a few cases there are intraplevic causes to3 ,in a few cases there are intrapelvic causes pg #gbj ,changed3 he knows at once that the headadche is relieved to3 he knows at once that the headache is relieved pg #gbd ,changed3 kness so close together that they rub in walking to3 knees so close together that they rub in walking pg #gdb ,changed3 these phemomena also become bilateral to3 these phenomena also become bilateral pg #ggj ,changed3 curvavature decrease in the volume of the lower to3 curvature decrease in the volume of the lower pg #ggj ,changed3 that should be considered are spastic parlaysis to3 that should be considered are spastic paralysis pg #ghh ,changed3 arising from the layer of non-tuberculus granulation to3 arising from the layer of non-tuberculous granulation pg #gij ,changed3 flacid and bilateral and may exist to3 flaccid and bilateral and may exist pg #gij ,changed3 must be cut over the invoved area to3 must be cut over the involved area