Part I

).

To =determine the presence of a movable kidney=, it is best to have the patient in the dorsal position, the head slightly lowered and the abdominal walls relaxed by flexing the thighs moderately upon the abdomen. Then with the left hand in the lumbar region behind the eleventh and twelfth ribs, and the right hand in the hypochondriac region, the kidney can usually be detected after full inspiration followed by complete expiration; or, have the patient in a standing posture with the body bent slightly forward and the hands placed upon a table, then perform bimanual palpation; or, perform the manipulation in the knee-elbow position. When in this position (knee-elbow), if the kidney has become dislodged, a resonant note will be obtained by percussion over the normal location of the kidney.

FOOTNOTES:

[98] Journal of the American Osteopathic Association, July, 1904.

[99] Journal of the American Osteopathic Association, Dec., 1904.

DISEASES OF THE BLADDER

Cystitis

=Cystitis= is an inflammation of the mucous membrane of the bladder. Retention of the urine; foreign bodies, such as stones, in the bladder; the use of dirty catheters; exposure to wet and cold; injuries to the bladder and over the pubes; irritations to the sacral nerves; spinal lesions in the dorsal enlargement of the cord; innominate lesions; irritating drugs; enlarged prostate and urethral strictures are the principal causes of cystitis. The disease may be secondary to fevers, infectious diseases and inflammation of adjacent organs. A displaced uterus may produce a chronic irritation of the bladder.

=Pathologically=, there is hyperemia of the mucous membrane of part or of the whole of the bladder, with redness, congestion and edema. The secretion of mucus that covers the mucous membrane is of a dirty gray color. If the congestion is very extensive, a bursting of the capillaries may take place. In a few cases the neck of the bladder and the urethra, where it passes through the prostate, is involved. In chronic cases the mucous membrane becomes thickened and covered with patches of false membrane. The muscular coat of the bladder becomes hypertrophied and the veins tortuous.

=Symptoms.=—The onset may be sudden with rigors and fever, but in many cases a frequent desire to micturate will be the first symptom. This is followed by tenderness and pain over the bladder and contiguous parts, loss of appetite, depression and sleeplessness. Tenesmus of the bladder, caused by a spastic condition of its muscles, and a burning along the urethra are usually present. The urine is alkaline in reaction and contains pus, epithelium and blood.

=Diagnosis.=—The diagnosis is usually easy. =Pyelitis= causes pains in the lumbar region and along the ureters and there is a frequent desire to urinate. The bladder is not subject to spasms and the urine is of an acid or neutral reaction.

=Prognosis.=—In many cases the prognosis is favorable, but in cases of long standing and in hypertrophy of the bladder, prognosis must be guarded.

=Treatment.=—Rest in bed with strict attention to diet is necessary. Milk is the best food and avoid highly seasoned articles and acid foods. The use of plenty of pure water is helpful to dilute the urine, and if necessary the bladder should be washed out carefully. If the case is severe, emptying the bladder several times a day with a catheter will be necessary. Always be careful about the cleansing of the instruments. Warm applications over the pelvic region will be comforting to the patient. Lifting the abdominal viscera from the bladder is of assistance. The patient may be placed in the knee and chest position for this or the usual method employed.

Treatment to the second, third and fourth sacral nerves controls the neck of the bladder, and strong inhibition will generally control the spasms of the sphincter. The fundus of the organ is supplied by sympathetic fibers from the pelvic plexus. Direct treatment over the bladder, if applied carefully, will act on the terminal fibers of the sympathetic. Lesions to the nerves of the sphincter of the bladder oftentimes occur between the fifth lumbar and sacrum, also from a displaced innominate. Such lesions are apt to be found in cases of incontinence of urine. The lesion to the vertebra is usually a lateral one.

Thorough treatment to the genito-urinary center (lower dorsal and upper lumbar) will also be of aid. In males direct treatment of the prostate gland is occasionally important as is also the plexus of nerves at the trigone of the bladder. In =treating= the =prostate gland= introduce a finger into the rectum and work about the base of the gland to relax the tissues, and thus remove obstructions of the vascular, lymphatic and nervous structures to the gland. Do not work too much upon the gland itself (commonly once a week or ten days), as it may irritate, but release surrounding edema. Also treat the innervation at the eleventh and twelfth dorsals, fifth lumbar, and first, second and third sacrals. Spreading the ischii will occasionally be beneficial; this tends to release the anterior commissure where it is attached to the symphysis.

Follow the above with a “general treatment” in order to secure a general systemic reaction. This is of value in all infectious disorders.

It is important in =young boys= to examine the condition of the penis in bladder diseases. The prepuce may become adherent or other irritations may be found that are a source of disturbance to the bladder, or even to the kidneys, on account of the intimate connection of the sympathetic system in this region and the relation of one organ to another.

An =irritable bladder= is usually due to disorders of nearby tissues, especially the urethra, vagina, uterus and rectum.

=Enuresis=, exclusive of paralysis, is frequently due to some local mechanical disturbance. =Nocturnal enuresis= or =bed wetting= is caused by lower dorsal and lumbar lesions (especially the fifth lumbar), displacements of the innominate, or phimosis, hooded clitoris, contracted meatus, highly acid urine, worms, lack of discipline, etc. The patient is usually =neurotic=, which demands attention to the neuromuscular system of the entire body. Care of the general health and habits is important. Constipation may be present.

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 chest. Primary inflammation of the pericardium is rare. Such cases usually result from cold and exposure or injury or tuberculosis, and are most commonly met with in children.

The exciting causes of =secondary pericarditis= are rheumatism, Bright’s disease, tuberculosis, gout, diabetes, eruptive fevers, various septic conditions and dyscrasia. Pericarditis may result by extension of inflammation from contiguous organs, as the disease may occur in pneumonia, pleuropneumonia, chronic valvular diseases, and ulcerative diseases of the esophagus, bronchi, vertebræ, ribs, stomach, etc.

Displacement of the ribs over the heart and involvement of the corresponding vertebræ predispose to pericarditis, by weakening the innervation of the pericardium and thus disturbing the circulation. Lesions of the cervical region affecting the left phrenic are to be considered. Upper rib lesions may disturb the internal mammary artery and the lymphatics, which have important relationship with the pericardium. The disease may occur at any age. Males are more frequently attacked than females.

The morbid conditions vary with the stage. The stages are (1) acute, plastic, or dry pericarditis; (2) pericarditis with effusion, serofibrinous, hemorrhagic or purulent; (3) absorption or adhesive pericarditis. These different stages or varieties commonly succeed one another, although medical writers place so much importance in them that each is described separately. =Acute pericarditis= is by far the most common and often the inflammation subsides at this point instead of going on to more serious involvement. There is a possibility that in some cases the forms are independent of each other.

The changes are the same as in various serous membranes. Hyperemia and alteration of the epithelium is most marked on the visceral layer. This is followed by an exudation from the hyperemic vessels. There is roughening and loosening of the epithelium and the fibrin is precipitated upon the walls of the pericardium. More or less lymph is exuded and sometimes injected capillaries burst and cause a bloody exudation. From this stage the morbid appearances vary according to the progress of the disease. The disease may undergo resolution and fatty degeneration and absorption of the products in point take place. As the stage of effusion occurs, the parietal and visceral layers of the pericardium are separated by a serofibrinous exudate. This condition may increase until the quantity of the exudation is considerable, or the effusion may become absorbed. Rarely does the exudate become purulent.

Adhesions may be formed between the layers of the pericardium, during the last stage, by bands of various lengths or the layers are more or less separable.

=Symptoms.=—Simple cases may not present any symptoms. Usually a chill or cold feeling at the heart, followed by pains in the cardiac region, ushers in the attack. Fever is commonly present, rarely exceeding 103 degrees F. Tenderness over the heart is noticeable. There is dyspnea and the patient is restless.

In the =effusive stage= the symptoms depend largely upon the amount of diffusion. The pain is sharp and stitch-like. Nausea, vomiting and hiccough sometimes occur. The pulse is irregular and feeble. Insomnia, headache and even delirium may occur. Distention of the veins of the neck may cause dysphagia and a cough may be present, owing to the irritation of the trachea. The recurrent laryngeal nerve may be compressed as it winds about the aorta and thus cause aphonia.

The friction sound is a characteristic physical sign of the first stage. In the effusive stage there may be precordial bulging. The area of dullness is enlarged, the diaphragm and liver may be crowded downward, causing an epigastric bulging. As the effusion increases, the heart sounds become less distinct; the friction is not heard. In the =third stage= there is usually a return to normal, although =adhesions= may form and cause precordial retraction and permanently embarrass the heart’s movements. The young are more subject to permanent disability. Extension of heart impulse, which is undulatory; diastolic shock to hand placed over heart; increased area of dullness; prominent precordia; position of patient does not change apex beat; and when pericardium is adherent to diaphragm a systolic tug is noted over points of attachment, are essential signs and symptoms.

=Diagnosis.=—Pericarditis is frequently overlooked. It is a serious disease and one should be especially careful. In cases of rheumatism the osteopath must always be on his guard. Tonsillitis may be the origin of the infection. Care has to be taken in distinguishing between dilatation and cardiac hypertrophy and pericardial effusion. Hydro-pericardium may be mistaken for pericardial effusion.

To distinguish between endocarditis and pericarditis should not be a difficult task if one understands thoroughly the nature of each disease. A large pericardial effusion may be confounded with a pleural effusion. In doubtful cases utilize the X-ray.

=Prognosis.=—In mild cases of pericarditis the large majority rapidly recover in two to three weeks. In cachectic subjects and where adhesions have formed, the duration is longer. Relapses may occur. The purulent effusions are always serious.

=Treatment.=—Demands prompt and effective measures. Absolute rest mentally and physically, is necessary. Too much stress cannot be laid upon this point, as death has occurred from neglect of this. To quiet the heart’s action is the first necessary requisite, and then give treatment to limit the inflammation. In the early stage relaxing the upper dorsal musculature to control innervation, and raising and freeing all the upper ribs and clavicles to promote lymphatic drainage is effective. In the second stage prevention of cardiac failure and promotion of absorption are the indications to be met. Too much importance cannot be placed upon the point that general strength, good nursing, dieting and free elimination are essential, not only in securing a rapid subsidence of the inflammation, but to prevent further complications.

Raising and separating the ribs over the heart will be of great aid in lessening the inflammation and promoting absorption. In many cases lesions to the ribs on the left side and subdislocations of the vertebræ affecting the vasomotor nerves, the lymphatics and nerves to the heart will be found. The first five ribs and corresponding vertebræ is the region where one may expect to find the lesions. In addition to absolute rest, an inhibiting treatment in the dorsal region between the scapulæ will aid in slowing the heart’s action. Correcting any lesion that may be found to the vagi nerves will also be a help in controlling the heart’s action; besides, most of the vasomotor fibers to the heart are in the vagi. These lesions are usually found at the atlas. One should also examine carefully all the cervical vertebræ for derangements that might affect the cervical sympathetic, especially the superior and middle cervical ganglia. These ganglia are primarily affected from the fifth cervical to the first dorsal. 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 heart; also, inhibit in the upper dorsal. The warm bath will quiet the heart, but care should be taken not to weaken the patient. The general treatment has the effect of lessening nervousness and quieting the heart.

The function of the phrenic nerve must be borne in mind when regarding the pericardium. The phrenic is usually primarily affected at the third, fourth and fifth cervicals, and occasionally there are connecting fibers as low as the fourth and fifth dorsals. Ice-bags may be found of value in retarding the progress of the effusion and in lessening the heart’s action. Liquid food, as milk and broths, should be given throughout the disease. If the effusion is very large the services of a surgeon should be secured and tapping performed. If the effusion is of a purulent nature, a free incision should be made with antiseptic precautions.

In chronic cases carefully graduated breathing exercises and moderate stretching of the adherent regions, if pathology permits, should be considered.

Endocarditis

=Endocarditis= is an inflammation of the lining membrane of the heart. The process is usually confined to the valves; the lining of the cavity of the heart may also be affected, especially in severe cases. Three forms are recognized: simple acute endocarditis, ulcerative endocarditis, and chronic endocarditis.

=Simple Acute Endocarditis.=—This form usually results from acute articular rheumatism. Tonsillitis may be associated with endocarditis. It may also be caused by other infectious diseases, especially scarlet fever, but rarely, by typhoid fever, measles, chicken-pox, diphtheria, smallpox and erysipelas. Acute endocarditis is frequently found in chorea. It is also met with in diseases attended with emaciation and general weakness, as cancer, gout, Bright’s disease and diabetes. It is not uncommon in phthisis. Micro-organisms play an exciting part, but back of this the osteopath finds lesions of the heart innervation important predisposing features. Prophylactic osteopathic treatment is a potent factor in preventing endocardial changes in the above diseases. Keeping the muscles relaxed and the osseous tissues intact is of great value.

=Pathologically=, the left side of the heart is most commonly involved. The disease is characterized by the presence of small vegetations on the segments or on the lining membrane of the chambers, although in mild cases there is simply swelling of the valves. The mitral valves are more often affected than the aortic. The vegetations appear, usually, on the auricular surface of the mitral and the ventricular surface of the aortic valves, a little back of the valve edge. Their seat corresponds to the point of maximum contact (Sibson). These growths are liable to be broken off at any time and carried as emboli by the blood current to distant organs, particularly the brain, spleen and kidneys. This is not uncommon in acute endocarditis or chronic valvulitis. In favorable cases the vegetation is ultimately absorbed and the valve is but slightly altered beyond a simple sclerotic thickening. This is often the starting point of sclerotic valvulitis. Osteopathic measures undoubtedly lessen the liability of cardiac involvement, prevent extensive changes and promote absorption of disease products, by lowering heart tension and improving the cardiac nutrition, as well as increasing free elimination of the toxins in the blood.

During the fetal life, the right side of the heart is most commonly involved. The chorda tendinæ are sometimes affected, but rarely alone.

The vegetations are composed of proliferated connective tissue cells. The superficial elements undergo a coagulation-necrosis and fibrin is deposited from the blood. Micro-organisms are found and are the specific agent in causing acute endocarditis.

=Symptoms.=—A large number of cases are latent, the autopsy first disclosing the lesion. In many cases there are slight fever, a frequent, sometimes irregular, pulse, palpitation and dyspnea. There is seldom any pain.

=Physical signs= are very uncertain. They may not be present in mild cases and in those in which the valves are not affected. Usually auscultation furnishes the only indication of endocarditis—a soft, blowing, systolic murmur which is heard most frequently at the apex, as the mitral valves are the ones generally involved. When the aortic valves are affected, the murmur is heard at the second interspace at the right edge of the sternum.

=Diagnosis.=—This depends entirely upon the etiology and physical signs. The greatest danger is in the disease becoming chronic.

=Treatment.=—The patient should be kept as quiet as possible, so that the work required of the heart may be reduced to a minimum. The disturbed circulation can be controlled by careful attention to the vasomotor nerves at the various centers along the spine. Attention should be given the disease that is causing the endocarditis. Keep the patient well protected by flannels and beware of damp rooms and sudden changes of temperature.

Treatment should be given to correct any lesion found in the upper five dorsal vertebræ 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 innervation. The vasomotor nerves to the heart’s vessels are found in the vagi nerves, consequently care should be taken that lesions to these nerves do not exist. An inhibitory treatment to the suboccipital nerves acts reflexly on the vasomotor nerves and tends to equalize the general vascular system. This treatment quiets the heart’s action. Ice applied locally is advocated by many practitioners. Flannels should be placed next to the skin and the ice-bag placed over the flannel. This reduces the fever, lessens the pulse-rate and quiets the heart action. The same points are obtained by the inhibitory treatment at the suboccipital region. The ice-bag also relieves pain and oppression. Be very careful in the use of ice when there is much cardiac dilatation. Treatment of the middle and inferior cervical regions may have some effect in controlling the heart’s action. A general treatment to quiet the patient is effective. Do not allow any overexertion. The patient should have nourishing liquid food.

Emery[100] says: “Many of us have been in the habit of saying, just because we hear a decided murmur in the heart region, that the patient has valvular heart trouble; that the patient has organic heart trouble. This is a common error... When there is an anemic condition of the body, apparently the cusps of the valve will be so weakened, and the attachment will be so weakened that the blood will force its way between the valves and back into the heart, causing regurgitation murmur, when as an actual fact there is no deformity and no real disease of the valves, and as soon as the general condition of the anemia is improved, the valve will do its work fully and the murmur entirely cease. So if you have the murmur without the hypertrophied condition, which at once follows such a valvular lesion, you must be guarded in your statements, for if an actual valvular lesion existed, compensation would take place, and it would be the means of corroborating such a valvular condition; if no hypertrophy is found, then we are not justified in definitely stating that a valvular or organic lesion exists, for such a weakened condition as has been mentioned might be the only pathology present, and be the cause of the murmur.”

=Ulcerative or malignant endocarditis.=—This is an acute, infectious or septic disease, characterized locally by necrosis or ulceration of the valve. It is generally a secondary affection to septicemia, pneumonia, erysipelas, scarlet fever and acute rheumatism. Acute endocarditis often precedes the ulcerative variety, the latter being simply an increase in severity of the former.

=Etiology and Pathology.=—It is doubtful if there can be a primary form of ulcerative endocarditis. Chronic valvular defects are the most important predisposing causes. Pneumonia is most frequently, of all the acute diseases, associated with severe endocarditis. It is rare in tuberculosis, diphtheria, typhoid fever and chorea. It occurs in association with erysipelas, gonorrhea and rheumatism. Septicemia, pleurisy, meningitis and puerperal fever are other possible causes of ulcerative endocarditis.

Deep seated lesions, which means firmly anchored lateral flexions and rotations due to fibrotic changes, are important predisposing local factors, while other lesions that disturb blood elaboration and resistance and lessen elimination, are predisposing systemic causes.

=Pathologically=, the lesions are either vegetative, ulcerative or suppurative. The vegetations are composed of granulation tissue, granular and fibrillated fibrin, and colonies of micro-organisms. They become necrotic and break down into ulcers. The ulcerative changes may lead to perforations or produce valvular aneurisms. Of the valves the mitral is the most frequently affected; then the aortic; then the mitral and the aortic together; then the heart walls; then the tricuspid; then the pulmonary. In a few cases the right heart alone is involved. The lesion is not always confined to the valves, but may involve the mural endocardium. The most common organisms found are the pneumococcus, streptococci and staphylococci. The bacillus diphtheriæ, bacillus coli, gonococcus, bacillus anthracis and other organisms have been found. Associated pathological changes include the lesions of the primary disease and the changes due to embolism. The spleen, kidneys, brain, intestines and skin may be the seat of embolism. When found in the lungs, they originate in the right heart.

=Symptoms.=—If in the course of any of the diseases previously named under etiology, chills followed by fever and sweats occur, ulcerative endocarditis should at once be suspected and a thorough examination be made. The general symptoms are high, irregular fever, delirium, sweating, great prostration, rapid pulse, hurried breathing and sometimes jaundice and diarrhea occur.

The occurrence of delirium, coma or hemiplegia points to involvement of the brain; pain in the region of the spleen, with increased dullness on percussion, point to trouble in that organ; hematuria may occur from involvement of the kidneys. More rarely there will be impaired vision from retinal hemorrhage; and there may be suppuration and sometimes gangrene in various locations, depending upon the position of the embolism.

The =septic type= is secondary to suppurating external wounds, puerperal sepsis or acute necrosis. Occasionally gonorrhea is the cause. The symptoms presented are rigors, irregular fever, sweats and exhaustion—the signs of septic infection. The symptoms may resemble a quotidian or a tertian ague. The =typhoid type= is the most common. The characteristic symptoms are irregular temperature, sweating, prostration, delirium, drowsiness, diarrhea, petechial and other rashes, distention of the abdomen and pain in the right iliac region. The heart symptoms may be overlooked, as in the septic type. The =cardiac type= are cases of chronic valvular diseases in which fever, rigors and sweats, and the symptoms of embolism may develop. In the =cerebral= cases the symptoms may simulate meningitis. Acute delirium may be the distinctive symptom. Heart symptoms may be overlooked.

=Physical Signs.=—The heart symptoms may be latent. Even after a careful examination, there may be no murmur present. When murmurs are present it is often difficult to locate them.

=Diagnosis.=—The previous history should be considered and this, together with the symptoms, makes a correct diagnosis possible, even though physical signs are absent. The duration is from a few days to several weeks.

=Treatment.=—The treatment of this form of endocarditis is likely to be of little avail, although in a few cases where the source of infection can be eradicated the condition may be considerably improved and life prolonged. About the same treatment as in simple endocarditis should be followed. Absolute rest is essential and this, coupled with the local treatment of simple endocarditis and a nourishing liquid diet, constitutes the principal treatment.

Chronic Endocarditis

This condition may begin as a chronic inflammation or follow the acute form, which is more often the case. There is a =sclerosis= of the valves which causes deformity, owing to the contractions. The onset is usually insidious.

It is well known that the larger percentage of valvular lesions are the result of either acute or chronic endocarditis. Thus rheumatism stands foremost as a cause of valvular defects. Alcoholism and overeating (through introducing irritating influences into the blood, or by causing rheumatism, gout and allied diseases) are important etiological considerations. Nephritis and syphilis are considered among the causative factors. Infections and senility, when associated with high blood pressure, is a phase not to be overlooked. Chronic endarteritis extending from the aorta to the valves, resulting in thickening and degeneration of the tissue, may be an insidious source of valve disease. This is probably often of syphilitic origin.

A potent cause of special interest to the osteopath (for the reason that his treatment is so effective), is continued =muscular strain= as seen in athletes and laborers. The heart muscle itself may be strained, particularly the valve leaflets and the tissues about the valve, which effect often terminates in valvular leakage. In addition, the orifice of the valve openings may become stretched and distorted through strain superinduced by prolonged exertion, by flabbiness of heart tissue, and by dilatation of the ventricles. In these latter cases it is seen that the leaflets of the valves may remain intact, but still they are unable to stretch completely across the opening.

With the above condition it is readily noted that thickening, curling and adhesions will take place when inflammation attacks the valves and contiguous tissues, and following these, limy infiltration and fatty degeneration may be a consequence.

Predisposing osteopathic lesions as noted in acute endocarditis, are not to be neglected.

=Thickening and hyperplasia= are immediate consequents of connective tissue overgrowth; and especially is chronic endarteritis accompanied with atheromatous and calcareous degeneration. Thickening, at times, is only slight and the function of valves is not impaired.

In curling or =retraction=, there occurs a shrinkage of the hypertrophic or hyperplastic tissues. This condition is very apt to become permanent.

=Adhesions= of the valve leaflets is a self-evident condition. 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 action; the =laceration= or rupture or erosion always occurs at the point of maximum contact. Thus the eroded surface allows an opportunity for the rheumatic or septic micro-organisms to lodge, multiply and grow, and adhesions result. Carefully applied osteopathic methods are very efficacious in impending acute heart disturbances, and this without doubt is the reason why so many of our rheumatic cases get well without any heart affections. Keeping the heart quieted and slowed prevents the strong and rapid action and thus lessens the probability of lacerations, ruptures and erosions of the valve tissues. General resistance is increased and elimination improved, which have a decided effect in preventing complications.

=Calcification and atheroma=, as has been mentioned, may follow the above diseased processes. The calcification is sometimes so marked as to be of the character of a bony ring.

The question arises here, What effect have =osteopathic lesions= as direct =causative factors= in valvulitis? It appears reasonable that the heart is not exempt from the influences of the vertebral and rib maladjustments. Furthermore, clinical experience has abundantly proven that the heart tissues are affected by these lesions in the same manner as any tissue or organ is affected. Again, osteopathic dissection reveals direct nervous connection from the upper dorsal spinal ganglia to the heart ganglia.

No one will question that the integrity of heart function and life are dependent upon normal coronary artery supply, upon vasomotor equilibrium, and upon motor control. All of these functions are influenced by the status of cervical vertebræ, upper dorsal vertebræ, and rib relations. Just what the pathological affection is when these anatomical parts are disturbed is beyond us until more careful dissection and experimentation have taken place. How cervical and dorsal sympathetics, vasomotor and motor nerves with their spinal connections, vagi and phrenic, are so disturbed as to involve valvular parts and induce inflammation, is a problem for us to investigate. Through analogous reasoning from other organic ailments and through the fact that osteopathic therapeutics corrects heart lesions, we know in a general way that the correction of osteopathic lesions decidedly influences the heart.

Two well known =physiological facts= relative to the heart are: first, the heart increases in size up to adult life, and, second, the heart muscle can actually be increased in size. This latter fact occurs in physical development and training. A heart that is weak and flabby can be increased in strength, tone and size. This helps us to understand how certain strains and distortions of the heart, with consequent valvular lesions, may be corrected through rest, exercise and treatment; somewhat analogous to the correction of an atonic, prolapsed and dilated stomach. Then it also seems probable that disturbed innervation and blood supply to heart areas or to the heart as a whole would predispose to congestions, inflammations and degenerations whereby rheumatism, septic states, etc., and muscular strains would act only as exciting causes, not true causes.

No one is going to expect that thickened, retracted, adhered, or ruptured valves are to be made anatomically correct; but the right treatment will certainly reduce the morbid state to the minimum. Then there are cases where osteopaths have eliminated all murmurs when specialists stated the disease was incurable; showing that it is impossible by signs and symptoms to always diagnose the morbid tissue state. Only the resulting effects of size and of leakage are definitely revealed by auscultation and percussion. Hence there is a class of valvular diseases that can be successfully treated by osteopathic measures, which, if left to terminate under drug medication, will reveal (at post-mortem) the pathological signs of valvular heart disease.

Downward displacement of the =first rib= may interfere directly with the subclavian artery and thus cause constriction of that vessel and a consequent regurgitation; also, cardiac fibers of the recurrent laryngeal nerves may be impinged by a dislocation of this rib. Many lesions which interfere with the right side of the heart occur at the =second= and =third ribs= and lesions of the =third=, =fourth= and =fifth ribs= may interfere with the valves. Lesions of the =corresponding vertebræ= produce the same results as the ribs. These lesions are probably to the sympathetic nerves along the dorsal region. Lesions may be found anywhere along the cervical vertebræ which may involve inhibitory (vagi) fibers or accelerator (sympathetic) fibers to the heart. Also, in some cases the =floating ribs= are dislocated downward and cause a prolapse of the diaphragm, and thus a constriction of the aorta, which may result in regurgitation and valvular disorder.

=Mitral Regurgitation.=—Mitral regurgitation is a leakage of blood from the left ventricle, through the mitral valves, into the left auricle. The opening of the valve may be distorted, or the valve leaflets thickened, rigid, or retracted, thus allowing an escape or reflux of blood from ventricle into auricle. The tendinous cords may also be thickened and adhered, with consequent prevention of free action.

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 auricle, an overdistention of the auricle takes place. The auricle, then, from the extra amount of work required, becomes hypertrophied and dilated. There may be no noticeable symptoms at first. Later on shortness of breath, cough, irregularity of heart’s action, indigestion, liver congestion, and so on, occur.

The =apex beat= is forcible and downward to the left. Of course the area of dullness is to the right and left. There is a =systolic murmur= in the mitral area, which is transmitted to the left axilla.

Every osteopath should understand the mechanism of this most frequent valvular lesion. Following hypertrophy and dilatation of the left auricle, the reflux may be so excessive that a residue remains. The auricle not being able to handle all the =blood=, stasis of the pulmonary vessels takes place, and pulmonary edema and hydrothorax are sequelæ. Then comes dilatation of the right ventricle and back pressure on tricuspid valves and right auricle. The =veins= throughout the body become turgescent, and the liver is apt to be indurated. It should be emphasized, however, that “back pressure” is only an effect commonly due to myocardial degeneration, caused by some infection, of which auricular fibrillation is an important part of the pathology.

Before the breaking down of the left heart compensation, osteopathic methods, as all know, are effective in maintaining balance. Even after the lungs begin to be affected, careful and thorough treatment will result in good, and in cases of general venous sluggishness treatment, particularly to liver, diaphragm, bowels and limbs, will generally materially help in slowing the downward course of the disease.

=Mitral Stenosis.=—In stenosis there is narrowing or constriction of the valve opening. Thus in mitral stenosis the free flow of the blood from left auricle to ventricle is hindered.

The =cusps= are usually thickened, rigid and adhered. The valve opening may be so stenosed as to be but a narrow slit. In all cases stenosis is a =structural defect=. It can occur by strains, as regurgitative effects sometimes result.

The =symptoms= of mitral stenosis are practically the same as those of mitral regurgitation, owing to similar effects upon the circulation.

Under =physical signs= we find the apex-beat is only slightly displaced. Palpation will reveal, near the apex, a rough presystolic thrill. The increased area of dullness is to the right. There is an abruptly terminating, rough, presystolic murmur.

=Aortic Regurgitation.=—Aortic regurgitation is a reflux of blood from aorta to left ventricle, following ventricular systole. This is considered the =most serious= of the valvular diseases. The valve opening is either too large, so the valve leaflets do not fit tightly, or the segments themselves are thickened and retracted. Structural defects of the aortic valves are largely of the same character as in diseases of the mitral valves.

The =regurgitation= first causes dilatation of the left ventricle. This is followed by hypertrophy. If the mitral valve holds intact, no further effects result. But if the mitral valve is diseased or becomes incompetent from the dilated ventricle, the same morbid states follow as was noted under mitral regurgitation.

There is a forcible apex-beat, displaced downward to the left. The increased dullness is to the left. There is a long, loud =diastolic murmur=. The well known “water-hammer” pulse is felt.

=Aortic Stenosis.=—Aortic stenosis indicates a narrowing of the aortic orifice. It is a structural defect. The free flow of blood is obstructed from the left ventricle into the aorta.

Aortic stenosis is much less frequent than regurgitation. Aortic stenosis and regurgitation are very apt to be associated. The beat is commonly forcible, and the increased area of dullness is to the left. There is a systolic murmur, heard best at the right second interspace, which is conducted into both carotid arteries.

=Tricuspid Regurgitation.=—Tricuspid regurgitation is the most common valvular lesion affecting the right heart. It is rare as a primary lesion. The affection may be of a structural character, or functional.

Hypertrophy of the right ventricle occurs after the manner of left ventricle hypertrophy in mitral regurgitation. The sequelæ of venous turgescence follow, also, in the same way as was given under the mitral lesions. Tricuspid regurgitation rarely exists independent of some other cardiac or pulmonary ailments.

The apex-beat is diffused toward the epigastrium. Increased cardiac dullness is toward the right. There is a systolic murmur, which is heard best just above the xiphoid cartilage. The jugular vein pulsates; in severe cases there is pulsation of the liver.

Osteopathic treatment is usually effective in relieving the engorgement of the veins, and particularly in reducing liver congestion.

=Tricuspid Stenosis.=—This affection is said to be the =most rare= of valvular lesions. Thickening, obstruction and adhesions from endocarditis cause the stenosis. As in other lesions of the heart, there is a congenital form. There is presystolic murmur, heard best at the xiphoid cartilage. The pulse is small and weak.

=Pulmonary Regurgitation.=—This is another rare lesion, and is seldom met with in a simple form.

There is forcible pulsation in the epigastrium. Increased cardiac dullness is downward. There is a diastolic murmur, heard most distinctly at the left second intercostal space.

=Pulmonary Stenosis.=—Another rare lesion. The effect of this lesion on the right ventricle is the same as that of aortic stenosis on the left. The congenital lesion is apt to occur with a patulous foramen ovale.

There is a systolic murmur, heard best at the second intercostal space on the left. =Many systolic murmurs= heard over the pulmonary opening =are functional=.

=Combined Valvular Lesions.=—When two or more lesions occur at the same time the terms, combined or associated, are employed. This is a very common occurrence. Two, three or all of the valves may be affected at the same time. =Stenosis= and =regurgitation= at the same orifice is the most common association of any two valvular lesions. When there is a joint affection of two or more valves, the =aortic= and =mitral= are most commonly associated; then mitral and tricuspid; then aortic, mitral and tricuspid.

=Prognosis and Treatment of Valvular Diseases.=—It is impossible to outline with exactness either prognosis or treatment of heart lesions. All will agree that the character of the lesion is the first consideration, and before records of these cases can be of any scientific benefit, we must look well to the nature of the valvular leakage or obstruction and note precisely what effect our therapeutics has. Perhaps of greatest consideration in the matter of prognosis is, to what extent =compensation= has been maintained. We know that compensation may be perfect; that hypertrophy and dilatation may balance the valvular defect so thoroughly that even the patient is not aware of a heart lesion. As soon as compensation begins to fail, when palpitation, irregularity of pulse, dyspnea, edema, etc., appear, we know that our treatment should pass from the realm of the defensive to that of the offensive. Then when compensation fails still more, prognosis and treatment must necessarily be changed according to the increasing gravity.

In our osteopathic work we should never forget that the condition of the lesion may be greatly influenced by environment. Habits, occupation and general daily life may affect the heart ailment for good or bad. Thus in =prognosis= we have =three features= in particular to note: character of heart lesion, extent of systemic involvement, and environment. In the immediate prognosis, the extent of general venous stasis, if any, is of great importance. In other words, the gravity of the complications is of first consideration.

Aortic regurgitation is ranked by heart specialists as the most serious lesion. Aortic stenosis is a grave lesion, but not so serious as aortic regurgitation. It is often stated that the character of the lesion is not of so much consequence as the extent of involvement the lesion has engendered. Mitral stenosis is more grave than mitral regurgitation. Right side heart lesions are usually relative, and, naturally, when the right heart is diseased from extension of the ailment from the left side, the situation is serious.

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 present.

In our =treatment= the first point indicated is to improve, if possible, the =integrity= of =heart muscle= and lessen the =valvular defects=, if such can be done. Owing to a dearth of statistics, it is impossible to state to what extent improvement in organic lesions has been accomplished. Very likely if we had statistics and no post-mortem findings, we would still be in the dark as to much of our work. This much is positive: osteopaths have time and again apparently cured grave valvular lesions; cases that eminent specialists diagnosed as absolutely organic lesions. Our practitioners have eliminated the murmurs, reduced the size of the heart, and removed any and all systemic symptoms. These patients are well, have been well for years, and are leading active lives. But were these cases suffering from organic lesions? No doubt there was valvular leakage, hypertrophy and dilatation, but was the valve defect a functional one? In other words, was it due to strain and distortion? In all probability the patients’ days were numbered and post-mortems would have shown grave lesions and quite likely more or less organic changes.

Does it not seem likely that some functional lesions may terminate in organic lesions? Through continued stretching of the valves and their immediate tissues, fatty degeneration may take place; the same as fatty degeneration of the heart muscle, occurring in dilatation of the chambers. If we can remedy functional lesions through specific work upon nerve centers and fibers, why cannot we influence organic lesions and at least reduce the gravity to a minimum? We know functional diseases of the heart, as palpitation, rapid heart, slow heart, etc., can be corrected, and from all indications, functional valvular leakages are generally easily and quickly remedied; it is only a step farther to affect truly organic lesions. The same valves, the same nerves, and the same osteopathic lesions are noted. Then it is only a continuation of the same process from functional disease to organic disease. Indeed, no one is able to draw a line between the two. Probably, as was intimated before, careful osteopathic treatment in rheumatism and other diseases that are apt to predispose to heart affections, will keep the heart so strong functionally and organically that resulting valvular lesions are not nearly so likely to develop. The heart can be treated and controlled as can any tissue or organ. It certainly stands to reason that osteopathic therapeutics is rational in both preventing and curing valvular lesions. The M. D. gives his drugs with the hope of maintaining heart muscle integrity, of lessening a too forceful beat, of increasing waning power, of promoting general circulation, of preventing and lessening complications. We can do the same thing with our methods, even more effectually, and with no probability of harmful effects.

It would appear there are at least two ways in which organic lesions may develop. =First=, as stated above, through =functional distortion=, the normal heart muscle being strained from severe exercise, or a weak, flabby, or disused heart muscle being overtaxed by ordinary exercise. Here it will be seen that in the first instance immediate rest will probably correct the weakness; in the second, rest and general building up of the body if the atonic heart muscle resulted from some debilitating disease. If from local causes correction of the specific osteopathic lesion should be effective.

=Secondly=, through strong and rapid heart action the =valves= are =ruptured= or =lacerated=, always at the point of =maximum contact=, and thus present a favorable surface to micro-organisms.

Owing to the valves being a reduplication of the endocardium, they have no muscles or blood-vessels, so that in =functional leakages=, inflammation does not play a part, hence, a possibility of degeneration occurring from excessive stretching.

The large majority of =osteopathic lesions= are unquestionably found in the upper five dorsal vertebræ and the first five or six ribs on the left side, although cervical lesions, in many instances, play an important secondary, if not the primary, role. These maladjustments affect vasomotor nerves to the heart, that is, to coronary vessels, the dorsal and cervical sympathetics, the vagi, and the phrenic. We are unable to state just how these lesions disturb nerve conductivity; what present anatomy and physiology teach us does not fully explain. Osteopathic dissection must be the means to the end of the explanation. We have many clinical results, but not the physiological knowledge, as yet, to support it.

The dropping down of the first rib, as well as the clavicle, interferes with the large blood-vessels, especially the subclavian, and causes increased resistance of the heart’s action and probably a certain regurgitative effect. This regurgitative effect would also occur in cases of obstruction to the aorta by constriction of the diaphragm from dropping of the floating ribs. To what extent this latter feature has been demonstrated is not known. In valvular diseases it is practical to divide them for treatment into, =first=, where the =lesion= is =compensated=; =second=, where =compensation= is =incomplete=; =third=, where =compensation= is =lost=. With all cases we should give consideration to environment, temperament, habits, food, clothing, exercise, etc. Often these secondary matters are of vital importance, especially when compensation is failing. The Schott method of treatment may be of some avail; this treatment, which is composed of a series of resistant exercises, tends to lessen peripheral resistance, develop heart muscle, and remove heart stasis.

Speaking in general, =hypertrophy= and =dilatation= follow valvular leakage, as a =secondary effect=. It is a compensatory condition, and whenever compensation is failing, there is naturally a breaking down of the structural tissues of the heart; that is, the muscular hypertrophy is losing in integrity. Our primary aim, then, should be to keep up the compensation, which is represented in the hypertrophy, although there are cases that fail rapidly, especially in emphysema and cirrhosis of the lungs. Generally, in hypertrophy and dilatation, there is a =disproportion between= the =amount of work the heart has to do= and its =ability= to do it. One of two things has occurred; there is an increase in peripheral resistance or the volume of blood through the heart is abnormal in quantity[101]. Loudon[102] says: “The treatment of chronic disease of the heart requires a longer time, as a rule, than the same disorder in the acute stage. Some cases cannot be materially helped; a vast majority may be greatly benefited after a thorough trial; while more than we might at first suppose, can be entirely cured. We desire to quote at length from Hare relating to this point. He says: ‘A chronic structural change in the heart resulting from an acute process is not always synonymous with chronic heart disease. Thus, acute endocarditis occasions a variety of changes of the mitral and aortic valves which long may indicate their presence by their characteristic murmurs, and yet in time these may wholly disappear. That many such cases outgrow the valvular trouble, especially mitral lesions, there can now be no doubt. The majority, even of those in whom valvular murmurs permanently continue, do not have their health unfavorably affected for years, and in many of these, the duration of life is not appreciably shortened.’” This statement, from such an author, gives the osteopath great encouragement; for add to those above referred to, which recover in time from all valvular trouble, the many cases of valvular insufficiency, due to dilatation, owing to osteopathic lesions to the trophic nerves, and which may be cured by removing such lesions, we find that quite a percentage of cases are thus disposed of.

“It is doubtless true, also, that the cases above mentioned having valvular thickening and vegetations, could have been cured in quicker time and greater number had osteopathic treatment been given to tone the heart, upbuild the general circulation and increase the activities of the excretory organs. The importance of the lungs is often overlooked in the treatment of cardiac diseases. The osteopath’s ability to expand the chest and increase the capacity of the thorax should be demonstrated in both cardiac and pulmonary troubles. It is said to be a universal law throughout the animal kingdom ‘that muscular power is directly proportional to the amount of oxygen consumed.’ Hence give the power, and have your patient live as much out of doors as practicable. =Exercise= should be =moderate= and always =stopped= short of =fatigue=.”

Treatment of the abdominal organs should not be neglected, for improved circulation here and thorough removal of effete products will influence the heart. Freedom from worry, strains, etc. are essential. Tepid baths are best.

A person may have a valvular leakage and not be aware of it. Probably it is best to inform them, except in certain neurotic individuals. For then they can take special care of themselves, as to overwork, strains and intercurrent infections, and their life and usefulness be greatly prolonged.

When compensation begins to break, certain symptoms are noticed, as heart irregularity, difficult breathing, particularly at night, shortness of breath, and more or less anemia. Later there is disturbance of rhythm, cyanosis, dilatation of heart and dropsy. Frequently, considerable can be accomplished through the upper dorsal treatment, attention to the chest mobility, manipulation of the abdominal organs and diaphragm, and special attention to the diet, rest and some exercise. A light general treatment will assist the labored circulation and improve assimilation, and a change of climate may be of benefit.

Hypertrophy of the Heart

=Hypertrophy= of the heart is an enlargement of the heart, due to an increase in the muscular tissue. It is usually associated with dilatation. The ventricles are more often involved than the auricles, and the left ventricle is more likely to be affected.

=Etiology.=—Valvular disease of the heart causing an obstruction to the outflow of blood, as mitral insufficiency, diseases of the aortic valve; increased intra-vascular pressure, caused by sclerotic changes in the walls of the vessels; contraction of smaller arteries, due to irritation of toxic substances in the blood, as in Bright’s disease. Overeating or drinking and excessive physical exercise would also induce hypertrophy of the left ventricle. Hypertrophy of the right ventricle is caused by valvular lesions on the right side. Lesions of the mitral valve causing an increased resistance in the pulmonary vessels are etiologic factors; also diseases of the pulmonary vessels in the lungs, as in cirrhosis and emphysema. There are conditions affecting the heart, as the use of tea, alcohol and tobacco. Disturbed innervation, as in exophthalmic goiter; derangements of the vertebræ, and ribs corresponding to the upper five dorsals; downward displacements of the floating ribs, causing a prolapse of the diaphragm and a consequent retardation of blood through it to and from the heart, will affect the heart’s action. Simple hypertrophy never occurs in the auricles; it is always accompanied with dilatation. The condition develops in the left auricle in mitral lesions; in the right auricle when there are disturbances of the pulmonary circulation. The tricuspid is rarely affected primarily.

=Pathologically=, the left side of the heart is more commonly enlarged than the right; the ventricles than the auricles. The shape of the heart varies when the left ventricle is hypertrophied, the conical shape being more or less lost; it lies more horizontally and is elongated. When both ventricles are enlarged the heart is round. When the right ventricle is affected, it occupies the largest part of the apex. The increase in the size of the heart is probably due to a numerical increase in the muscle cells. The muscle is firm, of deep red color and cuts with considerable resistance. Normally, the heart weighs from eight to nine ounces. In general hypertrophy it may weigh from fifteen to thirty ounces.

=Symptoms.=—Hypertrophy, being a conservative process or an act of =compensation=, does not necessarily present any symptoms at first. At the beginning there is rarely any pain, but a sense of fullness and discomfort is present. As the hypertrophy increases, the arteries become fuller, the veins less full and the circulation accelerated. In hypertrophy associated with arteriosclerosis the blood pressure is increased, and the pulse full and firm. Epistaxis may be of frequent occurrence and the face congested. Pains occur in the precordial region. There are nervousness, headache, hot flushes, palpitation, cough and vertigo. In hypertrophy of the =left ventricle=, the apex is lower and to the left. The carotids pulsate visibly and the radial pulse is strong and tense. Percussion reveals enlargement to the left and downward. The first sound is louder and prolonged. The aortic second sound is intensified. In hypertrophy of the =right ventricle= the enlargement is to the right edge of the sternum. The second sound in the pulmonary area is increased. The apex-beat is displaced outward. The pulse at the wrist is usually small. Hypertrophy of the =auricles= always occurs with dilatation, which is most common in the left auricle. The physical signs are characteristic. They are caused by diseases of the mitral and tricuspid valves and diseases of the lungs, as emphysema and cirrhosis.

=Diagnosis.=—If a careful examination is made, hypertrophy can hardly be mistaken for any other condition. There may be a resemblance to pericardial effusion, pleuritic effusion, aneurism or mediastinal tumor, when near the heart. The X-ray will be of assistance.

=Prognosis.=—Depends largely upon the cause producing the hypertrophy. Remember that hypertrophy is a compensatory act. The prognosis is more or less unfavorable if resulting from emphysema, Bright’s disease or in old age; also in degeneration of the vessels. In most cases of functional overaction, persistent treatment can usually accomplish considerable.

=Treatment.=—The treatment must be according to the cause of the hypertrophy. There are many etiological factors, consequently the treatment depends upon the influence of these factors. The principal treatment will be found under endocarditis, as valvular diseases are usually caused by endocarditis, and hypertrophy of the heart is a conservative process of nature—an act of compensation secondary to valvular and arterial lesions. The indications are to lessen the force and number of pulsations of the heart and remove the cause if possible.

Dilatation of the Heart

There may be =dilatation= with thickening of the walls, and dilatation with thinning of the walls, or they may be normal. It may be produced by impaired nutrition of the cardiac muscle or increased endocardial tension. More frequently the two conditions act jointly, although they may act singly. Impaired nutrition of the cardiac muscle may diminish the resisting power and thus cause dilatation. Weakening of the cardiac walls may occur in scarlatina, typhoid, typhus, rheumatic fever, etc. It is met with in chlorosis, anemia and leukemia. Increased endocardial tension occurs in sudden, extreme exertions and in valvular diseases. A normal heart through excessive exertion is rarely if ever dilated. The important causes are considered under hypertrophy. Both impaired nutrition and increased endocardial tension are influenced directly by the extent and severity of the osteopathic lesion. This point has been considered under chronic endocarditis.

=Pathologically=, the right side is more commonly affected than the left. In advanced aortic incompetency, all the divisions may be dilated. When one ventricle alone is dilated the septum may be seen to bulge. In extensive dilatation, the auriculo-ventricular rings are often dilated. Other orifices may also be dilated. The condition is often associated with =hypertrophy= and =fatty degeneration=. The muscle may be normal in appearance. The endocardium is often opaque, and roughened in patches. There is degeneration of the ganglia of the heart.

=Symptoms.=—Dilatation causes weakness of the walls of the heart, but as long as the hypertrophied walls can compensate, no symptoms result. When the hypertrophy weakens, greater dilatation occurs and symptoms of venous stasis appear, as dropsy, feeble irregular pulse, dyspnea, cough and scanty urine. In some instances there may be brief precordial distress, faintness or palpitation.

=Physical Signs.=—On =inspection= the apex-beat is diffuse and feeble, or it may not exist. As observed by Walsh, the impulse may be visible and yet not palpable. =Palpation=—the impulse is diffuse, feeble and fluttering. The pulse is small, rapid and irregular, rarely is it slow. =Percussion=—the area of lateral dullness is increased to the right. There is increase in the dullness downward to the sixth interspace and upward to the second rib in many cases. =Auscultation=—the sounds are weak and sharp. The first sound is shorter, lacks its muscular element and becomes more like the second. The sounds are obscured, the cardiac murmurs are present. In many cases the characteristic gallop rhythm is present. When the right heart is chiefly dilated, the true apex-beat cannot be felt, while an impulse may be felt below the xiphoid cartilage, and a wavy impulse is seen in the fourth, fifth and sixth interspaces to the left of the sternum.

=Diagnosis.=—When a clear history can be obtained, together with the characteristic features, the diagnosis can be readily made. =Prognosis= depends upon the cause.

=Treatment.=—The treatment of dilatation is that of valvular heart disease. It is important that the patient should have plenty of rest, suitable food and regulated exercises.

In acute dilatation absolute rest is necessary. Limit the fluid intake, and open the bowels thoroughly. In serious cases, bleeding, a pint or more, should be considered.

Myocarditis

=Myocarditis= is an acute or chronic inflammation of the heart muscle. In many cases where the muscle substance of the heart is diseased, there is no doubt that =osteopathic lesions= are potent underlying factors. The lesions lessen nervous integrity and thus have a direct bearing upon the muscular strength and the likelihood of inflammatory invasion.

=Acute Interstitial Myocarditis.=—This affection is met with in fevers, in connection with endocarditis and pericarditis. Of the infections diphtheria and typhoid are the most frequent. Septic emboli may block the coronary arteries in pyemia, septicemia and malignant endocarditis and cause infarcts in the myocardium with abscess formation. It may be a complication of gonorrhea. Males are affected more often than females.

=Pathologically=, in =acute interstitial myocarditis= the changes take place in the intermuscular connective tissue. This becomes swollen and round-cell infiltration takes place. The muscle substance is pale and soft. =Acute parenchymatous degeneration= is characterized by degeneration of the muscle fibers, which are infiltrated with granules. The cardiac muscle throughout is pale and soft. =Acute suppurative myocarditis= is a rare condition. In this form abscesses occur, which vary in size from a pin’s head to a pea. They vary greatly in number and are usually multiple. They may not cause any disturbance and may not be recognized before death. On the other hand the abscess may rupture into the heart cavities or the pericardium, or it may perforate the intraventricular septum, thus allowing the venous and arterial blood to intermingle. It may cause a cardiac aneurism.

=Symptoms.=—These are very uncertain. If during the course of any of the causal diseases, the pulse suddenly becomes rapid, small and irregular and compressible and palpitation and syncope develop, all of which point to cardiac weakness, myocarditis may be suspected. Signs of venous stasis develop later in the affection. The physical signs are those of dilatation. This is extremely grave. Cases do, however, recover.

=Treatment.=—The treatment is the same as that given under endocarditis and pericarditis. Rest in bed is absolutely necessary. Pay particular attention to the nourishment and to the hygienic surroundings of the patient. Especially attention should be given to the upper dorsal area, both to the muscles and the interosseous lesions, for this influences cardiac muscle innervation and nutrition. Then lesions of the upper cervical are important owing to their relationship to the vagi which control muscular impulses of the heart muscle.

=Chronic Interstitial Myocarditis.=—Among the causes of this form of myocarditis are the excessive use of tobacco or alcohol; gout, rheumatism, malaria, diabetes, chronic nephritis, syphilis and lead poisoning. Acute interstitial myocarditis may lead to the chronic form. This form is “commonly caused by the narrowing of a coronary branch in a process of obliterative endarteritis” (Osler). It may be due to injuries of the anterior and lateral portions of the chest. Unquestionably =osteopathic lesions= of the upper dorsal vertebræ and ribs and cervical region affect the integrity of the heart muscle and predispose to congestion, inflammation and debility of the tissue. Males of middle life are more predisposed to chronic myocarditis.

The =pathological changes= occur most frequently in the left ventricle and the septum, but they may occur in any portion. The patches and streaks that are in the walls are sometimes only seen upon very careful examination. They are of a gray or grayish-white color, and when fibers that have undergone fatty degeneration are intermingled, they have a grayish yellow tint. The condition may be associated with hypertrophy and dilatation. A part of one of the heart cavities may become dilated, producing what is known as cardiac aneurism. There is destruction of the muscular fasciculi with subsequent development of new fibrous tissue. Fatty degeneration is also seen.

=Symptoms.=—Advanced fibroid myocarditis may be present without any symptoms. Slight degrees present no symptoms. The symptoms when present are: a feeble, irregular, slow pulse; attacks of angina pectoris and sometimes arhythmia. The blood pressure is increased. Upon exercising there is more or less pain, cardiac distress and dyspnea. If fatty degeneration is also present the pulse will be quickened and irregular.

=Diagnosis.=—This is often very difficult and it requires careful and persistent study of a case to be able to make a correct diagnosis.

=Prognosis.=—This is grave, though unquestionably a number of cases have been distinctly improved through osteopathic methods. Sudden death is liable to occur at any time from complete obstruction to the coronary arteries, as this condition is associated with sclerosis and narrowing of these arteries or their branches.

=Treatment.=—The treatment of chronic myocarditis is largely included in chronic endocarditis. The cause of the disease should be determined, if possible. Careful treatment to the ribs of the left side, from the first to the sixth, and the corresponding vertebræ, will be of great aid in controlling the disease. The cervical region demands attention, owing to the influence of the vagi on conduction of the heart impulse and to vasomotor effect. Attention should be given to the diet and hygiene of the patient. Outdoor life, bathing of the skin, and careful treatment of the vasomotor nerves will be of great help.

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 functions.

Degeneration of the Heart Muscle

In fatty degeneration, the sarcous substance of the fasciculi is converted into fat. In fatty overgrowths there is an excess of fat in and about the heart.

=Fatty degeneration= is very common and is due to an interference with the nutrition of the cardiac muscles. It is found in the impaired nutrition of old age, of cachectic states, of grave infectious diseases and of wasting diseases. In poisoning by arsenic and phosphorus, intense fatty degeneration is produced. Pericarditis may be associated with changes in the superficial layers of the cardiac muscle. Lesions of the coronary arteries will produce this condition; also impairment of the oxygen-carrying power of the blood. It occurs most frequently in men after forty years of age. The affection may be either general or local. It is most commonly seen in the left ventricle. When the condition is general the heart is dilated, flabby and relaxed. Microscopically, the muscular fasciculi exhibit a loss of nuclei, and oil drops and granules appear in the fibers. The affection may be present without any noticeable symptoms. Slight degrees and localized fatty degeneration are unrecognizable. =Dilatation= must be present to produce =symptoms=. This is apt to occur early. Dyspnea; asthma; cough; angina pectoris; dropsy; slow, weak pulse; palpitation, and toward the end, Cheyne-Stokes breathing may appear. Mental symptoms, such as maniacal delusions, may come on and last for weeks. =Prognosis= depends upon the cause and extent of involvement.

The =treatment= is largely that of dilatation of the heart. An effort must be made to determine the cause, and treatment should be applied accordingly. Considerable can be done in improving the nutrition of the tissues of the heart by hygienic and dietetic measures. Light exercises will often be of aid, but care has to be taken that the exercises do not tax the patient too severely. A general treatment of the body will be a helpful measure in invigorating the system as a whole and toning the cardiac tissues. The diet should be nutritious; largely nitrogenous.

Raising the ribs over the heart and increasing the chest expansion will be of help in cases where there are attacks of dyspnea and angina. Many cases present deep seated lesions in the upper dorsal region. When there are attacks simulating apoplexy, lay the patient flat upon the back with the head slightly elevated.

=Fatty overgrowth= is associated with general =obesity= and sooner or later this infiltration impairs the nutrition of the cardiac muscle and true fatty degeneration results. This form occurs more frequently in men, and between the ages of forty and seventy years. The characteristic changes consist of an increase in the normal fat. The heart may be enclosed in a thick covering of fat. The fat may also be deposited between the fasciculi, sometimes reaching the endocardium. Fatty overgrowth is certain to exist in extreme obesity. No =symptoms= are produced until the muscular fibers weaken so that =dilatation= occurs. The presence of extreme obesity, combined with signs of cardiac weakness, point to fatty overgrowth. The =treatment= of fatty overgrowth of the heart is largely the same as that of obesity. Oertel’s method of lessening the amount of liquids, proteid diet and graduated exercises is effective in cases where heart compensation is intact.

Neuroses of the Heart

=Palpitation= is a more or less rapid action of the heart, of which the patient is conscious. There is usually an irregular or forcible action of the heart, as well as a frequency of the heart-beat. There is generally some local irritation to the cardiac nerves; especially are =lesions= found to the third and fourth ribs, although a lesion may be higher or lower in the dorsals or it may be in the cervical area. Muscular lesions are frequent. These lesions predispose to the disturbances of reflex stimuli, still the general health may be so weakened or the reflex irritation so pronounced that palpitation results independently of predisposing osteopathic lesions. Females are more liable to be affected. The neurotic state is a common source of the disorder. If palpitation is long continued it causes hypertrophy. It often occurs at puberty, during menstruation and at the climacteric period. Anemia, the acute infectious diseases, dyspepsia, disturbances of the ovaries and other pelvic organs are common causes. The abuse of coffee, tea, alcohol, tobacco; diseases of the stomach, overwork, fright, grief, anxiety, and sexual excesses are causative factors. Palpitation may be associated with organic diseases of the heart, but as a rule it is a purely nervous affection.

The patient’s perception of the increased action and force of the heart is the =essential element= in palpitation. The action of the heart varies greatly and at times it may be a mere fluttering which lasts but a few minutes. In severe cases the heart beats violently and the pulse may be rapidly increased and reach 160 or more. The face is usually pale, but may be flushed. The heart’s action is not increased in some cases. The attack generally lasts only a few minutes.

The first consideration in =treatment= is to locate the disturbing factor. Raising the ribs over the heart and lowering the first rib; correcting the clavicle in a few instances, or inhibiting along the upper dorsal region will usually quiet the heart’s action. Stimulation of the vagi nerves, as they pass along the side of the neck, may be all that is necessary; in some cases inhibition of the superior cervical sympathetic or of the middle cervical region, acting on the depressor nerve of the heart, will lessen the tumultuous action of the heart. It will be recalled that either there is irritation of the accelerator nerves of the heart or the vagus is inhibited.

All =reflex disturbances=, as a displaced uterus, indigestion, etc., must be removed before the palpitation can be permanently stopped. Rest and confidence in the treatment are of great importance. 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 activity. In =anemic cases= hygienic measures and a proper diet, coupled with the treatment for anemia, are indicated. If the attack is severe, the patient should rest in a recumbent posture and drink something warm, besides receiving the indicated treatment. When the patient is not a decided neurasthenic a rapid five or ten minute walk will often normalize the heart’s action.

=Tachycardia= is rapid action of the heart and commonly occurs in paroxysms. There are no heart sensations, as in palpitation. Either the sympathetics are stimulated or the vagus inhibited. It is not generally related to lesions of the heart, but is in reality a =disorder= of the =nervous system=. In some instances the condition is physiologic. Nervous strain, in the form of =osteopathic lesions= to the upper dorsal or cervicals irritating the sympathetic, is the most common cause. Emotion, fright and severe exercise are other causes. It is found in neurasthenia, anemia, hysteria and in those using an excessive amount of tobacco, tea and coffee. =Reflex stimuli= from abdominal or pelvic disorder, especially during the climacteric may induce tachycardia. In exophthalmic goitre the sympathetics are overstimulated, and in some instances the vagus inhibited, leading to “heart hurry.” Tumors, hemorrhages, enlarged glands, etc., obstructing the action of the vagus, are a source of rapid heart.

Sudden onset with rapid action of the heart, small weak pulse, headache, flushed face and faintness are common =symptoms=.

The =treatment= is somewhat similar to that outlined under palpitation. Locating the cause is the first essential. Besides removing local osteopathic lesions, inhibition to the cervical and dorsal sympathetics is effective. Raising the ribs over the heart will lessen the pulse-rate.

Rest, diet and general care of the patient may be necessary. Outdoor exercise and cold bathing are beneficial. In a few cases springing the dorsal spine forward, raising the floating ribs, and slight traction of the cervical spine are effective in slowing the heart’s activity. A few cases are very refractory, especially in neurotics.

=Brachycardia=, or slow action of the heart, is the opposite of tachycardia. In a few cases it is physiologic. It usually occurs secondarily, following infectious diseases; accompanying nervous disorders, as hysteria, melancholia and neurasthenia, and is associated with diseases of the digestive organs, pulmonary disorders and toxic effects of coffee, tea, tobacco, and drugs and the toxins of jaundice, diabetes, uremia, etc. Obstructions to the cervical sympathetics and irritations of the vagus, from osteopathic lesions, may be either direct causes in themselves or predisposing factors in the above diseases.

A =slow, weak pulse= is the characteristic symptom. The heart sounds are feeble. When the pulse beat is below sixty per minute it is diagnostic.

In the =treatment= of slow heart, as in the other neuroses of the heart, the cause should be first determined. A stimulating treatment to the cervical sympathetics and inhibition to the pneumogastric will readily relieve many cases, at least temporarily. The lesion may be directly to these nerves and of course removal of the same is essential. Inhibition of the pneumogastric probably affects the activity of the depressor nerve, and stimulation of the cervical sympathetics, besides acting on the accelerator fibers of the heart directly, influences the blood supply of the body and thus increases arterial tension. Stimulation to the upper chest anteriorly and posteriorly, over the cardiac region, will increase the rapidity of the slow heart. Rest and care of the general health is necessary.

=Arhythmia=, or an irregularity of the heart’s action and pulse beat, often due to lesions in the cervical region interfering with the vagi, symis pathetic or vasomotor nerves to the heart. In a number of cases the first, second or third rib on the left side is at fault and a correction of it will relieve the irregularity immediately. It is claimed that there are nerves at the fourth and fifth dorsals that tend to control the rhythm of the heart-beat. Other causes are organic diseases of the heart and nervous system, reflex disturbances, excessive use of tobacco, coffee and tea.

“Normally, the contraction of the heart originates at the sinoauricular node, at the mouth of the superior vena cava, is conducted to the auricle, and thence to the ventricle by way of the auriculo-ventricular bundle (bundle of His or Gaskell’s ridge). Under conditions of abnormal stimulation, contractions may originate in the auriculo-ventricular node in the wall of the right ventricle near the coronary sinus; or in the auriculo-ventricular bundle on the ventricular side of the node; or in the auricular tissue itself.”—Clinical Osteopathy.

Fibers from the right vagus pass to the sinoauricular node, and from the vagus to the auriculo-ventricular bundle. 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 nerve. Thus the rhythmic power of the heart, rate and strength, and conductivity of impulse may be readily influenced, which is borne out by clinical experience.

There are several forms of irregular heart action. For a description of same it is probably best to refer the student to special works.[103]

The more common forms are =Sinus= Irregularities, the =Extrasystole=, =Paroxysmal Tachycardia=, =Auricular Fibrillation=, =Auricular Flutter=, and =Heart-block=. =Pulsus Alternans= is a rare form, and is of grave significance when the heart muscle is degenerated. A knowledge of =auricular fibrillation= is of special value, for it is a common form and often indicates a serious condition.

Most of the irregularities are not of special pathological importance, providing the heart muscle is healthy. They are best studied through instrumental means and require considerable experience in order to determine the exact condition.

Frequently, unnecessary worry has been the result in discovering irregularities in the young as well as in otherwise healthy adults. Only when the cardiac muscle is diseased or degenerated through various infections and toxic properties in the blood should they receive unusual attention.

Dorsal and lower cervical lesions that affect the heart by way of the sympathetics no doubt disturb nutrition of the heart tissues. And lesions of the vagi, particularly of the upper three cervicals, will disturb the rhythm, rate, strength, and conductivity of the impulse through auricles and ventricles. 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 heart. Stimulatory and inhibitory efforts will frequently suffice, but in our judgment it is always better to secure interosseous adjustment if possible.

Though a number of individuals with heart irregularities are of a neurotic type, that predisposes to nervous disturbances of various kinds, still it would be an interesting study, especially in cases of children, to note what percentage are the result of upper cervical lesions caused by birth injury.

Angina Pectoris

=Angina pectoris= is characterized by pain in the cardiac region which usually extends to the inner side of the upper arm and forearm. “This region corresponds to the peripheral distribution of the lower cervical nerves (6th and 7th in the arm) and the upper three or four dorsal nerves (in the upper arm and the chest).”[104] Occasionally similar areas of the right side are affected, and in a few there is pain in the lower jaw and back of the ears. “The starting of the pain is usually across the chest, about the level of the third ribs, or as low as the fifth ribs,” although the inception may be anywhere in the left chest or the arm. The duration of the pain is from a few seconds to several minutes; sometimes it may remain for several hours.

Osteopathic lesions are invariably found in the upper dorsal, including ribs, or lower cervical region, which are predisposing factors that tend to exhaust and weaken the cardiac muscle, and disturb the coronary circulation, so that resistance is lowered. Thus toxic agents and infections may readily involve the cardiac tissues. Many cases present more or less arteriosclerosis, which involves the heart and affects its circulation. Inflammation of the root of the aorta from syphilis is a frequent cause. Valvular heart disease and chronic nephritis are other underlying factors. Worry, strenuous living, and continued physical strain are to be considered. There are a group of cases, that are comparatively mild and frequently found in women, that are of toxic origin, due to intestinal stasis as a result of constipation, adhesions, etc. The ileo-cecal section is commonly involved in these instances. Focal infections may be an exciting cause.

The =osteopathic lesions= undoubtedly affect the cardiac innervation, particularly vasomotor and trophic, thus leading to consequent disturbances of cardiac circulation and resulting irritation to the ganglia. Sclerosis and spasm of the coronaries, ischemia, cramping, exhaustion, and degeneration of the heart muscle, and cardiac neuralgia, are various results that may take place.

The =paroxysm= usually begins suddenly, often during exertion or intense mental emotion. The pain is agonizing and of a grip-like character, and there is a feeling of impending death. The intercostal muscles are constricted and there may be a feeling of suffocation. The pains radiate up the neck and down the arm, and may be accompanied by numbness or tingling. There is usually extreme pallor, and the skin is ashen. Sweating is not uncommon, and dyspnea may be present. The attacks occur at intervals, varying from a few days to many years. After the paroxysms there is instant relief.

Other cases may present less severe attacks.

In the =diagnosis= the only condition with which true angina pectoris is liable to be confounded is pseudo-angina pectoris. =Pseudo-angina= or hysterical angina occurs chiefly in women or in neurasthenic men. These cases are often excited by toxemia. The attack usually occurs at night and is unassociated with organic heart disease. There is a feeling of cardiac =distention instead of constriction= as in true angina. There is emotional excitement and the attack lasts one or two hours, which is usually longer than that of true angina. The =prognosis= is unfavorable, although many cases live for a number of years. A few cases have recovered under a thorough course of treatment.

The =treatment= of angina pectoris consists in correcting the disordered upper dorsal vertebræ, the upper left ribs over the heart, and the lower cervicals. Invariably lesions are found in this region and if the treatment is applied to correct these disorders, the attack can frequently be relieved. By following up the treatment during the intervals, a number of cases can be practically cured. A common lesion found is a slight lateral curvature in the upper dorsal region. This curvature is oftentimes great enough to cause a subdislocation of several of the ribs, which certainly complicates the derangement, at least as far as a quick cure is concerned.

=During= the =attack= raise the ribs over the heart at the point of constriction so as to relieve the impinged nerve fibers. Hot drinks are of value. The vagi and phrenic nerves may also be at fault in some cases. The sensory nerves to the heart are from the first, second and third dorsals.

Ice-bags or heat applied locally will be a helpful measure. In cases where there is high arterial tension, an inhibitory treatment to the upper and middle cervical regions will be of special aid, as it relieves this tension by affecting the vasomotor nerves. This treatment will at least overcome the =vasomotor form= of angina pectoris. Hot foot-baths and friction will also be found of value. In many cases under forty or forty-five syphilis is a cause. In cases past middle life there is often organic disease of the circulatory organs.

The patient should at all times avoid any excitement and live a very quiet life. He should take frequent vacations. He should take the best of care of himself and his food should be nutritious. In pseudo-angina the treatment is to relieve the irritation to the nerves affected as well as the underlying affection.

FOOTNOTES:

[100] Journal of the American Osteopathic Association, April, 1906.

[101] Valvular Heart Diseases, A. O. A. Journal, March, 1905.

[102] Journal of Osteopathy, February, 1904.

[103] Mackenzie, Diseases of the Heart; Lewis, Mechanism of the Heart Beat; Macleod, Physiology and Chemistry in Modern Medicine.

[104] Mackenzie, Oxford Medicine, Vol. II.

DISEASES OF THE ARTERIES

Arteriosclerosis

(ATHEROMA)

This is a thickening of the intima of the arteries, due to an inflammatory increase of the connective tissue, associated with more or less fatty degeneration and calcification.

Old age, alcohol, lead, gout, syphilis, rheumatism and other infections, laborious work, overeating, nephritis, and calcareous water tend to produce the condition. =Excessive eating= and =drinking= are common causes of both atheroma and chronic renal diseases and should always be regulated. Physical overwork, chronic intoxications, etc., produce hypertension of the vascular system and thus lead to changes of the vessel walls. A rigid spine is invariably found; this may be a causative factor in itself, or an associated condition. All of the above list of causes are important.

=Pathologically=, the arteries are thickened, tortuous and rigid. The intima may be occupied by rough, calcareous plates. In extreme cases the sub-endothelial tissue undergoes degeneration and breaks down in spots, forming “atheromatous abscesses.” The disease may be =circumscribed= or =diffuse=; in the latter there is a widespread distribution of the affection. Owing to the general effect, the heart, liver and kidneys receive less blood and tend to atrophy. Microscopically, there is found more or less fatty degeneration of the different coats, and an overgrowth of connective tissue in the intima. The arteries most frequently affected are the aorta and coronary.

=Symptoms.=—=Circulatory.=—There is a high tension pulse and accentuation of the second aortic sound. There is also dyspnea, severe pain in the left side, palpitation, pallor, and the left ventricle is hypertrophied. =Cerebral.=—Such symptoms as headache, tinnitus, aphasia, vertigo, syncopal or epileptiform attacks may be present. =Renal.=—There is an increase in the quantity of urine, which is of a pale color and low specific gravity; at times it is albuminous. The disturbance leads to atrophic nephritis. There may be gastro-intestinal symptoms, as constipation, pain, etc., due to hardening of the splanchnic vessels. In some cases the peripheral arteries become obliterated. The veins become hardened.

=Sequelæ= are cardiac dilatation, heart failure, paralysis, apoplexy, fatty heart, aneurism, contracted or senile kidney, angina pectoris, and in extreme cases, gangrene of the extremities.

=Diagnosis.=—The characteristic symptoms are hardened arteries, high tension of the pulse, hypertrophy of the left ventricle and accentuation of the aortic second sound. The average blood pressure is from 160 to 180 mm. of mercury, though it may be considerably higher.

=Prognosis.=—Many cases can be greatly benefited by osteopathic treatment, and at the incipiency the improvement is generally marked. It usually runs a very chronic course.

=Treatment.=—The treatment must necessarily consist, principally, in the removal of such conditions as are producing the degeneration. The rigid spine should be carefully treated by methods (preferably traction) that overcome the contractures and release the intervertebral discs. The dorsal and lumbar areas, and the abdominal organs should receive special attention. Outdoor life and plenty of rest are important. Alcoholism, gout, rheumatism, syphilis, etc., must be remedied before there can be much change in the arteries. Freeliving and all excitement must be stopped. The patient’s cooperation is invaluable. A milk diet is often beneficial. Besides treatment of the primary disease, a general treatment will be of much avail in equalizing and reducing arterial tension. Brunton[105] speaks of cases of atheroma being cured by exercise and manual treatment to the rheumatic joints themselves. One, apparently suffering from senile dementia, was much improved after two years of this treatment applied to the joints, and showed benefit to the cerebral circulation. The bowels and kidneys should be kept active, and the general health of the patient carefully watched. Keeping the skin active by daily baths is an essential factor in the treatment. Very frequently the disease is not only retarded, but improved. In high blood pressure venesection may be of benefit.

FOOTNOTES:

[105] Lectures on the Action of Medicine, p. 343.

DISEASES OF THE BLOOD

BY EARL R. HOSKINS

=General Considerations:=—It has been said that each individual is a part of all the generations which have preceded him. In the same way it might be said that every drop of our blood is a part of every other cell in our bodies. 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 supplies. We are accustomed to speak of certain organs as being those of blood formation, yet it is true that every tissue furnishes its quota of blood composition, making up the mass which we call blood.

It is in one way an algebraic sum of good and baneful substances, without which there can be no normal function, and sometimes being of itself a menace as well as an aid to other tissues, as in sepsis. There can be no perverted function of any tissue without there being a direct effect upon the blood. We may not always be able to measure this effect with our present laboratory methods. We may not be able to detect clinically the result of this alteration of the blood stream because of compensatory influences, dilution, phagocytic action, enzymatic action, oxidation, and the intricate processes of excretion. It must also be remembered that normal blood is not of a certain definite chemical or physical composition. It must vary from minute to minute according to the normal metabolic phenomena which make up our succession of events associated with life.

But comparatively little is known about this most important fluid. 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 arrangement. We have an ever widening field of investigation in the blood plasma in which we are constantly being told of newly discovered complexities. Certainly the field of the unknown is big enough to contain our unexplained blood reactions.

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 body. We can measure the number and proportion of formed elements, and the relative efficiency of the erythrocytes by the amount of hemoglobin which they carry. The genesis of the formed elements is to be kept in mind in considering therapy. The erythrocytes and granular cells developing in adult life, principally from the red marrow, 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 ribs. 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 verified. 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 stream.

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 contains. The actual changes taking place in blood character are often thus sufficiently indicated for us in terms of our present methods of examination, to at least aid in the arrival at a diagnosis. We sometimes have to remember that the adaptation to abnormality may be efficient enough to keep the apparent significance from telling the “whole truth.”

The Anemias

The class of diseases which are referred to as the Anemias are those in which there is an actual, or apparent, decrease in the oxygen carrying element or hemoglobin. This may not be due to an actual decrease in amount of hemoglobin, but rather to a decrease in the ability of the red cells to carry it. This decrease in ability may be due to alteration in the erythrocytes themselves, or to effects of change in the molecular concentration of the plasma in which they are suspended. The plasma may also contain certain poisons probably protied, which may make impossible the efficient carrying of hemoglobin by the erythrocytes.

The simplest form of anemia is that due to removal of a large percentage of erythrocytes from the body. This condition is fulfilled in acute hemorrhage. If the amount of blood lost does not exceed the amount necessary to maintain circulation, roughly fifty per cent of the total quantity, the fluid portion lost is quickly replaced from the fluids of the body and from material ingested. 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 proportion.

A blood cell may be considered as passing through a life cycle of infancy, adolescence, maturity, and senility before it is finally destroyed. If the demand for new cells is not too great it will be met with mature cells. If the call is more urgent, younger and older cells will both be put into the conflict, while in a time of extreme stress all types of cells, from the “school boys” to the “gray-beards”, will have to be utilized to maintain life. So, roughly, 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 service.

The pigment, hemoglobin, is slowly regenerated even as compared to erythrocytes, so that the color index is usually the last finding to return to normal after a hemorrhage. The leucocytes are usually increased after hemorrhage, probably as a protective mechanism, nature having learned by hard experience that she has less resistance to infection, when there is loss of a considerable quantity of blood.

To be considered, also, is the fact that constantly blood cells are outliving their usefulness—some must be disposed of. 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 shops. The regeneration of blood after hemorrhage depends upon the severity of the loss, the nutrition, upon the treatment given, and indirectly the ability of resistance developed by the patient.

In the chronic anemias we may have either defective development of erythrocytes, or defective function of them, or a relatively too great destruction of these same agents.

A bank account may be depleted either by too small deposits to account for current expense, or by extravagant withdrawals. It is sometimes difficult to determine on which side the fault lies. It seems to be nature’s plan not to subject to active work an erythrocyte until after the nucleus has disappeared, judged by ordinary methods of staining. A sudden call for an increased number of erythrocytes may force the organism to send in some with nuclei, but the circulation does not receive those which have not been standardized, as to shape and staining reaction, unless the crisis is of grave import. Evidence of increased destruction of these cells is shown by broken forms—shadow forms, and by an increased excretion of the pigments derived from the breaking down of hemoglobin, namely bilirubin and urobilin. A great deal of information can be obtained by a study of the other formed elements of the blood.

In general the symptomatology of all the anemias will be that of lessened metabolism because of deficient oxygenation. This is accompanied by imperfect nutrition and general impairment of function. Among the usual results are muscular weakness, malaise, headache, dizziness, anorexia, and cutaneous and membranous pallor, with tendency to local hemorrhages. The heart is often rapid, easily disturbed in rhythm, may possess a hemic or functional murmur, and gives a soft compressible pulse of low pressure. As a compensatory attempt the respiration may be rapid, but is likely to be shallow, and dyspnea results from disproportionately small exertions.

There may be either troublesome constipation, or diarrhea; often there are alternating periods of each. In the severer forms convulsions, coma, delirium, stupor, localized edema of the ankles or eyelids may be seen.

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 stream. 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 lost. If the loss is severe enough to give rise to shock, emergency measures are necessary of introducing into the venous stream an artificial fluid to make up for the fluid part of the blood lost. If the condition can be predicted and a suitable donor obtained, blood transfusion is of greatest advantage to the patient. More often the urgency of the condition will require an artificial fluid to be given in haste. Probably the best so far devised solution is Fischer’s physiological salt solution. In the anemias due to chronic metal poisoning as from lead and mercury, or from systemic poisoning such as syphilis or malaria, or from the retention of metabolic products as in some of the diseases of the kidneys or of the liver, the anemia can only be successfully treated by normalizing its primary cause—as it occurs in the role of a symptom or result, and hence is only indirectly a blood condition.

Costogenic Anemia

(BURNS’ ANEMIA)

Costogenic Anemia is a result of functional disuse-atrophy of the hematopoietic organs, there being an insufficient supply of erythrocytes to meet the demands of the metabolism of the body. It results from insufficient opportunity for nutrition and drainage of the red marrow of the ribs, and gives the clinical picture of an anemia due to too slow production of erythrocytes.

=Etiology.=—The condition is predisposed to by any factor which tends to limit the action and nutrition of the ribs. We are too prone to forget that the function of the ribs is to produce erythrocytes; it is really a matter of secondary importance that they make up part of the thoracic wall. The change from the horizontal to the upright position has tended to a drooping of the whole chest from gravity. The human animal seldom develops the free hinge rib motion as often seen in quadrupeds. The passage of both arterial and venous blood, is not normally free and copious, and as a consequence the tissue supplied functions less efficiently. This function of the red marrow is to produce erythrocytes. Any structural lesion of the dorsal vertebral column, or its costal articulations, which interferes with the free motion of the rib thus interferes directly with the efficient function of these particular ribs. The severity of the condition varies with the number of ribs affected and the impedance to nutrition and drainage.

=Diagnosis.=—The condition may be of gradual onset, and may be associated or coincident with some other condition leading to a loss of tone or opportunity for free rib action. The systemic symptoms are due to a deficient oxygenation of all tissues as a result of the above disuse. The thorax is usually rigid—forced respiration requires unusual effort without proportionate thorax expansion. The type of breathing tends toward diaphragmatic. The quantities of tidal and supplemental air are both markedly decreased. The lack of tissue oxidation renders elimination less active, hence constipation. Gas accumulation, weakness, insomnia, with slightly increased amount of urine, and low in total solids, is the rule.

“The blood itself is rather characteristic. Coagulation time is increased; specific gravity and viscidity diminished; red cell count normal or only slightly diminished; hemoglobin 6 to 10 grams per 100 c. c. of blood (Meischer); 40% to 80% (Dare). The red cells are small, pale, vacuolated, sometimes nucleated. The white cell count is normal, slightly increased or slightly diminished. The hyaline cells are normal, or slightly relatively increased. (These, being formed in lymph nodes, tonsils, etc., are not affected by rib changes.) The mononuclear neutrophiles are relatively increased. The nuclear average of the polymorphonuclear neutrophile is low. Vacuolated and atypical neutrophiles are often found. Basophiles, myelocytes and amphophiles may be found in considerable numbers. Nuclei in all granular forms present evidences of immaturity or degeneration—they may be swollen, vacuolated, extruded, ragged, or with variable staining reaction” (Clinical Osteopathy).

=Treatment.=—The treatment is to obtain a normal function in the inactive tissues. This is done by getting better rib hygiene. Whatever is interfering with rib function and metabolism is to be removed. Breathing exercises are given not only to “ventilate the thorax, but to exercise its walls”. Carefully selected horizontal bar work is often of great value. The diet should be of such nature as to supply material for manufacture of erythrocytes and for loading them with hemoglobin as well. Hence the foods with high chlorophyl or hemoglobin content should be emphasized.

=Prognosis.=—This depends on patient’s desire for improvement of his condition. He can be improved by correction of whatever lesions there may be interfering with his freedom of thoracic motion. He can be benefited by manipulations which adjust the ribs, but his cooperation is essential. Lack of cooperation on the part of the patient, which would tend to increase the mobility and metabolism of the ribs, renders him more liable to any of the intercurrent pulmonary infections, as a result of his deficient thoracic ventilation.

Encourage free thoracic respiration especially when in school, or when under conditions which ordinarily would tend to slovenly habits of breathing.

Chlorosis

(GREEN SICKNESS)

An anemia characterized by great reduction in the amount of hemoglobin. It most frequently occurs in adolescent girls. It seems to be associated with neurotic manifestations and menstrual irregularities.

=Etiology.=—Its cause is not well understood. Poor hygienic conditions may be a factor, but it is a condition found in all stations of life. The age and sex have led to investigation as to probability of lack of an ovarian internal secretion. The reports of workers are contradictory. The name of the condition is derived from the color of the skin, which usually ranges from a pale greenish tint to a slight pallor. Occasionally there is localized vasodilation of the cheeks giving brilliant color. Constipation accompanied by copremia seems to be either a causative factor or result. In many cases it appears to act in the dual role. Fixation of the middle and lower ribs accompanied by osteopathic lesions from the mid to the lower dorsal spine seem to be constant findings. The costal fixation leads to lessened respiratory excursion and resulting diminished oxygenation.

=Diagnosis.=—Chlorosis may be suspected from the color of the skin, perverted appetite, wandering neuralgias, heart palpitation, edematous infiltration, and shallow type respiration, but the diagnosis is not to be made without the aid of the blood count. The striking part of the blood picture is the great reduction in amount of hemoglobin carried by each erythrocyte. There is usually some reduction in the erythrocyte percentage but not in proportion to the decrease in color index.

There are usually many pessary-shaped and shadow erythrocytes. These are of all sizes, but seldom is the condition of such gravity as to cause more than an occasional nucleated red cell, and when found are most likely to be normoblasts. The staining reaction is of wide limits. Cells of all degrees of relative alkalinity are found and often there is a wide variation of staining reaction in the same cell. The number of erythrocytes is usually slightly decreased but not in the proportion that the hemoglobin percentage is, so that the color index is therefore strikingly low. Probably, the average color index for a typical case of chlorosis is 50, with an erythrocyte count of 4,000,000 and a hemoglobin of 40 per cent (Dare.) 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 anemia. The blood plasma is increased and the specific gravity is lowered, sometimes reduced from 1.055 to about 1.030.

=Treatment.=—The treatment of any malady in which the etiology may be apparently of widely different natures will naturally rationally vary with the apparent cause. If there is copremia, which seems to be a definite causative factor, this should be at once corrected. These patients form the cathartic habit readily, so physical and dietary methods of returning the digestive motility to normal should logically be given first trial. If it is a matter of lessened metabolism as a result of insufficient exercise, or blood oxygenation, outdoor gymnastics and breathing exercises may incite the stimulus to normal erythrocyte hemoglobinization. The diet should be of such nature as to furnish material both for erythrocyte formation and iron in form for ready absorption by them. The organic iron compounds of animal hemoglobin and vegetable chlorophyl are our most common and cheapest as well as most effective sources.

The medical treatment of chlorosis is based on the empiric use of inorganic iron. “The exact method in which iron exerts a favorable influence upon chlorosis still remains unsettled. It is difficult to understand why iron salts in the food which are sufficient for all ordinary needs, are insufficient in chlorosis. It seems most probable that iron cures chlorosis by acting as a stimulant to the =blood forming organs=” (Beifeld, The Basis of Symptoms.)

Clinically, 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 hygiene.

=Prognosis.=—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 stimulus. The blood may show chlorotic relapses with concomitant symptoms if in later life secondary anemia develops from hemorrhage, hook-worm infection, or other causes.

Pernicious Anemia

This anemia is of obscure etiology, characterized by progressive destructive hemolysis of the erythrocytes, usually with fatal termination. The cells retain their hemoglobin carrying ability, so that while the hemoglobin is decreased in percentage, the proportionately greater decrease in the number of erythrocytes leads to a marked increase in the color index. 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 deformed, or in various stages of degeneration. Cells which in times of health would have been sent to the “salvage station” are retained to carry an over-load for them of hemoglobin to the needy tissues. Immature nucleated cells of all types are drawn into the battle long before they can be efficient carriers to help supply oxygen to the tissues. Seldom will a secondary anemia be severe enough to produce megaloblasts in the blood stream yet they are a rather constant finding in pernicious anemia. With these cells of irregular carrying capacity and development, anisocytosis and polychromatophilia are expected findings.

=Symptoms.=—The condition must be regarded as a symptom complex or a result of pathologic process or processes. A type of anemia very similar in symptoms and blood findings to the pernicious anemia is produced by the toxins of advanced malignancy, and by at least two forms of intestinal parasites, the ankylostoma duodenale and the bothriocephalus latus. In the true pernicious anemia we have similar results but are not able to locate the primary pathology. There are present synchronously, enormously increased destruction of erythrocytes and enormously increased production of them but we are unable to determine which is primarily at fault. 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 need. Occasionally, the algebraic sum of regeneration and destruction may be apparently balanced and not tell the tremendous amount of pathology both productive and destructive, that the body is going through.

The first symptoms are of easily produced fatigue of all the body, brain, muscles, diminished digestive secretion, and dyspnea. As a result of poor tissue oxygenation, fatty degeneration takes place in the more active organs as the heart, kidneys and liver. There may be extensive degeneration of varying areas of the central nervous system. Some of these areas are due to hemorrhages from the general tendency to breaking down of vessel walls. Often these areas of destruction affect the posterior horns of the spinal cord, and, occasionally, a blood count differentiates between similar symptoms of pernicious anemia and tabes dorsalis. There is seldom any emaciation; usually the patient appears “puffy” with a “pasty” color. There is variable subcutaneous edema. The symptoms being of such wide distribution and character, 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 anemia.

=Treatment.=—The treatment of the form due to intestinal parasites gives striking results on removal of the causative organisms. Some advise treating all cases having these blood findings on the assumption that the presence of these parasites is responsible for the condition. 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 body. Rest in bed coupled with the digestible and assimilable limit of nutrition often gives temporary improvement. Removal of questionable teeth also often aids for a time. Correction of troublesome osteopathic lesions is often accompanied by the same result. The symptomatic osteopathic treatment always makes the patient more comfortable, often gives temporary improvement, and, occasionally, has given a return to normal that has persisted for several years.

=Prognosis.=—It is nearly always possible to obtain transient improvement, but the pernicious anemia patient is usually dead within two years from the time the diagnosis is well established.

The Leucemias

As a result of any inflammatory process, there is a physiological reaction or stimulus leading to an increase in the number of neutrophilic leucocytes found in the peripheral circulation. As long as this increase does not crowd out other cells, red and white, sufficiently to interfere with their ability to function there is nothing but gain to the body of the character of more efficient bacterial destruction. After the need for these cells has passed, their number is decreased by destruction and the lessening of their production, until an equilibrium is reached which will be maintained.

This same process of making and destroying is constantly going on for all of the different classes of cells found in the blood stream. Over-production of any type will lead to actual increase of that sort of cell in circulation, and, if unaccompanied by over-production of other types, will lead to a relative decrease of the other elements.

It is very difficult for the body to furnish normal cells very much in excess, relatively, of the normal number, 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 stream. As an example, the case of leucocytosis which has a white count of 60,000 is extreme and the patient nearing death, yet it may not show many, if any, abnormal types of cells. A case of myelogenous leucemia with a white count of 60,000 would not be proportionately sick, 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 blood. The leucocytosis patient is suffering more from the =cause= of his increase in number of cells, while usually the leucemia patient suffers because =of= the increase of cells. In one, the cause is usually extrinsic, and, in the other, it is intrinsic as far as the blood is concerned.

In general, then, the symptoms of a leucemia parallel in intensity the increase in cells. It takes energy to make these cells—other tissues are made to suffer from lack of this energy. Erythrocytes and white cells cannot occupy the same space at the same time. The increase in white therefore crowds the red cells out of function. Disease in relative and absolute content of erythrocytes decreases the oxygen carrying capacity of the blood stream. Hence, metabolism of the whole body suffers. Often, then, the whole apparent symptomatology of a severe leucemia is that of a secondary anemia.

The primary pathology is of hyperplasia of the particular genetic tissue of the type of cells which are in excess, and is proportionate in amount to the excess developed.

Splenomedullary Leucemia

(MYELOID LEUCEMIA; MYELEMIA)

Myelemia is a disease characterized by an enormous increase in the white cell content with proportionate changes in the spleen, liver, and the blood marrow.

=Etiology.=—It is a disease occurring at all ages, but the majority of cases are recognized in adult males.

Heredity, trauma to the spleen, malaria, syphilis, and rapid repetition of pregnancies seem to be at least exciting factors. A few cases have been reported in which tenth, eleventh, and twelfth rib lesions were definite etiologic factors by pressure.

=Diagnosis.=—The patient goes through a period of vague, indefinite, and wandering symptoms. General malaise, weakness often accompanied by dyspnea, and emaciation similar in many ways to incipient pulmonary tuberculosis, except that the slight temperature changes are not typical. At the same time there may be digestive discomfort of various kinds without typical pathology. Of these early symptoms the most persistent is the =dyspnea= which is a structural result of the increase in size of the spleen. As a direct pressure result of this hyperplasia, there may develop dropsical infiltration of the lower extremities and ascitic accumulation in the abdominal cavity.

With the changes in the blood itself, the blood vessel walls break down more easily, and subcutaneous hemorrhages, epistaxis and hematemesis are common.

In an attempt to destroy the excessive amount of white cells, the liver may become enlarged. But this occurs later and of much less degree than the enormous increase in size of spleen. There may be areas of hemorrhage with resulting softening in the spinal cord. The most likely areas to suffer are the posterior and lateral horns, with resulting paraplegia, spastic or ataxic.

Usually, the course is slow, and the condition is truly chronic. But, occasionally, the rapid increase and succession of symptoms, with concomitant blood changes, change the diagnosis to acute myelogenous leukemia.

The total cell count, red plus white, is diminished, for while there is enormous relative increase of the white cells a greater actual decrease takes place in the reds. This decrease in reds is partially relative from crowding out of erythrocytes by leucocytes, but there is also actual decrease in their formation, so that there is an actual anemia present as well as a leukemia.

In some respects the red cells behave as in chlorosis, each carrying a diminished percentage of hemoglobin, resulting in a low color index. Atypical staining reactions and morphology, together with many fractured forms, are the rule. Normoblasts are common throughout the course of the disease, but megaloblasts seldom appear until near fatal termination.

The changes in the white cells are enormous, both as to numbers and character of cells found. The total white count often exceeds 350,000. This, with the accompanying reduction in number of erythrocytes, leads to a reduction of the ratio between reds and whites to as low as 1 to 5 or 3, or occasionally 1 to 1. There is an actual increase in number of all the white cells with the possible exception of the lymphocytes. In the actual increase of polymorphonuclear neutrophiles and eosinophiles is rendered a sharp relative decrease by the enormous production of myelocytes. Basophiles are usually both relatively and absolutely increased. In a white count of 350,000 it is not unusual to have present 325,000 myelocytes, with 25,000 as the actual number of ordinary leucocytes. There is, therefore, a =mild leucocytosis= coupled with a =violent= leukemia. These two are combined with an =anemia= that varies with the course of the disease.

=Treatment.=—The treatment is largely hygienic, including thorough osteopathic attention to the lower dorsal and costal area. Symptomatic treatment is often followed by temporary improvement both clinically and in the blood picture, but complete recovery seldom takes place. Occasionally, roentgen therapy has given a “cure” lasting several years.

=Prognosis= is not good. These patients are frequently carried away quickly by some oftentimes slight intercurrent infection. Even if carefully guarded from such, the course of the process usually leads to death from exhaustion in two or three years.

Lymphatic Leucemia

Clinically, this is a parallel condition to myelogenous leucemia, except that the hyperplasia of cells occurs in lymphoid tissue, and leads to an enormous over-production of lymphocytes rather than myelocytes. It is more readily divided into acute and chronic forms than myelogenous leucemia from differences in symptomatology.

In the =acute form=, adolescents are usually affected, the condition beginning with tumefaction of the lymph glands, first noted in the cervical region, but usually a general involvement. Dyspnea results from pressure upon trachea and bronchi by the enlarged glands of the mediastinum. There is pyrexia of 103 to 105 degrees, intermittent in character.

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 paths. The blood vessels of the skin are easily broken down so that slight injuries result in great suggillation. The patient rapidly develops anemia, and later goes into a syndrome similar to the cachexia of malignancy. In fact, the rapid termination and clinical course of acute lymphatic leukemia is parallel to the action of malignancy. Probably the condition will eventually be properly classified as a neoplasm of the blood itself.

The =chronic form= occurs in later life, and, instead of being an abrupt rapid process, is slow, progressive and painless. It has the lymph gland hyperplasia, but the enlargement is so gradual that compensation is established to a remarkable degree. It is usually a generalized process, first noted in the cervical and axillary glands because of their accessibility. Usually both the spleen and liver are enlarged, but this also is a slow and later development.

There may be exacerbations of temperature, but they are not constant or usually severe. Hemorrhages into the skin are not common, but pruritus may be very troublesome.

The patient comes to a physician because of symptoms resulting from his secondary anemia, dyspnea, dyspepsia, and palpitation.

The =diagnosis= cannot be made without the aid of a blood study. The blood picture shows a severe anemia with both the number of erythrocytes and the hemoglobin percentage very much lowered. Of the two findings, the hemoglobin percentage is relatively more decreased, so that the color index is markedly lowered.

In the acute form nucleated reds are common. Just before death these may show various forms and sizes as well as the normoblasts. In the chronic form normoblasts do not appear except as the case grows decidedly worse. As compared to myelogenous leucemia the anemia of lymphatic leukemia is of greater severity.

In the leucocyte count there is great increase in numbers, the greater part being composed of the lymphocytes. The lymphocytes may be either of the large or small variety, and occasionally are found in about equal proportions. In contra-distinction to the myelogenous type, the increased type of cells are of the mononuclear nongranular types. It is not very unusual to find a well advanced case of lymphatic leucemia without abnormal cells in the blood count, the expression of pathology being in the shape of disturbance in number and proportion of cells rather than in development of abnormal types. 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 myelogenous. In other words, a patient with lymphoid leucemia showing a count of 90,000 leucocytes with 90% of these lymphocytes is a much sicker man than the myelogenous case showing a 350,000 leucocyte count.

Usually there is an actual as well as relative decrease of all the granular types of leucocytes with the polymorphonuclear neutrophiles especially decreased.

The =treatment= is systemic and symptomatic. Recovery is not to be expected, but these unfortunates can be made relatively comfortable and given occasional respite by judicious osteopathic care.

Hodgkin’s Disease

(LYMPHADENOMA; PSEUDO-LEUCEMIA)

In a general way, the several conditions which are clinically leucemia, yet do not possess leukemic blood, can be classified as pseudo-leukemias. 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-leucemias.

Syphilis, malaria, tuberculosis, and malignancy are all considered as factors, and probably certain cases can be definitely associated with these conditions.

All of this group of pseudo-leucemias are characterized by early swelling of cervical lymph glands, followed by general gland enlargement, and by great destruction of the erythrocytes. There may be metastatic-like growths of lymphoid tissue in other organs. The enlargement of cervical glands usually begins on one side near the angle of the jaw, and most commonly in young male adults. These glands progressively increase in size, first are soft, then later become hard through fibrous proliferation. Each gland tends to increase in size by itself, not to coalesce with its neighbors, so that each separate gland can be palpated. This is more readily done as there is little tendency to fibrous adhesion formation to the overlying skin. These glands are painless throughout the course of the disease, and tend neither to caseate nor to suppurate.

The excised glands show a combined hyperplasia and connective tissue proliferation. In the soft stage of the tumefaction, the lymphoid hyperplasia is in preponderance, while, at the stage of hardening, the fibrous tissue derived from the trabeculae and capsule of the gland is in prominence. There is increase in the size of the spleen, and occasionally of the liver, but these are never as marked as those resulting from leucemia.

The =symptoms= are, first, those due to the glandular enlargement in the order of: dyspnea, hydrothorax, dysphagia, ascites, swelling of the extremities, and jaundice.

The destruction of red cells gives a resulting anemia which goes with and exaggerates the pressure symptoms.

A process of this kind to induce such grave changes over as well protected organs as make up the lymph system, must be virulent enough to set up other symptoms, to be associated with those due to pressure or to anemia. These are usually emaciation (giving greater prominence to glandular tumefaction), cachexia, and the implantation of masses of lymphatic tissue in organs where normally only traces of this tissue exist.

Fever is dependent upon the disturbed thermic metabolism and may be practically absent or subject to wide variations.

The erythrocyte count shows a progressive decrease with a greater proportion of broken down cells and abnormal types as the condition advances. The actual count is usually between 2,000,000 and 3,500,000 per cubic millimeter. The hemoglobin usually reduces in proportion to the erythrocytes, so that there is little change in color index.

The leucocytes are not markedly changed in number (seldom over 10,000), and this is often the =diagnostic= finding between leukemia and the pseudo-leukemias. Hodgkin’s disease usually has a high percentage of lymphocytes, so that there is an actual as well as relative decrease of the granular leucocytes.

The =treatment= is unsatisfactory, and is in the main symptomatic. Roentgen therapy has given temporary improvement, in some cases lasting several years. In general the =prognosis= is hopeless, the end occurring within four years of the time the condition is recognized.

DISEASES OF THE THYROID GLAND

Congestion

Physiological congestions of the thyroid gland are not uncommon during puberty, painful menstruations, pregnancy, and the menopause. The =premenstrual= congestion may persist after the menstrual function has been established, but this is comparatively rare. When the enlargement remains there is more or less hypertrophy, and it should receive appropriate treatment. Upper dorsal and cervical lesions are common. The congestion during =pregnancy= occurs in the majority of cases and seems to be a physiological process, wherein there is more or less hypertrophy and hyperplasia, which probably counteracts the waste products especially caused by this state, or due to the inactivity of the ovary. During =delivery= the gland may rapidly enlarge and remain so for an indefinite time. 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 organ. When the enlargement occurs during the =menopause= special care should be taken that the goiter is not malignant.

Other possible causes of congestion are overfatigue, particularly when associated with heavy lifting; tight clothing about the neck; overuse of the voice; and in a few cases it may be discovered in boys at puberty.

The =symptoms= are congestion, the gland being very vascular, either soft or tense, somewhat painful owing to the tension of the capsule, and in persistent cases there may be hypertrophy and hyperplasia. The treatment is the same as given under simple goiter.

Inflammation of the Thyroid

Inflammation of the thyroid is not of frequent occurrence. In the several cases that the authors have seen there was some previous enlargement of the organ, which probably caused a =lowered resistance= of the local tissues. There is almost invariably some infection elsewhere in the body. The exciting causes are usually streptococcus, staphylococcus, or bacillus coli. The inflammation may follow pneumonia, tonsillitis, rheumatism, typhoid, puerpal infections, enteritis, diphtheria, influenza, mumps, etc. Trauma, carrying weights on the head, and cold, may be etiological factors.

Commonly, one lobe is involved, though the entire gland may be affected. There is swelling, the capsule is distended and painful, and small hemorrhages occur which in the case of suppuration form the site of the abscess. The swelling involves the parenchyma and interstitial tissue.

The =onset= is usually sudden with chills, fever, and pain over the glands. The patient keeps the head flexed to release the muscular tension, swallowing is painful, and there is a sense of constriction. A rapid heart may be a prominent symptom. Much depends at this period on the =treatment= given. If the drainage can be freed, by lowering the first ribs and raising the clavicles with attention to the dorsal and cervical innervation, prompt subsidence of the condition commonly takes place. This should be carefully accomplished in order not to bruise the parts.

=Diagnosis= is not difficult as a rule. The symptoms and history of infection will generally suffice. Hemorrhage may occur in a goiter and somewhat simulate inflammation. A possibility of =malignancy= is to be considered.

If the condition does not yield to treatment, surgical interference may be necessary.

=Tuberculosis= and =syphilis= of the thyroid are rare conditions. =Woody thyroiditis= may be mistaken for malignancy. The gland is very fibrous, and when cut has a dry surface. The connective tissue is hardened and crowds upon the parenchyma. This condition is usually found in young men. It develops rapidly, with more or less pain and dyspnea. =Adenocarcinoma=, =carcinoma=, and =sarcoma= are rare diseases[106], still one should be on his guard as to their possibility. They are most apt to occur after forty. A rapid enlargement should be regarded with suspicion.

Simple Goiter

We employ the term simple goiter to designate chronic enlargement of the thyroid gland not due to inflammation, exophthalmic goiter, or malignancy, although the latter conditions are frequently associated with or follow the former. There is usually an enlargement of the gland in cretinism, and occasionally in myxedema, but the functional grade of the gland is far different from that in other diseases of the thyroid.

The disease is very prevalent in certain regions of Europe and Asia, although in the United States it is not so common, except in the environs of the Great Lakes, the District of Columbia, and the Northwest states. The second decade of life, probably owing to adolescent changes, especially in girls, develop the greater number of goiters. It is infrequently congenital, and occasionally a case will develop as early as four or five years of age.

=Etiology.=—Disturbed innervation of the gland unquestionably seems to be the predisposing cause of the deranged secretion and vascular changes, which if continued finally lead to hypertrophy and hyperplasia of the tissues. These lesions are found from the fifth dorsal to the occiput and to the corresponding ribs. They probably involve secretory fibers of the sympathetic that emerge from the upper dorsals, first to fifth inclusive, maximum effect second, third and fourth. “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 ganglion.”[107]. In both these ganglia impulses to the thyroid pass from preganglionic fibers to the outlying neurones. This also includes the area of vasomotor[108] innervation of the head and neck.

In a number of cases cervical lesions alone will disturb the thyroid innervation, especially from the second to fourth segments. These may involve the superior cervical sympathetic, owing to its relationship to the rectus capitis anticus major muscle. Then there are afferent association fibers that pass down through the lateral horns and whose connecting fibers emerge via the upper dorsal.

The lymphatic drainage of the thyroid should not be neglected. Lesions of the upper ribs and clavicles are very prone to impede its circulation, and thus predispose to secondary infections.

Infection from septic foci are important secondary factors. This is particularly true of focal infections of the upper respiratory tract and buccal cavity, although infections and toxins from various regions may be exciting factors. Toxemia due to intestinal stasis is not rarely an important consideration.

McCarrison insists that infection from certain waters is the cause of goiter. He finds that boiling the water renders it harmless.

=Pathologically=, the first effect upon the gland is to lessen its iodine content. The circulation is increased, with hyperplasia of the epithelial tissue, and a lessened amount of colloid material. If the condition continues, the alveoli will again become distended with the colloid material so that the epithelial tissue cells are almost flattened. This represents the so-termed =colloid goiter=. The gland, commonly the whole organ, though one side may be involved, is fairly uniform in size. In rare instances, the gland may surround the trachea—the so-termed circular goiter. Hemorrhages may occur, and there may be various alterations and degenerations. When the vessels are much dilated, it is often called a vascular goiter, though the colloid changes are present.

The =nodular goiter= is another form characterized by new formation of gland tissue that is not diffuse but circumscribed. These cases are apt to follow persistent involvement of the gland at puberty. The two forms may occur together, and there may be various combinations and changes. In the nodular goiter there is comparatively little colloid. There are many blood-vessels, and small hemorrhages are frequent. This latter point should be remembered by those who treat over the gland, which at best is a doubtful procedure. Various changes may take place, as local points of =necrosis=, =cystic= formation, and =calcification=, are not uncommon.

=Symptoms.=—The essential feature in goiter is distension of the alveoli and formation of new ones, associated with dilated vessels, and usually degeneration of the colloid. Often the function of the gland is not noticeably disturbed. Usually, it is for the pressure symptoms or the unsightliness, due to the distension, that the patient seeks relief. Pressure upon the windpipe, gullet, or blood-vessels is not rare, and may cause more or less difficulty in breathing or swallowing. Coughing and huskiness may be troublesome. The recurrent nerves and vagus may be compressed. Disturbance of the heart, such as palpitation, tachycardia, and hypertrophy may be caused by the effect of pressure upon the blood-vessels, or to changes in the secretory function of the gland.

=Treatment.=—Adjustment of the upper dorsal and cervical lesions will be followed by recovery in the majority of cases. Dr. Still emphasized the point that the vertebral ends of the first ribs are frequently displaced upward and outward. This lesion is often found in cases following confinement. The effect of the change here is probably to the stellate ganglion, or to the lymphatic drainage of the gland. Treatment over the gland should be cautiously given, if at all. Definite correction of the lesioned vertebræ and ribs will be sufficient, but muscular manipulation and halfway measures are practically useless.

Lesions of the lower spine may be the primary source of a compensatory lesion of the upper dorsal, or they may derange the pelvic organs, or be the predisposing factor of intestinal stasis. Attention to possible focal infections, and thorough elimination, are to be considered. In goitrous regions boiling the water is of value. In obstinate cases the X-ray may be of service, and as a final resort surgery may be employed.

“Marine observed that the amount of iodine is inversely proportional to the degree of hyperplasia of the gland, and when the hyperplastic condition becomes fully developed, scarcely a trace of iodine is contained in the gland. Later, when the hyperplasia gives place to colloid goiter, the iodine increases again, both absolutely and relatively. Moreover, it has been found that if iodine be administered to an animal suffering from hyperplasia, the hyperplastic condition very quickly disappears and the animal becomes normal.”[109]. His viewpoint of the hyperplasia is that an effort is being made to compensate for an “insufficiency due to inability to absorb or assimilate sufficient iodine”, and thus the effect of the administered iodine is to normalize the gland by stimulation.

No one can question that this may be effective under certain conditions, particularly where there is deficient iodide in the water, but it is an essential element of the body. 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 economy. It may be somewhat parallel to giving iron in anemia, when often the real difficulty is one of assimilation, and not insufficient iron in the alimentary canal. Moreover, case after case of goiter has recovered through osteopathic measures following a most thorough trial of the iodine treatment. It is very obvious that the cause of the goiter rested elsewhere. Dogs are susceptible to thyroid enlargement. Lesioning of the cervical region has resulted in goiter formation, and recovery has followed adjustment of the lesion. And dogs having goiter without experimental lesions have frequently been normalized by adjusting an abnormal cervical spine.

Exophthalmic Goiter

In exophthalmic goiter there is an excess of the thyroid secretion or thyroid autacoid which passes into the circulation, due to hypertrophy or hyperplasia of the secreting cells. The disease is characterized clinically by nervousness and irritability, rapid pulse, flushed and moist skin, tremor, and increased nitrogenous metabolism. A goiter is usually present, but not always noticeable. There is apt to be protrusion of the eyes, especially after the disorder is established, though it may never appear. A disturbed coordination of the muscles of the eyelid, eyeball, and orbit are frequent characteristic symptoms.

=Etiology.=—The essential factor in the cause of this disease is probably osteopathic lesions that irritate the secretory fibers of the thyroid tissue. These lesions are almost invariably found in the upper dorsal, first to fifth, and most often localized at the second-third or third-fourth segments. They are definite interosseous changes, combined rotation and lateral flexion, and are generally very sensitive upon palpation. The constant stimulus thus produced passes through the sympathetic fibers to the cervical ganglia, and thence to thyroid secreting tissue, which through vascular changes and hypertrophy and hyperplasia increases the output of the thyroid hormone.

The sensitiveness of the lesions is probably of more than passing interest. For this actual tenderness is not to be confused with a neurasthenic state, which may be associated with the disease, or even be a source of confusion in the diagnosis. The lesion is of such a distinct character that there is considerable local irritation and congestion. This constant stimulus is a cause of the increased number of impulses carried to the sympathetic, and results in not only an excess of thyroid secretion and the concomitant hypertrophic changes, but also in the rapid removal of the colloid into the circulating blood. This seems to be a very important link in the pathologic chain.

Other underlying lesions may be present, as outlined under simple goiter, and do not require repetition here.

The mechanism of the thyroid gland may be further upset or deranged by various exciting causes, such as focal infections, toxic states, intestinal stasis, and occasionally an enlarged thymus is an important factor. An inherited neuropathic tendency, excessive strain, worry, and mental shocks may have more or less influence in either predisposing or exciting the disorder.

The particular points for the practitioner to remember are that exophthalmic goiter is due to a toxic state, of which there are many gradations, from the excessive secretion of the thyroid gland; that the normal resistance of the gland is lowered through definite lesions of its innervation or circulatory channels, or occasionally of lesions of the other organs of internal secretion which are closely associated; that infections and toxins are often important considerations; and that direct manipulation of the organ may increase the disorder.

=Pathology.=—The enlargement of the thyroid gland is commonly an early symptom, occurring before the nervous, cardiac and exophthalmic manifestations. There are instances where it follows a simple goiter, although Graves’ disease does not seem to be any more prevalent in regions where simple goiter is endemic than elsewhere. In these particular instances intestinal toxemia is often present. There are cases where the gland is very slightly enlarged, containing only small areas of hyperplasia. There is usually very little colloid, though there may be marked exceptions. It should be emphasized that there are various degrees of changes found in the gland though fundamentally of the same order. The blood supply is extensive, and the veins especially are fragile. The alveoli are distorted, due to the increase of epithelial cells. Lymphoid nodules are frequently noted through the glandular tissue.

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 Clinic. An examination of cervical sympathetic ganglia removed at operation from such cases and certain animal experimentation has given definite results. The following is a summary of their principal findings:

“Degree of hyperpigmentation, granular degeneration, and reduction in the number of cells was in direct ratio to the continuance of symptoms of hyperthyroidism. 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 continued.

“Increase of connective tissue in the ganglia from the chronic cases may be interpreted as due to the irritation from inflammation, or as merely a replacement following the destruction of the ganglionic nerve cells.

“Ganglia were intimately connected by firm adhesions to the surrounding tissue.

“There were changes in the outer and middle coats of vessels, and in the nerve fibers. There was an increase of connective tissue throughout the ganglion.

“It appears that definite histologic changes do occur as (a) hyper-chromatization, (b) hyperpigmentation, (c) chromatolysis, and (d) atrophy, or (e) granular degeneration of the nerve cells. All of these are but successive steps in degeneration which, if uninterrupted, proceed to complete destruction of the ganglion cells affected. 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 conditions. There is some evidence that in ganglia from cases clinically improved some of the cells have partially or wholly recovered.”[110] They are inclined to the view that local infection in the cervical sympathetic ganglia plays an important part in the etiology.

The above pathologic changes of nerve fibers and ganglia support in many ways the findings noted at the A. T. Still Research Institute, not alone in the cervical region but in other regions of the body, that is, they are changes common to interosseous lesion pathology of various areas of the spine, and thus are predisposing factors that establish lowered resistance of tissue and derangement of function.

An important feature of the pathology is hyperplasia of the thymus. Simmonds finds it enlarged in three out of four cases. MacCallum[111] has found it enlarged in all autopsies that he has seen. The lymphoid structures of the spleen, liver, kidneys, intestines, and bone marrow is increased, while the lymphatic glands of various regions of the body may be enlarged, especially the cervical, bronchial, and axillary. This is probably due to a toxic condition.

Dilatation and hypertrophy of the heart is common, and in advanced cases myocardial degeneration is apt to take place.

=Symptoms.=—The outstanding feature of hyperthyroidism is the excessive secretion of the gland. The symptoms seem to be largely dependent upon the amount thrown into the blood stream; still there is a possibility that there may be a certain perversion of the secretion, though if such exists it has not been discovered. It should be kept in view that in certain instances where the secreting activity of the gland has been markedly curtailed, by surgical means, for instance, even to hypo-functioning there may still exist some of the symptoms of exophthalmic goiter, which goes to show that other factors may be of decided importance. The thymus and other related organs, as well as the sympathetic nerves, are not to be neglected.

Kendall and Plummer (Mayo Clinic) “believe that the location of the active constituent of the thyroid, when it functions, is within the cells not of any particular set of organs or portion of the body, but that it is a constituent of cellular life and activity. Plummer states that the active constituent of the thyroid determines the rate at which any particular cell can produce energy, that is, it establishes the quantum energy which any cell can produce when it is stimulated, either from within itself or from without, so that the thyroid is directly related to the production of energy within the body. 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 150 pounds.” This shows how important the secretion is not only to all related glands but to every cell of the body, and assists in establishing a physiological basis in the correlation of the symptoms of both hyper- and hypo-functioning of the organ.

As a rule the =thyroid= is not greatly =enlarged=. The size, shape, and consistency varies. It may follow a simple goiter. Many of them are soft and yielding, or cystic; others are hard, of a fibrous resistance, or nodular. Probably in the instances where hypertrophy is not discoverable there is hyperplastic tissue scattered through the gland. Or it is possible there may be an intrathoracic thyroid, or =accessory= tissue in other regions, varying from the root of the tongue to the aortic arch, which has become diseased. Generally, both lobes are enlarged, though the derangement may be confined to a portion. Often there is pulsation and a thrill over the gland. Systolic murmurs are frequent. In the early stage of goiter, tenderness is noticeable due to the distension of the capsule.

The =eye symptoms= are: widened palpebral fissure or Dalrymple’s sign; failure of the upper lid to follow the downward movement of the eyeball or V. Graefe’s sign; insufficiency of convergence of the two eyes or Moebius’ sign; exophthalmos, which may be unilateral (in about seventy five percent of the cases); and rareness of involuntary winking, are the principal eye signs.

=Rapid heart= action is an early and important symptom. This is given by all observers as the most constant of all symptoms. Palpitation is often disturbing. The pulse is forcible, especially in the vessels of the neck. There is generally a low blood pressure. The heart is apt to be dilated, and in chronic cases hypertrophy and degeneration are often found.

A =fine tremor=, eight to ten times a second, is an important symptom. This is usually present and is considered one of the cardinal diagnostic points.

Profuse sweating, emaciation, muscular weakness, especially of the legs, vomiting, diarrhea, a feeling of dyspnea, and polyuria are frequent symptoms. Anxiety, apprehension, headache, irritability, and fatigue are often early symptoms, but care should be taken that they are not entirely dependent upon a neurasthenic state.

Pruritus may be a distressing symptom. There may be abnormal pigmentation. Menstrual derangements are common, especially amenorrhea, owing to the anemia. And there may be various sexual disturbances. Exophthalmic goiter occurs oftener in women than in men.

The disease is commonly a chronic one lasting several years, unless the morbid cycle can be broken; still there are cases where it appears very suddenly and runs a rapid course.

McCarrison[112] says: “Our consideration of the morbid changes met with in Graves’ disease will have brought into prominence the fact that they are indicative of toxic action. The lymphocytosis, the lymphatic hyperplasia, the lymphocytic infiltration of the thyroid, the liver and other organs; the chronic toxic inflammatory changes in the thyroid, liver and pancreas; the changes in the muscles, in the nervous system and in the adrenals; all these point to a condition of chronic irritation as the underlying factor in their production, and to the gastro-intestinal tract as the most common source of the toxic irritant.”

=Diagnosis.=—The diagnosis as a rule is not difficult. Difficulty may arise where there is incomplete development of the disorder. Irritation of the sympathetic nerves is of the greatest significance, for the characteristic symptoms are dependent upon this condition. Neurasthenia, hysteria, paralysis agitans, and tobacco poisoning and alcoholism may mislead one. The enlarged and active gland, with murmur in the majority of cases, loss of weight, excessive sweating, diarrhea, tremor, and tachycardia, even without the eye symptoms, are specially significant. The tenderness of the osteopathic lesions is very often noticeable.

=Prognosis.=—A great deal depends upon the cooperation of the patient. Rest and diet are such important features of the treatment, that if the patient is not willing to follow instructions, great difficulty will be encountered in securing satisfactory results. Adjustment of the lesions and elimination of toxins are highly essential, but only in a certain number of cases will this suffice. This, however, will usually lessen the severity of the condition, and the patient gets along fairly well, but this may be far from securing the possible maximum results. The duration of the disease is often from five to twenty years, or even longer. And the patient frequently dies from some intercurrent disease, particularly pneumonia and tuberculosis. Weakness of the heart is the most important cause of death. Severe vomiting and diarrhea may so exhaust the patient that a fatal termination takes place. Surgical interference should not be too long delayed if there is no indication of improvement by other means.

=Treatment.=—Every case requires individual study, owing to the many possible exciting causes, especially those where infections and toxins play so important a role. The four cardinal features of treatment are: adjustment of the osteopathic lesions, rest, diet, and elimination of infectious and metabolic poisons.

=Specific adjustment= of the upper dorsal spine is primarily essential. The work should be definitely and quickly accomplished. Soft tissue manipulations amount to but little except as a preparation for the interosseous adjustment. Do not tire the patient. Often, following exact adjustment a definite lessening of the severe symptoms will be noticed. The activity of the thyroid will be appreciably decreased; the heart’s action slowed; the eye symptoms less noticeable; the tremor lessened; and the strength of the patient improved. Do not treat too often. Once a week is far better than every day. But usually twice a week in the majority of cases will secure the best results. Then later once in two weeks will be the best course to pursue. The tissues are irritable, and require time to establish a physiological balance, that if kept constantly excited by too frequent or too severe manipulation will increase rather than lessen the condition. This, however, does not apply to those cases where a certain amount of general treatment is demanded to improve systemic tone and overcome intestinal stasis, but even here do not unduly tire the patient, and keep away from the thyroid innervation except at stated intervals. There is nothing more important in osteopathic therapy, except definite adjustment, than not over-treating.

The cervical region should be normalized, and the upper ribs and clavicles carefully adjusted. But leave the gland alone, for manipulation over it further stimulates its function and there is a possibility of rupturing its fragile vessels. Normalization of the entire spine is important, owing to its bearing upon interdependent relationship, mechanically and physiologically, and the necessity of correcting all metabolic irregularities.

Both =physical= and =mental rest= are essential. This tends to lessen the excitability of the nerves, conserves the strength, increases the metabolism, improves muscle tone, and rests the heart. At least several extra hours in bed is always best. Lying down two or three hours during the middle of the day will accomplish considerable. In severe cases absolute rest in bed until the disorder is under control is imperative. In mild and moderate cases all excessive fatigue should be avoided. Unless such measures are followed the treatment otherwise may not accomplish anything. Stopping short of fatigue is the rule that must be followed.

The =diet= is important in order that the strength may be increased and harmful foods eliminated. If the carbohydrates in the small intestine are not sufficient, they may decompose into toxic substances that are harmful when absorbed into the circulation. An abundance of green vegetables and fresh fruit is best. Milk, fermented milk, butter milk, butter and cream are allowable. The patient should drink freely of water. Meat should be used sparingly, and avoid tea, coffee, and condiments.

Free elimination and fresh air are also important. It is the aggregate of details that counts so much, particularly in such a toxic and excitable disease as exophthalmic goiter. The neutral bath (95 to 96 degrees) is better than either hot or cold baths. In such a nervous disease as this, suggestion is unquestionably a valuable measure in quieting the nerves and improving the mental viewpoint.

All focal =infections=, such as often found in the throat, nose, and buccal cavity, in the appendix region, gall-bladder, etc., should be eradicated.

If under carefully controlled treatment the patient does not definitely respond within from two weeks to a month, surgical measures should be seriously considered.

Myxedema

Myxedema is a chronic disease due to loss of thyroid function, and characterized by markedly decreased metabolism, trophic disturbances of the skin and subcutaneous tissues, and a cessation of mental development corresponding to the time of the injury of the thyroid.

McCarrison restricts the term “cretinism” to those cases where there is congenital thyroid deficiency. “After the first year of life, when ossification has proceeded to the extent of closure of the fontanelles, the case is only distinguishable from one of cretinism by this fact.” In the =child=, all the functions are depressed, there is a low temperature, the bones do not develop, and the child may become stout. The mental development is retarded, and also the sex organs.

In the =adult= cases there is the same depressed metabolism. The skin is sallow, dry, and increased in thickness. The tongue is enlarged, the lips thick, and the feet and hands considerably changed in size. The nails may be thickened, and the hair falls out. The abdomen is apt to be pendulous. Heavy pads occur below the clavicles and on the chest, neck, abdomen, and sexual organs. Usually the thyroid cannot be palpated. In a few, the gland may be goitrous.

The =mental= faculties are sluggish. The speech is slow, and the voice more or less changed. Physical exertion is an effort, and the patient may have some difficulty in walking. And there is anemia, loss of appetite, and poor digestion. The number and character of symptoms are innumerable, depending upon the extent of thyroid insufficiency, and often upon predisposing and associated disorders. But the essential symptoms are those pertaining to the skin, and the mental apathy. In children the retarded physical and mental growth is the outstanding condition. Development of the disorder is slow.

=Etiology.=—Lesions of the thyroid innervation may cause a lessened function of the gland, for correction of the lesions has been followed by markedly definite improvement in a number of cases. The disorder has followed operation on the gland. In other cases some form of infection, primary or secondary, is probably the cause of the injury and subsequent atrophy. In some instances there is evidently a family tendency. It occurs more frequently in women, and in cold than in hot climates. The menopause seems to be a predisposing factor. Overwork, anxiety, poor nutrition, and conditions that lower tissue resistance, are among the etiological considerations.

In well marked cases the =diagnosis= is easy. In others the disease may be mistaken for nephritis or jaundice. X-ray examination of the ossification centers is of decided value. The =prognosis=, in untreated cases, is considered hopeless, the duration being from four to seven years. The treatment with thyroid extract, or alpha-iodine, has resulted in marked improvement, though in severe cases it must be kept up continuously in order to supply the deficiency.

=Treatment.=—There have been several well marked cases that have responded to the osteopathic treatment. Adjustment of the lesions affecting the gland, and attention to the general health have been the methods administered. The response in a number of children has been most notable. In fact, to such an extent that all faculties and functions were completely recovered. Even in cases where thyroid extract had been administered with comparatively little results, the adjustment of the upper dorsal and cervical lesions, with attention to the diet, elimination, and general hygiene, was followed by normalization.

That the thyroid function when deranged, hyperthyroidism, hypothyroidism, or otherwise, can often be recovered through osteopathic treatment, adds a very important therapeutic measure in the treatment of this gland. But in view of the brilliant results secured in hypothyroidism, through the administration of the thyroid extract, one should not hesitate to use it if improvement is not otherwise forthcoming. Nevertheless, the very important point remains that thyroid extract is only supplying a necessary substance, however essential, to the bodily metabolism, and does not strike at the essential etiology of the disorder.

Cretinism

It should be kept in mind that there are many gradations and alterations in both hyperthyroidism and hypothyroidism, and that a “goiter” may present either picture, partly or wholly, or on the other hand may be normally functioning.

MacCallum says: “Unlike the myxedema cases which occur anywhere and everywhere, regardless of environment or hereditary taint, these people, known as cretins, are found in regions where the condition seems to be endemic or inherent in the environment, and we can usually trace in their parents or ancestors some similar thyroid defect.”

This disease is found in various countries, particularly in certain parts of Switzerland, Austria, and Italy. McCarrison presents an interesting study of 203 cases of Endemic Cretinism found in Himalayan India. He thinks it is due to infection. There are a few cases in North America, probably mostly due to immigration. It is frequently confused with myxedema.

Cretins are of short stature, flat-chested and pot-bellied. The face is broad, low forehead, broad nose, prominent cheeks, thick lips, and large nose. The development of the bones is retarded; the skin is thickened and edematous; the hair is thin, and the nails brittle; the sexual organs as a rule do not develop; and in most cases a goiter, sometimes of huge size, is present. Most of them are stupid and apathetic; others are distinct idiots. Deafness is common.

There are sporadic and endemic cases, but the same underlying cause is probably present. It is claimed that most cases of the former should be classed as congenital myxedema.

Early diagnosis is essential. Removal of the patient from the goiter region, and thyroid substance is the treatment given, though results are not so marked as in myxedema.

FOOTNOTES:

[106] Ewing, Neoplastic Diseases; Grotti, Thyroid and Thymus.

[107] Cannon and Cattell, The Secretory ennervation of the Thyroid Gland, Am. Journal of Physiology, July, 1916.

[108] Gaskell, Involuntary Nervous System.

[109] Macleod, Physiology and Biochemistry in Modern Medicine.

[110] Collected Papers of the Mayo Clinic, 1916, ’17, ’18.

[111] MacCallum, A Text Book of Pathology.

[112] McCarrison, The Thyroid Gland.

DISEASES OF THE PARATHYROID GLANDS

Tetany

The clinical manifestations of the insufficiency of function of the parathyroid glands is well understood. This came about through the study of endemic tetany, and, especially, noting that tetany followed operations when the entire thyroid gland was removed. Considerable experimental work on animals was next in order, until the discovery was made that the thyroid gland and parathyroids are anatomically independent, and that tetany is entirely dependent upon the loss of function of the parathyroid glands. =Operative tetany= is now comparatively rare, since the surgeon is particularly careful not to injure the parathyroids in his operations on goiters, though mild forms may occur through damage of the tissues or extension of inflammatory processes.

There are =other forms= of tetany aside from operative, that occur in both adults and children, but instability and insufficiency of the function of the glands are basic to all cases. This is the common factor, which may be modified by tissue resistance and various hygienic factors.

In tetany there are paroxysmal, and often painful, contractions of the muscles of the extremities. Both sides are affected, and occasionally the spasms may extend to other muscles of the body. This is due to an abnormal excitability of the nervous system. Probably the secretion of the parathyroids have normally a restraining effect upon the nervous impulses, which when removed, or insufficient, or possibly perverted, results in the tonic spasms.

Thus the =predisposing condition= of tetany may be either =acquired= or =congenital=. Children may be born with defective parathyroids. In such instances there is probably a hypoplasia of tissue, which may markedly vary in a series of cases, and give rise to different degrees of tetany. Other factors, nutritional and toxic, would, very likely, be important exciting causes. Hemorrhages and fibrosis have been noted in some cases, that add to the injury of the tissues.

The blood and nerve tissues in tetany show a decreased amount of =calcium=. It is claimed by some that the abnormal excitability of the nervous system is due to the lack of calcium. Noel Paton[113] believes that, though this may bear some relationship, the parathyroids control the metabolism of =guanidine=, and that guanidine intoxication is the cause of the symptoms. Guanidine seems to regulate the tone of the skeletal muscles, and is closely related to urea.

Tetany may occur under many conditions: during pregnancy and nursing, the infectious and nutritional diseases, the diseases of the thyroid and very often gastro-intestinal disorders. There are various exciting causes, such as cold, worry, overfatigue, etc. Alcohol, ergot, morphine, chloroform, and other poisoning may precipitate an attack. But in all these cases the parathyroids are previously damaged.

The blood supply to the glands is from branches supplying the thyroid organ. This intimacy implies that the same sympathetic nerves to the thyroid vessels are in control. Probably there are distinct secretory nerves, as well as vasomotors, that are connected with the upper dorsal and cervical sympathetics. =Lesions= related to the corresponding spinal areas probably affect the integrity of the parathyroid function.

Schafer says: “The parathyroids are amongst the most vascular organs in the body. They are supplied each by a special branch of the inferior thyroid artery. The sinus-like capillaries come into close relationship with the epithelial cells of the gland. The nerves of the parathyroids, like those of the thyroids, pass both to the vessels and to the secreting cells. Some evidence has been adduced which seems to show that the cell-activity is controlled by the nervous system.”

Hence it would seem that in many cases of tetany, aside from those cases due to operative injury and possibly certain congenital instances, =osteopathic lesions= affecting the nerve and vascular supply of the organs may so lessen, or pervert, the secreting cells that tetanic states may supervene, especially where lowered nutrition, toxins, and infections are inciting factors.

=Symptoms.=—The tonic contraction of the muscles may last a few minutes or may persist for several hours, and are usually confined to the hands and feet. The fingers and toes are first affected by the spasm, which extends upward toward elbows and knees. This is commonly preceded by numbness and more or less pain in the parts. Occasionally there is a general ill-feeling, depression, and headache. There may be rise of temperature, and some edema of the affected parts. There are no mental symptoms.

The fingers are partly flexed at the metacarpo-phalangeal joints and rigidly extended at the inter-phalangeal joints, the thumb is markedly adducted and the fingers drawn close together. The wrist may be flexed, and in severe cases the elbows flexed and adducted. When the feet are contracted the toes are drawn together, flexed, and may overlap, and the feet are arched.

=Trousseau’s phenomenon.=—The spasm is increased by pressure over the median or ulnar nerves, or blood-vessels supplying the parts. This may also excite an attack. =Chvostek’s phenomenon.=—Percussion over the facial nerve will cause quick contraction of the muscles innervated. =Erb’s phenomenon.=—The electrical excitability of the motor nerves is markedly increased.

=Diagnosis.=—The characteristic attitude, and the irritability of the motor and sensory nerves, make diagnosis easy. It may be confused with =meningitis=, but in tetany there are no brain symptoms, while in meningitis there are no characteristic signs of tetany. Generally, there is little probability of confusing the disease with =tetanus=, or =hysteria=.

=Treatment.=—Most cases are of a mild type, and recovery is the rule. A great deal depends upon the underlying cause. Malnutrition, if long continued, is a very important factor that may readily predispose to the disorder. Rickets in children is often a basic consideration.

Rest, warm baths, and careful inhibitory relaxation of the tissues materially assist in controlling the spasms. Attention to the thyroid innervation should not be neglected. In indicated cases thyroid feeding may be of assistance. The diet is of special importance, for many cases present some disorder of the gastro-intestinal tract. Meat should not be given. Milk is of great value, owing to its calcium content. The administration of calcium is highly recommended, for reasons stated under etiology.

Diseases of the Thymus

There is little known relative to the functions of the thymus. It is most active during the growth of the body, attaining its greatest weight from the eleventh to fifteenth years, after which it gradually atrophies, though a certain amount of the tissue remains throughout life. There is usually a gradual atrophy of the organ after puberty, associated with increase of connective and adipose tissues. In cases where it does not atrophy, there is often hyperplasia of the entire lymphatic system in the body.

There is some relationship between the thymus and sexual organs, and in experiments where the organ has been removed, ossification is delayed, muscular weakness and tremor occur, there is hyperplasia of the thyroid, parathyroids, and adrenals, and general cachexia, acidosis, and mental deterioration take place.

The inferior thyroid and internal mammary arteries from above, and the pericardiophrenic from below, comprise its arterial supply. The nerve supply is from the sympathetic, vagus, and possibly the phrenic. In cases of exophthalmic goiter there is frequently an associated enlargement of the thymus, which may be shown by the X-ray, due to failure of normal involution or a renewal of growth, that may be definitely influenced by adjustment of the osteopathic lesions.

In some of the acute infections as pneumonia the thymus may atrophy with some fatty degeneration and increase of connective tissue. This also occurs in starvation. If the condition is not of long standing recovery will take place.

In =status lymphaticus= there is hyperplasia of the thymus and enlargement of the lymphoid tissue of the body, and hypoplasia of the cardiovascular system. This is a constitutional defect, so that slight injuries or infections may prove fatal. It is found in some cases that there is hypoplasia of the chromaffin system. Whether this latter condition is primary or secondary has not been settled.

In males the secondary sexual characteristics are not fully developed. The figure resembles the feminine type. The skin is pasty, and the beard is lacking or but little developed. In females the distribution of the hair may be somewhat similar to the male sex, slender limbs and chest, and disturbances of the menstrual function are noticeable.

The thyroid, thymus and lymphatic tissues are usually enlarged, while there is hypoplasia of the adrenals and chromaffin system.

The condition is met with in children who have a weak muscular system, increased adipose tissue, pasty complexion, enlarged tonsils and adenoids, and frequently are anemic. In children where the thymus is enlarged there may be excessive lymphocytosis.

The enlarged thymus may compress the trachea, interfering with breathing so that cyanosis and temporary loss of consciousness occur. Young children may die in the attack, probably due to compression of the trachea or to heart shock. Death in adults has occurred from trifling injuries, shocks, infections, and anesthesia. The underlying cause is probably a constitutional weakness.

=Diagnosis= is made from the clinical signs, percussion of the thymus and the X-ray picture, although these may not be positive. An excessive lymphocytosis is suggestive.

=Treatment= should consist of good general care of the patient, avoidance of injuries and shocks as far as possible, and careful attention to all lesions, especially of the upper chest and neck. By following this plan the child may overcome the condition. X-ray treatment is being employed with success in some cases. Operations have been successful in thymic hyperplasia where it has complicated exophthalmic goiter, and also in serious mechanical pressure in children.

Diseases of the Adrenal Glands

Experimental work supports the view that the cortex and the medulla have separate functions. The =medulla= of the adrenals is part of the chromaffin system, which includes tissue of the same character in the ganglia of the sympathetic, the carotid gland, and the accessory gland called Zuckerkand’s organ. This system is derived from the same cells as the sympathetic nerves. The medulla receives a richer blood supply than any tissue in the body. The secretion of the chromaffin tissue is called adrenalin or epinephrin. The blood receives a continuous supply of the secretion, which acts upon the small blood-vessels and assists in maintaining blood pressure. It also stimulates glandular tissue, and has some effect upon voluntary muscle which tends to counteract fatigue.

The =cortex= of the adrenal glands is of epithelial origin, and is part of the so-called interrenal system, which comprises very small masses of tissue in the sympathetic ganglia. These are located in the hilus of the kidney, broad ligament, inguinal canal, prostate, epididymis, and along the spermatic veins (Baker). The cortex is the chief glandular tissue of the interrenal system. The amount of tissue is not so great after puberty as before. The blood supply of the cortex is not so rich as that of the medulla. Abnormal activity is claimed to be the cause of certain sexual derangements, particularly sexual precocity.

Schafer states that the adrenals are very richly supplied with nerves. Each receives no less than thirty-three nervous filaments (Kolliker), derived in part directly from the splanchnic, in part from the suprarenal plexus, which is itself constituted by branches from the celiac, phrenic, and renal plexuses.

We have noted that in lesions (experimental) of the splanchnics a few cases presented acute pathological changes, congestion with some degeneration of cells, in the adrenals.

Macleod states that of the many functions of the adrenals that which is most directly associated with epinephrin is the production of glucose from glycogen. “When the nervous system is stimulated in such a way as to excite the glycogenolytic process, two effects both operating in the same direction with regard to the glycogenic function are developed: the one, a hypersecretion of epinephrin, which activates the sympathetic nerve endings, the other, the transmission of the nerve impulse to the liver cell.”

Addison’s Disease

This is a rare, chronic disease, more often occurring in men, that is characterized by muscular and vascular weakness, digestive disturbances, and pigmentation. Tuberculosis of the adrenals has been the most constant lesion found. In others, syphilis and atrophy have been noted, while in a few the condition seemed to be functional. It should be remembered that it is possible that lesions elsewhere in the chromaffin system may be the cause in some cases, for all the chromaffin tissues secrete adrenalin.

It is quite likely that in most cases there is some constitutional defect of the chromaffin system which underlies a certain tendency to the disorder. Infections, injuries, physical and mental strains may lower resistance and predispose to the condition.

Osteopathic lesions of the splanchnics may congest the organs, or derange the secretions, or be of such a character that hemorrhages result, or fibrous changes follow, that would definitely incapacitate the cells and lower resistance.

=Pathologically=, the most common change is tuberculosis. Next in importance are atrophy and interstitial inflammation. Cancer of the organs has been noted in a few. The adrenal ganglia, the semilunar ganglia, and the solar plexus are often involved. The thyroid gland may be altered, which, when affected, is usually decreased in size. Brown atrophy of the heart is common.

=Symptoms.=—An insidious onset with muscular weakness, languor, and weak action of the heart are generally the first symptoms. Digestive derangements, such as nausea, hyperacidity, loss of appetite, may occur at the same time, or shortly succeed the general debility. Headache, insomnia, and depression frequently take place. Pigmentation, usually, shortly follows, though there are cases where it is only slightly noted. The disease is very chronic, of several years duration, with periods of intermission. Occasionally, a case runs a very rapid course.

The general weakness is most noticeable. There is low blood pressure. The derangement of the stomach and intestines is characteristic. And the pigmentation, which at first is light yellow later assumes a dark brown color. The pigmentation may be more or less general, but the axillæ, nipples, genitals, the palms of the hands, and the neck, waist or wherever the clothing presses upon the skin, are most pigmented. And pigmentation of the mucous membrane may be noted.

=Diagnosis.=—In typical cases, where there is esthenia, pigmentation, and gastro-intestinal disturbances, the diagnosis is not difficult. Where the clinical picture is incomplete, the diagnosis may be very difficult.

Pigmentation may occur in several other disorders, notably: in bronzed diabetes, abdominal malignancy, tuberculosis of the peritoneum, exophthalmic goiter, pellagra, marked intestinal stasis, stomach ulcer, pernicious anemia, certain skin diseases, etc., so great care has to be taken in atypical cases.

=Treatment.=—General treatment, with special attention to the adrenal innervation, diet, rest, and fresh air will accomplish something. In functional derangements, which are very few, recovery may follow. But owing to the often constitutional defect, the probability of tubercular, syphilitic, and other serious lesions, the prognosis is unfavorable.

FOOTNOTES:

[113] Paton and Finlay, Jour. Exp. Phys., 1917.

DISEASES OF THE NERVOUS SYSTEM

DISEASES OF THE NERVES

Neuritis

=Neuritis= is an inflammation of the nerve fibers. It may be confined to a single nerve, localized; or general, involving a large number of nerves, when it is known as multiple neuritis. Osteopathically, there are =invariably lesions= of the osseous or muscular tissues, that correspond to the nerve fibers involved. The lesion either irritates the nerve directly or disturbs the circulation to the nerve. In those cases where the osteopathic lesion is not the immediate exciting cause, there will be found anatomical irregularities that predispose to the affection.

=Localized neuritis= may be due to: Local osteopathic lesions; Exposure to cold; septic foci; traumatism; and inflammation of contiguous tissues.

=Multiple Neuritis= may be due to: Osteopathic lesions, which are associated with infectious diseases, as in diphtheria, typhoid, scarlet fever, etc.; prolonged strain or exposure; metabolic poisons, as in diabetes, anemia, tuberculosis, cancer, etc.; alcohol, lead, mercury and arsenic poisoning; and =beri-beri=, which is probably due to lack of vitamins, or possibly micro-organisms, or carbonic gas poisoning.

The inflammation may chiefly involve the connective tissue surrounding the nerve—perineuritis—or it may involve the deeper structure—interstitial neuritis. =Parenchymatous neuritis= is really a degeneration, due to excessive or prolonged irritation or pressure which cuts the nerves off from their centers. This is found in deeply seated osteopathic lesions. In experimental osteopathic lesions the first effect is degeneration of the medullary sheath. This is followed by degeneration of the axis cylinder. The local circulation is notably impaired. An acutely inflamed nerve is red and swollen. In =perineuritis= there is an infiltration of the nerve sheath with leucocytes. In the =interstitial form=, lymphoid cells are found between the nerve bundles. In the parenchymatous form, inflammatory signs are wanting. The muscles atrophy. Associated in all these forms the =osteopathic lesion= plays either an exciting or predisposing role, by disturbing nutrition to the tissue and thus setting up inflammation, which may lead to Wallerian degeneration[114].

=Symptoms.—Localized Neuritis.=—In the case of a sensory nerve, there is severe pain following the course of the affected nerve, with tenderness upon pressure. This may be followed by loss of sensibility. Trophic symptoms, such as glossiness of the skin and brittle nails, arise in more chronic cases, while in advanced cases, there is wasting of the muscles. Sweating, herpes, and occasionally effusion into the joints, occur. When a motor nerve is principally affected, muscular power is impaired, motion painful and muscular twitchings will occur. Finally contractions, wasting of the muscles, and even reactions of degeneration, may take place. A rare form is the so-called =ascending neuritis=, in which the inflammation extends upward from the peripheral nerves to the larger nerve trunks, or even the spinal cord, resulting in =myelitis=. This occurs most commonly in traumatic neuritis. The duration is variable. Many acute cases get well in a few days. Other cases may persist for months and even years.

=Multiple Neuritis.=—Inflammation involving several nerves which are affected simultaneously or in rapid succession. =Acute form.=—The attack usually follows overexertion or exposure to cold and wet, with probably some infection. This form is characterized by a chill, followed by a rapid rise in temperature which may reach 103 or 104 degrees F.; headache; pains in the back and limbs. There is weakness of the legs or arms, depending upon region involved, which may be so severe that the muscles atrophy. Sensory symptoms are variable. Most cases recover, though there are instances where the vagi, the nerves to the bladder, rectum, or heart, may be involved.

=Alcoholic Neuritis= results from a moderate amount of alcoholic drinking, continued over a long time. The first symptoms are usually numbness and tingling in the fingers and toes. Loss of power soon becomes marked, first in the lower, and then in the upper, extremities. The extensor muscles are most affected, causing wrist and foot drop. Occasionally there is paraplegia. There are hyperesthesia, tenderness and pain, especially in the legs. The cutaneous reflexes are commonly intact, and the deep reflexes, as a rule, are lost. Delirium is common, and hallucinations or illusions occur.

Neuritis from =lead poisoning= usually present the “wrist drop” and “foot drop”, with colic, and “blue line” on gums.

=Infectious Diseases= neuritis is due to an attack of some infectious disease, and may be local or multiple. It is due to toxic materials absorbed into the blood. It is most common after diphtheria. The symptoms presented are those of neuritis due to any other cause.

=Senile neuritis= is probably due to arteriosclerosis.

=Diagnosis.=—As a rule, the diagnosis is not difficult. In the alcoholic form in some instances, there may be difficulty, and in cases with paralysis, care should be taken. The =prognosis= of neuritis is generally favorable.

=Treatment.=—It is very evident that the successful treatment of neuritis depends upon being able to ascertain the cause. Rest is important in all cases. Rarely has one any difficulty in locating the deranged structures that are predisposing to the attack; and usually correction of these disturbances, which are in the region involved will give considerable relief. If the parts are too sensitive to handle insist on absolute rest and hot fomentations. The affected area should be kept warm and protected. Attention to the diet, and free elimination, are important. Metabolic disorders should be corrected, if possible. Give particular attention to any septic foci. A change of occupation may be necessary in some cases.

In alcoholic cases, the alcohol should be stopped as soon as possible. Passive movements and massage are helpful, but of course bear no comparison to specific osteopathic treatment. Relaxation of muscles along the spinal column and along the course of the nerve will at least give temporary relief.

If contractures and other changes remain after the acute attack, persistent treatment will generally result in recovery. (See also Painful Shoulders,