Chapter XX: Introduction (5)

The specific virus is the streptococcus erysipelatis, which acts as a local irritant producing the dermatitis. These are found in the lymph vessels and cutaneous connective tissue. The fever and constitutional symptoms are due to toxic agents.

It is an inflammation of the skin, and if uncomplicated, no other structures are involved. Subcutaneous and mucous tissues may be involved, but rarely; if so, there is apt to be suppuration. Visceral complications are of a septic character. Endocarditis, pericarditis, pleuritis-pneumonia, and nephritis are possible complications.

=Symptoms.=—The incubation period varies from two to seven days. The onset is generally sudden with chill, followed by fever, 104 or 105 degrees F. There may be nausea, headache, and pain in the back and limbs. The local inflammation of the skin follows, usually on cheeks and bridge of nose, or at site of an abraded surface. The area is red, smooth, and edematous. It spreads rapidly, the patch being elevated above the surrounding tissue and tense. The swelling may be so great as to close the eyes and distort the features. The cervical glands are swollen. The temperature continues high for four or five days and falls by crisis. The eruption begins to subside and a moderate desquamation occurs. If the disease takes a fresh start the fever again rises and continues as long as the disease spreads. There is usually headache and sometimes delirium. The tongue is furred, and bowels constipated and the urine scanty. As a result of intense infiltration the part may become gangrenous. Suppuration frequently occurs in facial erysipelas. The inflammation may extend to the mucous membrane of the throat and mouth.

=Diagnosis.=—This is not difficult. The fever, the acuteness of the disease, the rapidily spreading eruption, and the constitutional disturbances will serve to distinguish it from all others.

=Prognosis.=—This is usually favorable; healthy persons rarely die. Convalescence may be slow.

=Treatment.=—Isolate the patient for the disease is contagious, and a third person may convey the virus. The poison may cling to clothing, furniture, etc. The physician should not take care of confinement cases.

A number of cases of erysipelas have been cured by correcting disorders in the region of the second, third, fourth and fifth dorsals. The lesions are principally subluxations of the ribs and severely contracted muscles. The disorder at the points named interferes with the vasomotor nerves to the face, thus predisposing to an attack of erysipelas by allowing the micro-organism congenial tissue for its devastations. In many other cases derangements have been found higher than the upper dorsal, principally through the middle and upper cervical vertebræ. Lesions in these regions would also interfere with vasomotor fibres, especially through the fifth nerve directly.

The treatments on the whole are to examine for lesions to the innervation of the affected region and remove them, besides giving special attention to the bowels, a nutritious diet, and absolute rest. In cases where there is much restlessness and insomnia, treat the upper cervical region, especially the deep posterior muscles[57]. Locally, use cold water applications; adhesive strips applied near the inflamed area or tincture of iodine, may prevent the disease spreading.

Yellow Fever

=Definition.=—An acute, infectious disease, characterized by a febrile paroxysm followed by short remission and then relapse, jaundice, toxemia, suppression of the urine, and gastric hemorrhage.

=Osteopathic Etiology= and =Pathology=.—While a specific germ is the cause of yellow fever, it has not as yet been isolated. Extended tests by United States Army surgeons in Cuba show conclusively that the infection is alone carried by the _stegomyia fasciata_, but “It remains somewhat uncertain whether the mosquito is the sole means of transmission.” (Anders). Season is the chief predisposing cause as the outbreak is usually in summer and a frost ends its spread. Immunity is generally conferred by one attack. Tucker[58] noted that all cases examined had liver lesions and that most of the patients were of the malarial or bilious type. Spinal lesions were not marked in some cases, but when present were in the liver and renal areas. Tete[59] believes it to be a virus secreted in the human organism under certain atmospheric and other conditions in certain types, i. e. people subject to hepatic and renal disturbances. He also says the vagus is an important factor.

=Pathologically=, there is more or less jaundice and hemorrhagic extravasations under the skin. The blood serum is red-tinted, owing to the destruction of the red cells. The liver is pale and presents extensive fatty degeneration, with necrotic masses in and between the cells. The gastro-intestinal mucous membrane is swollen, congested and presents numerous minute hemorrhages. The kidneys show parenchymatous inflammation. The spleen is not enlarged. The heart sometimes shows fatty degeneration. The stomach contains more or less of the “black vomit,” which is a mixture of transuded serum and transformed blood pigment.

=Symptoms.=—The incubation period varies from one to five days. The attack generally begins with a chill, fever, 102 to 105 degrees, headache and pains in the loins and legs. The pulse is accelerated, the face is flushed, the tongue is coated, the throat sore, the bowels constipated and the urine scanty and albuminous. Recent observers state that bile is present in most cases before the albumin is noted. Nausea and vomiting may be present at the onset, but become more severe about the second or third day when the black vomit appears. The =febrile stage= or stage of invasion, lasts from a few hours to several days and is followed by a decline in the fever when the severity of the other symptoms abates. This is called the =stage of remission= and in favorable cases convalescence sets in or the patient may pass into the second febrile paroxysm. The temperature rises again, jaundice appears rapidly, nausea and vomiting return. The tongue becomes dry and coated. The stools are black and offensive, the urine is albuminous, scanty and may be suppressed; there may also be hematuria. Death may occur from exhaustion or from uremia. Recovery may follow the gravest symptoms, even when there has been black vomit. The duration of the entire attack covers about one week. Relapses sometimes occur.

Price says there is a point in differential diagnosis in yellow fever and it is a symptom not met with in any other febrile affection. It is the progressive fall of the pulse-rate during the congestive stage of the first sixty or seventy hours, i. e., a variation of from five to ten beats less each morning and evening. He adds, “As long as the kidneys are active there is but little to fear.”

=Diagnosis.=—=Remittent fever= has not the deep jaundice, the clear mind, the black vomit, or the albuminuria of yellow fever. The enlarged spleen and the presence of the organism of Laveran in the blood in remittent fever will decide the diagnosis. =Dengue= is sometimes confused with yellow fever.

=Prognosis.=—This is always a grave disease, and in its severe forms very fatal. Recovery, however, may occur after the severest symptoms have been manifested. Black vomit is not always a fatal sign. Enough cases have been treated osteopathically to state that osteopathy is particularly effective. Improved sanitation is doing much to reduce mortality.

=Treatment.=—Prophylactic treatment should be carefully carried out. All patients should be quarantined and carefully screened so they cannot be bitten by the mosquito and the disease spread further. People that are not acclimated should keep away from infected districts. All pools, cisterns and other places which can breed mosquitoes should be drained or screened. A systematic warfare should be waged against them. The patient must be put to bed at once and plentifully supplied with fresh air. Everything must be scrupulously clean—body and bed linen. Use a tube for nourishment and a bed-pan for excretions as the patient must not make the slightest exertion.

Spinal lesions may or may not be found. They have been observed in the cervical, eighth dorsal and second lumbar.

The treatment on the whole is symptomatic. The chills and fever of the first stage should be controlled by thorough work at the upper cervical, upper dorsal, lower dorsal and lower lumbar regions. Treatment at these points controls the superficial and deep vascular areas of the body through the vasomotor nerves. The irritable stomach, delirium and severe neuralgic pains of the head, back, epigastrium and limbs are to be treated according to the conditions and severity of the symptoms. The kidneys and bowels should be watched carefully, and at the onset should be freely opened and control of the kidneys never lost. Let the patient drink freely of water, which will aid. Hydrotherapeutic measures, as a cold bath or sponging, may be employed to aid in controlling the fever, the nervous symptoms, and the eliminative power of the excretory organs. Discontinue the use of hydrotherapy when a spontaneous fall of temperature occurs.

At the beginning of the first stage and during the stage of remission are the periods that the osteopath should do very effectual work by paying particular attention to the four large vascular areas of the body, viz.: head, lungs, abdomen and legs. Treat the vasomotor nerves to these regions, thoroughly, as given in the treatment of the first stage. During the third stage everything should be done that is possible to support the system. Ice slowly dissolved in the mouth will be of aid to an irritable stomach. Hemorrhages and the various symptoms are to be treated as they arise.

Good nursing, dieting, ventilation and keeping the skin, kidneys and bowels active are the primary points to consider. During the period of depression, the heart must be closely watched. The diet should be a light, liquid one, of the nature of peptonized milk or light broths. No food is recommended by some at the onset nor until the crisis is passed. Others feed during the stage of remission and give stimulants. During the last stage rectal feeding is suggested if gastric irritability is pronounced.

Tetanus

(LOCK-JAW)

=Definition.=—An infectious disease, caused by Nicolaier’s tetanus bacillus, characterized by persistent, tonic spasms of the muscles with violent exacerbations.

=Etiology= and =Pathology=.—The exciting cause of tetanus is a specific bacillus which usually gains access to the system through some wound. The site of infection is the only place the germs are found.

The disease is much more prevalent in some localities than in others. It is found in hot countries, as in India and the West Indies, far more commonly than in temperate regions. Exposure to damp cold is one of the recognized causes, also those localities where there are rapid changes from cold. Such regions seem to produce conditions favorable to the existence and growth of the bacilli.

Earth mould, particularly where putrefaction is taking place, as in soil that has been manured, is especially favorable to the existence of the bacillus. It is frequently found in the intestinal tract of the horse, so that the soil about stables is apt to contain the germs. The highly fertilized soil of France and Belgium rendered it a special menace to the wounded of the Great War. Antitetanic serum, according to all reports, was particularly efficacious.

Wounds and abrasions of various kinds, particularly contused and punctured wounds of the hands and feet, favor the excitation of tetanus. When an open wound is present, the term =traumatic tetanus= is given to the disease; =idiopathic tetanus= when no wound is discoverable; =tetanus neonatorum= when it attacks infants—this form is usually due to insanitary conditions, especially the improper care of the umbilical cord; =lock-jaw= or trismus when the jaw alone is affected; =cephalic tetanus= when the throat and face is involved.

Characteristic lesions have not been found in the cord or the brain. The bacilli develop at the site of the wound where the toxin is manufactured. The bacilli do not invade the blood and organs. The toxalbumin is one of the most virulent poisons known.

Congestion occurs in various organs, due to obstruction of the movement of the blood during a spasm. The brain, cord, lungs and muscles are congested. The nerves are often found swollen.

=Symptoms.=—The period of incubation is from one to twenty days. This is time required for the poison “to be absorbed by the end plates in the muscles and to pass up the motor nerves to the spinal cord.” In most cases the incubation is from five to ten days. A chill precedes other symptoms in a few cases. The onset is quite sudden, with stiffness in the neck, jaw and tongue. There are headache, stomach disturbance and languor. Opening the mouth is difficult, but is not painful. Deglutition is difficult. The stiffness increases and extends to the spinal muscles, abdomen and legs which are held in a firm spasm. Thus, the trunk and legs are inflexible.

These symptoms vary in degree of severity, dependent upon the extent of involvement. The jaws may be firmly locked or they may yield to forced extension—“lock-jaw.” The muscles of the face may be involved, the angle of the mouth drawn out, and the eyebrows raised—“risus sardonicus.” The neck and trunk muscles affected produce opisthotonos. Spasms of the pharynx and esophagus may occur, especially when there are injuries to the fifth nerve.

Associated with these tonic convulsions is intense pain. The distress of the patient is extreme when the chest muscles are affected. All symptoms are increased during the paroxysm. A foot fall, the slamming of a door, a draught of air or any slight sensory impression may excite a paroxysm. The paroxysm may relax and during the interval the patient may walk about. The spasms vary in frequency from a few minutes to one in several hours. During spontaneous or induced sleep the spasm usually ceases. The febrile reaction is generally slight and apparently of nervous origin; in many cases 102 degrees F. In severe cases the temperature may be considerably higher. Perspiration is excessive. The urine is scanty and high colored. The bowels are usually constipated. The mind remains clear throughout. Death is generally caused by exhaustion. =Chronic tetanus= presents similar symptoms, but less marked, and it develops slowly.

=Diagnosis.=—The history of a wound followed by the characteristic symptoms would rarely occasion an error. =Strychnine poisoning= differs from tetanus in the history, in the more rapid development of the symptoms, no trismus at the beginning, marked involvement of the extremities, and absence of rigidity between the paroxysms. In =tetany= the extremities are chiefly affected by the spasms, the muscles are relaxed during intervals, and trismus is a late or very rare condition. In =hydrophobia= trismus does not occur and the respiratory spasm is caused by attempts at swallowing. The mental symptoms increase.

=Prognosis.=—The prognosis is unfavorable. Eighty per cent of traumatic and fifty per cent of the idiopathic cases prove fatal. Cases that are fatal usually die within six days. Cases where there is slight elevation of temperature, and where the spasm is localized to the muscles of the face, neck and jaw, or where muscle stiffness is late in appearing, are more likely to recover.

=Treatment.=—Free incision and thorough disinfection with hydrogen peroxide and cauterization with pure carbolic acid, of the wound are necessary. The patient should be put in a dark room and there remain as quietly as possible. Avoid all sources of peripheral irritation. Liquid food is to be given, and if the jaws are firmly set, rectal feeding may be employed or food may be passed through the nose with a catheter.

For the spasms, strong inhibition of the nerve centers controlling the affected muscles may be of use. Probably the most effectual treatment for the paroxysms would be strong, thorough treatment of the upper cervical region. Hot baths give relief to the spasms. All the excretory organs should be greatly stimulated, particularly the kidneys, lungs and bowels. Other symptoms are to be treated as they arise. Tetanus antitoxin is highly commended by surgeons who used it during the Great War. As death is at a two to one ratio any method of treatment is justified. A few cases have been treated osteopathically with fair success, following antiseptic measures.

Simple Continued Fever

=Definition.=—An acute, febrile disease, mild in character, of short duration, not excited by any special organism and depending on a variety of irritating causes.

=Osteopathic Etiology.=—The most frequent cause of this form of fever is probably gastro-intestinal disturbance. In children it may be due to gastro-intestinal derangement, or to the eating of decomposing food or to exposure to wet and cold. It may be caused by exposure to the sun or great heat, or mental or physical fatigue. It may be the result of exposure to cold sufficient to produce a slight bronchitis, tonsillitis or other affection producing an unnoticed localized inflammation. It may follow a prolonged exposure to noxious odors or gas. Lesions, osseous or muscular, are always present, corresponding to the tissues and organs disturbed. Muscular lesions, especially, are prominent.

=Symptoms.=—The onset is usually sudden with a feeling of lassitude, weariness, chilliness, and headache. The temperature rises quickly to 102 or 103 degrees F. or over, and is usually apt to terminate suddenly by crisis on the third or fourth day. The pulse is frequent and the face is flushed. The child is often irritable. Mild delirium may occur. Anorexia is present, and the bowels are constipated. Convalescence is rapid.

=Diagnosis.=—This depends upon excluding other probable diseases. If the fever cannot be attributed to some of the causes already referred to, there may be a doubt as to its character for the first twenty-four hours, but, if after a careful examination, one finds no other cause and no symptoms develop of any of the recognized diseases, acute continued fever can hardly be mistaken for any other disease.

=Prognosis.=—Always favorable, recovery without sequelæ being the rule.

=Treatment.=—It is necessary to find out the irritative cause in order for one to be able to treat intelligently. Rest in bed with treatment of the disturbing factor of the disease, whatever that may be, is the principal treatment to be given. Careful examination of all the organs, with due consideration of the symptoms, will generally leave no doubt as to the cause, and treatment applied accordingly will be sufficient. If there is any gastro-intestinal disorder, thorough treatment of the splanchnics, anterior treatment to the abdomen and thorough evacuation of the bowels are indicated. Use an enema if necessary. Besides the usual fever treatment, sponging the body with tepid water at the time of day when the fever is highest will aid in lessening the temperature and render the patient more comfortable. In cases where nervous symptoms are prominent, care should be taken against any excitement and, if insomnia results, a quieting treatment in the cervical region is usually sufficient. Use plenty of water internally, which is not only necessary for the tissues on account of the fever, but is of great aid in keeping the skin and kidneys active, and thus a great help in the elimination of waste material. A liquid, nutritious diet is best. Milk, broths and soups will be enough. The demands on the digestive tract are not great when a light diet is administered, besides not exciting the nervous and vascular systems unduly.

Tuberculosis

=Definition.=—A general or local infectious disease caused by the bacillus tuberculosis of Koch. The bacillus produces specific lesions of the form of nodular bodies called tubercles that undergo caseous necrosis with a tendency to involve neighboring tissue. There may be a diffusion of the infection by way of the lymph and blood vessels to various tissues and organs.

=Osteopathic Etiology and Pathology.=—Tuberculosis exists in all countries. It generally prevails more extensively in warm than in cold climates, and is of more frequent occurrence in the city than in the country. Altitude, however, exerts more influence than latitude. The disease rarely occurs in mountainous countries, owing to the purity of the atmosphere. The disease is very prevalent in the West Indies and the South Sea Islands. Tuberculosis is frequently met with in Canada among the French Canadians and the English. All races are subject to tuberculosis, but the Indians of this continent, the South Sea Islanders and the colored race are very susceptible to the disease. It is estimated that from seven to ten percent of the present death rate in the United States is due to tuberculosis.

The tubercle bacillus was discovered by Koch in 1881. It is a short, straight or slightly bent, rod. This bacillus has an exceedingly tenacious hold on life and is found in greater or less numbers in all tuberculous lesions.

It can live almost indefinitely outside the body. The bacilli are found in great numbers in the sputum, which dries and flies in the atmosphere in the form of dust. The organism is thus widely spread in regions frequented by phthisical patients. The bacillus gains entrance into the body by way of the respiratory tract in the vast majority of cases. Milk from tuberculous cows will produce the disease, especially in children, causing intestinal and mesenteric tuberculosis. The meat of tuberculous animals is not necessarily infectious, although there is a possibility of infection by this means. Tuberculosis may be transmitted by direct inoculation; this does not often occur in man, but when it does, the disease usually remains local, although general infection may occur. Persons who follow certain occupations, as butchers, dissectors of dead bodies, and handlers of hides, are more or less subject to local tubercles of the skin. The virus may enter the body through any fissure or excoriation on the skin; thus by washing the clothes or bed linen of phthisical patients, by the bite of a consumptive, or by a cut from a broken sputum glass of a consumptive, one may become infected. It is stated that there may be hereditary transmission. In some cases the virus may be transmitted and the disease may not appear for many years.

=Predisposing Causes.=—Hereditary predisposition, which renders the person more liable to accidental infection; delicate constitution; scrofulous tendency; previous infectious diseases, as influenza, whooping cough, measles, typhoid fever; diabetes mellitus, etc. In young children meningeal, mesenteric and lymphatic forms of tuberculosis are the most frequent. Pulmonary tuberculosis is usually met with in adults, especially between twenty and thirty years or age. The development of tuberculosis is favored by damp localities; by improper and insufficient food; constant inhalation of impure air; injuries to the chest, with or without laceration of the lungs, and various osteopathic lesions that weaken the tissue through faulty nutrition. Corresponding to the innervation of the organ or tissue diseased will always be found anatomical derangements. “Every case has a defective spine and thorax.” (Hayden[60]).

Bronchial catarrh, tonsillitis, diseases of the stomach and intestines, especially enterocolitis, tubercular pneumonia, pleurisy (rarely), intrathoracic tumors and congenital or acquired contraction of the orifice of the pulmonary artery increase the susceptibility to infection. Lessened vitality of the tissues, whether inherited or acquired, is necessary before the germ can become implanted and proliferate, producing tuberculosis of the tissues and organs. In nearly every instance, when the lungs are involved, lesions are found at the second, third, or fourth ribs. These lesions undoubtedly predispose to the tubercular infection, by lessening the vitality of the lung tissues through interference with the innervation or vascular supply. Possibly a lesion at the second rib or second dorsal vertebra would interfere directly with the vasomotor nerves of the upper thoracic ganglia. The condition of the middle and lower cervical vertebræ should be carefully examined, for lesions at that point would involve the lymphatics of the lungs. The lowered vitality caused by the lesion is the predisposing cause and the tubercular bacillus is the =exciting cause= which determine the character of the affection.

C. A. Whiting in Clinical Osteopathy says:

“=The spinal outline= characteristic of tuberculosis and of the pretubercular stages presents the following peculiarities: The cervical spine presents various abnormalities, usually lesions involving single vertebræ and associated with irregular muscular tensions. The upper thoracic spine is anterior, the ribs drooping and rather more freely movable than normal; the vertebral articulations are less movable than normal; the tissues in the neighborhood of the upper two or three dorsal spines are abnormally sensitive and the muscles innervated from these segments are contracted irregularly when the disease involves the apices. The lower interscapular region is found sensitive and these muscles are contracted when the lower lobes of the lung are involved, and the location of these sensitive areas may be employed in the localization of the lung area infected.

“In every case recorded in this clinic, lesions involving the area of the origin of the upper and middle splanchnic nerves have been found. The typical tuberculosis spine must include lesions of the lower dorsal area. Probably these lesions are predisposing factors in tuberculosis, partly because of the effects produced upon nutrition thereby, but doubtless the lack of the normal mobility of this part of the spine prevents the normal stimulation of the liver, the spleen, perhaps the pancreas, thus the normal opsonic index is lost, and immunity broken. The treatment of tubercular cases should include careful attention to the splanchnic area, the maintenance of the normal mobility and structural relationship of the entire spinal column, and such stimulating movements to the ninth and tenth thoracic neighborhood as is indicated in each individual case.”

=Pathology.=—In adults the most common site of tubercles is the lungs; in children it is the lymphatic glands, joints and bones. No organ is exempt; the salivary glands and pancreas are the least frequently involved. The military tubercle is the beginning of tubercular deposits. This may develop in any tissue where the tubercle bacillus is found and it is only distinguished by the presence of a tubercle bacillus, as similar conditions are produced by the aspergillus glaucus and actinomyces.

In the development of a tubercle there is proliferation of the fixed tissue cells, particularly those of the connective tissue and the endothelium of the capillaries, due to the irritation of the bacillus, producing the epithelioid cells and in some instances the giant cells, in both of which bacilli may be found. The epithelioid cells vary in shape. The giant cells are formed by enlargements of the epithelioid cells and a repeated division of their nuclei or possibly by fusion of several cells. On account of the inflammation produced by the bacillus, there is migration of leucocytes from the adjacent vessels and lymphoid cells. The leucocytes are largely polynuclear and are rapidly destroyed, but later mononuclear leucocytes appear, which are able to resist the action of the bacilli so that they are not so readily destroyed. A reticulum of connective tissue is formed around the various cells. The tubercles are non-vascular and when once formed undergo caseation and sclerosis.

=Caseation= is a process of coagulation-necrosis or destructive change, beginning at the central part of the growth, due to the action of the bacilli. The primarily transparent tubercular tissue may become a gray gelatinous body containing bacilli. Frequently the caseation is followed by softening; less frequently, calcification, or it may be surrounded by fibrous tissue.

During the time the cell destruction is going on at the center of the tubercle, hyaline and fibrous changes may render the tissues =sclerotic=. These changes, =caseation=, the destruction of forces, which are dangerous to the patient, or =sclerosis=, which is a healing process, depend upon the power of the body to produce an antitoxin to overcome the effects of the special toxin produced by the bacilli.

There may be a widespread =tuberculous involvement=. This is the result of fusion of the new foci of infection or of miliary tubercles. The lungs are the usual site of infection, varying from a small area, to a lobe or a still greater area.

The irritation of the bacilli is capable of producing =associated inflammatory processes= in its own neighborhood. There may be an overgrowth of interstitial tissue. In other instances, changes to catarrhal or croupous pneumonia may occur. Suppuration is associated with tuberculosis, especially of the lungs, and is due to a mixed infection or the presence of pus organisms. Some authorities claim that the tubercle bacilli alone are able to produce suppuration; it is, however, more probable that suppuration is due to a mixed infection. The constitutional features in tuberculosis are more dependent upon this secondary infection, especially by the streptococci, than upon the primary infection.

Tuberculosis of the Lymph Glands

(SCROFULA)

=Scrofula= is a true tuberculosis of the lymphatic glands. The virus is less virulent than that from other sources, which accounts for the slow development and milder course of tuberculosis of the glandular system.

=Tuberculous Adenitis= may occur at all ages, but is most common in children and young adults. It is rarely congenital. Catarrhal inflammation of the mucous tissues weakens the resisting power of the lymph tissue, thus allowing the bacilli to develop, and is an important predisposing cause. The glands most frequently affected are those of the neck; more rarely there is involvement of all the lymphatic glands of the body. Invariably lesions of the upper and middle cervical vertebræ and upper dorsals and corresponding ribs are found, as well as lesions to the lymphatics at various points along the spinal column and ribs. These lesions affect the innervation to the lymph glands, as well as mucous membranes, and thus predispose to the disease. In all cases anatomical derangements are found in the region of the innervation to the involved gland.

In =general tuberculous adenitis= all the lymph glands of the body are more or less involved, while the other organs and tissues are rarely affected. All the visible glands are found to be swollen, tender and painful. There is more or less protracted fever, with wasting and debility. This is a rare affection.

In =local adenitis= the glands of the neck are most frequently affected and this is especially the case with children. Negroes are more frequently affected than whites. It is seen especially among those living in an unsanitary environment. Measles, whooping cough and an hereditary tendency are predisposing factors. The submaxillary glands are usually the first affected. At first they are swollen to various degrees and are tender; later they suppurate and rupture if one is not able to cure them. There may be fever. The skin over the glands is usually freely movable; it may, however, be adherent.

The glands above the clavicle, those in the posterior cervical triangle, and the axillary glands may all be affected. In such cases it is likely that the bronchial glands are also involved and may infect the living tissue.

Lesions of the upper and middle cervicals and deep muscles are always found and undoubtedly are the underlying causes. Lesions of the lower cervical, upper dorsal, ribs and clavicle, are of frequent occurrence. Infection may gain entrance by way of the pharynx and tonsils.

The affection often runs a slow course.

The =bronchial= glands may be affected primarily, but usually secondarily to infection of the lungs. The primary form is seen most commonly in children and is apt to be associated with suppuration. Lesions of the upper and middle dorsals and of the cervicals will be found. Catarrh of the bronchial tubes is a predisposing cause. The X-ray is of great value in the diagnosis.

The most noticeable symptoms are those due to pressure or irritation.

Systemic infection may follow rupture into a vessel. Local infection of the lung may occur and the pericardium become infected.

=Mesenteric= cases occur among children and may be primary or secondary. The primary form is rare. Swallowed sputum is a frequent cause. The trunk and limbs are puny. The child is anemic, and often the abdomen is tympanitic. Diarrhea is marked and there is pain and indigestion. Fever is almost constantly present and of an intermittent type. The disease is most frequently met with among poor children in unhygienic, poorly ventilated houses. There may be an associated tuberculosis of the peritoneum.

Acute Tuberculosis

This shows best the truly infectious nature of tuberculosis. In it miliary tubercles develop in many and various parts of the body. In some cases these growths seem to be uniformly distributed throughout all the viscera. In other instances they are localized in the lungs or in the meninges of the brain. In nearly every instance it is an auto-infection, arising from an old tuberculous focus, which may be latent and quite unsuspected. General infection, in most instances, arises from the rupture of a nodule into a vein, from tuberculous lymph glands, tuberculosis of the bones, joints, or even the skin.

=General Miliary Tuberculosis or Typhoid Form.=—This is similar to a general infection of the body and resembles, to a marked degree, the symptoms of typhoid fever. The onset is rarely rapid.

In most cases there is a period of incubation, during which the health fails, the appetite is lost, headache occurs, and the patient soon becomes feverish, with increased debility. The temperature rises and the pulse is rapid and feeble. The tongue is dry. The respirations are increased. Delirium may be present. In rare cases, there may be little or no fever. The temperature ranges from 101 to 103 or even 105 degrees F. It is irregular and marked by evening exacerbations and morning remissions. Occasionally there is an inverse type of temperature in which it rises in the morning and falls in the evening. In some cases the pulmonary symptoms are marked, while in others the meningeal symptoms are more prominent. Tubercle bacilli are rarely found in the sputum.

The spleen is usually enlarged. Constipation is present, as a rule, but there may be diarrhea, and hemorrhage from the bowels may occur. The urine may contain traces of albumin. There may be excessive sweating, and herpes is often present. Choroid tuberculosis is frequently met with. In doubtful cases the blood should be examined for tubercle bacilli, although they are not always present. The duration is from two to four weeks, the disease usually terminating unfavorably.

=Diagnosis.=—It is often very hard to differentiate between this form of tuberculosis and typhoid fever. In =typhoid fever= epistaxis is a common, early symptom. The temperature curve of the continued type is quite diagnostic. The Widal test should be made. The respirations are moderately hurried and the pulse is often dicrotic. Diarrhea is frequent. Typhoid rash is diagnostic. No tubercles are found on the choroid. No tubercle bacilli are found in the blood. Hemorrhages from the bowels are common.

=Pulmonary Form.=—When the lungs are chiefly affected the pulmonary symptoms are marked from the onset. It may develop suddenly or there may be a long period during which the general health fails markedly. In children the disease may follow measles or whooping cough. There is dyspnea, cough and the expectoration is mucopurulent. There is broncho-vesicular breathing with sibilant and subcrepitant rales. The temperature is high, ranging from 103 to 105 degrees F., or higher. Respiration and pulse are rapid.

The disease may last from several weeks to months, or, on the other hand, it may prove fatal within a few days. As the end draws near the signs of suffocation become intensified.

=Diagnosis.=—The history and general symptoms, together with the dyspnea and cyanosis, will generally decide the diagnosis. The blood should be examined for malarial parasites. The Widal test will differentiate typhoid.

=Cerebral or Meningeal= (Tuberculous Meningitis).—This form which is sometimes called acute hydrocephalus, occurs quite frequently and is an infection of the pia mater of the brain or cord.

It occurs most frequently in the first two years of life, although it may occur later. It is usually tuberculous in some other region, especially in the bronchial glands. Rarely does the disease involve the meninges primarily.

The meninges at the base of the cerebrum is the principal involvement. There is more or less inflammation, with fibrous purulent exudation. There are tubercles along the blood vessels. The ventricles may be distended.

=Symptoms.=—The onset is slow, lasting one or more weeks. Headache, constipation, vomiting and chills, followed by a fever, are the initial symptoms. When the onset is sudden, the disease is generally ushered in with a convulsion. The fever rarely rises above 102 or 103 degrees F. The pain is often severe, causing the child to give a sudden cry—the hydrocephalic cry. During sleep the child is restless and there are slight muscular twitchings.

The =irritative symptoms= now abate. The child becomes quiet and is dull and apathetic. Constipation still persists. The abdomen is boat-shaped, and the neck may be retracted. The pupils are dilated. Convulsions and other cerebral symptoms may occur. The temperature ranges from 100 to 103 degrees F. The respiration is irregular and sighing.

Following this, the mental faculties are lost and coma occurs. Convulsions or spasmodic contractions of the muscles of the neck, back and limbs may occur. The pupils are dilated and do not respond to light. The pulse is frequent, irregular and small. The temperature rises to 103 to 105 degrees F., or it may be subnormal. The duration is from two to five weeks; chronic cases may last for a number of months.

=Prognosis.=—Generally very unfavorable.

Acute Pneumonic Phthisis

The infection of the lungs is rapid and may be primary or secondary. This form is met with most frequently in children and young adults, but may occur at any age.

The =Pneumonic form= is more rare than the bronchopneumonic form and may be very rapid in its course. The attack sets in abruptly with a chill and the temperature rises rapidly. There is pain in the side; cough; dyspnea and mucous and rusty sputum, which may contain tubercle bacilli. There is impairment of resonance, increased fremitus, and bronchial breathing. The whole or part of the lung may show signs of consolidation and dullness, all the symptoms of pneumonia being present. The patient rapidly loses flesh. This attack may come on a person in good health after exposure to cold; but there may have been a debilitated condition, or a predisposition to phthisis. Death may occur in the second or third week or the case may continue from three to four months.

One or both lungs may be involved. The lung is heavy and airless, sinking quickly in water. There is destruction of lung tissue and upon section, cavities are found. The cavities are generally small and are surrounded by tubercles. Older caseous areas of a yellowish white color may be visible. Miliary tubercles are found upon careful examination.

The =bronchopneumonic form= is the most common and occurs most frequently in children. It often follows the infectious diseases, especially measles and whooping cough. The child may be taken ill suddenly with what seems to be an ordinary bronchitis, the temperature rises, the cough is severe, and there may be consolidation with submucous and subcrepitant rales. Rapid respiration and sweating are often marked. The course of the disease varies. There is rapid loss of flesh, and in many cases the disease develops into chronic phthisis. In other instances death occurs in from three to eight weeks.

The disease may attack the adult whose resistance is impaired. Chills, fever, pain in the chest, hemorrhages, wasting are most noticeable symptoms; these are the various signs of bronchopneumonia. Tubercle bacilli are often found in the sputum. The course is usually from three to eight weeks, while a number pass into a chronic stage.

Areas of caseous tubercles are found, which later suppurate, break down and form cavities. The bronchial lymph nodes are found enlarged, and usually there is acute tuberculous pleurisy.

=Diagnosis.=—In the =pneumonic form= it may be impossible to make a diagnosis early in the disease. Tuberculosis may be suspected if the patient has been in bad health, has a predisposition to phthisis, or has had any pulmonary disorder. Pneumonia will present the typical symptoms, but if fever continues, tuberculosis will be suspected. Examination of the sputum will probably decide.

In the =bronchopneumonic= form it is very difficult, in the early stages, to distinguish it from simple bronchitis and bronchopneumonia. The irregular fever and rapid loss of flesh are important signs. The sputum will show elastic tissue and tubercle bacilli early in the disease and should be carefully examined.

Chronic Pulmonary Tuberculosis

The chronic form of the disease is more common than the acute. It seems probable that many cases of pulmonary tuberculosis are due to inhalation of the tubercle bacillus, though no doubt, particularly in children the bacillus frequently gains entrance to the system through the intestinal tract from infected milk and food. =Deformities= of the chest, especially where there is constriction and rigidness of the upper part, with more or less immobility of the first, second and third ribs and the junction of the manubrium and gladiolus, associated with weak muscles and a stooped posture are definite predisposing factors. This condition may be congenital or acquired. The local innervation, blood supply and lymphatic drainage is involved, so that the individual is less resistant and consequently susceptible to infection. The bronchi are thus weakened, favoring the infectious process so that the disease may advance and involve the neighboring tissues, or if infection has gained entrance to the lymph or blood stream elsewhere, the susceptible pulmonary organs may become diseased.

Owing to the above predisposing factors the =primary lesion= of the lungs is often in the bronchus a little below the apex near to the posterior and external borders. A lower lobe may be involved, or several lesions may occur at the same time, involving one or both lungs. Frequently the other lung is infected from the lesion or lesions of the first.

In the acute cases the exudative process involves the lung tissue, becomes caseous and softened, and later necrotic with cavity formation. In the =chronic type= the exudative process is slower, with thickening of the walls of the air vesicles and increase of fibrous tissue. =Cavities=, the result of caseation, are of various size, ragged, often coalesce and open into the bronchus. Fibrous tissue forms about them and frequently arrest the process. In the necrotic involvement blood vessels are often injured causing hemorrhages. Pleurisy, empyema, catarrhal bronchitis, and bronchiectasis are often associated involvements.

In addition to the tubercle bacillus, other micro-organisms, streptococcus and staphylococcus pyogenes, influenza bacillus, and diplococcus pneumoniæ, are often found, and no doubt are important exciting factors.

The =bronchial glands= are swollen, and contain tubercles. They may undergo purulent disintegration. Tuberculosis of the =larynx= is common. In severe cases there may be amyloid changes of =liver=, =kidneys=, spleen, and mucous membrane of the intestines. Tuberculous lesions are found in the intestines, spleen, kidneys, and brain in nearly equal proportions; then come the liver and pericardium.

=Symptoms.=—The onset of the disease is either abrupt or gradual. Frequently it succeeds influenza, measles, or bronchitis. There is a cough, expectoration, loss of weight, afternoon temperature and probably night sweats. The disease is likely to develop slowly. In other cases gastro-intestinal disorders are the first symptoms, especially with weakness and debility. Again, the disease may follow pleurisy. When the attack is abrupt, pneumonia is simulated. However, the apex of the lung, instead of the middle or lower lobe, is involved; expectoration is considerable and the fever is not so high and pronounced. Hemoptysis frequently occurs.

The =local symptoms= are important. =Pain= is an early either moderate or severe, symptom, although there are cases where it is absent. When associated with pleurisy, it is severe. The pain is usually situated at the base, anteriorly or laterally, of the scapulæ, but may be between them. =Cough= is present, in the majority of cases, throughout the entire course. It usually grows worse, and is dry and hacking at the beginning but looser and paroxysmal and accompanied by a mucopurulent expectoration later on. The =expectoration=, at first, is slight and there may be more or less blood mixed with it, or even hemorrhage may occur. With the formation of cavities, the expectoration increases and is of a greenish-gray or greenish yellow color. In some instance the sputum is more or less fetid. The expectoration is composed of pus cells, blood, elastic tissue, fat globules and tubercle bacilli. =Hemoptysis= is present in a majority of cases. Early hemorrhages are usually slight, due to rupture of weakened vessels. When there is softening or cavity formation, erosion of vessels may be pronounced and hemorrhage considerable. Dyspnea is a variable symptom, but is characteristic of lung changes.

=Fever= is a characteristic symptom. It is probably always present at the beginning and the afternoon increase of temperature is common. Where there is softening and formation of cavities, a remittent or intermittent type is present. The pulse is frequent, regular and compressible. =Sweats= may occur at any time, but especially during sleep. They indicate fever activity, and are increased during cavity formation. =Emaciation= is a prominent symptom. This is due to gastro-intestinal disorders and prolonged fever. Loss of weight is gradual, especially if the disease is advancing. Where the lung is considerably diseased, heart disturbances are common.

Other disorders, as of the gastro-intestinal tract, genito-urinary, cutaneous, and nervous systems, are frequent, especially in long standing cases. The =gastro-intestinal disturbances= are gastric catarrh, vomiting, loss of appetite, coated tongue, constipation, and later on, diarrhea. Among =genito-urinary symptoms=, albuminuria is frequent. The kidney involvement may be either of an acute or chronic character. Pyelitis and cystitis are present in some cases, and amyloid degenerations are not uncommon. With the =cutaneous symptoms=, the skin is frequently dry and scaly, and the hair of the head dry. The hectic flush is common. Upon the chest and back there may be pigmentary stains. The =nervous symptoms= vary according to the involvement. Tuberculous meningitis is rare. The mind usually is clear and even in advanced stages the patient is always hopeful.

=Physical Signs.=—=Inspection= reveals that the shape of the chest is often characteristic. A phthisical thorax is flat, especially the thoracic opening with wide intercostal spaces, prominent costal cartilages, and depressed sternum. Sometimes the lower sternum forms a deep concavity (funnel breast). Another type of thorax is long and narrow, with very oblique ribs, and little expansion. In other instances the chest is of apparently normal build. Defective expansion is observed early, especially at the apex of the affected side. The clavicle of the affected side often stands out more prominently.

=Palpation= shows there is decreased expansion and increased fremitus. Normally, the fremitus is stronger at the right than at the left apex. If the pleura is thickened, the fremitus is decreased, but increased in lung involvement.

On =percussion=, if the diseased areas are minute, the percussion note may not be changed. Always compare the two sides of the chest. Dullness is first noted, as a rule, above, on or below the clavicle. As the disease progresses, the dull sound increases. The size of the cavity, its walls and the amount of secretion modify the note. Large, thin-walled cavities elicit the “cracked-pot” sound. Consolidation, thickened pleura, large amount of material in a cavity and a connecting bronchus impair resonance.

On =auscultation= the breathing is harsh and the expiration is prolonged and high-pitched (bronchial). Early in the disease crackling rales may be heard. After consolidation takes place there is bronchial breathing and crepitant rales. When softening occurs they become moist, louder and sometimes bubbling. These may be heard upon inspiration and expiration. Pleuritic friction sounds, as in case of pleurisy, may be heard at any stage. Vocal resonance is increased.

The =signs= of =cavity= are: =Percussion.=—There is more or less defective resonance or tympany. Over large cavities a “cracked-pot” resonance is obtained. This is best obtained when the patient has his mouth open. There may be normal resonance if the cavities are covered with a considerable thickness of unaffected air cells.

=Auscultation= may detect cavernous or amphoric breathing, pectoriloquy and coarse, bubbling rales. Metallic tinkling may be heard over large cavities. Vocal resonance is increased.

=Complications.=—The larynx and trachea frequently undergo tubercular inflammation, due to invasion from the lung tissue. Pneumonia is of common occurrence. Gangrene, pleurisy and endocarditis are other complications.

=Diagnosis.=—Bacilli may be found in the sputum before the physical signs are well developed. It may be necessary to examine the sputum several times before the tubercle bacilli are detected. The presence of bacilli will set the diagnosis at rest, provided clinical symptoms are present. Fever, hemoptysis, cough, emaciation and a continuous, local induration are diagnostic. The X-ray should be employed as an aid in diagnosis.

=Prognosis.=—The prognosis of pulmonary tuberculosis varies greatly in different cases. Undoubtedly a number of cases have been cured; many arrested; even spontaneous cures have occurred. A great deal can be done to prolong life and to make the patient comfortable. The average duration is about three years, although by careful treatment this time is probably being increased.

Fibroid Phthisis

This term is applied to a form in which there is induration, followed by contraction of the affected lung tissue, due to an overgrowth of fibroid tissue. The greater number of cases are primarily tubercular, but have run a fibroid course. Other cases are primarily fibroid, followed by tuberculous infections. It may begin as an ordinary ulcerative phthisis, or it may begin as an inhalation bronchitis. In other instances it may follow a chronic tuberculous bronchial pneumonia or pleurisy.

The =onset= is extremely insidious. There is persistent cough, often paroxysmal in character. Dyspnea is marked, especially on exertion, but little or no fever is present. The expectoration is profuse and mucopurulent. There is slight loss of weight. In the later stages edema is marked. It is a disease of long duration, lasting from ten to twenty years. The patient is often able to pursue some occupation and may have fair health.

There is marked dullness over the affected side, which is commonly much depressed. There is distinct bronchial breathing at the base, while at the apex there may be cavernous sounds. The heart is frequently displaced and the right ventricle hypertrophied. The bronchi are dilated. The clinical history is identical with that of simple cirrhosis of the lung from which it is often separated with difficulty. Both lungs may become the seat of tuberculous disease. Prolonged suppuration results in amyloid changes in the liver, spleen, kidneys and intestines. X-ray plates are of value in diagnosis.

Tuberculosis of Other Tissues

The =alimentary tract= is frequently the seat of tubercular inflammation. The intestines may be involved primarily or else secondarily from the lungs or peritoneum. The =primary form= is most common in children. There is slight fever, pains of a colicky nature, irregular and persistent diarrhea. The disorder is commonly unrecognized, being mistaken for appendicitis or other intestinal disorders, until emaciation, sweats, the continued fever or lung involvement are manifested.

The stomach, esophagus, pharynx, tonsils, palate, tongue and lips may be the seat of a tubercular lesion.

The =serous membranes= are usually secondarily involved. The peritoneum is generally invaded from contiguous organs, especially the intestines, although the pleurae may be the starting point (and in the female the generative tract is a source). The disease may be either acute or chronic. In the former it starts abruptly with vomiting, pain in the abdomen, fever, and possibly diarrhea. In the chronic form there are fever, pains, emaciation, weakness and the abdomen is distended. The enlarged glands may be felt through the walls. There may be ascites, or the walls of the peritoneum are adherent, or the tubercles may ulcerate.

The endocardium is occasionally the seat of acute or chronic tuberculosis. It is usually secondary. Likewise the pleurae are sometimes involved. The chronic form is more common.

The =genito-urinary system= is subject to tuberculosis. The bladder, ureters and pelvis of the kidney are attacked, and from these the kidney; or possibly the kidney involvement is part of a general tuberculosis. (See pyelitis). The ovaries, Fallopian tubes and uterus are also subject to tubercular invasion. The =diagnosis= depends upon finding the bacilli, the symptoms indicating, oftentimes, an inflammation only. Also the prostate, testicles and seminal vesicles are attacked.

Tuberculosis of the mammary glands is rare. In miliary tuberculosis the liver is commonly affected, often secondary to other tissues, especially the peritoneum, lymphatics and lungs.

The blood-vessels and heart are sometimes involved from nearby organs or from miliary tuberculosis. The brain and cord are also at times invaded. This has been described under meningeal tuberculosis.

=Diagnosis and Prognosis of Tuberculosis.=—The osteopath should be familiar with the various forms of the disease. An understanding of the pathology and clinical symptoms is essential. The finding of the bacillus, provided there are symptoms of inflammation, is diagnostic. Much depends upon the patient’s constitution, hygiene, sanitation, food, fresh air and general management. The osteopathic lesion is decidedly an important factor, but the treatment must be balanced from both the distinctive osteopathic view and that of general management. Then the patient’s part is as necessary as the osteopath’s. Under proper care and treatment, unless the disease has progressed to a marked degree, there is always a tendency toward recovery, but, to emphasize again, the osteopathic treatment, the environment and general hygiene should be thoroughly understood and appreciated, for at best, the disease is treacherous. Even after an apparent recovery is made, the patient should be under observation; there is always danger of recurrence. Tuberculosis can often be treated successfully, or arrested, provided the disease has not progressed to a late stage; although many times, in the later stages, life can be considerably prolonged by careful treatment.