Chapter XXXIII: Introduction (18)

=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.