The Osteopathic Approach to the Flu Pandemic

Pandemic Flu:
Lessons from the Past….
Thoughts for the Future
Richard Chmielewski, DO, FACEP, NMM/ OMM
Board Certified, Emergency Medicine
Board Certified, Neuromuscular Medicine/ Osteopathic Manipulative
Medicine
Falcon Clinic for Health, Wellness and Recovery
St. Elizabeth Medical Center
Utica, New York

I had a little bird,
Its name was Enza.
I opened the window,
And in-flu-enza.

INFLUENZA – definition
 The name influenza comes from the
Italian influenza, meaning "influence" (
Latin: influentia). The most common
symptoms of the disease are chills, fever,
sore throat, muscle pains, severe
headache, coughing, weakness and
general discomfort.[1] Fever and coughs
are the most frequent symptoms. In more
serious cases, influenza causes
pneumonia, which can be fatal,
particularly for the young and the elderly.
http://en.wikipedia.org/wiki/Influenza

The Influenza virus
http://upload.wikimedia.org/wikipedia/commons/3/3b/3D_Influenza_virus.png

Flu Facts
 Each year almost 35,000 Americans die from the flu and its
complications
 Because it is caused by a virus, anyone can get it
 Kids under 5, adults over 50 and people with chronic medical
conditions, such as asthma, chronic bronchitis or heart
disease, are at high risk for complications.
 Being immunized by a flu shot or the inhaled FluMist ( FDA-
approved only for healthy people ages 5 to 49) significantly
reduces the risk of getting the flu.
 Most folks who get the flu shot have no reaction. Up to 25%
may have some redness and slight swelling at the site. A
small percentage may experience a slight fever, chills and
headache within 24 hours. These symptoms end within a few
days.
 The flu virus mutates from year to year, so a vaccination
from last season is ineffective against this year’s strains.
USA Weekend – Oct 5-7, 2007

Flu Fiction
 Flu is just a bad cold – although it’s considered a respiratory infection,
it affects the entire body, causing high fever ( up to 104 F) that’s
accompanied by body aches, headaches, nausea and dehydration.
Even after the infection is gone ( it can last up to 2 weeks) people can
be weak for several more days.
 You can get the flu from the flu shot – No, you can’t. The vaccine is
not made from a live virus
 You can get the flu from wet hair or cold weather – No, you get the flu
by coming into contact with someone who is infected. In the cold of
winter, when people cluster indoors, exposure to the flu virus is more
likely, but cold weather itself doesn’t cause the flu.
 The flu shot is only for high risk people – False. People at high risk
definitely need the vaccinatjon, but those at low risk also should get
the shot to help keep the flu from spreading.
 If I haven’t had the flu by December, I’m in the clear – Flu season can
extend through May. Although it’s never too late in the season to get
the shot, the ideal period for immunization is from mid-October to
mid-November.
USA Weekend – Oct 5-7, 2007

Modes of Transmission
 Typically, influenza is transmitted through the air
by coughs or sneezes, creating aerosols
containing the virus. Influenza can also be
transmitted by bird droppings, saliva,
nasal secretions, feces and blood. Infection can
also occur through contact with these body fluids
or through contact with contaminated surfaces.
Airborne aerosols have been thought to cause
most infections, although which means of
transmission is most important is not absolutely
clear. Influenza viruses can be inactivated by
sunlight, disinfectants and detergents.[4][5] As
the virus can be inactivated by soap, frequent
hand washing reduces the risk of infection.
http://en.wikipedia.org/wiki/Influenza

Announcement of H1N1
Pandemic for 2009
 the novel H1N1 flu outbreak was first detected in
mid-April 2009
 On June 11, 2009, the World Health Organization
(WHO) signaled that a global pandemic of novel
influenza A (H1N1) was underway by raising the
worldwide pandemic alert level to Phase 6 .
 This action was a reflection of the spread of the
new H1N1 virus, not the severity of illness caused
by the virus.
 At the time, more than 70 countries had reported
cases of novel influenza A (H1N1) infection and
there were ongoing community level outbreaks of
novel H1N1 in multiple parts of the world.

 From April 15, 2009 to July 24, 2009,
states reported a total of 43,771
confirmed and probable cases of novel
influenza A (H1N1) infection. Of these
cases reported, 5,011 people were
hospitalized and 302 people died
 On July 24, 2009, confirmed and probable
case counts were discontinued.
Aggregate national reports of hospitalizations
.

Total U.S. Novel H1N1 Flu Hospitalizations and Deaths
Posted August 14, 2009, 11:00 AM ET
Data reported to CDC by August 13, 2009, 2:00 PM ET
Reporting States and
Territories
Hospitalized Cases Deaths
51 7,511 477
http://www.cdc.gov/h1n1flu/surveillanceqa.htm

 A CDC model was developed to try to determine
the true number of novel H1N1 flu cases in the
United States. The model took the number of
cases reported by states and adjusted the figure
to account for known sources of underestimation
(for example; not all people with novel H1N1 flu
seek medical care, and not all people who seek
medical care have specimens collected by their
health care provider). Using this approach, it is
estimated that more than one million people
became ill with novel H1N1 flu between April and
June 2009 in the United States

How have different age groups in the United States been
impacted by novel H1N1 flu in terms of infection rates?
 The information analyzed by CDC
supports the conclusion that novel
H1N1 flu has caused greater
disease burden on people younger
than 25 years of age than older
people.

Novel H1N1 Confirmed and Probable Case Rate in the
United States, By Age Group
http://www.cdc.gov/h1n1flu/surveillanceqa.htm#grapha

Spread of H1N1 Novel Flu in Poland
May, 2009
June, 2009
July, 2009

Poland H1N1 ( swine flu) Statistics
 The first H1N1 (swine flu) case in Poland was
confirmed on May 7th, 2009
• As of August 21st, 2009 there are 153
confirmed cases of H1N1 (swine flu) in Poland
• As of August 21st, 2009 there have been 0
H1N1 (swine flu) deaths in Poland
 • The number of H1N1 (swine flu) infections in
Poland has risen by -129 cases or -45.7% in the
seven days between August 14th and August
21st.
http://h1n1.flu-virus.org/Cases-.php?in=Poland

Fear and the Flu
The Influenza Pandemic of 1918
 The influenza pandemic of 1918-1919
killed more people than the Great War,
known today as World War I (WWI), at
somewhere between 20 and 40 million
people. It has been cited as the most
devastating epidemic in recorded world
history. More people died of influenza in a
single year than in four-years of the Black
Death Bubonic Plague from 1347 to 1351.
Known as "Spanish Flu" or "La Grippe" the
influenza of 1918-1919 was a global
disaster.
http://www.stanford.edu/group/virus/uda/index.html

Many influenza experts, policy makers, and
knowledgeable observers believe that a novel
influenza A (H1N1) strain directly caused most deaths
during the 1918–19 pandemic, often from
a hemorrhagic pneumonitis that rapidly progressed to
acute respiratory distress syndrome and
death
http://www.cdc.gov/eid/content/14/8/pdfs/07-1313.pdf

An illustration of what influenza can be like:
a copy of a letter by Professor N R Grist (Glasgow) published
in the British Medical Journal of 22-29 December 1979:-
 “It is salutary to remember that we
do not really understand why the
devastating pandemic of 1918-19
was so severe, and that we cannot
therefore be confident that our
modern medical measures would
succeed against a similar future
challenge.”
http://web.uct.ac.za/depts/mmi/jmoodie/influen2.html

An illustration of what influenza can be like:
a copy of a letter by Professor N R Grist (Glasgow) published
in the British Medical Journal of 22-29 December 1979:-
 These men start with what appears to be an ordinary attack
of LaGrippe or Influenza, and when brought to the Hosp. they
very rapidly develop the most viscous type of Pneumonia that
has ever been seen. Two hours after admission they have the
Mahogany spots over the cheek bones, and a few hours later
you can begin to see the Cyanosis extending from their ears
and spreading all over the face, until it is hard to distinguish
the coloured men from the white. It is only a matter of a few
hours then until death comes, and it is simply a struggle for
air until they suffocate. It is horrible. One can stand it to see
one, two or twenty men die, but to see these poor devils
dropping like flies sort of gets on your nerves. We have been
averaging about 100 deaths per day, and still keeping it up.
There is no doubt in my mind that there is a new mixed
infection here, but what I dont know. My total time is taken
up hunting Rales, rales dry or moist, sibilant or crepitant or
any other of the hundred things that one may find in the
chest, they all mean but one thing here -Pneumonia-and that
means in about all cases death.

 The effect of the influenza epidemic was so severe that
the average life span in the US was depressed by 10
years.
 The influenza virus had a profound virulence, with a
mortality rate at 2.5% compared to the previous influenza
epidemics, which were less than 0.1%.
 The death rate for 15 to 34-year-olds of influenza and
pneumonia were 20 times higher in 1918 than in previous
years (Taubenberger).

 People were struck with illness on the street and died
rapid deaths. One anectode shared of 1918 was of four
women playing bridge together late into the night.
Overnight, three of the women died from influenza
(Hoagg). Others told stories of people on their way to
work suddenly developing the flu and dying within hours
(Henig).
 One physician writes that patients with seemingly ordinary
influenza would rapidly "develop the most viscous type of
pneumonia that has ever been seen" and later when
cyanosis appeared in the patients, "it is simply a struggle
for air until they suffocate," (Grist, 1979).
 Another physician recalls that the influenza patients "died
struggling to clear their airways of a blood-tinged froth
that sometimes gushed from their nose and mouth,"
(Starr, 1976).
 The physicians of the time were helpless against this
powerful agent of influenza

 The origins of the deadly flu disease were
unknown but widely speculated upon.
 Some of the allies thought of the
epidemic as a biological warfare tool of
the Germans.
 Many thought it was a result of the trench
warfare, the use of mustard gases and
the generated "smoke and fumes" of the
war

 Meanwhile the new sciences of the
infectious agents and immunology
were racing to come up with a
vaccine or therapy to stop the
epidemics

 Those who were lucky enough to avoid infection had to
deal with the public health ordinances to restrain the
spread of the disease. The public health departments
distributed gauze masks to be worn in public. Stores
could not hold sales, funerals were limited to 15
minutes. Some towns required a signed certificate to
enter and railroads would not accept passengers
without them. Those who ignored the flu ordinances
had to pay steep fines enforced by extra officers
(Deseret News). Bodies pilled up as the massive deaths
of the epidemic ensued. Besides the lack of health care
workers and medical supplies, there was a shortage of
coffins, morticians and gravediggers (Knox). The
conditions in 1918 were not so far removed from the
Black Death in the era of the bubonic plague of the
Middle Ages.

 Patients with the influenza disease of the epidemic were generally characterized by
common complaints associated with the flu. They had body aches, muscle and joint
pain, headache, a sore throat and a unproductive cough with occasionally harsh
breathing (JAMA, 1/25/1919). The most common sign of infection was the fever, which
ranged from 100 to 104 F and lasted for a few days. The onset of the epidemic
influenza was peculiarly sudden, as people were struck down with dizziness, weakness
and pain while on duty or in the street (BMJ, 7/13/1918). After the disease was
established the mucous membranes became reddened with sneezing. In some cases
there was a hemorrhage of the mucous membranes of the nose and bloody noses were
commonly seen. Vomiting occurred on occasion, and also sometimes diarrhea but more
commonly there was constipation (JAMA, 10/3/1918). A few physicians associated
psychoses with influenza infection. One article says that "the frequency of mental
disturbances accompanying the acute illness in the epidemic has been the subject of
frequent comment," (JAMA, 1/25/1919) The danger of an influenza infection was its
tendency to progress into the often fatal secondary bacterial infection of pneumonia. In
the patients that did not rapidly recover after three or four days of fever, there is an
"irregular pyrexia" due to bronchitis or broncopneumonia (BMJ, 7/13/1918). The
pneumonia would often appear after a period of normal temperature with a sharp spike
and expectorant of bright red blood. The lobes of the lung became speckled with
"pneumonic consolidations." The fatal cases developed toxemia and vasomotor
depression (JAMA, 10/3/1918). It was this tendency for secondary complications that
made this influenza infection so deadly.
http://www.stanford.edu/group/virus/uda/fluscimed.html

Medical Signs/ Tests monitored during
the 1918-1919 Influenza Pandemic
 Temperature
 Pulse rate
 Respiratory Rate
 Occasional chest x-ray
 The Wasserman Reaction – testing the blood for
antibodies
 White blood cell count
 Urine albumin
 Sputum , nasopharyngeal and blood cultures
(Commonly found were pneumococcus, streptococcus, staphylococcus and
Bacillus influenzae (JAMA, 4/12/1919)

Treatment during the 1918-1919
Influenza Pandemic
 Aspirin
 Sialicin
 cinnamon in powder or oil form with milk to
reduce temperature (BMJ, 10/19/1918 )
 Epinephrine injections for secondary pneumonia
 Oxygen either by mask or injected under the skin
 Quinine
 Rest, fluids and nourishment
 The serum of convalescent patients was used to
treat influenza patients
 Digitalis
 Isotonic Glucose, IV
 Sodium Bicarbonate, IV
http://www.stanford.edu/group/virus/uda/fluscimed.html

Nonpharmaceutical Interventions Associated
with Lower Overall Mortality Rates
Systematic analyses of mortality data from large US cities have
shown that
nonpharmaceutical interventions (e.g., isolation, quarantine,
closing schools, banning public
gatherings) were associated with lower influenza-related
mortality rates during the autumn of
1918 (33). Given the rapidity of spread of the pandemic,
reductions of mortality rate associated
with nonpharmaceutical interventions are unlikely to have been
primarily related to reductions of
influenza transmission (particularly in large US cities during
wartime).

A call to focus on prevention more than
just on treating the influenza
 We suggest that preparations for the next influenza pandemic should focus on more
than
 preventing and treating influenza virus infections. A modified influenza pandemic plan
might
 include the following components: 1) Before a pandemic, expand indications for and
decrease
 barriers to receipt of vaccination against S. pneumoniae (36–38,40). 2) During a
pandemic, in
 communities not yet affected, universally vaccinate with a safe and effective strain-
specific
 influenza vaccine, if available. 3) During local epidemics, treat all serious clinical cases
with an
 antibacterial agent that is effective against S. pneumoniae, S. pyogenes, H. influenzae,
and S.
 aureus (including methicillin-resistant S. aureus); isolate patients with clinical cases
from other
 patients and as many others as possible (35,37–39). 4) Conduct pandemic-related
surveillance
 that tracks the incidence, nature (e.g., species, affected sites, antimicrobial drug
sensitivities),
 and outcomes of bacterial infections that complicate influenza cases.
 Given highly variable colonization and drug-sensitivity patterns across

Novel H1N1 Vaccination
Recommendations
 CDC’s Advisory Committee on
Immunization Practices (ACIP), a
panel made up of medical and
public health experts, met July 29,
2009, to make recommendations on
who should receive the new H1N1
vaccine when it becomes available

Groups to be initially vaccinated with the Novel
H1N1 Flu Vaccine becomes available
 Pregnant women
 Household contacts and caregivers for children
younger than 6 months of age because younger infants
are at higher risk of influenza-related complications and
cannot be vaccinated. Vaccination of those in close contact
with infants less than 6 months old might help protect infants
by “cocooning” them from the virus;
 Healthcare and emergency medical services personnel
All people from 6 months through 24 years of age
 Children from 6 months through 18 years of age Young
adults 19 through 24 years of age Persons aged 25
through 64 years who have health conditions
associated with higher risk of medical complications
from influenza.
 Seasonal flu and novel H1N1 vaccines may be administered
on the same day.
http://www.cdc.gov/h1n1flu/vaccination/acip.htm

How to prevent the spread of the virus
 Take everyday actions to stay healthy
 Cover your nose and mouth with a tissue when
you cough or sneeze. Throw the tissue in the
trash after you use it.
 Wash your hands often with soap and water,
especially after you cough or sneeze. Alcohol-
based hands cleaners are also effective.
 Avoid touching your eyes, nose or mouth. Germs
spread that way.
 Stay home if you get sick. CDC recommends that
you stay home from work or school and limit
contact with others to keep from infecting them.
http://www.cdc.gov/h1n1flu/vaccination/public/vaccination_qa_pub.htm

Making a vaccine against the novel H1
N1 influenza virus
 Isolates sequenced at WHO and
CDC suggest that circulating novel
2009-H1N1 influenza viruses look
similar to A/California/07/2009 (the
reference virus selected by WHO as
a potential candidate for the new
H1N1 vaccine )

Vaccination
 Given the current lack of information to
the contrary,
 it is prudent to assume that 2 doses of
pandemic virus
 vaccine might be necessary for individual
protection.
 The number of doses required will be
adjusted as and
 when more information becomes
available.
http://www.who.int/wer/2009/wer8430.pdf

The clinical spectrum of pandemic A
(H1N1) 2009 virus infection is broad
 mild upper respiratory tract illness with or without
fever
 and occasional gastrointestinal symptoms such as
vomiting
 or diarrhoea and exacerbation of underlying
conditions,
 to severe complications such as pneumonia
resulting
 in respiratory failure, acute respiratory distress
syndrome
 (ARDS), multi-organ failure and death.
http://www.who.int/wer/2009/wer8430.pdf

 Gastrointestinal symptoms,
including vomiting and diarrhoea,
 have been reported in up to 50% of
patients
 with mild to moderate illness not
requiring hospitalization.

 While the vast majority of cases have
resulted in mild, self-limited ILI, the global
death toll caused by pandemic A (H1N1)
2009 influenza virus infection was 460 (as
of 9 July 2009) in only 3 months since its
inception and will soon exceed the total
mortality caused by highly pathogenic avian
influenza A (H5N1) virus infection since
2003.

 The main reason for hospitalization remains lower
respiratory illness due to primary viral pneumonia,
often described as “viral pneumonitis,” reflecting
direct viral invasion in lung tissues.
 Preliminary pathological findings
 including diffuse alveolar damage, haemorrhagic
 interstitial pneumonitis with lymphocyte proliferation
 and a relative paucity of neutrophils (suggestive of
viral
 pneumonitis) and ARDS. Secondary bacterial
pneumonia
 has been infrequently documented but has been
 found in some autopsied cases (in Chicago (USA)
and
 Manitoba (Canada)).

 In the USA, >70% of hospitalized patients
 and approximately 80% of fatal cases have had underlying
 conditions considered high risk for complications
 of seasonal infl uenza. Severe cases and deaths have
 been reported in pregnant women from all sites, especially
 in their third trimesters, with intrauterine fetal
 demise or spontaneous abortion; in some cases, treating
 physicians have performed emergency Caesarean section
 to rescue mother and baby.
 A high prevalence of obesity in very severe or fatal
 cases was initially reported from clinicians in Mexico

 a
 considerable proportion of severely ill patients have not
 received infl uenza antivirals until very late in the course
 of their illness. A frequently reported pattern is for clinicians
 to start empirical antimicrobial therapy for
 community-acquired pneumonia, while deferring antiviral
 therapy until laboratory test results have confi
 rmed H1N1 infection. Where pandemic A (H1N1) 2009
 infl uenza virus activity has been detected in the community,
 clinicians should not delay antiviral treatment,
 especially for patients with pneumonia or progressive
 lower respiratory tract symptoms. Empirical antiviral
 treatment with a neuraminidase inhibitor (oseltamivir
 or zanamivir) should be initiated as soon as possible
 upon hospital admission for any suspected case of pandemic
 infl uenza.

Tamiflu ( oseltamivir phosphate)
 Tamiflu twice daily for 5 days for
acute illness, start within the first 2
days
 Tamiflu once daily for 10 days as
prophylaxis, after exposure, or
community outbreak of H1N1
influenza.

Relenza (zanamivir)
 Delivered by blister pack inhalation
of powder using a special dispersal
device.
 Each blister pack has 5 mg. Dose is
two of the 5 mg blisters, twice daily,
about 12 hours apart for 5 days for
people over 7 yr old.
 Prophylaxis is one blister pack, 5
mg, once daily for 10 days.

The Osteopathic Approach to the FluThe Osteopathic Approach to the Flu
PandemicPandemic
Why?Why?

 During the Spanish influenza pandemic,
an
 estimated 30% of the world’s population
became ill and 50
 million people died
Johnson NP, Mueller J. Updating the accounts: global mortality of the
1918-1920 “Spanish” influenza pandemic. Bull Hist Med. 2002;76:105-15.

 Effective vaccines will be difficult to produce before a novel human
pandemic strain emerges and will take substantial time to manufacture
and distribute in quantity.
 The world’s annual production capacity for influenza vaccine
is 300 million doses - enough for 4.5% of the
world’s population.
 These facts have caused some governments
to develop response plans to pandemic influenza
that involve creating antiviral stockpiles and increasing the
capacity to handle surges in the need for medical care.

A case series report of Vietnamese patients
with H5N1 influenza suggested that:
 “supportive care may be
the only option available”.
Even if more effective standard pharmaceutical
treatments are produced, it is unlikely that
sufficient quantities will be rapidly or widely
available because of financial, logistical, and
health care delivery limitations.
Tran TH, Nguyen TL, Nguyen TD, Luong TS, Pham PM, Nguyen VC, et al. Avian influenza A
(H5N1) in 10 patients in Vietnam. N Engl J Med. 2004; 350:1179-88

 It may very well be that,
depending on the availability of
resources including antiviral
drugs, hospital beds, ICU beds,
respirators, antibacterial
antibiotics, personnel healthy
enough to care for the sick, the
treatment of a massive H5N1
“Avian Influenza” pandemic will
include many different
approaches.

WHAT ABOUT
OSTEOPATHYOSTEOPATHY?

 The philosophy and methodology of
Osteopathic Medicine was founded
by Dr. Andrew Taylor Still in the
1870s.

 He served as a surgeon in the Union Army during the Civil
War. By the early 1870's Still criticized the misuse by
doctors of drugs common to the day.
Still supported a different philosophy of medicine:
He advocated the use of osteopathic manipulative
treatment.
Still's philosophy focused on the unity of all body parts.
He identified the musculoskeletal system as a key element
of health.
He recognized the body's ability to heal itself and stressed
preventive medicine, eating properly, and keeping fit.

Osteopathy is about Circulation
The Rule of the
Artery reigns
Supreme….
Andrew Taylor Still, MD, DO

http://static.howstuffworks.com/gif/adam/images/en/lymphatic-system-picture-c.jpg

Fluids, macromolecules,
and cells extravasated
from blood capillaries
enter lymphatic
capillaries in peripheral
tissues and are then
transported via the larger
collecting lymphatic
vessels and the thoracic
duct back to the blood
vascular system for
recirculation.
http://www.nature.com/jid/journal/v126/n10/fig_tab/5700464f1.html

Cellular level
Lymph node level
http://www.precadet.com/english/health_issues/lymphaticsystem.html

Osteopathy is “Leveropathy”
The philosophy and techniques of OSTEOPATHY are not
about treating bone disorder or “popping joints” to make a
noise. That doesn’t heal anything.
The body’s FASCIA, which contains all of the elements of
the nervous system and circulatory system, attach at some
point to various bony structures in the body.
By using the bones as LEVERS ( thus, “leveropathy”), an
osteopathic physician can affect the various elements of the
circulatory and nervous system.
This assists in making the body more effective in the
healing process of many disorders.

Andrew T. Still, M.D., D.O.
“ I have successfully treated many cases of
pneumonia, both lobar and pleurotic, by
convecting the ribs at their spinal
articulations… I carefully adjust misplaced
ribs…”

Andrew T. Still, M.D., D.O.
“The osteopathic prognosis for speedy
relief of influenza is good when the
osteopath has been called to the case
within reasonable time.”

Spanish influenza-what and why?
E.E. Tasker, D.O.
J.A.O.A. 1919 Volume 19
Insurance companies 13% deaths due to
influenza and 87% due to pneumonia
1,350 D.O.s1,350 D.O.s
43,500 cases of flu43,500 cases of flu
only 160 deaths160 deaths (apparent 0.375%
mortality vs. 2.5%)
at the allopathic rate, would have
expected death toll of 2,1752,175 from cases
treated by D.O.s

One hundred thousand cases of influenza with a death
rate one-fortieth of that officially reported under
conventional medical treatment
R.K. Smith, M.D., D.O.
J.A.O.A. 1920 Volume 19
 2,445 D.O.s
 sometimes 100-120 cases
per physician
 1/40th the mortality rate of
patients treated by MDs

CRITIQUES
 Not “statistical enough” – “it’s only
a survey”
• Statistics as we understand it now doesn't really
come around until the middle of the 20th Century.
Surveys were the best available.

CRITIQUES
 D.O.s were concentrated in rural
and mid-country regions that were
not as hard hit as urban and coastal
regions
 True and False – Most of the osteopathic schools were in
the middle of the United States but several were in urban
areas and Philadelphia and Los Angeles both had schools.
 D.O.s migrated all over the country
 D.O.s comprised <5% of the physicians but were
responsible for treating 10% of the population (M.D.s
were inducted into the armed services and served in WWI
as officers and D.O.s were not if they were above the
typical draft age)

CRITIQUES
 Osteopathy was a “drugless” approach
and some of the benefits may have been
because allopathic physicians may have
used dangerous or lethal interventions

“In a non-controlled observational study
that lacked today's rigorous scientific
standards, Smith reports that patients
that received [OMT] had a mortality
rate of 0.25% as compared to the 5%
for those that did not receive
manipulative treatment.”
One Hundred Thousand Cases of Influenza With a Death Rate of One-Fortieth of That
Officially Reported Under Conventional Medical Treatment (LETTER)
JAOA • Vol 108 • No 9 • September 2008 • 484-530
MarkAlain Déry, DO, MPH, Fellow, Infectious Diseases
Tulane University School of Medicine Section of Adult Infectious Diseases New Orleans, La

 J.A.O.A. January 1919
 62 cases
 9 developed pneumonia
 7 bronchopneumonia - 2 lobar pneumonia
 1 case developed edema glottitis and required surgery
 2 cases terminal
 “When rib mobility is re-established in pneumonia, your
case has progressed far towards recovery.”

C. Earl Miller, D.O.
 Prolific writer and teacher on
Lymphatic fluid techniques (1920’s)
 So much so that thoracic pump
technique has been referred to as the
eponymous“Miller thoracic pump
technique”

 J.A.O.A. January 1919
 Description of physical and clinical signs associated with
pneumonia
 “Pneumonia may be defined from an osteopathic
viewpoint, as a general infection with local manifestations
in the lungs.”
 “Osteopathic lesions present in all pneumonia cases.”
 “We have it from many of our most reliable (osteopathic)
physicians that they have treated 100, 200, or 300 cases
of lobar pneumonia without a single fatality.”
 Estimates less than 2% mortality vs. 10-25 %2% mortality vs. 10-25 %
otherwiseotherwise

 M.A.Lane also author of rare but informative book on
Dr. Still
 Experiment with rabbits exposed to antigen treated
with manipulation
 Possible relationship of continued manipulation on
rise in antibody levels

 J.A.O.A. February 1922
 Canadian D.O. wrote on specific
findings and treatment of Lymphatic
tissues
 Textbook devoted specifically to
treatment of lymphatics
 Brief treatments repeated several
times per week

The effect of direct splenic stimulation on the
cells and antibody content of the blood stream in
acute infectious diseases
Castillo - Ferris – Swift- 1934
 Splenic stimulationSplenic stimulation
 increase in leukocyte count in 80% cases
 average increase 2,000 cellsaverage increase 2,000 cells
 shift to the rightshift to the right (mature cells)
 increase in opsonic index in >80%opsonic index in >80%
cases with expulsion of formed antibodies
into the general circulation
 decrease in erythrocyte count in 75%
cases
 bacteriolytic power of serumbacteriolytic power of serum
increased in 68%increased in 68%

Revisiting Castlio and Ferris-Swift's Experiments on Direct
Splenic Stimulation in Patients With Acute Infectious Disease
Donald R. Noll, DO; Jane C. Johnson, MA; Joseph E. Brooks, DO
 Results: Contemporary statistical analysis confirms a modest
posttreatment increase in leukocytes, a decrease in erythrocytes,
a decrease in the Arneth index, and an increase in reticulocytes
after the application of direct splenic stimulation for patients
diagnosed with acute infectious disease. Contemporary
reanalysis also confirms statistically significant
posttreatment changes in the immune function tests.
Findings were less conclusive for the leukocyte differential cell
counts and for the effect of varying the number of splenic
compressions.
 Conclusions: Analysis of Castlio and Ferris-Swift's 1934 data
using contemporary statistical methods supports many of their
original conclusions. However, faults in study design common to
that era limit the article's applicability for modern researchers.
Additional research on splenic pump techniques using
contemporary study designs and statistical methods is
recommended.
JAOA • Vol 108 • No 2 • February 2008 • 71-79

 J.A.O.A. November 1939
 Comparison Los Angeles County Osteopathic Hospital
vs. N.Y.C. Municipal Hospital
 Bronchopneumonia
 10.66 vs. 29.6% mortality10.66 vs. 29.6% mortality
 Lobar pneumonia
 11.2% vs. 10.8%11.2% vs. 10.8%

 Osteopathic Annals 1982, Vol. 10 No. 3
 Study published in J.A.O.A. 1982
 all subjects inoculated with pneumovaxall subjects inoculated with pneumovax -
polyvalent vaccine
 study subjects treated twice daily for one weektreated twice daily for one week
 study subjects showed a significant increase insignificant increase in
antibody response to many of the sub-antibody response to many of the sub-
serotypesserotypes when compared to matched control
subjects

Comparison of thoracic manipulation with incentive
spirometry in preventing postoperative atelectasis
Sandra L. Sleszynski, D.O. and Albert F. Kelso, Ph.D.
 J.A.O.A. August 1993
 One year randomized researcher blinded trial
 21 received thoracic lymphatic pump and 21 received
incentive spirometry
 Atelectasis occurred in 2/21 (5%) patients regardless of
treatment (predicted value for postoperative patients is
15-20%)
 Thoracic lymphatic pump treated patients had earlier
recovery and quicker return toward preoperative values
for FVC and FEV1 than treated by incentive spirometry

thoracic pumpthoracic pump
incentiveincentive spirometryspirometry
pre-op day 1 day 2 day 3 day 4 day 5
0.4
0.6
0.5
0.9
0.7
0.8
1.0Forcedvitalcapacity

Transient basophilia following the application of
lymphatic pump techniques: A pilot study
 7 study subjects
 All received lymphatic pump technique
 pectoral traction and splenic pump
 blood samples collected at 15, 30, 60, 120,
and 240 minutes after treatment
 All subjects showed significant basophilia
 5 Control subjects
 None received lymphatic pump technique
 No change in white blood cell count
 Significance is that Basophils and Mast cells may
play a more significant role in initial immune
response

Effect of lymphatic and splenic pump
techniques on antibody response to
hepatitis B vaccine: A pilot study
 Experimental (n=20) vs. control (n=19)
 Vaccinated at 0, 5, and 25 weeks with
recombinant hepatitis vaccine
 Experimental group received OMT
3x/week for 2 weeks after each
vaccination
 50% of experimental group reached
protective antibody levels on 13th week
vs. 16% of controls

Increased Lymphatic Flow in the Thoracic Duct During
Manipulative Intervention
E. Marty Knott, OMS V; Johnathan D. Tune, PhD; Scott T. Stoll, DO, PhD; H. Fred Downey, PhD
JAOA • Vol 105 • No 10 • October 2005 • 447-456

Abdominal OMT
Thoracic OMT Exercise

WHAT SHOULD WE DO?WHAT SHOULD WE DO?
OMTOMT
Osteopathic Manipulative Treatment

Influenza Epidemic or Pandemic?
Time to Roll Up Sleeves, Vaccinate Patients, and
Hone Osteopathic Manipulative Skills
Gilbert E. D'Alonzo, Jr, DO
AOA Editor in Chief
JAOA • Vol 104 • No 9 • September 2004 • 370-371

The Osteopathic Approach to the Flu Pandemic

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