SPINAL LESIONS AND THEIR RELATION TO DISEASES OF THE GASTRO-INTESTINAL TRACT (continued 2)

Chronic lesions of the vagi nerves may exist and produce chronic diarrhea in the same manner as in acute diarrhea. Rest and a liquid diet, preferably boiled milk and albumin water, will be a helpful treatment; the diet requirement is to have a minimum amount of waste, so that the residue will cause the least possible irritation. Beef peptonoids with the milk will be a nutritious addition to the diet, and change of air and surroundings may be an aid to a more speedy cure. The skin and kidneys should be kept in a healthy condition and, if necessary, the bowels thoroughly emptied by injections.

Diarrhea of Children

Three forms of diarrhea are recognized in children: Acute dyspeptic diarrhea, cholera infantum, acute enterocolitis.

Acute Dyspeptic Diarrhea

This disease is most frequently due to errors in diet; the mother’s milk may be altered in quantity or quality from taking improper food; the child may be over-nursed, or the foods given in place of the mother’s milk are at fault. Too often a filthy bottle is the cause. The predisposing causes are dentition and extreme heat; and these, combined with constitutional weakness, bad hygiene and a weak spine, diminish the resisting power of the infant. Hence, in artificially fed children of the poorer classes, this disease is very prevalent.

Pathologically, there is catarrhal swelling of the mucosa of both the small and large intestines. The amount of mucus is increased, and there is more or less involvement of all the lymphoid tissue. The submucous membrane is often infiltrated. If there is much inflammation ulcers may occur.

Symptoms.—The child may seem to be in its usual health, with slight restlessness at night and an increased number of stools. This restlessness may be due to nausea and colicky pain. The stools are copious and offensive, containing undigested food and curds. In children over two years old these attacks may follow the eating of unripe food or drinking tainted milk. In other cases the onset may be sudden with vomiting, purging, and griping pains. The fever may rise rapidly to 103 or 104 degrees or more, sometimes followed by convulsions. The stools become more numerous—there may be twenty in the twenty-four hours—gray or green in color, and sometimes containing much mucus, rarely blood.

Diagnosis.—The sudden onset and the character of the stools, which never have a watery, serous character, distinguish this from cholera infantum. And the small amount of mucus which the stools contain distinguishes them from those of ileo-colitis. This form often precedes the onset of specific fevers.

Prognosis.—Among the better classes this is generally favorable, but among the weak, half-starved children of the poor it is often unfavorable, especially in hot weather.

Treatment.—The child should be clad warmly, kept absolutely clean and given a change of diet and air if possible, with frequent baths. Sterilized milk should be given at regular intervals; or if the diarrhea continues, beef juice and egg albumin instead. The bowels should be thoroughly cleansed by injections. The spine should be thoroughly treated through the lower dorsal and lumbar regions, and if the abdomen is not sensitive, a light treatment to the bowels directly will aid recovery. Frequently it will be found that the muscles of the neck and upper dorsals are considerably contracted, especially where the child has fever and is very restless.

For acute intestinal indigestion Ruhrah gives the following dietetic treatment: “Withhold all food for the first twenty-four hours, except a little albumin water. This is best given in small doses at not too great intervals. Plain boiled water may be used instead. Very weak tea to which a little red wine has been added may be given if the child is weak. On the second day the albumin or barley water may be given with the addition of weak strained broth, and on the third day malted milk may be added to the list. After four or five days cow’s milk diluted and boiled or peptonized may be tried. It is best mixed with a farinaceous gruel or with malted milk to start with. It may be given every other feeding for a day or two if it agrees, and the former feeding gradually resumed.

“In nursing infants withhold the breast twenty-four hours and feed as above. After that the breast may be given once for a few minutes and the feeding pieced out with albumin- or barley water. If it agrees the breast may be given for three or four feedings, every other feeding followed by albumin- or barley water. On the following day the breast may be given at each feeding. The time of nursing should be increased gradually until the child is back on its old schedule.”

Cholera Infantum

Definition.—An acute, catarrhal inflammation of the mucous membrane of the stomach and intestines, with some disturbance of the sympathetic ganglia. This is a disease of childhood during the first dentition.

Etiology and Pathology.—Probably due to the poisonous products of decomposing and fermenting foods acting upon the system. The predisposing causes are hot weather, dentition, bad hygiene, the previous presence of some slight dyspeptic derangement, dyspeptic diarrhea, and enterocolitis.

The pathological changes are similar to the morbid anatomy of catarrhal gastritis and enteritis. The serous discharges and rapid collapse are due to the intense irritation of the sympathetic system. The kidneys and liver may become involved, and bronchopneumonia is a possible complication.

Symptoms.—The disease is of sudden onset, setting in with severe vomiting, which is increased by giving food or drink. The stools are copious and frequent, at first containing some offensive fecal matter, and later becoming watery, and odorless. There is decided fever, reaching as high as 105 degrees. The pulse is rapid and feeble, ranging from 130 to 160. Prostration, pinched features, hollow eyes, depressed fontanelles and loss of weight are characteristic symptoms. The tongue is coated at first, but soon becomes dry and red, and thirst is intense. Even at this time a reaction may set in, but more commonly death results with symptoms of collapse and high temperature. In other cases there are restlessness, convulsions and coma. As there is no cerebral lesion, this condition is probably due to toxic agents absorbed from the intestines.

Diagnosis.—This is not difficult, as the toxic symptoms, the severe vomiting, the profuse watery discharge, rapid emaciation and prostration, and the hyperpyrexia are significant.

Prognosis.—Grave, even with the most favorable surroundings, although in numerous instances osteopaths have successfully treated this disorder. Much depends upon the promptness of treatment.

Treatment.—A change of air, complete rest, removal of all foods for a short time, and absolute cleanliness are of great importance. Thorough treatment should be given along the entire spine, particularly to the splanchnics of the stomach and the intestines, and to the vagi nerves in the cervical region. Frequent bathing with cool water, or better still, wrapping the child in cold, wet sheets, will reduce the hyperpyrexia.

Thorough cleansing of the stomach and intestines with warm water occasionally gives excellent results. In collapse the use of a hot bath is indicated, followed by wrapping the child warmly in blankets and placing him in a horizontal position. The food of the child should consist of peptonized milk, raw beef juice, diluted egg albumin, barley water and chicken broth. Nourishment should be given gradually, and only after the intense symptoms have subsided.

Acute Enterocolitis

In enterocolitis the ileum and colon are chiefly affected, especially the lymphatic glands or lymph follicles.

Osteopathic Etiology and Pathology.—Warm weather, the artificial feeding of children, dentition and bad hygiene are predisposing causes. The disease usually occurs between the ages of six and eighteen months, but it is not infrequent in the third or fourth year. This disease is not confined to the warm weather, but may set in at any season of the year. Previous light attacks of diarrhea are often a predisposing factor. Lesions in the spine occur from the eleventh dorsal to the fourth lumbar.

The mucous membrane is congested and swollen, and the solitary follicles and Peyer’s patches are swollen and often ulcerated. The changes may end here or the ulcers enlarge and extend into the muscular coat with the separation of a slough. There may be infiltration and thicking into the submucous and muscular coats, followed by induration of the tissue, producing abnormal rigidity.

Symptoms.—The disease may be a sequel of dyspeptic diarrhea or cholera infantum. The temperature increases and the stools change in character, being at first yellow, and later green. They contain traces of blood and mucus. Vomiting may be present, but is not a constant symptom. The abdomen is distended and tender along the course of the colon. The disease may abate here, recovery from the condition being slow; or the symptoms may increase in severity with persistent, small, painful stools, mainly of blood and mucus, tenesmus, and with scanty urine. The child grows pale and emaciated, and assumes a senile appearance. These cases last five or six weeks, death being preceded by coma and convulsions; though a few recover. Relapses are not uncommon and should be guarded against. Ulcerative and membranous forms may occur. Pneumonia and nephritis are possible complications.

Diagnosis.—Enterocolitis is distinguished from dyspeptic diarrhea by the greater severity, more fever, greater prostration, the stools containing more mucus and even blood, and by the greater pain and suffering. Cholera infantum may be recognized by the abrupt onset, very high fever, constant vomiting, and early collapse. If typhoid fever seems a possibility, the Widal test should be used.

Prognosis.—Grave; recovery follows prompt treatment with favorable surroundings.

Treatment.—Attention should be given to the condition of the spine from the eleventh dorsal to the fifth lumbar. An inhibitory relaxing treatment over the sacral foramina will lessen the tenesmus. When the ileum and colon are involved, disorder is usually present at the third and fourth lumbar vertebræ, although the lesion may be higher. Relaxation of all muscles in this region and correction of the vertebral lesions are essential.

Irrigation of the bowels once a day with a pint of cold water is very beneficial and even pieces of ice may be introduced into the rectum. Fresh, pure air, rest and cleanliness, with a restricted diet and daily warm baths are important. In a word, hygienic and dietetic treatment similar to that for acute diarrhea should be employed.

In all forms of diarrheal diseases in children much depends upon previous osteopathic attention, diet, hygiene, and environment.

Cholera Morbus

Definition.—An acute, gastro-intestinal catarrh of sudden onset, characterized by violent abdominal pains, incessant vomiting and purging.

Etiology and Pathology.—This disease greatly resembles Asiatic cholera; so much so that one seems justified in suspecting that cholera morbus, like true cholera, is due to a specific organism. No single bacillus has yet been designated as the specific germ, although one has been recognized resembling very much the common bacillus of true cholera. Until this has been fully decided, cholera morbus must be regarded as severe inflammation of the mucous membrane of the stomach and intestines, due to some poison generated from the improper food, which seems to be the cause of the disease, such as indigestible fruits, cabbage and cucumbers. It is most prevalent in hot weather, but is also caused by exposure to cold and damp. The condition of the mucous lining of the intestines is the same as in acute diarrhea. In fatal cases of cholera morbus there is the same shrunken, ashy appearance of the skin that characterizes cholera.

Symptoms.—The onset is sudden, with intense cramps in the epigastrium and frequently in the lower limbs; nausea; vomiting, and purging of bilious material, which later becomes almost like water, and in severe cases the discharge becomes serous, finally resembling the rice water discharges of true cholera. There are also intense thirst, moderate fever, rapid emaciation and loss of strength; the surface becomes cold and covered with clammy sweat; the pulse is frequent and feeble. The patient becomes restless and anxious.

Diagnosis.—Asiatic Cholera.—There is no way of distinguishing between Asiatic cholera and cholera morbus, except by examination of the discharges for the bacillus. Similar attacks are produced in poisoning by arsenic, corrosive sublimate and certain fungi, and are only discriminated from it by clinical history and cause.

Prognosis.—In the majority of cases the prognosis is favorable, death rarely occurring. The duration is from twenty-four to forty-eight hours.

Treatment.—A strong inhibitory treatment to the gastro-intestinal nerves is at once demanded. This relaxes the muscles of stomach and intestines, dilates the blood-vessels and lessens peristalsis. The treatment should be kept up until relief is given. In some cases, gentle treatment over the stomach and intestines quiets the distress. Inhibition at the occiput gives relief, especially to the nausea and vomiting. Hot applications should be applied to dorsal and lumbar spine.

The vomiting is relieved principally at the fourth and fifth dorsal vertebræ on the right side near the angle of the ribs. Cold carbonated water and pieces of ice swallowed are useful. The diet must be regulated, the further after treatment being symptomatic. Clear the bowel by warm enema if any irritating matter is still present.

Inasmuch as food passes through the small intestine in 4 to 6 hours, and requires 20 hours to pass through the colon, the colon should be emptied by high irrigation in all acute intestinal disorders.

Intestinal Colic

This is a painful spasmodic contraction of the muscular layer of the intestines.

Osteopathic Etiology.—Lesions of the splanchnics derange the intestinal nervous mechanism, with a consequent upsetting of circulatory equalization and chemical function of the intestines. Thus irritations and obstructions of the reflex arc predispose to lowered resistance, congestions, and disturbed chemism. Indigestible food, flatulency and impaction of feces oftentimes produce intestinal colic. Exposure to cold and emotional upsets may be factors. Foreign bodies, intestinal worms, abnormal amounts of bile discharged into the intestines, and reflex causes from diseases, as from the ovaries, uterus, liver, kidneys, etc., will produce the disorder; also lead poisoning, syphilis, rheumatism, locomotor ataxia, chronic malaria and hysteria.

Kerley says: “Children who take too much milk, too strong milk, or who take milk too frequently are the usual subjects of colic. Probably the most frequent cause of colic is indigestion of the proteid of the milk; either the proteid is in excess or the child has poor proteid capacity. Not a few cases of colic are due secondarily to defective bowel action.”

Symptoms.—Severe paroxysms of pain, centering around the navel and diffused throughout the entire abdomen. The pain is of a piercing, cutting and twisting nature, relieved upon pressure. The abdomen is distended and the patient restless and continually changing his position. The attacks alternate with periods of complete quietude. In severe attacks the features may be pinched and the surface cold, with feeble pulse, vomiting and tense abdominal walls, all indicating incipient collapse. The duration of the attack is from a few minutes to several hours, eased at intervals and usually ending by a discharge of flatus.

Differential Diagnosis.—In lead colic the history, the slate-colored skin, blue line on the gums, sweetish metallic taste, constipation, slow pulse, retracted abdominal walls, and lead in the urine will designate this disease. Biliary colic presents pain in the hepatic region, radiating to the back and right shoulder; also jaundice, calculi in the stools and bile in the urine. Tenderness over the gall bladder is important. Nephritic colic is accompanied by pain radiating down one or both ureters to the inner side of the thigh, with retraction of testicle of side affected, or the labia, and blood, mucus, pus or calculi in the urine. In uterine colic there is dysmenorrhea and pain in the pelvis. In ovarian colic there is extreme pain upon pressure over the ovaries, and hysteria. Abdominal aneurism presents tumor, pulsation, bruit. In inflammatory and ulcerative disorders of the abdomen there is tenderness upon pressure, and fever. The pain of acute appendicitis is at first general, centering in the right iliac fossa in about 24 hours. The X-ray may be of definite aid in renal and biliary conditions and various disorders, such as intestinal adhesions, angulations, etc.

Treatment.—Relief of pain is the first indication and is best accomplished by strong inhibition in the splanchnic region, which relaxes the spasm of the intestinal muscles, by normalizing the reflex arc. If disorders of the spinal column are located, it is of primary importance that they be corrected. In cases of irritation of the intestinal mucous membrane, a contraction of muscles of the spine will be found according to the area of the intestines involved, e. g., irritation of the mucous coat of the jejunum causes contraction of the muscles at the tenth and eleventh dorsals. It is a viscero-motor, viscerosensory or viscerotrophic reflex sign. On the other hand, a lesion at the tenth and eleventh dorsals may produce colic or other disorders of the jejunum. The portion of the bowel affected, therefore, can be often told by noticing the places of muscular contraction along the spinal column. Generally the jejunum and ileum are the portions of the bowel affected in intestinal colic. The pain can frequently be controlled if in the jejunum, at the tenth and eleventh dorsals; if in the ileum, at the twelfth dorsal; if in the ileo-cecal region, including the vermiform appendix, at first to third lumbar; if in the colon, at the third to the fifth lumbar; and if in the rectum, over the sacral and coccygeal nerves. Occasionally the duodenum and jejunum are reached by nerves as high as the fifth dorsal (usually vasomotor nerves, not sensory), and the other portions of the bowel lower, according to their respective positions. The relief is given by way of the splanchnics and sympathetics to the mucous (sensory) coat of the intestines, although inhibition relaxes intestinal muscles (motor nerves) and dilates blood-vessels (vasomotor nerves). Though precisely localized inhibition is of decided value, still if normal alignment, through adjustment, can be secured results are usually quicker and more satisfactory.

Anterior treatment to the abdomen helps to relieve the contracted fascia of the mesentery, with a consequent freeing of the circulation. It aids peristalsis of the intestines and expulsion of the irritating material. This probably produces considerable effect by way of the axone reflex. Direct treatment to the abdomen for the peristalsis relieves also constipation, impactions and the enteralgia, the latter principally by firm pressure. Peristalsis is also increased by stimulation of the vagi and inhibition of the splanchnics. The latter treatment, of course, is not given to relieve pain directly, but to facilitate the removal of irritating substances if such are the source of trouble. If this does not produce a movement of the bowels promptly, a warm enema will assist greatly. The cecum and sigmoid should not be overlooked.

Flatulency can be relieved by direct pressure upon the solar plexus, which apparently removes obstructions to the abdominal nervous system (particularly the nerves of the digestive glands, as fermentation and flatulency are due to a disproportionate secretion of digestive juices) and thus the gaseous formations are absorbed. Additional treatment to the lower dorsal vertebræ and lower ribs to relieve nerve lesions and increasing both thoracic and abdominal circulation may be indicated.

As stated in the etiology of intestinal colic, the splanchnic nerves contain not only sensitive fibers, but motor and vasomotor fibers as well. The same is true of the vagi nerves; they exert upon the intestines not alone a motor influence, but also a blood control; consequently, our work in a certain region can be for more than one purpose. Hot applications to the abdomen may be of benefit. And hot fomentations to the spine for 20 or 30 minutes (affecting reciprocal innervation) is often of great benefit. The diet should always be regulated for a few days at least.

Constipation[77]

Constipation is an unnatural retention of feces from any cause. The following causes are frequently met with: A deficiency of the bile or other secretions that aid peristalsis; many acute and chronic diseases which lessen the secretions and impair peristalsis, such as anemia, hysteria, chronic affections of the liver, stomach and intestines and acute fevers; certain drugs and strong purgatives; strictures; concentrated food; sedentary habits, overfatigue and neglect of the calls of nature. Atony of the colon may be caused by chronic disease of the mucosa and by general disease causing debility. There may be weakness of the abdominal muscles, due to obesity and the distention of frequent pregnancies, or obstructions, such as displaced uterus, pregnancy, prolapsed cecum, sigmoid or rectum, and displaced coccyx. Constipation is really a symptom, in most cases, of some disease; many times it is about the only symptom observed. One has to take into consideration the many causes that would produce constipation when the treatment of a case is undertaken. A disordered structure may be found in almost any region of a body, which would bear directly or indirectly in the causation of constipation.

Irregular habits often bring on the most obstinate cases of constipation in later life. There may also be local causes, such as disturbances of the normal secretions, impairment of intestinal walls, due to inflammation, and mechanical obstructions caused by tumors, intussusception, twists, etc. Constipation in infants is usually caused by errors in diet, but may be congenital.

In all obstinate cases the X-ray should be employed in diagnosis.

In the majority of cases lesions will be found in the vertebræ of the lower dorsal and lumbar regions, or in the lower ribs of either side. The lesions may affect the vascular supply and innervation of the intestines directly, or the lesion may cause the constipation by affecting some other digestive organ first. Lesions to the vagi affecting the peristalsis of the intestines are common.

The usual symptoms are frequent stools, debility, lassitude, headache, loss of appetite, anemia, furred tongue and fetid breath. Serious symptoms may result in long continued cases, such as piles, ulceration of the colon, perforation, enteritis and occlusion. The fecal mass may become channeled and diarrhea may occur from the irritation. In long standing cases of constipation, if the patient suddenly develops diarrhea the rectum should be well examined to see if there are impacted feces present. Neuralgia of the sacral nerves may also be caused by impacted feces in the sigmoid flexure.

Treatment.—Naturally, owing to the numerous etiological factors, each case is a special study and the treatment is necessarily varied. Many cases will present slight impaction of the bowels, a sluggish liver, spinal lesions and so on, which simply require a specific treatment and all the symptoms will be removed. On the other hand, constipation may be due to prolonged ill health and thus require a careful, systematic treatment, not only of the bowels, but of the entire system. Of primary importance in these cases is regulation of the diet, plenty of exercise, sufficient sleep, and regularity in going to stool at a fixed hour each day. The effect of attention to the latter point, in some instances, will be sufficient to perform a cure. Too much cannot be said in regard to the beneficial effect of systematic habits.

Lesions may be found in the spinal column producing constipation from about the fifth dorsal to the coccyx, although principally the lower three dorsal and upper two lumbar vertebræ are at fault. Constipation may be caused by defects at any point in the intestines, and consequently the sections of the spinal column sending nerves through the intervertebral foramina to the several sections of the bowels should be examined. At any point from the fifth dorsal to the coccyx, certain vasomotor, motor and secretory nerves of the intestines may be affected by various lesions. The vasomotor nerves keep up the vascular tone of the bowels, the motor nerves the peristaltic action and the secretory nerves attend to the intestinal juices. In constipation, disorders of the spinal column are generally found on the right side. There is no good reason offered as to why this is so.[78] In those cases where the liver is impaired, the answer might be because most of the nerves to the liver are on the right side, but the right side is just as often affected when the lesions are in the lumbar region and the nerve supply to the hepatic region intact. Dr. Still considered the fifth dorsal of importance.

The vagi nerves have important bearing upon the motor apparatus of the intestines. Lesions in the upper cervical, involving intestinal fibers of the vagi, occur occasionally. Stimulation of these fibers increases the peristalsis of the intestines. Mechanical stimulation of the mid and lower dorsal region, as shown by osteopathic experiments, increases peristaltic action and vaso-constriction in the stomach and intestines.

The value of direct treatment over the intestines from the duodenum to the rectum in most cases of constipation cannot be overestimated. It aids peristaltic action, removes impactions, stretches adhesions, strengthens weakened muscles of the intestines and abdomen, and in general gives tone to all of the abdominal organs. The treatment should not be given in a hap-hazard manner, but each effort should be for a definite purpose. Care should be taken not to bruise the intestines or other organs, as by gouging or severe punching; the flat surface and the palms of the hands should be used. This means that the part of the bowel involved should be treated intelligently, the osteopath reaching underneath the section and the patient drawing the bowels up and in. Obstructions and impactions of the gut, especially at the ileo-cecal and sigmoid regions, should be carefully corrected. At all angles of the gut, impactions and prolapses may occur.

J. H. Sullivan[79] makes the following observation concerning severe, deep abdominal treatment: “I have noted that this often resulted in the reverse of good effects. In constipation, naturally then, I am chary about treating abdominally, confining my work principally to the biliary regions, the ileo-cecal and left iliac regions and have attained good results when a promiscuous working of the abdomen had not so resulted.” This emphasizes the point that specific treatment is as much indicated for the abdomen as it is for the spine.

Frequently there will be found a spastic condition of the pelvic colon, often associated with congestion and adhesions. This probably sets up a reversed peristalsis. Treatment by inhibitory relaxation, with patient in knee-chest position, and adjustment of lumbar and innominate lesions, is indicated.

Direct treatment to the liver and biliary ducts is necessary in many cases, as the bile secretion is often defective; thus a slowness or inactivity of the liver and bile ducts might cause costiveness.

Some cases result from anesthesia of the rectum, due to pressure of the fecal matter collecting in the rectum. Simple dilatation of the rectal sphincters and a stimulating treatment through the sacral nerves will bring about a healthy activity of these parts. Occasionally the coccyx becomes displaced and produces paresis of the rectal nerves; or a displaced uterus or a tumor may produce the same result.

The use of proper food is essential. Coarse food leaves a great amount of residue, and on the other hand, dainty food leaves but little residue, both causing costiveness. As a rule increase the amount of fruit and vegetables. The patient should drink considerable water, and the time is of importance. Have a glass of cool, not iced, water taken on arising and if breakfast is delayed sufficiently, another in half an hour. Most people do not drink enough water. Unless contraindicated eight or ten glasses daily should be insisted upon. An enema[80] occasionally is indicated and is a great aid when used, particularly in cases of paralysis of the intestines and in impactions. Correct breathing and out door life are beneficial.

Treatment of the Constipation of Infants.—Repeated small enemata at a fixed hour each day will often be satisfactory but be certain that the tissue is not irritated. Two ounces of tepid water at a time should be injected. Careful spinal treatment and massage to the abdomen will be useful, as will slight dilation of the anus, which is usually done with the little finger, but in obstinate cases a soap stick may be used. When there has been continued straining at the stool, the sigmoid and rectum will often be found prolapsed, causing a mechanical obstruction. With the finger well lubricated this can be corrected and often is all that is needed. These directions, with care in the foods, are usually sufficient in any case not congenital. In chronic constipation Ruhrah outlines dietetic treatment as follows: “In infants see that they get sufficient fat and protein; well cooked and sweetened oatmeal gruel is useful. Orange juice, baked apple, or prune juice taken on an empty stomach is of service. Olive oil, the malted foods, or malt extracts are useful. In older children fresh fruits, vegetables, and oatmeal porridge are of value. Graham bread, dates, figs, and prunes may be used.”

Intestinal Obstruction

(Ileus)

This is due to a sudden or gradual closure of the intestinal canal at any point. Closure of the gut may be caused by strangulation, intussusception, twists and knots, abnormal contents, strictures, tumors, kinks, spastic states, adhesions, etc.

Strangulation.—This is the most frequent cause of acute obstruction of the bowels. There may be stricture of the bowels due to inflammatory processes producing bands or adhesions, or due to the adhesion of a bowel to an abdominal wound; a vitelline remnant, as a blood vessel, may remain and act as a strangulating cord, or in Meckel’s diverticulum one end may be attached to a mesentery or abdominal wall and thus form a ring through which the gut may pass and become strangulated.

Strangulation may take place through the foramen of Winslow or the foramen ovale, or between the pedicle of a tumor and the abdominal wall.

Peritoneal pouches, mesenteric and omental slits, adherent appendix or Fallopian tubes and diaphragmatic hernia may be other causes. An internal strangulation (hernia) may take place in the crural or inguinal canal, in the umbilicus, in the sacro-sciatic notch or in the opening through which the infra-pubic vessels pass. In strangulation there is a constriction of a portion of the bowel causing an arrest of the circulation of blood at that point, and more or less stoppage of fecal matter of the intestine.

In ninety per cent of cases the strangulated part is in the lower abdomen and sixty-seven per cent occur in the right iliac fossa, according to Fitz.

Intussusception or Invagination.—Intussusception is a slipping of a part of the intestine into another part immediately below it, as the slipping of a part of a finger of a glove or a coat sleeve into another part. The portion involved may be anywhere from half an inch to a foot or more in length. This produces compression and inflammation of the intestine, and obstruction to the intestinal contents. It occurs principally in children and is more common in males.

Spasms of the intestinal muscles and perverted peristalsis are probably the most common causes. One part of the bowel may be dilated and an adjacent portion contracted, thus allowing an invagination. Diarrhea, habitual constipation and intestinal polypi are important exciting causes. Invaginations oftentimes occur just before death, probably due to irregular peristalsis.

Following engorgement and inflammation of the invaginated portion, a tumor is usually present, and lymph is exuded which may cause the layers of gut to adhere, so that the invaginated portion is firmly held. Necrosis and sloughing are then likely to take place.

Intussusception varies according to location and is named according to the part of the bowel involved. There are commonly recognized (1) Ileo-colic, when the ileo-cecal valve enters the colon. (2) Enteric, of the small intestines. (3) Colic, of the large intestine. (4) Colico-rectal, of the colon and rectum. (5) Rectal, of the rectum.

Twists and Knots.—These occur more frequently in males, usually between the ages of thirty and forty. In nearly all cases the twist is axial, accompanied by relaxed and lengthened mesentery. One portion of the bowel may be twisted about another, or a loop of bowel twisted upon its long axis. A bowel being impacted or overdistended by feces and gas, is quite likely to roll on its axis or knot and become dislocated, its weight and inactivity thus producing compression and obstruction of the bowels. The volvulus commonly occurs in the large intestine, at the sigmoid flexure and in the ileo-cecal and cecal regions. It occasionally occurs in the small intestine.

Abnormal Contents.—Obstructions may be caused by gall-stones, enteroliths, lumbricoid worms, certain medicines (such as magnesia and bismuth), fruit stones, coins, needles, pins, buttons, etc., and fecal matter. Foreign bodies usually lodge in the ileo-cecal region and in the small intestine, while fecal impactions occur in the large intestine, more frequently in the lower part. Females are more subject to it than males.

Its causes are many and are similar to those of constipation. Spinal lesions are very frequent, probably causing paresis or paralysis of a segment of the bowel; or all the forces that maintain a normal activity of the intestines may become impaired. Hemmeter[81] says it is “more frequently the result of defective innervation of the intestine.”

Impactions are frequently met with and are easily overlooked under any diagnosis which does not include thorough palpation of the abdominal viscera. The impaction may be so large as to produce dilation of the bowel. The obstructive mass becomes very hard and dry and perhaps channeled, allowing some material to pass until, finally a large piece of fecal matter will obstruct the passage completely. In diagnosis it must not be confused with neoplasms, tumors, etc. Impactions may occur at any point of the colon and the weight so drags the bowel out of position as to be misleading. The principal points are the ileo-cecal region, sigmoid flexure, and rectum. Tenderness is usually present, as may be diarrhea which must not be taken as evidence that the bowel is clear. Impaction gives rise to many reflex symptoms and is often the real cause of many mistaken conditions.

Too much cannot be said on the importance of a thorough examination of colon and its connections, which should be routine of every examination as the large bowel is impacted much more often than suspected and may be the seat of many reflex and direct disturbances. The heart may be affected by weight upon the vessels, gastric disturbances and signs of auto-intoxication from absorption may appear.

Dilatation of the sigmoid flexure, especially when it is congenitally long, may even be so great as to crowd up and interfere with the liver and diaphragm; in these cases the coats of the intestines are usually hypertrophied.

Strictures and Tumors.—These usually occur in adults, more frequently in women and generally involve the large intestine and lower part of the abdomen, most of them occurring in the left iliac fossa. They frequently result in chronic obstruction. Occasionally, a stricture may be spastic, due to vertebral lesions, that is severe enough to cause complete blockage of intestinal contents. These are usually of the pelvic colon. There are cases where the opposite condition, paralysis of a section, generally of the small intestine, occurs. This may be due to injuries to the bowel, or to damage of the blood supply, or to derangement of the innervation.

Scar tissue, following ulceration of the bowel; tumors of various kinds; and congenital defects, are possible sources of intestinal obstruction.

Symptoms.—Acute Obstruction.—There is constipation, nausea, vomiting, and pain. The pain is of a colicky nature and may come on abruptly. After the contents of the stomach have been vomited, the material becomes colored with bile, and finally stercoraceous vomiting occurs. Observing the contents vomited (gastric, bile-stained, and fecal) will greatly aid in the diagnosis. The contents of the bowel, below the obstruction, may be emptied or complete constipation may remain. All the symptoms, as a rule, rapidly grow more pronounced. The pain is more severe; tenderness occurs over the abdomen in limited areas; there is slight tympany; the eyes are sunken; the skin is cold and clammy; the pulse is quickened and feeble; there is rapid increase of leucocytes; the urine highly colored; the tongue is dry and there is incessant thirst; tenesmus and tumor may be marked, and fever occasionally occurs. The above condition may continue from three days to a week, when collapse and death may occur, if relief is not obtained.

Chronic Obstruction.—In fecal impactions constipation of long standing is commonly observed. In some cases the fecal mass has become channeled, allowing the bowels to remain open; the patient possibly not knowing that there is any trouble. In fact, diarrhea may be present, due to irritation above the impaction. Finally, however, obstruction occurs; the breath is offensive, the appetite is poor, the abdomen swells, and there is fullness and weight within the abdomen, accompanied by pain and vomiting. Upon examination before complete closure, the fecal impactions can easily be felt through the abdomen externally. The tumor is a yielding mass. It has been mistaken for an enlarged liver or gall-bladder, a kidney, or a tumor of the stomach or duodenum. Other symptoms may be present as hiccough, jaundice, tenesmus, tumultuous peristalsis, local peristalsis, local peritonitis and collapse. In stricture caused by cicatrices that may have been formed years before, complete obstruction takes place. Transient attacks often occur. Usually the general health is greatly impaired long before complete occlusion.

Diagnosis.—A diagnosis can usually be made by careful, thorough examination through the abdominal wall, in connection with the symptoms, and the physical signs. The region of intestinal trouble is manifested by contracted muscles at certain points along the spinal column, corresponding with the particular portion of the bowel involved, as indicated under intestinal colic. Examining the patient in the knee-chest position will often give a better opportunity to locate and outline the obstruction. Rectal and vaginal examinations should not be neglected. Intestinal obstruction may be confounded with tumors, hernia, intestinal colic, enteritis, peritonitis, hepatic colic and renal colic. Peritonitis may be differentiated by the history, the early fever, diffused tenderness and absence of fecal vomiting. When invagination occurs, besides the symptoms of obstruction, the age, tenesmus, bloody discharges and the sausage-shaped tumor in the line of the colon, will be diagnostic. In stricture, the history, gradual onset, and ribbon-like and bloody stools will distinguish that disorder. In tumors the gradual onset, age, bloody discharges, and cachexia will be important symptoms. X-ray diagnosis may be of value in certain cases.

Treatment.—Treatment of the bowels directly is required, and each case must depend for its relief upon the ingenuity of the osteopath. Rules to be followed cannot be given, as cases vary in manner of involvement and in location, consequently the correction of the disorder depends as much upon the ability of the osteopath as does the determination of the diagnosis. Taxis is the method commonly used in relieving intestinal obstructions, though other methods may be employed.

In invagination, raising the buttocks and lowering the chest, with thorough injection of oil or tepid soapsuds, or an inflation of the colon with air, may give relief. In addition to thorough but cautious manipulation of the bowels as in impaction, irrigation of the lower bowel with warm water, soapsuds, or glycerine and water, will usually be of material aid. In strangulation, high injections of warm water, and assuming the knee-elbow or lateral position, may straighten out the acute obstruction. Twists and knots are best relieved by direct treatment, although injections may be of aid. Kinks of the pelvic colon, ileum, and duodenum are best treated with the patient in the knee-chest position. Tumors and strictures will require, sooner or later, surgical interference in most cases, but to treat as in impaction will be effective for a short time at least. If there is no indication of immediate relief within three days, surgical interference should be instituted. Besides the ordinary treatment for the nausea and vomiting, washing out the stomach will help allay such disorder, quiet the peristalsis and relieve the abdominal distention and pressure above the seat of obstruction. Strong thorough treatment of the spinal nerves to the stomach and intestines will be of great help in lessening pain, establishing normal peristaltic action and in suppressing inflammation. The vagi also should be treated for perverted peristalsis. Hot fomentations will be of service. The nutrition of the patient is best retained by rectal injections of food.

Spastic states, particularly of the pelvic colon, frequently cause constipation of various degrees of chronicity. Reaching beneath the spastic area and inhibiting and raising (knee-chest position) the parts will often give marked relief.

Adhesions can often be stretched sufficiently to restore normal function of the bowels.

Treatment of impactions and abnormal contents requires an additional word. The first step is to free the colon of the fecal mass. The enema is of great assistance in this, for cases of long standing present a hard, dry mass, often adherent, and the mucous membrane is sensitive from inflammation. Much abdominal treatment must not be given until the mass is softened by water. When in the sigmoid or rectum it may, if not dislodged by repeated enemata, have to be removed by a colon spoon, perhaps under anesthesia. Impaction of the small intestine is rare and out of reach of the enema, although if taken as hot as can be borne, it will exert considerable influence high up. In these tendencies and in constipation, when the bowel must be kept open before treatment has produced much effect, there should be an effort made to break up any cathartic habit which may be formed. The enema is a most valuable aid, but it must be given correctly. The patient should be instructed that a fountain syringe is preferable, and that it must never be taken standing. This merely fills and distends the rectum, or lower sigmoid at the best, and is passed without any or with very little effect. Lying on the right side is a very good position, as is also on the back with hips elevated, but the knee and chest is best in most cases. The water should be a little above body temperature and can be saponified or used clear. The effect will be about the same. The tube should be perfectly smooth and well lubricated and introduction must be made with care so as not to bruise or irritate. The water, having been allowed to run to expel the air, may be now started and will separate the mucous folds and allow easy penetration. The rubber tube should be held between the thumb and finger, so the flow can be stopped as soon as it meets an obstruction. When this is passed the flow can begin again and continue until the required amount (from one to two quarts for an adult), has been taken, or until the feeling of distention becomes too great. By following this method, much of the distress and colicky pains which sometimes accompany an enema, may be avoided. Water should be held for some minutes, to allow softening of the fecal mass. In many impactions it is important to get the water into the ascending colon. For that purpose nothing is better than a Coles sigmoid irrigator. This is shaped somewhat like the letter S and is about a foot long from tip to tip. Its introduction is not difficult, but care must be used. Place the patient on the right side and stand in front, having the bag suspended near. Introduce the tube and with slow, gentle pressure let it follow the course of the bowel. When the splenic flexure is reached, it will stop, but by letting a little water flow, the bowel will distend and it will pass. When in the full length, the end will be near the median line and in the transverse colon. Now let the water flow slowly, stopping frequently, and with one hand gently lift and work the abdomen. This will both soften the contents and aid the water in reaching the farthest point. It is not well to give more than a quart the first time, as there is apt to be some prostration. The tube also has the mechanical effect of raising and replacing the sigmoid, descending colon and splenic flexure. When there is lack of tone to the bowel or when very little stimulus is needed, a half pint of cold water taken in the morning, will often act quickly. Appliances which force the water into the bowel when the patient is sitting, are not recommended, as they tend to stretch the muscular coat by pressure from lifting a column of water.

Hernia.—There are several methods of replacing a hernia. The first endeavor, in every instance, must be to reduce it, whether it be strangulated, incarcerated or simply protruded. One of the easiest and commonest methods is to place the patient on his back, the buttocks elevated, the legs flexed upon the thighs, the thighs flexed upon the abdomen, and the limb on the affected side slightly rotated inward, so that the columns of the ring about the hernia may be relaxed. After the hernia is protruded a little more, so that its contents may be emptied readily, a gentle pressure with the thumb and finger is made upon the upper part of the tumor, when the rest will follow. A gurgling noise is heard upon reduction. Cases that cannot be reduced and are causing acute obstruction of the intestines, should be treated surgically. Incomplete hernia, which does not show externally, may be present and cause severe reflex symptoms. Considerable attention has been given to this by some investigators. The patient is placed in the Trendelenburg position and the bowel lifted out of the fossa. If any signs of hernia are present a well fitting truss will often cause it to heal. Exercises, in a few instances, will be beneficial.

Appendicitis

Appendicitis is an inflammation of the appendix vermiformis. In a few cases the cecum and surrounding tissues are involved (typhlitis, perityphlitis). The vasomotor nerve supply comes from the lower three dorsals and upper two lumbars. The sensory nerves make their exit from the three lower dorsals. Appendicitis is nearly always predisposed by injury to the innervation of the vermiform appendix and immediate region, vertebral derangements or subdislocations from the tenth dorsal to the third lumbar. The vermiform appendix is a peculiarly constructed organ, and its function has not been determined with positiveness. It undoubtedly has a function and possibly a very useful one. Sir William Macewen[82] does not share in the general belief that the appendix is without function, but protests against its indiscriminate removal, believing it has a powerful influence over the function of the colon. “Yet thousands have been operated and show no ill effect.” This is in keeping with the ideas of Dr. Still, who always maintained that the appendix is of importance to the human economy. Although the organ has been found in various localities of the abdomen, this fact and others do not necessarily indicate that it is a functionless relic. It is richly supplied with lymphatic and blood-vessels and has a peristaltic action peculiar to itself. When the organ is in perfect condition, foreign material probably would not find a lodging point in it, on account of its peristalsis. Dr. Still[83] suggests that the appendix has a sphincter, also the power to contract, dilate or shorten, should any foreign substance enter, and he worked with this idea in view with uniform success. The truth of this theory has been proved by Abrams[84] who has demonstrated by the aid of the fluoroscope that peristalsis of the appendix can be stimulated by percussion at the 10th dorsal and it made to empty and fill itself. Abrams makes use of this fact in the treatment of catarrhal appendicitis. Appendicitis may also be caused by fecal impactions and foreign bodies in the bowel contiguous to the appendix. In these cases there is usually an impaired innervation from the spine, due to vertebral and lower rib lesions, resulting in a weakened muscular coat and catarrhal congestion of the mucosa. In a word, prolapse of the bowel at this point is a predisposing common cause. In various instances abrasions of the coats of the tube occur, or the innervation or vascular supply is impaired, and pathogenic bacteria, as bacilli coli communis, streptococci pyogenes, staphylococci pyogenes aureus, typhoid bacilli, tubercle bacilli and others, find a favorable lodging point and determine the nature of the disease. Injuries to the spinal column and displacements of the vertebræ in the lower dorsal and lumbar regions, straining and lifting, tight lacing, torsion of the appendix, traumatism, impaction of feces, concretions and foreign bodies, acute indigestion, indigestible food, overeating, exposure to wet and cold, and infectious diseases (as typhoid fever, tuberculosis and influenza), are all in the list of causes of appendicitis.

Pathologically, in most cases the inflammation is catarrhal. This includes many of the mild attacks. The mucosa is inflamed similarly to catarrhal processes elsewhere, although the inflammation may rapidly spread to the deeper structures unless immediately cared for. The inflammation may be so severe that the lumen becomes closed. This is termed obliterating appendicitis. When this occurs the attack may cease and danger from subsequent attacks are at an end, but inflammation may go on to purulent involvement and even to ulceration, gangrene and perforation or peritonitis. An abscess may be within or without the appendix. Adhesions are likely to form about the mass.

Symptoms.—A sudden, violent pain in the abdomen, usually localized in the right iliac region, although at first this pain may be general. The point of greatest tenderness is detected over McBurney’s point—a point at the intersection of a line between the umbilicus and the anterior iliac spine, with a second drawn along the outer edge of the right rectus muscle. The patient usually lies on the back with the right leg drawn up. The severity of pain is not indicative of the seriousness. If the pain ceases suddenly, it is commonly a serious indication. There is usually fever at the onset, the temperature being from 100 to 102 or even 104 degrees F., and very rarely preceded by a chill. In favorable cases the temperature gradually falls, reaching normal in from five to seven days. If recovery has not begun by this time an abscess is probably forming. If suppuration takes place the temperature continues with but slight fall, although in some cases there is a rise, or it may become almost normal. Pain in the right iliac fossa, without fever, rarely points to an acute attack of appendicitis. Vomiting and nausea are more or less frequent, and more commonly present in the event of perforation or rupture of an abscess. In favorable cases vomiting rarely lasts beyond the second day. In the majority of cases constipation is present from the beginning of the attack, due to paralysis of the bowels. There may be diarrhea, particularly in children.

“Urine is febrile in character with large quantities of indican. The blood shows leucocytosis. A leucocyte count of 20,000 is high and indicates an acute appendicitis, with pus, gangrene or peritonitis.”

On inspection of the abdomen at the onset of the attack, the sides look alike, but on palpation there is rigidity of the rectus abdominis muscle and the other muscles overlying the seat of inflammation. The whole abdomen may be slightly distended. In the majority of cases there is a progressive development of a hard swelling or tumor in the right iliac fossa. These tumors vary in size, but are usually oval and the size of a hen’s egg, and generally situated a little above Poupart’s ligament. Fluctuation of the tumor is indicative of suppuration. There is often great irritability of the bladder and frequent micturition. A sudden fall in the temperature often indicates that a perforation has taken place, or that a small abscess has ruptured into the intestines. In favorable cases the temperature falls at the end of the third or fourth day, the pain lessens, the tongue becomes clearer and the bowels are moved. If the tumor persists, the patient is very liable to have a recurrence of the condition.

Rapid growth of the tumor and aggravation of the several symptoms point to suppuration, especially extreme tenderness over the point of inflammation. If the appendicitis goes on to suppuration, there is danger of rupture into the peritoneum. In a few cases the abscess may rupture into the bowel, in which case the patient recovers. Other terminations are lumbar abscess, hepatic abscess and perinephritic abscess. Death may be caused by septicemia or pylephlebitis. These events may be delayed a variable length of time, depending upon the extent and strength of the adhesions that form about the abscess. “The gravity of the appendix disease lies in the fact that from the very outset the peritoneum may be infected; the initial symptoms of pain, with nausea and vomiting, fever, and local tenderness, present in all cases, may indicate a widespread infection of this membrane.” (Osler). He also says local signs are not so trustworthy as the general symptoms.

There is liability to relapse in appendicitis. The attacks may recur for years at different intervals. In some cases these intervals are very short. In some cases perfect recovery may take place after repeated attacks.

Diagnosis.—In many cases the diagnosis is easy, but other cases require careful study and close observation. Sudden pain becoming localized, tenderness and rigidity in the right iliac region are three symptoms that together almost positively indicate appendicitis. The leucocyte count is of particular value. A pseudo-appendicitis, with all symptoms of true appendicitis in the initial stage, may be caused by the downward dislocation of the twelfth rib on the right side, and occasionally the eleventh rib on the same side. The rib lies obliquely downward toward the crest of the ilium. In a few cases the obliquity of the lower rib is so great as to very nearly touch the ilium. The dislocated rib may produce severe irritation, pain, tenderness, rigidity, and even inflammation, of the abdominal muscles. The patient nearly always complains of the pain being deeply seated, thus possibly confusing one. In typhoid there is a gradual development of the fever, characteristic temperature curve, enlargement of the spleen, epistaxis and diarrhea. The Widal test should be made. The absence of fever and intermittent pain in the abdomen, with complete constipation, fecal vomiting, general distention of the abdomen, bloody stools and marked tenesmus would determine intestinal obstruction. In tubal disease a gradual onset, a more dull and constant pain, the history, and pelvic examination will usually differentiate this disorder from appendicitis. Kelly[85] gives these points in differential diagnosis, between acute salpingitis and appendicitis: “In the former it will usually be found that there has been a yellowish vaginal discharge for some period before the attack. The local pain and tenderness, usually located deeper in the pelvis, is most intense on palpation in the region of Poupart’s ligament. On vaginal examination exquisite tenderness is felt on either side of the uterus.” In biliary colic the pain is higher along the biliary ducts and gall-bladder, extending even as high as the shoulder, and jaundice is generally present. In renal colic the pain extends along the ureters down to the inner side of thigh and testicle, and back into lumbar region. There is absence of fever and rigidity. The pain in perinephritic abscess is downward into groin, as in nephritic colic, and there is tenderness of the lumbar region. Exploratory incision may be necessary.

Prognosis.—Naturally, the prognosis depends upon the character of the appendicitis, but on the whole the prognosis is favorable. A large proportion of cases recover. Surgical operations are many times deferred until too late; undoubtedly on account of the uncertainty of the condition. Still, on the other hand, many serious cases recover under the proper treatment when an operation seemed almost absolutely necessary; all going to prove the fact that very much depends upon diagnosis of the true condition. The statement that there is “no medical treatment for appendicitis,” seems rather broad in view of the report of the medical inspector[86] of the French Army in Algeria. Out of 668 patients suffering from appendicitis, 188 were operated upon and 23 died, while 408 were treated medically and only three died. He concluded that a meat diet tended to increase the number of cases. “It is exceedingly common and the prognosis is, on the whole favorable. Tafft, of Copenhagen, found adhesions in the neighborhood of the appendix in 35 percent, of all bodies subjected to post-mortem examinations[87].

Treatment.—Confine the patient in bed at once. Cases have undoubtedly been lost by not enforcing this point. Attempts should be made to correct the disordered condition of the dorsal and lumbar regions. Thorough and careful treatment should be given at this point, and in most instances the pain can be relieved by correction of the disordered vertebræ. If the case is seen at the beginning of the attack, careful manipulation that especially lifts the cecum and surrounding structures and local application of ice are indicated. However, great care should be exercised here, for some of the most severe cases show no induration. Temperature, pulse, and blood picture are invaluable as guides. When the case is advanced, extreme care should be used in manipulating over the swollen and inflamed region. Hot applications will be helpful in such instances.

When due to fecal impaction and foreign bodies, thorough, direct, elevating treatment over the involved region, and high rectal injections are indicated. This applies to the onset, for if the disease has progressed to the point where pus may be present, the bowel must be absolutely at rest. Do not give or allow to be given purgatives at any stage of the disease. When sure that there is no pus, direct, careful work over the cecum and appendix is allowed and is of value. It should be a lifting of the colon and relaxing of nearby tissues, to promote the circulation. Treatment of the spine is necessary in all cases, to relieve pain, to correct the nerve and vascular supply, and to increase peristalsis so as to remove irritating bodies from the vermiform appendix. “Colitis follows appendectomy more frequently than any other abdominal operation. The explanation for this is that the appendicitis is seldom localized in the appendix but is complicated by colitis, or rather the colitis is complicated by the appendicitis. In such cases, removal of the appendix aggravates rather than alleviates. A conclusion to be drawn is, to carefully palpate the colon in all appendicitis cases and reserve diagnosis, prognosis and advising of an operation until it can be definitely determined as to the location, extent and degree of the disease. The formation of pus is an indication requiring immediate evacuation.

“If good surgical advantages are available and the case begins with considerable virulence and a surgeon can be had within the first twenty four hours, it is in all probability best to operate; but if the case begins slowly or no good hospital advantages are available, or if the case is not seen until some forty-eight hours have elapsed after the onset, in all probability it is strictly an osteopathic case and should not be touched by surgery. Some advocate in all instances to wait until pus is formed before operative procedure is resorted to. This is a rather dangerous attitude to take, for I have seen hundreds of cases operated and have operated upon a great many myself and I have never seen a case die unless it was a pus case.”—S. L. Taylor.[88]

The case should be most carefully watched, and a surgeon should be promptly called for consultation if the occasion demands it in the least; and if thought advisable, operation should be resorted to before too late. Do not assume too much responsibility in these cases. The patient should be nourished on a restricted diet of milk and animal broths. Asa Willard[89] strongly recommends no food by mouth, as it is bound to set up peristalsis and cause increased irritation. He sustains the strength by rectal feeding. This view is held by other authorities, even to withholding water when the inflammation is at its height. Tasker confirms the advisability of restricted feeding and advises resting the bowel even to the point of discontinuance of food. The course of the attack is usually so short that there is no danger of starvation and little loss of strength results. This point is a highly important one in cases of any degree of severity.

In chronic cases of a fibrotic character, no pus, carefully lifting the parts and loosening adhesions in addition to spinal adjustment will often restore normal circulation. These conditions aside from the local disorder frequently cause hyperchloridia and other digestive disturbances.

Diseases of the Liver and Bile Duct

Primary diseases of the liver will invariably present osteopathic lesions from the fourth or fifth dorsals to the eleventh or twelfth. The ribs on the right side are commonly involved. These lesions probably disturb the liver by way of the vasomotor fibers. Displacements of the duodenum, of the hepatic flexure and transverse section of the colon and displacements of the right kidney are frequent sources of liver disorders. Care should be taken in differentiating primary from secondary diseases, for naturally the relative importance of the various factors in treatment will vary. In many secondary diseases there will be found predisposing osteopathic lesions, and these secondary disorders and degenerations can at least be palliated and occasionally the degeneration retarded or stopped by persistent osteopathic treatment, diet, and hygienic measures.

Hyperemia of the Liver

This is an abnormal fullness of the blood-vessels of the liver, followed by an enlargement of that organ. It is active when there is abnormal pressure in the portal veins (afferent vessels); passive when there is excessive pressure in the sublobular veins (efferent vessels).

Osteopathic Etiology and Pathology.—Active hyperemia is usually due to indiscretions in diet. After each meal a physiological hyperemia of the liver occurs, which is greatly increased by habitually overeating and overdrinking. This condition may lead to functional disturbance and possibly to organic change. Traumatism and lesions of the vertebræ and ribs, irritating vasomotor nerves, are important. Habitual constipation, malaria, heat, and arrested menstrual epoch, and infectious fevers are also causes of the active form. Enteroptosis is not a rare cause.

Passive hyperemia is due to obstructions of the efferent circulation. Valvular heart disease is the most common cause. Lung diseases, as emphysema or cirrhosis; obstruction to the vena cava or interference with the flow of blood through the liver; and diseases of the pleura, are among the causes.

Most cases of congestion of the liver present lesions to the vasomotor nerves of the liver, fifth to ninth dorsal. Especially are the ribs over the liver apt to become displaced and affect the organ.

Pathologically, the liver is enlarged and engorged with blood. The appearance of the organ depends upon the duration of the hyperemia. In passive hyperemia the central portion of the lobule and the area of the hepatic vein are deeply colored. The periphery and the area of the portal vein are pale. This alternation of the dark and light color gives rise to the nutmeg liver, which is so noticeable upon section. In cases of long standing, atrophy of the liver cells and overgrowth of connective tissue result.

Symptoms.—Active Hyperemia.—Dull aching and a sense of fullness in the right hypochondrium, aching of the limbs, coated tongue, nausea, vomiting, constipation, highly colored urine, and slight jaundice.

In passive hyperemia the symptoms are the same, but less marked. The onset is gradual and the liver may attain considerable size. In severe cases following tricuspid regurgitation the liver may pulsate. In severe cases dropsy takes place.

Diagnosis.—Active hyperemia is occasionally confounded with catarrhal jaundice. Usually congestion of the liver is easily diagnosed.

Prognosis.—In active hyperemia the prognosis is good, unless repeated attacks lead to atrophic degeneration. In passive hyperemia the prognosis depends entirely upon the cause.

Treatment.—Active hyperemia.—The treatment consists of measures which tend to diminish the congestion, principally a thorough, direct manipulation over the liver by raising and spreading the ribs. Careful and thorough treatment to the dorsal splanchnics of the liver is also indicated. The substitution of a scanty for a heavy diet is essential. The foods given should be such as are easily digested, as milk and broths; fats and sugars are to be avoided.

In passive hyperemia the treatment consists of correcting the disorder causing it. Often heart diseases are the cause. A thorough depletion of the bowels will aid largely in relieving ascites that may follow passive congestion (See ascites).

In liver congestions it is well to pay attention to the intestinal condition in order that the circulatory mechanism here may be thoroughly coordinated with the hepatic.

Simple Catarrhal Jaundice

Definition.—Jaundice due to inflammation of the terminal portion of the common duct, not the result of impacted gall-stone. The disease probably starts as a catarrhal inflammation of the stomach and upper portion of the small intestine. The bile is retained and absorbed.

Osteopathic Etiology and Pathology.—A frequent predisposing cause is the subdislocation of the tenth rib on the right side, thus interfering with the innervation to the bile ducts, and causing congestion of the mucous membrane of the common duct; although lesions above and below this point may occur. Extension of gastro-duodenitis into the common duct is a common source of the inflammation. Sagging of the duodenum will disturb the bile-duct through its being a portion of the duodeno-hepatic ligament. Duodenal catarrh usually follows errors in diet, exposure, malaria, Bright’s disease, portal obstruction and chronic heart disease. Infectious fevers, as pneumonia and typhoid fever, and emotional disturbances are among the causes. Catarrhal jaundice may occur in epidemic form.

Pathologically, the duodenal end of the duct is most commonly involved. The mucous membrane is swollen and the orifice fills with mucus. The inflammation may involve the common and cystic ducts and even the hepatic. The liver is enlarged and the gall-bladder distended.

Symptoms.—The only symptom present may be simply the jaundice. There is always tenderness upon pressure over the ducts. The patient many times complains of a stabbing pain when pressure is exerted over the duodenal opening. Usually the course of the bile duct can readily be felt upon deep pressure, owing to the tumefaction. Accompanying this condition may be general malaise, loss of appetite, nausea, vomiting, constipation or irregular action of the bowels, pains in the back and limbs and a slight fever.

Diagnosis.—Where jaundice is present without pain, it generally indicates catarrhal jaundice. The absence of emaciation or of evidences of cancer or cirrhosis usually makes the diagnosis easy. Good general nutrition and a negative physical examination favor simple jaundice as to the diagnosis.

Prognosis.—The prognosis of catarrhal jaundice is favorable, unless accompanied with infectious diseases or hypertrophic cirrhosis. When diseases are associated with jaundice the danger is usually from the disease. The duration of the disease is generally given as from two to eight weeks, but osteopathic treatment generally lessens that time at least one-half.

Treatment.—The treatment is directed toward relieving the inflammation of the bile ducts and increasing the flow of the bile into the intestines. Great relief to the patient will be experienced from thorough treatment over the bile ducts, especially at the duodenal end. Press slowly but firmly over the region of the ducts, then execute a downward motion with firm pressure over the course. This performance should be repeated several times, until the tenderness in this region is almost or entirely relieved. The idea of this treatment is, first, to slowly but firmly bear down upon the abdominal muscles over the congested tissues, so as to relax the tissues and get as close to the ducts as possible, and second, with the downward movements to reduce the congestion of the ducts and at the same time to remove any mucus or other material from the orifice, thus allowing a freer flow of bile. It will be recalled that the normal flow of bile is under very low pressure. Care should be taken not to gouge or dig into the tissues with the ends of the fingers, but to use the flat surface of the fingers. Any gouging or severe treatment will not allow one to accomplish his purpose, owing to the stimulus or irritation it would give the abdominal muscles and thus cause them to contract; and furthermore, it would more or less bruise the parts. An inhibitory treatment should be given along the spine on the side affected to help relax the abdominal muscles before this treatment is administered. In all circulatory disturbances of the bile-duct and other hepatic tissues lift the duodenum at about the second lumbar where it lies beside the ascending colon. This tends to release portal vein, hepatic artery and bile-duct, the duodeno-hepatic ligament.

Direct treatment is given to the liver by more or less kneading or working the organ and also by raising and spreading the ribs. This treatment is to stimulate the activity of the liver. Reaching under the cartilages of the eighth and ninth ribs on the right side and bearing inward and downward will empty the gall-bladder and thus be of aid in relieving the tension in the biliary passages. It is probably a stimulus to these cutaneous fibers that causes a relaxation of the sphincter muscles of the gall-bladder and thus allows it to empty. Stimulation of the tenth nerve contracts the gall-bladder. Then it should also be noted that work over the duodenal end of the bile-duct relaxes the orifice while through reciprocal relationship the fibers of the gall-bladder contract. When all of the muscles of the hepatic region have been carefully relaxed and softened, a thorough examination can then be made of the vertebræ and ribs that might embarrass the innervation or vascular supply of the liver. Lesions of the vertebræ and ribs affecting the liver may occur from the sixth to the eleventh dorsal. Lesions to the vagus and phrenic nerves may occasionally involve the organ.

Irrigation of the large bowel with cold water may be employed. The cold excites peristalsis of the gall-bladder and ducts. Drinking freely of water will be helpful. A non-stimulating diet should be given. The stomach may not be in a condition to bear solid food; and furthermore, food on entering the duodenum will increase the local inflammation of the common bile duct. Give diluted milk, buttermilk, light meat-broths, clam-broth, egg albumin and pressed beef juice. After the pain, vomiting and fever subside, the diet can be gradually increased.

Cholecystitis

Cholecystitis is an inflammation of the gall-bladder caused by infection. Stagnation of bile due to obstruction (especially gall-stones) of the bile ducts, or a slowing of the bile flow owing to deranged innervation from osteopathic lesions or sagging bowel, are predisposing factors. Fibrotic changes in the appendix are fairly common sources that derange the nervous reflexes of the biliary function. The disorder may be associated with specific fevers.

Exciting factors are the colon bacilli, streptococci, staphylococci, typhoid bacilli, and pneumococci.

Symptoms.—The gall-bladder feels hard and full. There is inflammation and thickening of the mucous membrane, with considerable increase of mucus. Owing to the infection there may be ulceration and suppuration, with possible perforation and peritonitis. When the inflammation extends outside of the bladder there are usually adhesions.

The onset is commonly sudden, with pain and tenderness in the right hypochondrium. Great care should be taken in deciding the location of the inflammation, for the pain and tenderness may be over the stomach, or along the duodenum or ascending colon as low as the cecum. Nausea, fever, constipation, and possibly jaundice, are other symptoms.

Treatment.—Exercise special care in treating these cases. Although in many instances the inflammation will rapidly subside, still owing to suppuration there is danger of aggravating the condition. It is better, in doubtful cases, to confine the treatment to spinal work, and to influence drainage by placing the patient in knee-chest position and carefully raise cecum, ascending colon and duodenum. Rest, restricted diet, plenty of water, and hot fomentations will be beneficial. In severe cases surgical interference is indicated.

Jaundice

(Icterus)

Jaundice is a symptom and not a disease. It consists of the discoloration of the skin and other tissues by material derived from the bile. The discoloration may vary from a mere paleness to a yellow or brown olive hue.

Toxic jaundice occurs in acute yellow atrophy, pernicious anemia, pyemia, specific fevers, and the action of poisons.

Obstruction by foreign bodies as gall-stones and parasites are important causes. Inflammation and swelling of the biliary ducts and duodenum are common causes as well as stricture of the duct by tumors and various growths, either internal or external, to the biliary ducts. In some instances pressure from without by the pancreas, stomach, kidneys, enlarged glands, fecal matter, a pregnant uterus, etc., has been the cause. Irritations and obstructions of the splanchnic nerves, due to lesions in the lower dorsal vertebræ and the ribs from the sixth to the eleventh, will often markedly affect the liver. Also lesions at these points may predispose to inflammation and tumefaction of the bile ducts.

Symptoms.—Besides the discoloration of the skin, there is itching of the skin, on account of bile pigment deposits; even eruptions may occur. The mucous membranes are often colored and a constant symptom is the bright yellow discoloration of the sclerotic coat of the eye. The secretions are colored. It may be first noticed in the urine. The perspiration is colored, rarely the saliva and tears. There is frequent sweating.

As very little bile passes into the intestine, the feces are pale and gray, and sticky. The bowels are generally constipated, but diarrhea may occur, owing to decomposition resulting from absence of the normal ingredients. Other symptoms may be associated with the gastro-intestinal derangements, as nausea, fetid breath and loss of appetite. A slow pulse may occur, due probably to some stimulating effect on the inhibitory action of the vagus nerve. Lesions are often found at the atlas and axis, affecting the vagus. Pain back of the right scapula is a symptom of liver trouble; it has been suggested that it is due to a stimulus passing up the vagus to the spinal accessory, and thence to the trapezius muscle.

Various cerebral symptoms may be present, as great depression, irritability, headache and vertigo. In severe cases there may be delirium and coma.

In hemolytic and toxic jaundice the destruction of blood is due to some toxic agent. The feces are not clay colored and the urine is less stained with bile. The general symptoms may be very severe depending upon the underlying cause.

Diagnosis.—To mistake for jaundice the dirty yellowish discoloration of the skin commonly termed sallowness is an error often made. This condition indicates malaria, uterine disease or general ill health. Very likely it is an anemia and is readily diagnosed from the jaundice as the secretions and conjunctiva are not stained. Addison’s disease somewhat resembles jaundice, but the feces are normal, the urine and sclerotic coat are not colored, but exposed portions of the body and flexures of the joints are deeply stained.

Prognosis.—Depends entirely on the cause producing it. Ordinary cases run from two to six weeks, while others may not recover for several months. Jaundice from impaction of the bile ducts may be manifest for only a few days. Toxic form may terminate fatally, owing to the disease causing it. The extent of resorption of bile and destruction of red blood cells in the liver varies to a considerable degree.

Treatment.—The treatment for the different forms resulting secondarily will be found under the diseases causing them. A simple icterus, caused by disturbance through the innervation of the liver and bile ducts directly, can be relieved readily by thorough treatment of the liver and bile ducts as described under catarrhal jaundice. Carefully raise the intestines if they are prolapsed, especially the colon and duodenum.

Cirrhosis of the Liver

This is a chronic disease of the liver, characterized by hyperplasia of the connective tissue with destruction of the liver cells, resulting in the organ becoming hard and usually small.

Etiology.—The disease usually occurs in the male sex and in middle life. When occurring in children, it is commonly of the syphilitic form, though it may be due to other infections. The abuse of spirituous liquors is a common cause. It follows chronic diseases, such as syphilis, long continued malarial intoxication, gout and tuberculosis. Passive congestion, due to chronic heart and lung disease, causes some cases. A few cases are caused by inflammation of the bile ducts, due to infection and obstructing calculi; others to a stimulating diet, while some cases are inexplicable.

Pathologically, the first stage is hyperplasia of the connective tissue and consequent enlargement of the organ. As this increases the connective tissue destroys immense numbers of the hepatic cells, owing to the pressure. Often the enlargement is accompanied by tenderness. In the later stage the overgrowth of imperfectly developed tissue seems to contract the hepatic cells that still remain, causing atrophy and degeneration of most of them, and thus reducing the size of the organ, which is followed by sclerosis. The portal and hepatic circulations are greatly obstructed. An occasional form is termed hypertrophic sclerosis in which sclerosis is found while the organ continues enlarged.

There are two common and well defined varieties, atrophic cirrhosis and hypertrophic cirrhosis; other forms (rare) are met with.

Atrophic cirrhosis is the common form, and is usually due to alcoholic excess. The surface of the liver is rough and uneven in addition to its hardness and reduction in size. It may also be greatly deformed and covered with granulations (“hob-nails”). The normal weight is four or five pounds, but it may be so reduced as to weigh no more than one pound or a pound and one-half. Sometimes there is fatty infiltration, which enlarges the liver to such an extent that the contraction is not noticed. There is an overgrowth of the connective tissue, which contracts and constricts the branches of the portal vein, causes atrophy and degeneration of the hepatic cells, and even sometimes obliterates the bile ducts. The new connective tissue is well supplied with blood-vessels from the hepatic artery, thus aiding greatly in the growth.

In the hypertrophic form, as well as in the atrophic cirrhosis, there is an overgrowth of connective tissue, but in the hypertrophic form the new form of tissue exhibits no disposition to contract. The enlargement of the organ is largely due to hyperemia. As the tissue does not contract there is no pressure on the portal vein and atrophy is prevented. There is early jaundice (which is a characteristic symptom) owing to obstruction of the biliary channels. The surface is smooth and its color is greenish yellow.

Symptoms.—Atrophic Form.—There may be practically no symptoms. As there is obstruction of the portal circulation, there may be congestion of the stomach and intestines, resulting in chronic gastric or intestinal catarrh having the following symptoms—anorexia, distress after eating, distention, constipation and coated tongue. Owing to the anastomotic communication between the portal and caval circulations, as the portal circulation becomes more obstructed, the superficial abdominal veins become greatly distended. Hemorrhoids occur, owing to the communication of the superior hemorrhoidal, which is a branch of the portal vein through the inferior middle hemorrhoids, with the hypogastric vein and the vena cava; hence hemorrhoids are a characteristic symptom. There is enlargement of the spleen and hemorrhage from the stomach or bowels. Edema of the legs and ascites are due to engorgement of the portal system. Ascites is much more common than edema of the legs. There may be slight jaundice, although this is a rare symptom in atrophic cirrhosis. There is always decided emaciation. On examination there is a diminished area of hepatic dullness, while the splenic dullness is enlarged. It is often impossible to outline these organs, as the abdominal distention prevents it. The urine is scanty, high colored and often loaded with urates, but seldom bile-stained.

In the hypertrophic form slight jaundice appears at the onset, which gradually deepens until it is intense and persistent. Occasionally there is fever. The disease as a rule is decidedly chronic, though acute symptoms may develop at any period. The urine is often bile-stained, but of normal quantity. On examination the liver is large, smooth and round and can be felt below the ribs. The spleen is greatly enlarged.

Diagnosis.—In atropic cirrhosis.—With ascites without dropsy elsewhere, history of alcoholism, hemorrhage from stomach or bowels and reduction in size of liver, the diagnosis is absolute.

Hypertrophic cirrhosis.—In cancer of the liver the patient is advanced in years, has no splenic enlargement, and more commonly ascites is present; while in hypertrophic cirrhosis there is chronic biliary obstruction, the liver is only moderately enlarged and hard, marked jaundice, with causes leading to or evidence of hepatic obstruction. This form of cirrhosis is also to be differentiated from amyloid liver and echinococcus cyst.

Prognosis.—Unfavorable, although in some cases the disease can be arrested during the early stage, provided the habits are regulated and treatment is continuous and persistent. Death usually occurs from one to two years after appearance of dropsy. Ascites is difficult to contend with.

Treatment.—If the disease is recognized at the beginning and persistent treatment given to the liver, the chances are that atrophy of the cells and connective tissue formation will not take place. But ordinarily cases of cirrhosis are incurable. The most that can be done is to reestablish a compensatory circulation in the liver. Otherwise it would be no more unreasonable to say that one could cure a chronic valvular lesion of the heart. The patient should live a quiet outdoor life. Alcoholic drinking should be stopped. The diet should be light and nutritious, preferably a milk diet. The bowels should be kept open, the skin active and the kidneys closely watched.

Fatty Liver

In fatty infiltration there is no loss of function. The fat infiltrates the cell, crowding aside the protoplasm. This is largely a normal process, though fatty degeneration may be associated.

In fatty degeneration the cell loses its structure and is changed into fatty tissue. Chronic intoxication from infectious diseases, such as phthisis puerperal fever, typhoid fever, pneumonia and syphilis are the principal causes. Alcoholism and phosphorous poisoning are other causes.

Amyloid Liver

There is infiltration into the tissues of the liver, of the so-called amyloid substance. The infiltration begins in the blood-vessels, the hepatic artery first, then the central zone or periphery, and finally all structures of the liver. This disorder should be viewed as a disturbance of metabolism.

Etiology and Pathology.—This condition is usually found in cases of prolonged suppuration, especially associated with tubercular disease of the bones as in hip-disease, syphilis, rickets, malaria, cancer and leukemia. It is believed by some to be the result of microbic invasion, especially the tubercle bacillus and staphylococcus. Lesions are frequently found from the fifth to the tenth dorsal vertebræ, which probably act as predisposing factors.

The liver is considerably enlarged and rounded. It is pale or waxy in appearance and is doughy in consistency. On section it is anemic and whitish, partly due to infiltration into the walls of the blood-vessels narrowing the lumen. The amyloid changes may be circumscribed and in some cases fatty infiltration is present.

Symptoms.—There are no characteristic symptoms except the enlargement of the liver, although the complexion may be waxy and there may be some gastro-intestinal disturbances. Pain is absent, although occasionally there is a dragging sensation, due to the weight of the organ. Jaundice is not present, but the stools may become light colored, owing to a diminished secretion of bile. The urine may be increased in amount and contain some albumin if amyloid occur in the kidneys. Emaciation and anemia are present and ascites seldom occurs. Amyloid changes involve the spleen, kidneys, intestines and other organs.

Diagnosis.—The organ being large, hard and smooth, with absence of jaundice and ascites, the presence of albuminuria and an enlarged spleen and with the history of the case, mistakes are not likely to be made.

Prognosis.—Depends upon the cause. The progress may be rapid or slow.

Treatment.—Careful attention to the primary disturbing factor and direct treatment to the liver will, in some instances, reduce the size of the organ. Nitrogenous food and hygienic measures should be instituted. The vasomotor nerves of the portal system (fifth to last dorsal) should be treated thoroughly.

Gall-Stones

Gall-stones are concretions that originate in the gall-bladder and occasionally in the hepatic ducts. “The primary formation of gall-stones is itself largely dependent upon stagnation of bile, such as may arise in the gall-bladder if an intermittent or incomplete closure of the cystic duct be brought about by such things as tight lacing, pregnancy, or even unequal sagging of the abdominal viscera.”—MacCallum. The stone is largely composed of cholesterin, and may form without any inflammation of the gall-bladder, owing probably to the stagnation affecting the bile salts so that the cholesterin is precipitated instead of being held in solution.

More often there is inflammation of the wall of the gall-bladder due to micro-organisms. This causes an exudate from which is derived the calcium. The calcium with bilirubin is deposited in layers on the stone which give it the various colors of yellow, brown or green.

A rare type is one formed in the hepatic ducts, which is soft, green, and composed of calcium bilirubin concretions.

The stones “contain a great deal of organic material derived from desquamated epithelial cells and coagulated albuminous matter, as well as pigment.” The colon bacilli, staphylococci, streptococci, typhoid bacilli, and pneumococci are the bacteria most frequently found. A cholecystitis may be a predisposing factor or it may be secondary to the concretion.

Osteopathic Etiology and Pathology.—This is a disease of middle life and is more frequently found in women. Sedentary habits and constipation combined with overeating, are other important factors. It is found in stout subjects who are particularly fond of starchy and saccharine food. Catarrhal jaundice is a predisposing factor. Depressing mental influences may predispose. The thicker the bile the more likely it is to deposit. Dr. Still’s theory is that lesions of the ribs on the left side from the sixth to the tenth dorsal are factors in the formation of the stones as they interfere with pancreatic secretions. No matter how it comes about, the fact is that in all cases of gall-stones the osteopath finds lesions to the eighth, ninth and tenth ribs on the left side, as well as lesions from the fifth or sixth to the tenth dorsal, deranging innervation to the liver and bile ducts. It is possible that lesions over the spleen probably interfere with the activities of the spleen and thus in some manner this organ does not properly elaborate the blood before it passes to the liver. Sagging of the duodenum may, through tension on the duodeno-hepatic ligament, interfere with the flow of bile. This would cause derangement of the nervous reciprocal relationship between opening at duodenal orifice and gall-bladder. In carcinoma of the liver and stomach, gall-stones are said to be frequent.

The stone itself is a brownish object, nearly spherical, faceted and in some instances polygonal in shape, varying in size from a pea to a hen’s egg.

The stones are found anywhere in the biliary tract from the duodenal orifice to the ramification of the bile vessels. Usually there is more or less of an accumulation in the gall-bladder. At any point the stone may produce ulceration and suppuration. Perforation may occur into the peritoneal cavity or adjacent organs.

Symptoms.—Gall-stones may be in the gall-bladder for years without giving rise to any symptoms. Their presence is made known only by their expulsion from the gall-bladder. If they lodge in the duct in transit from the gall-bladder to the duodenum biliary colic is produced, which is the characteristic symptom of an impacted gall-stone. Small stones may pass into the intestine without producing symptoms. The pain is very sudden, piercing and excruciating in the region of the gall-bladder, when a stone attempts to pass. The pain radiates through the abdomen, right chest and shoulder, and the patient writhes in agony and occasionally faints. Downing[90] emphasizes the point that when a patient comes in with a history of repeated attacks of biliary colic and no stone found in the stools one should at once suspect that one of considerable size obstructs the common duct.

There is always tenderness in the biliary region with more or less contraction of the abdominal muscles. Nausea, vomiting and sweating are usually present, followed by a weak pulse, cool skin and pale and anxious face. Fever is soon present and a chill is common. The paroxysms continue as long as the stone remains lodged, which may be from an hour to several days. There are remissions of pain, entire relief being given as soon as the stone reaches the duodenum. Jaundice usually follows a prolonged attack. The liver is sometimes enlarged. The spleen is enlarged. Should the stone become impacted, ulcerative perforation, with consequent peritonitis and shock, follows.

Diagnosis.—The diagnosis is conclusive when the gall-stones are found in the stools or when they can be felt in the gall-bladder. All the above symptoms are characteristic. If a patient complains of severe pain radiating from the hepatic region, and nausea and vomiting are present, subsiding suddenly with a slight jaundice, the disease should hardly be mistaken.

Tenderness over the gall-bladder frequently indicates infection or gall-stones or both. Radiographic examination may be of aid.

Nephritic colic should never be confounded with hepatic colic as in the former the pains start in the lumbar region and radiate downward into the groin, the testicle and the inside of the thigh. In appendicitis, jaundice and bile-stained urine are not found. A pseudo-biliary colic is occasionally found in nervous individuals especially when the eleventh and twelfth ribs (or ribs as high as the seventh) on the right side are displaced downward.

Prognosis.—Is usually favorable. Ulceration, perforation, and suppuration may prove fatal, although much depends upon surgical interference.

Treatment.—During the attack of biliary colic, the osteopath should usually be able to readily locate the position of the gall-stone in its transit from the gall-bladder. He should usually proceed at once to aid the stone in its downward passage by careful manipulation over the duct. Still this treatment should be given with great caution, for if there is suppuration or ulceration, perforation and resultant peritonitis may occur.

Usually one will not have much difficulty in dislodging the stone and relieving the sufferer in a few minutes. The recumbent position, with the thighs flexed on the abdomen, is the position assumed for treatment, and if the muscles in the hepatic region are very tense and rigid, interfering with locating the gall-stone, an inhibitory treatment to the posterior spinal nerves supplying the contracted muscles will aid one materially. An inhibitory treatment of the nerves of the biliary tract (the ninth and tenth dorsals), may be a helpful measure in dilating the duct. Also, hot application over the affected area and to the dorso-lumbar region will aid.

During remissions two or three treatments per week should be given to correct the lesions at the eighth, ninth, tenth and eleventh segments. Give particular attention to any enteroptosis that may be found. Average cases should not require more than two or three months’ treatment. Hildreth, who has had many cases, is much opposed to operation as his experience has been that where there is not complete obstruction the correction of lesions will prevent further formation of stones. While he finds the trouble ranges from the third to the eighth dorsal, still, as a rule, it is between the fifth and sixth that best results are obtained. Probably if the treatment is a rightly directed one the stones already formed may be disintegrated. Willard[91] reports 393 cases.

Permanently impacted gall-stones require surgical treatment. Prophylactic treatment, as a regulated diet, daily exercise and a discontinuance of excesses, should be strongly urged. The patient should not be allowed any fatty or saccharine food. Water freely taken will be of aid.

Diseases of the Spleen

Diseases of the spleen are usually secondary to other disorders. The following osteopathic treatment under Splenitis will, in addition to the probably primary disturbance, be applicable to active and passive splenic hyperemia and amyloid degeneration of the spleen. Surgical and other measures are to be employed when indicated.

Owing to the role that the spleen plays in infections, the osteopath pays considerable attention to stimulating the organ through its spinal innervation in these cases.

Splenitis

In acute splenitis there is generally a blocking up of the smaller splenic arteries by fibrous coagula (hemorrhagic infarct), which have formed in the left ventricle of the heart in consequence of endocarditis. Malarial infections, septicemia, typhus and acute exanthematous fevers may cause coagula formation in the splenic veins. Injuries to the vertebræ or ribs on the left side over the spleen (ninth to eleventh ribs inclusive) are occasionally the predisposing cause of primary inflammation of the spleen. Following the formation of abscesses the entire organ may suppurate; it may produce pyemia, or it may burst and the pus be discharged into the peritoneal sac, causing peritonitis, or into the pleura, stomach or colon. Chronic splenitis is induced by passive congestion, leukocythemia and splenic anemia.

Symptoms.—Tenderness and enlargement of the spleen are the principal symptoms. The organ may be twice its normal size, but in a few cases the tumefaction is so insignificant that it can hardly be found on percussion. Dull pain generally exists if the enveloping membrane or adjacent organs are involved, the pain being increased upon percussion and deep inspiration. In a few cases the pain radiates to the left shoulder and if the peritoneal covering is involved, a sharp pain will be present. Fever and rigor follow if suppuration has taken place, and peritonitis follows in case of rupture or perforation. Marked hypertrophy and chronic inflammation may cause cough, nausea, vomiting and dyspnea.

Treatment.—In the treatment of both the disease producing splenitis, and of primary splenitis, a thorough treatment of the spine, eighth to the eleventh dorsal, is necessary. The nerves (vasomotor) to the spleen are from the left splanchnics, consequently treatment of the left side is more effectual. Particular attention should be given the ribs over the spleen—the ninth, tenth and eleventh—as disorders of these ribs are a common cause of splenic disturbances. Careful and fairly firm treatment is always indicated, care being taken not to add irritation to an already inflamed organ, and especially beware that force is not used where there is danger of rupture. Stimulation of the tenth nerve contracts the spleen. In cases of suppurative splenitis the direct treatment should not be given.

Stimulating treatment over the spleen, as over the liver and kidneys, gives tone to the strong elastic capsule surrounding it, so that direct manipulation over these organs, coupled with the power of the strong elastic capsule and highly elastic tissue of the inner organ, will greatly aid in lessening the engorgement and hyperemia. In a few cases where the spleen is involved, lesions are found in the upper cervical which affect the right pneumogastric nerve and thus impair the normal activity of the gland.

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