Chapter XXVI: Introduction (11)

In addition there may be single spinal or rib lesion in the same area, or cervical lesions affecting the pneumogastric, which is the secretory nerve to the stomach. (See chapter on the “Lesion and Its Applied Anatomy.”)

=Pathology.=—Chronic gastritis probably never develops as such without going through several preliminary stages beginning with alimentary hypersecretion, or hypersecretion occurring only during the active period of digestion. These are the cases usually classified as hyperchlorhydria. At this time no actual pathology can be demonstrated in the glandularis.

If the condition is not treated intelligently at this time the next step will be periodic attacks of what is known as “hypersecretion periodica chronica” followed by “hypersecretion continua chronica.” The stomach contains abnormal amounts of gastric juice even after a night’s rest. At this stage there is a transition from the functional to the organic condition. All stages are characterized by an abundant secretion of mucus.

If allowed to go on there will finally result a destruction of the secreting cells known as Atrophic Gastritis or Achylia Gastrica in which the stomach presents a smooth functionless appearance.

=Secondary Chronic Gastritis.=—Portal obstruction from any cause predisposes to chronic gastritis. The most common of these is failing compensation in heart lesions, which through back pressure causes portal stasis; the same thing may follow obstruction in the liver itself. Chronic gastritis is also a late accompaniment of the nephritic trinity, kidneys, heart and arteries. It may also be associated with diabetes, gout, anemia and other constitutional disorders.

Tuberculosis is commonly ushered in by symptoms of chronic gastritis. We should be constantly on the alert to avoid the mistake so commonly made of treating the stomach as an entity and overlooking the real trouble in some other part of the anatomy.

It is probably safe to say that there are only two primary diseases of the stomach, ulcer and cancer. All others are suspiciously associated with diseased processes elsewhere, and when the spinal lesion is given its full significance even these will be found to be directly traceable to anatomical perversions somewhere within the mechanism of local nutrition.

=Symptoms.=—These are governed by the stage of progress in which the patient is seen. During the stage of hypersecretion of acid gastric juice there will be vague feelings of distress, fullness and burning in the stomach, and “heartburn” during digestion. When the stomach is empty all symptoms will subside. Later there will be periods of a few days or weeks when there will be more or less continuous distress with some vomiting of highly acid gastric juice containing mucus.

When the condition has progressed to the stage of continuous hypersecretion there will be continuous symptoms as above, but with nausea, vomiting becoming more frequent especially late at night or in the morning, always accompanied by sticky mucus.

Appetite is variable, there is often a disagreeable taste in the mouth (the “dark brown” taste of the chronic alcoholic). Heart palpitation and vertigo and other vagus symptoms are common.

=Diagnosis.=—On physical examination the stomach is found distended, and in some cases displaced (gastroptosis). There will be diffused tenderness on pressure over the whole organ which should help to distinguish it from gastric ulcer or cancer in which the tenderness is quite localized.

Chronic gastritis cannot be =positively= diagnosed without making a gastric analysis. Many cases are wrongly diagnosed through neglect of this very important procedure.

The cases in which gastric analysis should be made are so well stated by Lockwood that we will take the liberty of quoting them in their entirety.

“(1) Gastric analysis should always be made in every case of dyspepsia, no matter whether these symptoms be apparently gastric or intestinal, unless passage of the tube is contraindicated.

“(2) Gastric analysis should be made in every case of chronic diarrhea that is not due to evident disease of the colon or rectum.

“(3) Gastric analysis should always be made in all cases of intestinal toxemia, or recurring headache of toxic origin, and in patients who complain of the symptom complex which is spoken of by the laity as ‘biliousness’.

“(4) Gastric analysis should be made in all cases of anemia and general physical wretchedness without known cause and which are rebellious to treatment.”

The finding of excessive gastric mucus intimately mixed with food remnants is the chief differential point in the diagnosis of chronic gastritis.

=Differential Diagnosis.=—A complete statement of differential diagnosis by Kemp cannot be well improved upon.

“CHRONIC GASTRITIS.—No severe pain, no circumscribed spot, painful to pressure; no hematemesis; no cachexia; no marked emaciation, except in severe cases of long duration; free hydrochloric diminished or absent; gastric mucus present; slow course.

“ULCER OF THE STOMACH.—Hyperchlohydria present, but not invariably so; severe pain in the epigastrium with intervals free from pain when stomach is empty; local tenderness which is circumscribed; dorsal pain; hematemesis, or occult blood in the stool or gastric contents; microscopic pus; no mucus; patient has appearance of suffering; no true cachexia.

“CANCER OF THE STOMACH.—Age usually over forty-five; rapid course; free hydrochloric acid usually markedly diminished or absent; lactic acid present; pain generally continuous, but not so acute as in ulcer; Boas-Oppler bacillus; cachexia; tumor on physical examination; small amount of visible or occult blood; hematemesis much less than ulcer; foul odor to vomitus at times present.

“ACHYLIA GASTRICA.—Slow course; scarcely any gastric juice; acidity very low or entirely absent; absence of pepsin and rennin; usually no mucus or lactic acid.

“These differential considerations apply to typic cases, and the observer must be on the qui vive for various gradations and modifications of these clinical pictures.”

=Prognosis.=—The outcome of chronic gastritis depends upon our ability to locate and remove every factor in the etiology, the willingness of the patient to cooperate and the patience and resourcefulness of the physician. At best the progress is slow and one must expect temporary setbacks usually due to failure of the patient to carry out instructions.

=Treatment.=—The most successful treatment is prophylactic, but until the public has been educated up to this form of economy we must begin with conditions as we find them.

First get the patient’s confidence by making an intelligent examination, a scientific diagnosis, and a reliable prognosis based upon your findings. All lesions, bony, ligamentous, muscular and psychic must be intelligently and carefully removed.

Specific lesions which would directly or reflexly interfere with the nerve and blood to the stomach must be corrected.

The rigidness commonly found in the vertebræ and ribs of the splanchnic area must be overcome first by specific adjustment, and the normal flexibility maintained by teaching the patient proper exercises for the purpose. This should include deep breathing with the spine flexed to the limit, and the ribs fixed, by the patient reaching around as far as possible and grasping the ribs as described by Dr. Harry Forbes. This will tend to overcome the flat dorsal so characteristic in all gastro-intestinal conditions.

Direct manipulation over the stomach has no particular value and may be even harmful.

Inasmuch as nausea and vomiting and excessive gas formation are only the result of hypersecretion we cannot expect to give more than temporary relief except by methods which remove causes. Much comfort may be given by inhibition in the splanchnic area. In severe cases it may be necessary at times to wash out the fermenting, irritating mass by gastric lavage. Outdoor life, frequent vacations and change of occupation are often of decided benefit.

=Diet.=—Indiscretions of diet must be avoided and this cannot be too positively impressed upon the patient. It is always best to make a list of foods to be taken for breakfast, lunch and dinner and insist that no other foods be taken without further instruction.

Just what these foods shall be depends upon the gastric secretions as shown by gastric analysis. They should always be nutritious and given in quantities sufficient to maintain nutrition.

The stomach should have rest and yet is expected to do its part in the process of digestion. All foods must be given in a finely divided form and well masticated to spare the stomach the mechanical effort of grinding.

In hyperacid gastritis all foods of an irritating nature must be positively prohibited. The classical breakfast of grapefruit, oatmeal, ham and eggs and coffee will not do. Starchy foods must be reduced owing to their tendency to ferment in the presence of highly acid juice and the delay in the stomach due to the high acidity.

In subacid gastritis advantage must be taken of the fact that carbohydrates digest well and proteins do not.

=Diet for Hyperacid Gastritis.=—Before breakfast: Wash the stomach with warm water and an ounce of Phillips Milk of Magnesia, allowing the water to remain in the stomach 20 minutes or a half hour, lying down and turning from side to side on the face in order that the water and magnesia may be brought in contact with all parts of the stomach.

For breakfast: Prunes, allowed to simmer for four hours, without boiling, and put through a colander, to remove the skins. Soft cereals, such as farina, cream of wheat, or wheatlet, thoroughly cooked, and served with middle heavy cream, no sugar. Two eggs, soft boiled, or poached. Zweiback, thoroughly masticated, with a liberal quantity of butter. Cocoa (Phillips).

Luncheon: Puree of peas, beans or lentils, made with cream. Asparagus, green peas, boiled rice, spinach chopped very fine, creamed carrots, boiled onions, baked potato, well done. Chicken, boiled lamb or beef, ground; oysters in any form but fried; fresh fish. Desserts: Choice of junket, cornstarch, custard, rice pudding, floating island, gelatine or tapioca.

Evening meal: Same as luncheon except substituting eggs for meat.

Cup of hot water before luncheon and dinner.

If patient requires quick building up give milk between meals and at bed-time.

Gastric Neuroses

Gastric neuroses include =motor=, =sensory= and =secretory= derangements. Though the sensory disturbance is often the most marked, still motor and secretory symptoms are usually present. In other words there is commonly a complex of the different forms.

Where gastric neuroses can be positively diagnosed, by a process of elimination, there is no more plausible explanation than that of the spinal lesion. The success of osteopathic physicians in treating so-called “stomach trouble” proves conclusively the superiority of the osteopathic method. A note of warning should be sounded, however, for as diagnostic methods have become more exact it is found that many cases which were formerly diagnosed as neuroses prove to be referred from some organic change, such as infected gall bladder, appendix, tube or ovary, tonsil, tooth or sinus. It has been proven that many cases of sensory and secretory disturbances have entirely cleared up when these causes have been removed. Though infection may play an important role, still in some instances, especially gall bladder, duodenum and appendix, the gastric neurosis may be simply due to a nervous reflex.

Gastroptosis, atony, and in many cases splanchnoptosis, has been found to be the underlying cause of many hitherto unaccountable gastro-intestinal symptoms.

Gastric crisis of locomotor ataxia if not properly diagnosed by the finding of the other well known symptoms may give us much trouble and discouragement.

Ulcer and cancer have quite characteristic symptoms, yet it is well known that they are often treated as neuroses in the early stages, much to the detriment of the patient, especially if the case proves to be cancer.

In the =sensory= disturbances, which are probably the most common, hyperesthesia and =neuralgia= are the special features. In the former a feeling of weight, fullness and burning are complained of, which are frequently manifestations of a neurotic temperament. In fact, hysteria and neurasthenia are very often basic conditions. The same is true in gastrodynia, where the pain starts in the pit of the stomach and extends around the lower chest and ribs. There may be other neurotic symptoms such as excessive hunger and a constant desire for food. Menstrual irregularities, the menopause, worry, constipation, and anemia are important factors. Special care should be taken that there is no organic disorder of the gastro-intestinal tract or of the nervous system.

The =motor= neuroses comprise a variety of derangements. Excitation of the motor functions of the stomach, as a direct result of irritated nerves or of reflex stimuli, are not uncommon. Owing to this the food may not remain in the stomach long enough or the stomach activity may be too pronounced. There may be also more or less rapid vomiting of the food, without any particular strain. Other motor neuroses may be spasms of either the cardiac or pyloric sphincters, and in a few instances there may be atony of the stomach walls. Although these conditions may be of a neurotic character, still great care should be taken that some organic disease is not basic.

The =secretory= derangements consist of hyperacidity, supersecretion, and lessened amount of acid secretion or achylia gastrica. Many of these cases are associated with hysteria and neurasthenia, though in achylia gastrica, cancer may be the cause. Hyperacidity may be associated with ulcer. Pelvic diseases, nervous reflexes from the gastro-intestinal tract, constipation, and anemia are to be considered as possible etiological factors.

=Diagnosis.=—These cases require the most painstaking inquiry into the history, the most complete physical examination, and all findings carefully checked up by laboratory tests.

Inquiry will often show that all symptoms subside when on a vacation with a change of scene and climate.

Lockwood gives the following rules for arriving at a diagnosis of “nervous indigestion.”

“(1) A diagnosis of nervous indigestion should not be made in the presence of more than 30 c. c. of fluid in the fasting stomach, the fluid giving a strong reaction for hydrochloric acid. Hypersecretion is generally an expression of pyloric stenosis, organic or spasmodic, and this is due to an organic cause.

“(2) A diagnosis of nervous indigestion should not be made in the presence of persistent hyperacidity accompanied by epigastric pain. Nervous hyperchlorhydria may occur, but is not accompanied by either pyrosis or pain. The association of either of these latter symptoms should suggest an organic origin for the complaint.

“(3) Achylia gastrica may be of nervous origin, but this is not probable when serious motor error is in evidence. Achylia with food-stagnation is strongly suggestive of cancer of the stomach.

“(4) Achylia gastrica, accompanied by pain or vomiting, indicates an underlying organic cause.

“(5) The diagnosis of nervous indigestion should not be made when recognizable food remains are repeatedly found in the fasting stomach. Under the influence of fear, nervous shock, or vicissitudes of temperament the motor functions may be temporarily interfered with, but this would not be the case permanently.

“(6) The diagnosis of nervous indigestion should not be made when epigastric distress or pain occurs regularly at a definite time after eating. The very fact of this disturbance coming on at a definite time argues against a neurosis.

“(7) The diagnosis of nervous indigestion should not be made when one symptom alone persists, without other evidences of nervous instability. The presence of one definite symptom in itself presupposes an organic cause.

“(8) The physician should be on the qui vive for drug addictions, for these habitues can sometimes present a syndrome of symptoms that will puzzle the most experienced.

“(9) The diagnosis of nervous indigestion should not be made in persons over forty or forty-five, in whom indigestion is a new symptom. Such patients are usually developing a serious systemic or malignant disorder.

“(10) Finally, digestive nervous neuroses and organic disease may be concomitant, and the presence of either need not exclude the other.”

=Treatment.=—First get the patient’s confidence by making a most complete examination. This desirable beginning is usually hastened by the osteopathic physician, when after a few treatments symptoms are greatly relieved. Correct all lesions wherever found, particularly those anatomically connected with the stomach. When the symptoms are sensory relief can always be given by inhibition over the splanchnic area. Occasionally the ensiform process and the lower costal cartilages are lesioned.

=Diet.=—When hyperchlorhydria is the chief symptom foods must be selected which bind acidity or those which lessen its secretion, such as milk, eggs, cream cheese, fats such as butter, cream, olive oil, boiled or broiled fresh fish, =boiled= beef or lamb run through a grinder, oysters in any form but fried, white meat of chicken, vegetable puree made with cream or milk (no meat stock), gelatine, custard, junket or =sponge cake=.

Many neurotic patients are under-nourished through fear of food. They must be positively assured that if the food is well chosen and carefully masticated there need be no fear of discomfort. Care should be taken that the patient is not constipated.

Some cases can only be reached by a “rest cure” of four to six weeks, which together with the treatment outlined above will prove most satisfactory.

In all cases guard against worry and overfatigue. Build up the general health as rapidly as possible. Outdoor life, sufficient sleep, frequent vacations, and change of scene are specially beneficial.

Gastric and Duodenal Ulcer

Statistics show that peptic ulcer is far more prevalent than is supposed by the casual observer. “In the combined statistics of 59,450 autopsies of various series evidence of healed or unhealed ulcer were observed in 4.4 per cent.” (Bassler.)

The reason for this is that peptic ulcer may present very definite symptoms which are readily interpreted or they may be so atypical as to make definite diagnosis impossible. Like all gastro-intestinal diseases, many of the symptoms are easily confused with so-called indigestion or “stomach trouble.”

=Etiology.=—One characteristic of gastric and duodenal ulcer is that it only occurs where the mucous membrane is subject to the influence of hydrochloric acid and pepsin; lower end of esophagus, stomach and first part of duodenum.

Similar ulcers are often found in the sigmoid and rectum where the feces often become acid due to bacterial action, or on account of slow movement, hydrochloric acid and pepsin which may have escaped neutralization in the duodenum may attack the mucosa.

For the part played by spinal and rib lesions on the glandular layer of the stomach, the reader is referred to a previous discussion of the lesion.

Probable secondary causes of gastric ulcer are: (1) Embolism of an artery (gastric arteries are terminal). These emboli are supposed to be caused by toxic and infectious agencies which enter the circulation, as sometimes occurs in pyemia and large burns of the skin.

(2) While hydrochloric acid associated with pepsin seems to be an important factor, it is doubtful whether it can attack the mucosa without there being a previous abrasion or other injury. It is said that a normal secretion of mucus is nature’s protection against self digestion.

The swallowing of substances of a coarse or irritating nature or those chemically corrosive or at extremely high temperature may so injure the mucous membrane as to permit an attack by HCl and pepsin.

Certain occupations seem to predispose to gastric ulcer, such as cobblers, or others who in their work press various objects against the stomach.

Sharp blows over the stomach have been followed by acute ulcer. A frequently associated condition is gastroptosis, which seems to be explained on the basis of narrowing of the blood vessels and their more ready occlusion. Probably sagging of the duodenum is an important predisposing factor.

Anemia and chlorosis should not be overlooked as predisposing causes. And tuberculosis and syphilis are possible associated disorders.

Of all the theories advanced, the lowering of vitality, due to lesions of the splanchnics and vagus nerves remains the most logical.

=Symptoms.=—The most characteristic symptom is pain, which in a typical case comes on at a regular time after taking food. It may be a half hour, an hour or two hours, and in the case of duodenal ulcer may be as late as four hours. The distance beyond the cardia at which the ulcer is located seems to govern the time; also the time at which the secretion of hydrochloric acid reaches its height, which varies in different individuals.

The pain is due to free acidity (that which is not combined with the food) irritating the raw surface of the ulcer. Pain is often increased or lessened by posture. If turning on the left side gives relief the ulcer is probably at the pylorus; if worse when standing than reclining the ulcer is probably on the greater curvature.

The pain is usually localized by the patient, and pressure at the given spot increases the pain. In many cases there is referred pain in the region of the 9th, 10th and 11th ribs on the left side.

At the height of pain vomiting may occur, due probably to pylorospasm resulting from high acidity. Vomiting always gives relief. The taking of protein food or alkali will usually relieve the pain of ulcer, (hunger pain). Ulcer patients are usually well nourished owing to the habit of relieving themselves by eating, or they may be thin due to their fear of food.

In acute ulcer frank blood may show in the vomit, and may be the first indication of trouble, whereas in the chronic type it may be occult, or occult blood may be found in the feces. The hemorrhage of ulcer, unlike that of cancer, is not constant.

=Diagnosis.=—Diagnosis of duodenal ulcer, as distinguished from gastric, is made by finding the tender spot to the right and below the pylorus, the pain coming on three or four hours after taking food, and the finding of blood in the feces (tarry stool) and not in the stomach contents. Repeated examinations may be necessary owing to the fact that hemorrhage is not constant.

The large percentage of stomach ulcers are near the pylorus, and of the duodenal ulcers the ascending portion is the area almost invariably involved.

Ulcer is differentiated from functional disorders by a history of real pain as distinguished from the vague disturbances of sensation often called pain by neurotic patients. Also its regular appearance in relation to food. The pain of “gastralgia” has no regular habit and is not influenced by food.

Referred pain from cholecystitis, chronic appendicitis, etc. has no relation to food and is not relieved by food or alkalies.

Ulcer is to be distinguished from cancer by the age of the patient (in cancer usually over 40) with a previously good gastric history, except in cases where cancer has been grafted on to a chronic ulcer. In these cases a careful inquiry will bring out a characteristic ulcer history up to a certain time, when all symptoms change; pain becomes constant; is not relieved by food or alkali; vomit becomes dark in color and has a characteristic odor, appetite fails, and signs of cachexia set in.

Gastric ulcer should be suspected in all cases of persistent gastric symptoms which are not readily relieved by treatment and regulation of diet, and in which there is found high acidity and continuous hypersecretion not accompanied by mucus.

The X-ray and gastric analysis should never be neglected in suspected cases, keeping in mind the possible injury from the tube in case of recent hemorrhage.

=Treatment.=—Osteopathic treatment of gastric ulcer will be almost uniformly successful if we will analyze all of the factors entering into the problem.

It is obvious that in order to heal the ulcer we must remove all factors which interfere in any way with nutrition. Then give the stomach as near absolute rest as possible while at the same time building up the nutrition by a generous but well chosen diet.

When acute hemorrhage has recently occurred, complete rest in bed with a trained nurse in attendance is the first indication. Complete rest of the stomach, all nourishment being given by nutrient enema. An ice bag is to be placed over the stomach, and removed every three or four hours to allow surface circulation to react. Warm applications should not be used while there is any marked bleeding.

During this period no effort on the part of the patient should be permitted, and no manipulative treatment which would tend to increase blood pressure should be given.

After all evidence of hemorrhage has ceased for ten days, or at once in case of chronic ulcer, we may carefully correct all spinal or rib lesions in the splanchnic area especially the 6th dorsal, or cervical lesions affecting the pneumogastric. Pain and pylorospasm may be relieved by steady pressure at the 4th and 5th dorsal on the right side.

After spinal lesions have been corrected without unduly irritating the stomach, careful relaxing treatment should be given with the patient on the back, keeping in mind that all exertion will tend to irritate the ulcer.

If special care is observed, frequently definite relief may be given by placing patient in knee-chest position and gently raising the lower portion of duodenum where it lies alongside of ascending 3rd and colon, 4th lumbar.

During this period a hot water bag or a thermal pad should be kept over the stomach night and day.

In certain cases of perforation in a few obstinate conditions, and in a few where mechanical obstruction is marked, surgery may be indicated.

The following diet will be found best during the first week:

7 A. M. A half glass of cooked milk, with the leathery substance which rises on the top removed, and the yolk of one egg stirred into it and sweetened, if desired; taken luke warm or cool, but never ice cold. This amount to be increased on the second day to three-fourths of a glass, and on the third to a full glass, which is to be continued for a week. If the milk produces diarrhea, add two tablespoonfuls of lime water to each portion.

9 A. M. A saucerful of gelatine (Knox’s or Crystal Rock) with 2 tablespoonfuls of cream and a teaspoonful of sugar.

12 M. A half to full glass of milk prepared as above.

3 P. M. A saucerful of gelatine, with cream (medium) and sugar as at 9 A. M.

6 P. M. A half to whole glass of milk, as before, with one egg stirred in and sweetened. The egg yolks at 7 A. M. and 6 P. M. are to be increased until six are taken daily at the end of the week.

8 P. M. A half to a full glass of milk.

The whites of the eggs are to be stirred up in the water in the proportion of a white to a glass of water, 4 teaspoonfuls of sugar to be added to every glass, this to be taken by the patient only when thirsty. If the bowels do not move, no laxative can be taken, but an injection of warm water or a little soap may be employed. If much discomfort is produced by the food, a hot compress must be laid over the stomach or above the navel.

During the second week the diet should remain much the same except for the addition of one or two pieces of Zweiback three times a day.

During the third week, if pain and blood in the feces are lessening, we may add soft, well cooked cereal like cream of wheat, cocoa, puree of split pea made with cream.

Fifth week add minced chicken, coddled egg, =boiled= beef or lamb put through a meat grinder, soft vegetables such as chopped spinach, squash and mashed or baked potatoes with liberal quantities of butter.

During and after the sixth week we may add all vegetables which can be served in puree form, fresh fish, oysters, apple sauce, inside of a baked apple, prune whip, custard junket, corn starch pudding.

At this time also if all goes well the patient may sit up in bed and gradually move about, being careful to avoid all sudden movements which would put a strain on the epigastric region.

If necessary we may also increase our manipulative treatment at this time.

The patient must be warned against the use of any article of diet which will be chemically or mechanically irritating to the stomach, for a period of months, and an examination of feces should be made from time to time to make sure of no return of hemorrhage.

Dilatation of the Stomach

A dilated stomach is a stretched stomach having increased capacity, due to nervo-muscular atony or to pyloric obstruction. Every stomach which is not retracted when empty is a dilated stomach. A dilated stomach may occur either as an acute or as a chronic condition, but it is to be distinguished from temporary distention and a normally large stomach.

=Osteopathic Etiology= and =Pathology=.—The nervo-muscular atony causing dilatation may be due to obstructive lesions in the stomach splanchnics, or to a general debility of the spine in the dorsal region (usually a kyphosis), or to continued overeating and improper food causing a stasis and fermentation. It may also be due to overdrinking and various diseases, as phthisis, liver and lung diseases, anemia, chlorosis, acute fevers and kidney diseases, causing more or less of a general nervo-muscular atony. Dilatation may result from a mechanical obstruction, or narrowing of the pylorus or the duodenum, by a cicatricial contraction of an ulcer; by hypertrophic thickening due to various diseases, by adhesions and tumors. Occasionally the pyloric obstruction is congenital. A floating kidney may fall upon the horizontal portion of the duodenum and thus mechanically obstruct the passage of food from the stomach, which consequently dilates. Tight lacing might prevent the liver, when congested, from passing in front of the kidney, thus luxating the kidney. Dilatation of the stomach occurs at all ages, although most frequently in middle aged persons.

=Pathologically=, the muscular coat is thinner and paler than normal, with more or less atrophy of the glandular tissues and an increase in capacity of the stomach. When obstruction exists at the pylorus, hypertrophy of the muscular coat may occur.

=Symptoms.=—The symptoms are those of the disease causing the dilatation plus those of persistent chronic catarrh. The patient complains of a sense of fullness in the epigastric region and there is flatulency, eructations and vomiting. The cavity of the stomach being much enlarged, great quantities which are usually considerably decomposed are vomited each day or two. There is often lessened acidity of the vomited mass, though in some cases it is increased. Passage of the food from the stomach to the intestine is delayed and the bowels are constipated, the fecal matter being dry and hard. The urine may be scanty and the skin dry. Anemia, debility and emaciation are always present to a greater or less extent, and on account of the absorption of poisonous matter drowsiness may occur.

=Physical Signs.=—=Inspection.=—In some cases the outline of the distended stomach can be plainly seen. There is prominence of the epigastric region, the tumefaction being at the pyloric end of the stomach. =Palpation.=—The resistance upon manipulation of a dilated stomach is like that of an air cushion. If the patient is made to drink a half tumbler of water, bimanual palpation will cause a splashing sound to be heard along the circumference of the stomach at its lowest point; and by moving the water about by changing the position of the patient, the outline of the stomach can be made. If the sound is not heard at the first manipulation, it must not be concluded that the stomach is normal for the stomach may be so dilated and flabby that it falls behind the abdominal wall like an apron. =Percussion.=—The note is tympanitic over the greater part of the stomach until the lower curvature is reached when the sound is dull (due to the liquid contents of the stomach), followed by a tympanic sound again when the intestines are reached. When percussion is made the patient should always be in a standing position if possible.

When there is =pyloric obstruction= a tumor usually presents itself, and vomiting is more severe and peristalsis more active than when the dilatation is due to atony of the walls of the stomach from an obstructed innervation.

=Diagnosis.=—This is usually easy if due care is taken in making the examination. Goetz has shown by the use of his spinegraphometer that in cases of visceral prolapse the spine is commonly posterior in the dorso-lumbar region. The X-ray is of value in determining the size and function of the organ.

=Prognosis.=—In a case of nervo-muscular atony the prognosis is favorable. If due to a malignant disease recovery is usually impossible. In hypertrophy of the pylorus or the duodenum, recovery is probable by means of surgical interference.

=Treatment.=—When the dilatation is due to atony of the muscular walls of the stomach from obstructed innervation at the spinal column, treatment is usually successful. Attention should be given to the condition of the spinal column in the splanchnic region (fourth dorsal to twelfth dorsal), the spine being usually posterior. A thorough and persistent course of treatment must be given, not only to restore the normal activity of the nerves to the muscular coat and glands of the stomach, but to build up and restore strength in the weakened spinal column. Lesions in the spinal column, even higher than the fourth dorsal, may affect the innervation of the stomach. There are cases where lesions have been found at the fifth, sixth and seventh cervicals that interfere considerably with the action of the stomach, causing nausea, flatulency, eructations, and even vomiting. Such an affection may be through the fibers of the splanchnic nerves or through fibers of the vagi nerves.

The vagi nerves have an important bearing upon gastric dilatation as paralysis of the gastric branches of the vagi arrests the peristalsis of the stomach and thus tends to favor retention of food within its cavity. The stomach in such cases becomes enlarged, mainly by the weight of the food and the presence of gases due to decomposition of the retained food. Thus lesions may be found higher than the lower cervicals and cause obstruction and paralysis of the fibers of the vagi to the stomach.

Direct stimulation over the stomach in the form of thorough manipulation of the stomach walls causes contraction of the muscular fibers of the stomach, mainly the circular fibers. This treatment, with additional treatment of the splanchnic and the vagi nerves, will tend to build up the weakened plexuses of the stomach. Much time can be saved by putting the patient to bed and treating him every day for several weeks. When the stomach is dilated or dilated and prolapsed, to any extent, it usually requires three to five months treatment at least; this time can be shortened one-half by keeping the patient in bed, treating the spine three times a week, and the abdomen every day. Light food at frequent intervals, upper thoracic breathing, and frequent drawing up and in of the abdomen should be required. The patient may also manipulate his own abdomen twice a day to advantage; teach him to manipulate, draw and pull it upward. There is no danger of too frequent treatment as long as there is no bruising of the parts; this, however, does not apply to the spine. It is not an uncommon thing to correct a dilated stomach or a dilated and prolapsed stomach that is an inch and a half or two inches below the umbilicus. Care must be taken in all cases that other viscera are not prolapsed. It is a common experience to find enteroptosis, which can usually be readily functionally corrected, with the stomach ptosis. But where the kidney, or possibly both, is much prolapsed only fair results can be secured until the kidney is replaced and kept there, and if necessary by surgical means. Also, note whether the liver is enlarged. (See special article on Prolapsed Organs).

When the disease is due to cancer and various growths of the pylorus or the duodenum, nothing can be done but palliate. Such cases require surgical attention. In all cases it is necessary that care and preoccupation of the patient should be removed. Baths, changes of air, a carefully regulated diet and caution in the use of liquids will be of great aid to the general health of the patient, and thus the weakened nervous system will be indirectly but greatly benefited. Too great care cannot be taken of the patient, as there is created in the organism a special aptitude for the tissues to become inflamed and thus weaknesses at various parts of the body may occur. Phthisis, typhoid fever and various diseases are apt to follow dilatation of the stomach, as the nutritive and resistive process of the body are impaired.

The meals should be taken regularly and with great care, the patient not eating too quickly nor too much. Solids should be used but little; the artificially digested foods, such as peptonized milk and beef peptonoids, probably being the best. Beef juice and scraped beef are excellent foods, as they are easily digested. Fatty and starchy foods should be avoided.

Washing out the stomach is useful, but it should not be indiscriminately employed. Lavage will not be necessary in all cases of mechanical obstruction. It relieves the distention, by removing the weight and the fermenting and decomposing material.

In =acute dilatation=, which may be due to prolonged diseases, general anesthesia, injuries of the spine, and to narrowing of the duodenum, vomiting, pain and collapse occur. Empty the stomach, and place patient in knee-chest position. Reach beneath the duodenum and raise this part of bowel. Start well down, as low as third or fourth lumbar. If this does not give quick relief stand patient on his head.

Gastroptosis and Enteroptosis[74]

(GLENARD’S DISEASE)

=Definition.=—A displacement of the stomach and intestines.

=Osteopathic Etiology= and =Pathology=.—A weakened, debilitated spine is the common cause. A slight posterior curvature is a frequent occurrence. A debilitated spine impairs the innervation to the abdominal viscera and to the muscles of the abdomen. Many cases are of congenital origin due to lack of complete development and weakness of the supporting tissues. Other causes are muscular strain, repeated pregnancies, tight lacing and malnutrition. A downward displacement of the floating ribs, and a consequent prolapse of, and atony of the diaphragm, is an important cause.

=Prolapses= of the stomach and intestines are of frequent occurrence in both sexes, and very common in women. It is a condition oftentimes overlooked, and when recognized, little has been done in the way of a cure. It is the cause of much disturbance, not only to the stomach and intestines, but to the various abdominal viscera and to the pelvic organs, and it is the cause of a large percentage of prolapses of the uterus, (excluding lacerations from childbirth) for not only is the great suspensory ligament of the uterus (the peritoneum) prolapsed as a consequence, but all of the abdominal viscera and the parietes of the abdomen are also prolapsed and crowded down into the pelvis. The small or large intestine or the stomach may be prolapsed singly. This is frequently the case with the transverse portion of the colon, which may be elongated and tortuous and prolapsed nearly to the symphysis pubis. Prolapse of the liver, spleen and kidneys may occur singly or with a general displacement of all the organs.

=Symptoms.=—The abdominal walls are weak, oftentimes flabby. The viscera of the abdomen do not have normal resistance upon manipulation. The spinal column presents lesions. There is dyspepsia, flatulency, constipation, abdominal pains and various neurasthenic symptoms.

=Diagnosis.=—Is readily made by the lack of tone to the abdominal walls and viscera and the general debility of the patient. Inflation of the stomach with air will determine between gastroptosis and dilatation. The X-ray is of special value in determining position, function, spasms, kinks, etc. of the digestive tube. There are innumerable gradations and phases of this condition.

=Treatment.=—To remove the cause is of primary importance. This is to be followed by treatment of the spinal column, correcting its various derangements and improving the innervation to the atonied viscera and abdominal parietes. Direct treatment over the abdomen helps to give tone to both the viscera and abdominal muscles. In many cases the treatment will have to be a prolonged one in order that the tissues may regain their normal condition. Usually a treatment from two months to a year, or possibly more, is required. Exercises and manipulations that tone the tissues, correct the posture, and raise the chest, diaphragm, abdominal and pelvic viscera, and release spasms, kinks, and adhesions, are indicated. The diet of the patient should be nutritious, and sufficient in emaciated cases to increase his weight if possible. A supporting bandage will often give some relief. A few cases will require surgery.

Particular attention should be given to the colon, duodenum and diaphragm.

Relative to the treatment of gastroptosis and enteroptosis, W. E. Harris writes as follows: “I first set to work trying to correct the spinal irregularities; coupled with this I give deep and careful manipulation of the gastric and intestinal walls—treating my patient two or more times per week for a period of one to three years. A lesser period is not long enough to bring the desired result in such cases. I also instruct the patient to knead his own bowels, which I prescribe as a necessary proceeding, and to be performed twice daily on retiring and before rising. Of equal importance with the osteopathic treatment, come local, specific abdominal exercises. These are to be of the resistive type, and must also be taken for the general musculature. I have my patient retract the abdominal walls and voluntarily draw the abdominal contents towards the diaphragm, in regular series. These exercises must be faithfully performed and continued after the treatment has ceased in order to be of real value. I do not find our treatment, without the hearty cooperation of the patient in doing his exercises conscientiously, to be sufficient in itself. Have the patient avoid overloading the digestive tract. Use concentrated foods, in small quantities, i. e., only sufficient to sustain strength, twice daily and without taking fluids at meal times. Of course water, in small quantities and at frequent intervals, may be taken between meals. To summarize—First, corrective treatment. Second, resistive exercises. Third, attention to diet.” (See Dilatation of the Stomach.)

DISEASES OF THE INTESTINES[75]

Acute Diarrhea

=Definition.=—A diffuse inflammation involving the entire intestinal tract to a greater or less degree. Usually the seat of disease is found in the small intestine and the upper part of the large bowel.

=Osteopathic Etiology= and =Pathology=.—Acute diarrhea may be caused by overeating, drinking impure water, unripe fruits, and poisons produced in decomposed and fermented milk and other articles of food. This sometimes takes place in perfectly harmless substances in an inexplicable manner. Milk and ice cream may produce intestinal catarrh. Dr. Still often referred to the harm resulting from iced drinks. Changes in the weather, tending to weaken the system, often cause diarrhea; hot weather favors this, although a chilling of the system by a sudden fall in the temperature may produce the disorder. Dr. Still was of the opinion that sitting on the cold ground (a common habit of children) is a frequent source of intestinal derangements. Changes in the quantity and quality of the secretions also induce the disorder; thus the bile, if in too great a quantity, increases the peristalsis to such a degree that diarrhea is produced; if diminished, it favors the fermentation and decomposition of the food. Pancreatic diseases may be a cause of diarrhea. Infectious diseases, through their specific poisons, such as cholera, dysentery and typhoid fever; inflammation, extending into the bowels from adjacent parts; inflammation caused by peritonitis and intestinal obstructions, as invagination and hernia; hyperemia, secondary to diseases of the liver, heart and lungs; cachectic states met with in Addison’s disease; the last stages of Bright’s disease; cancer and marked anemia are all among the causes of diarrhea.

As in constipation, diarrhea is oftentimes simply a symptom of various disorders; still, it may be the only symptom manifested. Lesions are found in various regions of the body, but chiefly in the lower dorsal and lumbar vertebræ and the lower ribs at either side. Also lesions may be found to the vagi, thus increasing the peristalsis or affecting the blood supply of the intestines. The lesions to the splanchnics may involve the motor, vasomotor or secretory fibers to the intestines. Oftentimes the innervation to the liver is disturbed, affecting the secretion of the bile. The left side of the spinal column is involved more often that the right side, by vertebral, rib and muscular lesions.

=Nervous Diarrhea= frequently follows fright and other causes of nervous excitement, and is often found in hysterical women. There is simply an increase in the peristalsis and secretion of the bowel, due to a vasomotor paresis of the intestinal vessels, producing an outflow of the serum.

The intestinal condition is one of hyperemia. The secretory glands are frequently inflamed. In decided cases the mucous membrane may be red and injected, but more often it is pale and covered with a layer of mucus. Sometimes the solitary follicles are considerably enlarged. These enlargements may become filled with pus, forming abscesses which rupture, leaving an ulcer. Peyer’s patches may also be involved.

=Symptoms.=—The diarrhea is the important, and often the only, symptom of enteritis; the stools are frequent, varying from two or three to fifteen or more a day; they are thin and watery, varying in color according to the amount of bile they contain. They are usually of a yellowish or greenish color. They contain undigested food, mucus, columnar epithelium and mucous cells, micro-organisms and triple phosphate. The reaction of the discharge is either acid or neutral. There are colicky pains in the abdomen, rumbling noises or borborygmi, intense thirst, dry and coated tongue, with loss of appetite, and, rarely, a fever. When fever is pronounced care should be taken that some infectious disease is not the cause. =Chronic catarrhal diarrhea= may follow the acute form. If the stools contain much undigested food the inflammation is in the upper bowel; if thin, watery and containing mucus, the lower bowel is involved. In prolonged cases the general health is affected. Definite tender areas along the spine and deep muscular contractions are invariably important etiologic and diagnostic clues.

=Diagnosis.=—This is ordinarily made easy by giving attention to the above symptoms. In distinguishing as to whether the large or small intestines are involved the following is important: In catarrh of the =small intestines=, diarrhea is not so well marked; there is much undigested food, but very little mucus; and there is usually pain of a colicky nature in the middle or inferior part of the abdomen. When the =large intestine= is involved there may be no pain; when present, it is intense and usually in the upper and lateral parts of the abdomen; there are borborygmi and thin, soupy stools, mixed with much mucus. If the lower portion of the bowel is involved there may be marked tenesmus, with marked contraction of the muscles over the sacral foramina.

=Duodenitis= is often associated with acute gastritis. Placing the patient in the knee-chest position one may be able to palpate the duodenum. If the inflammation involves the bile duct, there is jaundice; in these cases the urine may be bile-stained.

=Prognosis.=—Commonly favorable if early and prompt treatment is employed; though it should be remembered that some infections, or constitutional disease, or intestinal ulcer may be an underlying cause.

=Treatment.=—Many cases of acute diarrhea will recover by restricting the diet, with rest. Where improper food and water are the causes, an entire change of diet should be considered. Withdrawal of all food and the substitution of boiled milk will be of great aid. The bowels should never be confined if there is reason to suspect that all irritating matters have not been removed; and when fermentation and irritation exist in the lower bowel, an enema will often be beneficial. The spinal column should be examined, especially on the left side, from the fifth dorsal down to the coccyx. The vertebræ may become displaced and cause diarrhea, by derangement of the vasomotor nerves.

Either an increased blood supply through the intestines, or an affection of the motor nerves will produce an increased peristalsis. An active condition of Meissner’s plexuses may be produced sympathetically, resulting in increased secretion of intestinal juice and thus in diarrhea. The ribs may become displaced and be a source of irritation to the nerves of the intestines. The muscles of the spine are apt to become contracted by colds, injuries, strains, etc., and stimulate or inhibit the action of certain centers in the cord and produce disordered intestines. Conversely the muscles of the back may be thrown into a contracted condition by irritating substances in the bowels acting as a stimulus to the centers in the cord, and thus reflexly to the muscles. Trouble may arise in the colon and rectum by lumbar lesions, the slipping of an innominate, a dislocated coccyx, or contracted muscles over the sacrum. In a word, thorough inhibition, relaxing contracted muscles and correcting abnormal vertebræ and ribs are the osteopathic essentials of treatment for diarrhea. Inhibition of the lower dorsal and lumbar is very effective; it dilates the mesenteric vessels by way of vasomotor fibers, and thus controls secretions and lessens peristalsis. This has been clearly proven in the osteopathic experimental work of Burns and Pearce.

Hot fomentations over the dorsal and lumbar spine will frequently, through the nervous reciprocal relationship, be of decided value.

Direct treatment over the mesenteric circulation, i. e., through the abdomen anteriorly, will be helpful in some cases. It relaxes tissues, removes irritations and frees the circulation generally about the mesenteric vessels and intestines. When giving this treatment one should be certain of the underlying pathology. The liver should be kept active. Treatment of the vagus nerves is important, as they help to control the blood supply and the motor nerve force through the intestines. Daily hot baths and increased activity of the skin and kidneys are beneficial.

Chronic Diarrhea, and Mucous Colitis

=Definition.=—A chronic inflammation of the mucous membrane of more or less of the large intestines. There may be ulceration.

=Osteopathic Etiology= and =Pathology=.—Chronic diarrhea may be the result of repeated attacks of the acute form or may be caused by cancer, tuberculosis, Bright’s disease, typhus fever, disease of the liver, organic disease of the heart and lungs, obstructions to portal circulation or impactions of any nature that occasion passive congestion. Frequently cases of long standing are due to chronic lesions of the lower ribs or lower dorsal or lumbar vertebræ. The lesions of the lower ribs usually consist of downward displacement of the ribs, affecting the innervation to the intestines directly, or possibly dragging the diaphragm downward to such an extent as to interfere with the blood and lymph vessels as they pass through it, thus causing congestion of the intestines by obstruction to the lumen of the vessels.

In many cases the =pathological changes= are simply those of the acute form. In more pronounced cases the mucous membrane becomes a brownish red, livid gray or slate color; this discoloration being due to hyperemia and blood extravasation. The mucous coat is also swollen and thickened. Atrophy of the mucous membrane, and in some cases of all the coats, with destruction of the glands, may be a result of the chronic form. Ulcerative changes occur chiefly in the lower part of the ileum and colon; these may be follicular or there may be large ulcers and considerable areas of ulceration.

=Symptoms.=—Constipation and diarrhea frequently alternate; the stools are thin, mixed with a large amount of slimy mucus; the small intestine is most frequently involved, and the patient complains of pain in the umbilical region; there is distention of the bowels with gas; the health gradually declines; there is great pallor, and the patient becomes emaciated, gloomy and irritable.

=Mucous Colitis= is a chronic form of colitis, characterized by paroxysms of severe pain and the discharge of large masses of mucus, forming gray translucent casts, which are not fibrinous but mucoid in character. This disease occurs usually in women of nervous type, but is occasionally seen in men and children. When there is no underlying organic disease, it is probably largely a secretion neurosis. Mental emotions and worry, sometimes errors in diet, or dyspepsia bring on the attack. Overfatigue is often an exciting factor. The nutrition is generally well maintained, but in other cases there may be a gradual emaciation and ultimate death. This is undoubtedly one of the most persistent and troublesome diseases that one will meet; still the osteopath can do much for these cases and not infrequently bring about a cure. But the treatment must be consistent and persistent.

Mucous colitis is not hard to diagnose, although many cases are treated for simple indigestion. It is needless to say that a correct diagnosis is paramount. In these cases there is almost invariably some visceral prolapse, which undoubtedly is the underlying cause, by favoring venous congestion of the bowels. The liver is usually congested; this alone may cause the venous stagnation, but more often it is simply due to the common cause. Back of the visceral prolapse and congestion will almost invariably be found a posterior dorso-lumbar curvature; still there may be a scoliosis or single lesions only, and a downward displacement and constriction of the floating ribs.

The =treatment= requires most persistent and careful work for at least three months, and probably six to nine months. Correction of the spine and floating ribs should be of first consideration; then intelligent treatment over the abdomen, by raising and toning the bowels, not only the bowels as a whole, but especially in the ileo-cecal, hepatic flexure, transverse colon, splenic flexure, sigmoid flexure, and rectal regions. The direct treatment should be cautiously given when there are indications of ulceration.