Chapter XXVII: Introduction (12)

Have the patient help himself by manipulating his bowels night and morning, drawing the abdomen up and in, and by thoracic breathing. Prescribe plenty of drinking water and reduce starchy and saccharine food to a minimum. Again emphasis is placed upon the necessity of persistent treatment, two and three times per week, for several months. The mucus is hard to remove. It is tenacious and frequently causes colicky pains.

To the student Von Noorden’s[76] monograph on this subject is especially instructive. He notes that almost without exception the patients suffer for some weeks or months prior to the development of colica mucosa from obstinate constipation. For acute attacks, among other things, he advises rest in bed, hot applications, and high water injections. He believes in massage of the large intestine (particularly of the sigmoid flexure), in cases of atonic constipation and also in spastic constipation, provided the patient has a diet that leaves a large residue. “A coarse, laxative diet of Graham bread, leguminous plants, including the husks, vegetables containing much cellulose; fruit with small seeds and thick skins, like currants, gooseberries, grapes; besides, large quantities of fat, particularly butter and bacon.”

=Diagnosis.=—Diagnosis is always easy. The presence of blood, pus, or fragments of tissue in the stool point to ulceration. Ulcers in the rectum, and as high as the sigmoid flexure, will be recognized by examination with the speculum.

=Prognosis.=—Osteopathy has undoubtedly changed the prognosis of other treatment. Many cases can be cured and most other cases greatly benefited. The deep seated ulcerations may cause circumscribed peritonitis, or even abscess, and the prognosis becomes grave as these complications arise.

=Treatment.=—As diarrhea may be caused by lesions anywhere from the sixth dorsal to the coccyx, a most thorough examination is necessary. On the one hand, diarrhea may be due to a marked lateral or posterior spinal curvature, which is plainly seen upon inspection, but on the other hand, it may be due to a slight twist or deviation from normal of a vertebra which would require considerable osteopathic ability to exactly locate. Diarrhea may result from subluxation in the lower costal region, one or more of the three lower ribs on either side being involved. Record of one case, in particular, of chronic diarrhea is of interest as it was due to a rib dislocation. It was the case of a man fifty years of age, who had suffered from chronic diarrhea, several stools a day, for over thirty years. He was completely cured in one treatment by correcting the dislocation of the vertebral end of the tenth rib on the left side. This case is cited to impress upon the student the necessity of precise diagnosis and treatment. Rarely will diseases be cured by a single treatment, but when such happens it exemplifies the potency of the osteopathic lesion. Treatment on the left side is usually more effective in diarrhea than treatment on the right side. When diarrhea is a symptom of some constitutional disturbance, correction of dorsal, lumbar and rib lesions, with thorough inhibition, careful dieting and rest, will commonly suffice provided the primary disease is intelligently looked after.

=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.