Chapter XXVIII: Introduction (13)

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

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

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

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

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

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

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

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

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

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

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

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

Diseases of the Liver and Bile Duct

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

Hyperemia of the Liver

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

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

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

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

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

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

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

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

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

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

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

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

Simple Catarrhal Jaundice

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

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

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

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

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

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

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

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

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

Cholecystitis

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

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

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

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

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

Jaundice

(ICTERUS)

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

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

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

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

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

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

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

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

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

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

Cirrhosis of the Liver

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

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

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

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

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

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

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

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

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

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

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

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

Fatty Liver

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

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

Amyloid Liver

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

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

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

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

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

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

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

Gall-Stones

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diseases of the Spleen

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

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

Splenitis

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

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

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

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

FOOTNOTES:

[74] See special article, Prolapsed Organs, Part I.

[75] The student will receive many helpful suggestions by reading Macleod, Physiology and Biochemistry in Modern Medicine; Cannon, The Mechanical Factors of Digestion; Carlson, The Control of Hunger in Health and Disease; Gaskell, The Involuntary Nervous System; Pottenger, Symptoms of Nervous Disease.

[76] Von Noorden, Colitis, 1904.

[77] See Philosophy and Mechanical Principles of Osteopathy, p. 190.

[78] There are several possible suggestions. (1) Developmental (See Mayo, Relation of the Development of the Gastro-intestinal Tract to Abdominal Surgery. Jour. A. M. A. Feb. 7, 1920). (2) Owing to the appendix, cecum, ascending colon, duodenum, and biliary tract being frequently disordered. (3) Imbalance of muscular tension, owing to the muscles of the right side being often the better developed. Muscular lesions and lymphatic involvement of the cervical region seem to occur oftener on the right side than on the left.

[79] Journal of Osteopathy, May, 1900.

[80] For points on enema, see treatment under Intestinal Obstruction.

[81] Diseases of the Intestines, Vol. I, p. 240.

[82] The Lancet, (London,) Oct., 1904.

[83] Philosophy of Osteopathy, p. 226.

[84] Medical Record.

[85] The Vermiform Appendix and Its Diseases, p. 711.

[86] Dr. Chauvel, 1902.

[87] Rose and Carless.

[88] Clinical Osteopathy.

[89] Journal of the American Osteopathic Association, Dec, 1902.

[90] Journal of American Osteopathic Association, March, 1905.

[91] Journal of American Osteopathic Association, March, 1905.

DISEASES OF THE RESPIRATORY SYSTEM

DISEASES OF THE LARYNX[92]

Acute Catarrhal Laryngitis

=Definition.=—An acute, catarrhal inflammation of the mucous membrane of the larynx. This may be ushered in as an independent disease or it may be associated with inflammation of the upper respiratory passages.

=Osteopathic Etiology= and =Pathology.=—One of the principal causes of acute catarrhal laryngitis is exposure to cold and dampness, which contracts the muscles of the neck region, especially about the larynx. Lesions in the upper and middle cervical vertebræ are important predisposing causes. Occasionally the first rib becomes luxated, causing a greater or less congestion of the laryngeal mucous membrane by contracting the lower antero-lateral muscles of the neck, and affecting lymphatic drainage. Improper placing of tone, as well as too constant use of the voice in speaking and singing, are common causes. Inhalation of irritating gases or dust, and mechanical injuries to the larynx are occasional causes. The disease may be associated with certain infectious diseases, as measles, diphtheria, influenza and whooping cough.

=Pathologically=, the mucous membrane is intensely reddened and inflamed; this inflammation involves both the true and false vocal cords and may extend into the trachea and about the epiglottis. The membrane is covered slightly with mucous secretion. In rare instances edema of the glottis may occur. The muscular contraction about the larynx impedes blood and lymphatic drainage and thus induces congestion. The contraction may be so severe as to slightly prolapse the organ. The vertebral lesions impinge upon or affect vasomotor fibers and thus bring about congestion.

=Symptoms=.—There is hoarseness and cough with a sensation of tickling in the larynx; these are the most constant symptoms. The cough is dry and the voice altered. At first the voice is husky, but some attempts at speaking are attended with more or less pain and finally the voice may be entirely lost. Deglutition is painful. At first the expectoration is scanty, but later it becomes mucopurulent. There is rarely much fever. When there is considerable edema, dyspnea and asphyxia are prominent features.

=Prognosis.=—Simple catarrhal laryngitis never terminates fatally. When there is dyspnea or asphyxia indicating edema of the larynx, the prognosis is grave. The attack usually lasts from one week to ten days, but this can be materially shortened by careful osteopathic treatment. In severe infections it may be two or three weeks before the larynx returns to its former condition.

=Treatment.=—In a few cases confinement of the patient to his room, and possibly the bed, will be necessary; especially should the larynx have rest from phonation, and the taking of food of an irritating character should be avoided. Smoking is to be prohibited. The room should be at an even temperature, from 70 to 75 degrees F., and the atmosphere saturated with moisture by the generation of steam.

The tissues in the cervical region about the cervical sympathetic and vagi nerves should be carefully adjusted. The deep posterior muscles of the cervical spine are to be relaxed and direct treatment given over and about the larynx. Relaxing tissues and raising the larynx will be very effectual in relieving the =huskiness= of the voice and in controlling the congestion and inflammation of the laryngeal mucosa. Besides the treatment of the vagi nerves at the atlas and their course down the lateral and anterior portion of the neck, the superior laryngeal may be treated at the upper portion of the great cornu of the hyoid bone and the inferior laryngeal at the inner side of the cleido muscle near its sternal attachment. Adjust the tissues along the course of the external carotid and subclavian arteries, chiefly the first rib for the latter. Give careful treatment to the internal jugular and innominate veins. Correct any tissues that may impinge upon the lymphatics of the mucous and submucous coats of the larynx where they are drained into the deep cervical glands. Release any immobility of the upper chest, relax the pectoral, auxiliary and upper dorsal muscles, and adjust the first four or five dorsal vertebræ.

Prompt action of the skin, freedom of the bowels, placing the feet in a hot bath and continued local hot packs, or even an ice-bag in severe cases, will be of special value at the onset; but due attention should be given these throughout the entire course. The fever is easily aborted by the cervical treatment and proper attention to the bowels and sweat glands.

Chronic Catarrhal Laryngitis

=Definition.=—A chronic, catarrhal inflammation of the mucous membrane of the larynx.

=Osteopathic Etiology= and =Pathology=.—The causes of chronic laryngitis may be numerous, but lesions of the cervical vertebræ are the most common. The contractured cervical muscles, especially the deep vertebral ones, are usually the result of corresponding osseous deviations.

Other causes given under the acute form, as overuse and abuse of the voice, inhalation of irritating substances, excessive use of tobacco and alcoholic drinks, tumors, etc., are important etiological factors. Thus irritations inducing acute attacks, if repeated, will result in chronic catarrh.

The =pathological= changes as revealed by the laryngoscope are swelling of the mucous membrane, occasional superficial erosions, and rarely ulceration.

=Symptoms.=—The voice is usually hoarse and rough, being due to a thickening of the vocal organs. In severe cases the voice may be lost. There is fatigue and pain after slight use of the voice, a sense of tickling in the larynx which produces a desire to cough, and expectorations of viscid mucus and mucopus.

=Prognosis.=—The prognosis is sometimes unfavorable, although many cases are cured.

=Treatment.=—The patient must learn to take care of himself properly. He should avoid overheated rooms and the use of tobacco and alcohol, and the throat should not be protected too much. It is a good plan to bathe the neck every morning and night with cold water. He should avoid loud speaking; the sound should be expelled by the abdominal muscles and diaphragm and not by the muscles of the throat. Examine the upper air passages carefully for any obstructions and infections that might exist which are a source of irritation to the larynx.

Special attention should be given to the atlas, axis and third cervical. Lesions lower down the spine may be found, for other laryngeal nerve fibers, other than those from the superior cervical ganglion, may be at fault. Palpate the =hyoid= to see if it is tilted by contracted muscles, as will often be the case.