Chapter XXV: Introduction (10)

It develops rapidly. Joint pains, anemia and irritability are early symptoms. The child is pale, has a muddy complexion and may show signs of rickets. The gums may be soft and spongy. There is tenderness and pain on motion. There may be hemorrhages under the skin. The lower limbs are drawn up and motionless. The bones become thickened from sub-periosteal hemorrhage, and there is apt to be softening between the shaft and epiphysis. The back and legs become very weak. The lesions are usually symmetrical. The temperature is variable.

=Treatment.=—The treatment of scurvy in children consists in, first, omitting all proprietary foods and substituting fresh cow’s milk, meat juice, strained gruel and a moderate quantity of fresh orange or lemon juice. Under this treatment, cases that have not progressed too far will promptly recover.

Northrop says: “It is a significant fact that the country which furnishes most of the literature on scorbutus in children is the same which is posted from end to end with advertisements of proprietary foods.”

Purpura

=Purpura= is a symptom rather than a disease. It is characterized by extravasation of blood into the skin and bleeding from the mucous membranes, irrespective of direct injury. These extravasations do not disappear upon pressure and vary greatly in size. They may be small, (petechiæ) or large (ecchymoses). They are bright red and gradually become darker. Clotting of normal blood requires three to five minutes, purpuric blood, ten to fifteen minutes.

It is a symptom of =infectious diseases=, as in pyemia, septicemia, mycotic endocarditis, typhus fever, smallpox, etc. =Toxic=, as produced by venomous snake bites and by =certain medicines=, as copaiba, mercury, quinine, iodides and others in overdoses. =Cachectic purpura= may be observed in cancer, tuberculosis, Bright’s disease, scurvy, etc. In =senile purpura= the spots are generally confined to the extremities. In certain =nervous diseases=, bleeding spots appear on the skin, as in tabes, myelitis and severe neuralgia. =Mechanical purpura= is seen in venous stasis; this is rare.

=Purpura simplex= affects only the skin. It occasionally follows attacks of infectious diseases. The spots are found upon the legs, more rarely upon the trunk and arms. Articular pains may or may not occur. Fever is seldom present. Loss of appetite, diarrhea and slight anemia may be manifested. The duration is one to four weeks.

=Purpura rheumatica= is a much more serious affection, characterized by multiple arthritis of rheumatism. Seldom seen under five years, and lasts about two weeks. The joints are swollen and painful and the temperature rises to 101 and 103 degrees F. The amount of edema varies greatly and occasionally it is quite excessive. In addition to the purpura there is usually urticaria. =Henoch’s purpura= is seen most frequently in children and is characterized by severe gastro-intestinal disturbances as pain, vomiting and diarrhea, hemorrhages from the mucous membranes and acute enlargement of the spleen, in addition to the symptoms already named under the foregoing form. There is some danger of hemorrhage into the kidneys.

The disorder of =purpura hemorrhagica= is usually associated with rheumatism, malaria and other infectious diseases. This is the most serious form of purpura. It is most commonly met with in delicate girls during early life; but it may occur at any age and in the most robust of either sex. Fever, weakness, vomiting and diarrhea are the early symptoms. After a couple of days of languor and weakness, purpuric spots appear upon the skin; and bleeding occurs from the mucous membranes and may cause profound anemia. Hemorrhages into the internal organs occur. Favorable cases recover in ten days or two weeks. Others may end fatally. Care should be taken not to confuse the disease with scurvy.

=Treatment.=—In the treatment of purpura the disease from which it develops should receive due attention. Occasionally there is danger of overlooking the primary disease and treating some symptoms of the disease, although it is true that sometimes an important symptom is nearly all that is manifested. Outside of treating the conditions under which purpura arises, general measures should be considered, as a nutritious diet, rest, fresh air, and general treatment of the patient so that normal circulation and strength may be restored. The treatment of the purpura locally should be such as to restore normal circulation of the part by removing any obstruction or irritation of the blood supply that may be found, by careful manipulation of the tissues. As stated the management of the disease under which it arises should be embraced in the treatment. In cases of hemorrhage from various organs see article under hemorrhage. Some cutaneous hemorrhages are best relieved by local manipulation.

Hemophilia

(BLEEDER’S DISEASE).

Hemophilia is a hereditary condition manifested by a tendency to uncontrollable hemorrhage with or without injury. The usual mode of transmission is through the female line, rather than by the male. The mother does not necessarily have to be a bleeder, but the daughter of one, in order to transmit the disease to her offspring. Atavism through the female alone is almost the rule. Not all the children of a bleeding family are afflicted; the male children are more subject to the condition than the female children. The tendency usually appears within the first two years of life. The families of bleeders are often large and are commonly healthy looking and have fine soft skins. It is claimed blondes are most likely to be afflicted.

=Pathologically=, an unusual thinness of the blood-vessels with a fatty degeneration of the intima has been noted. In many cases there is deficient coagulability of the blood and a lessened number of leucocytes. Hemorrhages have been found in and about the capsules of the joints, and in a few instances inflammation of the synovial surfaces. The arteries are situated superficially, but that does not explain anything. The real nature of the disease has not been determined. Emotional excitement is a factor, consequently vasomotor disturbances may be important. The frailty of the blood-vessels and the peculiar constitution of the blood preventing thrombotic formation are the two facts of importance that have been recognized.

=Symptoms.=—Hemorrhages occur from the most trifling injuries. Blowing the nose may cause severe epistaxis; the extraction of a tooth is a frequent cause of hemorrhage; the prick of a pin, a slight cut, a scratch, or a blow may result in profuse bleeding. The bleeding may occur spontaneously from the mucous membrane of the mouth, nose, lungs, intestines, etc.; or it may occur directly from the fingers, toes, back of the hands, and lobes of the ears. The hemorrhages may last several hours. As soon as checked the patients rapidly resume natural appearance providing the bleeding is not often repeated, thereby causing a permanent anemia. There may be attacks of arthritis with fever, as with acquired hemorrhagic tendency, closely resembling rheumatism.

=Diagnosis.=—Hereditary tendency and persistent hemorrhage from slight injury.

=Prognosis.=—In a few cases the tendency to bleed gradually diminishes until at last it entirely ceases. The younger the subject the more is it liable to prove fatal. In the majority of cases death occurs between the first and eighth years. After maturity the chances of an attack are much lessened.

=Treatment.=—Members of the bleeder’s family, particularly the boys, should be guarded against traumatic influences, and operations of all kinds should be avoided. Outdoor exercise, fresh air, bathing and plain nourishing food, in fact, the hygienic surroundings, and all food should be carefully watched so that the threatened subject may become strengthened and hardened. Marriage should be discouraged, especially with the daughters, as it is through them the tendency is propagated. Possibly, coupled with the foregoing prophylactic treatment, a stimulation of the glands of elaboration of the blood will be of service to build up the physical constitution of the patient. During attacks absolute rest and the required symptomatic treatment should be given. For resultant anemia the usual treatment is to be employed.

In severe cases direct transfusion should be considered.

FOOTNOTES:

[67] Billings, Focal Infection.

[68] Massachusetts Journal of Osteopathy, Jan. 1906.

[69] Journal of the American Osteopathic Association, November 1919.

[70] Diabetes, p. 90.

[71] Journal of the American Osteopathic Association, Oct., 1904.

[72] Journal of the American Osteopathic Association, Oct., 1904.

[73] Practical Medical Series, 1905.

DISEASES OF THE DIGESTIVE SYSTEM

Diseases of the Mouth

Stomatitis

=Definition.=—Inflammation of the mouth.

=Etiology.=—Chemical, mechanical, thermal or parasitic irritations; secondary to disorders of the gastro-intestinal tract, scarlet fever, measles and variola; cachexia, due to such diseases as cancer and phthisis; dentition; artificial feeding; hot weather and poor hygienic surroundings are the most common causes. Lesions to the innervation and vascular supply of the mouth are found, principally, in the upper cervical vertebræ, occasionally in the upper dorsal vertebræ and corresponding ribs.

=Varieties.=—Catarrhal, aphthous, ulcerative, parasitic, gangrenous.

Catarrhal Stomatitis

=Etiology.=—Most common in infants and children. Hot and irritating substances; secondary to diseases of the stomach, to measles, scarlet fever and variola; difficult dentition; alcoholic or tobacco excesses.

Hazzard says in all cases of stomatitis “there is generally lesion to the bony or other tissues in the cervical region (sometimes also in the upper dorsal), which deranges vasomotor control of the tissues of the mouth and tongue, obstructs venous return, weakens the tissues and lays them liable to the effects of some particular irritant, local or in the system, but there is, generally, lesion affecting the gastro-intestinal tract which is the real underlying cause of the trouble.”

=Symptoms.=—Diffuse, red swelling of the mucous membrane, heat and pain in the mouth, increased flow of saliva, fetor of breath, restlessness and languor. In children there is a disinclination to nurse and a slight fever may be present. The sense of taste is blunted and there is commonly a bitter taste in the mouth. The neck glands are enlarged.

=Treatment.=—Removal of the exciting cause is the most important point in the treatment. Good hygienic conditions must be enforced. The mouth should be kept clean. Wipe it out at frequent intervals with a soft piece of absorbent cotton and cold water. A borax solution is frequently used. Attention should be paid to the diet and secretions. Light but thorough treatment of the upper cervical region is to be given, with careful attention to the tissues about and below the angles of the jaw, so that the innervation, blood and lymphatic supply may be equalized.

Aphthous Stomatitis

(CANKER)

This disease is characterized by little, painful, grayish-white spots upon the superficial layer of the mucous membrane. They consist, primarily, of an exudate of fibrin and wandered-out leucocytes. It is principally a disease of childhood. Among the common causes are difficult dentition, disorders of digestion and uncleanliness of the mouth, such as neglect to cleanse the child’s mouth after nursing. It may be a symptom of measles or of local diseases.

Probably the innervation to the region of the little grayish-white spots or canker is obstructed at some points by a disordered tissue. The lesion may be mechanical or it may arise from a disordered digestion. If one is able to locate such a lesion and remove it, a cure will be hastened. The seat of the infection is the internal surface of the cheeks, gums, roof of the mouth, tongue and lips.

=Symptoms.=—There is redness of the mucous membrane of the mouth, followed by the appearance of the vesicles with a red areola. Pain in the mouth and an increased flow of saliva occur. Mastication, deglutition, and even speaking, may be painful. This condition is followed by sleeplessness, feverishness, diarrhea and fetor of the breath.

=Treatment.=—Removal of the cause, as in other varieties of stomatitis, is paramount. Give attention to the food. The milk should be sterilized. The disordered digestion should be corrected at once. All secretions must receive prompt attention. The child should be nursed at regular intervals. Locally, keep the parts clean and carefully treat the innervation.

Ulcerative Stomatitis

This is a disease of children, although it may not be limited to them, as it occasionally occurs in epidemics and affects all ages. It occurs chiefly in the families of the poor and in places where the hygienic surroundings are bad, the food poor and personal cleanliness lacking. It may begin as an aphthous stomatitis. Often sufferers from severe, acute diseases are subjects of attack.

=Symptoms.=—The gums of the lower jaw are chiefly affected. They are at first congested, swollen and bleed readily. Pain is increased by mastication and deglutition, the mouth is hot, the breath fetid, the saliva dribbles and the digestion and bowels are disordered. The ulcers may appear at various points upon the cheeks, lips and tongue; the deposit is yellowish-gray.

In the more severe cases the gums are spongy and the teeth are loosened. In proportion to the constitutional disturbances, fever and enlargement and tenderness of the submaxillary glands occur. Even necrosis of the bone may follow.

Parasitic Stomatitis

(THRUSH)

The exciting cause is a fungus known as Laccharomyces albicans. It is claimed that a catarrhal stomatitis is the soil upon which the fungus develops. Parasitic stomatitis is chiefly a disease of nursing children and is promoted by unhygienic conditions. It is seldom seen after ten years of age, occurring in adults only in the last stages of consumption, cancer, and severe chronic diseases.

=Symptoms.=—Upon inspection there are seen numerous milk-white elevations. These appear first about the angles of the mouth, soon extending to all parts of the mouth, and in a few cases, even to the pharynx and to the esophagus. When removed bleeding points are left. The general symptoms of stomatitis are present—pain upon mastication and swallowing; fetid, hot breath; increased saliva; increased temperature; restlessness; swollen lips and disordered digestion occur.

=Diagnosis.=—The microscope will remove all doubt as to the nature of the affection. In aphthous stomatitis the ulcers are preceded by the formation of vesicles.

=Prognosis.=—Is favorable in the majority of cases.

=Treatment.=—Hygienic measures, absolute cleanliness, correction of the disorders of the gastro-intestinal tract and local treatment as in other forms of stomatitis, is the required treatment. A boric acid solution will be found beneficial.

SPINAL LESIONS AND THEIR RELATION TO DISEASES OF THE GASTRO-INTESTINAL TRACT

Acute Gastritis, Chronic Gastritis, Gastric Neurosis, Gastric and Duodenal Ulcer.

By CHARLES J. MUTTART

The instant relief that Osteopathy can give in acute indigestion is one of its outstanding achievements. It impresses the patient and his friends with a deep conviction of the superiority of osteopathic therapy. The results in these cases are not, in any sense, a matter of chance. They follow logically from the osteopathic viewpoint, teaching, reasoning, and practice. In dealing with the manifestations of disease, such as heredity, onset, course, duration, subjective and objective symptoms, etc., and in the effort to differentiate cause from effect, and to reconstruct a mental picture of the sequence of cause, effect and sequelæ, the osteopath has the advantage of binocular vision in that he recognizes two distinct pathologies cooperating to produce the symptom complex, syndrome or disease which he is called upon to treat. One pathology is to be found in one or more of the vertebral and rib articulations and the immediately adjacent or corresponding segments of the spinal cord. The other is in some one or more of the organs or tissues connected with the pathological segment or segments of the cord.

=The function of the joint is MOTION.=—Unrestricted normal range of motion is essential for the normal function of all parts of the articulation as well as for the nutrition of the nerve mechanisms immediately adjacent. When a spinal articulation ceases to perform its function all of its parts are more or less impaired, muscles atrophy, ligaments lose their tone, and circulation to and from the spinal segment is interfered with because action is a large factor in promoting the flow of blood and lymph and maintaining normal stimulus.

As a result of this spinal pathology, internal organs and tissues, supplied by nerves arising in the segment that is in lesion, will be variously disturbed in their function.

Dr. Carl P. McConnell says: “My observation of lesioned animals so far as the digestive organs are concerned is that the lesion affects the reflexes of and through spinal and sympathetic ganglia so that the vasomotors are involved with a consequent hyperemia of the submucous coat. This means involvement of the endothelial layer of the blood-vessels, diapedesis, derangement of the secretory function and disturbance of the motor mechanism, all of which lead to functional upset and disturbance.”

The dominant part played by the osteopathic lesion as a causative factor in acute and chronic diseases of the alimentary canal becomes increasingly evident as clinical observation and laboratory research permit a more thorough appreciation of the anatomy and physiology of the parts involved. The abnormal stands out more clearly from the normal. Finally, the task of restoring normality is becoming a clear-cut problem to which the correction of the osteopathic lesions furnishes an almost complete solution.

The normal alimentary canal transports food, macerating it, mixing it, and treating it with various chemicals and enzymes on the way, breaking it down physically and chemically, and absorbing from it such end-products as are needed to maintain metabolism. The abnormal alimentary tract may be at fault in any of these functions. This delinquency is generally traceable to a mechanical origin. Correction of the mechanical deviation is followed by restoration of normal function except in cases where extensive tissue changes have occurred.

=Thorough mastication= is essential to good digestion. Any dental defects or deficiencies should be corrected. =The temporo-mandibular articulation= should be examined, and full free motion restored if lacking. The muscles on the affected side are softer than on the sound side. Tonic spasm rigidly closes the mouth. It may be due to tetanus, caries of the lower teeth, cutting of the lower wisdom tooth, or other irritations to the sensory branches of the inferior maxillary nerve. There is enough space back of the wisdom teeth to pass a catheter to administer food.

=The tongue= assists in mastication and deglutition and is the seat of most of the nerves of taste. The hypoglossal nerve, which supplies it, leaves the skull through the anterior condyloid foramen and may be impinged there or lower in its course. =Lesions of the occiput and upper cervical vertebræ= and obstructions to the lymphatic drainage at the angle of the jaw may cause pressure on this nerve and cause disturbances in the movements of the tongue, atrophy, swelling, etc. Swelling may be due also to endocrine disturbance, constitutional diseases, anemia, glossitis, local irritants, injuries, etc. Pressure may be made on the hypoglossal nerve behind the angle of the jaw.

=The special sense of taste= plays an important role in normal digestion. The lingual nerve supplies the anterior two-thirds of the tongue with taste. The sense of taste may be lost, impaired, perverted or otherwise abnormal.

The sense of smell plays an important part in our appreciation of flavors, and when it is impaired by colds, adenoids, or other affections of the nose or pharynx, the sense of taste is measurably impaired. =Normalization of nose and pharynx= restores the sense of taste in such cases. Impairment or loss may also be due to lesions of the chorda tympani, or glosso-pharyngeal nerves. Lesions of the mandible, hyoid, occiput or upper cervical nerves, parotid disease or obstructed lymphatic drainage behind the angle of the jaw may cause pressure directly or indirectly on the glosso-pharyngeal and chorda tympani nerves. Perversion of taste occur in pregnancy, hysteria, epilepsy and insanity.

=Foul taste=, fetororis in the mouth is frequent in pneumonia, typhoid fever, peritonitis, septicemia and other severe fevers; also after ingestion of pungent foods or strong drugs; in constitutional diseases; as a result of inattention to oral hygiene, excessive smoking, mouth breathing at night, furred tongue, etc. It clears up on removing the cause.

=Furred tongue= occurs in gastritis, fevers, and a variety of other conditions. The fur is composed of broken down epithelium which would normally be removed by friction with solid food. When none is taken, the fur accumulates. When blood or hematin becomes mixed with the broken down epithelium, the fur is brown. Ordinarily it is white. =A clean red tongue= is frequently found in hyperacidity. It is probably due to vasodilatation due to hyperactivity of the autonomics or inhibition of sympathetics. The sympathetic supply is from the =superior cervical ganglion=. It may be affected by lesions of the occiput, atlas, axis and third cervical vertebra, of the hyoid, by anterior cervical muscular contractures, by obstruction to venous and lymphatic drainage and blood supply. Correction of the lesions named and normalization of the other structures involved will usually restore the tongue to normal condition.

=The salivary glands= have a two-fold innervation. The thin, full, watery, salty secretion is produced by activity of the cranial autonomic fibers; the sparse, viscous secretion containing the organic elements, ptyalin, etc., is produced by the sympathetics. =The sympathetic nerve supply= is from the middle and superior cervical ganglia and can be disturbed by lesions affecting them as mentioned above. The secretion of ptyalin may be disturbed by any lesion from the fifth dorsal up.

It must not be forgotten that a =posterior occiput= draws the superior cervical ganglion back against the axis and third cervical with just as much pressure as is exerted by an anterior atlas or third cervical. This pressure or stretching tends to inhibit it, preventing vaso-constriction and permitting vasodilatation of the internal carotid artery and its branches and congestion of the parts supplied, mid-brain, cerebrum, etc.

If, for any reason, the venous drainage from the lateral sinus into the internal jugular vein, or the ebb and flow of the cerebrospinal fluid between brain and cord, is reduced or hampered, an extra burden is thrown on the cerebral veins and sinuses, and the intra-cranial pressure is raised at each heart-beat, ultimately producing pressure on the meninges and causing violent headache over the fifth and tenth cranial nerves which supply the meninges with sensation. These nerves are intimately connected with the digestive system. Any increase of intra-cranial pressure causes increased irritability and hyperactivity of the cranial nerves, many of which are concerned with various functions of the digestive system. Moreover, the nuclei of these nerves lie on the floor of the fourth ventricle which is supplied mainly by the vertebral arteries and the basilar artery. Lesions of the cervical vertebræ affecting the plexus on the vertebral artery or filaments to it from the upper parts of the cervical gangliated sympathetic cord, may impair the blood flow through the vertebral arteries and cause similar increased irritability of the nerve cells in the medulla, mid-brain and cerebellum. Such disturbance is reflected in awkward movement, hyperesthesia, and symptoms due to increased irritability of the autonomic nerves such as slow pulse and respiration, watering of the mouth, hypersecretion and hypermotility of the gastro-intestinal tract, rapid digestion and poor assimilation, vasodilatation, impoverished blood, and so through a vicious cycle back to still greater impairment of nutrition to the nerve cells within the cranium. Until the lesions are corrected, the condition becomes progressively worse till exhaustion occurs.

Ordinary medical hygiene can do little or nothing. The palliative remedies employed simply mask the symptoms, or actually accelerate the destructive process. Lesions that irritate the cervical sympathetics would cause vaso-constriction and give rise to opposite symptoms, namely, cerebral ischemia, decreased flow of saliva, atony of stomach, lack of digestive juices, sluggish intestinal peristalsis, rapid pulse and respiration, etc. Correction of the lesions and restoration of normal blood supply and drainage to the brain and removal of any lesions tending to inhibit the sympathetics from the fifth dorsal up, will usually in a short time restore the activity of the salivary glands to normal. The otic and sphenopalatine ganglia can be disturbed by abnormal conditions within the pharynx. These must be corrected when found.

=Deglutition=, or swallowing, is a very rapid, highly complex movement. It takes not more than a second for the food to cross the pharynx. The soft palate and larynx are raised to close off the air-way, making the food-way practically continuous for the second needed to complete the transfer of the food across the air-way. The tongue is pressed against the roof of the mouth and the mylohyoid contracts vigorously and shoots the bolus of food across the pharynx. Bolting the food leads to serious digestive disturbances, not the least of which is the loss of the normal reflex which prevents swallowing unprepared food. When lost, this reflex can be restored by thorough mastication for three or four months.

The voluntary part of swallowing is performed by the motor portion of the fifth cranial and the hypoglossus. The involuntary part involves afferent impulses over the superior laryngeal and efferent impulses over the inferior laryngeal. The levator palati which raises the soft palate is probably supplied by the spinal accessory nerve through the pharyngeal plexus. This nerve can be affected by lesions of the occiput, atlas, mandible and hyoid, and by any obstruction to lymphatic drainage which increases pressure behind the angle of the jaw. In paralysis of the levator palati, as =after diphtheria= or other peripheral neuritis, fluids regurgitate through the nose during the act of swallowing. The raising and closing of the larynx is accomplished by the superior and recurrent laryngeal nerves by way of the pharyngeal plexus. Pain in swallowing is generally due to some inflammation or infection of the tonsil or pharynx. This does not occur when everything is normal from the fifth dorsal up.

The second and third stages of swallowing occur in the =esophagus=. The esophagus receives esophageal branches from the vagus, carrying autonomic fibers which contract its longitudinal muscles and dilate its arteries. It also receives sympathetic impulses from the plexus on the arteries which supply it. These sympathetic impulses convey vaso-constriction and constriction of the circular muscles of the esophagus. Any lesion from seventh cervical to ninth dorsal might affect the esophagus; probably fifth dorsal is the most nearly specific, as the heartburn which results from regurgitation into the esophagus is usually localized there.

Lesions of the upper six dorsal vertebræ interfere with digestion and nutrition in another vital way by reducing the activity of the lungs and consequent =intake of oxygen= into the system. If there is not sufficient oxygen to oxidize the proteins to amino-acids there will be harmful products left for the tissues to neutralize. Lesions of the third, fourth and fifth cervical affecting the =phrenic= may have a like effect. Sub-oxidation must be noted when present and treated by removing lesions affecting respiration, by deep breathing exercises, and by diet rich in the needed mineral salts, and properly balanced. An improperly balanced diet changes the structure of the tissues and amounts in effect to an osteopathic lesion which causes disturbed function. It must be searched for, found if present, accounted for, corrected and kept corrected to obtain maximum therapeutic results.

The stomach, intestines and rectum are intimately related with the other abdominal viscera.

It will therefore be readily seen that any disturbance of the liver, gall-bladder, pancreas, spleen, duodenum, pleura or peritoneum will disturb the function of the stomach, and that any disturbance of any organ will disturb the function of the intestine. In fact, clinically, it would seem that the majority of cases can be accounted for by the lesions found, the stomach or intestinal disturbances which are regarded as reflex from some other organ, being in reality caused by the same lesion as disturbed the organ which first manifested disturbance.

Going more deeply into the nature of the mechanism whereby symptoms of gastro-intestinal disturbance are produced, we find that the alimentary tract has an ingenious conveyer mechanism with a number of sphincters. These are operated by intrinsic sympathetic or myenteric nerves, called plexuses of Meissner and Auerbach. In conveying food, impulses are passed from one portion of the tract to the next over these myenteric arcs. Normally the peristaltic movement is always forward because the point of highest irritability is at the proximal end. There is an exception to this rule in the ascending colon, where antiperistalsis occurs normally. When the irritability of a distal point of the alimentary tract becomes greater than the more proximal points, an antiperistaltic wave is set up causing vomiting. The myenteric activities are regulated by the autonomic impulses over the vagus, and by the sympathetic impulses over the splanchnic nerves. The autonomics contract the longitudinal muscles, dilating and shortening the tube. They also stimulate secretion of digestive juices and fluids and mucus and dilate the blood-vessels. The sympathetics contract the circular fibers and sphincters, narrowing and lengthening the tube, retarding the food, inhibiting the secretions and constricting the blood-vessels. The myenteric reflexes can continue after the vagi and splanchnics are cut. The vagi simply stimulate them and the splanchnics inhibit them. The pathways are from the coeliac plexus where the vagi and splanchnics meet with various other plexuses on the arteries and following the courses of the arterial supply to the minutest parts of each organ. Each cell is surrounded by nerve fibers. Visceral-afferent fibers over both vagi and splanchnics convey impulses to the cord segments and medulla which modify the systemic blood supply, drawing blood from the head and surface by constricting their arteries during digestion and filling the abdominal arteries. If opposite impulses should be received drawing blood away from the abdominal arteries, digestion would be interfered with. Any lesion or other condition causing hyperirritability or overstimulation of the vagus will result in overstimulation of the myenteric nerves, with vasodilatation, hypersecretion, contraction of the longitudinal coat, widening and shortening of the digestive tube, sluggish peristalsis but rapid movement of food through the sphincters, incomplete digestion and undernourishment. Inhibition of the splanchnic nerves will produce a like result. The opposite condition would come about as a result of inhibition of the impulses over the vagus to the myenteric nerves, or of overstimulation of the splanchnic nerves.

Inhibition of the splanchnic nerves may be secured by extreme flexion of the spinal column. This raises the cord in the spinal canal, lengthens it, stretches or draws on the nerve roots and vessels, squeezes the fluid out of the cord, and inhibits the splanchnics in two ways, first by a partial anemia or ischemia of the cord, and secondly by direct traction of the visceral afferent fibers in the posterior and anterior roots.

Conversely, stimulation of the splanchnic nerves may be secured by complete extension of the spinal column. This lowers the cord in the spinal canal, shortens it, releases the strain on the nerve roots and vessels, flushes the cord with blood, and tones up the sympathetic impulses in two ways, first by increasing their relative and absolute nutrition, through richer supply of richer blood, and secondly by releasing the nerve roots from strain, permitting free entry of afferent impulses over the posterior roots, and free exit of visceral-efferent impulses over the anterior roots.

Any lesion, inasmuch as it limits or alters the normal motion in a joint, produces an exaggeration or diminution of the normal spinal curves, and more or less lateral curvature. The altered equilibrium thus produced affects the viscera in three ways: 1. Mechanically, by pressure, gravity, altered position of ribs, vertebræ, diaphragm, etc.; 2. Reflexly, influence on nerves to and from affected segment; 3. Directly, by interference with nutrition of nerve cells by hyperemia or ischemia.

There is always a functional kyphosis in visceroptosis or splanchnoptosis. The nerves in the cord are inhibited. The skeletal muscles are hypotonic, allowing the functional kyphosis to occur, and the viscero-motor nerves are inhibited, allowing the abdominal viscera to become hypotonic and sag out of place within the abdominal cavity. The ribs are held up by the cervical fascia, and the abdominal muscles are held up by the ribs. The hypotonic condition extends to intercostals and abdominal muscles, with the result that the abdominal muscles are unable to play their part in maintaining the viscera in their proper places. The contraction or tonus of the abdominal muscles, the external and internal oblique, transversalis, rectus abdominis, diaphragm and levator ani, maintain the viscera firmly in position. It is only when the muscles of the abdominal wall have lost their tone that any strain or weight is thrown on the peritoneal and vascular supports. The inhibition of the restraining sympathetic impulses via the splanchnic nerves, allows hypersecretion and hypermotility of the alimentary tubes and further complicates the clinical picture by a colicky diarrhea or spastic constipation.

There are eight sphincters of circular unstriped muscle in the alimentary tract. Inhibition of sympathetic supply or increased autonomic supply causes sphincter insufficiency, overstimulation by sympathetic impulses or an insufficient supply of balancing autonomic impulses causes sphincter spasm, stasis, vomiting, fermentation, putrefaction, auto-intoxication. At each of these sphincters food is held back and controlled till the proper time has elapsed and the proper chemical environment is prepared for it in the next portion of the tract. Normal function of these sphincters is absolutely essential to normal metabolism and nutrition. The upper esophageal sphincter controls the entrance to the esophagus; the cardia controls the entrance to the stomach, the pylorus controls the entrance to the duodenum, the X-Ray shows a duodenal sphincter that controls the entrance of food into the jejunum. Here the food enters the long tract of the jejunum and ileum which measures twenty-five feet when the longitudinal muscles are relaxed and the circular muscles tonic, and which a short time later may measure only fifteen feet when the longitudinal muscles are contracted and the circular are relaxed. This section ends at the ileo-cecal valve, which controls the entrance of food into the cecum. There is the mid-colic sphincter about the junction of the proximal third with the distal two-thirds of the transverse colon, and the recto-colic sphincter which controls the passage from the sigmoid to the rectum. The rectum ends in the internal sphincter ani. There is some evidence of a ninth sphincter, the mid-gastric at the point where the peristaltic waves of the stomach begin. Absorption takes place mostly from the ileum and jejunum and it is worthy of note that four of these sphincters hold the food up on its way into this part of the tract, and four of them hold it back on its way out. Any lesion may affect one or other of these sphincters. It is believed that antiperistalsis from the mid-colic sphincter to the cecum during digestion is normal permitting more complete absorption of nourishment. Yet here, after absorption is complete, and at all times elsewhere in the alimentary tract, peristalsis is normally forward because the point of highest irritability is at the upper esophageal sphincter and the irritability decreases as the tract is further from the esophagus.

When the splanchnics are inhibited and the vagus autonomic impulses are normal or increased, the intestinal sphincters from the pylorus down may all be incompetent, so that food passes along too rapidly to be properly digested and absorbed. This results in undernourishment.

Any lesion anywhere in the body will affect =peristalsis=. It begins at the lower third of the stomach where it joins the pyloric portion and goes forward to the internal sphincter ani, being modified in its course by local conditions. Compensation may be established. Many cases of diarrhea and constipation are thus to be accounted for. =Diarrhea= is a symptom due to vasodilatation, hypersecretion and relaxation of the circular muscles especially at the sphincters. When these three factors are cleared up by correction of the lesions and hyperextension of the spine, the diarrhea stops unless some other factor is at work to irritate the myenteric nerves or to excite the autonomics or inhibit the splanchnics. Lesions from the sixth dorsal down are usually accompanied at first by some diarrhea, which afterwards becomes constipation, through loss of tone in the longitudinal muscles especially in the distal part of the colon. In these cases, correction of lesions, and extreme flexion of the lower dorsal and lumbar spine will give relief while the body is returning to normal.

When gastric digestion begins, simultaneous action is set up in the ileum. When disease of the cecum, appendix or ascending colon is present, there is contraction of the ileo-cecal valve causing stasis of the lower ileum and disturbed or retarded action of stomach and duodenum. These reactions are brought about by impulses to and from the myenteric plexus. The sympathetic and autonomic nerves affect the motor system of the alimentary tract not directly but through the myenteric or Auerbach’s plexus.

The =external sphincter ani= muscle is supplied by the pudendal nerve from the third and fourth sacral segments. It is in a state of tonic contraction, and having no opposing muscles keeps the anal orifice closed. The autonomic supply to the longitudinal muscles in the descending colon and rectum is from the second and fourth sacral. Inhibition here will, therefore relax the longitudinal muscles and external sphincter and permit free peristalsis in the descending colon and rectum. Pelvic disturbances may affect these nerves, or pressure due to visceroptosis, etc. The circular muscles of this section are supplied from the lumbar cord. They may be affected in any lumbar lesion, with the end result of spastic constipation by reason of a shortened markedly distended descending colon, sigmoid and rectum, and little peristalsis because of inhibition of the circular fibers, and contraction of the external sphincter ani.

The fundus of the stomach, lying in the left dome of the diaphragm, always contains a cushion of air which supports the left dome of the diaphragm, as the convexity of the liver supports the right. Normally the air is regulated and causes no symptoms. A lesion, usually of the mid-dorsal or lower dorsal segments may inhibit the circular fibers and permit distension, which becomes enormous when the pylorus is obstructed. The shortness of breath, palpitation of the heart, etc., accompanying this distension are probably due to pressure on the heart and lungs from which the stomach is separated only by the diaphragm.

Eighth, ninth and tenth dorsal lesions play a large part in peptic ulcers by permitting hyperemia, hypersecretion, and lowered vitality of the mucosa, and pyloric incompetence or spasm, because the pylorus, pyloric end of the stomach and first part of the duodenum get their chief sympathetic supply from the ninth and tenth dorsal segments of the cord. The tenth vertebra is more freely movable than the higher dorsal joints and is therefore more frequently in lesion, which helps to account for the greater frequency of duodenal ulcer.

The main sympathetic supply to the appendix seems to be derived from the eleventh dorsal segment. The appendix has the same motor and secretory mechanism as the rest of the alimentary tract but is richly supplied with lymphoid follicles. One of the twigs from the eleventh dorsal nerve pierces the rectus muscle to supply the skin at McBurney’s point, thus explaining the great frequency of pain and cutaneous hyperalgesia at this situation in appendicitis. Lower dorsal and upper lumbar lesions are unquestionably causes of many cases of appendicitis and other obscure diseases traceable to appendicitis. Correction of these lesions has restored the appendix and related structures to normality in hundreds of cases.

Sensory reflexes are shown in hyperalgesia and pain or tenderness in the abdominal skin and muscles and the parietal layer of the peritoneum from the ensiform cartilage to the pubes in an area extending about two inches on each side of the mid-line, corresponding to the distribution of the twigs of the lower six thoracic nerves which supply sensation to this region. =Esophageal= disturbance at the cardia causes pain in the region supplied with sensation by the fifth and sixth dorsal, near the ensiform. =Gastric derangement= causes pain midway between the ensiform and umbilicus, which radiates to the left, in the area supplied by the eighth dorsal. =Hepatic disturbance= causes pain on the right of the median line, radiating to the right in the sensory distribution of the ninth dorsal. =Intestinal pain= is located in the sensory distribution of the tenth dorsal nerve in an oval area around the umbilicus. Pain due to =duodenal ulcer= is sharply localized at a point about an inch or two above and to the right of the umbilicus where twigs of the tenth dorsal nerve come to the surface. This point corresponds closely to the normal position of the underlying duodenum, though the duodenum may be displaced, and the sensitive spot remain at the same point. The pain from =fundal gastric ulcer= or =carcinoma= is usually localized sharply about an inch or two to the right of the median line midway between the ensiform and umbilicus, at the spot where the twigs from the eighth dorsal nerve pierce the rectus and come to the surface. In the disease of the =pylorus=, reflex pain is lower; of the =cardiac end=, higher. The reflex pain at McBurney’s point in =appendicitis= has been referred to, but it must be borne in mind that pain from disturbance in the =colon= also shows in the sensory distribution of the eleventh dorsal nerves midway between the umbilicus and pubes. Pain may also be referred to areas supplied in the back by the corresponding segments. These reflex pains can usually be stopped by inhibiting along the spine corresponding to the sensory area affected. This reduces the impulses entering the posterior roots and lowers the irritability of the segment.

The =motor reflexes= from gastro-intestinal disturbances result in muscular contractures of spinal, abdominal and other muscles supplied by motor nerves arising in the anterior horn of the segment which innervates the part of the viscus that is affected. Stomach, liver, gall-bladder, pyloric and duodenal disturbances cause increased tone, contraction, contracture and rigidity of the rectus muscles above the umbilicus, for instance, and the other viscera contract it in lower portions. More important are the extreme contractures of the musculature of the back which is supplied by the segments which supply the affected part of the viscus. These contractures produce some distortion and loss of motion in spinal joints and thereby produce the same effects as primary lesions, causing widespread disturbance which persists until the spinal musculature is normalized. In =colic=, the lumbar segments being involved, there is marked contraction of the ilio-psoas which causes the characteristic drawing up of the thighs on the abdomen, while the extreme contraction of the rectus abdominis draws the thorax down.

Most persistent vomiting may arise reflexly from other organs as in so-called biliousness, jaundice, pregnancy, brain affections, appendicitis, onset of acute infectious diseases, alcoholism, sea-sickness, colic, hernia, intestinal obstruction, migraine, shock, and anesthesia. Irritation of any sensory branch of the vagus or of nerves which connect with it in the medulla, or reflexly from consciousness via the cerebral cortex, as in the case of nauseating sights, smells, tastes, as well as irritation from any viscera innervated from the sixth dorsal down, may overstimulate the corresponding efferent nerves going to parts of the alimentary tract supplied by that segment, increase its irritability and start antiperistalsis. Similarly disturbances in almost any viscus may reflexly disturb the normal balance between sympathetic and vagal autonomic stimuli resulting in hypersalivation, hyperchlorhydria, pylorospasm, distension, gastric atony, gastrosulcorrhea, enterocolitis, spastic constipation, achylia, or colicky diarrhea. In these cases, the derangement of the viscus reflexly disturbs the alimentary tract through central nerve connections. Correction of the primary trouble is followed by removal of the reflex symptoms. In this connection it is important to note that the visceral reflex symptoms may arise from irritation of the alimentary tract by improper diet, poor cooking, or wrong combinations. Carbohydrates digest quicker than proteins, and these more rapidly than fats. Food is handled by the fundus in the order in which it was swallowed. If the fats are swallowed first, the starches may be held up for five or six hours, subjected to the acid stomach secretions and allowed to ferment causing distension, which reflexly produces a variety of symptoms.

Mental exertion, strong emotions, heavy physical exertion, interfere with the function of the alimentary tract and set up disturbances in the balance of sympathetic and vagal autonomic impulses, through the nervous reflexes via the cortex, and through the demand for blood, which impoverishes the abdominal circulation at a time when it needs all the blood it can get. The ischemia produced in this way has about the same effect as ischemia produced by a spinal lesion. Conversely, disturbances of the alimentary tract produce profound changes in character and personality, by reflexes to the cerebral cortex causing dullness of perception, in all the senses, poor memory, sluggish thought, erratic judgment, irritable disposition, fear, worry, lack of ambition, indecision, lack of energy, vacillation, and finally a psychosis in which manic depressive symptoms are balanced by paranoiac symptoms.

The alimentary tract is so intimately bound up with the whole stream of vital activity, whether vegetative, sensorimotor, or psychic, that any disturbance of body or mind is likely to affect it in some part, and conversely any disturbance of the alimentary tract is bound to affect all the rest of the body and the mind. A satisfactory classification of its diseases is therefore difficult to make, but the one here adopted is probably the best for the purpose. The early stages of gastro-intestinal diseases are often so similar that it is nearly impossible to differentiate them with certainty; the classification is therefore based on the clinical picture and pathology of advanced stages. Fortunately, with the exception of cancer, diseases treated in the early stages usually clear up when the lesions are corrected, and the necessary attention given to the other causative factors present.

Acute Gastritis

Acute dyspepsia is one of the frequent disorders of the stomach. It may occur as an early symptom of an infectious disease, but very often it is due to some non-specific irritation. The usual exciting causes are errors of diet, over-indulgence in improperly cooked and highly seasoned food, or food that has been spoiled, such as meat, fish and milk, or over or under ripe fruit. Food that is either too hot or too cold may develop an attack. Alcohol is a common cause in those not accustomed to its use. Overuse of tobacco may bring on an attack. Many acute “bilious” attacks are brought about by some mental shock or excitement at the time of taking food, for it has been shown by the researches of Pawlow that both gastric motion and secretion are altered by mental irritation during digestion.

Unquestionably osteopathic lesions of the splanchnics and vagi are important predisposing factors. These lesions produce a lowered resistance of the tissues, which will frequently explain why certain exciting factors that will initiate an attack in one individual will not do so in another. A healthy mucosa will not be so readily irritated by either indigestible or partly decomposed food.

Osteopathic experimental work reveals that the vertebral and rib lesions readily affect both the spinal nerves and the sympathetic ganglia, which is followed by vasomotor and trophic disorder to the mucous and submucous coats of the stomach, as shown by eccymosis and hemorrhage of the submucosa and beginning parenchymatous degeneration of the free ends of the glands of the mucosa. Upon the other hand irritation of the muscles from dietetic errors always causes more or less contraction of the muscles in the upper and middle dorsal, which, in turn, may produce through imbalance of tension and fibrositic changes, constant interosseous lesions and thus be the cause of the catarrh becoming chronic. This vicious cycle phenomenon should not be overlooked. Viscero-motor, viscerosensory and viscerotrophic reflexes may be factors in the pathogenesis of the osteopathic lesion.

=Pathologically=, the mucous membrane is more or less covered with mucus. Upon removal of the mucus the membrane is found red and swollen, and the epithelial cells of the glands are granular. This is especially noted in the pyloric area. There are minute extravasations of blood and hemorrhages of the mucous coat, and infiltration of the submucous layer.

=Symptoms.=—Acute gastritis occurs at all ages, so particularly in children care has to be taken that the attack is not the beginning of some infectious disease. A careful inquiry into the history, and examination of the vomitus will usually make the diagnosis clear. The sudden onset of nausea, vomiting, pain in the epigastric region referred to the back and head, vertigo in some cases, if the infections can be ruled out should leave no doubt as to the nature of the disorder.

Other symptoms are weakness, and chilliness which later if the attack is severe, is followed by fever. The tongue is coated, the lips dry, and there may be herpes. Belching of gas, constipation in some and diarrhea in others, and dark colored urine are noticeable. There is tenderness on palpation over both the stomach and splanchnic areas. Examination of the stomach contents show deficient hydrochloric acid, the presence of organic acids, bile and undigested food, and considerable mucus.

=Diagnosis.=—In young children acute gastric indigestion is common, though a casual gastritis is rare. In the former prostration, vomiting, and undigested, greenish stools are noted. In some cases there is no fever, while in others it may range from 102 to 105 degrees. In all cases care should be taken, as has been stated, that the attack is not the beginning of some infectious disease. Appendicitis, acute bowel constriction, pregnancy, uremia, meningitis, gall-stone colic, and gastric crises of tabes dorsalis should be differentiated. Most attacks of acute dyspepsia are over in twenty-four hours. The prognosis depends upon eliminating the cause. The X-ray may be of value in protracted cases.

=Treatment.=—If the case is seen early, emptying the stomach by induced vomiting or the stomach tube is the first indication. If several hours have elapsed and much of the stomach contents have passed into the intestine, emptying the colon with an enema will commonly give quick relief. Withhold all food for from twelve to twenty-four hours, or longer if necessary. In some cases the sipping of hot water will be beneficial, while in others pellets of ice in the mouth will give some relief.

Whether or not there existed previous spinal lesions there will always be found muscular tension and spinal rigidness during an attack of acute gastritis. These should be corrected for immediate relief, but what is of greater importance, if these acute lesions are not corrected the patient’s recuperative forces are interfered with and recovery is delayed. Then, also, these lesions tend to chronicity and predispose to future attacks. Treatment should be given daily, or oftener if special indications arise. Though the most common area that demands attention is from the fourth to tenth dorsals, still the vagi nerves, especially the right, should not be neglected. Lesions of the upper three cervicals are the most frequent disturbances of the vagi.

=Vomiting= is a common and distressing symptom. Pathologically, it is due to an antiperistaltic contraction of the stomach and a spasmodic contraction of the diaphragm and the abdominal muscles. It is caused, usually, by irritation of the vagus in the stomach, or in the pharynx by irritation along the spine (particularly in the cervical and upper dorsal regions), or to the sympathetic nerves or to various parts of the body, or by direct influence of the brain. Relief can usually be given by inhibition of the vagus in the occipital region or by inhibition at the fourth or fifth dorsal vertebra on the right side. In a few instances, placing the patient in the knee-chest position and gently raising the abdominal organs gives relief. If this does not suffice the stomach and colon should be emptied, providing the vomiting is protracted. A frequently effective measure for nausea and vomiting that can be carried out by the attendant, is the application of hot fomentations to the dorsal spine.

=Flatulency= may be very distressing. The spinal treatment may be sufficient to control this condition, or careful direct pressure for a few minutes over the pit of the stomach. Adjustment of the lower ribs, especially of the left side, may be effective. Occasionally the gas can be passed into the intestines by careful inhibitory treatment in the region of the eighth and ninth dorsals. The inhibitory treatment causes relaxation of the pyloric orifice; also, inhibition of the left vagus relaxes the pylorus. Inhibition at the sixth and seventh dorsals relaxes the cardiac orifice, thus favoring the passing of the gas from the stomach out through the esophagus.

In all cases subject to gastritis the dorsal spine should receive considerable attention in order that recovery may be complete. The habits of the patient should be thoroughly regulated and overfatigue guarded against. And, also of special importance in recurring attacks, is the fact that a number of cases present some derangement of the biliary tract, or duodenum, or the appendix region.

=Diet.=—After twenty-four or forty-eight hours, if the attack has been severe, albumin water may be given in small quantities; also whey, milk, bouillon, and chicken or lamb broth. If there is no return of gastric distress, add junket, custard, cornstarch pudding, gelatine, dropped eggs, scraped beef, and white meat of chicken; vegetables purees made with cream or meat stock are usually well borne at this time. Foods containing much cellulose, fats and sweets should be withheld until all symptoms have subsided.

Chronic Gastritis

It is unnecessary here to repeat the causes of acute gastritis, any one of which continued over a long period of time will cause chronic catarrh of the stomach, as it is sometimes called.

Spinal and rib lesions anywhere from the occiput to the coccyx, but more particularly from the fourth to the tenth dorsal, will predispose to chronic gastritis, the particular type and degree of local pathology depending upon the exciting factor.

A commonly found _en bloc_ lesion is a flattening of the normal convexity in this region, with more or less immobilization, shown by attempting to reestablish the normal convexity through flexion.