The Practice and Applied Therapeutics of Osteopathy
Charles Hazzard, D. O.
1905
  
 
CHAPTER XII
 
DISEASES OF THE DIGESTIVE TRACT
 
 
STOMATITIS AND GLOSSITIS

    DEFINITION: Stomatitis is an inflammation of the mucous membrane lining of the mouth.  It may be catarrhal (simple or acute stomatitis); ulcerative (putrid sore mouth); aphthous (aphthae, vesicular stomatitis); parasitic (thrush, muguet); mercurial (ptyalism); or gangrenous (noma, cancrum oris).
    To the Osteopath these various forms present, in each case, practically the same aspects, so far as lesion and method of procedure are concerned.
    Glossitis is an acute or chronic parenchyinatous inflammation of the tongue.
    Stomatitis and glossitis may be discussed together.  The latter condition commonly complicates the former; both are forms of a vaso-motor disturbance referable to practically the same nerve and blood mechanism; both present the same bony lesions and are treated in the same manner.
    CASES: (1) Glossitis; the tongue raw and fissured for weeks; irritation was extending to the stomach.  Lesion was present as a contracture of the suprahyoid muscles, drawing the hyoid bone back against the pneumogastric nerve, and obstructing the blood drainage via the throat.  After the tissues were relaxed and the bone restored to its normal position the patient recovered.
    (2) Glossitis, in a patient with a diseased gastrointestinal tract, due to poisoning of the system by a patent medicine.  Quickly relieved by treatment to throat, neck, and  emunctories.
    (3) Case of glossitis, and stomatitis (ulcerative), due to body neck lesions.
    (4) Stomatitis associated with pharyngitis; medicines were used to no purpose.  The patient was unable to eat for 16 days.  After two days osteopathic treatment he could eat, and the condition was cured in one week.
 
 
LESIONS AND ANATOMICAL RELATIONS

    In these cases there is generally lesion to the bony or other tissues in the cervical region (sometimes also in the upper dorsal) which deranges vaso-motor 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 gastrointestinal tract which is the real underlying cause of the trouble.  Naturally there are many cases due to the irritation of a poisonous drug, of a decayed tooth, etc., which suffer from no specific lesion.  Yet the ordinary case shows cervical or upper dorsal lesion of some kind.  Lesions to the atlas, axis, lower cervical, or upper dorsal vertebrae; sometimes of the upper few ribs; of the clavicle; of the cervical muscles, especially those of the throat; of the hyoid bone; of the lower jaw, may be present.
    These lesions derange the nerve and blood supply of the mouth and tongue.  Contractured throat muscles may shut down upon the arterial and venous circulation (carotid, jugular), mechanically deranging it.  Lesion of the clavicle, first rib, and deep anterior cervical tissues may cause the, game results.  Contractured muscles in the cervical region, displaced vertebrae and ribs, may all disturb the spinal and sympathetic nerve connections having control of these tissues.  Inferior maxillary lesion may disturb the 5th nerve by impinging its articular branches.
    The vaso-motor supply of tongue and lining membranes of the mouth are mainly from the fifth cranial nerve.  According to the American Textbook of Physiology, the vaso-dilator fibers for the face and mouth are found in the cervical sympathetics; they emerge from the spinal cord by way of the 2nd to 5th spinal nerves, and connect with the fifth cranial nerve by passing from the superior cervical ganglion to the Gasserian ganglion. Other dilator fibers for the mucous membrane of the mouth seem to arise in the fifth nerve itself.
    The same authority shows that the cervical s and sympathetic contains vaso-constrictor fibers for the tongue.  The hypo-glossal nerve also contains vaso-constrictor fibers for the tongue.  The lingual (a branch of the fifth) and the glosso-pharyngeal nerves contain vaso-dilators for the tongue.
    In view of these facts it becomes at once apparent that atlas and axis, lower cervical and upper dorsal vertebral lesion, as well as upper rib lesion could affect these sympathetic connections of the fifth nerve, along this portion of the spine, and lead to a derangement of the vaso-motor state of the tissues of tongue and mouth.  (See also the anatomical discussion under Catarrh.)  Upper cervical lesion could likewise affect the glosso-pharyngeal and hypo-glossal nerves, since both are connected with the superior cervical ganglion.  The glosso-pharyngeal is also connected with the fifth, and could suffer with it from lesion.  The hypo-glossal is connected with both the fifth and the facial nerves.
    In these diseases, secondary lesions resulting in constitutional conditions favoring them will be found.
    The PROGNOSIS in stomatitis and glossitis is good.  The case usually quickly recovers under the treatment.  One or a few treatments give relief, and a short course of treatment is usually all that the case requires.  In gangrenous stomatitis, however, the prognosis must be guarded.  It is usually a surgical case.
    The TREATMENT must be directed particularly to the removal of the lesion.   Frequently the removal of this irritation results at once in a rapid recovery.  Thorough cervical treatment must be carefully given.  Following corrective work upon the lesion, and the cervical tissues must be entirely relaxed.  Especially all the tissues about the throat and angle of the jaws should be relaxed, but the treatment in these places must be gentle to avoid irritation.  The deep anterior cervical tissues low down should be thoroughly relaxed, and the clavicles should be raised to aid in free venous drainage from the affected parts.  The lower jaw should be carefully opened against resistance.  One should see that the adjustment of the temporo-maxillary articulations is correct.
    In all forms of stomatitis, proper attention must be given to cleanliness of the mouth.  It should be kept well washed out.  A mild alkaline wash is recommended.  Proper attention must be given to the general health.  Bowels and stomach should be kept active and in good condition.  In aphthous stomatitis, especial care must be taken to correct disturbed digestion, and the mouth should be washed before food is given.  In parasitic stomatitis the child's tongue should be wiped off with a soft cloth. It is recommended to soak the cloth in boric acid solution.
    Gangrenous stomatitis usually becomes a surgical case unless successfully handled early.
In catarrhal stomatitis and in acute glossitis ice may be applied to the tongue and to the angles of the jaws.  Antiseptic mouth washes are good in glossitis.  In chronic glossitis the food should be plain.    All stimulating or irritating articles, such as alcohol and tobacco should be avoided.  'The teeth should be kept in good repair, and bowels and stomach must be kept active.
    In mercurial stomatitis stop all mercury and use a mouthwash of listerine.
 



 
DISEASES OF THE SALIVARY GLANDS
 
HYPERSECRETION, XEROSTOMA

    In Hypersecretion (Ptyalism) and Xerostoma (Dry Mouth) one must expect much the same style of lesion as in glossitis and stomatitis, as the fifth nerve and the cervical sympathetics are again the ones' chiefly involved in the disease.
    Quain's anatomy states that secretory fibres for the submaxillary glands arise mainly from the second and third dorsal spinal nerves.  They ascend through the cervical sympathetic.  The fifth nerve according to Dana, is the nerve presiding over salivation.  The American TextBook of Physiology points out that vaso-constrictor fibres for the salivary glands are contained in the cervical sympathetics.  The chorda-tympami branch of the facial nerve is the vaso-dilator of the submaxillary, gland.  The glosso-pharyngeal nerve furnishes secretory and vaso-dilator fibres to the parotid gland.  The glosso-pharyngeal and facial nerves are closely connected with the fifth, and may suffer with it
from lesion.
    From the foregoing facts it is easily seen that lesions in the upper dorsal and cervical regions, etc., as pointed out for stomatitis, may, any of them, under the proper conditions, derange the vaso-motor and secretory conditions of these glands and lead to hypersecretion or dryness.
    Hypersecretion is sometimes of reflex origin from diseases of the teeth and mouth, digestive organs, sexual organs, etc.  In such cases it is still probable that the lesion has an affect in determining the disease to these glands. No lesion may be present when ptyalism is due to the use of a drug, such as mercury, gold, copper , etc.  Xerostoma is thought to be due to an affection of the nerve supply of all the glands of the mouth.
    PROGNOSIS: Ordinarily good success is had in correcting these conditions.  The prognosis must depend upon that for the disease to which these are commonly secondary.
    The TREATMENT must be directed to the removal of the lesion, as well as of the disease upon which the condition may depend.  A thorough neck and upper dorsal treatment should be carried out upon the lines laid down for the treatment of stomatitis.  Removal of lesion and treatment of nerve and blood supply does much to correct the secretions.
    Local work over the region of the glands externally, relaxing the tissues and stimulating the gland directly is much used in dryness of the mouth in fevers.  It is quite successful.
    Care for the general health is an important measure in  the treatment of these conditions.  It is fully as important as is the specific treatment.  The secretions of the body cannot be restored to normal unless the general health be repaired, inasmuch as most of these conditions depend, fundamentally upon systemic conditions.  The frequent use of small amounts of water, or of a little oil in the mouth, is a measure of relief.
 



INFLAMMATION OF THE SALIVARY GLANDS

    For Specific Parotitis see "Parotitis."  Parotid Bubo and Chronic Parotitis would be regarded, osteopathically, from much the same standpoint as parotitis, as far as specific lesion and mode of treatment are concerned.
    As parotid bubo is not a primary affection, particular attention must be given to the condition which it complicates. .As most of the cases are septic a special effort must be made to free the system of poison by active work upon bowels, kidneys and skin.  Thorough treatment must be given to the gland to guard against suppuration.
 



TONSILLITIS

    DEFINITION: Tonsillitis is an inflammation of the tonsils accompanied by enlargement of the gland, fever and various constitutional symptoms.  It is caused by lesions m the cervical region.
    CASES: (1) A case showing a right curvature of the spine; 2nd and 4th cervical vertebrae were, sore; the cervical muscles upon each side were contractured; the 3rd to 6th dorsal vertebrae posterior.  Vertigo was also present,
    (2) A case showing a straight spine, with many vertebral luxations, and emaciation of the upper dorsal muscles.
    (3) An acute case cured by two treatments thirty minutes apart.
    (4) A case in which the tonsils were ulcerated.  After four treatments the swelling and inflammation were reduced, and the ulcers healed in a few days.
    (5) A case sick for five days, the usual medical treatment affording no relief.  The fever was high.  After one treatment the size of the tonsils was reduced and the patient slept for the first time in two days.  Upon the third day of treatment the patient was out.
    (6) A case in a boy three years old, in which, after unsuccessful medical treatment for two months, removal of the tonsils was advised.  They were so enlarged as to almost close the throat.  They were soon restored to normal size by treatment directed to the upper cervical region, and to the glands, externally and internally.
    (7) A ease of acute tonsillitis in a boy of four years, whose tonsils were chronically enlarged.  The attacks were frequent and severe, lasting four or five days, and confining the child to his bed.  During an attack, one treatment reduced the fever, and four more treatments overcame all inflammation, The lesions were; contracture of upper cervical ligaments and muscles, and slight luxation of the atlas to the right.  The lesions were corrected in less than two months, the chronic enlargement was overcome, and in the nine subsequent months but one slight acute attack occurred.
    CAUSES: The lesion in the case may affect the general cervical region, but usually occurs high up, affecting the atlas, axis, or third vertebra.  The lower vertebrae are often found luxated, and contracture of the posterior and lateral cervical tissues often acts as the primary lesion.  Contracture of the upper hyoid muscles is always present, frequently as secondary lesion.  Luxation of the clavicle and first rib, and tension in the deep anterior cervical tissues about them are sometimes found.      Systemic conditions are often very prone to induce attacks.  Often these begin as biliousness and constipation, or as a nervous upset, or as a feature of a cold.  It is probable that many of the more particular lesions found are secondary.  Attention must be given to the system, and the general causes must be sought in its condition.
    Lesions of the atlas, axis, and third vertebra probably act by affecting the fifth nerve through its connections with the superior cervical ganglion.  Lesions of the throat, of the deep anterior cervical tissues, and of the first rib and clavicle, have an important effect by obstructing the circulation through the carotid arteries and the internal jugular vein.
    In persons subject to tonsillitis through the presence of these specific lesions, acute attacks are frequently aroused by exposure to cold and wet, by bad hygienic surroundings, and by various nervous disturbances.
    The PROGNOSIS is good in the acute follicular and acute suppurative forms and in ordinary chronic enlargement of the glands.  One or a few treatments may cure the case in the acute forms.      Great relief is almost invariably given immediately by the treatment.  The chronic enlargement requires long continued treatment.  In the chronic form described as naso-pharyngeal obstruction, or mouth breathing, the prognosis for cure is not good.  Much relief can be given, and long continued treatment aids the retarded mental and bodily development.
    Although Salinger and Kalteyer's "Modern Medicine" states that acute follicular tonsillitis cannot be aborted, it is the common experience with Osteopathy to abort the disease.
    In the TREATMENT of acute tonsillitis, due attention must be given general constitutional condition.  Liver, bowels, kidneys and skin must be kept active.  Thorough spinal treatment should be given for tonic effect.  The treatment should be directed at once to the reduction of the lesion.      Treatment is given the upper three cervical vertebrae to affect the superior cervical ganglion.  All the muscles and tissues of the neck are; gently but thoroughly relaxed.  Careful treatment is made over the suprahyoid muscles and over the region of the tonsils.  The extreme tenderness will allow of but gentle treatment, but by exercising care in applying the treatment at first, a deep and thorough treatment may be given after preliminary relaxation of the tissues.  All the cervical vertebrae and posterior tissues should be thoroughly treated for the sympathetic connections of the fifth. (Chap.  IV.)  The treatment over the throat as described is to relieve the inflammation by freeing the circulation in the substance of the gland and in the carotid and internal jugular veins.  As the large arterial supply is from branches of the external carotids, particular treatment is made along them by relaxing the muscles and tissues over them and by opening the mouth against resistance as already described.  This work over the throat is carried down to the root of the neck over the carotid and internal jugular veins.
    Manipulation over the tonsil aids the flow of the blood through the tonsillar plexus of veins into the internal jugular.  This vein is freed by raising the clavicle and relaxing the anterior -cervical tissues about it arid the first rib.  Momentary pressure should be made upon these veins, one at a time, followed by downward stroking from over the gland and down the vein.  If this be repeated, and kept up for a few minutes, the acute enlargement can be quite reduced for the time.  In the same way the carotid artery is stimulated in action.  Circulation in the substance of the gland is aided by internal treatment in the throat, made by sweeping and pressing the index finger over the gland, fauces and surrounding tissues.  This gives much relief.  All the treatment directed to the throat and inferior cervical region is the most important part of the treatment.  The large blood supply of the gland, and our ability to reach it directly more than through the innervation, make this part of the treatment important.  It is readily efficient.  Treatment to the first rib and over the upper anterior chest aids circulation.  The cold pack to the throat or hot applications give relief.  The diet should be liquid, bland and nourishing, such as milk and broth.
    The tonsils should be kept free from accumulation of secretions, which persist in chronic cases.  The fever is treated in the same way, being affected by the superior cervical and spinal work.  The spinal and general treatment relieves the chilly feelings, aches, etc.  The neck and throat treatments relieve the sore throat.  Careful treatment will prevent suppuration in the suppurative form (Quinsy).  The general tonic treatment must be persistent in these cases because of the severe general symptoms.
    Acute cases should be treated daily one or more times as necessary.  A few treatments are generally sufficient.  The chronic enlargements (hypertrophy) and the chronic naso-pharyngeal obstruction should be treated three times per week.  In the latter, local treatment upon the gland from within the throat is very helpful.  Many of these cases are, in fact, tubercular, and the practitioners must be observant of such condition.  Long continued treatment should be urged in all chronic cases to prevent, or to overcome, retarded mental and physical development.
 



PAROTITIS

    DEFINITION: Parotitis or mumps is an acute inflammation of the parotid glands.
    CAUSES: The lesions in such cases affect the upper cervical region, mainly the atlas, axis and third vertebra.  Other cervical vertebrae may be luxated, and the cervical muscles are contractured.  The deep anterior cervical tissues may be tensed, and clavicle luxated.  Secondary contracture occurs in the muscles and tissues over the region of the gland.
    Lesions of the upper three cervical vertebrae and to the tissues affect the superior cervical ganglion, and thus the carotid plexus through its ascending branch; the fifth nerve through this ganglion and through its sympathetic connections, and thus its auriculo-temporal branch; the second cervical nerve, and thus its auricular branch; while lesions to the muscles in this region may affect the facial nerve directly, and these other lesions affect it through the sympathetic connections.      Contraction of the tissues over the course of the external carotid arteries and the external jugular veins affect the flow of the blood to and from the gland.  Luxation of the clavicle and its tissues affects the external jugular vein.
    The PROGNOSIS is good.  Treatment is rapidly effective, and the course of the disease is shortened from the usual course, seven to ten days, to three or four days.  Some cases may become obstinate and require longer treatment.
    The TREATMENT is in most particulars identical with that given for tonsillitis, q. v., the lesions to vertebrae, tissues, and clavicle, etc., being practically the same.
    The tissues over and about the gland may be more readily relaxed as the condition is less painful.  The swelling is more persistent, and requires more treatment.  The fever is treated as before, and a thorough spinal and general treatment is given for the constitutional symptoms.  This should include treatment to the blood and nerve-supply of the breasts, ovaries, and testicles to prevent metastasis, which is probably usually due, in part, to lesions affecting these parts, and rendering them liable to this invasion.  Such should be looked to.  This point must not be neglected, as the inflammation may be driven by the treatment to these parts.  By thorough treatment of them the danger of metastasis is much lessened.  Thorough general treatment prevents the serious sequelae that sometimes follow parotitis, such as disorders of the eve, ear, optic nerve, albuminuria, arthritis, facial paralysis, hemiplegia, etc.  Careful nursing and care of the patient are necessary to prevent relapse.  The patient should remain in bed (luring the acute attack.  Hot or cold applications to the gland, and support with cotton and a bandage, afford relief.
 



 
PHARYNGITIS, (Sore Throat)

    DEFINITION: Acute Pharyngitis is an acute catarrhal inflammation of the mucous membrane lining the pharynx.
    Chronic Pharyngitis is a chronic catarrhal condition of the membrane, with hypertrophy or atrophy of the follicles.  It may be a chronic naso-pharyngeal catarrh, chronic hypertrophic pharyngitis (pharyngitis sicca), or follicular or granular pharyngitis.
    CASES: (1) Chronic pharyngitis in a professional singer.  The voice was impaired, the patient being hardly able to speak above a whisper.  Lesion of one of the middle cervical vertebra was found.  Treatment to it cured the case.
    (2) Acute pharyngitis and stomatitis.  The throat was ulcerated.  The usual medical treatment, tried for a number of days, was unsuccessful.  The patient could not eat for sixteen days.  He was enabled to eat by two osteopathic treatments, and the case was cured.
    (3) A case of chronic pharyngitis, showing lesion as marked tension and rigidity of the ligaments along the entire cervical region, with tenderness at the 2d and 3d vertebrae.  Chronically enlarged tonsils were present.  Both conditions were cured by restoring normal anatomical conditions in the cervical region.
    (4) Pharyngitis, chronic, caused by reflex irritation by lesion at the fourth right rib, which was twisted at its articulation.  The rib was replaced and the trouble disappeared, not having returned at a time six years later.
    LESIONS AND ANATOMICAL RELATIONS: These conditions are at once seen to be catarrhs.  They are closely associated with nasal catarrh, and with tonsillitis.  Largely the same nerve and blood supply suffers in pharyngitis as in these conditions, hence the remarks made concerning lesions and anatomical relations in considering them will apply with equal force to this disease.
    The nerve supply to the mucous membrane of the pharynx is from the pharyngeal plexus, composed of branches from the glosso-pharyngeal, pneumogastric, spinal accessory, and cervical sympathetic.  The sympathetic supply is from the superior cervical ganglion.  It has already been discussed how cervical and upper dorsal lesion affects this nerve mechanism.  Under certain conditions it is readily seen that the vaso-motor equilibrium of the pharyngeal mucous membrane would be upset, the lesion directly causing the inflamed condition, or weakening it and laying it liable to the effects of cold, exposure, tobacco, a depraved constitution, gout, scrofula, overuse, etc., commonly regarded as the active cause of the condition.
    It is significant from the osteopathic point of view that exposure causes the condition, and that the neck is stiff and sore.
    The hyoid bone is sometimes drawn back against the pneumogastric nerve by contraction of the hyoid muscles, irritating this nerve, and through it causing pharyngitis.  This is a very common condition in people using the voice to excess, such as public speakers and singers.  Almost without, exception these cases show marked contracture of the tipper hyoid muscles especially.  It is common, in these cases, to notice marked improvement after a few minutes treatment directed to the relaxation of these muscles.  In some cases lesions of the cervical vertebra cause spasmodic contractions in these throat muscles, resulting in pharyngitis in this way.
    Upper rib and clavicle lesion is sometimes present, deranging sympathetic connections and impeding circulation from the throat.  The clavicle may be back against the pneumogastric nerve.  Dr. Still holds this to be one of the commonest causes of irritation in the throat.  He also points out in these cases lesions of the first rib, sometimes at its sternal end. but especially at its head.
    Atlas, axis, and upper cervical lesions are the most frequent, but lesion may be found anywhere in the cervical region.  The former act chiefly by affecting the superior cervical ganglion.
    As pharyngitis is frequently associated with digestive disturbances one sometimes meets lesion in the splanchnic area causing pharyngitis indirectly in this way.  In some cases various kinds of lesions, causing depraved constitutional conditions, may be the ones present.  It is interesting in this connection, to note that many persons who have suffered from la grippe, etc., can be made to cough by spinal manipulation between the shoulders, which affects the vagus nerve through spinal sympathetic connections.  Lesions are usually present here.
    One case of aphonia was cured by reduction of lesion between first and second parts of the sternum.
    The PROGNOSIS is favorable, good results being almost uniformly gained.  The acute case is at once greatly relieved, and is cured in a few treatments.  Chronic cases are often entirely cured.  They are more frequently presented for treatment than are the acute.  Relief is at once apparent under the treatment.
    The TREATMENT is entirely that pointed out in detail for Catarrh and Tonsillitis, q. v.  Thorough correction of lesion, freeing of the circulation, and relaxation of the tissues is to be accomplished.  Removal of specific lesion is often able at once to cure the case. One must make a special point of keeping relaxed the tissues of the throat from the angles of the jaws to the clavicle.  This frees the circulation.  Likewise the clavicle should be raised.  The circulation in the pharyngeal plexus is also much relieved by the inward mouth treatment.  It is well to extend this well up to the openings of the Eustachian tubes, as in this way one may prevent the inflammation spreading to affect the ears.  The work beneath the angles of the jaws externally, and opening the mouth against resistance are particularly good treatments in this condition.  Sore throat and cough are often much relieved by grasping the larynx between thumb and fingers and applying a rapid shaking movement to it, extending the treatment down along the trachea as far as the sternum.
    In the acute case the patient may suck ice for relief.  A hot foot-bath is good.  The diet should be liquid or semisolid.
    Daily sponge baths should be used, with first tepid and then cool water, to harden the skin.
    In all cases the active source of irritation must be removed.  This is often bony lesion.  If it be smoking, the use of alcohol, etc., it must be dispensed with.
    The chronic case usually calls for a thorough course of treatment to enable one to overcome the chronic inflamed, hypertrophied or atrophied condition of the membrane.
    The corrected blood supply loosens and dispels the muco-purulent secretions, and normalizes the secretory function.
    It heals the ulcerations, builds up the atrophied membrane, or absorbs the hvper-trophied follicles. Constitutional treatment is often necessity.
 



 
ESOPHAGITIS

    DEFINITION: An acute inflammation of the mucous lining or the submucous coat of the esophagus.
    CAUSES: (1) A case in which the inflammation of stomatitis extended downward into the esophagus.  There was contracture of the supra-hyoid muscles, drawing the bone back against the pneumogastric nerve.
    (2) A case in which irritation the length of the esophagus, and a distressed feeling of the stomach were due to a posterior condition of the upper 4 or 5 dorsal.  Correction of this lesion removed the irritation and relieved the stomach.
    LESIONS AND ANATOMICAL RELATIONS: The lesions are often the same as those for stomatitis and pharyngitis, as this condition is often due to extension of inflammation downward from above.  Thus lesion to the hyoid bone and to the muscles of the throat, to the clavicle and upper ribs are all likely to occur. Lesion to the clavicle and 1st rib may interfere with the circulation to the esophagus via the subclavian and thyroid axis.  The various cervical lesions already discussed as capable of derailing the activities of the pneumogastric and sympathetic, both of which unite in forming the esophageal plexus, may react upon the esophagus.
    The esophageal plexus is in connection with the pulmonary plexus and thoracic sympathetic.  Thus is seen the close connection between upper spinal lesion, common in derangement of the esophagus, and its sympathetic, innervation, having charge of its circulation.  Spinal lesion in this way affects the circulation from the aorta to the esophagus.
    The cause is frequently traumatic, and no special lesion is present.
    The prognosis is good.  Cases usually recover in a few days; often spontaneously.  Generally one or two treatments are all that are required.  In the suppurative form, perforation, gangrene, or late stricture is apt to end in death.
    The TREATMENT is simple.  Any cause of irritation, mechanical, thermal, or chemical must be removed.  The circulation is corrected and the inflammation reduced by correction of lesion, treatment of the upper dorsal region, elevating the upper ribs and clavicle, and freeing the, circulation through the neck and about the throat.
    If due to catarrh, infectious fevers, etc., treatment must be made accordingly.
    A bland diet, especially of milk, is recommended.  In serious cases rectal alimentation may be necessary.  Small pieces of ice may be swallowed.  Warm demulcent drinks are good.
    In chronic cases the treatment must be more persistent.  Any source of continued irritation must be removed.  This form is often due to passive congestion from chronic heart or kidney diseases, and attention must be then given to the primary condition.
 



 
SPASM AND STRICTURE OF THE ESOPHAGUS

    CASES: (1) A man, aged fifty, suffered from a constriction of the esophagus, which occurred while eating.  The physician allayed the intense pain by injection of morphine, but was unable to overcome the obstruction.  The case became serious.  An Osteopath was called and after several hours effort relieved the condition.  The case was treated for two weeks and all effects of the trouble disappeared.
    (2) A case of constriction of the esophagus was cured by treatment to the  pneumogastric nerves and in the upper dorsal region.
    The LESIONS in these cases are usually upper rib and upper thoracic vertebral ones.
    There are many of the cases which present no special bony lesion, but are due to other causes, as when spasm depends entirely upon a nervous reflex, e. g., from the uterus, etc., or when stricture is due to congenital narrowing or to constrictive growth after burning with a corrosive fluid.
    Yet it is evident that a reflex irritation from a rib or vertebral lesion upon the direct nerve connections of the esophagus could be quite as effectual as a reflex irritation from the uterus in causing spasm of the esophagus.  Specific bony lesion may be the determining cause of the spasm in cases of hysteria, chorea, epilepsy, etc.
    In case of stricture the bony lesion may be the ultimate cause of the epithelioma, polypus, or ulcer, and cicatrix finally resulting in stricture.
    The PROGNOSIS for spasm is good.  It is commonly easily overcome by the treatment.  The prognosis for stricture is not favorable.  It is a surgical case, and can usually be relieved only by passing a bougie.
    The TREATMENT depends upon the cause.  In cases of spasm, if a nervous disease be present it must be carefully treated.  All cause of irritation must be removed.  Rib and vertebral lesion must be adjusted.  Thorough treatment in the upper dorsal, lower cervical, and upper thoracic region is quite successful.  In cases of stricture the diet should be semisolid or fluid, and concentrated.  Rectal feeding may become necessary.  Osteopathic treatment as above may be applied but it is likely that the bougie will have to be used.
 



 
ACUTE AND CHRONIC GASTRITIS

    DEFINITION: The acute form is an acute catarrhal inflammation of the mucosa of the stomach; acute indigestion.  The chronic form, chronic dyspepsia, is associated with structural changes in the mucosa, and with change in the secretions and muscular activity of the stomach..
    CAUSES: Lesions have been noted in various cases as follows: (1) 2d to 6th cervical vertebra to the right; 2nd cervical anterior; 8th to 10th dorsal vertebrae separated; break at the fifth lumbar. (2) Luxation of the 8th rib; tenderness at the 8th dorsal vertebrae. (3) Cervical and dorsal curvatures of spine, and luxation of the ribs.
    (4) A case of catarrhal gastritis in a man sixty-four years of age, of twenty years standing.  The patient was unable to take nourishment.  Lesion. was of the 4th and 5th right ribs, which were slipped at their vertebral articulations.  The patient was able to get up on the fifth day of treatment and returned to work in three weeks.  The ribs were entirely corrected in two months.
    (5) Chronic gastritis due to a downward displacement of the right fifth rib.  The lesion was corrected and the case cured.
    These cases, almost without exception, show lesion in the upper splanchnic region, between the shoulders, including the spinal area from the second to the seventh dorsal.  A common form is flatness or anterior position of this region.  Its tissues are often sore or sensitive under pressure.  The soreness may appear only coincidentally with more acute manifestations of the stomach disorder, or it may be better and worse according to the condition of that organ.
    Lesions at the atlas, axis and third cervical affect the vagus nerve through its connection with the superior cervical ganglion.  It may be obstructed along its course in the neck.  Lesions to the cervical region and to the pneumogastric nerves in the neck are of secondary importance in causing stomach disease.  The main lesions occur in the spine, affecting the splanchnic area, and may be of the ribs and their cartilages, of the vertebra, or of the spinal and intercostal muscles and other tissues mentioned.  Lesions to these structures occur mainly between the fourth and tenth dorsal region, but may occur either a little above or below these limits.  The pneumogastrics and the splanchnics both contribute to the solar plexus, which has charge of the functional activities of the organ.  The wide area of origin of the splanchnics along the spine, and their importance in the innervation of the stomach, accounts for the fact that lesions to this area are most potent in producing derangement.  At the same time this is so readily accessible to the Osteopath's work that results are generally easily attained in the treatment of such troubles.
    Lesions to ribs and cartilages act in part through interference with the intercostal nerves, which are in direct sympathetic connection with the solar plexus through the splanchnics.  Luxation of the ribs may also interfere with spinal nerves by derangement of the tissues about the head of the rib.  Lesions of spinal muscles, ligaments, and vertebrae act mainly through interference with the spinal nerves and thus upon the connected splanchnics.  Muscular lesion may often be secondary to stomach disease, but in such case indicates the point of treatment, and may point to spinal lesion at that place.  The vagi nerves carry sensory, motor and secretary fibers to the stomach.  The splanchnics contain vaso-motor and viscero inhibitory fibers for the stomach.  But as the influence of the abdominal brain is, according to Robinson, supreme over visceral circulation, and controls as well visceral secretion and nutrition, the results of our treatment upon the pneumogastrics and the splanchnics must affect the stomach mainly through the solar plexus.  As the splanchnics contain these vaso-motors for the stomach, the main treatment for gastritis, a vaso-motor disturbance, must be through them.  Lesions to the splanchnic area are likely to cause gastritis upon account of their being the vaso-dilators.
    McConnell states that lesion of the eighth and ninth costal cartilages may cause gastritis.
    The mechanical irritation of coarse, poorly masticated food, the fermentation of overripe fruit in the stomach, and the effects of constant overloading of the stomach and of indiscretion in diet, may irritate the mucosa and cause gastritis in the absence of specific lesion.  But in such cases secondary lesions are generally produced by the trouble.  In the ordinary case of gastritis sometimes beyond these must be sought, and the disease so frequently occurs without such indiscretions.
    The PROGNOSIS for recovery is good in both acute and chronic cases, The ordinary acute case is relieved immediately by a treatment.  More than one treatment may not be necessary.
    The TREATMENT must be directed to the specific lesion, generally of the splanchnic area, that is causing the trouble.  Its main object must be to correct the circulation, and thus to take down the inflamed condition of the mucosa and restore normal secretion.  The splanchnics and solar plexus, having charge of the circulation and secretion, afford a most convenient means of doing this.  The correction of lesion here, and the treatment given the splanchnics and solar plexus in conjunction with the removal of lesion constitute the main treatment in such cases.
    With the patient lying upon his side or upon his face, the muscles and deep tissues of the splanchnic area are thoroughly treated and relaxed.  The patient now lies upon his side, or sits up, and treatment is given the spinal vertebrae and ribs of this region.  The former are thoroughly treated and sprung, to relax all their related tissues and remove obstructions to the nerves.  The latter are raised, and adjusted in case of lesion, to aid in this process.  Vaso-motor activity is thus aroused and corrected.  This important process is aided by deep treatment of the solar plexus from the abdominal aspect.  (VI.  Chap.  VIII).  As this plexus has the main control of visceral circulation and secretion, treatment of it rouses and normalizes its functions.  Mechanical pressure of displaced ribs upon the stomach may be found.  The upper abdominal treatment aids circulation in the stomach. (V.  Chap.  VIII).  Attention is given the upper cervical region for lesions affecting the vagus.  It may be treated in the neck as a means of aiding the general treatment.  Inhibition by pressure upon the left vagus relaxes the pylorus.  This pressure may be made in the neck directly upon the nerve, or may be made at the third or fourth intercostal space near the spine.  This latter treatment is much used to relieve nausea and vomiting.  Its effect is probably through the sympathetic connections with the vagus.  In some cases pressure at this intercostal space has caused vomiting.  In some cases abdominal manipulation induces vomiting.  This should be encouraged to relieve the stomach of its irritating contents.  Excessive vomiting should be checked.  Thorough treatment along the spine (splanchnic area) will aid in this.  After inhibition of the left vagus to relax the pylorus, the patient may be placed upon his right side and deep pressure be made over or beneath the left hypochondrium, from the cardiac toward the pyloric end, to aid in the passage of the stomach contents into the intestine.
McConnell states that inhibition at the 8th and 9th dorsal relaxes the pylorus; inhibition at the 6th and 7th dorsal relaxes the cardiac orifice.  He has found that correction of lesion in the lower left ribs aids in the absorption of gas.  Deep pressure over the solar plexus also aids this process.
    Liver, bowels, and kidneys must be kept in active condition by treatment.  The patient should be absteminous in diet.  It should be light and easily digested, and may he according to prescribe dietaries.  The patient should masticate thoroughly.  He must avoid fats, alcohol, and sweets.  In severe cases he should be put upon a milk diet.
    Acute cases should be treated frequently, chronic cases three times per week.
 



 
DISEASES OF THE STOMACH (Continued)

    CASES: (1) Strain from heavy lifting, followed by severe lameness at the time, which gradually disappeared.  In a few months severe stomach disease followed: no food could be retained, and rectal feeding was resorted to.  Patient came under treatment too weak to walk or talk.  Muscular contractures under the right shoulder and a slightly displaced rib were the lesions found.  They are corrected and the case cured.
    (2) Ulceration of the stomach and complication of troubles, due to spinal curvature.  Correction of curvature gave great relief.
    (3) Acidity of the stomach and diarrhea, caused by abnormal tension in the spinal tissues.  Cured.
    (4) Gastralgia: Attacks so severe that they induced spasm in abdominal and neck muscles at the same time, The spasm was always stopped at once by inhibition of the solar plexus and of the posterior cervical nerves.  Attacks grew less frequent under treatment.
    (5) Gastralgia; agonizing pain followed taking even small quantities of food as long as it remained in the stomach.  6th, 7th, and 8th right ribs were down.  These being replaced the trouble disappeared.
    (6) Gastralgia of several years duration.  Lesions at 5th and 6th dorsal and 2d lumbar vertebrae.  Luxation of the 8th right rib.  Case cured by four month's treatment.
    (7) Gastralgia; three years standing; attacks after nearly every meal.  Lesion, a lateral twist of the 6th dorsal vertebra.  Cured in one year's treatment.
    (8) Gastralgia; incessant pain in left side, stomach, and bowels; 4th and 5th right and left ribs drawn together; 8th left under 7th; spinal muscles tense.  Great relief was given by one monthís treatment.
    (9) Gastralgia.  Seventh dorsal vertebra right; great tension at the 12th dorsal.
    (10) Gastralgia.  Lesions at atlas and 4th dorsal.
    (11) Gastralgia.  Luxation of the 11th rib.
    (12) Tenderness over the stomach (hyperaethesia); 8th dorsal vertebra very tender and 8th rib luxated: cured by two weeks treatment.
    (13) Dilatation of the stomach and a complication of diseases.  The spine was straight and flat; thorax flat; 2d and 3rd cervical vertebrae lateral; left cervical muscles tense; slight lateral curvature to left between the 5th dorsal and 3rd lumbar; spinal muscles tense.
    (14) A case of chronic dilatation of the stomach of some years standing, with constipation and gastric pain.  The appetite was ravenous at times, at times, but taking food aggravated the pain.  The case was cured in 5 months, the weight having increased from 104 to 158 pounds.
    (15) Chronic nervous dyspepsia of twenty years standing in a man of 42.  The stomach was dilated, and pain was present two hours after eating, Lesion was posterior condition of 6th and 7th cervical; lower dorsal and upper lumbar markedly posterior; compensatory anterior swerve of the upper dorsal region; The case was cured in eight months.
    (16) A severe acute attack of pain in the stomach with nausea and constant vomiting for 48 hours.  Medicine gave no relief.   One treatment greatly relieved the case, and in three days the patient was at work.
    (17) Gastric colic in a man of forty, resulting from injuries received six years previously, in which the spine was injured, and the lower right ribs were pressed inward.  The first attack of pain occurred 2 months after the accident, marked by severe pain and cramping in the right side above the crest of the ilium, radiating upward.  Attacks every 10 days, and accompanied by extreme nausea and vomiting.  The patient was confined to bed three of four days at each attack.  At times the cramping was so severe as to extend to all the muscles of the body.
    Lesion was present as anterior condition of the fourth dorsal vertebra.  The lumbar portion of the spine was prominently posterior.  The condition of the ribs was as above noted.  Kidneys and liver were involved.
    After the third treatment the patient was benefited.  The attacks grew less severe and less frequent.  The case was practically cured at the time of the report, three months having elapsed since the last attack.
    LESIONS: In all the above cases the splanchnic area was affected; neck lesion was rare, and apparently of secondary importance; lesions to the spine, including vertebrae and muscles were important; occurring in ten of the cases: rib lesions were the most important and specific, occurring in seven of the cases.  Lesions of the 5th to 8th ribs (area of greater splanchnic) occur most frequently.
Lesions to the splanchnic area through rib or spinal lesion, apparently occur in all cases of stomach disease.  We are not yet able to specialize as to lesion, and say that one particular style of lesion, or lesion of some individual rib or vertebra causes a certain kind of stomach disease.
    It is probable that in the future compilation of lesions may show considerable specialization of them in the etiology of stomach disease.  But it is also likely that such tabulation will indicate the probabilities only, for it is a matter of experience that a given lesion will produce in one patient one form of stomach disease, and in another a different form, depending upon individual peculiarities, and upon various attendant conditions.  Hence one must be upon the lookout for any various lesions in the splanchnic area in all stomach diseases.  They may cause a predominance of sensory, motor, secretary, or vaso-motor derangements, and complications thereof, and according to the predominating difficulty it may be that special lesion will be suspected, or that special areas will be treated in conjunction with the removal of specific lesion in the case.
    The practitioner's simple duty in stomach disease is most thorough examination of the splanchnic region of the spine, just above and just below, and of the thoracic parts in relation thereto.  When he has done this he has located the trouble, almost invariably, and his treatment of this region, removing the lesion, almost as generally cures or benefits the case.  Lesion outside of this area is of minor importance, and treatment directed elsewhere (abdomen and neck) is either secondary, or for alleviation merely.
    Special lesions have been noted as follows: in acidity, the lesser splanchnics and the 4th and 5th dorsal (A.  T. Still); in gastralgia, frequent luxation of the 8th and 9th ribs anteriorly (McConnell), also of the 5th, 6th and 7th dorsal; for gastric ulcer, frequent lesion of the 8th and 9th ribs anteriorly, and of the 5th to 8th ribs posteriorly (McConnell.)
    Secondary lesion in the form of contracturing of spinal muscles, particularly along the splanchnic area, is of very frequent occurrence in stomach disease.  Although in this case the result, and not the cause, of stomach disease, it is of much importance osteopathically. (1) It indicates the point of treatment, for it is an indication upon the surface of the body of what special nerve fibers or areas are suffering derangement by the particular form of disease present.  There is a direct path between the diseased stomach and the contractured muscle, over which the abnormal impulses, generated in the stomach, pass out.  It is Nature's landmark of a special diseased condition, or of a phase thereof.  Experience shows that in the absence of any other lesion whatsoever, treatment at the point of contracture may cure the condition.  It is evident that the nerve area thus indicated was the one needing treatment.
    (2) These contractures do not always occur at the same location, nor always affect the spinal muscles over the splanchnic area generally.  They may occur upon the one side of the spine only, high up in the splanchnic area or above it.  They must therefore indicate lesion in different nerve areas or fibers, according to some condition present and determining which fibers shall thus suffer and produce contracture.  It is possible that they indicate seat of lesion in the spine not otherwise discoverable.  In such case this weak point would be the determining condition in the location of the situation of the contracture.  Thorough treatment at this point may restore conditions and thus correct lesion which is important in the causation of the stomach disease.  Contracture and soreness in the cervical or lumbar regions may follow stomach disease, and possibly indicate important relations, by lesion or otherwise, between these parts.
    ANATOMICAL RELATIONS: Robinson states that the solar plexus is supreme over visceral circulation, that it controls also secretion and nutrition.  The important lesions noted in stomach trouble affect its spinal connections, the splanchnics, and may therefore cause circulatory, secretary, or nutritional disturbances in its connected organs. Likewise they may cause sensory and motor troubles, as the same authority, and the American TextBook of Physiology, as well, states that this plexus receives sensation and sends out motion.  According to Quain, the terminal branches of the pneumogastric unite with the gastric plexus of the sympathetic, and carry motor and sensory fibers to the stomach.  Flint shows that the pneumogastric has much to do with gastric secretions, as section of it leads to almost complete cessation of stomach secretions.  It is considered probable by investigators that its motor function in the stomach is derived from its sympathetic connections.  Osteopathic work seems to influence it more largely through its sympathetic connections.  It is treated also in the neck directly.  It is important in sensory and motor diseases.  The splanchnics contain vaso- and viscero-motor fibers.  Stimulation of the splanchnics lessens peristalsis; of the pneumogastrics increases it.  Thus important control is gained in various conditions.  Quain states that sensory nerves for the stomach pass from the dorsal nerves from the 6th to the 9th, the 6th and 7th supplying the cardia, the 8th and 9th the pyloric end.
    The PROGNOSIS in stomach diseases as a class is extremely good.  Many severe cases of long standing have been cured.  As a rule relief is immediately given, and cure follows.
    The TREATMENT of stomach diseases as a class is very simple.  It consists mainly in corrective treatment in the splanchnic area, together with a certain amount of neck and abdominal work.  This is supplemented by certain special treatments for various purposes in the treatment of special diseases.  Through the pneumogastrics and the sympathetic connections, the solar plexus and the splanchnics, control is had, to a marked degree, over the processes regulated by them; sensation, motion, nutrition, secretion, circulation.  Few diseases can remain after correction of these functions by removal of the lesion disarranging them.
    The treatment of the solar plexus, the spine (splanchnics), the pneumogastrics, and the removal of the various lesions likely to occur in these regions have already been discussed.
    The various motor, secretory, and sensory neuroses, described under the general name of nervous dyspepsia, are treated by removal of special lesion and by the work for the control of various functions as discussed.  In cases of supermotility, peristaltic unrest, and nervous eructation, special treatment may be given to stimulate the splanchnics and solar plexus to lessen peristalsis.  In nervous vomiting, the work should be directed to the cerebral centers, by treatment in the superior cervical region, and to the solar plexus.  Strong inhibition to the left pneumogastric in the neck will relax the pylorus and aid in passing the stomach contents into the duodenum.  Deep pressure at the 3rd and 4th left intercostal space near the spine will relieve nausea and stop the vomiting.
    In spasm of the cardia, inhibition should be made at the 6th and 7th dorsal for fibers controlling it, while in spasm of the pylorus the inhibition should be on the 8th and 9th dorsal and upon the left vagus.  In atony of the stomach, thorough stimulation should be given the vagi, splanchnic, and solar plexus, to increase muscular tone and to develop circulation.  Local manipulation over the region of the stomach would aid in toning the muscular walls (see treatment of Gastritis.)   In insufficiency of the cardia stimulation should be given the 6th and 7th dorsal, while in pyloric insufficiency the 8th and 9th dorsal and the left vagus must be looked to.  Local stimulation, by brisk work over the abdomen, aids the operation.
    In secretory disturbances, hyperacidity, super-secretion, and sub-acidity, work upon the vagus and solar plexus, through the splanchnics, corrects circulation and rights secretion.  Stimulation of the lesser splanchnics and of the 11th and 5th dorsal is important.
    In sensory disorder attention must be given the sensory innervation.  Hyperaesthesia needs a general stimulation.  Gastralgia needs deep inhibition at the solar plexus, splanchnics, and vagi.  Special inhibition should be made from the 6th to 9th dorsal, 8th and 9th ribs anteriorly, and the 5th, 6th and 7th dorsal vertebrae, all of which points seem concerned in the sensory innervation of the stomach.  For the abnormal sensations of hunger, lack of appetite, etc., general correction of secretions and sensation will be efficient.
    For dilation of the stomach, rapid cutaneous stimulation over the region of the stomach aids in contracting its muscular fibers.  Treatment should be given for the stimulation of the vagi, and accumulated food must be kept worked out of the stomach.  All causes of obstruction of the pylorus should be removed.  This obstruction may be of such a nature as to demand surgical attention.  In case the cause be overgrowth of tissue, cancer, cicatrix of an ulcer, etc., an attempt may be made to relax the pylons by inhibition of the vagus (vide supra), and to pass the food on through the stomach by manipulation as before described.  In case the obstruction of the pylorus be not total one may succeed in keeping the contents of the stomach passed until the course of treatment can reduce the cause of obstruction.
    Much the same plan must be followed in cases in which the obstruction is due to external compression, or from growth, displaced kidney, gallstones, etc.  One may  sometimes easily remove the cause of obstruction.
    In all cases not due to pyloric stenosis, as from overstrain of the muscular coats by repletion; chronic gastric catarrh, weakening the muscle; fatty, and other forms of degeneration; congenital weakness; impaired innervation, etc., one may apply the treatment first mentioned above for dilatation, always with due attention to the cause and to the lesions present.
    Careful attention to the diet is necessary.  It should be small in amount at a time, and fluid or semi-fluid or semi-solid.  In this way the food is soon passed through and has no tendency to dilate the organ further or to interfere with its repair.
    A thorough abdominal treatment should be given to tone local circulation.  Strengthen the abdominal walls, and stimulate the walls of the stomach itself. (See treatment of gastritis.)
    For gastroptosis one should apply treatment as described for enteroptosis, q. v.
    In peptic ulcer attention should be given to perfect freedom of circulation.  The condition of the 8th and 9th ribs anteriorly, and of the 5th to 8th ribs posteriorly, must be looked to.  Absolute rest is necessary.  The patient should remain in bed, and rectal feeding be resorted to in part, for alimentation.  The diet must be carefully regulated, and of a sort mostly digested in the stomach.  Skimmed milk, buttermilk, and pancreatized milk gruel are recommended.  The latter is used also for rectal injection.  A diet of ice cream is reported as leaving cured a number of cases.
    The vomiting, hematemesis and pain may be controlled according to directions given for those conditions.
    The removal of lesion and maintenance of a free circulation are measures greatest importance, as thereby the ulcer is healed.  As a derangement of the secretions, such as hyperacidity, predisposes to ulcer, it is seen that correction of circulation guards against it.  The same is true of the point that gastritis causes ulcer.
    A general course of treatment should be given to build up the health of the body and to improve the quality of the blood in such conditions as anemia, chlorosis, and amenorrhea, which favor the development of ulcers.
    In hemorrhage from the stomach (Hematemesis); inhibit the splanchnics, and the solar plexus carefully, to lessen the blood pressure for the general vaso-motor center, and make deep inhibitive treatment of the abdomen to dilate the great abdominal veins and call the blood away from the stomach.  One should proceed as in other internal hemorrhage. (See Pulmonary Hemorrhage).  One must treat the condition according to its cause.  If it be from local disease, such as ulcer, the first measure is to stop the hemorrhage as above directed.  The same remark applies to hemorrhage from traumatic causes.  If the cause be a mechanical impediment to the portal vein, this should be removed; if vicarious menstruation, the local hemorrhage of the stomach must be first controlled, while later treatment looks to the reestablishment of menstruation.
    In the treatment of hemorrhage from the stomach, the organ must be given absolute rest.  Rectal feeding may be resorted to for this purpose.  Cold applications may be made over the region of the stomach.  The patient must remain quietly upon his back.  No stimulants should be administered.
    In cancer of the stomach, general corrective work and particular attention to freedom of circulation must be relied upon. (See treatment of "Tumors.")
    Look for lesion to any of the special points mentioned in relation to the various diseases.  The bowels, kidneys and liver must be kept in free action.  The diet should in all cases be limited and easily divested.
 



 
CONSTIPATION

    DEFINITION:  "Infrequent or incomplete alvine evacuation leading to retention of feces" (Quain).  "A neurosis of the fecal reservoir" (Byron Robinson).  Osteopathically it is regarded as a neurosis due to obstructed action of the nerves supplying the bowel with secretion, motion, and circulation.  It may be symptomatic of other disease, or a complication.  It is very frequent idiopathic, due to specific lesion to bowel innervation.
    Cases have presented various lesions; (1) Contraction of the sigmoid flexure, (2) Spinal lesions, mostly in the lumbar, causing spinal cord disease and partial paralysis of limbs and bowel, (3) A posterior prominence of the whole lumbar region, (4) Lesion at 5th and 6th dorsal, 2nd lumbar, and 8th right rib, (5) At 3rd and 4th dorsal, 9th dorsal, 5th lumbar,  (6) Intense contraction of the external sphincter am, (7) Slight parting of 1st and 2nd lumbar, (8) Prolapsus of the sigmoid, (9) Retroversion of the uterus against the rectum, (10) Right curve of spinal column; 3rd to 6th dorsal vertebra posterior; 7th to 10th dorsal vertebrae anterior and flat; 11th and 12th dorsal and 1st lumbar posterior; 12th dorsal and 1st lumbar the seat of pain; 12th rib down; 2nd and 3rd lumbar close; 5th lumbar sore and anterior. (11) 2nd and 3rd dorsal separated, 3rd and 4th together, 3rd to 5th flat, 6th to the left, 11th dorsal to 2nd lumbar posterior, (12) 6th and 7th dorsal posterior, 9th to 12th flat, ribs irregular and prominent on the left, (13) Coccyx badly bent, lesion of 5th lumbar, (14) Separation between vertebrae from 8th to 10th dorsal, and between 5th lumbar and sacrum, (15) 2nd to 5th dorsal approximated and to the right, separations between vertebra, from 8th dorsal to 3rd lumbar, the right innominate up and back, (16) Spine rigid; atlas to the left; 2d, 3d, and 4th cervical vertebra to the right; 12th dorsal, al posterior; 11th rib overlapping the 9th and 10th, (17) 6th dorsal anterior; 4th and 5th lumbar to the right; spine stiff from 6th dorsal to 4th lumbar; right innominate posterior; 12th rib displaced upward, at its anterior end, under the 12th, (18) Lateral lesion of 10th dorsal vertebra, with marked rigidity of muscles and ligaments in the lower dorsal and lumbar regions.
    An examination of cases shows wide distribution of lesion, ranging from the upper dorsal to the coccyx, and affecting ribs, vertebrae, spinal muscles and other tissues, innominates, coccyx, etc.  The most important lesions in these cases appear in the region of the lower two or three dorsal, and in the lumbar region.  It is in this portion of the spine that origin is given to the sympathetic nerves supplying the bowel.  Particular attention should be given the 11th and 12th dorsal and the 1st and 2nd lumbar, as the sympathetic branches from these points supply the interior mesenteric ganglion and the rectum with motor fibers, and the abdominal vessels with constrictor fibers.  Sympathetic distribution for the small intestine is from just above the first lumbar; for the large intestine from the 1st to 4th lumbar,     Hence the importance of the lower dorsal and lumbar lesion in constipation, as it may interfere with the functions of motion, secretion and circulation by obstructing the spinal connections of these important sympathetics.
    Lesions of the lower two ribs are important causes of constipation, not only by spinal interference with the sympathetics mentioned, but by direct mechanical pressure upon the bowel, sometimes.  In yet another important manner they may cause bowel trouble by lesion to the diaphragm as already mentioned.  The whole subject of change in the diaphragm is an important one in relation to bowel disease.  It is reasonable to consider that certain spinal and rib lesions affect the diaphragm. They may cause it as a whole to weaken and sag, may cause contracture of the whole muscular structure, or may contracture or strain certain portions of it.  Thus impingement is brought upon the important structures passing through the diaphragm, and having much to do with abdominal activities.  The aorta, ascending cava, thoracic duct, pneumogastric, phrenics, and splanchnics may be interfered with.  Or the sagging of the diaphragm may set up ptosis of the abdominal organs, thug causing constipation mechanically or otherwise.  This subject has been discussed at length elsewhere.
Lesion to the fourth sacral nerve may cause contracture of the external sphincter, which it innervates.  Lesion to the lower dorsal and the lumbar nerves may lead to loss of energy of the muscles of the abdominal walls, as may other causes, and lead to constipation.  Robinson states that such a condition favors constipation by allowing congestion of blood and secretions, and by lessening intra-abdominal pressure.  Lesions to the liver and pancreas, usually from the 8th to 12th dorsal, or through the splanchnics or solar plexus, aid constipation by lessening the secretions of these organs, necessary to stimulation of peristalsis.  McConnell states that contractured muscles are generally found in constipation on the right side of the spine over the region of the liver.  Dr.  Still makes lesion of the 5th dorsal important in these cases.
    The coccyx may be so misplaced as to act as a mechanical obstruction to the passage of the stool. Lesion at this point may cause contracture of the sacral tissues and interfere with the fourth  sacral, or it may interfere in a similar manner with the sympathetic distribution to the rectum, and cause atony or contracture of its wars.  A prolapsed uterus, hernia, adhesions, or the presence of foreign bodies, fruitstones, etc., may  mechanically obstruct the bowel.
    Various lesions, as of the diaphragm, the weight of a loaded colon, of the spinal regions, etc., producing ptosis of the abdominal organs, or of the colon itself, cause a kinking of the flexures by their dragging upon their ligaments at those points.  The same causes allow of a sinking of the caecum and sigmoid into their respective iliac fossae, allowing also the sigmoid to fold upon itself.  In these ways obstruction to the passage of fecal matter along the bowel is caused.  In enteroptosis the pressure of organs upon each other limits motion, peristalsis, and circulation.  The elongated omenta and ligaments, in which the blood vessels and nerves run to the bowels, stretch these structures and abridge their function.  These become important causes of constipation.
    The anatomical relations have been described in detail in considering diarrhea, q. v.
    Various lesions, acting to weaken circulation and nutrition, lead to atony of the bowel muscles, and to constipation.  Any lessening of circulation acts to cause it, as the circulation of the blood about the nerve terminals in the bowel wall is necessary to their activity.
    The PROGNOSIS is good.  Most cases are cured in a reasonable length of time.  The ordinary acute form, occasional constipation, is cured in one or a few treatments.  Very quick results are often obtained.  Cases which have been most obstinate, and those that have been from birth, have been readily cured.  Many cases are obstinate under treatment, and require time and patience to effect a cure.
    The TREATMENT for constipation, from the nature of the case, must look to the correction of the lesion that is obstructing circulation, peristalsis, or secretion in the bowel, or to the removal of the mechanical stoppage that sometimes causes the disease.  Some one or more of the special lesions described are found, and may be removed by the appropriate methods.  The main treatment is for nerve supply, as practically all of the lesions, except mechanical causes, act in one way or another through the innervation.  The main treatment upon the spine is in the lower dorsal and lumbar regions, the seat of the chief lesions.  The removal of the lesion is often all the treatment necessary, but various points must be considered.  The treatment must, by the removal of lesion or otherwise tone the splanchnics,  spinal  sympathetics, and solar plexus, as well as Auerbach and Meissner's plexuses, controlling the motor, secretory, and other functions of the bowels.  Special attention must, be given to lesion at the points mentioned as liable to them in this trouble.
    Abdominal treatment should be a deep, slow, relaxing treatment carried along the course of the bowel. Very successful treatment is to spread both hands upon the abdomen, and work deeply, first with the fingers pressing upon the ascending colon, then with the thumbs upon the descending colon, thus alternating the pressure from side to side of the abdomen.  This treatment should begin low in the iliac fossae, and ascend gradually.  It relaxes all the tissues, and frees local circulation, affecting also the local nerve distribution.  It dwells particularly upon those portions in which are felt the aggregations of fecal matters releasing the tissues about them, softening and passing them along.  This is the special method of removing obstruction  of foreign bodies, such as fruit stones, etc.  This treatment should  be given especially to the caecal and sigmoid portion as they are generally full.  Attention must be given to raising and straightening them when necessary.  This may be done in the treatments described in III and IV, Chap.  VIII.  Likewise the colon is a whole should be raised and straightened to relieve kinking at its flexures and the evil results to nerves and blood vessels accruing from the stretching of its omenta in ptosis.  The patient should be placed in the Sims position, or, better, in the knee-chest position, and the bowels should be thoroughly pulled up out of the pelvis.  Spinal work and the correction of lesion tones these omenta to hold in position the replaced organs.
The liver should be thoroughly treated to stimulate the flow of bile.  By the removal of lesion, by treatment to its spinal connections through the splanchnics, and by raising the  8th to 12th right ribs, this is in part accomplished. It is treated at the abdomen, as are the gallbladder and bile duct. (V, IX, Chap. VIII.)
    The inferior mesenteric ganglion is the center for the fecal reservoir, and should be treated at the location already described.  The vagi may be treated in the neck to aid in the general process.  The coccyx should be straightened as the case requires. (XX, Chap. II.) A contractured sphincter should be dilated. (Chap.  IX, D.) Or it may be released by strong inhibition over the fourth sacral nerves.  They may be located, at the fourth sacral formania, just to the side of and below the bony prominences that mark the termination of the sacral canal, and which may be easily felt beneath the skin.
    Peritoneal adhesions may be broken up gradually by deep and careful work upon the bowel at their site.  In the absence of pain, or as it disappears, the treatment may be made strong, care being taken not to set up inflammation.
    Obstruction from volvulus may be sometimes overcome by manipulation at the seat of the obstruction directed to the straightening the bowel.  This requires long treatment at a time, and much care and patience.
    Symptomatic cases must be treated in conjunction with the primary disease.
    The use of cold and hot drinks before breakfast, rectal injections, cereal foods, fruits, regularity in habit, and exercise are all helpful.  The water should be drunk neither too soon nor too long, before breakfast.  About fifteen to twenty minutes generally gives the best results.
 



 
CATARRHAL ENTERITIS; DIARRHEA

    DEFINITION: An acute inflammation of the intestinal mucous membrane due to specific spinal lesions.  Diarrhea is often symptomatic of other diseases.
    CASES: Lesions were found as follows: 1) Tension of the spinal tissues from the 3rd to 11th dorsal, (2) Lateral lesion of the 7th, 8th and 9th dorsal vertebrae, (3) 9th to 11th right rib depressed, (4) Right 11th rib down onto the 12th; 4th and 5th lumbar anterior; spine weak, (5) 6th to 11th dorsal vertebra lateral to the left; 12th dorsal, 1st and 2nd lumbar posterior; extreme weakness and irritability of the muscles along the affected area, especially opposite the 2nd lumbar; ribs over the liver down, (6) 5th lumbar anterior; 6th and 7th dorsal posterior; luxation of lower four right ribs.
Lesions may occur anywhere along the splanchnic along the spine as low as the coccyx.  The most important lesions effect the region of the lower two dorsal and the lumbar vertebra.  According to Dr. Still, in all cases of diarrhea and dysentery there is lesion of the 5th lumbar, which, through the connected sympathetic innervation, paralyzes the lymphatics of the bowels, causing the exudations and the stools.  The 11th and 12th ribs on each side are sometimes found luxated, most often downwards.  Lesion may occur at the 2nd lumbar, the 5th lumbar, to the innervation of the small intestine above the fifth lumbar, to the innervation of the large intestine from the 1st to 4th lumbar, to the coccyx, or to the innominates.  Lesions from the 8th to 12th dorsal and ribs may affect liver and pancreas to aid the diseased condition.
    ANATOMICAL RELATIONS: In intestinal diseases as in stomach diseases, the importance of the splanchnics and solar plexus; must be borne in mind.  The former contain vaso- and viscero-motors to the intestines, these vaso-motors being, according to Flint, among the most important in the body, innervating the immense area of abdominal vessels, which when fully dilated, are said to be able to accommodate one-third of the total quantity of blood in the body.  They contribute to the solar plexus, which rules sensation, motion, secretion, nutrition, and circulation in all these viscera.  Our correction of circulation in these cases is an important consideration.  Robinson shows that movements of the intestines are largely dependent upon the amount of blood circulating in the intestinal walls.  For these reasons lesions anywhere along the splanchnic region may produce important disturbances of intestinal secretions, circulation, or motion, all of which may be disturbed in diarrhea.
    The whole abdominal sympathetic is important in these diseases.  Stimulation of it lessens peristalsis; stimulation of the pneumogastric increases peristalsis.  We, work not to directly stimulate or inhibit either of these for the purpose of controlling peristalsis, but to remove lesion from them as it produces through them abnormalities of motion.
    Auerbach and Meissner's plexus of nerves have to carry on gastrointestinal secretion.  Auerbach's is a motor plexus.  They lie in the intestinal walls, and may be directly influenced by work upon the abdomen, but are corrected by us through the removal of lesions affecting them through their sympathetic and spinal connections.  Lesions to them, disturbing both secretion and motion, are important causes of diarrhea.  Robinson states that the inferior mesenteric artery, located, externally, a little below and to the left of the umbilicus, innervates the muscular walls of the fecal reservoir, i. e., the left half of the transverse colon, the descending colon, and the sigmoid.  Spinal lesion to it, through its connected nerves, is active in production of diarrhea.
    The fact that afferent sympathetic fibers pass from the abdominal viscera to the thoracic sympathetic cord may explain the occurrence of secondary lesions in the form of contractured muscles along the thoracic spine.  The presumption is that they are sensory in function, and if so, sensory fibers for the abdominal viscera may be associated with them.  Quain states that among the medullated fibers passing into the sympathetic system, some derived from spinal nerves are sensory fibers.  This may be the explanation why inhibition of the splanchnic area will stop pain in the stomach or intestines.
    All these various facts indicate the importance in diarrhea of spinal or lower rib lesion, from the 6th dorsal to the coccyx, which may interfere with the spinal connections of all these abdominal sympathetics and derange their functions.
    Our most important treatment is given from the 10th dorsal down, in these cases.  Lesions in this lower spinal region are of prime importance in causing diarrhea.  The importance of the lesion to 11th and 12th ribs and vertebrae, and to the upper two lumbar, is found in the fact that nerve branches from the lower dorsal and upper two lumbar pass to the inferior mesenteric ganglion, shown above to innervate, the fecal reservoir.  These branches are motor fibres for the circular, and inhibitory fibers for the longitudinal, muscle fibers of the rectum.  At the same time these lower dorsal and upper two lumbar nerves send branches to the sympathetics and supply vaso-constrictor fibres to the abdominal vessels.  The motor fibers to the longitudinal, and inhibitory fibres to the circular, muscle fibres of the rectum are sent from the sacral nerves.  This explains why the lesion of the innominate or coccyx may cause a part of the trouble in diarrhea, also why strong stimulation to the sacral nerves relieves tenesmus.
    Branches from the four lumbar ganglia go to the plexus upon the aorta, and to the hypogastric plexus.  Lesion in the lumbar region may in this way further interfere, with the bowel.
    The various forms of enteritis and diarrhea seem to have as their basis derangement of nerve or blood supply in the form of inflammation (catarrh); lack of proper vaso-innervation, leading to congestion and exudation; improper preparation of digestive fluids, due to deranged glandular activity; or increased secretion and exudation.
    The removal of lesion obstructing nerve and blood supply corrects these manifestations of such derangement.
    The PROGNOSIS is good.  Most cases of diarrhea are checked at once by a single treatment, many needing no further treatment.  Cases of years standing have been in many instances cured in a short time.  The ordinary acute diarrhea needs but one or a few treatments.  Acute enteritis needs careful treatment for several days while the acute process lasts.  Even long standing cases that had their origin in army dysentery have been cured.
    TREATMENT for diarrhea consists in the removal of lesion as found, affecting any of the special points named above as subject to lesion in this disease.  The main treatment aside from this is very simple, and is often given as the sole measure of relief.  It consists of very strong inhibition of the spine from the lower dorsal to the sacrum.  It may be given with the patient on his side, as described in III, Chap. II.  The "breaking up" spinal treatment may be used for the same purpose. (XXII, Chap.  II.) The former seems preferable.  It may be applied to either side or to both sides of the spine.
    Inhibition may be made at the 11th and 12th dorsal region by setting the patient upon a stool, pressing the knee against the spine, first on one side then upon the other, and grasping the arms of the patient, raising them above his head, and bending the body backwards against the knee.  This not only inhibits these nerves, but stretches all the anterior spinal parts and related tissues in the lower dorsal and upper lumbar regions.  This result is more important than the mere inhibition.  The 11th and 12th ribs are often displaced downward, and may then drag portions of the diaphragm in such a manner as to prevent free circulation of blood and lymph in the vessels perforting it.  This result alone might cause diarrhea.
    Muscular contractions along the spine should be removed.  Deep but careful manipulation should be made upon the abdomen over the intestines for the purpose of relaxing all their tissues, freeing circulation and correcting the activities of the Auerbach and Meissner's plexuses.  One may treat to tone the solar plexus, splanchnics, and general abdominal circulation.  The liver should be thoroughly treated, lesion to it be removed, and the secretion of bile corrected.  Its presence in abnormal quantities may cause diarrhea through increasing peristalsis.  In other cases its presence in the bowel does not hinder the case, and it is said to allay irritation of the mucosa.  Lesion of the 8th to 12th dorsal and ribs may derange either liver or pancreas.  In fatty diarrhea the latter must be looked to.
For tormina or griping, inhibition of the splanchnics is done.  For tenesmus, or bearing down pains in the bowel, strong stimulation of the sacral nerves is made by thorough manipulation of the tissues over the sacrum.
    It is said that in such cases the abdominal facia is contracted and causes congestion mechanically. (Charles Still.) When contracted it should be relaxed by abdominal manipulation.
The vomiting and purging should not be checked if they are the evident means of getting rid of the irritating content of the bowel and stomach.  The ordinary case is seen after plenty of opportunity has been afforded Nature to remove the irritant by these means, and calls for immediate checking.
In acute enteritis the case must be seen several times daily.  Gentle relaxing treatment should be made over the abdomen.  The liver is to be lightly treated; spinal muscles relaxed; the spine gently sprung to release tension in its tissues.  The lower ribs may be raised a little and the neck treated for relief of the head.  Careful attention must be given to the diet of the patient. It should be light and restricted.  Meat broths, mucilaginous drinks, etc., may be given according to prescribed dietaries.  Warm baths and rectal injections may be employed.
    Cases of acute diarrhea and enteritis should remain quietly in bed.  The various measures described may employed as necessary.  Spinal inhibition alone may be sufficient.  When diarrhea is symptomatic of other disease it may be relieved by these treatments.  Its care depends upon the care of the disease present.
    The various diarrheas of children; summer diarrhea, gastroenteritis, cholera infantum, etc., are all treated along the same lines, with special attention to condition present.  There is quite commonly an acute dyspeptic condition present.  Hygienic and dietetic measures must supplement the osteopathic treatment.  Fresh air and cleanliness are essential. Cool bathing is recommended.  Cracked ice may be given to ally the thirst or small quantities of water at a time.  Thin broths, egg albumen, etc., may be fed to the child.
    These cases are frequently serious, but the success of osteopathic treatment has been very marked.
    Croupous or diphtheritic enteritis calls for no special discussion.  It should be treated as indicated for catarrhal enteritis, with special attention to the particular causes.
 



 
INTESTINAL ULCERS

    The various forms of intestinal ulcers are successfully treated osteopathically.  They are generally due to other intestinal disease, and are assignable to those lesions so common as the causes of derangement of intestinal function.  These general lesions have been described under "constipation," an "catarrhal enteritis."
 



 
DUODENAL ULCER

    DEFINITION: This is a small, round, perforating ulcer which attacks the walls of the duodenum.  It is the homologue of the gastric ulcer, q. v., and probably originates in the same way.  Such lesions as interfere with intestinal circulation and secretions are the causes.  An obstructed area of circulation in the tissues becomes devitalized as a consequence of the spinal lesion interfering with the nerves controlling blood flow.  These devitalized tissues are acted upon by the acid gastric juices, and the beginning of the ulcer is made.  These ulcers are associated with such conditions as cause gallstones and Bright's disease, and are referable to the same lesions.
    The TREATMENT is practically the same as that for gastric ulcer before described.  Lesion must be removed and circulation be kept free to correct secretions and functions of the intestine, and to heal the ulcer.  Continued thorough treatment should be directed to the seat of the ulcer to keep the tissues soft and prevent the occurrence of cicatricial contraction, which may result in obstruction.
 



 
INTESTINAL HEMORRHAGE (ENTERORRHAGIA)

    Hemorrhage is one of the most constant symptoms of duodenal ulcer, and may occur in other forms of intestinal ulcer, as well as from other causes.  The treatment of it must be upon the same plan as described for peptic ulcer, q. v., for pulmonary hemorrhage, q. v., and for hemorrhage in typhoid fever, q. v.
    Absolute rest must be enjoyed, and no food must be allowed, with but a little ice to suck for thirst.  Ice bags should be applied to the abdomen, and the foot of the bed should be elevated about six inches.  If the bleeding comes from low down, small injections of ice water are good.  All active handling of the patient must be avoided, but a little quiet inhibition may be made along the spine to quiet heart and peristalsis.
 



 
FOLLICULAR ULCERS

    These are due to necrosis of the apices of the solitary glands in enteritis.  They have the same etiology and pathology as has catarrhal enteritis.  The lesions and treatment described for that disease apply exactly to this condition.
 



 
STERCOREAL ULCERS

    These ulcers are due to mechanical irritation of hard fecal scybala or enteroliths, and are referable to such lesions as cause constipation.  Their treatment is a most thorough one for bowel as in constipation.  Rectal injection may be used to soften fecal accumulations.  The course of treatment removes lesion and builds up the circulation, which cures the ulcer.  The diarrhea, tenesmus, and colicky pains are treated as before directed.
 



 
SIMPLE ULCERATIVE COLITIS

    This condition is usually the result of chronic intestinal catarrh, and is due to such lesions and conditions as produce it.  The ulceration may involve considerable areas of the mucous lining of the bowel, showing an extensive disturbance of the intestinal circulation.  The treatment must be thorough and continued long enough to overcome the marked tendency  of the condition to become chronic.  The diarrhea, in the stools of which pus and blood are constant, must be treated as before.      Constipation may alternate with it.  Constitutional treatment must be given, as the disease is a drain upon the system, and the patient may become weak and emaciated.  One must exercise much care with these cases, especially in the aged.  The diet should be fluid or semisolid.
 



 
NEUROSES OF THE INTESTINE

    The various lesions producing derangement of the intestinal innervation, sensory, circulatory, motor, secretary and trophic, have been described.  Their anatomical relations to intestinal diseases have been fully discussed.  Various of these lesions may occur and produce intestinal derangements by special interference with certain functional activities of the intestines, through acting as lesions to the particular portion of the innervation having those functions in charge.  Thus the lesion may so act upon the sensory innervation as to cause sensory disease.  Or the predominating disorder may affect particularly the secretory or the motor functions.  Sensory, secretory, and motor neuroses of the intestine are common.  The lesion producing them are not different in nature from the ordinary lesions found as the causes of gastrointestinal disorders.  For some reason, not well understood, certain of these lesions may produce, in a given case, certain special kinds of disturbance of function.  In the diseases described below no special lesion has been yet described as the special cause of each condition.  One finds lesions already described producing them.  As a rule, however, these special sensory, secretory, or motor neuroses are noted in cases of bad intestinal health, and frequently seem to be specialized pathological manifestations of this general bad condition.  The sensory, secretary, or motor disturbance has gained the upper hand.  In some cases the neuroses is itself the sole manifestation of the results of the lesion.
 



 
SECRETORY NEUROSES

    Membranous Enteritis, Mucous Enteritis, or Mucous Colitis, is often met, frequently occurring in subjects of intestinal disease.  The special lesions present and disturbing bowel innervation act particularly upon the secretory fibers.  The result is over action in the mucous secreting glands.  The mucous membrane is not pathologically altered, and catarrh if present at all, is a secondary effect.  It is a purely nervous manifestation.  Special lesion is commonly found to be the active cause of irritation to the centers or fibers controlling this function.  Its results are apparent in the copious secretion of the intestinal mucous, which passes away from the patient in conglomerate masses forming the whole or a separate part of the stool, in long ribbon-like strips, or in a complete cast of the intestinal canal of some inches in length.
    It is not a serious condition, and removal of lesion, with thorough spinal and abdominal treatment, will at once begin to correct the over action of the glands.  Its cure may depend upon the restoration of a general healthy bowel condition.  Relief is generally, obtained at once from the treatment, but considerable treatment may be necessary to eradicate the chronic condition.  Tenesmus, when present, is relieved by strong sacral stimulation.  Colic is relieved by strong spinal inhibition and by the local inhibitive treatment at the seat of the pain in the abdomen.
 



 
SENSORY NEUROSES

    These disturbances are due to irritation to the sensory nerves supplied by the splanchnics to the intestines.
    Enteralia, Colic, or Intestinal Neuralgia, is met with in neurotic and anemic subjects, and attacks are induced by exposure, gout and local irritation to the sensory nerves of the intestine by inflammation, enteroliths, etc.  Excepting mechanical irritants, lead poisoning and like agencies, the actual cause that weakens the intestines and lays them liable to the action of such exciting causes, is spinal lesion irritating or weakening the sensory centers or fibers.  Many cases occur spontaneously from spinal lesion.  This spinal lesion may act by causing increased activity in the muscularis, leading to the ring-like contractions of the intestine present in colic.  In many of these cases intestinal cramps cause localized contractions in portions of the intestines, which may be readily seen or felt through the intestinal walls.  Here the most efficient treatment is by local manipulation over the seat of the contraction.  Deep inhibitive treatment here quiets the nerves and releases the spasm.  Such local work must be supplemented by corrective work upon the spine, which prevents further attacks.  Strong spinal inhibition may be used to quiet the pain.  Some point is generally found along the splanchnic area at which inhibition is effective.  This is often high up in the splanchnic region, but, varies with the case, and is found by trial.  Special lesion is to be removed, and stoppage of the pain may depend upon that.
    Diminished Sensibility of the intestines is a common neurosis.  It may be both sensory and motor, and leads to diminished peristalsis, constipation, and accumulation of the feces in a portion of the intestine, often in the rectum.  It is likely to occur in diseases of the brain and cord in which the centers are effected.  Special spinal lesion is often the direct cause, or causes the cord disease.  Cure of this condition in such cases depends upon cure of the primary disease.  In other cases, removal of lesion and restoration of activity to the local nerve mechanism overcomes the paresis.  Spinal and abdominal treatment, directed especially to the course of the intestine, to affect Auerbach's plexus, and to the solar plexus, will aid a cure.  Specific lesions may cause a paretic condition of a bowel segment and be responsible for the trouble.  A general weak condition of the nervous system, on account of which nervous shocks and other disturbances cause this condition, must be remedied by upbuilding it.
 



 
MOTOR NEUROSES

    Nervous Diarrhea is a condition in which increased contractability of the muscularis of the bowel is aroused by purely nervous causes.  It is an over-action of the bowel, not presenting the usual aspects of diarrhea.  The stools are softer than normal, and frequent, occurring two, three, four, or five times in twenty-four hours.  The subject is as a rule neurotic, being hysterical, neurasthenic, or of a very nervous temperament, but the characteristic lesions found in diarrhea, q. v., are present and so act upon the nervous mechanism of the bowel as to lessen its motor stability.  Thus its abnormal activity, made possible by the lesions, becomes the special manifestation of the nervous condition.  There must be some sufficient reason why the general nervous condition should be able to so center itself upon the bowel.  The presence of such lesions as anatomically weaken the bowel affords a reasonable explanation of this phenomenon.  These lesions usually of the lower dorsal and lumbar regions, probably affect, through its connections with the 11th and 12th dorsal and the 1st and 2nd lumbar nerves, the inferior mesenteric ganglion ruling motor activity in the fecal reservoir.
    A case of nervous diarrhea showed lesions of the 11th and 12th ribs, and of the lumbar spine.  It readily yielded to the usual treatment for diarrhea, coupled with tonic treatment to the general system.
    The treatment commonly employed for diarrhea is efficient in checking this form.  At the same time, thorough general spinal and neck treatment must be given to strengthen the nervous system.  Spinal causes of the nervous condition must be sought and overcome.  The case yields rapidly to treatment, but is very prone to setbacks due to nervous disturbance.  For this reason the patient must be kept as free from exciting influences as possible.  The condition is apt to recur until the nervousness has been lessened.  Fortunately this latter condition yields to treatment.
    Enterospasm is a neurosis of the intestine in which a spasmodic condition of portions of the intestinal walls recurs.  It may result in temporary obstruction, but its most usual manifestation is to cause the stools to be passed in separate, rounded masses, or in ribbon shape.  The latter is most frequent.  While often a nervous phenomenon, special lesion is necessary to account for this peculiar manifestation of nervousness.  Special lesion may affect the inferior mesenteric ganglion through its spinal connections, or the motor fibers of the circular muscles of the rectum, originating from the lower dorsal and upper one or two lumbar nerves, and passing thence through the inferior mesenteric ganglion to the rectum.
 



 
CHOLERA MORBUS; CHOLERA INFANTUM

    DEFINITION: Cholera morbus is an acute catarrhal inflammation of the stomach and intestines, characterized by severe abdominal pain, colic, vomiting, purging and muscular cramps.  This condition, when present in children under two years of age, is called cholera infantum.
    CASES: (1) A young man in intense pain; had vomited blood several times, and continuous severe vomiting and purging were present, had a chill; severe griping in the epigastric and umbilical regions.  Inhibition at the 4th and 5th dorsal vertebrae on the right stopped the vomiting.  Inhibition of the splanchnics stopped the purging.  Cracked ice was allowed the patient, and a hot enema was administered.  After the first treatment no vomiting or purging occurred, and rapid recovery followed.  In his previous attacks he had usually remained in bed for three days, being incapacitated for a week.  Morphine was usually necessary to stop the pain.
    LESIONS: Such lesions as described for enteritis, q. v., are present in these cases, weakening the bowel and rendering it susceptible to the agencies visually described as the exciting causes.  The irritation of bad food, etc., may affect a healthy bowel in this manner, but there is often no such factor in the case.  Simple chilling of the body may cause the attack, or slight indiscretion in diet may bring it on.
    The PROGNOSIS is good.  Treatment relieves the case at once, stopping the pain, vomiting, cramps, etc.  The patient rapidly recovers.
    TREATMENT: Correction of lesion protects the patient against further attacks.  The severe abdominal pain and colic are removed by strong inhibition of the spine, especially over the splanchnic area, and from the 9th to the 12th dorsal.  This quiets the sensory nerves of the viscera.  Deep inhibitive treatment upon the abdomen, over the seat of the pain and about it, aids in relieving it.  The vomiting is checked as before described, as is the diarrhea.  The cramps in the calves are relieved by strong inhibition over the sacrum and upon the popliteal nerve in the popliteal space.  The system should be strengthened against collapse by stimulation of heart and lungs and by spinal and neck treatment for the general system.
    The patient should rest, in bed, and no food should be allowed at first, but a little ice is to be used to relieve thirst.  Later a rigorously restricted diet is enforced.  Hot injections are a valuable measure, aiding in the removal of the irritant material from the bowel.  A mustard plaster over the abdomen relieves pain.
 



 
HEMORRHOIDS

    DEFINITION: Varicose enlargements of the inferior hemorrhoidal veins or of the hemorrhoidal plexus.
    (1) Hemorrhoids and constipation.  Lesion at 5th lumbar, coccyx badly bent. (2) 7th to 11th dorsal vertebrae posterior, coccyx anterior, innominate forward.  Hemorrhoids were accompanied by indigestion and jaundice. (3) Protruding piles of several years standing, constipation, prolapsed rectal walls.  Lesion caused by strain from heavy, lifting; a weakened lumbar region.  Cured in one month.
    (4) Constipation and piles of many years standing caused by a bent coccyx.  Four treatments gave great relief; case still under treatment.
    LESIONS AND CAUSES: The common bony lesion present is a bent or dislocated coccyx, which acts as a local irritant and mechanical impediment of the venous return from hemorrhoidal veins.  Luxated coccyx, by local irritation and interference with the fourth sacral nerve, may cause obstinate, contracture of the external sphincter, leading to constipation or straining at stool.  Possibly coccygeal and innominate or sacral lesion, by direct interference or by dragging of tissues, derange the sacral nerves supplying motor fibers to the longitudinal muscle fibers of the rectal walls, weakening them.  This result would probably be aided by the interference of these same lesions with the sympathetic (sacral) nerve supply to the circulation through branches contributed to the lower hypogastric and hemorrhoidal plexuses.  That of the coccyx seems to the most important lesion in hemorrhoids.
    Lumbar and lower dorsal lesion may be present and interfering with the innervation of the abdominal walls, relaxing them, lessening intra-abdominal pressure, and allowing of congestion of the abdominal circulation.  By direct effect or by causing constipation, this condition may cause hemorrhoids.  Lower dorsal and upper lumbar lesion to the nerve fibers which pass by way of the inferior mesenteric ganglion, to supply motor fibers to the circular muscles of the rectal wills may become a factor by weakening the wall, relaxing its tone, allowing of a congestion in its vessels.  Lesion to the splanchnic and lumbar areas, affecting the sympathetic supply which, through the splanchnics, solar plexus, and other sympathetic vaso- and viscero-motors originating along these same areas, rules circulation and muscular tonus in the abdominal and pelvic viscera, may contribute in an important way to causation of hemorrhoids.  Likewise those lesions to the spine and lower ribs, well known as causes of liver derangement, become causes of hemorrhoids by producing  obstructed portal circulation and constipation.  The chief drainage by the hemorrhoidal plexus of veins is through the portal circulation by way of the superior hemorrhoidal vein.  Lesions causing disease of the heart and lungs, q. v., may secondarily become causes of hemorrhoids through the systemic circulation.  Lesions causing atonic diaphragm and other causes of enteroptosis, q.v., produce hemorrhoids by the mechanical obstruction of circulation, and by deranged nerve supply, etc.
    The ANATOMICAL RELATIONS are pointed out above.  The American TextBook of Surgery calls attention to the fact that these veins are unsupplied with valves and also that they tend to become congested by the natural upright position of the body.  These facts aid in explaining the potency of the above lesions, and of any obstructive condition (pregnancy, overeating, etc.) in causing this condition.
    The EXAMINATION must be made by both inspection and palpation, the use of a proper speculum aiding a thorough inspection of the rectum.
    The PROGNOSIS is very favorable.  The usual medical treatment is palliative, or surgery is resorted to.  The latter may often become necessary, but the success of osteopathic treatment prevents many operations.
    Even the most severe cases have been successfully treated.  The treatment generally begins to succeed immediately.  Long standing cases are often cured in a few months.  Some cases are slow and obstinate.
    The TREATMENT is local, abdominal, spinal and constitutional.
    Local treatment is first directed to correcting the coccyx if necessary. (XX, Chap. II.) The external sphincter should be well dilated.  This may be accomplished by inserting two, or even three, fingers, well vaselined, and held together at the tips in wedge-shape.  After being well inserted, they are spread apart and withdrawn carefully.  The dilatation must be thorough.  The rectal speculum may be used for this purpose.  All the surrounding tissues, both externally and internally, are to be thoroughly but gently  relaxed.  Internally this operation should be carried as far up along the rectal walls as the index finger is able to work.  Pressure is made upon the injected veins to empty them of blood and to stimulate their local nerve and muscle substance to proper tonus.  In case of thrombi in strangulated veins, the manipulation about and upon them must be gently applied with the purpose of stimulating the circulation to a gradual absorption of them.  They must not be broken up or detached, as there is danger of their being swept into the circulation as emboli.
    After dilatation of the sphincter and relaxation of the tissues, protruding piles, first emptied if possible, must be gently pressed back beyond the sphincter.  If the rectal walls are prolapsed, as is often the case in protruding piles, they must be replaced by the index finger directed to straightening out and pushing them up on all sides.
    This local work removes irritation of the coccyx, frees the whole local circulation, tones the local musculature and other tissues, and stimulates the local sympathetics.  It may be the sole and sufficient treatment in many bad cases.  It should be given but once per week or ten days.
    Abdominal treatment is for the purpose of increasing freedom of circulation and to aid in the venous return.  The solar and hypogastric plexuses are stimulated and manipulation is made over the course of the inferior mesenteric and common and internal iliac arteries. Portal circulation is helped by deep abdominal work from the lower abdominal region upward to the liver.  Lesions to the latter organ are removed, and thorough treatment given to the liver, as in the treatment for constipation, q. v., which must be relieved, it being usually present. (V. Chap. VIII.)
    The viscera are raised, and treatment is made deep in the iliac fossae to stimulate the pelvic sympathetic plexuses and to aid venous return from the hemorrhoidal, vescical, uterine, and other related plexuses of veins.  (II, III, IV, Chap. VIII).  If the patient is placed in the knee-chest position while abdominal treatment is performed with the ideas explained above, the force of gravitation is made to assist in venous drainage of the parts. This is an important treatment, and should not omitted in these cases.
    Enteroptosis and diaphragmatic lesion are repaired as before explained.
    Thorough spinal treatment is given from the sixth dorsal down, stimulating splanchnics and other sympathetics, with all their contained vaso- and viscero-motor, circulatory, and trophic fibers.  This treatment is to strengthen circulation and to maintain its freedom.  It is supplementary to the abdominal work.  It also aids in restoring tone to the vessel walls, as well as to prolapsed rectal walls, and thus to maintain them in correct condition.  Anatomical relations between the spinal work and the effect gotten at the seat of the disease have been explained.
    Correction of spinal, rib, or innominate lesion is made if necessary.  In this way, and by work along the lower dorsal and upper lumbar regions, coupled, with the local treatment upon the abdominal walls, the latter are built up and restored to normal tonus if relaxed.
    The constitutional treatment consists in the general spinal treatment, and in special treatment for heart and lung diseases if present and causing the hemorrhoids.
    Light outdoor exercise and absolute personal cleanliness should be enjoined upon the patient.
 



INTESTINAL TUMORS

    Intestinal Tumors of various kinds, both benign and malignant have been frequently treated osteopathically with success.  Medical treatment is but palliative, and the only means of removal has been by surgical operation.  The fact that in numerous instances these tumors have been entirely removed by osteopathic treatment is in itself remarkable, and helps to sustain the claim often made, that the use of the knife is often obviated in the treatment of such conditions.
    THE TREATMENT is simple, and consists in the removal of spinal lesion, which may be of any of the kinds described as producing gastrointestinal disease.  At bottom the real cause of these growths is some obstruction or irritation to local blood and nerve supply.  It has already been shown how special lesion causes this obstruction, or lays the foundation of the condition which directly or indirectly produces the irritation.  The treatment is therefore the removal of lesion and the restoration of normal nerve and blood supply.  Spinal treatment, aided by abdominal work, accomplishes this object.  The latter is done, not upon the tumor itself, but upon the surrounding parts.  It relaxes tensed tissues, opens arterial blood supply and venous and lymphatic drainage, and restores normal condition.  In this way the progress of the morbid process is stopped, healthy tissue is built, and the tumor disappears, by absorption.  At least one case is upon record in which the tumor, a fibroid, was loosened by the treatment and passed per rectum.  (Cosmopolitan Osteopath, Feb.., 1900, p. 30.)   The diet should be light, and of a sort easily digested.  Rectal feeding has sometimes to be resorted to in cases where the turner causes obstruction.
    Attendant conditions, such as constipation, fecal impaction, colic, etc., are treated as described elsewhere.  See also section upon "Tumors."
 



 
APPENDICITIS

    DEFINITION: An inflammation of the vermiforni appendix, acute or chronic, caused by traumatism, or by specific rib or spinal lesions.  These lesions obstruct bowel action, limit its motion, deplete its nerve and blood supply, leaving a weakened condition, allowing of aggregation of fecal matter, foreign bodies, etc.  The vigor to pass these onward is lacking, and they are pressed into the appendix, which itself is suffering from a weakened state due to these causes.  Or direct irritation of lesion may affect nerve and blood mechanism, derange vaso-motion, and set up the inflammation.      Or the direct mechanical irritation of displaced lower rib may set up the inflammation.
    CASES: (1) Lesions; 2nd lumbar lateral, with heat and pain about it; 11th right rib luxated.  Treatment relieved at once, and the patient was cured in two weeks. Surgeon had been ready to operate. (2) 12th right rib down and inside of the crest of the ilium.  Setting the rib cured the case in a few days. (3) Recurring appendicitis; spine posterior in lower dorsal and upper lumbar; lateral curve at 6th to 9th dorsal; constipation chronic; cured by ten weeks treatment. (4) Tenderness upon right side of spine from 6th dorsal to 2nd lumbar, especially at the 6th to 10th dorsal and 1st and 2nd lumbar. (5) Lesion at lower dorsal and upper lumbar; 10th and 11th ribs overlapping 12th, due to a fall.  Operation had been advised, but two months treatment cured the case. (6) Appendicitis in a boy of twelve, for which operation bad been advised  Examination showed downward displacement of 11th and 12th ribs, a posterior condition of the 5th lumbar vertebra.  Incontinence of urine was also a feature of the case.  The case was cured by correction of the lesions. (7) A severe acute case, in which operation was about to be performed.  The patient was in great agony when the treatment was begun.  Treatment gave immediate relief, and the case was cured.  Lesion was found at the 5th lumbar.  (8) A chronic appendicitis of five months standing, in a young man of twenty-five.  Lesion was present as a lateral displacement of the 9th to 12th dorsal vertebrae to the left.  This same spinal area was anterior.  The bladder would not empty.  By twenty-two treatments the case was cured, within three months.  Pain at McBurney's point was relieved at the second treatment and did not recur.
    LESIONS AND CAUSES: (1) There is usually a history of constipation in these cases.  In some it follows diarrhea.  There can be no doubt that the lesions causing these diseases, q. v., are the real causes of appendicitis in many cases.  Many apparently robust men suffer from this disease, but experience shows that many such have unhealthy bowels to begin with.  Many show the specific spinal lesion.  The cases caused by a foreign body, seeds, shot, enteroliths, etc., would probably not become victims of appendicitis but for weakened bowel condition due to such lesions as cause constipation.  The fact that very often the body is a fecal concretion supports this view.  The inflammation is a vaso-motor disturbance.  Such disturbances, due to lesion, have been seen to be the causes of constipation, etc.  The appendix must suffer with the rest of the bowel from these causes, and thus being weakened cannot further resist special causes of vaso-motor disturbance.
    (2) Displacement, or dragging of the colon at the hepatic flexure prevents the passage of fecal matter and forces the introduction of fecal masses into the appendix.  It also obstructs circulation, causing congestion and favoring inflammation.
    (3) The most important bony lesions seem to be displacements of the lower two ribs on the right side.  They may add mechanical obstruction or irritation to deranged nerve connections at the spine.
    (4) Lesions of the dorsal and lumbar regions are very important on account of the nerve connections with the bowel.  From the 9th, 10th, 11th and 12th dorsal region sensory nerves pass through the sympathetics; to supply the intestines down to the upper part of the rectum.  For this reason strong inhibition to this portion of the spine is useful in controlling the pain in appendicitis.  The sympathetic vaso-constrictor fibers for the abdominal vessels pass from the lower dorsal and upper two lumbar nerves, while branches from the lumbar ganglia pass to the plexus upon the aorta and to the hypogastric plexus.  Thus lower dorsal and lumbar lesion has an important effect in disturbing the vaso-constrictor innervation, necessary to the production of this inflammation.
    (5) Direct traumatism to the region of the appendix, the presence of foreign bodies in the bowel, or extended inflammation from contiguous structures, may all be causative factors.
    The anatomical relations given for lesion in diarrhea apply to those in appendicitis.
    The appendix has the same structure as the caecum, practically; is nourished by a branch of the ileo-colic artery, possesses innervation (Auerbach and Meissner's plexus?), causing in it peristalsis and secretion of abundant tough mucous from its numerous mucous glands.  In health the free secretion of this mucous fills the cavity of the structure to the exclusion of foreign bodies, but upon lesion to the blood or nerve supply such as mentioned above, lessened secretion allows of room for the entrance of foreign bodies.  Byron Robinson says that active occupations in men, contracting the abdominal walls, favor thus the forcing of matter into the appendix, causing appendicitis. But it is very likely that some lesion, of the kinds above described, first weakens the tissues of the appendix and lessens its normal condition and secretions, laying it liable to such accident.
    Anemia may become a cause of the inflammation in it.
    The PROGNOSIS is favorable for recovery in nearly all cases.  The experience with cases, even the most dangerous acute ones, has been very satisfactorily. Many such are upon record, restored to health after operation had been advised as the last resort.  If seen in time, very few cases need ever come to the knife.  The point of surgical interference is, however, often reached.  Osteopathic treatment prevents the case falling into the chronic form so commonly met, and in which operation, to prevent an attack, is so often resorted to.  The acute case is usually aborted by prompt treatment.
    TREATMENT: The first consideration is the removal of the lesion if possible in the patient's condition.  This applies particularly to displacements of the 11th and 12th ribs.  Here gentle manipulation and slight elevation may be sufficient to remove the irritation.  Immediate attention should also be given to the relief of the constipation commonly present.  If not soon affected by the treatment, rectal injection should be employed.  This measure materially aids conditions by removing the pressure of bowel contents from tender points, by giving freedom of circulation in the bowel, and by aiding to remove foreign bodies.
    An essential part of the treatment is local treatment of the tissues at or above the site of the inflammation.  By care, little difficulty will be experienced in applying such treatment even in very painful cases.  The relaxation of the tissues thus accomplished gives immediate relief to the patient.  Not only the abdominal walls, but the deep tissues and circulation about the appendix are thus treated.  The treatment must be slow, deep, inhibitive and given with great care.  In the intervals of treatment, it may be necessary to apply the ice-bag or hot fomentations at the seat of the inflammation.
    It is not likely that in this contingency spinal work to increase peristalsis would be at all successful in removing the foreign body from the appendix.  Local manipulation must be depended upon for this.  The pain is relieved by spinal inhibition from the 9th to the 12th dorsal particularly.  Nausea, vomiting, fever, and hiccough, aside from being relieved by the general treatment of the case, may be relieved by the usual methods before described.
    The patient should go to bed at once upon the attack threatening.  A restricted fluid diet, taken a little at a time, should be enforced.  Attention should be given the kidneys and general condition.  The patient should be seen several times daily until out of danger. Continued treatment should be given for a while after recovery to prevent recurrence or relapse.
    The chronic case, possessing various degrees of chronic pain, tenderness of tissues, and inflammation in the right iliac fossa, is a familiar object.  The purpose of the work is to remove lesion, to restore perfect freedom of circulation, and by local treatment of the tissues to remove tenseness and pain.  Thorough spinal and abdominal treatment, and attention to the general condition of the bowel are necessary.  The disappearance of tenderness in the right iliac fossa does not remove the danger of acute attack, as extensive morphological changes have usually taken place in the tissues of the appendix, which call for a course of treatment to so restore circulation as to enable it to repair them.
    RECURRENT APPENDICITIS frequently comes under treatment, and presents the same lesions as have been above described.  No special mention need be made regarding its treatment, in addition to what has been in regard to the treatment of chronic and acute cases.
 



 
INTESTINAL OBSTRUCTION

    DEFINITION: The occlusion of the bowel may be but partial, persisting as a chronic condition.  In acute cases it may be wholly or partially obstructed.  It may be due to strangulation; to twists and knots, called volvulus; to strictures and tumors; or to intussuseption.
    CASES: (1) Fecal impaction.  Severe radiating abdominal pains, griping, and some dysentery had been present for twenty-four hours.  The impaction was located at the hepatic flexure.  Treatment relieved the pain at once, and the manipulation removed the obstruction.  Complete recovery followed.
    (2) Volvulus was diagnosed, located near the ileo-caecal valve.  The surgeon was ready to operate.  Persistent treatment straightened the bowel and a movement of the bowels was had.  The recovery was complete.
    (3) Impaction of the ileo-caecal valve.  The attack came on violently at night.  The family physician, after eighteen hours work over the patient, advised operation.  Osteopathic treatment reduced pain and inflammation at once, and allowed a further examination.  The impaction was located at the ileo-caecal valve, and manipulation removed it within a short time.  The patient was asleep in thirty minutes.
    (4) Intestinal obstruction from fecal impaction, in a boy.  Three physicians had given the patient up.  The abdomen was much swollen and intensely painful, and the seat of the obstruction could not be located.  Tension was found in the tissues of the spine at the 10th dorsal.  Inhibitive treatment was made here, while the pneumogastric were stimulated.  This treatment was kept up throughout the night.  An enema was given.  Early in the morning the bowels were gotten to move successfully, and in a few weeks the boy was quite well.
    (5) Intestinal obstruction in a child of 7 months of age.  Physicians gave up the case, and were ready to resort to surgery as the last hope.  By one treatment the babyís bowels were moved, and the case was entirely cured.
    (6) In a case of fecal impaction in the splenic flexure of the colon, ten minutes treatment relieved the intense pain and opened the bowels.  The patient had been about to undergo operation for appendicitis, as the condition had been wrongly diagnosed.
    LESION AND CAUSES: Only in rare cases would it be likely that some specific lesion would lead directly to this trouble, but in most of them it is probable that lesions would be present accounting for the bad condition of the bowel that resulted in some form of obstruction.  In general one would expect such lesions as have already been described as interfering with the abdominal organs.  Intussusception is sometimes due to irregular, limited, sudden, or severe peristalsis.  In such cases special lesion to the splanchnics, or to the sympathetic connections of Auerbach's plexus might result directly in the abnormal peristalsis producing the invagination.  In such cases the outer layer, or receiving portion of the bowel involved, draws up by contraction of its longitudinal fibers.  Such abnormal activity of these fibers might also be due to some special lesion to motor innervation.
In some cases McConnell suggests that special spinal lesion could cause paresis or paralysis of a bowel segment.  Such a condition could allow of a pouching of the affected portion, and of accumulation of feces or foreign bodies.  Specific lesion might also cause stricture by contraction of a segment.
    The fact that obstructions often follow constipation. or diarrhea shows the importance of lesions producing a bad bowel condition. Volvulus is especially frequent at the sigmoid and at the caecum, enteroptosis being the cause, through allowing the parts to prolapse and turn.   Volvulus may be caused by a long or relaxed mesentery.  The frequency of spinal lesions causing the weakened omental supports that allow of the ptosis shows the importance of spinal lesion as a factor in causing obstructions.  Spinal or rib lesion may be looked to as the original cause of a large number of the various forms of obstruction.  It may produce the tumor whose pressure obstructs the bowel; the peritonitis, following which adhesions cause strangulation; the ulceration in the bowel which gives place to cicatrization and stricture; or the inactive condition of bowel motion and secretion that allows of accumulation of fecal matters, foreign bodies, etc.  A healthy bowel, perfectly free from the effect of lesion of any kind, could only under rare conditions become the seat of one of the various forms of obstruction.
    The importance of lesion producing unhealthy abdominal or internal conditions must be acknowledged in the etiology of these cases.
    The ANATOMICAL RELATION of these various lesions have already been pointed out in the consideration of various intestinal diseases.
    The PROGNOSIS must be guarded.  Very many cases die, and surgical measures have generally considered necessary after the third day of obstruction.  Yet osteopathic treatment, has been successful in a number of cases after the necessity for operation had been urged.  Probably, as in the case of appendicitis, many lives could be saved by osteopathic means before surgery is resorted to.
In chronic cases the prognosis for recovery is very favorable.  Most cases could be prevented from coming to the point of absolute obstruction.  If they could be foreseen, most acute cases could no doubt be prevented by osteopathic treatment.
    TREATMENT: In such cases as depend upon a special lesion, it should be removed.  Generally the first consideration is the alleviation of the patient's condition.  Strong inhibition of the splanchnic area, especially from the 9th to 12th dorsal, and of the lumbar region, aids in lessening the pain.  This step might be necessary before abdominal manipulation can be borne.  The solar plexus should now be inhibited.  A slow, deep, but gentle inhibitive treatment should next be given over the bowel to relax the tissues, decrease the inflammation, and lessen the pain.  This treatment may be used to quiet abnormal peristalsis if present.  After this preliminary treatment the practitioner may proceed by careful palpation to locate the seat of obstruction if possible.  This is often impossible, and in such cases one must work over the bowel generally.  In some cases the obstruction is felt, or the seat of the pain is an indication of its position.
    The main work must be done by abdominal manipulation.  The parts of the intestine must be so managed as to be raised, straightened, and drawn away from each other.  The caecum and sigmoid may be raised and straightened, (Chap. VIII, divs. II, III, IV).  Deep treatment may be made in the right and left hypochondriac regions to free the hepatic and splenic flexures. In intussusception the parts should be raised and drawn from each other toward the extremities of the cylindrical tumor, if it can be made out.  In volvulus, raising and straightening the involved portions is relied upon.
    The stricture and adhesions may be manipulated with the purpose of softening, relaxing, and breaking them down.  Foreign bodies and fecal aggregations must be gradually loosened and worked along the bowel.  They are more readily handled than other forms.  It may be necessary to manipulate them after rectal injection, to aid in moving them.  Copious injections sometimes aid in overcoming intussusception, volvulus, etc.  Injections of Sedlitz powder solutions, injected separately, have been successfully used.  During the abdominal treatment it is well for the patient to be placed in various positions; upon the back, sides, upon the abdomen, in the knee-chest position, etc., to get the aid of gravity in righting the parts.  Some writers recommend thorough shaking of the patient.  He is held by four men by the arms and legs, first with the abdomen upward, then downward, while the shaking is done.
    There should be much persistence in the treatment.  The practitioner should remain continuously with the case, and treat it as much as practicable, until relieved.  In the intervals, hot applications over the seat of the pain may made.
    In chronic cases the treatment may be carried on as usual, upon the plan given above for the treatment of acute cases.  After removal of obstruction, a thorough course of general treatment should be undertaken for the removal of lesions that have originally impaired the bowel or have produced abnormal abdominal conditions.
 



ENTEROPTOSIS

    Enteroptosia is a disease in which various of the abdominal and pelvic viscera leave their natural positions, slipping downward into the abdominal and pelvic cavities.  It is a common and distressing complaint, frequently overlooked or not recognized.  It is sometimes regarded as a symptom group, but may, from the osteopathic point of view, be regarded as an idiopathic condition, due to specific lesion.
    These cases are often treated for some one feature, as for nervous dyspepsia, constipation, operation for floating kidney, etc.  It is a common error to overlook the essential condition of the disease.  The Osteopath who gives close attention to a class of neurasthenic, flat-chested, constipated patients, who complain of lack of bodily and mental vigor, many and various indefinite nervous symptoms, abdominal pulsation, vaso-motor disturbance, etc., will find most interesting material.  The multitude of symptoms may vary greatly in different cases, but the presence of neurasthenic conditions, altered thorax and spine, and unnatural abdominal condition, either of walls, viscera, or both, will usually afford an unmistakable sign of the disease.  After a little experience with such cases one learns to recognize them at a glance when presented for examination.  Once seen these cases can hardly be mistaken, and a few moments examination reveals a story of disease beginning imperceptibly, the growing conviction through many months or some years that something was wrong, the attempt to seem well because no decided disease seemed present, or a long course of treatment for various ills, none of which reached the true condition.  This most common disease it still but seldom clearly recognized or intelligently handled.
    LESIONS AND CAUSES: The common description of its etiology is unsatisfactory.  Tight lacing, traumatism muscular strain, and repeated pregnancies are mentioned.  The condition of relaxed abdominal walls and prominent viscera due to repeated pregnancies may probably be rightly regarded as a separate condition.  It is due to a physiological act, and does not present those specific lesions nor the resulting symptoms found in neurasthenic enteroptosis.  Tight lacing, traumatism, and muscular strain may produce those lesions found to be the cause of such conditions.
    These cases commonly present spinal, rib, diaphragmatic and abdominal lesions.  Spinal lesions may be of any of the kinds found in the spine ordinarily, and may occur anywhere along the splanchnic or lumbar region.  Rib lesions may occur in any or all of the lower six ribs on either side.
Mobility of the tenth rib is regarded by a German physician, Dr.  B. Stiller, (Phil.  Med.  Journal, Jan. 13, 1900,) as a pathognomonic cause of enteroptosis (Boston Osteopath, Jan. 14, 1900).  Undoubtedly it could interfere with the sympathetic connections of the abdominal viscera and become a factor in causing this condition.  But, from an osteopathic viewpoint, lesions of other ribs, and of spinal vertebrae, etc., may be as potent in producing the "basal neuropathy" concerned in this disease as its fundamental pathological condition.  Further, rib lesions may cause a condition of the diaphragm in which its normal tone is lost, and prolapse in it causes ptosis in the abdominal organs which it aids in supporting.  Spinal lesions may participate in causing the atonic condition of the diaphragm.
    Spinal and rib lesions, aside from derangement of the diaphragm, act to produce enteroptosis by interfering with the spinal sympathetic connections of the viscera and of their omental supports.  Impeded circulation and nerves supply, vaso-motor, motor, secretary, trophic and sensory produces at the same time derangement of function in the organs and weakness in their mesenteric supports.  These conditions work together to bring about the disordered function and the displacement of these organs.  The displacement of itself furthers the present bad conditions by mechanically interfering with the activities of organs, stretching nerve fibers and blood vessels which are carried in the now elongated omenta, kinking the colon at various points, etc.  The viscera, having sunk down into the abdominal cavity, cause prominence of the lower abdomen, leaving a hollow in the upper abdomen, thus giving to it the peculiar boat-shaped appearance described as "scaphoid abdomen."
    Lower dorsal and lumbar lesion may interfere with the spinal innervation of the abdominal walls, cause them to lose their tone and to dilate.  Intra-abdominal pressure is thus lessened and the organs are allowed to prolapse.
    According to Byron Robinson, enteroptosis begins with a weakening of the abdominal sympathetic, which loses its normal power over circulation, secretion, assimilation and rhythm.  That this weakness of the abdominal sympathetic and its consequent loss of function originates in spinal lesion to its origin in the splanchnic nerves has already been pointed out and fully discussed in considering the diseases of the stomach and intestines, q. v. The anatomical relation of such lesions to parts affected was pointed out.
    The PROGNOSIS in these cases is very favorable, but the progress of the cure is likely to be slow.  Generally improvement begins immediately upon treatment and may progress to a cure in a few months.  Other cases yield more slowly, though relief is soon given, and require an extended course of treatment to effect a cure.
    The TREATMENT must be both constitutional and local.  The latter consists in the removal of lesion and in abdominal treatment.  Lesions anywhere to the splanchnic and lumbar regions, to the ribs, thorax and diaphragm, must be treated after their kind, according to directions given in Part I. With spine, ribs, and diaphragm restored to normal condition, the underlying causes of the enteroptosis have been removed.  Corrected nerve and blood supply to the organs and their supports aids in correcting their function and strengthens the supporting tissues to hold them in place when restored by abdominal manipulations.
    Correction of spinal lesion also aids in restoring nutrition and tone to the relaxed and atrophied abdominal walls.  This process is furthered by a thorough treatment upon the abdominal walls.  This renders the use of the favorite abdominal bandage unnecessary, and it is gradually laid aside.  Throughout the course of the case the restored abdominal walls act as the bandage has done to hold the organs to their places as replaced by the treatment.  With corrected spine, free blood and nerve supply to all the visceral supports, and a strengthened abdominal wall, no difficulty is found in getting the parts to gradually be retained in their normal positions.  Thorough spinal stimulation over the splanchnic and lumbar; areas is kept up for the purpose of increasing the blood and nerve supply to the parts in question.
    Abdominal work, aside from treatment of the walls, is directed to raising and replacing the viscera.  This is readily accomplished by various treatments. (II, III, IV, Chap.  VIII.) This releases and renews circulation and nerve supply at the same time, removes pressure of organs upon each other, gives freedom of motion, and aids in strengthening the omenta to hold the parts in place.  The diaphragm has been restored to normal position, and tone by correction of those lesions originally deranging it.
    The constitutional treatment must be thorough and general to restore the patient from the nervous, circulatory, nutritional, and other effects of the disease.  A most thorough general spinal treatment must be given.  Thorough stimulation of heart and lungs, treatment of the cervical sympathetic, and attention to kidneys, liver and skin accomplishes the desired object.  The auto-intoxication usually present is overcome by this treatment of the excretory organs.  The constipation, dyspepsia, and other functional disorders are corrected by the restoration of the organs concerned.
    The patient should be much out of doors, free from worry, and careful not to become fatigued.  Deep breathing exercises are beneficial.
 


PERITONITIS

    DEFINITION: An acute or chronic inflammation of the peritoneum, localized or general.
    CASES: (1) A case diagnosed as septic peritonitis, probably caused by appendicitis, under the care of celebrated Chicago physicians grew steadily worse until death was expected in a few hours.  No hopes of recovery were entertained, and it was evident that the best medical treatment was of no avail.  As a last resort an Osteopath was finally called, all medical treatment was discontinued, and the treatment began.  Immediately, under the treatment, the great pain that had been present for hours at a time, was controlled, and during the next four weeks not two hours pain in all was experienced.  The other symptoms were also discovered upon examination, and led to inquiry concerning accident, which brought out the fact that the boy had had a serious fall a few weeks before.  The resulting lesions were held to be the primary cause of the peritonitis, and treatment directed to them was the cardinal treatment.  The fact that the child's life was saved at such a juncture, in disease of such a nature, by the removal of spinal lesion, is a convincing demonstration of the correctness of osteopathic theory and practice.
    The LESIONS expected in such cases are to the lower ribs, the lower dorsal and lumbar spine, and sometimes the pelvis.  In such cases as are secondary to other disease, such as inflammation in the various abdominal organs, typhoid or diphtheritic ulcer, appendicitis, volvulus, etc., the active lesion in the case must be sought for as the cause of the primary disease.  Such lesions may be various.
    ANATOMICAL RELATIONS: The nerve supply to the parietal peritoneum is from the lower intercostal and upper lumbar nerves, which supply also the muscles of  the abdominal walls. The abdominal sympathetics also supply the peritoneum, being chiefly vaso-motors for the blood vessels in the mesentery, but also having certain branches distributed directly, to the substance of the peritoneum.
    The blood supply is from the coeliac axis through the hepatic and splenic arteries, and from the blood supply of the parts with which the various portions of the mesentery are in relation.
    The fact that the chief sympathetic supply to the peritoneum is to the peritoneum is to the blood vessels in it is a significant one.
    The inflammation of peritonitis is a vaso-motor disturbance.  It has been before explained how spinal lesion deranges spinal sympathetic connections of the abdominal sympathetic and produces disease.  Thus certain lesions among the lower ribs, and along the lower spine, result in derangement of the sympathetic, which, when affecting the peritoneum, becomes a chiefly vaso-motor disturbance because of the peritoneal sympathetics being mostly vaso-motors, and the inflammation results.
    In another way, these lesions, affecting the lower intercostal and upper lumbar spinal nerves, may become the active cause of peritonitis.  Hilton shows that these nerves, supplying the skin and muscles of the abdominal walls, as well as the parietal peritoneum, probably also supply the visceral peritoneum and send sensory branches through the sympathetic to the intestinal walls.  Quain's anatomy shows that from, the 9th, 10th, 11th and 12th dorsal nerves, sensory nerves pass through the sympathetic to the abdominal viscera.  It also shows that from thoracic sympathetic and from the lumbar sympathetic cord vaso-motor fibres of the abdominal vessels take origin.  The ultimate relation between the spinal and sympathetic nerves is well known.  Hilton uses the facts he points out in regard to this connected nerve mechanism to explain why the abdominal walls become painful and contracted from the inward irritation of the inflammation.  The connection of this nerve mechanism for all these related parts also explains how lower rib, lower dorsal, and upper lumbar spinal lesions may so interfere with vaso-motor supply to the peritoneal vessels as to cause peritonitis.  This immense abdominal nerve supply, both superficial and internal, spinal and sympathetic, offers the Osteopath, both through its surface distribution and spinal connections, and its internal distribution, a vast and most readily accessible field for his work by superficial and deep abdominal and spinal treatment.  This fact well explains his good results, even in bad cases, in gaining control of the vaso-motor mechanism which is deranged in this inflammation.
    Through the connection of this local vaso-motor mechanism with the vaso-motor system of the whole body, reflex irritation is set up which leads to a general vasoconstriction of the vessels of the whole body surface.  Robinson thus explains why the whole skin is waxy pale and cold, saying that the patient, on this account, dies from circumference to center.
    Robinson also shows that traumatic action of the left end of the diaphragmatic muscle upon the gut wall, of the psoas magus upon the sigmoid, and abrasion of the bowel mucosa at the splenic and sigmoid flexures, very frequently become the causes of peritonitis by allowing the migration and foothold of pathogenic bacteria.  Spinal, or other specific osteopathic lesion, by causing bad bowel conditions which allow of the possibility of such traumatism, may be present and must be removed in the treatment for, or the prophylaxis of the disease.
    The PROGNOSIS in these cases is fair.  Considering that peritonitis patients often die under medical treatment in the acute form of the disease, and that operation must frequently be resorted to, the success osteopathy has had with serious cases is marked.
    The TREATMENT must aim at gaining vaso-motor control and thus reducing the inflammation.  Lesion must be corrected as soon as possible.  The treatment must be both spinal and abdominal.  The first step should be thorough but careful relaxation of all spinal tissues.  If the patient cannot be turned upon his side, he may continue to lie upon his back, and the operating hand may be slipped under him to work along the spine.  Inhibition should  be made along the splanchnic and dorsal, to upper lumbar regions, especially of the 9th to 12th  to quiet the pain through inhibition of the sensory fibres.  After spinal relaxation and inhibition, the abdominal treatment will be better borne.  Through this spinal treatment effect upon vaso-motor activities is gained by way of the sympathetic connections explained above.  This aids in freeing the circulation.  During the progress of the treatment of the case, the inhibitive spinal treatment may be alternated with a thorough stimulation of the sympathetic connections of the parts involved, to check peristalsis.  As soon as possible, thorough general spinal treatment should be given to equalize the general circulation, and to overcome the intense vaso-constriction of all the superficial vessels, so noticeable a feature of the case.  Heart and lungs should be stimulated, and inhibition of the superior cervical region be made.
After spinal inhibition very light abdominal treatment is given.  The walls are tense and painful, and much care is required in treating them.  The treatment should be gentle, relaxing, and inhibitive, thus relaxing the contractured muscles, aiding general circulation, and decreasing pain.  On account of the relation between the nerves of the abdominal walls and those of the inward parts involved, as pointed out above, work upon the abdominal walls has an important corrective effect upon the morbid conditions present internally.  The theory that work upon nerve terminals affects parts supplied by connected nerves is well supported by fact.  Thus restoration of a relaxed and natural condition of the abdominal walls is an important aid in restoring natural condition, in the parts supplied by these connected nerves.  Gradually, deeper work may be done, affecting the abdominal sympathetic locally, increasing circulation and stimulating absorption of the inflammatory effusions and other products.  Care must be taken in the treatment over the intestines, as their walls are intensely gorged with blood, and are friable.
    The obstinate constipation present is due to pressure from congestion of the bowel walls, and by edema into them, checking peristalsis.  As the circulation is restored this condition is corrected, and bowel action can be stimulated by the usual means.  The liver, kidneys, and skin should be stimulated to aid in carrying off the effusions and the effete products of the disease.  The hiccough is relieved by inhibition of the phrenic nerve (VIII, Chap. III).  Treatment for the fever and for the vomiting and tympanites is applied as before directed.  The treatment prevents the formation of adhesions, and takes down the thickening of the peritoneum.  The patient should be kept quiet in bed, no food should be allowed as long the vomiting occurs.  Later a restricted liquid diet is used in small amounts at a time.  Cracked ice may be used to allay the thirst.  Rectal injections may be necessary to relieve the constipation at first.
    The treatment of the chronic case is directed to the gradual breaking down of adhesions; the restoration of circulation to absorb pus or effusion, and to remove the chronic inflammation; and to the relaxation of the abdominal tissues.  Correction of the spinal lesion must not be neglected.
Cases of acute peritonitis secondary to other diseases must be treated in conjunction with them.  Cases resulting from gunshot wounds and other traumatisms are surgical cases.  In the acute case the patient should be seen two or three times per day as long as the severe acute symptoms predominate.
 



ASCITES, (HYPEROPERITONEUM)

    DEFINITION: A dropsical condition of the abdomen, due to an accumulation of serous fluid in the peritoneal sac.
    CASE: (1) Ascites following malarial fever, and of more than one years standing.  The condition was so pronounced that the patient could walk but little.  Lesion was present as a downward displacement of each 11th rib, and the whole lumbar region of the spine was affected.  The pulse was 156.  Under treatment rapid improvement took place.  The pulse, was reduced to 82, and the patient was able to go to work.
    (2) A case of ascites which had suffered from the condition two times previously, at one time for fourteen years, at another for one year.  Recovery was made from these attacks, but the disease again developed after an attack of the grippe, and was not relieved by the means which had before been successful.  It was of three years standing when it came under osteopathic care.  After the seventh treatment, dropsical fluid began to be absorbed into the circulation and thrown off by the kidneys. Ten pounds of fluid were excreted every twenty-four hours, and the patient's weight was rapidly reduced from 190 to 153 pounds.
    (3) See Cirrhosis of the Liver, case (1).
    The LESIONS in this disease are various, as it is commonly a condition secondary to some other disease, as of the heart, lungs, kidneys, liver, etc.  Lesions must be expected according to the nature of the primary disease.  If it be due to a local condition, such as obstructed portal circulation (see Cirrhosis of the Liver), peritonitis, q. v., or abdominal tumor, the lesions expected are the ones usually found in these conditions.  Lesions in the splanchnic area, the upper lumbar region, and among the lower ribs occur often in these cases as underlying causes, determining the local manifestation of the disease through interference with the sympathetic innervation of the abdominal vessels, as before explained.
    The vast area and capacity of the abdominal veins, the ease with which they are dilated, and the relation of the portal circulation to the liver, together with the frequent presence of lesions in the splanchnic and upper lumbar regions of the spine, weakening vaso-motor control of these vessels, are no doubt important anatomical factors in determining the dropsy to the abdominal region.
    The PROGNOSIS in these cases depends upon that for the condition producing the trouble.  Generally speaking, it is good except in cases of atrophic cirrhosis of the liver.
    The TREATMENT for ascites consists chiefly in the treatment of the disease to which it is secondary.  Special lesion as found must be removed.  Obstructed circulation must be opened, general abdominal circulation stimulated, and the collateral circulation through the superficial abdominal veins developed.  This is accomplished by spinal correction and stimulation of the splanchnic and lumbar vaso-motor areas.  The solar and other abdominal plexuses are stimulated, and deep abdominal manipulation is made from below upward along the course of the vena-cava and azygos veins, the portal vein, and the superficial abdominal veins.  Thorough stimulation of the liver and portal circulation is the most important factor in the treatment of this condition. (See Cirrhosis of the Liver).  Treatment over the course of the superficial abdominal veins results, in the course of a few treatments, in considerable enlargement of them.  As circulation is corrected the dropsical process is checked, and absorption of fluid already effused begins to take place. Stimulation of kidneys, bowels, and skin aid the process.  The distention of the abdomen may considerably hinder the treatment.  By laying the patient upon his side, so that the fluid gravitates away from the uppermost side, the latter may be treated by deep manipulation.  The patient may then be laid on the other side, and the process be repeated.  On account of the accumulation of fluid, paracentesis may have to be performed, but ordinarily under osteopathic treatment tapping does not become necessary, except in cases of atrophic cirrhosis of the liver.  The lower limbs should be treated to increase circulation in them and to empty their dilated veins.
    The patient should be treated daily.
 



 
JAUNDICE

    DEFINITION: A condition in which bile is absorbed into the circulation and colors the tissues of the body and the secretions.
    CASES: (1) Lesion from overexertion, in the form of a "twist" between the 6th and 7th dorsal vertebrae.  Jaundice followed immediately after its occurrence. (2) 9th and 10th dorsal vertebra anterior; intense congestion of the deep muscles of the right cervical region; looseness of the 7th cervical vertebra. (3) Catarrhal jaundice following difficult childbirth; extreme tenderness of the spine from the 10th dorsal to the 1st lumbar. (4) jaundice and constipation in a lady of 23.  The jaundice was of several months standing.  There was a lateral lesion of the 10th dorsal vertebra, with marked rigidity of muscles and ligaments in the lower dorsal and lumbar regions.  The case was practically cured in one month. (5) Jaundice of four years standing,.  There was external tenderness in the region of the hepatic flexure of the colon; luxation of the 10th right rib; posterior condition of the 9th to 11th dorsal.  Correction of lesions, with occasional abdominal treatment, cured the case in 4 months.
    LESIONS AND CAUSES: Spinal lesion anywhere along the splanchnic area has been known to produce the disease.  Lesion of the lower right ribs is common.  Prolapsus of the transverse colon, due to various lesions (see Intestinal Obstruction and Enteroptosis), may obstruct the duct by compression.  Various mechanical causes; stricture, gallstones, parasites, tumors, etc., are well known as causes of obstructed bile flow, leading to obstructive jaundice.  The relation of lesion to these causes, osteopathically, is found in the agency of various lesions, whose nature and action are well understood from discussions in the previous pages, in producing diseased conditions of the gastrointestinal tract leading to the presence of such obstructive agents.
    ANATOMICAL RELATIONS: The relation between spinal and other lesion and abnormal liver conditions will be discussed  (see Cirrhosis and Gallstones).  In catarrhal jaundice, the usual form presented for treatment as jaundice, lesion has occurred in the splanchnic area and is interfering with vaso-motor activity of the gastrointestinal tract, producing, or allowing other causes to produce, an inflamed condition of the mucous membrane of the gastro-duodenal mucosa and of the mucous lining of the ductus communis.
    The immediate appearance of jaundice after spinal lesion, as in case 1 cited above, as well as the presence of spinal lesion in other cases of jaundice, favors the probability of direct interference of such lesions with the innervation of the gallbladder and duct.  The presence in the sympathetic supply of the liver (hepatic and cystic plexuses, see (Gallstones) of spinal fibers which, upon stimulation or inhibition of the splanchnics, cause constriction or dilatation of the bladder and ducts; also the fact that stimulation of the pneumogastrics constricts the bladder, while relaxing the sphincter of the opening of the common duct into the duodenum, make it probable that certain lesion to the splanchnic area or to the pneumogastric, directly or indirectly through its sympathetic connections, might so pervert the normal workings of this mechanism as to lead to retention of bile, i. e., a form of obstructive jaundice.
    The PROGNOSIS is good.  The acute case yields immediately to treatment.  The usual course (two to eight weeks) is materially shortened.  In the chronic case, clearing of the tissues from the pigmentation is rather a slow process.
    The TREATMENT must look at once to the removal of such active lesion as described above.  Mechanical obstruction must be located if possible and removed by work upon the duet, proceeding upon the lines laid down for the manipulative removal of gallstones and of intestinal obstructions, q. v.  Prolapsus of the intestines and pressure from surrounding organs must be relieved (see Enteroptosis).
    In catarrhal jaundice the first step must be to gain vaso-motor control and relieve the inflammation.  A preliminary inhibition of the splanchnic area of the spine may be necessary to relieve pain and to gain a degree of relaxation of abdominal tissues before local work is attempted.  Next, slow, deep, inhibitive or relaxing treatment is directed to the upper intestinal region and ductus communis.  This relieves the inflammation, aids in taking down the swelling of the mucous membrane, and frees the secretion of mucous which may be obstructing the duct.  At the same time, treatment of the splanchnics aids in correcting circulation in the parts.
    After treatment for the inflammation and relaxation of the duct, the next step is the emptying of the gallbladder and hepatic ducts.  This is done by local manipulation which acts mechanically and by stimulation of the hepatic and cystic plexuses.  The patient ties upon his back and the operator stands at the left side; he places the palm of the right hand beneath the postero-lateral aspect of the lower four right ribs and, while raising them, presses down upon their anterior portions with the right forearm.  At the same time the left hand makes careful but deep pressure beneath the tip of the ninth rib, against the fundus of the gallbladder.  This mechanically empties the liver and ducts.  It also stimulates the local cystic plexus to cause constriction of the bladder and ducts.
    This same treatment, and the lower costal treatment Chap. VIII), carefully applied, are given to regulate the circulation through the liver and to free it of accumulated bile.  The splanchnics should also be thoroughly treated for the circulation.  By these treatments the flow of bile is increased, and the system is cleared of it.  Thorough stimulation of the kidneys and skin (2nd dorsal, 5th lumbar) aids in freeing the blood of the bile acids.  This allays the itching.  The superior cervical region (medulla) should be inhibited to correct general vaso-motor action.  This is for the itching and localized sweating.  The bowels and stomach must be treated to relieve the constipation or diarrhea, and the dyspepsia, as before directed.  Other symptoms may be allayed by appropriate treatment.
    The diet should be plain, avoiding pastry, starchy, fatty, and saccharine foods.  Plenty of water should drunk, lemonade and alkaline drinks are allowed.  Skimmed milk and buttermilk, lean meat, soups, bread, and green vegetables may be used.  Frequent, bathing is good to aid elimination and to clear the skin and restore its healthy condition.
    In toxemic jaundice the main object of treatment must be the removal from the system of the poison that is causing the trouble.  If due to a toxic disease, the treatment must be to it.  In any such case all the avenues of excretion must be kept active to cleanse the system.  The usual liver treatments etc., may be also applied.
 



 
CONGESTION OF THE LIVER

    DEFINITION:  An excess of blood in the vessels of the liver.  In active congestion, or acute hyperemia, an excess of arterial blood is circulating through it.  In passive congestion the liver is engorged by retention of blood in its portal circulation.
    CASES: (1) A case of active congestion, which was in a dangerous condition.  Lesion was present as a severe contraction of the muscles on the right side of the spine, from the 6th to 12th vertebra.  The intercostal muscles over the liver were also contracted. (2) Active congestion in a woman of 45, of two weeks standing.  There was muscular lesion in the region of the splanchnics.
    The LESIONS already discussed in connection with liver diseases, i. e., these of the splanchnic area and of the lower ribs, interfering with the vaso-motor control of the organ, lead to the congestion.  Heart and lung diseases are said to be almost always the causes of passive congestion, but the ordinary congestion of the liver, found in dyspepsia, biliousness, constipation, etc., is due, not to heart or lung disease, but to lesions in the splanchnic area.  The lesions here must be sought according to the case, and treatment made as thus indicated.
    PROGNOSIS is good.  These cases are usually readily cured.
    The TREATMENT is merely one to gain vaso-motor control.  Thorough stimulation of the splanchnic area and solar and hepatic plexuses is an important means of accomplishing this.  The lower costal and direct liver treatment indicated for jaundice, q. v., are used.  Besides directly stimulating the local nerve mechanism, these treatments, by squeezing the liver and mechanically forcing the blood into and out of it, cause the mechanical action of the blood upon the vessel walls to still further arouse vaso-motor activity.  Local treatment should be made upon the liver to stimulate the flow of bile and prevent jaundice.  A general spinal, neck, and abdominal treatment aids in correcting general circulation.  Treatment for the abdominal vessels quiets active congestion by dilating the abdominal vessels and drawing the blood to them.
    In active hyperemia correct errors in diet, and avoid the use of highly seasoned food and alcohol.  A milk diet is good.  Keep the bowels active.
    In passive hyperemia look well to the condition of the heart.  Keeping it stimulated. Due attention should also be given to the lesser circulation.
 



 
CIRRHOSIS OF THE LIVER, (SCLEROSIS OF THE LIVER.)

    DEFINITION: A chronic disease, characterized by an increase of connective tissue in or about the liver.
    CASES: (1) Atrophic cirrhosis; a case brought on by social drinking, diagnosed and treated by physicians as such.  The first tapping of the abdomen brought eight and one half quarts of fluid.  The case now came under osteopathic treatment, and it succeeded so well that a second tapping was delayed some time beyond the expected time.  Later a third tapping became necessary, after that none was required.  Under the treatment the patient was restored to perfect health.
    (2) Diagnosis of cirrhosis; 6th and 7th dorsal vertebrae anterior, 9th to 12th flat; ribs irregular and prominent on left.
    (3) Malarial, cirrhosis; entire lumbar region bad; 11th rib, on each aside down.
LESIONS AND CAUSES: The lesions commonly found in these cases affect the splanchnic area, the lower ribs on each side, or the lower right ribs.  The latter may cause mechanical pressure and irritation upon the liver.  The various lesions weaken the vaso-motor sympathetic supply and lay it liable to the action of special causes of the disease.
    In those forms of cirrhosis in which ascites develops, the contraction of the connective tissue causes pressure upon the soft walls of the branches of the portal vein.  Upon this account, and because of the low pressure of the blood in the portal system, obstruction soon follows, and ascites results.
    The PROGNOSIS must be guarded in all cases.  Various cases have been cured, among them even atrophic cirrhosis.  In the latter case the prognosis is very unfavorable, It is probable that other forms of the disease can be much benefited or cured under the treatment in many instances.
    The TREATMENT aims at gaining vaso-motor control, and thus taking down the inflammatory or congestive process that is allowing of the increase in connective tissue.  In those forms complicated with ascites as the main symptom , Special attention must be given to it as being most immediately dangerous to the patient's life. (See Ascites.)  It is doubtful if connective tissue, once formed, could be absorbed by the renewed blood supply.  But the process of its formation could be stopped, the liver substance could be kept softened by thorough work locally over the organ, thus preventing hardening and contractions of it, and maintaining freedom of circulation through it.  In this way danger of ascites could be avoided.
    Vaso-motor control is gained by removal of lesion, by thorough stimulation of the splanchnic area of the spine, and by local abdominal work over the liver and over the course of the portal vein.
Local work may be done as described in V. Chap.  VIII, working beneath the right ribs, directly upon the liver, while the pressure from above upon the ribs, pressing them down upon the liver, alternating with what that applied directly to the liver, is an efficient mode of stimulating the organ directly.
    In atrophic cirrhosis attention must be given to relieving the congestion of the spleen, stomach and intestines present.  This is done through treatment of the organs as described in considering diseases of them.  In case of the spleen only slight treatment should be made over it locally on account of danger of rupture.  Stimulation of the lower splanchnic area and raising the lower four left ribs, together with work upon the solar plexus and the abdominal circulation, are sufficient for it.  The constipation, gastric catarrh, nausea, vomiting, edema of the lower extremities, etc., are treated as before described.
    In billary cirrhosis, the chief object of treatment is to remove the obstruction to the duct and to empty the gallbladder (IX, Chap.  VIII.) The general corrective treatment for the liver as described is relied upon to soften the new tissue about the small ducts and to prevent its further formation.
    In congestive and malarial cirrhosis the chief point is to remove and prevent the congestion.      Otherwise the treatment is as indicated for the general case.
    In hypertrophic cirrhosis the main indication is to prevent the formation of new connective tissue, or to limit its formation.  This connective tissue does not usually show a tendency to contract, as in atrophic cirrhosis.  Possibly much might be done by renewed and stimulated circulation to absorb this tissue, since fibroid tumors have been removed by like means.  The kidneys must be kept well stimulated, as the amount of urine is decreased.  Careful treatment must be done about the spleen and abdomen, as the former is enlarged and tender, and there may arise perisplenitis and peritonitis.   Such complications may be avoided by proper attention to the circulation, etc.  The heart and general circulation must be looked after, to prevent cardiac complications and hemorrhages.
    In all cases the general treatment outlined, with attention to the special symptoms manifested, should be applied.
    In acute cases the patient should be seen daily.
 



GALLSTONES

    DEFINITION: Concretions in the gallbladder, chiefly of cholesterin, due to a pathological process usually caused by spinal lesion to sympathetic nerves in charge of liver functions.
    CASES: Very numerous cases of gallstones, some of gallstones, some of them noted, have been successfully treated.  It is one of the most common things treated, and in no class of cases have more uniformly good, even striking, results been attained.
    (1) In a case of gallstones, with chronic constipation and dysmenorrhea, the muscles of the lower dorsal region were much contracted, and there was lesion between the  11th and 12th dorsal vertebrae.  The case was cured.
    (2) A case of gallstones after typhoid fever, in which operation had been advised.  The stones were passed under osteopathic treatment.
    (3) A serious case of gallstones and catarrh of the stomach, in which every medical means of cure had been tried without avail.  The patient grew continually worse.  After a few osteopathic treatments the stones began to pass, and a large number of them, a large sized teacupful were gotten rid of.        After this a copious passage of mucus, amounting to several pints, took place.  Much of the mucous membrane lining of the intestines, gallbladder, duct and stomach was cast.  The stones continued to pass, and two as large as a man's thumb were among them.  At the passage of the last large stone the patientís limbs and lips were paralyzed, and her condition became critical.  The crisis was safely passed under treatment, however, and entire recovery followed.
    (4) In man of 45, who had been troubled for years with gallstones, the common bile-duct became impacted, and the ordinary methods of treatment were of no avail.  Hypodermic injections of morphine gave no relief from the pain, and an operation was advised.  The intense pain was relieved at the first treatment, which opened the duct.  After the second treatment thirty stones passed from the bowel.  The case was entirely cured.
    (5) A case of gallstones of 18 years standing, lesion was found as a depression of the 10th right rib, infringing the 10th intercostal nerve, which was sensitive along its entire course.  The treatment was directed to the lesion, and to the gallbladder and duct.  By two treatments, the colic and pain were overcome, and the case entirely recovered under further treatment.
    The LESIONS found in these cases are usually low down in the splanchnic area, affecting the lower four ribs upon either side, frequently upon the left, for the spleen.  Lesions of the 11th and 12th vertebra may not be too low to cause it.  However, any of those lesions to the ribs and splanchnic area, characteristic of bad gastrointestinal conditions may, from the nature of the case, affect the liver to produce gallstones.  The liver is innervated from the same nerve supply, gastrointestinal diseases are usually complicated with deranged liver function, and it is reasonable to find in the usual lesions producing the latter a sufficient cause for disease in the former, which, owing to some particular form, degree, or concentration of lesion, results in cholelithiasis.
    ANATOMICAL RELATIONS of lesion to disease: The liver is supplied by the splanchnics through the solar plexus, the secondary plexus, the hepatic, in the formation of which the left pneumogastric nerve participates, having special charge of the liver activities.  Its branches ramify throughout the liver upon the branches of the portal vein and the hepatic artery, the chief supply being to the latter.  The blood supply from both of these sources is thought to be essential to the activities of the liver cells.  The nutrient blood supply (hepatic) is chiefly governed by branches of the sympathetic.  A cystic plexus of the sympathetic supply is spread upon the gallbladder and bile ducts.  The American Textbook of Physiology states that special investigation has shown that these nerves are similar in function to vaso-constrictor and vaso-dilator nerves, and that stimulation of the peripheral end of the cut splanchnics causes a contraction of the bile ducts and gallbladder, while stimulation of the cut end of the same nerve cause reflex dilatation.  According to the same investigator, stimulation of the central end of the vagus nerve causes contraction of the gallbladder and at the same time an inhibition of the sphincter muscle closing the opening of the common bile duct into the duodenum.
    These interesting and instructive facts  cannot but be of much significance to the Osteopath.  Doubtless he could not avail himself of these detailed facts to manipulate at will the activities of the biliary apparatus, but spinal and other lesions affecting the sympathetic connections of the organs must be efficient causes in producing abnormal function.
    Osler states that any cause, such as tight lacing, bending forward at a desk, enteroptosis, etc., which produces stagnation of bile favors cholelithiasis.  From an osteopathic standpoint, and in view of the above facts, it is a reasonable conclusion that certain spinal lesion, acting through this nerve mechanism above described, may cause a stimulated, irritated, or overactive condition of the dilator fibers of the ducts and gallbladder, thus maintaining a permanent dilated or sluggish condition of the apparatus, favoring stagnation of the bile and the formation of gallstones.  Likewise one must concede the possibility of lesion to the central end of the vagus nerve, cutting off the normal impulses through the nerve which contract the gallbladder and relax the sphincter of the common duct, thus allowing of a lack of normal contraction of the bladder and opening of the duct; in other words, favoring a sluggish condition of the biliary apparatus leading to retention and stagnation of bile, thus to cholelithiasis.  If any osteopathic spinal lesion can interfere with sympathetic visceral supply, a point placed beyond controversy by demonstrated facts, it is a reasonable conclusion that spinal lesion to the sympathetic supply to the liver can become the cause of gallstones in this way.
    According to the catarrhal theory of the formation of gallstones, lithogenous catarrh of the mucosa of the bladder and duct modifies the chemical constitution of bile and favors the deposition of cholesterin about some nucleus, such as epithelial debris.  Cholesterin and lime salts are produced by the inflamed mucous membrane to form the calculus.  As shown above, both the hepatic and portal blood supply is under control of the hepatic plexus, i. e., of the solar plexus and the splanchnics.  According to the American Textbook of Physiology, stimulation or inhibition (section) of the splanchnics produces at once vaso-constriction or vaso-dilatation of the blood vessels of the liver.  Here, as in the case of gastric or intestinal catarrh, spinal lesion to the splanchnics could disturb vaso-motor equilibrium in the liver and cause catarrh of the mucous membrane.
    It is the practice of Osteopaths to give close attention to the condition of the spleen in case of gallstones.  Important lesions to this organ are often found in such cases (8th to 12th left ribs, A. T. Still).  Removal of this lesion seems to prevent further formation of the calculi.  What influence the spleen naturally exerts upon the liver is not known.  The splenic and superior mesenteric veins unite to form the portal vein.  The abundant venous flow from the spleen is carried directly to the liver in the portal circulation.  The American Textbook shows that there is little doubt that the materials actually utilized by the liver cells in forming their secretions are brought to them mainly by the portal vein.  The blood which has circulated through the spleen must compose an important part of the blood brought by the portal vein to the liver.  It may be that certain products of splenic activity are useful in maintaining the fluidity of the cholesterin and in preventing the formation of gallstones.  The spleen is enlarged and tender in this case.
    Sensory nerves pass through the sympathetic from the (6th, 7th, 8th, 9th and 10th spinal nerves (Quain).  This fact may explain the radiation of the pain in hepatic colic to the spine and right shoulder, and forms a good anatomical reason why inhibition over this spinal region will aid in stopping the pain.
    The PROGNOSIS is good, even in serious cases in which operation has seemed advisable.  The case is frequently presented to the Osteopath as the last resort before operation, and results have been almost uniformly good.
    TREATMENT: The success of the treatment seems to rest mainly upon the mechanical effect and upon the relaxation of all tissues concerned, gall ducts included, gained by the use of osteopathic methods.  The main treatment in these cases is locally about the region of the liver; is much of the relaxing and inhibitive treatment, and the main work of removing the stone are done here.  Spinal work is important, as here inhibition for the pain of the colic is made, lesion is corrected, and circulation is stimulated.  Nervous control is an important factor in the treatment.  It is gained by both spinal and abdominal work, perhaps alone by the removal of lesion.
    The objects of the treatment are: (1) To remove the stone, (2) To restore normal liver function and prevent further formation of stones.
    The former is palliative treatment; the latter is the real cure.
    In the acute case, if colic is present the first step is to make strong inhibition over the 7th to 10th spinal nerves.   (Some say upon the right side).  This will lessen or stop the pain, and allow of work upon the abdomen.  This is deep, relaxing inhibitive work upon the tensed abdominal walls, over the epigastric and lower anterior thoracic regions, arid over the course of the duct (IX, Chap. VIII).     The pain, which is due to inflammation of the mucosa of the duct and to the rotary motion of the stone, which is given this motion by the spiral arrangement of the Heisterian valve within the duct, is usually relieved in a few minutes.
    The stone is removed by working it along the duct after the preliminary relaxing treatment.  The patient should lie upon his back with knees flexed and shoulders slightly raised.  The lower ribs are raised, by inserting the fingers beneath their anterior edges, and manipulation is made deeply over the site of the fundus of the gallbladder (tip of 9th rib) and down along the coarse of the duct.  The latter may vary from its course on account of sagging of the intestines sometimes found.  This treatment must be thorough and persistent.  It should be firmly and deeply, but most carefully applied.  Sometimes a few minutes work will pass the stone, but often continued treatment for three-quarters of an hour or an hour be devoted to it.  Only careful manipulation could be borne by the patient for this length of time.  As long as the stone remains in the duct and causes the colic the attempt to remove it should be continued, though it may not be advisable to treat continuously all of the time.     The stone may or may not be large enough to be felt in the duct.  Stones are often passed without pain.  Some stones are soft and may be carefully broken down by the treatment.
    The spleen is treated by careful abdominal work over and beneath the lower left ribs, anteriorly.  It is chiefly affected by treatment to the splanchnics, raising the lower left ribs (8th to 12th), and removal of lower spinal and rib lesion.
    The jaundice, if intense, indicates impaction of the stone in the common duct.  Its cure depends upon the removal of the stone.  The kidneys should be kept active.
    Fever, if present, is allayed in the usual manner.  Fatal syncope sometimes occurs.  If imminent, the patient should be fortified against it by thorough stimulation of the heart. For obstruction of bowel by calculi, see Intestinal Obstruction.
    A dilated gallbladder and duct are treated locally by manipulation to remove the obstruction as for removal of the stone.  Thorough treatment must be given the liver locally, and thorough spinal treatment must be kept up for the purpose of increasing circulation, etc.
    According to Dr. A. T. Still the lesion of the 6th to 10th left ribs, found in cases of gallstones, is obstructing pancreatic secretions.  These, he says, dissolve gallstones.  They are absorbed from the intestines by the lacteals and carried by them into the portal circulation, and thus to the liver as portal blood, where they may influence the secretion of bile, and, mingling with the latter as a constituent of the bile, act upon stones already formed.  The patient should drink plenty of alkaline waters.
 



 
SUPPURATIVE CHOLANGITIS

    This is a suppurative process in the mucous membrane lining the duct, and is commonly the result of gallstones.  It may be due to parasites, or may arise after typhoid fever, dysentery, or other acute disease.
    The treatment is upon the lines laid down for the treatment of the liver, gallstone, etc.  The local circulation must be kept free to overcome the suppuration and to repair the membranes.  This, with treatment along the course of the duct opens it, and lets free the flow of bile.
 



 
DISEASES OF LIVER (Continued)

    CASES: (1) Hepatic abscess, complicated with gastric ulcer.  Lesions at the 3rd cervical, and at the 4th, 5th, and 8th dorsal; rigid spinal muscles; 7th to 10th right ribs overlapped.  The case was in a very serious condition, but began to improve after two weeks, and was finally cured by the treatment. (2) Torpid liver, with chronic gastritis; marked lesion at 4th and 5th dorsal; slight lesion at the 9th dorsal
    For HEPATIC ABSCESS the prognosis must be guarded and unfavorable.  While limited quantities of pus may be effectually and safely absorbed through increased circulation, any large quantity could probably not be thus disposed of.  Some cases have been cured by osteopathic treatment, and there are some chances of curing the ordinary case presented for treatment.  The fact that the disease has and can be cured warrants thorough trial.
    The TREATMENT must be to absorb the pus and heal the ulcer through increased circulation of the blood.  Removal of lesion is naturally the important step in this process, as it is obstructing proper circulation and innervation.  The usual lesions in liver diseases must be expected.  Full directions have been given for treatment of circulation to the liver.  Great care must be taken in local treatment over the liver because of danger of rupturing the abscess.  Pain, if present, is quieted as before.  Attention must be given to the gastrointestinal disorders, constipation and diarrhea.  As abscess is frequently secondary to some other disease, treatment must be made accordingly in such cases.  A bronchial cough, frequently present, may be guarded against by stimulation of the vaso-motors to the lungs.
    HYPERTROPHY OF THE LIVER is frequently presented for treatment, and as a rule good results are gotten.  Many cases are cured.  Complete restoration of size and function often results from the treatment.  In many other cases, while the size cannot be reduced to normal limits, functions is restored.  The general prognosis is favorable.  In true hypertrophy due to increase of connective tissue the new tissue can probably not be absorbed, but the further increase of it may be checked and the function is usually restored.
    In true hypertrophy due to increase in size or number of the parenchymatous cells, the treatment may reduce their size or number, and normal size and function of the liver is restored.  As the chief causes of hypertrophy are active and passive congestion (lesion to the vaso-motors), good results follow corrected circulation.
    In false hypertrophy due to cancer or abscess little is expected in the way of reduction.  When due to fatty infiltration, the renewed circulation removes the accumulated fatty particles and restores normal size and function.  In these cases diet is very important.  Avoid fats, starches, and wheat bread.  Use gluten or bran bread, also fish, lean meat, vegetables and fruit, but no alcohol.  Exercise and baths should be employed.  The treatment in these cases consists in the removal of lesion and correction and stimulation of circulation.  The prognosis is good.  The size of the liver can be reduced to normal.  When secondary, the primary disease is treated.
    In fatty degeneration of the liver good results may be expected from the treatment.  It consists simply in the removal of lesion and in the active stimulation of the circulation, with due attention to the primary condition upon which the degeneration depends.  Diet, exercise and baths should be used as in the treatment of fatty infiltration.  Recorded facts are lacking in regard to cancer and acute yellow atrophy of the liver.  The latter two are rare conditions, yellow atrophy exceedingly so.  Treatment for these diseases could be worked out according to the fates and principles given in relation to the various diseases of the liver already discussed.
    In AMYLOID INFILTRATION of the liver the starch-like deposit occurring in the connective tissues of the liver must be absorbed in the renewed blood supply.  But the condition of the blood is an important factor, apparently, as it is thought that in suppurative processes in the body, to which the disease is frequently due, the alkalinity of the fluids of the body has been decreased.  The general health must be built up, the excretion stimulated, and the blood purified.  The primary disease, such as tuberculosis, rickets, etc., must be attended to.  Any local lesions must be repaired, and the circulation be kept stimulated.  A thorough general course of treatment is necessary.  The diet should be carefully attended to.  It should consist of nitrogenous or animal food.  Starches and fats should be avoided. Lean meats and green vegetables, etc., are allowed.  Exercise and bathing should be encouraged.
 



 
SPLENITIS

    DEFINITION: Acute or chronic proliferative inflammation of the spleen.  Suppuration may occur.
    CASES: (1) Lady, fifty years of age, suffering from chronic inflammation of the spleen.  Spleen was much enlarged, and she was unable to wear corsets.  Lesion was found in the form of a misplaced rib pressing upon the spleen.  Its replacement caused the pain to disappear, and the waist measured two inches less the next morning. (2) Splenitis; the case showing lesion as depression of the 9th, 10th, and 11th left ribs, and a posterior swerve of the lower dorsal and lumbar region.
LESIONS occur in downward and forward luxations of the 6th to 12th left ribs. (A.  T. Still).  Diaphragmatic lesion thus caused may interfere with position, circulation, or innervation of the organ.  Direct pressure of a misplaced rib, or lower splanchnic lesion causing interference with spinal innervation, may cause the trouble.
    ANATOMICAL RELATIONS: Stimulation of the peripheral end of the splanchnic causes sudden and large diminution of the volume of the spleen.  It is probable that this diminution is due to contraction of its trabeculae and capsule, which are plentifully supplied with involuntary muscle fibers.  "The organ is richly supplied with nerve fibers which, when stimulated directly or reflexly, cause the organ to diminish in volume" (American Textbook of Physiology).  According to Schafer, these are contained in the splanchnics, which carry also inhibitory fibers whose stimulation causes dilatation of the spleen.
    In view of these facts it seems that treatment over the splanchnic area of the spine and locally over the spleen may produce change in its volume (through thus directly or indirectly stimulating these nerve connections) which is most useful in correcting circulation through it.  In addition to this, the same work would affect the vaso-motor mechanism of the organ.  The splenic plexus, ramifying upon the splenic artery, is composed of sympathetic fibers from the solar plexus and of branches from the right pneumogastric.  Local or spinal treatment affect these.  It is readily apparent, in view of the whole mechanism described above, that spinal and rib lesion may seriously affect the organ by disturbance of these nerve connections, producing inflammatory or congestive conditions.
    Anders states that splenitis is probably never primary, but in case (1) cited above it seems that the disease must have originated primarily in the spleen by action of the disturbance caused by the displaced rib.
    TREATMENT: As splenitis and congestion are frequently secondary to some other disease (malaria, typhoid, etc.) , such diseases must be treated primarily.  Removal of lesion, as in the above case, may be the only treatment necessary. Stimulation or inhibition of the splanchnics at the spine, and of the capsule and local plexuses by work directly upon the organ, is made.  Care must be taken in the latter process to avoid danger of rupture of the organ.
    Inhibitive work upon the splanchnics, the solar plexus, and the abdomen will dilate the abdominal vessels and draw the blood to them, away from the spleen.
    SPLENIC HYPEREMIA, active or passive, is readily reduced.  Chronic cases may yield at once or may require a patient course of  treatment Contraction of the tissues about the splenic vein has been known to cause great enlargement of the organ by passive congestion.  Upon removal of the obstruction the organ quickly returned to its normal limits.  The lesions and treatment are the same as indicated for splenitis.
 



 
DISEASES OF THE PANCREAS

    The lesions commonly found affecting the pancreas are those occurring at the lower ribs and to the lower dorsal, vertebrae.  Generally the diseases of this organ are complications of, or secondary to, other diseases, most frequently those of the gastrointestinal tract.  As the blood and nerve supply of these parts are closely related, it is not strange that the lesions affecting this tract should also often be the cause of derangement of the pancreas.  The blood and nerve supply are especially closely related to that of the liver, stomach, and spleen.  The nerves are from the splenic plexus, which is derived from the right and left semilunar ganglia and from the right pneumogastric.  The pancreatic plexus thus formed is closely connected with the hepatic plexus and with the left gastro-epiploic plexus.    These are all the offsets of the coeliac plexus.  The arterial supply is from the superior mesenteric, and from the coeliac axis by way of the hepatic and splenic arteries.  The venous drainage is into the splenic and superior mesenteric veins, thus directly into the portal system.
    Thus it may be seen at a glance how the interrelation of these anatomical parts lays the pancreas liable to the action of those lower dorsal lesions that cause disease in the stomach, liver, intestines, spleen, etc.
    Treatment to the spinal nerve connections in the region mentioned, and to these plexuses directly by work in the abdominal region over them, affects the pancreas.  Local or direct treatment is given it by deep manipulation in the median plane of the abdomen, midway between the ensiform and the umbilicus.  Abdominal treatment may also mechanically affects its blood vessels, and may remove obstruction from them, from the duct, or from the organ itself, when caused by growths in the abdomen, malposition of the contiguous organs, etc.  Local treatment over the pancreas should be done when the stomach is empty.
    ACUTE PANCREATITIS, hemorrhagic, suppurative, or gangrenous, is generally due to gastrointestinal disorders, such as dyspepsia, glycosuria, gallstones, catarrhal inflammation, etc.  Doubtless the lesion responsible for the primary disease is directly accountable for the effect upon the pancreas, the same lesion deranging the nerve and blood supply of each diseased part.
Traumatism may directly affect the substance of the gland, or it may cause various lesions to nerves and vessels, and produce either form of pancreatitis.  The disease is often secondary to tuberculosis, specific fevers, etc.
    The treatment must depend to some extent upon the cause.  In any case it is necessary to remove the lesion, and to take down the inflammation by removing all sources of irritation or obstruction to the circulation.  Treatment may be made along the course of the venous drainage as above pointed out.  The left lower ribs should be elevated, and the lower dorsal spine relaxed.  Local treatment over the organ must be carefully applied.  The pain should be treated by strong spinal inhibition and by relaxation of the upper abdominal tissues.  The nausea, vomiting, hiccough, constipation, diarrhea, etc., may all be treated as before directed.
    Every effort should be made to alleviate the patient's suffering.
    Mild cases of hemorrhagic pancreatitis may recover; the other forms are fatal.
    Chronic pancreatitis is to be treated upon the same plan.
    Treatment for other forms of pancreatic disease could be worked out according to general points given above.