At this time also if all goes well the patient may sit up in bed and gradually move about, being careful to avoid all sudden movements which would put a strain on the epigastric region.
If necessary we may also increase our manipulative treatment at this time.
The patient must be warned against the use of any article of diet which will be chemically or mechanically irritating to the stomach, for a period of months, and an examination of feces should be made from time to time to make sure of no return of hemorrhage.
Dilatation of the Stomach
A dilated stomach is a stretched stomach having increased capacity, due to nervo-muscular atony or to pyloric obstruction. Every stomach which is not retracted when empty is a dilated stomach. A dilated stomach may occur either as an acute or as a chronic condition, but it is to be distinguished from temporary distention and a normally large stomach.
Osteopathic Etiology and Pathology.—The nervo-muscular atony causing dilatation may be due to obstructive lesions in the stomach splanchnics, or to a general debility of the spine in the dorsal region (usually a kyphosis), or to continued overeating and improper food causing a stasis and fermentation. It may also be due to overdrinking and various diseases, as phthisis, liver and lung diseases, anemia, chlorosis, acute fevers and kidney diseases, causing more or less of a general nervo-muscular atony. Dilatation may result from a mechanical obstruction, or narrowing of the pylorus or the duodenum, by a cicatricial contraction of an ulcer; by hypertrophic thickening due to various diseases, by adhesions and tumors. Occasionally the pyloric obstruction is congenital. A floating kidney may fall upon the horizontal portion of the duodenum and thus mechanically obstruct the passage of food from the stomach, which consequently dilates. Tight lacing might prevent the liver, when congested, from passing in front of the kidney, thus luxating the kidney. Dilatation of the stomach occurs at all ages, although most frequently in middle aged persons.
Pathologically, the muscular coat is thinner and paler than normal, with more or less atrophy of the glandular tissues and an increase in capacity of the stomach. When obstruction exists at the pylorus, hypertrophy of the muscular coat may occur.
Symptoms.—The symptoms are those of the disease causing the dilatation plus those of persistent chronic catarrh. The patient complains of a sense of fullness in the epigastric region and there is flatulency, eructations and vomiting. The cavity of the stomach being much enlarged, great quantities which are usually considerably decomposed are vomited each day or two. There is often lessened acidity of the vomited mass, though in some cases it is increased. Passage of the food from the stomach to the intestine is delayed and the bowels are constipated, the fecal matter being dry and hard. The urine may be scanty and the skin dry. Anemia, debility and emaciation are always present to a greater or less extent, and on account of the absorption of poisonous matter drowsiness may occur.
Physical Signs.—Inspection.—In some cases the outline of the distended stomach can be plainly seen. There is prominence of the epigastric region, the tumefaction being at the pyloric end of the stomach. Palpation.—The resistance upon manipulation of a dilated stomach is like that of an air cushion. If the patient is made to drink a half tumbler of water, bimanual palpation will cause a splashing sound to be heard along the circumference of the stomach at its lowest point; and by moving the water about by changing the position of the patient, the outline of the stomach can be made. If the sound is not heard at the first manipulation, it must not be concluded that the stomach is normal for the stomach may be so dilated and flabby that it falls behind the abdominal wall like an apron. Percussion.—The note is tympanitic over the greater part of the stomach until the lower curvature is reached when the sound is dull (due to the liquid contents of the stomach), followed by a tympanic sound again when the intestines are reached. When percussion is made the patient should always be in a standing position if possible.
When there is pyloric obstruction a tumor usually presents itself, and vomiting is more severe and peristalsis more active than when the dilatation is due to atony of the walls of the stomach from an obstructed innervation.
Diagnosis.—This is usually easy if due care is taken in making the examination. Goetz has shown by the use of his spinegraphometer that in cases of visceral prolapse the spine is commonly posterior in the dorso-lumbar region. The X-ray is of value in determining the size and function of the organ.
Prognosis.—In a case of nervo-muscular atony the prognosis is favorable. If due to a malignant disease recovery is usually impossible. In hypertrophy of the pylorus or the duodenum, recovery is probable by means of surgical interference.
Treatment.—When the dilatation is due to atony of the muscular walls of the stomach from obstructed innervation at the spinal column, treatment is usually successful. Attention should be given to the condition of the spinal column in the splanchnic region (fourth dorsal to twelfth dorsal), the spine being usually posterior. A thorough and persistent course of treatment must be given, not only to restore the normal activity of the nerves to the muscular coat and glands of the stomach, but to build up and restore strength in the weakened spinal column. Lesions in the spinal column, even higher than the fourth dorsal, may affect the innervation of the stomach. There are cases where lesions have been found at the fifth, sixth and seventh cervicals that interfere considerably with the action of the stomach, causing nausea, flatulency, eructations, and even vomiting. Such an affection may be through the fibers of the splanchnic nerves or through fibers of the vagi nerves.
The vagi nerves have an important bearing upon gastric dilatation as paralysis of the gastric branches of the vagi arrests the peristalsis of the stomach and thus tends to favor retention of food within its cavity. The stomach in such cases becomes enlarged, mainly by the weight of the food and the presence of gases due to decomposition of the retained food. Thus lesions may be found higher than the lower cervicals and cause obstruction and paralysis of the fibers of the vagi to the stomach.
Direct stimulation over the stomach in the form of thorough manipulation of the stomach walls causes contraction of the muscular fibers of the stomach, mainly the circular fibers. This treatment, with additional treatment of the splanchnic and the vagi nerves, will tend to build up the weakened plexuses of the stomach. Much time can be saved by putting the patient to bed and treating him every day for several weeks. When the stomach is dilated or dilated and prolapsed, to any extent, it usually requires three to five months treatment at least; this time can be shortened one-half by keeping the patient in bed, treating the spine three times a week, and the abdomen every day. Light food at frequent intervals, upper thoracic breathing, and frequent drawing up and in of the abdomen should be required. The patient may also manipulate his own abdomen twice a day to advantage; teach him to manipulate, draw and pull it upward. There is no danger of too frequent treatment as long as there is no bruising of the parts; this, however, does not apply to the spine. It is not an uncommon thing to correct a dilated stomach or a dilated and prolapsed stomach that is an inch and a half or two inches below the umbilicus. Care must be taken in all cases that other viscera are not prolapsed. It is a common experience to find enteroptosis, which can usually be readily functionally corrected, with the stomach ptosis. But where the kidney, or possibly both, is much prolapsed only fair results can be secured until the kidney is replaced and kept there, and if necessary by surgical means. Also, note whether the liver is enlarged. (See special article on Prolapsed Organs).
When the disease is due to cancer and various growths of the pylorus or the duodenum, nothing can be done but palliate. Such cases require surgical attention. In all cases it is necessary that care and preoccupation of the patient should be removed. Baths, changes of air, a carefully regulated diet and caution in the use of liquids will be of great aid to the general health of the patient, and thus the weakened nervous system will be indirectly but greatly benefited. Too great care cannot be taken of the patient, as there is created in the organism a special aptitude for the tissues to become inflamed and thus weaknesses at various parts of the body may occur. Phthisis, typhoid fever and various diseases are apt to follow dilatation of the stomach, as the nutritive and resistive process of the body are impaired.
The meals should be taken regularly and with great care, the patient not eating too quickly nor too much. Solids should be used but little; the artificially digested foods, such as peptonized milk and beef peptonoids, probably being the best. Beef juice and scraped beef are excellent foods, as they are easily digested. Fatty and starchy foods should be avoided.
Washing out the stomach is useful, but it should not be indiscriminately employed. Lavage will not be necessary in all cases of mechanical obstruction. It relieves the distention, by removing the weight and the fermenting and decomposing material.
In acute dilatation, which may be due to prolonged diseases, general anesthesia, injuries of the spine, and to narrowing of the duodenum, vomiting, pain and collapse occur. Empty the stomach, and place patient in knee-chest position. Reach beneath the duodenum and raise this part of bowel. Start well down, as low as third or fourth lumbar. If this does not give quick relief stand patient on his head.
Gastroptosis and Enteroptosis[74]
(Glenard’s Disease)
Definition.—A displacement of the stomach and intestines.
Osteopathic Etiology and Pathology.—A weakened, debilitated spine is the common cause. A slight posterior curvature is a frequent occurrence. A debilitated spine impairs the innervation to the abdominal viscera and to the muscles of the abdomen. Many cases are of congenital origin due to lack of complete development and weakness of the supporting tissues. Other causes are muscular strain, repeated pregnancies, tight lacing and malnutrition. A downward displacement of the floating ribs, and a consequent prolapse of, and atony of the diaphragm, is an important cause.
Prolapses of the stomach and intestines are of frequent occurrence in both sexes, and very common in women. It is a condition oftentimes overlooked, and when recognized, little has been done in the way of a cure. It is the cause of much disturbance, not only to the stomach and intestines, but to the various abdominal viscera and to the pelvic organs, and it is the cause of a large percentage of prolapses of the uterus, (excluding lacerations from childbirth) for not only is the great suspensory ligament of the uterus (the peritoneum) prolapsed as a consequence, but all of the abdominal viscera and the parietes of the abdomen are also prolapsed and crowded down into the pelvis. The small or large intestine or the stomach may be prolapsed singly. This is frequently the case with the transverse portion of the colon, which may be elongated and tortuous and prolapsed nearly to the symphysis pubis. Prolapse of the liver, spleen and kidneys may occur singly or with a general displacement of all the organs.
Symptoms.—The abdominal walls are weak, oftentimes flabby. The viscera of the abdomen do not have normal resistance upon manipulation. The spinal column presents lesions. There is dyspepsia, flatulency, constipation, abdominal pains and various neurasthenic symptoms.
Diagnosis.—Is readily made by the lack of tone to the abdominal walls and viscera and the general debility of the patient. Inflation of the stomach with air will determine between gastroptosis and dilatation. The X-ray is of special value in determining position, function, spasms, kinks, etc. of the digestive tube. There are innumerable gradations and phases of this condition.
Treatment.—To remove the cause is of primary importance. This is to be followed by treatment of the spinal column, correcting its various derangements and improving the innervation to the atonied viscera and abdominal parietes. Direct treatment over the abdomen helps to give tone to both the viscera and abdominal muscles. In many cases the treatment will have to be a prolonged one in order that the tissues may regain their normal condition. Usually a treatment from two months to a year, or possibly more, is required. Exercises and manipulations that tone the tissues, correct the posture, and raise the chest, diaphragm, abdominal and pelvic viscera, and release spasms, kinks, and adhesions, are indicated. The diet of the patient should be nutritious, and sufficient in emaciated cases to increase his weight if possible. A supporting bandage will often give some relief. A few cases will require surgery.
Particular attention should be given to the colon, duodenum and diaphragm.
Relative to the treatment of gastroptosis and enteroptosis, W. E. Harris writes as follows: “I first set to work trying to correct the spinal irregularities; coupled with this I give deep and careful manipulation of the gastric and intestinal walls—treating my patient two or more times per week for a period of one to three years. A lesser period is not long enough to bring the desired result in such cases. I also instruct the patient to knead his own bowels, which I prescribe as a necessary proceeding, and to be performed twice daily on retiring and before rising. Of equal importance with the osteopathic treatment, come local, specific abdominal exercises. These are to be of the resistive type, and must also be taken for the general musculature. I have my patient retract the abdominal walls and voluntarily draw the abdominal contents towards the diaphragm, in regular series. These exercises must be faithfully performed and continued after the treatment has ceased in order to be of real value. I do not find our treatment, without the hearty cooperation of the patient in doing his exercises conscientiously, to be sufficient in itself. Have the patient avoid overloading the digestive tract. Use concentrated foods, in small quantities, i. e., only sufficient to sustain strength, twice daily and without taking fluids at meal times. Of course water, in small quantities and at frequent intervals, may be taken between meals. To summarize—First, corrective treatment. Second, resistive exercises. Third, attention to diet.” (See Dilatation of the Stomach.)
DISEASES OF THE INTESTINES[75]
Acute Diarrhea
Definition.—A diffuse inflammation involving the entire intestinal tract to a greater or less degree. Usually the seat of disease is found in the small intestine and the upper part of the large bowel.
Osteopathic Etiology and Pathology.—Acute diarrhea may be caused by overeating, drinking impure water, unripe fruits, and poisons produced in decomposed and fermented milk and other articles of food. This sometimes takes place in perfectly harmless substances in an inexplicable manner. Milk and ice cream may produce intestinal catarrh. Dr. Still often referred to the harm resulting from iced drinks. Changes in the weather, tending to weaken the system, often cause diarrhea; hot weather favors this, although a chilling of the system by a sudden fall in the temperature may produce the disorder. Dr. Still was of the opinion that sitting on the cold ground (a common habit of children) is a frequent source of intestinal derangements. Changes in the quantity and quality of the secretions also induce the disorder; thus the bile, if in too great a quantity, increases the peristalsis to such a degree that diarrhea is produced; if diminished, it favors the fermentation and decomposition of the food. Pancreatic diseases may be a cause of diarrhea. Infectious diseases, through their specific poisons, such as cholera, dysentery and typhoid fever; inflammation, extending into the bowels from adjacent parts; inflammation caused by peritonitis and intestinal obstructions, as invagination and hernia; hyperemia, secondary to diseases of the liver, heart and lungs; cachectic states met with in Addison’s disease; the last stages of Bright’s disease; cancer and marked anemia are all among the causes of diarrhea.
As in constipation, diarrhea is oftentimes simply a symptom of various disorders; still, it may be the only symptom manifested. Lesions are found in various regions of the body, but chiefly in the lower dorsal and lumbar vertebræ and the lower ribs at either side. Also lesions may be found to the vagi, thus increasing the peristalsis or affecting the blood supply of the intestines. The lesions to the splanchnics may involve the motor, vasomotor or secretory fibers to the intestines. Oftentimes the innervation to the liver is disturbed, affecting the secretion of the bile. The left side of the spinal column is involved more often that the right side, by vertebral, rib and muscular lesions.
Nervous Diarrhea frequently follows fright and other causes of nervous excitement, and is often found in hysterical women. There is simply an increase in the peristalsis and secretion of the bowel, due to a vasomotor paresis of the intestinal vessels, producing an outflow of the serum.
The intestinal condition is one of hyperemia. The secretory glands are frequently inflamed. In decided cases the mucous membrane may be red and injected, but more often it is pale and covered with a layer of mucus. Sometimes the solitary follicles are considerably enlarged. These enlargements may become filled with pus, forming abscesses which rupture, leaving an ulcer. Peyer’s patches may also be involved.
Symptoms.—The diarrhea is the important, and often the only, symptom of enteritis; the stools are frequent, varying from two or three to fifteen or more a day; they are thin and watery, varying in color according to the amount of bile they contain. They are usually of a yellowish or greenish color. They contain undigested food, mucus, columnar epithelium and mucous cells, micro-organisms and triple phosphate. The reaction of the discharge is either acid or neutral. There are colicky pains in the abdomen, rumbling noises or borborygmi, intense thirst, dry and coated tongue, with loss of appetite, and, rarely, a fever. When fever is pronounced care should be taken that some infectious disease is not the cause. Chronic catarrhal diarrhea may follow the acute form. If the stools contain much undigested food the inflammation is in the upper bowel; if thin, watery and containing mucus, the lower bowel is involved. In prolonged cases the general health is affected. Definite tender areas along the spine and deep muscular contractions are invariably important etiologic and diagnostic clues.
Diagnosis.—This is ordinarily made easy by giving attention to the above symptoms. In distinguishing as to whether the large or small intestines are involved the following is important: In catarrh of the small intestines, diarrhea is not so well marked; there is much undigested food, but very little mucus; and there is usually pain of a colicky nature in the middle or inferior part of the abdomen. When the large intestine is involved there may be no pain; when present, it is intense and usually in the upper and lateral parts of the abdomen; there are borborygmi and thin, soupy stools, mixed with much mucus. If the lower portion of the bowel is involved there may be marked tenesmus, with marked contraction of the muscles over the sacral foramina.
Duodenitis is often associated with acute gastritis. Placing the patient in the knee-chest position one may be able to palpate the duodenum. If the inflammation involves the bile duct, there is jaundice; in these cases the urine may be bile-stained.
Prognosis.—Commonly favorable if early and prompt treatment is employed; though it should be remembered that some infections, or constitutional disease, or intestinal ulcer may be an underlying cause.
Treatment.—Many cases of acute diarrhea will recover by restricting the diet, with rest. Where improper food and water are the causes, an entire change of diet should be considered. Withdrawal of all food and the substitution of boiled milk will be of great aid. The bowels should never be confined if there is reason to suspect that all irritating matters have not been removed; and when fermentation and irritation exist in the lower bowel, an enema will often be beneficial. The spinal column should be examined, especially on the left side, from the fifth dorsal down to the coccyx. The vertebræ may become displaced and cause diarrhea, by derangement of the vasomotor nerves.
Either an increased blood supply through the intestines, or an affection of the motor nerves will produce an increased peristalsis. An active condition of Meissner’s plexuses may be produced sympathetically, resulting in increased secretion of intestinal juice and thus in diarrhea. The ribs may become displaced and be a source of irritation to the nerves of the intestines. The muscles of the spine are apt to become contracted by colds, injuries, strains, etc., and stimulate or inhibit the action of certain centers in the cord and produce disordered intestines. Conversely the muscles of the back may be thrown into a contracted condition by irritating substances in the bowels acting as a stimulus to the centers in the cord, and thus reflexly to the muscles. Trouble may arise in the colon and rectum by lumbar lesions, the slipping of an innominate, a dislocated coccyx, or contracted muscles over the sacrum. In a word, thorough inhibition, relaxing contracted muscles and correcting abnormal vertebræ and ribs are the osteopathic essentials of treatment for diarrhea. Inhibition of the lower dorsal and lumbar is very effective; it dilates the mesenteric vessels by way of vasomotor fibers, and thus controls secretions and lessens peristalsis. This has been clearly proven in the osteopathic experimental work of Burns and Pearce.
Hot fomentations over the dorsal and lumbar spine will frequently, through the nervous reciprocal relationship, be of decided value.
Direct treatment over the mesenteric circulation, i. e., through the abdomen anteriorly, will be helpful in some cases. It relaxes tissues, removes irritations and frees the circulation generally about the mesenteric vessels and intestines. When giving this treatment one should be certain of the underlying pathology. The liver should be kept active. Treatment of the vagus nerves is important, as they help to control the blood supply and the motor nerve force through the intestines. Daily hot baths and increased activity of the skin and kidneys are beneficial.
Chronic Diarrhea, and Mucous Colitis
Definition.—A chronic inflammation of the mucous membrane of more or less of the large intestines. There may be ulceration.
Osteopathic Etiology and Pathology.—Chronic diarrhea may be the result of repeated attacks of the acute form or may be caused by cancer, tuberculosis, Bright’s disease, typhus fever, disease of the liver, organic disease of the heart and lungs, obstructions to portal circulation or impactions of any nature that occasion passive congestion. Frequently cases of long standing are due to chronic lesions of the lower ribs or lower dorsal or lumbar vertebræ. The lesions of the lower ribs usually consist of downward displacement of the ribs, affecting the innervation to the intestines directly, or possibly dragging the diaphragm downward to such an extent as to interfere with the blood and lymph vessels as they pass through it, thus causing congestion of the intestines by obstruction to the lumen of the vessels.
In many cases the pathological changes are simply those of the acute form. In more pronounced cases the mucous membrane becomes a brownish red, livid gray or slate color; this discoloration being due to hyperemia and blood extravasation. The mucous coat is also swollen and thickened. Atrophy of the mucous membrane, and in some cases of all the coats, with destruction of the glands, may be a result of the chronic form. Ulcerative changes occur chiefly in the lower part of the ileum and colon; these may be follicular or there may be large ulcers and considerable areas of ulceration.
Symptoms.—Constipation and diarrhea frequently alternate; the stools are thin, mixed with a large amount of slimy mucus; the small intestine is most frequently involved, and the patient complains of pain in the umbilical region; there is distention of the bowels with gas; the health gradually declines; there is great pallor, and the patient becomes emaciated, gloomy and irritable.
Mucous Colitis is a chronic form of colitis, characterized by paroxysms of severe pain and the discharge of large masses of mucus, forming gray translucent casts, which are not fibrinous but mucoid in character. This disease occurs usually in women of nervous type, but is occasionally seen in men and children. When there is no underlying organic disease, it is probably largely a secretion neurosis. Mental emotions and worry, sometimes errors in diet, or dyspepsia bring on the attack. Overfatigue is often an exciting factor. The nutrition is generally well maintained, but in other cases there may be a gradual emaciation and ultimate death. This is undoubtedly one of the most persistent and troublesome diseases that one will meet; still the osteopath can do much for these cases and not infrequently bring about a cure. But the treatment must be consistent and persistent.
Mucous colitis is not hard to diagnose, although many cases are treated for simple indigestion. It is needless to say that a correct diagnosis is paramount. In these cases there is almost invariably some visceral prolapse, which undoubtedly is the underlying cause, by favoring venous congestion of the bowels. The liver is usually congested; this alone may cause the venous stagnation, but more often it is simply due to the common cause. Back of the visceral prolapse and congestion will almost invariably be found a posterior dorso-lumbar curvature; still there may be a scoliosis or single lesions only, and a downward displacement and constriction of the floating ribs.
The treatment requires most persistent and careful work for at least three months, and probably six to nine months. Correction of the spine and floating ribs should be of first consideration; then intelligent treatment over the abdomen, by raising and toning the bowels, not only the bowels as a whole, but especially in the ileo-cecal, hepatic flexure, transverse colon, splenic flexure, sigmoid flexure, and rectal regions. The direct treatment should be cautiously given when there are indications of ulceration.
Have the patient help himself by manipulating his bowels night and morning, drawing the abdomen up and in, and by thoracic breathing. Prescribe plenty of drinking water and reduce starchy and saccharine food to a minimum. Again emphasis is placed upon the necessity of persistent treatment, two and three times per week, for several months. The mucus is hard to remove. It is tenacious and frequently causes colicky pains.
To the student Von Noorden’s[76] monograph on this subject is especially instructive. He notes that almost without exception the patients suffer for some weeks or months prior to the development of colica mucosa from obstinate constipation. For acute attacks, among other things, he advises rest in bed, hot applications, and high water injections. He believes in massage of the large intestine (particularly of the sigmoid flexure), in cases of atonic constipation and also in spastic constipation, provided the patient has a diet that leaves a large residue. “A coarse, laxative diet of Graham bread, leguminous plants, including the husks, vegetables containing much cellulose; fruit with small seeds and thick skins, like currants, gooseberries, grapes; besides, large quantities of fat, particularly butter and bacon.”
Diagnosis.—Diagnosis is always easy. The presence of blood, pus, or fragments of tissue in the stool point to ulceration. Ulcers in the rectum, and as high as the sigmoid flexure, will be recognized by examination with the speculum.
Prognosis.—Osteopathy has undoubtedly changed the prognosis of other treatment. Many cases can be cured and most other cases greatly benefited. The deep seated ulcerations may cause circumscribed peritonitis, or even abscess, and the prognosis becomes grave as these complications arise.
Treatment.—As diarrhea may be caused by lesions anywhere from the sixth dorsal to the coccyx, a most thorough examination is necessary. On the one hand, diarrhea may be due to a marked lateral or posterior spinal curvature, which is plainly seen upon inspection, but on the other hand, it may be due to a slight twist or deviation from normal of a vertebra which would require considerable osteopathic ability to exactly locate. Diarrhea may result from subluxation in the lower costal region, one or more of the three lower ribs on either side being involved. Record of one case, in particular, of chronic diarrhea is of interest as it was due to a rib dislocation. It was the case of a man fifty years of age, who had suffered from chronic diarrhea, several stools a day, for over thirty years. He was completely cured in one treatment by correcting the dislocation of the vertebral end of the tenth rib on the left side. This case is cited to impress upon the student the necessity of precise diagnosis and treatment. Rarely will diseases be cured by a single treatment, but when such happens it exemplifies the potency of the osteopathic lesion. Treatment on the left side is usually more effective in diarrhea than treatment on the right side. When diarrhea is a symptom of some constitutional disturbance, correction of dorsal, lumbar and rib lesions, with thorough inhibition, careful dieting and rest, will commonly suffice provided the primary disease is intelligently looked after.
Chronic lesions of the vagi nerves may exist and produce chronic diarrhea in the same manner as in acute diarrhea. Rest and a liquid diet, preferably boiled milk and albumin water, will be a helpful treatment; the diet requirement is to have a minimum amount of waste, so that the residue will cause the least possible irritation. Beef peptonoids with the milk will be a nutritious addition to the diet, and change of air and surroundings may be an aid to a more speedy cure. The skin and kidneys should be kept in a healthy condition and, if necessary, the bowels thoroughly emptied by injections.
Diarrhea of Children
Three forms of diarrhea are recognized in children: Acute dyspeptic diarrhea, cholera infantum, acute enterocolitis.
Acute Dyspeptic Diarrhea
This disease is most frequently due to errors in diet; the mother’s milk may be altered in quantity or quality from taking improper food; the child may be over-nursed, or the foods given in place of the mother’s milk are at fault. Too often a filthy bottle is the cause. The predisposing causes are dentition and extreme heat; and these, combined with constitutional weakness, bad hygiene and a weak spine, diminish the resisting power of the infant. Hence, in artificially fed children of the poorer classes, this disease is very prevalent.
Pathologically, there is catarrhal swelling of the mucosa of both the small and large intestines. The amount of mucus is increased, and there is more or less involvement of all the lymphoid tissue. The submucous membrane is often infiltrated. If there is much inflammation ulcers may occur.
Symptoms.—The child may seem to be in its usual health, with slight restlessness at night and an increased number of stools. This restlessness may be due to nausea and colicky pain. The stools are copious and offensive, containing undigested food and curds. In children over two years old these attacks may follow the eating of unripe food or drinking tainted milk. In other cases the onset may be sudden with vomiting, purging, and griping pains. The fever may rise rapidly to 103 or 104 degrees or more, sometimes followed by convulsions. The stools become more numerous—there may be twenty in the twenty-four hours—gray or green in color, and sometimes containing much mucus, rarely blood.
Diagnosis.—The sudden onset and the character of the stools, which never have a watery, serous character, distinguish this from cholera infantum. And the small amount of mucus which the stools contain distinguishes them from those of ileo-colitis. This form often precedes the onset of specific fevers.
Prognosis.—Among the better classes this is generally favorable, but among the weak, half-starved children of the poor it is often unfavorable, especially in hot weather.
Treatment.—The child should be clad warmly, kept absolutely clean and given a change of diet and air if possible, with frequent baths. Sterilized milk should be given at regular intervals; or if the diarrhea continues, beef juice and egg albumin instead. The bowels should be thoroughly cleansed by injections. The spine should be thoroughly treated through the lower dorsal and lumbar regions, and if the abdomen is not sensitive, a light treatment to the bowels directly will aid recovery. Frequently it will be found that the muscles of the neck and upper dorsals are considerably contracted, especially where the child has fever and is very restless.
For acute intestinal indigestion Ruhrah gives the following dietetic treatment: “Withhold all food for the first twenty-four hours, except a little albumin water. This is best given in small doses at not too great intervals. Plain boiled water may be used instead. Very weak tea to which a little red wine has been added may be given if the child is weak. On the second day the albumin or barley water may be given with the addition of weak strained broth, and on the third day malted milk may be added to the list. After four or five days cow’s milk diluted and boiled or peptonized may be tried. It is best mixed with a farinaceous gruel or with malted milk to start with. It may be given every other feeding for a day or two if it agrees, and the former feeding gradually resumed.
“In nursing infants withhold the breast twenty-four hours and feed as above. After that the breast may be given once for a few minutes and the feeding pieced out with albumin- or barley water. If it agrees the breast may be given for three or four feedings, every other feeding followed by albumin- or barley water. On the following day the breast may be given at each feeding. The time of nursing should be increased gradually until the child is back on its old schedule.”
Cholera Infantum
Definition.—An acute, catarrhal inflammation of the mucous membrane of the stomach and intestines, with some disturbance of the sympathetic ganglia. This is a disease of childhood during the first dentition.
Etiology and Pathology.—Probably due to the poisonous products of decomposing and fermenting foods acting upon the system. The predisposing causes are hot weather, dentition, bad hygiene, the previous presence of some slight dyspeptic derangement, dyspeptic diarrhea, and enterocolitis.
The pathological changes are similar to the morbid anatomy of catarrhal gastritis and enteritis. The serous discharges and rapid collapse are due to the intense irritation of the sympathetic system. The kidneys and liver may become involved, and bronchopneumonia is a possible complication.
Symptoms.—The disease is of sudden onset, setting in with severe vomiting, which is increased by giving food or drink. The stools are copious and frequent, at first containing some offensive fecal matter, and later becoming watery, and odorless. There is decided fever, reaching as high as 105 degrees. The pulse is rapid and feeble, ranging from 130 to 160. Prostration, pinched features, hollow eyes, depressed fontanelles and loss of weight are characteristic symptoms. The tongue is coated at first, but soon becomes dry and red, and thirst is intense. Even at this time a reaction may set in, but more commonly death results with symptoms of collapse and high temperature. In other cases there are restlessness, convulsions and coma. As there is no cerebral lesion, this condition is probably due to toxic agents absorbed from the intestines.
Diagnosis.—This is not difficult, as the toxic symptoms, the severe vomiting, the profuse watery discharge, rapid emaciation and prostration, and the hyperpyrexia are significant.
Prognosis.—Grave, even with the most favorable surroundings, although in numerous instances osteopaths have successfully treated this disorder. Much depends upon the promptness of treatment.
Treatment.—A change of air, complete rest, removal of all foods for a short time, and absolute cleanliness are of great importance. Thorough treatment should be given along the entire spine, particularly to the splanchnics of the stomach and the intestines, and to the vagi nerves in the cervical region. Frequent bathing with cool water, or better still, wrapping the child in cold, wet sheets, will reduce the hyperpyrexia.
Thorough cleansing of the stomach and intestines with warm water occasionally gives excellent results. In collapse the use of a hot bath is indicated, followed by wrapping the child warmly in blankets and placing him in a horizontal position. The food of the child should consist of peptonized milk, raw beef juice, diluted egg albumin, barley water and chicken broth. Nourishment should be given gradually, and only after the intense symptoms have subsided.
Acute Enterocolitis
In enterocolitis the ileum and colon are chiefly affected, especially the lymphatic glands or lymph follicles.
Osteopathic Etiology and Pathology.—Warm weather, the artificial feeding of children, dentition and bad hygiene are predisposing causes. The disease usually occurs between the ages of six and eighteen months, but it is not infrequent in the third or fourth year. This disease is not confined to the warm weather, but may set in at any season of the year. Previous light attacks of diarrhea are often a predisposing factor. Lesions in the spine occur from the eleventh dorsal to the fourth lumbar.
The mucous membrane is congested and swollen, and the solitary follicles and Peyer’s patches are swollen and often ulcerated. The changes may end here or the ulcers enlarge and extend into the muscular coat with the separation of a slough. There may be infiltration and thicking into the submucous and muscular coats, followed by induration of the tissue, producing abnormal rigidity.
Symptoms.—The disease may be a sequel of dyspeptic diarrhea or cholera infantum. The temperature increases and the stools change in character, being at first yellow, and later green. They contain traces of blood and mucus. Vomiting may be present, but is not a constant symptom. The abdomen is distended and tender along the course of the colon. The disease may abate here, recovery from the condition being slow; or the symptoms may increase in severity with persistent, small, painful stools, mainly of blood and mucus, tenesmus, and with scanty urine. The child grows pale and emaciated, and assumes a senile appearance. These cases last five or six weeks, death being preceded by coma and convulsions; though a few recover. Relapses are not uncommon and should be guarded against. Ulcerative and membranous forms may occur. Pneumonia and nephritis are possible complications.
Diagnosis.—Enterocolitis is distinguished from dyspeptic diarrhea by the greater severity, more fever, greater prostration, the stools containing more mucus and even blood, and by the greater pain and suffering. Cholera infantum may be recognized by the abrupt onset, very high fever, constant vomiting, and early collapse. If typhoid fever seems a possibility, the Widal test should be used.
Prognosis.—Grave; recovery follows prompt treatment with favorable surroundings.
Treatment.—Attention should be given to the condition of the spine from the eleventh dorsal to the fifth lumbar. An inhibitory relaxing treatment over the sacral foramina will lessen the tenesmus. When the ileum and colon are involved, disorder is usually present at the third and fourth lumbar vertebræ, although the lesion may be higher. Relaxation of all muscles in this region and correction of the vertebral lesions are essential.
Irrigation of the bowels once a day with a pint of cold water is very beneficial and even pieces of ice may be introduced into the rectum. Fresh, pure air, rest and cleanliness, with a restricted diet and daily warm baths are important. In a word, hygienic and dietetic treatment similar to that for acute diarrhea should be employed.
In all forms of diarrheal diseases in children much depends upon previous osteopathic attention, diet, hygiene, and environment.
Cholera Morbus
Definition.—An acute, gastro-intestinal catarrh of sudden onset, characterized by violent abdominal pains, incessant vomiting and purging.
Etiology and Pathology.—This disease greatly resembles Asiatic cholera; so much so that one seems justified in suspecting that cholera morbus, like true cholera, is due to a specific organism. No single bacillus has yet been designated as the specific germ, although one has been recognized resembling very much the common bacillus of true cholera. Until this has been fully decided, cholera morbus must be regarded as severe inflammation of the mucous membrane of the stomach and intestines, due to some poison generated from the improper food, which seems to be the cause of the disease, such as indigestible fruits, cabbage and cucumbers. It is most prevalent in hot weather, but is also caused by exposure to cold and damp. The condition of the mucous lining of the intestines is the same as in acute diarrhea. In fatal cases of cholera morbus there is the same shrunken, ashy appearance of the skin that characterizes cholera.
Symptoms.—The onset is sudden, with intense cramps in the epigastrium and frequently in the lower limbs; nausea; vomiting, and purging of bilious material, which later becomes almost like water, and in severe cases the discharge becomes serous, finally resembling the rice water discharges of true cholera. There are also intense thirst, moderate fever, rapid emaciation and loss of strength; the surface becomes cold and covered with clammy sweat; the pulse is frequent and feeble. The patient becomes restless and anxious.
Diagnosis.—Asiatic Cholera.—There is no way of distinguishing between Asiatic cholera and cholera morbus, except by examination of the discharges for the bacillus. Similar attacks are produced in poisoning by arsenic, corrosive sublimate and certain fungi, and are only discriminated from it by clinical history and cause.
Prognosis.—In the majority of cases the prognosis is favorable, death rarely occurring. The duration is from twenty-four to forty-eight hours.
Treatment.—A strong inhibitory treatment to the gastro-intestinal nerves is at once demanded. This relaxes the muscles of stomach and intestines, dilates the blood-vessels and lessens peristalsis. The treatment should be kept up until relief is given. In some cases, gentle treatment over the stomach and intestines quiets the distress. Inhibition at the occiput gives relief, especially to the nausea and vomiting. Hot applications should be applied to dorsal and lumbar spine.
The vomiting is relieved principally at the fourth and fifth dorsal vertebræ on the right side near the angle of the ribs. Cold carbonated water and pieces of ice swallowed are useful. The diet must be regulated, the further after treatment being symptomatic. Clear the bowel by warm enema if any irritating matter is still present.
Inasmuch as food passes through the small intestine in 4 to 6 hours, and requires 20 hours to pass through the colon, the colon should be emptied by high irrigation in all acute intestinal disorders.
Intestinal Colic
This is a painful spasmodic contraction of the muscular layer of the intestines.
Osteopathic Etiology.—Lesions of the splanchnics derange the intestinal nervous mechanism, with a consequent upsetting of circulatory equalization and chemical function of the intestines. Thus irritations and obstructions of the reflex arc predispose to lowered resistance, congestions, and disturbed chemism. Indigestible food, flatulency and impaction of feces oftentimes produce intestinal colic. Exposure to cold and emotional upsets may be factors. Foreign bodies, intestinal worms, abnormal amounts of bile discharged into the intestines, and reflex causes from diseases, as from the ovaries, uterus, liver, kidneys, etc., will produce the disorder; also lead poisoning, syphilis, rheumatism, locomotor ataxia, chronic malaria and hysteria.
Kerley says: “Children who take too much milk, too strong milk, or who take milk too frequently are the usual subjects of colic. Probably the most frequent cause of colic is indigestion of the proteid of the milk; either the proteid is in excess or the child has poor proteid capacity. Not a few cases of colic are due secondarily to defective bowel action.”
Symptoms.—Severe paroxysms of pain, centering around the navel and diffused throughout the entire abdomen. The pain is of a piercing, cutting and twisting nature, relieved upon pressure. The abdomen is distended and the patient restless and continually changing his position. The attacks alternate with periods of complete quietude. In severe attacks the features may be pinched and the surface cold, with feeble pulse, vomiting and tense abdominal walls, all indicating incipient collapse. The duration of the attack is from a few minutes to several hours, eased at intervals and usually ending by a discharge of flatus.
Differential Diagnosis.—In lead colic the history, the slate-colored skin, blue line on the gums, sweetish metallic taste, constipation, slow pulse, retracted abdominal walls, and lead in the urine will designate this disease. Biliary colic presents pain in the hepatic region, radiating to the back and right shoulder; also jaundice, calculi in the stools and bile in the urine. Tenderness over the gall bladder is important. Nephritic colic is accompanied by pain radiating down one or both ureters to the inner side of the thigh, with retraction of testicle of side affected, or the labia, and blood, mucus, pus or calculi in the urine. In uterine colic there is dysmenorrhea and pain in the pelvis. In ovarian colic there is extreme pain upon pressure over the ovaries, and hysteria. Abdominal aneurism presents tumor, pulsation, bruit. In inflammatory and ulcerative disorders of the abdomen there is tenderness upon pressure, and fever. The pain of acute appendicitis is at first general, centering in the right iliac fossa in about 24 hours. The X-ray may be of definite aid in renal and biliary conditions and various disorders, such as intestinal adhesions, angulations, etc.
Treatment.—Relief of pain is the first indication and is best accomplished by strong inhibition in the splanchnic region, which relaxes the spasm of the intestinal muscles, by normalizing the reflex arc. If disorders of the spinal column are located, it is of primary importance that they be corrected. In cases of irritation of the intestinal mucous membrane, a contraction of muscles of the spine will be found according to the area of the intestines involved, e. g., irritation of the mucous coat of the jejunum causes contraction of the muscles at the tenth and eleventh dorsals. It is a viscero-motor, viscerosensory or viscerotrophic reflex sign. On the other hand, a lesion at the tenth and eleventh dorsals may produce colic or other disorders of the jejunum. The portion of the bowel affected, therefore, can be often told by noticing the places of muscular contraction along the spinal column. Generally the jejunum and ileum are the portions of the bowel affected in intestinal colic. The pain can frequently be controlled if in the jejunum, at the tenth and eleventh dorsals; if in the ileum, at the twelfth dorsal; if in the ileo-cecal region, including the vermiform appendix, at first to third lumbar; if in the colon, at the third to the fifth lumbar; and if in the rectum, over the sacral and coccygeal nerves. Occasionally the duodenum and jejunum are reached by nerves as high as the fifth dorsal (usually vasomotor nerves, not sensory), and the other portions of the bowel lower, according to their respective positions. The relief is given by way of the splanchnics and sympathetics to the mucous (sensory) coat of the intestines, although inhibition relaxes intestinal muscles (motor nerves) and dilates blood-vessels (vasomotor nerves). Though precisely localized inhibition is of decided value, still if normal alignment, through adjustment, can be secured results are usually quicker and more satisfactory.
Anterior treatment to the abdomen helps to relieve the contracted fascia of the mesentery, with a consequent freeing of the circulation. It aids peristalsis of the intestines and expulsion of the irritating material. This probably produces considerable effect by way of the axone reflex. Direct treatment to the abdomen for the peristalsis relieves also constipation, impactions and the enteralgia, the latter principally by firm pressure. Peristalsis is also increased by stimulation of the vagi and inhibition of the splanchnics. The latter treatment, of course, is not given to relieve pain directly, but to facilitate the removal of irritating substances if such are the source of trouble. If this does not produce a movement of the bowels promptly, a warm enema will assist greatly. The cecum and sigmoid should not be overlooked.
Flatulency can be relieved by direct pressure upon the solar plexus, which apparently removes obstructions to the abdominal nervous system (particularly the nerves of the digestive glands, as fermentation and flatulency are due to a disproportionate secretion of digestive juices) and thus the gaseous formations are absorbed. Additional treatment to the lower dorsal vertebræ and lower ribs to relieve nerve lesions and increasing both thoracic and abdominal circulation may be indicated.
As stated in the etiology of intestinal colic, the splanchnic nerves contain not only sensitive fibers, but motor and vasomotor fibers as well. The same is true of the vagi nerves; they exert upon the intestines not alone a motor influence, but also a blood control; consequently, our work in a certain region can be for more than one purpose. Hot applications to the abdomen may be of benefit. And hot fomentations to the spine for 20 or 30 minutes (affecting reciprocal innervation) is often of great benefit. The diet should always be regulated for a few days at least.
Constipation[77]
Constipation is an unnatural retention of feces from any cause. The following causes are frequently met with: A deficiency of the bile or other secretions that aid peristalsis; many acute and chronic diseases which lessen the secretions and impair peristalsis, such as anemia, hysteria, chronic affections of the liver, stomach and intestines and acute fevers; certain drugs and strong purgatives; strictures; concentrated food; sedentary habits, overfatigue and neglect of the calls of nature. Atony of the colon may be caused by chronic disease of the mucosa and by general disease causing debility. There may be weakness of the abdominal muscles, due to obesity and the distention of frequent pregnancies, or obstructions, such as displaced uterus, pregnancy, prolapsed cecum, sigmoid or rectum, and displaced coccyx. Constipation is really a symptom, in most cases, of some disease; many times it is about the only symptom observed. One has to take into consideration the many causes that would produce constipation when the treatment of a case is undertaken. A disordered structure may be found in almost any region of a body, which would bear directly or indirectly in the causation of constipation.
Irregular habits often bring on the most obstinate cases of constipation in later life. There may also be local causes, such as disturbances of the normal secretions, impairment of intestinal walls, due to inflammation, and mechanical obstructions caused by tumors, intussusception, twists, etc. Constipation in infants is usually caused by errors in diet, but may be congenital.
In all obstinate cases the X-ray should be employed in diagnosis.
In the majority of cases lesions will be found in the vertebræ of the lower dorsal and lumbar regions, or in the lower ribs of either side. The lesions may affect the vascular supply and innervation of the intestines directly, or the lesion may cause the constipation by affecting some other digestive organ first. Lesions to the vagi affecting the peristalsis of the intestines are common.
The usual symptoms are frequent stools, debility, lassitude, headache, loss of appetite, anemia, furred tongue and fetid breath. Serious symptoms may result in long continued cases, such as piles, ulceration of the colon, perforation, enteritis and occlusion. The fecal mass may become channeled and diarrhea may occur from the irritation. In long standing cases of constipation, if the patient suddenly develops diarrhea the rectum should be well examined to see if there are impacted feces present. Neuralgia of the sacral nerves may also be caused by impacted feces in the sigmoid flexure.
Treatment.—Naturally, owing to the numerous etiological factors, each case is a special study and the treatment is necessarily varied. Many cases will present slight impaction of the bowels, a sluggish liver, spinal lesions and so on, which simply require a specific treatment and all the symptoms will be removed. On the other hand, constipation may be due to prolonged ill health and thus require a careful, systematic treatment, not only of the bowels, but of the entire system. Of primary importance in these cases is regulation of the diet, plenty of exercise, sufficient sleep, and regularity in going to stool at a fixed hour each day. The effect of attention to the latter point, in some instances, will be sufficient to perform a cure. Too much cannot be said in regard to the beneficial effect of systematic habits.
Lesions may be found in the spinal column producing constipation from about the fifth dorsal to the coccyx, although principally the lower three dorsal and upper two lumbar vertebræ are at fault. Constipation may be caused by defects at any point in the intestines, and consequently the sections of the spinal column sending nerves through the intervertebral foramina to the several sections of the bowels should be examined. At any point from the fifth dorsal to the coccyx, certain vasomotor, motor and secretory nerves of the intestines may be affected by various lesions. The vasomotor nerves keep up the vascular tone of the bowels, the motor nerves the peristaltic action and the secretory nerves attend to the intestinal juices. In constipation, disorders of the spinal column are generally found on the right side. There is no good reason offered as to why this is so.[78] In those cases where the liver is impaired, the answer might be because most of the nerves to the liver are on the right side, but the right side is just as often affected when the lesions are in the lumbar region and the nerve supply to the hepatic region intact. Dr. Still considered the fifth dorsal of importance.
The vagi nerves have important bearing upon the motor apparatus of the intestines. Lesions in the upper cervical, involving intestinal fibers of the vagi, occur occasionally. Stimulation of these fibers increases the peristalsis of the intestines. Mechanical stimulation of the mid and lower dorsal region, as shown by osteopathic experiments, increases peristaltic action and vaso-constriction in the stomach and intestines.
The value of direct treatment over the intestines from the duodenum to the rectum in most cases of constipation cannot be overestimated. It aids peristaltic action, removes impactions, stretches adhesions, strengthens weakened muscles of the intestines and abdomen, and in general gives tone to all of the abdominal organs. The treatment should not be given in a hap-hazard manner, but each effort should be for a definite purpose. Care should be taken not to bruise the intestines or other organs, as by gouging or severe punching; the flat surface and the palms of the hands should be used. This means that the part of the bowel involved should be treated intelligently, the osteopath reaching underneath the section and the patient drawing the bowels up and in. Obstructions and impactions of the gut, especially at the ileo-cecal and sigmoid regions, should be carefully corrected. At all angles of the gut, impactions and prolapses may occur.
J. H. Sullivan[79] makes the following observation concerning severe, deep abdominal treatment: “I have noted that this often resulted in the reverse of good effects. In constipation, naturally then, I am chary about treating abdominally, confining my work principally to the biliary regions, the ileo-cecal and left iliac regions and have attained good results when a promiscuous working of the abdomen had not so resulted.” This emphasizes the point that specific treatment is as much indicated for the abdomen as it is for the spine.
Frequently there will be found a spastic condition of the pelvic colon, often associated with congestion and adhesions. This probably sets up a reversed peristalsis. Treatment by inhibitory relaxation, with patient in knee-chest position, and adjustment of lumbar and innominate lesions, is indicated.
Direct treatment to the liver and biliary ducts is necessary in many cases, as the bile secretion is often defective; thus a slowness or inactivity of the liver and bile ducts might cause costiveness.
Some cases result from anesthesia of the rectum, due to pressure of the fecal matter collecting in the rectum. Simple dilatation of the rectal sphincters and a stimulating treatment through the sacral nerves will bring about a healthy activity of these parts. Occasionally the coccyx becomes displaced and produces paresis of the rectal nerves; or a displaced uterus or a tumor may produce the same result.
The use of proper food is essential. Coarse food leaves a great amount of residue, and on the other hand, dainty food leaves but little residue, both causing costiveness. As a rule increase the amount of fruit and vegetables. The patient should drink considerable water, and the time is of importance. Have a glass of cool, not iced, water taken on arising and if breakfast is delayed sufficiently, another in half an hour. Most people do not drink enough water. Unless contraindicated eight or ten glasses daily should be insisted upon. An enema[80] occasionally is indicated and is a great aid when used, particularly in cases of paralysis of the intestines and in impactions. Correct breathing and out door life are beneficial.
Treatment of the Constipation of Infants.—Repeated small enemata at a fixed hour each day will often be satisfactory but be certain that the tissue is not irritated. Two ounces of tepid water at a time should be injected. Careful spinal treatment and massage to the abdomen will be useful, as will slight dilation of the anus, which is usually done with the little finger, but in obstinate cases a soap stick may be used. When there has been continued straining at the stool, the sigmoid and rectum will often be found prolapsed, causing a mechanical obstruction. With the finger well lubricated this can be corrected and often is all that is needed. These directions, with care in the foods, are usually sufficient in any case not congenital. In chronic constipation Ruhrah outlines dietetic treatment as follows: “In infants see that they get sufficient fat and protein; well cooked and sweetened oatmeal gruel is useful. Orange juice, baked apple, or prune juice taken on an empty stomach is of service. Olive oil, the malted foods, or malt extracts are useful. In older children fresh fruits, vegetables, and oatmeal porridge are of value. Graham bread, dates, figs, and prunes may be used.”
Intestinal Obstruction
(Ileus)
This is due to a sudden or gradual closure of the intestinal canal at any point. Closure of the gut may be caused by strangulation, intussusception, twists and knots, abnormal contents, strictures, tumors, kinks, spastic states, adhesions, etc.
Strangulation.—This is the most frequent cause of acute obstruction of the bowels. There may be stricture of the bowels due to inflammatory processes producing bands or adhesions, or due to the adhesion of a bowel to an abdominal wound; a vitelline remnant, as a blood vessel, may remain and act as a strangulating cord, or in Meckel’s diverticulum one end may be attached to a mesentery or abdominal wall and thus form a ring through which the gut may pass and become strangulated.
Strangulation may take place through the foramen of Winslow or the foramen ovale, or between the pedicle of a tumor and the abdominal wall.
Peritoneal pouches, mesenteric and omental slits, adherent appendix or Fallopian tubes and diaphragmatic hernia may be other causes. An internal strangulation (hernia) may take place in the crural or inguinal canal, in the umbilicus, in the sacro-sciatic notch or in the opening through which the infra-pubic vessels pass. In strangulation there is a constriction of a portion of the bowel causing an arrest of the circulation of blood at that point, and more or less stoppage of fecal matter of the intestine.
In ninety per cent of cases the strangulated part is in the lower abdomen and sixty-seven per cent occur in the right iliac fossa, according to Fitz.
Intussusception or Invagination.—Intussusception is a slipping of a part of the intestine into another part immediately below it, as the slipping of a part of a finger of a glove or a coat sleeve into another part. The portion involved may be anywhere from half an inch to a foot or more in length. This produces compression and inflammation of the intestine, and obstruction to the intestinal contents. It occurs principally in children and is more common in males.
Spasms of the intestinal muscles and perverted peristalsis are probably the most common causes. One part of the bowel may be dilated and an adjacent portion contracted, thus allowing an invagination. Diarrhea, habitual constipation and intestinal polypi are important exciting causes. Invaginations oftentimes occur just before death, probably due to irregular peristalsis.
Following engorgement and inflammation of the invaginated portion, a tumor is usually present, and lymph is exuded which may cause the layers of gut to adhere, so that the invaginated portion is firmly held. Necrosis and sloughing are then likely to take place.
Intussusception varies according to location and is named according to the part of the bowel involved. There are commonly recognized (1) Ileo-colic, when the ileo-cecal valve enters the colon. (2) Enteric, of the small intestines. (3) Colic, of the large intestine. (4) Colico-rectal, of the colon and rectum. (5) Rectal, of the rectum.
Twists and Knots.—These occur more frequently in males, usually between the ages of thirty and forty. In nearly all cases the twist is axial, accompanied by relaxed and lengthened mesentery. One portion of the bowel may be twisted about another, or a loop of bowel twisted upon its long axis. A bowel being impacted or overdistended by feces and gas, is quite likely to roll on its axis or knot and become dislocated, its weight and inactivity thus producing compression and obstruction of the bowels. The volvulus commonly occurs in the large intestine, at the sigmoid flexure and in the ileo-cecal and cecal regions. It occasionally occurs in the small intestine.
Abnormal Contents.—Obstructions may be caused by gall-stones, enteroliths, lumbricoid worms, certain medicines (such as magnesia and bismuth), fruit stones, coins, needles, pins, buttons, etc., and fecal matter. Foreign bodies usually lodge in the ileo-cecal region and in the small intestine, while fecal impactions occur in the large intestine, more frequently in the lower part. Females are more subject to it than males.
Its causes are many and are similar to those of constipation. Spinal lesions are very frequent, probably causing paresis or paralysis of a segment of the bowel; or all the forces that maintain a normal activity of the intestines may become impaired. Hemmeter[81] says it is “more frequently the result of defective innervation of the intestine.”
Impactions are frequently met with and are easily overlooked under any diagnosis which does not include thorough palpation of the abdominal viscera. The impaction may be so large as to produce dilation of the bowel. The obstructive mass becomes very hard and dry and perhaps channeled, allowing some material to pass until, finally a large piece of fecal matter will obstruct the passage completely. In diagnosis it must not be confused with neoplasms, tumors, etc. Impactions may occur at any point of the colon and the weight so drags the bowel out of position as to be misleading. The principal points are the ileo-cecal region, sigmoid flexure, and rectum. Tenderness is usually present, as may be diarrhea which must not be taken as evidence that the bowel is clear. Impaction gives rise to many reflex symptoms and is often the real cause of many mistaken conditions.
Too much cannot be said on the importance of a thorough examination of colon and its connections, which should be routine of every examination as the large bowel is impacted much more often than suspected and may be the seat of many reflex and direct disturbances. The heart may be affected by weight upon the vessels, gastric disturbances and signs of auto-intoxication from absorption may appear.
Dilatation of the sigmoid flexure, especially when it is congenitally long, may even be so great as to crowd up and interfere with the liver and diaphragm; in these cases the coats of the intestines are usually hypertrophied.
Strictures and Tumors.—These usually occur in adults, more frequently in women and generally involve the large intestine and lower part of the abdomen, most of them occurring in the left iliac fossa. They frequently result in chronic obstruction. Occasionally, a stricture may be spastic, due to vertebral lesions, that is severe enough to cause complete blockage of intestinal contents. These are usually of the pelvic colon. There are cases where the opposite condition, paralysis of a section, generally of the small intestine, occurs. This may be due to injuries to the bowel, or to damage of the blood supply, or to derangement of the innervation.
Scar tissue, following ulceration of the bowel; tumors of various kinds; and congenital defects, are possible sources of intestinal obstruction.
Symptoms.—Acute Obstruction.—There is constipation, nausea, vomiting, and pain. The pain is of a colicky nature and may come on abruptly. After the contents of the stomach have been vomited, the material becomes colored with bile, and finally stercoraceous vomiting occurs. Observing the contents vomited (gastric, bile-stained, and fecal) will greatly aid in the diagnosis. The contents of the bowel, below the obstruction, may be emptied or complete constipation may remain. All the symptoms, as a rule, rapidly grow more pronounced. The pain is more severe; tenderness occurs over the abdomen in limited areas; there is slight tympany; the eyes are sunken; the skin is cold and clammy; the pulse is quickened and feeble; there is rapid increase of leucocytes; the urine highly colored; the tongue is dry and there is incessant thirst; tenesmus and tumor may be marked, and fever occasionally occurs. The above condition may continue from three days to a week, when collapse and death may occur, if relief is not obtained.
Chronic Obstruction.—In fecal impactions constipation of long standing is commonly observed. In some cases the fecal mass has become channeled, allowing the bowels to remain open; the patient possibly not knowing that there is any trouble. In fact, diarrhea may be present, due to irritation above the impaction. Finally, however, obstruction occurs; the breath is offensive, the appetite is poor, the abdomen swells, and there is fullness and weight within the abdomen, accompanied by pain and vomiting. Upon examination before complete closure, the fecal impactions can easily be felt through the abdomen externally. The tumor is a yielding mass. It has been mistaken for an enlarged liver or gall-bladder, a kidney, or a tumor of the stomach or duodenum. Other symptoms may be present as hiccough, jaundice, tenesmus, tumultuous peristalsis, local peristalsis, local peritonitis and collapse. In stricture caused by cicatrices that may have been formed years before, complete obstruction takes place. Transient attacks often occur. Usually the general health is greatly impaired long before complete occlusion.
Diagnosis.—A diagnosis can usually be made by careful, thorough examination through the abdominal wall, in connection with the symptoms, and the physical signs. The region of intestinal trouble is manifested by contracted muscles at certain points along the spinal column, corresponding with the particular portion of the bowel involved, as indicated under intestinal colic. Examining the patient in the knee-chest position will often give a better opportunity to locate and outline the obstruction. Rectal and vaginal examinations should not be neglected. Intestinal obstruction may be confounded with tumors, hernia, intestinal colic, enteritis, peritonitis, hepatic colic and renal colic. Peritonitis may be differentiated by the history, the early fever, diffused tenderness and absence of fecal vomiting. When invagination occurs, besides the symptoms of obstruction, the age, tenesmus, bloody discharges and the sausage-shaped tumor in the line of the colon, will be diagnostic. In stricture, the history, gradual onset, and ribbon-like and bloody stools will distinguish that disorder. In tumors the gradual onset, age, bloody discharges, and cachexia will be important symptoms. X-ray diagnosis may be of value in certain cases.