By Charles J. Muttart
The instant relief that Osteopathy can give in acute indigestion is one of its outstanding achievements. It impresses the patient and his friends with a deep conviction of the superiority of osteopathic therapy. The results in these cases are not, in any sense, a matter of chance. They follow logically from the osteopathic viewpoint, teaching, reasoning, and practice. In dealing with the manifestations of disease, such as heredity, onset, course, duration, subjective and objective symptoms, etc., and in the effort to differentiate cause from effect, and to reconstruct a mental picture of the sequence of cause, effect and sequelæ, the osteopath has the advantage of binocular vision in that he recognizes two distinct pathologies cooperating to produce the symptom complex, syndrome or disease which he is called upon to treat. One pathology is to be found in one or more of the vertebral and rib articulations and the immediately adjacent or corresponding segments of the spinal cord. The other is in some one or more of the organs or tissues connected with the pathological segment or segments of the cord.
The function of the joint is MOTION.—Unrestricted normal range of motion is essential for the normal function of all parts of the articulation as well as for the nutrition of the nerve mechanisms immediately adjacent. When a spinal articulation ceases to perform its function all of its parts are more or less impaired, muscles atrophy, ligaments lose their tone, and circulation to and from the spinal segment is interfered with because action is a large factor in promoting the flow of blood and lymph and maintaining normal stimulus.
As a result of this spinal pathology, internal organs and tissues, supplied by nerves arising in the segment that is in lesion, will be variously disturbed in their function.
Dr. Carl P. McConnell says: “My observation of lesioned animals so far as the digestive organs are concerned is that the lesion affects the reflexes of and through spinal and sympathetic ganglia so that the vasomotors are involved with a consequent hyperemia of the submucous coat. This means involvement of the endothelial layer of the blood-vessels, diapedesis, derangement of the secretory function and disturbance of the motor mechanism, all of which lead to functional upset and disturbance.”
The dominant part played by the osteopathic lesion as a causative factor in acute and chronic diseases of the alimentary canal becomes increasingly evident as clinical observation and laboratory research permit a more thorough appreciation of the anatomy and physiology of the parts involved. The abnormal stands out more clearly from the normal. Finally, the task of restoring normality is becoming a clear-cut problem to which the correction of the osteopathic lesions furnishes an almost complete solution.
The normal alimentary canal transports food, macerating it, mixing it, and treating it with various chemicals and enzymes on the way, breaking it down physically and chemically, and absorbing from it such end-products as are needed to maintain metabolism. The abnormal alimentary tract may be at fault in any of these functions. This delinquency is generally traceable to a mechanical origin. Correction of the mechanical deviation is followed by restoration of normal function except in cases where extensive tissue changes have occurred.
Thorough mastication is essential to good digestion. Any dental defects or deficiencies should be corrected. The temporo-mandibular articulation should be examined, and full free motion restored if lacking. The muscles on the affected side are softer than on the sound side. Tonic spasm rigidly closes the mouth. It may be due to tetanus, caries of the lower teeth, cutting of the lower wisdom tooth, or other irritations to the sensory branches of the inferior maxillary nerve. There is enough space back of the wisdom teeth to pass a catheter to administer food.
The tongue assists in mastication and deglutition and is the seat of most of the nerves of taste. The hypoglossal nerve, which supplies it, leaves the skull through the anterior condyloid foramen and may be impinged there or lower in its course. Lesions of the occiput and upper cervical vertebræ and obstructions to the lymphatic drainage at the angle of the jaw may cause pressure on this nerve and cause disturbances in the movements of the tongue, atrophy, swelling, etc. Swelling may be due also to endocrine disturbance, constitutional diseases, anemia, glossitis, local irritants, injuries, etc. Pressure may be made on the hypoglossal nerve behind the angle of the jaw.
The special sense of taste plays an important role in normal digestion. The lingual nerve supplies the anterior two-thirds of the tongue with taste. The sense of taste may be lost, impaired, perverted or otherwise abnormal.
The sense of smell plays an important part in our appreciation of flavors, and when it is impaired by colds, adenoids, or other affections of the nose or pharynx, the sense of taste is measurably impaired. Normalization of nose and pharynx restores the sense of taste in such cases. Impairment or loss may also be due to lesions of the chorda tympani, or glosso-pharyngeal nerves. Lesions of the mandible, hyoid, occiput or upper cervical nerves, parotid disease or obstructed lymphatic drainage behind the angle of the jaw may cause pressure directly or indirectly on the glosso-pharyngeal and chorda tympani nerves. Perversion of taste occur in pregnancy, hysteria, epilepsy and insanity.
Foul taste, fetororis in the mouth is frequent in pneumonia, typhoid fever, peritonitis, septicemia and other severe fevers; also after ingestion of pungent foods or strong drugs; in constitutional diseases; as a result of inattention to oral hygiene, excessive smoking, mouth breathing at night, furred tongue, etc. It clears up on removing the cause.
Furred tongue occurs in gastritis, fevers, and a variety of other conditions. The fur is composed of broken down epithelium which would normally be removed by friction with solid food. When none is taken, the fur accumulates. When blood or hematin becomes mixed with the broken down epithelium, the fur is brown. Ordinarily it is white. A clean red tongue is frequently found in hyperacidity. It is probably due to vasodilatation due to hyperactivity of the autonomics or inhibition of sympathetics. The sympathetic supply is from the superior cervical ganglion. It may be affected by lesions of the occiput, atlas, axis and third cervical vertebra, of the hyoid, by anterior cervical muscular contractures, by obstruction to venous and lymphatic drainage and blood supply. Correction of the lesions named and normalization of the other structures involved will usually restore the tongue to normal condition.
The salivary glands have a two-fold innervation. The thin, full, watery, salty secretion is produced by activity of the cranial autonomic fibers; the sparse, viscous secretion containing the organic elements, ptyalin, etc., is produced by the sympathetics. The sympathetic nerve supply is from the middle and superior cervical ganglia and can be disturbed by lesions affecting them as mentioned above. The secretion of ptyalin may be disturbed by any lesion from the fifth dorsal up.
It must not be forgotten that a posterior occiput draws the superior cervical ganglion back against the axis and third cervical with just as much pressure as is exerted by an anterior atlas or third cervical. This pressure or stretching tends to inhibit it, preventing vaso-constriction and permitting vasodilatation of the internal carotid artery and its branches and congestion of the parts supplied, mid-brain, cerebrum, etc.
If, for any reason, the venous drainage from the lateral sinus into the internal jugular vein, or the ebb and flow of the cerebrospinal fluid between brain and cord, is reduced or hampered, an extra burden is thrown on the cerebral veins and sinuses, and the intra-cranial pressure is raised at each heart-beat, ultimately producing pressure on the meninges and causing violent headache over the fifth and tenth cranial nerves which supply the meninges with sensation. These nerves are intimately connected with the digestive system. Any increase of intra-cranial pressure causes increased irritability and hyperactivity of the cranial nerves, many of which are concerned with various functions of the digestive system. Moreover, the nuclei of these nerves lie on the floor of the fourth ventricle which is supplied mainly by the vertebral arteries and the basilar artery. Lesions of the cervical vertebræ affecting the plexus on the vertebral artery or filaments to it from the upper parts of the cervical gangliated sympathetic cord, may impair the blood flow through the vertebral arteries and cause similar increased irritability of the nerve cells in the medulla, mid-brain and cerebellum. Such disturbance is reflected in awkward movement, hyperesthesia, and symptoms due to increased irritability of the autonomic nerves such as slow pulse and respiration, watering of the mouth, hypersecretion and hypermotility of the gastro-intestinal tract, rapid digestion and poor assimilation, vasodilatation, impoverished blood, and so through a vicious cycle back to still greater impairment of nutrition to the nerve cells within the cranium. Until the lesions are corrected, the condition becomes progressively worse till exhaustion occurs.
Ordinary medical hygiene can do little or nothing. The palliative remedies employed simply mask the symptoms, or actually accelerate the destructive process. Lesions that irritate the cervical sympathetics would cause vaso-constriction and give rise to opposite symptoms, namely, cerebral ischemia, decreased flow of saliva, atony of stomach, lack of digestive juices, sluggish intestinal peristalsis, rapid pulse and respiration, etc. Correction of the lesions and restoration of normal blood supply and drainage to the brain and removal of any lesions tending to inhibit the sympathetics from the fifth dorsal up, will usually in a short time restore the activity of the salivary glands to normal. The otic and sphenopalatine ganglia can be disturbed by abnormal conditions within the pharynx. These must be corrected when found.
Deglutition, or swallowing, is a very rapid, highly complex movement. It takes not more than a second for the food to cross the pharynx. The soft palate and larynx are raised to close off the air-way, making the food-way practically continuous for the second needed to complete the transfer of the food across the air-way. The tongue is pressed against the roof of the mouth and the mylohyoid contracts vigorously and shoots the bolus of food across the pharynx. Bolting the food leads to serious digestive disturbances, not the least of which is the loss of the normal reflex which prevents swallowing unprepared food. When lost, this reflex can be restored by thorough mastication for three or four months.
The voluntary part of swallowing is performed by the motor portion of the fifth cranial and the hypoglossus. The involuntary part involves afferent impulses over the superior laryngeal and efferent impulses over the inferior laryngeal. The levator palati which raises the soft palate is probably supplied by the spinal accessory nerve through the pharyngeal plexus. This nerve can be affected by lesions of the occiput, atlas, mandible and hyoid, and by any obstruction to lymphatic drainage which increases pressure behind the angle of the jaw. In paralysis of the levator palati, as after diphtheria or other peripheral neuritis, fluids regurgitate through the nose during the act of swallowing. The raising and closing of the larynx is accomplished by the superior and recurrent laryngeal nerves by way of the pharyngeal plexus. Pain in swallowing is generally due to some inflammation or infection of the tonsil or pharynx. This does not occur when everything is normal from the fifth dorsal up.
The second and third stages of swallowing occur in the esophagus. The esophagus receives esophageal branches from the vagus, carrying autonomic fibers which contract its longitudinal muscles and dilate its arteries. It also receives sympathetic impulses from the plexus on the arteries which supply it. These sympathetic impulses convey vaso-constriction and constriction of the circular muscles of the esophagus. Any lesion from seventh cervical to ninth dorsal might affect the esophagus; probably fifth dorsal is the most nearly specific, as the heartburn which results from regurgitation into the esophagus is usually localized there.
Lesions of the upper six dorsal vertebræ interfere with digestion and nutrition in another vital way by reducing the activity of the lungs and consequent intake of oxygen into the system. If there is not sufficient oxygen to oxidize the proteins to amino-acids there will be harmful products left for the tissues to neutralize. Lesions of the third, fourth and fifth cervical affecting the phrenic may have a like effect. Sub-oxidation must be noted when present and treated by removing lesions affecting respiration, by deep breathing exercises, and by diet rich in the needed mineral salts, and properly balanced. An improperly balanced diet changes the structure of the tissues and amounts in effect to an osteopathic lesion which causes disturbed function. It must be searched for, found if present, accounted for, corrected and kept corrected to obtain maximum therapeutic results.
The stomach, intestines and rectum are intimately related with the other abdominal viscera.
It will therefore be readily seen that any disturbance of the liver, gall-bladder, pancreas, spleen, duodenum, pleura or peritoneum will disturb the function of the stomach, and that any disturbance of any organ will disturb the function of the intestine. In fact, clinically, it would seem that the majority of cases can be accounted for by the lesions found, the stomach or intestinal disturbances which are regarded as reflex from some other organ, being in reality caused by the same lesion as disturbed the organ which first manifested disturbance.
Going more deeply into the nature of the mechanism whereby symptoms of gastro-intestinal disturbance are produced, we find that the alimentary tract has an ingenious conveyer mechanism with a number of sphincters. These are operated by intrinsic sympathetic or myenteric nerves, called plexuses of Meissner and Auerbach. In conveying food, impulses are passed from one portion of the tract to the next over these myenteric arcs. Normally the peristaltic movement is always forward because the point of highest irritability is at the proximal end. There is an exception to this rule in the ascending colon, where antiperistalsis occurs normally. When the irritability of a distal point of the alimentary tract becomes greater than the more proximal points, an antiperistaltic wave is set up causing vomiting. The myenteric activities are regulated by the autonomic impulses over the vagus, and by the sympathetic impulses over the splanchnic nerves. The autonomics contract the longitudinal muscles, dilating and shortening the tube. They also stimulate secretion of digestive juices and fluids and mucus and dilate the blood-vessels. The sympathetics contract the circular fibers and sphincters, narrowing and lengthening the tube, retarding the food, inhibiting the secretions and constricting the blood-vessels. The myenteric reflexes can continue after the vagi and splanchnics are cut. The vagi simply stimulate them and the splanchnics inhibit them. The pathways are from the coeliac plexus where the vagi and splanchnics meet with various other plexuses on the arteries and following the courses of the arterial supply to the minutest parts of each organ. Each cell is surrounded by nerve fibers. Visceral-afferent fibers over both vagi and splanchnics convey impulses to the cord segments and medulla which modify the systemic blood supply, drawing blood from the head and surface by constricting their arteries during digestion and filling the abdominal arteries. If opposite impulses should be received drawing blood away from the abdominal arteries, digestion would be interfered with. Any lesion or other condition causing hyperirritability or overstimulation of the vagus will result in overstimulation of the myenteric nerves, with vasodilatation, hypersecretion, contraction of the longitudinal coat, widening and shortening of the digestive tube, sluggish peristalsis but rapid movement of food through the sphincters, incomplete digestion and undernourishment. Inhibition of the splanchnic nerves will produce a like result. The opposite condition would come about as a result of inhibition of the impulses over the vagus to the myenteric nerves, or of overstimulation of the splanchnic nerves.
Inhibition of the splanchnic nerves may be secured by extreme flexion of the spinal column. This raises the cord in the spinal canal, lengthens it, stretches or draws on the nerve roots and vessels, squeezes the fluid out of the cord, and inhibits the splanchnics in two ways, first by a partial anemia or ischemia of the cord, and secondly by direct traction of the visceral afferent fibers in the posterior and anterior roots.
Conversely, stimulation of the splanchnic nerves may be secured by complete extension of the spinal column. This lowers the cord in the spinal canal, shortens it, releases the strain on the nerve roots and vessels, flushes the cord with blood, and tones up the sympathetic impulses in two ways, first by increasing their relative and absolute nutrition, through richer supply of richer blood, and secondly by releasing the nerve roots from strain, permitting free entry of afferent impulses over the posterior roots, and free exit of visceral-efferent impulses over the anterior roots.
Any lesion, inasmuch as it limits or alters the normal motion in a joint, produces an exaggeration or diminution of the normal spinal curves, and more or less lateral curvature. The altered equilibrium thus produced affects the viscera in three ways: 1. Mechanically, by pressure, gravity, altered position of ribs, vertebræ, diaphragm, etc.; 2. Reflexly, influence on nerves to and from affected segment; 3. Directly, by interference with nutrition of nerve cells by hyperemia or ischemia.
There is always a functional kyphosis in visceroptosis or splanchnoptosis. The nerves in the cord are inhibited. The skeletal muscles are hypotonic, allowing the functional kyphosis to occur, and the viscero-motor nerves are inhibited, allowing the abdominal viscera to become hypotonic and sag out of place within the abdominal cavity. The ribs are held up by the cervical fascia, and the abdominal muscles are held up by the ribs. The hypotonic condition extends to intercostals and abdominal muscles, with the result that the abdominal muscles are unable to play their part in maintaining the viscera in their proper places. The contraction or tonus of the abdominal muscles, the external and internal oblique, transversalis, rectus abdominis, diaphragm and levator ani, maintain the viscera firmly in position. It is only when the muscles of the abdominal wall have lost their tone that any strain or weight is thrown on the peritoneal and vascular supports. The inhibition of the restraining sympathetic impulses via the splanchnic nerves, allows hypersecretion and hypermotility of the alimentary tubes and further complicates the clinical picture by a colicky diarrhea or spastic constipation.
There are eight sphincters of circular unstriped muscle in the alimentary tract. Inhibition of sympathetic supply or increased autonomic supply causes sphincter insufficiency, overstimulation by sympathetic impulses or an insufficient supply of balancing autonomic impulses causes sphincter spasm, stasis, vomiting, fermentation, putrefaction, auto-intoxication. At each of these sphincters food is held back and controlled till the proper time has elapsed and the proper chemical environment is prepared for it in the next portion of the tract. Normal function of these sphincters is absolutely essential to normal metabolism and nutrition. The upper esophageal sphincter controls the entrance to the esophagus; the cardia controls the entrance to the stomach, the pylorus controls the entrance to the duodenum, the X-Ray shows a duodenal sphincter that controls the entrance of food into the jejunum. Here the food enters the long tract of the jejunum and ileum which measures twenty-five feet when the longitudinal muscles are relaxed and the circular muscles tonic, and which a short time later may measure only fifteen feet when the longitudinal muscles are contracted and the circular are relaxed. This section ends at the ileo-cecal valve, which controls the entrance of food into the cecum. There is the mid-colic sphincter about the junction of the proximal third with the distal two-thirds of the transverse colon, and the recto-colic sphincter which controls the passage from the sigmoid to the rectum. The rectum ends in the internal sphincter ani. There is some evidence of a ninth sphincter, the mid-gastric at the point where the peristaltic waves of the stomach begin. Absorption takes place mostly from the ileum and jejunum and it is worthy of note that four of these sphincters hold the food up on its way into this part of the tract, and four of them hold it back on its way out. Any lesion may affect one or other of these sphincters. It is believed that antiperistalsis from the mid-colic sphincter to the cecum during digestion is normal permitting more complete absorption of nourishment. Yet here, after absorption is complete, and at all times elsewhere in the alimentary tract, peristalsis is normally forward because the point of highest irritability is at the upper esophageal sphincter and the irritability decreases as the tract is further from the esophagus.
When the splanchnics are inhibited and the vagus autonomic impulses are normal or increased, the intestinal sphincters from the pylorus down may all be incompetent, so that food passes along too rapidly to be properly digested and absorbed. This results in undernourishment.
Any lesion anywhere in the body will affect peristalsis. It begins at the lower third of the stomach where it joins the pyloric portion and goes forward to the internal sphincter ani, being modified in its course by local conditions. Compensation may be established. Many cases of diarrhea and constipation are thus to be accounted for. Diarrhea is a symptom due to vasodilatation, hypersecretion and relaxation of the circular muscles especially at the sphincters. When these three factors are cleared up by correction of the lesions and hyperextension of the spine, the diarrhea stops unless some other factor is at work to irritate the myenteric nerves or to excite the autonomics or inhibit the splanchnics. Lesions from the sixth dorsal down are usually accompanied at first by some diarrhea, which afterwards becomes constipation, through loss of tone in the longitudinal muscles especially in the distal part of the colon. In these cases, correction of lesions, and extreme flexion of the lower dorsal and lumbar spine will give relief while the body is returning to normal.
When gastric digestion begins, simultaneous action is set up in the ileum. When disease of the cecum, appendix or ascending colon is present, there is contraction of the ileo-cecal valve causing stasis of the lower ileum and disturbed or retarded action of stomach and duodenum. These reactions are brought about by impulses to and from the myenteric plexus. The sympathetic and autonomic nerves affect the motor system of the alimentary tract not directly but through the myenteric or Auerbach’s plexus.
The external sphincter ani muscle is supplied by the pudendal nerve from the third and fourth sacral segments. It is in a state of tonic contraction, and having no opposing muscles keeps the anal orifice closed. The autonomic supply to the longitudinal muscles in the descending colon and rectum is from the second and fourth sacral. Inhibition here will, therefore relax the longitudinal muscles and external sphincter and permit free peristalsis in the descending colon and rectum. Pelvic disturbances may affect these nerves, or pressure due to visceroptosis, etc. The circular muscles of this section are supplied from the lumbar cord. They may be affected in any lumbar lesion, with the end result of spastic constipation by reason of a shortened markedly distended descending colon, sigmoid and rectum, and little peristalsis because of inhibition of the circular fibers, and contraction of the external sphincter ani.
The fundus of the stomach, lying in the left dome of the diaphragm, always contains a cushion of air which supports the left dome of the diaphragm, as the convexity of the liver supports the right. Normally the air is regulated and causes no symptoms. A lesion, usually of the mid-dorsal or lower dorsal segments may inhibit the circular fibers and permit distension, which becomes enormous when the pylorus is obstructed. The shortness of breath, palpitation of the heart, etc., accompanying this distension are probably due to pressure on the heart and lungs from which the stomach is separated only by the diaphragm.
Eighth, ninth and tenth dorsal lesions play a large part in peptic ulcers by permitting hyperemia, hypersecretion, and lowered vitality of the mucosa, and pyloric incompetence or spasm, because the pylorus, pyloric end of the stomach and first part of the duodenum get their chief sympathetic supply from the ninth and tenth dorsal segments of the cord. The tenth vertebra is more freely movable than the higher dorsal joints and is therefore more frequently in lesion, which helps to account for the greater frequency of duodenal ulcer.
The main sympathetic supply to the appendix seems to be derived from the eleventh dorsal segment. The appendix has the same motor and secretory mechanism as the rest of the alimentary tract but is richly supplied with lymphoid follicles. One of the twigs from the eleventh dorsal nerve pierces the rectus muscle to supply the skin at McBurney’s point, thus explaining the great frequency of pain and cutaneous hyperalgesia at this situation in appendicitis. Lower dorsal and upper lumbar lesions are unquestionably causes of many cases of appendicitis and other obscure diseases traceable to appendicitis. Correction of these lesions has restored the appendix and related structures to normality in hundreds of cases.
Sensory reflexes are shown in hyperalgesia and pain or tenderness in the abdominal skin and muscles and the parietal layer of the peritoneum from the ensiform cartilage to the pubes in an area extending about two inches on each side of the mid-line, corresponding to the distribution of the twigs of the lower six thoracic nerves which supply sensation to this region. Esophageal disturbance at the cardia causes pain in the region supplied with sensation by the fifth and sixth dorsal, near the ensiform. Gastric derangement causes pain midway between the ensiform and umbilicus, which radiates to the left, in the area supplied by the eighth dorsal. Hepatic disturbance causes pain on the right of the median line, radiating to the right in the sensory distribution of the ninth dorsal. Intestinal pain is located in the sensory distribution of the tenth dorsal nerve in an oval area around the umbilicus. Pain due to duodenal ulcer is sharply localized at a point about an inch or two above and to the right of the umbilicus where twigs of the tenth dorsal nerve come to the surface. This point corresponds closely to the normal position of the underlying duodenum, though the duodenum may be displaced, and the sensitive spot remain at the same point. The pain from fundal gastric ulcer or carcinoma is usually localized sharply about an inch or two to the right of the median line midway between the ensiform and umbilicus, at the spot where the twigs from the eighth dorsal nerve pierce the rectus and come to the surface. In the disease of the pylorus, reflex pain is lower; of the cardiac end, higher. The reflex pain at McBurney’s point in appendicitis has been referred to, but it must be borne in mind that pain from disturbance in the colon also shows in the sensory distribution of the eleventh dorsal nerves midway between the umbilicus and pubes. Pain may also be referred to areas supplied in the back by the corresponding segments. These reflex pains can usually be stopped by inhibiting along the spine corresponding to the sensory area affected. This reduces the impulses entering the posterior roots and lowers the irritability of the segment.
The motor reflexes from gastro-intestinal disturbances result in muscular contractures of spinal, abdominal and other muscles supplied by motor nerves arising in the anterior horn of the segment which innervates the part of the viscus that is affected. Stomach, liver, gall-bladder, pyloric and duodenal disturbances cause increased tone, contraction, contracture and rigidity of the rectus muscles above the umbilicus, for instance, and the other viscera contract it in lower portions. More important are the extreme contractures of the musculature of the back which is supplied by the segments which supply the affected part of the viscus. These contractures produce some distortion and loss of motion in spinal joints and thereby produce the same effects as primary lesions, causing widespread disturbance which persists until the spinal musculature is normalized. In colic, the lumbar segments being involved, there is marked contraction of the ilio-psoas which causes the characteristic drawing up of the thighs on the abdomen, while the extreme contraction of the rectus abdominis draws the thorax down.
Most persistent vomiting may arise reflexly from other organs as in so-called biliousness, jaundice, pregnancy, brain affections, appendicitis, onset of acute infectious diseases, alcoholism, sea-sickness, colic, hernia, intestinal obstruction, migraine, shock, and anesthesia. Irritation of any sensory branch of the vagus or of nerves which connect with it in the medulla, or reflexly from consciousness via the cerebral cortex, as in the case of nauseating sights, smells, tastes, as well as irritation from any viscera innervated from the sixth dorsal down, may overstimulate the corresponding efferent nerves going to parts of the alimentary tract supplied by that segment, increase its irritability and start antiperistalsis. Similarly disturbances in almost any viscus may reflexly disturb the normal balance between sympathetic and vagal autonomic stimuli resulting in hypersalivation, hyperchlorhydria, pylorospasm, distension, gastric atony, gastrosulcorrhea, enterocolitis, spastic constipation, achylia, or colicky diarrhea. In these cases, the derangement of the viscus reflexly disturbs the alimentary tract through central nerve connections. Correction of the primary trouble is followed by removal of the reflex symptoms. In this connection it is important to note that the visceral reflex symptoms may arise from irritation of the alimentary tract by improper diet, poor cooking, or wrong combinations. Carbohydrates digest quicker than proteins, and these more rapidly than fats. Food is handled by the fundus in the order in which it was swallowed. If the fats are swallowed first, the starches may be held up for five or six hours, subjected to the acid stomach secretions and allowed to ferment causing distension, which reflexly produces a variety of symptoms.
Mental exertion, strong emotions, heavy physical exertion, interfere with the function of the alimentary tract and set up disturbances in the balance of sympathetic and vagal autonomic impulses, through the nervous reflexes via the cortex, and through the demand for blood, which impoverishes the abdominal circulation at a time when it needs all the blood it can get. The ischemia produced in this way has about the same effect as ischemia produced by a spinal lesion. Conversely, disturbances of the alimentary tract produce profound changes in character and personality, by reflexes to the cerebral cortex causing dullness of perception, in all the senses, poor memory, sluggish thought, erratic judgment, irritable disposition, fear, worry, lack of ambition, indecision, lack of energy, vacillation, and finally a psychosis in which manic depressive symptoms are balanced by paranoiac symptoms.
The alimentary tract is so intimately bound up with the whole stream of vital activity, whether vegetative, sensorimotor, or psychic, that any disturbance of body or mind is likely to affect it in some part, and conversely any disturbance of the alimentary tract is bound to affect all the rest of the body and the mind. A satisfactory classification of its diseases is therefore difficult to make, but the one here adopted is probably the best for the purpose. The early stages of gastro-intestinal diseases are often so similar that it is nearly impossible to differentiate them with certainty; the classification is therefore based on the clinical picture and pathology of advanced stages. Fortunately, with the exception of cancer, diseases treated in the early stages usually clear up when the lesions are corrected, and the necessary attention given to the other causative factors present.
Acute dyspepsia is one of the frequent disorders of the stomach. It may occur as an early symptom of an infectious disease, but very often it is due to some non-specific irritation. The usual exciting causes are errors of diet, over-indulgence in improperly cooked and highly seasoned food, or food that has been spoiled, such as meat, fish and milk, or over or under ripe fruit. Food that is either too hot or too cold may develop an attack. Alcohol is a common cause in those not accustomed to its use. Overuse of tobacco may bring on an attack. Many acute “bilious” attacks are brought about by some mental shock or excitement at the time of taking food, for it has been shown by the researches of Pawlow that both gastric motion and secretion are altered by mental irritation during digestion.
Unquestionably osteopathic lesions of the splanchnics and vagi are important predisposing factors. These lesions produce a lowered resistance of the tissues, which will frequently explain why certain exciting factors that will initiate an attack in one individual will not do so in another. A healthy mucosa will not be so readily irritated by either indigestible or partly decomposed food.
Osteopathic experimental work reveals that the vertebral and rib lesions readily affect both the spinal nerves and the sympathetic ganglia, which is followed by vasomotor and trophic disorder to the mucous and submucous coats of the stomach, as shown by eccymosis and hemorrhage of the submucosa and beginning parenchymatous degeneration of the free ends of the glands of the mucosa. Upon the other hand irritation of the muscles from dietetic errors always causes more or less contraction of the muscles in the upper and middle dorsal, which, in turn, may produce through imbalance of tension and fibrositic changes, constant interosseous lesions and thus be the cause of the catarrh becoming chronic. This vicious cycle phenomenon should not be overlooked. Viscero-motor, viscerosensory and viscerotrophic reflexes may be factors in the pathogenesis of the osteopathic lesion.
Pathologically, the mucous membrane is more or less covered with mucus. Upon removal of the mucus the membrane is found red and swollen, and the epithelial cells of the glands are granular. This is especially noted in the pyloric area. There are minute extravasations of blood and hemorrhages of the mucous coat, and infiltration of the submucous layer.
Symptoms.—Acute gastritis occurs at all ages, so particularly in children care has to be taken that the attack is not the beginning of some infectious disease. A careful inquiry into the history, and examination of the vomitus will usually make the diagnosis clear. The sudden onset of nausea, vomiting, pain in the epigastric region referred to the back and head, vertigo in some cases, if the infections can be ruled out should leave no doubt as to the nature of the disorder.
Other symptoms are weakness, and chilliness which later if the attack is severe, is followed by fever. The tongue is coated, the lips dry, and there may be herpes. Belching of gas, constipation in some and diarrhea in others, and dark colored urine are noticeable. There is tenderness on palpation over both the stomach and splanchnic areas. Examination of the stomach contents show deficient hydrochloric acid, the presence of organic acids, bile and undigested food, and considerable mucus.
Diagnosis.—In young children acute gastric indigestion is common, though a casual gastritis is rare. In the former prostration, vomiting, and undigested, greenish stools are noted. In some cases there is no fever, while in others it may range from 102 to 105 degrees. In all cases care should be taken, as has been stated, that the attack is not the beginning of some infectious disease. Appendicitis, acute bowel constriction, pregnancy, uremia, meningitis, gall-stone colic, and gastric crises of tabes dorsalis should be differentiated. Most attacks of acute dyspepsia are over in twenty-four hours. The prognosis depends upon eliminating the cause. The X-ray may be of value in protracted cases.
Treatment.—If the case is seen early, emptying the stomach by induced vomiting or the stomach tube is the first indication. If several hours have elapsed and much of the stomach contents have passed into the intestine, emptying the colon with an enema will commonly give quick relief. Withhold all food for from twelve to twenty-four hours, or longer if necessary. In some cases the sipping of hot water will be beneficial, while in others pellets of ice in the mouth will give some relief.
Whether or not there existed previous spinal lesions there will always be found muscular tension and spinal rigidness during an attack of acute gastritis. These should be corrected for immediate relief, but what is of greater importance, if these acute lesions are not corrected the patient’s recuperative forces are interfered with and recovery is delayed. Then, also, these lesions tend to chronicity and predispose to future attacks. Treatment should be given daily, or oftener if special indications arise. Though the most common area that demands attention is from the fourth to tenth dorsals, still the vagi nerves, especially the right, should not be neglected. Lesions of the upper three cervicals are the most frequent disturbances of the vagi.
Vomiting is a common and distressing symptom. Pathologically, it is due to an antiperistaltic contraction of the stomach and a spasmodic contraction of the diaphragm and the abdominal muscles. It is caused, usually, by irritation of the vagus in the stomach, or in the pharynx by irritation along the spine (particularly in the cervical and upper dorsal regions), or to the sympathetic nerves or to various parts of the body, or by direct influence of the brain. Relief can usually be given by inhibition of the vagus in the occipital region or by inhibition at the fourth or fifth dorsal vertebra on the right side. In a few instances, placing the patient in the knee-chest position and gently raising the abdominal organs gives relief. If this does not suffice the stomach and colon should be emptied, providing the vomiting is protracted. A frequently effective measure for nausea and vomiting that can be carried out by the attendant, is the application of hot fomentations to the dorsal spine.
Flatulency may be very distressing. The spinal treatment may be sufficient to control this condition, or careful direct pressure for a few minutes over the pit of the stomach. Adjustment of the lower ribs, especially of the left side, may be effective. Occasionally the gas can be passed into the intestines by careful inhibitory treatment in the region of the eighth and ninth dorsals. The inhibitory treatment causes relaxation of the pyloric orifice; also, inhibition of the left vagus relaxes the pylorus. Inhibition at the sixth and seventh dorsals relaxes the cardiac orifice, thus favoring the passing of the gas from the stomach out through the esophagus.
In all cases subject to gastritis the dorsal spine should receive considerable attention in order that recovery may be complete. The habits of the patient should be thoroughly regulated and overfatigue guarded against. And, also of special importance in recurring attacks, is the fact that a number of cases present some derangement of the biliary tract, or duodenum, or the appendix region.
Diet.—After twenty-four or forty-eight hours, if the attack has been severe, albumin water may be given in small quantities; also whey, milk, bouillon, and chicken or lamb broth. If there is no return of gastric distress, add junket, custard, cornstarch pudding, gelatine, dropped eggs, scraped beef, and white meat of chicken; vegetables purees made with cream or meat stock are usually well borne at this time. Foods containing much cellulose, fats and sweets should be withheld until all symptoms have subsided.
It is unnecessary here to repeat the causes of acute gastritis, any one of which continued over a long period of time will cause chronic catarrh of the stomach, as it is sometimes called.
Spinal and rib lesions anywhere from the occiput to the coccyx, but more particularly from the fourth to the tenth dorsal, will predispose to chronic gastritis, the particular type and degree of local pathology depending upon the exciting factor.
A commonly found en bloc lesion is a flattening of the normal convexity in this region, with more or less immobilization, shown by attempting to reestablish the normal convexity through flexion.
In addition there may be single spinal or rib lesion in the same area, or cervical lesions affecting the pneumogastric, which is the secretory nerve to the stomach. (See chapter on the “Lesion and Its Applied Anatomy.”)
Pathology.—Chronic gastritis probably never develops as such without going through several preliminary stages beginning with alimentary hypersecretion, or hypersecretion occurring only during the active period of digestion. These are the cases usually classified as hyperchlorhydria. At this time no actual pathology can be demonstrated in the glandularis.
If the condition is not treated intelligently at this time the next step will be periodic attacks of what is known as “hypersecretion periodica chronica” followed by “hypersecretion continua chronica.” The stomach contains abnormal amounts of gastric juice even after a night’s rest. At this stage there is a transition from the functional to the organic condition. All stages are characterized by an abundant secretion of mucus.
If allowed to go on there will finally result a destruction of the secreting cells known as Atrophic Gastritis or Achylia Gastrica in which the stomach presents a smooth functionless appearance.
Secondary Chronic Gastritis.—Portal obstruction from any cause predisposes to chronic gastritis. The most common of these is failing compensation in heart lesions, which through back pressure causes portal stasis; the same thing may follow obstruction in the liver itself. Chronic gastritis is also a late accompaniment of the nephritic trinity, kidneys, heart and arteries. It may also be associated with diabetes, gout, anemia and other constitutional disorders.
Tuberculosis is commonly ushered in by symptoms of chronic gastritis. We should be constantly on the alert to avoid the mistake so commonly made of treating the stomach as an entity and overlooking the real trouble in some other part of the anatomy.
It is probably safe to say that there are only two primary diseases of the stomach, ulcer and cancer. All others are suspiciously associated with diseased processes elsewhere, and when the spinal lesion is given its full significance even these will be found to be directly traceable to anatomical perversions somewhere within the mechanism of local nutrition.
Symptoms.—These are governed by the stage of progress in which the patient is seen. During the stage of hypersecretion of acid gastric juice there will be vague feelings of distress, fullness and burning in the stomach, and “heartburn” during digestion. When the stomach is empty all symptoms will subside. Later there will be periods of a few days or weeks when there will be more or less continuous distress with some vomiting of highly acid gastric juice containing mucus.
When the condition has progressed to the stage of continuous hypersecretion there will be continuous symptoms as above, but with nausea, vomiting becoming more frequent especially late at night or in the morning, always accompanied by sticky mucus.
Appetite is variable, there is often a disagreeable taste in the mouth (the “dark brown” taste of the chronic alcoholic). Heart palpitation and vertigo and other vagus symptoms are common.
Diagnosis.—On physical examination the stomach is found distended, and in some cases displaced (gastroptosis). There will be diffused tenderness on pressure over the whole organ which should help to distinguish it from gastric ulcer or cancer in which the tenderness is quite localized.
Chronic gastritis cannot be positively diagnosed without making a gastric analysis. Many cases are wrongly diagnosed through neglect of this very important procedure.
The cases in which gastric analysis should be made are so well stated by Lockwood that we will take the liberty of quoting them in their entirety.
“(1) Gastric analysis should always be made in every case of dyspepsia, no matter whether these symptoms be apparently gastric or intestinal, unless passage of the tube is contraindicated.
“(2) Gastric analysis should be made in every case of chronic diarrhea that is not due to evident disease of the colon or rectum.
“(3) Gastric analysis should always be made in all cases of intestinal toxemia, or recurring headache of toxic origin, and in patients who complain of the symptom complex which is spoken of by the laity as ‘biliousness’.
“(4) Gastric analysis should be made in all cases of anemia and general physical wretchedness without known cause and which are rebellious to treatment.”
The finding of excessive gastric mucus intimately mixed with food remnants is the chief differential point in the diagnosis of chronic gastritis.
Differential Diagnosis.—A complete statement of differential diagnosis by Kemp cannot be well improved upon.
“Chronic Gastritis.—No severe pain, no circumscribed spot, painful to pressure; no hematemesis; no cachexia; no marked emaciation, except in severe cases of long duration; free hydrochloric diminished or absent; gastric mucus present; slow course.
“Ulcer of the Stomach.—Hyperchlohydria present, but not invariably so; severe pain in the epigastrium with intervals free from pain when stomach is empty; local tenderness which is circumscribed; dorsal pain; hematemesis, or occult blood in the stool or gastric contents; microscopic pus; no mucus; patient has appearance of suffering; no true cachexia.
“Cancer of the Stomach.—Age usually over forty-five; rapid course; free hydrochloric acid usually markedly diminished or absent; lactic acid present; pain generally continuous, but not so acute as in ulcer; Boas-Oppler bacillus; cachexia; tumor on physical examination; small amount of visible or occult blood; hematemesis much less than ulcer; foul odor to vomitus at times present.
“Achylia Gastrica.—Slow course; scarcely any gastric juice; acidity very low or entirely absent; absence of pepsin and rennin; usually no mucus or lactic acid.
“These differential considerations apply to typic cases, and the observer must be on the qui vive for various gradations and modifications of these clinical pictures.”
Prognosis.—The outcome of chronic gastritis depends upon our ability to locate and remove every factor in the etiology, the willingness of the patient to cooperate and the patience and resourcefulness of the physician. At best the progress is slow and one must expect temporary setbacks usually due to failure of the patient to carry out instructions.
Treatment.—The most successful treatment is prophylactic, but until the public has been educated up to this form of economy we must begin with conditions as we find them.
First get the patient’s confidence by making an intelligent examination, a scientific diagnosis, and a reliable prognosis based upon your findings. All lesions, bony, ligamentous, muscular and psychic must be intelligently and carefully removed.
Specific lesions which would directly or reflexly interfere with the nerve and blood to the stomach must be corrected.
The rigidness commonly found in the vertebræ and ribs of the splanchnic area must be overcome first by specific adjustment, and the normal flexibility maintained by teaching the patient proper exercises for the purpose. This should include deep breathing with the spine flexed to the limit, and the ribs fixed, by the patient reaching around as far as possible and grasping the ribs as described by Dr. Harry Forbes. This will tend to overcome the flat dorsal so characteristic in all gastro-intestinal conditions.
Direct manipulation over the stomach has no particular value and may be even harmful.
Inasmuch as nausea and vomiting and excessive gas formation are only the result of hypersecretion we cannot expect to give more than temporary relief except by methods which remove causes. Much comfort may be given by inhibition in the splanchnic area. In severe cases it may be necessary at times to wash out the fermenting, irritating mass by gastric lavage. Outdoor life, frequent vacations and change of occupation are often of decided benefit.
Diet.—Indiscretions of diet must be avoided and this cannot be too positively impressed upon the patient. It is always best to make a list of foods to be taken for breakfast, lunch and dinner and insist that no other foods be taken without further instruction.
Just what these foods shall be depends upon the gastric secretions as shown by gastric analysis. They should always be nutritious and given in quantities sufficient to maintain nutrition.
The stomach should have rest and yet is expected to do its part in the process of digestion. All foods must be given in a finely divided form and well masticated to spare the stomach the mechanical effort of grinding.
In hyperacid gastritis all foods of an irritating nature must be positively prohibited. The classical breakfast of grapefruit, oatmeal, ham and eggs and coffee will not do. Starchy foods must be reduced owing to their tendency to ferment in the presence of highly acid juice and the delay in the stomach due to the high acidity.
In subacid gastritis advantage must be taken of the fact that carbohydrates digest well and proteins do not.
Diet for Hyperacid Gastritis.—Before breakfast: Wash the stomach with warm water and an ounce of Phillips Milk of Magnesia, allowing the water to remain in the stomach 20 minutes or a half hour, lying down and turning from side to side on the face in order that the water and magnesia may be brought in contact with all parts of the stomach.
For breakfast: Prunes, allowed to simmer for four hours, without boiling, and put through a colander, to remove the skins. Soft cereals, such as farina, cream of wheat, or wheatlet, thoroughly cooked, and served with middle heavy cream, no sugar. Two eggs, soft boiled, or poached. Zweiback, thoroughly masticated, with a liberal quantity of butter. Cocoa (Phillips).
Luncheon: Puree of peas, beans or lentils, made with cream. Asparagus, green peas, boiled rice, spinach chopped very fine, creamed carrots, boiled onions, baked potato, well done. Chicken, boiled lamb or beef, ground; oysters in any form but fried; fresh fish. Desserts: Choice of junket, cornstarch, custard, rice pudding, floating island, gelatine or tapioca.
Evening meal: Same as luncheon except substituting eggs for meat.
Cup of hot water before luncheon and dinner.
If patient requires quick building up give milk between meals and at bed-time.
Gastric neuroses include motor, sensory and secretory derangements. Though the sensory disturbance is often the most marked, still motor and secretory symptoms are usually present. In other words there is commonly a complex of the different forms.
Where gastric neuroses can be positively diagnosed, by a process of elimination, there is no more plausible explanation than that of the spinal lesion. The success of osteopathic physicians in treating so-called “stomach trouble” proves conclusively the superiority of the osteopathic method. A note of warning should be sounded, however, for as diagnostic methods have become more exact it is found that many cases which were formerly diagnosed as neuroses prove to be referred from some organic change, such as infected gall bladder, appendix, tube or ovary, tonsil, tooth or sinus. It has been proven that many cases of sensory and secretory disturbances have entirely cleared up when these causes have been removed. Though infection may play an important role, still in some instances, especially gall bladder, duodenum and appendix, the gastric neurosis may be simply due to a nervous reflex.
Gastroptosis, atony, and in many cases splanchnoptosis, has been found to be the underlying cause of many hitherto unaccountable gastro-intestinal symptoms.
Gastric crisis of locomotor ataxia if not properly diagnosed by the finding of the other well known symptoms may give us much trouble and discouragement.
Ulcer and cancer have quite characteristic symptoms, yet it is well known that they are often treated as neuroses in the early stages, much to the detriment of the patient, especially if the case proves to be cancer.
In the sensory disturbances, which are probably the most common, hyperesthesia and neuralgia are the special features. In the former a feeling of weight, fullness and burning are complained of, which are frequently manifestations of a neurotic temperament. In fact, hysteria and neurasthenia are very often basic conditions. The same is true in gastrodynia, where the pain starts in the pit of the stomach and extends around the lower chest and ribs. There may be other neurotic symptoms such as excessive hunger and a constant desire for food. Menstrual irregularities, the menopause, worry, constipation, and anemia are important factors. Special care should be taken that there is no organic disorder of the gastro-intestinal tract or of the nervous system.
The motor neuroses comprise a variety of derangements. Excitation of the motor functions of the stomach, as a direct result of irritated nerves or of reflex stimuli, are not uncommon. Owing to this the food may not remain in the stomach long enough or the stomach activity may be too pronounced. There may be also more or less rapid vomiting of the food, without any particular strain. Other motor neuroses may be spasms of either the cardiac or pyloric sphincters, and in a few instances there may be atony of the stomach walls. Although these conditions may be of a neurotic character, still great care should be taken that some organic disease is not basic.
The secretory derangements consist of hyperacidity, supersecretion, and lessened amount of acid secretion or achylia gastrica. Many of these cases are associated with hysteria and neurasthenia, though in achylia gastrica, cancer may be the cause. Hyperacidity may be associated with ulcer. Pelvic diseases, nervous reflexes from the gastro-intestinal tract, constipation, and anemia are to be considered as possible etiological factors.
Diagnosis.—These cases require the most painstaking inquiry into the history, the most complete physical examination, and all findings carefully checked up by laboratory tests.
Inquiry will often show that all symptoms subside when on a vacation with a change of scene and climate.
Lockwood gives the following rules for arriving at a diagnosis of “nervous indigestion.”
“(1) A diagnosis of nervous indigestion should not be made in the presence of more than 30 c. c. of fluid in the fasting stomach, the fluid giving a strong reaction for hydrochloric acid. Hypersecretion is generally an expression of pyloric stenosis, organic or spasmodic, and this is due to an organic cause.
“(2) A diagnosis of nervous indigestion should not be made in the presence of persistent hyperacidity accompanied by epigastric pain. Nervous hyperchlorhydria may occur, but is not accompanied by either pyrosis or pain. The association of either of these latter symptoms should suggest an organic origin for the complaint.
“(3) Achylia gastrica may be of nervous origin, but this is not probable when serious motor error is in evidence. Achylia with food-stagnation is strongly suggestive of cancer of the stomach.
“(4) Achylia gastrica, accompanied by pain or vomiting, indicates an underlying organic cause.
“(5) The diagnosis of nervous indigestion should not be made when recognizable food remains are repeatedly found in the fasting stomach. Under the influence of fear, nervous shock, or vicissitudes of temperament the motor functions may be temporarily interfered with, but this would not be the case permanently.
“(6) The diagnosis of nervous indigestion should not be made when epigastric distress or pain occurs regularly at a definite time after eating. The very fact of this disturbance coming on at a definite time argues against a neurosis.
“(7) The diagnosis of nervous indigestion should not be made when one symptom alone persists, without other evidences of nervous instability. The presence of one definite symptom in itself presupposes an organic cause.
“(8) The physician should be on the qui vive for drug addictions, for these habitues can sometimes present a syndrome of symptoms that will puzzle the most experienced.
“(9) The diagnosis of nervous indigestion should not be made in persons over forty or forty-five, in whom indigestion is a new symptom. Such patients are usually developing a serious systemic or malignant disorder.
“(10) Finally, digestive nervous neuroses and organic disease may be concomitant, and the presence of either need not exclude the other.”
Treatment.—First get the patient’s confidence by making a most complete examination. This desirable beginning is usually hastened by the osteopathic physician, when after a few treatments symptoms are greatly relieved. Correct all lesions wherever found, particularly those anatomically connected with the stomach. When the symptoms are sensory relief can always be given by inhibition over the splanchnic area. Occasionally the ensiform process and the lower costal cartilages are lesioned.
Diet.—When hyperchlorhydria is the chief symptom foods must be selected which bind acidity or those which lessen its secretion, such as milk, eggs, cream cheese, fats such as butter, cream, olive oil, boiled or broiled fresh fish, boiled beef or lamb run through a grinder, oysters in any form but fried, white meat of chicken, vegetable puree made with cream or milk (no meat stock), gelatine, custard, junket or sponge cake.
Many neurotic patients are under-nourished through fear of food. They must be positively assured that if the food is well chosen and carefully masticated there need be no fear of discomfort. Care should be taken that the patient is not constipated.
Some cases can only be reached by a “rest cure” of four to six weeks, which together with the treatment outlined above will prove most satisfactory.
In all cases guard against worry and overfatigue. Build up the general health as rapidly as possible. Outdoor life, sufficient sleep, frequent vacations, and change of scene are specially beneficial.
Statistics show that peptic ulcer is far more prevalent than is supposed by the casual observer. “In the combined statistics of 59,450 autopsies of various series evidence of healed or unhealed ulcer were observed in 4.4 per cent.” (Bassler.)
The reason for this is that peptic ulcer may present very definite symptoms which are readily interpreted or they may be so atypical as to make definite diagnosis impossible. Like all gastro-intestinal diseases, many of the symptoms are easily confused with so-called indigestion or “stomach trouble.”
Etiology.—One characteristic of gastric and duodenal ulcer is that it only occurs where the mucous membrane is subject to the influence of hydrochloric acid and pepsin; lower end of esophagus, stomach and first part of duodenum.
Similar ulcers are often found in the sigmoid and rectum where the feces often become acid due to bacterial action, or on account of slow movement, hydrochloric acid and pepsin which may have escaped neutralization in the duodenum may attack the mucosa.
For the part played by spinal and rib lesions on the glandular layer of the stomach, the reader is referred to a previous discussion of the lesion.
Probable secondary causes of gastric ulcer are: (1) Embolism of an artery (gastric arteries are terminal). These emboli are supposed to be caused by toxic and infectious agencies which enter the circulation, as sometimes occurs in pyemia and large burns of the skin.
(2) While hydrochloric acid associated with pepsin seems to be an important factor, it is doubtful whether it can attack the mucosa without there being a previous abrasion or other injury. It is said that a normal secretion of mucus is nature’s protection against self digestion.
The swallowing of substances of a coarse or irritating nature or those chemically corrosive or at extremely high temperature may so injure the mucous membrane as to permit an attack by HCl and pepsin.
Certain occupations seem to predispose to gastric ulcer, such as cobblers, or others who in their work press various objects against the stomach.
Sharp blows over the stomach have been followed by acute ulcer. A frequently associated condition is gastroptosis, which seems to be explained on the basis of narrowing of the blood vessels and their more ready occlusion. Probably sagging of the duodenum is an important predisposing factor.
Anemia and chlorosis should not be overlooked as predisposing causes. And tuberculosis and syphilis are possible associated disorders.
Of all the theories advanced, the lowering of vitality, due to lesions of the splanchnics and vagus nerves remains the most logical.
Symptoms.—The most characteristic symptom is pain, which in a typical case comes on at a regular time after taking food. It may be a half hour, an hour or two hours, and in the case of duodenal ulcer may be as late as four hours. The distance beyond the cardia at which the ulcer is located seems to govern the time; also the time at which the secretion of hydrochloric acid reaches its height, which varies in different individuals.
The pain is due to free acidity (that which is not combined with the food) irritating the raw surface of the ulcer. Pain is often increased or lessened by posture. If turning on the left side gives relief the ulcer is probably at the pylorus; if worse when standing than reclining the ulcer is probably on the greater curvature.
The pain is usually localized by the patient, and pressure at the given spot increases the pain. In many cases there is referred pain in the region of the 9th, 10th and 11th ribs on the left side.
At the height of pain vomiting may occur, due probably to pylorospasm resulting from high acidity. Vomiting always gives relief. The taking of protein food or alkali will usually relieve the pain of ulcer, (hunger pain). Ulcer patients are usually well nourished owing to the habit of relieving themselves by eating, or they may be thin due to their fear of food.
In acute ulcer frank blood may show in the vomit, and may be the first indication of trouble, whereas in the chronic type it may be occult, or occult blood may be found in the feces. The hemorrhage of ulcer, unlike that of cancer, is not constant.
Diagnosis.—Diagnosis of duodenal ulcer, as distinguished from gastric, is made by finding the tender spot to the right and below the pylorus, the pain coming on three or four hours after taking food, and the finding of blood in the feces (tarry stool) and not in the stomach contents. Repeated examinations may be necessary owing to the fact that hemorrhage is not constant.
The large percentage of stomach ulcers are near the pylorus, and of the duodenal ulcers the ascending portion is the area almost invariably involved.
Ulcer is differentiated from functional disorders by a history of real pain as distinguished from the vague disturbances of sensation often called pain by neurotic patients. Also its regular appearance in relation to food. The pain of “gastralgia” has no regular habit and is not influenced by food.
Referred pain from cholecystitis, chronic appendicitis, etc. has no relation to food and is not relieved by food or alkalies.
Ulcer is to be distinguished from cancer by the age of the patient (in cancer usually over 40) with a previously good gastric history, except in cases where cancer has been grafted on to a chronic ulcer. In these cases a careful inquiry will bring out a characteristic ulcer history up to a certain time, when all symptoms change; pain becomes constant; is not relieved by food or alkali; vomit becomes dark in color and has a characteristic odor, appetite fails, and signs of cachexia set in.
Gastric ulcer should be suspected in all cases of persistent gastric symptoms which are not readily relieved by treatment and regulation of diet, and in which there is found high acidity and continuous hypersecretion not accompanied by mucus.
The X-ray and gastric analysis should never be neglected in suspected cases, keeping in mind the possible injury from the tube in case of recent hemorrhage.
Treatment.—Osteopathic treatment of gastric ulcer will be almost uniformly successful if we will analyze all of the factors entering into the problem.
It is obvious that in order to heal the ulcer we must remove all factors which interfere in any way with nutrition. Then give the stomach as near absolute rest as possible while at the same time building up the nutrition by a generous but well chosen diet.
When acute hemorrhage has recently occurred, complete rest in bed with a trained nurse in attendance is the first indication. Complete rest of the stomach, all nourishment being given by nutrient enema. An ice bag is to be placed over the stomach, and removed every three or four hours to allow surface circulation to react. Warm applications should not be used while there is any marked bleeding.
During this period no effort on the part of the patient should be permitted, and no manipulative treatment which would tend to increase blood pressure should be given.
After all evidence of hemorrhage has ceased for ten days, or at once in case of chronic ulcer, we may carefully correct all spinal or rib lesions in the splanchnic area especially the 6th dorsal, or cervical lesions affecting the pneumogastric. Pain and pylorospasm may be relieved by steady pressure at the 4th and 5th dorsal on the right side.
After spinal lesions have been corrected without unduly irritating the stomach, careful relaxing treatment should be given with the patient on the back, keeping in mind that all exertion will tend to irritate the ulcer.
If special care is observed, frequently definite relief may be given by placing patient in knee-chest position and gently raising the lower portion of duodenum where it lies alongside of ascending 3rd and colon, 4th lumbar.
During this period a hot water bag or a thermal pad should be kept over the stomach night and day.
In certain cases of perforation in a few obstinate conditions, and in a few where mechanical obstruction is marked, surgery may be indicated.
The following diet will be found best during the first week:
7 A. M. A half glass of cooked milk, with the leathery substance which rises on the top removed, and the yolk of one egg stirred into it and sweetened, if desired; taken luke warm or cool, but never ice cold. This amount to be increased on the second day to three-fourths of a glass, and on the third to a full glass, which is to be continued for a week. If the milk produces diarrhea, add two tablespoonfuls of lime water to each portion.
9 A. M. A saucerful of gelatine (Knox’s or Crystal Rock) with 2 tablespoonfuls of cream and a teaspoonful of sugar.
12 M. A half to full glass of milk prepared as above.
3 P. M. A saucerful of gelatine, with cream (medium) and sugar as at 9 A. M.
6 P. M. A half to whole glass of milk, as before, with one egg stirred in and sweetened. The egg yolks at 7 A. M. and 6 P. M. are to be increased until six are taken daily at the end of the week.
8 P. M. A half to a full glass of milk.
The whites of the eggs are to be stirred up in the water in the proportion of a white to a glass of water, 4 teaspoonfuls of sugar to be added to every glass, this to be taken by the patient only when thirsty. If the bowels do not move, no laxative can be taken, but an injection of warm water or a little soap may be employed. If much discomfort is produced by the food, a hot compress must be laid over the stomach or above the navel.
During the second week the diet should remain much the same except for the addition of one or two pieces of Zweiback three times a day.
During the third week, if pain and blood in the feces are lessening, we may add soft, well cooked cereal like cream of wheat, cocoa, puree of split pea made with cream.
Fifth week add minced chicken, coddled egg, boiled beef or lamb put through a meat grinder, soft vegetables such as chopped spinach, squash and mashed or baked potatoes with liberal quantities of butter.
During and after the sixth week we may add all vegetables which can be served in puree form, fresh fish, oysters, apple sauce, inside of a baked apple, prune whip, custard junket, corn starch pudding.