Chapter VII: Introduction (4)

Treatment to the =intestines= through the abdomen is an effective treatment. In the various obstructions to the intestines, constipation, etc., the direct work is essential. Treatment of the intestines is to correct any abnormal position that they may have assumed, to relieve constrictions of the gut caused by contracted tissues, to relieve impactions and adhesions, to increase peristalsis and to tone up the intestinal coats in general. The treatment consists in a manipulation of the intestines, especially in the right and left iliac fossæ, and the pelvic colon, ascending colon and duodenum, as impactions and prolapses of the gut are more liable to occur at these points than in any other locality. In manipulating the intestines, work for a definite purpose and not give a general kneading treatment unless the walls of the abdomen and the coats of the intestines are weakened; in the latter case the spinal treatment is the primary one. In treating over the iliac region, draw upward and inward on the folds of the gut. It is claimed by some authorities that nerves pass from the cutaneous surface of the abdomen directly to the intestine by way of the peritoneum; if such is the case, manipulation of the abdominal walls would have direct effect upon these nerve fibres. The abdomen may be treated when the patient is sitting up, but the treatment is not satisfactory. (See Prolapsed Organs).

=The Pelvis.=—The treatment of the pelvis is easy, but the difficult work is in making a diagnosis of the position of the pelvic bones. The pelvis is especially apt to become deranged by jars and falls. Some of the most successful osteopathic results have been obtained in correcting the pelvic region.

To relax the muscles over the pelvis, the patient should be on the side or upon the face; then relax the muscles by manipulating them upward, chiefly those over the sacral foramina. It is a good rule to adjust the lumbar first owing to release secured to the nerves supplying pelvic muscles and also to the fact that many pelvic distortions are secondary or compensatory to lumbar lesions. The easiest method to correct the innominata is to have the patient lie upon his side; then by standing in front of the patient slip one hand between the thighs and grasp around the tuberosity of the ischium, and with the other hand upon the crest of the ilium, the innominatum can be moved upward or downward and forward or backward (wheel and axle principle). Simply pulling or pushing upon these two points in whatever direction necessary is all that is required providing the soft tissues are thoroughly relaxed. By having the patient flat upon the back practically the same treatment can be given, but not to so great an advantage. In cases where the ilium is posterior and the ischium anterior, the physician may stand back of the patient, while he is lying upon his side, and place one knee against the sacrum and with one hand upon the ilium, with the other take hold of the ankle of the affected side (the involved side being uppermost in all cases where the patient is lying upon his side); pressure can be exerted upon the ilium and the limb pulled backward, thus correcting the derangement. This treatment should be avoided as much as possible, as there is considerable danger of pulling back too severely and injuring the patient; the lever is long and the amount of force exerted upon it cannot be judged precisely.

Another method is, with the patient on the back, flex and evert the knee to the side so the side of the foot lies flat on the table. Grasp the ankle with one hand and with the other on the crest of the ilium of the opposite side then, by pushing down firmly on the knee the articulation is gaped and at the same time the operator pushes with his body against the knee with a sharp thrust. This may have to be repeated a few times before the articulation is released and if one is keen he will easily detect the slight concussion carried down the femur as the adjustment takes place. This will correct a forward and downward innominate. For an upward and backward one, place the patient in exactly the same position and go through the same motions except that the knee is pulled toward the operator. If the desired “chug” is not felt and adjustment is not definite, the leg may be pulled down rather smartly by the ankle to a parallel with the other. This is a technique that is easy, both for the patient and operator, and will correct any but the most stubborn.

In the case of a greatly relaxed and atonic condition of the ligaments of the pelvis much trouble is experienced, often, in making the adjustment permanent. Many suggestions have been made and most of them useless but, probably the use of a belt of non-elastic webbing about two inches in width buckled tightly around the pelvis just below the anterior spines will do as much as anything and is a procedure well to follow in all such cases. Where there is a pendulous abdomen a support in the shape of a simple belt which should be so fitted as to act as a sling will transfer the weight of the abdominal viscera from the muscles, already stretched and atonic, to the belt and put the burden over the sacrum. This prevents the pulling of the innominatum in lesion again. Overcorrection is suggested as a means on the ground that it sets up irritation and induces fibrous ankylosis and for the same reason W. W. Howard places his patient prone and with thumb works the ligaments associated with the joint until they are thoroughly inflamed. The patient is then put in bed a few days and after the inflammation has cleared up the ligaments will be found to have shortened.

To correct a rotary lesion between the pelvis and fifth lumbar the patient should be placed upon the side, and with the body held firmly, the pelvis can be forced backward or forward as the occasion demands. (See Coccyx).

=The Legs.=—The origin of many symptoms manifested in the legs, as in the arms, are due to spinal lesions corresponding to the region of innervation to the affected tissues. The derangements of the pelvic bones are a frequent source of symptoms that are referred to the legs and feet. The osteopath finds that a slight dislocation of the hip may occur which is especially likely to affect the knee. This partial dislocation is apt to be an upward-posterior one; the head of the femur resting in the upper and posterior part of the acetabulum. Many diseases of the legs and feet are due to local displacement of the bones. The method of treatment is the same as given in surgical works. (See Sprains).

A general treatment of the legs and thighs is oftentimes necessary; it consists of flexing the thighs quite firmly upon the abdomen, and executing thorough external and internal rotary movements of the thighs and legs. In a few cases both limbs are flexed strongly at the same time upon the abdomen. After giving these movements manipulation over the saphenous opening and beneath the popliteal space is performed. This general treatment tends to increase the circulation of the entire limb and to relax thoroughly all contracted fibres.

=The Arms.=—In treating the arms, care has to be taken that the affection is not due to spinal derangements; otherwise the arms are manipulated according to the disorder. Complete dislocations of the shoulder comes under the province of surgery. Many times the osteopath locates slight or incomplete dislocations of the shoulder. Partial dislocations of the shoulder are generally anterior. (See Sprains).

In cases where pain exists in the shoulder or arm, outside of locating the cause in the shoulder joint, the affection may be due to fibres contracting over the coracoid process, or a dislocation of the second or third rib, and in some instances the clavicle is deranged. Special care should be given to a possible bursitis and tendo-synovitis. Occasionally muscular fibres may slip out of the bicipital groove. Dislocations of the bones of the arm are treated according to surgical methods. The pains and various troublesome symptoms that may be manifested in the fingers or the hands are oftentimes caused by slight dislocations of the elbow, shoulder, ribs, or vertebræ, as low as the sixth to eighth dorsals.

=The coccyx.=—The coccyx, owing to its exposed position and rather unstable attachment, is subject to many injuries; more indeed than come to notice. Its injury results in many local and general disturbances owing to its close relation to the sympathetics. Successful treatment of deviations often bring startling results. They may be divided into =fractures= and =displacements=.

In =complete= or =partial= fracture of the coccyx, as well as in dislocation, if the patient can be seen with reasonable promptness after the accident much can be done for relief of the pain and the prognosis is good for complete recovery.

Examination should be made externally and internally and after the condition is diagnosed about the same procedure is indicated for any of the conditions. With the patient on the left side introduce the right index finger, well lubricated, into the rectum and carefully relax all tissue within reach of the tip. If there are spasms of the coccygeal muscles, inhibition of the anterior nerves will quiet them. When this has been done place the left index finger externally along the body of the coccyx and holding it firmly both within and without release it longitudinally and then adjust. After this has been done it is well to hold it there until all danger of returning spasm, which might displace it again, is over, when the finger can be withdrawn.

The pain following will depend on the severity of the injury, but will keep up more or less constantly for several days. When severe, relief is often given by introducing the finger and relaxing contracted tissue which is pulling it from its position. Hot water bags placed next to the part will be of benefit. The bowels should be kept confined for forty-eight hours if possible in cases of fracture. Watch carefully the progress of union that the bones are _in situ_ so there will not be deformity.

In diagnosing the first injury be sure that there is no splitting of the first segment or splinters which may require surgical interference. In old cases of fracture where there is complete bony ankylosis it is not justifiable to attempt any change, but where there is motion and a fibrous union, after preparatory treatments about one week apart, it can usually be replaced. Look well to any muscular contractions which might interfere with it. Force must never be used nor any attempt to replace until it has been first released from its articular attachment. In the various forms of =displacement= the same technique applies as in fractures, or the finger and thumb of one hand may be used, the tip of the finger internally at the sacro-coccygeal articulation and the thumb externally at the same point. Complete control of the part is secured in this manner. Great care must always be used in treatment of any displacement of the coccyx. Contractions of its muscular attachments will often cause deviations in contour. Removal of the irritation and relaxation will allow it to assume its normal position.

=The sacrum.=—Adjustments of the sacrum as distinguished from the ilium in strictly innominate lesions are not many. When posterior with the patient on a stool the knee of the osteopath coveted by a pillow and placed against the sacrum and both hands grasping the anterior borders of the ilia, strong traction will move it into position. In a downward displacement with the aid of an assistant from behind holding the crests of the ilia firmly as the patient sits on the table, the osteopath in front clasping both arms about the patient and with a rocking motion from side disengages the sacrum and at the same time lifts it into position.

For anterior displacements use the technique described in replacing upward and backward innominate dislocation first right side and then left, which will result in correcting the lesion.

The preceding osteopathic technique includes a few of the treatments given by the osteopath. Although many osteopaths use methods not given here, those outlined are sufficient for illustrative purposes. A point which cannot be too thoroughly impressed upon the student is that osteopathic treatment is in reality =constructive= work, that is, readjustive, not only in detail, but in viewing the body structure as a whole. Detailed readjustment is an essential, still do not lose sight of the relation of the part to the whole. In our distinctive work anatomical construction is the basis of physiological function, although physiological stimulus is essential to anatomical development.

=How often to treat.=—How often to treat a case depends entirely upon the nature of the disease from which the patient is suffering. Just as in giving drugs the frequency of treatment is entirely dependent upon the seat of the disease and its severity. Acute cases require a thorough treatment at least once daily, and many times in severe cases the treatment has to be repeated several times daily. In subacute and chronic cases, as a rule, treatment should not be given as often as in acute cases; possibly once a day, but usually alternate days is better. In office practice cases are commonly treated two or three times weekly. Still it is better not to treat some cases oftener than once a week.

There is more danger in treating too often and too long than in not treating often enough. The distinctive work of an osteopath is to correct disordered anatomical structures; and when a certain derangement has been corrected the tissues should have rest and plenty of time for repair. When treatments are given often, it simply keeps the tissues in an irritated state and nature does not have time to heal the diseased tissues. Always make it a point at each treatment to correct some definite lesion, and when the work is accomplished let the parts alone until the tissues have recovered as much as possible from the effects of the previous treatment before another treatment is attempted. The reason why some cases do not get cured under osteopathic treatment is simply because the osteopath keeps the diseased tissues in an aggravated state by the constant treatment so that they do not have the least chance to heal; the physician is thus adding irritation to the disease.

It is only by experience that one can tell how often to treat. Each case is a special study; what would be quite sufficient for a certain individual with a given disease would not be at all suitable for a second individual with the same disease. As in drugs what is suitable for one person would not be adapted to another, because the make up of each individual is entirely different; but here the parallelism diverges, for in drugs there is a foreign agent introduced into the system, while in osteopathic treatment the curative agent is entirely harmonious with the idiosyncrasies of the individual. It is for this reason that experience in practice is so essential.

Most cases should not be treated, as a rule, after a meal unless the patient is suffering from some digestive disturbance; for treating other regions of the body outside of the digestive tract causes more or less stimulation of the parts treated and thereby draws blood away from the organs of digestion. Cases of disordered brain circulation, where the patient is unable to rest or sleep at night, should be treated at about their retiring time so that the circulation of the body may be equalized, thus giving the patient undisturbed rest.

To show in a practical way the methods of experienced osteopaths in this matter G. J. Helmer[32] is quoted: “I submit the following table to illustrate the frequency of treatment in one hundred cases taken from my practice: one case three times per week, sixty-three cases two times per week, twenty-two cases one time per week, nine cases once every two weeks, five cases once every four weeks. Comparing the present with the past, I find I am lengthening the time between treatments with much better results.”

Another very practical side of the question and one which will be greatly appreciated by the patient, is the lessened cost for the same result in the less frequent treatments, as well as the saving in time. With the loss in going to the office, rest after treatment, not to mention possible wait while there, three times weekly represents more time than the average person can well spare and not infrequently will deter him from continuing. More especially is this true of those coming from a distance.

=Length of Treatment and Overtreatment.=—Naturally the length of treatment depends upon the case at issue and nothing more. There is no reason why any two cases should be treated for the same length of time unless they present identical lesions and then the personal equation of the two might present such a wide difference of aspect as to forbid such a proceeding.

The question of time has no place in the matter, save that it must not exceed physiological limits and be sufficient for the needs of the case. The patient should understand at once that it is to accomplish a specific purpose that the treatment is given, just as definite as a surgical or dental operation, and when the work is done it is time to stop. He would hardly be attracted to the dentist who guaranteed to use forty-five minutes in extracting a tooth. Good judgment is required in this as in all matters pertaining to osteopathy. There is a generally expressed opinion among the older osteopaths, based on experience, that: first, a short specific treatment is productive of best results and, second, treatments given under high tension when quick work is necessary are most satisfactory. Long treatments are debilitating and over stimulation amounts to inhibition. Further, in a long treatment it is necessary to go over the whole body, thus dispersing the vital forces (which have been stimulated for healing and upbuilding the pathological area) to parts not involved, thus defeating the very purposes intended. Dr. Still always advocated and gave the short, specific treatment.

The point always to be considered is the individual characteristics of the patient, and effects of the first treatment should be carefully observed. After a patient has been under treatment for any considerable time it is well to give him a vacation from treatment, and it is remarkable what improvement will be shown at times by such a measure and how seldom he will lose ground. Dr. Still presented this subject vividly as follows: “To treat the spine more than once or twice a week and thereby irritate the spinal cord, will cause the vital assimilation to be perverted and become death producing by effecting an absorption of the living molecules of life before they are fully matured and while they are in the cellular system, lying immediately under the lymphatics. If you will allow yourself to think for a moment of the possible irritation of the spinal cord and what effect it will have on the uterus, for example, you will realize that I have told you a truth. Many of your patients are well six months before they are discharged. They continue treatment because they are weak, and they are weak because you keep them so by irritating the spinal cord.” It is not a rare experience for a patient to leave apparently with little or no improvement only to report a complete recovery a little later.

=Misapplied Treatment.=—Probably in spinal treatment more risks are taken than in any other region of the body. To us as a school it is by far the most important and interesting area we have to treat, consequently it is not surprising that various general treatments and methods have been devised with the idea of getting quicker and easier results. Herein lies the danger outside of mistaken diagnosis, for short cut treatments can never take the place of time and skill. Technically speaking, if one thoroughly understands the philosophy of osteopathy and is conversant with the underlying principles of its therapeutics, there is absolutely no danger of even the slightest injury. It is the one who takes chances by not properly diagnosing and by not being cautious enough with delicate persons when applying his treatments that is apt to overstrain some tissue or organ and otherwise do bodily harm. Of the treatments considered dangerous not one of them is without merit if judiciously applied, but unfortunately in many cases they are in general and indiscriminate use. It is well to remember that we are moving structures which have never been moved before and that time enough has not elapsed to observe what the ultimate result may be. Again, in adjusting a subluxation of the spine do not forget that the force necessary for that adjustment, if misapplied, is sufficient to produce a lesion, and there is no doubt that this has happened. Your patient’s interests are above everything and must never be sacrificed for any reason whatever, so if at any time there is uncertainty always give the patient the benefit of the doubt. On the other hand the osteopath must have the courage of his convictions and fortunately when these are coupled with good judgment the results are all that could be desired. The following should be used with great caution if used at all:

First, =Indiscriminate stretching= of the spinal column with the aid of an assistant. It is not good osteopathy although there are some cases where it may be beneficial. While not specially dangerous, generally, in delicate patients, elderly people, arteriosclerotic conditions, and in some stages of Pott’s disease it is absolutely contraindicated. Moreover in most spinal cases except impacted vertebræ and symmetrical curvatures the stretching of the vertebral ligaments locks the lesion firmer.

Second, =Extreme rotating= of the cervical region. This cannot be considered good treatment in any case with the exception of the muscle stretching. On the contrary it is dangerous; first, it is not osteopathy for it is not specific; second, the nervous shock is severe, an important consideration in delicate people; third, the cervical ligaments become stretched and the vertebræ are easily displaced, while damage to a diseased vertebra, an aneurism or in arteriosclerosis would be irreparable. No other region of the body should have greater care in treatment than the neck.

Third, =Hyperextension= of the spine with the patient on his face. This treatment is rarely indicated. In fact, it is barbarous and a relic of an early day. Possibly more cases have been injured by this treatment than all others combined.

Fourth, =Rough separating= of the vertebræ and ribs while the patient is on his face. This is a most excellent treatment in many cases, but great judgment is necessary. Delicate patients, heart disease, and necrosed vertebræ and ribs should be carefully excluded.

Fifth, =Innominate adjustments= such as placing the patient on the side and putting the knee against the sacrum while grasping the leg at the knee. Or, the placing of the patient face down with one hand on the sacrum and the other holding the knee. In both these there is a tremendous leverage and in the latter the strain is at the lumbar rather than where needed. There are other unnecessarily risky methods for this operation, while it is easy to perform in most cases and without danger.

Sixth, =Abdominal treatment= gives wonderful results when intelligently applied, but it may be productive of great harm in conditions of tumors, malignancy, and pus formations.

=Misapplied treatment= is always dangerous, no matter to what part of the body given, and it is proof of wrong diagnosis when given. As a rule treatment is given without proper diagnosis in such cases, so a misapplied treatment has two interpretations—first, ignorance; second, laziness. In the former lies the greater danger for ignorance coupled with force and lack of skill is an appalling combination.

Cases are frequently reported where tumors have passed from the vagina, rectum, nose, etc., the osteopath thinking it was the result of good treatment, without considering that it was simply the breaking of a long pedicle with great danger from hemorrhage. The greatest care should be exercised in treating cases where aneurism, osteomalacia, and arteriosclerosis are present, also in the leg treatment of tabes dorsalis and in the weak, thin ribs of elderly people and those with a gouty or rheumatic diathesis. Imagine treating an abscess directly, yet it has been done, as have varicose veins with the terrible danger of rupture and embolism. Aneurisms have been ruptured in the same way.

One could go on indefinitely with this subject, but to sum up: if the osteopath is not familiar with the feel of the living anatomy in its giving and resisting under treatment both in health and disease and does not know his osteopathy, nothing can prevent him doing harm. A successful practitioner means an understanding of pathology, then experience plus common sense.

FOOTNOTES:

[31] See Ashmore’s Osteopathic Mechanics.

[32] Journal of the American Osteopathic Association, Dec., 1903.

OSTEOPATHIC CENTERS

“Osteopathic spinal centers” was a term commonly used in the early period of osteopathic development. From the facts, first, that a few centers have been actually determined in the cord, viz., genito-urinary, vasomotor, etc.; second, that the innervation from the spinal segment to various thoracic, abdominal and pelvic viscera correspond with a considerable degree of accuracy to certain vertebral sections, and third, displacements of tissues of the spinal column affect viscus integrity, depending upon the locality of the structural perversion as to the organ involved and is a clinical observation of great import, arose the misnomer “osteopathic centers.” For one to ask what “centers” should be “treated” in this or that disease shows a lack of the conception of osteopathy as if he asked what “movements” to give when “treating” a certain disorder. It is as unosteopathic, as it is unscientific, broadly speaking, to suppose osteopathic technique implies the application of movements to certain nerve centers.

Osteopathic Stimulation

“Osteopathic stimulation” is another term loosely used without extensive clinical experience to support it. Mechanical stimulation is frequently utilized in the physiological laboratory. But to employ it extensively and comprehensively in the treating room or at the bedside the therapeutic potency of it will be found wanting; that is, to employ it to the exclusion of that most important basic treatment, readjustment, is a great mistake.

Clinically, the pathologically slowed heart may be stimulated by a stimulus to the cervical sympathies, the gall-bladder emptied by a stimulus near the costal cartilages of the ninth and tenth ribs (this is probably via the spinal segments), etc. Normally, these organs and others may be temporarily stimulated. Experimentally, Burns[33] of Los Angeles and Pearce[34] of San Francisco have shown the potency of osteopathic mechanical stimulation. For example, stimulation (mechanical) in the middle and lower dorsal regions irritates and increases peristaltic action and vaso-constriction in the stomach and intestines.

Osteopathic Inhibition

Likewise the term “osteopathic inhibition” has not always been scientifically employed. Mechanical inhibition is probably used less frequently than stimulation but still it is of more importance. Probably the true interpretation of considerable of so-termed stimulatory and inhibitory efforts, is simply one of normalization of tissues, physiologic equilibrium resulting from such changes.

Clinically, to relax contracted muscles by inhibition, to relieve neuralgia by impinging nerve courses, to relax the cardiac orifice of the stomach by pressure at the ninth or tenth dorsal vertebra on the left side, etc., are excellent examples of the therapeutic value of inhibition. Experimentally Pearce and Burns produced the opposite results to that of stimulation. Inhibition in the middle and lower dorsal region caused relaxation of the muscles of both the stomach and intestines, decreased peristalsis, and caused dilatation of the blood vessels.

The employment of stimulation and inhibition rounds out to a certain extent our therapeutics, that is, makes it more practical and specific. We should not, however, over-rate the relative value of stimulatory and inhibitory treatment as compared with the readjustive treatment. Not but what the former is of considerable practical importance, but the point to be emphasized is that it gives a scientific demonstration of how pathological effects result, if long continued, from the various osteopathic lesions. In a word, it shows the physiological process from cause to effect, or rather a step in the beginning pathological (perverted physiological) in many disturbances.

Therapeutically, all will agree with Cherry[35] that “stimulation and inhibition should be employed in all forms of acute disease as palliative measures until such time as the primary lesion may be removed.”

As a preparation for adjustment of any bony lesion there is no question but that simple inhibition for a brief time in the area will bring about relaxation of soft tissues in a much more satisfactory manner than the usual massage like method. McPherson, Montreal, has developed a technique of sacral pressure which he uses exclusively in his practice. Without going into the merits of his theory there is no doubt that inhibition at the second and third sacral will bring about relaxation of the muscles of the lower trunk in a most gratifying manner. Another thing, if there is difficulty in introducing the finger in making either a vaginal or rectal examination, a minute’s pressure at these points will, in most cases, cause the sphincter to relax so as to cause no discomfort to the patient. This pressure will, also, have a great effect on the hypogastric plexus and the pelvic organs.

Osteopathic Readjustment

Readjustment or adjustment is many times particularly emphasized in this work as the key to osteopathic therapeutics.

If the theory of readjustment can not stand the most searching tests of science osteopathy will have to be relegated to a most subservient place, on a par with massage, Swedish movements, and various medical gymnastics. Consequently the readjustment theory is again referred to, and especially so when the subjects of osteopathic centers, stimulation and inhibition are outlined.

No doubt many stimulatory (so-called) and general treatments exert their greatest influence by inadvertently readjusting tissues. Then how much more effective would the readjustment treatment be if applied intelligently. In certain acute disorders, e. g., “colds,” immediate relief is often obtained by relaxing muscles through either stimulation or inhibition; in reality the final result, as far as the muscle is concerned, is one of readjustment. Likewise in stretching and rotation of tissues and sections of the body the effect may either be stimulatory or inhibitory, and still it may be, also, readjustive.

After all has been said the ultimate physiological effect of any of these treatments, if of any therapeutic value, must be one of stimulation to a part or to the body generally. But there is a vast difference between physiological stimulation and the one method of obtaining the same termed mechanical stimulation. It is not the purpose here to enter into anything like an exhaustive survey of stimulation and inhibition but simply to outline a few practical hints on the relative values. Everyone is aware that overstimulation is equal to inhibition, and even applying it to very delicate subjects the therapeutic end we may wish to obtain may be lost and as a consequence the patient exhausted; whereas at the same time readjustment possibly could have been employed and real permanent effects secured.

So we should whenever possible utilize the basic principle of our therapeutics, readjustment, for this represents in the majority of cases, first, permanent results; second, a saving of much time, and third, less exhaustion on the part of both patient and physician.

McConnell[36] has shown in his series of laboratory experiments on animals the reality and potency of the readjustment fundamental. The effect of malaligned vertebræ and ribs upon contiguous vascular channels and nervous tissues, not only affects immediate skeletal muscles by simple contractions but even produces interstitial myositis. Through narrowing of the intervertebral foramina and tension upon the fibrous tissue anchoring the spinal nerve in its exit, and through pressure and strain on the sympathetics in contact with the heads of the ribs, which are secured there by the parietal layer of the pleura, organs in corresponding cavities become diseased. Some of the diseases produced in the series of experiments were catarrhal and parenchymatous changes in the stomach and intestines, congestion of the liver and spleen, acute nephritis, goitre, inflammation of the lymphatics, edema of the cornea, and degenerations of nervous tissues. Still too much emphasis should not be placed upon the narrowing of the foramen for certain pathologic changes are shown to be due to other conditions than Wallerian.

The osteopath, as stated, may inadvertently correct osteopathic lesions. _Vis medicatrix naturae_ undoubtedly corrects many osteopathic lesions; this is evident from the fact that many bodily strains, sprains, and injuries are overcome naturally or involuntarily, that is, without any voluntary assistance from an osteopath. On the other hand all osteopathic lesions are not due to outside influences or forces, e. g., in pneumonia the severely contracted dorsal muscles often partially dislocate the vertebral ends of the ribs and thus increase the seriousness of the disease; and this is true in many acute conditions wherein visceral changes will reflexly contract spinal muscles and also through these contractions produce osseous lesions. Here is where osteopathic treatment in acute diseases will not only correct the primary lesion but also these secondary ones and thus abort, or shorten, or lessen severity, or prevent complications of the disease. But it should always be borne in mind that when certain disease processes occur it will take a definite time at best for curative changes to predominate. In other words pathological changes are just as real and potent as physiological facts or anatomical data and the character of the same should always be considered.

Consequently in readjustment work a distinctive etiology and pathology has to be taken into account. The color, contour (whether the lesion is simply a local one or there is a composite or group lesion), condition (irritation, debility, contractions, and tenderness), and movement of the several regions, and the spine as a whole should be noted. And the student should always keep in mind that the osseous vertebral lesion may be, (a) a twist between two vertebræ (this generally means a rotation of one section of the spine on another section), (b) malalignment of several vertebræ (the composite or group lesion), or (c) the impacted or strained lesion, (this is a lesion that Clark attaches considerable significance to, wherein there is injury to the articular surfaces and ligaments without osseous derangement, followed by exudation and other inflammatory products, limited motion, etc.).

VasoMotor Nerves

It is extremely important that the osteopath should be thoroughly conversant with the regions where he may affect the vasomotor nerves to various tissues and organs. Many anatomical derangements undoubtedly involve the vasomotor nerves, and it is therefore necessary to know where they may be affected. The following table is taken mostly from the physiology of Landois and Stirling, but many of the statements have been noted at various times; it is, therefore, impossible to give full credit.[37]

The vasomotor center is in the medulla, consequently the osteopath gives cervical treatment to influence this center. Treatment of the upper cervical region has undoubtedly a marked effect in tending to equalize the vascular system of the body, when it is disturbed.

=Head.=—The cervical sympathetic for the same side of the face, eye, ear, salivary glands, tongue, etc., and possibly the brain. Lesions are found in all the tissues about the cervical region, but usually in the vertebræ, which influence these nerves. Deep contracted muscles oftentimes involve them. The spinal vaso-constrictors for the vessels of the head are from the first five or six thoracics. Many lesions are located in the upper five or six dorsal vertebræ, or corresponding ribs, that have apparently a direct influence upon the vessels of the head. Not only congestive headache and congestion of the brain tissues are influenced by lesions in this region, but disease of the eye, ear and face occasionally arise from such derangements. It is always best when the head, neck or even the arms are involved, to examine carefully this region. Vaso-dilator fibres for the face and mouth are found from the second to the fifth dorsals; these fibres unite almost entirely with the trigeminus, and pass from the superior cervical ganglion of the sympathetic, to the ganglion of Gasser. This fact is of great importance to the osteopath, for oftentimes when inflammation of the face and mouth occurs, lesions may be located along the upper dorsal vertebræ or ribs, or in the deeply contracted muscles of this region. Observation revealed in several cases of erysipelas that the causative lesion was located in the upper dorsal region; and the cases were cured by correcting these lesions, thus showing that probably the vasomotor nerves were the seat of the trouble. Other dilator fibres arise apparently in the trigeminus, for stimulation of this nerve between the brain and Gasser’s ganglion causes dilatation of the vessels of the face. The lingual and glosso-pharyngeal nerves are the dilators of the lingual vessels. The sympathetic and hypo glossal are the constrictors; these arise in the sympathetic and reach the nerves by way of the superior cervical ganglion. Stimulation of the cervical sympathetic causes constriction of the retinal vessels. This point is extremely interesting to the osteopath, because diseases of the retina and optic nerve are oftentimes due to subluxated cervical vertebræ, usually the atlas or third cervical. The retinal fibres leave the sympathetic at the superior cervical ganglion and pass along the communicating ramus to the ganglion of Gasser, from whence they reach the eye through the ophthalmic branch of the fifth nerve, the gray root of the ophthalmic, the ganglion and the ciliary nerves. Almost all the fibres to the anterior part of the eye are found in the fifth nerve; this, also, is another important point for the osteopath’s consideration. Cases of conjunctivitis, keratitis, corneal astigmatism and diseases about the eyelids and tear ducts are usually caused by lesions to the fifth nerve, due to a deranged atlas or third cervical. The vaso-dilators for the anterior part of the eye, and also dilating fibres to the iris may be affected at the first and second dorsals. This point is also taken advantage of by the osteopath, for lesions of these fibres occur oftentimes at the upper dorsal. It is claimed that important fibres that aid in the control of the metabolism of the retina, may be affected at the fourth and fifth dorsals.

=Lungs.=—Reflex constriction by stimulation of the intercostals, central end of the sciatic, abdominal pneumogastric and abdominal sympathetic. There is not a rich vasomotor supply.[38] The essential feature to the osteopath is that the vaso-constrictors to the lungs and bronchial tubes are very likely to be interfered with by rib and vertebral dislocations, from the second to the seventh dorsals, inclusive, but chiefly at the third, fourth and fifth. The heaviest innervation being from the third, fourth and fifth spaces, probably explains why asthma is often due to a dislocation of the third, fourth or fifth rib.

=Heart.=—First to fifth thoracic via ganglion stellatum and inferior cervical ganglion. Vasomotor fibres to the coronary arteries are found in the vagi.

=Intestines.=—Sympathetic, chiefly through the splanchnic nerves. Vaso-constrictors of the jejunum from the fifth dorsal down, for the ileum slightly lower and for the colon still lower. There are none below the second lumbar. Dilators are present in the same sheath, but more abundant in the last three dorsals and the upper two lumbars; all probably end in the solar and renal plexuses.

=Receptaculum Chyli.=—Stimulation of the splanclinics causes dilatation.

=Liver.=—The splanchnics chiefly on the right side. The vagus contains vaso-dilators. There are also fibres from the inferior cervical ganglia of the sympathetic.

=Kidneys.=—Vasomotor nerves from the sixth dorsal to the second lumbar, but principally from the ninth to twelfth dorsals, inclusive. In the large majority of kidney diseases, lesions are found from the tenth to the twelfth dorsals. Stimulation of the sciatic centers causes contraction. There are also fibres from the superior cervical ganglion.

=Spleen.=—Vasomotor fibres are in the splanchnics, third dorsal to third lumbar, principally, on the left side. There are some fibres direct from the brain. Stimulation of the vagi contracts the spleen.

=Portal System.=—Fifth to ninth dorsal.

=Generative Organs.=—For Fallopian tubes, uterus, vagina, vas deferens and seminal vesicles, vasomotor fibres are found in the lower dorsal, and the second, third, fourth and fifth lumbar nerves, principally.

=Coccyx and Immediate Region.=—Third lumbar down.

=Back Muscles.=—Dorsal Posterior branches of the lumbar nerves and intercostal nerves. These nerves arise from the gray ramus of the corresponding sympathetic ganglia.

=Arm.=—From the brachial plexus, the sympathetic, inferior cervical ganglion and first thoracic ganglion, and sometimes lower.

=Leg.=—Second dorsal down, the sciatic and crural nerves, and the abdominal sympathetics.

Sensory Nerves

Inhibition of various regions along the spinal column is frequently given by the osteopath to lessen pain. It is only a temporary or palliative treatment, but many times gives great relief. One should inhibit usually over tender points and contracted muscles. These (tender points and contracted muscles) are signs to the osteopath that disturbances exist at these points. The following table is taken from Quain, which is Head’s classification:

=Heart.=—First, second and third dorsals.

=Lungs.=—First, second, third, fourth and fifth dorsals.

=Stomach.=—Sixth, seventh, eighth and ninth dorsals. Cardiac end from sixth and seventh. Pyloric end from ninth.

=Intestines.=—(a) Down to upper part of rectum, ninth, tenth, eleventh and twelfth dorsals. (b) Rectum, second, third and fourth sacrals.

=Liver and Gall-bladder.=—Sixth, seventh, eighth, ninth and tenth dorsals.

=Kidney and Ureter.=—Tenth, eleventh and twelfth dorsals. Upper part of ureter, tenth dorsal. At lower end of ureter, first lumbar tends to appear.

=Bladder.=—(a) Mucous membrane and neck of bladder; (first) second, third and fourth sacrals; (b) over distension and ineffectual contraction, eleventh and twelfth dorsals, and first lumbar.

=Prostate.=—Tenth, eleventh (twelfth) dorsals. First, second and third sacrals, and fifth lumbar.

=Epididymis.=—Eleventh and twelfth dorsals and first lumbar.

=Testis.=—Tenth dorsal.

=Ovary.=—Tenth dorsal.

=Appendages, etc.=—Eleventh and twelfth dorsals, first lumbar.

=Uterus.=—(a) In contraction, tenth, eleventh and twelfth dorsals, and first lumbar. (b) Os uteri; (first) second, third and fourth sacrals (fifth lumbar very rarely).

Other points are used by the osteopath to relieve pain of certain regions, for such the reader is referred to the article on neuralgia; besides many tender points are found along the spine by the osteopath, where inhibition gives relief to the patient, provided such points have a connection with the case in question.

Hot fomentations if property applied, through reciprocal relationship of the nervous system, are of value in relieving pain, releasing spastic musculature and normalizing visceral function. Frequently, in both acute and chronic cases, this is an excellent preparatory measure, to be followed by careful adjustment. It will be recalled that the functional test, movement of a vertebral lesion is of primary consideration.[39]

FOOTNOTES:

[33] Burns—Partial Report of Experiments upon Visceral Reflexes. The Osteopathic World, Aug., 1905.

[34] Pearce—Some Laboratory Demonstrations of Osteopathic Principles. The Osteopathic Physician, Nov., 1905.

[35] Stimulation—Leslie E. Cherry, Journal of the American Osteopathic Association, Feb., 1905.

[36] McConnell—The Osteopathic Lesion,—Journal of the American Osteopathic Association.

[37] See also Gaskell, The Involuntary Nervous System; Pattenger, Symptoms of Visceral Disease; Mackenzie, Symptoms and Their Interpretation.

[38] MacLeod, Physiology and Biochemistry in Modern Medicine.

[39] See Luciani, Human Physiology, Vol. III; MacLeod, Physiology and Biochemistry in Modern Medicine.

PATHOLOGICAL SPINAL CURVATURES

SPINAL CURVATURES

Any deviation of two or more consecutive vertebræ from the normal curves of the spinal column is usually termed by the osteopath a pathological curvature. Of the common pathological curvatures of the spinal column there are found: (1) scoliosis or lateral curvature, (2) kyphosis, or excurvation, an antero-posterior curve with the convexity backward, and, (3) lordosis, or incurvation, an antero-posterior curve with the convexity forward.

=Osteopathic Etiology.=—Of primary importance in the causation of pathological curvatures of the spinal column, are injuries to the spine, such as strains, falls, blows, and various physical forces, acting directly or indirectly, as injuries to the chest, pelvis and limbs. The osteopath in his daily work finds more curvatures, as well as acute and chronic diseases, resulting from some simple injury to the spine, as a slip, strain or twist, than from any other cause. The dire effects of any violence to the spinal column cannot be overestimated.

Among =predisposing causes= may be mentioned, continued ill health, general weakness, rapid growth, rachitis, tuberculosis, etc. Any habitual one-sided position may result in a curvature. An injury to the chest, adhesions from pleuritis, chronic liver disease, obliquity of the pelvis producing unequal length of the legs, carrying heavy weights on one side, and various morbid growths of the chest and abdomen, may all produce curvatures. Many cases are found in school children who are growing rapidly, and whose muscular strength and development do not keep pace with their growth. Unilateral atrophy of the muscles, due to central changes or overuse, may be the cause of deviations of the spinal column. Sacro-iliac disease in some instances is a potent factor. Thus there may be a great variety of causes productive of the incipiency, and the spine being strained or irritated at a single point and in a certain way gradually develops a curvature. Every spinal and innominate lesion should be considered as a potential cause for a curvature.

=Scoliosis.=—This is the most common spinal deformity and is characterized by lateral deviation from the median line. In most cases the curve is to the right in the upper dorsal region, with a compensatory curve in the opposite direction in the lumbar region. The curve being to the right in the majority of cases, is probably due to the fact that most people are right-handed.

=Morbid Anatomy.=—The vertebræ in the region involved are rotated so that their spinous processes point toward the concavity of the lateral curve. The bodies of the vertebræ on the side next to the concavity are thinner, due to absorption; the intervertebral discs are made thin on the same side by pressure and absorption. The ribs are considerably distorted, depressed on the concave side and prominent on the convex side. The ligaments on the concave side are contracted, and stretched on the convex side. The muscles on the concave side are more or less contracted, and on the convex side they are stretched, causing atrophy and fatty infiltration of their tissues.

=Kyphosis.=—This may be a slight posterior curve really amounting to nothing, or it may be a very grave pathological condition as in Pott’s disease. Therefore it is very necessary that one should make a most careful diagnosis (see Pott’s disease).

The most common =causes= of kyphosis are Pott’s disease, rachitis, occupation, general weakness, rheumatism and old age.

In Pott’s disease, the posterior curve is characterized by a sharp angle, and by the spine being very rigid. This, taken in conjunction with the history and other symptoms should be sufficient to enable one to make a diagnosis. Radiographic examination should be made.

The condition of round shoulders, which in time produces marked kyphosis, is rarely a habit as it is usually termed. In nearly every case it indicates either a weakness of the back muscles or, what is more apt to be the cause, a strained posterior condition of the dorsal vertebræ, commonly of the lower dorsal region.

=Morbid Anatomy.=—In mild cases there is simply a relaxation of the ligaments of the vertebræ and a separation of the laminæ and spinous processes. In severe forms there may be absorption of the anterior portion of the intervertebral discs and the bodies of the vertebræ (Pott’s disease).

=Lordosis.=—This may be a congenital condition, especially when occurring in the lumbar region. Anterior curves of the spine are generally found in the lumbar or cervical regions, but occasionally occur in the dorsal region, causing the spinal column to be more or less straight, and thus weakening the individual. This curve is commonly compensatory to kyphosis, hip-joint disease and congenital dislocations of the hip.

=Treatment= of =Spinal Curvatures=.—The treatment of pathological curves of the spinal column, by osteopathic methods, has been highly satisfactory to both osteopath and patient. The success of the osteopath in these cases has been due to his comprehensive and exact knowledge of each vertebra, and of the spinal column in general. He recognizes curvatures that the ordinary practitioner, and it is safe to say the orthopaedic specialist, would not even notice or recognize. On account of the highly developed sense of touch of the osteopath, he is capable of detecting the slightest deviation of one vertebra from another, and of the spine in general from the normal. Thus by the uniqueness and peculiarity of his work he is capable, not only of discovering a curvature, but also of reducing a curve when found.

The work consists of, first, relaxing any muscles that may have become rigid over the seat of the curve. Then follows a treatment to each vertebra involved, by attempting to replace it, and treatment to the curve in general by springing it toward its normal position. At each treatment effort should be made to accomplish something toward correcting the spine; too many treatments are given in a “general” way, and being unspecialized amount to nothing. One must become familiar with the exact location of each vertebra involved, to attempt a correction of a curvature intelligently. Upon this one point it is impossible to speak too strongly, for a great many treatments have been wasted and improvement of cases retarded by not paying enough attention to the details of the diagnosis, either from pure slothfulness or from an imperfect conception of osteopathy. Corrective exercises are always of value in addition to treatment.

These remarks refer to incipient and certain moderate curvatures. In other cases radical measures (Abbott) should be employed if age and conditions permit. Remember, however, that the practitioner in his daily work of adjusting the many combinations of rotation and sidebending lesions corrects innumerable actual and impending curves.

=Lateral curvature= in the dorsal region is undoubtedly the hardest to correct on account of the ribs, which complicate the condition. A marked curve in the dorsal region is sure to be accompanied by a dislocation of the vertebral end of one or more ribs. Treat each distinct lesion separately, follow by general stretching, replacing and molding of the tissues. A good method to stretch tissues and adjust a moderate lateral curve is to utilize the swing, or in lieu of this have the patient stand just at arm’s length from the wall with concave side toward the wall with straight arm at right angles and palm resting against the wall. Stand in front of patient whose feet are firmly on the floor and reach around with both hands upon the spine. As the patient sidebends toward the wall it tends to correct the deformity, so if the operator coordinates his adjustment with that lateral movement of the patient, precise fulcra can be obtained and a certain, definite correction secured. The significance rests with the stretching of tissues and the definite fulcra obtained, thereby securing a maximum sidebending and rotation toward correction.

The =dislocation= of an =innominate= sometimes complicates matters, but is a simple point to remedy, and should not be overlooked.

The correction of a curvature presents a special study to the osteopath, whether it be scoliosis, kyphosis or lordosis, and special rules cannot be laid down for treatment. Cases of rare occurrence are what might be termed “symmetrical” curves; i. e., no vertebra presents separately a marked lesion, the column on the whole being simply bowed. Such cases can be treated by springing back the spinal column, and by the use of methodical exercises. Unfortunately most curvatures are characterized by various lesions between the vertebræ, and thus each lesion requires special work.

In simple curves the use of braces, jackets, and the various mechanical appliances are of very little use to the osteopath, in fact, more harmful on the whole, than beneficial. Naturally they would apply to a “symmetrical” curve, or where the patient is too weak to sit or walk, but they can be of very little use to the average patient, in place of correct osteopathic treatment. Mechanical appliances confine the movements of the patient, interfere with the development of the muscles, and impinge to a greater or less extent the spinal nerves. Due attention to hygienic surroundings and diet are certainly of aid. Proper exercises and occupation for the sufferer should be advised. Special care should be taken in examining (radiographic) for infectious lesions (arthritis).

=Straight Spine= is a term used particularly by osteopaths for a condition seldom recognized by orthopedic surgeons. The following is from H. W. Forbes[40]: Straight spine is “a departure from the normal in the conformation of the chest; characterized anatomically by bilateral diminution in size, decrease in the antero-posterior diameter, relative increase in the transverse diameter and flattening of the anterior and posterior walls; characterized clinically by diminution of respiratory capacity, lowered lung and heart resistance, impaired general nutrition and predisposition to neurosis.

“Of the many possible manipulations that may be used to lift and overcome the morbid bend of the ribs I will attempt the description of but one.