N^ /v UEFAF',' GF LLIEfTfE GF GG KVSforA.ffr; AjTEXT BOOK OF The Principles of Osteopathy BY GKDU HULETT, B. S., D. O. PROFESSOR OF PRINCIPLES AND PRACTICE OF OSTEOPATHY, AMERICAN SCHOOL OF OSTEOPATHY; MEMBER OF CLINICAL STAFF OF THE SCHOOL AND STAFF OF PHYSICIANS OF THE A. T. STILL INFIRMARY, KIRKSVILLE, MISSOURI. ILLUSTRATED. 1903 JOURNAL PRINTING COMPANY KIRKSVILLE, MO. ti/XKMcVHS COPYRIGHT 1903 BY THE AUTHOH. PREFACE. In presenting this work on the Principles of Osteopathy, the author is aware of many imperfections both in thought and arrangement of subjects; yet he is further cognizant of the fact that, owing to the dearth of satisfactory literature of the nature of which this work is illustrative, there are many in the student ranks as well as in the field who will welcome it in spite of its many faults. It must be understood at the outset that the work is designed primarily for the student who is but beginning to be interested in the new method of heal- ing. Hence to those who are already practitioners of that method the matter contained in the following pages may not seem particularly new or satisfying in the way of suggesting ideas of an immediately practical nature. Yet we are not without hope that even to the latter class there are many points of interest which will help to throw light upon some of the many vexing problems that continually arise in the ex- perience of the busy practitioner. Neither should it be assumed that the work is intended to treat exhaustively of the numerous questions of theory that are associated with the science. That is entirely beyond the scope of a work that is prepared especially for him who, under the circumstances of a comprehensive curriculum of study crowded into a period of time all too short, must of necessity limit his reading in all subjects to those texts which give but a comparatively brief treatment. This work therefore, is rather but an outline of the various subjects that are most closely related to the fundamentals of the science, with sug- gestions as to the direction further investigation should take. The various subjects outlined and the manner of their treatment are the result of the labor of the author which has been especially devoted to the principles of osteopathy during PREFACE. his course as teacher in the American School of Osteopathy for the past three years. In large part the work here pre- sented is a revision of lectures delivered before the classes in Principles of Osteopathy. The work is divided into Parts I and II, indicating a dif- ference in the nature and arrangement of the matter treated. This difference lies in the more general nature of the sub- stance of Part I, the more specific in Part II. Certain funda- mental propositions bearing on the general problems of life, health, and disease are discussed in the former, while the de- ductions drawn therefrom are applied specifically in the lat- ter to the various regions of the body. Acknowledgment of indebtedness is hereby made to all those who, either directly or indirectly, have aided in the elaboration of the subject matter, and in the preparation of the volume. To Dr. A. T. Still, the founder of the science, special thanks are due for continued oversight and frequent correction a fact for which is felt the deepest gratitude. Dr. Charles Hazzard, the pioneer as an author of a text book, and an exponent of osteopathy of wide and enviable reputa- tion, has as teacher and co-laborer, been of very material aid and inspiration in the work. Other members of the faculty of the American School of Osteopathy, as well as numerous practitioners in the field have incidentally or specifically con- tributed to the material which has been systematized and formulated in this volume. To Dr. C. M. T. Hulett, of Cleve- land, Ohio, the author is under obligation for many sugges- tions, and especially for his patience and care in reading the manuscript. Kirksville, Mo., August, 1903. CONTENTS. PART I. CHAPTER I. INTRODUCTORY. An Evolution, 12. Hippocrates, Galen, Paracelsus, Harvey, Sydenham, Haller, Virchow, Ling, Hilton, Pasteur, Koch, Klebs, Krukenberg. The Revolution, 18. CHAPTER II. SOME FUNDAMENTAL CONSIDERATIONS. The Boundaries of Osteopathy, 20 Definition, Legal, Technical. The Viewpoint of Life, 22. Definition of Life, Vital Force, Basis for Functioning, Law of Change. Structure and Function, 25. Develop Co-ordinately, First Product. Cell Doctrine Insufficient, 27. Ante-cellular Elements, Cellular Structure, Protoplas- mic Bridges, Syncytium, Body as a Whole, Chains of Disorders, Administration of Drugs, Inheritance. Cause of Disease not in the Cell, 32. Auto-intoxication, LaGrippe, Blood or Nerve Influence, Error, Modify Conditions, Inherently Healthy. Man a Machine, 36. Machine, Mechanism. The Body a Chemical Laboratory, 38. Conditions Needful, Fundamental Facts, Inferences, Iron, Fibrin. CHAPTER III. SOME FUNDAMENTAL CONSIDERATIONS (CON.). The Energy of the Body, 43. Conservation of Energy, Transformation of Energy 2 PRINCIPLES OF OSTEOPATHY. Chemical Action, Molecular Attraction, Mass Attrac- tion, Mechanical Energy, Nerve Energy, Potential vs Kinetic, Summary. Body Fuel, 53. Essential, Metabolism, Reserve Supplies, Average Diet, Dining, Disease Conditions. More than a Machine, 59. Self -sufficiency of the Organism, 60. Self-regulating Power, Functionally in Health, In Disease, Structurally, Fundamental Proposition. Tendency to the Normal, 64. Normal Condition, Symptoms, Heredity, Adaptation, Both Necessary, Physical Principles, Chemical Princi- ples, Vital Principles, Association of the Three. CHAPTER IV. THE ETIOLOGY OP DISEASE. Abnormal Structural Conditions, 69. Gross Anatomical Disturbances, Why Limit the Appli- cation, Evidence. Disease Maintained by Structure, 72. Original Stimulus, Acute Conditions, Predisposition. The Lesion, 75. Definition, Positional Relations, Size Relations. Media through which Lesions Produce Disease, 77. Direct Pressure, Artery, Vein, Lymph Channel, Nerves. Miscellaneous Notes, 80. Vitality of Tissue, Adjustment Possibilities,Transferred Pain, Other than Pain Conditions. The Causes of Lesions, 84- External, Internal. CHAPTER V. THE ETIOLOGY OF DISEASE (CoN.). Abuse of Function, 88. Over-use, Under- use, Perverted Use. Predisposing and Exciting Causes, 91. Definition, Reversibility of Causes. CONTENTS. 3 Germ Theory of Disease, 94. Definite Relation, Buzzards, Manner, Immunity, Con- clusion. CHAPTER VI. THE DIAGNOSIS OF DISEASE. The Symptom, 101. Heart Rate, Pain, Temperattire,Vomiting and Diarrhoea, Rapid Respiration, Glycosuria, Inflammatory Condi- tions, Disadvantage, Definition. Methods of Examination, 106. Inspestion, Palpation, Percussion, Auscultation, Men- suration. The Diagnosis of Lesions, 109. Functional Activity, Functional Rest, Perversion of Function, General Attitude, Position, Sensory Change, Definition of Pain, Direct, Referred, Segmental Struc- tures, Referred Tenderness, Tender Spots, Associated Muscle Tissue, Amplitude of Movement, Temperature Change, Color. CHAPTER VII. THE TREATMENT OF DISEASE. Prophylaxis and Therapeutics. 121. Prophylaxis, Therapeutics, Higher Plane. Curative versus Palliative Treatment, 125. Adjustment of the Osseous Lesion, 126. Exaggeration of the Lesion, Rotation, Pressure. Adjustment of Muscular Lesions, 129. For Diagnosis, Preliminary to Further Treatment, Pri- mary in Itself, Removal of Cause, Pressure, Stretching, Approximation of Origin and Insertion. Treatment of Other Lesions, 137. Perverted Size Relations, Connective Tissue. CHAPTER VIII. THE TREATMENT OF DISEASE (CON.). Stimulation and Inhibition, 140. Definition. PRINCIPLES OF OSTEOPATHY. Difficulties in Direct Control, 143. Nerve Functions, Different Functions, Unusual Situ- ations, Direct Manipulations, Reflex Basis, -Proportion to Need, Recoil. Objections to Direct Control, 147. Interfere with Normal Function, Reaction, Conceal- ment, Treatment Habit, Choice of Evils. Indications for Attempts at Direct Control, 150. Lesion not Apparent, After Removal, Impossible Re- moval, Force Obstruction, Tide Over a Crisis, Treat Symptom. Do We Stimulate or Inhibit, 152. Deceptive Terms, Summary. Treatment of Disease Caused by Abuse, 155. Negative, Where Unable to Abstain, Simple Absti- nence. Miscellaneous Notes, 157. Lesions not Immediately Removed, Lesions not Entire- ly Removed, Frequency of Treatment, Length of Treatment, Rapidity of Movement, Possibility of Harm. CHAPTER IX. COMPARISON WITH OTHER SYSTEMS. Drug Therapy, 164. Empirical Method, Stimulant, Sedative, Neutralization, Substitution, Germicide, Results, Real or Satisfactory, Combat Effects, Adds to the Burden, Cumulative Ef- fect, Other Organs not Involved, Habit Formation, Un- certainty. Electrotherapy, 174. Curative Value, Effective or Satisfactory, Roantgen Ray, Phototherapy. Hydrotherapy, 177. Thermal Agent, Stimulant, In Constipation. Psychotherapy, 179. The Principle. Mechanotherapy, 181. Massage, History, Swedish Movements, Summary, Technique, Special Effects, New Growths, Control of Circulation, Nerve Massage and Vibration, Tender CONTENTS. Points, Non-essential Differences, Essential Distinc- tion. Summary, 190. Similarity of Basis, Stimulant or Sedative, Neutraliza- tion, Substitution, Destroy the Micro-organism, Abso' lute Difference. PART II. CHAPTER X. THE SPINE. General Survey, 194. Contour, Rigid Spine, Lateral Curvatures, Single Ver- tebrae, Aerial Number, Position, Other Points, Relative Use, Median Furrow, Tenderness, Contracture, Sounds, Average Lesion Slight in Extent. General and Specific Effects of Spinal Lesions, 202. Spinal Lesion, Entire Field. A Typical Condition, 203. Torsion, Artery, Vein, Lymphatic, Spinal Nerve, Sym- pathetic Nerve. The Sympathetic System, 206. Embryology, Gangliated Cords, Plexuses, Connection, First Type White Ramus, Second, Third, First Type Grey Ramus, Second, Third, Fourth, Fifth, Last, Functions, Possibilities of Disorder. The Vaso -Motor System, 214. Definition, Two Classes, Local Mechanisms. Spinal Lesions Affecting Vaso-Motors, 216. Striking Fact, Irritation, Not Simple Condition, Mus- cle Contracture, Radiation of Impulses, Hart's Theory. Other Effects, 223. Other Functions, Secondary Contracture. CHAPTER XI. CERVICAL LESIONS DIAGNOSIS AND TREATMENT. Superficial Structures, 226. Examine in Different Functional Conditions, Horizontal 6 PRINCIPLES OF OSTEOPATHY. Position, Sternomastoid, Scaleni, Posterior Muscles, Hyoid, Throat Structures, Tonsils, Cartilages, Thyroid Gland, Vascular and Nervous Structures. Cervical Vertebrae, 234. Examination, Atlas, Axis, Third to Filth, Seventh. Adjustment of Cervical Vertebrae, 240. Principles, Methods, Posture. Inferior Maxillary Bone, 243. Examination, Lesions, Treatment, Effects. CHAPTER XII. CERVICAL LESIONS EFFECTS. Effects From Direct Pressure, 246. Spinal Cord, Thyroid Gland. Effects From Vascular Obstruction, 247. Carotid System, Vertebral, Intervertebral, Thyroid. Effects on Spinal Nerves, 251. Cervical Plexus, Brachial Plexus. Effects on Cranial Nerves, 254. Fifth, Facial, Glosso-Pharyngeal, Vagus, Spinal Ac- cessory, Hypoglossal. Effects on Cervical Sympathetics, 258. Superior Cervical Ganglion, Middle, Inferior, Connec- tion with Spinal Nerves, Eye, Ear, Fauces, Respiratory and Alimentary Canals, Heart, Thyroid Gland, Minor Plexuses, Grey Rami to Cord. CHAPTER XIII. THORACIC AND LUMBAR LESIONS SPINAL. Thoracic Lesions General, 266. Examination, Flat Interscapular Region, Overcome the Condition, Lateral Swerve, Thickened Ligaments, Pos- terior Convexity, Overcoming the Posterior Curve, Dr. Still's Chair. Thoracic Lesions Local, 276. Torsion, Separations, Anterior Luxations. Lumbar Lesions, 277. Noting the Condition, Curvatures, Single Vertebrae, Overcoming Lesions. CONTENTS. 7 CHAPTER XIV. THORACIC AND LUMBAR LESIONS COSTAL. Examination, 282. Different Positions. Some General Types, 284. Fiat Chest, Barrel-shaped Chest, Box-shaped Chest. Single Ribs, 286. Landmarks, Articular Mechanisms, Forms of Lesions, Tenderness, Contracture. Special Ribs, 291. Atypical, First Rib, Floating Ribs, Examination, Up- ward Displacement, Posterior End. Adjustment of Ribs, 296. Considered as a Whole, Vertebral Disturbance, Specific Movements, First Rib, Floating Ribs. Sternum and Cartilages, 302. Primary Disorders, Treatment. The Clavicle, 304. Slight Subluxations, Treatment. The Scapula, 306. Change in Position, Treatment. CHAPTER XV. THORACIC AND LUMBAR LESIONS EFFECTS. Direct Pressure, 308, Flattened Chest. Vascular Obstruction, 308. Intervertebral System, Lumbar Vessels. Spinal Nerves, 309. Thoracic, Lumbar Plexus, Sacral Plexus, Nerve Trunks, Sympathetic Fibres. Sympathetic Nerves, 312. Cervical Ganglia, Heart and Aorta, Arm, Lungs, Stom- ach, Liver, Spleen and Pancreas, Intestines, Ovary and Uterus, Kidney, Hypogastric Plexus, Generative Organs, Supporting Tissues, Lower Limbs. Direct Pressure from Ribs, 328. Lungs, Heart, Abdominal Organs, Stomach and Intes- tines. 8 PRINCIPLES OF OSTEOPATHY. Rib Pressure on Vascular Channels, 332. Double Effect, Superior Opening, Intercostal System, Diaphragm. Rib Pressure on Nerves, 336. Superior Opening of Thorax, Intercostals. CHAPTER XVI. PELVIC LESIONS. Examination and Diagnosis, 339. Pelvis, Landmarks, Examination, Upward Subluxa- tion, Length of Limb, Determination of Length, Which Limb Involved, Posterior Superior Spines, Anterior Superior Spines, Lesions of Sacrum. Adjustment of Pelvic Structures, 346. Withdrawing the Wedge, Other Methods, Wheel and Axle, Knee, Pubic Articulation. Lesions of Coccyx, 349. Coccygeal Articulation, Common Subluxation, Treat- ment, Coccyx Alone. Effects of Pelvic Lesions, 351. Direct Pressure, Vessels. Effects on Nerves, 352. Sacral Plexus, Spinal Nerves, Pelvic Plexuses, Bladder, Uterus, Organs of Generation, Secondary Disorders. PART I . CHAPTER I INTRODUCTORY. A statement of the principles which underlie the science of osteopathy must, in the nature of things, be a very incomplete one. No one recognizes the fact more thoroughly than does the practitioner himself when he is compelled to apply theoretical propositions to actual cases. Nor should he be astonished at the discovery. If, as we continually re- iterate, osteopathy is a system built upon the facts of anatomy and physiology, then the foundation must be an absolute and knowable one before we may presume to pronounce the build- ing in any sense complete. Unfortunately for the building,, the foundation itself is incomplete, but "ever becoming." It is a perennially recurring surprise to the students of the bio- logical sciences, to learn that in comparison with what is yet to be determined, the total bulk of demonstrable fact relating to these sciences is infinitesmal. "When the student, in tak- ing up the study of osteopathy, is told that the osteopath is successful by virtue of his complete knowledge of anatomy and physiology, he glories in the assertion. But when he learns, as he certainly will, that the most expert is equipped with only a meager supply, he is likely to be disappointed. True, in anatomy we are comparatively well grounded, but our knowledge of physiology and its related sciences is ex- tremely unsatisfactory and must remain so for long. Why need we then apologize for an incomplete statement of the principles of osteopathy? But another fact is very apparent. Dr. Still himself has repeatedly asserted that osteopathy is yet 2 10 PRINCIPLES OF OSTEOPATHY. V in its infancy. Why pretend then that there be any possibility of presenting it in the garb of maturity. Because of its youth, we must be content with a proper modesty of state- ment. It is unfortunate that in the rapid growth of the system and in the increase in number of its adherents, time has not been given sufficiently to a careful analysis and record of cases which tend to substantiate the fundamental propositions ; and since only an infinite number of observed instances will thoroughly satisfy the demands of inexorable logic, sufficient data has not yet been collected to warrant unqualified state- ment. A careful presentation then of certain very general but unequivocal propositions,supplemented by numerous pro- visional ones, is the duty of him who would formulate a "plan and specification," upon which the practitioner is to build his superstructure. It is further necessary to make a fairly clear distinction between principles and practice. It is a pecular character- istic of the average beginner to long for the opportunity to observe and experiment upon cases. He has imbibed the idea that osteopathy consists essentially in the performance of certain movements upon the patient, which in one sense is correct. But it is necessary to emphasize that before such movement shall be intelligently applied, certain fundamental facts are essential; and it is in the development of these re- quired facts that the principles of osteopathy consist^. Dr. Still has emphasized in his Philosophy of Osteopathy and time and again by word of mouth that a "plan and specification" is necessary before intelligent work can be done. There must be in the mind of the student a "living picture," not only of the form and feature but also of the function, the ten- dencies toward and away from the line marked out by hered- ity, and every phase and fact that may be known regarding the complete life of the individual. It is true no such pic- ture was held by the pioneer in earlier times. It is true that osteopathy like all other sciences had its beginning as an art. It is no discredit to the science that the art occupies first INTRODUCTORY. 11 place in point of time. Musicians and poets are "born" and the art of music and poetry existed long before the laws of harmony and metre were known. But it is significant that there are few great poets or musicians who are ignorant of the laws underlying their art. The farmer may be able to produce a crop with no knowledge whatever of the chemistry of soils or the laws of plant growth; but the present develop- ment of agriculture could never have been, had not such laws been discovered and formulated. The school teacher may be able to instill knowledge into the minds of the young and still be ignorant of pedagogics, but he can never occupy first place. In osteopathy we have no exception to this rule. In his Autobiography Dr. Still mentions the fact that while yet a boy, a case of headache was aborted incidental to the resting of his sub-occipital region within a rope swing. That was the art of osteopathy. Similiar cases and observation of other facts accumulated until an inkling was obtained of a law un- derlying the several facts. The recognition of that law and the application of it to still further cases constituted the be- ginning of the science. The facts continually accumulating with few Exceptions that could not be explained, and their systematization, justified the presentation of a working hy- pothesis. It is the discussion of this hypothesis and the facts substantiating it, the taking it as' far as may be from the realm of theory into the realm of demonstration, that con- stitutes the principles of osteopathy. The application of the principles to specific cases of disease constitutes the practice of osteopathy. A system of healing cannot properly be separated from a philosophy of life. This is true by virtue of the involved nature of disease. We may prate of pure science and declare that we will accept nothing not susceptible of demonstration, and that a system of healing must depend for its perma- nency upon pure facts of observation. We may insist that laboratory knowledge is the only brand that will be permitted to enter the sacred field of science. And yet the fact re- 12 PRINCIPLES OF OSTEOPATHY. mains that the details of every branch of learning have been wrought out and established through the application of pre- concieved theories based upon comparatively few facts. The beginning of knowledge comes by induction, but its comple- tion is only accomplished by deduction. A theory of life is at the basis of the osteopathic science. The proof that it is a law rather than a theory is the problem of the osteopathic reasoner and practitioner. That proof must of necessity re- quire time, and inasmuch as confirmative evidence is daily accumulated, let no one be discouraged. AN EVOLUTION AND A REVOLUTION. What is that philosophy? It is both an evolution and a revolution. To make our position clear it is necessary to look back into history and trace out so far as may be possible the evolutionary outcropping^ that have appeared from time to time, culminating finally in a condition that has made possi- ble the revolution inaugurated by Dr. Still. ' If we turn to antiq- uity, we find an abundance of philosophy with little of fact. Remedial agencies were employed with little regard to the nature or the manifestations of the disease; which is not to be wondered at, because of the paucity of knowledge regard- ing the body either in a condition of health or disease. It is true the records would indicate that in the time of the Ptolemies, post-mortems were held; the ancient Brahmins were aware of the variations in the specific gravity of the urine depend- ent upon diseased conditions, and practiced a crude form of urinalysis. In some respects the remedial measures of that day may be considered a lost art, for the legends have it that measures were known, the use of which would prevent the pitting of smallpox, and antidotes efficient for the most ven- omous of snake poisons were compounded. The Chinese rec- ognized the diagnostic value of changing conditions of the pulse, though the connection between the condition observed INTRODUCTORY. 13 and the remedy employed is unexplained. The Hebrews, while recognizing certain fundamental facts in regard to the ethical relations existing between man and man, and the moral relations between man and his Creator, gave to the world little of value in the way of treatment of individual body conditions. The world is,however,indebted to that race for the most elaborate system of hygienic matters that has been devised, some of the provisions of which might well be incorporated in modern sanitary regulations. Until the era of Hippocrates little was given to the world of a permanent nature that would assist in solving the problems of disease and death. In Hippocrates (460 37 7 B.C.) the medical world recognizes its first great figure, not so much by virtue of any great depth of reasoning, but by virtue of his ability to observe, and further, by his recognition of the necessity for recording his observations. Hence,in the Hippocratic collection of writ- ings we find a vast field covered, embracing as it does every branch of the healing art, both of prophylaxis and thera- puetics. Hippocrates further deserves the title, "Father of Medicine," because of his work in gathering together not only his own observations, but those which he considered worthy of others of his time and those who preceded him. It must be noted, however, that the value of the observations of Hippocrates lies in their relation to the symptoms rather than to the explanations or the treatment of disease. He added to the knowledge of effects but not to the knowledge of cause or its removal. The philosophers, Aristotle and Plato, with their contemporaries, dealt largely with speculation and little with experimental determination. It is interesting to note that in their time arose the pneuma theory, or the theory of the spirits, which in effect was the precursor of Priestley's demonstration a thousand years later, of the presence of oxy- gen in the air and of the important role that element plays in all life processes. The same era produced Empedocles and Heraclitus, who with their theories of evolution and the struggle for existence, respectively, anticipated Darwin and 14 PRINCIPLES OF OSTEOPATHY. his followers, and which in the last half century has so pro- foundly modified every phase of the life question. While the modern biological investigator has reverence for the name and fame of Hippocrates, he recognizes in the Roman anatomist Galen(131 201 A. D.) the first investi- gator endowed with the so-called scientific spirit. That spirit was manifested in experimental methods of study which were careful for that age of the world. As an anat- omist and physiologist, Galen was able to disprove some of the contentions of the Hippocratic school as well as to add a considerable number of important facts to existing knowledge by dissections and vivisections. That Galen's influence was profound and permanent is evidenced from the fact that cer- tain of his classifications are still employed, and that for four- teen centuries his word was law. In spite of his contribution to biological knowledge, Galen added in a direct .way not a whit to the understanding of the cause or the treatment of disease. From the time of Galen throughout the Middle Ages up to the fifteenth century, little advance was made in any of the sciences related to the healing art. Through the schools of France, Italy, and Spain, fact and tradition were preserved unmodified. All knowledge centered in the records of Galen until,with the general revival of learning 1 individuals once more began to investigate and reason for themselves. A striking character arose early in the sixteenth century. Dis- putant, philosopher, mystic and egotist, Paracelsus (1493 1541) proclaimed to the world a profound contempt for the learning of the past as recorded in books, insisted that know- ledge must be gained subjectively, and formulated a theory of nature. Three of his affirmations we wish to emphasize: first, all nature is a unit; second, nature is never complete, but forever becoming; third, nature is a macrocosm, man a microcosm. That these three ideas have become part and parcel of mod- ern thought, is a proposition requiring little substantiation. The close relation that they bear to the osteopathic doctrine becomes more and more apparent with further study. From INTRODUCTORY. 15 this time forward the path of history is marked with the names of individuals who stand out prominently because of added biological facts or demonstrable theorems. Harvey (1578 1657) gives to us the proofs of a complete circulation and the dictum never yet refuted, omne vivum ex ovo, the former of which had been suggested by Galen and by others less noted. We need hardly dwell upon the importance of both of these facts to the osteopath. Van Helmont(1577 1644) a follower of Paracelsus, emphasized the inter-relations between matter and energy, and suggested the doctrine of ferments as explaining the digestive processes. The philos- opher, Descartes (1596 1650), while emphasizing certain and numerous ideas of a general nature regarding matter and mind, gave rise to one concept that is of the utmost signifi- cance to the osteopath. The idea that wan is a machine and the operation of his organism is dependent upon mechanical laws, is a view fundamental to osteopathic reasoning, and to Descartes we are under obligations for that emphatic state- ment. Growing out of this conception arose the iatromechan- ical school, whose chief advocates, Borelli (16081679) and Marey of our time, have made the application chiefly to the systems of animal movement; while a rival school, the iatro- chemical, founded by Sylvius, insisted on the application of chemical principles as explanatory of various functions. At this stage in the historical development we find an immense impetus given to the investigation of the problems of life through the invention of the compound microscope where- by not only the cellular theory of living structure was form- ulated, but also the discovery was made of microscopic forms of life. This was followed first by the interminable discus- sion of spontaneous generation and later gave birth to the germ theory of disease a theory which has profoundly modified medical thought and practice during the closing years of the nineteenth century. In the latter half of the seventeenth century the English physician Thomas Sydenham, em- phasized another fact which is basic to osteopathic theory. 16 PRINCIPLES OF OSTEOPATHY. He made emphatic claims for the healing power of nature and thereby anticipated the contentions of all those of later time who insist that it is nature who cures and not the physician. Priestly, in the latter half of the eighteenth century, by his discovery of the element oxygen was able to replace in sub- stantial form the pneuma of the early philosophers, which, en- tering the body through the breath gave life to its tissues. Haller (1708 1777), following Glisson in the investigation of the property of irritability, enlarged upon the conception of a vital force underlying all life phenomena and independ- ent of known chemical and physical laws a conception Vhich still commands the adherence of a respectable number of scientists, and which is yet perhaps neither susceptible of proof nor disproof. The relation existing between physiolog- ical activity and electricity has been the subject of study since Galvani (1737 1798) proved the generation of electric currents by living tissues, and the recent facts of physical chemistry regarding the electrical nature of certain chemical reactions bid fair to throw further light upon the part played by electric energy in the body organism. During the nineteenth century a few figures stand out strongly in the further development of biology. In special prominence we note the tendency of all modern investigators to an objective study, leaving severely alone, too severely we believe, all matters of a speculative nature. Hahnemann (1755 1843), with his "law of similars" and his insistence on smaller dosages, has most profoundly modified the practice of heroic drugging which had reached an alarming stage. Virchow (1821 1902) with his investigation into the pathol- ogy of cells, has cleared up many of the mysteries associated with pathologic conditions, incidentally throwing light upon the general cell doctrine, although his views and those of his fol- lowers can but be regarded as extreme and in some respects impossible. Ling'(1776 1839), by virtue of his systematiz- ation of the various methods of movement cures, gave an im- petus to the study of the physiological effects of mechanical INTRODUCTORY. 17 stimuli, a fact which has led to no little confusion both on the part of the laity and profession, in regard to the distinc- tion between these various methods and that of osteopathic practice. Hilton, the English surgeon, has emphasized Sydenham's contention relating to the healing power of na- ture, in its surgical aspects, and has served to show, inno- cently enough, the essential identity in the standpoint of os- teopathy and conservative surgery. Pasteur and Koch and Klebs and a host of others, through their investigations of the processes of fermentation in and out of the body, to- gether with the demonstration of the close relationship be- tween disease and micro-organisms, have greatly added to our knowledge of the pathological changes taking place in specific diseases, although their explanation of such rela- tionship is not accepted in its entirety by the osteopath. Modern biologists have added a vast amount of data to the sum of knowledge accumulated in the past, and to them the members of all the schools of healing are greatly indebted. In so far as that knowledge has been applied in explaining the cause of disease and suggesting its treatment there is a pitiable poverty. The ground work for a rational system was laid. The inauguration of that system remained for a leader. The use of drugs, which had come to occupy first place among the healing agencies, was found sadly wanting. As early as the first half of the last century, the tendency of the later time was stated by Krukeiiberg, a German phy- sician, in these words as quoted by Park: "Physicians should be filled with a pious reverence toward nature; the organism is a whole and must be contemplated in this sense; medical art is undoubtedly capable of decisive action, but let us not mistake that in many cases its activity is quite superfluous, in very many null and inadequate, and in many injurious." That there has been a remarkable turn- ing away from drugs in the last half century is evidenced from numerous facts. Note the rise of Christian Science and the numerous other cults whose systems are based on the re- 18 PRINCIPLES OF OSTEOPATHY. lation between mind and body, which number their adher- ents by the millions, and whose reputed cures emphasize Krukenberg's statement that in many cases medical art is superfluous, and substantiates Syndenfiam's declaration that the healing power resides in nature; electrotherapy for a time flourished and still has its enthusiastic admirers ; hydro- therapy has become an adjunct of practically all systems, the use of which has been emphasized to the ignoring of its abuse which in reality has been productive of the greater results; the development of serotherapy co-existent with the develop- ment of a knowledge of toxins produced by pathogenic bac- teria has had far reaching results; the known facts relating to internal secretions, together with the observation of path- ologic conditions resulting from the absence of some organ, usually a ductless gland, has led to the rise of organotherapy, and has served to distinguish between organic food elements and inorganic chemical substances. The rise of these vari- ous systems, all indicating the desertion of the drug, has not been dependent upon a realization by the physician alone of the inadequacy of the drug, but equally upon that realization by the thinking laity. The time was ripe for a revolution in the conception of cause and treatment of disease. THE REVOLUTION. It was stated that in osteopathy not only was there an evolution but there was a revolution. Heretofore the phy- sician had confined his attention to appearances, which in truth was all that he could do, inasmuch as the cause re- mained unknown. Every system of treatment thus far de- veloped had been one designed primarily to combat effects. It remained for Dr. Still to determine the fundamental cause of all disease, and to inaugurate a system of treatment based upon that cause; and in the statement that perverted struc- tural conditions prevent the return to normal functions we have the essence of the osteopathic doctrine, and in the appli- cation of measures designed to remove these structural condi- INTRODUCTORY. 19 tions, we have the essence of that revolution. Dr. Still's great work then lies in the determination of cause, and through a knowledge of that cause, the application of an ef- fective treatment. The study of the nature of this revolu- tion in its various general and detailed aspects, constitutes the subject matter of the remainder of this volume. 20 PRINCIPLES OF OSTEOPATHY. CHAPTER II. SOME FUNDAMENTAL CONSIDERATIONS. THE BOUNDARIES OF OSTEOPATHY. All systems and sciences, whether related to healing or other aspect of human endeavor, are a result of growth. Growth presupposes a beginning less mature than the end. Hence it were presumption at the present time to attempt to set definite limits to the science of osteopathy. Professor Ladd of Yale states a very important fact when he says that the proper definition of a science is one of the latest and most difficult achievements of that science. Recognizing the extreme youth of osteopathy we must be content with only a provisional setting of limitations in any attempt at a statement of its constituent elements. Admitting this to be the case, yet we do not deem it presumption to attempt to formulate in a concise manner the essential ideas in the form of what may be called a definition. We protest against the position that is assumed by some that there cannot be a platform upon which we may stand. Our system must have a basis, staunch, unshaken, if it shall stand. We are willing to listen with patience to the presentation of new facts that may cause us to modify our platform, but these must come as fact and not as theory before we shall recede from the principles enunciated in that platform. And so far in the history of the system the original conception still re- mains unimpaired, even though sometimes hastily considered inadequate to cover the ground. We believe that if care is taken to analyze the facts it will be found that instead of modi- fying the original concept, they do but confirm and make it the more impregnable. It is needless to say that a single word cannot indicate in any comprehensive way the nature of the system. Hence we have no intention to explain in any apolo- SOME FUNDAMENTAL CONSIDERATIONS. 21 getic and compromising terms why the word osteopathy came to be used. We do insist, however,as compared to the termin- ology of other systems it comes much more nearly striking the keynote, and is far superior to any other name that has been suggested. The legal definition given to the system by the statutes refers to it as a "system, method, or science of healing." We must recognize at a glance that it is systematic and method- ical. The more pertinent inquiry remains, is it a science? That it is not a completed science we have already by infer- ence emphasized. That it embraces all the elements of a science we affirm. The definitions that have been given for the word science have been many and various. Succinctly, "systematized truth" may serve the purpose as well as many of a more pretentious character. In so far as the facts that have been gathered when arranged in definite logical order tend to support a definite hypothesis we have a science. In so far as the conditions in disease are shown to depend in defi- nite ways upon certain properties of the structural arrange- ments, thereby occupying the relation of cause and effect, we have the essentials of a science. Finally, inasmuch as anat- omy and physiology are sciences, osteopathy, which is but the application of these two toward the cure of disease, must par- take also of the nature of a science. True, there are many things yet to be reconciled, yet to be classified, but that fact does not in any way impair its validity as a science. Not touching upon the details that remain yet to be work- ed out a technical definition' must suggest a concept of the cause and the treatment of disease. In regard to the latter it must not only embrace therapeutics but prophylaxis as well. For medicine in the broad use of that term must include not only measures employed to assist the body in recovering its equilibrium but also those designed to assist the organism in' maintaining that equilibrium. Indeed the latter is logically of far greater importance, but because of an unfortunate ten- dency on the part of human nature to procrastination the for- Y V ^ V (/ 22 PRINCIPLES OF OSTEOPATHY. mer will of necessity demand the most of the physician's labor. In order that our definition shall include essentials and give to us a basis of support the following propositions must be either directly or by inference included : 1. Cure is the prerogative of the organism. 2. Functional disorders will be self -adjusted except where complicated with or dependent on structural disorders which are beyond the limits of self -adjustment. 3. Removal of structural disorders constitutes the treat- ment. In accordance with these provisions we have in another publication (Journal of the American Osteopathic Association, May, 1902) suggested the following definition of osteopathy: A system of therapeutics which, recognizing that the maintenance and restoration of normal function are alike dependent on a force inherent in bioplasm, and that function perverted beyond the limits of self- adjustment, is dependent on a condition of structure perverted beyond those limits , attempts the re-establishment of normal function by m i a l ni&- ulative measures designed to render to the organism such aid as will enable it to overcome or adapt itself to the disturbed structure. The elaboration of the various provisions in the above definition will appear as the subject is further developed in the follow- ing chapters. The science then by virtue of its recognition of the inter- relations between structure and function is eminently, as has been so often stated, the application of anatomy and physiol- ogy to the cure of disease. THE VIEWPOINT OF LIFE. We have spoken of the fact that a system of healing can- not be separated from a philosophy of life. As introductory to a further study of the osteopathic doctrine it is necessary to consider in brief a few aspects of the life problem. Not that it is possible to give an accurate definition of life; for it "is obvious that no such definition can be given of a thing; the essential nature of which is unknown. For we know- not SOME FUNDAMENTAL CONSIDERATIONS. 23 what life is ; we are only acquainted in part with the substance with which life is associated and with a few of its manifesta- tions. "We know that in one sense life is a property of a certain kind of molecule (Wilson), but the explanation of that property and how it is associated with the molecule is not forthcoming. We know that life is inherent in this certain kind of mole- cule. ^ Dr. Still has stated that life is an individualized principle of nature. jA part of the universal life has become in- dividualized in an aggregation of protoplasmic molecules. How it became thus individualized, and at death it again be- comes merged into the universal life, is yet and in all likeli- hood will always remain a mystery. " The materialist hopes sometime to be able to explain life in terms of physics and chemistry. While it is true a large number of functions formerly considered vital, in the sense of being out of the realm of physics and chemistry, have in more recent years been satisfactorily explained on purely physical or chemical laws, yet avast number of much more difficult facts of func- tion remain entirely beyond physical or chemical explana- tion. Until these are explained and life is shown to be but a peculiar arrangement and action of atoms in a peculiar molecule with no hyper- mechanical or hyper- chemical actors, we must assume the presence of an essence which for lack of a better term is called the vital force. This con- ception corresponds with Dr. Still's "matter, motion and mind." We shall not attempt to identify the vital force with mind. The argument for or against that contention is purely a matter of speculation. Suffice it to notice that a force of some kind animates all living matter and is, so far as can bo at present determined, outside the realm of matter and mo- tion. This force apparently initiates, controls and co-ordi- nates function throughout the entire organism. It is a force continuous throughout the entire organism through the med- ium not alone of blood continuity, nerve or cell-contiguity, but also through the less known but undoubtedly important fact of protoplasmic continuity to which we shall later refer 24 PRINCIPLES OF OSTEOPATHY. in more detail. Truer words were never spoken than those used by Krukenberg and suggested by others that "the or- ganism is a whole and must be contemplated as such." Re- cent biologists have called attention to the fact that proto- plasmic bridges exist between cells in a remarkably large number of organs and tissues, and Spencer's suggestion is significant that a particle of protoplasm may during the course of time pass to all parts of the body. While it is not possible to accept the materialist's con- ception of living matter yet recognition must be made of the fundamental importance of chemical and physical law as a basis for functioning. The chemical nature of pro- toplasm is significant; composed of a dozen or more of the known elements most of which are of low atomic weight, we find a very complex molecule. If paramount importance can be assigned to any single element, nitrogen could reasonably be placed first. That element is characteristic of living ma- terial and is fundamental in the way of giving to the complex molecule its own peculiarities. Nitrogen unites with a suffi- ciently large number of other elements but in comparatively loose combinations, separating readily to form new associa- tions. It is in this respect that nitrogen is fundamental to the living molecule. The most striking characteristic of liv- ing tissue is its tendency to continual change not only of a physical but also of a chemical nature. The response to a stimulus is dependent upon this readiness and since life may be considered in large part a response to stimuli the necessity for the ability to change becomes apparent. In this connec- tion Spencer's classical definition of life is illuminating: " The continuous adjustment of internal relations to external rela- tions.'' 1 As we shall have occasion to repeatedly refer to the fact of adjustment this conception of life should be borne in mind. Every change in the environment of the organism constitutes a stimulus of greater or less intensity upon that organism. The continuous proper response to these stimuli represents a normal condition of the organism ; a failure to- SOME FUNDAMENTAL CONSIDERATIONS. 25 respond, or a response too intense or insufficient is evidence of and further sause for a disease condition. In the sense of a continuous response to continuous stimuli the organism constitutes amoving equilibrium. When that equilibrium be- comes disturbed by too intense or too prolonged stimuli dis- ease results, while in the continuous adjustment to circum- stances we have the normal condition of the living organism maintained. Considering life, then, in certain of its manifestations, we are led to the conviction that the law of change is a law of living matter as represented in man. The study of those changes and the determination of methods to assist the organism in its response to stimuli, constitutes the life pro- blem and the problem of the physician. STRUCTURE AND FUNCTION. In this continual adjustment dependent on change in the physical and chemical relations of the molecule above re- ferred to, it is to be noted that both structure and function are concerned. Discussions are rife regarding the relative position of structure and function in the development of an individual or of a race. We shall not enter into the argu- ment except to attempt to show that for all practical purposes the two develop co-ordinately. That structure changes y function must be admitted in countless cases. This fact is fundamental in osteopathic theory, according to which most diseases are either causedjjrjj^intained D Y structural con- ditions interfering with function. On the other hand it is equally certain that in numerous cases we have evidence of the modifying influence of function on structure. The cell doctrine as commonly understood is insufficient to explain the phenomena of the complex, organized living being. The cell represents the expression of life which is in- herent in the common s^nicjtualba^is, protoplasm. It re- 7 mains further to state, as~Dr. Stilf Itfjnself has emphasized, that protoplasm is the first product of the life essence. A THE CELL DOCTRINE INSUFFICIENT. From the middle of the seventeenth century when Schlei- den and Schwann discovered in the case of plants and ani- mals respectively that living material was divided into innum- erable microscopic parts having a more or less definite shape, up to the present decade, the cell doctrine has been growing in importance as one of the great facts of biology. When the nature of the cell was first determined and the essential ele- ments had been differentiated from the non-essential, it was believed that a long step had been taken toward the solution of many of the life problems. As the investigator learned that each of these individual divisions had a more or less dis- tinct life of its own, the attention of the physiologist was turned from a consideration of the action of the cell groups to that of the individual cell, until in the literature of to-day the statement is constantly reiterated that the problem of physiology is the problem of the cell. Virchow, in his mon- umental work on the cell structure with special reference to its pathology, has emphasized more than any one man the in- dividuality of the cell and the fundamental necessity for nor- mal cell life in order that body activity as a whole shall be normal. To detract from his reputation is not the part of 28 PRINCIPLES OF OSTEOPATHY. wisdom or a thing at all possible or desirable, but it must be insisted that the problem of physiology can never be solved by the rule of the cell, and that for the simple reason that the cell is not the fundamental element in living tissue. Within later years the extreme views have been modified and modern in- vestigators are searching for the demonstration of what we may provisionally call the ante-cellular elements. That such exist there can be little question. That is, more simple elements which have the fundamentaljlife faculties, lie back of the cell and are responsible for the cell, f If we were asked to suggest the simplest possible conception of life in its manifes- tation, we would insist that protoplasm, plus an organ- izing force dwelling within that protoplasm constitutes the simplest conceivable life condition!] This conception is not that of the cell doctrine. The strucjifral conditions necessary in the cellular arrangement are but one of the expressions of the life. As Wilson puts it, "All parts of the cell are but the local differentiation of a common structural basis." The cyto- plasm is one specialization, the nucleoplasm is another, and the cell wall is a third of the specializations of this structural basis. It is not enough to say that there must be the com- bination of nucleus and cytoplasm in order that life may be manifested. It is a common statement that the nucleus is necessary and hence any protoplasm devoid of a nucleus cannot represent the fundamental unit. We affirm that cyto- plasm does live and does manifest life after having been sep- arated from all connection with nucleoplasm. It shows amoB- boid movement, it is irritable, it flows about nutrient sub- stances and digests them. Hence life is still present, and without question there are present more elementary biolog- ical units. To the objection that the cytoplasm very soon dies, and under no circumstances can reproduce itself, we may reply that the same is true of any of the complete cells of multicellular man when they have become separate. It is purely a question of degree and length of life'and not one of kind. SOME FUNDAMENTAL CONSIDERATIONS. 29 With modern methods of research, our knowledge of the actual structural conditions of the human body has been con- siderably increased and in large part corrected. One of the more striking of the observations which bear directly upon the subject in hand, has reference to the fact that the body is by no means entirely made up of cellular structure. It has long been known that in the case of plants numerous of their cells were structurally continuous. The same fact has been shown to be true in the case of animals. In the developing ova of fishes it has been found that the cells as they were formed were not separated but still maintained the continuity of their protoplasm. The]same is true with reference to the ovarian cells of mammals. In the higher animals, including man, many epithelial cells on close inspection show the presence of protoplasmic bridges, which is significant as bearing on its relation to the secretory activity of epithelium. Cartilaginous and many other forms of connective tissue cells are connected through protoplasmic extensions. In the case of the muscle cells of the heart we have a typical condition. There the cells are markedly branching and the branches are continuous one with another. This is of fundamental interest, as throwing light upon the peculiar properties of the cardiac muscle. It has long been known that the contraction of the heart takes the form of a wave passing downward from the sinus venosus to the apex. It was formerly assumed that this wave was propagated from auricle to ventricle through the medium of nerve connection. This has been shown to be erroneous, since the nerve tissue can be rendered ineffective while the propagation of the wave remains unaltered. What is the explanation? Older anatom- ists taught that there was no muscular connection between auricle and ventricle. This, according to Gaskell, has been disproved and it is now known that the propagation of the contraction wave from auricle to ventricle takes place through a continuity of muscle protoplasm. While the continuous nature of cardiac muscle cells has long been known, it is only 30 PRINCIPLES OF OSTEOPATHY. within more recent years that proof was given for a similar though less marked condition in the case of all involuntary muscle tissue. This becomes of special interest because of the long known fact that a contraction wave started at one end of the intestinal canal passes through a greater or less ex- tent of the tract without further stimulus. Therein further lies the suggestion of an explanation of the Traube-Herring curves which are produced by the rhythmic action of the ar- terial walls and which are entirely independent of the pulse. According to one investigator of recent years, up to the time that the white corpuscle passes out into the lymph or blood, while it is seemingly perfect in its development it remains still attached by protoplasmic filaments to the mother cells in the lymphoid tissue. It is even suggested that the appear- ances indicate a power on the part of the white cell of reform- ing its attachments. If this be true, the already known func- tions of the 1 eucocyte would be prodigiously increased and the possibilities from that power would appear to be infinite. From the above considerations it would seem that the conception of the human body as a syncjrtium is not at all inappropriate, and that there is justification for the conclu- sion stated by Meyer, (Wilson on "The Cell") that "both the plant and the animal individual are continuous masses of protoplasm in tvhich the cytoplasmic substance forms a morphological unit whether in the form of a single cell, a multi-nucleated cell, or a system of cells." While it is impossible at the present time to prove that this protoplasmic continuity is present to any extreme degree in the human body there is much to be said in favor of it as an abstract proposition. We have continually referred to the necessity of considering the body as a^ whole and not as an aggregation of independent particles. (. This is fundamental in the osteopathic philosophy and practice.J If the body is a syncytium then the practice of removal of any organ of the body because of its supposed absence of function is fundamentally erroneous. All organs and all parts of the body will perform to a certain extent all functions of the body. While there is specializa- SOME FUNDAMENTAL CONSIDERATIONS. 31 tion no part of the body will completely lose its original properties. This emphasizes the fact that in the human or- ganism we have the most complex as well as the most simple func- tioning capacities, and as such it can meet all conditions of en- vironment on a common level, whether these conditions them- selves be complex or simple. And this is of importance in the organism's struggle for existence. When man is com- pelled to resist another organism of complex nature such as the mammal he may do so by the use of his own special- ized complex nature. He can meet brain with brain and muscle with muscle. Compelled to resist the effects of poi- sonous substances, whatever the occasion for their presence in his body, he may meet toxin with anti -toxin a process known to take place. Compelled to withstand invasion of his own body by the unicellular organism, such as a pathogenic bacter- ium, he may meet cell with cell, for phagocytosis is an ac- cepted physiological fact. The same idea is emphasized in the case of the internal secretions. It is known that many of the organs of the body provide certain substances that are essential to the body as a whole. If there is a protoplasmic circulation it is doubtless true that every part of the body gives and receives from every other part. A further interesting suggestion along this line refers to the relation between this protoplasmic continuity and various reflex disorders and chains of disorders. A pathologic condition of a group of cells too slight to affect the nerve connections or the quality of the blood, may still be capable through the added influence of the flow of protoplasm, of changing the metabolism of remote structures. This fact would further emphasize the necessity for looking to other parts of the body for lesions than merely to the regions commonly involved through a disturbance of the nerve or blood mechanism. In like manner we may understand the deleterious effects on other and all parts of the body from the administration of drugs. It will thus be impossible to limit the action of a drug to the tissue involved in the disease; once having come in contact 32 PRINCIPLES OF OSTEOPATHY. with the protoplasm of a single cell, unless thrown out by defensive action, it may pass to every part of the body with* out leaving its protoplasmic medium. A final interesting suggestion and one that may throw light upon the general problem of the inheritance of dis- ease has reference to the protoplasmic continuity as a me* dium for transmitting through the germ cells of the body, ele- ments from each of the other cells. This might suggest why it is that a child does to all appearance inherit some peculiar quality in his body or mental functioning. We have thus emphasized the fact that there is in all probability a uniform protoplasmic continuity, in order to draw attention to the necessity of considering the body as much more than the sum of its parts. It is true that the cells in- dividually exercise a profound influence over the body as a whole, but it is equally true that the body as a whole exercises an immense influence over the cell and groups of cells. This latter fact must be continually recognized in all cases of di- agnosis and treatment of disease. CAUSE OF DISEASE NOT IN THE CELL. But in another sense the cell doctrine as commonly un- derstood is inadequate. Virchow and others have placed biologic science under great obligation for numerous facts with reference to the role of cell metabolism in disease. From the conception that the body is an aggregation of groups of cells, each of which has its own independent function, comes the natural deduction that a disease of any organ is due to a faulty condition in the activity of those cells. By the dem- onstration that protoplasmic metabolism was able to synthe- jjtfise various substances that were auto-toxic, a key to nu- merous diseases was believed to have been found. So far as fi I fr " ,a superficial conception goes, the assumption is correct. But ' it is manifest that it is a key that unlocks only a single door and one which leads only to further difficulty. It is true that every cell may produce substances which are ac- SOME FUNDAMENTAL CONSIDERATIONS. 33 tively toxic to its own protoplasm and to that of its neighbor if it be maintained in contact with such substance. It is not unlikely that any product of normal katabolism may be equally disastrous if permitted to remain. Everyone has experienced the sensation of fatigue. What is the condition present? Undoubtedly it represents an excess of normal waste material collecting in connection with sensory filaments distributed to the muscle cells. Every student of physiology is aware that in fatigue this toxic substance is produced. The blood serum taken from a fatigued animal and injected into the vascular system of one in a rested condition, will produce in the latter every symptom characteristic of the fatigued animal. La Grippe produces similar symptoms, and Verworn has attempted to identify the two conditions or at least to show their marked similarity. In the La Grippe condition there is present a material toxic to the cell and irritant to the nerve terminal, similar to the effect of the sarcolactic or other acid always present in excess in overworked muscle tissue. The presence of the bacterium is not necessarily a detriment to the organism but in many cases pathological conditions are undoubtedly caused in part from its activity. In these it is not the mere presence but the excretion pro- duct that constitutes the deleterious influence. Whether it be a toxalbumin similar in kind to that produced by body activity remains to be demonstrated. Sufficient for present purposes to note the fact that the material is toxic and must of necessity produce cell disorder if present in sufficient amount. Whatever the source of the toxic material, whether it comes from bacteria, over exercise, or perverted cell metab- olism, it is immediately a possible cause for harm. Cell metabolism may be abnormal from changed supply of blood or nerve influence. Undoubtedly in the case of most cells of the body, their activity is partly under control and co-ordination of nerve influence. An excess of that in- fluence will be the cause for the accumulation of the kata- 34 PRINCIPLES OF OSTEOPATHY. bolic products constituting the cause for fatigue. This means that the nerve initiates a too rapid transformation of potential energy of cell protoplasm into kinetic energy of chemical and vital activity. This additional activity will further initiate new changes immediate and remote and a chain of events be inaugurated. A deficiency of blood and nerve influence, on the other hand, will permit of a lowered resistance to other stimuli, with one or both of two effects, a trophic change in the tissue or a perverted quality of metabolism. In the latter case the complete products of the normal "metabolic cycle" will not be formed and hence various types of degeneration may follow. These considerations have led many into error. The statement is made that the cause of disease resides in the metabolism of the cell. This is true only in a limited sense. A more nearly correct statement would be that the disease is the faulty metabolism of the cell. It remains to trace the faulty metabolism to its source. It is obvious that, theoretic- ally, numerous forms of stimuli may come into relation with the cell protoplasm to modify its activity. Mechanical, ther- mal, chemical, electric, nervous all are known to affect protoplasm. But in every case these influences must be brought over channels that connect cell with periphery. For the cell, deeply situated, is in an environment of comparative quiet. Mechanical pressure does not act as a serious stim- ulus because that pressure is constant. Thermal conditions are unfavorable for producing response since it is only a sud- den change that is an efficient stimulus. Chemical stimuli only reach it through the medium of channels which trans- mit fluid capable of performing the office of a vehicle, while nervous influences are similarly carried over definite path- ways. We are thus brought face to face with the funda- mental fact in the osteopathic concept that a free channel be- tween cell and its source of supply unobstructed blood and nerve is the normal condition for protoplasmic functioning. The connection between blood and nerve having been made SOME FUNDAMENTAL CONSIDERATIONS. 35 such that nerve governs blood and blood replenishes nerve, the cell in immediate connection with both is entirely depend- ent on the normal condition of these for its proper function- ing. Over all is exercised that co-ordinating power, seem- ingly inherent in protoplasm and by] which the cell is main- tained in balance between its -anabolic and katabolic pro- cesses. Hence so long as the channels connecting cell with per- iphery be kept free, no break in the chain of events constitut- ing the metabolic cycle is possible. The cell will thus be able to select and reject at will. The normal hydrostatic and osmotic pressures will be maintained at such a level as to necessitate a correct functioning in vital selection. Nutrient materials will be taken in from the blood with ease and rapidity. Waste materials will be discharged with equal facility. Fatigue can- not long persist since a growing loss of irritability will neces- sitate rest and when rest is permitted the protoplasm is rap- idly renewed. Bacterial products though present in the blood will not aggravate for long, since the function of normal pro- toplasm is to secrete anti- toxin. An uninterrupted nerve influence will keep up a constantly normal chemical and vital protoplasmic change, Under such circumstances the cell, vital and self -sufficient, cannot easily go wrong in its action. But modify the conditions associated with the chan- nels of interchange and note the result. Changes in blood supply and drainage permit changes in osmotic ~ conditions and hence changes in activity of the cell selection and rejec- tion ; lessened cell nutrition and cell regulation will result. Disturb nerve discharge to the cell, and excess or deficiency in metabolism results, with varied abnormal tissue conditions. How will these interferences be produced? Largely by changes in structural arrangements associated with a tissue which is least subject to vital control, i. e., connective tissue, bone, ligament and muscle. "When these are disturbed a lessened possibility of adjustment must result. Failure to supply the blood with materials from which the cell claims its pabulum, 36 PRINCIPLES OF OSTEOPATHY. excesses of whatever kind all will have their influence, but at most it will be but temporary and so soon as the abuse for such it is ceases, repair is rapid and usually complete. Bacterial conditions cannot harm the cell since the blood is germicidal, antiseptic and antitoxic. Altogether, it would seem that the cell representing a definite bit of protoplasm cannot of itself cause a disease in itself or in its neighbor. It is inherently healthy and is utterly incapable of harm until the connection between it and its sources of supply and channels for drainage becomes im- paired. These connections are represented by blood stream, lymph channel, continuity of protoplasm, and nerve sub- stance. Interference^with these by persistent pressure from displaced structures^which are less subject to vital control of position, constitutes the factor which produces or maintains the disturbed cell metabolism. MAN A MACHINE. It has been stated that underlying the practice of oste- opathy there is the recognition of a close and fundamental relation between structure and function. Reference was made to the fact that the human body in structural aspects partook of the nature of a definite machine, the operation of which followed definite mechanical laws. That man is a ma- chine is an assertion trite enough, yet one that demands some consideration. A machine is an instrument by which force is changed in direction or intensity, and usually asso- ciated with the transformation of energy. "While the mechanic employs a vast number of mechanisms all may be reduced to a few simple machines, viz., the lever, the pully, the wedge. Each of these is represented in the human body. Practically every action of the voluntary muscles is depend- ent upon the principle of the lever. When one extends his fore -arm he does, so by the use of a lever of the first class; when he forces his body from a wall by placing his hands against it the lever is of the second class; when he flexes SOME FUNDAMENTAL CONSIDERATIONS. 37 his fore -arm he employs a lever of the third class. Borelli FIG. 1. Illustrating the mechanics of muscle and bone. and Marey in their investigations relating to muscular action of the locomotor organs have shown by mathematical and other demonstration the nicety of adjustment of those Organs to the work required to be done, emphasizing thereby the purposefulness of the body structure. In the superior oblique muscle of the eyeball, in the peroneus muscle, and in the long head of the biceps, are represented the pulley action by which the direction though not the intensity of the force is changed. In the "bag FIG. 2. Illustrating mechanics of the pulley, of Waters" at parturition, in the middle lobe of the right lung, in peristaltic action, and in certain parts of the process of vomiting we have illus- trations of the principle of the wedge. The laws of hydro- statics and hydrodynamics are made use of in numerous cases. Pascal's law of fluid pressure is at the basis of blood dis- tribution and blood flow; capillary attraction, osmosis, filtra- tion and diffusion play no inconsiderable part in body func- tioning; the fenestra rotunda of the middle ear with its mem- branous covering is a provision for the law of fluid incom- pressibility. The laws of air pressure are utilized in the pro - A.- PULLEY OP SUP OBLIQUE. 38 PRINCIPLES OF OSTEOPATHY. cesses of respiration and circulation, and in giving support to the articulations and the viscera. While we recognize that man is a machine, the term mechanism is one more descriptive of the real condition in that the former carries with it by association the idea of rigidity and unyielding parts. This latter characteristic is obviously not true of the living organism in which continual change is characteristic. Further, mechanism involves the idea of complexity which characteristic is markedly true of the human body. But it must be borne in mind that while the latter term is more descriptive of the actual body condi- tion, it involves largely the same principles as does the former. THE BODY A CHEMICAL LABORATORY. The body is not only a machine by reason of which it can produce various changes in the nature of the energy with which it comes into relation ; and through the operation of purely physical laws that are possible of expression through the arrangements of its numerous parts it can perform the function of a physical laboratory. It is in addition a chem- ical laboratory, the capacities of which have a reach that is entirely beyond the artifice of man. Substances are formed, torn down and re-formed, which have no counterpart in the world outside of organic life. No man yet has been able to synthetize living proteid from the inorganic or organic materi- als at his command. We may take the living tissue and analyse it, but when the analysis begins the proteid has lost its life essence. What remains we may analyze and determine in part its constituents. We may take of the products of living proteid and after analysis draw conclusions as to the original living tissue. But we are yet in the dark as to the fundamental quality in the chemical nature of living proto- plasm. Even the complete formula for the dead protoplasm defies exact statement. When that is once accomplished we then shall have little reason to hope for an immediate deter- SOME FUNDAMENTAL CONSIDERATIONS. 39 mination of the composition of the living tissue. For within the sacred precincts of the living proteid molecule we may not go, and the discovery of the intimate nature of that sub- stance must continue to be a subject for speculation and not demonstration. That the conditions needful for chemical action are markedly present in the human organism need hardly be emphasized. Suffice it to suggest a few points that call at- tention to it. The body as a whole is over sixty per cent water. The essential living part of the body, i. e. , the proto- plasm, contains a sufficiently greater amount to render it dis- tinctly fluid. This fact is of fundamental importance from the standpoint of chemical possibilities especially. That it is fluid rather than solid is suggested by the fact that it flows as in the case of the streaming process noted in the cells of cer- tain plants; by the tendency which the white blood corpuscle and other typical protoplasm exhibits to assume a spherical shape ; and the further tendency of other fluids to assume that shape when absorbed within an environment of protoplasm such as is noticed in the case of fat droplets. Owing to this fluid nature chemical action may take place more efficiently and more rapidly, which is a fact of considerable value for the purpose of quick response to stimuli so necessary to a com- plex life. Contained within this fluid material we have a dozen or more of the lighter chemical elements held in rather loose chemical combination so that when materials from the outside world have become absorbed into the protoplasmic substance a rapid change of atomic and molecular associa- tions is readily effected. We have before referred to the fact that of the elements found associated with protoplasm a few seem to be of fundamental importance, namely, the oxy- gen, the nitrogen, and the carbon. A few others seem to be essential but appear to perform a less important role in met- abolism, while still others in special forms may be present or absent. The proteid material found in the body is in large part what is spoken of as combined proteid. Verworn gives the 40 PRINCIPLES OF OSTEOPATHY. following formula of one of the moat important of the com- bined proteids, namely, haemoglobin, which suggests the extreme complexity of the substance and the infinite possi- bilities of re-arrangement in the processes of vital chemistry : CeooHgeoNisiFei 830179. This represents but one of a large number of the combined proteids. If we permit ourselves to dwell upon the resources from which the body chemist may draw and the numerous products that are continuously formed we cannot be otherwise than astonished at the uner- ring precision and nicety of adjustment which is maintained throughout the life of the normal individual. The division point between chemical action in the body and that dependent on other forms of energy is not a defi- nitely determined one. Yet we know that many of the funda- mental facts of physiology are chemical ones. Proteid foods in the alimentary canal are acted upon by the pepsin and the trypsin and reduced to simpler and more diffusible forms in a manner seemingly entirely identical with that which takes place outside the body. The oxygen entering the blood and later the tissues, forms a combination with car- bon which is identical with oxidation processes wherever found. Hydrogen and oxygen unite to form water in a man- ner similar to its synthesis elsewhere so far as can be deter- mined. Urea, formed by the liver cells from ammonia and COa in the blood, is in all likelihood a process similar to its formation in the chemist's laboratory. We thus emphasize that the body organism is capable of chemical possibilities not only entirely like those outside organized life, but in ad- dition surpasses'the known laws and possibilities of labora- tory chemistry. From the above considerations we may draw several im- portant inferences. Every substance necessary to the body in normal functioning will be formed by the organism's own chemical processes. Iron compounds have for long been the staple remedies for anaemia. In this disease there is a deficiency in the haemoglobin of the red corpuscles, to- SOME FUNDAMENTAL CONSIDERATIONS. 41 gether with a deficiency in the number of these bodies them- selves. Iron is one of the necessary elements for the hsemo- oglobin. It was assumed that by the administration of the iron compounds the deficiency of that element was provided against. It has been definitely proven that the iron thus ad- ministered passes through the body unchanged. But the practice of administering the iron still is prevalent. Note this fact : the fault is not one of a limited source of iron, but a limited power of assimilation of iron. The food materials of an ordinary diet contain enough iron as well as all other ele- ments for all normal functioning. Increasing the amount of iron even though it may be assimilable in such form as it is given, which is doubtful, must of necessity fail as a remedial measure. It has been recently contended that arsenic in small amounts is a constant constituent of certain of the tissues, and from this was derived the assumption that the giving of arsenic in certain diseases, long a thing of practice had thus found its justification. Reasoning could be no more faulty. The argument against iron in anasmia holds equally against the use of arsenic. In both of these cases, if a deficiency in the assimilation of the substance be the real condition, then the logical consideration would be the deter- mination of the faulty condition of the part which prevented the organism itself from selecting and utilizing those sub- stances which are found in sufficient abundance in the blood. Another important deduction is this : when unusual conditions arise which demand unusual compounds, the latter will be formed. Haemorrhage is self-limited in most cases. Why? Fibrin, not found in normal blood conditions, is immediately formed from the interaction between thrombin and fibrinogen which are present either actually or potentially in the blood, on the exposure to air or other foreign substance. Thus the blood clot is formed. Why are individuals immune from certain diseases? In some cases by a so-called natural im- munity which presents elements in the blood antagonistic to infective agents. In other cases through the excessive 42 PRINCIPLES OF OSTEOPATHY. activity due to a previous attack whereby an increase in the neutralizing substance was brought about. What is the source of lactose? It is a sugar found only in connection with the secretions of the mammary glands, generated from the stimulus associated with the pregnant and lactation periods. Further instances might be supplied but the point is sufficiently plain. The body organism by virtue of its ability to act upon and be acted upon is continually meeting new conditions as they arise and responding in a manner which insures its continued activity as a separate and self-sufficient organism in a world of contending organisms and inanimate forces. Through its chemical activities, aided by a favorable medium, it is enabled to successfully maintain an identity given to it by a long line of ancestors, but at the same time permitting of sufficient variation in its less important struc- tural and functional details to prevent disintegration that would result were it of a less yielding nature. SOME FUNDAMENTAL CONSIDERATIONS. 43 CHAPTER III SOME FUNDAMENTAL CONSIDERATIONS. (CON.) THE ENERGY OF THE BODY. The suggestion that man is a machine gives rise to the problem of the nature and source of the energy that must of necessity be associated with the body. For one of the char- acteristics of the machine, whether it be animate or inanimate, is its ability to convert one form of energy into another. So far as is at present known no creation or loss of energy is possible. This law of the conservation of energy is one of the most fundamental and significant of the laws made emphatic during the last century. It is no less true of the living body than of other mechanisms and other worlds, that the various manifestations of motion are but the different forms into which the one universal energy may be changed from time to time. What is energy? Authorities differ in details, but all are agreed that energy may be most nearly conceived of as motion. Dr. Still has emphasized the triune nature of the body in his discussions of "Matter, Motion and Mind." Mat- ter is inert in so far as it may be independent of motion. But matter can not be independent of motion and manifest itself to the senses. The two are one and inseparable. The motion of an atom is an integral part of the conception of an atom. As soon as matter becomes separate from motion the uni- verse as such must cease to exist. We know that appear- ances are continually changing. We know that change is a law of nature. And change is only possible through the numerous forms of energy that are associated with the sub- stance of which all natural things are composed. We may conceive of mass motion, and molecular motion, and atomic motion. These are in all likelihood different phases of the Same great energizing principle which lies back of the man- 44 PRINCIPLES OF OSTEOPATHY. ifestation. All are concerned with the one inherent property of all matter that which we denominate energy. It has been said that energy remains the same in essence. How is it that it appears so different under different circum- stances? We are led thus to a consideration of a corollary to the proposition that energy is never lost or created, and that is, that there is a continual transformation of energy. This capacity for transformation depends upon the circum- stances of the matter with which the energy is associated. Any mechanism which is able to cause a new appearance in the manifestation of energy is a transformer, not a creator of energy. The human body, as of all living bodies, is such a transformer. The proposition may be illustrated by several instances. One of the forms which energy assumes is that of chem- ical action which may be considered as an attraction be- tween atoms. It is needless to more than call attention to the fact that body functioning is largely dependent upon the attraction that thus exists. The source of such energy is ultimately from the external world, i. e. , from the food mate- rials taken into the body and from the potential capacities of the living cells which were transmitted to it from its parent- age. Of the latter we are forced to assume an inherent vital- ity which inaugurates the various changes of a chemical na- ture with which the embryological processes are associated. Here we undoubtedly have a transformation of vital into chem- ical energy. But that added chemical energy further assists vital activities in which new vital energy is shown, and a re- transformation appears. The food materials taken into the alimentary canal represent immense quantities of stored chem- ical energy. As soon as this material comes in contact with certain other substances in the canal which are the product of other vital and chemical factors, the potential energy of the food mass becomes kinetic in the liberation of new chem- ical action and heat. The oxygen taken into the body through the membrane of the air cell passes into the blood, is carried SOME FUNDAMENTAL CONSIDERATIONS. 45 to various parts of the body, unites with the carbon of the food and of the body tissue and in the chemical changes thus initiated, heat is set fre. In the finer" processes of assimila- tion and dissimilation the same changes and reverse changes are produced through the continual interaction of chemical and vital activity. There is a cohesive force characteristic of certain body actions. This may be spoken of as molecular attraction. Every molecule has an attraction or a repulsive effect on every other molecule. This is true whether the substance in or of the body be solid, fluid, or gas. The constant inter- mixing of the fluids of the body in the processes of diffusion, filtration and osmosis represents but a difference in the attrac- tions between the molecules of the different substances. By virtue of this action a continual interchange between parts of the body becomes possible, and considering the fact of proto- plasmic continuity it becomes doubly significant as a factor in body metabolism. The difference in gaseous pressures be- tween the oxygen of the air in the alveoli and that in the blood explains in part the presence of oxygen in the blood. Similarly the excess of the carbon dioxid in the blood with reference to the amount in the lung spaces provides a means for excretion of the noxious gas. In the process of molecular action and interaction new conditions favorable to different atomic affinities arise and we have the molecular energy transformed into atomic energy. The energy of gravitation while not apparent as such in the body is responsible for certain actions that there take place. We may speak of this energy as the attraction be- tween masses and while this attraction undoubtedly exists in the case of different masses of the body tissue it is insig- nificant as compared to the attraction between the body and the earth. In this connection it is interesting to note the fact that the urinary apparatus of the human body is so situated as to take advantage of gravitation and by virtue of this fact alone the kidneys are in large part continually drained of 46 PRINCIPLES OF OSTEOPATHY. their excretions; while in all animals gravitation is made use of in the discharge of excretions from the body. Dr. Still has suggested the important point that in case of fever conditions or other weakening states, the body should be placed in an inclined position in order to assist, through the energy of gravitation, the discharge of the excretions through the ureters. Transformations occur in the interaction between gravitation energy and that of other forms. Molecular and chemical movements occur in opposition to the force of grav- itation with a consequent production of new forms of energy such as heat and electric action. The mechanical energy of pressure and friction and change of shape associated with the different parts of the same substance are very manifest in the body and in its rela- tions to the external world. By virtue of the continual move- ment of the body parts and the movements associated with environment pressures and friction occur with the resulting liberation of heat and other forms. The friction, of the blood upon the vessel walls accounts to some extent for the resist- ance to the blood flow which is so necessary to a normal blood pressure. This friction invariably produces additional changes in form, and as a result heat and electric and chem- ical action appear. The mechanical pressures of external matter and internal matter upon nerve terminals and less respon- sive body protoplasm, produces impulses which are nervous or muscular in character, either directly or through an interme- diate chemical energy which is in turn converted into a nerve impulse. The latter acting upon the stored materials in the nerve cell body is rechanged into chemical and vital energy which will thence further the chain of action. Mechanical energy acting in the nature of a stimulus is of prime import- ance to the osteopath. / For it is largely through the influence of pressures that he is able to explain the various effects from mechanical displacements of tissues constituting the lesion which is the most important cause of disease. In a special kind of molecular movement is seen another SOME FUNDAMENTAL CONSIDERATIONS. 47 form of energy with which the body is associated and which is denominated thermal energy. This is spoken of as a molecular vibration, the increase of which explains the condi- tion of a rising temperature, the absence of which constitutes the absolute zero point. That a certain heat level is necessary to body functioning is evident not only from experimental ob- servation but from the known remarkable apparatus present in man which maintains that level in spite of a fluctuating temperature of the environment. The sources of this form are direct from the external world through the medium of radi- ation from the sun and other warm bodies, or the materials taken in through the alimentary and respiratory tracts in the form of warm food and air ; but in large part the heat energy is indirect from a transformation of chemical energy the source of which we have already indicated. Practically every chem- ical action will be associated with the liberation of heat, although in most anabolic processes the consumption of heat will be in excess of its liberation. Of the chemical actions concerned with the liberation of heat oxidation processes are by far the most important. The amount of oxygen consumed in the course of twenty -four hours amounts to 700 grams or about sixteen quarts per hour. This is suggestive as indi- cating the immense amount of oxidation that takes place in the body. While it is thus true that the heat is in large part derived from chemical action together with that resulting from mechanical energy of friction and movement, it is also true that a transformation back into chemical and mechanical energy takes place in extreme degree. One chemical change liberates energy in the form of heat. This heat by furnishing a normal medium initiates new chemical change and is in other cases perhaps converted directly into muscular and other movement. Throughout the various metabolic processes these continual transformations are manifest. Photic energy is essential to life processes. Light has been defined for lack of more definite knowledge'as ether vibra- tion. This vibration is ultimately essential for all life processes. 48 PRINCIPLES OF OSTEOPATHY. The process of formation of the organic foodstuffs has thus far defied all laboratory attempts and the only source of the synthesis of proteid, carbohydrate, and fat is the cell of the living organism. From the plant the animal gets its food material ready made. But in order that the plant shall be able to effect this synthesis light is necessary. Through some power seemingly associated with the chlorophyll bodies the plant is enabled to utilize the ether vibration in the chem- ical processes concerned in the food formation from inorganic materials. But it is not alone in this indirect way that light is essential to animal life, for observation shows that individuals living in an environment of greater or less deprivation of Irght become abnormal in their functioning. This fact suggests the necessity for looking to the environment of the individual for the preservation of normal health. From this fact has arisen the light cure by which it was hoped to overcome disease conditions through an excess of the energy, a certain amount of which is essential. An excess of any force or factor is never logical o.s a method of cure. That an excess of light is deleter- ious there is sufficient evidence to show. Ordinary sunburn in fair-skinned individuals is a pathologic condition as also are the burns from X-ray applications. Individuals working in factories where light is generated or in other conditions where an excess of light is present suffer from various forms of cutaneous and other disorders. Light is further a normal stimulus for the function of sight. In this case the ether vibra- tion coming into relation with the pigmentary layer of the retina is transformed into chemical energy which influences nerve terminals and which in turn results in the definite sub- jective sensation. Whether in the human body light is pro- duced from transformation of other known forma remains to be proven. In the case of certain of the lower and especially the marine animals, chemical action or other energy is quite appreciably transformed into light. Ether stress or electric energy is undoubtedly asso- ciated with a large number of body processes. In the exper- SOME FUNDAMENTAL CONSIDERATIONS. 49 imental laboratory i-t can be shown that both chemical and mechanical energy may be transformed into electricity. It is probable that similar conditions in the case of the living organism are responsible for the electrical .manifestations known to be present. It is known that in conditions of activ- ity and of pathology a difference of electric potential exists in muscle such that the active and the resting state are electric- ally opposite in sign, which is also true of the normal and the injured tissue. Undoubtedly the chemical stress in these various states are different and hence a difference in elec- tric stress is entirely reasonable. This becomes of special interest in view of the recent investigations into electro -chem- istry which tend to show a marked similarity between chem- ical and electric action, if not an actual identity. The in- vestigation into the electric conditions of the body has only begun and the further results are awaited with much interest. Dr. Still continually assumes the presence in normal as well as abnormal conditions, of a force of an electric or magnetic nature, and no demonstration to the contrary has yet shown that he is wrong, while what experimental evidence is avail- able suggests that he is correct. The fact that such "cur- rents" exist has given rise to numerous attempts to make use of the fact in a therapeutic way, but thus far electrotherapy has proven as unsatisfactory as has the drug, and for the reason that the form of electricity present in living organisms is a special product of the particular organism. With reference to nerve energy little can be said. Its fundamental importance is obvious and will be continually referred to. What it is we know not. It may be measured in its rapidity, it may be judged by its effect. Whether it be electrical or chemical or neither we can not at present say. Suffice it to note that it results from transformations of all other kinds, and in turn may be converted into numerous forms. Mechanical force, chemical action, light all may influence its action and assist in co-ordinating its impulses. It is unique among the body forces and to the osteopath 50 PRINCIPLES OF OSTEOPATHY. represents a most interesting field of study. When its ulti- mate nature is once known and its manifestations and varia- tions understood, much will be done toward explaining the numerous facts of body functioning and a long stride will have been taken toward the solution of many vexed problems in osteopathic practice. In connection with the above considerations the following table modified from Hall's Physiology is suggestive. Note that the energy of the body finally is given off largely if not entirely in the form of heat. Owing to the fact that the lat- ter is fairly subject to measurement, approximations of energy expenditure can easily be determined: BALANCE SHEET OF ENERGY FOR MAN AT LIGHT WORK. Inc. in Cal. Exp. in Cal. Proteids : 110 grams at 4000 calories Fats: 100 " " 9400 Carboh: 400 " " 4180 Expenditure Mechanical work reduced to calories Excreta loss (1900 grams) 440,000 940,000 1,672,000 500,000 47,500 Warming of inspired air 84,500 Evaporating 660 grams perspiration 330 " H 2 O from lungs Radiation and conduction from skin 384,120 192,600 1,843,280 3,052,000 3,052,000 Thus far the fact has been emphasized that energy in various forms is fundamental in the life processes. It should be understood that in any form of energy it may exist either as potential or kinetic, i. e., as latent or active, and that these are changeable. The combination of the molecules and atoms in foodstuffs represents potential atomic and molecular energy, which, on coming into relation with certain environ- ments furnished by the body, is converted into the kinetic -.' GF . CGLLEG c'tfhs SOME FUNDAMENTAL CONSIDERATIONS. 51 energy of chemical action and heat. The free molecule of oxygen in the plasma of the blood, by virtue of its chemical affinities has potentially the power to unite with carbon and other elements and substances with the transformation into the kinetic energy of chemical action and liberation of. heat. The stored protoplasm in muscle substance represents poten- tially the activity that becomes manifest as mechanical energy on the application of a stimulus. The stretched con- dition of the aortic ivall immediately following the systolic discharge is potential energy which immediately becomes active in a recoil through its elastic property. Summarizing the foregoing and making a definite application we may make the general proposition that a nor- mal condition of health is dependent on a proper co-ordination of energies, and that disease represents a state of living matter such that inco- ordination results. If the condition of muscle tissue is such that its potential energy requires an excess of stimuli to be converted into a kinetic manifestation, then ab- normality exists. If a nerve cell body is in a condition of hy- per-excitability, due to disorders of its nutrition, the condi- tion is a too ready response to a stimulus with resulting change to a kinetic form. Further, these transformations all represent normal stimuli to body action. Life processes consist largely of response to the stimuli of a continuous stream of impulses that pass by the millions of afferent tracts from periphery to center. If the external or environmental changes are too rapid or intense for a normal response, or the organism is in a condition which prevents a sufficiently rapid assimilation of energy and its proper conversion, disorder must result. In the former the fault lies with the environment and is a cause of disease which we have in another section classified as an abuse of function. In the latter the condition will usually be found dependent on a condition of impaired structure which modifies the processes necessary to a proper co-ordination of energies. When through lesion to the digestive apparatus a deficiency of gastric secretion exists the balance between the c PRINCIPLES OF OSTEOPATHY. potential energy of the food and that of the gastric juices is disturbed. Hence disturbed chemical transformation results. Through a fault of the organic structure the heat re FIG. 3. Illustrating income, interchange and output of energy of the body. mechanism becomes deranged and an excessive chemical action with heat liberation results with a consequent rise in body temperature. This rise in temperature furnishes the occa- sion for further excessive transformations and a chain of effects follow. An injury to a muscle initiates chemical changes excessive in kind or degree, and a considerable difference in SOME FUNDAMENTAL CONSIDERATIONS. 53 electric potential is produced. The electric action then is re-converted into chemical and heat energies and inflamma- tory conditions result. The continued absence of any normal stimulus from environmental change, such as light, results in a loss of energy transformation which is dependent upon such stimulus, and a general weakness is a consequence. With the action and interaction of matter and motion, then, and all under the superintendency of a guiding force, call it mind, vitality or whatnot, the normal body metabolism will be maintained in harmony with itself and with its environ- ments. Through long ages the organism has been subjected to certain environmental conditions by which it has become adapted to ordinary and to numerous extraordinary circum- stances. In such adaptations of energy we have the most remarkable fact of living tissue. BODY F.UEL. The principal source of the energy of the organism is the food materials. It is manifest that for a proper transforma- tion and utilization of energy there must be a sufficient quan- tity and quality of the food to be disintegrated to yield the necessary forms. As an engineer insists on a good quality of the fuel as a prerequisite to a full capacity in the perform- ance of his engine, so the human engine must be supplied with materials appropriate to its needs. From analysis of body substance and from experimental observation it has been determined that there are certain organic and inorganic materials which are essential to normal body functioning. Among the former we note proteids, carbohydrates and /ate; among the latter, water and several salts, more especially sodium chloride. Numerous other salts are found in body tissues but are present in sufficient abundance in the organic foodstuffs to make it unnecessary to supply additional mate- rial. Indeed evidence is accumulating to show that except in the form of these complex organic substances, they will not be assimilated. The function ot the various inorganic salts is 54 PRINCIPLES OF OSTEOPATHY. in large part the regulation of the medium in which organic foods may be stored, transported and assimilated. Thus Thompson suggests the following functions: "To regulate the specific gravity of the blood and other fluids of the body; to regulate the chemical reaction of the blood and the various secretions and excretions; to preserve the tissues from dis- organization and putrefaction ; to control the rate of absorption by osmosis; to enter into the permanent composition of cer- tain structures, especially the bones and teeth; to enable the blood to hold certain materials in solution ; to serve special purposes, such, for example, as the influence of sodium chlo- ride on the formation of hydrochloric acid, and that of lime salts in favoring coagulation of the blood." Water is an ab- solute essential and must be taken in greater quantity than is present in the ordinary diet. Its functions are largely secondary to those of the organic foods but none the less es- sential. The very fact that sixty percent of the body is water indicates its great value. We have referred to the fact that the essential life substance protoplasm is largely fluid and for specific purposes. This fluidity is dependent on the pres- ence of water. We may enumerate the following as the more important uses of water to the body organism : solvent, diluent, medium for transportation, stimu)ant,and a thermolytic agent. Unquestionably there are individuals who take less water than is essential to a normal functional and structural condition. Proteids are the most essential of the organic substances. It has been shown by Pfluger and others that in case of the dog, of the organic foods proteid alone is sufficient to maintain life, while the absence of proteid material in the food is immedi- ately disastrous to normal function and soon results in death. In general the statement is true that proteids are the tissue builders while the carbohydrates and fats are energy producers, i. e., are oxidized with the liberation of heat. In the absence or deficiency of the latter two proteid may be converted into sugars and fats. With the finer processes of metabolism we are of ne- SOME FUNDAMENTAL CONSIDERATIONS. 55 cessity much in ignorance. "What takes place in the trans- formation from non-living to living proteid we cannot know except in the more gross details. We know this,that only those substances which are concerned with tissue building, secre- tion, and energy transformation will be permitted to remain in association with the living protoplasm. In this connection Dr. C. M. T. Hulett has emphasized the fundamental fact when he says, "The chain of events in metabolism is a closed chain and into this metabolic cycle no substances but those that serve as food can ever enter. Material not suit- able for its upbuilding cannot be imposed upon living sub- stance. It will take in only food elements and only such quantity of those as its needs determine, without regard to the supply which might be available. The only way in which other substances, e. g. drugs, can become incorporated with living substance is by destroying it. Acids and poisons unite with it in that way. The constituent events of the metabolic cycle do not follow each other in a single line but in many lines. Pfluger has emphasized the importance of the poly- merization of the proteid molecule in growth assimilation, in living substance, in which the simple molecule takes in from the materials of the environment atoms of food elements attaching them to itself until it becomes a polymeric mole- cule. It then breaks down into simple molecules, each of which repeats the process for itself, again and again, form- ing in that way numbers of chains of many similar links. Dissimilation is the reverse of this process, the end products being principally water, carbon dioxide, and urea. The suc- cessive chemical reactions in each chain or line have been compared to explosions on account of the great lability of the compounds." (Journal of the American Osteopathic As- sociation, Nov. 1901). By the process of selection which is a characteristic attribute of living protoplasm, every particle of the latter and every cell takes or rejects the materials fur- nished to it by the blood or lymph. In a similar manner it throws out from its substance into the blood or lymph every 56 PRINCIPLES OF OSTEOPAHTY. material that is of no further use to its functioning. This is true of the substances that are formed from cell katabolism but is equally true of those foreign elements which have tempor- arily gained access to the protoplasmic substance. In order that the two processes selection of food materials and re- jection of waste may be exactly balanced the medium for trans- portation must be normal in kind and quantity. The lymph must contain a sufficient available material from which the cell may select and must be in sufficiently normal condition of osmotic pressure and chemical condition as to offer no serious hindrance to the exchange of waste for nutrition. This man- ifestly will depend on a normal condition of the blood both with reference to quantity and quality. Since the latter is en- tirely dependent on a proper proportion of organic and in- organic substances the necessity for a proper food supply becomes at once apparent. It does not follow from the above considerations that every change in the dietary conditions will immediately or remotely produce a disturbance in the protoplasmic exchange. For, note that there are large possibilities of reserve sup- plies between the cell and the digestive tract. The cell itself is capable of carrying on its functioning for an appre- ciable time even though the blood be totally removed. This is true because it is a function of the cell to store an excess of food not immediately needed. In every cell under ordinary conditions there are fat droplets, glycogen, and other reserves which in addition to its own substance will be drawn upon as the needs require. In the lymph and blood and in the inter- cellular tissues there are immense quantities of stored material. This explains the fact that the organism may fast for weeks with little impairment of function though there will be an appreciable loss of substance which is in large part not im- mediately essential for proper activity. What are the essentials in a diet? The science of dietetics is still in a condition of chaos. Analysis of the body tissues and excretions have thrown some light on the problem. SOME FUNDAMENTAL CONSIDERATIONS. 57 Note this fact: the chemical composition of a foodstuff is not a sufficient criterion for judgment as to its value to the organism. If this were the case the food supply of the world would become a question of laboratory synthesis. The various elements must be in a definite condition of combination. Further, not all combinations seemingly alike in their various character- istics are equally available to the organism. Starch and cel- lulose are similar in composition but the latter is nearly indi- gestible. Various of the prepared foods, while containing all the elements and compounds in proper proportion, have been found deficient in their nutritive power. The condensed foods, pepsinized and otherwise pre- digested foods, are not suitable for ordinary conditions. The decrying of white flour and extolling the whole wheat variety was the fashion among the dietarians a few years back. Chemical analysis showed that the whole wheat contained the essential organic food- stuffs in more nearly a correct proportion than did the white. Yet analysis of the f eces shows that the proteids in the husks and outer part is much less available and hence in large part of no use to the organism except as a stimulant to peristalsis. With the average diet available to the ordinary Amer- ican the organism is amply able to extract sufficient of the nutritive principles to maintain body vigor. Statistics with reference to different people and different climates are illuminating more in that they show that what is chemically a very deficient diet is actually and physiologically a very sufficient one. The Esquimaux with his tallow and the Chinaman with his rice do not show sufficient difference ex- plainable alone from dietetic conditions, to make it a safe rule to rely upon chemical analysis alone for judgment of food values. In connection with the above Professor Atwater saya in "Principles of Nutrition and Nutritive Value of Foods," a bulletin published by the United States Department of Agri- culture: "Digestibility is often confused with another very 58 PRINCIPLES OF OSTEOPATHY. different thing, namely, the agreeing or disagreeing of food with the person who eats it. During the process of diges- tion and assimilation the food as we have seen, undergoes many chemical changes, some of them in the intestines, some in the liver, muscles, and other organs. In these changes chemical compounds may be formed which are in one way or another unpleasant and injurious, especially if they are not broken down (as normally they are) before they have oppor- tunity thus to act. Some of the compounds produced from the foods in the body may be actually poisonous. Different persons are differently constituted with respect to the chemical changes which their food undergoes and the effect produced, so that ic may be literally true that 'one man's meat is another man's poison.' Milk is for most people a very wholesome, digestible and nutritious food, but there are persons who are made ill by drinking it, and they should avoid milk. The writer knows a boy who is made seriously ill by eating eggs. A small piece of sweet cake in which eggs have been used will cause him serious trouble. The sickness is nature's evidence that eggs are for him an unfit article of food. Some persons have to avoid straw- berries. Indeed, cases in which the most wholesome kinds of food are hurtful to individual persons are, unfortunately numerous. Every one must learn from his own experience what food agrees with him and what does not." The time for dining or the frequency do not exercise as great an influence upon body conditions as we are led to think by numerous of the so-called "health" journals. True one may dine so often as to prevent recuperation between the periods of activity of the digestive apparatus. A fre- quency associated with a small amount at each period is not necessarily bad practice. Overloading under any circum- stances is objectionable. An abrupt change in dietetic habits is of more importance as a cause of digestive trouble than is the particular habit of the individual. With disease conditions present the viewpoint is- SOME FUNDAMENTAL CONSIDERATIONS. 59 somewhat changed. Yet we are largely in the dark with reference to the dietetic principle3 to be employed in partic- ular cases. In most cases appetite is a safe guide in health and within limits it is true in disease. Very few cases pre- sent themselves when it is advisable to force an individual to eat against his own desire. "Just a little to keep up strength" is advice and practice which is accountable for numerous prolonged disorders. The body needs house-cleaning. It is not the part of wisdom to bring in new furniture till the old is cleaned and re-arranged. The patient's desire will usually indicate the time. But it is equally faulty logic to withhold nourishment long after the appetite has returned. Fasting for ten, twenty, thirty days is advocated by various physicians, osteopaths and others, who rejoice in the reputation of follow- ing all methods of treatment that are natural ! Excesses are always unnatural. The individual, as in other unusual condi- tions, may get well, but the result is only another of the indi- cations that the organism may regulate its function even under adverse circumstances. MORE THAN A MACHINE. While it is necessary to make emphatic the fact that man is machine-like in his structure and operations it must not be forgotten that he is far more than a machine in the usual sense of that word. More, in the fact that the body is a self- feeding, self-oiling, self-operating and self-regulating machine. Ac- count for that fact in whatever way we can the fact stands undisputed. "Whether it be by virtue of special physical and chemical laws not yet understood or whether it be through the activity of a special vital force need not so much concern us at this time since the proof of either contention will not alter the fundamentals of our position. That force, whatever it may be, initiates, co-ordinates, and controls, in the most aston- ishing manner, the various activities of the body mechanism, enabling it to perform the greatest labor with the least loss of 60 PRINCIPLES OP OSTEOPATHY. energy being far more efficient in this respect than the most efficient of inanimate machines. THE SELF-SUFFICIENCY OF THE ORGANISM. By virtue of the facts emphasized above the body organ- ism is enabled to care for itself to a remarkable degree so long as it is supplied with normal diet. The importance of this idea is such that we shall consider ti at some length. If it were asked what fact is most striking and most fundamental In theosteopathic philosophy, we should unhesitatingly affirm, the self -regulating power inherent in bioplasm. At the outset it must be noted that the organism's power of self -pro- jection is not unlimited. While from one viewpoint it is pref- erable to consider all things as co-operating for the ultimate good to each other rather than as a life -and- death struggle for existence, yet the latter condition undoubtedly does represent one of the tendencies of all nature. Hence it is presumptuous, in view of known facts, to assume that thebody organism will triumph in all its encounters. But the fact that it is sufficient for ordinary conditions of environment and for numerous and extreme emergency conditions may be emphasized by a few illustrations. 1. It is self-sufficient functionally in health. Note an illustration in the mechanism of circulation : the stomach on the ingestion of food needs an increase of blood. The food materials act as a stimulus to certain nerve terminals in the gastric mucosa; afferent impulses are sent to a nerve center in the sympathetic ganglia or spinal cord where efferent im- pulses are generated resulting in a dilatation of the gastric arterioles; the general blood pressure remaining unaltered an increased blood flow to the stomach is inevitable. In respira- tion : by reason of an increase in metabolism, an excess of carbon dioxid is generated and modifies the normal condition of the blood ; that excess acts as a stimulant to certain nerve cells located in the medulla; these generating efferent impulses over the nerves controlling the respiratory apparatus cause SOME FUNDAMENTAL CONSIDERATIONS. 61 an increased activity of that mechanism whereby); the excess of carbon dioxid is eliminated. In heat regulation (thermotax- is) : the individual is exposed to a sudden lowered external* temperature; by nerve influence and direct effect superficial vaso- constriction and deep vaso-dilatation occur; hence not, only a lessened opportunity for heat loss, but through several* media an increased metabolism results, which means the maintenance of the average body temperature withiri narrow CENTER IN limits. In vomiting we have an ^MEDULLA example of emergency function ex- emplifying self -regulation ; an ir- ritating substance is taken into the stomach! which, acting as an intense stimulus on terminals of the vagus nerve, cause afferent impulses to pass to the so-called vomiting center in the medulla; efferent impulses sent out over the vagus, the lower intercostals, and the phrenic, cause a forcible expulsion of the irritating mate- rials, at the ; same time through other mechanisms the orifices of the stomach are co-ordinated, the glottis closed and anti-peristalsis of the esophagus occurs. In the depressor nerve another emergency function is provided for; under ism of vomiting. ordinary conditions of blood pres- sure that nerve is inactive. When by reason of increased peripheral resistance or other cause the pressure becomes ex- cessive terminals of the nerve in the walls of the ventricle are stimulated, afferent impulses are sent to the vaso -motor center and general and special dilatation occurs with a con- sequent lowering of pressure. But also in disease conditions we note the regulation. FIG. 4. Illustrating the mechan- '62 PRINCIPLES OF OSTEOPATHY. In the high temperature of the body we have a condition un- favorable to the development of micro-organisms which are known to be associated with various fever states ; that high temperature is brought about by the disturbed condition of the body, i. e., toxicity, excess of waste, etc., which acts as a stimulus to an excessive metabolism resulting in the over- active oxidation, the heat thus generated acting not only in the manner suggested above but assisting in ridding the body of foreign and waste material by "burning" it. In convul- sions, according to Dr. Still (See Philosophy of Osteopathy) is represented an effort to overcome a disturbance in the equilibrium of certain of the vital forces. The increased activity of the skin in disturbed renal conditions represents an emer- gency function as well as an example of the substitution power of the body organs. In infection the white blood corpuscles are increased in number and efficiency as a result of some stimulus dependent on the presence of pathogenic bacteria; while in addition to this function of phagocytosis of the white blood cell an increased antitoxic condition of the blood and tissues is produced dependent on the same factors. In starv- ation, the body is preserved in a remarkable manner, for not only are stored foods glycogen, fat, etc. first drawn upon, but when this source of supply becomes exhausted the organs least essential suffer first. The following table from Stewart's Physiology, giving percentages of total organ weight lost in starvation is extremely suggestive : Brain 3 Kidneys 26 Heart 3 Blood 27 Bones 14 Muscles 31 Pancreas 17 Testes 40 Intestines 18 Liver 54 Lungs 18 Spleen 67 Skin 21 Fat 97 2. It is self -sufficient structurally. Note the calloused condition of the palms in the case of an individual who per- SOME FUNDAMENTAL CONSIDERATIONS. 63 forms much manual labor; or the similar hardening of the gums of those who are without teeth i. e., structural change because of functional increase. The body is continually meeting with mechanical forces sufficient to temporarily dis- place parts, e. g. , the ribs, in which the normal tension of muscle and ligament is usually sufficient to re-adjust. In case of slight wounds blood and lymph together are able to approximate the parts and healing results. But also in disease the regulating power over structure is manifested. On the structural change in the semi- lunar valves permitting a regurgitation of blood, the ventricular muscle hypertrophies to correspond to the increased work to be done; in which case we have a compensatory structural change. In dislocation of hip where tension of ligaments and muscular effort are insufficient to accomplish reduction, com- pensatory changes occur, such as shortening and lengthen- ing of muscles, formation of new acetabulum with adhesions for ligaments. In broken bones where continual motion has prevented the "knitting" process, "false joints" have been formed with all the essential structures, i. e., articular sur- faces, ligaments and synovial membranes. In local dilatation of the upper intestine in case of absence of the stomach, and in the remarkable case referred to by Spencer where, as a result of partial obstruction at the cardiac orifice of the stomach, food material collecting in the lower part of the esophagus initiated processes resulting in a dilatation of the canal, the development of glands,and a crude form of gastric digestion, we have illuminating instances of the ability of the organism to rise to the occasion. The above facts have been emphasized for the purpose of impressing the fundamental proposition that all pro- cesses of healing are dependent on the inherent power of protoplasm; that that inherent power to heal will be exercised so long as struct- ural conditions are normal, and in the vast majority of cases where the structural conditions are abnormal, adjustment of the latter are not beyond its power; that the duty of the 64 PRINCIPLES OF OSTEOPATHY. physician is only to keep external things things external to function favorable to the exercising of that power. THE TENDENCY TO THE NORMAL. The considerations in the last section are partly explana- tory of but more properly lead up to a more definite determin- ation as to the nature of a normal condition and the rea- sons for such a tendency to continually maintain or restore that condition. If the question were asked as to what con- stitutes a normal condition few there are who would not be able to give a fairly satisfactory answer in general terms. But though the general conception were held by each, to explain the specific elements necessary in a normal condition is a task of some considerable difficulty. If we answer that a normal body is one in which the different parts are working in harmony we have a satisfactory general answer. But if we attempt to give the several elements a mathematical value and then insist in measuring every individual by that stand- ard we will certainly meet with insurmountable difficulty. If by careful estimates we determine that 33 grams of urea is the normal amount excreted in 24 hours, shall we call that individual abnormal who excretes only 28 grams? If we determine that 72 beats per minute shall be the standard for heart action, shall we decide that Napoleon whose heart rate was 40 and that others whose rate was below or above the average figure were not normal? In relation to men collect- ively, then, no standard of normality can be given. But how about the individual? Can we establish a standard for each individual? The difficulties are identical. The individual condition is continually changing in quality and quantity of functioning. The change is no evidence of a departure from the normal. It is the normal that varies and hence an absolute value cannot be given to the various elements constituting a normal. If we shall make symptoms the criterion of our judg- ment we shall certainly fail in numerous cases. Many dis- SOME FUNDAMENTAL CONSIDERATIONS. 65 ease conditions are present for long periods of time though presenting absolutely no noticeable symptoms, subjective or objective. Further, certain changes in appearance ordi- narily considered symptomatic of disease are not so in reality; for instance a rapid heart beat is usually apparent following the climbing of a steep hill. The individual is subjectively distressed and the objective symptom of rapid heart beat is present. But the actual condition instead of being abnormal is normal under the circumstances. Is pain an abnormal condi- tion? Not necessarily nor usually. Subjectively it is a psychic condition and as such is in one sense a product of cerebral activity. In so far as it is a warning it is a normal condition though it is usually if not always evidence of some abnormal condition. This is equally true of other subjective symptoms. We cannot, therefore, rely upon symptoms as a criterion for judgment of a normal condition. The best that can be done under the circumstances is the determination, by comparisons ivith the average condition of the average individual with modifications of judgment; dependent upon the presence or absence of symptoms, as to the degree of abnormality, the line of demarcation between normal and abnormal being a non-determinable quantity. While it is true that the details constituting a normal condition are not confined within known and unyielding lim- its, the general forces back of the ".tendency" may be de- termined. In the first place there are two fundamental forces associated with the life of each organism, the first of which is heredity. By the term we mean that peculiarity derived from the total ancestry that compels a likeness to type. What is in- herited? (a) The life principle itself and (b) the general form and function. It is to be noted that inheritance does not refer simply to the relation between immediate parent and offspring but between the whole line of ancestors and the individual. An individual may present the special peculiarities of his grandsire rather than those of his sire, in which case we have a special quality of germ plasm handed down through the 66 PRINCIPLES OF OSTEOPATHY. parents but not becoming manifest in them, to reappear in developed form in the grandson. Such a reversion to an- cestral characters is technically referred to as atavism. The second great force is that of adaptation by which we mean the peculiarity that permits an unlikeness to type a pe- culiarity which is dependent on the environment for its man- ifestation. What varies? The special features and functions. No two individuals are alike in their structural or their func- tional characters; and this individual variation, in so far as it is not a likeness to some ancestor, is dependent on condi- tions of environment, i. e., dependent on stimuli acting upon the organism during its separate existence. Both of the two great forces are necessary ; the one in order that stability shall be preserved and the identity of the species maintained; the other in order that the individual shall not be disintegrated because of an absolutely unyielding nature. Each one of the two forces tends to counteract the extreme tendencies of the other and hence the happy me- dium is maintained. Heredity alone would make an absolute condition necessary to a normal one. No adaptation to the continually arising new circumstances could be possible. Because of the adaptation associated with living material variation is possible. Hence the limits, the boundaries of the field of normal action are markedly widened. Recognizing the two forces we may explain in a general way individual peculiar- ities such as difference in heart beat, in bowel activity, and per- spiration; and circumstantial peculiarities such as increase in res- piration dependent on altitude, hypertrophy of the heart in valvular disorders, thickening of tissues in cases of continual wear. These considerations become of special interest and fun- damental importance to the osteopath especially in their ap- plication to the determination of lesions. In a later chapter we shall indicate in detail the points necessary to consider in the diagnosis of a lesion but in this connection we wish to emphasize one case. The tendency of the beginning osteo- path is to assume that every variation of structure, especially SOME FUNDAMENTAL CONSIDERATIONS. 67 in the position of the spinous processes, is a lesion. The foregoing considerations would suggest some possible ex- ceptions. And experience demonstrates that there are num- erous exceptions. The spinous process may be deviated be- cause of an over- development of muscles on one side the right in "right-handed" individuals, for example, or from a faulty condition of nutrition in foetal life, or from various other forces, which while causing an appreciable variation from the average condition does not cause or predispose to disease, and hence could not be rightly called a lesion. What is true of the position of parts is true of the several other conditions that may be present. In all considerations of diagnosis the possibility of unusual appearances being normal must be recognized. A normal individual, then, is one sufficiently like the species to maintain its identity as a member of that species but pliable enough to change sufficiently to meet the average emergencies of environment. If the incident forces are sufficiently intense or prolonged to produce a modification beyond the limits of adaptive response disease will result. Otherwise, while function and structure may be temporarily modified, disease beyond the limits of self-cure will not occur. This tendency to the normal results from certain well known principles which may be enumerated. 1. First are those of a physical nature. Self -reduc- tion of luxations depend to a considerable extent upon the difference in mechanical tension on opposing parts of the lux- ated structure; in the case of the formation of a new acetabu- lum the mechanical pressure operates to produce the cavity. The discharge of irritating particles from the bronchi is ef- fected by an apparatus which utilizes air pressure. 2. Or the tendency may depend upon chemical con- ditions. The carbon dioxid acts as a chemical stimulus to the nerve cells controlling respiration. The immunity to certain diseases through the medium of an increased antitoxic con- dition of the blood is secured by chemical means. The coagula- 68 PRINCIPLES OF OSTEOPAHTY. tion of the blood thereby preventing its own loss is largely a chemical process. 3. Finally, the tendency is dependent to a considerable degree upon certain vital principles. The protection from loss in the more essential organs in the case of the deprivation of food above referred to; the formation of a stomach and arrange- ments for gastric digestion in other parts of the alimentary canal when the stomach itself has been obliterated or render- ed ineffective; and the chemotactic action exhibited by the white corpuscle in the presence of the pathogenic bacteria are illustrations of this principle. It is not to be presumed however that these various sep- arate principles act separately in bringing about the adjust- ment. It is likely that in no case is this true but that the three are associated and co-ordinated by the vital force of the organism; and thus continually guarding and restor^ ing, the organism is enabled to pass its alloted existence in a world rife with changes of environment which may at any time be sufficient to inaugurate disease. But by virtue of the tendency exercised both in ordinary and extraordinary cir- cumstances it may usually triumph, and hence it is in a very real sense that the statement is true that "disease is the stimulus to its own cure." MJ<*M our fi^ ko-cAvtw . FIG. 5. Illustrating the action of forces of Heredity and Adaptation. THE ETIOLOGY OF DISEASE. 69 CHAPTER IV, THE ETIOLOGY OF DISEASE. In a previous chapter it was suggested that health repre- sents a condition of body harmony and that disease is body discord. For purposes of convenience we may accept as our definition of disease perverted function. While this is not entirely satisfactory in that most diseases are associated with structural changes also, yet the appearances so strongly emphasize the prime importance of functional perverson that we shall make use of the phrase. Granting that there are limits to the self -regulating power of the organism and that disease does exist, it becomes neces- sary to inquire into .the cause of disease ; and first will be mentioned the most important of two general causes. ABNORMAL STRUCTURAL CONDITIONS. Whatever in addition he may be man is certainly a ma- chine. It is further obvious that the function of a machine i. e., its action, is absolutely dependent on its structural in- tegrity and that just as soon as any part of the machine be- comes disturbed in relation to other parts disorder of action will result. Is this true of the man-machine? It would seem a simple proposition easily answered. Yet objection is of- fered. Without at this time entering into a discussion of the relative placing of structure and function, a few facts may be indicated tending to prove indisputably the contention that abnormal structural conditions are a fundamental cause of per- verted function. Medical and surgical history teems with records of cases where at least gross anatomical disturbances initiate definite and far-reaching physiological disorder. A few of such cases will be specified. Adislocated hip will cause sciatica. How does it do so? By direct pressure, not necessarily on 70 PRINCIPLES OF OSTEOPATHY. the nerve perhaps, but upon structures closely enough as- sociated with it its blood supply, for example to result in its disorder. A dislocated cervical or even lumbar vertebra will cause paralysis by pressure upon the spinal cord or upon its sources of supply. An occluded artery will cause dry gangrene and .an occluded vein will cause moist gangrene. Note Nancrede's statement: "Indeed except when the trau- matism physically disintegrates tissues as a stone is reduced to powder, heat or strong acids physically destroy structure, or cold suspends cellular nutrition so long that when this nu- trition becomes a physical impossibility vital metabolism can not be resumed, gangrene always results from total deprivation of pabulum." (Italics mine). He also indicates what most surgeons assert that the moist form depends in part upon in- terference with the drainage. Aflat chest vitiates lung tissue and renders it susceptible to invasion by bacteria. Pregnancy by pressure on renal vessels produces albuminuria. Sclerosis, i. e., overgrowth and hardening of connective tissue structures causes interference with nerve impulses in tabes dorsalis, spastic paraplegia, and similar conditions. A sprained ankle causes congestion and infiltration, thereby producing various sensory and motor disturbances directly and reflexly. And finally, as stated by Hill in Schafer's Physiology, "the movements of the muscles of the neck by pressing on the jugular vein are sufficient to affect the cerebral circulation." In all of the cases mentioned above we have illustrations of the fact that function depends on structure. That such cases exist is recognized by all authorities and is disputed by none. In all of these cases the anatomical perversion is a gross one and the functional change is also gross. Why should we limit the application of the principle to the gross cases? Let us further analyze some of the above instances. All are agreed that the dislocation of a hip can produce an inflamma- tion of the sciatic nerve. Is it a greater tax on the intellect to conceive of a less severe functional disorder dependent up- on a less severe structural perversion? If an intense stimu- THE ETIOLOGY OF DISEASE. 71 lus will produce the neuritis why will not a less intense but long continued stimulus produce, if not a neuritis, at least an appreciable disorder of some other kind, for instance a deaden- ing effect, a numbness, or a change in vaso-motor impulses that are carried by the sciatic nerve? And what is the source of this long continued but less intense stimulus? Among other things, a slightly subluxated innominatum or other of the bony structures which are closely associated through their ligamentous and muscular connection, with the sciatic nerve in its course or at its origin. Is it possible that the innomina-\ turn can be subluxated? Undoubtedly. Any bone having a , definite articulation can be subluxated. A slight twist of the innominatum at its articulation with the sacrum constitutes a j real subluxation and of sufficient degree to produce tension ) upon its associated structures. Note the case of the paralysis dependent on dislocation of a cervical vertebra. Is it an in- sult to intelligence to assent to the proposition that if a gross dislocation can produce a paralysis a less perversion, for in- stance a severe torsion or strain, may so impinge not upon the cord directly but upon the innumerable channels that connect the contents of the neural canal with the structures anterior to the spinal column, as to very materially interfere with the exchange between those regions? We think not. If it be possible that gangrene of a tissue is dependent on the total obstruction to the arterial supply to that tissue, why is it not reasonable that a partial interference with the flow of blood through an artery may result in a less completely starved condition? That partial interference may easily be produced by direct pressure of structures upon it or by inter- ference with the nerve mechanism which governs its diameter. If the lungs are weakened by a depressed condition of the tho- racic walls, why is it not true that the heart may suffer from a like crowding? If it be possible that contraction of cervical muscles produces a change in cerebral circulation why may not a contractured-ie. , chronically contracted- -muscle produce a chronic disturbance of that circulation and hence a conges- 72 PRINCIPLES OF OSTEOPATHY. tive headache. If a pregnant uterus by virture of its size and weight may produce renal disorder by pressure, why may not a tumor, a contractured muscle or a subluxated bone, acting upon a vital structure directly or indirectly connected to the kidney, produce disorder of that organ in a similar manner? If a sclerosis interfere with nerve impulses in the spinal cord, why may not a thickening of tissues connecting vertebra with vertebra produce similar disturbance in the nerve fibers or blood vessels which pass so numerously into and out from the spinal canal, among and between and through those connecting bands? If a sprained ankle is a common occurence and if congestion and infiltration are resulting conditions which cause direct and reflex disturbances, why is it such a draft upon credulity to believe that a similar common condi- tion of sprain with similar congestions and infiltrations and similar direct and reflex disorders may occur in the scores of articulations which are presented by the spinal column? But it is not necessary to rest the case entirely on assump- tion. Evidence has been accumulated and is still accumu- lating which is most confirmatory in character. Case after case has been found by osteopaths who are careful in obser- vation and logical in judgment, showing that these various structural perversions are present and are associated with functional disorders, the removal of the structural condition uniformly resulting in a disappearance of the disorder. It is at the present time not so much a question as to the fact that a structural disorder produces the disease as to the details of the manner in which the latter is brought about. DISEASE MAINTAINED BY STRUCTURE. It is not of such moment as to what was the original stimulus to a disordered function. We have no quarrel with those who insist that the functional disorder may result from a multitude of forces which 'act continually upon the organism. It is readily admitted that constant disregard for well known laws of health must of necessity produce disorder, THE ETIOLOGY OF DISEASE. 73 and in another section special attention is called to the fact. A thousand conditions of environment and of individual may initiate or predispose to disorder of function. This fact must be recognized in order that the individual shall understand that he must reap what he sows. It must be a part of the work of the physician as it is only less emphatically the duty of every man to assist in a proper understanding of the ordinary laws of responsibility for one's own health, body, mental and spiritual. Temperance in all things is absolutely a pre- requisite for continued well being. Any intemperance will result in at least a temporary impairment of function. With most normal individuals a few experiences will teach wisdom. Hence most individuals pass through life with a fair degree of health so far as disorders dependent on wilful abuse is con- ; Deemed. When, however, a disorder becomes manifest and persists in spite of removal of the intemperance or abnormal condition or environment we are justified in assuming that some other factor is maintaining the disease, for function is infinitely self-regulative. We maintain that the other factor is perversion of stricture and that structure is a part which is less immediately and less completely subject to vital control the more inert tissues such as bone, ligament, cartilage and other connecting structures. Hence where a disorder is maintain- ed, we assert from reason and observation, that the structural condition is the factor that prevents a return to normal functioning The question, therefore, is not as to the original force that caused the disorder, but why does not the sick man get well. It is just as much a normal power of the organism to produce a return to normal functioning as it is to maintain functional equilibrium manifest in the ordinary healthful life. It is in fact impossible to actually differentiate between the two. An excess of carbon dioxid is a normal stimulus to the removal of that excess. This is true in other cases. The organism restores continually its proper function largely through the medium of stimuli furnished by its own katabolic products. The pres- ence of other substances not nutritive in character, e. g., bac- 74 PRINCIPLES OF OSTEOPATHY. terial excreta, produces a similar result. Whether through ages of adaptation and from hereditary transmission or from inherent endowment coequal with life itself, the fact that this self -protective power exists may be affirmed with little proba- bility of error ; and that function is absolutely self-regula- tive while structure is only less responsive to the same forces is equally certain. Hence in the ordinary disorder that seems beyond the limits of self-restoration we must logically look to the structural condition for the factor maintaining the dis- order. And experience has shown that little in addition is needed, for with the average individual the average environ- ment constitutes a normal condition. With such an environ- ment to which the individual has long been accustomed the organism is master of the situation and needs only freedom to exercise its restorative powers. The truth of these considerations is evident in case of chronic disorder. But they are no less true if less evident in acute conditions. A certain prominent instructor in a recognized medical college told his students on the occasion of tfieir graduation that 95 per cent of their acute cases would get well whether they were treated or not. We are not sure that the percentage is too high. This does not argue for a policy of non-interference. For osteopathic experience shows unquestionably that the reparative forces may be given great- er freedom for action by appropriate treatment. In general the length of time required by the unaided organism to restore normal conditions may be lessened one-half. What is the philosophy of the treatment under such circumstances? Under the influence of an excessive stimulus, i. e., a marked disease condition, the organism exerts its full powers of response but very materially at the expense of certain secondary abnormal functioning. That is, the vital forces are all concerned with the state of emergency, which diverts attention from certain functional and structural conditions that under the circum- stances are secondary in importance. These together with the added disorganizing factor of an excess of stimuli due to THE ETIOLOGY OF DISEASE. 75 the disease become more or less deranged. As a result we see the varying symptoms which represent in large part evidences of the secondary disorganization. One of the most common of the latter is change in structural relations, e. g., contractured muscles. But contractured muscles, directly and through their attachment to bone or other tissue, further dis- turb structural relations and hence an additional causal factor is presented. This structural perversion which has been pro- duced secondarily is an added cause not so much of the dis- ease but of the inability of the organism to immediately re- cover. Hence by keeping the structural conditions reduced the total time for recovery will be appreciably shortened. If this assistance is not given the organism will recover in most cases unaided. But in others the disease will become chronic not because the f auction delights in irregularity nor because the environment or habit of the patient is necessarily an insur- mountable hindrance, but because the inert structure which was disturbed has become set in its new relations and the normal tension of surrounding tissues is insufficient to re- adjust. It is not necessary to assume that the perverted structure arose as a secondary result. It is enough to note that in countless cases there exists a deranged structural condition which, not of itself capable of producing marked disorder,. yet permits of a lessened resistance to the extraordinary stimuli and when the disease results from the latter, prevents a complete response to the new conditions by interfering with normal nerve or blood action. In such cases the structural difficulty is part of the original cause of the disease in that it represents a predisposition. It becomes the principal if not entire factor which prevents a ready return to normal. THE LESION. By osteopathic usage the word lesion has come to have a special significance. The surgical conception of lesion, i. e., any hurt or injury to a part, and the pathological concept, i. e., 76 PRINCIPLES OF OSTEOPATHY. any local or circumscribed area of tissue undergoing abnor- mal functional changes, must be carefully distinguished from the osteopathic concept which is any structural perversion which by pressure produces or maintains functional disorder. Note first that the definition includes all tissues. While it is true that the bony lesion occupies first place by virtue of history and importance muscular and ligamentous are rivals of the for- mer for pre-eminence. A viscus may act as a lesion, and sunong the most serious of diseases are those directly depend- ent upon pressure from prolapsed viscera. In the second place note that the structure must be perverted, that is not normal has departed from the usual or average condition. Third, note that the condition of function is included in the con- ception of lesion. This is of fundamental importance. From what has been said in a previous section it can be understood that a structure may be perverted in the sense of being unusu- al and still not be a cause of change of function. This varia- tion is still within the limits of normal adaptation. A spine may have its curves markedly exaggerated or completely ob- literated and the functional conditions still remain normal. To make of it a lesion in the osteopathic sense there must be included the idea of functional disorder as a consequence of the structural perversion. Finally, note that the disorder is produced by pressure. This latter idea is the keynote in disease causes. We believe this conception of the term lesion is the proper one from the standpoint of usage, convenience and simplicity. /. The perverted structural condition may be a disturbed positional relation of parts. These may be further class- ified into (a) dislocations, which usually refer to bony tissue and represent a condition in which there is a complete sepa- ration of the articular surfaces. An example of this class would be a hip dislocation, (b) Sub-luxation, also usually re- ferring to bony structures but in which there is an incom- 'plete separation of the articular surfaces. A rib is more commonly subluxated than dislocated, (c) Displacement is THE ETIOLOGY OF DISEASE. 77 more commonly applied to yielding structures and especially viscera in which there is no well marked or special articula- ting surfaces. We can more appropriately speak of a dis- placed uterus than of a sub-luxated or dislocated one. (d) The lesion may be in the nature of a contracture, more especi- ally of muscle tissue. While it is true that all living tissue is more or less susceptible to change in shape through the phenomenon of contraction, muscle tissue because of its specially developed power in this particular must occupy first place. While the contracture is a position change it is also a size change and might appropriately be considered in the next division. For there is undoubtedly in the majority of muscular contractures an increase in the total bulk of the muscle though not necessarily in the amount of muscular fiber. In the second place the disorder may be a disturbed size relation of parts. These may be also further classi- fied into (a) lesions from overgrowth. In the case of a hyper- trophied heart or a thoracic aneurism direct pressure is exerted upon the lungs and other thoracic structures with resulting disorder of their function, (b) Arrested growth and (c) atrophy are less common conditions but are occasionally noted. In the case of an atrophied liver the resulting dis- turbance of associated abdominal viscera may be directly de- pendent upon this size disturbance, (d) Perverted groivth as in the case of exostoses and tumors which are special forms of overgrowth conditions. We have referred to the fact fundamental in importance that the lesion produces diseases by a pressure effect. In what way is that pressure applied? The question demands a rather extended discussion but will be briefly outlined in this connection. MEDIA THROUGH WHICH LESIONS PRODUCE DISEASE. 1. Direct pressure may cause the organs to be involved in disease. A rib or ribs may be depressed thereby pressing directly upon the lungs, or what is equivalent to that pres- 78 PRINCIPLES OF OSTEOPATHY. .4 sure, prevents their normal expansion resulting in an imme- diate disorder or a lessened resistance to specific infection. A floating kidney may press directly upon the bowels thereby inducing constipation or other trouble. The pyriform&ts mus- cle or others closely associated may in contracture impinge directly upon the sciatic nerve causing a neuritis. 2 Pressure .upon the artery which supplies it causes an anaemic condition of the organ and a possible secondary hy- peraemia of some closely associated part. By virtue of a tor- sion of the cervical vertebra with a consequent tightening and thickening at intervertebral ligaments the blood flow through the intervertebral artery is hindered and the spinal cord suffers. An approximated condition of the upper ribs impairs the arterial supply to the mammary gland and the se- cretion of milk is hindered. An abdominal tumor or a preg- nant condition impinges on the renal arteries and kidney trouble is experienced. 3. Pressure upon the vein which drains it causes a hypersemia of the organ with a possible secondary anosmia of closely associated structures. A depressed sternum and anterior ends of clavicle and first rib through pressure upon the inferior thyroid veins causes goitre. A tightened muscular and ligamentous condition about the saphenous opening causes varicose veins. Muscular contractures in the cervical regions interferes with the drainage from the cephalic struc- tures and a congestive headache results. In cirrhosis of the liver an obstruction to the portal system occurs with a resulting abdominal dropsy and a secondary anaemia of other parts of the body. 4. The organ may be disordered by pressure upon the lymph channels with which it is associated thereby pro- ducing innumerable disordered conditions through the inter- ference with the nutritive and sewerage functions of the lymph, and by a secondary process materially affecting the general vascular system. 5. Pressure upon a nerve directly or reflexly con- THE ETIOLOGY OF DISEASE. 79 nected with it causes organic disorder. The heart may be interfered with by tightened ligaments causing pressure upon the cardiac accelerators which issue from the spinal cord from the first to the fourth thoracic segments, or it may be involv- ed in disorder partly dependent upon an excess of impulses transmitted to it by way of the hypogastric and solar plexuses from a disturbed uterine condition, in which case we have reflex effect. Or the accelerators may carry too many or rapid impulses to the heart dependent on contractured spinal muscles in the upper thoracic area, this being also a case of disturbance dependent upon reflex action. Note the physio- logical law that the total activity of a segment of the spinal cord va- ries directly with the total number of impulses passing to it. Hence a contracture of a spinal muscle, by increasing th6 incoming impulses through impingement on sensory nerves, will cause hyper-activity of the cord segment and a resulting increase of accelerator impulses out over the cardiac nerves. This law is uniform and will explain most visceral disturbances dependent on muscle contracture. Note the extreme number and variety of effects possible from nerve disturbance. A sensory im- pingement will produce pain, direct or transferred. Every sensory nerve is a possible pathway for impulses setting in motion a vaso motor change; hence anaemic or hypersemic con- ditions may result. It will also in- itiate excessive activity of the sweat glands and hence perspiration be- comes abnormal. It may carry the impulse which inaugurates the change in any efferent channel and FIG. 6. illustrating the numer- ^ence mo tion may be increased or - of disturbance of ous sources viscus. decreased, secretion accelerated or depressed inhibition modified, trophicity lessened. All of these effects, are dependent on interference with afferent or 80 PRINCIPLES OF OSTEOPATHY. sensory nerves. On the other hand the efferent channels themselves are equally subject to interruption while any change in the nutritive condition of a segment of the spinal cord or a center in the brain will affect to a greater or less degree all nerve pathways in direct or reflex connection with them. The medium of nerve interference is ivithout doubt the most important with which ice deal. Through these several media we may explain with great- er or less satisfaction the varied results that have been ob- served to follow the presence of a lesion. The difficulty lies in determining in each individual case which of the several explanations is the true one a difficulty at once apparent and in many cases insurmountable. It must further be noted that a lesion sufficient to produce impingement on one of the channels will be sufficient to affect another, so that in most cases we will have more than one of the channels interrupted and hence the greater possibility of extreme effects. MISCELLANEOUS NOTES. 1. The extent of the lesion bears no constant rteation to the in- tensity or extent of the effect. Note the case of the hunch-back whose lesion condition is quite apparent and great in extent. Yet in many cases his health is not markedly impaired. On the other hand a slight strain at the articulation between the eleventh and twelfth vertebra has resulted in immediate Bright' s Disease of a very serious nature. The strain was bare- ly noticeable on palpation or inspection yet the effect was far- reaching. Several facts suggest an explanation of the con- dition. The effect will vary directly with the vitality of the tissue interfered with. If a lesion brings pressure upon simple connective tissue little result may be looked for. The connective tissue is comparatively inert. If the pressure be upon nerve tissue the result is far-reaching. Nerve tissue is most vital. It is developed with the special end in view of furnishing a material quick to respond to stimuli and capable of conducting the impulse to other parts of the body. Hence THE ETIOLOGY OF DISEASE. 81 a lesser intensity of stimulus from pressure will be necessary to cause response than in connective tissue and a much more rapid transmission of the impulse will also result. A muscle impinged upon, less vital than nerve in respect to readiness of response and speed of propagation, will be associated with less immediate effect. An artery involved is more likely to result in disorder than is some other structures because of a wider influence and a more ready response to pressure. Again the adjustment possibilities of the structure involved in lesion is an important factor in modifying the response; and this is in turn largely dependent on the abrupt- ness and strength of the stimulus, i. e., the pressure from the lesion. A lesion produced gradually, as is true in most cases of curvature of the spine, will not constitute a change suffi- cient to be effective as a stimulus. For, note that it is an ab- rupt change of pressures that constitutes a mechanical stimulus. In the case, then, of the posterior curvature, the extreme kyphosis, the pressure has been so gradually applied that the structures in contact were not stimulated but were able to adapt themselves to the gradually changing conditions. It is a rule recognized by physiology that a change sufficient to produce a response in a tissue if continuously applied will later fail to produce such response. The tissue hag adapted itself to the stimulus and is not further affected thereby. In the case of the sudden wrench of an articulation causing nephritis the change in pressures was so intense and so abrupt as to constitute a very efficient stimulus so that the extreme result was brought about. It must be noted however that ultimately further adjustment will be impossible and the tis- sue must respond. Note that finally the hunch-back succumbs to conditions much less severe than would otherwise be the case. The summation of stimuli may help in the explanation of such. A stimulus ineffective at first, by repeated operation may cause such an accumulation of effect as to result in a discharge. The spine though gradually impinging upon a nerve or other tissue will finally produce a summation of effects and disorder will result. 82 PRINCIPLES OF OSTEOPATHY. 2. Another important fact that must be noted is that the region of apparent disturbance is not necessarily or usually the seat of the lesion. While this statement applies with more force to the subjective disturbance of pain yet it is noted in others not subjective. With respect to pain, sufficient to refer to a later chapter in which is discussed the condition of transferred pain. At present note that the pain caused by an irritation may be felt in any part of the distribution or course of the nerve irritated. In pressure at the elbow upon the ulna pain is not only felt at the point of pressure but also and in many cases most markedly in the fingers, i. e., where the nerves are specially developed for receiving stimuli. A lesion in the spine by pressure on fibres forming the intercostals may pro- duce pain felt over the anterior surface of chest or abdomen. Hilton's rule that pain felt superficially and not accompanied by a local rise in temperature indicates a spinal origin of the pain, is interesting and helpful especially to osteopaths. Especially is this likely to be the origin if the pain be symmetri- cal, i. e., on both sides of the median line at corresponding points. An associated local rise in temperature together with other evidences of local inflammation indicates the latter as the probable immediate irritant. But the application can be made to other than pain conditions. Note that a pelvic lesion primarily affecting the uterus may cause symptoms only with the heart, palpitation of that organ being a quite common result. In this case the patient and physician would naturally assume that the heart was primarily at fault. But experience suggests that it is otherwise, the heart being affected through the complicated mechanism of reflex activity. The impulse from a disturbed uterus may be transmitted, for aught we know, through a choice of numerous pathways involving the reflex the numer- ous centers and their connecting fibers associated with the pelvic, hypogastric, solar and cardiac plexuses, the sympa- thetic ganglia and the segment of the spinal cord being in- volved. But why should the heart be thus involved and not THE ETIOLOGY OF DISEASE. 83 .some other organ? In answer it may be said that in other cases and at times in the same case it is another organ. Byron Robinson's suggestion that it is dependent on a condition analogous to an electric arrangement is suggestive but un- satisfactory in that there are too many exceptions. His sug- gestion is that that organ will be involved reflexly which is connected to the primary organ by the greatest number of nerve strands. Unfortunately he does not show that such is the case. Personally the author prefers another explanation in which there are noticed few exceptions and those perhaps only apparent. Under the circumstances of a perfectly nor- mal condition of every other organ of the body, little disturb- ance if any will result when the one is disturbed. The excess of energy will be more or less equally distributed over the en- tire nervous system, perhaps indeed more to those offering the least resistance, i. e., to those having a greater number of nerve strands. But in most cases some one or more organs will be- found in an irritable state quite out of the ordinary. In such a case a nerve impulse coming from the organ pri- marily involved will be effective in a much less intense form than would be required in case the organ were normal. Hence the statement may be made after this manner: that organ will be involved reflexly which is in the more irritable condition. The excess of irritability in one organ over that in another will de- pend to a slight extent only upon inherent capacity, but in much greater part upon a disturbed nutrition dependent on an associated lesion. In case of a reflex disorder, then, we must look for additional cause in the way of a predisposition. In the majority of cases actual experience will show that predisposition results from a lesion in the region of the source of nutrition for the organ. Hence in case of the palpitation resulting from uterine disorder a lesion should be found in the region of innervation to the heart, or in those structures which may directly affect the heart. And such is the case. If our contention be valid the reflex impulse is but the exciting cause, the lesion, the predisposing; neither alone being suffi- 84 PRINCIPLES OF OSTEOPATHY. cient to destroy the cardiac equilibrium but acting conjointly are able so to do. It is a question whether a large number of so-called re- flex disorders should be considered reflex except in the manner suggested above. The occipital headache from uterine dis- placement will much more likely occur if there be a local lesion deranging the cephalic circulation; the "bilious" head- ache resulting from gastric disorder will usually present cer- vical lesion sufficient to cause the disturbance to appear; even the vomiting of pregnancy is often in direct proportion to the abnormal previous condition of the stomach. Hence let none rest content with the diagnosis of a "reflex effect." Prove that the local structural conditions are normal before sen- tencing the reflex mechanism as the sole cause for the dis- turbance. THE CAUSES OF LESIONS. For purposes of convenience we may classify the causes of lesions into external or environmental and internal. Among the former the most common is mechanical violence such as a blow, a fall, a mechanical shock or jar to the organism pro- duced in whatever way. It will be found on inquiring into the history of a vast number of cases of disease that the on- set of the disorder was noticed soon after having suffered the violence, and owing to this fact it is always the part of wisdom to inquire carefully into the history of the case. These mechanical causes act alike in producing bony, muscular,, ligamentous, or visceral lesions. A prolapsed uterus is often found to have its cause in a sudden mechanical jarring of the body. A luxated rib is a common result of direct pressure from without such as might occur in the strenuous periods of a football game or the less intense but more prolonged com- pression of certain steel braces constituting a part of the wardrobe of the modern woman. A sudden attempt to pro- tect one's self from falling will account for a strained muscle, a sprained articulation, or a sub -luxated vertebra. A second THE ETIOLOGY OP DISEASE. 85 important external cause is in that of temperature change. In order that a thermal condition shall produce its effect on re- sponsive tissue it must be a sudden change and usually a change from a higher to a lower temperature. "While experimental physiology indicates the possibility of a contracted muscle dependent on a change from a lower to a higher temperature, little evidence has been produced to show that a similar con- dition is produced in the normal living human body under those circumstances. Lack of evidence however does not prove that the contraction may not be brought about in the way suggested. With regard to the production of con- tractured muscles resulting from sudden exposure to cold atmosphere or a cold draught, all osteopaths are agreed in emphatic affirmation. In experimental physiology it can be shown that an isolated muscle so exposed to cold does con- tract and it would seem altogether reasonable that a similar condition should result in the case of the far more responsive living, attached human muscle. While it is agreed that muscle protoplasm is the typical variety that responds to a stimulus by definite and measurable change of shape it is not at all unlikely that other soft tissues of the body respond in the same way although not to the same degree. The primary effect in point of time and importance, then, will be the pro- duction of a muscular lesion. But remembering the intimate relation existing between muscles and other tissues it is easily understood how a bony or ligamentous lesion may come about as a consequence of a muscular contracture. A musole can- not contract without an approximation of the structures to which the muscle is attached. Hence if it be a spinal muscle a vertebral lesion will be produced, or if it attaches to a rib the rib will be depressed or otherwise disturbed. Of the internal causes of lesions posture of the body may be mentioned though perhaps with equal propriety it might be classed under external causes. Especially is this operative in the case of children and young people, the most common form of lesion which results being a curvature of the 86 PRINCIPLES OF OSTEOPATHY. spine. Any cramped or distorted position assumed for long periods at a time will with a fair degree of certainty result in a gradual change in the relation of parts. The continual bending over the desk at school is undoubtedly accountable for numerous spinal disorders. Professions and trades which require the assumption of peculiar positions furnish their quota of patients with characteristic lesion. The dorsal in- clination of the head in the process of lathing a ceiling, the stooped position in shoveling, the stooping of the compositor at his case, and the anterior lumbar curve assumed in order to acquire the so-called "erect form" are all illustrations of the point. In all of these there is a uniform force continually acting in a definite direction, the inevitable result being in the case of yielding human tissue, definite changes in structure. Nutritional disturbances are internal causes which com- prehend a variety of specific conditions such as congestions, anaemic states, and nerve irritations. These in'most cases are further dependent upon an adjacent structure but it be- comes necessary to seek for the cause of the congestion. Nerve irritation may initiate changes which produce muscle contracture or ligamentous thickenings but the cause of the irritation must be sought for elsewhere. An overworked organ through a resulting hypertrophy of its tissue will become a lesion. Not only will viscera act as lesions from congestive conditions but a muscle will become contracted through im- pulses transmitted by reflex pathways from the viscus. In prac- tically every acute case with which the osteopath comes in contact there will be found muscle contractures, in part pri- mary to the disease,. in part secondary to it. Is such a case possible? Observation by competent osteopaths indicate that such secondary contractures do occur. Is there any anatomi- cal and physiological explanation for that condition? Un- questionably. By the known anatomical facts of central as- sociation between spinal nerves and visceral nerves and the known physiological facts of the radiation of impulses from one part of the spinal cord to another, a reasonable explanation is THE ETIOLOGY OF DISEASE. 87 not difficult. Afferent impulses aroused by a disturbed viscus will be transmitted and given up to the spinal cord and possi- bly to the sympathetic ganglion, from both of which centers efferent impulses, motor or vaso- motor, pass to the spinal muscles. That such an explanation is reasonable is further suggested by reference to Head's law relating to sensory nerves. The law suggests an intimate relation between af- ferent nerves closely connected centrally; and knowing the peculiarities of reflex action it requires little tax on credulity to assume a similarly close central connection between an af- ferent visceral nerve and an efferent motor nerve. Conges- tion or other nutritional disturbances in the muscle tissue will undoubtedly lead to a contracture. Experimental investiga- tion in the laboratory shows that weak acids may be efficient stimuli to the contraction and it is to be noted that just such a condition is present in venous congestion or in the fatigued muscle. Venous blood, always less alkaline than arterial, becomes appreciably acid under various circumstances of the organism, due to the presence of carbonic or sarcolactic acid, the latter a common product of excessive katabolism. An excess of arterial blood in a muscle may be an efficient stimu- lus because of increasing its metabolic processes or because of soon becoming of a venous nature due to stagnation. This latter state may easily follow from a disturbance of the vaso- motor mechanism known to be associated with muscles as with all other parts of the organism. In fatigue of muscle from overwork or other cause we have conditions entirely favorable for the production of the special form of contract- ure which is so well known to the osteopath. Here the excess of katabolic waste including the sarcolactic acid referred to may easily be sufficient to produce the effect. On the other hand ansemic conditions may easily be responsible for abnor- mal states of the muscle and the cause of the lesion, though this is perhaps a more debatable proposition. 88 PRINCIPLES OF OSTEOPATHY. CHAPTER V. ETIOLOGY OF DISEASE (CON.) ABUSE OF FUNCTION. Osteopaths make no claim that there are no possible dis- ease conditions from other than structural perversions. Any one will recognize the fact that by abuse of any organ or its function departure from normal action may result. Indeed every life is a continual fluctuation between a normal and an abnormal condition so that it becomes evident that disease is but a relative term. If, as we recognize is true, a continued excess of carbon dioxid in the blood constitutes a disease, shall we decide that the amount necessary to arouse increased respiratory activity is a disease? That condition continues for an appreciable length of time and in so far as it does so continue it is normal. But on the other hand it is a normal stimulus to the respiratory activity and for ordinary purposes of discussion would not be considered disease. The organism is able to adjust its functioning immediately. What is true of the case of respiration is true of the body as a whole. The struggle between organism and environment is a ceaseless one in which the organism is usually triumphant, but there are times when the environment temporarily gains the su- premacy. In these cases enough of a departure from normal is apparent to be dignified by the term disease. It is this condition that is present in abuse of organ or its function. The excess of food, the overwork of muscle, the contaminat- ed air, all represent what is foreign to the organism, and as such stimulates it to an unusual response. In the vast major- ity of cases the organism will be victor though no external aid is given. At least 75 per cent of acute cases will be over- come without treatment of any kind. In every case the full THE ETIOLOGY OF DISEASE. 89 responsive power will be exerted in the attempt to overcome. If the stimulus is too intense or prolonged, disintegration of the organ will result. The duty of the physician in such cases is to secure and maintain such a condition of organism and environment as will allow the fullest freedom to the re- sponsive power of the organism. Of prime importance in this connection is the prevention and overcoming of secondary lesions. This with the additional attention to ordinary laws of hygiene and sanitation will usually suffice to enable a return to the usual grade of organic action. The abuse that will cause disease may depend on oveiv use in time relations. That is, the function evidencing itself through too great a proportion of the allotted time to allow for repair, will ultimately be disturbed. This disturbance may be in the nature of a hypertrophy of the organ that per- forms the function. An overused muscle will become en- larged as in case of the heart following aortic stenosis. A liver in an individual who constantly overeats will ultimately be somewhat increased in size. The constant abuse of the stomach may result in a thickened mucosa. In numerous of these cases the fact must be noted that the hypertrophy is in part physiological; for instance the hypertrophied heart is a necessity under the existing circumstances, i. e., the aortic stenosis. At the same time it is secured at the expense of a continual tendency toward the production of disorder in neighboring structures, for instance impaired respiration de- pendent on lung pressure from the enlarged heart. Sec- ondly, exhaustion will be a common result from abuse in point of time. In the case of the enlarged heart so long as "com- pensation" is maintained, little difficulty may be experienced, but usually the time comes when all reserve forces have been drawn upon, the heart is no longer able to increase its sub- stance to meet the increased demands, and exhaustion of its energy rapidly follows. The gastric glands, continuously called upon to do excessive work, will finally yield to the in- evitable and fail to supply the requisite amount of digestive 90 PRINCIPLES OF OSTEOPATHY. fluids. In any of these cases a third condition is likely to re- sult, i. e., that of atrophy. In this connection note the wast- ing of heart muscle following the period of "broken compen- sation," the thinning and waste of substance in the walls of the stomach, or the final condition of atrophy in an over- worked liver. Again the abuse may be overuse in intensity. Apoplexy resulting from sudden increase in blood pressure from over exercise of body or mind is a case in point. An aneurism is similarly caused. The excessive lifting, athletic efforts and the like may produce strains and ruptures in various of the body tissues. This does not include the cases where a pre-existing weakened condition makes the sudden strain, but an immediate or exciting cause, as for instance, the usual arterio- sclerosis in those individuals subject to apoplectic attacks. Instead of overuse constituting the abuse, underuse may result in a disorder. It is a well known fact that a mus- cle kept inactive for a considerable period will gradually waste away. This is true not of muscle only. It seems to be a fundamental biological law that a structure unused will become incapable of use and if evolution be accepted as proven we may explain the gradual disappearance of struct- ures in man and other animals on the basis of disuse. Note in the case of the lungs of an individual who contracts "lazy habits of breathing", that they are much more susceptible to disorders than are those of him who breathes naturally and deeply. The apices are the regions of lung tissue most com- monly involved in tuberculosis and involved first in point of time. The apex is the least exercised of all parts. The two facts may be closely associated. Again, proteid food sub- stances furnish the most efficient stimulus to the secretion of pepsin by the gastric glands. The consumption of pre-digest- ed, i. e., pepsinized foods may constitute a definite abuse through furnishing lessened exercise of the peptic glands with a consequent atrophy of those structures. THE ETIOLOGY OF DISEASE. 91 Finally we may speak of abuse in the form of perverted use of a function. The teeth are structures designed to grind the food materials. If that function is given to the stomach, through improper mastication, there is a perverted use of the stomach. Life in an environment of impure air, noxious vapors, and dust particles constitutes an abuse of the respira- tory function. According to the reports of certain witnesses in the recent coal strike investigation one of the causes of the shortened life period of the coal miner was the continued in- halation of coal dust. Numerous postmortems in the case of those who have worked for long periods in an atmosphere charged with metal or other particles, indicate the induration of the lungs from deposit of the material as a factor in the cause of death. Mouth breathing is a perversion and is ac- countable for occasional disorders of the respiratory or upper digestive channel. The introduction into the body through any pathway, of a material foreign to the organism consti- tutes a perversion. Hence drugs taken into the alimentary canal, pathogenic bacteria with their toxins and all other forms of poisoning constitute abuse conditions in the nature of per- verted use. In a large number of such cases the cause is of an exciting character, a predisposition being present which impairs the responsive power of the organism. This is es- pecially true of micro-organisms, a discussion of which is given in a further chapter. PREDISPOSING AND EXCITING CAUSES. The causes of disease may further be classified in ac- cordance with their relative capacity to produce disorder without the aid of any other factors, into predisposing and exciting. This classification is not an absolute one but may be used with advantage for purposes of convenience and better understanding. A predisposing cause is any con- dition of the organism or its environment which, while not producing sufficient disorder to constitute disease, renders the organism more susceptible to other causes. As illustra- 92 PRINCIPLES OF OSTEOPATHY. tions of such may be mentioned the following : in hay fever two conditions seem to be essential in the production of the characteristic symptom, an irritable condition of the nasal mucosaand a specific irritant, e. g., pollen from some certain plant, dust particles, and the like. The weakness is more or less continuously present, the specific irritant only at special periods. In this case the irritable mucosa with whatever has caused that condition, e. g., a lesion in the cervical region, constitutes the predisposing cause, the pollen or dust particles representing the exciting cause. Neither of these two is capable alone of producing the attack but acting conjointly are sufficient. The small boy is noted for his craving for green apples. If a lesion be present in his splanchnic region and he indulges the craving, an attack of cholera morbus is the result. In this case the green apple represents the "last straw" added to a stomach weakened from vasomotor dis- turbance maintained by the splanchnic lesion. A depressed thoracic region by limiting the amplitude of the respiratory movements renders the lungs less able to resist tuberculosis infection, the tubercle bacillus acting as the immediate cause of pulmonary consumption, the former the predisposition to the disorder. Pulmonary troubles tend to run in families. It is not the inheritance of the specific condition but the peculiar- ity of lung or chest structure. Most reflex disorders are satis- factorily explained from this double cause standpoint. For instance a common accompaniment of uterine disorder is pal- pitation of the heart. Such a disturbed heart rate is much more likely in an individual with a spinal lesion in the cardiac area than in one where heart control is not interfered with. Age, sex, temperament and race relating to the organism, and climate, season, atmospheric and other environmental circumstances may constitute predisposing causes or occasions. It is com- mon knowledge that children are more susceptible than adults to measles or scarlet fever, while arterio- sclerosis, paralysis agitans, and numerous other disorders only affect the adult or aged. The peculiar condition of the organism at these THE ETIOLOGY OF DISEASE. 93 different periods constitutes a predisposition. The Negro race is more susceptible to tuberculosis and less so to yellow fever and malaria than is the Caucasian ; and this by virtue of some inherent difference in the organism which is without satisfactory explanation. Climate is accountable for special disorders. Catarrhal affections of the respiratory tract are common in cold, damp, and changeable localities, while typhoid and other fever conditions are associated with late summer and autumn, in each case predisposing to the onset of the disease through the agency of various exciting stimuli. A point to be noted in this connection is the fact of what we may conveniently speak of as a reversibility of causes. That is, a lesion which in one set of circumstances constitutes a predisposition, may in another be an excitant. Note the case in hay fever. An individual manifests a lesion in the cervical region. Passing to that period of the season when pollen is plentiful the attack is initiated. In this case the lesion is predisposing, the pollen exciting to the disorder. Another individual continuously living in a pollen-laden atmosphere is unaffected thereby. But a lesion is produced when the attack at once supervenes. Thus predisposition and excitant have been reversed. Climatic condition may be the excitant or a predisposing cause. In the first case a lesion is present rendering the nasal tissues susceptible to the in- fluence of sudden changes of temperature the latter being the excitant of the disorder ; on the other hand an individual living in a changeable climate is predisposed to catarrhal dis- orders by virtue of the environment, the catarrhal condition itself being excited on the production of a specific lesion. An individual with a normal splanchnic region may continually abuse his stomach by overeating and still no gastric dis- turbance result but on the production of a lesion disorder soon becomes manifest ; on the other hand an individual with a lesion in his splanchnic region may show no marked evidence of stomach trouble but on abuse of his stomach by dietetic errors disease occurs. 94 PRINCIPLES OF OSTEOPATHY. It is to be noted further that while a predisposing cause of disease usually will not be sufficient to produce the disease, an excitant may produce it with or without the addition of the other factor. While it is much more likely that disease will result from the eating of green apples in the case of a child who shows specific splanchnic lesion experience would indi- cate that the green apples alone is an efficient cause. Finally it is to be noted that in a large number of disease conditions of any permanency in time they are dependent not on a single cause but upon numerous factors in which numer- ous lesions and numerous forms of abuse may be concerned in the various relations of predisposition, predisposing occa- sions, and exciting causes. (For an excellent discussion of "Summation of Causes in Disease and Death" see October, 1902 issue of the Journal of the American Osteopathic Asso- ciation, by E. R. Booth, Ph. D., D. O.) THE GERM THEORY OF DISEASE. It seems proper at this time to discuss a problem in rela- tion to disease which has in recent years assumed extreme importance. The germ theory of disease is not at all a new explanation of disease conditions, for ever since the inven- tion of the compound microscope in the middle of the seven- teenth century the fact that small forms of life were associ- ated with certain diseases has been known ; and not only was this association known but shortly following the discovery of the micro 'Organisms the doctrine of a causal relation be- tween such micro-organisms and the disease was promulgated and, as suggested by Abbot, amounted almost to a germ- mania. But like numerous other facts and theories based upon those facts this was practically lost sight of until late in the nineteenth century when it was again revived by numerous investigators of world -renown among whom the names of Pasteur, Klebs, and Koch stand pre-eminent. These, with others, placed the theory upon fairly sure ground in showing by methods to which no objections could be raised THE ETIOLOGY OF DISEASE. 95 that in certain cases there is such a definite relation be- tween the pathologic condition and the presence of the micro-organism. The question is not yet entirely settled as to the nature of that relation. Is the disease as it exists respon- sible for the presence of the micro-organism or do the bacteria pro- duce the pathologic condition? In accordance with these two ideas the micro-organisms have been classified into the saprophytic, or those which live only upon refuse matter and are hence beneficial to the organism ; and pathogenic, or those which by virtue of some deleterious action definitely produce the disease condition. Doctor Still has insisted that all are of the former class and compares them to buzzards whose function in the larger world than man is to render dead and decaying material incapable of further harm. In this as- sumption we are personally convinced that he is essentially correct, and that this view is not foreign to that of a large number of the best thinkers and closest investigators of today is becoming more and more evident. Admitting for the time that certain forms of bacteria to produce disease the question arises as to the manner in which it is effected. It has been explained on the theory little supported by fact, that the micro-organism abstracted the nutritive material and thus robbed the tissues of their source of supply; another explanation is that by their rapid multiplication a direct mechanical blocking of the channels and spaces of the body was produced with the resulting abnormal tissue changes; a further suggestion of some value is that the bacterium directly attacks and destroys the body cells including but not limited to the white corpuscles ; the explan- ation at present given and one that more nearly meets the requirements of all cases is based on the fact that in the rapid propagation of the organism toxins are formed which act in a definitely destructive way upon the tissue cells. In so far as the bacterium is responsible for disease or compli- cates the condition already present any one or more of these 96 PRINCIPLES OF OSTEOPATHY. several explanations may be correct but the last is undoubt- edly of paramount importance. Admitting, then, that inasmuch as the micro-organisms are present in disease and the toxins are produced which are destructive to living tissue, it is yet sufficient to say that the micro-organism is the essential cause of the disorder. While the germ theory was being pressed into service there were individuals who insisted that bacteria were already present in the tissue of normal individuals. The germ theorists them- selves in attempting to show the fallacv of this position have estab- lished a firm foundation for the claim that the micro-organism is not of itself sufficient cause. Note the significance of the fol- lowing statement from Abbot's Principles of Bacteriology: "Under careful precautions against which no objections could be raised the experiments of Billroth and Tiegel were repeated by Pasteur, Burdon, Sanderson, andKlebs, but with failure in every instance to demonstrate the presence of bac- teria in the healthy, living tissue". Why are they not present in healthy, living tissue? We believe the only answer possible s that absolutely healthy tissue is incompatible with the pro- pagation of the bacterium. The following facts are also sig- nificant : in any epidemic of diphtheria there is little difficulty in demonstrating the presence of the pharyngeal mucous membrane of normal individuals, the Klebs-Loffler bacillus; the micro-coccus lanceolatus is present in the sputum of many individuals not affected with pneumonia; even in cholera asiatica unaffected individuals may show the presence of the comma bacillus of Koch in the mucous of the intestinal canal. Why are not these affected? Why is not every individual stricken with the disease that passes through the community as an epidemic? The only possible answer is that they are immune and immunity proves nothing less than that the bacterium cannot be a sufficient cause of disorder. A few suggestions regarding the nature of immunity may not be out of place. It is spoken of as being natural or acquired. For instance in the case of the Negro comparative THE ETIOLOGY OF DISEASE. 97 immunity to yellow fever and malaria is noted ; many indi- viduals are never attacked with the small pox virus although they are continually exposed. These have a natural immun- ity. But it is further noticed that in many of the infectious diseases one attack renders the individual immune to a sec- ond, in which case the immunity has been acquired. There are three principle factors which secure to the individual such immunity. The first is the phagocytic action first empha- sized by Sternberg and later by Metchnikoff. This con- sists in the independent action of the white blood corpuscles by virtue of which it is enabled to flow around and digest the bacterium, in which case there is a germicidal action; a sec- ond factor is the antitoxic conditions secured by cell secre- tions which render the micro-organism incapable of poison- ing the organism ; and last the blood and tissues are aseptic partly because of their alkalinity which is sufficient to render conditions unfavorable for the development of most of the pathogenic micro-organisms and partly because of the pres- ence of nucleinic acid which is also unfavorable. These three factors are obviously dependent upon normal blood and hence it is that the blood is said to be aseptic, germicidal, and antitoxic. In case these several factors are not present in their full efficiency and the individual succumbs to a first attack, this of itself usually is a sufficient stimulus for pro- ducing the full efficiency of each factor and hence no second attack is probable. Meltzer, quoted by Vaughan and Novy in their work on * 'Cellular Toxins", sums up the organism's defense against bacteria in these words: "I maintain in the first place that in the struggle against bacteria the defense of the body is not carried on exclusively or chiefly by a single element. It is neither the body fluids nor the leucocytes nor the other cells alone which can claim the exclusive merit of maintaining the health of the body, but each and every one of them has its variable share in attaining the desired end Let us take as an illustration the protection of the conjunctival sac. 98 PRINCIPLES OP OSTEOPATHY. It is nearly in direct contact with the air and we might expect to find there an extensive bacterial settlement. Nevertheless Lachowitz and Bujwid found that in 69 per cent of cases the conjunctiva was perfectly sterile. The factors which accom- plish this sterility, or at least comparative sterility, of bacte- ria are : The reflex which causes the closure of the lids at the approach of dust (the carrier of bacteria); the blinking which occurs regularly a few times in a minute, which in conjunction with the lachrymal moisture throws out again mechanically the already landed bacteria; and finally, the bactericidal effects of the tears destroys the balance of the invaders. Or let us take the respiratory organ from the larynx down to the respiratory tissues including the corres- ponding lymph glands Through this path the out- side world stands in an intimate relation to the interior of the body, inasmuch as the air column is separated from the lymphatics and capillaries of the lungs merely by a single layer of the very thin epithelium of air cells. Even the se- rous cavities are separated from the lymph spaces by thicker layers. This arrangement is of course indispensable for the proper exchange of the blood gases with the air. But what prevents the bacterial invasion of the interior of the body by this open and direct way? Moreover, most of the writers agree that trachea, bronchi, and lung tissue of healthy ani- mals are entirely sterile. In a number of rabbits under morphine anaesthesia I found all these parts to be sterile. If one vagus or a laryngeal branch was cut then the upper part of the trachea contained bacteria but not .the lung. When both vagi were cut, then of course the lungs, too, were invaded. Jundell reported recently that by means of a special device he was able to test the human trachea and found that in the majority of healthy cases the region below the glottis proved to be sterile. What protects this path? In my opinion the result is accomplished by the cooperation of the following factors : The tortuous part of the respiratory path lying above the glottis removes perhaps the greatest THE ETIOLOGY OF DISEASE. 99 part of the bacteria contained in the inspired air column and the remaining number is, under normal conditions, just small enough to be disposed of by the factors present below the larynx. Bacteria which pass the glottis are either carried back outside of the glottis from the trachea and the bronchi by the steady movements of the cilia of the epithelium, or, if the germs are carried in the center of the air column down to the air cells, they quickly penetrate the thin epithelial layer and are immediately in the reach of the lymph glands, which take good care of them In connection with the respiratory path, I would like to recall here the interesting fact that both canals which lead farthest to the innermost of the body, that is, the respiratory and the female genital canal (which latter terminates in the peritoneum) have ciliat- ed epithelium, the movements of the cilia being outward and are as far as the epithelium extends, entirely or nearly sterile." In general, then, we arrive at the conclusion to which the old school physicians must come and in goodly number are already coming, that first, assuming that the bacteria may be able to gain access to the body substance, vitiated tissue is a necessary prerequisite before the bacterium may excite the specific disorder, and that second, the treatment must be di- rected to overcome the cause of this vitiated tissue, which is usually a lesion or abuse, and to assist the organism in keeping up its strength to overcome the bacterium or its products which constitute the exciting cause. It would seem therefore that the anathemas -hurled at the germ theory advocates by certain osteopaths are entirely un- called for. The position of osteopathy is impregnable regard- less of the ultimate demonstration of the exact relation be- tween bacteria and disease. If .it be shown that all such micro-organisms are simply associated and not causal factors, well and good. If the causal relation be established, it is no more true of them than of numerous other elements of en- vironment that they may promote disease. Continued life in 100 PRINCIPLES OF OSTEOPATHY. an atmosphere of dust certainly will cause disorder through abuse of the organs of respiration. An environment of ex- cessive microscopic life constitutes an abusing factor in the same way. The organism will be successful,8o far as success is at all possible, as long as the machinery through which life manifests itself is kept in its structural integrity. LEGE ior FH'.'SfCf/: THE DIAGNOSIS OF DISEASE. 101 CHAPTER VI, THE DIAGNOSIS OF DISEASE. THE SYMPTOM. Diagnosis consists in the determination of the location and nature of disturbed conditions. The osteopath recognizes the value of symptoms in that diagnosis. A symptom or group of symptoms does not constitute disease but is only the evidence that disease exists. That rule of practice is a con- fession of failure to trace the symptom to its cause, to treat the symptoms as they arise. It is only in occasional cases that it is necessary or advisable to treat symptoms and even then it is but incidental. The symptom, is an effect and a logi- cal, a legitimate, and under the circumstances a physiological effect. It is as much a matter of physiology that the heart rate should be increased when peripheral resistance is at fault as that the heart should maintain a normal rate under normal conditions of peripheral resistance. Pain is a physio- logical condition under the circumstances of pressure or other cause of sensory irritation, and it is markedly true of pain, that by its presence protection to the organism is secured. In the first place pain is a warning to the consciousness of the individual that something is wrong; second, the location of the pain together with the transference of the sensation gives fairly accurate location of the disturbance; third, pain in numerous cases enforces rest, thereby securing better op- portunity for organic repair; and fourth the pain condition by causing directly or indirectly or reflexly increased activity of other parts of the body may further aid in processes of repair. In the case of high temperature we have a condition that is directly advantageous to the organism in many in- stances. We know that in numerous fever conditions certain I I ' 102 PRINCIPLES OF OSTEOPATHY. pathogenic micro-organisms play an important role, not necessarily in acting as the original cause for the disorder, but at least in complicating the condition. By laboratory ex- periment and clinical observation it is found that with many forms of bacteria a high temperature is directly antagonistic to their development. Hence, the high temperature, while a definite symptom of a disorder is in addition a definite pro- tection to the individual. In an equal degree the profuse sweat which is often associated with fever cases is an ar- rangement whereby a temporary respite is given to the patient from the great discomfort due to the temperature. In the evaporation of the perspiration, the patient is temporarily re- lieved. In some cases, as in acute articular rheumatism the sweat is distinctly acid, and as such represents an excretion material. This suggests that the profuse perspiration is an aid to body purification. The chill, also often found in con- nection with various acute cases represents a physiological principle. If a case of malarial fever be examined just at the beginning of the period of the chill, it will be found that the temperature of the body is below the normal. If observa- tion be made shortly after the chill period, or even before that period ceases, a considerable increase in the temperature will be noted. Hence, the chill is a method for increased heat production a thing necessary under the circumstances. We know that most of the body heat results from oxidation pro- cesses taking place in active muscle tissue. In 'the chill we have a rapid contraction and relaxation of the muscle tissues of the body with the consequent elaboration of heat. Accord- ing to Lowy, (Schafer's Physiology) the simple process of shivering may increase the metabolism of the tissue 100 per cent. Since the chill is but an exaggeration of the shiver, the explanation of the increase in temperature becomes obvi- ous. In the convulsion we have still another condition where it is probably true that a physiological purpose is fulfilled. Dr. Still has repeatedly emphasized the fact that the muscular spasm is but nature's effort to produce a re-distribution of the THE DIAGNOSIS OF DISEASE. 103 forces and fluids. Note the extreme quiet that follows the epileptic spasm. For several hours there is deep sleep dur- ing which, recuperation is in progress. Vomiting and diarrhoea are symptoms indicating that there is disturbance to the nerve terminals in the diges- tive tract. But both are physiological. By the vomiting process the organism rids itself of material which if allowed to pass into the intestinal canal would create further disorder; while the rapid peristalsis associated with the diarrhoea car- ries onward material, which, having gained entrance to the canal is directly irritant. By this increased motion absorp- tion of the irritating material is naturally lessened, and hence, a definite protection is provided. The anorexia which is likely to be associated with both these conditions, is a dis- tinct protection in that it militates against taking into the alimentary canal additional material before the canal has cleansed itself of the irritant and before the assimilative pro- cesses are again in condition to function properly. In such a case, the absence of desire for food should be sufficient warn- ing to refrain from partaking. The warning is often in- creased by a definite nausea which is produced by the mere sight or thought of food. Needless to say, the warn- ing should be heeded, and yet, as a result of years of false teaching, there are many who utterly ignore the warn- ing and insist on forcing food materials upon a proper rebel- lious stomach. The rapid respiration in pneumonia is another typical symptom. It undoubtedly is a favorable condition under the circumstances. For in this disorder one lobe of the lung becomes incapacitated because of an infiltration into the air sacs and bronchioles of a material through which air cannot pass. As a result the lobe becomes solidified and compara- tively little movement is possible. But the demand for oxy- gen is just as great as before, hence, in order to keep up a proper supply other parts of the lung must be over active. Hence, by this hyper- activity the organism is protected 104 PRINCIPLES OF OSTEOPATHY. against a deficiency of oxygen that would otherwise result. In a similar manner increased activity of the heart muscle is called for when a valvular deficiency occurs. In order to keep up a normal circulation with deficient valves, there must be an exaggerated heart action. Clinical experience shows this to be the case. And not only does the heart increase its rapidity but it also increases its substance, purely a matter of accommodation resulting from the excess of action. Hence hypertrophy of the heart, while a symptom of organic cardiac disorder, is also a definite protection against failure of the circulation an evil much greater than an enlarged heart. Glycosuria, as it is found in diabetes is a definite symptom of liver or pancreatic disorder. It ought to be pre- sent in such a case. In fact the rather abrupt cessation of this symptom in a serious case of disease is a cause for alarm. For, if the sugar is present in excess in the blood, various fermentation processes will be inaugurated with the production of acetone and other substances favorable to the development of diabetic coma. When the sugar begins to accumulate in the blood it is the function of the kidney to throw it out, and so long as this is kept up the disorder may not be a serious one. The failure of the kidney to excrete is the cause for alarm. Associated with the ex- cess of sugar in the urine there is an increased quantity of the latter excreted, as much as twenty pints or more has been noted. Under the circumstances this is necessary. In order to keep the excess of sugar in solution, fluid must be supplied. The greater the amount of sugar present, the greater will be the amount of water excreted with it to hold it in solution. In this case, the symptom is an undoubted protection. In many inflammatory conditions there are certain appearances which suggest a definite protective action. It has been asserted with a good degree of evidence that the serous exudate in an inflamed area is a factor that tends to THE DIAGNOSIS OF DISEASE. 105 reduce the pain condition and assist in the healing process. In the case of an inflammation of a mucous surface, as in all catarrhal conditions, there is an excess of mucous secreted. This is unquestionably in most cases a decided protection. The ex- cessive blowing of the nose in an ordinary acute nasal catarrh is a detriment from this very fact. If the material is per- mitted to remain in contact with the mucosa, the healing process will be hastened. In croupous inflammations such as diphtheria, the removal of the membrane is decidedly contra- indicated, unless it forms so rapidly and in such amount as to offer serious obstruction to respiration. It is undoubtedly, as indicated by clinical experience and by abstract reason, a real protection to the raw surface which is exposed on remov- ing the membrane. Cases might be multiplied indefinitely where a peculiar appearance usually mentioned as a symptom, is not only the latter, but also is a protective means employed by nature. Not that every symptom is necessarily a benefit to the organ- ism or that it is evidence that the latter is making the attempt to overcome the disorder. In fact we know that to all appear- ances there are certain secondary changes that arise which are a disadvantage to the organism. But there are cer- tainly enough cases where a real benefit is derived to warrant the greatest of care in determining whether a symptom should be combatted. Certain it is that the rule of practice to "treat the symptoms as they arise" has no place in the philosophy or practice of the osteopath. While it is thus true that in many cases the symptom has a definite value aside from the fact that it is a key to the nature and location of the disease, it is with reference to this latter consideration that the physician finds it of decided practical value. Disease in large part is determined by symptoms, and we may define a symptom as any unusual manifestation in structure or function that suggests disease. The symptom, in case it is one noted only in the sensations of the patient, may be subjective, or where noted by physician 8 106 PRINCIPLES OF OSTEOPATHY. or other observer, is objective. As an instance of the former, pain is typical ; of the latter the coated tongue in digestive disturbances, the contractured muscle in spinal lesions, or albuminuria in case of nephritis. Of the classes of symptoms, subjective and objective, the latter is the one relied upon for determining the details ; the former, although customarily first used in point of time, is unsatisfactory. This is true because the subjective symptoms are subjective. Feelings are unreliable signs. The location of the disorder may be far remote from that which is apparently indicated by the sensation. The further fact that in numer- ous cases patients are unable to locate the sensation or are unable to give an accurate description of its ntaure, increases the difficulty in the way of a satisfactory diagnosis from sub- jective symptoms. On the other hand the conditions that can be seen and felt objectively by the physician constitute fairly accurate indications of the disorder, while the tenderness on pressure which is manifest on physical examination gives quite accurate data for legitimate conclusions. METHODS OF EXAMINATION. The methods of examination objectively are those in use by physicians of all schools although the osteopath empha- sizes one, palpation, above all the others. First in point of time is the method by inspection, which consists in observ- ing various changes in the appearance of the body, its func- tions and its products, by the sense of sight; for instance a coated tongue ', a sallow complexion, and a high colored urine are seen; by inspection lesions are determined, at least in general, as in the case of the carriage of the head in torticollis, the in- version of the toe in a dorsum dislocation of the hip, or a contractured muscle and deviated spinous process in a spinal disorder. Palpation is the second method in point of time but first in point of importance and consists in determining conditions by the sense of touch. For instance by palpation we may THE DIAGNOSIS OF DISEASE. 107 note an increased cardiac impulse, a difference in the respira- tory movement of the two sides of the chest, a ttimor of the ab- domen, a high temperature in fever conditions, a contractured muscle, a luxated rib, or a limited movement in articular struc- tures, and by pressure upon a part, though not by the sense of touch of the diagnostician, differences in sensory conditions of the patient may be determined. Osteopaths pride them- selves upon the delicacy of their sense of touch and it is well they should, because by no method can the lesion be deter- mined so satisfactorily or certainly as by palpation. If one of the various methods should be developed at the expense of others that one is palpation. It is characteristic of the founder of osteopathy that he makes use of palpation almost to the exclusion of other methods, and his ability to detect structural changes with little difficulty by his sense of touch is common knowledge. That there is large possibility of de- veloping that sense will be admitted by all, but to the osteo- pathic practitioner the fact becomes more and more striking as his experience and observation extend over a larger period and a wider field. A third method of objective diagnosis is percussion. This consists in the comparison between the sounds produced by a series of light blows over the normal organ. Every or- gan or structure will have its specific percussion note which is determined by its density and its relation to adjacent struc- tures or cavities which act as sounding boards or resonance chambers. Various names are given to different grades and tones of the percussion note; thus we speak of the resonant note of the normal lung, the dull note of the liver, the^a/ note of abdominal dropsy or the tympanitic note of the stomach distended with gas. The methods of percussion are immedi- ate (direct), or mediate (indirect), in the former of which light blows with the fingers or small mallet are delivered directly on or over the tissue ; in the latter which is most commonly used a pleximeter is interposed between the structures per- cussed and the fingers or mallet. 108 PRINCIPLES OF OSTEOPATHY. By auscultation the sense of hearing enables us to de- termine disordered conditions of various of the organs, though by this method the sounds produced by the organs in their functioning furnish the evidence. A change from the usual nature of the sounds of the heart is indicative of cardiac dis- order; the respiratory murmur gives evidence of a normal or abnormal condition; the rumbling sounds produced in the in- testines technically spoken of as borborygmus suggests over- active fermentation; or the friction sounds produced by the approximated pleural layers denotes the dry form of pleuritis. Mensuration is a method much employed by osteo- paths not so much perhaps in the way of definite tape-line measurement which is often helpful and occasionally essential, but by comparison in size and shape of paired or symmetri- cal structures . The difference in size between the sides of the chest is often noticed ; the difference in the width of the ilio-costal spaces is valuable in numerous cases; the shortening of a lower limb through lesion at the hip or pelvis will be noted by measurement or comparison ; or the increased cir- cumference of the shoulder joint will be diagnostic of a dislocated shoulder. These five methods modified and aided by pressure and rota- tion of parts will either singly or collectively yield sufficient data to indicate the essential nature of most of the disordered conditions with which the osteopath meets. All of them have their uses and their special value and the osteopath who entirely neglects any will certainly find occasion to regret his inability to make satisfactory use of that method. We shall not further discuss the question of symptoms in the diagnosis of special diseases, for that is not within the province of this work. It will, however, be entirely within the province to take up for discussion the diagnosis of lesions. A consideration of this question is distinctly and peculiarly osteopathic since it is only the osteopath who has recognized the existence of the lesion, at least in the special use of that term which has been indicated in another chapter. THE DIAGNOSIS OF DISEASE. 109 THE DIAGNOSIS OF LESIONS. The special and limited meaning of lesion is an osteo- pathic creation and hence it will be necessary to go quite into detail in the discussion of the factors entering into the determination of the presence of a lesion in any specific case. The fact has been emphasized that not every mal-position of bony or other structures constitutes a lesion. In a few cases such a condition may be the only evidence of lesion and still be a real lesion in the two-fold idea assigned to that word, i. e., structural change producing functional disorder, but in the majority of cases with which the osteopath deals there will be other evidences which substantiate the diagnosis. Further, in this discussion we shall not take up in detail the different forms of lesion as they may exist separately bony, muscu- lar, ligamentous, visceral but shall limit the consideration to a typical case where there is a combination of the first three named. For it cannot be too strongly emphasized that in most conditions of skeletal disorder the three will be asso- ciated in the causation of the functional perversion. In the discussion the presence of such an association is assumed, and the points essential in the diagnosis of that condition will be indicated. There are two fundamental principles to be noted in the method of making an examination of any part of the body, the one of which will tend to prevent pos- sible error arising from the other. The part should be ex- amined in its functional activity. A perverted function will be manifest in the appearance of the action of the organ which performs the function. In torticollis or wryneck the sterno-mastoid muscle presents an appearance when in action entirely different from that while at rest. Comparison of the muscle in the horizontal position with it in the erect position of the body will suggest facts that otherwise would escape attention. In the horizontal posture the neck muscles will be in functional rest. In the examination of a hip the action of it should be noted, but in addition the position of its vari- 110 PRINCIPLES OF OSTEOPATHY. ous parts should be determined by palpation during its rest. The movement of the chest should be noted and compared with that of a normal action, in addition to noting the posi- tion of the ribs while in expiration and pause. The move- ment of the inferior maxillary may suggest the nature of the lesion more markedly than will an examination of it in the quiet state. Passing to the details in diagnosis it will be noted that the first evidence that a lesion exists is the perversion of function of some organ or structure, which is likely to be first discerned by the patient or some one other than the physician. The patient gives the information that he has functional disorder of some special organ. That fact indi- cates in general the part of the organism where lesion is most likely to be found; if it be gastric disturbance the splanchnic or the vagal region will be suspicioned; if a uter- ine trouble, the lower thoracic, the lumbar or sacral struct- ures will first be examined; if the eye be impaired, the atlas and the upper thoracic is more likely disturbed. The general attitude is a factor in the determination of the approximate location of the lesion. Dr. Still has em- phasized the fact that the position that a patient assumes is normal to the existing structural condition, which is but a special applica- tion of the doctrine that function is normal to structure. To make a concrete case, suppose a lesion of considerable mag- nitude exists in the cervical muscles of the patient. The man- ner in which he carries the head' suggests a cervical lesion. If a rib be luxated the patient will sit in such a position as will secure him the least irritation. The careful way in which an individual afflicted with Pott's disease carries his body immediately suggests a spinal lesion. In all of these cases the position or the attitude is normal to the lesion, that is, it is such because the lesion or its effects compels it to be such. Hence the value, when a patient presents himself for examination, of making a preliminary survey of the individ- ual as a whole. THE DIAGNOSIS OF DISEASE. Ill The position of landmarks is a second point to be con- sidered. Having determined the probable region of the lesion by the method above described, a peculiarity in the positional relation between certain parts used as points for comparison may be noticed. If in the case of a vertebra, the relation of its spinous process to those adjacent may be al- tered ; the intercostal space, in case of a rib, may be found to vary in regularity throughout its extent, or may be narrowed or widened in comparison with those above or below; the lower margin of the liver, in a lesion condition of that organ, will be displaced. It seems necessary to emphasize the fact in this connection, that no greater mistake can be or has been made than that of assuming the existence of a lesion when- ever it is found that there is a variation in position of a structure. Reference has been made to the fact that structure as well as function can vary from the average within wide limits and still the condition be a normal one. While it is convenient to compare the body to a machine and insist that in both cases a variation of the slightest degree in structural parts will cause disorder in the one as in the other, the comparison is not illuminating if carried to extremes. The machine is an unyielding structure and has no power of adjustment, which makes the necessity for perfect structural alignment an ab- solute one. The living machine, on the other hand, is made up of yielding parts and has immense possibilities of adjust- ment to an abnormal structural change. The universal ten- dency on the part of the beginning student seems to be to make the assumption, unfortunate as that fact may be. In some cases it would seem that the apparant structural change is, of all the several evidences of lesion, the most unreliable. A further evidence of the presence of the lesion is the sensory change. While this usually takes the form of definite pain, in many cases it is of the nature of such pecul- iar sensations as anaesthesia, hyperaesthesia, or paraes- thesia; under the latter term is included the burning sensa- 112 PRINCIPLES OF OSTEOPATHY. tions, tightness of tissue, or of formication, i. e., sensation as of a small insect creeping over a part. Any of these may be present either at the local area of the lesion or may be re- motely situated and partake of the nature of transferred sensation. Pain is of such importance that we shall enter into detail showing its relation to lesion and disease. It has been de- fined as the "prayer of a nerve for pure blood", and this conception is apt in many cases. It is a sensation, perceived by the cerebral cells concerned with consciousness, produced by an irritation of some form to a sensory nerve. Without entering into the argument for or against the contention that there exist special pain nerves or special pain -receiving end organs, suffice it to hazard the opinion that any afferent nerve if sufficiently irritated will give the sensation of pain. Note the fact that the sensation is a brain sensation though it is usually projected to the part irritated. For instance the sensation from a burned finger is felt in the sensorium but the individual is entirely aware that the irritation is at the finger. With reference to this fact, note the want of logic in the reasoning of the individual who is content with giving a drug which renders the sensorium less capable of receiving or responding to the transmitted impulse. The pain is still present in so far as the nerve disturbance constitutes the pain. The drug has simply rendered the patient unaware of the existence of irritation. Pain, then, is a distinct advan- tage to the organism, and it is in relation to its advantage in the way of assistance in the diagnosis of the lesion that it will further be discussed. It is to be noted that pain may be direct as when caused by irritation produced directly upon the part to which the sensation is referred. For instance, an irritant taken into the stomach may cause the sensation referred to that region ; or the pressure upon the ulnar nerve causes pain at the point of pressure; a contractured muscle e. g., the pyriformis may irritate directly the sciatic nerve and the whole nerve will THE DIAGNOSIS OF DISEASE. 113 suffer. In this case the pain is felt not only at the point of pressure but throughout the entire neuron ; for note that in the pressure on the ulnar, while the pain may be felt at the pres- sure, it will likely be more noticed in the finger, i. e., at the peripheral end organs. In this case it is not necessarily simply a reference by consciousness, but an actual disturb- ance of molecular vibration throughout the entire nerve ele- ment, with a consequent arousing of impulses from all parts suffering the disturbed vibration, and the greatest intensity of impulse will come from those parts which are especially developed for the purpose, i. e., the sensory endings in the periphery. But the pain may be indirect or referred. In this case a peculiar fact is to be noted, a fact that has been put in definite formulation by Head and which is spoken of as Head's Law. This law states that, " When a painful stimulus is applied to apart of low sensibility in close central connection with a part of much greater sensibility, the pain produced is felt in the part of higher sensibility rather than in the part of lower sensibility to which the stimulus was actually applied." While this is a fairly correct statement of the real condition it should not be dignified by the name of "law," since in the above wording it cannot apply to all cases by any means. Head based the law on observations with especial reference to visceral versus spinal pain. It is known that many of the viscera are comparatively insentient Fig. T.-Illustratlng mechanism . ' in referred pain. under ordinary conditions. That is, the nerves capable of conducting an impulse producing the sensation of pain are comparatively few and inefficient, and hence the irritation sufficient to give pain must be corres- pondingly intense. But every one is aware that pain may be produced in a viscus, and in order to show that Head's 114 PRINCIPLES OF OSTEOPATHY. law holds, it must be proven that the part of higher sensibility is the part most noticed by consciousness on the application of the stimulus to the more insentient organ. That such is the case in numerous instances may readily be admitted but that it is true in all is disproved. Were it stated that the pain may be felt in the part of higher sensibility the objection to the statement would cease. Ii) this latter inter- pretation the question will be considered. Note that the law provides for a condition where there is a "close central connec- tion." It is to be remembered that though little evidence of an anatomical nature can be adduced, there is much from physiological and embryological investigation to show that the spinal cord and less noticeably the brain are segmental structures. We may arbitrarily divide the cord into seg- ments corresponding with the paired arrangement of the spinal nerves and assume with little possibility of error that this division represents a physiological segmentation. Each part of a segment acts more with reference to its other parts than with parts from an adjacent segment is a statement that is true in general. Hence, two nerve fibres having their cen- tral endings in the same segment will be in more intimate re- lation than fibres from different segments. This fact is in- dicated from various evidences derived from experiment, es- pecially in reference to reflex action. For instance Pfluger has shown that a stimulus applied to a limb of a "spinal frog'* produces its first response in motion of that limb, but the next effect, produced by a stronger stimulus will be upon the limb of the opposite side, showing the radiation of the impulse to parts in the same segment. An additional stimulus will cause effect on nerves from the immediately adjacent segments. But according to Head and others who have investigated the same problem, the phenomenon is not limited to a reflex mechanism such as is present in the above cases. A sensory nerve in connection with the same segment may be involved, or at least the pain may be referred to the area of distribution of that sensory nerve. Head calls attention to the fact that with THE DIAGNOSIS OF DISEASE. 115 a few possible exceptions, each viscus is related in this way to a definite area of cutaneous tissue. For instance, irrita- tion of the stomach is likely to be associated with pain in the skin areas supplied by afferent fibres from the sixth, seventh, eighth and ninth thoracic nerves. It is significant that the pain is not necessarily of a .simple "referred" or "trans- ferred" character. It is noted that in numerous cases there will not only be a referred pain, but what is a different thing, referred tenderness, in which case it is suggestive of distinct nerve disturbance rather than a reference on the part of consciousness. But the reference of pain is not necessar- ily from a diseased viscus. Osteopaths continually have this fact called to their attentionjby numerous cases. Hip trouble gives rise to pain in the knee. This may be due to direct pressure by the luxated structures upon the nerve supplying the articulation, or it may be due to impingement upon the terminals of branches distributed to the hip joint, referred back to the segment, and thence out over the branch to the knee. For we know that the same nerve trunks which supply the articular structures of the hip also supply those of the knee. Similarly Hilton calls attention to the fact that the same nerve trunk that supplies a joint, also supplies the skin which overlies it and the muscles that move it, and a further usual circum- stance of interest, th&tthebowel wall, the peritoneal structures asso- ciated with it, and the skin overlying these, are all supplied from the same segmental source. Attention is further called to the fact that ear-ache may be associated with disturbances in the nutrition of the teeth, both of these structures being supplied by the fifth cranial. In all of these cases we have a principle that is similar if not identical. Further facts suggested by Hilton in relation to referred pain may be of some value. He notes first that pain in the cutaneous structure not associ- ated with a high temperature of the part is suggestive of a distant origin of the pain, and usually that origin is in the spine. He instances in this connection what osteopaths have been able to corroborate in many cases, that a sensory disturbance 116 PRINCIPLES OF OSTEOPATHY. in the anterior terminals of the thoracic spinal nerves is often due to a spinal lesion, no local disorder being manifest. A further rule is that when the pain is symmetrical it is almost certainly caused by a central, i. e., spinal disorder. The ap- plication of the foregoing facts is apparent. By means of the pain or tenderness we may trace the situation of the seg- ment of the cord which is involved. That involvement maybe or may not be dependent on a lesion at the corresponding vertebra, but in the vast majority of cases such a lesion will be found. Even though the definite structural change be absent from this part, the organ involved will be indicated and indirect aid be given in the diagnosis. The tender spots, for the discovery of which the osteo- path is famous, are always significant. In most cases these points of increased sensitiveness are quite limited in extent and suggest in most cases not a referred but a direct condition of irritation. For instance in the examination for a lesion of the spine, just at the region between the spinous and trans- verse processes the tissues are tender on pressure. This is always suggestive of local disturbance, i. e., congestion, in- flammation, or contracture of tissues sufficient to irritate the sensory nerve terminals in the part. In palpation for such tender areas care must always be exercised or a tender spot may be produced where none before existed. Bear in mind that sufficient pressure in any part, whether normal or ab- normal, will produce pain or some other sensory change. The sensory condition of the part under examination must always be compared with similar adjacent areas, and with the average condition. This last must be a question of expe- rience, the average normal condition must be learned before there can be much possibility of detecting slight changes a statement true not only with reference to pain, but to all of the several factors enumerated. Emphasis has been laid upon the subject of pain as evi- dence of lesion, not only because of the complexity of the subject, but because of its primary value as a first evidence THE DIAGNOSIS OF DISEASE. 117 of disorder. Of the numerous changes that may be associ- ated with a lesion, the sensory one of local tender areas is among the most important and least associated with a possi- bility of error. Another valuable factor in determination of the presence of a lesion is the condition of the associated muscle tis- sue. This is usually spoken of as a contracture, the causes of which have been referred to in the section on causes of le- sions. It becomes necessary to distinguish between the meaning of contraction and contracture in order that confu- sion may not arise. The term contraction refers to the state of a muscle in the physiological process or condition of short- ening and thickening of the muscle not associated with appre- ciable change otherwise. The term contracture, on the other hand, has by usage become involved with the idea of a path- ological condition in which the contraction is not identical with the normal state, and though it is contracted it has in addition certain other characteristics. True enough, a con- traction long continued will usually result in a fairly typical contracture but that the ordinary contractured muscle with which the osteopath is so familiar is not identical with a pro- longed contraction will hardly be denied by any one who has carefully compared the two. Physiologists recognize that there exist conditions of change of shape in muscle not sim- ilar to the usual contraction, and to which have been given the name of idiomuscular contraction. Specific instances of such are noticed in case of fatigued muscles, which on the application of a stimulus e. g., a mechanical blow responds not by a wave of contraction passing to all parts of the muscle, but by a local swelling of the tissue to which the stimulus was applied. This change persists for some considerable time after the withdrawal of the stimulus and in this respect, therefore, also differs from a normal contraction. If the actual condi- tion of the muscle could be accurately analyzed, it would likely be found that the contracture with which the osteopath is peculiarly acquainted and the idiomuscular contraction 118 PRINCIPLES OF OSTEOPATHY. referred to by the physiologist, would more nearly be identi- cal than would the former with normal physiological contrac- tion. If a muscle is contractured it presents certain peculiar characteristics to the examiner. In the first place it will give evidence of a shortening and thickening, in which statement nothing is indicated showing any difference from the ordi- nary contraction. But in reality if care be exercised in pal- pation a distinct difference will be noted. Instead of a homogeneity of the contraction there will be an irregularity, some of the fibres apparently in a normal tonic condition, while others are distinctly knotted. A further noticeable fact will be the peculiar "ropy" feeling as the fingers are passed over the muscle at right angles to the course of the fibers. In other cases the term "welted" would be more descrip- tive. A further characteristic of the tissue is a peculiarity in the denseness, a sensation transmitted to the fingers diffi- cult of description, and due in all likelihood to a change in the nature, amount, and disposition of the various fluid ma- terials associated with the muscle, i.e., the blood, lymph, and muscle plasma. Another condition of the contractured tissue is the sensory change noted in it and to which sufficient refer- ence has been made. Emphasis should be laid upon the fact that a persistent contraction or contracture will invariably result in a sensory disorder of some kind. Finally, material aid may be given in the determination between a muscle physiologically contracted and one in contracture by caus- ing the individual or part to assume a position in which the ne- cessity for physiological contraction ceases to exist. For instance so long as the individual is in the sitting posture the deep cervical muscles will be functionally active. On assuming the horizontal position the necessity for their contraction ceases to exist and they will normally relax. If, however, the muscles be contractured, the relaxation on changing posi- tion will not be so apparent. Note that it is a condition of degree, for the abnormal muscle will undergo partial relaxa- tion when its contraction is no longer needed. THE DIAGNOSIS OP DISEASE. 119 The degree of amplitude of movement is a factor of much value in diagnosis of the lesion, and one which is close- ly associated with the condition of all the structures. We have noted that in most typical lesion conditions, bony, liga- mentous, and muscular changes are associated and interde- pendent. All three are concerned in producing the change in the freedom with which the part moves. A bony luxation usually will lessen the extent of movement, and so will ligamentous strain and muscle contracture. On the other hand a lax ligamentous and muscular condition will permit of excessive rotation. The condition of the spine spoken of as a "rigid", or "smooth" spinal column (Haz- zard) is a case in point. The rigidity may be due to "locked" vertebrce rare thickened and hardened connective structures, 'deposits in or absorption of intevertebral and articular carti- lages as in articular rheumatism, or to simple but general muscle contracture, in the latter case usually yielding on appli- cation of measures designed to relax the muscles. Bony anhylosis is a condition occasionally met with and will mani- fest itself by absolute immobility. Temperature changes in the local part are often found and usually are indicative of local lesion. The exist- ence of a lesion means local irritation. Irritation calls for or at least results in hyperaemia, and hyperaemia may pass into in- flammation. In either of the last two conditions there will be increased heat because of increased blood, the latter being the principal medium by which heat is distributed. But the increased temperature may be locally produced. Especially is this likely where local inflammation is present, the increased metabolic changes being responsible for an increased oxida- tion with liberation of heat. Attention is often called to a rib lesion through the difference in temperature along the course of the rib as compared to that above or below. It is not neces- sarily an increase, but may be a decreased temperarure that is noticed. A cold state of the posterior cervical structures is a common accompaniment of the lesion in that region. Dr. 120 PRINCIPLES OF OSTEOPATHY. Still calls attention to the lowered temperature of the skin in the gluteal and lower spinal regions in case of croup, while the ventral structures may show an increased temperature. The numerous cases noted and the equally numerous possible causes of changed temperature suggest the importance of a careful training of the fingers in the temperature sense. Finally, the color of the part under suspicion may be an indication of a lesion. In most cases the difference in color will be dependent on the amount of blood present, congestion causing redness, ischaemia producing pallor. Pigmentary deposits may occasionally be noted in the region of a lesion, from the blood or other change associated. In all the examination for the nature and location of a lesion the several factors mentioned should be borne in mind. In the vast majority of cases only a few of them will be ap- preciably present. The greater the number the more certain the diagnosis. The absence of one or all does not disprove the presence of a real lesion and a serious one, but renders its pres- ence much less likely. Note the fact that numerous osteo- paths are quoted in the expression "There was no lesion in the case." The want of logic evidenced by such assertion is quite apparent. It is not necessary in order that there be a real lesion that the condition can be determined with the eyes closed and gloves on the hands. To assume that every lesion can be detected is to assume the impassible. Lesions may be microscopic and still be lesions as judged by our definition, and he t who thinks it necessary, in the case of impreceptible lesion, to assume the existence of some other cause for the disorder than that of the lesion, or that the manipulation of a part which produced a cure of this disorder did so other than by removal of lesion, is making use of extremely faulty logic. THE TREATMENT OF DISEASE. 121 CHAPTER VII THE TREATMENT OF DISEASE. PROPHYLAXIS AND THERAPEUTICS. The ultimate end which we have in view in the determin- ation of the etiology and diagnosis of disease is but to pre- pare a rational basis for the treatment of disease. By the treatment of disease is meant any method or measzire which wilt assist the organism in re-establishing its normal function. More appropriately, it is the treatment of the diseased organism rather than the treatment of disease, for the disease will be- disposed of by the organism itself if freedom is given to th& healing agencies inherent in the organism. Broadly speak- ing there are two grand divisions comprehended in the word treatment, one of which is concerned with all of those meas- ures designed to prevent the onset of disturbed functioning-. Technically this is spoken of as prophylaxis. The term prophylaxis is a comprehensive one and has rather indefinite limits. In the first place it is concerned with the conditions of the environment of the individual. Sanitary measures employed by a municipality, including regulations governing sewerage systems, tenement house requirements, and the like,constitute definite prophylactic treatment applied collectively. Hygiene in the nature of cleanliness, normal exercise and the breathing of pure air or the eating of proper food in proper amounts, constitutes prophylaxis of the indi- vidual with regard to his environment. On the other hand prophylaxis is applied directly to the organism itself either by the removal of the predisposing cause, as for instance the in- creasing of the chest capacity by lifting and adjusting the ribs in order to avoid furnishing suitable soil for the propa- gation of the tubercle baccillus; overcoming the irritable mucous membrane of the nasal passages to prevent an at- 9 122 PRINCIPLES OF OSTEOPATHY. tack of hay fever brought on by the presence of dust particles in the air; or insistence on abstaining from further abuse of an organ which otherwise would ultimately result in ex- haustion and hence disease, for example, where there is a tendency to writer's cramp; or prophylaxis is applied in the avoidance of the exciting cause, or the direct destruction of that exciting cause. As illustration of this second method, the patient may be directed to remove to a climate more favora- ble to his health, as in the case of the hay fever victim who passes his summers in an atmosphere less laden with irritat- ing particles ; or the use of antiseptic washes in the case of contagious diseases. But measures may be applied in the treatment of the or- ganism after the disease is present, and this constitutes what is technically spoken of as therapeutics. It is necessary to observe as a precaution that many writers make use of this term to embrace both preventive and curative treatment. As a matter of convenience the two terms should be kept within their proper limitations. In the application of therapeutic treatment one or both of two policies may be pursued, the re- moval of the lesion condition or the abstinence from any use of the organ that under the circumstances would constitute an abuse. In the case of an individual afflicted with stomach trouble dependent upon a splanchnic lesion the proper treat- ment for such disorder would consist in the removal of the specific lesion. So long as the lesion exists some care may be necessary to avoid any overwork or other abuse of that organ. If on the other hand the primary cause of the gastric unrest is abuse by errors in diet, therapeutics would consist granting there were no lesion present in the regulation of the dietetic habits of the patient. Of the two ideas associated with treatment, that of pro- phylaxis occupies the higher plane, for prevention is al- ways better than cure though not necessarily in the ratio of the ounce to the pound. It is the dream of the idealist that a time may sometime come when there will be a greater de- THE TREATMENT OF DISEASE. 123 mand on the part of the people for prophylactic than for therapeutic treatment; when individuals will pay greater at* tention to laws of health and will go at frequent intervals to a qualified physician for the purpose of physical examination to detect any predisposing lesions that may have arisen since the last examination or treatment. But the dream of the idealist will hardly be realized in this generation and hence comparatively little prophylaxis of that nature will be used. The average osteopath will only be called upon to treat a case after the evidence of disorder is markedly present. Hence relatively greater stress must at present be laid upon the therapeutic side, except in that the physcian may make himself a distinct force for the dissemination of knowledge regarding the body and the laws of its health, together with a hearty co-operation with all legitimate efforts to enforce sanitary measures applied collectively to a city or commun- ity. The relation that the removal of lesion bears to prophy- laxis, even in case of a therapeutic treatment, we have dis- cussed in a former article ("The Ounce of Prevention", Nov. 1902 issue of the Journal of Osteopathy^ a part of which is reproduced in this connection : "But after all that may be said of the curative treatment, is not every osteopathic treat- ment a prophylactic one? The use of the term curative is essentially incorrect. The. physician does not cure. "We ob- ject to the definition of osteopathy which affirms that the physician "directs" the inherent recuperative forces of the body. The direction of those forces abides in a higher and more subtle power than can be exercised by the hand of an- other individual even though it may be guided by a high order of intelligence. Neither does he"regulate functioning", except in a very secondary sense; and herein lies one weak- ness in the philosophy of the "vital lesion" osteopath. Functions are controlled by an inherent force which we de- nominate "vital". That force itself cannot go permanently wrong. It will not cause permanent disorder of structure 124 PRINCIPLES OF OSTEOPATHY. except it be hindered by blocked channels of interchange. And herein also lies the fallacy of the Christian Scientist and all other mental healers. The "tendency to the normal" operates in psychic as well as in material substance, and the normal in mind and emotion will be assumed if the organiza- tion of cell life be intact. If then the physician does not reg- ulate functions or direct forces, what does he do? Funda- mentally, he clears the way. Does that cure? The disease as it existed before the lesion was removed was caused by perverted function resulting from the lesion. On the removal of the lesion the disease as it exists will be overcome by the restored normal functioning. The physician in removing the lesion has prevented the further progress of the disease. He has applied preventive treatment." "Is it the assertion of an extremist to say further that even in the removal of a lesion the physician is not overcoming a structural condition? In the vast majority of cases with which the osteopath meets, the treatment does not consist in "setting" a bone, if we use the term in the sense in which it is commonly used. In a case of a recently luxated hip the osteopath may be successful in one treatment. In such a case he perhaps is not simply aiding nature. But in the countless other lesions met with, chronic changes are present which do not admit of immediate replacement. In such cases the prime importance of the physician is as an assistant to the organism. When a lesion is produced by whatever cause one of several things takes place. Nature first attempts to overcome the structural disturbance and is usually successful. Every football player and every one who has watched the game will readily believe that numerous structural condi- tions are produced during the strenuous periods. Do every one of these need a treatment? Hardly. Tension of tissue supplies sufficient treatment. But occasionally a structural disorder is sufficient in degree to pass the limits of self -ad- justment. Failing in drawing the part back to normal the tissues on one side gradually yield, on the other gradually THE TREATMENT OF DISEASE. 125 shorten, and with other changes a partial adjustment to the new circumstances takes place. What must the osteopath do? In the case where nature is still making the attempt to re* align, he can assist by releasing the hindering structures and in the average case "nature will do the rest." In this case he is not curing, he is preventing. "Where complete ad- justment to the changed condition has taken place he is per- haps more surely applying a curative measure in the break- ing up of adhesions and stretching permanently shortened muscles and ligaments." "Hence after all we are using the ounce rather than the pound, though for various reasons some of which are indi- cated above, we are rather late in making the application. But time will remedy the difficulty to a large extent, and then we shall be able not only to prevent the progress but also the beginning of the pathological condition." CURATIVE VERSUS PALLIATIVE TREATMENT. A further classification of treatment is made having reference to the immediate purpose and effect, as to whether it be curative by virtue of aiding in the removal of the cause of disease, or whether it be palliative, in which case it is di- rected to a symptom rather than a cause. If the physician overcomes or assists the organism in overcoming a lesion of the spine which is causing heart disorder, or if the patient himself abstains from the abuse of his heart by over exercise where such has been the cause, a curative treatment has been applied. If on the other hand he exerts pressure in the up- per thoracic region and relieves a temporary palpitation or sensory distress, a palliative treatment has been employed. No definite dividing line can often be made between the two, for a curative treatment will in a large number of cases be palliative also. The adjusting of the ribs by the treatment in the thoracic region thereby taking off the pressure will give relief to the distressed cardiac structures. On the other hand in numerous cases a palliative treatment while given 126 PRINCIPLES OF OSTEOPATHY. explicitly for the purpose of temporarily overcoming a symp- tom may in the long run be curative as well. A treatment applied for the purpose of lessening the intensity of pain will in occasional cases give to the organism a better opportunity for repair, which was wanting so long as the nerve dis- turbance continued. Further, it may become necessary that a palliative treatment be given in order that the primary cause may be reached. For instance, an obstruction to the bowel from impaction may cause such a tension of the abdominal wall as to make impossible any direct manipulation of the impacted area. In such a case treatment would be given for the purpose of relaxing the abdominal muscles which would be preparatory to the primary or curative treatment. Or in the case of a wrenched spine the resulting congestion and contracture of the superficial spinal muscles may be such as to hinder treatment to the deeper structures, making it ad- visable if not essential to quiet the sensory disturbance and overcome the contractured condition before attempting the deeper work. Again, a palliative treatment may be essen- tial as a preliminary to further diagnosis. In appendicitis the bowel wall is so irritable and tense as to prohibit palpation deep enough to determine the condition of the caecum and appendix; or the superficial cervical tissues may be so con- tractured as to prevent the detection of a deep cervical lesion. In both of these cases the palliative or temporary treatment will be necessary before a satisfactory diagnosis is possible. ADJUSTMENT OF THE OSSEOUS LESION. The statement has been made that the three common forms of lesion, bony, muscular and ligamentous, were usu- ally associated in the production of the same disorder. In the treatment of the condition a movement which will affect one will affect the others. In the case of the bony and the muscular lesion at least, special and peculiar methods must be used. The ligamentous lesion will be affected only by work upon the others. Since we do find bony and muscular lesions associ- THE TREATMENT OF DISEASE. 127 ated the question arises as to which should have precedence in point of time. It must be confessed that there is a differ- ence of opinion regarding the matter. If the bony disorder is secondary to the muscular tension and is maintained in its position primarily by that muscular tension, manifestly the muscles should first be relaxed, and if no other cause of bony displacement be present that may be sufficient. Such a condition is a common occurrence among acute cases and hence the general rule that muscle contracture should have first at- tention in acute cases may be safe enough to follow. In chronic conditions, however, the vast majority of cases will present bony disorder not primarily maintained by muscular con- tracture; and in most cases the muscle contracture will be secondary to the bony disorder though in the beginning mus- cle contracture may have been primary. In such cases as these we are personally convinced that direct treatment to the muscles is secondary in point of time and importance, and so far as actual results are concerned the direct pressure and massage so often employed is entirely superfluous. We shall begin the discussion therefore with a consideration of a few general principles underlying the adjustment of the osseous lesion. The first of these principles may be spoken of by the phrase which osteopathic usage has authorized, exaggera- tion of the lesion. By this is meant a manipulation de- signed to make the structure more prominent in the direction toward which it is displaced. For instance if there be a right lateral luxation of a cervical -vertebra the head should be flexed to the left and pressure applied to the cervical tissues on the left of the displaced bone; if a rib is sub -luxated upward on the transverse process of the vertebra pressure is exerted up- ward at the angle of the rib and downward on the anterior extremity ; if the innominatum be luxated through a rotation up- ward and forward pressure will be exerted in an upward and forward direction on the iliac portion of the bone, upward and backward on the ischium. In the exaggeration of the lesion 128 PRINCIPLES OF OSTEOPATHY. several objects may be had in view. In the first place the measure tends to free the articular structtires, just as the driving in a trifle will free the articulation of a nail with wood in which it is imbedded and permit it to be withdrawn more easily. In the second place the movement effects a stretching and relaxa- tion of the deeper structures which in numerous cases is all the relaxation that is called for. Finally, there is secured the benefit of recoil which results from the stretching of the tis- sues and aids in initiating the movement backward towards the normal position. A second general principle is that of rotation. The value of rotation can hardly be over-estimated although the rotation itself may easily be too extreme. In effecting rota- tian of the part luxated, at some point during the circuit each of the fibres in each of the ligamentous and other connective structures will have been stretched and relaxed and the artic- ular surfaces kept sufficiently free to allow the progress of the part back to its original position. The comparison may be crude but the conditions in the case are similar to the movement of a trunk or box along a platform by rocking it back and forth with some rotation. The advantage of this method over that of dragging the box bodily is obvious. A final general principle in the adjustment is the simple one of pressure applied to the luxated structure in the di- rection toward its normal situation. In point of time the ex- aggeration of the lesion is first, rotation and pressure follow and are GO- extensive and co-ordinate in time. In all but a comparatively few cases these three principles can be ap- plied with advantage, and are applied although the physician himself may not have been aware of their application. In a few cases little direct pressure can be satisfactorily made, as in the case of an anterior lumbar vertebra, in which it is necessary to rely principally upon the pull of tissues in and following the process of rotation. In other cases the exag- gerafjion of the lesion may not be feasible ; but in no case is it impossible to apply rotation and in numerous conditions THE TREATMENT OP DISEASE. 129 where the lesion is slight, that of itself will be sufficient aid to the organism in effecting a normal adjustment. ADJUSTMENT OF MUSCULAR LESIONS. In most cases of a chronic nature and in practically all ^icute cases muscular lesion will be quite manifest. It is not necessary at this time to discuss the question as to whether that lesion will be primary or secondary; the fact that it ex- ists calls for discussion as to the methods of producing relax- ation. For whether the lesion be primary or secondary its removal is seldom if ever contra -indicated. Note first that one or more of several purposes may be had in view in the relaxation. One of the objects in such relaxation is that of diagnosis. In a large number of cases the muscular lesion will be the most apparent one, which fact has given rise to much hasty reasoning with the conclusion that no additional factors were present. The writer was once told when he was a student in jschool that when he "got into the field" he would find little beside muscular lesions. We are compelled to testify that "the informant has proved himself a false prophet ; if care be taken in analysis of conditions few chronic cases will be present unassociated with deeper than muscular lesions, while it is almost equally true of the acute forms. Indeed we be- lieve it not unsafe to assert that in most cases the muscular contraction is direct evidence of a deeper lesion. The difficulty of detection may be much more marked than the realness of the lesion. The fact that deeper lesion is usually associated makes it necessary, or at least in many instances helpful, to effect a superficial relaxation in order to detect the deeper condition. Note the case of a contractured cervical region. In numerous of such the ordinary osteopath will not be able to determine the condition of the cervical vertebrae until the ob- scuring muscle contracture is removed. It is often difficult, further, to detect the relative position of the posterior part of A rib at its junction with the transverse process of the verte- 130 PRINCIPLES OF OSTEOPATHY. bra until the associated contracture is overcome. A floating 1 kidney acting as a lesion will often be obscured by contract- ure of the quadratus lumborum and abdominal muscles. But not only for diagnosis of further lesion is removal of con- tracture necessary but also for determination of the organ in- volved and the nature of the involvement i. e., for diagnosis of the disease itself . Note the fact that in hepatic colic from the passage of a gall stone muscle contracture is so intense and painful that a palliative relaxation becomes imperative for definite diagnosis of the gall stone condition ; similarly an obstruction to the bowel will produce secondary abnormal tenseness sufficient to prohibit palpation of the impacted or otherwise occluded condition ; the rectal and vaginal sphincters may be so constricted as to hinder local examination of the position and condition of the uterus. In all such cases the beginning osteopath i.e., the inexpert finds it necessary to resort to the removal of the secondary obscuring lesions be- fore he is able to make a satisfactory diagnosis of the disease. A second object is as a preliminary to further treat- ment, the further treatment often though not necessarily being the primary one. The "Old Doctor" invariably allows his fingers or palms to "sink in" the tissues for a moment pre- vious to the movement for adjustment of a cervical vertebra. In this "sinking in" relaxation occurs which reduces the amount of force necessary to produce movement by rotation and pressure; in long standing cases of hip dislocation, where a crude new articulation has been formed with a consequent adjustment shortening and lengthening of muscle and lig- ament, it is impracticable and in most cases with the osteo- path of average skill, impossible to immediately reduce the dislocation and recourse must be had to a series of treatments designed to relax and otherwise change structural condi- tions which are secondary to the original dislocation ; in bowel occlusion from impaction of feces relaxation of the ab- dominal wall is essential to a further direct manipulation of the impacted area. THE TREATMENT OF DISEASE. 131 Finally, relaxation is used as a treatment primary in itself. A muscle contracture whether primarily or second- arily produced will exert pressure on tissues within itself, e. g., sensory nerve terminals, or disturb structures to which it is attached. As instance of the former note the conditions of congestion produced in the respiratory canal by virtue of contractures irritating afferent nerves which carry impulses to the segment of the spinal cord governing the vaso- motor mechanism to the part involved : relaxation of the muscle tissue in such a case removes the primary cause of the con- gestion. But by the tension upon the associated vertebra or rib displacement of the latter will further add to the difficulty and hence be additional cause; in this case the relaxation will permit of a return of the displaced structures to their natural relationship. Further instances are relaxation of supra-hyoid muscles which interfere with venous return from certain cephalic structures, thus relieving congestion ; pressure on the bowel wall in a spasmodic contraction of the muscular coats which relaxes the tissue and overcomes the cramp which so distresses. "With regard to the methods employed in producing relax- ation several are in vogue by different osteopaths. Among them we may specify the most important. The removal of the cause constitutes in all cases the fundamental method. Owing to the tendency on the part of students to apparently overlook the fact it seems necessary to emphasize that a con- tractured muscle remains in that state only by virtue cf a continuously acting stimulus. One of the inherent properties of muscle tissue is its ability to respond to a stimulus by a contraction. It is no less an inherent property of that tissue to relax as soon as the stimulus is removed. In both cases there is some evidence to show that the process is an active one. With a certain proportion of students and inexperienced osteopaths their first consideration on meeting with a case presenting contracture is the application of methods direct to the muscle designed to produce a relaxation. This is fundamentally erro- 132 PRINCIPLES OF OSTEOPATHY. neous. The first consideration should be the determination of the nature and source of the constantly acting stimulus. The second consideration should be the application of measures to remove that stimulus. If a muscle is contractured through simple exposure to a change of temperature the primary treatment is the negative one of removing the patient from the influence of the changing temperature. If the contrac- ture is caused by a direct irritation to the motor nerve through pressure from a deep bony or ligamentous lesion the essential treatment consists in opening up the space which transmits the nerve. A contractured condition of the anter- ior muscles of the thigh caused by impingement upon the anter- ior crural will be logically and surely overcome by the ad- justment of the luxated hip, pelvic, or lumbar structures causing the impingement. Note that the direct work upon the muscle in any of these cases will be getting at the diffi- culty from the wrong side and can only indirectly and in most cases temporarily reduce the contracture. Admitting the logic of the above considerations it yet re- mains a fact that specific methods other than those directly concerned in the way indicated above may be employed as a matter of expediency. Pressure with quiet and slight rota- tion of the tissues, usually more in a direction at right angles to that of the fibers than otherwise, is employed in numerous cases. In what way this pressure produces the relaxation is not definitely known. It is suggested that relaxation results because of an inhibitory effect upon the nerve terminals as- sociated directly with the muscle. Objection must be made to this as an entirely satisfactory explanation because of the known physiological fact that it is much more easy to produce a stimulation of a nerve than to produce a lessening of its activity. In fact it is with the utmost difficulty that a nerve can be in- hibited by pressure upon it when experimented upon in the laboratory. On the other hand stimulation is almost sure to result unless the most extreme care is exercised. It is not de- nied that gradually applied deep pressure is effective in pro- THE TREATMENT OF DISEASE. 133 ducing relaxation and it is true that the more gradual the ap- plication the more satisfactorily does it yield. And there is good reason for the latter fact. Note that a stimulus causing response of any kind in any tissue will be effective in proportion not to the total intensity or amount but to the abruptness of its application. It can be shown that the change from a higher to a lower potential in case of the electric stimulus, if the change be sudden, will be an effective cause of response. The same is undoubtedly true with regard to the several forms of stimuli ; it can be shown in the case of heat very nicely. A "spinal" frog's limb may be literally cooked without causing a reflex response if the heat be applied gradually, whereas a change of a degree or two in temperature if produced abruptly will elicit a mark- ed reflex. Hence if the explanation were entirely one hav- ing reference to an inhibitory action on the nerve terminals, none but the most gradually applied pressure would be effect- ive. We know, however, that in many cases relaxation does occur where the pressure is applied in anything else than a gradual way. The fact that the latter method is less effica- cious is no argument for the explanation based on inhibition of nerve force. It is simply evidence that rough treatment is associated with greater possibility of stimulation of the nerve terminals, Some other explanation then seems necessary. One such that has been suggested has reference to the fact al- ready mentioned, that in a typical contracture there is a con- dition that is markedly different from a simple prolonged contrac- tion. The condition is one in which a part or all of the muscle is changed in the nature and amount of the fluids present. Hence, when relaxation is effected by direct pressure and manipulation it may result from the expressing from within and between the muscle fibers the products of abnormal met- abolism. Owing to its congested state the muscle is enlarged bodily and is contractured, in part by stimuli of nerve ter- minals by chemical alteration or pressure from distension of its vascular system. These will be partially overcome by 134 PRINCIPLES OF OSTEOPATHY. compression of the body of the muscle. Further, the pres- sure upon the fibre directly may very materially assist in its relaxation by more or less forcibly re-arranging the particles of the muscle protoplasm. For we know that the essential mechan- ical difference between a fibre contracted and one at rest is the relative number of protoplasmic molecules in a definite cross -section of the fibre, i. e., in contraction the molecules come abreast while in relaxation they assume "single file." In the process of relaxation, then, there is forcibly produced a tendency to the single file arrangement. As examples of cases in which the pressure and manipu- lation method is efficacious are the following: in headaches we often find the sub-occipital region markedly tense in which case the gradual but deep pressure, a "sinking in" as Dr. Still calls it, forces the tissue to relax and often yields imme- diate relief ; in case of the passage of a gall stone along the duct the irritation is so intense as to cause direct contracture along the duct, the abdominal wall overlying it, and the spinal region from which it is innervated, in which case pressure is used both along the spine and the course of the duct; in croup and diphtheria the rapid inflammation and associated toxic condition cause rapid and intense contracture and congestion of the supra- hy oid muscles, which will in most cases rapidly, though perhaps temporarily, yield to the pressure and manip- ulation. Stretching a muscle is a method that is employed by many osteopaths for the purpose of producing relaxation. It is doubtful whether such a method will usually result satis- factorily. Theoretically there is much to be said against the process. The process of stretching a muscle is one method of insreasing the irritability of that muscle. Lombard is au- thority for the statement that "the irritability of muscles is likewise increased by moderate stretching and destroyed if it be excessive." Hence it would certainly seem illogical to at- tempt relaxation by increasing its irritability. Neither would it be the part of wisdom to destroy the irritability by exces- THE TREATMENT OP DISEASE. 135 sive stretching. A muscle in the condition of contracture will be stimulated to still greater contraction by throwing it on a tension, and yet there seems to be no question that in a large percentage of cases the process does result favorably and the explanation is sought. The stretching of a muscle, thus in- creasing its tension, corresponds in a way to the "exaggera- tion" in case of an osseous lesion, and in that case there is secured the "benefit of recoil." In addition reference is again made to the fact that muscle contracture is not identical with muscle contraction, and in the process of stretching, the con- gested material and waste products are more or less forcibly expressed from the contractured tissue though no relaxing effect might be gotten on a simple contraction. In all cases when attempting relaxation by this method a simple rule of guidance is usually sufficient. Separate the origin and inser- tion of the muscle. In case the scaleni muscles are found con- tractured on the left side, bending the head to the right with the shoulders a fixed point will separate the attachments and hence produce stretching; the hyper -extension of the thigh will stretch the anterior femoral muscles while extreme flexion of the thigh on the abdomen will put tension on the posterior muscles of the limb; the pulling of the middle portion of a muscle in a direction transverse to the course of its fibres will produce tension of the muscle although the absolute dis- tance between the two attachments of the muscle actually may have been lessened, as in the case of an upward and outward manipulation of the spinal muscles in the region of the lower thoracic. Another method less subject to abuse is that of approxi- mation of the origin and insertion. In this method the attached structures are forced to yield to the continued ten- sion of the muscle. That this method is efficacious as a tem- porary expedient few will deny. Just as the tension can be removed from a rope attached to posts by bending the posts toward each other so to an appreciable extent can the tension be taken from a muscle by forcing nearer together the points 136 PRINCIPLES OF OSTEOPATHY. of attachment. Further, this method seems to be a moat natural one and one resorted to involuntarily in many cases. Note the characteristic position assumed by a victim of peri- tonitis in which the superficial abdominal tissues are intensely tightened. The patient will lie supine with the limbs flexed at the hip and the head and shoulders raised, the total effect on the musculature of the abdomen being an approximation of the origin and insertion of most of the muscles concerned ; a further instance indicating the value of this method is the flexing of the head dorsally upon the neck in a case of sub- occipital contraction; or the flexion of the arm at the elbow for the pupose of relaxing the biceps preliminary to the reduc tion of a dislocated shoulder. It is seldom that any of these several methods will be used alone and it is in comparatively few cases that it is possible or advisable to avoid using two or more of them. For in- stance in the case of a contractured scalenus muscle a com- mon method is first to bend the head away from the side of the contracture which stretches the muscle, then rotate it back which approximates the origin and insertion, and at the same time pressure is exerted directly upon the muscle fibres. In this case three of the methods were employed and it is alto- gether likely that during the course of the movement the deeper structures were opened up, impingement taken off the nerve which supplied the muscle, and hence the irritation was re- moved and the fourth of the methods made use of. The point was emphasized in the case of the method by pressure that the application should be gradual. It is equally true of the other methods and not only with reference to the application but the removal of contact should also be gradual for if the re- moval be sudden there results an abrupt change, and abrupt change whether from a lower to a higher or from a higher to a lower level constitutes a stimulus, and a stimulus means further contracture. Another caution of some considerable value has reference to the relative temperature of the hand of the physician. If the manipulation is made direct upon the THE TREATMENT OF DISEASE. 137 tissues it is necessary for best results that the temperature of the part and of the physician's hand should be approximately the same. Especially it is advisable if the physician has cold hands to warm them before beginning the treatment, other- wise the shock produced by the difference in temperature will be a distinct added stimulus for further contraction, a result not at all to be desired. TREATMENT OF OTHER LESIONS. Thus far there has been discussed certain general prin- ciples underlying the treatment of bony luxations and muscu- lar contractures. It becomes necessary to suggest a few points of practical value in regard to the other forms of lesions which the osteopath must occasionally meet. In all of those cases of perverted size relations of parts we have to deal with some nutritive disorder which was responsible for the perverted growth lesion, and hence in such cases it is neces- sary to seek the further lesion or other cause of the nutritive condition and give attention to its reduction ; or in a second class of cases the lesion of perverted growth has resulted from direct violence producing a bruise or other enlargement in which the same considerations of treatment apply. The reduction of these is largely accomplished through depend- ence on normalizing all of the associated structures and re- lying on normal processes of absorption to remove the surplus material. In some cases it will be necessary to resort to sur- gical removal but only as a final resort. A tumor of the ab- domen is a perverted structure which by pressure upon the hypogastric plexus or other vital structure may produce dis- order of various forms. The treatment of such a lesion would be the removal of the original structural condition which per- mitted the deposit of the morbid material, together with the frequent movement and lifting up of the tumor itself in order to keep all channels as free as possible. Overgrown muscles and exostoses have been known to cause disorder and hence are considered as lesions ; the removal of such will depend 10 188 PRINCIPLES OF OSTEOPATHY. upon the same factors which were suggested in reference to the tumor. The overcoming of connective tissue lesions is a matter of no little difficulty and is a condition quite often met with. A typical lesion of this type is found in the rigid spine more or less normal to the aged individual and often met with in younger people who have suffered from some spinal vio- lence. This rigid spine condition, where it is not of a tem- porary nature such as would be produced by simple muscle contracture,is caused by a thickening, contracting, or lessen- ing of the fibrous and other ligamentous structures associated with the vertebrae ; or to a deposit in the articular structures of various salts, as in the case of chronic articular rheuma- tism; or finally, a condition of bony ankylosis. In all of these cases it is a serious question whether a complete cure can be effected or very great benefit given, owing to the diffi- culty of removing such lesion by any known methods. In most cases it will largely be a"breaking up process"designed to open up the deep structures thereby overcoming tension on nerve and blood vessel and permitting a free opportunity for absorptive processes to be maintained. A further type of connective tissue lesion is found in the case of cirrhosis of the liver where the connective tissue frame- work has been formed in excess and has subsequently contracted thereby reduc- ing quite appreciably the total volume of that organ and very considerably obstructing the portal circulation and the meta- bolic activities of the liver. In the case of sclerosis of the spinal cord we have also a connective tissue lesion of a serious nature In this case the neuroglia of the cord is thickened and contracted producing or following a degeneration of the nerve elements. In both cirrhosis and sclerosis the prognosis for removal is rather unfavorable especially in case of the latter. For we know that while a regeneration of nerves will take place in peripheral structures there are as yet no authen- tic oases of regeneration of the nerve fibre in the spinal cord when that degeneration had been experimentally produced. THE TREATMENT OF DISEASE. 139 All that can be reasonably expected in such conditions will be the limiting of the further progress of the disease and a partial absorption of the morbid deposit by establishing and maintianing a normal spinal circulation. 140 PRINCIPLES OP OSTEOPATHY. CHAPTER VIIL THE TREATMENT OF DISEASE. CON. STIMULATION AND INHIBITION. Like all systems of healing, osteopathy has been pre- sented by various classes of its advocates in various dis- guises, and as a result has been at times entirely misrepre- sented. While it is a matter of course that its professed en- emies should attempt to mislead, it is quite unfortunate that there are a few of its professed followers who, in attempting to uphold the system, have unwittingly placed it on a par with other systems by intimating or definitely asserting that osteopathy is a method of treatment by mechanical stimu- lation and inhibition of nerve impulses. It cannot be too strongly emphasized that such a position places the osteopath on the same plane wth all other schools ofhealng, the underlying principle being the same in kind, and differing only in degree. He who assumes that this definition of osteopathy is a new conception in therapeutics and one which embraces the essentials of the osteopathic philosophy has not only failed entirely to grasp that philosophy, but has shown an ignorance of medical history quite unjustified. For such history is re- plete with evidences that mechanical stimulation and inhibi- tion applied by definite manipulations has long been known and used centuries before osteopathy had been brought into the world. But with the rise and development of osteopathy and the newly awakened interest in drugless systems which in part resulted from that development, these various methods have been subjected to investigation as never before through the study of literature bearing on the subject, and the ap- plication of mechanical measures to disease conditions. Hence, by a hasty though not unnatural inference was de- duced the conclusion that the new method was but a special THE TREATMENT OF DISEASE. 141 modification and extension of the old. It is sufficient in this connection to affirm that stimulation and inhibition as definite osteopathic procedures are measures that have been super- added to the original and primary conception, and in so far as they may be used at all are insignificant in import- ance. The last statement suggests that there is a possible use for these methods and under the circumstances of an undeveloped and incomplete science and a lack of knowledge and skill on the part of the practitioner, the statement may be true. Under certain cir- cumstances it may be impossible or impracticable for the osteopath to apply specific osteopathic treatment and in such cases it will be necessary for him to place himself upon the same plane with the practitioner of other schools and use the least objectionable of the methods of the latter. In order to understand the nature and possible value of these methods it seems advisable to speak of them somewhat in detail. By stimulation of a nerve or an organ is meant the process of acceleration of the function of that nerve or organ. By inhibition is meant the process of retarding of the func- tion of a nerve or organ. Both of these processes are at- tributes of normal living tissue, more especially of the nerv- ous system. We may speak of the voluntary contraction of a muscle as a normal or physiological stimulation of that mus- cle ; the effect of food on the gastric mucosa as that of a nor- mal stimulation of the function of secretion ; the excess of carbon dioxid in the blood as a physiological stimulus to the respiratory center. On the other hand a voluntary impulse sent to the spinal cord center which cuts off the reflex movement that would otherwise occur is an instance of a physiological inhibition; the vagus nerve carries inhibitory fibres to the heart muscle which retards the activity of that tissue; im- pulses passing by way of the sympathetic filaments to the muscles within the wall of the intestinal tract causing a slower peristalsis are spoken of as viscero-inhibitory. These are all examples of the physiological or natural inhibition. By an 142 PRINCIPLES OF OSTEOPATHY. osteopathic stimulation or inhibition reference is made to the artificial process which causes or is supposed to cause by pressure a similar effect. Note that the process is artificial. A mechanical stimulus applied by the hand of the practi- tioner is emphatically not a natural but an artificial stimulus. It is said that the liver is stimulated by producing pressure directly on it or by otherwise compressing it ; the pneumogas- tric nerve is stimulated by pressure along its course for the purpose of increasing its function in lessening the cardiac activity; in prolapsus of the rectum the atonic walls are stimu- lated by local treatment. On the other hand the osteopath inhibits the phrenic nerve for controlling hiccoughs; pressure exerted along the splanchnic region inhibits the cramping in various forms of colic; pressure exerted in the lumbar and sacral regions and along the course of the sciatic nerve will often temporarily relieve sciatica. These treatments are referred to as stimulating or inhibi- tory and the assumption made that it is in truth the increas- ing or the lessening of nerve action by a direct process. Is such a control possible? We have heard the human body compared to the piano upon which the practitioner plays, bringing out the harmony of action as the musician produces the harmony of tone. We have heard it compared to an electric system upon which the intelligent osteopath may send mes- sages and shunt the currents and connect the circuits. We have heard the statement that the vital fluids and forces of the body are absolutely under the control of the skillful oper- ator. The essential thing lacking in these comparisons and statements is the element of truth. The human body is not at all like a piano, neither does the osteopath play upon it as would the musician. It is not an electric system that can be operated upon to any degree as the electrician manipulates his batteries or his keys. The forces and fluids of the body are fortunately beyond the control of the physician, skillful though he be. A few facts with reference to anatomy and physiology may not be out of place as indicating the insur- THE TREATMENT OF DISEASE. 143 mountable difficulties in the way of securing the absolute con- trol suggested above. It seems advisable to again repeat that function is self-regulative and structure nearly so, and it is the business of the osteopath to deal with structure, not func- tion, and to deal with structure only as that structure is in an abnormal condition. But can the nerve be stimulated and satisfactory results follow? DIFFICULTIES IN DIRECT CONTROL. In the first place we are just beginning to learn the functions of nerves. There are a few hundred million nerve fibres in the human body the function of most of whioh are not known. It was thought that the function of the pneumo- gastric in reference to the heart was known to be inhibitory, yet Schiff insists that the nerve has also an accelerator func- tion. It was assumed that the efferent nerve that passes to the muscle carries only an impulse resulting in contraction, but evidence is accumulating to show that it carries also an inhibitory impulse. It was believed that the sacral nerves carried motor impulses to one layer of muscle tissue in the rectal wall and inhibitory impulses to the other layer, but Langley, Anderson and others have exploded the "crossed in- nervation" theory. In the light of these facts as to the func- tion of the nerves it is presumption to assume that any such marked control over functions as suggested above can be gained. Greater difficulty in securing a very complete control of nerve action by direct means is obvious when the fact is noted that the same nerve may have different functions. Bear in mind that the nerve is not a separate structure but is made up of an indefinite number of nerve fibres each one of which may be associated with a distinct and different action. The vagus, for instance, has efferent fibres controlling motion and vaso- motion, secretion, inhibition and trophicity (?) and af- ferent fibres associated with pain sensation, vomiting, vaso- dilatation and perhaps a host of others. All these are bound 144 PRINCIPLES OF OSTEOPATHY. up in the same nerve sheath. Imagine the nicety of control possible to the practitioner under such an anatomical arrange- ment! Any afferent nerve may, on being stimulated by me- chanical means, modify any of the numerous functions of a spinal segment. Who will direct the excess of impulse into the right channel? Nearly every nerve that carries vaso-con- stricter fibres carries also those of a dilator function. The presumption in claiming an arbitrary choice of effects in vaso-motor stimulation is evident. A third factor is noted in that the nerve it is desirable to affect may not be in its usual situation. The inhibition of the phrenc nerve is often impossible because of the simple fact that it is not in the location where pressure is applied. Any one who has had occasion to do much work in the dissecting room will be impressed with the numerous exceptions to the rules of location of structures. Attention was recently called to a case showing the spinal acceessory nerve passing across the end of the transverse process of the atlas and to all ap- pearances it was an entirely normal condition. In close connection with the above the fact should be noted that the vast majority of nervea are beyond the possibility of direct manipulation, a very wise provision of nature. Stimulating the splanchnic nerves is spoken of as though those structures were laid bare to the touch. Perhaps in reality there is produced acceleration of function in many cases. But it certainly must be done through a very indirect route, and that through the complex arrangement of a reflex mechanism. The latter suggests a fifth very real difficulty in the way. Most stimulating and inhibiting treatments are explained on such a reflex basis, an explanation which in some, perhaps most cases seems rather strained. Note that the stimulation of the nerves associated with the spinal region, for purposes of affecting the splanchnic nerves must pass by the afferent spinal fibres fibres which have a choice of many neurons to which their charge may be delivered. Tt is but a remote pos- THE TREATMENT OF DISEASE. 145 sibility rather than a likely probability that sufficient of the excess of stimuli shall reach those cell bodies whose axons pass to form the splanchnic pathways. The argument that use is made of that explanation for the visceral disorders re- sulting from spinal muscle contracture, does not particularly enhance the proposition that the osteopath can cause the ef- fect that is produced by the lesion. Note that the lesion is either a much more intense stimulus or is prolonged over a greater period of time. Should the osteopath keep up continu- ous stimulation of such nerves for some hours sufficient ex- cess of stimuli might be discharged into the splanchnic chan- nels to amount to a real stimulation. But no such length of stimulation period is indulged in by the average practitioner. Further, to argue that the excess will all be poured into the channels needing it because nature "tends to the normal" hardly meets the demands. It is true that nature tends to normal, but it is further true that so far as function is con- cerned the tendency is in part toward that condition which is normal to the existing structure i. e., to that condition which is per- mitted by the existing structure. So long as structural con- ditions are at fault the function must remain so. When that condition is overcome no additional stimulus would be neces- sary. A further difficulty presents itself in cases where the stimulus may be applied either directly or reflexly. The in- tensity of the stimulus cannot be gauged in proportion to the need in the particular case. In laboratory work in physiology the mechanical stimulus is seldom made use of for this simple reason. It is effective but cannot be regulated in intensity, hence the use of the electric stimulus which is sus- ceptible of nicety of control. How much pressure shall be employed in order that the exact amount of increase of func- tion shall be produced? There can be no answer to the ques- tion. Why not employ the electric stimulus, then, instead of the mechanical in osteopathic practice? For the very good reason that electrotherapists themselves have tried it and 146 PRINCIPLES OF OSTEOPATHY. found it wanting. And not because of any particularly harm- ful effect on the tissues produced by the current as such but because the positive results were unsatisfactory. That it will be found equally true of the mechanical stimulation we are thoroughly convinced. We have finally to mention a fact that is of first impor- tance and that is, that in all cases where function is artificial- ly changed by increase or decrease there will be a recoil in the opposite direction. This is notably true with respect to experimental stimulation in the laboratory. Goltz' s experiment on the inhibitory action of the cardiac nerves of the frog is a case in point. The following is the description of the experi- ment as given in the American Text-book of Physiology. "In a medium sized frog the pericardium was exposed by carefully cutting a small window in the chest wall. The pulsations of the heart could be seen through the thin pericardial mem- brane. Goltz now began to beat upon the abdomen about 140 times a minute with the handle of a scalpel. The heart gradually slowed and at length stood still in diastole. Goltz now ceased the rain of little blows. The heart remained quiet for a time and then began to beat again, at first slowly, and then more rapidly. Some time after the experiment the heart beat about Jive strokes in a minute faster than before the experiment was begun. The effect cannot be obtained after section of the vagi." The italics are used to call attention to the fact that the final effect was not an inhibition, but a stimulation. Some experimentation has been and is being done at the present time by osteopathic investigators to show that a direct effect can be produced in case of man and lower animals (rabbit) by stimulation and inhibition in connection with the cardiac nerves and the splanchnics,a proposition to which assent ha& already been given. While these experiments seem to sub- stantiate the proposition that such a direct action is possible it remains to be shown that the effect is at all permanent or advisable, and more especially to prove that a recoil is not in- evitable or probable. Further observation of such experimen- THE TREATMENT OF DISEASE. 147 tation is awaited with interest. What is true in those cases in which accurate experimentation is possible is reasonably true of all others. Any swing of the pendulum past the position which is normal under the existing circumstances will be compensated for by a recoil of opposite sign. Note the fact that the organism brooks no interference with its function and will return to its normal activity when it has by sudden force been disturbed in that activity. Thus far reference has been made to some of .the difficul- ties which beset him who would attempt by nerve stimulation or inhibition to secure a definite control over the functions of the organism. Admitting that notwithstanding these diffi- culties there is still possible a limited and temporary control, it is necessary to consider certain objections to the use of those measures, and also the conditions where such treatment might be necessary or helpful. OBJECTIONS AGAINST ATTEMPT AT DIRECT CONTROL. By stimulating or inhibiting a nerve or other structure we interfere with normal function. It has before been suggested that function is normal to structure. Making simply a general statement, every function , be it usual or unusual ', is what it should be under the circumstances of existing structure. An increased peripheral resistance to the blood flow will cause an over-active heart. This latter condition is normal under the circumstances. It must increase its activity in order to keep up normal circulation. The attempt to limit the heart's action by inhibiting it is a distinct hindrance and an illogical treat- ment. Suppose that the peripheral resistance was maintain- ed so long as to exhaust the heart's action. The lessened force resulting is still normal to the structural conditions. The stomach in discharging its contents through the esophagus is performing a normal function and so long as it can by that method rid itself of irritant material vomiting should be un- hindered. Note further that a stimulus applied to a failing function 148 PRINCIPLES OF OSTEOPATHY. is in many cases crowding an already overworked organ. Notice one of the foregoing illustrations. When the heart by reason of an imperfect blood supply through lesion or other- wise is weakened, the work it is performing represents its capacity at the time. If a stimulus is applied to the accellera- tor nerves to hasten its action, only an earlier exhaustion will be the result. Attention is called to the factthattheaccellera- tors like other motor nerves cause an increased muscle ac- tivity, i. e., increase its tone, its excitability, and its conduc- tivity, which in turn depends on a more rapid katabolism. Hence in causing this increase only a more rapid exhaustion of the reserve force stored in the heart muscle or in its other centers of supply is produced. The same principle is applic- able to each organ in the body. Its function is not decreased because of an inherent laziness \ but because its force has been lessen- ed through exhaustion of nutritive material. The reaction may be as great as the original action. Leaving the structural conditions as they are, a temporary accellerated peristalsis of the intestine will be followed by a period of more lessened bowel activity. Just as in the use of a cathartic a constantly increasing dose is necessary to produce an action till finally it becomes ineffective, so a mechanical stimulus will be followed by a lessening response. A stimu- lation of the vaso-constrictors will be followed by a greater vas- cular dilatation. An inhibitory treatment for pain is occasion- ally followed by a return of the sensory disorder in greater intensity. In many cases the palliative treatment serves only to conceal a serious condition. Osteopaths condemn the old- school practice of giving morphine for lessening pain and yet in numerous instances make use of exactly the same reasoning and practice with barely a thought of the consequences. The concealment of a pain condition from the patient by any treatment without the removal of its cause is a crime against the patient, if the pain is necessary for diagnosis of the case. The THE TREATMENT OF DISEASE. 149 plea that the patient insists on it or that it gives nature a chance for repair is seldom a sufficient justification. The lessening of a rapid heart beat gives often a sense of security -entirely unwarrant- ed by the real state of that organ. The "tonic" treat- ment gives a temporary sense of exhilaration similar in kind if not in degree to that following moderate doses of morphine or alcohol. This form of deception is FIG. 8.-Theory of Inhibition. ]ittle more justifiable than any other and as often results disastrously. A final objection that is exemplified occasionally is the fact that a treatment habit may just as really be formed as will a drug habit. In both cases the organism eventually tends to rely on the artificial stimulus instead of the natural one for its proper functioning. That individual who requires frequent treatment to be kept in normal "tone" is as much a treatment habitue as is he who requires the daily application of the needle, a morphine fiend. And yet many osteopaths pander to the temptation by advertising the value and pleas- ure to be derived from a "tonic" treatment. But it would be incorrect to leave the impression that such attempt at direct control is never justified. Experience seems to suggest that while there are numerous possibilities of ineffectiveness or of real harm in such purely palliative treatment, there are occasions where such procedures may be a choice of evils. For it cannot be denied that in many cases stimulating and inhibitory treatments have been and will continue to be given with marked benefit. Note that it is not insisted that the good results gotten are necessarily dependent on nerve stimulation or inhibition. To this phase of the question reference 150 PRINCIPLES OF OSTEOPATHY. will later be made. At present we shall speak of those cases in which such treatment is theoretically or practically de- manded. INDICATIONS FOR ATTEMPTS AT DIRECT CONTROL. In those cases where a lesion is not apparent, and no other known cause is noticed a treatment in the region of innervation is often seemingly helpful. In occasional cases the ordinary practitioner will not be able to detect splanchnic or other lesion affecting the stomach and yet stomach trouble exists. Treatment applied in the lesion region for such dis- orders will often be effective. A lax condition of the general circulatory mechanism is sometimes apparent where no definite lesion can be assigned for the disorder. A general spinal "toning up" is resorted to with at least temporary benefit. An over active peristalsis is often checked by strong pressure in the lumbar or lower thoracic region. Pain is lessened by treatment over the structures associated with the sensory nerve involved. It would seem to be helpful to apply a stimulus after re- moval of lesion or other cause. The analogy is drawn be- tween the cases of a stalled horse whose progress is hindered by a stone in front of the wheel of a vehicle, and an organ working against a hindering lesion. In each case the pulling force has become discouraged. After removal of the stone it may be helpful to "touch up" the horse with a whip, and like- wise to "touch up" the organ through its nerve mechanism. The liver is often directly manipulated by pressure after the spinal lesion is removed. The sluggish kidney will seemingly respond to a treatment after the lumbar lesion is removed. A iiterine headache will be sooner overcome if a cervical treat- ment is given following the adjustment of the uterus than would otherwise be the case. In rare cases where removal of the cause may be impossible or impracticable. In such case it will be a choice of risks whether to leave all to nature or to attempt to V CF COLLEGE CF OG THE TREATMENT OF DISEASE. 151 bring out any latent power of nature that the condition itself fails to arouse. In an ankylosis of the spine the lesion is a bony union and as such is practically impossible of removal. The functions interfered with thereby may be aided by occa- sional treatment of the spinal regions and of the involved or- gans directly; flooding from the uterus following parturition may be lessened by a stimulus to the mons veneris ; intense nervous or mental excitement interfering with direct treatment to the primary lesion may be lessened by pressure applied in the sub-occipital region; it may be necessary to lessen paw, in case of such intensity as to prevent use of the various meth- ods of diagnosis, or the application of treatment measures. In some cases direct stimulation may force an obstruc- tion and hence be a factor in the removal of a lesion as well as overcoming an effect. Increasing the heart's force may overcome a congested venous or capillary condition. Direct work over the liver may increase bile secretion and thereby assist in removing obstruction to the gall duct. Direct treat- ment to muscle tissues may assist in adjusting the structures to which those tissues are attached. In occasional instances it may be necessary to resort to heroic measures in order to tide over the crisis. In case of a sudden heart failure direct pressure over the solar plexus or manipulation in the accelerator region may assi'st in prevent- ing collapse; in case, of hemorrhage an extreme stimulus ap- plied to the part may temporarily check the flow; spasmodic laryngitis or croup may be prevented from terminating fatally through strangulation, by treatment of the laryngeal and other structures. In some cases it may be advisable for the osteopath to place himself on the same plane with the old school physician and treat the symytoms as they arise, for it is to be noted that a symptom may in some cases be a distinct hindrance to normal processes of repair. With reference to pain, while it is of value to the organism in numerous ways its great intensity in some cases renders it a distinct disadvantage and inhibi- TCO nO 323JJOO I jjliAtOlc\ KS 152 PRINCIPLES OP OSTEOPATHY. tion may become helpful by lessening the nerve disturbance thereby giving the organism a better opportunity for repair; an excessively high temperature becomes a menace to the life of the individual and direct treatment for purposes of lower- ing that temperature may be called for; the rapid waste of the fluids of the body in certain diarrhceic conditions contrib- utes to an undue weakness and may be prevented by inhibi- tory treatment; in case of excessive vomiting where no longer irritant material is ejected the nervous disorder permitting it may be adjusted by inhibitory treatment. It will be noticed that in most of the foregoing cases the treatment partakes largely of the nature of a choice of evils and suggests what it is necessary to continually emphasize, that these measures are only to be employed where, in the judgment of the physician, the primary and logical treat- ment, i. e., removal of cause, is not immediately possible or practicable. Do WE STIMLUATE OR INHIBIT? But if further analysis is made of the above cases it will be found that the words stimulation and inhibition are decep- tive in many cases. In the ordinary acceptation of those terms it would be understood that the function of the part dis- ordered was increased or decreased directly or through its connecting nerve. But let us see. In the first set of condi- tions referred to stimulation was employed where no appar- ent lesion was present. Emphatically that does not mean that no lesion was present. In the application of a "stimulating" treatment to the region of innervation we are persuaded that instead of pure stimulation of those nerves by a quick pres- sure alternating with relaxation, there results in reality a re- moval of distinct impingement upon nerve or other structures which rendered their activity sub-normal. Note a typical case. In occasional instances of constipation no very distinct spinal lesion ia apparent; all experience indicates that a "stimulating" treatment through the lower thoracic and lum- THE TREATMENT OF DISEASE. 153 bar regions is more effective than is a quiet pressure treat- ment; if the results were dependent upon direct effects pro- duced on the splanchnic nerves the latter form of treatment should be the more effective, for the physiological result of stimulation of the splanchnic nerves is a lessened peristalsis. In such a case as this there is undoubtedly produced an effect upon the involved nerves, but it is done indirectly, through the removal of pressure conditions in the spinal region which were pro- ducing the existing inhibitory effect. What is true of the stimu- lation in this case we are persuaded is true in the vast major- ity of cases. If it is the direct stimulant effect on the nerve, why will not titillation of the skin in the process of tickling, or the application of an electric stimulus be productive of equal- ly good or more favorable results? In the second class of conditions the analogy between the horse and the organ is far-fetched. While it is true that the horse may become discouraged there is nothing to indi- cate a possibility of a similar condition in case of an organ ; on removal of the lesion the disease condition itself is the only "touching up" process necessary to arouse the entire respon- sive powers of the organism. When the removal of the lesion is impossible the so-called stimulation or inhibition that is supposed to be advantageous may perhaps be a real though incomplete removal of a part of the lesion condition. Any breaking up treatment of the spine in the rigid condition of that structure opens up the tissues and undoubtedly frees the nerve and vascular mechanism of the spine sufficiently to ac- count for the benefit that results from the treatment. With reference to the inhibition ofpam which is the typical example of the value of inhibition as a therapeutic measure, a few con- siderations may not be out of place. This proposition is fun- damental : The success in overcoming any pain condition is in di- rect proportion to the amount ofstructitral adjustment effected. Given a pain condition with little structural change present, the pos- sibility of diminishing that pain will be a minimum ; with the greater removable structural abnormality associated with the 11 154 PRINCIPLES OF OSTEOPATHY. pain will go the maximum possibility of pain removal. FOP instance there are numerous cases of pain resulting from vis- ceral disorders. In these cases there will be also muscle con- tractures in the spinal region either primary or secondary. In either case the pain will be overcome in proportion to the ex- tent to which the muscular contracture or other lesion is di- minished. Reference has been made to the fact that in ex - perimental physiology it is most difficult to apply pressure gradually enough to prevent stimulation not to speak of the possibility of lessening the nerve action concerned. This is possible, that the nerve action may be lessened by a destruc- tive process such as is associated with the action of the various anodynes. It is possible that the good effect from pressure continuously applied over the nerve terminals may result partly from this actual though temporary destruction of the nerve terminals. We are inclined to think that in so far as the pain condition is removed by this direct nerve pressure it is produced by some such disorganization or molecular dis- turbance of the nerve protoplasm ; which if true makes it at on 3e apparent that such treatment is one of doubtful value. It has been assumed that the stretching of the sciatic nerve produces the lessening of the pain by virtue of pressure of the nerve sheath upon the axis cylinder processes throughout their extent. Physiological experimentation shows that the stretching process at first renders the nerve protoplasm more irritable; if long continued its irritability becomes lessened or totally destroyed, in which case there must be produced a disturbance in the arrangement of the protoplasmic molecules such as to interfere with their normal relationships. Such an explanation may account for the good effects that often follow the stretching of the sciatic nerve in so-called sciatic rheuma- tism. The other explanation is the more probable, i. e., by the hyper- extension of the limb tension of the associated structures is removed with a resulting lessened impingement upon the nerve and its branches. In summing up the discussion emphasis is to be laid up- THE TREATMENT OP DISEASE. 155 on the fact that the removal of lesion or other cause of disorder constitutes the logical treatment for that disorder. Where a structure or organ needs stimulating or inhibiting, it can be done in but one proper way and that an indirect way, i. e., the removal of the cause that makes it necessary to stimulate or inhibit. Hence we formulate the two following similar propositions : 1 . The necessity for stimulation presupposes an existing inhibi- tion; the removal of the cause of that existing inhibition constitutes the legitimate method of stimulation. 2. The necessity for inhibition presupposes an existing stimula- tion ; the removal of the cause of that existing stimulation constitutes the legitimate method of inhibition. These propositions are fundamental and comprehend the essence of the osfceopathic view of the treatment of disordered conditions and are applicable to the entire field of disease. TREATMENT OP DISEASE CAUSED BY ABUSE. In discussing the causes of disease attention was call- ed to the fact that abuse of an organ or its function will ulti- mately produce a diseased condition of that organ. What con- stitutes the legitimate treatment for such cases? It is obvious that a negative treatment is undoubtedly called for, i. e., simple abstinence from abuse. If stomach disorder be caused by continual over-loading,lessen the load. If writer's cramp re- sult from excessive exercise of the limited set of muscles, stop writing. If the environmental conditions are such as to sub- ject the individual to abuse of the respiratory tract, move out and away from such environment. This proposition seems valid : In case of disease due only to. abuse and not associated with structural disorder, no positive manipulative treatment is indicated. Through ages of false training men have become established in the belief that for every apparent disorder something should be done in the way of definite artificial treatment. Reliance has heretofore been placed on the drug. With the one who has learned of the efficiency of osteopathic measures 156 PRINCIPLES OP OSTEOPATHY. he assumes a "treatment" is necessary under the similar cir- cumstances. In many cases he is right. In numerous cases he is wrong. In those cases where temporary disorder results from manifest abuse treatment is unnecessary and perhaps harmful. In this regard advocates of any form of psychic therapeutics are essentially correct. Let alone and nature will be the all-sufficient factor in cure. But experience and reason both indicate that there are limits to the recuperative power of nature, and osteopaths emphasize that in many cases that limit is represented by a definite obstruction in the machinery through which nature manifests her curative power. In such case artificial aid is indicated. Note this fact. Most cases pri- marily due to abuse are not unassociated with structural disturbance. In many cases ^predisposing lesion is present which represents a factor involving definite difficulty in nature's reparative processes. In more cases secondary lesions will arise which add to the disorder and constitute new causal factors. In both of these cases definite manipulative treatment is called for and without question is advantageous. Hence it is found that cases in which treatment is not necessary or helpful are comparatively rare, and the osteopath should never fail to carefully examine a condition before he pronounces it a case requiring no treatment except the negative one of abstinence. Will a patient recover under osteopathic manipulation when he refuses or is unable to abstain from abuse? Numerous cases of such are found. Occupations requiring life in adverse circumstances of environment must be con- tinued by many in order that life itself may be supported. The miner still must live in the mine, the writer still must use his exhausted fingers, the unfortunate must still use ill- nourishing food. Can such recover? In countless cases, yes. In any case, only with greater difficulty. As illustra- tion may be cited any number of cases of eye trouble that have been successfully treated at the A. T. Still Infirmary where the patient at the same time was taking the school course and was compelled thereby to abuse his eyes. So long, how- THE TREATMENT OF DISEASE. 157 ever, as abuse is the sole factor, which is only an occasional condition, little can be done if the abuse is continued. On the other hand, will a patient recover if, predispos- ing or secondary lesions be present, no manipulative treat- ment be given and the patient simply abstains from abuse? This is undoubtedly true in a large number of cases. For it has already been shown that while function is much more markedly self -regulative than in structure yet nature is suc- cessful, unaided in many cases, in overcoming a definite structural change. This will be more noticeably the case with reference to the lesions which have arisen as secondary processes during the course of the abuse than in those cases where a predisposing lesion was present from the beginning. In the latter case it is likely that the tendency to the disorder will not be overcome and hence the condition regained will be that of the organism previous to the abuse, i. e., there will still be a predisposition. But in all cases where lesion conditions of any kind are present practice and common sense indicate that removal of lesion and abstinence from abuse must go hand in hand if most satisfactory results are to be obtained. MISCELLANEOUS NOTES. A few questions of general interest invariably arise in the mind of the student with regard to the difficulty expe- rienced in overcoming the lesion, the time required to effect a cure, and the frequency and length of treatment, and it seems advisable to note a few of the facts which enable us to explain the varying results obtained, and suggest the factors necessary to be considered in judging cases, although it will be noted that in many instances the judgment of the physi- cian in the immediate case will be the court of final appeal. The first to be noted is an explanation of the fact that lesions are not immediately removed. Osteopathy has made its reputation before the world perhaps more be- cause of a few occasional startling instances where a single 158 PRINCIPLES OP OSTEOPATHY. treatment has overcome a case of long standing than by the vastly greater number who have been cured only after long and toilsome effort on the part of both physician and pa- tient. The strength of the system is derived from the latter class but it is most noticeably brought to the attention of the world by the former. Why is it that all cases are not of the "quick cure" class? If the treatment consists in re-arrang- ing the luxated parts why not do so immediately as does the engineer with his engine? There are several facts which serve to explain this situation. In the first place the man- machine does not quickly change its parts under normal con- ditions. While there is continual change it is a process requir- ing time. It is no less true in abnormal states. The vitaliz- ing force carries forward its work of repair certainly but slowly. In this there is a marked distinction from the man- made machine. Again, it is necessary to remember the con- ditions presenting themselves in case of a lesion. When first produced the tendency is to draw back into line or other- wise overcome the abnormal part by the inherent power of adjustment. In many cases nature is successful in this ef- fort. In occasional cases she is unable to accomplish the re- sult and in such we have the field of operation for the physi- cian. But note the second effort on the part of nature. Fail- ing in applying adjustment by drawing back to normal align- ment the perverted structure she applies it in the way of adjusting the surrounding structure in position and form, to the new abnormal one. This becomes especially noticeable in case of a hip dislocation where it is known that the su- perior hip muscles have permanently shortened while the inferior ones have correspondingly lengthened. A general re -arrangement of parts will also take place in case of a vertebral or a rib lesion, so that in numerous cases the new condition becomes finally a normal one in the sense at least of producing no marked abnormal functioning; not normal, however, in the sense of the new arrangement being as sub- stantial as the original. In a certain percentage of such THE TREATMENT OF DISEASE. 159 cases there will still be a partial failure to adjust and a real and chronic lesion prevails. It is necessary then for the physician to either overcome this partial adjustment or to give enough of aid by manipulation to permit a full adjust- ment to the new condition. In either case it is obvious that some considerable time will be necessary. Of course the above considerations have especial reference to chronic lesions. In acute cases much less time and fewer treatments will be required. Again, in many cases the lesion is not entirely re- moved, that is. in the sense of securing a complete return to normal of the perverted part. This is less often true when we consider the other side of the lesion idea, the perverted function. For while in many cases the structure may not be entirely overcome, in most of these the perverted function will have disappeared. Note the fact that as a general rule the function will have become normal before the structural parts will have been entirely overcome. This fact depends on the power of adaptability possessed by the organism. It is able to produce normal function with tools that are not as yet ideal. From this fact we see one explanation of the lesion's incomplete re- duction. The patient, as soon as he feels normal and sees no further symptoms of any disorder, will assume that his cure is complete; and for the time and perhaps permanently that is true. Hence he will refuse longer to pursue the treatment. In all such cases emphasis should be laid on the fact that the incompleted structural reduction will remain a weakened con- dition and hence be a continuous menace to the health of the individual either in causing a return of the original disorder or of another that is possible from the same lesion. Further, owing to the partial adjustment that has taken place in the chronic case the strength of the new articulation or adhesions may be such as to defy the most persistent treatment. We are persuaded, however, that in the great majority of cases the original normal condition of structure as well as function 160 PRINCIPLES OF OSTEOPATHY. may be restored provided opportunity'in the way of time is secured. With regard to the frequency of treatment, only gen- eral rules may be given. At the risk of becoming tiresome, the statement must be emphasized that it is not the physician but nature that heals. If it were the former one might be justified in frequent attempts to adjust a part. Since it is the latter, time must be permitted in order that the gradual pro- cess of repair should take place. It must be remembered that a condition which is such as to preclude immediate adjust- ment must be one in which a process of reverse growth must take place before the part can be restored to its original position. It will be a "growing back" in real truth and growth requires both time and quiet. If a beginning can be made in reduction at the first treatment one should be satisfied; then allowing sufficient time to elapse for adjustment to the new conditions that have been produced the process of repair and restoration will be carried forward with sufficient rapidity. In general a frequency sufficient to compel a continuous sore- ness throughout the entire interval is usually too great. In chronic diseases the average case will prosper most satisfac- torily with treatment applied two or three times per week. But each case must be a study in this sense as in others. In some cases oftener and in many cases a less frequency of treat- ment will be found most satisfactory. For instance, the "Old Doctor" has always insisted and younger practitioners are learning slowly that he is right that the ordinary case of asthma should not be treated oftener than once per week or ten days. On the other hand actite conditions require more frequent attention. In such the changes are much more rapid both with respect to repair and to the pathological states that are produced. Further, owing to the latter fact there are continually arising secondary lesions and other causes of dis- order which must have attention. An acute case will usually need treatment one or more times per day during the more critical periods. THE TREATMENT OF DISEASE. 161 The considerations in the above paragraph hold in part in regard to the length of the treatment. The young osteopath invariably will give more time to an individual treat- ment than will an older practitioner. It is characteristic of Dr. Still himself, that he "treats a case and goes," and his success is no less remarkable than the brevity of his treat- ment. There is such a thing as drawing upon the vitality of the patient by a too lengthy treatment. It is not likely a long treatment will be given except by him who gives a general rather than a specific one. For it takes but a few moments to produce sufficient irritation of a local part to cause serious and successful protest on the part of the patient. Where the body is treated as the masseur treats much time is required, but osteopaths are not masseurs. Cases are met with occasion- ally where, owing on the one hand to lack of skill on the part of the practitioner and on the other to an extreme tissue ten- derness of the patient, some preliminary treatment may be necessary before specific work can be given. In such cases time may be used to good advantage in somewhat prolonging the treatment. In nervous individuals any indication of hurry on the part of the practitioner will react unfavorably on the patient. With reference to the rapidity of movement a caution is necessary. In dealing with all cases, whether primarily a bony lesion or other tissue, quick movements are not advan- tageous with but a few possible exceptions. A quick move- ment will usually act as a stimulus to an already hyper-sen- sitive tissue. Hence the tissue is made to "set" against the effort to move it. Muscle and other tissues which are directly worked upon in treatment are structures which under all con- ditions change their shape and condition only gradually. The tissue can be led but only with difficulty and with much possi- ble harm will it be driven to its normal relationships. There is a possibility of harm in the treatment by manipulation. The statement is repeatedly made that "if osteopathy does you no good it will do you no harm." The 162 PRINCIPLES OF OSTEOPATHY. statement is interesting in that it is more or less untrue. Osteopathic manipulation properly applied will not be likely to result in danger but in the hands of an individual unacquaint- ed with the laws of leverage and the arrangements of the levers which he uses in most movements, there isjxmch pos- sibility of harm. While it is not true that the force sufficient to reduce a lesion is sufficient to prodiice one, yet there is enough of truth in it to be worthy of notice. The harm may result be- cause of the intensity of the application. The intensity may be either in the abruptness or in the absolute amount of force used. There are certain leverages in the body by which a, sufficient force may be applied to rupture the strongest liga- ment, while a force not so great but suddenly applied may easily produce serious injury. The harm may result because the treatment is too prolonged. In such a case the tissue either becomes exhausted or what is more common, over-irritated, with a resulting congested or even inflamed local area. In the same way irritation may follow too frequent treatment, in which time for repair is not given. Under such circumstances there is little possibility of producing satisfactory results and much chance of "causing further disorder. We do not speak thus at length on the possibility of harm from treatment wrongly applied simply because of theoretical reasons. Sufficient evidence is brought forward to show that disorder has resulted. With ordinary care and average judg- ment the treatment is entirely harmless but where those quali- ties are lacking it may not be so. In any case it would not be a difficult matter to show that while there may be some dar associated with the administration of osteopathic treat- me ; infinitely more safe than that of drugging. * reference to the method of the movement that may be er 'ed it is necessary to emphasize that probably no two p ,itioners who have been long in the field will execute a particular treatment in exactly the same way. There are a large number of methods in the employment of the same principles of adjustment each of which may, under certain cir THE TREATMENT OF DISEASE. 163 cumstances, present its own advantages. Individuals differ in the ease with which a movement can be executed. . Hence it is illogical for a teacher to insist that a method must be employed because it is the correct one. It is not necessarily so. The patients themselves differ quite markedly in refer- ence to the readiness with which they yield to particular treat- ment and it will be found by experience that what is perfect- ly appropriate in one individual will not be satisfactory in another although the lesion may to all appearances be the same in each case. True, in all movements account must be taken of the leverage employed ; the physician must know the situation of articulation, the attachments of muscles and the like. But he can only know these as they exist in the average case. Every new case will present new conditions and will require at least slight differences in the application of treatment. Hence in a later section discussion is given to a few common movements that are in general use merely to emphasize and illustrate the principles that underlie every adjustment that is effective. The mere imitation of any physician's peculiar methods will always be unsatisfactory. Understand the forces it is necessary to use, determine in each case through what parts those forces may be applied, then adapt the method to the circumstances of the case. By fol- lowing such a plan the student becomes a man of emergencies and learns to use his mental powers on each individual case instead of yielding to the pernicious habit of. passing each of his cases through the routine of an unvarying set of manipu- lations. 164 PRINCIPLES OF OSTEOPATHY. CHAPTER IX. COMPARISON WITH OTHER SYSTEMS. In the foregoing chapters considerations in general form have been given to the outlines of the osteopathic philosophy, suggesting the application of the latter to the etiology, diag- nosis, and treatment of disease. In the present chapter the description of the same picture will be continued by the method of contrast, attempting, in suggesting the salient points in the other systems, to show the indentity in concept between all other schools, and the distinct and fundamental difference between them and the osteopathic system. In making the comparison it will be necessary to refer somewhat in detail to the principles and methods associated with the other various systems. The items of information have been derived from various sources, all of which are authoritative. We shall discuss in order the following more or less distinct systems: drug therapy, electrotherapy, hydrotherapy, psychotherapy, and mechanotherapy. DRUG THERAPY. Throughout all ages men have relied quite largely upon the internal administration of other than food materials for hope of alleviating their physical disabilities. Whether the drug was used as a distinct combatant of -the disease entity that was formerly believed to exist, whether it was given for a direct chemical effect on the body tissues, or whether given as & placebo, it has held patient and physician in its thrall throughout the centuries. Until comparatively recent times little attempt was made to show any relation between the na- ture of the medicine and the effect on the disorder, all sub- stances in the pharmacopeia holding their position by virtue of the fact that observation of their effects on the organism seemed to suggest a curative value. That the observation was usually COMPARISON WITH OTHER SYSTEMS. 165 false is indicated by the brevity of life of each individual drug- the specific of one decade becoming a discarded relic in the next, a condition as true today as ever in the history of medi- cine. That the empirical method was practically the only one used in the past is evident and that it still is largely employed is equally true. Dr. T. Lauder Brunton is un- doubtedly an authority on the giving of drugs hence no ob- jection should be recorded against accepting his statement as representative of the general profession. In hia work on Lectures on the Action of Medicines, published in 1899, these words are found in reference to the use of alcohol in certain conditions: "The rule for the administration of alcohol is a very simple one. It is to sit by the side of your patient for a while and watch him after the administration of a dose of alcohol, and if you find that the alcohol brings back the various functions nearer to normal, then it is doing good ; if the functions of the organs diverge further from the normal after the administration of alcohol, then it is doing harm" (p. 329). But it must not be thought that at the present time nothing is being done by the advocates of the drug in the way of attempting to put the system on a scientific basis. Never in the history of medicine has so much attention been given to the investigation into the nature of the effects produced by the various drugs upon body tissues. Never has the study of the chemical conditions of the body been so intense as at the present time, in the hope that by determining the chemical nature of body tissues in health and disease chemical sub- stances could be obtained which would in a chemical way modify the body conditions. The study is primarily for the purpose of determining how, through a chemical medium, a function may be modified. The question demands an answer and the very fact that it is asked suggests that the old school investi- gators have an approximately correct conception of the nature of disease, i. e., perverted function. Unfortunately they have not yet been able to grasp the fact that function can only be 166 PRINCIPLES OF OSTEOPATHY. modified through the structure that is associated with the function. In the present stage of drug practice several specific pur- poses are kept in view. These various purposes will be briefly discussed. Drugs are given for their stimulant effect. In those cases where the activity of an organ is below par some drug is given which is believed to have a tendency to increase that activity. In certain nervous disorders strychnine is given, for its effect is known to be exerted upon the nerve centers there- by increasing the facility of discharge; digitalis is in very common use as a cardiac stimulant and exercises its influence upon the heart mechanism directly; morphine in small doses gives a peculiar sense of general well-being and as such ex- ercises a stimulant influence upon the nervous system; the numerous bitters used for purposes of increasing the appetite are further examples. It is to be noted in this connection that while the drug in one sense acts upon the tissue, it is the re- action of the tissue upon the drug that produces whatever good result may follow. The tissue exerts its excretory and other protective powers in order to rid itself of the presence of the irritant material, and in so increasing its activity its function may be temporarily normalized. A second effect produced by the drug is that of the seda- tive. Any drug which produces a lessening of activity is spoken of as possessing sedative properties. Opium with its alkaloidal extracts is the typical example; while in most cases it will produce a slight stimulant action, it is most used for purposes of deadening pain. Its principal effect lies in render- ing the cells of conscious sensation less responsive to incom- ing stimuli. Hence, while the irritant causing the pain is still present the pain itself may not be felt because of the lessened irritability of the higher centers; cocain lessens the over-activity of the spinal cord and of the peripheral nervous system by producing a lessened irritability ; aconite is a de- pressant of the heart and hence is used in cases of extreme COMPARISON WITH OTHER SYSTEMS. 167 activity of that organ ; various astringents are given which, acting upon the mucous membrane of the intestinal canal, lessen its peristalsis. A third function of the drug is that of neutralization. A simple illustration of this use is the household remedy for sour stomach, ordinary soda; formerly, the salts of salicylic acid were given in cases of rheumatism on the assumption that they hastened absorption of the deposits by neutralizing them; at the present time the medical fraternity is enthusiastic over the use of various serums which are assumed to have a neu- tralizing effect upon the toxins generated in the body by bac- terial action. Substitution constitutes another of the purposes in drug giving. It has long been known that in anemia there is 1 a poverty of red blood corpuscles and of haemoglobin believed to be due to a lack of iron. Hence arose the practice of ad- ministering inorganic iron compounds with the idea that this material could be directly substituted. The view has of late years been discarded since it has been demonstrated that practically none of the iron thus administered is assimilated, and while at the present time it is still administered its sup- posed good effects are explained from its stimulant action on assimilation processes; in the case of administration of the organic extracts from various of the ductless glands l the body we have other illustrations of the substitution idea. For some time it has been known that the absence, congenital or other- wise, of the thyroid gland results in a dwarfing of body and mind, and it has further been found that when these glands from other animals or extracts from the gland were given to the individual as a part of his food the condition was often partially or completely overcome. In such a case the ma- terial secreted by the gland of a lower animal constituted the substitution. This however partakes more largely of a dietetic than a drug treatment, for the material is already or- ganic and in such a form may be assimilated in the same manner as is food material. 168 PRINCIPLES OF OSTEOPATHY. A further action that certain drugs were supposed to ex- ert was that of a germicide. With the comparatively rapid rise and almost universal acceptance of the germ theory of disease the medical profession arrived speedily at the con- clusion that the problem of overcoming disease was solved. Since the bacterium was the cause of most disease conditions the only requisite for preventing and curing the disease was the drug or other means which would annihilate the micro- organism. Hence in the laboratory, experiments were car- ried on to determine what particular chemical substance would destroy or render inactive each specific micro-organ- ism. Unfortunately it was soon found that owing to the ex- treme tenacity of life manifested by the average bacterium, any drug sufficient to destroy its life was more than sufficient when administered internally to destroy the body cells. Hence the present use of germicides and antiseptics is largely limited to external administration in the form of sprays and antiseptic washes. Practically all effects of the drug may be classified un- der the above five divisions. The question arises, are the re- sults real and satisfactory. It is not denied that the admin- istration of the drug is sometimes effective and in numerous cases seems to temporarily relieve. There is no question that digitalis will usually stimulate the heart's action ; that mor- phine will often temporarily lessen pain; that fairly good evidence is presented that the diphtheria antitoxin may lessen the mortality rate; or that other drugs may sometimes be of some value. The question is, does the good resulting from their use exceed the harm? All experience goes to show that the harm is in excess and the better class of physicians of all schools are beginning to realize that fact. A few of the ob- jections to the use of the drug, suggesting how the harm is likely to result, may not be out of place. With the possible exception of the germicide every drug given is for the purpose of combatting effects and practi- cally ignoring the cause. A cholagogue is given to stimulate the liver functions. In doing so the physician recognizes COMPARISON WITH OTHER SYSTEMS. 169 only the torpid liver,, i. e., the effect; the opiate lessens the consciousness of pain but the cause of that pain still persists. An irritant drug given to stimulate an organ but adds to the burden. A renal stimulant causes double work on the part of the kidney ; that organ being already overworked with reference to its nutritive condition must, in addition to throwing off the toxic material from normal katabolic activity, eliminate also the drug which has passed into the vascular system. There is always danger from a possible cumulative ef- fect. In the constant use of digitalis as a heart stimulant the time will usually come when the ordinary dose instead of pro- ducing its usual stimulant effect will bring on a state of collapse with a possible fatal termination. The old school authorities recognize such to be the case although the explanation is not forthcoming. If it were possible to apply a remedy directly to the tis- sue that needs it without bringing it in contact with other or- gans not involved in disorder there would be less objection to the use of drugging. But in case of most of the organs the only ready channel through which the tissues may be reached is the circulatory system, and whether the drug be injected directly into that system or be taken by absorption from the alimentary canal all parts of the body must of necessity be contaminated with the drug. Such being the case it is not difficult to understand why other parts of the body become poisoned even though the diseased organ may have been benefitted. It is notoriously true that the stomach of the con- stant drug taker is in a continual state of disorder and simply because that viscus has been converted into a receptacle for material never designed to enter it. One of the most severe indictments of the drug system lies in the fact that there is always a possibility of habit for- mation. While this is especially true of a few drugs, such as alcohol and morphine, there is no drug which is exempt from the possibility. Thus Crothers in his work on "Morphinism 12 / 170 PRINCIPLES OF OSTEOPATHY. and Narcomania from other Drugs "enumerates a whole series in which observation shows the possibility and probability of the habit formation. Morphine, cocain, chloral, chloroform, tobacco poisons, ether, arsenic, quinine, and numerous others are named. That the drug addiction has gained an extreme hold upon the American people is indicated from the fact that one individual in every six hundred is permanently addicted to the use of morphine. When we stop to consider the dozen or other drugs in almost as common use the picture becomes ap- palling. And when the fact is understood that the effects from the use of morphine, cocain, and several others are equally as disastrous to the individual and to the nation as is alcohol, it would seem that the time is ripe for including in the tem- perance crusade evidence and anathema against the use of drugs. In this connection the statement of Dr. A. P. Grinnell in a late issue of the Medico-Legal Journal is suggestive : "Sooner or later the reformers of the world have got to divert some of their feverish antipathy to alcoholic stimulants and consider calmly and intelligently the drug evil. The deleteri- ous influence on the individual of all forms of drug addiction and the consequent effect on society and all relations of man- kind, make its considerations in its sociologic and criminal aspects of paramount importance. The courts have never given much judicial importance to drug habits, but widespread development of drug addiction must surely, sooner or later, bring the matter into greater legal prominence." In connec- tion further with the fact of habit formation, one of the most prominent medical journals {American Medicine) has this to say in a recent issue: "In the 'American Journal of Phar- macy' for November, 1902, is the report by Mr. Hynsori, chairman of the committee appointed by the American Phar- maceutical Association to investigate the question of the ac- quirement of the drug habit. This report, while it is written from the standpoint of the pharmacist, reveals a state of af- fairs so truly appalling that it merits the consideration of every physician, indeed of every person interested in the wel- COMPARISON WITH OTHER SYSTEMS. 171 fare of society. As perhaps the moat accurate means of de- termining the question of the increase in the drug habit in the last few years, the committee gives the statistics concerning the importation of two plants most commonly employed fop this purpose namely, opium and cocaine. Since 1898 the population of the United States has increased ten per cent. ; the amount of opium imported, however, has increased to the startling extent of Jive himdred per cent., and this despite the fact that it is less frequently used by physicians than in years past. The importation of opium for 1902 amounts to the as- tounding sum of 712,000 pounds; and this is exclusive of more than a ton of morphine. This increase in the importation of opium is paralleled in the case of cocaine, the quantity of that alkaloid brought into the country in the year covered by the report being three times as large as the importation of 1898. As the committee points out, it is impossible that there should have been any such enormous increase in the legiti- mate demand for the drug. Indeed, it would seem probable that the administration by physicians, certainly of opium and probably also of cocaine, has diminished rather than in- creased, and it is thus safe to conclude that practically all of this supernormal demand is by drug 'fiends.' From responses to letters addressed to a number of pharmacists and physi- cians in various cities and towns in the East, the committee concludes that in the eastern part of the United States out of every one thousand inhabitants about three are addicted to the use of some drug other than alcohol. The condition of affairs among certain classes is almost inconceivable; thus one of our correspondents, whose business is in the Tender- loin district of New York is personally acquainted with two hundred opium habitues, while the police officers assert that cocaine adulterated with acetanilid is peddled from door to door as an ordinary necessity of life. Such a condition of affairs is so threatening to the very existence of society that its causes cannot be too thoroughly investigated in order to discover a proper remedy." 172 PRINCIPLES OP OSTEOPATHY. A writer in another journal {Medical News) in discussing the rapid inroads patent medicines are making upon the health and finances of the American people has the following to say: "As a nation largely neurotic both ancestral and acquired we offer an inviting field to venders of such wares, who ply their trade with a vigor worthy a better cause, and with results of which we must make note if we would conserve the best interest of many whose well-being is given to our care. It goes without saying that the larger, by far, number of the many nostrums nervines, antineuralgic pills, powders, tablets, and liquids so much heralded and lauded for relief of pain and nervous unrest, have morphine as their active part. And this 'part* in some is not small. In one, largely advertised, there is one-eighth grain in each teaspoonful. The risk of morphinism, in certain persons, from that amount is large; in fact, a smaller, in a highly nervous patient on whom it acts kindly, will create the disease. A ten-years' case of morphinism, under my care, seven years ago, had its rise in a one-sixteenth grain daily dose. Even larger risk of inebriety obtains in using the various nostrums containing cocain, so much lauded for the relief of coryza andother nasal ills. In the form of catarrh snuffs and solutions, its power for harm is far greater than when taken by mouth ; in fact it ranks almost or quite with its subdermic effect, by virtue of the highly absorptive nasal mucous membrane, and its nearness to the brain, making its seductive power and ill effect on mental health especially prompt and pernicious. One of these nostrums contains i^j per cent, cocain two per cent, is the strength of ten used for anesthesia and any 'cure' having that amount is dangerous. Insanity is certain if its use be continued." The following table showing the percentage of alcohol in certain patent medicines is also suggestive, especially in view of the prevailing energetic campaign against beverages which contain greatly less percentages : COMPARISON WITH OTHER SYSTEMS. 173 Greene's Nervura 17.2 Hood's Sarsaparilla 18.8 Schenck's Seaweed Tonic 19.5 Brown's Iron Bitters 19. 7 Kaufman's Sulfur Bitters 20.5 Paine's Celery Compound 21.0 Burdock's Blood Bitters 25.2 Ayer's Sarsaparilla 26.2 Warner's Safe Tonic Bitters 35.7 Parker's Tonic 41.6 Hostetter's Stomach Bitters . . . . - 44.3 Finally it remains to consider as a definite objection to the use of the drug the .uncertainty of its effects. That it is uncertain what the result may be in any given case no in- formed physician will deny. The search for "specifics" has practically been abandoned and for good reasons. The fact that every living individual is a law unto himself was never more clearly emphasized than in the manner in which differ- ent individuals respond to the drug, or the same individual to the same drug at different times. Because of this individual peculiarity the use of drugs for curative purposes can never be satisfactory nor scientific. The following paragraph taken from an article in the July issue of the American Journal of Physiology (On the Effects of Subcutaneous Injection of the Extract of the Suprarenal Capsule upon the Blood-vessels of the Rabbit's Ear, by S. J. Meltzer and Clara Meltzer) is significant in connection with the above considerations: "Now our knowledge of the effects of all drugs, alkaloids, toxins, or metabolic products,is most- ly derived from a study upon normal animals or organs. Are the effects the same when the organs are deprived of their normal innervation? As far as we know this question has as yet hardly been seriously raised. Our experiments have demonstrated that the effect on pathological organs can be diametrically opposite to that on the normal ones!" (p. 260.) 174 PRINCIPLES OF OSTEOPATHY. ELECTROTHERAPY. The various forms of electric application are made use of for various purposes in connection with disease. At one time it was used more for diagnosis than for cure and in this re- spect at the present it is of some value. It is known that the application of a current to a nerve produces a definite and appreciable change in that nerve technically spoken of as electrotonus. Comparisons with respect to this condition be- tween normal and abnormal nerves will usually show distinct differences. Hence the "reaction of degeneration" is an important indication of disorder of a nerve structure. The same is true to a less noticeable degree in the case of muscle tissue. As a diagnostic agent it may further be of value in certain medico-legal relations, in determining a real from a simulated condition. In those cases where sinister objects are in view in assuming the symptoms of a particular disease in order to procure damages, the application may in many cases absolutely show the falsity of certain of the claims. But within comparatively recent years a curative value has been assumed for the application, and with the rapid desertion of the drug by both laity and profession recourse is had to the use of electricity. In general the same purposes are believed to be accomplished by the current as have been assigned to the drug. McGregor -Robertson (Physiological Physics) enumerates the following: stimulant, counter-irritant \ anti-spasmodic, electrolysis, cautery. Of these the last two are primarily surgical in their use and as such may have their legitimate place in the surgeon's armamentarium. Monell and Hay em both suggest a specific trophic action from the application, the former instancing a case of increased growth in stature by application to the . articulations. This action should be considered as a subdivision of the stimulant action. Is the method effective or satisfactory? Let the au- thorities and the practitioners experienced in that method answer. Hayem {Physical and Natural Therapeutics) emphat- COMPARISON WITH OTHER SYSTEMS. 175 ically declares it is more uncertain than the drug. Could there be a stronger statement ! In this connection he says : "But the reader has been able to see that our knowledge is still not far enough advanced for us to think of formulating in a pre- cise way the mode of action of electricity upon the organism. The only certain thing seems to be that this action is very complex even where it is exerted upon a healthy organism. A fortiori, it is still more obscure and more difficult to define when we are working in a therapeutic way i. e., by applica- tions upon parts modified by disease or upon parts whose manner of reacting deviates more or less widely from the normal. Moreover, under a great many circumstances we are ignorant of the real conditions under which we are intro- ducing the electric agent. We are almost absolutely igno- rant of the pathological physiology of the neuroses and of most of the diseases of the nervous or neuro-motor system, diseases which are precisely the ones in which electrization scores its most incontestable successes. It would be useless, therefore, for us to lay any stress upon the various theories upon which observers have thought to base the rational em- ployment of electricity. Empirical results are so far the only ones that can serve us as a guide. " Verworn in his work on General Physiology declares, "In cases where by disease a portion of a nerve has become temporarily impassi- ble to stimuli, medical treatment endeavors, often with suc- cess, to hinder the atrophy of the tissue supplied by the nerve by stimulating it artificially by electric currents, and in this action of the galvanic current lies the therapeutic importance of electricity." (Italics mine). Jacoby in his two volume work on the subject refers more or less at length in no less than sixteen separate paragraphs to the value of the application because of its psychic effect. Note the significance of this paragraph found on page 133 of Vol. II : "We should never forget that it is not the electricity as such that cures, but that it is the entire procedure of electrization, with all the physical and psychic effects thereby produced," and in an- 176 PRINCIPLES OF OSTEOPATHY. other paragraph he suggests the advisability of doing all ar- ranging of apparatus in presence of the patient being careful to avoid any failure in the attempt, otherwise the suggestive effect will not be so great. With reference to the value of the Roentgen ray as a therapeutic influence, little can be said at the present time. Its value as a diagnostic agent is unquestioned. Sufficient experimentation has not as yet been made relative to its therapeutic value to warrant definite claims one way or an- other. As a surgical accessory in removing morbid growth it may become of value. Note this fundamental fact, however: The ray sufficient in intensity to destroy a micro-organism or a cancer cell will also be sufficient to destroy a normal body cell, and further. the ray cannot be limited in its course or in its effect to the former. Here we have seemingly to deal with conditions that con- fronted the early germ theorists who attempted to render the micro-organism ineffective by giving a drug definitely de- structive to it only to find that while the germ was destroyed such was no less true of the body cell. Further evidence for or against the X-Ray is awaited, confident that its value is limited to a narrow field. The same considerations hold with respect to the various forms of phototherapy, whether the cure be in the form of violet rays, green rays, or allopathic doses of ordinary sun- light. All rest upon the same basis. It will be seen by a careful analysis of the foregoing statements that the foundation for the practice of electro- therapy is the same as that for the practice of drug medication. In other words, the electrotherapists are still fighting the battle from the rear by attempting to overcome disease by combat- ing its manifestations. When the electrotberapist applies his battery for the purpose of stimulating a lax organ he is using the same principle that the drug therapist employs in the use of chemicals for the stimulation of that organ. When he reduces a sensory condition, as of a neuralgia, he is merely destroying the sensibility of that nerve in a manner similar COMPARISON WITH OTHER SYSTEMS. 177 to its destruction by the use of an anodyne. When by ap- plication of electricity for secretory, vaso-motor, or trophic effects he attempts to increase metabolic processes he is still working peripherally rather than centrally. The real cause of disease conditions seems to be an unknown quantity, or the assumption is made that the removal of such cause is out- side the realm of possibility. HYDROTHERAPY. In hydrotherapy the osteopath has in numerous cases a less objectionable substitute. Not that it is desirable to incorpor- ate its practice as part of the osteopathic system but in that with the present development of the osteopathic science proper our ability to apply distinct and effective osteopathic proced- ure is limited. It is further to be noted that there are occa- sions where emergencies arise which can only be met with some foreign and artificial means. In most cases the use of water as a vehicle of heat or cold is the least objectionable. Its promiscuous use for occasions where it is entirely uncalled for is greatly to be deplored. Actual practice is found to need but an occasional use of such methods and if proper application could be made of the osteopathic principle such use would be an extreme rarity. The more common use of water as a therapeutic measure lies in its value as a thermal agent. In many cases of high temperature it is a distinct advantage for purposes of re- ducing such by means of a simple sponge bath or the more extreme and dangerous method of immersion. So far as actual experience indicates it is in extremely rare cases where the latter method is risked. Its use as a stimulant is of some value in certain cases. Where applied locally as in the case of a dash of water in the face of a fainting individual it is not associated with apparent danger; but where applied generally the reaction is always an uncertain quantity and hence the procedure is not to be advised except under extraordinary circumstances. That the 178 PRINCIPLES OF OSTEOPATHY. value of the reaction is as uncertain as in the case of drugs cannot be questioned and rests upon the fact that no two in- dividuals respond in the same way to the application. As a general stimulant repeatedly applied it is a pernicious practice and causes a condition of habit little less objectionable than that of the drug. For there is no question that the simple practice of a daily cold general bath is not an unmixed good. Man is not an aquatic animal so far as his external surface is concerned and neither should his normal metabolism be made to depend on the artificial stimulus supplied by the daily stimulating bath. Note that there are extremes in both directions. We do not argue for uncleanliness but we insist that a distinction be made between an excretion and a secre- tion. Herein lies the fallacy of the one extremist who insists that the "pores must be kept open" by continual washing with soap in order that the excretions may be removed. We insist that the skin is as much a secretory as an excretory organ. This is especially true with relation to the sebaceous glands the sebum from which acts as a nutrient material to the hair, an oil for both hair and skin, and a protection against infection over the entire body surface. It is a peculiarity of the sebum that the fats which it contains do not become rancid, i. e., they are unfavorable soil for the development of micro-organ- isms. He who robs the skin of this material by repeated applications of soap opens an easy pathway for infection. A further use for the application of water is as a sedative. Tt is common knowledge that numerous cases of pain asso- ciated with an inflammatory lesion may often be lessened by the application of either heat or cold, the choice of which is largely determined by experiment with each individual case. In numerous cases of constipation the warm water enema is valuable. Especially is this true in the various con- ditions of impaction where, associated with the opening up of the bowel by manipulation the movement can be effected with less difficulty. In this connection a word of caution is neces- sary. The writer has had occasion to examine a number of COMPARISON WITH OTHER SYSTEMS. 179 cases of atony of the rectum which he was persuaded were direct results of the regular use of the enema. It is absolute- ly as true of the enema as it is of the drug- that after continual use the bowel becomes largely dependent on the abnormal stimulus for its movement and like the drug requires increas- ingly more intense application. No claim for cleanliness or haste can justify other than an occasional use of the injection; for it must be remembered that all mucous membranes are self-cleans- ing and as such do not require the continual ablutions to which some individuals are unfortunately subjected. These considerations hold good not only for the mucous membrane of the rectum but are equally true with reference to lavage of the stomach, to vaginal douches, and to the washing out of the bladder. In all these cases the normal cleansing and protecting material mucous is removed, the glands become over -stimulated, and finally from lack of nprmal protection various pathological conditions are produced or established. PSYCHOTHERAPY. The rapid rise of a large number of cults who claim to be able to overcome disease through application of the fact that the mind has a direct influence over the body metabolism is one of the remarkable facts of the last half century. Whether they be styled Christian Science, magnetic healing, faith cure, or simple mind healing, all are based upon the one principle. That cases presenting considerable functional dis- turbance have been permanently cured under the ministrations of their followers is no longer questioned. In all of their con- tentions, absurd as some of them may be, there is an element of truth. That body affects mind and that in turn mind affects body are propositions subject to no dispute. The ex- tent of that influence in either case constitutes the battle ground of the contestants. At the basis of their philosophy we find a tenet which is fundamental to the osteopathic con- ception and that is what has been repeatedly emphasized, that it is the organism and not the physician that cures, and 180 PRINCIPLES OF OSTEOPATHY. that nature has a remarkable power of self -restoration. The objection to the psychotherapist of the extreme school is that he fails to recognize that there must be a limit and in reach- ing that limit nature must be aided before further progress can be made. Herein lies the physician's duty. It is not advisable at this time to enter into detail with reference to the methods or means of suggestion as a thera- peutic agent but a principle may be enunciated which will cover all cases of disordered mental conditions or body con- ditions resulting from the mental disturbance. In the first place it will be noted that so- called purely psychic di sorders will be the ones most readily overcome by the mental healer. There is such a condition which we may designate as the vital level, fluctuations and disturbances of which may be caused by extraordinary mental or emotional activity. This disturb- ance of the vital level will only be a temporary one, the or- ganism itself seeking its own level and restoring its own equilibrium. In case the mental or emotional excitement be extreme in intensity or prolonged in time structural conditions may be disturbed as a result of the extreme mental or emotion - al functioning. Even then in many cases the vital level will be restored, the structural changes having been overcome following the cessation of the psychic disturbance. But as has been indicated in other sections structural conditions are less immediately under the control of the reparative forces and hence will be more likely to persist. When such do per- sist the vital level is not restored and we have presenting a real structural. lesion. With such a case the osteopath has especially to deal in the removal of this secondary lesion. The principle for which we contend in all these cases is that mental and emotional as well as body conditions constantly tend toward the normal and if open channels of interchange are maintained between the cells at the basis of psychic functioning and their sources of supply those psychic functions will be restored in their integrity. The continued over- exercise of the psychic functions such as over-study, worry, and the like, constitute COMPARISON WITH OTHER SYSTEMS. 181 an abuse of psychic functioning, the abstinence from such abuse constituting the only necessary treatment in cases un- complicated by obstructive lesion. In psychic conditions, then, we have to deal with cases essentially similar to body con- ditions, for so far as our work is concerned the psychic activi- ties are the functions of certain nerve cells. Those functions will be normal if the structures at their basis are kept in a condition of normal nutrition, and since every case of any severity invariably presents more or less marked lesion, the treatment will be different only in the manner of helping the patient in abstaining from further abuse. MECHANOTHERAPY. The subject of cure by manipulations and exercises of an active nature has in late years gained a remarkable promi- nence. As one of the results of this interest in mechanical methods there is an unfortunate tendency on the part of many to assume that osteopathy is but a special form of what others have long been applying under the name of massage or Swed- ish movements. That there are seeming similarities, both in the objects in view and in methods of treatment no one will deny. But that these similarities are only apparent while the real difference is fundamental is a proposition agreed to by every one who takes the pains to investigate. It seems wise therefore to enter somewhat in detail into the subject. For the purpose of working upon safe ground, it is necessary to have a definite understanding as to what con- stitutes massage and these other mechanico- therapeutical measures. According to Kleen, "By massage (which means to press or to knead) we mean a mechanical action which is performed on the soft tissues for a therapeutical purpose, by means of certain manipulations, namely, stroking, rubbing, kneading and striking." Kellgren, after Ling, includes in massage also shakings and vibrations. Although massage strictly does not include the gymnastic movements which involve the exercise of the organs of motion, and Swedish 182 PRINCIPLES OF OSTEOPATHY. movements strictly do not include massage procedures, yet in practice and in the theory of effects of these procedures the two are so interwoven that they may with all propriety be considered together. To indicate the development of mechanical therapeutics it will not be amiss to give a brief statement of its history. Some idea of massage and its effect probably has been known from the earliest times. The ancient Persians, the Egyptians, and even the Chinese, 3000 B. C., made use of these physical means of cure. Among the Greeks considerable progress was made a century B. C. Hippocrates refers to the use of frictions in sprains, luxations and constipation, and records a list of cases. Among the Romans massage and gymnastic ex- ercises were in high repute, and in the second century of our era Galen made considerable study and application of mechanotherapy. Like other elements of civilization during the dark ages, little progress was made. In the fourteenth century when anatomy was studied with greater enthusiasm than ever before, the system was revived, and from that time to the present has had a more or less varied experience. That a knowledge of the effects of mechanotherapy was more or less prevalent in the time of Lord Bacon is indicated from the writings of that distinguished man who says: "Frictions make the parts more fleshy and full, as we see both in men and in the currying of horses. The cause is that they draw a greater quantity of spirits and blood to the parts ; and again they draw the aliments more forcibly from within ; and again because they relax the power and so make the better passage for the spirits, blood, and aliment; lastly, because they dissi- pate and digest any inutile and excrementitious moisture which lieth in the flesh, all of which helps assimilation." In the early part of the seventeenth century, massage was made to contribute to the service of beauty. Hoffman, in the early part of the eighteenth century greatly assisted in the promo- tion of mechanotherapy by his works, more particularly his writings. He declares "that on account of their influence COMPARISON WITH OTHER SYSTEMS. 183 upon the circulation, the appetite and general condition, gymnastics are the best of all remedies," and also following Hippocrates and Galen, treats quite fully of massage. Follow- ing Hoffman, individuals in Germany, England and France, separately and after their own manner contributed to the development. Mechanotherapy in Sweden began largely with Peter Henry Ling who lived from 1776 to 1839 and from him the Swedish movements as a system dates its origin. Ling was essentially a gymnast, being a teacher of gymnastics and fencing in the university of .Lund, and it was the beneficial effects of the movements upon himself that led to the develop- ment of his system. While employing these movements of the body for therapeutical effects, however, he did not neglect massage but recognized its helpfulness and incorporated it as a part of the Swedish movement system. Although this system is constantly associated with Ling's name, he by no means originated the several movements comprising it but undoubtedly he did exert a large influence on organizing the various therapeutical measures thereby creating a distinct system. It is since the middle of the nineteenth century that mechanotherapy has made its greatest advance, and in Hol- land, in Germany, in Austria, in England, and in France, as well as in Norway and Sweden, physical methods of healing have been and are being developed. In summing up, Kleen remarks that massage as yet hardly holds the place in thera- peutics to which it is entitled, and suggests as an explanation of this fact two reasons : First, the practice has largely been in the hands of unscientific persons and therefore in many cases has been more harmful than helpful; second, using his own words, "it must also be admitted that the unsatisfactory standing of mechanotherapy is partly the fault of us physi- cians. Hitherto the world of scientific medicine has neg- lected this form of treatment, the practice of which is always more troublesome than writing prescriptions and almost al- 184 PRINCIPLES OF OSTEOPATHY. ways less remunerative. Very many physicians are still so ignorant of mechanotherapy that they are alike unable to understand it or to teach it to others. Finally, there is a class of men in our profession afflicted with what I should call intellectual snobbery, who will on general principles have nothing to do with a method of treatment that calls for me- chanical labor." Further, quoting from Kellgren regard- ing the slowness of the development of mechanotherapy, we note this complaint which has such a familiar ring : "The result of the manual method in these and other nervous dis- eases would be still more successful if the patients had re- course to the treatment sooner. At present it is used as the last plank after everything else has failed. Not only then have we to contend with the diseases in their very advanced stage, but also with the sunken courage and lost energy of the patient which reacts so unfavorably on his general health." Passing to a consideration of the technique of massage several forms of manipulation are described. Effleurage con - sists of a series of strokings over a portion of the skin or other soft tissues in a centripetal direction. The more pronounced and immediate effect of this is acceleration in the circulation of the blood and lymph through the local part. According to Ling slight strokings tend to soothe pain in the superficial structures as well. Frictions are in the nature of rubbings in a circular direction over small areas and are employed to pro- mote absorption. Petrissage consists in a kneading of the tissues either between the thumb and fingers of the operator or against bony and other tissues of the body of the patient. It is supposed also to aid absorption and acts as a mechani- cal stimulation of the muscles as well as producing an effect on the nerve terminals within the tissue. Tapotement consists of light blows or choppings given by the flat of the hand, the fingers, or the edge of the fist, and acts as a mechanical ex- citant of muscle and nerve, the excitation causing contrac- tion of muscular tissue which results in increased activity of the flow through superficial vessels and nerves. The shaking COMPARISON WITH OTHER SYSTEMS. 185 movements as given by Ling, are applied to portions of the body more or less easily moved and are advantageous in promoting absorption, in its stimulating effect, and in its re- duction of congested and inflammatory conditions thereby lessening pain and increasing glandular activity. This move- ment is applied to the pharynx, larynx, thorax, and abdomen, as typical cases. For instance, in its application to the lower part of the thorax, the operator places one hand on either side, making quick compressions and relaxations, thus in- fluencing chest and abdominal activities. A modification of the shaking movement is seen in -vibration and is applied to the eyes, throat, chest, and abdomen. The effect is similar to that of the shaking movement but is supposed to be es- pecially efficient in reducing disturbed sensory conditions. In distinctively kneading movements effects are gotten on im- pacted bowels by direct work along the course of the intes- tine, while kneading associated with the shaking movement is declared to be helpful in biliary calculus. As to the special effects secured by the masseur, there are, according to the latter, many that the osteopath undoubt- edly secures indirectly. He often meets cases which are more or less addicted to the treatment habit, and who apply at his office for a "toning up" treatment to relieve them of the feeling of exhaustion. Masseurs have the same idea in mind when they indicate that massage, more particularly ef - fleurage, aids very materially in overcoming fatigue in groups of tired muscles. The products of muscle katabolism, which are largely responsible for the feeling of fatigue, are thus forced out more rapidly making way for nutritive supplies. Further, as Kleen states, massage acts both as a pressure and suction pump. The forcing of the fluid from the tissue creates a negative pressure which acts as a further force in circulation. This fact is taken account of in conditions of an inflammatory character which, as the masseurs themselves point out, be- gin with the dilatation of the small vessels of the part, with a subsequent slowing of the blood stream. Hence in the treat- 186 PRINCIPLES OF OSTEOPATHY. ment which consists of working around an inflamed area as in appendicitis, or tonsilitis, or gastritis the osteopath is do- ing merely what the masseur does. A case is cited in this connection of a cure in retention of urine from an enlarged prostate by direct manipulation of the gland, a procedure many osteopaths are free to advise and use. A further effect is claimed for massage in the prevention and possible cure of muscular atrophy, at least where that atrophy is due to pe- ripheral causes, for example lack of exercise of a certain muscle group. In this case there is, according to the reason- ing of the masseur a trophic effect, either through the medium of special trophic nerves or through the direct blood supply. And they have recognized a further effect of massage than the mere local and direct influence on blood flow; for in speak- ing of tapotement having an effect on the heart Kleen says: "So far as the human subject is concerned, little more can be said than that massage, no matter how it is employed, pro- duces reflex effects both during and after its application, which effects are seen in the narrowing as well as in the widening of certain blood vessels; in the rise as well as in the fall of arterial blood pressure; in the quickening as well as in the slowing of the pulse. Still it is safe to say that the particular character of these effects is determined by the manner in which the massage is given, by the place in which it is applied, and the organs reached by it," and he refers to the common experiment showing that after massage of one arm, probably through a vaso- motor effect a dilatation or a constriction of the vessels of the other arm results. He also speaks of a rise of blood pressure during addominal massage due to a constriction of the arteries of the mesentery. A further result to be gained by massage is in the break- ing down of newly formed capillaries where new growths are developing. Frictions are the procedures employed and in this connection the osteopath naturally thinks of his de- struction of the "feeders" in certain congested and inflamed conditions of the external coats of the eye or the eyelids. COMPARISON WITH OTHER SYSTEMS. 187 Ziegenspeck refers also to massage for the breaking down of adhesions between the uterus and rectal wall. Another purpose for which the masseur works is one which osteopaths constantly have in mind, namely, the con- trol of circulation; and the result is gotten, not only by the influence exerted on general blood flow and blood pressure through the medium of vaso- motors, as for instance when Kellgren indicates that shaking or other manipulation at the pit of the stomach exerts a direct influence on the circulation of the abdomen and hence of the entire body, or in another ex- ample in which he cites the relief of headache and congestion of the brain by work in influencing the circulation to the head through the effect gotten on the occipital nerves \ but he also attempts a direct control of the blood flow as evidenced by cases cited of circulation changes by direct pressure on the abdominal aorta and of the relief of fainting^from shock by pressure on the internal jugular veins. There are those who insist that in nerve massage and vibration the masseur has his most efficient therapeutic measure. As illustrative of the application the following cases are cited by various authors : overcoming the spasmodic action of the diaphragm both by inhibition at the origin of the nerve and by shakings applied at the pit of the stomach ; trouble with the eye in which direct pressure is made on the eyeball itself thereby stimulating its nerve mechanism ; vibration of the nasal and supra-trochlear branches of the fifth in catarrh of the nose and frontal headache ; vibrations of the dental branches of the fifth resulting in the relief of neuralgic toothache; the striking example given by Ziegenspeck in which he claims that slight choppings on the back and percussions transversely across the sacral region are said to induce the central nervous system to exercise a tonic influence upon the relaxed ligaments of the uterus', the still more remarkable instance in which Kellgren's work states in regard to frictions along the pneumogastric nerve, "its effect upon the heart is utilized when the action of the latter is too strong, "or referred to by Kleenin thiswise, 188 PRINCIPLES OF OSTEOPATHY. "I would point out that though we may by pres8ure upon the vagi in the neck cause slowing and even cessation of the heart, still it is by no means a harmless procedure and its usefulness under any circumstances whatever remains to be proven;" and still another example as given by Kleen in which stretching the sciatic nerve is advised in case of sciatic rheumatism. Not only is this direct effect gotten by means of nerve stimulation but also the possibility of affecting remote organs through reflex activities is granted. In Kellgren's work the following summary is given relative to the effects of nerve vibrations : "First, raising of the nervous energy ; sec- ond, diminution of pain; third, contraction of the smaller blood vessels; fourth, stimulation of the muscles to contrac- tion; fifth, increased secretion of the glands; sixth, diminish- ed excretion from the skin ; seventh, decrease of temperature. ' ' Finally, masseurs are aware of the fact'and the possible significance of tender points in the tissues along the spine over the area from which nerves are given off to organs which are in a diseased condition ; evidently, however, they have considered these tender points as always secondary to the diseased viscus. Cases are cited in one of which where there was a disease of the lungs, the patient was very sensitive along the spine between the shoulder blades, and in another, diseases of the generative organs, the bladder, and rectum were found associated with various tender places along the lumbar and sacral regions. Thus far it has been indicated that in many ways there is a similarity between the various systems of mechanotherapy and that of osteopathy. It remains to substantiate the propo- sition that there is a difference essential in kind and funda- mental in importance. What is that vital difference? A few differences have been presented to the public which are cer- tainly non-essential. It is declared that massage is general in its application, osteopathy specific; that it is only very rarely that massage is given to local parts for local troubles. From what has been said above it will be seen that this dis- COMPARISON WITH OTHER SYSTEMS. 189 tinction is decidedly lame. "While the general treatment in massage holds prominent sway, to declare that local treat- ment for local effect is very rarely used is, to say the least, over-stepping the bounds of caution. It will be seen from the foregoing that massage can be as specific in its application as is osteopathy so far as localizing the treatment is con- cerned. A second distinction made is that massage is only a part of a system while osteopathy covers the whole field of disease. A very little analysis only will be necessary to in- dicate the non-essential character of this distinction. It is true that osteopaths claim that their science covers the whole field of disease. It is also true that there are numerous dis- eases with which osteopathy has not yet come in contact, and further there are numerous diseases over which osteopathy so far has not been able to exercise much control. Admitting this is not granting that in a further development of the science it will not be able to control these diseases. So far as the masseurs are concerned, they make the claim for their practice that it is being found applicable to more and more of the disease conditions, and that the ultimate status of the system cannot be foretold. A third distinction which is made is that while osteopathic practice necessitates a thorough knowledge of anatomy,physiology,andetiology,these branch- es are not essential in massage. This so-called distinction, while indicating an ignorance of the practice of massage is also grossly unjust to the followers of that system. The dis- tinction merely compares the well trained osteopath to the un- instructed, untrained masseur, the unfairness of which is evident. True, a large number of the masseurs are unin- structed in these branches but are trained to perform certain movements and are under the direction, in many cases, of a regular physician ; the osteopath might take an ignorant man and without any instruction in these branches teach him to perform certain osteopathic manipulations which would be productive of good results, and yet should the claim be made that he were a representative of osteopathy a storm of ob- 190 PRINCIPLES OF OSTEOPATHY. jection would arise. There are fake masseurs and assistant masseurs as well as fake osteopaths and assistant osteopaths. The essential distinction between osteopathy and all other systems of healing based on manipulation clusters around the etiology of disease. While these other systems, as indicated at least by their practice, look at disease from a peripheral standpoint, osteopathy views it from a central standpoint. Starting with the cell theory as a basis, they have regarded life and hence disease as a series and a com- plication of cell activities. Taking a concrete case, a certain set of cells constitutes the liver. Under normal conditions the part taken by the liver in the life of the organism consists in the sum of the activities of that particular group of individual cells. A diseased condition of the liver is but the activity of the cells in the group, abnormal in kinder quantity; hence re- medial measures have been applied directly to them. The masseur, by compression, stroking, shaking, or nerve stimu- lation, acts directly upon the liver. On the other hand, the osteopath, taking into consideration the ability of nature to functionate properly, recognizes a central force sufficient to keep in normal action this particular group. And when a disturbance in the normal activity of those cells is manifest he reasons that the influence from this central force to the in- volved cell group has been obstructed, diverted, or otherwise interfered with, and his work consists in discovering the nature of that interference, the point of interference, and the removal of interference. This constitutes the only purely osteopathic consideration of health and disease, and if a differentiation is made between osteopathy and the other forms of mechanotherapy, this is the view that must be ac- cepted. SUMMARY. A few of the facts relative to the more important of mod- ern methods of dealing with disease have been touched upon and if care has been taken it will be observed that there is a COMPARISON WITH OTHER SYSTEMS. 191 remarkable similarity of basis throughout. We are pre- pared to insist that the bases are identical ; that a difference between any two is a difference in detail and in degree only, not a difference in essentials. The basis of all the methods is that enunciated boldly by the drug therapists, treat the symp- toms as they arise. In so far as any system is guided by such a rule of practice it must occupy an illogical position. The manner of treatment of symptoms, if such treatment be necessary, is a comparatively inconsequent matter. It is not meant by this that one method is necessarily as good as another in accomplishing the result, for such is hardly true. But it must be insisted that the position assumed is funda- mentally the same. On this basis the phrase "natural methods," in common use, is a misnomer. No method is a natural method where artifice is necessary. Only that method is natural in which the organism unaided effects a cure. The reason for the inclusion of every known method with the lone exception of drug healing in the category of "natural methods" must be regarded as a profound enigma. Why this singling out of the drug? If it be natural for the sick man to expose his nude body to the burning rays of the sun in taking the "sun cure" ; or to inject or otherwise use continued excess of water in the method of the hydrotherapist; or to introduce into the body a charge of electric energy ;or to ignore the fact of disease ;or even to apply manipulative stimulation or inhibi- tion; it certainly is no less so to administer a dose of soda for a sour stomach. Demonstrate that there is fundamentally any difference in the absolute between the action of the drug and the action of these others and there will be reason to con- fine condemnation to that alone as being unnatural. This is no plea for the drug. It is undoubtedly true that of them all the drug is associated with the greatest possibility of danger, but it must be insisted that that fact does not make any dis- tinction in kind. The author is opposed to all of them on the basis that they are all illogical methods; but in those cases where a logical method is not available it may be advisable to 192 PRINCIPLES OF OSTEOPATHY. resort to that least associated with danger. He who persists in inchiding in the osteopathic system these so-called natural systems has no aiithority to exclude the drug. In so far as he does include all these, his is not a system but a conglomerate and the practitioner should be willing to take his proper place among the naturopaths whose practice he follows but whose claim on his allegiance he ignores. Hence in the case of a disorder of an aggregation of cells a viscus for instance what is the treatment by the practitioner of other schools? It is the same in principle whether the agent be drug, electricity, water, heat, light, suggestion, or mechanical stimulation. If the organ be slug- gish a stimulant is given. An excess of impulses presum- ably reaches the organ which causes increased activity. What matter, fundamentally, whether the excess result from drug or nerve impulse from higher center, from mechanical irrita- tion or electric charge? Or if the organ be over-active what difference whether the inhibitory effect be produced by one or by another? If an excess of acid be present in the stomach is it the acid that is at fault that the drug giver should attempt to neutralize it by an alkali ; or is it the fault of the gland in being over-active that it should be quieted; or are the digest- ive forces derelict to duty that they should be whipped into normal activity by water, or by mechanical pressure, or by electric touch? These measures can at most be but temporary. The acidity, from whatever cause, will not be present except the instrument through which the digestive processes are performed be interfered with. The only essential in the treat- ment is to remove the interference to those processes which normally provide the neutralizing substances, or better, to relieve the condition which causes the necessity for a neutral- izing substance. And why attempt to substitute, whether it be a drug as iron for anemia, or a force as an electric current in nerve ex- haustion, when all such necessary substances and forces are COMPARISON WITH OTHER SYSTEMS. 193 present potentially in the food materials? Rather remove the impediment to the assimilation processes which prevents the normal conversion of that potential into a kinetic mani- festation. In like manner, why be satisfied with attempts, which' can never be entirely successful, to destroy the micro- organism? The body, by virtue of its white corpuscle, its alkalinity and its special acid substances, its nucleins and its alexins of the blood, and its numerous superficial structures and substances, is already thoroughly protected except when its nutritive condition is below par due to disorder of its me- chanism. Rather it is the part of wisdom to attend to the struc - tural condition of the organism which will permit or compel a normal function. Fundamentally then the difference is an absolute one. The distinct and peculiar position of the osteopath as an ad- vocate of a new system lies in his contention that disease is caused or maintained by structural disorder, the re- moval of which constitutes, the treatment. If the liver be- comes disarranged the drug therapist administers a chola- gogue; the electrotherapist introduces an electric stimulant; the hydrotherapist applies water ; the mental healer removes hindering mental conditions; the mechanotherapist com- presses and stimulates by mechanical means; while the os- teopath removes the hindering structural condition which prevents normal nutrition and hence restoration of normal metabolism. 194 PRINCIPLES OF OSTEOPATHY. PA RT I I . CHAPTER X. THE SPINE. GENERAL SURVEY. Because of the fact that the spine is of such fundamental importance to the osteopath a brief general survey of its structure and relationships will be given before taking up sepa- rate divisions for specific 'study. That the spine is of such importance is recognized by every practitioner, for it is only in occasional cases of disease that no treatment is given to it, while almost invariably regardless of the nature of the symptoms presented, the careful osteopath will make a study of its various parts in the process of diagnosis. With reference to the general contour of the spine a few points should be noted : The normal curves are four in number, two of which may be considered primary, the others secondary and compensatory. During fetal life and to the second year of infancy the anterior curvatures are not mark- edly developed indeed during intra-uterine life the spinal column constitutes the arc of a circle while in infancy it is comparatively straight. As the child assumes the erect pos- ture the anterior curvatures become developed, that develop- ment being necessary for purposes of equlibrium. The tho- racic and the pelvic curvatures are physiological in the sense of forming a cavity for the protection of various viscera. In addition to this advantage there is the equally important one of providing against the shock to the body generally and to the brain especially that would otherwise occur at every jar or even footfall, the column in this way performing the office of a mechanical spring. In noting the anterior and posterior curvatures the fact should be remembered that a vertical line THE SPINE. 195 cutting the tips of the spinous processes of the verterbrce is not parallel with the longitudinal aris of. the spinal column taken as a whole, this fact being dependent upon the difference in obli- quity existing between the spinous processes of the various regions; for instance in the raid -thoracic region owing to the extreme obliquity of the spinous processes a line passing through these will approach much more closely the spinal axis than it would in the lumbar region. Hence, a spine ap- pearing perfectly straight as judged by the row of spinous processes will not be so in reality. In making judgment with respect to the prominence or otherwise of the various curves the transverse processes should be noted, to correct errors arising from consideration of the spines alone. A spine which has in reality had its curves obliterated is technically spoken of as a straight spine and will often be associated with the so-called [smooth spine, a term which has come into use as representing a condition in which the connecting structures between adjacent processes have become thickened and in numerous cases contracted, giving it undue rigidity. The smoothness is not necessarily indicative of a state of lesion, for it may be a simple filling in of normal tissue, but the rigid- ity in most cases is evidence of a lesion. The rigid spine depends upon one or more of several pathological changes. It may be due simply to muscle con- tracture in which case the rigidity will temporarily yield to a relaxing treatment; it may be dependent on overgrown and contracted ligamentous tissues resulting from irritation, conges- tion, or inflammation of those structures; in some cases it is due to structural alterations in the articular and interverte- bral cartilages from erosions or deposits; while in extreme cases when associated with a former inflammatory lesion, it is due to bony ankylo sis, in which the diagnostician will not be able to detect any movement between adjacent vertebrae. In considering the case of the rigid spine the fact should be re- membered that with increasing age there will normally be in- creasing rigidity. 196 PRINCIPLES OF OSTEOPATHY. Cases are met with considerable frequency presenting the opposite condition to . the above, in which the laxity of the spinal column is quite apparent. This will be equally noticeable whether the patient is in the erect or horizontal posture. In the former, movement of the part is free and ex- treme and the patient will seem to be unable to hold the spine erect for any appreciable length of time; in the latter if he lies upon ttie side a lateral curvature will seem to be present with the convexity below, this appearance being due to the weight of the body upon the yielding column. Such cases are usually the result of a chronic condition in which nerve force and blood conditions have become altered; in many cases it simply represents a stage secondary to a former rigidity dependent upon muscle and ligamentous contracture. Lateral curvatures are among the more common lesions and are usually double, i. e. , if a primary curva- ture is present in the upper or middle thoracic toward the left, there will be a secondary or compensatory right lateral curva- ture in the lumbar region. This will be true of practically all lateral curvatures of any considerable degree of development, the compensatory condition developing in the same way and for the same purpose as those of the antero-posterior type, i. e. , for pur- poses of maintaining equilibrium. With refer- ence to the lateral curvature it should be noted that it is again true that the extent of the cur- vature of the spine taken as a whole may not be correctly represented by the line of spinous pro- cesses^ for with many cases of lateral curva- ture there will be a rotation of the vertebra upon its vertical axis in such a manner as to Fig. 9. NO. i JB cause a greater lateral drift of the body of the in more stable equilibrium than bone than of its spine. The cause of this No. 2. Hence compensatory peculiarity need not be here detailed except curvature IB* r physiological. to indicate that it is dependent upon the peculiar relations of the articular processes and the direction THE SPINE. 19T of the tension exerted by the muscles with reference to the leverages presented. The diagnosis will be determined by the line of spinous processes, the line and prominence of the transverse processes, the difference in the prominence of the angles of the ribs on the two sides, together with the carriage and attitude of the patient and individual peculiarities associ- ated with each case. For the purpose of determining the condition of any single vertebra, both the spinous and transverse processes must be examined. Of the two the trans- verse will be asso- ciated with less pos- sibility of error be- cause of two fads namely : they are less subject to caus- es compelling ab- normal growth con- ditions and hence will vary less from the typical shape and, second, the pair affords oppor- tunity for compari- son. The spinous processes are the more easily reached and are of advan- tage because of that fact. In noting the relative position of the fingers be rapidly down over Fitf. 10. Approximation between 8th and 9th and separation between llth and 12th thoracic spines. spines may drawn them or on either side, in this way tending to produce flush- 198 PRINCIPLES OF OSTEOPATHY. ing or pallor of the skin overlying them, in which condi- tion they may be compared with each other. Or in the rapid passing of the hand the muscular sense will suggest any slight swerves or deviation not noticeable on first inspection. Separations between spinous processes suggests a weakness dependent on overstretched ligaments. In most cases the condition is not a separation of the vertebrae as a whole but a separation of the posterior aspects with a corresponding approximation of the anterior parts, i. e., the bodies. In the lax spine, where a large area is involved, it is likely to be a real separation of the vertebrae as a whole, and dependent on a generally stretched condition of all the connecting struc- tures. On the other hand two adjacent spines may seem to be unduly approximated. This may be due to one or both of the opposite conditions, i. e., tightening and shortening of the ligamentous tissues posteriorly or throughout. Anterior subluxations will seldom be determined by reference to the spinous process alone but will be noted on comparison of the transverse processes with those above and be- low. The same is true with regard to the posterior, lateral, and twisted conditions. Perhaps the most common type of subluxation of a local part is the torsion or twisting of the column at the junction of two adjacent vertebras. Note that the total torsion possibility of the spine in normal conditions is about 100 degrees. (Holden). In the cervical region, the sacro-lumbar junction, and the dorso-lumbar articulation, most of the rotation is normally produced. In other parts there is present some turning while under the abnormal cir- cumstances sufficient may be present to be easily detected. This will be possible by reference to the position of the spin- ous process, the transverse processes, and the angle of the associated rib. In lateral subluxations of single vertebrae, not only the spinous process but the transverse will be out of line with those adjacent, and the angle of the rib on the side to- ward which the part is displaced will be prominent. Many conditions diagnosed as lateral will on closer analysis be THE SPINE. 199 found to be a torsion. Hence the necessity to take note of as many of the points of prominence as present themselves. To determine the serial number of the particular ver- tebra disordered, a few facts may be helpful. The second cervical is the first spinous process noted on superficial exam ination. It is prominent, bifid, and quite subject to variation in size as well as in relative development of its two tubercles. The bifid condition may not be noticeable to the amateur ex- cept on careful palpation. The third, foiirth, and fifth spines recede anteriorly in the erect position but may easily be noted when the patient is supine and completely relaxed. The last cervical and first thoracic on account of their prominence are easily detected. The last cervical may be distinguished by noticing the sixth whose spinous process usually rests upon that of the seventh in a saddle-like manner, and will often be felt as a tubercle upon the spine of the latter a few millimeters from its tip. The typical spines through the thoracic region will be on a level with the transverse processes of the vertebra next below, hence the level of the spine is not neces- sarily nor usually the level of the more important part of the lesion. The inferior angle of the scapula is on a level with the spine of the seventh thoracic. The spine, transverse pro- cesses, and spinal end of twelfth rib are on a level at the last thoracic. Also, there is usually a more marked separation of spines at the junction of the lumbar and thoracic regions than above or below. The level of the fourth lumbar is the level of the superior part of the innominata. The lumbo-sacral junc- tion is noted for its separation of spines and its greater mo- bility. This latter point may be essential to note in some cases where the first sacral spinous process is prominent. Do not be misled in reference to this junction. Often the fifth lumbar is anterior but more often it is a dipping forward of the articulation due to some weakness of the anterior or dis- proportionate strength of the posterior ligaments in which the process may not be as prominent as it normally is. Further, this is a region of wide normal variations and the abnormal 200 PRINCIPLES OF OSTEOPATHY. condition may be more apparent than real. Emphasis should be laid on the following with reference to the general survey of the spine. 1. Examine in more than one position. 2. Take note of other points than mere displacement of parts, i. e., soreness, contractures, and others to which at- tention has been called. 3. Inquire as to the relative use of the two sides, i. e., whether "right handed" or otherwise. Dr. Still calls atten- tion to the fact that all the bony prominences will be more prominent on the side most largely used. In many cases a slight curvature is noticed toward the side of greater develop- ment. 4. The row of spinous processes marks the middle line of a distinct median furrow, the regularity of which is a valuable general point in the diagnosis. This median furrow will be most noticeable in the dorso- lumbar region where its boundaries are composed of the muscle mass associated with the erector spinae system. 5. Tenderness is usually more noticed on the side toward which the subluxation was produced. But in most cases where present at all it will be no- ticed at all parts. Bending the head for- ward and downward strongly will often cause pain at the point of lesion that otherwise would not be detected ; this by virtue of the fact that the ligamentum nuchae, continued throughout the spine by the supra- spinous ligaments, exerts an upward and outward tension on the spinous processes which pass obliquely downward and outward. Pressure on the Fig. 11. Showing effect on ... , , ... ,. , , ,. vertebral spines of flexion head downward and with slight rotation will produce pain at the point of lesion. of head. UBF/RY OF COLLEGE fj p [J / c [ r f f f f r THE SPINE. 201 This is notably true of inflammatory conditions such as are present in Pott's disease. 6. Usually muscle contracture will be easily detect- ed as an associated lesion. In most cases this will locate the deeper bony and ligamentous distortion. Care must be taken to distinguish between a real contracture and a condition of tissue adjustment to the existing- deeper lesion, for in many cases prominences will be noted which are not at all due to a pathological condition of the muscle itself. On the convex side of a curvature there will often be greater superficial prominence while the actual contracture will be on the side of the concavity. 7. Note the sounds produced by movement of parts. These are more noticed in the cervical part of the spine and the costo- vertebral articulations. They depend on, first, friction of ligaments or articulations due to lack of lubrica- tion ; second, the same cause which operates to produce the snapping of the phalange -metacarpal junctions on extension of the fingers, the "breaking of the current" suggested by Dr. Still; third, adjustment of displaced structures. In most cases little importance is to be attached to the sounds unless unduly prominent for they can be produced in most normal individuals. 8. The. average lesion is slight in extent. It seems necessary to emphasize this fact continually because of the assumption on the part of the beginner that every lesion is comparable to a hip dislocation. In one sense this is true- that is, in so far as it is a change in position of the involved parts, but in most cases the displacement will be measured in millimeters rather than inches. This does not of course mean that the effect produced will be slight. Further, in noticing the prominence in the case of a lesion it should be remem- bered that the projection is not due simply to the bone but to the overlying softer tissues; for where the bone is displaced the tis- sue against which it is forced must of necessity suffer irrita- tion with a resulting condition of contracture or enlargement >: ; : : ; i .; i i c- > H S 202 PRINCIPLES OF OSTEOPATHY. from congestion and inflammation with infiltration, or finally of overgrowth. But there are exceptions in which a lesion of a single vertebra may be so marked that it would not be far from wrong to speak of it in terms of at least quarter inches. Such will either be complete dislocations suddenly produced, which are rare, or deviations gradually produced in which the bony and ligamentous growth has been sufficiently changed to allow of the displacement. That such a condition is occasionally met with will be agreed to by all osteopaths, and that it is possible is reasonable from the fact that the molecules of a block of granite may be gradually changed by sufficient pressure acting continuously. The gradual change of living bone under a muscle or other continuously acting force is much more reasonable and is known to occur. GENERAL AND SPECIFIC EFFECTS OF SPINAL LESIONS. A discussion of the manner in which the spinal lesion produces the disorder of function will represent the entire field, hence we shall speak at length of the immediate and remote results possible from such condition together with a consideration of those anatomical and physiological facts which tend to throw light upon the manner in which the lesion involves the organ in disorder. The fundamental considera- tion will be the anatomical relationships between the tissue acting as lesion and the structure artery, nerve, or other part acted upon by the lesion. Hence a recapitulation of certain known but little emphasized structural conditions will be given. Note that the entire field is covered. The spinal lesion may involve the organ by direct pressure , by impingement on artery, vein, lymphatic or nerve. In the cervical region the fol- lowing will be involved : vertebral, intervertebral, cartoid, and thyroid arteries and corresponding veins and lymphatics; the fifth, seventh, ninth, tenth, eleventh, and twelfth cranial, the eight pair of spinal, and the sympathetic nerves; direct pressure upon structures from an anterior condition of the THE SPINE. 203 cervical spine as a whole. In the thoracic region there will be direct pressure by crowding from an anterior displacement of the spine; pressure on cervico-thoracic, intercostal, and intervertebral vessels; the twelve spinal and the numerous parts of the thoracic sympathetic nerves. In the lumbar por- tion impingement will be made on lumbar and intervertebral vessels and the spinal and sympathetic nerves. In the pelvic spine, sacral nerves, both spinal and sympathetic, and vascu- lar branches will be affected, while the coccyx by its anterior distortion will directly involve the rectum and associated structures. In all of these situations the method of impingement and the explanation of results will in general be the same, and hence only general considerations will be given, reserving the details for those sections dealing with the discussion of the several divisions of the spine and body. A TYPICAL CONDITION. One of the most common lesions with which the osteo- path meets is torsion, or a twisted condition between two adjacent vertebrae. What will be the effect on the typical articulation? There are three body ligaments, anterior, pos- terior, and intervertebral substance; two lateral yellow elastic ligaments connecting the laminae; two articular structures with their typical parts; two spinous ligaments, the supra- spinous and intra-spinous; and two inter-transverse ligaments. In addition to this typical ligamentous material there is pres- ent the muscular slips of the deep layers of the spine, and all the space being filled up by supporting connective tissues. With the torsion condition present all of these various structures will be put upon the stretch as well as suffering greater or less change in sitiiation. Into and out of the spinal canal pass the following structures by way of the intervertebral foramen: the arterial branch coming off from the intercostal to pass within the spinal canal and aid in the supply of the spinal cord; the intervertebral vein or plexus carrying waste material from 204 PRINCIPLES OF OSTEOPATHY. the same region ; lymphatic vessels and spaces concerned with the nutrition of the same part; the spinal nerve made up of the junction of its roots, which occurs just within the fora- menj branches, many in number, from the various parts of the cerebro- spinal and the sympathetic nervous system. First, the artery may be impinged, not necessarily by the bony prominences but by the ligamentous and connective tissue tension and the general crowding resulting therefrom, and from an associated congestion and infiltration due to the original strain or displacement. The pressure upon the artery, if efficient, will produce in the part to which it is distributed, i. e., the spinal cord and other canal structures, a condition of ischcemia. This condition must of necessity produce greater or less disturbance of the metabolism of the cells in the spinal cord with a consequent disorganization oftlie impulses received and distributed therefrom- for while the axis cylinder process is not appreciably subject to fatigue, undergoing little katabolism and hence requiring little nutriment direct from the blood stream, the cell bodies are 'very susceptible to the changes in the quality and quantity of their food supplies. In this con- nection the physiological fact should be noted that the outgo- ing impulse from a nerve center is not the simple continuation of an impulse receivedfrom an afferent pathway, but depends directly upon changes, chemical and vital, brought about in various ways within the cell body protoplasm. Hence the ischaemic condition of the spinal cord, by deranging and limiting the metabolism of this cell protoplasm, will very materially in- terfere with normal nerve discharge. It is possible that if the pressure upon the artery is sufficiently long continued and irritating, a hypercemic condition may result. This would de- pend upon the gradual exhaustion of the tissues in the wall of the artery with the resulting lax condition permitting vascu- lar dilatation. The vein or venous plexus which drains the local spinal area will be more yielding to pressure than the artery because of the less rigid nature of the venous wall. Hence with the THE SPINE. 205 ischsemic condition produced by pressure on the artery there will be associated a venous hyperaemia, which, other things being equal, will likely be more serious than the former. This is due to the fact that the venous blood contains material of a nature ultimately toxic to the tissues and continually becom- ing more so the longer it is retained in a part. With such a condition present in the spinal cord a preliminary ex cited con- dition of the cells will be probable owing to the chemical structures of the acid and other materials in the venous blood acting upon them, but a later and more permanent condition of inhibition of impulses will result owing to the depressant effect of the prolonged presence of the toxic material. The lymphatic system may be more or less impaired by the same pressure conditions. This naturally would re- sult in the same general disorders of nutrition found in the arterial disturbance. The lymph being the medium from which the tissues directly get their nutriment, the necessity for freedom of that system becomes apparent. These three structures, artery, vein, and lymphatic, are so closely asso- ciated in their functioning capacities and in their anatomical relationships that the lesion affecting one will affect the other, and the resulting disorder will be practically the same in each case. The spinal nerve may be impinged upon by the same general crowded condition of affairs but owing to the fact that its nerve sheath is comparatively strong and unyielding it is less likely to suffer thus directly than are the other structures mentioned. Pressure may in some cases cause sufficient irritation of the nerve terminals within the sheath, i. e., the nervi-nervorum, or of the axis cylinders proper, to produce disorder in the parts to which the nerve is distributed. Hence conditions of a motor and sensory nature may result ; muscular contractures of nearby or remote tissue and neuralgic and other disorders of sensation are common. In addition to these disturbances which have reference to the special func- tion of the spinal nerve disorders of the sympathetic may re- 206 PRINCIPLES OF OSTEOPATHY. suit from the fact that practically all spinal nerves carry with them fibres derived from the sympathetic. It is suggestive to note the fact that in locomotor ataxia degenerative changes in the peripheral afferent system constitute the morbid anatomy, the degeneration according to some authorities beginning in the cell bodies in the ganglion on the posterior nerve root, this ganglion being closely related anatomically to the inter vertebral foramen and its associated structures and hence reasonably sub- ject to lesion. The sympathetic system may be involved by the lesion, and all things considered, is without doubt the most subject to interference by any of the forms of spinal lesion. Owing to its paramount importance in osteopathic reasoning and to the further fact that its anatomical and physiological relation- ships have not been sufficiently emphasized by the old school authorities, and because it is difficult for the average student to understand, a general survey of the entire system will be given, indicating the more important details. THE SYMPATHETIC SYSTEM. Fundamentally there is no distinction between the sympathetic and the cerebro-spinal systems. Under normal conditions the former is but an outgrowth from the latter during the earlier weeks of fetal life. At that period of the life of the embryo when a vertical section shows the medullary groove well de- veloped and the walls of which represent the ectodermal cells which give rise to the nerve cell bodies of the spinal cord and brain, on either side toward the upper aspect of the groove and later the canal there will be noticed a ridge of this origi- nal nerve cell tissue. This ridge eventually becomes separ- ated from the other part and, dividing into groups, develops into the ganglia of the posterior spinal nerve roots. As outbuddings from this ridge a little later will be noted a series of clumps of cells, most of which becoming separate from the original ridge, form the series of sympathetic ganglia which are known in the developed state as the gangliated cord of the sympa- THE SPINE. 207 thetic, but some of which in the form of migrating cells pass outward to various parts of the growing embryo and ultimate- ly develop into the ganglia of the sympathetic plexuses and in- trinsic ganglia of the viscera. These several clumps of cella with their outgrowing axis cylinder processes should logically alone comprise all of the sympathetic system. What is usually included are the double row of connected ganglia one on either side of the spinal column, the fibers passing to and from these ganglia making connection on the one hand with the spinal nerves through the rami communicantes and on the other with the various prevertebral plexuses formed largely by branches received from the gangliated cord and containing a few cell bodies, and the final distributing filaments from these plexuses to the various viscera. With regard to the gangliated cords, four divisions are spoken of. The cervical portion consists of the three ganglia with their connecting cords, and lies at the side of the bodies of the vertebrae behind the carotid sheath in the connective tis- sue and in front of the transverse processes from which they are separated by muscular and connective tissue. The thoracic portion consisting of eleven or twelve ganglia with their con- necting cords lies in front of the heads of the ribs in the areolar and other tissue lying behind the pleurae. The lumbar portion consisting usually of four ganglia lies to the inner side of the psoas muscle on the antero- lateral aspect of the vertebral bodies behind the large abdominal vessels. The sacral portion consisting of the four ganglia lies to the inner side of the row of sacral foramina in the connective tissue separating the pelvic organs from the sacrum. The cords in this region converge to form the ganglion impar lying in front of the coccyx, in a way similar to the formation of the ganglion ofEibes situated on the anterior communicating artery in the cranial cavity. In all of these regions the ganglia themselves, and less probably their connecting cords, are more or less subject to pressure from associated structures. The plexuses are numerous and are associated with 208 PRINCIPLES OF OSTEOPATHY. practically every viscus of the body. The cardiac made up from branches of the cervical ganglia is situated in close re- lation to the upper part of the heart and the arch of the aorta, and will be subject to lesion directly by abnormal conditions of the thoracic organs. The pulmonary plexus made up from branches received from the upper thoracic ganglia and a few fibres from the cardiac plexus, lies on the root of the lung, and will be subject to lesion in a manner similar to that of the cardiac. The solar plexus is the largest in the body and gives off fibres that make up the individual plexuses associated with most of the abdominal organs. This plexus is derived fron branches from the thoracic ganglia forming the three splanch- nic nerves, and lies upon the spinal column at the second lumbar and in front of and associated with the great vessels. It is subject to lesion by direct pressure from abdominal tumors, displaced viscera, impacted feces, and the like. Cords passing down from this plexus and re-inforced by fibres from the lower thoracic and lumbar ganglia make up the abdomi- nal aortic plexus. The hypogastric plexus continued from the aortic and re-inforced by fibres from the lumbar and sacral ganglia, lies between the two common iliac arteries upon the last lumbar body and the promontory of the sacrum, within the meshes of a dense connective tissue material. The tightening of this connective tissue, the general ptosis condition of the abdominal organs, or tumor and pregnant states may involve the plexus in disorder. From the lower part of the hypo- gastric plexus fibres are given off to either side of the cavity of the pelvis where they form the pelvic or inferior hypogastric plexuses. Throughout, these various plexuses are further added to by branches from some of the cranial or spinal nerves. The connection between the sympathetic ganglia and the central system is equally complex and important. The rami communicantes are usually considered a part of the sym- pathetic system although the white ramus is in reality a part of the central system. These communicating structures con- THE SPINE. 209 t and if pain IS present it Will cesses by forward flexion of likely be felt when the flexion is produced. In some cases where other methods fail to show tenderness this is quite effective. As a means of securing adjustment oi parts the ligament is valuable. By the pull upward parts maybe separated and moved some- what laterally, and if pressure with the free hand be employ- CERVICAL LESIONS DIAGNOSIS AND TREATMENT. 231 ed upon the spinous process movement of any vertebra may be effected. The hyoid. bone is a structure that should be carefully noticed. Having no articulation with other osseous tissues and being suspended within ligamentous and muscular struc- tures, its relative position is indicative of the condition of the latter. Usually there will be little difficulty in locating it but in occasional cases where there is an excess of other cervical tissue or a denseness of surrounding structures some difficulty may be encountered by the inexperienced in detecting its position. Note that it is the first dense structure lying above the prominence of the thyroid cartilage, the latter always be- ing sufficiently prominent to be easily detected. By placing the hand over the tissues on one side and pressing to the other, the greater cornua of the opposite side will be detected through the tissues. Then by maintaining contact with this and exerting pressure back again, the other will be felt. Note the readiness with which it yields to pressure between the fingers. Ii(it resists, ossification is well developed; other- wise, as in all younger individuals, it is quite yielding and indicates its cartilaginous composition. The cornuae can usu- ally be traced back to their continuation with the ligamentous structures which suspend the bone. Note these deep tissues . to determine their contracture and tenderness. Compare the two cornuae in regard to their respective levels. When one side is higher than the other it usually means a contracture on the same side, of the supra- hyoid muscles; less often a contrac- ture of the infra- hyoid muscles on the opposite side. The feeling of the tissues themselves together with the sensory condition manifested will render the difficulty of diagnosis less serious. The discussion of the hyoid leads logically to the con- sideration of the throat structures. These are, taken as a whole and separately, of the greatest importance. In every case of throat or nasal difficulty as well as disorders of other parts in that region, these muscles will be found in a condi- 232 PRINCIPLES OF OSTEOPATHY. tion of tenderness and contracture. Pain can be easily pro- duced by deep pressure upward and inward, in a normal condition, but will be quite marked where abnormality exists. In many cases of catarrh this region may be the only one presenting sensory disturbance. In their close re- lation to the cervical vessels and nerves, contracture of these tissues can very easily affect portions of the body above and below. The direct relaxation of the parts may be most readily effected by placing the patient in the supine position, and standing at the side, reach over and with the flat of the hand and fingers exert deep but gradual and careful pressure, at the same time rolling the head to the opposite side or lifting it up and flexing it directly over and upon the manipulating hand. This latter movement markedly increases the approxi- mation of origin and insertion and allows deeper pressure with less irritation. In many cases this treatment will be little more than a temporary expedient, and hence it will be necessary to look for the deeper lesions which can usually be found associated with disturbance of the upper cervical ver- tebrae, the removal of this last named being the logical meth- od for permanent cure. The tonsils will be noticed if they are in an inflamed or enlarged condition. Normally they are not subject to palpa- tion externally, but on considerable enlargement will be felt, together with the infiltrated tissues which is a usual ac- accompaniment by pressing deeply upward underneath the angle of the inferior maxillary bone toward thefaucial region. Internally, whether in a normal or other condition, they will be seen on either side of the isthmus of the fauces. The ton- sil is a lymphoid structure and should not be directly treated except with extreme care. The cartilages associated with the respiratory tract should be examined. The prominence known as "Adam's Apple" (pomum Adami) usually more marked in the male, is the most noticeable part of the thyroid cartilage and is valua- ble as a landmark for locating the hyoid bone above and the CERVICAL LESIONS DIAGNOSIS AND TREAMENT. 233 thyroid gland below. Note should be taken of the yielding or resisting nature of the cartilage, the latter suggesting an ossification which is comparatively common among elderly individuals and more common than a similar condition of the other cartilages. Movement of the thyroid against the cri- coid immediately below it, produced by lateral to -and -fro pressure, will usually show a form of crepitus. No particular significance is to be attached to the condition but the patient will often assume that something is wrong on discovering the peculiarity. In palpation over these structures a tendency to produce coughing may be noticed. This is suggestive of a hyper-irritable state of the vagus or of the laryngeal branches which supply the structures. Underneath the laryngeal cartilages in the median line and on either side will be felt the thyroid gland more develop- ed in the female adult. The isthmus which connects the two lateral lobes is a half inch in width and crosses the median line in front of the second or third tracheal ring of cartilage. The lateral lobes extend above and below this level to a vari- able distance. In many individuals the gland will be rather indistinct on inspection or palpation but in others it will be quite prominent. An enlarged condition is spoken of as goitre, and is a disorder quite commonly met with. Owing to the pliable nature of its parenchyma and to the fact that it is composed of lymphoid tissue any rough handling either of the normal or of the abnormal organ is to be condemned, though careful pressure is not dangerous. The usual lesions associ- ated with the disease are found in the upper chest and lower cervical regions. The various vascular and nervous structures have been mentioned in discussing the muscles. The external jugular vein with the associated superficial lymphatic vessels and glands crosses the sterno-mastoid in a vertical direction. This and the other vessels referred to often give valuable hints with reference to the condition of the heart action. The inferior thyroid vessels may be noticed in some cases where a 234 PRINCIPLES OF OSTEOPATHY. supra- thoracic crowding ia interfering with their function. The ph rente nerve passes down over the scaleni muscles from its mid cervical formation, into the region of the chest. Cerv- ical lesions often irritate its roots and obstinate hiccough result. The nerve can be more or less directly reached by pressure downward and inward in the angle formed by the junction of the sterno-mastoid. with the anterior end of the clavicle, or occasionally pressure downward and outward in the depression above the sternum. Thz gangliated cord may be reached indirectly by pressure applied to the front of the transverse processes of the vertebrae. The wisdom of such pressure is decidedly open to question since more harm than good will usually result. THE CERVICAL VERTEBRAE. These vertebrae are peculiar from several standpoints. Their greater mobility which renders them more susceptible to luxation, the .variety in the formation of the several bones, and their closer relation to the important medullary centers make a detailed discussion imperative for a clear understand- ing of the numerous disorders that may arise from a cervical lesion, and a proper appreciation of the effects secured by adjustment of the cervical tissues. In making an examination of the vertebrae it is often necessary to produce as complete a relaxation as is possible, and hence after noting the various peculiarities that may be presented while the head is held erect, the patient should as- sume the horizontal posture. Then by a quiet series of roll- ing of the head from side to side together with pressure and other methods for temporary relaxation, the patient will be in a proper condition for minute examination of the deeper structures. The flat of the hand should be laid careful- ly upon the an tero- lateral and postero- lateral aspects and while rolling the head to the side pressure is exerted in a direction opposite to the movement of the head. Or, stand- ing at the head of the patient and clasping the postero-lateral CERVICAL LESIONS DIAGNOSIS AND TREATMENT. 235 structures on each side the neck may be quietly manipulated sufficient to temporarily relax. In some cases where there is an inflammatory or makedly congested condition of the neck and throat muscles it may be painful to apply much direct pressure to the parts. In such case the writer has found the following method satisfactory especially in cases associated with much lymphatic enlargement and inflammation. Stand- ing at the head of the patient grasp the chin with one hand, the occiput with the other, then keeping the axis of the head parallel to the axis of the body, rotate the head through a complete circle and reverse. A few rotations thus applied slowly will open up the deeper structures and produce con- ditions that will quite appreciably lessen the tension and sen- sitiveness so that further examination becomes possible. Having gotten the superficial tissues relaxed several impor- tant points are noticed with reference to the nature and rela- tions of the cervical vertebrae. Note that in the erect position there will be a distinct anterior convexity, so much so that the spines of the third, fourth, and fifth will be only with diffi- culty made out. The considerable mobility of this part of the spine in comparison with other regions will be another strik- ing fact and any rigidity not dependent upon a voluntary though unconscious contraction of the cervical muscles sug- gests a thickened ligamentous condition. Rolling the head from side to side, showing a difference in the comparative amount of rotation, is a method of value to determine the lesion. The flexion of the head strongly forward on the chest should not be associated with much discomfort in the average in- dividual. If the latter be produced lesion is indicated. This same method should throw the vertebras sufficiently posterior to enable one to detect the spines with the exception of that of the atlas. In many cases the spinous, the transverse, and the articular processes of each of the vertebrase can be made out without great difficulty. It is usually stated that the rudimentary spine of the first cervical cannot be detected. Yet if sufficient care be taken with reference to a preliminary 236 PRINCIPLES OF OSTEOPATHY. relaxation, that process can be detected in twenty -five percent of cases. By gradually insinuating the finger in the depression between the occiput and the spine of the axis after a prelimi- nary relaxing treatment, the spine will be felt as a definite tubercle deeply within the tissue. But in most cases reliance must be made on the transverse processes and the surrounding tissues for the determination of the situation and condition of the atlas. The transverse processes will be detected between the angle of the jaw and the mastoid process of the temporal bone, varying within rather wide limits with individuals. In most cases they are easily detected but in a few there may be considerable difficulty in locating them owing to the condition of the tissues and the development of the processes. It would seem that the transverse processes of the atlas, more than the similar processes of others, are subject to great variation in relative position, size, and shape. Not only that but in half the cases examined there will be a difference in size, perhaps in shape, between the two processes of the same atlas. Hence the physician should be on his guard against a hasty judg- ment with reference to the nature of the atlas lesion. All things considered, the most satisfactory position for examining the atlas is the horizontal one with the examiner standing at the head of the table. Applying the surface of the index fingers gently on either side underneath the angle of the inferior maxillary, careful pressure is exerted toward the median line. In most cases the fingers will soon come in contact with the ends of the processes. If they are not im- mediately felt take time and allow the fingers and tissues to become accustomed to each other, then with careful explora- tion in all directions the processes will be detected. In some cases they will be found rather underneath or even behind the mastoid process. In others they will be forward and above a line passing through the most prominent part of the angles of the inferior maxillary. In many cases they will stand out on a level with the mastoid or the jaw, while in others they will be so deeply situated as to be reached only with difficulty. By CERVICAL LESIONS DIAGNOSIS AND TREATMENT. 237 comparison of the ends of the transverse processes on either side with the mastoid, maxillary, and other points of promi- nence, it can be determined whether there be a lateral, a twisted, a tipped, or otherwise distorted condition. Examine along the postero-lateral arches of the atlas. While these arches cannot be directly reached the overlying tissues will almost invariably indicate a lesion by their soreness, congested and contractured condition. In the region of the transverse pro- cesses tenderness and density of tissue will usually be mani- fest. Even in normal conditions the region of the transverse processes will usually be rather sensitive and hence care should be exercised in examining the part and in forming conclusions based on the sensory condition. In most cases one side will present a more marked sensory disturbance and that side will usually be the one toward which the vertebra is displaced. The movements that normally may take place between the atlas and the occiput are flexion, extension, and a lateral sliding, and in case a lesion is present it may be an extreme of any one or more of these. In many cases there will be a direct lateral condition with reference to the occiput, but an approximately normal position with reference to the other vertebrae, in which case the condition is more appro- priately a subluxation of the occiput. In other cases it will be distorted with reference to both. A tipped condition is a fairly common one. This is dependent usually on a greater muscular tension on one side than on the opposite. A common condition is a tightened posterior musculature which draws the posterior arch upward in close proximity to the occiput. Or one side will be more closely approximated and the level 'be dis- turbed. A torsion is often met with. This is indicated by the anterior position of one transverse process in comparison with a posterior position of the other. The whole vertebra may be somewhat anterior or posterior with reference to the occiput but can go only inappreciably posteriorly with reference to the axis, owing to the relation between the atlas and the odon- toid process of the axis. Yet it is illogical to affirm that it is 238 PRINCIPLES OF OSTEOPATHY. absolutely impossible. No change is impossible provided the force shall act sufficiently long or sufficiently intense. With reference to the disturbance between the atlas and axis, the condition is more commonly a torsion, rotation being the most marked normal movement and accounting for most of the rotation in the cervical region. Lateral subluxations are also common, while the other possible conditions are occasionally observed. In examination of the axis several landmarks present themselves. The prominent spinous process whose bifid nature is usually easily detected affords much information. Care must be exercised in forming conclusions from observation of this structure since because of its large size it is quite subject to variation in its growth. It is perhaps normally more de- veloped on the side of the body which is used the most, and hence in examination of this as in other vertebrae it is always wise to inquire if the patient be right-handed or left-handed. The transverse and articular processes afford further opportuni- ty for examination. The former will usually be found on a level with the spinous process underneath and behind the transverse process of the atlas. In some cases some difficulty will be encountered but usually the prominence will be suffi- ciently marked. The lesions associated with the axis are in general the same as those mentioned in connection with the atlas and will be detected by a comparison of the several points of prominence of the adjacent vertebrae,with the further notice of conditions of tenderness, contracture, and other states indicating lesion. In examination of the third to the fifth inclusive, a few additional facts should be noticed. In the erect position the normal individual will present an anterior convexity but in the supine posture the curvature may be obliterated. In either position manipulation will show marked mobility in an antero-posterior direction. In many cases if the finger be pressed horizontally across the spine of the fourth cervical, strong pressure of the head back upon the finger will produce CERVICAL LESIONS DIAGNOSIS AND TREATMENT. 239 actual pinching of the finger between the spinous processes of the second and sixth. In the diagnosis of lesion reliance is made upon the position and condition of the transverse and articular processes. The former are the more subject to nor- mal variations in size and shape and hence are not as satis- factory as are the latter. Further, owing to their irregular nature and the fact that very delicate structures lie immediate- ly in front i. e., the deep cervical vessels, sympathetic cord, and trunks of the spinal nerves greater care must be exer- cised or harm may be done in pressing down upon them. The row of transverse process are noticed if pressure be applied in front oi the sterno-mastoid muscle, backward and toward the median line, except in the lower part of the neck where they may be reached behind that muscle. On the other hand if pressure be made behind the sterno-mastoid, forward and toward the median line the row of articular processes will be felt. The articular processes less markedly the transverse- will appear as Bridge of bony tissue presenting regularly dis- tributed prominences. The latter represent the junction of two adjacent processes. It is at these points that prominence and pain will be most noticed if lesion is present. Then by reference to the other considerations of the lesion judgment may be made respecting the nature of the part under sus- picion. The depth, an tero- posteriorly, of the pharyngeal cavity, will be a point of interest in diagnosis of antero -posterior swerves of the cervical vertebrae, the posterior wall of the pharynx being formed of the bodies of the upper cervicals overlaid with connective, muscular, and mucous tissue. The sixth cervical is noticeable because of close approxi- mation of its spinous process to the superior surface of that of the seventh. The seventh is detected by its prominent spine which, though usually stated to be less, is often equally as protruding as the spine of the first thoracic. The transverse process of the seventh is usually felt just above and a trifle in front of the junction of the first rib with the process of the first thoracic. In many individuals a considerable mass of 240 PRINCIPLES OF OSTEOPATHY. muscular and other tissues in this region makes its detection somewhat difficult. By reference to the spinous process of the seventh which is on a slightly lower level aid will be given. Rotation and flexion oi the head on the neck in various ways will assist in determining the distinction between the spine of the laQ finished by slight longitudinal traction. This latter 242 PRINCIPLES OF OSTEOPATHY. movement should not be used with too much force and should be a straight pull, not a jerking or twisting movement. The same principles as the foregoing may be employed to advantage with the patient in the sitting posture. With the forehead of the patient resting against the chest of the physician the upper cervical tissues may be clasped by the fingers on either side of the atlas. Then by the chest and hands together and assisted by application of the chin of the physician to the crown of the patient's head, rotation and movement can be effected in any direction. Or with the patient sitting erect, the physician standing at the side places one hand on the crown of the head for purposes of rotation while with the other the cervical tissues are clasped in the usual manner. In case of a twisted atlas some pressue may be ap- plied to the transverse processes in the direction to effect restoration ; while in anterior lesions it may be necessary to get the fingers somewhat in front of the processes to exert a backward pressure. Bending the head strongly forward and pressing downward while at the same time working the part from side to side in many cases effects an adjustment of the anterior condition. All of these various treatments can be easily applied and with equal or greater success to other of the cervical ver- tebrae. Owing to their less obstructed situations direct pres- sure may be gotten upon most parts of the bones and hence pressure may be exerted without hindrance in the direction the part should go in order to re -assume its normal position. In most cases it will not be advisable or necessary to exert pressure upon the transverse processes. The articular and spinous processes and associated tissue being sufficiently prominent the part may be moved at will. Strong but care- ful rotation of the head to either side is of advantage not only in detecting various lesion conditions but also in overcoming the deep ligamentous or muscular thickenings. Flexion of the head on the chest will tend to draw any of the cervical vertebrae in a posterior direction. (See Fig. 21). This will CERVICAL LESIONS DIAGNOSIS AND TREATMENT. 243 be more true with reference to the sixth and seventh cervicals to which the ligamentum nuchae is more directly attached; if at the same time lateral pressure be applied to the spinous process alternately in each direction these two vertebrae can be very considerably affected. THE INFERIOR MAXILLARY BONE. The inferior maxillary is a structure deserving more notice from the osteopath than its apparent functions would seem to justify. By virtue of the close relations existing be- tween the articular structures of the condyle and certain im- portant nervous, muscular, and glandular structures, it is often found associated in a causal relation with various local disorders. In making the examination the two general principles already referred to should be remembered i. e., ex- amining the part during functional activity and functional rest. The normal movement of the bone is a complex one in- volving several sets of muscles, the elements of the movement being a vertical, a lateral, and an antero- posterior change in position. In examining the part in activity the patient should lie supine upon the table with the physician standing at the head. Then directing the patient to open and close the mouth note should be taken whether the mid -point of the chin de- viates from the median line. In numerous cases it will be seen on opening the mouth to swing to one side, which usually in- dicates a difference in the tension of the muscular or liga- mentous structures between the two sides, the deviation being toward the side of greater tension. This usually will depend on a pathological condition of the tissues on the side of greater tension but in occasional cases the lax articulation is the ab- normal one. If now the fingers of the physician be inserted deeply behind the ascending rami the greater tension of the one side will become quite apparent. During the process of movement of the jaw note should be taken of the sounds quite often produced in the articulation. These sounds are similar to those produced by pressure on the ribs at the transverse ar- 244 PRINCIPLES OF OSTEOPATHY. ticulations or in the cervical vertebrae on rotation of the head. In many cases it will be heard only on the one side and that the side of greater laxity. In others the sound seems to be produced equally on the two sides and in most cases will be more marked in those individuals whose other articulations are unusually lax. In many cases of these the condition would seem to be a normal one, at least in so far as other evidence of disorder is concerned. The lesions associated with the inferior maxillary con- stitute simple tension conditions of the articular structures and partial or complete luxation of one or both sides of the bone. The movement of the articular surface of the condyle upon that of the temporal bone is a complex one. One movement consists in a simple sliding forward of the condyle to the an- terior part of the articular surface which terminates upon the postero- inferior part of the articular eminence. In some cases of lesion it would seem that the condyle on one or both sides were resting directly upon this eminence. In other cases the subluxation consists in a lateral sliding of the bone as a whole. In these two types the part presumably is held in its abnormal position by muscular and ligamentous contracture. In a .complete dislocation the condyle will rest upon the articular eminence or more or less completely in front of it, in which case the mouth will be forcibly prevented from closing. Where the dislocation is a unilateral one the symptoms are not so marked and there is more or less possibility of move- ment. It is with the subluxations, however, that the osteo- path has most to do. The treatment of the inferior maxillary usually resolves itself, in the case of the slight subluxations, into overcoming the tightened muscular and ligamentous conditions. This means that in many cases definite lesions will be associated ' with the upper cervical region which cause the disturbance of the nutrition of the articular structures. It is often suffi- cient to make use of a few so-called specific treatments grouped under the general head of "springing the jaw." The artic- CERVICAL LESIONS DIAGNOSIS AND TREATMENT. 245 ulation can be affected by having the patient open the mouth against resistance. This is accomplished satisfactorily in the following manner: The physician standing at the head of the table, places the palms of the hands on the malar emi- nences and with the fingers grasps the point of the chin ; then holding the mouth closed the patient is directed to open it. The articulation will thus be loosened through the action of a lever of the third class in. which the chin is the fulcrum, the re- sistance of the articular structures the weight, while the power is applied through the digastric and other muscles passing from the hyoid bone to the horizontal ramus of the jaw near its anterior extremity. Placing a dense substance between the molar teeth and then approximating the incisors by pressure upward on the chin will produce a similar effect through a leverage of the first class. A third method producing similar results consists in closing the mouth against resist- ance. In this movement the fingers of the physician are in- serted, while the patient's mouth is open, into the depression in front of the auditory canal caused by the lowered coronoid process. Owing to the painfulness of the treatment the author is personally opposed to its use. Another method in which opening the mouth against resistance is employed, forces the condyle upward and forward. In this the move- ment is similar to the one first described except that the fingers are applied near the angle of the jaw or at least at a point posterior to the insertion of the muscles that depress the- bone. Among the effects of these various forms of inferior maxillary lesions, are neuralgias associated with branches of the fifth cranial with which the articulation and other parts of the jaw are in connection; ear aches are common effects of subluxated conditions of the bone ; throat and tonsil disorders are often noted while disordered conditions of the parotid gland may result owing to its approximation to the ascending ramus. 246 PRINCIPLES OF OSTEOPATHY. CHAPTER XII CERVICAL LESIONS EFFECTS. The disordered states that by observation have been found to depend on cervical lesions are extremely numerous and varied. It is theoretically if not practically true that any organ or tissue of the body may be made to suffer by inter- ference in this region ; it is not the purpose of this section to speak of all possible conditions, but those more commonly associated and which present a reasonable relation to the known anatomical and physiological facts in connection with the region. EFFECTS FROM DIRECT PRESSURE. In a previous section several ways were specified in which a lesion may affect an organ, viz., by direct pressure upon it, or impingement on artery, vein, lymphatic, or nerve mechan- ism associated with it. Through these several media the cer- vical lesion produces its effects. Few definite organs are closely enough associated with the cervical structures to suffer from direct pressure but those few are of some considerable importance. It is stated that the spinal cord may suffer from direct pressure in case of a luxated vertebra. Manifestly such a case must be rare, since a lesion sufficient to reach through the protecting coverings of the cord must be in the nature of a complete dislocation of the vertebra. It is known that there are such cases several of which have been treated by osteopaths and with success. A condition as severe must be profound in its effects, and such is true of the observed cases, a complete or partial paralysis resulting in the parts supplied from the cord below the lesion. The old school physicians recognize such possibilities. Hilton instances a CERVICAL LESIONS EFFECTS. 247 case or two where by a diseased or weakened condition of the ligaments supporting the odontoid, that process was allowed to fall back producing more or less direct pressure upon the cord. In these cases a fatal termination followed. In death from hanging the effect comes from the forcible rupture of the supporting ligaments of the odontoid which causes the latter to exert direct pressure upon the cord. It is not difficult to conceive of a less intense result to follow a less serious weakening of these same connecting structures from faulty nutrition; but in most such cases it is more reasonable to assume that the effect follows because of impingement, not directly on the cord, but upon the vascular and other structures which are concerned in keeping the cord in a normal condition of metab- olism. The thyroid gland may suffer from an anterior crowd- ing of the lower cervical region, thereby putting the adjacent tissues on irritation and tension. The sympathetic ganglia may suffer in like manner from vertebral, ligamentous, or muscular lesion. A discussion of the latter more properly comes under another section for which it will be reserved. EFFECTS FROM VASCULAR OBSTRUCTION. Among the effects of cervical lesions many are readily explained by reference to the obstruction of arteries, veins, and lymphatic vessels which connect with the various organs. Among these we may speak at some length of the carotid, vertebral, and thyroid arterial systems with their associated venous and lymphatic channels. The carotid artery passes from the cervico- thoracic junction behind the articulation of the sternum with the clavicle to pass upward toward a point midway between the angle of the inferior maxillary and the mastoid process of the temporal bone, dividing on a level with the superior margin of the thyroid cartilage and fourth cervical vertebra into the external branch which passes on to supply the extra-cranial structures, and the internal which, passing through the ca- 248 PRINCIPLES OF OSTEOPATHY. rotid canal, is distributed to the various intra- cranial struct- ures. In its cervical course it lies between the sterno-mas- toid, sterno-thyroid, sterno-hyoid, omo-hyoid, and platysma myoides on the external aspect, and the scalenus anticus and longus colli muscles, the trachea, larynx, thyroid gland, esophagus and pharynx on the posterior and internal aspects. It will, then, be more or less subject to obstruction by contrac- ture or other abnormal condition of one or more of these vari- ous structures. Note should be taken of the fact that a lobe of the thyroid gland often overlays the artery and in enlarged and hardened states of that organ it may offer serious impedi- ment to normal flow. By virtue of a narrowed cervico- thoracic junction serious hindrance may be caused to the flow from the deeper arteries from which the carotid arises, with not only a disorder in the parts supplied by its branches but also im- pairment of the integrity of the heart's action. The further distribution of the branches of the external cartoid in and among the muscles and other structures of the face and infra-maxillary region gives rise to numerous possibilities of impairment of blood flow when those structures are in a con- dition of lesion. The corresponding venous and lymphatic ves- sels are similarly disposed with reference to the structures in- volved in lesion and hence interference with lymph supply and venous drainage may produce numerous disorders re- sulting from congestion and infiltration of the various organs. Hence, various disorders dependent on venous congestion and arterial anaemia may result from contracture and other forms of lesion associated with the cervical region. These may be in relation to any part to which the vascular struc- tures are distributed, i. e., eye and ear affections, headaches dependent on cranial congestions or anaemias, or on similar conditions of the scalp; facial eruptions, hair malnutrition ; diseases of the throat, the nasal passages, and the deep and superficial structures of the neck, especially the upper part. Notice that in general the venous and lymphatic ves- sels accompany the arterial trunks and hence any lesion suffi- CERVICAL LESIONS EFFECTS. 249 dent to involve one will be likely to involve the others^ so that the total ill effect will be greater in the part than would result from obstruction to a single one of the systems. For instance pressure exerted by the tightened structures in the^region of the jugular foramen will likely affect the branches of the ca- rotid artery and tributaries of the jugular vein with a result- ing condition of in tra- cranial arterial anaemia and venous hypersemia. Note further that the pressure will affect the venous flow more markedly than the arterial, owing to the more yield- ing nature of the venous wall; hence while the arterial blood will not enter the cavity sufficiently rapid to maintain normal nutrition, it will pass inward more rapidly than the venous blood can return, with the result that a venous congestion will be added to the arterial anaemia. The second of the vascular systems likely to suffer from cervical lesion is the vertebral. The vertebral artery aris- ing from the subclavian passes upward and outward to enter the foramen in the transverse process of the sixth cervical vertebra, from whence its course is through the similar fora- mina of the other vertebrae. After passing through the for- amen of the transverse process of the atlas it passes back- wark and inward between the margin of the foramen magnum and the arch of the atlas and behind the articular surfaces, in close asso- wation ivith the occipito-atlantal ligaments. From thence it pierces the dura mater and arachnoid, dividing to send a branch up- ward to assist in the formation of the circle of Willis and others downward to supply the cord throughout its whole ex- tent. During its course the artery is subject to lesion from various structures. Before passing into the foramen in the process of the sixth cervical it lies between the longus colli and scalenus anticus muscles. Chronic contractures of these structures may easily produce disturbance of the blood flow. During its progress through the cervical foramina it is sub- ject to lesion by distorted osseous and ligamentous struc- tures. In the region of the atlas it is in contact with the superior oblique muscle and as it passes over the arch of the 250 PRINCIPLES OF OSTEOPATHY. atlas in company with the occipital nerve is subject to pres- sure by tightened conditions in that region which elevate or otherwise distort the first cervical or disturb its relations with the occiput. It is stated by Quain that in extreme rotation of the head the artery is put upon the stretch and is compressed on the side from which the head is turned. Under normal conditions this of course will not affect the blood flow for a sufficient time to result in disorder, but in chronic thickening of the structures and marked displacements it is not unreas- onable to assume a considerable possibility of harm. Branches from the vertebral artery pass off laterally and constitute the intervertebral system. These pass into and through the intervertebral foramina to supply the spinal cord and its surrounding structures including the general spinal column. Hence thickened ligamentous and muscular con- ditions as well as the common subluxations of the vertebrae may easily interfere with the interchange in this region. Other branches pass to supply the deep cervical muscles and other soft tissues and thus are subject to pressure from ab- normal states of these structures. The venous part of the intervertebral system, while not made up of the same size or number as the arterial, is in general distributed with the ar- terial and will be alike affected, producing, with reference to the blood supply of the various parts, the condition opposite to that produced by interference with the artery. In general, lesion to the vertebral system will affect the folloAving structures: the intra- cranial structures sup- plied by the circle of Willis, and some parts of the cerebellum and medulla; the spinal canal including the spinal column with connecting tissues and the enclosed nervous structures; the deep tissues of the neck posteriorly. The effects that may result from interference with the several parts of this vascu- lar system are extremely uncertain, numerous, and varied. Especially is this true where the disturbance affects those branches which supply the central nervous system. For, as al- ready briefly discussed, the effects from a disturbed metab- UBF/:PY CF 1 P K '.' f C f f f S /!' G f J CERVICAL LESIONS EFFECTS. 251 olism in the nerve cells within the cord are subject to laws but few of which are known, and in any given case no proph- ecy can be made as to the nature or even location of the effect that may result from an ancemia or a hypercemia of a part of the spinal cord. With reference to the branches distributed to the mus- cles of the posterior cervical region the same considerations hold, regarding the application otHarfs explanation of effects from contractured muscles, as were discussed in connection with the spine. Here these muscles by contracture may cause a secondary congestion in the branches that pass to the cervi- cal part of the spinal cord, since the intervertebral supplyjand the muscle supply of blood are from the same arterial branches. A third system of vessels likely to be involved from cer- vical lesion is the thyroid, also coming from the subclavian. The inferior thyroid branch passes upward from the thoracic cavity into the deep tissues of the anterior cervical region, lying in front of the longus colli muscle and the transverse processes of the vertebrae, to be distributed to the thyroid gland, trachea, esophagus, and deep muscles of the antero- lateral aspect of the neck. The other branches from the thyroid axis supply various structures in the cervico- thoracic region. The veins associated with this system ultimately pass with the innominate but those in connection with the thyroid gland are of special importance. Of these the inferior thy- roid are the most important, the middle and superior being small and less subject to lesion. Dr. Still emphasizes the . importance of the inferior thyroid in conditions of goitre, in which the closeness of the tissues at the cervico -thoracic junction may impair the flow of blood from the thyroid gland. These structures lie in close relation to the sterno-mastoid, the sterno-hyoid, and sterno-thyroid muscles and hence con- tracture of the latter may more or less seriously obstruct ven- ous drainage of the parts. EFFECTS ON SPINAL NERVES. Of the nervous structures that may be interfered with by 252 PRIHCIPLES OF OSTEOPATHY. cervical lesions are the eight spinal nerves, the fifth, seventh, ninth, tenth, eleventh, and the twelfth cranial, and the cervi- cal sympathetic system, including the superior, middle, and inferior cervical ganglia with their branches and connecting cords. The cervical spinal nerves with the exception of the first and second pass from the spinal cord through the inter- vertebral foramina and divide into anterior and posterior branches which supply corresponding portions of the cervical tissues with fibres of a motor and sensory function. The first or suboccipital leaves the cord over the posterior arch of the atlas in close relation to the vertebral artery, and hence, like the latter structure, is subject to pressure between the arch and the occipital bone. The posterior division of the nerve passes into the suboccipital triangle where it supplies numerous of the adjacent structures lying in close relation to the recti and obliqui and complexus muscles. Tightened conditions of these structures may produce various disorders of a sensory or motor nature from interference with the normal activity of this nerve and its segment of the spinal cord. The second cervical nerve with its principal branch, the great occipital, passes from the spinal canal between the posterior arch of the atlas and the lamina of the axis. It passes upward across the inferior oblique muscle throiigh the complexus and trapezius to reach the back of the head whose superficial structures it supplies over a considerable area. Occipital headaches in numerous cases seem to be dependent upon a crowded condition of this nerve in its superior cervical course. The posterior branches of the other cervical nerves are dis- tributedin association with the deep cervical tissueswhere they may be irritated by the posterior cervical muscles, or on the other hand cause disturbance of the latter. The anterior divisions of the cervical nerves form the cervical plexuses. The upper four which form the cervical plexus proper pass out, with the exception of the first, from between the inter-transverse muscles^ lying in relation with the CERVICAL LESIONS EFFECTS. 253 upper portion of the scalenus medius ; the first of the anterior branches emerges between the two recti muscles. The four branches joining in various ways form the cervical plexus which as a whole lies upon the scalenus medius and the leva- tor anguli scapulae muscles and beneath the sterno-mastoid. Hence in their deeper and superficial relations they are sub- ject to lesion from pressure by contraction of these various structures. These nerves carrying sensory and motor fibres are distributed to the skin and muscles of the cervical and cephalic regions, as well as sending a few branches to reach the upper thoracic tissues and forming one nerve of special importance, the phrenic, which passes to the diaphragm and other structures. Descending from its roots of origin the latter passes across the front of the scalenus anticus behind the sterno-mastoid, sterno- thyroid, and sterno-hyoid muscles. In the cervico -thoracic region it is therefore subject to lesion from bony and muscular conditions. The lower cervical nerves, by their anterior branches, emerge from between the scaleni muscles, and lying upon these form the brachial plexus which, passing under the superficial tissues at the base of the neck, courses over the first rib and underneath the clavicle to supply the arm, shoulder, and cervico -thoracic regions with sensation and motion. Distorted conditions of the lower cervical in the regions of the roots of these nerves, muscular contractures in the cervico-thoracic area, and narrowed costo- clavicular spaces may produce disorder of one or more parts of the plexus with a resulting weakness of the arm. In general the effects of lesions upon the cervical spinal nerves are muscular contractures, sensory disorders, and numerous other conditions near and remote, dependent upon a disturbed activity of the segments of the cervical portion of the spinal cord. Especially would this seem to be true of the upper cervical lesions which, disturbing the metabolism of the upper part of the cord may seriously interfere with the activity of the centers in the medulla. In all probability ^ it is 254 PRINCIPLES OF OSTEOPATHY. by Ie8sening the irritation to the medulla-through the medium of the suboccipital nerves that treatment in the suboccipital region in numerous cases will lessen general nervous distress, vaso-motor irregularities, and cardiac disorders. EFFECTS ON CRANIAL NERVES. The fifth cranial nerve being largely distributed to the facial structures and issuing from the cranium in regions well protected is not markedly subject to cervical lesion. A few branches distributed to the inferior maxillary articulation and to a few other structures in the lower facial region may be directly subject to superior cervical contracture or inferior maxillary luxation. Through coritractured conditions of the facial muscles disordered conditions of the nerve are quite common. Secondarily the nerve may be involved in disorder because of nutritional disturbances of the Gasserian ganglion or of its central origin, and through its numerous close con- nections with the ascending branches of the superior cervical ganglion of the sympathetic. The nerve as a whole may be considered the most important of those associated with the head and face, being distributed in large part to the eye and its appurtenances, the ear, the nose, and the mouth. These structures derive their sensory capacities from the fifth, while motor filaments are distributed to the muscles of mastication. Neuralgias associated with the various branches of the fifth are common disorders dependent on inferior maxillary and superior cervical lesions. While through the vaso-motor fibres that it carries, having received them from the sympathetic, it is often accountable for congestive and secretory disturb- ances of the eye and other cephalic organs. The relations between this nerve and the sympathetic system will be dis- cussed more in detail in the section on the sympathetic nerves. The seventh or facial nerve is the principle motor nerve to the face, and hence lesions affecting it are in the nature of spasms and paralyses of the facial muscles. Bell's paralysis is a typical example of the latter, in which most of the muscles CERVICAL LESIONS EFFECTS. 255 of one side of the face are more or less completely paralyzed. This nerve is subject to lesion at its exit from the stylo-mastoid foramen which is in sufficiently close relation to the inferior maxillary structures and transverse process of the atlas to be affected by disordered conditions of the muscles and con- necting tissues of those regions. The glosso-pharyngeal nerve is subject to lesion at its exitjrom the skull and during its course to its distribution to the tongue, pharynx, middle ear, and parotid gland, to which it furnishes fibres of various functions. It is sensory to most of the structures named, motor to the stylo-pharyngeus and middle constrictor,secretor?/ and vaso-dilator to the parotid gland. Passing from the skull in company with the tenth and eleventh cranials it courses downward in front of the transverse process of the atlas, then deeply passing in relation to the styloid muscles and the hyo-glossus. In these situations it is subject to lesion from atlas disorders or contractures in the anterior upper cervical areas. The tenth or vagus is one of the most important of cranial nerves, from its wide distribution, its diversity of function, and its relation to various structural parts which may act as an irritant. Atlas lesions are often found to dis- turb its function. The nerve passes down in front of the transverse process, and hence subluxated conditions of that structure, either by direct pressure or through the production of congestion and thickenings of adjacent and related tissues, will more or less markedly interfere with its condition. It then passes down the side of the neck in the common sheath of the nerve, carotid artery, and internal jugular vein, under- neath the anterior border of the sterno-mastoid and overlying the deep cervical muscles. In this region it is subject to osseous subluxations and muscular contractions sufficient to produce disturbance. In this region, too, it may be reached more or less directly by pressure against the anterior part of the sterno-mastoid, or in the lower cervical region, reaching underneath the tissues from in front and pressing inward, 256 PRINCIPLES OF OSTEOPATHY. then outward. In its cervico-thoracic course it and its laryngeal . branches are subject to 1 ^**"^/u r '^Ho-s^i irritation from a tightened \ &*\\***i*f if -V ft s condition of the inferior cer- ^S- - ^*fr / jj^^y^^'^ vical structures and from a narrowed superior opening of the thorax. A very common disorder, a light hacking cough, is often /Y f dependent on such a Fro. 22. Showing relation between Crowding of these tissues t nJ. er8e pro a w h i c h keeps up an i r r i- tation to the inferior laryngeal branches. The effects which may follow f zom lesion acting upon this nerve by the cer- vical disorders are most numerous and varied. It must be borne in mind that the vagus is in reality a bundle of nerves and is associated with nearly every type of function. It is afferent and efferent, motor, sensory, vaso- motor, cardiac inhibitor and probably augmentor, secretory and trophic. Any one or more of a large number of struc- tures may suffer from its disturbance. As suggesting its im- portance in this connection may be quoted a summary of its functions and distribution, from Quain : ''The pneumogastric nerve conveys motor fibres to the voluntary muscles of the soft palate (with the exception of the tensor palati), pharynx, and larynx, these being in part at least derived originally from the spinal accessory; to the unstriped muscle of the ali- mentary canal esophagus, stomach and intestine (with the exception of the rectum), and of the air passages trachea, bronchi, and their divisions in the lungs. Sensory fibres are furnished to the pharynx, esophagus and stomach, to the larynx, trachea and bronchial ramifications, as well as to the dura mater, the external ear and the pericardium. The vagi also supply nerves to the heart, both efferent (inhibitory also received from the spinal accessory), and afferent (de- pressor), and possibly inhibitory dilator fibres to the vessels CERVICAL LESIONS EFFECTS. 257 of the intestine. Lastly, pneumogastric fibres pass, either directly or through the solar plexus and its offsets, to the liver, pancreas, spleen, kidneys and suprarenal bodies. Each pneumogastric nerve is connected with the following cranial nerves the spinal accessory, glosso-pharyngeal, facial, and hypoglossal; also with some spinal nerves; and with the sympathetic in the neck, thorax and abdomen." In accordance with this distribution and functioning there are found disorders of the respiratory tract ^ sensory irrita- tions with cough, excessive mucous secretion, muscle con- strictions in the bronchial walls as in asthma, respiratory arrhythmias dependent on the fact that afferent impulses by way of vagus fibres aid in regulation of the respiratory cen- ter in the medulla; of the alimentary tract sensory disorders, undue vomiting tendencies either an excess or a deficiency, secretory disturbances of the glands associated with the tract, disturbance of motion by virtue of its motor fibres to the vis- ceral walls producing constipation or diarrhoea (undoubtedly rare), constriction or dilatation of the stomach; of the vascular system through interference with the inhibitor function of the nerve on the heart muscle, and vaso- motor function to the coronary arteries, the impairment of afferent impulses by way of the depressor nerve to the vaso -motor center in the me- dulla, and dilator fibres to vessels of the alimentary wall ; of other systems of nerves with which the vagus is connected, in- cluding the centers in the central nervous system upon which the nerve undoubtedly exercises a greater or less controlling influence. The eleventh or spinal accessory is another nerve which may be subject to the same lesions in the superior cer- vical region as the ninth and tenth. This nerve after passing from the foramen with the others named, immediate- ly perforates the sterno-mastoid and passes across the pos- terior triangle of the neck to be further distributed to that muscle and the trapezius. Tightened conditions of those mus- cles may affect it and possibly reflexly affect others. This 258 PRINCIPLES OF OSTEOPATHY. nerve is in large part a spinal nerve since it arises largely from offshoots from the upper five or six segments of the spinal cord to pass upward through the foramen magnum and be distributed with its own peripheral fibres and with those which pass to the pneumogastric. It is believed to carry from this region of the cord fibres which correspond to those which make up the white rami of the sympathetic in other parts of the cord. The twelfth or hypoglossal issues from the anterior condy- lar foramen, and from this point is subject to lesion from tightness in the region as it passes to supply the tissues of the tongue and of the hyoid structures, as well as in the region in which it gives branches to join with those of the sympathetic and upper spinal nerves. Disorders directly traceable to lesion of this nerve are apparently not at all numerous or im- portant. EFFECTS ON THE CERVICAL SYMPATHETIC. The cervical part of the sympathetic system consists of the three cervical ganglia and their connecting cords, branches to the spinal nerves, ascending fibres from the su- perior ganglion, connecting fibres to the thoracic ganglia, and rami efferentes that pass to aid in formation of the car- diac, esophageal, laryngeal, pharyngeal, and minor plexuses in the cervical areas. The superior cervical ganglion is the largest of all the cord ganglia being from three quarters to one inch in length and an eighth to a fourth of an inch in diameter. It is presumably a fusion of several ganglia,often being constrict- ed and usually connected with the upper four spinal nerves. It lies in front of the transverse processes of the second and third cervical vertebrae upon the rectus anticus major muscle in a network of connecting structures behind the internal carotid artery. Its ascending branches pass to supply the in- ternal carotid artery, forming in the cranium the carotid plexus, and with other branches, the cavernous plexus. CERVICAL LESIONS EFFECTS. 259 From these plexuses the fo 1 1 owing structures *\ o a* e i do- To "Mj^ (SWvuaU Fig. 23. Distribution of Cervical Sympathetic. are supplied : filaments to the Gasser- ian ganglion of the fifth cranial; to the third, fourth, fifth, and sixth c r an ial fi- bres; by the large 'deep pe t ro s sal nerve to aid in formation of the Vid- ian ; to the tympanic plexus; to the ciliary g a n gl i on from whence fibres pass to the eye; a n d t o the pituitary body. Later- al branches of the ganglion are given off t h a t aid in the forma- tion of t h e phary n g e a I and laryngeal plexuses, 260 PRINCIPLES OF OSTEOPATHY. from which fibres pass to the mucous membrane and other tis- sues and make connection with the superior and external laryn- geal nerves. A few filaments may pass to aid in formation of the esophageal plexus distributed to the mucous lining of that canal. Other lateral branches are given off which unite to form the upper cardiac nerve of the sympathetic which passes down lying in front Of the longus colli muscle, from whence it passes into the thorax to join the cardiac plexus, giving off in its course branches which connect with the other cardiac nerves and the pneumogastric with its inferior laryngeal branch, and giving off a filament to the inferior thyroid artery to be distributed to the thyroid gland.' Other lateral branches pass to the external carotid artery which are distributed with its branches to the submaxillary, otic, and geniculate ganglia, The middle cervical ganglion is occasionally absent and when present is the smallest of the cervical ganglia. It lies upon the tissues in front of the transverse process of the sixth cervical vertebra and is connected with they?/M and sixth spinal nerves. Its lateral branches pass to the inferior thyroid artery to supply the thyroid gland, and make connec- tion with branches of the pneumogastric and fibres from^he su- perior cervical ganglia. Other fibres form the middle cardiac nerve. The inferior cervical ganglion lying upon the con- nective tissue associated with the junction of the first rib with the body of the vertebra, is often united with the first thoracic ganglion. Fibres from this ganglion form the rami which connect with the two lower cervical nerves. Lateral branches form the lower cardiac nerve which is usually connected with the middle. Others in company with similar branches from the first thoracic ganglion pass to the vertebral artery and form upon it the vertebral plexus from which fibres are distributed to the various spinal nerves and to the terminal branches of the artery. Other fibres form a loop (the annulus of Vieus- sens) around the subclavian artery from which that artery is CERVICAL LESIONS EFFECTS. 261 supplied with a plexua. From this latter plexus fibres are given off which form a plexus upon the internal mammary artery. Communications with the phrenic nerve are made from this plexus and from branches direct from the lower cervical ganglia. The connection between the cervical sympathetic and the spinal nerves is somewhat different from that in the thoracic region in that there are no tvhite communicating rami. The grey rami are, however, equally developed. Fibres aris- ing in the cervical portion of the cord and similar in all struc- tural respects to the white fibres of the thoracic rami, pass out with the roots forming the spinal portion of the spinal ac- cessory nerve, and are distributed with branches of that nerve and with the pneumogastric and parts of the sympa- thetic with which the accessory is connected. Thus hurriedly has been given a description of the cervical sympathetic which throws some light upon the numerous dis- ordered conditions that result from lesions to the sympathetic in the cervical region. It remains to take up more in detail these various disorders. The eye and its appurtenances are often involved in dis- order from cervical ' lesions. Pupillo-dilator fibres ascend through the cervical sympathetic reaching the Gasserian ganglion and passing to the eyeball through branches of the fifth cranial. Occasionally disorders of the iris muscle re- sults from lesion affecting these. According to many investi- gators constrictor fibres for the pupil arise in the superior cer- vical and pass through a similar course. Motar fibres to the involuntary muscle of the orbit and eyelids pass in a similar manner through the cervical sympathetic. Secretory fibres pass to the eye by way of the branches from the fifth nerve, which may be partially under control of filaments from the sympathetic. Through the connection between 'the sympa- thetic and the third, fourth, and sixth cranial nerves, dis- orders of the muscles of the eyeball such as strabismus may result. But more important than any of these are the inter- 262 PRINCIPLES OF OSTEOPATHY. ferences with the sympathetic filaments that are concerned with the -vase-motor conditions of the eyeball and of the sur- rounding structures. P'or it is true of the eye as of other organs that most of its disorders are associated with a disturbance of its supply of blood. The numerous branches from the carotid and cavernous plexuses are concerned with regulat- ing the supply. The ear may suffer from an involvement of the cervical sympathetic. The tympanic plexus which is distributed to the inner surface of the middle ear is made up quite largely from the filaments derived from the intra- cranial branches of the sympathetic. The functions of these are not definitely ascer- tained but presumably are concerned in secretory, vaso-motor^ and in general trophic activities of the mucous surfaces which line the tympanic cavity, including the inner surface of the tympanic membrane and the mastoid cells. Through the regulation of the size of the carotid arterioles, the sympa- thetic probably exercises its greatest influence upon the func- tion of the ear. Disorder affecting the carotid plexus, then, may produce serious disorder of that organ. The faucial and nasal mucous membranes will be af- fected through interference with the sympathetic fibres that pass with the vessels which supply those regions. In addition fibres are given to \h.s fifth cranial which is the principal nerve to the mucous lining. These fibres exercise either directly or indirectly & secretory and trophic influence upon the membrane. Most catarrhal conditions are dependent on lesions in the upper cervical regions which in one or more of these several ways disorder the nutritive condition of the upper respiratory tract. The cervical parts of the respiratory and alimentary tracts are commonly involved in disorder through the irrita- tion to the branches that help form the plexuses distributed to the walls of those channels. The heart is likely to suffer from contractured or other lesion conditions of the cervical region although this is a CERVICAL LESIONS EFFECTS. 263 much less common region for heart lesion than that lower down the spine. Through irritations associated with the cervi- cal ganglia or the fibres forming the cardiac sympathetic, some of which may arise in the ganglia, disturbed conditions of the heart action may occur. These fibres are largely though not entirely accelerator in function, i. e., by their influence the heart muscle is kept in a condition of normal tone, irritabil- ity, and conductivity. Any or all of these factors may be decreased or increased through the interference with the fibres. Some evidence has been brought forward showing an inhibitory function associated with the sympathetic fibres. If such exists it ia undoubtedly minor in importance. Vaso- motor fibres are believed by some authorities to pass also by these nerves to be ultimately distributed to the coronary arteries. Hence disturbances of the nutrition of the heart will result. It has been suggested that angina pectoris is due to the temporary spasmodic constriction of the muscle fibres in the coronary system; and in numerous post mortem ex- aminations of individuals afflicted with that disease it has been found that the coronary arteries were more or less thickened and sclerosed. Pressure exerted downward upon the region of the annulus of Vieussens has been suggested as a treatment to inhibit an over-active heart. The treatment is unsatisfactory because of difficulty in reaching the part, an uncertainty in its effect, with a greater probability of stimu- lation than of inhibition, and hence personally the author is opposed to the treatment. Through the branches that pass to the thyroid gland from the several ganglia that organ may suffer. A very common lesion associated with goitre is a "break" in the cervico -thoracic spine. This will undoubtedly produce dis- turbance of the vascular and trophic conditions of the organ and various forms of disorder may arise. From the inferior cervical ganglion the branches that form the vertebral, mammary, and subclavian plexuses arise and may after or before their interlacement be subject 264 PRINCIPLES OF OSTEOPATHY. to disorder from lesion. Hence any or all of the structures which are supplied by these vessels may be made to suffer, i. e. , the brain and cord, the arm and shoulder, and the mammary gland and associated tissues. Finally emphasis is to be laid upon the effects that may result from the interference with the fibres that pass from the ganglia as grey rami to be distributed to the general spinal structures in a manner similar to that dessribed in the section discussing the general distribution of the sympathetic system (See Fig. 13). Thus through the lesions affecting those fibres the nutrition of the cord itself will be involved and therefore practically all of the structures already mentioned may be disordered because of the changed nature or number of the outgoing impulses from the various segments and through the various pathways. Of these latter some are by way of fibres passing up to the medulla and other parts of the brain where they may produce brain disorders proper, or interfere with the impulses that pass out by way of the cranial nerves. Others pass out with the spinal roots of the spinal accessory and are distributed with that nerve. Others pass down the cord and may affect almost any structure connected with the lower segments through the mediation of the law of radiation of impulses. Still others pass down to issue by way of the white rami in the thoracic portion, thence in part to pass up- ward into the cervical cord from whence they are distributed in the numerous ways already described. While still others may issue from the cervical cord through the grey rami by way of white fibres which are present in small number. This disturb- ance of the cord of course need not be dependent upon the irritation to the grey fibres that pass back to the spinal canal from the sympathetic ganglia. In large part it will result as has been before suggested, from posterior muscle contracture or other lesion which produces an excess of afferent impulses by way of the spinal sensory nerves. Notice should further be taken of the fact that with all the spinal nerves, both anterior and posterior branches, CERVICAL LESIONS EFFECTS. 265 there pass, through connection by grey rami, sympathetic fibres received from cells in the three cervical ganglia. These fibres are concerned with vaso-motion to the vessels of the muscles and superficial tissues; pilo-motor influences to the involuntary muscle in the skin ; and secretory fibres to the sweat glands. Hence lesion to the sympathetic will be accountable for numerous skin and superficial muscle disorder in the facial, occipital, cervical, and upper thoracic areas. Pimples of various kinds, eruptions, dry and scaly skin conditions, excessive or deficient sweat or sebaceous secretion and numerous other states of these areas are com- mon and are presumably related to the cervical lesions that are found. 18 266 PRINCIPLES OF OSTEOPATHY. CHAPTER XIIL THORACIC AND LUMBAR LESIONS SPINAL. THORACIC LESIONS GENERAL. Thoracic lesions involving the spine are among the more common and important, for it is in this part of the cord that most of the efferent impulses for sympathetic life pass from the spinal cord through the mediation of the white rami. A few of the characteristic lesions will be described and later their treatment and effects discussed. In making the examination do so first with the patient in the sitting posture. For purposes of inspection the skin should be bared. Note the position in which the spine is held. There should be when the individual sits in a natural and easy position a posterior curve beginning with the second and extending to the twelfth with the most prominent part of the convexity at the seventh or eighth spine. In many cases there will be either an exaggeration of this curve or a partial or even complete obliteration of it. Before determining that it is an abnormal condition the patient should be made to vary the curve by sitting over-erect and by "sinking" the spine upon itself to throw it as posterior as is possible. By obser- vation in the several conditions there will be less possibility of error. A very common condition of the upper thoracic spine is the flat inter-scapular region. As a result of this flattening there will be presented a more or less typical straight condition of the spine as'a whole, owing to a secondary and compensatory straightening in the lumbar region. Fur- ther the transverse processes should be noted, since a spine will appear straighter, owing to the greater obliquity of the spinous processes in the thoracic region than in the other parts, if examined by reference to its spinous than if examin- THORACIC AND LUMBAR LESIONS SPINAL. 267 ed by its transverse processes. These transverse processes will be difficult to detect by the average student, since the more or less marked protuberance and the depression external to it, as seen in the skeleton, will be quite completely covered by Jigamentous and musular tissues in the average living sub- ject. They can usually be detected if care be exercised, about one and one-half inches to the side of the spinous process. Remember further that the process of the typical thoracic vertebra will be on a line, not with its own transverse pro- cesses but with those of the vertebra next below or in some cases the second one below. A faily good rule to remember which must not be applied too vigorously is this : if on bending the head well forward the spinous processes of the thoracic ver- tebra below the second can easily be seen, the flattening is not very serious. If they are not drawn out sufficiently to be noticed on inspection it is fairly good evidence that there is an abnormal flattening. It will be noted further that in such a le- sion the antero-posterior diameter of the upper and perhaps lower part of the chest will be lessened. This can be best noted by applying a hand on either aspect and then noting the dis- tance between them. Aid will be further given if the patient is asked to respire deeply, noticing the amount of expansion possible, and the freedom of movement of the upper chest. In many cases but by no means all, with the flat thoracic state will be associated a general thickening of the deep tissue so that undue rigidity may be manifest. In long standing cases of this kind there may be little or no muscle contracture appar- ent but in many if care is taken in palpation, various areas will be detected where not only muscle thickening will be felt but also tenderness over certain areas will be experienced by the patient. Especially will the upper part of the thoracic spine be often involved in muscular disorder. In the writer's personal experience very few flat thoracic regions are found unassociated with the contractured state of the rhomboids and deeper muscles on either side of the third thoracic ver- tebrae. 268 PRINCIPLES OF OSTEOPATHY. Difficult as it may be to determine whether the flatness is normal or otherwise, it seems to the average beginner to be still more difficult to overcome the condition when once diagnosed. This arises partly from the fact that in many cases the condition is normal and hence should not be treated. But it is also true that the spine distorted in an an tero- posterior direction is, other things being equal, more difficult to over- come than a lateral displacement, and especially is this true of the upper thoracic. In a few cases an ideal condition can- not be brought about but in most a sufficient return toward normal can be effected to prevent further serious disorder from the lesion. The methods for reducing the condition are numerous but only a few will be indicated. Note that any method which produces a convexity posteriorly will tend to force the part back but the method unassisted will avail little. Hence to make the force acting in the posterior direction ef- fective, a movement laterally or in a rotary manner will give opportunity. One method consists in strongly bending the head forward thus putting tension on the ligamentum nuchae which is continuous with the supra-spinous ligaments. Note that the direction of the spinous process of the thoracic ver- tebra is backward and markedly downward. Hence the force of the upward pull will have a powerful leverage in pro- ducing movement at the part. Then while one hand is direct- ing this movement the other is used to manipulate the verte- bra from side to side. At the same time the head may be rotated to the side, which will give a lateral tendency to the force. This movement is most satisfactorily executed while the patient is on a low stool with the physician standing at the side. In another method, withithe patient on the stool, the physician may stand in front with the toe of his shoe on the stool and his knee against the upper sternum, separated from it by sufficient padding to diffuse the pressure and prevent depression of the ribs. Then bending the head forward he he reaches over on either side of the spine and while slight pressure is exerted laterally so as to spring the ribs the ver- THORACIC AND LUMBAR LESIONS SPINAL. 269 tebrse may be rotated from side to side. This treatment is to be used with utmost caution and in any case where there is dis- order or weakness in the upper ribs or marked disease in the chest structures much pressure with the knee is contra-indi- cated. The advantage of this movement lies in the fact that direct backward pressure upon the anterior vertebrae may be exerted through the mediation of the ribs. Another method consists in making use of the scapular muscles which attach to the vertebrae. The patient lies on the side, the arm is drawn strongly down and across the chest. This of itself will tend to draw the vertebrae somewhat back and if assisted by the other hand in working the spinous processes from side to side the result will be quite satisfactory. In all such condi- tions the physician must rely quite largely upon the lateral movements of the individual vertebrae to assist the organism in making the adjustment. Another common condition associated with the thoracic spine is a lateral swerve. In many cases this will be on the side of greatest muscular activity and hence perhaps be partly a normal condition. In this lesion the more promi- nent angles of the ribs on the convex side will be the most striking feature in the examination. Along with this there will be a greater noticeability of the transverse processes on the convex and an obscured condition on the other. The treatment will consist in exaggeration of the lesion by strong forcing of the spine to the convexity, then by exerting pres- sure upon that side, with rotation, the part is forced in the opposite direction. This treatment may be made with the patient in the sitting posture or lying upon the side. In most curvature conditions it is more satisfactory to exert pressure upon the transverse processes of the vertebra and angles and sides of the ribs as well as upon the spinous processes, since, because of the rotation of the vertebrae which has also occur- ed, the simple pressure on the spinous process may tend to produce a still greater rotation in the direction toward which it is already displaced. 270 PRINCIPLES OF OSTEOPATHY. In case of thickened ligaments acting as lesions greater or less difficulty is encountered in overcoming the dis- ordered structure. It must be remembered that the thoracic part of the spine is the least movable owing to the attachment of the vertebrae to the ribs forming a continuous wall which gives the chest the mechanical form of a cylinder a form presenting greater resistance to distortion and permitting of only a slight extent of movement. When, therefore, the already close articulations have been supplemented by a thickening of their connecting structures by a previous long continued state of congestion or inflammation, there will b.e a marked resistance to the production of any movement be- tween the adjacent vertebrae. In overcoming a tightened condition of any part of the spine diagnosis must be made be- tween the conditions due to simple muscle contracture and those associated with definite and substantial change in the ligamentous and other'articulating tissues. In most cases the distinction will not be very difficult owing to the fact that the rigidity dependent upon muscle contracture will vary from time to time and can temporarily be overcome by methods calculated to relax the muscles. Further, simple contractur- ed conditions are usually of recent production while the thickened ligament condition is one dependent upon irritation continued through a long period of time. The two conditions may both be present in which the diagnosis will be more or less difficult. Again, the ligamentous condition may follow the muscular disorder since both conditions are dependent upon some kind of spinal irritation. As a matter of actual ob- servation it would seem that by the time the ligamentous rigidity has become established the muscular contracture will have to a greater or less extent disappeared. In overcoming the rigidity due to muscle contracture it is only necessary to bear in mind the methods of reducing contractures which have been referred to in a previous chapter. Various rota- tions of the spine in the region of innervation of the muscles involved will serve to open up the deeper tissues and allow of THORACIC AND LUMBAR LESIONS SPINAL. 271 greater freedom for vascular and nervous interchange. "With the patient on the ventral aspect or on the side, direct pres- sure may be applied to the spinal muscles for temporary re- laxation. Usually the tissues are manipulated by the flat of the hand and not the tips of the fingers. If the latter are used irritation may result through excessive pressure over a small area. By the process of quietly applied but deep pressure with a very slight movement of the tissues underneath the fingers, and by torsion of the spine and other methods de- signed to separate and approximate the origins and insertions, the muscle tissues will usually yield without any great diffi- culty. It is not to be expected that these temporary relaxa- tions will result in a cure, for in numerous cases thecontrac- ture is but a condition dependent upon some further cause, and until the latter be determined and removed little can be expected in the way of a permanent cure. Where the rigidity is due to the thickened ligaments the quiet pressure treat- ment of the muscle is of little avail. This is a condition which must be more or less forcibly broken up and absorbed and hence rather vigorous methods must be employed. Theoretic- ally the various "breaking up" treatments which are in com- mon use might seem to be illogical in their application. For if the congestion and the later overgrowth and contraction were due in the first place to irritation it would seem that those treatments that tend to stretch the ligamentous and other connective tissues would result in still further irritation and hence further congestion and overgrowth. But from actual observation of cases it seems that the fear of further thickening is not well grounded and that the good resulting from the treatment is far in excess of any noticeable harm that may be possible. The treatment is largely the same in principle as that employed in the preliminary treatment in case of a long standing dislocation of the hip where the mus- cles and other structures have become structurally shortened. In such cases rotation of the limb and other manipulations are employed in order to lengthen these tissues by stretching 272 PRINCIPLES OF OSTEOPATHY. processes sufficient to permit of the reduction of the dislo- cation. In applying the various "breaking-up" treatments it is very essential that the physician shall know the amount of pressure he is exerting and the efficiency of his leverages. Other- wise he is likely to produce rupture of the connecting tissues rather than a simple yielding of them. Especially is this true with reference to the more anterior ligaments, i.e., those associated with the bodies of the vertebrae. If an examination is made of the skeleton it will be seen that the spine, especial- ly throughout its thoracic and lumbar portions, is not so ar- ticulated as to permit of appreciable anterior convexity. The structural conditions are such as to allow of a posterior con- vexity, lateral inclinations, and somewhat of torsion move- ments, but inappreciably a direct anterior convexity. Hence any forcible attempt to bend the spine in this direction is to be con- demned. There is a method of treatment designed to stretch and separate the more anterior structures which is in common use, but which is associated with considerable danger. With the patient on his ventral surface the lower half of the body is raised from the table by inserting the arm underneath the thighs, or by supporting the latter in a suspension apparatus. Then as this lower half of the body is swung from side to side pressure is brought to bear with the free hand upon the spine where it is desired to produce the breaking effect. The pressure with the thumbs while exerted downward is also ex- erted laterally in a direction opposite that of the swing of the body. This treatment may be efficient and harmless if a.p~ plied with judgment, but unfortunately there are a large num- ber of students and practitioners devoid of a sufficient amount of that useful faculty, and hence harm is likely to result in occasional cases. Especially will this be the case when the limbs are supported by a suspension apparatus'and the phy- sician has all his strength free to devote to the local pressure. He is likely, therefore, to use his strength and weight to a disadvantage to the patient. A good rule to remember in this connection is that the weight of the body itself while in THORACIC AND LUMBAR LESIONS SPINAL. 273 this position is sufficient for the spine to bear, and any addi- tional pressure applied to local points in the spine should be applied in a lateral direction as much as is possible. For ef- fects upon the lateral ligaments and other structures the patient may lie upon his side with the physician standing in front. The latter with one hand on the hip or the shoulder and the other reaching over and grasping the spinous processes, pro- duces a torsion of the body by exerting force with each of the hands but in opposite directions. This will tend not only to affect the lateral but also the anterior structures and inter- vertebral cartilages. A variation of this treatment consists in making use of the arm by drawing it across the chest and up by the face, in this way exerting a lateral tension upon the spinous processes through the medium of the trapezius and other muscles, at the same time assisting at the local point by the free hand. Or with the patient on the side and standing in front or behind a simple strong bearing down upon the spinous processes will more or less efficiently spring the spine. For affecting the posterior structures any method that produces a greater posterior convexity will be efficient. The method referred to in aonnection with the flat thoracic lesion by bending the head strongly forward thus exerting tension upward on the spinous processes may be employed to advantage. Similarly, with the patient on the back, the method of "rolling him upon his shoulders" by strongly flex- ing the limbs on the body and then lifting the lower part,may be of some value. In cases where the posterior convexity is increased, thus constituting a lesion, there are a number of methods that may be applied successfully. The diagnosis of such a condition is usually not difficult. The abnormality will usu- ally be found in the lower part of the thoracic spine though occasionally the upper part is the one to suffer. While the patient is sitting in his usual position the spine will appear quite convex. If on assuming a forcibly erect position the convexity disappears, it suggests, not a posterior curvature, 274 PRINCIPLES OP OSTEOPATHY. but a weakened and lax spine. If the convexity still re- mains while the patient is forcing himself to sit erect, it is quite good evidence of an abnormal condition. In most cases there will be associated a lessened state of mobility. Further, the condition of the lower ribs will be noticeable, the usual condition of these being a depression of the anterior extremi- ties, especially marked in the last two whose ends may be so depressed as to occupy a position nearly on a level with the ilium. Such cases usually are dependent on the continua- tion of the posterior convexity throughout the lumbar portion of the spine. A method for overcoming the posterior curvature, and one which is, with variations, equally applicable to later- al curvatures and numerous other lesions, consists in the following: with the patient on the table or stool the physician stands in front, reaching around with a hand on either side of the spinal column, the patient meanwhile leaning forward easily against the chest of the operator in order to take off any tension of muscles otherwise present and to furnish a chance for rotation by movement of the body of the physician ; then by a direct forward and lateral pressure on the spine, at the same time lifting up and rotating, a very powerful force is brought to bear. Another method which is a valuable one is used with the patient in the same position on the table or stool. In this the physician stands behind with one hand on the shoulder for purposes of rotation, the other with thumb or fingers on the lateral aspect of the vertebra. Then the shoulder is made to outline a circle whose plane is in an antero-posterior direction. As the shoulder is brought back- ward the hand at the vertebra on the opposite side of the spine is held immovable. Consequently the weight of the body acts as the force to drive the part in its normal direc- tion. Note that the force is not a directly anterior, but an antero- lateral one, which is always advantageous. Then re- versing the hands, the other shoulder is used and the part is forced forward and laterally but the last in a direction oppo- THORACIC AND LUMBAR LESIONS SPINAL. 275 site to that in the first case. The actual movement will be more complex than would appear from the description, and at some time during the circuit every part of the articular struc- tures will have been acted upon in a more or less advantageous manner. Further, at one part of the circuit exaggeration of the lesion is affected, for as the shoulder goes forward pres- sure is exerted downward which tends to throw the spine more posterior. This treatment is equally applicable to lateral and to almost any condition with the exception of the anterior luxations. With the patient lying prone, direct pressure downward may be made upon the transverse processes, but unless lateral movement is also produced it will not be quite satisfactory. Similarly the patient _may be treated in the position lying on the side. A method of special value requiring special apparatus has come into use within recent years. A stool with a back provided with a sliding part arranged to fie closely on either side of the row of spinous processes, and a seat bottom un- yielding in nature and with a wedge shape piece to prevent the ischii from lateral sliding, constitutes the apparatus. These are provided for in the Dr. Still's Chair. With the adjustable piece at the point of lesion and the physician in front or behind, the shoulders are gasped and by a figure-of- eight movement the body is rotated, the only movable part of the body being that above the fulcrum, the remainder being held by the pressure against the latter and downward upon the stool. In this treatment the spine above the fulcrum represents the lever arm, the "breaking" occuring more or less entirely at the fulcrum. By sliding the movable part up or down each of the involved vertebrae may be acted upon. Owing to the interference presented by the arms of the stand- ard supporting the movable fulcrum, there is little possibility of drawing the patient too far posteriorly and hence doing harm. A method of getting a fixed point by applying the knee or knees to the part has long been in use, and where ap- plied with caution is of much value. With the patient on a 276 PRINCIPLES OF OSTEOPATHY. low stool and the physician standing behind, the latter places the toe of his shoe on the stool and his knee at the side of the spinous process. Then by movement of the shoulders the body is rotated about the knee as a fixed point. With the physician sitting, both knees may be used except where the scapulae are too closely approximated to the spine. In this treatment there is always danger from the fact that the physi- cian is not aware of the amount of leverage he is using. It is necessary to emphasize the point that the knee knows noth- ing of pressure. In case of the fingers and hand there is de- veloped by training a sense of pressure and of weight. Hence with the fingers as the fulcrum the judgment of the physician is enhanced. Not so with the knee. True, the hands are placed on the shoulders when the knee is used and hence are in a position to judge of the pressure; but in most cases the physician will be thinking of keeping the knee in place and will ignore the hands. It is further true that the tissues over the knee as well as those over the spine are quite movable ; unless care is taken during the application the knee may slip to the side and shock be produced or even greater injury done. Altogether, if the knee treatment is used at all it is to be done with full knowledge of the cautions necessary. THORACIC LESIONS LOCAL. In addition to these several forms of general thoracic spinal lesions there are many of a distinctly local character. Of these, torsion between two adjacent vertebrae is common. In such a case there will be lateral deviation of the spinous process; differences between the prominence of the two trans- verse processes and between these and similar adjacent ones; greater prominence of the angle of the rib on one side; local contractures and sensory disorders. In overcoming the con- dition pressure is exerted laterally upon the spinous and an- teriorly upon the prominent transverse process at the same time that rotation is being effected by any of the numerous methods that have been already suggested. In many cases separations (See Fig. 10) between ad- THORACIC AND LUMBAR LESIONS SPINAL. 277 jacent spinous processes will be detected. This is perhaps more likely to occur in the upper than in the lower thoracic. A rotation about the part and other methods for producing re-adjustment of muscular disorders will usually be effective. Anterior luxations of single vertebrae are occasionally noted by the deeper situation of the spinous and transverse processes and the pair of ribs with which the vertebra articu- lates. Backward and inward pressure upon the sides and angles of the ribs will assist the rotary manipulation in draw- ing or forcing it back. Various other conditions may be met with and will be detected and corrected by methods similar to those indicated above. LUMBAR LESIONS. The lesions affecting the lumbar portions of the spine are in general the same as those associated with the thoracic por- tion. Owing to the absence of ribs the muscular structures are relatively more developed and hence in this part muscu- lar lesions as a rule will be more noticeable because of the greater amount of tissue involved. In noting the condi- tion it should be remembered that the normal curvature of the lumbar region is an anterior one beginning with the lower thoracic and ending with the prominence of the sacrum. Care should be taken to determine whether the position assumed by the patient represents a normal condition. For instance with a good many individuals a habit is formed of sitting in a rather lax condition which causes the lower part of the spine to protrude posteriorly. In the examination the patient should be requested to sit in as nearly a normal position as he can ; then by comparison of this condition with that of an extreme erect and extreme lax posture, more nearly correct judgment can be made. It is in this portion of the spinal area that the median furrow spoken of by Holden becomes of most importance. In numerous cases this groove, at the bot- tom of which will be found the row of spinous processes, be- ginning with the lower thoracic region and extending to the 278 PRINCIPLES OF OSTEOPATHY. sacrum will be found to vary in depth, width, and symmetry of outline. These changes are always suggestive of spinal lesion, either osseous or muscular. In many instances the lower boundaries of the groove will be decidedly prominent and tense, more noticeable when the patient is in the sitting posture. At the same time the groove may be appreciably narrowed. This usually is dependent upon a condition of contracture of the more bulky portions of the erector spinae muscle, and in most cases this again is due to deeper lesion associated with the lumbar spine, the sacrum, or the innomi- nate bones. The correction will therefore be dependent upon the adjustment of those deeper tissues. A further point to note in the examination of this part is the condition of the spinous processes. These are directed horizontally , which marks a distinct difference between them and the typical tho- racic vertebra. Further, these are extremely strongly de- veloped and in many cases palpation along their prominences will suggest a continuous, irregular, bony ridge, rather than a series of separate processes. This will be especially true of those cases where lesion is present in the form of thickened ligaments, or in those individuals who are strongly develop- ed naturally. The condition of the transverse processes should be noted. These in comparison with those of the thoracic region are longer and more developed otherwise. They are also much more subject to variation. Cases are on record where the process of the first lumbar was mistaken for the twelfth rib, and by individuals who were fairly careful diagnos- ticians. Usually the mobility of the rib will prevent any such mistake. These processes are often found quite tender to touch through the overlying muscular and other tissue. In such cases it is quite good evidence that something is wrong, either a contraction of these tissues, which, in contact with the prominences, produces sensory disorder; or because of a twisted or otherwise subluxated vertebra the process is more or less forcibly pressed into the parts and in that manner produces irritation. Further, the fact should be remembered THORACIC AND LUMBAR LESIONS SPINAL. 279 that there is in the average individual, a greater separation be- tween the spinous processes of the last thoracic and first lum- bar, and also between the last lumbar and spine of the sacrum. While this condition seems to be a normal one in many cases, yet experience would seem to show that these two points, es- pecially the latter, are more than the others subject to lesion conditions. Curvatures, lateral, anterior, and posterior, similar in kind and extent to those found in the thoracic spine are com- mon in the lumbar, and will in general be diagnosed and ad- justed in the same way. In most cases the lumbar region will compensate for a thoracic condition, and the reverse may be true. Hence in treatment of a lumbar curvature reference should be made to the condition of the thoracic spine and the treatment regulated in accordance therewith-. In most cases it is not a matter of absolutely vital importance as to which condition is the primary one and in many cases such deter- mination will be impossible- Both curvatures are attended to in the treatment and are corrected at the same time. It is probably true that if the primary curvature alone were cor- rected the secondary condition would to a marked extent dis- appear, but unquestionably the adjustment will be brought about much more quickly and efficiently when both are treated. Slight luxations such as lateral, anterior, posterior, and twisted conditions of single vertebrae are, owing to the greater amount of muscular tissue overlying, usually more difficult of detection in the lumbar than in the thoracic por- tion of the spine, and hence reliance must be made quite largely upon the contracture and other disturbance of the softer tissues. This latter condition will in most cases be quite well marked. For instance in the case of a torsion one transverse process owing to its considerable development, will be forced quite prominently into the softer tissues and hence a marked contraction and congestion will result which will be comparatively easy of detection. Anterior and pos- terior luxations, if more carefully diagnosed will fortunately 280 PRINCIPLES OF OSTEOPATHY. often be found to be mere angular antero-posterior changes, consequently throwing the spinous process more or less promi- nent. This is especially true of the fifth lumbar. While the statement that the fifth lumbar cannot go anterior is one that is not substantiated by the facts, yet it is a condition much less common than was formerly believed. An extreme an- terior bending at the junction of the fifth with the sacrum is a much more common condition than is the real anterior dis- placement. The angular condition causes the spinous pro- cess to be more or less obscure and gives rise to the belief that the vertebra is displaced anteriorly. In most of these cases if the patient is placed in such a position that the lum- bar spine may be drawn posteriorly the spinous process of the fifth will become apparent. Further, if the direction of the upper portion of the sacrum be noted the real condition will become obvious, for it will be found that the upper por- tion of the sacrum also has receded anteriorly. But that there are many cases which may with all propriety be spoken of as anterior fifth lumbar conditions, we are entirely per- suaded. The extreme cases of this kind that are met with would show, if the pathology could be determined, that there had been a more or less considerable change of the articulat- ing structures as a whole, including the osseous parts. For purposes of overcoming such anterior structures two or three methods may be suggested. With the patient sitting on a stool the physician stands at the side facing in the opposite direction while with the adjacent arm he. reaches across the chest and grasps the body underneath the axilla. Then strongly bending the patient forward so as to throw the spine posteriorly, rotation and lateral movement is given while pressure is exerted with the free hand upon the tissues lateral to the vertebra involved. Another method which has long been in use and productive of much good is one which is rather wearing on the physician. With the patient lying on his side the physician stands in front and strongly flexes the thighs upon the abdomen. Then reaching over with one THORACIC AND LUMBAR LESIONS SPINAL. 281 hand underneath the buttocks, the lower half of the body is lifted slightly from the table thus allowing the weight of the body to bend the spine laterally in the lumbar region. With the other hand the physician reaches over and grasps the spinous process of the fifth on its under surface, at the same time lowering the buttocks. By repetition of this movement a considerable effect is produced in opening up the tissues while the position in which the patient is held compels a con- tinuously acting posterior force. In all of the luxations associated with the lumbar region, as also true of other parts, it may be necessary to overcome a part of the muscle contracture previous to adjustment of deeper structures. This may be accomplished in any of the several ways which have been mentioned. 19 282 PRINCIPLES OF OSTEOPATHY. CHAPTER XIV, THORACIC AND LUMBAR LESIONS COSTAL. It is not very common that a serious thoracic spinal lesion will be present without a corresponding rib lesion, the inti- mate anatomical and physiological associations existing be- tween the two making them more or less interdependent with reference to their lesions. It is much more true that the rib is dependent upon the spine than that the spine is dependent upon the rib for the normal condition. It is quite often that a rib or several of the ribs will be found in a subluxated condi- tion without material disorder of the associated vertebrae, but only rarely that the spinal lesion leaves the normal condition of the rib intact. It is to be noticed that the ribs are sus- pended from their anterior ends and are supported from their vertebral ends. This support is the spinal column, through the double articulation between the rib and the vertebra. Hence any material lesion of the support will almost certain- ly involve the rib. EXAMINATION. In no region of the body is it more necessary to bear in mind the value of examination in different positions than in case of the chest region. Unlike the vertebral column the ribs are in continuous and obvious activity easily observ- able on inspection and palpation. Hence in the examination of the part during its functional rest it is a matter rather of degree, since the resting phase of the respiratory cycle is a definite movement. The examination will in either ease be made while the part is moving. But by causing the patient to respire deeply the action will thus be increased above the normal and any abnormal condition associated with the part will likely be made more prominent. This may not only be noticeable to the examining physician but the patient himself THORACIC AND LUMBAR LESIONS COSTAL. 283 will probably experience an increase in the subjective symptoms associated with the disorder. In numerous cases of recent rib subluxations considerable amount of pain will be manifest and this will be markedly intensified if the patient is made to thus inhale. But on the other hand in producing this forced activity, part or all of the lesion condition may be obscured. Hence the examination must be made with the part in as completely a relaxed condition as is possible. In many cases thus associated with pain the patient will indicate it by the position he voluntarily assumes, favoring the side associated with the lesion by sitting in a peculiar position or by a volun- tary lessening of the depth of respiration. For purposes of comparing the movement of the ribs inspection "and palpation both have their advantages. The rise and fall of the chest wall is easily noticed on inspection. In many cases the patient will not be able to produce very marked movement of the upper ribs even though the effort to do so costs him no discomfort. In such a case the upper ribs have become more or less permanently fixed. In many cases the rise and fall of the chest will be more easily detected by palpation in ap- plying the palms of the hands over the anterior chest region. While making the examination by inspection or palpation comparison of lateral halves of the chest is of much value. In certain disease conditions there will be an appreciable difference in \faaamplitudt of movement between the two sides. This is especially true of certain lung disorders in which a greater or less degree of consolidation has occured. In pneu- monia where a complete lobe of a lung is involved there may be practically no movement at all on the involved side while on the normal side through a process of compensation there will be an increased activity, usually not of depth but of rapidity. The general shape of the chest should be noticed with reference to the presence of depressions or prominences either of which indicates a disturbed condition. The size of the chest as well should be noted. In some cases one lateral half of the chest will be so depressed as to materially lessen 284 PRINCIPLES OF OSTEOPATHY. its circumference. It should be noted in this connection that with most individuals, on the side of the body which is used the most there will be a greater chest development, e. g., right handed individuals will usually show a greater circum- ference of the right hand half of the chest. SOME GENERAL TYPES. Any practitioner of experience will undoubtedly have been impressed by the fact that the general shape and con- formation of the chest as a whole varies remarkably with in- dividuals both with reference to normal and abnormal states. In relation to the normal shape the cylindrical chest of the young child is characteristic, while that of the adult shows a marked difference between the transverse and the antero- pos- terior diameters, together with the noticeable change from the roundness of outline dependent upon the development of the angles of the ribs and the more oblique position of the latter with reference to the spinal column. This latter will partly account for the abdominal type of breathing in child- ren and in male adults as compared with the thoracic type as- sociated with the female adult in whom there is usually a more depressed condition of the anterior ends of the ribs. These facts are of considerable value to the student since a failure to recognize them may lead to a serious error in both diagno- sis and treatment. Of the general types of abnormal chest conditions there are recognized three which are characteristic : the first is the flat chest which is a condition commonly found associated with disorders of the lungs. This form is remarkably often associated with tuberculosis of the lungs. In a good many cases it would seem to be a question whether the flattened condition were primary or secondary. It is un- doubtedly true that a wasting away of the lung tissues which is common in consumption will result in the gradual depres- sion of the chest especially in the upper part. It is equally certain that in many cases the flat condition exists prior to any infection of the tissue. Indeed we are persuaded that the THORACIC AND LUMBAR LESIONS COSTAL. 285 so-called hereditary transmission of tuberculosis is little else than the transmission of a narrowed thorax. In this case the condition of the lung tissues is such as to render them more susceptible to the influence of the tubercle bacillus. It is a significant fact that the pulmonary lesion usually begins near the apices of the lungs which is the principal region involved in the flattening. This flattening is a condition that prevents the normal nutritive processes and hence the ill-nourished condition furnishes the favorable soil for the propagation of the micro-organism. As a modification of this type there is the tapering chest in which the difference in the diameters is not so marked while the cavity of the chest partakes of the nature of a cone the apex of which is at the cervico- thoracic junction. This condition is also a common one in pulmonary disorders of various kinds. A second type is the barrel-shaped chest. This is what might be termed a modification of the infantile or cylin- drical type. It is much less common than is the flat chest and is perhaps as often secondary as primary to the disease con- dition associated with it. This type is most markedly noticed in a chronic asthmatic condition and especially where that disease has terminated in emphysema. Asthma is a disorder in which considerable bronchial constriction is present due to an irritant effect upon the nerves distributed to the muscle tissue in the bronchial walls. Under these circumstances the air is only with extreme difficulty forced into and out from the alveoli. Owing to the extreme force that is brought to bear upon the alveolar walls there ultimately results an exhausted and stretched condition of the tissue. We know that one of the principal forces in producing the expiratory phase of res- piration is the normal elasticity of the lung tissue which has been put upon the stretch during the inspiratory phase when the diaphragm is lowered and the chest wall lifted upward and outward. Normally this together with the other elastic structures is sufficient to produce the expulsion of the air in quiet respiration. When, therefore, this elastic condition 286 PRINCIPLES OF OSTEOPATHY. has been partially or completely destroyed the tendency of the more or less unopposed inspiratory muscles will be to keep the lung tissues permanently distended through a per- manent condition of lifted ribs. With less elastic tissue to draw the chest walls downward and inward the position of the rib is gradually changed from a greater to a less oblique condition, which partially accounts for the typical and characteristic barrel shape. In addition to this there is un- doubtedly a disturbance in the articulation between the rib and the vertebra and especially at the costo- transverse ar- ticulation. This latter fact is undoubtedly true in the asth? matic attack in which the barrel shape is quite often manifest while during the intervals of the disorder the general shape of the chest may not appear abnormal. The third type of the abnormal chest is one dependent up- on nutritional disorders of the bony tissue itself and is of such a character as to give it the partially descriptive name of box- shaped chest. This is the type that is found associated with rachitis commonly spoken of as rickets. The disorder in this condition is not apparently dependent upon disturbance of the articulation of the rib but upon the change in shape of the rib during its growth. The box shape in due to a flatten- ing of the sides of the chest and with production of a rather abruptly angular condition at the costo -chondral junction. This change in shape is due to the yielding nature of the ab- normal bony tissue which is influenced by the respiratory ac- tion. The nutritional disorder is not confined to the ribs but is noticed in connection with other osseous tissue, especially the cranium and long bones. SINGLE RIBS. The landmarks for examination of a single rib are the angle, the costo -transverse articulation, and the anterior end. While these are the parts which will give the most information with reference to the condition of the rib it is always advisa- ble to follow with the fingers the outline of the rib throughout THORACIC AND LUMBAR LESIONS COSTAL. 287 its entire extent. With the possible exception of the first, the head and neck of the rib are too deeply situated in their an- terior relation to the transverse process and the antero -lateral relation to the body of the vertebra to be detected. In order to better understand the lesion conditions that are found it is advisable to get a complete picture of the normal articulations and the normal movements that take place in connection. The rib has but the two typical articular mechanisms, namely, the costo- central and the costo- transverse the junc- tion of the anterior end of the rib with the costal cartilage and the latter with the sternum or other cartilage not being a typical articulation. Each rib with the exception of the first, eleventh, and twelfth, articulates with the bodies of two adja- cent vertebra in a wedge-shaped manner and is bound thereto by ligaments sufficiently strong to prevent any great possi- bility of serious luxation, a definite capsule being present which attaches the rib to both vertebras and the interverte- bral disc. This articulation permits of a pivot movement. The articulation with the transverse process is one which per- mits of considerable freedom of movement and which is the one more commonly involved in subluxation. Movement of the rib at this articulation is of a complex nature. Two move- ments are recognized, one of which consists merely in a roll- ing of the rib upon the articular surface of the transverse process. In this the axis of rotation passes through the two articulations. A second movement is of a gliding character in which the axis of rotation is represented by a line passing from the costo-central articulation to the chondro-sternal junc- tion. By virtue of this double movement not only is the antero -posterior diameter of the chest increased by the lift- ing up of the anterior end of the rib from a less to a greater angle with the spinal column, but also the transverse diameter is similarly increased by the lifting up of the lateral portion of the rib, thus causing it to slide as well as to roll upward upon the transverse process. In the vast majority of cases it will be found that the lesion consists in an extreme condition 288 PRINCIPLES OF OSTEOPATHY. of the rib in its relation to this articular surface. In some cases the rib will be felt rather prominently above the trans- verse process, in others it is apparently on a level. In either case the relation it bears to the immediately ad- jacent ribs should be noticed. In examining for the rib at the costo-transverse articula- tion the student will find considerable difficulty in lo- cating the part. While in the skeleton the prominence rig. 24.-showin g axes of rotation of the end of the transverse in movement of rib. (After Kirke.) and the depression just ex- ternal to that prominence are easily noted on palpation, it is not true of the living subject, for the depression will be large- ly filled with connecting structures and the prominence over- laid with muscular and other tissue. If care is taken in the examination the prominence of the transverse process will usually be noticed; then with careful palpation just external the rounded outline of the rib may be detected. Passing on externally or laterally the fingers will note the rather abrupt bend which the rib makes at its angle. This part of the rib is the most easily detected by the student and, fortunately for diagnosis, disturbances in the position of the rib will usually produce obvious change in the relations existing between ad- jacent angles. The angle of the rib, as already emphasized, is of value in diagnosis because of its greater comparative prominence. It is of further interest in that it marks a distinct change in the direction of the course of the rib. Note that the rib at the angle is bent and twisted upon itself so that when laid upon the table the isolated rib will not touch at all points, i. e. , all parts are not in the same plane. This fact makes possible a very different general shape of the chest than would otherwise be. It further permits of a more complex THORACIC AND LUMBAR LESIONS COSTAL. 289 '5* change in position of one part of the rib when another is dis- placed, e. g., a slight rotation about the axis passing through the two articulations at the posterior part will cause a different change in the position of the anterior end than would other- wise be the case. The various forms of lesions have been given names which are more or less provisional. We may speak of a downard sublimation. It is manifest that several ideas might be conveyed by such a term. The rib as a whole may be thus subluxated. This is the condition that should be associ- ated with the term. In such a case the disorder will be de- tected by reference to its rela- tion to the immediately adja- cent ribs. The intercostal space above will be increased through out its whole extent while that below will be decreased. In the region of the angles the de- pressed rib will seem to be in direct contact with the one be- low. In this condition the space throughout its extent will be more uniform than in other forms of disorder. In another case of downward displace- ment the rib is said to be de- pressed. This has reference usually to the anterior and not fifth> to the posterior part of the rib. For in many cases the antero- inferior condition will be associated with a postero- superior change. In such a case the rib at its articulation with the transverse process seems to be resting unusually high upon the upper part of the articular surface. This is but an exag- Fig. 25. Stabilisation of first, and twelfth ribs. 290 PRINCIPLES OP OSTEOPATHY. gerated upward gliding of the rib which in less degree con* stitutes a normal movement. In this condition it will be noticed that the space above the anterior part of the rib will be markedly widened while that below the posterior part, i. e., from angle tp transverse process, will be in the similar condition. Further, at the anterior end, most noticeably at the costo-chondral junction, the depression in the chest wall will in many cases be apparent, while at the angle it will be un- usually prominent due to the throwing outward of the inferior margin of the rib in that region. This condition is perhaps the most common of all rib luxations and is the form com- monly referred to as a twisted rib. It may be noticed in pass- ing that the latter term is often used where the actual dis- placement is so slight as to render certain diagnosis impos- sible. The tenderness on pressure is a valuable aid in diagnosis of any of the ribs. This will often be the fact most easily detected. Most osteopaths have met cases where the tenderness was practically the only evidence of a disturbed condition. In a typical rib lesion the area of 'tenderness will be quite well outlined and will be found to follow the course of the rib throughout its whole extent. In many cases the tenderness will be uniform along its course but in others there will be local areas of increased soreness, suggesting the typi- cal intercostal neuralgic condition. If pressure is exerted on any part of the subluxated structure the pain will be increased. In most cases of rib luxations there will be in addition to the above named indications, various conditions of muscu- lar contracture and changes in temperature and color of the parts involved. The more bulky muscles that are found on the posterior part of the thoracic region are usually easily detected in their abnormal condition. The intercostal and others of the deep muscles may not be sufficiently deranged to be detected by the inexperienced. Other evidences being detected, it may usually be assumed with little possi- bility of error that such a condition is present. Occasionally THORACIC AND LUMBAR LESIONS COSTAL. 291 one's attention will be called to a marked difference in the temperatiire between the tissues associated with adjacent ribs. If care be taken in inspection it will also be found more high- ly colored in the area of greater temperature, suggesting that the latter condition is due to an excess of blood from vaso- dilatation or other cause of congestion. SPECIAL RIBS. The above considerations are given with special reference to the typical rib. It should be noted that there are several which are atypical. Of these the first, eleventh, and twelfth are important. In these the common peculiarity of a lack of the typical angle is noted, while in the latter two there is but the one articulation with the spine and that the costo- central, and no attachment to sternum or upper ribs in front. Hence various points of difference are found in the nature, diagnosis, and treatment of lesion conditions associated with these special ribs. In case of the first rib several new factors must be noted. It is without the typical angle, articulates with but one verte- bra, and with absence of inter articular ligament a greater pos- sibility of vertical gliding of the vertebral end is presented. This will help to explain the common condition of an upward sub- luxation behind. It must be further remembered that the costo-central articulation is not, in this case, the peculiar wedge mechanism which is characteristic where the rib makes union with two adjacent bodies. The third peculiarity is worthy of mention since it has to do with the cause of sublux- ations. The mass of shoulder muscles together with the presence of the shoulder girdle prevents much possibility of direct violence to the rib. Hence in most cases the disorder may be traced to a disturbed muscular condition. This is usually associated with the scaleni. The function of these muscles is to fix the rib against the action of the intercostal and other muscles in respiration. They are usually in a more tense condition than the average muscle, whether in the in- 292 PRINCIPLES OF OSTEOPATHY. spiratory or expiratory phase of respiration and will therefore usually prevent a downward displacement of the rib. On the other hand they are the prime cause of the upward displace- ment. Undue contraction of these muscles will produce dis- turbance of either the cervical vertebrae or the first rib. Usual- ly it is the latter that is disturbed. It must constantly be borne in mind that the scalenal disorder will not persist without a cause acting more or less continuously. In most cases there will be a deeper lesion which affects the innervation to thescaleni, i. e., in the cervical region. It was said that owing to the strength and continued tension of the scaleni the first rib will seldom be displaced downward. But note the following : nearly every first rib subluxated upward is subluxated posteriorly which permits the anterior end as well as the whole upper anterior part of the thorax to fall posteriorly, and hence lessen the antero-posterior diameter of the chest and produce crowding on the structures passing through the superior opening of the.chest. Occasion- ally cases are met which seem to indicate & downward displace- ment of the rib as a whole in which the cause may have been traumatic force from above or muscular tension from below, in either case sufficient to cause the scaleni to yield. Other disorders of the upper rib may result from the undue con- traction or relaxation of the muscles attaching to the anterior part of the clavicle and upper part of the sternum. Among these are the sterno-mastoid, sterno-hyoid, sterno- thyroid, omo-hyoid, and thyro-hyoid. The more anterior fibres of the clavicular portion of the trapezius may also assist in an elevation of the first rib through the attachment of the latter to the clavicle by the subclavian muscle. Incase of the floating ribs, i. e., the eleventh and twelfth, still other differences from the typical condition pre- sent themselves. These have but the one vertebral articulation and are attached only to one vertebra each, and hence lack,as in case of the first, the inter -articular ligament. Owing to their practical freedom from attachment to the transverse processes behind and cartilages of the superior ribs in front, these two THORACIC AND LUMBAR LESIONS COSTAL. 293 have the greatest amount of mobility of the ribs. This fact is one of functional importance since the region of the body which they occupy is one where much crowding of tissues is necessary in the various flexions of the body which are con- tinually taking place. As a consequence of their looseness of articulation and extreme mobility in general, they are easily subluxated, and, fortunate circumstance, easily reduced by the organism itself. Owing further to their practical suspen- sion between muscular tissues they are largely dependent for position upon the play of forces concerned with the muscles. Direct violence will easily displace them. Tightened clothing will force them inward and downward. But unless a con- siderable subluxation takes pi ace at the loose vertebral ar- ticulation they will in all cases return to a normal position if irritation be removed from muscular tissue. Among the most common of the displacements is that in a downward direction (See Fig. 25). By this is usually meant a downward depres- sion of the anterior end although it is by no means rare that the posterior part may also be depressed. This condition may be much more extreme than the average student would believe possible until he has examined personally a number of cases. It is hardly an exaggeration to say that the twelfth rib may be almost vertical and parallel to the vertebral column. Many cases have been noted where the anterior end was almost if not quite on a level with the highest point of the iliac crest. The explanation of such a condition may be difficult. Nor- mally the rib ends in a small point of cartilage which lies be- tween the aponeurotic structures of the oblique and transverse muscles of the abdominal wall, connected to these by areolar tissue. In the extreme downward forcing of the rib in most cases it would seem to be a tearing loose from this areolar tissue and forcing down of the end between the layers of the muscular and aponeurotic tissue. In some cases it will be noted that there will be a general atonic condition of the abdominal walls, in which case the rib is simply carried along with the yielding tissue. The wearing of corsets and other 294 PRINCIPLES OF OSTEOPATHY. tight clothing is one of the most common causes for this downward depression. From this cause the rib will only gradually be depressed and hence it is a gradual yielding of the tissue, not a tearing that results. The tightened clothing will not necessarily produce a depression downward but may depress the parts inward which is a condition equally as faulty. Another cause of the depressed rib is that of over- active infra-costal muscles , i. e., abdominal and quadratus lumborum. The attention of the writer has several times been called to a depressed rib condition where the entire trouble seemed to be a subluxated innominatum producing the condition through irritation to the nerve distribution of the muscle or as likely to direct tension on the connecting tissues of the latter with a consequent downward displacement of the rib. Correction of the iliac bone has in a large number of cases very materially aided -if not entirely accomplished re- duction of the rib condition. In examination of the depressed rib the anterior end of the twelfth will usually be found at a point about on the mid-axillary line, i. e. , the rib reaches about half way to the median line in front. In most cases its end can easily be felt on careful palpation but where it is disturbed in its relations especially if the case be a recent one, much tenderness of tissue will be encountered, hence aare must be exercised or additional irritation and contracture will result. The rib can then be followed around to a point near its central articulation and further data secured for diagnosis. The anterior end of the eleventh will be found above and more toward the anterior than the posterior part of the body. In noting the condition of either, the point should be remembered that these are atypical ribs and hence more subject to differences in normal size, shape, and position than the others. In many cases the twelfth will be so short as to make possible the mistake of calling it the transverse process of a lumbar vertebra. Similar- ly, we have known of the latter being mistaken for a twelfth rib. Simple attention to the fact that the rib may thus vary THORACIC AND LUMBAR LESIONS COSTAL. 295 in length and mobility will make it extremely improbable that a careful diagnostician will be mistaken. Yet such has been the case. Further, the ilio-costal space should always be examined to determine whether it is widened or narrowed. Naturally this space varies with individuals. In a medium sized, man it will be equal to the breadth of two to four fingers. Where an inequality between the two sides exists it is always a fact for suspicion that something is wrong. Care must then be used to determine whether it be due to a faulty innomina- turn, lumbar spine, or rib. Nearly as often there is found an upward displace- ment of the anterior end of the rib. This will be noticed from the narrowed space between the anterior end of the rib and the one next above. In occasional cases -the tip of the twelfth seems to be held by a lock of some kind underneath and behind the anterior part of the eleventh. We have per- sonally examined several cases where we could follow the course of the rib anteriorly till it disappeared underneath the one immediately above. Just the relation the tissues here bear to each other it seems impossible to determine. Such cases will usually be quite obstinate ones to overcome. Then there are numerous cases where the posterior end has been displaced upward or downward, or the whole rib has been forced from its location. In 'a few it will be found luxated directly forward and situated so deeply in the tissues as to make its palpation quite difficult. Reference has been made in most part to the conditions associated with the last rib. The same considerations hold with reference to the eleventh which is similar in its formation, location, and relations. Occasionally the tenth will be also a floating rib, since its cartilaginous extension is usually not very perfect and often becomes broken loose from the carti- lage of the ninth. In most of such cases by movement of the anterior end a definite crepitus may be felt and sometimes heard. This seems to be the friction between the broken cartilao-e and surface to which it was formerly attached. 296 PRINCIPLES OF OSTEOPATHY. v ADJUSTMENT OF RIBS. As a general proposition covering the treatment of rib lesions it may be stated that the chest must be considered as a whole. Each rib is so intricately connected with the adjacent one that a considerable subluxation of one is alto- gether unlikely unless associated with some disorder of one or more of the others. This does not mean that one rib may not be subluxated and the others remain normal. The author has seen numerous cases where no abnormal condition what- ever could be detected in the ribs on either side of the one in- volved and yet the one showed marked evidence of its per- verted condition. As a matter of fact the larger number of cases with which the osteopath meets are those where only the slightest amount of actual displacement is present,though the effect of such may not be at all slight. But it is manifest that where the ribs are normally so closely approximated and are held between two sheets of muscular and other con- nective tissue, a very marked actual disturbance of one rib must produce an appreciable change in the next. This is of practical value when the application is made to treat- ment. For the tension exerted on one rib must be propagated to the next. Hence in adjusting any one of them an efficient force can be exerted by working upon another, preferably that next to it. For instance in an upward and inward crowd- ing of the anterior end of the eleventh, by tensing the quad- ratus lumborum and lower abdominal muscles a successful tension is exerted on the eleventh although the principle ef- fect is upon the twelfth. Similarly, lifting the upper ribs will assist very materially in overcoming a depressed condition of those lower down. Before beginning the treatment of any rib condition, es- pecially if it be one involving several ribs, care must be given to determine whether the rib disorder is not dependent on a vertebral disturbance. For in many cases the perverted rib condition is normal to the existing spinal condition. Hence the treatment to the ribs as a primary consideration is illogi- THORACIC AND LUMBAR LESIONS COSTAL. 297 cal and will likely be inefficient. The condition and position of the ribs is far more dependent on that of the vertebrae than is the position of the latter on that of the former. Yet it must be noted that the last named case may be a real one. A rib disturbed from its normal position and maintained thus will quite likely effect some change in the vertebral relations. In cases where the rib disorder is thus dependent, the logical treatment will be directed to the vertebral disorder. That overcome, the ribs may adjust themselves. Yet it is found in actual practice that treatment to both structures is more satisfactory in point of time and efficiency than that alone to either part and it is entirely reasonable that such should be true. So far as specific movements are concerned a few only will be mentioned enough to illustrate the principles which underlie practically all of the manipulations which are employed. With reference to the position for treatment osteo- paths differ. But either in the erect or horizontal posture the ribs are quite satisfactorily adjusted. Any manipulation that will pull the rib forward and out from the articulations with the spinal column will be effective in greater or less degree. In most cases the disturbance will be associated with the pos- terior part of the rib, and that obstruction released, the an- terior part will be self-adjusted. But additional movement given to the anterior part will add to the efficiency of the treatment in most cases. The parts made use of in adjustment are usually the angle and the anterior end, the latter either directly, as may be done by laying the flat of the hand upon the chest and exerting tension through sufficiently close ap- proximation to prevent slipping of the tissues, or by acting through the medium of one or more of the various muscles which are attached to the anterior and lateral aspects of the ribs. The latter is perhaps the more common and effective method. Exaggeration of the lesion is made use of as in most osseous disorders. Hence if the rib be depressed in front and lifted behind, downward pressure is exerted on the 20 298 PRINCIPLES OF OSTEOPATHY. anterior end and an upward thrust posteriorly as a prelimi- nary to the essentially corrective treatment. With patient on the left side, in case of right rib luxation, the physician stands in front and with the left hand reaches over to the angle of the rib where pressure may be made in the appropri- ate direction to either exaggerate or adjust. Then the pa- tient's right arm is grasped, drawn downward across the chest and face, and up over the head. The movement should be executed sloivly. For muscle as well as connective tissue under normal conditions will yield to a stretching force if gradually applied more satisfactorily than to the same force quickly applied. In the latter case the sudden motion will act as a stimulus to additional contracture and that condition is already too much in evidence. Further, owing to this lat- ter fact, the tissue is in an irritable condition and will respond with greater contracture to a lesser stimulus than would be necessary if the tissue were normal. Note the reason for the movement. The hand on the angle of the rib exerts pressure forward as well as in a direction to exaggerate or adjust. This pulls the rib away from its articulation sufficient to re- lease the deepest structures associated with the articulation. At the same time the same effect is being produced by draw- ing the arm downward across the chest and face through the mediation of the costo- scapular muscles. As the arm is lifted over the head a direct upward traction is made on the rib through the pectoral and scapular muscles which powerfully loosens the structures associated with the rib. Then as the arm is freed but with pressure still applied posteriorly, the rib will tend to settle back to its normal relations. This is a type of a large number of manipulations in common use in which practically the same principles are made use of. For instance the same effects are gotten with the physician standing be- hind instead of in front of the patient who is in the lateral horizontal position. In this the knee is sometimes placed at the angle of the rib and the free hand reaching over is laid flat upon the anterior part and in this way additional force THORACIC AND LUMBAR LESIONS COSTAL. 299 and control may be gotten. Bear in mind the danger always assooiated with the knee treatment. Until the student has become fairly familiar with handling himself and his patient he should leave all knee treatments alone. Another method in common use and one which is quite effective is used with the patient in the dorsal position. If a left upper rib be in- volved the physician stands at the head and to the left of his patient. Then the patient's left arm is.placed between chest and right arm of the physician while the right hand of the latter is passed beneath the cervico- thoracic junction to reach the angle of the rib. At the same time the physician's other hand may re-inforce the fulcrum underneath or be employed in direct work upon the anterior end of the rib. In this posi- tion the physician, by allowing his weight to be carried back- ward and downward drawing the patient's arm strongly with it, may get a very powerful and satisfactory leverage, especi- ally in those conditions where there is a generally depressed upper thoracic region The treatment is unsatisfactory when applied lower down. With the patient sitting the physician stands in front and reaching around underneath the axilla places his fingers on the angle of the rib distal to the spinal column. With the free hand the arm is grasped and passed in the usual manner over the chest and face. Or standing behind, the fingers or thumb may be used as the fulcrum while the arm is rotated. For making a fixed point at the anterior end of the rib so as to produce movement only at the vertebral part, various methods are employed, all based on the same princi- ple as the following one which is made use of quite common- ly by Dr. Still. The patient stands with chest against the wall or post which prevents material movement of the an- terior end. Then making use of the shoulder girdle to lift on the rib through the serratus magnus and other scapular and rib muscles, the posterior part of the rib is forced and guided by the free hand. The same forces are concerned when the pa- tient lies in the ventral position. With an apparatus, such as Dr. Still's Chair with its sliding fulcrum, additional ad- 300 PRINCIPLES OF OSTEOPATHY. vantages are gained. The patient sits, the fulcrum rests against the angles on each side of the spine and a fixed point is thereby gained. Then with appropriate movement of arms or body, standing in front or behind, the ribs are quite markedly under control. Standing in front the thumbs may be inserted so as to grasp the pectoral muscles on either side. Then by lifting and rotating the ribs may be quite satisfac- torily adjusted. In the case of the first rib, owing to peculiarities al- ready referred to, a few new and different factors must be considered. It has already been noted that the upward sub- luxation is the more common and that it consisted in a slid- ing of the rib at both its transverse and central articulation in an upward direction, owing in most cases to the tension of the scaleni muscles. Naturally the treatment will be the re- moval of the tension of the scaleni. Hence in all such cases the cause of the latter should be sought and removed. Never- theless it is found that in most cases this will not be sufficient since the rib will have become partially adjusted to its new position and must be directly worked upon for its correction. A method much employed consists in making use of the scaleni muscles themselves. It is manifest that for a down- ward displacement of the rib this treatment will be entirely appropriate, since by flexing the head to the opposite side a direct upward traction can be exerted on the muscles and hence on the rib to which they are attached. But in the case where the rib is already too high it must be looked at from another standpoint. The flexion of the head is used in the same way but this merely amounts to an exaggeration of the lesion. Thus as the head is returned to its normal erect posi- tion or passed on to the side of the luxation, downward and for- ward pressure is made upon the postero-superior aspect of the rib through the muscular tissues, and the rib is thus lowered to its normal situation. For acting upon the anterior end of the first rib the sterno-mastoid muscle may be made use of by bending the head back and to the side. Direct lifting of LfBFAPY OF COLLEGE OF GSTEGT FKYSfCr/WS THORACIC AND LUMBAR LESIONS COSTAL. 301 the anterior part of the clavicle or an upward lift of the shoulder girdle as a whole, will, through the subclavian mus- cle, assist in the manipulation of the rib through its anterior extremity. Note that the anterior end can only \>e palpated over a small area since the clavicle covers all but a small portion. In case of the posterior half of the rib little difficulty will be found in detecting the part. Reaching in front of the muscular mass formed by the trapezius muscle as it passes down over the cervico- thoracic junction, the hand is pressed gradually downward and backward and with care the un- yielding rib tissue will soon be felt. The posterior border of the rib will usually be too deeply situated to be readily de- tected unless it occupies an unusually high position. The floating ribs require in many cases different treat- ment from that employed in correction of the others. Owing to the fact before referred to, that these ribs are largely at the mercy of the muscle tissues between which they are sus- pended, the logical treatment would be directed toward pro- ducing an equalization of the tension of these tissues. It is manifest that if the rib be luxated downward because of con- tracture of the quadratus lumborum due to a slipped innomina- tum, replacing the rib by work upon it directly, while it may be temporarily effective, will seldom be permanently so. The rational treatment would consist in overcoming the distorted pelvis. This further fact should be noted : in very few cases of a downward subluxation of the twelfth and eleventh ribs, will the other lower ribs be in an entirely normal condition. In most cases if care be taken in diagnosis there will be a gen- erally depressed condition of the lower part of the chest. Hence the problem will not be simply that of reducing the luxated twelfth but the overcoming of the chest condition as a whole. Even though the other lower ribs be in a normal condition aid can be given toward the adjustment of the twelfth by the methods used to raise the others. In case of a condition where the lower rib lies up and under the one above, it is often helpful to elevate the upper ribs as well as 302 PRINCIPLES OF OSTEOPATHY. to give direct treatment toward depressing the lower. In this way a tendency toward separation of the locked parts will be produced. Granting that the treatment of the other ribs may be effective to a marked extent, it is found that a direct appli- cation to the rib involved is usually still more so. This may be done in various ways. By a torsion of the body when the patient lies on his side, produced by exerting pressure forward on the lower ribs and traction backward on the ilium, the rib. is acted upon through the mediation of the attached muscles. Still more direct effects may be gotten by apply- ing the thumb and fingers directly upon the rib. The latter is usually easily found and in most cases spanned by the thumb and fingers. Then as the arm is rotated to draw the upper ribs away from the lower, pressure may be exerted on the latter in a direction toward the normal situation. Usually the hand is applied to the rib along its course rather than up- on the extreme anterior end. In most cases of an abnormal condition of the rib the tissues overlying its end will be quite sensitive to pressure and hence any direct work upon the ex- treme end is to be condemned. Especially any careless "digging" attempts should not be made. In an occasional case it may be necessary and possible to get the fingers in- serted somewhat under the anterior ends and an upward and outward lift be given. If so, great care must be exercised and time must be taken to sufficiently relax the tissues and insinuate the fingers deeply. In most cases this treatment will be entirely uncalled for. By making use of the facts in relation to the peculiar condition associated with these lower ribs and applying the generel rules of exaggeration, rotation, and pressure, the student will be able to do effective work in overcoming rib le- sions in any position of the body and in any condition of the rib. The above suggested movements are representative of a large number that may be employed to advantage. STERNUM AND CARTILAGES. It is occasionally noticed that the sternum as a whole or THORACIC AND LUMBAR LESIONS COSTAL. 303 in part is prominent or depressed in relation to the ribs and their cartilaginous terminations. In such cases we may speak of them as lesions in so far as they are producing additional disturbance. It must not be supposed that such are neces- sarily primary disorders. In most cases a rib sublux- ation will be responsible for the abnormal condition of the sternum. Note that the only articulation of the latter is with the clavicle above and the rib cartilages laterally. Hence it is dependent upon these structures. Direct violence of course may cause a depression, in which case there is likely to be a- fractured cartilage. Occasionally the row of cartilages on- one side will be more prominent than that of the opposite- side. ^hQ junction between the rib and cartilage is not a typical articulation and permits of no appreciable move- ment. Quite often movement will be noticed but it will be found to be a fracture. A bending at the costo-chondral junction takes place to a greater or less extent during the respiratory actions, but not a gliding movement. The fact should be remembered that the sternum consists of three parts more or less independent parts which may be made to appear more distinct by lesion conditions. The ensiform is occasionally abnormal, either lateral, anterior, or posterior. In such the fault is a nutritive one in which the part has grown into its abnormal position. The junction of the gladiolus and manubrium should be noted. This is usually easily detected from its greater prominence and from the fact that the junction between these is the landmark for the sec- ond rib. In "pigeon breast" this junction is quite angular, though the union is efficient and will permit of little if any movement. The treatment for such irregularities is directed to the adjustment of the ribs and to a gradual pressure applied fre- quently to the prominent parts of the cartilage structures. Where the rib has been broken from its cartilage, as is fre- quently the case with the tenth, little likelihood of union is present. Cartilage is an inert structure and unless perfect ap- 304 PRINCIPLES OF OSTEOPATHY. proximation be maintained no union is probable. Fortunately the failure to unite does not seem to present great disadvan- tage, although in occasional cases a continued sensory irrita- tion will be a source of annoyance. In a few cases exquisite pain will be brought out on pressure over the part. This is true also of cases where the cartilage has seemingly been wrenched. Usually a freeing treatment in connection with the rib as well as the part immediately involved will be effi- cient. THE CLAVICLE. The clavicle is a structure which is occasionally found in a disordered condition. Numerous slight subluxations occur either as a result of direct violence or as a result of in- equality in the tension exerted by the attached muscles. The same possibilities for lesion are present in the clavicular ar- ticulations as exist in reference to other osseous structures which present definite articulating surfaces. Complete disloca- tion of the clavicle is common enough in surgical practice and presents its typical symptoms. It is not with such a condi- tion that this work deals, as that is sufficiently emphasized in the works on surgery. But the large number of patients who present themselves complaining of various pain and other symptoms seemingly related to the clavicular structures makes it necessary for the osteopath to examine carefully into such. A surprisingly large number of slight and serious disorders have been absolutely cured by overcoming some hardly ap- preciable disorder of one or both articulations of the clavicle. The following typical case illustrates the conditions met with : a young man in lifting the corner of a wagon box over his shoulder, permitted it to fall, striking him near the acromio- clavicular junction. For a few days thereafter some soreness of the tissues and pain on movement of the arm was manifest but within a few weeks no disturbance was noted. Shortly, however, interference with the free movement of the shoulder was noticed. Pain was felt on lifting the arm while weakness THORACIC AND LUMBAR LESIONS COSTAL. 305 of the latter became apparent. On presenting himself to the physician some two months after the accident a diagnosis of downward subluxation of the acromial end of the clavicle was made and treatment given accordingly. The actual change in position of the part was almost inappreciable though there was much tenderness and some contracture in close relation to the articulation. The only treatment given consisted in separating the two articulations and a lifting upward of the clavicle. Two such were given resulting in a complete and rapid recovery of normal conditions. This case is typical of a large number of very slight subluxations which, as in the one described, are produced by traumatism or, as in numer- ous others, results from a disturbed equilibrium of the muscle tension. Such cases are very common in practice and are among the most satisfactory to practitioner and patient alike. The treatment for clavicular lesions is usually a matter of no great difficulty. Naturally, if the disorder be due to some fault in the musculature of the bone, the nerve supply for such must be investigated. In a few such, overcoming the muscle disorder will be all that is necessary but in most a direct application to the part is helpful if not essential. Any method which tends to increase the distance between acromion and sternum will be helpful. The function of the clavicle is in part to form a brace for the shoulder girdle, and hence nor- mally there is a continued pressure exerted at either articu- lation. Separation of the two parts will therefore be advan- tageous in lessening the points of contact and thereby per- mitting muscular tension as well as the direct work of the physician to re- adjust the disturbed relations. In order to directly grasp the clavicle the physician may stand behind the patient who sits on a stool. If the left clavicle be involved, the right hand is passed in front of the patient the thumb is placed in the supra-clavicular fossa. Then with the left hand the operator lifts the shoulder girdle in a direction upward and forward by means of the elbow of the patient. This relaxes the tissues associated with the clavicle and allows the thumb 306 PRINCIPLES OF OSTEOPATHY. to sink in behind the bone, after which the part may be grasped between thumb and fingers. Then by drawing the arm back the articular structures are separated, and the clavicle can be guided into its normal situation. In inserting the thumb behind the clavicle care must be exercised or ex- quisite pain may he caused. By lifting the shoulder girdle and in that way raising the clavicle in front of the thumb which is held stationary, less pain and greater effeciency will result than by forcing the thumb down behind the part. This same treat- ment, so far as principles are concerned, may be used with the patient in the dorsal position. In this case the fingers rather than the thumb are used to insert under the clavicle. For purposes of separation of the articular structures a good method consists in placing the knee in the back between the shoulders; then with hands on the latter they are pulled di- rectly backward. The freeing of the articular surfaces and lessening of tension of associated tissue resulting will often be sufficient to overcome slight lesion of either or both ends of the bone. THE SCAPULA. The scapula is never luxated in the usual sense of that word since the only articulation it presents is with the acromial end of the clavicle and with the head of the humerus. But in oc- casional cases there is noted a change in position of the scapula which may be quite marked. The scapula, like the hyoid bone, is merely suspended between muscular and liga- mentous structures, and hence any disorder in position that it presents merely indicates that a disturbance in the equilib- rium of muscular tension exists, due to a weakness of one muscle or set of muscles or an undue tonic condition of others. The condition referred to as winged scapula is a typi- cal case of this kind. In such the latissimus dorsi which crosses the inferior angle, and other muscles which attach to the posterior margin of the scapula are in a condition of loss of tone. This permits the more anterior and unopposed mus- cles to draw the part forward and cause the marked projec- THORACIC AND LUMBAR LESIONS COSTAL. 307 tion of the angle which is characteristic. Tn other cases the scapula will be seen to occupy a position too closely approxi- mated to the spinal column. This always suggests an irrita- tion to the rhomboids and posterior fibres of the serratus magnus. Normally there is a space equal to a hand's breadth between the vertebral edges of the two scapulae. This fact will enable the student to determine a probable displacement. Caution must be used since the distance varies within wide limits. The treatment for the displaced scapula will depend on finding and removing the irritation that keeps up the un- due contracture or that has exhausted the tissue in its atonic condition. The student should be able to determine from his knowledge of the musculature the appropriate methods of directly relaxing the tissue, and from his knowledge of nerve origin the lesions likely to be responsible for the irritation. 308 PRINCIPLES OF OSTEOPATHY. CHAPTER XV. THORACIC AND LUMBAR LESIONS EFFECTS. DIRECT PRESSURE. Disorders resulting from direct pressure of the spine up- on the organs are not common, since it is only an extreme anterior condition that would sufficiently crowd the structures to produce disorder. But in many cases associated with a flattened chest the flat upper thoracic spine may interfere directly with the activity of various of the thoracic viscera. In the lumbar portion the spine is occasionally so noticeably anterior as to be easily palpated from the ventral aspect. Such may, in a way, produce effects by direct pressure. VASCULAR OBSTRUCTION. Interference with vessels is largely limited to the branches associated with the spinal column belonging to the inter- vertebral system. The arteries given off from the inter- costals pass directly back to supply in part the spinal canal structures through the intervertebral openings, and in part the muscles and superficial tissues on the dorsal aspect. Le- sions of the vertebrae or deep ligamentous structures may, therefore, cause a lessening of the nutritive supply of the spinal cord, which will produce any form and number of ef- fects dependent on interference with the nerve impulses pass- ing from the particular spinal segment involved. These ef- fects will be discussed more in detail in a succeeding section. In the same way the venous drainage being impaired, the venous congestion resulting will seriously impair the nerve discharge. The muscle contracture by interfering with the normal flow through the softer tissues of the spine may not only cause disorder of their own nutrition but collaterally pro- duce disorder of the next immediate branches, i. e., those pass- THORACIC AND LUMBAR LESIONS EFFECTS. 309 ing to the cord, if the condition is maintained sufficiently long. In the lumbar part of the spine the lumbar vessels passing in close relation to the psoas muscle may be interfered with by abnormal conditions of that structure, in addition to crowding of the branches that lie in their relation to the spine similar to those in the thoracic portion. In the upper thoracic re- gion the closeness of the upper thoracic spine to the sternum and anterior part of the clavicle and first rib may more or less seriously obstruct the flow through the large vessels in that region. These are more properly discussed in connection with the rib lesions because it is usually the rib structures which are mostly at fault. SPINAL NERVES. The nerves likely to be involved from lesion of the spine in the thoracic and lumbar portions are the same in kind as those in the cervical portion except that the cranial system will not be involved. Of the spinal nerves proper the twelve thoracic and five lumbar are situated in positions where marked luxation may produce irritation. The anterior branch of the first thoracic nerve aids in formation of the brachial plexus, that of the second sends an offset to supply the cutan- eous tissues of the arm, while from the last a branch is sent to the tissues overlying the hip. With these exceptions the an- terior branches are continued over the chest and abdomen as the intercostal nerves. So far as the spine is concerned these nerves will only be impinged at the intervertebral regions. The effects from such are varied in number and intensity. Intercostal neuralgias are common. These suggest purely an interference with the afferent spinal fibres. If a pair of nerves be involved it indicates a ' t more central disorder, i. e., involvement of the segment of the cord with which the nerve is connected. If a single side be disturbed it is more likely interference with the nerve or its ganglion cell body on the one side of the spine. Other disorders of sensation may be present. The motor organs may be involved. Tightenings 310 PRINCIPLES OF OSTEOPATHY. of the chest wall or of the abdominal parieties, either tonic or spasmodic may occur, while the atonic condition of the ab- dominal walls is a fairly common disorder. These spinal nerves, through their connection with the thoracic and lumbar sympathetic systems, carry fibres subserving the various functions associated with the latter system and will be spoken of later. It must further be noted that there is possibility of disorder of the thoracic viscera from involvement of the in- tercostals. This is true not only because of the disturbance of the action and condition of the chest wall, or through the reflex mechanism, but by virtue of the fact that the ter- minals of the nerves have been traced across the space be- tween the wall and the pleura; and into the latter structures. Hence pleuritic disorders may be partly dependent on spinal nerve irritation. The posterior branches of the thoracic and lumbar spinal nerves are distributed to the dorsal structures both superficial and deep. Irritation to them will produce muscular contracture, sensory disorders, and disturbance of associated sympathetic functioning. The "stitch" in the back, lumbago attacks, and many so-called kidney pains are in most cases disorders of the sensory nerves in these regions dependent on vertebral lesion or muscle contracture. Simi- larly those structures of the limbs supplied from the posterior branches of the lumbar nerves, which include the superficial tissues of the buttocks and upper thigh, may be involved in numerous forms of disorder. With respect to the anterior divisions of the lumbar nerves numerous facts must be borne in mind. These branches passing from the foramina with the exception of the fifth enter the psoas muscle to form the lumbar plexus. This muscle lies in front of and is attached to the transverse processes of the lumbar vertebrae. In this situation, therefore, we find a very reasonable possibility for irritation, not only from dis- torted conditions of the vertebras' themselves thus initiating muscle contracture or directly affecting the nerves, but from contraction of that muscle from other causes the plexus may THORACIC AND LUMBAR LESIONS EFFECTS. 311 be disordered in all or any of its parts. The sacral plexus is in part formed from the fourth and fifth lumbar nerves. This plexus lies upon the pyriformis muscle and enters into the great sacro- sciatic foramen where it continues as thegreat sciatic and/>:; Constipation, 152 cause of. 321,322, 331 water in, 178 Consumption, pulmonary, 328 Continuity of Protoplasm. 2! Con tract u re, as evidence of lesion, 117 as lesion, 77, 2()1, 219 causing rigid spine, 195 distinguished from contraction, 118, 133 idiomuscular, 117 of rib muscles, 29O secondary, 75, 222, 224 Control of Function, difficulty in direct, 143 indications for direct. 15O objections to direct, 147 Convulsions, a normal process, 62 Dr. Still on, 1O2 Corpuscle, continuity of protoplasm in white, 30 red, in anemia, 40, 167, 334 spherical shape of white, :'.'. white, in infection, 62 Cramp, writer's, 155 Crepitus, in rib cartilages, 2'.i5 Crothers, on drug habits. 169 Croup, temperature in, 1 L'U treatment of, 151 Curvatures of Spine, 194. 27! compensatory, 196, :',4o diagnosis of, 197 lateral, 196, 269, 340 posterior. 273 rotation of vertebrae in. 196 Cytoplasm, as specialized protoplasm, 28 D Definition, of lesion, 75 of life, 22 of machine, 36 of osteopathy, 2O Deposits, as lesion, 1 19 of pigment, 120 Depressor, nerve, 61 Descarteg, on man a machine, 1 5 Diabetes Mellitus, cause of, 32<> Diagnosis, an object in relaxation, 129 of disease, 101 of lesions, 109 Diaphragm, disorders from, 335 Diarrhoea, as symptom, 103 cause of, 322, 331. from muscle contracture, I'l'O. treatment of, 152 Diet, disease from errors in. 122 essentials in, 56 treatment by, 167 Diffusion, of body fluids. 37, 45 Digitalis. 166, 169 Diphtheria, baccillus of in normal individual. 96 Disease,caused by micro-organisms,! 7 caused by structural disorder,25 cause of not in cell, 32 INDEX. 359 definition of, 69 diagnosis of, 101 entity, 164 maintained by structure, 72 sett-regulation in. <>1 treatment of. 121. 15." Dislocation, definition of, 76 Displacement, definition of, 76 Doctrine, cell, 16.27 of spirits, 13 Drugs, as abuse of function, 91 as germicide, 168 as placebo, 164 combat effects, 168 cumulation of, 169 deleterious effect of, 31 desertion of, 17 elimination of, 169 for neutralising, 167 habit, 169 poisoning by, 169 results of treatment bv, 168 sedative action of, 166 stimulant action of, 166, 169 therapy. 164 treatment safer than, 162 uncertainty of, 173 E Ear, ache, 115, 245 lesions affecting, 262 vaso-motors of, 262, 312 Eczema, cause of, 315 Effects, combatting, 18, 168 of cervical lesions, 245 of inferior maxillary lesions, 246 of p"lvir, lesions, 351 of thoracic and lumbar lesions, 308. Effleurage, 184 Egyptians, on massage, 182 Electricity, currents of in muscle, 16, 49 in relation to disease, 174 Electrotherapy, basis for, 176 practice of, 145, 174 rise of, 1* Electrotonous.l 74 Kmphysema, 285 Empirical Method, 165 Enema, value of. 179 Energy, chemical. 44 conservation of, 43 diairram of. 52 definition of, 43 "let-trie, 48 gravitation, 45 health, as co-ordniation of, 51 kinetic, versus potential, 5() mechanical. 46 molecular 45 nervous, 49 of body, 43 photic, 47 thermal, 47 transformation of, 44 Van Helmont on matter and, 15 vital, 26, 44 Enteroptosis, cause of, 331 Epithelium, connection between cells of, 29 Equilibrium, moving, 25 of spine, 19." Hydrodynamics, of body, 37 Hydrotnerapy, as sedative agent, 178 as stimulant measure, 177 as thermal agent, 177 rise of, 18 Hygiene, as prophylactic, 121 of Hebrews, 13 Hyoid, 231 Hypertrophy, from overuse, 89 of heart, 104 Hypothesis, working, 11 latrochemical school, 15 latromechanical school, 15 Ilio-costal Space, 295 Ilium, subluxations of. 340 Immunity, forms of. 9( natural and acquired. 41 Incontinence, of urine, 320 Inferior Maxillary, examination of, 243 lesions and treatment of, 2 I I Inflammation, 119, from lesions to vaso-motors. I'll. Inheritance, of disease, 32 Inhibition. 140, 155 artificial, 142 as function of nervous system, 220 definition of, 141 diagram of theory of, 149 final result of lesion, 219 natural, 141 of phrenic. 144 possible uses of, 141 Innomlnatum, subluxated, 294, 340 Inspection, examination of spine bv, 266 definition of, 106 Intercostal, nerves, (>1, 309. 316 .".37. spaces in diagnosis. Ill vessels, :'..". 1 Internal Secretions, relation to organo- therapy, 18 relation to protoplasmic contin- uity, 3-1 Intestines, disorders of, 321. 331 vaso-motors of, 216, 321 Iron, in amentia. 40 Irritability, Haller and Glisson on, 16 .Tacoby, on electrotherapy, li 5 Jaundice, cause of, 320 K Katabolism, influenced bv massage, 185 in heart muscle, 148 products of cause disease, 33, 35 INDEX. 361 prodiirts of ,-is stimulus to cure, Kellgivn, on summary of massage,188 on Swedish movements, isi on treatment of pneumogastric, 187 Kidnev. disorders of, 325 floating. 7S. 331 stimulation of, 150 vaso-motors of, 210 Klebs. on bacteria in disease. 17, 94 Kleeii, on circulation, 180, 187 on niechanotherapy, 183 Kneading, in massage, 185 Koch, bacillus of, 9(5 on bacteria in disease, 17,94 Krukenberg, on medical art, 17 on organism as a whole, 24 Laboratory, body a chemical, 38 Lactose, source of, 42 Ladd, on definition of a science, 20 Lagrippe, bacillus of 33 Landmarks, in diagnosis, 111, 199 pelvic, 339 rib. 2S(5 sternomastoid as, 227 thyroid cartilage as, 232 Langley, on crossed innervation, 143, 323 Law, general physiological, 220 Head's, 87, U3 of change. 25 Khysical and chemical, basic in inction, 24, 30. 37 Lesion, adjustment of osseous, 126 " muscular, 129 causes of, 84 cervical, 226 costal. 282 definition of, 75 diagnosis of, 109 exaggeration of, 127 extent of, 80 first evidence of, 110 general thoracic and lumbar, 266 JS4 local thoracic and lumbar, 276, L>S< lumbar, 277. 308 not apparent, 150 not entirely removed, 159 not Immediately removed, 1 57 not in all structural changes, 111 pelvic. 33S, 351 predisposing, 150 producing stimulation, 145 removal of In stimulation, 155 relation of protoplasmic contin- uity to. 31 relation of heredity and adapta- tion to, 0(5 sacral, 345 secondary. 89, 150 slight in extent, 2O1 stimulation after removal of, 150 thickened ligaments as. 27O treatment of other than bony, 137 varieties, 76 v a so-motor disturbances from, Lever, principle of in body, 30 Life, definition of, 22 elementary units of, 28 viewpoint of, 22 Ligament, as lesion. 270 ilio-femoral, :+47 nut'ho*. 2i 0. 230 supra-spinous, 200 Light, definition of, 47 cure, 48 Limbs, disorders of, 310, 328 length of, 313, 344 vaso-motors of, 216 Ling, on niechanotherapy, 183 Swedish movements established by. 16 Liver, diagnosis of disorder of.lll glycosuria in disorder of. 1(4 stimulation of, H2. 15n. 15;, 168 vaso-motors of, 216, H19 Lombard, on irritability of muscle.134 Lowy, on heat fnmi metabolism, 102 Lumbar, lesions, 277 fifth, 280 vessels, 3C9 Lung, disorders of. 220,315, 328 tender areas in disorders of, 188 under use of, s-0 vaso-motors of 216. 315 Lymph, pressure on channels, 78, 333 Lymphatic System, effects of lesions on, 205 M Machine, man a. 15, 36, 59, 69 Macrocosm, nature a, 14 Malaria, 97 Mammary Gland. 78, :3. 334, 337 Marey, on animal movement, 15, 37 on function versus structure, 26 Massage, beauty, relation to, 182 countries where practiced, 183 definition of, 181 history of, 1 82 technique in. 184 Mastication, abuse of. 91 Matter, and energy, 15, 23, 43 McGregor-Robertson, on electrother- apy, 174 Mechanism, body a, 38 Mechanotherapy, 181 difference between osteopathy and, 188 Media, for effects from lesions, 77 Medical News, on patent medicines K2 Medicine, history of, 12 patent. 173 prophylaxis a part of. 121 Medulla.centers of in relation to cervi- cal lesion. 230, 253, 264 Meltzer, on effect of drugs. 173 on protection from bacteria, 97 Mensuration, 108 Metabolism, finer processes of, 55 . in disease. 32 in fever, 62 Metclmikoff, on phagocytosis, 97 362 PRINCIPLES OF OSTEOPATHY. Meyer, on syncytium, 30 Microcosm, man a. 14 Micro-orgjuiism, destruction of, 193 protection against 97, 178 relation to disease. 17, 33 Roentgen ray on, 176 temperature effect on, 62 Microscope, invention of, 15 Mind. Christian Science on, 17, 179 Descartes on, 15 Still on. -23 Molecular Attraction, 45 Monell, on electrotherapy, 174 Morphine for pain, 148 stimulant effect of, 166 use of resulting in habit, 170 Movement, amoeboid. 28 amplitude of in diagnosis, 119, 283 method of in treatment, 162 muscular asliberator of energy ,47 normal rib, 287 pivot, of rib, 287 principles back of, 240 rapidity of in treatment, 161 Swedish, 16, 183 Mucous Membrane, self-cleansing, 179 Muscle, action of affects bone, 26 an tic us major, 258 biceps, 87 continuity of protoplasm in, 30 contraction wave in, 29 fatigue. 33 leverages in, 86 peroneus, S7 posterior of neck, 229 psoas, 809, 310 pyriformis, 78,112 scaleni, 136, 228, 291, 300 sense in diagnosis, 198 sternomastoid, 109, 227, 257 trapezius, 257 tone of, 843 treatment of, 129, 137, 151 N Nancrede, on gangrene, 70 Nature, a macrocosm, 14 attempts at adjustment, 158 a unit, U never complete, 14 Sydenhiun, on healing power, 18 Negro, immunity of, 93. 9fi race as predisposing factor, 93 Nephritis, 81 Nerve, afferent function of sympa- thetic, 212 anterior crural. 811 cranial, effects on,254 depressor. 61, 215 external cutaneous, 311 facial, 254 fifth cranial, 254 function of not known, 143 glosso-pharyngeal, 255 hypoglossal, 258 intercostal, 82 massage of. 187 obturator, 311 phrenic, Gl, 142. 144, 234, 253, 337 pressure on, 78 pudic, 311 sacral. 143, J52 sciatic, 112, 154, 311, 352 secretory, of sympathetic, 212 spinal, 205, 251, 30, 353 spinal accessory, 144, 257 splanchnic, 317 stimulation, of splanchnics, 144 sympathetic, 206, 258. 312, 337 ulnar, 82 vagus, 255 vaso-motor, 214 Nervl-nervorum, 205 Neuralgia, facial, 245, 254 intercostal, 309, 837 Neuritis. 311 Neutralization, drugs given for, 167,192 Nitrogen, importance of, 24, 39 Normal, definition of, 67 tendency to, 64 Nucleus, relation of cytoplasm to, 28 Nutrition, disturbance, 85, 337 o Obstruction, vascular, 247, 308 Opium, as sedative, 166, 169 Organism, as a whole, 17, 21 cure, the prerogative of. 22 self-sufficiency of, 42, 60 Organotherapy, rise of, 18 Osmosis, in bodv, 37, 45 Osteopathy, boundaries of, 20 relation of other systems to,164, Ova, in relation to protoplasmic con- tinuity, 29 Ovary, disorders of from lesions, 334 Overgrowth, as lesion, 77 Oxidation, in heat production, 47 Oxygen, action of In body, 40 amount consumed, 47 discovery of, 13, 16 Pain, abnormal condition, 65 cause of, 79 definition of, 112 direct, 112 inhibition for, 148, 151, 153, 169 morphine for, 148 referred, 113 symmetrical, 82 symptom of, 101, 106 transferred, 82 Palpation, 106 Palpitation, 82 Pancreas, 104, 319? Paracelsus, philosophy of, 14 Paralysis, agitans, 92 Bell's, 254 caused by pressure, 70 Parturition, coccyx in relation to, 352 flooding after, 151 wedge principle in, 37 Pascal, law of, 37 Pasteur, on fermentation, 17 on germ theory, 94 Pathology, Vlrchow's influence on, 16, 27 Pelvis, 338, 339, 346 Pepsin, action on proteids, 40 Percussion, 107 Peristalsis, anti, 61 INDEX. 363 changed, 148 wedge principle in,87 Peritonitis, posture in, 136 Persians, on massage, 182 Perspiration, 79 Petrissage, 184 Pfluger, 114, 221 Phagocytosis, in infection, 31, 62 Sternberg and Metchnikoff on, 9> Philosophy, of life, 11 Phototherapy, 176 Phrenic Nerve, inhibition of, 142, 144 relations of, 234, 253 relation to vomiting, 61 Physiology, application of facts of, 22 chemical facts of, 40 of cell, 28 Pilo-motors, 223 Plato, 13 Pleuritis, cause of. 316, 331 friction sounds in, 108 from intercostals, 310 Plexus, aortic, 314 brachial, 229. 253, 309, 314 cardiac, 208, 313 cervical, 26S hypogastric, 208, 326 lumbar, 310 mammary, 263 Meissner's and Auerbach's, 321 ovarian. 324 pelvic. 208. 353 pulmonary, 208, 315 sacral, 311, 35'2 solar, 151, 2C8 subclavian. 263 tympanic. 2H2 vertebral, 263 Pneuma, theory, 13, 16 Pncumogastric, function of, 143 lesion of, 336 stimulation of, 142. 187 Pneumonia, bacillus of in normal, 96 respiration in, 103 Postmortems, in time of Ptolemies, 12 Posture, as cause of lesions, 85 in examination, 226, 282 in treatment, 242 Potts' Disease, 110,201 Practice, versus principles, 10 Predisposition, as cause of disease. 91 from perverted structure, 75 removal of as prophylaxis, 121 Pregnancy, acting as lesion, 78 disorder of, 355 Pressure, air in body function, 37,45 as diagnostic measure, 10ft as fundamental in lesion, 76 blood, 61 effects from lesions by direct, 77, 246, 308, 328. 351 effect of sub-occipital, 229 on nerves, 336 on vessels, 78, 332 massage, 185 negative, 185 stimulant action of, 31, 142 treatment by, 128, 132, 153, 240 Priestly, discovery of oxygen by, 13, 16 Principles, at basia of tendency to normal, 67 in psychotherapy, 180 vs practice, 10 Problem, of physiology, 28 Prophylaxis, a part of medicine, 21 definition. 121 in removal of lesion, 123 Prostate, disorder of, 365 treatment of, 186 Proteid, nature and value of, 54 Protoplasm, chemical and vital pro- perties of, 24, 38 healing power inherent in, 63 parts of cell a specialization of,28 physical basis of life, 25 Psychotherapy, effects from, 175 forms of, 179 principle in, 180 Ptolemies.medical practice in time of,12 Ptosis, of abdomen, 327, 330 Pulley, in body, 37 Pulse, Chinese on, 12 Trail be-Herring curves Independ- ent of, 30 Pupillo-dilators, 212, 223, 261, 312 Q Quain. 250 on nerves of ureters. 325 on pneumogastric, 256 on sacrum, 346 on sympathetic to pia, 214 Quinine, habit, 170 R Race, as predisposition, 92 Rachitis, chest in, 2s6 Radiation, of nerve impulses. 86, 221 Reaction equal to action, 148 from drug, 166 of degeneration, 174 Recoil, benefit of in treatment, 128, 135 of function. 146 Rectum, atony of, 179 examination per, 350 stmulation of, 142 Reflex, stimulation through, 144, 188 vaso-motor. 215 Region, cervical, 202 coccygeal. 203 interscapular, 266 lumbar. 203 pelvic, 203 suboccipital, 229 thoracic. 203, 26 Relaxation, by approximation, 135 by pressure, 132 by removal of cause, 131 by stretching, 134 for diagnosis, 129 methods of, 131 preliminary. 130 primary, 131 purposes, 129 Repair, after abuse, 36 Resistance, lowered, to stimuli, 34 peripheral, 147 Respiration, example of self-sufficiency, 60, 103 stimulus to. 88 tract, 155, 257, 262 364 PRINCIPLES OF OSTEOPATHY. Revival of Learning, 14 Revolution, osteopathy a., 12, 18 Rheumatism, salicylates for, 1G7 Ribs, 282 adjustment of. 296 articulations of, 287 depressed, 'J89 first, 291, :!0' floating. 22, 301 lesions of 289 mobility of, 293 presssure from. 828, 332, 336 Kindle, 2Sfi 8peoi.il, 291 subluxations, effects from, 332 twisted, 290 Robinson. Byron, on reflex, 83 Rd-ntgen Rax-, value of. 176 Romans, on mechanotherapy, 182 Rotation, axes of, in ribs, 287 axes of in innoininatum, 339. 842 n.8 diagnostic measure, 108, 23i In treatment, 128, 240 s Sacrum, lesions of, 345 Salicylic Acid, in rheumatism, 167 Salts, functron of in body, 54 Sanitation. Hebrews on, 13 measures. 123 Scapula, diagnosis and treatment, 306 Schiff, n function of vagus, 143 Schleidan and Scliwann, on cell struc- ture, 27 Schools, during middle ages, 14 iatrochemical and mechanical, 15 .Sciatica, cause of, 69, 3 '2. 352 inhibition for, 142. 188 Science, definition of, 20 osteopathy a, 21 Sclerosis, treatment of, 138 Season, as predisposition, 92 Sebum, value of. 178 Secreton, disorders of from lesion, 224, 319, 3 8 mammary. 335, 337 relation to organotherapy, 18 relation to protoplasmic con- tinuity, 31 Sedative, drug as, 16fi Segmental. arrangement of vaso- motors, 218 structures, 114 Selection, attribute ofliving tissue, 55 Self-regulation, by substitution, 62 in disease, 61 limits of, 69 of function and structure, 22, 27, 60 62, 157 Self-sufficiency, of organism. 60 Sensory Change, in diagnosis. 111 Separations, as lesions, 198, 276 Serotherapy, rise of, 18 Serums, Ifi7 Sex, as predisposition. 92 Sinus V 7 enosus,contraction wave from, 29 Skin, secretion of, 178 Smallpox, immunity from. 97 Soda, in sour stomach, 167 Sounds, in manipulation, 201 Specifics, search for, 173 Spencer, on definition of life, *>4 Spinal Cord, effects of lesions on, 246, 264 Spine, approximations in, 198 contour of, 14 general survey, 191 lax. 196,274 of ilium, 34> rigid, 119, 138, 195 straight U5 Spleen, vaso-motors of. 216, 319 Starvation, effect on organs, 62 Sternberg, on phagocytosis 97 Sternum, examination and treatment 3- 2 Still, on buzzards, 95 on cause of disease, 18 on convulsions, F2, 102 on diaphrairm. 335 on drainage of kidney, 48 on electric energy. 49 on frequency of treatment, 160 on goitre, 2>1 on length of treatment, 161 on lesions of pelvis, 346 on life, 23 on lymph. 333 on plan and specification, 10 on prominences. '200 on pro to i>l a sin, 25 on relaxation, 130 on sounds in manipulation. 201 on temperature in croup. 120 on youth of osteopath v, 9 revolution inaugurated by, 12. 19 Stimulation, 140, 192 after removal of lesion, 150 artificial, 142 by drlijrs, 166 by electricity, 174 by water, 177 definition, 141 intural, 141 ostfopathic. 142, 146, 155 possible use for, 141 Stimuli, causing contracture, 131 changes constitute, 24,81 electric. 145 intensity of, 145 lesions as, 145 mechanical energy as, 46 on protoplasm, 34 quick movement as, 161 response to. 13 1 strength and abruptness of, 81 summation of, 81 Stomach, condition in drug user, 169 disorders of, 318. 331 in vomiting, 147 secondary lesion from, 26 skin areas in connection with, 115 soda for, 167 treatment of, 15S vaso-motors of, 318 Strabismus, 261 Structure, adjustment of, 62 cell life affected by. 35 change of from psychic disorder, 180 INDEX. 365 maintains disorder. 72, 193 relation to function, 18, 22, 25, 145 Strychnine, 166 Subluxation, anterior spinal, 277, 279 cause of rib. 291 'definition of, 76 diagnosis of spinal, 198 of ilium, 340 of ribs, 289 Substitution, drugs for, 167 in treatment. 192 Summation, of causes. Booth on, 94 of stimuli, 81 Superior Opening, of thorax. 332, 336 Surgery, electricity in, 174 Rcjentgen ray in, 176 similarity to osteopathy. 17 Swedish Movement, 16, 181, 183 Sydenhain, on healing power of na- ture, 16, 18 Sylvius, founder of latrochemical school, 15 Symptom, definition of, 105 disad vantageous. 105 Hippocrates on, 13 in judgment of normal, 64 nature of, 1' 1 treatment of. 151, 191 varieties. 105 Sympathetic System, 206 associated with spinal nerves.264 cervical, 258 connection with central system, 208 connection with cervical nerves. 261 development of. 206 function of fibres of. 212. 223 ganglia ted cords of, 207 parts affected by lesion, 213 plexuses, 207 thoracic. H12 types of fibres of. 209 Syncytium, bmly a,30 Systems, comparisons with other. 164 T Tapotement. 184 Temperament, as predispostion, 92 Temperature, as cause of lesion, 85 as evidence of lesion, 119 as symptom, 101 differences in cervical lesions, 229 in rib lesions, 291 of hand in treatment, 136 treatment of high, 152 Tendency to Normal, 64. 124. 145, 180 Tenderness, associated with Inngs, 314 as symptom, 106 II*-', 188, 200 in relation to ribs, 290 Tension of Tissues, in self-adjustment, 124 Theorv. germ, 15 H art's. 222 inhibition, 149 of Basch. 322 pneuma, 13 Therapeutics, definition, 121 Thermotaxis, an illustration of self- regulation, 61 Thompson, on uses of salts, 54 Thoracic Duct, lesions affecting, 333 Throat, diseases of from lesion, 245. 248 structures associated with, 231 Tobacco, habit, 170 Tonsillitis massage in, 186 Tonsils, 232,245 Toothache, treatment of, 187 Torsion, as lesion, 198, 203, 27> Torticollis, 106, 109 Touch, necessity for delicate sense of, 107 Toxins, in metabolism, 33 from bacteria, 95 Traube-Herring curves, 30 Treatment, curative versus palliative, 125 frequency of, 160 habit. 149 185 internal 3il length of, 161 natural methods of, 191 negative. 155 of clavicle. 305 of connective tissue lesions, 138 of disease, 121, 155 ef flat spine, 268 of other lesions, 137 of scapula, 307 of sternum and cartilages, 803 of symptoms. 151 of temperature, 152 of pelvis. 346 possibility of harm in. 161 rapidity of movement in, 161 to force obstruction, 151 tonic, 19, 150 Trvp*in, action on proteids, 40 Tuberculosis, 92 284, 329 Tumor, as lesion, 78 treatment of. 137 u Unit, morphological. 30 nature a, 14 Urea, formation of, 40 Ureter, nerves of, 325 Urinnlysis, by Brahmins, 12 Urinary Apparatus, location of, 45 Urine, incontinence of. 326 retenti m of. 355 Uterus, displacement of, 338 flooding from, 151 lesions affecting, 324, 354 Vagus, congh from irritation to, 233 functions of, 143 influence in vomiting. 61 inhibition influence on heart. 141 VanHelmont, 15 Vaso-motors, action of. 216 associated with fifth. 254 associated with ninth, 256 definition of, 214 lesions affecting, 216 of bladder, 427, 354 of limbs, 328 of liver, pancreivs and spleen. 319 366 PRINCIPLES OF OSTEOPATHY. of ovary and uterus, 824 of sympathetic, 212 reflex mechanism of, 214 system, 214 varieties of, 214 Vein, inferior thyroid, 7S, 261 intervertebral. 204, 250, 308 jugular, 187,233 portal, 78 pressure on, 78 KaphenouK, 353 varicose, 78,353 vertebral, 249 vena caya, 336 Vertebra?, adjustment of, 240 cervical, 234 examination and treatment, 197, 199. 234. 238, 277, 279 lumbar, 277 relation of ribs to, 282, 296 thoracic, 26 Verworn, on electrotherapy, 175 on formula for protelds, 39 on lagrippe, 33 Vibration, in massage, 185, 187 Viewpoint, of life, 22 Virchow, on cell patholojry, 16, 27, 32 Viscero-motors, 212, 223, 319, 322 Vital Force, beyond physics, 23,63,59,68 Haller on, 16 In nerve action, 221 Vital Level, 180 Vomiting, as example of self-regula- tion, 61, 108 of pregnancy ,84 treatment for, 152 wedge action In, 37 w Water, as sedative, 178 as stimulant. 177 as thermal agent, 177 importance of In body, 39, 54 Wedge, action of in body, '37 action of sacrum, 347 Wilson, on life, 23 X X-Rays, burns from, 48 Ziegenspeck, on treatment of adhe- sions, 187 on treatment of uterus, 187 University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hilgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which it was borrowed. CAT. NO. 24 I6l A 000510224 9 UC RV NE LIBRARY 3 1970016237874 Hulett, Guy D. Text took of osteopathy 1903 principles of WB9UO H912t 1903 Hulett, Gj>y D. Text book of the principles of osteopathy MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664