The practice of osteopathy

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

Osteopathic Stimulation

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

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

Osteopathic Inhibition

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

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

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

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

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

Osteopathic Readjustment

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

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

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

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

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

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

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

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

VasoMotor Nerves

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

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

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

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

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

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

Receptaculum Chyli.—Stimulation of the splanclinics causes dilatation.

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

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

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

Portal System.—Fifth to ninth dorsal.

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

Coccyx and Immediate Region.—Third lumbar down.

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

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

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

Sensory Nerves

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

Heart.—First, second and third dorsals.

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

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

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

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

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

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

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

Epididymis.—Eleventh and twelfth dorsals and first lumbar.

Testis.—Tenth dorsal.

Ovary.—Tenth dorsal.

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

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

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

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