t> - * -v, s° '. - o ,0o. > '^«f ■ ^. •v^ >%- rv\ oo x ,v ^. ', O 0' ^ o> 3> -A V * % c ' »0 H ?r&tAt to . . -rr%**.*ist2 " «*- up . ■ _ 3*~*t-r***r(r. iltt Ut . ; < mump, ««s»~- ^ G'Cir-VT*^ *** Tr"" • C- *>-«-< ««.*,., * J «. eecnJ«tx| " " ' "ML *S^ * # f I # | f P "4 f (71 * / I ^ * ... Ma i / , ■■ 4 i| - 2 i ti' ms 1 'Sf xC*» - *f 1 M a&fftkh* apT I '*' iun 8 ' \I III ?' % 9m ; Diagram of dorsal muscles —4th layer. Adapted from a diagram in Cunningham's Anatomy. PRINCIPLES OE OSTEOPATHY BY V DAIN L. TASKER, D.O , D.Sc.O. Professor of Theory and Practice of Osteopathy and Clinical Osteopathy in the Pacific School of Osteopathy. Fellow of the Southern California Academy of Sciences. President of the California State Board of Osteopathic Examiners. Vice-President of the Pacific School of Osteopathy. Director of the South Pasadena Osteopathic Sanatorium. Member of the American Osteopathic Association. Associate Editor of the Journal of the American Osteopathic Association. Editor of The Osteopath. ILLUSTRATED. PUBLISHED BY BACMGARDT PUBLISHING CO. LOS ANGELES, CAL. 1903 the library of 1 congress, 1 Two Copies Received | APR 20 "903 Copy ught Entry clIass Oiy XXc No. COPY B.I Ac\ COPYRIGHTED 1903, BY THE AUTHOR, Dain L,. Tasker, D.O. LOS ANGELES, CALIFORNIA. PREFACE. This book on the Principles of Osteopathy is intended as a manual for the use of students and practitioners. There has been no effort on the part of the author to do more than give a short, terse exposition of the essential facts underlying os- teopathy. Realizing fully the great effort required to keep pace with the rapid progress of medicine in general we have tried to include in our chapters only that which will be solid food for our readers. We have long since learned that the hurried student and busy practitioner have no time to read long dessertations on any subject. Time is an essential factor in covering the necessary studies of an osteopathic curriculum. In order that the student may read these chapters intelli- gently he must have concluded at least ten months of study of Biology, Histology, Anatomy and Physiology. These sub- jects form the basis of the science of osteopathy. The author has kept in touch with the growth of osteo- pathy from year to year, through careful perusal of its pub- lished books and periodicals. The contents of this book are the condensed results of the author's study of recognized medical text books on Anatomy, Physiology, Histology, Pathology, Bacteriology and Diagnosis, of the works of the founder of Osteopathy, Dr. A. T. Still, Hazzard, Riggs, Henry and McConnell, of six years' expe- rience in the clinics of the Pacific School of Osteopathy, and the Infirmary in connection with this college, and six years of continuous teaching, two of which were devoted to Anatomy and Physiology and the remaining four to Theory and Prac- tice of Osteopathy and Physical Diagnosis. To enumerate the books from whose pages facts have been gleaned for corroborative testimony concerning the Principles of Osteopathy is impossible. Books have been read and laved 8 PREFACE. aside and what is here written may be the result of something which caught the author's attention for a moment only and then became a maverick. The illustrations to elucidate the text have been furnished principally by the laboratories and clinics of the Pacific School of Osteopathy. Without the hearty and efficient aid of my as- sociates on the faculty of this college much of the concise detail of this book would have been impossible. I am indebted to several osteopathic physicians for drawings of histological tis- sues which they had prepared during their college work. They are given credit under their drawings. The large number of excellent photographs of microscopic structures, patients and movements is the result of the skill of J. O. Hunt, D. O. A few of the photographs were made by M. E. Sperry, D. O., who also took great care to see that we had the best of photographic lenses with which to work. I am also greatly indebted to C. H. Phinney, D. O., and J. E. Stuart, D. O., for their accurate demonstration of osteopathic movements. My thanks are extended to Miss Louisa Burns, B. S., for reading the manuscript and suggesting corrections therein, also to Miss Gertrude Smith for preparing the manuscript for the publisher. Dain L. Taskkr, D. O., D. Sc. O. TABLE OF CONTENTS. CHAP. I. — The Cause of Disease. — Potential and Kinetic En- ergy — A Normal Stimulus — A Change in Resist- ance — Resistance — Cause and Effect — Cell Rela- tions — Excessive Stimulation — Structural Defects — Cell Life Dependent on Circulation — Osteopathic Therapeutics — Incidents in the History of a Disease Process — Fatigue and Excess — Methods of Cure — Subluxations are Mechanical and Chemical Stimuli. CHAP. II. — Structural and Contractile Tissues. — The Cell — Structural Tissues — Contractile and Elastic Tissues — Metabolic Tissues — Irritable Tissues — Circulatory Tissues — 'Mechanical Principles — Displacement by Violence, Passive — Obstruction to Vital Forces — Pri- mary and Secondary Lesions — Displacement by Mus- cular Contraction, Active — Summary — Contractile Tissue — Amoeboid Motion, Contraction — Stimuli — Direct and Indirect Stimulation — Structural Tissues Affected by Contraction — Circulation of Blood in Muscle — Effect of Contraction, Intrinsic — Extrin- sic — Summary. CHAP. III. — Irritable Tissue. — Nerve Tissue — Irritability — Conductivity — Trophicity — Unity of the Nervous System — Mechanical Irritation — Double Conduc- tion—Nerve Bundles — Central Nervous System — Segmentation — Reflex Action — Practical Applica- tion — Efferent Nerves — Sympathetic Ganglia — Diag- nosis — Objective Symptoms — Co-ordination of Sen- sations — Example. io TABLE OF CONTENTS. CHAP. IV. — Circulatory Tissue. — Functions — Lymph — Blood — Blood Corpuscles, Red — White — Chemical Constitu- ents — Distribution of the Blood — Circulatory Appara- tus — The Heart — Regulation of Contraction — Co-ordi- nating Centers — The Pneumogastric Nerve-Accelera- tor Center — Stimulation of the Heart — Inhibition of the Heart — Vaso-Motor Control of the Coronary Art- eries — Angina Pectoris — Action of the Heart Centers, The Depressor Nerve — Vaso-motor Nerves — Vaso- constriction — Vaso-dilation — Summary — The Sensory Nerves — Recapitulation — Vaso-motor Centers — Con- clusions — Pathology — Therapeutics — Case Illustra- tions. CHAP. V. — Secretory Tissue. — Metabolism — Arrangement of Gland Cells — Epithelium — Protective Epithelium — Se- cretory Epithelium — Sensory Epithelium — Gland For- mation — Sexual Cells — Summary — Filtration, Osmo- sis and Diffusion — The Individual Cell — Secretory Nerve Fibers — The New Viewpoint — Necessary Con- ditions for Secretion — Classes of Drugs which Affect Secretion — Unimpeded Blood Supply — Proper Food — Innervation — Osteopathic Pathology — -Therapeutics — Direct Manipulation — Hyperaemia of the Governing Center — Effect on Heart Beat — Classes of Stimuli — Perspiration — Importance of the Cell. CHAP. VI. — The Sympathetic Nervous System. — Unity of the Nervous System — Origin — Lateral Ganglia — Four Prevertebral Plexuses — Visceral Ganglia — Communi- cating Fibers — White Rami-communicantes — Distri- bution — Function — Gary rami-communicantes — Dis- tribution — Functions of the Sympathetic System — Independent or Dependent — Ganglia — Cervical Ganglia of Importance to Osteopaths — Superior Cervi- cal Ganglion — Connections — Vaso-constriction — Dis- tribution — Headache — Middle Cervical Ganglion — Distribution — Function — Manipulation — Recapitu- TABLE OF CONTENTS. n lation — The Thoracic Ganglia — Rami-efferentes — Up- per Five Thoracic Ganglia — Nerve Distribution — The Interscapular Region — A Case Illustrating the Cilio- spinal Center — Effects of Treatment, First to Seventh Dorsal — Great Splanchnic — Lesser Splanchnic — Least Splanchnic — Functions — Theory — Lumbar Ganglia — Sacral Ganglia — Distribution — Function — Cardiac Plexus — Position and Formation — Pulmonary Plexus — Physiology — Functions — Treatment — Results — Argument — Solar Plexus — Location and Formation — Distribution — Function — Centers — Hypogastric Plexus — Location and Formation — Pelvic Plexus — Distribution — Subsidiary Plexuses — Function — Sum- mary — Automatic Visceral Ganglia — Conclusion. CHAP. VII.— Hilton's Law.— The Law Stated— Methods of Studying Anatomy — Example of Hilton's Law — The Knee — Object of such a Distribution — Uniformity of the Law — Precision of Nerve Distribution to Muscles — Indications for the Use of Therapeutics — The Use of Hilton's Law in Physical Diagnosis— Comparison of Methods — Herpes Zoster — The Distribution of an Intercostal Nerve — Some of the Evil Effects of Rest — Head's Law — Application of the Law — The Viscera — Nerves of Conscious Sensation. CHAP. VIII. — Subluxations. — Definition — Diagnosis — Prima- ry or Secondary Lesions — Analysis — Occipito-atlantal Articulation — The Causes of Subluxation— The Atlas and Axis — Unequal Development — Caries — Spontane- ous Reduction — Cervical Vertebrae — Dorsal Vertebrae — False Lesions — Lateral Subluxations — Muscular Contraction — Compensation of Effects of Muscular Contraction — Separation of Spinous Processes — Ap- proximation of Spinous Processes — Subluxations, Pri- mary — Subluxations, Secondary — Limited Area for Lateral Subluxations — Characteristics of the 8th to the 1 2th Dorsal Vertebrae — Dorso-Lumbar Articulation — Kyphosis, Lower Dorsal — The Lumbar Region — Ex- 12 TABLE OF CONTENTS. animation of the Ribs — Costo-central Articulation — Costotransverse Articulation — Co-ordination — Inco- ordination — Nervous Control of Respiration — Costal Subluxations — First Rib — Tenth Rib — Eleventh and Twelfth Ribs — Effect of Position of Vertebrae on the Position of Ribs — Clavicles — Sacro-iliac Articulation — The Nerves Affected — Symptoms — Sacro-vertebral Articulation — Summary. CHAP. IX. — Osteopathic Centers. — Diagnosis — First Four Cervical Nerves — Example of Hilton's Law — The Pneumogastric Nerve — The Hypoglossal Nerve — Superior Cervical Ganglion — Sub-occipital Triangles — Cervical Plexus — Intensity of Reflexes — The Spinal Accessory — The Phrenic Xerve, Hiccoughs — The Trapezius and Splenitis Capitis et Colli Muscles — Vasomotion, Head, Face and Neck — Affections of the Cervical Nerves — Brachial Plexus Affections of the Brachial X T erves — A Case of Hemi- paresis below the Fifth Cervical Vertebra — Subluxa- tion of the Scapula — The X T erve of Wrisberg — The Interscapular Region — The Lung Center — Cilio-spinal Center — Heart Center — Stomach Center — Liver and Spleen Center — Leukemia — Large Intestine — Small In- testine — Center for Chills — The Language of Pain — Osteopathic Mew of Pathology — Center for the Gall- bladder — A Case Report — Intestines — Uterus — Ova- ries and Testes — Kidney — Second Lumbar — Paraple- gia — Lumbar and Sacral Plexuses — The Bladder — Sphincter Vaginae — Conclusions. CHAP. X. — Germ Theory of Disease. — Specific Causes — Con- ditions which Affect Life — Resistance — Immunity — Specific Treatment — Summary. CHAP. XI. — Compensation and Accommodation. — Definition — The Spinal Column — Compensatory Curvature — The Extremities — The Thorax — Skin and Kidneys — The Heart — Power of Encysting. TABLE OF CONTENTS. 13 CHAP. XII. — Inhibition. — Acceleration — Inhibition — Mus- cular Contraction — Secretion — Acceleration and Inhi- bition as Attributes of Nerve Tissue — Is the Work Done Proportionate to the Strength of Stimuli — Inhibi- tion a Normal Attribute of the Central Nervous Sys- tem — Physiological Activity is a Result of Stimulation — Hilton's Law — Inhibition — Therapeutics — How Vasomotor Centers Act — Over-stimulation equals In- hibition — The Guide for the Use of Inhibition — Patho- logical Changes which Accompany Over-stimulation — Rational Treatment — Hyperaesthesia of Sensory Areas, Diagnostic — Results of Inhibition — The Phrase "Remove Lesions" — The Human Body is a Vital Mech- anism — Structure vs. Function — Osteopathic Meaning of Inhibition — The Scientific Use of Inhibition — Inhi- bition as a Local Anaesthetic — Inhibition May Act without Removing a Lesion — Inhibition to Remove Lesions — Passive Movements vs. Rest — Inhibition as a Preparatory Treatment. CHAP. XIII. — Positions for Examination. — Testing Align- ment and Flexibility — Sense of Touch — Inspection — Palpation of the Ribs — Palpation of the Spine — Ex- trinsic and Intrinsic Muscles of the Back — The Diag- nostic Value of Hyperaesthesia — Testing Muscular Tension — Thoracic Flexibility — Examination of the Abdomen — Elevation or Depression of Ribs — Examin- ation of the Rectum and Prostate Gland — Examination of the Neck — The History of Lesions — The Extremi- ties — Subjective Symptoms. CHAP. XIV.— Manipulation. — Method of Procedure— Relax- ation of the Latissimus Dorsi — Relaxation of the Tra- pezius — Relaxation of the Rhomboids — The Pectoralis Major and Serratus Magnus — Quadratus Lumborum — The Erector Spinae — Treatment of Simple Kypho- sis — Lordosis — Upper Dorsal — The Variety of Move- ments which will secure the Same Results — The Head 14 TABLE OF CONTENTS and Neck as a Lever — Lordosis or Kyphosis may Affect a Function Similarly — Splenitis Capitis et Colli — Ky- phosis, Upper Dorsal — Kyphosis, Dorso-lumbar — Contra-indications — Other Movements — Dorsal Rota- tion — Know how to Apply Principles — Do not Copy Movements. CHAP. XV. — Reduction of Subluxations. — Lateral Subluxa- tion — Lower Dorsal — A Depressed Spine — Kyphosis, Pott's Disease — Rib Subluxations. CHAP. XVI. — Treatment of the Cervical Region, — To Raise the Clavicle — Subluxation of the Clavicle — Prepara- tory Treatment of the Neck, Trapezius — Sterno-cleido- mastoid — Scaleni — Splenius Capitis — Extension — Ro- tation — The Hyoid Bone — Mylo-hyoid and Hyoglossus — Sterno-thyroid and Sterno-hyoid — Intrinsic Muscles of the Larynx — The Atlas — Sixth Cervical. CHAP. XVII. — Treatment of the Extremities. — Diagnosis — Causes of Stiff Joints, Ankylosis — The Scapulo-hu- meral Articulation — Examination of the Brachial Plexus — Reduction of Dislocation by Traction — By Leverage — Elbow Articulation — The Radius — Old Dislocations — Muscles of the Lower Extremities — Quadriceps Extensor — The Adductor Group — Disloca- tion of the Femur — Stretching the Sciatic — The Calf Muscles — Scientific Manipulation — Saphenous Open- ing — Popliteal Space. CHAP. XVIII.— Manipulation for Vaso-Motor Effects.— The Fifth Cranial Nerve — Inhibition of the Sub-occipital. INTRODUCTION. Great strides have been made during the past twenty-five years in the practice of medicine. The relative positions for- merly held by drug therapy and surgery have been completely reversed. The concoctions of the pharmocopceia, with their vague and uncertain effects upon human tissues and functions, no longer entice the earnest seeker after medical truths to spend a lifetime experimenting with substances which are absolutely foreign to the human body. There was a time, not far away, when that person who treated human diseases by manipulation, water, diet and gen- eral hygiene was considered to be the chief of impostors. Go a little farther back in the history of medicine and we see sur- gery dishonored because it was mechanical, not mystical enough for the ponderous minds whose fort it was to deal with strange substances of the animal, vegetable and mineral king- doms. During all the years in which drug-therapy flourished there were a few real scientists who devoted time and talents to the structure of our bodies and the function of each part. Discoveries came slowly along these lines because the majority of medical men were concentrating their energies on ferreting out the effects of drugs. Facts in anatomy and physiology which are so patent to us at this time, remained obscure for centuries simply because there was no thought of studying the form and action of tissues, while all nature outside of our own bodies seemed to be a grand laboratory of specifics for human ailments. If osteopathy had been born fifty years ago, it would have died because the popular and scientific minds were not in a condition to receive it. Even the time at which it was born. i8 INTRODUCTION. scarcely twenty-five years ago, was hardly ripe for this new departure in medicine. Eight years easily cover the period of its active history. A Scientific Growth. — There is one distinctive point about osteopathy which should be especially emphasized: It is not an empirical system ; nothing is done on the cut and try plan. It has been developed in a purely scientific way. We might observe the action of the human body in health and disease indefinitely without securing any exact data to pass on to the next generation of observers if we fail to know the struc- ture of the body. A physician may learn many things in an empirical way w T hich are very poor assets for science. The strange part of medical history, to the modern inves- tigator, is the fact that discoveries in anatomy and physiology, which are of such vital importance to the successful treatment of human diseases, were left stored away between the covers of books, not deemed of any value except to whet the mind of the dilletante in medicine. Osteopathy as a distinct system of medicine has grown to its present proportions at a time when the older schools of medicine are making radical changes in their therapeutical procedures, e. g., serum-therapy. In spite of all these so- called scientific advances in drug-therapy, osteopathy has made steady advance into public favor, thereby showing that it is fully able to compete with the older systems of practice. The Founder of Osteopathy.— Dr. A. T. Still, of Kirks- ville, Mo., is the honored founder of this system of therapeu- tics. His early w T ork was of that persistent, plodding char- acter which is necessary in order to build a firm foundation for accurate observation in later years. He did not sit and lis- ten to flowing sentences from the mouths of lecturers, and straightway assert that certain things are causes of disease. His work was in studying the structure of our bodies directly, and thus gain an accurate knowledge of how bones, ligaments and muscles, blood-vessels, glands and nerves are placed. Then he sought that department of knowledge which we call physiology, and learned how these tissues act in health. Hav- ing had previous training in treating diseases by the drug meth- INTRODUCTION. 19 od, he was slow to discard the old method for one which had never been tried, even though it had good scientific reasons back of it. But the substitution did take place by degrees until his system of therapeutics no longer made use of drugs. It seems to be a popular idea that it is necessary for the founder of a system to have a creed or statement of belief. We do not doubt but that it is good for us at times to try to put our beliefs in writing, not to form a fixed position, but just as the architect draws many plans to gradually develop his mental pictures. These statements usually contain the truth about our work so far as we know it. We can thus see how far we have advanced and realize that we have much to learn. Dr. Still has, from time to time, expressed the result of his studies, that is, the observed facts upon which he has built his system of therapeutics. In 1874, Dr. Still stated his observations as follows : "A disturbed artery marks the period to an hour, and minute, when disease begins to sow its seeds of destruction in the human body. That in no case could it be done without a broken or suspended current of arterial blood which, by nature, is intended to supply and nourish all nerves, ligaments, muscles, skin, bones and the artery itself. * * *The rule of the artery must be absolute, universal, and unobstructed, or disease will be the result. * * * All nerves depend wholly upon the arterial system for their qualities, such as sensation, nutrition and motion, even though by the law of reciprocity they furnish force, nutrition, and sensation to the artery itself." Definitions. — Many definitions have been formulated and published to the world. Each one tends to limit one's con- ception of osteopathy in some particular. A definition always limits the thing defined, therefore, no definition of osteopathy can be complete, because we are dealing with a principle, the universality of which no one knows. Whereas, less than seven years ago, it was thought that osteopathy was an excellent method of treating chronic ailments, we now find osteopaths working day and night at the bedside of the acutely sick. Thus does it spread and become thoroughly recognized as a svstem applicable to all diseases. 2o INTRODUCTION. In order to bring before the student as full and compre- hensive an idea of the scope of osteopathy as possible, a series of definitions are quoted. These definitions have been taken from current osteopathic literature and are credited to their re- spective authors. One of the short paragraphs in Dr. Still's autobiography is sufficient to give a clear understanding of his idea of the human body. ''The human body is a machine run by the un- seen force called life, and that it may be run harmoniously, it is necessary that there be liberty of blood, nerves and arteries from the generating point to destination." The following definition is one which has been used in the American School publications for a long time: "Osteo- pathy is that science which consists of such exact, exhaustive and verifiable knowledge of the structures and functions of the human mechanism, anatomical, physiological and psychologi- cal, including the chemistry and physics of its known elements as has made discoverable certain organic laws and remedial resources, within the body itself, by which nature, under the scientific treatment peculiar to osteopathic practice, apart from all ordinary methods of extraneous, artificial, or medicinal stimulation, and in harmonious accord with its own mechanical principles, molecular activities, and metabolic processes, may recover from displacements, disorganizations, derangements, and consequent disease, and regain its normal equilibrium of form and function in health and strength." Mason W. Pressly, A. B., Ph. D., D. O. "Osteopathy is that science of healing which emphasizes, (a) the diagnosis of disease by physical methods with a view to discovering not the symptoms but the causes of diseases, in connection with misplacements of tissue, obstruction of the fluids and interference with the forces of the organism; (b) the treatment of diseases by scientific manipulations in con- nection with which the operating physician mechanically uses and applies the inherent resources of the organism to overcome disease and establish health, either by removing or correcting mechanical disorders, and thus permitting nature to recuperate the diseased part, or by producing and establishing antitoxic INTRODUCTION. 21 and antiseptic conditions to counteract toxic and septic con- ditions of the organism or its parts; (c) the application of me- chanical and operative surgery in setting fractured or dislo- cated bones, repairing lacerations and removing abnormal tis- sue growths or tissue elements when these become dangerous to the organic life." J. Martin Uttlejohn, IX. D., M. D., D. O. ''Osteopathy is a school of mechanical therapeutics based on several theories. 1. Anatomical order of the bones and other structures of the body, is productive of physiological order, i. e., ease or health in contradistinction to disease or dis- order which is usually due, directly, or indirectly, to anatomical disorder. 2. Sluggish organs may be stimulated mechanically by way of appropriate nerves (frequently by utilizing re- flexes) or nerve centers. 3. Inhibition of over-active organs may be effected by steady pressure substituted for the mechan- ical stimulation mentioned above. 4. Removal of causes of faulty action of any part or organ is the keynote of the science." C. M. Case, M. D., D. O. Thus the word (osteopathy) has come to mean that science which finds in disturbed mechan- ical relations of the anatomical parts of the body the causes of the various diseases to which the human system is liable; that science which cures disease by applying technical knowl- edge and high manual skill to the restoration of any or all dis- turbed mechanical relations occurring in the body." Chas. Hazzard, Ph. B., D. O. "Osteopathy means that science or system of healing which treats diseases of the human body by manual thera- peutics for the stimulation of the remedial and resisting forces within the body itself, for the correction of misplaced tissue and the removal of obstructions or interferences with the fluids of the body, all without the internal administration of drugs or medicines." Chas. C. Teall, D. O., President of the American Osteopathic Association. "Osteopathy is that school of medicine whose distinctive method consists in (1) a physical examination to determine the condition of the mechanism and functions of all parts of the human body, and (2) a specific manipulation to restore the 22 INTRODUCTION. normal mechanism and re-establish the normal functions. This definition lays stress (i) upon correct diagnosis. The osteopath must know the normal and recognize any departure from it as a possible factor in disease. There is not one fact known to the anatomist or physiologist that may not be of vital importance to the scientific osteopath. Hence a correct diagnosis based upon such knowledge is half the battle. With- out it scientific osteopathy is impossible and the practice is necessarily haphazard or merely routine movements. The definition lays stress upon (2) removal of the cause of disease. A deranged mechanism must be corrected by mechanical means specifically applied as the most natural and only direct method of procedure. This work is not done by any of the methods of other schools. After the mechanism has been cor- rected little remains to be done to restore function; but stimu- lation or inhibition of certain nerve centers may give tempo- rary relief and aid nature. The adjuvants used by other schools, such as water, diet, exercise, surgery, etc., are the common heritage of our profession and should be resorted to by the osteopath if they are indicated." E. R. Booth, Ph. D., D. O., Ex-President A. O. A. "1. Osteopathy is a physical method of treating disease without drugs. 2. Osteopathy is applied physiology. These two definitions refer to osteopathy in its broad sense. 3. The cell is the unit of the body which inherits its vitality. This vitality is kept up by pabulum received from the blood, while the waste is carried away by the lymph and venous streams. . The differentiated cell to be able to trophize properly must receive a nerve. Every cell has the inherent capacity to recuperate after injury, and as the nervous system controls the circulation of the blood, it follows that any abnormality of position or size of any tissue or any change in the chemical constitution of a tissue leads to disease. The nervous system yields most readily to mechanical stimuli, therefore "osteopathy is the art of treating disease by INTRODUCTION. 23 physical and mechanical means ; the science of aiding the vital processes by means of stimulation or inhibition of nerves, and by the removal of lesions or "obstructions." J. W. Hof- sess, D. O. "Osteopathy is a complete system of healing, wherein only food and water is allowed to enter the stomach, and all natural means are employed to place a diseased body under such conditions as will permit nature to effect a cure, includ- ing the most effective dietetic and hygienic measures, such as suggestion, fasting, exercise and hydrotherapy ; special use being made of manipulations that normalize the tonicity of muscles, the flow of blood and lymph, the transmission of nerve force and the functioning of bodily organs by replacing de- ranged anatomical structures, stretching and pressing mus- cles, vessels and nerves, freeing the movements of joints and correcting dislocations and subluxations." C. W. Young, D. O. "Osteopathy is that science or system of healing which, using every means of diagnosis, with a view to discovering, not only the symptoms, but the causes of disease, seeks, by scientific manipulations of the human body, and other physical means, the correcting and removing of all abnormalities in the physical relations of the cells, tissues and organs of the body, particularly the correcting of misplacements of organs or parts, the relaxing of contracted tissues, the removing of obstructions to the movements of fluids, the removing of interferences with the transmission of nerve impulses, the neutralizing and removing of septic or foreign substances from the body; thereby restoring normal physiological pro- cesses, through the re-establishment of normal chemical and vital relations of the cells, tissues and organs of the body, and resulting in restoration of health, through the automatic stim- ulation and free operation of the inherent resistant and remedial forces within the body itself." C. M. Turner Hulett, D. O. "Osteopathy is that science which reasons on the human system from a mechanical as well as a chemical standpoint, taking into consideration in its diagnosis, heredity, the habits 24 INTRODUCTION. of the patient, past and present ; the history of the trouble, in- cluding symptoms, falls, strains, injuries, toxic and septic conditions, and especially in every case a physical examination by inspection, palpation, percussion, auscultation, etc., to de- termine all abnormal physical conditions ; the treatment em- phasizing scientific manipulation to correct mechanical lesions, to stimulate or inhibit and regulate nerve force and circula- tory fluids for the recuperation of any diseased part, using the vital forces within the body ; also the habits of the patient are regulated as to hygiene, air, food, water, rest, exercises, climate and baths, such means as hydropathy, electricity, mas- sage, antidotes and antiseptics, and suggestion sometimes being used as adjuncts." Chas. C. Reid, D. O. "Osteopathy is a method of treating disease by manipu- lation, the purpose and result of which is to restore the normal condition of nerve control and blood supply to every organ of the body by removing physical obstruction, or by stimu- lating or inhibiting functional activity as the condition may require." Wilfred L. Riggs, D. O. "Osteopathy is a system of medicine, characterized- by close adherence to the physiological axiom that perfect health depends on a perfect circulation, and perfect nerve control in every tissue of the body. Its etiology emphasizes physical perversions of tissue relations as causes of disease. Its diag- nosis is mainly dependent on the discovery of physical lesions by means of palpation. Its therapeutics comprehends (i) manipulation, including surgery, for purposes of readjusting tissue relations; (2) scientific dietetics; (3) personal and pub- lic hygiene/' Dain L. Tasker, D. O. The above definitions have nearly all been taken from the Journal of the American Osteopathic Association. Osteopathic Diagnosis. — Physical diagnosis is and al- ways will be the leading factor in the success of osteopathic practitioners. This ability to take hold of an ailing human being and detect the disturbing factor in it, is the highest at- tainment of the physician. Osteopathy has developed the art of palpation to a wonderful degree. Basing this art on a definite knowledge of structure and function makes it the chief reliance INTRODUCTION. 25 in diagnosis. Every physical diagnosis begins with palpa- tion and proceeds with auscultation and percussion, and not failing to use chemical and microscopical methods when necessary. The student must learn to use his sense of touch continually, in fact, learn to see with his fingers. Add to this development of touch a training in chemical and microscopical analysis of secretions and excretions of the body, and we have a practitioner thoroughly equipped to make an accurate scien- tific diagnosis. Osteopathic Therapeutics. — Osteopathic treatment is based on this kind of physical diagnosis which we have just described. It takes into account the fact that the organism is a self-recuperating mechanism and requires proper food, proper surroundings, and perfect activity of every tissue, espe- cially the blood. Thus we divide treatment into three di- visions, (1) manipulation for the purpose of correcting the mal-position of any tissue, whether that tissue be bone or blood; (2) proper feeding, i. e., dietetics; and (3) proper surroundings, i. e., hygiene. If the condition of the body is such that none of the three methods just mentioned will right the difficulty, i. e., if there are broken bones, ruptured muscles and connective tis- sues or false growths, we can then use surgical means. Surgery is a part of the osteopathic system, just as it is of all systems of medicine. The chief assurance lies in the fact that the osteopathic system is very conservative as regards the use of the knife. Osteopathy includes all those qualities which make up a successful system ; its diagnosis is accurate and its treatment is comprehensive, including scientific manipulations, scientific dietetics, hygiene and surgery. In a recent article in the American Monthly Review of Reviews, the following sentences appear : "With but few exceptions, the entire vegetable and mineral kingdoms have given us little of specific value; but still, up to the present day, the bulk of our books on materia medica is made up of a description of many valueless drugs and preparations. Is it not to be deplored that valuable time should be wasted in our 26 INTRODUCTION. student days by cramming into our heads a lot of therapeutic ballast." This is probably the most recent statement of this kind in the public prints. It substantiates the position taken by the osteopathic colleges. We feel justified in claiming that os- teopathy today occupies a position which every other system of medicine must come to sooner or later. It is broad enough and liberal enough to accept truth wherever demonstrated. Its foundations being laid in the basic sciences, and its treat- ment never departing from the facts of these sciences, make it a system of lasting worth and capable of adding an entirely new conception of the phenomena of life to medical litera- ture. The formation of the name osteopathy (from osteon, bone, and pathos, suffering) seems to be as perfect a descrip- tive name as it is possible to form which would cover the basic principle of the science. The bones are the foundation upon which all the soft tissues are laid, and the osteopath makes all his examinations, using them as fixed points from which to explore for faulty arrangement. The name does not mean bone disease, but since the osteopath finds many diseases resulting from pressure due to slightly displaced bone, the name is used in the sense of disease caused by bone. We do not consider that all diseases are caused by displaced bone, but it is a cause which has heretofore been overlooked. We recognize that there are many causes of disease, and do not wish to be understood as trying to fit fact to theory, but as a result of observing certain facts, this basic principle of os- teopathy has been made clear. We believe that health is the natural state, and that this condition is bound to be maintained so long as every cell has an uninterrupted blood supply, and its controlling nerve is undisturbed. Therefore, the first effort of the osteopath is to remove all obstructions to blood and nerve supply, feeling certain that when these obstructions are removed, health will follow. Hilton in his lectures on "Rest and Pain," which are considered medical classics, has expressed himself forcibly on this subject, as follows: "It would be well, I think, if the INTRODUCTION. 27 surgeon would fix upon his memory, as the first professional thought which should accompany him in the course of his daily occupation, this physiological truth — that nature has a constant tendency to repair the injuries to which her struc- tures may have been subjected, whether those injuries be the result of fatigue or exhaustion, of inflammation or accident. Also that this reparative power becomes at once most con- spicuous when the disturbing cause has been removed; thus presenting to the consideration of the physician and surgeon a constantly recurring and sound principle for his guidance in his professional practice." Every system of curing human ills, which is based on the known facts of anatomy and physiology will last, because it is true. When systems of drug medication are known only as history, osteopathy will be ministering to the human race, because it knows no other path than that which leads to greater truths in physiology and anatomy. CHAPTER 1. THE CAUSE OF DISEASE. Potential and Kinetic Energy. — The cause of disease is in the cells of the body. They contain the stored energy, i. e., potential energy. When this potential energy is released by some other force, or stimulus, we have kinetic energy. Potential energy cannot transfer itself spontaneously into kinetic energy without first being affected by some other force which may be called a stimulus. The amount of potential energy converted into kinetic is not proportional to the amount of the stimulus used to initiated the process. All stored energy, i. e. potential energy, requires a certain strength of stimulus to start the process of conversion into kinetic. When this strength of stimulus is known it is called the normal. There are usually several kinds of stimuli, each one having a vary- ing degree of intensity. For example, the potential energy in a muscle fiber will be converted into kinetic energy as a result of mechanical, thermal, chemical or electrical stimuli. Certain amounts of each of these stimuli are required to initiate the change in the form of energy. A Normal Stimulus. — The potential energy in a muscle fiber has a certain degree of resistance to stimuli. A definite amount of any one of the four forms of stimuli named is necessary to cause the muscle fibre to contract. This definite amount, which is capable of stimulating the muscle to an average contraction is called the normal stimulus, and the action of the muscle is called the normal contraction. If the muscle should contract more vigorously than usual in re- 3o PRINCIPLES OF OSTEOPATHY. sponse to this normal stimulus, the resistance of the potential energy of the muscle fibre is below normal. The strength of stimulus and discharge of energy may vary greatly in their proportions within normal limits, but there are well marked lines above or below which resistance is spoken of as above or below normal. A Change of Resistance. — When the resistance of the potential energy is below normal, a normal stimulus causes too great an effect, that is, too much potential energy is trans- ferred into kinetic energy. When the resistance of the po- tential energy is normal, and the stimulus above normal, there also results an excessive discharge of potential energy. There- fore, excessive discharge results from lowered resistance, or increase of stimulus. Resistance. — Resistance is a quality of the cell proto- plasm. The stimulus is an external force. The cell depends on proper surroundings in order to maintain its resistance to external stimuli, such as bacteria. The strength of bacteria may also be increased or decreased by the nature of their surroundings. Cause and Effect. — After potential energy has been changed into kinetic energy, this latter may generate more potential energy, and this also may be converted into kinetic. Thus cause is converted into effect and effect into cause. This is an endless chain. When such a process is beyond the normal, as in the body when varying symptoms present themselves, therapeutic efforts must be concentrated on some one particular reflex in order to break the chain. Cell Relations. — The relation of a cell with its fellows that is, its structural relations, are the basis upon which its resistance, in large measure, depends. Therefore, anything which disarranges its normal relations will, in all probability, change its resistance to stimuli. All therapeutic methods which aim at lessening the too rapid conversion of potential into kinetic energy, that is, increasing cell resistance, must see that correct structure is attained. Excessive Stimulation. — In cases where almost com- plete exhaustion of potential energy has resulted from lowered PRINCIPLES OF OSTEOPATHY. 31 resistance and we find that even increased strength of stimulus fails to evoke a response, the same structural fault may exist. We know that stimulation, when excessive, passes into inhi- bition. Perhaps it is truer to state that over activity of a cell leads to exhaustion of its potential energy. The stage of exhaustion, in this sense, is consonant with inhibition. As an example : In case of structural changes in the lumbar re- gion, there may result a change in resistance in the secretory and contractile cells of the intestines due to changed blood supply. Diarrhoea results for a time, followed by constipa- tion. At the beginning of the rapid conversion of potential into kinetic energy the muscles feel tense. After the consti- pation, or period of exhaustion, sets in, they are flabby. Structural Defects. — Structural defects may result in lowered resistance in groups of cells. They also act as stimuli to set free the potential energy in these cells. In many cases we note only a predisposition to yield to weak stimuli. This is the condition in individuals who are "fairly well," but cannot endure any of the normal stimuli in average amount. They cannot exercise freely without a bad reaction. A slightly heavier meal than usual ; the excitement due to the presence of many people arouses "symptoms." Their physiological pro- cesses are easily perverted by normal stimuli because a struc- tural defect, either directly or indirectly, has decreased cell resistance. Cases of lowered resistance, supposed to be due to heredity, should be carefully examined for structural defects. It is not improbable that many an ancestor is wrongly accused of transmitting a "predisposition." While cell resistance remains below normal, all external stimuli, such as atmospheric changes and presence of bacteria, even if in only normal amounts, may call forth "symptoms of disease." Cell Life Dependent on Circulation. — The individual cells of the body depend on the supply of nourishment brought to them by the circulating fluids of the body. The protoplasm of the cells is a complex, chemical substance made up of an enor- uous number of complex molecules. These molecules, on ac- count of the looseness of combination of their atoms, require 32 PRINCIPLES OF OSTEOPATHY sufficient crude material brought to them to maintain the proper atomic tension. Upon this tension is based the re- sistance to normal or abnormal stimuli. The necessary food for cell protoplasm is brought to the cells by blood and lymph. Since cell protoplasm is entirely dependent upon the circulating media, any disturbance of these media changes the metabolism of the cell, and hence a change in resistance results. This resistance may be varied by failure on either the arterial or venous side of the general circulation, resulting in changed lymph circulation. The constant removal of katabolic products is of as much importance as the constant renewal of material for anabolism. Intracellular tension, i. e., the cohesiveness of the atoms of each molecule, is dependent on lymphatic circulation, this upon arterial and venous circulation. If there is abnormal va- riation in any of these circulatory fluids, there results a change in resistance of the cells. Therefore a normal stimulus may provoke too great a transference of potential into kinetic en- ergy and thus initiate a chain of such transferences of one form of energy into another. As a rule, the kinetic energy which results from the release of potential energy in excessive amounts acts as a stimulus to release still more potential energy and so on to the point of exhaustion of the supply of such stored energy. This change is exemplified in the series of symptoms which appear in many diseases. Each liberation of a new supply of energy gives rise to a new symptom. If the potential energy resides in a gland, excessive secretion re- sults ; if in muscle, excessive contraction, etc. The way in which the kinetic energy is manifested depends upon the manner in which its cause, i. e., potential energy, is stored. The secretion or the contraction may act as a stimulus to lib- erate still more potential energy. Osteopathic Therapeutics. — Therapeutics of osteo- pathic medicine is addressed : First, to correction of structure with consequent increase of cell resistance to stimuli ; second, to reducing the intensity and power of external stimuli to or below normal. "In no case can anything appear in the form of disease PRINCIPLES OF OSTEOPATHY. 33 which was not previously present in the body as a predisposi- tion ; external forces are able merely to make this predispo- sition apparent. . . . When the physician, by thorough observation and investigation, knows the conditions that influ- ence a given predisposition in a definite way, when he is scientifically trained and has a true conception of hygiene, and is at once physician and naturalist, then he is able to cure disease by use of the very same forces which serve to create or alter the human constitution. In this simple sense there is a true art of healing." Hueppe's Principles of Bacteriology. Page 249. It is therefore necessary that anatomy should hold the most important position among the studies requisite for a thorough understanding of osteopathic therapeutics. Physi- ology, the normal reaction of cells to normal stimuli, is next in importance. The study of external stimuli may be compre- hended under the titles Hygiene and Bacteriology. Symptoms are the surface play of kinetic energy. They lead to a broad understanding of vital phenomena. Incidents in the History of a Disease Process. — Other schools of medicine note uric acid or bacteria as causes of dis- ease processes. Osteopathic etiology views these as incidents in the history of disease processes. The cause lies in the cells and their lowered resistance to normal stimuli. The condi- tion of lowered resistance is viewed as a result of structural changes which interfere with the nerve control of the indi- vidual cells with the lymphatic circulation upon which the cells depend for nourishment. These changes strike at the very root of tissue life and resistance, hence open the way for external stimuli to cause too great a discharge. The presence of bacteria is of little moment until cell re- sistance has been reduced sufficiently to allow them to grow and manufacture their poisonous products. A fall or sprain may be responsible for a slight sublux- ation of a rib. This subluxation affects the nutrition of the cells forming the lungs, resistance is lowered. Baccilli of tuberculosis may be present in the inspired air. They find a fertile spot in this area of lessened resistance. Resistance 34 PRINCIPLES OF OSTEOPATHY. must be increased in this area in order to head off the disease process. Nature has two methods of overcoming the disease. First, she tries to eliminate it from the body; failing in this, she tries to compensate for it by throwing the burden of work on some other tissue, or again, to accommodate. We see compensation illustrated by increase of heart muscle in case of dilation. Accommodation is illustrated by forming a wall of connective tissue around a diseased area, thus prac- tically eliminating that area from direct physiological activity with the rest of the body, even though it is actually within the body. This last process is to all intents and purposes, equiva- lent to the first, i. e., elimination. Whether the illness be ascribed to uric acid or bacteria, there is something back of these which has been the cause. Some disturbance of the normal metabolism has resulted in the formation and retention of uric acid. We consider that some structural lesion, in the area of the spine from which the nerves of the gastro-intestinal tract emanate, must have dis- turbed the normal rythm. When rheumatism of an extremity exists, we do not use salicylates, but we examine the structures which might affect the innervation and circulation of the extremity. Fatigue — Excess. — Although structure is examined with the fact in mind that it may affect function, we do not forget the fact that function may affect structure. With this in view, we are interested in knowing what effects may have resulted from fatigue of any organ or the entire body, the ef- fects of excess in eating, drinking or sexual intercourse. We have stated that increase of normal stimuli may cause a lessened resistance. Thus indulgence in pleasurable sensa- tions, whether of eating, drinking or sexual intercourse may result in structural defects and lessened resistance. Methods of Cure. — To cure these various conditions, we use manipulations and surgical methods to correct struc- tural defects in so far as it is possible. Resistance is thus in- creased. External stimuli are decreased so far as possible. Hygienic living and antiseptics aid in decreasing external stimuli. Water may be sterilized to eliminate any typhoid PRINCIPLES OF OSTEOPATHY. 35 bacilli, mosquitos killed to check malarial infection. These are recognized as methods of decreasing external stimuli. Subluxations Are Mechanical and Chemical Stimuli. — Physiological writers mention four forms of stimuli of muscle and nerve, mechanical, chemical, thermal and electrical. The will may be named as a fifth form. Osteopathic medicine rec- ognizes a sixth form which may be mechanical or chemical. It is the stimulation occasioned by the pressure of bone, muscle, or ligament upon nerve fibres or blood vessels. If the pressure is exerted directly upon a nerve bundle, the stimula- tion is mechanical ; if it affects the metabolism of other tissues as a result of obstruction to circulation, the nerve endings are affected by chemical stimulation. This is an etiological factor not reckoned with in other schools of medicine. It is a distinctive feature of osteopathic medicine. A twisted rib affords an example of this form of stimu- lation affecting nerve fibres in relation with it. The intercostal nerves supply motor fibres to the intercostal muscles, sensory and secretory fibres to the pleura and skin. The irritation re- sulting from a twisted rib pressing upon the intercostal nerve may result in intercostal neuralgia, pleurisy, or herpes, com- monly called "shingles." If the irritation is removed, that is, the rib brought into proper relation with its fellows, the neural- gia, pleurisy or herpes is cured. They are the symptoms of a disturbed nerve. The stimulating impulses, originated by the pressure, cause changes in the activity of the tissues which are innervated by the irritated nerve. 36 PRINCIPLES OF OSTEOPATHY. CHAPTER II. STRUCTURAL AND CONTRACTILE TISSUES. The Cell. — Mechanical and vital phenomena are stud- ied carefully by the osteopath. In order to know these phe- nomena and correctly interpret them he must first study the structure and functions of the cell. 1 : .f x i < t> n. i «■ 5 Ox 3 n «,. * t 'A ~a Hr V , t« « tU f —M < W«*«* ^icr««|«. r„..,,tc §.->.»<, -.:i p5U:.)j»:'>...| . «!»<>- ,,£.£,^?CZ«vu-r- Fi'g. i. — Unicellular organisms possessing all of the vegetative and vital attributes. The attributes of this small element of the body are both vegetative and vital. Its vegetative attributes are three : metabolism, growth and reproduction. Its vital attributes are irritability and motion. PRINCIPLES OF OSTEOPATHY 37 Following these natural divisions we find that the col- lections of cells to form tissues divide themselves into groups possessing definite qualities or attributes corresponding to one or the other of these vegetative or vital attributes of the orig- inal cell. Fig. 2.- — Photomicrograph of dividing cells. Cross section of young white fish, Coregonus. From slide prepared by Prof. B. M. Davis, Biologist in State Normal School, Los Angeles, Cal. As the original cell divides and redivides we find certain groups of cells perpetuating, modifying and intensifying some special attribute of the parent cell. Naturally, as osteopaths, and following lines of tissue development, we are interested, first, in following the lines of development of structural tissues. Structural Tissues. — Under this head we collect a con- siderable number of tissues whose function or special labor is to support the more active tissues. They give form and sta- 33 PRINCIPLES OF OSTEOPATHY. bility to the body. Bone, cartilage, ligament, tendon, fascia and connective tissue form this class. Pi&- 3- — Cross section of bone. Camera lucida drawing by A. M. Hewitt, In- structor in the Physiology of the Eye, Pacific School of Osteopathy. Contractile and Elastic Tissues. — Muscle and elastic ligaments constitute this class and serve to infuse action into the combination of structural tissues just named. SCrUred Muscle. Fig. 4. — Muscle fibers, striated. Camera lucida drawing by J. E. Stuart, D. O. Muscle unites two attributes of the original cell, i. e., it is a vegetative structural tissue and a vital motor tissue. This combination of attributes brings about many strange phe- nomena, as we shall see later. Pig- 5- — Yellow elastic tissue. Camera lucida drawing by A. M. Hewitt. PRINCIPLES OF OSTEOPATHY. 39 Yellow elastic tissue as we find it in the ligamentum nuchae and the ligamenta subflava must be considered as some- thing more than structural tissue, hence we place it in this class. Metabolic Tissues. — No sharp lines of demarcation are drawn here. We name those tissues whose cellular elements exercise the power of preparing food for other tissues or of excreting waste material ; glandular tissue, mucous membrane, serous membrane and skin form this class. Fig. 6. — Kidney of a cat. X590. a, Glomeruli; b, Loops of Henle or collecting tubules. Drawn by A. M. Hewitt. Fig. 7- — Medulated nerve fibers. Drawn by A. M. Hewitt Irritable Tissues. — Muscle and nerve are the sole oc cupants of this class. 4 o PRINCIPLES OF OSTEOPATHY. The tissues thus far mentioned constitute the form and solid substance of a human cadaver. If tissues could live in- dependently of each other as amoeba live, then we might have Fig. 8. — Nerve cells, in different stages of development, from the cerebrum of a fetal rabbit two or three days before birth. The cells from i to 7 are Golgi cells of the first type. No. 8 is a Glia cell from the same preparation. X150. Original drawing by C. H. Phinney, D. O. life in this accumulation of cells, but since this is not possible we must add other tissues. Circulatory Tissues. — These are blood and lymph. They are vital to all that have just been mentioned. The blood and lymph are the media of exchange. The nerves are the media of communication. Blood and nerves complete the connection between all other tissues and fill us with wonder at the many phenomena caused by their activity. By considering blood as a tissue, we are not violating imagination nor becoming transcendentalists. "Every tissue is composed of two parts ; the cellular ele- ments and the intercellular elements. Upon the first of these depends the vitality of the tissue, while its physical properties are determined by the character of the second. The physical condition of the intercellular substances includes a wide latitude, varying from that of fluid, as blood or lymph, through all degrees of density until by the additional impregnation of calcareous matters, the well-known hardness of bone or dentine is attained." (Piersol.) Mechanical Principles. — Our next step is to consider some of the attributes of these several classes. Osteopathy has been built up on the mechanical idea of the body rather than the vital; i. e„ in the thought of the average PRINCIPLES OF OSTEOPATHY. osteopath, form and structure, mechanical pressure, leverage, bony pressure, etc., have preceded the more complex vital phe- nomena which make up the picture of disease in older schools F'.g. 9. — Blood Corpuscles under high magnification. 1, Groups of Red cells; 2, End view of Red cells; 3, Crenated corpuscles (Red); 4, Polymorphous Leuco- cyte; s. Mononuclear Leucocyte; 6, Polynuclear Leucocyte; 7, Eosinophyle corpuscle; 3, Transitional Leucocyte; 9, Rouleau of Red corpuscles. Drawn by A. M. Hewitt. of medicine. Therefore, in order to follow the subject along the lines of its development, we will consider the structural tissues first. Displacement by Violence — Passive. — Structural tis- sues may be displaced by violence. The human body receives a vast number of falls, slips, jars, etc., which are liable to destroy the delicate adjustment of its bony parts. The chief wonder is that we do not have more serious results in a larger number of cases. Up to the time of the advent of osteopathy in the field of medicine this etiological factor in disease was not taught. Slight structural displacements can not be successfully noted unless the diagnostician has been carefully trained in anatomy.- All the successes of the early osteopaths were achieved by hands trained to make use of anatomical therapeutics. 42 PRINCIPLES OF OSTEOPATHY It is not enough that an osteopathic physician should be able to recognize improper positions of bony parts; his ob- servation and his thought do not halt here, but follow the normal physiological action in the immediate and remote areas, then he realizes what pathological conditions may result from the physiological perversion. Obstruction to Vital Forces.— Since structural tissues are surrounded by vital tissues, irritable and circulatory, we may state the next proposition as follows : Displaced structural tissues make pressure on irritable and circulatory tissues. This proposition, simplified, means obstruction to vital forces. When the displacement takes place far from the centers of vitality, that is, the spinal cord and brain, the re- sulting perversion of function is not very wide spread. For example, the displacement of a tarsal bone will not create the disturbance that would be found as the result of a vertebral or costal subluxation. The result of the pressure is a change in the normal metabolism in the deranged area. If the media of commu- nication and exchange are cut off by this pressure, then met- abolism is bound to suffer in the injured area or by reflex nervous irritability, a changed metabolism is found in a distant area. This does not mean that only points distal to the seat of injury will be affected because their means of communica- tion and exchange have been cut off, but that an area appar- ently having no direct connection with the injured part may show metabolic changes because its nerve supply is given off from the same central area, and, in want of a better word to express my meaning, acts in sympathy with the injured part. Cartilage may become subluxated in some localities and be the disturbing factor. For example, in the knee or temporo- maxillary articulations. Ligaments may be strained and the resulting thickening cause obscure pressure symptoms. This is especially true of spinal ligaments. Primary and Secondary Lesions. — Bear in mind that thus far we have considered all of our disturbances to be the result of external violence, and are hence primary etiological factors of disease. No perfect cure can be expected unless PRINCIPLES OF OSTEOPATHY. 43 this primary disturbance is righted and obstruction to the vital forces removed. Early osteopathic literature noted especially these bony lesions and urged the osteopath to search diligently for them and remove them. The great value to humanity of this method is amply proven by a multitude of cases in every State. If all lesions were of this character and primary, there would be little need of my writing farther, but we are vital mechanisms, hence complexity of arrange- ment and reaction draw us on to interpret the phenomena met with in our practice. A lesion, according to osteopathic thought, is used to designate any derangement of tissue. When they are recognized or considered as primary lesions they are treated as the first cause, if they are recognized as resulting from other disturbances, then they are considered as secondary lesions, but this does not preclude the idea of treating them as primary and hence working a change in opposition to a vicous cycle of reflexes. A secondary lesion may be the result of a primary one and at the same time be the primary cause of another secondary lesion and so on from cause to effect and on again. Herein lies the opportunity of the osteopath to display his anatomical and physiological knowledge in fol- lowing these reflexes by a process of exclusion until he finds the primary one. This process of exclusion often requires a considerable time. Displacement by Muscular Contraction — Active. — Our next proposition in regard to structural tissues is as follows : They may be deranged by excessive activity of contractile tissue, muscle. This brings us to the consideration of a tissue which is both structural and vital, but since its form and attachments are merely for the purpose of allowing its vital qualities to affect other tissues, we are principally inter- ested in its vital attributes. Muscle contracts as the result of direct mechanical stimu- lation, such as a pinch or prick; or as a result of poisonous material in its blood supply ; or as a result of irritation of its controlling nerve, direct or reflex ; also in response to sudden temperature changes. With these four means of stimulation and the fact that in 44 PRINCIPLES OF OSTEOPATHY. the normal body, the controlling nerve of a muscle can be stimulated by temperature, pressure or poisonous chemicals in its blood supply, the fact dawns upon us that since muscles attach to bones, ligaments, tendons and fascia, and are subject to all these forms of irritation, contraction cannot help causing a change in structural tissues, and a faulty alignment of struc- tural tissues will be manifested to the osteopath's fingers as lesions, primary, perhaps, to the minds of many, but in reality secondary. Another form of displacement of structural tissues may be the result of secretory tissues, their excessive activity being the result of derangement of nerve and blood supply. The derangement may be the result of direct or reflex irrita- tion to the controlling nerves. Summary. — Thus we have noted three forms of dis- placement of structural tissues ; the first purely the result of extrinsic forces, violence ; the second and third resulting from vital activities. Whether the displacement be a primary or secondary cause it may occasion the following results : The lesion is an obstruction to blood supply, which equals a changed metabolism in the immediate area, resulting in irri- tation to the nerves in the immediate area either as result of pressure or lack of proper food. This is followed by an altered blood supply in distant or reflex areas through action of vaso-motor nerves, causing changed metabolism in said distant or re-flex area resulting in weakened tissue through failure of proper exchange of food and waste elements. This decreases resistance to bacteria, hence opens the way to specific infection. To picture these changes more vividly we will state them in relation to some specific disease, diphtheria for instance The atlas may be subluxated as a result of violence, such as a hard fall or stepping off a curb without being conscious of its presence. The shock and consequent strain of the muscles causes contraction resulting in subluxation. Both the shock and the resulting subluxation affect circulation in the immediate area, thus changing the metabolism going on in the suboccipital triangles. From this troubled area im- pulses are carried to the superior cervical sympathetic gang- PRINCIPLES OF OSTEOPATHY. 45 lion in such numbers and force that the normal action of this ganglion, vaso-constriction, is impaired. The nasal, laryn- geal and pharyngeal mucous membranes become congested, thus working a change in the metabolism of their cells which gradually decreases their normal resistance to bacteria. These weakened tissues which are exposed to the air are now in a condition to yield to an amount of infection far inferior in strength to what would be required to overcome normal re- sistance. This is an illustration of the osteopath's method of rea- soning carried through to the point of specific infection. The same train of reflexes may be originated by cicatricial tissue in any locality where the wealth of nerve connections or capillary circulation is sufficient to manifest the irritation. Contractile Tissue. — It has been noted that muscle is a structural tissue, but its vital attribute is of greater interest. The most distinctive thing about our bodies is their power to move spontaneously. We speak of being quiet, but are never so in life, we respond to every change about us, in- finitesimal changes in the atmosphere, every change is an evidence of muscular action. One-half of our bodies in weight consists of muscular tissue and contains about one- quarter of the whole amount of blood. It is muscular tissue which propels the blood and generates heat, in fact all of our functions depend on the muscles. Amoeboid Motion — Contraction. — Your studies in his tology will teach you the minute formation of muscular tissue, hence we need not spend time on that division of our subject. We know that the primative cell possesses the power of moving, called amoeboid motion, that in the pro- cess of differentiation of tissues muscular tissue is the spe- cialization of this attribute of the primitive cell. One form of epithelium, the ciliated, possesses power of motion in its cilia. Muscular tissue possesses the property of contraction, that is, the power to draw its extremities nearer each other. Owing to the various attachments of the muscles to the bones we enjoy the ability to make many motions. Stimuli. — Through the exercise of our wills our mus- 46 PRINCIPLES OF OSTEOPATHY. cles contract, but muscular tissue will respond to other kinds of stimuli; for instance, if a muscle fiber is pinched it will contract, or if it is subjected to the action of a strong acid it will contract. Rapid temperature changes affect it also. We do not lose sight of the fact that in the normal human body, muscles are not directly exposed to the action of ex- ternal stimuli such as have been mentioned but they do re- spond to these stimuli under normal conditions through the transference of the stimulation to them by nerves. When studying the phenomena of muscular activity in the living human body, we are compelled to constantly reckon with the nerves which control the muscles. We, as normal beings, act according to our will. In order to control our muscles there must be a connection between the brain and the muscles. The motor nerves carry our willed action to the muscles. If these nerves are cut we lose control of the muscles in which the cut nerves end, but the muscles have not lost the power to contract. Contraction is a property of the muscle, not of the nerve ; the nerve conveys the normal stimulus which causes the muscle to contract. The sensory nerves which are in muscles and go to the central nervous system, convey to our brain cells a knowledge of how the muscles are respond- ing to our orders. The nerve cells in our spinal cord are able to control many motions which we are not conscious of, hence attitudes, and positions of the vertebrae are assumed without sensory nerves informing our consciousness. It is possible therefore that muscles governed by these spinal nerve cells may contract in response to mechanical, thermal and chemical stimuli with- out conscious sensation being registered on the sensorium of our brain. Direct and Indirect Stimulation. — Two propositions will make our position clear. First, Muscle will contract in response to direct mechanical, thermal, chemical and electrical stimuli. Second, Muscle will contract in response to indirect mechanical, thermal, chemical and electrical stimuli. We have to deal almost exclusively with the indirect stimuli. It is not probable that muscles ever contract as a result of direct PRINCIPLES OF OSTEOPATHY. 47 stimulation while they are under nerve control. For them to be subject to direct stimulation would be disastrous to the nerv- ous system. In the case of burrowing parasites, trichinae, for example, there may be direct stimulation. A contraction of a muscle independent of nerve control while such control exists, is not conceivable; that is while the muscle has all the nerve connections intact between itself and the simplest kind of a nerve center. This fact compels us to consider all contractions of muscles as resulting from irritation of nerves, not of muscles directly. Motor nerves may be directly stimulated by sub- luxated bones, cartilage or by swelling, thus causing the muscles which they innervate to contract. Muscular con- tractions in the immediate and distant areas is coincident with all subluxations. As a result of chemical and thermal stimuli sensory nerves will pass their impressions to the motor side of a reflex arc and thus cause muscular contraction. Structural Tissues Affected by Muscular Contraction. A contracted muscle always exerts its influence on movable structures, bone, cartilage, tendon, fascia, skin ; or where muscle forms one of the layers of a hollow organ or vessel contraction lessens the caliber. Lessened size of blood vessels means lessened nourishment to the parts supplied by those vessels. Lessened caliber of bronchioles means lessened re- spiratory power, hence lessened oxygenation of the blood. When a muscle contracts it compresses its blood capillaries and raises blood pressure. If all the muscles of the body con- tract, as in violent exercise, blood pressure is enormously increased and the heart is put to a severe test. The relative effects on the whole circulation, caused by the contraction of one group of muscles might be small and yet be very detri- mental to local circulation in the contracted area. Alternate relaxation and contraction adds strength to a muscle, but continuous partial contraction, such as results from continued stimulation, not only results in destroying structural align- ment but injures the muscle substance. If the effects were all local, little attention would be paid to them but they es- tablish a chain of reflexes which manifest themselves end- lessly. 48 PRINCIPLES OF OSTEOPATHY. Circulation of Blood in Muscle. — A comparison of the blood which enters a muscle with that which leaves it shows that, whereas the former is bright red, contains a relatively large amount of oxygen and small amount of carbonic acid gas, the latter is dark blue in color and its proportions of oxygen and carbonic acid gas are the reverse of the former and contains other ingredients the result of katabolism in the muscle and its food ; the temperature is higher in the latter than in the former. When a muscle is contracted con- tinuously it does not receive its full amount of blood and this causes lessened irritability of the muscle substance, the same is true if the quality of the blood supplied is poor or the muscle vein is obstructed so that the muscle cannot get rid of its waste products. Restoration of irritability may be se- cured by removing the above causes. Michael Foster has well stated the importance of the mus- cular tissue where he says that the whole of the rest of the body is engaged "(i) in so preparing the raw food, and so bringing it to the nervous and muscular tissues, that these may build it up into their own substance with the least trouble ; and (2) in receiving the waste matters which arise in mus- cular and nervous tissues and preparing them for rapid and easy ejection from the body." Effect of Contraction — Intrinsic. — The intrinsic effect of continuous muscular contraction is lessened activity of the muscle, hence lessened inter-change of food and waste products ending in decrease of muscle substance. Extrinsic. — The extrinsic effect is principally noted in the amount of heat produced and the pernicious effect on circulation, both locally and systemically. Above all, to the osteopath the nerve reflexes which are the result of mechanical pressure resulting from contraction over a nerve trunk, or from a bone subluxated by over- contraction of an attached muscle, are most interesting. Summary. — A muscular contraction may not cause widespread reflexes unless situated so as to mechanically irri- tate the nerve trunk. All muscular contractions along the spine are so situated that they may be considered irritating PRINCIPLES OF OSTEOPATHY. 49 lesions, whether they are primary or secondary needs to be determined by careful physical examination and history. We pay little attention to the intrinsic effects of muscu- lar contraction or to the chemical changes in the blood stream as a result of such contraction. The structural changes with the resulting nerve reflexes are what we are most interested in. If the contraction is secondary to a bony lesion, it is frequently treated indirectly through reducing the subluxa- tion. If it appears to be primary, treatment may be applied to it directly or indirectly, i. e., by direct inhibitory pressure, stretching, inhibition of the motor nerve or thermally. Our reasoning concerning these lesions again follows from perverted structure to perverted function and may be stated much as before : The lesion is an obstruction to blood supply, which equals a changed metabolism in the immediate area, resulting in irritation to the nerves in the immediate area either as result of pressure or lack of proper food. This is followed by an altered blood supply in distant reflex areas through action of vaso motor nerves, causing changed meta- bolism in said distant or reflex areas, resulting in weakened tissue through lack of proper exchange of food and zvaste elements. This decreases resistance to bacteria, hence opens the way to specific infection. CHAPTER III. IRRITABLE TISSUE. A masterful knowledge of nerve tissue and its arrange- ment in the body to form the nervous system is an absolute prerequisite for success in osteopathic practice. Every vital phenomenon calls for interpretation by the skillful physician. Interpretation cannot be attempted without a definite knowl- edge of structure and function of that tissue which acts as a medium of communication between all other elements of the body. 5o PRINCIPLES OF OSTEOPATHY. The name of our system, Osteopathy, calls attention pri- marily to osseous structure, but it is only in connection with Fig. 10. -Pyramidal and Polymorphous cells from the cerebrum of a man 6n years old. X1.50. a, Polymorphous cells; b, Pyramidal cells. its effects on the tissues of communication and exchange, vital phenomena, we are actually interested. All physiological phenomena are characterized by the manifestation of attributes of nerve tissue, irritability, con- ductivity and trophicity; motion, sensation and nutrition are the vital phenomena whose perversion constitutes disease. Therefore whatever the pathological condition may be, we are called upon to note a change in some one or all of these at- tributes of nerve tissue. PRINCIPLES OF OSTEOPA THY. 5i We cannot proceed farther in a logical manner without frequent references to the special attributes of irritable tissue. Fig. 11. — Photomicrograph of a Purkinje nerve cell in the cerebellum, human. Golgi preparation. We will, therefore, devote this chapter to a special considera- tion of these attributes. fig. 12. — Photomicrograph of multipolar nerve cells in the anterior horns of the spinal cord. Nerve Tissue — Scarcely any thought of muscle is ever complete without the nerve impulse which controls the 52 PRINCIPLES OF OSTEOPATHY. muscle is also considered. For convenience sake we may' separate nerve and muscle when teaching their special attri- butes but for all practical purposes they are never separated. Fig. 13. — Drawn by J. E. Stuart, D. O. The elucidation of our subject requires us to call your attention to some facts in physiology of nerve tissue which are essential to the foundation of our system of therapeutics. The nervous system consists of sending, conducting and receiv- ing elements, that is, cells, fibers and end organs. It is the physiology of these elements, singly and en masse, which is of paramount importance in osteopathic diagnosis and thera- peutics. Irritability. — Muscle and nerve are both irritable, but we pay no attention to the irritability of muscle because un- der normal conditions we do not see any evidences of specific muscular irritability. We view muscular irritability as the result of nerve irritability. Therefore nerve tissue is the chief irritable tissue. Irritability is an attribute of cell proto- plasm whereby chemical and physical phenomena are enacted in response to irritants. Irritants may be mechanical, chem- ical, thermal and electrical. Practically all that physiologists know of the reactions of nerve tissue to irritants has been de- rived through experimentation by means of the electrical cur- rent. Osteopathists are bringing to light many facts con- PRINCIPLES OF OSTEOPATHY. 53 cerning mechanical stimulation. Hydrotherapists have dem- onstrated the utility of thermal stimuli. Drug therapy makes use of the chemical form of stimulation. Conductivity. — Nerve tissue is not only irritable ■ but possesses the ability to transmit its irritability to other tissues and cause certain activities to be initiated there. Conductivity, the second vital attribute of nerve tissue, is the power to carry impulses from the point of irritation to other points in the nervous system. Irritability would be of small moment if conductivity were not present to transmit the message to the center and arouse response. The nerve cell and its axis-cylinder are a continuous mass of protoplasm and as long as the continuity is maintained conductivity will be maintained. Trophicity. — The third attribute of nerve tissue, tro phicity, is very poorly understood. We do not use this term here to represent so much the nutritional influences of the cell-body over its axis-cylinder as the influence exerted by nerve tissue over other body tissues, causing them to grow and prosper. This nutritional influence over other tissues is an attribute which we are compelled to note quite frequently in practice. There are individuals in whom motion and sen- sation are normal but nutrition fails, hence we note that in some cases mechanical lesions may cause only a slight change in the nerve tissue upon which it infringes, and this change is manifested by variation in nutrition of the part controlled by the irritated nerve It is probably this attribute of nerve tissue which is perverted or lost when the tissues refuse to take up certain chemical elements which are ordinarily nor- mal to them ; for example, iron. In osteopathic practice we consider nutritional disorders as being the result of perverted trophic influence of nerves. Of course in cases where it is known that the ingested food does not contain the required element or elements we must regulate the diet. But there are many cases where all con- ditions appear normal except that the tissues do not take up nourishment as they should. In these cases we search for lesions in the same way we would if motion or sensation 54 PRINCIPLES OF OSTEOPATHY. showed perversion or loss. This phase of our subject can best be considered at another time. Unity of the Nervous System. — The unity of the ner- vous system is a structural fact, and this brings deep and superficial areas in close relation. Every portion of the body is able through the medium of the nervous system to work in harmony with every other part. Physiologists divide the nervous system into central and peripheral portions, but for practical purposes this division is of little use to us when attempting to make use of the irri- tability and conductivity of the nervous system for thera- peutic purposes. Since all portions of the nervous system are connected there must be some place where impressions made upon ter- minal nerve filaments may be assembled, co-ordinated and re- sponded to harmoniously. Wherever large numbers of nerve cells are assembled we expect to find such duties performed. Mechanical Irritation. — We have noted in the previous lecture that mechanical pressure made upon nerve fibers by subluxated bone or cartilage, contracted muscle or thickened ligament will set up changes in the protoplasm of nerve tissue. "Mechanical applications to nerve and muscle first increase and later lessen and destroy the irritability. Thus pressure gradually applied first increases and later reduces the power to respond to irritants." (Lombard, in American Text-Book of Physiology.) These structural displacements in the human body act as mechanical irritants to nerve tissue changing the chemical and physical condition of the protoplasm and thus altering its irritability, either plus or minus according to the intensity of the stimulation. The displaced structures may have other detrimental influences on nerve tissue, for in- stance the pressure brought to bear on the nourishing liquids surrounding the nerve, i. e. the blood and lymph, may cause sufficient chemical change in these liquids to materially affect irritability of the protoplasm of the nerves which they are expected to nourish. Conductivity is not destroyed by these slight mechanical pressures. If the protoplasm of the cell and axis-cylinder PRINCIPLES OF OSTEOPATHY. 55 were unable to conduct impulses and project them in such manner as to reach other cell bodies of the nervous system our work would be very limited. Conductivity depends on the continuity of protoplasm. The mechanical irritations we deal with in osteopathic practice seldom destroy conductivity. If they did do so, they would cease to be irritants the moment conductivity was lost. Other irritants may act for a time on the severed portions of protoplasm but the original lesion would have destroyed the continuity of the protoplasm. Double Conduction. — Double conduction is another physiological fact which explains to some extent the results observed in osteopathic practice- when pressure is made over nerve bundles ; but the complexity of fibers in the nerve bundle makes it impossible to say positively whether the cen- tral and peripheral phenomena are the results of double con- duction or the presence of afferent and efferent fibers. Since we know that nerve bundles are made up of both afferent and efferent fibers there is no particular need for us to explain results by double conduction. Nerve Bundles. — We have been dealing thus far with irritability and conductivity as attributes of nerve tissue. In a general way we have viewed the results of mechanical pressure on a solitary nerve fiber, not caring whether it is afferent or efferent or what its function. The next step is the consideration of nerve bundles. The fibers composing a nerve bundle may be efferent or afferent so far as direction of impulse is concerned. Efferent fibers may be further dif- ferentiated by the names, motor, vaso-motor, secretory ac- cording to the structures in which they end. Afferent fibers are usually termed sensory to denote their function of car- rying impulses to the central nervous system. Nerve trunks contain all of these various fibers, therefore, pressure will irritate all of the fibers and conductivity of individual fibers will transmit the impulses in the direction of the normal nerve impulse, thus causing contraction in the voluntary or involun- tary muscles or activity of secretory tissues ; sensory impulses will be transmitted to the central nervous system and will pur- port to come from the terminal distribution of the sensory 56 PRINCIPLES OF OSTEOPATHY. nerve. If the afferent impulse is such an one as will reach the patient's consciousness, we find that the central cells are misled as to the location of the stimulus and hence manifest a response in the supposed area. It is not necessary for the patient to be conscious of any irritation in order to bring about this result. The Central Nervous System. — The organization of the nerve bundle complicates our ideas of irritability and con- ductivity in the protoplasm of the cell and axis-cylinder of a nervous unit. Complexity of action and reaction increases as we near the central nervous system. We have considered that all impulses generated in the protoplasm of a nerve cell and axis-cylinder have been transmitted to all parts of that unit of nerve tissue, but has not in any way influenced any other unit. We have not considered the relations of cell bodies in the central system. It is sufficient for our present purpose to note that the afferent fibers enter the spinal cord as the posterior roots and that their cells are in the ganglia of these posterior roots. The efferent fibers leave the cord as its anterior roots and their cell bodies are located in the anterior cornua of the gray matter of the cord. Upon careful study of the spinal cord there are found other cells and axis-cylinders which do not leave the cord but serve to connect the afferent and efferent ele- ments and distribute impulses within the cord. These latter are found in enormous numbers in all portions of the central nervous system. Segmentation. — The first fact of great interest to us osteopathically, is the segmentation of the spinal cord. This is only relative in character, but yet is apparent not only his- tologically, but pathologically. We note that according to dis- tribution of afferent fibers in the spinal cord impulses are dif- fused both above and below the point of entrance. The cell bodies of the anterior roots are also somewhat diffused, but in practice we note that afferent and efferent impulses seem to be correlated within comparatively narrow limits in the spinal cord. How the impulses set up in the protoplasm of an afferent fiber are transmitted from it to the protoplasm of other cells Pig. 14. — Camera lucida drawing of a golgi preparation, made by J. E. Stuart, D. O. WTi 3 ■ Fig. 15. — Photomicrograph of a cross-section of the spinal cord. Golgi preparation. Photographed by T. O. Hunt, D. O. . 58 PRINCIPLES OF OSTEOPATHY. located in the spinal cord and thence transmitted to the pro- toplasm of efferent cells is not known, nor is it necessary for us to thoroughly understand the method in this instance so long as we recognize the results. Our specific knowledge must comprehend the exact point of entrance to and exit from the spinal cord of each nerve bundle and the peripheral distribu- tion of the same. Having a knowledge of the structure, the function comes naturally as a result. Segmentation refers to structure, and thus the next point, reflex action, which is physiological, is a logical sequence. Reflex Action. — The central nervous system is con- JTIustlf jj tKrr; Tfurvi- tflL Som* ;By- paths of JUrtfes. Concerned » a th*> btmplesl" Fig. 1 6. —Drawn by J. E- Stuart, D. O. stantly receiving impulses from afferent fibers and co-ordinat- ing them. We are almost entirely dependent on reflex action for the effects we secure on deep tissues. Our manipulations affect sensory nerves in skin, muscle and synovial membrane. These impulses are carried to the central nervous system and transformed into efferent impulses. During life there is no period when the body is not de- PRIXCIPLES OF OSTEOPATHY. 59 pendent on external stimuli. These ordinary mechanical and thermal stimuli keep a constant stream of impulses entering the central system to be translated into stimuli of muscle and gland. This ceaseless play of reflexes may vary in intensity, but so long as life lasts they are demonstrable. We expect the reflex to be initiated by the sensory side of the reflex arc, therefore the intensity of muscular contraction and glandular secretion is governed by the intensity of the initiatory impulse. This is certainly the case under normal conditions, but in the case of a subluxation, muscular contraction and secretory ac- tivity in the area of distribution of an irritated nerve trunk may be increased primarily, i. e., without the iniatory impulse being originated in a sensory nerve. The pressure on the ef- ferent fibers to muscle and gland stimulates them without the intervention of the central nervous system. Our methods of diagnosis take into consideration both the mechanical lesions which cause direct stimulation of a nerve trunk, and those pathological conditions which are the result of intensified nor- mal stimuli. Practical Application. — The segmental structure of the cord and the reflex action manifested therein show that on the whole, a definite muscle group and a definite cutaneous area arc innervated from a limited portion of the central system. Therefore we may count on the stimuli originated in the cuta- neous area being reflexed to the definite muscular area. An example in practice is as follows : patient's head is drawn slightly to the left side. Complains of pain shooting to the left shoulder and over the left clavicle whenever move- ment is attempted. History of exposure to draught of cold air. Physical examination discloses contraction of left trape- zius, levator anguli scapulae and scaleni. Pressure upon these muscles causes pain. When instructed to take a full inspira- tion, patient says he can not on account of pain which is sharp and darting in character and radiates over the infraclavicular portion of the left chest. When we consider the muscles in- volved and the area of painful sensations our attention is im- mediately called to a definite segment of the cord, in this case the point of origin of the third and fourth cervical nerves. 60 PRINCIPLES OF OSTEOPATHY. The cold air striking the skin, intensified the normal stimuli, and the efferent impulses from that segment of the cord were intensified as the direct result of the cutaneous irritation. The point of irritation, the cutaneous area, governed the location of the reflex. So long as the original stimulus was only mod- erately intensified all the reflexes emanate from one segment of the cord, but if they had been more intense or continued longer, we might have found a greater area reflexly affected. The stimuli which would have reached the cord would have been more widely diffused above and below the point of en- trance. Since we know that the highly organized spinal cord of man is not to be compared with the same structure in lower forms of animal life, and that segmentation in it is illy de- fined, the practical question arises as to how much dependence we can put upon reflexes in the human nervous system. "Will the reflexes guide us to definite segments of the spinal cord? Experience teaches us that a thorough knowledge of the dis- tribution of afferent and efferent nerves in man will interpret reflexes with sufficient exactness and invariably lead the in- vestigator to a spinal segment which is itself affected or is co- ordinating impulses from a known sensory area. Efferent Fibers. — When we follow the efferent im- pulses to their points of distribution our work is greatly com- plicated. To reason from contracted voluntary muscle to cu- taneous sensory area is a comparatively simple procedure; but to start with the sensory impulse and trace it through the central system, and. thence along efferent pathways, to esti- mate its final effects as mechanical work done by muscle and gland in many combinations, requires a' considerable knowl- edge of structure and function of all parts of the human system. Many of the efferent fibers of the cerebro-spinal system take their course through the sympathetic ganglia and are distributed in that system to plain muscle and secretory cells of the body. It has been ascertained by various careful ob- servers that these efferent fibers, after entering the sympa- thetic system, either er»d in the ganglia nearest their point of PRINCIPLES OF OSTEOPATHY. 6r emergence from the cord or pass up or down to ganglia above or below the one originally entered. Some fibers pass through these ganglia and end in the more peripherally placed plex- uses. Sympathetic Ganglia. — Wherever nerve cells are accu- mulated a certain amount of independent action is probably carried on. Terminal filaments of efferent fibers in sympa- thetic spinal ganglia are in relation with a large number of cells and the number of fibers leaving the ganglion is greater than those entering. Therefore diffusion of impulses from these ganglia must be very great. The accumulation of sen- sory impulses in these ganglia may be equally as great. Each ganglion must have a dominant influence over a certain vis- ceral area, and this influence is subsidiary to the control ex- ercised by the segment of spinal cord to and from which the larger number of its fibers proceed. Diagnosis — Objective Symptoms. — Osteopaths have in great measure discarded subjective symptoms, believing that they are of very doubtful value in the large proportion of patients. Having discarded subjective symptoms, they have developed a method which gives equal or better re- sults. It has three phases, two of which are structural and one which is partially subjective. First in order comes, skel- etal alignment ; second, muscular tone; third, condition of reflexes. These three divisions all come under the general head of palpation. As an illustration of the value of objective in preference to subjective symptoms, the following case is of considerable value. The gentleman whose physical condition is practically illustrated in Figs. 17 and 18 was examined in the clinic of the Pacific School of Osteopathy. He had been operated on surgically for a peculiar enlargement just above and ex- ternal to the right knee. The line of the incision is shown in Fig. 17. He stated that he had suffered pain at this point during more than a year, and his physician had decided that there was a tuberculous condition of the bone. The operation did not confirm this diagnosis. No unhealthy tissue was found. 62 PRINCIPLES OF OSTEOPATHY. Fig. ly. — Photograph of a case illustrating atrophy of the muscles of the right leg due to faulty trophic influence of the nerve cells in the spinal cord. The scar just above the right patella is superficial to a hypertrophic condition of the bone. PRINCIPLES OF OSTEOPATHY. 63 We noted his peculiar handling of the leg when walking, compared both limbs from toe to hip and discovered a marked difference in size, as is indicated in the photograph. By fol- lowing the course of the nerves to the spinal column, we dis- covered that the muscles on the right side of the spine were atrophied in proportion to those of the extremity. Fig. 18 shows the fact that the atrophied condition extends into the interscapular region, and the spinal column is bent. The patellar tendon reflex was lost on the right side, but present on the left. The right leg was ataxic, but the left leg was normal, thus presenting what might be called a uni- lateral locomotor ataxia. If this man's surgeon had taken the care to examine him from an objective structural stand- point rather than to depend on the subjective symptoms, it is highly probable that no operation would have been performed. Our examination demonstrated that this man's structural con- dition was at fault, and that the trophic influence of a part of his nervous system was being gradually lost. Both the motor and sensory nerves were acting feebly. It might be asked, "How could one secure a spinal reflex from the stomach?" In what way would the finding of such a reflex surpass ordinary methods of examination? The neurologist, when making examination of a patient suffering with some faulty condition of the sensory or motor portion of the nervous system, must possess a definite knowl- edge of the origin, course and distribution of nerve trunks in order to locate accurately the position of the lesion. The osteopath pursues the same method of examination, but fol- lows it farther. His investigation takes into consideration the dispersion of efferent fibers in the sympathetic system and the sensory impulses received from the spinal cord from that system. Edinger quotes Exner as follows : "One must not sup- pose that all the impulses reaching the spinal cord by the sensory roots are identical with what is ordinarily called 'sen- sation.' In order that an impression be perceived, it is not sufficient that it be conducted to the spinal cord, but it must be farther carried up, from the place where the peripheral 64 PRINCIPLES OF OSTEOPATHY. Fig. 1 8. — General view of case illustrated in the preceding figure. The spinal curvature is clearly indicated. Patellar tendon reflex ab- sent on right side but present on the left. PRINCIPLES OF OSTEOPATHY. 65 part ends, to the cerebral cortex. There is, however, no doubt at all that all these higher connections are few in number, and that contrasted with the multitude of fibers in the posterior roots, the number of such cranial connections is quite small. This alone makes the conclusion possible that there are, in- deed, many sensory impressions which arrive at the spinal cord, but that we are aware of but few of them at the time. All the viscera of the body, as the staining method has dis- tinctly shown, are traversed by an altogether unexpectedly large number of nerves, and their arrangement and course, their relations to blood vessels and glands, and to muscle fibers, bones, and enamel makes it more than probable that there is, in this connection, a large system which serves es- sentially to regulate impressions and reflex action." Anatomy of the Central Nervous System of Man and of Vertebrates in General. — Edinger. Co-ordination of Sensations. — It is the reflexes men- tioned in this quotation in which we are interested. Sensa- tion and perception are dissimilar. Sensations from the vis- cera are co-ordinated in fairly well-marked areas of the spinal cord, and when these sensory impressions are intense the ef- ferent fibers of the spinal cord manifest the condition exist- ing in a visceral area by causing an abnormal condition of muscular tone in the intrinsic muscles of the back. This con- tractured condition of the muscles is not the only evidence of the visceral reflex. Pressure on the contracted muscle causes pain. The intensity of the aesthesia is usually in pro- portion to the visceral irritation. Even though the patient does not say in so many words that there is pain on slight pressure, the examiner, if his palpation is good, can detect the reflex in the action of the muscle. Example. — A patient comes to an osteopath desiring to be examined. He does not vouchsafe any information as to his condition, merely saying, "I want you to examine me and find out what is the matter with me." This is a chal- lenge to the skill of the examiner and calls for something be- sides a long-distance catechising as to subjective feelings. The osteopath proceeds with absolute precision to determine 66 PRINCIPLES OF OSTEOPATHY. the condition of his patient's structural formation, (i) Skel- etal alignment, (2) muscular tone, and (3) segmental spinal reflex. Each yields valuable information. The examiner's fingers may develop a reflex around the sixth dorsal spine. This is noted as a reflex from the gastric area. Testing the segments above and below this will show how great a section of the cord is irritated and will be an indication of the extent of the internal irritation, i. e., whether other portions of the digestive tract are affected. The reflex might extend as far as the fourth dorsal and still indicate the gastric area. Find- ing the reflex at the sixth dorsal spine has directed the attention of the examiner to the gastric area and has located a point from which further examination is to proceed. Percussion over the stomach would reveal other facts, and then the ex- amination would be pursued along general lines of physical diagnosis to determine the character of the gastric disorder. The moment the examiner centers his examination on the stomach, the confidence of the patient is assured. Is not this confidence greatly to be desired in every case? Is it not a force which compels the patient to follow the direc- tions of his physician in matters of diet and hygiene? In this example we have illustrated the attributes of nerve tissue, (1) irritability, (2) conductivity. Other conditions which make this illustration possible are ( 1 ) muscular con- traction in response to nerve stimulation, (2) segmentation of the spinal cord, (3) reflex action. We have added nothing new to the world's knowledge of nerve tissue, but we have applied general knowledge of this tissue to specific uses. We have taken the results of labora- tory experiments and made them practical methods in the detection and alleviation of disease. It appears to us that sufficient research work has been done on the nervous sys- tem by medical men and sufficient general conclusions drawn from their investigations to justify all branches of the pro- fession in making more extensive use of such data. The correlation of laboratory data with the results of clinical ex- perience make the foundation of osteopathic practice at the present time. By this bold application of knowledge, which PRINCIPLES OF OSTEOPATHY. 67 to the medical profession at large has been regarded as specu- lative and at least impracticable, osteopathy has gained an impregnable position in the healing arts. Laboratories make scientists, not physicians ; hence phy- sicians have not always grasped the full significance of the scientific discoveries in physiology and applied them to thera- peutics. Whatever osteopathy may at present possess or gain in the future, is due solely to a close adherence to the facts of anatomy and physiology ; and the application of these funda- mental facts to scientific therapeutics. CHAPTER IV. CIRCULATORY TISSUE. From the histological standpoint, blood conforms to the general definition of a tissue, being composed of a cellular and intercellular substance. The intercellular substance being liquid, differentiates it greatly from other tissues. It con- tains cellular elements which differ from each other in form and function. Then, too, it is a moving tissue enclosed in a system of closed tubes. Functions. — The blood performs many functions. These may be stated in general terms as follows : 1. To convey nutrition to all other tissues. 2. To remove waste products from the tissues. 3. To convey oxygen for tissue respiration. 4. To distribute heat. 5. To repel invasion of bacteria. Lymph. — Lymph is another liquid tissue, less rich in corpuscular elements, but greater in total bulk than the blood. The lymph comes in direct contact with the elements of the 68 PRINCIPLES OF OSTEOPATHY. tissues. Stewart states the relationship tersely where he says, "The blood feeds the lymph and the lymph feeds the cell." Since we think of individual tissues as possessing some one well developed attribute or function, it is well to call blood and its congener, lymph, the media of exchange. This ex- pression covers at least four of the functions previously men- tioned. With this comprehensive but short statement of the re- lation of these liquid tissues to the structural, contractile, irri- table and secretory tissues, it seems hardly necessary to dis- cuss so self-evident a proposition as that health primarily de- pends on a perfect circulation. It is not even necessary to add to this the fact that the blood should be pure, because under or- dinary circumstances if the blood circulates properly it will be- come purified. All schools of medicine have a therapeutic principle around which their practice is built. From its earliest incep- tion the osteopathic idea has been that a perfect circulation is the foundation for perfect health. Blood. — We will attempt to outline the general prop- erties of the blood, and thus state the basic facts of the chem- istry, histology and physiology of this tissue, which plays such an important part in osteopathic therapeutics. Its color in the arteries is bright red, and in the veins is bluish purple. The difference in color is due to the relative amount of oxygen and carbon dioxide present in each. Ar- terial blood has more oxygen and less carbon dioxide, more extractives, salts and sugar, and less urea than venous blood. Arterial blood is usually warmer than venous. It is changed to a darker color when respiration is imperfect, or when the individual is subjected to a higher temperature. Venous blood becomes brighter when the individual is made to breathe pure oxygen. It is also brighter in the veins which drain an act- ively secreting gland or resting muscle. The temperature varies according to the location, that in the hepatic vein be- ing the warmest. The blood in the visceral is warmer than that in the cutaneous vessels. The proportion of blood to body weight is about one- PRINCIPLES OF OSTEOPATHY. 69 twelfth of the whole, i. e., twelve pounds of blood in a body weighing" 150 pounds. This amount of blood is distributed approximately as follows : One-fourth to the heart, lungs and great blood-vessels ; one-fourth to the liver ; one-fourth to the resting muscles ; one-fourth to the remaining organs." There is not blood enough in the body to maintain all of its activities at the maximum at the same time. Therefore it is difficult to do the best physical or mental labor just after digestion has be- gun. The splanchnic blood vessels are capable of containing so large a proportion of the whole amount of blood that death may result from lack of sufficient blood returning to the heart to cause it to beat. Blood Corpuscles, Red. — The physical constituents of the blood are the red and white corpuscles and platelets. The red blood corpuscles are the oxygen carriers.. It is estimated that the combined surface of the corpuscles con- tained in five litres of blood would be 2,816 square meters, i. e., over one-half acre. These cells retain a special form but possess sufficient elasticity to allow them to pass through capillaries of a diameter less than their own, and then assume their normal contour. They are quickly changed in appear- ance by a change in the specific gravity of their surrounding media. As before stated, the red corpuscles are the oxygen carriers. Their function depends on the presence of a sub- stance called haemoglobin, which unites readily with oxygen to form oxyhaemoglobin. Haemoglobin is a very complex substance, containing carbon, nitrogen, sulphur, iron and ox- ygen. It is commonly estimated that one cubic millimeter con- tains 5,000,000 red corpuscles. This number varies accord- ing to age, sex, nutrition, and altitude. Investigations seem to prove that these cells are derived from the red marrow of bone and end their life in the spleen and liver. White Blood Corpuscles. — White blood corpuscles have been known since 1770. They are far less numerous than the red corpuscles, colorless, and possess amoeboid mo- tion. There are several varieties, grouped according to stain- 7o PRINCIPLES OF OSTEOPATHY. ing reaction or miscroscopic structure. Not all possess amoe- boid motion. Probably seventy per cent have well denned power of movement. "It is indeed a question if the different forms of leuco- cytes are distinctive histological elements having independent origins and functions, or whether they do not, after all, rep- resent different stages in the development of a single cell, the lymphocytes representing an early, and the polynucleated leucocytes the last stages." The leucocytes are present in the blood in proportion to the red blood corpuscles about one to five hundred. Their number increases "after digestion, hemorrhages, pregnancy, in diseases in which suppuration occurs, and in leucocythae- mia." Fasting decreases their number. "Leucocytes are more numerous in the capillaries and veins of the spleen, liver, glands and intestinal mucosa than in the corresponding vessels of the skin, muscles, and general cellular tissues." The functions of these cells are many and varied. A white blood corpuscle may be considered as an unmodified cell retaining all attributes of the amoeba. Because of its independent movement, observers have called it a "wander- ing cell." They have the power to enter all tissues, passing from the plasma through the vessel-wall into the perivascular tissue. They re-enter the blood current with the lymph. This process of migrating is continually going on, but is greatly in- creased by pathological conditions. This action of the white cells is known as "diapedesis." After leaving the blood stream in response to some path- ological condition of the tissues, they may either re-enter the circulation, be organized into repair tissue, or die and become pus cells. Some of these cells have been observed to surround and dissolve foreign substances, and are hence called phagocytes. Not all leucocytes are phagocytes, nor is this function lim- ited to wandering cells. Some endothelial cells also possess this function. Metschnikoff has stated a theory of immunity to various bacterial diseases based on this phagocytic function. PRINCIPLES OF OSTEOPATHY. 71 These leucocytes or their products are concerned in the coag- ulation of the blood. The origin of the leucocytes is supposed to be the lymph glands, since more cells appear in the fluid leaving than in that entering the glands. Little of a definite character is known of the blood plat- elets. Fibrin is an albuminous substance which appears when blood coagulates. It is concerned in the stopping of hem- orrhages. The scope of this chapter does not contemplate a close research into all the constituents of the blood, but we de- sire to impress upon our readers the universality of function possessed by the blood. Chemical Constituents. — The chemical constituents of the plasma are very numerous, and it would require consider- able space to even enumerate them. There are inorganic and organic substances, some of which act as food for the tissues, others being the result of katabolism. Aside from the chemical constituents, there are many ferments. Besides the well known fibrin ferment, there are diastatic, glycolytic, lipolytic ferments. Serum also possesses a globucidal and bactericidal action. From this suggestive review of definite constituents of the blood, it will be readily noted that our classification of the functions of the blood is not too broad. Distribution of the Blood. — Granting that the blood possesses all these functions, the question still confronts us. How can we affect its distribution? This question leads us to a consideration of the physiological distribution of the blood. It is believed by the writer that nothing besides the use of water has so great an effect on the circulation of the blood as manipulation according to osteopathic methods. These methods do not depend on a mere physical assistance of the venous flow by means of centripetal stroking, such as is employed by a masseur. Effects on circulation are obtained in nearly all cases by knowing where definite nerves which control the action of the heart and blood vessels are placed and what their action in response to irritation may be. All 72 PRINCIPLES OF OSTEOPATHY. manipulations are given with a definite knowledge of the lo- cation of blood vessels and the nerve centers which control their variation in calibre. The response secured is a new co- ordination of the whole circulation brought about under the control of the nerve centers. Compression of the carotids by the fingers will lessen the amount of blood flowing to the brain, but such a compression has no effect after the fingers are removed. From the osteopathic standpoint this proced- ure would be considered useless. Physiological experiments have demonstrated that the blood vessels of the head and brain will contract in response to stimuli from definite areas ; therefore, osteopaths treat these areas and thus secure a re- adjustment of the entire circulation which is more lasting than can possibly be secured by definite compression. It has been stated that the blood is contained in a closed system of tubes. A short resume of the most important points in the anatomy and physiology of the circulation may pre- pare us for a clearer insight of the modus operandi of os- teopathic methods. The Circulatory Apparatus. — The circulatory appa- ratus consists of the heart, arteries, capillaries, veins and lym- phatics ; some writers include the spleen. Muscular tissue is found in the heart, small arteries and veins. The heart is practically all muscle, and its contrac- tions are governed by two sets of nerve fibers from the cerebro- spinal system, the first set is called accelerator; second, in- hibitory. Likewise, the small arteries and veins have two sets of fibres which increase and decrease the intensity of the contrac- tion of their muscular fibres, and thus change the calibre of the vessels. The capillaries are short, narrow tubes, having a thin wall composed of nucleated cells which possess the power of contraction. So far as known, the capillaries expand and contract in response to the degree of physical pressure exerted by the blood current coming from the arterioles. Thus the change in the calibre of the capillaries is passive. The lym- phatics begin in small irregular spaces in the cellular tissue out- PRINCIPLES OF OSTEOPATHY. 73 side of the blood vessels. They are found in direct relation with the cells of perivascular tissues, thus bringing the lymph to each cell. These openings lead to small lymphatic vessels which convey the lymph to the lymphatic glands which are situated so as to filter out the impurities, after which it is emptied into the venous circulation by the lymphatic ducts. The lym- phatic vessels possess power of contraction. The lymph equals about one-third of the body weight. The blood is a passively moving tissue. It is kept in constant circulation within a closed system of tubes by a com- bination of forces. The propulsion of the blood is almost entirely accomplished by the contraction of the heart. This initial force is supplemented by the aspiration of the chest dur- ing respiration, and the contraction of the skeletal muscles of the entire body. It is a debatable question whether or not the muscular coat of the arterioles and venules assist in the direct propulsion of the blood passing through them. It is the function of the heart to maintain a compara- tively uniform tension of the blood in the large arteries. The arterioles and capillaries are concerned in maintaining re- sistance to the passage of the blood. The degree of resist- ance in the capillaries, in large measure, determines the amount of nourishment received by the tissues. The relation between capillary resistance to the passage of the blood and the meta- bolism carried on in perivascular tissues is a point of great im- portance. The current of blood ordinarily passes through the capillaries very slowly, at a rate of one inch in two minutes, and under low tension, thus giving ample opportunity for the escape of nourishing material for the surrounding tissues. Tension in the arteries is maintained by three factors : i. The initial force of the heart beat; 2. Friction in the vessels ; 3. Elasticity of the vessel walls. The first and third of these factors are under nerve control which act ac- cording to a large number of stimuli. The capillaries being passive in action, the tension of the blood stream in them is mainly dependent on the tension in the arterioles. It may be profitably noted that after the initial impulse is given to the blood stream by the heart, the distri- 74 PRINCIPLES OF OSTEOPATHY. bution of this blood depends solely on the arteries, arterioles and capillaries. This peripheral distributive mechanism is therefore responsible for the nutrition of the tissues, and its resistance oifered to the passage of the blood, regulates the amount of force exerted by the heart. Manipulatory treatments, according to the best authorities writing on massage and Swedish movements, have for their object the acceleration of the blood flow on the venous side of the general circulation. Osteopathic manipulations are es- sentially directed to the active instead of the passive side of the circulation. The osteopath makes use daily of the vaso-motor nerves in order to control the circulation of the blood in local areas ; therefore, it is necessary to make a detailed study of this won- derful mechanism in order to achieve the best results in prac- tice. The more we know of structure and function, the more rational ought our methods of treatment to be, because we will then have no excuse for using methods which do not have a scientific basis to recommend them. The Heart. — In order to affect the active side of the circulation our manipulations must affect the heart beat. There are two sets of nerve fibres arising in the cerebro-spinal system which exert a regulating influence on the beat of the heart. Heart muscle possesses an inherent power of rhyth- mical contraction as can be readily proven by removing the heart from the body and stimulating it mechanically. It will beat rhythmically for hours if the muscle be kept moist with a one per cent salt solution. Contraction begins in the auricles and ends in the ven- tricles ; hence, it is thought that the auricular rhythm is trans- mitted to the ventricle. Any influence which changes the auricular rhythm also changes the ventricular rhythm. Regulation of Contraction. — Since the heart possesses inherent power of rhythmic contraction, the nervous system acts merely as a regulator of the rate of contraction. The two centers of cardiac control act in a manner to increase or decrease the rate. The speed of the blood current is depend- PRINCIPLES OP OSTEOPATHY. 75 ent on the rate and strength of the cardiac contractions. The pressure of the blood is dependent on the rate and strength of the cardiac contractions, together with the resistance offered by the arterioles and capillaries. Considering the arterioles and capillaries as possessing fixed diameters, an increase in the number and strength of the heart beats would increase the speed and pressure of the blood current. A lessened car- diac activity would have the opposite effect. The speed and pressure of the blood stream may vary within wide limits and still maintain a fair degree of health. Co-ordinating Centers. — The nerve impulses reaching the heart are co-ordinated in two governing centers in the cerebro-spinal system. These centers are located in the bulb. The inhibitory center is connected with cells in the walls of the heart by fibres which form a part of the pneumogastric nerve. Section of the pneumogastric nerve removes the in- hibitory influence over the heart's action. Stimulation of this nerve slows the heart. The relaxation period is lengthened which results in greater filling of the heart and the pressure in the veins is increased while arterial pressure decreases. These results have been noted by many physiologists. The Pneumogastric Nerve. — The pneumogastric is one of the nerve trunks which can be reached by direct pressure made through the skin and muscles of the neck. Its inhibi- tory action can be aroused by pinching the sterno-cleido- mastoid muscle between the thumb and forefinger, taking care to work deeply under the internal margin of the muscle. It is no uncommon phenomenon to have a patient faint as a result of this manipulation. Individuals differ greatly as to their response to this stimulation. The stimulation should be a gentle pressure of a constantly varying intensity. A pulse tracing is appended, Fig. 19, which shows the results of stimulating the pneumogastric in the manner just described. The gentleman upon whom the experiment was made was in excellent health, and possessed a quiet, well- balanced temperament. The tracing shows that the number and force of the beats was lessened and arterial pressure de- creased. This tracing is probably typical of the change, in a 76 PRINCIPLES OF OSTEOPATHY. well person, in response to stimulation of the pneumogastric. No sensation of faintness or other disagreeable feeling was noted. The inhibitory action of the pneumogastric seems to be most active in individuals who suffer from some disorder of the digestive tract. In such patients the constant irrita- tion of the sensory fibres of the pneumogastric, which arise in the mucosa of the digestive viscera, seems to increase the irritability of the whole nerve trunk to such a delicate point that the slightest stimulation made at any point along the i / / Wm / / / / pig. -Stimulation of the pneumogastric Dy pinching the nerve trunk in the neck. course of the nerve will excite its inhibitory action. Many osteopaths, just starting in practice, have had their self-pos- session severely tried by a patient fainting during manipula- tion of the neck. I have never heard of any fatal results from manipulation of the pneumogastric. Why stimulation of the pneumogastric should result in cardiac inhibition rather than in phenomena connected with its other branches seems incapable of explanation. Sometimes spasm of the laryngeal muscles will accompany cardiac inhibition. The intensity of action of the pneumogastrics is so well known to experienced osteopaths that they are careful to test PRINCIPLES OF OSTEOPATHY. 77 its irritableness in cases before undertaking any extensive manipulations along its course. The inhibitory center is continually active, and acts ac- cording to the blood pressure within the arteries. A rise in peripheral resistance causes a decrease in number and strength of the heart beats. Accelerator Center. — The accelerator center is con- nected with the heart by fibres which descend in the cord to the upper portion of the dorsal region ; here connection is made with the cells whose fibres pass to the sympathetic spinal ganglia, 1st, 2nd, and 3rd dorsal, and end there around other cells whose fibres convey their impulses to the heart. The action of the accelerator center is not so readily demonstrated as is the case with the inhibitory center. It causes the heart to beat faster and stronger, thus bringing about a rise in arterial blood pressure and a fall in venous pressure. This center acts in response to lowered peripheral resistance. The products of metabolism brought about by physical exercise also excite it. Deep, steady pressure made on the muscles lying on each side of the 1st, 2nd and 3rd dorsal spines causes a decrease in the rapidity of the heart's action. **& l%^Wii Fig. 29. — Retina of a cat's eye showing sensory epithelia. Drawn by A. M. Hewitt. tered here and there among the ordinary epithelial. For ex- ample, the goblet cells found in the mucous membrane. The 104 PRINCIPLES OF OSTEOPATHY. protoplasm of these goblet cells produces the slimy substance known as "mucus." The mucus is accumulated within the cell capsule until the tension becomes so great that the capsule breaks and the protoplasmic product is discharged upon the surface of the membrane. When the cells of protective epi- thelium are sufficiently interspersed with gland cells it is called a glandular membrane. A vertical section of such a membrane shows the "goblet cells" crowded away from the surface but a slender prolongation gives them access to it. When many glandular cells are collected together, invagination occurs, thus increasing the extent of surface. Such a forma- tion is called a multicellular gland. This method of invagina- tion may cease in its simple tubular form, or proceed to the formation of extensive organs like the salivary glands, pan- creas or liver. Sexual Cells. — The sexual cells are found among epi- thelial cells. Since epithelial tissue is the oldest and the least changed, it is not surprising that sexual cells should be found generated in relation with this form of tissue. Sexual cells tend to form invaginations similar to those formed by glandu- lar cells, hence the use of the term sexual glands. Summary. — Since we find that epithelial tissue acts as a protection to all other tissues, that excretion and secretion are carried on by it, that some cells are so highly specialized that our special senses are dependent upon them, we realize how extensively we depend upon the integrity of this tissue. Its position at once places it in relation with external stimuli and internal activity. It is most closely associated with the central nervous system, therefore we can expect to secure far- reaching results by bringing our therapeutic methods to bear on this surface tissue. Arrangement of Gland Cells. — We will consider only those glands which give off an external secretion. They con- sist of epithelial cells arranged with definite relations to a base- ment membrane, on the other side of which is placed a net work of blood, vessels. The secretion is selected from the lymph which bathes the cells, and is poured out on the free surface. PRINCIPLES OF OSTEOPATHY. 105 All glands have the general structure just described but are oftentimes complicated in arrangement to suit the special function required. Just as the arrangement of glands varies, their secretions also vary. Filtration, Osmosis and Diffusion. — If we go back to the early study of secretory tissues we find the investigators describing secretion as a process of filtration, osmosis or dif- fusion. The basement membrane was supposed to affect the liquids passing through it. the differences in its intricate struc- ture accounting for the differences in the various secretions. The explanations of all physiological processes have been at one time expounded on a purely physical basis. Text books of ten years ago had very little to say in support of selective power of secretory cells. They were given an entirely passive roll. Our modern text books lay great stress on the part played by individual cells in the production of the characteristic secretions of definite glands. Close study of nerve endings when stained by the golgi method has re- vealed the wealth of nerve arborizations around epithelial cells. Thus it is noted that each cell is an important active unit in the work of the gland and that its perfect work is necessary for the successful action of the gland as a whole. Without our knowledge of this intimate connection between individual cells and the nervous system it would be hard to comprehend the physiological action of glands. So long as our knowledge took cognizance only of the general relation of cell to base- ment membrane and blood supply it was thought that the phe- nomena of filtration, osmosis and diffusion were sufficient ex- planation. If this were all, then vaso-motion, which regu- lates blood pressure, would be the mechanism by which secre- tion is controlled. The Individual Cell. — Physiologists had observed phenomena which were not explainable by the methods just mentioned. The pressures in the blood and secretions did not bear the proper relations to each other, in fact they were re- versed, this necessitated a complete reconstruction of theories in regard to secretion. The individual cell now takes its po- sition as a vital factor in the activity of the gland and it acts, 106 PRINCIPLES OF OSTEOPATHY. not according to blood pressure on the hither side of its base- ment membrane, but according to the governing impulse which reaches it over a nerve fiber which proceeds from a center of control. This center of normal control acts according to the sum of the stimuli reaching it from other centers. Secretory Fibers. — It is practically impossible to de- monstrate the presence of secretory fibers to all glands. It is difficult to separate the vaso-motor and secretory fibers even in those glands where the dual action is best demon- strated. Since true secretory fibers are known to exist in a few cases, physiologists are not slow to concede the proba- bility that they are present in all cases. The microscope is able to demonstrate the direct partici- pation of certain epithelial cells in the formation of the se- cretion from certain glands. The goblet cells can be studied as they discharge their mucous on the surface, likewise the cells in sebaceous and mammary glands. It is quite probable that not only the organic constituents of the secretions, but the amount of water and salts also are under the control of secretory nerves. For the experiments upon which these statements are based any of the recent physiological text books will furnish the data. The New View-point. — The students of ten years ago who studied carefully the phenomena of diffusion, osmosis or filtration find now very little emphasis placed upon these physical explanations of the phenomena of respiration, ab- sorption or secretion. A new physiological view-point has been formed which gives to the individual cells an import- ance hitherto ignored, and likewise gives us understanding of the far-reaching control of the nervous system, which makes us conscious of the fact that we are not a collection of me- chanical devices exemplifying physical laws but a co-ordi- nated mechanism, essentially vital, acting according to psy- chical as well as mechanical, thermal and chemical stimuli. When we have thoroughly incorporated in our minds the fact that the phenomena manifested in the manifold activi- ties of our bodies have a vital and a physical side we are prepared to study physiology without losing our balance be- PRINCIPLES OF OSTEOPATHY. 107 cause of fixing our attention too much on one side or the other. Necessary Conditions for Secretion. — Every gland re- quires four conditions for its proper activity ; ( 1 ) proper structure, i. e., it must have inherited normal power; (2) unimpeded blood supply; (3) the normal elements of its se- cretion must be in its blood supply; (4) perfect nerve con- trol. As physicians we view every perversion of secretory tissue in the light of these four requisites for perfect action. If the first condition exists we can do nothing toward remedying the deficiency but in some cases we can supply a substitute for the normal secretion of the defective glands. Sebaceous glands are frequently lacking and hence the skin is dry and harsh. It is the duty of the physician to supply a substitute for the product of these glands. Classes of Drugs Which Affect Secretion. — Nearly all diseases are characterized by some excess, defect or perversion of secretion and the major portion of therapeutic procedures are directly addressed to the alleviation of these conditions. Drug therapy is dependent on the action of chemicals to right the difficulties. We have only to note the names of classes of drugs to realize how extensively they are used to control secretion. Astringents, tonics, cathartics, diuretics, diaphoretics, expectorants, emmenagogues, sialagogues, er- rhines, etc., each drug in every class being a more or less intense poison. If it were not poisonous it would not act so promptly. It is not a food, hence cannot become incorporated in the protoplasm of the body cells. Being a foreign sub- stance, our bodies attempt to dissolve and eliminate it. Why pilocarpin is eliminated in the saliva and sweat in preference to the alimentary tract or kidneys is difficult to explain but the fact that it is forced out of the body as quickly as pos- sible ought to be sufficient evidence against using it. Drugs which promote secretion, do so at the expense of the vitality of the body. They call forth an excessive amount of energy in order to be ejected from the body. It seems to us that a sufficient number of cases have been 10S PRINCIPLES OF OSTEOPATHY. treated successfully by physiological means to warrant the cessation of the use of drugs. Unimpeded Blood Supply. — The second necessary con- dition for normal secretory activity has been stated as an un- impeded blood supply. This is a prerequisite for good func- tioning which cannot be ignored. This question of circula- tion is the basis of osteopathic practice, therefore we examine every case with special attention, knowing that if the proper amount of blood is not furnished to the secretory tissues,, under a proper speed and tension, improper function- ing will result. We know that the blood stream is subject to many influences of a mechanical character, external pressures exerted by subluxated bones, contracted muscles, etc., but far in excess of these purely structural difficulties we find that the influence of vaso-motor nerves is a condition which requires our attention. Secretory cells depend on the blood being brought to them under a certain pressure and speed. These conditions of the blood stream are governed largely by the vaso-motors. Vaso-motors act according to stimuli reaching their governing centers over sensory nerves ending in all the body tissues, but principally those ending in skin, mucous membrane and muscle. These sensory nerves are subject to mechanical, thermal and chemical stimuli. Therefore our search for causes of abnormal secretion compels us to investi- gate not only the prominent symptoms of the case but to note the structural conditions along the course of the nerves which control the secretory tissue. Palpation will usually discover some lesion which is the result of intense mechanical, thermal or chemical stimulation. The history of the case will fre- quently aid us in learning what the original stimulus was. Proper Food. — The third prerequisite for perfect se- cretion is the presence of proper elements in the blood to supply the needs of the secretory cells. The cases are very few in which the blood does not contain sufficient materials out of which the secretion may be formed. The secretion of the mammary glands requires large amounts of proper food ma- terial in their blood supply. The treatment of defective or perverted mammary activity is frequently dietetic. After all PRINCIPLES OF 0STE0PATPI&1& 109 obstructions to the blood supply have been removed, the quality of the blood must be considered. Quality, elaboration being normal, depends on the food eaten. Innervation. — The last condition, not in order of im- portance, necessary for proper secretion, is proper innervation. This fact is the recent addition to our knowledge of the mechanism of secretion. Its great importance can be grasped in an instant and makes the osteopathic idea of secretion and its control appear decidedly rational. Many phenomena heretofore unexplainable are now clearly understood by physiologists. So long as secretion was be- lieved to be controlled by vaso-motor nerves it was difficult to account for the lack of perspiration while the blood vessels of the skin are full of blood, or why the skin should perspire when pallid and bloodless. Knowledge of secretory nerves has been in the posses- sion of scientists for fifty years. In 1851 Ludwig demon- strated that stimulation of the chorda tympani nerve caused a rapid secretion from the submaxillary gland. Beginning with this important discovery experiments have been made to confirm a like control to other glands. Sufficient proof has been secured to establish nerve control as one of the important factors in the activity of secretory tissue. The secretory and vaso-motor nerves are usually in the same nerve bundle, hence experimentation with them inde- pendently is a difficult matter. The structural lesions found in connection with the perverted secretion usually exert an equal influence on both sets of nerves. It appears that both sets of nerves are not equally responsive to thermal or chemical stimuli as may be noted by the clinical picture of fever, hot dry skin. The addition of heat for therapeutic purposes suc- ceeds in arousing the secretory cells in the skin and perspira- tion starts. The use of heat to excite perspiration is an ex- cellent therapeutic procedure. It affects secretion reflexly, i. e., the sensory nerves of skin convey impressions to the cen- tral nervous system and then a change in the tension of the blood vessels on the surface takes place, together with an increase in the activity of the sweat glands. no PRINCIPLES OP OSTEOPATHY. Osteopathic Pathology. — Since so much is said about the necessity for a perfect circulation our readers may gain the impression that osteopathic pathology is entirely "humoral" in character. We do not wish this idea to become fixed in your minds. It is sufficient to call your attention to the stress put upon the facts set forth in this chapter that the in- egrity of the individual cell is all important, that the individual cells are governed by nerve influence, and if this influence be perverted they may refuse that which is brought to them by the blood. The fact that all cells can secrete while blood ves- sels are tied and some times fail to secrete when blood vessels are full, demonstrates a two- fold influence controlling secre- tion, one over the cell, the othes over the blood vessel. Thus we note that osteopathic pathology is as much "cellular" as "humoral." Therapeutics. — Having taken this general view of the conditions necessary for normal secretory activity we may note some of the general principles of therapeutics used to correct abnormalities. First, the blood must circulate actively in order to main- tain its vitality. Sluggishly moving blood, as in conditions where venous circulation is interfered with, is not conducive to good secretion. Second, a moderate increase in the circulation in a gland usually increases its activity, i. e., vascularity, within certain limits is conducive to perfect physiological action. Our therapeutics comprehend the safest and hence the best means of regulating the circulation in secretory tissues. There is no doubt that the pharmacopeia records many drugs whose action is rapid and effective so far as securing activity or decrease of secretion is concerned, but the element of danger, i. e., their destructive power is great. Often- times their action does not stop at the point desired or limit its effect to the therapeutic action sought. Direct Manipulation. — The simplest way of increasing the amount of blood in a secretory tissue is by direct manipu- lation. Simple massage of a mammary gland will greatly in- crease the amount of blood in it. This direct manipulation is PRINCIPLES OF OSTEOPATHY. in only transitory in its effect and hence not used by the osteo- path. Hyperaemia of the Governing Center. — Stimulation of the circulation in a gland may be secured by increasing the amount of blood in its governing center in the nervous system. In order to use this form of stimulation successfully one must possess an extensive knowledge of the connections of the gland with the nervous system, also a knowledge of the blood vessels of the gland. Effect on Heart Beat — Any manipulation which does not affect the heart beat and hence the initial force of the blood current will not have a lasting effect in a local area. All manipulations which aim to affect the circulation of a gland must be intense and prolonged sufficiently to bring about a general readjustment of the circulation. The force of the heart beat and the resistance of the arterioles must both be affected. Such an effect will tend toward permanency. The circulation of definite areas is governed within fairly well marked areas of the spinal cord and we can effect these areas by indirect manipulations, but it would not be conducive to the benefit of the whole body if one portion of it could be permanently excited or depressed by any thera- peutic means whatsoever ; co-operation of all portions is neces- sary to maintain the activity of any one portion. This fact proves that our therapeutics must be far-reaching in their effects. Therefore to increase the activity of a gland we must affect not only the tension of the blood vessels by means of vaso-motor nerves but also the force of the blood stream, the vis a tergo given it by the heart. True it is that the tension quickly reacts on the heart but clinical practice demonstrates that a longer effect is secured if both factors in the circulation are directly affected by manipulation. Classes of Stimuli. — Since secretory tissues are under the control of secretory and vaso-motor nerves, and these nerves respond to at least five forms of stimuli, our thera- peutic procedures may comprehend one or all of these forms of stimuli. The five forms are, mechanical, thermal, chemical, ii2 PRINCIPLES OF OSTEOPATHY. electrical and psychical. The osteopath uses all of these. Mechanical and thermal are the principle forms. Manipulation being the special therapeutic means used by the osteopath, we do not desire to take your^time and at- tention in a discussion of the other means of affecting secre- tory activity which are discussed at length in many useful volumes. Perspiration. — The secretion of the skin, perspiration, is a profound regulating factor in the health of every indi- vidual. Its normal activity must be maintained at all times. We are called upon frequently to either increase or check it. The treatment of fever is largely comprehended in the in- crease of this secretion for purposes of heat elimination. When we succeed in affecting the respiratory glands so that they will accept the material brought to them by the cutaneous blood vessels we have in large measure solved the problem of secretion in the kidneys. Any therapeutic procedure which favorably affects the blood tension in the skin also affects the tension in the kidneys, hence our treatment is not ad- dressed primarily to either system of secretory cells but to the readjustment of speed and tension of the blood stream throughout the body. The cardiac centers and large vaso- motor centers are the points which we desire to affect, de- pending on the readjustment of tension in the peripheral blood vessels to secure the desired results. Clinical experience seems to demonstrate that perspira- tion can best be established by manipulation in the interscapu- lar area, i. e., between the first and seventh dorsal vertebrae. A relaxation of the muscles in that area will frequently be followed by gentle perspiration over the entire body. This result is probably brought about by the inhibitory effect of the manipulation around the first dorsal spine, the cardiac accelerator center. It is also probably due to the fact that the vaso-constrictor fibers to the blood vessels of the head, neck, upper portion of the trunk and upper extremities pass out of the spinal cord between the second and seventh dorsal vertebrae. We have never seen a case of fever in which this manipulation was not at least partially beneficial. Its effects PRINCIPLES OF OSTEOPATHY. 113 are far-reaching. The average case of la grippe will yield to this treatment almost immediately if the treatment is given on the day of the attack. It is well known that fear, intense mental or physical pain will cause profuse perspiration and pallor of the skin. At rare intervals a case is seen where perspiration is intense during the sleeping hours and no mental or physical pain is experienced, nor is there any tuberculous infection. In all these cases the perspiration is a reflex condition and hence our manipulation must be addressed to the causative factor. Perspiration caused by pain is the most easily relieved by in- hibition of the pain. Heat may take the place of inhibition. Secretion in the Digestive Tract. — Too much or too scanty secretion in the digestive tract is the most common condition we have to deal with. Excessive intestinal secre- tion, as in diarrhoea, is in all probability more quickly and successfully treated by manipulation than by any other means. In this condition the secretory cells seem to be directly under the control of the spinal centers and respond almost imme- diately to inhibitory pressure over these centers. In the treatment of lack of intestinal secretion many fac- tors must be considered. The average case which comes to us with this complaint has been drugged to such a point that the integrity of the secretory apparatus is affected. Over stimulation by chemical means has resulted in atrophy of se- cretory cells. We must bear in mind that a large proportion of the so- called diseases we are called upon to treat are drug diseases.. Structure has many times been ruined by the use of drugs, hence we fail because the mechanism is destroyed. Pulmonary Respiration. — One more point in regard to secretion, i. e., the selective power of cells requires our earnest thought and attention. Respiration is a secretory process. Therefore our treatment must comprehend the same prin- ciples as has been noted in relation to other secretory tissues. Importance of the Cell. — The all importance of the cell and its harmonious working with its fellows seems to us to lend a new dignity and power to the position now being ii4 PRINCIPLES OF OSTEOPATHY. won by osteopathy. The treatment of disease according to the light of physiological knowledge is the system of thera- peutics which will win the confidence of the world. Os- teopathy is winning that confidence. CHAPTER VI. THE SYMPATHETIC NERVOUS SYSTEM. Unity of the Nervous System. — It gives a wrong im- pression to speak of the CEREBRO-SPINAL NERVOUS SYSTEM and the SYMPATHETIC NERVOUS SYSTEM, as though they are independent of each other. They are parts of a single system. They make all parts of the body inter- communicative, and make it possible for a slight stimulus to cause a widespread response. They convey all impulses of a sensory character to the central nerve cells and cause inter- nal activity and response to external stimuli. In fact, the harmonious action of the tissues in our body depends on every cell knowing the condition of every other cell. Each cell is capable of perfect life only so long as it is able to communi- cate with the central nervous system, ready to give and to receive, thus fulfilling the law of reciprocity. For convenience of description, the nervous system is divided into the cerebro-spinal and the sympathetic. We have already said that these are parts of one whole. They are con- tinuous anatomically and physiologically. In the attempt to write of them separately, we desire you to bear constantly in mind their interdependence. "The dependence and independence of the cerebro-spinal and sympathetic system of nerves may be compared to the State and Federal Governments, or the Municipal and State Governments. The former run in harmony, when friction PRINCIPLES OF OSTEOPATHY. 115 does not arise, yet the State lives quite a distinct, individual life — quite independent of the Federal Government. And the life of each is dependent, however, on the other. The inter- nal life of each (as of the sympathetic) maintains itself." — Byron Robinson in the "Abdominal Brain," page 55. Origin. — The sympathetic appears to originate from the ganglia on the posterior roots of the spinal nerves. (1) Lateral Ganglia. — The substance of the sympa- thetic is conveniently divided into four portions : ( 1 ) The lateral chains of ganglia, placed one on each side of the ver- tebral column. The chains are connected above by the Gang- lion of Ribes (French, 1800-1864), situated on the anterior communicating artery, and joined below by the Ganglion Im- par situated on the anterior surface of the coccyx. These chains of ganglia are connected with the cerebro-spinal nerves by well marked cords. (2) Four Prevertebral Plexuses. — The next prominent aggregations of nerve tissue are the great prevertebral plexuses situated ventral to the bodies of the vertebrae. The FIRST, or Pharyngeal, is situated around the larynx. The SECOND, or Cardio-Pulmonary Plexus, lies in the thorax. The THIRD, or Solar Plexus, encircles the Coeliac Axis and superior mes- enteric artery. The FOURTH is the Pelvic Plexus, which governs the generative organs and rectum. (3) Visceral Uanglia. — The third part of the sympa- thetic tissue is composed of those ganglia placed between the coats of viscera, and called the peripheral apparatus or "Au- tomatic Visceral Ganglia." (Robinson.) (4) Communicating Fibers. — All of these ganglia and plexuses are intimately connected with each other by numer- ous nerve fibres. These four parts constitute what is com- monly known as the SYMPATHETIC NERVOUS SYS- TEM. The nerve fibres in the sympathetic system consist of both the medullated and non-medullated varieties, i. e., white and gray. It is commonly believed that the white are cerebro- spinal and the gray are sympathetic fibres, though whether they belong to the one or other system cannot be told by ap- pearance alone. Function must also be considered. The ji6 PRINCIPLES OF OSTEOPATHY. fibres in the sympathetic system are principally of the non- medullated variety; hence, gray fibres are called sympathetic. White Rami-communicantes. — The chains of the lat- eral ganglia are connected with the spinal nerves serially by two distinct nerve bundles to each ganglion. These bundles are called rami-communicantes, and are composed of: (i) A bundle of white or cerebro-spinal fibres passing from the anterior and posterior roots of the spinal nerves to the ganglion, in which a few fibres may end; but the majority pass on to be distributed to the prevertebral plexuses, there- by giving direct communication between viscera and the spinal cord. These white fibres consist of both motor and sensory fibres. THE WHITE RAMI-COMMUNICANTES LEAVE THE SPINAL CORD BETWEEN THE SECOND DOR- SAL AND SECOND LUMBAR VERTEBRAE ONLY. Many of the fibres are de-medullated in the lateral ganglia ; others retain their sheaths as far as the prevertebral plexuses, where they also become de-medullated. The cervical region has no white rami-communicantes. Distribution. — The nerves in the sacral region which correspond to white rami-communicantes, pass to the viscera without entering the sympathetic ganglia. We may sum- marize what we have written concerning the ending of the white rami-communicantes as follows: (i) End in the lat- eral ganglia. (2) Pass through lateral ganglia and end in prevertebral plexuses. (3) ■ Split up before entering lateral ganglia and send some fibres to the ganglia, others to ganglia above and below, after passing into its own ganglia. Function. — The white rami-communicantes have many functions, and these can be determined by a close study of distribution and physiological action. The functions may be tabulated approximately as follows : First, it has been demonstrated that vaso-constrictors pass out of the cord be- tween the second dorsal and second lumbar vertebrae ; second, cardiac augmentors, ending in the lower cervical ganglia and first thoracic ganglion ; third, motor fibres to the plain mus- cles of the intestines; fourth, motor fibres to the sphincter of the iris leave the cord at the third dorsal and ascend in the PRINCIPLES OF OSTEOPATHY. 117 chain of sympathetic ganglia ; fifth, inhibitory fibres to the viscera ; sixth, sensory fibres from viscera. In other words, it may be tabulated as follows : The ab- dominal splanchnics contain viscero-motor and viscero-in- hibitory, vaso-constrictor, vaso-dilator and sensory fibres, which are white rami-communicantes. Since no white rami- communicantes leave the cord above the second dorsal or be- low the second lumbar, the cardiac augmentors and the con- strictors to the spincters of the iris probably leave the cord as white rami-communicantes in the dorsal region. We have thus far considered only those fibres which are supposed to originate in the cerebro-spinal system ; at least, they are medullated nerves, and hence are considered cerebro- spinal in character. As we have previously stated, the bond of union be- tween the sympathetic and cerebro-spinal systems consists of a white and gray bundle. Gray Rami-communicantes. — These gray fibres are non- medullated and originate in the lateral ganglia, being axis cylinder processes of nerve cells in those ganglia, passing thence to the spinal nerves and spinal cord. Distribution. — They pass first to the anterior, primary divisions of the spinal nerves and continue with them to their distributive area; or they may pass to the distribution area of the posterior division, to the distribution area of the recur- rent branch of the spinal nerve, and to the structures (dura) surrounding the posterior root of the spinal nerve and to the spinal cord. Function. — Since the function of the sympathetic sys- tem is to control the calibre of blood vessels, the plain muscle fibres, and the action of the secretory and excretory glands, we may state the function of these gray rami-communicantes to be as follows : ( 1 ) Vaso-motor to the blood vessels of the skin and skeletal muscles in the area of distribution of spinal nerves ; also secretory to the sweat glands, and motor to the plain muscle controlling the hairs; (2) vaso-motor to the blood vessels in the spinal cord and its membranes. The nerves passing from the lateral ganglia to the prevertebral n8 PRINCIPLES OF OSTEOPATHY. plexuses, therefore, contain white and gray fibres having the functions o'f the sympathetic and cerebro-spinal systems, and from these prevertebral plexuses, fibres pass to the distal ganglia in the walls of the viscera. Thus we see that all the ganglia of the sympathetic are closely connected with the cerebro-spinal. These ganglia demedullate the spinal nerves which enter them, and more fibres leave the ganglia than en- ter them. These ganglia have a trophic influence over the nerves which pass from them to the periphery. They are reflex centers. Functions of the Sympathetic System. — "In general it may be said that the sympathetic presides over involuntary movements, nutrition and secretion, holds an important in- fluence over temperature and vaso T motor action, and is en- dowed with a dull sensibility." (Robinson's "Abdominal Brain.") Independent or Dependent. — Whether the action of the sympathetic is independent or dependent is no longer subject for experiment and discussion. You have seen the heart beat after extirpation from the body ; also the ver- micular motion of the intestines. These are offered as evi- dences of independent action ; but it must be borne in mind that under, normal conditions the cerebro-spinal nerves can influence these activities, either repressing or augmenting them. Ganglia. — The ganglia of the sympathetic contain (a) nerve cells, (b) afferent fibres, (c) efferent fibres — and are therefore governing centers. They are able to receive sensa- tion, and transform this into motor impulses, and hence are, in a measure, independent. Cervical Ganglia of Importance to Osteopaths. — The cervical portion of the gangliated cord contains three ganglia which are designated as superior, middle and inferior, ac- cording to position. These ganglia are important to the os- teopath, because they are in a measure affected by direct manipulation, i. e., pressure can be transmitted to them through the soft tissues over them. Superior Cervical Ganglion. — The superior cervical PRINCIPLES OF OSTEOPATHY. ng ganglion lies on the rectus capitis anticus major muscle and sends branches upward which form a plexus around the in- ternal carotid artery (carotid plexus). The cavernous plexus is a continuation of this. From these plexuses many com- municating branches pass to unite with the cranial nerves of the cerebro-spinal system. Connections. — This ganglion is connected with the first four spinal nerves, and the ninth, tenth and twelfth cranial. Its branches are distributed on all the blood vessels of the head and face. Vaso-constriction. — Physiological experiment has de- monstrated that this ganglion exercises a vaso-constrictor in- fluence over the blood vessels of the head and face. Distribution. — "The terminal filaments from the caro- tid and cavernous plexuses are prolonged along the internal ca- rotid artery, forming plexuses which entwine around the cere- bral and ophthalmic arteries ; along the former vessels they may be traced into the pia mater ; along the latter, into the orbit,, where they accompany each of the subdivisions of the vessel* a separate plexus passing with the arteria centralis retinae, into the interior of the eye-ball. The filaments prolonged onto the anterior communicating artery form a small ganglion, the Ganglion of Ribes, which serves, as mentioned above, to con- nect the sympathetic nerve of the right and left side." (Gray's Anatomy, page 871.) Reasoning from the position of the ganglion, in the neck, its distribution to blood vessels of the head and face, and its vaso-constrictor functions to the vessels, we can readily un- derstand why mechanical lesions in the upper cervical region can be the cause of grave pathological conditions in the tissues of the head and face. Anything which disturbs the normal circulation in a definite area will necessarily affect the nu- trition of the tissues in that area; therefore, nutritional dis- orders of the eye are found to be caused by subluxation of vertebrae, or contraction of muscles in relation to the superior cervical ganglion. Headache. — Since sympathetic branches are distributed to the blood vessels of the pia mater, we may reasonably i20 PRINCIPLES OF OSTEOPATHY. expect to affect the calibre of these vessels in the case of congestive headache, by removing all obstructions, — e. g., contracted muscles causing dilatation, — to the active func- tioning of the superior cervical ganglion. The distribution of these sympathetic nerves to the orbit, nose, pharynx, ton- sils, palate, and sinuses, explains the possibility — yes, proba- bility- — of a mechanical lesion in the upper cervical region in these cases. Middle Cervical Ganglion. — The middle cervical gan- glion is the smallest of the three. "It is placed opposite the sixth cervical vertebra, usually upon or close to the superior thyroid artery; hence the name of 'Thyroid Ganglion' as- signed to it by Haller." It sends branches to the fifth and sixth spinal nerves. Distribution. — It sends branches to accompany the inferior thyroid artery to the thyroid gland, where they com- municate with the superior and recurrent laryngeal nerves. These branches regulate the calibre of the inferior thyroid artery and its branches. The chief nerve trunk passing from this ganglion is the middle cardiac nerve. The cardiac aug- mentors leave the spinal cord as white rami-communicantes to the second, third and fourth dorsal ganglia, then pass up- ward to the middle cervical ganglion. This ganglion is con- nected with the superior cervical ganglion. Function. — The functions of this ganglion are (a) vaso-constrictor (through connection with the superior cervical ganglion) to the blood vessels of the head and face; (b) vaso-constrictor to the vessels of the thyroid gland; (c) augmentor influence to the heart. Manipulation. — Therefore, inhibition (pressure) will lessen those influences, and stimulation (make-and-break pressure) will increase them. Since sympathetic centers (ganglia) control vaso-motion and secretion, we may consider that this ganglion controls vaso-motion and perspiration in the area of distribution of the fifth and sixth cervical spinal nerves. Inferior Cervical Ganglion. — "The inferior cervical ganglion is situated between the base of the transverse pro- PRINCIPLES OF OSTEOPATHY. 121 cess of the last cervical vertebra and the neck of the first rib, on the inner side of the superior intercostal artery." Distribution. — It connects with the ganglion above, and the fibres which connect it with the first thoracic ganglion pass both in front of and behind the subclavian artery. Its chief branch is the inferior cardiac nerve, which communi- cates with the middle cardiac nerve and the recurrent laryn- geal nerve. It sends gray rami-communicantes to the seventh and eighth cervical nerves ; also some branches which pass up- ward to the vertebral artery. The fibres which encircle the subclavian artery are called the Annulus of Vieussens, and some fibres to the cardiac nerve are given off from it. Function. — From this distribution we may draw the following conclusions as to the function of the inferior cervical ganglion; (a) It is vaso-motor to the area of distribution of the seventh and eighth cervical nerves; (b) it controls per- spiration in this same area; (c) it is vaso-motor to the ver- tebral artery and its branches in the posterior fossa of the skull; (d) vaso-motor to the internal mammary, inferior thy- roid, and nervi comes phrenici arteries; (e) augmentor in- fluences to the heart. Manipulation. — Treatment on this ganglion would les- sen its vasco-constrictor influence over the arteries named, and they would then carry more blood at a slower rate. The stimulation of this ganglion would raise blood pressure in the area it controls, and augment the force of the heart. Recapitulation. — It has been mentioned that the cervi- cal ganglia receive no white rami-communicantes from the cervical nerves, and that vaso-constrictor fibres pass from cerebro-spinal to the sympathetic system in the white rami- communicantes between second dorsal and second lumbar vertebrae; therefore, the constrictor influence manifested by the cervical sympathetics is derived from the second, third and fourth dorsal. They derive fibres also from the upper thoracic region, as follows: (a) augmentor fibres to the heart from the second, third and fourth dorsal; (b) secretory fibres to the salivary glands, second and third dorsal ; (c) pupilo-dilator and motor fibres to the involuntary muscles of 122 PRINCIPLES OF OSTEOPATHY. the eye and orbit from second and third dorsal; ( d) afferent fibres whose stimulation causes activity of the vaso-motor center in the medulla. Thoracic Ganglia. — "The thoracic portion of the gan- gliated cord consists of a series of ganglia which usually correspond in number to that of the vertebrae, but from the occasional coalescence of two, their number is uncertain. These ganglia are placed on each side of the spine, resting against the head of the rib and covered by the pleura cos- talis ; the last two are, however, anterior to the rest, being placed on the sides of the bodies of the eleventh and twelfth dorsal vertebrae. The ganglia are small in size, and of a gray color. The first, larger than the rest, is of an elongated form, and frequently blended with the last cervical. They are connected together by cord-like prolongations of their sub- stance. In the thoracic region the ganglia are connected with the spinal nerves by both white and gray rami-communi- cantes/' — (Gray's Anatomy, Page 804 in 1901 Edition.) Rami-efferentes. — The rami-efferentes or branches of distribution, are divided into an internal and external set. The external branches are smaller, being distributed to the bodies of the vertebrae and their ligaments. The internal branches may properly be divided into an upper and lower group, which are distributed to the viscera of the thorax and abdomen. Upper Five Thoracic Ganglia. — The upper five thoracic ganglia send branches which are distributed around the upper portion of the descending aorta. From the second, third and fourth ganglia are given branches to the posterior pulmonary plexus, which control the tissues of the lungs. You will re- member that the pneumogastric nerves are the motor, sensory and trophic nerves to the air passages. The sympathetic, second to seventh dorsal, are vaso-motor and trophic to the blood vessels of the tissues of the lungs. We have now laid a foundation of anatomical and physiological facts upon which we may base our principles of treatment. The upper thoracic region is an important one, because in it we find not only those white rami-communicantes which are distributed to the aorta PRINCIPLES OF OSTEOPATHY. 123 and lungs, joining with the pneumogastric nerve to complete the plexuses which control lung action, but also those white rami-communicantes which ascend to the cervical ganglia, and are distributed as follows : Nerve Distribution. — "(1) Pupilo-dilator fibres pass by rami-communicantes from the first, second and third tho- racic nerves, ascend in the sympathetic cord to the superior cervical ganglion to form arborizations around the cells. These gray fibres pass to the Gasserian Ganglion and reach the eye ball by the ophthalmic division of the fifth and long ciliary nerves; (2) motor fibres to the involuntary muscles to the orbit and eyelids, from the fourth and fifth thoracic nerves, following a similar course; (3) vaso-motor fibres to the head, secretory fibres to the submaxillary glands, and pilo-motor fibres to the head and neck, are derived from the upper tho- racic nerve, and reach their area of distribution, after similar interruption, in the superior cervical ganglion; (4) the ac- celerator fibres to the heart are derived from the upper tho- racic nerves, and end similarly in the middle and lower cervical ganglia, gray fibres in the cervical cardiac nerve com- pleting the connection." — (Gerrish's Anatomy, Page 18.) Interscapular Region. — Therefore, we have an area extending from the second to the seventh dorsal, in which we must make careful examination for lesions affecting vaso- motor, trophic and secretory activity in the thoracic viscera, upper extremities, and structures of the head, face and neck. This explains to you why a treatment in the interscapular region has such far-reaching effects. A Case Illustrating the Cilio-spinal Center. — As an il- lustration of the nerve connection between the cilio-spinal center, first, second and third dorsal and the eye, I wish to call your attention to a patient now in the clinic. There was extensive inflammation of the conjunctiva of the right eye, sight in that eye was almost gone on account of the opacity caused by the inflammation of the conjunctiva over the cornea. This condition was present for five years. The inflammation had traveled to the nasal duct, and as a result it was closed. The duct had been opened by the surgeon's knife long before we i2 4 PRINCIPLES OF OSTEOPATHY, saw the case. A close examination of the center likely to be irritated in such a condition disclosed the fact that the area between the first and third dorsal vertebrae was exceedingly sensitive, and, most interesting of all, pressure on this area caused intense pain in the inflamed eye, and caused the pupil to dilate. The muscles in the interscapular area were very much contracted. Treatment was given, and in proportion to the amount of relaxation gained in the interscapular area, the inflammation in the conjunctiva subsided. After one month's treatment, the patient could see to thread a needle, using only the formerly diseased eye. Pressure at the third dorsal spine still causes the patient to speak of a sense of pressure or swelling in the eye. (Two years have passed since this was written. The patient has continued to have perfect use of the eye.) The following extract from "The Osteopath" in regard to this case, is of interest to us while considering the sympa- thetic nervous system: "It is not surprising that diseases of the eye should affect the sympathetic nerve, and that by that path the center known as the 'cilio-spinal.' But by what sen- sory path would the influence of pressure be carried to the eye? We know of none. From the first two dorsal nerves, which are identical with the cilio-spinal center, sympathetic fibres are distributed to the dilating muscle fibres of the iris, and when stimulated cause dilatation of the pupils. From the third dorsal nerve fibres are distributed which regulate the calibre of the blood vessels of the eye. Under the pressure, either set of these fibres may be affected. The first may be stimulated, dilating the muscles of the iris so as to press upon filaments of sensitive nerves ; or, the pressure may inhibit the vaso-constrictor function of the other nerve, and by dilating the arterioles cause pressure upon the sensitive nerve ; or, both causes may operate and thus induce the pain. The abundant supply of sensory nerves to the ciliary muscle, iris and cornea, from the nasal branch of the ophthalmic division of the fifth nerve and the short ciliary branches from the ciliary (lenticu- lar or ophthalmic) ganglion makes it conceivable that any change of arterial pressure might affect these nerves to the PRINCIPLES OF OSTEOPATHY. 125 extent of causing pain. It seems reasonable to conclude that there was no inflammation, but congestion, and partial paraly- sis of the vaso-constrictor nerve." — (A. E. Brotherhood, D. O., D. Sc. O., in "The Osteopath," Vol. V., No. III.) Effects of Treatment, First to Seventh Dorsal. — Treat- ment in the interscapular region, first to seventh vertebrae, may reasonably be expected to affect the heart beat, the nu- tritional circulation in the lungs, and the circulation in the up- per extremities, head, neck and face. The remainder of the dorsal area constitutes what is called the splanchnic region. Three splanchnic nerves are given off from this region to be distributed to the prevertebral plexuses in the abdominal cavity. The Great Splanchnics. — The first is called the Great Splanchnic and takes origin from the sixth to the tenth dorsal nerves, and probably receives many filaments from the upper dorsal nerves. It is a large nerve trunk and contains many medullated nerves from the cerebro-spinal system. Its course is downward and inward, perforates the crus of the dia- phragm and ends in the semilunar ganglion. Some fibres end in the renal and suprarenal plexuses. Lesser Splanchnic. — The Lesser Splanchnic arises from the tenth and eleventh ganglia and their connecting cord. It also takes a downward and inward course, piercing the crus of the diaphragm, and ends in the Coeliac Plexus. It communicates with the Great Splanchnic, and sometimes sends fibres to the renal plexus. Least Splanchnic. — The Least, or Renal Splanchnic, arises from the last thoracic ganglion and ends in the renal plexus. It sometimes communicates with the lesser splanch- nic. Functions. — First, vaso-constriction ; second, viscero- inhibition. I mention merely those functions which have been well demonstrated by physiological experiments and osteo- pathic practice. Theory. — The osteopath reasons as follows concerning this Splanchnic area: Since the Great Splanchnic ends in the semilunar ganglion, from this ganglion and plexuses 126 PRINCIPLES OF OSTEOPATHY. around it fibres are distributed to the blood vessels of the stomach, liver, spleen and intestines; therefore, we operate in the area between the fifth and tenth dorsal spines for vaso- motor effects on the above-mentioned viscera. Again, the great splanchnic sends viscero-inhibitory fibres to the mus- cular layers of the stomach and intestines; hence, we con- trol excessive muscular activity in these viscera by removing obstructions to the normal inhibitory influence of these nerves. The Lesser Splanchnic has the same functions, but exer- cises its functions chiefly on that portion of the intestinal muscular layer comprised in the area supplied by the su- perior mesenteric artery; therefore, the tenth and eleventh dorsal area is a vaso-motor and motor-inhibitory center for a segment of the intestines. The renal splanchnics exert a vaso- constrictor influence on the blood vessels of the kidneys, and the osteopath secures vaso-motor effects on the blood vessels of the kidneys, and hence effects secretion by removing ob- structions to the normal influence of this nerve. The twelfth dorsal spine marks a renal center. These nerves contain sensory fibers which carry sensation from the prevertebral plexus in the abdomen to the spinal cord. There- fore, a disturbance in the viscera can reflex its painful sen- sations to the area of greater sensibility which is in close central connection with the seat of disturbance. It should be borne in mind that the power of movement resides in the muscular wall of the intestine and is initiated by the Automatic Ganglia in its walls, which are excited by the pressure of food. We may state that the intestines possess an intrinsic nerve apparatus which initiates peristalsis, but the control of the movement after it is initiated is exercised by cerebro-spinal nerves. The pneumogastric nerve exercises a decided motor influence over the intestines. And, as pre- viously stated, the great and lesser splanchnics are inhibitory nerves to the musculature of the intestines. Lumbar Ganglia. — Four small ganglia, connected above and below by intercommunicating fibres, constitute the lumbar portion of the sympathetic ganglia. These ganglia are connected with the cerebro-spinal lumbar nerves by rami- PRINCIPLES OF OSTEOPATHY. 127 communicantes. The first and second ganglia are the only ones in this region receiving white rami-communicantes. The functions which we found were exercised in the lower dorsal area are continued into the lumbar ganglia as far as the sec- ond. These ganglia send fibres to the aortic plexus, the hypo- gastric plexus, and thence to the pelvic plexus. They also send branches, as in other regions, to the blood vessels sup- plying the bones and ligaments of the spinal column. Since vaso-constrictor fibres do not enter the sympathetic ganglia below the second lumbar, we may reasonably expect to influence the circulation of the lower extremities by manipu- lations in this area. The descending colon and rectum are supplied with viscero-inhibitory fibres from this area. Vaso-constrictor fibres are supplied to the blood vessels in the lower portion of the abdomen. The influence exerted by the lumbar sym- pathefics may be tabulated as follows : 1st: Viscero-inhibitory to descending colon and rectum. 2nd : Vaso-constrictor to lower abdominal blood vessels. 3rd: Vaso-constrictor to the blood vessels of the penis. 4th : Vaso-motor fibres to the blood vessels of the blad- der. 5th : Vaso-motor fibres to the blood vessels of the uterus. 6th : Vaso-constrictor to the blood vessels of the pelvic viscera. 7th: Motor to vas deferens (male), round ligament (female). 8th : Vaso-constrictor to the blood vessels of the lower extremities. Sacral Ganglia. — The pelvic portion of the sympathetic chain usually consists of four ganglia situated along the inner side of the sacral foramina, and communicates with the four upper sacral nerves. These ganglia are connected with each other, as in other regions. The two chains connect by the Ganglion Impar on the anterior surface of the coccyx. Distribution. — The rami-efferentes are distributed to 128 PRINCIPLES OF OSTEOPATHY. the pelvic plexus ; or a plexus on the middle sacral artery, and to vertebrae and ligaments in the sacral region. "Through the pelvic plexus, the pelvic viscera are sup- plied with motor, vaso-motor and secretory fibres." (Ger- rish's Anatomy, Page 648.) The rami-communicantes in the sacral region are gray, hence, the influence of the cerebro-spinal system is carried down from the upper lumbar ganglia. "Below the second lumbar vertebra they are also of the gray peripheral variety." ('VYbdominal Brain/' Page 31.) In the sacral region the spinal nerves are distributed directly to the pelvic viscera ; some fibres pass into the pelvic plexus, thence to the viscera. The sacral region offers an area in which the osteopath can secure an influence on pelvic viscera without the exten- sive sympathetic connections encountered in other regions of the spine. Function. — These sacral nerves are : 1st: Vaso-dilator to the vessels of the penis and vulva. 2nd : Motor fibres to the rectum. 3rd : Motor fibres to the bladder. 4th : Motor fibres to the uterus. Cardiac Plexus. — The three great prevertebral plex- uses must now engage our attention. The first one, the car- diac plexus, is situated at the base of the heart, and in the con- cavity of the arch of the aorta; this portion is called super- ficial, while the deep portion lies between the trachea and the aorta. Position and Formation. — The cardiac plexus is formed by fibres from the pnuemogastric and cervical cardiac sym- pathetics. "It is very common to find upper cervical cardiac branches of the vagus and sympathetic united to form a com- mon trunk. In other cases, the nerves branch and communi- cate with each other in a plexiform manner." (Morris's Anatomy. ) The cardiac nerves form the cervical sympathetic chain; all enter the cardiac plexus, but their distribution is variable. The superficial plexus receives the "left superior cardiac nerve PRINCIPLES OF OSTEOPATHY. 129 of the sympathetic and the left inferior cervical cardiac branch of the pneumogastric.'' — (Morris's Anatomy.) The deep cardiac plexus "receives all the other cardiac nerves." From the superficial cardiac plexus branches pass to the plexus around the right coronary artery and pass to the left lung to join the anterior pulmonary plexus. From the deep cardiac plexus branches are distributed to the anterior pulmonary plexus of both sides, the left coro- nary plexus, right auricle, superficial cardiac plexus, and right coronary plexus. Pulmonary Plexus. — Thei anterior pulmonary plexus is formed by a branch of the pneumogastric and the sympa- thetic. It is situated on the anterior surface of the bronchi and the branches enter the lung on the bronchus. The posterior pulmonary plexus is formed by the pneu- mogastric and fibres from the second, third and fourth tho- racic ganglia of the sympathetic. Its branches enter the lung on the posterior aspect of the bronchus. Physiology. — Physiological experiments have demon- strated that the pneumogastric is motor to the muscles of the bronchioles, sensory and trophic, while the sympathetics are vaso-motor and trophic. Therefore, the function of the lungs and heart can be affected by operating on the inter-scapular region. Functions. — The functions of the thoracic plexus are : 1st: Cardiac augmentors, per sympathetics. 2nd : Cardiac inhibitor, per pneumogastric. 3rd : Vaso-constrictor to coronary arteries, per pneumo- gastric. 4th : Vaso-constrictor to bronchial arteries, per sympa- thetics, first to fifth dorsal. 5th : Sensory fibres to the pleura and lungs, per sym- pathetic, first to fifth dorsal. 6th : Sensory fibres to heart and pericardium, per sym- pathetic, second to fifth dorsal. 7th : Broncho-constrictor, per pneumogastric. 8th : Broncho-dilator, per pneumogastric. 13© PRINCIPLES OF OSTEOPATHY. 9th : Sensory fibres to mucous lining of air passages, per pneumogastric. Treatment. — A true inhibitory treatment would pro- duce greatest effect on the heart, if administered over the middle and inferior cervical ganglia. The heart would be slowed. Such a treatment is rarely given, because nearly every case presents some physical lesion, which if removed, allows normal impulses to meet in the cardiac plexus and be re-organized for proper distribution. Always bear in mind that a plexus is a re-organizing center for nervous impulses, and we can hope only to regu- late the function of an organ by attempting to equalize the impulses reaching its controlling plexus. This equalizing process is not ordinarily secured by the administration of inhibition to a definite nerve trunk which ends in the plexus, but by removing a lesion, — usually bony or muscular — which is affecting the ' nerve fibre in the direction of increase or decrease of function. The region between the scapulae is in close central con- nection with the lungs, pleura, heart and pericardium; hence, painful sensations originating in these organs may be re- ferred to this area. The muscles in this area will contract reflexly from irritation of these organs, or from exposure of the skin over them to a change of temperature. Hence, in the first instance the contraction is a secondary lesion; in the latter, a primary one. Pressure in this area practically causes relaxation of muscles, removes a lesion ; but the patient experiences a cessa- tion of pain, freer respiration, and less rapid action of the heart. Results. — After administering inhibitory pressure, the osteopath realizes that the muscles under his fingers are softer than formerly; then he knows that he has actually changed the physiological condition of an important tissue. Argument. — Coincident with the softening of the mus- cles, the heart beats slower; therefore, he has removed an irritant to the augmentor fibres of the heart ; the respiration is deeper, therefore, a change has been secured in the activity PRINCIPLES OF OSTEOPATHY. 131 of the walls of the thorax, and in the circulation of blood in the bronchial and pulmonary blood vessels ; the pain has de- creased, therefore, the sensory nerves in the lung tissue are no longer irritated by hyperaemic pressure or toxic substances in the blood. This illustrates to you why the osteopath studies and treats the interscapular region so carefully. Solar Plexus. — In the abdominal cavity we find the solar plexus, which on account of its great size and wonder- ful distribution, Byron Robinson calls the "Abdominal Brain.'' Location and Formation. — It is placed in front of the aorta at its entrance into the abdomen, and surrounds the Coe- liac Axis. It consists of two semilunar ganglia, which are placed on each side of the coeliac axis, and are connected by a large number of fibres which pass above and below the coeliac axis. From this circle of ganglia and nerves, fibres are given off which are joined by branches of the right pneumogastric, and by both small splanchnics. The great splanchnic ends in the semilunar ganglion. Distribution. — The branches of distribution from the solar plexus are prolonged on the branches of the abdominal aorta as subsidiary plexuses, taking their names from the arteries they accompany, as splenic, gastric, hepatic, dia- phragmatic, suprarenal and renal, superior mesenteric, inferior mesenteric, aortic and spermatic. The ultimate distribution of the branches of the solar plexus is to the muscular and secre- tory tissues of all the abdominal viscera, and to the muscular coat of the arteries supplying these viscera. This great plexus is the vaso-motor center for the abdominal viscera. "It is con- nected with almost every organ in the body, with a supremacy over visceral circulation, with a control over visceral secre- tion and nutrition, with a reflex influence over the heart that often leads to fainting, and may even lead to fatality." — "Ab- dominal Brain," Page 76. Function. — We find that the great and the small splanchnics and right pneumogastric are the chief contributors to the solar plexus, and in order to get a clear idea of the func- tions of this plexus, we may tabulate them as follows : 132 PRINCIPLES OF OSTEOPATHY. ist: Viscero-motor to stomach, small intestines, as far as sigmoid flexure, per pneumogastric. 2nd : Sensory to stomach and small intestines, per pneu- mogastric. "If the pneumogastric nerve be divided during full di- gestion in a living animal, in which a gastric fistula has been established, so that the interior of the stomach can be ex- amined, the muscular contractions will be observed to cease instantly; the mucous membrane to become pale and flaccid; the secretion of the gastric juice to be arrested, and the organ to have become insensible. There can be no doubt, also, that stimulation of the pneumogastric nerves causes the stomach to contract, and that digestion may, to a certain extent, at least, be re-established by stimulation of the peripheral ex- tremities of the divided nerves. " — (Chapman' Phys., Page 680.) 3rd : Viscero-inhibitory, per splanchnics. 4th : Vaso-motor, per splanchnics. 5th : Sensory, per splanchnics. 6th : Sensory, per pneumogastric and splanchnics. The fibres of the great and small splanchnics come from the sympathetic ganglia in the dorsal region, sixth to eleventh. These ganglia may receive fibres from some of the upper dorsal. Centers. — The facts just stated give us a foundation for osteopathic treatment to influence motion, sensation, se- cretion, and vaso-motion in the abdominal viscera. The area in the vertebral column which we may consider as containing centers for these various functions lies between the sixth and eleventh dorsal spines. The fibres from this region have a segmental distribution to the abdominal viscera ; therefore, the stomach, liver, gall bladder, spleen and intestines, each have a limited portion of this area which is their special center ; at least, painful sensations are reflexed from them to a definite point in the vertebral column between the sixth and eleventh dorsal spines. The enormous regulative influence which can be excited by an osteopathic treatment in this area is being demonstrated daily. PRINCIPLES OF OSTEOPATHY. 133 We have already mentioned the fact that the intestines will contract after being separated from the body, thereby, proving that the intrinsic power to cause movement lies in the nervous mechanism in the gut walls. Keep constantly in mind the regulative character of the impulses which enter the ''abdominal brain" over the pneumogastric and splanchnic nerves. The vaso-motor phenomena in this area have been dis- cussed in another chapter. Hypogastric Plexus — Location and Formation. — The great re-organizing center for the pelvic viscera is called the hypogastric plexus, which lies anterior to the fifth lumbar vertebra. It is formed by a continuation of fibres from the aortic plexus which are joined by fibres from the lumbar sympathetic ganglia. In front of the sacrum the plexus divides into two portions, which join the pelvic plexuses lying on each side of the rectum and bladder, in the male, and of the rectum, vagina and bladder in the female. Pelvic Plexus. — These pelvic plexuses contain many small ganglia, and are joined by fibres from the upper sacral sympathetic ganglia, and by direct branches of the second, third and fourth sacral cerebro-spinal nerves. Distribution. — The branches of these plexuses are dis- tributed on the coats of the arteries to the pelvic viscera, and frequently enter the substance of the organ. Subsidiary Plexuses. — According to the artery fol- lowed, we have subsidiary plexuses, called hemorrhoidal, vis- ceral, prostatic, vaginal, and uterine. Functions. — The functions of the pelvic plexus are as follows : (1) Vaso-constrictor, (2) vaso-motor, (3) sensory, (4) viscero-inhibitor, per hypogastric plexus. (5) Motor to rectum, vagina and bladder, (6) sensory to rectum, vagina and bladder, (7) vaso-dilator to sexual or- gans, erectile tissue, (8) viscero-constrictor to neck of uterus, per second, third and fourth sacral. Summary. — With the arrangement and functions of 134 PRINCIPLES OF OSTEOPATHY. these nerves well in mind, we recognize two paths over which we can influence the pelvic viscera : ( i ) Sensor}- influences may be reflexed through the hypo- gastric plexus, and thence to the second lumbar ; or, they may pass over sacral nerves to the same point, second lumbar. In connection with disturbance of the pelvic viscera, pain may be reflexed on to the back of the sacrum, or to an area around the second lumbar. Disturbance of function in the uterus Causes reflex sensitiveness at fourth and fifth lumbar. (2) Vaso-constrictor influences come through hypogastric plexus from spinal nerves about second lumbar. (3) Vaso-dilator influences come directly to the pelvic plexus from second and third sacral nerves ; nervi erigentes. (4) Viscero-motor influences chiefly from second, third and fourth sacral. (5) Viscero-inhibitory influences, chiefly through hypo- gastric plexus, probably from upper lumbar spinal nerves. We have therefore a vaso-constrictor center for pelvic viscera at second lumbar ; a vaso-dilator and motor center at second and third sacral. Automatic Visceral Ganglia. — The last portion of the sympathetic is but little known, and physiologists have re- frained from speculating on it until more definite knowledge is obtained. Byron Robinson mentions a number of "automatic vis- ceral ganglia" situated in the walls of the hollow viscera. The fact that the heart, intestines, uterus, bladder and fallopian tubes will contract rhythmically in response to mechanical stimulation after all nerve connections are severed, seems to prove the existence of ganglia in the walls of these viscera which are capable of receiving sensation and sending out motor impulses. Conclusions. — We will therefore conclude that the sympathetic system can act independently of the cerebro- spinal ; that it receives sensation, and initiates motion ; gives tone to the arteries, and controls secretion. We influence the functions of the sympathetic through its connection with the cerebro-spinal system. PRINCIPLES OF OSTEOPATHY. 135 CHAPTER VII. HILTON'S LAW. In the years 1860-61-62 a series of lectures was delivered by John Hilton, F. R. S., F. R. "C. S., "On the Influence of Mechanical and Physiological Rest in the Treatment of Ac- cidents and Surgical Diseases, and the Diagnostic Value of Pain.'' These lectures were afterward published in book form under the title of "Rest and Pain." This book is a medical classic and worthy of careful perusal by all students of medicine. The careful observations and reasonings therefrom which are reported in "Rest and Pain" explain many of the phe- nomena noted in osteopathic practice. We desire to give all due honor to this man who was so far in advance of his time. We shall quote a few paragraphs from "Rest and Pain" which have a direct bearing on osteopathic methods of diag- nosis and therapeutics. The Law Stated. — After careful study of the distribu- tion of nerves throughout the body, Hilton sums up his ob- servations in a terse sentence which we choose to call a law. "The same trunks of nerves zvhose branches supply the groups of muscles moving a joint, furnish also a distribution of nerves to the skin over the insertion of the same muscles, and the interior of the joint receives its nerves from the same source." Hilton further states that "Every fascia of the body has a muscle attached to it, and that every fascia throughout the body must be considered as a muscle." Methods of Studying Anatomy. — These statements 136 PRINCIPLES OF OSTEOPATHY. lead us to a closer study of each joint and its controlling muscles and governing nerve or nerves. We may study anatomy under artificial divisions such as Osteology, Syndes- mology, Myology, etc., and still, after securing an accurate technical knowledge of details, we have nothing of practical value. It is in the correlation of these tissues with their in- terdependence quite fully understood that we have a working knowledge. With this thought of the influence of one tissue on another and the harmonious action secured by the com- paratively varied distribution of the nerve trunks, we find a new and vital interest in anatomy. This law is based upon the facts of anatomy and physi- ology, and makes our concrete knowledge of these subjects of constant practical value in both diagnosis and therapeutics. This law shows us the "why" of certain vital and mechanical manifestations, and teaches us practical methods of treat- ment. Example of Hilton's Law. — An example of Hilton's law is the distribution of the sciatic nerve to the ankle. The muscle moving the joint, the synovial membrane and most of the skin over the joint are all innervated by it. The Knee. — The knee has three nerves. Each one has a motor and sensory control. The extensor muscles and the skin over them is innervated by the anterior crural. The flexor muscles and the skin over them is innervated by the sciatic. The obturator, in addition to these nerves, furnishes sensory filaments to the synovial membrane. All the joints of the body may be examined in the light of this law. The same segment of the central nervous system which gives off a purely motor nerve trunk, gives off also a sensory nerve whose filaments are distributed over the same area. Thus it is some- times necessary to go to the central nervous system to dis- cover this association of motor and sensory distribution. In practice we always do this, because it is easier to work from the center of the areas of distribution. The Object of Such a Distribution. — Hilton says : "The object of such a distribution of nerves to the muscular and ar- ticular structures of the joints, in accurate association, is to PRINCIPLES OF OSTEOPATHY. 137 insure mechanical and physiological consent between the ex- ternal muscular, or moving force, and the vital endurance of the parts moved, namely, of the joints, thus securing in health a true balance of force and friction until deterioration occurs." "Without this nervous association in the muscular and articular structures, there could be no intimation by the internal parts of their exhausted condition." "Again, through the medium of the muscular and cutaneous nervous association great security is given to the joint itself by those muscles being made aware of the point of contact of any extraneous force or violence. Their involuntary contraction instinctively makes the surrounding structures tense and rigid, and thus brings about an improved defence for the subjacent structures." The Uniformity of the Law. — "This articular, muscu- lar and cutaneous distribution of the nerves is, in my opinion, a uniform arrangement in every joint in the body. We may find numerous illustrations of the same method of distribution in other parts of the body, which have the same definite re- lations to each other, and in this respect present the same physiological and mechanical arrangement observable in joints. This same principle of arrangement, anatomic- ally, physiologically, and pathologically considered, is to be observed with an equal degree of accuracy in the serous and in the mucous membrane. Thus considered, it presents a prin- ciple, which, if it has any application in practice, must be one certainly of large extent." Precision of Nervous Distribution to Muscles. — "The great precision with which muscles are supplied by their nerves is worthy of remark; and is such that if we have before us a contracted muscle, we may be sure of the nerve which must be the medium, or the direct cause of it." "In studying the supply of nerves to muscles over every part of the body, we find a great degree of precision, which marks one difference between their distribution and that of the arteries." Indications for Use of Therapeutics. — "I should say in aid of other means, employ this cutaneous distribution of nerves as a road or means toward relieving pain and irritation 138 PRINCIPLES OF OSTEOPATHY. a -3pinai Cord b poslhior pfimo-vu cluA-sum C Inlir.tal brcutch . ( CuXaneou.s ) £, 5u»ri|oaWiet» " ganejlu»a . 8. T^etu.) » t'nt branch h Wna. ca.i/u_ Infrviur. I. ,P|o»'ta. fc. 5y nipatheCi l brunch. are maintained by i43 PRINCIPLES OF OSTEOPATHY. the unequal contraction of opposing groups of muscles which is brought on by these accidents. Take, for instance, the va- rious twists of the atlas found by osteopathic methods of physical diagnosis. Gray says : "The Recti Laterales are mainly concerned in the slight lateral movements." This is the movement concerned in a lateral subluxation. The posi- tion in which we usually find the atlas is an oblique one, hav- ing the right transverse process hugging the angle of the jaw while the left is too close to the mastoid process. Gerrish describes this position as the "obliquely lateral" a normal movement. We also consider it normal if it possesses the ability to slip back into a position having similar rela- tions on both sides. It is a subluxation when it can not get out of that position without assistance. If there is free move- ment in the occipito-atlantal articulation, every change of the position of the head will change the relations in this joint. Our bodies are constructed so that when the bones form- ing a joint are moved to their fullest extent pressure is usually exerted on soft tissues around the joint. This is normal, but when these normal relations are retained too long and the bones do not resume their easy resting position the condition becomes abnormal; it is then a subluxated joint. There is no articulation in the body whose bony parts are abnormally related when the extreme movement in the joint is made. We will except the sacro-iliac articulation, be- cause it is not considered a moveable joint. The subluxa- tion consists in the relation of the bony surfaces in a posi- tion other than that which they should hold during relaxa- tion or equal tension of all the muscles. The normal posi- tion of the transverse processes of the atlas is pictured in Fig 31. The subluxations are pictured in Fig 32. The normal relations of the atlas are illustrated by photo- graphs of the skull and first cervical vertebra in Fig. 33. Fig 34 shows an oblique side view. In Fig. 35 the atlas is slightly twisted, so that the right transverse process is posterior. This rear view shows the distance between the left mastoid and left transverse process increased. The right transverse pro- cess is prominent. The same relations viewed from below are PRINCIPLES OF OSTEOPATHY. Fig- 3i. — Normal surface marking of the transverse process of the Atlas i5o PRINCIPLES OF OSTEOPATHY. shown in Fig. 36. The right transverse process is slightly posterior to the mastoid. Figs. 37 and 38 show side and lateral views of a twisted atlas. In preparing these bones for photographing, it has Be! ■•» ^ ^C .^ a Fig. 32. — -Abnormal surface markings of the transverse process of the Atlas. been borne in mind that the articulating surfaces must be kept in close apposition. The relations illustrated are normal to the articulation, but abnormal when retained in these posi- tions after relaxation of opposing muscles. PRINCIPLES OF OSTEOPATHY. '5* Fig. 33- — Xormal relations between the Atlas and Occipital bone. Fig. 34. — Xormal relations between the Atlas and Occipital bone- 152 PRINCIPLES OF OSTEOPATHY. If, as Cruveilhier says, there is a slight rotation in this joint — and osteopathic practice proves Cruveilhier's state- ment true — ,then what muscle could by its persistent contrac- tion cause this rotation to be maintained? The Rectus Capi- tis Anticus Minor is so placed as to cause this movement. It arises from the anterior surface of the lateral mass and root of transverse process of the atlas and passes obliquely upward and inward. It is inserted into the basilar process of the oc- cipital bone. This muscle has as its external relation the supe- rior cervical ganglion of the sympathetic, and as a contracted Fig. 35- — Right transverse process of the Atlas too far posterior. muscle is thicker than an uncontracted one, pressure may be exerted on this ganglion which may also be irritated by the transverse process of the atlas being pulled toward it, thereby lessening its normal space in more than one direction. The reflexes originated by this irritation of the superior cervical ganglion or its connections may initiate changes in the caliber of the blood vessels of the brain, eyes or any other circulatory area under control of the ganglion. The influence exerted directly on circulation by the sub- luxation of the atlas is probably most active where the verte- bral arteries pass through the foramena in the transverse PRINCIPLES OF OS TEOPA TH Y. 153 processes. It might be argued against this view that nature has not failed to provide a certain amount of elasticity in the artery and surrounding structures to meet just such a condi- tion. Nature has certainly done this, but not with the idea in view that any such exaggerated condition is to be main- tained for any great length of time. Subluxations of the atlas are found in connection with a great number of disturbed areas, but the pathological con- dition in each is the same. For instance, there is no differ- ence between a hyperaemia in the nasal, pharyngeal or laryn- Fig. i>6- — Right transverse process of the Atlas too far posterior. geal mucosa and a congestion of the retina, except in loca- tion. We must not view retinitis as a distinct disease from laryngitis. If we should do so, we fix our attention on symp- toms and see a picture which conceals causes. When the superior cervical ganglion has its function of vasoconstric- tion inhibited by continued irritation, the work of maintain- ing vascular tone is passed along to peripherially placed gan- glia. If the eyes are strained by over work, the resistance of their nerves is decreased. This, added to the weakened vaso-constrictor action of the superior cervical ganglion, al- lows congestion, a retinitis. Wearing high collars weakens 154 PRINCIPLES OF OSTEOPATHY. the resistance of nerve endings in the skin of the neck. This, added to low power in the ganglionic station, leads to con- gestion in the pharynx or larynx. Treatment must be ap- plied to the structures around the ganglion, and peripheral nerve power increased by gradually exposing the skin to the atmosphere. The Atlas and Axis. — The articulation between the at- las and axis is the most intricate in the whole spinal column, consisting of four distinct joints. Rotation takes place be- tween these bones, but this motion is limited by the check Fig. 37- — Twisted Atlas-rotation. ligaments. Dislocation of the odontoid process causes instant death by pressure on the lower part of the medulla oblongata. The articulations between the articular processes of these bones are arthrodial. The articulation between the odontoid process of the axis and anterior arch of the atlas holds the bones firmly together. Most of the rotation in the cervical region is in this joint. Although there is so much movement allowed by these articulations we seldom find the axis sub- luxated. Unequal Development. — Deviation of the spine of the PRINCIPLES OF OSTEOPATHY. 155 axis from the median line is a frequent condition, but in the majority of cases is its normal relation on account of uneven development. Caries. — Hilton describes cases of disease of the artic- ulation between the atlas and axis, showing how destruction of the transverse ligaments allows the head to tip forward, thereby causing the odontoid process to impale the medulla. We may safely say that dislocation of the atlo-axial artic- ulations is probably the rarest condition we will ever meet. Fig- 38- — Twisted Atlas-rotation Various degrees of rotation may be met with which are in the nature of subluxations due to muscular contractions. Spontaneous Reduction. — Since the above paragraph was written, an article in the Medical Record, March third, 1900, has come under my observation. The article is entitled, "Spinal Fracture — Paraplegia." The author, Dr. Robert Abbe, exhibits a radiograph illustrating a case of dislocation of the neck. The dislocation is between the articular pro- cesses of the atlas and axis. The most interesting feature of the case is the spontaneous reduction of .the dislocation 156 PRINCIPLES OF OSTEOPATHY. while the patient was asleep. The author thinks that the relax- ation of sleep and the restlessness of the patient combined to reduce it. Cervical Vertebrae. — The remaining cervical. vertebrae are occasionally forced from their proper relations by vio- lence. Quite a number of cases are on record which show how great the disturbance is in such conditions. Those cases recorded in medical literature are complete dislocations, and hence can not be classed with subluxations such as are met with in osteopathic practice. In order for complete disloca- tion to take place, i. e., so that the articular processes are both locked, the intervertebral disks would have to be torn and would bring great pressure on the cord. All grades of subluxation are found between cervical ver- tebrae. Where the violence has not been sufficient to cause locking of the articular processes, it has exaggerated the nor- mal movement sufficiently to injure the ligaments or muscles, which therefore maintain the subluxated position. We can not estimate the extent of the systemic effects of a lesion in the spine. What might appear to us to be a very slight lesion, might be the cause of a very profound ner- vous disorder. The position of the lesion is the chief means of estimating results. To illustrate this point, we may mention the case of Mr. Norton Russell. A lesion of the sixth cervical vertebra was found. The vertebra was slightly twisted. Mr. Russell had not slept during one hundred nights and days without the use of sulphonol or morphine. The first osteopathic treat- ment applied to the sixth cervical vertebra made it difficult for him to keep awake until he reached his home, and then he feli into a profound sleep. There was a history of severe accident. Muscular contraction was very evident. Fig 39 illustrates the appearance of the posterior surfaces of the cervical vertebrae, second to the seventh, when all the vertebrae are in normal position, i. e., articular surfaces evenly opposed to each other. The changing character of the spinous processes is readily noted. Nearly all of these processes are unevenly developed, showing that palpation of these prom- PRINCIPLES OF OSTEOPATHY. 157 inent points can not help being unsatisfactory. The tubercles on the back and outer surfaces of the inferior articular pro- cesses present a much more uniform development and they can be easily palpated after one has become accustomed to the feel of the cervical muscles. Fig. 39- — Normal relations of the cervical vertebrae. Fig. 40. — Third cervical vertebra subluxated to the right. The superior articular process of the fourth cervical is vis- ible. Fig 40 shows the third cervical subluxated to the right. The tubercle on the left inferior articular process is made more prominent. The muscles over this point will be found contracted. Dorsal Vertebrae. — When the spines of the dorsal ver- tebrae are palpated, the trained fingers may find individual spines which are not in line with those above and below, or that the spacings between the spines is not equal. These de- viations from the normal are indicative of changed relations between the vertebrae. The normal movements in the dorsal region are flexion, extension and rotation. The lesions in this region correspond with these movements. False Lesions. — We must guard against being misled by the deviations which we find, especially lateral ones. Fig. 41 illustrates a decided lateral inclination of the third dorsal spinous process. Such a deflection from the median line would be noted by the unskilled touch of a layman. This deflection 158 PRINCIPLES OF OSTEOPATHY. has no diagnostic significance, unless there is pronounced sensitiveness around it, and then it is the hyperaesthesia and not the osseous formation that must be noted. The most skillful osteopathic diagnostician would be misled by this lesion. There does not appear to be any way to protect against a wrong interpretation in a case like this except the experi- ence of the physician in weighing all the evidence. Fig. 41 -Abnormal development of the spinous process of the third dorsal vertebra. A False L,esion. Lateral Subluxation. — Fig. 42 illustrates a genuine lat- eral subluxation of a dorsal vertebra. The arrangement of the Rotatores Spinae accounts for such a lesion as this. They arise from the upper surfaces of the transverse processes and insert into the laminae above. The subluxated vertebra in this group is the fifth. The digitition of the Rotatores Spinae between the right transverse process and lamina of the sev- enth must contract in order to produce this condition. This digitation may respond to a severe visceral reflex and cause a subluxation of this character. Direct violence may cause it, also a cutaneous reflex iniated by temperature change in the atmosphere. Muscular Contraction. — Muscles contract as a result of excessive straining or wrenching, or exposure to cold and of reflex irritation. If opposing muscles under all condi- PRINCIPLES OF OS TEOPA TH Y. 159 tions of temperature, mechanical and reflex irritation would continue to exert equal influence on a joint, then nothing but a complete dislocation would be possible. A moveable joint contains a synovial membrane which facilitates the rapid re- turn to a normal position. All the mechanical conditions in and around a joint are conducive to the quick return to nor- mal. It is the vital and not the mechanical principle which keeps up a condition of maladjustment. No intermediate po- Fig. 42. — Lateral subluxation of a dorsal vertebra. sition is possible, there being no unevenness of surface to become locked, unless we take into consideration the vital activity as manifested in a contracted muscle. Comparison of Effects of Muscular Contraction. — J. E. Stuart, D. O., has made an apt comparison between the pull of the muscles of the back on the individual vertebrae and the well recognized insufficiencies of the ocular muscles. All physicians recognize the serious effects of long continued in- sufficiency of an ocular muscle, but few, indeed, have given any thought to the possibility of a similar condition affect- ing structures less moveable or less sensitive than the eye ball. The relation of a vertebra with its fellows is of great im- portance to the delicate nervous tissue which it surrounds. It is not necessary for a vertebra to press upon the spinal cord or nerve fibers coming from or going to it in order to produce irritation. There is a nerve strain in connection with these lesions which is not the result of direct pressure, but of i6o PRINCIPLES OF OSTEOPATHY. the efforts of the central nervous system to balance and co- ordinate the contraction of the muscles pulling on the vertebra. It is not necessary for divergent or convergent squint to be so marked that the expression of the eyes is instantly noted by all observers before any symptoms of eye strain are felt by the patient. Neither is it necessary for a vertebra to be dislocated in order to create a disturbance. It is conceivable that a completely dislocated vertebra might, after a time, cause as little irritation as an eyeball which is so divergent that no effort is made to use binocular vision. The body becomes accommodated to the change. Fig. 43. — Flexion in the dorsal region showing spinous processes sepa- rated and superior ar- ticular processes par- tially uncovered. Fig. 44. — Lateral view of same condition as Fig. 43. Separation of Spinous Processes. — Figs. 43 and 44 give two views of the fifth, sixth and seventh vertebrae, illustrat- ing the separation of the spines as in extreme flexion. Note that the superior articular facets are uncovered by the move- ment. The vertebrae assume this position in kyphosis. We find frequently that there is a gap between two spines while the spacing above and below is quite even. Either the space directly above or that below this gap is lessened. Fig. 45 shows the spines of the fifth, sixth and seventh dorsal ver- tebrae in the position of extreme extension. The spines crowd hard upon each other. These illustrations all show normal PRINCIPLES OF OSTEOPATHY. 161 positions, but they are the ones which our ringers discover as lesions of the vertebrae. Approximation of Spinous Processes. — When two spines are closely approximated, as in Fig. 45, there is nec- essarily a widening of the next space above or below, accord- ing to which vertebra is affected. The contracted space will usually be sensitive to digital pressure. There is a contract- ured condition of the muscles causing this extreme movement of extension. This contracture disturbs the rhythm of nerve impulses from that section of the spinal cord in closest rela- tion with the disturbed vertebra. There is a lack of co-ordi- Fig. 45. — Extension in the dorsal region showing approxima- tion of the spinous processes. nation of movement in the affected joints. When several vertebrae are tightly bound together, a straight, nonflexible spinal column is the result. The muscles are tightly contracted and more or less sensitive to digital pressure. Subluxations — Primary. — These conditions as here il- lustrated are what osteopaths usually designate as spinal sub- luxations which are causative factors in disease. They are sources of irritation to the spinal nerves in direct central ref- lation with them, and these nerves convey disturbed or ar- rythmical impulses to the viscera and blood vessels, thus caus- ing the various perversions of function which are recognized as symptoms of disease. l62 PRINCIPLES OF OSTEOPATHY. Subluxations — Secondary. — These lesions must also be recognized as structural changes resulting from excessive, irri- tation to the peripheral end of sensory nerves, either those ending in skin and subject to the temperature changes, or those ending in the visceral mucosa and subject to irritation from the presence of food of an indigestible character, prod- ucts of fermentation, etc. We must recognize the fact that sensory nerves are subject to excessive stimulation in cases of gluttony or masturbation. Both of these bad habits may result from the stimulation of a spinal lesion, but experience Fig. 46. — Posterior view of five lower dorsal vertebrae, nor- mal relations. Fig. 47. — Side view of five lower dorsal vertebrae, normal rela- tions. with humanity teaches the physician that mankind in general delights in gratifying the senses. We do not wish to place spinal lesions at the bottom of man's moral weaknesses. Limited Area for Lateral Subluxations. — Lateral sub- luxations may exist as low as the tenth dorsal spine. The articular processes of the eleventh and twelfth dorsal verte- brae take on the character of the lumbar, hence rotation is practically impossible. There is a digitation of the Rotatores Spinae between the eleventh and twelfth dorsal vertebrae. PRINCIPLES OF OSTEOPATHY. 163 Characteristics of the Eighth, Ninth, Tenth, Eleventh and Twelfth Dorsal Vertebrae. — Figs. 46 and 47 give a pos- terior and lateral view of the five lower dorsal vertebrae. The /changing characteristics of the spinous processes of these ver- tebrae should be carefully noted, so that the student may not be misled as to the significance of that which his palpation may Fig. 48. — Dorso-lumbar kyphosis. The patient is sitting as erect as possible. discover. The eleventh dorsal spine takes a horizontal direc- tion, and in some cases this makes either a very narrow space between it and the tenth or a very wide space between it and the twelfth. Dorso-lumbar Articulation. — The junction of the dor- sal and lumbar regions is very flexible. A large portion of flexion and extension of the spinal column is made in this articulation. The most common condition noticeable in the 1 64 PRINCIPLES OF OSTEOPATHY. lower dorsal region is increased prominence of the spines, and incipient kyphosis. This condition frequently affects the junc- tion of the dorsal and lumbar regions, as in Fig 48. Kyphosis — Lower Dorsal. — A slight kyphosis in the lower dorsal region is indicative of loss of tone in the extensor muscles governing the articular surfaces. The spines are sep- arated farther than normal and the inferior articulating sur- faces are partly uncovered by the superior ones. See Fig. 48. Fig. 49. — Lumbar region, normal. Side view- Fis. -Lumbar region. Rear view — normal. This weakened condition of the back may be brought on by injury, or reflexes from the bowels or kidneys. Continual vi- bration of the spinal column, as in cases of street car men, weaken the back, and then functional disturbances of the kid- neys are noted. Lumbar Region. — Figs. 49 and 50 illustrate the lateral and posterior appearance of the normal lumbar vertebrae. The spinous processes are easily palpated in this region. Their development varies enormously in different individuals. The formation of the articular processes prevents any rotation, PRINCIPLES OF OSTEOPATHY. 165 hence we do not find any lateral subluxations in this region. The position of individual vertebrae is rarely affected. "Breaks," that is, separations of the spines, are sometimes noted, but not often. Violence is the chief cause of these sep- arations. The muscles in this region are thick and powerful, hence their influence is not exerted so much on individual ver- tebrae as upon the whole series of vertebrae. Therefore we find curves instead of subluxations in this region. Exagger- ation of the normal movements is responsible for kyphosis, lordosis or scoliosis. Extreme weariness as a result of main- taining a sitting or standing position leads the individual to shift the weight of the body so as to take some advantage of the ligaments which limit a movement. The strength and flexibility of the lumbar region is fre- quently a very good criterion of the patient's bodily vigor. It is easier to affect this portion of the spinal column by lever- age movements than any other region. Examination of the Ribs. — The position of the ribs is always noted by the osteopathic physician. It is noted in medical text-books on diagnosis that the general conforma- tion of the thorax is indicative, to a variable degree, of either the past medical history of the individual or is evidence of the present existence or predisposition to certain diseases. A full, round, nonflexible chest denotes asthma or emphysema; flat chest denotes tendency to tuberculosis, etc. These state- ments are generalizations based on long observation, and are usually very near the truth. The respiratory movements should be noted, whether full and free compared with the capacity of the thorax. The osteopathic physician goes farther than these excel- lent generalizations in his diagnosis. The relation and po- sition of each individual rib are extremely important. The con- dition of the whole thorax, and its contents, is dependent on the relations of the bones which form it. With this idea in mind, a careful examination of each rib is made. The ribs are, normally, quite moveable. Their spinal articulations are so arranged that an easy rise and fall of the shaft of the rib is permitted. The rise and fall is the result 1 66 PRINCIPLES OF OSTEOPATHY. of rotation of the rib on an axis passing through the costo- central and costo-transverse articulations. Costo-central Articulations. — The costo-central articu- lations of the first, tenth, eleventh and twelfth ribs have no interarticular ligament. The movement of the heads of these ribs is limited by the capsular ligament. The heads of all the other ribs are held in place by interarticular ligaments attached to ridges on the heads of the ribs and to the intervertebral disks. Costo-transverse Articulations. — The tubercles of the ribs articulate with the transverse processes of the vertebrae Fig. 51. — Norrrtal relations of the fifth and sixth ribs. forming arthrodial joints. The superior costro-transverse lig- aments prevent the dropping down of the costro-transverse articulation. There is very limited gliding movement in this articulation. As before stated, the movement in the costro- central and costro-transverse articulations is rotation. The shaft of the rib lies obliquely downward, therefore the rota- tion of the rib during inspiration turns the anterior extremity upward and outward. The axis of the rotation through the costro-vertebral articulations is obliquely downward, there- fore the lateral position of the shaft of the rib is elevated dur- ing inspiration and the lower border is turned outward. Co-ordination. — Fig. 51 illustrates the normal obliquity of the fifth and sixth ribs. When the contraction of all the PRINCIPLES OF OSTEOPATHY. 167 muscles of respiration is properly co-ordinated, the intercostal spaces are all equal in width. The respiratory rhythm should be equal in all parts of the thorax. When through some nervous reflex, inspiration is made difficult, the inspiratory muscles expand the thorax to its fullest extent and retain the expansion. Then the diameters of the thorax are increased. This position of extreme inspiration is typical of the asthmatic chest. Inco-ordination. — There may be lack of co-ordination of the muscles in any intercostal space. This inco-ordination may be manifested by too much contraction or relaxation. The result is a change in the normal width of an intercostal space. Nervous Control of Respiration. — Respiration is carried on by a complicated mechanism. Its chief center of normal control is in the medulla, but subsidiary centers in linear series exist in the spinal cord. Each spinal nerve which innervates intercostal muscles or other muscles of inspiration arises from a subsidiary respiratory center. One of these subsidiary cen- ters may become too active or passive as a result of local irri- tation, due to circulatory changes. The muscles governed by this disturbed center will not act harmoniously, hence the rhythmical movement of all the ribs is interfered with. We have noted that spinal muscles contract unevenly as a result of direct spinal injury, exposure of the skin over them to cold, or from visceral reflexes. The respiratory muscles are subjected to the same conditions. A lateral subluxation in the dorsal region carries its articulated rib with it. Palpation will discover their changed relations. A kyphosis in the dorsal region causes the ribs to rotate upwards, thus increasing the diameters of the thorax. Lordosis in this region has the op- posite effect. Costal Subluxations. — Figs. 52 and 53 illustrate the changes in spacing of the ribs due to inco-ordination of mus- cular contraction. These positions of the ribs are spoken of as costal subluxations. In Fig. 52 the upper rib is rotated down- ward as a result of a contraction of the intercostal muscles of the space below it or the relaxation of those above it. Palpa- tion elicits sensitiveness at the lower border of this fifth rib. 1 68 PRINCIPLES OF OSTEOPATHY. The sensitiveness is usually found where there is compression due to the dropping of the rib and the contraction of the muscles. This rib might have become displaced as a result of violence, or the patient might have been exposed to cold air while sweaty, or some disease of another part of the body might have caused sufficient weakness to allow this rib to drop as a result of pressure occasioned by the position in bed or otherwise. Whatever the cause of these subluxations, they certainly become sources of great irritation to the nervous system. Some- times the body becomes accommodated to these subluxations, Fig. 52. — Approximation of the fifth and sixth ribs. but the fact that cases of asthma have been cured, after years of suffering, by reducing these malpositions is prima facie evi- dence that accommodation is something that can not always be depended on. The heads of the second to ninth ribs cannot be dislocated without rupture of the interarticular ligaments. Considerable change in the position of the shaft of the rib occasions very little change in the position of the head of the rib. First Rib. — The first rib does not move in the same manner as those below. The attachment of the scalenus an- ticus keeps the shaft always raised. No matter how flat the remainder of the thorax may be, the first rib stands out promi- PRINCIPLES OF OSTEOPATHY. 169 nentlv. The chief change in its position is cine to the con- traction of the scalenus anticus, therefore it needs to be de- pressed rather than elevated. Tenth Rib. — The head of the tenth rib is articulated with the body of the tenth vertebra, there is no interarticular ligament. This allows freer movement. Its anterior extrem- ity is insecurely articulated to the cartilage of the ninth rib. This connection is frequently broken, thus making an added floating rib. Eleventh and Twelfth Ribs. — The eleventh and twelfth ribs are very loosely articulated to the vertebrae. They S./ ■ ': . ■ .. F'S- 53- — Separation of the fifth and sixth ribs. have no costotransverse ligaments, hence depend on the action of muscles to hold them in place. They are frequently found rotated upward or downward. We have endeavored to show that the normal movements of the ribs as a whole may become very abnormal when made individually or out of rhythm with each other. The depres- sions or elevations of individual ribs have not dislocated their articulations ; they have merely carried and retained them in positions out of harmony with the remainder of the ribs. They have become discordant members of a harmonious body, and unless made to co-operate for the general welfare, they will rapidly make other members inharmonious. 170 PRINCIPLES OF OSTEOPATHY. Fig. S4- — Normal surface markings of the relations of the sacrum and ilia. PRINCIPLES OF OSTEOPATHY. 171 Effect of Position of Vertebrae on Position of Ribs. — Lack of symmetry in the dorsal vertebrae causes a change in the position of the ribs. Both conditions can be corrected by reduction of the vertebral subluxations. Clavicles. — The clavicles may be elevated or depressed by muscular contraction. Their depression affects the vessels crossing the first rib to and from the upper extremity. The subclavius muscle is responsible for depression of the clavicle. Pig- 55- — .Normal relations of sacrum and ilium. Sacro-iliac Articulation. — The articulation between the sacrum and the ilium is variously described. Some claim it has a synovial membrane ; others deny it. It may be that age and sex have much to do with this question. Ordinarily there is no movement in this articulation. It serves the same pur- pose for the pelvis as the cranial sutures do for the head, that is, to minimize shocks. The articular surfaces of the sacrum and ilium are covered with cartilage, the ligaments are strong, muscular contraction has no effect on their relative positions, nothing but a very severe shock could displace them. 172 PRINCIPLES OF OSTEOPATHY. Fig. 56. — Upward and forward dislocation of the right ilium. PRINCIPLES OF OSTEOPATHY. 73 According to the above facts and our definition of the term subluxation, nothing but a dislocation can take place in this joint. There is no normal movement, hence any change in the relation of surfaces is a dislocation. Whenever the ilium is found raised above its normal relations with the sacrum, the patient will give a history of accident. Fig. 54 illustrates the osseous relations on the posterior surface of this articulation. Normally the posterior superior spines of the ilia are on a horizontal line running through the Fig. 57. — Ilium forced upward and forward. second sacral spine. The crests of the ilia are on a level with the fourth lumbar spine. Fig 55 shows these bones in their normal relations. The Nerves Affected. — The structures which are quite liable to irritation by dislocation of the ilium, are the nerves passing out and in through the great and lesser sacro sciatic foramena; also the lumbar nerves in relation with the psoas magnus muscle. Symptoms. — From the symptoms complained of in 174 PRINCIPLES OF OSTEOPATHY. five cases observed by the author, we note the following : first, a soreness on the bruised part, which soon ceases to attract attention, then pains in the extremity resembling rheumatism ; about this time the patient seeks relief, is treated by the ordi- nary drug methods with no success. During these months of drug treatment the hip rotators begin to contract and stiffen the joint. Within eighteen months after the accident the hip Fig. 58. — Ilium forced upward and backward. joint has lost its function. It always becomes fixed in the extended position. Pain is practically constant. Physical examination showed the relations pictured in Fig. 56. The crest and superior posterior spine of the ilium were above their normal relations. The leg on the injured side was shortened. These five case presented almost exactly the same symptoms. The upward and backward position of the ilium is illustrated in Figs. 58 and 59. The shape of the great sacro- sciatic foramen is changed. Fig. 57 illustrates an upward and forward position of the ilium. The obliquity of the pelvis at the time of the acci- dent has much to do with the direction in which the luxation PRINCIPLES OF OSTEOPATHY. 175 takes place. When the luxation is caused by a severe shock on the posterior surface of the tuber ischii, the ilium is twisted and the superior posterior spine is very prominent, but below the level of the second sacral spine. In one case examined the pa- tient was jolted out of a spring seat and struck on the tire of the wagon wheel. The above described position of the ilium re- sulted. Fie. 60 gives the surface indications. Fig- 59- — Posterior superior spine of the ilium is too prominent. Hypersensitiveness will be found internal to the posterior superior spine of the ilium, center of the crest of the ilium and over the crest of the pubes. Fig. 61 is a drawing from an X-ray photograph of a lux- ated left ilium. Quite a number of cases of luxated ilia have been reported in osteopathic literature. The reports are fa- vorable. We are compelled to report unfavorably on all cases we have seen. This is a serious luxation, and one not easily reduced. None of my cases were examined osteopathically until after a lapse of two years. During these two years move- ment in the hip was lost and the ilia became absolutely fixed. 176 PRINCIPLES OF OSTEOPATHY. Fig. 60. — Posterior superior spine of the ilium is prominent 'and slightly below the second sacral spine. PRINCIPLES OF OSTEOPATHY. 177 In one case sufficient force was us ?d to move the ilium, but it could not be forced into its normal position Pain was greatly relieved in all cases. Sacro-vertebral Articulation —The articulation be tween the sacrum and fifth lumbar is one w Kich is subject to 3 . i | 2 4 4 10 1 10 5 5 11 7 7 5 6 9 9 6 6 . Fig. 6i. — Dislocation of left ilium upward and backward. i, Sacrum; 2, 5th Lumbar Vertebra; 3, 4th Lumbar Vertebra; 4, 4, Illiac Fossae: 5, 5, Head of Femur; 6, 6, Lesser Trochanter of Femur; 7, 7, Pubes; 8, 8, Obturator Fora- men; 9, 9, Tuberosity of Ischium; 10, 10, Greater Sacro-sciatic Foramen; 11, Spine of Ischium. great strain. The thick cartilage between the bodies of these bones allows considerable compression and thereby preserves the articulation from harm. It is not uncommon to find the fifth lumbar forced too far anterior by the obliquity of the sacrum. This articulation seems to be the one principally con- cerned in lordosis of the lumbar region. In connection with this malposition we find pelvic disorders resulting from irri- 178 PRINCIPLES OF OSTEOPATHY. tation of the hypogastric plexus situated on the anterior sur- face of this vertebra. Every individual has his or her particular develop- ment. When examining patients this must be taken into consideration. All subluxations must be judged according to the condition of the reflexes along the nerve tracts which they might influence. Summary. — A subluxation is evidence of unequal ac- tivity of opposing muscles, caused by twist, strain, fall, ther- mal change or reflex irritation from viscera. It is an evidence of vital activity unevenly manifested. The mechanical condi- tion which we call a lesion may be only evidence of a lesion which lies in the excessively active muscle or at some other point in close nervous connection. A subluxation may be called a primary lesion when it re- sults from accident. It is secondary when due to reflex ac- tion. It is not always possible to determine whether a lesion is primary or secondary, but in general it is best to reduce them wherever found if any disturbance can be traced to them. In rare instances one treatment has been found sufficient to reduce a subluxation. The fact that the majority of cases must be treated two or three months proves that they are not easily kept reduced. CHAPTER IX. OSTEOPATHIC CENTERS. Certain points on the surface of the body are spoken of as "Centers." This word has become a part of the osteopath's technical vocabulary. It does not convey to the mind of the osteopath the same meaning which attaches to it when used in physiological text-books. A physiological functional center in the central nervous system is that point where the action of a certain viscus or other structure is governed. An osteopathic center is that point, on the surface of the PRINCIPLES OF OSTEOPATHY. 179 bodx which has been demonstrated to be in closest central con- nection with a physiological center, or over the course of a governing nerve bundle. In Chapter III, under the sub-heading Segmentation, ref- erence is made to the division of the central nervous system into sections which may, to a moderate degree, functionate inde- pendently. No portion of the nervous system ever function- ates absolutely independently. The action of every portion af- fects all other portions, but certain areas in the brain and spinal cord seem to be somewhat set apart to govern or co- ordinate the physiological activity of certain organs. Physi- ology has demonstrated a large number of these centers. "Physiology shows how not only the individual ganglia which lie in the intestines function with relative independence, but how even structures like the spinal ganglia frequently reck- oned in with the central system still enjoy relative indepen- dence from it functionally." "What we know of the anatomical structure and of the functions of the central nervous system of vertebrates forces us more and more to the conclusions (1) that even individual parts of the central system are themselves in a position to function to a certain extent independantly, and (2) that even the brain and spinal cord of vertebrates are composed of a series of centers. Whether the one or the other of these is more highly developed, whether they are in connection with deeper centers, whether they have connections among themselves and with higher centers, determine the measure of the higher or lower development of the central system. We will find later that, in the course of the development of a class, individual centers connected with the central nervous system have reached a high development, while others have arrived at a certain stage (or reached a certain type) where they remain stationary, and throughout all subsequent posterity remain everywhere alike. "One can conceive that in its essentials every nervous system is composed of afferent tracts and efferent tracts, and of tracts which form the connection of the elements among themselves." (Anatomy of the Central Nervous System of Man and of Vertebrates in General. Edinger, page 26.) 180 PRINCIPLES OF OSTEOPATHY. Anatomy and Physiology demonstrate that from a cer- tain segment of the spinal cord nerve fibres are distributed to skin, skeletal muscles, involuntary muscles and mucous membrane of viscera, and to the muscular coats of the arteries supplying all these structures. Physiology and Pathology demonstrate that impressions made upon sensory elements in skin, mucous membrane, mus- cle, or other structures, are carried to a center in the central nervous system. These impressions are co-ordinated in this center, and affect the physiological action of all structures in- nervated from the same center. When we speak of two or more structures being in close central connection, we mean that they are innervated from the same segment of the central nervous system. Diagnosis. — In diagnosis these segments serve the pur- pose of calling the osteopath's attention to the condition of several correlated structures. For example : A hyperesthe- sia at any point along the spinal column fixes the attention of the osteopath upon all the structures of the body which are innervated from the segment of the central nervous system which furnishes nerves for this over-sensitive area. Exami- nation of all the structures thus supplied will probably dis- cover the point chiefly affected. In order to give the student a clear insight into the prin- ciples underlying osteopathic diagnosis, we will examine the osteopathic centers serially, commencing at the atlas. First Four Cervical Nerves. — We will first divide the spinal column into sections according to the location of certain groups of nerves. Remember that these divisions are made with reference to the points of exit of the spinal nerves from the spinal column. The first section contains the first four cervical nerves. The first cervical nerve leaves the spinal canal between the occipital bone and the atlas. A study of its distribution will inform us what structures are governed by it. Its anterior di- vision forms a part of the cervical plexus. This division com- municates with the sympathetic nerves on the vertebral artery, the pneumogastric, the hypoglossal, and superior cervical sym- PRINCIPLES OF OSTEOPATHY. 181 pathetic ganglion. It innervates the Rectus Lateralis and An- terior Recti. The posterior division of the first cervical nerve is called the suboccipital. It supplies motor fibres to the posterior Recti muscles of the head, the Superior and Inferior Oblique, and the Complexus. Sensory fibres from the scalp form part of this nerve. Example of Hilton's Law. — With this outline of dis- tribution before us, we can note some of the results of stim- ulation of this nerve. Since the anterior division supplies a few fibres to the occipito-atlantal articulation, we have an ex- ample of Hilton's law of distribution of a nerve trunk. The synovial membrane of the occipito-atlantal articulation, the muscles which govern movements of the joint, and the skin over the joint are all innervated by this first cervical nerve. The muscles moving the occipito-atlantal articulation act according to impulses reaching the point of origin of the first cervical nerve over sensory fibres ending in the skin covering the back of the head and this articulation, also from those ending in the synovial membrane of the joint. These im- pulses are co-ordinated in higher centers of the brain which govern equilibration. The muscles of this joint act also accord- ing to our will. The Pneumogastric Nerve. — Furthermore, the anterior division of this nerve communicates with the pneumogastric, hypoglossal, and the superior sympathetic ganglion. The pneumogastric has such a wide distribution that we cannot afford to follow all of its paths of influence at this time. The student is referred to any extended work on anatomy for the details. The muscles and mucous membranes of the larynx are innervated by the pneumogastric, hence any irritation of the larynx may reflex impulses to the center of origin of the first cervical nerve and cause undue contraction of the mus- cles innervated by it. This muscular contraction can result in changing the relation of the bones forming the occipito-atlantal articulation until a condition exists which we call a sublux- ation of the atlas. Having followed the impulses from the lar- ynx to the center of co-ordination and out again to the mus- i82 PRINCIPLES OF OSTEOPATHY. cles of the occipito-atlantal articulation with consequent sub- luxation, we may profitably note the fact that sudden temper- ature changes may affect the skin over these muscles, arousing impulses which are carried to the center of co-ordination, thence to the muscles, causing them to contract with result- ing subluxation. Some of the reflex impulses may find their way to the larynx and cause congestion of its mucosa. The atlas may be subluxated by violence, then the sensory impulses originate in the synovial membrane of the joint and in the muscles moving the joint. These impulses may be reflected in such manner as to affect the larynx, pharynx and other structures innervated by the pneumogastric. The reflex in- fluences existing between the first cervical nerves and the pneumogastric are chiefly confined to the larynx and pharynx, because spinal nerves usually receive sympathetic reflexes from the segment of the body which they cover. If we should fol- low all of the divisions of the pneumogastrics, we would find a wonderful diversity of distribution. We do not expect that reflexes from the heart, lungs, stomach, etc., are going to be subject to co-ordination in the area of origin of the first cerv- ical nerve, just because there is communication between the pneumogastric and this nerve. The pharynx and larynx are, in part, structures governed involuntarily, and hence they are in large part removed from the influence of nerves carrying voluntary impulses, i. e., spinal nerves. The pneumogastric is essentially sympathetic in character. The tissues of the lar- ynx and pharynx are practically under the influence of the first cervical nerve. Your attention is called to Hilton's law as he has stated it in relation to mucous and serous surfaces. "This same principle of arrangement, anatomically, physio- logically and pathologically considered, is to be observed, with an equal degree of accuracy in the serous and the mucous mem- branes. Thus considered, it presents a principle which, if it has any application in practice, must be one certainly of large extent." Since the spinal accessory forms part of the pneumo- gastric above the point of communication between that nerve and the first cervical, we can perceive the reason for the great PRINCIPLES OF OSTEOPATHY. 183 influence which temperature changes, affecting the skin over the sterno-cleido-mastoid and trapezius muscles, have on the action of the muscles forming the suboccipital triangles. The spinal accessory innervates the sterno-cleido-mastoid and tra- pezius. These muscles will contract reflexly when the sensory nerves in the skin over them are affected by temperature changes. The action of these muscles affects the position of the head chiefly by causing movement in the occipito-atlantal articulation whose accurate adjustment depends on the mus- cles innervated by the first cervical nerves. The point of origin of the first two cervical nerves is prob- ably a bilateral center. In order to secure co-ordinated move- ments, both sides of this bilateral center must act recipro- cally, but if the impulses coming into the center from one side are much greater in number and intensity than those enter- ing on the opposite side, this reciprocity of action may be in- terfered with and subluxation result. The Hypoglossal Nerve. — The Hypoglossal nerve is the motor nerve to the muscles of the tongue, and to the mus- cles moving the larynx and hyoid bone. It communicates with the first cervical nerve. Movement in the occipito-atlantal ar- ticulation affects the relations of the points of origin and in- sertion of the muscles innervated by the hypoglossal ; there- fore, impulses passing over both nerves are co-ordinated at about the same area. Superior Cervical Ganglion. — Probably the greatest cause for disturbance along the course of the first cervical nerve is the communication with the superior cervical gan- glion and the sympathetic plexus on the vertebral artery. This communication subjects all the structures innervated by the first cervical to reflexes initiated in various areas of the head, neck and brain. The superior cervical sympathetic ganglion has a vaso- constrictor influence over the blood vessels of the head, neck and brain. It is a well known clinical fact that ice applied to the surface of the neck over the occipito-atlantal articulation will cause constriction of the blood vessels of the brain. This constriction is a reflex effect due to the communication of the i84 PRINCIPLES OF OSTEOPATHY. first cervical nerve with the superior cervical sympathetic ganglion. Suboccipital Triangles. — When the first cervical nerve is sensitive to moderate pressure over the suboccipital tri- angles, we may be sure that it is evidence of disturbance of circulation in some part of the head, neck or face. We look for this disturbance in the structures which are subjected to the greatest amount of work, i. e., the eye, pharynx or larynx. The brain, last, because it is not easily fatigued. . Sensitive- ness is nearly always associated with a subluxated atlas, i. e., one is indicative of the other. Whether the subluxation is primary or secondary, it is a source of irritation and must be reduced ; therefore, in prac- tice our treatment is applied primarily to this changed struct- ure. The results of practice prove this to be the best method. Patients rarely complain of sharp neuralgic pain in the area of the suboccipital triangles. A dull ache or tension is the usual subjective symptom. We have described the characteristics of this center with considerable detail in order that the student may understand how thoroughly an accurate knowledge of anatomy and phys- iology enters into the work of the osteopath. Every center must be understood in this same manner. We do not deem it necessary to go into such detail in describing all of the remain- ing centers in order that the student can understand their sig- nificance. In order to make the characteristics of the first cervical nerve stand out prominently, we have described it as though it were individual in its action and reaction. This is not strictly true. Analysis compels us to note ill-defined separations in the nervous system. In order to get a right conception, we must view the first cervical nerve as only one of a group of four cervical nerves which act in harmony. Cervical Plexus. — The first four cervical nerves are in- terwoven to form a plexus. Each distributive branch from this plexus probably contains some communicating fibres from the four primary nerve trunks. Viewing the plexus as a whole, we find that its branches are distributed according to PRINCIPLES OF OSTEOPATHY. 185 Hilton's law. They innervate the skin of the neck as low as the fifth cervical spine posteriorly, then obliquely forward as low as the sterno-clavicular articulation anteriorly, and the acromio-clavicular articulation laterally. The skin of the pos- terior surface of the cranium and the ear receives sensory fibres from this plexus. These' are the gross points to be re- membered concerning cutaneous sensory distribution from this plexus. The muscles under this cutaneous area all receive mo- tor fibres from the first four cervical nerves. Anatomists divide the cervical nerves into anterior and posterior divisions, then describe these separately. This is an artificial division which does not serve any useful purpose for us. It multiplies detail without giving an adequate concep- tion of the real character of the whole nerve. When you study the ultimate distribution of the anterior division of a nerve forming the cervical plexus, do not fail to remember that the ultimate distribution of the posterior division is a part of the same nerve. If the anterior division communicates with a sympathetic ganglion, the posterior division receives impulses from and sends impulses to this ganglion. If the anterior di- vision communicates with the vagus and hypoglossal nerves, the posterior division is a party to this communication, and in all ways benefits or suffers by it according to the number and intensity of the stimuli applied at any point along the course of either nerve. This upper portion of the neck is the most flexible part of the whole spinal column. It is subjected to more changes of temperature and more strains or twists than other portions of the spine. The constant effort to save the head from injury puts a severe tax upon the activity of the muscles moving this portion of the spinal column. Subluxations of the atlas and third cervical are quite frequent. Muscular lesions, contrac- tions, are found here in connection with functional disorders of many kinds located in the brain, eyes, ears, nose, mouth or throat. Almost invariably a relaxation of these contrac- tions will be a necessary step in relieving disorders in the areas named. Intensity of Reflexes. — Individuals differ greatly in 1 86 PRINCIPLES OF OSTEOPATHY. the intensity of their reflexes. Anatomatically considered, the connections between the sympathetic and cerebro-spinal sys- tems are alike in all individuals, but physiologically consid- ered, there is a vast difference in the degree of independent functioning of these systems. Patients will be found whose symptoms and lesions do not show any marked tendency to- ward reflexing impulses from one system to the other. The sympathetic nerve cells may be so vigorous that severe lesions affecting cerebro-spinal nerves do not in the least disturb the rhythm of the sympathetic system. Likewise severe func- tional disturbances may exist in the area of the sympathetic control without causing very definite conscious sensations. The Spinal Accessory. — The sterno-cleido-mastoid and trapezius muscles are innervated by the spinal accessory. This nerve arises from the spinal cord as low as the sixth cervical, therefore, its impulses are co-ordinated with the cervical plexus in the area of its normal control. The Phrenic Nerve — Hiccough. — The phrenic nerve is the motor nerve from the cervical plexus. It innervates the diaphragm. It is formed by branches of the third, fourth and fifth cervical nerves. The position of this nerve in its course along the anterior surface of the scalenus anticus, makes it convenient to apply direct inhibitory pressure over the nerve trunk. This pressure has a restraining influence over the im- pulses traveling to the diaphragm ; therefore, we inhibit to stop hiccough. We have treated cases in which inhibition was of no avail. In such cases a strong movement of the head and first three cervical vertebrae, as a solid lever, to secure rota- tion and relaxation between the third and fourth cervical verte- brae may give good results. Since hiccough is a reflex due to stimulation of sensory nerves, especially the pneumo- gastric, it should not be expected that inhibition of the motor nerve, phrenic, would entirely stop hiccoughs while the sen- sory stimulation is continued. Clinically, we find that inhi- bition of the phrenic nerve is sufficient to stop the ordinary case of hiccoughs. Therefore, we call the area over the course of the phrenic nerve, as it crosses the scalenus anticus muscle PRINCIPLES OF OSTEOPATHY. 187 opposite the fifth cervical transverse process, the "center for hiccoughs.'' See Fig 165 The Trapezius and Splenitis Capitis et Colli Muscles* The cervical plexus communicates with the brachial plexus ; therefore we expect that those large muscles, such as the tra- pezius and splenitis, which are innervated by nerves from seg- ments of the spinal cord, at various levels, will transmit by their action the influence reflexed to them at any point of their serial innervation. The spinal accessory innervates a large part of the cervical fibres of the trapezius. The third and fourth cervical nerves send branches to this muscle. There- fore any distrubance along the course of these nerves, or along the course of other nerves in close central connection with them which may cause abnormal contraction of the trapezius, will influence, more or less, all the points of attachment of that muscle. The trapezius is seldom abnormally contracted. Any lessening in the normal range of its action is quickly noted by the patient. The contractured condition is easily removed by a willed action. We use the trapezius muscle as a means of transmitting power to various portions of the spinal column, i. e., in our efforts to move one or more vertebrae. Vaso-motion, Head, Face and Neck. — The superior cer- vical ganglion communicates with the first four cervical nerves, therefore the area over the spines of the first four cervical ver- tebrae is called a vaso-motor center for the head, face and neck. Affections of the Cervical Nerves. — These upper cer- vical nerves are seldom paralyzed. Paralysis in this region would stop the action of the diaphragm. Neuralgia may af- fect the nerves of this group. Spasmodic contraction of the muscles innervated from this area is not uncommon. Brachial Plexus. — The four lower cervical nerves arise from the cervical enlargement of the cord and form the bra- chial plexus with their anterior divisions, while their posterior divisions supply motor fibres to muscles on the sides and back of the neck, and sensory fibres to the skin over these muscles. The anterior division of the first dorsal nerve forms a part of the brachial plexus. i88 PRINCIPLES OF OSTEOPATHY. Fig. 62. — Surface marking of the brachial plexus. PRINCIPLES OF OSTEOPATHY. 189 Figure 62 illustrates the superficial area in which the reflexes from the skin and muscles of the arm are manifested. Subluxations, or muscular contractions, in this area may af- fect one or more branches of this plexus. Affections of the Brachial Nerves. — Neuralgia, paraly- sis or spasm may affect the area innervated by this group. Cervico-brachial neuralgia is quite common. A lesion will usually be found affecting the painful nerve at its point of exit from the spinal column. Paralysis rarely affects this plexus independently of the nerves leaving the cord at a lower level. Spasm is represented by such a condition as writer's cramp. Lesions causing cramp or neuralgia may be located at the point of exit of the nerve from the spinal column, but the clot or other pressure causing paralysis is usually located in the brain. Paralysis of the brachial plexus is a part of a hem- iplegia ; it does not occur independently of the more general condition. Paralysis of certain groups of muscles of the arm, forearm or hand can usually be traced to the direct injury of individual nerve trunks in the arm. Hemiparesis Below Fifth Cervical Vertebra. — Figures 63, 64 and 65 illustrate the results of pressure upon the spinal cord at a point between the fourth and fifth cervical vertebrae. The child was not very strong at the time of the injury. A slight fall, while playing, subluxated the fifth cervical. No notice was taken of this slight fall. The next day, while bath- ing the child, the mother noted a peculiarity in the position of the shoulder. The arm could not be raised above the head. The author examined this case the day the mother discovered the change in the shoulder. At first glance from the side, it appeared to be a sub-spinous dislocation of the humerus, but palpation disproved this. Careful examination showed a hem- iparesis of the whole left side below the fourth cervical nerve. None of the normal movements were lost, but it required the utmost effort of the patient to make them. Now and then the left toe would strike the floor too soon and slightly trip her. Palpation of the fifth cervical vertebra showed a lateral 190 PRINCIPLES OF OSTEOPATHY. subluxation. The slightest pressure at this point caused the patient to cry out with pain. After our examination (these photographs were taken at that time) the child was taken to a surgeon, who prescribed a surgical operation to stitch the latissimus dorsi to its proper Fig. 63. — Front view of case of unilateral paresis. position on the lower angle of the scapula. He did not recog- nize the paretic condition of the whole left side. After a short time, the child was brought to us for treatment. Our sole effort was to reduce the subluxation of the fifth cervical vertebra. The tenderness was so great that this was mani- festly out of the range of possibilities with a delicate child. PRINCIPLES OF OSTEOPATHY. 191 After two weeks of relaxing around this articulation a di- rect movement was made to reduce the subluxation. The alignment was perfected, but no immediate good results were noted. A continued increase in nerve power has gradually, in large measure, overcome the deformity. Subluxation of the Scapula. — The deformity is the ef- fect of uneven contraction of muscles. The latissimus dorsi, Fig. 64. — Side view of case of unilateral paresis. rhomboids and serratus magnus are weakened while the le- vator anguli scapuli and cervical fibres of the trapezius are contracting with their customary power. The muscles inner- vated by nerves from above the lesion are acting normally, but their action is not resisted. This results in subluxation of the scapula. The Nerve of Wrisberg. — A division of the first dor- sal nerve forms the first intercostal nerve. The inner and 192 PRINCIPLES OF OSTEOPATHY. back side of the arm receive cutaneous branches from the first dorsal nerve. There is communication between the cutaneous nerves to this area and the second intercostal nerve by means of the nerve of Wrisberg, hence pain is frequently felt along Fig.. 6s. — Rear view of case of unilateral paresis. the inner surface of the arm in cases of heart trouble, inter- costal neuralgia in the second space, or pleurisy. The Interscapular Region. — The division of the spinal column between the first and seventh dorsal vertebrae is com- monly called the interscapular region. It is an exceedingly important one. It is sometimes called the pulmonary region, because it is the area from which the lungs derive many nerves, Sensory impulses from the lungs are co-ordinated in this area. PRINCIPLES OF OSTEOPATHY. 193 Fig. 66. — Anterior surface markings of the lungs. Figure 66 illustrates the anterior surface outline of the lungs, while Fig. 67 shows the outline on the posterior sur- face of the thorax. These markings were made on the surface according to physical methods of diagnosis. They represent the average position of the lungs in a healthy man. 194 PRINCIPLES OF OSTEOPATHY. Fig. 67. — Posterior surface markings of the lungs. Lung Center. — Figure 68 illustrates the lung center within which sensory impulses from the lungs are co-ordi- nated. A large proportion of cases of bronchitis, pulmonitis or pleuritis of either the simple or bacterial types, are accom- PRINCIPLES OF OSTEOPATHY. 195 panied by great sensitiveness in this area. This sensitiveness is in the contracted muscles or, when the shape of the thorax is- greatly changed, at the angles of the ribs. Subluxations of ribs or vertebrae in this area are sometimes found in con- nection with the inflammations above named. Whether they are the cause or the effect of the inflammation can only be told by the history. Because the two conditions, that is, inflam- mation in the thoracic viscera and osseous subluxation, exist at the same time is no reason for saying that the subluxation is necessarily the cause of the inflammation. That is a mere dogmatic assertion which lacks scientific proof. The condi- tion might be just the opposite. We do not desire to confuse our readers in the least, but it should be remembered that before making a dogmatic statement such as "disease is the result of anatomical abnormalities followed by physiological discord," we should be certain that our statement is not based on a series of selected coincidences. The old saw : "It's a poor rule that does not work both ways," is decidedly applicable to nerve reflexes. Cilio-spinal Center. — Tenderness in this area is not necessarily indicative of physiological disturbance in any tho- racic viscus. Fig. 69 indicates two centers. The one be- tween the second and third dorsal is called the cilio-spinal center. Detail concerning this center will be found in the chapter on The Sympathetic Nervous System. The fact that the vaso-constrictor fibres to the cervical sympathetic ganglia leave the spinal cord below the second dorsal vertebra show that some reflexes from the head, face and neck may be co-ordinated in the interscapular region. Heart Center. — The point between the fourth and fifth dorsal spines is noted as a heart center. We have not found any text-book authority for this statement. Clinical experi- ence leads the author to locate a heart center at this point. What the absolute influence of this center is we do not know. From observation of cases of angina pectoris it appears to be a sensory and vaso-motor center for the heart. Stimulation of this center by a quick percussion stroke of the fingers will bring on an immediate attack of pain in the heart, blueness 196 PRINCIPLES OF OSTEOPATHY. 68. — The lung- center. of lips and finger tips. Heavy digital pressure at this point re- lieves the pain. Steady extension of the whole spinal column does not stimulate such cases, but as the pull is reduced and the vertebrae are drawn closer together, this point is fre- PRINCIPLES OF OSTEOPATHY. 97 Fig. 69. — Cilio-spinal and heart centers. quently stimulated. In order to avoid an attack after exten- sion, it is necessary to lessen the force of the pull very gradually and evenly. 198 PRINCIPLES OF OSTEOPATHY. Fig. -Surface outline of the heart. Fig. 70 illustrates the surface markings of the heart. This organ has three centers. (1) The pneumogastric nerve exerts an inhibitory influence. This nerve can be stimulated in the neck. See Fig. 166. (2) The accelerator center in- PRINCIPLES OF OSTEOPATHY. 199 Fig. 71. — Surface outline of the stomach. eludes second, third and fourth dorsal. See Chapter VI on the Sympathetic Nervous System. (3) Vaso-motor and sen- sory center is found between fourth and fifth dorsal. PRINCIPLES OF OSTEOPATHY. Fig. J2. — The stomach center. Stomach Center. — The surface outline of the stomach is given in Fig. 71 while its reflex surface center on the back is indicated in Fig. J2. This center lies wholly within the pulmonary area, therefore it will be readily noted that there PRINCIPLES OF OSTEOPATHY. Fig. 72. — The splanchnic area. is opportunity for much careful reasoning in order to deter- mine whether a lesion between the first and seventh dorsal vertebrae is connected with disturbance of the lungs, pleura, heart, eves or stomach. Clinically, we distinguish somewhat PRINCIPLES OF OSTEOPATHY. Fig. -Posterior view of a case of leukemia. as follows : A lesion covering a large part of this area is probably pulmonary. A lesion in the lower half and extending below the seventh spine is probably gastric in character. When the lesion is at the third or fourth and decidedly lim- ited i. e., the tenderness is sharply circumscribed in this area, it is impossible to tell, except by further examination of the heart, bronchi and eyes, to which it belongs. The experienced diagnostician can frequently estimate the probable relation of a lesion by his power of reading the signs of disease as evi- denced by expression, posture and general indications. PRINCIPLES OF OS TEOPA TH Y. 203 Fig' 75- — Posterior surface outline of the liver and spleen with their centers indicated. The splanchnic area is a large and important one. It is indicated in Fig. 73. We have noted in this photograph the upper connections of the splanchnic nerves in the pulmonary area. This explains the high position occupied by some re- 204 PRINCIPLES OF OSTEOPATHY. J Fig. 76. — Side view of case of leukemia. flexes from the first part of the gastro-intestinal tract. Won- derful influences can be secured in this area, over circulation in the abdominal viscera. The physiological actions gov- erned from this area are described on page 125. (See Great Splanchnics under the Sympathetic Nervous Svstem, Chapter VI.) Leukemia. — To illustrate the osteopathic view of the effect of osseous disorder on the functional activity of viscera, we present a series of three photographs, Figs. 74, PRINCIPLES OF OSTEOPATHY. 205 Fig. yy. — Anterior view of case of leukemia. j6 and JJ, of a case of leukemia showing the condition of the spine in the splenic area. The marked limited kyphosis in connection with the enlargement of the spleen is a striking example of the relation existing between a viscus and its center. This case has been in our clinic only a short time, two weeks, therefore we cannot tell what the effect of the treatment will be. It is an extreme case. The blood exam- ination shows thirty per cent of hemoglobin. The number of 2C6 PRINCIPLES OF OSTEOPATHY Fig. 78. — Anterior surface outline of the liver and large intestines. white blood corpuscles is 448,000 to the cubic centimeter, that is, about forty-four times the usual number. The treatment is being limited to the spinal area involved. Thus far the patient notes cessation of all pain. PRINCIPLES OF OSTEOPATHY. 207 Fig. 79. — Center for large intestine. The arrow marks point of close connection of cerebro-spinal nerves with the hypogastric plexus. Liver and Spleen Center. — The liver and spleen receive their sensory and vaso-motor innervation from the eighth, ninth and tenth dorsal nerves. The surface markings and 208 PRINCIPLES OF OSTEOPATHY. Fig. 80. — 'Center for chills. center are indicated by Fig. 75. The liver frequently reflexes its disturbed sensory influences to the right shoulder. We have noted cases of gastric disorder or enlarged spleen which reflexed sensory impressions to the left shoulder. Large Intestine. — Fig. 78 pictures the surface mark- ings of the liver and large intestine. These average normal outlines should be thoroughly remembered and used when PRINCIPLES OP OS PROP A PH Y. 209 Fig. 81. — Center for the gall bladder. making a physical examination. The spinal center of the large intestine is indicated by Fig. 79. Small Intestine. — The first portion of the small intes- tine, duodenum, is innervated from about the same area as 2TO PRINCIPLES OF OSTEOPATHY. Fig. 82. — Center for the ovaries. Reflexes from the ovaries may follow the ovarian plexus to the aortic and reach the cerebro-spinal system at this point. This is true for the testes also. the liver. Fig. 80. It must be borne in mind that the splanchnic area is a large one and comprehends these smaller centers. Many of these points indicated as centers are the PRINCIPLES OF OSTEOPATHY. Fig. 83. — Posterior surface outline of the kidneys. areas which clinical experience has noted in connection with visceral disturbance. The repeated experience of many cases gives them value for diagnostic and therapeutic purposes. PRINCIPLES OF OSTEOPATHY. Fig. 84. — End of the spinal ccrd. Physiological center for parturition, defection and micturition. Center for Chills. — Within the area indicated by Fig. 80, there is a center usually described as the eighth dorsal, which has received the name of "the center for chills." Our first observation of the action of this center was in connection PRINCIPLES OF OSTEOPATHY. 213 with a case of malarial fever. Heavy inhibition of this area lessened the severity of the chill. By following this method from day to day, at the time of the onset of the chill, this case was cured. Another case treated at the same time did not respond to this line of treatment, i. e., the cure could not be attributed to this one mode of treatment. Even in this case, the inhibition gave relief. We have observed the effects of in- hibition of this center in many cases of chill due to nervous- ness, onset of La Grippe or othe» infectious diseases, and to abscess formation. In all cases the treatment was dis- tinctly helpful to the patient. The Language of Pain. — Homeopathic medical prac- tice notes variations in the character of pain, and uses these characteristics as indications for the administration of special drugs, as though a nerve fibre expressed a language of pain. To the osteopathic physician, it is sufficient that a nerve ex- press a disturbance at some point of its course. This cry of the nerves calls for just one thing, remove the cause. Search is made for this cause along its entire course, and the course of its connections. Osteopathic View of Pathology. — Another particular in which the osteopathic pathology differs from other schools of medicine is in the way we view varying conditions of a viscus. To the medical practictioner, simple gastritis is a vastly different condition from gastric ulcer. To the mind of the osteopath, these conditions differ in degree not in kind. The same organ, the same blood supply, the same nerves are involved in both conditions, therefore we treat these struc- tures. Our dietetic treatment takes account of the differing activity of the stomach, but our manipulative treatment does not. We apply this same method to all organs. Our manipu- lative therapeutics are based on structure more than on func- tion. Center for Gall Bladder. — The gall bladder lies under the anterior extremity of the tenth rib. In cases of gall stone the area of the tenth dorsal spine has been found to be sensitive. All of the structural and functional changes con- 214 PRINCIPLES OF OSTEOPATHY. nected with gall stones have seemed to center at this area, and along the tenth rib. Fig 81 indicates the center for the gall bladder at the spine. A Case Report. — Qn October 20th, 1900. a patient was brought to the free clinic of the Pacific School of Osteopathy for our examination. "The ordinary questions as to history, symptoms, etc., were not asked until a thorough physical ex- amination had been made. The general appearance of the patient was of one greatly emaciated by long illness. There was considerable sensitiveness at several points along the spinal column, but no apparent mal-position of vertebrae. Pressure on a level with the head of the tenth rib, right side, caused a painful sensation along the entire course of the tenth intercostal nerve ; therefore our attention was called to that particular area. The tenth rib was found to be twisted and depressed, so that the upper edge of the eleventh rib pressed into the groove on the lower border of the tenth, which ordinarily protects the tenth intercostal nerve. Thus there was a constant irritation of that nerve. This irritation was reflexed to the spinal cord and thence over the splanchnic nerve to the gall bladder, liver, stomach and spleen. The history of the case, physical examination and afterward the examination of the gall stones left no doubt as to this wo- man's trouble. The cause of the gall stones was the irrita- tion of the tenth intercostal nerve caused by the slight dis- placement of the tenth rib." "Owing to the length of time this irritation had existed, the whole sympathetic system seemed to be excited. Stimu- lation of the pneumogastric nerve caused the patient to become unconscious — inhibited the heart — hence the treatment admin- istered was to raise the ribs, replace the tenth, inhibit reflexes, and direct manipulation over the gall bladder. " "The fact that the treatment, as directed, acted imme- diately, shows that it was logical and scientific." "We have no doubt there are other causes of gall stones, but this is something new to be added to the etiology of the disease. It does even more than establish a new etiological factor, it helps to establish the claim of the osteopath to a dis- PRINCIPLES OF OSTEOPATHY. 215 tinctive pathology, and a system of therapeutics based on anatomy and physiology." — Vol. IV, page 174, The Osteo- path. Intestines. — The small intestines are governed from the lower part of the splanchnic area, ninth, tenth, eleventh and twelfth dorsal. The large intestine is controlled by nerves from the lumbar region. There is a segmental distribution of these nerves to the large and small intestines. This seg- mental arrangement is exemplified in cases of diarrhoea. If the large intestine is the part affected, our manipulation is devoted to the lumbar region. Reflexes from the bowels may be found at any point between the ninth dorsal and the fourth sacral. In five consecutives cases of appendicitis, the reflex was located at the third and fourth lumbar spines. Fig. 79 indi- cates the area concerned in reflexes from the large intestine. Uterus. — The position of the arrow in Fig. 79 indi- cates the point of apparently close connection between the hpyogastric plexus and the cerebro-spinal system. This point is frequently the seat of great tenderness which is entirely reflex in character. All of the pelvic viscera at times send reflexes here. The uterus more than any other pelvic organ manifests its disturbed condition by tenderness at this point. The uterus is such a changeable organ that it is the chief disturber of sympathetic rhythm in a woman's body. A change in its position causes a change in its blood supply fol- lowed by congestion of its mucosa. This congested condition sets up a series of impulses in the sympathetic system which may never reach the cerebro-spinal system. They spend their force on the various organs governed by the sympathetic nerv- ous system, the heart, stomach, bowels, etc. Fig. 87 illus- trates the difference in the hearths rhythm in the same patient. The first sphygmogram was taken while the patient had con- siderable difficulty in moving about on account of the heart's very irregular action. The uterus is prolapsed. Patient has worn a stem pessary for years. When the patient takes the genu-pectoral position and inhales strongly, while pulling up- ward on the abdominal muscles there is great relief, but when 2l6 PRINCIPLES OF OSTEOPATHY. Fig. 85. — Areas of the lumbar and sacral plexuses. the heart becomes as irregular as this sphymogram indicates, she is afraid to take this position. After twenty-four to seventy-two hours' of irregular action, the heart regains its rhythm. The position of the uterus becomes changed by the PRINCIPLES OF OSTEOPATHY. 217 moving of the patient in bed. The perineum is badly torn and the uterine ligaments are greatly lengthened, hence the organ cannot be kept in one position. She has refused opera- tion. Many different points are named as centers for the uterus, but they all rest on the fact that after the organ has initiated a large number of impulses in the sympathetic system, they may be passed to the cerebro-spinal system at any point of union of the two systems. Ovary and Testes. — These organs receive their sym- pathetic innervation from the plexus which lies on their arteries. The ovarian plexus is given off from the aortic plexus which receives fibres from as high as the eleventh and twelfth dorsal ganglia. Therefore a lesion in the area of the eleventh and twelfth spinal nerves is frequently in connection with the ovaries or testes. Fig. 82 indicates the height of the influence of the aortic plexus through its direct connection with the cerebro-spinal system. Kidneys. — Fig. 83 indicates the surface marking of the kidneys and the junction of the last dorsal and first lumbar vertebrae. Lesions of either the eleventh or twelfth dorsal may affect the kidneys. The reflexes of this organ may reach the cerebro-spinal system over the renal splanchnic. The articulation of the last dorsal and first lumbar allows considerable movement. It is probably the weakest part of the back. The area of the twelfth dorsal nerve is usually sensitive when the kidneys are affected. This sensitiveness may extend a short way upward, as far as the tenth dorsal. In patients whose abdomen is moderately thin, it is pos- sible to affect the renal sympathetic plexus by deep manipu- lation above the umbilicus. The kidneys lie above the level of the umbilicus. Have the patient lie in the dorsal position with flexed thighs so as to relax the abdominal muscles. The balls of the fingers of both hands should be pressed deeply into the abdomen about two inches above the umbilicus, then move the fingers laterally toward the kidneys. Pressure is thus brought to bear upon the renal artery. The mechanical 218 PRINCIPLES OF OSTEOPATHY. stimulation of the renal plexus usually results in vasoconstric- tion of renal arteries. Second Lumbar. — The lumbar enlargement of the spinal cord is the physiological center for several functions performed in the pelvis. Defecation, micturition, and partu- rition, are all reflexly controlled at this point, second lumbar. The spinal cord ends at the lower border of the first lumbar vertebra. The second lumbar vertebra is indicated in osteo- pathic literature as a center for the three functions named above. We understand by this that an injury at this point may involve the functional activity of the rectum, bladder, or uterus. Disturbances in these viscera are not necessarily man- ifested to the osteopath by tenderness around the second lum- bar vertebra. Any point along the spinal column below the second lumbar may be sensitive as a result of disturbance in the pelvic viscera. Fig. 84. During parturition there is conscious aching along the whole lumbar area, thus demonstrating that the sensory nerves of the uterus can reflex their irritation to all the lumbar nerves. Injury of the spinal column at the junction of the dorsal and lumbar portions may affect motion, sensation and nutrition of all the structures innervated by the cauda equina. An injury below the second lumbar vertebra will not have as far-reaching effect as an injury of the same character above that point. Paraplegia. — When the back is broken at the dorso- lumbar articulation, paraplegia results. It is not necessary to actually break the back in order to cause paraplegia. A se- vere strain, caused by a fall may induce such an exudate around this articulation that pressure is exerted on the lumbar en- largement of the cord. Many of the so-called broken backs, which are spoken of as causative of paralegia, are not broken at all, but the ligaments are badly sprained. The same con- dition exists here as in other sprained joints. There may be marked kyphosis, but this does not necessarily indicate dis- location. The paraplegic condition may be perpetuated by the pressure of connective tissue formed in the repair of the injury. This is especially liable to follow if some form of PRINCIPLES OF OSTEOPATHY. 219 Fig. 86. — Center for the bladder. manipulative treatment is not persisted in for from one to three years. The author has fortunately been able to observe the slow regeneration of nerve tissue following complete para- plegia as a result of injury of the dorso-lumbar articulation. 220 PRINCIPLES OF OSTEOPATHY. This case has been observed by us during nearly four years. During all of this time, she has received osteopathic treatment. This method of treatment was not begun until ten months after the accident, therefore, synovial adhesions had formed to such an extent in the joints of the limbs that much painful manipu- lation of these joints has been necessary. Following the accident, there was motor and sensory paralysis of the extremities, bladder and rectum. Control of the bladder and rectum returned after two months' of osteo- pathic treatment. Sensation and motion have returned to the extremities. There is deformity as a result of the adhesions formed during the ten months previous to the first osteopathic manipulation. The patient had been massaged during the ten months mentioned. Lumbar and Sacral Plexuses. — From the nerves of the cauda equina are formed two large plexuses, the lumbar and sacral, indicated in Fig. 85. The branches of these plexuses innervate the muscles of the lower extremities. The spinal area from which these plexuses receive their fibres should be carefully examined whenever any difficulty of movement or sensation in the lower extremities is presented. The student should learn the sensory and motor distri- bution of each branch of these plexuses, so that peripheral disturbance can be immediately associated with the point of emergence, from the spinal column, of the affected nerve or nerves. The Bladder. — Fig. 86 indicates the superficial area in which reflexes from the bladder are most frequently found. The sensory fibres to the bladder are found in the first, second, third and fourth sacral nerves. The first to third give the strongest evidence of sensory disturbance. When the mucous lining of the bladder is congested, these sensory nerves are stimulated. Motor fibres to the bladder are found in the sec- ond and third sacral nerves. The stimulation of the sensory nerves results in reflex stimulation of the motor nerves, which cause contraction of the muscular tissue of the bladder. In- flammation of the bladder is accompanied by almost continuous desire to micturate. PRINCIPLES OF OSTEOPATHY. 221 The sacral spinal nerves take a more direct and unin- terrupted course to the pelvic viscera than do nerves from other portions of the spinal column to their respective areas of distribution. Inhibitory pressure over the sacral foramina has a very marked effect on the sensory nerves of the bladder. This pressure does not directly affect the anterior divisions of the sacral nerves, nevertheless the effect is the same as though the anterior divisions were subjected to the inhibitory pressure. Jrfs^U^t^ <*«* *■ Uttrt^ njLxcs. M Aj.Ur i-nhHritt'o-n /^-k*^ t :*t J*****'. * : l Sa-rrre «-*».«e odlZr wt,jUxc% ^f.a~**J- **"t -*A* >*••*!#* •} tPt+lrr "^N J^^J^^J ^J ^J ^^J^— J ■~o Fig. 87. — Sphygmograms illustrating the effect of uterine reflexes on the heart. This is evidence of the close harmony between the two di- visions of a spinal nerve. The inhibitory pressure not only lessens conscious pain in the bladder, but also changes the vaso-motor conditions. In this respect it much resembles the action of heat applied to the surface. Sphincter Vaginae. — The sphincters of the vagina and rectum are controlled from the area of the third and fourth sacral nerves. When the vulva, vagina or rectum are highly sensitive, we usually find a hyperaesthetic area at the third and fourth sacral spines. When this area is sensitive, the point where the pudic nerve crosses the ischiatic spine is also decidedly sensitive to pressure. Fig. 88 indicates the super- ficial relation of the pudic nerve. This nerve is sensory and motor to the skin and muscles of the perineum. This point will be found sensitive when the prostate is enlarged ; in fact, almost any disorder of the male sexual organism is accompa- nied bv this sensitive condition. PRINCIPLES OF OSTEOPATHY. Fig. 88. — Surface marking of the pudic nerve. Inhibitory movements over the back of the sacrum and ischiatic spine will result in relaxation of the perineal muscles. It affects spasmodic stricture of the urethra in a wonderful PRINCIPLES OF OSTEOPATHY. 223 manner. The local anaesthetic effect of inhibition is not so easily demonstrated in any other portion of the body as in this sacral area. When the uterus is turned either backward or forward, or prolapsed there are impulses aroused in sensory nerve fibres in the rectum or bladder. These impulses are reflexed to the sacral area, while those aroused in the uterus pass to higher points in the spinal column. Inhibition of this sacral area will have a temporary effect. The only treatment worth while is the correcting of the position of the uterus. Conclusions. — There are many more so-called "centers" mentioned by osteopathic writers. We have not attempted to even recapitulate those other centers which seem to us to be quite too fanciful for practical use. The centers mentioned in this chapter are those which can be demonstrated in daily practice, and hence are used continually, both as guides for diagnosis and as indications for the application of manipula- tive therapeutics. No sympathetic spinal centers for "sensa- tion," "motion" or "nutrition" can be demonstrated. These are characteristics of nerve fibres in general, and it is entirely misleading to limit these characteristics to any one portion of the spinal column. Every osteopathic center should be capable of demonstration anatomically, physiologically and clinically. Only those which can pass this test satisfactorily are worthy of our consideration. CHAPTER X. THE GERM THEORY OF DISEASE. The germ theory of the causation of disease has been so positively and persistently advocated, during the past decade, that any theory which is promulgated contrary to the popular view must, necessarily, have a foundation which is capable of withstanding the assaults of specific bacteriologists. A large proportion of the data used to support the germ theorv of disease mav be utilized to show that the final thera- 224 PRINCIPLES OF OSTEOPATHY. peutic methods necessary to combat bacterial diseases are essentially osteopathic, i. e., natural. Even those who have devoted their lives to the investi- gation of the life and activity of bacteria do not agree in their conclusions after observing the same phenomena. This is an evidence that bacteriology has not passed beyond the stage of historical tabulation. The amount of work done and the de- votion of the workers speak well for the scientific spirit of in- vestigation which has characterized the progress of this theory. The irony of it all is the fact that with the heaping of fact upon fact, and experience upon experience, it all proves that when we eat wholesome, nutritious food, in proper amount, labor sufficiently to promote a good circulation, sleep about one-third of the time, wear clothing which does not hamper cutaneous respiration, drink clean water and reside in well drained localities, we have those conditions which are condu- cive to a healthy life. This much we knew before, but we didn't know it scientifically. Specific Causes — Then, too, bacteriology appeals to the human instinct to attribute diseased conditions to some specific thing. In times gone by, disease has been ascribed to all sorts of mythical spirits, cabalistic signs, God's punish- ment, etc. Bacteriology is in direct line of descent from these conceptions. You will note by referring to Chapter II of this book that we have taken the broad view — essentially monistic of the cause of disease. The osteopath cannot view disease from any other standpoint. We must not substitute subluxations or muscular contraction for bacteria as the cause of disease. If we make this substitution, we are open to as much criticism as the specific bacteriologist. Bacteriology as it stands today is the result of the study into the causes of spontaneous germination, fermentation and decay, and the origin of disease. Bacteria are plants of the lowest group. Bacteriology includes now, not only the study of these low forms of plant life, but also some low forms of animal life. Bacteriologists have from time to time, classified these 13 PRINCIPLES OF OSTEOPATHY. 225 bacteria into groups according to form, method of forming spores, etc. These groups are much disturbed by the way in which the members change when grown in different media. Conditions which Affect Life. — The first fact of great importance to us is that bacteria, like other forms of plant life, are greatly affected for their good or ill by their relations with other forms of energy, light, temperature, etc. It is as a result of experiment to determine the conditions best suited for life and growth of bacteria that we now understand pro- cesses of sterilization, disinfection, and the use of antiseptics. We have learned to destroy or modify the life of bacteria. The next great fact is that the human body is a con- stantly changing collection of cells whose molecular constitu- tion is also varying from day to day and hour to hour. The human body is a reservoir of energy with which bacteria come in contact. If the resistance of the body is sufficiently strong, the bacteria are either killed or reduced in power. The re- sistance of the human body is changed for good or ill ac- cording to its relations to other forms of energy, such as food, sunlight, etc. Resistance. — We find that the intensity of the life of bacteria and the human body are modified by their food supply and their environment. This being true, we are principally concerned with knowing what conditions are most detrimental to the life and growth of bacteria and the most exalting to the general resistance of the body. This is the scientific basis of hygiene. The human body possesses certain powers which are cap- able of combating bacteria. These protective powers have been recognized and analyzed by bacteriologists. We wish to call attention to the fact that Dr. A. T. Still stated, years ago, the physiological axiom that a perfect cir- culation of blood is requisite for health, recognizing, of course, that the blood must contain the proper food elements for the nourishment of the tissues. Immunity. — Bacteriological researches have demon- strated this statement to be true. We will note some of the means whereby the body protects itself from bacteria. The 226 PRINCIPLES OF OSTEOPATHY'. term immunity is applied to that condition of the body which exists when specific resistance to bacteria is exhibited. Hankins' definition of immunity is as follows : "Immunity, whether natural or acquired, is due to the presence of sub- stances which are formed by the metabolism of the animal rather than that of the microbe, and which has the power of destroying the microbes against which immunity is possible or the products on which their pathogenic action depends." In other words, immunity exists when tissue resistance is strong. Immunity is a quality of the body not of the bacteria. Immunity is sometimes inherited, a racial peculiarity, or is ac- quired by having the disease. It is claimed for vaccine virus that by causing the simple condition of vaccinia, the body resistance to smallpox is enhanced. Considerable work has been done along this line, but it cannot be said to be suc- cessful. It is an illogical and dangerous method of building up body resistance. Vaccination has a big task to prove an alibi in connection with many constitutional conditions fol- lowing hard after it. We quote as follows from Nancrede's Principles of Sur- gery, page 66 : "Observers have extracted certain substances — 'defensive proteids' — from the livers and spleens of ani- mals, capable of destroying bacteria. These are never found in normal blood ; but when the febrile state has supervened, these substances in active state are detectable in the circu- lating blood. Blood serum is well known to be germicidal in virtue of the nucleinic acid it contains, dissolved out of or resulting from the disintegration of the Phagocytic leucocytes." The relative immunity of certain races to the attack of certain diseases, for example, immunity of the negro to yellow fever, may prove that there is such a condition as inherited immunity, or it may simply demonstrate that the anapholes does not enjoy the taste of the negro's cutaneous excretions, and therefore does not prey upon him. Some persons resist the attacks of bacteria for a long time, but finally yield. This condition has been explained by the results of experiments made on animals. An animal which is known to be immune to a definite bacterium, if fed on such PRINCIPLES OF OSTEOPATHY. 227 food as will radically change the condition of its blood will lose its immunity. Fatigue will also destroy immunity. Dur- ing and for some time after fatigue the products of metabolism clog the tissues, not only obstructing lymphatic circulation, but depressing the activity of the tissues, thereby lessening the general circulation and loading the blood with waste material. Hence, as a result of these experiments it is determined that immunity depends upon a perfect circulation of blood, i. e., blood containing proper food for the tissues. Nancrede writes : "The tissues then can only maintain their normal re- sistance by having an abundant blood supply; but this must move at a normal rate, in vessels of a certain calibre — although these conditions may vary within somewhat wide limits — oth- erwise germs will, for purely physical reasons accumulate in overwhelming numbers. Still further, if this blood does not move at a proper rate, it will not promptly carry away the poisonous products of cell metabolism, which will otherwise directly injure the cells. Again this poison laden, because sluggishly moving blood may incite the tissue cells to abnormal metabolism productive of toxic substances, even in the ab- sence of germs, which when absorbed will produce most seri- ous constitutional effects." Since it is clearly recognized that hyperaemia lessens the resisting power of the engorged tissue, we can readily under- stand how hyperaemia of the intestinal tract opens the road to general infection of the body, or how the resisting power of any exposed structure, such as the lung will be lessened. Therefore, if we can lessen the calibre of blood vessels through the medium of vaso-motor nerves, the rapidity of the blood current will be increased and the resisting power of the tissues restored. The phagocytic action of some luecocytes and fixed endo- thelial cells serves as a protection to the body. These phago- cytes have the power to encapsulate a bacterium or spore and even in death set free nucleinic acid which is antiseptic . Besides this power of a certain class of blood corpuscles to rid the system of bacteria, the liver, spleen, kidneys ancY intestines are active agents in eliminating germs from the 228 PRIXCIPLES OF OSTEOPATHY. body. This indicates to us that we may assist nature in over- coming bacteria by removing obstructions to the circulation, and by stimulating the eliminating organs of the body. It is a well-known fact that one attack of certain germ diseases gives comparative immunity to the individual as far as future attacks of the same bacteria are concerned. It is on this fact that vaccination is based. It is true that an attack of typhoid fever gives a degree of immunity to future attacks ■a; S* | > ; - i - <& v 1 Fig. 89. — Tubercle bacilli in sputum. Photomicrograph made by J. O. Hunt, D. O. of the typhoid bacilli, but it also gives susceptibility to the attacks of some other bacilli, i. e., the cells learn to resist typhoid bacilli, but not tubercle bacilli, hence if we depend upon immunity acquired by having a disease, or by innocu- lation, we may be immune only in a special way not strength- ened in general tissue resistance. Specific Treatment. — Physicians of all schools of prac- tice have been imbued with the idea that specific treatment is the logical sequence of the discovery of bacteria. On this basis intestinal antiseptics were recommended for typhoid PRINCIPLES OF OSTEOPATHY. 229 fever, and diphtheria antitoxin for diphtheria. The antiseptic treatment for typhoid fever has proved decidedly unsatisfac- tory. Drug medication aims to stimulate cell resistance. This method has proved unsatisfactory, although the object aimed at is the right one. The simple hydriatic measures em- ployed by the early empirical hydropaths were so eminently successful that water is now recognized as the best means of stimulating cell resistance. Under this method the death rate of typhoid fever has been reduced to two or three per cent. Diphtheria is the best example of the bacteriologist's spe- cific methods of treatment. It is a well recognized fact that one attack of this disease does not confer immunity. Dr. Fer- dinand Hueppe, Professor of Hygiene in the University of Prague, a bacteriologist, who has developed from that hot- bed of bacteriologists, the Prussian Army Medical Depart- ment, writes as follows in his work on the Principles of Bac- teriology: "Favorable specific effects, such as an immunity against living parasites and an habituation to their poisons, are often deceptive, if we fail to consider sufficiently the method of introduction or innoculation. A state of protection by way of the skin may be present in cases where immunity does not exist at all to infection by way of the blood or brain ; it may be present for one side of the body or for one extremity and be lacking in other organs. If this fact is for- gotten then it may appear as if the influence of the body fluids were pre-eminent, but in reality the last word rests with the body cells. On this basis Schleich has very happily attempted to explain why diseases like diphtheria, that start from the membrane of the throat, or that start in the lungs, like pneu- monia and influenza, or from the intestines, like cholera, con- fer upon the organism little or no immunity from another at- tack; it is because large tracts of cells remain exempt from the effects of the first invasion and therefore acquire no protec- tion. It seems as if, perhaps, toxic properties did not exist when in reality toxic manifestations are prevented only by chance. The alleged non-poisonous diphtheria serum itself, when introduced into the derma shows a toxic action which 230 PRINCIPLES OF OSTEOPATHY. manifests itself in pains and in swelling of the joints and in the form of peculiar and obstinate skin affections at times like those of scarlet fever or measles, as well as in bleeding, kid- ney inflammation and paralysis, and it is very doubtful whether the list of possible injuries is yet exhausted, for perhaps other mischievous effects may come to light with other methods of use. Occasionally marked degeneration of heart, kidney and liver are witnessed immediately after the injection of the diph- theria serum ; and this fact shows clearly that in the use of this antitoxin a danger exists of the same character as that displayed in Buschke's experience with the tetanus serum. If the action of the serum were simply antitoxic, danger of this kind ought to be impossible. We have a paradox of an anti- toxin producing a toxic effect. According to Emmerich, ani- mals that have been treated with diptheria serum afterwards succumb more easily to an infection with Staphylococci and Streptococci, a fact that points also to the poisonous action of the antitoxin upon the tissues. In man an acute outbreak of tuberculosis has been more than once observed to follow a serum injection." Several specific methods of treating so-called germ dis- eases have flashed on the horizon of medicine, but thus far none have proved generally successful, at least, the cures at- tributed to them are not lifted out of the realm of coinci- dence. As long as the fact exists that many cases of diphtheria get well under osteopathic treatment, which is addressed pri- marily to increasing tissue resistance by maintaining a perfect circulation of blood, we are justified in using the manipulatory method, which is free from the dangers attendant on the ad- ministration of antitoxin. Summary. — We have tried to show in this very gen- eral chapter on germ diseases that, (i) both bacteria and the human body, being living organisms, the intensity of life is modified by their food and their environment; (2) bacteria can be reduced in strength or killed by heat or chemicals ; (3) when the bacteria are in the body, the use of chemicals cannot be specific, because the body cells may be adversely PRINCIPLES OF OSTEOPATHY. 231 affected as well as the bacteria ; (4) serum-therapy is not specific because it also is not without danger to the body cells; (5) the resistance of the body cells increases under the influence of favorable food and environment. Therefore, those methods which enhance general tissue resistance are the proper methods to use in the treatment of germ diseases. The sanitary methods which are gradually being evolved for the betterment of our health are applied to those condi- tions which nurture and increase bacteria before they enter the human body. By decreasing the strength and number of bacteria on the one side and increasing the tissue resist- ance of our bodies on the other, we combine sanitation and hygiene in the most successful manner. Mankind must not depend on osteopathy or any other system of medicine to guard him from the inroads of disease. True, we can ofttimes find a structural defect which has a bad effect on some particular function, but it is not sufficient to remove this defect and leave the patient to feel that he has no active part to perform. The only kind of inoculation we advocate is that which inculcates the idea of personal respon- sibility for disease. We quote again from Hueppe : "If a person contracts a bacterial disease, tuberculosis for example, then, according to Koch, only the tubercular bacillus can be held responsible. It is just this belief that has made the science of bacteriology so popular in the eyes of the unreflect- ing multitude and of many easy-going physicians. We need no longer, it is supposed, be solicitous about our own mistakes and peccadilloes. Come what may, we are morally protected, and, secure in the consciousness of our individual merit, we now lay all responsibility upon 'the bacteria' as formerly upon 'catching cold.' A fatal blow is dealt to these self-deceptions and illusions by simply pointing to the fact that bacteria pro- voke fermentation only when they come in contact with fer- mentable substances under proper conditions, and produce ill- nesses and disease only when predisposition towards disease exists. Such liabilities of predisposition, we may either in- herit from others or acquire by faults of our own. When no susceptibility to disease exists, we may harbor the bacillus 232 PRINCIPLES OF OSTEOPATHY. with impunity. We should, then, revile the malicious bacteria no longer, but take ourselves to task and mend our ways. Not that, some measures of reform having been effected, we should behave ourselvse irrationally for eleven months in the year, then go to a medical Tetzel and have prescribed as indulgence a four weeks' sojourn at a watering place. It is better for the majority of men to put themselves, through sensible ways of living, into such a condition that bacteria can get no lodgment in their systems. This, in a few words, is the practical lesson of bacteriological discoveries, Koch to the contrary notwith- standing. It is the less comfortable doctrine, but it is scien- tifically more nearly correct than the other." The purpose of this chapter will be amply fulfilled if it arouses the reader to pursue investigations, and study along the lines here laid down. We have not considered it worth while to recount here a long list of cases of bacterial diseases successfuly treated by osteopathic methods. We may sum up our conclusions as follows : The blood contains the ingredients for overcoming bacteria. In order to afford the blood the greatest opportunity to exercise its antiseptic qualities, it must circulate freely and be fed properly. The heart is controlled by nerves from a definite center, which is in connection with the surface. Large vascular areas are in close central nervous connection with the surface of the body, therefore, the anatomical and physiological factors are present whereby we may influence circulation by manipu- lation or other therapeutic methods affecting the surface of the body. The eliminating powers of the kidneys and intestines can be effected by therapeutic methods applied to the skin and mucous membranes. Therefore osteopathy treats germ diseases by removing obstructions to the circulation of the blood and to the elimi- nating power of the emunctories, and by attention to sanita- tion, diet and hygiene. PRINCIPLES OF OSTEOPATHY. 233 CHAPTER XL ACCOMMODATION AND COMPENSATION. Examination of patients frequently reveals the results of accidents or disease which do not appear to have any present deleterious influence on their health. It is always necessary for the physician to estimate the relations which these changes have, in the past, borne to the general health, or may at pres- ent, be liable to exert under known conditions of climate, diet and environment. Definition. — In speaking of structural and functional changes, we use the words accommodation or compensation. Accommodation means "adaptation or adjustment;" histo- logically, "the occurrence of changes in the morphology and function of cells following changed conditions." Compensa- tion means, "to make up for," "to counterbalance," "that which makes good the lack or variation of something else." The examples of accommodation and compensation are very numerous and it is necessary for the physician to be able to recognize the cases in which the body has exercised, or may, with proper assistance, exercise this power to a great degree. It is sometimes said that disease is an effort of the body to accommodate itself to new conditions, that is, changes in the quantity and quality of stimuli occasioned by variations in climate, diet, environment or accident. Osteopathy apparently originated from the fact that struc- ture affects function. With this as a basis, all examinations are made from the structural standpoint and therefore if we follow this method too literally we are apt to overlook the fact that the cells of our bodies have the power of accommo- dating themselves to very pronounced changes in all those things which are considered essential to perfect functioning. Function in these affected cells may not be perfect, measured by their former activity, and yet apparently answer all the de- mands made upon them by the conscious or sympathetic life of 234 PRINCIPLES OF OSTEOPATHY. the individual. There may be other cells, somewhat similar in character whose increased activity can compensate, that is, "make good the lack of" activity in the affected cells. The Spinal Column. — The examination of the spine fre- quently reveals the irregularities in its structure. Disturbed function in some viscus or other group of tissues is sometimes attributed to this structural variation even when no direct nerve influence over the affected tissues can be directly traced to the spinal area. Mere change in structure cannot warrant us in considering it primary to a functional disturbance which does not exist in a location whose control can be traced to it. The effort on our part to always connect structure with function, having the relations of cause and effect, sometimes leads to very far-fetched reasoning. It is necessary for us to decide, in a given case, whether or no the present condition of the individual is as good as it can be made. Our decision will manifest to the keen observer whether we have recognized the extent of possible accommodation and compensation. Curvatures of the spine present many phases which must be considered before treatment is begun. The curvature of an old case of Pott's disease seldom affects sympathetic life to the extent that we would expect. The very gradual pro- gress of this disease seems to give ample opportunity for the structures in close relation to the diseased area to accommo- date themselves to the changed conditions. It is hardly con- ceivable that anyone would fail to recognize the accommoda- tion manifested in these cases, and yet we have heard of those who advocated forcible straightening of the spine. The ques- tion to be decided is whether it is better to risk life by forcible straightening of the spine or endure deformity with fair health. Deformity is always a wound in the self-esteem of the individual: Many would risk life time and again to be rid of it. It is this which gives the experimenting physician or surgeon ample opportunty to try his skill or his ignorance. It is all one to the patient, a chance to be rid of deformity. Compensatory Curvature. — A lateral curvature of the spine usually has two parts, the primary and the compensa- tory curve. The compensatory curve is the effort to maintain PRINCIPLES OF OSTEOPATHY. 235 the erect position, that is, have the shoulders and hips level. The physician must determine which is primary and which is compensatory. When the hip is dislocated or any condition exists which shortens one leg, the spinal column is curved to compensate for this reduced length. It would be useless to treat a com- pensatory spinal curvature without lengthening the leg by reducing a hip dislocation or putting an extension on the shoe. When the femur is dislocated, all the thigh and hip muscles accommodate themselves to a new position, then the spinal column curves to let the pelvis tilt enough to compen- sate for the lack of length in the extremity. The longer the dislocation has existed the more perfect is the accommoda- tion and compensation. To reduce the dislocation we must undo the work of accommodation, that is, lengthen the muscles and force the head of the femur into the acetabulum. In cases of congenital hip dislocation it is questionable whether they can be reduced by the slow osteopathic method of re- laxing the muscles. Accommodation and compensation are very pronounced in these cases. The acetabulum having never been used is practically non-functional. We have seen Dr. Lorenz demonstrate his radical method for the reduction of congenitally dislocated hips, but we are not able to give the final result because sufficient time has not elapsed. Judging from our previous personal examination of some of the cases he operated upon, we are opposed to treating them osteo- pathically or otherwise. They were healthy, active children. The Extremities. — Accommodation and compensation can be noted very quickly in many cases of injury of the ex- tremities. A fixed scapulo-humeral articulation is partially compensated for by increased mobility of the scapula on the thorax. When the anterior tibial group of muscles is paralyzed the patient compensates for inability to raise the toe by flexing the thigh. When the hip joint is fixed in the extended position, the lumbar portion of the spinal column becomes very flexible. The Thorax. — Drooping of the ribs lessens the antero- posterior diameter, but increases the vertical diameter. The ! 236 PRINCIPLES OF OSTEOPATHY. full round chest of large capacity is usually less flexible and active than the small chest. The question in each case is whether the thorax is doing the amount of work necessary for the body. All individual spinal lesions must be judged carefully as to their relations to functional disturbance. The fact that spines develop unevenly in many cases makes it hard to de- fine their exact condition. A lateral subluxation may exist to which the body has become accommodated. To reduce this subluxation might again subject the individual to disturbed function. Skin and Kidneys.— A spinal lesion might cause a dis- turbance in the functioning of the kidneys, decrease of activity, which in turn is compensated for by increased activity of the skin, which in time is compensated for by increased activity of the bowels. The diarrhoea in this case would be compen- satory and yet it is very difficult for the physician to note this fact. If therapeutic means were used to stop the diarrhoea and the kidneys or skin did not immediately take up the work of elimination, the body would call upon the serous mem- branes and areolar tissue to take care of the surplus liquid in the circulation. As a result there would be edema of the extremities, ascites, pleuritic effusion. When all the serous cavities, pleura, pericardium, peritoneum and tunica vaginalis, and areolar tissues were well filled with liquid, even the cranial and spinal cavities would be pre-empted, thus destroy- ing the nervous tissue. The compensating action which may take place between the kidneys, skin, mucous and serous membranes is one which is more frequently recognized and made use of by physicians than any other example of the same power manifested in the body. The fact that the skin and kidneys respond to each other's needs, forms the basis for many therapeutic pro- cedures. Mucous membranes become active when the skin fails. Perspiration reduces activity of the mucous membranes. Serous membranes cease their excessive activity when mucous membranes eliminate freely. The oedema of areolar tissue gives way to activity of mucous membranes. The physician PRINCIPLES OF OSTEOPATHY. 237 must recognize which is the diseased tissue and which is the compensating one. The failure of the kidney to excrete might not be the fault of its own structure, but result from the vis a tergo given the. circulation by a diseased heart. The Heart. — Compensation by the heart for some me- chanical defect in it, is the most interesting subject studied by the physician. As a result of contraction of the orifices of the heart or faulty action of its valves, there is an increase in the size of one or more of its chambers. This increase is at the expense of the thickness of its walls, thus resulting in disproportion between the size of the cavity of the ventricle or auricle and the amount of muscular tissue required to empty them of their contents. When the proportion between the cavity and its walls is so far restored that the heart is able to overcome the stasis of the blood in that portion of the circulatory apparatus behind the lesion, we say that compen- sation exists. The ability to recognize the existence of a heart lesion is of great value to a physician. Power of Encysting. — In this western country, Califor- nia, Ave have ample opportunity to witness the ability of in- dividuals to do hard, tedious work after a considerable por- tion of the lung has been diseased and expectorated. The healing which takes place under favorable climatic condi- tions, seems to leave the remainder of the lung in perfect func- tional condition. We have examined two cases in which the whole right lung was destroyed and the heart had been drawn into the right half of the thorax. Both of these individuals were able to compete with their more perfect fellows for a living by doing hard manual labor. One of these patients had a discharging abscess in the axillary line between the ninth and tenth ribs. This abscess had discharged continu- ously for four years. The patient did not complain of a single symptom of ill health. He earned his living as a miner. This shows how thoroughly the system may become accom- modated to very marked changes in the condition of its tissues. This abscess was in the man, but apparently not affecting his functions. Probably the abscess was walled off from the active body tissues by a protective membrane such as that 238 PRINCIPLES OF OSTEOPATHY. which surrounds a tubercle in the lung and separates it from the healthy tissue. The history of the lodgment of bullets in various portions of the body demonstrates that what cannot be thrown off by ordinary means may become encysted and thus not interfere with the activity of the tissues. CHAPTER XII. INHIBITION. Acceleration — Inhibition. — We have noted in the chap- ter on irritable tissue that the attributes of nervous tissue are irritability, conductivity and trophicity. We may add to these acceleration and inhibition. We do not use the terms stimulation and inhibition as denoting opposite conditions, be- cause stimulation applies to the initiation of an impulse. This impulse may be acceleratory or inhibitory in character. We may stimulate a nerve whose chief function is inhibition. An impulse whether acceleratory or inhibitory in character is the result of stimulation. All bodily functions require stimulation, in the sense we have used the term, i. e., something must initiate an impulse which is designed to excite activity. After this activity is started, it must be governed. It is the means of governing these activities we are interested in studying. It is not our aim to make an exhaustive study of the in- nervation of each organ in order to understand the manner of governing activity in them. Only the simplest and most use- ful points will be noted here. Muscular Contraction. — Muscle may be stimulated to contraction. This contraction may be increased or decreased, thus showing that after the initiatory impulse starts on its way to the point of conversion into work done by the muscle it is accelerated, increased, or inhibited, restrained by certain in- PRINCIPLES OF OSTEOPATHY. 239 fluences which we cannot easily analyze. The contraction and relaxation phenomena of muscle are equally important. Vaso- constriction and vasodilation are examples of these phe- nomena. Secretion. — The activity of secretory tissues is regu- lated by some arrangement similar to that controlling muscu- lar action. After a cell becomes active It ?-s still under the control of a governing center which accelerates or inhibits ac- cording to the necessities of the case. Acceleration and Inhibition as Attributes of Nerve Tissue. — Cells are full of potential energy which needs a stimulus to start its conversion into kinetic energy. We may ask ourselves the question, Why isn't all of the potential energy converted into kinetic at one time or in response to a single stimulus? If the explosive material in a magazine is ignited it all explodes, there is complete conversion of potential into kinetic energy. There is no restraining or accelerating in this case. The element, nitrogen, whose liberation in this case causes such dire results, is the same element in the cells whose liberation is noted as "work" done by muscle or gland. Why isn't all of the nitrogen in the cells liberated by a single stimu- lus as in the magazine? We can think of no explanation ex- cept that impulses passing over nerves are qualified by other impulses passing over other nerves, the two stimuli of opposite character thus modifying each other, or in some cases, adding their forces when of like character. Inhibition as an attribute of the nervous system does not seem to be exercised in short reflex arcs, neither does it ap- pear to be exercised by centers in the spinal cord. It may be that a certain amount of inhibitory influence is exerted in these subsidiary centers, but thus far investigations demonstrate this attribute to be possessed by the brain cells. Experiments on pithed frogs by members of my classes showed that stimuli, electrical or mechanical, applied to the spine called forth the fullest possible contraction of the ex- tensor muscles. Every stimulation excited a veritable explo- sion of energy. The spinal cord of the frog functionates in a more independent manner than does that in man, hence if 240 PRINCIPLES OF OSTEOPATHY. inhibition were an attribute of these spinal centers, we would expect it to be manifested in the frog. The strength of the stimulus seemed to have no qualifying effect on the strength of the contraction, i. e., weak or strong stimuli brought forth a strong response. Two matches will not cause a given amount of powder to explode harder than will one. Is the Work Done, Proportionate to the Strength of Stimuli? — In therapeutics, we are compelled to consider the question: Is the amount of work done by muscle or gland proportionate to the strength or number of stimuli ? We say, Yes ! This answer is made as a result of observation and experiment, and our further consideration of the subject of inhibition will be from this standpoint. Inhibition a Normal Attribute of the Central Nervous System. — Inhibition is a normal restraining influence pos- sessed by the central nervous system. When the osteopathic physician speaks of inhibition, he means a therapeutic pro- cedure which exercises a restraining influence over some func- tion. This restraining influence being independent of that inhibition which is an attribute of the central nervous system. Anything which decreases the number or strength of sen- sory impulses reaching a reflex center is inhibitory in charac- ter. The medical profession has made use of a large number of agents for this purpose, opium, for example. Physiological Activity Is the Result of Stimulation. — All the functions of our body are initiated by stimuli. It must not be inferred from this statement that the author is satisfied that life consists of nothing but reflexes. So far as we can note the phenomena of muscle and gland, we are com- pelled to recognize the fact that most of them are reflexes. Work done by muscle and gland is initiated principally by sensory stimuli. Excessive sensory stimuli excite increased work in muscle and gland, sometimes to the point of exhaus- tion. To decrease the amount of work, we must decrease the number of stimuli. The stimuli originate at the periphery of sensory nerves. Sensory nerves are most numerous in the skin, mucous membrane and muscle. Inhibitory influences must be applied to one or more of these structures. Skin is PRINCIPLES OP OSTEOPATHY. 241 the surface tissue, richly supplied by sensory nerves, and un- der it are muscles also well supplied by sensory nerves. Hilton's Law. — Hilton, by showing that the skin, mus- cles and synovial membrane of a joint, or the skin, muscles of the abdomen and contents covered by peritoneum are inner- vated from the same segment of the cord, laid a foundation for the rational use of inhibition in osteopathic practice. Inhibition — Therapeutic. — Inhibition as a therapeutic procedure consists in a steady, digital pressure made over some nerve trunk, or over an area which is closely connected with a spinal segment from which nerves pass to an internal viscus which we desire to affect. In order to explain the necessity for this movement and its beneficial effects, we must note the prenomena of vaso motion. How Vaso-motor Centers Act. — Vaso-motor centers act according to the sum of the stimuli reaching them from skin, muscle, glands, etc. If the sensory nerves of one lateral half of the body are stimulated, as by pricking with needles, the temperature of that half of the body will be higher than the other, thus demonstrating that excessive stimulation of sen- sory nerves ends in vaso-dilation, i. e., loss of tone of the mus- cular coat of the blood vessels. Since excessive, i. v v o:

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