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ACADEMY OF APPLIED OSTEOPATHY:
1949
SELECTED OSTEOPATHIC PAPERS
and
MANIPULATIVE THERAPY
DEMONSTRATIONS
Published by
THE ACADEMY OF APPLIED OSTEOPATHY
Affiliated with the
AMERICAN OSTEOPATHIC ASSOCIATION
All Rights Reserved American Academy of Osteopathy®
All Rights Reserved American Academy of Osteopathy®
ACADEMY OF APPLIED OSTEOPATHY
YEAR BOOK
1949
SELECTED OSTEOPATHIC PAPERS
and
MANIPULATIVE THERAPY
DEMONSTRATIONS
MEMBERSHIP LIST
Published by
THE ACADEMY OF APPLIED OSTEOPATHY
Afiliated with the
AMERICAN OSTEOPATHIC ASSOCIATION
All Rights Reserved American Academy of Osteopathy®
Copyright 1949
ACADEMY OF APPLIED OSTEOPATHY
Lithoprinted in U.S.A.
EDWARDS
A N N
BROTHERS,
A R B O R ,
INC.
M I C H I G A N
1949
All Rights Reserved American Academy of Osteopathy®
FOREWORD
The first paper in this Year Book for 1949 written and illustrated by Dr. Howard
A. Lipplncott describes a unique and most valuable type of osteopathic technic developed by Dr. William G. Sutherland, the discoverer and nationally known teacher of Cranial Osteopathy. This technic is based on the same principle of respiratory cooperation
on the part of the patient which plays such an Important role in Cranial Osteopathy.
Without doubt Dr. William G. Sutherland has made the greatest single contribution to the advancement of manipulative osteopathy since Dr. Andrew Taylor Still established it three quarters of a century ago and in recognition of his great contribution
to the osteopathic profession we affectionately dedicate this 1949 Year Book to him.
Aside from the usual group of papers from the Annual Convention and solicited
contributions we are reprinting several basic articles by permission that appeared some
years ago in the Journal of the American Osteopathic Association by the late Dr. Charles
Hazzard and Dr. Albert E. Guy. Dr. Anne L. Wales has also written a review and digest
of a most valuable contribution by Dr. Carl E. McConnell which appeared in the Journal
in April 1905.
Consistent with the main objective of the Academy of Applied Osteopathy which
from the beginning has been to help develop manipulative therapy to a higher plane of
usefulness and a more scientific application in the treatment of disease, the Academy
has inaugurated a program of Post Graduate Osteopathic Training Courses, the first of
which was given at Oakland, California, December 28-31, 1948
and It is the purpose of
the Publication Committee to include in this and succeeding Year Books such material as
will best support this program. We are privileged to include in this book several lectures by Dr. Perrin T. Wilson and Dr. C. Haddon Soden that were given last June before
the British Osteopathic Association as a part of a two weeks Post Graduate Course.
Every effort is being made to improve the quality of the Year Book. -More papers
are being solicited and more of them edited. However, it is the purpose of the Publication Committee to continue to print individual clinical observations and technical developments for the benefit of our membership. We accept these individual opinions and
observations as an effort on the part of the author to be of service to the profession
without endorsement by the Academy or the American Osteopathic Association being given
or implied. Such papers are to be considered as preliminary reports and the author
should be credited with the same sincerity of purpose and integrity as one would wish
to be accorded under similar circumstances. It seems better to publish some of these
papers as they are presented and unedited rather than to risk the loss of a valuable
observation because the editor does not grasp the full import of the observation.
The usual geographic listing of Academy members and Academy reports have been
omitted as It is planned to issue a complete Annual Report and Directory of members at
the close of the fiscal year. An alphabetical list of members as of December 20, 1948
will be found at the back of the book.
Our sincere appreciation to all who have cooperated by providing material for
this book and to the members of the Publication Committee for their help in preparing
manuscripts.
We feel keenly the loss of Dr. Ralph W. Rice from the Publication Committee by his untimely death. This is the first book in several years which has not carried a good number of photographs taken by him. Appreciation Is due Miss Mary P. Boniface for typing of manuscripts and proofreading.
Thomas L. Northup D.O.
Chairman of Publication Committee
ix
All Rights Reserved American Academy of Osteopathy®
TABLE OF CONTENTS
The Osteopathic Technic of Wm. G. Sutherland D.O.
H. A. Lippincott D. 0. . . . . . . . . . . . . . . . . . . . . . . . .
Fundamentals of Technic
H. V. Hoover B. S., D.O. . . . . . . . . . . . . . . . . . . . . . .
The Use of "The Pattern" in Treatment of an Acute Traumatic Lesion
H. V. Hoover B.S.,D.O. . . . . . . . . . . . . . . . . - - . . . . .
Contribution of Carl P. McConnell D.O. to Osteopathic Literature
Anne L. Wales D.O. . . . . . . . . . . . . . . . . . . . . . . . . .
The Rule of the Artery Is Supreme .
Charles Hazzard Ph.B., D.O. . . . . . . . . . . . . . . . . . . . .
The Osteopathic Concept Viewed Biophysically and Biochemically
Charles Hazzard Ph.B., D.0. . . . . . . . . . . . . . . . . . . . .
Some Remarks Upon the Technic of Intracranial Pressure
Charles Hazzard Ph.B., D.O. . . . . . . . . . . . . . . . . . . . .
Essay on Vertebral Lesions
Albert E. Guy D.O. . . . . . . . . . . . . . . . . . . . . . . . . .
Vertebral Mechanics
Albert E. Guy D.O. . . . . . . . . . . . . . . . . . . . . . . . . .
Our Osteopathic Action
Quintus L. Drennan D.O. . . . . . . . . . . . . . . . . . . . . . .
Does the Gross Mechanical Picture Stop at the Occipito-Atlanta1 Articulation?
Harold I. Magoun A.B., D.O. . . . . . . . . . . . . . . . . . . . .
The Cranio-Vertebral Junction
Beryl E. Arbuckle D.O. . . . . . . . . . . . . . . . . . . . . . . .
The Problem Low Back
Alexander F. McWilliams D.O. . . . . . . . . . . . . . . . . . . . .
The Intervertebral Discs - A Book Review
Mary Alice Hoover D.O. . . . . . . . . . . . . . . . . . . . . . . .
Burns' Studies of the Disk
Mary Alice Hoover D.O. . . . . . . . . . . . . . . . . . . . . . . .
Dr. Burns' New Book
Mary Alice Hoover D.O. . . . . . . . . . . . . . . . . . . . . . . .
The Importance of "Pathogenesis of Visceral Disease Following Vertebral Lesions"
W.V.ColeD.0. . . . . . . . . . . . . . . . . . . . . . . . . . .
Dr. Louisa Burns and Her Research Laboratory
Mary Lewis Heist D.O. . . . . . . . . . . . . . . . . . . . . . . .
Tribute to a Great Book and a Great Movie . . . . . . . . . . . . . . . . . . . .
Finding the Still Lesion
Perrin T. Wilson D.O. . . . . . . . . . . . . . . . . . . . . . . .
The Osteopathic Treatment of Asthma
Perrin T. Wilson D.O. . . . . . . . . . . . . . . . . . . . . . . .
X i
All Rights Reserved American Academy of Osteopathy®
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Xii
Page
Osteopathic Adjustment in Pneumonia
Perrin T. Wilson D.O. . . . . . . . . . . . . . . . . . . . . . . . . 173
Angina Pectoris
Perrin T. Wilson D.O. . . . . . . . . . . . . . . . . . . . . . . . . 176
Sciatica
Perrin T. Wilson D.O. . . . . . . . . . . . . . . . . . . . . . . . . 178
Gall Bladder Disease
Perrin T. Wilson D.O. . . . . . . . . . . . . . . . . . . . . . . . 182
The Painful Shoulder
Perrin T. Wilson D.O. . . . . . . . . . . . . . . . . . . . . . . . . 185
Osteopathic Manipulative Surgery Under General Anesthesia
C. Haddon Soden D.O., M.Sc. . . . . . . . . . . . . . . . . . . . . . 188
Shoe
Interpretation - Its Importance to Structural Balance
C. Haddon Soden D.O., M.Sc. . . . . . . . . . . . . . . . . . . . . . 196
The Osteopathic Management of Post-Operative Intervertebral Disc Retropulsion
C. Haddon Soden D.O., M.Sc. . . . . . . . . . . . . . . . . . . . . . 199
Lecture Notes on Chapman's Lymphatic Reflexes
C. Haddon $oden D-O., M-SC. . . . . . . . . . . . . . . . . . . . . . 201
Clinical Aspects of the Chapman Reflexes
Edward A. Brown, A.B., D.O. . . . . . . . . . . . . . . . . . . . . . 212
Osteopathic Structural Analysis
Wm. A. Ellis D.O. . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Membership List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
All Rights Reserved American Academy of Osteopathy®
THE OSTEOPATHIC TECHNIQUE OF WM. G. SUTHERLAND, D.O.
H. A. Lippincott, D.O.
At the time that Dr. Sutherland received his osteopathic training at Kirksville Dr. Andrew Taylor Still was carefully supervising all the instruction
given at the college. The principles that
were taught had to conform exactly to his
concept. Dr. Sutherland made good use of
every opportunity to learn and understand
them and has adhered closely in his thinking and practice to Dr. Still's principles
throughout his professional career. In
consequence the technique which he has
presented to us is a reflection of the
clear vision of our founder. In these
days of rapid changes in medicine older
methods are constantly being replaced by
the new and there is scoffing at the procedures that were used in the day of our
grandfathers.
On the other hand, the
changes in the human structure, due to environment, are such that it is now even
more susceptible to the strains that were
considered by Dr. Still to be the most important cause of disease. Physical response to various types of osteopathic
treatment is essentially the same now as
in the nineteenth century. The technique
presented here is of more than historical
interest, it is of real practical value in
our everyday work.
General
Considerations
Ligamentous Articular Strains
Osteopathic lesions are strains of
the tissues of the body. When they involve joints it is the ligaments that are
primarily affected so the term "ligamentous articular strain" is the one preferred by Dr. Sutherland. The ligaments of
a joint are normally on a balanced, reciprocal tension and seldom if ever are they
completely relaxed throughout the normal
range of movement. When the motion is
carried beyond that range the tension is
unbalanced and the elements of the ligamentous structure which limit motion in
that direction are strained and weakened.
The lesion is maintained by the overbalance of the reciprocal tension by the elements,which have not been strained. This
locks the articular mechanism or prevents
its free and normal movement. The unbalanced tension causes the bones to assume
a position that is nearer that in which
the strain was produced than would be the
case if the tension were normal, and the
weakened part of the ligaments permits
motion in the direction of the lesion in
excess of normal. The range of movement
in the opposite direction is limited by
the more firm and unopposed tension of
the elements which had not been strained.
Principles of Corrective Technique
Since it is the ligaments that are
primarily involved in the maintenance of
the lesion it is they, not muscular leverage, that are used as the main agency
for reduction. The articulation is carried in the direction of the lesion, exaggerating the lesion position as far as
is necessary to cause the tension of the
weakened elements of the ligamentous
structure to be equal to or slightly in
excess of the tension of those that were
not strained. This is the point of balanced tension. Forcing the joint to move
beyond that point adds to the strain
which is already present. Forcing the
articulation back and away from the direction of lesion strains the ligaments
that are normal and unopposed, and if it
is done with thrusts or jerks there is
definite possibility of separating fibers
of the ligaments from their bony attachments. When the tension is properly balanced the respiratory or muscular cooperation of the patient is employed to overcome the resistance of the defense mechanism of the body to the release of the
lesion. If the patient holds the breath
in or out as long as possible there is a
period during his involuntary efforts to
resume breathing when the release takes
place. In appendicular lesions the patient holds the articulation in the
All Rights Reserved American Academy of Osteopathy®
2
position of exaggeration and the release
occurs through the agency of the ligaments
when or just before the muscles are relaxed.
There are exceptions to the general
principle of correction by exaggerating the
lesion position. The disengagement method,
with the rib technique as an example, uses
a fulcrum upon which a leverage tends to
separate the bony surfaces and tense the
ligamentous connections. This method is
combined with exaggeration of the lesion
position in treatment of the long bones of
the extremities. Under some circumstances
it is unwise to add tension to the involved
ligaments, as in the case of a severe
strain of recent production. In that event
the pain will be increased under exaggeration and the correction is made by holding
the more distal bone in the direction of
the normal position while the patient participates by gently and slowly moving the
proximal bone toward its proper relationship. This is known as "direct action"
technique. It is used in the postural sacroiliac or iliosacral lesion in which the
irregularity of the auricular surfaces prevents a wide range of motion, especially
on the axis through the second sacral segment.
The participation of the patient in
the technique is a matter of importance.
If the operator holds the bone which is in
lesion and the patient moves the one upon
which it is lesioned there is less likely
to be undue strain placed upon the ligaments than if the operator exerts the force
necessary to accomplish a reduction. Con-‘
sidering the lesioned bone as the 'bolt'
and the one proximal to it as the 'nut', it
is a better mechanical principle for the
operator to hold the bolt and allow the patient to turn the nut than for the operator
to turn the bolt.
The physical equipment needed for
this technique is simple. An osteopathic
table, a stool and a chair are the main
items. Mention is made of use of the Ritter stool in some of the procedures. It is
a stool that tilts from the base, the seat
turns and is adjustable for height. The
stool is made with a minimum height of
twenty one inches for use in this work. Of
greatest importance, however, is the mental
equipment of the operator, his ability to
visualize the structures concerned in the
lesion, and the keen tactile sense common
to osteopathic physicians.
Cervical Vertebrae
From the axis to the seventh cervical vertebra the articular surfaces lie in
a plane that is tipped anteriorly from the
coronal, so in flexion the articular processes of one vertebra move upward and forward in relation to the one below and in
rotation sidebending the movement is in
that direction on the side that is anterior
and convex. In extension the articular
processes move relatively downward and posteriorly as does the one on the posterior
and concave side in rotation sidebending.
The anterior convexity of the cervical
curve is reduced or straightened when the
neck is bent forward in flexion, increasing
the distance from the occiput to the shoulders. That distance is also increased on
the anterior side in rotation sidebending
and is reduced in extension as well as on
the posterior side in rotation sidebending.
The technique for correction of cervical
ligamentous articular strains makes use of
those principles. The articular processes
that are relatively anterior or that move
anterosuperiorly more easily are held
anterosuperiorly to balance the tension of
the capsular ligaments and the shoulders
of the patient are placed so that the lesion position is exaggerated.
The manner in which the patient
holds the neck, especially in acute lesions, and the altered bony relationships
and soft tissue pathology noted under palpation give evidence of the location and
type of lesion. The determining factor,
however, is the freedom or restriction of
motion. The articulation moves more freely
and usually with less discomfort to the patient in the direction of the lesion than
in the opposite direction.
The technique is best applied with
the patient supine and relaxed, but when
circumstances do not permit this the physician can use his ingenuity in adapting the
technique to the position that can be assumed. It is said that Dr. Still, meeting
a patient on the street, would even stand
him against a tree to reduce a sacroiliac
lesion. There is considerable latitude in
applying Dr. Sutherland's technique providing the underlying principles are not violated. The position of the shoulders is
All Rights Reserved American Academy of Osteopathy®
3
Fig. 1. Cervical Technique
In this case the fingers are crossed to contact the articular processes on the opposite side.
taken without appreciable strain or tension
of the musules, the purpose being only to
affect the ligamentous tension by altering
the relative position of the attachments of
the ligaments.
Flexion Lesions
The articular processes of the upper
of the two vertebrae involved are held anterosuperiorly by the tips of the operator's fingers, the direction being in the
plane of the articular surfaces. The patient lowers both shoulders toward the hips
avoiding any abduction of the arms. The
point of balanced tension is found by the
operator and held during respiratory cooperation in inhalation which also tends to
reduce the anterior convexity of the cervical spine.
Extension Lesions
These are corrected with the processes of the lower of the two vertebrae
held anterosuperiorly, the patient's
shoulders moved cranialward, and respiratory cooperation in exhalation.
Rotation Sidebending Lesions
The articular process of the upper
vertebra on the side of convexity is relatively anterosuperior and it is held in
that direction by the operator. The one on
the opposite side of the vertebra below is
held anterosuperiorly under the inferior
facet of the upper one which is relatively
posterior and downward. The shoulder is
lowered on the side of convexity to increase the separation of the facets and the
opposite one is elevated to carry the superior process of the lower vertebra anteriorly and upward. The patient holds
the breath either in or out, sometimes depending on whether the strain is greater
where the articular processes are Separated or approximated. Respiratory cooperation follows the general rule that inhalation is associated with flexion and external rotation, exhalation with extension
and internal rotation. The point of balanced ligamentous tension may be rather
elusive, making it necessary to slightly
alter the degree of pressure on the articular processes or the height of the shoulders. The greater strain may be in the ligaments of either one side or the other, so
the tension may have to be varied to attain
balance.
Condyloatlantal Lesions
The articular pits of the atlas converge anteriorly and inferiorly and they
curve cranialward to a position anterior to
the occipital condyles. The motion permitted is a nodding of the head as the condyles rock forward and back in the cupshaped pits of the atlas.
Correction of the condyloatlantal
lesion Is made with the patient supine as
the position of choice. The operator
places the tip of a finger against the
posterior tubercle of the atlas and holds
that bone anteriorly to prevent it from
moving dorsally with the condyles as the
patient nods or tips his head forward,
avoiding flexion of the cervical spine.
This rocks the occiput posteriorly in the
pits, releasing the condyles from the atlas,
and tenses the ligaments. The right and
Fig. 2. Condyloatlantal
All Rights Reserved American Academy of Osteopathy®
4
left articulations will find a point of
balance between them, perceptible to the
operator as a slight springing or elastic
resistance of the ligaments. This position
is held while the patient holds the breath
in either inhalation or exhalation. Release
of the fixation is frequently perceptible
to both the patient and the operator, usually during the respiratory efforts just
before the patient must resume breathing.
This technique is effective whether the
lesion be unilateral or bilateral, or the
condyles be held in the anterior, posterior
or lateral position.
Atlanto-Axial Lesions
Dr. Sutherland finds that ligamentous strains of the atlanto-axial articulation frequently become apparent following
the successful reduction of those of the
condyloatlantal articulation, indicating
that they are of a compensatory nature. It
occurs to him that the ligamentous agencies
of that region function somewhat in the
manner of the hairspring of the balance
wheel of a watch, causing motion of the
occiput to be reciprocated between the atlas and axis.
Although the articular structure and
the motion are quite different from those
of the typical cervical vertebrae, the tech
nique is similar. In arriving at a ligamentous balance between the atlas and axis
it is to be remembered that the motion is
almost entirely rotation with little sidebending and that the superior facets of the
axis face cranialward and laterally. The
shoulder and respiratory cooperation are
employed as in the technique for lesions of
the typical cervical articulations.
Thoracic
the upper one moves dorsally. Elevation of
the shoulders tends to separate the transverse processes and move the inferior articular facets anterosuperiorly on the superior articular surfaces of the vertebra below, approximately the relationship which
exists during flexion. When the shoulders
are lowered the articular processes assume
the relationship present in extension. Elevating one shoulder separates the transverse processes on that side and the upper
one moves anteriorly, as on the side of
convexity in sidebending rotation, while
lowering of the shoulder produces the relationship which is present on the side of
the concavity. Technique for the correction of thoracic vertebral lesions employs
cooperation by the patient based on these
principles.
Palpation for
Motion
With the patient seated or supine
the operator places a finger on each transverse process of the vertebra in question.
The patient elevates the shoulders slowly,
then lowers them toward the hips, then
raises one and lowers the other alternately
while the operator palpates for freedom of
motion. The location and direction of the
strain having been ascertained, the transverse processes of the involved vertebrae
which (processes) are in the relatively anterior position are held anteriorly in the
plane of the articular facets to exaggerate
the lesion position.
Vertebrae
The facets of the superior articular
processes face dorsally, cranially and laterally, those of the inferior processes
facing ventrally, caudally and medially.
Consequently in flexion the transverse processes of one vertebra move anteriorly and
superiorly in relation to those of the one
below, and in extension, posteroinferiorly.
In sidebending rotation the transverse process on the side of convexity moves cranially, anteriorly and slightly medially away
from the one below and on the side of concavity the two processes approximate and
Fig. 3. Thoracic vertebra
The transverse process on only one side may
be ield anterosuperiorly for exaggeration of the
lesion position.
All Rights Reserved American Academy of Osteopathy®
Flexion Lesions
The processes of the upper of the
two vertebrae are held anterosuperiorly
while the patient elevates both shoulders
to balance the ligamentous tension as determined by the operator. This position is
held while the patient inhales and holds
the breath.
Extension Lesions
Extension lesions are corrected with
the transverse processes of the lower of
the two vertebrae being held anterosuperiorly, and the patient's shoulders lowered.
Respiratory cooperation is in exhalation.
Sidebending Rotation Lesions
On the side of convexity the transverse process of the upper vertebra and on
the concavity that of the lower one are
held anterosuperiorly. The patient elevates the shoulder on the side of convexity, lowers the other one and carries it
slightly posteriorly. The point of balanced tension is found, and the respiratory
cooperation may be in either inhalation or
exhalation, - inhalation if the ligamentous
imbalance is mainly on the side of convexity and exhalation if on the concavity.
Patient on Knees
of
- Operator
In another method of correcting tho
racic vertebral lesions the patient is seat
ed on the knees of the operator, or on a
Ritter stool, facing the table. The forearm of the operator holds the patient's
pelvis posteriorly. The patient rests his
elbows on the table and walks or inches
forward with them to carry the inferior
5
articular processes craniad in relation to
the superior ones of the vertebra below.
The operator palpates at the transverse process for limitation of motion and for-the
point of balanced ligamentous tension.
Flexion
If the lesion is of the flexion type
a finger on each transverse process of the
upper of the two vertebrae lightly encourages their anterosuperior movement while
palpating for the proper degree of separation from the vertebra below as the patient
steps forward with his elbows on the table.
When that point is reached the correction
is accomplished with the patient holding
the breath in inhalation.
Extension
The operator's fingers areplaced on
the transverse processes of the lower of
the two vertebrae involved, the patient
steps forward with his elbows until that
vertebra is felt to move upward. The transverse processes are then held gently in an
anterosuperior direction while the patient
steps backward with his elbows for an inch
or two. This carries the articular processes of the upper of the two vertebrae
back to exaggerate the extension position
at he point of lesion. The correction is
mad during exhalation.
Sidebending
Rotation
In correcting these lesions the forearm of the operator which is on the side of
the convexity holds the pelvis posteriorly.
A finger of the other hand is placed on the
transverse process of the upper of the
vertebrae involved, on the side of convexity. That finger gently holds the process
in an anterosuperior direction as the patient steps forward on his elbows until tension is palpated with the finger. Then the
patient moves forward the elbow on the side
of convexity, lowering the shoulder on that
side toward the table, as directed by the
operator. The respiratory cooperation may
be in either inhalation or exhalation.
Lumbar Vertebrae
Fig. 4. Thoracic Vertebra
Convexity to the Left.
The two inferior articular processes
of each lumbar vertebra are cupped anteriorly and laterally between the superior articular processes of the vertebra below.
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6
This pattern is usually present at the dorsolumbar and lumbosacral junctions. It per
mits one or both facets of one vertebra to
glide up and down in the trough made by the
facets of the next lower vertebra. The arrangement of the joint surfaces and of the
capsular ligaments is kept in mind as the
corrective technique is applied.
Fig. 6. Lumbar Correction
Convexity to the left. The ilia are held
posteriorly by the fingers.
Fig. 5. Lumbar
Palpation of motion as the hips axe elevated
alternately.
The patient is seated on the operator's knees or on a Ritter stool facing the
table. The operator holds the patient's
pelvis with his forearm anterior to the ilia
and the patient moves his elbows alternate1
forward on the table. This increases the
tension on the capsular ligaments and separates the spinous processes. Tilting the
patient's pelvis laterally with the knees
produces sidebending of the lumbar spine
which can be localized by the palpating fir
ger of the operator, placed on the spinous
process of the vertebra in lesion.
Flexion
-
The patient moves forward with his
elbows until the increase of ligamentous
tension is noted by the operator, the spinous process of the upper of the two vertebrae is held in a cranial direction to exaggerate the lesion position, and the patient then holds the breath in inhalation
for correction.
Extension
In the extension lesion the pelvis
is steadied, the ligaments are tensed as
above, the operator holds the spinous process of the lower of the two vertebrae
anterosuperiorly, and the patient moves
back on his elbows to balance the tension
in extension at the point of lesion. Then
the respiratory cooperation is in the exhalation phase.
Sidebending
The sidebending lesion position is
exaggerated to the proper extent by elevating the pelvis on the side of concavity.
The arm of the operator on. the side of convexity holds the pelvis posteriorly as the
patient steps forward with his elbows to
tense the ligaments. The operator holds
the spinous process of the lesioned vertebae
toward the convexity and the patient comes
back with his elbows until the finger on
the spinous process notes a balancing of
the ligamentous tension. Then the patient
inhales and holds the breath for correction
which usually occurs at the beginning of
exhalation.
Ribs
The rib lesion is considered as an
articular strain of the capsular, radiate
and interarticular ligaments connecting the
head of the rib to the bodies of the vertebrae. In the corrective technique the ligaments are tensed by using first degree
leverage of the rib to lift its head anterc
laterally from the facets on the vertebral
bodies. The rib is shaped somewhat like a.
horseshoe with a long arm from the angle to
the anterior end and the short arm from the
All Rights Reserved American Academy of Osteopathy®
angle to the head of the rib. The costotransverse articulation acts as the fulcrum as the operator holds the shaft of
the rib to prevent it from moving forward
when the patient rotates the bodies of the
vertebrae away from the head of the rib.
The technique is usually applied with the
patient seated and the operator on the side
of lesion holding the rib. However it may
be done with the patient lying on the back
or on the side opposite the lesion. The
patient is instructed to keep his head
erect and not twist the neck as he turns
the body slowly, carrying posteriorly the
shoulder on the side opposite the lesion.
In other words, the operator holds the
'bolt' while the patient turns the 'nut' to
release the fixation. Sensing the point at
which the ligaments are tensed but not unduly stretched, the operator instructs the
patient to hold that position while he inhales and holds the breath for correction
of the lesion.
Diagnosis is made in the usual manner, considering history of trauma, pain
and tenderness, tissue tensity and induration, possible abnormality of position, and
restricted motion. If the first and the
last two diagnostic points indicate a rotation of the rib in a particular direction,
that position may be held in exaggeration
for the correction, otherwise simple disengagement of the costocentral articulation
alone is used.
Fig. 7. Rib Technique
thumb, of the hand which is toward the
front of the patient, follows upward and
backward from the axilla, close to the scapula, to contact the rib as near the angle
as possible. The thumb maintains that contact while the patient gently lowers the
shoulder, like slipping a glove down over
the thumb, thereby causing a minimum of discomfort to the patient. A finger of the
same hand holds the anterior end of the
shaft and a finger of the other hand holds
the posterior part of the rib near the point
where it meets the transverse process. The
thumb of this hand is placed at the inferior
part of the lateral border of the scapula
and holds that bone medially, posteriorly
and upward away from the other thumb. The .
patient's elbow is allowed to drop close to
the body. Leaning toward the operator, the
direction in which the rib held, rotation of the trunk and respiratory cooperation are similar to the technique described
above.
Fourth To Tenth
For lesions of the fourth to tenth
ribs, inclusive, the middle finger of one
hand of the operator is on the angle and
the middle finger of the other hand on the
anterior end of the shaft of the rib, and
the thumbs are placed laterally on the
Firs Rib
shaft. Firm contact is obtained by the paWhen contact with the first rib cantient leaning toward the operator. The rib not be made comfortably by way of the axilla
is held to prevent it from moving anterior- it may be accomplished with the thumb startly and the patient slowly rotates the upper ing lateral to the trapezius and following
part of the body, carrying the opposite
the rib medially under the muscle, advancing
shoulder posteriorly, to the point of balas the patient inhales and holding during
anced tension of the ligaments. He then in- exhalation to arrive at the posterior surhales and holds the breath.
face of the rib. If necessary the hold may
be through the muscle itself, but this is
Third
not as specific or effective. The rest of
-Second and
These ribs are covered posteriorly
the technique is as above.
by the scapula and the first rib by heavy
muscles, necessitating a different approach Bedside Technique For
Upper
- Ribsin holding those ribs posteriorly. The paA simple procedure for the reduction
tient raises the shoulder and the operator's of upper rib lesions that can be used at the
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8
Fig. 8. First Rib
Thumb under the trapazius.
bedside is to have the patient seated with
his hands or forearms resting on the shoulders of the operator who is seated facing
him. The operator holds the sternal end of
the rib posteriorly with the fingers while
the patient rotates the body, carrying posteriorly the shoulder opposite the lesion.
This disengages the head of the rib for car
rection with respiratory cooperation.
Fig. 10. Eleventh and Twelfth Ribs
Middle finger acts as a fulcrum.
while the patient rotates the trunk and
holds the breath.
Rib Lesions Associated with Hyperextension
-of the
- Vertebrae
A distressing type of rib lesion is
the one associated etiologically and pathologically with rather extreme extension of
the spine. Produced during extension and
perhaps sidebending with the convexity on
the side of lesion, the head of the rib is
caught in a depression between the bodies
of the vertebrae caused by a separation of
the demifacets while in that position.
This interferes with flexion and bending
toward the side of lesion, which motions
are painful. The involvement may be bilateral due to the ribe being traumatically
forced posteriorly or pulled by the pectoral muscles when the spine is hyperextended.
Correction is made on one side at a time
and it sometimes is difficult of accomplishment. With the patient lying on the side
opposite the lesion and in partial flexion
the operator stands in back of him. One
Fig. 9. Rib Technique at the Bedside
hand draws the sternal end of the rib posteriorly and the other lifts toward the leThumb holds the shaft of the rib
sioned side the spinous processes of the
in a posterior direction.
two vertebrae forming the costal pit. This
Floating Ribs
rotates the bodies of the vertebrae away
There is no costotransverse articula.- from the head of the rib and the costotranstion to serve as a fulcrum for the eleventh verse articulation moves forward, the leverand twelfth ribs. Consequently in correct- age lifting the head of the rib out of the
ing lesions of the eleventh and twelfth,
depression between the demifacets. The lithe rib is held as are the other middle or
gaments are tensed to the proper degree and
lower ribs, but the finger which is placed
held for respiratory cooperation.
There Is another method that is freposteriorly is held firmly forward against
the rib near the vertebra to act as a fulquently successful in correcting rib lesions
crum. The shaft is held posterolaterally
that are associated with hyperextension of
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Fig. 11. Rib Lesions with Spinal Hyperextension
Two assistants elevate the shoulders.
the spine. The patient is seated and his
shoulders are lifted by two assistants, one
on each side with a hand under the axilla,
the patient's elbows remaining at his sides,
This tends to open a gap between the demifacets and release the head of the rib.
The lift should be just sufficient to tense
slightly the intervertebral ligaments and
it is maintained while the operator proceeds with the respiratory technique for
the rib involved.
Pelvic Girdle
The auricular surfaces of the sacrum
and the ilium, covered by cartilage, lie
more or less in sagittal planes, but flaring anteriorly and inferiorly. Their shape
is that of a broad letter "L", the long arm
being directed dorsoventrally and from its
anterior end the short arm extends cranially. Roughly following the line of this
"L" there is usually a curved ridge on the
auricular surface of the ilium which fits
into a groove on the sacrum. They describe
an arc around a transverse line running approximately through the spinous process of
the first or second sacral segment. The
arrangement of the ligaments is such that
the sacrum can swing within limits between
the ilia along the line of those ridges
without materially changing the tension.
Meanwhile the ligaments are limiting the
tilt of the sacrum, downward and forward at
the base and backward and upward at the
apex, caused by the weight of the trunk
through the lumbar spine when in the erect
position. There is a notable absence of
muscles between the sacrum and ilia which
would control the motion of one upon the
other.
Doctor Sutherland has called attention to an involuntary movement of the sacrum between the ilia in contradistinction
to the postural mobility of the ilia upon
the sacrum. This involuntary motion is associated with what is termed in his cranial
concept as the 'primary resiratory mechanism' which concerns a motility of the neural axis. The dural membranes, the cerebrospinal fluid and the cranial bones and
sacrum participate in the movement. The
primary respiratory mechanism is fundamental to the pulmonary respiratory, the cardiovascular and the various other systems
of the body, so is not to be confused with
diaphragmatic breathing. In the involuntary movement of the sacrum its base alternately moves cranialward and recedes downward as a part of the primary respiratory
mechanism. The inhalation or flexion phase
of the movement causes the base to draw upward and the apex to move anteriorly, the
sacrum swinging on the arc of the L shaped
auricular surface or the ridge and groove
described above. Since this movement reduces the anterior convexity of the lumbosacral junction and since it bears no relationship to the movement of the sacrum as
the trunk bends forward in the standing position, the term respiratory flexion is
applied to it. "Respiratory extension' of
the sacrum takes place when the base is
lowered, the lumbosacral convexity is increased, the sacrum swings posteriorly in
its arc and the apex moves posteriorly.
Postural or voluntary movement of
the ilium upon the sacrum is familiar as
the rotation of the innominate bone anteriorly or posteriorly on a transverse axis
through the body of the second sacral segment.
Respiratory Lesions of
- the- Sacrum
Diagnosis of sacral 'respiratory)
lesions is made with the patient in any position, usually seated.' The thumbs or fingers of the operator bridge from the posterior superior spanes of the ilia to the dorsum of the sacrum near the base or from the
posterior inferior spines to the contiguous
part of the sacrum. The respiratory motion
is accentuated by having the patient breathe
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10
deeply, and the freedom or limitation in
ward from between the ilia. When the disthe movement of the sacrum in its arc is
engagement is palpated the patient is inpalpated. The lesion may be either in the
structed to walk back a short distance with
flexion position with limited movement of
his elbows to allow the sacral base to move
the sacral base forward and downward toward posterosuperiorly and exaggerate the lesion
the extension position or vice versa, it
position. The operator with his knees
may be unilateral or bilateral, or it may
changes the position of the tuberosities of
be in flexion on one side and extension on
the ischii to find the point of balanced
the other.
ligamentous tension and holds for correcFor the technique of correction the
tion while the patient holds the breath in
patient is seated on the operator's knees
inhalation.
or on a Ritter stool, facing the table.
Respiratory Extension
The patient's knees should be together and
For "respiratory extension" lesions
feet forward. The operator stabilizes the
the operator holds the base of the sacrum
pelvis with a forearm against the anterior
forward and downward on the side of lesion
superior spines and the patient bends forward to walk on the table with his elbows with his finger, and the apex posteriorly
or hands of necessary, away from his pelvic with his thumb under one side of the apex.
The forearm on the side of lesion holds the
bones. This draws the sacrum anteriorly,
tending to disengage it from its wedged po- pelvis posteriorly while the patient steps
forward on the table with his elbows or
sition between the ilia, causing it to be
hands. The proper point of balanced tension
virtually suspended. It also releases the
tension of the iliopsoas muscle.
Respiratory Flexion
If the lesion be of the "respiratory
flexion" type with the sacral base drawn up.
ward and slightly posterior and the apex
forward, the operator steadies the pelvis
with the forearm on the side of lesion,
avoiding a posterior pull upon it. The
thumb of the other hand holds the apex forward, swinging the base upward and posteriorly for exaggeration of the lesion position. The patient then steps forward with
Fig. 13. Respiratory Extension Lesion
of the Sacrum
depends upon the amount of pull as the patient's shoulders move forward, the degree
to which the lesion position is exaggerated
by the operator's thumb and finger, and the
relative position of the ischial tuberosities as they are moved by the operator's
knees. Correction occurs with the patient
holding his breath out as long as possible.
Bilateral
Bilateral flexion or extension lesions of the sacrum may be reduced with one
procedure or on one side at a time. If the
his elbows or hands on the table drawing the sacrum be rotated so that the ligamentous
imbalance is toward flexion on one side and
sacrum forward and, because of the flexed
position of the lumbar spine, slightly down- extension on the other it is simpler to
Fig. 12. Respiratory Flexion Lesion
of the Sacrum
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11
correct each side separately.
Postural Lesions
Postural sacroiliac or iliosacral
lesions are diagnosed with the patient
seated on the operator's knees. The tuberischii are alternately elevated and the motion between the sacrum and the posterior
the position of correction. (This is
"direct action" technique, so if it is an
anterior rotation lesion the bone is held
in posterior rotation, and vice versa.)
The patient then flexes the knee which
Fig. 14. Postural Sacroiliac, Diagnosis
superior iliac spines is palpated. If the
motion is free as the tuberosity is elevated and moved posteriorly and limited when
moved the opposite direction, the ligamentOUS articular strain denotes anterior rotation of the innominate bone. Restricted
motion when the tuberosity is moved backward and upward indicates a posterior rotation lesion. The diagnosis may be made with
the patient seated on a Ritter stool, lowering the pelvis on one side or the other.
The diagnostic motion or its limitation is
elicited as the patient abducts the knees
alternately.
Correction of the postural lesions
IS made with the patient standing, his hands
on a stool which is placed on the table.
The leg on the side of lesion is crossed in
front of the other one and the foot rests
on its outer edge, lateral to the one on
which he stands. In this position the
weight is transmitted from the spine through
the sacrum to the innominate bone which is
not directly concerned in the technique.
The sacrum is thus stabilized and the lesioned innominate is left suspended. The
operator, sitting at the side of the patient, holds the tuberischium in the palm of
one hand and the crest of the ilium in the
other. The innominate bone is rotated with
the hands, anteriorly or posteriorly toward
Fig. 15. Correction of Anterior Rotation
of the Innominate
Operator rotates the ilium posteriorly on
the sacrum.
bears his weight to about 135 degrees, keeping the other leg relaxed, and returns to
the erect position while the operator maintains the rotation of the innominate in the
direction of correction.
Pubic Symphysis
The symphysis pubis is subject to
ligamentous strain, frequently in association with sacroiliac 1esions. There is an
intervening cartilage between the pubes denoting motion. The bones are bound together by strong ligaments, some of whose fibres are diagonally placed making them especially susceptible to strain or imbalante. An unevenness of the superior borders
of the pubic bones may be palpated. The
inferior ligament, extending between the
inferior rami, is pierced by the urogenital
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table are placed between the inferior rami
near the symphysis with a finger of the
other hand between the proximal phalanges
to act as a fulcrum or wedge to spread the
tips of the fingers apart. This tenses the
interpubic ligaments and the tension may be
balanced by advancing one or the other- finger anterosuperiorly. The patient cooperates by pressing his knees together. A
thick pillow between the knees is helpful.
In the female patient the thumb of one hand
and fingers of the other are used to spread
the symphysis.
Upper Extremity
Clavicle
The object of the technique for correction of lesions of the clavicle is to
hold it cranialward and laterally while the
patient lowers his shoulders and rotates
the trunk, dlsengaging the sternal, costal,
coracoid and acromial articulations to
tense their ligaments. The patient sits on
the table and the operator sits facing him,
Fig. 16. Correction of Posterior Rotation
ducts and by a branch of the internal pudic
nerve in close proximity to the symphysis,
which is an indication of some of the symptoms that may be present.
A spreading or disengagement of the
articulation is accomplished with the patient lying on the side with his thighs
flexed. The operator stands in back of him
The tips of the index and middle fingers of
the hand which is toward the foot of the
Fig. 18. Clavicle
Fig. 17. Pubic Spread
a thumb under each extremity of the clavicle. The fingers of one hand rest over the
acromioclavicular junction for the purpose
of palpatlon and a finger of the other hand
is placed medial to the sternal end of the
clavicle to hold it laterally. The patient,
with his arm on the involved side lateral
to the operator's arm, rests his hand on
the latter's shoulder. The patient drops
his weight forward on the thumbs of the
operator, who balances the ligamentous tension at the acromial end of the clavicle by
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carrying his shoulder and the hand resting
on it backward away from the patient.
Under direction the patient draws his opposite shoulder posteriorly to move the
sternum away from the clavicle and tense
the ligaments at that articulation. The
clavicle is balanced over the costoclavicular ligament and the patient inhales and
holds the breath for correction.
Humerus
Freedom of rotation of the humerus
in the glenoid cavity is tested with the
arm at an angle of 45 to 90 degrees laterally from the body, and the elbow flexed.
Fig. 19. Testing External Rotation
of the Humerus
Comparison of the motion on the two sides
is made by carrying the hand laterally and
upward to test external rotation of the
humerus and medially and downward for internal rotation. Restricted motion in one di-
Fig. 20. Testing Internal Rotation
of the Humerus
13
rection indicates lesion in the opposite
position.
Correction is made with the patient
seated, the operator standing on the side of
lesion, facing him and with the hand which
is toward the back of the patient palpating
the shoulder joint. The other hand under
the axilla, against the ribs and as close
to the head of the humerus as possible,
acts as a fulcrum for disengagement. The
patient places the hand of the involved
side over the distal third of the opposite
clavicle and holds that shoulder. The internal rotation lesion is exaggerated by
the patient elevating the elbow, external
Fig. 21. Corrective Technique, External
Rotation of the Humerus
rotation by lowering it, the operator directing to the degree necessary to arrive
at the point of balanced tension. The patient is instructed to move his uninvolved
shoulder posteriorly, carrying with it the
Fig. 22. Corrective Technique, Internal
Rotation of the Humerus
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14
hand of the lesioned side. This draws the I
lower end of the humerus across the chest
in order that the leverage over the fulcrum
provided by the operator's hand disengages
the head of the humerus. Respiratory cooperation is then employed to correct the
lesion.
Forearm, Wrist and
Hand
The bones of the forearm move in relation to each other on a double swivel.
The proximal head of the radius rotates in
the annular ligament and the distal head
around the end of the ulna. Little motion
is possible between the humerus and ulna
except flexion and extension. The capsular
ligament of the elbow is composed of interlaced and confluent fibers that operate as
a unit and unbalanced tension may be caused
by strain of the elbow joint or result from
rotation lesions of the humerus. Strains
which disturb the position of the olecranon
process prevent complete extension of the
arm and those which affect the coronoid process prevent complete flexion. The semilunar notch between these two processes, which
receives the trochlea of the humerus, opens
anteriorly at about a right angle to the
shaft of the ulna but is frequently at an
angle of more nearly 135 degrees.
Ulna
The corrective technique for ulnar
lesions is applied with the patient seated
facing the table, elbow flexed to about 90
degrees and his hand, palm down, on the
table. The fingers are spread as widely as
possible to release the metacarpals and the
distal row and possibly all of the carpal
bones. The operator sits on the side of
lesion and rests his fingers over the dorsun
of the carpus and proximal ends of the metacarpals and the thumb on the styloid process
of the ulna for palpation. The fingers of
the other hand grasp the olecranon process.
The patient inverts and everts the humerus,
raising and lowering the elbow, while the
operator finds the direction in which the
motion is limited and determines the point
of balanced ligamentous tension. The operator then holds the proximal end of the ulna
away from the humerus by means of the olecranon process, or the patient may steady
the wrist with his other hand while the operator holds both the olecranon and coronoid
processes, tending toward rotation of the
ulna to the proper degree. The patient then
Fig. 23. ulna
raises his shoulder to draw the humerus out
of the semilunar notch of the ulna for release and correction. The direction of the
pull on the humerus may need to be at an
angle greater than 90 degrees to prevent
binding on the olecranon process, the operator's sense of touch deciding that point.
Radius
Lesions of the head of the radius
prevent free supination or pronation of the
forearm. For correction the position is
similar to that for ulnar lesions, except
that the patient's elbow is only slightly
flexed. The operator holds both ends of
the radius with his fingers, palpating for
the ligamentous imbalance as the patient
circumducts his elbow upward or downward
and medially to rotate the humerus in relation to the radius. When the point of balanced tension is found the radius is held
firmly by the operator for stabilization,
Fig. 24. Radius
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15
and the 'patient circumducts the elbow a
little farther for exaggeration and correction.
Wrist and Hand
In dealing with lesions of the wrist
and hand it is well to remember the intercommunicating artlcular cavity of the
joints and the dorsal convexity of the arch
formed by the wedge shaped proximal heads
of the metacarpal bones, narrowed on their
volar aspect. The patient sits with his
hand on the table, palm down and fingers
spread. Facing him, the operator holds
downward the dorsum of the distal end of
the metacarpal with his thumb, and he lifts
and separates the proximal heads of that
and the metacarpal on either side of it
with the ball of his middle finger, placed
under the palm between the proximal ends of
the shafts of the bone being held by the
thumb and of the one on either side. When
Fig. 26. Hand
Dr. A. T. Still used his flexor profundus digitorum muscles in correcting lesions of the wrist and hand. He interlaced
his fingers with the patient's wrist between his palms. The patient spread and
extended his fingers, making the back of
the hand as nearly concave as possible.
Varying the pressure by means of the flexor
profundus digitorum muscles Dr. Still found
the point of balance at the exact location
of the lesion and allowed the bones to
spring back into normal relationship as the
patient relaxed his hand.
Fig. 23. Wrist
the metacarpals are lifted dorsally and separated they are also rolled on their long
axes. The operator's other hand on the dor
sum of the wrist stabilizes the carpal
bones. With this procedure the restriction
is found and the ligamentous tension is
brought into balance and held. Then the pa
tient spreads his fingers more widely to
disengage the lesioned- articulation for cor
rection. Lesions of the carpal as well as
the metacarpal bones may be reduced by this
technique. The procedure is completed by
the operator holding and rotating on their
long axes the involved fingers, one at a
time, while the patient, keeping his fingers widely spread, slowly withdraws his
hand, raising and lowering his elbow.
Fig. 27. A.T. Still's Wrist Technique
Lower Extremity
Hip Joint
The capsular ligament of the hip
joint is strong, comparatively lax, permits
a wide range of motion and is frequently
subjected to strain. Diagnosis of lesions
of this articulation is made with the
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16
Fig. 28. Testing External Rotation
of the Femur
patient standing, the weight on one foot.
Without turning the pelvis he rotates the
leg that is not bearing his weight, pointing the foot laterally and medially to determine the degree of external and internal
rotation of the head of the femur in the
acetabulum.
Comparison of the motion in
either direction on the right and left side:
designates the lesion., In another method
of diagnosis the patient is seated on the
table with one leg resting over the other
knee. The operator, facing him, holds the
leg at the knee and ankle and rotates' the
femur in question by tilting the leg in
either direction over the knee on which it
rests. Restrictions caused by exostosis or
other bony abnormalities are usually indicated by a less resilient limit of motion
than is present in ligamentous articular
strains.
For the corrective technique, the
patient sits across the table with the uninvolved hip next to the end. The leg of the
lesioned side is crossed over the other
knee, resting midway of the shaft of the
fibula. The operator sits at the end of the
Fig. 29. Testing Internal Rotation
of the Femur
table, one hand medial to the shaft of the
involved femur near its head, holding it
laterally. The other hand reaches around
in back of the pelvis to palpate the motion
at the greater trochanter.
In the case of an external rotation
lesion, the patient holds his knee laterally and downward with his hand for exaggeration, sidebends and rotates his body
Fig. 30. Testing External Rotation
of the Femur
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Fig. 31. Testing Internal Rotation
of the Femur
away from the lesioned side and leans backward. The operator firmly maintains his
fulcrum against the shaft of the femur and
determines the point of ligamentous balance
The correction occurs with exaggeration of
the lesion position and disengagement of
the articulation.
Fig. 32. Corrective Technique, External
Rotation of the Femur,
variation from the text.
Internal rotation lesions are corrected with the operator holding the fulcru
on the femur more proximally than in the
former technique and palpating for ligamentous balance with the other hand at the
greater trochanter as above. The patient
draws his knee medially and upward with his
hand, leans forward and sidebends and rotates the body toward the side of lesion for,
exaggeration to the proper degree.
Dr. A. T. Still used a similar .tech-
Fig. 33. Corrective Technique, Internal
Rotation of the Femur, Variation.
nique in which he sat on the patient's uninvolved thigh and the leg on the side of
lesion was crossed over Dr. Still's knee.
The principle of exaggeration and fulcrum
disengagement was used for correction.
Tibiofemoral
Tibiofemoral lesions, sometimes referred to as dislocated semilunar cartilage, are caused by a sudden or forcible ro_
tation of the tibia in relation to the femur, usually in conjunction with a sidebending strain upon the knee. In a majority of
instances the medial condyle of the tibia
has been rotated anteriorly when the foot
was turned laterally and the knee bent medially, the lateral articulation of the knee
joint having acted as a fulcrum. History
of the injury, location of the tenderness,
inability to fully extend the knee in most
cases, pain and restriction on attempting
to reverse the lesion position, and palpation establish the diagnosis.
For correction the patient is seated
with the involved leg balanced over the opposite knee. Facing him, the operator
places one hand on the knee and grasps the
foot, just below the ankle, with the other
hand. If the lesion be of the medial condyles the operator provides a fulcrum on
the lateral condyle of the tibia with his
thumb, one or two fingers are on the medial
condyle of the femur for palpation, the
knee is carried medially and upward, tipping
the foot laterally and downward, to disengage the lesioned joint surfaces and tense
the ligaments. The tibia is rotated externally or internally by the other hand at the
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Fig. 34. Tibiofemoral
Fig. 35. Fibula
foot to exaggerate the lesion position to correction are accomplished by the patient
the point of balance. The patient is then drawirgthe leg backward away from the operainstructed to resist the turning of his
tor and moving it lengthwise of the fibula
as the operator holds that bone anteriorly
foot and the result of that effort is to
glide the medial condyle of the femur into with his fingers.
its proper position on the tibia. When the
lateral condyles of the knee joint are in- Tarsal Arch
volved the fulcrum is on the medial conFollowing the fibular correction an
dyle of the tibia, the articulation is dis- effective technique for lifting the tarsal
engaged by tipping the leg over the knee
arch is performed with the operator at the
on which it rests so the knee moves downfoot of the patient. The fingers are interward and the foot upward. Exaggeration of laced over the dorsum of the foot and the
the lesion position by rotation of the foot crossed thumbs on the plantar surface hold
and the correction by the cooperation of
the internal cuneiform and cuboid apart to
the patient in resisting that movement fol- spread the arch and exaggerate the translow the same principle as is used in leverse flattening to the point of balanced
sions of the medial condyles.
tension. For correction the patient, with
his foot in plantar inversion, dorsiflexes
Fibula
and then plantar flexes it against the reMost lesions of the fibula'affect
sistance of the operator's thumbs.
both its proximal and distal articulations
and cause added tension through the inter- Tibio-Calcaneo-Astragalus
Lesions of the complex articular
osseous membrane which is in close proximity to the vessels of the leg. Tenderness, disturbances of the ankle joint and
circulation of the foot, and limited motion
of the fibula in relation to the tibia
give evidence of the lesion. For correction the patient sits with his leg, near
the ankle, over the other knee. The operator holds both ends of the fibula anteriorly with his fingers to the point of balanced tension of the ligaments. The patient dorsiflexes and externally rotates
the foot and presses downward on the knee
or lifts it upward and medially with his
hand. This rotates the fibula and releases
it at both ends from the tibia and from
the astragalus. Further disengagement and
Fig. 36. Tarsal Arch
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19
structure of the foot are corrected by a
method contrived by Dr. Sutherland based on
the beneficial effects of removing a tight
boot by means of the old fashioned bootjack
Each time the device was used the user gave
himself a foot treatment.
Characteristic of the fallen arch
are the anterior position of the astragalus
between the malleoli and in relation to the
calcaneus, and the lowering of the calcaneu:
anteriorly, of the medial part of the cuboid, and ofthe longitudinal and transverse
arches. The technique, like the operation
of pulling the foot out of the boot, lifts
and moves the structures back into their
normal relationship.
In preparation for the corrective
technique the patient or the operator holds
the tuberosity of the calcaneus and the metatarsals medially with the fingers. The
thumbs on the inner side of the foot at the
junctions of the calcaneus with the talus
and the navicular with the internal cuneiform lifts those structures laterally and
hand grasp the posterior part of the Calcaneus and hold it medially and downward
while the thumb lifts laterally and upward
on the inferomedial aspect of the cuboid.
The operator rotates the anterior part of
the foot internally and externally to balance the ligamentous and fascial tension
and continues to hold medially and downward on the tuberosity of the calcaneus
while the patient draws on the achilles
tendon for exaggeration and correction.
Fig. 38. Tibio-Calcaneo-Astragalus
Fig. 37. Preparatory to "Bootjack" Technique
upward, bending and stretching the foot
around the thumbs. Following that procedure the patient drops the foot and ankle
into plantar flexion and the operator place
between two of the toes the web of the
thumb of the hand that is toward the latera
side of the foot. The thumb holds the dorsum of the distal heads of the metatarsals
downward and the middle finger of that hand
under the shafts of the metatarsals rolls
them on their long axes and lifts and separates the proximal heads, which are wedgeshaped and narrowed inferiorly. This releases the metatarsal and the distal row of
the tarsal bones. The fingers of the other
Astragalus, Calcaneus, Tarsal Arch
Another useful procedure in the release and correction of tarsal lesions,
especially the astragalus, makes use of the
fact that strong dorsiflexion of the foot
elevates the arch. The operator interlaces
his fingers in back of the' heel and with his
palms holds the astragalus and calcaneus
firmly in the position they would take in
extension of the ankle joint. The patient
dorsiflexes and inverts and everts the fore
part of the foot against the resistance
provided by the operator.
Non-Osseous
Structures
Soft tissue treatment in osteopathy
has been frowned upon since the early days
when Dr. A. T. Still referred to some types
of it aslengine wiping'. It has been associated in the minds of many of us with rubbing
or massage, yet intelligent and scientific
adjustment of non-osseous structures is as
truly osteopathic as correction of bony lesions. Dr. Still regarded the body as a
complex unit composed of interrelated parts
working in harmony, each endowed with the
All Rights Reserved American Academy of Osteopathy®
20
inherent desire, intelligence and ability
to perform its function according to the
plan of a Master Mechanic. When circumstances prevent any part of the body, whether bony or soft tissue, from doing so,
the effects are far reaching. Perfect
health ensues when each part is in perfect
adjustment and free to do its work. Dr.
Still had the greatest respect for the humours and the fasciae, the nerves, vessels,
viscera and all the other elements that
compose the body. He had a remarkable faculty of being able to locate maladjusted
tissue, of associating cause with effect,
and tracing effects back to cause. That
quality is reflected in Dr. Sutherland's
technique.
The fasciae envelop, separate, protect and support the various structures.
Not the least important of their functions
is to encourage and direct the movement of
tissue fluids and to promote the flow of
lymph through its channels. The various
layers of fascia interconnect and present a
continuity from head to foot. Dr. Still
recognized 'drags' on the fasciae which are
caused by hypotonicity, the weight of viscera, strains, and posture. Treatment to
restore the normal tension, hence function,
of the fascial system is extremely effective.
the table or side of the bed facing the operator. His body is flexed and head hangs
forward. The operator directs his thumbs
posteriorly and downward over the clavicle
just lateral to the attachment of the sternomastoid muscles. With the arms lateral
Fig. 39. Cervical Fascia, First Position
to those of the operator the patient rests
his hands on the shoulders of the operator
and slowly drops his weight forward. This
advances the thumbs down into the mediastinum just anterior and to either side of the
trachea. The operator approximates his
thumbs enough to gently hold the pretrachea
fascia while the patient slowly assumes the
erect posture, but with the neck remaining
Anterior Cervical Fascia
in flexion. It is unnecessary to go so
The anterior cervical fascia is atdeep into the mediastinum as to be uncomtached to the base of the skull, the mandible, hyoid, scapula, clavicle and sternum. fortable to the patient. This technique
Through the pretracheal it is connected with lifts the fascia and reduces the 'drag'
from below.
the fibrous pericardium, and thence with
the diaphragm. It surrounds the pharynx,
larynx and thyroid gland, it forms the carotid sheath, and by way of the prevertebral
fascia is connected with that which surrounds the trachea and esophagus. Therefore,
the cervical fascia is concerned quite directly with lymphatic drainage of the head,
neck, thorax and upper extremities. Not
only voluntary movements, but,respiratory
activity is a factor in this vital function
of the fascia, moving it forward in exhalation and backward in approximation to the
spine during inhalation. Restoration of
free movement of the deep cervical fascia
renders unnecessary much of the soft tissue
treatment of the neck and helps in overcoming intrathoracic congestions.
The 'drag' on the cervical fascia is
eliminated by having the patient seated on
All Rights Reserved American Academy of Osteopathy®
21
Diaphragm
Because of its relationships the
diaphragm deserves consideration other than
as a muscle of respiration. The pericardium is firmly attached to it above, the
peritoneum below, and the great vessels and
esophagus pass through it. Being rather
closely associated with the organs of respiration, circulation and digestion, it is
important that the full excursion of the
diaphragm be unimpeded. This is prevented
by a 'drag' on the abdominal fascia and may
be restored by a technique known as the diaphragmatic lift. The object of the treatment is to draw the diaphragm cranially,
eievating the floor of the thorax, drawing
upward on the abdominal contents and promoting venous and lymphatic drainage from
the lower half of the body. Visceroptosis
and even internal hemorrhoids respond to it
tension affecting the important structures
passing through the arches of the diaphragm
is relieved. The patient seated, the operator facing him from the front or at his side
starts his thumb under the twelfth rib just
lateral to the erector spinae mass. The
right thumb is used for the left side of
the patient and vice versa. The patient
Fig. 42. Arcuate Ligaments
bends his trunk over the operator's thumb
which gently and gradually advances upward
and posteriorly as the patient exhales, and
holds its position as he inhales. When the
thumb arrives at a point against or under
the ligament it is drawn laterally with a
rolling motion which relaxes the external
and often influences the internal arcuate
ligament.
Liver Turn
Fig. 41. Diapbragmatic Lift
A treatment to stimulate the liver
-With the patient supine The operator
to increased activity is given with the paintroduces his fingertips under the costotient lying on the back. The operator
chondral junctions. If that area is particularly sensitive the patient hooks his own
fingers under them and the operator lifts
on his hands. As the patient exhales the
operator lifts the lower rim of the thorax
in acranial and slightly lateral direction.
The advancement that is made is held during
inspiration and is increased on exhalation.
The patient is instructed not to hold the
breath in, but to exhale immediately after
inhalation. After several respiratory cycles there is no further upward progress and
the patient is told to breathe out, close
the throat and attempt to expand the chest.
Arcuate Ligaments
In a Technique utilized for relaxation of the external arcuate ligaments, the
Fig. 4.3. Liver Turn
All Rights Reserved American Academy of Osteopathy®
22
inserts the ends of the fingers of the
to the mild cases which escape recognition.
right hand between the inferior border of
Usually the patient is more comfortable
the right costal cartilages and the liver.
with the thighs and the lumbar spine flexed
The fingers of this hand should be slightly upon the pelvis, there is difficulty in
flexed with the dorsum resting against the
arising directly from the supine to the
anterior border of the liver. The left
sitting position, and pain is referred down
hand placed over them presses them downward, the leg because of irritation of the nerves
holding the anterior border of the liver in of the lumbar plexus passing through the
a medial and caudal direction, while the
belly of the muscle. The psoas fascia has
patient inhales and holds the breath. The
a connection with the diaphragm by way of
diaphragm holds the body of the liver cauthe internal crus, indicating a restricting
dally until on the sudden exhalation it el- influence upon the excursion of the diaevates. Since the anterior border is still phragm. The course of the ureter Is on the
held downward by the fingers the liver
medial side of the psoas major and the techmakes a turning movement probably attended
nique for relaxation is an aid to the passby suction within its substance.
age of renal stones since the hand of the
operator almost reaches the ureter. The
Biliary Drainage
kidney, cecum, descending colon and small
'intestines rest upon the psoas and are afIn another treatment for sluggish
liver the patient is seated and the operafected by the technique which lifts the
tor holds his thumb firmly in the right hy- muscle out and free from the underlying
pochondrium.
nerve ganglia and vascular channels.
The patient leans slightly
With the patient seated the operator
forward and rotates the body to the left,
causing the thumb to advance further toward places his thumb along the crest of the ilithe inferior surface of the liver. Closing um, pointed posteromedially, and rolls it
his throat he attempts to inhale, after the over the crest into the iliac fossa. The
manner of the military order, indelicately
thumb Is held firmly in a medial, posterior
and slightly caudal direction, following
expressed as, "suck in your guts." This
drains the bile passages and the pancreatic the internal surface of the ilium while the
patient bends his body to bring the psoas
duct.
muscle in approximation with it. The operator is seated in front of the patient who
Abdominal Treatment
bends and leans laterally and forward to
Treatment directly over the abdomen
"put the glove on the thumb." The patient
should be administered carefully and with
due respect for the viscera within. To lift may rest his arms on the operator's shouland hold the sigmoid flexure or raise the
ders in which case he leans forward, causing
the thumb to advance to its position against
cecum from the pelvic bowl, the fingers of
and posterior to the psoas major, lifting
one hand are introduced close to the ilium
the muscle forward. The patient then inand are supported and slowly lifted by the
hales deeply, holds the breath, and on
other hand. This permits use of a keen,
tactile sense and the ability to employ the
various fingers as needed to restore proper
peristalsis, circulation or drainage. Intestinal activity may be increased by holding the left eleventh rib downward and medially to limit its excursion during two or
three respirations. The false ribs may be
treated similarly, Dr. Sutherland reporting
the passage of gall stones without pain when
the tenth rib on the left was held in that
manner. The effects are produced by way of
the sympathetic chain lying in close proximity to the heads of the ribs.
-Psoas Muscle
Contractures of the psoas muscles
exist in varying degrees, from acute spasm
Fig. 44. Psoas Muscle
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23
exhalation straightens the trunk as the operator releases his pressure on the muscle.
If the patient is bedfast he lies on his
side with a pillow under the shoulder to
produce the sidebending, the rest of the
technique following the principles of that
described above. When the treatment is
given for its influence upon the cecum, a
chronic appendix, colon, small intestine,
kidney or ureter, the psoas is held forward
while the patient rotates his thigh alternately internally and externally. In the
bedside technique this is done with the patient more or less in the Sim's position,
lifting the knee laterally and lowering it
to the bed.
Iliopsoas Tendon
The iliopsoas tendon may be lifted
or stretched by holding it forward at a
point just proximal to the lesser trochanter, the patient lying on the back. This
treatment relieves the anterior tension upon the spine in lordosis, gives relief in
the passage of renal calculi and is an effective measure for sciatica.
An effective technique for reducing
the 'drag' on the fasciae is applied with
the patient lying on the left side. His
thighs are straight or slightly flexed to
Fig. 45. Pelvic Lift
the position in which the floor of the Pelvis is most relaxed. The operator stands
in back of him and starts the tips of the
fingers medial to the right tuberischium
and advances them upward between the obturator membrane and the rectum while the
-Pelvic Lift
The fascial connections from the
patient exhales. During inhalation the poneck to the diaphragm have been mentioned.
sition of the fingers is held gently, but
The direct attachment of the diaphragm to
firmly, not allowing them to recede. This
the liver, and the connections to the stom- hand may be supported by the other hand to
ach, duodenum, psoas and peritoneum complete allow the fingers to hold more steadily and
a chain embracing the viscera all the way
to note more carefully the resistance of
down into the pelvis. Fascial 'drag' has
the tissues. After several cycles of deep
an adverse influence on the support and
respiration the resistance will be felt to
function of the organs and on the circuladiminish suddenly and the tissues spring
tion and drainage of the lower half of the
upward in advance of the fingers.
body. The aorta lies against the bodies of
This technique is adaptable to the
the vertebrae and is crossed anteriorly by
various pelvic prolapses that are bound to
the crura of the diaphragm. Thus the 'drag' cause a drag on the fascia and that persist
on the crura has a constricting effect upon partially because the support of that agency
the aorta, throwing an extra load upon the
has been reduced. The fingers may be diheart and predisposing to cardiac insuffici- rected cranially and medially or anteriorly
ency. Dr. Still described this phenomenon
toward the cecum, uterus, bladder or prowith the parable of the goat and the boulder. state for specific effect upon those organs.
The boulder represented the crura, the path It will be found easier and less uncomfortwas the aorta, and the valves of the heart
able to the patient than local treatment.
were the tail, the heels and the whole goat. If indicated the technique may be applied
"The goat, finding the boulder in its path, to the left side of the pelvis.
backed up and gave it a butt and his tail
went up. Not to be outdone he backed up
Popliteal Drainage
Movement of fluids from the poplifurther, came a-running and gave it another
butt and his tail and heels went up. Then
teal space and below may be accelerated by
he backed up further and with a supreme ef- drawing apart the tendons of the biceps and
fort gave it another butt and the whole d--- semi-terdinosus muscles, just above the
works went up."
knee. The patient is supine with his knee
All Rights Reserved American Academy of Osteopathy®
24
Conclusion
Fig. 46. Popliteal
Drainage
slightly flexed and he alternately presses
against the table with the heel and relaxes. The effort to flex the knee tends
to compress the tissues of the popliteal
space, and it expands when the patient relaxes the leg and the operator separates
the tendons. The effect is that of a boost
er pump in the return of the fluids toward
the heart.
The osteopathic articular lesion,
being primarily an unbalanced tension of
the ligaments with strain as the usual
cause, is corrected mainly through the
agency of the ligaments themselves. The
natural tendency of the body is to revert
to normal when the balance is restored and
the factors preventing the return are removed. It will be noted that as a rule
gliding separation of the joint surfaces is
used to tense the ligaments in vertebral,
sacroiliac, carpal and tarsal lesions.
Fulcrum leverage for disengagement is employed in lesions of the long bones, combined with exaggeration of the lesion position in those of the extremities. The principle of the fascial treatment is to lift
the fascia at its more dependent part, the
patient cooperating.
Dr. Sutherland's technique seems a
radical departure to most of us. It avoids
the familiar thrusting and popping of
joints. However, it is based upon the fundamental principles of osteopathy as conceived by Dr. Still and accords with his
admonition that osteopathic technique
should be gentle, easy and scientific.
All Rights Reserved American Academy of Osteopathy®
FUNDAMENTALS OF TECHNIC
H. V. Hoover B.S., D.O.
5. Laboratory session on detection
of motion in normal and lesioned areas of
the spine.
1. A General Consideration of Teaching and Learning Technic.
2. Diagnosis of Pathology in Relation to the Osteopathic Lesion.
3. Nomenclature of Spinal Mechanics
6. Lecture on the finding of spinal
lesions by the methods described by Wilson,
Thomas, McWilliams, and others possibly,
indicating where to treat.
4. Teaching Technic.
methods.
in Relation to the Osteopathic
Lesion.
7. Laboratory session in above
5. The Use of the Pattern in Treat-
8. Lecture on the principles of
treatment in the light of 2,4,6. Theory of
treatment. Treating to the pattern. Measure of a technic.
ment of an Acute Traumatic Lesion. (Paper given at Boston)
6. A Measure for Osteopathic Technic
(modified paper printed in Year
Book as "Yardstick of Osteopathic Technic")
9. Practice in treatment with criticism in light of 2,4,6 and 8.
7. Tentative Course of Instruction
10. Lecture on sacro-lumbar area practice in diagnosis and treatment.
8. Postscript.
11. Lecture on occfpito atlantal
area - practice in diagnosis and treatment.
in Osteopathic Technic.
12. Lecture on soft tissue - muscles ligaments, fluids - practice in diagnosis
and treatment.
Tentative Course of
- Instruction
-in Osteopathic Technic
13. Lectures on organs - liver, spleen, intestines, uterus, etc - practice in
diagnosis and treatment.
A course of technic based on McConnell's admonition that "It is the fine distinctions which require elucidation" and
Still's belief that "The only assistance
others can give you will be a better understanding of fundamental principles" might
be outlined thus:
14. Lectures on appendicular technic practice in diagnosis and treatment.
1. Lecture on the functional anatomy
of the spinal organ, and a discussion of
physiology of circulatory system, nervous'
system, muscles etc related to the spine,
bringing in Principles of Osteopathy.
2. Lecture on pathology of the spina
lesion and the detection of this and system
ic changes in the tissue.
3. Laboratory session on detection
of normal and pathological tissue in the
spine including systemic effects.
4. Lecture on physiological movements of the spine.
Although the latter part was hurried
because of lack of time, such an outline
was followed when I taught technic in Kirkville last February and I believe it was a
successful presentation,. judging from the
continued interest and correspondence I am
still receiving from a considerable number
of the students. It gets away from the
thing that has made technic teaching so mediocre for years, by emphasizing "fundamentals" and "fine distinctions" and making
the actual demonstrations and practice incidental. I believe it is essentially the
way we must follow to secure the superior
results we so earnestly desire from this
teaching program.
25
All Rights Reserved American Academy of Osteopathy®
26
The teaching of practice, the treatment of specific diseases, is of secondary
importance to the learning of actual principles of technic. However it should be included as much as possible in the course to
give the wealth of experience of such men
as Wilson, Sisson, Fryette and others, to
the students. If time is limited, the cut
should be in practice, not in technic, because the physician is nothing without
technic and if he is bright, he will, with
sound osteopathic theory and a good technical foundation, develop a good treatment
for a disease even if not specifically instrutted how to treat it.
principles upon which Osteopathy is founded."
"They cannot demonstrate to you how to use it. If
you want to be an imitator, study in a bath house."
The teacher should impart fundamental principles and teach basic methods
which the student may apply creatively to
the condition at hand. He should not teach
'manips', movements, holds, positions, or
other routine procedures which may be indicated in a given case. They may not be. and
probably are not generally applicable.
Rather, the student must be trained to diagnose the abnormal condition and to apply
his knowledge of physiology and anatomy, so
that the patient's body may be altered and
the pathological condition favorably changA General Consideration of Teaching
ed. This requires that he learn a method
and Learning Technic
of observing, thinking, reasoning and acting in an orderly logical manner.
"If you understand the music all you
This process of reasoning from obhave to do to express the meaning is to
served effect to cause that characterized
know and apply the technics." Osteopathy
Still's methods of diagnosis, must be underand music have something in common. If you stood by the student or he will not compreunderstand the human body all you have to
hend the specific manipulation demonstrated.
do to produce health is to know the techNor will he understand the fine variations
nits. So acquiring technical ability is
in method, timing and place of application
important in both professions. Without it
required to meet diverse conditions. No
an osteopath and a musician are unable to
matter how skillful he may become, if he
accomplish their desired ends. Yet always
does not think clearly through each step,
to be useful, technical ability must be di- his treatment will be mechanical and imitarected to knowledge and understanding.
tive. He must be taught to reason before
acting and never to act without reason.
Technic applied merely as technic,
"--Every treatment demands initiative and
leads to disappointment and failure. This
creative effort."
concept that each student must "formulate
"--Creative technic ability if applying the
his own technic" to meet the needs of the
principles indicated in each problem--. Otherwise
varying situations he meets in practice lothere would be a gravitating to mere formulas. It
gically, leads the teacher to emphasize bais the fine distinctions that require elucidation."
sic thinking as he demonstrates specific
P 309.
manipulation. Technic is a tool. The mind
"Dr. Still was his own technician, studied
and hand must be trained to use the tool
and formulated his own technic--. YOU can do the
intelligently and skillfully, else the tool
same." P 351.
may prove useless or harmful. The presentaThese quotations from C. P. McConnell tion of a technic should not be made before
in "The Lengthening Shadow of Dr. Andrew
an understanding of its use and need is
Taylor Still" by Hildreth, indicate the
evident to the student.
Technic should be taught in relation
need for understanding and knowledge in developing technic. Teachers and students of to practice if it is to have real meaning:
technic can get inspiration from this conthat is, a specific condition in a specific
cept. Dr. Still said (as quoted by Gavett
patient should be visualized when a speciin the 1948 Year Book of the Academy of Ap- fit technic is shown. For example, in presenting a treatment for the relief of replied Osteopathy, P 49)
tarded digestion in a patient who has just
gotten up following an attack of influenza,
"The only assistance others can give you
will be a better understanding of the fundamental
the procedure would obviously be unlike
All Rights Reserved American Academy of Osteopathy®
that described for the same patient who
from the basic principles he has learned.
has dyspepsia due to viseroptosis, resultHe is then able to practice osteopathy with
ing from-postural strain of years standing. a technic worthy the name. He can do the
A student learning the technic which might
specific thing indicated. Osteopathic
be effective for normalizing the stomach
treatment may mean almost anything under
the therapeutic sun. The type and locale
function in the first condition and applying it to the second case would have cause
of manipulation varies widely. Depending
on the circumstances, anything from gentle
to be disappointad in his results. What
osteopathic physician has not seen demonstroking or pressure in certain areas to a
strated technics for the relief of such
general loosening and moving of all movable
conditions as constipation, high blood
tissue with considerable violence, is depressure, cramps etc without reference to
scribed as osteopathic treatment and rightthe etiological factors, diagnosis or conly so. Treatment depends upon the patient's
dition of the patient? A specific technic
needs. If the condition of the patient has
for non-specific conditions. This is not
been properly diagnosed, osteopathically, a
manipulation directed specifically toward
reasonable.
improving that condition, is osteopathic.
Clinical experience on the part of
the physician provides the connection which Understanding and reason are the indispensgives technical demonstration meaning.
able prerequisites of any treatment in
However, this is a dangerous point. The
order that the results be the best possible
teacher must be careful to be objective.
under the circumstances. Stereotyped treatIf he recites cases and experiences on a
ment may be beneficial in many cases but
subjective level, he leaves his statements
not the best. Herein lies the danger of
open to question and his conclusions to
routine treatment. It leads to mediocrity.
doubt. Students resent self aggrandizement Only the average case gets benefit and the
by the instructor. They are apt to reject
unusual one may suffer when it should be
conclusions, even if true, based on a case
helped.
history or two. Enthusiasm is an essential
Since the treatment depends upon the
in teaching but it is no substitute for
patient's needs, it must be preceded by a
conclusions arrived at by a critical precareful consideration of the patient and of
sentation of the facts involved. The inthe disease so that their relationship may
structor should present a clear cut demonbe discovered and a diagnosis made. The
stration based on definite anatomical and
question HOW is this disease possible in
physiological grounds and backed by an osthe patient?' when answered should lead to
teopathic diagnosis and only after this and the question How can this patient be
as a supplement, give case histories and
changed to make this disease impossible or
illustrations. The thrilling experience of at least less destructive?' Then treatment
seeing patients recover from serious illbegins and technic is created to meet the
ness as the result of osteopathic treatment, need of the patient at that time.
should be presented in a manner acceptable
Since a specific treatment is creatand understandable to the student and with- ed for a given patient at a particular time
out making the doctor and profession appear to meet certain definite conditions, it is
unscientific because of unsubstantiated
obviously impossible to standardize technic.
statements.
For example, one cannot say that a certain
In the actual teaching of a technimanipulation is for the relief of a slugCal process, the first step is that of angish gall-bladder without qualifying it by
alysis and second, that of synthesis. The
stating under what conditions it should rephysiological factors and movements and the lieve the condition. Consequently such a
anatomical changes in relation, are discuss- thing as an osteopathic prescription is uned step by step and part by part so that
scientific, unless all factors are definite
when the whole is reconstructed and prely stated, a thing impossible to do since
sented as a method of treatment of the pathe patient's condition is not static.
tient for a Specific condition, the process
In conclusion, this concept of treatis comprehended by the student.
ment is fundamental. An osteopathic physiA specific condition requires a spe- clan must learn to reason from his anatomicific technic. The practicing physician
cal and physiological knowledge about the
must make this technic to fit each situation relationship of disease to body integrity
All Rights Reserved American Academy of Osteopathy®
28
in order to establish a diagnosis and
understand what and why he must treat. He
must then decide upon a course of action
which his knowledge and reason 'lead him to
conclude is most effective in changing the
body toward normal and in checking the progress of disease. Then he may apply his
anatomical and physiological knowledge to
do specific manipulations or other therapeutic measures which change the body so
that disease becomes less compatible with
it. Only those specific measures arrived
at by this process of diagnosis and reasoning are indicated. All others are contraindicated. They may be harmful. The
"Let's try this and see what happens"
school of thought, is a dangerous one.
Technic teachers and students must keep
this concept in mind in order that the student understands the methods taught.
And finally, a word should be said
directly to the persons who are concerned
in this process of exchanging ideas. The
concert master is not always the best
teacher. The successful physician may not
be able to impart his knowledge and ability
until he learns how to teach. On the other
hand many who may not be so proficient may
be able to teach successfully. Each of
those who have some knowledge of the philosophy of osteopathy and the technic of its
application to human ills, should contribute to the best of his ability that much
to the contemporary stream of knowledge.
That particular contribution may be the
means of helping someone strengthen some
weak link in his osteopathic technics, it
may be the thing many thinking physicians
are seeking. And, if it is worth presenting for study, It is worth presenting well
and studying thoughtfully. The teacher
should do his best. The student is under
obligation to do likewise. There must be
tolerance and understanding on both sides
of the teacher's desk to make the process
most valuable.
Diagnosis of Pathology in Relation
to the Osteopathic Lesion.
It is practically impossible to define an osteopathic lesion so that what a
lesion is and what it is not, are unequivotally stated. Yet the important characteristics of the lesion are well known and can
be demonstrated. In spite of lack of proof
from the research scientist, certain groups
of physical findings can be said to constitute a lesion. The detection of these
physical conditions are the evidence from
which a diagnosis of the lesion can be made.
The interpretation of these findings according to osteopathic principles as they
affect the body economy, is osteopathic diagnosis.
For our purpose, let us define an
osteopathic lesion as a change in structure
which alters function.* This definition is
based on the osteopathic tenet that normal
function depends on normal structure and
the law taught in biology that structure
determines function. Therefore, a change
from normal structure may produce and maintain abnormal function, and a return to
normal structure permits function to normalize if the process still is reversible.
The physical findings of a lesion
are the evidence of certain changes which
have taken place within the body, and their
discovery constitutes a recognition of
existing pathology and/or displaced structure.
The problem in diagnosis is, first,
to recognize such changes and second, to
interpret them, preparatory to treatment.
An understanding of the pathology of the
lesion is prerequisite to intelligent diagnosis. A brief review of this pathology
and a correlation of it with physical findings enables one to present his technic of
diagnosis in a manner easily grasped.
According to Louisa Burns, the pathology of the osteopathic lesion is basically, as would be expected, that of inflammation. The detection of the stage of inflammation, and as treatment is administered, the resulting changes are the object
* This broad definition is not the usual one given since when an osteopathic lesion is mentioned, an
articular lesion is commonly meant. The official definition sanctioned as Standard Osteopathic Nomenclature for Osteopathic Technic (P 242 J. A. O. A. January 1936) is: "An osteopathic articular lesion is
any alteration In the anatomical or physiological relationships of the articular structures resulting in
local or remote functional disturbance."
All Rights Reserved American Academy of Osteopathy®
of diagnostic search. The ability to discover abnormal tissues is one of the most
difficult arts to master. Educated touch
coordinated with an intelligent, alert, inquiring consciousness, will find much information overlooked by the novice, as well
as by the careless or hurried technician.
Unfortunately, the finer distinctions are
never sensed and appreciated in many practices. The development of diagnostic ability requires concentration and application
to detail and constant study in correlating
osteopathic theory with detailed findings.
For descriptive purposes, the traumatic spinal lesion may be chosen as a typical osteopathic articular lesion. The
following discussion relates to such a lesion*, other lesions may also be understood by the application of reason. The
student should study this from Burns' new
book.
The first detectable change after
the production of an osteopathic spinal lesion and preceding the onset of inflammatory changes, is the shock reaction. The
chief characteristic of this reaction is a
decreased tonicity of periarticular tissue,
amounting to flaccidity in some cases.
Muscles are relaxed and mobility of the
joints in the area is increased. However,
careful testing will show that usually motion is slightly less in one direction than
in others, indicating the presence of a lesion. There is a reflex change in circulation, locally and in related segments, due
to narrowing of arterioles after the shock,
followed by an increased permeability of
the capillaries and a beginning of edema,**
which gradually increases.
The detection of shock reaction is
difficult. Increased mobility makes the
limitation of motion on one or more directions appear to be normal because the relatively limited motion may still be as great
as normal motion. Tissue relaxation may be
overlooked by fingers feeling only for increased tensions and for the changes characteristic of inflammation. Alteration of
relative position is often not detectable
because contraction of longer muscles
29
(white muscle), due to inflammation is not
yet active in producing deformity.
The chief diagnostic point noted in
the stage of shock is an alteration of tissue feel detected by very light palpation.
The pads of the fingers, scarcely touching
the skin, are stroked lightly across the
area parallel to the long axes of the muscles. The skin presents to the slowly moving fingers a slightly cooler feel and a
decreased drag, as compared to normal temperature and drag. This leads the diagnostician to investigate the area more carefully for the flaccidity and altered mobility characteristic of the lesion in the
stage of' shock.
Because the phase of shock is fleeting, lasting only from a few moments to an
hour, it is seldom seen by the physician
except as the result of trauma administered
by himself in indiscriminating treatment.
Many unexpected results following treatment
may be explained by the local, or segmental,
and systemic effects of shock reactions.
On subsequent examination, the physician
may be surprised by the presence of an aggravated lesion where he thought he had
made an excellent correction. True, shock
reaction may at times be of value, as in
the control of nosebleed by shocking the
upper cervical segments, but an accurate
osteopathic diagnosis is necessary to guide
the physician's hand if shock is to be used
therapeutically. When produced accidentally, it should be recognized and appropriately treated.
Subjectively, in shock, the patient
may point out the lesioned area as one in
which a sudden twinge was felt, possibly
accompanied by a "click" or "pop". There
is little or no pain on motion. In fact,
if the area was previously painful or
tight, the patient may say he now feels
fine. However, after the lesioned person
has cooled off following injury, he will
complain of the onset of symptoms that result from the development of acute inflammation.
In the second stage of traumatic lesion pathology, that of acute reaction
* Dr. Burns' new book has this step by step.
**C. H. Kauffnan attributes the edema to disturbed tensions due to changed anatomical relationship. The
edema accumulating because the tensions prevent normal drainage may act as an irritant causing fibrosis
without passing through the acute inflammtory stage in some reflex and compensatory contra&urea. "A
Discussion of Osteopathy and its Relation to Physical Medicine", a pamphlet published and copyrighted
1945 by Dr. C. H. Kauffman.
All Rights Reserved American Academy of Osteopathy®
following the shock stage, we find the usual will complain of a catch, if the motion is
pathology of inflammation in greater or less in the direction of correction but will not
complain if the lesion is slightly exaggerdegree, depending on the severity of the
process. The edema of the shock phase
ated. However, exaggeration beyond a slight
degree increases pain rapidly and the pagradually increases as vaso-construction
tient may become panicky from fear of furgives way to vaso-dilatation. Capillary
beds become engorged and veins distended.
ther injury, seeming to sense that this was
how the injury originally occurred.
Petechial hemorrhages from impaired capilIf treatment is proper or spdntanelaries add to the disturbance of cellular
function initiated by the edema, clogging
ous reduction occurs, the inflammation wili
the lymphatics, and further affecting nerve subside by resolution. If it does not so
subside, the pathological process progressendings. This causes pain and reflex efes to the subacute and finally to the chronfects locally, segmentally and generally.
Muscles contract. The shorter muscles, (red ic stage. Fibrosis of muscles, thickening
muscle) which have to do with protection of of ligaments and generalized increase of
the joint and maintenance of the status quo, white fibrous tissue contracts to scar tiscontract protectively to oppose the deform- sue which takes on a supporting and protective function to the lesioned joint. Acute
ity producing pull of longer muscles if
irritation, edema and hemorrhage decrease.
possible. The area becomes swollen, warm,
Long muscles relax in proportion as congespainful and sometimes red in degrees varying with the acuteness of the lesion and ex- tion lessens and heat, swelling and pain
tent of the trauma. Refiex effects are
decline. Later, muscular atrophy occurs
those of vaso-dilatation in related segments. and this added to the contraction of scar
Such a lesion is not difficult to
tissue decreases the volume of soft tissue.
detect. Pain may be so great that deep pal- The flush of the acute lesion gives way to
pation and movement are prevented and aca pale glistening skin. Pain lessens and
curate diagnosis becomes extremely diffifinally disappears.
cult. Inspection may pick out the area.
Louisa Burns in discussing "The
Light stroking will usually detect swelling Changes of the Skin over Human Lesions"
and heat. An increased drag on stroking
under the "Pathology of the Lesion" in her
fingers indicates vasomotor reaction with
recent book pathogenesis of the Visceral
increased moisture on the skin. Bulges or
Disease following Vertebral Lesions says:
depressions in tissue indicating abnormal
"During the next few months or a year or
relationship of vertebral segments and a
more (following the period of hyperemia of
swollen condition of the tissue may also be
the acute lesion) a brownish pigment may
detected by light stroking.
appear in the skin immediately over the tip
Deep palpation must be done careof the spinous process. The skin itself is
fully on an acute lesion because of pain
thickened in the same area."
and possible damage to tissue friable from
This is due to degeneration of red
inflammatory reaction. Tensions of the
blood cells and the fibrotic proliferation
deep short muscles and the ligaments are
which follows failure of resolution and
often obscured by superficial tension and
precedes contraction and atrophy. The palswelling and may not be palpable. A gentle pating fingers with light touch can be
testing for altered mobility may be attempt- taught to detect the characteristic feeling
ed to determine which of the physiological
of the subacute lesion as well as that of
movements are limited. While motion is
the acute and chronic conditions which prelimited in all directions, some motions are cede and follow it. The slowly moving finlimited sharply while others are freer
gers are retarded, not by moisture but by
though not normal in range. If the motion
a roughening of the surface. Fine discriis gentle, the range is not as limited as
mination with light stroking can thus give
that found in chronic lesions. Quick or
a reasonably accurate picture of the pathorough motions irritate tissue and motion is logical state of the skin. This knowledge
limited by contracting irritated muscles.
giving as it does an indication of the
Subjectively, the patient complains pathology of underlyfng tissues can be useof localized pain of varying degree, aggra- ful in determining the type and force of
vated by certain motions but seldom radiat- corrective treatment chosen to normalize
ing to the periphery of the segment. He
the lesioned spinal organ.
All Rights Reserved American Academy of Osteopathy®
31
Light stroking of a chronic trauma- 1the experienced physician in locating Pritic lesion reveals a slick and cool area
nnary lesions.
Secondary lesions do not start with
causing less drag on the fingers than the
acute lesion indicating decreased circulathe severity characteristic of the traumation and tissue fluids. The skin area feels tic lesion. They do not present shock findsoapy or greasy to the finger pads. Deeper ings and seldom those of the acute lesion.
palpation reveals fibroses and atrophy of
Rather they seem to be subacute from the
muscles, giving a copy effect with little
beginning and soon pass into the chronic
resiliency. The area is tough and resiststage.* Because of a less violent onset,
ant, indicating toughening of ligaments and and the greater area involved, they develop
deep muscles. In the chronic lesion, moa more even fibrosis over a less localized
tion is limited in all directions, but the
area of pathology. The combined fibrosis
limitation is greater in certain physiologi- and contracture of muscle necessary to maincal movements than in others. Chronic letain position under strain develops group
sions exhibit more freedom of motion than
lesions with characteristic findings includsubacute and acute lesions, but within a
ing less mobility than in chronic traumatic
more limited range.
lesions. These group lesions may be scoliSegmental effects may be frequently otic curves or disturbance in the anterodetected in relation to chronic lesions.
posterio balance. They seldom cause subNoticeable changes may be present in the
jective or referred distress, unless a seskin and muscles of the segment. Sensation cond insult disturbs their function, almay be altered. Pain and paresthesias may
though the deformity may be considerable.
follow the nerve from a lesion to the peLesions in the spinal region due to
riphery. In this stage lesions secondary,
reflex Irritation from viscera or skeletal
or compensatory, to the primary lesion often structural lesions must be recognized.
cause more discomfort than the primary leAcute reflex lesions exhibit some of the
sion itself causing the unobservant physiphysical findings of mildly acute traumatic
cian to treat effects of the primary lesion lesions; light stroking will usually locate
while overlooking the chronic cause of symp- the area of reflex irritation. History of
toms.
visceral disturbance vs strain or trauma
Subacute lesions do not lend themhelps in differentiation.
Chronic reflex lesions produce a
selves to clear discussion since they may
slowly developing fibrosis leading to tissue
vary greatly in the stage of pathological
changes comparable to, chronic secondary ledevelopment.
Some lesions require years to pass
sions. Reflex lesions are not necessarily
from the acute traumatic to the chronic
associated with articular displacement.
stage. Others develop chronicity rapidly.
Mobility of the joints involved, while reThe formation of fibroses and resultant seal stricted, is not necessarily restricted in
tissue is Nature's way of defense against
one direction more than another.
the injury of abnormal motion present in
Acute traumatic lesions superimposed
lesioned joints. Many so called cures by
on chronic traumatic or compensatory or remasseurs, physical therapists and others are flex lesions occur frequently and the ostemerely the rapid production of chronicity ix opathic diagnosis of such a condition taxes
an area subacutely inflammed, with resultant the ability of any physician. If possible
freer but not normal motion and freedom from it is well to treat the acute lesion In
pain. The physician should understand this such a way that it is returned to the patpossible contribution to a pathological pro- tern which existed before the acute lesion
cess and resolve not to-employ such injudi- occurred. Reflex lesions are frequently
produced in areas where traumatic or compencious treatment.
Traumatic lesions, as well as other satory lesions exist and vice versa, making
imperfections, bring about chronic postural diagnosis difficult and complicated. Recognition of the previously existing condition
and balance changes which develop into sein the area of a newly produced lesion, the
condary, or compensatory, lesions. These
lesions tend to fall into patterns useful to "pattern", as well as noting recent changes
* See previous note relative to the role of physical change in procducing edema and eventually fibrosis.
P. 10.
All Rights Reserved American Academy of Osteopathy®
32
pathic treatment. Adequate osteopathic diof the tissues, is a necessary preface to
agnosis and adequate osteopathic technic are
successful treatment and prognosis.
Factors such as malnutrition, poor
requisite steps in translating theory into
elimination, infections, glandular, nervous practice. Osteopathic theory plus osteopathic technic equal osteopathic treatment.
and psychic perversions of physiology must
be considered and looked for. Their effect Treatment can be effective only if theory,
diagnosis and technic are sound and effecon the tissue is often detectable, giving
tive.
characteristic sensations to the palpating
What methods of diagnosis and defingers.
In taking up the study of the letails of technic are to be taught? How are
sion, the student should be impressed by
they to be presented? Why are they valuable? These and other questions are to be
four facts: First, that there are many
things which may be learned by skillful and answered by the teacher himself. It matters
little what method of diagnosis or what deintelligent examination. Second, that his
fingers can learn to feel all these things
tail of technic is demonstrated or in what
through patient intelligent effort. Third, manner these are taught if the altered phythat he does not need to be able to detect
sical relationships and the fundamentals of
more than the grossest of these findings in the pathology present in a given case with
order to start practice and achieve some
the resulting need for specificity in its
success but, fourth, that he should continu- management are emphasized. It must be
ously seek throughout the years of his prac- plainly taught that osteopathic technic
tice to detect the finer points and interused to treat a specific lesion must be depret them intelligently if he is to develop vised to meet existing conditions. Treata satisfactory professional skill.
ment must be applied only after an evaluDirected by fine discrimination, the ation of all local and general symptoms and
signs as well as laboratory findings and in
Ideal osteopathic physician directs his
the light of clearly understood osteopathic
treatment so that the part and function to
theory.
be changed are favorably affected. He refrains from touching any part or doing anything that would affect the part and funcNomenclature of Spinal Mechanics
tion unfavorably. He does that which is
In Relation to the Osteopathic
indicated. He does not interfere with the
Spinal Lesion
effect of the indicated therapy by meddlesome or routine treatment. He Is specific.
Technic is the performance of an
He is not an "engine wiper." It is imporact or series of acts with a definite theratant to be able to decide what to do. It
is wise to know what not to do.
peutic end in view. These acts the instrucCareful examination following treat- tor must demonstrate in a manner clearly
ment discloses changes in the physical find- understood by the student. In order that
ings, Here we have a method of determining the acts be comprehended, a word picture of
the effect of the corrective measure which
the anatomy and physiology involved in the
aids in prognosis and may even aid in the
process must be given. Few people learn by
discovery of hysteria or malingering. It
observation only. Seeing must be reenforced
gives the skilled and Intelligent physician by hearing, writing and doing.
an advantage over others who have no such
Technic can be described with words,
fine gauge with which to measure the effect but to be understood the words must have a
of treatment.
meaning common to teacher and student. To
The teacher of technic should indi- that end the American Osteopathic Associcate the pathology present in the lesion and atlon, through its proper committee estabteach a specific procedure calculated to
lished in 1933 a nomenclature. This terchange the pathological state toward normal. minology is already understood by recent
And the teacher of the practice of osteopgraduates and students, but it is necessary
athy should indicate the technic best calfor the older graduate to become familiar
culated to change the specific pathology of with it in order that his usage may not
the person, with a disease, toward the nor- cause confusion. It is not easy to change
mal. Only In this way will the student be
a lifetime habit of thought and action.
able to link osteopathic theory to osteoHowever, adherence to common usage of words
All Rights Reserved American Academy of Osteopathy®
33
is the better practice, if such usage will
clearly convey the ideas. If one feels he
mUSt vary from standard nomenclature he
should be sure his hearers know the deviation and are reminded each time it is used.
Definitions do not always convey the
full implication of the term as used, so
following several definitions a brief description will be given of the major findings discovered on examination of the parts
under observation. These descriptions will
apply only to the spinal organ, since generalizations including appendicular, sacral
and cranial joints are impossible and since
each extraspinal articulation must be considered separately. Both to teach and to
learn technic accurately, these definitions
and the statements of the physiological motions of the spine must be clearly understood and remembered.
Flexion of the spine Is the position
assumed by the vertebrae in physiological
forward bending from the hips. This increases the anteroposterior curve in the
thoracic and decreases it in the lumbar and
cervical areas. The upper facets of the
articulations move cephalad in relation to
their opposing facets causing ligamentous
and muscular tensions which impose certain
limitations (to be discussed later) on free
movement of the parts.
Lesions (1) in this position exhibit certain characteristic physical findiws, whatever the pathological state of
the tissues may happen to be. The spinous
process of the lesioned vertebra is prominent and the interval between it and the
one below is increased. It appears to be
posterior and an indiscriminating examiner
may call it a posterior lesion. If the
whole area is placed in flexion the lesionec
vertebra becomes Indistinguishable by obser
vation from unlesioned vertebrae in this respect.
Tension and tenderness are present
in the interspinous tissues. Both articulations are moved equally creating similar
tension and tenderness in affected ligamentc
and muscles on both sides. This tension
limits motion in the direction of extension
while motion is permitted freely into increased flexion. This tension existing in
marked flexion prevents lateroflexion unless it is preceded by rotation. Rotation
is free If followed and accompanied by lateroflexion.
Extension of, the spine Is the position assumed by the vertebrae in physiological backward bending from the hips. This
increases the anteroposterior curve in the
lumbar and cervical areas while the curve
is decreased in the thoracic area. The upper facets of the articulations move caudad
in relation to their opposing facets causing ligamentous and muscular tensions which
impose certain limitations on free movement
of the parts.
Lesions in this position exhibit
certain characteristic physical findings,
whatever the pathological state of the tissues may happen to be. The spinous process
of the lesioned vertebra Is depressed and
approximated to the one below. It appears
to be anterior and may be mistaken for an
anterior lesion by a careless examiner. If
the whole area is placed in extension the
lesioned vertebra becomes indistinguishable
by observation from unlesioned vertebrae in
this respect.
Tension and tenderness are equally
present in affected deep ligaments and muscles on both sides of the spine. This tension limits motion In the direction of flexion but motion is permitted freely into
increased extension. The tension produced
in extension prevents lateroflexlon unless
it is preceded by rotation. Rotation is
free if followed by and accompanied by lateroflexion.
Extension or flexion lesions uncomplicated by rotation and lateroflexion are
rare but possible.
There is no term officially recognized to describe the normal position of the
spinal segments when there is perfect balance and neither extension or flexlon
exists. The terms "neutral" or "easy normal" are used by some. The former seems
preferable.
Rotation is movement of a vertebra
around a vertical axis. It is always accompanied by lateroflexion. In flexion and
extension rotation always precedes lateroflexion while in neutral lateroflexlon
(1) Osteopathic Lesion--herein used to mean anatomical and physiological changes in the spinal organs
resulting in histopathological changes and functional disturbances. In disturbed intevertebral relationships the upper or more cephalad of the two is commonly considered to be the one in lesion although the lower may be thought of as in lesion if it is desirable.
All Rights Reserved American Academy of Osteopathy®
34
precedes rotation. This will be discussed
Rotation cannot occur in neutral because there is no tension to create a fixed
later under the physiological movements of
point for an axis so lateroflexion must octhe spine.
Lateroflexion is the tipping of a
cur first followed by rotation. This law
vertebra to one side--right or left. It is may be stated thus. If an area of the
sometimes called sidebending (unofficial).
spine be in neutral and lateroflexion takes
The conditions which permit lateroflexion
place, rotation of the body occurs to the
in relation to rotation are stated in the
opposite side. Thus we have neutral, laprevious paragraph.
teroflexion, rotation in the order named.
These motions. extension, flexion,
Correction can reverse the order of producneutral, rotation and lateroflexion are the tion; i.e., rotation, lateroflexion to the
components of the physiological movements
opposite side of rotation and neutral.
'
of the spine. A recognition of these comLesions in the position (extension
ponents in a lesion constitutes a diagnosis (or flexion) rotation and lateroflexlon to
of the path the lesioned vertebra traveled
the same side) exhibit certain characteristo reach the altered position. It theretics. They are most often lesions involvfore is a prerequisite to accurate correcing two vertebrae only. The spinous protion of the lesion. Without a knowledge of cess is approximated to the one below if
the physiological movements technic becomes the area is in extension or separated from
unsystematic and except in the hands of the it if flexion exists and in either case it
artist who senses the necessary movements
is carried to one side or the other of the
of correction, inaccurate. Armed with a
spinous process of the one below. (Anomaknowledge of the movements even a tyro is
lous spinous processes make this a poor diable to make good corrections if he is able agnostic aid.) The body of the vertebra is
to make accurate diagnosis. They lead to
found moved to the side opposite the side
precision and accuracy and should be under- taken by the splnous process. That is If
stood and used by all students of technic.
the spinous process travels to the left, the
A study of the physiological movebody goes to the right and vice versa. In
ments of the spine may be divided into two
assuming this position, the transverse proparts:
(1) That in which the area of the
cess on the side toward which the body has
spine under consideration is in tension as
moved the concavity of the curve is approxfound in extension or flexion. (2) That in imated to and posterior to the corresponding
which the spine is in balance, without ten- part of the vertebra below due to turning
sion, as found in neutral. Under each of
and tipping of the vertebra. On the side
these circumstances, the components of the
to which the spinous process moves the conmovements of the spine can be stated in the vexity of the curve the transverse process
is separated from and carried anterior to
sequence in which they occur and therefore
diagnosis and correction of practically all that of the vertebra below. Also the one
on the concavity is posterior to its fellow
lesions of the spine can be described by
reference to two laws. These laws are easi- on the convexity and becomes known as the
posterior transverse process while its felly learned and once a part of ones mental
process, become an indispensable part of his low of the convex side is called the anteritechnic.
or transverse process.
Lateroflexion cannot occur if the
Tension is found in the interspinous
spine is in extension or flexion, but rota- ligament with tenderness on the side to
tion occurs freely so it precedes laterowhich the spinous process moves, the convexflexion which always accompanies it. The
ity. The intertransverse ligaments and
law may be stated thus. If an area of the
short muscles are contracted and in spasm
spine be in extension (or flexion) and rota- in the side toward which the body tips and
tion takes place, lateroflexion occurs to
turns, the concavity; and stretched on the
the same side. Thus we have extension (or
opposite side, the convexity. Long muscles 8
flexion) rotation and lateroflexion, -in the
may
be relaxed on the concavity and stretchCorrection will reverse the
ed on the convexity to a slight degree.
-order named.
order of production; i.e., lateroflexion to Tenderness is usually more marked over the
the opposite side, rotation to the same
posterior transverse process in the conside. as lateroflexion and flexion (or exten- cavity although very deep palpation may disslon) in that order.
cover soreness over the anteriortransverse
All Rights Reserved American Academy of Osteopathy®
35
spinous process.
If the area of the lesion is in exLesions in this position exhibit
tension, freer motion is possible in the
certain characteristics. They usually ocdirection of increased extension and limited cur In groups forming curves. The spinous
in the direction of flexion. The reverse is process is found slightly to one side of
the vertebra below it and the body of the
true if the area is in flexion. Freer movertebra in lesion is rotated to a greater
tion is also possible in the direction in
which rotation and lateroflexion have occur- extent to the same side, the convexity.
red but is restricted in the 0pposite direc- The transverse process on the convexity iS
separated from the one below and moved ipostion. This is due to the inability of the
terior in relation to it while in the confacet of the upper of the two vertebrae
cavity the transverse process is apprOXieither to move freely cephalad on the conmated to the one below and moved slightly
cave side or caudad on the convex side.
The body of the vertebra in lesion will ro- anterior. The former is called the posterior and the latter the anterior transverse
tate better into the concavity than in the
process. Tension if found in the interother direction.
spinous ligament and tenderness, usually
In the posture known as neutral,
the spine when it moves acts like a pile of slight if present, is found on the side to
which it moves, the convexity. The interblocks held together by plastic material.
Weight is born chiefly by the bodies nuclei transverse ligaments and muscles are
pulposi. Physiological movement differs
stretched on the side toward which the body
from that found when the spine is limited
turns, the convexity, and contracted and in
in motion by tensions produced by flexion
spasm on the side to which it tips, the conor extension because there is equal or bal- cavity. Long muscles are relaxed on the
anced tension in all directions.
concavity and considerably tensed on the
Movement from the position of neuconvexity. Tenderness may be found over
tral in the anteroposterior plane throws
the posterior transverse process. Motion is
the spine into either extension or flexion. free or possibly exaggerated in lateroflexSince the change in relationship of the seg- ion and rotation, which increases the disments of the spine cannot be forward or
placement in the lesion and is prevented in
backward without destroying easy normal pos- the direction of normal. Extension and
ture, the only primary motion possible in
flexion are restricted by the tensions which
this relaxed position can be sideways or in- hold the joints in abnormal relationship.
to lateroflexion. Primary rotation is imIt should be remembered that there
possible because no fixed points exist which are three components of each
of the two
will act as an axis until lateroflexion
physiological movements. These components
creates tension. Lateroflexion doesnot ocdo not occur separately but always together
cur physiologically without rotation. When
and in a certain order. Correction of lethe lateroflexing vertebra tips to form a
sions produced should exactly reverse the
concavity pressure is produced in the conorder as well as the direction of the mocavity and the body of the vertebra is per- tion. Improper order of movements, leaving
mitted by the plastic supporting structures out or using wrong direction of movement are
to rotate away from the pressure and into
common errors of technic.
the convexity.
(For comparison it will be
Dr. H. H. Fryette who first interremembered that rotation of the body of the preted Lovetts research, does not agree
vertebra in extension or flexion of the
with all of the foregoing statements and
spine moves into the concavity.3
especially with the definitions of flexion
Lateroflexlon is initiated by the
and extension. The laws are stated differweight bearing body of the vertebra and ro- ently by him to conform to the following detation is added to the motion so that the
finitions:
(Extension is the opposite to
body leads the way for the whole segment.
flexion) Flexion in an area of the spine is
It travels farther than the tip of the
an increase of the convexity of the curve.
spinous process but drags it in the same di- Thus flexion would be backward bending in
rection. If the body moves to the left or
the cervical and lumbar and would be the OPright, so does the spinous process but to a posite to the accepted meaning of the term.
lesser degree. Thus the vertebra seems to
Because Dr. Fryette originated the laws and
rotate around a point posterior to the
is their leading teacher and exponent, his
process.
All Rights Reserved American Academy of Osteopathy®
36
views should be included here. For this
purpose I quote from the article "Dr.
Fryette's Spinal Technic" in the 1948 Year
Book of the Academy of Applied Osteopathy.
(Quote) Corrective treatment of spinal lesions to be most effective and least damaging to the tissues must be physiologic, following certain definite movements determined by the mechanics of the spine.
The physiological movements of the
spine, two in number, according to Fryette,
may be stated thus:
(1) "If any area of
the spine be in physiological extension or
in extreme flexion so that the facets are
locked, it is necessary to rotate toward the
side to which sidebending is desired before
sidebending can take place. This operation
occurs naturally in the sequence of extension or extreme flexion, rotation and sidebending."
(2) "If any area of the spine be
in neutral and sidebent, the body of the
vertebra rotates to the convexity of the
curve so formed. Thus we have in sequence
neutral, sidebending and rotation."
The term sidebending Is preferred
by Fryette as being less cumbersome and confusing than that of lateroflexion. The
term neutral, is preferred to easy flexion
or easy normal, as used by some, to indicate
that condition of the spine In which the
facets have not been locked in any degree of
extension or in extreme flexion.
"It has always seemed strange to me
that so many of our profession, even the
committee of nomenclature, Insist that flexion and extension of the trunk on the thighs
is analogous to flexion and extension of the
spine. As a matter of fact, it has no more
to do with flexlon and extension of the
three anteroposterior curves of the normal
spine than have flexion and extension of the
arm or foot."
"When speaking of the cervical region, for instance, one is quite obviously
not speaking of the entire spine and it is
inaccurate to speak of backward bending of
the cervical region as extension of the cervital curve. The same is true of the lumbar
area. It just happens that flexion of the
trunk on the thighs results in flexion of
the thoracic curve and that backward bending
of the trunk on the thighs results in extension of the thoracic curve. This is not
true of the cervical and lumbar curves.
They may say, "What's the difference?" Just
this: Let us divide spine up into its three
anatomical parts and see how each functions.
First, take the lumbar, with its anterior
curve and put It in neutral. The facets
are idling, not working: we sidebend, let
us say to the right, and what happens?
(Remember there is a superimposed load-don't forget that). The bodies rotate to
the left, that is, they move in the line of
least resistance and crawl out from under
the load as far as the ligaments and muscles
will permit. As Lovett says, they behave
like a pile of blocks. Second, take the
dorsal with its posterior curve. Put it in
neutral and sidebend, and what happens?
Just what happened in the lumbar, except
the articulating facets in the dorsal do
not permit quite as free rotation and a little freer sidebending than the lumbar facets;
still the same thing happens that happened
in the lumbar. Third: Now we will take
the cervical with its anterior curve similar to the lumbar, put it in neutral and
sidebend, what happens? The bodies rotate
out from under the load and to the convexity,
just as they did in the lumbar and thoracic,
except as to degree, here again the facets
permit a little less rotation than in the
dorsal and a little more sidebending."
Now let us see if we can compile
this into a law.
In the lumbar when the spine is
sidebent from neutral, the bodies rotate to
the convexity and crawl out from under the
load. The same thing happens in the dorsal
and in the cervical, so we may say: When
any given area of the spine is put in neutral and is sidebent the bodies rotate to
the convexity. The sequence is neutral,
sidebending, rotation - never in any other
order.
Now let us observe what happens when
we put these three areas in extension, that
is when we straighten out the normal curve,
and sidebend. Let us take the lumbar first.
We bend the lumbar forward until the facets
are separated to the limit of motion, then
we try to sidebend but we cannot until we
rotate slightly in the direction of sidebending, or toward what is to be the concavity. Therefore in extension, we rotate
and sidebend in the sequence of extension,
rotation sidebending - never in any other
order.
Now let us take the dorsal. We extend the normal curve by backward bending.
In this position the facets are approximated
to the extreme limit and are in control of
motion, even more than they were In the
All Rights Reserved American Academy of Osteopathy®
37
lumbar when they were separated, because in
extension of the lumbar curve the weight is
increased on the discs, whereas in extension of the dorsal curve the weight is diminished on the discs, and therefore, the
facets have less stress to overcome in rotating the body to the concavity, so that
It can sidebend.
(Important!
This accounts
for the fact that we have many more extension, rotation, sidebending lesions In the
dorsal than in the cervical and lumbar.)
To extend or straighten out the norma1 cervical curve we bend the head forward.
The cervical area behaves as the lumbar
area did, except as I have said, the structure of the cervical permits more sidebending and less rotation than the lumbar.
Then we arrive at this conclusion,
which Is really a law: In any area of the
spine when the normal antero-posterior curve
is put into extension the bodies of the
vertebrae must be rotated toward the side
to which the spine is to be sidebent before
It can be sidebent, Therefore, when any
given area of the spine is put in extension
rotated and sidebent, the sequence of operation Is extension, rotation sidebending never in any other order.
"If the spine be cut posterior to
the bodies, according to Lovett, the posterior part acts like a flexible ruler or
corset stay which must be twisted in order
to be sidebent. The anterior part, the
bodies, acts like a pile of blocks which
if sldebent tends to crawl out from under
the load, or go to the convexity. This is
the anatomical explanation of the physiological movements of the spine. Lesions
are produced by the inexorable pull of
gravity on the unstable human spine in one
or the other of these two patterns. The
action of gravity must be considered in
every lesion. Gravity is the force and
anatomical structure is the guide which
makes the spine behave as it does in the
physiological movements. Gravity tends to
make the spine collapse, while the structure of the spinal column determines the
nature and extent of the deformity. Gravity causes lesions to develop in one of the
two physiological patterns described, depending on the position in which it finds
the spine. It is the most pernicious influence acting on the body."
The reason for distinction between a
lesion produced in extension and one pro-
duced in neutral is obvious, because of the
difference in direction and sequence of rotation of the vertebral body in relation to
sidebending. The reason for distinguishing
between a lesion produced in extreme flexion and one produced in extension Is not so
obvious and may be the point where some of
his students fail to understand completely
Fryette's idea of correction of lesions
along physiological lines.
From the fact that the spine acts
similarly when it rotates and sidebends in
extension and extreme flexion, it might be
concluded that correction of a lesion in
both cases should be identical; i.e., extension or extreme flexion, rotation sidebending in the reverse of production. This
conclusion would be true if one circumstance did not prevail which changes the
conditions; i.e., the impossibility of the
body maintaining extreme mechanical flexion
for any considerable period of time. The
extreme flexion of the original lesion soon
changes to moderate flexion. When the area
of the spine where the lesioning occurred
moves either into moderate flexion or neut ral the mechanics of the back force the
bodies of the vertebra Involved to move,
under the pull of gravity, from the concavity to the convexity and we have a lesion
of the neutral type in flexion. Dr. Fryette
says he has never actually seen a lesion of
the extreme flexion type with the bodies
rotated to the concavity in forty years of
experience. "For all practical purposes
extreme flexion, rotation, sidebending lesions may be disregarded in treatment."
A large majority of all lesions of
the spine are either (1) flexion, sidebending rotation lesions, or (2) extension rotation sidebending lesions. Treatment is
applied by placing the spine in the proper
degree of extension or flexion and reversing rotation sidebending or sidebending rotation, depending on the type of lesion, to
permit the lesioned vertebrae to be carried
into normal relationship.
A clear diagnosis of the lesion described in terms of the physiological movements tells exactly in what position the
spine must be placed and automatically commands a certain accurate corrective series
of movements. It contraindicates other
movements as superfluous and incorrect.
In correcting an extension rotation
sidebending lesion, the area is extended
and the sidebending taken out by straighten-
All Rights Reserved American Academy of Osteopathy®
38
necessity of differentiation in diagnosis
ing the spine. Rotation and sidebending
if treatment is to be effective. A knowlfollow in that order in the direction of
edge of the physiological movements as decorrection. This movement is slight, just
enough to start the process. It must not be scribed will enable the teacher of technic
overdone. The thrust on the lesioned verte- to diagnose the lesion in such a way that
correction can be done step' by step and exbra is directed in such a manner as to free
the facet, facets and/or body contact and
plained simply and clearly. By teaching
to carry the area into flexion. The opera- technic in such a way it is possible to
show the student how treatment is done by
torts mind is kept on the ends of his fingers. The joints are not scuffed or jammed technical processes formulated to meet the
exact conditions found by diagnosis.
and too much rotation and sidebending is
A lesion may be diagnosed in terms
avoided. Flexion is used to take out the
of physiological movements and corrected in
extension present in the lesion.
the same way. For example a vertebra may
Other factors which may complicate
the lesion, such as slips forward, backward be found in lesion in an area of extension
or to the side, must be considered, but the with its body rotated and lateroflexed to
vast majority of extension lesions are cor- the left. After diagnosis, a knowledge of
rected by the application of simple mechani- the physiological movement by which the
cal rules. No matter what position the pa- part got into that position will enable the
teacher to know exactly what movements are
tient may be in or what unusual conditions
may interfere with the physician's technic, to be done in correction. In correcting
the lesion mentioned the area is placed in
the same mechanical principles apply. An
extension rotation and lateroflexion to the
understanding of them will help the physileft. (This is to place the lesion in pocian devise a technic adapted to cope with
sition for correction.) Now lateroflexion
every condition, making his correctioninis produced to the right, the body of the
variably accurate and specific.
vertebra is rotated to the right and then
The neutral or moderate flexion
sidebending rotation lesion, usually in the the area is carried into flexion in that
order. In whatever position the patient Is
form of a group curve lesion, is corrected
by placing the area in extension and rotat- treated and whatever the state of the soft
tissues and the health of the patient, this
ing and sidebending in the direction oppoformula applies. It is comparatively simple
site to production.
Correction of practically all osteo- to understand and teach spinal articular
pathic spinal lesions may be made by the ap-corrections, if technic is so systematized.
Such a codification of technic is
plication of these two rules, with less
necessary to avoid the confusion and complitrauma and greater certainty of correction
cation of holds and manipulations which
and less probability of recurrence of the
have contributed toward making a difficult
lesion than with technics not specifically
following physiological lines. To a scient- art doubly difficult to teach and learn.
1st and a perfectionist like Dr. Fryette, it It does away with the "This is how I do it"
is a painful thought that many students are type of teaching and places instruction on
ineffectually trying to learn how to correct a scientific basis. Consciously or unconspinal lesions and many conscientious physi- sciously, those who have become artists in
clans are attempting to teach them in a hap- osteopathic technic use such a system. The
hazard and relatively ineffective manner be- late George Webster described a system
cause they are not guided to good and conwhich was effective in his hands, though not
sistent technic by these simple rules.
so simple and teachable as the one described.
(Unquote)
There are probably others.
A very high percentage of spinal leIn conclusion, technic for the corsions are of these two types. Other lesions rection of spinal articular lesions can be
probably considerably less than 1% of the
taught systematically and scientifically.
total, are atypical and are named as diagThe basic principles which may be used are:
nosed. The naming indicates the corrective (1) The path of correction should follow
technic, as for example an anterior atlas
as closely as possible the path of producsuggests moving it posterior on the axis.
tion.
(2) Production of a lesion is along
A comparison of the two types of the physio- the path of the part as it follows one of
logical movements and lesions will show the the two types of physiological motions.
All Rights Reserved American Academy of Osteopathy®
39
(3) Correction reverses these physiological motions. These are the fundamentals.
Each artist in the field of osteopathic
technic uses these or very similar fundamentals when he corrects a spinal lesion
as a basis for the refinements which make
his treatment a thing to be admired and appreciated by the patient. If it can be so
taught, students will readily acquire an
appreciation of technic they may never obtain from an unorganized presentation, no
matter how skillful and even spectacular
the demonstration may be or how eloquent
the lecture which accompanies it.
Teaching Technic
Technic must be as carefully conceived and as reasonable as the diagnosis
which precedes it. A good diagnosis is
futile unless it is implemented by good
technic. The teacher must train the student so he will know how to give a good
treatment under any and all circumstances.
How can this be done? Obviously it is an
impossible task to teach specific treatment for all types and degrees of disease.
What then is the answer?
A physician can be proficient in
technic if he understands the principles
involved and is able to apply them. A good
physician can devise a procedure accurately
adapted to the needs of each specific situation, whether he has encountered it before
or not. If he is able to make a specific
osteopathic diagnosis, he can give a specific osteopathic treatment and if the diagnosis has been correct the treatment will
be beneficial. Therefore, the teaching of
technic should consist first of principles
and second of practice in translating these
principles into action. If he learns these
lessons well, the student may then give an
intelligent treatment under any reasonable
circumstance.
The fundamentals of technic as applied to the osteopathic articular lesion
are simple,* though the technic may be complex. A few elements can be compounded into many complex actions. By careful diagnosis, the bony displacement at the articulation, the limitation of motion and the
alteration of the condition of the soft
tissues can be determined. Also with experience the effect of the lesion on the
body economy and the general health of the
patient can be evaluated and the desirability of a change in the lesion decided. This
knowledge indicates what the technic shall
be.
Corrective articular technic implies specific motion. This means in articular technic that some mass is moving at
some rate over a certain distance in a certain direction. Diagnosis tells what to
move at what rate and in what direction
and how far. Technic is the action of the
physician doing what diagnosis indicates.
For example, if diagnosis indicates that a
vertebra is in lesion in such a way that
the area is extended, rotated and lateroflexed to the right and is held by tissues
exhibiting the characteristics of an acute
inflammatory reaction of considerable intensity, a course of action is indicated
by the changes found. Likewise, if the
vertebra is extended, rotated and lateroflexed as before but is held by tissues
showing the effects of chronic inflammation
another course of action is indicated. Although both lesions are diagnosed as extension, rotation and lateroflexion to the
right the treatment varies considerably.
What is to be moved and the direction and
distance of the motion are determined by
the positional diagnosis but the manner of
moving it and the treatment of the soft
tissues is influenced by the conditions of
the supporting tissue as well as a consideration of the systemic effect of the movement.
An athlete and an old lady may have similar
local lesions from the standpoint of relative position of the parts but technic of
treatment may vary considerably because the
condition of the tissues varies. Furthermore, should the athlete have meningitis
and the old lady be in excellent health,
the treatment would be further modified because of systemic conditions. Diagnosis
finds and evaluates the systemic conditions
and determines their relation to the lesion.
Also it explores the pathology at the point
of lesion. Technic is the means of putting
osteopathic principles into constructive
action in the treatment of the abnormal
* A review of the chapter on Terminology and Diagnosis of Anatomical Changes in the Spinal Articular
Lesion will help recall some of these fundamentals. The Chapter on Diagnosis of Pathology in Relation
to the Osteopathic Lesion will give others.
All Rights Reserved American Academy of Osteopathy®
40
conditions, local and systemic, found by
diagnosis. It cannot be applied empirically. No prescription can describe it be.
cause in every instance it has to be an
original creation designed to meet a specific diagnosis.
An articuiar lesion may be corrected
in one of two basic ways:
(1) Direct technic: the method of
moving one bone or segment of the articular lesion directly to a normal relationship with its neighbor. This is accomplished against the resistance of tissues
and fluids maintaining the abnormal relationship. It sometimes involves more
trauma than the second method to be described. Direct technic is the most commonly taught and used type of corrective
treatment. Unfortunately it is too often
applied without careful study of the exact
relationships and pathological conditions.
Shock reactions are too frequent, resulting in increased inflammatory reaction.
Direct technic is valuable but it must be
used with discretion. It has great possibilities for benefit or damage and its
intelligent use requires fine judgment based on accurate diagnosis.
(2) Indirect technic: the method
of moving one bone or segment slightly in
the direction away from the direction of
correction until the resistance of holding
tissues and fluids is partially overcome
and the tensions are bilaterally balanced;
then allowing the released ligaments and
muscles themselves to aid in pulling the
part toward normal. Other body forces including that of respiration may be employed. It is the type of technic described
as "exaggerating the lesion" before correction although actually the lesion is
not carried beyond the point where the insult took place which produced it and exaggeration does not actually occur. The "exaggeration" is done to relieve as much as
possible the tensions which maintain abnormal relationship preceding the enlistment
of the natural pull toward normal. During
correction, if diagnosis has been accurate,
the 'displaced part should retrace the
course it took in becoming lesioned.
Therefore, shock and inflammatory reactions
seldom result from careful indirect corrections, especially if done with respiratory
cooperation.
The teacher of technic should indicate clearly which type of technic, direct
or indirect, he is demonstrating and should
explain why he has chosen it, with due consideration of the abnormal conditions present and the condition of the patient.
What has been said previous to this
point has applied to the spinal lesion and
to reduction of articular displacement.
It has been stated that accurate diagnosis
indicates the treatment. This is of course
true of any lesion.
However, there is another consideration in every treatment that must be definitely decided. It is this: How much and
what kind of soft tissue work is to be
done and at what point in the treatment is
it best used? Each physician must answer
this question during each application of
treatment. The instructor must be prepared
to help the student decide it. What the
teacher says will depend on the instruction
he himself has received and his own experience.
Certain things must be considered
before teaching the use of soft tissue
treatment. First, for our purposes, in
teaching technic let us eliminate visceral
and other ventral structures from consideration and define soft tissue as tissue not
bone or cartilage related to the joints in
lesion, confining it to muscles, soft connective tissues, nerves, blood vessels and
and fluids affected by and helping maintain the articular dysfunction. Second,
let us understand that all technic of correction of joints is applied to and changes
only the soft tissue. This is true of the
work of the so-called specific technician
who says he moves bones only and never
does soft tissue work. Third, since Burns*
has shown from animal experimentation and
Kauffman** has reasoned from a review of
the literature that manipulation of soft
tissue may cause local harm by increasing
inflammatory reaction and blocking the lymphatics, unwise manipulation may cause an
* Louisa Burn's experiments on rabbits show any corrective manipulation to lesioned areas produces inflammation as evidenced by increase in petechial hemorrhages.
** C. H. Kauffman in "A Discussion of Osteopathy and Its Relation to Physical Medicine" maintains that
most so-called physical therapy as well as drug medication, blocks lymphatic6 and disturbs the vasomotor
and proprioceptive impulses originating in the area.
All Rights Reserved American Academy of Osteopathy®
41
increase of pathology and dysfunction.
Fourth, some so-called corrected lesions
are actually chronic lesions with attendant
decrease of pain and apparent though not
actual improvement of function, this chronic condition having been hastened in its
development by unwise treatment. From
these facts we may reason that any manipulation of a lesion will irritate soft tissue to some extent and should therefore be
used with understanding and for a definite
purpose. Soft tissue work itself must be
specific.
The recommendation that unindicated
manipulation be avoided because of possible
damage to soft tissue, does not mean that
soft tissue treatment is to be eliminated
completely. Soft tissue pathology frequent
ly is the cause of recurring articular lesions either by direct mechanical effect or
by reflex action to related structures.
These soft tissue lesions must be corrected
if diagnostic evaluation shows they are
causing functional adisturbance, however remote that may be. Like any osteopathic lesion, the corrective measures are specific.
What should be done, is done; no more, no
less. There is no excuse for thoughtless
and routine work.
Technics of treatment of the viscera, like specific articular and soft tissue technics, are directed to the correction of definite anatomical displacements
or pathological conditions. As in any tech.
nit, an intimate and accurate knowledge of
the exact anatomical relationships found
and a careful correlation of these findings
with observed dysfunctions, directs the
physician's effort. Each organ presents
specific problems and is worthy of close
study to find how it may best be assisted
in maintaining normal function.
There are fields of technic which
need exploration and development. Wales*
has suggested that natural forces in the
patient's body be made use of by the physician. New concepts developed in recent
years are being brought to the profession.
Sutherland has pioneered. in cranial technic
and Chapman in his so-called reflexes.
These methods need discriminating study and
development and more general appreciation.
Exaggerated breathing as an aid to manipulative technics in anatomical correction in
any locality has been advocated because respiration is a physiological movement and
as such should be considered in technical
procedure. Development in technic as in
any creative art needs imagination to give
it originality and meaning. The teacher
should bring out this quality in the student. He will then have given the younger
physician a priceless tool, adaptable and
effective according to the ability and interest he shows in using it.
In technic instruction, an exact description of the lesion in question is
first required. This includes both anatomical and pathological changes. Second,
the effect of the lesion on local segmental
and systemic function and structure is postulated and the advisability of correction
determined. Third, the method of correction is described and justified by reference to the previous diagnosis, which indicates the technic to be used. Fourth, the
manipulation is done slowly. Each step is
mentioned but not discussed in detail at
the time. The steps may be repeated in
most cases without harm if the work is carefully done. Fifth, the four preceding steps
are now recapitulated and questions answered. Sixth, the student may practice what
he has learned on appropriate subjects, being watched closely with the view of preventing the formation of wrong habits and
encouraging the habit of independent thought
and reason as it directs accurate hands to
intelligent action.
It may seem to some instructors that
this makes technic teaching too intricate
and difficult. Let those who so think consider the number of mystifying or misleading demonstrations he has seen put on by
clever and intelligent people using less exacting methods. Let them remember that accuracy in treatment and the ability in diagnosis which it implies is the hall mark of
the osteopathic physician. Without it he is
futile. With it highly developed, he is
without peer.
* Osteopathic Dynamics--Yearbook Academy of Applied Osteopathy
1946.
All Rights Reserved American Academy of Osteopathy®
THE USE OF "THE PATTERN" IN TREATMENT OF AN ACUTE TRAUMATIC LESION
H. V. Hoover B.S.,D.O.
After the physician has decided
that an osteopathic lesion exists and that
change is indicated, the exact treatment
to be applied must be determined before
corrective forces are used. Diagnosis dis
closing the path of physiological movement
of production of the lesion and the physiological and pathological changes in the
local and remote related tissues indicates
what disturbance exists and the direction
and type of force applied for correction.
If the parts were in normal postural relationship before the insult which produced
the lesion occurred, obviously they should
be returned to normal conditions and position. But if, as is more frequently the
case, the parts were conditioned by long
standing postural strains before the lesion under consideration was produced,
treatment must be modified in consideration of the pre-existing conditions. This
calls for careful evaluation of existing
and pre-existing conditions as a preface
to the application of treatment.
Normal posture is a rarity. Certain curves, tensions and balances in time
become fixed characteristics of the posture of the idividual. These changes
from perfection in posture are the answer
of the defensive mechanism of the body as
it resists the pull of gravity and other
forces which may act on it. Similar conditions such as, for example, an uneven
sacral base or an uneven occipital base
tend to produce characteristic patterns of
compensation in the spine and cranium.
These basic patterns are perversions of
structure but because of their slow development and the ability of the body to
adapt to slowly occurring change, they may
not cause recognizable disturbance. However, if upon these basic patterns a new
lesion is superimposed, symptoms develop
not only in relation to the site of the
new lesion but in other parts of the pattern, thrown out of balance by the new lesion. These 'symptoms bring the patient to
us demanding relief and the new conditions
causing them are what need treatment. If
the new lesion can be removed by placing
the parts in the relationship and condition
obtaining in the old pattern and the imbalances resulting from the new lesion removed
from the old pattern, the individual should
be quickly relieved of his newly acquired
pains and functional disturbances, although
still retaining his original postural deviations from normal.
To clarify this point let us consider two cases.
Case 1. A patient presents herself
with an acute "catch" in her back, brought
on several hours earlier in the day by lifting a small box while stooping in a cramped
position. The history reveals a weak back
which is stiff and tires easily. There
have been previous episodes of similar
"catches" which however were not as severe
nor as incapacitatirig as the present one.
The patient because of pain which has
steadily grown worse since its onset, needs
assistance even to change position and has
difficulty preparing for examination. Xray is indicated but pending the report
something must be done. General physical
examination reveals nothing which would
cause the severe symptoms. Examination of
the back by light palpation shows an acute
inflammatory reaction at the level of the
second and third lumbar vertebrae. The patient, as well as the palpating fingers,
says "that's the spot." Above and below
the acute lesion are found evidence of
chronic lesioning and careful examination
shows that the acute lesion is at the apex
of a normal flexion (or neutral) group
curve to the left of the midline, which extends from an uneven sacral base low on the
left, to the lower thoracic area where the
curve crosses the midline and forms a group
curve to the right of the midline, the
apex of which is at about the 6th thoracic
segment and which again crosses to the left
side in the upper thoracic; I. e., a typical
functional scoliotic type of back. Soft
tissue examination reveals chronicity
throughout the extent of the back, indicating a postural strain of long standing.
42
All Rights Reserved American Academy of Osteopathy®
.
43
acutely lesioned segments are moved into
The acute lesion in the lumbar area breaks
the symmetry of the curve and obviously de- the relationship they held as a part of the
scoliotic curve, knowledge of the physiolostroys the balances set up by the curves
compensating for the tilted sacrum. The
gical movements of the spine being used in
decision as to what treatment to apply to
properly positioning the patient and physi-'
the acute lesion which is causing the pain
ological motion of respiration being emis modified by the previous condition of
ployed to free and move the segments into
the back.
their place in the curve. Following this
There are several courses of proce- the area may be taped to hold the curve,
dure open to consideration.
and the patient is rested to permit resolu1. The patient may be put to bed
tion of inflammation.
and the part rested until the acute pain
This latter method often causes the
subsides. Cold applications and traction
operator to move a segment not toward but
may be used as well as sedatives, narcotics away from ideal normalcy of posture with
and/or local anesthesia. This is not the
the vertebrae all in the midline, and thereway most osteopathic physicians handle such fore the corrective procedure may appear
a case and, except in the presence of exillogical and harmful. Yet if one stops to
treme and unrelenting pain preventing other realize that the patient was comfortable
treatment, is not the procedure of choice.
and functioning fairly well until the sym2. A frequent procedure is that of metry of the compensating curve was destroymanipulating the soft tissue to relieve ten- ed, it seems reasonable to replace the body
sions, spasms and edema so that the bony
at least for the time being in that comrelationships may be corrected more easily. fortable and functioning posture in order
This often includes the use of radiant heat, to relieve the acute pain. This procedure
or diathermy. After the tissue has been
is the method of choice in treating acute
put in condition to permit it, correction
lesions. If ineffective for any reason,
of the bony relationships is effected. The one of the other approaches may then be
correction may be at the first or at any
used.
one of several subsequent visits. This meIt is not always easy or possible
thod is the least effective procedure deto restore the pattern. The rub often
scribed and is mentioned to be condemned.
comes in determining the pattern. A patNeedless manipulation and heat, other than
tern may have developed on the original patmoist heat properly applied, increase the
tern due to trauma subsequent to the oriexisting inflammation and congestion and are ginal cause. Also the pattern may have
contraindicated in the type of case under
been shattered beyond repair and if so, the
consideration.
posture must be completely reconstructed.
All this complicates diagnosis and treat3. A procedure often used is that
of correcting, sometimes with considerable
ment. Experience in observation and palpaforce, the relationships of all of the parts tion of tissue is a valuable aid in deterin immediate relation to the acute lesion.
mining the pattern. Dr. Robert B. Thomas
This involves in our case leveling the base has developed a functional method of testby sacral correction, removing the compening which detects postural strain by observsating curves and placing the acutely leing muscle clonus in areas of strain. At
sioned vertebrae in normal relationship to
best, however, diagnosis of patterns is a
each other. Following this, taping to main- difficult procedure but worthy of careful
tain the corrected position, rest, sedastudy in every case because results of
tives, etc., may be used as in the previous- treatment are startling and gratifying if
ly described procedure. Dr. Martin Beilke
the pattern has been determined and it is
of Chicago has conducted clinical experipossible to make accurate restoration.
ments at the Chicago College of Osteopathy
Case 2. A woman has fallen backwhich indicate the efficacy of this method
wards and struck her head. Upon recovery
over the so-called palliative and/or soft
of consciousness it was found that her metissue approach.
mory for words and numbers was impaired so
4. The procedure which is producthat she could no longer dial the telephone
tive of quickest and most spectacular relief and in conversation would stop to grope for
of pain and return to easy function consists the most common words. Her head ached seof treating only the acute lesion. The
verely and she complained of soreness behind
All Rights Reserved American Academy of Osteopathy®
44
her ear and in back of her head. She says
that was where she must have hit her head.
Examination was made about a week
after the accident. The tenderness in the
head is localized to the occipito mastoid
area and is due to a severe lesion at that
suture and not to a bruise. The rest of
the head is sensitive but shows no marked
traumatic lesions. There is a rotation
sidebending of the spheno-basilar articulation to the left. This rotation and sidebending is not marked but the position and
'shape of the bones of the cranium and face
conformed to it indicating a condition of
long standing, possibly from birth. The
right temporal exhibits internal rotation
of the petrous portion more marked than one
would expect to find in relation to the
mild sphenobasilar lesion.
What should be done in this case.
The physician has here as in the previous
case several choices of procedure.
1. He may use purely palliative
measures as ice packs, sedatives, rest,
heat etc, which is the only course open to
physicians who are not trained cranially.
2. He may use bulb compression to
attempt to relieve the fluid and membranous
tension. This may be effective eventually
but with the head so tender and in the presence of such a pronounced traumatic lesion
this method would be used rarely.
3. He may attempt to correct all
of the postural lesions in relation to the
sphenobasilar and in so doing normalize the
acute traumatic lesion at the occipito-mastold. This must be done in some cases
especially when the pattern cannot be deter
mined accurately or it has been hopelessly
shattered.
4. He may free by appropriate methods the temporal and mastoid and permit
the natural pull of membranous tensions and
force of fluids to bring the bones into the
relationship that existed before the accident occurred. These forces will tend to
place the temporal in its old pattern which
leaves it still in internal rotation. This
method secures the quickest and most satisfactory results. The chief point to be
noted is that the temporal bone is still in
a position of internal rotation after accur
ate correction and while in this position
the patient gets complete symptomatic relic
The later treatment of the pattern
itself is a matter of judgment on the part
of the physician. He must decide whether
it is better to leave the patient with his
accustomed pattern or to change it. Many
factors other than the reaction of the patient to the injury enter into the decision,
as age, general health, stability of the
pattern, acuteness or chronicity of tissue
reactions, occupation, and financial conditions. It is not always easy to determine
whether it is wiser to embark on a program
of rebuilding the patient or to leave him
as he is. If he is to be reconstructed
both the physician and patient should be
aware of what it may mean in health, time,
energy and money.
A Measure for Osteopathic Technic
A system or method of judging a
technical procedure in osteopathic treatment is obviously of value to the physician.
If he can examine a piece of technic and
determine if it is physiological in its application, effective in its results and efficient in saving the strength and time of
the operator, he is able to accept or reject technics with assurance, and to examine his own procedure with benefit. Thus
he becomes more efficient by improved technical methods, appreciated by both doctor
and patient.
The evaluation of a technic falls
naturally into two parts. The first has to
do with the question "Is the technic physiological?" The second concerns itself with
the effects of the technic on the patient
and the doctor.
The physiological movements of the
spine are known to osteopathic students.
Consequently they know the path a segment
of the spinal organ follows to reach the
position where the insult took place which
produced the unphysiological conditions,
known as an osteopathic lesion. Since technic of reduction of a lesion should be so
designed as to reverse the procedure of production it is clear that the process of reduction of the lesion should take into consideration the elements of the physiological
movements of the spine; i.e., flexion or
extension, rotation and lateroflexion or
other motions possible in certain areas.
The soft tissue involved in the correction must be considered and the technic
adapted to meet the conditions found so
that the application of forces is as physiological as possible. Acutely irritated
All Rights Reserved American Academy of Osteopathy®
,
tissue requires a different approach than
does chronic fibrosed tissue.
Any technic which does not consider
these factors in reversing the motion of
lesion production and the state of the soft
tissue is deficient. Any good technic includes them whether the physician is conscious of it or not.
For instance, a technic designed to
correct a rotation lateroflexion of the
second thoracic segment on the third thoracic which does not take into consideration the component of extension or flexion
is doomed to failure. This is because of
the fact that if the lesion was produced in
extension (or flexion) it should be correct.
ed by taking out the extension (or flexion)
at the same time the rotation lateroflexion
is eliminated. Otherwise the lesion persists in a modified form. The operator
then wonders why his correction is not permanent, often blaming factors other than
his own lack of care in diagnosing and correcting all components of the lesion. Also
if acute spasm or fibrosis prevents correction it is useless to attempt it until the
soft tissues are properly treated.
The second part of the evaluation
concerns the effects of the treatment. To
the patient the procedure must be primarily
beneficial and secondarily comfortable. To
the doctor it must preserve primarily his
health and secondarily his time. The improvement of the patient's health is the
primary reason for administering a technic
and under extreme circumstances is the only
consideration. But lacking emergency, the
physical and psychic comfort of the patient
deserves consideration. The technic least
likely to cause pain should be used, if a
choice is possible. Also if one technic
may embarrass the patient and the other not,
the embarrassing one should be discarded.
Some patients dislike bodily contact. Some
dislike "popping" of joints. These and
other factors may modify the application of
treatment.
The doctor before using a technic
must consider whether the resulting benefit
to the patient warrants the drain on his
own strength and vitality or if some less
taxing method, perhaps only slightly less
45
effective, may be sufficient. Also, if the
condition of the patient may be changed for
the better in a few minutes it will be foolish to use a technic no more effective but
requiring a longer time, providing the
shorter one is not uncomfortable to the patient or too taxing to the physician.
To summarize, a technic must be
proven to be physiological. It is to be
judged for benefit and comfort of the patient and for the effect on the health and
the use of time of the physician.
To be efficient each physician
should constantly evaluate his own technic
to see if it meets these requirements. If
it does not meet them, he should make it
do so.
Postscript
Before I came to the end of the
task of writing these pages, I realized
that they were being written, not so much
for the profession in general as for one
member of the profession in particular who
demonstrates technic occasionally, writes
articles about it at times and has attempted to teach it. What started out with the
idea of pointing out some observationsand
opinions on technic to demonstrators and
teachers, became a means of crystallizing
amorphous and unsystematized ideas previously floating about in the author's mind. He
has in this process received considerable
benefit. I recommend to every physician
who wishes to progress and develop professionally that he put his ideas on paper.
The process will bring him to the realization of the need for improvement, as nothing else will.
This is not the last word on teaching osteopathic technic. It is merely intended to open up a question which has received too little study and consideration
in the past. It is the author's hope that
it will be the starting point for a serious
examination of the technics and teaching of
osteopathy to the end that the graduates of
our Colleges and as far as possible, the
practicing physicians may be taught how to
deliver more effective osteopathic treatment.
All Rights Reserved American Academy of Osteopathy®
THE CONTRIBUTION OF CARL P. MCCONNELL, D.O.
TO OSTEOPATHIC LITERATURE
Anne L. Wales, D.O.
Carl P. McConnell, D.O. from the be.
ginning of his professional career, contri
buted to the advancement of Osteopathy.
He was born in West Salem, Wisconsin in
1874.. While studying science at the University of Wisconsin his eyes began to fail
him and grew progressively worse although
he was under a specialist's care. He became a patient of Dr. C. E. Still when Dr.
Still was located at Red Wing, Minnesota,
and improved rapidly. This experience engaged his interest in Osteopathy and led
to his matriculation in the American School
of Osteopathy in Kirksville, Missouri, in
the fall of 1894.
Dr. McConnell graduated with the
class of 1896 and practiced as an assistant
to Dr. H. M. Still for several months in
Chicago, Illinois. He held the chair of
Theory and Practice in the American School
of Osteopathy for two years and served at
the same time on the staff of the A. T.
Still Infirmary. In the fall of 1900 he
located in Chicago for the private practice of Osteopathy.
Dr. McConnell was president of the
American Osteopathic Association during
the year 1904-1905. As president of the
young association he acquired a knowledge
of the problems of the profession and a
perspective from which he evolved a philosophy for the development of the science of
Osteopathy. His views and his evaluations
are not only illuminating in an historical
sense but they also reveal the fact that
the profession today is still concerned
with the same processes of development.
In the following address, which Dr. McConnell made before the Greater New York Osteopathic Society while he was president
of the A.O.A., he shows the breadth and
depth of mind which he subsequently applied
to great purpose in furthering the teaching of Dr. Andrew Taylor Still. It is possible to see in his argument why and how
he came to devote himself to research in
osteopathic pathology.
The fruits of Dr. McConnellls labors
are to be found in osteopathic literature
over the years following his year of office. It is hoped that this rich contribution will be progressively retrieved from
the archives and made available to the profession today in a series of condensed reviews for the Academy of Applied Osteopathy. For the works of such minds cannot
serve their full purpose unless they live
on in the minds of those who follow in the
same service.
The following paper has been chosen
as an introduction to the projected series
because of the comprehensive view it offers
not only of the author but also of the
problems and the field to which he applied
himself in later works. It is condensed
and edited to a slight degree in the interests of smoother reading. The full address appears in the Journal of the American Osteopathic Association, Vol. 4, No. 8,
page 288, April, 1905.
Limitations of the Osteopath
An Address before the Greater New York
Osteopathic Society, December
17, 1904, by Carl P. McConnell,
D.O.
In discussing the limitations of
the osteopathic practitioner, let it be
clearly understood that I am in no way referring to the limitations of Osteopathy,
for I firmly believe that the science of
Osteopathy is the system of medical science and art that completely and absolutely includes and is applicable to all the
field of medicine in its broadest sense.
Dr. Still is unquestionably the originator of the theory that the character of
structural relations and alignments is a
true basis of the etiology of disease.
The point I am desirous of emphasizing is
that the drug school's teaching of the
past decade is unmistakably leaning toward the osteopathic.
46
All Rights Reserved American Academy of Osteopathy®
47
Neither am I to discuss the limitations of the osteopathic theorist, for he
is in an advanced class by himself. Fortunately for Osteopathy we have always had B
good theorists and not a small portion of
our inspiration has been due to them. They
have continually held before us (and thus
illumined our way) a delineation of the logical path of osteopathic development.
This has been no small part. The evolutionary tendency of osteopathic probabilities and actualities has been a guide to
all practitioners that boded much good.
Practically all of our work has been pioneer work. Case after case has come to us
which we should be able to cure or benefit
according to our philosophy. What then
would we have done without our theorists?
No one aside from Dr. Still had the experience to support our decisions. Consequently, judgement based upon practice had to
be substituted for the time being, by logical deductions.
Our philosophy has been stated in
such clear, concise, and simple terms that
even the layman has been able to grasp its
logic and significance. Of course our
theorists have had anatomic, physiologic,
and therapeutic facts on which to base
their theories. It is true that our theorists could not have written so forcefully
and appealingly if our practitioners had
not obtained results. As stated, our
theorists are in a class by themselves, and
well they should be, for a theory in its
proper use signifies the highest form of
knowledge.
Our paper then is to be a discussion
of the actualities that confront the osteopath in the field and point out a few of
our limitations or weak spots, as well as
to suggest a remedy for them.
What Confronts the Practitioner
There are genuine problems which
confront the osteopath in the field. A
discussion of these will help to broaden
and develop us all. To the studious practitioner must we look for the real advancement
in Osteopathy. The practitioner represents
the unit in our profession and his welfare
and relations constitute the basis of practical Osteopathy. Not that our colleges are
unnecessary and do not represent the highest type of education, but their special
function is to teach and crystallize osteopathic thought and theory. The practical
test of our therapeutics, the test of real
worth and value, falls upon the field member.
It is true that our colleges aim
to turn out capable practitioners; and
their efforts have been crowned with success. But no matter how practical a college course may be there are always a
thousand and one problems the graduate will
meet only in the field. His tact and judgement will often be taxed with problems
quite foreign to clinics and theories.
Often upon his decision of these problems
will his success as a practitioner depend.
Not that I depreciate thorough scientific
education, for no one appreciates it more
than I, but there is another part of education, tactful and practical education, which
is dependent upon a balanced brain, and
without this one's perspective may easily
get distorted. This side of the education
can be developed to the maximum in the
field; it can be included in the college
course to a minimum extent only. Thus a
classmate whose college examinations were
of no particular credit may be a successful
physician provided he has a thorough comprehension of practical Osteopathy backed by
mature judgement. Consequently, there are
problems arising with the field practitioners that our college professors may be
largely strangers to, and still at the same
time the evolution of Osteopathy is dependent upon.
The osteopathic theory is not supported in all detail instances by a series
of established facts; if it was, abstract
principles of the science would not be necessary, although we are in the unique position of having a dearth of theories to
explain definite and exact results obtained
in practice.
(It should be noted here that
I am not referring to the general theory of
Osteopathy.) In drug medicine it is usually the reverse; practice is largely deduced
from theories. The only point in common of
the various schools of practice in medicine
is the induction of principles from the results of practice, of which the osteopathic
stands by far the foremost. Unless the
general principles or theory of a science
is based on actual results, the so-called
exposition may be nothing but a false fabric. Hence, one of the reasons why the
science of osteopathy is logical and in
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48
many instances drug science illogical is
because the former is deduced from actualities and the latter is nothing but hypotheses.
The Practitionerls Limitations
I. His conception of Osteopathy
One's success in practice will depend almost directly upon his conception
of the science; that is to what extent and
in what character the concept has taken
root. He may be able to appreciate that
Osteopathy is applicable. superficially
only, to health and ill health. Although
his belief in the science may be firm in
what he terms a limited application, there
are others whose application may be extensive and comprehensive of all physiological
functions. The statement may be logically
made, that if Osteopathy is applicable
superficially and fragmentarily, it is applicable consistently to the whole. The
same basic principles apply to one part of
the body as to other parts. Lack of osteopathic education or little, experience can
be the only reasons why due appreciation of
osteopathy as a complete system of medicine
is not forthcoming from the honest practitioner.
If one's conception of osteopathy
is not based upon logical, sane, and broad
grounds, that practitioners' usefulness and
ability is limited. He can do justice
neither to himself nor to his patients.
This is the member who so readily chases
therapeutic rainbows. His osteopathic basis is not solid. Even if he tacitly admits that the system is partially right, he
proves his lack of logical reasoning and
thorough understanding by not admitting
more. Real osteopathic work cannot be
partly right; the system is a science or
it is not, for the simple reason that its
truths either do or do not permeate consistently in all functional and organic
The entire body is controldisturbances.
led and governed by the same dynamics,
whether the extremities, the chest, or
elsewhere; and consequently, one system or
character of forces does not provide functioning in one locality and other systems
somewhere else. The body economy is regulated by definite and precise law; its
equilibrium is rigidly maintained in character; the transference of body energy is
according to exact rule. Consequently, it
is preposterous to intimate that osteopathic principles are only partly right, for.
its fundamentals are absolutely harmonious
with the fixed laws of nature. The laws
of mechanics and through them the exchange
of energy from the physical plane to the
therapeutical plane is just as applicable
to one part of the body as another. Ehysical energy transferred to a physiological
or therapeutic equivalent through anatomical adjustment, stimulation, or inhibition
is appreciated as much in one tissue as
another. Therefore, osteopathic therapeutics are not fragmentary, except as the
practitioner may ignorantly apply them.
These statements are certainly elementary, but it seems that at the present
stage of osteopathic development a comprehensive and consistent understanding of
fundamentals is, in some quarters depLorably lacking. Our practitioners' education
and enthusiasm should be osteopathically
The inconsistent broadening
rock-ribbed.
out process should be stopped. I refer to
the catch-penny freak practices of a few of
our colleagues. Legitimate 0steopathy contains problems to be solved that will keep
the profession extremely active for generations. Our desire should be to awaken a
thoroughly scientific spirit in the field
practitioner; then mercenary motives will
be reduced to a minimum and the good done
Osteopathy will be invaluable. In a 'conversation with Dr. Still only a few weeks
ago he made the statement that it was his
belief that the man who sought truth for
truth's sake would always be provided for.
Could a more inspiring statement come from
a scientist and a philosopher? Hasn't his
life been a shining example?
Hereditary customs and traditions
are potent factors in the present medical
development. Because of this it is hard
for some of us to thoroughly and consistently apply our science unless we are dyedin-the-wool osteopaths. The courage of our
convictions is in danger of being neutralized through inheritance and present customs and environment.
On the other hand, there are practitioners who are such extremists that they
occasionally attempt the impossible through
osteopathic therapeutics. They encroach,
for illustration, upon the distinct field
of surgery. The reason for this is a distorted perspective. These practitioners,
All Rights Reserved American Academy of Osteopathy®
49
however, make a much greater success than
those who are constantly seeking the limitations of applied osteopathy. After a
few mistakes they find the true perspective
a point where mature judgement backed by
experience tempers the work. And where are
the practitioners who do not make mistakes?
These men and women become our safest and
best physicians, for they start with a
foundation that is true, and in a short
time practical experience polishes their
technique, renders judgement more infallible, and quickens decision.
There is a class of osteopaths who
are constantly impressing upon others what
Osteopathy cannot do rather than what it
can. These individuals get the "cart before the horse". Caution is always advisable, but to twist the logical sequence of
facts about so that emphasis does not fall
upon primary factors is a mistake and ultimately leads to much indecision and lack
of executive.ability on the part of the
practitioner at the bedside.
III. -His narrow
- conception -of osteopathic
etiology.
We should continually hold before
us a broad basis of osteopathic etiology.
Broad in the sense of being comprehensive
but still consistent with osteopathic
standards. It is so easy to forget or not
even realize that the very nucleus of osteopathic originality is our idea of etiology.
Osteopathy is not characterized alone by a
unique and distinct terapeusis; that is a
secondary feature. The primal characteristic of Osteopathy is exhibited in the retognition of an independent etiology. This
is the distinction between Osteopathy and
other schools of the healing art. Therapeutics cannot be developed and evolved
without a base or starting point. Our
therapeutics, owing to their radicalism,
are apt to eclipse the greater portion of
osteopathy, our etiology. The spectacular
exhibition of manipulation, stimulation,
et cetera has outshone the greater part,
osteopathic etiology. Also the general
treatment weakling has attempted to cover
II. His acceptance and practice of various up his ignorance by a great show of bull
medical theories withouT first
strength and mulishness. These things proanalyzing and interpreting them
stitute the work and years are required to
through osteopathic principles.
correctly inform and educate the duped.
This is another reason why the osteStructural disorder of the tissues
opath is apt to be limited in his applied
causing malrelation and malposition of the
therapeutics. Reading medical literature
parts is unquestionably the basis of osteois both commendable and essential. But
pathic philosophy. A fair percentage of
there is always the danger of being sidedisorders are due absolutely to these
tracked by the ever changing theories of
mechanical disorders. Call the body what
medicine instead of constantly interpreting you will, a machine, a vital mechanism, or
and weighing the literature by osteopathic
what not, the great underlying fundamental
truths. A certain amount of medical liter- cause of disease is mechanical derangement
ature is in harmony with the osteopathic
of the tissues,- tangible conditions deschool, but there are others which at first tectable by the skilled practitioner.
sight seem plausible and logical unless one Moreover, disharmony of function, which
is extremely guarded. Holding in mind the underlies other disease producing factors,
osteopathic philosophy when perusing mediI believe to be traceable to original mechcal literature will redound to great good.
anical discord.
It will strengthen one's faith in his work
What is really exasperating at this
and give him a fund of information that if
stage of our development is to see some of
rightly used will be invaluable. Late medi- our colleagues following lesser if not
cal literature is especially rich in hyfalse gods. How, in the name of all the
gienic, sanitary, and dietetic facts. One
great problems demanding solution, can a
must be careful not to fall into a hotchpractitioner be so lost and beside himself
potch practice by worshipping some of the
as to chatter about scrubbing brushes or
faddish cast-off methods of the old schools. some such theme, as if the future of our
Some practitioners have called this liberwork depended upon such incidental exploialness. Alas!
tations, instead of adding his manhood
weight to the real elaborating of our
science, is beyond me. It must seem that
the scientific perspective of such a one is
All Rights Reserved American Academy of Osteopathy®
50
entirely embryonic.
One of the purposes of this paper
is to briefly speak of several etiological
factors germane but still usually secondary to the great primal cause of diseases,
deranged tissues. My object is to specially call attention to forces and agencies
that we should recognize and study more
than we do. An understanding of these will
help to round out our appreciation of disease processes.
A) -Cosmic forces
I speak of cosmic forces in
order to emphasize that one's horizon
should not be too narrow. There is danger
on the one hand that the practitioner may
become hypnotized by details and thus lose
sight of the relation of the part to the
whole. The student is so apt to become
lost in the maze of details unless his instructor has the ability to occasionally
lift him above the minutiae and show him
relative values and place emphasis where
it should be. On the other hand, there is
also the danger of observing generalities
only. This quickly leads to superficiality
and superficial work in osteopathy is represented by the general treatment and
trusting to luck. Vis medicatrix naturae,
fortunately for the patient but detrimental
to the practitioner as a scientific physician, often comes to one's aid. The physician who can most nearly arrange the logical sequence of factors to the ideal is
without doubt the sanest and safest physician.
Cosmic forces play a part in influencing health, although just what the forces are and how they act is largely unknown. Pandemics and epidemics are certainly influenced by such forces. They
leave many chronic sequellae behind them
to manifest later. Unhygienic surroundings,unsanitary conditions, poor food, and
polluted water, atmospheric and electric
changes with other disturbances of an universal nature, disturb physiological harmony and may overwhelm it. The powers of
nature, gaseous contents of the atmosphere,
abnormalities of air pressure, et cetera
are probably potent forces in influencing
fluctuations of disease, periodicity of
epidemics and the like. Of course fear of
infection is an important factor in increasing susceptibility to disease. It is
interesting and well that we should bear
these things in mind. Someday these prob-
lems will be solved. Until they are a recognition of their influence will aid us
materially in treating diseases.
3) Heredity
Whether heredity is cumulative,
mediate, or immediate it has often been
overlooked by the osteopath. There are
two good reasons why we have been at fault
here; first, the medical profession has
attempted to make too much of heredity and'
second, the. osteopathic practitioner in
the field has found that previous medical
diagnosis was wrong particularly where an
M.D. has said the condition was inherited
and the osteopath has been able to absolutely rectify the condition. Thus the oisteopath has minimized hereditary tendencies.
We are somewhat given to being
hasty in our diagnosis and making 'snap
judgement decisions, instead of studying
our cases more and arriving at a decision
after deliberate judgement. Although the
anatomical evidence is so clear that 'we may
be justified in making quick diagnoses, it
is well to deliberate only after collecting all the facts, including laboratory
findings, in a certain percentage of cases.
We know that family traits are occasionally pronounced for many generations
and also racial characteristics. Certain
families and certain races are more prone
to diseases that others are not so susceptible to. The explanations are wide and
varied but we should remember that it is
usually organization of anatomical and
physiological features that are inherited
and not diseases, with few exceptions.
What does this teach? It teaches
us to be more careful in diagnosis, and as
a consequence our treatment will be more
rational. Literally ramming ahead and giving a treatment regardless of a definite
course to pursue and object in view is ignorance inexcusable.
It has been said that constitution
is the state of the human organism from
the moment of birth to death; it is "the
resultant at any and every moment of the
interaction between the organism and its
environment."
"Environment is the sum of
the circumstances affecting the organism
from birth until the moment under consideration." "Heredity is the state of the organism as determined by the ancestors."
Constitution is always changing; heredity
is fixed and determined. Diathesis is fixed and determined; this represents intra-
All Rights Reserved American Academy of Osteopathy®
51
uterine history, and "is a state intermediate between heredity and constitution."
C) Predisposition
A predisposing factor whether
due to natural or congenital causes may be
a potent one. A diathesis is not a disease
but a condition or tendency.
In preventive medicine the predisposing condition is of the utmost importance, and preventive medicine is a field
so far little developed but its possibilities are tremendous and Osteopathy holds
the key.
The time is rapidly approaching
when the layman will go to the osteopathic
physician for examination and possible preventive treatment somewhat similar to the
lay-man's relation to his dentist, knowing
that a little prevention often saves immeasurable suffering. No one will question that the true osteopath is the ideal
person for this service.
We are especially well fitted for
eliminating and correcting predisposing
causes. Anatomical malalignments and deviations are our main forte, and a large
percentage of predisposing influences are
directly traceable to an unsymmetrical physique, consequently osteopathic manipulations are peculiarly applicable here. Anatomical predisposing factors are such an
integral part of prophylaxis that our practitioners should be alert in this field.
Defects in standing, sitting, and walking
are potent forces in paving the way for
insidious and positive beginnings of ill
health, so we should be constantly on our
guard.
D) Environment
There are cases where osteopathic lesions are well marked but relief
is practically impossible until the environment of the patient is bettered. We
are apt to get heredity and environmental
influences confused, for often the effects
of either of the forces are mixed. It is
well to keep in mind that rarely is a disease inherited; but a special tissue weakness may be inherited with a consequent
predisposition to diseases common to the
defective tissue which through environment
will be the direct means of developing the
disease.
The same would be true of any impoverished body that is housed unduly,
given poor food and constantly coming into
contact with pathogenic organisms. The
real surprise is that there is not more
disease than now exists. Certainly the
body will stand much abuse.
Environment is really a stronger
and more common factor in producing disease
than heredity. As osteopathic physicians
we should lay special stress on environment. Do not ignore it. It is in absolute
harmony with osteopathic tenets, -in other
words with common sense.
All of us suffer from the lack of a
simple life. The modern hurly-burly of the
city keeps one on a constant tension both
mentally and physically, and the chain of
symptoms and diseases that can be directly
traced to this kind of life are well known.
E) Hygiene and sanitation
Hygiene science of health
and its preservation, and sanitation, the
establishment of conditions favorable to
health, are broad subjects.
It is not my purpose to reiterate
established and well known practices but
to awaken in our practitioners an interest
for a wider field of usefulness. We are
not doing all that is possible. Our practitioners are capable of a greater and better work than they are now doing. Distinctive osteopathic etiology and therapeutics
we will grant, if practiced alone is a
specialty. But Osteopathy as a school of
medicine is not specialism. No doubt that
osteopathic therapeutics as practiced by a
number is clearly limited in applicability.
This suicidal tendency is just what we
must avoid. Our future is before us and
there is not a doubt but that we can make
of it what we will. We can specialize in
the osteopathic school as in other schools.
But to say that osteopathy is a specialty
by virtue that our characteristic work is
manipulation is not logical. We treat
both acute and chronic diseases with equal
success. The treatment is not limited to
diseases of any one tissue or section of
the body.
Neither are we a sect. True we
follow a leader in our distinctive work
but there is much other ground that seems
to be a stumbling block to many. These
practitioners must raise themselves from
the thralldom of sect. We would be a sect
if we blindly or absolutely followed a
leader, if we practiced the characteristic
manipulations of Dr. Still only. Dr. Still
has never asked us to follow or imitate
his individual practice. He has given the
All Rights Reserved American Academy of Osteopathy®
52
world a general theory of disease, a philosophy that is as broad as the universe.
He has asked us to apply this theory to all
diseases, to all sciences pertaining to
the medical art. It has been tried and
not found wanting. Our venerable founder
is always ready to appreciate medical facts
from various sources.
We are a school or method of practice, a system if you will, for our exhibition of essential principles or facts is
complete and arranged in a rational connection and applicable to the entire field
of medicine. Thus we should encourage our
colleagues to fully round out their practice. True we are followers in our main
work, characteristic osteopathic revelations of Dr. Still, and well we should be
for he has not only added distinct knowledge to medical science but has given it a
theory, established on facts, that is applicable to and renders the whole a rational and logical system. The limitations of
the osteopath cover a somewhat large field
but still that field is a self-made field
in proportion to the practical ability of
the osteopath.
Hygiene and sanitation are inclusive
of much that is of vital moment to the
health of the individual and of the community. The osteopath will have to share
the responsibility in these matters as
well as others if he expects to be classed
among physicians.
F) Dietetics
Regulation of the diet is another important field of work that all physicians should familiarize themselves with.
This is no ordinary problem especially with
some classes, and we will find that frequently certain disorders of the body will
not yield to a successful issue without
regulation of the diet.
In order to become skilled in diagnosis and prognosis a thorough understanding of pathological processes is absolutely
necessary not only for prescribing and executing the correct treatment but also for
avoiding the wrong treatment. We must have
thoroughly educated physicians. The public
is demanding it. Our labor in the sick
chamber shows this, that we can successfully treat all diseases. Our success is
no more marked in one line than another.
Of course, strictly osteopathic knowledge
is supplemented by common medical knowledge, but common medical knowledge is our
heritage. Moreover, would it not appear
ridiculous to ask legislative bodies to
legalize and protect our practice if we
possessed simply a side show? The evolutionary forces of our science will not allow any retrograde movements. We have deliberately placed ourselves in the breach
and we have no alternative but to surge
ahead. The potential situation of our
science is tremendous and we will not be
doing our duty if we do not truly meet the
probabilities and possibilities of our
school. I am sorry to say that the earnest
men and women within our ranks who belittle
the resources of Osteopathy are our worst
enemies, for a combination of earnestness
and ignorance is extremely hard to combat.
The lack of pathological science
is one of our weak spots. I do not refer
so much to medical pathology as to osteopathic pathology. How much real scientific
osteopathic pathology has our school developed? Our opportunities are simply unlimited. We have the richest most vital
field possible.
There is not a member of our association but who is abundantly capable
and able to help develop this field. Here
we are, four thousand strong and rapidly
growing, and have the key to a fund of
IV. His superficial knowledge of pathology. knowledge that will develop scientific
All are aware that pathology is one
medicine practically to the point of perof the essential studies of the osteopathic fection if we will only get down to genuschool. It is not enough to know physiolo- ine labor. Are we going to leave this,
gy, but an understanding of perverted phywithout making an attempt for a future
siology, of pathology, is necessary in orgeneration?
I hope not. I fully realize
der to have a clear understanding of dithat a lot of our dilly-dally talk is temsease processes. Disease being a condition porarily necessary to hold some of our
of the body forces, it is readily seen why
practitioners who are inclined to worship
a knowledge of how etiological influences
lesser gods, in check. So1idarity is necpervert physiologic&l processes, and also
essary. The keeping in line of public
just what is the character of the morbid
opinion and legislative development are
tissue, is important.
essentials. They are necessities of the
All Rights Reserved American Academy of Osteopathy®
53
circumstances. As a rule, the'skilled ospresent. We have accomplished much in a
decade, above all in healing the sick, but
teopath is an expert diagnostician. The
we have not developed all our posslbiliability to correctly diagnose is in proporties by considerable. What is more we do
tion to one's understanding of relative
not seem to be doing all that is possible
etiological factors plus skill in the meat the present. Osteopathic pathology In
thods of diagnosis.
particular is still scientifically vague,
Osteopathic diagnosis is distinctly
and at a time when it should not be. Our
in a class by itself. Although it includes
art is far in advance of our science, which for its major portion the diagnosis of our
is an unusual situation in the scientific
school, it should be kept in mind that
field. It is a deplorable apathy in the
there are other methods, especially laboraprofession that is retarding us. We must
tory methods, which we should use as Well.
wake up and at least shake off the cobwebs. A word relative to more thorough osteopathTo know that we got results in
ic diagnosis is in order. One of the easitreating a certain lesion is one thing, to
est things in our practice is to become
know how results were attained is another.
slip-shod in osteopathic diagnosis; to beWhat little real pathology we have is frag- come proficient requires much practice and
mentary but is substantiated by a sound
experience. It is an accomplishment that
logical theory and backed by universal,
also requires time and personal instruction
practical, and successful results. Is
in order to become even passable.' Educatthis sufficient for a scientific body?
ing the senses of touch and sight, especiSome one says to give us more time. There
ally the former, is a slow process. To
will come a time, if we are not careful,
detect the difference between the normal
when we will wake up to find our medical
and abnormal tissues by the sense of touch
brethren, who love us so well, have usurpis particularly difficult. This part of
ed our throne, and then the devil may take
osteopathic education is by far the most
the hindmost.
tedious. An understanding of etiology and
The practitioner who remains true
pathology ‘and a skillful application of
to osteopathic fundamentals and strives to
therapy is decidedly easier to surmount.
his utmost to exploit these fundamentals
Too much of our diagnosis is likewill be successful to the maximum extent,
ly to be general and superficial. Diagfor he is building his monument on the
nosis of minute structural derangements is
rock foundation. Let each of us endeavor
what really counts in osteopathy. It is
to add at least one mite to real science.
not enough to note that a gross spinal
Let us conduct our studies, our research
curvature may exist, or that there Is a
work, and our practice with the scientific
decided twist between two vertebrae or the
thought uppermost,. The pathological field
ribs or an innominate are subluxated, but
presents the widest field for lnvestigamuch more. Slight structural deviations
tion. Medical pathology is usually good
should be diagnosed which require an acas far as it goes. The area for exploitacurate and acute sense of touch. Such
tion between the influences and forces
diagnosis means many months and even years
producing disturbances of structural relaof constant practice to become proficient.
tions and the actual morbid tissue, in
Herein rests one of the greatest
other words the forces and agencies at
differences between skilled and unskilled
work back of the diseased cell, has been
practical osteopaths, the ability to depractically untouched. Here rests for sotect the minutiae of anatomical irregularilution the greatest medical problem of the
ties. Here is the secret of successful
present time.
specific treatment. Such is characteristic
and distinctive osteopathic diagnosis.
V. His deficiency in Diagnosis
This is not learned from text books; -perMany of us are apt to be deficient
sonal instruction and plenty of it is abrather than defective In diagnosis. Before solutely essential.
we can intelligently and specifically apply
Other methods of diagnosis, in
a treatment we must be able to accurately
distinction to that of strictly osteopathic
diagnose. The statement we hear so often,
origin, should be utilized more. These
"a case thoroughly diagnosed is half curlaboratory methods are not only aids to
ed", is more or less true, depending upon
osteopathic measures but are often necessi-
All Rights Reserved American Academy of Osteopathy®
54
ties for specific diagnosis. By employing
these means we fully complete our diagnosis as all physicians should. How can we
hope to be scientific men and women capable of advising as family physicians, as
hygienists, as sanitarians and the like,
if we do not appreciate and understand the
import and relative value of all medical
and allied sciences?
Another point under diagnosis is
the fact that many cases of illness tend
to recover with or without professional
care. The general non-specific treatment
will benefit these. The superficially
trained physician is too apt to consider
his apparent results in these instances as
evidence that his clientele requires only
the minimum of general treatments to satisfy them. Rather than work conscientiously
and give his serious attention to each
problem that arises, he grows careless and
thus begins the end of his professional
career. We should always remember and appreciate the power of Nature but we should
not depend upon it to such an extent that
we fail to render the best osteopathic
care to our patients.
VI. His superficial practice of therapeutics.
To a degree the therapy of osteopathy has eclipsed more important features
of our school. Great stress has been
placed upon our therapy with a resultant
show of manipulation. Osteopathic manipulation is only a means to an end at best.
Unless we have distinct and logical etiology, pathology, and diagnosis our therapy amounts to naught more than massage or
movement methods. Inclusive of the lesser
importance of manipulation is the great
concern we should have for the correct
execution of our therapeutics.
Many so-called osteopaths have done
more to prostitute osteopathy than all
other things combined. Through their ignorance they force osteopathy to the manipulative and movement-cure rubbish heap.
Their one desire is to know what movement
to give for this disease or that disorder.
Osteopathy offers a clean clear cut
method of treatment as exact as the laws
of dynamics and mechanics upon which it is
based. Too often the incidenta. work of
relaxing and stretching of tissues and
methods of stimulation and inhibition are
made the greater part of treatment. For-
tunately for the patient at the time, but
unfortunately for the welfare of Osteopathy, this general pommeling may result
in permanent good by inadvertently correcting deep structural disturbances.
In our therapeutical endeavors we
should always remember that there is a
comcatenation of the different physical
systems. The nervous system "binds together all the other systems of the body
in a living reciprocity of energies and
Our therapeutics are peculifunctions."
arly harmonious with natural laws so that
an adaptation of means to an end is most
readily forthcoming. Specific treatment
always illustrates this. General treatments and movements are the great impediment to developing scientific Osteopathy.
I believe genuine osteopathic
treatment coupled with right living, proper environment, and correct food will invariably result in the maximum amount of
good in all medical and many surgical cases. Just in proportion to one's divergence from these practices will his success be minimized.
The Remedy
I am well aware that my paper has
been one of criticism rather than of praise.
But it has not been adverse osteopathic
criticism. We should examine the niches
of our superstructure occasionally and,
note what it needs in order that it may
be more symmetrical and beautiful. I do
not-believe one of us realizes the extent
of usefulness that our beloved science
will occupy in the future. We must keep
the science intact and undefiled. There
is a class of osteopathic practitioners
which seems to fear that those who are
earnestly striving to practice pure osteopathy will become narrow minded. They
continually preach the efficacy of other
methods and ludicrously place some hobby
on a par with Osteopathy. The relative
value between Osteopathy and these faddish
methods may be likened to the light given
off by the sun as compared to a star of
the fourteenth magnitude. Why they devote
their energy to some incidental matter and
not to the real magnificent problems of
science is beyond me. Can it be that
their conception of Osteopathy is the narrow one?
All Rights Reserved American Academy of Osteopathy®
55
On the other hand there is the
class of osteopath which is extremely anxious and watchful lest the science become
lowered by false practices. This class
comprises the bulk of the profession and
I am proud to state that my sympathy is
here. These men and women are the ones
who must guard most zealously the fundamentals of psteopathy. These are the
apostles who know full well the illimitable field of osteopathic resources.
Hence my plea has been to broaden
and deepen the ramifications of osteopathic truths. Not to worship false gods but
to hold fast to the tenets of our theory,
to strengthen the profession, and still
grow and develop as our resources warrant.
Far be it from me to advocate things foreign to the basic principles of Osteopathy.
My one desire is to be a thorough osteopath, thorough in the meaning of the fundamentals of Osteopathy. Before one can
realize and appreciate the illimitable
field of osteopathic philosophy, his
groundwork, his nucleus, must be more than
mere theoretical chimera,- it must be revered with an insight which can be obtained only through thorough, practical,
specific results.
Thus my criticisms can only be
friendly, but with the earnest and jealous
desire that every one of us may personally
and gradually widen the space between the
osteopathic manipulator and the osteopathic physician.
The remedy lies in more thorough
education. Research is the cornerstone of
all scientific development. We as practitioners should continuously strive to
broaden our usefulness and to delve into
the mysteries of life processes. There
are many niches that remain to be filled
and if mutual encouragement may be forthcoming, the object of my discourse will be
obtained. After all we are limited more
from lack of experience than from thorough
theoretical ideals. Through all of our
observations, studies, and research we
should continually keep before us the
philosophy of the Science of Osteopathy.
All Rights Reserved American Academy of Osteopathy®
The Journal of the
American Osteopathic Association
PUBLISHED MONTHLY BY THE AMERICAN OSTEOPATHIC ASSOCIATION
Vol. 30
CHICAGO, ILLINOIS, MAY, 1931
No. 9
seek to influence. Quantities of blood may be drawn
to or away from a part of the body, and so arranged
C H A R L E S H A Z A R D, P h . B . , D . O .
as to restore the equilibrium of the circulation, and
New York, N. Y.
equalize it throughout the vascular system to the
“The moment of interfererue in this life stream marks the
best advantage of health. In many cases our sucbeginning of disease. “-Still.
cess, at the time of treatment, depends largely upon
It is a cardinal principle of osteopathy that how we handle the blood-mass.
blood flow must be free; that if it be not so disease
Reflex vascular relations, throughout the body,
results and the osteopath must go to work to remove are marked. It has been shown that ice held in one
every barrier to perfect circulation. This necessihand makes it first cold and anemic, then hot and
tates a full knowledge of the anatomy and physiolred
; and that similar changes of lesser degree occur
ogy of the circulatory system. Says Dr. Still of the
osteopath, “He must know how the blood is driven in the other hand. According to Eccles, massage of
away from the heart, where it goes, what it does, one limb increases its circulation and temperature,
and that of its fellow likewise. There is a close reand how it is returned.”
lation between skin and abdominal circulation.
To move, to breathe, to think, to have an emo- Burns and scalds upon the surface of the body protion, is to affect the circulation, sometimes pro- duce internal congestion, inflammation and ulcerafoundly. Anyone may, by the simplest means, affect tion. Any manipulation of the body at once affects
the circulation, but to know when and how to do circulation. A mere stroke upon the surface of the
this, within the limits of safety, to the best advan- skin is followed by a white line, quickly changing
tage of the case, and how to find and remove the to red, by reason of the vasomotor reflex aroused.
cause of disordered circulation, which is resulting A vascular reflex is thought to arise, sometimes, at
in disease, is the work of the skilled osteopath.
the first synapse, which may lie upon the blood vesIt is the purpose of this paper to present the sel itself.
results of a careful study of this matter, from an
All the natural agencies of the circulation may
osteopathic viewpoint, in order to contribute to a
by our treatment be quickened in their action. By
clearer understanding of just how we may gain
appropriate manipulation the heart beat may be
curative effects by adjusting and controlling the cirmade quicker and stronger. Pressure and motion
culation. (To the writer it seems that this end may
applied to the thoracic and abdominal walls aid and
best be accomplished by manipulation of the blood
quicken their natural play and affect circulation.
en masse.)
Muscular motions given to the limbs, spine, or neck,
The blood mass is an entity. It is a tissue of simulate the effects of the natural play of the
the body, just as are the muscular, nerve, or bone muscles; squeeze and pump the blood and lymph
tissues. It, like they, is liable to various mechanical out of the tissues and along their natural channels.
disarrangements, with resulting ill effects upon the
The periphery of the body is our great field.
health. Any disturbance of the blood-mass in one
Wherever we treat it we affect the blood flow, dipart may, and usually does, affect it in another. Farectly or reflexly. According to McGillicuddy, senmiliar illustrations of this important fact are seen
sory impulses, resulting in reflex motor action, may
in. the itching nose in portal congestion, the conreach the vasomotor reflex centers through the sengested throat in uterine disorders, the sneezing from
sory nerves of the cerebrospinal system. Baruch
uterine irritation, the hemorrhoids in congested
and Howell go even further in saying that probably
liver, etc.
all the sensory cutaneous nerves of the body conAs a mechanical factor in the etiology of dis- gregate in the vasomotor centers in the medulla,
ease, the mechanical status of the blood-mass con- where they connect with all the vasomotors of the
stantly attracts our attention. This is a great fact, arteries of the body; also that the nerves supplying
and its proper appreciation by the osteopath is of the vessels of the pia mater experience a steady
importance (that he may correctly diagnose condi- tonic excitation from the cutaneous sensory nerves.
tions, and that he may intelligently handle the blood Graham shows that light friction of the skin quickin order to mechanically correct and restore to ens the heart-beat.
proper form and condition this fundamental tissue
If these be the facts, it is clear that any work
of the body).
upon the body must, everywhere and always, proBy proper treatment, the blood-mass may be so foundly affect circulation in the body. Cut of still
manipulated as to dispose its bulk. and portions greater importance is the fact that we, by the repair
thereof, as best to aid the health of the parts we of the many lesions which we find, remove from the
The Rule of the Artery Is Supreme
All Rights Reserved57
American Academy of Osteopathy®
58
THE RULE OF THE ARTERY IS SUPREME-HAZZARD
periphery the irritation which is keeping up a per- veins should not be used in cerebral congestion due
manent disturbance of vasomotor equilibrium, with to arteriosclerosis; and must be used with much
its numerous resulting ills. This results in a rear- care in all cases of high blood-pressure.
rangement of the various portions of the bloodMcClellan shows that the subclavian vein is
mass ; congestions are let free, local anemias are attached to the back of the clavicle and follows the
overcome, the caliber of the vessels is readjusted, movements of that bone. Thus our treatment apand vascular equilibrium is restored.
plied in “raising the clavicle” stretches and pulls
As we well know, irritations produce vasomotor this vessel considerably, while at the same time the
changes in remote parts, and McGillicuddy, in pressure of our fingers applied behind the bone
speaking of this fact says that the anemia or con- causes a momentary stoppage of the flow, with a
gestion thus produced causes pain. An example of consequent backsetting of the blood and dilatation
this is seen in frontal headache from gastric irrita- of the vein and its tributaries, with a resulting freetion. We know from experience that these sources dom of blood flow.
I have seen Dr. Still thrust his thumbs strongly
of irritation are often osteopathic lesions.
against
the femoral arteries for the period of one
Just in line with these facts is a class of cases
frequently met. The patients, mostly women, suffer heart-beat, causing a brief stoppage, followed by a
from soreness and aching in the calves of the legs, stronger effort of the heart, and thus acceleration
feet, palms, and often in the joints. They are sore of the whole circulation.
Stevens calls attention to the old-fashioned
to the touch along the spine; often the whole flesh
is very tender. General nervousness and weakness method of stopping hemorrhage in pu1monary tumark these cases. They always show marked spinal berculosis by the application of a temporary ligalesions and, usually, abdominal or pelvic disorders. ture to one or more members, which hinders the
Irritation from these sources arouses abnormal vas- flow of blood in the veins, and may materially aid
cular reflexes, causes anemia or congestion of joints, in checking the bleeding. That is to say, that slowfeet, calves, palms, spine and flesh, resulting in pain ing the circulation at one point effectually slows it
and in soreness on pressure. Correction of lesion throughout. Stoppage at one point in the ‘circuit
is the radical cure. Short of this, these cases always affects the whole blood-mass. So it is in disease.
show marked improvement as soon as spinal abdom- A congested liver means a congested portal system,
inal and pelvic circulation is toned. Light prelim- as evidenced often by hemorrhoids. It means also
inary treatment to lessen the soreness by rousing congested cerebral vessels, as evidenced by the headcirculation is often necessary before radical treat- ache commonly present in these cases. It is clear
that the blood responds en masse to conditions afment can be carried on.
Mechanical work upon vessels is often an im- fecting the vascular status at any given point, the
portant aid in regulating blood flow. For example, effect upon the mass being, of course, in proportion
Ziegenspeck shows that in cases of congestive head- to the influence exerted upon it. By the application
ache momentary pressure upon the jugular veins of the principles described we may, by our treatcauses the blood to backset in the tributaries of ment, alter vascular states, re-arrange the bulk of
these vessels, dilating them back to the capillaries, the blood-mass, and restore vasomotor equilibrium.
From the viewpoint of regulating the disposiafter which, on account of the dilatation, the flow is
free and the congestion is relieved. This principle tion of the blood-mass, work upon the abdomen, tomay be applied to any large vein that can be reached gether with that part of the spine from which
by direct pressure. I have used it with immediate springs its nerve supply, is by far the most imporresults in the form of reduction of the swelling in tant; its vascular relations with all other parts of
the body are so intimate that the condition of its
acute inflammation of the tonsils.
After pressing the thumbs for three or four circulation becomes at once important when we decounts upon the jugular veins, one should make deep sire to reach the circulation to other parts. Accordpressure over the forehead with the flat of the palm ing to McGillicuddy, changes in the digestive tract
of one hand, reinforced by pressure from his own and uterus manifest themselves by irritations
trunk. This should be followed by relaxing treat- throughout the whole of the spinal column, and the
ment down along the line of the median longitudinal entire nervous system, and, by the spinal and. ceresinus in the skull, and by pressures exerted in the bral nerves, all portions of the body respond to
suboccipital fossae, immediately beneath the occipi- these changes.
The skillful diagnostician takes account of this
tal protuberance, over the transverse processes of
the atlas, and at the second dorsal. This causes relation, and looks well to the vascular status of the
vasomotor effects by inhibitions of branches of the abdominal viscera in reading the signs of disease.
fifth nerve over the forehead, and by affecting the
The abdominal veins can dilate enough to resuperior and inferior cervical ganglia through their ceive at lease one-third of the total blood-mass. We
spinal connections.
can call to or send from these vessels large quantiWith the patient lying on his back, a salt or ties of blood, with important effects. For example,
sand bag, or other firm roll of proper calibre, may pressure on the solar plexus and abdominal treatbe placed transversely across the neck at the base ment often relieve congestive headache.
of the occiput to continue an inhibition upon the vasoThese abdominal veins possess no valves, but
motors. This is greatly helpful in draining away are supplied with vasomotor nerves.
They are
cerebral congestion. The salt bag may be heated easily dilated, and are thus prone to disturbance,
if desired.
their circulation being readily impeded. Robinson
The pressure treatment applied
to
the
jugular
shows
that oftheir
tonus depends much on the state
All Rights Reserved American
Academy
Osteopathy®
THE RULE OF THE ARTERY IS SUPREME-HAZZARD
59
of the abdominal walls. If the latter are lax, abblood pressure by compression of the abdominal
dominal circulation becomes sluggish by reason of
vessels.
He says that vomiting after cerebral condecrease of intra-abdominal pressure, allowing of
cussion, which is usual, compresses the great
dilatation of the veins and retention of the blood.
splanchnic veins and replenishes the heart. ComThis leads to a long train of evils. Campbell says
pression of the belly may increase the work of the
that flaccid abdominal walls allow of flatulence, COSheart 30 per cent by squeezing the blood from the
tiveness, ptosis, and accumulation of blood in the
splanchnic area into the other vessels. He says that
portal area. Hence the importance of keeping free
the abdominal veins are very susceptible to presfrom lesion that portion of the spine supplying
sure, and quotes Leonard Hill to show that squeeznerves to the muscles of the abdominal walls, in
ing
the blood out of them into the heart stimulates
order to keep the walls themselves in a proper conit
and
reestablishes circulation. It has even been
dition to help maintain perfect vascular conditions
demonstrated, experimentally on animals, that after
in the viscera behind them.
Strong abdominal
section of the spinal cord which paralyzed the vasomuscles are natural stays. Of greater importance
motors
and allowed the blood to collect in the
is the removal of all lesions from the splanchnic
splanchnic veins, emptying the heart, pressure on
area of the spine, whence come the vasomotor
the abdomen squeezed the blood into the heart again
nerves of the abdominal vessels, described by Flint
and reestablished circulation.
long ago as the most important vasomotors in the
body. As a matter of fact, both the splanchnic
Goltz, in his celebrated experiment, by beating
nerves and the nerves supplying the abdominal walls
lightly and rapidly upon the abdomen of a frog,
arise from the same area of the spine, as the walls
caused the heart to slow its beat, and finally to stop
are innervated from the last seven thoracic nerves.
an instant in diastole.
Hence the same lesion that affects the bowel
Baruch points out a collateral relation between
through the splanchnics will sometimes affect the
the Skin and the abdominal circulation, and quotes
walls through these seven nerves. We occasionally
Schuller to the effect that even light pressure on the
meet cases in which, on this account, lax abdominal
belly of a rabbit caused dilatation of the veins and
walls accompany conditions of marked constipation.
arteries of the pia mater, and that cold wet comRestoration of tone to the walls always favorably
presses on the abdomen caused dilatation in the pia
affects the constipation.
and pulsations in the cerebral vessels to become
By reason of the connection of this important
more pronounced and slower.
splanchnic vasomotor supply with the reflex nerve
Treves points out that the skin of the abdommechanism of the heart we have the so-called deinal wall is supplied from the last seven dorsal
pressor nerve phenomena. From the heart and the
nerves, which also give origin to the splanchnic
arch of the aorta, under proper conditions, come imnerves.
pulses by the way of the cardiac depressor nerve
These facts illustrate not only the importance that
and the medulla which, acting through the bulbar
the osteopath attaches to examination of this portion of
vasomotor center, cause a dilatation of the splanchthe spine in splanchnic disease, but they also point to
nit and other vessels. They, dilating, receive from
the importance of a close examination of the splanchnic
spine in circulatory disorders, and to the far-reaching
the system a large amount of blood, with the result
effects that may be gotten upon the circulation by apthat general blood pressure is lessened, arterial tenpropriate treatment of spine and abdomen.
sion falls, and the heart beat is quieted. Thus the
There is a still wider relation existing between vascudepressor nerve mechanism acts.
lar states in the abdomen and those in other and distant
parts of the body. There is a close reflex relation between
We often meet the pathological aspect of these
the abdomen and the head. According to (Byron) Robinfacts. Anything suddenly lessening intra-abdominal
son, a blow on the solar plexus causes syncope by reflexpressure or tension allows these easily-dilating abaction on the heart via the vagus. Reflex irritation from
dominal veins to receive a large quantity of blood
the stomach causes headache by congesting the cerebral
vessels. Flatulence and ascites, says Campbell, press blood
from the system. This may go to such an extent
out of the splanchnic veins into the system, and the work
that grave results follow. Campbell calls attention
of the heart is increased. Flatulence and constipation, for
to cases of fainting in women upon removal of the
such a reason, cause dizziness. Robinson says that cerecorsets. The sudden removal of the support they
bral circulation is disturbed in constipation by reflex irritation from the abdominal viscera via the lateral chains
afforded to the abdominal walls lessened intraof sympathetic ganglia, the splanchnics, and other sympaabdominal pressure and allowed of the gravitation
thetics.
Dizziness, he says, results from pressure either
of blood to the abdominal veins in quantity suffiof the finger, or of feces, upon the hemorrhoidal plexus.
cient to produce cerebral anemia and syncope. He
of nerves.
calls attention, too, to cases of syncope in old men,
We continually meet these cases. When the subject
due to suddenly arising from bed at night and empof such a complaint is an elderly person of full habit, the
tendency to apoplexy is greatly increased.
In such patying a full bladder. This act so lessens intra-abtients a little excitement or exertion may readily cause
dominal pressure as to allow of vascular dilatation
an apoplectic seizure. It is well in all cases, to look
and cerebral anemia. Indeed, cases have been rewell to the condition of bowel, liver and stomach in
corded in which so great and sudden was the deterorder to equalize circulation. remove irritation and lessen
vascular tension in the brain. Many a man would never
mination of blood to these abdominal veins that not
have suffered the stroke had this simple matter been
enough was left in the arterial system to keep the
attended to. Elderly persons, who have recovered from
heart going, with the result that death ensued.
a stroke, with resulting hemiplegia, are often flatulant and
Hence has arisen the expression, “Bleeding to death
constipated. These factors greatly increase the well known
tendencv of such cases to suffer another stroke. In the
into one’s own abdominal veins.”
management of them, frequently under our care for the
On the other hand, according to Campbell, powhemiplegia after the first attack, it is imperative to look
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erful contraction of the abdominal muscles
well to all
these abdominal
conditions.
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THE RULE OF THE ARTERY IS SUPREME-HAZZARD
that the liver thus acts as a shunt in certain emergencies
Dr. Still makes use of this relation between circulapreventing the blood from returning to the heart in dantion in abdomen and head. In the treatment of apoplexy
gerous amounts.
he forbids the use of the customarv cold application to
the head because it deadens or congests instead of frees
Robinson enunciates what he styles the law of vascuBut he directs the application of heat to
circulation.
lar engorgement and elastic capsules. All the viscera are
the abdomen, which dilates the abdominal vessels and
supplied -by the sympathetic- with automatic visceral
calls the blood from the head. This preference is eviganglia. Every visceral organ during activity is, say’s he,
dently a wise one.
in a state of vascular congestion, turgescence, or enlargeMcGillicuddy says that colic and diarrhea, with resultment. The liver has its normal and regular rhythm, coning abdominal irritation, cause spasm of the arteries of
tributed to it bv its elastic causule of Glisson. its autothe lower limbs and a rush of blood to the head. This furmatic sympathetic ganglia, and the active functioning of
nishes us another reason for looking well to the abdominal
its vessels and cells. Any irritation interferes with its
status.
rhythm, deranges function, and produces malnutrition.
Spinal or other lesion to the nerve-supply of the liver proFurther effects of abdominal conditions upon vascular
duces various irregularities of rhythm and disease follows.
states in other parts of the body may be pointed out. In
It is our duty to seek and remove the lesion acting as the
peritonitis, says Robinson, the waxy paleness of the sursource of irritation. How well our spinal and other corface of the body is due to reflex irritation from the perirective work affects the health of the liver we we’ll know
toneum leading to intense vasoconstriction of all the
from experience. The full import of the results we attain
superficial vessels. The patient dies, he says, from circan be judged only upon an understanding of the relations
cumference to center. According to the same authority
that the liver bears to the circulation as a whole.
Irritation from any viscus is liable to cause v a s o c o n s t r i c tion, while nervousness contracts the peripheral arteries
The emphasis laid upon the importance of thorough
and affects the heart.
liver treatment, especially in all cases of liver disturbance,
There is a close relation between abdominal condition has been none too great.
and circulation in the feet and lower limbs. It is common
As to the spleen, its relation to the circulatory system
to meet persons suffering from a digestive disturbance
is unique. Its function is such that the blood passing
who are weak in the lower limbs. Weakness of the leg
through it must emptv out of the vessels bringing it into
is noted in people with tape-worm. Nervous persons,
the organ so that it- may come into intimate relation with
suffering with congestions of abdominal organs, have cold
the splenic pulp. Such being the case, provision must be
hands and feet.
made for the forcing of the blood out of it into the circuTreatment of the lower limbs affects circulation in
lation again. This-is provided for by the structure of
the abdomen. Likewise a proper abdominal treatment
the capsule and trabeculae, which are supplied with a large
quickens circulation in the legs.
amount of unstriped muscle tissue. This capsule is supplied bv the splenic plexus of the svmpathetic. and bv
Vasomotor disturbances in the lower limbs, due to
virtue of its rhythmic action the blood is pass& along.
abdominal conditions! sometimes become marked and may
In fact, the spleen is mechanically a part of the vascular
produce even functional paralysis in these members.
system. “The spleen,” says Hall, “is as exclusively conMcGillicuddy shows that digestive and uterine disorders
nected with the circulatory system as is the heart.” Mccause cramps and aching in the lower limbs by reflex
Clellan styles it a blood diverticulum.
vasomotor effects, and extreme coldness of the extreinities; that ovarian irritation causes spasmodic vasomotor
It is altogether probable that the spleen exerts an
activity, and may even produce functibnal paraplegia; that
actual propel&g force upon the blood. In the dog, cat
one of the first signs of uterine disease is weakness and
and certain others of the lower animals it has been obweariness of the b&k and limbs; that irritation from the
served to have an active rhythm. Baruch says: “It would
digestive and genito-urinary systems causes contraction of
(also) seem not improbable that our own elastic, muscular
blood vessels, which may be great, and long continued
and highly pulsating spleen performs some (such) presenough to lead to atrophy: that similar irritations, by caussure-regulating function for the portal circulation..”
ing contraction of the vessels of the cord and lack of
In line with this subiect I recall the case of a woman
arterial blood in it, may lead to functional paraplegia.
in whom the spleen was greatly enlarged, its dimensions
In certain cases so great is the loss of tone in the
being about ten by twelve inches. Lesion existed in the
abdominal vessels that practically a vasomotor paralysis
form of subluxation of a rib in such a way that its shaft
results, and the aggregation of blood in the splanchnic
Dressed upon the capsule. Dr. Still held that this, causing
veins becomes a cause of considerable enlargement of the
a paralysis of the capsule, allowed of the great dilatation
abdomen, sometimes simulating pregnancy. Such cases I
and engorgement with blood. Treatment soon caused a
have ten respond easily to treatment.
considerable diminution in the size of the spleen, and
Among the abdominal organs the liver and the spleen
several boils appeared, the probable result of the absorpdeserve special mention for their relation to both abdomition of the dead blood.
nal and general circulation. The splenic vein, into which
Now the osteopath may make practical use of these
empties the inferior mesenteric, unites with the superior
facts relating to abdominal circulation and its effect upon
mesenteric vein to form the portal vein. Practically all
other parts of the body. By relaxation of the abdominal
of the abdominal blood flow thus passes through the
walls and viscera and inhibition of the splanchnic nerves
liver. Any interference with free flow through this organ
and solar plexus he may draw the blood in quantity to
upsets abdominal circulation, which, in turn, disturbs the
the abdomen, lessening vascular tension- in the body, and
blood mass throughout the body. The hepatic plexus,
quieting the heart, by arousing the action-of the depressor
an offset of the solar plexus, sends its branches to acnerve mechanism. On the other hand, by pressure on the
company the blood vessels throughout the liver and to
abdominal walls and by quick, stimulative work over the
ramify to the remotest corner of the organ. This plexus
abdomen and splanchnic spine, he may raise vascular
rules circulation in the liver. It is prone to irritations
tension in the body and quicken and strengthen the pulse.
from other viscera, with which it is closely connected by
He may, by direct treatment of a viscus, relieve it of
sympathetic nerves. Hence it is important that all sources
congestion or draw to it blood which it lacks. The liver
of irritation should be removed. Spinal lesion in the
is in an exposed position, and offers a very accessible
splanchnic area is most important in this relation.
field for treatment. By direct mechanical treatment upon
The portal system alone can contain one-third of all
it, through the abdominal walls and beneath the ribs, it
the blood in the body, or even more.
may be cornmessed. squeezing the stagnant blood in its
Thayer is authority for the statement that extremes
vessels against the vessel walls containing it, rousing them
of emotion or severe pain may reflexly lead to such a
to action stimulated thereby. The hepatic plexus may,
dilatation of the abdominal vessels that they contain the
by such treatment, be roused to action, impulses thus
greater portion of the blood, resulting in cerebral anemia
generated being carried by its filaments throughout the
and syncope and under such conditions one may actually
liver, to every distant vessel and cell.
bleed to death into his own portal system. Heart failure
The spleen may be treated in a similar manner, with
after extreme emotion is due to such a cause.
similar results.
The diversion of a considerable
quantity
of
blood
to
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stasis
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61
The play of the thorax, too, has important conseparts of the body may be influenced and regulated by
quences upon the whole circulation. Its inspiratory action
proper abdominal work.
results in aspirating the venous blood from the abdomen
C. Lovatt Evans in a late edition of his work, “Recent
and lower parts of the body into the right heart. It also
Advances in Phvsiology.” calls attention to the areat sip.sucks the venous blood out of the head, neck and arms.
nificance of the so-called carotid sinus and carotid body.
Pressure in the veins is less than in the arteries. From
Here, it has been found, is an apparatus,. subsidiary to
the left heart outward, until the circuit of the blood is
the cardiac and aortic pressor and ‘depressor mechanism
finished, blood pressure steadily falls,, so that it is norabove alluded to, which has for its special function the
mally least of all in the thorax, where it is always negative
control of cerebral circulation.
The common carotid artery divides into the internal during inspiration. The pulmonary arteries possess slight
tone and great distensibility. The resistance in the pulthe upper
and external carotids at about the level of
monary capillaries is very low. Inspiratory action not
edge of the thyroid cartilages, deeply placed behind the
only aspirates the blood into the right heart, but it also
edge of the sternomastoid muscle, anterior to the translowers the pressure in the pulmonarv artery by lessening
verse processes of the cervical vertebrae. Upon the inresistance in the whole lung circulation, as must natural
ternal carotid. at its point of origin. there is a sinus.
follow when all the diameters of the chest are increased
Nearby lies ‘a small body, similar in structure to the
by the free raising of the ribs in inspiratory action. Hall
adrenal glands. called the carotid body.
points out that the thin walled auricle and veins expand
“Within recent years,” says Evans, “another imporunder negative intrathoracic pressure in inspiration to
tant mechanism has been revealed through the researches
receive blood which at that time rushes into the thorax.
of a number of physiologists. These investigations have
shown the existence of an important zone in the neighThe lung vessels are exceedingly distensible, readily
borhood of the bifurcation of the common carotid artery,
accommodating a considerable afflux of blood in an emerby which heart rate and vasomotor tone are reflexly congency. Thus the lung circulation acts as a shunt, as does
trolled. in response to various stimuli. conspicuouslv to
the liver, safeguarding a possible dangerous overflow of
those due to *alterations in the degree of distention of
blood upon the left ventricle, as does the liver for the
the walls of the blood vessels in this region.”
right ventricle. According to Hall, mechanical stimulaThe term, carotid sinus, signifies a specially innervated
tion of the heart results from the inflow of the blood due
part of the vessels and tissues in the neighborhood of this
to negative intrathoracic pressure.
bifurcation, and includes also the carotid body. Around
Free abdominal and free diaphragmatic play aid free
these structures is a network of nerves, afferent in funcDuring inthoracic play in its effect upon circulation.
tion, which connect with the glossopharyngeal, the suspiration. when the ribs are raised. lessening intrathoracic
perior cervical ganglion, and the ganglion of the vagus trunk.
pressure,’ the diaphragm descends; thus in&easing intraStimulation of the carotid sinus, electrically or meabdominal pressure. with the result that the blood is
chanically, causes a combined reflex of cardiac inhibition
thus squeezed out of the great splanchnic veins just at
and fall of blood pressure, just as does stimulation of
the time that it is sucked into the thorax and right heart
the cardiac depressor nerve before mentioned.
by insuiratory play. The reverse of this. of course. is
It was shown that rise of arterial pressure in #he head true as well. Particularly is it true, according to Campproduces fall of pressure in the body both by means of
bell, that during diaphragmatic inspiration intra-abdominal
cardio-inhibition and by vasomotor relaxation, and that
tension is increased at the time that intrathoracic pressure
pressure changes in the head produce their effects upon
becomes negative. The pressures in these two cavities
the heart rate entirely through reflexes generated from
thus run counter, with a most important resulting effect
the carotid sinus.
upon the circulation. Lack of free diaphragmatic play,
It was further shown that the chief sites of the efthen, interferes with circulation.
fector agents in the reflexes affecting cerebral circulation,
The lymph is pumped from the peritoneum into the
are in the abdominal organs.
pleura, through stomata in the diaphragm. by respiratory
It was also found that the reflexes involving vasomovements of the thorax and diaphragm. Its flow in
constriction are accompanied by an output of adrenaline
the lymphatic vessels is chiefly aided, says Hall, by muscufrom the suprarenals, and those involving a vasodilatalar activity and negative intrathoracic pressure. So imtion with a reduction of adrenaline output.
portant an influence has diaphragmatic play upon lymph
It would therefore seem probable that this structure,
flow that, says Campbell, ascites is often prevented by the
so situated in the neck-region as to be readily susceptible
to the effects of mechanical pressure or stimulation by the active movements of the midriff. Edema and ascites, he
says, are counteracted by free lymph circulation due to
hand of the osteopath, could be used by him to advantage
respiratory capacity and exercise. Inspiration expands
in controlling cerebral circulation.
a11 the pulmonary and pleural lymphatics and sucks the
It is of interest to note the important part played by
fluid into them, while expiration accelerates its flow. Inthese reflexes in counteracting the effects of severe hemorspiration also favors lymph flow by lessening pressure in
rhages, for example, or the part played in compensatory
the large veins into which the ducts enter.
hydrostatics when one changes his posture, as in rising
Here we should mention, also, the importance of the
upright after lying down; or in compensating cerebral
so-called Miller’s “lymphatic pump,” which we use with
circulation in a long necked animal like the giraffe, or in
such good effect in affecting lymph drainages of head, chest,
the bat, which sleeps head downward.
I t i s w e l l t o k n o w t h e s e f a c t s f o r t h e l i g h t t h e y and mediastinum.
Preaching, speaking, declaiming; singing, all induce
throw upon the diagnosis of multitudes of diseases, and
active use of the lungs, active thoracic play, and thus
for the intelligent perception of conditions, pathologic and
therapeutic, that are met or used. By understanding how
are good in all forms of passive engorgement of the lungs,
as, for example, from heart disease. Singers are remarkthe blood mass is affected in disease and how it may be
influenced in the treatment of disease, one is better -able
ably free from pulmonary diseases.
Not only has inspiratory action an important effect
to use it to advantage.
upon circulation, but so, also, has expiratory action. AcBut, knowing the secrets of the circulation, the most
cording to one authority upon this subject, expiration
important thing to accomplish is the removal of the first
drives the blood out of the pulmonary vessels. It is a
cause of its unbalancing; the lesion which, however it
most important aid to arterial circulation, increasing
acts, unsettles the equilibrium of the blood mass, and,
soon or late, produces small ill or widespread disaster,
arterial tension and helping to drive the blood to the
furthermost cell in the body. During forcible expiration
according to the conditions of the case. Manipulation of
the blood mass, as outlined above, occupies an important
intrathoracic pressure changes to positive. This positive
place in our therapeutics, but it is not first in importance,
pressure may be raised very high by appropriate maneuvand would indeed be futile without also accomplishing
ers. Camnbell shows that a forcible exniration causes
loss of the radial pulse by compression of- the subclavian
that most important and distinctive function of the osteopath, namely, the removal of the lesion.
arteries by strongly raised first ribs, and that forced effort
at expiration, with-closed glottis, raises intrathoracic presThis done, or in the process of being done, the blood
sure to such a height as to cause serious pressure upon
mass may be manipulated in accordance with the above
the heart and intrathoracic blood vessels, and seriously
facts and principles, but first causes must be removed to
interfereAcademy
with circulation.
It is even said that the heart
effect radical cures.
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THE RULE OF THE ARTERY IS SUPREME-HAZZARD
may be so gripped between the lungs, in forcible expiraduces atrophy of spinal and abdominal muscles. and comtion, as to stop its beat momentarily.
presses abdominal- vessels, engorging heart ‘and other
vessels. A familiar example of this is the red nose due
From these considerations it is clear that the mechanical means prepared by Nature to secure free thoracic and to tight lacing.
Various lesions often combine in a way to produce
diaphragmatic play must, in the interests of health, be
intact. “Thoracic mobility is natural and necessary to the most profound effects by hindering thoracic and spinal
health.” sluggish
plav means sluggish lung circulation free play, congesting spinal Centers, compromising lung
-circulation. and thus that of the whole body. These rewith its tendency to disease. McGillicuddy- points out
sults are often met in simply flat-chested people, but are
that flattening of the chest through the shoulders falling
best illustrated in a numerous class of cases who have
forward favors lung disease by lack of expansion. Campbeen markedly affected by la grippe in its commonest,
bell shows that people with feeble muscle systems are
or so-called spinal, form. Here the spinal muscles have
likely to develop phtbinoid chests through mere inactivity
been greatly affected. being much contractured. and often
of the thorax. A familiar illustration of the harm resulting
more or less atrophied. The spinal muscular system loses
from restricted thoracic play is seen in obese persons,
its proper tone. Spinal activity and circulation have been
who are notably subject to chronic bronchitis. The simple
reduced sometimes to such an extent that the cord itself
weight of the fat collecting about the thoracic walls preis insufficiently nourished, affecting spinal centers and
vents their being freelv expanded. with the result that
nerves. Thus. aided by muscle contractures and atrophies,
both thoracic and diaphragmatic free play are prevented
as well as by nerve and central lesion, the thoracic bony
and stagnant lung circulation and bronchitis are favored.
parts lose their perfect adjustment, and rib and vertebral
Upon thus account such diseases are more dangerous in
lesions readily occur.
Often these cases become flatthe obese, and fatal pneumonias are common.
chested, all the ribs having slipped a little downward
Lack of free rib play is seen in persons suffering from
(urolansus of the thorax). often being partly off their
emnhysema. in whom the distended. barrel-shaped chest
articulations at the head and tubercle. T h u s i t b e c o m e s
becomes rigid, the sternum and ribs’ rising and falling as
mechanically impossible for these cases to have thoracic
one piece and the distended lung alveoli stretching out
or spinal, or abdominal, or diaphragmatic free play. They
the lung arterioles and capillaries, impeding circulation.
are always poor breathers. I have often had them comFor these reasons enlargement of the right ventricle,
plain to me that an attempt at deep breathing required
which develops to force the blood through the impeded
more muscular energy than they could well command. It
vessels, becomes a feature of emphysematous cases. In
is impossible, for the weakened muscles to freely raise
a similar way, persons with scoliosis, in whom the chest
the prolapsed ribs.
becomes compressed on one side, limiting free play of the
Prolapsed ribs and contractured or atrophied spinal
thorax and obstructing lung circulation, develop enlargemuscles at once congest the cord and its centers. Anament of the right ventricle.
tomicallv the intercostal arteries. arising from the aorta,
each divide into an anterior, or proper intercostal branch;
Lack of free rib play means an unexpanded or poorly
and a posterior or dorsal branch. The latter subdivides
expanded lung, and this; as Campbell shows, means that
into a muscular branch, supplying the muscles and integuin it are many collapsed alveoli. Thus people with flat,
ment of the back, and a spinal branch, which supplies, in
narrow, or phthinoid chests are notably subject to pulpart, the cord and its membranes. Now, by reason of
monary tuberculosis, a disease that kills one in every
the ribs being prolapsed and approximated, and the spinal
seven people.
muscles contractured and atrophied, these vessels, exThe weak chested are always at a disadvantage in
cepting only the spinal branches, are variously stretched
emergency. Campbell, in commenting upon the fact that
and compressed with the probable effect of crowding the
external compression of the chest lessens and retards the
blood back upon the cord, congesting it. These facts
output of the heart and affects circulation, states that in
crowds in panic, women and children with compressible chests may serve to explain the profound effects often exerted
upon the nervous system by la grippe. T h e r e c a n b e
are first affected, while the strong, such as men with rigid
little question that these causes produce stagnant circulachests, escape:
tion in the spinal cord directly, as well as aiding indirectly
It is clear that a robust chest is a desirable agency
to bring about the same result by limiting thoracic, spinal,
of health. Persons with a tendency to heart,. lung or
diaphragmatic, and abdominal free play, thus stagnating
circulatory diseases should by all means cultivate the
or unbalancing the general circulation. We occasionally
thorax. Every person should make a habit, of breathing
see cases of sufferers from the sequelae of la grippe, in
deeply.
whom these causes have gone to the extent of so robbing
These considerations point out one of the most fruitful
the cord of nutrition as to result in paraplegia, or other
fields for the osteopath’s work. We know from experiparalyses.
ence what bad results follow rib lesion. and how imI desire to call attention especially to the fact that
portant it is that all ribs, thoracic vertebrae, and spinal
numerous cases with anterior dorsal spinal lesion have,
and intercostal muscles and ligaments, all of which go
as a result of the anterior dorsal spine, a drooping of
to make up the thorax, be in right mechanical condition.
the ribs, which results in so narrowing the thorax and
The importance of our distinctive osteopathic work, which
the costal-arch, as to narrow the whole region of the
repairs all such lesions, cannot be too strongly insisted
diaphragm, with a consequent droop of that muscle, proupon.
ducing enteroptosis and all its brood of ills.
Correction of spine, raising of ribs. deep breathing
Hall shows that the intercostal nerves carry motor
and chinning exercises and stretching of the costal arch;
fibers of both inspiratory and expiratory muscles. Rib
all quickly aid in restoring the tonus of the diaphragm,
or spinal lesion to the intercostal nerves compromises
with much better abdominal health.
the muscles of free thoracic play. The vasomotors for the
pulmonary vessels pass from the cord by way of the
The pressure of a first rib or clavicle upon the subthoracic spinal nerves from the second to the seventh.
clayian vessels may slow the circulation in the entire
Any rib, spinal or other lesion of these nerves or their
body; the luxated vertebra in the splanchnic may cause
various branches may reflexly influence lung circulation,
an irritation to be carried to the liver, leading ‘to conas well as interfere with the mechanical work of free
gestion, with possible resulting congestions in limbs, cord
thoracic play.
and brain. The irritation carried into the vasomotor system, the mechanical pressure thrown upon the vessels, or
It is easy to see that quite as important as free play
the catch that hinders thoracic rhythm, may happen in
elsewhere, is free spinal play, with its resulting freedom
any one of a thousand ways. The osteopath’s work is
of all nerves or vessels that leave or enter the spinal
to find which one of the thousand, and to act accordingly.
canal. Lack of free spinal play is likely to affect these.
as well as to limit free play-in-the thorax. Free circulaUp to date, he is the only diagnostician who has this
tion to and from the cord and spinal tissues depends,
way of looking after the causes of disease. H e i s t h e
of course, as much on the affects of free motion here as
only therapist who performs the rational and radical work
does the circulation in any part of the body depend upon
which corrects causes and which builds upon the right
general free play. McClellan shows that the spinal veins
foundation of natural and perfect mechanical relations
are prone to congestions by reason of the fact that they
the superstructure of health that abounds in the natural
have no valves. Campbell shows that
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63
We must take knowledge where we find it, from books
and from experience, and applying our own osteopathic
reasoning and methods of examination and treatment,
work out the logical and desired result, the cure of disease. For this the world has been waiting for centuries
while her medical men have been lost in curious speculation. This osteopathy is steadily accomplishing, by its
quiet work day after day. It can give, is giving, to the
world a natural, reasonable and successful system of
medicine. “As Still put it, ‘the artery is supreme,’ and
that artery. carries a happy measure of throbbing, pulsing
life; in that blood-stream is a gallant host of thinking, purposeful cells.” (Gaddis.)
BIBLIOGRAPHY
McCillicuddy: Functional Nervous Disorders in Women.
Baruch: Hidrotherapy.
Campbell: Respiratory Exercises in Health and Disease.
Ziegenspeck: message in Diseases of Women.
Eccles: Principles of Massage.
Fassett: JO U R N A L O F A M E R I C A N Ostiopathic AS S O C I A T I O N, March
1904.
Quain’s Anatomy.
Gray’s Anatomy.
McClellan’s Regional Anatomy.
Hall: Textbook of Physiology.
American Textbook of Physiology.
Flint: Physiology.
Thayer: pathology.
Byron Robinson: The Abdominal Brain.
Stevens: Practice of Medicine.
Wood: Reference Handbook of the Medical Sciences.
Evans: Recent Advances in Physiology.
Howell: Human Physiology.
The foregoing article and those which follow reprinted from
The Journal of the American Osteopathic Association are copyrighted
by the Association and reproduced here by special permission which
is gratefully acknowledged.
The Osteopathic Concept Viewed Biophysically and Biochemically
C H A R L E S H A Z Z A R D, P H . B . , D . O .
New York City
The science of medicine is founded upon chemistry; the science of osteopathy upon physics. The
word chemistry derives from the temples of Chemi,
Egypt, where the priests experimented with simple
chemicals for the preparation of medicines. But
progress in medicine, as related to chemistry, has
often gone with halting step. For example, the
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64
SYMPOSIUM ON THE ART OF PRACTICE
discovery of ether took place in the 13th Century,
but its value as an anesthetic was not realized until 1846; thus for 500 years men suffered the lack
of the good offices of a valuable anesthetic which
might have averted untold pain. Magnesium sulphate was known to chemists as early as 1694, but
not for 200 years was it found to be an agent of
great relief in the treatment of burns, lockjaw and
strychnine poisoning. Amy1 nitrite was discovered
by the chemist 23 years before the physician found
that it could be used to relieve the tortures of
angina pectoris.
Medicine is founded upon chemistry ; osteopathy
upon physics; but whereas osteopathy is founded
upon the physics of the body, medicine is founded
upon the chemistry of nature; and it is not, ‘nor has
it ever been, founded upon the chemistry of the
body, which would have been the only logical basis
for a system of chemical medicine. The science of
medicine never began seriously to advance until in
recent years biochemistry came to claim the earnest
attention of the medical ‘men. “Physiology and
Biochemistry in Modern Medicine,” by McLeod of
the University of Toronto, the first edition of which
was copyrighted in 1918, is apparently the first
scientific treatise attempting seriously to apply to
clinical medicine the facts of physiology and biochemistry as shown by the words of the author in
his preface to the first edition: “Biochemical
knowledge is treated . . . from the physiologist’s
standpoint, as an integral part of his subject, particular attention, nevertheless, being paid to the
far-reaching applications of this latest department of
medical science (italics ours), in the elucidation of
many obscure problems of clinical medicine.” Certainly this was a late awakening. Osteopathy on
the contrary, being founded upon the physics of the
body, has always just as truly been founded upon
the chemistry of the body; for just as function is
founded on structure, a truth which with us is axiomatic, so does biochemistry rest upon biophysics.
We say, in the words of Deason, that “perverted
structure perverts function by perverting the cellchemistry.” In the simple phrase of Still, “The
body has its own drug store; the osteopath sees to
it that this drug store is well run”; and this, “Disease is the result of anatomical abnormalities, followed by physiological discord.”
The osteopath deals more correctly with the
intimate chemistry of the human body in the treatment and cure of disease than does the medical man.
Correcting structure corrects cell-chemistry, and
thus corrects function, which is always the end result of cell chemistry. Dealing as it does with the
physics of the human machine, osteopathy restores
normal balance to its workings, puts it in fit condition to provide freely all the chemical substances
necessary to its health. Therefore, when it comes
to the question -of chemistry, the osteopath is a better drug doctor than the “‘drug doctor” himself.
In further pursuit of a clear understanding, let
us consider a few of the things we do. Osteopathic
treatment has repeatedly corrected pathological
states of kidney, allowing an applicant, previously
rejected, to be accepted for life insurance. In numerous cases of hypochlorydia and hyperchlorydia,
the chemical unbalance of stomach secretions has
been shown by test to have been corrected. In ty-
phoid fever, osteopathic treatment changes the temperature chart and alters the reaction of the blood
and urine to the Widal and Diazo tests. Osteopathic treatment has caused lacking ear wax and
lacking perspiration to be secreted ; it has caused
hair to grow, running ears to heal, birthmarks to
disappear, and so on. Only through correcting cell
chemistry could such results be achieved. Let us
consider definitely just how we do what we do.. Let
us attempt to gain an intimate idea of just what results of this kind mean, biophysically and biochemically considered. We say that we correct the lesion, thus correcting nerve and blood supply,
thereby normalizing structure and function. Of
course, correcting nerve and blood supply is only
the first step, and the after care and attention to a
case is (not always but often) just as important as
after any other surgical operation.’ In correcting
nerve and blood supply we aim through them to
correct and regulate the whole of the internal workings of the body; that is, by adjustive treatment we
correct the biophysics, and by correcting biophysics
we correct biochemics-the whole of the intimate
chemistry of the body; for we thereby, as an end
result, normalize all such things as internal secretions, endocrines, ferments, enzymes, hormones,
chemotactic substances, electrical reactions of cations and ions, etc. It could not be otherwise, and
we should fully realize all the far reaching implications of the dosage we administer under the name of
an osteopathic treatment. We should realize that
the mechanics, physics, and chemics of each of the
billions of body cells are all directly influenced by
our work.
I now call to your attention the subject of
edema. We meet it frequently; in many cases we
relieve it promptly by our osteopathic measures.
We know that often a few minutes treatment will
quite remove the edematous swelling from a tissue.
Considering edema biochemically and biophysically,
we find it to be due to a disturbance of the forces
which control the direction and flow of fluids
through the body membranes. These are: diffusion
pressure ; hydrostatic pressure, i. e., capillary blood
pressure; osmotic pressure of blood proteins ; and
differences in electrical potential.. It has been
shown that the capillary wall may vary from time
to time in its permeability towards proteins, and
that the cell wall may show a selective permeability
towards ions which are of equal diffusibility. There
also enters a difference in the electrical potential
of the ions. The correlation of the four factors just
mentioned for the purpose of maintaining the water
balance of body tissues is effectively maintained
through the nervous system, some believing in the
existence of a nervous system, some believing in
the existence of a nervous control center in the
hypothalmus, although hormone control also plays
a part. It is also shown that electrical currents are
produced in the body during muscular, nervous and
glandular activity.
In the case of the edemas which we correct, we
do, by opening up drainages and circulations, by
bringing to the part fresh blood circulation and
nerve tone, control the various diffusion, hydrostatic, and osmotic pressures involved, and also no
doubt the electrical potentials. Furthermore, it is
obvious that we do this even to the extent elf alter-
All Rights Reserved American Academy of Osteopathy®
65
SYMPOSIUM ON THE ART OF PRACTICE
ing the very permeability of the capillary walls and
of the cell walls themselves. We have among us
expressions that state that if a man is fat he is
bloated and full of poison. It is quite true that
many an apparently adipose individual is suffering
from a waterlogged and toxic state of the general
body tissues. In many such cases, as well as in
many other kinds of cases, “acid retarded ductless
glands” are responsible for the widespread endocrine unbalance which works havoc within the system.
Research at the A. T. Still Research Institute
‘has shown that when osseous lesion is artificially
produced the tissues about the lesioned area become
edematous and the reaction of the tissue fluids concerned become acid. The same must be true of tissue lesions, no matter how produced. Let us consider, therefore, the train of pathological events thus
started. Lesion produces edema and local acidosis
ensues. Now, physiological, experimentation has
shown that a weak acid tends to short circuit the
vasomotor nerves. Such being the case the blood
supply to the involved area is at once affected and
congestions ensue. But as soon as the blood supply
is altered the tissue metabolism is altered. When
the cell metabolism is altered the cell chemistry is
altered. The occurrence of edema means that the
very permeability of the cell wall and of the vessel wall
is alter&d. Furthermore, the electriCa reaction of
the ions must also be altered, and this change in the
electrical potential must also affect that quality of
selective permeability shown by the cell wall towards ions most needed and desired by it for its integrity of tissue and function. Where then could a
limit be fixed beyond which, in the production of
dysfunction and disease, this pathological trail
might not lead?
Any sluggish tissue is per se acidosed; that is,
its hydrogen ion concentration has been changed.
In this sense any stagnant tissue fluid or other fluid
of the body tends to become acidly toxic. It is
readily seen, to go a step further, that any ‘tensed
or congested tissue is in a similar state. This is so
because any sluggish area of tissue or of fluid is being underoxidized. Such sluggishness effectively prevents to a greater or lesser degree the free ingress
of the blood, ‘the hemoglobin of the red cells of
which is loaded with the oxygen it has absorbed
from the air in the lung vesicles. Therefore, the
CO,, the carbonic acid waste, accumulated in the
tissues and awaiting cartage back to the lung via
the red cells, is not properly evacuated. The fluids
and tissues involved, therefore, tend at once to become acidly toxic, and the whole pathological train
just outlined is initiated. To take a step further:
it becomes at once apparent that any degree of
anoxemia, no matter how slight or how produced,
tends to produce such status of acid toxicity. Thus
originate the small beginnings of death.
Another angle of the proposition may be considered: Take the tissue tensions which more or
less we encounter in practically any human body
we touch. A tension in tissue, readily felt under the
examining fingers, is a congested tissue, with all the
potentialities of congestions and sluggish tissue outlined heretofore. But a tissue tension which, by
the way, keeps itself going, feeds itself, tends to increase, never actually lets up entirely day or night,
must have some reason for its being. What is it
that keeps a tensioned tissue tense? We may not
know, entirely. Factors just mentioned certainly
enter into the situation. But whatever its ultimate
cause, certainly it does require some sort of energy
to keep it up. Therefore I feel safe in saying that
tissue tension is a source of nerve leakage. It is always using up “current.” It is like burning the
electric light all night. It is a source of unjustified
demand upon tissue, which tends in the long run
to lower it, to devitalize it, and to make it a weak
spot which is a danger spot. This phase is, of
course, quite apart from the mechanistic features
of tissue tensions which constitute lesions either primary or secondary. Thus do tensions and toxins
take their toll; thus do men become literally embalmed in their own poisons-stewed in their own
juices.
If in what I have had to say I have succeeded
in presenting to your minds a clearer picture of
what conditions and forces we deal with when we
deal with the human body in disease, it may assist
you in your efforts for the alleviation of human
suffering.
REFERENCES
McLeod: Physiology and Biochemistry in Modem Medicine, 5th
edition.
McDowall: Clinical Physiology.
Hewlett: Pathological Physiology.
.
Howell: Human Physiology:
Gibbon, Helen: JO U R . -41.x. O S T E O. AW N., June, 1930, p. 347.
The Diblomot. ~rrran of the National Board of Medical Examiners,
Nov.,
1929:
-
SOME REMARKS UPON THE TECHNIC OF
INTRACRANIAL PRESSURE
C HARLES H A Z Z A R D , PH.B., D.O.
New York, N. Y.
(Condensed)
Some eight years ago, I reported to the Eastern States
Osteopathic association, at its meeting in Atlantic City the
cure of a desperate case of infantile convulsions in a threemonths-old babe.
I wish now to recapitulate briefly that report, and to supplement It in introducing my remarks upon the subject upon
which I am to speak.
This was a case of forceps delivery, the child’s skull
being badly misshapen by the forceps. After a few weeks
in which it appeared to be normal, the child gradually over
a period of some two months, developed a condition darked
by wry-neck, cross-eye, oscillation of eyeballs, spasm of the
spinal muscles, and severe convulsions.
The convulsions were eventually extremely severe. I n
two weeks’ time, one hundred and ninety convulsions oc-
curred. As many as twenty occurred in twenty-four hours
Keeping the child under morphine did not control them
Death was imminent as a result, and at this stage, osteopath;
was used as a last resort.
A prominent and anomalous feature of the case was the
occurrence of a marked periodic bulging of the fontanelles
and the parietal bones, the swelling out or “ballooning” of
them coming on and subsiding at irregular intervals. None
of the physicians seeing the case could understand this feature.
Lumbar puncture had been,performed twice, but with the
production of no cerebrospinal fluid, only a little blood. Then
a little cerebrospinal fluid was withdrawn from the subarachnoid space beneath a fontanelle, giving a few moments temporary relief, and affording fluid for pathological test, which
was negative,
My own procedure at first was to give a light relaxing
treatment of the spine and neck (with much trepidation, as
the child might die at any moment) together with the caref$ though easily accomplished, reduction of a slight subluxatlon of the axis to the right.
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SPECIAL ARTICLES
output, hemorrhage, or the collecting of considerable :amounts
Briefly, the results of my treatments were that the conof blood in veins and caDillaries mav likewise cause it.
vulsions ceased, the opisthotonos relaxed, the strabismus,
It is appropriate to remark that it is shown physiologically
torticollis, nystagmus, and “ballooning” of the skull were al!
that the cerebrospinal fiuid, although quite small in amount,
corrected; tht skull was gradually moulded into a normal
may be secreted and absorbed with great rapidity, and is
shape, and the child was cured.
constantly being secreted and absorbed. It is mainly a prodAlthough predictions had been made by the doctors that
uct of the choroid plexus in the ventricles of the brain and,
if the child did not die it would be idiotic or epileptic, the boy
circulating constantly throughout the ventricles of the brain,
is today, at the age of ten years, well, strong and normal in
passes from the fourth ventricle, through the foramina of
every particular, barring a slight muscular tension in the right
Luschka and Maaendie. into the subarachnoid sDaces of
rectus muscle of the right eye.
’
brain and cord. In my report, I called special attention to this bulging
The main source of the absorption is by way of the subof the skull for, though this feature was quite beyond the exarachnoid Gilli or pacchionian bodies, which are minute properience of all of the doctors in the case, it was, according
jections of the arachnoid into the veins and sinuses of the
to my working hypothesis, the safety-valve which really oper.
brain.
ated to save the babv’s life until the treatment released the tenIts susceptibility for rapid production and absorption
sion? along the spine, removed the obstructive lesion in the
constitute a measure for its rapid increase or dirninution
neck, and equalized the circulation of the cerebrospinal fluid
which is normally protective to brain and cord against the
Recalling that sDina1 ouncture was unoroductive of cerebrovarying physical exigencies of the body.
spinal fliid, and that t&e removal of a &tle cerebrospinal fluid
from the skull cavity had afforded momentary relief. I thereIn the Years that have elaDsed I have given much thought
fore constructed thk theory that all the ceiebrospinal fluid
and study -to the subject of- the effect of our work upon
was aggregated within the skull, that its intense pressure was
the circulation of the cerebrospinal fluid, and its efficacy in
sufficient at times to bulge it and to produce that degree of
normalizinE these oft-occurring variations in the status of
anemia of the cerebral cortex which resulted in the extremely
the intracranial pressures, and anemias and congestions of
frequent and severe general convulsions; and that the conthe cerebral cortex concomitant with such variations, and
stant pressure or irritation of this unbalanced state of the
*hat vast array of cases which we, in our work, are so concerebrospinal fluid was at all times sufficient to produce the
stantly meeting, which are characterized by symptoms affecting
various symptoms of cortical irritation present in the form o*
the head, neck, eyes, ears, nose, throat, spine and general
nystagmus, strabismus, and torticollis. Therefore, when I pernervous system.
formed the, to us, comparatively simple and asy operation of
These symptoms majt be very slight or very severe,
removing the obstructions and equalizing the circulation of
according to the conditions of the individual case. and mav
the cerebrospinal fluid about the brain and cord, all such corvary from slight headache, dullness, drowsiness, nervousness,
tical pressure and irritation were removed, the anemia af the
and the like, to such severe and desperate symptoms as
cerebral cortex was conquered, and the child recovered.
characterized the case quoted.
Up to the tipe of my own entry into the case, the hypoIt is my conviction that much of the work that we do
thetical diagnosis of the case rested upon the assumption,
in our cases, affecting the general blood and lymph circunatural enough under the circumstances, that the symptoms
lation, has a. concomiiant aid highly important-affect upon
were due to direct injury of the cortical tissue by the forceps.
these cerebral factors, and that the normalizing and freshenHowever, the outcome of the case disproves, effectually,
ing up of the cerebral cortex thus accomplished is a potent
that theory. and abundantlv substantiates mv own.
factor in our results.
I found some confirm&ion of a part oi my theory in the
A headache, a neckache, a backache is often due, so to
well known facts in those cases of cardiac disease disDlavinn
speak; to a sore pia mater, and the “tired business man”
the symptom complex known as the Stokes-Adams sytidromg
who, after our appropriate ministrations, “steps forth new”,
In such a condition we have the following status:- In those
up to his efficiency, and ready to compete with his fellows,
cases of heart-bloc which have reached 2 stage in which the
does so because his whole cerebral cortex has been freshened
“wiring of the heart” is so far affected that the pace-making
U P bv our treatments affecting a normalizinl of the intraimpulse originating in the sino-auricular, or Keith-Flack,
cranial pressures, cerebral circulation, removal of stagnant
node, and transmitted by it to the Bundle of His, or auriculotissue juices from the brain and nerve tissues, which are
ventricular bundle. for distribution to the musculature of the
sogging and stagnating the cells of the cerebral cortex and
ventricles, is no longer continuously effective, there is an innervous system.
terval in the cardiac pathology when the failing action of the
It could not be otherwise. I may, perhaps, make more
sino-auricular node is not normally effective, and, before the
clear my meaning by referring to that condition of the tissues
ventricles have initiated their own rhythm, which they will
which we know as edema, which we meet so frequently and
presently do, the enfeebled myocardium cannot at all times
which we so promptly relieve by our osteopathic measures.
sufficiently supply the cerebral cortex with blood. The cereWe know that often a few minutes of treatment will remove
bral cortex, therefore;becomCs at times sufficiently anemic to
the edematous swelling from a tissue.
cause the patient to lapse into that condition, frequently nocConsider, for a moment, the biophysics underlying this
turnal, characterized by coma and convulsions, and called
condition, which we find to be due to a disturbance of the
the Stokes-Adams syndrome. These clinical facts will serve
forces which control the direction and flow of fluids through
to illustrate, by a well-known condition of anemia of the
the body membranes. These are:
cerebral cortex, the probable pathology in this baby’s case,
(1) Diffusion pressure: (2) hydrostatic pressure-i.e.,
although in the latter the cortical anemia was due to a greatly
capillary blood pressure; (3) osmotic pressure of blood proincreased intracranial pressure, which ‘compressed the brain
teins; (4) differences in electrical potential.
to the point of causing a degree of cortical anemia which reIt is my contention that by an appropriate choice from
sulted in the convulsions. etc.
among all the mea.sures ava,ilable to a skillful osteopathic
For it is established’in the literature of physiology that
physician, we can, and continuallv do. normalize the various
the intracranial pressure, which is the pressure in the sub&physical and tiiochemical stat&es knderlying pathological
arachnoid space between the skull and the brain, varies diconditions. This also “goes” for the whole body.
rectly with the venous pressure within the skull, and that it
Certainly. in the case of the edemas which we correct.
passively follows changes in the pressure in the auricles and
we do, by opining up drainages and circulations, by bringing
ventricles of the heart; that intracranial pressure is inio the part fresh blood circulation and nerve tone, control
creased by compression of the veins of the neck (which we
the various diffusion, hydrostatic and osmotic pressures
know will speedily cause unconsciousness) and by a general
mentioned above, and also, no doubt, the electrical potentials
rise in arterial pressure; and that the major symptoms of
of the various ions. It is, furthermore, obvious that we do
cerebral compression are due to anemia of the medulla.
this even to the extent of altering the very permeability of
The fact that the intracranial pressure passively follows
the capillary walls and of the cell walls themselves.
changes in the pressures in the auricles and ventricles implies
Applying this thought to the problem of the cerebral
close relations (for its efficiency) with the circulation in, and
circulation, intracranial pressures, secretion and circulation
upon alterations in the capacity of, the v,essels of the splanchof the cerebrospinal fluid, which we are considering, the
ntc area, which is the greatest area of blood in th’e body.
analogy may aid us in visualizing what our measures may acIt is also shown that hypotensions, as well as hyperc o m p l i s h w i t h r e g a r d t o t h e m . A moment’s thought will,
tensions, may, in an oppposite manner, cause anemias of the
moreover, convince an osteopathic mind that these principles
cerebral cortex ; and that such causes as diminished cardiac
extend
to our
treatment of the whole body; and that our
All Rights Reserved American
Academy
of Osteopathy®
67
work radically deals with and affects the biophysics and the
biochemics of every cell in the body. For example, one may
say that any stagnated body tissue, is, per se, an acidized
tissue. This must be so because stagnation implies a failure
of the normal circulation of tissue fluids. That is to say,
the blood is not continuallv bringing to that tissue its freshening supply of oxygen, nor rem&&g from it its CO,, or carbonic acid waste. It is, therefore, acidotic and toxic. Moreover, it has been shown that a weak acid in the tissues shortcircuits the vasomotors. Such being the case, we begin to
have an instant change in the tissue metabolism. The whole
circuit slows, blood- and nerve supply alter, tissue-status
changes, disease ensues. Hence we happen upon the express i o n - “ acid-clogged ductless glands” with its broad implication
of endocrine damage and unbalance throughout the body.
Consequently, it is clear to our fraternity that the very
numerous measures at the command of the capable osteopathic physician applicable to the control of cerebral circulation (some of which I shall demonstrate at the proper
time) may be so used as to profoundly affect intracranial pressures, production and circulation of the cerebrospinal fluid
and the circulation to and nutrition of the cerebral cortex.
REFERENCES
Howell: Human Physiology.
McDowall : Clinical Physiology.
Hewlett : Pathological Physiology.
M c l e o d Human Anatomy.
: Physiology and Biochemistry in Modern Medicine.
All Rights Reserved American Academy of Osteopathy®
The Journal of the
American Osteopathic Association
PUBLISHED MONTHLY BY THE AMERICAN OSTEOPATHIC ASSOCIATION
430 N. Michigan Ave., Chicago, Ill.
Vol. 32, No. 7
March, 1933
Essay on Vertebral Lesions
E. G U Y, D . O .
Mount Vernon, N. Y.
A LBERT
CAVEANT LECTORES
Our editor is adamant on the propriety of prefacing an article with an introduction, of defining the
caption and of defining the scope; therefore, ho! for a
brief exordium to the four parts of these quixotic
ramblings.
There still lingers in my memory the favorite saying of an old teacher when imposing a just pensum:
qui semel scripsit septem legit, and I found its application always valuable; this article may then be considered as an assemblage of personal notes intended
originally for the purpose of better fixing the writer’s
attention, step by step, upon various aspects of the
problem of the lesion, which ceaselessly confronts the
osteopathic practitioner.
Broadly, any structural derangement which interferes with normal function may be, for convenience,
considered as a lesion. If it can be detected by our
methods of examination and palpation, and furthermore, is amenable to reduction by means of osteopathic
manipulation, it might be called an osteopathic lesion
but for the fact that the term is more than ambiguous,
has an element of bumptiousness, and considerably
narrows the field of operation. Effectively, as practice
amply shows, there are a great many forms of local
disorders, distant from the spine, which are not amenable to local treatment, but which, however, are found
reducible through appropriate manipulations of the
vertebral organ. To such as those, that term would
certainly not apply. Besides, away from “Main Street,”
in foreign lands for instance, osteopathy is at once
taken at its face value, that is, bone disease and, by
extension, a system of bone disease treatment; a fortiori, the expression osteopathic lesion is evidently not
adaptable to requirements urbis et orbis.
From the pompous caption, Essay on Vertebral
Lesions, the readers must not expect to find herein a
plethoric census of pedigreed and mongrel lesions observable in their vertebral habitat; instead, they will
quickly be made to realize, to their dismay perhaps,
the vengeful intent of the writer to expose again the
deplorable dearth of knowledge extant anent the topography of that habitat. It is obvious that the lesion
cannot successfully be tracked down to its lair if the
hunter is but superficially acquainted with the
labyrinthine passes and other peculiarities of the region. It will be indicated, however, that the understanding of the detailed structure of a vertebral unit
will suffice to secure that of the whole vertebral
column; and then, with the normal tissues well in
hand, the detection of functional topographic derangements will be much facilitated. It is advisable to bear
constantly in mind that there is no such thing as a
single lesion; it is a material impossibility, since every
single part of the body is dependent upon others for
its existence, and that any disorder affecting it must
necessarily affect not only vicinal but also distant parts.
Since an apparently single local disorder involves at
once a multiplicity of lesions, and that furthermore,
the involvement may assume numberless aspects, census taking would be an impossible task.
PART I
EXONUCLEAR LESIONS
In some of the earlier anatomy texts may be
seen illustrations of the sagittal sections of vertebrae
and articular discs, in which irregular extensions of
the basement cartilage are located within the cancellous
tissue of the bones. Then the conventional biconvex
form of the disc is somewhat altered and there are
depressions present in the floor at the roots of the
extensions. It seems as if some of the cartilage had
been extruded by pressure from within the disc. Poirier
mentions extensions of the nucleus pulposus into the
bones and also through the posterior layers of the
annulus fibrosus, reaching close to the periphery. In
the bone the nuclear substance is sheathed by cartilaginous tissue, soft within, but showing gradual ossifi’
cation without. Some extensions are filiform, some
cavitary, and others are fissural. These fortuitous observations open up a vast field of practical considerations.
Normally, tiny apertures exist on the inner surface of the basement cartilage, which seem a little
larger in the region of the nucleus prober. The purpose served by those apertures is not, as far as we
know, mentioned anywhere; possibly they are the terminals of some sort of canals located in the bones,
through which exudate of nuclear substance is fed into
the disc; this appears quite plausible, but it remains to
be proven through careful and appropriate study, as
the subject is important from many points of view.
However, whatever may be the connections beyond
the apertures, it is quite obvious that under ordinary
circumstances there must exist means of preventing
the extrusion of the nuclear substance, and then we
are warranted in believing that these means are dependent upon the integrity of the circulation of body
All Rights Reserved American Academy of Osteopathy®
69
70
ESSAY ON VERTEBRAL LESIONS-GUY
fluids. Should this fail for some cause or other, so between the nodule and the nucleus. Depending of
that a given aperture be left insufficient protection, course upon the amount and size of the extruded mass,
then the nuclear substance could be forced to make its effects upon the contents of the vertebral canal
its way insidiously outwards, sheathed in cartilaginous vary. (c) With a fissure of large proportions, offering
tissue, and the final result would be filiform extension. difficulty of consolidation because the movements of
A cavitary extension is the filling in of a depres- the body ceaselessly produce irritation of the osseous
sion, of a caving of the bony structure of the vertebral surfaces affected, the belief is fully warranted that the
body, by a lining of cartilaginous tissue and an ex- disorder begins action as the etiological factor of vatrusion of nuclear substance. The osseous floor may rious kinds of so-called vertebral disease: the germs,
have been crushed in through the application of a sud- filtrable or otherwise, follow in its wake.
den, excessive pressure, generated within the articular
In recent years attention has been increasingly
disc. The symptoms of such lesions are well nigh focussed upon the occurrence of spinal disorders
undefinable ; there may have been at the time of their caused by the presence of extruded nuclear substance.
occurrence a local lancinating pain accompanied by a within the vertebral canal. As usual, the publication
general commotion throughout the entire vertebral of a few reports dealing with extreme cases, sufficed
column, and a painful sensation of shock in the occipi- to awaken interest and to bring forth a large number
tal region; in the young particularly, violent exertions of observations, the importance of which may not have
are common, high jumping, falls of all kinds, blows, been fully realized at the time, but which it seems now
etc., exact their measure of sharp but passing pain possible to incorporate into a well coordinated whole.
sometimes there lingers for a while a condition of While in some instances the traumatic origin of the
sprain, of backache. In the acute stage, and when the extrusion was undeniably established, in others the posexact nature of the injury is unknown, the x-rays are sibility of neoformation, of fibroid tumor, of chonof little or no help ; it is only much later, when ossifi- droma, of chordoma derived from persistent remains
cation is fully established, that the extrusions may be of the embryonic notochord, was seriously entertained
seen, particularly when suspected.
and discussed. Almost invariably the pseudo tumor
The fissural extensions occur following the split- was found formed of a central core whose tissue had
ting of a vertebral body through the action of sudden, the characteristics of the nuclear mass, and of a fibroviolent effort of compression directed axially. There cartilaginous coating of variable thickness, the texture
may be at first a caving of the osseous floor of the of which tends towards ossification. The traumatic
disc, immediately followed by a wedge-like intrusion theory is now thought the most acceptable, particularly
of cartilage and nuclear substance. The symptoms because, as stated before, traces of continuity exist
would then be far more pronounced than for the other between the nucleus and the nodule.
To the osteopathic profession the subject should
lesions, and recovery would require much longer time.
But even after complete local recovery and with no prove of very great importance for several reasons.
discernible pathological sequelae, there is a possibility In the first place, one might think that the cases reof displacement of the articular facets which, when ported thus far represent after all but a grouping of
discovered through ordinary palpation, would as a isolated instances; however, in view of the facts prematter of course, be considered as one of the usual sented by Dr. Andrae, an assistant of Professor
vertebral lesions, easily amenable to manipulative cor- Schmorl, in “‘A Study of Cartilaginous Nodules of the
rection. Such cases are found in practice, which have Disc,” one must realize the possibility of the existence
resisted the efforts of many expert hands and of adepts of a large number of totally unsuspected cases. He
in specific treatment. It is in order, after a few at- examined 356 vertebral columns and found 56 exonutempts at correction, to consider the possibility of per- clear lesions, or a frequency of 15.73 per cent. The
manent osseous deformation, to endeavor to obtain a ratio of male to female .subjects was about three to
history of the occurrence of injury, and to secure a five. The size of the tumors varied from that of a
grain of wheat to that of a bean; they seemingly had
radiograph of the region affected.
According to the degree of the original injury the same macroscopic aspect, the same lateral location
several aspects may be considered : (a) In a mild case, upon the posterior aspect of the disc, and finally the
in which good consolidation of the osseous structure same histological structure as found in tumors opertakes place, the body may gradually adjust itself to ated on by surgeons.
In a most able article on the subject published in
the positional changes of the vertebra, and there are
no appreciable sequelae. (b) Even after consolidation La Presse Medicale of December 6 and 20, 1930, by
the osseous structure may remain weakened in certain Drs. Alajouanine and Petit Dutaillis is presented a reparts and thus present insufficient resistance to the markable clinical study of two acute cases under their
progress of further extrusion of the nuclear substance care, which is replete with details concerning as well
under the influence of pressure generated within the the symptoms as the operation of laminectomy. :In spite
disc by the exertion of sudden and violent efforts. In of the difficulties of such an intervention the recovery
such instance it has been found that the extruded of the two patients was particularly rapid and their
mass, instead of reaching towards the other face of the condition is now as near normal as could be expected.
vertebra, is deviated in the direction of least resistance, Altogether these’ doctors have investigated some 21
that is, towards the posterior wall of the vertebral cases, 10 of which affected the cervical region, 3 the
body. It may then be stopped by the denser tissue of dorsal, and 8 the lumbar. These figures, pertaining
the wall, or it may break through, bearing against the only to one series, should merely indicate that the most
posterior vertebral ligament; there, part of the mass mobile regions of the column are most likely to be
is removed by resorption, and the rest undergoes rapid lesioned.
fibroid degeneration. It is found at autopsy in the
Another article by Drs. Calve and Gaillard, in the
form of flat nodules, or bean-shaped tumors, but it is La Presse Medicale of April 16, 1930, on the “Nucleus
always possible by careful work All
to Rights
trace aReserved
continuity
Pulposus,”
very interesting ; it deals mainly with
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ESSAY ON VERTEBRAL LESIONS-GUY
.
71
cases of nuclear intrusion within the cancellous tissue formed by the displacement of the nuclear substance,
of the vertebrae. They were shown some 4,000 ver- which was forced through the posterior fibrocartilagitebral columns by Professor Schmorl, and found a nous lamellae, but without, however, extending past
frequency of about 38 per cent affecting all ages, but the fibrous envelope of the disc ; anteriorly the disc
greater for males than for females. These doctors, in was intact, as could well be expected in view of its
charge of the great establishment at Berck, are re- structure. From this, we must not hastily conclude
nowned bone specialists. The above percentages should that-since the test pressure must have been far greater
not be accepted as representing a general condition, than that developed by mere muscular exertion in the
but rather as concerning series of cases of spinal de- aforementioned case, and yet had proved insufficient
formations, although, unfortunately, such cases are to cause extrusion of the nuclear matter, therefore it
much too frequently encountered.
is not proven that the said exertion had caused that
Dr. Byron Stookey presents in a study on the matter to extrude. It might justly be argued that the
“Compression of the Cervical Cord by Anterior Ex- structure of the disc, including its peripheral lining,
tradural ,Chondromas” in Archives of Neurology and must have been weakened by disease of some kind or
Psychiatry August, 1928, in which the symptoms and other. On the other hand we must not forget that a
surgical treatment of seven cases are exposed in great suddenly applied load is capable of developing stresses
several times greater than the intensity of that very
detail.
load.
Quite a number of other observations have come
This point is most important ; without discarding the
to light recently, and no doubt they will now be followed by many others, as the subject is of more than possibility of disease, our own experiments, mentioned
ordinary interest. We may therefore consider it well in T HE J OURNAL of July, 1930, and which had for
established that there is such a thing as an exonuclear object the study of the elastic properties of the nuclear
lesion; that it has been found of fairly frequent occur- substance, have shown that by spacing off the applicarence ; that its symptoms cover a wide field, depending tions of pressure it was possible finally to cause the
of course upon the region affected, and that conse- extrusion of the substance along the posterior wall of
quently it is difficult to detect and to trace properly. the disc; the extrusion was not jet like, but rather a
It stands thus, unsuspected, somewhat on the same sustained oozing out. From the start, after each appliplane as an obscure, but potent, focus of infection (dis- cation of pressure, the latter was released and the disc
eased tooth, tonsil, blood, etc.) In reading through given time to return towards its normal shape ; the rethe reports one gains the impression that the earlier turn was increasingly slow, thus evidencing the impairobservers were reluctant to admit the possibility of the ment of elasticity. The transverse section of the disc
occurrence of an excrescence in a so well protected disclosed permeation of the entire annulus fibrosus by
area which would be other than a tumor, which as the pulp, but with a greater distension of the lamellae
ordinarily understood is a formation due to the influ- on the posterior side.
ence of a germ, of a refractory embryonic element, of
Even under the greatest pressures gradually ata humoral extravasation, etc. But when caused by a tained, but without interruptions, it was not possible
sudden intrusion, or development, of a foreign body, to disrupt the disc, although the bulge was much prothe term pseudo tumor has been applied.
nounced, and there was some extrusion ; and ultimately
One most convincing report is that of Drs. Mid- the bodies of the vertebrae themselves were seen to
dleton and Teacher in the Glasgow Medical Journal fissure.
of July, 1911, on “Injury of the Spinal Cord Due to
Pondering over these observations led us to some
the Rupture of an Intervertebral Disc Through Mus- interesting conclusions ; a great abnormal initial stress
cular Exertion.” A laborer while lifting a heavy me- may cause the pulp, which is very viscous, to penetrate
tallic plate sensed a cracking in the lumbar region, and the interlamellar spaces; because of this viscosity the
felt a most acute pain. For a moment, maintaining a resultant clogging of the fibers would require some
flexed position, he was able to continue. his work; but time before clearing up; occasional repeated abnormal
the next day the man suffered a sudden and atrocious stresses would interfere with the clearing process and
pain radiating from the lumbar region to the lower add to the clogging; so that eventually the annulus
limbs, and then complete paraplegia set in along with would reach a critical stage of diminished resistance
sphincteral disorders. He died on the sixteenth day which might permit the sudden, massive, extrusion of
of uremic infection. On autopsy a whitish mass, 15 the pulp into the vertebral canal; once there the mass
mm. in diameter and 5 mm. thick was found on the could remain in the form of a nodule encapsulated in
posterior aspect of one disc; the cord presented signs fibrocartilaginous tissue, as found by the observers
of acute compression and had undergone local soften- mentioned. In very acute cases the mass may be large
ing with diffuse infiltration of blood ; the mass had enough to come into contact with the cord ; the sympthe same histological structure as the nuclear sub- toms are then of extreme severity and develop from
stance. The verdict was very obvious, death ensued the onset of the disorder. When of small size the mass
from disorders caused by the bursting of a disc and may not reach the cord and thus disturb the ordinary
intrusion of a nuclear mass into the vertebral canal.
activities of the body, but a wrong position, a sudden
Wishing to study the process of production of violent exertion, may force a passing contact which
such a lesion, Middleton and Teacher secured the lum- will produce sharp pain and distress symptoms. Genbar section of a spine from a fresh subject ; they placed erally speaking, the presence of such a nodule, of whatit in a bench vise and exerted a gradual endwise pres- ever size, within the vertebral canal is a permanent
sure thereon. They watched the development of a element of danger. There is no doubt that once a disc
bulge on the posterior aspect of the discs, which, under has been affected by overstraining there must be some
greater pressure, reached to practically the same size change in the alignment of the vertebrae which, to the
as that found at autopsy. On a transverse section of uninitiated, would appear as an ordinary vertebral
lesion, quite
susceptible
of reduction. let us beware
the disc it was seen that the bulge, or nodule,
had
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72
BLOOD TYPING AND TRANSFUSION IN EMERGENCY PRACTICE-JOHNSON
of chronic and refractory lesions: many of them are
amenable to conscientious and patient treatment, but
not to the presto pronto “specific” kind. There lies
all the difference between the artisan and the tinker.
Citation of a case referred to us by an allopathic
friend is deemed worthy of attention as regards gross
symptoms, treatment and results. The patient, a young
lady, was a constant sufferer from ambulatory hindrance-short steps, unsteady gait-coupled of course
with a varying degree of dizziness; the acuity of vision
of one eye was somewhat below normal, that of the
other was gravely impaired ; there were menstrual disorders-irregularity, duration, profuseness, pains, general disturbances; the patient was stout, much inclined
to obesity ; there were no evidences of blood disorders,
and no record of infancy diseases. The upper dorsal
region, particularly to the right, was very rigid, the
lumbar very tender, and the cervical much involved.
The case was very puzzling; however, it was evident
from the response to the first three applications of
osteopathic treatment that the gross vertebral column
possessed structural integrity ; then, whence the disorders ? Under persistent questioning, the mother
could not recollect any untoward accident, shock, fall,
etc., but finally, most willing to help with any kind of
clue, she stated that up to the eighth month her baby
had been in most perfect health, then all of a sudden
became affected in some obscure manner and thereafter did not develop normally ; the baby could not
walk until past two years old. Evidently something
had happened which seriously impeded normal development. Avoiding any form of prompting, it was finally
brought to light that the baby had been cared for by a
rather indifferent nurse, who one day in a moment of
inattention allowed the child she was carrying on her
arm, in a sitting position, to drop abruptly backwards,
hanging by the knees. It was then remembered that
PART II
shortly afterwards the change in the child became apparent, but no one thought of connecting the seemingly
ordinary incident with that change. We feel fully warranted in the belief that to the abrupt backward fall. of
the child-being the one salient point in the whole history of the case-may be attributed the formation of a
number of exonuclear lesions to which may be traced
the origin and development of the disturbances affecting the patient.
Under ordinary osteopathic treatment the menstrual disorders gave way totally, dizziness disappeared,
walking became practically normal ; the ocular muscles
functioned well and, according to the eye specialist
now in charge of the case, vision in both eyes is making rapid and satisfactory progress.
To some practitioners this tracing of etiology may
seem fanciful; for us it was helpful because, sensing
the integrity of the osseous structure, we bent our efforts upon the utmost activation of the circulation
which, alone, could be depended on for the gradual
reduction of the abnormal growths, or rather, of the
pseudo tumors most probably existing in the vertebral
canal.
Two others, but rather extreme instances, might
be cited, which could be held to prove that many ‘ills
in after life may actually originate at birth. Both concerned babies less than one month when referred to
us ; one had most severe torticollis, with of course the
whole cervical region extremely involved ; the other
could not take nourishment of any kind because of an
intense constriction of the cardiac end of the esophagus
produced by severe spinal lesions. These troubles were
easily traced to remissness both during delivery and
after. They were extraordinary cases, it is true, but
common, daily observation suffices to make us realize
the influence which the dangers incurred during the
formative years of the individual may have upon the
health and comfort of the grown-up.
A.list of
references will accompany the final article in the series.
Essay on Vertebral Lesions
SUGGESTIONS FOR A PROGRAM OF RESEARCH
Normal function depends on the integrity and
the mobility of parts. This is fundamental and, incidentally, is the osteopathic tenet. It immediately implies
the possession of a most intimate knowledge both of
the structure of the said parts and of their functions.
The practice of osteopathy has fully demonstrated its
worth, but the development of its theory, so urgently
needed in view of the a d v a n c e of others, h a s n o t
progressed very far beyond the dicta of A. T. Still.
True, laboratory experiments have here and there
amply verified the well founded basis of these dicta ;
nevertheless there is lacking a well outlined continuity
of impeccable demonstrations, as well as a far more
advanced knowledge of the anatomy, histology and
physiology of every component part of the spine than
that which we have too complacently relied upon.
Our mode of investigation must be patterned upon
that of such men as-Claude Bernard and Ranvier, for
example, if we wish to accomplish the desired results.
Thus, before undertaking a given demonstration, we
must have a clearly defined program of action; if we
wish to study the effects of an artificially produced
vertebral lesion upon a certain nerve, we must know
in advance what tissues will be involved, the kind,
degree and specific effect of that involvement upon
the nerve itself as well as’ upon each of the correlated
parts ; we must know precisely why the lesion, once
formed, remains so, and what conditions obtain immediately after correction. It is therefore clear that
physiological experimentation can proceed with as-
surance only when fundamental knowledge of the
parts dealt with is securely at hand; otherwise it will
tread among so many complexities that it will fail to
convince, even if seemingly successful. The needed
information is not to be found in our anatomy textbooks; but there is ample evidence of a widespread
desire for it, as shown by published accounts of investigations here and there pursued by practitioners
of great ability. In the field of research concerning
the intimate parts of the spine it was our heritage to
lead; shall we be contented with merely joining?
As a mere worker, it seems to me that some of
the main subjects to which attention should be most
diligently applied may be listed as follows:
(1) the vertebral column viewed as an entity;
(2) the vertebral unit, composed of two adjacent
articulated vertebrae ;
(3) the intervertebral disk; the annulus lamellosus ; the nucleus pulposus ; the exonuclear lesions’
(4) the intervertebral ligaments ; their innervai
tion ; their control functions ;
(5) the apophyseal articulations ; the mechanics
of their displacements ;
(6) the deep vertebral musculature; its innervation ;
(7) the contents of the intervertebral foramen;
(8) the nerve sinu vertebral ; its function as vasoregulator of the blood supply and drainage of the
meningeal tissues and of others located in the vertebral canal and in the intervertebral foramina.
(9) the supporting or connective tissue: i t s
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ESSAY ON VERTEBRAL LESIONS-GUY
73
The spine has always been viewed as a strut a
column sustaining a vertical load increasing from the
top to the base. The cervical region pyramided down
to the base of the 7.C, then the column tapered down
to about the 4.D., and thenceforth pyramided down to
the base, that is the lumbosacral articulation. Made
up of a succession of parts, or vertebrae united by
very ‘strong fibrocartilaginous connections, the intervertebral disks, it formed a highly resisting,’ articulated
assemblage which was considered as an organ of sustentation, capable of suppporting not only the weight
of the body parts attached to it, but also heavy loads
carried by the individual. As a whole it had, like a
twig, flexibility in all directions, but to a degree varying according to region; it was capable of rotation and
of circumduction ; and for each intervertebral articulation the same kind of motion had been carefully observed and recorded, although (according to Cruveilhier’s Descriptive Anatomy, 1852) their detection, is
possible only through the study of the total displacements of the entire vertebral column.
It seems therefore that the notion has persisted
through all ages that, since man is essentially a biped,
intended by nature for the erect station, it was necessary to conceive that means of maintenance of that
station should be in the form of a sturdy pillar. What
more natural then could it be than to endow the spinal
structure with the attributes of the long bones of the
limbs intended primarily as compression members ?
This conception is now firmly rooted; our best textbooks dwell upon the attempts made. to determine
mathematically the strength of the spinal column; to
compare it to the relative strength of a straight column, or even of a single elastic arc, and of a structure
made up of several arcs. They tell us that the conformation of the vertebral canal, together with the
yellow ligament linings greatly add to the resistance
of the spine, etc. The best proof advanced, which
should preclude any further argument, is the very fact
that the spine is pyramided downwards, so that the
lumbosacral articulation offers the greatest area of,
support, and consequently, cannot be otherwise than
considered as the true base of a pillar, a column of
sustentation. All these points are made in chapters
devoted to articulations, which follow those dealing
THE VERTEBRAL COLUMN IS NOT A PILLAR
with the minute description of bones and ligaments.
There is a most regrettable lack of information It is only further on, in myology, that the muscles,
in the usual textbooks and in the schools concerning their attachments and their functions, actually enter
the structure and function of the elemental organ ; the field.
that is because attention has increasingly been too
It is most surprising, even inconceivable, that ap-.
much absorbed by the intricate study of pathology parently no published work has thus far shown the
of tissues, of complexity of symptoms, to realize the utter material impossibility for the normal spine-conprimordial importance of the sound knowledge of sidered alone, as an entity composed of an elastic asboth the structure and its function. As a proof, and semblage of vertebrae and intervertebral disks-to act
as concerns the knowledge brought to light by the as a vertical supporting column. A well prepared
pioneer investigators with that printed in our up-to- spine, promptly obtained from a fresh subject, would
date books: Starting with Galen, in about 170 A. D. not be able to sustain the weight of the. head; that is
(Latin translation of ISSO), we come to Borelli, 1680; quite obvious, although in this case a certain amount
then to Blancard, 1695, and finally to Alexander
of rigor would obtain, which would stiffen up the
Monro, 1726, whose work “On the Anatomy of Bones”
contains most precious information, of clearly out- structure. If the spine possessed an elastic rigidity of
standing value. It is based upon deep study of the its own, that would always be evident in the living
authors cited above as well as keen individual re- subject, but it is common knowledge that in states of
search and observation. Since then, only a few extreme relaxation, exhaustion, of deep sleep, of loss
details have been added, but nothing really funda- of consciousness, of prostration, of syncope, and in
mental, so that today we find that the philosophy of some stages of inebriety, the human body is totally
the subject, despite numerous desultory attempts, has limp; the cervical spine is unable to sustain the head
remained at the same point to which Monro brought in equilibrium; the trunk cannot maintain a vertical
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it some 206 years ago.
position,Academy
even with
the subject seated; in fact the body
hygrometric properties ; its role, in edematous and inflammatory processes in relation with the lymphatic
circulation;
(10) the purpose and physiological effects of the
abrupt and intentional separation of the apophyseal
articulations, with incidental “popping” ; the physics
of this latter;
(11) the analysis of the maintenance of the
relative displacement of two adjacent vertebrae or
so-called “lesion,” in a position within the normal
range of motion, nevertheless permitting a certain
amount of mobility ;
(12) the pathological effects of the maintenance
in a fixed position, either normal or abnormal, of the
articulations of two adjacent vertebrae the remedial
procedure through osteopathid manipulation for such
a condition ;
(13) the analysis of the effects of osteopathic
manipulation of soft tissues; drainage of the latter;
abatement of congestive conditions ; activation of
arterial circulation ; reduction of acidosis, hence of
irritation both to the nerve terminals and to the trunks,
and consequent appeasement of superficial and deepseated tenderness ;
(14) the costovertebral articulations ; the influence of their disordered conditions upon the nutrition
of the costal tissues, ligaments, musculature, bones,
marrow and its hematopoietic functions ; study of the
development of eruptive disturbances such as herpes
zoster, of costogenic anemias and toxemias, of the
influence of the latter upon the genital functions.
Obviously many more items could be added to
this program of chapters of research work, whose
well developed ensemble would form, at’ the very least,
a large volume of reference matter, of great practical
interest to the profession. In Part I of this article
the subject, “Exonuclear Lesions,” was merely
skimmed; its importance demands far greater degree
of skilled treatment than was accorded to it. Some
of the other items will be merely touched upon
throughout these pages, and the writer will feel gratified. if some of his suggestions should be found
worthy of attention in our research laboratories and
classrooms.
74
ESSAY ON VERTEBRAL LESIONS-GUY
But we may go further and point out again. a vast
is without control and may flex in any direction. It is
also well known that in animals freshly slain there is and yet unexplored field ; that of the ligamental sense.
It is the role of the muscles to obey in a coordinate
a complete limpness.
Therefore, we are led to the logical conclusion manner the command of the nerves and to move certhat the spine-by itself-cannot be considered as a tain parts: it is our conviction that the articular ligaments possess the faculty of sensing the extent-of
pillar, as acolumn of sustentation.
The characteristics of the spinal column as re- motion, and hence, of issuing a warning of the apgards stability and resistance under a vertical load are proach to the limit of normal motion, that is, of
about of the same order as those of a piece of rubber danger. There are many indications to that effect, but
so far no definite study of the subject has been underhose held upright upon a support.
At this juncture the writer communicated with taken. It seems quite clear that the intervertebral disk
Dr. H. V. Halladay, whose most skilfully prepared and the apophyseal articulations must play a most imspines are well known by osteopathic practitioners ev- portant part in regulating the sectional displacements
erywhere, and whose opinion consequently is of pre- of the spine and consequently the latter, when alive,
cious value ; with his kind permission we quote at then ceases to be merely an inert assemblage of verterandom from his letters: “A person sits erect because brae and intervertebral disks, as just stated.
It is rather significant to find workers of other
certain muscles contract and maintain the body in that
position. The natural tendency of the spine is to flex schools becoming increasingly interested in the study
when the muscles are removed. With my specimens of some vertebral elements, a subject of the greatest
the same thing occurs, and when placed upright on importance to our profession. This matter will be
given attention in a subsequent part, as well as in the
the table they all flex or bend to one side or the other.
The spine thus simply flexed by the gravity pull is bibliographic notes; for the present, an article by Drs.
maintained in that position by the resistance of the A. Jung and A. Brunschwig, in Presse Medicale of
ligaments, but the flexion may be increased by forces February 27, 1932, “Histological Research on the Inapplied by the demonstrator. The specimen will not nervation of the Articulations of Vertebral Bodies,”
spring back to the upright position any more than one may be mentioned in relation with the preceding paracould keep upright without the staying action of the graph. These doctors have traced a number of nonmuscles. . . . The same conditions obtain in a subject medullated nerve fibers within the anterior and the
whose muscles are all flaccid. In the early part of my posterior common ligaments, and they conclude that
work we took roentgenograms of patients and ob- just as for the articulations of the limbs, studied by
served the spine for the purpose of verifying this fact, Rauber and Regand, (a) the innervation of the verteand we found it true. But here is another interesting bral amphiarthrosis obtains only within the ligaments ;
(b) likewise the sensory elements are to be found exthing; if I turn the spine upside down, taking the
weight off, or suspend it from the pelvis, it still retains clusively therein ; (c) therein are initiated the reflexes
the normal curves. Again, if I remove two vertebrae controlling the statics and the equilibration of the
from the rest of the specimen, and then move the one vertebral column, as well as the vertebral pains ; (d)
on the other, the weight of the one above being SO the nerves and the nerve terminals, although not nuslight, they will resume what we might call “a position merous, are found mainly in the anterior ligaments
of rest,” that is, about half way between the extremes and in much lesser amount in the lateral and posterior
of the normal range of motion. This proves that the ligaments.
ligaments of the spine offer some resistance to the exTaken at their face value these findings tend to
tremes of movement, but not sufficiently to overcome confirm the deductions arrived at through elementary
completely the force of gravity. . . . The maintenance reasoning. It is in the nature of things that adequate
in the erect position is effected by the action of the safeguards be provided for every single part throughmuscles.”
out its ephemeral life. And thus we would expect to
As seen laterally the spine is composed of three find in this instance properly located means for senselastic arcs, anteroconvex cervical, anteroconcave dor- ing certain dangerous extremes of motion; for oversal, and anteroconvex lumbar, and it is -evident that extension of the vertebral column would badly affect
under a weight placed at the top each of these would blood vessels, nerves and ganglionic chains located and
be subjected to flexural rather than compressive attached prevertebrally ; likewise, to a certain extent
stresses ; and the curvature of each would be increased. would excessive sidebending. For detecting the limits
In whichever way the load is applied there is no doubt of rotation and flexion, most probably other means
that the structure is designed to withstand bending will be found in the innervation of the yellow ligaefforts ; but alone it cannot any more withstand these ments. For an interested investigator the problem is
than support a load ; it is only when braced all along to verify such findings as just mentioned; to search
its length that the spine may be visualized either as a for other traces of innervation relating to the apomost wonderful and sturdy pillar, or as an equally physeal articulations; to discover the nature of the
wonderful lever arm, of great strength and of nerve terminals, hence by what means they are imextraordinary adaptability to suit an infinity of attitudes and efforts. We understand fairly well the pressed, and whereto the impressions are conveyed;
responses of the muscles to the voluntary nerve im- to find the nature of the reflexes and the mechanism
pulses, and less those to the involuntary stimuli ; cease- of the resultant reactions. We readily perceive that
lessly active for the purpose of insuring the equilib- what little bits of information are picked up by chance
rium and healthy-conditions of the structures, through here and there in current literature, while precious
imperceptible modifications of attitudes. Itself an indices in themselves, would enhance in value, if methinert organ, the spine becomes incessantly mobile when odically brought forth in the course of systematic
animated by the living forces controlling the body; research endeavors.
such considerations justify the views expressed before
Guy, Albert E.: Vertebral Mechanics, JO U R . AK O S T E D , AS S N. ,
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which led me to define it “an animate
beam.“*
July,
1930.
ESSAY ON VERTEBRAL LESIONS-GUY
.
75
THE VERTEBRAL UNIT
vertebral articulation is to represent it as a flat bag
We may fittingly terni vertebral unit the working made of elastic material, like rubber, fixed on top and
assemblage of two vertebrae one intervertebral disk bottom to the aces of the vertebral bodies, and filled
and two apophyseal articulations, since from the axis with a very viscous substance possessing no better
to the first sacral there are twenty such assemblages, elastic qualities than plain water. Assume that the
and the characteristics of one are typical, that is, are substance is introduced under a slight pressure so that
common to all. Of these parts the disk seems to have when the bag is sealed its peripheral wall is bulging
received the greatest share of attention, while the a little. Now then, with one body held fixedly, the
last two, Cinderella-like, have been relegated to the other may be inclined in any direction, circumducted,
scullery, as befit poor relations. As a matter of fact, and rotated to some extent; it may also be axially
these three articulations form the closest imaginable pressed down upon the bag and still remain free to
copartnership and must be considered all together in move. Whatever the motion it could be performed
the study of the intervertebral joint. The disk has with far greater ease and freedom than could be obadvanced from the state of mucous ligament of Galen tained with a ball bearing, and particularly so, since
and his predecessors, to that of cartilage, and finally there would be no fixed pivotal point within the subhas reached that of fibrocartilage of today. Monro stance, and this applies to the full in the case of lumsays : “The external fibrous part of it is capable of bar vertebrae each of which has an axis of displacebeing greatly extended, and of being compressed into ment located posteriorly, away from the bodies. It is
a very small space, while the middle fluid part is in- thus seen that such a bag serves (a) as a strong tie
compressible, or nearly so, and the parts of this liga- uniting two adjacent bodies ; (b) as a perfect bearing
ment between the circumference and center approach instantly adjustable to all possible relative displacein their properties either in proportion to their more ments of the bodies; (c) because of the elastic qualsolid or more fluid texture. The middle point is there- ities of its wall, as a soft cushion ; and (d) because
fore a fulcrum or pivot, on which the motion of ball of the viscosity of the fluid, as an ideal shock aband socket may be made, with such a/gradual yielding sorber capable of withstanding great flexural compresof the substance of the ligament, in whichever direc- sive efforts. The essential requirements are that the
tion our spines are moved, as saves the body from peripheral wall be sufficiently strong to permit incesviolent shocks, and their dangerous consequences. This sant and rapid changes of shape of the bag, consequent
ligamentocartilaginous substance is firmly fixed to the upon the various displacements of the fluid, and
horizontal surfaces of the bodies of the vertebrae, to staunch enough to prevent the extrusion of the fluid
connect them, in which it is assisted by a strong mem- under pressure.
It is quite obvious that upon the puncturing or
branous ligament which lines all their concave surface, and by a still stronger ligament that covers all sectioning of the bag the soft mass would seem to
their anterior surface.” To this most fitting descrip- spring out as if impelled by its own elasticity, whereas
tion, we may, with due reverence, add that the exterior the same effect would occur with plain water, the
fibers extend much farther inwards anteriorly and lat- cause being in each instance the release of the elastic
erally than on the posterior aspect, consequently, as a tension of the wall.
container for the fluid mass, the annulus fibrosus is
In the actual intervertebral articulation the mateweakest posteriorly. Of course, there is no such thing rial of the wall is not compact like rubber, nor has it
as a middle point, or pivot, within a mass permeating. by far the elasticity of the latter; it is made up of flat
the whole disk.
fibers, or lamella, arranged weather-board fashion and
The notion of a ball and socket articulation reaching obliquely, at an angle of between 45 and 60
brought forth by the ancients, and adopted by such degrees, from one body to the other. A ring is thus
authority as Monro, has remained practically undis- formed of an assemblage of such fibers, and the whole
puted, although palpably erroneous, probably because wall consists of a relatively large number of such rings,
it represented an easy explanation of a problem, the or layers, concentrically and closely disposed, but in
importance of which had never been fully recognized. such a way that the obliquity of the fibers of one ring
Some authors, like Morris, in his “Anatomy,” have is the reverse of that of the preceding, so that in the
even taken upon themselves to emphasize it to the end the whole is in reality a lattice-like structure. Its
point of the ludicrous by providing blithely the only name, annulus fibrosus, is somewhat misleading, as
thing that was missing to make it exactly that kind of suggesting the usual form of fibers; certainly with
articulation; thus in ‘part 1, page 222, of the 4th edi- round fibers, additional enclosing membranes would
tion, we find that: “The pulpy nucleus or central por- have been needed to insure staucchness; the overlapping of the lamella most adequately provides that; if
tion is situated somewhat behind the center of the
disk, forming a ball of very elastic and tightly com- this rather unique construction had been fully understood at the time, it is most likely that the wall would
pressed material, which bulges freely when the confining pressure of the laminar portion is removed by have been more fittingly named the annulus lamellosus.
either horizontal or vertical section. Thus, it has a The obliquity of the lamellae is a most helpful factor in
constant tendency to spring out of its confinement in maintaining staunchness under great pressures, as it
the direction of least resistance, and constitutes a pivot provides a compensating arrangement to make up for
round which the bodies can twist, tilt or incline. . . .” the spreading of the fibers when the disk bulges out.
It is of utmost importance to bear in mind that
Unfortunately there are lesser luminaries who
the pulpous substance permeates the whole of the disk,
dare not shake the magister dixit yoke, and cannot
and that while there is in the inner part an indefinite,
admit what is so readily perceived, that the nucleus amorphous, fluid mass called the nucleus pulposus,
pulposus has the same fluidity in man as in animal
it does not form a separate entity, but instead, it is
spines, which latter can be seen, in section, at any time continuous with the intralaminar and interlaminar uncof the day in a meat market.
tuous fluid.
Perhaps the simplest way to understand
the Reserved
inter- American
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Furthermore,
Academy ofwe
Osteopathy®
must dismiss the notion of an
76
ESSAY ON VERTEBRAL LESIONS-GUY
elastic intervertebral articulation functioning just as outgrew his clothes and was compelled to secure an
the mechanical device instanced heretofore because, entirely new photograph for his card of identity-for
while the latter can spring back instantly to its initial which he thoroughly berated us. (N.B. The writer
alignment upon release from the deviating forces, the is not even an aspiring candidate for the Ananias
former is comparatively inert and requires the pull of club).
the muscles immediately attached or distantly involved
AMPHIARTHRODIAL LESIONS
to change from one forced position into any other,
When the constituent parts of an organ are known
and also to relaxation. The elastic properties of the
lamellae seem intended only to suit prompt adjustment it is easy to list the main derangements liable to affect
to the conditions imposed by the deformations of the each part specifically. Each derangement is a lesion,
disk due to external efforts; they are of a totally dif- in the sense that it may cause some dysfunction of the
ferent order from those possessed by the muscles; part itself, of proximal tissues and possibly of distal
whatever elasticity they have is most wonderfully organs. Unfortunately, in this instance, such lesions
supplemented by their mechanically efficient disposi- cannot be directly detected, and radiography is helpful
only, if at all, in well advanced cases. The practitioner
tion in oblique rows.
must then analyze all likely symptoms and gradually,
From these considerations we may now visualize through reasoning, he may finally locate the seat of
the comportment of the disk in normal and abnormal
trouble. The parts which should be well studied are:
activity. After the nocturnal repose demanded by
( 1) the nucleus pulposus ; (2) the annulus fibrosus ;
nature to refect the human organism the height of the
(3) the basement cartilages; (4) the common liganormal individual is slightly greater than it was at the
ments ; (5) the periosteum ; (6) the bony structure of
beginning of that repose, that is, at the end of a period
the bodies ; (7) the innervation and vascularisation of
of strenuous and Prolonged activity. The length of
the bones has not changed, but the disks ‘have been all the preceding. We have already dealt with a few
flattened appreciably, since with the spine as an ani- phases of the extrusion of the pulpy mass, but very
much more is required, for instance, regarding its formate beam the vertebra: are the compression members
mation, its maintenance, that is, its nutrition and elimof the structure and the disks are, by construction, the
only organs susceptible to deformation. This fact was ination; its gradual transformation with age and fatigue into a fibrous structure ; its susceptibility to the
well known by the ancients; Abbe Fontenu (1725)
mentions further that man may become taller after a influence of cold, humidity, inflammatory conditions,
plentiful meal, while the reverse obtains after fasting sarcolytic extravasations from vicinal affected tisor evacuations. Here we may place some personal ob- sues, et cetera. All this applies in some manner to all
servations on the effects of fatigue on stature. Years the soft tissues concerned with the articulation. The
ago, before the laws were modified so as to impose bones may be split, fissured, eroded. The ligaments
general compulsory military duty in a certain Euro- may be stretched, ruptured, repaired, spontaneously
pean country, there was a minimum height of stature and with scar tissue formations. The periosteum may
below which the young conscripts were exempted from easily be involved when the ligaments are overstretched, and that may open the way to most serious
service. An individual whose pate did not reach the consequences,
exostosis with eventual ankylosis, osteominimum gauge limit was in luck, not good enough
necrosis, et cetera. The subject is so broad that one
as cannon fodder. There were young men, however,
who knew they could just scrape the gauge, and some is apt to feel discouraged when confronted with the
who could overstep it by a trifle, sometimes as much few items mentioned here.
As to the origin of many of the disorders affectas one centimeter; now- what with necessity as the
mother of invention, and with reliable sub rosa tips, ing the intervertebral articulation, it may be hereditary,
those who thoroughly disliked military glory would congenital, faulty delivery, infantile disorders, malpomake certain secret preparations just previous to in- sitions, eruptive diseases, violent exertions, brutal
spection by medical authorities, With a rather sub- shocks, careless athletic training, prolonged cold imstantial pack strapped on their shoulders and back they mersions, casual or imprudent exposures, and so on,
took to the road and walked a good many miles for and of course, accidents; all of which may be borne in
several consecutive nights, with the ultimate and grat- mind when establishing the history of a case.
ifying result that on the fateful day, when officially
measured, they cleared the, yoke handsomely. Of
course, here and there alas, some foxy old major
would. cast a fly in the ointment by compelling the
runts to take a complete rest for full day in the hospital, following which, the test found them restored
to normal height, hence bound for service.
We would suggest as an experiment that some of
our students should endeavor to ascertain systematically, by careful measurements before and after,
whether or not a thorough relaxing treatment may
affect the height of a patient. We know fairly well
that an extended course of treatment is likely to do it,
as we found personally with a number of shellshock
and hunchback cases; but that is quite a different matter ; we’remember particularly one of the’ latter, a subject 37 years old, with a badly distorted and rigid
spine, who improved to such an extent that he gained
1.5 inches in height-for whichAllheRights
thanked
us- American
; he
Reserved
Academy of Osteopathy®
The Journal of the
American Osteopathic Association
PUBLISHED MONTHLY BY THE AMERICAN OSTEOPATHIC ASSOCIATION
vol. 32, No. 9
430 N. Michigan Ave., Chicago, Ill.
May, 1933
Essay on Vertebral Lesions
A LBERT E.
D.O.
Mount Vernon, N. ‘Y.
G UY,
P a r t
MECHANICS OF THE VERTEBRAL UNIT
The assemblage of the vertebrae and their connecting ligaments forms an inert structure devoid
of the rigidity and of the elasticity commonly attributed to it in the living body. This assertion has
been fairly proven, I think, by the considerations
advanced in a previous part of this essay, which
showed that in a totally relaxed body the spine is
absolutely unable to sustain it in position, and also
that a specimen spine, such as prepared by H. V.
Halladay, was unable to sustain a. light weight applied at its upper end. Normally, the ligaments
possess a certain amount of elasticity which checks
them gradually at their limit of extension. They are
pliant, fibrous bands whose main function is to
maintain the union of the osseous parts of an articulation while allowing the fullest range of motion.
They are provided with a system of innervation, the
terminals of which are capable, in a manner still
obscure, of sensing the approach to dangerous extremes of motion and of setting up appropriate reflexes for safeguarding the integrity of the structure. Their nutrition and elimination processes must
be like those of other tissues, under the control of
vasomotor innervation. Separated from the body
they gradually acquire an extraordinary degree of
‘hardness which, as experienced in the dissection
laboratory, is probably responsible for the lasting
impression that the spine is really a very rigid organ
of sustentation. Their pliability may be appreciably restored through prolonged immersion in a
fluid preparation, the main ingredient of which is
neat’s-foot oil.
If the spine consisted solely of vertebrae united
by intervertebral disks, such a structure would be
totally inadequate in several respects : mechanically,
for insuring accuracy of motion; and for the protection of highly specialized organs. Therefore nature has wisely provided for each intervertebral
union two guides in the form of apophyseal ‘articulations; in each of these a process extends from the
junction of the lamina and pedicle of the vertebra
above, and terminates as a facet engaging in smooth
and constant contact a similar facet extending in the
same manner from the vertebra below. The structural
details are fairly well known, and we had occasion to
I I I
deal with them before in “Vertebral Mechanics.“* A
very pliant capsule encloses each articulation, thus providing both protection and lubrication to the contact
surfaces.
Special emphasis is placed purposely on guides
and constant contact because these are factors of the
utmost importance in the present analysis. Effectively, if we assume that the contact is intended to
be constant (and we have every reason to do so),
it follows that any displacement of one vertebra relatively to the other must be directed in accordance
with the geometrical contour of the guiding surfaces. The orientation of these differ according to
the region of the spine considered, and it changes
abruptly in passing from one to the other of the
three recognized regions, the cervical, the thoracic
and the lumbar, but the principle involved obtains
for all.
In the normal, living body, all the ligaments
concerned in the union of two adjacent vertebrae,
constituting one vertebral unit, are entirely inadequate, not only to insure the necessary working contact, but also to guard against the separation of the
apophyseal surfaces. This separation may be effected in two ways: normally, through the action
of two opposed forces pulling the facets apart; and
through slightly oblique pull, opening the articulation in hinge-like fashion. ‘Throughout our most
strenuous exertions, our most violent efforts, the
whole body is ever watchful, jealously protecting
the entire spine against any local disarticulation. It
is evident that, with the body tensed in action, a
forced apophyseal separation would entrain a sudden axial disalignment of the vertebrae involved,
uncheckable in time to prevent most serious injury
to the cord, to the roots, to the blood vessels, the
ganglionic chains and other organs attached to the
spinal structure. Such occurrences are unfortunately very frequent, as in falls, shocks, blows and
brutal sports, and often result in persistent lesions
and disabilities.
In the daily application of the osteopathic technic it is currently found necessary’ to produce
“Guy. Albert E.: Vertebral Mechanics, JO U R. AM.
1930, Aug.. Sept.
All Rights Reserved77
American Academy of Osteopathy®
O S T E O. AS S N .,
78
ESSAY ON VERTEBRAL LESIONS-GUY
apophyseal separation for the specific purpose of
normalizing the position of one vertebra with respect to the adjacent ones. This is always done
judiciously after due manipulatory preparation of
the vicinal tissues. Originally intended for just
such a purpose, this practice soon had to be extended to other parts of the spine, because to one
well defined lesion always corresponds at least one
other, as a compensatory’ one, and most usually a
series of others. Then it was found beneficial to
proceed further in some cases, and thoroughly to
loosen up the whole spine. Incidentally this form of
manipulation proved useful in demonstrating the
extent of freedom and mobility of the spinal articulations. Although the precise occurrence of an intentional separation is readily sensed by the operating
hands, and the patient does not feel incommoded
thereby, it is accompanied by a certain factor, ominous and somewhat disconcerting to the subject,
in the form of a cracking noise which, however, may
be attenuated almost to the vanishing point through
appropriate technic.
This novel form of treatment which, when needed,
involves the direct and precise manipulation of the
vertebra, was combated from the beginning by adherents of other schools, who could not, and cannot
even today, admit either the feasibility of disjointing
the articulations without causing irreparable damage
to the body, or the demonstrated beneficial results of
osteopathic manipulations.
It is difficult to reconcile this attitude of absolute
negation with the statements printed in recognized
standard books. Thus we find in the latest edition of
Poirier’s Anatomy, Arthrology section, page 62, that
“the apophyseal movements are essentially gliding and
rocking. Because of the laxity of the capsule they are
but partially controlled by the configuration of the
articular surfaces. In gliding the surfaces slide upon
one another in all directions; in rocking they remain
in contact at one of their extremities, but separate at
the other, and the articulation stands gapping. . . . ”
It seems impossible to imagine a grosser misconception of the subject, yet similar citations from recognized authorities could be given here, the mere
reading of which would leave us like the above articulation, gaping. But before we start on a career of lapidation at long range let us be on guard against boomerang effects, and save some of our pebbles for vicinal
targets; for we have on our own shelves some works
dealing with the matter of the vertebral lesion, masterfully attributing it to the hooking of the edge of one
articular facet into the surface of the corresponding
one: thus forming an ingenious structure akin to the
druidic dolmen of past ages. A late addition to these
is an opus on anatomy, unfortunately illiterate in
redaction, which again upholds such a contention.
And so we stand in dismay, confronted by a divergence of understanding of a point of basic, vital
importance ; on the one hand we find most positive
assertion to the effect that the spine is a closely knitted
entity, susceptible of flexural mobility, while on the
other we are told that, in an important aspect of that
mobility, in rocking, every one of the twenty-three
spinal pairs of apophyseal articulations ceaselessly
works through a series of gapping contacts. If this
were true how could we account for the cracking noise
coincident with the intentional separation of the
joints? Or again, would not any movement of the
spine be accompanied by series of creaks?
An analytical comparison would be a waste of
time, for it is evident that on both sides the notion of
function as the controlling factor received but the
scantiest of attention. And yet, with it as a guide the
difficulties of the problem are reduced to a study of
the intimate details of the structure involved. We
may then proceed tentatively as follows: (a) the vertebra: must be firmly united in a manner that will permit flexural displacement, hence the intervertebral articulation with its strong cartilaginous and ligamentous attachments, forming also a wonderful cushion
capable of instant adjustment to any oscillation of the
bones ; (b) vertebral motion must be precisely guided,
and specially important organs safeguarded, hence the
apophyseal guiding articulations ; (c) these articulations must comprise two elements, one being the necessarily guiding structure proper, is provided by the
articular facets working in smooth contact; the other
is the means of constantly maintaining this contact,
and we should particularly note that its conception as
such has never, to the writer’s knowledge, been described before ; (d) besides a vascular system there
must be another, nervous, to preside over the needs
of the tissues, to warn of the approach to danger
limit of displacement and to guard against the disruption of contact between articular facets.
We have studied before the motions of the
apophyseal articulations, and indicated a method of
determining the centers and axes of oscillation, but
these questions will be, further on, given additional
and perhaps more convincing’ attention.
It is clear that in normal activity the vertebral
ligaments may be considered as very strong pliant
bands, possessing a certain amount of elasticity ; some
of them, the yellow ligaments, are more elastic than
the others because of the muscle fibers in their structure. (This is true according to such anatomists as
Poirier and Testut.) But if we reason that the separation of the articular facets is produced by an effort of extension applied to a region of the spine situated above one given vertebra held fixedly by the
hand, as a fulcrum (as is the case for all dorsal vertebrae), we realize that all the ligaments are of very
little help in resisting the disruption of contact. By
operating in this manner we may, according to our
ability and strength, disrupt both contacts at once, or
only one at a time, but then, if the separations are
effected separately we have, perhaps unconsciously,
employed a method based on a different principle,
which is used specially for the cervical and lumbar
regions. Thus, instead of selecting one whole vertebra as a fulcrum, we make a fulcrum of one apophyseal articulation, twist the spine and separate the other
articulation. This method is general and is applied to
all parts of the spine by many most skillful operators.
However it is accomplished, the stages of the operation are always the same: (1) preparation of the
tissues; (2) positioning; (3) sensing of thorough relaxation ; (4) separation of the articulation ; (5) immediate reflex closing of the gap with coincident cracking noise ; (6) digital verification of the normal adjustment of the articulation ; (7) final manipulation of the
vicinal tissues.
When effecting the separation one is conscious
of a strong, deeply seated resistance which, with an
initiated and thoroughly relaxed patient, may be
Guy, Albert E.: Vertebral Mechanics, JO U R. AM . Osteo. AS S N. ,
July.
1930,
All Rights Reserved American Academy of Osteopathy®
ESSAY ON VERTEBRAL LESIONS-GUY
79
easily overcome by a slow but steady effort, with a Figure 1, as they ascend along the spine ; they are :
resulting very soft cracking noise; with a nervous (1) and (2), th e anterior and posterior intertransand anxious subject quick action is necessary to versales; (3) the rotator brevis, extending from the
take advantage of a propitious moment of relaxa- lateral aspect of the transverse process of one vertion ; then the noise is bound to be sharper. Now, tebra to the external lower edge of the lamina of
the question before us is : what is the nature of that the vertebra above; (4) the rotator longus, extendresistance?
ing from the transverse process of one vertebra to
We may safely assume that the separation de- the internal lower edge of the lamina of the second
velops gradually, whether produced by extension vertebra above; (5) the infraspinalis (branch of the
or rotation, but that is a small point. The important multifidus), extending from the transverse process
one to consider is that the resistance encountered of one vertebra to the root of the spinous process
must be a force directed perpendicularly to the con- of the third vertebra above; (6) the supraspinalis
tact surface of the facets, and that it must be over- branch of the multifidus, extending from the transcome by an opponent force also normal to that sur- verse process of one vertebra to the top of the spiface, hence the necessity to insure proper positioning. nous process of the fourth vertebra above ; (7) the
Each pair of facets seems to be incessantly held in interspinales.
close contact as if acted upon by a spring. Leaving
Interspersing the whole mass are fibrous septa
aside the ligaments, there is nothing prevertebrally and connective tissue fasciae, either separating, inthat could produce such an effect; on the posterior vesting, or connecting the muscle elements, and
aspect there is no adequate structure capable of main- themselves forming innumerable interstitial areas of
taining one direct and steady elastic pressure upon passage and distribution for the lymphatic, vascular
the back of the outer apophysis; therefore we may and nervous systems. This mere statement opens
conclude that the resistance is the resultant of several up a chapter of vital interest in the study of the
forces, and that each of the latter must be the pull lesion, as will be indicated a little further on.
of an elastic organ, that is, of a muscle. It seems
THE TRUE VERTEBRAL LESION
then logical to visualize the musculature of the back
This
expression
is intended to apply to the conas comprising two sections. The more superficial,
having for function the production and control of dition of one vertebra maintained deviated from its
the various movements of the trunk and upper parts normal position with respect to the next vertebra
of the body, is composed of long and strong bundles, above or below. This forced displacement may ocso attached and so capable of coordination, that they cur within the range of the articulations; it may not
can exert great efforts with the most efficient lever- appreciably interfere with the mobility of the spine,
age; while the other, deeply nestled within the ver- or may painfully do so ; it may or not be sensed by the
tebral grooves, is made up of short bands forming patient; it may produce local or distant effects. We
(1) the multifidus spinae muscles, whose recognized are now interested only in the formation of such a
action is to erect and rotate the spinal column, and lesion by means of the elements studied thus far; later
(2) the rotatores spinae muscles that act to rotate on we shall deal with its generation through the agency
the column; but, while it is apparent that these last of vascular and nerve elements influenced by morbid
two sets of muscles can perform the stated function conditions.
In general, two types of vertebral lesions should
to a certain extent, neither their size, their attachments, their orientation, nor the leverage they can be recognized: the mild or minor, and the severe or
command would indicate that extent as an all im- major. In the first, as mentioned above, the one
portant and unique factor affecting the spine as a vertebra selected for study is discovered unable to
whole, as compared with that of which the more revert to the neutral position it occupied with the
superficial mass is capable. A closer study of their body normally at rest; it is produced in a very ordistructure, although their accurate dissection is a nary way through exposure, fatigue, emotional
very ticklish undertaking, tends to show that they stress, etc., and it involves no organic alterations
are also intended to fit another purpose, most essen- of the vicinal tissues. It does not occur singly.
tial, which is the maintenance of the apophyseal ar- There may be others close by, companions as it
ticulations in close, although elastic juxtaposition. were, or compensatory further away ; therefore, not
Together with these are the intertransversales and standing out prominently, it has been vehemently
the interspinales muscles, whose separate action denied recognition by other schools. Another reawould be almost negligible, whereas in cooperation son for this is the fact that such lesions coexist with
with the others, the power and efficiency of the such intense and deep contractures as are found in
whole may reach the maximum. That we are war- pneumonia, pleurisy, influenza, chills, asthma, etc.,
ranted to expect this effect with the deep muscula- and that usually attention is given exclusively to
ture is amply assured by the known fact that a body specific symptoms, whereas the application of osteomovement is never produced through the action of pathic treatment produces a complete relaxation
one single muscle, but instead, through that of which permits the detection, access to, and reducbundles belonging to parts of various muscles, co- tion of the lesion.
ordinated at the moment to achieve a given purpose.
The mild lesion may give way spontaneously
This is readily confirmed by palpation of contrac- through rest, hot applications, usual home attention,
tured tissues in the dorsal region, for instance.
and leave no trace ; it may also linger, becoming perIt may be well to review briefly the arrange- manent and thus involving alterations in various
ment of muscles in one vertebral groove in the dor- tissues, sclerosis, atrophy, fibrosis, etc., as in certain
sal region, for example, knowing that in principle neuroses and focal infectious disorders.
The major lesion is generally the result of a
a similar one obtains in the other regions. Seven
muscles are distinguishable, the four middle ones sprain ; thus a violent effort may cause a momenforming the remarkable combinations
sketched in tary dislocation in which the parts of an articulation
All Rights Reserved American Academy of Osteopathy®
80
ESSAY ON VERTEBRAL LESIONS-GUY
Fig. 1. Sketch
showing muscles
in vertebral
grooves.
will be forced beyond the extreme range of motion,
with consequent injury to the various tissues of
the attachments, of nearby structures and organs.
With a bilateral involvement the vertebra may return to its neutral position, while with one more
severe on one side than on the other, the vertebra
will return partially, and then be maintained in a
strained condition of combined twist and flexion.
At first there is always inflammation and pain ; later
on, due to the reorganization of the injured tissues,
there may remain a certain degree of functional impairment of the articulations.
We may also consider as major lesions in the
upper dorsal region those evidencing persistent
characteristics, responding sluggishly to treatment.
A large percentage of these disorders is found in
women; they are mainly of costogenic origin, with
active foci mostly about the right sternal aspect of
the ribs, and abnormal approximations of the ribs in
the axillary region. Bearing this in mind, appropriate treatment may be devised, to which the two
kinds of disorder will be found amenable.
Traumatopathic lesions require special consideration, if meant to designate those in which the
articulations failed to return to some position within the normal range of motion, because then we
have to deal with conditions of altered structures.
Analytic study would perforce be largely conjectural
for any given case, and we must be contented with
the proofs of daily experience that such lesions are
well responsive to osteopathic treatment.
We propose here to demonstrate diagrammatically that one given vertebra may be maintained in
deviation, that is, in lesion, with its articular facets
in extremes of displacement, yet in working contact with the corresponding ones, instead of being
held in separation, or hooked on to one another, as
unfortunately imagined by some writers. We would
like first, to emphasize the point that wherever
found, either on fresh specimens, on dry prepared
spines, or on spines practically spoiled through prolonged inhumation in damp soil, the articular surfaces present a smooth and unctuous area of contact; in articulations long immobilized by exostosis
of the edges, the areas are found practically unimpaired after the osseous growths are cut away. This
good condition could not be expected to obtain if
the surfaces had been maintained in separation, as
in complete dislocation, in the living body, for then
there would be great possibility of osseous alteration. Even in skeletons of hunchback bodies we
have observed the normal state of the surfaces. All
these remarks confirm our contention that the articular facets are kept constantly in working contact
through some powerful means, which must be specifically intended for that-purpose, and which is the
diversified action of the deep muscular mass nestled
in the vertebral grooves.
In constructing the annexed diagram (Fig. 2)
purporting to represent the assemblage of a number
Fig. 2. Diagram showing vertebral lesion.
All Rights Reserved American Academy of Osteopathy®
ESSAY ON VERTEBRAL LESIONS-GUY
of vertebrae, similar in size and shape, the vertebral
axis is assumed as a straight line ; the posterior contour line would likewise be straight for normal conditions, and the centers of oscillation be located on
a straight axis. This is to simplify the demonstration ; it will become obvious later that by using the
measurements taken from an actual spine a construction can be drawn which will lead to the same
results and conclusions as with the present one. The
center of oscillation is not that of the nucleus pulposus;
its position was determined from measurement on the
llth D. of a spine just at hand ; the radius of curvature was found to be a little over 1½ inches, with the
distance between centers about one inch. The curvature of the two upper facets corresponded practically
to that of a spherical surface, so that there was only
one center of oscillation, which permitted perfect circumduction. In some vertebra there may be one
curvature, anteroposterior and another transversal, so
then in studying the kinetics of two assembled vertebra! two axes of oscillation must be considered, as
explained in “Vertebral Mechanics” (THE J OURNAL ,
July, 1930). Each vertebra is shown in templet form
resembling somewhat the lateral aspect of a “low back
chair,” the. front foot of which terminating as a ball
is received in a socket carried by the templet next below; on top of the foreleg is a similar socket receiving
the ball foot of the templet above. The socket is a
guide bearing allowing the free circumduction of the
leg; however, it is shown elongated to the right, merely
to indicate accommodation to anteroposterior displacement to suit apophyseal separation.
The upper and transverse part of the templet
ends, at the right, as a guide process, the contour line
of which is the generatrix of the spherical surface containing the facet areas of the real articular processes
of the vertebra. The whole construction rests then
upon the principle that the facets, in this instance
spherical segments, are the true fixed guides for the
motion of the vertebra above, and that their contour
line is an arc of a circle. It follows that the motion
must take place about the center of that arc, which
then becomes established also as a fixed point, whose
position is easily determined by elementary geometry,
but which, having no material entity as a pivot, is in
reality a virtual center of oscillation. The templet terminates downwards at the right as a guided process
intended to represent one of the lower articular processes of the vertebra, and it is shaped so as to conform
exactly with the contour of the guide process of the
vertebra below. The ensemble of one guide and one
guided process constitutes an apophyseal articulation; the working surfaces are kept constantly in contact by the resultant pressure from deep muscle mass
action. A certain range of angular displacement is
indicated, having a neutral position, an extreme in
flexion and an extreme in extension.
It is clear that intentional separation may be effected by selecting one vertebra, resting it posteriorly
against a fulcrum, and exerting a thrust on the vertebra above in the direction of the neutral position
axis shown at the lower end of the diagram. No matter how this is done it is almost certain to be gradual,
beginning at the upper end of the, guide process, and
then extending instantly throughout the contact area.
To the experienced and careful observer it appears as
if, for once, the vigilant muscles having been caught
off their guard, either through very swift action, or
through cautelous slow proceedings, had suddenly
81
realized their unwarrantable laxness and then, with
lightning speed, slammed back the guided process in
contact with the guiding surface, which fully and satisfactorily accounts for the pop or cracking noise.
Furthermore, the muscles seem to have doubled the
patrol, since in a normal subject it is not possible to
produce another separation at the same point until
after a lapse of several hours, sometimes until the
next day. In a subsequent article attention will be
given to the effects of the separation, which may be
beneficent when the latter is normal, and highly detrimental when produced by unskilled and forceful
exertions.
We are now facing a most terrible situation, for
we have shamelessly omitted to take the famous nucleus pulposus into consideration as the all important
factor of the intervertebral articulation. Unlike some
others we wish to remain unbiased in this respect, and
feel amply justified in adopting the notion that the
guiding surface is the prime factor to which all the
other parts of the articulation are subjugated. The
nucleus remains the wonderful cushion, essentially
and instantly adjustable to all the normal displacements of one vertebra relatively to the adjacent one,
but for us it is not the ball bearing element of the
ancients and of Monro, of Morris, etc., etc.; its center
proper does not exist, and if it did it could not have
the fixity of position of our virtiual axis of oscillation.
Let the diagram represent a sagittal section of
part of the spine, in which the lower vertebrae and the
top one are in normal position and alignment; the
three others are involved in posteroanterior deviation;
the lower one of these is in extreme flexion with respect to the one normal below ; the second is in extreme
extension with the first ; the third is in extreme extension with the second and in extreme flexion with the
normal vertebra above. We have then a condition
frequently observed in practice, in which one vertebra
is fixedly held in anterior displacement.
By applying the same method another diagram
may be constructed, in which the vertebra would be
shown in posterior displacement. Likewise we can
draw a figure showing lateral displacement to the right
or to the left, and then, with a little more labor the
vertebra may be placed in simple rotation, or again, in
a position involving the three kinds of displacements,
sagittal, transverse and rotative. Thus we may picture
any one of the varieties of vertebral lesions commonly
known, and in each case the apophyseal articulations
would remain in normal apposition even at extremes
of the range of motiotin Q.E.D.
If the diagram had been made to represent an
exact sagittal section of an actual spine the deformation would be seen more pronounced, due to the curvature of the column. The sketch shown here would
concern conditions obtaining in the dorsal region,
whereas for the cervical and the lumbar other constructions would be required, because the oscillation
axes are differently located and there are two main
axes usually involved for each articulation. However,
the delineation presents no special difficulties for any
one keenly interested in the subject, but it must be
predicated upon the notion that articular facets are
normally maintained in contact through muscular action, and that when separation is intentionally produced the contact is instantly and noisily restored.
Now the question arises : when a vertebra is positively found out of alignment, either through visual
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a2
OSTEOPATHIC PATHOLOGY OF SPINAL MUSCLES-BURNS
observation, palpation or radiographic representation,
what maintains it in abnormal position?
With a lesion of long standing the ligamentous
attachments must have become adjusted to the abnormal conditions, but even with alteration in their
length and pliant qualities, they could not be accepted
as the main maintenance factors, except perhaps in
extreme cases of spinal deformation. The main factor
is the permanent contracture of the muscular mass
nestled within each of the vertebral grooves. The
production of the lesion is due to exaggerated action
developed by that muscular mass or by parts of it;
while the causation of it is abnormal and disordered
stimulation of sensory nerve terminals, conveyed to
the central system, and thence reflected in the form of
abnormal motor impulses to the muscle cells. Although
the muscular masses are symmetrically disposed, so
that a strand in one has its antagonist partner in the
other, it does not follow that action is always coordinated; instead, we find that a spot on one side may be
so tensed as to cause tilting, or rotation, or a combination of both, affecting some osseous part, while the
corresponding spot on the other side remains practically relaxed. We have ample evidence of the existence of local muscular disorder with every patient in
our daily practice, in the symptomatic form of tenderness revealed to the patient through deep palpation of
the groove muscles.
In some cases the deep muscles may remain for
a time in a condition of excessive contraction and in
perfect coordination of action ; the whole, a certain
length of the vertebral column is then in a state of
intense axial compression. Relaxation may take place
spontaneously, though gradually, or may result from
some form of treatment ; but it may also happen that a
slight exertion will cause a sudden disruption of equilibrium of the structure, accompanied by excruciating
pain felt in some region of the spine; this occurs frequently in the incipient stage of lumbago. This is in
accord with the laws governing the flexural buckling
of beams and columns, of any shape, all of which have
a definite limit of stability under load. See “Flexure
of Beams,” by A. E. Guy, Van Nostrand, N. Y., 1903.
Such buckling occurs also in torsional efforts.
Now that the possibility of the maintenance of
vertebra: in deviation has been demonstrated we can
understand the gradual deformation of the vertebral
column in scoliotic and kyphotic cases; as it seems
obvious that in the formative period the osseous structure, being kept deviated ‘at various points through the
incessant pull of the contractured deep muscles, must
necessarily undergo extraordinary changes in shape.
The next article will deal with the properties of
the fibrous tissues (tendons, ligaments, connective
tissue, etc.) ; their innervation, vascularization and
sensibility, in reference to the vertebral lesions.
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ESSAY ON VERTEBRAL LESIONS-GUY
83
Essay on Vertebral Lesions
A LBERT E. GUY, D.O.
Mount Vernon, N. Y.
IV
the general function of the chain is to keep the cell
All of pathogeny may be expressed in two words, fit to respond appropriately to that command.
impression and reaction ; diseases then may be viewed
Complex equations are but combinations of most
merely as transformed impressions, stated as Bouchut elemental factors, the knowledge of which is imperasaid in his General Pathology (1857). The effects tive to reach a solution. In active practice, however,
of morbific impressions upon the organism are reflexes that knowledge must be kept at par value, through
of special nature such as irregular molecular actions ceaseless review of the factors themselves and of their
induced by ischemia, or by paralytic capillary hyperfunctions. Likewise here then, at the risk of apparent
emia. Put tritely, it follows that disease results from triteness, a brief review of the factors involved, the
impaired circulation ; and that leads us to the terse links, will prove of great help in discussing the case
dictum of Dr. Still: the rule of the artery is supreme, of the common cold, the production of which is cerwhich, considered solely at its face value is open to tainly the most frequent causative factor of vertebral
argument, as it may be assumed then that the artery lesions; indeed, treating of it will not be found a
is the main agent of circulation, directing it here and digression from our main theme. On the contrary,
there under normal conditions, and if blocked here it will furnish us with the most positive arguments
for some cause, forcing the whole of it there, in desirable.
parts of facile access but where, however, it is not
In sequence, then we have (a) the cell, or eleneeded, with consequent intense hyperemia, inflammental
region ; (b) the arteriole conveying the nutrimation of tissues and profuse exudations. That this
is not an exaggeration is proven by a recent attempt ent fluid ; (c) the capillaries through which the fluid
to explain the development of the “common cold”. is provided to the region and the wastes are removed:
(d) the venule conveying the tainted fluid to the
Thus we are told that through exposure, the skin congeneral
collectors; (e) the sensory nerve endings, detracts, superficial capillaries are closed and the blood
unable to reach the outer areas, goes to those tissues tecting the condition of the region ; ( f) the sensory
most richly supplied with blood vessels, namely, the nerve transmitting the message to the posterior brachial
mucous linings of the respiratory tract, wherein a ganglion ; (g) the connecting fibers between the poshyperemic condition sets in, with engorgement of the terior ganglion and cells in the gray matter of the
tissues and hypersecretion of mucus. That, of course, cord; (h) the connecting fibers between these cells
is not what Dr. Still meant. It may be argued also and the sympathetic ganglion attached anteriorly and
that the vein is more important than the artery, in laterally to the vertebral body; (i) the connecting
the sense that impaired elimination of waste material fibers extending from the ganglion to the muscular
is vastly more detrimental to the body than temporary walls of the arteriole ; (j ) the terminal plates of these
dearth of nutrition, and that congestion of body fluids fibers, disposed for action upon the muscles cells ;
(k) the motor nerve fibers extending from cells in
is the protogenic element of decomposition, acidosis
and toxemia. But neither the artery, the capillaries the gray matter, through the main trunk, to the musnor the vein have the power to rule, for they function cular walls of the venule; (1) the terminal plates of
solely as conduits for the blood flow; they cannot these fibers, disposed for action upon the muscle
mete out the varying supply of this fluid to suit to the cells ; (m) minute sympathetic ganglions vicinal to
requirements of a given region ; the proper distribu- the region, yet incompletely studied, but whose function is effected through the mediation of nerves ; the tion seems most likely one of local vasomotor control,
nerves themselves are merely transmitters of mes- suitable for average fluctuation of nutrition and elimsages, one from the region to a ganglion, making ination ; (n) the nerve sinu vertebral formed, immediknown the condition detected by the nerve terminals, ately outside of the intervertebral foramen, of sensory,
and another from a central cell to the muscle walls motor and sympathetic fibers, and which after traof the blood vessels in the region, altering the caliber versing the operculum passes through the interverof these to suit the needed rate of flow. And thus, tebral canal, innervates the various organs therein and
as concerns the living process of the cell, we become extends its ramifications to the vascular system of the
cognizant of the existence of a chain, each part of regional spinal cord and appendages; (0) and last
which is after all but a mere link, performing an but not least, the connective tissue permeating the
essential and definite function. The needs of the whole tissular structure of the body. Now, with these
cell are supplied through the activities of the chain, main elemental factors at hand let us tackle the
whence it follows that the wellbeing of the cell may subject.
be affected in two ways, first by direct abnormal imThe common cold affects the whole body.-The
pression, and second through interference with any three most usual symptoms are turgescence of the
link of the chain, either directly or by reference from nasal mucous membrane, with discharge of varying
distant disturbances. The cell exists because, as part character according to the stage of the trouble; it
of the organism, it has a function to perform, which may be profuse, watery, a mixture of mucus and
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while American
serum, Academy
then becoming
mucopurulent ; sore throat at
THE “COMMON COLD”
84
ESSAY ON VERTEBRAL LESIONS-GUY
times; and always general malaise. Osteopathic palpation discloses muscular tenseness and tenderness
in the cervical, dorsal and lumbar regions, affecting
particularly the deep-seated tissues ; and often vertebral lesions are found, which interfere with the
general mobility of the articulations. It is unnecessary to reproduce herein detail matters that may be
found in many books on diagnosis and with which the
reader is well acquainted. However, two quotations
from Sajous’s Analytic Cyclopedia of Practical Medicine cannot fail to interest our practitioners, and besides, they fit very well in the framework of this
essay. Thus, on page 325 in volume 1, on the subject
of acute rhinitis, we have this about the exciting
causes:
“Although certain depraved conditions of the
body may be said to predispose to attacks of acute
rhinitis,’ usually there are certain causes to which
the attack may be definitely attributed. Exposure to
cold and wet when the body is overheated; exposure
to sudden or extreme changes in the atmosphere; the
wetting of the feet when the system is debilitated
from other diseases; or the chilling of the body from
any cause, especially as to allow a draft of air t o
strike the back of the neck or head. This seems to
support theory, advanced by some that the i m -
of action, constriction or dilatation of the vessels, the
nervous system governs all the chemical phenomena
of the organism. . . .”
In his celebrated “Lessons on Toxic and Medicamental Substances” Claude Bernard studies at great
length the effects of curare and strychnine; the first
of which paralyzes the motor nerves without affecting
the sensory system; the second does the contrary. He
found that in either case neither the nerve fibers nor
the muscle cells were affected to the extent of losing
their property of response to galvanic stimulation;
the same thing obtained also for the spinal cord. The
effects of the poisons centered then upon the nerve
terminals proper, but the exact modality of the paralyzing action remains to this day undisclosed All of
these findings were amply confirmed by the extensive
researches of such men as Brown-Sequard and Vul:
pian. For our purpose perhaps the most important
points are-first, the proven fact of the independence
of action of any given motor nerve which, when isolated while the rest of the organism is under the influence of the poison, may perform its regular function when suitably stimulated; and second, the proven
fact that the lesion of one posterior root is transmitted
by the cord to all the other roots, so that the effects of
a poison acting upon the peripheral part of the sensory
pression of cold on certain parts of the body produces system, once reaching the cord, are transmitted to all
an inhibitory effect upon the vasomotor nerves con- the motor nerves.
Besides the effects of poisons on the nervous
troIling the blood supply of the nasal mucous membrane. . . .” As to treatment, we have on page 327: system these authorities have. also studied those pro. . . Grayson recommends, instead of medicine, duced thereon as the result of application cold
good vigorous exercise several times a day, claiming and heat upon the teguments, and have proved that
that ‘the quickened capillary circulation and vigorous the aforesaid findings applied generally as well in
one case as in the other. How can we then reconcile
action of the sweat glands that accompany hard exercise are incomparably more beneficial than the the hesitation manifest in the first, citation anent the
recognition of the influence of the nervous system in
merely passive leakage that follows the use of diaphoretic drugs. If in addition to this an abundance the generation of the effects observable in the common cold, with the assurance given in the second that
of water is drunk and the supply of food is greatly
repeated vigorous exercise is a more potent curative
reduced-almost. stopped in fact-we may look for
an amelioration of all the coryza symptoms in a much means than the application of, the various usual medi-.
shorter time than if our main reliance is vested in camental substances enumerated?
quinine, belladonna, and opium combinations, that
Most certainly vigor&s exercise is potent, but
have had too long a vogue . . . ’ ”
it is not generally self-applicable to all cakes, particuIn the italicized part of the first quotation I would larly with the modem mode of living;, it is, therefore
like to emphasize the condescending expression “the necessary to have recourse to practical manipulation
theory advanced by some.” We are bound to wonder of the body tissues, which is the more efficient as the
when we reflect that those some are’ the greatest recipient thereof is in the most passive, or relaxed
physiologists known, who have spent years in arduous condition. But whether self developed exercise or
research work, which resulted in the establishment of passive manipulation are used, the practical and
the’ theory of circulation as it is now taught the world theoretical effects are based upon the same general
over in schools and laboratories, To cite but a few principle, that is, the tissues of the body are acted
we have Richard Lower (1640)) Haller (1757), on in such a way as to induce a suractivation of cirBichat ( 1799), Magendie, Claude Bernard, Kolliker, culation, producing at first a drainage of the congested
Snellen, Schiff, Brown-Sequard, Sappey, Vulpian, parts, followed by the flow of an increasingly purer,
Virchow, Ranvier, Heidenhain, etc. The researches blood, with consequent lessening of acidosis, hence
of Claude Bernard in 1852, on Animal Heat finally appeasement of the irritation affecting the sensory
culminated in the demonstration of the influence of nerve terminals, and decrease of the inhibition of the
the nervous system as the regulating agent of blood sympathetic or vasomotor nerves.
Then why on the one hand cast pedantic doubt
circulation. . He said :
. . . The vascular system is under the control on the influence of the nervous system, and on the
of two nervous systems, more or less distinct, the other herald as the most efficient a procedure basically
sympathetic and the cerebrospinal. The first is the dependent upon that influence ?
moderator of the vessels ; when stimulated it effects
We may mention briefly here an item of great ina constriction more or less considerable of these ves- terest to our earlier physiologists and which ceasesels, which retards the circulation. On the contrary, lessly occupied their attention, that is, the mechanism
stimulation of the cerebrospinal nerves provokes dila- of the transmission of impressions from the posterior
tation of these same vessels. That is all the mechan- root ganglion to the cells in the gray matter of the
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ESSAY ON VERTEBRAL LESIONS--GUY
sympathetic chain, to the motor pathways and to the
vasomotor nerves serving the cord proper as well as
its dependencies. It was observed on laboratory animals as well as on the cadaver that in many cases of
nervous disorders the effects of hyperemia or of
ischemia centered mainly upon the gray substance
of the cord, which it is held, goes far towards explaining general vasomotor as well as muscular disturbances in distant parts of the body. That, of
course, concerns acute cases, with well developed
morbid conditions ; however, ‘even in benign cases, it
teaches us that one of the disturbing effects of the
abnormal impression transmitted through the sensory
path is possible interference with the function of the
cells in the cord, such as to delay the return to normal
of the reflexively affected parts.
Reverting to the common cold we may try to
solve the problem of the development of a mild case
of rhinitis, with profuse watery discharge, brought
about after removal of rubber shoes, worn during a
brisk walk in rainy or snowy weather. Just before
that removal the feet felt warm but moist ; immediately after there was a chilly sensation, and with a
cold ground draft on a concrete floor, all the necessary disturbing elements were present, particularly so,
if the person remained inactive for a considerable
period of time. The most apparent symptom to the
observer is the profuse flow; it has been well investigated by Ch. Robin in his Treatise on Humors; its
composition varies with the stage of the disease, but
generally speaking, it is made up of exuded and
secreted fluids, all of which are of course derived
from the blood stream; the manner in which the transformation may take place is the key to the problem.
Incidentally, the principle involved applies fundamentally to all normal processes of nutrition and upkeep
of the body tissues. The second symptom is the turgescence of the nasal mucous membrane, from the
surface of which the abnormal flow is given off. According to our premises, which illustrate but a common cold occurrence, the original disorder affected
only the extremities and not at all directly any part
‘of the nasal region ; hence we have here a clear case
of reflex action. The better to study it I prefer to
submit here a graphic demonstration.
Let us assume that the diagram in Figure 3 represents a cell, a gland, or more liberally, a very small
region into which blood is at first fed through the
arteriole at the left into capillaries at the bottom, and
then after collecting the wastes passes out through the
venule at the right. To suit the normal condition of the
region a certain level must be maintained therein. We
imagine that a delicate contact detector receives an
impression which is transmitted to a motor cell or
ganglion and thence relayed to the gray matter cells,
from which one reflex is started which is transmitted
to the sympathetic vasomotor regulator, causing a
constriction of the arteriole walls, the mechanism of
which is represented here in the shape of a valve, and
the incoming supply is therefore reduced another
reflex is simultaneously sent to the motor nerve regulator, causing the outlet valve to be opened more
widely, which obviously, corresponds to some relaxation of the tonus of the muscular wall of the venule,
that is to dilatation of that vessel, whence there is
increased outflow. As a result of these combined
actions the fluid content of the region is reduced and
the level may be restored to normal. Should the level
85
Fig. 3.
fall below the normal a reverse process automatically .
functions through precisely the same mechanical
elements.
For a long time the sympathetic system was
thought sufficient to regulate the circulation, through
the simple reflex action of the sensory system ; effectively, inhibition of the sympathetics would cause
relaxation of the vasotonus, hence vasodilatation ;
whereas activation would cause increase in vasomuscular tonus, hence constriction. That would imply, of
course, that inhibition, for instance, would cause
simultaneous increase of the caliber of both the arteriole and the venule; obviously then in case of subnormal level, the inflow would be increased, but, as
the outflow would be similarly augmented, the same
volume of fluid would pass in and out, and the regional contents would remain subnormal. To make
up the deficiency the inflow must increase and the outflow be checked. Vulpian and Ranvier pointed out
the necessity of a mechanism of venous constriction ;
and they insisted upon the fact that the musculature
o the walls increases in inverse ratio to the caliber
of the veins, in which they differ from the arteries,
thus clearly evidencing a construction intended to fill
a definite function.
But the circulation is not intended solely for the
immediate nutrition of the body tissues; it must also
supply the various glands with sufficient quantity
of blood from which they, in turn, take secretions
essential for the performance of certain most important functions, salivary, gastric, enteric, etc.; and as
the volume of these assume enormous proportions, we
are compelled’ to recognize that the inflow into the’
region, or gland, of our diagram, must operate to the
full caliber of the arteriole and actually produce an
overflow from the region into the outer spaces. This
is only possible, obviously, when the venule is sufficiently constricted; and if the sympathetics are inhibited to permit dilatation of the arteriole, some other
agency must instigate the muscle contraction of the
venule wall. The simple contact level detector still
suffices when the gland is inactive, but it must be
supplemented by some appropriate means, receptive to
impressions issued from the sensorium or collected
from nearby sensory terminal organs. The reflex is
developed as before, with inhibition of the sympathetics and activation of vasoconstrictor nerves.
The nasal mucous membrane contains a large
number of glands; Sappey found 30 to 50 to the
square centimeter. Besides, there are extensive venous
plexuses, which increase in size from the outer surface
towards Academy
the basement
layer, attaining their greatest
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86
ESSAY ON VERTEBRAL LESIONS-GUY
proportions within the mucous membrane covering the very elastic. With the evacuation of the fluid conconchae. There the membrane is seemingly trans- tents, through release of the venous constriction or
formed into a special kind of cavernous tissue, which some other appropriate means the membrane would
according to Zuckerkandl bears analogy with that of then readily return to its normal state. But know
erectile organs. Now then, with paralytic inhibition that there is inflammation, and we find it of great
of the sympathetics and suractivation of the motor interest to understand the adjustment of the memnerves, we may readily understand the development, branous tissues to that condition. Thus, are the cells
merely distended by an absorption of fluid, so that
not of hyperemic conditions within the mucous linings,
but more properly, of an intense congestion followed the membrane becomes thicker and its various layers
by a profuse exudation of fluid made up of mucous increased in area, so that the whole is in a state of
and seromucous glandular secretions together with extraordinary tension which, at the limit, might lead
watery serum derived from disordered diapedesis to overstretching and tearing of the constituent tissues,
through the walls of the cavernous plexuses. The or are there new cell formations which would facilisubject should be treated extensively, as it deserves; tate the great increase of volume of the mass, so
however, the above suffices for our purpose. There readily observable? With the cells merely distended,
remains to establish the connection between the result- here again, the evacuation of the fluid would insure
ant nerve inhibition and suractivation and the initial prompt return to the normal. If we consider the
fact, first brought to light by Schiff, in 18.54, and since
incident. At the time of removal of the overshoes the
verified
in many laboratories, that the complete inhibifeet were very warm and moist, as the result of the
great activity of the tissues, of the circulation and of tion of regional sympathetics, or vasomotor paralysis, .
the sweat glands. After the cessation of exercise a is capable of determining a passive congestion of the
period of time is required for the various organs to periosteum, with an inflammatory processus as direct
return to their normal condition, and there is a sort of consequence, and a production of osseous substance,
surge in the circulation which is felt as a sensation we are easily led to recognize an additional function
of heat throughout the body; in addition the perspira- of the sympathetic, and that is the control of the
tion becomes more profuse. Unless the moisture is growth of tissues. For, what is easily observable as
dried Up at once and the clothing is changed the skin regards the bone is likewise so in the case of other
remains covered with a humid layer which requires a tissues. Thus we have shown’ that just as in the
long time for evaporation, while on the contrary it welding of two pieces of steel the molecules of metal
may cool off rapidly even at ordinary room tempera- in the ends in apposition must be heated almost to
ture. It is common knowledge that with the skin the point of fusion in order to unite, similarly the
moist the perception of impressions by the sensory parts of any organic tissue will unite only when their
nerve terminals is far more acute than when the skin end cells will be transformed into what we termed a
is dry. Therefore in our case we have abrupt cessa- near embryonic state. That there is a process of transtion of activity, rapid cooling of moist layer and con- formation is evidenced by the tumefaction present
sequent persistent impression not only of the terminals which, starting at some distance, increases gradually
in the skin of the feet, including the multitude of to its culmination in the plane of repair; but that in
nerve endings about the blood vessels and within the addition there is intense proliferation of the ‘cells of
sweat glands, but also to a certain degree in the in- each tissue involved is shown by the time required,
tegument of the whole body. These impressions are after the union is formed, to remove the surplus of
transmitted to the posterior roots and thus the whole material so that, under propitious circumstances, no
sensory system becomes involved. Through reflex conspicuous trace of the disorder remains. In each
action the motor nerves are stimulated with conse- instance and for each kind of tissue there must be
throughout the organism something akin to a cell
quent contraction of the striated musculature; there
is inhibition of the vasomotor nerves, resulting in the ferment which, when placed in a suitable medium,
development of a certain degree of congestion such as active congestion of hyperemic origin, is capthroughout the body tissues. When the impressions able of initiating a process of proliferation. So long
are too intense or too persistent there may be pro- as the sympathetic system of the region is able to
nounced stasis, from which acidosis may easily result. function as a whole, although perhaps inhibited locally,
This would provoke additional irritation to the sensory it exercises proper control over the processes involved
endings and aggravate all the symptoms. The con- in the repairs of a certain part. The regional obliteragestion itself would interest mostly all the mucous tion of vasomotor nerves aimed at in some operations
membranes of the body, but as the Schneiderian is of sympathectomy, which is now increasingly considthe most responsive, because of its peculiar structure, ered in surgical practice, is fraught with the danger
it easily becomes turgid. Now, a most interesting of the removal of the factor capable of restraining
sequence of events takes place; the normal secretion irregular and unnecessary proliferation. This was
may be decreased, indeed actually arrested, and then brought forward by Cunliffe Shaw in The Lancet of
November 5, 1932, in an article on “The role of the
proliferation of the epithelium occurs; with the intersympathetic
in tissue alterations”. It was shown that
vention of the leukocytes and their penetration into
certain irritants of the derm and epiderrn may,
the swollen tissues the copious flow is initiated.
through the sympathetic, bring about pathological
Note on Inflammatory Process-The word pro- changes in the tissues, characterized by hyperplasia of
liferation, just mentioned, deserves profound attenthe epitheliums and elastic fibers. Thus the develoption. If the Schneiderian membrane were of true ment of the coal tar cancer is seen as more rapid in
erectile tissue, as some authors would have it, its tur- the zones of skin which have been deprived of sympagescence would be explained by extraordinary conges- thetic terminals. Hence the sympathetic or the paration of blood within its cavernous processes; the membrane would be distended just as a rubber bulb under
Albert E.: Vertebral Mechanics. Jour. Am. Osteo. Assn.,
internal pressure, and its walls would necessarily be Sept.,‘Guy,
1930.
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ESSAY ON VERTEBRAL LESIONS-GUY
87
sympathetic hormones would seem to exert an in- of our treatment is its specificity, is anything welcome
fluence on the initial development of neoplasms ; their which is apt to refresh and to strengthen our reasonsuppression acts essentially in disturbing the physico- ing by widening its scope. Thus in this essay do we
chemical balance of the tissues, and the passive effects derive great satisfaction to find, in gleanings from the
of vasodilatation are then but of secondary im- fields so well tilled by the old masters, the confirmation that the fundamentals of osteopathy, so truly
portance.
From this we derive the interesting lesson that, visualized by the Old Doctor, are based on universally
recognized facts adduced by the great investigators.
in general, congestion of a part is not merely a turThe researches of Magendie and Claude Bernard
gescenee easily removable by appropriate drainage of
the tissues, but rather should be considered as a on the sensibility of the pia mater had indicated the
medium eminently suitable for the potential organ- certainty of the presence of recurrent nerve fibers
ization of cell ferments, which is the essential pre- within the vertebral canal ; but anatomy had not yet
cursor of hyperplasia. Now, the most widespread is sufficiently advanced in that field. Soon, however,
the interstitial tissue, or the connective tissue be- in 1850, Luschka gave an extensive description of a
tween the cellular elements of the body; it is the most small nerve trunk, which, formed outside of the interreadily affected by congestion because it forms infinite vertebral canal by the combination of fibers derived
pathways for the capillaries, the nerve fibers and the from the motor root, the sensory root, and the vicinal
lymph channels. When affected in some parts by pro- sympathetic ganglion, enters that canal and distributes
liferation, the whole region will return to normal only branches to all the structures within it; and then, exafter elimination of the wastes and of the surplus tending into the vertebral canal provides branches to
material has been completed. This explains why, even the meninges, to the cord, to the blood vessels, to the
after the most effective treatment applied, some lapse ligaments, to the periosteum and even to the osseous
of time is required by the superactivated circulation parts.2
to clear the tissues completely. And so, we come to
The importance of this nerve, the sinu vertebral,
consider affection of the connective framework as a is not to this day appreciated as it deserves, although
most serious pathological element which, under the occasionally we find attention directed to it. Thus,
name of cellulitis has received more attention perhaps the Presse Medicale of May 10, 1924, contains an
elsewhere than in this country. A little reflection “Essay on the Pathology of the Sinu Vertebral Nerve”
following perusal of clinical and laboratory reports by Prof. R. Leriche, which deals with reflexes emanwould make US appreciate its importance in spinal ating from a cicatrix neuroma in a stump, and which
disorders in which the osteopathic practitioners more reaching a spinal ganglion, find two paths before them,
particularly specialize. Effectively, in many instances one long, through a mixed nerve serving the stump,
Brown-Sequard, Vulpian, and others, have found that and a short one through the sinu vertebral nerve. If
the diseased conditions of the cord, and more often the reflex follows the latter it is bound to disturb the
of the gray substance, undubitably originated from vasomotor innervation of the corresponding zone incongestion of the interstitial tissues which, even in cluding the cord, the meninges and the roots. Thus
the mild cases- contemplated in this essay, may prove will be produced the usual vasodilatation of the zone,
sufficiently intense to produce hemorrhagic disorders more or less localized in the corresponding side, but
within the various parts of the cord and of the men- capable of affecting the other side; hence pain will
inges. And as the meningeal membranes extend into become manifest, but more or less diffuse, without
the intervertebral canals, we understand more readily clear definition. This also seems to explain vasomotor
the observed instances of inflammatory conditions af- disorders which are at the root of the edema and the
fecting all the elements located in these canals, and ulceration of the stumps.
the resulting compression of the nerve roots, with its
The distribution of the sinu vertebral branches
far reaching effects, which for too long a time was, varies somewhat from one region to the other, but
unfortunately, so positively attributed to the so-called one thing is clearly established, and that is that every
vertebral lesion, origin of all mischief,
one of the intervertebral foramina receives a trunk;
In his extensive work on Nervous Diseases, Vul- within the vertebral canal the branches may extend
pian repeatedly points out the influence of cold ex- up and down and mingle with others from above or
posure upon the initiation and development of spinal below; so that the innervation involves all of the
disorders, and there seems to be no doubt that if the contents along the entire length of the canal. Now,
true history of infantile paralysis cases could be estab- bearing in mind that the trunk is made up of (a)
lished, it would be found that too long immersion in sensory fibers emanating from the posterior spinal
cold water, prolonged contact of the body with cold ganglion; (b) of motor fibers coming from the anand moist ground, too abrupt cooling of the body while terior root ; and (c) of fibers coming from the nearby
in active perspiration, and influences of similar order, sympathetic ganglion, we have for each vertebral
were the real causative agencies rather than the much segment an exact replica of the general vasoregulator
sought for virus, which thus far has eluded the most system. Furthermore, as we have seen that any imintense researches.
pression affecting regional sensory terminals is communicated to the whole sensory system, there is no
Contractions, L e s i o n s, Tenderness.-We mentioned the detection of these symptoms through the doubt that the sinu vertebral branch is also affected
usual routine of osteopathic palpation, and that in but, as the service of that branch is from the Vertebral
numerous instances the patient was unaware of their canal to the posterior ganglion, whatever the original
impression may be, it is without direct effect upon
existence ; it is always meet for the practitioner to
dwell often upon these matters, as the process is cer- the organs it serves. This is quite logical, although
tain to bring forth here and there some apparently contrary to the views of some neurologists who claim
novel aspect of some point involved in a complicated
*A fuller description may be followed in Vertebral Mechanics, Jour.
case ; and especially, since the predominating
factor Am. Osteo.Academy
Assn.. Jan.,
1931, p. 207.
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that an extra intense impression may send such a metrical. Contractures engender disorders of vasostrong influx to the posterior ganglion, that the latter regulation, venous constriction, congestion, edematous
cannot accommodate all of it, and that consequently condition, acidosis, whence irritation of sensory nerve
a sort of surge is developed which causes the influx terminals, hence pain, etc.
to follow unusual collateral paths, What really takes
Sensibility of the Ligaments -This question has
place is that the impression, whatever its strength, is held the attention ever since Haller (1750) mainrelayed to the cells in the gray substance, whence re- tained that these membranes possessed no serrsibility
flexes are sent out through the motor and sympathetic at all ; the opinion of Bichat (1799)) now classic, was
paths. So that finally, the organs within the vertebral that a special kind of sensibility was necessary to
canal are bound to be affected by whatever takes insure regularity of function of the articulations; it
place in parts exterior to it, and may suffer a local
was Sappey who, in a celebrated Memoir, 1866,
vasoregulation disturbance developed from the effects demonstrated that contrarily to the general opinion
of an impression received at the end of a correspond- fibrous tissues contained a considerable number of
ing path located at some distant place in the body.
nerves as well as a rich vascularization. Then folFrom this we may take it for granted that in lowed the discovery of various forms of corpuscles
(Pacini, Vater, Krause, etc.), which by process of
all cases of persistent contraction, contracture, lesion
analogy leads to the admission that they play in the
and tenderness, there is a regional involvement within
ligaments the same role they do in other parts of
the vertebral canal. It follows therefore that complete
reduction of ‘external disorders through osteopathic the organism where they are found. This is founded
manipulations cannot be accomplished until the canal on experimentation, and the ‘conclusion is that the
sensation we have of the extent, rapidity, duration and
organs have been restored to normal function, and
that through suractivation of circulation, itself in- direction of movement is due, in the major portion,
duced by those very same manipulations. This to the sensibility of the ligaments provided with
accounts for the necessity, in obstinate cases (paraly- Pacinian corpuscles; and this applies particularly to
sis, muscular atrophy, etc.), of the long drawn out the control of the ‘maximum extent of articular discourse of manipulative treatment, which unfortu- placement. It follows then that the impressions renately, taxes the patience of both patient and operator, ceived by the nerve terminals in the vertebral articular
whose guiding motto should most appropriately be ligaments must be referred to the cord, whence emathe old adage: labor improbus omnia vincit. It also nate motor reflexes intended for the activation of the
explains why certain positional attitudes favor the deep muscles whose function seems to be, as we
have seen, to insure the structural integrity of the
response to treatment, whereas others seem to exacervertebral column. Thus any disorder affecting the
bate the disorder and to hinder recovery.
Generally speaking, contraction affects the super- intervertebral articulation is bound to produce some
the deep musculature all along the vertebral effect upon the deep musculature, whence the possibility of production of contractures and of vertebral
The first is the more readily amenable to
lesions. It is easily conceivable that the sinu vertebral
manipulative reduction ; it concerns the- voluntary
nerve, because of its mode of distribution which inmuscles proper, while the other, usually considered
as of the same kind, certainly cooperates with the first cludes the ligaments within the vertebral canal, is
in the performance of the same functions; however, involved to a considerable extent.
Apophyseal Separation .-With the apophyseal
daily evidence shows that after superficial muscles
have been satisfactorily relaxed, the deep layers filling articulations, so zealously guarded in apposition by
the vertebral grooves often remain contracted and the deep muscles, the necessity for their intentional
tender, which, as discussed before, clearly indicates separation may well be questioned. It is so in fact
that they are mainly intended to suit another and most by those of other schools, and by the uninitiated paimportant purpose, and that is, to preserve the func- tients who dread the ordeal; the results, however,
tional integrity of the vertebral assemblage. Contrac- speak for themselves. When accidental, brutal, or
tures of the deep muscles have been observed long be- unskilled, the separation may well be expected to profore the advent of osteopathy, and in the writings of duce trauma; if it never occurs in any of the activiBrown-Sequard, for instance, many interesting de- ties of the normal body, of what benefit can it be
scriptions may be found. Vulpian, previously, and when effected in the course of usual treatment?
also in his 1877 lectures on nervous diseases, particuPerhaps this momentous question is best anlarly in dealing with spinal meningitis, describes in swered by quoting from some of the works of Browndetail the deep contractures along the spine, pointing Sequard, such as his “Lectures on Diagnosis and
out that the points of maximum rigidity and pain cor- Treatment of Functional Nervous Affections” (Philaresponded to the level of regions in the vertebral canal delphia 1868), in which reference to many of his
which were affected with meningitis. The observations “Notes” published in various bulletins is to be found.
of many other could be cited, but these two amply He attached himself to the subject of “Spinal Episuffice to prove that our argument rests on solid lepsy’!, treated and studied many cases, and his reports
foundations.
are most instructive. In one subject, whose lower
Now we can more readily visualize the genera- limbs were completely paralyzed, insensible to pain,
tion of vertebral lesions, affecting the mobility of the and unresponsive to voluntary movement, it sufficed
spinal structure, maintaining the apophyseal articula- to touch the limbs at any point to provoke a sudden
tions in fixed constrained positions, although remain- attack of tetanic extension and of clonic convulsions
ing within the range of normal relationship, etc., and in those parts. The greatest combined efforts of the
all that through reflex action provoked by disordered doctor and an assistant could not flex the foot upon
conditions obtaining within the vertebral canal; which the leg, the latter upon the thigh, or that upon the
action initiates various degrees and location of con- trunk. One day, while endeavoring to dress the patractions of the deep muscles, All
whether
or not symtient,
. theof assistant
secured a chance hold son the
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big toe of the foot, and all of a sudden there
was complete relaxation of the limbs. Experimenting
on this patient showed that intentionally provoked
tetanic extension could always be reduced by forceful
flexing of the toe. This observation was of great
value to Brown-Sequard, and he made use of it in the
study of a number of cases of epilepsy and hysteria.
His published reports were found in agreement with
those of a number of other physicians interested in
nervous diseases, and it became generally recognized
that, not only on human beings but on laboratory animals, sudden, forceful, and at times, violent exertions
upon the muscles first affected in the epileptic attacks,
or in cases of cramps and clonic convulsions, succeeded in abating the crises, and often in aborting the
attacks. Such empiric results demanded logical explanation, lest medical practitioners were taxed with
charlatanism, and that which won general approbation is (a) that there exist at the base of the encephalon, or along the cord, abnormal conditions capable of
provoking reflexes causative of the epileptic attacks;
(b) that forceful impression upon the terminals of
centripetal nerves is referred to the nervous center
commanding the mechanism of the attack ; (c) and
89
that there is then inhibition of the activity of the elements concerned in that morbid command.
That the intentional apophyseal separation, as
practiced osteopathically, is beneficient in overcoming
the contractures of the deep muscles and thus permitting the reduction of vertebral lesions, and furthermore in suractivating the general circulation, is amply
proven, not only by the sensation of well being, of
relief, felt instantly by the patient, but also by the
after effects. That the principle involved is also based
upon well proven and most logical considerations is
evident from the fact that these were first established
by men of sound learning, and recognized among
the greatest authorities in the medical world. Perusing
and meditating over the old texts is earnestly commended to those of our profession ; their belief in the
principles to which they devoted themselves is bound
thereby to be more firmly assured ; they will realize
that there is more to osteopathy than has yet been
taught to them; and that it is capable of accomplishing far more by itself than when burdened with too
lightly considered adjuncts. To our detractors, if
ever sincere, review, or perhaps discovery, of those
old texts, is also commended.
BIBLIOGRAPHY
Alajouanine, Th., and Petit-Dutaillis, D.: Intervertebral Discs,
La Presse Med., 1930 (Dec. 6), 38: 1657.1663 and 1930 (Dec. 20),
38: 1749.1751.
Andrae, R.: Ueber Knorpelknotchen am Hinteren Ende der Wirbelbandscheiben im Bereich des Spinalkanals (A study of 5 cartilaginous
nodules of the disc), B&r. z. Path. Anat. u. z. Allg. Path., 1929,
82: 464.
Bernard, Claude: Toxic and Medicamental Substances. Cows de
medicine du College de France, Paris, 1857, Physiology and Pathology
of the Nervous System, J. B. Bailliere et fils, Paris, al858, Properties
and Alterations of the Body Fluids, H. Bailliere, New York. 1859;
Properties of Living Tissues, Bailliere Brothers, New York, 1866.
Bichat, Xavier: Treatise on Membranes. Quotation from original
French edltion, Richard, Caille & Ravier, Paris 1799. There is an
English edition published by Cummings and Hllliard, Boston, 1813.
Blancard, Stevens: Anatomia reformata sive concinna corporis
humani dissectio 1695.
Borelli, J. A.: De Motu Animalum (it treats of the physiology of
animal motion), Vol. 2 of 4 volumes, Rome, 1680.
Brown-Sequard, Charles Edward: Diagnosis and Treatment of
Functiotlal Nervous Affections, J. P. Lippincott, Philadelphia, 1868.
Brown-Sequard, Charles Edward, and Tholozan: Experiments on
the Influence of Cold on the Human Body, Jour. de Physiologie de
l’homme et des animeaux, Paris, 1858, p. 497.
Calve, J., and Galland, Marcel: Nucleus Pulposus, La Presse Med.
1930 (Apr. 16) 38: 520-524.
Fontenu, AbbC: quoted by A. Monro in his Anatomy of Bones,
7th edition, 1763.
Galenus, Claudius: De usu partium corporis humani, 1550.
Guy, Albert E.: Flexure of Beams-Discovery of New Laws of
Buckling, American Machinist, 1901 and 1902. Published in book
form by D. Van Nostrand Co., New York, 1903.
Haller, Albertus: Elementa physiologiae corporis humani, Lausanne,
1763.
Jung, Adolphe, and Alexandre Brunschwig: Recherches Histologiques sur 1’Innervation des Articulations des Corps Vertebraux,
La Press Med., 1932 (Feb. 27) 40: 316-317.
Kolliker, Albert: Human Histology, J. W. Parker & Son, London,
1860 & 1872.
Leriche, Rene: Essay on the Pathology of the N. Sinu Vertebral,
La Presse Med., 1924 (May lo), 32: 409; Sensibility of Articulstions,
La Presse Med. 1930 (Mar. 26), 38: 417-420.
Lovett, R. W.: Contribution to the Study of the Mechanics of
the Spine, Am. Jour. Anat., 1903 (Oct. l), 2: 457-462.
Lower: Tractatus de corde, 1640. Translated by Oxford University Press. 1932.
Luschka, Hubert van: Die Nerven des menschlichen Wirbelkanales, H. Laup, Tubingen, 1850.
Magendie: A Complete list of Magendie’s works are found in
Bernard’s Toxic and Medicamental Substances, pp. 31.36.
Middleton and Teacher: Injury to the Spinal Cord due to Rupture
of a Disc through Muscular Exertion, Glasgow Med. Jour., 1931 (July).
Monro, Alexander: On the Anatomy of the Bones, Ed. 1, 1726.
The references are found in the 7th edition, 1763.
Morris, Henry: Anatomy, Ed. 4, P. Blakiston’s Son and Co., Philadelphia, 1907, part 1, p. 222.
Poirier, Paul: Human Anatomv-Arthroloey-Nervous System,
Masson and Company, Paris, 1901.1911.
Ranvier, M. L.: Systeme nerveux, Vol. 2, F. Savy, Paris, 1878.
Robin, C. P.: Treatise on Humors, J. B. Bailhere and Sons, Paris,
1867. P . 848. Also Diet. Encvcl. in 100 VOLs.
Rouviere On the Structure of the Discs, C. R. Sot. Biol., 1921.
Sajdus: Analytic Cyclopedia of Practical Medicine, F. A. Davis
Company, Philadelphia, 1930.
Sappey, Marie P. C.: Human Anatomy, A. Delahaye and E.
Lecrosnier, Paris, 1899. Memoir-Vascularization and Innervation of
Fibrous Tissues, C. R. Acad. SC ., 1866.
Schiff. J.: Influence of Nerves on Bone Nutrition. 1854.
Shaw,. Cunliffe: The Role of the Sympathetic in Tissue Alterations,
The Lancet, 1932 (Nov. 5).
Stookey, Byron: Compression of the Cervical Cord by Anterior
Extradural Chondromas,. Arch. New. & Pych., 1928 (Aug.), 20:
275-291.
Testut, Leo: Human Anatomy! 0. Doin, Paris, 1921-1922. On
Symmetry as Regards Skin Affectmns, Paris, 1877. Vascularization
and Innervation of Body Fluids, Paris, 1880.
Trolard: On Vertebral Articulations, Intern. Monatschr. Anat..
1893.
Vulpian, Alfred: Physiology of the Nervous System, 1866. The
Vasomotor System, G. Bailliere, Paris, 1875. Disease of the Nervous
System, 0. Doin, Paris 1879.
Zuckerkandl: Ueber den Circulations apparat in der Nasenschleimhat, Denkschr. d. k. Akad. d. Wissensch. Wienn, 1886.
All Rights Reserved American Academy of Osteopathy®
The Journal of the
American Osteopathic A ssociation
PUBLISHED MONTHLY BY THE AMERICAN OSTEOPATHIC ASSOCIATION
Vol. 29
CHICAGO, ILLINOIS, JULY, 1930
Vertebral Mechanics
No. 11
motion thus obtained seems abnormally large indeed,
but that is because of the slimness of the structure
as compared with the bulk of the body to which it
belonged, and the observation of a few ordinary gymnastics suffices to convince us of the naturalness of
the performance.
The flexibility of the column as a whole is too
obvious to be in question; the overwhelming importance of the mobility of its individual articulations is
not understood outside the realm of osteopathy. Luxations are recognized and treated, the term being
merely synonymous with dislocations, meaning condition of a bone out of its normal position or articulation. Subluxations are partial or incomplete dislocations. Those two always imply evident gross pathologic disorder. The osteopathic lesion, with its far
reaching influence, is a concept difficult of acceptance by pathologists at large, and is generally considered as beneath attention through professional
antagonism, although extremely serious attempts have
been made at various times and places to involve it,
under another name of course, as causative of well
observed disorders.
The view of anatomists towards the spine as an
articulated organ may well be represented by the following typical statement translated from the most
recent edition of an anatomical treatise widely known
and copied: “The dominant characteristic of the spine
is not its mobility. Nature has lavishly provided all
that could contribute towards its consolidation. In
multiplying the vertebra, it has so enmeshed them
together that they tend to immobilize themselves in
solidarity for action . . .”
The view of the pathologist anent the mobility
of vertebral articulations was rather forcibly expressed
not long ago to the writer by a leading professor of
a great medical university who, witnessing for the
first time the osteopathic correction of some cervical
lesions threw up his arms and unleashed an unexpected extensive vocabulary, the meaning of it all,
when boiled down, was that he considered it a murderous act to attempt manipulation of the vertebrae,
because the consequent displacements would bring
pressure directly upon the cord, with death rapidly
ensuing. The cracking noise, although subdued under
proper control-was absolutely unthinkable, etc.
Luckily, as we will see later, there are other good men
whose views are more charitable, and whose theories
are worthy of our most serious attention.
ALBERT E. G UY, D.O.
Paris, France
This paper is intended as a little contribution to
the study of the vertebral lesion familiar to the osteopathic profession. It is based upon readings from
the works of foreign authors such as Claude Bernard,
Ranvier, Virchow, Sappey, Testut, Poirier, Duchenne
(de Boulogne), Hovelacque, Sicard, Forestier, Tanon,
Tinel, Ruiz Arnau, etc.; upon readings of osteopathic
literature with reference to laboratory tests at Los
Angeles, together’ with personal observations and deductions. The points considered are: (1) The vertebral column as an animate beam ; (2) the intervertebral disk ; (3) the annulus pulposus ; (4) the
annulus fibrosus; (5) the common ligaments; (6) the
apophyseal articulations ; (7) the capsular ligaments ;
(8) interspinous and supraspinous ligaments; (9) the
ligamentum flava; (10) the spinal canal (protection
of cord) ; (11) the intervertebral foramen; (12) blood
cellulitis and neurodocitis ;
lesions; (16) indirect
the standpoint of mechanics the main
factors’ involved are bones, ligaments and muscles;
it is our purpose here, in studying some of their
physiological functions, particularly in extreme range,
to visualize the conditions under which lesions may
be formed.
Bones are rigid living structures whose functions
are to maintain the form, the position, of various parts
of the body, and to afford protection to the most
delicate and important vital organs. In the limbs and
the vertebral column they act as lever arms and compression members.
Skeletal ligaments are fibrous bands which connect the bones together, maintain them in functioning position, limit and control their articular displacement. They are articular tension members.
Skeletal muscles are contractile organs which
produce angular movements of bones, such as that of
one bone about its articulation with another.
As a structure the vertebral column is essentially
composed of bones and ligaments. This is most
practically demonstrated by the spines so skillfully
prepared by Dr. H. V. Halladay, with which the profession is fully acquainted. In such a spine there is
almost perfect mobility at each articular ‘point, while
both the individual and the total displacements remain
strictly within the natural range. Through most careTHE VERTEBRAL COLUMN AS AN ANIMATE BEAM
ful dissection only the skeletal ligaments have been
In vertebrates the spine is never at rest; whether
preserved, and the various desired bendings and the body is in natural stationary position, or in distwistings of the structure are produced by external placement, the vertebrae are always in motion relaforce, so applied as to represent approximately the tively to one another; the degree of relative motion
pull of one or several muscles. The amplitude
of the American
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varies inAcademy
accordance
with the needs for preservation
91
92
VERTEBRAL
MECHANICS-GUY
of equilibrium and of comfort. In man, the equilib- kgs. The pressures per sq. cm. are respectively:
rium even in the simple upright station requires in- 34.7 :13.92=2.49 kgs., and 29.13 :2.88=10.2 kgs. I t
cessant readjustment of the position of the vertebrae. follows that the unit pressure on the articular facets
From this we see that the textual conception of the is 10.12:2.49=4.06 times the unit pressure on the
vertebral column as a strut or support for the body face. Now, as the body of the fifth lumbar is the
weight cannot hold, the term “animate beam” would largest of all the vertebra, and was thought purposedly
probably be the most adequate to define it, both ac- intended to serve as the base of a strut and to sustain
cording to mechanics and to function. Effectively, consequently the maximum load, it seems clearly inadin life, it is subjected to various kinds of bending
and twisting; but whereas in an inanimate beam there
is no control over the strains (or deformations) produced by the stresses, there is in this animate beam
an incessant control tending to limit the displacements and the strains so as to protect the integrity
of the structure while allowing a marvellous diversity
of postures and a likewise marvellous precision of
movement. This control is instinct&e, independent of
the will, and might well be considered as a sense, in
the same manner as some authors consider the nicety
13 92
of adjustment of antagonist muscles as due to a
muscle sense.
To uphold their contention of the vertebral column as a strut, anatomists point to the fact that as the
body weight (load) increases from the head downwards so does the size of the bodies of the vertebrae
and of the articular surfaces increase from the skull
down to the sacrum. Without referring to this
structural feature in quadrupeds, it certainly helps to
sustain the beam hypothesis; and the greatest periphery obtaining at the base of the column would indicate that the control index is within the peripheral
ligaments, thus governing the region where the need
for stability of structure is greatest.
The general aspect of the column predisposes
against the strut conception; its sinuosity shows it
fig. 1.
already bent along three deformable arcs, and it is
obvious that any anteroposterior movement, for instance, is bound to modify the curvatures, thus in- missable to maintain such an assumption, as it cannot
creasing or decreasing the flexual stresses. It is be held logical that the articular facets have been
interesting, however, to investigate the pressure con- intended to withstand regularly a stress so much
ditions obtaining at the base of the column, that is, greater than that applied to the face. Of course, the
at the lumbosacral joint, assuming that the weight
stresses developed in the passive upright station of
supported there, say 100 pounds or 45.3 kilograms,
the
trunk obtain constantly in our daily activity ; furis that of the upper part of the body in upright posithermore, in simple walking they may even be doubled,
tion.
In the following discussion the vertebrae used while in running and jumping’ their values may inbelong to a spine purchased some years ago from the crease three or fourfold, even then they appear small
Nurses’ Home of the American School of Osteop- as compared with those resulting from bending efforts,
athy, where for a long time it was an object of study. as will be seen presently.
Let us note in passing the immense difference
It does not appreciably differ, as to sizes, neither from
other spines in the writer’s possession, nor from the between the blood pressure, assumed at 180 mm. kg.,
cuts in Toldt’s Atlas, for instance. Another thing, and the pressures thus far calculated, viz.: on the
all computations are intended for comparative work base, 2.49 kg. per sq. cm., or 35.4 lbs. per sq. in., or
only, and thus the figures may be found sufficiently 1830 mm. kg. ; on the facets, 10.12 kg. per sq. cm., or
convenient, although perhaps lacking a little in pre- 143.9 Ibs. per sq. in., or 7430 mm. kg. The ratio is
over 10 to 1 on the face, and over 40 to 1 on the facets.
cision.
The inferior face of the fifth lumbar is shown in The question of nutrition of the parts offers a magFig. 1, its area is about 13.92 sq. cm.; the articular nificent field for research work.
The lower face of the first dorsal is sketched for
facets are in a plane practically perpendicular to the
face, and their surfaces are shown developed below, comparison only ; its area is about 4.96 cm. sq. ; it is in
their total area being about 2.88 sq. cm. The plan the ratio of 1 to 2.8 to that of the fifth lumbar, which
of the lumbosacral joint may be fairly accepted as affords no ground for conclusions of interest.
In Fig. 2 we have a bent lever pivoted on a fixed
forming an angle of 40” with the horizontal plane.
By resolving the vertical force into two components, support or fulcrum ; the short arm of length is conone at right angles with the plane of the vertebral nected to the support by a spring ; at the end of the
joint, and the other with that of the articular facets, long arm of length L a weight W is suspended. The
it is seen that the pressure on the face is 76.6 lbs., or resistance R provided by the spring is calculated from
Americanthe
Academy
of Osteopathy®
equation
of moments WL = dR, whence W L :
34.7 kgs., and that on the facetsAllisRights
64.3 Reserved
.lbs., or 29.13
VERTEBRAL MECHANICS-GUY
d = R.
For any point along the arm, at a distance L
from the point of suspension of the load, the moment
is WL: it is resisted by the molecular forces of the
material of the, arm. Above the neutral axis the forces
are tensile, below they are compressive. For a lever
arm of uniform section throughout these forces vary
in intensity directly as the moment. The maximum
effort is obviously at the point of support.
93
are fully applicable to this link beam. In order to fix
the ideas let us analyze, for example, the conditions
shown in Fig. 4, in which a man sitting on the
ground, with his feet applied against a firm support,
pulls ‘horizontally, and steadily, with both hands, a
rope passing over a pulley and sustaining at its end a
weight of 45 kgs., say about 100 lbs. The sacrum is
thus firmly anchored, and the vertebral column is subjected to a flexural effort in an anterposterior plane.
As measured on a convenient subject at hand, the lever
arm or distance L from the upper face of the sacrum
to a point of application of the load situated about the
third dorsal, was found approximately equal to 38 cm.
The maximum bending moment at the lumbosacral
joint was therefore 38 X 45 = 1710. Assuming the
axis of the tension forces at about 5 cm. from the
center of gravity of the upper face of the sacrum, this
would represent the small arm of the lever. Consequently the ligament and muscle pull would equal
1710~5 = 342 kgs. and the pressure supported by the
disk through the bending effort only would also be
342 kgs.
In addition, assuming for convenience’s sake, the
weight of the upper part of the body as before, in
the vertical position, as 45.3 kgs., the components
would be 34.7 kgs. on the face, and 29.13 kgs. on the
articular facets. Directly applied to the facets is also
the shearing force of 45 kgs., that is the weight pulled
by the hands. So that altogether there is 342 +34.7
= 376.7 kgs. on, the face, and 29.13 + 45 = 74.13
kgs. on the facets.
Besides this there is a tendency to shear off the
The total load divided by the area sustaining it
arm at every point of its length and, neglecting the
weight of the arm itself, the shearing force is pre- gives the pressure per unit of area; therefore upon
cisely equal to the weight supported, and is of course the face we have 376.7: 13.92 = 27.06 kgs. per cm.
sq.; and upon the facets 74.13:2.88 = 25.73 kgs. per
the same a: every point.
cm. sq: In round figures this comes to 385 and 366
Let us assume that the lever arm instead of a
pounds per sq. inch, respectively. These are indeed
solid beam is made up of an assemblage of links as
enthralling figures, worthy of our keenest attention.
shown in Fig. 3, each supported by the other by
means of articular facets a and b. Above, the links But this is not all, the loads dealt with were of a
are connected by tension springs S; below they bear static kind, whereas in action dynamic effects are
on elastic pads p, which serve as pivots. It is evi- commonly produced which may easily double or treble
dent that each link is a lever of the kind shown in the unit pressure. Thus in rowing, with the position
Fig. 2. The whole assemblage is a link, or articulated, practically the same as in Fig. 4, an ill measured pull,
beam. The shearing force is supported by the articular too sudden, may readily double the bending moment
facets; the tension forces are represented by the and consequently the stresses.
Thus far we have taken it for granted that the
springs, and the compression efforts are resisted by
facets
were bearing symmetrically upon the full exthe pads. We have thus a structure similar in mechanical action to the vertebral column, in which the tent of their articular area, and with the bending or
springs S are made up of ligaments and muscles, and pressure efforts applied in one determined plane. But,
the pads are the intervertebral disks. It can be easily because of the flexure of the column, the disks are
shown that this form of structure, particularly with compressed, each vertebra is angularly displaced with
the actual location of the articular facets in the respect to its neighbor, consequently the facets in apcolumn, may take care of lateral bending efforts, position slide upon one another, with the result that
ligaments and muscles attached to the lateral ver- the bearing surface may be greatly diminished and the
tebral processes resisting the consequent tension unit pressure proportionately increased.
Under purely static conditions the pressure beAll this, thus far, is fundamentally
stresses.
tween
the facets could be very much greater than we
sound ; the other functions of the vertebrae,
such as the protection of the cord and the guidance have yet calculated and no damage would ensue, but
of the nerve roots, are not interfered with in this with displacement, that is, sliding of the facets under
construction; and finally we realize that the column is great load, we would fear a grave danger of gripping
in reality an animate beam, since it can adjust itself or abrading the surfaces in contact. Effectively, gripautomatically, and independently of the will, to in- ping occurs with steel running on cast iron under a
numerable varieties of positions and movements, with load of 50 kgs. per cm. sq. Usually about 15 kgs. is
any portion of the beam assuming a certain degree of considered a high working pressure.
In case of sidebending it is obvious that one facet
required rigidity while the other portions may flex
alone may have to sustain the whole pressure.
or twist to suit a given purpose.
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Well,
after ofpainting
the facet situation in such
94
VERTEBRAL MECHANICS-GUY
dark colors we would expect to obtain ready confirmation of our grave fears in the finding of more or less
extensive deterioration of the articular surfaces in
specimens selected either at random, or purposely. Examination of perhaps more than fifteen spines has
completely failed to reveal one single case that could
be ‘used to prop up the theory that the vertebral lesion
may be caused by the abrasion or the indentation of the
articular surfaces. Some of the vertebrae were seen
in the dissecting laboratory; others had been buried
for years in the back lots of the college town by once
ambitious students ; some we're disconnected from
dried up spines prepared by Dr. Halladay, and loaned
by him to the writer. In some instances the articular
facets were completely encased in osseous growth. In
all cases the transverse cutting through the intervertebral disk required some force, particularly with
very old specimens, but once the capsular ligaments or
the osteophytic capsules of the facets were separated,
the latter were found free from adherence, and the
working surfaces smooth and unctuous to the touch.
With very fresh specimens obtained from animals just
sacrificed, the apophyseal processes have a semitransparent appearance, giving one the impression, because of their hardness and smoothness, of dealing
with odontoid structures. Warning is in order as to
hasty conclusions drawn from examination of vertebrae
that have been subjected to prolonged boiling in lye
solutions, and beautifully bleached; the hyaline cartilaginous lining of the facets is removed leaving rough
and seemingly distorted surfaces.
Ominous as are the conditions affecting. the compression members of the animate beam-even a s
judged so hastily as we have-far more portentous
will we find those obtaining for the tension members,
that is, the ligaments. But before dealing with the
latter it is necessary to examine in some detail the assemblage of two vertebrae, so as to analyze the effects
of compression on the disk itself and on the surrounding organs.
fibers of one layer is from left to right, that of the
fibers of the preceding and succeeding layers is from
right to left; in other words, the obliquity is alternating with each succeeding layer. Histologically it appears that the concentric layers are formed of connective tissue fibers bound by a sparse fundamental
substance into which are found cartilage cells; we
have thus the so-called fibrocartilage tissue of the texts.
According to Sappey, muscle fibers may be found in
the connective tissue of the layers. All the fibers are
implanted at their extremities into the substance of the
basement layers. The whole disk is enclosed at the
periphery by the anterior common ligament whose
lateral extensions are continuous with those of the
posterior common ligament, and is thus encapsulated.
. The disk fibers are in reality interosseous ligaments; their structure accounts for their remarkable
elasticity, for of all fibrous and fibrocartilaginous parts
of mobile articulations none are as well supplied with
cartilage cells. Their union with the anterior and posterior common ligaments is very intimate, hence the
tremendous resistance of this assemblage, capable of
withstanding most extraordinary efforts without rupturing. Thus, with a freshly prepared spine, on which
all the vertebral ligaments are left whole, an extreme
backward bending does not tear the disk ligaments
apart, but brings about the separation of the disk
from the faces of the vertebrae. This is clearly shown
by extravasation from. the blood vessels in the bodies,
which spreads underneath the peripheral ligaments
still adherent to the bones. All these ligaments are
well provided with blood vessels and nerves.
Because each layer is distinct from its neighbors,
we may safely infer that there is a space, however
harrow, between any two adjacent layers; furthermore, we have good reason to admit that this space is
filled with the same substance found about the fibers
themselves ; in fact, this may be easily demonstrated
by making a transverse section through the disk in a
fresh specimen, the various layers are seen apart from
THE INTERVERTEBRAL DISK
one another, and as bathed in fluid. Histologically the
Any two adjacent vertebrae are connected to- central portion is formed essentially of fibrocartilage in
gether by a structure called the intervertebral disk, which the connective tissue fibers, very scanty, cross
usually described as a lenticular mass composed of a in every direction. The fundamental substance confibrocartilaginous body, the annulus fibrosus, in the tains, besides ordinary cartilage cells, more or less
center of which is a soft and gelatinous part, the bulky masses of special cells, with clear protoplasma,
nucleus pulposus. Such a description is quite inade- sometimes multinucleated, often vesicular, others
quate in view of the importance of the intervertebral pleated and irregular, representing remnants of the
articulation.
dorsal cord. In some places the fundamental subThe articular surfaces of the bodies of the ver- stance is soft and assumes a characteristic gelatinous
tebrae, particularly of the dorsals and lumbars, are consistency. From this we may conclude that it perslightly concave, whence the biconvexity of the disk, meates the whole encapsulated disk and is the true
as a whole. These surfaces. are covered with a layer pressure bearing element. Its state of semi-fluidity,
of hyaline cartilage which in the middle part, appears particularly in the young, in athletes, agile and very
thicker and more distinct. The two layers or base- active individuals, permits of ready adjustment of one
ment cartilages should be considered as parts of the vertebrae upon the other to suit the great variety of
disk. The union between the outer face of each layer positions of which the spine is capable. The peculiar
and that of the vertebral body is very intimate, car- ring-like arrangement of the fibrous layers maintains
tilaginous processes penetrating the bony substances the distribution of the fluid mass throughout the pad,
and becoming gradually calcified. The inner face is while preventing its escape along the periphery.
soft. The annulus is formed of numerous fibrocarSchematically the arrangement of the annulus
tilaginous layers, concentrically disposed ; some of fibrosus is as sketched in Fig. 5 ; the fibers of each layer
these layers are ring like, others are discontinous, extend obliquely and continuously around. The disk .
much like the layers of an onion bulb. Each layer is as a whole is laterally convex, as at A; it remains so,
composed of fibers, each extending obliquely at an but to a lesser extent, even when entirely free from all
angle of 50 to 60 degrees from the lower basement muscular and external ligamentous attachments ; this
cartilage to the upper one. If the
obliquity of the means
of of
course
that any two adjacent vertebral
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bodies are drawn together by some force. It seems merely stretched parallel to the axis of the vertebrae,
for instance, the compression of the disk would have
as if the inside were made of a disk of soft rubber
caused through the bulging and consequent lengthenof the same peripheral size as the base of the bodies,
ing of the peripheral wall a dangerous spreading of
and that the latter were then pressed towards one another, thus causing the rubber disk to bulge out con- the fibers.
vexly and to remain in that position until a network of
fine threads was fixedly laced up between the edges of
the two bodies. Upon removal of the pressure the
vertebae would not change position, nor the depressed
disk its form. With application of greater axial pressure the disk flattens and bulges out accordingly more,
as at B. With pressure released the structure reverts
to its original shape. Fresh specimens of lumbar vertebrae taken from a rabbit were subjected to enormous
axial pressures in a vise; the disk bulged out considerably but remained without a trace of transudation of
the fluid in the annulus pulposus. When free from
pressure the structure regained its natural shape again,
but the return was very slow.
From quite a number of such tests the results preC
sent for consideration two questions of some ima
portance: (a) By what means were the contents of
the disk prevented from flowing out while subjected
to such abnormal pressures ? (b) By what means were
(b) The second question is rather involved.
the two bodies brought back to their original posiTaking again a fresh specimen with all muscles and
tions ?
ligamentous attachments removed, leaving only two
The answer to the first question appears easy. In vertebrae with their encapsulated intervertebral disk,
Fig. 6, assume that au,, bb, are two fibers of one layer,
we observe that with one vertebra held fixedly the
while cc,, dd, are two fibers of an adjacent layer, and
that the two pairs are symmetrically disposed with the other may be flexed laterally in all directions, or be
disk at rest in the position AB. Now, under compres- pressed axially towards the first and spring back
sion the disk is flattened to the size AB,; the points lively to original position upon removal of the external
force. One has the impression of dealing with a somec, d, and a, b, have dropped vertically from plane B
to plane B,, and apparently the fibers are shortened, what closely coiled and sheathed spiral spring. There
thus cc, has become cc,,. The fibers must possess are three factors to consider, viz : the nucleus pulposus,
elastic properties, to what extent we do not know, but the annulus fibrosus, and the anterior and posterior
we are safe in assuming that it would not suffice to common ligaments.
ANNULUS PULPOSUS
account for such a difference in length, and we may
disregard it for the present if we consider, which is
The central mass is soft, whitish, lighter in color
more important, the amount the disk has bulged out- and more gelatinous in the young, yellowish and harder
ward and the consequent increase in its equatorial in the old subjects. When the disk is cut open the
diameter. Thus, each fiber has changed its slight con- mass expands outwards as if propelled by some intervex form into a much more pronounced one; further- nal pressure. Left immersed in cold water for several
more the great pressure applied axially has been hours it doubles in volume ; immersed in boiling water
resisted by an increased internal pressure distributed it does not increase in volume ; it acquires’ then a
uniformly throughout the fluid part of the disk. Con- density somewhat alike that of interarticular fibrosequently the fibers forming the outer wall of the con- cartilages (Sappey). Dried up it reduces to a hard
tainer have been increasingly stressed, so that instead thin plate which, however, swells up rapidly in cold
of contracting through a mere displacement of the water. Extensions of the mass reach in varied numbasement planes towards one another, they have been bers and forms towards the periphery. Sometimes to
strained in extension and thus elongated. The point the posterior common ligament and even, excepinvolved is rather complex, but for our purpose we tionally, into the vertebral body. (Poirier.) We have
may safely assume the length of the fibers as prac- already stated that the mass is essentially formed of
tically unchanged.
fibrocartilage in which the connective tissue fibers
We see in the Fig. 6 that the distance t between cross in every direction. The elasticity of these fibers
two parallel fibers has diminished to t, because of their may play some part in the spring action of the disk.
displacement and that, therefore, the compression of
Incidentally, the hygrometric properties of the
the disk has brought about what is equivalent to a central mass should be noted with particular attention
closer weaving of the annulus fibers. Thus, it seems as they obtain as well for all the cartilaginous parts
that automatically nature has provided the wall with of the disk. We have observed that whole disk disincreased resistance to meet an increase of pressure tended throughout after immersion in cold water.
produced within the disk. We may well ponder upon Ranvier in his Technical Histology describes the alterthe wisdom of providing such a lattice formation for ations cartilage cells undergo when prepared for mithe annulus, first in this case, to insure its resistance croscopic examination and immersed in various liqand tightness, and second, as we will see further, to uids. He finds that water and blood serum produce
maintain within bounds the relative displacement of practically the same destructive effects. This points
two adjacent vertebrae. Effectively, with
the Reserved
fibers American
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that when an intervertebral arAll Rights
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VERTEBRAL MECHANICS-GUY
ticulation is in a condition of diminished resistance it
may readily be affected by extravasation of body fluids
with which it may come in contact, and would help to
explain the mechanism of rheumatismal pains, for
instance, which may be intensified by atmospheric
changes, etc., and lead to the formation or the continuation of a lesion.
Thinking that perhaps the central mass was endowed with a substantial compressibility we have subjected a sufficient volume of it to pressures varying
from 300 to 400 lbs. per sq. inch, applied between
plungers well adjusted in a strong metal tube. The
volume was then reduced a little but, with removal of
pressure, came back as observed in the actual disk.
There is a bare possibility that in the latter the central
mass contains tiny gaseous bubbles, consequently highly compressible, but we found nothing to substantiate
such an assumption, and it may be safely admitted that
under the pressure obtaining in the living articulation
the central mass is practically as incompressible as
water. (However, we must not forget that under very
high pressures water is shown very compressible, its
modulus of elasticity being much over hundred times
less than that of steel.)
It seemes probable that in the fresh state, and
within the disk, the central mass possesses the same
kind of elastic properties as gelatin; it Fends to regain its shape, so to speak, after an attempted deformation, differing in that from flaccid substances like
grease, tar, etc. This would of course help the return of the bodies to their normal position, but to a
very small degree.
ciently convincing to warrant us in admitting that fact
without further demonstration.
So far we have dealt only with bending efforts,
but the spine is capable of two kinds of twisting, one
real and one apparent. Effectively, considering the
normal vertebral assemblage we may conceive that
two adjacent bodies may be bent axially in all lateral
directions; thus one body being fixed, the other pivoting on the disk can be subjected to a movement of circumduction about the vertical axis of the first. In this
there would be no actual rotation of one body with
respect to the other. Similar circumduction could be
practised successively on all the bodies of the column
so that, starting from the base and adopting a constant inclination per couple of bodies, but for instance, bending the first couple in an anteroposterior
plane, the second couple in a plane at 45 with the
first, and so on to the end, we would then see the
vertical axis (assumed for convenience as originally
straight) describing in space a conical spiral with
three convolutions, while markings which had been
made on the anterior side of all the bodies, for observation purpose, would all face anteriorly, thus
showing that the rotation concerned only the axial
displacement and was but apparent for the bodies
themselves.
If we refer to Fig. 1 we note the positions of the
centers of oscillation; these were carefully measured
on three spines, and corresponded probably to a fair
normal average. The centers are posterior for the lumbars, axial for the eight lower dorsals, anterior for the
four upper dorsals, and posterior for the five lower
cervicals. Such a center is understood as that of the
THE ANNULUS FIBROSUS
This has the important function of mechanically curvature of the surfaces of the two articular facets
limiting the displacement of one vertebra with re- for any given vertebra; and as the facets act as
spect to an adjacent one, while otherwise allowing guides for the relative displacement of two bodies, it
freedom of flexure and rotation about the axis, follows that that displacement obtains about the corWhile the layers have a certain amount of elasticity, responding center of oscillation. This matter will be
since like all connective tissue they are made up in elucidated at length later on, for the present it will
part of elastic fibers, they may fairly be considered, be interesting to consider the question of real twistafter reaching a certain degree of high tension,, as in- ing that may be produced in the mid and lower dorsal
extensible. In Fig. 6 let aa1 and cc1 be two fibers regions, and as affecting only the intervertebral disk.
symmetrically disposed ; they are attached to the
If in Fig. 6 we deal with two symmetrical fibers
basement planes A and B. Since the bodies are com- au, and cc1, and attempt to rotate the upper body
pression’ members, when the spine is bent plane B about the common vertical axis, say clockwise, we
may be simply pressed axially towards A, occupying see that cc1 will become tense and aa, slack, and of
the position B1 with c1 at c11 and a1 at a11, In the
course, all the fibers in the disk will be accordingly
sketch the fibers appear shortened, but as the disk affected, one half inclined in the same direction as
has bulged out (as mentioned before), their curva- cc1 will bear tension, while the other half disposed
ture only has changed and not their length ; they are as au, will be free from direct pull. This means,
very tensed because of the pressure within the disk, obviously, that the resistance to torsion is sustained
and consequently are bound to hinder any lateral dis- by only one-half of the disk fibers, and that the latter
placement of the upper body to the right and to the are consequently more subject to injury than w h e n
left. It seems quite likely that in forward bending, working in bending. The tension of the fibers profor instance, the tension of the fibers helps towards duces a centripetal pressure on the disk, hence a
diminishing the load on the articular facets.
tendency towards increasing its thickness. This in
When the vertebral column is bent, for example turn permits the fibers to straighten out sufficiently to
to the left to suit Fig. 7, the plane B is inclined and suit the angular displacement required for rotation to
displaced to B2 ; the fixed distance a11 c11 has shifted take place but the total amount of the latter cannot
a little to the left, and the fibers aa11, cc11 maintain be obtained without an elastic stretching of the fibers
it in that position. It would be useless of course to themselves. We are thus led to recognize such elasspeculate on the trajectory of point c1 and attempt to tic stretching as a property of the fibers, and in a
demonstrate the fact that point c11 is so located that measure as a factor in bringing about the return of
the articular facets have remained in working con- the disk to its original position when the stress is
tact, as many unknown factors are involved and place removed.
The above considerations are of value for underthe matter quite beyond the realm of geometry; obstanding
formation of lesions in animals, by
servation of the motion in a fresh
specimen
is suffiAll Rights
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97
forceful means, as it is practised in the laboratory of
the A. T. Still Institute, the results of which are so
well described in THE J OURNAL by Dr. Louisa Burns.
Lateral pressure exerted upon the spinous process of
a given dorsal vertebra causes the latter to rotate
about its vertical axis, which passes through the center of oscillation, and the angular displacement is SO
great that, for one thing, the disk fibers are strained
beyond their limit of elasticity and part of them give
way, slip, as it were; what is left may not be sufficiently strong to bring back the body to its original
position, and a permanent lesion is thus formed.
Sometimes the return to position may take place
through the efforts of “other vertebral ligaments or
the chance pull of muscular tissues. Anyhow, the
usual repair processes are set at once in action to
remedy the injury, with consequent inflammatory and
edematous reactions which may affect nearby tissues,
particularly the connective sheets, as we will see
later on,
As with all mechanical structures subjected to
bending and twisting efforts the greatest stress obtains in the fibers’ farthest from the neutral axis ; thus
in a beam of rectangular cross section the extreme
upper and lower layers bear respectively the greatest tension and compression; in a round rod in
torsion the peripheral fibers bear the greatest shearing stress. Consequently in the intervertebral disk
the peripheral layers are the most exposed to strain,
whether in flexure or rotation, and the danger lies
precisely in the disturbances produced in tissues and
organs in the vicinity, during the various phases of
even a quite normal process of repair. It has been
advanced by some that the seat of lesion trouble could
be generally located in the nucleus pulposus, which
would then be viewed as a center; it seems, from
what we have seen, that this notion is inaccurate ; it
originated probably from the fact that the central,
amorhous mass was called a nucleus and, as such,
was thought to possess special attributes.
Since the disk fibers are doomed to injury in extreme displacements it is quite logical to admit that
nature has provided means of protection in the form
of nerve terminals, which are plentiful along the
periphery of the disk, and which may sound danger
signals when the normal range limit is approached, in
sufficient time to permit the body to so adjust its position as to lessen the strains in the threatened region;
this would establish one important step towards the
recognition of the existence of a Ligamentous, or artitular sense, of the same order as the muscle sense.
THE
ANTERIOR
AND
POSTERIOR
COMMON
LIGAMENTS
To describe them would be merely quoting from
the textbooks, but for our purpose they may be considered as performing two functions: (a) that of
encapsulating the intervertebral disk; (b) that of
maintaining a state of compression within the disk,
serving thus as strong elastic bindings between any
two vertebrae by means of their inner fibers, and connecting several adjoining vertebrae by means of their
outer fibers. This action is incessant, even when the
body is entirely relaxed, as in sleep. They permit
varied motion between two adjacent bodies ; it is
probable that they limit the extent of the motion and,
because of the large amount of elastic fibers in their
structure, they are subject to contracture, in the same
sense as the muscle tissue itself but, precisely because
of their relatively great elasticity, they are less likely
to suffer from overstrain than the disk fibers. From
our own observations we formed the opinion that
they are the main factors in causing the vertebral
bodies to return to original position when free from
the action of external forces.
14 Rue de Tilsitt.
All Rights Reserved American Academy of Osteopathy®
The Journal of the
A merican Osteopathic Association
PUBLISHED MONTHLY BY THE AMERICAN OSTEOPATHIC ASSOCIATION
Vol. 29
CHICAGO, ILLINOIS, AUGUST,
Vertebral Mechanics
1930
No. 12
Some misconceptions.-Justly proud of a manipulative technic that daily accomplishes much good,
A L B E R T E. G U Y, D . O .
and at that, without adjuncts of any sort, the
Paris
osteopath must be capable of explaining in detail,
to himself first, and to any patient whenever necesPART II
sary, the purpose as well as the effect of his moTHE APOPHYSEAL ARTICULATIONS
tions. That requires an accurate knowledge of the
Any two contiguous vertebrae have two com- mechanics of the body in *general and of the vertemon posterior articulations. These have the same bral articulations in particular. That the practifunction as the neutral axis of the plain material cians are not unanimous on some very important
beam shown in Fig. 2, but instead of serving as points is instanced here and there in published form,
virtual hinge for any one given cross section, which and while the authors endeavored most sincerely
is considered for bending in one plane only, they are to solve arduous questions, it is a matter of regret
shaped to accommodate the great variety of flexural to find that so near the goal they struck what seems
and torsional positions which the spine may assume. to us a discordant note. Thus in one case, quoting
Generally, it may be said that on each lamina from a book on technic, we read:there are two extensions, or processes, or apophy“Primary lesions are due to a sudden straining
ses; the upper one, with an articular surface, or of an articulation beyond its normal range of mofacet, directed posteriorly, is braced anteriorly to tion so that it is unable to return spontaneously.
the corresponding pedicle by means of a strong There is then found to be a double deviation, a
fillet; the lower one strongly filleted to the spinous deviation in two directions, from midposition, as
process, has its facet directed anteriorly. The articu- though having reached the limit of normal motion,
lar facets are not plane; in the cervical and the and being strained farther, it turned in some abthoracic regions they are mainly portions of spheri- normal way. In such position the articular surcal surfaces, while in the lumbar region they are faces are no longer parallel but assume an angle
to each other. Some part of one side then engages
practically cylindrical surfaces.
Each facet is covered with a strongly adherent against the opposite surface, and makes a dent, so
layer of hyaline cartilage. The lower facets of one that when released it does not slide back normally,
vertebra articulate with the upper ones of the sub- but under the tension of the stretched ligaments
jacent vertebra. Unlike the intervertebral articula- assumes even a sharper angle, restrained by the
tion, in which the surfaces are connected by fibrous dent it has made. The ligaments, radially disposed,
rings, here the surfaces are free and may slide upon permit this abnormal motion and even provide for
one another in various directions; they are lubri- the secondary deviation. In the resulting position
cated by synovial fluid supplied from the inner the fibres of this ligament are not necessarily all
layer of the fibrous capsule which encloses each stretched, but possibly only a few are stretched,
the rest relaxed.
articulation.
“The factors in lesion then are: motion beyond
The apophyseal articulations are classified as
arthrodias for the cervical and dorsal regions, and as normal under high tension; assuming of an angle;
trochoides for the lumbar vertebrae. Dorland’s defini- indentation of a surface by a projecting portion;
tion of trochoides is: “a pivot-like joint; articula- high tension of part or all of restraining ligaments;
tion by a pivot turning within a ring, or by a ring in partially returning toward normal the assuming
turning around a pivot.” If in a lumbar apophyseal of position still farther from normal.”
articulation, composed as it is of small portions of
from another source (italics ours), “We
practically cylindrical surfaces, the articular facets of f i n d v e r t i b r a e . . . pivoting from the top and
the lower vertebra can be considered as parts of a bottom of the nucleus pulposus.
ring and those of the upper vertebra as parts of a
“The nucleus pulposus is the mechanical axis for
cylindrical pivot, the articulation may-be accepted as the gliding movement of the facets. It maintains
trochoides, then it can easily be demonstrated that essentially a constant distance between the vertebra
all apophyseal articulations, from the axis down to at the center of the intervertebral disk, which comthe sacrum, are trochoides; it suffices to admit that presses anteriorly and goes on stretch posteriorly
the spherical articular surfaces of the cervical and in forward bending, and vice versa.”
dorsal vertebrae are similar in effect to the practically
We have studied the nucleus pulposus in a
cylindrical surfaces of the lumbar region, and to visual- preceding article and have seen that it is far from
ize the general form of the articulation rather than the a mechanical entity, being merely the fluid portion
extent of its angular displacement All
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VERTEBRAL
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MECHANICS-GUY
tions determined by the forces acting upon the
vertebrae and by the guiding articular facets;
furthermore, its thickness varies according to the
axial pressures exerted, which offsets the assumption of a constant distance between the vertebrae
As for the angular deviation of the facets with
respect to one another, that would be a most serious matter, a luxation in fact; the facets are very
hard and their indentation scarcely conceivable as
a factor in the lesion, in the usual sense of the
word. It may be noted also that in many instances
the lesion involved but a slight angular displacement instead of one past the normal range of motion. A study of the geometry of the articulation
will clear up the misunderstanding and establish
the various directions and ranges of motion ; it will
prove more interesting than an academical discussion of hypotheses.
Centers of curvature If an arc of a circle coincides with an arc, or element, of a curve, the radius
of the circle is the radius of curvature of the curve
element, and consequently the circle and the element have a common center. The radius of curvature is always perpendicular to the curve element
at any chosen point of its length. A curved surface
may have at a given point thereon several radii
of curvature depending on the axial- planes along
which each curvature is measured. The application
of these simple principles to the measurement of
the apophyseal surfaces is very easy: it suffices to
prepare a number of templates, such as shown in
figure 8, made of bristol board, with gradually increasing radii; one end is convex and the other concave, but both have the same radii for each template. By successively trying on several templates
to the faces of a pair of upper or lower facets, one
may rapidly determine the correct radius and, by
holding the template plane perpendicular to the
curved surfaces, the direction of the radial plane,
and finally the position of the required center of
curvature. When the facets seem curved in more
than one direction the same process is repeated
with other radii until’ one is found suitable, and
again a center of curvature is located. When the
surfaces are spherical the two radii tried are equal
and, of course, the center of curvature is common
to both directions.
Occipito-atloid Articulation -Starting with the
upper facets of the atlas, assuming that all the
vertebraae are held perfectly rigid and that the head,
with its condyles bearing upon these facets, is alone
free to move, we find as shown in the cut, Fig. 9,
in which the radii are represented by wires, as
well also the curved axis, that the radius in the
lateral plane. is much greater than that in the
median plane; that the upper center serves as center
of oscillation of the head in the lateral plane; that
the lower center seemingly is placed on a curved
axis, and that it serves as a center of oscillation of
the head in the median plane; that the head may
be inclined laterally at first and then, in addition,
inclined forward and backward; that consequently
the head may be inclined obliquely along the direction of the resultant of two simultaneous movements, one lateral and the other mesial. The
schema shown in Fig. 10 may help to visualize
the geometry of these various displacements ; the
facets are made rectangular for convenience’s sake.
It remains to explain the motion of a curved axis.
In a mesial oscillation alone, the head pivots about
a straight axis passing through the centers C C ;
but if the mesial oscillation follows a lateral oscillation the points C C occupy other positions; therefore in order to cover the whole range of motion,
C C must move on an arc of a circle whose center
is C,. With rectangular facets receiving neatly likewise rectangular condyles the mesial motion could
not take place ; it would be necessary for the condyles to bear unevenly on part of the facet, leaving an undesirable play along the rest of the surfaces. To overcome this mechanical difficulty nature
FIG. 8
has arranged that the anterior aspects of the facets
are close together, while the posterior aspects are
very much spread apart. Furthermore, each facet
is found in many instances practically divided into
two portions, one anterior, the other posterior.
All of the above description may be easily verified on the skeleton by holding the skull in place
upon the atlas and studying, carefully the various
possible displacements ; it will be seen that it differs
appreciably from that in Piersol’s anatomy, page
142, paragraph on the Movements of the Head.
We should note that the articulation as a whole
does not permit of a lateral translation, which leads
us to a remark of great importance that applies to
the whole spine. Effectively any articulation is
made to accommodate only the displacements resulting from the pull of the muscles acting upon
the movable bone received in that articulation, and
the path of displacement is always along the plane
in which the resultant pull is situated at the instant
considered. The temptation is great indeed to
study in detail in this article the action of the various antagonist muscles which are intended to produce the nodding, or mesial motion of the head, the
side-rocking, or lateral oscillation, or the resultant
displacement due to the compounding of the mesial
and lateral pulls. Such a study would lead us too
far, as it would have to be applied to each of the
vertebral articulations. We suggest again, however,
that it be pursued in our colleges, where myology
deserves to be treated differently than it is in
the textbooks, in which nomenclature and topography predominate, with, at the tail end, a short
notice, vague and general, concerning the action
of such and such muscle, usually considered as
part of a group. With us, Myology should be
treated essentially from the utilitarian point of
view; that means to give function the first place
for each muscle, which is entirely logical since, after
all, skeletal muscles are intended solely to place or
maintain bones in given positions, consistent with
the mechanics of their articulations. Such a method
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VERTEBRAL MECHANICS-GUY
100
would greatly facilitate the understanding of the
physiology of movements, the detection of abnormal
conditions, and the development of corrective technic both generally and individually.
Atlanto-axial Articulations -The first of these
is the atlanto-odontoidal, the second is the apophyseal. Examination of the odontoid process reveals
that movement may take place about a vertical
FIG. 9
axis, producing horizontal rotation of the atlas;
but as the articular face of the process is not truly
cylindrical, having a double convexity, one horizonal or short radius, permitting greater angularity
of motion, and one vertical of much greater radius,
it follows that a small oscillation, or anteroposterior
rocking is provided for.
The apophyseal articulation has always proven
puzzling because it presents a character of unstability quite unique among all the vertebrae. In
Fig. 11 the vertical axis is shown with a spiralled
arrow, indicating to and fro rotation; wires represent the radii of curvature of the articular facets
which are in effect portions of a spherical surface.
The upper facets of the axis have the same radius
of curvature as that of the atlas, as measured in a
lateral plane, but measured mesially they are upwardly convex with a much smaller radius of curvature, the center of which is located about the
middle of the third cervical. In this way the faces
in apposition, of each pair of facets, are not in
entire intimate contact; this condition is necessary
to suit the rocking motion of the atlas upon the
axis, which is possible in any position within the
angular range of-rotation of the atlas. The stability
is insured mainly by the transverse ligament, which,
although very strong of itself is further reinforced
by others, the whole structure forming the cruciform
ligament. The great amplitude of the angular motion necessitates special means of limitation to prevent injury to the cord. The axis of rotation of
the atlas is away from the axis of the spinal foramen, and as the angular displacement amounts
sometimes to 45 degrees, the spinal foramen of the
atlas is much greater laterally,-if it were otherwise, the cord would be sheared off, or at least
crushed. The lateral odontoid, or alar ligaments,
connect the -top of the odontoid process to the
occipital condyles ; although these ligaments are
very strong it does not seem possible that they
deserve to be called check ligaments, meaning that
their function is to limit the rotation of the atlas.
The small distance between the axis of the odontoid
process and the point, on the outer face, of the
attachment of the ligament is too short a lever to
insure the security and precision of movement required. It is more likely that the checking is
obtained mainly through the fibers of the outer
capsules which are particularly well developed
between the atlas and the axis, and also by
the ligaments attached to the spinous process,
since the farther away the check ligaments are
from the center of rotation, the more effective they
FIG. II
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may be. This point deserves a more detailed study
than is found in the texts.
Second to Third Cervical Articulation -Here we
have two radical changes; in the first place the
bodies of the vertebrae are connected through an
intervertebral disk; then the articular. facets have
a center of curvature located posteriorly and upwardly, whereas that of the atlanto-axial was dawnward; the change is certainly abrupt. The upper
face of the body of the third cervical is saddleshaped to receive the lower part of the axis’ body.
It is quite evident that true lateral displacement is
not possible, nor for that matter, true axial rotation
of one body upon the other. In Fig. 12 the third
and fourth cervical vertebrae are shown assembled
for the purpose of better indicating the positions of
the two centers involved. The oblique axis provided with a spiralled arrow passes through the
upper center of curvature; its direction mesially,
is towards the vertical axis of the bodies, where it
FIG. 12
101
increases because the lower part of the axis’ body
becomes then more closely wedged in the saddletop of the third vertebra. In extension the rotation
becomes ampler because less restricted by the
lateral processes of the saddle, the side clearance
between the lateral faces in apposition of the two
bodies being then greater because of the tilting
backwards of the oblique axis towards the extreme
range of extension. It is equivalent to considering
two V-shaped parts fitting one into the other; the
more they are separated along the V axis the more
lateral play there will be.
All the other cervical vertebrae articulate with
one another in precisely the same manner as previously described ; the only variations to be observed are the length of the radii of curvature and
the position of the centers.
Seventh Cervical and First Dorsal Articulation.Fig. 13 shows a most interesting condition,-that
of a complete reversal in the position of the centers
of curvature of the apophyseal surfaces of the seventh cervical. The superior articular facets have
their main concavity facing’ posteriorly and upwardly, while the inferior facets have it facing anteriorly and downwardly, consequently the two
main centers of curvature are directly opposite.
Hence, the sixth cervical may oscillate about the
oblique axis, as indicated by the spiralled arrow,
while also oscillating in a fore and aft manner about
axis C, as indicated by the double arrow at the top
center, to suit flexion and extension movements.
In flexion and extension the seventh cervical
may oscillate about a center A located practically
at the middle of the body of the first dorsal. We
should note that for all vertebrae the centers of
curvature and consequently of fore and aft oscillation, are located anteriorly and downwardly, and
relatively at about the same point on the body of
the vertebra. The seventh cervical may also oscillate about a center C. This transverse motion is
however of limited extent because the upper face
of the body of the first dorsal has two lateral processes, last vestiges of the saddle form obtaining in
the cervical region, which act as abutments. Sometimes the attachments of the head of the first rib
act in the same manner. In manipulating the
two vertebrae together it is seen that there
is a possibility. of an oscillatory motion about
an oblique axis passing through the centers
A and B. This motion is of greater amplitude than
the transverse, because when one side of the seventh body bears against the lateral abutment and
the head of the first rib the other is clear of such
obstacles and may move through a relatively great
distance until checked by the various ligaments
affected. These various motions may take place
separately or in combinations, while the articular
facets in apposition preserve a normal amount of
contact. It becomes increasingly evident as we
proceed that lesions do not form through a mere
tilting of articular facets, with or without actual
denting of their surfaces. The articular motions
have well-defined directions and ranges, guarded
by efficient and very vigilant ligaments. Whenever a movement oversteps the range the ligaments
are overstrained and need repairs, which nature at
once proceeds to make; the affected vertebra may
remain relatively displaced, with attendant disturbances in the region, until conditions are mended
intersects a transverse axis passing through the
middle of the body of the fourth cervical. On this
latter axis is the center of the anteroposterior curvature of the upper articular facets.
The axis vertebra may therefore oscillate forward and backward, that is, move in flexion and
extension about a transverse axis or fulcrum passing through the body of the third cervical at about
the middle of this latter. In so doing it carries
back and forth the oblique axis, as indicated by
the double arrow located at the upper center of
curvature. In any position on this range it may
also oscillate about the oblique axis, but this angular rotation is limited increasinglyAllasRights
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102
VERTEBRAL MECHANICS-GUY
ical vertebrae are oftener in lesion to the right than
to the left sides? Our experience indicates that
about 90% of the lesions are on the right side.
It is interesting to consider the position of
antagonist muscles intended primarily to rotate a
cervical vertebra about its oblique axis. Such are
the semi-spinalis colli; their origin are on the articular processes of one given vertebra, and their
insertion on the spinous process of the second
vertebra above. When one contracts it pulls on
the spinous process laterally and downwardly; the
direction of the pull is nearly tangent to the arc of
circle described by the spinous process while turning about the oblique axis ; return to mid-position
or rotation to the other side are, of course, produced by the action of the companion and antagonist semi-spinalis muscle. As we may realize,
the position and connection of these muscles are
such as to insure the most efficacious action. Incidentally, we should note that these muscles are
sometimes described as “supporting the spinal column,” for instance, in Dorland’s dictionary, in
muscles, a statement quite illogical.
Thoracic Vertebrae.--It seems that each of the
four upper dorsal vertebra7 have two centers of oscillation; one center about which mesial rocking takes
place is located at the middle of the body; the
other, having to do with side rotation, is situated
anteriorly, as at D,, D,, etc., Fig. 14. The rest of
the dorsal vertebrae have only one center common
for both motions. With all the dorsals flexion and
extension have relatively greater amplitude than
rotation, because the latter is hindered by the abutments formed by the heads of the ribs. Taking it
for granted that lesions are produced by disturbances occurring at extreme range of motion, we see
in the sketch, Fig. 15, representing a mid-dorsal
vertebra, that in rotation about center 0, the region
a, at the posterior end of the vertebral foramen,
must withstand the‘ greatest amount of displacement, hence of stretch. It is there that we should
expect trouble. By the same reasoning, that region
is likewise most severely affected in mesial oscillation, since it is located the farthest from center 0.
We do not consider the extreme displacement of the
FIG. 13
tips of the spinous processes because the ligaments,
holding them are suitably disposed, and lax enough
With the cervical vertebre lateral flexion or to withstand it. The ligament most affected is the
extension are quite limited. This is evidenced on ligamentum flavum. This seems well established
any patient when lateral pressure is applied to the by examination of a number of specimens in our
head: the neck itself remains practically straight; possession, and is accepted by several well known
but at the base of the neck, just below the seventh authors. Injury to this ligament may result in
cervical, there is considerable movement, This con- processes of ossification, example of which will be
dition is utilized in the technic for adjusting the shown later in the form of actual photographs. Of
first rib on the side opposed to the direction of course, in extreme extension we should expect the
pressure. The rotation about the posterior oblique anterior aspect of the common ligament to suffer
axes, combined with extreme extension, permits of overstretching. This is very serious and may prove
ready adjustment of the whole cervical area. The the beginning of wasting disease affecting the antechnic for this is extremely simple when based on terior portion of the vertebral body.
Another point of serious import is the disturbthe above considerations and oriented in the direcance, through extreme rotation, to the attachment
tion of the least resistance, and either difficult or
impossible, therefore very dangerous, with the of the head of the rib, with consequent tilting of the
cervical vertebrae in extreme flexion. It should be rib itself. The matter is complicated here by the
noted that most cervical lesions involve dis- fact that the sympathetic ganglia are located preturbances laterally, in a direction where motion is cisely upon the ligaments holding the heads of the
structurally very limited, which often develop much ribs to the vertebral bodies. Therefore any permatenderness under the touch, and sometimes ex- nent disturbance about a costal articulation is
cruciating pains, as in torticollis. One interesting bound to have some effect on the functions of the
sympathetic nerves directly, and by reflex action
question still awaiting an answer
is why
the cervAll Rights
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spontaneously, or as the case may be, by actual
manipulation.
This question, however, will be
studied subsequently.
VERTEBRAL
103
MECHANICS---GUY
upon the nerve branches, and even through the
nerve of Luschka upon the spinal cord itself.
Lambar Vertebrae.--An abrupt reversal of the
position of the centers of rotation takes place with
the apophyscal articulation of the first lumbar with
the twelfth dorsal vertebrae The centers for all
the lumbars are posterior and located somewhere
within the mesial plane of the spinous process,
practically as shown in, Fig. 14. The centers of
mesial oscillation remain, however, situated about
the middle of the body of each vertebra, that of the
fifth lumbar being about the middle of the first
sacral.
We see from the sketch in Fig. 16 that the
region most stressed in rotation is at a, on the
anterior face of the body; the lateral aspect of the
latter comes next, the stress diminishing in intensity to the level of the posterior wall of the body.
In extension the same region a is the most stressed.
In both cases the anterior common ligament has to
bear the brunt of the tension. Both thoracic and
lumbar vertebra are limited posteriorly in extension by the abutment of the spinous processes. In
flexion all the posterior ligaments help in sustaining the tension, but in all cases the ligamentum
flavum is the most stressed and subject to injury.
At this juncture if we consider generally and
briefly the technic of the so-called correction of a
lesion, with which so many seem satisfied, we see
that for the cervical region it is obtained most
easily with the neck in extreme extension and in
such rotation as to suit the articulation aimed at;
that is clearly indicated by the study of the radii
of oscillation. The popping noise is produced
when the facets of an apophyseal articulation,
after being abruptly separated, are brought back
sharply in contact through the reaction of the
ligaments and muscles situated in the neighborhood. In this case, the displacement of one upper
vertebra is involved, all the other vertebrae below
being locked in position. Usually only one of the
apophyseal articulations gives way at a time. Thus,
for example, the patient lying on his back, the
head and neck being in extreme extension, with the
face to the right, the articulation on the left will
be maintained in forced contact, while that on the
right will give way and produce the noise upon its
spontaneous return to position.
For the dorsal area an upper vertebra must be
displaced posteriorly along the long radius of rota
tion as an axis, all the lower ones being locked
The complete articulation (that is, the two apophyseal articulations) may give way at a time. The
direction of effort must be varied to suit the axial
direction suitable to each vertebra. This point has
been fully explained by various authorities on technic, particularly by Dr. Taplin. In all cases, briefly
speaking, the separation takes place in a direction
normal to the plane of the articular facet.
For the lumbar area the conditions are changed.
The upper vertebrae are locked and the separation
takes place through the displacement of one given
lower vertebra. Thus with the patient on his right
L-a-4
side, the operator presses down and posteriorly with
one hand upon the *left shoulder, maintaining it in
position, while with his other hand or forearm, he
produces a twisting thrust downward and forward
upon the pelvis. In this way the apophyseal articulation on the right side will be forcibly maintained
in position, while the separation of the facets on
the left side will be produced, with the usual accompanying noise. To produce the separation of the
right side articulation the patient is placed upon his
left side, the right shoulder being maintained firmly
in posterior and downward direction, the pelvis is
then thrusted forward and downward,, that is, effectively twisted.
Anteroposterior lesions belong in a class by
themselves and require a most attentive study of
general and local conditions. They are susceptible
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104
VERTEBRAL MECHANICS--GUY
of reduction, but usually through extended series
of treatments; quite rarely may they be corrected
by a single, snappy treatment.
The Sacro-iliac Articulation -Although this subject does not seem at first to fit in with the mechanics
of the vertebrae, it has, however, some fundamental
points of resemblance with an ordinary vertebral
articulation which are worthy of close attention. I t
is not unusual to have transient patients on foreign
shores call on the osteopath for the purpose of having their sacro-iliac lesion corrected. If one is bold
enough to ask how do they know that they possess
such a rare thing, he is peremptorily informed that
the osteopath at home discovered it and hammered
at it periodically, so there . . . . get to work and
please fix it. Invariably then, if the patient is placed
on the back, one leg is found shorter than the other,
which, in the, absence of specific symptoms of pain
clearly indicates that the sacrum is rotated upon
the lower face of the fifth lumbar (that is the most
usual disturbance.) This is proven by the operator
placing his left hand on the anterior aspect of the
right ilium, with the right hand on the anterior
aspect of the left ilium, and sharply twisting the
pelvis away from the side of the short leg. The
ankles are then found practically on the same level.
That, of course, is merely a demonstration of fact,
the correction of the lesion itself entails a conscientious preparation of the tissues affected
through proper manipulative treatment of the lumbar and sacral regions, after which the replacement
of the lumbosacral articulation is easily effected.
Unless there should be chronic disorder in the articulation the effects of the treatment are lasting. In
case of a real sacro-iliac lesion the two main symptoms are : (a) great tenderness evolved under palpation of the posterior aspect of the sacro-iliac articulation, either on one side or on both sides; (b) tenderness at the superior aspect of the symphysis
pubis. This latter symptom is always indicative of
sacro-iliac affection or displacement.
Treatment
for the reduction of such a lesion is quite involved
and requires special consideration.
The question of the sacro-iliac joint as an articulation has been the subject of many arduous
discussions. The textbooks do not enlighten us
appreciably on it, but considering the pelvic girdle
as a whole, some of the older anatomists, particularly the French, claim that a movement may take
place through an elastic separation of the symphyseal joint in women at parturition time. They cite
certain gynecologists who have asserted that they
observed considerable spreading of the bony structure, amounting in some cases to more than two
centimeters. Such statements lack the stamp of
general confirmation. As to the function of the
articulation itself, nothing of a definite character
seems to have been brought forth. Some of our
people endowed with more than ordinary skill in
palpation, claim that they are able to detect evidence of motion between the ilium and the sacrum;
they certainly must have beengifted by nature with
uncommon power. But it is not at all necessary to
be so gifted nor to possess an extraordinary knowledge of anatomy to demonstrate either on an old
dried up specimen or on a fresh one that, by con-
struction, the joint is intended by nature as an
articulation. Reverting to a vertebral articulation,
we know that it is composed of a fibrous intervertebral member or disk, maintaining elastically two
adjacent bodies in position, and two guiding apophyseal articulations. With any specimen it is always possible, once the capsular ligaments are slit,
to introduce freely a thin flexible blade between the
articular facets; the fibers of the disk are very hard
to cut through in an old specimen, and relatively
tough in a fresh one. Now, with a sacro-i1ia.c joint
we have on each side of the sacrum an extensive
and extraordinarily strong fibrous connection,. the
interosseus sacro-iliac ligament, between the upper
portion of the faces in apposition; by slitting the
capsular ligament around the lower and anterior
portion it is always possible to insert a thin flexible
blade between the bony surfaces in apposition. Just
as the articular facets are always unctuous to the
touch, likewise are the auricular facets of the sacrum; furthermore, the latter are well provided with
synovial fluid through surrounding appropriate
membranes. The demonstration may easily be made
on the body of an animal, a rabbit for instance; as
soon as the capsular ligament is cut the ilium can
be moved angularly to and fro about the sacrum.
When we are convinced that the joint may articulate we want to know the purpose thereof. We
cannot err very much in assuming that the function
of the articulation is similar to that of a shock absorber, and that the slight give that may take place
between the articular faces, through the exertion
of violent efforts, as in jumping, sudden pulling or
lifting, reduces the violence of the transmission of
the induced stresses to the spinal colunm.
The apparent shortening of one leg, as measured by the difference of level of the ankle bones,
has often been too lightly attributed to a real sacroiliac lesion. Since it is so difficult for the average
practician to detect movement between the ilium
and the sacrum, the possible maximum displacement must indeed be very small under normal conditions, and would not, most probably, in case of an
ordinary lesion, produce an upward displacement of
the leg amounting to centimeter. Now it is noti
uncommon to have patients showing a difference
in ankle level amounting to between one and t w o
centimeters, which certainly cannot be attributed
to such a lesion. The explanation of such a difference is very easy if we consider the angu1ar position of the lumbosacral disk. Assuming that the
angle formed by the upper face of the sacrum with
the horizontal amounts to about 45 degrees, we
realize then that when the pelvis as a whole is
twisted, for instance, from right to left, the C O X Ofemoral articulation carrying the right leg goes
down, while the other raises the left leg. The difference in ankle level is then the total displalcement
of the two legs. With a bilateral sacro-iliac lesion
the ankle level would be unchanged; with a unilateral lesion one leg only would be raised to a
small extent, as stated above. The correction for
a right to left lumbosacral twist is most obviously
accomplished by twisting the pelvis from left to
right, all duly in accordance with proper technic.
14 Rue de Tilsitt.
All Rights Reserved American Academy of Osteopathy®
The Journal of the
American Osteopathic Association
PUBLISHED MONTHLY
Vol. 30
BY THE AMERICAN OSTEOPATHIC ASSOCIATION
CHICAGO, ILLINOIS, SEPTEMBER, 1930
Vertebral Mechanics
ALBERT E. GUY, D.O.
Paris
PART III
The Capsular Ligaments.-We have mentioned
that the articular facets are lined with a strongly
adherent layer of hyaline cartilage; this layer is
thicker in the central portion; its average thickness
varies from 0.8 to 1 mm. in the cervical region,
from 0.5 to 0.8 m the dorsal, and from 0.8 to 1.5
mm. in the lumbar. Its working surf ace, although
very hard, is smooth and always unctuous to the
touch, even in old specimens. In some cases of
esostosis where evidently the apophyses had been
immobilized for a long time, it was necessary to
break the bony growth all around the edge of each
articulation in order to obtain separation of the
surfaces, and it was then seen that the cartilaginous coverings had remained intact in the major
portion of their area, the edges alone having been
affected by ossification. From this we are justified
in assuming that each cartilage, as a living organ,
did not depend for its nutrition and its upkeep upon
the fluid excreted by the capsular membranes; it
seems evident that the nutrition was derived from
the periosteum of the articular processes.
Histologicallv, the structure of the capsule is
that of fibrous tissue, i. e., numerous connective
fasciculi arranged in several layers, bathed in rather
abundant amorphous substance. The elastic fibers
are thin and rare. Fat cells are present in the tissue; in the neighborhood of the insertions there are
capsulated cartilage cells, and the fibrocartilaginous
sheet thus formed becomes calcified at its contact
with the bone. The main physical properties of the
capsular ligaments are strength and flexibility. The
strength is greater than that of tendons and even
of bone. This explains the well known and observed fact that in ligamentous sprains tearing of
the osseous insertion is found oftener than rupture
of the ligament itself. The flexibility is very great ;
that of course is common with fibrous tissue in
general. It has been held that it is greater in the
young and diminishes in the old ;’ obviously flexibility decreases in cases where the capsule and the
ligaments are affected by ossification.
Extensibility and elasticity are functions of the
amount of true elastic tissue. The capsule and its
reinforcing fasciculi, whose structure is almost exclusively fibrous, are practically inelastic and inextensible. When a displacement reaches a certain
extent the ligament is taut and the tension naturally maintains it fixedly so; with an abnormal displacement the ligament ruptures, or tears away its
insertion. However, it should be noted that if the
ligaments do not stretch under a sudden traction,
No. 1
they do so under a continuous effort. Thus with
the foot, when the muscles are impaired the weight
of the body produces a deformation of the arches
and the ligaments become gradually elongated. In
an articulation affected by an infiltration the capsule is distended little by little and the articular
cavity becomes abnormally much greater. In these
instances the elongation of the ligamentous fasciculi is due to a, modification of their structure and
not to a special property.
The capsule is well supplied with vessels and
nerves. The arteries enter the ligaments on their
periphery; they pass between the fibrous fasciculi
by dividing and anastomosing, and thus form a very
extensive network which ends on the inside into the
synovial membrane ; the capillaries form arcades
from which spring the veins; these accompany the
arteries, there being generally one vein for each
art&y.
The nerves, very numerous, are attached to the
arteries along the greater part of their traject, and
form plexuses among the various networks. Some
are vasomotors, but the greater number are sensory. They terminate either in unsheathed interstitial expansions or as corpuscles of Ruffini, or as
corpuscles of Vater.
The wealth of nerve endings in capsular ligaments explains their sensitiveness on distension,
which manifests itself when the ligament is subjected to an abnormal traction, The existence of
these nerve endings is probably intended as means
of control of the extent of the tensions and pressures sustained by the ligaments, and consequently
of the position of the articulation.
The articular cavities contain a very small
quantity of a clear, transparent and very viscous
fluid, the synovial liquid, which bathes the articular
surfaces. In this liquid are found synovial cells,
either intact or in fragments; cells from the surface
of the cartilages; leukocytes; free nucleii; elastic
fibers; fat droplets; bits of snynovial membrane
and of the articular cartilage. The origin of the
synovia is not definitely known, but it is generally
admitted that the fluid is a transudation of the
blood serum, to which are added the waste material
from the superficial cells. According to Hammar it
is but the result of the liquefaction of eroded cartilaginous and synovial cells dropped in the cavity.
Effectively, the chemical composition of the synovia is quite analogous with that of cartilage, and it
seems pertinent to assume that it might be a sort
of fluid form of the amorphous substance of the
supporting tissues. This would explain that in the
articulations of many vertebrates of lower orders
and in the amphiarthrodias of man there are no
definite limits between the articular cavity and its
walls; even in the synovial layers of diarthrodias
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this limit is not always clear. Synovia, synovial
membrane and cartilage would then. form a connective whole diversely differentiated.
For osteopathic purposes we should note here
that the extensive vascular and nervous arrangements of the articular capsule render it susceptible
to anything affecting the blood supply and the
nerve conductivity. We will consider this matter
again a little later.
The function of the capsule is to keep the articulation covered, inclosed, protected from the influence
of the surrounding tissues or organs, and to provide
adequate lubrication of the working surfaces throughout the whole range of the relative displacements of
the latter. The diagram in figure 17 represents at A
two articular processes in neutral position ; at B the
upper one is displaced to the left a considerable
amount which may be assumed as within the ordinary
range ; observation shows that in many instances the
displacement is even of greater extent; it is not onesided and may be of equal extent to the right, for
instance. To suit such conditions the capsule cannot
be a mere sheet of tissue, a wrapper, possessing
extraordinary stretching qualities. Effectively, in man,
it is attached to the processes, outside of the articular
faces, continuous with the periosteum, presenting a
plurality of folds festooned somewhat as shown in
figure 18, at A. In extreme range, as at B, the capsule
is spread, at the left, so as to cover the underside
of the upper facet, and at the right to cover the
upper facet of the lower process. It is not possible,
of course, to demonstrate this on a human subject,
nor even on the cadaver, where the tissues’ have
undergone well pronounced changes, but on the
body of an animal such as a rabbit a most interesting study can be made. Once the muscular tissues are speedily removed so as to expose the free
vertebral articulations, one may see, particularly in
the lumbar region, conditions represented by the
sketches in figure 19. At A, in neutral position, the capsule is festooned somewhat as shown; instead of being
inserted at the edge of the upper process, as in man,
it is so much farther up that the end of the process
appears as a tooth, clear and smooth on its upper and
lower aspects. Upon rocking one vertebra upon another subjacent, the capsule spreads as at B, covering
the upper part of the lower facet, and as at C, covering the upper and lower surfaces of the tip of the
upper process. One cannot help marvelling at the
smoothness of action of the capsule while folding
and unfolding, and also with the articular faces in
apposition working to and fro without losing contact with one another. It is very difficult to break
this contact without damaging some of the various
structures involved. The observer must realize
then that the notion that the articular facets act
as guiding and controlling organs for the whole
vertebral articulation is fully confirmed by actual
demonstration.
To function properly the capsule must be always in contact with the working parts so as to
follow incessantly . their displacements ; even in
breathing they move; it must provide synovial fluid
for the lubrication of the facets and serous exudation to suit the contact with external tissues. Consequently the blood and nerve supply must be
adequate and uninterrupted. As it is soft and jellylike, in a way, it does not possess, unaided, sufficient
elasticity to insure very strong application against
the parts; we are thus led to the examination of
the structures with which it is in relation, these
include the periosteum, from which proceed the
blood and nerve supply, the ligamentum flavum, and
the tendinous attachments of the various muscles.
in the vicinity.
This examination is not intended as a mere
description, which could be had from standard: texts
in far more precise and accurate form than our
meager knowledge and experience could ever presume to present, but rather as an essay on the
study of disturbing conditions leading to the understanding of pathology affecting the tissues involved
and thus to the formation of lesions. These may
be traumatic, caused by forceful stretching or tearing of the capsule, or consequent upon edematous
occurrences produced by interference with the
blood and lymph circulation, or again by toxic conditions directly affecting the quality of the blood.
The Periostennz.-According to Leriche and Policard (Physiology of Bone, Paris, 1926), the periosteum is the fibrous membrane which invests the
bone and separates it, from surrounding tissues: it
is but that. Its morphology is not everywhere the
same. Where muscle fibers attach to the bone its
fibrous organization is quite different from that in
which the bone is situated under a mucous membrane or under the skin. In some regions there is
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107
absolutely no periosteum, the muscle fibers insert- tissue which inserts at each extremitv into a bone
ing directly upon the bone : thus the linea aspera of or an organ. Just as the cell axis may shorten,
the femur. This anatomical detail has long been likewise may that of the whole assemblage of cells,
known, but its importance was somewhat over- the fundamental aim being the approximation of
looked, although of a kind leading to throw S U S - the points of insertion of the muscle, hence of the
picion on the osteogenic function of the periosteum. bones or organs involved.
We know that the muscle may contract wholly
In the adult the periosteum is formed of solid
connective fasciculi. It is the result of a perios- or only in parts, therefore we realize the necessity
seous connective condensation pushed outward for each part to be specially ensheathed in confrom the inside when the bone is free. It is then nective tissue framework continuous with each cell
clearly isolable. Two layers may be considered, sheath, which explains the thickness of the fascias
one external, the adventitia, made up of loose con- separating the various so-called “fasciculi or muscle
nective tissue, and one internal made up.. of solid bundles.” We thus see that the muscle insertions
fibrous fasciculi, mostly parallel with the great into the bone are made by means of condensed conaxis of the bone, and of elastic fibers. Fusiform nective tissue only, without any participation of
intrafascicular connective cells are seen. The elas- the muscle cells proper-which is the point we
tic fibers abound in the periosteum, but their pres- wanted particularly to make clear-and that as the
ence is yet unexplained. The internal layer adheres insertion tissue progresses from the muscle to the
to the bone without interposition of any cellular bone the structure of the connective fibers resemble
element. The adherence varies according to re- increasingly that of the periosteum, that is, princigion ; it depends on the presence of oblique fibers pally as regards the function of the latter as proinserted both in the periosteum and in the bone; tective covering for the bone. Therefore, whether
these provide a means of union of extreme the periosteum completely ensheathes the bone or
strength.; the degree of adherence between bone does it partially, as it is claimed, the ultimate effect
and perlosteum is function of the quantity and is obtained through the combination of periosteum
strength of these osteoperiostic fibers. With longi- and fibrous muscle insertions. This consideration
tudinal fibrous fasciculi the union fibers are scanty, is of great importance, as will be seen later, in cases
but at the direct insertion of muscle fibers the of sprains affecting ligamentous and tendinous bony
periosteum disappears about the osteomuscular insertions, with consequent tearing or fissuring of
periosteum, thus allowing the formation of ostejunction.
At this point it seems to us justifiable to enter our osis or of osseous spurs, according to the region
objection against the use which, in common with many affected.
The muscle cell’s nutrition and innervation are
others, the authors cited above, make of the expression muscle fibers. Quoting from Cunningham’s Anat- provided by blood vessels and nerves distributed
omy we have the following description: “A typical throughout the connective tissue sheathing; conseskeletal muscle consists of a number of fasciculi quently this latter will be. the first affected in case
or muscle bundles, enveloped in a connective tissue of traumatic injury, sprains, etc., and also by the
sheath termed fascia, and usually connected at one edematous conditions resulting from vascular inor both extremities, with bundles of white fibrous jury, toxicity, paucity of arterial supply, venous or
tissue which constitutes some variety of tendon. lymphatic stasis, and even from the development
“Each fasciculus is surrounded and bound to its of repair processes of the tissues which organize at
neighbors by-a delicate connective tissue, the peri- once following a disturbance of the normal
mysium externum, and each consists of a number physiological status. As the nerves are nourished
of elongated muscle fibers, held together in their all along their path by branches of the arteries acturn by the perimysium internum. The perimysium companying them (see Quenu and Lejars, Anatomical
internum is connected on the one hand to the sarco- Study of the Blood Vessels of Nerves-Archives de
lemma (or cell wall of the muscle fiber) and on Neurologic, Jan., 1892), it follows that any local disthe other to the perimysium externum, by which it turbances are bound to directly affect vicinal nerves,
is brought into connection with some part of a thereby producing pain symptoms and, by reflex
tendon.”
action, affect distant attachments or organs.
From any point of view, and particularly from
It seems most certain that connective tissue
that of osteopathy, as regards the genesis of path- must possess hygroscopic properties ; the tests that
ology and of lesions, such a description seems we have personally conducted, while positive on
fundamentally inappropriate. Mechanically speak- this point, are much too few to warrant their uning, a muscle is an assemblage of special, elemental disputed acceptance. A question of great imcells, each of which has the property of changing portance to our practicians is that of the formation
form while retaining a constant volume when under of congestion in the muscular tissues. As a consethe influence of nerve stimulus. Each cell is an quence of exposure to cold-as one exampleentity; it is completely unsheathed in a fine net- whole areas in the back and shoulders become conwork of fibrous connective tissue; fusiform when gested and are found painful upon palpation ; proat rest, it tends to become ovoid when stimulated ; longed soft tissue manipulations, assuage the pain
its long axis is then either actually shortened or and may remove it entirely, while the muscles have
maintained in a state of tension, according to func- their suppleness restored, the whole process being
tional requirements. The whole muscle might be due to thorough drainage of the stagnant body
compared to an assemblage of honeycomb cells, fluids and to hyperactivated arterial flow. We must
gradually tapering off at each end, but with the not forget that stagnancy of these fluids always
supporting fibers continuous from end to end little brings about their partial decomposition, with atby little becoming closer, and finally condensing tendant disengagement of gases and formation of
into either a tough sheet or a cord-like
tendinous acidity, which in turn is a factor of dysfunction of
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VERTEBRAL MECHANICS-GUY
108
nerves. It is highly desirable that laboratory tests
should establish the starting point and the sequence
of events leading to the congested condition; it is
suggested that the fibrous framework plays a most
important part in that process, which is well worthy
of extensive investigation.
It is frequent in practice to find by palpation
in the dorsal region wide fibrous areas, usually
deeply seated, and which, crackling under the
touch, give one the impression of sheets of parchment embedded in the tissues. They are in reality
atrophied muscles, as we find in our dissection
work, and always indicative of previous diseases
suffered by the patient, such as for instance,
pleurisy, pulmonary trouble, eruptive fevers, etc.
It seems as if the whole muscle had lost ‘its elemental cells, and that its framework had become
stouter through cicatricial processes following the
disease. We have found that such atrophied conditions are responsive to osteopathic manipulations,
but that patience and perseverance are main factors
in the reestablishment of near normal status of the
muscle. That this recuperation is at all possible is
due most probably to the fact that the wasting
process affected the bulky substance of the muscle
cell, leaving intact the nucleus and a few remnants
of that substance which, through the induced hyperactivation of the blood flow, and consequent nutrition, gradually regained activity and reformed the
cell. This also offers a fertile field for laboratory
investigation.
Fig. 20
is always better differentiated, less so, however,
where in contact with the bone than at a fraction
of a millimeter farther on. It possesses numerous
capillaries, fibrous elements in evolution, and connective cells of a young type. It is continuous with
the connective tissues of the medullary spaces
which open on the surface of the bone; there is no
interruption between the connective tissue of the
haversian canals and that of the periosteum. It is
to this layer, hardly differentiated, that a specific
osteogenic role was attributed, whence the names
of “osteogenic layer,” “subperiostial blastema,”
“subperiostial medulla,” etc. But it is impossible
to find in these cells cytological characteristics permitting to distinguish them from those of connective tissue.
Ossification .-At first seemingly irrelevant, the
consideration of this subject will gradually be seen
of priniordial importance, in its general application,
for the understanding of certain aspects of the
causation and maintenance of lesions. Dr. Still was
fond of parables; they. admirably served his purpose of making clear to others his explanation of
life’s phenomena as he conceived them; we may
therefore hope to be forgiven if, by following his
method in this instance, we can demonstrate a most
interesting parallel in the processes of union applying as well to inorganic and to organic matter. Let
us assume that a blacksmith has to weld together
two iron rods of the same diameter, a thing that
we may have watched in wonder when we were
boys. The two pieces are first heated to a bright
red color, and each is hammered and bumped as
shown at B, figure 20. Heated again; each is shaped
as at C, to form what is known as a scarf. Now the
stage is set for the welding proper. The pieces are
then heated to an almost white color (white heat),
and watched carefully until brilliant sparks fly
about; the pieces are quickly jerked out of the fire
and shaken to clear them of oxide and other impurities; they are assembled at the scarfed ends
on the anvil and hammered skillfully until the
artisan is satisfied that the union is well accomplished; the solid rod is still very hot and appears
humpy about the joint, as at D; when entirely
cooled, if the work has been, done with extraordinary care, the welded rod will be practically of uniform diameter throughout. The explanation of the
sequence of operations is very simple: the ends
were “bumped,” spread out, so as to provide a large
weld surface ; the scarfing was not essential to
welding, but it is an old practice and it always
insures a better joint; the sparking at white heat
indicated that the ends had reached the melting
point, consequently were ready to flow together
when quickly assembled, thereby proving that iron
Reverting n o w to the periosteum, classic
treatises describe, not very precisely however, an
internal layer of embryonic character located in welds to iron only -when brought back to melted state.
intimate contact with the bone, which would be
Observation discloses that a remarkably
dormant in the adult, while remaining susceptible similar process obtains in the repair, the union, of
of resuming activity through the influence of irri- organic tissue of the same kind. Thus in ordinary
tation. Such a layer does not exist. In reality be- superficial cut there is hyperemia ; profuse productween the fibro-elastic layer and the bone only tion of serum ; edema ; distension of cells,, hence
scanty capillaries are found, which reach through increase of the surfaces to be apposed, with atto the haversian canals, but no special cells are tendant swelling extending some distance back of
seen. In the fetus and the infant the periosteum is the cut; then metaplasia, or the conversion of the
formed of a layer of connective tissue, young and cells involved, gradually, stage by stage, into cells
embryonic, just as are at that time tendons and approaching the embryonic type, requisite to perligaments. On its deep aspect are the osseous layer form the union; the whole equivalent to the gradof the young bone. Later on the
membrane
ualAcademy
reversion
of the solid, fixed state of the iron
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VERTEBRAL MECHANICS-GUY
109
into the “near embryonic” or fluid state, with heat ism tends to undergo an infiltration of calcareous
doing for the one what hyperemia does for the salts, from which follows. a kind of progressive
other. The scabs or necrosed cells represent the petrification, examples of which are very numeroxided scales and other impurities.
ous : calcified tubercles, calcified fibromas, lithoIt is the same for a fractured bone. The edges pedions, calcified goiters, pleural calcifications in
may be apposed in the most skillful manner, they old pleurisies, etc When the chance combination
will not unite until the gradual cell transformation of an embryonic connective tissue medium with a
is fully established. There must be hyperemia, calcified deposit takes place ossification follows
posttraumatic hemorrhage between the fragments through plain, ordinary processes. The form of the
and in the periosteum, production of special serum heterotopic ossification is determined by the
or preosseous substance, distension of cells, swell- architecture of the medium in which it develops.
ing of the apposed parts, reversion to near em- It is this tissue which models the osseous formation
bryonic cells, fusion of the ends, gradual resorption and makes it a plate, a nodule, a spicule, etc. In
of waste or superfluous tissue, calcification and re- all such cases the sequence of phases is practically
duction of the shape of the repaired bone to the as follows: (1) Formation of ossifiable medium;
normal size. It appears therefore that the forma- (2) calcareous deposit and its resorption; (3)
tion of new bone is conditioned upon the genetic formation of the heterotopic ossification; (4) or
activity of what may be termed a bone ferment or ganization and maintenance of this ossification.
seed which, dormant in the normal formed bone, Consequently, contrarily to the classic opinion, it
may be liberated by a special process of repair seems that the periosteum does not possess osteowhich involves the causation of the return of the genic characteristics. It is only a medium of facile
osseous tissue to a near embryonic connective sub- ossification for the very reason of its juxta-osseous
stance, the same as derived from primitive mesen- neighborhood, and any fibroconnective membrane located near a calcareous or osseous center may develop
chyma.
the
same properties.
For a long time it was held that the periosteum
Preventive Factors.-Ossification is not possible
was a main factor in osteogenesis. This notion
was firmly supported by the almost invariable unless there is combination of a medium, or
success obtained with the transplantation of grafts ossification soil, and an osseous ferment. Anything
made up of this membrane. Leriche and Policard interfering with this combination is a preventive
demonstrated that while, effectively, the graft factor. In the clot surrounding fractured bone conbands were lifted from the surface of the bone nective granulation tissue grows, coming from all
everything depended on the technic of removal. parts, specially from haversian canals, from the
Thus, Ollier, whose work was universally recog- marrow and from the periosteum. If the fragments
nized, and who affirmed in the most positive are too far apart the serum from the clot may colmanner the osteogenic characteristic of the lect within the limiting muscles, thus forming a
periosteum, always operated with a sharp knife, sort of false cyst, which may at times, attain large
taking care to scrape closely to the surface of the proportions; fibrine deposited on the muscle walls
bone,, the purpose being to secure the greatest prevents resorption ; connective tissue not developamount of tissue.
Other operators met with ing in liquids, there is no possible peri-or intermarked lack of success, although to all appearances fragmental organization ; connective union cannot
they had painstakingly followed the Ollier method take place and there is no possibility of osseous
of grafting, and it was thought that they were union. In other circumstances the hemorrhagic
not endowed with the requisite skill of the master clot being insufficient, and the periosteum missing,
surgeon. Eventually it was shown that they had with no other nearby connective coating present,
missed the most important point of the technic: no appropriate ossifying medium can be estabthey had merely detached the periosteum by pull- lished; therefore no connective callus is formed.
ing it gently off the bone, breaking the fibrous and interfragmental ossification is impossible.
adhesions with a dull blade, and thus securing only Pseudo arthrosis may result from muscular interits true membranous part. Peculiarly, Ollier orig- position between fragments. It may also follow ininally thought that the membrane was not osteo- fection at the seat of fracture. Infection acts pringenic, and became convinced that it was so by the cipally by causing a sclerous evolution of the conregularity of his successful operations. The theory nective tissue, thus constituting almost invincible
was later advanced that in lifting the periosteum mechanical obstacles. Of course, when it is light
he inadvertently gathered by scraping, the true it may, by congesting and infiltrating edematously
osteogenic elements, so-called bone ferments or and extensively the parosteal connective tissue,
seeds. To prove this numerous tests were made at favor the formation of a voluminous callus. But
various times ; in some, the Ollier scraping technic when a certain degree of infection is reached,
was followed with satisfactory results; in others, necrosis of the tissues, prolonged suppuration, conthe membrane was merely pulled off the bone, and secutive vascular alterations, leave finally a fibrous
failure ensued. Even in heterotopic ossification, as connective tissue, dense, inimical to ossification,
in muscle tissue, it was observed that the process which forms only irregularly and insufficiently.
developed due to the implantation, either fortuitous Besides, suppuration may also trouble the local
or experimental, of connective membranous tissue calcic mutations, either by completely preventing
to which bone ferment was attached, or which was them, or by carrying them elsewhere and modifyin contact with a calcified deposit or a phospho- ing the calcareous materials, thus accounting for
calcareous point of concentration, that is, with the origin of the peculiar excrescences observed in
bony substance either actual or in the making. To pseudo arthroses of diaphyseal extremities. Infecexplain this, there is a sort of biochemical law to tion is detrimental in another way: ossification
the effect that any dead or dying part
of an Reserved
organ- American
never takes
place
where there are polynuclear
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of Osteopathy®
110
OSTEOPATHY AS ENGINEERING-WEBSTER
Journal A. 0. A.
September, 1939
neutrophiles.
Blood infection, infectious diseases, is called specific and is ultra rapid, a very few minor generally, the presence of toxic matter in the utes being required for the entire performance.
vascular system, are preventive factors of main im- Unfortunately, the persistency of recurrence of
portance.
To this may be added mechanical disorder tells a different story, and additional lesdisturbances, such as friction between fragments or ions of undesirably permanent type often result
tissues, induced by untimely movements, causing from such treatments. Patient and prolonged soft
detrimental irritation.
tissue preparation is often sufficient to correct
lesioned parts, the popping being considered, when
Osteophytic Lesions -Osteopathy is deeply concerned in anything affecting the integrity and the at all necessary, not as a means, but merely as a
mobility of the spine; then it is that skillful,* well proof that an articulation is in proper operative
trained fingers are needed for the detection of the condition.
We wish to remark that in the paragraph dealseat of trouble, while extensive knowledge of
anatomical, physiological and pathological details ing with the ossification we have used the expresmust be at hand first for the understanding of that sion “near embryonic tissue” advisedly; the point
trouble, secondly, for its correction. Aside from of view being that in the fetus all the embryonic
cases of infection, bruises and wounds, it is almost tissues are under a control, the principle of which
certain that sprain is the originating factor of is absolutely beyond the comprehension of the huordinary disorder. Strain may be termed the man mind; in malignant growths the embryonic
specific molecular or cellular resistance to any cells develop at the expense of the entire organism,
specific effort, or stress, applied to an organ; when because they are beyond the original form of constrain, however intense, does not produce perman- trol; in the repair processes, in ossification for inent cellular deformation, it is physiologically stance, the embryonic matter is generated normally
normal; when the normal range is exceeded and under proper control similar to the original, and
fibers or cells are torn or otherwise injured we are when the repairs are completed the architecture of
dealing with sprain in some form or other, in which the parts involved shows at times very little traces
ligaments and muscle insertions are concerned. of the ordeal.
14 Rue de Tilsett.
Thus with ankle sprain the ligamentous attachments are most certainly involved. In the fertile
field of research so successfully tilled at the Sunny
Slope Laboratory, where lesions are artificially
produced on anesthetized animals by first forcefully deflecting and maintaining a given vertebra
out of normal position, and then studying patiently
the physiological and pathological developments,
the gross manner of producing the lesion is well
understood, but the detailed manner in which the
various local disorders are generated is probably
beyond the reach of direct observation. The mere
displacement of the osseous part would not suffice
to account for the ensuing trouble; ligaments must
be torn, sprained; likewise the capsules; the disk
fibers must be affected; and in many instances the
periosteum may be torn, fissured, lifted. With the
repair processes which are spontaneously started,
with consequent hemorrhage, edema, inflammation
of the various connective tissues, it is always possible to visualize some form of ossification affecting the ligaments themselves, as will be shown
later, or the apophyseal articulations, or the intervertebral articulations themselves. There will be
thickening of the ligaments through scar tissue
formation; that may in turn affect the circulation
and interfere, for one thing, with the secretion of
lubricating fluid for the articulations, which would
account in great part for the cracklings spontaneously produced upon movements of upper dorsals
and principally, cervicals, and also for the recurrence of lesioned positions, hence for the long
series of treatments necessary for their permanent
correction.
These considerations should make clear the
ever present possibility of causing permanent damage through the practice of forceful manipulations
intended for the correction of rebellious lesions.
There are, outside of our profession, manipulators
who impress upon their patients the belief that
popping noises are the indices that corrections are
accomplished, that the bones have finally been set
in their normal position ; theirAllmode
treatment
Rightsof
Reserved
American Academy of Osteopathy®
The Journal of the
steopathic Association
A merican
PUBLISHED MONTHLY BY THE AMERICAN OSTEOPATHIC! ASSOCIATION
No. 2
CHICAGO, ILLINOIS, OCTOBER, 1930
vol. 30
Vertebral Mechanics
ALBERT E. GUY, D.O.
Paris
PART IV
Osteophytic Lesions (c o n t i n u ed)-Ligamenta
flava.-Standard texts at times prove disappointing,
principally so in matters of great importance, which
one had been led to believe fundamentally established
long ago. Thus in Arthrology, as treated in the latest
edition of Poirier’s Anatomy, Paris, 1926, we find a
cut reproduced here in figure 21, which is intended
to represent the arrangement of the ligamenta flava
in the cervical region. (1) The articular facets are
so disposed that their center of oscillation is located
anteriorly instead of posteriorly, as was demonstrated
in Part 2 ; (2) a synovial bursa is shown heavily in
black between each pair of articular facets; such a
construction would be highly detrimental to the
proper mechanical functioning of the articulation, and
a constant source of derangement; it is probable that
the early investigators forced some substance like
tallow or wax, for instance, inside the capsule, thus
distending it, and then made a sketch supposedly
representing the observed conditions; the text states
that the synovial sack communicates with “a serous
bursa inserted back of the yellow ligament”; one
would most seriously question the existence of such
a bursa, since its presence as described would not
seem required for purely mechanical reasons ; furthermore, the anterior aspect of the serous bursa is not in
relation with the yellow ligament itself, since the
latter is shown covering the inner capsule; (4)
all capsules are shown as flat membranes covering the edges of the articulation,’ instead of being
festooned as described in Part 3, which is required to permit the capsules to follow the articular
processes in their various and incessant displacements,
and thus to properly perform their intended functions
which consist mainly in protecting and lubricating the
articular surfaces. The sketch, figure 22, would more
appropriately than that in figure 21 represent the true
condition of the various parts involved. Unfortunately we may see the cut again, when decorating the
works of some of our enterprising text rehashers;
which demonstrates forcibly once more the imperative
need of thoroughly reliable data for the minutious
analytical study of every part concerned in a vertebral articulation, in order that lesions may’ be located,
their origin traced,. and their development understood.
The ligamenta flava form the posterior wall of
the vertebral foramen, but as the vertebrae are
ceaselessly in motion, the ligaments are so made and
attached that in all positions they afford the utmost
protection to the cord. Their elasticity is considerable, as may be seen by freeing several vertebra of
all other attachments along a portion of the column,
and then exerting axial traction at the extremities ;
there is an elongation of several millimeters for each
pair of ligaments, which vanishes upon cessation of
the traction. This proves that to a very large extent
they contribute through their elastic reaction in returning the spine, after flexure, to its normal position.
Q.22.
In postero-anterior flexion they are all in action; in
bending to one side only those on the opposite side are
tensed ; in rotation all are tensed but, as we have seen
in Part 2, the location of maximum strain depends on
the region affected; in the dorsal this is at the most
posterior point of the vertebral foramen. Obviously
the ligament will be most severely strained through
a combination of side-bending and rotation, particularly in quick and sudden application of the stress;
and to better understand the consequences of this, it
is necessary to examine in detail the structure and
attachments of the tissues involved.
The yellow ligaments are essentially composed of
elastic fibers anastomosed in dense networks, with
meshes mainly longitudinal, interspersed with strong
connective tissue fasciculi. Being constantly active it
is natural to expect that their nutrition and innervation are fully adequate, and yet most recent authorities could be quoted to the effect that “a few capillaries may be seen, while the nerve supply is still
uncertain.” What a wonderful opening this is then
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American Academy of Osteopathy®
111
VERTEBRAL MECHANICS-GUY
112
for conscientious and fruitful investigation. For each
intervertebral space there are two ligaments, one light
and one left, adjoining at the median line, as the apex
of an obtuse triangle spreading out laterally and anteriorly. There are 23 pairs, the first being between
the axis -and the third cervical, and the last between
the fifth lumbar and the sacrum. Each ligament is a
sort of irregular quadrilateral plate, thicker mesially
than externally, and of dimensions varying according
to location. The upper border is bevelled posteriorly
so as to attach to the anterior aspect of the lamina;
the lower border attaches upon the superior border
and also upon the posterior aspect of the subjacent
lamina; the internal border is on the median line,
where it joins the internal border of the adjacent ligament, while allowing openings for the passage of
blood vessels, and where also it connects with the interspinous ligament ; the external border ends in
contact with the apophyseal capsule, to which it
unites, but in a manner not yet very clearly defined;
it forms thus part of the posterior edge of the opening of the intervertebral canal. The thickness varies
from two millimeters in the cervical region to about
3.5 mm. in the lumbar. Sometimes the fibers of one
ligament extend downward, passing over the anterior
aspect of the intervening lamina to unite with the subjacent ligament. The anterior face of the ligament is
in relation with a profusion of venous plexuses which
surround a loose fibro-adipose mass extending the
whole length of the vertebral canal posteriorly, thus
forming a peridermal protective mattress. The posterior face is in relation with the muscles located in
the vertebral sulcus.
We now have to consider what may affect the integrity of the yellow ligaments and the sequel= thereof. The first cause of disorder, and probably the
main one that presents itself, is evidently sprain induced by violent and sudden traction resulting particularly from a combination of flexion and rotation
elastic fibers proper do not attach directly to the bone,
their fibro-elastic supporting tissue does so; this is
necessary because the attachments, as they come
nearer and nearer to the bone must have the structure
of their fibers gradually approaching that of the periosteum, with which they are to unite, or which they
may replace, according to circumstances, so that in
any case the bone may be assured a nutrient, protective and controlling covering, as shown in Part 3.
Because of the great strength of the ligament,
while longitudinal interfibrous slippage may occur, it
is oftener the case that the attachments themselves
give way at places, with attendant tearing off of small
bony fragments in the form of platelets or splinters,
thus leaving the affected surfaces rough or striated.
The injury may be purely local, as when produced by
a false movement of the body itself or, as in a fall,
a blow, masses of other tissues or organs may be involved. However, for each part the, repair processes
organize spontaneously to suit the local needs. Considering only the ligaments and their insertions, it is
certain that capillaries having been injured, hemorrhages are present, serum accumulates and an edematous condition develops; this is followed in time by
metaplasia, or the gradual transformation of the cells
of each tissue into near embryonic cells, a process absolutely essential, as stated in Part 3, to the mending
and the reunion of the torn parts. Eventually there
is resorption of the waste and superfluous materials
and normal state is gradually reestablished. Because
of the denseness of the ligamentous tissue and of the
irritation entertained therein by the movements of the
body, a long time is required for the completion of the
repairs. We should note in passing that nature attempts to restrict mobilization through the stiffening
of body parts in the neighborhood of the seat of injury. This, of course, is not without serious disadvantages, considering our mode of living.
Fig. 23
Fig. 24
efforts, as in a fall, a blow, in pulling or lifting. The
The disorder affecting the insertions is of far
fibers may slip within the mass of the ligaments,
thereby tearing the connective tissue network which, greater import; the sequelae differ according to the loborder of the
as we have seen for the muscle, contains the dense cation considered. Thus for the upper
.
The
ligaments
the
contents
of
the
vertebral
canal are toelastic material within its innumerable
meshes.
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VERTEBRAL MECHANICS-GUY
tally unsuited to exert a pressure that would maintain
the insertions and laminae in needed apposition. Consequently the process of ossification which is bound
to follow the lifting and tearing of the periosteum
and of the connective fibrous insertions results in the
growth and development of bony extensions, platelets
or spicules, within the mass of the upper portion of
the ligaments. Examples of such abnormal growths
are shown in figures 23 and 24, which are photographs
of lower dorsal vertebrae from a subject past 60 years
113
operator were to attempt a demonstration of skill in
correction of lesions, and insisted on forcefully popping the articulations as a means therefor, the result
might well be the breaking of the osteophytic
growths and the consequent causation of severe
lesions. While experienced osteopaths are usually
very cautious in applying their technic it seems nevertheless advisable to call attention to such otherwise
unsuspected conditions, which must be handled with
the utmost care. Sometimes also, and we have ex-
F I G. 2
5
.
old. It is hardly necessary to point out the enormous reduction in area of the vertebral foramen, and
anyone versed in the art may readily draw conclusions as to the disastrous effect of this upon the whole amples at hand, similar hooks are formed at the posnervous system. The most distressing point about terior edges of the articular processes in the lumbar
this is that neither palpation, however skilled, nor region; in this case there is interference with rotation
radiography, may detect the true condition of the of the vertebra, while flexion and extension are relastructures because they are concealed inside the canal, tively free; there also we may have a lack of popping
response to our corrective technic, either by twisting
hence completely out of reach.
It seems at first extraordinary that ossification or by the anteroposterior thrust method. It also
should take place in most cases at the outer borders happens in the dorsal region that there is a hook as
of the ligaments, as shown in the photographs, since well at the lower end of the upper articular facet as
we have seen that, for the dorsal region, the point at the upper end of its mate, which then constitutes a
most strained is about the median plane, particularly double lock.
When the lower border insertions are involved
in flexion and rotation, the reasons therefor are most
likely that the trouble results from a combination of the conditions are different, although the periosteum
side bending and rotation, for in side bending one may have been injured; that is due in part to the
ligament only is in action, and that on the outer bor- imbrication of the laminae, and to the pressure exerted
der, because of its union with the capsular ligament, posteriorly upon the vertebrae by the mass of tissues
which must be loose in order to function properly, adhering thereto or gliding theron. Effectively, the
the yellow ligament is weakest. Its ossification there posterior aspect of the yellow ligaments is accessible
entrains invariably at least partial ossification of the only when the column has a certain degree of flexion,
capsule. We have at hand a number of specimens with whereas in extension the laminae imbricate upon one
well pronounced bony projections, or hooks, extend- another while gliding upon sublamellar serous meming anteriorly and downward over the superior edges branes. Consequently when there is tearing of the
of the articular processes, as shown in figure 2.5. attachments, fissuring or lifting of the periosteum,
This is very serious and bids us to pause and to cere- entraining the tearing of bone platelets and splinters,
brate (Dr. Deason’s coinage) ; for aside from the these tissues become naturally swollen, thus developmost undesirable reduction in area of the interverte- ing abnormal pressure between corresponding laminae,
bral foramina, with its baleful effect on the nerve which is helpful in maintaining the torn insertions in
roots, there is a question of everyday practice in- contact with their respective laminar seats. Ossificavolved. Effectively, if a novice or aAllsuper-strong
tion follows
in of
the
regular process of repair, with
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114
VERTEBRAL MECHANICS-GUY
resorbs easily; everything of course depending on the
ambient conditions. Resorption may develop in two
distinct ways, osteoclasis and osteolysis, or in a variable combination of both. Osteoclasis is a phenomenon
of ordinary; phagocytosis which interests the totality
of the elements of bone, whether the latter is alive or
dead. Osteolysis is a humoral phenomenon which,
dealing only with osseous and calcareous materials,
interests only living bone. Resorption is after all the
rupture of a physicochemical equilibrium within the
colloids forming the interstitial plasma, brought about
by the intervention of at least the following known
factors: (a) Composition and quality of blood; (b)
degree of activity of interexchanges in the region involved; (c) condition of the connective tissue, itself
depending on that of the cells and principally on endocrinal secretions; (d) morphogenetic action of pressures, tractions, tangential displacements, etc., which
are exerted through the intermediary of the fibrillar
web of connective tissue; (e) vasomotricity as affected
by the nervous system.
The presence of any extraneous matter in the
body is always repellent to the latter and urges it
to set forth all the means at its command to bring
about the removal of that substance. That is the
case for an ordinary splinter, for catgut ligatures,
for bone implants and spikes, etc., and it even explains the failure of one current fad, that is of
gland grafting, in which the gland implant is gradually reduced to shreds, these to be eventually
replaced by fibrous connective tissue. We are justified in considering osteophytic growths as extraneous matters, but while their presence may cause
various derangements injurious locally or generally
to the functioning of the body, their environment
may be -such as to hinder their removal by resorption. Should, something occur however, capable of
setting up the proper agencies, there is a possibility of modification, of partial, or even total eradication of the growths. Interesting examples are
cited by very conscientious observers. Thus, in one
instance, a callus had been clearly located by radiography; several months later a severe attack of
grippe brought about the apparition of redness, heat
and pus at the seat of the osteosynthesis; this in
turn acted locally in developing hyperemic conditions, the results of which was finally, and unexpectedly, the prompt resorption of the callus.
Sympathectomy is now very much in evidence;
in one case of peri-arterial sympathectomy, the
acute resorption of a callus located about the femorotibial epiphyses was observed both by radiography and by palpation. This is explained by the
hyperemic conditions resulting from vasodilitation.
One of our patients, a man 37 years old, a
hunchback with a spine distorted laterally in the
form of a tremendous interrogation mark, with
kyphosis in the dorsal region and lordosis in the
lumbar, begged for treatments in the hope of relief
from digestive troubles, from severe headaches, and
from pain in the feet and difficulty in walking. He
had had medical attention now and then practically
all his life, his case being diagnosed as one of congenital syphilis. No encouragement could be offered, of course, except to express the belief that
osteopathic manipulations would prove somewhat
Osseous Resorption .-Despite the apparent fixity beneficial in at least stimulating the circulation.
of its characteristics the osseous tissue is extraordi- The patient was treated twice weekly for about
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Reserved American
Academy
and of
a Osteopathy®
half months, then once weekly for three
narily labile ; it is susceptible ofAll
rapid
dissolution
; it three
more or less disturbance, according to the location
and the extent of the injury, but the osteophytic
growths are certainly less pronounced than is the case
with the upper border insertions. It would seem also
that the ossification does not affect the apophyseal capsules to the same extent. Figure 26 is copied from
the Thesis of J. Forestier, on the “Intervertebral Foramen.” Paris, 1922. At A there is a characteristic
stalagmitic growth resulting evidently from ossification
of the lower insertion of the yellow ligaments; it extends mainly between the apophyses ; the mesial aspects
of the capsules must have been affected, but posteriorly
the articulations appear free. At B, however, there is
a well defined interlaminar ankylosis; it would be difficult to trace the origin of this condition, and unwise
to attribute it peremptorily to an extension of the
trouble affecting the yellow ligament. We should be
guided by the rule according to which abnormal growth
of bone, in this case, exostosis, does not take place
unless the protective and controlling bone covering is
disturbed ; disrupted by trauma, inflamed or dissolved
by morbid fluids, as in rheumatismal disorders, etc.
Here we may be certain that the tissular mass over the
exostosis was itself affected by some disease which
prevented it from applying a pressure sufficient to limit
the growth of the bone and to induce its resorption.
We realize now, even from the above meager
analysis, the immense importance of the yellow ligaments as regards the mechanical functioning of the
vertebral column and, by extension, as regards the
beginning and furthering of spinal deformations, such
as scoliosis, kyphosis, etc. Thus in kyphosis, for instance, we can conceive that the development of osteophytic hooks, as shown in figure 25, can bring about
a limitation of spinal extension which may eventually
increase, following a gradual accentuation of the
osseous neoformations. The apophyseal articulations
become restricted in the position they would assume
in vertebral flexion and when the lesion extends bilaterally over a plurality of vertebrae, say 5.6 or more,
kyphosis is established permanently and possibly irreducibly.
When one vertebra is found decidedly deviated to
one side, or in a position termed anterior or posterior,
and there is evidence that the disorder is of long standing, there is -a strong probability of ligamentous involvement and possible ossification. Rectification of
such a -condition demands extreme caution, and is certain to require an extensive period of treatment. However, experience shows that through patient, careful
and insistent work, the resolution of single and multiple lesions involving osteofibrous complications
has been realized in innumerable instances, evidence thereof being the rectified and straightened
spines which have served greatly to establish the
reputation of osteopathy throughout this country.
The facts are there, and in various ways we know
that rectification has been effectuated; we also
know that to accomplish that it has been necessary
to disrupt osteofibrous growths, a process so much
dreaded, and against which we have. Issued earnest
warnings; how can we now reconcile our fears, our
warnings, and our successful results? In the first
place, the manipulative process has been slow and
methodical, and then we have had succor from the
most wonderful assistant imaginable : circulation.
VERTEBRAL MECHANICS-GUY
115
months more, and finally, occasionally thereafter.
In such cases it seems established that there must
The work was concentrated at first upon the dorsal have been some degree of ligamentous ossification,
region which was found despairingly rigid ; owing and that gradually the treatments brought about
to the characteristic deformation of the thoracic the disruption of the ankylosed fibrillar attachcage the usual technic was of no avail, and a special ments which, together with the superactivation of
one had to be studied and developed. The per- the circulation, produced a modification of their
formance was certainly more trying for the oper- structure, gave them back an appreciable degree of
ator than for the patient. Eventually, the efforts suppleness which proved of great help in restoring
were rewarded by the production of a give at two some flexibility to the spine.
lower dorsal articulations ; gradually, but slowly,
We may readily concede that violent efforts,
others moved until finally a certain degree of flexi- too abrupt movements, or shocks, are apt to disrupt
bility became established. We say flexibility ad- the yellow ligaments, thus initiating the developvisedly, instead of mobility, for this is usually ments previously mentioned, but that mild tensions,
understood to mean freedom of articulations, well within the normal range can produce remarkwhereas not at more than four points in the lower able deformations is not thought of until attention
dorsal area was it possible to elicit the character- is called to the spinal deviations to be seen at any
istic cracking sounds. The lumbar conditions were time with the people about us. We may casually
more easily improved, while the neck responded observe many individuals, as we daily pass along
satisfactorily after a little while. The bones of the who, otherwise seemingly enjoying good health, are
feet were distorted beyond hope of rectification and nevertheless afflicted with abnormally curved spines
consequently did not receive as much attention as in the form of round shoulders, stooping back, and
the more important parts.
various degrees of kyphosis. That some of these
After an absence of some three months the conditions are bordering on pathology we know by
patient turned up for treatment one evening, pre- experience in practice ; in many instances their
senting a marked difference in appearance; the face origin is traceable to faulty attitudes in early life,
had a healthy color and was so much fuller that in at school, at times of rapid evolution; diseases,
applying for renewal of his identity card, the old eruptive and infectious fevers, etc., all are apt to
photographs were refused and new ones had to be leave evil traces in their wake, affecting mainly
furnished; the head was more erect ; the chest was the ligamentous tissues and thence the articulations
expanded and the patient had put on flesh to such proper. The spine may have sufficient mobility and
an extent that he had to invest in a new wardrobe, be capable of ample flexion, but with limited exfor which he roundly cursed the operator; the tension.
In European countries principally, where trastraightening of the spine permitted him to reach
1¼ inches farther up with his fingers. These de- ditional farming methods are firmly anchored, the
tails, while somewhat ludicrous, may find excuse old people tend to their burdens with their body
in capping the description of a case in which oste- bent way down, and maintained so for hours at a
opathy proved its value, almost in spite of the time. They cannot straighten up any more and yet
operator himself, who most certainly entertained their spine is capable of some flexibility, which can
but little hope of accomplishing anything worth- be exaggerated when needed to reach further downwhile, and was loath to assume a dangerous re- ward. Numerous are the old time professions in
sponsibility. It may be of interest to note that which unremitting application to the task develops
instead of working directly upon the vertebrae them- characteristic plicatures.
In all these cases, with either mild or accentuselves in order to promote their mobility, use was made
of the rigidly attached ribs which served then as pow- ated deformations, the ligaments have been suberful levers, the idea being that once their ligamentous jected to prolonged tractions which in time proattachments were loosened, the stiffness of the ver- duced their elongation ; the tissues then accommotebral articulations would be lessened, which as- dated themselves to the imposed conditions and
sumption fortunately proved well founded. We developed in accordance with the resultant modified
have had occasion since to use the same method on circulation. The yellow ligaments, most interested
of all, have their elasticity impaired, and their
two other hunchbacks, with fair results.
A different case was that of a man about 57, structure consequently altered to such an extent
short in stature, with a powerful chest, but with that in advanced stages they are seen in the dissuch a pronounced kyphosis that he was unable to section room as hard, transparent plates.
sleep on his back, even with the aid of several pilInflammation of the Yellow Ligaments -The relows to support his head, because the latter was so pair processes following injury to the ligaments
bent forward that the supports rather increased his involve necessarily some congestion of the tissues,
malaise than afforded relaxing comfort. The thor- some sort of inflammatory condition, whence an
acic cage was so rigid that unconsciously at first, increase of volume which, blocked externally by
the operator felt that his efforts would prove as the laminea, must expand internally towards the
unavailing as if he had dealt with a wooden Indian. cord; the result is consequently compression of a
For about four months bi-weekly treatments were substantial area of the fibro-adipose epidural mass.
given fairly regularly, until the patient went travel- The local effects may be felt directly by the cord,
ing; his spine had straightened appreciably, and and also by the nerve trunks squeezed within the
flexibility was acquired to such an extent that the intervertebral foramina by the extrusion of the
patient delighted in demonstrating his ability, while adipose mass from the vertebral canal; they may
on his back on the treating table, to extend his spread over nearby segments. The situation is
spine and touch the table with the back of his head. much complicated when there is also involvement
He was no longer compelled to sleep lying on his of the articular disk, the inflammation of which
side. Certainly not more than four vertebral artic- causes protrusion of it posteriorly into the vertebral
canal, hence
a further constriction of the epidural
ulations had been appreciably freed. All Rights Reserved American
Academy of Osteopathy®
116
VERTEBRAL MECHANICS-GUY
mass. Such involvement is much more frequent cause of the imbrication of the spinous processes,
than is usually realized, mainly in the lumbar re- the ligament is practically reduced to a simple
gion, owing to the fact that a great part of the vestige.
psoas muscle insertions arises from the outer interMechanically, the function of the ligament is
vertebral disks attachments above each lumbar seemingly negligible and should really be considered
vertebra, and the adjacent rims of the vertebrae along with that of the supraspinous; it might at
from the inferior border of the 12th dorsal to the most serve as a check in extreme range of flexion.
upper border of the 5th lumbar ; now, since injurious When injured it may become appreciably an impedicontraction of a dorsal affects more severely its ment to the flexibility of the spine. Thus,, some
insertions than its own mass, it follows that in such lumbar ligaments have been observed with a. fibroa case the intervertebral disks must suffer.
cartilaginous structure, others had become progresThrough contact with the epidural mass, the sively ossified through. extension of the spinous
inflammation of the yellow ligaments with its at- processes; in old subjects these processes are found
tendant exudation, may disturb that mass itself as with articular facets incrustated with cartilage,
well as the blood vessels that are in close proximity ; actually constituting arthrodias.
even if the cord was not at first directly involved
Supraspinous Ligament-This extends as a fiit may become so through the pressure produced brous band from the external occipital protuberance
by the increase of volume due to the sympathetic to the-sacrum, while attaching to the tips of all the
inflammation of the mass; that, as before, would spinous processes. Histologically it is made up of
also affect the nerve roots in the intervertebral connective tissue and of a large quantity of elastic
foramina. A number of clinical instances are on fibers. It differs in form according to location, but
record in which pressure in the vertebral canal was it seems to be more of an aponeurotic raphe than a
removed through laminectomy ; the intervention real ligament, although in the cervical region the
gave almost immediate relief from pain and the texts give it specific consideration as the “posterior
symptoms gradually quited down until ultimate re- cervical ligament.” In man this latter is much more
covery was obtained. It is stated that the stability developed than in all other Primates, and instead
of the vertebral’ column remained, satisfactory ; of being a rudimentary organ it is in reality a neoprobably some supporting and protective means formation made up mainly of fibrous fasciculi dewere provided thereafter for the patients. The rived from the fasciae of the nuchal muscles (trapinteresting point for us is that upon removal of the ezius, splenius, rhomboids, serratus monor poslamime and of the attached yellow ligaments the terior and inferior, great complexus), together with
release from pressure allowed the normally straight special fasciculi extending from the tips of the
cylindrical mass in the vertebral canal to expand spinous processes and converging down and backin the form of lobes limited by band-like strictures wards towards the tip of the process of the seventh
at the level of the yellow ligaments. In such cases cervical vertebra.
the disorder was due to some kind of rachialgia withFrom the viewpoint of mechanics the considerout primary involvement of the ligaments.
ation of the interspinous and supraspinous ligaSo far no reference has been made to the ments would then appear as superfluous, were it
nerves, as the treatment of this question will re- not for casual observation of some curious pheceive special attention later on; for the present it nomena which occurred in dissection work on rabsuffices to mention that the anterior aspect of the bits and which, when repeatedly verified, pointed
laminae and the yellow ligaments are innervated to an interesting field of investigation. Once in
by branches of the N. sinu vertebral, or N. of particular when attempting to clear the spine from
Luschka, which, because of its peculiar origin, just the 10th dorsal to the tip of the sacrum of all musoutside the operculum of the intervertebral fora- cular attachments, while leaving all spinal ligamen, is made up of motor, sensory and sympathetic ments as intact as possible, so as to permit close
fibers. We may thus surmise that it wields a tre- study of the functioning of the latter, the large
mendous influence in vasomotility, in controlling muscle masses had been rapidly removed, and atthe range of the ligaments, and by reflex action, tention had been centered for a while on the mias a factor of the contracture, or exaggerated nutious clearing up of the ligaments, when it was
tonicity of the neighboring muscles.
accidentally observed that as the work neared comInterspinous Ligament.-This is a fibrous septum pletion the spine, originally convex posteriorly, had
located in the median plane, attached above to the now become entirely the reverse. Not much imlower aspect of the spinous process of one vertebra portance was at first attributed to this, on the
and below to the superior aspect of the. spinous thought that in the end, owing to the perfect flexiprocess of the next vertebra ; the anterior border bility of the spine, and with special preserving
attaches to the raphe of the yellow ligaments, treatment, the object in view would be attained
while the posterior border mingles with the sup- without trouble. Eventually, however, it became
raspinous ligament. The structure is made up of apparent that considerable damage had been profibrous fasciculi and of a large amount of elastic duced through the extreme extension then estabfibers, all of which are obliquely directed down and lished. Just above and below the articular disks,
forwards in the cervical and dorsal regions, down and under the anterior common ligament, which
and backwards in the lumbar. This obliquity en- was in perfect order, there was a red line tending
ables the ligament to adjust itself to the displace- to encircle the vertebral body ; this clearly indicated
ments of the spinous processes with a minimum of the separation of the disk from the two adjacent
elongation. In the cervical and lumbar areas the bodies, which was easily verified later on by cutting
lateral aspects of the ligament are in relation with the ligament along its periphery. The interspinous
the interspinales muscles, serving then as the apo- and supraspinous ligaments had contracted and lost
of their flexibility because, being thin, they
neuroses of the latter. In the All
thoracic
region,American
be- most
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SYMPOSIUM ON THE ART OF PRACTICE
dried up more quickly than the other more bulky
parts. Effectively, upon severing them the spine
was easily restored to nearly its normal shape. That
this was not an exceptional occurrence was proved
by repeating the dissecting process in exactly the
same manner on other specimens.
This brings us back again to the characteristics
of fibrous connective tissue, one of which is being
highly hygroscopic, that is, capable of expanding or
shrinking according to the amount of ambient
moisture; but of course the question of the effects
of the dessication itself is too trite to mention, for
they are well known as a constant source of annoyance in dissection work. The outstanding point is
that the force of contraction acting on the spinous
processes as levers, produced the actual separation
of the disks from the vertebral bodies. We must
realize that there are numbers of circumstances in
life in which extreme contraction of the muscles is
apt to cause intense disorder in ligamentous attachments and in articulations. Seemingly insufficient attention has been given- to this matter as re-
117
gards the initiation of deep seated trouble in
various parts of the body. As an instance, the
separation of the disk must entrain considerable
hyperemia, exudation, inflammation, metaplasia in
the different tissues involved, and if the repair process is disturbed in some manner the consequences
may be of the gravest import; besides exostoses in
some vital places, there may be softening of the
vertebral bodies and wasting of their substance.
Clinically we have been able to trace the origin of
an appreciable number of cases of partial paralysis,
affecting either the lower or the upper limbs, to
prolonged immersion in cold water, or to cold exposure. In treating such cases much work is required every time, to overcome the muscular contracture, but the operator is bound to realize that
the trouble lies deeper and that the ligaments are
so involved that the vertebral bodies are drawn
together with tremendous force. It is only when
the ligamental contracture is gradually overcome
that flexibility begins to manifest itself and that
slowly, very slowly, improvement develops.
All Rights Reserved American Academy of Osteopathy®
The Journal of the
American Osteopathic Association
PUBLISHED MONTHLY BY THE AMERICAN OSTEOPATHIC ASSOCIATION
CHICAGO, ILLINOIS, NOVEMBER, 1930
Vol. 30
Vertebral Mechanics
ALBERT E. G UY, D.O.
Paris
PART V
The Vertebral Canal and the Intervertebral Foramen.-Dual Circulation. By definition a foramen is
No. 3
Bernard in his “Lessons on the Physiology and the
Pathology of the Nervous System,” 1858, and on
the “Properties of Living Tissues,” 1864. Here incidentally, we find the most emphatic confirmation
of the well founded osteopathic theory. According
to Claude Bernard the vascular system is subject
to the influence of two nervous systems, more
or less distinct: the sympathetic and the cerebrospinal; the first is moderator of the vessels; its
stimulation produces varying degrees of vasoconstriction, thus hindering or slowing down circulation. On the contrary, stimulation of the cerebrospinal fibers produces vasodilation. That is all
there is to the mechanism of the influence of the
nervous system. Through these two modes of action, constriction or dilation of the vessels, the nervous system governs all the chemical phenomena of
the organism.
Vasoconstriction is the contraction of the muscle fibers in the sheaths of the vessels, contraction
induced by sympathetic nerve fibers; vasodilatation
on the contrary is induced by the inhibitive action of
the cerebrospinal system upon the sympathetic. The
purpose of sympathectomy is then, through resection of certain nerve fibers, to induce a greater influx
of blood to a given part and a considerable exaltation of chemical phenomena; modification of the
regime of circulation may prove beneficial in the
reduction of congestion affecting an arthritic joint,
for instance, and may prove a factor in rapid ossification in fracture zones by establishing the required
connective tissue medium suitable for the utilization
of material freed by resorption, etc. The famous
motto of Dr. Still about the supremacy of the rule
of the artery, which was the constant guiding fanion
of his untiring activity, is here upheld by one of the
most illustrious of French physiologists, and that
alone should be a most precious encouragement to
the followers of Dr. Still.
But Claude Bernard tells us that instead of resecting the sympathetic fibers to obtain the effects
he mentioned, a sensory nerve of the cerebrospinal
system may be so stimulated as to react upon the
sympathetic and to inhibit its influence. Thus, in
a most elementary experiment, the pinching of a
body part causes it to redden through inhibiting
(paralyzing) action upon the muscles of the blood
vessels, which then acquire a larger volume and
thus contain more blood. Likewise when a gland
begins functioning, at first pale it becomes turgescent, the blood rushes to it because of the modification in size of the vessels. Thus anywhere the
chemical actions are intensified there is sympathetic
an orifice or short passage; its importance seems inversely proportional to its length, for the intervertebral duct in its extent of five or six millimeters carries “Caesar and his fortunes,” not only metameritally but also systemically through numerous reflex mechanisms. Within it are adequately organized the means required for the protection and the
nutrition of the nerve fibers which, just issued from
the cord, conjoin at a point ceaselessly disturbed by
the physiological motions of the body parts, consequentiy always fraught with danger, to prepare their
interstitial entry and progress through the tissues
and organs to which they convey regulating and
controlling impulses and stimuli. That the function of the various body organs is dependent on the
nervous influence, in the sense understood nowadays, has been progressively realized since the seventeenth century ; witness for one instance the
magistral memoir of Pourfour de Petit, presented
to the Royal Academy in 1725, in which are related
his experiments dating from 1717, establishing the
connection between fibers issuing from the three
first dorsals and the ciliary muscles; these fibers
ascend through the cervical sympathetic chain to
the superior cervical ganglion and the carotidian
ramus, thence anastomose with the Gasserian ganglion, pass through the ophthalmic ganglion, to finally reach the ciliary nerves, dilators of the pupil.
Evidently this important discovery has not received
practical application outside the osteopathic realm,
and like many others evolved from the patient
labors of learned physiologists, has but a. topographical value. The tendency to treat disease topically
has predominated throughout the ages, and though
many modes of treatment might be adduced to combat this statement, the rebuttal itself could be
proven but apparent; thus in cases of germ pathology a friendly germ or a friendly antitoxin were
sought to overcome the bad germ and its toxin that
had squatted somewhere in the body; serums were
devised galore either to overcome the germ in its
own habitat, or to fence in the body generally
against its invasion; radium rays, electric rays, were
applied certainly with topical intent; light rays are
in vogue ; and to crown it all we have a tremendous
surge of sympathectomy. This latter is at once a inhibition, hence dilatation of blood vessels. Inrenascence and a recrudescence of the application versely, when these phenomena diminish, the toniof the notions SO admirably developed
by Claude
cityAcademy
of the ofsympathetic
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action upon the muscular sheaths of the vessels, and other experimenters had found them in other
now more energetic, constricts appreciably their glandular organs ; and so it was plausible to generalize and to admit the existence of similar conneccaliber.
Now then we may realize more clearly the prac- tions throughout all the elements of the organism,
tical, the utilitarian side of osteopathy as estab- thus recognizing a dual capillary system, a double
lished by Dr. Still. By dint of incessant and analy- circulatory path for the blood going from the artic observation he developed the notion that disease teries to the veins: one direct, formed by special
was caused by impediment of the normal circula- and contractile canals connecting the two great cirtion, which alone could insure the nutrition and the culatory trunks ; the other more circuitous, passing
upkeep of the body tissues and organs ; then his through the small, noncontractile, capillary vessels
extraordinary ingenuity led him to seek further and in which occur the phenomena of endosmosis, of
to discover -that the local impediments were not secretion, of extravasation, etc.
Normally the entrance into the small capillaries
alone, that symptomatic disturbances existed not
only along the. path of the cerebrospinal nerves but may become choked by some obstruction arresting the
also, and mainly, about the tissular masses in the the circulation therein, so that the blood has to folimmediate neighborhood of the spinal roots them- low the arteriovenous path ; consequently we may
selves, powerful enough in their effects to even up- conceive that at the end of the capillary arterioles,
set the equilibrium of the vertebral structure. He just before they cease to be contractile, there are
reasoned that the removal of the disturbances at special sphincters, normally of course more or less
their sources proper, that is at the spinal outlets, relaxed, and whose function would be to regulate
should be effective in overcoming the local impedi- the regional irrigation ; abnormal occlusion of these
ment, thus restoring the circulation to normal and, capillaries would at once account for regional anein cases, hyperactivating it, and consequently over- mic or ischemic conditions.
Comparative anatomy demonstrates in a way
coming the disease itself. This led to experimentation on the living body and, his hypotheses being the truth of this hypothesis, as what we deduce
amply confirmed by the ready response he obtained, from experimental data and assume for all animals
to gradually develop the manipulative technic now of a superior order, has been positively observed in
so well established and recognized.
some cases. Thus the larvae of large marine
Perhaps some will contend that the title affixed crustaceans possess an, arterial system contiguous
to our subject, “Vertebral Mechanics,” is a mis- with a lacunar venous system, and at the ends of
nomer because we have many times digressed from the arterioles special sphincters have been observed
the path of the geometry of motion, of Kinematics whose constriction may regulate, and even comand Dynamics; perhaps it is so, but the side lanes pletely interrupt,. any communication between the
we have entered took us to interesting viewpoints. two circulatory systems. Well, the action of the
Paraphrasing the old saying that “all roads lead to sympathetic nerve fibers regulates the state of conRome,” we may state that all these lanes in some traction or of closure of our small sphincters, and
way or other led us towards our real objective, inversely, paralysis of this nervous system induces
which is the understanding of “the why and how of dilation of capillary vessels through the relaxation
lesion.” Such a lane invites us at this juncture and of the sphincteral fibers.
we may follow it without regret. Claude Bernard
We have just at hand a memoir presented to
in many of his lectures treats extensively of the in- the Paris Academy of Medicine by Drs. Laubry and
fluence of the nervous system upon circulation. He Tzanck, on July 24, 1930, which treats’ of venous
states that it is now demonstrated (1858), that con- circulation and thus some 72 years later, confirms
trarily to long-established opinions, capillary ves- in a way the views of Claude Bernard, strengthens
sels are contractile, as may be seen by a description and completes them. These authors show that the
of their system. Arteries are continued by arteri- return circulation of the blood towards the heart is
oles whose walls are still made up of three super- inadequately explained by the mechanism composed membranes, one serous, the intima, one elas- monly accepted, which invokes the vis a tergo, the
tic and one contractile; the elastic membrane, very pleural depression, the cardiac suction ; the princithick in the large arteries, thins out progressively pal role belongs, according to them, to the vasoas the vessels become smaller, so that it is the con- motor nerves of the capillary vessels and of the
tractile membrane which becomes the important veins, which insure the permanent tonicity of a
part, relatively predominating, of the vascular receiver whose capacity is much greater than the
sheath of the arterioles; these- in turn are continued volume of the contents. It is then easily conceived
by the capillaries whose envelope is devoid of con- that the relaxation of the walls of such a receiver
tractile membrane and is formed solely of an ex- is apt to cause stagnancy of the mass of blood and
ceedingly thin layer of nucleated cells. Following stoppage of the return circulation to the heart.
these come the venules and gradually the veins Quite a number of physiological and pathological
through which the blood is returned to the heart. phenomena are thus explained, according to the
But the contractile capillary arterioles and venules authors who cite some examples, by means of this
are also connected independently of the capillaries conception of the venous circulation.
proper, in such a manner that blood may flow from
We should note that the question of venous cirthe ones to the others without passing through the culation has received attention from several quarnoncontractile vessels. These direct arteriovenous ters during the last few years, and it seems strange
connections were then well established scientifically that it has been so long neglected, in view of the
for the major systems, such as the liver, where there fact that the vein sheaths contain a considerable
is a by-pass between the vena cava and the portal amount of muscle tissue which, of itself, is inert
vein; Virchow had observed them in the kidneys, and responds only to nervous influence. It is selfAll Rights Reserved American Academy of Osteopathy®
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evident that any muscle element must be under the
control of at least two kinds of nerve action, sensory and motive, in so far as its main function is
concerned.
Resuming, we see (1) that certain degree of
blockage of the capillary flow may produce anemic
or ischemic conditions; (2) that constriction of the
vessels may induce congestive conditions; and (3)
that this blockage and that constriction are controlled normally by the action of vasomotor nerve
fibers derived from the sympathetic system. In disease it is but natural to expect that the conditions
of the affected tissues and fluids must exert a decided effect upon the nerves, in some cases intensifying their action, inhibiting it in others. By means
of the above and of other data concerning spinal recurrent nerve fibers, mostly all of which was gathered purposely from old and reliable sources, we
believe it possible to visualize more logically the
development of the lesion, instead of remaining
meekly contented with the rather indefinite, common notion of its generation through pressure on
the nerve roots in the intervertebral foramina.
The Intervertebral Duct.-Figure 27 is a schematic transverse section of the vertebral canal and of
its two adjacent intervertebral ducts; at the left are
shown the main elements to be found in the duct,
and at the right the radicular arteries and the various ramifications of the nerve of Luschka; the plane
of the section passes at the upper edge of the apophyseal articulations. There was no special purpose in selecting the fifth and sixth dorsals for an example, except perhaps that they seemed suitable to
represent average conditions of structure. The
contour of-the vertebral foramen was drawn accurately from the sixth vertebra of a male subject
of large proportions; a template of it, made to scale,
fitted almost exactly that of the second dorsal of
a female subject of average stature, but no conclusions of value may be derived from that just now,
except as to suggest a line of investigation. The
proportions of the osseous parts are correct, but
those of the cord, of the roots, and of the various
membranes and ligaments are problematic, although
based on findings gathered from a number of reliable sources.
The osseous contour of the duct is formed anteriorly by the posterior external part of the fifth
dorsal, whose pedicle arches over to the upper edge
of its lower articular facet, thus forming a curved
roof; the posterior aspect is formed by the anterior
surface of the articular process of the sixth dorsal;
it is continued by the upper surface of the 6. D.
pedicle, forming the curved floor of the duct which
ends at the upper edge of the 6. D. body ; the remaining gap is filled mesially by the intervertebral
disk, and externally by the insertion’ of the head
of the sixth rib.
The bony surface is covered by the periosteum
to which are added fibrous tissue extensions from
nearby ligaments, such as the anterior common lig.;
the posterior common lig. ; the stellate lig. ; the costomeniscal lig. ; the yellow lig., the location of which
is well understood ; the capsular attachments of the
apophyseal articulations. Externally the orifice is
closed by a sort of felted mass of fibro-elastic tissue
spreading far over the border, where it appears as
an extension of the continuous fascia which lines
121
the periosteum on the anterior and posterior aspects
of the vertebral bodies, as well as on the transverse
processes and attached structures. This mass extends also well inside, for perhaps one-third of the
length of the duct; some foreign anatomists have
termed it an operculum and consider it as performing
the function of a drum membrane, as the tympanum
in the auditory canal. In this they have been influenced by the fact that they dissected dried specimens in which the mass had condensed to the point
that it appeared as an actual plate. On fresh specimens from animals in a butcher shop such a plate
does not exist, in its stead we may readily observe
the felted mass. The intimate connection of, the
operculum with the fascia is most interesting, in
this sense that disturbances befalling the latter are
bound to affect the former and thence the organs
in the intervertebral duct. The operculum attaches
also unto the costomeniscal ligament, a fibrous fasciculus which extends from the posterior aspect
of the head of the rib, through the intervertebral
duct, under the posterior common ligament, and
fastens upon the posterior aspect of the disk. Movement of the head of the rib may cause this ligament
to pull or twist the border of the operculum. The
latter has many orifices through which pass the
nerves, arteries, veins and lymphatic vessels issuing
from, or entering, the duct; it is closely attached
to each of these organs and ensheathes them for
some distance externally, just as a fascia. Much
has been said and written about the compression
of the nerves in the duct, but the conclusions have
been far from convincing. The reason therefore is
most probably that the compression has been considered from the viewpoint of bony displacements.
It seems to us that the matter may be more profitably discussed by dealing directly with actual structural conditions.
Figure 28 represents drawn to scale, but enlarged, the external aspect of the intervertebral
foramen formed between the fifth and sixth dorsal
vertebrae from the spine of an adult subject; no
special attempts were made in the selection of these
because, except in cases of abnormal shapes or sizes,
any two adjacent vertebrae should answer the purpose of the study. The delineation of the foramen
and of the articular facets is very close to shape ;
that of the bodies themselves is schematic. We see
that in extreme extension the movement is limited
by an abutment at A, formed (in this particular instance) by a bony edge ; it is also restricted by the
contact of the fifth spinous process with the posterior ridge of the sixth; this is not shown in the
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VERTEBRAL MECHANICS-GUY
figure; we may note in passing that in forced extension there is a possibility of great trouble due to
the fact that the spinous contact is unstable, and
therefore the fifth process may be deviated laterally
and made to slide on one side of the sharp crested
sixth spinous process; the local consequences of
such an occurrence may be: tearing of the supraspinous and interspinous ligaments, gaping of the
apophyseal articulations, forced rotation of one body
upon the other, overstraining of the capsular ligaments, overstraining of the so-called operculum.
In extreme extension the area of the foramen
is at a minimum, yet there seems no reason to fear
for the contents of the duct, for the upper facet has
traveled to the extreme range provided by nature
and, unless the position should be unduly maintained, the temporary compression of the contents
must be comparable to that of the vessels and
nerves in a normally fully contracted muscle.
The normal outline in the figure is of course assumed as is also that of extreme flexion ; both may be
accepted as fairly correct. In this flexion the foraminal area is at its maximum, consequently the
operculum, or occluding membrane, is stretched to
the limit; this would seem perhaps more important
as a disturbing element than the compression of the
contents, for measured diagonally the fibers must be
stretched about one-fifth of their length in normal
position, and we would expect a tremendous pull on
the attachments to the contents of the duct. As
both extremes of flexion and extension are within
the physiological range, and as there is nothing on
record regarding the development of lesions due to
the opening and narrowing of the foramen, we must
assume’ that nature has provided some means of
adjustment of the parts, whereby the ceaseless relative displacements of the vertebrae may occur in our
daily activities without producing pathological derangements. We are led to assume that the concept of some of the leading anatomists who describe
the operculum, in books issued within the last few
years, as a membranous plate of appreciable thickness covering the foramen, is untenable and that,
instead, the occluding mass, as we have observed
ourselves, is not merely made up of elastic fibers
capable of extensive stretching, but is formed- as a
flexible spout, drawn inwards during extreme flexion, and pushed outwards in extreme extension.
In view of the fact that many lesions are detected, treated and corrected, in which the vertebrae
affected are found temporarily immobilized in positions well within the range of physiological motion,
we feel amply justified in reaching the conclusion
that the pathological condition of the contents of
the duct did not proceed from mechanical compression caused by the narrowing of the duct, nor by
the pull incident to the extreme stretching of the
operculum of course we must not lose sight of the
fact that while the palpation, or even the radiographs, may show the vertebrae practically in place,
there is a possibility that the lesion was actually
produced through a sudden displacement of much
greater, amplitude than the normal, with consequent
pinching or other injury affecting the spinal nerves;
after which the spine may have, even spontaneously,
resumed its alignment, while thence on the developments of the lesion followed their course according
to the gravity of the case. It is obvious that the
consideration of such an occurrence cannot impugn
our conclusion.
There is an aspect of the question upon which
we desire to call attention with the utmost emphasis, as it has been thus far totally ignored, and we
suggest that its study be undertaken in our research
and college laboratories at an early date ; the attendant work consists of minute dissection, and its
success depends on clear and unbiased observation.
In pounding over and over again figure 28 we were
led to visualize the possibility that the’ operculum
could be attached firmly to the bony structure of
the upper vertebra, extending across the greater
part of the foramen from B to C to D and thence to
B, in the manner of a loose tympanic membrane,
while the lower part attached to the subjacent vertebra could have folds and festoons. In this manner the motions of the upper vertebra could take
place without disturbing the nerve and vessel bundle which, implanted in the operculum, would be
carried up and down with it. Such an arrangement
may be represented schematically as in figure 29;
the capsule which must have entire freedom of displacement is underneath the operculum; the latter is
attached beyond the capsule to the body of the
upper articular process, and it is continued ‘by the
common fascia ; it is attached also to the ligamentous structures maintaining the head of the rib in
the seat provided on the edges of the vertebral
bodies. We hope that our suggestion may be acted
upon and that the results of the investigation may
clarify this most interesting point.
Contents of the D&.--Within the duct are: (1)
the radial nerve, formed by the apposition of sensory and motor nerve fibers, and sheathed in extensions of the meningeal membranes ; (2) the terminal strands of the posterior root at their union
with the ganglion, the ganglion itself, and the
strands of the anterior root; all these structures
have meningeal sheathings ; (3) the spinal artery ;
(4) at least one spinal vein, sometimes several,
draining the blood from the cord and the nerve
roots, from the meninges, from the ligaments and
other supporting tissues, from numerous and extensive plexuses ; (5) venous plexuses ; (6) lymphatic
vessels ; (7) loose epidural supporting tissue ; (8)
an epidural sheath surrounding (7); (9) a fibroadipous mass filling the annular space between the
epidural sheath and the periosteum lining the duct;
(10) the nerve of Luschka, or N. sinu vertebral, or
N. recurrent meningeal.
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123
Some authors claim that the duct contains three ditions: (A) the structure of the meningeal sheath;
very distinct concentric departments: (A) one cen- (B) the cerebrospinal circulation; (C) the settling
tral, for the spinal nerves and artery, enclosed by a in the infundibula of leukocytes and of the toxic
dural sheath; (B) one annular, located between the matters they may contain. The nerve fasciculi in
dura mater and the epidural sheath, filled with loose contact with such stagnant material undergo a localized degeneration; then follows a fibrous organizasupporting tissue and with abundant lymphatics;
(C) the last one is filled with fibro-adipous tissue tion of the sheaths, a real symphisis which may conand with the veins and their plexuses; it extends be- tribute in producing an irreparable nervous lesion;
tween the epidural sheath and the periosteum. If that is the processus of the radicular transverse
it were so, obviously the weakest point in the whole neuritis described by Nageotte. In transient meninstructure would be in the third compartment, with- gitis the radicular lesion heals, leaving generally a
in which compression of the veins and plexuses sclerous nucleus traversed by nerve fibers, dissocould easily occur, and with far-reaching results, as ciated and sometimes bereft of myelin. In prowill be shown further on.
longed meningitis the degeneration of the posterior
The spinal roots are usually represented as sub- root, at first localized in the infundibulum may exstantial funiculi originating from the cord and fin- tend towards the cord and reach an intramedullar
ally uniting, past the ganglion, into one larger area. And thus is established a real lesion of tafuniculus, the spinal nerve proper, issuing from the betic kind which is common to all meningitis, parintervertebral duct. Each original funiculus is ac- ticularly tubercular and cerebrospinal, when they
tually formed of a number of radicular filaments ; have lasted long enough for it to develop ; these are
posteriorly there is an uninterrupted series of eight true histologic tabes.
to ten filaments regularly spaced vertically, and
Cranial and spinal roots are subject to similar
each insulated in meningeal sheathing; they descend lesions resulting from the same causes. For both
gradually, to coalesce when traversing the dura the degeneration of the roots in contact with leukomater about at the level of the duct; incidentally, cytic masses is the much’ more intensive as the
this disposition permits the funiculus to more read- nerve fasciculi are most divided. Hence the anily adjust itself to the motions of the spine; arriv- terior root traversing the region as a compact buning at the ganglion the filaments appear to separate dle is usually but little affected, whereas the posbefore penetrating it; the spaces between the vari- terior root is seriously lesioned only where the inous branches are filled with arachnoid tissue and fundibulum is affected in the neighborhood of the
are bathed in cerebrospinal fluid. Anteriorly the internal aspect of the ganglion, where the root is
radicular filaments issue from the cord in groups divided into a number of fasciculi, in the interstices
of two or three, each containing from four to six of which the toxic deposits accumulate. This is the
secondary fibers, and they align vertically in two weak spot of the posterior root; it is found in the
or three rows in a space of two to three mm.; the sheath of the lumbar roots of the upper sacral, and
interval between two anterior roots is always clearly of the lower cervical plexus; there it is that the dedefined and appreciably greater than that between structive action of meningitis obtains most often.
the various filaments of one root.
Cranial nerves, particularly the third or oculoAround each funiculus are, concentrically dis- motor, and the fourth or trochlear, have also a weak
posed, the pia mater, the arachnoid, and the dura spot through fascicular dissociation, and these lemater, all continued from the main membranes sur- sions are severest when the affected sheath reaches
rounding the spinal cord. In this way are formed its level.
two infundibula which unite into one enclosing the
Any processus of coalescence or of partial symexternal part of the ganglion and the anterior root phisis of the meningeal sheath, such as results from
bundle, so that practically from the external aspect age or from minor irritations tends to locate these
of the ganglion to the main dural space there is cere- weak spots away from the infundibulum and thus
brospinal fluid. But the circulation in each fundus more difficult of access by the toxic elements. Thus
cannot be as active as in other wider spaces, and may be explained certain variations of the localizamay in pathological conditions become sluggish to tions and of the lesions of meningitis and tabes.
the point of stagnancy.
Besides the action of the toxin accumulations
This consideration inspired Dr. Tine1 to write a in the infundibulum and of which leukocytes seem
“Thesis on Radiculitis and Tabes” (Paris, 1911), in as the vehicles, a place should be reserved for the
which the author attributes to the impeded circu- diffuse actions of soluble toxins, whose role is demlation thus localized the causation of inflammatory onstrated on the core as well as on the roots, and
processes affecting the roots, but oftener the pos- even on the ganglion and the peripheral nerves.
terior. He claims that in any case of meningitis
While any meningitis is apt to produce anato(spyhilitic, tubercular, cerebrospinal, etc.) a con- mically a kind of tabetic lesion, clinically it is
siderable accumulation of leukocytes may be found found that syphilitic meningitis alone leads curin the infundibular interstices, whereas in the sub- rently to the tabetic syndrome. This is likely due
dural space there is only but a discreet reaction. to slowness and duration of evolution, and to the
The work contains about sixty micrographic illus- specific toxic coefficient ; it reaches the tabetic status
trations of sections of spinal and cranial nerves, and only when the disease is in latent, attenuated form.
It seems logical to ascribe the noci-action of the
of ganglia. The conclusions are of great interest
in themselves and lead to considerations of impor- leukocytes, in contact with the nerve fasciculi, to
tance to our profession. It seems obvious that any microbian endotoxins, but it is possible that the
meningitis tends to promote radicular lesions be- leukocytes themselves may prove toxic, since it is
possible
also for
the red cells to become so. In one
cause of certain anatomical and physiological
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case of cerebral hemorrhage it was observed that other. Depending on the manner of handling the
blood filled the sheaths, settled in the infundibula, blood the results differed in degree of severity.
dissociated the nerve fasciculi, and that wherever After exposure to the air, the serum separated from
the red cells infiltrated the latter there was consid- the mass, and when injected into either animals
symptoms of putrid infection developed, usually
erable demyelination.
It is customary in clinical and laboratory circles with fatal results. With the blood kept at normal
to inculpate specifically germs, endotoxins, exo- temperature and preserved from atmospheric action
toxins, soluble toxins, dead phagocytes, etc., as the during various lengths of time, it was found that it
primary causative factors of disease ; but that the had nevertheless become toxic, and increasingly so,
organic fluids themselves may prove toxic and, of course, as it had been kept longer before injecthrough the permeability of the nerve elements, in- tion. In these latter cases the blood was merely
duce action on the tissues and organs of the body kept at rest, prevented from circulating, so to speak,
favorable to the preparation of a terrain suitable and yet, away from outside influences it became
to the invasion of the germs and development of the decomposed. What useful conclusions may we
toxins, is a theory almost irreducibly impossible of draw from all these considerations?
Of course anyone may point out the obvious
general acceptance by the medical profession ; yet
the soundness of this theory may be established by danger of reintroducing into one’s body blood that
the results of investigations conducted by two of had been removed from it, but while that repreits most eminent men, viz.: Claude Bernard and sents a very extreme condition, we must recognize
that there are others in which the blood, while not
Ranvier.
Toxicity of the Blood.-In his lectures on the removed from the body, is nevertheless hindered in
physiological properties and the pathological altera- its course. That is the case with congestions intions of the organic fluids, delivered in 1859 at the duced by many causes such as exposure, physical
College de France, Claude Bernard conducted many and mental fatigue, emotions, over-exertions, digesexperiments on the transfusion of blood in animals. tive disorders, etc.; in all of which muscular conFor instance, two subjects, two rats, similar in every tracture is ever present, affecting directly some part
respect and in the best normal condition were se- or other; the circulation is retarded; there is some
lected: one was fed regularly while the other was degree of chemical disorganization of the: body
deprived of solid food for a certain length of time; fluids, formation of acidity with consequent sympblood was drawn from the latter and immediately toms of pain, acute, rheumatic, or latent (revealed
injected in the vein of the well fed rat, which very by palpation) ; in the processes of repair of the various
soon developed pronounced symptoms of illness and body tissues, as we have mentioned at times,, there
became as weak as the famished rat. This was only is always congestive involvement, that is necessary,
gross experimentation. In another test two rats but when there is insufficient power of resorption
were selected as before, but their blood was first the gravest consequences may result. In short,
analyzed; then one rat was famished and the other congestion opens the door to discomfort, at least,
fed for a period of time, at the end of which the to dysfunction, and prepares the terrain for disease.
blood of each rat was tested again, and that of the After all this is all in accordance with the universal
weak rat injected into the well one. The results law of ceaseless activity; it rules the infinitely great
were of course the same as in the previous test, as well as the infinitely small, and any arrest of that
but this time they were explainable, due to the fact activity is fraught with danger of disruptive consethat the analyses showed that in normal condition quences, of disaster and, at the limit, of death as
the blood of the two animals was practically uni- we understand it. The very few experiments hereform in quality, whereas that of the famished rat in cited should suffice to illustrate our viewpoint;
had undergone such considerable chemical modi- for more enlightening information the reader is refications as to render it toxic for the other rat.
ferred to the numerous works of Claude Bernard.
The same kind of tests were conducted on other The following short quotation translated from his
animals, some of which were kept normal while “Experimental Pathology” (Paris, l859), may whet
some others were subjected to prolonged muscular the appetite of the seeker after knowledge: “As we
exertions resulting in intense fatigue. Blood taken rise towards the higher orders we see the nervous
from the latter and injected into the well rested system increasingly developed, but also that disanimals brought these to a painful state of fatigue; eases are more frequent, more varied in form and
not only did they appear as tired as the over- more complicated in kind. We should not -wonder
exerted animals, but in addition they seemed to at this, since all our organs, in their vital manifestasuffer pain. This is explainable by the fact that in tions, normal or pathological, depend on thee nervone case the fatigue was gradually developed, ous system. If we consider one after the other the
whereas by injecting the “fatigued blood,” which divers organs of the body, we may easily (demonwas analyzed and found greatly modified, an actual strate that all the symptoms of the diseases likely
disease condition was introduced into the normal to affect them may be traced to the direct influence
subject.
of the corresponding nerves. We may even proThe tests just mentioned arc well known and duce all of the anatomical lesions characterizing
have been repeated many times in laboratories; these diseases by experimental action upon the spetheir results are such as would be expected since cific nerves; for instance . . . etc., etc.”
we now understand the effects of chemical changes
Effect of the Surrounding Medium on the Nerve.
in the blood, that were purposely induced. But in Most exacting experiments performed and deother tests two similar normaI animals were se- scribed by Professor L. Ranvier during his lectures
fected; blood was drawn from one, kept aside for on “Histology of the Nervous System,” at the Colde France,
1876-1877, throw a most impressive
injected
into American
the lege
about thirty minutes, and then
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light upon this subject. We have already described
some of them in the Journal of Osteopathy, Kirksville,
1927. Their consideration coupled with the findings
of Claude Bernard and of Dr. Tine1 will prove valuable in the pursuit of our subject.
A live rabbit was secured on a board, and an
incision made as to permit the sciatic nerve to be
exposed for a length of nearly two centimeters. The
wound was spread apart in cup shape, with the
nerve at the bottom and its surface entirely free
from contact with the surrounding tissues. Then,
water at the temperature of the animal, was allowed
to flow in the cavity without impinging upon the
nerve itself. In this way the temperature was maintained practically constant and the bath remained
really aqueous. Effectively, if the cavity had been
merely filled with water, the latter would have diffused into the surrounding tissues which, in exchange, would have given up part of their plasma,
so that the nerve would have been bathed, not in
water, but in a heterogenous mixture of water and
blood serum.
After an irrigation lasting twenty minutes the
nerve had lost all its properties. Electrical or mechanical excitation produced neither pain nor motion, whereas above the denuded region the nerve
was still sensitive, and below was still motor. It
was observed that after a few minutes of irrigation
water must have begun its action upon the nerve,
causing an excitation evidenced by convulsive motions of the leg involved; these gradually ceased and
the irritability of the nerve diminished progressively.
Another experiment was conducted on a rabbit,
the two sciatic nerves of which were exposed and
prepared as before. One was irrigated with tap
water and the other with a 5% saline solution, both
at the same temperature of 30° C. After twenty
minutes, the nerve in the aqueous solution had lost
all its properties, whereas that in the saline solution was perfectly sensitive and remained so even
after one hour of irrigation. On another rabbit the
saline irrigation was maintained for five hours, and
it was found that the nerve responded perfectly to
various stimuli.
In one test, after twenty minutes of aqueous
irrigation the wound was closed, and three days
afterwards functional tests of the nerve were made ;
it was then seen that the segment below the irrigated part and which, immediately following the
experiment had retained its properties, had now
lost all its excitomotor power along it5 entire extent. The nerve was then removed, treated with
osmic acid and prepared for microscopic examination. It was seen that modifications had taken
place exactly similar in kind to those manifest in
the peripheral end of a sectioned nerve. Water had
thus stopped permanently the conductivity just as
would obtain through section with the knife.
T he modifications in the nerve structure were
practically the same with the aquous as with the
saline irrigations. Water penetrated at the node,
pushed the myelin on each side away from it, perhaps absorbing a little of it; the axis cylinder, then
in a medium becoming more and more aqueous, gradually swelled up until it filled all the space from
which the myelin was displayed, limited only by
the sheath of Schwann and the protoplasma sur-
125
rounding it. We must regretfully leave aside the
wealth of details given by Professor Ranvier, and conclude rather too briefly that the saline solution, while
penetrating at the node and swelling the axis cylinder did not, as the aqueous, alter the essential
parts, so that these were not disorganized and the
nerve fibrillae remained good conductors of the
nervous influx. The saline solution is ordinarily
used for intravenous injection after severe loss of
blood ; its density and action resemble those of
animal fluids ; hence it does not seem too strange
that it was without marked effect on the nerve
fibers; the lesson these experiments teach us is that
any change in the composition of the body fluids in
contact-externally-with nerves is bound to affect
the structure of the latter, and to a certain extent
their function, depending upon the degree of diminution of the alkalinity of the fluids, consequently
more so when the latter is neutralized and when
acidity may be present. (Although the plasma may
contain a dangerous amount of carbonic oxide,
the blood as a whole must of course retain an
alkaline reaction, failing which life would come to
an end).
Role of the Meningeal Membranes in the Infundibula. -In his thesis, Dr. Tine1 lays the greatest stress
on the circulation of the cerebrospinal fluid within the
restricted spaces between the roots and the internal
aspect of their envelopes, and accepts as proven that
any meningitis tends to promote radicular lesions of a
tabetic kind. If by meningitis we understand the disease in general as diagnosed according to specific
symptoms, the matter is far less interesting for us
than when we consider the definition of the word
itself: meningitis meaning inflammation of the enveloping membranes of an organ. The archnoid
is composed of two layers separated by a capillary
space. Bichat in his “Treatise on Membranes”
(Paris, 1800), described it in great detail as a serous membrane intended for the protection and the
insulation of delicate organs. To that effect the
inner, or visceral layer, follows the nerve roots to
their confluence in the infundibula, then reflects
upon the internal aspect of the dura, at first loosely,
as a parietal layer which, further on, adheres
strongly to the dura in the form of an endothelial
film. The interlayer capillary space contains a fluid
whose obvious function is to lubricate the surfaces
in apposition, thus permitting their free relative
displacements, and also preventing their adherence ;
this would show that provision was made for an
infundibular adjustment of the roots to the motions
of the spinal column. It has been observed in
cases of inflammation of the arachnoid that a considerable viscous exudate was present. The normal fluid must originate from some kind of transformation of the blood; it his subject to deterioration
and is the recipient. of waste materials from the
vicinal tissues, hence it is imperative that it should
be evacuated; therefore there must be an active
circulation serving particularly such an essential
membrane; any such circulation must be under the
control of nerves. Consequently, a cause producing dysfunction of these nerves would induce disturbance of the circulation, congestion, inflammation of the arachnoid, hence local meningitis, hence
formation of a noxious medium surrounding the
roots, with all the serious consequences mentioned
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126
VERTEBRAL MECHANICS-GUY
heretofore; We see then that it is not necessary
to invoke the impeded circulation of the cerebrospinal fluid as the main causative factor of meningitis. In fact much could be said anent this circulation; if it exists as such, it must be controlled
very adequately by special means to suit the delicate organs ‘bathed by the fluid in the infundibula,
a n d n o w h e r e do we find a description of these
means which, besides, would necessarily be under
nerve control themselves.
An interesting statement is found in Poirier’:
Anatomy regarding the finding of ossiform plates
on the arachnoid, often on the spinal, more rarely
on the cerebral. These plates, more common in old
subjects and in chronic diseases of nerve centers,
were found also in the spine of normal subjects
in the proportion of six in twenty, four of which
were in twenty-five to thirty-five year old individuals. They are usually multiple, star-shaped,
and formed of fibrocartilage infiltrated with calcareous salts. This is of extreme importance far
us as it permits to visualize the unsuspected existence of chronic spinal lesions, a subject to be considered later on.
Vertebral Mechanics
ALBERT E. G U Y, D . O .
Paris
PART
VI
The Intervertebral Duct.-Nutrition and Elimina-
tion-As the cells, tissues and organs of the body
proceed towards higher degrees of specialization
their needs in nutrition and elimination likewise increase in importance. To the brain, because of its
conscious or subconscious functions, is assigned the
first place ; the cord and its spinal branches occupy
the second. In each case the vascular system is
specific; thus, the spinal branches having for function the conveyance of messages from distant organs
to the cord, reporting certain conditions affecting
them, and from the cord to the former, commanding
consequent requisite action to entertain normal conditions in these organs, and all this while the spinal
column undergoes ceaseless physiological displacements, it is to be expected that all precautionary
measures are provided for safeguarding the integrity of such vital transmission work. Each nerve
filament has a function of its own, to perform which
it must be closely insulated; then it must receive an
ample supply of arterial blood; but this blood must
be supplied to sheaths of the &lament in such a
manner that the insulation be not disturbed and,
furthermore, that the nerve current, or impulse, be
not affected by even the attenuated pulsations of
the capillaries. The venous drainage must be arranged in similar fashion about the filament, and
then suitable means must be provided to insure its
rapid discharge into the systemic circulation; such
means are of use also in activating the flow of the
lymph in its various channels.
We have seen in Part V that arterioles and
venules are controlled by nerves which insure their
physiological function, and we may now review the
distribution of the circulating organs within the
duct and the vertebral canal so as to better visualize
the effects of lesion disturbance upon the radicular
nerves themselves. Unfortunately, anatomists are
weak as concerns the description of the spinal vascular system; they are at variance with one another
on a number of important points ; and nowhere can
we find a clearcut realization of the very essential
role attributed by nature to the spinal circulation.
Here and there we find some memoir, some paper,
dealing with one single aspect of the question; one
deals with the arterial system alone and demonstrates that its disturbance may engender all sorts
of disorders; another deals faintly with the nervous
system ; the lymphatic organs are but lightly
touched upon ; or the cerebrospinal fluid is accused,
through a possible stagnant state, of harboring disease germs; another points out the inflammation of
the fibro-adipous tissue as the main factor in the
production of pressure upon the radicular nerves;
we have also the self sufficient and exceedingly
vague concept of the osteopathic lesion which satisfies extremists with the notion of bony displacement, bony pressure, while others, more mature,
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VERTEBRAL MECHANICS-GUY
think in an imprecise manner of contracture, of tissular inflammation; but nowhere do we find a true
realization of the essential role played by the nerve
of Luschka upon the regulation of all the spinal organs, consequently upon the whole of the organism.
We shall essay to deal with these various items
later on in a general review. As for the regrettable
divergence of views regarding the circulation
proper, that is excusable because the dissection material had to be accepted just as luck presented it,
with subjects sometimes more or less abnormal,
affected by acquired diseases or by congenital conditions.
The arterial system of the cord is continuous
with the cranial vessels and is, in addition, fed by
some sixty branches issued from 34 or 36 different
arteries. Anteriorly, two branches originate from
the vertebral arteries, proceed downwards a little
and fuse together, in the embryonic period when
the anterior funiculi become apposed, to form a
single vessel extending to the filum terminale.
Posteriorly the two branches, originating also from
the vertebral arteries, continue separately down to
the conus medullaris, where they unite with the anterior artery. The three mains are connected all
along their path by numerous anastomotic rami, the
whole forming an extensive network. The anterior
spinal artery descends along the anterior median
fissure of the cord, giving off (1) central branches
ramifying to feed the anterior horns, the commissural region, the base of the posterior horns including Clarke’s column; (2) peripheral branches inserting into the radiating fissures of the cord and
of the anterior roots. The posterior spinal arteries
run downwards either in front or behind the posterior roots; their peripheral branches also insert in
the fissures of the cord, particularly through the
posterior median fissure, the intermediary and posterior collateral fissures, and feed the major portion
of the posterior horns. Arterioles branch out to
connect the mains to the radicular arteries running
along the roots. We should note that it seems
proven that the central branches reach a motor area
in the gray substance, while the peripheral feed a
sensory area ; furthermore, the territory covered by
a central artery being greater than that of a peripheral artery, the effects of a vascular obliteration,
such as from an embolus or a thrombus will be of
greater import in the first than in the other.
The capillary vessels which connect the arteries
and the veins are disposed in simple systems uncomplicated by repeated subdivisions and reunions.
Their networks are modeled to suit the nervous
elements they surround. The venous arrangement
resembles the arterial fundamentally while differing
from it on several important points; thus there are
also central and peripheral veins, but whereas the
arteries represent the largest portion of the afferent
vessels located on the central aspect, the central
veins are small and the major part of ‘the blood
flows out through the peripheral veins, mainly
through the posterior ones; again, except for the
anterior median vein,. the veins are not in general
satellites of the arteries, and they belong rather to
the solitary type with an independent course,
The lymphatic vessels of the cord and of all
nerve centers have an altogether particular conformation; instead of being independent canals as
127
in other organs they are arranged in continuous
sheaths around the vessels, whence their name of
“lymphatic sheaths”; such a disposition may be observed on the mesentery vessels of various animals,
particularly the frog.
Arteries, veins and lymphatics are contained
within the pia mater enveloping the cord; their extensive anastomotic networks therefore enclose
thoroughly the latter. The continuous arterial network constitutes a reservoir of blood supply, just
as in the periosteum, and thus insures both a regularity of supply and of pressure. There is thus a
physiological vascular homogeneity which overcomes the possibility of segmental distribution. Inside the cord the capillary endings do not enter
squarely the nerve elements; the entrance is in the
supporting tissue, running parallelly with the elements. This is one of the natural safeguards alluded to before, it serves to attenuate even the effect
of the pulsations in the afferent vessels on the nerve
flux.
The arteries of the intervertebral foramina, or
spinal arteries, are derived according to the region
considered; in the cervical area, from the vertebral
A. which passes through the first interspace, and
for the eighth cervical, from the ascending cervical
A.; in the dorsal area, from the intercostal arteries;
in the lumbar area, from the lumbar arteries. Each
of these areas deserves a special study which, however, would be out of place in this very limited
work, therefore we may consider only the vessels in
the middorsal area. The spinal radical artery enters the intervertebral duct and follows closely the
nerve; at the confluence of the two roots it divides
into two main branches, each of which follows closely the filaments of one root to their emergence from
the cord, and ends into the fibrous structure of the
pia mater, where it anastomoses with the branches
of the spinal arteries proper. The main function of
the radical arteries is then to supply nutrition to
the spinal roots; besides this they supply blood to
all the organs in the duct and in the vertebral foramen; that includes the periosteum of the body posteriorly, of the pedicles, of the laminae, the -posterior
common ligament, the ligamenta flava, the fibroadipous extradural supporting tissue, the dura
mater, the various fibroconnective tissues, the capsular ligaments, etc.
The arteries supplying the nerves are known
generally as vasa nervorum ; aside from this nutrient
function they perform another which may at times
assume a great importance in the matter of collateral circulation. Long ago a number of clinical
observations revealed that, contrary to the common
assumption, this circulation takes place only to a
small extent through the muscle arteries and that it
follows mainly through the vasa nervorum. Thus,
each nerve being accompanied by one artery, which
receives from place to place a series of anastomoses
from nearby vessels, collateral pathways are then
naturally formed. In a number of cases nerve vessels were found greatly dilated by blood deviated
from its normal path; in others such a condition
was positively traced to the obliteration of one large
artery. It became obvious that the collateral circulation must be insured in a threefold manner:
through the muscle arteries, the cutaneous arteries
and through the vasa nervorum. Whether the nerve
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128
VERTEBRAL MECHANICS-GUY
is subcutaneous or deep, the arterial supply is ar- except, however, around the four veins. This
ranged in the same general way, and that applies plexus is internal to the ganglion; it furnished tenualso to the root filaments. Each arteriole divides ous rami which enfold the fibrous sheath and form
and subdivides continuously so as to form series of a periganglional plexus closely adherent to the
arcades attached to the nerve trunk; just as for roots. In the dorsal area the connections of the
the cerebral arteries which have many bends, creep plexus with the nerve are closer than in the lumbar;
upon the surface of the organ, so that never there in the cervical region the plexuses are very thin
is a perpendicular incidence which would cause the and their meshes are so dense that the pathway of
blood stream to impinge directly upon the en- the nerve appears as a restricted duct located at the
cephalic mass, likewise the same precautions obtain center of a regular mass of large venules intimately
for the nerves. When a nerve trunk receives its apposed one to the other.
The role of these plexuses is most important;
vessels from a satellite artery these always penetrate under a more or less oblique incidence after they convey all the blood from the medullary spaces,
describing a few curves, or loops, or a recurrent from the osseous, membranous, ligamentous and
path, and thus the final arterial rami reach the nerve fibro-adipous parts ; in emptying they permit the
fibrillea only in the form of filaments of the greatest systolic dilatation of the cord and the displacement
tenuity, which constitutes one more analogy with of the cerebrospinal fluid. Their congestion exerts
the circulation in the nerve centers. Sometimes an a tremendous influence upon the posterior ganglion
arteriole relatively large, after following the nerve and the roots, which they so’ closely enfold. The
surface for some distance disappears suddenly; it distribution of the venous capillaries along the nerve
suffices then to follow it to observe that it only fibrillae follows precisely the same order as that of
traverses from the surface towards the center, in the arterial ; their emergence and intrafascicular
the shortest way, and once arrived within the cel- division being such as to avoid disturbance of the
lular and fatty axis of the nerve, it ramifies contin- function proper of the nerves.
ually, and the tenuous branches terminate between
Fibro-adipous Supporting Tissue .-The dural
the fasciculi. Within the nerve the largest rami membrane is attached to the periosteum by means
are in fact found in the large neurilemmatic spaces, of irregular fibrous extensions; they are somewhat
and the arterioles entwine the fasciculi only after better defined on the anterior aspect of the dural
having reached a state of extreme tenuity. The ex- sack, starting from the median line and spreading
tremely rich vascular network permeating the cel- obliquely on each side, forward and downward, and
lulo-adipous tissue surrounding the nerve fibrillrae, ending upon the posterior common ligament. These
and as it were, bathing the latter in a blood stream, attachments, however, are so disposed that the
becomes an important factor of disorder when a movement of the vertebral column does not disturb
collateral derivation follows one given nerve, as con- the function of the cord and of the spinal nerves.
gestion may affect it considerably. Then we realize The extradural space is filled with a mass of fibrothat a nerve may, as we have seen in Part V, be adipous tissue extending through the whole length
affected by abnormal change in the composition of of the vertebral canal; it appears as a tube of conthe body fluids in nearby tissues, and in addition by siderable thickness enveloping the dural sheath
alternative (conditions of hyperemia, stasis or anemia, proper and extending into the intervertebral ducts.
due to irregularity of flow of its own nutrient blood. It contains numerous lymphatic vessels. It is a
The Venous System.-While the arterial networks sort of fatty mass, fairly fluid in the living subject,
within the duct appear incredibly involved. the ven- and is found as well in obese as in lean individuals.
ous system is still far more complicated, particularly In the vertebral canal it is somewhat lobulated; it
so because of the presence of extensive plexuses does not adhere to the dura nor to the walls, and
collecting return blood from various parts in the the venous plexuses enfold it without penetrating it.
spinal canal. In this latter we have vertically on The thickness is minimum in the cervical and dorsal
each side of the median line the anterior and pos- areas, and more pronounced in the lumbar region.
terior plexuses; then horizontally, at the level of In the intervertebral duct it is placed between the
each vertebra is the anterior transverse plexus which plexuses and the dura to which its fibers adhere
connects together the two anterior longitudinal rather snugly. Within the subdural space the cereplexuses, while a posterior transverse plexus does brospinal fluid is the organ of protection and of
the same to the posterior longitudinal plexuses; support for the cord, whereas within the extradural
two more lateral plexuses are situated one above space this fibro-adipous mass performs these imporand one below the internal aspect of the opening tant functions.
of the duct. The combination of all these plexuses
Because of its extensive vascularization and of
form a sort of ring, circellus foramninis, around the its wealth of lymphatic contents the fibro-adipous
membranous cone infolding the spinal roots. From mass may easily become the seat of infections more
the lateral plexuses start four veins, two upper and or less latent, of sclerous transformations; with
two lower, diagonally disposed, which traverse the pathological modification of its fluidity, consequent
duct and end into a large collecting vein, either ver- upon the advent of edematous conditions, of inflamtebral, intercostal or lumbar; these veins are said mation processus, the mass may become hyperto form, through transverse anastomoses, an exter- trophied, and the only way in which an increase
nal venous annulus.
of its volume may be accommodated, enclosed as it
Besides the four veins, their anastomoses and is within the solid walls of the vertebral canal (osthe adjunction of secondary veins, numbering from seous structures and ligamenta flava), is by the contwenty to sixty, form a real plexus held against the striction of the dural sack and extrusion of the mass
wall of the duct by means of loose fibro-adipous through the intervertebral foramina; in such a case
tissue, whose adherence is rather
easily overcome a compression is established which affects all of the
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VERTEBRAL MECHANICS--GUY
intradural organs ; the cerebrospinal fluid circulation is impeded and the pressure extended to the
cerebral ventricules produces a direct mechanical
disturbance upon many important structures therein, centers, plexuses, etc.; the cord and its nutrient
sheath are disturbed; in the intervertebral duct the
first organs to suffer are evidently the venous
plexuses, compression of which results in stasis,
stagnation of the return circulation, with attendant
decomposition of the blood and reduction of its alkalinity. It is obvious that the effects of these disorders are not merely local, although they may develop within a region either more intensely lesioned
or possessing an abnormally deficient resistance,
t h e y m a y extend to distant areas through
direct mechanical connection, or through nervous
reflex action.
The arterial networks, because
of their natural robustness, may perhaps withstand the compression at first better. than the venous
systems, but in time they are bound to suffer also;
then the nutrition of the nerve filaments will be
directly involved, the consequences of which can be
easily conjectured, depending upon the regions considered. Because the lymphatic circulation is a
slower process it is possible that the effects of compression are less consequential than upon the other
organs, although they are bound to become so in
course of time, particularly as regards elimination
of waste materials, so important in everything concerning nerve upkeep and function. As to compression of the nerve itself, as a main causative factor
of pain and of functional disturbance, that is a point
which has been originally maintained at the front
rank by many of our profession; there is no doubt
that mechanical irritation of a nerve, such as pulling, squeezing, twisting, has a disturbing influence
both local and distant, but it would be quite unwise
to jump at a final conclusion in this matter; and
above all, we must leave to others, insufficiently
versed in the art, the responsibility of advertising
far and wide the unfortunate notion of the osseous
impingement upon the nerves as the common basis
of all pathological derangements. And so, it does
not seem to us that the compression of the nerve
roots within the duct, as a result of the hypertrophy
of the fibro-adipous mass is as portent as the pathological condition of the vascularization of the nerve
filaments themselves, and mainly of the surrounding tissues. In fact, we may go a step further and
fully accept as axiomatic a conclusion arrived at by
Claude Bernard, i. e., that the vascularization of an
organ produces effects which reach throughout the
course of the nerves connected to it.
The truth of this statement holds even concerning purely physiological functions ; thus in experiments on animals in a state of fast, pronounced
irritation of the pneumogastric nerve was unproductive of pain symptoms, whereas during digestion the slightest irritation of that nerve provoked
painful sensations manifested by the cries and convulsive movements of the animals, and yet no morbid transformation was involved in these cases.
There exist then variations purely physiological of
sensibility, which are so much more important to
know that the sensory nerves are the most powerful intermediaries in the generation of diseases, and
that the motor centers receive in many instances
129
their excitations from the periphery. In the above
examples it is certainly not in the brain that we
should seek the cause of the great difference in
sensitiveness observed in the pneumogastric between the conditions of fast and digestion; we
should find it at the periphery, at the nerve endings
in the stomachal mucosa, which is seen tumefying
and reddening through contact with food, whereas
it remains pale and exsanguine when the stomach
is empty. The affluence of blood about the nerve
endings appears then as the real exciting agency,
or medium, which permits the development of such
an extraordinary modification of the nerve sensibility. The question of how the latter takes place is
most entrancing. Our hypothesis is that in fast
the antagonistic activities of the pneumogastric and
cerebrospinal nerves are in latent equilibrium, there
being no substance in the stomach capable of stimulating sensory reflexes, the viscerospinal nerves are
at rest, and irritation of the vagus produces but a
local effect of vasomotion, hence without pain
symptoms ; in digestion the sensory nerves are in
action as detectors of biochemical requirements,
and the vasomotor nerves function as regulators of
pneumogastric constriction or relaxation impulses ;
consequently, when an external agency, such as the
experimental irritation of the vagus, comes into
play, the function of the latter is contraried, which
means that at a critical moment of digestive activity there is a vasocerebrospinal unbalance, the circulation is deficient in one way or other, and the
sensory nerve endings are affected, most probably
by resultant hyperacidity, whence the pain symptoms observed. Furthermore, inasmuch that many
distributing agencies are known to affect the digestion process, such as emotional stresses, exposure to abnormal temperatures, shocks, etc., it seems
to us that the same reasoning would apply in the
analysis of the sequence of events obtaining in the
development of nervous unbalance leading to discomfort or even to disease.
According to Dr. Forestier the compression of
the spinal nerve and of all the nearby tissues within
the duct is the origin of severe rachialgiae and even
of peripheral disorders, such as the sciaticas, accompanied by contracture of the deep spinal muscles.
The fatty hypertrophy does not appear as a mere
aspect of a pathological processus without any casual
action upon the symptoms of the disease; instead, it is this hypertrophy which is the origin of
the syndrome, and the hypothesis of such a pathogenesis is verified by the results of operative intervention. In many countries sciaticas and lumbagos
have led the physicians a merry chase, and treatises
and memoirs on these subjects, not forgetting of course
the sacro-iliac lesions, are numbered by the thousands;
yet it cannot be said that a general understanding has
been reached, whether on etiology or nosology, and far
less on specific methods of treatment. In cases of
chronic funicular sciaticas, rebellious to usual therapeutic means, physical, radiotherapic, or others, Dr.
Forestier advocates two modes of action, one of
which consists in the injection of lipiodol into the
epidural space, a practice somewhat in vogue
at present in Europe; the other is laminectomy.
Several cases are cited in which the opera-
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130
VERTEBRAL MECHANICS-GUY
tion promptly relieved the pains and all other clin- ical elements select from the endomedium, the
ical symptoms, so that a complete cure ensued ; the blood, the divers substances with which their chemflexibility of the spine was restored to normal and ical constitution makes them apt to combine; most
its solidity gave no fears. The lamimae were re- often they elaborate these substances, assimilating
sected and,. after detaching the yellow ligaments, them in part, in one form or other, rejecting afterthe epidural fibro-adipous mass was exposed; free wards, likewise in various forms, the residues of
from constraint it appeared lobulated, the narrow this nutritive processus. These incessant interexparts corresponding to the level of the articular changes which constitute the life of the anatomical
disks; wherever the mass appeared in bad condition element do not take place through a mysterious
it was removed; so that the ablation of the affected force, as was formerly held, but by virtue of pure
mass, the resection of the laminae and the conse- chemical affinities; the cellular activity as one, the
quent removal of the yellow ligaments, all within blood plasma as another, are the two factors of nua couple of vertebral interspaces, suppressed the trition. Hence we may conclude that the greater
cause of the compression and prevented its recur- the vascularity of a tissue, the greater also will be
rence, by transforming into a supple, elastic struc- its nutritive activity; hyperemia, whatever its
ture, the posterior wall of the epidural space which, origin, will promote a tendency to hypertrophy ; inbefore, was semi-osseous.
versely, atrophy will always be connected with a
While we are not interested in laminectomy as diminished blood supply.
a curative means for lumbagos and sciaticas, and
The veins and lymphatics have for function the
for the very good reason that osteopathy has proved collection of the residues of this nutrition within
its worth in numberless such cases, it is well to the tissues. But their activity is not limited to the
know from reliable sources that inflammation may resorption of these waste materials, it exerts itself
affect the epidural supporting mass to such an ex- also, through the same mechanism, upon all fluid
tent as to produce the symptoms of pain and dis- or gaseous substances derived from ambiant tissues
order common to such diseases, and furthermore or from extraneous sources, which come into conthat positive proof thereof is demonstrated by the tact with their structure. They become thus prime
complete relief obtained after the decompressing agencies for this most important function generally
operation, we are far from being convinced that the termed elimination.
turgescence of the mass was the primary causative
To’ be functionally effective, arteries, veins and
factor of disease. Obviously, it suffices to call atten- capillaries must be under the incessant control of
tion to the matter to realize that this turgescence the nervous system; the great law of requirement
was due to some disturbance of the circulation ; con- and supply applies even to the smallest anatomical
sequently, if the casual factor of this disturbance element; its infringement means unbalance, diswere known it would probably be possible to gradu- order, death somewhere; the needs of the element
ally reestablish the circulation by overcoming its must be promptly reported to headquarters, and
impediment. It is not like the age-old question of compliance therewith likewise promptly’ afforded.
determining which came first, the egg or the hen; And so within the restricted spaces encompassed
it is fortunately much more logical and simpler, as by the vertebral and intervertebral ducts, we ‘behold
demonstrated currently in osteopathic clinic. In an infinity of nerve fibrillae with their imperceptible,
all the cases above mentioned we observe fine ex- yet most efficient terminals, here detecting impresamples of symptomatic diagnosis, which still insists sions, there conveying commands for action, for
upon indicting local morbid conditions, germ infec- succor, all for the supreme purpose of insuring safe
tions, inflammation, exostosis, etc., as prima facie traverse of the span of life, as inexorably ordained
primary and sole causative factors, and then calls from the ovum to the grave, as well for the simple
cell as for the whole organism.
for most drastic measures of eradication.
We have seen the spinal roots accompanied
Before leaving the subject, the thought occurred to us that the supporting mass is made up of throughout their course by the vasa nervorum, that
adipous tissue mainly for the purpose of affording is, the arteries, veins and their endless ramificaprotection to the cord and the spinal roots against tions, and all these, in turn, by a double system of
sudden changes of temperature. Effectively, these nerves, the sensory and the vascular. Sensory
organs are relatively quiescent within the strong branches extend plentifully to the ligaments and to
walled vertebral canals, for the good reason that the articular organs. Of the impressions gathered
the integrity of their functions requires that they by the sensory terminals some are referred to the
be spared the shocks and disturbances which the ideation centers in the brain, there to be elaborated
nerves distributed throughout the muscles and and transformed; they have to do with the safe
other active organs of the body can easily withstand limitation of movement and of posture ; others are
because normally, intense circulation, ‘friction of concerned with the trophicity of the tissular eleparts, respiration of the tissues, etc., help to main- ments and reach the cord, where transformed into
tain a healthy average temperature. In this rela- reflex phenomena they are referred back to their
tion we suggest that it would be most instructive starting point. The vascular nerves hold in. their
to study the etiology of a disease! quite prevalent dependence the smooth muscle fibers of the arteries
in the summer season, i. e., poliomyelitis, from the and veins; in accordance with the reflexes these
point of view of overexposure to the sun rays as fibers contract, dilate or simply remain in a state
well as to prolonged cold immersion. We may of tonus, thus diminishing or enlarging the caliber
of the vessels and controlling the flow of blood
eventually deal with this and other allied matter.
The Nerve of Luschka .-The arteries bring to the within the tissues. The vascular nerves are the
living tissues the liquid or gaseous principles neces- regulators of local circulations and exert a preponderating,
exclusive action upon the interstiAll Rightsthe
Reserved
American
Academyifof not
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sary for their nutrition and function;
anatom-
VERTEBRAL MECHANICS-GUY
131
tial nutrition. Here as elsewhere in the body the root is formed, in one-fourth of cases, of two filaperformance of such functions requires, the pres- ments originating near one another on the anterior
ence of three sorts of nerve fibers, sensory, motor aspect or on the upper surface of the spinal nerve,
and sympathetic, and as they cannot emanate within exceptionally on the posterior face; it is directed inthe ducts, they necessarily must originate exter- wards towards the intervertebral foramen, anternally from divers sources, assemble and then pro- iorly to the spinal nerve and rarely above; after a
ceed into the intervertebral ducts. We should note traject of about three mm. it unites with the sympacarefully that through this external origin, not only thetic branch at an angle open forward, outward and
will the nerves deal with the local control of the in- most always downward.
ternal organs, but also that they may convey outside
The sympathetic root is very variable, almost
influence inwards, and vice versa. We realize then always situated on a plane below the cerebrospina!
that interruption of the diastaltic, or reflex arc, will root; it may proceed directly from the upper pole
cause perturbation in the nutrition processus, of the subjacent ganglion, but that is exceptional;
whether this interruption interests the centripetal most frequently it originates through one or two
or the centrifugal nerves.
branches of the most posterior and internal ramus
From the university town of Tubingen, Wurt- comm. issued from the subjacent ganglion; sometenberg, came in 1850 a most important contribu- times one root comes from the ramus comm. and
tion to the knowledge of anatomy ; its signification the other, more voluminous, applied snuggly
has been recognized by few, and merely classified against the costal head, starts directly from the subas interesting among many other precious findings jacent ganglion, close to the ramus comm.; finally
of those times. From the viewpoint of our profes- in about one-fourth of the cases the arrangement is
sion, which is entirely utilitarian, based upon imme- quite special, the sympathetic root being formed of
diate reduction to practice, this contribution is the two filaments, one coming from the subjacent
keystone of the understanding of lesion. Luschka ganglion and the other from the ganglion above,
gave an extensive description of a small nerve the former crossing the anterior aspect of the ceretrunk which, at the level of each intervertebral fora- brospinal root.
men, enters the vertebral canal and distributes its
The two roots spread out in the midst of the
filaments to the vertebrae, to the venous sinuses, to ramifications of the spinal artery and of those of
the arterial branches, to the dural sheaths and ex- the regional veins, veins so variable in their divitradural fibro-adipous mass, to the ligaments, etc. sions and anastomoses as to preclude description.
Because of its mode of distribution Luschka proThe sympathetic root, more extensive, travels
posed calling it the Sinu vertebral N., or Osseous among these vessels, here in front, there in the rear.
and Vascular N.; it originates from two roots, one The ensemble is screened by the adipous mass, so
cerebrospinal, the other sympathetic ; its disposi- thick and consistent, which fills the region and
tion is apt to vary and not always the same on both hides completely vessels and nerves.
sides of one vertebra. The spinal root is often
When constituted the sinu vertebral N. extends
double and starts within the intervertebral duct not more than three mm. before crossing the operabout three mm. externally to the posterior gang- culum; it is not rare to see it divided into two or
lion; for the sacral region it starts a little closer to three rami, each of which traverses the operculum
the ganglion.
The sympathetic root is much through one special orifice. It runs anteriorly to
smaller than the other; it comes from one of the the spinal nerve and the anterior veins in the duct;
rami communicantes.
T h e u n i o n o f t h e t w o sometimes hidden among the veins, at others it is
branches occurs about the external aspect of the located forward in contact with the osseous surface.
longitudinal venous plexus; the trunk of the nerve From the initial portion of the nerve, or oftener
is short and surrounded by a thick fibrous layer; it from its sympathetic root, arise some collateral
divides into terminal branches located in variable branches, tenuous filaments reaching the vertebral
ways with respect to the plexuses, either in front or arches (Luschka), and particularly a long one exback of them; except in the sacral region rarely tending outward against the upper aspect, then
does the nerve reach the median plane before divid- upon the internal face of the costal head, and then
ing. In its traject the sinu vertebral nerve gives spreading into the periosteum. Shortly after its enoff fine collateral fibers, some of which supply the trance into the duct the nerve divides into terminal
vertebral arches and the apophyseal articulations ; branches, some short, ending at once upon the longiit is evident, although almost impossible to follow tudinal venous plexuses; others proceed with varithem definitely, that they penetrate into the thick- able obliquity through the epidural space, peneness of the bone; a costal branch reaching the neck trating inside the bone in the posterior aspect of the
of the rib is more distinct, it is also found about the vertebral body and the anterior aspect of the lamilumbar costiform processes. Of the terminal fila- nae, reaching the posterior‘ common ligament; some
ments some reach the vascular sheaths, others again apply against the dura, spreading out into
seemingly mostly composed of sympathetic fibers numerous ramifications before penetrating it. Etc.,
end into the fibro-adipous mass separating the dura etc., figures 27 and 30.
We do not expect to be forgiven for the jumfrom the periosteum.
In the thoracic region the cerebrospinal root bled presentation of the above maze of technical
originates from the spinal nerve, not close to the details concerning the arterial, venous and nervous
posterior ganglion, as stated by Luschka, but after systems obtaining within the vertebral canals. Unthe nerve is entirely clear of the intervertebral duct able to secure requisite information in regular textand has traversed the fibrous operculum, that is, be- books, we had to investigate various sources dating
tween the latter and the internal border of the an- from different periods, which explains the seeming
contradictory
expose'
at times, but on the whole,
terior costotransverse ligament. The
cerebrospinal
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132
VERTEBRAL MECHANICS-GUY
we shall feel amply rewarded if the harsh criticism
we expect may be turned into a firm desire to have
our schools delve thoroughly into the subject
merely pointed out here, the knowledge of which is
so essential to the comprehension of the osteopathic
principles.
Edema..-Mechanism of Production.-Elimina-
tion .-The multiplicity of delicate organs within the
vertebral canals is fraught with peril of numerous
local and distant derangements, all of which however have to do with circulation, that is, with life
and functions of tissues. The one disturbance commonly found at the start is edema. It may be
caused by hyperemia or by anemia; through intravascular or extravascular. pressure ; through disturbed vascular innervation; through blood or
lymphatic vascular obstruction. The extant serosity
is not a mere transudation of blood or lymph serum,
as proven by numerous chemical analyses. When
a vein is obliterated and the blood does not find in
collateral veins sufficient passage to return freely
to the heart, edema develops within the organic
territory drained by that vein. This was established by the experiments of Lower as early as
1680, and later by many others in such a way as
to fix beyond doubt the relation existing between
the edema and the vascular lesion. The facts are
naturally explained by the increase in blood pressure below the obliteration and by the exudation as
immediate consequence.
Edema occurs also when the arterioles and
capillaries of a region are obstructed; the blood in
the continuing veins ceasing to be drawn towards
the heart by the vis a tergo loses its pressure, and
there is a retrograde flow from neighboring veins
towards the capillaries, which increases the pressure
somewhat, but mainly contributes to stasis followed
by serous transudation (collateral edema). An identical phenomenon is observed in some cases of main
arterial obliteration.
the consideration of reflex action, stating that:
Prolonged irritation of sensory nerves often produces a lasting reflex dilatation of the vessels, with
edema as a consequence. Vulpian, who held at first
for a casual disturbance of the capillary circulation
conditioning “collateral capillary fluxion,” and also,
as before stated, the venous “retrograde fluxion,”
suggested another mechanism. He thought that
centripetal irritations due to nerve lesions were reflexed, not to the arteries, but exclusively to the
smooth muscles of the veins and venules; these
vessels becoming constricted would interfere with
the return circulation, pressure would increase in
the capillaries and serous transudation would consequently ensue. This interpretation quite naturally leads us to a most interesting consideration of
the vasomotor processus which, even up to date, is
so unconvincingly expounded in textbooks, and to
what we believe is a novel presentation of the
subject.
In the first place we were taught that circulation is regulated by the action of nerves; some of
these conveyed stimuli to the smooth muscles in
the arterial sheaths ; the muscles contracted ; the
vessels constricted; the flow of blood was then
restricted. The sequence of events was faultlessly
logical, easily understood, and the notion of vasoconstrictor nerves unreservedly accepted. The
return to normal flow was readily explained by the
relaxation of the muscles and the simultaneous expansion of the sheaths through their structural
resilience. Increase of blood flow through vasoexpansion was naturally assigned, as a matter of
course, to the action of vasodilator nerves and
muscles. But here was a great stumbling block;
whereas everywhere in the body muscle antagonism was the rule, as for instance where a. flexor
muscle always worked conjointly, and reversedly,
with an extensor muscle, here the, dilators could
not be found, either within nor outside the sheaths,
While the influence of the nervous system and there the question remained, unsolved despite
upon the. formation of edema had long been the unremitting efforts of the average physiologists,
suspected, it was only in 1869 that Ranvier demon- a set of well intentioned, but often disappointing
strated through extensive experimentation that, ex- people who at times build up magnificent struccept in cases of actual rupture of blood vessels, the tures upon hypothetical foundations, which they
vasomotors were the main instrumental factors. seem to take special delight in uprooting, to the
The modus operandi became clear later on when great dismay of the confiding student.
(To be comtinued)
Schiff, in his Physiology of Digestion,
brought in
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133
VERTEBRAL MECHANICS-GUY
EDITOR'S NOTE
Following the suggestion of several Academy members we are reproducing here two very worth while articles by the late Dr. Charles
Hazzard on "The Rule of the Artery Is Supreme and"The Osteopathic
Concept Viewed Biophysically and Biochemically".
There have also been many requests for the reprinting of the
two series of articles by Dr. Albert E. Guy who has very graciously
consented to their inclusion in this volume. These are two w'onderful studies on spinal mechanics and the osteopathic vertebral lesion
and it seems worth while to have them altogether in one volume for the
convenience of Academy members. and particularly those who will be
participating in the Academy Post Graduate Program.
The Publication Committee would appreciate the suggestion of
other articles worthy of inclusion in subsequent Year Books.
Permission to reprint these copyrighted papers by the American
Osteopathic Association for the benefit of the membership of the
Academy of Applied Osteopathy is greatly appreciated.
.
Vertebral Mechanics
ALBERT
E . G U Y, D . O .
Paris
PART VI
(Continued from January issue)
of vital importance ,to the subject failed to receive
the due consideration which would have led directly to the required solution of the problem. The
first is that venous sheaths contain muscle fibers,
not to the same extent as the arteries, to be sure;
that these muscles must be there for a purpose,
undoubtedly vasoconstriction ; that wherever there
is a muscle fiber there are always at least two kinds
of nerves concerned, sensory or detector, and
motor. The second point is that whenever vasoexpansion is called for, it is not intended for the
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134
VERTEBRAL MECHANICS-GUY
nerve purpose of flushing the blood vessels, but
rather to carry a larger blood supply to a territory
served by a given capillary network, either in need
of it, or accidentally compelled to receive it willy
nilly. If instead of simple flushing we were to deal
with collateral circulation, then of course the resistance to the flow must be reduced, and consequently the arterial and venous muscle fibers
completely relaxed so as to provide through vasoexpansion. the best possible area of passage. But
to suit extra supply to the territory the arterial
muscles must be completely relaxed, while the
venous muscles are contracted; hence the venous
passage is constricted, the pressure increases in the
artery, the arteriole and the arterial capillaries;
they become distended and the enlarged superficial
area of the capillaries permits of greater osmotic
action which, together with the greater internal
pressure, insure the penetration of the extra volume
of blood elements into the surrounding tissues. Normally the tissues must soon be drained of the fluid
and waste accumulation, then the process is reversed, the venous muscles are relaxed while the
arterial ones may be contracted, the blood supply
is reduced., the intratissular pressure added to the
vis a tergo, which now has free rein, insure penetration into the venous capillaries and thus restore
the return circulation to normal.
In principle that is all there is to the operative
mechanism of capillary circulation; it suffices fully
in the three main conditions ranging from plethora
to normal,, then to depletion. In normal flow the
sheaths are maintained in incessant state of vibration, first through the pulse, and then through rapid
alternate contraction and relaxation of the muscle
fibers under nerve control ; this is essential in all
organs of regulation which may be called upon to
respond instantaneously to a demand for variations
in range of operation; we may observe the reduction to practice of this principle is high speed
machinery, steam turbines for instance, where the
governor is kept constantly oscillating so as to
avoid sluggishness in starting its work of control
of the uniformity of speed, when the latter is
threatened. by sudden changes in power requirements.
In plethora we have in sequence, relaxation of
arterial muscles ; contraction of venous muscles ;
venous constriction ; increased arterial flow ; fluid
surge in the capillaries ; increase of pressure in the
latter, then in the arterioles; consequent distension
of the artcerial vessels, whence maximum delivery
of ‘blood. Should this condition be maintained
through some cause affecting the nerve control,
hyperemia would obtain, followed by infiltration of
the tissues ; insufficient absorption through the
usual connective tissue pathways would result ‘in
congestion, with transformation of plasma into
serosity, thus establishing edema. Any stagnant
fluid in the body undergoes some form of decomposition, with attendant production of acidity,
(lactic acid particularly), and release of CO,. For
normal function muscle fibers require an alkaline
medium; it is well known that muscle contraction
is affected when this medium is modified, even by
an acid so diluted as not to chemically alter the
tissues. (Claude Bernard, 1859.) Acidity is decidedly irritant to the nerves, and particularly so
Consequently we realize
that a local edematous condition is bound to affect
the musculature of the blood vessels, the nerve
endings in the sheaths, in the territory served by
the capillary network, all of which will further
aggravate the circulatory disorders and, through
contiguity or by reflex action, cause disturbance in
near or distant parts. The circulation which at first
was accelerated by arterial expansion may become
so reduced as to propoke stasis, fibrination, coagulation of blood in the network, which leads directly
to inflammation processus ; effectively, the region
in which obliteration occurs is always recognized
as the primary seat of inflammation and of eventual
suppuration.
In vaso depletion, or diminution of the circulation in a network territory, there may be simultaneous constriction of the arteriole and the venule,
or constriction of the arteriole only, with the venule
at first unaffected. The maintenance of such a
condition would obviously produce anemia, lack of
nourishment, hence wasting of the territorial tissues and of the capillaries themselves. It is unnecessary to speculate at length on this aspect of
the question; we may remark, however, that the
local disorders would require appreciable time to
develop into serious pathology, while their effects
on the nerve terminals would probably be less consequential for distant organs, through reflex action,
except of course when concerning highly specialized structures, than would those resulting from
severe hyperemia.
As to elimination, we have already mentioned
that it takes place through the agency of the vessels
within the connective tissues, that is the veins and
the lymphatics.
All the above considerations apply generally
to capillary circulation through the organism, but
we must recognize now that they apply also, and
with still greater force, to the delicate structures
located within the vertebral canals, because of their
most intensive vascularization, and that the development of edematous conditions in their midst is
bound to produce distant effects far surpassing
mere local tissular disorders. One point of primary
importance for us is the determination of the process through which distant disturbances may affect
the cord structure, starting therein reflexes which
may be influential in the production of what we
recognize as lesions. The existence of these is
revealed through palpation, in the form of contractures, of vertebral displacements, of painful areas,
of disordered function, of impaired mobility, etc.
We may then attempt to delineate schematically
the mechanism of the transmission of impulses
which sets into action the operative mechanism of
capillary circulation described above.
Mechanism of Capillary Circulation.-For the
purpose of discussion we may conceive a vascular
system as sketched in figure 30, in which art artery
divides into a number of branches, or arterioles ;
each becoming an arterial capillary out of which
nutrient materials pass into the surrounding tissues ; immediately following comes the venous
capillary into which are discharged CO2, waste
matter and fluid residues from these tissues ; this
continues into a venule which in company with
many others combine to form the collecting vein,
a branch of the return circulation system; we
to the sensory nerves.
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VERTEBRAL MECHANICS-GUY
assume that a certain territory is served by one
given capillary network, which provides its nutrition and drainage.
The sheaths of the artery, arterioles, venules
and vein have muscle fibers; consequently each of
these fibers is under nerve control, and evidently
since each kind of vessel has a function of its own,
each must have specific control. The condition and
wants of the territory are detected by the terminal
organs of sensory nerve filaments anastomosing
into a branch S which, after passing through a
local ganglion, is referred finally to the posterior
root and to the spinal cord. From the gangion issue
two motor nerve branches A and B, with terminals
distributing to the arteriole and venule muscles.
It seems plausible that for routine function the impressions gathered by the sensory terminals are
transmitted to a master cell C in the ganglion where,
according to their intensities, they cause impulses
to be generated, which are directed through A and
B to the muscles. It follows that, depending on
circumstances, A may be inhibited, thus relaxing
the muscles and allowing the arterioles to expand
while simultaneously B is actioned and the venules
contracted ; or on the contrary B may be inhibited
and A actioned ; or again the two may together be
actioned or inhibited. The mechanism of the discerning and selective activity of cell C has not yet
been exposed; however it must be very simple, and
possibly is a mere function of the intensity of
sensory impressions; the reflex is formed by S and
its terminals, the cell C and the terminals of A and B
amply suffice for the ordinary needs of the territory. Stronger impressions would require stronger
action, in which case the nerve filaments D and E
may convey impulses to the artery and vein, causing their expansion or constriction in the same way
as for the smaller vessels. Over intense impressions may cause dysfunction of cell C, and be conveyed by Ss to the sympathetic ganglion, and then
referred to the cord and to the ideation centers,
where pain or disorder sensation may be evolved.
In response motor stimuli may be sent by reflex
action from these centers, to the cord segment, the
sympathetic ganglion, thence to the local ganglion
and probably to adjoining ones. It is most certain,
judging from clinical and experimental observations, that the over intense impressions reaching
the sympathetic ganglion will affect other sensory
endings there, and that the whole territory served
by the regional sensory nerve will be affected, thus
in turn causing dysfunction in parts distant from
the original disturbed area. Once we admit the
plausibility of this reasoning we readily understand
the reverse process, that is, the effects of disturbance within distant organs, peripheral parts, cerebral or medullar centers (emotional, etc.), extending
distally to elemental vascular systems, causing
plethora or depletion, whence blushing or pallor,
sudor or dryness, pilus erection, warmth or chill,
contracture or flabbiness, pain sensations, etc.
As a practical illustration-or diversion-let us
consider the case of a patient diagnosed as acute
pericarditis, in accordance with symptoms of remittent fecer, distress, nausea, vomiting, disturbed
cardiac action, precordial tenderness and *pain,
slight dry cough. If we know the cause we might
feel more at ease. However, we may prescribe as
135
usual: absolute rest in bed, quiet, milk diet, either
hot or ice applications to the precordium, with
morphine or atrophine to reduce the pain. or,
if we are merely an osteopath we proceed with
careful palpation while intensively cerebrating in
this manner: precordial pains are impressions conveyed by sensory nerves; such nerves on the naterior aspect of the pericardium are terminal branches
of the right phrenic nerve, although the left may
contribute ; the phrenic nerve receives its principle
root from the fourth cervical, and secondary ones
from the third and fifth cervicals.-Palpation of
the neck reveals an extensive lesioned area involving mainly the third, fourth, fifth and sixth vertebra ; in addition the neck and shoulder muscles are
found contractured, particularly on the right side;
thumb pressure applied on a spot about two-thirds
down the scapula, on the bisectrix of the lower
angle, provokes an excruciating pain, more pronounced on the right side ; the right shoulder is
very tender; painful irradiations extend in the arm
to the level of the elbow; the upper dorsal area
close to the spine is very tender. This being an
acute case, and there being no prima facie evidence
of infection, what is the verdict? The osteopath
then suggests to the patient that his trouble may
be the result of exposure to cold, particularly affecting the shoulder and upper back muscles on the
right side ; this, after a little reflection, is admitted
to be the case: automobile ride after a tramp
through the country, exposure to direct and back
draft. Upon what bases was this diagnosis established? The case was acute; the cervical lesions
were of recent origin ; the vast extent of the body
contracted, in pain, or even tender, s u g g e s t e d
regional irritation of sensory nerves; cold exposure
could produce all that.
The pain symptom in the infraspinous fossa of
the scapula is very presious; invariably it indicates
lesions of the fourth and fifth cervicals; it affects
the infrascapular nerve, a branch from the suprascapular, formed mainly from the 5 C. root. The
pains in the shoulder were due to irritation of the
cutaneous branches of the supraclavicular N. (4, 5,
6 C), and of the axillary N. (5, 6 C) ; the pain in
the arm was due to irritation of the musculocutaneous N. (5, 6 C), and of the internal branch of
the radial N. The disturbed cardiac function could
be ascribed in part to the action of the rami communicantes issuing from the 5 and 6 C roots, which
join the middle cervical ganglion; from the latter,
and through the sympathetic chain, connections are
established extending to the cardiac plexuses. The
other symptoms could be traced in similar fashion.
The course of treatments consisted in careful but
most thorough relaxation of the soft tissues, and
correction of the cervical lesions. This was a n
actual case. The conclusions seem obvious.
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VERTEBRAL MECHANICS--GUY
Vertebral Mechanics
ALBERT E. GU Y, D.O.
Paris
PART VII
To&cc&.-Just as in our school days, after we
became initiated to the mysteries of elementary algelx-a, we delighted in tackling problems as they presented themselves here and there, and thus became
proficient in practice, so it is also with us in the field
we have chosen, and we find great and profitable
pleasure in analyzing not only the cases we handle
daily, but principally those that are brought to our
attention by more matured and experienced practitioners. Some of our most difficult cases usually come to
us after everything else has been tried, and osteopathy
is called upon as a last resort. Therefore, excusably
at that, we start with some trepidation, in spite of our
faith and our methods, and as we progress and ultimately achieve success, we cannot help wondering in
awe at the potency of the treatments. This peculiar
feeling is engendered from the fact that outside our
profession we must not expect credit for the success
of our efforts, as it is well nigh incredible for other
schools that mere manipulations and simple spinal corrections could accomplish that which balked most
conscientious adepts of widely recognized medical
means. We can overcome this feeling, not by compiling extensive statistics of cases, unconvincing to the
adamant state of mind of the outsiders, but, individually, by minutely analyzing the cases as they come
to our notice ; so that we may more and more clearly
visualize the pathology involved, study the various
causes of disorder, devise the most likely means to
overcome these latter, and finally observe the effects
of these means and catalog them for future reference.
We cannot afford to remain satisfied with what ordinary routine treatment can accomplish; we must be
constantly guided by the thought that osteopathy is
bigger than any osteopath, bigger even than its
founder, Dr. Still, and indeed the Old Doctor was
ever ready to recognize that fact; and that imposes
upon us the: task, most pleasurable after all, of ceaselessly “living with our cases,” somewhat in the manner suggested above.
A most interesting case is recently called to our
attention by Dr. Charles Hazzard, who had successfully treated it, and who presented a detailed review
of it before the Technic Section, Annual A.O.A.
Session at Philadelphia It was one of forceps delivery. After a few weeks, in which it appeared to be
normal, the child gradually, over a period of two
months, developed a condition marked by wryneck,
cross eye, oscillations of the eyeballs, spasms of the
spinal muscles, and severe convulsions. An anomalous feature of the case was the occurrence of a
marked periodic bulging of the fontanelles and of the
parietal bones. Lumbar puncture had been performed
twice, but with the production of no cerebrospinal
fluid, only a little blood.
As a problem, the primary or cardinal points are:
(1) forceps. delivery ; (2) proven absence of congenital infection ; (3) robust constitution which kept the
child in apparently normal condition for a few weeks
after birth; (4) gradual development of the symptoms
enumerated above. The question is to trace the origins
of this development.
‘The Journal, Sept. 1930, p. 33 .
Wryneck or torticollis is an affection characterized by severe contracture of the cervical muscles,
accompanied at first by excruciating pain upon the
least movement of the head and neck. The head is
maintained inclined to one side and the cervical vertebra are consequently held in lateral bending position,
with their convexity on the opposite side of the head.
The first muscle affected is usually the sternocleidomastoideus; then follow the scaleni, the splenius, the
trapezius, and to a certain extent the platysma and
the cervical fascia ; but such a sequence is far from
proven, and it must be adjusted to suit the true origins
of the disorder. In the textbooks the causes are attributed to cold exposure, to overexertion, to overrotation of the head and neck, to trauma, to injury at
birth, to infection, all of which has been demonstrated,
Some authors, however, have gone a long way past
the goal in stating that: A few cases of acute torticol-
lis are caused by some of the deep muscular fibers
becoming caught around a process of a vertebra:. It is
greatly to be regretted that such an anatomical stunt
has never been described with details and illustrations
worthy of the most extraordinary phenomenon.
Whatever may be the original cause, one thing is
certain, and that is the muscular contracture characterizing the disorder. Contracture is a state of contraction of an skeletal muscle which is beyond the
power of voluntary control. Muscle substance possesses the property of changing form under the
influence of certain stimuli, but it cannot do so spontaneously, for living matter cannot any more than the
inanimate, impart motion to itself, therefore the stimuli
are generated by extraneous means and conveyed to
the muscle cells by the nerves. As contracture is
always an abnormal condition, this elementary reasoning leads us to admit the existence of a disturbing
factor affecting the nerves themselves, or their roots,
or the cord, and accordingly, producing specific
symptoms.
Although we know that the head was misshapen
by the forceps, there is no direct evidence of external
injury to the cervical parts; if the spinal accessory
nerve had been injured by pressure directly at its exit
through the jugular foramen, immediate+ symptoms of
disorder would have been manifest. It is then plausible
to admit that the lesions affecting some of the numerous organs within the vertebral canal were produced
by pulling or twisting during the expulsion process.
Such lesions may concern the yellow ligaments, the
posterior common ligament, the periosteum, the articular capsules,, but not necessarily the meningeal membrane directly. The repair process which began at
once involved some degree of hemorrhage, extravasations, edema,. phlegmasia (always present, as we
have seen in previous articles, whenever any tissue
undergoes repair), all of which would tend to establish
a regional compression within the canal of sufficient
intensity and extent as to interfere with the downward
circulation of the cerebrospinal fluid. This would suffice to account for the fact that two lumbar punctures
failed to release any fluid, except a little blood, and to
relieve the intracranial pressure. If we agree upon
such a location of the lesion we can easily understand
the progressive development of the pathology, which
was aided undoubtedly by the effects of the intracranial conditions upon various important centers.
The repair depended mainly upon extensive nutrition
and elimination, but both processes became increasingly interfered with, with the result that a state of
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.
MECHANICS-GUY
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hypo-alkalinity was established within the tissues and cervicals, whose fibers traversed the inferior cervical
the fluids, which was bound to affect the vicinal nerve ganglion; thus understood it could be compared to the
elements. Of these, the most exposed are obviously great splanchnic nerve. Such an opinion has been conthe roots of the spinal accessory nerves, three to six firmed by experimental data, and it was shown that the
of which emerge from the lateral sulcus of the bulb, vertebral nerve represents the assemblage of a certain
while the others ascend alone the cord, emerging from number of rami communicantes, and that it contains
its posterolateral aspect from a level which may be as accelerator nerves which reach the heart after passing
low as the sixth cervical root. This nerve is motor through the cervical ganglion and connecting with the
to the Sterno-cleido-mastoideus and to the trapezius; inferior cardiac nerves. From this we clearly see that
its irritation will of course induce the contraction of cervical lesions, such as those resulting from a condithese muscles.
tion of torticollis, may have far-reaching effects, not
A point which he has not found mentioned in the only upon the function of the heart but also upon the
texts, but which the writer has had the disagreeable intracranial circulation. That of course concerns priexperience to observe and study upon himself, is that, marily the arterial distribution, but as we have seen
except in certain forms of trauma, torticollis is of in the previous articles, any congestion within the
insidious origin, which involves most always, and to vertebral canal is bound to affect at once the multisome degree, the cord and its meningeal membranes. tudinous venous plexuses within it and interfere most
At first the contraction of the muscles is bilateral; it seriously with the process of waste elimination. With
may spontaneously disappear; but if not it will grad- a blocked drainage the rule of the artery completely
ually increase in intensity, with the consquence that the loses caste.
In this case it would seem that the convulsions
intervertebral discs will be subjected to great abnormal
pressure, that the vertebral ligaments will become were caused by hemorrhages, probably mostly meninaffected and that the discs will tend- to bulge all geal, and by a certain degree of consequent meningitis.
around, and particularly within the vertebral canal. The cervical compression of the, cord interfering with
The cervical part of the vertebral column will then the circulation of the cerebrospinal fluid downward,
become in a condition of unstable equilibrium. Then was bound to be reflexed intracranially in the form of
a sudden movement, a draft, a cold application, an congestion, accumulation, and of pressure which
emotional stress, will cause a sudden rupture of that tended to help along the absorption of the fluid by
equilibrium, and as the column cannot give way later- the usual channels; all of which resulted in spasmodic
ally, there will be an abrupt twist of the head and neck, action with an extremely abnormal periodicity. The
with production and maintenance of an exceedingly movements of the eyeballs, controlled as they are norsharp pain. The twist is usually to the left and the mally by voluntary muscles, themselves controlled by
cervical vertebrae present a marked convexity on the cranial nerves, became disordered when these nerves
were affected at their roots, both by hypo-alkalinity of
right side.
the fluids and tissues, as a result of blocked drainage,
Although we have no information regarding the and also probably by the great intracranial pressure
development of the wryneck condition in the present due to congestion of cerebrospinal fluid and of the recase, we have every reason to assume that the process turn blood.
evolved in the manner just stated. It is a question
It is most worthy of remark, and we have here
whether at first the 2nd, 3rd and 4th cervical nerves, much food for thought, that all’ the pathological conwhich contribute branches to the sterno-cleido-mas- ditions reported gave way under the judicious ministoideus were involved, but it is certain that as soon terings of Dr. Hazzard, which consisted exclusively in
as the wryneck was established they became so, with osteopathic manipulations and correction of the spinal
the consequence that other muscles contracted, such lesions, particularly those in the cervical region.
for instance, as the scaleni. Then followed in sequence Manipulations of the soft tissues promoted at once a
the change from contraction to contracture; the up- decongestion, a drainage of the waste fluids they conward displacement of the first and second ribs, with tained, and the consequent relaxation of the muscles
the attendant disturbance of the costovertebral articu- from their former state of contracture; with drainage
lations ; the tilting of the clavicle and the displacement reestablished, arterial flow promptly resumes its sway.
of the scapula. As soon as the trapezius and the deep The repositioning of the cervical vertebra became easy
cervical muscles were affected, the trouble extended of accomplishment as soon as the contractured muscles
readily to the spinal muscles in the upper dorsal region, were relaxed. So far, this is a mere reiteration of well
which meant certain involvment of the heart action known and understood matters ; the really interesting
and consequent further impediment to the general cir- point is the study of the mechanism by means of
culation.
which the pathological conditions within the vertebral
We must not leave out of consideration a most canal were overcome.
important organ, not generally recognized, but to
There are many persons, while readily acknowlwhich the name vertebral nerve has been given by edging the beneficial results of osteopathic treatments,
Cruveilhier, and which forms the vascular plexus of are at a complete loss to understand,’ to visualize, the
the vertebral artery. It is usually made up of three mechanics of an apparently simple process, applied exbranches, ascending with the artery and the venous net- ternally, which nevertheless is capable of far-reaching
works through the intratransverse canal, receiving on effect upon internal organs, for instance. Besides, we
the way anastomotic filaments from practically each have many osteopaths who devote but a short time to
cervical nerve. The right and left cervical plexuses ar- soft tissue preparation, and then apply what is known
riving within the cranial cavity fuse together about the as specific treatment; with the patient placed in approbasilar trunk into a single plexus which then gives off priate position the operator skilfully performs a series
secondary plexuses all along the collaterals of this of corrections and vertebral or costal replacements,
arterial trunk. It has been observed that the vertebral while the patient is aware that only a few bones have
nerve was formed by rami from the 3rd, 4th, and 5th been cracked. Some of the patients actually feel
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VERTEBRAL MECHANICS-GUY
slighted; they had come prepared to sustain an extensive siege of operations, and it is only after the manifestation of the beneficial results that they become
reconciled, although left in lingering doubt because
of a complete lack of understanding of the modus
operandum.
Some eighty years ago-the exact date is not at
hand just at present-a celebrated French doctor, in
charge of one of the largest hospitals in Paris, performed the then most surprising feat of reducing a
fleshy tumor simply by digital kneading of the mass of
tissue involved; it is said that such a treatment was
quite awe inspiring his staff of internes who had
always understood that in such a case the usual application of heat and appropriate unguents was the sole
method to be considered. The attending success was
such that a detailed report was duly presented to the
Academy. It was explained that the kneading relaxed
the tension of the tissues, and forced the drainage of
the pathological fluids through the veins and the connective tissue networks from which they were absorbed by the lymphatic vessels. Here of course the
accent is most appropriately placed upon kneading.
Now in case of cervical lesions such as we have considered above, what are we dealing with? External
contractures are easily amenable to manipulation, but
what are the conditions within the vertebral canal?
No muscles are involved, but the elastic ligaments are
in trouble ; they may have been sprained, torn, in which
case the periosteum is certainly affected ; or they may
have been affected by contact with the internal parts
disordered by hemorrhagic and inflammatory conditions. Normal ligamentous tissue is highly resistent
throughout its physiological performances, but when in
pathology its sensitiveness is exacerbated, with the interesting result that it may become contractured, just
the same as a skeletal muscle. As we have seen with
the ossification processes, any tissue undergoing repair
is to some extent in a phlegmasial condition involving some degree of contraction ; but this contraction
does not usually interfere with the repair; on the
contrary, when contracture sets in, it maintains a state
of congestion, with stasis of both nutrient and the
waste fluids, and hence production of acidity and
lowering of regional alkalinity, highly irritative to the
tissues and the nerves, and greatly obstructive to the
repair process.
Leaving aside the subjects with hypermobile
articulations, often, and wrongly so, selected for demonstrative proof of the skill of the instructor’ in
technic, the average osteopathic treatment consists in
overcoming the muscular contracture, with consequent
and immediate drainage of the external tissues-as
proven by the prompt abatement of regional painsthen of mobilizing the spinal articulations. This mobilization is equivalent in fact to kneading the various
ligaments connecting each pair of vertebrae. But complete relaxation of an intervertebral articulation cannot be obtained until the yellow ligaments are stretched
to an extent sufficient to overcome their contracture.
With the patient well positioned, the final effect is
applied with a quick motion, usually, although that
is not always physiologically required, and a popping
noise is produced, scaring the patient and gratifying
the operator.
Apophyseal articulations were not intended by
nature to be separated. We have never observed a
normal individual, or an animal, going about usual
activities, and even when performing feats of strength
or agility, emitting vertebral creakings or poppings.
We know of course the noises attendant to arthritic
conditions, but then the articular surfaces are always
affected by disease. The apophyseal articulations are
intended for guidance and control of the spinal movements. When they are forced apart the separation is
of extremely short duration ; it seems as if the guardian ligamentous structures had been taken by ruse, by
surprise, as if they thought that the preliminary
positioning of the body, with the customary objurgations of the osteopath: “Please relax, breathe deeply,”
etc., meant only a call for an extra physical effort,
and they complacently relaxed their own vigilance.
Taking a mean advantage of this misplaced confidence
the operator senses the opportune moment and quickly
applies the fatal-eventually beneficial-thrust, and
there is separation. Realizing instantly their lapse in
vigilance the controlling ligaments contract at once
and, aided in that by the deep muscles, bring back
forcibly the articular facets into contact; the result
is a shock, with -a popping noise, bone against: bone,
within a mass of flesh. The shock is both physical,
or material, and physiological ; it sets up a reaction,
a sort of shaking up of all the interested tissues, and
for hours afterwards there is a period of readjustment affecting various organs within the intravertebral
canals. There is new activity, new life, set up, speeding elimination of waste or sluggish fluids, naturally
following which the arterial blood supply overcomes
the detrimental hypo-alkalinity and thus restores the
normal functioning of the nerves. During this period,
and for several hours after the correction is made, it
is not possible to repeat the same performance with
the expectation of eliciting the popping noises. This
is of course readily demonstrable by cracking the
phalangeal articulations of one hand ; we all know
that some time must elapse before a repetition is obtained, unless one should have specialized in this sort
of amusement, or mania. Even in the simple experiment of cracking one’s fingers, the observer may
derive valuable information applicable to the study
of vertebral technic; thus, immediately following the
cracking one experiences a feeling of weakness in the
joint, which is followed by the sensing of a gradual
readjustment. Here we deal mainly with an articulation, also not intended by nature to be disturbed,
whereas with the spinal manipulations, the object is
not at all to elicit the spectacular popping noises for
the mere purpose of edification of those not versed
in the art. It should always be made clear that the
popping is a mere incidental, and not at all a curative
means. The sound may be of value to the operator
as a proof that, after due soft tissue preparation and
mobilizing work on the spine, the articulations are
at last free to the extent of disengagement, and at
that, for the time being.
The observed fact that a period of readjustment
invariably follows a spinal correction leads us to
ponder over the wisdom of our leader, the Old Doctor,
who tersely advised the operator to find the lesion,
to correct it, and to leave it alone. Too often repeated treatments-each being so powerful in its
effects-may interfere with the readjustment by keeping up a condition of hyperactivity in tissues and
structures actually in need of repose. The acquisition
of practical experience must never be done at the
physical expense of the patients, and the Italian say-
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VERTEBRAL MECHANICS-GUY
139
cord, the roots or the meninges, or indirectly through
ing : che va piano va sano, holds good here as in many
other fields.
causes obtaining within the vertebral canals and disMany years ago, while visiting regularly for a turbing by contact, adherence, phlegmasia, etc., the
time at a large New York hospital, I had occasion delicate nervous structure of the region.
one day to ride in the elevator with a passenger of
According to reports emanating from the most
Ethiopian hue. At the landing were a number of authoritative sources, universally recognized, dealing
internes; they looked at us and then scurried away
with autopsies, with physiopathological investigations,
in the most apparent dismay. At first, naturally it is proven beyond doubt that the disease leaves its
enough, feeling not guilty, I looked at my fellow imprint upon external parts, but unfortunately also
passenger, but found him complacently wearing an upon such vital organs as the cord and the meninges,
extensive grin. Evidently, not guilty. As for me, not to mention cerebral structures themselves, in the
hastily making for a nearby looking glass, most surely form of alterations of the dura mater, of the arachexpecting to find a pestiferous mark, I was finally noid, of the pia mater, of sclerotic patches on certain
convinced that outward symptoms, at least, were quite regions of the cord, all indicative that the effects of
favorable. The mystery was explained in due time. the disease were centrally reflexed and generated some
It seemed that the other fellow had trouble with his degree of myelitis or meningitis. Beginning at birth
right shoulder articulation, and that with or without as in the case mentioned here, we come to the so-called
provocation the arm readily sprung out of joint, so children’s diseases, usually thought benign, but in
that about every other day the smile that would not reality capable of leaving indelible marks: variola,
come off positively haunted the whole hospital staff, diphtheria, whooping cough, typhoid fever, venereal
every one of which in succession having tried his disease, exposure to cold, to dampness, to prolonged
skill, succeeded in making’ the replacement, and sent immersion, to traumatic violence ; vertebral lesions,
the patient on his way with the most sincere wishes fatigue, overwork, extensive superficial burns, amputations, infections, poisoning, emotional strains, etc.,
that he would stay put. Well? . . . Well, we have
had occasion to hear most friendly medical men assert and the list could be further extended. Confronted
that undoubtedly osteopathy has many good points, by such an ominous array, what is the osteopath going
but that the beneficent results of the treatment are to do? In the first place he must maintain his most
not lasting. We have also met many patients afflicted precious adjunct, that is his faith in osteopathy; ostewith chronic lesions, and who became reconciled to opathy teaches him that his work consists solely in
their fate, although bemoaning the fact that they were putting the body in condition to take care of itself,
compelled to periodically seek osteopathic readjust- and thus be enabled to pursue to infinity of biochemiments. They complained that they had visited many cal activities, beyond the ken of human mind, through
practitioners here and there, that they had been treated which cellular life is ceaselessly maintained for the
by regular wizards in the art, and that almost invari- benefit of the whole being. This can be accomplished
ably the operator had seemed completely satisfied with by keeping the external structures in proper tone, in
his own work after obtaining a succession of popping proper mobility, and through judicious spinal mobilizproofs that the vertebral articulations were at last ing work effectuating what amounts to a kneading
in condition of normal replacement. And the wearied of the organs contained within the vertebral canals.
smile keeps on hauntingly, tauntingly. There must Experience in other fields has proven that activated
be a reason, and there is a reason. We have found vascularization of affected parts can bring about resuch patients, mostly transients, responded satisfac- pair of the most delicate nerve tissue; effectively,
torily to extended soft tissue manipulations, and that regeneration of a nerve cannot take place unless
intensive mobilization of the vertebral articulations elimination of waste and ample provision of arterial
proved more effective than the ordinary forms of re- flow are assured. We know by daily ‘experience what
placements in maintaining the latter securely for ordinary osteopathic work can do, even with seemlonger periods than experienced before. The treat- ingly desperate cases, it is then only necessary, when
ment required about forty-five minutes of work, but needs be,’ to direct our technic so as to aim specifically
on the other hand, the best results were obtained with for action upon the innermost structures of the verjust one weekly session, at the start. We were guided tebral column.
by the reasoning that since the soft tissues and the
spinal articulations responded so well to treatment,
without, however, preventing the recurrence of the
lesions, the cause of the trouble must be deep seated,
not necessarily immediately external to the vertebral
structures, but rather within the vertebral canal or
the intervertebral foramina. That of course is a
little vague, but we can make the meaning more precise by inveigling the meningeal membranes and to
some extent portions of the cord itself. When a vertebral displacement occurs it is invariably due to the
combined action of muscles and ligaments, which obey
exclusively to nerve control ; recurrence of the lesion
may indicate a weakening the other parts involved,
and perhaps some impairment of nerve control; but
with the periodic recurrence while the external parts
are felt in fair order, nerve impairment is certainly
indicated, either directly at the source,
that is in the
All Rights Reserved American Academy of Osteopathy®
OUR OSTEOPATHIC ACTION
Quintus L. Drennan D.O.
Webster's Dictionary definition of
Osteopathy correctly reflects, to my mind,
our basic professional philosophy as conceived and enunciated by the immortal
Dr. Still. The same definition may be logically applied to Osteopathic Action which
then, is described as "A system of therapeutics based on the theory that diseases
arise chiefly from the displacement of
bones with resultant pressure on nerves
and blood vessels and can be remedied by
manipulation of the parts". On reflection,
therefore, it becomes apparent that when
Osteopathic Action deviates from these self
established frontiers, it invades foreign
territory.
Our science and opinions vary in
accordance with our interpretations of the
teaching and application of the osteopathic
principle in relation to our concept of the
lesion. The basic method of applying Osteopathy consists mainly in the manipulation of joints and tissue.
(From page 22 Philosophy of Osteopathy by Dr. Still) "If we wish to be governed by reason, we
must take a position that is founded on
truth and be capable of presenting facts,
to prove the validity of all truths we present. A truth is only a hopeful supposition if it is not supported by results".
I believe this type thinking expresses the
very fibre of the Academy membership in
relation to the profession.
We have seen much action in all
fields of the healing arts and where we,
as Osteopaths, used to think in words, we
now think in accomplishment. Any science
progresses by using the dead and dying
ideas of today as stepping stones for tomorrow. In our future Academy Osteopathic
Action, as co-owners of the profession, we
must pledge a new devotion to an organization welded together by its individual members working for a principle with -some - ob-.
jective. We, of the Academy, are familiar
with our professions ability to accept
ideas and the formal demands made by our
executive bodies in these various fields
that expect, or hope, to have as a basic
objective, the recovery of private rights,
osteopathically speaking. The A.O.A.
should be in its entirety what we as a special group represent. People create their
own lack of opportunities. Osteopathy has
been made great by its followers who used
it.
My role, or subject, Our Osteopathic Action, is not that of Mark Hopkins
on one end of the log, but of Socrates on
one end of a question. My function is to
get up steam in the cranial boilers of the
students and fellows of osteopathy and our
leaders for future use. A student does not
stumble on the right principle or answers
to Osteopathic Action; the real teacher, by
challenging him, forces him to think the
question through, osteopathically. I have
always considered it an honor to be a pioneer in the developing of Osteopathy.
Aside from the financial phase of practice
there is what I'd call a "psychic income"
that equals the intelligent appreciation
of the soul beyond life in the realm of
osteopathic service. A "psychic income"
which is that inner satisfaction of serving and succeeding - and in the gratitude
and confidence of those whom we serve where
others have failed. I have practiced and
studied Osteopathy for thirty three years
because I believe in it.
I hope the Academy may have a
great influence in charting the future
course of Osteopathy for I feel sincerely
that it is the Academy of Applied Osteopathy upon whose shoulders rests the future of our profession. There are some
fine new ideas now being considered by the
Academy officers for future stepping stones
for advancement. The difficulties encountered in making progress can be eliminated
to a great extent, by cooperative action
of the membership. The problem is in knowing what to do next. At this point, knowing what to do next, let us ask and try to
answer a few modern questions from the
Academy's angle, including some ancient
facts.
Why don't we stick to Osteopathy?
141
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142
Because there are those who wish to revolutionize our basic principles by replacing
our system of practice through the implementation of medical theories which, to say
the least, is alien dogma. It is reform,
sincere but presents the question again on
the "ten fingered osteopath" versus the
"hypodermic medical osteopath". Each has
the right of opinion. The public, the profession and the schools are the agencies
which should determine our policy, not a
competitive profession. I'll give you this
example of the question: At the St. Louis
World's Fair in 1904 in St. Louis, Doctors
Harry Still, Herman Goetz, George Laughlin,
Hullet, Clark, Young and others put on a
six weeks post graduate course which according to the records found in my father's
papers, was a big success. The whole theme
was developing the structural cause for
disease on osteopathic fundamentals. At
the Kansas City Child Health Clinic in
1948, one speaker mentioned the osteopathic
idea a few times in the three days - another passed out mimeographed sheets giving
the dosage shots, hypodermic regularity,
etc. That's forty four years of progress
for Osteopathy.
Why do we argue the point? The only
cure for disease is found in the natural
function of nature. The considering of the
germ theory, anti-toxin, vaccines, chemical
drugs and surgery represent a true form of
medical treatment, and we should know about
it for diagnosis of disease. Regardless of
classification, all branches have to fall
back on nature for the ultimate cure and
we have let go of that natural principle
upon which Osteopathy was built; that all
disease is functional from the start. An
example of what I mean in my special field,
let us say the handling of a congenital
hip - it is reduced osteopathically and
then nature builds up the deeper socket.
The cure of the lesion is not to be found
at the corner drug store.
How long will Osteopathy live?
There are several ways in which we can rule
ourselves out of the opportunity to serve
humanity. First, of course, is the mimicking of the M.D. - by trading with them and
the true sell out to them, i.e., the Homeopath and Eclectic.
(2) When we quit teaching and using Osteopathy it will die.
(3) The separation of our profession into
two groups, each suspicious of the integrity of the other, is not conducive to long
life, and pertinent facts should be offered
for some future plan. (4) Are you prepared
or do you care to throw criticism at some
of the experts who offer advice on our technical problems and nothing acceptable for
educational purposes? The public has demonstrated one positive fact which extends our
life line - that it wants Osteopathy and
will support it. I confess a state of confusion exists in the therapeutic balance
between the practitioners of Medicine and
Osteopathy, but the intelligent lay public
is open minded and concerned about our osteopathic future.
How can we compete in business?
The true situation is, we have six(6) approved or Class A rated Colleges as compared to sixty nine (69) Class A Medical Col1eges. We resort to Progress Fund or passing the hat for our schools, whereas the
medical colleges are endowed up into the
millions, or State supported. Both have
their troubles with the financial problem
and their administration. These sixty nine
Class A Medical Schools limit the freshman
enrollment to an average of about sixty
five (65) per year, to say nothing of the
lower rated schools. Our six Class A
Schools limit to say one hundred (100), and
even on that basis we can get a real picture of future graduated power in the field
of practice, influence and financing ability.
Can we meet the program financially? In analyzing this phase of the matter
we must think terms of dollars and policy,
as it now exists. First, we cannot tax and
spend over our income as individuals or as
a profession, and that's final insofar as
the dollar problem is concerned. Financially, we cannot mimic the medical profession
nor hope for State and Federal support on
a pro ratio basis. Also, we have, I believe, pretty well milked our profession on
the pass the hat or Progress Fund. We cannot waste our limited resources or promote
any unsound business programs in the future. From experience, I know what it
takes in effort, profit and loss, etc., to
overcome problems that arise under the
broad coverage of a policy in business and
the same is applicable to a profession good and bad times reflect their influence
in your cash intake and output and it is
always due to some policy action. Now,
professionally, our National Association
has in recent years adopted a broad policy
All Rights Reserved American Academy of Osteopathy®
4
of "un-restriction" - no limited. privileges
laws, teaching, etc., and followed the
standards of the medical profession. Since
these changes in the A.O.A., the colleges
and the requirements, the osteopathic aspect has likewise changed. Further, we
have gone, like our Federal Government, into a big show policy, minus the finances,
colleges with more employees than students,
heavy obligations to pay over a long period of time, and poor business administration. It all adds up to this, we cannot
exist on such a business basis or policy.
Upon whom does the burden fall? It
is most obvious to me that some changes
are needed in our setup - administrative,
financial, colleges and future policies in
general. The future security of any business or profession depends on youth development for modified standardization in
that particular field or specialized commodity which is being presented to the
public. We can well afford to spend some
time in developing young men to take, over
some of our problems. We can find Osteo;
paths who are qualified to function in any
specialized field, men willing to give a
genuine service to Osteopathy. We have
had, and we are no exception, both good
and bad leadership. Now the time has arrived when we in the profession must find
individuals who are willing to serve without profit. We must get interested in the
re-establishing of the fine osteopathic
basic principle on a sound business basis.
It is perfectly clear, to me, that
educational stability ranks the number one
problem in the future of Osteopathy. Our
colleges either do not teach technique or
recent graduates will not use it in the
field. I believe, if it is possible, that
the Academy's future Osteopathic Action
should be directed toward improving the
teaching or real Osteopathy in our colleges. To summarize this personal idea,
I quote Wm. P. Talley - "Education is concerned with action and life - the life of
reason. Its goal is a disciplined person,
applying and directing his knowledge and
his powers". Our supplement to this idea
can be in the field of research. Our goal
and hope rests in our individual abilities
being placed at the disposalof our Academy
leaders to form a cooperating, understanding body, thinking clearly and frequently
on Osteopathic problems.
On the United States Archives Build-
143
ing in Washington, D.C., there is this
motto - "The Past is Prologue". How frequently in the past years have I thought
in the terms of that motto as it applies
to our problems, progress and actions. . If,
and we of the Academy do, appreciate the
Science of Osteopathy, we must exchange
ideas, forget jealousies, cooperate with
the colleges, executive national departments, and finish what we have started for
our own future security. Let us not be
discouraged by the natural marked differences of opinion concerning the proper solution of the multiple problems involved
in such a step forward. First plans are
never acceptable to all concerned, but
they form a foundation for negotiations
and adjustments for greater development.
We have reached a point of development
that now calls for positive action on the
part of the Academy members and officers.
The matter of faith and duty is
paramount in our professional lives. We
have faith and doubt not the pathology of
the lesion, Dr. Still's works, and the
cause and effect basic principles established by Dr. Burns. All these physiological osteopathic action lesions were covered by Dr. C. C. Reid who gave four subheads under Action from the anatomical
side - (1) the mind; (2) energy; (3) chemistry and (4) mechanics. His talk was
full of real appreciation of Osteopathys
trustworthiness in handling the question
and he emphasized the art of handling the
four functions, osteopathically.
Dr. Still,
the philosopher, expressed his faith in
Osteopathy by saying - "Intelligence will
accomplish our great objective - world recognition - and the future will dwarf the
past in the collective talents of my followers". When we study our science and
practice it, we eliminate doubt and establish faith in our field. We must work to
make it better and expand our facilities.
Osteopathy must be taught - it is,-not mechanical. It must be demonstrated - it is
not reading matter. It proves itself. It
has appeal and alleviates suffering.
People who use Osteopathy are
high type, and loyal to the principles of
the osteopathic profession. We have a
specific field in which to operate that
does not exist in the field of medicine.
It makes no difference about the terminology such as "physical medicine", "manipulative therapy", etc., so long as this high
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144
type clientele continues to appreciate the
intelligent presentation of osteopathic
service. To be recognized by some twenty
insurance companies as an authority on partial and total disability in their problem
c&es - to have Circuit Court cases stopped
by a Judge to have the case examined, reported and settled the next morning on osteopathic written testimony - to investigate and prosecute and dissolve "Medical
Racket Rings" in industrial fields - to be
consulted by medical authorities on osteopathic matters, City, State and National to be recognized and appreciated as an Osteopath establishes with me, a greater confidence in our future program. This program must provide a strong, tangible group
of statistics based on specific Osteopathy
in all fields of research. Such issues
should be of utmost interest to us all.
We must demonstrate a willingness to
reinforce words with action against any who
oppose our belief and work in behalf of
Osteopathy. We must not indulge in petty
politics nor the usual lazy legislative
channels of permitted acceptance or we will
be failing miserably to comprehend the memberships demand that something be done NOW
about saving Osteopathy. Let's keep future
educational plans as the backbone for the
expansion of ideas on the lessons we have
learned and offer onlyconstructive business
and professional advice to our administrators. Present the individual problems for
analysis to the proper committee knowing
that Same will be analyzed, perhaps benefit
others, and prevent useless issues arising
in the administration of Academy affairs.
With our City, State and National
Official Organizations functioning under
"rules and regulations", our colleges operating under standard requirements, we can
function as the third reality. This idea
of Newman's is particularly applicable today, for the profession is (osteopathically
speaking) in such a state of chaos that we
are swaying between total destruction and a
new era in civilization. The uneducated or
partly educated individual is likely to become frightened or influenced by the opinions of others and thereby rush to a hasty
and unintelligent conclusion. On these
last two problems, an osteopath must have
considerable strength of mind and common
sense to overcome quick emotion. Perhaps
if we had more such men in the world today
we would not be faced with such a black future, and the profession and the nations
could be thinking of prosperity instead of
war.
Dr. A. T. Still faced our present
problems over a half century ago almost
alone, and never gave up hope. I believe
today in his many proved convictions and
am not alarmed over our future. Dr. Still
had laws of living governing everything he
thought and did, osteopathically. Today, I
feel as he must have felt that these are
laws of the spirit, not of the letter, and
have to do with the way we deeply feel and
think, osteopathically, with our inward attitude and our outlook toward all that is
without.
Evidence seems to be accumulating
to support the view that we are facing some
sort of an adjustment period, professionally. We have been concentrating so intensely on the defensive that we have overlooked
the normal forward progress of Osteopathy.
Favorable and unfavorable factors can be
balanced through mutual combined effort of
us all, and we can and will go forward together in establishing Osteopathy on its
original foundation.
St. Louis, MO.
All Rights Reserved American Academy of Osteopathy®
DOES THE GROSS MECHANICAL PICTURE STOP AT THE OCCIPITO-ATLANTAL ARTICULATION?
Harold I. Magoun, A.B., D.O.
The gross mechanical picture or
greater lesion complex has heretofore referred to a definite pathogenic syndrome
involving the spine and its soft tissues.
A rib resection or breast amputation may
initiate the structural deviation in the
upper spine. More commonly an increased
sacral base inclination as from high heels
or an off level sacral horizon as from a
short leg is fundamentally responsible.
Regardless of the etiology, and no matter
what pattern that develops, the result is
increased tension on the supportive structures, contractured guy-rope muscles and
ligamentous articular strain throughout,
as well as bony lesions at the areas of
greatest stress.
The question then arises as to
whether this picture stops at the upper
end of the spine or whether the strain also involves the cranium and its membrane?
To answer intelligently let us first review
briefly the fascial and muscular attachments involved.
The deep fascia of the neck is our
principle concern. It finds its anchorage
at many points on the basicranium and also
fuses with the periosteum at the superior
nuchal line on the occiput, along the superior temporal crest, the mastoid process,
the arcus zygomaticus and the inferior
margin of the mandible. These layers surround muscles, nerves, vessels and the
upper intestinal tube with a complicated
system of compartments, which have a vital
part in the mechanical functions of the
body, since so many important structures
are there crowded together in so small a
space. Below, the deep cervical fascia is
continuous with the mediastinal partitions,
pericardial envelope and central tendon of
the diaphragm.
While most of the cranial bones
serve for muscular attachment at some
point those pertinent to this discussion
are mainly the occiput and temporal. You
will recall the attachment of the trapezius; semispinalis capitis; rectus capitis
posticus major, minor and lateralis; su-
perior oblique and occipitalis bunched between the nuchal lines of the lower occipital squama. You will remember the insertion of the digastric and longus capitis on
the mastoid process of the temporal. Note
also that the splenius capitis and the
Sterno-cleido-mastoid overlap the occipitomastoid suture at their attachments on both
bones.
There are others which we are not
mentioning. However here are fascial and
ligamentous and muscular attachments to
such vulnerable leverage points as the mastoid process and the supra occiput. The
pull may not only be straight down but definitely laterally or anteriorly or posteriorly in addition. Unilateral strains, such
as wry neck, either acute or chronic, are
common. The average osteopathic practice
is full of neck strains causing head symptoms.
Many of these muscles arise from
the upper ribs and insert into the skull.
If the free motion of a rib can be deranged
by muscular contracture or strain what of
the bone at the other end? Can you consistently say that the physiology is any different in the rib where the muscle originates than in the cranial bone where it inserts? The only difference in motion between rib and cranial bone is one of relativity.
The rib, it is true, has an articular cartilage for gross motion and is .
held in place by ligaments and muscles.
It is equally true that there is an articular pivot between the temporal and occiput
that is cartilagenous throughout life.
These or any other cranial bones are held
in place by soft tissues, consisting of
membranes such as the falx and tentorium
and the dural envelopes, which extend thru
all sutures between the bones. Both rib
and crainal bone move with respiration or
suffer deranged motion with trauma and mus
cle or ligamentous strain. This has been
proven beyond a doubt on many hundreds of
cases by Dr. Sutherland and his cranial
students.
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146
The old texts on anatomy denied motion at the sacro-iliac. Someday they will
acknowledge cranial motion, realizing the
difference between the stiff dry-stick effect of the cranium under rigor mortis as
contrasted with the live specimen in which
the sap still flows. Cranial motion is
minute as compared to rib motion but is
none the less real. Lesion correction is
not manifested by a chug but is a soft
slippage of the membranous, cartilagenous
or bony element within its dural envelope
in relation to its fellow, when the natural
motive forces of cerebrospinal fluid fluctuation and membranous pull are put into
operation.
Dr. Still held a rib in position to
exaggerate the lesion, asked the patient to
breathe and it corrected itself. Dr.
Sutherland holds a cranial bone similarly,
directs physiological cooperation by the
patient and secures a like result. In so
doing he has called our attention to this
hitherto unexplored field of osteopathy.
Obviously this brief discussion is
not meant to imply that influences from
below art? the only cause or the chief cause
of cranial lesions. The gross 'mechanical
picture does not stop at the occipito-atlantal articulation in either
- direction.
Cranial lesions do occur as the result of spinal imbalance such as short leg
or other acute or chronic trauma. Witness
a case of tic douloureux (X-ray) relieved
by attention to a short leg problem and the
secondary cervical lesions but with no
cranial treatment. The pain recurred a
year later when a new pair of shoes was not
altered and promptly subsided with one cervical treatment after the lift was added.
In studying such gross mechanical pictures
it has been my experience to consistently
find the low occiput and the externally
rotated temporal occurring on the side of
the contractured cervical muscles and fascia as the pulled down by them.
What of influences in the reverse
direction? The vast majority of cranial
lesions are primary to that region, be they
incidental to birth trauma or later local
disease or injury. It would seem from this
fact that there would be a little relation
between the lesions of the skull and possible secondary patterns below. There is
more dependence than one might think. The
cranial picture, in so far as it influences
the central nervous system, dictates the
structure and function of the entire body.
The infant, subjected to a birth injury
especially of the condylar parts of the
occiput, may have very definite spinal
anomalies resulting as the development below is shaped by the abnormality above.
Cranial lesions can be the direct cause of
spinal lesions. Indeed one of the commonest sources of recurring atlas lesions is
to be found in the occipito-mastoid fixations which maintain muscle contraction
and, through the malignment of the facets,
joint pathology below.
Thus it becomes necessary to revise our concept that the greater lesion
complex usually proceeds from below upward.
Many times the reverse is true. The approach taken in this paper is from the
known to the unknown, for those of you who
have not studied the cranial concept. It
is an attempt to emphasize the fact that
Dr. Sutherland has opened a new field for
osteopathic endeavors, he has vastly widened our horizon and shown himself to be not
only a true disciple of Andrew Taylor Still
but also one of the few original thinkers
of our day. Cranial osteopathy, sponsored
and nurtured by the Academy of Applied Osteopathy, opens a new epoch in the art of
healing and is proving that the gross mechanical picture does not stop at the occipito-atlantal articulation.
All Rights Reserved American Academy of Osteopathy®
THE CRANIO-VERTEBRAL JUNCTION
Beryl E. Arbuckle D.O.
The crania-vertebral cavity houses
the brain and spinal cord. In the Philosophy of osteopathic science which Dr.
Still taught his followers, he laid stress
upon the importance of the arteries carrying nutriment in an unimpeded fashion to
every body fibre and expressed the control
of this all important' function in the following manner.
"Any variation from perfect health
marks a degree of functional derangement
in the physiologic department of man. Efforts at restoration from a diseased to a
healthy condition should present but one
object to the mind and that is to explore
minutely and seek the variation from the
normal . . . First examine the neck, because of its position and connection with
the brain, which is the physiologic source
through which nerve force is supplied and
suited to the convenience of the heart, to
assist in delivering such burdens as it
may send forth to nourish and sustain the
body . . . You must know what the neck is
with all its parts and responsibilities,
or you will fail in proportion to your
lack of knowledge, not theoretical but
practical, which you can only obtain by
experience . . . Begin at the head and
start at the first bone of the neck, and
don't guess, but know that it fits to the
skull properly above."
The development of the condylar atlantal articulation bears consideration.
As early as the eighth week in fetal life
the components of the vertebrae are chondrified. Endochondral ossification centres soon appear, a median ossification
centre giving rise to the centrum and a
centre in each neural process extends dorsally to form the lamina and complete the
neural arch.
Likewise in the developing skull
there is a concentration of mesenchyme
about the notochord, which extends as far
rostrally as the future dorsum sellae of
the sphenoid. This concentration extends
more rostrally and soon becomes chondrified forming a supporting floor for the
developing brain. At eight weeks there is
a confluence of the primordial parts of
the chondro-cranium which in the course of
development will form separate bones from
endochronal ossification centres.
It appears that in the course of
evolution there become fewer bones in the
entire mature structure. Likewise in the
growth of the human skeleton from the neonatal period to adult life is there a decrease in the number of bones or portions
of bones. At birth the two bones, the
occiput and atlas, which bear the articulating facets of the pair of articulations
under present consideration, each consist
of four parts which develop synchronously
from their primordial structures to maturity.
The occiput consists of four
parts, the basilar, two condylar and the
squamous portion, surrounding the foramen
magnum. The atlas likewise consists of
four parts, two lateral masses and an anterior and posterior arch encircling the
dens of the axis, the associated ligaments
and the continuation of structures enclosed by the foramen magnum. There is fusion
of the lateral masses of the atlas with
the posterior arch from the third to
fourth year at the time of fusion of the
squama with the condylic parts of the occiput. From the seventh to eighth year
fusion occurs between the lateral masses
and anterior arch of the atlas and between
the condylar parts of the occiput and its
basilar portion. It is these lines of fusion which pass obliquely through the respective facets of the occipito atlantal
articulations, the anterior quarter of
each facet being anterior to the line of
fusion.
Some of the causes of malalignment of the separate parts of the developing atlas and occiput during the fetal and
early neonatal stages and consequent maldevelopment of these bones with asymmetry
of their articular facets, have been described in previous papers.
At this point we shall consider
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148
the ligaments that enter into this crania
vertebral junction. As what might have
been the body of the atlas completes the
dens of the axis these ligaments constitute the occipito-atlanto-axial group.
The articular capsules surround and
loosely connect each pair of condylar atlantal facets; There are lateral reinforcements of these capsules known as the
lateral ligaments extending obliquely upward and medialward on each side from the
base of the transverse process of the atlas
to the jugular process of the occipital
bone. Each capsule is continuous anteriorly with the anterior atlanto occipital ligament which is broad and dense and connects
the anterior margin of the foramen magnum
with the superior border of the atlas.
This in front is very strongly reinforced
between the basilar portion of the occiput
and the anterior tubercle of the atlas.
The posterior margin of the foramen
magnum is connected to the upper border of
the arch of the atlas by the posterior atlanto occipital membrane which is broad
and thin and incomplete on either side below, helping to form with the groove on the
upper anterior aspect of the posterior arch
of the atlas, the opening for the vertebral
artery. Branches from these form the anterior and posterior arteries of the cord.
The vertebral arteries join to form the
basilar artery, the branches of which supply the structures in the petrous portion
of the temporal bone the pons, medulla and
cerebellum and it terminates by bifuricating into the two posterior cerebral arteries. Thus the vertebral arteries contribute to a.11 the choroid plexuses and what
might this mean in the event of structural
malalignments, stresses and strains or congestion around this area to the formation
of the cerebra spinal fluid, "the highest
known element in the human body."
There are synovial membranes lining
these condylar atlantal articulations and
also one lining the articulation between
the anterior superior part of the odontoid
process and the posterior part of the anterior arch of the atlas with which this
articulates.
The plane of this particular
facet is determined by many developmental
factors. It varies, being almost vertical
with the facet on the anterior aspect of
the upper part of the odontoid process or
more nearly horizontal with the odontoid
facet being almost in a superior position.
The articular capsules of the atlanto axial articulations are strengthened
medially on the posterior aspect of each,
extending from the body of the axis near
the base of the odontoid process to the lateral mass of the atlas near the attachment of the transverse ligament. These reinforcements together with those on the
lateral aspect of the occipito-atlantal
capsules may be visualized as part of the
formation of one of the many supporting
and strengthening triangles in the construction of man.
The transverse ligament of the
atlas is a thick strong band retaining the
odontoid process of the axis in relation
with the anterior arch of the atlas. It
is strongly attached on either side to a
small tubercle on the medial surface of
the lateral mass of the atlas. Superiorly
and inferiorly from the middle of this ligament are thinner prolongations attached
respectively to the posterior part of the
inner aspect of the basilar portion of the
occiput anterior to the apical ligament
between the dens and the superior part of
the anterior rim of the foramen magnum, and
to the posterior part of the body of the
axis. These vertical portions and the
transverse ligament together constitute
the cruciate ligament of the atlas. The
alar ligaments also anterior to this cruciate ligament and lateral to the apical ligament, extend from either side of the upper part of the odontoid process upward
and lateralward to be inserted into rough
depressions on the medial side of the occipital condyles.
Posterior to the cruciate ligament
is the membrana tectoria. This may be considered as the upward prolongation of the
posterior longitudinal ligament of the
vertebral column. It is firmly attached
to the posterior part of the body of theaxis and its very strong bands diverge anteriorly, covering the odontoid process
and its ligaments and is attached in a V
shaped manner with its apex cephalward to
the basilar groove of the occipital bone.
Some of its fibres mingle with those of
the cranial dura mater. We notice also at
the posterior part of the foramen magnum
to a lesser extent the intermingling of
fibres of the dura mater and those of the
posterior occipito atlantal ligament.
The cranial dura mater consists
as we know of two layers, the inner of
All Rights Reserved American Academy of Osteopathy®
149
direction and transmission of forces trawhich presents the reduplications forming
the falx cerebri and falx cerebelli, the
velling through the skull. These areas
tentorium cerebelli and the diaphragma
are known as the buttresses of the skull.
sellae. Throughout these dural membranes
The firmest dural attachments are found on
are reinforcements of white fibrous bands
the intracranial aspect of the buttresses
laid down in a very consistent manner
and externally these buttresses give rise
throughout the otherwise elastic tissue.
to aponeuroses and fasciae. The very thin
These are known as stress bands of the
parts of the skull, such as the temporal
dural membranes and are arranged in the
and inferior occipital areas are covered
following groups, horizontal, vertical,
externally by heavy musculature.
The superior buttress extends from
transverse and circular. There is no definite break in these fibres but an interthe inion anteriorly in the median plane
mingling or continuation of one group with
of the vault to the glabella and posterioranother so that forces may be directed and
ly including the crista galli of the ethcontrolled throughout this mechanism.
maid. The inferior buttress extends anIn experiments being carried out
teriorly in the mid plane from the inion,
dividing at the vermion fossa to encircle
in Bethesda where the brains of monkeys
are viewed through artificial plastic crathe foramen magnum and uniting at the banial vaults the movements of the brain itsion, continues anteriorly through the
basilar portion of the occipital bone exself are photographed and the direction of
impulses being changed by the membranes
tending as far forward as the posterior
part of the sphenoidal sinus. For the
can be pictured.
purpose of treatment the superior and inIn understanding the cranial concept as taught by Dr. W. G. Sutherland, in
ferior buttresses together are referred to
striving to know the development, formaas the median sagittal buttress. The antion and purpose of every bone, its spicterior buttress extends from the glabella
ules, angulations, bevellings and planes,
on either side over the supraorbital ridges
in feeling and learning and with the dawn
to the zygomatic angle of the frontal which
of appreciation of the complexities of the
is also the superior limit of the zygomatic
formation of the dural structures it seems
pillar of the face. The posterior buttress
reasonable to believe, and in view of the
extends laterally on either side from the
experiments with the aforementioned moninion over the superior nuchal line to the
keys, much easier to understand that by
mastoid process. The lateral buttress on
manipulation rhythm may be restored to the
each side extends from the tip of the masmovement of the brain and fluctuation of
toid process posterior to and above the exthe cerebra spinal fluid.
ternal acoustic meatus and at the articular
"Manipulation" as quoted from the
tubercle anterior to the mandibular fossa
late A. D. Becker, "is the result of a way
divides into the oval buttress with an exof thinking".
ternal limb passing over the zygomatic
Visualize the condylar articular
arch to meet the zygomatic pillar of the
facets, occupying most of the anterior
face, and an internal limb on each side exhalf of the margin of the foramen magnum.
tends forward over the infratemporal crest
These facets facing anteriorly, laterally
and meets the pterygoid pillar of the face
and caudad, converge anteriorly and also
as it continues with the lateral extremity
converge medially and each is convex in
of the sphenoidal ridge. The oblique butits two diameters to articulate with the
tresses of the skull follow the petrous
concavity of the corresponding superior faridges and the sphenoidal ridge constitutes
cet on the atlas. The medial margins of
the transverse buttress.
these two pairs of facets are more caudad
As stated by Browden, as well as
than their lateral margins. This gives us
others, "the rounded shape of the vault,
a picture of the articular facets about
the elasticity of the bones and the formathe foramen magnum being cradled or even
tion of the secondary arches make the skull
funnelled by those of the atlas.
moderately resistant to external trauma."
Of great importance in addition to
Picture the protection these buttresses
the membranes with their strengthening
afford the venous sinuses of the dura.
bands, we have areas of increased density
Likewise will the arches of the
throughout the cranium which influence the
atlas be flexible about the lateral masses
All Rights Reserved American Academy of Osteopathy®
150
rotation of the sacrum; depending upon the
thus enabling a wider separation of the
severity of the blow and also the curve of
posterior part of the condyles to be prothe sacrum will be the degree of strain
duced. As the posterior arch is the larger and more flexible, compression in an an- through the spinal membranes producing a
caudad tug about the foramen magnum pulling
terior lateral manner with thumb and index
the condylar facets deeper into those of
finger on its posterior aspect will result
in a widening between posterior parts of
the atlas.
the facets. This will decrease the conSo in considering correction. of
condylar atlantal lesions by this method
striction which may have been produced upon the occipital condyles because of some
stabilization of the sacrum is necessary,
previous trauma having driven the skull
preferably by an assistant or in the abanteriorly into the convergence of the sag- sence of one by the cooperation of th.e p,aittal planes of the atlantal facets. Again tient following instructions as to position
the skull may have been driven caudad with
of legs and feet, while fixation against
a slight medial approximation of its own
the posterior arch of the atlas, as precondyles with a resultant flattening or de- viously described is maintained. In severe
crease In the curve of the portion of the
conditions utilization of the cranial butInferior buttress around the foramen magtresses to alter the strains through and
num resulting in an A.P. elongation of this about the foramen magnum will greatly faforamen.
cilltate the correction which is brought
about by respiratory cooperation.
Depending upon the location of the
sustained trauma, the direction of its apIf all these phases, which are so
plication, and the way in which its forces
easy when properly understood, are well
might be directed through the skull by the
mastered and correctly applied there will
buttresses and areas of greater flexibility be no nausea or vomiting, headache or strathe forces being again curbed and changed
bismus following attempts at correction
by the dural stress bands, the one side of
with this method. When such occur it is
the occiput may be driven deeper into the
because the structure and physiology, has
atlas atlas the other side or the one side
not been understood or properly considered
may be driven further forward than the
and a further insult has been added to an
other. So we may follow the strains
area already in difficulty.
Depending upon the degree of corthroughout the buttresses with the generalrection obtained will be the release of
ized warping effect upon all the dermal
tensity through the dural membranes and
bones and the resultant restriction of
normalization of the fluctuation of the
movement of the various sutures. Restriction of movement constitutes an osteopathic cerebra spinal fluid with the effect of
change of all body fluids and the clinical
lesion.
observation of general relaxation. From
With this particular consideration
here it is much easier, with no further reof the occipito atlantal articulations let
us picture the possible result of a fall up-. laxatlon, to continue with any other neceson the sacrum. The crania sacral mechanism, sary bony correction, cranial or spinal.
In conclusion we will again be rebeing a part of the cranial concept is
minded of one of the admonitions of Dr.
fairly generally understood and has been
Still. "You must know the neck with all
described in detail upon other occasions.
its parts and responsibilities . . . Begin
With physiological flexion of the spheno
basilar there. is also flexion of the lumbar at the head and start at the first bone of
the neck, and don't guess, but know that it
sacral junction. Suppose the force on the
fits the skull properly above."
sacrum be great near its apex, that is a
considerable distance below the axis of
920 N. 63rd Street
Philadelphia, Pa.
All Rights Reserved American Academy of Osteopathy®
THE PROBLEM LOW BACK
Alexander F. McWilliams D.O.
Every low back case is a potential
problem until a diagnosis has been established, after a diagnosis has been established it ceases to be a problem, but frequently judgment and skill is required in
caring for same.
Even the simple low back case can
become a problem, dependent upon the type
and frequency of treatment, for instance
one of the profession asked me to see a patient whom the Doctor said was going to
quit Osteopathy. After seeing the case I
advised no further treatment for a week.
The patient was symptom free in four days.
It was a case of the Doctor wanting to do
a special job for a prominent man and
treated him every day with the result that
nature had no chance to assert itself.
The time allotted will permit of
only hitting a few of the high spots in a
gross way, that might be of value to some
of you in your every day practice.
The worst of the conditions involved in problem low back cases and those
most dangerous in which to attempt any adjustment are Cancer, Tuberculosis, Pagets,
Arthritis, and other bone diseases, Fracture, Ankylosed, Deformed and some Disc
cases.
With the possible exception of the
common cold we see more low back cases
than any other one type of case, we also
lose more low back cases than any other
type of case. We should not. We cannot
afford to lose a patient to Osteopathy any
more than we can lose a friend.
Uncertainty is what bothers most
patients, but if we explain the condition,
tell the patient what to expect and what
to do for themselves they will usually return provided that they have not been unduly hurt or frightened by harsh treatment,
that they have not been impressed due to
incompetent or routine treatment, or that
the Doctor is too negative. There is too
much of that bad habit of I think, or I
guess.
It is embarrassing in caring for a
low back condition (or any other type of
case) to find that we have not been treating the cause or have not made a proper
diagnosis, but it is more embarrassing if
some one else learns of our mistake.
To understand why there is such frequent crippling pain, etc., in the low back,
which is the strongest part of the spine,
it might be well if we consider the spinal
column for a moment.
From a purely mechanical standpoint
with any change in the alignment of the
spinal column with its two anterior and two
posterior curves there must be a corresponding change at the tops of the curves.
C
B D
*
d ,
a .
b
b
15
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152
With any spinal lesion at the top
of a curve there will be a corresponding
lesion at each top of the spinal curves as
noted by the corresponding letters. There
will also be corresponding rib lesions 1st
and 12th, 2nd and llth, etc.
Knowing the corresponding tops of
the spins.1 curves is of special value when
for any reason it is not possible or advisable to manipulate in one arc one can
get the same results by manipulation in a
corresponding top of another curve.
Corresponding spinal lesions can be
further divided than those shown in the
diagram. For instance adjustment of the
second dorsal on the right side will activate liver or gall bladder disfunction and
release tension at the seventh Dorsal vertebra.
When muscle spasm exists it is caused by one or more rib lesions.
With this explanation of the corresponding tops of the spinal curves it
should be understood why the low back disturbance is caused by or can be associated
with almost any sort of disturbed function,
I have not counted the number of causes of
low back disturbance, but I recently read
an article the writer of which was an Orthopedic Specialist who stated that he
knew of fifty-four causes.
To name just a few causes of low
back disturbances, the nerve center of
which is in various spinal areas, Tonsillitis, Sinusitis, Eye Strain, Cardiac Disease, Liver and Gall Bladder Dysfunction,
Gastric or Duodenal Ulcer, Kidney Disease,
Constipation, Grippe, Weak Arches,Emotions,
Fatigue, etc.
You all have your own ideas as to
where the nerve centers are for the above
condition, but in whatever area you find
them you still have your corresponding spinal lesions at the tops of the curves.
This knowledge is always useful especially
when it is not advisable or difficult to
treat one area as results can be obtained
by treating or adjusting a corresponding
area.
It is well to remember that to have
a disturbed function you must first have
irritation in a spinal nerve centre, and
also to remember that the spinal cord ends
at about the second lumbar vertebra, therefore any low back irritation must first
arise in a nerve centre above the second
lumbar vertebra.
The stopping of an allergy, an occupational or other habit, using a heel
lift for a short leg, a directional heel
lift for an eversion, or an inversion, or
correcting heel balance to relieve lumbosacral strain frequently corrects the existing condition or relieves enough spinaltension so that lesions are easily adjusted.
The recurring low back pain recurs
only because we have not found or eliminated the cause, that the patient did not
have sufficient follow-up Osteopathic care,
or he did not follow advice given.
The patient should always be advised.
There is one type of lesion that
acts like a turnbuckle in that it contracts
spinal muscles from the occiput to the coccyx and directly or indirectly causes contraction of many other muscles of the body
thereby causing various disturbed functions.
This lesion is an extension of the
fourth dorsal vertebra and must be adjusted
in flexion, i.e. by drawing the head forward and if the lesion is an extension side
bend the head is also drawn to the lesioned
side, your fulcrum being at the point of
lesion. At times this lesion adjusts so
easily that all you feel is a release of
tension, and other times to adjust it will
try the patience of a saint.
The results obtained In such various
conditions is well worth your adjusting it
when found. You will not ring the bell
every time, but stay with it.
The why of how results take place
with the unknown nerve conditions is beyond me.
I think that Dr. Arthur Hildreth
spoke more of a fourth dorsal lesion than
any other lesion.
To illustrate results of adjusting
an extension lesion of the 4th dorsal..
One of the Clinicians of the Out-PatientDepartment of the Massachusetts Osteopathic
Hospital asked me to see a patient, stating
that the spine was so rigid he did not know
where to commence treatment.
The patient was a six year old
pasty-face boy whose speech was not understandable, the father stating that all. he
wanted to do was to sit in the kitchen and
play with dolls. He had had him to three
mental clinics who said there was nothing
they could do for him.
In making the spinal examination
and evaluating the spinal tissue changes,
All Rights Reserved American Academy of Osteopathy®
153
there should be an answer, I think that
I stated that the 4th dorsal was the outstanding lesion and demonstrated the adthe answer to the low back problem in diagnosis, while we should use every available
justment of same. After standing there
for a few minutes talking, the clinician
means in making a diagnosis I think most
examined the spine and said he did not
of our diagnosis should be made through our
think there was any further treatment need- ability to interpret tissue changes. It is
ed as such a change for the better had
all there in the spinal tissues if we can
taken place.
interpret it.
I saw this boy one month later and
We might not attain perfection, but
he was a husky looking boy. His father
we can improve our ability to interpret
stated it was nice to have a boy in the
tissue changes by constant practice.
'In interpreting tissue changes we
family, he was as tough as any in the
neighborhood, hardly had any time for meals know the difference between hot. and cold,
dry and moist, body heat and fever, rough
in his hurry to get out of doors. His
speech was greatly improved. I saw him
and smooth, spastic and flacid, and we know
by tissue changes the amount of improvement
once more six weeks later, he was a very
normal boy, his speech was practically nor- the patient is making and we know more or
less the tissue changes caused by or allowmal. His father said to me, what do you
think he wants now, I told him I did not
ing fatigue, emotions, exposure to heat,
know, said he wanted a ball, a bat and a
cold, dampness and the tissue changes causglove. I made the remark that he could
ed by many of the most common disturbing
not play baseball, the kid said "Huh, that foods, such as fats, eggs chocolate, Coffee,
is what you think."
bran, asparagus, shell food, strawberries,
In any adjustment of or for the low
etc.
back, leave the spine as a whole free of
If we know the above it seems logical that the field of diagnosis by intercontraction or contracture by adjusting
contributing vertebral or rib lesions. It
pretation of tissue changes is limited only
is a rib lesion that causes muscle spasm.
by the time and effort to which we apply
My experience in private practice
ourselves.
and of eighteen years in the Out-PatientTo my mind interpreting tissue
Department Clinic of the Massachusetts Oschanges is the most interesting phase of
teopathic Hospital has been that we freOsteopathic practice, that is outside of
quently place too much reliance on X-ray
trying to be a good technician.. You cannot
findings. The X-Ray shows more poor align- be a good Osteopathic technician unless you
ment and bony changes in the supposedly
do interpret spinal tissue changes.
good backs than in those having the cripplTo conclude let me say again that
ing low back pain.
the low back problem ceases to be a problem
Now with any statement or proposal when properly diagnosed.
All Rights Reserved American Academy of Osteopathy®
THE INTERVERTEBRAL DISCS - a Book Review*
Mary Alice Hoover, D.O.
.
of this wear and tear a functional trauma
In Dresden, Germany, beginning with
the year 1925, Dr. Georg Schmorl was allow- is always present, often working far-reached to remove the entire spine of every sub- ing damage. He regards the spine, thereject. brought to post mortem in a large
fore, as a delicately organized structure,
clinical center. Between 1925 and 1931,
continually subject to relatively violent
Schmorl examined approximately 7,000 spines destructive forces.
some 600 of which he preserved in a museum,
In the studies recorded in this book
together with hundreds of smaller preparaa knowledge of normal states is made the
tions of parts of spines. With an opporprerequisite for the recognition of develtunity for study such as researchers in no
opmental and traumatic abnormalities. The
'other part of the world have ever been able entire developmental history of spinal
to obtain,, Schmorl assembled an impressive
structures, particularly that of the discs,
body of information as to regarding the
is as far as possible described. Normal
spine, its anatomy, developmental and adult, changes during adulthood and senescence
its functional activity and its abnormal
are noted, in order that they may be difstates. Expecially did he collect informa- ferentiated from pathological processes.
tion on the intervertebral discs. He was
The life history of the disc is found to
the discoverer during the study of a series be one of high fluid content and elasticiof some 2000 spines in l927-8, of the proty in the youthful spine with a gradual
lapsed disc, which has been under continuloss of fluidity and elasticity as age apous discussion in the subsequent twenty
proaches.
years.
Articulations between the bodies of
It is highly fortunate for the scithe spinal vertebrae are described as peentific world that before the rise of Hitculiar, first in that they bear the weight
ler one of Schmorl's students, Ormond A.
of the spine and meet the stresses of both
Beadle, a traveling fellow from Britain
functional activity and physical shock
who studied in Dresden from 1929 to 1931,
and, second, that they have no joint caviwas moved to take Schmorlls findings, comties but present instead, between each two
bine them with observations of his own and
bodies, the complex and highly specialized
preserve them in a book. This book under
structure of the disc. Each individual
the title The Intervertebral Discs, Obserdisc is adapted to the particular level of
vations on their Normal and Morbid Anatomy
the spine at which it is found and to the
in Relation to Certain Spinal Deformities,
age and occupation of the person concerned.
with fifty illustrations from specimens,
Discs have no fixed structure. It is their
gross and miscroscopic, was published in
function, by continual change in structure,
London in 1931. Fortunately also for the
to respond to and control the continual and
osteopathic profession the book fell into
infinitely various cross-currents of tenthe hands of H. H. Fryette D.O., who, recsion, torsion, pressure and mechanical
ognizing its value, financed a reprint of
shock which interplay with each other
it to be distributed to members of the
every moment of life. Their nuclei are
Academy of Applied Osteopathy as a part of
living centers, believed by Schmorl to be
their 1946 membership benefits.
composed of descendents of the primitive
Beadle states as the central theme
mesenchymal -cells.**
of his book that the human spine, more
The nucleus pulposus in the young
than any other part of the body, is subpossesses a strong turgor and power of exject to the continual wear and tear of
pansion. Surrounding and restraining it
functional activity and that as a result
is the annulus lamellosus, composed of
* Read before the Puget Sound Academy of Applied Osteopathy, Feb. 19, 1948.
**Schmorl's belief was confirmed by later histological findings. Arey, in his Developmental Anatomy,
154
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fibrocartilage, whose heavy white fibers
run from one vertebral body to the other
in wide curves, fusing front and back with
the anterior and posterior spinal ligament:
and dividing into finer fibers above and
below to penetrate the plates of hyaline
cartilage enclosing the disc. Also some
fibers of the annulus lamellosus extend
further to become firmly attached to the
epiphyseal ring of the vertebral body.
Schmorl finds that the vertebral epiphyseal
ring, contrary to its name, does not function as a growth zone, but as a fixation
organ important in spinal architecture
rather than development. The actual growth
zone is the surface of the cartilage plate
of the disc facing the vertebral body.
Fibers from the interior of the disc penetrating the cartilage plates, therefore,
exert an important influence on the events
of growth. If for any reason they become
ineffective, developmental anomalies occur.
Beadle's description presents the
normal intervertebral disc as a highly complicated organ consisting of (1) the nucleus pulposus, fluid in consistency, elastic, composed of cells able to respond effectively to changing physical demands;
(2) the annulus lamellosus, fibrous, strong
serving as a capsule to the nucleus pulposua and anchoring it firmly to adjacent ligmentous and bony structures, differentiated fibers at the same time functioning in
growth and repair; and (3) the cartilage
plates, most resistant parts of the disc,
fitting over its ends like drumheads, holding the highly expansible nucleus within
bounds, protecting the spongiosa of the
vertebral bodies and providing the bodies
with their zone of growth.
Pathological conditions in the discs
are considered in three age periods: adolescence, maturity and old age. In the
adolescent spine, one of the commonest
pathological findings is nuclear expansion
of the discs, seen usually in the lower.
dorsal and lumbar areas, apparently never
155
in cervical area.. Where such expansion
occurs, the cartilage plates are found to
be difinitely thinned and it is here that
even the slight trauma of functional activity may cause small breaks, gradually
widening into fissures through which the
turgid tissue of the nucleus pulposus escapes into the spongy interior of the vertebral bodies. The youthful kyphotic spine
characteristically shows a. row of disc prolapses of various sizes and shapes in the
lower dorsal and lumbar areas. In youth
the discs themselves are ordinarily not
much altered, remaining rather well preserved though narrowed due to a part of
their substance having escaped. Usually,
the prolapsed tissue in young spines does
not undergo degeneration.
Caution is observed by Beadle in
ascribing reasons for the frequency of occurrence of cartilage weakness with subsequent nuc1ear prolapse in adolescent spines;
yet in an extended discussion he repeatedly
returns to the conviction that developmental weakness must be the basic cause. "It
should be reflected," he states, "what a
far-reaching change of function the spine
has undergone in the assumption by man of
an upright habit." In the four-footed animals, this organ, exercising a simple supportive function is not subject to undue
strain and stress. The human spine, however, due to tensions and shocks in a. vertical direction, is confronted with conditions that from the standpoint of the horizontal habit are no longer physiological.
Also in the human manner of life and occupation these tensions and shocks recur intermittently, so that the adaptive forces
suffer from confusion and, so to speak,
lack of decision, which can but manifest
itself in developmental weakness. Undue
strains, as when adolescents become suddenly employed in strenuous occupations or
severe athletic activities may contribute
to the tearing and fissuring of thinned
cartilage plates, but the thinning itself
1946 edition, describes, at about the nineteenth day, in the embryonic disc, between the neural tube
and the primitive gut, the formation of the primitive axis of the body. This structure, called the
notochord, or chorda dorsalis, is composed of original mesodermal cells of even earlier origin than
those of the mesenchyme and around it later the spine develops. As the vertebral bodies form, the
notochordal cells in their centers become surrounded by bone cells which crowd upon them and cause
them gradually to disappear. In the intervertebral discs, however, the notochordal cells persist as
the nucleus pulposus. Undoubtedly, like primitive connective tissue cells in other parts of the body
'these cells exercise an adaptive function, being capable of what some one has described as "an infinite self-adjustment" to body needs.
All Rights Reserved American Academy of Osteopathy®
156
cannot be proven to be anything else than
A strong resistance of the
developmental.
cartilage plates to trauma from outside
has been observed, as has also resistance
to destructive diseases attacking the vertebral spongiosa. The conclusion is that
the more usual and most important cause of
injury to the cartilage plates is not
coarse violent trauma but the imperceptible
influence of functional life working upon
cartilages which are in some way inferior
in resistive power.
In middle life, prolapses of the
discs often show extensive cartilage injuries with more or less damage to the entire disc:. Often it is observed that large
parts of the cartilage plate on one or,
both sides of the disc have disappeared or
that the disc has pushed through at various
Points in the cartilage, like dough passing through a sieve. Fragments of cartilage may be carried into the spongiosa
leaving an irregular border between disc
and vertebra.1 body. The general degeneration usually involves also the disc which
has largely lost its turgor. It is not
considered that these middle-age conditions
are due to pure trauma. Cartilage plates
do not easily give way to physical violence. The explanation is sought, as with
the youthful spine, in some primary degenerative change in the cartilage itself.
As time passes the cartilage plate becomes
progressively brittle and dry, finally
showing fissures in its matrix.
In aged spines, prolapse of the
discs often accompanies osteoporosis of the
spongiosa, due to senile changes. The
cartilage plates in many of these cases
remain intact, though in others there may
be breaks, and fissures. The gradual softening of the spongiosa in osteoporosis removes the firm background against which the
cartilages rest, allowing the discs to
bulge on either side in a wide, smooth
curve. In extreme cases the discs are so
widened that they seem to occupy a larger
area than do the vertebral bodies.
In either middle life or old age,
if prolapses of the youthful type are encountered, they may be considered as left
over from the early growth periods.
With regard to age and sexincidence,
the examination of 3,000 spines of persons
of all ages dying of all causes showed 38%
having disc prolapse of various kinds, 39%
of all males and 34% of all females. Of
the ages from 18-59, 40% of the males had
prolapses and 20% of the females. After
the age of 60, the males with prolapses
numbered only 23% while the percentage of
females advanced to 44%. The excess of
males during the early and middle periods
of life is probably connected with the
harder work performed. After the retiring
age, women are more active than men as
they continue to carry on their housekeeping duties. These findings are considered
to indicate that the slight physiological
trauma of accustomed activities may be the
deciding factor in the eventual fracture
of weakened cartilage plates.
Having proceeded thus far in his
treatise on the discs, Beadle now states
that the prolapse he has described is an
ideal one only and that actual examples
with such a simple structure are very few,
for the reason that immediately the prolapse occurs, reactive changes begin and
are almost invaribly in evidence in examined specimens.
Any given disc prolapse in its early
stages shows a whitish, hard consistency
due to the formation of cartilage, beginning at the edge of the prolapse and extending inward to completely enclose it.
Prolapses of longer standing display a layer of compact bone lying between the cartilage and the spongiosa. These cartilaginous and bony changes are most typically
seen in the youthful spine but are also
found, more irregularly arranged, in the
more destructive prolapses of the mature
spine Even in the aged spine, where the
cartilages have not been fractured but
where osteoporosis of the spongiosa has
allowed the disc to bulge into It, a protecting layer of compact bone may be found.
The origin of the protective cartilage is
traced to cells from the disc itself. The
new bony layer has origin from the spongiosa.
Newly-formed cartilage may be found
inside the disc tissue as well as in the
prolapsed part. Also, the torn edges of
the cartilage plate are likely to proliferate in the body's attempt at repair.
"It must be understood", says Beadle
that the tear in the cartilage plate that
gives rise to the prolapse of the nucleus
is nothing less than a wound, a physical
injury . . . Therefore it is to be expected that these wounds will undergo the same
healing processes as any others." There is
All Rights Reserved American Academy of Osteopathy®
a certain difference between the healing
processes in youthful discs and those seen
in middle and later life. In youthful prolapses the discs retain elasticity enough
to enable them to function so that there is
no strong stimulus to start the healing pro
cess. The tissues protect themselves from
further damage by a slowly progressing process that makes an attempt usually unsuccessful to fill the gap in the cartilage
and a more successful one whereby a complete capsule of new bone is formed around
the prolapse. The youthful prolapse does
not degenerate but persists in a chronic
state.
In later years the more complicated
and destructive type of prolapse stimulates
to more immediate and extensive healing activities. Blood vessels from the spongiosa
enter the prolapse, and often the disc itself, to destroy the disc substance and
convert its degenerated parts into, first,
granulation tissue, then scar tissue and
sometimes even bone. In senile osteoporosis, the healing processes are rarely seen
because the spongiosa has little power or
proliferation left.
So far, the studies of prolapsed
discs have been of those prolapsed into the
spongiosa. Schmorl, in 1929, made a study
of the posterior surfaces of a series of
some 2000 vertebral bodies discovering in
about 50% of them extrusions of nuclear
substance, from the size of a hemp seed to
the size of a bean, through fissures in the
annulus lamelloseos into the spinal canal,
usually in the region of the posterior longitudinal ligament. The causes of these
posterior prolapses he assumed to be the
same as those of the central ones; namely
degeneration and slight trauma. They were
found to be subject to the same degenerative changes as the central type.
It is noted that purely traumatic
posterior protrusions of the disc were also
found to occur, not to be confused with
posterior nuclear expansion. The traumatic
type are usually protrusions of the entire
disc and may heal with proliferation of
fibrous tissue. In the lordosis of the
aged, degenerated discs may soften and
swell out into the spinal canal.
A section of the book now takes up
disc lesions of external origin. Mentioned
again, to make the record complete, are the
slight shocks of normal life that work on
the spine in its daily functional activity,
157
causing fine tears gradually widening into
fissures in cartilage plates having developmental weaknesses.
Fracture of one or more vertebral
bodies was found, as a rule, not to affect
the discs. It is striking to note, says
Beadle how much of injury of a violent nature can be sustained by the spongiosa with
little or none to the cartilage plates. A
few disc injuries are recorded, however,
and in an occasional case the disc was
found to be crushed without injury to the,
bone.
In a study of disc injuries due to
disease, severe destruction of vertebrae
by spondylitis in connection with typhoid,
influenza, glanders and various other infections was found commonly to occur without injury to adjacent intervertebral
discs. The only condition in which extension of infectious spondylitis into the
disc occurred was when the cartilage plate
had been previously broken and there was
free communication between spongiosa and
disc tissue. In purulent osteomyelitis,
however, vertebrae, cartilage plates and
discs alike were found to undergo dissolution and the whole spine to swim in a bath
of pus and necrotic tissue. The same was
true of the extensive destruction occurring in caseating tuberculous spondylitis.
Benign tumors, common in the vertebral bodies were found seldom to invade
the discs. Myeloma left the cartilage
plates and discs intact. Hodgkins disease of the vertebral bodies did not touch
the discs.
All kinds of malignant metastases
were found to attack the vertebrae, but of
26 spines showing advanced metastatic new
growths only two were found with invasion
and destruction of the discs. Where prolapses had already occurred, the metastatic tissue had usually grown around them
leaving a clear sharply defined margin.
The final section of the book discusses the effects of disc lesions on the
condition of the spine as a whole. It is
stated that the various degenerations and
injuries to the discs described in the
preceding chapters were nearly always found
in association with varied degrees of spinal curvature, including the kyphoses,
spondylosis deformans and many transitional and unclassifiable conditions. Excluded is the large and important group of the
scolioses. In the scolioses disc pathology
All Rights Reserved American Academy of Osteopathy®
158
is not commonly found.
The last paragraph of this section
and of the book itself summarizes:
"This short survey of several welldefined forms of spinal deformity should
make it possible to reach a somewhat greater degree of clarity about the part played
by the intervertebral discs in health and
disease. In the section on juvenile kyphos
is an attempt has been made to trace the
disease back to a disposition rooted in the
constitution of the child, and to suggest a
concrete theory of how this may act by examining closely certain gross alterations
in the intervertebral discs found in youth.
It was then found that an element of trauma, or over-burdening must also come into
play, and Schmorl suggests that this is an
important indication for disallowing sports
or other violent exercise in children at
the susceptible ages. In later life the
natural changes in the discs have been
studied and the gradual loss of their functional adaptability established. Place is
also allowed here for an inborn disposition
which inclines the tissues to fall a prey
to degenerative changes with great readiness in some individuals. But a traumatic
element also plays an important part. Tissues which are overtaxed in relation to
theirinnate strength undergo the severest
changes, and it has been seen how males
during the active working years are more
seriously affected than females, whereas
in old age, when the men have laid down
their tools, the figures for the women are
the highest.
"The great lesson from all these
observations is the all-importance of the
intervertebral discs in the preservation
of the normal form of the spine during the
infinite changes of shape, the compressions, extensions and torsions, it undergoes in functional life. How severe this
task is, is proved by the exceeding readiness with which the discs yield to senile
changes, long before these appear in other
tissues; and when this has happened the
whole spine shows itself as functionally
exhausted, and rapidly gives under the
strain, becoming stiff and permanently deformed."
All Rights Reserved American Academy of Osteopathy®
BURNS' STUDIES OF THE DISK
Mary Alice Hoover, D.O.
Osteopathic research as to the intervertebral disk antedates by some years the
work of Schmorl and Beadle as reviewed in
the preceding article. Early in her experimental work Louisa Burns began studies
of the spinal articulations and of the
disk. "NO satisfactory description of normal or abnormal joint tissues was available
when our experiments were begun," she
writes. "Part of our earlier work consisted of studies of normal articular tissues
using different families of laboratory animals of different ages and embryos of different stages of development . . . Since
that time many reports of normal and abnormal structure have been published, verifying several but not all of our findings . .
"A study of the intervertebral disk"
Burns states, "is a necessary part of the
study of the lesion and its effects. We
first studied the normal disks of laboratory animals and of a few persons. Since
these original studies were made, several
other descriptions of the disk and its development have been published. Of these
publications one of the most exhaustive is
that of Beadle."
In Bulletin IV of the A.. T. Still
Research Institute, published in 1917,
Burns gives a detailed account of her findings regarding the development of the disk.
Quoting:
"Very early in embryonic life the
notochord is formed, following the foundation laid by the primitive streak, itself
one of the very first indications of differentiation of structure found in the embryo. The notochord persists as a whole
throughout life in only a few of the lowest
fishes. It is, in very nearly all vertebrates, superseded by the spinal column.
In all mammals, as development goes on, the
notochord and its neighboring mesenchyme
become segmented. In each of these segments an upper cartilaginous portion becomes the anlage of the body of the vertebra. The lower portion retains in its center the original embryonic notochordal
structure throughout life. The mass of
cells which ultimately becomes in the adult
the nucleus pulposus is surrounded by an
area of soft cartilage which retains to a
certain extent something of its embryonic
qualities throughout life. The nucleus pulposus thus represents what is perhaps the
most primitive tissue found within the
adult human body."
Descriptions follow of adult disk
structure, with drawings of cells of the
nucleus pulposus and substantia fibrosa.
Studies of the disks of the rabbit, the
guinea pig, cat, dog, sheep, cow, and human
show that variations in the disks when present are due more to differences in size
and shape than to essential factors. The
nucleus pulposus is found to be without
nerve endings or blood vessels and, with
the substantia fibrosa, to receive its nutrition from lymph derived from the blood
vessels of the adjacent vertebral surfaces.
The disk, especially the nucleus,
Burns found to be markedly hygroscopic,
swelling in all solutions of the ordinary
salts, acids, alkalies, tap water and diluted blood, a characteristic important in
consideration of its function in giving the
spine strength and resiliency. Quoting:
"Increased acid content of the
blood causes edema of the disks. The fibrous tissue becomes soft and logy, like
putty rather than like rubber; like soft
lead rather than like steel springs. Such
tissues do not return to the normal state
after.compression is removed nor do they
efficiently resist the influence of abnormal stress."
Senile changes are noted, with
their effect on normal spinal curves. The
effect of preliminary studies as to the effect of vertebral lesions on the disks is
given, clinical applications are indicated
and treatment for disk conditions outlined.
All this some 14 years before the
appearance of Beadles' book!
Studies of the disks have been continued in the Research Institute from its
beginnings to the present time. Examination of the disks adjacent to a lesion is
159
All Rights Reserved American Academy of Osteopathy®
'
160
routine procedure in the experimentation
program. In Burns' recently published book,
reviewed in another part of this volume,
factors concerned in studying the changes
due to lesions occupy several pages. Reports are given of experimentally lesioned
guinea pigs, rabbits, cats, dogs, of various ages, killed at various times from immediately after the production of the lesion to 5 years later. Some human autopsies were also held.
The effect of vertebral lesions on
the nucleus pulposus is found to be an increased water content, within 5 to 10 hours,
as evidenced by a greater pressure exerted
on the peripheral fibers. During successive weeks this edema increases, elasticity
diminishes and the fibrous portion of the
disk becomes slightly thinner in the area
subjected to the greatest pressure by the
nucleus.
As the lesion becomes chronic, edema
diminishes and after a year or a few years
nearly all fluid is absorbed from the nucleus pulposus. The typical cells die and
become unrecognizable and the intercellular
substance diminishes gradually in amount.
The entire nucleus becomes whiter and more
opaque in appearance, and tougher, harsher
and more brittle in palpable quality. Microscopic examination of the nucleus pulposus of rabbits whose lesions have been
present for 4 or more years shows abundant
granular debris and many fine connective
tissue fibrils. A few connective tissue
cells are associated with these fibers but
there are few or no recognizable cells of
the original notochordal type. The granular material is persistently hygroscopic.
It has not yet been possible to
bring the granular debris in vitro to the
condition of normal nucleus pulposus but
experiments in vivo indicate that at least
a certain degree of recovery is possible if
the normal circulation can be established
in animals not too old . . . The cells have
not been restored in any case and this is
not to be expected.
The results of osteopathic manipulative treatment on the nucleus pulposus is
illustrated as follows:
"A litter of 5 young rabbits was selected for experiment. One was kept as a
control. A first lumbar lesion was produced in 4, and the lesion was permitted to remain for 3 years. One rabbit was then killed; the nucleus pulposus showed the inspis-
sated condition described previously. Two
rabbits received 10 osteopathic manipulative
treatments which restored normal vertebral
relations so far as we could determine by
palpation. They were permitted to live for
6 months longer. Lesions did not recur.
One of those treated was killed. The nucleus pulposus of the disks adjacent to the
lesion showed pulpy material and a few Cells
of the notochordal type. The others lived
6 months longer, when the 3 remaining rabbits of the group were killed. The nuclei
pulposi of all the intervertebral disks of
the control rabbit showed normal structure.
The rabbit whose lesion remained present
showed normal disks of all spinal segments
except those adjacent to the lesion, and
these showed the changes. described previously . The rabbit which had received corrective treatments showed normal disks for
all segments except those adjacent to the
lesion, and these showed almost normal
gross structure, though the notochordal
cells were less numerous than in a normal
disk."
The fibrous portions of the disks
next to the lesion are found by Burns to be
perceptibly diminished in elasticity within
4 days after lesioning in small and young
kittens , guinea pigs and rabbits. Elasticity continues to diminish gradually the
next few weeks. By the end of a year the
fibrocartilaginous portion of the disk has
lost much of its matrix. The fine fibers
which unite the layers are fragile and
easily broken. All the fibers are waterlogged and putty-like in palpable quality
and are without recognizable elasticity.
During the second year the disk becomes
harsh and dry and assumes permanently the
form imposed on it by the abnormal position
of the lesioned vertebrae. Elasticity is
completely absent, flexibility almost gone.
After the second year correction of
the lesion in laboratory animals is difficult. Many treatments are required and it
may be impossible to secure permanent and
adequate restoration of normal vertebral
relations. However it is possible to increase the mobility of the spine and to relieve the symptoms due to the lesion.
Lacking its normal elasticity the disk
which has been affected by a lesion for 2
or more years seems unable to readapt itself to its original normal position.
Of great interest is Burns' observation on the relation of the hygroscopic
All Rights Reserved American Academy of Osteopathy®
161
property of the disks to spinal curvature
increased hygroscopic quality of the disks
and that many children are found to develop
in children. In children, she concludes,
the probable pathogenesis of spinal curvaspinal curvature after a period of malnuture includes increased imbibition of fluid trition.
by the intervertebral disks and increased
Dr. Burns states that further study
mobility of the spinal column, plus some
of the normal structure of articular tisasymmetrical spinal strain. However, such
sues and of the disks is indicated; also
strains are frequently found among all
that the biochemical interrelations of
children while spinal curvature is relablood plasma, tissue fluids, synovial flutively rare. This discrepancy is explained ids and the fluids of the disk have receivby the fact that increased hydrogenion con- ed very little attention in any laboratory
centration of the blood plasma., such as is
and offer an interesting field for investipresent in malnutrition, is associated with gation.
All Rights Reserved American Academy of Osteopathy®
DR. BURNS' NEW BOOK*
Mary Alice Hoover, D.O.
Many appreciative words have been
said about Dr. Louisa Burns' recently published book. Many more should be said.
"It establishes experimentally the fact
that the osteopathic lesion exerts a disease-producing influence and describes
the nature of the disease process by this
particular type (traumatic) of osteopathic
lesion," writes L. C. Chandler in the
book's preface. S. V. Robuck in a foreword says: "Not content to study only the
pathology of the spinal joint lesion, Dr.
Burns pushed on into the more dramatic and
more difficult problem of determining some
of its effects upon the nervous system and
the organs of the body. The greater lesion complex truly challenges the patience,
ingenuity and technical skill of a Pasteur,
a Koch, a Metchnikoff or an Ehrlich and requires something of the clinical acumen of
an Osler or a Mackenzie . . . This book
will undoubtedly become more valued as
years pass, for its contents deal with
data that are basic." The late, R. E. Duffell, who edited the book for publication,
said: "Every osteopathic physician will
want to own a copy of this latest book by
Dr. Burns."
Among significant events at the
1948 Convention of the American Osteopathic
Association in Boston, was the initial appearance of this book and of the moving
picture** produced by Dr. Burns and the
late Ralph W. Rice, complete with sound
and color, to illustrate findings as to
the effect of certain vertebral lesions on
the heart.
Graphically described in the book
and vividly portrayed in the movie is the
heart affected by third or fourth thoracic
lesions. Quoting: 'Anesthetized animals
show immediate and characteristic pulse
changes after an upper thoracic lesion, especially the third or fourth, has been produced. The pulse becomes rapid, weak and
slightly irregular. During the next 10
minutes the pulse gradually becomes slower,
stronger and more nearly regular, but it
never becomes quite normal so long as the
lesion persists."
"During the several weeks or months
after a lesion has become permanent, the
heart beat assumes a peculiar, abrupt palpable quality resembling the ticking of a
clock and here described as 'staccato'.
This quality faintly suggests Corrigan's
pulse except that full expansion does not
occur. The sudden collapse is easily palpable. It is present even though the
pulse shows slightly increased force, for
example, during exercise . . . .
"If a lesion remains present for
several months or years, the pulse, becomes gradually feebler, slightly uneven
in force, slightly less regular in rate.
After 3 years or more, in certain rabbits,
the pulse may become rather rapid as well
as more feeble, but in other rabbits the
pulse remains slow and weak as long as the
lesion persists."
"The anesthetized normal animal
whose thorax has been opened shows a heart
which beats strongly and which continues
to belt for a time whose length is determined by the nature of the experiment being
performed. After it has been removed from
the thorax and placed, emptied of blood, on
a flat surface, it stands up in rounded
form. If it is beating strongly when it
is removed from the thorax, it continues
to beat strongly for a. considerable time
thereafter. The heart of an average normal young adult rabbit, for example, not
subjected to severe experimental procedures
* Pathogenesis of visceral Disease following vertebral lesions, by Louisa Burns, M.S., D.O. Published
by the American Osteopathic Association, Chicago, 1948. Price $6.00.
**Heart Disease - Effects of Selected Spinal Lesions upon Function and Structure of the Heart. 16 rmn
film in color and sound, the latter for exhibiting changes in heart tones. A sound projection apparatus
is necessary in showing the picture. Bookings available with the American Osteopathic Association,, 212
East Ohio St., Chicago.
162
All Rights Reserved American Academy of Osteopathy®
163
during anesthesia, confined under a tambour connected with a manometer, beats
strongly enough to cause a column of mercury 120 mm. high to oscillate visibly.
"Certain cardiac conditions are uniform in the hearts of animals with third
or fourth thoracic lesions. During anesthesia and after the thorax is opened,
whether or not experiments are performed,
the heart beat is visibly less vigorous and
less regular than is the normal beat. The
contraction becomes weak after relatively
short periods of anesthesia, with or without experimentation. After the heart is
removed and placed on a table it becomes
flattened, obviously because of loss of
tone. The heart of such an animal is about
two-thirds the height of the control heart
so placed. It often ceases to beat after
being removed from the thorax even though
it had been beating fairly well before it's
removal. If the removed heart beats at all,
the pulsations are feeble and soon cease.
At all times after the thorax is opened
the heart Is palpably softer and weaker
than the normal heart. Such a heart, confined under a tambour connected with a
manometer, rarely moves a column of mercury which is more than 100 mm in height."
Histological specimens are obtained
from the hearts of animals not used in
other tests. The thorax of the anesthetized animal is opened and the heart still
beating, is packed in dry ice till frozen.
In slides of normal hearts quick frozen
while the heart is beating "alternate waves
of contracting and relaxing muscle fibers
are easily recognizable, but within each
wave the striations are uniform. Longitudinal striae are very dim if they are
visible at all. Nuclei are distinctly
outlined and lie at the periphery about
midway between the ends of the muscle cell.
"Blood vessels present normal strutture. Arterioles and venules contain a
central core of blood cells surrounded by
a peripheral plasma layer. In no case
does a blood cell touch the intima. Larger
blood vessels contain the same peripheral
plasma layer, but the central core of blood
cells is relatively much larger. The capillaries have a diameter not more than that
of an erythrocyte. Many capillaries contain only a thin layer of plasma, with an
occasional erythrocyte.
"From the histology of the heart of
an animal which has had a third or fourth
thoracic lesion for a year or more, it
might be inferred that this lesion primarily affects the vasomotor control of the
heart. Blood vessels are crowded with cells
The peripheral plasma layer is nowhere visible. Capillaries contain many blood cells,
touching and crowding one another, and distending the capillary to 2 to 5 times its
normal lumen. Cells in the act of escaping
through the capillary wall by diapedesis
are abundant. Erythrocytes crowded against
the intima of arterioles and small arteries
occasionally are seen penetrating the intima, into the space between this membrane
and the subjacent muscular Coat. Minute
petechial hemorrhages also are abundant,
and these present various stages of coagulation, digestion, and absorption, or of
coagulation, organization, and the development of a minute mass of connective tissue.
In many cases these small fibrotic areas
appear to have diminished the lumen of a
vessel; in a few areas a capillary, arteriole or venule appears to have been occluded
completely by these masses of scar-like
connective tissue. General fibrosis is associated with ischemia of small areas of
myocardium. Before fibrosis is marked the
heart wall is extremely bloody. It often
resembles a sponge which has been soaked
in blood. Small coagula are present both
in blood drained from the cardiac cavities
and in blood which flows from the sectioned
or torn myocardium.
"Cellular changes found in the
hearts of animals with upper thoracic lesions (especially the third and fourth
thoracic) appear to be due to changes in
nutrition. Living and quickly frozen preparations show constant mild edema. The
thin layer of tissue fluid which is present around the cells of the normal heart
is greatly increased in the heart of the
experimental animal, usually to several
times its original thickness. Myocardial
cells are swollen, their cross striations
are uneven, and the longitudinal striae
distinctly visible. Contraction waves
found in hearts frozen while still beating
are uneven in outline. In each wave small
areas appear which seem to be out of place,
that is, in a band which seems to be contracting, a small area of relaxing cells
may be seen, while in a wave of apparently
relaxing cells, there may be small areas
of cells which are, apparently, contracting. Nuclei are less distinct than in
All Rights Reserved American Academy of Osteopathy®
164
normal hearts. They often lie deeply within the muscle cell and sometimes they lie
nearer the ends of the cells than in normal tissue."
Atlas lesions or those of the occiput or upper cervical vertebrae, experimentally produced under anesthesia, are
found by Dr. Burns to show the following
effects: "For a few minutes the pulse becomes stronger, very irregular and usually
extremely slow. Within the next 10 or 20
minutes the pulse returns toward normal
though it never becomes normal so long as
the lesion persists . . . During the next
few days or weeks the variation of the
pulse waves develop into a fairly rhythmic
grouping . . . After six months or so a
"missed beat" may be found. Up to the present time no consistent or definite pathology has been found grossly or microscopi-
cally in the heart affected by an atlas lesion. It seems probable that upper cervical lesions affect the vagi and their centers and so cause the functional variations."
Much more than is quoted here is
included in Dr. Burns' chapters on the
heart. And the heart is only one of the
body structures that she has scientifically
explored in relation to vertebral lesions
and has reported in this book. On page 39
we note some of her findings as to the intervertebral disk. Equally revealing are
studies of the eyes, the nervous system,
the tissues of the nose and throat, the
lungs, the gastro-intestinal system, and
the kidneys. As we close this review we
can but echo Dr. Duffell's admonition:
"Every osteopathic physician will want to
own a copy of this book."
All Rights Reserved American Academy of Osteopathy®
THE IMPORTANCE OF 'PATHOGENESIS OF VISCERAL
DISEASE FOLLOWING VERTEBRAL LESIONS'
W. V. Cole D.O.
This volume is the compilation of
the results of many years of investigation
and clinical observation. It is in this
publication that Dr. Burns has described
the methods of laboratory investigation,
the results of experimentation, and the
most important of all the practical application of these findings to the practice
of osteopathic medicine.
Furthermore, throughout this book
there is present the underlying concept
that the osteopathic physician is primarily interested in the patient with the disease rather than the disease with the patient. The latter is commonly referred to
as the symptomatic approach to therapy.
This fundamental idea in the treatment of
disease has been thoroughly investigated
by laboratory methods and these findings
are presented in such a manner that they
are of use to the clinician. Dr. Burns
has spent many years in an accurate evaluation of these factors, and in this book
describes why it is as important to remove
the mechanisms that permit the invasion of
bacterial infections as it is to destroy
the invading organism itself.
In the present volume Dr. Burns has
also described the origin of osteopathic
research and its development since the
turn of the century. It is true that pure
research material is often not immediately
useful to the general practitioner, and
this book is not to be considered a 'practice book'.
The material contained is essential
for a complete understanding of osteopathic
principles and philosophy both of which are
necessary to the general practitioner and
specialist in osteopathic medicine.
Osteopathic research has long been
the step child of the profession and it is
only through the efforts of Dr. Burns and
more recent investigators that this phase
of professional endeavor has reached the
importance it deserves. The advance of
osteopathy will depend upon both laboratory and clinical investigation.
Although much of the reported material in the present book is based on a
purely scientific approach Dr. Burns' wide
clinical experience has influenced the conclusions. For this reason they are much
more valuable to the practising physician
than they otherwise would be. The aim has
always been to utilize the experimental
results in practical clinical osteopathic
medicine.
This is a book with which every osteopathic student and practitioner should
be familiar and will become a valuable
source of explanation for phenomena encountered in the practice of osteopathic
medicine.
DR. LOUISA BURNS AND HER RESEARCH LABORATORY
Mary Lewis Heist D.O.
If I wanted to do something nice
for you, I know what it would be. I would
take you to Los Angeles to Dr. Louisa
Burns and her Research Laboratory. She
might be busy and even tired, but her eyes
would light up and her kindly smile would
welcome you; You might be one of the
great ones of the profession or you might
be a student, your welcome would be the
same. Your questions might be profound, or
even stupid, you would be-answered in the
same gracious manner. Dr. Burns is never
too busy to welcome visitors. She is never
too absorbed in her work to stop and explain
what she is doing and why. Three of the
shortest months of my life were spent in
her Research Laboratory.
I have spent many years in the practice
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All Rights Reserved American Academy of Osteopathy®
of osteopathy. I have attended conventions search compared well with other research at
and special courses and tried to underthat time and does now. She has given her
stand why I have succeeded and why I have
life to it. I have never known any one who
failed in my efforts to relieve human suf- KNOWS SO MUCH ABOUT OSTEOPATHY. She has a
fering. There were few days in those three large library of microscopic slides, many
months that some of my doubts and questions of which she has photographed and had the
were not cleared up.
photographs enlarged. These latter are a
In the many years that Dr. Burns has great aid in understanding the effects of
experimented with animals she has establesions. She prizes case records sent in
lished a definite relationship between
by osteopathic physicians in the field.
spinal lesions and organic disease. Right She is correlating her findings in experihere I want to quote her indirectly and as mental animals so that they may be applied
nearly as I can recall. "NO, SHE DID NOT
to human distress.
PROVE THE PRINCIPLES OF OSTEOPATHY. NO
When a Research Laboratory was set
SCIENTIST ATTEMPTS TO PROVE ANYTHING BUT
up in Chicago to determine the basic princiSEEKS THE TRUTH."
ples of osteopathy, Dr. Burns went there
Few of the profession have any idea, to assist. That was long ago. The severe
and no one knows, all that Dr. Burns has
winters in Chicago proved so destructive to
done for the Science of Osteopathy. She
theaexperimental animals that the laborahas written many books and also articles
tory was moved to California and has been
for the Journals. When her health permit- there since. For many years it has been
ted, she was always one of the principal
supported by The American Osteopathic Asspeakers at our National Conventions. A
sociation and is now under a special comnew book is just out, "Pathogenesis of
mittee of the Association. The College of
Visceral Disease Following Vertebral LeOsteopathic Physicians and Surgeons prosions". She and the late Dr. Ralph Rice
vides the laboratory which is in a building
have collaborated in making movies of her
on the college campus. Still to me, it is
research. The last one on "Heart ReacDr. Burns' Laboratory for without her there
tions to Lesioned Areas", was Dr. Rice's
would not have been this laboratory and it
last effort and he showed it at the Boston is she who keeps it going.
.
Convention.
When you go to Los Angeles be sure
Dr. Burns was graduated from the
to visit Dr. Burns at her Laboratory. You
Pacific College of Osteopathy in 1903.
.
will be inspired, as I have been.
She soon began keeping records of clinic
patients and comparing results of osteopathic care. She was a Master of Science
when she became interested in osteopathy.
November 2, 1948
Little research was attempted in any line
703 Kent Bldg.,
in the early nineteen hundreds. Her reToronto 1, Ontario
A GREAT BOOK AND A GREAT MOVIE
The Academy of Applied Osteopathy
in session at Boston in July 1948 had been
shown the wonderful new sound movie showing the result of vertebral lesions on
cardiac function and the subsequent cardiac pathology; the wonderful contribution
of the late Dr. Ralph W. Rice and Dr.
Louisa Burns and the new book published by
the American Osteopathic Association
"Pathogenesis of Visceral Disease Following Vertebral Lesions" had during the Con-
vention week been put on sale and there developed a spontaneous demand that greetings
be sent Dr. Louisa Burns, the first Honorary Life Member of the Academy.
A telegraphic message of greeting
was sent and post cards were distributed for
signatures. The following photostat was
made of the autographs of those present and
Dr. Burns' reply are printed here for the
benefit of the many friends of Dr. Burns,
who also could not be present. at the Convention.
All Rights Reserved American Academy of Osteopathy®
FINDING
THE STILL (OSTEOPATHIC)
LESION
Perrin T. Wilson D.O.
There is ample evidence that the
ordinary American M.D. classes Osteopathy
in the category of massage and physiotherapy. Within the month previous to my sail.
ing for this conference I had two specific
illustrations of this understanding of Osteopathy by two prominent Boston M.D's.
One was an internist, the other a surgeon.
The Internist called me and said
that he was attending a former patient of
mine who had been stricken with a cerebral
hemorrhage. The patient wanted a treat-,,
ment. The Internist said, "I don't see __
what good massage will do in such a case,,
but it is alright with me for you to go
and see him. Maybe the visit will help
his morale". The surgeon called and said
that he had just done a hysterectomy on a
patient of mine and her back was troubling
her. He thought physiotherapy would help
her and suggested that since the patient
wanted me it was agreeable to him to have
me see her.
Another thing we occasionally hear
from those who think they know what Osteopathy is,, concerns a type of treatment
used in the Pacific Islands by the natives.
I have actually heard it said, "Why Osteopathy was practiced by the Micronesian Islanders before Dr. Still was ever born."
There certainly is a type of spinal treatment practiced by the natives, and it is
indeed very beneficial. My sister, a missionary to those Islands has had the
treatment. Young girls from five to ten
years of age are trained as 'treaders".
The patient lies on his face and the child
works up and down one side of the backbone
treading with her toes. Then she crosses
over and works up and down the other side
of the backbone in the same way. A great
deal of treading is done over the muscles
of the buttocks. Sister says it is very
beneficial but in a recent letter she said,
"I hope in a couple of years to get a
holiday so that I can go to Hawaii where I
can get a good adjustment between my
shoulder blades."
If the word "adjustment" is kept in
the forefront of the physician's mind, he
will do things for his patient that no
amount of massage, physiotherapy or "treading" can possibly do.
Dr. Still adjusted the various
structures of the body to fit the pieces together in a way that they were intended to
be. The problem we face is to find that
structure which needs adjustment; and that
is what I want to discuss with you at this
time.
With the aid of certain members of
the Academy of Applied Osteopathy I have
worked out a series of tests of motion
which I believe quickly demonstrates the
presence of a Still Lesion in certain areas
of the body, and having then settled upon
an area where trouble is, a more careful
search of that area is made to determine
the specific vertebra or vertebrae involved.
I seat the patient on the table
and extend the head and neck. The head
should follow an arc of approximately ninety degrees. If it stops short of that I
0
register it thus: H-ext 60 . Now I am
reasonably sure that there is trouble in
the top three cervical vertebrae or, of
course, it may extend down to the upper
thoracic area. Now flex the head. In
flexion the head should describe an arc of
0
approximately 45 . I do not register normals. Having tested for extension and
flexion, I proceed to right and left rotation. Normal rotation approximates ninety
degrees. Frequently we find rotation restricted, and it may be registered thus:
0,
This would indiH.r rt 60 H.r lft 90o.
cate that rotation to the left is normal
and therefore the restricted rotation to
the right is not due to a general stiffening found as we grow old. As a matter of
fact we often encounter elderly people in
excellent health who do have ninety degree
rotation right and left. In this illustrative case we would be reasonably sure of
finding one of the bodies of the vertebrae
from C.3 to T.2 side slipt to the right.
Now to determine the presence of
a Still lesion from T.2 to T.8 or 9, I drop
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All Rights Reserved American Academy of Osteopathy®
first one shoulder and then the other. The mentioned in Dr. Downing's book, but I beangle of inclination of the shoulders when
lieve Dr. Ray first used this as a test of
the spine is lateral flexed should be ap- mobility for the joint.
proximately 45 degrees. A very flexible
The patient lies on his back, the
young spine will do better than that where- thigh is flexed on the abdomen and then ciras a stiff spine will stop short of that
cumducted and straightened. If circumducamount, but each side should be equal. If
tion is lateral the leg should lengthen.
one side is reduced say to 300 we would re- If medial the leg should shorten. If the
gister it thus T lat flex rt 300. With
leg as measured by the ankle bones moves up
such a restriction of motion there will be
and down, I do not consider that there is a
one or more bodies of the vertebrae rotated sacro-iliac lesion. The fact that the two
to the right. The nucleus pulposus would
ankles are not in juxtapostion is more apt
be decentered to the right. The reason I
to indicate a lumbar lesion than a sacrofeel that it is the bodies and the nucleus
iliac lesion, altho if the ankles are even
at fault rather than the soft tissues is
do not let this lull you into thinking that
that if it were soft tissues, correction
there is no lesion of the sacro-iliac, bewould be made by forcing the spine in the
cause a lesion of the lumbar area may comdirection of the restriction. However, a
pensate in length of leg for a lesion at
better correction is made by forcing it in
the sacro-iliac. Hence be sure and test
the opposite direction with the lines of
for motion. The usual lesion of this joint
force concentrated on squeezing the nucleus is S rt flexion lock.
pulposus between opposing planes; as one
Now grasp the heels and rotate the
would pop a marble out from between the
femur in the acetabulum and note any reducfingers.
tion in rotation in that joint, the foot
If, with the patient still seated,
should describe at least a ninety degree
we test for rotation of the body, we can
arc.
note any restriction in the action of T.10
The knee should be flexed and exto L - 1. The shoulders should describe an tended to test freedom of motion and if rearc of approximately 900 right and left.
stricted should be so noted. The fibula at
That is 1800 from far right to far left.
its proximal end may be tested for motion
Lumbar 2 to L 5 may be tested in the by flexing and extending the foot while one
standing position. I have the patient ashand is on the head of the fibula. The
sume the position he would assume if stand- flexion and extension of the ankles may be
ing talking with a friend with his weight
compared as well as the arch and each metaslumpt on to one leg. It is usually neces- tarsal.
sary to show the patient what position you
The arc if abducted should describe
o
wish him to assume, for if you just tell
an arc of 180 and should it fail to do
him to stand with his weight on one leg he
this as in bursitis, the amount of the arc
will raise the other off the floor. Have
should be registered.
him slump back and forth from the right to
Now here we have a quick way of
the left. The inclination of the pelvis
localizing
the area of the Still lesion,
0
usually assumes about a 45 angle. The
and then we must go back and diagnose by
thing to note is the difference and record
specific lack of motion in one vertebra or
the degree of inclination that is reduced.
group of vertebrae, and by tissue feel just
This would be registered as L lat flex rt
what vertebra is involved.
20o and we would know that one or more of
Note the mobility, the position
the bodies of the lumbar vertebrae had side of the spinous process, the transverse proslipt to the right.
cess, and the tissue feel. It pays on the
For testing the mobility of the
first examination to take plenty of time
sacro-iliac joints, I use the method first
then one can quickly attack the problem of
showed to me by Dr. T. L. Ray. It is also
correction, and not depend on aimless manipulation to get results.
All Rights Reserved American Academy of Osteopathy®
THE OSTEOPATHIC TREATMENT OF ASTHMA
Perrin T. Wilson D.O.
The Osteopathic treatment of Asthma
is divided into two phases. First what the
patient does for himself, and second what
the Osteopathic Physician does for the patient.
Each of the above divisions are subdivided in the following manner:
I The patient's responsibility
entails
a. rest
b. upper thoracic friction
c. diet
d. breathing exercises
e. elimination
f. avoidance of air laden
irritants
II The Osteopathic Physician's
responsibility entails
a. alignment of upper thoracic vertebrae
b. freeing of the 4th and
5th ribs both right and
left
c. ventral technique to
free diaphragm
d. alignment of the occiput
e. cranial flexion
f. inhibition between the
4th and 5th thoracic
transverse process
Under I(a), we must realize that
asthmatics are apt to be excitable above
the average individuals. The paroxysms of
Asthma are very exhausting, and rest is
more essential to asthmatics than to the
ordinary individual. These people as a
rule don't want to rest, especially between attacks, so we must be very definite
about this and see to it that he takes adequate rest. The minimum time that should
be spent in the horizontal position is nine
hours out of each twenty-four. This need
not be taken all at 'one time, but should
not be, skipped. I would rather an asthmatic take ten hours a day in the horizontal position than eight. Make sure he gets
rest enough!
I(b), The patient should take a
bath towel, or friction brush, and use
friction much as he would in drying between the shoulders. The idea was given
me by Dr. C. S. Edmiston whom I would like
to quote as follows:
"In Asthma the conditions are
somewhat different. The skin in an asthmatic case may have a normal amplitude of
reaction but it is a thin skin, its vessels
are rarely ever full, and it possesses an
acute degree of sensibility, this special
quality makes it susceptible to affection
from any wandering stimulus.
This whole complex affair is caused by a lazy skin, a thin skin, a poor
skin. The treatment is to try and restore
a normal skin function which can be done
in many ways. Friction alone will do it,
loosening up the shoulder 'girdle and stimulating the skin nerves along the spine
manually will do it.
And any treatment designed to cure
the condition must take the condition of
the skin into account."
I have found this to be helpful.
One husband applied the friction so vigorously to his wife that he created a blister
as large 'as the palm of the hand. That patient has not had an attack in five years.
I(c), It has seemed to me that
whether or not the skin allergy test registers negative to wheat, it is a good
thing to eliminate this item from the (diet.
For many years I have used rye-krisp or
hard tack in place of bread for asthmatics,
and asked them to eliminate wheat in every
form. I am convinced that it has helped
to modify the severity of the Asthma. Few
patients will completely cooperate in this,
and one must be constantly checking to see
that the orders are being carried out. An
elimination diet consisting of Pluto water
and nothing but fruit for three days is
sometimes used. Following this add one
item at a time until a food causes asthma.
This may be more accurate than the usual
scratch tests.
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All Rights Reserved American Academy of Osteopathy®
171
I(d), Some asthmatics use practically no diaphragmatic breathing. These persons should be taught to place the hands
akimbo on the lower ribs and move these
ribs laterally and medially as far as possible, particularly medially. This should
be done as an exercise morning and night
and depending upon the reaction can start
with six inhalations and six exhalations.
Each time, gradually, the number may be
increased until each period of exercise
consists of twenty five.
I(e), Free elimination from the
bowels should be encouraged. Not by cathartics but by enemas, either an oil retention enema or plain water. copious
water drinking will often help a sluggish
bowel. Hot fruit juice drinks is another
good way to normalize bowel activity.
Cathartics should be avoided, and I am sure
there are few people who can not control
their bowel elimination by drinking plenty
of water. Keep this item in mind when
treating asthmatics.
I(f), Air laden irritants are certainly factors in certain asthmatics.
Horses, cats, dogs and even canary birds
have been found to be the specific allergy.
that starts an attack. Plant life also
comes in for its share as an exciting cause
of attacks. House dust, mattress dust and
pillow dust should be carefully checked.
If we have an air conditioned room available one can readily place the patient
where air laden irritants may be eliminated. It has been my experience that with
proper Osteopathic and hygienic regime
instituted, the air laden irritants become
less of a factor.
II(a), The alignment of the upper
thoracic vertebrae may be done in any one
of a number of ways. Nearly all of these
cases present a segmental break at the
fourth thoracic vertebrae. The upper four
vertebrae side bend to the left as a segment with the spine of the fourth rotated
towards the right and the body of the
fourth side slipt to the right on the fifth
The first, second, third and fourth thoracic vertebrae seem to move as a unit as
their spinous processes are in alignment
while the spinous processes of the fifth,
sixth, seventh and eighth are also aligned
but at a different angle.
It has been my custom to place the
patient on the table face down, but up on
his elbows and the forearms parallel to the
table lying out in front of him. The
points of the elbows should be far enough
forward so that the upper arms are at a
right angle to the table, or slightly front
of a right angle. This position suspends
the spine in a hammock of muscles, and cannot hurt the breasts or sternum. I stand
on the side of the table so that I face his
left side. I place my right hand on the
spine in such a way that the knuckle of the
middle finger is on the right transverse
process of the fifth thoracic vertebra and
the heel of my thumb on the left transverse
process of the fourth thoracic vertebrae.
My left hand in on the top of the patient's
head, which is in easy flexion. Do not
place the left hand in a position near the
back or crown of the head because it is not
desirable to get forced flexion of the neck
My body is equally placed between my two
hands and I lean down so as to get my
shoulders in a mechanically easy position
to approximate my two hands. I turn the
patient's face slightly to the right and
side bend the neck and upper four thoracic
vertebrae slightly to the right. In this
position I am ready to use a quick light
thrust approximating the two hands. I may
at times just use a strong slow effort to
approximate the hands. The pressure on
the transverse process of the fifth drops
it from under the fourth permitting the
fourth to side bend to the right. The
pressure on the transverse process of the
fourth helps to drive it upward and aids
in realigning the segment. If I am not
adept enough I may adjust this area in the
following manner:
The patient stays in the same position. I place the pad of my right index
finger over the left transverse process of
the fifth thoracic vertebra, and the pad
of my right middle finger over the left
transverse process of the same vertebra.
I then place my left forearm (close to the
elbow) over these fingers and I use a quick
thrust with my left arm in any forty-five
degree angle towards the table and towards
the head.
II(b), With the patient in the
same position, I draw the angle of the
fourth right rib down and push the angle
of the fifth right rib up. I reach around
front with my left hand and find the front
end of the fourth right rib so that I can
raise it as I lower the angle. I reverse
this process for the fourth and fifth left
All Rights Reserved American Academy of Osteopathy®
172
ribs, separating them at the angles instead of approximating them as shown for
the right side. Either in this position
or with the patient sitting up, I make
sure the front ends of the ribs are perfectly spaced.
II(c), Ventral technique in Asthma
is designed mostly to increase the flexibility Of the diaphragm and lower ribs.
Often these cases may have a big barrel
shape chest but the lower ribs are drawn
in and there is very little expansible
ability. In adjusting that area I have the
patient lie on his back and I place my
thumbs low on the sides of the ensiform
cartilage, with my fingers resting over
the lower ribs. On deep expiration I sink
my thumbs into the muscles of the abdomen
as if I were helping to push the diaphragm
cephalward. At the same time my fingers
over the lower ribs press medial. On inspiration my hands remain in the same position, but my pressures are transferred to
the palms and heel of my hands as I help
the ribs flare laterally and raise a bit.
Care must be used in these techniques because a slip of the thumbs on expiration,
or the hands on inspiration, may cause a
skid over the cartilages resulting in a
painful bruise or possibly a costo-chondral
separation. I have had one or two accidents of this nature, but none where the
tenderness lasted over three to four weeks.
II(d), You all have your own methods
of adjusting the occiput. I have usually
found the position of this bone one of extension on the atlas on the right. This is
usually spoken of as an anterior occiput
(Rt.). I use many different methods to
lift the occiput, and draw it back on the
right. The movie, "Anterior Occiput",
available from the A.O.A. goes into detail
on my usual procedure.
II(e), Cranial flexion--cranial
technique is so difficult and complicated
that it is usually wise to take a course
specially designed for cranial work, but if
you depend upon respiration rather than applied force for the adjustment there is no
harm in trying simple flexion of the crani-
u m Dr. Sutherland feels that all Asthmatics have the cranium fixed in extension.
That is both greater wings of the sphenoid
are up and the occiput is up. In thinking
of these movements one must of course
think in terms of infinitesimal strains.
When one gets used to the feel of a craniurn that is locked, and one that is not, it
is not too difficult to tell which condition exists. To this day, however, there
are many cases that I cannot be positive
about.
I try to bridge the fronto-parieta1 suture line to have my left thumb on
the right greater wing of the sphenoid and
my ring finger or middle finger on the left
greater wing of the sphenoid. My right
hand cradles the occiput from right to left
with the occipital protuberance cupped in
my palm near the little finger border. I
hold the cranium thus in easy flexion using traction downward towards the feet on
the occipital protuberance, and holding the
greater wings of the sphenoid downward towards the chest, not towards the table.
The patient is then asked to breathe (deeply
either in sniffs or one continuous breath
and to hold as long as he reasonably can.
Usually just as he starts to let his 'breath
out, one can feel an infinitesimal give.
There is, of course, not as much motion as
in a sacro-iliac as it lets go, but there
is a sense of relaxation and if the suboccipital muscles are palpated before and
after, one can tell whether or not the.
cranium has unlocked for these muscles will
feel more normal in texture.
II(f), I like to sit the patient
up at the end of the above manipulations
and place my fingers over the first ribs
and my thumbs between the transverse processes of the fourth and fifth thoracic
vertebrae. In this position I use deep
pressure on the fingers and thumbs for
about two minutes. This pressure alone in
an acute attack is often effective.
I like to treat asthmatics once a
week for one to two years. It may be discouraging but the outcome is usually worth
it.
All Rights Reserved American Academy of Osteopathy®
.
OSTEOPATHIC ADJUSTMENT IN PNEUMONIA
Perrin T. Wilson D.O.
Before the advent of the Sulpha drugs
and Penicillin there was very little in the
medical field that was of value for the care
of pneumonia. Even the use of serums was of
questionable value, yet the experience of
the Osteopathic physician in caring for
pneumonia was exceptionally good. I believe
that I am conservative when I say that as a
profession our death rate was less than five
per hundred cases treated. I personally
handled sixty-six cases with but two deaths.
Both of the cases that died got out of bed
against orders. I think I would have pulled one of these thru if my orders had been
followed out.
Now, of course, the publicity given
modern medical procedures in pneumonia have
created such a pressure of public opinion
that the Osteopathic physician is practically forced to employ some medication. Having
had some experience with post pneumonia patients treated with the above mentioned
drugs who have not had the benefit of Osteopathic supervision, I can say unequivocally
that certain patients have poor reaction to
said drugs. I am of the opinion that Osteopathic care alone would still give a lower
death rate than can be duplicated by any
medical procedure, but since we must use
penicillin in these cases, I am convinced
that a delay of twenty-four to forty-eight
hours in the administration of the drug is
beneficial, thus allowing the body's own defense mechanism to function. I am convinced
that the amount of drug necessary is less
and the recovery faster if this delay is
employed.
One of the interesting things about
reviewing the Osteopathic treatment of the
different doctors who have been successful
in handling these cases is the variety of
technique employed, all of which, with the
exception of one, has one thing in common
viz : lymphatic drainage.
Dr. Medaris abducts the arm to a
right angle and with one hand on the heads
of the ribs uses the other to pump the arm
in and out getting drainage in the axillary
lymphatics, and through the intercostals.
(demonstrate)
Dr. Geo. Riley says, "I sat down
beside the bed and placed my eight fingers
under her body on the left side of her
spine, the side next to me, and from the
seventh cervical down, began the long siege
of relaxing those tense, contracted and excruciatingly tender muscles. Patiently,
persistently, I gave all I had to the relaxing of those spinal tissues on both
sides. I kept up my determined effort until I secured that reaction, that feel
that I was so intent upon obtaining."
(demonstrated)
Dr. Still wrote, "I have successfully treated many cases of pneumonia, both
lobar and pleuritic, by correcting the ribs
at their spinal articulations".
Dr. Harry Gamble says, "I feel my
best weapon is elevation and separation of
the ribs, springing the spine gently but
firmly as much as prudence permits." Dr.
Gamble always manipulates the legs because,
"We must remember that the patient has but
so much blood and that when blood mass is
congested and stagnated within the chest or
lungs, there must essentially result a corresponding lack of blood or anemia in the
extremities."
(demonstrate)
Dr. 0. M. Walker said, "I thoroughly relax all of the deep muscles up and
down the spine, with the patient on his
face, going in deeply pushing or drawing
the muscles away from the spine, relaxing
all of the deep muscles and getting as much
motion in each vertebral joint as possible."
(demonstrate)
Dr. Ralph M. Crane, who had probably treated more cases of pneumonia than
any of the rest of us had this to say of
treatment.
"The lesions most involved in
pneumonia are those of the third and fourth
dorsal. I believe this has been generally
recognized. To most effectually treat
them, it is best to have the patient lie in
the dorsal position, the operator carefully
slides both hands, palm surface up, under
the covers until the fingers rest on the
spine at the level of the third and fourth
dorsal, being extremely careful not to allow
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174
the air to rush under the covers. Lift the
spine somewhat. After a few minutes, if
the proper pressure is applied, the operator senses a relaxation of the spine. The
sensation is as though the patient is letting go of a tension, and is comfortably relaxing and allowing the operator to lift
that section of the spine from the bed without resistance. If the operator is in too
much of a hurry or uses too much force, the
patient invariably resists." (demonstrate)
Dr. John A. MacDonald, with whom I
had worked on pneumonia cases, had the objective of maintaining maximum diaphragmatic
excursion. He did this by grasping the
lower ribs and in rhythm with respiration,
increase the excursion.
(demonstrate)
I have given you this cross section
of opinion so that you will see that there
is no standardized treatment of pneumonia
by Osteopathic physicians. I am strongly
of the opinion that there is an optimum
Osteopathic procedure in this disease. It
has not yet been worked out because no one
physician has taken the trouble to see and
record the reaction to different procedures;
no one physician sees a sufficient number
of cases to draw conclusions, and Osteopathic technique has been such an individualistic art that we have not cooperated to develop a prescription for Osteopathic procedure.
It has seemed to me that much of the
Osteopathic procedure mentioned above while
possibly beneficial is arduous and unnecessary. I give you my conclusions for what
they are worth. I know these procedures
work for me and I wish they might be tried
on a sufficient number of cases to see how
well they work in other hands.
1. Keep the twist out of the spine.
If we have a right lower lobe involved you will find a segmental break in the
spine whereby the transverse processes 'and
angles of the ribs from the sixth down are
posterior to those above. Rotate these forward until you feel the release as they
move. This may be done right through the
bed clothes with the patient lying on the
left side and a broad contact with the hand
directly over the transverse processes.
2. Traction on the occiput.
With the patient on the back cup the
occiput in one hand, and the forehead with
the other.. Use slow rhythmic traction until
the' occiput is felt to lift from the atlas.
3. Raise the diaphragm.
The abdominal contents may be lifted and forced against the diaphragm with
benefit. Also reach in below the covers
and grasp the lower edge of the chest, cage
on each side and draw towards the head on
each of three inspirations.
4. Extend the third and fourth thoracic vertebrae.
This may be done as outlined by Dr.
Crane above. It should be done carefully
and until the patient lets go.
This procedure might take as much
as thirty minutes at the first visit, but
should not take more than ten minutes at
any subsequent visit. Usually two visits
a day are sufficient. In our hospital
where interne service is available three
adjustments a day are given, and in severe
cases we advocate a five minute treatment
each hour.
Now it may be that the unorthodox
orders for nursing care which the successful Osteopath employs may contribute a
good deal to the low death rate in pneumonia at Osteopathic hands.
1. Bathing the patient is not permitted and an alcohol rub is anathema to a
good Osteopath. There is no doubt but that
vaso motor shock is an item in the causation of pneumonia and cooling to the surface of the skin should be avoided at all
hazzards. The patient may smell bad. it
doesn't bother the patient and the nurse
can stand it for the few days of the disease. A hot towel rub may be employed if
used under the bed clothes.
2. Two or three acid enemas should
be given at once and then it may be well
to avoid future interference with the
bowels until the temperature is down. Irrigation with a low tube and a two way
valve may be used if desired. Dr. Crane
did not use any enema nor did he use cathartics.
3. Wear a sweater or jacket. This
must include sleeves. We would like no
air to reach the skin at any time.
4. Hot water bottles. One at the
feet if a child with a bad cough, this one
can be at the buttocks. One on each side
of the patient.
Hot drinks every hour
5. No food.
if the patient will take them. Hot water-lemon--orange--prune--tea--gingerale--tomato or pineapple juice may be employed.
All Rights Reserved American Academy of Osteopathy®
175
Some patients are so annoyed by hot drinks
that we have to substitute cold, but a short
explanation to the patient of the advantage
to them of the hot drink usually brings
ready cooperation.
6. Do not have the bed clothing too
heavy. It is best to have the patient between blankets instead of sheets, and a
puff is better than a series of heavy blankets.
7. Air should be circulating and
warm, also humified. In the home an electric plate and a tea kettle with the snout
pointing towards the patient's face is of
distinct advantage.
8. Visitors should be excluded and
the doctor should not whisper in the hall
to the nurse nor to members of the family.
Talk loud or not at all until well out of
ear shot.
9. Turning the patient is not essential when it is getting Osteopathic
therapy, but it is well to shift the patient's position every few hours if it
makes them more comfortable.
10. Do not move from the bed in
which he is taken sick. Raising the legs
of the head of the bed about six inches is
helpful, and use a very low pillow. At
least one as low as the patient will permit .
All Rights Reserved American Academy of Osteopathy®
ANGINA PECTORIS
Perrin T. Wilson D.O.
I have read carefully Dr. Still's
Research and Practice to get his idea on
Osteopathic Therapy for the condition known
as Angina Pectoris. Possibly in the pioneer
days when he practiced, heart disease was
hot as prevalent as today, or at least it
was not recognized for he gives little on
the treatment of the heart. He seems to
blame the failing function of the lungs for
creating back pressure and hence heart disease.
Fortunately or maybe I should say unfortunately I have seen many cases of Angina
Pectoris and Coronary Disease in my thirty
years of practice. I feel confident that
Osteopathic Therapy has much to offer these
cases. Let me list the Osteopathic Objectives which I believe to be beneficial.
1. Extend T 1,2, and 3.
2. Adjust T. 3 and rib (left)
3. Raise the sternum
4. Raise the diaphragm
Here too the patient has certain responsibilities which I list.
1. Rest
2. Mental poise
3. Correct the hunch of the shoulders-- set back from table
4. Wear an abdominal belt
5. Diet
6. Fomentations to the T - L area
7. Exercise
Now I am a family physician and not
a heart specialist, and on most of these
cases of Angina Pectoris I have the help of
a cardiologist. However, I do not relinquish the patient for I am convinced that
much can be done Osteopathically.
There are of course fat men and thin
men, and tall men and short men who have
Angina Pectoris, but my observation has
been that there is a certain spinal type
and chest type. The anterior curve of the
neck is exaggerated, and T 1,2,3, and often
c 6 are in flexion. This raises the posterior end of the ribs. The whole sternum
slips downward, the first section not as
much as the second section, carrying with
it the front end of the ribs and the top of
the sternum drops backward narrowing the
thoracic inlet. The lower-end of the sterium pushes forward. Let me sketch it if I
can.
Note the normal doming of the diaphragm in
the normal chest, and the flat diaphragm in
the angina pectoris and coronary disease
chest.
I am ready and willing to have this
posture type refuted by any heart specialist for I do not see these cases by the
But I am willing to predict that
hundreds.
you will be much pleased with results in.
the treatment of these cases if you will
attempt to correct the structure along the
lines I will show you.
Item 1. Adjustment of the upper
thoracic vertebrae requires much traction.
The head may be pulled off the table as
the, patient lies on his back. The edge of
the table being at T 3. Traction and gentle
extension will gradually straighten the
cervico-thoracic area. Under exercise I
have the patient assume this position across
the edge of a hard bed or while lying on a
book. I have him place his hands under his
head to support the neck and spring the upper thoracic vertebrae backward.
Item 2. There appears to be a segmental break between T 3 and T 4 and an especial effort should be made to bring T 3
back to its correct position on T 4. Sometimes I have the patient assume the exercise position I have mentioned while I put
my thumb and forefinger under the patient
to grasp the spine of T 3. With my left
hand on the patient's forehead I extend
and swing right and left till I feel T3
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All Rights Reserved American Academy of Osteopathy®
177
give. Examine carefully the front end of
the third ribs. It has been my experience
that the left rib is depressed at its front
end. By standing in back of a patient sitting on a stool it is easy to reach the rib
with the right hand while the left hand
raises the left arm of the patient to get
the help of the pectoralis minor muscle.
When all tissues are tense have the patient
inhale deeply as you tease the front end of
that rib up and anteriorly.
Item 3. The whole chest cage should
be raised by grasping the ribs and pulling
up on them. Possibly the patient can reach
around your body as he lies on the table
and you stand at his head. Thus as you
lean back hi's muscles raise the ribs. At
the same time your hands guide the ribs and
sternum.
Item 4. It is of course difficult to
reach the diaphragm but Dr. Carl McConnell
used to employ a technique which I use.
The thumbs are placed one on each side of
the ensiform cartilage as the fingers are
spread out over the lower ribs. The patient now takes a deep breath while the
physician maintains contact with his hands.
The patient then exhales as far as possible
and the operator sinks the thumbs deep into the tissues pressing cephalward as the
fingers press medtalward on the lower ribs.
I repeat once or twice.
Patient's
Responsibilities
Item 1. Rest should be taken in the
middle of the day and not less than nine
hours at night.
Item 2. It would seem to me that as
in ulcers of the duodenum the mental habits
of the patient have much to do with Angina
Pectoris. Certainly fear of death is a
usual phenomenon while the pain is on. In
three cases of Angina Pectoris, who later
developed a senile dementia, all pain disappeared and one case in particular could
walk up stairs freely whereas before she
lost her mental alertness, she was unable
to walk on the level to say nothing of the
stairs.
Item 3. Most of these cases are what
I call shoulder hunchers. Instead of allowing the shoulder girdle to relax and rest
comfortably on the thorax, the muscles are
tensed and the shoulders held up tense. I
believe this to be an Important item in the
relief of Angina Pectoris and I go over
this with my patient at each visit.
Item 4. An abdominal belt which
holds the belly wall in and holds the diaphragm up by pressure on the abdominal contents is very useful. It helps to take the
weight of the heart off of the large blood
vessels and tissues from which it is supported.
Item 5. These patients should of
course avoid eating large meals. If hungry
eat more often. Coffee is undoubtedly a
sympathetic system stimulator and should be
eliminated. Since smoking is certainly one
of the main causes of Berger's Disease, I
see no reason why it would not effect unfavorably the arterioles of the heart and I
attempt to stop that habit.
Item 6. If there is a general cardiorenal syndrome with hypertension, I try
to have the patient take hot fomentations
to the thoraco-lumbar area twice a week.
This may be done easily by protecting the
bed with oilcloth or rubber sheet, wringing
out a towel with hot water, lying on the
side apply the wet towel, place a hot water
bottle against it and cover with a big bath
towel and rest there for an hour. Several
of my patients do this for themselves without bothering other members of the family.
Item 7. Exercise to strengthen the
abdominal muscles and to extend T 1,2, and
3 should be instituted. Just lying with a
book under the shoulders for fifteen minutes
twice a day will help correct the flexion
of the upper thoracic.
Pathology may of course have progressed to such a state when the patient is
first seen that one cannot do much in the
way of a cure but even in extreme bed-ridden
cases the relief a good Osteopathic treatment produces is well worth the effort.
All Rights Reserved American Academy of Osteopathy®
SCIATICA
Perrin T. Wilson, D.O.
Oftentimes a brilliant cure of a
case conditions the mental attitude of a
physician so that it handicaps him in the
treatment'of similar conditions in the future.
This occurred with me in Sciatica.
On my summer vacation after one term at the
Osteopathic College, I was called to see a
neighbor who was suffering terrifically
with Sciatica, and low back pain of a
month's duration. It appears that he had
had consultation with Dr. Goldthwaite's
Assistant who told him it was "Goldthwaites
Disease". He might be laid up for months
and could never go back to his job as carpenter.
I was able to get a very good case
history. This man was stirring cement in a
bin. There cement was thick and hard to work
so that he placed the handle of his shovel
against the right hip to reinforce the push .
On one of the thrusts the shovel hit the
head of a nail that had worked, up through
the floor of the bin. The shock to his innominate was severe but he continued with
his job. At noon he lay on the ground for
a rest and when he went to get up it was
difficult to move because of a backache.
The next day he worked with difficulty and
quit early. The following day he didn't
work. A few days later the pain extended
down the right leg.
At the end of a month he was more or
less bed-ridden and used crutches when he
moved about the house. As I had not had
training in Osteopathic adjustment I made
no attempt to treat the man, but told him
to call an Osteopathic Physician. The next
morning the wife came to my house and said,
"Fred was very much impressed with the way
you traced the cause of his condition and
he wants you to try what you can do".
Not knowing any particular type of
adjustme.nt I figured that if a blow by a
shovel had hit the right innominate backward, I would grasp the innominate and pull
it forward. I therefore knelt upon the bed
flexed his thigh so that I held his knee in
my axilla. The heel of my right hand was o.n
the tuberos ity of the ilium pushing towards
the bed and my left hand circled the crest
pulling up on the posterior superior spine.
My axilla pushed down on the acetabulum.
This reversed the process that occurred with
the shovel. I was inexperienced, nervous,
and not sure of just what I was doing.
After about five minutes of this I had to
rest. On the second try between the nervousness and the strain I began to shake
Suddenly there was a very
perceptibly.
loud pop which scared me to death, and I
jumped off the bed. The patient said, "Oh!
what a relief." I cautioned him to stay
abed and that I would be over the next day.
The following day he was up shaving when I
arrived. He waited two days more and went
back to his old job and never had any more
trouble.
It took me several years to get over
the idea that I ought to cure every case of
sciatica in one treatment by correcting an
innominate that was posterior or as is now
spoken of as a flexion lesion of the sacrum.
In the presence of sciatic pain it
is well of course to rule out cancer of the
lumbar vertebrae or sacrum, tumors of the
prostate or uterus. These are rare but do
occur as does diabetes.
Osteopathic Therapy for Sciatica entails the following:
1. Adjust the Lumbar Vertebra if offending
2. Adjust or remove a ruptured disk
3. Adjust the Sacro-iliac if offending
4. Adjust the head of the femur in
the acetabulum if offending
5. Adjust the foot if offending
6. Relax the sacro-sciatic (sacrotuberus) ligament
The patient should:
1. Be abed on a hard mattress
2. Never sit in a semi-reclined condition
3. Lift with the knees not the back
4. Wear a lift in the heel if indicated (rare)
5. Detoxicate himself
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All Rights Reserved American Academy of Osteopathy®
6. Exercise
In my previous lectures I have outlined how to find the offending lesion so
that I will not take up all of the six
items listed under Osteopathic Therapy.
The Osteopathic Therapy for 1 and 2
is the same and since they are the most common causes of sciatic neuritis I will discuss them.
179
posus which will be squeezed not only to
the right but backward. This force tends
to rupture at the edge of the posterior
spinal ligament. But it is my opinion that
in most instances it does not rupture but
decenters in the cartilage, preventing
straightening up and causing a list to the
right.
The typical case history will be one
Lat
A-P
of two or three bouts with "lumbago" but
nothing that really laid me up. There then
We used to think that sciatica was
occurred a fall in a twisted position, a
on the side of the lateral flexion due to
heavy lift to the right or left of the mid- a narrowing of the foramina. But it is not.
line or cold wet feet, or a draft on the
In this case the person will have a left
back. In fact the cause of a low back
sciatica and when I drew this picture on
strain may be one of many things including
the board in the Kirksville College and
sitting for a long time 'On the back of your asked which side the sciatica was on it was
neck". The American women have a terrible
our Phd. physiologist who was sure it was
habit of washing their feet in the lavatory on the left. He knew it because our rewhich is conducive to Osteopathic pathology. searches have proved conclusively that efI would like to present what I befort to restore balance sets up the harmful
lieve to be the picture in sciatica. At
reflexes. Let me quote from "The Neural
least since I have been adjusting on this
Basis of the Osteopathic Lesion" by Irvin
basis my results have been faster.
M. Korr, Phd. Journal of A.O.A. Dec. 1947.
The nucleus pulposus as you know is
"It is concluded that osteopathic
the universal joint around which the verte- lesion represents a facilitated segment of
bra can flex, extend, or side bend. If this the spinal cord maintained in that state by
nucleus pulposus decenters all the lines of impulses of endogenous origin entering the
force tend to hold it out of place. If it
corresponding dorsal root. All structures
decenters far enough it will rupture the
receiving efferent nerve filum from that
ligament which holds the annulus fibrosus
segment are, therefore, potentially exposed
and we have what is called a ruptured disk. to excessive excitation or inhibition.
I am convinced that many times we get a
"Evidence is presented that the
displacement of the nucleus in the substance stretch and tension end organs (propriocepof the fibro-cartilage without rupture.
tors) in the muscles and tendons are the
Picture if you will a man bending
most important source of afferent impulses
forward and to the right to lift a heavy
which produce the changes in the cord that
object. The lines of force are up through
are associated with the Osteopathic lesion."
the right leg and down through the vertebral
I have gone into considerable detail
column. The lumbar area is flexed separat- to give you this picture for if you really
ing the articular facets which permits a
grasp it the adjustment is easy. The nugreater movement of the bodies of the verte- cleus pulposus has been squeezed out of
brae. Not only is the lumbar area flexed
center by forces approximating two inclined
anteriorly but it is also flexed, or side
planes. Our objective then is to reverse
bent to the right. The inclined planes of
the inclination of those planes and squeeze
the lumbar vertebrae are going to exert a
it back. The body of the vertebra will be
terrific shearing force on the nucleus pul- side slipped to the side of the sciatica,
All Rights Reserved American Academy of Osteopathy®
180
the transverse process will be more posteri
or on that side and it will be separated
from the one below in comparison with its
counterpart on the other side.
In preparation for this adjustment I
have found it advantageous to get general
traction for a few minutes. This may be
done by having the patient suspended from
the roof with a sling under the arms as
Dr. Still used to do. Or the patient on
face may grasp the head of the table or
bed while the physician steps between the
feet and holding one to each side leans
backward getting good traction.
Now let's put a pillow under the
thighs to get lumbar extension. Stand at
the left side of the table, put the heel of
the right hand on the left transverse process of L 4 and think derotation of the
body and squeeze of the nucleus pulposus.
The direction of force then will be towards
the table-- towards the transverse process
of L 5 and towards the right. Spring till
you feel it roll. Ask the patient to
breathe deeply. It aids correction.
While L 4 is in my experience the
most common offender, it is by no means
universally so. In fact I have found L 3,
L 5, and L 2 involved in cases of sciatica
neuritis. One case in particular was one
of my own profession, a Dr. C. from Maine,
who had a left sciatica of long standing.
He had had his sacro-iliacs popped; his lum
bar popped; a lift put in his shoe, diather
my, and a brace used. Careful diagnosis
showed the condition to be L 2 in just the
position explained above. The technique I
used was exactly as outlined. Let me quote
from his letter to me received one month
after adjustment applied once.
"Since I saw you I have been really
normal for the first time in seven years."
Item 3. There are many ways of adjusting the sacro-iliacs and I will not go
over them here.
Item 4. Is rarely involved but
should be checked by standing at the foot
of the table and grasping the heels in such
a way as to rotate the femur in the acetabu
lum. If there is a drag or restrictton in
motion, I place the patient on the right
side, slip my left arm between the thighs
right up to the buttocks and place my right
hand on the lower end of his left femur.
Thus I can use my left arm as a fulcrum to
pry the head out of the acetabulum and
loosen all the muscles. I then turn the
patient on the back and use Dr. Still's
technique--Research and Practice P. 53:
"Bend the knee very slightly, place
one hand under the foot and the other hand
under the trochanter Major; with the hand
at the foot while the leg is bent, push
knee up towards patient's face; put your
chest or chin against the knees and with
chin or chest push knee from you, --- -- so,
bring the lame leg over and across the knee
of the well leg, pull down slightly on the
foot and as you take the lame leg off the
sound knee straighten the leg out."
Item 5. The sacro-sciatic (sacrotuberus) ligaments may be relaxed by deep
pressure at its attachment along the posterior border of the ischium. This ligament is usually not tense if the sacroiliac joint is not involved.
Now we turn to what the patient
should do.
Item 1. Unless the pain is severe
it is hard to keep the patient abed, but
bed rest on a hard mattress certainly aids
recovery. Most of our patients try to keep
going. A former Governor of Massachusetts
had sciatic pain for two years before he
came for Osteopathic care. I said, "Governor, will you give us twice a week for three
months to see what we can do?" He said
that that was better than an operation
which had been decided upon by his other
physicians. At the end of two months just
as the pain was beginning to subside some
he walked in a parade for four miles. We
were four months working on him, but a
check five years later showed there had
been no return of the sciatica.
Item 2. So many times we get these
patients quite a bit better and we suddenly
find them go bad. Frequently we learn that
they were sitting up in bed reading or to
eat a meal; or were sitting on a chaise
lounge, or in over-stuffed furniture with
their feet on a foot stool. A semi-reclined position will surely decenter the nucleus
that has once been misplaced as you can see
if you followed my reasoning on the original
cause of the pain.
Item 3. Requires a retraining in
methods of stooping to pick up objects.
The use of the leg muscles must be encouraged and the knees should always be bent.
In making a bed--touch the knees to the
edge of the mattress. In stooping to the
floor have one foot ahead of the other and
bend the knees well down.
All Rights Reserved American Academy of Osteopathy®
181
Item 4. Rarely is it necessary to
wear a lift in the heel of the shoe in sciatica. If Osteopathic Therapy has been
well applied the sacrum will level fairly
well, but occasionally where a definite
short leg exists, it is advantageous to use
a lift.
Item 5. A number of cases of sciati
ca seem to be complicated by a full bowel
or at least a toxic bowel. It is usually
good practice to empty the bowel with enema
or irrigations and to place the patient on
a fruit juice or raw vegetable diet for a
few days.
Item 6. In cases of sciatica from
an unstable low back, I use exercises to
strengthen the back.
(a) with patient on the face lift
thorax and thighs with knees straight (swan
dive fashion) five times twice a day.
(b) on the back lift both feet with
straight legs five times twice a day.
(c) Hanging from a bar twice a day
if possible.
Frequency of treatment depends upon
the severity of the pain. A bed-ridden patient I see each day. An office patient I
usually see two days in succession to see
the reaction to treatment and then two or
three times a week until cured. The cure
varies from immediate relief to three to
six months depending upon the amount of
pathology involved. In a good many hundred
cases that I have seen in thirty years
there have been I believe only two go to
surgery.
All Rights Reserved American Academy of Osteopathy®
GALL BLADDER DISEASE
Perrin T. Wilson D.O.
There are a great many malfunctioning gall bladders in America, and no doubt
in every country where the abdominal muscles are allowed to relax and bulge. The
diseased gall bladder runs all the way from
failure to empty the bile from muscular
laziness or from ptosis, catarrhal congestion, stones, pus, or cancer.
In Dr. Still's Research and Practice
page 204 he states:
"When I am called to a patient suffering with such miseries in the right side
in the region of the gall bladder, I lay my
patient on his back, flex and bring the
knees up far enough to slack the abdominal
muscles in order that I may explore in the
region of the gall duct for any foreign
substances. I will say to the operator
that this is no place for gouging with the
points of the fingers. If you ever intend
to be useful by working in this region with
your fingers lay them flat. While you are
sitting on the left side of your patient,
bring your elbow up towards the patient's
right shoulder lay your hand easily on the
side of your patient, letting your fingers
extend about three inches below the umbilicus . Then with your right little finger
back of the lump push it from the gall-duct
to the left slowly and easily, holding the
little finger firmly to the place. Then
bring the next finger alongside of the little finger and firmly hold in place. Then
the middle finger, holding it firmly awhile.
Then bring the index finger to bear firmly,
but gently behind the lump. Each finger in
turn reinforcing the first. Be patient,
move slowly and give the gall duct time to
dilate. About this time the lump will disappear as it enters the intestines."
Soon after I graduated from the Osteopathic College, I heard a lecturer ridicule this procedure on anatomical lines.
He spoke about the impossibility of reaching
the gall bladder or duct. Unfortunately for
several years I believed him and thereby
neglected to do for my gall bladder patients
what I could have done.
May I quickly sketch a few cases for
you. In 1927 I had a call at a distance
which I suspected of being cholecystitis.
I sent a young assistant who had just come
to me. I told him what I expected and
showed him how to treat the woman who was
about 40 years of age. On his return he
told me that my diagnosis was correct, that
she had a temperature of 102 and that it
was a surgical case. I asked him if he did
what I told him to. He said he had. I
then told him I would go out with him the
next day, and he could do a blood count.
The next day we arrived to see the patient
sitting up in bed reading the paper. The
temperature was 99.2 F and she reported
that about a half hour after her treatment
she began to feel better. In the ensuing
eleven years I treated her every two or
three months. She has never had a recurrence.
Another case. Mrs. Merrill had been
treated by family doctors, and heart specialists for tachycardia, "Weak heart muscle" and myocarditis. She had taken digitalis about five years and at seventy years
of age was more or less of a heart cripple.
Examination of the spine revealed Osteopathic pathology at T. 6,7, and 8 much more
than at T.3 and 4. The gall bladder seemed
to me to be full. X-ray showed no evidence
of gall stones but failure of the gall bladder to fill. Treatment as I will explain
later was instituted once a week. Within
three months digitalis was stopped. She
was going up and down stairs as often. as
desired instead of once a day and now three
years later she tells me that she has had
the best year this year for the past ten
years.
I could go on with case histories
but that is enough to show you that a. diseased gall bladder can be reached, stones
can be felt through the abdomen and I have
known definitely of two cases where I have
passed them into the intestines. Furthermore a full gall bladder may be emptied
either by getting over it directly or by
pressure of the contiguous tissues.
Just one more case. Mrs. Adams, age
182
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183
70, had been operated on two years previously for intestinal obstruction. She came
down with acute cholecystitis with a blood
count of 18,000 and a temperature of 102.
One of the best surgeons in Boston saw her
and said that he wanted the temperature to
subside before operating. After two weeks,
it refused to subside. I was called in and
emptied the gall bladder. In four hours
the temperature started down. The surgeon
was delighted, and said, "Now take her home,
build her up and let me operate before the
next attack which will be in less than six
months." I have had the woman under my
care for two years"seeing her every fortnight. We have had no attack yet.
I do not want to leave you with the
impression that none of my gall bladder
cases are ever operated on, but I use the
conservative approach first. In the past
fifteen years, I believe only three have
gone to surgery while there are close to
twenty who have been saved from surgery by,
Osteopathic therapy.
...
Osteopathic Therapy
1. T 6,7,8,9 and ribs on the right
2. Drain the gall bladder
3. Raise the liver
The Patient's Responsibility
Adequate rest
2. Mental poise at meals
3. Wear a woolen abdominal band or
underwear
4. Have the foot of the bed elevated
5. Exercise and diet
When called to see a gall bladder
case, the patient may be in such distress
that he cannot stay still long enough to
apply Osteopathic Therapy. If this is the
case, I administer morphine, codein, or
pantapon and wait until the pain has subsided enough to permit the patient to relax
enough to treat him.
In cholecystitis without the presence of cholelithiasis with a stone in the
duct it is rarely necessary to use anything.
I place the patient on his left side.
Standing behind him I put the heel of my
right hand on the transverse processes of
T 6,7,8,9, allowing my fingers to lie along
the shaft of the ribs, with a straight arm
attack I gently spring the vertebrae until
I feel the whole segment give.
Sometimes the area is so tense that
it is impossible to get a good release of
tissues this way and I apply a more powerful technique as follows:
I place my right arm in front of the
patient who is still lying on his left side.
I grasp his right elbow so that through the
leverage of his humerus, I can prevent the
upper thorax from being rolled forward. I
nestle my right humerus into his groin
right up tight against his right anterior
superior spine of the ilium. Thus I hold
his pelvis from rolling forward. Then with
my left hand I contact the left transverse
processes of T 6,7,8,9 and reinforce that
hand with my chest against it and ask the
patient to take a deep breath. The tissues
may release just as he lets his breath out.
If they do not I give a vigorous thrust.
When you are sure that this segment is relaxed turn the patient on the back. Bend
his knees up and feel for the stone'. I
know positively that I have felt stones in
four cases. Two I passed and recovered in
the stools. One was too big to pass and
was operated on. It was about the size of
the rubber tip to a crutch. The other was
too big to pass as shown by X-ray. The man
is 73 years of age, a bleeder and has had
bad reaction to both gas and novocain as
demonstrated by extraction of teeth. It
was therefore decided five years ago to see
what palliative treatment would do. The
weight of the stone creates so much ptosis
as shown by X-ray that the gall bladder
does not empty easily. The man remains
very comfortable unless he is on his feet
too long at a time. He then gets relief by
my emptying the gall bladder. He knows and
I know when it empties. When I see him
regularly every two weeks he does fairly
well.
If there are no stones palpable and
the gall bladder is full, stretched and
ptosed the feel of the tissues are so different from the left upper quadrant that
there is no mistaking the presence of pathology. Tenderness varies with the degree
of pathology.
At the beginning of this paper I
quoted Dr. Still's method of moving a stone.
This same general procedure I use in emptying the gall bladder of bile or pus. I reemphasize the importance of placing the
fingers flat on the abdomen and getting below and lateral to the mass. By squeezing
the gall bladder up against the underside
of the liver and over towards the center
ever so gently, but with a steadily main-
All Rights Reserved American Academy of Osteopathy®
184
tained pressure one can usually feel when
the mass diminishes in size. Usually three
or four attempts are required before satisfactory results are obtained. The patient
should get a definite sense of relief.
The gall bladder now being drained
one can more easily raise the liver itself.
I am indebted to Dr. H. V. Hoover to calling my attention to the prevalence of a
ptosis of the liver when gall bladder disease is present. It may well be that this
ptosis disturbs the drainage of the ducts.
The flat of the hand is placed on the
abdomen. The little finger and side of the
hand parallel to and just below the edge of
the liver. The left hand reinforces the
right hand helping to sink the right hand
into the abdomen and keep it in contact
with the liver. Now the patient is asked
to take a little breath and then exhale as
far as possible. At the time of exhalation
follow the edge of the liver up by keeping
the side of the right hand in contact and
at the point of deepest exhalation tease
the liver upward. Repeat twice.
Now to
- the
- patient's
responsibility
Item 1. I put rest first because it
is the thing the patient likes least to do.
But in the presence of pathology anywhere
in the body adequate rest is essential if
the body is to make its maximum repair. If
one can lie down for thirty minutes after
each meal well and good. At least nine
hours should be spent in bed at night.
Item 2. Mental poise at meals needs
little mention in a group of this nature.
I remember a. patient who came to me for
gastric distress. I was unable to tell
whether it was a pyloric spasm troubling
her or a gall bladder spasm, but the reflex
in the spine was at T 5 so I always thought
it gastric in origin. As long as I treated
her every week she got along nicely, but
when I tried to lengthen the intervals of
treatment back came the distress. One day
she said that she was afraid her husband
was going to have a shock because his face
twitched on the right side. Examination of
the husband showed a perfectly healthy man
of 55 who had a habit muscular tic of the
right side. I suggested that she change
her seat at the table so that she could see
only the left side of his face, and of
course she was reassured about her husband's
condition. From then on her gastric symptoms were no longer present.
Item 3. I believe it essentiaL to
wear a woolen abdominal band winter and
summer. A devitalized gall bladder seems
to be very sensitive to cold whether from
in front of the patient or on the back.
Two of the patients that I am following
have left off the woolen protection during
the hot weather but sooner or later they
will have a mild flare up and they will
quickly resort to their band.
Item 4. As in all cases of ptosis
it is helpful to have the foot of the bed
raised on four inch blocks. That is not
enough to disturb the patient but seems to
aid in abdominal drainage.
Item 5. Exercise by sitting on a
chair or stool and rotating the trunk right
and left is very helpful. Also any exercise that will tighten up the abdominal
muscles --such as being on the back and raising both feet at the same time or throughout
the day remembering to tense the abdominal
muscle both sitting and walking. Diet
should of course avoid the animal fats especially all pork products. Avoid chocolate and coffee as well as cream. Skim
milk because of the presence of large
amounts of methionine is beneficial. Much
medical procedure on diet is helpful.
All Rights Reserved American Academy of Osteopathy®
THE PAINFUL SHOULDER
Perrin T. Wilson D.O.
Dr. Still's 'Research and Practice" p. 361
"In a large percent of neuralgic suffering of the shoulder whether there be
swelling or not, I find the outer end of
the clavicle pushed too far back."
It has been my experience that not
only is the outer end of the clavicle too
far back, but the whole shaft is not only
back but medial. While the position of the
clavicle is no doubt the prime consideration in the Osteopathic pathology of the
painful shoulder there are other considerations which I wish to point out.
Painful shoulder may result' from
resting the arm on a high window sill or an
auto, lying with arm over the head, exposure to cold, an awkward reach, hanging on
a strap in a moving vehicle. This position
can easily place the clavicle posterior and
medial. If we get a history of direct
trauma of any severity of course X-Ray is
indicated but here one may at times be misled because I had a case (Mrs. Atherton)
who fell to the ground and hit her shoulder
(rt) on a stone. It was very oedematous so
I immediately obtained an X-Ray which was
negative. After some three months of treatment she still could not get her hand to
her hair. My Orthopedic consultant felt
that in spite of negative X-Ray there must
be some rupture of a tendon, because he had
seen one previously. Operative procedure
revealed a rupture of the supraspinatus tendon near its attachment. It was stitched
up and then with Osteopathic care a very
good result was obtained.
Arthritis and bursitis with or without calcification, neuritis, and myalgia
with a history as previously mentioned are
by far the most common cause of painful
shoulder. While neuritis alone may not
cause restricted motion most of our shoulder cases do have restricted motion and my
treatment using long lever technique is usually disastrous especially in the acute
stage. Dr. John MacDonald, late of Boston,
devised a short lever technique which seems
to work well and the patient will not be
hurt thereby.
Let me list the objectives for Ostepathic Therapy in conditions under discussion:
1. Draw C 5 or 6 back in line.
2. Lateral traction on the head of
the humerus.
3. Draw the clavicle lateral and forward.
4. Relax the tendon of the Infraspinatus and Terca Minor by deep
pressure with the thumb.
5. See the patient daily until the
worst of the pain is over--2 per
week 'till cured--l to 6 months.
The patient should:
1. Wear a sling
2. Relax to the pain
3.Have hot fomentations applied as
long and as often as he can get
anyone to do it.
Or
4. Apply an ice bag. Lie with the
arm behind one. About one fourth
of these acute shoulders do not
tolerate heat. This is noted by
an increase of the throbbing pain
when heat is applied either by
fomentations, a hot water bottle
or electric pad. In these cases
an ice bag will allay the pain.
Now to return to discussion of what
we as Osteopathic Physicians can do for
this suffering patient.
At the Chicago College of Osteopathy
a series of lateral X-Rays of the cervical
spine was run in cases of neuritis and painful shoulder. These X-Rays showed such a
similarity in pattern that since seeing
them, I have never failed to look well to
the lower cervical. The X-Ray showed a
sudden angulation in the natural curve of
the neck as if C 5 had slipped forward on
c 6 or as though the nucleus pulposus had
squeezed anteriorly and caught there--let
me illustrate:
185
All Rights Reserved American Academy of Osteopathy®
I
All Rights Reserved American Academy of Osteopathy®
laid gently over the shoulder and reapplied
frequently. I doubt if epsom salts add
much to the effectiveness of the fomentations. As mentioned before, there is an
occasional shoulder that will not tolerate
heat. These may be helped by the applica-
187
tion of an ice bag.
It is usually unnecessary to instruct a patient how to lie with this condition, they find the least painful condition, but often being on the shoulder with
the arm thrown behind the body will be a
comfortable way to sleep.
All Rights Reserved American Academy of Osteopathy®
OSTEOPATHIC MANIPULATIVE SURGERY UNDER GENERAL ANESTHESIA
C. Haddon Soden D.O., M-SC.
Manipulation under anesthesia to restore normal articular motion occupies an
important place in osteopathic therapeutics.
Muscular spasticity or contraction is often
of such a degree that mobilization of
joints cannot readily be produced without
the administration of an anesthetic. This
method of treatment has been used in the
Osteopathic Hospital of Philadelphia for
the past 18 years. The older school of
medicine has also used joint mobilization
under anesthesia, and a report of 200 cases
of low back pain was presented in Piersol's
International Medical Clinics in 1938. In
this series complete cures ranged from 94
to 97 per cent. These figures are in general agreement with our own results.
It should be pointed out here as a
note of caution that the abolition of protective stabilizing function of the muscles
which facilitates mobilization under anesthesia also creates a condition in which
the mobilized joint can be easily traumatized if great caution is not exercised.
It follows that anyone who undertakes to
use this method must be a good diagnostician and a thoroughly competent technician.
The importance of the technical ability of
the physician cannot be overestimated, and
we have seen a number of patients previously treated under anesthesia, who had received no benefit, or were made worse, and
in whom later mobilization under anesthesia
by us resulted in improvement.
Selection of Cases
Some of the conditions in which mobilization under anesthesia has produced
satisfactory results in our hands are chron
ic fibrosis, chronic productive arthritis,
such as Spondylosis, Spondylarthritis,
Spondylarthrosis, lumbarization, sacralization, selected cases of Paget's disease,
chronic disc changes, old compression fractures, intractable brachial, intercostal,
or sciatic neuritis, acute traumatic joint
lesions, chronic joint lesions, increased
muscle tension, thickened ligaments, and
traumatic torticollis. In all of these
conditions, careful selection of cases is
of the utmost importance. The contraindications are very definite. Under no circumstances should patients with the following conditions be subjected to this procedure: Malignancies, fractures, tuberculosis, acute inflammations (diffuse osteochondritis, acute arthritis, spinal cord
inflammation), spinal cord tumors, malacic
bone disease, primary bone tumors, acute
changes in the intervertebral disc, and
ankylosls. To this list should be added
those cases of cardiac, renal, or other organic disease in which the-shock incident
to the procedure might prove injurious.
In general patients selected for mobilization under anesthesia are those who
have received regular osteopathic manipulative treatment over a long enough period
of time to have produced results under
average conditions, and in whom no improvement either symptomatic, or in character or
range of articular motion has occurred.
In testing these patients, the vertebral column appears very rigid and the spinal musculature is spastic. When an attempt
is made to produce motion, the rigidity and
the spasticity is very much increased.
Where this condition does not change. after
several treatments, anesthesia reduction is
indicated.
Why
Anesthesia
The answer to the question of "Why
Anesthesia" lies not only in the successful
clinical results, but also in the physiology of anesthesia. According to Dr. William Baldwin (Professor of Physiology at
the Philadelphia College of Osteopathy),
general anesthesia carried well into the
surgical stage causes the abolition of reflex response due to a paralysis of the
sensory side of the reflex are, and an accompanying change in the graded synaptic
resistance at the segmental levels. There-
All Rights Reserved American Academy of Osteopathy®
189
fore, due to the above factors, postural
tonus of the muscles is abolished. With
the removal of this postural tonus, there
is lost, the muscle function of joint stabi
lization and the splinting action of the
muscles of the joint structures. The loss
of these factors of muscular function is
desirable in producing joint motion by
manipulative procedures, especially when
there has been present, previously, a reflexly maintained increase in the postural
tonus.
In spondylosis there is a calcium
infiltration of the para-vertebral structures and in Osteo-arthritis or spondylarth
ritis we are dealing with articular changes
This calls for elimination of all possible
resistance, or the articulation must be in
tune as it were to manipulative approach.
General anesthesia carried well into
the surgical stage abolishes reflex response
and removes any impediment to mobilization
by manipulation. Under anesthesia there
remains only ligamentous action and articular changes to limit joint motion; this
enables the physician freely to put an articulation through its normal range of motion, providing restriction adhesions are
not developed to the point where they cannot be overcome.
Anesthesia
Procedures relating to anesthesia
for this type of work have been described
by Smith who says that cyclopropane is the
anesthetic of choice for correction of osteopathic lesions. The average adult patient is given morphine sulphate l/4 gr.
and scopolamine l/150 gr. one to two hours
before the inhalation of cyclopropane. Cyclopropane Is of such potency that it can
be used to produce any depth of anesthesia
and permit the use of oxygen in the anesthetic mixture. It is the combination of
potency, rapidity of action, lack of irritation to the respiratory tract, and high
oxygen content that makes cyclopropane-oxygen an ideal anesthetic in manipulative
correction work. The usual objections of
its explosive character and inability to
use adrenalin with it ordinarily do not
have to be considered in work of this type.
The rapid induction, adequate relaxation,
and rapid recovery with cyclopropane make
it an ideal agent in cases such as this
where the operative procedure is short but
in which perfect relaxation is essential.
Ether, so far as the relaxation is concerned, compares very favorably with cyclopropane, but from every other standpoint for
this type of work, cyclopropane is to be
preferred. The disadvantages of the use of
chloroform far outweigh the advantages in
this type of work, and Smith sees no reason
for using it.
Cyclopropane should never be given
by other than one experienced in anesthesia,
and only with apparatus built to deliver
cyclopropane and oxygen. It can be readily
appreciated, therefore, that the logical
place to administer it is in a hospital
where the patient may receive the benefits
of a competent anesthetist, suitable apparatus, adequate consultation, etc. These
facilities are rarely available in the office of a general practitioner.
Anesthesia is carried to the second
plane of the third stage.
Case Histories
I have selected several cases for
presentation to illustrate the type of condition treated and the management of these
patients.
Case 1 - PERITENDONOSIS CALCAREA
The patient, male age 53 years, complained of intermittent pain in right
shoulder from February 1946 to Dec. 3lst,
1946. The shoulder had not been injured.
Roentgen therapy to the right shoulder
caused pain to be unbearable.
Shoulder joint motion was restricted
80% to 85%. The lower cervical vertebrae
were fixed in extension and the upper dorsal vertebrae were fixed in flexion.
Roentgen studies 7/2/47 showed a
quite large, irregularly delineated opacity
possessing a calcium density, manifest within the soft tissues, regional unto the superolateral marginal limits of the capitate
portion of the right humerus. This quite
large or rather extensive irregular calcification within right shoulder periarticular soft parts possesses the characteristics of an undoubtedly long standing or
well established peritendonsis calcarea.
The patient was treated by manipulation under general anesthesia (cyclopropane ) 7/4/47. The patient had 75% motion
of the right shoulder joint and was prac-
All Rights Reserved American Academy of Osteopathy®
190
tically symptomatic free 48 hours after mobilization.
.
The roentgen study 9/19/47 is reported as follows: Particular attention is directed to an apparent resorption of the previously established large, irregular soft
tissue calcification regional unto the superolateral marginal limits of the right humeral head. At present only small and faintly delineated shadows of increased tissue density are visualized in the area of previously recorded large peritendonosis calcarea,
this being further appraised as in accord with a most satisfactory therapeutic response.
Motion is now restored 97%.
A
July 2, 1947
B
Sept. 19, 1947
Case 2 - OSTEOPOROSIS
The patient, female, age 59 years, injured her right shoulder joint, when throwing a cloth up over a clothes line and increased the trauma when she fell in bathroom.
B
Feb. 23, 1948
All Rights Reserved American Academy of Osteopathy®
191
Upon regaining consciousness her right arm
was over the side of the bath tub. An Orthopedic surgeon tried unsuccessfully to
restore motion under anesthesia and following this, she had herpes of the right arm,
forearm, wrist and hand. The arm was quite
swollen. The right shoulder was fixed, motion restricted 75% and the pain was severe,
An electroencephalogram was negative. Roentgen studies of right shoulder were negative. X-rays 10/8/47 showed a marked demineralization or osteoporosis of the right
distal forearm, carpal, metacarpal and phalangeal structures.
The patient was treated under general anesthesia 10/22/47. Results were very
satisfactory. Roentgen re-check 2/23/48
demonstrates a now only moderate generalized demineralization or osteoporosis of
the right distal forearm, carpal, metacarpal and phalangeal structures. A decided
or marked improvement of respective osseous
structural density is now established upon
comparison with film obtained elsewhere
10/8/47 and submitted, this thereby indicating a generally improved structural
trophlcity or trophovascularity.
Case 3 - UNI-LATERAL DISCOGENIC RESORPTION
OR DISTURBED INTEGRITY OF 5TH LUMBAR DISC.
The patient, female, age 39 years,
complained of an acute, painful lower back.
Continuous pain, posterior aspect of left
thigh, resulting from lifting, later on aggravated by tripping over carpet and later
on Oct. 1946 falling down stairs.
"Recumbent posterior and lateral
lumbopelvic film studies obtained demonstrate a quite marked sinistral inclination
of the bony pelvis and a concomitant sidebend of the lumbar column, with the vertebral convexity toward the left, reaching
maximum proportions in the lower lumbar
area. A lumbar numerical variation is determined with six (6) vertebral segments in
evidence, while particular attention is directed to a chiefly right unilateral axial
narrow or resorption of the 5th lumbar intervertebral disc. This latter 5th lumbar
disc narrowing, which is decidedly more
marked on the right side, is further evaluated as of a discogenic order, with some
marginal productive spondylotic changes located to the anterior and lateral limits
of the adjacent surfaces of the 5th and 6th
lumbar segments. In accordance with the
altered lumbar vertebral alignment, there
prevails a slight right unilateral axial
compression of the 3rd and 4th lumbar disc
structures. Spondylarthrotic reactionary
changes attendant upon longstanding physlologic stress and strain are believed to
involve the facet joint between the 5th and
6th lumbar segments on the right side,
while the lumbar vertebrae are otherwise
negative for gross bone or joint pathology.
The sacroiliac articulations and, as well,
the hip joints are essentially negative and
no lytic or productive osseous pathology is
observed involving the quite symmetrical
pelvis.
For purposes of record, it may be
stated that the patient's physical status
at the time of initial study did not permit oblique film evaluation of the lumbar
column.
Supplementary anteroposterior and
lateral film studies obtained of the dorsal spine demonstrate a moderate compensatory sidebend of the entire dorsal column,
with the vertebral convexity toward the
right. The mid to lower dorsal vertebral
bodies display anterior marginal productive
spondylotic changes of a physiologic order,
while attention is likewise directed to
productive spondylotic changes at the right
lateral extent of the adjacent surfaces of
the 11th and 12th dorsal segments. The
axial height of dorsal Intervertebral discs
is generally well preserved and respective
vertebrae are otherwise negative for gross
pathology.
An erect, standing lumbopelvic study
secured with some difficulty due to patient's quite marked disability, fails to
establish an appreciable deficiency in leg
length at film measurement. There is determined a minimal unleveling of the sacral
base plane to the left side and a lower
lumbar pelvic shift to the left of the midbody gravital line. With patient weight
bearing, there is to be emphasized a marked
dextral inclination of the mid to upper
lumbar column, with some right unilateral
axial compression of the-4th lumbar disc
and the altered vertebral mechanics appearing to centre chiefly to the level of the
5th lumbar disc, the latter disc structure
manifesting the forementioned right unilateral resorptive pathology.
The patient was treated under general anesthesia 2/20/48. X-rays 10/3/47 of
the dorsal spine records a minimal sidebend
of the major extent of the dorsal column,
All Rights Reserved American Academy of Osteopathy®
192
Roentgen studies 2/19/47 showed the following:
B
Feb. 19, 1947
D
Oct. 3, 1947
All Rights Reserved American Academy of Osteopathy®
with the vertebral convexity towards the
right, reaching maximum proportions at the
level of the seventh dorsal intervertebral
disc. Respective vertebral alignment is
otherwise satisfactory and the symmetry of
the thoracic cage is preserved. Lumbopelvie structures exhibit some shift to the
left of the mid-bony gravital line and
there is present a moderate, dextral inclination of the mid to upper lumbar column,
the altered vertebral mechanics centering
chiefly to the level of the fifth lumbar
segment and second lumbar intervertebral
disc.
PROCEDURE
Mobilization under anesthesia is,
exclusively, a hospital procedure. It is
most Important before the patient enters
the hospital, that the physician instruct
the patient on the Importance of becoming
determined not to fight the anesthetic.
This makes for a more smooth anesthesia,
and a more successful after-result; in that
the majority of the patients take the anesthetic very nicely and come out of it
gradually, otherwise, if they struggle during the anesthesia, they will struggle
afterward, and this might cause the production of lesions.
A complete history and physical examination should be made and a preoperative
diagnosis established. When Indicated,
gynecologlc, neurologic, cardlologic, myelographic, or other studies should be carried out.
Preferably, the patient should be
hospitalized the afternoon preceding the
operation. General orders to be written
include no breakfast, laboratory studies
including urinalysis, complete blood count,
and serologic tests for syphilis, radiographic study, if this has not been done,
and physical examination, including charting of all spinal lesions.
The chief anesthetist (preferably a
graduate osteopathic physician) evaluates
the patient as to the preoperative medication preferred. The routine medication,
morphine sulphate grs. l/4, with scopolamine grs. l/150 (for the average patient)
is administered one hour before mobilization.
The corrective procedure is usually
carried out in the anesthesia or operating
193
room, using a regulation treating table.
The physician and his several assistants
stand to the sides of the patient. The
assistants take the pulse, and have the
other hand in readiness to place on the
patient's arm, in case he struggles. The
arms are held against the table, and the
forearms (controlled by the other hand) are
allowed to move in flexion and extension.
The lower extremities are controlled more
easily by leaning across them and holding
the opposite side of the table. The introduction of the anesthetic agent is continued until the second plane of the third
(surgical) stage is reached.
1 - The pulse rate - The rate will increase
as the anesthetic is introduced, and the
patient is. in the second (excitement) stage.
As the surgical plane of the third stage is
approached, the pulse rate will become more
regular.
2 - The respiratory rate will at first lncrease in rate and amplitude as the second
plane is approached. When the patient enters the third stage, the respirations will
decrease to a normal rate and amplitude.
3 - When the patient is In the surgical
stage of anesthesia, the pupils will be
fixed, become small and contracted; the
eyeball is fixed and oscillatory motion is
lost.
4 - The physician should flex and extend
the upper and lower extremities to be sure
that there is complete muscular relaxation.
Sometimes, in flexing the left forearm,
there is complete relaxation, and yet, we
find rigidity upon flexion of the right
forearm. This is a guide which should be
carefully watched as the patient is, evidently, only in the excitement stage. So,
the correction is not attempted until the
resistance is eliminated, or complete muscular relaxation is obtained. Occasionally,
in attempting to, or in mobilizing the sacroiliac articulation, or the fifth lumbar
on one side or the other; the patient will
become very rigid.
Do not attempt any correction at
this stage as you can fracture just as easily as breaking a dry twig.
The physician must wait, until the
surgical stage is again reached and from
this point on, mobilization of any or all
articulations may be completed.
All Rights Reserved American Academy of Osteopathy®
194
The assistant standing to the right
side of the patient places one hand under
One of the most important things to
the left posterior superior iliac spine,
remember in anesthesia reduction, is to
the other hand over the left anterior surealize how easily the patient can be traperior iliac spine. The operator standing
umatized; because we are dealing with the
to the foot of the table grasps the distal
ligaments as stabilizers, therefore, if too end of the leg with both hands, elevates
much force is used when mobilizing, there
it about 8 inches and slightly abducts
same.
might be a tendency to traumatize. In
Mobilization is attempted by tracother words, all that is necessary under
anesthea is
a minimum amount of pressure. tion while simultaneously the assistant
If no motion is detected, it does not mean
pulls upward on the posterior superior ilithat we have failed. The follow-up attempt ac spine and presses caudad on the anterior
at motion without anesthesia produces mosuperior iliac spine.
tion so readily and easily, that anesthesia
reduction proves its place in our therapy;
Left Anterior Lesion
in that maximum motion in some, minimum
The same technique is used as for a
and apparently no motion in others, eventu- posterior with these exceptions. The leg
ally gives maximum results.
is elevated about 18 inches and when tracThe manipulative procedure is cartion is used, the assistant presses caudad
ried out on an ordinary treating table, and throughout the posterior superior iliac
some of the basic techniques used by us are spine and cephalad through the anterior
the following:
superior Iliac spine.
Caution
Sacro-iliac
Lesions
-Left Posterior
P Rotation Lesion
The patient is placed in the right
lateral recumbent position. The operator,
standing behind the patient's pelvis,
grasps the patient's left leg just below
the patella with his left hand and places
his right hand over the left posterior
superior iliac spine. Mobilization is attempted by flexing, elevating, and extending the left leg and thigh while pressing
slightly forward with the right hand.
The right posterior rotation lesion
is corrected in the same relative manner
with position reversed.
Left Anterior
- Rotation Lesion
The same technique is used as in. the
posterior lesion except that the operator's
right hand is placed over the sacrum just
medial to the sacro-iliac articulation instead of over the posterior superior iliac
spine.
The right lesion is corrected in the
same relative manner.
Osteo-arthritis - Sacro-iliacs
-Left Posterior
- Lesion
The patient is supine.
Bilateral Flexion of
- the- Fifth
- Lumbar
- Vertebra
The patient is placed in the prone
position, the abdomen and chest resting on
a pillow. The operator, standing to one
side of the table, places one hand over
the spinous process of the fifth lumbar
vertebra with fingers pointed toward the
sacrum. Mobilization is attempted by using a springing pressure directed through
the lesioned vertebra in a downward direction and toward the sacrum.
Bilateral Extension of
- the - Fifth- Lumbar
Vertebra
The patient is placed in the right
lateral recumbent position. The physician,
standing in front of the patient's pelvis
flexes the patient's left thigh, leg over
the side of the table, and hyperflexes
both thighs by hyperflexing the right
thigh. He places his left hand anterior to
the patient's left shoulder and his right
forearm posterior to the apex of the sacrum. Mobilization is attempted as follows: The associate keeps springing or
hyperflexing the right thigh, while the
operator anchors the patient by pressing
backward with his left hand and using a
springing pressure or a thrust with the
right forearm in a forward, upward direction.
All Rights Reserved American Academy of Osteopathy®
Left Rotation of the Fifth Lumbar Vertebra
The patient is placed in the left
Simms position. The physician places the
thenar eminence of his left hand on the
right side of the spinous process of the
fifth lumbar vertebra, and reaching over
the patient's right leg, places his fingers
in the left Popliteal space. The associate
presses downward on the right shoulder and
scapula with his right hand, controlling
the spine in rotation-flexion and places
his left hand under the distal end of the
left thigh.
Mobilization is attempted or Produced as
Follows:
The associate maintains a downward
pressure through the patient's right shoulder and as both the physician and associate
flex and elevate the thighs, the physician
presses downward through the spinous process of the fifth lumbar vertebra.
Rotation of the lumbar vertebrae or
lower dorsal vertebrae Is treated the same
way, with an increased flexion of the
thighs.
Left Side Bending of the Fifth Lumbar Vertebra
The same technique is used as for
rotation, the chief consideration being
that pressure of the thenar eminence is
down through the spinous process which is
to the convex or right side.
Lower Cervical, Upper Dorsal Lesions
The patient is placed in the left
lateral recumbent position. The physician
stands in front of the patient, places his
right hand under the left side of the patient's head and face and his left axilla
over the proximal end of the right arm.
Lean lightly on the right arm in order to
control 'the dorsal vertebral column. The
head and cervical column is held by the
right hand in neutral, slightly flexed or
an extended position and maintained. Mobilization is now attempted by a combination of elevation (right side bending) left
rotation of the head and cervical column
and these movements are exaggerated by an
upward pressure or traction.
195
The Right Shoulder Joint
The patient is placed in the supine
position. The physician holds the patient's
right shoulder with his left hand, and
grasps gently the distal end of the arm
with his right hand. While anchoring the
shoulder, elevate slightly the arm and release. Try this several times. Slightly
abduct the arm and release several times.
As a rule this does not produce motion,
but seems to be an entering wedge. The
patient is now placed in the left lateral
position. The physician flexes the patient's right forearm and passes his right
hand and forearm under the patient's forearm, the hand up over the right shoulder
which it anchors, or protects. The left
hand placed on the elbow, presses downward
very carefully, releases, then elevates
slightly and releases. This is tried
several times. Next while protecting the
shoulder with the left hand, grasp the distal end of the forearm with the right hand
and try to elevate, release, abduct carefully and release. Repeat several times.
The right forearm is now flexed and placed
very carefully behind the patient's back.
The physician places his right hand on the
right shoulder his left hand on the elbow
and moves the arm slightly forward and
backward. During any of these movements,
the adhesions give or break. Once the adhesions let go, then increase all physiological articular motions until the shoulder joint is completely free.
Hot compresses of lead water and
laudanum are applied to the shoulder joint
for several days if there is much pain.
After one month of rest, from manipulation,
careful traction is applied once or twice
a week and at the end of the next two
months, shoulder motion is at least 97%
normal.
Summary
Mobilization of spinal joints under
anesthesia in selected cases has a definite
place in osteopathic manipulative procedures. Selected cases are presented. Mobilization under anesthesia is a hospital
procedure. Cyclopropane-oxygen is the anesthetic of choice. Manipulative techniques are described.
All Rights Reserved American Academy of Osteopathy®
SHOE INTERPRETATION--ITS IMPORTANCE TO STRUCTURAL BALANCE
C. Haddon Soden, D.O., M.Sc.
Normal Weight Distribution
In a normal foot approximately 60%
of the weight load on a foot is carried by
the heel,, and 40% is distributed to the
metatarsals or forefoot. The first metatarsal carried about 14% and each of the
other metatarsals receive and distribute
about 7%. Normally, the first metatarsal
is longer and twice as wide as any other
metatarsal bone.
is again in the same ratio as weight bearing. The first metatarsal carried twice
the load of any one other metatarsal, or
ratio of 2:l:l:l:l.
Pronation (pes planus) will show on
the x-ray as a separation between the internal and middle cuneiform bones, with increase in the width of the second metatarsal.
Abnormal Weight Distribution
In an extreme case described by
Dudley J.. Morton in which the first metatarsal is so short that it may not contribute at all to the load of weight bearing,
the second metatarsal will then carry about
2 l/2 times its normal load. The third
and fourth will carry more than normal,
while the fifth may only be bearing 50% of
its normal. In less severe cases or a
slight shortening of the fifth metatarsal,
it may carry half of its normal load, the
second twice its amount, the third and
fourth about a third more than normal,
while the fifth may only be bearing half
its load.
In cases of pronation, we see that
the first metatarsal is again an offender
in shifting its burden. The milder cases
show the first carrying about l/4 of its
normal load, the second twice Its normal,
the third and fourth more than normal and
the fifth about 59%.
In extreme cases of pronation (pes
planus) the first metatarsal will carry
about 75% of its normal load, the second
2 l/2 times, the third about l/3 increase,
the fourth may only carry l/2 of its normal,
while the fifth may not carry any load.
Roentgen studies of these various
types of feet will substantiate the above
findings. The metatarsal shortening, and
the increase In width of the metatarsals,
due to increased weight bearing, can be
seen and measured.
The increase in metatarsal width is
in direct ratio to percentage of the increase in load. Normal width of metatarsal:
Shoes
The majority of patients never complain of foot trouble, it Is always lower
back or back. When asked if their shoes
are comfortable, invariably they say "the
shoes are the most comfortable, they have
ever worn". Do not let this misguide you.
Examine all shoes, in order to realize the
important role they play in contributing
to structural instability or structural
stability.
The average shoes when viewed externally, look as if they fit the feet properly. It is possible to see the soles
need wedging along the medial, or lateral
longitudinal arches, and that Is about all.
The real story is woven Internally.
There one can see depressions and various
shades of discolorations on the linings and
inner soles, which mean much to one who has
the knowledge of interpreting these findings or foot marks.
Examination
Hold a shoe up to a window, or use
a flash light and look inside towards the
fore part and side walls for the following:
Condition of lining, such as discoloration,
depressions, or if worn through. The impression of the toes and their positions on
the insole. Indentations or discolorations
made by the distal ends of the metatarsal
bones. Measure the length of the shoes and
the width across the anterior arch. Measure the length and width of the patient's
feet when sitting, and standing. When the
patient is standing measure as to how far
forward metatarsal pads should be placed.
196
All Rights Reserved American Academy of Osteopathy®
Interpretation
Depressions in the medial or lateral lining indicates shoes should be either
an inflare, or an outflare last, and if
discolored, or worn through, it gives a
greater index as to the amount of pressure being exerted on the side walls.
The impressions of the toes, their
positions and indentations made by the
metatarsal bones will show how the foot
distributes its weight load. In the case
of an extreme short first metatarsal, the
discoloration will be posterior and the
greatest indentations will be where the
heads of the second, third and fourth metatarsals make their contacts.
When the shortening of the first
metatarsal is only moderate, the discoloration is less posterior and the insole will
show the greatest indentation under the
second and third metatarsals.
When pronation exists, the impression on the insole will again be greatest
where the second and third metatarsal heads
press, but the first metatarsal is on the
same forward level and the shoe will bulge
at the medial border behind the vamp.
In metatarsalgia, there is a depression under the first metatarsal bone.
In the average shoes, only two toes,
the first and second will have space anteriorly, or in the horizontal, whereas
the other three are in the perpendicular
or pressing against the outer longitudinal
wall. This indicates too narrow a shoe
and if the first or second toes are pressing well up into the toe-cap they are not
long enough. There may be a light or very
brown spot on the insole where the metatarsal heads are pressing.
197
convinces the patient as to the importance
of shoes.
Prescribe proper fitting shoes, and
three roentgen standing studies, one in
stocking feet, one in original shoes and
one with the prescribed shoes, before treating. As a rule, the patient will express
pleasure over the change in the lower back
since wearing new shoes which is an indication of improved structural stability. In
quite a number of cases, the first and
third studies show a similar stability
whereas the one with improper shoes will
show more of a lateral inclination of the
femoral weight bearing line, or sacral base,
or both with an increased structural instability.
When sacro-iliac and lumbo sacral
motion is established, add whatever heel
lift is necessary on the side to which the
sacral base is inclined.
In two or three weeks place metatarsal pad l/8” thick (may only be necessary in one shoe) or pads under second,
third and fourth metatarsal bones, or use a
Dr. Ellis Cuboid pad, or cuboid pads.
In metatarsalgia place a small pad
one half inch wide, three quarters of an
inch long and one sixteenth of an inch
thick under the first metatarsal bone.
Have shoes conform to the feet, rather than have feet conform to whatever
shoes the salesman has on hand.
Proper fitting shoes help to eliminate some foot, leg, thigh, hip and lower
back troubles in contributing to better
structural stability.
Summary
Make a study of shoes, in order to
realize their importance in helping to mainManagement
tain structural stability.
Show the patient the difference in
Roentgen studies show l/4" sacral
measurements of the feet while sitting and base inclination (standing 0) in stocking
standing, then compare the standing meafeet, and 3/8” sacral base inclination
surements with the shoe measurements. This (standing 1) with shoes and increased structural instability.
All Rights Reserved American Academy of Osteopathy®
198
Standing 1
Standing 0
Bibliography
Osteopathic Care of Feet
Mechanical Interpretations of the Feet, 1939
Carter H. Downing, M.D.; D.O.
The Human Foot
Dudley J. Morton, 1935.
Functional Disorders of the Foot
J. B. Lippincott, 1939.
Cuboid Pads
Dr. William A. Ellis, 1945.
Standing Foot Roentgen Studies
Dr. William Tannenbaum, 1944.
All Rights Reserved American Academy of Osteopathy®
THE OSTEOPATHIC MANAGEMENT OF POST-OPERATIVE
INTERVERTEBRAL DISC RETROPULSION
C. Haddon Soden,,D.O., M.Sc.
We are of the opinion that structural instability is one of the contributing factors to disc retropulsion. It is
caused by Improper fitting shoes, hip joint
lesions, sacro-iliac lesions, lumbo sacral
lesions, lumbar lesions, lower extremity
length variations, sacral base lnclinations. musculo-fasciae changes and inelasticity of the ligamentum subflavum.
We know from experience, an operation Is necessary to remove the nucleus
pulposus which is causing the radicular
syndrome, thereby helping the system to
now be receptive to Osteopathic manipulation. Therefore surgery contributes to,
but does not restore structural stability.
Evaluation
Before treating the post operative
disc we must keep in mind the trauma that
has existed for some time, as well as the
surgical trauma. Therefore the treatment
given in this particular condition is one
that is supportive, rather than one which
might be too strenuous, thereby aggravating an already traumatized tissue.
Examine the shoes very carefully,
and prescribe new ones if necessary. Arrange for a standing lumbo pelvic roentgen
study, in order to see how much heel elevation is necessary to level the sacral
base. Do not prescribe heel lifts until
sacro-iliac and lumbo sacral physiological
articular motion has been established, as
it may produce a greater structural strain,
or increase the structural instability.
When motion is detected, the structure now
has the ability to compensate, and the
heel can be elevated. Do not try to mobilize the sacro-iliac and lumbo sacral
articulations if there is an ankylosis or
fusion.
Treatment
We use the Soden foot technic and
the Still sacro-iliac, lumbo sacral, lumbar and hip lesion technics.
Fascia, Muscular, Ligamentous Connections
Fibrous bands, or thickened portions of the fascia, bind down the tendons
in front of, and, behind the ankle in
their passage to the foot. They comprise
three ligaments, viz., the transverse crural, the cruciate crural and the laciniate;
and the superior and inferior peroneal retinacula. In binding down the flexor and
extensor muscles of the leg, and keeping
in mind the fascia, muscular and ligamentous relations, throughout the whole structure, we use the foot as a lever, to produce a springing motion through the sacroiliac and vertebral articulation. What
effect, from the standpoint of a pump, it
has on lymphatic drainage or cerebra spinal fluid flow remains to be proven.
Foot Technic
The patient is supine. The physician is standing, or preferably sitting,
facing the patient's left foot, and places
his left hand under the left calcaneus.
The tendon achilles is put on and maintained in traction, by pulling caudad with
the left hand on the calcaneus. The hypothenar eminence of the right hand, fingers
pointing lateralward, Is placed under the
distal metatarsal bones, the fingers resting lightly on the dorsum of the phalanges.
While maintaining traction with the left
hand, the right hand presses upward through
the metatarsals (not the phalanges) producing a dorsi flexion, then press lateralward and release to plantar flexion. APPLY
this several times, then dorsiflex, press
medialward and release. This technic must
be smooth and is applied for several minutes to each foot.
Only use a very mild dorsi flexion
pressure or one the tissue can tolerate.
Do not raise the leg, as then the
dorsi flexion pressure becomes piston like
and traumatizes.
Sacro-iliacs
Assuming that we are dealing with
199
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200
the right anterior sacro-iliac lesion, the
patient is lying on the left side in the
Simms position, both arms over the sides
of the table, the thighs flexed at right
angles to the body. The physician is
standing back of the patient in line with
the pelvis.; he places his left hand posterior to the right ala of the sacrum and
places his right hand on the right leg just
below the patella. Motion Is attempted or
produced by flexing, elevating, and extending the thigh. This procedure is repeated
several times.
Assuming that the left side shows a
posterior sacro-iliac lesion, the patient
is lying on the right side, Simms position.
The physicfan, standing back of the patient, places his right hand posterior to
the left posterior superior-iliac spine,
his left hand on the left leg just below
the patella. The corrective technic is
the same as for the correction of an anterior sacro-Iliac lesion.
Lumbo-sacral
_ and
I Lumbar
- Lesions
The patient is placed in the Simms
position, either right or left side, the
physician standing back of the patient, on
a line with the patient's pelvis. Assuming that the patient is lying on the right
side, the physician places his right hand
back of each lesion, and his left hand on
the left leg, just below the patella. Motion is attempted or produced by an easy,
smooth flexion, elevation and extension of
the left thigh. The right hand detects
whether or not motion is produced. Flex,
elevate and extend the thigh several times.
Then the patient is instructed to lie on
the left side and the same procedure is
used as for the right side.
Hip Joint Lesions
If the hip joints are lesioned, motion must be established, otherwise it
will be impossible to maintain physiological articular motion in the sacro-iliac
articulations.
-Tests for
- Lesions
The patient is standing with the
feet about eight inches apart; the physician is sitting facing the patient, holding the patient's pelvis. The patient is
instructed to evert and then invert first
one foot, then the other; the main objective being to notice whether or not inver-
sion or eversion is restricted.
Technic
If the inversion is restricted on
the left side correction is made as follows: The patient sitting on a stool,, the
distal end of the left leg is resting on
the distal end of the right thigh. The
physician, facing the patient, places his
left hand on the distal end of the left
leg, his right hand on the left knee.
While pressing backward with the left hand
and downward with the right, the patient
is instructed to lean forward or hyperflex the vertebral column. This is repeated several times. If, on the other
hand, eversion is restricted, the patient
and the physician assume the same positions, the only difference in the corrective technic being that the patient leans
backward or in hyper-extension. This
maneuver is repeated several times.
Then, with the patient standing,
the physician holds the pelvis and has the
patient repeat the inversion and eversion
in order to notice how much motion has
been established.
Sequence of Treatment
Acute Stage--Apply foot, sacro-iliac-, lumbo-sacral and lumbar technic twice
a week for one month if necessary.
Chronic Stage--Apply all three methods once a week, once every two weeks,
or less often as the symptoms diminish.
Sacral Ease Inclinations--Now that
motion is established one of the most important considerations is the sacral base
Inclination, which adds to the instability
of the vertebral column.
Regardless of the inclination of the
sacral base line, or the pelvic weightbearing line, whether parallel or contraparallel, the main objective is the vertebra1 column or vertebral balance. If the
vertebral column shows no scoliosis, or
very little scoliosis, the leveling of the
sacral base is not necessary. If, on the
other hand, there is a marked scoliosir3,
leveling of the sacral base is absolutely
necessary, and whichever side the sacral
base is inclined towards, that side must
be elevated.
If the sacral base is inclined
inches or more and the patient sits for
long periods, for Instance, a typist or
auto driver, prescribe a gluteal pad.
This aids in stability.
All Rights Reserved American Academy of Osteopathy®
LECTURE NOTES ON CHAPMAN'S LYMPHATIC REFLEXES
C. Haddon Soden, D.O., M.Sc.
Dr. Andrew Taylor Still had much to
say about the body structure and its fluid
parts. Let me quote a few paragraphs that
are pertinent to our study of Chapman's
Lymphatic Reflexes.
The Spinal Cord
"To treat the spine more than once
or twice a week, and thereby irritate the
spinal cord, will cause vital assimilation
to be perverted and become the death producing executor by effecting an abortion
of the living molecules of life before
they are fully matured and while they are
in the cellular system, lying immediately
under the lymphatics."
The Body Fluids
"The rule of artery and vein is
universal in all living beings, and the
Osteopath must know that and abide by its
rulings, or he will not succeed as a healer. Place him in open combat with fevers
of winter or summer and he saves or loses
his patients just in proportion to his
ability to sustain the arteries to feed
and the veins to purify by taking away
the dead substances before they ferment
in the lymphatics and cellular system."
"Therefore if the dead substances
ferment in the lymphatics and cellular
system they should have a high place of
consideration in our therapy."
"The cause of nerve irritation must
be found and removed before the channels
can relax and open sufficiently to admit
the passage of the obstructed fluids."
The Fascia
-- "As life finds its general nutrient
law in the fascia and its nerves, we must
connect them to the great source of supply
by a cord running the length of the spine,
by which all nerves are connected with the
brain. The cord throws out millions of
nerves to all organs and parts which are
supplied with the elements of motion and
sensation. All these nerves go to and
terminate in that great system, the fascia."
"We must remember, as we study the
fascia, that it occupies the whole body,
and should we find a local region that is
disordered, we can relieve that part
through the local plexus of nerves which
controls that division. Your attention
should be directed to all the nerves of
that part. Blood must not be allowed to
flow to the part by mild motion. Its flow
must be gentle. to suit the demands of nutrition, otherwise weakness takes the
place of strength, and we lose the benefits of the nutritive nerves."
The Lymphatics
"The system of lymphatlcs is complete and universal in the whole body.
After beholding the lymphatics distributed
along all the nerves, blood channels, muscles, glands and all the organs of the
body, from the brain to the soles of the
feet,' all loaded to fullness with watery
fluids, we certainly make but one conclusion as to their use, which would be to
mingle with and carry out all impurities
of the body, by first mixing with the substances and reducing them to that degree
of fineness that will allow them to pass
through the smallest tubes of the excretory system, and by that method free the
body from all deposits of either solids
or fluids and leave nourishment."
"Let the nerves all show their powers to throw out every weight that would
sink or reduce the vital energies of nature."
Therapeutic Secrets
"LET US ENTER THE FIELD OF ACTIVE
EXPLORATION."
Chapman's Reflexes
Chapman's reflexes is the term given the hypercongestions manifest by soreness or tenderness at the distal ends of
spinal nerves because of the osteopathic
physician who discovered and charted their
location and therapeutic value in the diagnosis and treatment of disease. These
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202
hypercongestions vary in size according to
location., and to the proportion of pathology present. Dr. Chapman had worked alone
with his ideas of lymphatic drainage for
about twenty years calling these areas of
hypercongestion, lymphatic centers. Chapman charted over two hundred separate and
distinct reflexes, each one having a definite and specific effect upon the endocrine.
gland or viscus with which it is in association. When he found a given combination
of tender areas he always found a given
disease entity or organ pathology present,
or vice versa with the manifestation of a
certain disease entity or pathology there
would always be present a definite combination of tender areas.
These reflexes are located in the
lymphoid tissue in the fascia and are manifested in the acute stage by soreness or
tenderness at the distal ends of the spinal
nerves. For instance, in the thorax there
is lymphcaid tissue between the anterior
and posterior intercostal fascia. It is
within this tissue that the Chapman's reflex may be found. Each one of you will
probably have tenderness In varying degrees at the second interspace. Locate the
junction of the manumbrium and body of the
sternum at the side of which articulates
the second rib below which is the second
interspace in which is found, close to the
sternum, the thyroid reflex always more or
less involved according to the degree of
pelvic pathology, bony or otherwise present.
The sympathetic fibres we know are
passing with the lymphatics which are continuous with those lymphatics of the deeper structures so that treatment of these
reflexes or receptor organs will effect all
structures so connected.
Dr. Owens, who continued with this
work after the death of Dr. Chapman, realizing the importance of the autonomic phase,
called these areas reflex centers and he
has stressed the importance of the pelvicthyroid-adrenal syndrome, or gonad group.
So far we know a Chapman reflex lesion is the result of a lymph stasis in
the viscus or glands. This lymph stasis is
responsible for the dysfunction of that organ or gland. Both the lymph stasis and
the resultant dysfunction are reflexly responsible for the Chapman lesion due in
part to nerve impulse and to a chemical reaction of the lymphatic tissue in which
the reflex lesion is found.
Head's law states that "when a painful stimulation is applied to a part of
low sensibility in close central connection with a part of much greater sensibility, the pain produced is felt in the part
of high sensibility rather than in the
part of lower sensibility to which the
stimulus was actually applied."
Head formulated this law of the location of visceral pain because he recognized two types of sensation in Internal
viscera, one in the organ itself which is
more that of discomfort and uneasiness and
one on the surface of the body which is a
true painful sensation. The human body is
dependent for the maintenance of its integrity upon the preservation of its structure and its normal chemical balance than
the chemical balance is to deranged body
structure.
To understand Chapman's Reflexes we
must have a knowledge of the autonomic
nervous system, the endocrine system, the
embryologic segmentation and fascia, as
well as of the lymphatic system, necessary
to work out the pathways from viscus or
gland to associated lesions. The significance of these reflex or receptor organs
is two fold--they are a reliable index to
the nature of the disturbance within their
associated organs or glands and they are a
specific means of correcting the disturbances.
By the stimulation of these receptor organs both the afferent and efferent
vessels draining the surrounding tissues
will be affected, as will also the entire
lymph system of this area. These receptor
organs are easy to palpate because of the
edema or congestion localized around the
area.
This method of diagnosis gives an
exact picture of the existing condition
even to the extent of involvement, and
treatment, correctly applied, usually obtains the specific results desired.
A bony lesion may be primary or it
may be secondary to some functional disturbance. Any lesion which disturbs the
bony pelvis interferes with the blood and
nerve supply to the gonads which in turn
directly affect the thyroid, whose function
it is to influence the oxygen content of
the blood. All the blood passes through
the thyroid gland at least twice an hour
and there receives thyroxine, the secretion of the thyroid, which is carried to
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203
every tissue cell. Thus with a pelvic lesion is started the imbalance to the endocrine
system which in turn interferes with nutrition to body structures.
Result--impaired function of gland or viscus and possible further result--bony lesion.
This is the reason that no attempt should be made to correct bony lesions until the
corrected nutritional disturbances responsible for the pathology nave been re-established at the site of such lesions. Frequently by that time the lesions will have disappeared or their correction will be a very easy accomplishment. And because of this
removal of tissue pathology at the site of the bony lesion that lesion when corrected
will stay corrected.
This point has been experienced by many Osteopathic Physicians especially in the
treatment of chronic conditions that manipulative treatment will add to the discomfort
of the patient and to the severity of the condition.
This happens because of a lack of understanding of the need for the removal of
the underlying tissue pathology before the attempt of bony correction which oft times
aggravates a chronic state causing still further stasis of body fluids.
Equally important in this connection is the fact that corrective work before the
nutritional change has been re-established is apt to dissipate the effect of the reflex
work or at least tend to obscure the usual spectacular results.
Examples of Specific Chapman Reflexes
Anterior and Posterior Reflex Centers as worked out by Dr. Chapman are given
here for illustrations together with four descriptive charts showing their location.
Figure 1
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204
Retinitis or Conjunctivitis
Anterior: Front of humerus. Middle aspect surgical neck.
Posterior: Occipital bone. sub-occipital nerve. Retinitis.
Occipital bone. Ant. br occipital nerve. Conjunctivitis.
Cerebellar Congestion
Anterior: Tip corocoid process of scapula.
Posterior: Across transverse processes Atlas.
Cerebral Congestion
Anterior: Laterally from spinous processes 3-4-5 cervical vertebrae.
Posterior: Between the transverse processes l-2 cervical vertebrae near their
tip ends.
Torticollis
Anterior: Inner aspect, upper end of humerus, surgical neck downward.
Posterior: Posterior aspect transverse processes 3-4-5-6-7 cervical vertebrae.
Otitis Media
Anterior: Upper edge of clavicle, just beyond where it crosses 1st rib,
Posterior: Upper edge posterior aspect, tip of transverse process 1st cervical
vertebra.
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205
Pharyngitis
Anterior:
The front of the first rib for a matter of three quarters of an inch
to an inch toward the sternum from where the clavicle crosses the rib.
Posterior: Midway between the spinous process and the tip of the transverse
process of the second cervical vertebra, on the posterior aspect of
the transverse process.
Tonsillitis
Anterior: 1st intercostal space near sternum.
Posterior: Transverse process 1st cervical, midway between spinous process and
tip of transverse process.
Laryngitis
Anterior: Upper surface 2nd rib 2-3 inches from sternum.
Posterior: Midway between spinous and tip of transverse process.
vertebra.
Sinuses
Arms
2nd cervical
Anterior: Upper edge 2nd rib--3 l/2 inches from sternum.
Posterior: 2nd cervical--transverse process midway between spinous and tip of
transverse.
Anterior: Muscular attachment Pectoralis minor muscle to 3-4-5 ribs.
Posterior: Superior angle of scapula--1-2-3 ribs along inner margin of scapula.
Bronchitis
Anterior:
Intercostal space between the second and third ribs close to the sternum.
Posterior: Across the face of the transverse process of the second dorsal vertebra, midway between the spinous process and the tip of the transverse process.
Myocarditis
Anterior: Intercostal space between the second and third ribs close to sternum.
Posterior: The space between the transverse process of the second and third
dorsal vertebra, midway between the spinous process and the tip of
the transverse process.
Upper Lung
Anterior:
A gangliform contraction between the third and fourth ribs near the
sternum.
Posterior: Between the third and fourth transverse processes, midway between
the spinous processes and the tips of the transverse processes of
the third and fourth dorsal vertebra.
Lower Lung
Anterior:
A gangliform contraction between the fourth and fifth ribs, close to
the sternum.
Posterior: Fourth intertransverse space.,
Hemorrhoids
Anterior: Just above the tuber ischii.
Posterior: On the sacrum, close to the ilium, at the lower end of the ilio-sacral articulation.
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206
Figure 3
Sciatic Neuritis
Anterior:
A gangliform contraction starting one fifth of the distance below
the trochanter and for a space of from two to three inches downward
on the posterior outer aspect of the femur.
Second--A gangliform contraction commencing one fifth of the distance above the knee, and continuing upward for a matter of two inches on the posterior outer aspect of the femur.
Third--A gangliform contraction in the mid-posterior region of the
femur and one third of the distance upward from the condyles.
Supplemental Points
(a) Both sides of the fibula from its upper attachment or articulation with the tibia to the outer malleolus.
(b) Midway between the trochanter and the tuber ischii and above the
trochanter, transversely.
(c) Just below the posterior superior spine of the ilium.
Note: Loosen up the initial or principal contractions first, before
touching the supplemental points.
Posterior:
Upper part of the sacrum inside of the sacro-iliac articulation.
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An innominate lesion will usually be found in such conditions.
Atonic
207
Constipation
Anterior: A gangliform contraction of the muscle tissue between the anterior
superior spine of the ilium and the trochanter of the femur.
Posterior: On the face of the eleventh rib at the end of the transverse process
of the eleventh dorsal vertebra.
Prostate
Anterior:
From the trochanter downward on the outer aspect of the femur to
within two inches of the knee joint, and laterally on either side of
the symphysis, identical with the uterine center in the female.
Posterior: Between the posterior superior spine of the ilium and the spinous
process of the fifth lumbar vertebra.
Ovaries
Anterior: The round ligaments from the upper border of the pubic bone downward
to the attachment of the muscles on the lower border. A gangliform
contraction in or along the round ligament or at the bony attachment
of the muscles in relation to it at the lower pubic border indicates
ovarian congestion or probably inflammation.
Posterior: A gangliform contraction, between the ninth and tenth dorsal intertransverse space, indicates an involvement of the inner half of the
ovary, while a gangliform contraction between the tenth and eleventh
Figure 4
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208
Uterus
dorsal intertransverse
space, indicates an involvement of the outer
half of the ovary.
Anterior :
At the upper edge of the
junction of ramus of
pubes and ischum.
Posterior: Between posterior super1
or spine of ilium and
spine of the fifth verte
bra.
Broad Ligament
Anterior:
From the trochanter down
ward on the outer aspect
of the femur to within
two inches of the knee
joint.
Posterior : Between the posterior
superior spine of the
ilium and the spinous
process of the fifth lum.
bar vertebra.
Rectum
Anterior:
Lesser trochanter of the
femur downward.
Posterior: On the sacrum close to
the ilium, at the lower
end of the ilio-sacral
articulation.
cystitis
Anterior:
You will find a gangliform or seemingly callous
state of the tissues
around the umbilicus.
Posterior: Upper edge of the transverse process of the second lumbar vertebra.
Kidneys
Anterior:
.
Laterally on an area located about an inch on
either side of the medial
vertical line of the abdomen and one inch above
the horizontal plane of
the umbilicus.
Posterior: Intertransverse space between the twelfth dorsal
and the first lumbar
vertebra, midway between
the spines and the tips
of the transverse pro-
cesses.
Adrenals
Anterior:
An area from two to two
and a half inches above
and one inch on either
side of the umbilicus.
Posterior: Intertransverse spaces
on both sides of the
eleventh and twelfth dorsal vertebra, midway between the spinous processes and the tips of
the transverse processes
when both adrenals are
involved and on the affected side where only
one is at fault.
Small Intestines
Anterior:
Intercostal spaces between the eighth and
ninth, ninth and tenth
and tenth and eleventh
ribs near the cartilages
on both sides of the
body.
Posterior: Intertransverse spaces
of the eighth and ninth,
ninth and tenth, tenth
and eleventh dorsal vertebra on both sides-, midway between the spinous
processes and the tips
of the transverse processes.
Pyloric Stenosis
Anterior:
On the front of the sternum at the junction of
the manubrium with the
gladiolus, down to the
ensiform cartilage.
Posterior: On the face of the tenth
rib at its juncture with
the tip of the transverse process of the
tenth dorsal vertebra on
the right side.
Congestion of the Liver and Gall Bladder
Anterior: A gangliform contraction
of the tissues in the
intercostal space from
the mid-mammillary line
up to the-sternum on the
right side between the
All Rights Reserved American Academy of Osteopathy®
sixth and seventh ribs.
Posterior: Between the transverse
processes of the sixth
and seventh dorsal vertebra, midway between the
spinous processes and
the tips of the transverse processes, on the
right side.
Examination
Sacro-iliac Lesions
Diagnosis:
If there is more unilateral muscular tension when inverting one foot than
the other, Poupart's ligament is thickened
on that same side, the pubic bone is higher
and the crest and gluteal area is depressed
or less prominent than the opposite side,
we are then dealing with a posterior innominate lesion on that side.
If it is an anterior innominate, the
pubic bone will be higher, the iliac crest
will be more prominent lateralward.
Patient supine
1. Before starting examination of
the anterior and posterior reflex centers, Various Iliac Positions
stand at the foot of the table. Place
1. One innominate (usually the
right) rotated backward.
both hands under the calcaneal bones,
slightly elevate the legs and forcibly in2. One may be rotated backward and
vert the feet. Note difference in muscuthe other forward.
lar tension, by resistance to inward rotaEither
one may be rotated for3.
tion, for indications of innominate lesion
ward.
2. Have the patient flex thighs
4. Either one may be down at the
and legs, the feet resting on the table.
symphyseal articulation.
The physician facing the foot of the table
5. Either one may be up at the
places the thumbs about two inches medial
symphyseal articulation.
to the anterior superior spines and press6. Both may be down or up at the
es downward on Pouparts ligaments. The
sacrum.
ligament will be thickened on the affected
innominate side and the area will be senSacro-iliac Lesion Correction
sitive to pressure.
Right Posterior Rotation - Position
Place the fingers over the
patient on left side, knees drawn up toward
flare of the iliac crests and extending
the body. Standing behind the patient,
down over the glutius minimus and medius
slip your right arm between the patient's
to see which of these areas is prominent
thighs, until the bend of your right elbow
or depressed.
is even with the front of the patient's
Place the index fingers on the
right thigh, your arm resting close against
abdomen close to the pubic bones and later. the crotch of the patient, with weight of
al to the symphysis. Press toward the pu- leg supported upon your arm and foot extendbic bones and feel which is high or low.
ing beyond the edge of the table. By this
procedure the weight of the leg acts as a
Treatment
fulcrum to spread the lesioned joint.
Next rest the elbow of your left
Hypercongestions of any part of the
arm against your left side just in front of
body for which the reflexes centers have
been worked out may be greatly reduced by
the anterior superior spine of your left
a brief treatment of the anterior and
innominate, with heel of your left hand
posterior reflex centers and in this order resting against the posterior superior spine
For spectacular, convincing results of the patient's ilium, and your forearm as
and one that would affect a more lasting
a prop, ease the innominate back into normal
reflex effect and so hasten recovery, firs. position by the weight and rotation of your
correct the pelvic lesions and then treat
own body.
the anterior and posterior reflexes, parLeft Posterior Rotation - To correct
ticularly the anterior with the terminal
a left posterior rotation the procedure is
phalanx of the index or middle finger with the same as for right posterior rotation,
a light rotary movement for about 15 to 30 except you reverse the position of patient
seconds. The pressure must be light.
and of your hands.
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210
Right Anterior Rotation - To correct
a right anterior rotation, place patient or
left side and stand facing patient. Place
heel of right hand against the front of the
anterior superior spine, left hand back of
the tuberosity of the ischium, with patient's knee against your abdomen. Exert
equal pressure with both hands, 'pushing
away from you with right hand and pulling
toward you with left hand.
Left Anterior Rotation - To correct
a left anterior rotation place patient on
right side. Place the left hand in front
of the anterior superior spine and right
hand back of the ischium, with patient's
knee against your abdomen. Exert equal
pressure with both hands, pushing away from
you, with your left hand pulling toward you
with right hand.
Ma1 Position at the Symphysis - When
the innominate is down at the symphysis,
place patient on back. Stand opposite side
of table from the lesioned innominate.
Flex the leg on lesioned side and bring it
toward you across the patient's body at an
angle of 45 degrees.
If it is a right innominate down
place your right hand on patient's knee and
your left beneath the tuberosity of the
ischium. Bring the leg on lesioned side
toward you and press down on the knee to
spread the sacral articulation and lift
with your left hand on the tuberosity.
If it is a left innominate that is
down, stand on right side of table and with
left hand resting at patient's knee and
your right hand beneath the patient's tuberosity bring the leg on the lesioned side
toward you and press down on the knee to
spread the sacral articulation and lift
with your right hand on the tuberosity.
If either innominate is up at the
symphysis place patient on opposite side
from the lesion. Stand behind then 'slip
your arm between the patient's thighs and
grasp the top side of the lesioned innominate, with the weight of patient's leg rest-
ing upon your arm, pull down with the innominate-engaged hand and push forward with
your free hand against the posterior superior spine. This will easily rotate the
joint into position.
Once the pelvic lesion has been detected and corrected attention should be
turned to relieving the congested lymphatic
drainage.
In order to more readily visualize
and remember the reflex centers I have!
filled them in on the charts, starting with
the Eye, Ear, Nose and Throat, Respiratory,
Circulatory, Digestive, Glandular, etc.
In order to get the maximum results,
always treat the sacro-iliac lesion, and
then if it is, for example, a digestive
disturbance, treat only the involved digestive reflex centers. If respiratory,
treat the sacro-iliac lesion and the involved respiratory reflex centers etc.
Relaxing the Thorax - The patient is
prone. Place pillow under the patient's
chest and one under the frontal bone, arms
hanging loosely on either side of table.
Place thumbs above the ribs lateral
to the transverse processes of the first
dorsal vertebra on either side using heavy
pressure. Have patient extend or swing
his arms toward the head of the table and
inhale. On reaching the limit of extension
have the patient exhale and return arms to
their original position, move the thumbs to
the same position 2nd dorsal vertebra and
proceed as before, vertebra by vertebra until the entire thorax has been relaxed.
This method of relaxing the thorax, stimulates the sympathetics through the splanchnit area, expands the chest and lungs, and
if vertebral or rib motion are present, it
makes their replacement much easier to accomplish.
Warning - Prescribe a plain water
enema before retiring, as the detritus, present in the colon will cause the patient to
become very toxic if not removed.
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211
Bibliography
An Endocrine Interpretation of
Chapman's Reflexes . . . . Dr. Charles Owens
1937
A Pelvic Lesion and the Pelvic
Thyroid Syndrome . . . . . Dr. Charles Owens
1942
The Philosophy and Mechanical
Principles of Osteopathy . . Dr. Andrew Taylor Still 1902
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CLINICAL ASPECTS OF THE CHAPMAN REFLEXES
Edward A. Brown, A.B., D.O.
No skill has been developed without
patient, persistent effort on the part of
the individual who has determined to master the fundamentals and applications of
the principles involved. In the practice
of Osteopathy this is all too true. To one
who would practice manipulatively it is essential that one understand (1) the anatomical, physiological, and pathological relations of the human body; (2) that he properly correlate these with the signs and
symptoms he elicits; (3) that he apply
specific treatment in accordance with his
findings and therapeutic aims; and (4) that
he develop palpatory and manipulative
skills that will enable him to achieve his
objectives in treatment.
The normalization of Osteopathic lesions has long been a prime objective in
the restoration of the body to health.
Much time and effort has gone into this
project since Dr. A. T. Still first pronounced the system of therapy called Osteopathy. There is no doubt but that Dr.
Still was very specific in his treatment of
lesion pathology, and indeed the progress
of Osteopathy has been dependent upon the
ability of his students to duplicate his
work.
The Chapman reflexes form a very important part of the lesion pathology picture, both from a diagnostic and therapeutic aspect.
I. - Research in the Chapman reflexes has
been a very real problem. It has been extremely difficult to map out a rational approach whereby these reflexes can be demonstrated and proved. To date we have only
the clinical results of the application of
the reflexes discovered by Chapman and promulgated by Owens for the raison d'etre of
this therapeutic effort.
II.-The anatomical dissection of the
Chapman reflex manifestation anteriorly by
Small in 1937 at The Chicago College of Osteopathy has been duplicated at The Philadelphia College . As yet tissue specimens
from cadavers on which the clinical and
pathological diagnoses have been made have
not been obtained. No doubt this will be
part of the program of research. It will
serve to link definitely the relation of
organ to specific reflex center.
Of utmost importance is the fact
that for each organ the anterior lesion is
always found in the same relative position.
This consistency of reflex pattern insures
the value of these reflexes from a diagnostic viewpoint. In addition, the anterior centers are sufficiently widespread so
that confusion as2to which organ is involved is eliminated.
The anterior reflex center may
range in size from that of a small pea to
several inches in length in the adult. It
is characterized by a peculiar granular
feel of the underlying tissues of the skin
to extremely light palpation. In some
cases the center may feel almost edematous.
There may or may not be pain in connection
with palpation of the center. The intensity of pain denotes the relative amount
of involvement of the related organ. The
complete lack of pain denotes a process of
long duration and very marked involvement.
The anatomical pathway over which the reflex is manifested is probably the sympathetic division of the autonomic nervous
system. These reflexes are not to be confused with the reflexes of referred pain.
III.-The physiology of the Chapman reflex is open to study and to constructive
criticism. One must remember that clinically it is operative. Since Chapman theorized that lymphatic stasis in an organ produced the irritation which set off the reflex phenomenon and demonstrated clinically the reversibility of the pathway thru
which the reflex was mediated, one must
ponder the question as to how the stasis
of lymph could occur.
(a) The imbalance of the pelvis associated with the imbalance of the endocrine system may result in a state of imbalance between the autonomies and the endocrines, or in other words a neuro-chemical clash by means of which susceptible organs may become involved.
212
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(b) Toxins and/or other substances
noxious to the contractile and permeable
elements of the capillaries may so alter
their caliber and permeability that lymphatic stasis may be induced. Much of the
water from the tissue spaces is absorbed by
the venous capillaries. The lymphatic vessels being more permeable, absorb both
water and the protein elements from the
tissue spaces. Since the noxious agents
usually increase the permeability of the
capillaries there is a tendency for an increased amount of protein to be filtered
thru into the tissue spaces, thus placing
an increased absorptive load upon the lymphatics. This lymphatic stasis or inflammatory edema is localized to an area of
varyi s g extent surrounding the injured
area.
(c) Neurotrophic disorders may affect the caliber of the capillaries, thus
affecting their permeability. The capillaries can and do contract independent of
the arterioles, and they have been observed
to resist an arteriolar pressure of as much
as 100 millimeters of mercury. They receive efferent fibers from the sympathetics
and stimulation of the sympathetics may
cause changes in the size of the capillaries without regard to changes in the arterioles. Afferent fibers of the sympathetics come down as far as the arterioles,
some ending in Pacinian bodies.4 These
neurotrophic disorders may be and probably
are induced by Osteopathic spinal and
cranial lesions.
It may be reasoned now, that with
irritation in a viscus involving the capillaries and the lymphatics, impulses may
pass upward to the spinal cord either antidromically along the efferent pathways, or
directly along the afferent pathways, or
both. Having reached the central nervous
system, this abnormal bombardment of impulses probably follows a somatic course
outward into the cutaneous site of the
Chapman reflex center, where an active process is instituted, creating the phenomenon
before described as the anterior reflex
center.
Since stimulation of the sympathetics will cause independent contraction of
the capillaries in experimental animals,5
so too, will stimulation of the Chapman reflex center cause changes in the capillaries of the viscus associated with this facilitated reflex pathway.
213
Now let us proceed to the clinical
aspects of these reflexes. I want you to
pay particular attention to Dr. Mitchell
as he presents the crux of the Chapman reflex treatment--the balancing of the bony
pelvis. Upon this delicate balance depends
a large share of the effectiveness of a reflex treatment. If the pelvis is not balanced properly, a large part of the reflex
treatment is nullified. If the pelvis becomes unbalanced, as it frequently will,
signs and symptoms will return. It is not
always possible to balance the pelvis and
have it remain in balance from the first
treatment on. Oftimes the pathology is so
severe that it tends to unbalance the pelvis. Sometimes it may take several weeks
before the pelvis remains in balance. This
is a particularly trying period, as symptoms tend to recur. The balance of the
pelvis is one of the criteria of the progress of the patient and his treatment.
The diminution and disappearance of the
involved centers are further criteria of
progress.
As one progresses in the administration of the Chapman reflex treatment, he
observes that for certain conditions there
is a striking similarity in the pattern of
the reflex centers involved. Since only
those centers involved are to be treated,
this lends specificity with a capital "S"
to one's treatment. It is as specifically
measured as a dose of medicine. One notes
too, that he tends to interpret his findings as groups of organs, a departure from
the usual forms of diagnosis.
The Pelvic-thyroid syndrome, the imbalance between the structural pelvis, the
gonads, and the thyroid gland is a constant
pattern. In the analysis of such a clinic:
al problem as peptic ulcer, there Is a pattern of reflexes as follows: pelvic-thyroid- syndrome--basic; gonads, gastric hyperacidity, gastric mucosal congestion,
phlorus, duodenum--characteristic. In mucous colitis or spastic constipation there
is: pelvic-thyroid syndrome--basic; gonads, spastic colon, torpid liver, gallbladder, duodenum--characteristic. In bronchitis there is: pelvic-thyroid syndrome-basic; bronchial, upper and lower lung centers, groin gland centers, spleen, panThere are many
creas--characteristic.
other stable patterns of which these are
but a few.
The role of the pancreas is little
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214
known in the various disease problems which
we are called upon to treat generally.
However, there is a direct relationship between the pancreas and these various diseases, and the pancreatic reflex is nearly
always the last to clear up. There. is also
a direct relationship between the pancreas
and adrenals, and these two are frequently
associated in lesion patterns.
When one has spent considerable time
in study of the Chapman reflexes, and has
spent many hours in perfecting his technique and in observing these patterns as well
as his clinical results, he arrives at conclusions concerning the intimate relationships existing between the functions of the
various organs of the body. These conclusions are not always in keeping with some
of the present day accepted theories, but
they are strong circumstantial evidence,
and in action upon them, one is gratified
by some very startling clinical results.
I should like to bring to your attention the Evans mesenteric flush technique.6 This is a lymphagogic stimulant, in
that a fairly large quantity of isotonic
saline is administered. This isotonic saline increases the flow of lymph. It is
especially helpful in acute infectious
diseases..
After the initial examination, it is
possible to balance the pelvis and administer a Chapman reflex treatment in from six
to ten minutes. One does not dwell upon
the Chapman centers except with a light
touch and for not more than ten to fifteen
seconds for each center. More Chapman
treatments have been nullified by gouging
at the centers with a heavy finger for too
long a time than by any other error.
I should like to conclude by telling you of the treatment of one clinical
picture. That is the menopausal syndrome,
and I have chosen it because of its dra-
matic results.
The centers treated are: pelvilcthyroid syndrome--basic; gonads, ovaries,
adrenals, spleen, pancreas. The patient
is treated about three times a week for
two weeks, which is usually sufficient.
Usually after the first or second treatment the patient is completely relieved of
all untoward symptoms. However, because
of this, the patient usually engages in a
great deal of strenuous physical effort,
which promptly unbalances the pelvis. The
symptoms return at once. The next treatment corrects the pelvis, again, and ‘by
the end of the second week the pelvis will
usually remain balanced for a long period
of time. After a course of treatment so
described, I have had patients remain free
of symptoms for periods of from six months
to more than a year without further treatment.
It requires a great deal of time,
patience, and study as well as practice
to become proficient in diagnosis by means
of the Chapman reflex centers and in the
administration of the Chapman reflex treatment. The routine of the treatment is outlined in "An Endocrine Interpretation of
The Chapman's Reflex' by Charles Owens,
D.O. One cannot sit down with the book
and be able to administer a reflex treatment. He must apprentice himself to someone who has mastered the work, then return
to his book from time to time to assure
himself that he is not adulterating his reflex work with the addition of other bits
of therapy which may nullify its good.
The Chapman reflexes are no better than
the intelligent application of their principles; they are delicate and will not
stand alone without causing an untoward
.
reaction in the patient; they are worth
all the study one is willing to devote to
them.
Bibliography
1. An Endocrine Interpretation of Chapman's Reflexes, Owens, Pg. 1.
2. Ibid. Pg. 3.
3. Physiological Basis of Medical Practice, Best and Taylor, Pg. 52.
4. Ibid. Pgs. 423-27.
.
5. Ibid. Pg. 426.
6. An Endocrine Interpretation of Chapman's Reflexes, Owens, Pg. 114.
All Rights Reserved American Academy of Osteopathy®
.
OSTEOPATHIC STRUCTURAL ANALYSIS
Wm. A. Ellis D.O.
During the past few years, many articles have been written about postural
balance, and many lectures given on the
same subject, but all of those which I
have read or heard seemed incomplete. They
have not included all points which are necessary to give the entire picture. As I
see it, structural analysis is a vital part
of osteopathy because it is one of the
fundamentals of basic osteopathy. And yet,
structural analysis is not complete unless
you can visualize what connection there is
between what you find and the patient's
symptoms and complaints. Therefore, I
would like to explain to you, what I feel,
are the basic points of such structural
analysis. They are eight in number:
(1) Shoes; (2) Feet; (3) The ankle joint;
(4) The Knees; (5) The hip joints; (6) The
pelvis; (7) The Lumbosacral articulation;
and (8) The spine and upper structure.
Following is the breakdown of each, starting at the bottom or foundation and working up.
The first is shoes: These play a
very important part in our everyday lives,
much more so than the average person or
doctor realizes. We have many different
kinds of shoes: in fact, in the United
States today, there are twelve hundred and
eighty six different makes of shoes, so it
is a difficult task for any person or physician to analyze all makes of shoes and
select those which they feel are the most
important types of shoes for people to
wear. But let us consider the different
types of shoes. Beginning with the women's
shoes, the first type for consideration is
the health shoe. The health or orthopedic
shoe should be made of leather and have a
large leather heel not over l-1/2" in
height with a walking surface the size of
a silver dollar. This shoe is an oxford
usually having six or seven eyelets and a
round toe. It has a high-fitting quarter
and is made in a combination last of at
least three widths difference between the
forepart and the heel. It has a very
strong shank, as well as a good heavy in-
sole and outsole.
The second type is a Semi-Style
type of shoe. This type has a heel ranging in height from twelve-eighths to sixteen-eighths, or one-and-a-half to two inches in height with a walking surface usually the size of a quarter. It is an oxford generally having four or five eyelets,
with a high-fitting quarter pattern and a
pointed toe, with thinner insoles and outsoles than the health shoe and carries a
semi-rigid type of shank. This shoe tries
to combine the main features of a health
shoe as well as the style pattern of the
style shoe.
The third type is the style shoe.
This type of shoe generally has from a
sixteen-eighth to a forty-eighth heel
height, or from two to six inches in
height and has a walking surface no larger
than a nickel. This shoe is seen as 'a
heelless or toeless shoe, as well as a
Pump. These shoes must be fitted short in
order to keep the heels on. This type of
shoe is always pointed, and in the toeless
shoes, the opening is placed in front of
the third toe and causes the woman to push
her big toe out through the opening so she
can say that she is wearing a much shorter
shoe than she normally should be wearing.
This shoe also has a thin insole and outsole, with a semi-rigid type of shank in
the shoe.
Then there is the fourth classification that has been introduced during the
past few years, and this is the shoe called the "loafer" including sandals and huaraches. This type of shoe has absolutely
no support, little or no heels and allows
the foot to be sloppy, which is just the
way the shoe looks.
In men's shoes we have three classifications: We have the first type, which
is the health shoe or everyday type, made
up with the large type of men's heel using
six or seven eyelets in a high-fitting
quarter, a medium to wellrounded toe, and
has a heavy insole and outsole as well as
a very rigid shank.
215
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216
The second type is the style type,
which is made up of almost the same characteristics as the health shoe with the
exception that it is pointed or superpointed or with a heavy overlay of leather
for creating the style pattern, such as
the "wing-tips". Many of these carry a
semi-rigid shank and thin insoles to help
give them a neater appearance.
The third type is the "loafer" type,
wherein again we find men wearing loafers,
sandals or slippers.
We must consider shoes as the fundamental part of our problem, for all people
wear shoes the greatest majority of hours
that they are up and about. Therefore,
any irritations that are set up by the
shoes, can create reflexes in the feet
which may produce many diseases. so it is
up to you, as osteopathic physicians, to
include shoes as part of your armamentarium, prescribing the use of proper shoes to
all your patients to make sure that these
reflexes are not in existence. Generally
speaking; we are unable to normalize the
function of a broken down or weak foot, so
we try to do the. best we can by approaching normalcy through the use of manipulation, shoes, strapping and padding. In
this way we can eliminate the reflexes
which are producing many other ailments in
remote parts of the body. What is most
vitally important to all of us, is your
recommendation of the proper shoes for the
children who are your patients and friends.
It is up to you, if you are a real physiclan to make sure that these children's
feet develop normally. It is up to you to
make sure that they wear the proper type
of shoes, and in this way, their feet will
be normal feet when they become adults, instead of finding as we do today, 85% of all
adults having foot trouble.
My- recommendations are that you keep
all children in oxfords or the 3/4 height
shoes (this shoe divides the height between
an oxford and a high shoe--the top fits
just to the ankle bones.) The reason why
we make this statement is that high shoes
definitely weaken feet and prevent the norma1 development, of feet. Observe the next
child who comes into your office wearing a
pair of high shoes. Notice the atrophy of
the fat and the muscles under the high top
shoes and how the flesh bulges out over
the top of the shoes. This is why you
must recommend oxford type shoes to these
children's parents. Please help to keep
normal feet developing normally!
The second point is feet: In the
foot we have twenty-six bones which for
the sake of foot function can be divided
into an important and unimportant groups.
The important group is the OS calcis, cubold, talus, the three cuneiformes, and the
navicular or scaphoid. The unimportant
bones are the five metatarsals and the
fourteen phalanges. It is necessary for
each of us to understand the normal positions, as well as the abnormal positions
of the bones of the feet in order that we
may judge when we have structural balance
within each foot. Therefore, we will try
to give to you what we consider the normal
positions of the bones of the feet, and
tell you what happens when they go into lesion and form the various types of foot defects.
To start with, we analyze the feet
by having the patient stand in his bare or
stocking feet so that we can see the position of the tendo-achilles. We watch especially the medial side, as in a normal
foot this tendon is straight up and down.
The more. convex it becomes on the medial
side, the greater the weakness shown in
the arch of the foot. We term these weaknesses in this manner: First degree, second degree, third degree, and fourth degree or totally flat foot. We also must
ascertain the difference between the norma1 type of foot and the weakness of a
higher arch, and this is done along the
same manner. In other words, by holding
up the inner longitudinal arch until the
medial side of the tendo-achilles is in a
straight line, we are able to judge the
normal height of the medial longitudinal
arch. When we allow this foot to relax
and it pronates, then we are able to conelude the amount of weakness as this medial
longitudinal arch drops. We find in our
'practice and research that high arches
make up 90% of the people's feet which
we examine, 5% in the medium-height normal
arch, 3% to 4% in the normal low arch,, and
from 1% to 2% in the normal flat foot.
This works in the reverse ratio as to the
weakness of feet, for the strongest foot
is the normal flat foot, and the weakest
type of foot is the high arch.
Now let us take into consideration
the bones of the feet in the order of their
importance: In my opinion, the cuboid is
All Rights Reserved American Academy of Osteopathy®
the most important bone in the foot. The
reason why, is this: On the postero-inferior aspect and on the medial side of the
cuboid, we find a prolongation of bone with
a facet which articulates with a facet of
the OS calcis. Therefore, when the cuboid
is in Its normal position, it holds the OS
calcis in its normal position as well as
the cuneiformes and the fourth and fifth
metatarsals, then we have definitely a normal foot. But, when the cuboid goes into
lesion and rotates inwardly and downwardly,
it allows the OS calcis to change its position and thus we have the start of a weak
foot. It is easy to detect a cuboid lesion
by observation and by examining the foot.
On observation, when we see a dropped
fourth metatarsal bone and a rotated and
upward-thrust fifth metatarsal with the
styloid process very prominent and with the
little toe riding up in the air similar to
a hammer-toe and sometimes over-riding the
fourth toe, we can be sure this cuboid is
in lesion. On examination when we palpate
the inferior medial aspect of the cuboid
which is found halfway across the foot
from the posterior aspect of the styloid
process of the fifth metatarsal, we know
that the cuboid is in lesion. The cuboid
is also the base of the so called posterior transverse arch, and as long as the cubold is in its normal position, it definitely holds up the external, middle and
internal cuneiformes so they can function
normally in holding up the metatarsals to
which they articulate.
The next bone of importance is the
OS calcis, or the heel bone. This bone
normally carries approximately 60% of the
body weight in its static form. It has
its normal axis and position, which we
have already explained, by examining the
inner side of the tendo-achilles. We have
also explained that the OS calcis does
not go into lesion until the cuboid has
gone into lesion. When this happens, we
find one of two lesions taking place in
the OS calcis. The first type, which we
find more frequently is the inversion or
pronation of the OS calcis. This lesion
gives us the commonly called weak arches
or flat feet, The second lesion is when
the OS calcis drops straight forward. This
lesion causes a change in the triangular
weight fulcrum and causes the weight to be
shifted forwardly and the results are a
slapping foot or the forepart of the foot
217
hitting hard in walking.
The next bone of importance is the
talus or astragalus. Its importance comes
from its transmission of body weight as it
comes down through the tibia and fibula,
and then transmits it through Its facets
to the other bones of the foot so that all
parts of the foot are carrying their normal amount of weight. As we discern in
the skeleton foot, these facets are heaviest in the direction of the greatest amount
of weight flow. We observe on its lnferior aspect a large facet transmitting approximately 60% of the weight (considering
each foot as a 100% unit) to the OS calcis.
We note the next largest facet articulating with the cuboid as it in turn transmits
the weight toward the styloid process of
the fifth metatarsal and the heads of the
fourth and fifth metatarsals. This directional weight thrust transmits about 30%.
We see a large facet articulating with the
navicular or scaphoid and dividing the
weight thrust of approximately 10% through
each of the cuneiformes and on to the heads.
of the first, second and third metatarsal
bones. Those percentages are for the static or stationary foot. When the cuboid
and OS calcis are in normal relationship
with the talus, the talus holds a normal
position and transmits body weight in its
normal lines. But when we discover a cuboid lesion, we note an inward or outward
rotation of the talus. The Inward rotation
causes the weight to be switched from the
outer side of the foot to the inner side
of the foot, and we eventually note that
the person starts turning his entire foot
laterally. The outward rotation causes
the weight to be shifted more laterally
and results in an excess of weight to be
carried and in many cases simulates a pes
cavus foot.
The three cuneiformes are next in
importance, for their normal position depends greatly upon the normal position of
the cuboid. When it rotates inwardly and
downwardly, it takes the base of the transverse arch out from under it, thus allowing the external or middle cuneiforme to
drop downwardly and the inferior cuneiforme
to rotate inwardly and downwardly. When
this takes place, the external cuneiforme
when in lesion allows the head of the third
metatarsal to drop, the middle cuneiforme
allows the second metatarsal to drop, and
the internal cuneiforme when it rotates,
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218
allows the first metatarsal to rotate also.
The continued amount of rotation of the
first metatarsal and the subsequent muscular pull causes a dislocation of the metatarsophalangeal articulation. This is the
hallux valgus or the, commonly called,
bunion.
Last and least significant of the
important bones is the scaphoid or the
navicular. This bone acts as a ball and
socket and its position follows the weight
thrust as ascertained by the other six important bones, but more especially that of
the talus. This can be seen easily on the
examination of the skeleton foot and noting
the type of facets or the shape of the
bones.
The unimportant bones of the feet
are the five metatarsals and fourteen phalanges. The reason we say that these are
unimportant, is due to the fact that their
normal position depends almost entirely
upon the position of the significant bones
of the feet and especially the cuboid and
three cuneiformes as previously described.
Most of the metatarsal pain which is found,
has been attributed to a breakdown of the
important bones of the feet with the exception of a patient, who wears shoes
which are too short, too narrow, too pointed, poorly constructed, the wrong type of
shoes and also who wears hose that are too
short. This is creating a breakdown by
external force.
Our next point is the ankle joint:
In this we include the articulations between the tibia and fibula and the astragalus or talus. There are two types of
lesions in the ankle joint which we note,
one of which we have already described-rotation of the talus which in turn creates
a lesion between the talus and the tibia.
The second lesion, which causes much more
damage, and which today we are finding so
prevalent, is the posterior deflection of
the tibia on the talus, thus causing an
alteration in the weight thrust from its
normal fulcrum in a posterior direction,
and so, creating a slapping foot. The
fibula, when in this lesion, usually drops
downwardly and forwardly and this lesion
is dependent on muscular pull and its action from the cuboid, for it is noted that
whenever we have a cuboid lesion, the head
of the fibula is always posterior.
Our fourth point is the knee joint:
This particular area is one point over
which much controversy rages. The reason
for this is the fact that too many of our
anatomists have given us the anatomy of
the knee joint and proved to us that we
have seventeen ligaments in the knee joint
many of which hold the cartilages or menisci in their normal position. But when we
palpate these knees and feel a lump at the
articular surface, we are not feeling the
menisci but a swelling in the articular
capsule. I have taken care of quite a few
thousand football players and in all my
years of experience, I have seen only
three cases in which I have been able to
palpate the menisci, and in each case the
knee was severely torn and it was necessary for the patient to submit to surgery.
In my opinion, whenever you tear a cartilage loose , you have torn the ligaments so
severely that nature will not heal them in
their normal position, consequently, surgery must be employed for correction.
Very frequently, I have had cases where
examination revealed there has been a rotation of the tibia on the femur, thus
creating a smaller articular surface which,
therefore, does not allow the knee to go
through its normal range of motion. A
second lesion, we encounter, is the rumpling of the cartilage itself either forwardly or backwardly and so creating a
limitation of motion in the knee joint due
to these high spots that are created by
the compressed cartilage. Later we will
demonstrate a technique which we have used
for many years in the correction of both
those lesions; for if you have one or the
other, the same manipulation will correct
either one.
Our fifth point is the hip joints:
It is very essential for us to consider
the hip joints in postural analysis due to
the fact that we do find a change in the
normal angulation of the neck of the femur.
This may be slight or it may be exaggerated, but any difference in the normal angulation of the neck of the femur will definitely produce a short leg on the side
of the lesion. So, in x-rays, taken of
the pelvis and hip joints, it is very important to include the neck of the femur
so we can determine whether there is any
difference in the angulation.
Our sixth point is the pelvis: The
pelvis itself must be taken First as an
entire entity, and next divided into its
component parts. We must analyze in our
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219
own mind on examination whether or not to
have an anterior, posterior, or a combination antero-posterior lesion of the ilia.
We must also take into consideration any
rotations or deviations of the sacrum. It
is imperative for us to consider the deviations as created by the lack of motion
through the axis of the sacrum in its relation with the cranium. I might further explain that the axis of the sacrum runs between the second sacral segments, and on
inspiration the sacrum goes up and back,
on expiration it goes down and forward. We
make this diagnosis by having the patient
lie face down on the table, and then with
our fingers placed on the base of the sacrum and the apex of the sacrum, have the
patient take a deep breath and exhale. If
the sacrum does not rock on its axis, then
we know that there is a cranial lesion.
When it does rock, but is restricted in its
joint facets, we know then that it is a
sacroiliac lesion. The sacroiliac facets
are "L" shaped so there is a possibility
for us to have a variety of lesions or limitations of motion in this articulation.
We may have a limitation of either of the
upper poles or the two lower poles or any
combination of both upper or lower and an
upper on one side and lower on the opposite
or the two upper and two lower poles. We
can have also an anterior or posterior deflection of the sacrum thus causing a posterior limitation of motion on the upper
poles and anterior limitation of motion on
lower facets. Thus in good diagnostic procedure, it is most important to do the best
job to get best results for the patient,
and one must definitely analyze this articulation to determine the type of lesion
that is found so it can be accurately corrected.
The seventh point is the lumbosacral
articulation: This articulation is fundamental as It is at this point that there is
a transmission of the weight from a singular structure (the spine) to a larger or
diffuse structure for the transference of
the weight thrust down both legs into the
feet. We note that in lesion at this articulation, the fifth lumbar must first go
anterior before it rotates. This is quite
significant, for in postural analysis in
order to help us analyze what has taken
place at this particular articulation, it
is necessary for us to make sure that we do
a standing lateral X-ray.
The eighth point is the remainder of
the spine and upper extremities, which many
men have talked and written about. Therefore, we will not include an explanation
here, but we would be willing to show technique of any of these articulation if you
so desire during our manipulative phase of
the evening.
At this point, I would like to explain with the aid of our charts what we
mean by postural integrity. This commences,
as you will note in the first chart with
LATERAL
ASPECT
ANTERO POSTERIOR
ASPECT
CENTER OF GRAVITY FALLS‘
MIDWAY BETWEEN ANKLES
GRAVITY LINE PASSES THRU
ASTRAGALO SCAPHOID JOINT
Figure 1
the normal position of weight balance as It
is transmitted through the posturally perfect individual. As you will note, we find
the feet in straight alignment with the
ankles, knees, hip joints, lumbosacral articulation, the square hips, the square
shoulders, and the straight head. In the
lateral view, we note that the center line
of gravity passes through the astragaloscaphoid joint, through the knees, the hip
joints, the shoulder joints, and the occi-
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220
pita1 articulation--thus giving us a posturally perfect individual. But then what
happens.
First let us consider the differences in postural alignment attributed to
many different defects in the developmental
growth of the Individual or injuries which
create an anatomically short leg. We have
found, through our years of work and research, that 60% of all the people we have
examined in schools, colleges, lecturing
to luncheon groups, as well as our own
practice, have short legs and this figure
has been upheld by those figures found by
other schools of practice.
By the next two charts we will show
you what happens. In the first place, we
ALTERED LATERAL EQUILIBRIUM
SINGLE TOTAL CURVATURE
SCOUOTIC CURVATURE
ALTERED LATERAL EQUILIBRIUM
GROSS SCOLIOTIC CURVATURE
GRAVITY LOAD DEFLECTED TO LONG LEG
Figure 3
Figure 2
can have one leg shorter than the other and
still have the center line of body weight
held equally between our two feet, and have
what appears to be normal feet, but we see
a difference in the heights of the hips and
in some instances, a difference in the
heights of the shoulders as well as some
who have square shoulders. The defect discovered most frequently was termed as a
function curve of the spine.
Then we must take into consideration those people who compensate for the
defect of the short leg. In a single type
of total curvature, this type of individual
having a short leg (let us say on the left)
has the greatest amount of weight projected
on the long leg, thus creating an inversion
of the right foot and an eversion of the
left foot. We also find a compression on
the outer side of the right knee and the
medial side of the left knee. We will also
note a difference in the heights of the
pelvis, with the right side high and the
left low. Usually in this type of case,
we find the shoulders will tip in the opposite direction, the right shoulder being
low and the left high, and the head is
tilted toward the high shoulder or to the
All Rights Reserved American Academy of Osteopathy®
short side.
In the scoliotic curvature, we note
some changes in this, but the main change
Is found in the amount of curvature to the
spine, for as in the single total curvature
type, we find a greater amount of the weigh
being thrust on the long leg, and again the
inversion of the right foot and eversion of
the left. The same compression in the knee
exists, the same change in the heights of
the hips, the right being higher than the
left with a side sway toward the left or
short side. We also note a greater curvature, which usually is of an "S" type, with
the right shoulder low and the left high,
and again the head is tilted toward the
high shoulder--but It rotates toward the
low side.
In the gross scoliotic curvature,
our best explanation of this condition, is
that nature has compensated. It compensates by shifting the body weight from the
long leg side to the short leg side, and
in this case we see an eversion of the foot
on the short leg or left side, and inversion of the right foot; the same type of
compression at the knees on the inner side
of the short leg and outer side of the long
leg; a low left hip with a side-bending to
the long leg side; with the corresponding
low right shoulder and high left shoulder;
and with the head tilted to the low shoulder and rotated toward the high side or to
the left.
Of course, one can take the various
types of individuals from those who are the
long, lank, and lean type to the short,
obese type, and in these we have a change
of body weight in its antero-posterior equi
librium. It is this type with its complications of the scoliotlc type as well as
those who produce a torsional or twisting
curvature that are the most severe types to
take care of in our office and get results.
It is here that I must bring forth
a word of warning. We must remember in tak
ing X-Rays of our postural patients that we
have approximately 35% to 50% error in the
standing position in the AP as well as on
the laterals. When we analyze these particular films, we must consider that the
only help that these X-rays can give us is
in showing to us the amount of shortness in
the leg and the amount of change in normal
angle of the lumbosacral articulation, also
the amount of bone pathology. We cannot,
221
from our X-rays, determine the amount of
lateral deflection, the amount of torsional
deflection, or the amount of antero-pos-.
terior deflection. Therefore, our analysis
has to be made up from some other source
or instrument to be able to determine what
procedure we should follow to take care of
our postural patient.
Another consideration that has to be
taken into account is the shoe problem, for
when we take X-rays of the patient's feet,
they are taken in stocking or bare feet;
and shoes, with their differences of construction, heel heights, and materials, alter the position of weight thrust. Therefore, may I again say to you that your analysis of the entire problem is only as good
ALTERED ANTERO POSTERIOR EQUILIBRIUM
GRAVITY LOAD DEFLECTED ANTERIORALLY
Figure 4
as your visualization of the information
the patient has given you and what you
have found; and the correlation between
the patient's symptoms and complaints and
your findings.
All Rights Reserved American Academy of Osteopathy®
222
ALTERED ANTERO POSTERIOR EQUILIBRIUM
WEIGHT DEFLECTION ANTERIOR
ABDOMINAL OBESITY
WEIGHT DEFLECTION POSTERIOR
ABDOMINAL OBESITY
Figure 5
I would like to leave you with this thought: Our heritage given to us by Dr.
Andrew Taylor Still, makes us superior in the healing arts, and thus we should be proud
that we are osteopathic physicians, for an osteopathic physician using manipulative
therapy, has no competition. Only those who use other competitive therapies have to
worry about what the other fellow is doing.
NOTE:
Postural Charts used with this article were prepared and copyrighted by Institute of Postural
Mechanics and Chas. A. Roberts - 117 E. Fifth, Austin; Texas. Courtesy of C. A. Roberts.
All Rights Reserved American Academy of Osteopathy®
ACADEMY OF APPLIED OSTEOPATHY*
HONORARY LIFE MEMBERS
Louisa Burns
Harrison H. Fryette
Thomas L. Northup
LIFE MEMBERS
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* As of December 20, 1948.
223
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Auld, J. Myron Jr.
Axtell, Hazel G.
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224
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Jr.
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Churchill, A. G.
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Clark, Clyde A.
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225
Clark, J. Ione
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Coker, R. Philip
Cole, Wilbur C.
Coles, Charlesanna B.
Collinge, P. T.
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Cook, Carl M.
Cook, S. W.
Cornell, Philip H.
Corwin, S. G.
Cosner, E. H.
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Coulter, Lawson B.
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Craig, D. E.
Craig, Ralph B.
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Crismond, Joseph J.
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Cunningham, E. Jane
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custis, w. w.
Daily, Dar D.
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Daniels, Lester R.
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Darling, W. E.
Darnall, E. C.
Davis, C. J.
Davis, H. Edward
Davis, Harry L.
Day, Robert L.
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Diebold, Wendell
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Dinges, Ransom L.
Dinkler, J. F.
Dobbs, Elizabeth
Doddridge, Frank E.
Dodge, F. Chandler
Dohren, Lester G.
Donovan, J. B.
Dorman, Stanley
Doron, Chester L.
Dorrance, R'. Gilbert
Downing, Bradley C.
Downing, Wilbur J.
Doyle, L. A.
Drennan, Quintus L.
Dressler, Otterbein
Drew, Howard A.
Drinkall, Earl J.
Du Mars, A. E.
Dunkelberger, L. Roy
Dunlap, Emmett E.
Dunn, Arthur V.
Dunn, R. Kenneth
Dunning, Helen M.
Dunning, J..J.
Dunnington, Wesley P.
Durham, A. D.
Dye, Arthur M.
Earley, John W.
Ebert, Kenneth B.
Eckhoff, P. F.
Edmiston, S. Cameron
Edmiston, T. Burton
Edmund, John Martin
Edwards, F. O.
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Edwin, E. S.
Eggleston, Allan A.
Elmerbrink, John H.
Elbert, J. W.
Elderkin, Emma C.
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Elliott, Gordon L.
Elliott, Virgene
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Ellis, Sidney A.
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Englehart, W. F.
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Facto, Lonnie L.
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Fagen, Lester P.
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Farquharson, C. L.
Farquharson, Lester M.
Farran, R. S.
Farrar, J. M.
Fehr, Allen F.
Feige, Richard
Fenner, Edwin C.
Ferris, Ruth
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Field, Howard M.
Fielding, Anne M.
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Fish, A. V.
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Fleming, Thomas A.
Fleck, Charles E.
Fletcher, Daisy
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Flynn, J. P.
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.
Forbes, J. 'R.
Foreman, Oliver C.
Forrister, R. M.
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Fox, John H.
Fraker, J. Franklin
Frankowsky, Erich
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Freeman, Beryl
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French, Paul O.
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Fuller, George S.
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Gamble, Mary E.
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Gettler, Ferd C.
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Gillies, Mary Eleanor
Ginn, Christopher L.
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Glenn, H. V.
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Goddard, Francis D.
Goehring, Frank L.
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Golden, Mary E.
Goldner, J. Henry Jr.
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Gooch, Robert E.
Goode, George W.
Goodfellow, W. V.'
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Gordon, R. B.
Gordon, W. C.
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Gravett, H. H.
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Green, Charles S.
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Grieves, M. J.
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Handy, 'Chester L.
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Hard&n, J. Ella
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Harman, D. C.
Harris, Frances W.
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Harrison, Leo C.
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Hasty, W. A.
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.
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227
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MacCracken, Frank E.
MacDonald, Ernest R.
MacFarlane; Thomas Jr.
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MacGregor, P. J.
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Money, J. V.
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Moore, Albert G.
Moore, Ernest M.
Moore, Floyd
Moore, George P.
Moore, Riley D.
Morehouse, P. R.
Morelock, Isabelle
Morelock, Josephine E.
Morgan, I. N.
Morgan, Thomas L.
Moriarty, Lucile M.
Morrill, Wm. J.
Morrison, Carl
Morrison, David
Morrison, James G.
Morrison, Martha B.
Morrison, Thomas H.
Mossman, Edward C.
Mossman, Luceo
Mulford, J. W.
Mullet, Sevilla
Murphy, F. J.
Murphy, G. Glenn
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Naylor, Stephen G.
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Nelson, C. R.
Nelson, Ellen
Nelson, Frank C.
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Newell, John R.
Newland, W. A.
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Nicklas, H. W.
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Noble, Lillian W.
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Norwood, R. W.
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229
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Purdy, V. W.
Purtzer, O. R.
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Sharp, F. C.
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Slaughter, Betty
Slocum, Anna L.
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Smith, Charles K.
Smith, E.. *Claude
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231
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DECEASED 1948
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Crane, Ralph M.
Laughlin, George H.
Martin, Lewis D.
McGowan, A. L.
Nye, Carlos
Rice, Ralph W.
Sullivan, Anna
Turfler, Francis Sr.
Ulrich, N. A.
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