Principles of Osteopathy
Dain L. Tasker, D. O.
CHAPTER VII - The Nervous System (Continued)
Alignment, Tone, Reflexes. - Osteopaths have,
to some extent, discarded subjective symptoms, believing that they are
of very doubtful value in the large proportion of patients. Having
discarded subjective symptoms, they have developed a method which gives
equal or better results. It has three phases, two of which are structural
and one which is partially subjective. First in order comes skeletal
alignment; second, muscular tone; third, condition of reflexes. These
three divisions all come under the general head of palpation.
Clinical Illustration. - As an illustration
of the value of objective in preference to subjective symptoms, the following
case is of considerable value. The gentleman whose physical condition
is practically illustrated in Figs. 20 and 21 was examined in the clinic
of the Pacific College of Osteopathy. He has been operated on surgically
for a peculiar enlargement just above and external to the right knee .
The line of the incision is shown, in Fig. 20. He stated that he
had suffered pain at this point during more than a year, and his physician
had decided that there was a tuberculous condition of the bone. The
operation did not confirm this diagnosis. No unhealthy tissue was
Inspection. - We noted his peculiar handling
of the leg when walking, compared both limbs from toe to hip and discovered
a marked difference in size, as is indicated in the photograph. By
following the course of the nerves to the spinal column, we discovered
that the muscles on the right side of the spine are atrophied in proportion
to those of the extremity. Fig. 21 shows the fact that the atrophied
condition extends into the interscapular region, and the spinal column
Patellar Tendon Reflex. - The patellar tendon
reflex was lost on the right side, but present on the left. The right
leg was ataxic, but the left leg was normal, thus presenting what might
be called a unilateral locomotor ataxia. If this man's surgeon had
taken the care to examine him from an objective structural standpoint rather
than to depend on the subjective symptoms, it is highly probable that no
operation would have been performed. Our examination demonstrated
that this man's structural condition was at fault and that the trophic
influence of a part of his nervous system was being gradually lost.
Both the motor and sensory nerves were acting feebly.
Gastric-spinal Reflex. - It might be asked,
"How could one secure a spinal reflex from the stomach?" In what way would
the finding of such a reflex surpass ordinary methods of examination?
The neurologist, when making examination of a patient suffering with some
condition of the sensory or motor portion of the nervous system, must possess
a definite knowledge of the origin, course and distribution of nerve trunks
in order to locate accurately the position of the lesion. The osteopath
pursues the same method of examination, but follows it farther. His
investigation takes into consideration the dispersion of efferent fibers
in the sympathetic system and the sensory impulses received by the spinal
cord from that system.
Sensation. - Edinger quotes Exner as follows:
"One must not suppose that all the impulses reaching the spinal cord by
the sensory roots are identical with what is ordinarily called 'sensation.'
In order that an impression be perceived, it is not sufficient that it
be conducted to the spinal cord, but it must be farther carried up, from
the place where the peripheral part ends to the cerebral cortex.
There is, however, no doubt at all that all these higher connections are
few in number, and that contrasted with the multitude of fibers in the
posterior roots, the number of such cranial connections is quite small.
This alone makes the conclusion possible that there are, indeed, many sensory
impressions which arrive at the spinal cord, but that we are aware of but
few of them at the time. All the viscera of the body, as the staining
method has distinctly shown, are traversed by an altogether unexpectedly
large number of nerves and their arrangement and course, their relations
to blood vessels and glands, and to muscle fibers, bones and enamel, makes
it more than probable that there is, in this connection, a large system
which serves essentially to regulate impressions and reflex action."
Visceral Sensation. - It is the reflexes mentioned
in this quotation in which we are interested. Sensation and perception
are dissimilar. Sensations from the viscera are co-ordinated in fairly
well marked areas of the spinal cord and when these sensory impressions
are intense the efferent fibers of the spinal cord manifest the condition
existing in a visceral area by causing an abnormal condition of muscular
tone in the intrinsic muscles of the back. This contractured condition
of the muscles is not the only evidence of the visceral reflex. Pressure
on the contracted muscle causes pain. The intensity of the aesthesia
is usually in proportion to the visceral irritation. Even though
the patient does not say in so many words that there is pain on slight
pressure, the examiner, if his palpation is good, can detect the reflex
in the action of the muscle.
Dependence on Objective Symptoms. - A patient
comes to an osteopath desiring to be examined. He does not vouch-safe
any information as to his condition, merely saying: "I want you to examine
me and find out what is the matter with me." This is a challenge to the
skill of the examiner and calls for something besides a long-distance catechising
as to subjective feelings. The osteopath proceeds with absolute precision
to determine the condition of his patient's structural formation - (1)
skeletal alignment, (2) muscular tone, and (3) segmental spinal reflex.
Each yields valuable information. The examiner's fingers may develop
a reflex around the sixth dorsal spine. This is noted as a reflex
from the gastric area. Testing the segments above and below, this
will show how great a section of the cord is irritated and will be an indication
of the extent of the internal irritation, i.e., whether other portions
of the digestive tract are affected. The reflex might extend as far
as the fourth dorsal and still indicate the gastric area. Finding
the reflex at the sixth dorsal spine has directed the attention of the
examiner to the gastric area and has located a point from which further
examination is to proceed. Percussion over the stomach would reveal
other facts, and then the examination would be pursued along general lines
of physical diagnosis to determine the character of the gastric disorder.
The moment the examiner centers his examination on the stomach, the confidence
of the patient is assured. Is not this confidence greatly to be desired
in every case? Is it not a force which compels the patient to follow
the directions of his physician in matters of diet and hygiene? In
this example we have illustrated the attributes of nerve tissue, (1) irritability,
(2) conductivity. Other conditions which make this illustration possible
are (1) muscular contraction in response to nerve stimulation, (2) segmentation
of the spinal cord, (3) reflex action.
Depth and Extent of Lesions. - From the clinical
standpoint lesions may be classified somewhat according to depth and extent;
for example, the lesions which are due to trauma of somatic tissues, involving
one spinal articulation, would be deep and as soon as the patient is placed
in a position of rest, the extent of the muscular contraction would greatly
decrease. This is not the case when the lesion is due to a visceral
irritation. The viscus has a pluri-segmental connection with the
nervous system and hence the contraction of muscles in the spinal area
is usually of greater extent. The position of rest, i.e., reclining,
does not usually cause the muscles to relax. This shows that the
contraction is not a normal effort to maintain the upright position but
a hyper-tension due to visceral disturbance.
Lesion Picture in Autotoxemia. - As soon as
we have an autotoxemia to deal with our lesion picture is greatly enlarged.
This is well illustrated in the various manifestations of indigestion.
In such cases, not only lesions in the areas segmentally associated, but
also above and below, will be found. Some cases will complain of
the whole length of the spine while the autointoxication is at its height.
As the intensity of the autointoxication decreases the lesion areas become
restricted to the physiologically associated spinal areas. This is
true in the infections as well. The backache in tonsilitis, la grippe,
smallpox, etc., are well known and evidently not located in physiologically
associated areas. The phenomena of spinal hypertension and hyperaesthesia
are very prominent in these cases. Nothing seems to palliate this
spinal condition due to toxemia to the same extent as manipulation.
We say palliate because the toxemia which causes the tension is not overcome
by relieving the spinal tension.
Lesions Independent of Segmental Reflexes.
- As soon as we find lesions that seem to have arisen independently of
what we can readily recognize as segmental reflexes, they must be explained
on the basis of some integration of the body other than nervous.
This is the case in the toxemias. The circulating media are the integrating
factors which explain the backache as well as many other aches in those
cases where there is no visceral involvement which may reasonably be associated
with them. Increasing elimination will usually correct these spinal
lesions due to toxemia.
The Lesion as an Expression of Some Form of Integration.
- Any spinal lesion may be analyzed from several standpoints, because it
may be a partial expression of one or more integrating factors of the body,
i.e., the structural, circulatory or nervous. The traumatic lesion
shows itself subject to position, i.e., can be rested and lessened by a
position which mechanically lessens the strain. The lesion due to
nervous integration is not so quickly relieved by the means which relieve
the traumatic lesion. The fact that it is a reflex presupposes an
adequate point of irritation elsewhere. This point must be located
before the lesion is adequately relieved. This is well illustrated
in the reflexes in the mid-dorsal area due to fermenting food in the stomach.
Emptying the stomach relieves the lesion.
Circulatory Integration Lesion. - The lesion
due to circulatory integration is hard to recognize because one naturally
thinks of the other forms of integration and attempts to square his findings
with these forces. Then also the circulatory integration is largely
under the direct influence of the nervous system. It is a good plan
to analyze lesions first on a basis of structural integration, then nervous
and finally circulatory. This evolutionary method of following a
natural plan helps to keep ones mind working in a logical manner.
Protective Reactions. - The protective reactions
of the body are not all segmental nor even within small groups of segments.
So long as they are purely segmental we are reasonably certain that the
condition is not constitutional because a constitutional ailment involves
the whole fighting power of the body to such an extent that the clinician
readily recognizes the seriousness of the situation. Take for instance
the progressive involvement of lung tissue in tuberculosis. The early
stages of the disease may show very little or no constitutional symptoms
such as chill, fever, sweat and loss of flesh. At this time somewhere
in the interscapular area will appear a lesion, muscular contraction and
tenderness to digital pressure. This lesion is not distinctive of
pulmonary tuberculosis any more than of any other irritation in its associated
visceral area. It merely indicates the segment or segments involved
in the circulatory disturbance characterized by the congestion in the infected
area. As the pulmonary lesion involves larger areas the spinal lesion
grows proportionately. This is probably true except when the pleura
is inflamed. Then we have a protective rigidity of a vastly more
pronounced character. As soon as effusion takes place the intensity
of the rigidity lessens because pain is lessened. As soon as the
tubercular process shows constitutional symptoms the spinal lesion picture
varies from morning to night, that is, fluctuates with the varying intensity
of the disease reactions. The positive and negative phases of the
body's reactions are reflexly evidenced in the spinal areas. As the
disease progresses and areas of pulmonary tissues are lost or fibrous tissue
formed, with consequent lessening in antero-posterior diameter of the chest
and decreased amplitude of the respiratory movements, lesions of a structural
character appear in the spinal area, such as flattening of the dorsal curve
and elevation of the angles of the ribs caused by the rotation downward
of the anterior extremities of the ribs in the flattening of the chest.
The change in the chest causes a change in the tension of the scaleni muscles
in the neck and in case only one pulmonary apex is involved there is unequal
tension in the scaleni of the two sides of the neck, thus causing the extensors
of the neck to exert a compensatory action. The change in cervical
vertebral alignment and muscular tension constitutes in this instance a
spinal lesion which is properly compensatory and therefore not helped by
corrective movements. Many such lesions, profoundly compensatory
in character, should receive no direct corrective manipulation. Since
they are dependent upon tissue involvement elsewhere we must make our diagnosis
from cause to effect in order to get our therapeutics in right sequence.
Pains Incident to Chill and Fever. - The headache,
neckache, backache and legache of chill and fever are subjective symptoms
prominent in a host of cases. These symptoms are of varying intensity
but even when not complained of, a tenderness in the neck and back is readily
elicited by digital pressure. As the fever subsides these areas of
sensitiveness to pressure grow less and less, showing that their great
extent in the beginning is a constitutional condition. It is readily
recognized that our spinal lesion in pulmonary tuberculosis has changed
with each phase of the disease. This is probably true of all diseases,
hence there is no fixed lesion associated with any visceral or somatic
disease. A slightly varying set of reactions accompanies each disease
process. These reactions are usually true to type but not capable
of classification except in a general way. The organs of the body
are innervated from fairly definite areas of the cord and we speak of these
as nerve centers, but as before stated these centers consist of cells placed
vertically and extending through several segments. The spinal lesions
found in visceral disease are hence pleuri-segmental and, if there is toxemia,
there is a set of lesions expressive of this condition superimposed on
the first, then, in case of destruction of tissue, compensatory changes
in structure are noticeable. The three major forms of integration
are involved in any severe illness and hence the diagnostician must try
to separate the various evidences of the body's protective reactions.
The greater variation will be in those symptoms due to circulatory integration.
This is evidenced by the rapid changes in cases of autointoxication.
The lesion which is characterized by its, persistence will be located in
that seg-ment or segments most closely allied with the center of visceral
disturbance. The lesion of still more permanence will be the primarily
traumatic or secondarily compensatory.
The Practical Use of Knowledge. - We have
added nothing new to the world's knowledge of nerve tissue, but we have
applied general knowledge of this tissue to specific uses. We have
taken the results of laboratory experiments and made them practical methods
in the detection and alleviation of disease. It appears to us that
sufficient research work has been done on the nervous system by medical
men and sufficient general conclusions drawn from their investigations
to justify all branches of the profession in making more extensive use
of such data. The correlaion of laboratory data with the results
of clinical experience make the foundation of osteopathic diagnosis at
the present time. By this bold application of knowledge, which by
the medical profession at large has been regarded as speculative and at
least impracticable, osteopathy has gained an impregnable position in the
Laboratories make scientists, not physicians; hence
physicians have not always grasped the full significance of the scientific
discoveries in physiology and applied them to therapeutics.
Whatever osteopathy may at present possess or gain in the
future, is due solely to a close adherence to the facts of anatomy and physiology;
and the application of these fundamental facts to scientific therapeutics.