The Principles of Osteopathic Technique A. S. Hollis, D.O. 1914     THE BASIC PRINCIPLES OF OSTEOPATHIC PRACTICE  

    In presenting the following discussion of certain fundamentals of osteopathic practice we shall attempt to make clear and definite a few main thoughts that lie at the very foundation of our Science.  Unfortunately Osteopathy has frequently been judged by its opponents on the ground of several misrepresented fundamentals and the claims of the Science have been disregarded, because some of those fundamentals were often apparently at variance with known anatomical facts.  In every new Science a difficulty, such as this one, is found, and it is only when the basic ideas are stated with extreme accuracy and exactness that any claim to scientific precision can be made for them.  We shall attempt herein to a state our ideas with as much clearness as possible, so that whether or not out readers agree with the contentions put forward they cannot but grasp the thoughts and follow the lines of reasoning.
 

The Lesion.

    The first conception that we wish to determine clearly is the lesion.  What is the lesion?  How widely are we justified in applying that term from the osteopathic viewpoint?  Do the commonly accepted ideas of the lesion clash with the Anatomy of the spine as we know it?  In answer to these and similar questions we would say that an OSTEOPATHIC LESION is a condition which is found in the spine associated with disease and serving as a causative factor of it.  It is an abnormal condition
of the ligamentous and other articular structures of such a nature that the movements between the vertebrae become perverted.

    This definition is designed to emphasize the essential nature of the condition which is under discussion, and this is that some PERVERSION Of MOVEMENT is the MANIFESTING FACTOR in a lesion.  This perversion may be in the nature of an excessive amount of movement, though this is rare, or it may be in the nature of a deficient amount, and this is very commonly the case.  Such a condition, namely a deficient amount of movement between the vertebrae, is called RIGIDITY.  Hence, RIGIDITY is the essential feature of most osteopathic lesions.  Now rigidity between articular surfaces means that the ligaments and the synovial membranes, etc., of the articulation in question have become thickened and perverted in their nature to the extent that THEY limit the normal movement.  Hence the essential pathology of an osteopathic lesion is to be looked for mainly in the articular structures themselves, though also we may look for it in the ligaments that elsewhere bind the vertebrae together, such as the common and the supraspinous ligaments.  We need do scarcely more than merely mention the fact after what has been already said, that any "bony" lesion will be manifested by limitation of movement WITHIN THE RANGE OF THE NORMAL MOVEMENT OF THE VERTEBRAE AFFECTED.  We mention this to combat the thought of the "dislocated" vertebra, that is to say, the thought of a vertebra wrenched beyond its normal range of movement; for as soon as such a "lesion" is found it is analogous to a dislocated ankle and should be treated in a manner similar to such a condition.

    A question naturally arises as to the causative factors underlying the reduction of lesions, and on careful analysis we find that we may accurately speak of two main types.  These we might name: (a) primary, (b) secondary.  By a primary lesion we mean either one that is developed spontaneously owing to a certain architectural weakness that seems inherently to cling to man's spine, and this is due largely, in all probability, to his upright position; or one that can be traced to some trauma.  A secondary lesion refers to a contracture of the musculo-ligamentous structures of the back, owing to a toxic congestion that occurs concurrently with acute troubles in the body.  In a somewhat different sense, the term "secondary" is often applied to lesions that occur in the neck and back as a result of and to compensate for lesions lower down.  Lesions of such a nature, and they are common, will themselves remain corrected only if their primary lesions be thoroughly worked upon and adjusted.  This is a strong argument for working from below upwards when giving a treatment, which indeed should always be done.  By working this way these "secondary" lesions will often adjust themselves to a great extent.  The main point we would emphasize here is that an osteopathic lesion will be manifested by a lessened degree of movement in the majority of cases; these will always be SOME PERVERSION OF MOVEMENT and generally also some tenderness will be found on attempted motion.
 

Adjustment.

    A thought that demands a word of explanation at this point is: granted that such be the case, what does the Science of Osteopathy suggest as a curative procedure?  The answer is that osteopathic practice aims to RE-NORMALIZE ABNORMAL TISSUES.  We may use to advantage in this connection the expression "adjustment," as being a fitting term to express what Osteopathy aims to accomplish.  What is meant by this is that a certain normal standard is regarded as existent for every individual spine, and that if there are found present variations from that standard it is the work of the osteopathic physician to NORMALIZE those structures and, thus to give free play to Nature and to Nature's processes.  It is well to remember that Osteopathy was founded on the premise that Nature is striving for each one of her children to be well; health is normal, and if not present there is but one reason, namely that somehow Nature's attempted efforts are being thwarted or are not being afforded free play.

    The striking feature of osteopathic practice is of course the manipulative procedures employed, but if we associate the term "adjustment" with Osteopathy, we must see that any methods which will harmonize with Nature's efforts to produce normal conditions are strictly to be concluded under the heading of the osteopathic principle.  We must aim not only to adjust the individual parts of the organism in order that harmony may result within and without, but also we must adjust the organism
to its environment.

    In correcting abnormalities in the organism the attempt is made to drive away congestion, to dissipate and absorb excess tissue that may have proliferated around the articulations of the vertebrate, to stretch and otherwise normalize the capsules surrounding the articulations of the vertebrae, and to reestablish generally a normal condition of the vertebral tissues.

    In other words, to the extent that we "adjust" the tissues of the vertebral column to the normal, are we employing the essential feature of osteopathic practice.  Many times in using manipulation a "pop" is heard between the articular surfaces.  This is due to the separation of those surfaces and is not of supreme importance in itself.  In fact, the more strictly normal an articulation is the more readily, frequently, it can be "popped."  In other words, if a pop can not readily be obtained between almost all the vertebrae, there are generally but two explanations possible.  One is that the line of force used was not properly
applied, and the other is that the tissues so congested and the ligaments etc., so thickened that the force applied was insufficient to cause a separation of the articular surfaces.  At this point we would simply mention the fact that too frequent popping of vertebral articulations (and especially of those in the neck) undoubtedly causes irritation and is itself productive of considerable harm; also in some people there is present so lax a condition of the connecting tissues that the vertebrae pop at the slightest provocation.  Many osteopathic movements do not produce a "pop," and in these cases the force is applied directly in the line of the plane of the articulation and the principle employed is analogous to that employed in breaking up adhesions in one of the large joints of the body.

    The exact mechanism whereby the osteopathic lesion produces its effects upon the nervous system is hard to determine precisely.  Concerning two facts we may probably feel fully assured, and they are: (a) that any trouble that may result from or be associated with osteopathic lesions, is produced by some vascular changes occurring around nerve cells; these cells being either in the cord itself or in the sympathetic ganglia; (b) that direct pressure upon the nerve trunk or upon the blood
vessels in the intervertebral foramina is a negligible factor in the production of disease.  We are not in this latter connection denying the possibility that the vessels may become contracted in size in the intervertebral foramina; they may conceivably do so, but if they do, that condition is produced by an irritation of their vasomotor cells, and not by direct pressure.
 

Classification of Lesions.

    We are now ready to discuss somewhat more fully a point that we have touched upon above, viz: The types of lesion that may be found.   Under this heading we have suggested the following classification: Lesions may be (a) primary; (b) secondary.  Primary lesions may themselves be (1) traumatic, or due to extraneous force;   (2) idiopathic, or self-originating.  Secondary lesions are reflex from toxic conditions or inflammatory processes elsewhere in the body.    This latter type of lesion we will consider more fully when discussing the relation of the lesion to acute diseases.  About primary lesions we may to advantage say a little right here. The term traumatic is self-explanatory, though the lesions to which this term may be applied are comparatively rare.  However we see examples of this lesion especially in the Innominate articulation.  Indeed perhaps the majority of innominate lesions are traumatic in origin, that is, the symptoms arising from them date from some injury that was directly felt by that joint.  The idiopathic lesions form probably the large majority of lesions met with in clinical practice.  They
develop in the spine because of its peculiar structure, and because of a certain inherent architectural weakness existent in the spine of man in his upright position.  They are important because of the proximity of the spine to the nervous system and by their presence oftentimes is produced an irritation of the nervous system which may manifest itself as a disease of some organ or part.

    We would here again call attention to the necessity of distinguishing between the initiating primary lesion and any that may be present as compensatory to it.  These latter will never respond to treatment until the former are thoroughly adjusted.

    OSTEOPATHY IS NATURE'S METHOD OF CURING DISEASE, and we find therefore that the logical scope of osteopathy includes all diseases rationally curable by Nature’s own processes.  The osteopathic physician is entitled to use, in addition to his manipulations, common sense aids, such as the enema, dietetics, antidotes, hot and cold water, etc., but these do not constitute any essential feature, of his especial curative methods. The surgeon realizes the value of anaestheties and employs them, but an anaesthetic is not any special possession of the surgeon.  An osteopathic physician who refuses to give or advise an enema occasionally is as foolish as a surgeon would be to refuse to allow a patient to take an anaesthetic because this latter was not strictly along the line of his individual work.

    The scope of Osteopathy is very broad and it is easily seen by following the line of thought suggested that acute diseases rationally fall into the field of osteopathic practice, for it is universally recognized that normally an acute disease is self-limited and the up-to-date physician trusts to this fact almost exclusively while employing ordinary hygienic procedures.  Those procedures we are as entitled to use as is the medical man and hence even if our peculiarly specific work, the osteopathic manipulations, was of no avail, we should at least be as well equipped as is the medical practitioner.  That the osteopathic manipulations are of GREAT and STRIKING value we will attempt to prove a little later in this article.  Except in a very few acute diseases the pathology in the early stages is such as readily to be dissipated by natural means, and to the extent that this can be done, excellent results will follow.
 

Pathology and Prognosis.

    The next thought that we would suggest for consideration is the relationship that the pathology of a disease bears to the prognosis of that disease, and in this connection we wish to quote from an article by the writer in the Bulletin of the Atlas and Axis Clubs for October, 1912.  We reproduce the following excerpts:

    "It has been well said that Pathology determines the Prognosis of Disease, and that the limits of every therapy are set with absolute precision by the Pathology of Disease.  By this we mean that in diseases causing structural changes in the organism, the possibility of cure is determined by the extent of those changes and by the degree to which Nature can compensate for them.  Underlying this thought is one that is of great importance; indeed upon its validity the very rationale of therapy depends.  We refer to the apparent EXTRAVAGANCE AND PRODIGALITY with which in most cases Nature has provided the various tissues of our bodies.

    "Surgically and experimentally it has frequently been demonstrated that the human body can maintain an unimpaired functional integrity with one kidney extirpated, with one ovary or one testicle removed, or with a portion of the stomach or a section of the intestine taken out.  We know that in a healed tubercular process of the lung, the cure is brought about by the complete obliteration of the involved portion of the lung, with its transformation into solid nonfunctioning connective tissue.  If it was not for the compensating mechanism within our bodies, which is dependent entirely upon this apparent prodigality of Nature, no cure of an organically involved structure would be possible.  In a word, it is the fact that Nature has provided in most parts of the human body tissue in excess of that needed for bare functional necessities that enables that body to react to organic disease at all.

    "In many diseases that are 'cured' by some therapy we find on close investigation that the functional integrity of the part that was involved has been restored, though the anatomical relations are perverted and permanently disturbed.  Indeed this is found in the majority of diseases in which structural changes have been wrought.  It is this phase of the curative process that is dependent upon the prodigality of Nature mentioned above.  Nature thereby is able to draw on the excess functional tissue and thus to reestablish a physiological integrity.

    "The diseases that are OSTEOPATHICALLY CURABLE we believe are coextensive with the limits of Nature's ability to react to a pathological process, which means that this class includes every disease in which the pathological process has not advanced to such a stage as to be beyond Nature's own reactive power.  In other words we believe that this class includes all diseases in which Nature has not been perverted beyond her limits of compensation.  What is curable from Nature's standpoint is curable from the standpoint of Osteopathy, for we look upon them as synonymous.

    "From this standpoint it might be asked why Osteopathy is powerful in combating disease.  We know, from clinical experience, that there is developed around the articulations of the vertebrae a tissue perversion either antecedent to or concomitant with disease of the organism elsewhere.  This tissue perversion is manifested by impaired mobility of the spine, and the restoration of a normal degree of movement between the articulations means that the tissues have been normalized in this region.  NATURE WANTS US TO BE WELL and she is able to function perfectly, provided she is not taxed beyond her capacity for reaction.  By restoring normal movement in the spine we give Nature, in very many cases of disease, the necessary assistance to enable her to combat the condition successfully."

    The line of thought that we have been following naturally leads us to the determination of the relation that must exist between the osteopathic lesion and acute and chronic diseases.  We would also discuss briefly the relationship that Osteopathy bears to Surgery.
 

Osteopathy and Acute Diseases.

    There are many factors that cooperate in the production of disease in its acute stages; for example, if we take a concrete instance of Typhoid Fever, it is well known that there are several such causative factors at work.  The age of the patient, the season of the year, the dietary habits, previous mental or physical strain, the typhoid bacillus, etc., all are important as factors to be taken note of.  It is true that an idiopathic lesion is very frequently present as a cause of the rundown nervous system,
but it need not necessarily be so.

    The disease itself is manifested by a series of effects.  Indeed every disease presents a fairly typical picture, upon which the average practitioner bases his diagnosis.  The "effects" are looked upon as "symptoms" of the disease, though to what extent they are really so will be seen in a moment.  Suffice it for the present to say that an abundance of toxin is produced by the infection and that the majority of symptoms are symptoms of toxic poisoning.

    What then is the relationship that exists between Osteopathy and an acute infection?  It is this: Many of the symptoms that are commonly regarded as symptoms of the disease are in reality symptoms of a secondary osteopathic condition which arises owing to the toxic infection and which by its persistence maintains that infection by preventing a free elimination of the toxin.  This secondary condition is placed midway between the "cause" and the "effect," and it is this factor that the osteopathic physician works upon.  A "good treatment" will relieve very materially many of the symptoms of the disease, because many of the symptoms are really effects of the secondary osteopathic condition.  Thus the aching will be eased, fever will be mitigated, the bowels will be regulated, etc.

    Thus the osteopathic physician is able to handle acute diseases better than a medical physician because not only can he employ the same hygienic methods that this latter physician employs, such as the enema, the bath, dietary restrictions, rest, etc., but also he has it in his power to combat an extremely important secondary causative factor that the medical man is ignorant of.  If we glance at the "circle of causes" as represented in the accompanying diagram we may ask which of them a medical man can attack?  Can he affect the age of the patient, the season of the year, the previous dietary habits, the mentally or physically rundown condition present, or the typhoid bacilli?  The answer is obvious, and indeed his inability to combat the majority of these factors has driven him to attempt to overcome the last mentioned.  The failure of attempted "sera" is too well known to need comment in this connection.  The osteopathic physician, then, is from every standpoint as well equipped to handle acute infections as is the medical man, and from the standpoint of his own specialty he has a lever that raises him into a class entirely by himself.  We wish it to be clearly understood that Osteopathy does not claim that typhoid fever is caused by a displaced vertebra or by a slipped rib, but it claims that such a factor oftentimes causes sufficient irritation to the nervous system to produce a rundown condition, which is well known to be a necessary forerunner to such disease, and it further asserts that as a result of the accumulation of toxins in the organism a secondary reflex contraction of the spinal muscles occurs; it is this latter factor which the osteopathic physician attempts to combat, because he realizes that many of the apparent symptoms of the "fever" or "infection" are in reality symptoms of the secondary osteopathic lesion.  Moreover, if there was present a deep-seated lesion at the outset of the infection, the continued treatments during the siege of the fever will generally remove it by the time the patient is about again.
 

Osteopathy and Chronic Diseases.

    With some slight adaptations we can apply a line of thought similar to that used in the case of the acute diseases, when we consider the relation that exists between Osteopathy and chronic diseases.   In this latter discussion, however, we shall find that the primary traumatic or primary idiopathic lesion in many cases plays a far more striking part than it played in connection with the acute eases.  In some chronic conditions practically the only causative factor is the osteopathic one; in this class we would include most cases of sciatica, many cases of headache and neuralgia, etc.  In these instances the symptoms are the direct results of the osteopathic cause.  In other chronic diseases there is a more complex "circle of causes," and it is these diseases we will consider for a moment. The accompanying cut represents these different relations diagrammatically.

    Why then is Osteopathy powerful in combating any such disease when there are so many causes operative?  For this reason: Anything that will BREAK INTO the "Circle of causes" will tend to give Nature the necessary boost for her curative and reactive processes.  There is no factor known today in the medical world that is so POWERFUL TO BREAK THIS CIRCLE AS THE REMOVAL OF THE OSTEOPATHIC LESION.  Remember always the osteopathic physician does not cure any disease, he REMOVES OBSTRUCTIONS to Nature's operations.  NATURE IS THE GREAT PHYSICIAN.  This last fact explains why it is that in some few cases methods other than osteopathic seem to accomplish good results: in those cases the factor utilized was stronger than the osteopathic factor in breaking into the "circle of causes." However the strength of Osteopathy lies in the fact that IN THE MAJORITY OF DISEASES THE MOST POWERFUL LEVER THAT IS KNOWN FOR BREAKING INTO THE "CIRCLE OF CAUSES" IS THE REMOVAL OF THE OSTEOPATHIC LESION.  In this last statement lies the secret of the success of Osteopathy.
 

Osteopathy and Surgery.

    Some osteopathic physicians seem to regard Surgery as almost a criminal procedure, and this attitude has somewhat biased the medical profession against Osteopathy, because the value of Surgery in selected cases is known positively and to assert dogmatically that all Surgery is butchery can do nothing but expose the ignorance of the person making the statement.  In considering the relation of Osteopathy to Surgery we would call attention to the fact that Surgery embraces both a constructive and a destructive phase.  For example, no one will deny that a surgeon is in his rightful sphere when he sets a broken arm or a dislocated wrist; indeed the principle underlying such work is the same as the principle underlying Osteopathy, namely the restoration to normal of abnormally affected structures.  Now there are many surgical operations that aim to correct conditions exactly similar in principle to the broken arm, as when a surgeon repairs a hernia or suspends a uterus.  The principle underlying such operations is the principle underlying osteopathic mechanics and as such must be given due credit by the osteopathic physician.  The other side of surgical practice is the phase of "destructive" Surgery, and here again we will find no difficulty in brining about a reconciliation between its principle and the principle of Osteopathy.  "Destructive" Surgery aims to remove some structure that, either by its advanced pathology, or by its complete collapse has proved itself to be beyond the power of Nature to combat unless some radical assistance be forthcoming.  There are some processes which can advance so far as to become analogous almost to a condition of poisoning, that is to say something drastic has to be done to combat the process.  Under the first heading mentioned above we would include such conditions as virulent cancers, under the second a prolapsus uteri warranting complete hysterectomy.  Surely no one would cavil at conservative surgery of this type, for whether constructive or destructive, the principle it is built upon is essentially osteopathic.
 

Conclusion.

    Briefly recapitulating we would say that the osteopathic lesion is essentially a tissue-perversion involving the musculo-ligamentous structures around the articulations of the spine, and manifesting by an abnormal mobility, which is generally in the line of a lessening of the movement; that lesions are primary or secondary and if primary they may be traumatic or idiopathic, whereas if secondary they are reflex from toxic irritation; and that Osteopathy attempts to correct "lesions" by a gradual restoration to normal of abnormal condition.  We would also urge that a "popping" of an articulation is indication of the setting of a lesion and that the only sign that a lesion has been set is that a normal condition has replaced an abnormal one.  It is also important to remember that the limits of the osteopathic therapy are determined by the pathology of the disease under consideration, and that no pathological condition that Nature cannot handle can be handled by Osteopathy or by any other therapy, save perhaps by Surgery.  In acute diseases by our treatments we improve elimination and thus enable Nature to combat the toxin of the infection more readily; in chronic diseases the removal of the osteopathic lesion presents the MOST IMPORTANT lever that is known today to break into the "circle of causes" and thus to combat the symptoms or effects and enable a remedy to be obtained. Finally, Osteopathy has no quarrel with conservative Surgery, whether it be constructive or destructive in nature, for at the last analysis the principle underlying such Surgery is essentially the osteopathic dictum of "adjustment."