Osteopathic etiology and pathology constitutes the most interesting
chapter of osteopathic science. The primal divergence of the
osteopathic schools from previous systems is to be found in the
osteopathic interpretation of disease causes and processes, and not in
osteopathic therapy as some may think. Osteopathy makes claim to an
independent school because it possesses a distinct etiology, pathology,
diagnosis and treatment. Thus osteopathic practice is not a mere
method, but instead a system, a school, a science.
At no period of medical history have physicians of the older schools
felt more keenly the futility of medical methods and the lack of an
all-embracing principle of medicine than at the present. A recent
writer[15] who claims to have discovered a principle that encompasses
the entire field of medicine, says: “We found, we may say, that the
backbone of medicine was the absent factor, and that if the patient
labors of so many great minds had not proven as useful in the
development of practical medicine as they should, it was because they
lacked such a fundamental framework to afford a fixed _nidus_ for each
discovery, wherein its true relation to other discoveries would at once
become evident.”
Since the conception of osteopathy its fundamental framework has not
changed one iota as to principle, although the application of the
principle has been greatly elaborated. When Dr. Still proclaimed that
“the rule of the artery is supreme” he gave utterance to a basic
physiological truth. But when he demonstrated that osseous and other
anatamo-mechanical lesions disturbed the artery and caused disease, and
that readjustment of the anatomical cured the disorder, thus allowing
the physiological to potentiate and revealing that the living body
contains all the attributes of a vital and physical mechanism, did his
teaching contain the germ of a comprehensive philosophy; this gave
osteopathic science a “backbone” with a consequent fixed _nidus_ for
all existing facts and future discoveries. And thus, it should always
be emphasized that mechanical readjustment of the component parts of
the vital body is the eternal keynote of the osteopathic school of
healing.
=The Osteopathic Lesion.=—Broadly speaking a lesion is “any morbid
alteration in a tissue whether attended by a recognizable structural
change or not; but especially a change in which the continuity of some
of the tissue elements is broken in upon.[16]” There are several kinds
of lesions expressing the tissue involved, character of degeneration,
locality of same, etc. But upon analyzing the medley of arbitrarily
defined lesions the fact will be evident that much of medical etiology
and pathology has not been logically and consistently sifted and
arranged; and moreover, it will be found the =cause of causes= of many
diseases is unknown.
Herein, arises the great significance of the osteopathic lesion, for
the lesion alters the very governing and controlling tissues of the
body, viz., the nervous tissue and the vascular channels. Hulett[17]
defined the osteopathic lesion as “any structural perversion which
by pressure produces or maintains functional disorder.” The constant
maintenance of the structural perversion will, also, cause organic
disease, although it is granted that functional disorder must
necessarily result prior to any organic change.
The osteopathic conception of a lesion, functional and organic disorder
caused by pressure from disturbed structures, does not bring us into an
absolute new field. Medical literature of all ages contains references
to diseases caused by pressure of tissues on nerves, blood vessels, or
other channels. But the osteopathic idea is an absolutely new one in
the application of this principle universally. It simplifies and makes
uniform the arbitrariness of present semeiology.
Thus the osteopathic idea that many diseases originate, primarily,
from anatomically malaligned, malpositioned, or malrelated tissues
causing a blockage of vital processes, immediate or remote, is a theory
inclusive of disturbances to all tissues. This principle is fundamental
and is supported by the physiological truth that uninterrupted vital
channels preserve health; moreover clinical and experimental data, as
will be shown later, substantiate this fundamental. It at once places
interpretation of a lesion in an entirely new light from preconceived
concepts, and is analogous to and co-extensive with etiology and
pathology.
=Etiological Factors.=—The osteopath believes in the potency of
inherited and environmental influences. There can be no question that
a few diseases and certain disease tendencies may be inherited, the
principle feature, however, from the standpoint of heredity is, various
organs and tissues have less vital resistance. These should not be
confounded with congenital weaknesses and diathetic tendencies.
Environmental influences are very important factors. One’s
surroundings and daily habits in the home, shop, or office count
for much in the aggregate. Food, drink, air, rest, sleep, clothing,
exercise, mental attitude, etc., are all factors in the sum total of
health, and consequently ill health may be traceable to their abuse.
In fact, all hygienic and sanitary measures are duly considered by the
osteopath. Various abuses, over use, and disuse of the functions will
certainly be followed by physiological discord.
The germ theory contains much truth, but in the very large percentage
of cases where the micro-organism is a factor its significance is
only of secondary consideration. Immunity and resistance comprise an
important part of the health problem, of which the intact anatomical is
of first consideration. Usually the micro-organism plays the role of an
exciting and determining factor; before it can multiply and grow there
must be a field that is first nutritionally disturbed. Nutrition of the
tissue is the one great point always to be considered. The constitution
of an individual is the pivot about which predisposing, environmental,
and exciting factors of disease center. Health represents the integrity
of the artery as well as a maintenance of that master tissue, the
nervous system, and anything that produces or influences, directly or
indirectly, a disturbance of physiological functioning borders on the
pathological.
Hence the osteopath recognizes many of the common medical causes of
disease, but reserves the privilege of rearranging their relative
positions, for the osteopathic cause of disease greatly modifies their
value.
=Osteopathic Etiology= distinctively emphasizes structural derangements
and perversions. Of =first= importance, owing to static requirements,
is the =osseous lesion=. This lesion is represented by any abnormal
change of position or relation of the many bony constituents of the
body. The framework of the body is subject to not only any and every
physical violence of any mechanism, but moreover being the corporeal
foundation of a vital mechanism is subject to both direct and indirect
biochemic changes and influences.
Thus the osseous lesion is caused (a) by traumatism, e. g., strains,
falls, blows, etc.; (b) indirectly by atmospheric changes, over and
violent exercise, the slumped posture, debilitating habits, etc.,
through the media of muscle changes and imbalance; (c) by nutritional
effects disturbing the elements of bony tissue; (d) by ligamentous
change such as thickening of a capsular ligament; (e) by infections;
(f) compensatorily and reflexly through the media of body distortions
and muscular irritability or debility, e. g., an innominate lesion
may be compensatory to a lumbar curvature, dietetic errors may cause
dorsal muscular irritation and contraction produce a constant osseous
lesion which in turn may result in chronic indigestion.
The pathological changes in the osseous lesion are commonly one of
structural derangement, deviation or complete displacement. The
vertebral segments are of primary consideration owing to their
important relations to the spinal nerves, spinal cord centers and
sympathetics; the ribs owing to the close sympathetic and spinal
nervous relations; and then other osseous tissues, as the innominata,
clavicles, etc., depending upon their importance to contiguous vessels,
nerves and organs. It should always be remembered and emphasized
that mechanical changes of the anatomical structures is the primary
essential in osteopathic etiology; this is the one great inception of
pathological variations from the distinctively osteopathic conception,
which the osseous lesion typifies. Consequently the osseous lesion
factor is actually a luxation (complete, or partial, even to a very
slight degree), or malalignment of the bony constituents, which by
virtue of their physical malposition impinge or irritate contiguous
tissues. The essential test is the functional one, movement. The degree
of involvement may be one of many gradations ranging from a slight
malposition or impaction to a marked deviation or firm anchorage.
=Second= in importance from the static requirement of support is the
=muscular lesion= though from the standpoints of movement and dynamics
it is often of the first consideration etiologically. Many interosseous
lesions are the result of spastic involvement of deep seated spinal
muscles, of fibrotic changes and of tensions and weaknesses that either
establish a rigidness of the segments, compromising nervous stimulus or
vascular channel, or produce an imbalance of muscular tone and tension.
In the latter instance some type of sidebending-rotation osseous
lesion occurs, commonly anchored within the physiologic movements of
the spine. The muscular lesion may be an actual dislocation of either
muscle or tendon, but rarely. Commonly it is a contracted, or tensed,
or contractured muscle. The muscle, also, may be diseased either from
primary or secondary causes through nutritional and infectious sources
and thus be an etiological feature.
The muscular lesion is caused, (a) by direct or indirect violence the
same as the osseous lesion; (b) by atmospheric influences; (c) by
slumped posture, debilitating habits and various errors of living; (d)
infections; (e) by reflex irritations; (f) by compensatory changes;
(g) by disease causing hypertrophy or atrophy; and, (h) secondary to
osseous lesions, being the result of impingement to the muscles’
nervous control. The tensed or stretched muscle may result from a
separation of the points of origin and insertion.
Herein the fundamental osteopathic concept is the resulting affection
due to the physical encroachment, directly or indirectly, of the muscle
tissue upon vascular channel or nerve fibre, or the effect upon the
movement or alignment of the osseous tissue.
Muscular contractions, displacements, and tensions play a most
important part in acute disorders, although muscular lesions that
are secondary to other lesions are usually taken into account when
treatment is given. Muscular lesions affect, (a) blood and lymph
vessels; (b) nerve fibres. Muscular contractions, especially, impede
mechanically the return of the venous blood to the heart. The lesions
to the nerves may be manifested in innumerable ways, depending upon the
location of the muscle and the function and distribution of the nerve
affected.
Then there is the relaxed, overstretched, and atonied muscle. This
condition results as a secondary effect to mechanical strains, these
being so severe and constant as to cause direct stretching and possibly
tearing of the muscle fibres. This should be distinguished from the
exhausted or debilitated muscle, e. g., as found in neurasthenia and
anemia.
Diagnostically there are, (a) contractions of more or less area, due to
atmospherical changes; (b) the deeply seated contractions involving a
very small area, caused by vertebral and rib lesions; (c) contractions
due to reflex disturbances; (d) contractions caused by postural effects
and deformities; (e) contractions from spasms of the blood vessels as a
result of nervous irritations; (f) contractions due to toxicity of the
blood. All of these characteristic muscular lesions give a direct hint
as to both etiology and prognosis.
=Third=, the =ligamentous lesion=, as a lesion _per se_, is usually of
secondary importance to the osseous lesion. In chronic cases affections
of the capsular ligament and muscular fibrosis commonly maintain
malalignment or rigidness. There are two features that should be noted
in particular when considering this lesion; first, thickenings and
adhesions; and, second, relaxations.
The tone and integrity of the ligaments cannot but be of vital concern
to the stability, suppleness, and adaptability of the bony framework in
all physical movements. No matter how slight the osseous lesion may be
the ligament must of necessity be involved. The osseous derangements
are either a source of irritation to the ligamentous tissue, resulting
in congestion and inflammation and hence thickening and adhesions,
or else the ligaments are so strained and tensed that in time atony
may occur. Probably, in a fair percentage of atonied cases the first
disturbance to the ligament is one of irritation and congestion, and
from long continued involvement irritation is supplanted by debility.
Consequently the primary consideration of the ligamentous lesion from
the etiological standpoint is the character of the tissue (ligament)
changes. This, also, gives us a direct hint that is of the utmost
value in prognosis. The independent displacement of a ligament is
rare, thus ligamentous lesions from the viewpoint of purely physical
displacements are secondary to if not an actual part of the osseous
lesion. Ligaments, when displaced or tensed, readily impinge or
irritate contiguous tissues, but the original cause of the structural
perversion is commonly either the osseous or muscular lesion. Hence,
whatever factors enter into the production of these lesions will at
least indirectly produce the ligamentous lesion.
=Fourth=, the =visceral lesion= is frequently overlooked as being of
much moment as an osteopathic lesion. Visceral displacements acting
as a source of functional and organic annoyance on the physical plane
(structural perversion which produces and maintains pressure) alone are
not in the least uncommon.
Any or all of the abdominal viscera, or even the organs of the thorax,
may be displaced (physically) pathologically. Actual displacement of
the viscus is a prolific source of distinct disorders and many obscure
symptoms. True it is the organs are most frequently displaced from
indirect causes, but nevertheless the actual physical malposition is in
turn a primary cause of still another train of symptoms and diseases.
Visceral lesions are caused by, (a) vertebral lesions; (b) postural
defects; (c) direct violence; (d) nutritional disorders; (e)
childbirth; (f) unhygienic measures (tight lacing, heavy skirts, etc.);
(g) congenital weakness.
From the displaced heart due to valvular and debilitating influences
to the displaced liver, the stomach, the kidneys, the intestines, the
ovaries, and the uterus, may arise a source of direct or indirect
irritations, a train of apparent or masked symptoms, or a group of
nutritional disturbances that include an extremely important chapter
in etiology. Moreover not only may one organ alone be involved but
several may be displaced or prolapsed as a whole as in splanchnoptosis;
and even these in turn may be the direct cause of further organic
displacements as the abdominal viscera prolapsing upon the pelvic
organs. Here is a very fruitful field for the diagnostician, for to
separate cause from effect requires keen perception, an acute sense of
touch, and above all, most careful weighing of all the factors that
enter into the maze.
=Fifth=, the =composite lesion= is not always recognized as an
extremely important osteopathic factor. By composite lesion is meant a
structural lesion that primarily includes the osseous, muscular, and
ligamentous tissues as a whole. This may be termed a lesion _en bloc_
or _en masse_.
Composite lesions are of exceedingly frequent occurrence. Indeed, many
composite lesions are overlooked and instead of treating the _en bloc_
disturbance as a consistent whole the component factors are treated
separately with no concern or attention to the whole.
Postural defects are excellent types of the composite lesion. The
various curvatures, the tilted pelvis, etc., are representative of the
composite lesion. Etiologically, pathologically, diagnostically, and
therapeutically the contour of the spine and ribs, the relation of
the innominata to the sacrum and spine, and the symmetry of the body
generally should be recognized and appreciated. The relation of the
part to the whole and of the whole to the part are of vital etiological
concern. An incipient curvature may be easily overlooked, a pendulous
abdomen neglected, and a slipped innominatum passed unnoticed wherein
as a result the entire vertebral column is malaligned in relation to
the physiological curves or to the perpendicular line of gravity.
Frequently attempts are made to correct individual lesions when
attention should be directed to the composite lesion and _vice versa_,
e. g., a displaced rib is usually dependent upon a corresponding
vertebral lesion, and thus the transverse plane or section of the body
should be considered as a whole. A single lesion may be dependent
upon a composite lesion or a composite lesion dependent upon one or
more single lesions. A slipped innominatum or a disordered hip joint
may bring about a strain to a greater or less section of the spinal
column, or a twisted vertebra may cause a curvature, whereas on the
other hand postural defects may cause a strain at its maximum focal
point resulting in over-stretching and relaxing of ligaments so that
an osseous lesion results, or a spinal curvature cause an innominatum
displacement. Thus there is a constant establishing of equilibrium,
physically and physiologically, through the medium of compensation,
but at some phase of the change there are apt to be pathological
phenomena resulting, and very frequently physiological harmony is
not reestablished but instead irritation, debility and other disease
symptoms are constant effects until relieved.
Consequently osteopathic etiology is many sided and complicated. To
know whether an osseous, ligamentous, muscular, visceral, or composite
lesion is primary or secondary, compensatory, reflex, predisposing, or
exciting, requires a command of theoretical knowledge backed by much
actual clinical experience.
In noting the above distinctive osteopathic etiologic features the
student should not lose sight of the constitutional status of the
patient which may be modified by inherited, congenital, diathetic, and
environmental influences, all of which go to make up the predisposition
of the individual and have an important relation to osteopathic
factors. Then it should be recalled that disease processes may be of
insidious progress, and the products and effects of pathologic changes
accumulative.