Articles On Manual Therapy


Charles S. Green, D.O.
Journal of the American Osteopathic Association
January, 1921

(Read before the New York Osteopathic Society, Utica, October 22, 23, 1920.)

DURING the close of my last year at the American School of Osteopathy, where at that time it was the prevailing custom of the student members of the various fraternities, clubs and cliques to obtain special lessons in manipulations outside of the clinics and classrooms, I had an argument with one of the members of the operating staff, protesting against such practice.

I maintained that while there were a great many in these classes who might profit by these hired demonstrations, the majority might suffer untold harm, due to their lack of mechanical ability and their failure to interpret the art of osteopathic therapeutics.

He said that possibly I was right in my deduction, that "osteopathy is an absolute science, but the art needs a new introduction."  While this, perhaps, was a crude way of putting it, his statement was too true and still is quite apropos.

Let us look, for a moment, at some of the methods of accomplishing what is regarded as osteopathy by different types of practitioners.  First, we have the radical type, who considers nothing but the spine, who ignores all the scientific means of diagnosis and disregards the potent factors of general regime, habits and environment of the patient.  Second, we have the osteopath who has discarded all the methods taught and swears by strap-technique, if such can be termed technique. Third, the man who gets correction of all vertebral lesions by sacral pressure, and scorns the proved teachings of our Founder.  A fourth type uses and advocates the use of some laborsaving device, table or appliance, applicable alike to each and every type of patient and condition, and advertised to save backs and impress patients.

Another believes that he must pop all the joints of the vertebral column -- the dynamic type of treatment in its crudest form.  There is another type, the physiologic type who soothes the patient by gentle manipulation and claims to coax the lesion into place.  Then we have the physiologic-dynamic type who, through relaxation of the tissues and direct force, claims to correct any lesion without pain.  An eighth type has made a failure and finds it impossible to cope with the imitator in his town in making cures, so he studies such imitation, and advertises himself as completely equipped in the administration of mechanical therapeutics.  If this type has the courage of his convictions, I believe he should be congratulated, for he has evidently awakened to the fact that he must get adjustment.  This man was not in competition with the imitator, he was in competition with himself, and had he spent the same amount of time and money in furthering his knowledge of osteopathy and its principles he would have saved himself the ridicule and ostracism of his former colleagues, as well as retained his social standing in the community.

Then we have the various dabblers in electricity and other adjunctive methods, which should be left in the hands of specialists.  The masseur type is another who has utterly failed in the interpretation of osteopathic principles and when he gets a patient, it is "up one side, down the other, on the face -- back up, on the back -- face up, then finally, twists the legs, relaxes the neck, managing to spend a half hour to an hour and a half, tells his victim to call again in two days, relates a funny story and leaves the room.  Such men are not osteopaths, but good salesmen.

Do all these types meet with success?  I answer yes, but only conditionally, dependent upon the type of personality each possesses and the personnel of his clientele.  My conception of a real osteopathic physician is one who possesses sufficient education, academic and professional, and mechanical ability to be able to make a proper osteopathic diagnosis and then administer the proper corrective treatment, using any natural method that may be suggested by the condition present and be able to decide when surgery or any other assistance is required, leaving these latter to the recognized specialists in their own particular lines who are willing to co-operate with him in the attempt to relieve the patient.

Let us begin with osteopathy -- the absolute science, which means "a definite knowledge of things as they actually exist."  Technique is "the manner of artistic performance; the details, collectively considered, of mechanical performance in art."  Now what is art?"  Webster says that art is "the skillful and systematic arrangement or adoption of means for the attainment of a desired end."

The "desired end" in osteopathic practice is the correlation of the physiological action of the human body through normalization of the relationship of structure.  The manner and means adopted to produce this normalization of structure is "technique," but we cannot become technicians until we have made a skillful arrangement in our minds of each and every condition, direct or contributory to the maintenance of the abnormality, before attempting a correction.  Until then we may have no technique.  We enjoy a moderate amount of success by utilizing every method employed by the members of our profession, but no one particular method is applicable to all cases nor to all cases of the same type.  Again, the physical ability of the operator, dependent upon size and stature, must be taken into consideration.  This is the one great objection to any plan to attempt a standardization of technique.  Another is the tendency of many merely to imitate the manipulations employed by a demonstrator without giving due thought and consideration to his particular reasons for their employment.

We often hear the question: "How do you correct a first rib lesion?" Granted that there can be but one lesion of the first rib, there is no stock manipulation that may be employed to correct it, for we must take into consideration how much lesion was primarily produced, the existing contractures, the degree of pain suffered, the sensitiveness of the patient, the interference with function and the habits and occupation of the individual.  Perhaps the rib lesion is only an attempt to balance a strain to the skeletal framework, compensatory to some disturbance to posture or poise indirectly associated with it.  Yet only a year ago at Rochester it was demonstrated that a strap adjusted in a certain way, plus some activity on the part of the patient, would correct any lesion to this particular structure.  A great many, and in all sincerity, were convinced that this was the panacea for rib lesions, took lessons, bought a set of straps and settled into a lethargic finality of personal satisfaction that they had at last discovered the alpha and omega of first-rib technique.

Do they always confine this method to first-rib lesions?  Unfortunately, they do not.  Every patient who has a pain or disturbance in the shoulder girdle or upper extremity has the strap applied and becomes a martyr to a new fad.  Is this method conducive to satisfactory results?  I say "yes," in some cases, but not in the majority.  I will say "in many cases," but I have seen cases of acromio-clavicular bursitis involving first ribs, to which were a strap applied and used as I saw it used, the osteopath would be severely reprimanded and osteopathy become the subject of adverse criticism by the patient and his friends.

I do not condemn the strap-method, as such, but I do condemn its universal use as unscientific and an inadequate and incomplete substitute for manipulative therapy, as originally conceived by Dr. Still.

Any and all of the possible lesions found in the practice of our profession, coupled with the various slings, tables, appliances and labor-saving devices, might be used as illustrations, but please bear in mind that osteopathy and not the osteopath is the real sufferer when mistakes are made.

Many of us are smitten with the idea that certain appliances have a peculiar psychological effect on the patient.  This is too true in regard to some patients and some appliances but the greatest psychological effect is the one produced by the relief experienced by the patient and not the means employed.  What can give us greater satisfaction than to be consulted by a patient referred to us by some one whom we have relieved?  Does that patient come to us because we administered our treatment through the media of straps, complicated tables or "gravitizers?" No -- he comes because he believes that he may obtain relief, regardless of method employed.

To begin with, the patient should be examined every time he consults us for treatment, examined for some abnormality of structure, spinal or otherwise, and for disturbances to normal functioning.  He may assume an unnatural posture in his occupation, producing improper poise and balance, which state, if neglected, may not only aggravate any lesions present, but may produce others and counteract Nature's effort to compensate.  Environment and occupation play a most important role in the maintenance of lesions and their production, and an eradication of these secondary or contributory causes is a potent factor in their correction.

Perhaps a patient has become mentally warped or psychologically disturbed, a result of working continuously under high pressure.  He is irregular in his habits of eating and sleeping.  He takes no exercise whatever and perhaps depends upon tobacco to steady his nerves and alcohol or coffee to stimulate him to extra effort.  These contributory conditions, together with a careless posture, produce marked strains on the structures of the body and are followed by secondary or compensatory lesions that affect the function of the organs or structures supplied by the nerves, both somatic and sympathetic, emanating from the cells in the spinal cord or sympathetic ganglia at the site of the lesions present.

Will correction of the spinal lesion alone give the relief expected in a patient of this type?  No, --the contributory lesions must be under complete control before we may expect anything like a permanent correction of the spinal lesion.

Take the instance of our average man of big business, the executive who is responsible for the things of importance.  We make it our business to visit him in the execution of his duties.  What do we learn?  He is constantly interviewing, he becomes mentally tired.  Due to the pressure brought to bear upon him by all his responsibilities he dare not take time for his lunch, or if he lunches it is at irregular hours and he eats business instead of food.  He feels that he cannot take time to exercise or breathe properly so he assumes all sorts of positions at his desk to give him physical relief.  Gradually his framework sags and sooner or later he is advised by his family physician to go away for an indefinite period that he may recuperate.  While away he feels good, for he is relieved of the high pressure of his work, but so soon as he returns to the old environment and habits he gradually reverts to his former mental and physical state.  He finally becomes a perverted functional derelict.  He has headaches, indigestion with its various phases and sequelae, depression, insomnia, is unstable in his judgment, has sudden outbursts of temper and finally becomes melancholic.

After having run the gamut of the heart specialist, the stomach specialist, the nerve specialist and others, ad libertum, he consults an osteopath.  The osteopath looks at him, gives him a cursory examination, influenced at the same time in his judgment by the various reports conjectures, and findings of the other physicians whom the patient may have consulted, asks few, if any, questions that might give him a more intelligent picture of the case and proceeds to administer a treatment.

Patient feels good after his first visit and the next morning calls up on the telephone and wants another treatment.  Of course, he gets it, and as often as he wishes thereafter until he finds that he is not receiving any lasting benefit and decides to go to a Turkish-bath, where he can be rubbed for a longer period and made to feel just as good -- and a whole lot cheaper.

The osteopath should have seated himself with the patient, with the express purpose of getting in mind all the contributory conditions incidental to his ill-health, then made a complete structural examination, including blood-pressure, urinalysis, heart, and using any other methods of diagnosis, laboratory or general, that might have been indicated.  He would have found upper dorsal lesions, lumbar compensatory lesions, cervical lesions, depressed thorax, pendulous abdomen and so on.  He should have attempted to correct not only these bony lesions, but should have paid equal attention to each and every contributory cause if he hoped to accomplish lasting results.  If the patient had been sitting continuously at his desk, with a posture of left lateral scoliosis centered around the dorsal lesions, attempted correction of the dorsal lesions alone by manipulation may have given temporary relief, but to have made a permanent adjustment; his sitting posture should have been changed in order that Nature might have had an opportunity to compensate for the abnormal functioning. Nature will compensate, but only to a limited extent.  If his desk were too high or his chair too low, patient would have had a right scoliosis, and vice versa, but the simple corrective treatment would have not have been sufficient for any permanent improvement.  The high blood pressure was no doubt attributable to the general toxemia and poor elimination resulting from his improper habits of eating, his diet and to his spinal lesions.

This type of patient needs advice as to diet, posture, simple but persistent exercises and breathing as outlined by Dr. Beeman this morning, and lastly, a correction of the spinal lesions.  This correction will not take from a half hour to an hour and a half, but just long enough to change the position and attempt to restore normal mobility to the mal-aligned part.  Persistence in this method of treatment will give a permanent cure in this type of case and win for osteopathy an everlasting friend -- not one who looks upon osteopath as a substitute for exercise or the ancient high-ball.

We often hear in informal discussions that the early graduates, as a class, were the most successful. This, in a sense, is correct, but the types of cases consulting osteopaths today are as a rule far different front those that sought treatment in the early days.  They were of the simple lesion type alone, and we get many of that type today, but that does not relieve us of our responsibility to equip ourselves for the present-day patient, nor will a knowledge of drug therapy add to that equipment.  The extra time spent in the study of drugs if applied to our better knowledge of the human body and to perfecting ourselves in osteopathic principles will prove to all of us that Dr. Still was right.

Today, many of our graduates are sent out with their minds filled with a preponderance of irrelevant matter, perhaps necessarily forced upon them by the requirements of some State Boards, but nevertheless having a tendency to becloud their vision of Dr. Still's original conception.  Witness the small proportion of osteopaths licensed this year in comparison with those of a few years ago, as mentioned in Dr. Williams' report in the last blotter.

Again, many take on side-lines and specialties to the exclusion of the primary factor, which factor must be taken into consideration before the use of adjunctive methods and procedures are indicated.

My experience and mistakes of over fifteen years in conducting a moderately successful practice, with special attention given to the examination of students entering preparatory and finishing schools, have led me to believe that we must always pay strict attention to posture, and that posture is ever dependent upon the maintenance of a normal equilibrium.  I brought this to your attention during my demonstration of technique, a year ago, at Rochester, and I do so again with greater conviction, with the hope that you may prove to your own satisfaction that my premise is correct.

I have endeavored to call your attention to only a few of our mistakes and shortcomings, and to impress upon you the necessity of our strict adherence to the philosophy and teachings of our founder, else we will blunder along, existing perhaps, until some cult or the old line system of machine steals our thunder and swallows us. It behooves us to be ardent observers as well as manipulators.