The Practice and Applied Therapeutics of Osteopathy Charles Hazzard, D. O. 1905      CHAPTER VII   TREATMENT OF THE THORACIC LESIONS  
 
    The thoracic portion of the spinal column is anatomically a part of the thorax, but has already been discussed under another head.
    Osteopathic treatment of the thorax is directed generally, to the restoration of the ribs and other bony portions to correct mechanical relations.  It includes with this, work upon ligamentous, cartilaginous, and muscular lesions, which are usually secondary to bony lesion.  Thus while osteopathic treatment of the thorax consists largely in the putting of ribs into proper position, this work is always done with an eye to those other lesions, and effects all surrounding tissues; muscles and ligaments; nerves and vessels; centers and viscera.
    Thoracic is inseparable from spinal work, owing to the intimate anatomical relations of these parts.
    There are various ways of setting ribs.  Many of them rest upon the principle that the head of the rib, being but slightly movable, is the fixed point; that pressure upon the angles tends to move them about this fixed point; and that this pressure may be guided and aided by elevation of the arm or rotation of the shoulder, bringing traction upon the pectoral and latissimus dorsi muscles, etc., which are attached to the ribs.
    In some treatments, the sternal end is made the fixed point and the parts are manipulated accordingly; in some, both ends of the rib are fixed, etc.
    Exaggeration of lesion, fixing of a fulcrum, traction upon attached tissues, and rotation of related parts are principles applied to the work.
    I.  With the patient sitting upon the side of the table, the practitioner, standing in front, passes an arm about the body of the patient, extending his hand past the spine behind, and pressing with the fingers upon the angles of the ribs of the further side. With the other hand he raises the patient's arm of the side in question, in front of the body and high over the head rotating it downward and backward.  This brings traction upon the pectoral muscles and soft tissues of the whole anterior aspect of the side of the chest, elevates the entire side, and effects particularly the ribs upon the angles of which pressure is made.  Care must be taken to maintain this pressure, until the end of the movement of the arm.
    This motion may be repeated, the pressing hand traveling down the back to each successive rib in need of treatment.
    This treatment elevates all the ribs and tones all connected muscles, ligaments, vessels, nerves, etc.
    II.  The patient sits upon the stool; the practitioner stands behind, and, resting one foot upon the stool, makes a fixed point of his knee at the angle of the rib under treatment.  One hand holds beneath the lower edge of the ribs, in front, while the other elevates and rotates the arm as in I, or the first hand may press down upon the upper edge of the rib, in front, while the arm is drawn from in front downwards to the side of the body, and backwards.
    In these ways the ribs may be forced downward or upward.
    III.  With the patient sitting or lying upon his side, the rib is thrown into action by the patient's taking a full breath.  The operating hands are applied, one at either end of the rib in question, and advantage is taken of the relaxation of tissues and the motion of the rib, which take place as the patient expels the breath.  The whole rib is manipulated at this time toward its normal position.
This treatment is aided in some cases by pushing the rib still further from its normal position before an attempt is made to restore it to place.  In this way the principle of exaggeration of the lesion is called into play.
    IV.  Treatment II may be applied with the patient lying upon his side instead of sitting.  Here the practitioner stands behind, rests one foot upon the table, bending his limb so as to bring the flat of his knee against the angle of the rib.  The treatment then proceeds as in II.  The arm may be rotated either forward and up, or downward and back, pressure being made at either margin or at the sternal end of the rib as desired.  This treatment allows the practitioner more latitude than does II.
Great caution must be exercised in any application of the knee to the chest, either anteriorly or posteriorly.  Active work with it should be avoided, use being made of it only as a fixed point.
    V.  A fixed point may be made of the flat of the knee at the sternal end of the rib; the aim of the patient upon the same side is manipulated for traction as before, while the other operating hand is passed over the patient's opposite shoulder and applied to the spinal region of the rib.  This treatment is applicable to luxations of the heads of ribs.  The patient is sitting.
    VI. With the patient supine, the practitioner stands at one side and reaches across the patient to manipulate the ribs of the opposite side.  One hand is slipped beneath the back and applied as a fixed point to the angles of any ribs in question; with the other hand the patient's arm is rotated as before for traction.
    VII.  With the patient lying prone, the practitioner, standing at one side, reaches across the body and makes a fixed point of his elbow upon the angle of the rib.  At the same time the hand of the same arm grasps the patient's forearm upon that side drawing it back and up.  Thus, while the rib is in action the pressure of the elbow forces the head into place.
    VIII.  With the patient lying prone, pressure with the operating hands may be brought vertically downward upon heads or angles of ribs, springing them into place.
    IX.  With the patient lying supine, the practitioner stands at the side of the table and raises the patient's arm of the same side to a level with the shoulder.  With the arm thus horizontal, traction is made upon it, away from the body, and in such a direction as to bring longitudinal tension upon the costal cartilages.  The other hand manipulates the cartilage to reduce any twist or anterior prominence of it.
    X.  With the patient sitting, the practitioner stands facing him, making pressure with one hand upon the sternal end of the rib in question.  The other arm is passed about the patient's body, and the hand locates and brings pressure upon the head of the same rib with both ends of the rib thus fixed, the motion of the practitioner's body is used to rotate the patient's trunk about these fixed points, at the same time manipulation is directed to the restoration of the rib to position.
    It may be said that, as a rule, the setting of a rib requires time and patience though in many cases this may be accomplished at once.  It is rarely the performance of a set motion that does this work.  On the contrary, the practitioner, with his hands in position and the parts under his control as described in any particular treatment, must continue his efforts, with varying traction, pressure, rotation, etc.  Movements of the patient's whole trunk, bending, turning, raising the parts, etc., may all contribute to the gradual relaxation and yielding of the parts to the persistent, well-directed, and carefully judged efforts of the Osteopath.
    In the case of the FIRST AND SECOND RIBS many of the general principles and treatments, as already described, may be applied.  Special methods, however, are generally necessary to replace them.  As already stated, these ribs are usually luxated upwards, but may, as well, be displaced downwards.
 
 
I.  UPWARD DISPLACEMENTS

    (1) The scaleni muscles are first relaxed and stretched (Chap. IV, div. XI), the head is now bent toward the shoulder of the affected side, and pressure is brought directly downward upon the upper margin, the sternal or spinal end of either or both ribs (Chap.  VI).  In this way, either rib may be lowered as a whole or at either end.
    (2) With the patient lying upon his back, the practitioner stands at the head of the table; presses the palm of the thumb down upon the upper margin of the first rib; with the other hand he raises the arm of the patient upon the side in question, and pushes it across the chest at the level of the shoulder, thus relaxing the tissues at the side of the neck, and elevating the clavicle so that the thumb may be thrust more deeply behind it.  Pressure may be applied anywhere along the upper margin of the rib, lowering it to its normal position.
    (3) A most effective treatment is shown by Dr. Still.  For example if the lesion be to the right rib, the patient is to sit sidewise upon the table.  The practitioner sits beside him, at his left, passing  right arm under the left axilla and placing his right fingers on the upper aspect of the rib.  His left hand is pressed against the patient's head.  First the patient's head is drawn toward the practitioner while his body is pushed slightly away.  This swerves the spinal column and throws the luxated rib up higher, exaggerating the lesion.  Now the head is pushed well away from the practitioner, while the body is drawn to him, with accompanying strong pressure of the right hand downward upon the shaft of the first rib, which is thus replaced.
 
 
II.  DOWNWARD DISPLACEMENTS

    (1) With the patient sitting, the practitioner stands behind and brings pressure with his fingers upon the inferior margin of the first or second rib.  At the same time the head is bent to the opposite side, bringing traction upon the rib through the scaleni muscles, and rotated backward.  This rotation tends to bring more traction upon the anterior end through the scalenus anticus (in case of the first rib.) The treatment may be used to elevate either rib.
    (2) The treatment as described under II and IV of this chapter may be used.
    (3) With the patient sitting and the practitioner standing in front, pressure may be made by the fingers below the region of the heads of the first and second rib, (see Chap. VI), while the head is bent to the opposite side and rotated forward.  This rotation tends to bring more traction upon the posterior ends of the first and second ribs through increased traction respectively of the scalenus medius and scalenus posticus muscles.
    (4) In case of anterior protrusion of the cartilages (see Chap. VI), pressure may be brought upon them while treatment I above is being given.
    Or the patient's arm is raised to the level of his shoulder and drawn backwards, bringing traction upon the cartilages, while pressure is applied to them.
    The first two ribs may be separated, as follows: The patient lies supine and a hand is slipped beneath his shoulder, bent to form a fulcrum beneath the two ribs; the patient's arm is grasped at the elbow, raised, and bent strongly across the anterior chest at the level of the shoulder.  This tends to drive the two ribs sternum-ward, and to separate them anteriorly owing to the intercostal space being wider at its anterior end than at the other.
 
 
THE ELEVENTH AND TWELFTH RIBS

A. DOWNWARD DISPLACEMENTS

    A preliminary step must be taken in the relaxation of all muscles and tissues about the ribs, especially of the quadrati lumborum muscles.  This is easily accomplished by manipulation of the tissues.  A special method of stretching the quadati is as follows: The patient lies upon his side and the practitioner stands in front.  He grasps the arm of the patient and draws it diagonally forward, at the level of the shoulder, in a direction away from the pelvis.  At the same time his other hand makes pressure upon the anterior iliac crest in a direction diagonally backward, i. e., in a direction exactly the opposite from that in which the arm is drawn.  This stretches the muscles diagonally and rotates the lumbar portion of the spine.  The motion is now reversed by standing in front of the pelvis, grasping the crest of the ilium, and drawing it diagonally forward in a direction away from the shoulder.  At the same time the other hand holds the bent arm rigid at the side and pushes it in a direction opposite from that of the traction applied to the pelvis.  This motion gives the opposite diagonal stretch to the quadratus lumborum, and rotates the lumbar region of the spine.
    The eleventh or twelfth rib itself is readily manipulated upward or downward by taking advantage of three points; (1) The head usually remains a fixed point, (2) Pressure made upon the outer aspect of the rib in the region of its angle (or turn in case of the twelfth, which lacks the angle) may be so directed as to move or rotate the rib upward or downward about the fixed point, (3) The free end may be readily moved upward or downward by the pressure of a finger, and this pressure, combined with pressure in the opposite direction applied at the angle, readily rotates the rib about its horizontal axis.
    One hand easily spans the rib, leaving the other hand free to manipulate the body and aid the operation.  The thumb is pressed against the free end of the rib and forces it upward or downward, while the fingers of the same hand bring pressure in the opposite direction at the angle of the rib.  In this way the rib is rotated about the head as a fixed point and may be raised or lowered as desired.
    I.  With the patient lying upon his side, his knees flexed and supported against the abdomen of the practitioner, the operating hand, manipulates the rib as above described, forcing it upward.  At the same time the free arm has grasped the semi-flexed limbs, raised them slightly to rotate the pelvis and lower lumbar spine, and thrusts them downward in extension to stretch the soft tissues and aid in increasing the distance between ribs and pelvis.
    II.  This movement may be varied, grasping the limbs in the same way and drawing them and the pelvis over the side of the table, rotating them downward about the edge of the table, extending the limbs and rotating them upward and onto the table.  The rib is manipulated as in I. This is a strong treatment, and applies great force to the rib.
    III.  With the patient sitting, a hand is applied to each end of the rib.  The patient takes a full breath to throw the rib into activity; pressure is so applied as to exaggerate the lesion, and the rib is finally pressed upward to its normal position as the patient exhales.
    IV.  The patient lies upon his side; one operating hand grasps the ilio-costal tissues and draws them diagonally downward and forward in the direction in which the rib points.  The other hand is placed upon the angle of the rib and pushes it in
the same direction.  In this way the tissues are stretched and the lesion exaggerated.  The motion is finished by an upward turn of the hands, the former pressing the end of the rib upward, the latter forcing the shaft of the rib upward.
 
 
B. UPWARD DISPLACEMENTS

    In these cases the anterior ends of the ribs are upward under the rib above.  All tissues are first relaxed as before, and the free end is located by deep pressure beneath the ribs and tissues.  The rib may be manipulated as before described.
    Treatments I, II and III may be applied equally as well to the reduction of upward displacements; the appropriate pressure being made to force the rib downward.
    The STERNUM, if PROTRUDFD or RETRACTED as a whole, is restored to normal through the general shaping of the thorax by methods already described.  The ensiform appendix, being cartilaginous, is usually easily sprung by pressure and trained toward its normal position.
    In case of luxation between the first and second parts of the sternum, traction is brought upon the first part through the deep cervical tissues and the sterno-mastoid muscle of either side by rotation of the head backward and to one side.  At the same time pressure is made upon the prominent end of the first or second part, reducing it.
    The CLAVICLE may be restored from any of its usual malpositions as follows: The patient lies supine and the practitioner stands at the head of the table, slightly to one side, the fingers of the operating hand are pressed, palm up, behind the clavicle, the tissues being relaxed by slightly raising the shoulder.  The free hand now grasps the arm of the patient just above the elbow and pushes the bent arm across the chest, up over the face, above the head, and rotates it down to the side again.  This motion has raised the clavicle and allowed the fingers to be pressed deeply behind it.  They may be applied particularly to the sternal end.  The elevation of the shoulder has widened the anterior end of the costo-clavicular space and allowed the fingers to be brought well forward toward the sternal end.  As the arm is now rotated outward, the increase of distance between the sternal and acromial attachments of the bone draws it down hard upon the fingers between it and the rib, forcing it upward from either an anterior or posterior downward dislocation.
    In case the sternal end has been dislocated upward on the sternum, the motion would have been the same, except that during the outward rotation of the arm, pressure would have been made above the sternal end to force it downward.
    In case the acromial end had been downward or upward the same motion would be applied, with the operating hand directed to that end of the bone.  During the outward rotation of the arm the bone would be grasped between the fingers behind and the thumb in front and moved upward or downward from its displacement.
    Here, as in case of the ribs, it is less probable that the performance of a single set motion would accomplish the work than that insistent, though not violent, traction, pressure, rotation, etc., according to the manner of the described treatment, would secure the result.
    The posterior margin of the clavicle may be tipped upward, so that the space between its outer end and the scapula is widened.  The tissues at this point are then tender.  The condition may be remedied by the proper application of the above treatment for reduction of displacement of the acromial end.