The Principles of Osteopathic
A. S. Hollis, D.O.
PRINCIPLES OF OSTEOPATHIC TECHNIQUE
To undertake to outline the principles of osteopathic
technique may seem a somewhat ambitious task. Therefore we would preface
the few suggestions we may offer with a statement clearly delimiting our position
in this matter. We do not believe that it is at all advisable to attempt
to "standardize" technique in the sense that the term "standardize" is very
frequently employed. The element of individuality plays too large a part
in osteopathic mechanics. However in a sense somewhat different from that
usually accorded to it, we do believe in a "standard" technique, in so far as
the principles underlying osteopathic manipulations can be absolutely determined,
because they are built upon the bedrock foundation of anatomical facts.
We shall attempt therefore to describe the most striking diagnostic points in
the determination of osteopathic lesions, and also we shall endeavor by explanation
and by diagrams to suggest the lines of force that must be employed in the correction
of lesions after diagnosis. We shall also show methods whereby the principles
are put into actual practice, but we would urge the consideration of the fact
that it is towards this department of our task that most criticism can be directed,
as methods that may appeal to one may not do so to another, and vice versa.
THE PRINCIPLES UNDERLYING MANIPULATIONS ARE ABSOLUTE, THE METHODS OF APPLYING
THOSE PRINCIPLES ARE LEGION. Out task therefore will be TO SHOW CLEARLY
THE PRINCIPLES and TENTATIVELY TO SUGGEST METHODS OF APPLICATION. It is
however in this latter phase of the subject that we can do little more than
offer suggestions, as in the end the individual mechanical skill of the operator
will prove to be the main point of importance in correcting lesioned conditions
of the spine.
We shall follow our line of thought in as orderly
a manner as possible, from the anatomical standpoint, and to accomplish
this result shall work from above downwards. We shall discuss therefore,
first of all, the neck, back and front, and the temporo-maxillary articulations,
then, the dorsal region and the scapulae, then, the lumbar region, innominates,
and the coccyx, and finally, the thorax (ribs) and the clavicles.
GENERAL PRINCIPLES UNDERLYING MANIPULATIONS.
Before stating specifically any manipulations or
diagnostic principles we would say by way of preface that to be scientific
any manipulations employed must be anatomical. We must, that is to
say, know the planes of the articulations before we can intelligently apply
force to normalize perversions. We shall therefore illustrate as
clearly as possible the various planes in the different regions of the
spine. Also we must remember that if a full degree of normal movement
is restored between vertebrae that are "in lesion" the condition will be
corrected, or as we say the "lesion will be set." The great aim therefore
is to establish a full degree of movement in regions, or in special locations,
of the spine, at which that movement is abnormally limited. This
end result is obtained by the utilization of three procedures: (1) muscular
relaxation (2) separation of the articulations in the region involved,
(3) direct attempts at movement. As we have urged elsewhere the separation
of articulations gives a "pop," which in itself is of little significance,
unless it is produced in a region where there is considerable rigidity,
in which case the reaction to the separation causes an additional flow
of blood around the part involved, which results in a condition slightly
more near the normal than was preent before. Repetition of such a
procedure at intervals, in the end completely "adjusts" the abnormality
to its normal condition. This is called "setting a lesion."
We would here just touch on the fact that some patients seem to have a
very lax condition of the vertebral tissues, which in itself is a lesion
of importance. Such a lesion is best treated against resistance,
the force employed in this way gradually toning up the tissues at fault.
[FIGURES I, II AND III.
THE NECK - BACK.
1. The Typical Cervical Vertebrae.
The superior articulations of the typical cervical
vertebrae, that is of the third, fourth, fifth, and sixth, face approximately
back and up. The superior facets of the third usually have also a
slight inward inclination, though this is not of material importance mechanically.
Also the facets of the sixth approach the direction of the upper dorsal
facets, which is back and out. However for practical purposes the
direction of the superior facets of the typical cervical vertebrae is back
and up (see Fig. I). The movement provided for in this region is
lateral flexion with some slight degree of spiral rotation. In order
to obtain separation in this region the neck must be carried to its limit
of movement in this direction and then, while still on tension, carried
slightly beyond. An attempt to show this diagramatically is made
in Figures II and III. Manipulations employing this principle must
be used with care and under. titandingly, as unless the parts are well
supported and the line of force is exactly right, a marked strain may be
produced. It is also very important not to relax the tension just
previous to the final separation, as by so doing the jerk may do considerable
harm. "Neck-popping" should be used advisedly and with the tissues
fully supported. The well known osteopathic physician, Dr. Charles
C. Teall in an article in the April 1912, Journal stated:
"The man who invented the neck twisting treatment,
which snaps each of the articulations first right then left, has much to
answer for in the retarding of the growth of Osteopathy. It is absolutely
futile as a corrective measure and it permanently stretches ligaments and
impairs the integrity of the cervical column. It often causes the
patient the greatest distress, and the fear of it has driven more patients
away from Osteopathy than the combined efforts of all its enemies.
This is a strong statement but in my experience there is nothing which
so frightens a patient as to have his 'neck broken' as the perpetrators
so graphically put it. Hundreds have taken the first and last treatment
as a result of it. When the knack is once acquired there is an irresistible
impulse for one to give it to every patient, no matter what the case.
At rare intervals it may be indicated but surely not every time."
In another place in the same article Dr. Teall says:
"I have used the term 'coaxed into position' meaning
the employment of gentle methods where the strenuous ones have failed,
and it is a well applied phrase. BY TRYING OVER AND OVER AGAIN WITH
MODERATE EFFORT AND COMPLETE CONTROL OF THE PARTS INVOLVED THE MOST OBSINTATE
LESIONS CAN BE REDUCED. Suppose the methods are not moderate, but
are of the ultrastrenuous type, what happens in cases of coerced reduction?
First, there is tearing of structures involved, straining of adjacent tissues
and often severe shock. Force takes the place of judgment and it
is an almost absolute certainty that the work will have to be done over
again because conditions were not right for permanency. Shock at
such times is often considerable and a quantity to be taken seriously."
Though Dr. Teall is speaking in this last paragraph
in general terms, what be says has special weight in connection with neck
manipulations, as in this region it is extremely easy to underestimate
the force employed, and this may result in considerable harm to the patient,
as the parts are but poorly supported by Nature. Two cuts are here
given which show methods of localizing the force as herein suggested.
[Cut showing the position on
the neck of the articular processes in the cervical region.
[Cut showing method of obtaining
a localized separation in the cervical region, patient lying down.
Lesion is on same side as operator. Page 23]
[Cut showing method of obtaining
a localized separation in the cervical region, patient on stool.
Lesion is below fourth finger of operator. Page 24]
The diagnosis of a neck lesion depends on: (a)
palpable thickened tissue (see cut); (b) limitation of movement.
Tenderness is also generally associated with the thickening of the
tissue mentioned. The limitation of movement will be diagnostic
only, to a certain extent, as muscular contractures alone may produce
such a condition. Moreover the limitation of movement is generally
on the opposite side from the lesion. It is well to remember
in this connection also that it is advisable sometimes to stretch
the Trapezium and the Ligamentum Nuchae to overcome muscular coptractures.
Besides the movements suggested any manipulations
employing simply lateral flexion of the anteriorly flexed spine are valuable
in order to restore a slightly perverted articulation to normal, and will
result in the gradual reestablishment of and approximation to the original
condition, or in a "setting of the lesion." Remember, most of osteopathic
work represents a slow growth; the sudden and miraculous cures met with
once in a while serve but as "exceptions that prove the rule." In utilizing
methods of lateral flexion care must be taken to obtain movement at every
articulation, as carelessness in this respect may result in an involved
articulation being untouched and in all the normal articulations being
abundantly worked upon, of course to no purpose.
2. The Atypical Cervical Vertebrae.
(a) The movement between the occiput AND THE ATLAS
is of a nodding type, and normally is free and easy. A lesion here
is very rare, and when present is hard to correct. It is not by any
means a trustworthy point of diagnosis to test the locations of the transverse
processes of the Atlas, as asymmetry is often found here. A lesion
in this location will frequently produce a tilt of the chin away from the
middle line. We reproduce a cut showing such a tilt. When this
lesion is present attempts should be made to re-establish the normal movement
to its full extent. Any LESION IN THIS LOCATION IS RARE.
[Cut showing the tilt of the
chin In an Occipito-Atlantal Lesion. This condition is very
rare. Page 26]
[Cuts showing method of obtaining
a Localized Movement between the Atlas and the Axis. Page
(b) Perhaps the most commonly involved articulation
in the body, from the osteopathic viewpoint, is the ATLAS-AXIS. Tenderness
and palpable thickened tissue on a level with the angle of the jaw are
invariably noted, and by careful testing the movement on the side of the
lesion will be found to be limited. In a normal case the range of
movement is about 90 degrees -- the chin traveling between the mid-point
of each clavicle. In a lesioned articulation the movement is sometimes
limited by one-half. It is necessary when testing for the movement
between these articulations to make sure that the rotation obtained is
solely between the Atlas and the Axis and that none of it is from lower
down. This can be ensured by grasping the back of the neck firmly
with one hand and the occiput with the other and twisting simply at the
Atlas-Axis articulation. A little practice enables such a test to
be carried out quite accurately and successfully. For some reason
there is a prevailing idea that a great amount of force is necessary to
obtain movement in the spine. It is well to remember that, although
the amount of movement is small, the actual provisions for movement are
in no wise different in the spine from elsewhere, and if an articulation
is normal, movement should be as freely obtainable in the spine as at the
wrist or elbow, etc. Oftentimes a directly applied twisting motion
is very valuable in correcting trouble between the Atlas and the Axis,
provided the movement is exclusively localized at this articulation.
This is a manipulation that we have tested out with very pleasing results
in a large number of cases. See Fig. IV. and cuts.
(c) The SIXTH-SEVENTH CERVICAL and the SEVENTH CERVICAL-FIRST
DORSAL articulations may be considered practically as in the upper dorsal
region and movements applying there may be used in the former articulations.
We would call attention in this region finally to
a condition that we have touched upon above, namely the contraction of
the "Ligamentum Nuchae." In some cases this is very marked and considerable
results may be traced to it. An effective movement to correct such
a condition is to rest the head of the patient upon the crossed arms of
the operator whose hands are placed on the patient's shoulders. From
this position the patient's head can be elevated to put the Ligamentum
Nuchae upon almost any degree of tension desired.
In passing we would call attention to the acute neck
strains met with occasionally. Such conditions can sometimes be helped
at the very outset by long, very gentle treatment. More commonly
however rest and heat are advisable until the extreme tenderness passes
off. In cases such as these there is undoubtedly a rupture of the
capsular ligaments and time is needed for the mending of the torn tissues.
After the extreme tenderness has left, osteopathic work is of great value
and unless employed there is a danger of permanent stiffness resulting.
A lesion of this nature will have been produced by some sudden rather
abrupt movement. It should be distinguished from a "muscular
spasm" which sometimes is met with. In this latter condition, as
the name suggests, a painful contracture of some muscle fibres occurs;
this condition also generally follows a strain. Considerable pain
is produced in this way, but the condition is not so serious as the strain
[Cut showing a tilted Hyoid
bone. Page 29]
[Cut showing one method of correcting
a tilted Hyoid Bone. The second finger of the operator's right
hand is pressing bone from below. Page 29]
1. The STERNO-CLEIDO-MASTOID muscle is important
osteopathically. It often becomes congested, especially in its upper
part, and will be found thickened and very tender. Such a lesion
is the almost invariable accompaniment of a bad cold and acute catarrhal
congestion of the throat and nasal passages, etc. When this condition
is found, it should be worked upon until some relief is obtained.
The congestion mentioned is generally associated with congestion and tightening
of the other tissues of the throat. See below.
2. The HYOID REGION is frequently a seat of osteopathic
lesion. When this is the case the hyoid bone is often tilted (see
cut), or if the tissues are contracted on both sides this bone may be held
tightly up on both sides correspondingly. The tension of the tissues
is the best guide to the trouble. The hyoid bone itself varies considerably
in its position in normal cases, and in rare instances may apparently be
absent. A reliable guide to this bone is the following: Place the
palmar surfaces of the tips of the thumb and index finger on the "Adam's
apple"; from this position separate these tips so that the thumb and finger
will grasp the sides of the thyroid cartilage; then advance upwards towards
the superior loorder of the cartilage; above this border a sagging will
be felt, which is the thyrohyoid membrane, and above this membrane the
hyoid bone may be palpated. Treatment to normalize the thickened
suprahyoid tissues and thus to restore the hyoid bone to its natural position
produces remarkable results in many cases of throat trouble, such as tonsillitis,
pharyngitis, etc. Often several minutes is required for such treatment
but, provided the tissues do not become irritated thereby, one's efforts
should not be relaxed until definite results have been obtained.
It is well worth while to pay considerable attention to this region in
THE TEMPORO-MAXILLARY ARTICULATION.
A lesion of the temporo-maxillary articulation is
by no means uncommon. It is found in many cases of neuralgia and
kindred troubles of the face and mouth and often very remarkable cures
can be obtained by correcting the perversion of tissue around this joint
and by adjusting the lesions. A diagnosis of lesion of this articulation
can generally be made by noting whether or not the jaw opens straight or
with a "kink," as it were; also the feel of the tissues around an involved
articulation is very characteristic and shows a certain tension that is
quite marked. There are many methods of correcting trouble in this
region and most of them depend for their results on getting a good spring
and abundant free movement in the joint.
A good method is the following. With the patient
lying prone, tell him to protrude the jaw to its limit; often if there
is a lesion of the articulation this can only be accomplished with considerable
difficulty and frequently the jaw will protrude more on one side than on
the other. Now place the fingers behind the posterior borders of'
the jaw and hold it firmly forward. Next tell the patient to open
and close the protruded jaw several times.
This will often cause considerable pain and judgment
must be used to prevent overdoing the strain. Frequently it takes
a number of treatments to correct a badly lesioned temporo-maxillary articulation.
There are of course many other good manipulations designed to normalize
this articulation when it is involved. Care however must be taken
that no manipulation used should unduly strain the joint for it is very
easy to spring it with considerable vigor. Another good method is
to wrap handkerchief around the thumb and grasp the jaw on the side involved
with the thumb on the molar teeth and the fingers holding the body of the
jaw. With this grip it is easy to manipulate the articulation freely.
We reproduce a cut showing the first method suggested.
Remember a lesion manifests itself by some perversion of movement and this
is generally in the nature of a lessening of the range of motion in the
articulation in question. If the full range of movement be restored,
the articulation will as a result be normalized find the lesion will be
[Cut showing a method of "springing"
the temporo-maxillary articulation. Page 31]
THE DORSAL REGION.
1. The Upper Dorsal Vertebrae.
The articular facets of the Dorsal vertebrae face
back and out. (See Fig. I.) That is to say, the facets are
located on the arc of a circle whose center is in the center of the front
of the vertebral body. (See Fig. II.) The provision therefore by
Nature for movement in this region is rotary in type and this is on two
planes, lateral and supero-inferior. In other words flexion and very
slight extension are provided as well as lateral rotation. A lesion
therefore, may be found involving either or both of these planes of Movement.
It is easily seen that the direction of the spinous processes is such as
absolutely to contraindicate much extension of the dorsal spine, as the
result of so extending the spine will be to lock these processes and thus
render any degree of lateral movement impossible.
[FIGURES I, II AND III.
We devote considerable space to the principle underlying
the diagnosis of upper dorsal lesion, as we wish to make sure that our
readers grasp fully the method we are endeavoring to suggest. Also
if we make quite clear the principle at this time we can apply it in our
discussions on the rest of the spine, merely making such changes in technique
as the anatomy would suggest, and as will be described in the appropriate
sections. We would emphasize here a point which perhaps has not been
explicitly stated in the previous discussions, namely, that many lesions
in the neck and dorsal region are in a sense compensatory to lesions in
the sacro-iliac and lumbar regions, and must be regarded as such.
Because of this fact it is generally wise to treat from below upwards,
as these compensatory lesions will only respond to treatment provided their
initiating lesions are corrected, and oftentimes they will correct themselves
provided this is done. The reason that these articles are written
in the order that they are, is simply that it is customary so to do, and
anatomically it seems more natural to start at the top and work down.
As an introductory thought at this point, we would
say that perhaps in no other region of the spine are lesions more frequently
found than in the upper dorsal region, and oftentimes in no other region
are they harder to correct. In attempting to find trouble between
the upper dorsal vertebrae it is well first to note: (a) the tension of
the supraspinous ligaments; (b) the position of the spinous processes.
These two points are to a certain extent associated though there are several
thoughts to bear in mind when utilizing them as diagnostic factors.
Normally the feel of the supraspinous ligaments in
this region presents a certain resilience to the touch: in many cases of
lesion this resiliency is lessened or entirely lost. This is important
to note. Moreover, often associated with such a condition it will
be found that two of the spinous processes are approximated, leaving a
gap between one of these and the one either above or below it. (See Fig.
III. and Cut.) Occasionally there is a slight lateral tilt to one
of the spinous processes, though this is not so common as the supero-inferior
approximation of two spines. When there is apparently such a lateral
tilt it is never safe to diagnose a lesion until the movement has been
tested between this vertebra and the one above it and the one below, as
just such a condition is frequently simulated by the presence of a bent
spinous process. (See Fig. IV.) The importance of remembering this
last fact is emphasized when it is noted, on the examination of a large
number of skeletons, how frequently such bent processes are present in
normal spines. Having noted then the tension of the supraspinous
ligaments and the relation of the spinous processes to one another it is
well to note any thickening of tissue over the articular processes and
transverse processes. It must be remembered in this relation that
a transverse process in this region is about two inches up and one inch
out from the tip of the spinous process corresponding to it and that the
inferior articular process lies about half way between the spinous and
the transverse processes.
We have still to suggest the most important and reliable
guide to the presence of a lesion between the vertebrae we are here considering
and this is THE TESTING FOR MOVEMENT BETWEEN THE INDIVIDUAL VERTEBRAE.
There are no doubt other methods of arriving at the same conclusions as
are arrived at in this way; the procedure outlined however is absolutely
trustworthy and possibly it may suggest a new thought to some who are perusing
these articles. We would say however that if satisfactory results
be not obtained at the first few trials from this method we would urge
that it be not discarded as unworthy or of little significance, as undoubtedly
the principle it exemplifies, that of INDIVIDUAL VERTEBRAE MOVEMENT, is
a most important osteopathic fundamental. We would suggest then the
following plan of testing for osteopathic lesions in the upper dorsal region
as absolutely trustworthy and we can guarantee that after some little practice
a considerable degree of skill can be obtained in interpreting what is
felt in this manner. The patient is seated on a stool, with the head well
flexed; the operator stands at the patient's side and grasps the flexed
head in the crotch of his arm so that patient's forehead rests on operator's
biceps, and the side of patient's head rests against operators chest, while
the hand of operator falls on to and over the upper dorsal spines.
Operator then places fingers of other hand on patient's further shoulder
so that his thumb falls between any two spinous processes. In this
position it is very important for operator to remember not to rotate the
patient's head which should simply be well flexed and firmly grasped by
operatorís arm and chest. The operator is now in position to TEST
FOR THE MOVEMENT BETWEEN INDIVIDUAL VERTEBRAE IN THE UPPER DORSAL REGION,
and the method seems very simple as one states it, and is very simple as
soon as some little skill has been
obtained; it is however quite difficult for many at the start.
From the position we have just described THE OPERATOR MUST LIGHTLY TEETER
THE HEAD IN A ROTARY MANNER, and if this is done properly, every movement
so made will be felt by the thumb of operator placed between the spinous
processes as suggested above. There is no need for any exercise of
the imagination in the slightest degree in testing this way, as the movement
can be very distinctly felt if the procedure is exactly carried out.
[Cut showing a quite common finding
in the upper dorsal region, namely: an approximation of two of the
spinous processes. Page 36]
Remember, SCARCELY ANY FORCE IS NECESSARY AS WE ARE
HERE SIMPLY TESTING FOR THE PRESENCE OF LESIONS; the question of correction
will be dealt with a little later. It will often be found that but
little tenderness will be complained of by patient when a lesion is first
discovered, but as soon as attempts are made to correct it sometimes considerable
tenderness manifests itself; this is generally a good sign, as it shows
that one's efforts are dissipating congestion, stretching tensed ligaments,
etc. We again emphasize the fact that PRIMARILY IT IS RIGIDITY THAT
IS THE CONDITION TO BE COMBATTED. The lesion is essentially a perversion
of movement between two or more vertebrae and the term "correction of lesion"
means the restoration of a normal degree of mobility where that movement
was impaired. In other words it is a fact that as a spine is limbered
up lesions disappear; that this is true however should be no excuse for
laziness in diagnosing and attempting to correct specifically osteopathic
lesions, for to the extent that we do this, do we prove ourselves "anatomical
engineers" and not mere "enginewipers," and the results obtained will be
correspondingly the more gratifying and scientific.
[Cut showing one method of testing
for the degree of movement in the upper dorsal region. This
manipulation can readily be adapted for use for corrective purposes.
[Cut showing the application
of the principle of movement in the correction of upper dorsal lesion
upon a mechanical table. It will noticed that the spine can
here easily be well flexed and then rotated. Page 38]
There are many good manipulations for correcting
lesions in this region. The first one we would suggest is the amplification
of the one we have described as a method of testing for lesions.
That is to say, instead of lightly teetering the head as there stated,
considerable power can be used in the attempt to force movement, wherever
that movement is limited. It is a good plan for the operator to hold
patient's near shoulder firmly against his own body and to grasp the further
shoulder with the fingers of the hand whose thumb is against the spinous
processes. It is remarkable what a strong grip can be obtained in
this manner and how powerful a lever can be used.
In association with this treatment it is well to stretch
the supraspinous ligaments thoroughly, especially if the lesion
has produced an approximation of two spinous processes as shown
in Fig. III. and in the Cut. This can be accomplished by placing
the palm of one hand firmly on the spinous processes below the contracted
ligament and with the other hand or with the body bearing down strongly
on the top of the head so as to arch the region markedly.
In this way the force can fairly well be localized to any given
point. A thorough spring with popping of the articulation
can also be obtained in several ways, the principle underlying them
being that the back is well arched and then with the tissues thoroughly
tensed the arch is exaggerated segment by segment. The well
known manipulation in which the patient's hands are clasped behind
his neck and his wrists are held by the operator whose arms thus
pass under patient's axillae exemplifies this principle well.
It is best in this manipulation to have patient keep his elbows
well in and not flaring; also operator must make a fixed point about
the middle dorsal with his chest. Oftentimes too it is wise
to work against a slight degree of resistance on the patientís part
as this voluntary tension in some cases seems to help in obtaining
the separation aimed at. Some operators use the knees in the
back quite a good deal in work in this region as well as lower;
this is good provided the operator exercises his judgment constantly.
In certain cases manipulations employing the knees in this way,
when used without judgment, are capable of causing quite serious
harm. We reproduce several cuts to make more clear the thought
we have been outhning. These aim to show: (1) an approximation
of the first and second dorsal spines with consequently an increased
space, between the second and third; (2) the method suggested for
testing and correcting lesions in this region; and (3) an excellent
movement for obtaining the aimed at on the McManis table.
REMEMBER HERE AS ELSEWHERE PROVIDED GOOD MOVEMENT IS OBTAINED IN
THE INVOLVED ARTICULATIONS THE LESION WILL TAKE CARE OF ITSELF IN
SO FAR AS IT IS RIGIDITY THAT IS THE ESSENTIAL FACTOR TO BE COMBATTED
OSTEOPATHICALLY. Get free movement in the joint and you set
the lesion automatically.
The Middle and Lower Dorsal Vertebrae.
In this region as in the upper dorsal region the
most trustworthy diagnosis is obtained by testing for the movement between
the vertebrae, both collectively and individually. From the collective
standpoint a very interesting and instructive point may be noted when several
vertebrae are affected on one side, and from its extreme obviousness it
may be of value to persuade a patient or a patient's friend that the spinal
method of treatment at least has a basis in actual fact. Let the
patient be seated on the table, in a relaxed manner with folded arms and
with back to operator. Let operator place hands on patient's shoulders
and lightly turn him in a rotary manner from side to side, noting carefully
the amount of force required to twist him in this way. Quite frequently
it will be found that, using the same amount of force on either side, patient
will rotate considerably further on one side than on the other. This
difference is visibly noticeable and shows clearly that OSTEOPATHIC LESIONS
MANIFEST THEMSELVES AS PERVERSIONS OF MOVEMENT; that is to say, their pathology
is such as TO LIMIT THE NORMAL RANGE OF MOTION in the region involved.
Again from this same standpoint of collective involvement,
several vertebrae may be "anterior," that is to say, the spine may be straighter
than is normal -- the ordinary dorsal curve being partially obliterated,
or again several vertebrae may be slightly twisted. We will therefore consider
the diagnosis of each of these conditions. When a spine is anterior,
the condition is very easily palpable, as the dorsal convexity is largely
absent and the spinous processes are more closely approximated than is
usual, even for this region; also when patient bends head forward, the
convexity is but very slightly improved as the spine is essentially more
or less straight. Often only three or four vertebrae
seem to be affected in this way and this condition is spoken of as an "anterior
upper dorsal, or an "anterior middle dorsal," etc.; sometimes the entire
dorsal region is affected. See cut.
[Cut showing a bad "anterior
dorsal" spine. In this case the convexity of the dorsal region
is almost entirely obliterated, the spine being quite straight from
the third to the twelfth dorsal vertebrae. Page 41]
[FIGURES I, II and III.
The rotary twist of the vertebrae is best diagnosed
by noting the prominence of the angles of the ribs on one side or the other.
Thus patient is seated on stool, with arms hanging between knees and with
head and back well flexed; operator now stands in front of patient and
looks down his back. In this way even the slightest prominence of
the ribs is markedly exaggerated and very frequently the ribs on
one side will be considerably elevated above the ribs on the other.
Such a condition can of course only be caused by a twisting of the vertebrae
around a vertical axis. See Figs. I. and II.
[Cut showing a slight bulging
of the ribs at the cross. It Is very difficult to obtain a
good picture of this condition though it is frequently present.
It will be noticed that the one side is fuller than the other, however.
It is possible for an anterior dorsal to be produced
in association with the collective rotary twist that we have described.
That is to say, as the vertebrae twist in the manner suggested they may
sink in slightly as a consequence. When, therefore, an anterior dorsal
is to be corrected it is well to note carefully whether there is any prominence
of the ribs on one side, because if there is, the rotary twist thus demonstrated
is partly responsible for the anterior condition of the vertebrae in question.
We suggest this simply as a point worthy, in certain cases, of consideration.
[Cut showing method of testing
for the movement between individual vertebrae in the middle and
lower dorsal regions. This type of manipulation is of great value
also in treating in these regions. Page 44]
As to lesions between individual vertebrae, these
should always be carefully tested for. They are often secondary to
the collective involvements such as we have already noted, or again they
may be compensatory to lesions below. They are, however, also frequently
present as primary conditions, needing individual attention. Lesions in
this region can be determined as exactly as in the upper dorsal region
and by a similar type of manipulation. A variety of methods can be
used to obtain a
suitable leverage, and the following is simply suggested as a good
one. Patient sits with arms across chest and hands on shoulders;
operator, standing behind patient, grasps his further arm and shoulder.
Operator then places thumb of other hand between spinous processes and
lightly teeters the body. If this is done correctly no great force
is required and the movement between individual vertebrae can be easily
felt for diagnostic purpose. The principle involved herein is illustrated
in Fig. III. A little practice is all that is required. Remember,
individual lesions in the dorsal region -- whether slight rotations or
merely rigid approximations -- can all be thought of from the standpoint
of the essential principle underlying them. As we have urged before
THIS PRINCIPLE IS, THAT THE PATHOLOGY OF A LESION IS OF SUCH A NATURE THAT
THE LESION MANIFESTS ITSELF IN A LESSENED DEGREE OF MOVEMENT WITHIN THE
FULL RANGE OF MOTION OF THE ARTICULATION, AND THE CORRECTION OF THE LESION
IS OBTAINED WHEN AND ONLY WHEN THE FULL DEGREE OF NORMAL MOVEMENT IS RESTORED
THERIN. We might here mention one more point that is of importance
from the standpoint of both diagnosis and, as we shall see later, of treatment;
it is, that often when there is a slight rotary twist of several vertebrae,
compensated for by a twist below of several other vertebrae in the opposite
direction, an obstinate "individual" lesion will apparently be present
at the point of juncture of the two twists. It is obvious that, unless
the collective rotary twists be recognized, neithor specific nor general
work, directed to "set" this individual lesion, will be successful, as
the lesion itself is, as it were, secondary entirely to the two rotary
twists and the lesion will persist until the rotary twists be recognized
Summing up the lesions to be looked for in the dorsal
region we would suggest the following classification. Such lesion
may be: (a) collective; (b) individual. If collective we find: (1)
the normal convexity more or less obliterated; (2) a rotary twist of several
vertebrae, frequently associated with a compensatory twist in the opposite
direction either above or below. If individual we find rigidity manifesting
in very slight rotations or in supero-inferior approximations, etc.; further,
individual lesions are frequently secondary to the rotary twists above
mentioned or even to other lesions of the innominates or lumbar vertebrae.
[Cut showing an excellent method
of re-establishing the normal dorsal convexity in an "anterior dorsal"
spine. Page 46]
Before describing methods of treating lesions in
the lower and middle dorsal regions we wish again to impress upon our readers
the fact that we are not attempting in these articles to describe dogmatically
the only methods of "setting lesions," or in other words, of normalizing
the spine. We urge again that the PRINCIPLES underlying spinal therapy
are ABSOLUTE, being built upon anatomical and physiological facts, and
in these articles we are attempting to show along what lines involvements
of the vertebrae may be found -- no matter by what names such involvements
are called -- and also to show the principles utilized in the correction
of spinal abnormalities. In any discussion, therefore, dealing with
the correction of trouble in the region we are here considering, the best
we can do is to suggest the lines that may be used in obtaining results
osteopathically and then to trust that the individual mechanical skill
of the operator may enable him to apply more specifically in actual cases
the principles thus suggested.
[Cut showing a second method
of treating an "anterior dorsal" spine. Operator's hands are
clasped beneath ribs and while patient takes full breath pressure
is applied by operator's chest above. The principle of above
manipulation can readily be understood. Page 47]
A. Correction of an Anterior Dorsal Region.
Under this heading we would suggest two methods,
as follows: Place the stool about 12 inches from side of table and let
patient sit upon it with his side to edge of table; let operator, standing
between patient and table and facing opposite way to patient, place his
axilia over the base of patientís neck so that his forearm will pass under
patient's axilla while his hand will more or less support patient's back.
Operator can now take a step forward so as to throw patient back and off
his balance. It is well for operator to balance himself with his
other hand on treating table. From this position operator can exert
a steady pressure upon the dorsal spine so as to bow it to any extent desired.
It is well always to use this manipulation on both sides of patient, as
otherwise there is a possibility of straining the back somewhat unduly
on one side.
[Cut showing a method of taking
out a rotary twist from several vertebrae by employing the lever
of the prominent ribs. It is well to follow such a manipulation
by a traction of the entire spine. Page 48]
The other method we would suggest is as follows:
Let patient lie on side on table with head well flexed so as to put some
tension on the supraspinous ligaments. Let operator sit on table
in front of patient's body with his hands clasped under patient's ribs.
Now let him put his chest on near ribs and instruct patient to fill up
his lungs fairly full. As patient does this, operator compresses
patient's chest laterally and rocks him slightly back and forth.
This pressure should not be continued during expiration of patient and,
as in the previous manipulation, the operator should work from both sides,
that is to say, with patient first on one side and then on the other, to
avoid any possibility of straining one side more than the other.
The pressure can be employed to advantage five or six times on each side.
The manipulation we have just suggested is of great value for the condition
specified and in many cases also of poor nutrition it will be found very
B. Correction of a Rotary Twist.
A rotary twist is best taken out of the spine by
utilizing the long lever presented in the prominent ribs, and by then employing
traction in some way upon the spine as a whole. The accompanying
diagram (Fig. II.) well shows the principle employed in this first step
suggested. For the second step a mechanical table offers the most
easy method of getting good traction with but little effort on the operatorís
part. We would here simply mention the fact that those lateral curvatures
that are amenable to osteopathic treatments will respond to the application
of the principle we have outlined above, namely, a pulling forward on the
prominent ribs, with perhaps some little pressure on the spinous processes
TOWARDS the prominent ribs, to be followed by a traction of the entire
spine. Also, when a rotary twist is compensated for by a second one
as is often the case, best results "are obtained by working first upon
the primary twist, then upon the secondary, and finally again upon the
primary one. In this way the maximum degree of "untwisting" can be
procured, and the result obtained at each treatment will be found to be
more or less permanent.
The lesion, whose correction we have described above,
is one that is very frequently present though it is also quite often overlooked.
We would urge therefore the importance of examining for prominent ribs
with the patient seated upon a stool and flexed well forward. Remember
such a prominence -- when found -- can only be caused by a rotary
twist such as we have described. Remember too, that when found in
association with an anterior dorsal, this latter condition is possibly
secondary to the rotary twist, in which case it will respond satisfactorily
only when treated from this standpoint, in association with other methods.
Also remember that "individual" lesions are frequently present at the juncture
of two such rotary twists and will be found persistently to resist treatment
until the primary conditions producing them are corrected.
C. Correction of Individual Lesions.
In association with the special methods we have suggested
it is generally necessary to employ methods designed to free up the individual
articulations. Separation of the articulations is of value in many
cases. A series of pops is thereby produced and every osteopathic
physician knows manipulations that will produce this desired result in
this region. Such a manipulation is best followed by one desired
to obtain actual movement -- along the plane of the articulation between
the involved vertebrae. There are many well known manipulations that
obtain separation, as for example when the patient lies prone and the operator
places one hand on either side of the spinous processes, takes out the
"slack" from the spring of the spine, and then delivers a "thrust" towards
the table. This is of value if used with care and not too roughly.
Other operators place the knees in the back with the patient sitting on
stool and grasp their hands in front of patient's chest. Indeed every
operator has his own method of obtaining separation in this location.
The best method of obtaining movement in the dorsal
spine is by an amplification of the principle suggested for the diagnosis
of lesions, and we would outline the following technique as being of value.
We specify 'left' and 'right' for clearness only, and the manipulation
is of as great power exactly reversed, and should of course be used on
both sides. Let patient sit on table with arms crossed over chest,
as before suggested, and with hands placed on lateral base of neck.
Let operator grasp patient's left elbow or left shoulder with his right
hand and rotate the spine from the lever thus obtained, at the same time
opposing the rotation, segment by segment, by his left thumb placed between
spinous processes on the left side. Fig. I will make clear the principle
utilized and the cut reproduced on Page 44 will show the manipulation in
actual use. This is a very powerful movement, though, no doubt, there
are levers that in other operatorís bands are as powerful as the one suggested
or even more so.
Remember if not mechanically inclined an osteopath
will never be more than a mere imitator, slavishly copying someone elseís
moves, and if mechanically inclined, provided the principle be thoroughly
grasped, the method will suggest itself. It is our endeavor in these
articles to write for the mechanically inclined osteopath and we are therefore
attempting above everything else to state clearly WHAT IS TO BE LOOKED
FOR and we trust that the operator himself will have sufficient ingenuity
to correct trouble if be understands exactly of what nature that trouble
The scapula is an important bone from the osteopathic
viewpoint. This is because it is attached to a large number of muscles,
any of which may become unduly contracted and thus prevent it from moving
freely throughout its full range. There are no less than six important
muscles attaching the scapula to the vertebrae or to the ribs. (See diagram).
These are the Serratus Magnus, the Trapezius, the Lavator Anguli Scapulae,
the two Rhomboidei, major and minor, and the Latissimus Dorsi. The
first of these muscles is inserted along the full length of the underside
of the vertebral border of the scapula, taking its' origin from the upper
8 or 9 ribs and is the great sling muscle of the body. In quadrupeds
the two Serati muscles serve as a hammock-like structure whereby the thorax
is suspended from the shoulder-blades. The Trapezius may be considered
for our present purpose as a muscle running from the ligamentum nuchae
and the superior curved line of the occiput to the upper border of the
spine of the scapula. The Levator Anguli Scapulae with the Rhomboideus
Major and the Rhomboideus Minor are inserted into the vertabral border
of the scapula. Of these the Levator takes its origin from the transverse
processes of the Atlas and the two or three upper cervical vertebrae, while
the Rhomboidei take their origin from the spinous processes of about the
seventh cervical and the upper five dorsal vertebrae. The Latissimus
Dorsi has a very extensive origin below and inserts into the bicipital
groove of the humerus. Between the main origin and the insertion
a slip is given off from the underside of the muscle as it passes over
the interior angle of the scapula and thus this angle is held, firmly under
the muscle and it is quite impossible for the scapula to slip out on top
of the Latissimus. We mention this expressly to combat an idea at
one time prevalent that a scapula could "jump" a Latissimus, that is, could
slip from under it. This possibility from the anatomical facts present
is out of the question. The actual condition when a scapula is prominent
in such a manner as to lead to this belief is practically always a paralysis
or a certain degree of lost tone in the Serrattus Magnus muscle, which
causes the scapula to protrude unduly. The insertion of these muscles
with the directions of their pulls is shown in Fig. 1.
[Cut showing a good hold on the
scapula for the purpose of normalizing the tissues all around it.
As suggested above it is extremely important to make
sure that the scapulae are neither bound down tightly to the ribs, nor
prevented from moving normally through a quite large range, and frequently
we find one or the other of these conditions present. A number of
movements are employed to free up the scapulae and the following is but
outlined as an example. As patient lies on right side, operator places
patientís left arm over his own right forearm at the same time grasping
the vertebral border of the scapula with his right hand and placing his
left hand on the patient's shoulder. From this hold a rotary movement
of the scapula can be established, and it can be determined whether or
not there are contractures preventing the scapula from moving as freely
as it should. Considerable tenderness can often be found associated
with such an abnormal condition as is herein suggested. We refrain
from describing other methods for obtaining the results desired as manipulations
will readily suggest themselves. However we do not wish to dismiss
this region without emphasizing the fact that it is very important to make
sure that a perfectly normal condition is established in these tissues.
There is an abundant blood supply around the scapula and the venous drainage
undoubtedly is disturbed when a condition of abnormality is present in
this region. We might almost say: Make sure that the scapulae are
normal and a great deal will take care of itself. Sometimes a lot
of treatment is required to obtain the condition aimed at, but results
will amply justify the expenditure of time and energy.
THE LUMBAR REGION.
The lumbar spine is frequently involved in lesions.
As stated earlier in these articles lesions in the upper part of the back
are very often secondary to lesions in the lumbar region or between the
innominates and the sacrum. Therefore it is well to spend time thoroughly
to examine and treat these regions, as otherwise efforts directed to the
correction of the upper spine may not get the results expected, the lesions
worked on being secondary to trouble lower down. This is not necessarily
always true; the fact however that it is fairly frequently so is worth
while remembering, as therein may lie the solution of certain somewhat
obstinate cases, which might otherwise not respond to treatment.
[FIGURES I, II AND III.
[Cut showing a method of treating
a posterior lumbar spine on a mechanical table. Page 55]
The Lumbar Vertebrae.
There are a few points of considerable interest in
connection with the anatomical formation of the lumbar vertebrae.
The bodies are very large, and kidney-shaped, and the intervertebral disks
are the largest that are found in any part of the spine. The spinal
foramen of the lower lumbar vertebrae does not contain any of the cord,
as the 'Conus Medullaris' or terminal portion of the cord is found at the
first or second lumbar vertebra. Instead, it contains the 'Filum
Terminale' and the 'Cauda Equina,' accompanied by veins and arteries.
The 'Filum Terminale' is the anchoring ligament which holds the cord down,
being itself attached to the coccyx, and the 'Cauda Equina' consists of
a bundle of nerves which leave pair by pair through the lumbar and sacral
foramina. The articular processes project markedly, and are placed
in such a way that the inferior facets are grasped by the superior of the
vertebra below. The plane of the articular facets is on the arc of
a circle whose center is in the spinous process. We may describe
this direction as being back and in. See Fig. II. It is obvious
from but a cursory glance at the manner in which the inferior facets are
clasped by the superior that direct rotation of the individual vertebrae
is impossible in the lumbar region, for as soon as it is attempted the
articular facets will clash. The spinous processes are club-shaped
and project almost directly backwards so that a lumbar body and a lumbar
spinous process are on the same plane. See Fig. III. This is
strikingly different from the relationship existing between body and spinous
process in the dorsal region. The transverse processes are long and
slender being in reality lumbar ribs and occasionally it will be found
that these processes on the first lumbar vertebra are not fused to the
rest of the vertebra. The other processes are of little moment.
[Cut showing an effective method
of treating a very stiff lumbar spine on a mechanical table.
In the lumbar region as elsewhere, the most prominent
and noteworthy feature of a lesion is the fact that in some way there is
a disturbance of movement between the vertebrae, either individually or
collectively. From this standpoint it is very interesting to note
the manner in which gross involvement manifests itself. A patient,
for example, will move stiffly and complain that he cannot bend as easily
as he used to, thinking that the reason of this lies in his muscles.
As a matter of fact, much of the trouble is in the lumbar spine, stiffness
and rigidity in which is preventing a normal amount of flexion from taking
place. A simple experiment shows this point very readily, and it
also gives an insight into many of the results that are obtained by physical
culture methods. For example, if the attempt is made to touch the
floor with the hand without bending the knees this perhaps is accomplished
with difficulty; after some practice, however, it can be done readily.
What has happened is this: the tightened ligaments and the thickened capsules
and the congested muscles of the lumbar spine have been more or less normalized
by a definite stretching along the plane of their natural movement, and
by the time the patient has managed to accomplish his end aimed at he has
automatically "set" some of the osteopathic lesions which were manifesting
in rigidity. We believe that quite a number of the cures obtained
under physical culture system are due, not to the strengthening of the
muscles of the trunk and extremities, as the patient believes, but to the
limbering up of the spine which has gone along with this latter, owing
to the fact that the patient employed twisting, stretching, bending, etc.,
in his physical culture movements. Herein is a line of thought that
can be amplified to an almost unlimited degree, and undoubtedly a few simple
exercises practiced by patients daily and consisting of bendings and twistings
of the various regions of the spine will often accelerate results obtained
under osteopathic care. ALWAYS REMEMBER THE GOAL AIMED AT IS THE
COMPLETE NORMALIZATION OF THE SPINE, that is to say, the restoration of
a normal degree of mobility and the re-establishment of the natural curves.
In principle it matters very little what methods are actually employed,
provided the end-result is obtained, and the various systems of spinal
therapy that have sprung up since Osteopathy was instituted are all, more
or less, crude attempts to bring about this ideal in one way or another,
by a "thrust" or a "jarring" of the spine, trusting that Nature will produce
a normal condition as a result of the recoil.
It should first be noted whether or not the lumbar
spine is much posterior, because sometimes the entire spine appears almost
straight, as mentioned earlier the dorsal curve being obliterated and the
lumbar spine unduly prominent. Also there may be a rotary twist of
the lumbar vertebrae, of a similar, nature to the twist spoken of in the
dorsal region. We reproduce a cut showing a quite extreme example
of such a rotary twist. In a case of this nature the twist of the
vertebrae makes the long transverse processes very prominent and also carries
the whole body of the musculature backwards on the side of the twist.
Such a condition can be noticed by looking down the back of the patient
from above and in front, having flexed it strongly so as to put the entire
back on tension.
[Cut showing a bad rotary twist
of the lumbar vertebrae with consequent prominence of the musculature.
This picture is taken looking down a well flexed back. Page
In testing for "individual" lesions tenderness over
the transverse and articular processes can often be found, and undue separation
or approximation of the spinous processes should be looked for. That
is to say, flexion and extension being normal movements in this region,
the individual vertebrae may be held at the limit of their motion along
these lines. Whatever such a condition is found, on testing for the
movement between the vertebrae under consideration, as suggested below,
lessened amount will be noted. An impacted condition of the whole
lumbar spine is sometimes met with, in which there is a stiffness
throughout the whole region, every articulation being involved.
[Cut showing a good method of
diagnosing and treating lesions in lumbar region. Page 60]
A good method for testing the movement between the
individual vertebrae is the following: Place the patient upon the side
with legs raised to a right angle with the body. Support patient's
knees in the abdominal wall and place both hands on the lumbar spinous
processes. From this position operator should flex and extend patient's
legs by movement of his own body. See cut. Every such movement
of his body will be felt by the hands on the spinous processes and it is
simply a matter of practice before considerable skill can be gained in
making a correct interpretation of what is felt by the hands. We
would emphasize the fact that a great amount of movement is not required
when testing in this manner. Just a little lateral motion of the
body, and the ability to interpret what is quite readily felt in this way,
are the two necessary requisites. Some method similar to the one
just explained will be found very valuable and quite trustworthy in the
majority of cases. On a mechanical table, the principle we have outlined
can be applied with less effort to the operator. This is especially
true when the same principle is employed for corrective purpose, as we
will suggest later, the greatest drawback to the manipulation in that instance
being, that it is somewhat of a strain on the operator's own back.
The manipulations that are in common use for the
lumbar region are many and varied. Some of them obtain separation
between the vertebrae while some of them are designed simply to force movement
along the plane of the normal movement of the region involved. We
will outline a few of each kind, again urging our readers to remember that
it is the principle and not the exact technique that we would especially
emphasize. Most osteopathic physicians to a large extent adapt their
movements both to the patient, and to the condition present, and in the
end the success of the attempts made to do this depends upon the mechanical
instincts of the individual operator. For this reason
the very best instruction that can be written down appears crude when read
by an experienced operator and of course it is needless to say that no
one can become skillful by merely reading such suggestions as may be offered
in these pages. The great difficulty in compiling articles such as
we are attempting in this series is that it is extremely hard to write
in concrete terms instructions that shall be neither altogether too dogmatic
to allow play for the individual application of skill nor too general to
be of any real practical value. In this region perhaps more than
in any other it is often permissible e to give a general "breaking up,"
as the vertebrae are very firmly held to one another by the massive muscles
and strong ligaments, and provided in general a full degree of free movement
is obtained Nature will tend to restore normality where abnormality exists.
As regards a general posterior lumbar spine, we would say that correction
is a matter of growth and training of the vertebrae. Any movements
that will tend to restore the normal contour are valuable, as, for example,
when patient is seated on stool while operator sits on table and works
with his knees in the lumbar region, trying to force the spine gradually
to take up a more anterior position. Or again, with patient on face,
the raising of the limbs from the table with one arm while with the other
hand pressure is brought to bear upon the lumbar spine, is of value.
Some operators are in the habit of raising the limbs in this way and while
they are thus elevated, move them from side to side. This is unwise
and may do harm as the spinous processes can very easily be bruised by
this procedure and the tissues damaged. The side to side movement is excellent
provided the limbs are not unduly elevated, and on a mechanical table especially,
where the manipulation is not such a great effort to the operator and where
even some traction can be applied in addition, very good results may be
obtained. We reproduce two cuts showing the exact application of
this principle on a mechanical table and it will be readily seen that the
movement thus easily obtained could not be obtained ordinarily without
great strain and effort to the operator. For the general restoration
of movement in the spine an excellent method is to have patient seated
on table and to grasp one shoulder while with the thumb of the other hand
fixed points are made between the lumbar spinous processes as patient's
body is thrown back and rotated from the lever of the shoulder. We
reproduce a cut showing this method which will be found a valuable one.
It is well for operator to support his elbow upon the anterior superior
iliac spine. At first this method tires the thumb badly but soon
this is not noticed.
[Cut showing an easy method of
getting movement in the lumbar region. Page 62]
[Cut showing an effective method
of "breaking up" a stiff lumbar spine. Page 63]
A good general "breaking up" manipulation for the
lower dorsal and the lumbar regions is the following: With patient seated
on table, operator passes right arm under patient's right axilla and grasps
patient's neck with his hand. Operator then sits beside patient on
his left side, and with his left hand grasps the front of the table, holding
down patient's left leg strongly and with his body firmly supporting patient's
sacrum on left side. This technique may seem very cumbersome at the
start; however it soon becomes easy and can be done without effort.
From the position so far described patient can be thrown forward and rotated
from the lever of the neck. It will be found that the further forward
patient is thrown before being swung round the lower the force will be
felt on the spine. The manipulation should be tried from both sides.
[Cut showing a method of correcting
a rotary twist in the lumbar region. In this picture operator's
right hand is pulling round and forward while his left hand is pressing
the spines of the vertebrae toward the prominent side. Page
The amplification of the method suggested for diagnostic
purposes will be found of great value as a manipulation designed to produce
movement between the vertebrae. That is to say, with patient on side
with his legs flexed and supported by operator, (see cut) increased flexion
of the legs will produce movement in the lumbar spine while the two hands
can be used to localize the movement in the particular segment desired.
In utilizing this principle as suggested above a mechanical table can be
used to great advantage.
When a rotary twist exists in the lumbar region,
either as a similar one elsewhere, a method somewhat like the one suggested
for the dorsal region may be employed, though it is harder in this region
to get a good lever. It is well to place the ball of one hand on
the spinous processes and while the other hand is pulling forward and round
on the prominent side to attempt to push the spinous processes towards
the prominent side. This will help to "untwist" the vertebrae, if
we may use that expression. We reproduce a cut showing this principle
in practice. As emphasized elsewhere some traction applied to the
spine will often prove of ovalue if judgment a employed in its use.
Some of the manipulations described in this article
will produce popping of the articulation, and some of them will not.
It is by no means a safe guide to work for pops. If a manipulation
produces a separation of the articular surfaces a pop will result unless
there is considerable degree of rigidity present, when it will require
sometimes weeks and months of treatment to normalize the spine sufficiently
for the separation to occur. WORK TO NORMALIZE THE SPINE, and if
the articular surfaces make a popping sound this is simply a point in passing,
and not one to be taken a great amount of notice of. The Old Doctor
in his "Osteopathy, Research and Practice" says:
"One asks, 'how must we pull a bone to replace it?'
I reply, pull it to its proper place and leave it there. One man
advises you to pull all bones you attempt to set until they 'pop.'
That 'popping' is no criterion to go by. Bones do not always 'pop'
when they go back to their proper places nor does it mean they are properly
adjusted when they do 'pop.' If you pull your finger you will
hear a sudden noise. The sudden and forcible separation of the ends
of the bones that form the joint causes a vacuum and the air entering from
about the joint to fill the vacuum causes the explosive noise. That
is all there is to the 'popping' which is fraught with such significance
to the patient who considers the attempts at adjustment have proven effectual.
The osteopath should not encourage this idea in his patient as showing
The Innnominate Articulations.
Osteopathically there is probably no articulation
that is more commonly involved in lesion than is the Sacro-Iliac joint.
This is due to two reasons: first, the articular surfaces are large and
there is but comparatively little movement provided therein, while secondly
all of the stains, etc. , to which the lower part of the body is subjected
are very liable to be felt most especially at this particular joint because
of its unique position. It is needless to say that it is important
to make sure that those basic articulations are normal seeing that theoy
serve as a foundation to the rest of the spine.
The anatomical points involved.
The two bones which form the Sacro-Iliac joint are
the Sacrum and the Innominate, and the surface upon each that articulates
is called the auricular surface because it is shaped somewhat like an ear.
Upon the sacrum the surface extends down to about the third segment of
bone, and upon the Innominate it covers an area just above the great sciatic
notch. The main ligaments are so arranged that the Sacrum is suspended
in a hammock-like fashion between the two Innominates, the posterior sacro-iliac
ligaments serving as the supporting ropes. See Fig. I. The
joint is now universally recognized as an amphiarthrodial articulation
despite the statements made by the older anatomists to the contrary.
That is to say, there is undoubtedly in this region a certain amount of
movement which is normal to the part, and as we will show later, if such
be not found, this is indicative of a lesion of the articulation.
The two ligaments that give most support to the joint and form a large
part of the capsule around it are named the posterior and anterior sacro-iliac
ligaments, and are very important osteopathically. Of these the posterior
are the ones upon which the greatest amount of strain is most frequently
brought to bear. There are also two sacro-sciatic ligaments which
run from the front and the back of the Sacrum on to the spine and the tuberosity
of the Ischium respectively. These latter ligaments serve to check
the range of motion of the articulation, and are so placed that they anchor
the Innominate and prevent it from moving around too freely. The
posterior sacroiliac ligaments are especially strong and form a very powerful
support to the back of the articulation. One can readily locate the
region of the articnlation by palpating the posterior spine of the Ilium
and working up and out from this point. It is well to remember that
the back of the Sacrum and the posterior portion of the crest of the Ilium
are regions from which a large number of important muscles take part of
their origins. We find for example that the Latissimus Dorsi, the
Erector Spinae mass, and the Multifidus Spinae muscles are all of them
firmly attached to these places.
The Lesioned Innominate:
At the outset of any discussion of a lesioned Innominate,
it is well to make sure that there is no misunderstanding regarding the
possible conditions in this region. Thus we would say at the very
start that we perfectly realize that lesions will be found resulting from
some violent trauma that may seem to differ in their pathology from the
conditions that we will describe as typical ones, in so as certain violent
strains of the articulation may result in conditions hard to handle owing
to the great straining and even tearing of the ligaments. A few suggestions
that may be valuable in such cases of hypermobility will be made later
in this article. On the other hand, there are cases that will be
met with in which a lesion, even though of several years standing, will
respond to one or two treatments. Such cases are not the type however
that will be met with most frequently in a general practice, for in such
instances we have examples of the exception rather than the rule.
In this latter class of cases we shall find that a single sharp drive in
the direction of the perversion will be all that will be necessary to correct
the condition. We mention these possibilities to avoid conveying
any wrong impressions as to our not recognizing them, but we do not bring
them forward as conditions that are the ones most frequently to be met
with, for they are not; indeed the pathology that we suggest as the general
pathology of the ordinarily perverted articulation is the pathology that
must be borne in mind as what is commonly found.
It is especially important that a clear conception
be obtained of the exact condition that is present when the somewhat careless
statement is made that the Innominate was found to be "slipped" and undoubtedly
the frequently employed term "a slipped Innominate" is responsible for
a great deal of misconception as to the real nature of the pathology in
the majority of the lesions at this articulation. The term "setting"
an innominate is used so frequently that many think of this lesion as they
do of a dislocated shoulder and imagine that the work that is done on the
reticulation by the osteopathic manipulations is really of the same type
as that done when a true dislocation of the shoulder is set by a surgeon.
That this is in general a wrong conception is obvious if we take into consideration
the anatomy of the region and of the joint itself. Many osteopaths
carry the point of diagnosis and treatment to such an extreme in this joint
as to assert that a so-called anterior innominate is an entirely different
condition from a posterior innominate. We do not believe that this
is a justifiable position to take up, and we would impress right here that
a lesion of this articulation is essentially the same whether we call it
an anterior slip of the bone or a posterior slip, in so for as the idca
that underlies the two conceptions is the same. We mean by this that
in each there is present some perversion of movement resulting from a thickening
of the ligaments and a proliferation of the connective tissues around the
joint. It is important to dissipate once and for all if possible
the thought of the ordinary lesion being like a dislocation of some one
of the larger articulations of the body. The condition is entirely
different and a careless use of terms is responsible for the fact that
such an idea ever gained ground.
We reproduce three diagrams in the attempt to make
clear a possible explanation of the actual mechanism of an Innominate lesion.
Figure I. diagrammatically represents the hammock-like suspension of the
Sacrum between the two Innominates. In this figure the central circle
represents the Sacrum and the other two represent the innominates.
It will readily be seen that ligaments 1 and 2 will hold the sacrum swinging,
as it were, between the Innominates while ligament 3 will prevent the innominate
moving beyond a certain definite limit. Fig. II. is an attempt
to represent the full range of movement of the Innominate upon the sacrum,
the symphysis remaining fixed. Fig. III. represents the mechanism
of the movement in this joint looking from in front. From this figure
it may be seen readily why it is that in many cases of innominate lesions
there is a difference in the lengths of the legs.
[FIGURE I, II AND III, page 69]
The commonest lesion of this articulation is what
is generally called a posterior Innominate, and by this term is meant a
condition in which the Innominate is either held at its posterior limit
of movement or held so that all the movement in this joint is limited around
this posterior part of the motion. There are a number of quite easily
recognized diagnostic points that may be noted when such a condition is
present, and these we will consider later.
Occasionally there is found a lesion in which the
Innominate is held at or towards the anterior limit of its normal motion
and we speak of such a condition as an anterior Innominate. There
is a third possibility of lesion that is not often spoken about, though
undoubtedly it is responsible for a great deal of trouble in and around
the articulation, and this lesion is one in which there is simply present
a condition of tightness or rigidity in the articulation, without the Innominate
being held at or towards
the anterior or posterior limits of movement. In this latter
condition the joint in lesion might be spoken of as a " midline " innominate,
as the rigidity is in reality holding the bone in its mid position, and
there is inadequate movement either anteriorly or posteriorly.
Diagnosis of Innominate lesions.
There are a number of points that are interesting
in connection with the so-called slipped innominate, and they are all points
that can readily be reasoned out from a direct knowledge of the exact condition
present. That is to say, if we have a proper understanding of a lesion
and do not think of it as a dislocated bone but rather as a condition of
congestion in and thickening of the tissues within many cases a proliferation
of the fibrous material around the articulation, we shall readily see that
the most essential point to test and the most important fact to determine
is whether or not the amount of movement in the articulation is normal.
In principle it matters little whether the Innominate is held at its posterior
limit of motion, or whether it is held at its anterior limit, or whether
it is held in the midline of its motion, seeing that there is an essential
feature common to the three lesions and this is that in each the movement
is limited. Other diagnostic points, though interesting, are therefore
by no means so important as the knowledge of some method whereby the actual
amount of movement may he tested, and an understanding obtained of the
degree of limitation with to a certain extent a knowledge of the direction
of that limitation. Indeed we regard as a point of the utmost importance
the employment of some method whereby such an idea may be obtained, for
unless this is done, a diagnosis can never be much more than guesswork,
and a wrong conception of the lesion is very liable to be obtained.
We shall describe a number of such diagnostic points besides discussing
a method whereby the actual amount of motion in the joint can be determined;
we regard these various diagnostic points, however, as subsidiary to the
main thought that we are suggesting.
As a method therefore whereby we may obtain a knowledge
of the amount of movement in the sacro-iliac articulation we would suggest
With patient on side, let operator flex the upper
legs of the patient and support the knee in his abdominal wall. Then
grasping the Innominate directly with both hands -- the one on the tuberosity
of the Ischium and the other on the crest of the Ilium -- a little rocking
movement of the body will enable the operator to determine whether
or not there is movement in the articulation. The accompanying cut
shows this diagnostic manipulation in use, and a few more points may be
suggested. It is well for the hand that is upon the crest of the
Ilium to grasp this portion of the bone in such a way that the tips of
two or three fingers come over the posterior spine of the Ilium onto the
sacral tissues. In this way the Innominate can easily be felt as
it moves over the Sacrum. It is important that the operator be careful
not to attempt to obtain a large amount of movement as the normal amount
is not a great deal; care must also be taken to obtain the movement in
the innominate articulation and not between the Femur and the Innominate
or in the lumbar region. If such a movement has not been attempted
before, it often requires some little practice before a skill that can
be relied upon can be gained; it is however simply a matter of practice,
as the motion obtained is the motion that is normal to the articulation,
and should be as readily felt as is the movement upon one's own body.
This latter can very easily be felt by placing the two hands on the crests
of the Innominates with thumbs pointing backwards and over the posterior
spines of the Ilium; from this position a little rocking motion of the
body can readily be felt as a movement of the posterior spines in the tissues
under the thumbs.
[Cut showing a good hold whereby
the amount of movement in the sacro-iliac articulation can be determined.
This same hold can be used to establish movement in a rigid articualtion.
As to the other points of diagnosis we would suggest
the following: tenderness around the posterior spine of the Ilium and also
over the articulation itself; tenderness over the pubic spines; a difference
in level in the two posterior iliac spines; and a difference in the lengths
of the two legs.
Some osteopathic physicians make their diagnoses
on the degree of out-turning of the two legs from the middle line when
the patient is lying upon the back, but we do not believe that this method
is sufficiently trustworthy in many cases to be relied upon as a universal
procedure. We will say a few words about the various points we have
suggested indicating the importance of each.
First of all as to the tenderness that is manifested over
the articulation of the Innominate and around the posterior spine
of the Ilium. This is very important and in the large majority
of cases will be found quite noticable as soon as the operator attempts
to manipulate around the articulation; there is also very frequently
certain lack of resilience in the tissues when there is a lesion
of the articulation. As to the point of the difference of
level in the posterior spines this is quite frequently of value
as a method of diagnosis, and as a general thing it may be said
that when the two spines are not level the lower of the two is the
one that is in lesion, because a posterior Innominate is far more
common than is an anterior one and a posterior lesion will of course
ensure in the majority of cases a lowering of the spine. It
is probably best to place the sides of the thumbs in the notches
under the actual spines as this will give a more sure landmark to
measure from. The tenderness the pubic spines is not of extremely
great value in most cases. In the matter of the length of leg, we
are presented with a problem that is of more interest than actual
value in so far as this diagnostic point has undoubtedly been exaggerated
in its importance. It is quite easy for a patient by a slight
twist of the pelvis while lying the table, to disturb the lengths
of the legs when there is no actual lesion present, and many true
lesions of these articulations do not present any differences in
the lengths of the legs.
In a large number of cases, however, a lesioned Innominate
will found associated with such a difference and when this is noted, it
is an additional point of interest, and often will persuade a patient that
there is at least some anatomic basis for the claims of Osteopathy.
From this viewpoint it is well often to note whether or not the two internal
malleoli are on a level. The limitations of this procedure must be
well realized, however, or untrustworthy diagnoses will be made in some
Correction of an Innominate Lesion.
In the majority of instances the correction of an Innominate
lesion is not a difficult task, though certain cases may resist
the very best efforts. This is unusual, however, and to one
case that will prove intractable, a large number will give way without
much trouble, provided a fairly accurate technique be employed.
It is important to bear in mind the general pathology of an Innominate
lesion when attempting to correct it, as carelessness in diagnosis
often results in a wrongly applied force to the articulation.
There are again, in this region as elsewhere, two general principles
that underlie the manipulations that are employed to normalize a
sacroiliac articulation. These principles are: direct movement
along the plane of the individual articulation, and separation of
the articular surfaces involved. Remember as a general thing
in the majority of cases, the lesion is set when the movement between
the articular surfaces in question is completely normalized. We
do not want however to be understood as asserting that a sudden
and swift drive will not in some cases apparently completely normalize
the articulation in one treatment. We do however believe that
such a drive in any particular case in which it may have proved
valuable had the effect of jarring the articulation so that as a
result a more free blood flow was established around the joint and
in consequence a completely normal condition was obtained -- there
being in that particular instance considerable congestion, perhaps,
with but little thickening of tissue, etc., relatively to the immobilization
present. In the majority of cases however, a normal condition
of the articulation results only from a course of treatment, which
means that restoration of the normal condition of the articulation,
or a setting of the lesion, is a gradual process.
[Cut showing a difference in
the level of the two posterior superior spines of the Illium on
a patient with an Innominate in lesion. Page 74]
[Cut showing method of stretching
the hamstring muscles preparatory to springing the sacroiliac articulation.
As we said above the osteopathic manipulations chiefly
in use employ either a forcible separation of the articular surfaces or
else are of such a nature as to procure forcibly direct movement in the
articulation. There are a number of excellent manipulations that
may be employed to "set" an Innominate lesion, though the majority of osteopathic
physicians do actually employ just three or four moves which they learn
to utilize with considerable judgment and skill. And right here we
would say that in order to obtain consistently good results on this region
a great deal of judgment is needed; more indeed perhaps than in setting
lesions in any other region. We mention this because it is so easy
to "miss out" in adjusting lesions of this articulation to the extent of
not getting complete results, although apparently the joint may respond
temporarily. We also again urge our readers to remember that any
technical procedures we may suggest are not described as the only methods
possible of working upon this articulation; they do represent, however,
certain methods of applying the main ideas of osteopathic therapy which
have been found to be practical. Other osteopathic physicians may
and undoubtedly do use similar procedures with slightly different holds,
perhaps, and the sole essential point is that the mechanics of the articulation
be thoroughly understood, as then it will simply be a matter of applying
such well recognized osteopathic principles as we have elsewhere described.
[Cut showing a good method of
springing the sacroiliac joint to set an Innominate. Page
A manipulation that "springs" the articulation very
successfully can be performed as follows: With the patient on his back,
the leg is first flexed well on to the patient's chest; this cannot always
be performed with ease at first as there is often considerable contraction
of the hamstring muscles etc., and these muscles have to be stretched thoroughly
before complete flexion can be obtained. Having flexed the leg fully
in this way, the tension may be let up for a moment and the leg -- flexed
now to a right angle with the body -- abducted firmly.
The abducted knee may now, be held in the physician's
abdominal wall or iliac fossa while one hand presses down on the opposite
anterior superior spine the other hand grasps the ankle of the abducted
leg and carries the leg to full extension. Generally in this way
a jar of the articulation results with sometimes a slight popping of the
joint, and the effect of such a procedure continued over some time is to
normalize any abnormality that may have been present in the region.
Such a procedure as this is very frequently of great value, though it is
fully as important to know how to use the technique described as it is
to know the actual technique. That is to say, just as a carpenter
must not only understand the theoretical use of his tools, which understanding
can of course be obtained from a book, but must also know in himself just
how to apply that understanding, so an osteopathic physician must not only
thoroughly appreciate the abstract side of the technique but must also
in every case apply that technique in a way that only an experienced judgment
can give him the power to do. We again urge our readers to remember
that Osteopathy cannot be learned from a book because the real essence
of the whole practice is founded upon a mature judgment which gives to
the operator the power to apply correctly a technique that without it is
necessarily a haphazard understanding and that with it transforms a crude,
imitator into a skilled physician worthy of any man's trust and complete
[Cut showing one method of employing
a driving force on to the sacro-iliac joint to set an Innominate
in lesion. Page 78]
Another manipulation that is of considerable value
if properly used is as follows. With the patient on his face, the
operator stands on the side of the table away from the Innominate that
is involved in lesion and supports the further leg just above the knee
in his one hand. At the same time he should place that portion of
his other hand between the thenar and hypothenar eminences on the posterior
spine of the Ilium that is in lesion. He should then raise the knee
from the table drawing the leg slightly towards and over the middle line
of the body, while at the same time he presses firmly on the posterior
spine and when all the tissues are on tension delivers a fairly strong
drive toward the table with this latter hand. This is a manipulation
that above all others needs to be used with the greatest judgment as it
is the easiest thing in the world to strain a joint unduly and thereby
to cause a lot of trouble to follow the attempted correction of a lesion.
We have seen several cases where this manipulation in inexperienced hands
or used without due consideration of the force employed and the long lever
utilized has strained an articulation markedly and produced a condition
that has taken a lot of careful treatment to overcome. The fact that
this is the case however means no more than it would mean for a carpenter
to say that his tools were sharp and that if they were used without due
appreciation of this fact either the person so using them or others around
might very easily be hurt. In experienced hands this manipulation is one
that will give a very good result in many cases.
A method that is perhaps the safest of all and that
will give many very excellent results is an amplification of the manipulation
that we described for the diagnosis of an innominate lesion. That
is to say, if the operator has the patient lying on the well side and draws
up the leg that is involved in lesion to a right angle so that he may support
it in his own abdominal wall, and if he then grasps the crests of the Illium
with one of his hands and the tuberosity of the Ischium with the other,
he may employ considerable force along the plane of articulation and thus
directly re-establish movement where that movement is lacking. We
have found this manipulation of great value in a number of cases.
Another procedure that we will suggest is designed
to drive the Innominate back along the plane of its movement and is often
of special value in an anterior Innominate; it can be described somewhat
as follows: With the patient lying on his back, the operator may flex the
involved leg to a right angle and proceed to stretch the muscles thoroughly
as we before described; he may then place one hand on the anterior superior
spine while he links the other arm around the upper leg in such a way that
he may get a firm pull on the hamstring muscles. From this position
operator may take a step forward thus getting a strong pull on the hamstrings
and at the same time he may drive down on the anterior spine. In
this way sometimes the articulation may be normalized when other methods
have failed, for it is a well-recognized fact that people respond differently
to treatments and that what will obtain results on one patient will not
do so on another.
It is important always to bear in mind the thought that
any results obtained come from the reaction to the treatment more
than they do from the treatment itself; we mention this as some
seem inclined to attribute to their own positive efforts any cures
obtained, forgetting a fact, which the "Old Doctor" has so often
emphasized, that if the structure of the body be restored to normal
then health returns as the natural result. Moreover, health
is to be expected in such a case not as a consequence of the stimulative
efforts of the operator upon the patient but as a result of the
restoration of those conditions in the patient that make for health
and not disease. This is a very important consideration.
Another method whereby an Innominate can often be
restored to a normal condition is simply by driving down on the knee of
the flexed leg. This has the effect of opening up the articulation
forcibly from the back, and will often assist in obtaining a normal condition
in the articulation. Again judgment is needed to get the best results
by this manipulation.
We wish here, to say a few words upon the subject
of hypermobility in an Innominate articulation, because some cases, as
suggested above, may present a great deal too much movement, and every
effort must then be directed to "tightening up" the articulation.
In some cases it is well to have the patient remain in bed for a considerable
time, while applying heat to the joint. In certain instances we have
found it of value to produce a little irritation in the articulation by
working right over the region of the joint itself. This is
sometimes followed by considerable pain for several hours or a day, which
will however let up after that time. Then occasionally we have found
it of value to bind the whole pelvis with adhesive tape, so as to give
the articulation a temporary support.
[Cut showing a method of driving
down upon the sacro-iliac articulation with patient on back.
Operator's one hand drives down on the anterior superior spine,
and the other arm locked around patient's leg, pull strongly up.
When using this method, the greatest care and judgment
must be exercised to prevent any undue irritation of the skin, and this
is sometimes excessive. It will be found that the Oil of Wintergreen
is the least irritating agent that can be used for the removal of the tape
and Lanolin is an excellent preparation to dispel any feeling of discomfort
in the skin after the tape has been removed. We have found that two
inch adhesive tape is the best for use in this way. It is often wise
to keep the tape on
for only a few hours at the start, and later the skin will become hardened
and be able to stand it on for a couple of days or so. The total
length of time that the tape must be used varies in every instance.
We have been enabled to obtain results in some cases of hypermobility of
this articulation in this manner after all other methods have failed.
It is also well just to mention the fact that hot
sitz baths are of extreme value in certain cases of lesions at this location.
These may be employed sometimes as a preparatory measure to the treatments,
sometimes in association with the treatments, and sometimes after treatments
have failed to give relief -- say in a sciatica -- though the lesion itself
may have been corrected.
To conclude these thoughts upon this region we would
just mention the possibility of a lesion at the pubic end of the Innominate,
or as we might put it at the symphysis pubis. This is very rarely
found, but undoubtedly it is present occasionally after some trauma, such
a fall which has strained the articulation in the front, etc. in such a
case there will be a slight difference in the level of the two pubic spines
with marked tenderness over this point. In certain cases of bladder
irritability this lesion will be noted, following some strain as mentioned
above. The normalization of this condition means the application
of simple mechanical principles to the separation and movement of the pubic
symphysis, and when this lesion is found, which will however be only very
rarely, it will generally be corrected readily.
As we said at the beginning of this article on the
Innominate, there is probably no articulation in the body that is more
commonly involved osteopathically than this one. The resultants of
such an involvement may generally be looked for either in the direction
of some pelvic trouble or in the direction of some irritation of the leg,
say in the form of a sciatica or a contraction of muscles, etc. This
is an articulation that must be looked to very carefully by the osteopathic
physician who hopes to get the best possible results, and who wishes to
establish a reputation for conscientious work and thoroughness of practice.
The "Old Doctor" has written in his "Research and Practice" as follows:
"We have relieved constipation, uterine hemorrhage,
and bladder trouble by adjusting the Innominates and the Sacrum.
********* We as anatomists and physiologists should record the truths
learned from our experience, for the reading and consideration of the future
generations. I want the osteopaths to raise the flag of reason and
fight for victory over such diseases as are named above. I want the
osteopath to be a hunter and to find his game, otherwise his work will
The coccyx, with the tissues attached to the bones
forming it, is sometimes found in lesion. By this we mean that there
may be congestion of these tissues of such a nature that the coccyx presents
a considerable amount of tenderness and may seem to be tilted out of its
normal relationship with the rest of the spine. As a general thing
it may be said that in the majority of cases in which this trouble is noted
there will either be quite a lot of pain in and around the region of the
coccyx producing a condition somewhat neuralgic in nature or there may
be some functional disturbance, such as hemorrhoids or a spasmodic contraction
of the external sphincter muscle causing constipation. This latter
condition often requires a direct stretching of the muscle by a rectal
dilator for its complete correction, but in some cases the irritation that
is produced by the lesioned coccyx is almost directly responsible for the
abnormal contraction of the muscle.
Anatomical points of interest.
The coccyx is formed anatomically of five bones,
though in most cases two or three of these ankylose as an individual grows
older. The coccyx, considered as a unit, is united to the sacrum
by anterior, posterior, and lateral ligaments, which hold it fairly firmly
in position. Also there is a disk of fibro-cartilage interposed between
the sacrum and the first piece of the coccyx which is somewhat analogous
to the intervertebral disks between the other vertebrae. On to the
back surface of the coccyx there are fastended the gluteus maximus and
the external sphincter ani muscles, while on to the anterior surface are
fastened the coccygeus and the levator ani muscles. The front surface
of the bones is covered by the pelvic fascia, which is separated from the
coccygeus muscle by a little areolar tissue. On the front of the
coccyx also the terminal ganglion of the sympathetic system, the so-called
ganglion impar is located, and this fact should be borne in mind when treating
locally per rectum.
A lesion of the coccyx.
When the coccyx is involved in lesion, there will
often be found considerable tenderness on the outside on the tissues over
the union of the sacrum with the coccyx, and the coccyx will seem to be
tilted away from its normal position in the middle line.
Symptoms referable to the condition should be looked for.
Many times trouble in this region can be corrected
by external manipulations designed to spring the coccyx and to reestablish
a normal blood supply in the tissues involved. A method whereby this
may be accomplished is the following: Place patient on side with flexed
legs; work well in the tissues of the ischio-rectal fossa and at the sides
of the coccyx and around the ischial spines endeavering to drain these
regions and to drive out any congested blood that may be in them.
Sometimes great tenderness will be found and considerable care is to be
used to get the results aimed at. It is well also to try to spring
the coccyx out to some extent by using the lever of the gluteus maximus
muscle that runs out and down to the femur from its attachment to the segments
of the coccyx. This manipulation can in certain cases be used to
greater advantage by leaving the patient lie over the end of the table,
with the feet on the floor. Work in the manner suggested in the regions
named will frequently accomplish excellent results when there is a congested
condition of the tissues preventing a normal drainage from these parts.
If the external treatment as suggested is unsuccessful,
recourse may be had to rectal treatment, though this in the majority of
cases should not be employed more than once a week. Let the patient
lie on his side with his legs flexed as before, and let the operator, standing
at the back of the patient, carefully insert his index finger, well vaselined,
into the rectum. In doing this it is important to remember that the
direction of the last inch or so of the rectum is in a line from the orifice
to the umbilicus. In some cases it may be necessary to go very slowly
as the external sphincter may involuntarily contract at the attempted entrance.
Having inserted the index finger to its full length the coccyx may be grasped
between the thumb and the index finger in the rectum. Normally there
is about as much movement in this region as there is between the second
and third phlanges of the fingers. The finger in the rectum should
straighten out the folds of the mucosa of the rectum and attempt to secure
some movement of the coccyx itself. The terminal bone of the coccyx
also should be smoothed out, as it were, and straightened if need be.
If this procedure is successfully accomplished, it will help to establish
a normal drainage to the tissues and to restore a good tone to the parts.
Once in a while very remarkable results may be obtained by normalizing
this region, as prolapses of the rectal mucosa and conditions of that nature
may sometimes be corrected thereby.
[FIGURES I, II, AND III.
Stretching the external sphincter ani muscle.
In certain patients complaining of obstinate constipation
it will be found that in addition to the correction of lesions of the spine
something has to be done directly to the external sphincter ani muscle.
This is necessary because the external sphincter may have become so tightened
that it is necessary to force it, to give way by somewhat drastic measures.
It is hardly within the sphere of these articles to do more than simply
state this fact, though as we do so we would urge that in the suggestion
put forward there is a great field of important thought for the osteopathic
Besides the vertebral lesions, such as we have described,
and also in many cases in association with them there may be what are commonly
called rib-lesions. This is important to remember, though it is important,
to bear in mind, the fact that a chronic rib lesion is but rarely found
without an associated chronic vertebral lesion. That is to say, it
is always wise to look for a vertebral lesion whenever there is apparently
a chronic rib lesion that is giving trouble.
The attachments of the ribs to the vertebrae.
It should be remembered that each of the typical
ribs articulates with two vertebral bodies and with one transverse process.
The two bodies that are used for this articulation are the one of the same
number as the rib and the one above that number; that is to say, the fourth
rib will articulate with the third and the fourth vertebral bodies.
The transverse process that is used is the one of the same number as the
rib, that is, the fourth rib articulates with the fourth process.
In considering rib lesions it is essential that the
anatomy of the parts be borne in mind. We reproduce two diagrams
showing the ligaments that attach the typical ribs to the vertebrae, and
will say a few words of explanation at this place. There is of course
a well formed capsule at both the regions of attachment, that is both where
the rib attaches to the body and where it attaches to the transverse process.
In addition to these capsules there are other ligaments, as follows: At
the body attachment there is a strong thickening called the radiate or
stellate ligament which is generally formed of three parts, the one attached
to the vertebral body above, the second running on to the intervertebral
disk, and the third fastened onto the body below; while in addition there
is an inter-articular ligament that stretches from the ridge on the head
of the rib across to the intervertebral disk and that divides the cavity
into two distinct parts, each of which has a complete synovial membrane.
This last ligament is absent in the case of the first, tenth, eleventh,
and twelfth ribs, and in these cases therefore there is but a single synovial
cavity. The attachment of the rib to the transverse process is just as
complete as it is to the body. We find that besides the capsule,
surrounding the articulation and definitely limiting the range of movement,
here also there are some additional ligaments present to strengthen it.
There are in other words several so-called costo-transverse ligaments,
which stretch between the rib and the adjacent transverse processes.
names are applied to these ligaments and the following description is adequate
for our present purposes. There is one ligament from the roughened
surface of the back of the neck of the rib to the front of the transverse
process; this is called the middle costo-transverse ligament, or sometimes
the ligament of the neck of the rib. There is another that is fastened
to the apex of the transverse process and which runs from this apex to
the tubercle of the rib; this is called the posterior costo-transverse
ligament, or the ligament of the tubercle of the rib. A third important
ligament is to be found attaching the upper border of the neck of the rib
to the lower border of the transverse process immediately above it; this
is called the anterior costo-transverse ligament, or sometimes the superior.
We would also call attention to the attachments of the serratus magnus
muscle, which is fastened to the upper eight or nine ribs, and of the levatores
costarum muscles which run from the transverse processes to the ribs immediately
below. The external and internal intercostal muscles which connect
the ribs together for almost their entire lengths should also be remembered
as it is only by keeping in mind the gross anatomy of these parts that
a proper conception of the lesioned conditions that may be found involving
the ribs can ever be obtained.
The movements of the ribs on the vertebrae.
We do not believe that we can do better,
in discussing the movements that are possible between the ribs and the
vertebrae, than to quote what is given in the English Edition of Gray's
Anatomy upon this point. We read on page 399 of this text as follows:
"The heads of the ribs are so closely connected to
the bodies of the vertebrae by the radiate and the interarticular ligaments
that only slight gliding movements of the articular surfaces on one another
can take place. Similarly, the strong ligaments binding the necks
and tubercles of the ribs to the transverse processes limit the movements
of the costo-transverse joints to slight gliding, the nature of which is
determined by the shape and direction of the articular surfaces.
In the upper six ribs the articular surfaces on the tubercles are oval
in shape and convex from above downward; they fit into corresponding concavities
on the anterior surfaces of the transverse processes, so that upward and
downward movements of the tubercles are associated with rotation of the
rib neck on its long axis. In the seventh, eighth, ninth, and tenth
ribs the articular surfaces on the tubercles are flat, and are directed
obliquely downward, medialward, and backward. The surfaces with which
they articulate are placed on the upper margins of the transverse processes;
when, therefore, the tubercles are drawn up they are at the same time carried
backward and medialward. The two joints, costo-central and costo-transverse,
move as if on a single joint, of which the costo-central and costo-transverse
articulation form the ends. In the upper six ribs the neck of the
rib moves but slightly upward and downward; its chief movement is one of
rotation around its own long axis, rotation backward being associated with
depression, and rotation forward with elevation. In the seventh,
eighth, ninth, and tenth ribs the neck of the rib moves upward, backward,
and medialward, or downward, forward, and lateralward; very slight rotation
accompanies these movements." Physiologically the movements are often
described as taking place along two axes, the one being drawn through the
anterior extremity of the rib and the costo-central articulation and the
other being drawn through the two articulations of the rib with the vertebra,
namely, at the transverse process and at the body. We reproduce two
figures showing these movements from a diagrammatic standpoint.
[FIGURES I, II, III AND IV.
Lesions of the ribs.
We will consider lesioned conditions of the ribs
in as orderly a manner as possible, suggesting the main points that may
be of value in connection therewith. Before doing so however, we
would again urge that frequent association of a vertebral lesion with a
rib lesion be not forgotten. Practically, in most chronic lesions
the real trouble is in the vertebrae that are associated with the rib and
the lesion of the rib will give way only when the vertebral lesion that
is really causing it is found and corrected.
A. The first and second ribs.
In order to understand the possible lesions of the
first and second ribs it is important that the main anatomical points connected
with them be thoroughly grasped. The first rib especially is peculiar
in its attachments. It must be remembered that these ribs are placed
more or less flatly, that is to say so that they may serve as a roof
to the thorax. This statement especially applies to the first rib.
Then too, there are three important muscles which are fastened to these
ribs; they are the three scaleni. These muscles take their origins
from the transverse processes of the cervical vertebrae, and are inserted
on to the upper and outer surfaces, whichever they may be considered, of
these two ribs. The normal range of these two ribs and especially
of the first is chiefly in the upward directions, there being of course
a well defined range through which they should be able to pass freely.
It is possible to "raise" either first rib temporarily
by inclining the head laterally toward the opposite shoulder.
This will put the scalene muscles and other tissues on a full stretch
and will cause the rib to be drawn up. To a slight extent
this may sometimes be shown in the case of the second rib also,
but in this latter instance the movement is not so well defined.
It is often possible to correct lesioned second ribs by adapting
slightly manipulations that work essentially upon the first rib,
and we will here consider especially the first rib, simply suggesting
a few points of interest regarding the second after we leave the
Diagnosis and correction.
To diagnose a lesioned first rib, a good method is
to place the hands on the patient's shoulders so that the third fingers
will lie along the clavicles; then the second fingers will fall naturally
on to the first ribs. When making a diagnosis of trouble connected
with this rib, it is essential that both hands be used together, in order
to test by comparison, as otherwise a mistake is very liable to be made.
It must be remembered that the region thus palpated is always somewhat
tender, and if the palpation is done carelessly tenderness will be found
whether or not there is a lesion present. In connection also with
this region we would say that often a lesion of the first rib is associated
with lesions of the upper dorsal or of the middle cervical vertebrae or
in both these regions, and these latter lesions will have to be corrected
before any permanent results can be obtained with the lesioned rib.
Essentially then, the cause of a lesioned first rib is the pull of the
tissues upon it which are dragging it toward its uppermost limit of movement
and then holding it there. Some manipulation then which will stretch
these tissues must be the manipulation that will be of greatest value in
correcting the actual condition and then manipulations designed to prevent
the contracting of the tissues a second time should be employed.
An excellent method which may be utilized to obtain the first of these
two results and which is based upon the simplest application of mechanics
and anatomical knowledge, is the following: Bend the patient's head over
the side of involvement, say the right side, and place the right hand firmly
onto the most prominent part of the first rib; then by placing the left
hand on the patient's head it can be lightly rotated, and the weight of
the head itself may be utilized largely to accomplish the result aimed
at. While the head is being rotated in this way, the operator should
keep a considerable amount of force applied all the time on the involved
rib; in this way the anterior tissues call be stretched thoroughly.
It is remarkable what a great amount of power can be obtained by this simple
manipulation and very successful results will be gained in many cases.
Associated with such a manipulation as the above it is important to work
also on the neck and upper back, so as to make sure that the tissues involved
shall receive their normal blood and nerve supply; in this way any further
contraction of the muscles can be obviated. There are many other
manipulations that are used and that obtain the same result as the one
we are suggesting but the principle that must underlie the successful "setting"
of a first rib is the complete normalization of the tissues that are responsible
for the condition as it exists.
[Cut showing method whereby t
he tissues attached to the first rib may be thoroughly stretched.
Head is just bent over towards the rib and then while considerable
force is being applied on the rib, head is carried forward and to
the opposite side. A very powerful stretch can be obtained
in this way. Page 92]
[Cut showing method whereby a good spring can
be given to the upper dorsal and the upper ribs. When tissues
are on tension a sharp drive will tend to correct any lesioned condition
of the tissues and articulations. Page 93]
Right here we would simply mention a condition which
is met with occasionally, and which, when thus encountered may cause some
confusion unless the possibility of its presence be understood and recogmzed.
This is what is called technically a "cervical rib" and is actually an
enlarged anterior tubercle of the transverse process of the seventh cervical
vertebra. If this is not recognized when present a misdiagnosis is
liable to be made as the condition may be thought to be a displaced first
rib. If this abnormality be remembered there is but little danger
of such a mistake being made, as it is from a lack of knowledge of the
existence of the condition that the possibility of error arises.
A good manipulation that will spring the upper ribs
and the region of the upper dorsal generally is the following: With the
patient on the stool, let the operator place his hand on the upper ribs
with the thumb near the articulation with the transverse processes; then
let him place his other hand on the patient's head and carrying it around
towards the side of the lesioned rib, when every tissue is on tension drive
downward with both hands. See Cut. A similar result can be
obtained by standing behind the patient, who is seated on the table, and
carrying one arm across the chest so that the hand comes on to the root
of the neck from the front; then the other hand can be placed on the head
and the patient having been thrown off his balance by the operator taking
a step toward the side a drive downward may be given as before.
The correction of a lesioned second rib can often
be accomplished by applying the principles that we have outlined for the
first rib. In some cases however the adaptation of the principles
we will suggest for the lower ribs will be found to get better results.
We would especially emphasize the association of upper dorsal lesions with
lesions of these upper ribs.
B. The middle section of the ribs.
A lesion of one of the typical ribs, that is one
of the middle section, is usually a slight upward rotation of the rib.
That is to say the rib is held to a slight extent in the position that
it would normally assume if the whole section of the ribs should be raised
as in breathing. There is in other words a tension of the surrounding
tissues that is preventing the rib from taking up its more normal relations
with the other ribs and which is holding it slightly twisted all of the
time. In a typical rib lesion there will be found to be a prominence
of the rib in the mid-axillary line and often at the angle also; there
will generally too, be found considerable tenderness over the region of
articulation of the rib with the transverse process, and in the majority
of cases there will be symptoms that may be directly referred to the rib
lesion, such as a neuralgic condition of the intercostal nerve, etc.
In some cases also tenderness will be found at the chondral ends of the
ribs, that is at the ends that articulate with the costal cartilages.
[Cut showing method whereby an
individual rib can be adjusted in its articulation with the vertebrae.
In cut operator's right hand is on rib involved, and his left hand
is close against the spinous processes on the near side. Page
As a general thing, the correction of a rib lesion,
unless it is simply acute in nature, is dependent largely upon the correction
of the vertebral trouble that will be found associated with it. However
in many cases it is necessary to do some definite work upon the ribs themselves,
and in these cases results will be accomplished either by springing the
articulation of the rib with the transverse process, or by forcing the
rib to go through its full range of movement. We will suggest methods
that will accomplish both of these effects. In either case the end-result
obtained is the complete normalization of the rib involved and the tissues
that are associated with it.
[Cut showing a method whereby
the ribs may be sprung in their articulations with the vertebrae.
To spring a rib articulation thoroughly one method
is to have patient lying on face and to employ a drive downward on the
rib in question. The operator should stand on the side of the patient
away from the involved rib and place the hypothenar eminence of one hand
close to the spinous processes a little below the level of the vertebra
that articulates with the rib in question. Then he should place his
other hand firmly on the rib involved so that the ball of the band be on
the angle. See Cut. When working in this way it is best to
use the left hand on the rib when it is the right rib that is in trouble,
and to use the right hand when it is the left rib that is involved.
From this position every tissue should be put on tension, which will mean
that the hand near the spinous processes will be carried up until it is
upon the transverse process of the vertebra which is at fault or which
has the rib adjoining it at fault, and that the other hand will have the
rib tissues on thorough tension. When every tissue is on good tension
then a fairly strong drive should be given with both hands and often the
rib will be felt to slip slightly under the hand that is upon it.
[Cut showing method of putting
the tissues associated with a rib lesion on full tension.
Operator holds down on rib below the one involved and patient takes
a full breath while carrying his arm up and around. Page 97]
Another method that is very satisfactory is the following:
With the patient on the back let operator, standing on the side opposite
from the one involved, insert one hand between the ribs in lesion and the
table. The hand should be clenched somewhat that the ribs may have
a firm place upon which they may be supported. Then the patient's
elbow of that side should be supported against the operator's chest and
held in the other hand of the operator; from this position a strong drive
when all the tissues are on tension will again often accomplish a good
springing of the rib, in its articulation with the transverse process.
To secure a full range of free movement between the
rib and its articulations there are also a large number of possible manipulations
that can be employed. A good one is the following: Let the patient
be seated on the table, with his back to the operator. Then let the
operator sit by the side of the patient as in the cut. Next let operator
encircle the thorax of patient and grip the rib below the one which is
in lesion. Then let him instruct the patient to take a deep breath
and at the same time to carry his arm through a full circle of movement
up and back. While the patient is doing this, the operator should
endeavor to hold down the entire lower segment of the ribs, a task which
will often be found quite difficult. This should be repeated several
times, and will be found to be a very powerful movement to restore the
full range of motion to the rib.
Another method that is of value and that is frequently
employed may be described as follows: Let the patient be seated and let
the operator stand back of him. Then let the operator place one hand
on the shoulder of the patient on the side opposite from the rib that is
in lesion. This hand should be so placed on the shoulder that the
thumb will pass down and over the spinous processes and on to that part
of the lesioned rib that is just outside the transverse process.
Holding this hand firmly in this position operator may carry the arm on
the side of the lesion up and round and finally back. The manipulations
may be completed by a jarring upward of the arm that has been carried around.
Often the rib may be felt to slip under the thumb that is pressing upon
There are many other manipulations that are of value
but it is impractical to do more than simply to suggest the general principles
of the correction of the abnormal conditions that may be found and then
it is best to leave the actual working out of the details to the operator
who is attempting to make a correction in an individual case.
A good manipulation for the lower middle ribs is
the following; it should however be used with considerable care as a very
powerful spring is thereby obtained. Have the patient lying on his
face and instruct him to raise up on his elbows so as to bow the lower
part of his back. See Cut. Then standing on the side of the
patient, opposite from the side on which the lesion of the rib is, let
operator place his hand on the lower segment of the ribs below the inferior
angle of the scapula, and let him place the other hand on the nearer of
the patient's two knees. See cut. Next after raising himself
on his toes let him sway two or three times from side to side and then
deliver a drive towards the table with the hand that is on the ribs.
Very frequently this manipulation will produce a separation of the articulations
and if there was any trouble in the rib it can often be corrected by this
[Cut showing method of springing
the lower ribs in their articulations with the vertebrae.
C. The lower ribs.
The condition that is most frequently found in the
lower two ribs is a depression of their extremities so that they point
more towards the crest of the ilium than they should do. Sometimes
the condition is met with in which these ribs are held upward, though this
is not so common as the downward lesion just mentioned. In either
case it is well to remember the essential anatomical points that are involved.
These ribs are embedded in the abdominal musculature quite firmly and are
united to one another by the intercostal muscles as are the other ribs.
The twelfth rib has attaching to it the quadratus lumborum muscle which
is also attached to the lumbar transverse processes, and which takes it
origin from the rest of the ilium. Any lesion of these ribs then must be
associated with congestion and contraction of the muscles that are attached
to them as otherwise the ribs could not be in any way out of position.
In point of diagnosis the most noteworthy feature of a lesioned condition
is the extreme tenderness that is to be found on the tips of the ribs involved
in lesion and the tense condition of the muscles attached; there is also
very often associated with a lesion of these ribs a deep pain and congestion
in the region of the iliac fossa.
The best way to handle lesions of these ribs is to
use the pull of the muscles that are attached to them. We will describe
one method that may be found valuable in a depressed condition of the ribs
and a very little adaptation or figuring will be all that is necessary
to correct any other types of lesions that may be met with. Let the
patient lie on his back, with his legs flexed; let the operator hook one
arm under the crotch of the flexed knee and raise the legs up from the
table so as to form them into a pump-handle lever with the body.
Then let him carry them round and at the same time work deeply in the tissues
immediately below the rib and between it and the crest of the ilium.
Work of this kind and also direct stretching applied to the tissues below
the rib will in time do a great deal of good in conditions of lesion of
these parts. In cases in which there is a greater contraction of
the intercostals than of the quadratus lumborum the pull must be directed
to a restoration of a normal condition of tone to these muscles and the
pull must be upon the ribs themselves directly.
[Cut showing method of working
on the tissues associated with a twelfth rib lesion. Page
Besides the considerations that we have suggested
for the individual ribs it is often helpful to elevate the entire set of
ribs on one or both sides. This is frequently spoken of as "raising"
the ribs. One method that is of value is the following: Let the patient
lie on his side, say the right side, and let the operator pass his own
left arm under the patient's left arm, while with the other he exercises
some pull directly upon the ribs themselves. Then from this position
he may pull upon the entire set of the ribs by using the patient's arm
as a lever.
[Cut showing method of raising
the entire set of ribs on one side. Page 102]
This movement is one that can very frequently be
employed to the greatest advantage in a general over-hauling of a patient,
such as it is well to give in certain cases.
Before making any suggestions with reference to abdominal
treatment given osteopathically, we wish to say a few words in introduction.
The idea of working upon the abdominal musculature is not an osteopathic
innovation, as is the idea of adjusting the spine. Indeed the value
of massage of the abdomen has been recognized for some time and has been
employed to advantage in certain cases, such as constipation. The
manipulations used by an osteopathic physician however upon the abdomen
are not of quite the same as are the manipulations such as a masseur employs,
in so far as the work that the former does is conducted as an attempt to
overcome a sagging of the intestine, and to produce a normal arterial flow
to the viscera. The fact that working the abdominal viscera is of
value cannot be gainsaid and any who would not include this phase of manipulation
in their osteopathic technique are either unduly narrow or else ignorant
of the good that can be obtained in selected cases by its use. Possibly
the most important locations that should be worked are the two iliac fossae
and the general course of the colon may to advantage be followed.
It is extremely important to observe that the fingers be not dug into the
abdomen in such a way as to damage any organ or bruise the intestines in
any way. If any tender places be found or hard impacted regions be
noted then the treatment should be designed to overcome them and to restore
a normal condition to the tissues that are thus abnormal. In this context
we would just mention the great value that the enema is to the osteopathic
physician who understands its limitations and who is wise enough to use
it realizing that therein as in other similar procedures is a tool that
is very valuable if properly employed and dangerous if its employment be
abused. As regards the abdominal manipulations it is essential that
the patient's legs be flexed and sometimes better results can be obtained
by lifting the patient's flexed legs well on to the abdomen by one arm
passed under the flexed knees and by thus relaxing the tissues still more
effectively, while with the other hand deep work be done upon the abdominal
viscera. The knee chest position may also be frequently employed
In this connection we would also mention the lesion
of a very lax abdominal wall that will be found in certain patients.
This is due to a complete loss of tone in the muscles themselves and even
in some cases to an atrophy of the actual muscle tissue. Such a condition
consitutes an important osteopathic lesion and. in some patients results
will not be obtained by the spinal manipulations until the tone be restored
to the muscles of the abdominal wall. The restoration of this tone
lies largely with the patient as it is just as important for the patient
to exercise these muscles and thus to restore the normal tone gradually
to the region as it is for the osteopathic physician to work on the spine
and to correct the lesions that will of course be found in such cases.
ANY FINAL AND COMPLETE CORRECTION MEANS THE GRADUAL RESTORATION OF A NORMAL
CONDITION TO TISSUES THAT AT THE OUTSET WERE ABNORMAL. Right here
too we might mention the extreme importance of working upon a misplaced
uterus, when such be found, and stretching its ligaments locally, in the
attempt to correct the misplacement. This often requires a number
of treatments, but is frequently successful in the end. In cases
too, presenting a stenosis of the cervix of the uterus, its very gradual
dilation and especially the dilation of the internal os stimulates growth
and is of considerable value in helping to overcome the trouble.
Pressure over the pubic spines with the palm of the hand on the locations
of the round ligaments is often of value in checking the pain of a dysmenorrhea,
and abdominal pressure can often be used to check gastric and intestinal
The only region of great osteopathic import that
is left for consideration is the clavicle. This bone may be the seat
of lesions both at its sterno-clavicular articulation and also at its acromio-clavicular
end. The commonest lesion that is found involving the clavicle is
what is termed a depressed clavicle, the lesion being at the sterno-clavicular
articulation. Operator's can make a diagnosis of this lesion by having
the patient lie on his back and, while standing at the head of the table,
after making sure that the patient is lying quite straight running the
two thumbs along the two clavicles until they reach the sternal ends.
If these two ends are not in line, then one or the other must be in lesion,
and it is generally the one that is down that is at fault. It is
important to remember however that the opposite condition is found occasionally
and the general condition of the tissues together with associated tenderness
and other points that will suggest themselves will determine which is the
A lesion of the acromio-clavicular articulation is
also met, and is generally associated with a history of a slight strain
or injury to the region; for example, such a condition may follow the strain
of carrying a heavy weight or may be found in a baseball pitcher who has
in some way overtaxed the arm, etc. We will find that when such a
lesion is present there will be considerable tenderness over the actual
articulation and at the same time, there will be symptoms that will seem
to be in the tissues of the arm itself, such as quite acute pain in the
biceps muscle, or a feeling akin to rheumatism in the shoulder joint, and
so on. Sometimes the pain from such a lesion will radiate up the
trapezius muscle toward the neck and the occipital region. It is
important to remember that lesions of this articulation are often associated
with lesioned conditions of the upper dorsal region and frequently the
trouble associated with the lesion of the clavicle will not clear up until
the upper dorsal condition has been corrected.
[Cut showing method of adjusting
the clavicle by putting every tissue on tension and carrying the
arm well up, back and round. Page 105]
Correction of lesions of the clavicle.
A. The sternal end.
Several methods can be employed to set a lesion of
the sternal end of the clavicle. The commonest lesion as has been
suggested is the depressed condition of the bone, due to a contraction
of the tissues that attach it at this end to the first rib, and we will
suggest two methods that may be used to advantage in the correction of
this trouble. First, however, we would simply say that if there is
a lesion here, resulting in an elevation of this end, the condition can
best be corrected by attacking the real causative factor which is the sterno-cleido-mastoid
muscle; this muscle, in such a condition, should be thoroughly stretched
and the nerve supply completely normalized in order, if possible, to restore
a condition to the articulation of perfectly adjusted surroundings.
As a result of such work the clavicle will be restored to its normal relations
with the surrounding tissues. The more common condition however is
the depression of this end of the clavicle, and some manipulations must
be used which will draw the clavicle up and away from the sternum.
We will describe a couple of such manipulations that are of value in the
correction of the condition that we are describing. One that is good
is as followes: With the patient on his back, clasp the wrist on the side
of the lesion and placing the side of the thigh in the patient's axilla,
carry the whole shoulder girdle up to its fullest range of movement, at
the same time bearing up well with the fingers that are behind the clavicle.
We reproduce a cut showing this manipulation in use. This move gets
so much leverage upon the clavicle and especially upon the sternal end
of it that it will accomplish very good results. Another manipulation
that may be used to advantage in contracted conditions around the sternal
end of this bone is as follows: With the patient upon his back support
the elbow of the affected arm in the iliac fossa, and with one hand support
the entire shoulder girdle. First establish good motion in the sternal
articulation by moving the arm up and down several times towards and from
the patient's head. Then place the thumb of the other hand under the clavicle
and about an inch from the sternal end, and continue the movement of the
shoulder girdle up and down as before. See, Cut. The amount
of force employed may be regulated by the force exerted by the thumb under
the clavicle. Either or both of these manipulations may be used to
advantage in trouble at the sternal end of the clavicle. A lesion
at the acromial end will sometimes respond to the first of the above described
manipulations, though it is frequently necessary to employ also some special
separation at the articulation. The following manipulation found
useful: With the patient sitting on the table, operator stands behind him,
and clasps the elbow of the affected arm in his own hand of the same side;
that is, he clasps the left elbow in his own left hand. Then as be
carries the arm around he can either press the clavicle forward with the
fingers of his other hand or inserting his other arm under the patient's
axilla he may pull forward on this clavicle. Generally if this is
done several times a grinding of the articulation will be both felt and
heard, and often simply the one treatment will be all that is necessary;
frequently however several treatments must be given, and some cases will
be found to resist treatment most obstinately. In many cases involvement
of the upper dorsal will be found associated with the acromio-clavicular
trouble, and unless the former region be corrected the latter will not
[Cut showing one method of elevating
the sternal end of a clavicle. Operator's thumb under clavicle,
near sternum serves as a fulcrum. Page 107]
[Cut showing method of obtaining
separation of the acromio-clavicular articulation in cases of lesion
at this location. Page 108]