Principles of Osteopathy
Dain L. Tasker, D. O.
CHAPTER XX - Manipulation
There has been a very rapid evolutionary development
of manipulation as a therapeutic method. It has been found to be
a wonderfully adaptable means of alleviating human suffering. Undoubtedly
the principles underlying any method of manipulation contribute something
to all other so-called systems of movement cures. Manipulation is
hand practice in the surgical sense. It is applicable in a tremendously
wide range of disorders, for example the treatment of fractures, sprains,
breaking adhesions, reducing dislocations, assisting venous circulation,
stimulating peristalsis, reducing congestions, quieting reflexes, stimulating
nerve centers, and many other things of a helpful character.
The form of manipulation most generally understood
is massage. This term is used by some to mean any method of manual
manipulation. Massage is a method of manipulation which has been
extensively practiced and written about, hence there is no excuse for the
prevailing slovenly use of the term to cover all forms of hand manipulation.
The characteristic movements of massage are friction and kneading.
They have proven wonderfully satisfactory as adjuvants in overcoming venous
stasis and toning the neuro-muscular mechanism of the body. No one
who is at all conversant with the phenomena of natural recovery fails to
recognize the great assistance which even the crudest use of massage furnishes.
The next step of a scientific character in the development
of manipulative methods was Swedish movements. These introduced leverage
and voluntary resistance as new factors in increasing the tone of the neuro-muscular
apparatus. A very limited field was accorded to massage and Swedish
movements. Both these methods were practically never used except
as prescribed by a physician. Practically no diagnostic ability or
initiative is credited to those who apply the methods. Surgery was
"Formerly that branch of medicine concerned with manual operations tinder
the direction of the physician." If the evolution of surgery can be used
as a criterion for judging the future of manual manipulation, there can
be no doubt as to the commanding position that will be attained.
Osteopathy has introduced a new factor in manipulative
therapeutics, i. e., the adjustment of joint luxations and subluxations.
It is interesting to note that the art of manipulation applicable to this
corrective work was developed independently of massage and Swedish movements.
Osteopathic movements could not have evolved naturally from massage and
Swedish movements, because osteopathic technique is the direct result of
the theory, sturdily asserted and defended by Dr. A. T. Still, that structure
governs function." His recognition and treatment of joint lesions, "subluxations",
led to the development of a system of movements primarily surgical in character.
No matter how much any osteopathic physician may take issue with him in
matters of theory the fact exists that not one of them believes that he
has ever been approached in skill in the art of corrective manipulation.
Present day osteopathic physicians are beneficiaries
of all the successes credited to massage, Swedish movements, Dr. A. T.
Still's original work, special operations devisee by orthopaedists all
over the world, and the brilliant work. of Professor Lucas Champoniere
in the treatment of' fractures by "gluco-kinesis" and mobilisation.
We are beneficiaries of all these because Dr. Still believed in fundamental
medical education and the establishment of a school of medicine and surgery
primarily devoted to the scientific development of manipulative therapeutics.
Since at the time of his most active work in practice and teaching, the
abuse of drugs and surgery was at its height, it is no wonder that he desired
to establish a system of practice which would not be burdened by inheritance
of the foibles and failures of drug-therapy.
As a result of the success of osteopathic theory
and practice, there has been the inevitable plagiarizing of its literature
and methods by those who find it profitable to impose on an ignorant public.
This plagiarizing has been done under several names, but especially under
that of chiropractic. The history of this attempt to appropriate
the principles and methods, of osteopathy, without requiring any creditable
educational work to make them safe means of treating ailing human beings,
is a sad travesty on the standards of medical education in this country.
Under our present laws new schools of, medicine may be started as short
cuts to avoid the moderately severe requirements of established schools.
So long as this is possible, there will continue to appear "new schools"
exploiting some phase of established methods under new names.
Methods of Procedure. - Osteopathic physicians
frequently differ as to methods of procedure, but they all work according
to the same principle. For instance, a subluxation of a vertebra
might be discovered by two osteopaths. The first one might undertake
to reduce the subluxation without any preliminary work on the muscles,
believing that it is best to go right to the seat of trouble and remove
it. His treatment would be severe because much strength would be
required to overcome the resistance of the muscles governing the articulation.
The second one might spend considerable time on the preliminary work of
relaxing the muscles of the articulation, increasing flexibility, reducing
sensitiveness, etc., before attempting any specific reduction of the lesion.
The ultimate result of both methods would be alike. The question
of which method is best lies wholly with the individual osteopath.
Some like to put forth a severe effort for a short time, others a moderate
effort for a longer time. Outside of the special choice of the osteopath,
lies the business one of satisfying the patient. Severe work at the
outset frightens some patients, furthermore, it actually bruises some of
them. The ultimate result of the treatment may be excellent, but
the patient does not quickly forget the methods used. There is a
parallel between the immediate after-results of a severe osteopathic treatment
and surgical shock. This shock should be avoided as much as possible.
The movements hereafter pictured and described are
all made with reference to structure rather than function. Few references
are made concerning their applicability to special diseases. We do
not care what the name of the disease is. The groups of symptoms
which make up the pictures described in symptomatology have very little
significance to the osteopath. His movements are not made with reference
to a named disease, but to a faulty structural condition. The structural
condition may be the basis for the physiological. Function does affect
structure. We are not to lose sight of this fact. Function
may be perverted by bad habits, hence our therapeutics must comprehend
the hygienic and dietetic side of life as well as structural.
Every movement herein outlined secures a definite
effect on a muscle, or is used to affect the relation of bony parts.
The movements made to affect the muscles of the back
and spinal column are based upon the attachment of the muscles and the
leverage they exert on the spinal column.
Relaxation of the Latissimus Dorsi. - The
arrangement of the back muscles has been noted in the chapter on Positions
for Examination. In order to relax these muscles in their natural
relations, i.e., from superficial to deep groups, we begin with such a
movement as will separate the extremities of the most superficial muscles
to their fullest extent. Fig. 162 illustrates the method of relaxing
the latissimus dorsi. One hand extends the arm to its fullest extent,
the other hand anchors the ilium. It will be noted that the lower
dorsal and lumbar portions of the spinal column are lifted by the pull
of this muscle. Also the four lower ribs are raised.
The intrinsic effect of this stretching movement is to take most of the
tension out of the muscle itself and increase the amount of metabolic change
taking place within it. But that is not what is primarily intended.
The intrinsic effects are mere incidents in the physiological life of the
muscle, and as such are found following all kinds of muscular movements.
The extrinsic effects are what concern us most; the effect upon the vertebrae
and ribs, the change in the form of the chest.
There are three uses for this movement. First,
as preparatory to work upon muscles lying beneath it, i. e., purely relaxing.
Second, in case of overlapping by any one of the four lower ribs.
It is a common condition to find the twelfth rib under the eleventh, or
tenth under eleventh. The pull of the latissimus dorsi is exerted
on all alike, hence the individual ribs are brought into their proper relations.
Relaxation usually allows a return of the faulty position, but if the ribs
are held at their extremities by the operator for a few seconds after relaxation,
the intercostal muscles and quadratus lumborum will be filled with arterial
blood which tones them. The patient should be directed to hang by
the hands several times per day so as to get a good effect on the position
of the lower ribs. Third, to affect lateral curvature of the spine
in the lumbar or lower dorsal portion.
Relaxation of the Trapezius. - The trapezium
is another of the superficial group of back muscles. Its fibers are
so variously attached that several movements are required to relax all
its divisions. Fig. 163 illustrates the method of grasping and holding
the scapula while relaxing the trapezium. The scapula is rotated
on the thorax as far as possible toward the head so as to stretch those
fibers extending from the spine of the scapula to the sixth and twelfth
dorsal spines; then away from the head to affect the cervical fibers, then
away from the spinal column to relax the short fibers between the tipper
dorsal spines and scapula. There is a vast difference in the way
the scapula can be moved about in different cases. Those having any
tendency to asthmatic trouble will present a very fixed scapula.
The more marked the asthmatic condition is, the more difficult it is to
move the scapula. Pleurisy and lung troubles, especially when coughing
is frequent, tend to hold the scapula fixed. Lifting the patient's
body above the table by the scapula gives instant relief in many cases
of pleuritic pain, intercostal neuralgia or angina pectoris. This
result is explained by the removal of the pressure exerted by the scapula
when it is held too close to the thorax by contracted muscles which are
acting reflexly. A subluxated rib is usually responsible for the
pains mentioned, but the muscles of the scapula are partially respiratory,
hence act in connection with disturbances of normal rhythm of intercostal
muscles. The pressure of the scapula helps to fix the whole chest
in an unyielding condition. That which was at first purely helpful
in character becomes in itself an added irritant. This movement or
series of movements affects the tone of the muscle fibers, then the whole
Relaxation of the Rhomboids. - In the second
group of back muscles we find the rhomboids, major and minor, accessory
muscles of inspiration. Fig. 164 illustrates a method of stretching
these muscles. The patient's elbow is placed against the physician's
abdomen. Pressure against the elbow forces the scapula back, and
makes its vertebral border prominent. The physician's fingers grasp
this border securely, and then lift steadily upward. This movement
is excellent for the purpose intended. That which has been written
concerning the trapezium is applicable to the rhomboids. Outside
of the intrinsic effects on the muscle and on respiration, a slight effect
may be exerted on a lateral curve in the interscapular region. It
is generally used as preparatory to work on deeper structures.
The Pectoralis Major and Serratus Magnus.
- Following these movements, where general thoracic and spinal relaxation
are desired, the movement illustrated in Fig. 165 may be used. It
affects the Pectoralis Major and Serratus Magnus. By pushing the
patient's elbow as far back as possible, the scapula is approximated to
the spinal column, hence the serratus magnus is put upon a tension which
lifts the eight upper ribs. The pectoralis major also affects the
upper ribs. The physician's hand on the angle of the ribs accentuates
the expansion of the chest. This is a general movement, but one which
has far-reaching effects upon respiration and circulation. It is
adaptable to many specific structural defects of the ribs.
In Fig. 166 the physician again uses the humerus
and scapula as means by which to affect the spinal column. The left
hand exerts traction on the muscles above the spine, while the right hand
and arm forces the patient's scapula toward the head and spine. The
movement is made to enable the physician to relax the serrattis magnus
and some of the fibers of the fourth layer of the back. Slight torsion
of the dorsal spinal column is also secured.
Quadratus Lumborum. - The relaxation of the
quadratus lumborum is secured according to Fig. 167. In all displacements
of the twelfth rib, it is necessary to secure a free circulation in the
muscles attached to that rib. The fact that it is a floating rib
makes its position dependent on the tone of the muscles attached to it.
It is frequently slipped under the. eleventh. This movement separates
Fig. 168 is in some respects similar to the movement
illustrated in Fig. 166, except that the scapula is forced downward, and
the left hand is able to work through the relaxed superficial muscles.
After the use of the movements already illustrated, it is astonishing how
easily one can work upon the fourth layer or examine the condition of deep
Erector Spinae. - The work upon the fourth
layer should be done according to Fig. 155. The fingers are placed
between the muscles and the spines of the vertebrae and then drawn away
from the spines in such a manner as to stretch the muscles. The fingers
should never be allowed to slip over the muscles. Work steadily and
deeply. Do not move the fingers over the skin. When you place
your fingers, compel all soft tissues beneath them to move with them.
In this way you secure relaxation of the erector spinae and continuations,
take out soreness of the muscles, and prepare for specific work upon the
ribs or vertebrae.
The erector spinae is rarely contracted throughout
its whole length. Your work should be centered on that portion which
your examination has demonstrated to be contracted, either as a result
of visceral disturbance, osseous subluxation, strain or cutaneous reflex
Having now prepared our patient for specific manipulation,
we will note the results to be obtained on the general contour of the spinal
Treatment of Simple Kyphosis. - Fig. 169 illustrates
one of the simplest methods of springing a spine which is kyphosed at the
junction of the dorsal and lumbar. The physician's forearms are placed
against the patient's shoulder and ilium while the fingers rest over the
kyphosed portion of the spinal column. The hands draw forward while
the forearms push away. Considerable force can be exerted in this
way on slender patients.
Great force can be exerted on a posterior curve of
the lower dorsal and lumbar portions by the movement shown in Fig. 170.
This movement is also used for purposes other than corrective of structural
defects. Since the leverage is so great, it is quite easy for the
physician to carry it too far. The result is an active congestion
of the lower portion of the spinal cord, followed by excessive activity
of the nerve centers located there. In giving this movement to women,
ascertain whether pregnancy exists. If so, do not under any consideration
use it. The center for parturition might be excited by it, even though
the movement made is slight.
There is practically no danger in this movement when
intelligently used, except in the case of pregnancy. A slow, steady
lift made while the physician is watching carefully the amount of resistance
offered by the back will usually inhibit the excitement of the centers
located in the lumbar enlargement of the spinal cord. The slowness
and steadiness of the movement relaxes the muscles of the fifth layer and
secures better drainage for blood in the spinal canal. No active
congestion is brought on, hence a sedative effect is gained. Quick,
intense execution of this movement has frequently a reverse effect, because
the sharp strain put upon the muscles results in added contraction, active
congestion and obstruction to good drainage of the spinal canal.
These conditions result in functional activity of those organs governed
by the nerve cells in the lumbar enlargement., Active congestion of a center
results in increased function of the organ governed by that center.
As a general rule, this movement is contra-indicated
for any purpose but that of correcting a structural defect. The reaction
of many patients is an uncertain quantity, hence it is not wise to use
this treatment for purely functional effects.
As a result of the ignorant use of this movement
by those who are palming themselves off as osteopaths, the author knows
of several cases where dangerous conditions were brought on.
Lordosis - Upper Dorsal. - An anterior curve,
or straightened condition of the spine in the interscapular region, is
rather difficult to treat on account of inability of the physician to use
the extremities as levers. Fig. 171 illustrates a method of applying
leverage by means of the cervical vertebrae. The position of the
knee on the spinal column regulates the extent of the force of the movement.
The knee is the weight to be lifted, the spinal column is a flexible lever.
The physician's forearms are the fulcrum, while his hands apply the force
to lift the weight (the knee) which bends the lever at the point governed
by the position of the weight and fulcrum. The position of the physician's
hands is important, because the cervical is not the portion of the spinal
column we desire to bend. If the hands are allowed to rest close
to the head, the force exerted is nearly all spent on the neck; the most
flexible part of the spinal column is affected - a result not desired.
Place the hands as nearly over the cervical and first dorsal spines as
possible. Since the junction of the dorsal and lumbar segments is
a very flexible point, the knee should be located higher.
Fig. 172 illustrates another method of producing
flexion in the upper dorsal region. The leverage in this position
is so great that the operator must exercise caution in its use. The
operator should never aim to overcome the patient's resistance by exerting
a greater force. The patient will usually relax under the influence
of a tetering movement, i. e., short, gentle application of the leverage.
The Possible Variety of Movements Which Will Secure
the Same Results. - All of the effects described may be secured by
movements differing from those outlined. The author desires to illustrate
the application of osteopathic principles. It is believed by him
that the series of movements illustrated have the virtue of directly and
forcibly affecting the part desired without using up too much of the physician's
strength in their application, Where much work is done by a physician,
it becomes a vital problem with him how to conserve his own strength.
By the selection of those movements which give the greatest leverage, he
The Head and Neck as a Lever. - If the anterior
or straightened condition of the spine is very marked in the upper dorsal,
it is possible for the physician to use the head and neck in securing his
leverage. When the position of the spine is as described, the spinal
muscles in that area will be very contracted. The vertebrae will
be held tightly together, thus lessening the flexibility. Loss of
flexibility of the spinal column results in poor circulation in the spinal
cord with consequent perversion of the activity of the physiological nerve
centers located there. Congestion, passive type, usually exists around
these centers when drainage is interfered with by these contracted muscles.
Lordosis or Kyphosis May Affect a Function Similarly.
- A change in the contour of the spine, either anterior or posterior, may
result in the same disturbances in the peripheral distribution of the nerves
from the distorted section. The anterior curve in the interscapular
region usually causes the ribs to droop, which occasions a flat chest.
The thoracic cavity is lessened, hence respiration is feeble. People
with flat chests may develop wonderful breathing capacity by persistent
exercise. The respiratory muscles lift the ribs. Exercise of
these muscles will increase the antero-posterior diameter of the chest.
When directing a patient about the details of exercise
to increase the breathing capacity, do not fail to impress the fact that
a full round chest without flexibility is just as bad a condition as an
abnormally flat chest. Flexibility is the keynote of health.
Those exercises which merely increase the contracting power of muscles,
without at the same time increasing their relaxing power are not healthful.
Examination shows that whether we have anterior or
posterior conditions in the interscaptilar region, the spinal muscles are
contracted. The patient's power to relax them is lost. The
patient may feel tired and weak, but these muscles will not cease their
contraction. The rigidity has passed beyond the patient's control.
The patient can do something toward restoring flexibility
to an anteriorly curved or straight spinal column in the upper dorsal region.
Fig. 173 illustrates the effect of flexing the neck forcibly by pulling
down with the hands. These spines are greatly separated, and hence
the muscles of the fourth and fifth layers are relaxed.
Fig. 174 illustrates how the physician can use the
dorsal and cervical vertebrae as a flexible lever, and by shifting the
position of the hand upon the spine apply the movement specifically to
any particular vertebra. No movement which uses the arms as levers
will affect the position of these vertebrae, because the first and second
layers of muscles which are affected by arm movements do not control the
intrinsic mobility of this portion of the spinal column. The fourth
and fifth layers of back muscles are the groups which cause the malposition
of vertebrae in this region.
Splenius Capitis et Colli. - The Splenius
Capitis et Colli, a muscle of the third group, extends as low as the sixth
dorsal spine. As its name indicates, it is a bandage muscle, and
binds down the muscles under it. Its long attachment in the dorsal
region gives it a considerable influence there, when its superior attachments
to the head and neck are forced anteriorly by flexion of the neck.
It is the influence of this muscle which makes the movements described
so effective. These movements are for a general corrective effect
on a section of the spinal column. They are not well adapted to treatment
of an individual vertebra.
Kyphosis - Upper Dorsal. - A posterior curve
in the upper dorsal region can be treated by the method illustrated in
Fig. 175. The physician's right arm is placed above the patient's
right shoulder and under the chest, so that the 'hand can be placed in
the patient's left axilla. The patient's head should be turned away
from the physician, so that the upward pressure of his arm will not interfere
with the trachea. The physician's left hand may be moved from place
to place along the spinal column. The farther the hands are separated,
the more leverage is gained. Considerable force can be exerted in
this movement without any danger to the patient, in fact, to be of any
value it must be made forcefully. The primary use of this procedure
is to reduce the excess of posterior curve.
That which has been written concerning the nerve
centers in the interscapular region, when straightening or anterior curvature
of the spine exists, applies equally to the posterior curvature.
Posterior curvature is accompanied by increased antero-posterior
diameter of the chest, and loss of flexibility. This movement increases
flexibility. It can easily be adapted to the treatment of the fifth
or sixth ribs.
Kyphosis - Dorso-lumbar. - When the kyphosis
is at the junction of the dorsal and lumbar regions, it is easy to secure
enormous leverage. The arms can be used as levers while the physician's
knee rests against the kyphosis as in Fig. 176. If the patient's
buttocks are held to the stool, the whole force of the leverage is spent
on the back under the physician's knee. This movement should not
be carried too far. It, like all other movements in which the physician
has tremendous leverage, is liable to produce more than the desired effect.
It stretches the thorax and abdomen very decidedly.
Contra-indications. - The author expects that
all who use this and other high power movements, have examined their patients
carefully before administering them. The presence in the abdomen
of an aneurism, ovarian cyst, or gravid uterus, contra-indicate the use
of any movement which compresses the abdominal contents, and also in the
case of a gravid uterus any movement which is liable to cause active congestion
of the lumbar enlargement of the spinal cord.
Other Movements. - Fig. 177 illustrates another
method of exerting pressure on the prominent part of a kyphosis.
The leverage is not so great as in the preceding method, but where the
kyphosis is slight, it is the better movement.
Still another simple method of springing the lumbar
portion of the spinal column is shown in Fig. 178. The patient's
knees are held against the physician's abdomen, while the physician's hands
make counter pressure over the apex of the kyphosis. The buttocks
are forced backward by the pressure on the patient's knees. Some
osteopaths object to this movement or any other which necessitates pressure
of the patient's knees or elbows against the abdomen. There is an
element of danger to the osteopath.
This position, Fig. 178, is used frequently where
strong inhibitory pressure in the lumbar region is required. For
example, in cases of diarrhoea or cramps. Any hyperactivity of structures
governed by cells in the lumbar enlargement may be inhibited in this region.
When lordosis of the lumbar region exists, it is
necessary to flex that region in order to counteract it. Fig. 179
illustrates an easy method of accomplishing this result.
This same movement with the physician's right hand
under the spine can be made to do duty in correcting a posterior curve.
When the hand is placed directly under the kyphosis, the back is lifted;
then if the buttocks be forced to the table, the spine will be sprung in
the direction desired.
Functional Kyphosis. - A large proportion
:of patients whose spinal columns exhibit a tendency to kyphosis, in the
splanchnic area, suffer from either visceral reflexes or a hypotonic condition
of the erector spinae muscles. There is scarcely a case of visceral
ptosis that does not present a hypotonic condition of these extensor muscles.
The functional kyphosis so frequently apparent in this region is tremendously
benefited by rather forceful leverage movements which are accompanied by
counter pressure at the apex of the kyphosis. If this counter pressure
is applied suddenly, but not severely, it usually produces a sound in the
arthrodial articulations of the spinal column under the point of counter
pressure. This popping sound can be produced by a variety of methods,
many of which are illustrated in this chapter. The patient practically
always feels an increase of muscle tone after the popping sound is elicited.
This is evidenced by a feeling of greater ability to hold the body erect.
There is a genuine feeling of increased power, aside from any psychological
effect that may accompany the phenomenon. As a simple experiment,
one may voluntarily extend one's fingers in opening the hand to its fullest
extent, after having had it flexed for a considerable time. There
is a feeling of limitation of the extensor movement which is done away
with if we passively extend the fingers with the other hand. After
this passive extension by manipulation we are able to voluntarily extend
the fingers with greater power and to a greater extent than before.
This equalizing of the forces of extension and flexion is probably what
takes place, when we hear the sound, incidental to movements which produce
sudden passive extension, in a joint which is in a state of imbalance on
account of a static error, or visceral reflex.
Wherever we find the muscles which are prime movers
of a joint in a state of imbalance, we are apt to produce a sound in the
joint when we exaggerate the movement so as to suddenly stretch the dominant
muscle or muscle group. This produces' a readjustment of the joint
surfaces. Since the spinal arthrodial joints are apt to be in a state
permitting spinal flexion, due to static conditions, fatigue, or visceral
ptosis, we are able more frequently to produce sounds in these joints than
in most others, when sudden correction is made by counter pressure.
This phenomenon of sound in a joint, incidental to a quick readjustment
of its joint surfaces, when muscular tension controlling the joint is equalized,
has led to the invention of many ingenious methods for producing it.
Tables have been devised of various heights, having adjustable pads and
separable sections so as to allow the patient to lie prone across openings
in the surface of the table, thus greatly increasing the advantage of the
operator in making sudden downward pressure on a selected joint in the
spinal column. No apparatus is necessary to enable one o do efficient
adjusting work if the conditions necessary for the production of the popping
sound are understood.
The effort to produce such a sound in all so-called
subluxations will surely result in strain of the peri-articular tissues.
The operator must have a trained sense of tissue resistance and be governed
accordingly. Leverage and counter pressure should never be used in
the treatment of any joint which exhibits symptoms of inflammation.
In case of inflammation in a joint, its position is probably self-protective
and hence should not be roughly treated. The lack of ability to diagnose
the true condition of a joint leads to frequent misuse of manipulative
New Schools. - It is astonishing how varied
a class of patients is benefited by rather heavy counter pressure movements.
This fact has led to the rapid exploiting of so-called "new schools" which
claim their methods are different from and far superior to osteopathic
methods. It is an interesting fact, testified to by many patients
who have been treated by many osteopathic physicians, that no two of their
physicians operated alike. This is characteristic, in that the osteopathic
colleges have not concentrated so much on a particular method as on teaching
principles which are capable of many methods of application.
Various Applications of a Principle. - If
a patient with a functional kyphosis, in the splanchnic area, lies prone
on the floor or any other unyielding surface, as in Figs. 182 and 183,
it often suffices to merely make sudden downward pressure on the apex of
the kyphosed area with the palm of the hand. One, or several, popping
sounds will be heard if the patient relaxes and the force of the sudden
pressure is properly proportioned to the passive resistance of the spinal
tissues. It may be necessary to concentrate the point of pressure,
i. e., use a thumb or heel of the hand, reinforced with the opposite hand.
The reason some operators use low tables is merely to allow them to use
their own weight to the best advantage in using downward pressure.
According to the extent of the "lesioned area," i. e., the kyphosis, and
according to the voluntary power of relaxation characteristic of the patient,
the operator can use a large or small contact area, i. e., the heel of
the hand, hypothenar eminence, or the thumb. The amount of pressure
must be proportioned to the passive resistance of the tissues. No
effort should be made to overcome any active resistance on the part of
the patient. The operator must contrive to use the pressure before
the patient can bring his muscles into active contraction. Herein
lies the necessity for the exercise of considerable discretion as to when
the advantage of the patient's off guard moment should be taken.
The Use of a Fulcrum. - Advantage over a patient's
natural spinal resistance is gained by using a fulcrum at some chosen point
on the anterior surface of the body. A very simple use of this principle
is illustrated by Fig. 184, wherein the operator's forearm serves the purpose
of a fulcrum.
Figs. 185 and 186 illustrate the application of the
same principle with the patient sitting. This is probably the easiest
position for the operator to use counter pressure. His knees serve
as a fulcrum. His hands, grasping the patient's elbows, have a secure
hold, so that a sudden pull backward serves to force the weight of the
upper portion of the patient's body over the fulcrum and thus fulfill the
conditions of extension and counter pressure required for correction of
the kyphosis. By varying the position of the operator's knees
and interlocking his fingers over the patient's chest, as in Fig. 185,
the movement can be made very specific as to a single spinal segment.
A movement of great adaptability is illustrated by
Fig. 187. The patient places his hands on opposite shoulders and
then allows his weight to rest on the operator's forearm. In this
manner the operator may use his left or right hand, according to convenience,
as a fulcrum to be applied at any selected point in the dorsal or lumbar
area. By lifting the patient's body against the fulcrum, either suddenly
or gradually, the operator is able to concentrate corrective leverage and
pressure at any desired point. Rotation of the spinal column can
be secured by this movement and hence it serves as one of the most adaptable
movements for all sorts of corrective work. The operator does not
actually carry much of the patient's weight on his arm.
The first four dorsal vertebrae are rather difficult
to manipulate. The position illustrated by Fig. 230 shows, how the
hypothenar eminence of the operator's left hand serves as a fulcrum, while
the rest of the hand reinforces the neck, so that the head and neck thus
reinforced can be used as a lever, which is forced backward by the right
hand on the patient's chin. Fig. 189 shows how more powerful leverage
may be applied, by one who has a keen sense of tissue resistance.
Any movement, embodying great leverage, must be used with extreme caution.
Coordination of Corrective Movements. - The
success of any of these movements depends entirely on the operator's ability
to coordinate his movements so as to affect the special point in the spinal
tissues requiring adjustment. just as one's eyes coordinate to produce
binocular vision, one's hands must work harmoniously to secure good results.
The skillful operator causes practically no pain by his movements.
They are timed and graduated to suit the needs of his case.
Fig. 191 illustrates a method of everting leverage
and pressure to correct a lateral subluxation in the upper dorsal.
The operator's right hand serves to force the head and neck in a direction
to bend the column over the thumb of the left hand, as a fulcrum.
The patient's face is inclined toward the lesion side, so as to accentuate
rotation, which is the actual corrective part of the movement.
Dorsal Rotation. - Fig. 181 is a simple method of
securing flexibility in the lower dorsal portion of the back. Rotation
is possible in the dorsal but not in the lumbar region, hence, by holding
the shoulders down and lifting one hip, rotation is secured in the dorsal
region. This movement forces the normal action between individual
vertebrae of the lower dorsal region. If any particular articulation
is at fault, it will not yield to such a general movement as this.
The only gain made by it, in that case, is to prepare the surrounding tissues
for more specific work.
Lateral Curvature. - This kind of deformity
is frequently found and a large proportion of such cases are benefited
by osteopathic manipulations A weakened condition of the whole body predisposes
to the formation of a lateral curve. Fig. 192 illustrates an uncompensated
lateral curve, that is, the curvature is all in one direction. In
such a case the muscles on the convex side are not doing their full duty.
The patient is allowing the weight of the upper portion of the trunk to
be held by the ligaments instead of the muscles. This simple curvature
can be readily overcome by exercises which will develop the weak spinal
Fig. 134 illustrates a compensated curve, that is,
a letter S curve. The primary curve is in the interscaptilar region
and is compensated for by a curve in the opposite direction in the lumbar
Know How to Apply Principles. - The osteopath
should know how to apply his principles so thoroughly that the position
of his patient, whether lying, sitting or standing, will not confuse him.
Some osteopaths desire to give their manipulations to the patient sitting,
others like the reclining position better. On the whole, it seems
best to select the position suited to the special work required.
Do Not Copy Movements. - Do not copy anybody's movements.
Learn the principles, then apply them in the manner most satisfactory to yourself
and helpful to the patient. To understand the principles and apply them
intelligently, one cannot know too much concerning all the subjects which are
the basis of a broad medical education.