Principles of Osteopathy
4th Edition
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 respiratory process.

    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 them.

    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 structures.

    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 from cold.

    Having now prepared our patient for specific manipulation, we will note the results to be obtained on the general contour of the spinal column.

    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 saves himself.

    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 methods.

    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 muscles.

    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 region.

    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.