Having noted a few movements which have a general beneficial effect on groups of structures we will now examine a few of the movements which are applicable to, specific subluxations.  In the chapter on Subluxation in the theoretical section of this volume, we called attention to the fact that "A subluxation is a slight abnormal relation between bony surfaces, maintained by uneven contraction in opposing groups of muscles which control the articulation.  The causes of the contraction are violence, temperature changes and reflex irritation.  A reduction is secured by equalizing vital activity." With this statement in mind, we will study first the lateral subluxations in the dorsal region.

    Lateral Subluxation. - A lateral subluxation is possible only in those portions of the spinal column where the formation of the articular facets allow rotation.  The cervical and dorsal are the regions in which this occurs.  Lateral subluxation is most common in the articulations of the atlas, third cervical, and anywhere in the dorsal with the exception of the twelfth.  The inferior articular facet; of the twelfth are lumbar in character, hence allow only flexion, extension and circumduction.

    It makes no difference what the cause of the lateral subluxation may be, the uneven contraction of muscles is the final result, hence all are treated in the same manner.

    When the vertebral spine is discovered out of line with those above and below and tenderness noted on its prominent side, we are disposed to consider it a true lesion, an irritant to the nervous system.  Whether it is the result of accident, cold or reflexes does not need to be seriously considered.  While it exists, it is a continual source of irritation to the nervous system, hence should be removed without delay.  If it is the result of reflexes, its reduction will at least remove one disturbing factor from the case.

    The prominent side of the spine is the one on which the muscles are contracted.  The contracted muscles must be those which are holding the bone in its malposition.  In order to exert this influence, they must be attached in such a way as to move the bone in this direction when they act normally.  Their present condition is one of hyperactivity.  With this line of reasoning, any articulation can be examined, the pull of its muscles determined and movements made in accordance with the normal action of these muscles.

    In Fig. 193 we observe the subluxation to the left of a mid-dorsal vertebra.  Intrinsic rotation of the dorsal spines is the result of the contraction of the rotatores spinae, one of the fifth group.  In order for this vertebra to remain subluxated, i. e., more rotated than any of its fellows, the particular digitation of the rotatores spinae attached to it must remain contracted, after the other irritations have become relaxed.  The work laid out for us is relaxation of this one digitation.  The digitation which is acting is working from below, i. e., arises from the transverse process of the vertebra below the one which is subluxated.

    The first movement consists in "exaggerating the lesion." The patient's body is flexed laterally away from the prominent side of the lesion as in Fig. 194.  This procedure stretches the contracted rotatores spinae and also separates the three vertebrae, i. e., the subluxated one and the superior and inferior ones, thus making it easier to push the subluxated vertebra into its true position.

    The second movement is an anterior flexion to permit of greater freedom of movement between the articular processes.  By forcing the body first into the position of lateral flexion, then anterior flexion, all the muscles of the fifth group which affect the subluxated vertebra are relaxed.  During this anterior flexion, a "click" is sometimes heard which is evidence of relaxation sufficient to allow approximation of the subluxated surfaces.  During all the time of making these flexions, the physician's right thumb should make steady pressure against the prominent side of the spine, thus taking advantage of the relaxation gained by each flexion.  The anterior flexion is illustrated in Fig. 195.

    The final movement is lateral flexion toward the lesion while lifting the patient from the stool in such a way that the weight of the body below the lesion exerts its influence to separate the vertebrae.  Fig. 196.  Counter pressure with the thumb is made vigorously during this final movement.

    The successful reduction of this subluxation may be accomplished without any "click" or other evidence of movement of the surfaces.  The vertebra usually moves into its true position without any audible sign.  The physician's fingers can determine the success or failure of the movement.  If the subluxation was caused by accident or cold, its reduction is all that is needed, but if it is the result of reflex irritation, originating in a viscus, the physician must direct such a mode of living that rest may be secured for the stimulated viscus.  Habits of life must be looked into.

    Fig. 197 illustrates another method of reducing a slight lateral subluxation.  The physician's left arm passes under the patient's left axilla, then the hand is placed firmly on the base of the neck
posteriorly.  This gives the physician great leverage.  The physician's knee, right or left, is placed against the spinal column at a point four or five inches below the subluxation.  This compels the flexible spinal column to yield to the force applied at the neck, in such a way as to relax the deep muscles controlling the subluxation.  Counter pressure applied to the prominent spine by the physician's right thumb completes the movement.  By this movement about the same result is obtained as when counter extension is given by two men pulling at the head and feet of the patient, while a third one devotes his attention to forcing the vertebral spine into place.  When the patient is short and heavily muscled, it is impossible to execute this movement satisfactorily.

    Lateral Subluxation - Lower Dorsal. - A lateral lesion of the ninth, tenth or eleventh dorsal is more easily handled than those higher up, because the physician can grasp the patient in a much ignore satisfactory manner.  Fig. 198 illustrates the method.

    The series of movements is always the same as already described, that is, lateral flexion or "exaggeration," anterior flexion, then lateral flexion toward the lesion, as illustrated by the cut.  With this same position, other forms of subluxation in the lower dorsal and lumbar regions can be corrected.

    A Depressed Spine. - Slight depression of a dorsal spine with sensitiveness over it, that is, between its apex and the spine below, indicates that the muscles in that situation are sufficiently contracted to draw the spine of the upper vertebra downward.  The depressed spine indicates that the body of the vertebra is slightly tipped backward and downward.  See chapter on subluxations.

    To reduce this lesion, a flexion of the spinal column as far as the vertebra below the lesion is made anteriorly.  If the depressed spine is any one of the upper six dorsal, use the pull of the splenius capitis et colli, i. e., flex the head and neck as in Fig. 174.  The physician's right hand is placed on the spine of the vertebra below the subluxation, thus allowing all the force of the movement to terminate in a pull on the muscles between this vertebra and the depressed spine.  This same principle can be applied to all portions of the spinal column.

    When individual spines are prominent and sensitiveness is found above the process instead of below, we have a condition the reverse of that just described.  Its treatment is similar to that of the preceding, except that by changing the position of the right hand to rest upon the prominent spine, our leverage affects the contracted muscles above the spine.

    Kyphosis - Pott's Disease. - Whenever a "knuckle" is found in the spine, inquire carefully as to the possibility of direct injury, predisposition to tuberculosis, etc.  Pott's disease of the spinal column may cause prominence of a single vertebral spine.  As other vertebrae are affected, a kyphosis is developed.

    Rib Subluxations. - Rib subluxations present many difficulties to the osteopath.  The methods used in their reduction are as varied as can well 'be imagined.  A few of the most useful and direct are given here.

    In Fig. 199 the physician is applying a method of spreading the lower ribs.  When the tenth rib sinks under the ninth and there is a general jamming of the four lower ribs together, the physician stands behind the patient who raises his hands above his head to spread the lower ribs by means of the latissimus dorsi.  While the hands are elevated, the physician grasps the anterior extremities of the ribs and holds them up while the patient lowers his hands to his thighs.  Such a movement at this will replace the ribs in their right relations, but a flexion of the patient's body will undo the work.  Continual well directed treatment and voluntary exercise are needed to b ring them to place and hold them there.

    The four lower ribs can be separated and the antero-posterior diameter of the thorax increased by the method illustrated in Fig. 200.

    The left hand lifts on the angles of the depressed ribs while the patient's arm is extended beyond his head, thus making use of the leverage gained through the attachment of the latissimus dorsi.  This movement increases the right and left hypochondriacal spaces.

    The position of an individual rib is affected by the contraction of the intercostal muscles above and below it.  The spacing determines whether the rib is elevated or depressed.  The width of an intercostal space will not be the same between the angles and anterior extremities.  This is caused by the fact that the head of the rib is fixed so that it cannot move up or down.  The movement which takes place between the head of the rib and the vertebra is a slight rotation.  The costo-transverse articulation allows a slight gliding of the articular facet of the rib upon that of the transverse processes.  As an example, take the fifth rib, when the space between it and the fourth rib is lessened by the contraction of the fourth intercostals.  The lower margin of the rib becomes prominent because the rib is twisted when raised.  The anterior extremity is depressed, making the fourth intercostal space wider anteriorly.  Palpation of this rib in this condition will show a prominent angle with corresponding depression of the anterior extremity.  When the rib is depressed at the angle, its anterior extremity will be prominent.

    Palpation is the only method of discovering these subluxations.  To reduce them, the same principle we applied to reduction of vertebral subluxations must be applied here, i. e., the relaxation of the contracted muscles.

    The tendency in asthmatic and bronchitic patients is to cause elevation of the ribs, thus developing a barrel-shaped chest.  When all the intercostal muscles act equally, the ribs are equally spaced, but in a case of bronchitis, some local portion of the bronchial tubing is especially irritated.  From this area, irritant impulses reach the spinal center with which it is most closely associated.  The intercostal muscles in direct relation with this center receive a greater number of impulses, hence, contract more vigorously.  A strain or blow might cause the same result.

    To bring this fifth rib down to its proper position, the physician may stand behind his patient, as is illustrated by Fig. 201.  His left hand grasps the patient's right elbow and pushes it above the shoulder, thus causing the muscles to lift the ribs.  This movement will pull on all the ribs of the right side, and tend to equalize the spacing.  The physician places his left knee directly over the angle of the fifth rib, his right hand on the anterior extremities of the fifth, sixth and seventh ribs, the middle finger of this hand being applied against the lower margin of the fifth rib.  The !rib being now in right relation with its fellows, the critical period of the movement is when relaxation is allowed by lowering the arm.  The knee above and over the angle, pressing forward and downward, while the middle finger of the right hand prevents depression of the anterior extremity.  This leverage forces the rib to retain right relations with its fellow in relaxation of the chest.  The termination of the movement is illustrated by Fig. 202.

    A general depression of all the angles of the ribs causes their superior margins to be prominent.  A flat chest is the result.  This condition frequently follows pneumonia or some disease which causes the patient to lie on the back during a long period of weakness.

    When a single depressed rib is found, it usually has been caused by a strain which has weakened the intercostal muscles in the space above it.  Treat it while standing in front of the patient.  Place the middle finger of the left hand under the angle.  The patient's right elbow may rest against the physician's abdomen.  Pressure made on the elbow forces the scapula back and brings into action the serratus magnus which lifts the ribs.  Ask the patient to inspire and this will raise all the ribs.  When relaxation comes with expiration, lift the angle of the rib forcefully, and it will regain its proper position.  Fig. 203 illustrates this movement.  Some osteopaths grasp the patient's right wrist and extend the arm first forward, then above the head, and back to the side, instead of placing the patient's elbow against the abdomen.

    It will be noted that all these movements are based on the effects of muscular contraction and relaxation with resulting changes of the position of the structures to which they are attached.

    Figs. 204, 205 and 206 illustrate the method of raising and spreading the lower ribs.  With the patient in this position, the physician can make extensive passive movements without much resistance.  These movements are similar to that illustrated by Fig. 199.

    When the ribs "droop" to a marked degree, there is a decided change in the shape of the diaphragm.  The extent of the thoracic floor is lessened, and it may be that the structures passing through the diaphragm are detrimentally affected by it.  The movement pictured in Pig. 199 is well calculated to spread the lower ribs and thereby increase respiratory capacity.

    The first rib is so strongly held by the scalenus anticus that it practically never is depressed.  It is, however, frequently elevated to such all extent that it infringes on structures around the first thoracic sympathetic ganglion, thus affecting heart action.

    To depress the first rib to its proper position, it is necessary to take the extra contraction out of the scalenus anticus.  This is done by making the first rib a fixed instead of a movable attachment.  Fig. 218 illustrates the method of relaxing the scalentis anticus.  The physician's thumb holds the first rib down while the muscle is stretched by forcing the patient's ]lead directly to the opposite side.  The scaleni muscles call be easily detected by placing one's fingers on the side of the neck near the base.  They will be felt hardening during inspiration.

    Luxations of the Innominate Bones. - Examination of the innominate bones requires very close observation of all the factors concerned in tilting the pelvis and varying the length of the lower extremities.

    The only way to determine the condition of the innominates is by palpation and mensuration.  Have the patient stripped and sitting in a perfectly upright position on a level surface.  Determine the condition of the lumbar portion of the spinal column.  Have the patient's shoulders level.  While the patient is in this position the relative prominence of the posterior superior iliac spines can be noted by palpation.  Find the second sacral spine and note the relations of. the iliac spines to it.  They should all be on a level.  See Fig. 91 in Chapter XIII.  Palpate for sensitiveness around the iliac spines, crests of the ilia and crests of pubes.  Measure from the anterior superior iliac spines to the adductor tubercles on the internal condyles of the femur, when the patient rests evenly in the dorsal position.  This measurement is not entirely satisfactory, because any change in the thigh muscles or hip rotators may easily vary the measurements.  The only fixed structures from which a reckoning can be made are the second sacral and posterior superior iliac spines.  The relations between the sacrum and ilium are never greatly changed, therefore it requires the examiner to exclude practically all measurements which might be varied by muscular tension.

    The posterior superior iliac spine may be less prominent than its fellow on the opposite side, or vice versa.  There may not be enough upward or downward displacement to make a well recognized change in horizontal relations with the second sacral spine.  This being the case, it is decidedly difficult to determine which side is normal and which is abnormal.  Hyperaesthesia will have to be depended on to determine this point.  The related subjective symptoms of the patient will decide which is the affected side.

    The shock which is transmitted to this articulation in an accident usually strikes the tuber ischii from below, or posteriorly, or strikes the knee and the force is exerted against the ascetabulum.  When the force is against the tuber ischii from below, or posteriorly, we have an upward displacement, or a twist, causing the posterior superior iliac spine to become more prominent.  When the force strikes the ascetabulum by means of the femur, the twist is in the opposite direction, and the spine is less prominent.

    Have the patient give details, if possible, concerning his position with reference to the direction of the force at the time of the accident, or if the condition appears to be due to other causes, strive to find out what they are.

    Having determined the direction of the twist, the force of our manipulation must be made counter to that applied at the time of the accident.  Since the hip joint is very movable, we cannot use the thigh as a stiff lever, therefore, our force must be applied to either the anterior or posterior surface of the tuber ischii and to the anterior or posterior superior spine of the ilium, i. e., push and pull, such as turning a wheel on its axle.  This movement is illustrated in Fig. 207.  The original force which this movement is trying to overcome was transmitted from the knee by the femur to the acetabulum, and resulted in a twist of the ilium which made the posterior superior spine less prominent than its fellow of the opposite side.  In order to make this movement effectual, an assistant must make steady, even pressure over the articulation of the sacrum and fifth lumbar vertebra, i. e., overcome the tendency of the twisting movement to merely affect the movable sacrovertebral, instead of the immovable sacroiliac articulation.

    By flexing the patient's thigh on to his abdomen, sufficient opportunity is given the physician to make pressure on the anterior surface of the tuber ischii, and pull forward on the posterior superior iliac spine, thus reversing the movement illustrated by Fig. 207.

    Fig. 208 illustrates an effort to use the thigh as a lever to affect the sacroiliac articulation when the posterior superior spine is prominent.  This is a dangerous movement, and should not be used.  The force transmitted by the thigh as a lever will not reach the joint desired, and will only result in straining the ilio-femoral ligament.

    A sacroiliac subluxation is difficult to correct, because the joint is practically without normal movement.  The pelvis tends always to resist any appreciable movement in its joints, therefore the physician must devise ways of securing leverage to directly affect these joints without transmitting his corrective leverage through the very movable sacro-vertebral joint above or the hip joint below.  This is a difficult condition to fulfill.

    Anterior Rotation of the Ilium. - When the ilium is rotated forward, the posterior superior spinous process is less prominent than its fellow of the opposite side.  This condition can be met by having the patient prone on an unyielding surface, slightly padded so as not to bruise the anterior superior spine of the ilium.  Since the twist may be considered as an ilium rotated forward or the sacrum rotated backward, we may meet the conditions necessary for correction by making sudden pressure on the sacrum at a point between the first sacral spine and the crest of the ilium.  This point lies sufficiently above the axis of rotation in the sacroiliac articulation to give the operator some leverage to assist in securing reduction of the subluxation.  The operator should use the hypothenar eminence of one hand, reinforced by the other hand, to make contact with the proper area on the back of the sacrum.  The pressure must be exerted in a direction parallel with the iliac crest.  After contact has been made with the hand the operator should prepare to deliver a sudden forceful pressure, as though he was trying to compress a very stiff spring which would not show any compression without throwing his weight on it.  It may be necessary to increase the operator's advantage by putting a special pad under the anterior superior spine of the ilium so as to eliminate any support by the soft tissues of the abdomen.  A further advantage may be gained by allowing the patient's leg, on the side of the lesion, to hang off the table so as to be at a right angle to the spinal column.  This tends to tilt the pelvis backward and thus permit a greater downward movement in response to the sudden pressure.  Sometimes it is advisable to use several partial applications of the pressure before the final corrective effort, without removing the contact hand.  This tends to permit the patient to relax by taking away the feeling that protective resistance must be made.  The operator must create and recognize the psychological moment for the application of the corrective movement.

    The principle underlying the operation just described can be applied if the patient lies on his back.  The leg on the lesion side should be flexed on the thigh and the thigh on the abdomen, thus tilting the pelvis backward.  By placing the pelvis so that the ilium on the lesion side is just off the padded edge of the table, the operator can place his chest against the flexed leg and thigh while his hands rest on the opposite anterior superior spines of the ilia.  A sudden downward pressure, coordinated with an attempt to spread the ilia apart, will be met by the resistance of the padded edge of the table against the side of the sacrum, between its first spinous process and the iliac crest.  These movements have the advantage of applying corrective force without having any of that force dissipated by passing it through a movable joint before reaching the intended point of application.  This is a very important factor if the patient is anaesthetized.

    Posterior Rotation of the Ilium. - When the posterior superior spine of one of the ilia is apparently too prominent, care should be taken to note whether the apparent prominence is not due to a rotation and tilting of the pelvis in its relation to the spinal column.  Since the flexion of the trunk on the pelvis is characteristic, in the sitting posture, and all people tend to rest themselves while standing by transmitting the weight of the body through one leg, continued maintenance of these positions changes the relation of the pelvis to the spinal column, i. e., causes a unilateral lumbo-sacral subluxation.  Static errors are characterized by a compensatory tilt of the pelvis, hence all the factors that might produce such a condition must be taken into consideration.  As previously noted, the one test of whether a subluxation exists is a comparison of the relative positions of the posterior superior spines with relation to the second sacral spine.

    To correct a posterior rotation we use practically the same position and leverage required to correct a tilt of the pelvis on the spinal column.  The patient should recline on the normal side, thus presenting the subluxation area to the operator.  Force must be applied on the crest and side of the ilium close to the posterior superior spine, so as to rotate the ilium forward.  The body must be rotated backward, thus tending to hold the sacrum from rotating idly with the ilium.  These conditions can be fulfilled if the operator takes the position illustrated in Fig. 211, i. e., grasps the patient's elbow with his hand and presses his own elbow against the patient's shoulder, thus securing an advantageous hold for forcing the patient's body to rotate backward.  The operator places his other forearm solidly against the crest of the ilium and gluteal tissues just above and external to the posterior iliac spine.  By rocking the pelvis forward and the body backward a few times the patient will yield to the movement and the operator should select the moment of the patient's greatest relaxation to suddenly accentuate these opposing rotations.  No attempt should be made to make more than a moderate rotation until it is felt that the patient is permitting the movement to be made without interposing any strong protective muscle tension.  It is quite impossible to correct a subluxated ilium if the patient exerts any protective contraction of his muscles.  The force of the rotation movement must go through the muscles without resistance, so as to reach the ligaments and other deep structures around the joint.  The art of getting successfully by the muscular tension of the patient without exerting a force capable of producing trauma requires no small degree of skill.  No great amount of force seems ever to be required if one has a fine sense of tissue resistance.

    By working skillfully in applying corrective force one learns to recognize a psychological moment when, by intensifying the force suddenly, the deep structures which are the object of our operation can receive the full benefit of our effort without interference from muscular contraction.  The operation, at the climax of the application of the corrective force, is characterized by a popping sound.  The position here described serves in an almost identical manner for treating unilateral subluxations in the lumbar arthrodials or the lumbo-sacral articulation.  The only change required is the shifting of the forearm from the ilium to some selected point higher on the crest and lumbar region.  Since the lumbar arthrodials face nearly directly inward and outward, the forcing of the shoulders and pelvis in opposite directions tends to take out tension in the muscles controlling these joints and the force is evidently applied with the same angle of incidence to the surfaces of the lumbar arthrodials as we secure in the dorsal area of the spinal column by a sudden counter pressure and extension.

    After a successful correction has been made of a case of subluxated innominate it is advisable to reinforce the pelvic ligaments by strapping the pelvis with surgeon's adhesive plaster.  Plaster three inches wide serves very well.  Apply the first strip so that its upper edge just reaches the posterior superior spine of the ilium.  Pass the strip forward so that it comes just above the crease at the junction of the thigh and the abdomen, the upper margin of the strip covering the anterior superior spine of the ilium.  The pubic hair must be shaved so that the ends of the adhesive strip may lap over the pubes.  The second and third strips are brought around the body on lines similar to the first and overlapping each other about an inch.  The strips should be put on tightly so as to bind the pelvis and give the patient a sense of security and comfort.  The s trips may be left on for ten days, then a series of treatments of a tonic character which will serve to strengthen the tissues is advisable.  It may be necessary to repeat the corrective movements many times if the case is one of low vitality or has a static area which does not permit the pelvis to hold its normal relation to the spinal column.