The treatment of the clavicle must be considered here, because its position so frequently interferes with the drainage of the tissues of the neck.  When it is held down too closely to the first rib, by shortening of the subclavius muscle, it is quite sure to affect venous circulation in the head and neck.

    To Raise the Clavicle. - To raise it place the right thumb on the first rib as illustrated by Fig. 214, then carry the patient's left forearm across his face above the head as in Fig. 215.  Then as far outward as the physician's arm.  This movement causes the clavicle to press down on the physician's thumb, where it rests on the first rib, and thus stretches the subclavius.

    Subluxation of the Clavicle. - Articulations, such as the sterno-clavicular and acromio-clavicular, which depend entirely on their ligaments to keep them together and to limit their motion, cannot be retained in place if their ligaments have been injured.  If the ligaments of the sternoclavicular joint become relaxed, the pull of the sternocleido-mastoid lifts it upward.  Slight irritation of the pneumogastric nerve may be occasioned by this change of position.

    Preparatory Treatment of the Neck - Trapezius. - The preparatory treatment of the neck consists in movements to relax the various groups of muscles.  Fig. 216 illustrates the method of relaxing the cervical portion of the trapezius.  One hand on the shoulder holds it firmly down, while the other hand forces the head as far as possible in the opposite direction.  Relax the opposite
muscle in a similar manner.

    Sterno-cleido-mastoid. - Next, relax the sterno-cleidomastoid by separating its attachments as far as possible, as in Fig. 217, also by direct manipulation.  Observe whether both muscles will relax equally.  These large muscles are frequently found unevenly contracted.  Since the spinal accessory nerves control these muscles, any contraction should lead the physician to examine all parts in connection with them.  A reflex from the laryngeal branches as well as pneumogastric branches might account for it.

    Scaleni. - The scaleni muscles should be treated as already mentioned in Chap.  XXI.  See Fig. 218.

    Splenius Capitis et Colli. - Fig. 219 illustrates a method of stretching the ligamentum nuchae, as well as all the extensor muscles on the back of the neck.  This may be modified by forcing the chin backward with one hand, while the other flexes the head as sharply as possible.  This stretches the muscles and ligaments on the posterior portion of the occipital-atlantal and axial articulations.  The retraction of the chin governs the amount of stretching exerted by the flexion.

    Extension. - Direct extension of the neck makes an equal pull on all the vertebrae.  When the patient's feet are anchored, the force of the pull is felt in the weakest portions of the spinal column.  The average patient requiring this treatment enjoys a delicious stimulation after relaxation of the extension.  A few who are extremely nervous may give a bad reaction.  The influx of blood in the spinal cord is highly beneficial to those who have sufficient vaso-motor tone to hold it there, but those who lack this tone will feel faint or even absolutely lose consciousness.  Simply allowing them to rest on the table until the vascular system reacts, will enable them to reap the full benefit of the treatment.  The extension should be made with absolute steadiness.  The relaxation period is usually the one in which any vaso-motor phenomena are noted.  The tension should be lessened very slowly in all cases.  Fig. 220 shows the position of the physician's hand.

    Rotation. - The following movement is one for which long practice is required, in order to get anything like a successful result from its use.  It consists in grasping the patient's neck with the left hand as in Fig. 221.  The patient's head rests against and slightly to the right of the physician's forearm.  The right hand grasps the chin while the forearm rests firmly against the patient's head.  The object is to hold the neck and head rigid above the point grasped by the thumb and fingers of the left hand.  While holding the head and neck rigid, they are moved so as to force circumduction in the joint below the grasp of the left hand.  After each circumduction the left hand is shifted the depth of one vertebra nearer the head.  Thus all the intervertebral articulations in the cervical region are relaxed and specific work on a definite articulation can be done more easily.

    The Hyoid Bone. - Work on the anterior portion of the neck consists in affecting the condition of groups of muscles forming the floor of the mouth and extrinsic muscles of the larynx.

    The Hyoid bone is the movable part which can be grasped by the physician's fingers.  Drawing it downward and to the right, as in Fig. 222, relaxes the stylo-hyoid and posterior belly of the digastric.  A contractured condition of these muscles may affect the pneumogastric nerve.

    Mylo-hyoid and Hyoglossus. - The mylo-hyoid and hyoglossus forming the floor of the mouth may be treated as in Fig. 223.  When the maxillary glands are congested, it is necessary to relax these muscles.  The physician's right hand grasps the hyoid bone, being careful to provide enough loose skin above the ])one so that the force will not be exerted on the cutaneous tissues instead of the muscles underneath.  After the hyoid bone is pulled downward, the tension of the mylo-hyoid is increased by using the pressure of the fingers of the left hand.

    Sterno-thyroid and Sterno-hyoid. - The depressor muscles of the larynx and hyoid may be stretched by forcing these structures toward the angle of the jaw, while the free hand makes direct manipulation of tile muscles.  In all cases of congestion of the glands, mucous membranes or cellular tissues of the mouth, pharynx or larynx, these muscles should be relaxed if the position of the atlas has been corrected.

    Intrinsic Muscles of the Larynx. - The intrinsic muscles of the larynx sometimes need attention.  The crico-thyroid is the tuning muscle of the larynx.  This may be demonstrated by grasping the thyroid cartilage with the thumb and forefinger of one hand, while the thumb and forefinger of the other hand grasps lightly the cricoid cartilage, as in Fig. 224.  If the cartilages are slightly separated while the patient makes a vowel sound, the pitch of the voice will be perceptibly lowered.  This is occasioned by relaxation of the vocal cords by separating the cartilages, which stretches the crico-thyroid.  This muscle is innervated by the external branch of the superior laryngeal branch of the pneumogastric.  The motor fibers of the superior laryngeal come from the spinal accessory, hence we find lesions in the cervical articulations, which are primary causes of laryngeal disorders.

    The Atlas. - The atlas, on account of its position, freedom of movement, numerous muscular attachments, etc., is subject to frequent subluxation.  Fig. 102 shows the normal relations of the mastoid process, transverse process of the atlas, and the angle of the jaw.  Fig. 103 shows the abnormal relations of these various prominent points as they are frequently found by the osteopath.  When the right transverse process is near the mastoid, the left is too close to the angle of the jaw, and vice versa.

    In reducing this twist of the atlas, the physician should work on the side which shows the transverse process to be posterior.  The same principle is applied in reducing this subluxation as was described in connection with the dorsal lateral subluxations.  Fig. 225 illustrates "exaggeration." Fig. 226 shows lateral flexion to the left, while the physician's fingers make firm pressure back of the prominent transverse process, thus steadily taking advantage of all the relaxation gained in each portion of the movement.  The termination of the movement is illustrated in Fig. 227.  Sometimes the atlas slips into place with an audible "click," but more often the physician feels a "gritting" sensation as the articular surfaces rub over each other.  When the subluxation of the atlas is reduced by this movement, it will hold its true position more firmly than will any other vertebral articulation which has been affected in a like manner.  This is because the condyles of the occiput fit more deeply into the superior articulating surfaces of the atlas than is the case between articulating surfaces of pairs of vertebrae.  Fig. 229 illustrates a method of relaxing the muscular tension in the muscles which move the atlas.  This method is used to force the atlas forward.  It will be readily noted that by over-extending the head on the neck and using counter pressure on the posterior surface of the atlas the mechanical requirements for forcing the atlas forward are fulfilled.  By moving the head up and down and from side to side, muscular tension will be sufficiently reduced to permit reduction of the subluxation.

    Sixth Cervical. - The sixth cervical vertebra is especially difficult to treat. When the cervical muscles are well developed, it is obscured to the touch posteriorly, but the 31 carotid tubercles anteriorly can be felt.  It is not wise to exert much pressure upon bony structures from the anterior surface of the neck.  There are so many glands, nerves, arteries, etc., lying over the transverse processes, that direct pressure is liable to injure them.

    Fig. 228 illustrates a method of reducing a subluxation of the sixth cervical vertebra.  The patient's chin rests in the physician's hands, which are placed on each side of the neck and near enough to the chin to support it by the little finger.  The thumbs are used to affect the spine directly.  The compression of the head and neck above the lesion, by both hands, keeps them rigid and all are moved together, first to exaggerate the lesion of the sixth, then anterior flexion is forced in the articulation affected, then lateral flexion with counter pressure by the thumb on the prominent side of the spine.

    This movement can be applied to subluxations of the first and second dorsal.

    General Principles Underlying Corrective Movements. - The same general principle, governing the correction of subluxations in other portions of the spinal column, is applicable in the cervical region, i. e., the movement, or series of movements, must be made so as to overcome the influence of a dominant muscle group.  As we have previously noted, the position of an arthrodial joint is expressive of the relative tension of the muscles which activate it.

    The Simplest Form of Correction. - The simplest form of corrective movement is extension, i. e., a direct pull in the long axis of the spinal column. This tends to put equal stress on all the joints, but, in reality, it will be felt most in any lesioned articulation.  The lesioned articulation is the "weakest link" and therefore is most sensitive to the effect of the extension.  Extension of this kind is grateful to most patients and when made by one who has a keen sense of tissue resistance, is practically without danger.

    Torsion and Counter Pressure. - Since the cervical region is normally very flexible, considerable skill is required, if an operator makes use of rotation and counter pressure for correction of joint lesions.  The results secured by these means are very gratifying, but there is a larger element of danger than in the use of extension.  The skillful operator must have a good knowledge of the anatomy of the region and a sense of tissue resistance.  A torsion movement is a powerful lever and should be used very carefully.  Although it is possible to describe the relative positions of the operator's hands and the general direction of the movements, it is not possible to convey to the reader an idea of the amount of force used, or the relative amount of resistance to be overcome.  It is this variable element which makes the difference between success and failure in operative work.  Normal muscle tone is equal to about six pounds' pull, hence if a patient voluntarily relaxes, or is placed in a position which does not require any exertion to overcome gravity, it is very evident that no great amount of force will be required to change the position of an arthrodial joint.  If the operator will always bear in mind that great force is not required, there will be no accidents.

    Rigidity. - When the patient holds his neck stiff and rigid, it is necessary to determine why it is so held before we attempt any movements to alter the condition.  Disease of the vertebrae, or inflammation in the joints, is characterized by bilateral muscular tension, which is necessary to protect the structures from the strain occasioned by movement.  No attempt should be made to relax this tension by manipulation.  The usual case of "stiff neck" is unilateral.  It consists of a unilateral muscular contraction.  Usually the patient cannot turn the head toward the lesion, but can turn it in the opposite direction.  This is the differential diagnostic point between a muscular and a ligamentous lesion.  The ligamentous lesion does not permit rotation away from the lesion because such action stretches the ligament.

    The Favorable Position for Corrective Movements. - As stated in a previous chapter, the position of election, for the use of rotation as a corrective movement, is extension.  Some operators prefer to have the patient sitting and thus have the head balance its weight on the vertical vertebral column.  It is then very easy to use the weight of the head as an assisting factor in securing the leverage necessary to correct slight rotation lesions.  By allowing the patient's chin to rest in the operator's right or left hand, while the opposite hand supports the suboccipital region, Fig. 230, the head may be rotated and flexed, or extended, in such manner as desired by the operator, to correct a cervical subluxation.  The hand, which supports the suboccipital region, is made to do double duty by acting through its lower border, as a fulcrum, over which the spinal column is bent, so as to accentuate the force of the corrective movement in a certain joint.  The corrective rotation movement is always associated with a little flexion or extension, according to the character of the lesion.  The head is rocked gently in the direction required for the correction and when the rotation reaches a point where the resistance in the lesion is felt, Fig. 231, the operator strives to create a condition of relaxation by admonishing his patient not to resist, so that by a sudden but very slight increase in rotation the lesion will receive the full effect of the movement and yield to it.  The yielding is usually accompanied by a clicking sound in the joint and a feeling of comfort.  The range of voluntary movement in the articulation is increased and the patient usually experiences a feeling of added power.

    The position of the fulcrum individualizes the character of a movement, therefore the shift of the depth of one vertebra either makes or mars the success of one's effort at correction.  In order to use the fulcrum hand with more specificity, or force, the operator may rest the patient's chin in the bend of his elbow and then, by anchoring the head with his body, forearm and hand, Fig. 189, extend the patient's neck by a gentle lift.  This extension frequently overcomes enough of the muscular tension to permit a slight additional rotation movement, with counter pressure, to correct the lesion.

    Several illustrations are presented herewith, to show the manner of applying the osteopathic principle of correcting cervical subluxations by extension and torsion.  The position of the patient, either lying or sitting, is purely arbitrary with the operator.  The principles involved in the operation are the same in either position.  Fig. 232 shows how torsion and counter pressure may be used when the patient is recumbent.  The position of the right hand illustrates how the influence of the leverage may be carried into the upper dorsal region.  Fig. 191 illustrates the application of the same principle when the patient is sitting.. As we have previously stated, the position of the fulcrum is the part of any corrective movement, of this character, which localizes the effect.  Since we are aiming to change the relations of the bony elements in a flexible lever, the spinal column, at a certain point, the fulcrum must be used with reference to the kind of movement characteristic at that point.