The eleventh and twelfth ribs are simply joined to the pedicles of their respective vertebrae, posterior to the bodies, at some distance from the transverse processes, which are very short.  They stand as it were erect, without other bony support or limitation.

    In these two ribs all movements are possible, limited only by ligaments and muscles that attach to them.  Of these the capsular ligaments are the most strict, but have no effect on the varieties of motions possible.  Ligaments doubtless attach to the transverse processes, and should be studied.  The intercostals fascia is poorly represented.  The most effective of the ligamentous limitations, however, is this intercostals aponeurosis, which in the twelfth rib extends down and in to the costal process of the first lumbar, and above, up and out to the eleventh rib.  It draws the rib down and in, from the middle third, and up and out from the spinal end.
 
 
LESIONS

    Any movement of a character sufficiently extreme to carry the base away from its articulation on the pedicle may create a lesion.  The tensions that hold the rib to its base draw not directly to that base, but quartering toward the spine.  When strained beyond the normal articulation with the base, these tensions so draw it against the articular surface that in trying to return to normal a wrinkle may be made, which wrinkle may hold it as a lesion.

    The lesion may be in any direction from the base.  The most usual direction is upward and forward, produced by blows from behind and below (almost the only blows that reach it) or by wrenches in which the shoulder is twisted backward on that side.  In this movement the tension of the abdominal muscles acting mostly on the tip, draws down and forward, while the ligaments to the eleventh rib, together with the intercostals muscles, draw upward near the head.  The combined tensions gap open the upper part of the articulation, twist the rib, slide it upward in the twisting, and leave it as a lesion.
 
 
DIAGNOSIS

    Diagnosis of lesion of this rib is made by comparison with the opposite side, with ribs above, with the average normal, and by sensitiveness and visceral disturbance traceable to it.

    For those ribs, particularly the twelfth, exact technic is perhaps the most difficult of all parts of the body, on account of the absence of bony leverage by which to draw the rib away from its point of engagement.
 
 
TECHNIC

    Patient kneels on table, feet over edge, and sits back on heels; clasps hands behind neck.  Operator stands behind and to side of lesion.  Assuming right twelfth rib to be in lesions—operator passes right hand under right axilla and places it over clasped hands of patient; places left thumb on rib as near to head a possible; between it and the eleventh if lesion is upward; below if lesion is downward.  Operator then swings patient’s spine to right, so that he sinks off from seat on heels to right; supporting weight with right hand and arm under axilla; keeping neck as near the median line as possible.  In this position the spine is bent to the right to the limit of its motion, the twelfth rib is drawn up at its outer extremity by the intercostal muscles tensed by the raising of the arm; the intercostals aponeurosis below, acting on the center of the rib, acts as a fulcrum, and the thumb pressing forward, outward and downward, moves the head to its normal seat.

    The same principle may be applied with patient seated on table.  Operator stands behind.  Patient places left hand behind neck, operator passes left hand under left axilla and places it over patient’s hand on back of neck, forearm supporting axilla.  With right hand he presses forward on eleventh dorsal vertebra until spine is in full extension; then with right thumb on head of rib as above, he produces side-bending to right, retaining neck as near median line as possible, focusing motion at the twelfth rib.  To this complete extension and complete lateral flexion, then some rotation is added until the lesion sis felt to be released.  If not released, operator may then press downward on neck, carrying spine suddenly to flexion, while maintaining side-bending rotation and pressure with thumb; and may alternate extension and flexion until correction is made.

    The same principle may be employed with patient on hands and knees.

    In all of these forms of technic deep inspiration may be of some assistance.  In deep inspiration the intercostals muscles are tensed, drawing up and to the spine, and the diaphragm is also tensed, drawing up and on the tip of the rib and transversely across the body.

    The technic for the other ribs in general may be used for these ribs.
 
 
TENTH TO THIRD RIBS:  MOVEMENTS

    In inspiration the ribs turn slightly on the transverse processes, and slide forward on the lower and backward on the upper facet against the bodies of the vertebrae.  From extreme expiration to extreme inspiration the total of motion is rarely over two inches at the tips of the longest ribs, and in some of this at least the vertebrae themselves share; a maximum of two inches at the tip of the rib means very slight motion indeed at the transverse processes and facets; even the slight apparent motion being diminished by the motion of the vertebra itself and the yielding of the elastic cartilages and ligaments.

    In flexion and extension of the body the ribs move as in inspiration and expiration.

    In side-bending of the body each rib moves with the vertebra to which it belongs, the vertebra above sliding on the superior facet of the rib.  It may even press the rib down on the concave side, the rib sliding down and out on its inferior facet, and out on the tubercle at the transverses process; doubtless this motion is in all cases exceedingly slight; but it explains the discrepancy between the center of rotation of the articular processes and that of the costal facets.

    In this motion the tips of the ribs remain relatively stationary on both sides, being fastened together in front, unless there is inspiration at the same time; while on the convex side the extreme lateral part in the axillary line moves relatively down (unless there be inspiration at the same time) and on the concave side, up; with corresponding turning at the transverse processes.

    In rotation side-bending each rib moves with its vertebra; transverse process of the vertebra moves up and out and forward on the convex side, carrying with it the rib; but the ribs are all fastened together in front by the cartilages attaching them to the sternum; so that the ribs on the convex side must separate in the axillary line; but since the spine turns relatively more than the ribs, these must slide upward on the transverse processes; and on the concave side the reserve; giving the downward motion to individual ribs as noted in preceding paragraph.  Any confusion of thought that arises here may be clarified by recalling that the tubercle-transverse process joint is concave on the transverse process, convex on the tubercle; so that, as in the shoulder, motion down of the shaft means motion up in the socket.  Since this is just the point where lesions occur, the picture should be clear.
 
 
LESIONS

    Limitations to motion are the ligaments of the joints, and the intercostals aponeurosis, drawing down and in below and up and out above, with a slightly greater distance from the spine on the lower side; so that the general tendency is to upward luxations of ribs.  This is particularly true of the human subject, standing erect with the full weight of ribs and muscles bearing downward on ends of ribs.  (This is the reverse of the general direction of pressure in the animal, in which the pressure from weight of viscera carries ribs down and forward, that from muscular effort toward the head).  Lesions may, however, be either up or down, at the tubercle.  Lesions of the head, if they exist, are indistinguishable from those at the tubercle.

    The intercostals muscles, along the full length of the rib, act in lesions so as to distribute the tension.  Certain fibres will be over-strained and others relaxed, those between remaining normal.  The latter should be found at the juncture of the middle third with the anterior and posterior thirds, which are therefore apparent centers of rotation.

    The intercostals muscles so act, however, only when on tension, which is not the usual state in the erect trunk of the human subject.  The position of a rib in lesion is therefore determined usually by the position of the tubercle and of the head and tip—when up at the tubercle its lower edge will be exposed behind, its tip will be drawn back and depressed.  When all of the intercostals muscles are on tension it tends to correct the lesion.

    To become familiar with the motions of ribs, have patient seated, operator standing behind; place thumbs of both hands on corresponding ribs of two sides, thumbs as near the spine as it is possible distinctly to feel the bone; place fingers on margins of same ribs, as far along as they will reach.  In this position have patient inhale and exhale, and go through various movements; trying to distinguish the bone from the contracted muscle.  Then do the same things with passive movements.  Assume position to give the cork screw movement; place thumb and fingers on rib as above; execute cork screw movement and various other movements with the patient completely passive.  It will be discovered that the movements of ribs are quite complicated.  It is probably best to focus the mind on what is happening at the transverse process and the position of the vertebra, tracing back from the points where the fingers lie to those points with the imagination.

    To develop an efficient technic it is not enough to have done this once, but requires that it be done long enough to become almost subconscious; and it should be rehearsed again with each case that presents any difficult features.
 
 
DIAGNOSIS

    Diagnosis of rib lesons is best made where it exists—at the juncture of the rib with the transverse process.  The rib is not quite a continuation of the process, but extends out from its upper half in the lower vertebrae, its center in the mid dorsals, and its lower half in the upper dorsals.  It will be remembered that these facets are inclined, not flat with the spine; that they incline upward in the lower, forward in the mid, and downward in the upper vertebrae.  Lesion will therefore carry them in these respective directions; in the lower chest, they will be less prominent posteriorly if the lesion is downward, more prominent if the lesion be upward; the reverse in the upper chest, and neutral in the middle; except that the curve of the neck of the rib acts to bring the angle to greater prominence in any lesion, from second or third to ninth or tenth ribs; and that approximately to the rib above makes a rib seem less prominent.  Failure to form a mental picture of this curved neck, in those ribs where it exists, may be responsible for much confusion in diagnosis.

    Secondary deviation may be found along the shaft of the rib in lesion, but this may be masked by the tension of muscles, especially in inspiration.  In general, a rib that is up at the transverse process will be down in front, its tip pointing at a greater angle; its inferior border will be palpable behind, and it will be not parallel with the ribs above and below.  If the lesion be downward at the transverse process, its tip will point more up than its fellows, its inferior border behind will be half concealed and its upper border may be palpable.

    If the vertebra to which it is attached is in lesion, upward on the right, then the right rib will be raised as the transverse process is raised, but will turn on the process and assume a position as when it itself is in lesion upward.  On the opposite side, the reverse.  If actual lesion then occurs between rib and transverse process, this tends to offset the deviation.
 
 
TECHNIC

    Assuming a lesion of the eighth rib upward on the right.  Patient is seated on table; places right hand on left shoulder; operator stands behind, facing right; places left axilla over patient’s shoulder and hand thereon, passes left arm around body and under patient’s elbow, places fingers on the eighth rib in front of the axillary line; places right thumb on eighth rib as near the transverse process as possible, the fingers as far along as possible.  Exerting slight pressure on the rib in all of these directions, he then executes the cork screw movement a time or two, then bows the spine convex to the right to complete side-bending of the eighth segment, at the same time rotating to left to complete limit of rotation; and alternates bowing to this ribs.  This technic is available from the twelfth to the fourth side and rotation until the lesion is felt to be released.

    The effect of this technic is as follows:  The pressure with the right thumb and fingers carries the rib away from the transverse process enough to overcome the catch or wrinkle that is  holding it in lesion; pressure by the fingers on the front end down in and centrally, overcomes the resistance of the intercostals muscles and, acting through the curved spring of the rib, still further aids in carrying the rib from the transverse process (pressure back and in on the front ends of ribs makes a fulcrum of the thumb in the back, and tends to gap not only the articulation at the transverse process, but also that at the head of the rib).  The movements then act to tense all muscles, to gap open the joint at the top, and with the pressure of thumb to carry it to normal.

    It is impossible to distinguish lesions at the head—if indeed such lesions exist—from those at the transverse process; and the technic seems to be the same.  In any case in all of the most successful technic for ribs, this element of pressure on both ends is evident.  As for instance, the following:

    Patient seated, places right hand on top of head (highest point).  Operator stands behind, passes right arm under patient’s axilla, supporting it, places hand on top of patient’s hand on head; places left thumb on rib as near transverse process as possible; presses to right and forward with thumb while carrying vertex to left and slightly back, with lifting of axilla, to full limit of side-bending convex to right end of extension of segment in lesion.

    The effect of this treatment is as above, except that in place of pressure by the fingers backward on the front end of the rib we have traction backward and upward through the pectoral and intercostals muscles.

    Caution.  The neck should not be turned sharply nor bent sharply, as is the natural tendency; it should be bent as little as possible, the focus of motion being on the lifting of the ribs and the bowing of the spine.  The head should be slightly turned to right to increase separation between transverse processes.

    This technic is not strongly corrective, but is mild and soothing for nervous cases.  It is excellent for relaxation in the upper dorsal region.

    Many forms of this technic are in use, the patient prone or supine or on side or against door jam, using the arms in different ways; and doubtless each of them has its advantages which vary in different cases.  In all, caution must be used not to exceed the normal limits of motion of the shoulder joint itself, which is much more sensitive than most other joints of the body—protected by more sensitive nerves because of the somewhat greater danger of straining it.  For instance in this:

    Patient supine; operator stands at side of lesion; assuming eighth rib of right side in lesion, stands at right side; places fingers of right hand under angle of eighth rib, ready to press upward and toward patient’s head; grasps patient’s right wrist with left hand, carries it directly up in the axillary line with slight pressure backward, to the limit of motion, while the patient inhales a deep breath; at the same time pressing upward and toward the head with the finger on the affected rib.

    The effect of this position of the arm is to carry the rib to the upper limit of motion on the transverse process, while the front end is held down, controlled by the tensed serratus magnus muscle; this gives it therefore an angle, at the top limit of its motion—causes it to assume as nearly as possible the position of the lesion, or the position it was in when it became a lesion, while yet all of the surrounding tissues are exerting on it tension to the normal.  The deep inhalation helps in this effect.  Slight lifting with the finger is thus often able to release it from the catch.

    Holding all in that position for a brief second while the ligaments stretch, all is then reversed; the right hand is brought forward, in front of shoulder and carried to full extension over the head; the pressure of the finger on the rib is changed to lift the rib toward the feet; the breath is released all at once.  This tends to raise the front end of the rib and lifts the tubercle on the transverse process over the catch and toward normal.  This is one of the oldest forms of technic.  Its chief drawback is the strain upon the shoulder.

    This technic may be used with the patient prone, the table supplying the pressure on the front ends of the ribs as in the previous technic; or with a pillow placed against a door-jamb and the patient’s breast pressed against the pillow; or with an assistant pressing on the front end of the rib; or, less accurately with the operator’s knee against the back end of the rib, the fingers moving the front end, the other hand moving the patient’s arms.
 
 
FIRST AND SECOND RIBS: MOVEMENTS

    The motion of these two ribs is much slighter than that of the others.  The motion of the sternum is forward, and up; but the excursion of the lower part is much greater than that of the upper part, leaving very little for these first two ribs.  Beside this they have a slight wing motion, under the traction of the scalene muscles, opposed by the intercostals; little more than a ligamentous yielding.
 
 
DIAGNOSIS

    On account of the thickness of the over-lying muscles it is very difficult as a rule to examine effectively these two ribs except at the sternal ends.  Unevenness on the two sides in front argues probability of a lesion, but to know which side is in lesion, one must rely upon relative sensitiveness.  Lesion upward at the transverse process draws the sternal end backward, making it seem smaller than its fellow, and making it also sensitive; lesion downward, the reverse.  About one inch of the first rib may be felt beneath the collar bone.  By drawing the shoulder blade away and slightly lifting it, in thin subjects the spinal ends may sometimes be felt; but they bend almost directly forward from the transverse process, leaving little surface for examination and little certainty therein.  With patient lying on side and shoulder blade lifted, the thumbs may find and examine one side at a time.
 
 
LESIONS

    As in the other ribs, lesions at the transverse processes cannot be distinguished from those at the head, up and forward, down and back if slight; but the curve if the latter exist.  Lesions at the transverse process are up and forward, down and back.  They seem more prominent if up, on account of the spacing, less so if down.
 
 
TECHNIC

    Assuming right first rib to be downward on transverse process; patient seated on table; operator stands behind; places right foot on table and places knee under patient’s right axilla, arm hanging loose; presses down on arm to carry shoulder blade away from spine and to put upward tension on sub-clavius and pectoralis minor muscles; swings knee with patient slightly to right to secure full extension of ribs; places right thumb against the angle of rib where it leaves transverse process, endeavoring to get beneath it, between it and the second rib; places left hand on patient’s head and carries to left to limit of motion to produce tension on scalene muscles; in this position turns face first toward left to lift transverse process and produce an angle between it and the rib, then to right and backward to carry transverse process backward away from rib, changing the angle.  With gentle exaggerations of these tensions the rib may be brought to normal.  If necessary swing head and neck in extreme side-bending from left to extreme right; repeat until lesion is reduced.

    A slightly different use of the pectoral muscles may be made with the patient supine; operator draws patient’s right arm across breast, high up; places his sternum against elbow, ready to press down; places left hand under first rib, knuckles against table, fingers bearing up against rib; with right hand carries head to left side, then to right; gentle exaggeration of all of these tensions will tend to bring the rib to normal.

    Patient may be seated, elbow against operator’s sternum, technic as above.

    If lesion is upward, it is a simple matter to exert pressure from abaove and with technic as above, to carry it downward to normal.