Chapter VI: Introduction (3)

All of the above have a positive bearing on prognosis. The osteopath should study his technique well. He will find that it gradually changes and improves from year to year. In a word, as he gains in experience he will become more skillful by giving careful attention to the development of the sense of touch, by noting the resistance of the tissues, and a score of details that are very hard to describe but the sum total of which determines and indicates the successful osteopath.

Another practical point that bears upon prognosis as well as upon the health of the osteopath is the manner of giving treatment. First, the height of the treating table should correspond to the height of the practitioner. The table should be made for the practitioner and not the practitioner fitted and warped according to a certain table. Second, give part of the treatments on a treating stool. Here there is greater freedom of movement on the part of the patient, hence greater and more effective leverage can be obtained. Suit your treatment to the patient, not your patient to the treatment. Third, make your weight count for energy expended in the treatment. As soon as one set of muscles become tired substitute another set, e. g., the back muscles and the arms, the arms and the hands. Fourth, whenever possible substitute the weight of the patient for expended energy. Fifth, when lifting keep the spinal column straight; do the bending of the body at the knees. Hence a better treatment and a more favorable prognosis, and besides that new occupation neurosis, the “=osteopathic back=,” will be materially lessened in both severity and frequency.

FOOTNOTES:

[26] See Tubby, Deformities.

[27] Clark’s Applied Anatomy, p. 334.

[28] Clark’s Applied Anatomy, p. 331.

[29] Prognosis—Journal of the American Osteopathic Association, Jan., 1906.

[30] Prognosis—Journal of the American Osteopathic Association, Nov., 1902.

OSTEOPATHIC TECHNIQUE

The technique of treatment is, in a sense, a personal factor, for it is a well known fact no two osteopaths treat just alike. Nevertheless, the principles of technique are constant and universally applicable, and he who applies them with specificity manifestly secures the best results, and exhibits a technique that is finished and characteristically osteopathic. General manipulations are not essentially osteopathic, although by employing them a few definite results may be obtained; still such technique should not be classed as distinctive osteopathic therapy. Every case is a law unto itself and must be studied individually in order to be able to understand it perfectly. So much depends upon the ability of the osteopath in the treating of a case, that in order to meet the indications intelligently he must have command of the various anatomical details of the body, not only in his mind but upon his finger tips.[31]

The =sense of touch= should be very acutely developed and this requires months of persistent, practical experience. A carefully educated sense of touch is the keynote to both osteopathic diagnosis and operative technique. From the very nature of the osteopathic conception—the physical body viewed as a mechanism whose disordered or diseased conditions demand anatomical readjustment—it is imperative that a delicate and educated sense of touch be acquired in order to logically and successfully apply its tenets. Proficiency means not only being able to note certain small physical irregularities, and various degrees and areas of muscular contractions, and variations in body temperature, but the extent and state of vital resistance, that is, tissue condition, and the feeling of organic resistance, e. g., the heart, lungs, liver. These are the special features wherein osteopathic fingers detect disease causes and traces. To know the difference between normal and abnormal structural deviations and distortions, as well as organic changes, requires an accurate, detailed knowledge of anatomy and pathology with a systematic daily education of the sense of touch; but to realize, appreciate and know by tissue resistance feeling that nutritional condition is improving requires much more practical experience.

Thus two very practical points should be taught to and thoroughly impressed upon every osteopathic student: First, =the sense of resistance of the tissues=. This gives us an absolute clue to the vitality of the patient. As has been stated, there is a vast difference between the feel, the sense of resistance, of normal and abnormal tissues; for instance, a normal muscle and a contractured muscle, a normal liver and a congested liver, a normal intestine and a prolapsed intestine and these differences comprise innumerable gradations.

Second, =the receptivity of the patient to treatment=. This is dependent upon the vitality of the tissues. The sense of resistance to touch gives us an important diagnostic clue; the receptivity of the patient to treatment tells us much as to prognosis. After a few treatments the receptiveness will be positive or negative; that is, the patient is, or is not, responding to treatment. Consequently the receptivity of the patient usually tells much as to the state of nutrition.

Definite principles should be followed when applying the technique, for the osteopathic lesion is a “structural perversion,” thus indicating mechanical readjustment for its correction. The time is coming when the technique will be taught graphically and mathematically. This would not be a difficult thing to do, and it could not but prove invaluable aid to the student. He can then the more readily and comprehensively grasp the principles involved. To resolve and illustrate manipulative readjustment to and by the principles of mechanics would add considerable to osteopathic development. For example, how nicely the correction of certain innominata maladjustments illustrates the principle of the wheel and axle. Vertebral and rib displacements when readjusted make application of the principles of the simple machines. We are gradually approaching a more comprehensive understanding of the physiologic movements of the spine and of the etiologic role of muscle tension. This is part of the foundation work. Great care must be exercised in correlating this data with the individual case, for in therapy we are dealing with abnormalities—not alone normal physiologic changes. If our distinctive dynamics and therapeutics were taught in this manner the average osteopath would be more specific and comprehensive in his work and as a consequence more scientific. And consequently the principles involved in each and every case would stand out clearly. Hence diagnosis would be more exact, routine pommeling discarded, and better all around technique executed.

Two general rules are applicable to all dislocations, whether partial or complete: 1. Exaggerate or increase the dislocation. This is to relax the tissues about the dislocated articulation and to disengage the articular points that have become locked. 2. Reduce the dislocation by retracing the path along which the parts were dislocated. Hence to =correct= a =lesion=, for example, a vertebral lesion: (1) Exaggerate the lesion. (2) Place the fingers of the hand that are not employed in exaggerating the lesion over the extended portion of the lesion. (3) Extend the region that is flexed when the lesion was exaggerated. (4) When the lesion is being extended produce traction and slight rotation of the region. (5) At the same time extension, traction and rotation is being produced push in upon the extended portion of the lesion. To this might be added for sake of clearness and greater assurance of success: (a) Be positive the focal point absolutely corresponds to the lesion, or else most if not all of your effort will be useless. (b) Just before reaching the maximum of exaggeration have your fingers correctly placed for the readjustment, and at the very moment of maximum exaggeration or just a fraction of a second prior begin to correct or readjust, or else you will lose the vantage gained and the operation will probably be a failure. (c) The general traction and rotation are to aid in unlocking the lesion, not to readjust as some may think. Inhibiting and releasing the soft tissues, such as spasms, contractions and contractures of muscles, and stretching thickened and adherent ligaments is very important preliminary work. Then, next to securing exact leverages an essential point is to maintain the release or exaggeration until the readjusting step is incepted. In other words, coordination of all factors is the desideratum. The lack of this is the cause of many failures. Hot fomentations frequently assist in relaxing irritable and spastic soft tissues. This, however, is but a preliminary measure. All rough handling, needless snapping of parts, and excessive rotation and stretching are not only apt to tighten the lesion more, shock the system and irritate the parts, but it may be absolutely dangerous.

It should not be forgotten that the osteopath includes many measures in his treatment of various diseases, as nursing, dieting, hygiene, sanitation, hydrotherapy, antidotes, antiseptics, etc., and does not depend upon readjustive manipulation alone, although correcting disordered anatomical structures and perversions are paramount in the treatment.

=The General Treatment.=—A general treatment but accentuates the ignorance, in a majority of cases, of many so-termed osteopaths. It is a deplorable fact that there is a tendency among some osteopaths to give general treatments in every case presented. The only explanation of such a procedure that one can think of is a lack of conception as to what osteopathy really is. To give a general treatment in every case is not only actually detrimental to the patient but it is the height of folly on the osteopath’s part, for it gets him into a slovenly habit of procedure from both scientific and curative points of view, besides giving the outside world an impression that osteopathy is but little different from massage and Swedish movements instead of skillful, mechanical engineering of the human body. But a “general treatment” is not to be confused with definite attention to be a series of more or less interrelated lesions. The essential point is to normalize the body when and where distinctly indicated and after a skillful manner.

A general treatment, broadly speaking, should be given only under three conditions: (1) Constitutional diseases that are to be treated symptomatically. (2) Certain anemic cases. (3) When one is ignorant of the real cause of the disease. Each of these conditions is self-evident why a general treatment should be given. A fourth might be added, for those individuals who think they are not getting value received unless they are treated from head to foot. Such patients are usually ignorant of the philosophy of osteopathy and it is the osteopath’s duty to teach them differently.

The general treatment consists in stretching the spinal column from the atlas to the coccyx and relaxing all contracted muscles along both sides of the spinal column, besides giving special treatment to the cervical region, between the scapulæ, the splanchnics and internal and external rotation of the legs. It is no wonder that fake osteopaths do cure a case occasionally. They are quite certain to correct some disorder by pulling and hauling a patient around in such a manner. Still on the other hand they are very likely to do injury to the patient. Those who claim that no injury can come from osteopathic treatment are mistaken. One can injure a person by treatment if he is not careful. It does not stand to reason that the most delicately constructed mechanism should stand any amount of manipulation and misdirected force that may be given it.

=Positions of the Patient and Physician in Treating.=—The position of the patient when a treatment is given depends altogether upon the affection to be treated. Probably about one-half of the cases can be treated to advantage upon a table, the remainder sitting on a stool. Many osteopaths treat nearly all their patients upon a table. It is much better to change back and forth, because to correct a certain disorder may be hard upon the table, but will be comparatively easy when the patient is on a stool, and _vice versa_. Besides, constantly changing back and forth rests a physician greatly.

Learn to treat in various positions, because it will be impossible to have all cases assume a certain position when being treated; and especially in treating acute cases one is obliged to suit his treatment to the patient and not the patient to the treatment. There is also a tendency for one to get into slovenly habits of treating when patients are all placed practically in one position, and certainly one cannot treat all cases in one position to equal advantage. Also learn to treat as well with one hand as the other. Many times one will be in such positions that equal use of either hand will be required. Carefully educate the sense of touch in both hands.

Another point should receive consideration: learn to shift the strength exerted in treating from one set of muscles to others. For example, when one is standing for a long time he will continually shift his weight from one limb to the other. In the same manner in treating use the strength of the hands awhile, then the arms, then the muscles of the back, then the weight of the body, etc.; all in such a manner that there is a constant change by utilizing certain groups of muscles for the same work, as well as utilizing the weight of the body of both physician and patient to advantage. It rests a physician greatly and thus allows him to perform a maximum amount of work with a minimum amount of strength and labor.

It is frequently an advantage to the physician to treat upon the nude skin, thus preventing the fingers from becoming tender. Gowns can be easily made that open down the back so that the patient does not have to disrobe.

=The Neck and Head.=—In the treatment of the neck the patient may assume the sitting posture or lie flat upon the back. The latter is preferable, as then one has complete control of the neck and head. Absolute control of a part is always necessary and when this is secured the dangers are reduced to a minimum, provided always that reasonable discretion as to the amount of strength, is used. Before correcting the various deviations of the cervical vertebræ it is usually best to thoroughly relax all the muscles, superficial and deep, about the field of operation. In relaxing muscles three methods may be employed. The muscle may be firmly grasped and manipulated until relaxed, or a firm pressure may be exerted upon the muscle and thus inhibit its nerve force until the muscle relaxes, or the muscle may be longitudinally stretched. The second method is comparatively slow and is usually given in acute cases where the patients are so weak and exhausted that they cannot stand any severe manipulation. This method, however, has certain advantages when employed as a preparatory step in interosseous adjustments, though steady traction accompanied with slight rotation, if precisely localized, has many advocates.

In relaxing muscles by manipulation, grasp firmly the belly of the muscle and draw outward on the muscle several times until it relaxes. If the patient is sitting, place one hand upon the head of the patient or about the chin in such a manner that complete control of the head is maintained throughout the procedure; then with the fingers of the other hand upon the contracted muscular fibres a manipulating or kneading of the muscle can be given. It is best to flex the neck and head to the side where the contracted muscles are, so that a better hold of the muscle may be maintained; then by a series of flexions and extensions with manipulation of the contracted muscles outward, results can be readily obtained. When the patient is lying on the back the physician may stand to one side of the patient’s head and with one hand on the forehead of the patient and the other hand around the opposite side of the neck, a rotary motion of the head and neck, which is equal to flexion and extension in the sitting posture, may be given by the hand on the frontal region while the other hand relaxes the muscles; or the osteopath may stand at the head of the patient and with either hand on the side of the head and neck of the patient a series of rotary movements of the head and neck may be given with manipulation of first one side of the neck and then the other; the hands and fingers being placed in such a manner that when the fingers of one hand are relaxing the muscles on its side the other hand is executing the movements of the head and neck, each hand continually alternating in the work. This latter method requires some practice in order to do the work readily and successfully, for quite a variety of movements are required.

In the former method after one has worked on one side he is obliged to change to the other side and go through the same process. Movements may also be given to stretch the contracted muscles, thus overcoming the contraction and producing relaxation of the muscles.

After having relaxed the muscles over the field of operation, correcting the vertebræ will generally be easier to accomplish. In readjusting an atlas it matters but little whether the patient is sitting up or lying down. A firm hold of the atlas can be gotten in either instance. In correcting the middle and lower cervical vertebræ it is best to place the patient upon the back.

In correcting dislocations, as heretofore suggested, two general rules should be followed: (1) Exaggerate or increase the dislocation. This is to relax the tissues about the dislocated articulation and to disengage the articular points that have become locked. (2) Reduce the lesion by retracing the path along which the parts were dislocated. One can readily see that a dislocated ball and socket joint could be reduced only by the dislocated bone retracing the path by which it left its socket, for the capsular ligament would at once prevent its returning to the socket by any path other than that taken when dislocated. This applies to all dislocations to a greater or less extent.

After locating the exact position of the abnormal vertebra the first rule is applied, i. e., exaggerating the lesion by flexing the head in the opposite direction to which the vertebra is dislocated. Then with one or two fingers placed firmly upon the side of the vertebra in the direction dislocated, so that when the proper time comes the vertebra may be pushed or slightly rotated back into its normal position, with the other hand produce flexion of the neck, so that the angle of flexion is exactly over the involved vertebra; next produce slight traction, so as to be sure that the articular points will be disengaged; and then with rotation and extension of the head to a normal or upright posture, at the same time pushing in on the disordered vertebra, are the movements to be executed in reducing a dislocated vertebra. It takes considerable practice to be able to correct a vertebra and to know when it is corrected. The amount of force applied varies greatly in different cases. Cases of recent subdislocation require but little force unless there is marked spasticity of tissue, while in long standing cases many times the amount of force required is about all that one wishes to exert. As a rule in many chronic cases it is better to give a series of preparatory treatments in order to reduce muscle fibrosis and thickening of capsular ligament. Remember that often it is a slight rotary movement or twist given that aids the most in executing rule second. No matter to what position a vertebra is rotated or side-bent the principles applied are the same in each case.

Be very careful when flexing, extending or rotating the neck that too much strain is not brought to bear upon the ligaments. Some osteopaths seem to take delight in rotating and flexing the neck to a great degree. It is a dangerous procedure and moreover does not accomplish anything in particular. It should be kept in mind that osteopathic treatment is scientific and not a number of general movements of various regions of the body. Locate the lesions exactly and then a specific treatment can be given in every instance. To illustrate the treatment according to the preceding rules we will assume that a certain cervical vertebra is anterior, say the fourth cervical. This means that there is an interosseous lesion between the fourth and fifth. The inferior articular processes and facets of the fourth have slipped upward and forward on the opposing facets of the fifth. First, hyperextend the head in such a manner that the fulcrum comes exactly over the displaced articulating planes, thus throwing the fourth vertebra still more anterior, or in other words, exaggerating the lesion or increasing the space anteriorly between the fourth and fifth cervicals, so that when the head is flexed forward and pressure is exerted upon the anterior part of the vertebra (body or transverse process) the vertebra will have room and release enough to occupy its normal position. Second, when the head is hyperextended place a finger anterior to the transverse process of the dislocated vertebra and with the other hand around the head, that is producing the hyperextension, throw the head forward with slight traction and rotation and at the same time push posteriorly quite strongly upon the dislocated vertebra. Follow out the same principles in all cases, no matter in which way the vertebræ are deranged.

There are several methods of applying the underlying principles of adjustment. Relaxation and leverages may be secured in various ways. Preciseness, expeditiousness and skillfulness can be attained only by considerable personal experience.

In cases where the lesion is between the skull and atlas have the patient sit on a stool with the back part of his head against your chest, and reach around the head with one hand under the chin; then with the other hand around the transverse processes of three or four upper cervical vertebræ pull the spinal column toward the median line, while at the same time lifting up on the skull with the other hand and throwing the skull toward the median line. The object of lifting up on the skull is to relax and disengage the articulations, by inhibition, traction and rotation, between the occipital bone and atlas. This is one method applicable to the various lesions of the occiput, which are of frequent occurrence.

In treating the =pharynx=, =tonsils= and =larynx=, outside of correcting spinal lesions, an anterior treatment to these organs is very effective. Examine the deep muscles beneath the angle of the jaw when the pharynx and tonsils are involved; and when the larynx is affected note the condition of the muscles on either side of the larynx. After locating deeply seated contracted muscles in the region of the angle of the inferior maxilla place the fingers over the contracted tissues, and then by a downward, inward sweeping motion toward the median line the muscles may be readily relaxed. When treating the larynx relax the tissues on both sides by an upward, inward movement. These treatments are very effectual when applied directly to the disordered tissues.

Attention should also be given to the lymphatics. In simple infections treat the glands very lightly but attempt to break down the surrounding edematous barrier. Release all the tissues down to and including clavicles, first ribs and pectoral and axillary regions.

To treat slight lesions of the =inferior maxillary= articulation, stand at the head of the patient when he is lying down and hook the fingers about the jaw just in front of the angles, and with the thumbs over the bridge of the nose have the patient open the mouth while considerable force is exerted against his effort. This reduces any slight dislocation of the inferior maxilla. When the jaw is completely dislocated place a piece of wood or hard substance between the molars and exert pressure upward and backward on the chin. If the dislocation is bilateral work on one side at a time.

The object of treatment to the =face= is to stimulate or inhibit points of the fifth nerve that come near the surface (see neuralgia of fifth nerve). While the patient is lying flat upon the back carefully stimulate these various points, especially the supraorbital and nasal, with a downward and outward movement, or inhibit as indicated.

In treating the =scalp= relax the muscles over the scalp thoroughly. This is secondary treatment to correcting the innervation to the scalp at the upper four or five cervical vertebræ.

In cases of pharyngitis, tonsillitis, croup, hay fever, etc., an effective local treatment may be given through the =mouth= upon the soft and hard palate. Introducing a finger into the mouth clear back upon the roof of the soft palate, and with a downward and backward sweeping movement from the median line on either side toward the tonsils, considerable relief can be given the patient. This treatment relaxes the tissues, relieves the congestion, and gives a stimulating treatment to the local nerves. A treatment of the same nature may be given over the hard palate to affect the palatine nerves, especially in hay fever, when the itching of the palate and sneezing are extreme. In cases of young children it is best to protect the finger by wrapping a piece of cloth around it.

An osteopath should never give a manipulation or movement unless he understands why. Just as soon as one gives general imitating movements, from that moment his work is not that of a scientific osteopath, but of a Swedish movement curist and masseur and a poor one at that. The osteopath’s work is to locate the anatomical derangement and correct it, as a mechanic would adjust any disordered mechanism. General treatment amounts largely to naught, although in some few instances it is of benefit.

To give a detailed description of the treatment of all lesions that may be found in the cervical vertebræ would be impossible in this sketch; only a general survey of the work can be given. Each case calls for special treatment, but the same general principles are applicable in each case. If there is any one thing that should be eliminated from osteopathic treatment it is those mechanical routine movements of rotating, flexing, extending, and various Swedish-movement-massage-like manipulations that certain osteopaths give in each and every case. It shows that they are imitators and do not have a correct conception of osteopathic therapeutics. True it is, that routine movements will have stimulating and other effects upon the system. But does the body require such treatment? Is it lack of exercise on the part of the patient? If it is, then let the patient exercise himself. You do not want to lower yourself to be a mere “engine wiper,” or an exerciser. If it is not the lack of exercise and the system is in need of certain treatment, then seek the cause and apply a specific treatment. Do not hide behind generalities.

=The Ribs.=—In correcting dislocated ribs many methods may be employed, but all are subject to the same principles as given under the treatment of the neck and head.

One of the best methods to correct typical ribs is to have the patient upon the side with the side of the affected ribs upward. Find out exactly the nature of the dislocation, i. e., what is the relation of the dislocated rib to the other tissues. Note whether the rib is upward, downward, inward or forward, locate exactly the dislocated rib. Then, while standing back of the patient, place your fingers upon both ends of the rib. Place your fingers in such a manner that when the proper time in the procedure arrives, all that will be necessary will be to push the ends of the rib into their articulations. For instance, if the rib is raised anteriorly and lowered posteriorly, you will place the fingers on the sternal end, above the affected rib and the fingers on the vertebral end, below the rib, so that when the rib has been released from its abnormal position it may be slipped into normal position. After having placed the fingers in the exact position necessary, have an assistant take the arm and draw it obliquely across the face, while at the same time the patient takes a forced inhalation. The object of drawing the arm across the face and the deep inhalation is to exaggerate the lesion—to draw the ribs out of their locked position—so that the fingers upon either end of the rib may push the rib into normal position. Drawing upon the arm raises all the upper ribs as well as the dislocated typical rib, principally by the use of the serratus magnus; also inhalation has an effect to throw the rib outward and upward and thus away from its articulation. Thus after the lesion has been increased sufficiently to loosen the rib from its abnormal position, the arm is relaxed, the patient exhales, and the fingers upon the ends of the rib correct the dislocation. This treatment is used to the greatest advantage when there is a dislocation of a typical rib; it can be given while the patient is lying down or sitting up, although the former position is preferable.

An excellent method, when the =sternal end= of the rib is dislocated is to have the patient sit upon a stool with his back toward the physician; then by placing the knee in the back (while standing up, or easier still for the physician to sit upon an operating table back of the patient) over the vertebral end of the rib so that the rib may be held rigid posteriorly, reach around with one hand over the dislocated end of the rib and place the fingers upon the rib in the direction dislocated; so that when the rib is sufficiently released from its abnormal position it can be readily pushed into place; then with the other hand under the axilla of the arm on the affected side, pull up and back on the shoulder, so that the rib may be pulled away from its sternal articulation; and at the same time have the patient take a deep inhalation so as to aid in throwing the rib outward, upward and away from its sternal attachment; then when the end of the rib has been released sufficiently, relax the hold underneath the axilla, have the patient exhale, and slip the rib into its normal position by the fingers over the end of the rib. This is an excellent method. It is easy to give and does the work admirably.

Practically the same procedure may be gone through when the =vertebral end= is dislocated, by changing your position to the front of the patient, but there is danger of the knee slipping off from the sternum during the operation and injuring the ribs. Several other treatments may be given to correct dislocations of the vertebral ends of the ribs. For example, while the patient remains sitting the osteopath stands in front of the patient and reaches around both sides upon the angle of the ribs; then with an outward and upward movement of the fingers upon the angle of the ribs, they are pulled away from their locked position and allowed to slip into normal articulation. This treatment is applicable only when the ribs are dislocated downward, but it is one of the best treatments for such cases.

Another method oftentimes employed in correcting dislocations of the vertebral end of the ribs is to have the patient lie flat upon the side with the affected side upward; then by flexing the arm on the forearm and placing the elbow against the chest or abdomen reach over the patient upon the angle of the dislocated rib and pull it away from the vertebra; when it is pulled away from the spinal column sufficiently, push upward or downward on the angle of the ribs, as the case may demand. The elbow placed against you gives complete control of the patient and aids, by your weight, in throwing the rib upward or downward.

A treatment somewhat like the preceding one which is commonly employed, is to reach underneath the patient’s upper arm, when he is lying upon his side, with the arm extended upward across the face; then by placing the fingers of the hand underneath the patient’s arm over the angles of the affected rib or ribs and reinforcing the hand by the fingers of the other hand an upward, outward and rotary movement can be given the ribs, which pulls them out of their abnormal position and allows them to return to their normal articulations.

An effectual treatment to spread and raise the upper ribs is to have the patient flat upon the back, and with the fingers of one hand underneath the angles of the ribs and the other hand upon the elbow of the patient’s arm of the same side throw the patient’s arm across the chest transversely and bear down upon the elbow, at the same time spring upward and outward on the angles of the ribs with the other hand. By throwing the arm across the chest and bearing down upon the elbow a strong leverage can be obtained upon the upper ribs, especially those between the scapulæ. This treatment is very efficacious in certain lung and heart diseases.

Still another method of adjusting ribs is to have the patient flat on his face upon an operating table with the arms hanging down on both sides of the table and a small pillow or folded blanket beneath the upper part of the chest; then standing beside the table, or better still, with one foot upon a low stool and the knee of the other limb upon the table in such a manner that one is directly over the patient’s dorsal region one is then in a position to have full control of the vertebral end of the ribs. If the ends of the ribs are displaced downward, placing the thumbs over the angles of the ribs and pushing upward and outward on the angles, the ribs can be very readily crowded into position. If the ribs, especially between the scapulæ, are dislocated in any direction, they may be quite readily corrected by placing the hand over the shoulder posteriorly and throwing it outward and upward and away from the spinal column in such a manner that the ribs are pulled away from the abnormal position; then upon relaxing the hold upon the shoulder with the one hand, the fingers of the unemployed hand may push upward or downward, as the occasion requires, on the angles of the affected side so that the ribs may be slipped into place.

Many times one is obliged to treat the ribs of one side as a whole. In such instances the ribs are almost invariably thrown downward except on one side of scoliosis of the dorsal region. Several methods may be employed to raise the ribs. Probably the best method is to have the patient upon the side and with one hand upon the angles of the ribs and the other hand holding the wrist of the upper arm of the patient, an upward lifting movement is given both upon the angles of the ribs and upon the arm of the patient while the patient inhales. The work upon the angles of the ribs is to raise the ribs directly; the work upon the arm is to raise the ribs indirectly, principally by the use of the serratus magnus. Another effective treatment is to have the patient upon the back and with one hand over the anterior ends of the ribs and the other hand over the angles of the ribs an upward movement is given them by springing the ends of the ribs toward each other and by strong inhalation on the part of the patient. This treatment is most effective where the false ribs are at fault and especially in case of hemiplegia. While the patient is upon the back an assistant may take hold of the arm and draw it upward over the head of the patient, producing considerable additional upward tendency of the ribs, and the physician giving the same treatment of the ends of the ribs as before; or the physician may take an arm in one hand and raise it above the head of the patient and with his other hand around the angles of the ribs, and the patient inhaling deeply, the ribs may be raised.

A treatment used a great deal in raising the ribs as a whole is to have the patient sit upon a stool, and reaching around the patient from the front, place the fingers upon the angles of the ribs and raise them upward on both sides at the same time. This treatment can also be given by standing behind the patient and reaching around upon the anterior ends of the ribs and lifting upward while the patient aids you by deep inhalation. Remember that many times the ribs are drawn downward by contraction of the muscles, due to atmospherical changes and slumped postures. One should begin at the upper ribs in all treatments where the ribs are to be raised, as a whole, and work downward.

To correct the =first= and the =floating ribs= a different treatment has to be given than the foregoing.

An =upward displacement= is the most common lesion of the =first rib=. To correct such a dislocation, have the patient sit upon a stool and with one hand pull the head to the opposite side in order that the lesion may be exaggerated by traction of the lateral muscles of the neck (principally the scaleni) upon the rib; this disengages the rib from its abnormal position; then with the fingers of the other hand upon a point midway of the ends of the rib, exert a downward pressure at the moment the extended head is relaxed describing a short arc. But don’t relax head until readjusting pressure is exerted upon rib. If the patient is unable to sit up, and it is not best to give the foregoing treatment, have the patient flat upon the back, with one hand take hold of the arm on the affected side and pull down and out upon the shoulder so that the rib may be somewhat drawn away from its articulation and released from its position; then with the fingers of the other hand upon the center of the rib, or its highest point, press downward when the hold upon the arm is being relaxed. Correction of an upper displacement of the first rib is an every day occurrence. =Downward dislocation of the first rib=, is rare. To reduce this dislocation, place the thumb beneath the vertebral end of the rib, and with the other hand lift up strongly on the shoulder from beneath the axilla, at the same time exerting pressure upward with the thumb on the end of the rib.

The =floating ribs= may be dislocated obliquely downward, or the free end of the rib may be caught underneath the end of the rib above. In either case, in order to correct the displacement, place the patient upon the back with the thigh on the affected side flexed upon the abdomen so that the tissues about the field of operation are relaxed; then bear down carefully but firmly over the free end of the rib with the fingers until one finger can be hooked underneath the end of the rib; then with the other hand over the vertebral end of the rib, have the patient take a deep breath, at the same time springing the ends of the rib toward each other, thus relaxing the rib from its locked position; then have the patient exhale quickly and at the same time spring the rib into its normal position. It oftentimes requires repeated trials, especially in stout persons, and quite often the operation is painful to the patient. It is necessary that one should understand this operation thoroughly, as it is one of the most common treatments in osteopathic practice. The floating ribs are very liable to dislocations and may be the cause of many pains in the side, disturbances of the vessels as they pass through the diaphragm and inflammation in the iliac region. A palliative treatment may be given the floating ribs by having the patient lie flat either on the back or on the side; then place the hand near the vertebral end of the ribs and raise them upward while the patient takes a deep breath.

Treatment of lesions between the =manubrium= and =gladiolus= are best given by placing the patient with the face downward upon the operating table, and having the articulation of the manubrium and gladiolus just over the edge of the table. An assistant should hold the patient firmly upon the table while hyperextension or flexion, as the case may require, with traction, is exerted upon the head, neck and shoulders, and manipulation of the articular points is given to reduce the dislocation. The same principles are employed here as in correcting lesions elsewhere.

Correction of the =cartilages along the sternum= is very easily accomplished by having the patient sit upon a stool and the osteopath standing behind the patient places a knee in the back; then reaching around with one hand over the cartilages and the other hand underneath the axilla, execute the same movement as given in correcting dislocations of the sternal ends of the ribs.

A treatment sometimes used to release a depressed condition of the =cartilages= of the =false ribs= is to stand behind the patient while he sits upon a stool and reach around him with fingers underneath the cartilages and raise them upward as he inhales. By having the patient take a deep breath and then exhale quickly while the fingers are over the cartilages a much better grasp of them can be obtained. This treatment should be carefully given, as there is danger of tearing the cartilages loose from the ribs.

=The Dorsal and Lumbar Spinal Regions.=—Here, as in other regions of the body, before an attempt is made to correct the vertebræ the muscles should be thoroughly relaxed. One of the easiest methods to relax the muscles is to have the patient lie upon the side, and then by standing in front of the patient and reaching over him with the fingers upon the contracted muscles an upward and outward rotary manipulation is given; or the patient may sit upon a stool while the physician stands in front with the arms around the patient and the fingers over the contracted muscles manipulating them upward and outward. Another very easy method is to stand behind the patient while he sits upon a stool and place a thumb over the contracted fibres, with the other hand underneath the axilla lifting the shoulder upward and backward so as to favor a relaxation of the muscles, while the thumb manipulates them.

In relaxing the =muscles= of the =lumbar region= have the patient on the side upon the table; then flex the thighs upon the abdomen with your weight against the knees so as to control all movements of the patient; reach over the patient with the fingers upon the contracted tissues and manipulate them outward and upward on either side until they are relaxed. A method sometimes employed to relax the muscles of the dorsal, lumbar and sacral regions is to place the patient flat on his face upon the table; then by pushing up on the muscles from above downward with the flat of the hand they are easily relaxed. This treatment should be especially given when the patient’s muscles are contracted by atmospherical changes and from standing in one position for a long time. When the muscles of the back are contracting they draw downward and many times draw the ribs with them, as well as tensing the tissues over the sacral foramina and obstructing or irritating the sacral nerves. By using the modern table longitudinally relaxing, or stretching, the lumbar and dorsal musculature saves considerable strength and effort of the physician.

To correct =vertebral lesions= of the =dorsal region= the same rules should be followed as in treating lesions of the cervical vertebræ. Treatments may be given with almost equal ease whether the patient is lying on the side or sitting up.

To illustrate the treatment of the dorsal region when the patient is lying down, assume that there exists a lateral lesion, combined rotation and sidebending, between two vertebræ; if the lesion is below the seventh dorsal use the legs as a lever, and if the lesion is above the seventh dorsal use the head and neck as the lever. Have the patient lie upon the side toward which the lesion is pronounced, either reach under the neck or around the limbs with one hand, and with the other hand upon the lesion bend the head and neck or the thighs in such a manner that the angle of the flexion is directly over the break in the spinal column; this is to exaggerate the lesion; then by lightly lifting up on the neck or limbs and with a slight rotation of this lever the flexed parts should be extended, at the same time exerting pressure with the hand over the lesion in such a manner that the vertebra is pushed forward toward its normal position.

Practically, the same treatment is given when a patient is sitting up, with the exception, of course, that the limbs cannot be used as levers. Lesions of the dorsal region or even the lumbar region can be corrected while the patient is sitting up. By this method considerable lifting is done away with. In fact, the weight of the patient can be used to great advantage by substituting it for one’s strength. No matter in what direction the lesion is, the physician reaches around the patient’s shoulders so that he just holds the weight of the patient from falling to one side or the other; thus with one hand manipulating the lesion the other arm is around the patient guiding the weight of the body in flexion, rotation and extension. It is not always necessary to lift up on the patient but just let the weight of the patient act as strength applied to the power arm. Always make it a point when working upon dislocated vertebræ in any region that just as soon as one has obtained a slight movement in the lesion =do not attempt= to correct it any more for the time being. A slight movement toward the right direction may be all that is necessary to relieve the ill effects of the lesion. In fact it might be impossible to get the lesion anatomically correct as the shape of the vertebra may have conformed in a greater or less extent to its abnormal position.

An excellent method to correct the various combinations of rotation and sidebending of the third to ninth dorsals is to have the patient sit up with the physician either sitting or standing, depending upon height of seat, back of the patient. Have the patient lean back until head is supported upon shoulder of physician, and the anterior and posterior musculature of torso, abdomen and pelvis are thoroughly relaxed. Reach around the patient’s chest with one arm, the hand of which is placed beneath the axilla. The thenar eminence of the other hand is placed upon the posteriorly prominent transverse process of the lesioned segment. Then with careful hyperextension, traction, and rotation and, sidebending of the torso, the anchorage is released, care being taken that localization is exact; this moment of coordination is accompanied with a thrust of the thenar eminence upon the transverse process. Relaxation, leverages and thrust must be precise and thoroughly coordinated.

To reduce vertebræ that are =deviated anteriorly= in the dorsal region, especially between the scapulæ, is often a hard matter. A satisfactory method is to stand behind the patient, while he is sitting upon a stool, and reach around both sides of him upon the sternal ends of the ribs corresponding to the anterior vertebræ; then have the patient relax with the head upon the chest, and at the same time take a full inhalation while pressure is exerted posteriorly upon the sternal ends of the ribs. The object of this method is to pull back the rigid ribs (the lungs being filled with air) which are attached to the anterior surfaces of the transverse processes of the vertebræ, and thus upon the anterior vertebræ pushing them posteriorly; all of the muscles of the body being quite passive and the head relaxed on the body, a separation of the vertebræ is accomplished, thus favoring a crowding posteriorly of the subdislocated vertebræ.

To correct =vertebræ= of the =lumbar region= is on the whole much easier than in the dorsal region. Here the legs can be used as levers to great advantage. By the same method of flexion, rotation, and extension, as employed in the dorsal region when the patient is lying on the side, the result can generally be obtained.

Sidebending is the most common single lesion of the lumbar vertebræ, though there may be some rotation at the lumbo-sacral juncture. Occasionally malformation is found at the fifth. To correct the lumbar lesions the following method is often used: place the patient upon the side of the rotation or sidebending with knees flexed, buttocks well back and entire spinal column straight. Next bring torso and head, with spine straight, well forward to edge of table. Then with hand upon ilium tilt it slightly forward, and with other hand upon shoulder rotate entire spine, including head, so that spine is locked and the point of localization exactly corresponds to the lesions. This brings the spine back to nearly a straight position. Next, after a moment or two of tension-relaxation, either thrust back upon the shoulder or forward upon the ilium. Again exactly coordinating localization, relaxation and leverages is the key of the method.

=The Abdomen.=—Direct treatment of the abdomen is given in many diseases of its organs. The patient should lie flat upon the back, the legs flexed upon the thighs and the thighs flexed upon the abdomen, so that the abdominal muscles will be thoroughly relaxed; and then the various organs of the abdomen can usually be manipulated with ease. Remember that in many diseases of the abdominal viscera the treatment of the splanchnics and vagi will be the primary treatment rather than direct abdominal treatments.

In treating the =liver= directly, the ribs over the liver should be raised and separated, and the lower border of the liver manipulated directly, as considerable therapeutic results can be obtained, particularly when the liver is congested and enlarged. Manipulation of the =bile ducts= is very essential in many liver diseases. The treatment relieves congestion of the ducts and removes any collections of mucus in the ducts due to the congestion, as well as freeing obstructed flow of bile. The manipulation should be a deep, downward one, directly over the path of the ducts (from about the cartilage of the ninth rib to the duodenal orifice of the biliary tract, the latter being about one and one-half inches diagonally downward and to the right of the umbilicus). Be very careful when first manipulating, and bear down lightly over the duct so that the structures superficial to it may be relaxed as the duct is deep below the surface of the abdomen. Usually the gall-gladder can be emptied by light pressure over the skin above the cartilages of the eighth, ninth and tenth ribs. The light manipulation acts, probably, by way of the spinal segment, as a stimulus to the dilators of the sphincters of the gall-bladder. Very likely through reciprocal innervation relaxing the sphincter of the bile duct will contract fibres of the gall bladder.

Manipulation of the =stomach= has considerable effect in strengthening its circular fibres and toning up the coats in general. In cases of gas formation, the gas in some instances may by manipulating over the stomach, be forced through the cardiac or pyloric orifices.

Direct treatment over the =spleen= by raising the eighth, ninth, tenth and eleventh ribs of the left side is effectual in congestion and enlargement of the organ.

In thin subjects the =kidneys= can be treated directly by pressing down carefully but deeply over the kidneys, and lightly crowding them upward and outward. This treatment also has some effect in relieving contracted tissues about the renal vessels and kidneys.