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.
Treatment to the =intestines= through the abdomen is an effective
treatment. In the various obstructions to the intestines, constipation,
etc., the direct work is essential. Treatment of the intestines is to
correct any abnormal position that they may have assumed, to relieve
constrictions of the gut caused by contracted tissues, to relieve
impactions and adhesions, to increase peristalsis and to tone up the
intestinal coats in general. The treatment consists in a manipulation
of the intestines, especially in the right and left iliac fossæ, and
the pelvic colon, ascending colon and duodenum, as impactions and
prolapses of the gut are more liable to occur at these points than in
any other locality. In manipulating the intestines, work for a definite
purpose and not give a general kneading treatment unless the walls of
the abdomen and the coats of the intestines are weakened; in the latter
case the spinal treatment is the primary one. In treating over the
iliac region, draw upward and inward on the folds of the gut. It is
claimed by some authorities that nerves pass from the cutaneous surface
of the abdomen directly to the intestine by way of the peritoneum;
if such is the case, manipulation of the abdominal walls would have
direct effect upon these nerve fibres. The abdomen may be treated when
the patient is sitting up, but the treatment is not satisfactory. (See
Prolapsed Organs).
=The Pelvis.=—The treatment of the pelvis is easy, but the difficult
work is in making a diagnosis of the position of the pelvic bones.
The pelvis is especially apt to become deranged by jars and falls.
Some of the most successful osteopathic results have been obtained in
correcting the pelvic region.
To relax the muscles over the pelvis, the patient should be on the side
or upon the face; then relax the muscles by manipulating them upward,
chiefly those over the sacral foramina. It is a good rule to adjust the
lumbar first owing to release secured to the nerves supplying pelvic
muscles and also to the fact that many pelvic distortions are secondary
or compensatory to lumbar lesions. The easiest method to correct the
innominata is to have the patient lie upon his side; then by standing
in front of the patient slip one hand between the thighs and grasp
around the tuberosity of the ischium, and with the other hand upon the
crest of the ilium, the innominatum can be moved upward or downward
and forward or backward (wheel and axle principle). Simply pulling or
pushing upon these two points in whatever direction necessary is all
that is required providing the soft tissues are thoroughly relaxed. By
having the patient flat upon the back practically the same treatment
can be given, but not to so great an advantage. In cases where the
ilium is posterior and the ischium anterior, the physician may stand
back of the patient, while he is lying upon his side, and place one
knee against the sacrum and with one hand upon the ilium, with the
other take hold of the ankle of the affected side (the involved side
being uppermost in all cases where the patient is lying upon his side);
pressure can be exerted upon the ilium and the limb pulled backward,
thus correcting the derangement. This treatment should be avoided as
much as possible, as there is considerable danger of pulling back too
severely and injuring the patient; the lever is long and the amount of
force exerted upon it cannot be judged precisely.
Another method is, with the patient on the back, flex and evert the
knee to the side so the side of the foot lies flat on the table. Grasp
the ankle with one hand and with the other on the crest of the ilium
of the opposite side then, by pushing down firmly on the knee the
articulation is gaped and at the same time the operator pushes with his
body against the knee with a sharp thrust. This may have to be repeated
a few times before the articulation is released and if one is keen he
will easily detect the slight concussion carried down the femur as
the adjustment takes place. This will correct a forward and downward
innominate. For an upward and backward one, place the patient in
exactly the same position and go through the same motions except that
the knee is pulled toward the operator. If the desired “chug” is not
felt and adjustment is not definite, the leg may be pulled down rather
smartly by the ankle to a parallel with the other. This is a technique
that is easy, both for the patient and operator, and will correct any
but the most stubborn.
In the case of a greatly relaxed and atonic condition of the ligaments
of the pelvis much trouble is experienced, often, in making the
adjustment permanent. Many suggestions have been made and most of them
useless but, probably the use of a belt of non-elastic webbing about
two inches in width buckled tightly around the pelvis just below the
anterior spines will do as much as anything and is a procedure well to
follow in all such cases. Where there is a pendulous abdomen a support
in the shape of a simple belt which should be so fitted as to act as
a sling will transfer the weight of the abdominal viscera from the
muscles, already stretched and atonic, to the belt and put the burden
over the sacrum. This prevents the pulling of the innominatum in lesion
again. Overcorrection is suggested as a means on the ground that it
sets up irritation and induces fibrous ankylosis and for the same
reason W. W. Howard places his patient prone and with thumb works the
ligaments associated with the joint until they are thoroughly inflamed.
The patient is then put in bed a few days and after the inflammation
has cleared up the ligaments will be found to have shortened.
To correct a rotary lesion between the pelvis and fifth lumbar the
patient should be placed upon the side, and with the body held firmly,
the pelvis can be forced backward or forward as the occasion demands.
(See Coccyx).
=The Legs.=—The origin of many symptoms manifested in the legs, as in
the arms, are due to spinal lesions corresponding to the region of
innervation to the affected tissues. The derangements of the pelvic
bones are a frequent source of symptoms that are referred to the legs
and feet. The osteopath finds that a slight dislocation of the hip
may occur which is especially likely to affect the knee. This partial
dislocation is apt to be an upward-posterior one; the head of the
femur resting in the upper and posterior part of the acetabulum. Many
diseases of the legs and feet are due to local displacement of the
bones. The method of treatment is the same as given in surgical works.
(See Sprains).
A general treatment of the legs and thighs is oftentimes necessary;
it consists of flexing the thighs quite firmly upon the abdomen, and
executing thorough external and internal rotary movements of the thighs
and legs. In a few cases both limbs are flexed strongly at the same
time upon the abdomen. After giving these movements manipulation over
the saphenous opening and beneath the popliteal space is performed.
This general treatment tends to increase the circulation of the entire
limb and to relax thoroughly all contracted fibres.
=The Arms.=—In treating the arms, care has to be taken that the
affection is not due to spinal derangements; otherwise the arms are
manipulated according to the disorder. Complete dislocations of the
shoulder comes under the province of surgery. Many times the osteopath
locates slight or incomplete dislocations of the shoulder. Partial
dislocations of the shoulder are generally anterior. (See Sprains).
In cases where pain exists in the shoulder or arm, outside of locating
the cause in the shoulder joint, the affection may be due to fibres
contracting over the coracoid process, or a dislocation of the second
or third rib, and in some instances the clavicle is deranged. Special
care should be given to a possible bursitis and tendo-synovitis.
Occasionally muscular fibres may slip out of the bicipital groove.
Dislocations of the bones of the arm are treated according to surgical
methods. The pains and various troublesome symptoms that may be
manifested in the fingers or the hands are oftentimes caused by slight
dislocations of the elbow, shoulder, ribs, or vertebræ, as low as the
sixth to eighth dorsals.
=The coccyx.=—The coccyx, owing to its exposed position and rather
unstable attachment, is subject to many injuries; more indeed than come
to notice. Its injury results in many local and general disturbances
owing to its close relation to the sympathetics. Successful treatment
of deviations often bring startling results. They may be divided into
=fractures= and =displacements=.
In =complete= or =partial= fracture of the coccyx, as well as in
dislocation, if the patient can be seen with reasonable promptness
after the accident much can be done for relief of the pain and the
prognosis is good for complete recovery.
Examination should be made externally and internally and after the
condition is diagnosed about the same procedure is indicated for any of
the conditions. With the patient on the left side introduce the right
index finger, well lubricated, into the rectum and carefully relax all
tissue within reach of the tip. If there are spasms of the coccygeal
muscles, inhibition of the anterior nerves will quiet them. When this
has been done place the left index finger externally along the body of
the coccyx and holding it firmly both within and without release it
longitudinally and then adjust. After this has been done it is well to
hold it there until all danger of returning spasm, which might displace
it again, is over, when the finger can be withdrawn.
The pain following will depend on the severity of the injury, but will
keep up more or less constantly for several days. When severe, relief
is often given by introducing the finger and relaxing contracted tissue
which is pulling it from its position. Hot water bags placed next to
the part will be of benefit. The bowels should be kept confined for
forty-eight hours if possible in cases of fracture. Watch carefully the
progress of union that the bones are _in situ_ so there will not be
deformity.
In diagnosing the first injury be sure that there is no splitting
of the first segment or splinters which may require surgical
interference. In old cases of fracture where there is complete bony
ankylosis it is not justifiable to attempt any change, but where there
is motion and a fibrous union, after preparatory treatments about one
week apart, it can usually be replaced. Look well to any muscular
contractions which might interfere with it. Force must never be used
nor any attempt to replace until it has been first released from its
articular attachment. In the various forms of =displacement= the same
technique applies as in fractures, or the finger and thumb of one hand
may be used, the tip of the finger internally at the sacro-coccygeal
articulation and the thumb externally at the same point. Complete
control of the part is secured in this manner. Great care must always
be used in treatment of any displacement of the coccyx. Contractions
of its muscular attachments will often cause deviations in contour.
Removal of the irritation and relaxation will allow it to assume its
normal position.
=The sacrum.=—Adjustments of the sacrum as distinguished from the
ilium in strictly innominate lesions are not many. When posterior with
the patient on a stool the knee of the osteopath coveted by a pillow
and placed against the sacrum and both hands grasping the anterior
borders of the ilia, strong traction will move it into position. In a
downward displacement with the aid of an assistant from behind holding
the crests of the ilia firmly as the patient sits on the table, the
osteopath in front clasping both arms about the patient and with a
rocking motion from side disengages the sacrum and at the same time
lifts it into position.
For anterior displacements use the technique described in replacing
upward and backward innominate dislocation first right side and then
left, which will result in correcting the lesion.
The preceding osteopathic technique includes a few of the treatments
given by the osteopath. Although many osteopaths use methods not
given here, those outlined are sufficient for illustrative purposes.
A point which cannot be too thoroughly impressed upon the student is
that osteopathic treatment is in reality =constructive= work, that is,
readjustive, not only in detail, but in viewing the body structure
as a whole. Detailed readjustment is an essential, still do not lose
sight of the relation of the part to the whole. In our distinctive
work anatomical construction is the basis of physiological function,
although physiological stimulus is essential to anatomical development.
=How often to treat.=—How often to treat a case depends entirely upon
the nature of the disease from which the patient is suffering. Just
as in giving drugs the frequency of treatment is entirely dependent
upon the seat of the disease and its severity. Acute cases require a
thorough treatment at least once daily, and many times in severe cases
the treatment has to be repeated several times daily. In subacute and
chronic cases, as a rule, treatment should not be given as often as in
acute cases; possibly once a day, but usually alternate days is better.
In office practice cases are commonly treated two or three times
weekly. Still it is better not to treat some cases oftener than once a
week.
There is more danger in treating too often and too long than in
not treating often enough. The distinctive work of an osteopath is
to correct disordered anatomical structures; and when a certain
derangement has been corrected the tissues should have rest and plenty
of time for repair. When treatments are given often, it simply keeps
the tissues in an irritated state and nature does not have time to
heal the diseased tissues. Always make it a point at each treatment to
correct some definite lesion, and when the work is accomplished let
the parts alone until the tissues have recovered as much as possible
from the effects of the previous treatment before another treatment is
attempted. The reason why some cases do not get cured under osteopathic
treatment is simply because the osteopath keeps the diseased tissues in
an aggravated state by the constant treatment so that they do not have
the least chance to heal; the physician is thus adding irritation to
the disease.
It is only by experience that one can tell how often to treat. Each
case is a special study; what would be quite sufficient for a certain
individual with a given disease would not be at all suitable for a
second individual with the same disease. As in drugs what is suitable
for one person would not be adapted to another, because the make up
of each individual is entirely different; but here the parallelism
diverges, for in drugs there is a foreign agent introduced into the
system, while in osteopathic treatment the curative agent is entirely
harmonious with the idiosyncrasies of the individual. It is for this
reason that experience in practice is so essential.
Most cases should not be treated, as a rule, after a meal unless the
patient is suffering from some digestive disturbance; for treating
other regions of the body outside of the digestive tract causes more or
less stimulation of the parts treated and thereby draws blood away from
the organs of digestion. Cases of disordered brain circulation, where
the patient is unable to rest or sleep at night, should be treated at
about their retiring time so that the circulation of the body may be
equalized, thus giving the patient undisturbed rest.
To show in a practical way the methods of experienced osteopaths in
this matter G. J. Helmer[32] is quoted: “I submit the following table
to illustrate the frequency of treatment in one hundred cases taken
from my practice: one case three times per week, sixty-three cases
two times per week, twenty-two cases one time per week, nine cases
once every two weeks, five cases once every four weeks. Comparing
the present with the past, I find I am lengthening the time between
treatments with much better results.”
Another very practical side of the question and one which will be
greatly appreciated by the patient, is the lessened cost for the same
result in the less frequent treatments, as well as the saving in time.
With the loss in going to the office, rest after treatment, not to
mention possible wait while there, three times weekly represents more
time than the average person can well spare and not infrequently will
deter him from continuing. More especially is this true of those coming
from a distance.
=Length of Treatment and Overtreatment.=—Naturally the length of
treatment depends upon the case at issue and nothing more. There is no
reason why any two cases should be treated for the same length of time
unless they present identical lesions and then the personal equation
of the two might present such a wide difference of aspect as to forbid
such a proceeding.
The question of time has no place in the matter, save that it must not
exceed physiological limits and be sufficient for the needs of the
case. The patient should understand at once that it is to accomplish
a specific purpose that the treatment is given, just as definite as a
surgical or dental operation, and when the work is done it is time to
stop. He would hardly be attracted to the dentist who guaranteed to use
forty-five minutes in extracting a tooth. Good judgment is required in
this as in all matters pertaining to osteopathy. There is a generally
expressed opinion among the older osteopaths, based on experience,
that: first, a short specific treatment is productive of best results
and, second, treatments given under high tension when quick work is
necessary are most satisfactory. Long treatments are debilitating and
over stimulation amounts to inhibition. Further, in a long treatment
it is necessary to go over the whole body, thus dispersing the vital
forces (which have been stimulated for healing and upbuilding the
pathological area) to parts not involved, thus defeating the very
purposes intended. Dr. Still always advocated and gave the short,
specific treatment.
The point always to be considered is the individual characteristics of
the patient, and effects of the first treatment should be carefully
observed. After a patient has been under treatment for any considerable
time it is well to give him a vacation from treatment, and it is
remarkable what improvement will be shown at times by such a measure
and how seldom he will lose ground. Dr. Still presented this subject
vividly as follows: “To treat the spine more than once or twice a week
and thereby irritate the spinal cord, will cause the vital assimilation
to be perverted and become death producing by effecting an absorption
of the living molecules of life before they are fully matured and
while they are in the cellular system, lying immediately under the
lymphatics. If you will allow yourself to think for a moment of the
possible irritation of the spinal cord and what effect it will have on
the uterus, for example, you will realize that I have told you a truth.
Many of your patients are well six months before they are discharged.
They continue treatment because they are weak, and they are weak
because you keep them so by irritating the spinal cord.” It is not a
rare experience for a patient to leave apparently with little or no
improvement only to report a complete recovery a little later.
=Misapplied Treatment.=—Probably in spinal treatment more risks are
taken than in any other region of the body. To us as a school it is
by far the most important and interesting area we have to treat,
consequently it is not surprising that various general treatments
and methods have been devised with the idea of getting quicker and
easier results. Herein lies the danger outside of mistaken diagnosis,
for short cut treatments can never take the place of time and skill.
Technically speaking, if one thoroughly understands the philosophy of
osteopathy and is conversant with the underlying principles of its
therapeutics, there is absolutely no danger of even the slightest
injury. It is the one who takes chances by not properly diagnosing
and by not being cautious enough with delicate persons when applying
his treatments that is apt to overstrain some tissue or organ and
otherwise do bodily harm. Of the treatments considered dangerous not
one of them is without merit if judiciously applied, but unfortunately
in many cases they are in general and indiscriminate use. It is well
to remember that we are moving structures which have never been
moved before and that time enough has not elapsed to observe what
the ultimate result may be. Again, in adjusting a subluxation of the
spine do not forget that the force necessary for that adjustment, if
misapplied, is sufficient to produce a lesion, and there is no doubt
that this has happened. Your patient’s interests are above everything
and must never be sacrificed for any reason whatever, so if at any
time there is uncertainty always give the patient the benefit of the
doubt. On the other hand the osteopath must have the courage of his
convictions and fortunately when these are coupled with good judgment
the results are all that could be desired. The following should be used
with great caution if used at all:
First, =Indiscriminate stretching= of the spinal column with the aid of
an assistant. It is not good osteopathy although there are some cases
where it may be beneficial. While not specially dangerous, generally,
in delicate patients, elderly people, arteriosclerotic conditions, and
in some stages of Pott’s disease it is absolutely contraindicated.
Moreover in most spinal cases except impacted vertebræ and symmetrical
curvatures the stretching of the vertebral ligaments locks the lesion
firmer.
Second, =Extreme rotating= of the cervical region. This cannot be
considered good treatment in any case with the exception of the
muscle stretching. On the contrary it is dangerous; first, it is not
osteopathy for it is not specific; second, the nervous shock is severe,
an important consideration in delicate people; third, the cervical
ligaments become stretched and the vertebræ are easily displaced, while
damage to a diseased vertebra, an aneurism or in arteriosclerosis would
be irreparable. No other region of the body should have greater care in
treatment than the neck.
Third, =Hyperextension= of the spine with the patient on his face. This
treatment is rarely indicated. In fact, it is barbarous and a relic of
an early day. Possibly more cases have been injured by this treatment
than all others combined.
Fourth, =Rough separating= of the vertebræ and ribs while the patient
is on his face. This is a most excellent treatment in many cases, but
great judgment is necessary. Delicate patients, heart disease, and
necrosed vertebræ and ribs should be carefully excluded.
Fifth, =Innominate adjustments= such as placing the patient on the
side and putting the knee against the sacrum while grasping the leg
at the knee. Or, the placing of the patient face down with one hand
on the sacrum and the other holding the knee. In both these there is
a tremendous leverage and in the latter the strain is at the lumbar
rather than where needed. There are other unnecessarily risky methods
for this operation, while it is easy to perform in most cases and
without danger.
Sixth, =Abdominal treatment= gives wonderful results when intelligently
applied, but it may be productive of great harm in conditions of
tumors, malignancy, and pus formations.
=Misapplied treatment= is always dangerous, no matter to what part of
the body given, and it is proof of wrong diagnosis when given. As a
rule treatment is given without proper diagnosis in such cases, so a
misapplied treatment has two interpretations—first, ignorance; second,
laziness. In the former lies the greater danger for ignorance coupled
with force and lack of skill is an appalling combination.
Cases are frequently reported where tumors have passed from the vagina,
rectum, nose, etc., the osteopath thinking it was the result of good
treatment, without considering that it was simply the breaking of a
long pedicle with great danger from hemorrhage. The greatest care
should be exercised in treating cases where aneurism, osteomalacia,
and arteriosclerosis are present, also in the leg treatment of tabes
dorsalis and in the weak, thin ribs of elderly people and those with a
gouty or rheumatic diathesis. Imagine treating an abscess directly, yet
it has been done, as have varicose veins with the terrible danger of
rupture and embolism. Aneurisms have been ruptured in the same way.
One could go on indefinitely with this subject, but to sum up: if the
osteopath is not familiar with the feel of the living anatomy in its
giving and resisting under treatment both in health and disease and
does not know his osteopathy, nothing can prevent him doing harm. A
successful practitioner means an understanding of pathology, then
experience plus common sense.