The Practice and Applied Therapeutics of Osteopathy Charles Hazzard, D. O. 1905      CHAPTER II   TREATMENT OF THE SPINE  
 
    In this chapter it is proposed to outline the general method of procedure in spinal treatment.  As no specific case or disease is now under consideration the student must bear in mind that the treatments described are general methods and that in any given case he would find it necessary to select and combine these different modes in a manner best calculated to enable him individually to reach the case.
    As far as practicable the specific lesions mentioned in Chapter I will be considered, and treatments appropriate to their reduction will be given.
    These treatments are all manipulative.  They have as their object the righting of what is mechanically wrong.  They are therefore mechanical of necessity, and are founded upon the necessities of the human mechanism when deranged.
    In treatment, the practitioner may have in view either or both of two objects.  He works to right the spine itself, and to affect it alone, or he works upon the spine to affect some other part of the body pathologically connected with the part of the spine in question.
  I.  The patient lies upon the ventral aspect of the body in as comfortable a position as possible.  The head turns easily to one side, and the arms hang down loosely at the sides of the table.  The practitioner must see that the patient thoroughly relaxes the muscles of the whole body.  He now, standing at the side of the patient, uses the palm of the hands or the cushions of the fingers to thoroughly manipulate and relax all the spinal muscles.  In treating the muscles upon the side toward him, he works from one side of the spinal column to the other, in a direction at right angles to the general direction of the muscular fibres.  He treats the muscles of the opposite side by spreading them away from the spinous processes.
    In this way all contractures of the muscles are released, flabby muscles are toned, blood and nerve mechanisms are freed and upbuilt.  This removing of contractures is sometimes a necessary step to the diagnosis of deeper lesions which may have been masked by them.
  II.  The patient lies upon his side, the practitioner stands at the side of the table, in front of the patient; with one hand he grasps the uppermost arm of the patient just above the elbow; with the other hand he holds under the spinous processes of any portion of the spine under treatment.  Now, using the arm as a lever, he pushes it downward and forward, at the same time springing the spine toward him.
    This treatment releases tension in all deep structures, restores free-play between bony parts, and removes pressure from blood-vessels and nerves.  It may be applied in all cases of curvature, sagging, or swerving of a portion of the spine, lateral deviations of vertebrae, in separating or approximating vertebrae, etc.
  III.  Practically the same effect may be obtained upon the lower portion of the spine as follows: with the patient still upon the side, his thighs and legs are flexed, and fixed by pressure of the abdomen of the practitioner against them.  Both hands are now free and spring the spine strongly upward toward him, or to manipulate the muscles; or,
   IV.  With the patient still lying upon his side, the practitioner leans over him, placing his forearms, one against the iliac crest and the other against the shoulder.  He now with his forearms pushes these two points further apart, while with both hands he springs the middle portions of the spine toward him, or manipulates the muscles.
    It will be observed that the treatment described under II, III, and IV above all may be used to thoroughly stretch any portion of the, spine by laterally directed force.  In this way deeper stretching of all spinal structures may be accomplished within the limits of safety than by stretching the spine as a whole by longitudinal traction.
  V.  The latter is applied with the patient lying upon his back; the practitioner, standing at the head of the table, passes one hand beneath the occiput, the other beneath the chin, and draws toward him.  The required degree of resistance is afforded by the weight of the patient or by an assistant holding the ankles.
    The neck must not be rotated during this forcible tension, and jerking must be avoided.
   VI.  The principle of exaggeration of the lesion is one that may be applied to the treatment of many bony luxations.  It consists in so manipulating the parts as to tend to further increase their malposition, and in then applying pressure to them in such a direction as to force them back toward normal position at the same time as the part in question is released from its condition of exaggeration.  This motion releases tension, loosens adhesions, and gains the benefit of the natural recoil of the structures from their exaggerated position.
 VII.  With the patient prone and the practitioner kneeling upon the table at one side of the patient, or with a knee upon either side, direct pressure may be applied, from above downward, to all spinal parts.  This position of relaxation is favorable for forcing vertebrae, or the heads of ribs into place and for the stretching of the deep and anterior spinal ligaments.
  VIII.  The patient lies across the table with the abdomen and anterior chest resting upon it, the arms and head hanging loosely down upon one side and the legs upon the other.  The practitioner may stand at either side of the table (or kneel upon it,) and work for results as in VII, with the additional advantage that the arms, neck, or limbs may be manipulated at will in the course of the treatment.
   IX.  The patient, sits, the practitioner stands in front, slightly to one side facing backward from the patient.  He passes the arm nearest the patient back of the neck, and slips his hand under the opposite axilia from in front.  This bends the neck and upper spine forward and swings the opposite side of the thorax backward, thus rotating the spine.  By using the free hand as a fixed point at various points along the spine, its successive portions may be thoroughly rotated and all of its structures loosened.
   X.  The patient sits; the practitioner stands behind, pushing the head forward and to one side with one hand, while with the other he makes fixed points along the upper spine, upon the side from which the head has been forced.  The head is now swung forward and to the side opposite its first position while the hand brings pressure upon the fixed points, one after the other.  This motion makes use of the neck as a lever of the first class, the fulcrum being formed by the hand at the fixed point, with the lesion (weight) below, and the power (hand applied to the head) above.  It is a method of  "exaggeration of the lesion,"  and is especially useful for the reduction of lateral luxations in the upper part of the spine.
   X. (a)  A variation from the above applies the same principles to lesions lower down in the spine.  The patient sits; the practitioner stands at one side and passes one arm in front of him, grasping his body securely, and rotating his trunk about fixed points made at any desired place along the spine by the application of the free hand to it.  The cushion of the thumb of this hand is pressed firmly against one side of the spines of the vertebrae suffering from lesion, while the bent index finger is pressed against the other.
  XI.  The patient sits and clasps his hands behind his neck; the practitioner stands close behind, passes his arms beneath the axillae and his palms behind the patient's wrists, which he grasps
in his hands.  As the practitioner straightens his body and draws the patient back against his abdomen the neck and upper dorsal spine are bent forward, the scapulae travel back and up, and all of the ribs, except the first three or four pairs, which are sprung forward and downward, are drawn strongly backward and upward.
    This treatment thoroughly stretches most of the spinal ligaments, costo-spinal ligaments, muscles of the back of the neck, scapulae, and of the spine.  It also brings tension upon, most of the intervertebral, the costo-vertebral, the costo-sternal, acromio- clavicular and claviculo-sternal articulations.
  XII.  With the patient sitting, the practitioner, standing behind, may place one knee beneath the patient's axilla thus raising and fixing the shoulder and the ribs of one side of the thorax.  This relieves the spine of the weight of these structures and affords the practitioner two free hands with which he may manipulate the spine or opposite side of the thorax, using the neck and other arm of the patient as levers, if desired.
  XIII.  The ligaments of the posterior lumbar and of the sacroiliac regions may be thoroughly relaxed by bending the body of the patient, who is sitting, far forward between his well separated knees.
  XIV.  The same object is accomplished with the patient supine, while the legs and thighs are both forcibly flexed to their limit.
   XV. To stretch the posterior scapular, rhomboid, and levator anguli scapulae muscles, the patient lies upon his back while the practitioner slips one hand beneath the shoulder and grasps the spinal edge of the scapula, which has been approximated as closely as possible to the spinal column.  The other hand holds the arm of the patient just above the elbow, and the arm is raised and pushed across the chest, the patients hand being in this way forced across well into the opposite axilla.
  XVI.  With the same position of the patient, the anterior scapular muscles may be reached by thrusting the fingers of one hand deeply beneath the spinal edge of the scapula, while the other hand grasps the point of the shoulder.  Now the whole lateral half of the shoulder-girdle may be rotated, the first hand continually working deeper beneath the scapula.
   XVII.  A thorough "breaking up" of the lower dorsal and lumbar regions of the spine is accomplished as follows: The patient lies prone; the practitioner stands at the side and passes one arm beneath the thighs of the patient, just above the knees which he raises just free of the table, moving them horizontally from side to side.  At the same time his free hand is applied to the part of the spine in question, the thumb upon one side of the spinous processes, the fingers upon the other.  The thumb and fingers make lateral pressure upon the spine, alternating with, and in a contrary direction to, the movement of the limbs.
    This treatment loosens and separates the vertebrae, releases tension of muscles and ligaments, and upbuilds nerve and blood-action.
   XVIII.  Dr. Still, in case of lateral spinal lesion, stands in front of the patient, who is sitting.  He passes both arms around the body and clasps his hands over the point of lesion; "sinks" the spine down upon this point, bends the patient toward the side of deviation of the vertebra, then with the hand makes pressure upon the vertebra to force it back to place while lie rotates the body toward the opposite side.
    Very many more treatments might be described, but enough general treatments have been given to reach all parts of the spine and to correct the lesions that are likely to be met with in practice.  These treatments may be combined or may be taken as the basis of new ones which the practitioner may often find necessary to work out in order to reach some special lesion or to treat some special case.
In this portion of the text, the treatments can of necessity be described, and their application be given, only in a general way.  They are outlines of methods of procedure, and the application of the principles embodied in them must be made to the specific lesion met with in a given case by the practitioner.
    The lesions described in Chapter I, such as lateral deviation of a vertebra or lateral swerving of a portion of the column; vertebrae separated or approximated; anterior or posterior luxation of vertebrae; the "smooth spine"; the loss of normal curvature; the rigid or relaxed spine, etc., may all be reduced by various applications of these treatments.
    Generally speaking, the results attained by the use of these treatments are, the relaxation of contractured muscles; the release of tension in nerve, muscle, ligament or other fibrous structure; the reduction of bony lesion; the removal of obstruction from, and the renewal of blood and nerve-currents.
  XIX.  The fifth lumbar vertebra, after luxation, way be restored in various ways.  The posterior displacement is the most frequent.  In this case one may place the patient upon his side, flex the knees against one's abdomen, fix the fifth lumbar by holding beneath it with one hand, while the other, slipped beneath the thighs, rotates the weight of the lower part of the body about the fixed point.  Recent dislocations may be adjusted in this way without difficulty.  In long standing cases, continued treatment is necessary, the work of relaxation of parts, etc., in preparation for its reduction, being performed in part by the application of principles already described.
    With the patient upon his back and the body below the fifth lumbar protruding over the foot of the table, the practitioner, standing between the limbs and holding one under each arm, places both hands beneath the pelvis, makes a fixed point at the fifth lumbar, and by the movement of his own body rotates the lower half of the patient's body about the fixed point.
    With the patient upon his back, the practitioner standing at one side, the clenched hand is placed beneath the body at one side of the fifth lumbar spine.  The leg and thigh are now strongly flexed by the free hand, external circumduction of the thigh is made, and the weight of the body is thrown onto the fixed point.  In some cases this treatment is sufficient for replacing the bone.
    In case the vertebra be anterior the above treatments may be applied for the purpose of loosening all the ligaments.
    Also the principle of exaggerating the lesion may be applied by making a fixed point of the practitioner's knee at the fifth lumbar, the patient sitting.  The patient's body is bent backward against the fixed point and then rotated forward.  Also, with the patient sitting and the fifth lumbar fixed with one hand, the free arm grasps the body of the patient and rotates it about the fixed point.  The bodies of the vertebrae may be thus warped or slightly moved upon each other, drawing the bone back to place.
    In many long-standing cases of bony lesion, the strengthening of the surrounding muscles and ligaments must take place and be depended upon to hold the ground gained as the part is gradually, during a course of treatment, brought back toward its normal position.
   XX.  In case the sacrum be found to be anterior or posterior from its normal position, this is a matter partly relative to the position of the innominate bones, luxations of which will be discussed later.
    In cases of posterior protrusion, after relaxation of the sacroiliac ligaments, pressure may be made with the knee directly upon the sacrum from behind, with the patient either sitting or lying upon his side.  At the same time the pelvis and the upper parts of the body are drawn strongly backward.
  XXI.  In restoring the coccyx to normal position both external and rectal treatment may be necessary.  In some cases external treatment alone will be sufficient.  The saccro-coccygeal articulation is generally quite pliable.  In external treatment, attention must be first given to the relaxation of the muscle and fibrous tissues concerned.  The bone may then be grasped and moved or sprung from either side toward the median line, may be forced anteriorly, or the finger may be gently inserted beneath its tip and may draw it back toward its natural position.
    Rectal treatment should not be given oftener than once a week or ten days.  The patient lies upon his side or bends, face downward, over a table.  The index finger, anointed with vaseline or oil is inserted, palm down, into the rectum.  It is then turned palm up; laid along the hollow of the coccyx, and swept from side to side, to free the action of blood-vessels and nerves.  With the finger in the rectum and the thumb outside, the bone may be grasped and moved toward any position necessary.  As a rule its restoration to a normal position is only gradually accomplished.