Principles and Practice 
of Osteopathy 
-BY- 
CARTER HARRISON DOWNING, D.O. 
Graduate Massachusetts College of Osteopathy. 
Graduate University of Massachusetts Medical 
School. 
Former Director of Clinics and Professor of 
Technicology, Massachusetts College of 
Osteopathy. 
Associate Professor of Osteopathic Diagnosis and 
Technicology of American School of 
Osteopathy. 
President, Polyclinic & Postgraduate Institute, 
Kansas City, Mo. 
Consulting Diagnostician, Bowling Green 
Sanitarium, Bowling Green, Missouri. 
Lecturer on Osteopathic Therapeutics. 
Member: American Osteopathic Association. 
Massachusetts State Osteopathic Association. 
Boston Osteopathic Association. 
Published by 
WILLIAMS PUBLISHING CO 
Kansas City, Missouii COPYRIGHT. 1923. BY 
CARTER H. DOWNING. D O. INTRODUCTION 
J. H. Styles, Jr., D. 0. 
Osteopathy is an exact science. Its basic, elemental fea- 
tures are as precise and changeless as the laws of the Medes 
and Persians. It was given tangible form and objective ex- 
pression by the master genius of the greatest anatomist and 
physicist who ever lived. Its fundamental principles are 
reared upon sound physical facts; and the tenets of its splen- 
did philosophy are, without exception, corollaries of demon- 
strable anatomic propositions. 
There was not the shadow of a doubt in the mind of 
Andrew Taylor Still, nor in the minds of his immediate dis- 
ciples, concerning the definite and eternally abiding inter- 
relationship between structure and function. Indeed, the in- 
itial success of osteopathy as a universal therapeutic agency 
was based upon a profound and comprehensive appreciation 
of the specific pathologic significance of all mechanical per- 
versions of the body machine. 
Time, however, has introduced many vicious modifica- 
tions and changes. Heresies of every sort and description 
have crept into osteopathic thought, distorting or obscuring 
original findings and paralyzing the once implicit faith of the 
osteopathic physician in the universal efficacy of his peculiar 
system of therapeusis. 
Nowhere has this utterly demoralizing tendency been 
more apparent than in the realm of osteopathic diagnosis of 
bony lesions and the technic of their adjustment. It is not 
too harsh a judgment to assert that the technical procedures 
of a majority of modern osteopaths are too often based upon 
unsound and empiric personal opinions rather than upon 
scientific facts. 
Osteopathy, reduced to its simplest forms, is a matter of 
living anatomy and physics; and its technical maneuvers are 
exact geometric propositions. No matter how the practical application of the latter may be modified to suit the physical 
limitations of the individual physician and the immediate 
needs of his patient, their mechanical features must be at all 
times consistent with the requirements and limitations of the 
geometry of the osseous framework of the human mechanism. 
Countless exploiters of technic have flourished since the 
Old Doctor’s time. All sorts of instructors in osteopathic 
mechanics, good, bad and indifferent, have held the stage for 
varying seasons and expounded their conceptions of the prac- 
tical phases of osteopathic science and art. 
Until recently, however, no individual has in any sense 
dominated this essential field of professional endeavor. In- 
deed, most so-called technicians have been and are but more 
or less blundering artisans in osteopathy. They have come 
and gone, at variance with each other and often with the 
Founder of their science. 
Fortunately for the future of scientific physio-therapy 
an osteopathic Moses has at last loomed upon the horizon of 
this heterodox age and, by the sheer compelling power of his 
anatomic and mechanical genius and practical demonstra- 
tions initiated a wide-spread and saving revival of faith in 
basic first principles. 
Dr. C. H. Downing is indubitably the greatest osteopath 
since Andrew Taylor Still. He is a thorough-going scientist, 
a natural-born bone-adjuster and an outstanding teacher of 
his art. 
This present volume represents the most complete and 
scientific text on osteopathy extant. It is practical, entirely 
readable and extremely easy to follow. Diagnostic and 
technical procedures are presented in such a manner as to 
make their visualization and subsequent execution notably 
simple. 
Each chapter is complete in itself and comprehends all 
that is scientifically proven with regard to the diagnosis and physical adjustments of lesions occurring in the anatomic 
locale of which it treats. 
Dr. Downing’s work in technic is easily the outstanding 
feature of this osteopathic generation. This record of his 
modus operandi faithfully and literally outlines that technic 
so that any physician of ordinary intelligence and average at- 
tainments may readily grasp and apply its principles. 
If the writer of this introduction had to dispense with 
all of his osteopathic books save one, he would choose to re- 
tain his Downing. The spirit of osteopathy permeates it; the 
greatness of osteopathy shines through it; and the therapeutic 
universality of osteopathy is its lodestar. 
Osteopathy is either supreme in therapeusis or it is noth- 
ing. If, therefore, the principles upon which Andrew Taylor 
Still founded his system are fundamental expressions of nat- 
ural law, nothing else can take their place nor constitute a 
satisfactory substitute for them. For there can be no playing 
fast and loose in science. 
Dr. Downing believes, as the Old Doctor believed, that 
osteopathy is all in all. His science and art have no limita- 
tions. Indeed, they are as untrammelled as infinity, for they 
are but the conscious appropriation and intelligent direction 
of infinite forces. FOREWORD 
F. P. Millard, D. 0. 
Few men should write a book. Few men have that to 
impart which justifies it. C. Harrison Downing, D. 0., is one 
who has. 
Some one said the other day, “I don’t see how a young 
man can teach me anything.” I looked at him and said nothing 
—but thought much. 
Unto a few is given insight—a reflection of genius. A 
small book could contain the names of all the real geniuses 
in the world. Dr. Downing is a genius. 
I have yet to see a man who could produce a splendid 
article along any line, without having trained himself 
thoroughly for that work. Dr. Downing is highly trained. 
The best violin the world ever produced was made a few 
weeks ago. There are those who may imagine it was made 
over night. Critics listened to the maker play his violin be- 
hind screens, and then heard him play on a Stradivarius, sup- 
posedly the best violin in the world. Possibly it was, until 
this new genius produced his masterpiece. Investigation re- 
vealed that this man had been making violins for about forty 
years; had lived and loved his work, and devoted his entire 
time and attention to the one idea—that of producing some- 
thing better. His dreams were along the line of fairies play- 
ing on strings. His visions were those of a symphony that 
would almost parallel that of the angels. 
Dr. Downing had a vision, too. No man can make me 
believe otherwise. He likewise, must have burned the mid- 
night oil, perused many a musty tome; made many an in- 
tricate adjustment. No man can understand the mechanism 
of the human anatomy without tremendous concentration. 
By nature, Dr. Downing was given body-mechanical talent. 
Were it possible to visualize his cerebral cortex, I imagine it would be full of joints. He can joint a joint quicker than any 
man I have ever seen. He is adapted to that work. 
It is possible for some men to understand the mechanics 
of the human body; likewise, it is impossible for other men, 
if they lived three lifetimes. An individual gifted by nature 
along a certain line, can, by concentration, comprehend a sub- 
ject in one year; while another, digging away and practicing 
for twenty years, has to be painstakingly taught principles 
that he had not discovered during these twenty years of 
practice. 
Some of the greatest inventions in the world were by 
young men. Some of the greatest poets, the greatest play- 
wrights, the greatest orators, were men in their early years. 
Age has nothing to do with it. It is a matter of intellect, tal- 
ent and comprehension. 
Give credit wherever it is due. Praise the genius; en- 
courage him. He is responsible for all progress and evolu- 
tion. He is usually a sensitive soul. As a rule he does not live 
long. He burns out his energy. Get the best out of him 
while he is running full speed. 
There is such a thing as a man having quality along with 
quantity. A writer, for instance, may produce a novel a year 
for several years, like that great man from Indiana. A 
“Mark Twain” could write twenty-five volumes in compara- 
tively short time, and yet make every word valuable. Schubert 
produced several hundred great compositions, yet he died at 
the age of thirty-two. 
If an osteopath can produce a better book on the me- 
chanics of the human body and explain the various joints 
and their articulations more thoroughly than anyone else, 
give him the credit that is due him. 
There may be members of the fraternity who think that 
ten or fifteen dollars paid for a book is ridiculous. If so, they do not stop to realize that the author has spent hundreds 
of hours, possibly thousands; gone without sleep; forgotten 
his food, turned away his practice, neglected his other affairs 
and become almost exhausted at times, in trying to complete 
the work that he has visualized. On and on he goes, building 
the structure that to him once was only a dream. The prac- 
tical vision becomes a reality. His product is placed upon the 
market. His fellow men have access to all of his findings and 
research work for a pittance. There should be no complaint. 
It is impossible to pay the author of such a book a price com- 
mensurate with what the reader gains by perusal and ob- 
taining the viewpoint of the one who has done the research, 
concentrating and heavy work of compilation; gone through 
the throes of publication, and last, but not least, paid the 
printer’s bill. 
When a man with a great message leaves his practice, 
forgets self, devotes his time to instructing his fellow men, 
and absents himself from his own fireside to travel to dis- 
tant cities, states, and possibly across the continent, he should 
be appreciated, encouraged, welcomed and listened to with 
respect. 
If every osteopath could appreciate the wonderful work 
that Dr. Downing is doing, and attain his viewpoint by a few 
lessons of instruction, he would advance years in his profes- 
sion, save time and effort and increase his renown through 
the more successful handling of a larger list of gratified 
patients. 
We are justly proud of Dr. Downing and his accomplish- 
ments. There may be others who have as good technic, but 
we know that there is no one in our profession who can 
make adjustments in all parts of the body more cleverly and 
with better results than Dr. Downing. PREFACE 
In preparing this treatise, the author has not attempted 
to cover osteopathic therapy in all of its phases. Indeed, the 
subject is so exhaustive that this could not be accomplished in 
a single volume. It would require a series of books and even 
then the whole might not be told, as the topic is so comprehen- 
sive and its possibilities so great that new developments are 
being made daily and will continue to be as time goes on and 
as the practical aspects of this great branch of science unfold. 
There are a great variety of themes upon which the 
author has not touched but with which the student and prac- 
titioner have become familiar in the class room and in general 
practice. He has sought to confine himself rather to the most 
important of newer developments in osteopathy: more par- 
ticularly to those which his own experience, observation and 
research have brought to light and which have been demon- 
strated to be of value in reducing the discomfort of the pati- 
ent, lessening the effort of the operator and increasing the 
effectiveness of his labors, and all with a vast economy of 
time. 
His activities have uncovered other topics of far reach- 
ing significance to practitioners and students which, up 
to this time, have not been presented in a lucid manner. It is 
his intention to treat of these matters at some future time 
when other duties will permit. 
This present work is published in the belief that it will 
increase the technician’s efficiency and simplify the labors of 
any physician or student who will study it conscientiously and 
demonstrate in his daily practice the principles outlined. 
CARTER HARRISON DOWNING. THIS BOOK IS DEDICATED 
To My Wife 
FLORENCE RUSSELL DOWNING, 
who has splendidly served as a sympathetic and an 
untiring amanuensis; to 
J. H. STYLES, JR., D. O. 
whose literary advice has been invaluable; to 
H. C. DAVISON, 
who has rendered a fine technical assistance; and to 
R. H. WILLIAMS, D. O., 
whose faith has made the volume possible. Contents 
Chapter 1. 
OSTEOPATHY, the Science 17-53 
Pages 
Structure and Function—Significance of Structure in 
Regard to Disease—The Cell in Disease—The Osteopathic 
Lesion—The Circulation—The Vasomotor System—Arterial 
Tension—Sympathetic System—The Autonomic Nervous 
System—The Nervous Mechanism—Branches of Distribution 
—Cervical Sympathetics—The Reflex Arc—Head’s Law— 
Hilton’s Law—The Disturbed Reflex and the Production of 
Symptoms—Sympathetic Segmental Disturbances—Abdom- 
inal Pain of Sympathetic Origin—The Occulo-Cardiac Reflex 
(Aschner’s) — Vagotonia — Sympatheticotonia — Inhibition 
and Stimulation—“Find It, Fix It, and Leave It Alone”— 
Causes of Disease—The Germ Theory. 
Chapter II. 
THE OSTEOPATHIC SPINAL LESION . 54-71 
Etiology—Pathology—Obstacles to Overcome in Lesion 
Correction—Force Plus Velocity—The Principles of Tech- 
nique—Methods—The Taplin Table—Principles of Osseous 
Adjustment — Physiological Locking—Anatomical Locking 
—Osseous Technique Divided Into Two General Classes— 
Timing Adjustment—Nature and Character of Arthritic and 
Rheumatoid Conditions—Bony Landmarks of the Normal 
Spine—Cervical Region—Thoracic Region—Lumbar Region. 
Chapter III. 
THE VERTEBRAL COLUMN 72-111 
Equilibrium — Antero-Posterior Equilibrium — Lateral 
Equilibrium—Balance—The Pelvis—Nervous Mechanism of 
Balance—Lateral Curvature—Wolff’s Law—Organic Curva- 
ture—The Scoliotic Spine—Lumbar Scoliosis—Total Scoliosis 
—Dorsal Scoliosis—Compound Curvature—Functional Cur- 
vature—Diagnosis of Lateral Curvature—Posture—Types of 
Functional Curvature — Lythospondylosis—Sterospondylosis 
—Corrective Exercises—Flexible Types of Curvature—Treat- 
ment of Scoliosis—Pott’s Disease—Spondylitis Deformans— 
—Typhoid Spine. Chapter IV. 
Pages 
OCCIPITAL-ATLANTAL SUBLUXATIONS 112-142 
The Occipito-Atlantal Articulation—The Superior Artic- 
ular Facet—The Vertebral Artery and Suboccipital—Lesions 
of the Occiput—The Anterior Grouping—Bilaterally Anterior 
Occiput—The Unilateral Anterior Occiput—Principles of 
Adjustment for Lesions of the Anterior Grouping—Flexion 
—Side-Bending—Fixation of the Arch of the Atlas—Rotation 
—Technique of Adjustment Using Occipital Leverage—Ex- 
tension—Side-Bending Rotation—Compensatory Lesions of 
the Atlanto-Axial Articulation—Posterior Grouping—Bilat- 
erally Posterior Occiput—The Unilaterally Posterior Occiput 
—Principles of Adjustment for Lesions of the Posterior 
Grouping Using Occipital Leverage—Technique of Adjust- 
ment Using Occipital Leverage—Occipital Adjustment via 
the Atlas—Principles of Adjustment by Occipital Leverage 
—Lateral Occiput—Pseudo-Rotation Lesion of the Occiput— 
Principles of Adjustment Using Occipital Leverage—The 
Impacted Occiput. 
Chapter V. 
THE ATLANTO AXIAL SUBLUXATION 143-151 
The Rotation Lesion—Principles of Adjustment—Tech- 
nique of Adjustment—Adjustment by Indirect-Action Tech- 
nique. 
Chapter VI. 
SUBLUXATIONS OF THE CERVICAL VERTEBRAE 
FROM THE SECOND TO THE SEVENTH 
INCLUSIVE 152-175 
Flexion of the Cervical Vertebra—Extension of the Cer- 
vical Vertebra—Lesions of the Cervical Vertebra—Etiology 
of Cervical Lesions—Rotation Side-Bending or Side-Bending 
Rotation Lesions—The Principles of Adjustment—Approxi- 
mation— Adjustment — Technique of Adjustment—Direct- 
Action Technique—The Flexion Lesion—The Extension Le- 
sion—Dislocation of a Cervical Vertebra. Chapter VII. 
SUBLUXATIONS OF THE THORACIC 
VERTEBRAE 176-220 
Pages 
Applied Anatomy—Thoracic Vertebral Articulations— 
The Intervertebral Substance—Side-Bending or Lateral Flex- 
ion—Side-Bending Rotation—Lesions of the Thoracic Verte- 
brae—The Extension Lesion—Rotation-Side-Bending Lesion 
—Side-Bending-Rotation Lesion — Differential Diagnosis— 
Principles of Adjustment of the Upper Dorsal—Principles for 
the Use of Cervical Leverage—Methods Utilizing Cervical 
Leverage—Principles for the Use of Physiological Locking— 
Importance of Proper Table Selection—Technique for the 
Adjustment of the Extension Type of Lesion—Technique for 
Adjustment of the Flexion Type of Lesion—Technique for 
Adjustment of the Rotation Lesion. 
Chapter VIII. 
SUBLUXATIONS OF THE LUMBAR 
VERTEBRAE 221-243 
Applied Anatomy—The Lumbo-Sacral Articulation— 
Flexion—Extension—Side-Bending — Rotation — Lesions of 
the Lumbar Vertebrae—Flexion Lesions—Etiology and Diag- 
nosis—Differential Diagnosis—The Extension Lesion—The 
Side-Bending Rotation Lesion. 
Chapter IX. 
SUBLUXATIONS OF THE SACRO ILIAC 
ARTICULATIONS 244-286 
Ligaments of Importance—Lesions of the Sacro-Iliac 
Articulation—The Bilaterally Anterior Sacrum—The Unilat- 
erally Anterior Sacrum—Diagnosis Based on Functional or 
Physiological Findings—The Unilateral Posterior Sacrum— 
Physiological Findings—The Combined Unilaterally-Poste- 
rior Unilaterally-Anterior Innominates—The Pseudo-Twisted 
Pelvis—The Relation of Bryant’s Triangle and Nelaton’s Line 
to Sacro-Iliac Lesion. 
Chapter X. 
COSTAL SUBLUXATIONS 287-320 
Characteristics of a Typical Rib—Articulations of the 
Ribs—Costal Movements—Pump-Handle Movement—Bucket- Handle Movement—Combined Pump- and Bucket-Handle 
Movement—Enarthrodal Movement—The Vertebro-Sternal 
Ribs — The Vertebro-Chondral Ribs — Vertebral Ribs — 
Muscles of Respiration — Lesions of the First Rib—Le- 
sions of the Second to Sixth Ribs, Inclusive—Lesions of the 
Seventh to Tenth Ribs, Inclusive—Lesions of the Eleventh 
and Twefth Ribs—An Analysis of Objectives—Principles for 
the Use of the Cervical Column in Rib Adjustment—Adjust- 
ment of First and Second Rib Lesions—Inspirational Lesion 
—Expirational Lesion—Combined Pump- and Bucket-Handle 
Lesion—Lesions of the Eleventh and Twelfth Ribs, Rib Ele- 
vated and Rotated on Its Long- Axis—Rib Depressed and 
Rotated on Its Long Axis—Raising the Ribs—The Flat 
Dorsal—Doming the Diaphragm—Fracture of the Ribs— 
Cervical Ribs. 
Chapter XI. 
FOOT SUBLUXATIONS 321-353 
Pages 
Applied Anatomy—The Talus—The Cuboid—The Navic- 
ular—The Internal Cuneiform—The Middle Cuneiform—The 
External Cuneiform—The Metatarsal Bones—The Phalanges 
—Sesamoid Bones—Movements of Ankle Joint and Foot— 
Arches of the Foot—-Foot Deformities—The Use of Heels— 
Subluxations of Foot Bones—General Unclassified Measures 
for Varying Foot Conditions—Dislocation of Ankle Joint— 
Hammer Toe—Metatarsalgia—Retro-Calcaneum. 
Chapter XII. 
LUXATIONS, PARTIAL AND COMPLETE 354-402 
Forward Luxation of the Mandible—Luxations of the Sternal 
End of the Clavicle—Luxations of the Acromial End of the 
Clavicle—The Depressed Clavicle—Luxations of the Shoulder 
Joint—Dislocation of the Shoulder-Girdle—The Supra-Cora- 
coid Luxation—Luxatio Erecta—Derangement of the Biceps 
Tendon—Luxations of the Elbow Joint—Dislocation of the 
Ulna—Dislocations of the Radius—Subluxation of the Head 
of the Radius—Dislocation of the Inferior Radio-Ulna Artic- 
ulation—Dislocation of the Wrist—Dislocation of the Carpal 
Bones—Luxations of the Hip—Luxation of the Knee—Luxa- 
tions of the Patella—Luxation of the Fibula—Derangement 
of the Semilunar Cartilages—Derangement of the Hyoid. Osteopathy, the Science 
17 
Chapter I. 
Osteopathy, the Science 
Osteopathy is a philosophy of medicine (healing) having 
a complete system of therapeutics, basing its treatment of 
all abnormal conditions of the body on the natural laws and 
vital principles governing life: namely, the adjustment of all 
these vital forces of the body, whether physical, chemical or 
mental, in so far as we have knowledge thereof. 
—C. H. Downing. 
“Osteopathy is the name of that system of the healing 
art which places chief emphasis on the structural integrity of 
the body mechanism as being the most important single fac- 
tor in the maintenance of the well being of the organism in 
health or disease.”---(Dr. C. B. Atzen.) 
Mason W. Pressley, A. B., Ph. D., D. 0., defines osteo- 
pathy as: “that science which consists of such exact, exhaus- 
tive and verifiable knowledge of the structure and function 
of the human mechanism, anatomically, physiologically and 
psychologically, including the chemistry and physics of its 
known elements, as has made discoverable certain organic 
laws and remedial resources within the body itself, by which 
nature, under the scientific treatment peculiar to osteopathic 
practice apart from all ordinary methods of extraneous, arti- 
ficial or medicinal stimulation and in harmonious accord with 
its own mechanical principles, molecular activities, and meta- 
bolic processes, may recover from displacements, disorganiz- 
ations, derangements, and consequent disease and regain its 
normal equilibrium of form and function in health and 
strength.” 
A science and philosophy so all-embracing as osteopathy 
is difficult to define. Its program is too vast for ordinary 
comprehension. It defies strict analysis. 18 
Doivning Principles and Practice of Osteopathy 
Structure 
and 
Function: 
All living matter is subject to the “LAW 
OF CHANGE.” As represented in man, 
evolution should be taken as adapta- 
tional or environmental, the effort of the body to maintain 
its highest efficiency. Consequently the normal for an in- 
dividual is variable and subject to change. Normality is never 
twice alike. The relationship between structure and function 
is never constant. Both develop co-ordinately, one dependent 
upon the other, and this same interdependence holds true 
throughout every manifestation of life, throughout all its 
changes, whether in health or disease, and regardless of the 
plane affected, whether physical, mental, or chemical. 
Thus, the integrity of one is always predicated upon the 
integrity of the other. There cannot be a change or perversion 
of function without a corresponding change in structure, 
whether it be within or beyond the limits of what is broadly 
considered normality: and vice versa, we cannot have dis- 
turbed or perverted structure without a corresponding effect 
upon function. 
There is no lost or vacant space in the normal body econ- 
omy, for genetic changes and growth of external structure 
proportionately develop hand in hand with, and are dependent 
upon the development of the contained viscera until full com- 
pletion and maturity is reached. Therefore, it is obvious 
that the shape, size, and contour of those organs will pre- 
destine and determine to a marked degree the appearance and 
proportion of the external architecture. 
After the completion of ossification, however, splanchnic 
changes no longer greatly affect skeletal morphology; and 
it may well be stated that from that time on the container 
largely determines the size and shape of its contents. External 
measurements of the physical being will thereafter give an 
approximate estimate of the proportions of internal organs. 
Thus, by inspection and other diagnostic and physical 
methods, we can forecast with a fair degree of certainty Osteopathy, the Science 
19 
physical predispositions and latent potentialities which may 
later become of sufficient import to occasion disease. 
The function of an organ depends upon and is propor- 
tionate to its development, although physiological demand is, 
in the last analysis, the primary incentive and trophic 
stimulus to complete somatic evolution. Generally speaking, 
then, function depends upon structure after maturity. This, 
however, is not a fixed postulate inasmuch as the evolution- 
ary processes of life must still continue and the physiological 
demands be answered, although less readily than before. The 
higher the organism ascends in the mammalian sphere, the 
more complex its nervous system becomes and, therefore the 
more easily it is thrown out of functional balance. 
The human body is an aggregate of cells and tissues, a 
sum total of parts mutually banded together, dependent one 
upon another and in a delicate state of morphological and 
physiological balance. Moreover, none of the component 
parts of such an organized being can be modified without 
other parts being affected by reason of the close functional 
relationship between its constituents. Therefore, if normal 
functioning is not maintained, or coordinate balance re-estab- 
lished by proper adjustment, death of the whole organism 
ensues: for, because of this very specialization, the parts of 
all higher forms of life are not endowed with the power of 
independent and indefinitely continued living. As Pearl 
states: “this is the price paid for differentiation of special 
function.” 
“In every epoch of life, special morbidity resides in the 
special morphology of the organism.”—De Giovanni. 
“There is a margin of safety or zone of physiologic varia- 
tion within which both structure and function may fluctuate 
but remain within the boundaries necessary to maintain life.” 
—Deason. 20 
Downing Principles and Practice of Osteopathy 
Significance of 
Structure in 
Regard to 
Disease: 
Hulett says: “Function is infinitely 
self-regulative”—that structure is less 
immediately and less completely subject 
to vital control—especially the more inert 
tissues such as bones, ligaments, cartilage 
and other connectives. Hence, where disorder is maintained, 
we assert from reason and observation that structural perver- 
sion is the factor that prevents a return to normal 
functioning. 
The unhampered tendencies of the body are always 
toward the normal in both health and disease. All reactions 
of the body, whether constructive or destructive, have that 
ultimate end in view. The logical conclusion, therefore, must 
be that perverted structure is the greatest preventative to a 
return to normal in disease, provided all external causes lead- 
ing to perversion of function are eliminated. 
The human cell is a nucleated, circum- 
scribed mass of protoplasm capable of as- 
similation, growth and reproduction. Tt w 
the albuminous material basis of life. Cells collectively form 
tissues; tissues, organs; and organs, systems. Each cell has 
its particular function. “The cell cannot of itself cause 
disease either in itself or in its neighbor. It is inherently 
healthy and a disturbance in its metabolism is due to impair- 
ment of its blood, lymph, nerve or protoplasmic continuity.” 
(Hulett.) This is fundamentally true. 
A disordered cell shows four primary disturbances. They 
are: 
1. Cellular irritability. 
2. Metabolic. 
3. Structural. 
4. Special functional. 
Irritability may be increased or decreased by thermal, 
mechanical, chemical, electrical, or nervous variations. Pri- 
marily, irritability is increased; secondarily, it is decreased, 
The Cell 
in Disease: Osteopathy, the Science 
21 
due to the fact that potential energy is ultimately diminished 
within the cell beyond a point of response. 
Metabolism is influenced in that catabolism is greatly in- 
creased and is concomitant with heightened irritability. It 
is likewise decreased only when potential energy is lost or 
depleted beyond a point of response. 
The special function of a cell is the expenditure of kinetic 
energy and is dependent upon potential energy—therefore the 
same rule obtains in this connection. The cell as a defensive 
organism is of the very greatest importance. For example: 
in the presence of bacterial infection we have a poisonous 
toxin produced which acts as a chemical irritant or stimulus 
to the cell. Irritability is increased and catabolism immedi- 
ately follows in the form of anti-bodies or anti-toxins. The 
cell, in order to maintain its own individual life, must fight 
for it and to carry this out with the highest degree of effici- 
ency there must be a like efficiency on the part of the circula- 
tion and nerve supply, unless the cell has been the recipient of 
direct injury and then it cannot perform its function. For 
only through these channels can the material necessary to 
cellular anabolism be obtained, or substances manufactured 
to maintain the increase of function which is demanded by 
way of defense; namely, the formation of anti-bodies and 
anti-toxins. We can therefore logically state: 
First—Faulty metabolism on the part of the cell begins when 
that cell does not functionate in the manner or extent 
intended by nature. 
Second—This physiological deficiency is due to a lack of 
potential energy caused by a perverted circulation or 
nerve supply, thereby lessening the cell’s resources; or 
else it is due to direct injury to the cell. 
The osteopathic lesion is any structural 
disturbance with consequent functional 
deflection. The effects produced by lesions 
are by direct or secondary pressure. The 
structures involved by this pressure are arteries, veins, lymph 
The 
Osteopathic 
Lesion: 22 
Downing Principles and Practice of Osteopathy 
channels, nerves and adjacent tissues. The more adynamic 
or static the structure affected, the lower its power of self- 
adjustment. Vessels and nerves are highly self-adjustive. 
The severity of the symptoms occasioned by a lesion thus de- 
pends more upon the length of time it persists, the rapidity 
of occurrence and the nature of tissues involved than upon 
the extent of structural defect. Moreover, the nature, rather 
than the amount of structural perversion will determine the 
prognosis. This is due to the greater vital capacity of cer- 
tain tissues and the extent of nature’s adaptational efforts. 
A lesion may be primary or secondary. A primary lesion 
is one directly related to the cause; i. e., trauma. A secondary 
lesion is one dependent upon a previously existing lesion. It 
may also be adaptational; as, for instance, the hypertrophied 
heart in valvular diseases. The spinal lesion, when secondary, 
is produced by the great medium of nerve reflex and may 
persist to a variable extent after the causative factor, or 
primary lesion, has disappeared. Likewise, secondary lesions 
may be counterbalancing. 
Major lesion is the term applied to the lesion causing the 
greatest functional disturbance. A minor lesion is one which 
causes a lesser disturbance. The latter is usually reflexive 
from a major lesion. 
The latent or potential spine lesion is a palpable ligament- 
ous and osseous anomaly which is evidenced by no immediate 
or active symptomatology which can be traced obviously, al- 
though it seems to be a predisposing factor and lowers the 
margin of safety of that particular organ or tissue with which 
it is related. If not beyond the power of compensation by 
collateral blood and lymph supply, its irritative stimuli are 
held in partial abeyance thereby, and the functions of struc- 
tures within the sphere of its influence will be conducted on a 
lower margin but within the limits of a somewhat variable 
and elastic state of so-called normality. Indeed, the removal 
of functional etiological factors may precipitate spontaneous Osteopathy, the Science 
23 
adjustment providing the adynamic or static structural fac- 
tor be insecure and dependent upon such a vegetative back- 
ground. Thus, chronicity will more or less determine the 
relative fixation or stability of the structural factor inasmuch 
as it encourages greater structural stabilization. Recuper- 
ative and adjustive possibilities vary under many conditions 
and in various individuals, so that this allows of no fixed pos- 
tulate. 
Osteopathic lesions (spinal) are usually bony subluxations 
with ligamentous tension or shortening and muscular tension 
or contracture. By impingement lesions affect the circula- 
tion, particularly at certain points of entrance and exit from 
the spinal cord. The result is either passive hyperemia (drain- 
age affected); rarely anemia (arterial impingement) with 
ultimate nutritional disturbances and impoverishment of 
nerve supply. These perversions are accomplished by way of 
the lymphatic channels, inasmuch as all terminal circulation 
is conducted through these avenues. Due to pressure, edema 
first appears in the meningeal cul-de-sac between the poste- 
rior root and the superior pole of the posterior root ganglion, 
and immediately begins to markedly interfere with the 
proper circulation of cerebro-spinal fluid at this point. 
Hence, sensory impulses are disturbed as they pass from 
the cells in the posterior root ganglion to the spinal cord; 
consequently, this pressure edema constitutes a prolific first 
cause of peripheral and visceral pathological physiology. 
Important in this group of cells is the Cell of Dogiel, 
a connector which serves to conduct impulses from the pos- 
terior root to the neurone of Golgi, type II; and also, together 
with sensory neurones from the posterior root ganglion, 
serves to link up, by synapsis with conduction paths, both 
higher and lower reflex arcs as well as that of the same 
segment. Thereby impulses are carried from the sympathetic 
to the cerebro-spinal system, to be interpreted and acted 
upon. 24 
Downing Principles and Practice of Osteopathy 
Lesions may be classified as follows: 
1. Positional—In the form of subluxations, dislocations and 
displacements. 
2. Gross Anatomical—In the form of contractures, atoni- 
cities, hypertrophies, hvperplasms, atrophies, fatty infil- 
trations, tumors, etc. 
3. Microscopic Pathological—In the form of parenchymatous, 
fatty, colloid, albuminous, mucoid, hyaline and other 
cellular degenerations. 
The 
Circulation: 
Dr. Still stated in 1874: “A disturbed ar- 
tery marks the time to an hour and minute 
when disease begins to sow its seeds of de- 
struction in the human body.” At that time he further assert- 
ed that in no case could this be accomplished without a 
broken or suspended current of arterial blood which by nature 
is intended to nourish and supply all nerves, ligaments, mus- 
cles, skin, bones and the artery itself; and, that the rule of the 
artery must be absolute, universal and unobstructed or dis- 
ease will be the inevitable result. All nerves depend wholly 
upon the arterial system for their nutrition and such qualities 
as sensation and motion, even though, by the law of recipro- 
city, they furnish vital force and sensation to the artery itself 
and regulate its nutrition. 
The artery carries nutritional substances and oxygen to 
the tissues. Its functional impairment results in deficient 
oxidation. Contrariwise, any circulatory perversion affects 
the respiratory function. Upon the lymphatic circulation 
falls the duty of direct cell-feeding and drainage. Veins are 
charged with general drainage. They are more easily com- 
pressible than arteries on account of their thinner and more 
flaccid walls. Interference with their physiological activities 
results in passive hyperemia and a storing up in the tissues 
of catabolic products. Osteopathy, the Science 
25 
3 
i 
X 
11 
Seven points of palpation in making a lymphatic examination. 
—Courtesy of F. P. Millard, D.O. 
Any decrease in normal blood or lymph supply to the 
cord or drainage from the cord diminishes the efficiency of 
the cells in that structure. The presence of oxygen is neces- 
sary for normal nerve conductivity, which is decreased in the 
presence of carbon dioxide (Bulletin 1—A. T. Still Research 
Inst.) Increased arterial supply and venous drainage in- 26 
Downing Principles and Practice of Osteopathy 
creases the activity of the segment affected (Series 16 & 17, 
Bulletin 1, A. T. Still Research Inst.) 
Using the Marchi, Weigart, Pal, Williamson and Nissl 
methods, Deason has shown that the coats of the arterioles, 
capillaries, veins and in some instances arteries, are deranged 
from the endothelial cells through to the muscle fibers and 
from the outer layer into the surrounding tissues; and that 
from the escape of blood plasma to leukocytal invasion, 
diapedesis and hemorrhagic foci, the pathological picture is 
complete. Small arteries may even show signs of endarteritis. 
Burns (A. 0. A., July, 1921) states that the lesion affects 
the circulation through the sensory ganglion of the same and 
immediately neighboring segments, usually causing at first a 
slight and temporary constriction, then an inconsiderable but 
more lasting dilation of the arterioles. Such a ganglion pre- 
sents a slightly redder appearance than normal. The liminal 
or threshold value of neurons of the first class is lowered, so 
that stimulation which is usually subliminal is now able to 
initiate sensory impulses. Thus, by reason of the slight gang- 
lionic congestion, many normally imperceptible sensations are 
appreciated. Edema is coincident with congestion, and oc- 
casions an increase in the carbon dioxide content of inter- 
cellular fluids. This, together with the pressure effects of 
the edema, partially blocks the passage of impulses over con- 
duction paths. A decrease in total sensation results and im- 
pulses fail to affect the spinal centers, the cerebellar or basal 
ganglia, the centers for control of complicated motions and 
higher cortical centers. This results in an admixture of in- 
creased, decreased and modified sense-perceptions, which op- 
erate to the perversion of the sentient faculties of the consci- 
ous, and the vegetative functions of the subconscious, mind. Osteopathy, the Science 
27 
Above illustration shows circulation in a section of the spinal 
cord and spinal arteries, together with correlating spinal branches 
from the intercostal. 
—Courtesy of F. P. Millard, D.O. 
The spinal branches of the sacral, lumbar, intercostal and vertebral arteries accompany the 
spinal nerves through the intervertebral foramina, traverse dura mater and arachnoid and divide into 
a dorsal and ventral radicular artery. These accompany nerve roots to the surface of the cord and 
then break up into an anastomosing plexus in the pia mater. From this plexus are derived three 
tortuously coursing longitudinal arteries and numerous central branches which penetrate the cord 
direct. The anterior spinal artery zigzags along the anterior median fissure. The two posterior spinal 
arteries course longitudinally near the lines of entrance of the dorsal root fibers, one on each side. 
The venous system is quite similar to the arterial. The blood of the central arteries collects into 
corresponding central venous branches which converge into a superficial venous plexus in which are 
six main longitudinal channels, one along the posterior median sulcus, one along anterior median 
fissure, and one along each of the four lines of the nerve roots. These comprise the posterior and 
anterior external spinal veins. 
The vasomotor system deserves special mention in this 
connection, for treatment of it by osteopathic measures does 
much to regulate and to coordinate the distribution of the 
blood. Physiologists have demonstrated the fact that there 
are both constrictor and dilator fibers. The secretory aug- 
mentors and inhibitors depend partially for efficient function- 
ing upon co-operative efforts in the vasomotors. 
The caliber of capillaries and venules may, under a diver- 
sity of conditions, dilate or contract individually and inde- 28 
Downing Principles and Practice of Osteopathy 
pendently. The maintenance of this tonus is dependent upon 
the supply of blood received. When the vessel gets little blood, 
its tonus diminishes and dilatation follows. Thus it will 
readily be seen that it must, perforce, become relaxed and 
admit more blood in order that it may regain its normal tone. 
It is logical to assume that every capillary alternately 
opens and closes and that this shunting of blood from one 
place to another allows all areas to be uniformly supplied and 
irrigated sufficiently. This is a specially protective mechan- 
ism for those parts which may be poorly supplied as well as a 
physiologic one for those demanding an extra supply during 
functional activity. 
Superimposed upon and controlled by vasomotor influ- 
ence, this inherent capacity of terminal vessels acts as an 
automatic stimulus to vasomotor activity and in case of vaso- 
motor paralysis it will, to some degree, control the situation 
irrespective of its loss of higher control. Some authorities 
claim that there is an additional chemical factor which has 
some control over the action of the capillary and venule. This 
is indicated by the action of certain drugs. The hormonic ac- 
tion of the internal secretions of certain glands may also 
have some effect on their behavior. In this connection it 
is interesting to note the experiments of Sajous which go far 
to prove that internal respiration is not due to partial pres- 
sure of gases but rather to the specialized and selective ac- 
tion of the endocritic product of the adrenal gland, which 
gives to hemoglobin a peculiar affinity toward oxygen. 
Disturbances of sympathetic vasomotor innervation are 
common. Generally speaking, these conditions are due to 
hypotonia of the sympathetic, with resultant derangement of 
the normal, circulation of the blood; especially in the hands Osteopathy, the Science 
29 
and the feet. They signify vasomotor instability. This 
sympathetic inefficiency may be an hereditary weakness of 
the sympathetics, or part of a generalized acquired atonia, or 
vagotonia. Trophic disturbances may also be be noted. In- 
deed, such perversions of the autonomic system will often 
show a change in the blood picture so that occasionally a high 
leukocyte count and slight eosinophilia is noted. Confirmed 
vasomotor instability at the menopause is responsible for hot 
flashes and pathologic changes in the distribution of the blood. 
The irritative state of the vasomotor centers allows splanchnic 
vasoconstriction, primarily forcing blood into the superficial 
peripheral vessels; then the stimuli are suddenly directed 
elsewhere and active vasodilation within the viscera follows, 
aspirating blood into these vessels. 
In acidosis the capillaries take up the products of in- 
complete combustion in the body, which are non-volatile acids. 
These toxins find their way into the general circulation, dis- 
place carbonic acids by combining with the alkalis present and 
thus the alkaline reserve is diminished. 
An osteopathic lesion, inasmuch as it produces a definite, 
localized disturbance of vasomotor control, eminating from 
the involved spinal segment, results in specific vasomotor im- 
balance in the organ or tissues supplied from that segment. 
The following illustration shows an anterior view of the 
cord and membranes. The lymph bathes all these cells and 
tissues. (1) Posterior horn. (2) Anterior horn. (3) Spinal 
nerve with covering. (4) Dura mater. (5) Turned back. 
(6) Spinal cord bared. (7) Arachnoid. (8) Anterior nerve 
roots. (9, 10) (top number) Lateral surface of cord. (10) 
Anterior nerve passing through dura mater. 30 
Downing Principles and Practice of Osteopathy 
% 
10 
* 
k 
■ 
i 
s? 
From within outward the sjunal cord is supported and protected by three membranes, the pia 
spinal or cerebro-spinal fluid which gains access to the brain and ventricles through the foramen of 
mater, arcahnoid, and the dura mater, the spaces between which are supplied with the encephalo- 
Magendie. The cerebro-spinal fluid is a lymph formation. The continuation of the same three cover- 
ings of the spinal cord envelopes the encephalon also. 
Arterial Tension is defined as normal, continuously 
stable vasotonus, at a radial maximum tension of between one Osteopathy, the Science 
31 
hundred and forty to one hundred and fifty mm. hg. In other 
words, a state of arterial tension is that condition in which 
the automatic, spontaneous and reflex excitability of the 
cardio-vascular and neuro-muscular mechanisms possess a 
high grade of coordination and adaptability to varying de- 
mands. 
1. Significance of Low Blood Pressure (Hypotension) 
(a) Congenital conditions 
(b) Endocrine exhaustion 
(c) Certain constitutional diseases and infections 
1. Tuberculosis 
2. Pneumonia 
3. Typhoid, etc. 
2. Significance of High Blood Pressure (Hypertension) 
(a) Factors which decrease the peripheral circulation or 
diminish the caliber of its vessels. 
(b) Increased volume of blood, other factors being equal. 
(c) Increased rate of flow, other factors being equal. 
(d) Abnormal viscosity. 
It is not the author’s object to treat ex- 
haustively upon this extremely important 
subject, other than as it may clarify and 
correlate certain viewpoints of value to osteopaths as a pro- 
fession. It must not be forgotten that reflexes are of tre- 
mendous importance to the osteopath. The reflex arc is 
probably the main channel of reciprocal innervation in the 
presence of the osteopathic spinal lesion; moreover, its field 
is unlimited and little understood. The time may come when 
the osteopathic fraternity will understand its intricate work- 
ings to the extent that it shall better know how to direct its 
therapeutic energies more specifically. 
The Autonomic Nervous System is divided into two parts: 
1. Sympathetic (Thoracico-Lumbar outflow). 
2. Parasympathetic (Cranial, midbrain, medullar and sacral 
outflow). 
When the sympathetics and parasympathetics are dis- 
tributed to the same structure, their effects are antagonistic. 
Sympathetic 
System: 32 
Downing Principles and Practice of Osteopathy 
The sympathetic nerves and the sympathetico-trophic glands 
of internal secretion; namely, the thyroid, adrenals, parathy- 
roids, etc., aid in the defense of the organism against such 
conditions as enemies from without, such as infections, pain, 
anger, injury, heat, cold, asphyxia and shock. From the 
viewpoint of metabolism, the sympathetics are naturally de- 
structive in their activities (catabolic) together with the 
glands with which they are intimately associated. It is inter- 
esting to note that the chromophyl element of the suprarenal 
is an embryological outgrowth of the sympathetic nervous 
system. 
Parasympathetic nerves and parasympathetic glands, 
such as the pineal and pituitary bodies, and intestinal glands, 
provide the body with an appetite and its secretions, such as 
saliva, gastric juice, bile, pancreatic fluid and intestinal re- 
agents, for the digestion of food and motive power to the 
gastro-intestinal tract for the combining of the food materials 
with juices, propelling it onward, and for expelling refuse 
from the body. From a metabolic viewpoint, their actions are 
anabolic. 
The antagonistic actions of both parts may be tabulated 
as follows: 
Sympathetic 
1. Pupillary dilatation 
2. Cardiac acceleration 
8. Peristaltic inhibition 
4. Retardation of digestive 
processes. 
5. Contraction of vesical and rec- 
tal sphincters. 
Parasympathetic 
1. Pupillary contraction. 
2. Cardiac retardation. 
3. Peristaltic stimulation. 
4. Stimulation of digestive proc- 
esses. 
5. Relaxation of vesical and rec- 
tal sphincters. 
The Nervous 
Mechanism: 
The generic nervous system is divisible 
into two parts: 
1. The central nervous system, composed of: 
(a) The brain or encephalon 
(b) The spinal cord or medulla spinalis. 
2. The peripheral nervous system, composed of 
(a) The cranio-spinal nerves. 
(b) The sympathetic. Osteopathy, the Science 
33 
Their association is so intimate that subdivision is only 
arbitrary. 
Physiologically, and to some extent structurally, the 
nervous system is also divisible into: 
1. The cerebro-spinal or somatic system, consisting of 
(a) The central system. 
(b) The cranio-spinal or cerebro-spinal nerves. 
2. The sympathetic or autonomic system, which is that por- 
tion of the peripheral nervous system, especially concerned 
with the re-arrangement and distribution of impulses to 
and from the brain and cord, and 
(a) The secreting glandular epithelium. 
(b) The cardiac muscle. 
(c) Non-striated visceral muscles (intestinal) 
(d) Certain striated visceral muscles (rectal). 
(e) The arrectores pilorum. 
(f) The non-striated vascular muscles. 
Although the activities of the sympathetic system are 
usually under the control of the central nervous system, it 
may mediate impulses without involving the latter at all. 
Biologically considered, the sympathetic system is an out- 
growth of the brain and spinal cord and remains anatomically 
and physiologically connected with them throughout life. 
It consists of a complex of spinal and cranial nerve-fibers 
and sympathetic fibers intermingled with groups of gang- 
lionic cells and is made up principally of: 
1. A pair of gangliated cords or trunks. 
2. Four great prevertebral plexuses. 
3. Terminal ganglia and plexuses. 
4. Nerve fibers (communicating and distributive). 
The cerebro-spinal nerves are forty-three in number on 
either side; twelve cerebral, attached to the brain, and thirty 
one spinal, connected with the medulla spinalis. They serve 
as means of communication between and control of 
1. Special and general senses. 
2. Voluntary muscles. 34 
Downing Principles and Practice of Osteopathy 
The nerve fibers encountered within the sympathetic sys- 
tem include two sets: 
1. Those derived from the cerebro-spinal system, which are 
usually medullated; 
2. The sympathetic fibers proper, which are usually non-medul- 
lated. 
The distinction between medullated and non-medullated 
fibers is, however, somewhat indefinite, since the medullated 
spinal or cranial fibers often become non-medullated before 
terminating; while the sympathetic fibers are occasionally 
medullated throughout their course. 
Physiological and anatomic investigations have shown 
that autonomic nerve-fibers arise primarily, though indirect- 
ly, through the intervention of ganglia from four chief 
regions in the central nervous system: 
1. From the midbrain emerging in the third cranial nerve 
and passing via the ciliary ganglion; 
2. From the bulbar region, emerging in the seventh, ninth, 
tenth and eleventh cranials; 
3. From the thoracic spinal nerves (first thoracic to second 
lumbar). 
4. From the sacral region by way of the so-called nervi eri- 
gentes, supplying the lower colon and genital organs with- 
out passing through the gangliated cord. 
The nerve impulses discharged by these cells are trans- 
mitted indirectly, not through one, but through two succes- 
sively arranged neurons. The first, a fine white, medullated 
fiber, emerges from the medulla or spinal cord in association 
with the large motor-root fibers, passing to the skeletal 
muscles (anterior primary division), and after a variable dis- 
tance leaves these fibers to arborize around and become 
physiologically related to nerve cells in a sympathetic gang- 
lion. The second, a fine, dark, medullated fiber, emerges from 
one of the cells of this ganglion, and after pursuing a much 
shorter or longer course, branches and becomes histologically Osteopathy, the Science 
35 
and physiologically related to cardiac, non-striated visceral 
or vascular muscle tissue and glandular epithelium. 
The first neuron, originating in the cranio-spinal area, 
is termed pre-ganglionic and is usually medullated. 
The second neuron, originating in the sympathetic gang- 
lion, is termed post-ganglionic and usually unmedullated. 
The cerebro-spinal and sympathetic nerves convey vari- 
ous impressions. The sensory fibers, called also centripetal 
or afferent fibers, transmit to the nervous centers impres- 
sions made upon their peripheral extremities and thus: 
(a) the mind, through the medium of the somatic affer- 
ent nerves becomes aware of external impressions; 
(b) certain automatic centers in the central nervous 
system are called upon through the medium of the splanchnic 
afferents, but without evoking consciousness. 
The centrifugal or efferent fibers transmit impressions 
from the nervous centers to the parts to which the nerves 
are distributed. These impressions either excite muscular 
contraction or influence the processes of growth, nutrition 
and secretion. 
For convenience of study it is well to consider such nerves 
as having their cell of origin, the spinal root ganglion (affer- 
ent somatic), in the central nervoussystem, and cerebro-spinal 
nerves and all nerves having their cells of origin extrinsic to 
this as belonging to the sympathetic system. However, it 
must be borne in mind that actually there are not two nerve 
systems, but one. This may morphologically be divided into 
two portions: 
1. That which has its peripheral distribution in association 
with skeletal muscles; 
2. That which has its peripheral distribution through the 
intervention of a series of ganglia, and is associated with 
cardiac or non-straited muscle and glandular epithelium. 
The rami communicantes serve to connect the sympa- 36 
Downing Principles and Practice of Osteopathy 
thetic with the central nervous system. They are denomi- 
nated white and gray rami communicantes. 
White rami communicantes are composed of very fine, 
medullated motor and sensory fibers which pass from the 
anterior primary divisions of certain spinal nerves (1st or 
2nd thoracic to 2nd lumbar) to the gangliated cord. The 
visceral branches of the 2nd, 3rd, and 4th sacral nerves (pel- 
vic splanchnics) correspond to the white rami although they 
do not join the gangliated cord but pass directly out to the 
prevertebral plexus. In this group are also included the vis- 
ceral branches of the 3rd, 7th, 9th, 10th and 11th cranial 
nerves. The white rami contain medullated nerve fibers 
derived from both the anterior motor route (splanchnic ef- 
ferent fibers) and the posterior sensory route (splanchnic 
afferent fibers). The cervical and lower lumbar nerves 
do not give off white rami. The cerebro-spinal fibers, 
as such, probably never actually gain the tissues of an organ, 
the last link in the pathway of connection being a sympa- 
thetic fiber. 
Splanchnic efferent fibers are motor to the non-striated 
muscles of vessels and a portion of the rectum, inhibitory to 
the stomach and intestines, secretory to glandular tissues, and 
cardiac accelerator. Somatic vasomotor, pilomotor and se- 
cretory fibers course along with the white rami. Splanchnic 
afferent fibers are the axones of spinal ganglionic cells and 
course along with white rami. They run without interrup- 
tion from the viscera to the posterior root ganglia. They are 
sensory fibers of the cranio-spinal type, collecting impulses 
in the domain of the sympathetic. Afferent sympathetics 
proper consist of fibers arising in the sympathetic ganglia 
which enter the spinal root ganglia by way of the rami com- 
municantes and arborize around the cells of the spinal ganglia. 
It must be remembered that white rami are absent in the 
cervical area, due to the arrangement of visceral afferents 
in the upper thoracic. Osteopathy, the Science 
37 
The gray rami communicantes are bundles of axones of 
sympathetic neurons which pass from the gangliated cord to 
each one of the entire series of spinal nerves and are then dis- 
tributed to the area supplied by these nerves, such as the skin, 
sweat glands, blood vessels and the arrectores pilorum mus- 
cles. Their origin from the gangliated cord is irregular. After 
joining the spinal nerve, the course of their fibers may be 
either 
1. Along with its anterior or posterior primary divisions and 
convey vasomotor, pilomotor or secretory impulses to the 
involuntary structures of the somatic area; or 
2. They may enter the spinal canal by way of the anterior or 
posterior nerve roots and supply the meninges and intrin- 
sic blood vessels, but not the medulla itself. (Each gray 
ramus gives off a delicate recurrent or meningeal branch 
which goes to the interior of the canal). 
3. Other filaments pass over the bodies of the vertebrae and 
supply the intercostal and lumbar arteries, the ligaments 
and the bones themselves. 
The branches of distribution from the gangliated cord in- 
clude somatic and visceral fibers. The former are the grey 
rami communicantes. The latter, or efferent rami, comprise 
the splanchnic efferents, both white and grey, and the white 
splanchnic afferents. 
The cervical sympathetics contain both medullated and 
non-medullated fibers, a large portion of the former being of 
cranio-spinal origin. Where white rami are absent, there- 
fore, visceral efferent fibers must enter the cord via white 
rami elsewhere, as is the case from the upper four or five 
thoracic nerves. 
The thoracic portion receives most of the spinal fibers 
connected with the sympathetic system. It has both white 
and grey rami communicantes. It contains many types of 
nerve-fibers, the functions of a few of which are herein 
enumerated. It has vasoconstrictors to pulmonary vessels 
and the upper and lower limbs, secretory to sweat glands, 
pilomotor, viscero-inhibitory to stomach and intestines, vaso- 38 
Downing Principles and Practice of Osteopathy 
motor to abdominal vessels, sensory afferent fibers, motor 
fibers to the circular fibers of the rectum, and inhibitory 
fibers to the longitudinal muscles of the same. 
The lumbar portion consists of spinal fibers which pass 
into the sympathetic by way of the one or two upper lumbar 
nerves, also receiving branches from the lower dorsal. It 
contains vasomotor nerves to the genitalia, and motor fibers 
to the bladder and uterus. 
The sacral portion of the cord has no spinal fibers pass- 
ing from the sacral nerves to the sympathetic chain, but the 
latter contains medullated fibers which descend from the 
lumbar region and terminate in the sacral ganglia. It gives 
off secretory, pilomotor, vasomotor, the chief motor fibers 
to the bladder and uterus and longitudinal musculature of the 
rectum, inhibitory fibers to the circular muscles of the rec- 
tum, vasodilator fibers to the penis and clitoris, secretory 
fibers to the prostate gland, and many others. 
In cross section the spinal medulla presents, histologi- 
cally, a variegated appearance. It is seen, macroscopically, 
to consist of white and gray nervous substance. The white 
matter is situated externally and constitutes the greater part 
of its bulk. The gray substance occupies the center and is so 
arranged as to present on the surface of the section two 
crescentic masses, placed one in each lateral half and joined 
by a transverse band, the gray commissure. Each crescentic 
mass has an anterior and a posterior horn. The latter is long 
and narrow and approaches the surface of the postero-lat- 
eral fissure, near which it presents a slight enlargement. The 
anterior horn is short and thick and does not quite reach the 
surface, but extends toward the point of attachment of the 
anterior roots of the nerves. 
The following diagram graphically represents the trans- 
verse microscopic morphology of the medulla spinalis: Osteopathy, the Science 
39 
B. 
G. 
PH 
CP 
r/// 
MLZ 
AGB 
BP 
/77ofor torts. 
Sensory facts. 
G. Column of Goll. B. Column of Burdach. P.H. Posterior Horn. A.H. Anterior Horn. D.C. Direct Cerebellar Tract. 
C'.P Crossed Pyramidal Tract. L.G.B. Lateral Ground Bundle. G.T. Gowers’Tract. M.L.Z. Mixed Lateral Zone. 
A G.B. -Anterior Ground Bundle. D. P. Direct Pyramidal Tract. 
Cross section of the spinal cord showing anterior and posterior nerve 
roots, nervous connections and nerve tracts. 40 
Doivning Principles and Practice of Osteopathy 
The 
Reflex Arc: 
The somatic afferent neurons send out 
two processes, one of which is physiologi- 
cally dendritic and passes to the end- 
organs in the peripheral and visceral tissues associated with 
the same or adjacent segments. Afferent impulses are the car- 
riers of scientific facts and collectively constitute the vehicle 
of motor control. The axonic processes continue into the 
spinal cord, forming for the most part its posterior roots. 
Around the cells of origin of these same nerves the dendritic 
portions of the cells of Dogiel may arborize, which, together 
with the posterior root fibers continue into the cord by way 
of the posterior root ganglia. Within the medulla these ax- 
ones divide again, one branch passing upward in one or more 
of the long tracts (Goll or Burdach). The other may pass 
downward through several spinal segments by way of the 
lateral ground bundle and then, by means of its intrinsic cells, 
which are associative or commissural in function, re-enter at 
different levels after associating themselves with these levels. 
Certain of the fibers entering through the posterior root 
ganglia pass directly to the posterior root andarborizearound 
the cells of Golgi, type II, which do not leave the confines of 
the grey matter. They constitute the simplest and most direct 
route by which connector nerve impulses of an afferent char- 
acter are immediately transferred to efferent nerves in the 
ventral horn and spontaneously acted upon. Certain of the 
nerves entering the posterior horn of grey matter may 
arborize around the cells of Clark’s column. It must be re- 
membered that nerve reflexes carried over Golgi type II 
neurons are the simplest and quickest avenues of lower re- 
flexive activity, and need not go out of their immediate seg- 
ment. 
Fibers which enter the long tracts carry afferent im- 
pulses upward to act upon, stimulate and correlate the centers 
in the cerebellum, pons, midbrain, thalami and cerebral cor- 
tex. As the long tracts end in the nucleus cuneatus and 
nucleus gracilis, they are further relayed and thus conscious- Osteopathy, the Science 
41 
ness is affected, probably by way of the fillet or lemniscus. 
The afferent fibers to the cerebellum come from a variety of 
sources. Their projection system, however, is largely through 
the cells of Purkinje and the dentate neucleus. These path- 
ways are not simple, but complex, and they send in collateral 
and associative fibers which re-enter the grey matter in the 
cord and by means of many conduction paths co-ordinate 
many portions of the brain. This particular phase of the re- 
flex arc cannot be dealt with at length. 
Consciousness is affected only in the very outer layer of 
the cerebral cortex. The deeper layers of the pons, cerebel- 
lum and basal ganglia offer cross-paths and effect the media- 
tion of reflexes, although consciousness may or may not be 
affected until after motor response has been initiated. Simple 
spinal reflexes give a single reply to a single demand. The re- 
flex is a physiological answer. Afferent impulses through 
higher meditation are much more complex, for they co-ordi- 
nate and fill a physiological demand of an involved nature 
with appropriate responses in an entirely automatic manner. 
Sensory impulses acting through the cortex are subject to 
judgment and reason. They may be associated with emotional 
qualities, together with co-operative changes in respiration 
and circulation. 
Certain complex reflexes are working constantly for the 
welfare of the body, as for instance, the kinetic static sense 
in the semi-circular canals. The minimum of afferent stimulus 
required to produce a primary sensory and secondary motor 
response is termed liminal intensity, or threshold stimulus. It 
varies from day to day according to variant circumstances. 
Nerve pathways, long disused, respond less quickly, as do those 
in which the resistance of the structures through which the 
stimuli must pass is greater than normal. Nerve tissue dif- 
fers from other body tissues in that its potentiality is high, 
likewise its metabolic rate. It is the controlling system and 
easily thrown out of balance physiologically. Its electrical 
polarity and directive force is one way, with the exception of 42 
Downing Principles and Practice of Osteopathy 
some of the cranial nerves. Nerve cells are not easily fatigued 
but require a refractory rest period of approximately .003 
of a second. 
Abrami has proven experimentally that it is practically 
impossible to break the conductivity of nerve action along 
its axonic course. Artificial blocking of certain nerves, 
by anesthesia, shows that a nerve at its conclusion will evince 
practically unimpaired activity. Nerve impulses, then, tend 
to jump any minor obstacle along their course. Aug- 
mentation of this force increases as the stimulus 
passes, showing evidences of a re-establishment of energy 
outside of the cell body. Intiation of cell impulses, however, 
can come only through dendritic or receptor elements, and, 
hence, through a cell body. A nerve will tend to show nor- 
mal capacity of constant intensity until an occasion arises 
which forces it to temporarily cease all activity. The weak- 
est link, from the standpoint of conductivity, is the synapse. 
Constant bombardment at this point may weaken the contact 
to a degree that the receptor or dendritic action may become 
temporarily exhausted and the initial impulse cease. In this 
case, as, for example, the osteopathic lesion, the connector 
elements are most influenced. Initiation of various forms of 
incoordinate stimuli follow, besides those which the initial 
reaction produced. Dendritic bombardment, and resultant 
exhaustion of the synapsis lead to a complex disorganization. 
The cell of Dogiel carries, along with the nerves of the pos- 
terior root ganglion, disturbed impulses from the sympathetic 
to the cerebro-spinal system and is consequently a very im- 
portant link in the production of what McKenzie calls his 
“viscero-motor reflex.” This consists, in a general way, of 
the transference of effect from a disturbed sympathetic to a 
closely connected and intimately related sensorium. The 
question as to how this comes about can be brought out only 
in a general way, as the intricate working of a disordered 
nervous mechanism can manifest itself along many path- 
ways. Osteopathy, the Science 
43 
The nearer a cell-station in the sympathetic system is to 
the ultimate axionic termination, the more local the disturb- 
ance and the more localized its effect upon the sensorium. 
This is especially true of the cranial output of the sympathe- 
tics. Ganglia act as distributing centers for a widespread dis- 
semination of sympathetic impulses. Somatic nerves which 
are preganglionic in character give local, accurate reflexes; 
while automatic, postganglionic fibers give an immediate, 
generalized effect. 
In order of sequence the author will assume an initial 
sympathetic disturbance resulting in irritative impulses which 
are relayed to the spinal cord, producing a viscero-motor re- 
flex and through the operation of the laws of Head and Hil- 
ton, an osteopathic lesion perforce results. This is followed 
by edema of the cul-de-sac over the posterior root ganglion, 
which in turn produces still further disturbance and dis- 
organization, particularly in the somatic afferent cells of the 
posterior root ganglion, including the cells of Dogiel. A 
widespread dissemination of cerebro-spinal and sympathetic 
impulses follows therefrom, with the accumulative result that 
all restraint and coordination of nerve impulses of the reflex 
mechanism are impaired, together with an extraneous de- 
velopment of harmful and unnecessary reflexes and an in- 
hibition of others through exhaustion at the synapse. If 
more than one segment becomes involved, the disturbance 
becomes pluri-segmental. 
If these irritative impulses persist over a sufficient period 
of time, they signify the beginnings of an osteopathic lesion, 
inasmuch as certain factors complicate the issue, factors 
which are not self-regulative. The viscero-motor reflex of 
McKenzie is nothing more than a somatic efferent and affer- 
ent expression of the spinal disturbance. Its visceral connec- 
tion is well determined, although hidden: hence the osteo- 
pathic lesion in disease. If the lesion continues the pathology 
involves nervous structures. Nerve groups and the gray 
matter of the cord are subject to primary degeneration, a 44 
Downing Principles and Pmctice of Osteopathy 
form of dissolution in which the nutrition to the cells is pro- 
gressively depleted. 
Conscious sensations due to vertebral lesions vary great- 
ly in their liminal values. These depend upon the nature of 
the subluxation, its time element and the psychic state of the 
individual. This threshold value is somewhat determined also 
by the type of circulatory disturbance present. During the 
active hyperemic state, or early congestive period, subliminal 
impulses may be perceived. In fact, they may become acutely 
troublesome. After the stage of inhibition, and when the 
circulation is in a more or less passive state, impressions are 
harder to receive over these afferent pathways, hence the 
liminal value is higher. 
Two important basic laws previously mentioned are: 
Head’s Law—“When a painful stimulus is applied to a part 
of low sensibility in close central connection with a part 
of much greater sensibility, the pain produced is felt in 
the part of higher sensibility rather than in the part of 
lower sensibility to which the stimulus was actually 
applied.” 
Hilton’s Law—“A nerve trunk which supplies any given joint 
also supplies the muscles which move the joint and the 
skin over the insertion of such muscles.” 
McKenzie says that all the symptoms on 
which a diagnosis is based are reflex in 
origin. In some, the reflexes are disturb- 
ed by the entrance of the stimuli through 
the nervous system and in others the dis- 
turbance operates through the circulation. To the former 
class belong the symptoms of such diseases as gastric ulcer, 
renal calculus and gall stones. The symptoms in infections 
are due to the disturbance of the reflexes through the circula- 
tion, as in influenza, malaria, typhoid and typhus fevers, 
measles and abscess formations apart from the swelling. In 
some diseases there is a mixture of both types, as in appendi- 
citis where there is not only local tenderness and pain in the 
external body wall, with contraction of the muscles of the 
The Disturbed 
Reflex and the 
Production of 
of Symptoms: Osteopathy, the Science 
45 
abdomen, but the feeling of exhaustion, rapid pulse, and a 
tendency to vomit. In cholecystitis a similar complex is en- 
countered. The need for more accurate identification of 
symptoms is seen when contemplation is had of the difficulty 
with which such seemingly simple affections are gastric ulcer 
and appendicitis are diagnosed. Although surgeons have been 
operating for these conditions for years, the most experienced 
find in many cases that they were mistaken in their diagnoses. 
This is in a great measure due to the fact that the precise 
nature and modus operandi of their symptoms have never 
been fully understood, and because those manifestations have 
never been clearly diffentiated from the signs of other 
diseases which resemble them. 
It is undoubtedly true that every normal physical act 
which we perform during the daily course of our existence, 
as well as the vital activities of those organs over which we 
have no voluntary jurisdiction, is determined through the 
sphere of reflex activity. Many of these reflexes remain 
vague, misunderstood, and, to a great extent, unrecognized. 
Every reactive force of the body, whether in health or 
disease, whether for the conduct of normal activity or those 
highly specialized protective functions demanded by varying 
emergencies, must carry out its individual duties in such a 
way as to preserve and perpetuate life and in such a manner 
that the organism will appreciate and meet every environ- 
mental variation. This disorganization and incoordination 
incident to the osteopathic lesion is a more or less harmful 
factor and constitutes a pernicious block to the carrying out 
of these vital activities. One authority has stated that a 
cancer is “cell metabolism gone mad.” The same figure is 
appliable to the chaos and disorder of nerve impulses eminat- 
ingfrom a segment adjacent to an osteopathic lesion. 46 
Doivning Principles and Practice of Osteopathy 
(A. 0. A. Journal, March, 1922—excerpts quoted from the 
Medical Times, 1921, by Dr. Henry Winsor.) 
Sympathetic 
Segmental 
Disturbances: 
“The object of these necropsies was to de- 
termine whether any connection existed 
between minor curvatures of the spine 
on one hand, and diseased organs on the 
other. In fifty cadavers with disease in one hundred and thir- 
ty-nine organs, there was found curve of the vertebrae be- 
longing to the same sympathetic segments as the diseased 
organs one hundred and twenty-eight times, leaving an ap- 
parent discrepancy of ten in which the vertebrae in curve 
belonged to an adjacent segment to that which should sup- 
ply the diseased organ with sympathetic filaments. How- 
ever, the nerve filaments entering the cord or leaving it 
travel or have traveled up or down the cord for a few seg- 
ments, accounting for all of the apparent discrepancies. The 
check amounts to one hundred thirty-eight and when the one 
body, No. 12, which had a faint curve with slight pathology 
only, is added, we have the original, one hundred thirty-nine, 
showing that the figures are fairly accurate.” 
The original observations, omitted through lack of space, 
are now re-examined for discrepancies as a check system on 
the tables. Fifty cadavers exhibited a total of one hundred 
and five curvatures; two of which showed Pott's disease, two 
gross scoliosis, leaving one hundred and one minor patho- 
logical curves. Of these, ninety-six showed evidences of dis- 
orders (diseases) in some of the structures supplied by that 
portion of the sympathetic system coming from the vertebral 
segments in curvature. There were nine curvatures without 
any evidence of disease in the organs belonging to the same 
sympathetic segments as the vertebrae in curve. As four of 
these were gross curves, (Pott’s disease or gross scoliosis) five 
minor curves are left without disease in the organs supplied 
by the same part of the sympathetic as the vertebrae in curve. 
Reversing the process of thought, two hundred and twenty- Osteopathy, the Science 
47 
one structures other than the spine were found diseased. Of 
these, two hundred were observed to belong to the same sym- 
pathetic segment as the vertebrae in curvature. Nine diseased 
organs belonged to different sympathetic segments from 
those of the vertebrae out of line. These figures cannot be 
expected to exactly coincide with those in the tables, for an 
organ may receive sympathetic filaments from several spinal 
segments and several organs may be supplied with sympa- 
thetic filaments from the same spinal segments. 
In another series of twenty-five bodies, especially studied 
by the writer as to minor curvatures, spondylitis deformans, 
irritation of the sympathetic system and disease in the organs 
supplied by the same sympathetic nerve as the vertebrae 
affected, it was found: 
1. That nearly every one of the twenty-five bodies showed 
rheumatoid arthritis, either of the heads of the ribs, of 
the intervertebral discs, or of the bodies of the vertebrae 
in curvature; 
2. That rheumatoid arthritis was comparatively rare except 
in and around the vertebrae in curve; 
3. That it was commonly found in the joints of the extremi- 
ties; 
4. That disease was nearly always found in the organs that 
were supplied by that part of the curvatures where there 
was rheumatoid arthritis; 
5. That it was rare to find an organ diseased which was not 
supplied by the same sympathetic nerve as the vertebrae 
in curvature with rheumatoid arthritis thereon; 
6. That the inflammatory exudate of rheumatoid arthritis 
of the ribs, discs and vertebral bodies involved in abnormal 
minor curvatures pressed directly upon that part of the 
sympathetic system related to the viscera found to be 
diseased; 
7. That instead of passing to the diseased organs in a 
straight line the sympathetic nerves were stretched in 
an angular manner over this exudate; 
8. That even where no bony exudate was found, there was an 
intense rigidity of segments, showing that fibrous or 
callous exudate could irritate the sympathetic. 48 
Downing Principles and Practice of Osteopathy 
Unfortunately it is impossible to accurately gauge the 
amount of disturbance resulting from the osteopathic lesion, 
which is not sufficiently stabilized to produce gross patho- 
logic changes, but sufficiently disturbing to cause physio- 
logical imbalance. It is not, however, a far step into the realm 
of conjecture to assume their existence in the sphere of func- 
tional disease. The disordered reflex is sufficient proof of 
this. 
Abdominal Pain of Sympathetic Origin is localized to 
the great ganglia associated with the organ or organs in- 
volved, but is not referable to the organ itself. If abdominal 
pain is elicited elsewhere it is significant of involvement of the 
parietal peritoneum. Hyperalgesia of the abdominal wall is 
found in nervous women without changes in the internal 
organs. This may be confirmed by pinching folds of the skin 
on either side and comparing findings, or by testing muscula- 
ture by laying a hand over the painful area and requesting the 
patient to raise the upper part of the body, thereby causing 
contraction of the abdominal muscles. Pressure against the 
contracted muscles will elicit sharp pain. These two tests 
will confine the reactions to the skin and muscles. 
Sympathetic pain is not as intense as that of the cerebro- 
spinal system proper and it is usually more diffuse. It is 
further characterized by muscular contractures and circula- 
tory and trophic disturbances; whereas involvement of the 
cerebro-spinal system is characterized by paralysis, impotence 
and more sharply defined pain. Neuralgia of the sympathetic 
system, causing both sensory and vasomotor disturbances, is 
essentially a neurosis and should be treated as such. Stajano 
speaks of a phrenic reaction in gynecology in which he found 
spontaneous pain and tenderness along the costal arch on 
both sides, with special intensity at the diaphragmatic point, 
particularly increased by force inspiration, signifying disease 
in the female genitalia. In cases of high blood pressure Pal 
claims that there is a sympathetic reflex due to arteriospasm Osteopathy, the Science 
49 
giving rise to cephalic pains. This is somewhat different 
from the symptoms of meningeal vasomotor disturbances as- 
sociated with auto-intoxication, menstrual disorders, etc., 
wherein the pain is reflex. Idiopathic complexes of reflex 
disorders due to a general sensory overflow and secondary 
reflex developments, result in a systemic imbalance, and pro- 
duce hyperirritability of the sensorium. This excessive affer- 
ent stimulation causes an excessive efferent irritation. By- 
ron Robinson, in his explanation of visceral neuroses, states 
that the nervous system and the organs in the abdomen are 
not living in harmony. Moreover, if one organ is disturbed, 
it will tend to unbalance the remainder, indicating that irri- 
tation is reflected by a nerve arc from one viscus to another. 
This is pathologic physiology. 
This is a slowing of the rhythm of the 
heart following compression of the eye- 
balls. A slowing of from five to thirteen 
beats per minute is normal; thirteen to 
fifty or more, exaggerated; and one to five, diminished. If 
ocular compression causes acceleration of the heart, the re- 
flex is inverted. This test demonstrates whether or not the 
individual has normal coordinate activity of the vagus and 
vegetative nervous system; and, if abnormal, which predomi- 
nates. 
This condition is caused either by hyper- 
tonia of the vagus or a hypotonia of the 
sympathetic (a substandard vegetative nervous system). 
Bradycardia of a more or less pronounced character is 
encountered in this condition when the above test is used. 
Such conditions as epilepsy, hypothyrodism, hab- 
itual constipation, asthma, gastric and duodenal ulcers, 
pylorospasm, hyperacidity, gout, urticaria, mucous colitis, 
hydrops of joints, constitutional disturbances characterized 
by fermentative purin metabolism, and others, are produced 
by this predominance of the vagus. 
The Oculo- 
Cardiac Reflex 
(Aschner’s): 
Vagotonia: 50 
Downing Principles and Practice of Osteopathy 
Sympathet- 
icotonia: 
This condition is evidenced either by a hy- 
potonia of the vagus, or a hypertonia of 
the sympathetic. Tachycardia of a more 
or less pronounced character is met with in this condition 
when the test is used. In other words, the test is invert- 
ed. Such conditions as hyperthyroidism, general paresis 
and tabes dorsalis are examples of this type of disordered 
nervous mechanism in which the sympathetic system pre- 
dominates the vagus. Euziere and Margorot refer to 
apprehension and anxiety as characterized by extreme 
irritability of the sympathetic nervous system, and that this 
hypertonia is a constant physiological substratum of the 
psychical element of anxiety. In so-called functional neurosis 
Kempf states that uncompensated changes in the tension of 
unstriped muscle, and the special sense organs, act as the 
great etiological background for the production of these phe- 
nomena; and, that there is a continuous attempt on the part 
of the vegetative apparatus to neutralize autonomic tensions 
caused by the lack of equalization between a human dynamic 
factor and a universal opposing environmental force. Biologi- 
cal tension remains and must be neutralized if equilibrium of 
the body economy is to be restored and maintained. This has 
reference particularly to ungratified sex hunger, unfulfilled 
for social reasons. It is essentially a hypertonia of the sympa- 
thetic system. 
The oculo-cardiac reflex is subject to so many individual 
variations that it is not a positive sign in differential diag- 
nosis, but rather an indicator of probability. The centripetal 
path of the oculo-cardiac reflex is constituted exclusively by 
sensory branches of the trigeminal, and its centrifugal path 
mainly along the vagus and in some measure through the 
sympathetics. Complete antagonism is rare, as balance is 
easily upset by toxic or infectious processes and reflex dis- 
turbances. When inversion of the reflex is present, surgical 
operation is contraindicated because of the danger to the 
patient. Osteopathy■, the Science 
51 
Inhibition 
and Stimulation: 
In a vast majority of cases or conditions 
these may be obtained only indirectly. In 
osteopathic therapeusis we are apt to use 
these terms indiscriminately, inasmuch as we employ, for in- 
stance, in the case of a patient in pain, inhibitory measures, 
and in the case of an individual in whom we wish to incite a 
physiological reaction, or re-awaken a dormant activity, 
stimulatory methods, without in either case having a clear 
conception of just what these terms imply. Take pylorospasm 
as an example: in this condition the objective of treatment 
is increased activity of the sympathetic control of the pylorus 
and the procedures employed are in no sense truly inhibitory. 
Again, in the case of a patient with chronic constipation, 
stimulation of peristalsis is the rational therapeutic aim. 
If, therefore, the sluggishness is due to hypertonicity of the 
sympathetic system, inhibition is in order. 
Careless use of these terms leads to much confusion, for 
they have no specific indications in therapeusis, each case 
being a law unto itself. Hulett very concisely expresses this 
idea as follows: 
1. “The necessity for stimulation presupposes an existing 
inhibition; and the removal of the cause of that inhibition 
constitutes the legitimate method of stimulation.” 
2. “The necessity for inhibition presupposes an existing stim- 
ulation; the removal of the cause of that stimulation 
constitutes the legitimate method of inhibition.” 
With but few exceptions it may be properly said that 
physicians should treat the lesion and let stimulation or in- 
hibition take its own course. 
“Find it; fix it; and leave it alone.”—(A. T. Still.) 
Exceptions are sometimes noted in which beneficial clini- 
cal results are obtained by the use of direct stimulation or in- 
hibition. In a highly irritable lesion the corrective procedure 
must be carried out with the greatest care, to avoid mechan- 52 
Downing Principles and Practice of Osteopathy 
ical stimulation. In a chronic lesion of long standing, mechan- 
ical stimulation may result in increased activity, for the num- 
ber of stimuli passing through a given segment may be great- 
ly augmented in the same space of time merely by the degree 
of mechanical stimulation evoked. This in a measure explains 
the relative value of the use of these general physical re- 
agents. 
The etiologic factors in disease may be: 
1. Physical. 
2. Chemical. 
8. Psychical. 
All causes must be primarily external and secondary internal. 
External causes may be: 
Environmental and functional abuses. 
Chemical causes may be: 
Dietary, ingestion of drugs, alcoholism, etc. 
Psychical causes may be: 
Fear, anger, hatred, and worry; overuse, under- 
use of function. 
All external causes must become internal before they can 
affect the human organism. The internal causes are likewise 
1. Chemical. 
2. Psychical. 
3. Physical. 
Chemical causes may be: 
Faulty metabolism, i.e., lithemic diathesis, saline 
starvation or other acidosis, perversions of 
internal secretions. 
Physical causes may be: 
Osteopathic spinal lesions, displaced organs, pos- 
ture, etc. 
Psychical causes may be: 
Reflex disturbances, etc. 
Causes of 
Disease: Osteopathy, the Science 
53 
The relationship between bacteria and 
disease is not clear on account of two 
factors: 
1. The extreme variations in individual immunity; 
2. The relative virulence of the germ. 
However, science is fast proving that the germ itself as 
an entity is not wholly independent, but rather variably 
dependent on tissue devitalized by predisposing factors; 
but that the course and pathology of the disease is markedly 
influenced by the type of the invading organisms. Each 
type has its own particular manner and method of de- 
structive activity. The toxin, rather than the bacterium itself, 
is the prime cause of tissue injury. Certain bacteria have a 
predilection for certain parts of the body. In fact, bacteria 
may be perfectly harmless in one portion of the body and 
highly pathogenic in another. 
1. The importance of structural states 
in disease; a better and broader outlook 
on disease, and its causes, particularly the 
latter. 
2. The greatest contribution to thera- 
peutics in the whole history of medicine, 
so stupendous and complete in character as to revolutionize 
the entire therapeutic world. 
3. The first, best and only complete theory of natural 
immunity to be formulated; since proven by scientific investi- 
gation to be true. “The body itself contains within itself all 
the chemicals and all the medicines necessary for the cure of 
disease.”— (Dr. A. T. Still.) 
4. The fallacy of internal drug medication. 
The Germ 
Theory: 
Dr. Still’s 
Achievements 
and Contribu- 
tions to 
Medicine: 54 
Douming Principles and Practice of Osteopathy 
CHAPTER IL 
THE OSTEOPATHIC SPINAL LESION 
Etiology: 
To define all the causes of the osteopathic 
lesion would be impractical, other than to 
summarize them in a general manner. 
(a) The vast majority of lesions are caused by recipro- 
cal innervation through the medium of the reflex arc. 
Some of the factors causing these reflexive phenomena 
are as follows: 
1. Psychic (fear, anger, hatred, and worry.) 
2. Orifical (adenoids, hemorrhoids, fistulae, impacted 
molars, hooded clitoris, phimosis, etc.) 
3. Environmental (poor hygiene or sanitation.) 
4. Functional (misuse, overuse, or underuse of func- 
tion.) 
5. Thermal (exposure to extremes of heat or cold.) 
6. Chemical (drugs, ptomaines, faulty dietetics, etc.) 
Broadly speaking, reciprocal innervation may be due to 
a multitude of physical, chemical, or psychical irritative dis- 
turbances. Moreover it may be intimately connected with 
any of the following classifications: 
(b) Postural defects—disturbance of the centers of 
gravity. 
1. Heredity (inherent weaknesses as congenital luxa- 
tions, etc.) 
3. Habit (faulty posture, sitting and standing, etc.) 
3. Occupation (postural anomalies, as found in shoe- 
makers, tailors, painters, violinists, etc.) 
4. Secondary acquisitions (certain diseases, such as 
tuberculosis, infantile paralysis, obesity, and con- 
ditions such as flat feet, abdominal obesity, frac- 
tures, etc.) The Osteopathic Spinal Lesion 
55 
Postural defects may be in the form of lordosis, scolosis, 
or kyphosis. 
(c) Toxemia (By way of the blood stream.) 
1. Exogenous toxins (bacterial, chemical, and diete- 
tical.) 
2. Endogenous toxins (fatigue, faulty metabolism, 
such as, for example, acidosis from disturbed sugar 
tolerance.) 
(d) Directly physical: 
1. Trauma, (wrenches, falls, blows, etc.) 
(a) Gross changes. 
1. Malposition or subluxation of the vertebra in lesion. 
2. Unequal and imbalanced muscular tensions. 
(a) Contracture where there is approximation 
(hyper-tonic.) 
(b) Tension where there is separation (atonic.) 
3. Ligamentous shortening and thickening occur con- 
comitantly with muscular contracture. 
Lengthening and tension of ligaments occur co- 
ordinately with muscular tension. 
4. Compression and decompression changes are found 
in the intervertebral disc. 
5. Edema and induration of the surrounding tissues. 
(b) Microscopic changes. 
Edema and acidosis are present in the tissues surround- 
ing the vertebra in lesion. Carbon dioxide tension is plus, and 
oxygen tension is minus. Other end-products of cellular meta- 
bolism are present. This is principally due to circulatory dis- 
turbance, inasmuch as the circulation to the cord is markedly 
influenced by pressure. As the veins are more subject to 
compression than the arteries, the result is usually a conges- 
tion, rarely anemia. Circulatory interference in the cord is 
not only found in the segment corresponding to the vertebra 
in lesion, but may to a lesser degree disturb the segments 
above and below the lesion. 
Pathology: 56 
Downing Principles and Practice of Osteopathy 
Low grade fibrositis of the connective tissue elements oc- 
curs, consisting of a hyperplasia and hypertrophy (largely 
hypertrophy.) Interstitial changes depend upon the chroni- 
city of the lesion and the degree of catabolic toxemia present. 
Muscular changes occur in the following order: 1. con- 
tracture; 2. congestion and capillary hemorrhage; 3. edema 
and acidosis. The acidosis is due to defective excretion of 
muscular catabolites, particularly carbonic and sarcolactic 
acid. 4. Low grade myositis with interstitial hypertrophy 
as a final result. Atrophy of muscle fibers follows. The small 
muscles adjacent to the vertebra in lesion suffer most. On 
palpation the tissues have an edematous, doughy feeling and 
the muscles and ligaments give the sensation of a corrugated 
whipcord. 
Induration, thickening, and shortening of the ligaments 
occur concomitantly with muscle changes. Proliferative 
changes may ensue. In the chronic lesion, the ligamentous 
changes are more pronounced, while in the acute, the muscu- 
lar contractures predominate. 
Nerve pathology varies according to the type of the 
nerves and their situation. The sympathetic unmedullated 
nerve fibers are most affected. They may show a primary 
degeneration or worse. The nerve trunk may have a slightly 
thickened neurilemma, granular medullary sheath, and a 
slightly swollen axis cylinder. Inasmuch as trophic function 
depends upon the complete integrity of the entire reflex mech- 
anism, it is easy to visualize the far-reaching effect of such 
nervous pathology. The visceral efferent and afferent nerves 
show particular pathology. 
The synovial membranes are first congested and there is 
an increased output of synovial fluid; later the synovial mem- 
brane becomes thickened and roughened, and the output of 
synovia is decreased. The articular capsules are thickened, 
particularly on the side which rotates anteriorly. In an old The Osteopathic Spinal Lesion 
57 
lesion, the joint changes are very similar to those of a rheu- 
matoid arthritis. 
Disturbed reflexes, worthy of mention are: 
1. Cerebro-Spinal 2. Sympathetic 
(a) Motor (a) Vasomotor 
(b) Sensory (b) Viscero-motor 
(c) Secretory 
Vasomotor disturbances occur in both the immediate area 
of the lesion and in the viscus supplied by related nerves, 
but in the former the ratio of vasomotor incoordination is 
augmented in direct proportion to the pressure disturbance. 
1. Malposition or subluxation of the 
vertebrae in lesion is noted. 
2. Tenderness or hyperesthesia of the 
lesioned area, due to irritation from tis- 
sue toxemia and pressure edema is 
present. 
It is less pronounced in chronic lesions than in acute. 
3. Restricted motion of vertebrae in lesion with those 
adjacent can be detected when physiological movement of 
that area of the spine is utilized. 
4. A slight elevation of temperature is rarely found. It 
signifies a co-existent inflammation. The degree of surface 
temperature largely depends upon the acuteness of the under- 
lying condition. 
5. Disturbance of function in the parts supplied by the 
spinal segment influenced by lesion may or may not be 
obvious. 
6. Referred pain (Head’s law) is usually more pronounc- 
ed in the acute lesion. 
7. The position the patient assumes in relation to the 
existing structural anomaly is suggestive. 
Symptoms and 
Diagnosis of 
the Spinal 
Lesion: 58 
Downing Principles and Practice of Osteopathy 
L Sicbflaj'cis 
Intervertebral 
J)Crcs 
'Znfer.ep tnousZip ** 
intrSacro Iliac Ziff. 
1 Obturator . 
l Membrane' 
l£esser SeialicZig. 
Syrufjhjfst% 
Leftscr Set a/c'r fora men, 
\orenter Sacra Scicvtcc /. n/ 
Sagittal section of the spinal column with ligaments. The Osteopathic Spinal Lesion 
59 
8. Unequal muscular tension and soft tissue anomalies 
are easily palpable by reason of their corrugated, ropy and 
doughy feeling, respectively. 
9. In the chronic lesion, pigmentary changes of the skin 
may be found around the involved area. 
10. In a chronic, impacted lesion, there will be an area 
of hypermobility immediately above or below the lesion 
(compensatory). 
11. The subjective symptoms and history may aid by 
directing the physician’s attention to certain features, as for 
example, the history and character of trauma. 
12. In acute lesions, muscular contracture predominates; 
while in chronic lesions, ligamentous thickening is ascendant. 
Obstacles to overcome in the correction of a lesion: 
1. The inertia of rest. 
2. Contractured muscles. 
3. Shortened and thickened ligaments. 
4. Presence of rheumatoid arthritis, adhesions, 
ankylosis, etc. 
5. The elimination, insofar as possible, of all fac- 
tors concerned in the production of the lesion. 
Force plus velocity correctly applied is essential 
to produce motion in any lesioned articulation. A certain 
amount is necessary to overcome the inertia of rest present. 
A still greater amount is needed when we stop to consider 
the hypertonic condition of muscles and ligaments in the 
lesioned area. If interstitial fibrosis of ligaments and mus- 
cles is present, still more force is required and repetition may 
be necessary—for example, the chronic spinal lesion. 
We realize, last of all, that in the presence of too great 
a sum total of resistance, there is a limit to the amount of 
effectual force and velocity that can be safely used, as in 60 
Downing Principles and Practice of Osteopathy 
case of adhesions, ankylosis, etc. Certain other conditions 
indicate caution, not particularly because of the resistant 
phase, but more because of the underlying pathology, for 
example, rheumatoid arthritis. This is no contra-indication 
to adjustive treatment, other than that it should be directed 
at right angles to the planes of articulation to break fixation, 
rather than parallel to the planes of the articulation to restore 
pathway. It will then give nature an opportunity to restore 
partial normality to the articular surfaces wherein the second 
directive form of treatment given at the beginning would 
tend to increase irritation by the law of friction. Certain 
conditions, because of their underlying pathology, demand 
immobilization rather than mobilization, and should there- 
fore be left strictly alone in a manipulative sense; for ex- 
ample, acute infectious arthritis, tuberculosis, etc. 
(I) Diagnosis, visualization, and analysis 
of the lesion are necessary. A positive 
diagnosis must first be made, following 
which the planes of articulation and the structural 
maladjustment must be thoroughly visualized. This having 
been done, analyzation of the mechanics of movement of the 
lesion can be made, and a definite technique evolved by which 
to retrace the pathway taken by the vertebra in lesion to its 
arthrodial limit; break the fixation, or otherwise conduct di- 
rective forces which ultimately have the readjustment of the 
vertebra in view. This is complete when a full range of 
arthrodial movement has been re-established—in other words, 
when mobility is complete. It also demands the reduction of 
any deep spasticity and imbalance of soft tissues which may 
react in such a way as to reproduce the lesion. 
(II) Normalize soft tissues through manipulation and 
muscular relaxation. 
(a) Approximation of attachments of 
muscles: 
1. With manipulation of the belly of the muscle at 
right angles to the course of the fibers. 
The Principles 
of Technique: 
Methods: The OsteojKithic Spinal Lesion 
61 
2. With steady, firm pressure. 
3. Without pressure or manipulation. 
(b) Separation of the attachments of muscles: 
1. With manipulation of the belly of the muscle at 
right angles to the course of the fibers. 
2. With firm, deep pressure. 
3. Without manipulation or pressure. 
(c) With neither approximation nor separation. 
1. Firm, deep pressure. 
2. Manipulation of belly of the muscle at right angles 
to the course of its fibers. 
(d) Functional relaxation by active exercise. 
Too much importance should not be attached to soft 
tissue manipulation for the osseous lesion is the main factor 
of clinical significance. Bony adjustment tends to break 
the vicious circle of reflex activity at its source, the spinal 
center in which or near which are the cells of origin of the 
nerves affected. Muscular contracture is, in the ordinary 
case, the result of continuously acting stimuli (providing it 
does not undergo interstitial changes), and osseous adjust- 
ment has the greatest effect upon the seat, or source, of the 
irritation. Muscular relaxation, however, is not only neces- 
sary to maintain bony adjustment, but is of value at times in 
the diagnosis of underlying bony lesions, as contractures 
sometimes prevent an absolutely satisfactory palpation of the 
osseous condition. 
The operator should remember to make his soft tissue 
treatment soft and gentle in character. Abrupt and too 
vigorous manipulation, the stimulus of cold hands, over treat- 
ment, and hurting the patient are some of the factors to be 
guarded against. The best method to use depends entirely 
upon the condition at hand. To produce the best relaxation 
in the average case, use the approximation of the attachments 
with manipulation at right angles to the belly of the muscle. 62 
Downing Principles and Practice of Osteopathy 
Approximation of the attachments tends to produce physi- 
ological relaxation of the muscle by a removal of the tension. 
It is assumed that manipulation frees the circulation and pro- 
motes better drainage of the muscle, and, if correctly given, 
the benefits more than counteract the intramuscular stimu- 
lation naturally expected from knowledge of the fact that it 
is easier to stimulate than to inhibit. Approximation of the 
attachments of the muscle (spinal extension) with deep pres- 
sure is indicated in such conditions as excessive vomiting, 
diarrhea, hysteria, headache, gall stone colic, renal colic, 
lumbo-sacral pains in childbirth, etc. It modifies the irri- 
tative reflex impulses of a sensory character. It gives the 
patient great relief and is a good clinical example of what 
is termed inhibition. Active and passive exercises have 
their own particular fields, and will not be enlarged upon 
here. 
Fills a great gap in our therapeutic needs. 
The author knows of no better method to 
reduce deep spastic tensions, and 
muscular and ligamentous imbalances, than by gradually in- 
creased, subtained, then gradually decreased, deep pressure 
covering the entire region of the lesion with the patient prone 
on the table and using the Taplin mobilizer. The period of 
sustained pressure should be approximated one minute. This 
will leave the lesion in better physiological repose after re- 
duction and mobilization. 
1. Reduce fixation by directing force at 
right angles to the planes of the articu- 
lations upon the transverse processes of 
the lower of the two vertebrae entering 
into the fixation. Arthrodial movement may not 
be desired at the time, other than physiological 
movement, which will tend to normalize arthrodial 
motion, and is compatible to the joint planes. If 
the first basic principle is not desired, then 
The Taplin 
Table: 
The Principles 
of Osseous 
Adjustment: The Osteopathic Spinal Lesion 
63 
2. Restore arthrodial movement by directing force 
against the vertebra in lesion to its full limit par- 
allel to the planes of the articulation in the direc- 
tion opposite to that of the fixation. This necessi- 
tates physiological locking or some form of anat- 
omical locking. 
3. Reduce fixation and restore arthrodial movement 
by combining both of the above principles. 
4. Secure deep mobilization after the reduction of 
the lesion together with an elimination of deep tis- 
sue anomalies so as to leave the joint in the best 
physiological state possible. 
Taplin chart with arrows indicating the direction at which force must be applied 
to be at right angles to the planes of the articulations. 64 
Downing Principles and Practice of Osteopathy 
Physiological 
Locking: 
Is not necessarily physiological movement 
as carried out by the individual dynami- 
cally, but rather the utilization of such a 
movement or series of movements as will tend to physiologi- 
cally (articularly) lock the spine in the particular area and in 
the particular plane and direction in which the corrective 
force is to be applied. It is not a locking by forced tension of 
tissues. This principle may, or may not be taken advantage 
of, depending upon the type of technique used. It must not, 
however, be confused with physiological movement, as physi- 
ological movement is designed to give the greatest range of 
articular motion possible and reaches a point of limitation 
through forced tension of tissues rather than through 
articular locking. Physiological locking is designed rather to 
limit the possibility of excessive articular movement, that ad- 
justive forces may in no way produce injury. Physiological 
movement carried to its full completion is, as has hereinbe- 
fore been mentioned, a forced locking by tissue tension. The 
capsular ligament is particularly strained thereby and if 
direct adjustive force is applied in the same direction in which 
the joint has been carried, it is apt to be torn or injured; 
whereas physiological locking carries the joint to a point of 
articular locking without undue strain on soft tissues. 
In a general way physiological locking is obtained by 
primary side-bending and secondary reverse rotation. 
is just what the term implies. It is not a 
locking by the physiology of joint move- 
ment, as is physiological locking, but 
rather an enforced locking through some inherent or directly 
incidential anatomic factor. It may be the result of a certain 
definite physiological movement, or an anatomically applied 
fixation such as will tend to lock the spine for leverage, ad- 
justive or protective purposes. It may be called upon in the 
use of certain specialized forms of adjustive technique. 
Two particular examples of this type of locking are cited: 
Anatomical 
Locking': The Osteopathic Spinal Lesion 
65 
(1) Lumbar flexion—the degree of which will determine 
locking to any desired point in the lumbar column. 
It is an anatomical locking by forced tension for 
leverage purposes. 
(2) Thoracic extension—This is an anatomical locking 
due to limitation, arrived at through the bony con- 
tact of the lower border of the inferior articular 
facets of the vertebra above against an indenta- 
tion on the lamina of the vertebra below. 
(1) Direct action technique. This is a 
form of technique in which the entire ad- 
justive force used is applied to some por- 
tion of the vertebra in lesion as the objec- 
tive. There may or may not be prepara- 
tory physiological movement along the 
plane where the corrective force is to be applied 
for the purpose of locking adjacent vertebrae 
and creating counter-resistance above and below 
the lesion, that the corrective force may be effec- 
tual. Physiological locking is primarily protective. 
It is secondarily a locking and at the completion 
of the locking it becomes immediately and auto- 
matically transformed into leverage force. “Tak- 
ing the slack out,” is essentially an incorrect term, 
as forced tension of tissues will do that, without 
any obvious physiological locking. 
(2) Indirect action technique: This is that form of 
technique in which the force of gravity, muscular 
leverages, resultant forces, anatomical locking or 
fixation above or below the lesion by means other 
than physiological locking are used. 
The physician should adjust in such man- 
ner that he will catch the articulation un- 
awares,—in other words, he should act at 
Osseous 
Technique May 
Be Divided Into 
Two General 
Classes: 
Timing 
Adjustment: 66 
Downing Principles and Practice of Osteopathy 
the psychological moment when the patient is at the great- 
est point of relaxation. He should demand physiological re- 
laxation by enforcing pacificity and partial relaxation on the 
part of the patient. The psychological value of a positive 
attitude on the part of the physician cannot be emphasized 
too greatly. The patient cannot assume anything but a nega- 
tive attitude growing out of the mere fact that a passive and 
relaxed physical state is demanded of him. This gives the phy- 
sician a tremendous advantage. He must dominate the patient 
and his own technique as well. It might be added that this pe- 
cular receptive state of the patient is not only of immense 
value to the physician in the application of his technique, but 
it opens a vast field for psycho-therapeutics and suggestive 
therapy. 
The objective should be the point of greatest leverage on 
the vertebra in lesion. Avoid long leverages as much as possi- 
ble, as they are awkward, faulty, and uncertain. Short lever- 
ages are specific and more easily controlled. 
The point of contact is the anatomical part of the patient 
through which the corrective force is applied. It may be the 
transverse processes, spinous process, etc. 
The instrumentality of force is that part of the physi- 
cian’s body through which the corrective force is applied. It 
may be the thumb, the pisiform bone, the hypothenar 
eminence, combined thumb and index finger, etc. 
The applied force is the thrust. The velocity should be 
high, but the amplitude of motion slight. 
The question will arise as to what form of technique to 
use. That depends upon the underlying pathology, the 
psychology of the patient and the objective to be gained. Many 
factors enter into its determination. The author has made it 
a rule to never utilize more than a certain amount of force 
and velocity, and never to the point of conscious hurt to the 
patient, or possible injury. The physician should have many The Osteopathic Spinal Lesion 
67 
diverse forms of adjustment for the same lesion, making it 
possible to shift from one type of technique to another. No 
human agency can explain why certain forms of technique or 
types of adjustment will work very successfully in one case 
and not in another. It may be due to some peculiar structural 
variation in the patient. To reduce articular fixation de- 
mands a minimal amount of physical force. Assuming an 
articular facet of the spine in fixation, more or less glued 
tightly by exudative debris, it is easy to visualize that force 
directed parallel to the plane surfaces will necessarily need to 
be greater than that delivered laterally. As a matter of fact, 
force applied at right angles to the planes of the articulations 
must encounter a minimum of resistance. Indeed, much less 
force is necessary to accomplish a breaking of the fixation 
than in either of the two methods mentioned above. In the 
old, chronic lesion which is more or less subject to pathological 
changes, and generally unprepared to meet the emergency of 
joint mobility, due caution must be exercised. Its joint sur- 
faces may be subject to a rheumatoid arthritis and arthrodial 
movement paralleled to the planes of the articulation, by the 
law of friction, will cause increased irritation and further 
pathology. Merely breaking the fixation, allowing nature to 
reassume her reparative function for a time before attempt- 
ing to restore full arthrodial motion to the joint, is usually 
productive of better permanent results. 
Inasmuch as these conditions are of con- 
siderable importance in handling joint 
pathology, they will be briefly discussed. 
The Nature and 
Character of 
Arthritic and 
Rheumatoid 
Conditions: 
It must be borne m 
mind at the outset 
that focal infection plays a role in relation to these conditions. 
However, too great emphasis should not be placed on what 
Etiology: 68 
Downing Principles and Practice of Osteopathy 
has within the last few years become too radical a procedure 
in medical therapeusis. 
Exposure to cold and wet, affecting the oxidative func- 
tions, as shown by the lowering of the dissociation curves of 
hemoglobin for oxygen, and concomitant decreased sugar 
tolerance are important factors. 
Basal metabolism is usually lower than normal. The 
renal function will show a slight lag in elimination of water, 
salt and nitrogen; not sufficient to consider it causative but 
rather a more or less secondary disturbance. At best it acts 
only as a predisposing element. 
Arthritis shows a lowering of sugar tolerance in direct 
proportion to the severity of the disease (high blood sugar). 
This is indicative of a disturbance of oxidative or combustive 
changes. It is the direct antithesis of diabetes in the matter 
of sugar metabolism; in fact, arthitis in this condition is very 
unusual. 
The blood supply of the affected joints is inherently poor. 
In fact, they receive no blood to speak of and are almost en- 
tirely dependent upon synovial fluid, which lacks the active 
blood elements upon which nutrition and metabolism depend. 
This is easy to understand when we realize that the same 
volume of blood carries approximately forty times as much 
oxygen as plasma. 
In gout the level of uric acid in the blood stream is high, 
as may also be noted in certain types of nephritis. Cereal 
gout is caused by too heavy a carbohydrate diet, (potatoes, 
cereals, etc.,) and is really a sugar intolerance rather than a 
true pathognomonic form. There is undoubtedly a nervous 
factor in gout; an imbalance between the sympathetic proper 
and the parasymphathetics. The purins, which are derived 
from nucleic acids, are converted into uric acid as an end 
product of metabolism. In the joint cavities of the gouty indi- The Osteopathic Spinal Lesion 
69 
vidual there is a precipitation of fine, needle-like crystalline 
bodies consisting largely of sodium biurate. 
The role of the internal secretions in these disorders, 
particularly those of the thyroid and suprarenals, is im- 
portant because of their indirect control of oxidative pow- 
ers; likewise the pituitary, by reason of its influence on sugar 
metabolism. 
Any factor which will cause a heightened 
rate of metabolism is of benefit. Osteo- 
pathic treatment should be directed to this end. Massage, 
hydrotherapy, heliotherapy, Bier’s hyperemic treatment, ex- 
ercise, fasting (being careful to avoid acidosis), taking pains 
to assure active eliminatory processes, vigorous passive move- 
ments of the joints in some cases, and supportive treatment 
for a time in others, are all valuable. Osteopathic treatment 
should be administered to secure an increase in the internal 
secretory functions of the suprarenals, thyroid and pituitary 
body. Certain authorities even go so far as to induce fever 
by injection methods so as to bring up the rapidity of the 
rate of metabolism. Because a joint surface may be par- 
tially destroyed is no contra-indication to vigorous passive 
movement, as this will reactuate natural processes which will 
tend to re-form a good functioning joint. A strict dietary re- 
form is absolutely essential on the part of the patient. 
1. Cervical region. Transverse process 
of the atlas is felt midway between the 
mastoid process and the angle of the jaw. 
2. The spine of the axis is the first 
prominence below the occiput in the median line. 
3. The spines of the third, fourth, and fifth cervical verte- 
brae are felt with the patient supine. 
4. The sixth cervical spine feels like a small tubercle over- 
lapping the seventh. 
Treatment: 
Bony Landmarks 
of the Normal 
Spine: Downing Principles and Practice of Osteopathy 
70 
5. The spine of the seventh cervical (vertebra prominens) 
is easily felt but is sometimes confused with the spine of 
the first dorsal. Strong flexion of the cervical column 
causes forced flexion of the seventh cervical and brings 
its spine into greater prominence than it does the first 
dorsal. In the normal position the spine of the first 
dorsal is slightly more prominent. 
Place one finger transversely across the lower re- 
gion of the back of the neck, bend back the cervical 
spine. The spinous process of the seventh cervical will 
be felt underneath the finger. 
6. The transverse processes of the cervical vertebrae may 
be palpated as follows: 
(a) Posteriorly and to each side the posterior tubercles 
of the transverse processes can be felt. 
(b) Anteriorly and to either side the anterior tubercles 
of the transverse processes can be felt by pushing 
back the belly of sterno-cleido-mastoid muscle. 
1. The transverse processes of the thor- 
acic vertebrae are situated at the level of 
the spine above and about one inch to the side. 
2. The first thoracic spine is the most prominent in the 
region. 
8. The spine of the third thoracic is on a line drawn through 
the roots of the spines of the scapulae. 
4. The spine of the seventh thoracic is on a line drawn 
through the inferior angles of the scapulae. 
5. The eleventh thoracic vertebra is considered as the 
middle of the spine. 
6. The dorso-lumbar and cervico-thoracic junctions are 
weak points of the spine because they are the dividing 
points for muscular origins and insertions. 
Thoracic Region: The Osteopathic Spinal Lesion 
71 
1. The first lumbar spine is on a level 
with a point an inch and a half below the 
ensiform cartilage (same level as pyloric orifice of the 
stomach.) 
2. The third lumbar spine is usually on a level with the 
umbilicus. 
3. The fourth lumbar spine is on the same level as the crests 
of the ilia. 
4. The transverse processes of the lumbar vertebrae lie half 
an inch higher than the highest point of the same spine. 
Lumbar Region: 72 
Downing Principles and Practice of Osteopathy 
CHAPTER III. 
THE VERTEBRAL COLUMN. 
Each vertebra, excepting the atlas, is composed essenti- 
ally of three parts; a body and two lateral portions. The 
vertebral column, including the sacrum and coccyx, is the sum 
aggregate of the vertebrae in natural order. The column pro- 
tects the contents of the vertebral canal, affords attach- 
ments to important muscles, supports the head and serves to 
protect the viscera and furnishes points of attachment for 
their supporting structures. 
The vertebral column increases in size from above down- 
ward and is pyramidal in form. Viewed from in front the 
superimposed bodies present three pyramids. The first is 
formed by the cervical vertebrae from the second to the 
seventh, inclusive. The bodies of the lumbar and lower nine 
thoracic vertbrae from another pyramid which is much 
longer. An intermediate one, short and inverted is formed 
by the first three dorsals. A fourth, which is also short and 
inverted, is formed by the sacrum and coccyx. 
A profile view of the column presents four curves, two 
primary and two secondary. The first or cervical is convex 
anteriorly. The primary thoracic is much longer and larger 
and is convex posteriorly. The lumbar curve is convex an- 
teriorly and ends abruptly at the sacro-vertebral angle. Last 
of all is the primary pelvic curve, which corresponds to the 
shape of the sacrum, and is convex posteriorly. 
Dorsally the column presents a median and two lateral 
rows of processes. The median row comprises the spinous 
processes and the lateral rows the transverse processes. 
Functionally the mechanics of the vertebrae conform to 
three demands. They must adapt themselves so as to support 
the head, present motion between their individual segments 
and allow for group motion. The head rests directly upon The Vertebral Column 
73 
the lateral portions of the atlas and the weight is conveyed 
through the occipital condyles to the lateral portions of the 
atlas. The weight is then conveyed through the superior 
articular processes to the bodies of the vertebrae with the 
exception of a portion which is deflected to the lateral masses 
of the remaining cervical vertebrae and through them to the 
bodies of the dorsal and lumbar segments. Thus there are 
two perpendicular weight lines in the cervical column: one 
directly through the superior articular facets of the axis to 
the bodies of the vertebrae; and another passing downward 
from the same point through the columniform articular re- 
gion of the cervical vertebrae to the dorsal region, where it 
merges with its fellow to pass through the bodies of the verte- 
brae which now sustain the weight of the superincumbent 
mass. Although the spinal column proper is subdivided into 
three subordinate pyramids, the whole column, in a general 
way presents a cone, whose base is somewhat more than 
double the diameter of its apex. This disposition of parts 
gives rise to a structure of great strength and which is well 
adapted to the special demands made upon it. The degree of 
motion between any two vertebrae is great importance in 
the study of the mechanics of the vertebral column as any 
indisposition of one segment leads to disruption and inco- 
ordination of the whole. 
Group movement is dependent upon and proportionate to 
the special demands made upon it. Pressure and traction can 
mould the bodies, the intervertebral discs, and the articular 
processes to any desired shape, so that the correlation of the 
weight of the body and muscular action may cause the verte- 
bral column to assume one of a number of curvatures, if these 
forces are abnormal. This is a matter of accommodation to 
the forces mentioned. 74 
Downing Principles and Practice of Osteopathy 
Profile of a normal spine. The Vertebral Column 
75 
Equilibrium: 
The efforts of an individual to maintain 
the upright position and balance himself 
resolves itself into the maintenance of an antero posterior 
and a lateral equilibrium. Having assumed bipedism, man’s 
weight falls through the long axis of the spine, which is at 
right angles to that for which it is mechanically best adapted. 
The added difficulties for maintenance of the erect position 
can be well demonstrated by Ashmore’s table, giving a corn- 
resolves itself into the maintenance of an antero-posterior 
with that of the human. 
Quadruped. 
Horizontal 
Four limbs 
Large 
Low 
Moderate 
Swung between 
supports 
Ribs fall into 
expansion 
Ribs pulled up 
At right angles 
Small 
Man. 
Upright 
Two limbs 
Small 
High 
Large 
Disposed in line of 
weight 
Ribs pulled up and 
thorax expanded 
Ribs fall 
In long axis 
Great 
Spine 
Support 
Base 
Superstructure 
Mass supported 
Thorax 
Inspiration 
Expiration 
Viscera carried 
Muscular effort neces- 
sary to maintain 
balance 
Antero-Posterior The weight of the head is borne on the 
Equilibrium: condyles of the occiput and a perpendicu- 
lar line let fall from this point should pass 
through at those points where the spinal curves merge into 
one another. This line should fall through the extreme an- 
terior edge of the promontory of the sacrum and from this 
point through the astragaloscaphoid joint so that with the 
use of the least amount of muscular exertion the occiput 
and atlas lie vertically above the astragaloscaphoid joint. 
If any part of the skeleton lies in front of this perpendicular 
line, it must be counterbalanced by a deflection posteriorly 
of some other portion. 
The foot is the primary base of support with the indi- 
vidual standing. A vertical line passing through the center 76 
Downing Principles and Practice of Osteopathy 
of gravity must fall within its base of support and maximum 
stability is assured if it falls midway between the anterior and 
posterior pillars of the foot constituted, respectively, by the 
heads of the first metatarsal bones anteriorly and the tuber- 
osity of the calcaneus posteriorly. This point is the astragalo- 
scaphoid joint which is the highest level on the arch, immedi- 
ately in front of the ankle joint, from which the weight is de- 
flected anteriorly and posteriorly, respectively, to the heads 
of the metatarsals and the calcaneus. In the normally erect 
posture the center of gravity falls slightly in front of the cen- 
ter of motion of the hip, the ankle and the knee joint. Hyper- 
extension of the hip joint is prevented by the iliofemoral liga- 
ment and hyper-extension of the knee by the posterior, lat- 
eral, and crucial ligaments. Muscular effort is required of the 
posterior cervical musculature to hold the head erect as the 
greater weight of the head is anterior to the condyles and 
the musculature of the back of the legs must contract slightly 
to prevent dorsiflexion of the ankle. 
The curves of the spine are such that the first or cervical 
curve begins at the top of the odontoid process and terminates 
at the middle of the second dorsal vertebra. It has its con- 
vexity in front and forms eighteen degrees of a circle, whose 
radius measures six and five-eighths inches. Its most prom- 
inent anterior point is the forepart of the body of the fourth 
cervical vertebra. The second or thoracic curve begins at the 
middle of the second and terminates at the middle of the last 
dorsal vertebra. It has its concavity forward and forms 
forty-two degrees of a circle whose radius measures twelve 
and two-eighths inches. Its most prominent point posterior- 
ly is the dorsal edge of the body of the seventh or eighth seg- 
ment. The third or lumbar curve begins at the middle of the 
last dorsal and terminates at the lower end anterior edge of 
the last lumbar vertebra. It is convex anteriorly and forms 
eighty degrees of a circle whose radius is five and three- 
eighths inches. The fourth or pelvic curve, more acute than 
any of the others, begins at the upper edge of the sacrum and The Vertebral Column 
77 
terminates at the top of the coccyx. It forms one hundred 
twenty-five degrees of a circle whose radius is two and five- 
eighths inches. The degrees of curvature is not uniform, but 
is greatest a little below the middle. A direct line from the 
superincumbent weight of the head passes through the odon- 
toid process and points of confluence of the spinal curves 
where they run into and support each other. It falls through 
the anterior edge of the promontory of the sacrum in its 
continuance downward. Normally this line passes in front of 
the fifth to the ninth vertebrae, inclusive, and consequently 
leaves the greater portion of the dorsal curve behind the line 
of gravity. Compensation for this deflection is provided for 
in the secondary cervical and lumbar curves, the directions of 
which are reversed. 
If the line of gravity is disturbed antero-posteriorly, bal- 
ance can be so disrupted and equilibrium become so unstable 
that it is lost. Gravity then predominates and the body will 
fall unless supported. This holds true if a perpendicular line 
through the center of gravity falls so far from the center of 
the arch of the foot as to pass forward or backward beyond 
this base of support. When the spine is partially involved a 
primary curve will result. It may be fully compensated for 
by a secondary one. Involvement of the lower limbs will 
ensue only if compensation is incomplete, in which case flexion 
or extension of the hips will be necessary to complete the com- 
pensation. If the primary condition is gross and the first two 
steps are not sufficient so that compensation is still incom- 
plete, then the vertical line will not pass through the center 
of the base of support but in front or behind it, as the case 
may be. 
No matter what the disturbing factor or factors, any 
agency or influence which directly or indirectly disrupts the 
architectural integrity of the vertebral column must of 
necessity be compensated for. If this does not occur the spine 
and its associated osseous elements will speedily cease to func- 
tion mechanically, and equilibrium will thereafter be seriously 
impaired or lost entirely. 78 
Downing Principles and Practice of Osteopathy 
Arrows point out an eleventh dorsal vertebra immobilized in flexion. 
Spinal extension of the lower dorsal column is restricted, the postural equation is 
bad and associated gastro-intestinal disturbance and ptosis are present. This 
lesion is undoubtedly a responsible factor for the visceral condition. The Vertebral Column 
79 
In ordinary bending forward the anterior projection of 
the head and upper portion of the trunk in front of the center 
of gravity is counter-balanced by the increased posterior pro- 
jection of the hips and lower portion of the trunk. The verti- 
cal line through the center of gravity cuts through the base 
of support and equilibrium is maintained. When the spine is 
extended the body inclines backward. Any considerable de- 
gree of extension at the hips is prevented by its ligamentous 
control and, if hyper-extension is great enough so that the 
center of gravity falls behind the base of support of the foot, 
equilibrium is lost and gravity predominates. If the body is 
inclined forward so that the vertical line through the center 
of gravity is in front of the base of support of the feet, then 
equilibrium is likewise lost. 
When the hip joint is diseased flexion usually results as 
hyperextension is prevented by the iliofemoral ligament. The 
center of gravity is therefore forward. A secondary lordosis 
follows in the lumbar region. The knees may become flexed 
and if both compensations are not sufficient, added sup- 
port in the nature of crutches may be used. Hyper- 
flexion of the hip is common in coccyalgia and con- 
genital luxations of the hip, causing incidentally an 
increase in the pelvic inclination. Increase in the 
dorsal curve or kyphosis, and increase of the lumbar curve, 
lordosis, are apt to be found together, one compensating the 
other. The etiology of this type of spine is usually confined to 
causative factors above the pelvis and does not involve the ex- 
tremities. Lordosis is compensatory to prevent the center of 
gravity from going too far forward, and kyphosis prevents 
it from going too far backward. 
In the upright position the center of gravi- 
ty falls midway between the ankles of the 
two feet. The fact that there are two 
points of support adds to stability. In standing, the weight 
is transmitted from the promontory of the sacrum to the 
Lateral 
Equilibrium: 80 
Downing Principles and Practice of Osteopathy 
femoro-sacral arches with some deflection through the pos- 
terior sacro-iliac ligaments to the hip joint. It then passes 
downward through the long bones of the leg to the astragalus. 
Lateral equilibrium is maintained by muscular force except 
when symmetry is perfect or a position of rest assumed. Lat- 
eral movement is confined largely to the subastragaloid joint, 
which allows of lateral movement, and to the hip joint which 
allows of both abduction and adduction. A position of rest 
is possible in which there is lateral movement so that the cen- 
ter of gravity falls on one leg which is kept extended. This 
allows the opposite hip to descend and the leg to flex both at 
the hip and knee. This lateral movement is a position of rest 
and with the exception of a slight amount of muscular effort 
in the lumbar area and thigh, very little muscular energy is 
involved. The accommodation is mostly taken care of in the 
hips and in the position of the legs and its control is largely 
ligamentous. In lateral flexion of the spine a perpendicular 
line through the center of gravity shifts from the midline to 
the side toward which the trunk is inclined. To restore equili- 
brium the hips are inclined to the opposite side so that the 
center of gravity may be brought midway between the ankles. 
If the deviation of the lower part of the torso is compensated 
for by a deviation of the upper part to the opposite side, equili- 
brium will be stable from the pelvis down, providing the cen- 
ter of gravity is still in the midline. If the curve is double 
and confined to the spinal column, such as that found in or- 
ganic curvature when the primary curve is completely coun- 
terbalanced by the secondary curve, there is no lateral shift- 
ing of the pelvis or shift at the mid-point between the ankles. 
If the primary curve is not completely compensated by the 
secondary curve there is a deflection of the pelvis and maybe 
some shift in the mid-point between the ankles. Shortening 
of one limb produces the same effect as the lengthening of the 
opposite one as it causes a pelvic tilt carrying the lower part 
of the spine with it, with the convexity of the lumbar curve 
toward the same side as that of the tilt. There may be a sec- The Vertebral Column 
81 
ondary compensatory curve above carrying back to the mid- 
line a double “S” curve. 
A curvature which originates in the spine is not accom- 
panied by tilting in the pelvis if spinal compensation is com- 
plete while the lateral curvature depending upon shortening 
of the leg is characterized by tilting of the pelvis. In lateral 
movement, if a perpendicular line passing through the center 
of gravity falls lateral to the midpoint between the ankles, 
equilibrium is unstable. If it falls outside of this base of sup- 
port, equilibrium is lost and gravity predominates. This 
occurs providing the forces of counterbalance are not suffici- 
ent. Extra supportive measures may make up for its defici- 
ency. A slight degree of lateral curvature, convexity toward 
the right, is found in the dorsal area in right handed individ- 
uals—due presumably to the greater use made of the right 
arm. Left handed individuals may show the opposite type of 
curve. 
The spine is a curved, segmented, weight- 
bearing rod, balanced by muscular action 
and dependent upon a definite normal relation of the parts 
one to another. Balance is reflex and instinctively dependent 
upon the automatic correlation which exists between the 
muscular system and the mental sense of balance and equili- 
brium. The living individual is continually overcoming the 
positions induced by gravity by assuming the position of bal- 
ance. The sense of equilibrium overcomes the force of grav- 
ity. Balance must be maintained both in the dynamic and the 
static state. When in motion the position of the bones is 
controlled largely by the muscles while at rest the bones are 
controlled by the ligaments. Whether in a state of motion or 
at rest the superincumbent weight is constant, although sub- 
ject to rapid shifts as regards its points of bearing when the 
body is active. Due to the constant shifting of weight forces 
a continuous adjustment to a constantly varying position of 
the line of gravity is necessary. The nicety of balance and 
Balance: 82 
Downing Principles and Practice of Osteopathy 
equilibrium must not be lost, otherwise disability or deform- 
ity may result from the excessive points of strain and stress 
developed. Ligamentous stretching and weakening, muscular 
fatigue and impairment will secondarily develop and still 
further aggravate the disorder. 
With the body erect the feet are the basis of support, with 
the pelvis acting as a secondary base; while in a sitting pos- 
ture the pelvis is the sole basis of support. In the former the 
weight is transmitted from the base of the sacrum through 
to the acetabula, thence through the long bones, and in the 
latter to the tuberosities of the ischia. 
The pelvis is made up of two main arches 
which are known as femoro-sacral and 
ischio-sacral, and is further strengthened by two secondary 
arches which link up the extremities of the main arches still 
further to immobilize and strengthen them. The femoro- 
sacral arch passes upward from one hip joint crossing the 
middle of the sacrum, which is the keystone, and then 
passes downward to the opposite hip joint. The weight is 
transmitted through this arch with the patient standing, pass- 
ing from the center of the base of the sacrum in a zigzag 
manner to the heads of the femora. From the sacrum it is 
first deflected downward and outward to the posterior sacro- 
iliac ligaments and then outward and forward to the heads 
of the femurs. The secondary strengthening arch is formed 
by the rami and bodies of the pubic bones passing downward 
and anteriorly from one hip through the pubes upward 
and backward to the opposite hip joint. 
The stability and structural integrity of this arch and its 
accessory reinforcement in front are dependent absolutely 
upon the sacro-iliac ligaments behind and the cartilaginous 
interval in the symphisis pubis in front. 
The Pelvis: The Vertebral Column 
83 
Section of pelvis showing the suspensory action of (he sacro-iiiac ligaments. 
The ischio-sacral arch passes upward from one tuberosity 
of the ischium through the sacrum, which is the keystone, 
down to the opposite tuberosity. This arch allows the super- 
incumbent weight to be transmitted from the base of the sac- 
rum through the ilia and bodies of the ischii to the tuber- 
osities when the patient is sitting. The subsidiary strengthen- 
ing arch passes forward from one tuberosity through its 
ramus and the descending ramus and body of the pubis 
through the symphysis pubis and on through the opposite 
ramus of the ischium to the tuberosity of the ischium of that 
side. 
It is then obvious that the femoro-sacral and its subsidiary 
arch constitute a mechanical protection acting with the pati- 
ent upright. The ischio-sacral and its secondary arch act 
when the patient is sitting. 
The cerebellum is the largest portion of 
the rhombencephalon. It lies in the in- 
ferior fossae of the occipital bone and is 
separated from the cerebrum by a fold of 
dura mater, the tentorium cerebelli. It is divided into two 
The Nervous 
Mechanism 
of Balance: 84 
Downing Principles and Practice of Osteopathy 
hemispheres, connected by a central lobe, the vermiform proc- 
ess. It is composed of grey matter externally and white mat- 
ter internally. The grey matter consists of four general types 
of cells found in three layers. From within outward the 
molecular layer contains stellate cells; the layer of Purkinje 
contains cells of Purkinje and Golgi type 2 neurons; the 
granular layer consisting of granule cells. 
The white matter consists of the association and projec- 
tion system; the association system connecting various 
regions of the cerebellar cortex, and the projection system 
connecting with certain structures in the cerebrum, pons, 
medulla and spinal cord. The afferent fibers come from a 
variety of sources, particularly through the dorsal spino- 
cerebellar fasciculus, (direct cerebellar tract), the superficial 
ventro-lateral spino-cerebellar fasciculus (Gower’s tract) 
and perhaps from the spino-olivary nucleus. 
The nuclei of the cerebellum are in the central core of 
white substance. There are four pairs, known as the dentate 
nucleus, the nucleus emboliformis, the nucleus globosus, and 
the nucleus fastigii. The ventral vestibulo-spino-fasciculus 
(Lowenthal’s tract) is one of the main descending conduction 
paths for nerve connections for equilibrium in Dieter’s, the 
vestibular nerve, and the nuclei fastigii in the cerebellum 
and medulla. A certain number of fibers pass down through 
the intermediate fasciculus or mixed lateral zone. The func- 
tions of the cerebellum are largely confined to the coordina- 
tion and harmonizing of such muscular action as is necessary 
to maintain equilibrium during station or progression. All 
movements of this character are primarily volitional but from 
repetition gradually come to be performed independently of 
consciousness and are classified as acquired or secondary 
reflexes. It is therefore obvious that where the simple lower 
reflex arc is not sufficient for readjustment of the body posi- 
tion, a complex higher reflex arc is developed through the 
cerebellum and associated structures and that it does not The Vertebral Column 
85 
necessarily involve consciousness. A lesion of one hemisphere 
will cause lack of harmony and coordination for the opposite 
side of the body. Partial compensatory mechanism is located 
in the cord, pons, medulla and cerebrum. Disease will cause 
muscular tremors, vertigo, opisthotonos and pleurothotonus 
which make standing or walking difficult. The coordinating 
mechanism is largely reflex through its afferent connections 
with cutaneous, muscular, optic, vestibular and associated 
end-organs. They all indirectly connect with cerebellar struc- 
tures. The efferent nerves indirectly connect with the gen- 
eral musculature of the body and mediate thereby such influ- 
ences as are necessary to maintain equilibrium. 
Lateral curvature may be divided into two 
gross types: functional and organic. Or- 
ganic curvature, or scoliosis, is a confirm- 
ed curvature maintained permanently in a position which no 
normal spine can assume. It may be congenital or acquired 
as malformation of bone from a congenital source may be a 
primary cause. Acquired organic curvature may be one of 
two varieties, the first being that type which is produced 
without passing through an intermediate postural stage, such 
as those associated with bone diseases like rachitis, etc., or 
muscular atrophy as in infantile paralysis. Those curvatures 
which pass through an intermediate postural stage, primarily 
belong to the functional type but later through neglect, poor 
treatment and resultant bony and soft tissue changes after 
a period of time become organic. 
The postural or functional curvature is characterized by 
habitual inability to stand correctly. It is, moreover, capa- 
ble of elimination ,which is not true of the structural type. It 
consists of a swerve to one side with only slight appreciable 
rotation of the bodies of the vertebrae. It is found most often 
from the eighth to the tenth dorsal with its greatest deviation 
at this point and the curve usually to the left. The functional 
movement which approaches nearest to that of organic curva- 
Lateral 
Curvature: 86 
Downing Principles and Practice of Osteopathy 
ture is the flexion side-bending-rotation movement in the 
thoracic area in which the bodies of the vertebrae rotate to- 
ward the convexity. There is none of the deformity, however, 
which characterizes the organic scoliosis. With the exception 
of this functional movement all other functional curvatures 
are characterized by a rotation of the body of each vertebra 
toward the concavity of the curve in contradistinction to 
organic curvature in which the bodies of the vertebrae always 
rotate markedly to the convexity of the curve. 
“Every change in the formation and func- 
tion of the bones or of their function 
alone is followed by certain definite changes in their internal 
architecture and equally definite secondary alterations of 
their external conformation in accordance with mathematical 
laws. Plasticity of bone, particularly in children, implies 
structural changes in the vertebrae and adjacent structures.” 
Although a flexible straight rod can be bent either an- 
tero-posteriorly or laterally without torsion, a curved rod 
cannot be bent laterally without twisting or torsion and con- 
sequently all lateral curvatures are characterized by rota- 
tion of the bodies of the vertebrae to a greater or lesser de- 
gree, depending upon the nature and extent of that curvature. 
The mechanism of transition from func- 
tional to structural curvature may be 
summed up as the result of constant 
super-incumbent weight, and abnormal transmission of 
that weight with resultant weakening of the under- 
lying structure. When the causative factor is mus- 
cular, traction is of importance, as for example, in 
infantile paralysis where one group of muscles is paralyzed 
and the pull of the opposite group unopposed. In children, 
where the bones are more or less plastic, the result of these 
abnormal points of weight bearing over a long period of time 
will lead to compressive changes in the bones themselves. If a 
Wolff’s Law: 
Organic 
Curvature: The Vertebral Column 
87 
bone is diseased or abnormally plastic, as is the case in rachitis, 
its shape may be modified in a short space of time. The 
rapidly growing adolescent must accommodate himself to a 
very rapid shift in balance. This inherent instability leads 
to muscle-fatigue and muscle-fatigue to postural curvature 
which may develop into organic curvature, providing condi- 
tions are in accord. The age, sex, size, development, nutrition, 
and posture should be noted for their etiological significance 
and bearing on the condition. Joint pathology, abnormal 
muscular influences, fractures, luxations, adhesions, drain- 
age, scars, etc., which cause alterations in the muscu- 
lar or bony symmetry must be carefully noted. The general 
physical condition of the body and faulty habitual posture are 
indirect influences. The presence of diseased conditions must 
be carefully noted and their mechanical influence, if any, 
taken into consideration. A good example of such a diseased 
condition having a marked influence is empyema in which rib 
resection is followed by some collapse of that side of the 
thorax with marked adhesions, which is a direct mechanical 
force of disturbance. Chronic appendicitis may cause a child 
to bend toward the side of disturbance and curvature will re- 
sult. In the indolent or rachitic child improper clothing, 
errors of refraction, defective hearing or some disturbing in- 
fluence less gross in character may be sufficient to produce 
curvature of an organic type. Because of the structure and 
mechanism of the spinal column, this guiding influence is 
such that when the spine is laterally inclined torsion of the 
flexible rod must take place and with only one exception, that 
rotation is controlled in such manner that it must be toward 
the concavity of the curve. If the lateral inclination becomes 
constant the line of transmission of superincumbent weight 
is laterally deflected from its normal central situation, bring- 
ing abnormal stress upon the vertebrae involved. Muscles and 
ligaments become weakened by this persistent strain to which 
they are subjected. The effect is such that after compression 88 
Downing Principles and Practice of Osteopathy 
of the intervertebral discs and associated soft tissues, the 
bodies of the vertebrae attempt to rotate out from under the 
superincumbent weight and toward the convexity of the 
curve. Providing concomitant structural changes take place 
in the vertebral bodies, articular processes, intervertebral 
discs, the ribs, and associated soft tissues, permanent rota- 
tion of the bodies of the vertebrae away from the line of stress 
follows. This rotation is proportionate to the amount of 
structural change; and the rapidity of the process is depend- 
ent entirely upon the time required to provoke the structural 
changes. Scoliosis may vary in degree from slight asymmetry 
to pronounced distortion. The nature and amount of abnor- 
mal weight distribution will, by the character of its strain and 
stress, determine to a greater or lesser degree the transfor- 
mation which the joints and bones must undergo. The de- 
formity established is conpensatory for the changed position 
of the superincumbent weight and the altered trans- 
mission of its gravity line. 
Further, it is a well established fact that a scoliotic spine 
may and usually does present a variety of clinical pictures in 
the course of years. Not only does the total curve very fre- 
quently change to a compound type, but in addition structural 
curves modify the body outline often by the addition of com- 
pensatory curves. Generally speaking, however, such later 
variations are but exaggerations of earlier structural abnor- 
malties. 
There is no hard and fast rule by which these changes 
come about. Each individual is a law unto himself. Every 
patient, therefore, must be examined and classified in the 
light of his own peculiar pathology and regarded from that 
standpoint alone. The Vertebral Column 
89 
c 
D 
A 
B 
E 
E 
B 
% 
C‘ 
D 
Diagramatic representation of the changed position and 
contour of the ribs and vertebra in organic curvature. 
The altered functional demands must be satisfied and 
the structural metamorphosis must, with the greatest econ- 
omy of effort and materials, satisfy this intrinsic demand and 
yet afford a maximum of strength and stability. 
The scoliotic spine shows characteristic structural 
changes. The bodies are wedge-shaped, particularly where 
the curve is the most acute, due to the marked compression 
on the postero-lateral border of the convex side. The spinous 
processes are deflected toward the concavity of the curve. 
The articular facets become altered in their directions and 
aspects according to the extent of the lateral deviation of the 
bodies of the vertebrae. In the lumbar area they may assume 90 
Downing Principles and Practice of Osteopathy 
a very oblique direction. In the dorsal area they may be so 
far depressed toward the abdominal cavity that they cannot 
be felt by external examination, while those on the convexity 
of the curve project backward and in very severe cases may 
rise approximately to the level of the apices of the spinous 
processes. In the dorsal area their crowding together re- 
sults in an increased size of the articular processes on the 
side of the concavity and a decrease on the convex side. The 
deviation in the position of the transverse processes is ex- 
tremely important from a diagnostic point of view and will 
enable the physician to diagnose a curvature in the lumbar 
region in cases where no lateral deviation of the spinous proc- 
esses exists. The ligaments on the concave side are shortened 
and thickened and on the convex side are stretched, thinned 
and atrophied. The muscles of the back become atrophied 
from disuse, due to the rigidity and fixation associated with 
the curvature. This is particularly true on the convex side 
as secondary fibrotic changes frequently occur in the muscles 
on the concave side. 
The angulation of the ribs is correspondingly changed. 
They are crowded together on the concave side with straight- 
ening of their angles but abnormal increase of the curves of 
their shafts, and with less obliquity of position. The ribs on 
the convex side are widely separated with a concomitant in- 
crease in the acuteness of their angles, with considerable pos- 
terior projection and with a lessening of the normal curves 
of the shafts. 
Lumbar scoliosis presents less deformity, due principally 
to the fact that rotation is slight in the lumbar area. The 
changed contour of the waist-line, presence of an apparently 
larger hip, together with a series of palpably prominent 
transverse processes on the convex side is significant that 
lumbar curvature is present. Evidence of its organic nature 
can then easily be elicited. 
Total scoliosis of an organic type is usually transitional The Vertebral Column 
91 
and is characterized by a high shoulder on the convex side 
with changes in the lower ribs; and it varies from the func- 
tional in that it is a confirmed deviation into deformity and 
not capable of total elimination. 
Dorsal scoliosis is characterized by the greatest deform- 
ity. The line of spinous processes is not a true indicator as to 
the amount of rotation present in the vertebral bodies as the 
bodies in organic curvature move farther from the midline 
than do the spines. 
The more common type of scoliosis is the compound 
curvature. In a period of years the total curve may change 
to the compound type. This is due to the fact that eventually 
the compensatory curve becomes organic. There are several 
clinical types and in probable frequency of occurence they 
are; compound, dorsolumbar, dorsal, total, lumbar and cer- 
vicodorsal. 
The dangerous age for scoliosis is between 8 and 16 and 
the onset is insidious. Pain, if any, is localized in the back 
and is probably due to muscular and ligamentous strain. Gen- 
eral symptoms are usually constant. The viscera, happily, 
can usually accommodate themselves to the alterations in the 
shape of the thorax and spine without any particularly notice- 
able disturbance. Possible pressure-effects exist and their 
consequences may be such as to cause pressure upon nerve fi- 
bers, lessen respiratory capacity, possibly displace the heart 
and crowd down upon the abdominal contents. The effect 
upon the ribs is such that occasionally anemia, of a costo- 
genetic type, may secondarily develop. If marked muscular 
rigidity, abnormal temperature, localized tenderness, and the 
hot-water test are negative, the possibility of certain com- 
plications is thereby eliminated. X-ray shows the character- 
istic deformity. Rachitis must be ruled out as early as pos- 
sible. This condition usually occurs between the ages of 4 
and 6 and its onset is insidious. The child will give a rachitic 
history and characteristic anomalies may be noted. 92 
Downing Principles and Practice of Osteopathy 
Functional 
Curvature: 
Any prolonged alteration in the relation- 
ship normally existing between the axis of 
the shoulders and the axis of the hips is 
functional curvature, providing that curvature is capable of 
elimination. Functional curvature is an habitual inability to 
stand correctly and is a type of curvature which any normal 
spine can assume. It is a partial immobilization in lateral 
flexion or rotation. The etiological factors depend upon the 
maintenance of faulty posture, either occupational or hab- 
itual, particularly during the period of growth. It may re- 
sult from anatomic deviations elsewhere, as follows: pelvic 
asymmetry, femoral inequality, with either Bryant’s line or 
the shaft short, or both, pathologic variations of the verte- 
brae, or pathologic involvement of the extremities such as 
flat feet, diseases of the hip or knee, or of the soft parts. The 
most frequent curve is the long left lateral. In the purely 
functional scoliosis, pathologic involvement of the extremi- 
ties or of the spine or pelvis is rarely concerned as they are 
usually accompanied by a structural curve. Flat foot is a 
common source of the functional type. The shortening of 
Bryant’s line may be due to congenital or acquired dislocation 
of the hip, abnormality of position of the acetabulum, coxa 
vara from fractures of the neck of the femur and congenital 
and acquired anomalies of the angle of the neck of the femur. 
Slight shortening or lengthening of this line may also be due 
to slight subluxation of an innominate. Shortening of the 
line from the greater trochanter to the external malleolus 
may be due to shortening of the femoral shaft, excessive bow- 
ing of the tibia, shortening of both femur and tibia, or unusual 
size and development of the opposite trochanter. 
Functional curvature occurs in all areas and is named ac- 
cording to the convexity of the curve and the area wherein 
found. It may be cervico-dorsal, dorsal, dorsal-lumbar or 
lumbar. It may be total postural, in which case it is a single 
curve and may be of sufficient length to involve both the The Vertebral Column 
93 
lumbar and dorsal areas through their greater extent. 
Transition to a double or organic “S” curve may follow. 
Differential diagnosis between functional 
and organic curvatures may be summed 
up as follows: 
Diagnosis of 
Lateral 
Curvature: 
Functional. 
No deformity. 
Capable of elimination. 
High side is upon the concavity 
of the curve. 
Organic. 
Deformity. 
Not capable of elimination. 
High side is upon the convexity of 
the curve. 
The procedure of examination should first include a 
thorough routine physical search for any obvious cause for 
scoliosis. A very careful history should be taken to ascertain 
the a priori relationship of early influences. The occupation 
should be carefully noted as well as the habits, posture and 
general functional conduct of the patient. 
The respective levels of the shoulders and hips should be 
determined together with any lack of general symmetry in 
the body outline such as lateral displacement of the trunk, 
increased prominence of the hip or scapula. Notations should 
be made of any osteopathic spinal defects or sacro-iliac 
anomalies. Sacro-iliac subluxations should be noted if present 
before any attempt is made by measurement to ascertain the 
length of the lower extremities. 
Measurement of the lower extremities should be con- 
ducted as follows: by first measuring the distance from the 
anterior superior spines to the internal malleoli and compar- 
ing them. Following this measure from the greater trochan- 
ters to the external malleoli. If inequality is present the first 
measurement indicates it and the second measurement deter- 
mines whether it is below the greater trochanter or not. To 
still further substantiate the second finding, Bryant’s line 
should also be determined, for by this means structural or 
pathological involvement and variation of position of the head 
and neck of the femur and acetabulum can be noted. 94 
Downing Principles and Practice of Osteopathy 
Determination should be made as to whether or not the 
curve disappears, is materially lessened, or is not changed 
with a support under one foot, or with the individual lying 
down and bent forward in flexion. If a curvature exists, the 
area of affection should be noted and the presence of a high 
side, whether upon the concavity or convexity. With the pati- 
ent standing and a plumb-line erected from the cleft between 
the buttocks and the top of the spinal column, any lateral 
deviation of the spine can be noted as well as its associated 
structures, such as, for example, the relative distance of the 
scapulae from the sagittal plane. 
Correct posture is a fundamental neces- 
sity for there is unquestionably an a priori 
relationship between postural defects that develop early in 
life and spinal and visceral disorders that sooner or later 
make their appearance. The physician of today, regardless 
of his school or specialty, should not neglect this important 
phase of human welfare. 
The correct posture for both child and adult is to stand 
with the the head up, chin in, chest up and out, but not stiff 
or puffed out, shoulders up, abdomen in, legs straight and feet 
forward so that the body inclines forward slightly. The object 
of this bearing is to distribute the weight so as to effect the 
greatest economy of effort. MacDonald of Boston empha- 
sizes that the individual, to obtain correct posture, must stand 
erect with an effort and at the same time have the arms and 
shoulders hanging loosely. He further adds that by attempt- 
ing to “stand tall” one develops control and by this continuous 
efficiency determines his own expenditure of effort. 
With the chest full, but not restricted, the dome of the 
diaphragm is high allowing plenty of space for the abdominal 
viscera and with no abnormal strain or tension of their in- 
trinsic supportive tissues. With the abdomen in, effective 
support is supplied by the strong abdominal musculature. 
Conservation of energy is assured with the acquisition and 
Posture: The Vertebral Column 
95 
maintenance of correct posture. The body thus represents a 
highly efficient mechanism, capable of the greatest activity 
with the least expenditure of energy. By increasing resist- 
ance to bodily ills, it is an adjuvant source to natural im- 
munity. 
Bad posture is the opposite. The head is flexed, the shoul- 
ders stooped, the chest sagged down and narrowed, and the 
abdomen protrusive. In this type of postural defect lumbar 
lordosis follows and the knees become hyper-extended and the 
feet tend to pronate and flatten. The chest cavity is con- 
tracted and the dome of the diaphragm is lowered so that 
there is decreased space for the abdominal viscera, which are 
in turn pressed downward. The upright position under such 
circumstances is maintained only by constant muscular effort 
and this excessive muscular contracture affords a loop-hole 
through which much energy is lost. Defective posture is one 
of the greatest single factors, if not the greatest, for the pro- 
duction of excess muscular contraction. The end result of 
postural defect is muscle fatigue and circulatory congestion, 
both in the muscles and viscera. Activity upon the part of 
the child so afflicted will diminish reserve energy needed for 
developmental welfare. 
The causes of postural anomalies may be divided into 
two groups: congenital and acquired. In the congenital causes 
are placed defects of development in children. The tall, slen- 
der child is particularly susceptible to postural defects and 
secondary visceral disorders as they usually have a long 
mesentery which adds to the tendency to visceroptosis. 
Children with lax or atonic muscles and loose joints are prone 
to bad posture. Under acquired causes come distortions of the 
lower extremities and pelvis, femoral inequality, knock-knees, 
bow-legs and pronated or flat feet. The end-result of these 
conditions is a tilting of the pelvis. An associated compensa- 
tion for some of these conditions may produce a secondary 
lordosis, prominent abdomen, narrow chest, round shoulders, 96 
Downing Principles and Practice of Osteopathy 
etc. Occasionally scoliosis may be the end-result. There is an 
added tendency to ptosis by reason of the lack of abdominal 
muscular support and the associated strain and weakening of 
the intrinsic visceral supportive tissues. The symptomatology 
is characteristic and is based upon muscle-strain, fatigue and 
early gastro-intestinal symptoms. Muscle-strain and fatigue 
manifest themselves in leg, knee and foot ache and in a gen- 
eral feeling of fatigue and lassitude. Nervousness and irriti- 
bility, restlessness at night, lack of concentration, and poor 
scholastic progress are other characteristic symptoms. 
The ptosed stomach and sagging, kinked intestines may 
produce a variety of symptoms as a result of improper and in- 
complete evacuation of the stomach contents and because of 
the drag on the duodenum with partial blocking of drainage 
from the bile ducts. This will cause gastric attacks with 
nausea, vomiting and fever. The ptosed and kinked large in- 
testine does not permit proper elimination of bowel contents 
and this leads finally to chronic constipation. The latter con- 
dition is followed by an associated intestinal toxemia and 
when the accumulative effect of this reaches a certain point, 
acute gastro-intestinal attacks take place. This type of tox- 
emia more or less explains the reason for cyclic vomiting. 
Malnutrition is usually marked and the child is frequently 
considerably under weight. Rachitis must be looked for as a 
large percentage of these cases either have a tendency toward 
or definite signs of rickets. Some authorities have called at- 
tention to the fact that there is an intolerance for fat in most 
of these cases and as it is a food element which is particularly 
important because of the nature of its vitamin content, and 
because of the relative prevalence of rickets it must not be 
overlooked. Diet is therefore a very important factor in the 
treatment. Functional albuminuria is frequently noted in 
children with lordosis and poor posture. 
Fatigue is an inseparable companion to poor posture and The Vertebral Column 
97 
their inter-relation is such as to establish a vicious syndrome 
of cyclic activity, fatigue aggravating poor posture and 
poor posture aggravating fatigue. Another claim to exces- 
sive fatigue is the compensatory increase of neuro-muscular 
circuit-impulses necessary to maintain the upright position 
under such conditions. This leads to nerve-tire. 
The treatment of these cases falls under three heads: 
diet, general care and correction of the underlying structural 
defects, and exercise. Osteopathic treatment is necessary for 
two reasons: first, to build up the patient’s general physical 
tone and secondly to change the relation of parts which have 
a direct bearing on the postural defect and at the same time 
to rehabilitate the neuro-muscular mechanism which is con- 
nected with spinal muscular co-ordination. It is needless to 
say that imbalanced muscular tensions are consistent and con- 
stant associates of the spinal subluxation. Adjustment of the 
subluxation will abolish the abnormal reflex initiating this 
muscular contracture so that automatic control of spinal co- 
ordination will ensue. Renewed coordination of the spinal 
muscles without the continual conscious control of the patient 
is a distinctively osteopathic result of spinal adjustment. In 
correcting deformity, restriction of apparatus as much as 
possible is desired. 
If rickets is present a diet with a high fat content and 
cod liver oil is indicated to promote the utilization of calcium. 
Exercises should be carefully given, their object being to 
tone up and educate to proper action the musculature of the 
entire body. Special attention, however, should be paid to 
those muscles that preserve the erect position and work 
against gravity. The muscles which are most concerned in 
holding the erect position are the abdominal muscles, muscles 
of the shoulder girdle and the gluteal muscles. Exercise 
tolerance must be carefully noted; and in dealing with the 
child exercises at first should be given daily in recumbency. 98 
Downing Principles and Practice of Osteopathy 
At the end of two weeks the correct standing position should 
be taken up and the child instructed how to maintain it. Ex- 
ercises with carefully timed periods of rest should be con- 
tinued until the child can stand correctly without support. In- 
struction is given to the parents so that the less complicated 
exercises may be given at home. The child should report at 
intervals for examination and supervision should be main- 
tained until results are apparently permanent. 
In the adult caution should be exercised as regards ordi- 
nary calisthenics and gymnastic procedures. Special exer- 
cises should be designed for the special needs of the case. Ex- 
ercise should be so given as never to interfere with the 
respiratory function and to strengthen the muscles involved. 
MacDonald of Boston advances reasons why the ordinary 
methods of physical culture have failed in many cases. He 
states that the ideal exercise is the one which automatically 
involves movement with unconscious cerebration. The initia- 
tory process takes place in the lower reflex and is thereafter 
transmitted to the upper cerebellar neuron for mediation of 
control. He states that it is better to cultivate along the line 
of instinct as reliable for body-control, instead of the prevail- 
ing methods, which have failed because they are founded on 
volitional control of body-movements which should be auto- 
matic. Encourage exercise which does not have the object in 
mind of carefully scrutinized and performed volitional move- 
ment but rather which cultivates the animal instinct of un- 
conscious cerebration, maintaining that exercise in a natural 
rather than an artificial sphere. Cultivate the animal instinct 
for stretching, complete relaxation and play. 
There is more than a grain of truth in the above state- 
ments. There is no harder patient to deal with in the realm 
of functional disorders of the neuro-muscular mechanism 
than a gymnast, the individual who has placed in the sphere 
of conscious cerebration constantly scrutinized and volition- 
ally controlled movements which would have been better left 
to automatic development. Such an individual cannot lose The Vertebral Column 
99 
sight of his neuro-muscular reactions and therefore limits 
his possibilities of relaxation, complete power over which is 
lost. 
In a study of the neuro-muscular mechanism of equili- 
brium, we first note that there is a simple reflex, quick to 
intercept impulses and act upon them. This we term the 
lower neuron. Coordination, however, is dependent upon the 
upper neuron and without adequate upper neuron-control, 
impulses of the lower neuron can develop to any degree from 
tension to spasticity. There are two routes of impulses for 
mediation of control and coordination. One is through the 
cerebellar tracts to the cerebellum and the other through the 
cerebro-spinal tracts to the cerebrum. The latter is the tract 
of voluntary control and the former that of unconscious con- 
trol, although both may work hand in hand. The more com- 
plicated the instruction and complex the movement, the less 
opportunity there is for automatic control and the greater is 
the conscious cerebration. If unhampered, the biological 
tendencies can assert control, and the individual should not 
consciously build up obstacles to the unconscious working of 
a perfect neuro-muscular mechanism which he can only im- 
perfectly duplicate and, at best, only interfere with. Exer- 
cise must be handled in an intelligent fashion and from a 
neuro-muscular point of view. 
Functional curvatures may be grossly di- 
vided into two types: those involving the 
antero-posterior equilibrium and those in- 
volving lateral equilibrium. 
Antero-posterior curvatures may be such that the nor- 
mal curves are accentuated. Such a type of curvature is 
characterized by lordosis of the lumbar and kyphosis of the 
dorsal areas. This sort of a condition leads to a symptom- 
complex with a history of backache and, in the older adults, 
there are occasional evidences of a rheumatic diathesis. The 
Types of 
Functional 
Curvature: 100 
Downing Principles and Practice of Osteopathy 
curves are more pronounced in persons who exercise the body 
greatly and in those who are accustomed to carry weights on 
the head. It may be secondary to a flexion lesion of the sa- 
crum or bilaterally posterior innominates. Congenital dis- 
location of the hips may be due to lordosis of the lumbar 
area and a frequently secondary dorsal kyphosis. In these 
cases the pelvic inclination will be greater. This line is 
drawn from the lumbo-sacral angle to the upper border of the 
symphysis pubis and represents the relation it bears to the 
horizon. The lumbo-sacral angle is more acute. In the 
sthenic type barrel-chest may be noted, while in the asthenic 
individual or one suffering with general muscular debility, 
round shoulders and sunken chest are usually present. Indi- 
viduals suffering from this type of spine are usually clumsy, 
walk heavily and most generally complain of backache. The 
fatigue syndrome is usually pronounced and the individual 
may show neurotic tendencies. Endogenous toxemias, par- 
ticularly in the form of a rheumatic diathesis, are commonly 
associated. 
In the kyphotic spine the swerve is generally backward 
and the spine may be partially or considerably involved in this 
posterior curvature. This type of curvature is found in old 
men, where a flattening of the vertebral discs presents a 
curve from pressure. Rheumatic gout may cause this con- 
dition. The condition is such that the dorsal and lumbar 
spines usually form one convexity backward. This condition 
is physiologically a persistence of the infantile position. The 
cervical area may be carried into exaggerated extension. 
Atonicity of the extensors is particularly evident, the sacrum 
is usually in extension and the innominates are bilaterally an- 
terior. The knees and hips are usually chronically flexed to 
compensate for the spinal defect. Careless and faulty posi- 
tion, both in sitting and standing, such as for example, the de- 
butante slouch in young girls and the common slouching posi- 
tion while sitting, particularly of men sitting in the so-called 
“easy chair,” over-weighting of the shoulders with heavy The Vertebral Column 
101 
Demonstrating, on the Halladay spine, dorsal flexion. It is interesting to 
note the considerably greater range of movement possible in flexion, in contra- 
distinction to that of extension. It must be borne in mind, however, that the ribs 
limit any great degree of motion in either direction. 102 
Downing Principles and Practice of Osteopathy 
clothing, heavy pendulous breasts, too rapid growth, over- 
work, bad air and poor hygiene are factors which are respon- 
sible for such a condition. 
The lordotic spine is apt to be compensatory to prevent 
the center of gravity going too far forward. This anterior 
curvature is concave forward and is sometimes known as 
“saddle back.” It is often found in pregnant women and very 
fat men with “pot belly.” Congenital dislocation of the hips 
will cause a secondary lordosis. Pseudo-hypertrophic par- 
alysis will do the same. 
Lythospondylosis or willowly spine is a hypermobile spine 
in which excessive mobility is the paramount feature. It is 
usually found in tall, slender young girls and boys and accom- 
panied by poor muscular and ligamentous development. Func- 
tional curvature is apt to develop from its presence. Peculiar 
idiosyncrasies of the muscles with marked elasticity of their 
fiber-element and muscle-fibers, which are abnormally long, 
give the appearance of a long muscle with a decreased diam- 
eter of the belly. The ligaments are long and stringy. Such 
a condition is a developmental defect. In the treating of any 
such condition, exercise tolerance must be carefully checked 
up and resistant exercises should be given to build up the 
spinal musculature, keeping always well within their capacity. 
Sterospondylosis is a chronic condition of the spine in 
which hypomobility is the paramount feature. It is usually 
associated with postural anomalies, and is commonly kyphotic 
in character. Chronic toxemia, either endogenous or ex- 
ogenous, is frequently a positive feature. It is commonly as- 
sociated with rheumatic and rheumatoid conditions, and oc- 
casionally with hypertension so that a mistaken diagnosis of 
arteriosclerosis may be made. Proof of this mistake is that 
after partial breaking up of this rigidity the blood pressure 
will immediately drop without the added aid of other thera- 
peutic measures or a special dietary regimen. Treatment 
should be designed to remove the rigidity by deep mobiliza- 
tion. For this purpose use the Taplin table and mobilizing The Vertebral Column 
103 
apparatus. Passive stretching and forcible correction of the 
very rigid areas should be attempted, providing there is no 
bone pathology to contraindicate this procedure. Posture is 
usually involved and therefore these defects must be elimi- 
nated. Corrective gymnastics are indicated in some cases, 
supportive treatments in others. The physician should not 
neglect to examine for the presence of focal infections, 
rheumatic or gouty diatheses. 
The straight spine is that type of spine in which the nat- 
ural curves are decreased. There is straightening of both the 
dorsal and lumbar curves. Such a type of spine is usually 
associated with poor muscular development, and the patient 
suffers from the general effects of the postural disorder. 
Military training is particularly apt to develop this type of 
spine. It is especially prone to lateral swerves as the spine 
in these particular cases is inherently weak, although the de- 
formity is very apt to be overlooked as it is not particularly 
obvious. The American youth is particularly prone to this 
postural defect, especially those whose physiques are not 
strongly developed. 
In disturbances of antero-posterior equilibrium, the 
curvatures produced thereby are apt to be associated with 
scoliosis. 
Fundamentals of treatment should consist as much as 
possible in overcoming the etiological factors. Careful osteo- 
pathic supervision and treatment and corrective gymnastics, 
if necessary, also supportive treatment are indicated. The 
etiology demands a complete analysis of the patient’s mode 
of living, personal hygiene and sanitation, diet, occupation, 
habits, posture, hereditary and structural influences. 
The patient should first be instructed in 
the fundamental standing position. If 
possible the pelvis should be fixed during 
exercise, otherwise it acts as a free agent and movement be- 
Corrective 
Exercises: 104 
Downing Principles and Practice of Osteopathy 
comes general and not specific. Fixation will enhance the 
value of exercise and there will not be any lost and ineffec- 
tual movements. Lovett advises the use of Bade’s apparatus. 
Exercise No. 1.—From the fundamental standing posi- 
tion the patient stretches the whole spine upward, keeping 
heels firm on the ground. With deep inspiration and con- 
comitant elevation of the shoulder girdle the muscles which 
maintain the proper erect position, particularly the extensors, 
are called upon and the elevated fixed position of the shoulder- 
girdle maintains a fixed point for the pull of the inspiratory 
muscles. At the end of deep inspiration, expire and relax to 
the fundamental standing position. This exercise tends to 
produce a general stretching of the spine. 
Exercise No. 2.—From the fundamental standing posi- 
tion the shoulders are raised as in Exercise No. 1. The pati- 
ent inspires and bends the trunk forward to the horizontal 
position, maintaining the spine straight and the shoulders 
raised. Movement is confined to the hip joints. From this 
position he returns to the upright posture with the shoulders 
still raised and the spine straight and from this point relaxes 
to the fundamental standing position. 
This movement has the corrective value of Exercise No. 
1 and is a good extensor spinal exercise with the lumbar curve 
straightened. It is of value in cases with a tendency to ex- 
aggeration of the lumbar curve. It may be modified and 
strengthened by having the patient place the hands behind his 
neck with elbows held back as far as possible. This raises the 
center of gravity of the trunk and increases the power of 
the leverage effect. 
Exercise No. 3.—From the fundamental standing posi- 
tion the patient flexes until the trunk is horizontal, the arms 
maintained at the sides and the elbows flexed. The hands are 
held together against the chest wall. Inspire and extend the 
arms upward beside the head. Describe a half circle with the 
arms outward and back to the sides of the body. Expire as The Vertebral Column 
105 
the arms return to position. This is a valuable means of 
strengthening the spinal extensors and overcoming flexible 
round shoulders. 
Exercise No. 4.—The patient lies prone on the table with 
the spine straight. He then clasps his hands behind his back 
on a level with the lumbo-dorsal area. The elbows are flexed 
and the clasped hands rest against the spine. He forcibly 
hyperextends the torso, meanwhile extending the arms and 
elbows backward and keeping the hands interlocked. This 
exercise is especially adaptable to round shoulders and, by 
raising the center of gravity, tends to counteract kyphosis of 
the dorsal area. It may be reinforced by dumb-bells or other 
paraphernalia. 
Exercise No. 5.—With the patient lying supine on the 
table and with the head, trunk and legs straight and the feet 
strapped, he attempts with his arms folded across the chest 
to rise to the sitting posture, with the spine stiff and not 
allowed to flex. After completing this first move he returns 
to the primary position in the same manner with the spine 
still stiff and the base of the head touching the table before 
the back. This effectually exercises all of the abdominal 
musculature. 
Exercise No. 6.—The patient lies supine and a weight is 
placed at the head of the table. The patient extends his hands 
above his head, parallel to the torso. He grasps the weight 
and carries it up to right angles with the body and table. He 
then carries it back slowly to the table. This is of value when 
the general toning up of the spinal musculature of the dorsal 
area is desired. 
Flexible types of curvature are best treated by gymnas- 
tics. Supportive or retentive measures, however, may be 
necessary to maintain the correct position between treat- 
ments. Resistant cases must be first made flexible by osteo- 
pathic measures, manual stretching, gymnastics, forcible cor- 
rection and stretching in apparatus after which the condition 106 
Dotvning Principles and Practice of Osteopathy 
must be maintained in the improved position as would be the 
case in the flexible type. If the shoulders are held forward 
by contraction of the soft parts, forcible correction may be 
necessary. In the milder cases, postural re-education, simple 
gymnastics, and easy, passive stretching may be sufficient. In 
the more severe cases, after forcible correction, a jacket 
should be applied to maintain the improved position. 
Abdominal support is occasionally necessary when the 
abdominal muscles are particularly lax and the gastrointes- 
tinal disturbance correspondingly great. Support should be 
applied only long enough for the abdominal muscles to short- 
en and recover tone. They should be so applied that the pres- 
sure diminishes from below upward. 
The use of supports should be limited to those cases in 
which the lax muscles and general asthenic state of the pati- 
ent is such as to not enable them to hold the erect position 
between treatments. It is also necessary after forcible cor- 
rection to retain what is gained as these resistant cases fre- 
quently cannot maintain improvement between treatments. 
Organic or structural scoliosis presents 
the problem of first eliminating partially 
or completely the deformity and, second- 
ly, of retaining the ground gained. The age, amount of de- 
formity, special physical characteristics and the state of 
health of the individual patient are all factors which must be 
given careful attention. Remedial attention must be paid to 
the underlying causes to prevent scoliosis from becoming 
greater and to retain the advantages gained at the end of 
the treatment. 
Treatment of the curvature itself depends upon whether 
or not any permanent advantage can be gained by forcible 
correction, although every effort should be made to prevent 
its further progress. 
Treatment of 
Scoliosis: The Vertebral Column 
107 
Ordinary gymnastics are usually more harmful than 
beneficial and should be used judiciously. The reason for this 
is that the spine is rendered more flexible and this breaks 
down nature’s protective barrier. The splint-like rigidity and 
stiffening of the affected region, which is always associated 
with curvature, is a supportive measure and, if eliminated, the 
spine may readily sink into a worse position and the curve 
become increased, providing preventive measures are not in- 
voked. The atrophy of spinal muscles present in scoliosis of 
the organic type is more or less dependent upon the rigidity 
which is a direct inhibitant to muscular development. To- 
gether with correct manipulative and supportive treatment, 
carefully regulated exercises are of value in the treatment of 
curative types of organic curvature as the increased flexi- 
bility facilitates muscular development. It must be always 
kept in mind, however, that flexibility must never be obtained 
unless the physician is sure that he can control it to a bene- 
ficial end. 
E. G. Abbott offers a fundamental mechanical foundation 
for the correction of curvature. Many modifications have 
been brought out since but his fundamental principles have 
not been altered. Flexion of the spine is the keynote of the 
treatment as in this position the vertebrae are unlocked and 
side-bending-rotation is then possible. This latter movement 
will carry the bodies of the vertebrae to the convexity of the 
curve. They must, however, be maintained in this position 
until sufficient bony changes of a normal character have 
taken place to retain the advantage gained. Partial correc- 
tion primarily is secured by placing the patient in an Abbott 
frame, applying bandages which can be pulled in various di- 
rections and thereafter applying a plaster of Paris jacket 
with proper paddings underneath. To do this, the patient 
lies in a hammock or canvas swing in the Abbott frame. The 
pelvis is immobilized by bandages made fast to the frame on 
the side of the convexity. The low shoulder is raised and the 
concavity lengthened by a bandage encircling the axilla and 108 
Downing Principles and Practice of Osteopathy 
attached to the head of the frame. Another bandage against 
the convex side of the curvature is made fast to the frame on 
the concave side. With the patient immobilized in the position 
of flexion in the hammock and by an additional pull exerted 
by the tightening of the bandage, partial correction results. 
Following this the patient is immobilized in a plaster of Paris 
case with pressure pads so applied as to secure rotation of the 
vertebra. The maximum degree of pressure is brought to 
bear upon the angles of the ribs on the convex side with coun- 
ter-pressure over the ventral aspect of the ribs on the side of 
the concavity. Windows or openings are cut in the cast in 
the reverse position to that of the pressure points, or in other 
words, over the angles of the ribs posteriorly on the concave 
side, and diagonally across on the convex side anteriorly. This 
allows respiratory action to take place in such a way as to 
cause the ribs to regain their normal position and shape. Main- 
tain the cast until such time as is necessary to obtain over-cor- 
rection. This is accomplished by means of felt pads slipped 
under the jacket to increase the pressure over the desired 
points. After over-correction has been obtained, a celluloid 
or other supportive jacket is worn to maintain this readjust- 
ment and exercises are then indicated to restore muscle func- 
tion. This treatment applies to those cases of scoliosis for 
which definite and permanent results can be obtained. The 
types most amenable to treatment are the simple forms, par- 
ticularly those with total curvature. In double scoliosis each 
curve may be treated singly and independent of the other al- 
though the primary curve, which is usually the dorsal one, 
should be treated first, and the secondary or compensatory 
curve will disappear unless organic changes have taken place. 
When combined with kyphosis the curvature is much 
harder to eliminate unless flexion can be obtained beyond that 
held in the curvature. 
Osteopathic treatment should be assidously given with 
the purpose in mind of obtaining greater flexibility and of 
building up the general tone of the patient. The Vertebral Column 
109 
Pott’s Disease: This condition, which was first described 
by Pott, is charactesized by an angular 
curvature and is usually due to a tubercular infection of the 
vertebral bodies. Its onset is insidious and it most frequently 
attacks children, particularly between the ages of 4 and 6, 
who have a tubercular predisposition. There is, however, no 
age limit. It more frequently involves the dorso-lumbar re- 
gion than any other Syphilis, cancer, acute osteomyelitis, ex- 
anthematous fever, or trauma are casual influences. 
When tubercular, the intervertebral disc is usually first 
involved and is secondarily followed by a tuberculous osteitis. 
It may extend to other vertebrae or, more rarely, other por- 
tions of the same vertebra. The superincumbent weight bear- 
ing down upon the partially destroyed, softened and diseased 
vertebrae and discs produces the characteristic angular de- 
formity. The patient is sickly and loses weight, is easily 
fatigued and very irritable. He complains of vague pains, 
usually referred to the anterior part of the abdomen. He 
walks in a peculiar manner in order to hold the back stiff and 
prevent motion. The affected area is very painful. Faradism 
or the hot water test causes pain. Muscular rigidity is exces- 
sive. There is a tendency to night cries and to secondary ab- 
scess development. Temperature is usually present although 
the rise is rarely over one degree. The deformity is charac- 
teristic and x-ray will show the focus of infection in the spine. 
Treatment consists of rest, plenty of fresh 
air and sunshine, a careful dietary re- 
gimen and special supportive apparatus to maintain im- 
mobilization of the affected region in a position of extension. 
Prolonged recumbency may be necessary to obtain satisfac- 
tory results as ambulatory treatment frequently fails. Albee’s 
method of bone-transplantation is valuable and may be used 
as the results are quite uniformly satisfactory. 
Treatment: 110 
Downing Principles and Practice of Osteopathy 
This disease is an ostearthritis of the 
spine, characterized by excess bone for- 
mation causing the vertebrae to become 
ankylosed. The borders of the vertebral bodies are most fre- 
quently affected but any portion of a vertebra may be at- 
tacked. It may attack an individual at any age. There is 
usually a total kyphosis of the spinal column with persistent 
pain and tenderness. The amount of rigidity present is 
usually out of proportion to the amount of muscular rigidity. 
In fact, because of the pressure on the nerve roots, muscular 
atrophy frequently follows. The nerve involvement is fre- 
quently pronounced and may be such as to produce ascending 
degeneration of the cord. 
Typhoid spine is an aftermath of typhoid 
fever with tenderness of the spinal column 
and rigidity of the musculature. The patient is subject to 
periodic exacerbation of temperatures. The pain may be 
general or localized. It may be in the nature of a general 
aching or it may be such that it is felt only on motion, or 
both. Prognosis for recovery is good. 
A majority of authorities also describe 
certain border-line conditions which do 
not easily fall into any of the above classi- 
fications. Among them are to be noted the following: 
Hysterical spine, encountered in hysterical individuals 
and characterized by a dull, chronic ache which is occasionally 
sharpened to pains of a neuralgic character. The entire dorsal 
area of the body, especially in and near to the midline, is 
markedly hyperesthetic. There is usually some noticeable 
lumbar deformity, and the thoracic spine may present a 
swerve as well. There may or may not be a history of trauma. 
Treatment is for the most part constitutional, although man- 
ipulation designed to overcome the deviation, if any, is also in 
order. 
Spondylitis 
Deformans: 
Typhoid Spine: 
Neurasthenic 
Disturbances: The Vertebral Column 
111 
Neurotic spine resembles the above condition closely ex- 
cept that it is not complicated by hysteria. It occurs usually 
during adolescence and is most often encountered in females. 
The patient with such a spine complains of a constant, tired 
feeling and of a continual ache in the sub-occipital and lumbo- 
sacral regions. Occasional exacerbations of sharp, shooting 
neuralgias are also described. Physical examination discloses 
a distinct round-shouldered picture, and the entire spine ap- 
pears atonic and weak. As in the preceding instance, treat- 
ment is for the most part constitutional. A general toning up 
is indicated and is secured by the employment of careful man- 
ipulative maneuvers, combined with a selected dietetic 
regimen and judicious exercise. Deep breathing is also dis- 
tinctly valuable. It must always be borne in mind, however, 
that treatment is not local but general; and that, while relief 
may be given in a comparatively short period of time, com- 
plete recovery depends absolutely upon a restoration of 
nervous tone and balance throughout the entire body of the 
patient. 
An Aged Spine is also mentioned by some authors. Its 
name is well-nigh sufficiently descriptive. It presents a more 
or less well marked rigidity with a varying degree of kyphosis, 
although the latter, for the most part, is characterized by 
stooped and rounded shoulders rather than by any great 
amount of exaggeration of the thoracic curve. Guarded 
traction, very carefully administered, is the therapeutic indi- 
cation in this connection. Improvement is secured slowly, but 
is possible and fairly certain if persistence and patience are 
had. 112 
Downing Principles and Practice of Osteopathy 
CHAPTER IV. 
OCCIPITO-ATLANTAL SUBLUXATIONS 
The occipito-atlantal articulation is condyloid in char- 
acter and composed of the superior articular facets of the 
Oceipiln atloid. 
Articulation 
Capsular 11$■ <A 
A tic axoidArtUniat ion j 
Section of the occipital bone, the atlas and the 
axis seen from behind, showing the articulation of the 
head with the atlas and the axis. 
atlas together with the condyles of the occipital bone. The 
condyles of the latter are oval-shaped and their articular sur- 
faces are convex from before backward and from side to side. 
They look downward, slightly forward and lateralward. The 
anterior extremities are directed slightly forward and medial- 
ward and therefore converge somewhat. The posterior ex- 
tremities are on a level with the middle of the foramen 
magnum. 
The superior articular facets of the lateral masses of the 
atlas are elongated, large, oval, concave depressions which 
approach each other anteriorly and diverge posteriorly. They Occipito-A tlantal Subluxations 
113 
face upward, slightly medialward and backward to form 
fossae for the reception of the corresponding condyles of the 
occiput. The floor of each facet is deeper at each end with 
a slight elevation in the middle, the isthmus. The peculiar 
conformation of the atlas should not be overlooked, especially 
in that the atlas is without body or spinous processes, (the 
posterior tubercle excepted), but has larger lateral masses 
and prominent transverse processes. 
The vertebral artery and suboccipital nerve (first cervical 
nerve) pass in the groove behind the superior articular facets. 
Important structures in front of the anterior arch and trans- 
verse process of the atlas are from within outward: 
(1) Superior Cervical Ganglion. 
(2) Internal Carotid Artery. 
(3) 10th, 11th, and 12th Cranial nerves (Vagus, Spinal 
Accessory, and Hypoglossal.) 
(4) Internal Jugular Vein. 
Normal movements of the occipito-atlantal articulation 
are flexion, extension, side-bending or lateral flexion. Any 
appreciable degree of rotation is not essentially characteristic 
to this articulation. 
Certain authorities point out that there are sexual dif- 
ferences of the atlas in that the lateral masses and their 
glenoid indices vary. 
There are eleven possible lesions of the 
atlanto-occipital joint. They are tabulat- 
ed in the order of frequency of occur- 
rence. 
1. Unilaterally anterior occiput on the left (torsion 
lesion.) 
2. Unilaterally anterior occiput on the right (torsion 
lesion.) 
Lesions of 
the Occiput: 114 
Downing Principles and Practice of Osteopathy 
Carnhil Canal 
Mid lac for 
ift. riiht - j 
Maiar Sutr 
ft a I r d 
Pad Mitres 
' \ l J'A ' II] 
P a l\ aj t e,'w 
Ant. pa/J 
\fariunah 
Base of the skull, external surface. 
3. Bilateral anterior occiput (extension lesion.) 
4. Left lateral occiput (side-bending lesion to the 
right.) 
5. Right lateral occiput (side-bending lesion to the 
left.) 
6. Bilaterally posterior occiput (flexion lesion.) 
7. Unilateral anterior occiput on the left, posterior on 
right, (pseudo-rotation lesion.) 
8. Unilateral anterior occiput on the right, posterior on 
left (pseudo-rotation lesion.) 
9. Impacted occiput. 
10. Unilateral posterior occiput on right, (torsion 
lesion.) Occipito-Atlantal Subluxations 
115 
11. Unilaterally posterior occiput on left, (torsion 
lesion.) 
.fiiberde 
Oiecfr Zip1"? 
T/ti/i.v 
JivCrsS 
.in!. Tubt-rda 
Atlas seen from above. 
The Anterior By this designation is indicated those 
Grouping: lesions in which either or both condyles 
are fixed in a relatively anterior position 
on the superior articular facets of the atlas. In this grouping 
are included both the unilateral anterior occiput on the right 
and left and the bilaterally anterior occiput. 
Bilaterally The bilaterally anterior occiput is an ex- 
Anterior tension movement on a transverse axis, 
Occiput: wherein the condyles of the occiput move 
bilaterally forward, upward and slightly 
outward on the superior articular facets of the atlas with sub- 
sequent immobilization in this position. The posterior ex- 
tremities of the condyles are at a much lower level than the 
anterior. 
Etiology: The question might arise as to why the 
greater frequency of lesions of the an- 
terior grouping. It is perfectly obvious that from a func- 
tional point of view flexion is a much more abused factor than 
is extension. Whether or not the Darwinian hypothesis is true, 
it is not illogical to accept some conclusions deduced from 
Darwin’s observations. No part of the human body shows 
greater inherent and faulty mechanical adaptability for the 116 
Downing Principles and Practice of Osteopathy 
upright position than the human spine. If it is assumed for the 
moment that in pre-evolutionary days, and when on “all 
fours/’ there was necessity for a much more powerful ex- 
tensor grouping of muscles in the cervical area and the lessen- 
ed necessity for that extremely powerful musculature, con- 
sidering our present-day posture, it is easy to visualize the 
why of the extension lesion. The abuse of flexion is more than 
offset by the fact that the posterior cervical masculature is 
so much more powerful. 
The lack of protection of the special senses of the face 
make the back of the head and suboccipital region more sus- 
ceptible to trauma, wrenches, etc. Forced extension from the 
sudden starting of a car, unexpected stepping down from 
higher levels, etc., are good examples. Reflex contracture due 
to thermal exposure, drafts, etc., to the back of the neck is a 
common cause of lesion. It is associated sometimes with pos- 
tural conditions, especially round shoulders and kyphosis of 
the dorsal area when compensation does not take place in 
the cervical region. (Cervical curve.) Functional abuse as- 
sociated with occupational habitual posture necessitating 
long continued extension—for example painters and paper 
hangers. 
Sub-occipital contractures and tenderness 
are invariably present and bilateral in 
character. The head is held in extension with the chin point- 
ing upward and forward, as this is the position which must 
be assumed in relation to the existing structural condition. 
The posterior arches of the atlas assume greater prominence 
posteriorly and are easily palpated. Restricted motion is 
greatest in the direction of flexion (apparently greater). The 
normal separation of the ramus of the mandible and the outer 
anterior portion of the transverse process is bilaterally in- 
creased, while a corresponding bilateral decrease, or approxi- 
mation, occurs between the outer posterior portion of the 
transverse process and the tip of the mastoid process. The 
Diagnosis: Occipito-A tlantal Subluxations 
117 
tissues surrounding the tips of the transverse processes of the 
atlas are abnormally sensitive. It must be remembered, how- 
ever, that they are more or less sensitive to pressure at all 
times. Disturbance of function and subjective symptoms 
vary. Referred pain (Head’s law) often manifests itself in 
the form of occipital headaches, vague neurotic pains through 
the back of the head and neck and other sensory disturbances. 
If the lesion (occipital) is primary there is a secondary accen- 
tuation of the cervical curve as is also the case when the exten- 
sions are in a hypertonic state. If the occipital lesion is sec- 
ondary there is usually straightening of the cervical curve, 
as an a-priori compensatory relationship exists between the 
two. 
If necessary, relax the suboccipital and 
posterior cervical musculature, previous 
to and following adjustment. Inasmuch as bony subluxation 
is reduced unilaterally by correcting one side at a time, the 
technique for adjustment will be given under adjustment of 
the unilateral lesion. 
The unilateral anterior occiput is a torsion 
lesion. It must be remembered that in nor- 
mal movement the occipito-atlantal arti- 
culation is on a transverse axis: further- 
more, that any torsion movement partakes of the nature of 
rotation, a movement which to any considerable degree is ab- 
normal to this joint. Any movement of a rotary character 
necessitates a vertical axis for rotation. Obviously the only 
portion of the occiput which could perforce act as this axis 
would be the vertically disposed condyle. If one condyle de- 
scribes an arc of motion forward, its fellow, the opposite con- 
dyle must act as the pivotal point or axis for this movement. 
The movement on this side is in the nature of a screwing mo- 
tion of the condyle of the occiput upon the articular facet of 
the atlas, thereby allowing the condyle of the lesion side to de- 
Treatment: 
The Unilateral 
Anterior 
Occiput: 118 
Downing Principles and Practice of Osteopathy 
scribe an arc of motion forward, upward, and slightly medial- 
ward, and become fixed at a slightly higher level. The pecu- 
liar mechanics of this lesion movement must be borne in 
mind as it is of extreme importance from an adjustive angle. 
Trauma, directly or indirectly transmit- 
ted, is a frequent cause, as for example, 
falls, wrenches, etc. Suboccipital contractures may be 
unilateral; or if bilateral, the balance of muscle tension 
may not be equal in their hypertonic state, as one group may 
predominate over the other. It may be counterbalancing for 
some lesion lower in the spine which is disturbing the vertical 
line of gravity—as for example the “twisted” pelvis. It may 
be secondary to such conditions as faulty posture, lateral 
curvatures, unequal muscular tensions, ptosis of the uppey 
eye lid, defective hearing in one ear, etc. 
Unequal muscular tension in the suboc- 
cipital area can usually be detected, 
together with suboccipital tenderness particularly upon the 
anterior or gross lesion side. The posterior arch of the atlas 
on the side of gross lesion will assume greater prominence 
posteriorly, due to the relative anterior position of the occiput 
on that side and the compensatory rotation posteriorly on that 
side of the atlas on the axis. Because of the fixed relationship 
of the occiput to the posterior arch of the atlas, any change in 
their relativity is the most accurate physical finding at our 
command. This finding can best be ascertained by comparing 
the posterior arches with the occiput above and with each 
other. No appreciable change will manifest itself on the 
side opposite that of gross lesion. 
The normal separation between the end of the transverse 
process and the angle of the jaw is increased on the side of 
the gross lesion, while a corresponding decrease or approxima- 
tion occurs between the end of the transverse process and the 
tip of the mastoid. The arc of motion on the opposite side to 
Etiology: 
Diagnosis: Occipito-A tlantal Subluxations 
119 
that of gross lesion is so slight as to hardly produce any pal- 
pable change. The tissues surrounding the transverse process 
upon the side in gross lesion are usually abnormally sensitive. 
In this connection it is necessary to emphasize the point that 
too much importance must not be given to the relationship 
between the mastoid process with the angle of the jaw and the 
transverse process. It is a common cause of error in diagnosis 
for two reasons: first, that the transverse processes of the 
atlas are subject to many variations in size, shape, and posi- 
tion; these structural anomalies render it more or less inac- 
curate; second, the mastoid and the angle of the jaw are not 
fixed points, relatively speaking; hence we are dealing with 
variables. For probable diagnosis, they are of value and 
should be utilized as such; but diagnostic conclusions should 
depend, in the last analysis, upon the fixed relationship of the 
posterior arches of the atlas and the occiput. 
The position the patient’s head assumes in relation to 
the existing structural variation is suggestive. Supine, the 
head in relaxation assumes a slightly extended position and is 
tilted toward the side of gross lesion. Restricted motion is 
more evident on the side of lesion. 
1. Flexion: As lesions of the anterior 
grouping are of the extension type, either 
unilateral or bilateral in character, flexion 
is the antithesis in joint movement. It 
should therefore be used, if possible, not 
only for that reason, but moreover be- 
cause it places the condyle in better me- 
chanical position to slide down the inclin- 
ed plane of the superior articular facets of the atlas. 
2. Side-bending: With side-bending is carried out two 
principles. It gaps the articulation that it is necessary to 
move; and, secondly, approximates the opposite articulation 
which it is desired to have act as a fixed-point axis for rota- 
tion by the laws of compression and friction. 
Principles of 
Adjustment for 
Lesions of the 
Anterior 
Grouping Using 
Occipital 
Leverage: 120 
Downing Principles and Practice of Osteopathy 
3. Fixation of the Arch of the Atlas: It is necessary to 
oppose the direction of the corrective force of rotation by 
fixation of the arch of the atlas on the side toward which 
rotation is made. The reason for this is obvious—when it is 
considered that immediately below the occipito-atlantal artic- 
ulation is the atlanto-axial articulation, constructed for rota- 
tion of the freest character. Rotation is the basis of the ad- 
justment in a joint not normally constructed for that purpose 
and moreover in state of lesion when resistant forces are at 
their highest. 
4. Rotation: The adjustment is completed with rota- 
tion. The bilateral lesion should be dealt with in the same 
manner as the unilateral, except that the procedure is carried 
out bilaterally instead of unilaterally. The reasons for so 
doing are indicated by an illustration. It is assumed that a 
heavy block of granite with a vertically disposed projection 
at either end is lying in an inverted position—this to resemble 
an occiput with its vertically disposed condyles. By applying 
leverage at one end, thereby describing a sufficient arc of 
motion, the block could be unilaterally replaced into a more 
anterior or posterior position. The side opposite to which the 
leverage was applied, would, through the increased compres- 
sion, act as a fixed-point axis. Shifting the leverage to the op- 
posite side the operative mechanics would be reversed and the 
opposite side moved to the desired point. This would constitute 
a bilateral adjustment. In other words—by shifting arcs and 
axes of motion the stone could be moved by one individual 
whereas it would take a group to move it en masse, either 
forward or backward. This illustrates the method of pro- 
cedure in a bilateral anterior occiput. Using the procedure 
for a unilateral anterior occiput on the left followed by that 
for a unilateral anterior on the right, makes it possible to ad- 
just a bilateral lesion with the greatest ease and efficiency. It 
is almost impossible to get sufficient favorable fixation below 
the point of lesion to make bilateral adjustment possible. It 
cannot be done without considerable strain upon the patient Occipito-Atlantal Subluxations 
121 
and possibility of injury, as the operator is in nowise able to 
control accurately or focalize corrective forces. 
For purposes of convenience and clarity of 
procedure the following hypothetical le- 
sion is considered—an occiput unilater- 
ally anterior on the left. The principles of 
adjustment as carried out in order would 
be as follows: 
1. Flexion (easy flexion.) 
2. Side-bending to the right. 
3. Fixation of the arch of the atlas on the left. 
4. Adjust with rotation of the occiput toward the left. 
Technique 1. Patient supine. Operator flexes and side- 
bends occiput to the right, angle of side-bending approximate- 
ly 15 degrees with the midline of the body. He then places 
left index finger, reinforced by middle finger, against the 
posterior arch of the atlas on the left. The left forearm and 
hand rest against the postero-lateral aspect of the head. The 
operator places the palmar aspect of right hand against the 
angle and ramus of the jaw on the right side. Keeping firm 
pressure against the atlas with the index finger reinforce- 
ment, operator rotates occiput toward the left by directing 
right transverse force with left forearm, and left transverse 
force with right hand. (Do not disturb flexion and side-bend- 
ing when completing adjustment.) 
Technique 2. Patient sitting. The mechanical principles 
are the same as are used with patient supine. Operator stands 
at the side of the patient on the same side as the lesion he 
wishes to correct, flexes and side-bends occiput to the right 
to an angle of about 15 degrees with the mid-line of the body. 
The operator cups the patient’s chin in the apex of the flexed 
left forearm, with the fingers of the same hand resting firmly 
upon the vertex of the head. The patient is instructed to lean 
Technique of 
Adjustment 
Using Occipital 
Leverage: 122 
Downing Principles and Practice of Osteopathy 
“a 
Position for adjustment of a unilaterally anterior occiput on the left using 
occipital leverage. Primary movement of flexion is followed by side-bending to 
the right to create by resultant compression a fixed point axis for rotation on 
that side. Arrow A indicates the posterior arch of the atlas on the left which 
must be firmly held to oppose the direction of the corrective force of rotation 
and retain the atlas as a stationary body. Arrow B indicates the direction of 
the corrective rotation. Occipito-Atlantal Subhixations 
123 
against operator that he may relax better. The fleshy por- 
tion of the operator’s right thumb is placed firmly against 
the posterior arch of the atlas on the left side. Maintaining 
firm fixation of the atlas, a rotary traction force is brought 
to bear upon the lesioned articulation by the proper coordi- 
nating action of the operator’s left arm. 
The author also utilizes other methods carrying out the 
same fundamental principles which cannot here be enlarged 
upon, (as the two mentioned are very specific and satisfac- 
tory), but instead the student’s attention is drawn to an abso- 
lutely different mechanical basis for adjustment of the same 
lesion—not from the standpoint of occipital leverage, but 
rather from the standpoint of force directed to the atlas. 
The success of this procedure depends upon speed and 
velocity. It lacks the nicety and mechanical advantage of oc- 
cipital leverage, but is, however, a very satisfactory method 
if properly utilized. The author designates it a “column of 
blocks” technique. This is not a particularly good technical 
expression, but is appropriately expressive. For illustration, 
the student is here carried back to the heydey of childhood, 
when playing with blocks was an erudite task. Piling these 
blocks end on end the child would attempt to snap one of the 
under blocks from the column without disturbing the rest. 
This of course depends upon the degree of dexterity and the 
velocity used. 
Now to regard the lesion from a slightly different me- 
chanical view-point. The axis of motion passes vertically 
through the condyle on the side opposite the lesion. From 
the standpoint of the atlas—two lever handles are apparent— 
a long and a short lever handle. The short lever handle con- 
sists of that portion of the lateral mass and the transverse 
process of the atlas lateral on the right to the axis of move- 
ment. The long lever handle consists of all that portion of the 
atlas lateral on the left to the axis of movement. It must be 
remembered that the left condyle is not an axis for movement, 124 
Downing Principles and Practice of Osteopathy 
therefore the long lever handle will be all that portion of the 
atlas lateral to the right condyle. The right condyle, in an in- 
verted sense, has a function corresponding very closely to 
that of the odontoid process in the atlanto-axial articulation. 
Corrective forces must be directed against the long lever 
handles as the objective in this technique. Before attempt- 
ing adjustment, however, it is necessary to carry out the fol- 
lowing movements: 
1. Extension. This physiological movement locks the 
lower cervical. Carry it to the degree sufficient to lock from 
below upward as far as the atlanto-axial articulation. 
2. Side-Bending Rotation: A slight degree of side-bend- 
ing toward the side of the lesion, rotation toward the side op- 
posite the lesion (side-bending to the left, rotation to the 
right.) This should not be forced, as a stabilization locking of 
the cervical column (a stabilization locking is not a complete 
physiological locking) is desired. Extension of the lower 
cervical, and side-bending rotation of the upper cervical gives 
this locking. The degree of side-bending must be carefully 
watched (not over 4 or 5 degrees) as the operator wishes to 
retain the condyle on the right side as the fixed point axis. 
3. Adjust by directing force anteriorly against the lateral 
posterior aspect of the posterior arch of the atlas on the side 
of lesion. The velocity should be high; the amplitude of mo- 
tion short. Occipital counterforce, opposing adjustive force, 
is obtained by stabilization of the occiput manually. 
Technique 1. Patient supine. Operator stands at the 
head of the table—extends the occiput and cervical column, 
side-bends the occiput and upper cervical area approximately 
four or five degrees to the side of lesion and rotates them 
toward the opposite side. The lateral aspect of the index 
finger of the left hand is the instrumentality of force and is 
placed firmly against the posterior arch of the atlas on the 
left side. The palmar aspect of the operator’s right hand is 
placed along the right side of patient’s head and face for Occipito-A tlcmtal Subluxations 
125 
occipital counterforce. Sudden force is directed by the ad- 
justive hand (left) in an anterior direction against the pos- 
terior arch of the atlas, while a simultaneous exaggeration of 
counterforce is obtained by exerting a little increase of stabili- 
zation pressure. 
Technique 2. Patient sitting. Operator stands on the 
side opposite lesion, facing the patient. The flexed middle 
finger of the right hand is placed firmly against the posterior 
arch of the atlas on the left side. Extension, side-bending, to 
side of lesion, and rotation toward opposite side are complet- 
ed, in the order named. The palmar aspect of the operator’s 
left hand is placed against the lateral aspect of the patient’s 
face and head for occipital counterforce. Adjustment is com- 
pleted by strong quick snap of the middle finger in an an- 
terior direction with increased counterforce at the moment 
of adjustment. 
A point it is desired to emphasize in the use of the above 
varieties of technique is the absolute necessity of velocity. It 
is obvious that with the patient sitting, the superincum- 
bent weight is greater, as the articulation is then bearing the 
weight-load of the head. With the patient supine, this factor 
is obviously mitigated and the operator is free of that parti- 
cular obstacle. 
Only one type of lesion has been considered from the 
point of view of adjustment—the unilateral anterior occiput 
on the left. If the lesion were a unilateral anterior 
on the right the operator would merely reverse the mechanical 
procedures. If the lesion were bilateral in character, adjust- 
ment would be given both sides by unilateral methods. 
In the anterior grouping, lesions of a tor- 
sion character, or, in other words, unilat- 
eral lesions are complicated by a definite 
act of compensation between the atlas and 
the axis. Assuming that a condyle is dis- 
placed anteriorly and to a slightly higher level, the condyles 
Compensatory 
Lesions of the 
Atlanto-Axial 
Articulation: 126 
Downing Principles and Practice of Osteopathy 
which are normally constructed and situated to bear their 
respective share of the superincumbent weight can no longer 
share equally this burden, first because the superincumbent 
weight line must pass posteriorly instead of centrally through 
the long axis of the condyle in lesion and, secondly, because 
the anterior condyle is at a higher level. This means that the 
opposite condyle must bear the brunt of the burden and na- 
ture, to compensate for this inequality, causes the atlas to 
rotate posteriorly on the side of lesion, so as to bring the 
weight-lines to more nearly equal points through the respec- 
tive condyles. In the posterior grouping of lesions of a unilat- 
eral character, the arc of rotation of the atlas is in the opposite 
direction, having the same object in view. 
This is an added factor as to why the posterior arch of 
the atlas is relatively so much more prominent and would 
seemingly be indicated by its changed relationship with the 
occiput in the anterior grouping of lesions. The presence of 
this compensatory lesion is easy to detect, inasmuch as in any 
posterior rotation of the atlas on the side of lesion, the pos- 
terior arch will not only be more prominent posteriorly, but 
will crowd the median line and in the case of an anterior rota- 
tion on the lesion side (posterior grouping of the lesions) it will 
not only be relatively more anterior but more laterally 
disposed. 
When using the “column of blocks” technique both for the 
unilateral anterior and posterior groupings, the same correc- 
tive forces which adjust the occipito-atlantal subluxation will 
adjust the atlanto-axial compensatory lesion. Inasmuch as 
the mechanics and adjustment forces are applicable to both. 
This however, does not apply when using occipital leverage 
and an absolutely distinct procedure must be used for ad- 
justment of the compensatory lesion. 
By this term is meant those lesions in 
which one or the other condyle, or both 
condyles are fixed in a relatively posterior 
position on the superior articular facets of the atlas below. 
The Posterior 
Grouping: Occipito-Atlantal Subluxations 
127 
In this grouping, are included both the unilateral posterior 
occiput on the right and left and the bilaterally posterior oc- 
ciput. 
This is a flexion movement on a trans- 
verse axis, wherein the condyles of the oc- 
ciput move bilaterally backward, down- 
ward and slightly inward on the articular 
facets of the atlas below, with consequent immobilization in 
this position. The anterior extremities are at a lower and 
the posterior at a higher level than normal. 
Functional disturbance of this joint in 
flexion occurs more often than in any of 
its other classified movements. This is, however, so complete- 
ly offset by the powerful extensor grouping of muscles that 
this type of lesion occurs much more rarely than has been 
stated in previous texts. Occupational or functional disturb- 
ances in which the head is constantly flexed, as for example, 
students, jewelers, office workers, etc., may be causative. 
Habitual faulty posture is a compelling factor. Atonicity of 
the extensors or hypotonicity of the flexors, particularly the 
former, may also be responsible. The special senses of the 
face protect the individual to a considerable extent from le- 
sions of traumatic origin. This lesion occurs occasionally as a 
compensatory lesion, usually as compensatory for an exagger- 
ation in the cervical curve—however if a hypotonic state of 
the extensor grouping exists, there is usually straightening of 
the curve, as is also the case when the occipital lesion is 
primary. 
With patient standing, the head assumes 
the position of flexion and is slightly more 
apparent than with the patient sitting. Motion is restricted 
particularly in the direction of the extension; in other words, 
it is apparently greater because of the relative fixation of 
the condyles. Suboccipital contractures are not present as a 
Bilaterally 
Posterior 
Occiput: 
Etiology: 
Diagnosis: 128 
Downing Principles and Practice of Osteopathy 
usual thing, unless the lesion be of traumatic origin. A hypo- 
tonic state of these muscles is usually noted as the lesion is 
more often of long duration both in point of occurence and 
chronicity. The posterior arches of the atlas are relatively 
anterior and not easy to palpate. The normal separation of 
the ramus of the mandible and the outer anterior portion of 
the transverse process is bilaterally decreased, while a cor- 
responding bilateral increase or separation occurs between 
the outer posterior portion of the transverse process and the 
tip of the mastoid process. The tissues surrounding the tips 
of the transverse processes of the atlas are abnormally sen- 
sitive. Unless the lesion be of traumatic origin, suboccipital 
sensitiveness is not marked. In fact, because of its chroni- 
city, it is rarely as sensitive as its opposite fellow, the bilater- 
ally anterior occiput. Subjective symptoms vary—patients 
usually complain of the sense of strain at the base of the 
occiput, rather than of marked discomfort. 
Eliminate all etiological factors insofar 
as is possible. Reduce bony subluxations 
unilaterally—one side at a time, as it is the most efficient way. 
The unilaterally posterior occiput is a tor- 
sion lesion conforming to the same me- 
chanical misconduct as that of the unilat- 
erally anterior occiput with the exception that the condyle of 
the lesioned side moves on an arc of motion backward, down- 
ward and slightly medialward instead of forward, upward, 
and slightly medialward. The opposite condyle acts as the 
fixed-point axis for the arc of motion of its fellow and the 
axis of this motion could well be represented by a line drawn 
nearly vertically through the long axis of the condyle and the 
center of the articular facet of the atlas. 
Unusual muscular tension, trauma, faulty 
posture, occupational factors, forceful un- 
expected flexion, principally on the side of the lesion, counter- 
Treatment: 
The Unilaterally 
Posterior 
Occiput: 
Etiology: Occipito-Atlantal Subluxations 
129 
balancing to other conditions, functional or habitual anoma- 
lies, refraction errors, etc., all are etiological factors which 
may produce this lesion. Dynamic and adynamic lesioning 
forces seldom have the same parallel intensity, consequently 
the torsion lesion is the expected sequence. 
The fixed relationship of the same side of 
the posterior arch of the atlas to the oc- 
ciput will be so changed that it will assume a relatively more 
anterior position. This, of course, will cause the opposite side 
to be relatively posterior in relationship to its fellow, but not 
with the occiput. Moreover, the side of gross lesion will give 
evidence of greater sensitiveness and unequalized muscular 
tensions. Superimposed to this is the fact that the normal 
separation between the angle of the jaw and the end of the 
transverse process is decreased on the side of gross lesion and 
the opposite holds true between the end of the transverse proc- 
ess and the tip of the mastoid process on the same side. Cor- 
related, these findings give an accurate diagnosis of the lesion. 
No appreciable changes will manifest themselves on the side 
opposite that of gross lesion. The compensatory lesion of the 
atlanto-axial articulation must be kept in mind at all times 
and ruled out by the measures previously suggested. The 
position the patient’s head assumes in relation to the existing 
structural condition is suggestive. Supine, the head slightly 
in relaxation assumes a fixed position and is tilted to the side 
opposite the lesion. Restricted motion is more evident on the 
side of lesion. 
Principles of Adjustment for Lesions of the Posterior 
Grouping Using Occipital Leverage. 
1. Extension: As lesions of the posterior groupings are 
of the flexion type, either unilateral or bilateral in character, 
extension is the antithesis in joint movement. It should there- 
fore be used if possible, not only for that reason, but moreover 
because it places the condyle at the best mechanical ad- 
Diagnosis: 130 
Doivning Principles and Practice of Osteopathy 
vantage to glide up the inclined plane of the superior articular 
facet of the atlas. Extension is almost absolutely necessary 
due to the nature and inclination of the joint surfaces as bony 
contact of joint planes would be the result of attempting this 
adjustment in any other position than extension. This would, 
perforce, limit complete adjustment. 
2. Side Bending: With side bending are carried out two 
principles. It gaps the articulation it is necessary to move; 
and, secondly, approximates the articulation it is desired to 
have act as a fixed point axis for rotation, through the laws 
of compression and friction. 
3. Fixation of the Arch of the Atlas: Oppose the direc- 
tion of the corrective force of rotation by fixation of the arch 
of the atlas on the side toward which rotation is necessary. In 
lesions of the posterior grouping the fixation of the arch of 
the atlas will be on the side opposite to that in gross lesion; 
whereas, in lesions of the anterior grouping, it was on the side 
in gross lesion. 
4. Rotation: Adjustment is completed with rotation. 
In lesions of the posterior grouping, rotation is conducted on 
an arc forward on the side of gross lesion and backward on 
the side opposite gross lesion; in other words, rotation is away 
from the side of lesion or toward the side opposite, whereas 
in lesions of the anterior grouping, rotation is toward the side 
in gross lesion. 
For purposes of convenience and clarity 
of procedure consider the following 
hypothetical lesion—an occiput unilater- 
ally posterior on the left. The principles 
of adjustment as carried out in order are 
as follows: 
1. Easy extension. 
2. Side-bending to the right. 
3. Fixation of the arch of the atlas on the right. 
Technique of 
Adjustment 
Using Occipital 
Leverage: Occipito-Atlantal Subluxations 
131 
4. Adjust with rotation of the occiput toward the right. 
Technique 1. Patient supine. Operator stands at head 
of table, extends occiput and side-bends to the right 
to an angle of approximately 15 degrees from the midline of 
the body. He then places the index finger of his right hand, 
reinforced by the middle finger, against the posterior arch 
of the atlas on the right, while the right forearm rests against 
the antero-lateral aspect of the head. The operator thereupon 
places the palmar aspect of his left hand against the angle and 
the ramus of the jaw on the left side keeping firm pressure 
against the postero-lateral aspect of the arch of the atlas with 
the index finger reinforcement. He then rotates the occiput 
toward the right by coordinating the parallel forces of the 
right forearm and left hand. He does not disturb extension 
and side-bending when completing adjustment. 
Technique 2. Patient sitting. The mechanical principles 
are the same as were used with the patient supine. The oper- 
ator stands to the side opposite that of the lesion and leans 
against the patient so as to throw him off balance toward the 
side of lesion. He cups the patient’s chin in the apex of his 
flexed right arm with the fingers of the same hand resting 
firmly upon the vertex of the head. The fleshy portion of the 
operator’s left thumb is placed firmly against the posterior 
arch of the atlas on the right side. Maintaining a firm fixa- 
tion of the atlas, a rotary force toward the right is brought 
to bear upon the lesioned articulation by the leverage action 
of the operator’s right arm. 
The following technique is used occasionally by the 
author. It is very effective. 
Technique 3. Patient supine with head and cervical 
column over the end of the table. Correct right side first. 
Operator places right hand under patient’s occiput, left hand 
under chin, and abdomen against vertex of patient’s head. The 
cervical column should be flexed to its limit of motion, and the 
head, in full extension, lifted so that the weight of the body 132 
Downing Principles and Practice of Osteopathy 
is pulling downward on the atlas. Carry the head to the right 
side. This gaps the articulation (do not side-bend the head, 
then, keeping the patient in the same position, shift 
hands and repeat on the opposite side. 
3. Strong upward pull against the chin with the left hand; 
but hold firm and stationary so as to allow gapping to take 
place). To make adjustment three things should be carried 
out synchronously: 
1. Downward and forward pressure of abdomen against 
vertex of patient’s head to increase extension. 
2. Forceful upward thrust against base of the occiput 
with the right hand. 
Adjustment of a bilateral condition can be easily affected 
by unilateral methods given above—the only difference being 
that they are applied to both sides in succession. 
(“Column of Blocks” Technique.) The 
same mechanical principles used with oc- 
cipital leverage technique can be used in 
this maneuver, although the lesion is re- 
garded from a slightly variant viewpoint, and attacked from 
a different angle. The axis of motion passes vertically 
through the condyle on the side opposite the lesion. Two 
lever handles are apparent; a long and a short. The long lever 
handle is approximately twice the length of the short one. In 
this particular case the short lever handle is our objective and 
we carry out the same preliminary mechanical procedures of 
extension and side-bending. The side-bending is away from 
the side of lesion, so the articulation it is desired to use acts 
as the fixed-point axis. Our corrective forces are directed 
against the short lever handle. Before attempting adjust- 
ment, it is necessary to carry out the following movements: 
1. Extension: This physiological movement locks the 
lower cervical and places the condyle in lesion in the best me- 
Occipitial 
Adjustment 
Via the Atlas: Occipito-Atlantal Subluxations 
133 
chanical position possible to glide up the incline plane. 
2. Side-bending Rotation: A slight degree of side-bend- 
ing away from the side of lesion, followed by rotation toward 
the side of the gross lesion (side-bending to the right, rota- 
tion to the left), gaps the articulation the operator wishes to 
move, approximates and stabilizes the articulation he wishes 
to have act as a fixed point axis and the rotation gives a sta- 
bilization locking to the upper cervical. 
3. Adjust by directing force anteriorly toward the lat- 
eral posterior aspect of the posterior arch of the atlas on the 
side opposite that of gross lesion. The velocity should be high, 
the amplitude of motion short. The occipital counter-force 
opposing adjusting force is obtained by stabilization of the 
occiput by pressure of the hands of the operator. 
Technique 1. Patient supine. The operator stands at the 
head of the table, extends the occiput and cervical column, 
side-bends the occiput and upper cervical area approximately 
4 or 5 degrees to the side opposite that of the lesion, and at 
completion of this, rotates toward the opposite side to a point 
of stabilization locking. The lateral aspect of the index finger 
of the right hand is placed firmly against the postero-lateral 
aspect of the arch of the atlas on the right side. The palmar 
aspect of the operator’s left hand is placed along the left side 
of the patient’s head and face, for occipital counter-force. 
Sudden force is directed by the adjusting hand (right) in an 
anterior direction against the posterior arch of the atlas, 
while a simultaneous exaggeration of counter-force is obtain- 
ed by exerting a little increase of stabilization counter-pres- 
sure with the left hand. 
Technique 2. Patient sitting. Operator stands on the 
side opposite lesion, facing the patient. The flexed middle 
finger of the left hand is placed firmly against the postero- 
lateral aspect of the posterior arch of the atlas on the right 
side. Extension, side-bending away from the side of lesion, 
and slight rotation toward the side of lesion are respectively 134 
Downing Principles and Practice of Osteopathy 
completed. The palmar aspect of the operator’s right hand is 
placed against the lateral aspect of the patient’s face and 
head for occipital counter-force. Adjustment is completed by 
a strong, quick snap of the middle finger against the posterior 
arch of the atlas with increased stabilization counter-force at 
the moment of adjustment with the right hand. 
There is no objection to the use of the above technique. 
The mechanics are nearly perfect. There is, however, only one 
drawback, and that is that by working with a short lever 
handle more force is demanded. This, however, is very hap- 
pily counteracted by the type of force used. It is cumulative 
force—velocity. It has two advantages: one, the fact that 
the mechanical principles are correct; and secondly, that the 
method is easy of accomplishment. Moreover, this same cor- 
rective force for the occipital lesion reduces the atlanto-axial 
lesion at the same time. 
Only one type of lesion has been considered from the 
standpoint of adjustment—the unilateral posterior occiput on 
the left. If the lesion were a unilateral posterior on the right, 
the operator would merely reverse his mechanical procedure, 
as before stated. If the lesion were bilateral in character, ad- 
justment should be given for both sides. 
The lateral occiput is a lesion wherein the 
joint is fixed in a position of side-bending 
or lateral flexion. The condyle of one side 
moves medialward and downward, while that of the opposite 
side moves outward and upward. There is lateral tilting to 
the side which has moved medialward and downward, con- 
sequently a larger share of the superincumbent weight of the 
occiput is borne by the condyle of that side. 
Unequal muscular tension, especially a 
contracture of any of the following mus- 
cles, rectus capitis lateralis, semispinalis, splenius capitis, or 
The Lateral 
Occiput: 
Etiology: Oceipito-Atlantal Subluxations 
135 
sternocleidomastoid, may be causative. The condition also 
may be produced by trauma, occupation, postural defects, etc. 
It may be secondary to rotation lesions in the neck. 
If side-bending is to the right, the con- 
dyles of the occiput will appear displaced 
to the left, and there will be a compensatory swerve in the 
cervical area. The transverse process on the right will ap- 
pear to be nearer the occiput and mastoid process-in other 
words, higher in the apex of the angle formed by the two, 
and will also be more prominent laterally. The mastoid 
process of the same side and the angle of the jaw are less 
prominent, and tend to point more medialward, due to the 
inclination of the head. The direct antithesis holds true on 
the left. A very reliable probable sign of this lesion from 
the standpoint of inspection, is as follows: 
The patient supine, and the head thoroughly relaxed, the 
midline of the face will tend to bisect at an angle the mid- 
line of the body. In other words the midline of the trunk, 
continued upward, seems to bisect the midline of the forehead, 
nose and chin, in such a manner that a large portion of the 
forehead falls on one side of the line, (right) and a greater 
portion of the chin on the opposite side of the line (left). 
Tenderness is greatest over the transverse process which 
is most prominent. Restricted motion is apparently greatest 
in the direction opposite to that of the fixation (side-bending 
to the left). Subjective symptoms vary. 
The first principle is to obtain a stabiliza- 
tion locking of the cervical column. This 
may be done in the following manner: 
(1) by the use of forced flexion which 
locks the cervical from above downward, 
the degree determining the amount and the point downward 
to which this locking will carry. The author sometimes 
utilizes extension, which locks from below upward but does 
Diagnosis: 
Principles of 
Adjustment by 
Occipital 
Leverage: 136 
Downing Principles and Practice of Osteopathy 
B 
A 
0 
c 
Position for adjustment via the atlas of unilaterally posterior occiput on the 
left. Extension side-bending to the right and rotation to the left determines 
physiological locking of the upper cervical and a pivotal point for rotation through 
long axis of the neck of the right condyle. Stabilization resistance of the occiput 
is maintained while rotary adjustive force is applied against the short lever 
handle (arrow C) allowing long lever handle (arrow A) to rotate backward carry- 
ing facet backward under condyle. Arrow B indicates direction in which chin 
must point while adjustment is being made. Occipito-Atlantal Subluxations 
137 
not include the atlanto-axial articulation, which he locks by 
side-bending rotation. In both instances he uses a stabilization 
locking sufficient to protect the cervical column from strain 
or injury, and moreover to give the maximum advantage of 
his adjustive and leverage forces. 
The next fundamental principle is that of side-bending. 
This side-bending must be opposite to that in which fixation 
occurred. This is the physiological antithesis of lesion move- 
ment. 
Technique 1. As the hypothetical lesion throughout, a 
lateral occiput to the right is considered. A fixation estab- 
lished in side-bending to the left. 
Patient supine. Easy extension of the cervical column is 
the first step and locks all but the extreme upper cervical 
which are in turn locked by side-bending rotation (largely 
rotation) toward the left. The operator hooks the fingers of 
his left hand under the mastoid process of the patient. The 
combined thumb and flexed index finger (instrumentality of 
force) are applied to the angle of the jaw and the mastoid 
process, respectively. Reference is had to the right hand of 
the operator and the right side of the patient. With the 
cervical column locked together with a moderate degree of 
side-bending of the occiput to the right, simultaneous traction 
with the operator’s left hand and transverse force with the 
right hand completes the adjustment. 
Technique 2. Patient supine. Operator locks the upper 
and mid-cervical areas by forced flexion of the cervical col- 
umn. The occiput is maintained in a position of side-bending 
to the left. The operator applies vertex pressure with the 
abdomen in such a manner as to cause the resultant force to 
pass obliquely through the condyle on the right side. This 
tends to force this condyle downward into the facet and in- 
versely tends to force the opposite condyle up and out of its 
facet. Super-imposed to this he applies adjustive force with 
the combined thumb and index finger of right hand against 138 
Downing Principles and Practice of Osteopathy 
the angle of the jaw, and the mastoid process, respectively, on 
the right in a transverse direction and opposes this with coun- 
ter adjustive force with the left hand against the lateral as- 
pect of the vertex. This force is transverse in character also. 
It must be kept in mind that relaxation of the lateral 
cervical musculature, although not absolutely necessary, is 
often indicated for the best possible results. The prepara- 
tory movements which lock the cervical column below the 
point of lesion have no particular effect upon the occipito- 
atlantal articulation, other than if forced they may to some 
extent limit motion by forced tension of soft tissues. The 
aim of all adjustive technique is to stabilize, protect and lock 
the column adjacent to the vertebrae in lesion, but to leave 
the joint involved absolutely unprotected, that the full capa- 
city of leverage and adjustive force may in no wise be limited. 
Technique 3. Patient supine with head and cervical 
column over the end of the table. Operator stands at the 
head of the table and grasps the head as follows: 
(a) Right hand against right side of head and face. 
(b) Abdomen against vertex of patient’s head. 
(c) Left hand against left side of head with fingers 
firmly against posterior arch of atlas. 
Operator side-bends cervical spine to the right and head 
to the left. Three things are to be carried out synchronously: 
(a) Increase side-bending of head with pressure of 
abdomen. 
(b) With right hand operator should make a strong 
thrust with a little rotary twist to the right. 
(c) Finger of the left hand should hold the arch of the 
atlas firmly, while palm of hand exerts lifting pres- 
sure against side of head. This movement serves 
to dislodge anterior extremities of the condyle 
(usually posterior); and if they do not, maintain- 
ing patient’s head in same position, shift left hand, Occipito-Atlantal Subluxations 
139 
so that fingers are under the angle of the jaw 
(palm in same position.) 
Use the following method to finish reduction of the pos- 
terior extremities of condyles: 
(a) Increase side-bending by pressure of the abdomen. 
(b) Strong pressure against the base of the occiput with 
the right hand. 
(c) Lifting pressure with the left hand; now with rock- 
ing motion and strong outward rotary movement, 
directed to bring greatest tension and separation 
to left latero-posterior position of the articulation 
correction is completed. 
It is easier whenever possible to correct unilaterally. The 
operator may localize his efforts more specifically and effici- 
ently by doing so. The same applies to moving any object. It 
is easier to move things by prying at the edges. The above 
technique, like the farmer moving the large rock, aims to 
follow out that principle. 
The pseudo-rotation lesion is a torsion 
lesion made up of a complexity of move- 
ments taking place at various intervals 
of time and having such peculiar physical 
aspects as to make it appear rotary in character. It is not a 
single combined movement, excepting when of traumatic 
origin, when external dynamic forces, rather than inher- 
ent mechanical possibilities, control the situation. External 
violence may act in such a manner as to cause both condyles 
to move at the same time in diverse directions around an im- 
aginary central axis. 
In the usual lesion, the unilaterally anterior, the occiput 
is the primary offender. The condyle in lesion describes an up- 
ward, forward and medialward arc of motion and the op- 
posite condyle acts as the fixed-point axis. An indefinite 
period of time may elapse following which the condyle in 
Pseudo-Rotation 
Lesion of the 
Occiput: 140 
Downing Principles and Practice of Osteopathy 
gross lesion may act as a fixed-point axis for an arc of mo- 
tion of the opposite condyle downward, backward and medial- 
ward. Shifting arcs and axes of motion characterize this le- 
sion. Because of the respective levels the condyles are obliged 
to assume an element of side-bending enters into the lesion. 
This side tilt is toward the side which is unilaterally posterior. 
This is not a true rotation lesion, having no central axis for 
rotation, hence the term pseudo-rotation. 
In any unilaterally anterior occiput there 
are certain mechanical forces which, if the 
lesion remains chronic for a long period of time, are apt to 
result in the pseudo-rotation lesion. Recall the fact that the 
condyle which acts as the fixed-point axis goes through a 
screwing motion—in other words, revolves upon its long axis. 
Visualize for a moment the direction of that revolution and 
you have the mechanical reason. Superimposed to that is the 
added factor that the inclination of the plane surface of the 
articular facet of the atlas is backward. Opposing this is 
the counter-force of extension which, although greatest on 
the side of gross lesion, must exert a secondary though minor 
effect upon the opposite condyle. 
If it were not for the fact that the atlanto-axial articula- 
tion takes up a large percentage of traumatic rotary forces, 
the role of trauma in the production of this lesion would be a 
particularly heavy one. As it is, however, it exerts a minor 
influence only. 
The diagnosis is not difficult. The fixed 
relationship of the posterior arches of the 
atlas to the occiput and to each other will show greater dis- 
parity than in any other type of torsion lesion of the occiput. 
One is not only relatively anterior, but the other is corre- 
spondingly relatively posterior. Immobilization is greater 
than it is in the torsion lesion, both condyles being fixed; 
whereas in the unilateral lesion only the condyle in gross le- 
Etiology: 
Diagnosis: Occipito-A tlantal Subluxations 
141 
sion is firmly fixed. The changed relationship between the 
mastoid process, the tip of the transverse process, and the 
angle of the jaw on one side is exactly opposite in character to 
that on the other. Sensitiveness will be approximately the 
same on both sides. By the simple act of rotation the atlanto- 
axial articulation fulfills the compensatory demands of the 
unilaterally anterior occiput on one side or the unilaterally 
posterior on the other. 
With the patient supine and the head thoroughly relaxed, 
the midline of the face will be parallel but lateral to the mid- 
line of the body. In other words, the midline of the trunk 
continued upward would pass parallel, but lateral to the mid- 
line of the forehead, nose and chin. This same finding is 
characteristic to lesions of the atlanto-axial articulation, but 
with this main difference, that rotation around an imaginary 
central axis or in other words on a horizontal plane will show 
marked limitation of rotation in the direction opposite to that 
of the fixation if it is an atlanto-axial lesion. This movement 
does not affect the pseudo-rotation lesion of the occiput. Of 
course, the compensatory lesion of the atlanto-axial articula- 
tion must be ruled out. This can best be done by adjusting 
it previous to making the test. 
Extension: Since this lesion partakes of 
the characteristics of both a unilaterally 
anterior and a unilaterally posterior occi- 
put it is impossible to use both flexion and 
extension at the same time. It is therefore 
necessary to utilize the one which is of greatest value. It is 
possible to get along without flexion, as it is easier for the 
anterior condyle to slip down the inclined plane than it is for 
the posterior condyle to slide up the inclined plane, particular- 
ly as the parallel inclination of these planes is so arranged as 
to render it almost impossible because of contact limitation. 
Therefore easy extension is used. 
No side-bending: Inasmuch as both condyles are in le- 
Principles of 
Adjustment 
Using Occipital 
Leverage: 142 
Downing Principles and Practice of Osteopathy 
sion in opposite directions and we do not wish to enforce any 
limitations of motion upon either one of these condyles in 
making adjustment, side-bending should be ruled out. 
Fixation of the Arch of the Atlas: It is necessary to op- 
pose the direction of the corrective force of rotation by fix- 
ation of the arch of the atlas on the side toward which it is 
desired to rotate. 
Rotation: Adjustment is made with rotation together 
with slight traction around an imaginary central axis. This 
movement must be on as near an horizontal arc as is possible. 
Technique: Any of the technical procedures given for 
the torsion lesions previously discussed is satisfactory, pro- 
viding the above principles are fulfilled. 
This, as the term signifies, is a fixation 
with the joints in their central range of 
motion. It is due to a hypertonic state 
of both the anterior and the posterior suboccipital groupings 
of musculature. There is marked restriction of motion, ap- 
parently no greater in one direction than in another. The 
whole suboccipital area appears sensitive to palpation and 
diffusely contractured. The patient may complain of a great 
deal of suboccipital discomfort ranging from vague neurotic 
pains to well-defined congestive headaches. 
Treatment is traction. Alternate traction and release of 
traction. A technique which the author uses, and which is 
highly effective for this condition is Technique I, under treat- 
ment of the lateral occiput. The only difference in the ap- 
plication is that the combined thumb and index finger is used 
to secure a stabilization force rather than an adjustive force, 
and the object is to break fixation and gap the joint surfaces. 
This method is used bilaterally, gapping one articulation at 
a time. 
The Impacted 
Occiput: The Atlanto-Axial Subluxation 
143 
CHAPTER V. 
THE ATLANTO-AXIAL SUBLUXATIONS 
The atlanto-axial joint has four distinct articulations, 
each covered by a synovial membrane. The atlas revolves on 
a nearly vertical axis around the odontoid process of the axis, 
forming a pivot joint with two articular surfaces, one be- 
tween the odontoid process and the anterior arch of the atlas, 
and the other between the odontoid process and the trans- 
verse ligament. The lateral articular processes are arthrodial 
articulations. The articular surfaces are raised in the center 
and fall away at the edges, thus allowing, at first, some 
ligamentous slackening in rotation, thereby increasing the 
amount of this movement. The mobility of this joint for 
rotation is marked, the atlas and the skull moving en masse 
upon the axis. Movement beyond a certain limit, however, is 
prevented by the alar or check ligament. Primary movement 
is asymmetrical, the axis of movement being in the atlanto- 
axial articulation of the side to which the head is rotated. This 
soon changes and the movement becomes symmetrical around 
the odontoid process of the axis. The muscles producing this 
movement are the sternocleidomastoid and semispinalis 
capitis of one side acting with the longus capitis, splenius, 
longissimus capitis, rectus capitis posterior major and obliquis 
capitis superior and inferior of the opposite side. The second 
cervical nerve passes out behind the superior articular proc- 
ess of the axis. 
Normal movement of the atlanto-axial articulation is 
largely confined to rotation, although a slight degree of 
flexion, extension, and side-bending is possible. 
The common lesions of this joint are: 
1. The unilaterally anterior atlas on the 
right, posterior on the left ( rotation lesion 
to the left.) 
The Rotation 
Lesion: 144 
Downing Principles and Practice of Osteopathy 
/W. Synovia/ 
Ozvi/jy 
Ant. Synovia/ 
Cuvi/y 
\&tebm/ Vein* 
\7hsg*. 
'Vertebral.A rt. 
ast. Qrcrvaf Xervv 
Articulation between odontoid process and atlas. 
2. The unilaterally anterior atlas on the left, posterior 
on the right (rotation lesion to the right). 
The nature of the joint is such that these lesions are many 
times nothing more than functional disturbances due to un- 
equal muscular tension. They are frequently secondary, 
counterbalancing to other lesions. In fact, a rotation lesion 
of this articulation is more often compensatory than primary. 
The lesion when primary, is usually due to 
reciprocal innervation through the me- 
dium of the nerve reflex with resultant muscle spasm and im- 
balance of tensions. It may be due to unequal muscular ten- 
sion or perverted equilibrium, as a result of a lesion of a 
neighboring vertebra. It is one of, if not the most common, 
counterbalancing or secondary lesions found in the cervical 
column. It is invariably present in the unilateral, pseudo- 
rotation, and side-bending lesions of the occiput, providing 
those lesions are of long standing. It is occasionally counter- 
balancing for upper thoracic vertebral lesions and sometimes 
for first or second rib subluxations through the scalemus mus- 
cles. Functional abuse may be a predisposing factor, as for 
instance in the case of a violinist in the act of playing. Trauma, 
providing it is of a torsion character, is an important factor. 
The point of greatest sensitiveness is in 
the sub-occipital area, over the posterior 
arch and transverse process of the atlas, which has rotated 
Etiology: 
Diagnosis: The Atlanto-Axial Subluxation 
145 
p 
WMv 
Trans 
/‘roc 
/‘orfion of Irr rru/ta 
seen wtffUn Vertebrta.1 canal 
The axis, anterior view. 
posteriorly. The relative position of the posterior arches of 
the atlas are significant. The posterior arch which rotates 
posteriorly crowds the median line, while its fellow rotates 
anteriorly and is more laterally situated. Therefore one arch 
is postero-mesial and its fellow is antero-lateral. The position 
that the head of the patient assumes when in the supine posi- 
tion and completely relaxed is such that the midline of the 
trunk continued upward passes parallel to, but lateral to the 
midline of the forehead, nose and chin. Functionally, test the 
joint by rotating the head from side to side, being careful to 
eliminate all extraneous cervical movement by making this 
rotation with the head in the erect position (neither flexion 
nor extension) and on a horizontal plane. There will be limited 
rotation toward the side opposite that of fixation; that is to 
say, rotation is limited toward the anterior side. 
1. Easy extension: Easy extension locks 
the cervical column from below upward, 
the degree of extension determining the 
extent and the point to which this will carry. This extension 
should not be forced. The atlanto-axial articulation is not in- 
fluenced; in fact, practically all movement of side-bending 
rotation is confined to the very upper cervical. As the lesion 
is a rotation lesion, we have enforced no limitation upon the 
joint in lesion and consequently no limitation in adjustment 
possibilities. It is left unprotected for adjustment. 
Principles of 
Adjustment: 146 
Downing Principles and Practice of Osteopathy 
2. Side-bending: This side-bending must be toward the 
side unilaterally posterior. This is the first fundamental law 
in physiological or articular locking as it fulfills the necessity 
for approximation of facets. Physiological locking is impos- 
sible to obtain unless the facet surfaces are in close apposition, 
inasmuch as it is an articular locking and not forced tension 
of soft tissues. Without close apposition of the facet sur- 
faces motion is then limited only by the forced tensions de- 
veloped in the soft tissues in and around the joints and ad- 
jacent muscular structures. This movement, moreover, gaps 
the opposite side, allowing plenty of room for that particular 
joint to retrace its lesion pathway without application of ad- 
justive force. This side-bending depends upon the situation 
in the cervical column and the obliquity of the plane sur- 
face. In this particular instance, the degree of side-bending 
is approximately 12 degrees from the midline of the body. 
3. Rotation: By means of rotation toward the side 
unilaterally anterior, we complete our physiological locking 
of the upper cervical. We cannot lock the vertebrae in lesion 
because of its lesion position but we have physiologically lock- 
ed the spine in the area in the direction and in the plane in 
which we are going to apply corrective force, this corrective 
force being directed against the posterior arch which is 
unilaterally posterior. 
4. Adjustment: The adjustive hand delivers adjustive 
force in an anterior direction against the point of greatest 
leverage, the arch of the atlas which is unilaterally posterior. 
Physiological locking has been completed in the direction and 
plane and on the side on which this adjustive force is to be 
given. 
The opposite hand accomplishes three things: 
1. It supports and protects the very upper cervical 
column, acting somewhat as a splint. 
2. It aids and largely controls the act of physiological 
locking (side-bending and rotation). The Atlanto-Axicil Subluxation 
147 
3. Further exercise of the forces of physiological lock- 
ing after the locking has been completed consti- 
tutes leverage force. This transition is automatic 
and instantaneous. 
We will consider as the hypothetical le- 
sion a rotation lesion of the atlas to the 
right in which the atlas is unilaterally an- 
terior on the left and posterior on the right. The mechanics 
of adjustment are as follows: 
Technique of 
Adjustment: 
1. Easy extension. 
2. Side-bending to the side unilaterally posterior, 
angle approximately 12 degrees. 
3. Rotation toward the side anterior. 
4. Adjust with simultaneous utilization of adjustive and 
leverage-force. 
Odonloiti Process 
wifh Aflc^ 
for Check ligament 
for 
Transverse ligament 
Spinous Process 
Trans 
Process 
X- Inferior 
ZArf- surface 
Lateral view of the Axis. 
Technique 1: Patient supine. (Direct-action technique). 
The objective is the transverse process which has rotated pos- 
teriorly. The instrumentality of force is the lateral aspect 
of the index finger of the right hand (adjustive hand). The 
head and cervical column is carried into easy extension side- 
bending to the side unilaterally posterior and rotation to- 
ward the side unilaterally anterior (left). The left hand is 
placed along the lateral aspect of the suboccipital area of 148 
Downing Principles and Practice of Osteopathy 
the left side. Rotary adjustive force is delivered against the 
posterior arch of the atlas (right side) and the left hand co- 
ordinates with it in such a way as to deliver counter-force and 
leverage-force. 
Technique 2: (Direct-action technique). Patient sitting. 
The operator stands facing the patient and to the side op- 
posite the transverse process posterior. The palmar aspect 
of the slightly flexed middle finger is placed firmly against 
the posterior arch of the atlas which is unilaterally posterior, 
and the patient rests the head on the hypothenar eminence of 
the same hand (left hand). The right hand of operator is 
placed along the left lateral aspect of the patient’s face and 
head. This is counter and leverage-force. The left hand de- 
livers the adjustive force. The physiological movements of 
extension; side-bending to the side posterior and rotation to- 
ward the side anterior, must be completed before adjust- 
ment is attempted. 
A point which must be emphasized in the use of side- 
bending and rotation is that these forces must be focalized 
to the point of lesion. The apex of the angle formed by the 
midline of the body in relation to the side-bending of the head 
and upper cervical column must be at the point of lesion. 
The rotation must be focused in such a manner as to bring the 
greatest possible rotary strain at the point of lesion. This 
principle is true for any articulation in which physiological 
locking of side-bending rotation is used. 
Indirect methods are not as easily control- 
led as are direct methods. Ease of accom- 
plishment of adjustment is greater in 
direct-action technique. The following 
technique is of value, however, and is not particularly difficult 
to apply. 
Indirect-action technique: Patient supine. Fixation with 
fingers of one hand on vertebrae below (axis), especially the 
Adjustment by 
Indirect-Action 
Technique: The Atlanto-Axial Subluxation 
149 
transverse process upon the same side that vertebra in lesion 
(atlas) has rotated forward. With other hand against side of 
face and head, retrace the pathway of lesion movement by 
rotating occiput and atlas en masse toward anterior side. The 
patient’s head should be held in a position of side-bending to- 
ward the side which is unilaterally posterior. This movement 
causes a separation on the side which is unilaterally anterior 
thereby allowing plenty of room for a backward movement on 
that side. With slight variations same technic may be used 
with patient in sitting posture. 
Other possible lesions of the atlas are: 
1. Lateral atlas to the right. 
2. Lateral atlas to the left. 
3. Extension lesion of the atlas. 
4. Flexion lesion of the atlas. 
The Lateral 
Atlas: 
Due to the inclination of the articular 
facets of the axis, slight lateral gliding 
may take place with rotation in the 
atlanto-axial joint. This is a sort of skidding movement of 
the atlas as it rotates around the odontoid process so that the 
side which moves anteriorly tends to slip laterally and slight- 
ly downward, while the opposite side tends to slip medially 
and slightly upward, crowding odontoid process on that side. 
Illustrative of this movement of the facet forward is the 
familiar sight of the skidding of an automobile on a curved, 
crowned road. The result of this movement is that the side 
which rotates forward is more lateral and at a lower level 
than normal; while the other is at a higher level and more 
central. The atlas, therefore is laterally displaced on the side 
which rotates anteriorly. For example: a lateral atlas to the 
right is the result of a rotation to the left in which the atlas 
has moved forward, slightly outward, and downward on the 
right. These lesions are usually compensatory for torsion 
lesions of the occiput, and also the lateral occiput, (lateral 
occiput to the right, lateral atlas to the right). 150 
Downing Principles and Practice of Osteopathy 
Diagnosis: 
Marked lateral projection of the end of 
the transverse process of the atlas on the 
side which has rotated anteriorly, together with the assump- 
tion ctf a slightly lower level are characteristic to the anterior 
side. Less prominence of the end of the transverse process 
with the assumption of a slightly higher level are char- 
acteristic of the posterior transverse process. These par- 
ticular features superimposed upon the diagnostic tendencies 
and physical findings of the rotation lesion will give a correct 
analysis of the lesion, inasmuch as side-bending is not an in- 
dependent movement, but merely a portion of a composite 
tendency of rotation side-bending. Under certain conditions, 
a proportionately greater amount of side-bending may take 
place. 
Adjust as a rotation lesion, using the same 
technique with only slight variation. If 
direct-action technique is used, emphasis should be laid upon 
preliminary rotation (less side-bending and approximation). 
The extension lesion is nothing more than a functional 
or counterbalancing movement in which there is separation 
in front with slight upward gliding of atlantal articular sur- 
face upon the anterior articular surface of the odontoid and 
approximation posteriorly with slight compression of the 
articular disc. 
The flexion lesion is a functional disturbance with move- 
ment the reverse of that of the extension lesion. 
Both lesions should be directed to the 
etiological factors and not to the condi- 
tions themselves. 
The atlas cannot be bilaterally displaced anteriorly or 
posteriorly on account of the odontoid process of the axis, 
the anterior arch of the atlas, and the transverse ligament 
without fracture of the odontoid process or anterior arch of 
Treatment: 
Treatment: Subluxations of the Cervical Vertebrae, 2d to 1th 
151 
the atlas, or rupture of the transverse ligament. This knowl- 
edge is taken advantage of in execution by hanging, in which 
the transverse ligament is ruptured and odontoid process 
driven into substance of spinal cord. 
Fracture of the atlas is rare but several cases are on 
record where it has taken place as the result of extreme 
trauma. Its effect on the higher vital centers of the medulla 
is great. 
A valuable sign of meningeal irritation is Brudzinski’s 
neck sign: an involuntary flexing of the legs on the thighs, 
and of the thighs on the pelvis when the head is passively 
forced toward the sternum (forced flexion). It is pathog- 
nomonic of irritation of the meninges. The Binda shoulder 
sign of tuberculous meningitis is a sudden movement of the 
shoulder, when the head is passively turned toward the other 
side. It appears contemporaneously with Brudzinski’s sign. 152 
Downing Principles and Practice of Osteopathy 
CHAPTER VI. 
SUBLUXATIONS OF THE CERVICAL VERTEBRAE 
FROM THE SECOND TO THE SEVENTH 
INCLUSIVE 
A typical cervical vertebra will be reviewed here only with 
reference to those factors wThich are important to osteopathic 
mechanics and to which later allusion will be made. 
The body of the vertebra is small and broader laterally 
than antero-posteriorly; its anterior surface is at a slightly 
lower level than its posterior. Superiorly the body presents 
a prominent lipping of its posterior and lateral borders, while 
the inferior surface has a projecting lip on its anterior border 
which helps to prevent a slipping backward of the vertebra. 
This latter feature is a protective provision of nature and sta- 
bilizes the cervical curve, which is convex anteriorly. The 
lateral lipping is a protection against lateral displacements. 
The superior and inferior processes on either side are 
situated at the junction of the pedicles and laminae, which 
form, by their fusion, lateral columns of bone. The articular 
facets are nearly flat and oval in outline. The superior mem- 
bers face upward, backward, and slightly lateralward and 
the inferior downward, forward, and slightly inward. 
The third cervical vertebra is the smallest of the series. 
It occupies the apex of the cervical curve. The above facts 
together with its relative position in the cervical spine make it 
particularly responsive to lesioning forces. 
The transverse process of the cervical vertebrae present, 
near their bases, foraminae for transmission of the vertebral 
arteries, veins, and plexuses of sympathetic nerves. The ex- 
tremity of each process is bifid with each arm terminating 
in a tubercle referred to as the anterior or posterior tubercle. 
Considerable care should be taken in palpating around 
the anterior or costal tubercle of the transverse process of Subluxations of the Cervical Vertebrae, 2d to 1th 
153 
the sixth cervical vertebra as the carotid artery is compress- 
ed against it. This tubercle is known as Chassaignac’s 
tubercle or the tuberculum caroticum. 
Normal motion between the second and third cervical 
vertebrae is less free than elsewhere in the cervical spine. 
This is particularly true of flexion and is due to the thinness 
of the intervertebral fibro-cartilage. 
Sup Artproc 
/Probein foramen forVcrtArL 
%JostMer(J* 
Body 
ItlfArt pror. 
Anterior view of cervical vertebra. 
The pulpy nucleus or central portion of the intervertebral 
fibro-cartilage is situated somewhat behind the center of the 
disc and forms a mass of very elastic and tightly compressed 
material which constitutes a central elastic pivot or ball upon 
which the middle of the vertebra rests and upon which its 
body can twist, tilt, or incline. It is separated from im- 
mediate contact with the bone by a thin plate of cartilage. 
Embryologically it is a persistent vestige of the fetal noto- 
chord. 
The articular processes steadily influence and limit the 
movements of the spinal column, assist in bearing the super- 
incumbent weight of the body, and endow the spine with a 
capacity for movement by muscular agency. 
The normal movements of the cervical spine are flexion, 
extension, and rotation side-bending or lateral flexion. 
Rotation and side-bending are inseparable because of 
the position and inclination of the articulating facets, causing 
movement to take place upon an oblique axis. However, from 
above downward the obliquity of the articular facets 
increases, thereby relatively increasing the proportion of 154 
Downing Principles and Practice of Osteopathy 
side-bending in the lower cervical spine. Due to this fact 
Ashmore calls lesions of the upper cervical area rotation-side- 
bending and those of the lower cervical area side-bending- 
rotation. No inference should be drawn from this as to the 
direction of the rotation of the bodies of the vertebrae as in 
both cases it is to the concavity of the curve. Flexion and 
extension influence rotation and side-bending in that 
the total amount of movement is increased with the 
spine in easy flexion and slightly limited in easy ex- 
tension. Forced extension limits it markedly and forced 
flexion limits it slightly. The ratio of rotation has a 
tendency to be increased with the spine in extension, and the 
ratio of side-bending is increased with the spine in flexion, 
although as previously stated, extension and hyper-flexion 
limit the total amount of movement. 
Section of the cervical column looking downward, indicating planes 
of articulations and general morphology. Subluxations of the Cervical Vertebrae, 2d to 1th 
155 
In rotation-side-bending and side-bending-rotation the 
ratio of anterior articular movement upward and forward 
on one side is approximately three or four times greater than 
downward, backward articular movement of the opposite side, 
as the latter can move only slightly (approximately one-six- 
teenth of an inch) before it reaches its limit. The lower an- 
terior lip catches over the body of the vertebra below, the 
lower anterior portion of the inferior articular facet catches 
at the base of the superior articular facet or the lamina of 
that vertebra and the transverse process hooks over its 
superior articular process. The above bony contact limita- 
tions of this side are such as to prevent further movement 
and the axis for rotation shifts from the nucleus pulposus 
and becomes an oblique axis passing through the articular 
process and facet of this side, thereby allowing of further 
movement upward and forward on the anterior or opposite 
side. Movement changes from the symmetrical to an asym- 
metrical type due to the shift from a central to a unilateral 
fixed-point axis. 
Fryette claims that when any area is in easy physiological 
flexion and side-bent, the bodies move toward the convexity 
and if any area is in hyperflexion, or to a lesser extent ex- 
tended and side-bent, the bodies rotate toward the concavity. 
Moreover, that this is due to the fact that in slight or easy 
flexion, articular facets are not in contact or locked and the 
load is thrown more upon the bodies of the vertebra, so that 
the superimposed weight becomes an important factor, and 
when spine is side-bent, the bodies have a tendency to crawl 
out from under the load by rotating toward the convexity. 
Side-bending-rotation with body rotated to the convexity 
is applicable alone to the mid-dorsal spine in a position of 
hyperflexion: in fact, the author believes it to be found there 
only under the above circumstances. 
Rotation of the body of a vertebra toward the con- 
vexity of the curve outside of organic curvature and the above 156 
Downing Principles and Practice of Osteopathy 
functional inclination which has been mentioned is considered 
impossible. If such rotation does occur the physical reasons 
for the phenomenon are still unproven and have not been sub- 
stantiated by scientific investigation. Providing that, as in 
the case mentioned by Fryette, side-bending is the primary 
movement, an apposition of the articular facets soon occurs 
and from that point movement becomes side-bending-rotation 
and the body must then rotate toward the concavity of the 
curve for the plane of movement is thereafter controlled or 
directed by the articular facets and associated dynamic mus- 
cular influence. The preceding factors are of considerable 
value in the study of functional curvatures. 
A more succinct statement of the facts is as follows: 
When any given area is in easy flexion and side-bent, the 
proportion of rotation of the body of a vertebra toward the 
concavity is considerably lessened over that occurring in the 
erect position and, with any given area in hyperflexion or ex- 
tension, in side-bending the rotation of the bodies of the verte- 
brae toward the concavity is increased over that possible in 
the erect position. Moreover, in the former, side-bending is 
the primary movement and in the latter rotation is the 
primary movement. 
This movement occurs upon a transverse 
axis through the center of that portion of 
the body of each vertebra which is in con- 
tact with the nucleus pulposus of the in- 
tervertebral disc below. This pulpy nucleus of the interverte- 
bral fibro-cartilage is, throughout the entire movement of 
flexion, the pivot or ball-bearing over which movement must 
take place. 
The inferior articular facets of the vertebra above move 
upward and forward on the superior facets of the vertebra 
below and become bilaterally anterior in their relation to the 
latter. 
Flexion of the 
Cervical 
Vertebra: Subluxations of the Cervical Vertebrae, 2d to 1th 
157 
The posterior ligaments are tensed, due to the separation 
of their attachments and the relative length of the column is 
increased posteriorly thereby obliterating to a more or less 
extent the normal cervical curve. The amount of this obliter- 
ation is dependent upon the amount of flexion. This same 
rule holds true to the relative increase in the length of the 
cervical spinal column posteriorly. 
Anteriorly, all changes are approximal in character. The 
relative length of the spine anteriorly is diminished, the con- 
vexity of the cervical curve anteriorly is lessened, the anterior 
portion of the inter-vertebral disc is subject to compression 
and the adjacent ligaments slackened. 
When the entire spinal column is moderately flexed the 
upper cervical and lumbar regions become locked, this being 
a forced tissue tension locking of an anatomical character. In 
extreme flexion the whole spine is locked although the lower 
cervical and thoracic column can not be as completely locked 
in flexion, even though that flexion be severe, as is possible in 
the physiologic movement of extension in which the first 
areas to lock are the lower cervical and dorsal parts of the 
column. If such lockings are primarily attempted the pos- 
sibility of subsequent rotation or side-bending in the locked 
areas is prohibited. 
In the cervical column flexion locks from above down- 
ward and extension locks from below upward and these two 
opposing movements nullify each other at the third cervical, 
their opposition being complete at this point. 
The inferior articular facets of the verte- 
bra above move bilaterally downward and 
backward upon the superior articular 
facets of the vertebra below. However, 
movement of the inferior articular facets downward and 
backward is short-lived, as transverse articular fixation 
almost immediately takes place. Primarily, movement occurs 
Extension of 
the Cervical 
Vertebra: 158 
Downing Principles and Practice of Osteopathy 
upon the same axis as that of flexion, the nucleus pulposus 
acting as a pivot or ball-bearing. It is logical to assume, after 
relative comparison of the amount of flexion and tension in 
the cervical area together with their respective articular 
movements, that the axis for further movement of extension 
must shift from the nucleus pulposus and body of the vertebra 
to a transverse axis drawn transversely through the articular 
processes of the vertebra, thus allowing more pronounced 
separation anteriorly. Posteriorily, all changes are approxi- 
mal in character. In brief, the reverse of flexion, with the 
relative length of the column increased posteriorly, ligaments 
relaxed and slackened and anterior convexity increased is 
encountered. 
Forced extension locks the entire spine because the in- 
ferior articular facets of each vertebra are jammed down on 
the laminae of the vertebra below7. Moderate extension locks 
all but the upper cervical column, the last one or tw7o dorsal 
and the lumbar area. The upper dorsal is the first to lock in 
extension, and the last to lock in flexion. This is nature’s way 
of protecting and reinforcing vertebrae in extreme positions. 
Knowledge of these particular anatomical lockings is import- 
ant in consideration of their value when fixation or immobil- 
ization is desired for any corrective purpose. 
The common lesions of these articulations 
are: the rotation side-bending, or side- 
bending rotation lesion to the right, (syn. 
unilaterally anterior on the left, posterior 
on the right) and the rotation side-bending or side-bending 
rotation lesion to the left (syn. unilaterally anterior on the 
right, posterior on the left). 
Other possible lesions are flexion and extension lesions 
(syn. bilaterally anterior or bilaterally posterior, respective- 
ly). These lesions are confined to the very lowermost cervi- 
cal vertebrae, i. e., the fifth, sixth and seventh. 
Lesions of 
the Cervical 
Vertebrae: Subluxations of the Cervical Vertebrae, 2d to 7th 
159 
Tucker states that cervical vertebrae may be also unilat- 
erally posterior on the right or left or unilaterally anterior 
and that this particular type of torsion lesion does not neces- 
sarily infer a corresponding displacement on the opposite 
side. Of these lesions, he further states, the unilateral pos- 
terior is the more common. 
Such a type of lesion, however, necessitates asymetrical 
movement of a unilateral order, with the axis of movement 
passing obliquely vertical through the articular process and 
articular facets on the side opposite that of gross lesion. The 
mechanical difficulties of such a primary movement are such 
as to preclude any great frequency of this type of lesion. 
Under forced conditions, it may possibly occur, although rare- 
ly. The author has previously stated that rotation first takes 
place on a more or less oblique although nearly vertical axis, 
passing through the nucleus pulposus of the intervertebral 
disc and that this movement of rotation is symmetrical until 
bony contact limitation prevents further downward, back- 
ward movement on the side which rotates postero-inferiorly. 
This allows of a fixed-point axis, an axis passing obliquely, 
although approaching the vertical through the articular proc- 
ess and facets on the side to which the vertebra is rotated. 
Movement of rotation, further continued, must be asymetri- 
cal, revolving around this fixed-point axis and allowing of a 
much greater arc of motion of the articular facet which ro- 
tates upward and forward. Under such circumstances as 
Tucker mentions, however, there is nothing to maintain one 
articular process as a fixed-point axis of an arc of movement 
of the opposite facet. The mechanical difficulty of such a 
state is therefore entirely obvious. 
Directly lateral lesions on the right or left are lesions 
mentioned by Tucker as being characterized by a lateral dis- 
placement maintained evidently by a catch of the lateral lip 
of the body of the vertebra against the tissues at the base of 
the opposing bone. Such a type of condition is rarely found 160 
Downing Principles and Practice of Osteopathy 
and only apt to occur in the lower cervical spine, if at all. 
The mechanics of correction for such conditions should 
suggest themselves. In brief, adjustment consists of flexion 
and strong side-bending with a rocking motion to separate 
and dislodge the catch. 
A cervical lesion, when primary, may be 
due to that particular nerve reflex pheno- 
menon which we term reciprocal innerva- 
tion. The resultant muscle-spasm and imbalance of tensions 
is sufficient to produce a subluxation, the character of which 
is responsive to and dependent upon the nature of the unequal 
muscular tensions. It may be due to some postural, occupa- 
tional, or functional anomaly, in which case the stabilization 
of its adjustment is dependent upon the removal of the under- 
lying primary factor. Trauma is another common cause and 
the subluxation is then the result of some wrench, twist, or 
direct violence. It is occasionally secondary to other spinal 
lesions for which it may be counterbalancing or compensatory 
so as to maintain the greatest possible efficiency of equili- 
brium. It may be the result of an extension of inflammation, 
and in nature a rhemuatic diathesis with a focal infection 
elsewhere. 
Exposure of the neck to rapid thermal changes, drafts 
etc., may be a causative factor. Defective hearing and visual 
disorders may either reflexly or because of the particular 
position the patient has to assume because of his ailment, have 
a pronounced etiological bearing. It would be impossible to 
enumerate each and every cause of the cervical lesion. 
A cervical vertebra, second to the seventh, 
inclusive, maintained unilaterally an- 
terior on the right, posterior on the left, 
and vice versa, a vertebra immobilized un- 
ilaterally anterior on the left, posterior on 
the right, is a rotation side-bending or 
side-bending rotation lesion to the right and left, respectively. 
Etiology of 
Cervical Lesions: 
The Rotation 
Side-bending, or 
Side-bending 
Rotation Lesion: Subluxations of the Cervical Vertebrae, 2d to 1th 
161 
Diagnosis: For the purposes of convenience, we will 
consider a hypothetical lesion, a third 
cervical vertebra immobilized unilaterally antero-superiorly 
on the left, postero-inferiorly on the right. The above lesion 
is a rotation side-bending to the right. 
The deviation of the spinous process is to the left and 
the body of the vertebra rotates to the right and assumes a 
slightly tilted position so that the intervertebral disc is pinched 
on the right side. The transverse and articular processes on 
the left move upward and forward and become approximated 
with those of the vertebra above on the same side. The an- 
terior or costal tubercle is more prominent anteriorly, very 
sensitive to palpation, and a diagnostic land-mark of value. 
The transverse and articular processes on the right assume 
a downward and backward position and are approximated to 
those of the vertebra below on the same side. The posterior 
tubercle of the transverse process and the articular process 
itself are more prominent posteriorly, very sensitive, and 
diagnostic land-marks of value also. 
The main points on which to base a diagnosis are the rel- 
ative comparison in position of the anterior and posterior 
tubercles of the transverse processes together with the chang- 
ed positions assumed by the articular processes. Comparison 
should be made of one side with the other. There is usually 
marked tenderness over the spinous, articular and transverse 
processes. The articular process which is rotated posteriorly 
is particularly sensitive as is also the costal tubercle which 
has rotated anteriorly. 
The position that the patient’s head and cervical column 
assumes in relation to the underlying structural conditions 
is somewhat characteristic and a more or less probable sign 
of the nature of the condition. Lengthening of the cervical 
column occurs on the anterior side. The nature and location 162 
Downing Principles and Practice of Osteopathy 
of soft tissue changes and subjective symptoms will deter- 
mine only the presence of a lesion, but give no definite infor- 
mation as to the nature and character of it. 
The relative position of the spinous processes cannot be 
relied upon as an accurate diagnostic feature as they are so 
often subject to anatomic variations. They may help to sub- 
stantiate other findings but should never be relied upon as 
giving a true estimate of the position of the vertebra in lesion. 
Too much emphasis is sometimes given to them as they are so 
obvious and freely palpable. 
One of the most accurate means of diagnosis at our com- 
mand is, by the utilization of physiological movement, to ex- 
aggerate the lesion. In the above hypothetical instance, fix- 
ation is in rotation side-bending to the right. Exaggeration 
of the lesion then consists in rotation side-bending to the left. 
In other words, in moving that area of the spine in which the 
lesion is situated, through the utilization of specific physi- 
ological movement in a direction which is the exact antithesis 
to that in which the lesion is immobilized. If on so doing, the 
vertebra apparently in lesion gives the appearance of being 
still more decidedly in lesion, there is added proof of the pres- 
ence of fixation and of the nature and character of that fix- 
ation. If, on reversing the side-bending rotation, the verte- 
bra in lesion apparently disappears, there is still more con- 
clusive proof of its presence, as you have then ruled out the 
possibility of some anatomic variation being the cause of an 
apparent subluxation. In conclusion, it must be stated that 
if a vertebra shows anatomic findings which indicate a lesion 
of a certain type with the cervical column in a normally erect 
position, (neither flexion, extension, side-bending nor rota- 
tion) and if this same vertebra shows evidence of decided in- 
crease of anatomical variance when physiological movements 
are utilized, the direct opposite in direction of those in which 
the lesioned vertebra is immobilized, the presence of fixa- 
tion and the nature thereof are thereby fully demonstrated. Subluxations of the Cervical Vertebrae, 2d to 1th 
163 
The same combination of movements that produced the lesion 
carried to their full capacity in that area, would cause the le- 
sion apparently to disappear, providing there is no anatom- 
ical malformation of the vertebra in lesion, and providing 
sion apparently to disappear, providing there is no anatom- 
range of activity, in which case the condition would be a 
dislocation rather than a subluxation. 
This method of diagnosis by physiologic restriction of 
motion can be utilized for all areas and all types of spinal sub- 
luxations. It is probably the one best diagnostic maneuver 
at the operator’s command as he can only draw inferences 
from objective physical findings as to the position of the ver- 
tebrae, while the physiologic findings give a true estimate of 
the underlying condition. 
1. Flexion Extension or the Erect Posi- 
tion. The first step in the production of a 
complete physiological locking of the area 
involved consists in the proper use of flexion extension, or 
the erect position. Its particular value is to bring the great- 
est amount of side-bending rotation in and about the verte- 
bra in lesion, that the physiological locking may be as com- 
plete as possible, and thereby insure a full range of arthrodial 
movement to the vertebra in lesion in the direction opposed 
to that in which it has become fixed. The author has pre- 
viously stated that flexion locks the cervical column from 
above downward and extension locks it from below upward; 
and that their opposition is complete at the third cervical. The 
correct inference to be drawn from this is that the greatest 
range of side-bending rotation movement is at the third cer- 
vical and possible only when the cervical column is in the 
erect position. In other words; in neither flexion nor exten- 
sion. All adjustments of torsion lesions at this point should 
be made in the erect position. All adjustments of lesions 
above this point should be made with a gradual increase in 
extension, the higher in the column the lesion is, the greater 
Principles of 
Adjustment: 164 
Downing Principles and Practice of Osteopathy 
the degree of extension. All lesions below the third cervical 
should be adjusted in a gradual increase of flexion from 
above downward, the lower in the column the lesion, the 
greater the degree of flexion. Proper use of the above move- 
ments can be so accurate as to confine the greater propor- 
tion of movement to the articulation in lesion, which is the 
desired thing. It is obvious, then, that in a lower cervical 
lesion we have enforced no limitation upon the joint in lesion, 
so that it has a full possibility of complete arthrodial motion 
in the reverse direction to that of fixation but that with the 
same movement we have superimposed upon the area above 
the lesion an anatomical locking in flexion. 
In a lesion of the upper cervical, extension is the prime 
movement as it effects an anatomical locking of the lower 
cervical and at the same time enforces no limitation upon the 
joint in lesion, but rather gives it the fullest possibility of 
complete arthrodial motion in the reverse direction to that 
of the fixation. 
In both instances the lesion is left unprotected for ad- 
justment. 
2. Side-bending: This side-bending must be toward 
the side unilaterally postero-inferior as this is the first 
fundamental law in physiological or articular locking. Ap- 
position of articular facets is necessary and this apposition 
must be upon the side on which adjustive force is to be given. 
It must be understood that articular or physiological locking, 
as it is called, is not a locking through forced tension of tis- 
sues, but rather a locking in which the inherent mechanics of 
the articular facets play a considerable part. This prime move- 
ment enforces a physical restriction upon the articular facets 
themselves by the added compression to which they are sub- 
jected. Superimposed upon this primary movement of side- 
bending is secondary rotation in the reverse direction to that 
of the side-bending which brings the articular facets on the 
side of lesion upward and forward to a point of complete limi- Subluxations of the Cervical Vertebrae, 2d to 1th 
165 
tation where they articularly lock without possibility of 
strain or injury to the soft tissues in and around the joints 
and adjacent confining structures. Moreover, the movement 
of side-bending gaps the opposite side allowing plenty of room 
for the anterior articular facet to retrace its full arthrodial 
excursion. The degree of side-bending depends upon the situ- 
ation in the cervical column and the obliquity of the plane 
surface. For lesions between the second and third cervical, 
the amount of this side-bending should approximate an angle 
of fourteen degrees with the midline. The apex of the angle 
of this side-bending should be at the point of lesion. In other 
words, the midline of the body and the line of side-bending of 
the cervical column above the point of lesion should consti- 
tute two sides of this angle and its apex should be at the 
point of lesion—the point of junction of these two lines. It is 
therefore obvious that the lower in the column the lesion, the 
wider the sweep of the occiput from the midline, if the same 
degree of angulation is to be effected at the point of lesion, 
as the line lengthens from above downward. Because of the 
increased obliquity of the plane-surfaces from above down- 
ward there is an increase in the degree of angulation of ap- 
proximately one degree for each vertebra. 
Occipui 
1C 
2 
3 
4 
5 
6 
7 
Diagramatic key showing degree and apex of angulation of side-bending 
necessary for adjustment of cervical vertebrae. 166 
Downing Principles and Practice of Osteopathy 
3. Rotation: Rotation must be toward the side unilat- 
erally antero-superior. This procedure performs a dual func- 
tion as it primarily completes physiological locking by carry- 
ing those vertebrae immediately above and below the lesion to 
a point of articular locking in the direction in which we are to 
apply our adjustive force. At the completion of this locking 
produced by dissemination of the forces of side-bending and 
rotation above and below the lesion, we still have force, bear- 
ing in at the point of lesion, although this force is no longer a 
locking mechanism but rather an effective natural leverage 
force. Rotation should be such that the rotary strain is great- 
est at the point of lesion and the direction of this rotary strain 
should be parallel to the planes of the articulations. The end 
result of this focalization of forces to the articulation in le- 
sion produces a maximum amount of leverage force and at 
the same time gives a complete combination of physiological 
and anatomical locking of the cervical column at all points 
other than the articulation in lesion. 
The muscular action of side-bending, reverse rotation is 
such that these two muscular agencies oppose each other. The 
action of one harmoniously and completely nullifies the ac- 
tion of the other in such a way as to add to the efficacy of a 
locking process with complete avoidance of muscular strain. 
4. Approximation: This particular mechanical force 
may or may not be utilized. It is occasionally necessary when 
dealing with hypermobile types of spines, as it enhances and 
strengthens physiological locking through the enforced com- 
pression and added friction induced. Vertex pressure with 
the operator’s abdomen at right angle to the planes of the 
articulation gives the desired effect. 
5. Adjustment: The last step in the adjustive pro- 
cedure is a slight rotary thrust upward, forward, medialward 
and parallel to the planes of the articulation. This force is 
directed against the objective after the cervical spine is in a Subluxations of the Cervical Vertebrae, 2d to 1th 
167 
completed state of combined anatomical and physiological 
locking. 
Concomitantly with the adjustive force slight exaggera- 
tion of the side-bending reverse rotation is made. The con- 
centration of this force is at the point of lesion for two rea- 
sons: first, because the forces were primarily focalized to 
that point; and, second, because there can be no further dis- 
semination of these forces upward or downward as the neigh- 
boring vertebrae are in a state of complete articular locking. 
In consequence this force acts in a powerfully adjunctive man- 
ner, and is an effectual and corrective leverage force directed 
against the articulation in lesion. This powerful lever, ap- 
plied with a minimum amount of adjustive force, gives a max- 
imum of efficiency with a minimum of strain and velocity. 
The adjustive force should be given so that the velocity 
is high but the amplitude of motion short. 
From a standpoint of physics, two lever arms are avail- 
able. The long lever arm is the transverse process which ro- 
tates antero-superiorly and the short lever-arm the one which 
rotates postero-inferiorly. Naturally the best objective will 
be the point of greatest leverage. In this case the mechanical 
advantage is such that the transverse process which rotates 
postero-inferiorly is the point to which direct force can be 
applied with the best results. The objective is therefore the 
combined transverse and articular processes of this side. The 
instrumentality of adjustive force is the operator’s index or 
middle finger. The applied force is the thrust. With these 
principles in view adjustment can be carried out by direct 
action technique with the patient supine or in a sitting pos- 
ture. 
Consider as the hypothetical lesion a rota- 
tion side-bending lesion of the third cer- 
vical vertebra immobilized unilaterally 
antero-superiorly on the left, postero-inferiorly on the right. 
The mechanics of adjustment are as follows: 
Technique of 
Adjustment: 168 
Downing Principles and Practice of Osteopathy 
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uoijbjoj esaaAOJ jo uoijaaaip puo ‘l>uipuaq-apis jo saajJiap ‘spusq jo uoijisoj Subluxations of the Cervical Vertebrae, 2d to 7th 
169 
1. The erect position (neither flexion nor extension). 
2. Side-bending to the side unilaterally postero-in- 
ferior; the angle of this side-bending is approxi- 
mately thirteen degrees with the midline of the 
body. 
3. Rotation toward the side antero-superior with the 
rotary strain greatest at the point of lesion and 
conducted parallel to the planes of the articulation. 
4. Approximation, if necessary. Adjust with simul- 
taneous utilization of adjustive and leverage- 
force. 
While the adjustive hand delivers adjustive force to the 
vertebra in lesion, the opposite hand accomplishes several im- 
portant functions. It is so placed as to support and protect 
the cervical vertebrae above the point of lesion and acts more 
or less as a splint to the lateral aspect of the cervical column. 
It aids and largely controls the act of physiological locking in 
side-bending rotation and when locking is arrived at further 
exercise of the physiological movements comprising this lock- 
ing constitutes leverage force. 
Technique No. 1: Direct Action Technique: Patient 
supine. The objective is the transverse process which has 
rotated posteriorly. The instrumentality of force is the lat- 
eral aspect of the index finger of the right hand (adjustive 
hand). The head and cervical column is maintained in the 
erect position, side-bent to the side unilaterally posterior 
(right) and rotated toward the side unilaterally anterior 
(left). The left hand is placed along the lateral aspect of the 
cervical column of the left side. Rotary adjustive force is de- 
livered against the combined transverse and articular proc- 
esses of the third cervical on the right side. At the same time 
the left hand coordinates with it in such a way as to insure 
counter-force and exaggerate leverage force which is accom- 
plished by slight increase of the side-bending and reverse 
rotation. 170 
Downing Principles and Practice of Osteopathy 
Position for adjustment of a seventh cervical vertebra immobilized in rota- 
tion side-bending to the right. The objective is the transverse process fixed 
postero-inferiorly on the left. The anatomical locking of flexion locks the upper 
cervical and merges into the physioloigic locking of the lower cervical obtained by 
side-bending to the side posterior and reverse rotation to the side anterior. With 
the cervical column completely locked, a leverage mechanism is assured. Super- 
impose to leverage force adjustive force against the objective in an upward, for- 
ward and medialward direction, parallel to the planes of the articulation. Subluxations of the Cervical Vertebrae, 2d to 1th 
171 
Technique No. 2. Direct Action Technique: Patient 
sitting. The operator stands facing the patient on the side 
opposite that on which the transverse process is posterior. 
The palmar aspect of the slightly flexed middle finger is 
placed firmly against the unilaterally posterior transverse 
and articular processes, while the patient rests his head upon 
the hypothenar eminence of the same hand (left hand). The 
right hand of the operator is placed along the left lateral as- 
pect of the cervical column for the maintenance of counter- 
force and exaggeration of leverage force. The left hand de- 
livers the adjustive force. The physiological movements of 
side-bending to the side posterior, and rotation toward the 
side anterior with the cervical column in the erect position, 
(neither flexion nor extension) must be completed before ad- 
justment is attempted. 
Adjustment by Indirect Action Technique: Indirect 
methods are not as easily controlled as direct methods. For 
ease of accomplishment and specificity, direct action techni- 
que is much to be preferred. The adjustment may be ac- 
complished with the patient either sitting or supine. The ob- 
ject in mind is to maintain a fixation of the vertebra below 
the one in lesion, on the same side the lesioned vertebra has 
rotated upward and forward. This is accomplished by main- 
taining counter pressure against the articular and transverse 
processes of the vertebra below the one in lesion on that side. 
Next, retrace the pathway of lesion movement by rotation of 
the head and cervical column toward the anterior side. Side- 
bending should be maintained throughout this procedure to- 
ward the side which is unilaterally posterior. 
A cervical vertebra, second to the seventh, 
inclusive, whose inferior articular facets 
are maintained bilaterally anterior is a 
flexion lesion. There is approximation of the spinous and 
transverse processes of the vertebra in lesion with those of 
the vertebra above and corresponding separation with those 
The Flexion 
Lesion: 172 
Downing Principles and Practice of Osteopathy 
.5 
T 
M 
Position for adjustment of a fifth cervical vertebra immobilized in rotation 
side-bending to the left. F indicates decree of flexion, S indicates focalization 
of side-bending to the point of lesion. Arrow indicates direction of corrective 
force of rotation. Subluxations of the Cervical Vertebrae, 2d to 1th 
173 
of the vertebra below. This lesion may occur singly but is 
usually found as a group lesion, counterbalancing or com- 
pensatory in character. If a compensatory group lesion, pro- 
ducing a straightening of the cervical curve, correct the 
etiological factors, inasmuch as cervical vertebrae in this case 
are not in an immobilized state and their position is an as- 
sumed one, due to muscular influences. If found singly cor- 
rect with indirect action technique heretofore described, ad- 
justing first one side, then the other. These lesions are rarely 
found and are confined to the lower cervical region, usually 
the sixth or seventh cervical. 
A cervical vertebra, second to the seventh, 
inclusive, whose inferior articular facets 
are maintained bilaterally posterior is an 
extension lesion. The amount of articular movement is rel- 
atively less in comparison to that found in the flexion type 
of lesion. The transverse and spinous processes of the le- 
sioned vertebra are approximated with those of the vertebra 
below. The obliquity of the plane of the spinous process is 
increased, consequently the process is less prominent and 
more impalpable posteriorly. Normal separation from the 
vertebra above is increased. This lesion may occur singly but 
more often is found as a group lesion when accentuation of 
the cervical curve is demanded for purposes of counter bal- 
ance. If found singly, correct unilaterally, first one side then 
the other, by strong obliteration of the cervical curve nearly 
to the point of locking, then using a modification of direct 
action technique, heretofore described. 
Dislocations of the lower six cervical ver- 
tebrae are the most common dislocations 
of the spine, and the articulations be- 
tween the fourth and fifth, and the fifth 
and sixth segments are most frequently involved. Diasta- 
sis or rupture of the ligaments may be complicating fac- 
The Extension 
Lesion: 
Dislocation 
of a Cervical 
Vertebra: 174 
Downing Principles and Practice of Osteopathy 
Position of hands and patient for adjustment of a fifth cervical vertebra 
immobilized in rotation side-bending to the right. Middle finger of adjustive 
hand is placed firmly against the articular process which is postero-inferior. 
Opposite hand is placed along the lateral cervical column to splint, support and 
protect the area. It also controls largely side-bending and reverse rotation which 
together enforce physiologic locking of the area. After completion of this lock- 
ing, exaggeration of these physiologic moves determines leverage force as a result 
of the automatic transition which follows. Subluxations of the Cervical Vertebrae, 2d to 1th 
175 
tors. The bilateral and unilateral forward displacements 
are the more common, and the bilateral backward and the 
bilateral in opposite directions less frequent. Dislocation may 
occur with or without cord symptoms. Movements of the 
neck are usually extremely painful and the deformity is ob- 
vious, although the X-ray is the only means of differential 
determination as to whether the condition is a fracture or 
dislocation. Treatment should consist of hyper-extension and 
immobilization with a collar. 176 
Downing Principles and Practice of Osteopathy 
CHAPTER VII. 
SUBLUXATIONS OF THE THORACIC VERTEBRAE 
Applied Anatomy: The typical thoracic vertebrae are 
intermediate in size to those of the cervical and lumbar re- 
gions and increase in bulk from above downward. The most 
distinguishing features of these vertebrae are the depressions 
on the bodies and transverse processes, respectively, for the 
reception of the heads and tubercles of the ribs. 
The bodies of the thoracic vertebrae simulate those of 
the cervical and lumbar vertebrae at their respective ends. 
The intermediate members are heart-shaped, thicker behind 
than in front, and approximately the same width in both their 
anterio-posterior and transverse diameters. The pedicles 
face backward and the inferior intervertebral notches are 
large and deep. The laminae are broad, thick and overlap 
one another. The spinous processes are long, directed 
obliquely downward and end in tuberculated extremities. The 
superior articular facets face backward and somewhat up- 
ward and lateralward. The inferior articular facets face for- 
ward, downward and medialward. The transverse processes 
are thick, strong and project obliquely backward and lateral- 
ward. The inferior articular processes of the twelfth thor- 
acic vertebra are convex and turned outward, partaking of 
the nature of those of the lumbar vertebrae. 
The thoracic curve, which is primarily concave forward, 
commences at approximately the middle of the second and 
terminates at approximately the middle of the twelfth tho- 
racic vertebrae. This posterior convexity is due largely to the 
fact that the bodies of the vertebrae are slightly thicker be- 
hind than in front. 
The different segments of the thoracic 
column are connected by spinal ligaments 
similar to those of the cervical and lum- 
bar regions. The ligaments connecting 
Thoracic 
Vertebral 
Articulations: Subluxations of the Thoracic Vertebrae 
177 
Superior- facet 
iftflr' *' ! 
Inferiorfacet 
Spme 
Thoracic vertebra, anterior view. 
the bodies of the vertebrae are the anterior common liga- 
ment, the posterior common ligament and the intervertebral 
fibro-cartilage or disc. Those connecting the laminae are 
the ligamenta subflava. The transverse processes are con- 
nected by the inter-transverse ligaments. Those connecting 
the articular processes are called the capsular ligaments. 
They are lined on their inner surface with synovial mem- 
branes and form double arthrodia, superiorly and interiorly. 
Spt nous 
process 
All movements of the thoracic vertebrae are restricted 
to reduce interference with respiration. The almost com- 
plete absence of an upward inclination of the superior artic- 
ular facets prohibits any marked flexion, while extension is 
checked by bony contact limitation of the inferior articular 
margins with the laminae, the approximation of the spinous 
processes with one another and the tension in the anterior 
common ligament. 
Lateral view of typical thoracic vertebra. 178 
Downing Principles and Practice of Osteopathy 
A 
A 
3 
3 
C 
c 
Demonstrating position assumed by vertebra immobilized in flexion. Note 
aproximation of transverse processes of vertebra BB' to those of vertebra above, 
AA', and separation from those of vertebra below CC'. Note increased obliquity 
spinous process of the vertebra involved and its increased prominence posteriorly. 
Buckling of the yielding column is apparent so that the vertebra is en masse pos- 
terior, although the inferior articular facets have moved bilaterally upward and 
forward on those of the vertebra below. Subluxations of the Thoracic Vertebrae 
179 
The 
Intervertebral 
Substance: 
The outer portion is composed of a large 
number of concentric layers of fibrous 
connective tissue. This enveloping portion 
is called the annulus fibrosus. The central 
portion is a soft, pulpy mass of highly elastic fibro-cartilage 
and is in a greatly compressed state. It is called the nucleus 
pulposus and is embryological vestige of the notochord. It 
acts as a ball-bearing mechanism and is the fulcrum for the 
greater percentage of movement of the bodies of the verte- 
brae. 
Any movement of the column which de- 
scribes a forward arc of motion is desig- 
nated flexion. In this movement the anterior common liga- 
ment is relaxed and the intervertebral substance is compress- 
ed in front; while the posterior common ligament, ligamenta 
subflava, and the inter- and supra-spinous ligaments are 
stretched, together with the posterior fibers of the interver- 
tebral disc. The interspaces between the laminae are widen- 
ed and the inferior articular processes of the vertebra above 
glide upward on the superior articular processes of the verte- 
bra below. Flexion is the most extensive of all the move- 
ments of the vertebral column. The thoracic spine is the 
first to lock in extension and the last to lock in extreme 
flexion of the entire spine. Flexion is freer in the lower tho- 
racic than any other portion of the region. 
This movement is the converse of flexion 
in that there is an exactly opposite dis- 
position of parts. The movement is limited to a greater rel- 
ative extent than flexion by the anterior common ligament 
and bony contact limitation. The inferior border of each 
articular process comes in contact with the lamina of the 
vertebra below. There is an approximation of the spinous 
processes and to a lesser degree the transverse processes. Ex- 
tension is extremely limited in the thoracic area, particularly 
in the mid and upper thoracic regions and has its freest range 
of motion in the lower thoracic area. 
Flexion: 
Extension: 180 
Downing Principles and Py-actice of Osteopathy 
A 
A 
13 
6 
C 
c 
Demonstrating position assumed by vertebra immobilized in extension. Note 
approximation of transverse processes of vertebra BB' to those of vertebra below 
CC', and separation from those of vertebra above A A'. Note increased oblquity 
of spinous process of the vertebra involved and its lessened prominence posteriorly. 
Buckling of the yielding column is such that the vertebra is en masse anterior, 
although the inferior articular facets have moved bilaterally downward and back- 
ward on those of the vertebra below. Subluxations of the Thoracic Vertebrae 
181 
Side-bending 
or Lateral 
Flexion: 
The intervertebral discs are compressed 
laterally and motion is limited by the re- 
sistance of the surrounding ligaments 
and also by approximation of the trans- 
verse processes. Side-bending is freer in the lower thoracic 
than in any other portion of the dorsal spine. 
This movement is quite free around a ver- 
tical axis drawn along the mid-ventral 
line of the bodies of the vertebrae. The movement is pro- 
duced by a slight torsion of the intervertebral substance. 
This, although slight between any two vertebrae, produces 
considerable range of motion when taking place throughout 
the entire length of the column. Rotation is most pronounc- 
ed in the upper part of the thoracic column. 
The cervical column enjoys the greatest degree of each 
variety of movement. In the thoracic region all movements 
are limited, particularly in the mid-dorsal. In the lumbar 
area motion is free with the exception of rotation. 
These movements are invariably combin- 
ed and one never occurs without the other, 
yet the direction and amount of each 
varies, depending upon which is the primary movement. In 
the above case, when side-bending is primary, rotation of 
the body is limited by the opposing action of the two physi- 
ological movements, providing obvious rotation is attempted 
in an opposite direction to that of the side-bending. Regard- 
less of whether the side-bending is primary or secondary, if 
the rotation is attempted toward the same side as the lateral 
flexion, the body of the vertebra will rotate toward the con- 
cavity of the curve. The bodies of the vertebrae will act dif- 
ferently under varying degrees of flexion or extension and 
depending upon whether or not the movement is voluntary 
or passively enforced. In side-bending reverse rotation in 
which the patient is side-bent toward one side primarily and 
rotated toward the opposite side secondarily, a slight tend- 
Rotation: 
Side-bending 
Rotation: 182 
Downing Principles and Practice of Osteopathy 
A 
A 
B 
B 
I 
c 
c 
Demonstrating position assumed by vertebra immobilized in ordinary rotation 
side-bending, or side-bending rotation. Note postero-inferior position of right 
transverse process B and antero-superior position of left transverse process B'. The 
spinous process is deviated to the left. This lesion is a combination of the 
physiologic movements of rotation and side-bending to the right. These move- 
ments are inseparable, although in varying proportions. This is a common type 
of subluxation. Subluxations of the Thoracic Vertebrae 
183 
ency to rotation of the body toward the convexity of the curve 
is noted, provided the spine is in the erect position, easy 
flexion or easy extension. In voluntary movements in which 
the patient himself attempts side-bending to one side and 
rotation toward the opposite side, the tendency is to lock the 
bodies of the vertebrae in the midline by the opposing action 
of the two forces, except when the spine is in flexion, in 
which case the bodies of the vertebrae of the upper mid-dor- 
sal area can rotate slightly toward the convexity of the curve. 
In passive movements, when side-bending is alone in- 
duced, the tendency is for the bodies of the vertebrae to rotate 
slightly toward the concavity of the curve. In voluntary 
side-bending on the part of the patient, the possibility of any 
tendency to rotation of the bodies of the vertebrae toward the 
convexity is questionable unless an obviously forcible at- 
tempt is made by the patient to rotate his body toward the 
side opposite that of side-bending. 
In conclusion it may be stated that a tendency for rota- 
tion of the bodies of the vertebrae toward the convexity of 
the curve is possible in passive movements when the patient 
is obviously side-bent to one side primarily and secondarily 
rotated to the other; and this only in case the spine is neither 
locked anatomically in hyperflexion or extension. In volun- 
tary movement when primary side-bending is followed by a 
secondary attempt at rotation toward the side opposite that 
of the lateral flexion the body of the vertebra tends to re- 
main in the midline or rotate slightly toward the concavity 
except with the spine in hyperflexion in which case there is a 
slight rotation of the upper mid-dorsal toward the convexity. 
In a general way the element of rotation is greater when the 
spine is in extension and the percentage of side-bending cor- 
respondingly increases with the spine in flexion although this 
13 not a hard and fast rule. 184 
Downing Principles and Practice of Osteopathy 
A‘ 
A 
13 
8 
C 
c 
Demonstrating position assumed by vertebra immobilized in side-bending 
rotation. B' indicates postero-superior position of left transverse process. B 
indicates antero-inferior position of right transverse process. Slight deviation of 
the spinous process to the right may o.r may not be noted. Primary side-bending 
to the right is followed by secondary rctation to the left and is consequently a 
movement of side-bending, secondary reverse rotation. This lesion is found oniy 
in combination with flexion and is confined to the upper mid-dorsal. Subluxations of the Thoracic Vertebrae 
185 
Lesions of the 
Thoracic 
Vertebrae: 
1. Flexion Lesion. 
2. Extension Lesion. 
3. Rotation Side-bending Lesion. 
4. Side-bending Rotation Lesion. 
The Flexion Lesion (Syn. Bilaterally Anterior Lesion). 
The flexion lesion is an immobilization of the vertebra 
in the position of flexion. It is bilaterally anterior if con- 
sidered from the relative change in position of the inferior 
articular facets of the vertebra in lesion upon the superior 
of the vertebra below. However, from its relative disposition 
in the dorsal column and because the obliquity of the spinous 
process is decreased and the convexity of the thoracic curve 
increased, it is relatively more prominent posteriorly, and is 
therefore considered by many as an en masse posterior le- 
sion. It may be single or in group formation in which latter 
case it results in the production of a so-called dorsal kyphosis. 
Trauma, sudden strains, particularly with 
the dorsal spine in flexion, and the lifting 
of heavy weights are some of the causes of individual lesions. 
The group lesion is usually occasioned by a gradual process 
extending over a long period of time. Occupational and 
faulty postural habits, general atonicity of the extensor 
muscles, hypertonicity of the flexors, etc., are examples of its 
predisposing factors. The larger percentage of individual 
lesions are the results of reciprocal innervation. A small 
percentage of lesions are the result of infection. 
The spinous process of the vertebra in le- 
sion is less oblique, therefore relatively 
more posterior; and, moreover, it is separated from that of 
the vertebra below and approximated with that of the verte- 
bra above. Restriction of motion upon the vertebra below is 
such that the degree of separation of the spinous processes 
cannot be changed either by flexion or extension. Move- 
ment is free between the vertebra in lesion and the one above, 
Etiology: 
Diagnosis: 186 
Downing Principles and Practice of Osteopathy 
although there is approximation of the spinous processes. 
The articular facets have moved bilaterally upward and for- 
ward, and there is some separation of the articular surfaces 
posteriorly, due to the tipping and different level maintained 
by the vertebra in lesion. The transverse processes and 
laminae of the vertebra in lesion are slightly separated from 
those of the vertebra below. The posterior ligaments are 
stretched, thinned and atrophied, and the anterior are thick- 
ened and shortened. The body of the vertebra is slightly tilt- 
ed and the articular facets are not in parallel planes. The 
intervertebral disc is compressed anteriorly and decompress- 
ed posteriorly. 
(Bilaterally Posterior Lesion). The ex- 
tension lesion is an immobilization of the 
vertebra in the position of extension. It 
is bilaterally posterior if considered from 
the relative position of the inferior articular facets of the 
vertebra in lesion upon the superior of the vertebra below. 
From its relative disposition in the dorsal column, namely, 
because of the increased obliquity of the spinous process and 
the decreased convexity of the thoracic curve at the point of 
lesion, it is often considered as an en masse anterior lesion. 
It is relatively less prominent anteriorly and may be single 
or in group formation. In the latter case the condition is 
termed a dorsal lordosis. 
The fulcrum upon which this movement takes place is 
the nucleus pulposus of the intervertebral disc which is the 
same pivot utilized in flexion. 
Trauma or sudden strain, particularly 
with the dorsal spine in extension, are the 
causes of the primary type of individual lesion. The group 
lesion is usually secondary and compensatory in character 
for some flexion condition elsewhere, a typical example of 
which is the straight spine. A larger percentage of indivi- 
The 
Extension 
Lesion: 
Etiology: Subluxations of the Thoracic Vertebrae 
187 
dual lesions are the result of reciprocal innervation. A con- 
siderable number are traumatic and a very small proportion 
are the result of infection. 
The spinous process of the vertebra in le- 
sion is more oblique and relatively less 
prominent posteriorly. It is separated from that of the ver- 
tebra above and approximated to that of the vertebra below. 
Motion is restricted where there is approximation; in other 
words, with the vertebra below; and free where there is sep- 
aration, or with the vertebra above. The articular facets 
have moved bilaterally downward and backward and the 
transverse processes and laminae of the vertebra in lesion 
are approximated to their respective neighbors on the verte- 
bra below. In the chronic group lesion the anterior ligaments 
are stretched and weakened and the posterior shortened and 
thickened, with corresponding muscular changes. 
The rotation side-bending lesion is a sub- 
luxation of a vertebra in primary rota- 
tion, secondary side-bending in which the 
vertebra is maintained in rotation to the 
concavity of the curve. Physiological movement in which 
rotation side-bending, or side-bending rotation is such that 
both have been made toward the same side, will result in rota- 
tion of the bodies toward the concavity of the curve. Regard- 
less of whether side-bending or rotation is primary, if the at- 
tempted physiological act is to side-bend in one direction and 
rotate the other, the opposing action of the forces will serve 
to limit both acts, but particularly that of rotation. From the 
varying conditions of flexion or extension the body then 
rotates toward the convexity but not to any appreciable de- 
gree unless the secondary rotation is reversed to that of the 
side-bending and the spine is in hyper-flexion. 
Diagnosis: 
Rotation 
Side-bending 
Lesion: 188 
Doivning Principles and Practice of Osteopathy 
Side-bending 
Rotation 
Lesion: 
The side-bending rotation lesion is a le- 
sion maintained in primary side-bending 
and secondary rotation with the rotation 
in the reverse direction to that of side- 
bending. This lesion is rare and occurs under peculiar forces 
of torsion or trauma with the thoracic spine in hyperflexion. 
The nearest approach to it physiologically is side-bending to 
one side, and obviously attempting rotation toward the op- 
posite side from a flexed position. 
Differential Diagnosis: 
Third Dorsal Sidebent to Right: 
Third Dorsal Rotated to Right: 
1. Vertebra is tilted to right. 
2. Spinous process deviated to the 
right (concavity). 
3. Body rotated to the left to- 
ward convexity. 
4. Right transverse process 
moves downward. 
5. Left transverse process moves 
upward and backward. 
6. Left third rib is posterior and 
approximated to rib above. 
7. Right third rib relatively an- 
terior and approximated to 
rib below. 
8. Intervertebral disc is com- 
pressed on the right. 
9. Occurs usually in flexion with 
strong sidebending to right, 
secondary rotation to left. 
1. Vertebra is tilted to the right. 
2. Spinous process deviated to the 
left (or toward the con- 
vexity) . 
3. Body rotated to the right (to- 
ward concavity). 
4. Right transverse process 
moves downward and back- 
ward. 
5. Left transverse process moves 
upward and forward. 
6. Left third rib anterior and ap- 
proximated to rib above. 
7. Right third rib relatively pos- 
terior and approximated to 
rib below. 
8. Intervertebral disc is com- 
pressed on the right. 
9. Comprises the vast majority of 
lesions involving rotation 
and sidebending, or side- 
bending and rotation. 
The main point to remember in the differential diagnosis 
between the two types of lesion is that in rotation, for instance 
to the right, there is tilting and rotation to the right; and in 
side-bending to the right, a tilting to the right, but a rotation Subluxations of the Thoracic Vertebrae 
189 
Demonstrating rotation side-hending of the dorsal column. Rotation of the 
lumbar vertebrae does not show up. It must be borne in mind that in all instances 
rotation of the lumbar vertebrae is extremely restricted. 190 
Downing Principles and Practice of Osteopathy 
to the left. Moreover, that in the former the right transverse 
process is the most prominent and in the latter the left is the 
most prominent. 
The possibility of the side-bending rotation lesion being 
an etiological factor by allowing of a certain amount of pre- 
disposition to a lateral curvature of the organic type is a rea- 
sonable supposition, although it is not a substantial fact. 
For the matters of convenience adjust- 
ment is subdivided into those methods for 
the upper dorsal and those for the mid- 
and lower dorsal areas. There are three 
basic types of adjustive mechanics for re- 
duction of upper dorsal subluxations: (a) Methods utilizing 
cervical leverage, (b) Methods utilizing physiological locking, 
(c) Methods using direct force, with neither physiological 
locking nor cervical leverage, but occasionally combined with 
anatomical locking. 
In using the cervical column for adjust- 
ment of upper dorsal lesions of the rota- 
tion side-bending, or the side-bending 
rotation types, certain definite principles 
must be fulfilled in order that the cervical 
column may be thoroughly locked against possible strain or 
injury, and may, moreover, act as a unit lever-handle to bring 
the maximum amount of leverage force of a corrective na- 
ture upon the vertebra in lesion. The principles involved 
necessitate the use of the physiological movements of exten- 
sion, side-bending and rotation. 
Extension is the primary move and is required to fulfill 
two necessary laws: first, that of protection because exten- 
sion locks the lower cervical column anatomically; and, sec- 
ondly, unification of the lever handle so that the involved 
series of articulations can be used effectively as such. 
Principles of 
Adjustment of 
the Upper 
Dorsal: 
Principles for 
the Use of 
Cervical 
Leverage: Subluxations of the Thoracic Vertebrae 
191 
The next movement is side-bending and should be toward 
the side unilaterally antero-superior in the case of the rota- 
tion lesion and the postero-superior side in the case of the 
side-bending lesion; and in both cases toward the side on 
which the transverse process is uppermost. The degree of 
side-bending should be approximately 10 degrees with the 
midline of the body and the apex of the angle of this side- 
bending should occur at the point of lesion. 
The third movement is that of reverse rotation, or, in 
other words, rotation toward the postero-inferior side in the 
case of the rotation lesion and antero-inferior side in case of 
the side-bending lesion; and in both instances toward the side 
on which the transverse process is at a relatively lower level 
than its opposite fellow. This reverse rotation brings about 
separational strain of the articular facets, particularly on the 
side on which the transverse process is downward. It also 
brings tension leverage in an upward direction on the same 
side, through the semispinalis cervicis and capitis, the longis- 
simus cervicis and capitis and associated muscular tension 
pulls. It also serves to steady and further lock the cervical 
column, particularly the upper cervical, and give greater sta- 
bilization and resistance to adjustive force at the point of 
lesion. 
Varying amounts and degrees of these combined physi- 
ological movements are necessary to direct their focalized 
effect specifically to the point of lesion. It may be said in a 
general way that the lower in the dorsal column the lesion 
occurs, the greater the amount of extension, the wider the 
sweep of side-bending, the longer the resultant lever-handle 
and the greater the arc of reverse rotation. 
Cervical leverage is effective when utilized for adjust- 
ment of vertebral subluxations in the upper dorsal spine. In 
no instance should it be carried to the degree of strain neces- 
sary to focalize its forces to lesions beyond its proper sphere 
of activity. It should never be utilized for lesions below the 192 
Downing Principles and Practice of Osteopathy 
seventh dorsal and then only when certain types of technical 
procedure are used. 
Technique No. 1. Patient sitting, hypo- 
thetical lesion of the third dorsal, rotated 
unilaterally antero-superior on the right, 
postero-inferior on the left (rotation le- 
sion on the left). Patient sits on a stool 
and the operator on the table facing the patient’s back. The 
operator places the thumb of his right hand against the con- 
vex, or in other words, the right side of the spinous process of 
the vertebra in lesion. The patient’s left axilla rests over the 
operator’s flexed knee and he is side-bent to that side. The 
operator’s left foot is placed on the stool beside the patient 
with the knee in flexion, to allow for the above movement. 
The patient’s torso is side-bent and the cervical column to- 
gether with that portion of the upper dorsal column enter- 
ing into the long lever-handle is brought back to a vertical 
plane, thereby enforcing the principal of side-bending to the 
antero-superior side; and, moreover, effecting this in such a 
manner as to allow the operator to work with the greatest 
mechanical advantage and with a more unified counter-re- 
sistance to his adjustive efforts. With the cervical column 
in extension and with side-bending completed, the last physi- 
ological movement of reverse rotation additionally focalizes 
gerater leverage force at the point of lesion. Occasionally 
the operator can make complete circumduction of the pati- 
ent’s head, ending with the head and cervical column in posi- 
tion of side-bending to the right, extension and rotation to 
the left, thereby arriving at the same point with a slightly 
greater leverage tension. The patient’s right arm should 
hang limply over the left thigh, so as to allow the shoulder 
girdle of that side to be thoroughly relaxed at the moment of 
adjustment. Occasionally it is necessary to ask the patient to 
allow the shoulder-girdle to sag. The opposite shoulder gives 
no trouble and it is not necessary to demand relaxation of the 
patient for that particular side. Adjust with slight exaggera- 
Methods 
Utilizing 
Cervical 
Leverage: Subluxations of the Thoracic Vertebrae 
193 
tion of leverage force; or, more explicitly, with slight forci- 
ble increase of side-bending and reverse rotation and simul- 
taneous transverse force against the right side of the spinous 
process of the vertebra in lesion with the thumb of the right 
hand. This force is directed transversely to the left. 
Technique No. 2. With the patient sitting on the treat- 
ment table, his back to the operator, the above method, modi- 
fied, is equally efficient. Instead of side-bending the patient 
so that the axilla rests over the flexed knee, the patient is 
side-bent, but not so completely as to be off balance. What 
little stabilization is necessary can be rendered by the oper- 
ator by slightly leaning against the patient’s torso. The 
physiological movements of extension and reverse rotation 
further complete the leverage force. It is always wise to 
make it a point to place the fingers of the left hand on the 
vertex of the head, resting at this point in such a position as 
to control reverse rotation and allow the full length of the 
flexed forearm to rest along the left lateral aspect of the 
cervical column in such a way as to protect it in a splint-like 
manner. The lower portion of the forearm rests lightly on the 
shoulder and is closely approximated to the root of the neck. 
This protective mechanism is of great value in that it pre- 
vents all possible strain, and still further unifies and steadies 
the lever handle effect of the column. This protection of the 
lateral aspect of the cervical column is necessary both for 
protective purposes and control of leverage action; and it 
must be used. 
Technique No. 3. With the patient sitting, and the objec- 
tive the transverse process which is postero-inferior instead 
of the convex side of the spinous process. The instrumental- 
ity of force is the pisiform bone of the proximal hand and the 
applied force is directed upward, forward, and slightly later- 
alward. The opposite hand is placed over the vertex of the 
head, and the flexed forearm along the side of the head and 
the lateral cervical column with the semi-flexed elbow rest- 
ing lightly on the shoulder at its junction with the root of the 194 
Downing Principles and Practice of Osteopathy 
B 
• A 
Position for adjustment of a first dorsal vertebral subluxation immobilized 
in rotation side-bending to the left. Extension of the cervical column, side-bend- 
ing to the side unilaterally anterior and rotation to the side unilaterally posterior 
(arrow B). Arrow A indicates direction of transverse adjustive force against 
convex side of spinous process. Subluxations of the Thoracic Vertebrae 
195 
neck. Extend the head and cervical column and follow with 
side-bending toward the antero-superior side and reverse 
rotation or rotation toward the postero-inferior side. Adjust 
with sudden vigorous thrust against the transverse process 
of the vertebra in lesion together with concomitant exagger- 
ation of leverage force. 
Technique No. 4. Another very good method for the ad- 
justment of this particular type of lesion is as follows: 
Assuming the same hypothetical lesion, the third dorsal 
rotated unilaterally antero-superior on the right, postero-in- 
ferior on the left, the patient is made to lie on the left side. 
The right arm is dropped over the edge of the table, and 
held between the operator’s knees, so as to enforce stabiliza- 
tion of the right side of the shoulder girdle. The left shoul- 
der, which is in contact with the table, is sufficiently stabiliz- 
ed by superincumbent weight. The objective is the convex side 
of the spinous process or, in other words, the right side. The 
thumb of the operator’s left hand is placed firmly against 
this objective. The head and cervical column are extended, 
side-bent to the right and rotated to the left. The operator’s 
left hand is placed firmly against the left lateral aspect of the 
root of the neck, and the forearm against the left lateral as- 
pect of the upper cervical column and side of the head. Ad- 
justment is completed with exaggeration of leverage-force 
and simultaneous spinal transverse force directed to the left 
against the convex side of the spinous process. 
Technique No. 5. Patient prone. The same hypothetical 
lesion is to be corrected. The chin is tilted forward, acting as 
a pivot and incidentally serving in such a manner as to en- 
force extension of the occiput and cervical column. The next 
physiological movement is that of side-bending, which should 
be carried to the right and closely followed by reverse rota- 
tion, or rotation to the left, the chin acting as the pivot for this 
movement. Protect the occiput and lateral cervical column 
on the left side with the left hand and forearm and control 
leverage force by this same anatomical mechanism. Op- 196 
Downing Principles and Practice of Osteopathy 
Position for adjustment of a second dorsal vertebra immobilized in rotation 
side-bending to the right. Cervical leverage consists of extension followed by 
side-bending to the side unilaterally anterior and rotation toward the side unilat- 
erally posterior. Arrow A indicates the direction toward which the occiput rotates. 
Arrow B indicates the direction in which corrective force is directed against the 
convex side of the spinous process. Arrow C indicates the direction toward 
which the column is side-bent. Subluxations of the Thoracic Vertebrae 
197 
pose leverage force by counter adjustive force directed 
against the transverse process of the vertebra below the one 
in lesion on the left side and at right angles to the plane 
of the articulation. 
Technique No. 6 . The above technique may be modified 
in such a way as to be particularly applicable to the first and 
second dorsal, in contradistinction to the above technique, 
the applicability of which is greater lower down in the dorsal 
column. In fact, Technique No. 5 can be used effectively as 
low down as the seventh, which is very much the exception, as 
the other methods described should not be used below the 
fourth. 
If the chin is not used as a pivot and the patient is allow- 
ed to rest on the side of the face with his cervical column in a 
position of easy extension, side-bending and reverse rotation, 
the focalized leverage force is peculiarly effective to the first 
and second dorsal. In this technique the objective is the con- 
vex side of the spinous process and adjustive force is di- 
rected transversely. The occiput and lateral cervical column 
must be protected by proper placement of the operator’s 
hand and leverage force must be controlled by this same 
anatomical mechanism. 
Physiological locking may be utilized for 
all lesions partaking of the nature of 
rotation side-bending, or side-bending 
rotation from the third dorsal to the 
twelfth dorsal, inclusive. As in the 
cal column it must be very exactly secured and maintained. 
Extension is the primary move. In fact, if extension is 
exaggerated it results in anatomical locking. But as utilized 
for physiological locking, it is not of sufficient degree to en- 
force the above type of locking but only a slight physiologic 
limitation. The next move is that of side-bending and the 
acute lateral flexure should be at the point of lesion, which 
Principles 
for the Use of 
Physiological 
Locking: 198 
Downing Principles and Practice of Osteopathy 
Position for adjustment of a third dorsal vertebra immobilized in rotation 
side-bending to the right. Extension, side-bending and reverse rotation of the 
cervical column comprise leverage mechanism. The chin acts as a pivot. Arrow 
D shows direction in which chin points and arrow C the direction that occiput 
points. Arrow A indicates direction of leverage force, arrow B indicates trans- 
verse process of the vertebra immediately below the one in lesion and indicates 
direction for counter adjustive force. Subluxations of the Thoracic Vertebrae 
199 
is the junction of the midline of the body and the laterally in- 
clined upper torso. Apposition of facet surfaces is absolutely 
essential to the production of articular or physiological lock- 
ing. Forced tissue tension locking is not physiological lock- 
ing. Without this apposition of facet surfaces the capsular 
ligaments are endangered and are subject to injury if placed 
on tension, which is apt to result if physiological locking is in- 
correctly accomplished. This may produce rupture, capillary 
hemorrhage, and other associated injuries. Side-bending is 
necessary in that it places the articular facets in such posi- 
tion that their inherent mechanics are evoked by a correct 
combination of physiological moves with the ultimate effect 
that enforced limitation ensues in a certain definite direction 
without forced tension of capsular ligaments and other ad- 
jacent tissues, muscular or ligamentous. And, moreover, this 
enforced limitation of movement is in the direction in which 
corrective force is to be applied. It serves, therefore, as one 
of the factors that bring about physiologic conditions by 
which the vertebrae above and below the lesion are amply pro- 
tected against further movement. Thus the possibility of le- 
sion production when force is applied is minimized and the 
force is entirely localized to the articulation in lesion. Out- 
side of its locking principles it has the additional value of 
bringing about leverage force of an adjustive character. The 
same combination of forces which produces a locking above 
and below the point of lesion must carry on when locking is 
completed in the same general direction. And, as their 
focalization is greatest at the point of lesion, they carry on 
in the nature of leverage force so that this locking force not 
only serves as a locking force, but is thereafter automatically 
transformed into leverage force. This complete locking in- 
duces a very effective counter resistance or stabilization to 
adjustive force on the side against which this adjustive force 
is directed. 
Rotation is the last of the physiological moves. It com- 
pletes this locking and is directed toward the side unilaterally 200 
Downing Principles and Practice of Osteopathy 
antero-superior. It serves to carry the articular facets on 
the postero-inferior side upward and forward to their limit 
of motion in that direction, all arriving at a point of physi- 
ological locking except the one of the vertebra in lesion, which 
is immobilized postero-inferiorly on that side. It is there- 
fore obvious that the movement is a passively enforced pri- 
mary side-bending toward one side with a passively enforced, 
secondary reverse rotation or rotation toward the opposite 
side. This rotary force should be greatest at the point of 
lesion and sufficiently disseminated to serve to lock the verte- 
bra and above and below the point of lesion. When locking 
is completed this rotary strain is then greatest at the point 
of lesion and thereby the leverage force which automatically 
ensues is greatly enhanced. 
Stabilization, which is always a valuable asset in verte- 
bral adjustment as a counter agent to adjustive force, is 
amply provided for by the opposed muscular tension effect 
of side-bending with reverse rotation. The muscular tension 
pull of side-bending is completely opposed by the muscular 
tension effect of reverse rotation. The character of their 
opposition is such as to prevent strain. 
Side-bending is of value inasmuch as by its approximat- 
ing effect on the side unilaterally postero-inferior, it inverse- 
ly gaps and brings about separational strain between the 
articular facets of the opposite side and as no adjustive- 
foree is directed to this side, allows this particular lever 
handle to rotate downward and backward when upward, for- 
ward and medial force is directed against the opposite lever 
handle, the transverse process which is postero-inferior. As 
in the cervical column, there are two lever handles, a short 
and a long, and adjustive force is directed to the shorter of 
the two. Subluxations of the Thoracic Vertebrae 
201 
Demonstrating side-bending and attempted reverse rotation. These particular 
physiologic movements enforce physiologic locking upon the spine. Side-bending 
enforces physical restriction, reverse rotation physiologic restriction, and com- 
bined they determine physiologic or articular locking. The muscular action of 
side-bending is opposed by the muscular action of reverse rotation so that stabili- 
zation locking of the column ensues. This is a preventative to buckling or yielding 
of the flexible column. This complete muscular opposition is directly adjunctive 
to the articular locking. 202 
Downing Principles and Practice of Osteopathy 
The objective is the transverse process 
which is postero-inferior. The instru- 
mentality of force is the pisiform bone. 
The applied force is a thrust, the velocity 
of which is high, but the amplitude of 
motion slight. Have the patient interlock 
the arms. The operator then passes his arm over the shoulder 
on the opposite side so as to rest his axilla over this point. He 
then passes his arm across the chest and underneath the pati- 
ent’s axilla on the opposite side. He interlocks his fingers 
and brings the pisiform bone of the opposite hand firmly 
against the proper transverse process of the vertebra in le- 
sion. He then takes a long step from the side opposite the 
lesion to the side of lesion, thereby employing the principle of 
side-bending. At the same time he pivots and brings his pati- 
ent into extension and rotation toward the opposite or antero- 
superior side, thus bringing him to a point of locking without 
any undue strain or effort either on his own or the patient’s 
part. The patient should never be carried completely off bal- 
ance and the operator should always keep in line with the 
direction of his locking and adjustive forces. He side-bends 
with the patient, and without any loss of side-bending pro- 
ceeds with extension and reverse rotation by merely pivoting 
and carrying the patient into the position of locking. He is 
then in direct line with and at his best mechanical advantage 
to deliver adjustive force. With his opposite arm he also has 
a position which allows him to obtain an effective stabilizing 
resistance and leverage force with but a very slight exagger- 
ation of extension, side-bending and reverse rotation. Ad- 
justive force is carried upward, forward, and medialward. 
This particular method can be used for adjustment of any 
side-bending rotation or rotation side-bending lesion from 
the third to the twelfth dorsal, inclusive. 
Method of 
Adjustment 
Using: 
Physiological 
Locking: Subluxations of the Thoracic Vertebrae 
203 
Illustrating on a Halladay flexible spine anatomical locking in extension of 
the dorsal column. This area of the spine is the first portion of the entire 
column to lock in extension and the last to lock in flexion. 204 
Downing Principles and Practice of Osteopathy 
Method of 
Adjustment 
Using 
Physiological 
Movement: 
This method is more complicated than 
that previously described and not gener- 
ally as effective or accurate. It is sHghtly 
cumbersome and awkward and not as 
easy of accomplishment. The first step 
in the procedure is to exaggerate the le- 
sion. If the lesion is an immobilization in rotation side-bend- 
ing to the right with the right transverse process postero-in- 
ferior, the primary movement consists in rotation side-bend- 
ing to the left. This exaggerates the lesion and brings the 
postero-inferior transverse process into still greater prom- 
inence. The point of the flexed knee is placed firmly against 
the posterior transverse process and this point of fixation 
acts as a fulcum and is maintained throughout the entire 
procedure. 
Extension and rotation side-bending toward the right 
against the resistance of the fulcrum cause the vertebrae 
above and below the articulation in lesion to rotate down- 
ward and backward on the left and leaving that bone in a 
corrected position as the remainder break away from their 
fixation with the vertebra in lesion. It is obvious that a 
full restoration of arthrodial movement is thus indirectly 
brought about. 
This method is effective for lesions between the fourth 
and the tenth dorsals. It is an indirect form of technique at 
best, and is not advised over those methods which utilize 
physiological locking. It can be best accomplished with the 
patient sitting on the stool and the operator on the table 
facing the patient’s back. 
In the last few years a lot of attention 
has been paid to adjustment with the pati- 
ent prone, using special forms of tables. 
As applicable to the thoracic column there 
is considerable value in this particular 
form of technique. It has gradually been augumented so as 
Methods of 
Adjustment 
With the 
Patient Prone: Subluxations of the Thoracic Vertebrae 
205 
Position of hands for adjustment of a fifth thoracic rotation side-bending 
lesion to the left. Right pisiform contact is against transverse process unilat- 
erally posterior on the left, left pisiform contact is against the transverse process 
unilaterally anterior on the right. Bilateral simultaneous adjustive force against 
both objective parallel to the planes of the articulation and concomittant break- 
ing of fixation by force directed at right angles to the planes of the articulation 
is carried out. Primary breaking of fixation is obtained by force directed by 
the right pisiform against the transverse process below the one in lesion on the 
left side. 206 
Downing Principles and Practice of Osteopathy 
to include the cervical and lumbar columns, for which it is 
not particularly specific and therefore not desirable. It has 
been previously mentioned that the thoracic column is the 
first portion of the entire spinal column to lock in extension. 
This is an anatomical form of locking. 
Any suspension or spring table automat- 
ically brings in this locking and is there- 
fore of value. The author utilizes par- 
ticularly the Taplin pneumatic table for 
this purpose, for several reasons. First, because of the air 
shift and displacement there is not only a point of yielding, 
which gives a very effective locking in extension, but also 
above and below the point of yielding there is an automatic 
uplift of air pressure which still further stabilizes and in- 
creases the effectiveness of the locking. The amount of ex- 
tension can be regulated by removing the cross-boards under- 
neath the air cushion. It is an absolutely safe table to work 
upon inasmuch as the patient can not be brought into such 
severe suspension as to produce unnecessary strain or pos- 
sible injury. Its mechanism is more or less fool-proof which 
cannot be said of the ordinary suspension or spring table, 
in the use of which considerable caution must be exercised. 
Too much adjustive force, or too great an amplitude of mo- 
tion is apt to produce injury on the latter type of table, and 
its mechanism, moreover, is not so automatically adapted to 
the needs of the operator. 
The cervical column should never be adjusted with the 
patient prone, as sufficient locking is not possible in that posi- 
tion, likewise, with one or two minor exceptions, adjustment 
of the lumbar vertebrae should not be attempted with the 
patient prone as it is not possible to get an efficient lock- 
ing of the lumbar spine in extension. 
Technique No. 1. This is a bilateral cross-hand applica- 
tion of force. It has a dual object: primarily a breaking of 
fixation between the vertebra in lesion and its adjacent fellow 
Importance of 
Proper Table 
Selection: Subluxations of the Thoracic Vertebrae 
207 
19 
iA 
m 
Position of patient for breaking of fixation by directing force at right angles 
to the planes of the articulations. This force is directed against the lower of 
the two vertebrae entering into the fixation. Arrows B and C show direction of 
counter force by automatic air displacement and uplift, insuring protection of 
vertebrae immediately above and below the point of yielding. 208 
Downing Principles and Practice of Osteopathy 
and almost simultaneously with a slight shift in the objectives 
and the direction of forces, a retracing of the full arthrodial 
range of motion. One hand, with the fingers pointing to- 
ward the head, is so placed that the pisiform bone is brought 
into contact with the transverse process of the vertebra be- 
low the one in lesion on the side on which the transverse proc- 
ess of the vertebra in lesion is postero-inferior. The point of 
contact must be against the postero-superior aspect of this 
process. The opposite hand, with the fingers pointing down- 
ward, is so placed that the pisiform bone is brought into con- 
tact with the transverse process of the vertebra in lesion, 
which has rotated antero-superiorly. Pressure is brought to 
bear upon these two points at right angles to the planes of 
their articulations, thereby breaking fixation between the 
articular facets through the separative or gapping strain 
provoked. At the summit of this pressure a quick twist of 
the wrist shifts the point of attack from the transverse proc- 
ess of the vertebra below the one in lesion to the postero-in- 
ferior transverse process of the one in lesion and the obliquity 
of this force is so changed as to bring it parallel to the planes 
of articulation. The opposite hand does not shift its position. 
In other words, the same objective is maintained but the 
obilquity of the force is increased so that both forces are 
parallel to the planes of the articulation, thereby retracing 
full arthrodial range of motion in a direction opposite to that 
of the fixation. The pisiform bone which makes its shift from 
the transverse process below the one in lesion to the one in 
lesion acts somewhat in the nature of a pry. These two com- 
bined movements merge in such manner as to give the entire 
technique the appearance of being one maneuver only. The 
shift of forces must be extremely rapid although the ampli- 
tude of motion is only slight. At the termination of adjust- 
ment the operator must quickly recover. If pressure is sus- 
tained considerable strain may be evoked. All muscular tis- 
sue must respond to mechanical stimulus and the nature of 
that response is a contracture of its functioning elements. Subluxations of the Thoracic Vertebrae 
209 
All of the soft tissues have a certain amount of elasticity and 
the nature of their response is recoil. To block this recoil 
would mean strain to the patient, therefore, the operator 
should get away quickly from the field of operation. The 
older idea that recoil had some influence from the point of ad- 
justment and that technique of this character depended upon 
recoil for its effective culmination is not true. The initial 
forces are the adjustive forces; recoil is only incidental, and 
the natural response of elastic and excitable soft tssues. Re- 
coil cannot be controlled either from the nature or the direc- 
tion of its influence; and moreover, it is never as great as the 
initial force inasmuch as natural resistance takes up a certain 
percentage of it. Adjustment by recoil is therefore out of 
the question in that it is uncontrollable and not sufficiently 
effectual. 
Technique No. 2. -This method does not involve partic- 
ularly the principle of the breaking of fixation. It consists of 
retracing the full arthrodial range of motion in an opposite 
direction to that of the fixation. The objective is the trans- 
verse process which is postero-inferior and the instrumen- 
tality of adjustive force is the pisiform bone. The direction 
of this adjustive force must be parallel to the plane of the 
articulation. Stabilization resistance is maintained with the 
heel of the opposite hand against the transverse processes of 
the three or four vertebrae above the one in lesion. This coun- 
ter stabilization resistance is brought against the transverse 
processes of the aforesaid vertebrae in a downward, slightly 
lateralward direction on a side opposite to that of the objec- 
tive. This, besides allowing for stabilization resistance and 
further increasing the effectiveness of anatomical locking in 
extension, evokes a certain amount of gapping strain at the 
point of lesion on the side on which adjustive force is to be 
given, thereby minimizing the amount of adjustive force 
necessary. Exaggeration of the counter force is carried out 
concomitantly with the application of adjustive force. 210 
Downing Principles and Practice of Osteopathy 
The direction of all forces must be such as to keep in view 
the natural contour of the dorsal column. Because of its nat- 
ural convexity all adjustive force must be radial to a more 
or less fixed point and that point is approximately the center 
of the sternum. 
Technique No. 3. -This method is somewhat similar to 
Technique No. 2 inasmuch as the objective and instrumental- 
ity of force are the same. Stabilization resistance is main- 
tained against the transverse process of the vertebra below 
the one in lesion on the side opposite to that of the objective 
or transverse process which is postero-inferior. It acts as a 
counter force to the objective force and is very efficient as 
such. Both forces must be carried out simultaneously to ef- 
fect adjustment. 
There are variations to these particular methods which 
may be utilized, but to my mind these are the three most ef- 
fective measures for adjustment in using bilateral force and 
anatomical locking in extension with the patient prone. The 
author does not approve of the application of direct force 
with the use of a single point of contact, this force being de- 
livered as a thrust without counter force or stabilization re- 
sistance and depending entirely upon the primary anatomical 
locking for protection. The amount of force necessary to 
move the vertebra under such conditions is great and con- 
siderably out of proportion to what it should be. 
Technique No. 4. Breaking fixation by directing force 
at right angles to the planes of the articulation, this force is 
applied to the lower of the two vertebrae entering into the fix- 
ation. This method can be easily accomplished manually; or, 
if desired, with the Taplin mobilizer. And inasmuch as the 
removal of fixation is the primary step in the correction of 
any lesion, it may be advisable under certain conditions to 
confine all procedures to that particular end only. This is 
particularly true in the handling of rheumatoid arthritis, 
rheumatic and infectious arthritis, stubborn joint lesions and Subluxations of the Thoracic Vertebrae 
211 
other conditions in which joint movement parallel to the 
planes of articulation should not be hastened. Mere removal 
of the fixation will promote natural reactive processes of a 
beneficial character; and, by avoiding the use of friction- 
provoking force parallel to the planes of the articulation the 
joint surfaces are thereby safeguarded until such time elapses 
as makes full arthrodial range of motion desirable and safe. 
This method of procedure is particularly 
effective in the extension and flexion 
types of lesion, but is also extremely ef- 
fectual in the rotation side-bending or 
side-bending rotation lesion when modi- 
fied to suit such types of lesion. There are two procedures 
which the author utilizes. 
Technique No. 1. With the patient’s fingers inter-lock- 
ed behind his neck, well down on the cervical column so as to 
produce no undue strain, the points of the elbows are brought 
together. If the lesion is an extension type or an extension 
rotation side-bending type, then this particular method 
should be utilized. If straight extension, the hand is so 
doubled up as to bring bilateral points of contact against the 
transverse processes, not of the vertebra in lesion, but of the 
one below. The operator places his forearm against the tips 
of the elbows of the patient, holding both in an immobilized 
position and in such manner as he can utilize them as lever 
handles. The patient is rolled over with the operator’s hand 
underneath, maintaining firm counter adjustive force against 
the vertebra below the one in lesion. Air line pressure is 
brought to bear upon the points of the elbow in such direction 
that the resultant force will pass antero-posteriorly through 
the vertebra in lesion. With the patient flat on his back, the 
parallel, shearing forces of the air line pressure plus the coun- 
ter adjustive force maintained against the vertebra below the 
one in lesion, break fixation. The leverage force of flexion 
of the unit lever handle of that portion of the dorsal column 
Methods of 
Adjustment with 
the Patient 
Supine: 212 
Downing Principles and Practice of Osteopathy 
above and including the one in lesion causes the vertebra in 
lesion to retrace its full arthrodial movement of flexion. 
In dealing with the extension rotation type of lesion, an 
additional point of contact is the transverse process which is 
unilaterally postero-inferior. When fixation is broken this 
added point of contact acts as a driving force against the pos- 
terior transverse process with the result that not only is fix- 
ation broken and restoration of arthrodial movement of 
flexion assured but also, because of the third point of contact, 
the removal of the rotation side-bending is automatically 
guaranteed. This method utilizes a complicity of forces, 
counter forces, leverage forces and culminating resultant 
forces. 
In certain hypermobile types, adjustment should be made 
under resistance, by asking the patient slightly to resist the 
operator, and particularly hold the position of flexion when 
adjustment is about to be made, relaxing, however, at the 
moment of adjustment. The position of the patient’s inter- 
locked fingers, shifted at different points behind the cervical 
column, will vary the amount of flexion and focus it at the 
point of lesion, low down when dealing with the upper dorsal 
column, and higher up when dealing with the lower dorsal 
column. This method is effective from the second dorsal to 
and including the first and second lumbar. 
Technique No. 2. The following method is particularly 
applicable to the flexion type of lesion and with certain modi- 
fications is of great value for the flexion side-bending rota- 
tion variety. The patient’s arms are folded across the chest 
in a more or less interlocked position although they do not 
come in contact with the chest wall. If a flexion lesion, the 
hand is so doubled up as to bring bilateral points of contact 
against the transverse processes of the vertebra below the 
one in lesion. The position of the hand is such that the thenar 
eminence is against the transverse process of the vertebra on 
one side and the second phalanx of the thumb against the op- Subluxations of the Thoracic Vertebrae 
213 
Position for adjustment of a thoracic verebra immobilized in extension. A 
and B indicate points of the elbows against which force is directed. C indicates 
direction of resultant force passing antero-posteriorly through the vertebra in 
lesion. D indicates direction of counter force maintained against vertebra below 
the one in lesion. E indicates direction of tension leverage force of flexion, 214 
Downing Principles and Practice of Osteopathy 
posite transverse process, spanning the spinous process in 
such a fashion that it rests in the groove between these two 
points. The operator should then immobilize the tips of the 
elbows of the patient by locking one in the apex of the axilla 
and in cupping the other in the palm of the hand so that he can 
utilize them as lever handles. The patient is then rolled over 
with the operator’s hand underneath, maintaining firm coun- 
ter adjustive force against the vertebra in lesion. Pressure 
is brought to bear upon the points of the elbows in an oblique- 
ly downward direction so that the resultant force will pass 
through the body of the vertebra in lesion from an antero- 
inferior through a postero-superior point anterior to the 
nucleus pulposus, which is the axis of motion of the vertebra 
in lesion. 
With the patient flat on his back, by means of the oblique, 
although parallel shearing forces, the counter adjustive 
force, and the above mentioned resultant force, together with 
the muscular leverage force incidentally evoked; fixation is 
broken and full restoration of arthrodial movement of exten- 
sion is assured. 
In dealing with the flexion, side-bending rotation type of 
lesion, a third point of contact is the transverse process which 
is unilaterally postero-inferior. When fixation is broken 
this added point of contact acts as a driving force against the 
posterior transverse process, automatically causing a reversal 
of the side-bending rotation. When adjusting the upper dor- 
sal the arms approach a right angle with the body plane. The 
lower in the column, the greater the obliquity of the position 
of the arms. They approach an acute angle in the very lower 
dorsal—so much so, in fact, that the arms are practically in 
contact with the chest wall, so that a certain amount of the 
breaking of fixation is the result of the ventral force brought 
against the point of the elbows and thereby indirectly trans- 
ferred to the long axis of the ribs articulating with the verte- 
bra in lesion. This force is additional to the resultant force 
passing obliquely through the body of the vertebra anterior to Subluxations of the Thoracic Vertebrae 
215 
its axis of movement. Occasionally, in certain types of 
spines, the scapulae will interfere with the operator in that 
they come in contact with the table and therefore destroy the 
effectiveness of the counter force. Moreover, they may be 
physical obstacles to the proper placement of the hands for 
the maintaining of this counter force. Under such circum- 
stances bring the points of the elbows together in the midlines 
so that each hand of the patient is in contact with the opposite 
shoulder. Immobilize the points of the elbows firmly and 
apply equal force upon the combined objective. 
In addition to the method previously de- 
scribed there are other methods by which 
adjustment of the extension lesion can be 
made, although the preferable technique 
from the point of specificity is the one 
heretofore given. The extension lesion cannot be corrected 
by direct action technique, but rather by indirect methods, 
usually utilizing strong flexion in such a manner as to bring 
the greatest degree of flexion tension upon the vertebra or 
vertebrae in lesion. If the lesion is secondary to flexion les- 
ions elsewhere, it is then necessary to correct the primary 
lesions also, and it is better to do this previous to the adjust- 
ment of the secondary lesion. A thrust should never be given 
directly to the lesion but may be used advantageously at 
times, above and below the involved articulation. In group 
lesions with weak musculature, physiological and corrective 
exercises should be given under resistance. A very good ex- 
ercise is the hugging exercise, in which the patient grasps 
his own shoulder blades firmly and concomitantly with deep 
inspiration attempts to bring his shoulder blades forward 
and medialward. The posture of the patient should receive 
due attention. 
The vertex pressure movement described by Ashmore 
may be used for the upper dorsal. Modifications of this 
technique may be used as long as the principles of adjustment 
Technique for 
the Adjustment 
of the Extension 
Type of Lesion: 216 
Downing Principles and Practice of Osteopathy 
B 
A 
Position of patient and direction of forces necessary for breaking of fixation 
and restoration of arthrodial movement of extension. A indicates direction of 
resultant force and B that of counterforce by bilateral fixation of the transverse 
processes of the vertebra below the one in lesion. Antero-posterior, parallel, 
shearing forces break fixation and oblique force through the long axis of the 
arms and shoulders determines arthrodial movement of extension. Subluxations of the Thoracic Vertebrae 
217 
are correctly applied. The operator should remember to 
carry out a degree of flexion which brings the greatest stress 
upon the articulation in lesion and cause the direction of this 
approximation force to pass through the body of the vertebra 
in lesion, anterior to the nucleus pulposus of the interverte- 
bral disc. 
The following method is very valuable. Its one fault is 
that it is hard to confine it absolutely and focalize it to the 
point of lesion. To keep it out of the realm of a general 
method and to confine it to a very definite, specific maneuver 
demands considerable care in execution. 
With the patient sitting or standing back to the operator, 
with the hands clasped over the posterior portion of the cervi- 
cal column, the operator passes his arms under the patient’s 
axillae and allows his hands to rest over those of the patient. 
The operator maintains a point of contact with the chest 
against the vertebra below the one in lesion. The greatest 
degree of flexion tension is upon the vertebra in lesion. At 
the end of expiration the operator lifts the patient slightly, 
bringing about a slight amount of traction. This is accom- 
plished by directing a slight uplift against the vertebra below 
the one in lesion with the chest wall, and by a slight raising 
of the arms which are tightly pressed against the axillae. 
With the patient in this position of slight traction, a sudden, 
forceful flexion of the head is given with the hands. This 
flexion is gauged so as to bring the greatest tension upon the 
vertebra in lesion. The “snap of the whip” effect of the 
posterior longitudinal ligaments is sufficient to force the 
vertebra into flexion. 
Another method of value with the patient sitting or 
standing, back to the operator, is for the operator to instruct 
the former to clasp his hands behind his neck. The operator 
then places his arms underneath the patient’s axillae so that 
the forearms cross the anterior chest wall of the patient, with 
the hands grasping firmly his opposite arm close to the shoul- 218 
Downing Principles and Practice of Osteopathy 
der. The operator maintains a point of contact with the chest 
against the vertebra below the one in lesion. The greatest 
degree of flexion tension is directed against the vertebra in 
lesion. The operator then enforces a slight amount of trac- 
tion, exaggerates the leverage force of flexion and at the 
same time brings pressure against the anterior aspect (ster- 
nal ends) of the ribs articulating with the vertebra in lesion. 
This latter force must be distributed antero-posteriorly 
through the vertebra in lesion. The culmination of such coun- 
ter force, leverage force, and resultant force carried out 
simultaneously results in adjustment. 
A method for adjustment of lesions of the lower dorsal 
area with the patient sitting is as follows: 
Flexion is carried out until the vertebra in lesion is under 
the greatest amount of tension. Adjustment is made with 
downward, backward approximation of pressure so that the 
direction of force is transmitted through the body of the 
vertebra and intervertebral disc anterior to the nucleus pul- 
posus. A firm counter pressure is maintained against the 
vertebra next below with the chest. 
In the group extension lesion of the dorsal area, for ex- 
ample the straight spine, considerable benefit may be derived 
from Forbes’ method of placing the patient on his side and 
making diagonal transverse pressure upon the lateral aspects 
of the ribs, concomitant with deep inspiration upon the part 
of the patient. 
One method has been previously describ- 
ed for adjustment of the flexion lesion. 
This lesion can be corrected by direct ac- 
tion technique. A thrust can be given di- 
rectly to the lesion providing the char- 
acter and the direction of this force is exact. It can best be 
applied bilaterally to the transverse processes of the vertebra 
in lesion and should be directed interiorly and forward at an 
angle of about one hundred and forty degrees to the planes 
Methods for 
Adjustment of 
the Flexion 
Type of Lesion: Subluxations of the Thoracic Vertebrae 
219 
of the articulation. Preparatory anatomical locking of ex- 
tension should be made and adjustment followed out with the 
patient in this position. The adjustment is best made with the 
patient prone. It may be accomplished with the patient 
sitting; and indirectly with the patient supine. 
With the patient prone and maintained in a considerable 
degree of extension localized particularly to the area of le- 
sion, deep sustained pressure is of great benefit, as it sub- 
jects the anterior longitudinal ligament to considerable ten- 
sion, and this stretching of this ligament results in a better 
stabilization of the adjustment. It also has a very beneficial 
effect upon the intervertebral disc by putting its fibers on 
tension and thus counteracting the effect of the sustained 
compression to which it has previously been subjected by the 
nature of the lesion. This can best be accomplished with the 
Taplin table, using the mobilizer. 
This form of technique can be utilized 
particularly in bedside work. The objec- 
tive is the transverse process which is 
postero-inferior. The instrumentality of 
force is the pisiform bone. The patient 
lies on his side, with the posterior trans- 
verse process uppermost. The forearm 
is flexed, with the point of the elbow resting against the 
groin. The shoulder girdle is manually immobilized by the 
hands of the operator and the pisiform bone is brought into 
contact with the objective. Traction, and extension of that 
area of the spine in which adjustment is to be made is brought 
about by upward pressure exerted against the elbow and the 
bi-manual immobilization of the shoulder girdle in a back- 
ward position. At the summit of this combined tension, ad- 
justment is made by bringing sudden force against the trans- 
verse process which is downward and backward, carrying it 
upward and forward. 
Method of 
Adjustment of 
the Rotation 
Lesion with the 
Patient on 
His Side: 220 
Downing Principles and Practice of Osteopathy 
With the patient standing, back to the 
operator, adjustment of the lower dorsal 
vertebra is possible by using the index or 
middle finger of the patient as the instru- 
mentality of adjustive force, and by plac- 
ing these fingers against the objective, or 
in other words, the transverse process which has rotated pos- 
tero-inferiorly. The operator steps close to the patient, fac- 
ing the patient’s back. With his chest firmly held against 
the patient’s hand, particularly the two fingers composing 
the instrumentality of adjustive force, he clasps the body of 
the patient, with the hands folded across the latter’s chest 
so as to hold his body firmly against him. Maintaining a firm 
fixation against the chest of the patient, he brings added 
pressure with the chest against the patient’s hand in an up- 
ward direction. The traction extension incidentially pro- 
duced is sufficient to insure locking and counter resistance to 
effect the adjustment. This form of adjustment is only ap- 
plicable to the very lower dorsal vertebra. 
Method of 
Adjustment of 
the Rotation 
Lesion with the 
Patient Standing: Subluxations of the Lumbar Vertebrae 
221 
CHAPTER VIII. 
SUBLUXATIONS OF THE LUMBAR VERTEBRA 
Applied 
Anatomy: 
The lumbar vertebrae are the largest 
movable segments of the vertebral column 
and can be readily determined by the ab- 
sence of foramina in their transverse processes, the distin- 
guishing mark in the cervical vertebrae, and by the fact that 
there are no costal facets on the sides of their bodies, the 
characteristic distinction of the thoracic vertebrae. 
The bodies of these vertebrae are large, wider trans- 
versely than antero-posteriorly, and are slightly thicker in 
front than behind. Lumbar spinous processes are thick, 
broad, quadrilateral in shape, and they project horizontally 
backward. The superior articular processes project upward 
and their facets are concave and face backward and medial- 
ward. The inferior articular processes project downward 
and their facets are convex, facing forward and lateralward. 
The former are wider apart than the latter and embrace the 
lower articular processes of the vertebra next above. The 
pedicles are directed backward from the upper part of the 
bodies of the vertebrae and consequently the inferior inter- 
vertebral notches are of greater proportionate depth. The 
laminae are broad, short, and strong. The vertebral foramen 
is intermediate in size to the thoracic and cervical region and 
triangular in shape. 
Thansrervo 
.proc&ss 
Lumbar vertebra, lateral view. 222 
Downing Principles and Practice of Osteopathy 
The transverse processes are long and slender; they are 
directed horizontally and lateralward in the upper three lum- 
bar vertebrae and tilt slightly upward in the lower two. 
They are situated just in front of the articular processes and 
are homologous to the ribs. Three tubercles are noted in con- 
nection with the transverse processes of the twelfth thoracic 
and lumbar vertebra; a superior, called the mammillary proc- 
ess, an inferior, the accessory process, and an external or 
costal process. The first two are rudimentary but true trans- 
verse processes and the third is the homologue of the rib. The 
twelfth thoracic vertebra is classified with the lumbars for 
purposes of convenience and because of the fact that its in- 
ferior articular facets are similar to those of a typical lumbar 
segment. 
The fifth lumbar vertebra is characterized by a body 
which is much deeper anteriorly than posteriorly, a smaller 
spinous process, and a wider interval between the inferior 
articular processes. The transverse processes are larger and 
thicker than those of the other lumbar vertebrae. 
The lumbo-sacral articulation is mechanically weak. The 
size and shape of the transverse processes are asymmetrical 
in a large majority of cases. Human nature seems to be in 
an incomplete evolutionary stage between quadrupedism and 
bipedism. The key to the situation lies largely within the 
Superior Art • 
process 
J7rattsvers*i 
Inferior Art 
Process 
SpiTlouar 
Process 
Lumbar vertebra, anterior view. Subluxations of the Lumbar Vertebrae 
223 
lumbar curve, for upon the nature and character of changes 
appearing at this point depends the proportionate advance- 
ment in the evolutionary change to the upright position. 
Therefore if the lumbar curve is subject to lumbo-sacral vari- 
ations, whether accidental, incidental, or evolutional, the fifth 
lumbar vertebra must bear a large share of the burden. 
Anatomical variations of the lumbo-sacral region are 
quite demonstrable in the living if one is willing to accept 
roentgenogram studies as proof of their presence. The 
lumbo-sacral and the ilio-femoral articulations are freely 
mobile if compared with the sacro-iliac joint. Compensation, 
therefore, will always seek the point of least resistance to 
establish counter balance or readjustment, and therefore the 
lumbo-sacral articulation compensates for many pelvic 
asymmetries. 
The normal lumbar curve is convex anteriorly, the con- 
vexity being greatest at the sacro-vertebral angle. The tho- 
racic and pelvic curves are the primary curves formed at an 
early period of fetal life and are due to the shapes of the 
bodies of the vertebra. The cervical and lumbar curves are 
compensatory or secondary and are developed after birth to 
secure and maintain the upright position. They are due 
primarily to the shape of the intervertebral discs together 
with the influence of heavy muscles of the back which are 
powerful factors in holding the spinal column erect. When 
they contract they steady the lower part of the spine, and also 
create more lumbar curve; in fact they act as powerful levers 
by co-operating with their sacral fixed points to stabilize the 
entire spine. The line of gravity or of weight bearing passes in 
front of the core (nucleus pulposus) of each intervertebral 
disc. The pull of the muscles is behind. Some authorities 
state that the line of gravity passes through the center of 
the body of the second lumbar vertebra, others give it as the 
third. It is probably an intermediate point. Constant lumbo- 
sacral disturbance, lumbar pain of a vague chronic aching 224 
Downing Principles and Practice of Osteopathy 
type is typical of muscle-fatigue or strain from the effort to 
maintain balance. By shifting the weight-bearing center, one 
can do much for the relief of these symptoms, as for example, 
changing the heels of the shoes; by correcting the posture and 
by comprehensive study of the basic principles involved in im- 
balance, as well as the particular causative factors involved in 
each individual case. 
Ante r-rLonyfilit^/J^Ll/J 
UfZvn^arfm 
vm /■ n Jniu 
Anterior view of intervertebral disc with the adjacent vertebral bodies. 
The 
Lumbo-Sacral 
Articulation: 
The ligaments connecting the fifth lum- 
bar vertebra to the sacrum are similar 
to those that connect the segments of the 
vertebral column to each other. The an- 
terior and posterior common ligaments are continued down- 
ward. The ligamenta subflava connect the arch of the last 
lumbar vertebra with the posterior border of the base of the 
sacrum. The capsular ligaments connect the articular proc- 
esses and allow for the formation of double arthrodia. The 
inter- and supra-spinous ligaments are present. 
The lumbo-sacral ligament is a thick triangular ligament 
which is attached to the lower anterior portion of the trans- 
verse process of the fifth lumbar vertebra and passes oblique- 
ly outward to become attached at a lower level to the lateral 
surface of the base of the sacrum. 
The ilio-lumbar ligament passes horizontally outward Subluxations of the Lumbar Vertebrae 
225 
from the tip of the transverse process of the fifth lumbar 
vertebra to the crest of the ilium, immediately in front of the 
sacro-iliac articulation. 
The fifth lumbar articulation is a comparatively free 
amphiarthrosis, having about the same physical character- 
istics as those of the other vertebra, although it is not un- 
common to find considerable variation in the relative posi- 
tional plane of its inferior articular facets. 
The core of the intervertebral disc 
acts as the fulcrum in this move- 
ment. Flexion is the freest of all movements in this 
area and can be normally carried to a point just beyond 
a straightening of the lumbar curve, the movement occur- 
ring in the vertical plane of the facets. It is greatest at the 
apex of the lumbar curve; in other words, it increases from 
above downward and is greatest between the fifth lumbar 
and the sacrum. There is compression of the intervertebral 
disc in front and decompression behind. The inferior artic- 
ular processes slide upward because of the buckling effect of 
the compression in front and decompression backward. Limi- 
tation of forward bending is determined by the degree of ten- 
sion of the posterior longitudinal, interspinous and capsular 
ligaments. The degree of compression of the disc in front is 
an added factor. A certain amount of ligamentous tension 
is maintained at all times for the reason that the ligaments 
lie longitudinally to the direction of tension and radially to 
the direction of motion. The intervertebral foramina are 
enlarged during flexion. 
Extreme flexion creates an anatomical locking of the 
lumbar spine and the lower thoracic so that little or no rota- 
tion and but slight side-bending are possible. A large percent- 
age of side-bending rotation lesions are produced in side-bend- 
ing rotation with the lumbar spine in moderate flexion. At- 
tempted recovery to the erect position may create an articular 
locking of the inferior articular processes of the upper verte- 
Flexion: 226 
Dozening Principles and Practice of Osteopathy 
bra as they pass beyond the upper edge of the superior proc- 
esses of the lower. They assume an angle and produce a conse- 
quent indentation of the lower edge of the articular facet 
against the articular facet and capsule of the opposing joint 
surface. The planes of the articular facets are not parallel, 
hence a resultant abnormal bony contact is produced, 
maintained and increased by the tension of the interspinous 
and other ligaments. The individual should recover from 
side-bending rotation before assuming the erect position. To 
recover from flexion at the angle imposed by side-bending 
Demonstrating flexion on the Halladay spine. Locking first takes place in 
the upper cervical and lower lumbar and is followed by locking of the upper lum- 
bar, lumbo-dorsal and lower cervical areas. The last to lock is the upper mid- 
dorsal or interscapular area. Subluxations of the Lumbar Vertebrae 
227 
rotation is comparable to the attempt to close a drawer at an 
angle. Nature has amply provided for all combinations of 
movements and unless there is uncoordinated or imbalanced 
soft tissue tension, recovery of the erect position at an angle 
can be accomplished with safety. 
The greater the flexion in the lumbar area from above 
downward, the lower the locking against rotation and side- 
bending. The greater the flexion from below upward in the 
lumbar area, the higher is the locking against rotation and 
sidebending. A considerable degree of flexion limits side- 
bending rotation passively and is, therefore, of aid in adjust- 
ment. It is possible to lock the lumbar articulations, one by 
one, with passive movement from above downward and below 
upward against side-bending rotation by a gradual increase 
in the amount of flexion either from above downward or 
below upward. 
An easy degree of flexion allows considerable passive 
movement of side-bending rotation of the body of the ver- 
tebra toward the convexity of the curve. Hyperflexion limits 
this possibility and in hyperflexion with attempted side-bend- 
ing, rotation of the body of the vertebra is toward the con- 
cavity. The same is respectively noted in passive movement 
in hyper extension and easy extension, the body of the ver- 
tebra in the former rotating toward the concavity and in the 
latter toward the convexity, when side-bending is the primary 
attempted passive movement. 
Extension: The core (nucleus pulposus) of the interver- 
tebral disc acts as the fulcrum. Movement occurs in the ver- 
tical plane of the articulation. Extension is confined largely 
to the dorsal and the upper two lumbar vertebrae. The rea- 
son for this is an evolutionary one: the change from quad- 
rupedism to bipedism in which an increase in the sacro-ver- 
tebral angle and resultant increase in extension of the lower 
lumbar has been a primary compensatory factor. All com- 
parative estimates are made with the patient in the erect 228 
Downing Principles and Practice of Osteopathy 
position, hence the limitation of further extension is readily 
appreciated. There is compression of the disc behind, and 
decompression in front and the inferior articular facets slide 
downward and also inward due to the character and direction 
of the buckling. Limitation of further movement is deter- 
mined by the tension of the anterior longitudinal ligament, 
compression of the disc, and bony contact—the inferior artic- 
ular processes of each joint approximating the laminae of the 
vertebra below. A secondary movement of a slight degree is 
possible, the axis of movement shifting posteriorly to the 
points of contact limitation, allowing slight further decom- 
pression of the disc and stretching of ligaments anterior to 
this point together with slight sliding of the bony contact 
points. The intervertebral foramina are diminished in size. 
Hyperextension restricts rotation to the dorso-lumbar 
area, locks the thoracic spine and limits side-bending to the 
lumbar area. The greater the degree of extension, the lower 
in the lumbar spine is the movement of side-bending. Vol- 
untary extension side-bending is always accompanied by 
rotation of the bodies to the concavity, although it is limited 
in the extent of the rotation by the degree of extension. 
Side-bending is a free movement in 
the lumbar area. It is greatest in the 
erect position and least in flexion. It is limited by extension. 
It is always associated with rotation. Side-bending rotation 
is highest in flexion, is lower in the erect position, and is low- 
est in extension. Voluntary side-bending rotation with rota- 
tion of the bodies of the vertebrae toward the convexity de- 
mands secondary rotation and is problematical. The oppos- 
ing quality of both forces would tend to lock the vertebrae at 
more or less of a central point with their bodies in a more or 
less central position. Any appreciable rotation of the body of 
the vertebra in primary side-bending, secondary rotation, 
with the body rotating toward the concavity is questionable, 
although its greatest possibility would be with the lumbar 
Side-Bending: Subluxations of the Lumbar Vertebrae 
229 
Demonstrating side-bending on the Halladay spine. Note the 
accompanying rotation to the concavity of the curve. 230 
Downing Principles and Practice of Osteopathy 
spine in erect position, easy extension, or easy flexion. In 
passive enforced movement, primary side-bending, secondary 
rotation, with rotation of the body of the vertebra toward the 
convexity is possible; when the spine is in the erect position, 
easy flexion or easy extension, but not in hyperflexion or 
hyperextension. 
Rotation: Rotation in the lumbar area is extremely 
limited, is diminished in hyperextension, 
and least in flexion. Rotation side-bending is highest in 
flexion, is lower in the erect position, and lowest in extension. 
The bodies of the vertebrae rotate toward the concavity of 
the curve, whether the result of voluntary movement or en- 
forced passive movement. Rotation and hyperextension is 
confined to the dorsal area. The centers of rotation are in the 
tips of the spinous processes. 
Lesions of the Lumbar Vertebra: 
1. Flexion Lesion 
2. Extension Lesion 
3. Rotation Side-Bending Lesion 
4. Side-Bending Rotation Lesion 
Right or Left Lateral 
Lumbar Lesions 
5. Combined Lesions 
The Flexion 
Lesion: 
(Bilaterally Posterior Lumbar). The 
flexion lesion is an immobilization of a 
vertebra in the position of flexion. The 
vertebra en masse assumes greater prominence posteriorly 
.and, if part of a group lesion, the concavity of the lumbar 
curve is decreased throughout the area involved. It is com- 
monly called a posterior lesion. The inferior articular proc- 
esses of the vertebra in lesion move upward and tilt slightly 
Backward, the facets passing beyond the upper edge of the 
superior of the vertebra below. The fulcrum is the core of 
the intervertebral disc and the movement occurs in the ver- 
tical plane of the facets, although the arc of motion is up- Subluxations of the Lumbar Vertebrae 
231 
ward and forward, the buckling is backward, consequently 
the lesion is posterior. 
Functional and postural abuse is the 
usual cause of the group lesion. It may be 
secondary to bilaterally anterior innominates and the pos- 
terior sacrum (base rotated backward, which in reality is an 
extension movement). It is often the forerunner of the 
straight spine and may be associated with atonicity of the 
lumbar extensors from a debilitated or toxic state. The in- 
dividual lesion may be due to reciprocal innervation, trauma, 
such as falls, wrenches or strains resulting from heavy lift- 
ing and extremes of forced flexion with ligamentous strain 
and injury. It is sometimes found as a secondary or counter- 
balancing lesion. 
The vertebra is en masse posterior be- 
cause of the backward buckling of the 
spine at this segment due to the compression in front and de- 
compression behind the axis of motion. There is approxima- 
tion of the spinous process of the vertebra in lesion with that 
of the one above and separation from that of the vertebra 
below. The spinous process of the vertebra in lesion is also 
relatively more prominent posteriorly; especially when the 
patient is in extension, as this exaggerates the lesion. Moder- 
ate flexion, although it throws all the vertebrae into greater 
relief posteriorly, tends to diminish apparently the amount 
of structural perversion of the lesioned segment. Motion is 
restricted where there is separation; in other words, between 
the vertebra in lesion and the one below. Motion is free 
where there is approximation, or between the vertebra in le- 
sion and the one above. Neither flexion nor extension can 
change the amount of separation between the spinous process 
of the vertebra in lesion and that of the one below. The 
inferior margins of the inferior articular processes assume 
greater prominence posteriorly. It must be kept in mind that 
Etiology: 
Diagnosis: 232 
Downing Principles and Practice of Osteopathy 
the fourth lumbar vertebra has normally a long spinous proc- 
ess and the fifth a short one, otherwise mistaken deductions 
may ensue. 
Confusion may exist at times as to wheth- 
er the lesion is a flexion lesion of a par- 
ticular vertebra or an extension of the 
one above. A safe rule to apply is—restricted motion where 
there is separation indicates a flexion lesion; moreover, 
the fact that extension will produce no apparent approxima- 
tion proves definitely the presence of a flexion lesion. Still 
more conclusive proof is the fact that there is free movement 
where there is approximation. In this particular instance, 
it would characterize the vertebra above the one in lesion. 
The reverse of the above would indicate an extension lesion. 
Technique No. 1. Using direct action 
technique the objective is either the in- 
ferior articular process or the spinous process and the applied 
force is directed inferiorly and downward with the patient 
prone. Place pillows under the thighs to bring patient into 
primary position of extension. Complete adjustment with bi- 
lateral application of the thrust against the inferior articular 
processes of the vertebra in lesion, or against the snwous 
process, in the latter case being careful to direct the force in- 
feriorly as well as downward. An additional measure of great 
value is the application of deep mobilization on the Taplin 
table. With the patient prone, using the mobilizer, ligament- 
ous and muscular structures anterior to the axis of motion 
may be subjected to strong, deep alternate stretching and re- 
laxation which leaves the anterior common ligament, psoas 
major muscle and other associated soft tissues in better physi- 
ological repose and less subject to imbalance which may pre- 
dispose to a recurrence of the lesion. It is merely an added 
factor in the stabilization of adjustment. 
Technique No. 2. With the patient sitting, operator 
stands directly behind. Have patient fold the arms. The 
Differential 
Diagnosis: 
Treatment: Subluxations of the Lumbar Vertebrae 
233 
objective should be the upper posterior aspect of the 
spinous process. The operator should use the hypothenar 
eminence as the instrumentality of adjustment. The applied 
force should be directed inferiorly and forward, and concom- 
itantly with bringing the patient back into extension. 
Unilateral methods of adjustment of this particular type 
of subluxation will be discussed in detail under the treatment 
outlined for the lateral lumbar lesions. 
(Bilaterally Anterior Lumbar). The ex- 
tension lesion is an immobilization of a 
vertebra in the position of extension. The 
vertebra en masse assumes greater 
prominence anteriorly and, if a group lesion exists the con- 
cavity of the lumbar curve is increased. It is commonly call- 
ed an anterior lesion. The inferior articular processes of 
the vertebra in lesion move downward and tilt slightly in- 
ward or forward. The superior articular processes move 
downward and backward, assuming greater prominence pos- 
teriorly. The spinous process is relatively more oblique. The 
fulcrum is the core of the intervertebral disc and the move- 
ment occurs in the vertical plane of the facets. 
Functional and postural abuse is a less 
common cause of this condition than 
when associated with the flexion group lesion. When found 
under these conditions it is usually secondary to such abnor- 
malities as pot belly, flat feet, high heels, etc. It may be coun- 
ter balancing for bilaterally posterior innominates or flexion 
of the sacrum, in which case it is the forerunner of the type 
of spine in which the normal curves are accentuated. 
The vertebra is en masse anterior because 
of the forward yielding of the spine at 
that point due to the compression behind and the decompres- 
sion in front. There is approximation of the spinous process 
The 
Extension 
Lesion: 
Etiology: 
Diagnosis: 234 
Downing Principles and Practice of Osteopathy 
of the vertebra in lesion with that of the one below and separ- 
ation from that of the vertebra above. The spinous process 
is relatively more oblique and less prominent posteriorly and 
this is particularly noticeable with the patient in the position 
of flexion, as the lesion is thereby exaggerated. The lesion 
is less noticeable with the patient in extension as the amount 
of structural perversion is thereby apparently lessened by the 
position of the adjacent vertebra. Motion is restricted where 
there is approximation or between the vertebra in lesion and 
the one below and is free where there is separation or be- 
tween the vertebra in lesion and the one above. Flexion and 
extension cannot change the amount of approximation be- 
tween the spinous process of the vertebra in lesion and the 
one below. The superior articular processes assume greater 
prominence posteriorly. The concavity of the lumbar curve 
is increased in the group lesion. 
Technique No. 1. Using indirect action 
technique with the patient supine and the 
objective the superior articular processes of the vertebra in 
lesion, the operator flexes the knees on the thighs and the 
thighs on the abdomen. Bilateral fixation of the superior ar- 
ticular processes is maintained with one hand and with 
further flexion of the legs and thighs the operator then with 
exaggeration of the pressure against the superior articular 
processes completes the adjustment with quick, forcible 
downward, forward pressure against the patient’s knees, in 
such manner that the resultant force passes through an im- 
aginary point in the lower portion of the sternum. Leverage 
and resultant forces are opposed by counter adjustive force 
and the sum total of these forces is sufficient to effect the ad- 
justment of this lesion. 
Technique No. 2. Using direct action technique with 
the patient prone and if possible in easy flexion. The thrust 
should be delivered bilaterally against the superior articular 
processes of the vertebra in lesion, being careful to direct 
force superiorly as well as downward. 
Treatment: Subluxations of the Lumbar Vertebrae 
235 
Technique No. 3. Patient is seated on the stool in a posi- 
tion of moderate flexion. Operator rests pectoral area on the 
shoulder of the patient, and upper arm of the same side on 
his opposite shoulder. Operator should grasp the stool firmly 
with the hand of the same side and attempt strong approxi- 
mation. He should graduate flexion to the angle necessary 
to bring the greatest leverage on the vertebral articulation 
in lesion. 
Unilateral methods of adjustment of this particular type 
of subluxation will be discussed in detail under the treat- 
ment outlined for lateral lumbar lesions. 
Nomenclature for this lesion is not based 
on whether side-bending or rotation is the 
primary attempted move, but rather upon 
the respective amounts of movement en- 
tailed—for instance, rotation might be 
the primary attempted movement, but because of the greater 
predominance of secondary side-bending, it is better to con- 
sider them as merely variations of side-bending rotation. 
Rotation normally is negligible in comparison with side- 
bending, although there are really two kinds of lateral lum- 
bar lesions. 
(a) The type of subluxation which occurs in primary 
side-bending, and more often in flexion. 
(b) A traumatic lesion, a type in which rotation is 
primary and side-bending secondary. There is 
more torsion in the traumatic lesion, and there- 
fore a greater percentage of rotation. 
A definite distinction cannot be clearly made for 
the reason that there may be such varied propor- 
tions of side-bending and rotation. The nearer 
the lesion approaches the mechanical possibilities 
of the lumbar spine, the greater is the percent- 
age of side-bending and the more it is typically a 
subluxation of primary side-bending. 
The Side- 
Bending 
Rotation 
Lesion: 236 
Downing Principles and Practice of Osteopathy 
This type of lesion is commonly involved with flexion in 
contradistinction to the traumatic lesion which may as readily 
occur in extension as in flexion. A lateral lumbar lesion in- 
volving extension would, therefore, be more or less traumatic 
in character and indicate a primary rotation. These lesions 
are commonly called right or left lateral subluxations and 
are, inversely speaking, side-bending lesions to the right or 
left. If a group lesion, a functional lateral curve will ensue. 
The bodies of the vertebrae rotate to the concavity in such 
cases. The axis of movement of side-bending is through the 
intervertebral core and point of limitation, but further com- 
bined with rotation, the axis of movement becomes a line 
drawn through the intervertebral core, and the articulation 
of the convex side. 
Functional or postural abuse may be the 
cause of the group lesion. The individual 
lesion is often the result of strain produced with the patient 
in a position of flexion and side-bending. Occasionally the 
lesion is produced during the return to the upright posture, 
particularly when lifting some heavy object. Reciprocal in- 
nervation is a common cause, as is also trauma, the former 
tending to produce the typical type of subluxation, and the 
latter the traumatic. Efforts to save oneself from falling and 
lifting heavy objects above the head are examples of the type 
of torsion productive of the traumatic lesion. 
Primary diagnosis can best be made with 
the patient in the position of easy flexion, 
as this throws the vertebrae into greater relief posteriorly. 
The muscular mass over the transverse processes of the ver- 
tebra in lesion will be thickened and contractured, and sensi- 
tiveness will be marked. If the operator possesses an ex- 
traordinary amount of palpatory skill he may be able to make 
a more or less accurate positional diagnosis, although because 
of their depth in the muscle-mass and irregularity, no ac- 
curate or positive diagnosis can be made with any great de- 
Etiology: 
Diagnosis: Subluxations of the Lumbar Vertebrae 
237 
gree of certainty. The lateral deviation en masse of the 
spinous process of the vertebra in lesion is the primary diag- 
nostic factor. The spinous processes of the lumbar vertebra 
are fairly accurate indicators as to the position of the verte- 
bra, as they are not usually subject to anatomical deviation. 
In other words, they are morphologically constant, in contra- 
distinction to the spinous processes of the vertebrae above. 
There are, of course, exceptions to this rule. 
In lateral flexion, the lower border of the spinous proc- 
ess of the vertebra in lesion will be relatively more palpable 
on the side of the convexity, and the upper border is usually 
relatively more prominent on the side of the concavity. The 
amount of rotation can be determined by comparison of the 
lateral borders of the vertebra in lesion. The greater the 
rotation, the less prominent the lateral border of the spinous 
process on the side of the convexity and the more prominent 
the lateral border on the side of the concavity. This is due 
to the greater deviation from the median line. In side-bend- 
ing the vertical plane of the spinous process bisects a line di- 
viding the spinous processes longitudinally. Normally these 
lines should be indentical. If flexion or extension are com- 
plicated with a lateral deflection it is suggestive as to the type 
of subluxation. It should be kept in mind that in the lumbar 
area the spinous processes are in a horizontal plane with the 
articulations of the vertebra. Restriction of motion is found 
between the vertebra lesion and the one below. Exaggera- 
tion of the lesion by side-bending rotation of the vertebrae in 
that area toward the convex side, in other words, toward the 
side to which the spinous process is deflected, immediately 
magnifies the relative amount of structural perversion. Side- 
bending rotation toward the concave side will cause the lesion 
practically to efface itself as far as apparent physical mal- 
alignment is concerned. 
It must be borne in mind that in the lumbar area the 
spinous processes are in approximately a horizontal plane 238 
Downing Principles and Practice of Osteopathy 
with the articulations of the vertebrae to which they are at- 
tached. Sensitiveness can usually be elicited over the trans- 
verse processes and on the concave side of the spinous proc- 
ess of the vertebra in lesion. The subjective symptomatology 
varies greatly. 
The general principles of adjustment 
proper are as follows: 
(1) Side-bending to the side of the convexity. 
(2) Adjustment with rotation toward the side of the 
convexity. 
Technique No. 1. With the patient sitting the lesion 
may be adjusted in varying degrees of flexion by increasing 
forward bending from above downward in such a way as to 
bring the apex of flexion at the point of lesion. The objective 
in this case is the lateral aspect of the spinous process on the 
convex side. Side-bending should be utilized in such a man- 
ner as to bring the patient slightly out of balance with the 
trochanter slightly off the table so that the patient is reflexly 
unable to contract at the moment of adjustment. The pati- 
ent can be maintained in such a position only a short time 
before he automatically attempts counterbalancing, there- 
fore, adjustment must immediately follow side-bending to- 
ward the convexity and off balance. The adjustive force is 
rotatory in character toward the convex side. 
Technique No. 2. A very good method of adjustment 
with the patient sitting is accomplished as follows: Hook 
the fingers in front and against the anterior superior spine 
of the innominate on the concave side and curve the thumb 
of the same hand firmly around the spinous process so that 
pressure is brought to bear on the lateral aspect of the convex 
side of process. After obtaining this hold, side-bend and 
rotate toward the convex side, at the same time maintaining 
firm fixation of the innominate and firm pressure against 
the spinous process. This procedure may be used on the three 
lower lumbar vertebrae. 
Treatment: Subluxations of the Lumbar Vertebrae 
239 
C 
B 
-A 
Position for adjustment of rotation side-bending lesion of the twelfth dorsal 
vertebra unilaterally posterior on the right, anterior on the left. Anatomical ten- 
sion locking by forced flexion down to and including the vertebra in lesion com- 
prises lever handle which carried in the direction pointed out by arrow C con- 
stitutes leverage force. Arrow B indicates direction of transverse corrective 
force against convex side of spinous process of vertebra in lesion. Arrow A 
points out pseudo-flexion lesion. 240 
Downing Principles and Practice of Osteopathy 
Technique No. 3. With the patient prone, adjustment 
can be made by bilateral pisiform contact and a superimposed 
trust. The pisiform bone of one hand must be placed against 
the transverse and superior articular process of the verte- 
bra below the one in lesion on the convex side. Adjustive 
force must be carried downward and slightly toward the 
head. The opposite pisiform bone should be in contact with 
the transverse process and superior articular process of the 
vertebra in lesion on the concave side, and adjustive force 
should be carried downward and slightly toward the foot, 
and both forces delivered simultaneously. 
Technique No. 4. The best and easiest method of adjust- 
ing side-bending rotation lesions is with the patient on the 
side as follows: Consider the hypothetical lesion a right lat- 
eral third lumbar. The patient should lie on the concave side, 
or in other words with the convex side up. Therefore the 
patient lies on the left side. Side-bending to the convexity 
ensues as the result of the fact that there are only two points 
of contact, the pelvis and the shoulder girdle, and the inter- 
mediate portion is in suspension. Thus the unsupported area, 
the lumbar region, must naturally assume a lateral flexion be- 
tween the above supports. The lumbar spine should then be 
anatomically locked in flexion from below upward as far as 
the articulation in lesion. The exact degree of flexion can be 
determined by placing the tip of the finger between the 
spinous process of the vertebra in lesion and that of the one 
below and follow with flexion until the force of flexion is 
sufficient to bring a slight separational strain and tension of 
tissue between those points. Do not carry beyond that point. 
The thoracic and lumbar spine above the vertebra in lesion 
should be maintained in a stabilization locking by a combina- 
tion of extension and reverse rotation. This extension and 
reverse rotation should carry down as far as the articulation 
in lesion. The anatomically locked lumbar spine is the lever 
handle through which the adjustment is completed. The 
stabilization locking is for the purpose of paralleling the Subluxations of the Lumbar Vertebrae 
241 
planes of articulation and maintaining counter resistance to 
the adjustive force. Rotation of the lower segment toward 
the concavity is better than any attempted rotation of the 
upper segment toward the convexity, principally because 
there is no effective lever handle through which the latter can 
be accomplished. The stabilization locking should not be used 
for that purpose. The adjustive force through the locking 
lumbar lever control should be directed forward and upward 
so that the adjustive force is applied in a plane parallel to the 
planes of the articulation and thus arthrodial movement 
throughout a proper range is restored. To correct lumbar 
lesions with this method, the higher in the lumbar area the 
lesion, the greater is the flexion from below upward and the 
shorter the extension and reverse rotation from above down- 
ward. Lengthen the extension from above downward and 
shorten the flexion from below upward for lesions lower 
down in the region. Proper graduation of the above locking 
forces is absolutely essential if adjustment and not indis- 
criminate popping is expected, This method of adjustment 
is effective for all vertebral lesions in the lumbar area and 
may also be used occasionally in the dorso-lumbar and lower 
thoracic areas. It is not advisable to attempt adjustment with 
it above the tenth dorsal. It is not necessary to bring digital 
pressure upon the spinous process of the vertebra in lesion 
as an aid to adjustment. A finger may be placed directly 
over the articulation in lesion to be sure that locking forces 
fall above and below and not upon that articulation as it must 
be left unprotected. 
The above technique used bilaterally instead of unilater- 
ally is an effective maneuver for the adjustment of the bi- 
lateral lesion in an inverse manner, for as the articular facets 
of one side describe the unilateral movement of flexion, those 
on the opposite side describe the unilateral movement of ex- 
tension. Carried out on both sides or bilaterally it is there- 
fore effective for either the flexion or the extension lesion as 242 
Downing Principles and Practice of Osteopathy 
A 
C 
D 
E 
Position of patient for adjustment of a second lumbar vertebra immobilized 
in side-bending rotation to the right (left lateral second lumbar). Primary move- 
ment of side-bending to the convexity is indicated by the lines A and B. B also 
indicates lower lever handle, unification of which is assured by anatomical tension 
locking of flexion. A indicates upper lever handle obtained by stabilization lock- 
ing in reverse rotation. Arrow D points out convex side of spinous process. 
Arrow E indicates direction of corrective force using lower lever handle. Subluxations of the Lumbar Vertebrae 
243 
both facets have unilaterally described the full range of un- 
ilateral flexion and extension. 
The rotation side-bending lesion, as has been mentioned 
previously, is of traumatic origin, and a greater percentage 
of rotation is found than is customary. There is usually 
greater deviation of the spinous process from the median line 
than is found in the side-bending rotation lesion. However, 
rotation at its best is more or less of a negligible factor; there- 
fore, clinically, it is not necessary to place particular empha- 
sis upon this lesion. The same methods of adjustment would 
be used as in the correction of the side-bending rotation 
lesion. 
The combined lesions are: first, side-bending rotation 
complicated with flexion or extension; and, second, rotation 
side-bending lesion complicated with extension or flexion. 
Adjustment of these lesions necessitates the removal of the 
side-bending rotation or the rotation side-bending as the fac- 
tor of prime maintenance of the lesioned condition. If the 
secondary factor of flexion or extension does not spontane- 
ously adjust itself, additional adjustive effort should be 
utilized. 
Stubborn or rebellious pain which defies all adjustive 
measures should be carefully handled and the physician 
should rule out by the x-ray or allied means such conditions 
as sacralization of the fifth lumbar which is due to a broad- 
ening of the body of the fifth and partial fusion with the sa- 
crum, arthritis due to over-strain of the lumbo-sacral artic- 
ulation which demands that the spine be kept erect and sup- 
ported to lessen irritation, spondylosis, with its history of 
specific infection, primary spondylitis deformans without 
any particular history, as well as deformities of the fifth 
lumbar, and other structural and pathological involvements 
of the lumbar vertebrae. 244 
Downing Principles and Practice of Osteopathy 
CHAPTER IX. 
SUBLUXATIONS OF THE SACRO ILIAC 
ARTICULATIONS. 
The sacro-iliac joint is an amphiarthrosis. It is incom- 
pletely covered with hyaline cartilage and has a rudimentary 
synovial membrane. The articulating surfaces are composed 
of two definite zones, a central or articulating, (which is 
smooth but wave-like), and a peripheral, (which is rough for 
JrUertra/isvcrse. 
Lie/ 
Lcnl J.umbar 
Jntertmnsverse 
Gripal Sctfro-ScicUicZig- 
Deej) Tastfulu* / 
Zh'n LumljcirZig 
Orf Sacro Sciahc\ 
If bra mere 
Anterior nr Lesser 
Sa<T<> SciaLicT.u/ 
. I . 
Post mot* 
\j,u) nf Symphysis 
lesser Sacra - Sciatic 
2brcunen 
Ofo u ret tor 
Membrane 
Posterior view of the articulations of the pelvis. Subluxations of the Sacro-iliac Articulations 
245 
fibrous tissue attachments). Occasional bands of fibrous tis- 
sue pass directly across the capillary space of the peripheral 
zone of the joint from one surface to the other. The two zones 
are :not concentric and the articular surfaces themselves, 
irregular and roughened, present marked concavities or con- 
vexities which receive corresponding convexities or concavi- 
ties from the opposing surfaces. These opposing surfaces are 
nearly of the same size, thereby limiting joint action greatly. 
The capsular ligament of the articulation is made up largely 
of the periosteal membranes of the two articulating bones. 
Structurally the sacrum is positionally placed between 
the two ilia so as to present the characteristics of a double 
keystone which is both wider in front than behind and above 
than below. The arrangement is such that the apex of one 
wedge is downward and backward (the anatomical apex of 
the sacrum) and that of the other is directed upward and 
backward (a cross diameter drawn through the dorsal aspect 
of the bone between its second and third segments). 
Inasmuch as the sacro-iliac articulation presents the 
characteristics of an inverted wedge and its articular sur- 
faces are too vertically disposed to allow it to serve as a 
weight-bearing mechanism, this particular function falls 
upon the posterior sacro-iliac ligaments which act in such 
manner as to hold the sacrum between the innominates in 
suspension. Moreover, they act as the axis for rotation in the 
joint, which movement is more likely to be about a traveling 
center than about a fixed point. 
The sacrum is the base of the spine and the sacro-iliac 
joints are always the bases of the two ilia. The ilia start 
from the sacro-iliac joints at their bases and proceed on a 
curved course until they converge at the pubes. They are 
powerful and rigid levers and have much to do with the sta- 
bility and instability of their basal joints. For example, if the 
left rectus abdominis and the right gracilis and adductor 
muscles contract violently at the same time, the pubes may 246 
Downing Principles and Practice of Osteopathy 
be pulled out of symmetry, left side up and right side down, 
which means that the ilia have created motion in one or both 
sacro-iliac joints commensurate with that exhibited at the 
pubes. These powerful levers are accurate indicators as to 
the type and degree of dislocation or subluxation, inasmuch 
as they magnify at the pubes very slight malpositions at their 
bases. They moreover suggest themselves as more or less 
effective lever handles for adjustment. 
sacral 
vertebra 
Lateral view of the sacrum. 
The weight of the body is transmitted through the pelvic 
girdle in a zigzag manner. It is received first centrally, upon 
the antero-superior surface of the sacrum. It is then direct- 
ed backward, and lateralward to the posterior sacro-iliac 
(suspensory) ligaments. From this point it is transmitted 
antero-laterally to the heads of the femora. This transmis- 
sion must accommodate itself to many shifts of position in 
the dynamic individual for the acts of walking or running 
necessitate rapid changes in weight bearing. Hence, the Subluxations of the Sacro-iliac Articulations 
247 
irregularity and frequent shift of weight transmission re- 
quires a necessary structural stability of the sacro-iliac artic- 
ulations. 
When heavy burdens are superimposed upon the spine, 
the sacral wedge tends to descend between the ilia, thus per- 
mitting the pelvic girdle to tighten up to its anatomic limit. 
The sacro-iliac joints are too nearly vertical to be regarded 
as weight-bearing areas. In fact they never bear weight un- 
less the individual lies on his side, in which case they are sub- 
ject to lateral compression. The sacro-iliac ligaments are 
the weight-bearing mechanisms of the joint. 
The horizontal axis is still retained in the change from 
quadrupedism to bipedism although a greater functional de- 
mand is made upon the lumbar curve in the latter instance. 
The forward end of the spine loses none of its original sup- 
port, but the added weight of the forelegs falls upon the 
sacro-iliac joint. All strains received from above downward 
must be computed through the torus of the lumbar curve. The 
weight-bearing sacrum serves to tighten the pelvic girdle, 
inasmuch as the bone tends to be driven backward between 
the innominates, principally because a mechanical estimate 
of such superincumbent weight must take into consideration 
its backward deflected distribution through the lumbar 
curve. The added tendency to a downward tilting of the base 
of the sacrum is prevented by a tautening of the sacro-sciatic 
ligaments plus a tightening of the wedge from below upward 
posterior to the axis of motion as a result of the apparent 
rotary inclination of the sacrum. The axis of this rotation 
passes transversely through the sacro-iliac ligaments inas- 
much as they serve as a fulcrum for such movements. 
The double wedge shape of the sacrum and the manner in 
which these two wedges are tightened by the position of the 
weight on the sacrum is highly significant in that it indicates 
that most innominate lesions occur or tend to occur with the 
individual recumbent; or, in other words, when the superin- 248 
Downing Principles and Practice of Osteopathy 
cumbent weight does not affect the joints. Under such cir- 
cumstances severe trauma can most easily produce lesioning 
of the sacro-iliac joints. 
JuP'S) two ///or Z if/.. 
A/il.Sacro 
L.Uf. v 1 
LuniboitUic 
Lz9. 
lunibo Sacra/ 
Lig. 
Sicf) 
pubicfaSLC 
<■ for 
ILIACUS INTERNUS atld 
PSOAS 
1, u/amen/une 
Teres 
Ant. pubic, l/g 
Jtursa of common tendon 
Anterior view of the articulations of the pelvis and hip. 
of PSOAS and ILACUS IfITERNUS 
When an individual is standing the lumbar spine assumes 
its characteristic curve and the sacrum retains its horizontal 
axis. However, when the patient is sitting, the axis of the 
sacrum is almost vertical. The same is true when a quadru- 
ped stands erect on its hind legs. Indeed a postural remedy for 
a patient suffering from lumbo-sacral pain is suggested by 
this knowledge of shifting axes. Normal standing posture 
should be such that the anterior superior spine and the sym- 
physis pubis are in a perpendicular plane parallel to the line 
of gravity of the body. 
The sacro-iliac joint is not constructed for particular, de- 
finite physiological movement, for the muscles of the pelvic Subluxations of the Sacro-iliac Articulations 
249 
girdle do not possess a direct or discernable connection with 
powerful movement of the bones, one upon another. It does, 
however, allow a slight yielding motion which is both ar- 
throdial and rotary in character. Nature endowed us with a 
rigid and stable support; but she was also careful not to 
make this support too rigid; otherwise she would have de- 
feated one of her great purposes. In other words: she ful- 
filled the functional demand for elasticity by providing this 
sufficiently yielding structure to withstand the shocks and 
jars transmitted upward through the pelvic girdle. These 
particular forces are amply cushioned by the action of the 
sacro-iliac ligaments and associated ligamentous structures. 
Thus, we have a most efficient shock-absorber in what casual- 
ly appears to be an extremely rigid structure. 
Antero-posterior section through the symphysis pubis. 
The relation and direction of movement in the sacro-iliac 
joint is such that if the sacrum is backward the ilium is for- 
ward, or downward if the other is upward. We must remem- 
ber at all times that immediately above and below the pelvic 
girdle we have particularly free mobility in the lumbo-sacral 
and ilio-femoral articulations which are capable of taking 
upon themselves greater functional demands than might or- 
dinarily be expected and in that way of protecting the sacro- 
iliac joints from excessive functional strain. 
The relation of the legs and feet to the sacro-iliac joints 
is important when the arches are relaxed. There is an inward 
rotation of the leg with strain, tension and stretching of the 
external rotators. The inward rotation of the legs brings 250 
Downing Principles and Practice of Osteopathy 
constant stress upon the external rotators and, indirectly, via 
the fibers of the posterior capsular ligaments, separational 
strain is brought to bear upon the sacro-iliac articulations. 
Rotating the thighs outward as in regular rotation exercise 
for foot treatment tones up the external rotators. 
The pyriformis muscle is the only muscle in the body 
whose attachments criscross in the pelvis. It is the chief sta- 
bilizer of the sacro-iliac joint laterally. A method for toning 
up this muscle is as follows: 
The patient is prone, and rotates the leg outwardly 
against the resistance of the operator, who grasps the heel 
and holds the foot and toes inverted. 
Pregnant women are prone to sacro-iliac subluxations 
> 'v 
yi rf> 
Process, 
res- 
Ky?br% 
mat I 
* I 
ajf/c JjSj 
STtt/tof/sj 
nc 
[iSf'c^vI 
GLUTEUS 
MAXIMUS 
&eir. 
ffe 
’Xotc/i for StySacJST 
Corn.ua- 
Posterior view of the sacrum. Subluxations of the Sacro-iliac Articulations 
251 
because of the softened and relaxed state of their ligaments, 
particularly near parturition. 
Dislocation of the sacro-iliac joint is very rare and usual- 
ly fatal, due to tearing and injury of intra-pelvic and abdom- 
inal organs and the iliac vessels. Separation of the pubic 
bones in riders from the effects of a severe jolt has been re- 
ported by various authorities. It is a rare injury. 
The posterior sacro-iliac ligament is ex- 
ceptionally strong and is the chief bond of 
union between the sacrum and the ilium. 
It consists of three series of fibers: (a) superficial horizon- 
tal (b) deep horizontal (c) oblique. The superficial fibers 
connect the first and second transverse tubercles of the back 
of the sacrum to the tuberosity of the ilium and the deep fi- 
bers are immediately internal to the superficial. The oblique 
fibers connect the third transverse tubercle of the sacrum to 
the posterior superior spine of the ilium. 
The anterior sacro-iliac is a weak ligament composed of 
thin bands attaching the anterior part of the sacrum to the 
pre-auricular sulcus and margin of auricular surface of the 
ilium. 
The great sacro-sciatic ligament (ligamentum sacro- 
tuberosum) arises from the fourth and fifth transverse tu- 
bercles of the sacrum, from the spine of the ilium, sacrum and 
coccyx and passes downward, outward and forward to be 
inserted into the inner margin of the tuberosity of the ischium. 
The lesser sacro-sciatic ligament (ligamentum saerospi- 
nosum) arises from the lateral margin of the sacrum and 
coccyx and is inserted into the spine of the ischium. Both 
sacro-sciatic ligaments act as check ligaments for flexion of 
sacrum. 
The lumbo-sacral ligament arises from the transverse 
process of the fifth lumbar vertebra and attaches to the base 
of the sacrum laterally and anteriorly. 
Ligaments of 
Importance: 252 
Downing Principles and Practice of Osteopathy 
The ilio-femoral ligament is the strongest ligament in 
the body. It attaches above to the anterior inferior iliac 
spine. Below it is Y-shaped, one band attaching to the great 
trochanter and the other to the intertrochanteric line. The 
ilio-femoral ligament is the chief agent in maintaining the 
erect position, without muscular fatigue or effort, for a per- 
pendicular line passing the center of gravity of the trunk falls 
behind the center of rotation of the hip joint. Therefore, 
the pelvis tends constantly to fall backward, but is prevented 
from so doing by the tension of the ilio-femoral ligament. 
The ilio-lumbar ligament arises from the front part of 
the body of the fifth lumbar vertebra; laterally it divides 
and is attached by two bands to the ilium. Other ligaments 
of less importance will not be considered here. 
1. Positional, as regards the sacrum. 
(a) Bilaterally Anterior Sacrum 
(b) Bilaterally Posterior Sacrum 
(c) Unilaterally Anterior Sacrum 
(d) Unilaterally Posterior Sacrum 
2. Positional, in the same order as above but from the 
standpoint of the innominates. 
(a) Bilaterally Posterior Innominates 
(b) Bilaterally Anterior Innominates 
(c) Unilaterally Posterior Innominate 
(d) Unilaterally Anterior Innominate 
(e) Combined Unilaterally Posterior (one side), Uni- 
laterally Anterior (opposite side). This is a true 
form of the twisted pelvis. 
(f) The Pseudo-Twisted Pelvis. This is an apparent 
asymmetry of the pelvis due to imbalanced lum- 
bar muscle tensions, subluxations of the fifth 
lumbar, etc. It is not a true pelvic twist inasmuch 
as it is secondary and more or less counterbal- 
ancing and exists without lesion of the sacro- 
iliac articulations. 
Lesions of the 
Sacro-Iliac 
Articulation: Subluxations of the Sacro-iliac Articulations 
253 
From oniory 
Arl. iJm / W L u inbrirVrrt* 
lea: 
2f- 
pw 
Wth- 
mmvu 
m 
COCGYGEU S 
with coccyx 
The sacrum, anterior view. 
The Bilaterally 
Anterior Sacrum 
(Syn. Bilaterally Posterior Innomi- 
nates). This lesion is characterized by a 
slight arthrodial slippage downward of 
the sacrum on the ilia, together with a rotation on a trans- 
verse axis through the posterior sacro-iliac ligaments in such 
manner as to allow the base of the sacrum to rotate forward 
and slightly downward. This movement is therefore essen- 
tially a forward, downward movement of the sacrum or a 
backward, upward movement of the innominates. The liga- 
ments in connection with this joint may be placed on tension 
or relaxed according to whether their attachments are ap- 
proximated or separated. 254 
Doivning Principles and Practice of Osteopathy 
Etiology: 
The majority of predisposing factors 
are chronic in character, their formation 
being due to a long continued process of structural changes. 
A few of the causes follow: 
Faulty posture, that type particularly associated 
with pot belly and lumbar lordosis. 
Factors which bring the vertical line of gravity anterior 
to normal, such as extreme cases of the straight spine, in 
which the normal lumbar curve is lost or reversed. We must 
not forget the mechanical influence of the normal lumbar 
curve in the transmission of the superincumbent weight and 
the maintenance of the transverse axis for movement of the 
sacrum. 
A relaxed or atonic posterior sacro-iliac ligament must 
allow a certain amount of yielding in such a direction as to 
tend to produce this type of subluxation. 
A small percentage of bilaterally anterior sacrums may 
be due to traumatisms, falls, etc. 
The reason for the much greater percentage of anterior 
lesions of the sacrum is because of the direction of the lesion- 
ing forces in relationship to the pelvic structures and their 
articulations. Forces directed upward through the aceta- 
bulum tend to force the innominates upward and backward. 
The superincumbent weight falls upon the base of the sacrum 
and this, of course, tends to force the sacrum downward 
through a combination of arthrodial and rotary movements. 
The lesion is more common than the diag- 
nosis. This is probably due to the fact 
that asymmetrical findings are not evinced and, therefore, 
the lesion frequently eludes the notice of the examiner. These 
lesions are common and frequently antedate unilateral le- 
sions. The two most noticeable factors in diagnosis are the 
increase in the sacro-vertebral angle and the decrease in the 
Diagnosis: Subluxations of the Sacro-iliac Articulations 
255 
pelvic inclination (the normal is 30 to 40 degrees in the hori- 
zontal position, before backward, line drawn from the sym- 
physis pubis, through the posterior superior spine of the 
ilium). The antero-posterior diameter is lessened (the nor- 
mal is 414 to 4% inches). The base of the sacrum is down- 
ward and forward and the apex is upward and backward. The 
posterior superior spines are more prominent posteriorly and 
are approximated, (the normal separation being 3% to 3% 
inches). The iliac crests tend to flare more superiorly and the 
anterior superior spines are farther apart (the normal dis- 
tance being from 8V2 to 91/3 inches. The fifth lumbar has the 
appearance of being markedly anterior, the spine of the 
fourth overlapping the fifth and approximating it. With 
the patient supine, both feet are strongly everted, due to the 
tension pull of the sartorius muscle. The apex of the angle 
formed by the junction of the ilium and sacrum (the sacro- 
iliac X) is more acute and is the seat of localized tenderness. 
In bilateral lesions both junctions are tender on their poste- 
rior aspects. The sacro-tuberous and -spinous ligaments are 
tensed as well as the fascia between the ischial tuberosity and 
the lower portion of the sacrum and coccyx. Motion is re- 
stricted equally in both joints and in all directions. 
Patient prone. The legs should be slight- 
ly abducted and feet everted. Using a 
Taplin table and a Taplin mobilizer, rocking the sacrum back- 
ward and forward will normalize mobility of both sacro-iliac 
joints simultaneously. In this particular case the operator 
should mobilize downward with force directed against the 
apex of the sacrum. This type of technique is particularly 
efficient, easy of accomplishment, and should be used as the 
method par excellence in treating a heavy patient. 
On a straight table a pillow should be placed under the 
thighs to obtain ilio-femoral leverage. The operator should 
then direct corrective pressures to the apex of the sacrum. 
In an extremely stubborn lesion, the operator can, by stand- 
Treatment: 256 
Downing Principles and Practice of Osteopathy 
ing on a stool at the side of the table, apply pressure with the 
knee against the apex of the sacrum, and allow freedom of 
the hands to exert outward and downward pressure against 
the ilia; thumbs behind the posterior superior spines, fingers 
along upper borders of the ilia. To enhance the value of this 
treatment instruct patient to place his hands on the table and 
slowly and strongly extend, as the operator applies extra 
pressure to the ilia, and return slowly to the prone position 
when extra-sacral pressure is applied to the apex. 
Patient sitting astride the table at the extreme end. The 
operator holds the patient across the shoulders and bends 
him over backward to the degree necessary to bring strong 
counter pressure of the outer portion of the table against the 
posterior superior spines. The abducted position of the pa- 
tient’s legs brings strong ilio-femoral leverage on both in- 
nominates and superimposed upon this is the contact pres- 
sure against the posterior superior spines. This necessitates 
only slight increase in extension to carry the sacrum through 
the bilateral movement of extension. If the table is extremely 
wide, too much abduction will result and the interlocking 
effect of the heads of the femora will prevent easy reduction 
of the sacro-iliac subluxations because of lateral compres- 
sion. 
This lesion may also be corrected as a unilaterally poste- 
rior innominate of first one side and then the other. Predis- 
posing causes must be thoroughly removed insofar as possi- 
ble to obtain the best permanent results. 
(Syn. Bilaterally Anterior Innominates). 
This is an infrequent condition consisting 
of an upward and backward rotation of 
the base of the sacrum. It is an extension 
lesion of the sacrum. The false pelvis is broader, the diameter 
of the inlet larger, and that of the outlet smaller. Both in- 
nominates are forward and slightly downward. The reverse 
is true of the sacrum. The ligaments in connection with this 
The Bilaterally 
Posterior 
Sacrum: Subluxations of the Sacro-iliac Articulations 
257 
joint may be placed on tension or relaxed, according to 
whether their attachments are approximated or separated. 
The causes of the type of lesion are va- 
ried. A few of them are as follows. 
Faulty sitting posture, especially extreme slouching, with 
the weight resting on the apex of the sacrum, is predisposing. 
Bedridden patients who have spent a long time on their 
backs will develop this condition. Etherization without a 
lumbar pad may precipitate an acute lesion of this type as 
will also parturition. Unusual forms of trauma may pro- 
duce it. 
In the main it is converse to that of the 
bilaterally anterior sacrum. The sacro- 
vertebral angle is decreased and the pelvic inclination increas- 
ed. The fifth lumbar and the base of the sacrum are more 
prominent posteriorly. The apex of the sacrum is more an- 
terior and the sacro-tuberous and -spinous ligaments are re- 
laxed. The posterior superior spines are further apart, not 
so prominent and at a correspondingly higher level. The an- 
terior superior spines, in relation to the posterior, are at a 
lower level and the distance between them is increased, 
although mensuration does not always show this, the differ- 
ence being very slight at times. The crests flare more than 
normal anteriorly. With the patient on his back, the feet tend 
to relax in inversion. There is considerable tenderness along 
the inner border of the posterior portion of the crests of the 
ilia. The sacro-iliac junctions (sacro-iliac X) show a decrease 
in the acuteness of their posterior angles, the angles becoming 
more obtuse. Restricted motion is equal and the same in 
all directions. The nature of the predisposing causes may 
aid in the diagnosis. 
Patient prone. Using a Taplin table and 
a Taplin mobilizer the sacrum can be 
mobilized in the direction of flexion by directing the mobiliz- 
Etiology: 
Diagnosis: 
Treatment: 258 
Downing Principles and Practice of Osteopathy 
ing force against the base of the sacrum in a downward, for- 
ward direction. 
Using the straight table with the patient supine, the fol- 
lowing method is satisfactory. Place a pillow under the an- 
terior superior spines. Adjustive force is directed against 
the base of the sacrum in a downward, forward direction. 
This method can be made still further effective by counter 
force applied to the ischial tuberosities. This lesion may be 
adjusted unilaterally by using technique for reduction of the 
unilateral anterior innominate, first on one side and then on 
the other. 
(Syn. Unilateral Posterior Innominate). 
This lesion is a torsion movement on an 
oblique axis approaching the vertical 
which passes through the sacro-iliac articulation of the op- 
posite side. A true rotation movement is not possible and 
the axis of the torsion movement is more or less a shifting 
one. The movement of the base of the sacrum is slightly 
forward and downward on the side of the lesion and is rotary 
and arthrodial in character. The portion of the sacro-iliac 
ligament allowing this movement is stretched and weakened. 
There cannot be a lesion on one side without compensatory 
changes on the other. The movement is complex and asym- 
metrical. There is a tendency toward separation between 
the sacrum and the ilia posterior on the side opposite the 
lesion and anteriorly on the side in lesion. This compensa- 
tion partakes of the nature of an anterior rotation of the op- 
posite innominate to re-establish stability and transmit sup- 
erincumbent weight efficiently. This anterior rotation is 
secondary. Fixation is not present usually, and therefore it 
is not a lesion in a true sense. When spontaneous adjust- 
ment of the primary lesion occurs the secondary condition 
will automatically disappear. This, therefore, implies 
specific direction of adjustive energies to the primary lesion 
alone. 
The Unilateral 
Anterior Sacrum: Subluxations of the Sacro-iliac Articulations 
259 
The fifth lumbar vertebra is maintained in side-bending 
rotation with the spine directed to the side opposite that of 
lesion. This is undoubtedly due to the tension pull of the 
ilio-lumbar ligament. Secondary lesions in the lumbar spine 
ensue as a result of the disturbance of equilibrium brought 
about by the pelvic asymmetry. It is very common to find 
a secondary third lumbar lesion compensatory to a lateral 
fifth; a second lumbar lesion compensating for a fourth. 
The twelfth rib on the lesioned side is frequently sublux- 
ated by being pulled down by the tension of the quadratus 
lumborum muscle and of the lateral spinal muscles, which are 
often in a contractured state. 
Inherent muscular and ligamentous im- 
balances of the adjacent region are pro- 
ductive factors. Unequal ligamentous tone of the posterior 
sacro-iliac ligaments has a pronounced influence upon the 
functional welfare of the articulation. Traumatisms such as 
torsion forces (sudden wrenches, falls, etc.) are frequent 
causes. This type of lesion may also be associated with oc- 
cupational and postural anomalies, scoliosis, functional cur- 
vatures, etc. 
Physical findings or, in other words, an- 
atomical findings, are a probable indica- 
tion as to the type and nature of the subluxation. Combined 
with functional or physiological findings they constitute a 
complete clinical diagnostic picture. 
Physical findings: With the patient sitting, the pos- 
terior superior spine is more prominent, at a lower level and 
nearer the median line of the body. The sacro-iliac joint on 
the side of the lesion is more sensitive than its fellow. Ten- 
derness of a lesser degree is frequently found on the side op- 
posite the lesion along the inner border of the crest, which is 
characteristic of the anterior type of innominate subluxation. 
Etiology: 
Diagnosis: 260 
Downing Principles and Practice of Osteopathy 
With the patient lying face downward a compensatory 
functional curvature may evince itself, the convexity being 
on the side of lesion. This is due to the contractured state of 
the musculature of the lesioned side. The buttock on the sub- 
luxated side is at a lower level than its fellow. The respective 
shift in these levels may or may not be particularly noticeable. 
With the patient on the back, the side opposite the lesion 
appears higher with the exception of the leg, which appears 
nearer to the table, due to the relative position of the aceta- 
bula. The ilium on the side opposite to the lesion flares more 
anteriorly and the anterior superior spine and crest is appar- 
ently at a slightly lower level. The side in lesion appears to hug 
the body more, making the hip appear smaller than its fellow. 
A demonstrable difference in the respective levels of the 
crests of the symphysis pubis is such that the side in lesion 
appears to be slightly elevated. The leg on the side of the 
lesion is shorter. This may be determined by drawing a line 
from the anterior superior spine or the umbilicus to the inner 
malleolus of each limb and comparing the length of both 
lines. The foot tends to evert due to the tension pull of the 
sartorius muscle. The side in gross lesion shows marked 
sensitiveness at the point of division of the gastrocnemius 
muscle. Standing, the shoulder of the patient on the side of 
lesion is lower than the opposite shoulder, although the crest 
of the ilium on the side of the lesion is apparently at a higher 
level than that of its fellow. 
Inasmuch as a sacro-iliac joint has a nor- 
mal yielding range of combined arthro- 
dial, rotary motion in an upward, back- 
ward, and a downward, forward direc- 
tion this knowledge can be utilized diag- 
nostically to advantage. By referring to this slight motion 
it is possible to determine, first, whether there is a fixation 
and secondarily, through comparative findings as to the range 
of motion of the opposite leg, to prove the relative position of 
Diagnosis Based 
on Functional 
or Physiological 
Findings: Subluxations of the Sacro-iliac Articulations 
261 
the leg in fixation. If the sacro-iliac joint is considered as 
having normal range of motion, necessarily our anatomical 
findings are dependent upon and must conform to its func- 
tional imbalance. A joint usually seeks as a resting point its 
central range of motion, but there is no law to prevent it, 
under certain circumstances, from resting in its uppermost or 
its lowermost range of motion and without transgressing the 
laws of normality. The essential physiological factor of any 
lesion is fixation and in the sacro-iliac subluxation its pres- 
ence must be proven, as it is the positional situation; and, after 
adjustive procedures have been carried out, it must also be 
proven whether physiologic balance has been restored; in 
other words, equal mobility in the same and all directions. 
And if the condition be in the nature of an excessively relax- 
ed sacro-iliac articulation with concomitant loss of tone in 
the sacro-iliac ligaments, hypermobility will be the physiologic 
finding and serve as an accurate indicator as to the exact 
character of the condition. 
Normally the sacro-iliacs may assume diverse ranges of 
motion. Anatomical findings indicate this fact but do not 
determine definitely the presence or absence of lesion as they 
do not prove or disprove the presence of fixation. Assume, 
for example, the presence of a posterior innominate on the 
left with fixation in that position. However, as the opposite 
leg might at the time of examination be in its posterior range 
of normal yielding motion, the anatomical findings would 
tend to be equal and symmetrical and would fail of a cor- 
rect diagnosis if the operator depended entirely upon the an- 
atomical situation. On the other hand, if, by the use of easy 
leverage forces, an operator may shift the position of the in- 
nominates anteriorly or posteriorly as desired and thereby 
create almost any type of positional anomaly, and, moreover, 
if he can by the same use of leverage in the case of a unilateral 
lesion and its resultant pelvic asymmetry, create symmetry 
and apparent normality anatomically by directing easy lever- 
age forces through the opposite innominate, the importance 
of the functional finding is apparent. 262 
Downing Principles and Practice of Osteopathy 
A standard upon which to build our diagnostic findings 
must be established. Anatomical findings alone are vari- 
ables; they are not fixed standards. Physiologic findings are 
true indicators of the presence or absence of fixation and, 
using the method which will be later described, are a correct 
index as to the type, degree, and position of the lesion. 
Superimposed, the physical findings are an admirable check 
upon the primary diagnosis. 
The author uses a method which will give a complete 
functional analysis of both sacro-iliac articulations. This 
is part of a routine examination in the case of any pelvic 
asymmetry when it is desired to establish or rule out the 
presence of a sacro-iliac lesion. Two different types of com- 
bined leverage force are possible. The one that gives the 
greatest range of motion possible to the innominate in a 
downward, forward direction is the combined leverage-force 
of the posterior fibers of the capsular ligament plus those of 
the ilio-femoral ligament. The combined tension leverage of 
these two ligamentous structures is produced by first bring- 
ing the leg across the median line, which tenses the posterior 
fibers of the capsular ligament and produces a separational 
strain at the sacro-iliac articulation, and by then superim- 
posing the pull of the ilio-femoral ligament by external rota- 
tion of the already adducted leg and thigh. The one that 
gives the greatest range of motion possible to an innominate 
in an upward, backward direction is the combined leverage 
effect of the capsular ligament plus the external rotators of 
the thigh. This combined tension leverage is produced by 
abducting the leg and thigh and internally rotating them 
while in this position. Capsular ligament tension, as in the 
aforementioned case, is of value in that it tends to focus 
separational strain upon the sacro-iliac articulation. The 
external rotators are the means by which rotary and arthro- 
dial leverage necessary to bring the innominate to its up- 
permost backward range of motion is applied. The pyriformis 
and the obturator internus muscles are added potential forces Subluxations of the Sacro-Iliac Articulations 
263 
in the production of this leverage. The position of the leg in 
both cases is such as to tend to bring valuable resultant 
forces into action in the first procedure in a downward di- 
rection, and in the second procedure in an upward direction. 
The routine method of procedure, as used by the author, is as 
follows: 
3 
A 
Position of leg and thigh in relation to the torso to effect shortening of 
the leg through forward rotation of the innominate. Capsular ligament tension 
leverage particularly through the ilio-femoral ligament is the means by which 
the above rotation is accomplished. A, B and C indicate the direction of rotation 
of the thigh and leg. 264 
Downing Principles and Practice of Osteopathy 
Lengthening procedure for one leg and shortening pro- 
cedure for the other, gives the total range of disparity of 
movement in one direction. Reversing the procedure by 
lengthening the leg previously shortened, and shortening the 
leg previously lengthened, gives the total disparity of move- 
ment in the opposite direction. Providing the entire range 
of disparity in both directions is equal and moreover will 
evince a total difference of from one to two inches in the re- 
spective levels of the inner malleoli, one may clinically assume 
a normal sacro-iliac joint. A bilateral decrease in motion of 
less than an inch is significant of bilateral restriction of move- 
ment in the sacro-iliacs. A bilateral increase in motion in 
which the total disparity in both directions is greater than 
two inches indicates hypermobility of both. A difference in 
the respective totals of disparity of movement in both direc- 
tions indicates fixation in the direction of the lesser of the 
two. This means that either the leg to which the shortening 
leverage was applied is fixed in an anterior position, or that 
its fellow, to which lengthening leverage was applied is im- 
mobilized in a posterior position. The next step in the pro- 
cedure is to rule out fixation either of the anterior innomi- 
nate or the posterior innominate of the opposite side. Using 
the lengthening leverage if the fixation is a posterior one, the 
leg on the side in lesion will refuse to lengthen, but by short- 
ening it both malleoli will assume the same level. This is 
functional evidence of a unilateral posterior innominate. On 
the other hand, if both legs lengthen but one leg refuses to 
shorten, the functional evidence points to an anterior innomi- 
nate on that particular side. If, however, with the use of 
bilateral lengthening and bilateral shortening, the display 
still remains, this gives evidence of a unilaterally posterior 
innominate on one side, and unilaterally anterior innominate 
on the other. Pelvic asymmetry is constant in this instance, 
in contradistinction to the case of the unilateral lesion in 
which pelvic asymmetry may be temporarily eliminated, for 
if one innominate is fixed posteriorly and the shortening Subluxations of the Sacro-Iliac Articulations 
265 
leverage is applied to the other leg, pelvic symmetry will re- 
sult; the reverse is true in the case of anterior innominate 
fixation in which a lengthening leverage applied to the op- 
posite leg to induce seeming pelvic symmetry. 
c 
B 
A 
Position of the leg and thif»'h in relation to the torso to effect shortening of 
the limb through backward rotation of the innominate. Capsular ligament and 
external rotator leverage is the means by which the above rotation is secured. A, 
B and C indicate the direction of rotation of the thigh and leg. 
The pseudo-twisted pelvis, in which there is no sacro-ilia? 
fixation, can be automatically and quickly eliminated, inas- 
much as pelvic symmetry is noted when both innominates are 
carried bilaterally anterior and bilaterally posterior with 
their corresponding leverage control; and, moreover, the total 
disparity of movement in both directions is equal. Bilateral- 266 
Downing Principles and Practice of Osteopathy 
ly posterior innominates will show no response to lengthen- 
ing leverages and the total disparity of movement will be so 
slight as to indicate double fixation, although equal in both 
directions. The opposite picture obtains in the functional 
findings associated with bilaterally anterior innominates. 
Studies of the posterior superior iliac spines and their 
action under the use of these leverage forces is interesting as 
well as instructive. By alternately using bilateral shorten- 
ing and bilateral lengthening measures, the posterior superior 
spines can be brought from greatly exaggerated approxima- 
tion to widely marked separation (approximately to 1 
normally). The application of unilateral leverages to the in- 
nominate will correspondingly change its position and compel 
it to assume the characteristic position of either the anterior 
or posterior innominate, depending upon the type of leverage 
used. Other palpable anatomical features will likewise as- 
sume a position commensurate with the change of position at 
the base; in other words, the sacro-iliac joint. 
Technique No. 1. Patient prone. If a 
straight table is used, place a pillow under 
the thighs with legs maintained in slight abduction and feet 
everted, particularly on the side of lesion, as this will tend to 
bring leverage-force through the ilio-femoral ligament. Ad- 
justive force is directed against the posterior superior spine 
of the ilium in a downward, lateralward direction. Counter 
adjustive force is applied against the apex of the sacrum, or 
in other words that section of the sacrum below the axis of 
rotation. The heel of each hand is the medium through 
which corrective force can be effectually administered, This 
is accomplished by placing the heel of the hand against its 
appropriate objective. As there are two objective points 
against which force is to be directed, both hands are utilized 
and both adjustive forces are delivered synchronously. Using 
a Taplin table, a pillow is not necessary. In fact, rocking the 
sacrum between the innominates with the use of the Taplin 
Treatment: Subluxations of the Sacro-iliac Articulations 
267 
mobilizer often serves to break the fixation and restore a 
normal range of movement to the sacro-iliac joint, rendering 
further adjustment unnecessary. 
Technique No. 2. Patient supine. If straight table is used 
a pillow is placed under the sacrum and posterior superior 
spines. The operator stands beside the patient on the side of 
the lesion. Flex the leg on the thigh, and the thigh on the abdo- 
men, slightly beyond a right angle with the table so that the 
point of the flexed knee is in the same vertical plane as the 
highest portion of the iliac crest. From this point without 
changing the vertical plane, adduct to the medial plane or 
midline of the body so as to bring strain on the posterior 
fibers of the capsular ligament. Interlock the fingers and 
with this particular instrumentality make a thrust downward 
on the flexed knee so that the force will pass approximately 
through the long axis of the femur. This force is transmitted 
through the long axis of the femur into the acetabulum in 
such manner and direction as to force backward that portion 
of the innominate below the axis of rotation which in turn 
means reverse rotation of that portion above this axis. Su- 
perimposed upon the adjustive force is passive counter force, 
made possible by the fact that the point of maximum contact 
with the table is the posterior superior spine. The thrust 
should be given at the end of expiration. 
Technique No. 3. Patient supine, with lesioned side near 
the lateral edge of the table. Operator on the same side facing 
the patient. Fingers of the proximal hand are placed beneath 
the greater trochanter and cupped in such a manner as to 
secure a tremendous leverage by interposing a fulcrum be- 
tween the trochanter and the pelvis at that point. The leg 
and thigh on the side of lesion are then flexed at right angles 
with the table and abducted to the point of limitation. The 
same degree of flexion must be maintained throughout this 
maneuver, so the weight of the abdomen is brought against 
the knee to stabilize the extremity in this position. The other 
hand is then utilized to hold the opposite innominate firmly 268 
Downing Principles and Practice of Osteopathy 
£ 
a 
El 
Position for adjustment of a unilaterally posterior innominate. Force is 
delivered in the direction indicated by arrow D through the long axis of the 
femur. This force is opposed by counter force as the posterior superior spine is 
in contact with the table on the side of lesion. Arrow B indicates direction of 
this force. Subluxations of the Sacro-iliac Articulations 
269 
to the table with its thumb over the pubes and fingers along 
the crest of the ilium. The thumb over the pubes helps to 
determine whether motion is being re-established. Slight 
exaggeration of force directed at all three points, that is to 
say, slight exaggeration of the abduction of the leg with ab- 
dominal pressure, an increased pressure lift with the fingers 
underneath the greater trochanter and counter force by ex- 
aggeration of the fixation of the opposite innominate will 
serve to force the innominate forward. To complete the 
procedure, the hand underneath the greater trochanter is 
shifted so as to bring pressure on the abducted knee, reliev- 
ing the abdomen from further duty. The hand maintaining 
the fixation of the opposite innominate is released so that 
the leg slightly above the ankle joint can be firmly grasped. 
Maintaining abduction, the patient is requested to kick 
straight out violently, and at the same time the operator gives 
a strong pull to the lower limb. The first effect of this lever- 
age is to break fixation by bringing a tremendous rotary 
leverage through the ilio-femoral ligament. The latter part 
of the procedure tends to bring the sacro-iliac joint, the 
acetabulum, and the long axis of the leg into a common ver- 
tical plane. The combination of these actions serves to force 
the sacro-iliac joint to rotate anteriorly. 
Technique No. 4. Patient supine. Flex the leg and thigh 
to a right angle with the body and attempt forcible external 
rotation of the thigh in that position. Maintaining these 
forces, straighten the flexed thigh. All this should be done in 
the midline. The forcible attempt at external rotation on a 
short axis exerts tremendous leverage on the ilio-femoral 
ligament when followed by extension of the thigh. The knee 
during this procedure is flexed and abducted across the 
median line. It is the lever handle through which these forces 
are secured and applied. 
Technique No. 5. Patient on the side, lesioned side upper- 
most, with knee and thigh flexed to right angle. The flexed 
knee is maintained in firm position by the abdomen of the 270 
Downing Principles and Practice of Osteopathy 
El 
a 
Position of the leg and thigh in relation to the torso necessary to evoke 
greatest possible leverage of the ilio-femoral ligament for adjustive purposes. 
Arrow A indicates direction of leverage pull of ilio-femoral ligament. Arrow B 
indicates right hand which is cupped beneath and behind the greater trochanter 
acting in the nature of a fulcrum. Arrow C indicates direction in which lever 
is carried. Note abduction of the leg and external rotation of the thigh. Subluxations of the Sacro-iliac Articulations 
271 
operator. The latter places his proximal hand over the pos- 
terior superior spine. With the opposite hand, he grasps the 
foot at the ankle joint and inverts it strongly. He then flexes 
the foot and knee to a point of easy limitation. With the lower 
leg as a lever handle, he attempts to circumduct the knee 
joint. With the knee locked in flexion, this results in a trans- 
ference of this force to the acetabulum bringing about a 
leverage tension of the external rotators of the thigh and 
posterior fibers of the capsular ligament. This results in a 
gapping of the sacro-iliac articulation. At the summit of 
this separational strain the foot is suddenly jerked straight 
down in the long axis of the torso. The snap-of-the-whip 
effect of the latter procedure superimposed upon the gap- 
ping strain of the former is sufficient to produce an an- 
terior rotation of the innominate, breaking fixation and re- 
establishing physiologic normality. 
Technique No. 6. Patient on the side, in a modified Sim’s 
position, lying upon under arm, with that arm extended back- 
ward and with legs and thighs both flexed. Operator stands 
behind patient and places the flexed knee against the posterior 
superior spine of the innominate in lesion and grasps the 
flexed knee of lesioned side with the adjacent hand. His 
other hand he places against the dorsal aspect of the up- 
permost scapula merely to exert a fixed point of stabilization 
pressure. The lesioned leg and thigh is flexed on the ab- 
domen slightly beyond a right angle, is then strongly ab- 
ducted, and, thereupon brought backward and downward, 
behind the under leg in a shearing manner so that at the end 
of the procedure it is in an extended, abducted position. The 
posterior superior spine and the scapula are maintained as 
fixed points during this procedure, offering resistance in 
such manner as to make the leverage forces possible. More- 
over, they obviously render the adjustment easier through 
the maintenance of a counter force against the posterior 
superior spine of the innominate. The latter part of the 
procedure brings leverage force to bear through the psoas 272 
Dotvning Principles and Practice of Osteopathy 
n 
c 
A 
Position for adjustment of an innominate immobilized in upward, backward 
rotation. B indicates sacro-iliac articulation, and D pivotal point for action of 
lever handle C. Circumduction of the latter determines i rotation of the femur on 
its long axis and tension leverage of the posterior fibers of the capsular ligament 
and external rotators. This composite action causes a gapping strain at the 
sacro-iliac articulation. When separational strain is at its maximum a straight 
pull of the leg (arrow A) determines anterior rotation of the innominate to com- 
plete adjustment. Subluxations of the Sacro-iliac Articulations 
273 
major muscle. This leverage is incidental but its influence 
on the sacrum is to stabilize the latter. 
Technique No. 7. Patient standing, face to the wall. Make 
pressure against the posterior superior spine in lesion and 
counter extension of the thigh on the same side, being careful 
also to obtain a slight amount of external rotation of the thigh 
and abduction of the leg. Exaggerate both forces simultan- 
eously to complete adjustment. This method is crude but 
effective. 
Technique No. 8. Patient sitting up. Swart’s strap technic 
for the posterior innominate is of value. It consists in passing 
the strap across the lesioned hip just below the crest of the 
ilium and on the opposite side above the iliac crest (so the 
strap in the latter instance does not touch the ilium) and then 
by carrying it around the patient’s heel on the side of lesion. 
The strap is thereupon buckled, short enough so that the leg is 
about one-third flexed. The patient should then attempt to 
straighten the leg by forcible pressure against the strap. 
Before or after correction of the innominates the fifth 
lumbar vertebra must be corrected as there is always an 
accompanying twist of this segment, its spinous process be- 
ing to the side opposite that of lesion. In this connection at- 
tention should also be directed to the twelfth rib which is 
many times pulled down by contraction of the quadratus 
lumborum muscle. 
(Syn. Unilateral Anterior Innominate). 
This lesion is a torsion movement on an 
oblique axis which approaches the verti- 
cal and passes through the long axis of 
the sacrum slightly posterior and mesial 
to the sacro-iliac articulation on the side opposite that of 
lesion. This is a shifting axis. The movement of the base of 
the sacrum is slightly backward on the side of lesion; a weak- 
ening of the posterior sacro-iliac ligament allows this move- 
The 
Unilateral 
Posterior 
Sacrum: 274 
Downing Principles and Practice of Osteopathy 
ment. Pelvic asymmetry of a complex nature is the result of 
the primary fixed anterior innominate of the lesioned side 
and the secondary compensatory posterior position of the in- 
nominate on the opposite side. The secondary lesion is sel- 
dom immobilized and usually does not demand adjustive 
measures. 
The fifth lumbar vertebra is maintained in side-bend- 
ing rotation with its spine directed toward the side of lesion. 
This is due to the relaxed state of the opposite ilio-lumbar 
ligament with a resultant secondary tonic tension pull of the 
ligament on the side of lesion. The pelvic asymmetry, by 
disturbing equilibrium usually occasions other compensatory 
lumbar lesions above the level of the fifth. 
The twelfth rib may or may not be in lesion. When a 
posterior innominate is primary the lesion is quite common 
but it is much less common when the posterior innominate is 
a secondary, compensatory factor. 
Imbalanced muscular and ligamentous 
tension, (particularly unequal tone of the 
posterior sacro-iliac ligaments,) are productive etiologic 
factors. Traumatisms partaking of the character of torsion 
forces such as sudden wrenches, falls, blows, etc., are fre- 
quent causes. The character, nature and direction of the 
lesioning force will sometimes be an indication as to the 
nature of the subluxation. Such a lesion may have an oc- 
cupational or postural source; it may be secondary to 
scoliosis, functional curvature, etc.; it may be due to atoni- 
city of the extensors or hypotonicity of the flexors, or it may 
be included in a marked lordosis of the lumbar column, ef- 
fecting an extension, either bilateral or unilateral, of tffe 
sacrum. When a straightening of the lumbar spine is not 
sufficient to produce extension or to include the sacrum in its 
posterior deflected swerve, it is a lesioning factor for produc- 
tion of the bilaterally anterior or unilaterally anterior 
sacrum. It is evident, therefore, that the effect of such 
Etiology: Subluxations of the Sacro-Iliac Articulations 
275 
totally diverse conditions depends entirely upon the degree 
and extent of this lordosis insofar as it may involve the 
sacrum in its posterior deflection. 
The physical anatomical findings in com- 
bination with the functional, physiologi- 
cal diagnostic signs will give a complete clinical analysis of 
the condition. The physical findings are as follows: 
With the patient sitting the posterior superior spine is 
less prominent, at a higher level and also further away from 
the median line of the body than normal. There is usually 
marked sensitiveness along the inner border of the iliac crest. 
With the patient prone a compensatory functional curvature 
may or may not be apparent concave on the side of lesion. 
The buttock on the subluxated side is at a slightly higher 
level than its fellow. 
With the patient supine the thigh on the side of lesion 
appears higher than that on the normal side, except the leg, 
which appears nearer to the table, due to the relative posi- 
tion of the acetabula. The ilium on the anterior side flares 
more anteriorly and the anterior superior spine is apparently 
at a lower level. The ilium of the opposite side flares less and 
appears to hug the body more, causing the hip of that side to 
appear smaller than its lesioned fellow. The respective levels 
of the crests of the symphysis pubis are such that the side in 
lesion is slightly depressed. The leg on the side of the lesion 
is longer, as is shown when lines are drawn from the anterior 
superior spines or the unbilicus to the inner malleoli of each 
limb and their comparative length noted. The foot tends to 
invert on the side of lesion. 
With the patient standing the high shoulder is on the 
side of the lesion although the crest of the ilium of that side 
is apparently at a lower level. Subjective symptoms vary and 
are not dependable. The operator should avoid the confusion 
which would exist in the diagnosis of the twisted pelvis as to 
whether the primary lesion is an anterior innominate on one 
Diagnosis: 276 
Doivning Principles and Practice of Osteopathy 
side or a posterior on the opposite by always conforming to 
physiologic findings and basing his differential diagnosis 
upon the results of such tests. Any attempt to base a diag- 
nosis on subjective symptoms, sensitiveness, or amount of 
structural perversion in the case of the unilateral lesion is 
unsatisfactory. The leg opposite the one in lesion may be 
subject to a greater disturbance than the one in lesion. This 
is explained by the fact that compensatory to the fixation of 
the lesioned innominate is a resultant hypermobility of the 
opposite side, and, moreover, by the fact that such hyper- 
mobility may be productive of a greater disturbance than 
the immobilization. 
The patient or the corsetiere will often notice that one 
hip is apparently larger than the other. This is characteristic 
of a twisted pelvis. 
First seek demonstrable proof of the 
presence of fixation and the nature of 
position: (physiologic evidence of an anterior fixation). 
Superimpose upon the above finding a differential diagnosis 
through the physiologic evidence of free mobility of the op- 
posite innominate. These findings combine to give an exact, 
correlated, clinical and differential diagnosis. The correct 
procedure for obtaining these findings has already been fully 
described. 
Technique No. 1. Patient sitting with back 
to operator. Grasp the innominate (iliac 
crest) firmly with the proximal hand so that the tips of the 
fingers are in the depression below the anterior superior 
spine, the palm along the crest and the thumb in the depres- 
sion under the posterior superior spine. 
(Note:—If the operator’s hand is not large enough to en- 
compass these points the hold may be modified to suit indivi- 
dual convenience. The patient is instructed to hold his arms 
across his chest. Next, the distal hand of the operator grasps 
Physiological 
Findings: 
Treatment: Subluxations of the Sacro-Iliac Articulations 
277 
the patient’s shoulder on the side of the lesion with the fore- 
arm against the latter’s chest. The patient is then flexed from 
above downward in such manner as to produce a complete 
anatomical locking of the lumbar spine to a point including 
the lumbo-sacral articulation. This changes the axis of rota- 
tion of the sacrum from a normally transverse axis to a near- 
ly vertical axis, passing through the long axis of the bone. 
Hold the innominates firmly and bring the patient forward 
to the limit of flexion. He is then instructed to relax 
thoroughly and allow his entire weight to rest upon the op- 
erator’s forearm. From this point of extreme flexion rota- 
tion on a small arc is carried out toward the side opposite 
that of lesion, utilizing the long lumbo-sacral lever handle, 
thoroughly locked, being careful at no time during the 
latter part of this procedure to disturb primary lumbar flexion 
inasmuch as the unit action of this lever handle is dependent 
upon the locking in flexion from above downward and any 
shift in this flexion will immediately and automatically de- 
stroy the integrity of this unit lever handle. The vertical axis 
for rotation of the sacrum allows the sacrum to rotate unila- 
terally forward on the side of lesion which movement is 
automatically adjustive to that side, providing firm counter 
force or resistance is maintained in opposition against the 
anterior superior spine of the innominate on the side of lesion. 
Technique No. 2. Patient on the lesioned side with the 
lower thigh and leg flexed strongly, leg on the thigh, thigh 
on the abdomen. The operator stands behind the patient and 
places his flexed knee against the base of the sacrum. One 
hand grasps the shoulder, firmly holding the torso in slight 
forward rotation of the uppermost side. The other hand 
grasps the flexed knee of the lesioned side firmly and exerts 
a quick strong adduction pull in an upward and backward 
direction. This brings tremendous leverage force to bear 
upon the posterior fibers of the capsular ligament of the 
hip joint and the external rotators of the thigh. The hand 
against the shoulder merely maintains a stabilizing and re- 278 
Downing Principles and Practice of Osteopathy 
sistance pressure against the upper torso in opposition to the 
adjustive forces. 
Technique No. 3. Patient on the side, lesioned side up- 
permost. The upper thigh is flexed to a right angle with the 
torso, and the knee carried in flexion to a point of easy limi- 
tation, considerably beyond a right angle. The flexed knee 
is maintained in firm stabilization against the physician’s ab- 
domen. The operator places his proximal hand over the pos- 
terior superior spine. With the opposite hand he grasps the 
forefoot and inverts it strongly. With the foot and lower 
leg as a lever handle, he then attempts circumduction of the 
knee joint. With the knee locked in flexion this results in 
transference of the force to the acetabulum, bringing about 
leverage tensions in the external rotators of the thigh and 
posterior fibers of the capsular ligament, thereby producing 
a gapping of the sacro-iliac articulation. At the climax of 
this separational strain the foot is suddenly jerked down- 
ward and forward. The snap-of-the-whip effect of the latter 
procedure superimposed upon the gapping strain of the for- 
mer is sufficient to cause a rotation forward of the aceta- 
bulum and consequently a backward rotation of the innomi- 
nate above the axis of rotation. 
Technique No. 4. Patient supine. Operator stands on 
the side of the lesion. He flexes the leg on the thigh and the 
thigh on the abdomen, slightly beyond a right angle with the 
table, so that the apex of the flexed knee is in the same ver- 
tical plane as the highest portion of the iliac crest. From this 
point he adducts across the middle line of the body, so as to 
bring the point of the flexed knee directly over the ilium of 
the opposite side and in the same vertical plane. Interlock- 
ing the fingers, and with this particular instrumentality at 
his command, he makes an oblique thrust upon the flexed knee 
in such a direction that the resultant force will pass through 
the lower abdominal quadrant of the side opposite the lesion. 
Through the medium of the external rotators of the thigh Subluxations of the Sacro-Iliac Articulations 
279 
and the capsular ligament of the hip adjustive leverage 
force is effective to the innominate in lesion. 
Technique No. 5. Patient prone. If using a straight 
table, place a pillow under the thighs to protect the patient 
from inquiry through contact with the hard table surface. 
Adjustive force is directed against the posterior aspect of the 
tuberosity of the ischium. Counter adjustive force is applied 
against the base of the sacrum, or, in other words, that sec- 
tion of the sacrum above the axis of rotation. The heel of the 
hand is the medium through which this corrective force can 
be delivered most efficiently in both cases. This is done by 
placing the heel of the hand against the desired objective. As 
there are two objective points against which force is directed, 
both hands are utilized and both adjustive forces delivered 
simultaneously. Using a Taplin table and mobilizer, rocking 
the sacrum between the innominates will usually serve to 
break the fixation and render further treatment unnecessary. 
Technique No. 6. Patient on the side, lesioned side up- 
permost. The operator flexes the upper thigh on the abdomen 
and stands between the patient’s legs in such a manner as to 
bring additional pressure on the apex of the flexed knee by 
exaggerated flexion and adduction of the thigh. He then 
interlocks the fingers of both hands and brings the heel of the 
proximal hand against the anterior superior spine and the 
fleshy portion of the opposite forearm against the tuberosity 
of the ischium. Exaggeration of the flexion and adduction 
focuses leverage force against the innominate in lesion through 
the tension of the external rotators of the thigh and the fi- 
bers of the capsular ligament of the hip joint. Superimposed 
to this leverage force are the adjustive forces of the heel of 
the hand against the anterior superior spine, applied in a 
backward direction, and the fleshy portion of forearm 
against the tuberosity of the ischium given in a forward di- 
rection. 280 
Downing Principles and Practice of Osteopathy 
Position ior adjustment of an innominate immobilized in forward, downward 
rotation. Leverage force of the external rotators is assured by extreme flexion 
of the thigh. Arrow A indicates direction of force against tuberosity of the 
ischium. Arrow B indicates direction of counter force against anterior superior 
spine. Subluxations of the Sacro-iliac Articulations 
281 
The combined 
Unilaterally 
Posterior, 
Unilaterally 
Anterior 
Innominates: 
This is in reality a twisted pelvis 
inasmuch as one innominate is immobi- 
lized anteriorly and the other posteriorly. 
Asymmetry is constant. The axis for 
this torsion movement is oblique and 
nearly vertical, passing through the long 
axis of the sacrum. 
The fifth lumbar vertebra is maintained in side-bending 
rotation with the spine directed to the side opposite that of 
the posterior innominate. Secondary lesions in the lumbar 
region of the spine ensue as the result of a gross disturbance 
of equilibrium. Each innominate lesion partakes of the 
nature and particular characteristics common to that type 
of sacro-iliac subluxation. 
Traumatisms in the nature of torsion 
forces such as sudden wrenches, falls, etc., 
are the most common causes. With the superincumbent 
weight off the pelvis and conditions favorable to the forcible 
shifting of the normal transverse axis for rotation of the 
sacrum to a nearly vertical one, the mechanical situation is 
then propitious to the production of such lesions. 
It is not necessary to enlarge upon physi- 
cal or anatomical findings inasmuch as 
the condition combines, respectively, the findings character- 
istic to both an anterior and a posterior innominate. 
Physiologic findings are an accurate index as to the 
nature of the condition. If, with the use of bilateral length- 
ening and bilateral shortening the disparity is constant, we 
have evidence of a unilaterally posterior innominate on one 
side and unilaterally anterior innominate on the other side. 
Pelvic asymmetry is constant. In contradistinction to the 
case of the unilateral lesion in which the pelvic asymmetry 
can be temporarily eliminated, the above method gives physi- 
ologic evidence of bilateral converse fixation. 
Etiology: 
Diagnosis: 282 
Downing Principles and Practice of Osteopathy 
Treatment: 
This lesion may be adjusted by unilateral 
means, that is to say, by adjusting each 
innominate separately. 
Technique No. 1. The technique about to be described is 
for bilateral, simultaneous adjustment. It is as follows: Pati- 
ent supine. The operator stands on the side of the anterior in- 
nominate. He flexes the leg of that side on the thigh, and 
the thigh on the abdomen slightly beyond a right angle with 
the table so that the point of the flexed knee is in the same 
vertical plane as the highest portion of the iliac crest. From 
this point he adducts it across the midline of the body so as 
to bring the point of the knee directly over the sacro-iliac 
articulation of the posterior innominate. Interlocking his 
fingers, with this instrumentality he makes a thrust down- 
ward on the flexed knee so that the resultant force will pass 
approximately through the lateral articulating portion of the 
sacrum of the latter side in an antero-posterior direction. 
Opposing this force is the shearing effect of counter force 
against the posterior superior spine of that side. This auto- 
matically takes effect from the fact that the posterior 
superior spine of the distal side is the major contact point 
of the pelvis on the table. These parallel forces will act in 
such manner as to correct the posterior innominate of the 
distal side. The oblique thrust upon the knee cap is directed 
in such manner as to deliver through the medium of the exter- 
nal rotators of the thigh and the posterior fibers of the cap- 
sular ligament of the hip joint adjustive tension leverage 
force to the anterior innominate of the proximal side. 
This is an apparent asymmetry of the 
pelvis due to imbalanced lumbar muscle 
tensions, subluxations of the fifth lumbar, 
etc. There is no lesioning fixation of the sacro-iliac articula- 
tions; therefore the condition is secondary and in itself needs 
no adjustive attention. 
Any existing confusion as to the nature of this condition 
The Pseudo- 
Twisted Pelvis: Subluxations of the Sacro-Iliac Articulatioyis 
283 
can be quickly eliminated by utilizing physiologic findings to 
prove or disprove the presence of fixation. 
A line drawn from the anterior superior 
spine of the ilium to the most prominent 
part of the tuberosity of the ischium con- 
stitutes Nelaton’s line. The very upper 
border of the great trochanter lies on 
Nelaton’s line and this point is, moreover, 
on a level with the center of the hip joint—in other words, the 
center of the acetabulum. With the patient supine, Bryant’s 
triangle is obtained as follows: A line is carried on a level 
with the anterior superior spine of one side across to the 
opposite side. Another line is continued from the anterior 
superior spine to the most prominent anterior point on the 
greater trochanter—almost coinciding with Nelaton’s line. A 
third line is continued upward in the long axis of the femur 
from the most prominent point of the great trochanter. This 
line joins at right angles the first or perpendicular line. This 
third line is known as Bryant’s line and is a means of measure- 
ment for determinating the amount of ascent of the greater 
trochanter in fracture and dislocation of the hip. 
Because of the element of rotation that enters into sacro- 
iliac subluxations, a certain amount of change and modifica- 
tion takes place in this triangle. When an innominate is im- 
mobilized downward and forward, Nelaton’s line becomes 
slightly less oblique, tending nearer the horizontal, thus 
shortening Bryant’s line in its corresponding relation to the 
perpendicular line. When an innominate rotates upward and 
backward, Nelaton’s line becomes slightly more oblique, tend- 
ing toward the vertical, and Bryant’s line is lengthened rela- 
tively to that of the perpendicular line. The triangle is 
slightly enlarged in the former, and decreased in the latter. 
The relation of the trochanter to Nelaton’s line remains un- 
changed, however. 
The Relation of 
Bryant’s Triangle 
and Nelaton’s Line 
to Sacro-Iliac 
Lesions: 284 
Downing Principles and Practice of Osteopathy 
The male pelvis. 
Sciatica is the pain-response of the sciatic nerve to irrita- 
tion or strain. It may be the result of some disturbance in 
the static balance of the body, over exertion, exposure, etc. 
Pain in the back is invariably on the same side as the muscular 
overstrain or static anomaly. Constitutional predisposition 
or some acquired etiologic factor is generally in evidence, such 
as the osteopathic spinal lesion, infection, intoxication, worry, 
thermal influences, etc. Meteorologic changes primarily 
effect sugar tolerance and the resultant suboxidation induces 
a toxic state of the muscular tissue which renders it more 
liable to reflex irritability and contracture. 
Localized lesions in the lower extremities or the back, in- 
cluding hip-joint trouble, rheumatoid arthritis, spinal disor- 
ders, flat foot, fractures, traumatic foot injuries, varicose 
veins, flail-joints, static weaknesses and gonorrhea are factors 
which, when localized on one side, correspond to the same side 
as that of the disturbed nervous mechanism. Their connection 
is unmistakable. The primary cause produces direct or indi- 
rect static insufficiency resulting in muscular strain, fatigue 
and irritation. A strained muscular function is significant as 
a factor in the production of neuritic symptoms. Lumbago 
in many cases can be traced to a primary muscle strain and 
secondary local neurotic symptoms. Pressure, chilling or a Subluxations of the Sacro-iliac Articulations 
285 
toxic state is responsible many times. Severe muscular effort 
may induce lumbago and, in severer cases, sciatica. A dimin- 
ished or lost Achilles reflex, together with more or less anaes- 
thesia, is suggestive of a neuritic tendency. A persistant sci- 
atica is usually secondary and is indicative of an obscure 
chronic cause, or it has become a traumatic neurosis which can 
best be treated by suggestion as the neurasthenic element 
must be dealt with. 
The female pelvis. 
In hip joint disease pain in the knee is more or less symp- 
tomatic. This is usually localized on the inner side of the knee 
joint itself, due to the fact that both the hip joint and the knee 
receive their innervation from the obturator nerve. In dis- 
turbances of the sacro-iliac joint, reflex pain over the obtura- 
tor nerve through the knee is frequently noted because of the 
close relationship of the nerve to that articulation, passing 
over it and occasionally distributing filaments to it. When 
the obturator nerve is paralyzed the patient is unable to press 
his knees together or to cross one leg over the other. When 
the anterior crural nerve is paralyzed the patient is unable 
to flex his hip completely. 286 
Downing Principles and Practice of Osteopathy 
Contracture of the pyriformis muscle has considerable 
influence upon the welfare of the sciatic nerve in that it 
passes behind and directly across the nerve and in a contrae- 
tured state tends to bring pressure to bear upon it. 
LEVATOR ANI 
Coccyx, anterior surface. Anterior or lateral subluxation common. 
Reduced through rectal manipulation. 
The deep portion of the fascia lata may become contrac- 
tured through reflex innervation and because of its attach- 
ment to the border of the great sacro-iliac ligament produce 
some narrowing of the sciatic aparture and thereby produce 
a pressure effect on the sciatic. This pressure, although not 
great enough to cause sciatic irritability, is sufficient to im- 
pinge the artery and vein which continues along with it 
and thereby to produce nutritional impoverishment. Its 
nerve supply is derived from the lumbo-dorsal area and the 
range of the distribution of this disturbed innervation is such 
as primarily or secodarily to induce a twelfth rib lesion. Costal Subluxations 
287 
Chapter X. 
COSTAL SUBLUXATIONS 
Characteristics 
of a Typical 
Rib: 
Each rib presents two extremities, a pos- 
terior or vertebral, an anterior or sternal, 
and an intervening portion, the body or 
shaft. The vertebral extremity presents a 
head, neck and tuberosity. The head is characterized by a kid- 
ney-shaped articular surface divided by a horizontal ridge 
into two facets for articulation with the costal cavity, formed 
by the conjoint demi-facets on the contiguous thoracic verte- 
brae. The bisecting ridge serves for the attachment of an 
inter-articular ligament. 
The thorax, anterior view. 
The neck is constricted, flattened, extends laterally from 
the head, and is approximately an inch in length. It is placed 288 
Downing Principles and Practice of Osteopathy 
in front of the transverse process of the lower of the two 
vertebrae with which the head articulates. On the posterior 
surface of the neck at its junction with the shaft is an emi- 
nence, the tuberosity or tubercle, which consists of an articu- 
lar and a non-articular portion, excepting in the case of the 
eleventh and twelfth ribs. It presents also a rough surface 
posteriorly for the middle costo-transverse ligament and a 
rough crest for the anterior costo-transverse ligament. 
The anterior or sternal extremity is flattened and pre- 
sents an oval, concave depression for the reception of the 
costal cartilage. The shaft is thin and flat, and presents two 
surfaces, an external and an internal, and two borders—a 
superior and an inferior. The external surface is convex 
and marked at its back part a little in front of the tuberosity 
by a prominent oblique line which gives attachment to a 
tendon of the ilio-costalis muscle and is called the angle of 
the rib. From this point the rib is bent in two directions so 
that its shaft as a whole is curved and slightly twisted upon 
its own axis. The internal surface is concave, smooth, and 
presents a ridge in front of the angle. The interval between 
this ridge and the inferior border presents a subcostal groove 
for the intercostal vessels and nerve. The superior border is 
thick and rounded and presents an external and an internal 
lip for the external and internal intercostal muscles. The 
inferior border at its posterior third presents a groove for 
the intercostal vessels and nerve and at its anterior two- 
thirds is sharp and thin. 
The peculiar ribs are the first, second, tenth, eleventh 
and twelfth. The first is short, broad, has no angle and but 
one facet on the head. Its upper surface is marked by two 
parallel grooves, separated by a tubercle for tne scalenus 
anticus muscle. In the posterior groove runs the subclavian 
artery and in the anterior the subclavian vein. The costal 
cartilage of the first rib is peculiar in that it is continuous 
with the sternum. Costal Subluxations 
289 
Jit ctVi 
Ant Caato -Central 
Ay- 
-Synovial Cavity 
Middle Casio -Tnuisvensv 
| Vert eh veil 
\ Foramen, 
Post- Coslo Tra nsversc 
Zig. 
SynovvaV 
Cavity 
Middle Costo-Transverse Luj ■ 
Costo vertebral articulations seen from above. 
The second resembles the first in that it is flattened and 
not twisted. The tenth rib has but one facet for articulation 
with the tenth dorsal vertebra. The eleventh has a single 
facet on its head, a slight angle, but no tubercle or neck. The 
twelfth has a single facet, but no angle, tubercle or neck. 
The costo-vertebral articulations are di- 
vided into two sets. 
(a) Those which connect the heads 
of the ribs with the bodies of the vertebrae—eosto- 
central. 
(b) Those which connect the necks and the tuber- 
cles of the ribs with the transverse processes—costo- 
transverse. 
The costo-central joints have each a double arthrodial 
connection between the head of the rib and the bodies of the 
two adjacent vertebra, except the first, tenth, eleventh and 
twelfth ribs, which are united to the vertebral column by but 
a single joint. Its inter-articular ligament consists of a short 
Articulations 
of the Ribs: 290 
Downing Principles and Practice of Osteopathy 
band of fibers attached by one extremity to the sharp crest 
which divides the two articular facets on the head of the 
ribs and by the other to the inter-vertebral disc, bisecting 
the joint into two distinct cavities. The first, tenth, eleventh 
and twelfth ribs have no inter-articular ligament. 
The anterior costo-vertebral or stellate ligament arises 
from the head of the rib, divides into three bands of fibers 
and inserts into the bodies of the vertebrae above and below 
and the intervertebral disc between. 
The capsular ligament is a thin, loose, ligamentous bag, 
which surrounds the joint between the head of the rib and 
the articular cavity formed by the intervertebral disc and the 
adjacent vertebrae. 
There are two synovial membranes in each of the articu- 
lations having an inter-articular ligament. 
The costo-transverse articulation allows a slight amount 
of arthrodial movement and has: an anterior or superior 
costo-transverse ligament which stretches between the lower 
border of the transverse process and the sharp crest of the 
upper border of the neck of the rib; a middle costo-trans- 
verse or interosseous ligament, which consists of short but 
strong fibers connecting the posterior part of the neck of 
each rib and the anterior surface of the adjacent transverse 
process; and a third, the posterior costo-transverse ligament, 
a short, thick fasciculus which passes from the summit of 
the transverse process to the non-articular portion of the 
tubercle of the rib. The capsular ligament is a thin, mem- 
branous sack surrounding the articular surfaces and is 
lined by a synovial membrane. 
The costo-sternal articulations of the true ribs with the 
sternum are arthrodial diarthroses with the exception of the 
first in which the cartilage is usually directly united to the 
manubrium, making it synarthrodial in character. The 
anterior chondro-sternal ligaments connect the chondral and Costal Subluxations 
291 
Inter' vertebral 
Fibro curtilage 
rlnt Cost. Vertebral 
Mid. Cost. Vertebral 
Inf. Cost.Vertebral 
Sup-Costo/ 
transverse Ligt 
/nfrCosto-transverh 
Lifj 
Ribs and corresponding vertebrae with ligaments; anterior view. 
sternal surfaces in front. The posterior chrondo-sternal con- 
nect them behind. Capsular ligaments surround all and 
synovial membranes are present in all but the first. The 
second has an inter-articular ligament as well. The chondro- 
xiphoid ligament connects the cartilage of the seventh and 
sometimes the sixth rib with the xiphoid appendix. The 
interchondral and costochondral articulations are covered by 
the perichondrium and periosteum of the cartilages and ribs. 
The anterior articulations of the cartilages of the sixth, sev- 
enth and eighth ribs and sometimes those of the fifth and 
ninth, are connected by external and internal interchondral 
ligaments, held together by capsular ligaments, and each is 
lined by a synovial membrane. 292 
Downing Principles and Practice of Osteopathy 
Costal Movements 
Movements of the ribs may be classified 
as follows: 
1. Pump-handle. 
2. Bucket-handle. 
3. Combined bucket-handle and pump-handle. 
4. Enarthrodial. 
In inspiration and expiration the ribs re- 
volve on a transverse axis drawn through 
their costo-transverse and costo-vertebral 
articulations. This results in a rotation of the rib on a long 
axis, the tubercle and head of the rib acting in a hinge-like 
manner, the latter having also a screwing motion. This move- 
ment increases the antero-posterior diameter of the thoracic 
cavity and does not materially affect the transverse. The rib 
may be regarded as a radius moving on the vertebral joint as 
a center and allowing the sternal attachment to describe an 
arc with the vertical plane of the body. 
In inspiration and expiration this move- 
ment is a rotation on an axis passed 
through an intermediate point between 
the costo-transverse and the costo-vertebral articulation pos- 
teriorly, and the costo-sternal articulation anteriorly. The 
movement in the costo-transverse articulation is such that the 
tubercle moves upward, backward, and medialward. The 
head of the rib moves downward, outward and backward. 
This movement causes an increase in the transverse diameter 
of the thoracic cavity and a decrease in the antero-posterior 
diameter unless associated with the pump-handle movement. 
This movement is a combination of the 
pump-handle and bucket-handle move- 
ment with an increase in all diameters. 
The primary motion is a pump-handle ex- 
cursion and is followed immediately by 
the bucket-handle variation. 
Pump-Handle 
Movement: 
Bucket-Handle 
Movement: 
Combined 
Bucket-Handle 
and Pump-Handle 
Movement: Costal Subluxations 
293 
S' 
c 
,D 
A 
■A' 
Diagramatic representation of axis of motion of the ribs. C to C' represents 
antero-posterior axis for bucket-handle movement. D to D' represents axis 
through the neck of the rib for pump-handle movement. 
D 
C 
B 
Enarthrodial This is peculiar to those ribs having free 
Movement: anterior extremities and which therefore 
permit slight movement in all directions, 
i.e., the eleventh and twelfth, or floating ribs. 
The ribs are divided into three classes, according to 
their attachments: 
1. Vertebro-sternal or true ribs—seven in number, 
each of which joins the sternum by a separate costal 
cartilage. 
2. Three vertebro-chondral or false ribs immedi- 
ately below, the cartilages of which join each other and 
with the seventh before uniting with the sternum. 
3. Two vertebral, free, or floating, which have no 
sternal attachments. 294 
Downing Principles and Practice of Osteopathy 
The first rib has pump-handle movement 
exclusively. Ordinary inspiration results 
in an excursion of the ribs in which the 
sternum is carried upward and forward 
by the action of the ribs immediately be- 
low. The first rib, of itself, enters into 
movement only passively. The action of the scaleni muscles 
in inspiration of a more or less forced costal type is such that 
when they contract they tend to cause a pump-handle move- 
ment of the first rib. When it has become stabilized in in- 
spiration it can then serve as a fixed point for further action 
of the ribs below. Their pull is such as to cause its neck to 
rotate downward and backward on its long axis. The first 
rib is only dynamically concerned in respiration when the 
scaleni muscles take their fixed point from above, contract 
and elevate the first and second ribs. It must be remembered 
that the sternal end of the first rib is more or less fixed and 
for that reason the manubrium and rib tend to move as one 
piece. The head is very movable and has no inter-articular 
ligament. Movement of this rib results in an increase in the 
antero-posterior diameter of the upper thorax only. 
The second rib has a less rigid sternal attachment, and 
the middle of the rib can also be drawn up, thus allowing a 
slight increase in the transverse as well as in the antero-pos- 
terior thoracic diameter. 
The third, fourth, fifth and sixth ribs are elevated by 
combined pump and bucket-handle movements which increase 
all diameters. The primary movement is the pump-handle 
variety and this is followed by a secondary bucket-handle 
movement. Bucket-handle motion increases from above 
downward and pump-handle movement decreases in the same 
fashion until at the seventh rib the latter is entirely lost and 
superseded by the bucket-handle type. At the fourth rib 
both movements are approximately the same. Above that 
point there is a corresponding increase in pump-handle move- 
The 
Vertebro- 
sternal 
Ribs: Costal Subluxations 
295 
ment; below it there is a proportionate decrease in the bucket 
handle variety. 
ST RN 0 
THYROID > 
ni 
Jfk^U>i{rinm 
3 rd 
- ofiuYiahis _ 
*4i 
7<* 
8>h 
Anterior view of sternum and costal cartilages. 
V ertebro- 
Chondral 
Ribs: 
The seventh, eighth, ninth and tenth 
ribs are elevated by a bucket-handle 
movement only, increasing the transverse 
and the lateral antero-posterior diameter, but decreasing the 
median antero-posterior diameter. With the exception of the 
seventh, which is a true rib, these costae belong to the ver- 
tebro-chondral order. 
The eleventh and twelfth, or floating 
ribs have enarthrodial joints and are 
capable of slight movement in all directions. Normally they 
are depressed when the others are elevated to form fixed 
points for the action of the diaphragm. The tip of the 
twelfth rib usually lies two inches above the middle of the 
crest of the ilium. 
Vertebral Ribs: 296 
Downing Principles and Practice of Osteopathy 
Muscles of 
Respiration: 
They are divided into two general classes: 
(a) Muscles of ordinary respiration. 
(b) Muscles of forced respiration. 
The muscles of ordinary inspiration are the scaleni group 
(anticus, posticus and medius). The serratus posticus 
(superior and inferior), external intercostals, levatores cos- 
tarum, diaphragm and quadratus lumborum. The muscles 
of ordinary expiration are the internal intercostals. The 
muscles of forced inspiration are the pectoralis major and 
pectoralis minor, serratus anticus, sternocleidomastoideus, 
and the muscles which extend the cervical region. The 
muscles of forced expiration are abdominal. 
Inter Artiaula r 
Fibro Cartilage \ 
Anterior sterna clavicular 
yf Jiteifarm proc ■ 
<Jnleroostal 
Synovial 
Sacs. 
8* 
Sternum and ribs with 
ligaments; anterior 
view. Left half sec- 
tioned with joint cavi- 
ties exposed. 
9,h 
to$ Costal Subluxatioiis 
297 
Lesions of the 
First Rib: 
1. Pump-Handle Lesion: (Inspirational). 
A lesion wherein the rib is elevated ante- 
riorly with a downward backward rota- 
tion posteriorly on the transverse process of the first dorsal 
vertebra. Although theoretically permissible it is rarely, if 
ever, found. Indeed, this lesion would be possible only 
through the pull of the scalenus muscle and its maintenance 
would depend entirely upon a retention of the fixed point 
above for the action of this muscle, which is unlikely. Due to 
the position of the attachments of the scalenus muscle the 
possibility of a slight amount of bucket-handle movement is 
problematical. 
To the author’s mind the motion of this rib is entirely 
pump-handle in character; and, moreover, his opinion is that, 
as far as inherent dynamics having sufficient control to pro- 
duce an inspirational form of pump-handle lesion of the first 
rib is concerned, it is impossible. If one considers the full 
significance of this contractured state, its dependence upon 
a fixed point and the static or adynamic forces which con- 
stitute a powerful and ever present corrective factor, it is 
easy to realize the practical impossibility of immobilization 
in such a position. 
dSERRATuS 
OS .* 
SCALENUS 
ANT1CUS 
Left first rib, superior surface. 
2. Pump-Handle Lesion: (Expirational). A lesion 
wherein the rib is depressed anteriorly and rotates upward 298 
Downing Principles and Practice of Osteopathy 
and backward posteriorly on the transverse process of the 
first dorsal vertebra. This lesion is extremely common. 
The defects in the upright position are important fea- 
tures in etiology. The spinal column, constructed to bear 
weight and sustain strain at a right angle, is obliged to do 
so in its long axis. The rib, which is more or less at a right 
angle to the spine was constructed to sustain strain in its 
long axis. It is obliged to do so at a right angle. Thoracic 
expansion has to work against gravity, and the weight of 
the anterior chest wall is such as to constantly bear down on 
the anterior extremity of the rib. Trauma, posture, and the 
adynamic forces of gravity are the usual causes of the lesion. 
An inspirational lesion of any rib (second to the tenth, 
inclusive) is characterized by continued maintenance in 
forced or exaggerated inspiration. The axis of rotation of the 
lesion depends upon the particular rib involved. 
An expirational lesion of any rib (second to the tenth in- 
clusive) is characterized by continued maintenance or im- 
mobilization in expiration, the character of which may or 
may not be exaggerated. The atypical ribs (first, eleventh, 
and twelfth) in a modified manner, subserve a respiratory 
function. 
These may be classified as follows: 
1. Inspirational lesions: 
(a) Pump-handle. 
(b) Combined pump- and bucket- 
handle. 
2. Expirational lesions (which occur in more or less re- 
verse form). 
(a) Pump-handle. 
(b) Bucket-handle. 
(c) Combined pump and bucket-handle. 
Lesions of the 
Second to the 
Sixth Ribs, 
Inclusive: Costal Subluxations 
299 
Lesions of the 
Seventh to 
Tenth Ribs, 
Inclusive: 
Lesions of the 
Eleventh and 
Twelfth Ribs: 
These are either inspirational or expira- 
tional. The axis of movement is antero- 
posterior, making lesions in this area 
bucket-handle in type. 
These may be in practically any direction, 
as these ribs have little capacity to move 
in all directions. They may be elevated 
or depressed, in or out, or rotated on 
their long axes. Their most common lesions are characterized 
by: (a) Depression and rotation on their long axes with then- 
free ends downward, upper borders outward and lower 
borders inward. (b) Elevation and rotation on their 
long axes with free ends upward, upper borders inward, and 
lower borders outward. 
An Inspirational Bucket-Handle Lesion may occur in any 
rib, second to the tenth inclusive, and is more common to the 
seventh, eighth, ninth and tenth costae. Movement is on an 
axis drawn from a point midway between the costo-trans- 
verse and the costo-vertebral articulations through the ster- 
nal junction, with consequent immobilization. The rib bulges 
laterally, the outer surface moves outward and upward, the 
lower border is everted and the upper border is inverted. 
There is separation from the adjacent rib below and approxi- 
mation to the rib immediately above. Exaggeration of the 
lesion is obtained by forced expiration, in which the gross mal- 
position of the rib can be better ascertained as the structural 
anomaly is thereby accentuated. Antero-posterior changes 
are not marked, as the total range of motion at these points 
is not great. The shaft of the rib, including the angle, having 
described the greater range of lesion movement, is the portion 
of the bone from which diagnosis is to be made. It can be 
best palpated under forced expiration by having the patient 
breathe out forcibly and sustain this position until examina- 
tion is completed. 
The Expirational Bucket-Handle Lesion occurs in the 
same ribs but movement is in reverse direction to the above. 300 
Downing Principles and Practice of Osteopathy 
Instead of the rib bulging laterally, it is apt to become propor- 
tionally less prominent in that direction. Its outer surface 
faces downward and outward, the lower border is inverted 
and the upper border is everted. There is separation from 
the rib above and approximation to the rib below. Immobi- 
lization of the costa can be determined by ascertaining the 
presence or absence of respiratory excursion. Exaggeration 
of the lesion is accomplished by forced expiration in which the 
gross malposition of the rib can be better ascertained as the 
structural malalignment is relatively magnified. This test 
can be best made by having the patient inspire forcibly and 
hold the breath until examination is completed. Antero-pos- 
terior changes are not marked; therefore the shaft of the rib, 
including the angle, is the portion of the rib upon which diag- 
nosis depends. 
The Inspirational Pump-Handle Lesion affects the first 
to sixth ribs, inclusive. The movement is characterized by 
rotation on a transverse axis, drawn through the costa-trans- 
verse and the costo-vertebral articulations with consequent 
immobilization in this position. The rib is elevated and slightly 
thrust forward anteriorly, with a downward and backward 
rotation of its neck on its long axis. 
Antero-posterior changes are marked and are therefore 
the findings upon which diagnosis is based. The neck of the 
rib and its laterally continuous portion assumes a relatively 
lower level in relationship to the transverse process. This 
can be noted at the point of junction, where the rib passes in 
front of the transverse process of the vertebra. Posteriorly, 
the rib is approximated to the rib below, the costo-sternal 
junction bulges anteriorly, is approximated to the rib above, 
and separated from the one below. The position of the lateral 
portion of the shaft of the rib is not modified sufficiently to 
make it of diagnostic value. Exaggeration of the lesion is ac- 
complished by forced expiration and can best be determined 
by making an examination at this time, if the patient will sus- 
tain the expiratory state for a short period. Costal Subluxations 
301 
Demonstrating lateral view of the normal spine with the normal antero-pos- 
terior curves straightened. The ribs are in an elevated state showing their 
relative position when in deep inspiration. Dorsal flexion increases when the 
ribs go into inspiration, although it is impossible to show this on the flexible 
spine. 302 
Downing Principles and Practice of Osteopathy 
The Expirational Pump-Handle Lesion.—This occurs in 
the same ribs, but by means of a reverse type of rotation, 
causing the rib to be depressed anteriorly with an upward, 
backward rotation of its neck on its long axis. Immobiliza- 
tion of the costa can be determined by ascertaining the limi- 
tation of the rib in respiratory excursion, particularly in- 
spiration. If the patient will sustain the inspiratory state for 
a short period, the exaggerated state of the lesion can be 
noted. 
Diagnosis is based upon antero-posterior changes. The 
neck of the rib and its laterally continuous portion assume 
a relatively higher level in relationship to the transverse proc- 
ess of the vertebra with which it articulates. Evidence of 
this can be had at the point of junction where the rib passes 
in front of the transverse process of the vertebra. Posterior- 
ly the rib is approximated to the rib above, and anteriorly the 
sternal junction is depressed, approximated to the rib below 
and separated from the one above. The lateral portion of 
the shaft of the rib is of little diagnostic value as it is not 
positionally modified to any very appreciable extent. 
The Combined Pump and Bucket-Handle Lesion may 
occur in any rib from the second to sixth inclusive. Move- 
ment takes place on both the pump- and bucket-handle axes, 
causing a combined lesion with the combined diagnostic fea- 
tures of pump- and bucket-handle lesions. These lesions may 
be inspirational or expirational; one type describing a reverse 
arc of movement to the other. 
Rib lesions may be primary or secondary. 
The theory sometimes advanced that the 
rib lesion is always secondary to a vertebral subluxation is 
without logical foundation. If a rib lesion is primary, it is a 
leverage force upon the vertebra with which it articulates 
and that vertebra will, by the action of the long lever handle 
—the rib in lesion—become secondarily involved. Removal of 
the primary cause constitutes the only way in which legiti- 
Etiology: Costal Subluxations 
303 
mate reduction of the secondary lesion may be accomplished. 
Occasionally both demand adjustive measures, particularly in 
the case of the chronic combined lesion where both conditions 
have become well stabilized. 
When the vertebral lesion is primary the articulating 
ribs are secondarily malposed, but usually reduction of the 
spinal condition will automatically eliminate the costal, pro- 
viding the rib involvement has not been of considerable dura- 
tion and become sufficiently stabilized to demand adjustive 
measures. 
Rib lesions are very troublesome and a source of con- 
siderable intercostal disturbance when present. Subjective 
visceral disorders may give a history which will tend to show 
a close association with, and relationship to, existing rib 
anomalies. 
Lesions of the upper ribs are more apt to be expiratory 
and those of the lower ribs inspirational in character, while 
osteopathology of the intermediate ribs proportionately 
partakes of both types. 
The causes of rib lesions are many and varied. Inherent 
dynamic forces of the body, such as muscular contractures, 
external dynamic forces such as trauma and adynamic forces 
such as gravity are all important in the etiological back- 
ground. Faulty posture is an ever-present menace. 
An objective in this connection is that 
portion of the rib to which adjustive 
forces may be directed to the best me- 
chanical advantage. In handling rib lesions it varies and 
is dependent upon the nature of the lesion. If we consider 
for the time a true bucket-handle lesion, we must recall that 
it has a double, fixed point axis, one fixed point posterior 
and the other anterior, and that the axis passes antero-pos- 
teriorly. In case of lesion it is natural to assume that both 
axes are involved and that both demand a certain amount of 
An Analysis 
of Objectives: 304 
Downing Principles and Practice of Osteopathy 
Demonstrating lateral view of the normal spine showing the normal antero-pos- 
terior curves and the ribs in a depressed state. Costal Subluxations 
305 
adjustive force. It is practically impossible to direct adjus- 
tive forces upon both at the same time, therefore we must 
seek an intermediate point and maneuver in such manner as 
to effect adjustment on both axes by means of a force pass- 
ing through the long axis of the shaft of the rib in both direc- 
tions. The amplitude of motion of such an adjustive force is 
considerably greater than the range of motion which would 
be necessary at the fixed point axis to complete adjustment. 
If the rib is bisected it might then be asssumed that the same 
amount of force was necessary anteriorly as posteriorly. But 
also visualizing the fact that posteriorly there are two articu- 
lations as against but one anteriorly and also realizing the 
measurably great resistance offered by these two vertebral 
articulations, it is obvious that bisection of the rib does not 
give the desired point of attack. Therefore, after bisecting 
the rib it is necessary to then bisect the posterior portion or 
segment which will designate the angle. From a mechan- 
ical point of view this is the point of maximum mechanical 
advantage for the adjustment of the true bucket-handle type 
of lesion. 
In the uncomplicated pump-handle lesion the desired 
point of attack is located midway between the costo-trans- 
verse and costo-central articulations. However, because of 
its situation in front of the transverse process it is impossible 
to utilize it. Therefore, we apply our adjustive force to a 
point as near the desired one as possible. In other words, the 
point of maximum mechanical advantage is located at the 
external portion of the rib just before it passes in front of the 
transverse process. For a matter of convenience the point 
of attack is termed the costo-transverse articulation. 
In the combined pump and bucket-handle lesion the point 
of greatest mechanical efficiency is midway between the 
costo-transverse articulation and the angle of the rib. How- 
ever, it is customary to combine both objectives by making 
the instrumentality of applied force of sufficient length to 
include both points. 306 
Downing Principles and Practice of Osteopathy 
Adjustive forces should be directed upward, forward and 
medialward, if the angle, the costo-transverse articular por- 
tion of the rib or the intermediate point, is down. If any 
one of these three points is up, then the adjustive force should 
be directed downward, forward and medialward. 
When using the cervical column there are 
three principles of procedure which must 
always be employed: First, extension of 
the cervical column, because it anatomi- 
cally locks the lower cervical segments 
and is a necessary factor in proper lock- 
ing for protective purposes and moreover, because it adds 
and gives perfection to the possible use of a unit lever handle 
which would otherwise be defective if this primary move- 
ment were not carried out. Adjustment must never be at- 
tempted with the cervical spine in flexion. Second, side-bend- 
ing to the side of lesion, to a degree sufficient to bring the 
vertex of the head directly over the rib in lesion so that when 
vertex pressure is brought into use the resultant force can 
pass through the costo-transverse articulation of the embar- 
rassed costa. Third, reverse rotation, or rotation toward the 
side opposite that of lesion. This movement locks the upper 
cervical and adds efficiency to the resultant force by bring- 
ing the vertex into better mechanical position as well as by 
giving stabilization resistance at the point of lesion. The 
strain of the reverse rotation is greatest at that point. 
To bring the first rib lesion into greater prominence, 
side-bend away from and rotate toward the side of lesion. 
This will tend to cause the transverse process of the first 
dorsal vertebra to rotate upward and backward and bring 
into greater relief the neck of the rib. 
Circumduction is of no particular mechanical signifi- 
cance other than that it tends to superimpose soft tissue ten- 
sions which, in a measure, take up the slack in adjacent tis- 
sues and bring about an added stabilization resistance which 
makes adjustment somewhat easier. 
Principles for 
Use of the 
Cervical Column 
in Rib 
Adjustment: Costal Subluxations 
307 
The starting point of such a movement should be com- 
bined extension side-bending toward the side of lesion and 
it should sweep toward the opposite side, maintaining ex- 
tension then be followed by flexion and by a carrying again 
across the midline in flexion; and from this point back into 
extension and to the starting point. Besides completing cir- 
cumduction, the cervical column is then in a position of ex- 
tension and side-bending. If rotation of the head to the op- 
posite side is added thereunto all mechanical movements 
necessary to the stabilization of the cervical column have been 
completed. 
When the patient is carried off balance, away from the 
side of lesion, the same thing has been accomplished as if the 
cervical column had been side-bent, providing the latter is 
maintained in the perpendicular plane. This allows the op- 
erator to work at better mechanical advantage and gives him 
greater additional resistive force to work against, as the 
patient’s torso is so placed that it will take up the adjustive 
force more efficiently and with less yielding or buckling 
under it. 
Expirational Lesions. Technique No. 1. 
This method can be efficiently used for 
lesions of the first to fourth ribs, inclu- 
sive. Patient sits on the stool or 
table, and the operator stands behind him. Hypothetical le- 
sion on the right side. If the patient is on the stool, the op- 
erator should place his left foot on the stool and flex the knee 
at right angles, then instruct the patient to lean toward the 
left side, with his axilla over that knee. If the patient is sit- 
ting on the table he should lean toward the left side against 
the operator’s torso in such a manner as to be slightly off 
balance. The thumb of the operator’s right hand is placed 
against the postero-superior aspect of the rib, adjacent to 
the costo-transverse articulation. His left hand is placed 
upon the vertex of the patient’s head, and the arm along the 
Adjustment of 
First and Second 
Rib Lesions: 308 
Downing Principles and Practice of Osteopathy 
lateral aspect of the cervical column. The cervical column 
is circumducted and brought to rest in extension, right lateral 
flexion or side-bending and reverse rotation. Adjust at the 
end of expiration by combining downward pressure on the 
vertex of the head and a downward, forward thrust of the 
thumb on the rib. 
Technique No. 2. This method can be used for the second 
to sixth ribs, inclusive. Patient prone. Reverse cervical 
procedure by extension, side-bending to the side opposite that 
of the lesion, reverse rotation, or rotation toward the side of 
lesion. Exaggerate cervical leverage. This tends through 
leverage action to bring the transverse process of the ver- 
tebra articulating with the rib in lesion upward and forward. 
Opposite this leverage force on the vertebra by counter force 
directed downward, forward and medialward against the 
postero-superior aspect of the rib adjacent to the costo-trans- 
verse articulation. 
Technique No. 3. Patient supine; head and cervical 
column over the edge of the table. Extend the cervical 
column, side-bend toward the side of lesion and rotate the 
upper cervical spine away from the side of lesion. Vertex 
pressure with the operator’s abdomen in such direction as to 
cause the resultant force to pass through the costo-transverse 
articulation of the rib in lesion. Adjustive force is applied 
downward, forward and medialward with the lateral aspect 
of the index finger. The palmar aspect of the opposite hand 
is placed along the lateral surface of the cervical column to 
stabilize and protect it. 
Technique No. 4. First Rib Only. Patient supine, op- 
erator stands at the side of the table opposite that of lesion, 
facing the patient. The middle finger is placed against the 
rib and the palmar aspect of the opposite hand along the lat- 
eral aspect of the cervical column, on the side opposite that 
of lesion. This position of the hand allows the operator to 
hold the cervical column in extension, side-bending and re- Costal Subluxations 
309 
verse rotation. At the same time adjustive force is brought 
to bear upon the rib in lesion with the middle finger of the 
opposite hand. This same procedure may be utilized for the 
first rib with the patient sitting. 
Technique No. 1. Patient sits on the stool 
or table and the operator stands behind. 
Hypothetical lesion on the right side. If 
the patient is on the stool, the operator should place his left 
foot on the stool and flex the knee at right angles and then 
instruct the patient to lean toward the left side with his axilla 
over that knee. If the patient is on the table he should lean 
toward the left side against the operator’s torso in such a 
manner as to be slightly off balance with his body weight 
falling mostly upon the left ischial tuberositv. The 
thumb of the operator’s right hand is placed against 
the postero-inferior aspect of the rib adjacent to the 
costo-transverse articulation. The operator’s left hand is 
placed upon the vertex of the patient’s head and the arm 
along the lateral aspect of the cervical column in such man- 
ner as to act in the nature of a splint for protective purposes. 
Circumduction of the cervical spine is carried out in the fol- 
lowing order: Extension, left lateral extension; left lateral 
flexion, flexion, right lateral flexion, and right lateral exten- 
sion. With the patient’s neck in this position rotate the head 
so that the chin points toward the left shoulder. Adjust at 
the end of expiration by combining downward pressure on 
the vertex with an upward, forward thrust of the thumb. 
Most of the above methods are effective for expirational 
lesions other than those of the first and second ribs. 
Pump-Handle Lesions: (third to the sixth ribs, inclusive). 
Technique No. 1. Patient sits on the 
table; operator stands behind. Extends 
the dorsal column slightly, side-bends to- 
ward the side of lesion, and rotates toward the opposite side. 
Operator places axilla over the shoulder opposite that of the 
Inspirational 
Lesions: 
Inspirational 
Lesions 310 
Downing Principles and Practice of Osteopathy 
lesioned side and passes forearm under axilla of patient on 
the side of lesion. The fingers which are free are interlocked 
with those of the opposite hand, the pisiform bone of which 
is placed against the postero-inferior aspect of the rib in 
lesion, adjacent to the costo-transverse articulation. Force 
is directed upward, forward, and medialward against the 
objective, while the torso is maintained and stabilized with 
sufficient extension, side-bending, and reverse rotation to 
maintain a physiological locking of that portion of the tho- 
racic spine adjacent to the point at which rib adjustment is 
being effected. 
Technique No. 2. Patient prone. The operator stands 
on the side of lesion, places his forearm under the axilla of 
that side in such manner that the fingers maintain firm hold 
on the shoulder-girdle. The pisiform bone of the opposite 
hand is placed against the postero-inferior aspect of the rib 
in lesion, adjacent to the costo-transverse articulation. Sta- 
bilizing the shoulder-girdle, the chest of the operator is 
brought to bear so that the additional force carries the hand 
maintaining the objective in a corrective direction. 
Technique No. 1. This procedure is ex- 
actly the same as that of technique No. 1 
for the adjustment of an inspirational 
lesion, except that the objective is the postero-superior aspect 
of the rib adjacent to the costo-transverse articulation and 
that the corrective force is delivered downward, forward and 
medialward. 
Technique No. 2. Patient supine, with arms folded 
across the chest so that the points of the elbows are brought 
more or less together in the median line and the hands are 
more or less in contact with the opposite shoulders. The 
patient is instructed to breathe deeply and at the completion 
of exhalation the operator brings downward and forward 
pressure to bear on the patient’s elbows in such a manner 
that the resultant force passes obliquely antero-posteriorly 
Expirational 
Lesion Costcil Subluxations 
311 
across the midline upward, backward and outward through 
the costo-transverse articulation of the rib in lesion. Oppos- 
ing this is a parallel force which is directed downward, for- 
ward and medialward against the costo-transverse portion 
of the rib in lesion. The shearing action of these forces is 
such as first to break fixation, which may exist in the costo- 
transverse articulation, and force the neck of the rib to rotate 
downward and backward on its long axis. The operator's 
one hand is cupped over the point of one elbow and the other 
elbow is held in a fixed position with the axilla of the same 
arm. The other hand is placed underneath the patient in 
such manner that the elevated first phalanx of the thumb is 
in contact with the postero-superior aspect of the rib adjacent 
to the costo-transverse articulation. The hand underneath 
exerts counter force to the adjustive force passing down- 
ward through the arms andsa secondary leverage force which 
is the result of muscle-tension. 
Technique No. 3. Patient prone. This method is the 
same as technique No. 2 under inspirational lesions, with the 
exception that the pisiform bone is placed against the pos- 
tero-superior aspect of the rib in lesion, adjacent to the costo- 
transverse articulation and the adjustive force is carried 
downward, forward and medialward. 
Technique No. 4. Patient on his side, lesioned side 
uppermost, facing the operator. The operator’s thumb is 
placed against the posterior portion of the angle of the rib. 
The lower border of the sterno-costal junction of the rib is 
maintained more or less fixed. The patient is instructed to 
inhale and exhale deeply, consonant with which the operator 
brings lateral pressure against the rib with his chest. At the 
beginning of inspiration the pressure is exerted downward 
and forward against the posterior extremity and upward and 
forward against the anterior extremity. The pressure should 
be maintained throughout, but accentuated during expira- 
tion. Springing the ribs in an antero-posterior direction and 312 
Doivning Principles and Practice of Osteopathy 
directing the adjustive forces in the same manner as the 
above is an efficient manner of effecting reduction. 
Combined Pump- and Bucket-Handle Lesion (third to 
sixth, inclusive). 
These lesions are of a conjoint inspirational and expira- 
tional character and the methods of their reduction are sim- 
ilar to those which have been outlined, with but few excep- 
tions. The objective is a little more lateral than that of the 
true pump-handle lesion. A very efficient maneuver is to 
join both objectives applicable to the true pump- and the 
true bucket-handle lesion. This can be accomplished easily 
by lengthening the distance of contact surface. 
Technique No. 1. The patient sits on the 
stool with themperator behind, either sit- 
ting on the table or standing. The hypo- 
thetical lesion is on the right side. The thumb of the operator’s 
left hand is placed against the posterior portion of the angle 
of the rib. The operator then grasps the patient’s right arm 
with his right hand so that the point of the patient’s elbow 
rests in his palm, and the forearm of the latter is held at 
right angles to the arm. The patient is instructed to inhale, 
slowly and deeply, and, at the same time, the operator raises 
the shoulder-girdle by upward pressure against the patient’s 
elbow, thereby creating tension of the following muscles: the 
rhomboidei, pectorales, trapezius, serratus anticus, and the 
latissimus dorsi. The operator then brings the elbow for- 
ward and medialward across the chest (the lower the lesion 
the greater the arc of movement). The arm is now raised 
above the patient’s head, and the right hand and forearm of 
the patient are allowed to drop behind his neck so that the 
fingers touch the opposite shoulder, creating particular 
tension of the serratus anticus and the pectorales major and 
minor. The patient is now instructed to exhale. At the end 
of expiration the arm is allowed to drop to the desired point. 
This varies greatly. If the third rib, it should be on the level 
The Expirational 
Lesion: Costal Subluxations 
313 
with the shoulder; if lower, it should be allowed to fall poste- 
riorly and inferiorly. The lower the rib, the lower and more 
posterior the point desired and the greater the sweep. The 
forearm is permitted to fall forward to the limit of its mo- 
tion, causing rotation of the head of the humerus. The thumb 
of the left hand during this manipulation maintains upward, 
forward and medialward pressure against the lower border 
of the posterior portion of the angle of the rib. 
The same technique is used except that 
the manipulation is reversed. Inhalation 
is carried to a point where exhalation 
commenced in the former and exhalation commences where 
inhalation stopped. The pressure of the operator’s thumb 
should be downward and forward against the upper border 
of the posterior portion of the angle of the rib. 
Technique No. 1. Patient supine, with 
hands folded behind the neck low down 
in the cervical column. The points of the 
elbows are brought more or less together 
in the median line. The patient is in- 
structed to breathe deeply and at the completion of exhala- 
tion the operator brings downward and forward pressure to 
bear on the patient’s elbows in such a way that the resultant 
force passes obliquely, antero-posteriorly across the midline, 
downward, backward, and outward through the costo-trans- 
verse articulation of the rib in lesion. Opposing this force is 
a parallel force which is directed upward, forward, and 
medialward against the angle of the rib in lesion. The shear- 
ing action of these forces breaks any fixation which may 
exist and forces the rib to retrace its pathway. The forearm 
of one hand is placed over the points of the elbows. The 
other hand is placed underneath the patient in such a way 
that the elevated first phalanx of the thumb is in contact with 
the postero-inferior aspect of the angle of the rib. The hand 
underneath exerts counter force to the adjustive force pass- 
The Inspirational 
Lesion: 
The Bucket- 
Handle Lesion— 
Expirational 
Lesion: 314 
Downing Principles and Practice of Osteopathy 
ing antero-posteriorly and a secondary leverage force which, 
in this particular case, is a direct aid to adjustive force as a 
result of muscle tension which tends to pull the rib upward 
at that point. These forces must vary according to the ver- 
tebra in lesion so that the resultant force will parallel to and 
pass in a shearing manner the adjustive force at all times. 
Technique No. 2. Hypothetical lesion is on the right side. 
The patient lies on the left side. The fingers of the right hand 
of the operator are placed beneath the lower border of the 
angle of the rib, and the left hand is placed under the lower- 
border of the sternal end of the rib. Simultaneously with 
deep inspiration, the arm is brought up and back (it is held 
between the right arm and the body of the operator during 
the manipulation), and strong upward pressure is directed 
against the rib with the fingers of both hands. Maintain 
firmly this position as the patient exhales. 
Technique No. 1. Patient sitting on the 
table, the operator, standing behind, ex- 
tends the dorsal column slightly, side- 
bends it toward the side of lesion and rotates it toward 
the opposite side. He the places his axilla over the 
shoulder of the patient on the side opposite that of lesion 
and passes his forearm under the axilla of the patient on the 
side of lesion. The fingers are thereupon interlocked and 
the pisiform bone of the opposite hand is placed against the 
postero-inferior aspect of the angle of the rib in lesion. The 
fingers are cupped underneath the inferior border of the 
shaft of that rib. A slight amount of traction is primary and 
is immediately followed by the application of adjustive force, 
upward, forward and medialward. The torso is supported 
and stabilized with extension, side-bending, and reverse rota- 
tion sufficiently to maintain a physiological locking of that 
portion of the thoracic spine at which the rib adjustment is 
being effected. 
Inspirational 
Lesion: Costal Subluxations 
315 
Technique No. 2. Patient prone. The operator places 
one hand, palmar aspect downward, against the transverse 
processes of the vertebra in the area of lesion, but on the side 
opposite that of the lesion. Maintaining this stabilization, 
adjustive force with the pisiform bone of the opposite hand 
is delivered, downward, forward and medialward, against the 
rib in lesion. 
Technique No. 1. In this lesion the rib 
sometimes has the appearance of being 
caught up under the tenth rib. The pati- 
ent sits on the stool or the operating table 
with the operator standing behind. The 
hypothetical lesion is on the right side. 
The operator’s left foot is placed on the 
stool and the leg flexed at right angles, or in the case of the 
table, the flexed leg rests on the table at the left side of the 
patient. The operator passes his left arm under the right 
arm of the patient and encircles the latter’s body, his left 
hand grasping the left side of the torso. Lateral flexion and 
rotation to the left is made with the patient over the oper- 
ator’s flexed knee as a fulcrum, and at the same time the 
combined thumb and index finger of the adjusting hand is 
brought to bear against the superior border of the rib in 
lesion. 
Technique No. 1. Rotation in this lesion 
is usually downward, so that the upper 
border is inverted and the lower border 
everted in contradistinction to the above 
lesion wherein the reverse is usually the case. Technique for 
adjustment may be the same as that used and described for 
the above lesion with the exception that instead of applying 
counter force against the superior border of the rib, the com- 
bined thumb and index finger, or such instrumentality as is 
most convenient to the operator, exerts an upward pull, or 
Lesions of the 
Eleventh and 
Twelfth Rib— 
Rib Elevated and 
Rotated on Its 
Long Axis: 
Rib Depressed 
and Rotated on 
Its Long Axis: 316 
Downing Principles and Practice of Osteopathy 
adjustive force in a corrective manner. The posterior innom- 
inate is a frequent cause of this lesion as it many times results 
in the contracture of the quadratus lumborum muscle which 
secondarily pulls the rib into lesion. 
Position for adjustment of the eleventh and twelfth ribs. Crosses indicate 
the position of the ribs. Adjustive force is applied to the rib through the agency 
of the thumb. Upper torso is the lever mechanism and the operator’s flexed knee 
is the fulcrum over which the leverage action takes place. Costal Subluxations 
317 
Raising the Ribs: 
The same leverage forces are utilized in 
raising the ribs as were enumerated in 
technique No. 1 for the correction of combined pump- and 
bucket-handle lesions, particularly the pectorales major and 
minor, the serratus anticus and the external intercostals. 
Making a fulcrum or fixed point with the palms of the hands 
against the angles of the ribs, the patient is first instructed 
to inhale deeply and hold the breath until his arms can be 
elevated above the head. The active resistance of the patient 
is of decided value in this maneuver. In other words, the 
patient should slightly resist the operator’s attempt to ele- 
vate the arms. By alternately raising and depressing the 
ribs the intra-thoracic pressure can be rapidly and forcibly 
changed, which in turn causes rapid shifts of intra-pulmonic 
pressures. This, of course, has a marked effect upon the 
respiratory capacity, in that alveolar ventilation is immedi- 
ately and favorably influenced, particularly in such condi- 
tions as pneumonia, and the volume of oxygen increased 
proportionately. Its effect upon the circulation is also 
marked. As a means of avoiding passive congestion and con- 
gestive conditions within the lung tissue the effect of this 
maneuver is tremendous. It also increases respiratory capac- 
ity and, therefore, oxygenation. The cardio-respiratory 
mechanism is so closely correlated that in the normal state 
cardiac output varies directly with metabolism and alveolar 
ventilation. 
In normal individuals, under exertion, the volume of 
alveolar ventilation and the volume of oxygen absorbed in- 
crease proportionately to a moderate degree. At levels in 
which the cardiac output is less than is theoretically de- 
manded, the factors of safety inherent in the gaseous carry- 
ing power of the blood, increased venous pressure, due to in- 
creased vascular tonus as well as increased tone of other 
muscles, and the power of the body to super-ventilate the 
lungs are brought into play. When these added resources 318 
Downing Principles and Practice of Osteopathy 
can no longer take care of the increased demand, physical 
effort cannot be longer sustained. 
There is no contraindication to raising the ribs. This 
is pulmonary tuberculosis, in which rest is the prime pre- 
requisite of treatment. Postural rest in these cases is impor- 
tant, for a patient inspires one thousand times per hour; 
therefore the position that produces the least motion in the 
diseased area is indicated. As an early sign of tuberculosis 
Molle refers to the pectoral and trapezius muscles as being 
particularly sensitive and contracted. Pain can be dieted 
if they are harshly palpated. Evidence of this pain can be 
noted by dilation of the pupil. Pottinger claims that in tuber- 
culosis reflex disturbances of pupillary accommodation and 
of the gastric and cardiac mechanisms (through the vagus 
afferent fibers), are present. A slower rate of respiration is 
indicative of tuberculosis. Knoff instructs his patients to 
breathe slower as a hysiological adjuvant to treatment. 
With the patient on the side the operator 
may apply lateral diagonal pressure to 
both sides of the thorax consonant with deep inspiration on 
the part of the patient. He can apply pressure with his chest 
against the upper side and maintain firm pressure against 
the lower side with his hands. This maneuver increases the 
antero-posterior diameter of the chest and tends to create 
mobility and uniform flexion in the dorsal area. The induc- 
tion of increased mobility for the dorsal vertebrae and ribs is 
indicated in such conditions as costogenic anemia, diseases of 
the upper respiratory tract, such as bronchitis, asthma, lar- 
yngitis, rhinitis, etc. Relaxing the anterior chest muscles, 
especially the pectorales major and minor and the serratus 
antieus will promote lymphatic drainage with consequent sys- 
temic reaction and leukocytosis. 
The Flat Dorsal: Costa l Subluxa tions 
319 
Doming the 
Diaphragm: 
By upward and lateral pressures against 
the lower ribs, especially the eleventh and 
twelfth, delivered simultaneously with 
forced expiration on the part of the patient, with the abdo- 
men pulled in, the operator can dome the diaphragm. This 
movement is especially valuable in conditions in which it is 
desirable to decrease the intra-thoracic pressure and thereby 
secondarily influence drainage, either pulmonic or intra- 
thoracic. When utilized together with technique for raising 
the ribs, it is undoubtedly valuable for relief of intra-thoracic 
circulatory disturbances. 
The ribs are frequently broken, although 
they are able to withstand great force be- 
cause of their yielding, spring-like action 
which gives them considerable immunity. The question of 
immobilization mechanically is one which demands consider- 
ation inasmuch as in the aged, the adynamic state of the ribs 
may lead to hypostatic congestion and this pneumonic condi- 
tion in turn cause death. Certain authorities claim better 
results and greater freedom from complications if no attempt 
is made at fixation. 
Occasional supernumerary ribs exist. In 
the cervical area they are due to excessive 
development of the costal element of the seventh cervical ver- 
tebra. The condition is usually bilateral. It rarely produces 
symptoms until after the twentieth year. Usually there is 
only a superficial pulsation of the subclavian artery. A pal- 
pable prominence and evidence of pressure to the brachial 
plexus is symptomatic. Abnormally large transverse proc- 
esses of the seventh cervical and adventitious ligaments may 
Fracture of 
the Ribs: 
Cervical Ribs: 320 
Downing Principles and Practice of Osteopathy 
simulate a cervical rib. Rib pressure may occasionally cause 
brachial plexus paralysis. This is more often found in the 
debilitated female following trauma and the pain is usually 
referred to the lowest cord of the brachial plexus (eighth cer- 
vical or first dorsal). Pain is usually referred to the inner 
side of the forearm in the character of tingling, numbness, 
feeling of pins and needles, coldness, etc. There may also be 
thermal anaesthesia, tactile impairment, motor weakness, or 
vasomotor changes. Foot Subluxations 
321 
Chapter XI. 
FOOT SUBLUXATIONS 
Applied Anatomy. The bones of the foot fall into three 
groups: the tarsus, the metatarsus, and 
the phalanges. 
There are seven tarsal bones (ossa tarsi). They are the 
calcaneus, talus, cuboid, navicular, internal, middle, and ex- 
ternal cuneiform. 
The calcaneous or os calcis is the largest and strongest 
bone in the foot. It is elongated, projecting downward and 
backward to form the heel, serving to transmit the weight of 
the body to the ground and forming a strong lever for the 
muscles of the calf. 
Its superior surface presents two articular surfaces for 
the talus which are separated by a groove for the talocalca- 
neal ligament; and internally a projecting process, the susten- 
taculum tali, for the calcaneo-cuboid ligament. 
The inferior surface is rough and excavated and presents 
two tubercles, an outer and an inner, for muscles and liga- 
ments. The internal surface is concave for passage of the 
tendons of the flexor hallucis longus and tibialis posticus, and 
plantar vessels and nerves. 
The external surface presents a tubercle (processus 
trochlearis) for the external lateral ligament of the ankle and 
grooves for the peroneal tendons. The posterior surface, 
projecting behind, (tuber calcanei) presents a smooth surface 
above for a bursa and is rough below for attachment of the 
Achilles tendon and that of the plantaris. It articulates with 
the talus and cuboid. Its muscular attachments are tendo 
Achilles, tibialis posticus, abductor hallusis, abductor minimi 
digiti, flexor brevis, digitorum accessorius and extensor 
brevis digitorum. 322 
Downing Principles and Practice of Osteopathy 
CaLcaneiim 
FLEX. B REV. 
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ABDUCT. POLLICIS 
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The talus or astragalus is an irregular short bone con- 
sisting of a body (corpus tali), neck (collum tali), and head 
(caput tali). It supports the tibia above, rests on the cal- 
caneus below, articulates on either side with the malleoli, and 
in front with the navicular. 
Its quadrilateral body presents four articular surfaces; 
one above for lower extremity of tibia and the internal and 
external malleoli; two below for the os calcis, separated by a 
deep groove for the interosseous talocalcaneal ligament; pos- 
teriorly there is a deep groove (sulcus m. flexor hallucis 
The skeletal foot, plantar aspect. Foot Subluxations 
323 
longus) for a tendon and anteriorly the rounded convex head 
supported by the neck articulates with the navicular ligament. 
Medially it presents a rough area for attachment of the deep 
deltoid ligament (internal lateral ligament of ankle). This 
bone has no muscular attachments. It articulates with four 
bones; tibia, fibula, navicular, and calcaneus. 
The Cuboid or os cuboideum—is a small, pyramidal, cube- 
like bone situated between the os calcis and the fourth and 
fifth metatarsal bones on the outer side of the foot. The 
upper or dorsal surface is rough for ligamentous attachment, 
the lower or plantar surface is grooved for the tendon of 
peroneus longus, behind which is a ridge for the long cal- 
caneo-cuboid ligament, terminating externally in the tuber- 
osity of the cuboid (tuberositas ossis cuboidei). The external 
surface has a deep notch, the outer extremity of the peroneal 
groove. The posterior surface has a triangular facet for the 
calcaneus. The anterior two facets are separated by a ridge 
and are for the fourth and fifth metatarsals; and the internal 
surface has a broad facet for the external cuneiform and 
sometimes a small facet for the navicular. It articulates with 
four and sometimes five bones. It has one muscular attach- 
ment, part of the origin of the flexor hallucis brevis. 
The navicular or scaphoid is a boat-shaped bone placed 
between the navicular and three cuneiform bones. The pos- 
terior concave surface articulates with the head of the talus. 
Its anterior convex surface has three facets for articulation 
with the cuneiform bones. Its internal border presents the 
tuberosity of the navicular and gives insertion for the tendon 
of the tibialis posticus which constitutes its only muscle at- 
tachment. Its other borders are roughened for ligamentous 
attachment. It articulates with the talus posteriorly and 
the three cuneiform bones anteriorly. 
The cuneiform bones with respect to their position from 
within outward are the internal or first, middle or second, 
and external or third. 324 
Downing Principles and Practice of Osteopathy 
The Internal Cuneiform (first) is the largest. It has its 
base directed downward and its apex upward. It articulates 
anteriorly with the middle cuneiform and second metatarsal. 
The plantar surface presents a tuberosity for insertion of 
part of the tibialis posticus and anticus tendons. 
The Middle Cuneiform (second) is the smallest. It has 
its base upward and its apex downward. It articulates pos- 
teriorly with the navicular, anteriorly with the second meta- 
JhttJrgr 
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The skeletal foot, dorsal surface. Foot Subluxations 
325 
tarsal and laterally with the internal and external cunei- 
forms. It has no muscular attachments. 
The External Cuneiform (third) is more regular in size 
and articulates posteriorly with the navicular; anteriorly 
with the third metatarsal; internally with the middle cunei- 
form and second metatarsal; and externally with the cuboid 
and fourth metatarsal. It gives attachment to the flexor 
brevis pollicis and tibialis posticus muscles. 
The Metatarsal bones are five in number. Each consists 
of a head, a shaft, and a base. They are arranged in a nearly 
parallel manner. The shaft of each is curved, prismoid, con- 
cave below—convex above. Their heads are rounded for 
articulation with the proximal phalanges, have tubercles lat- 
erally for ligaments, and grooves inferiorly for the long 
flexor tendons. Their bases are wedge-shaped for articula- 
tion with the tarsus and with each other. They are number- 
ed from within outward. 
The First Metatarsal is the shortest, thickest and strong- 
est. It articulates by its base with the internal cuneiform 
and second metatarsal, and by its head with the proximal 
phalanx of the great toe. 
It gives attachments to the peroneus longus, tibialis an- 
ticus and the first dorsal interosseous. 
The Second Metatarsal is wedged in by its base between 
the three cuneiforms and articulates with the proximal 
phalanx of the second toe and with the first and third meta- 
tarsals. The adductor hallucis and first and second inter- 
osseous muscles attach to it. 
The Third Metatarsal articulates at its base with the ex- 
ternal cuneiform, second and third metatarsals, and by its 
head with the contiguous phalanx of the third toe. It gives 
muscular attachments to the adductor hallucis, second and 
third dorsal and first plantar interossei. 326 
Downing Principles and Practice of Osteopathy 
The Fourth Metatarsal articulates at its base with the 
external cuneiform and cuboid and laterally with the third 
and fifth metatarsal and by its head with the first phalanx 
of the fourth toe. The adductor hallucis, third and fourth 
dorsal and second plantar interossei muscles attach to it. 
The Fifth Metatarsal has a well-marked tubercle on its 
outer side. It articulates with the cuboid, fourth metatarsal 
and fifth proximal phalanx, and gives attachment to the 
flexor brevis minimi digiti, peroneus brevis and tertius, 
fourth dorsal and third plantar interossei. 
The Phalanges, or Toe Bones, are fourteen in number 
and are arranged in three rows. They consist of the first or 
proximal phalanges, and the second and third or distal 
phalanges. The second phalanx is absent in the big toe. Their 
muscular associations are numerous. 
Sesamoid bones are small osseous masses independently 
developed in tendons to relieve pressure and for protection. 
One such bone is found in the tendon of the peroneus longus 
near its groove on the cuboid. 
The ankle joint is a ginglymus or hinge joint, formed by 
the lower ends of the tibia and fibula and their malleoli, and 
the talus. Its synovial membrane is continued upward be- 
tween the tibia and fibula for a short distance. It has four 
ligaments— 
1. Anterior—connecting the anterior margins of the 
tibia and talus. 
2. Posterior—a thin band of transverse fibers connect- 
ing the posterior margins of the tibia and talus. 
3. Internal lateral or deltoid ligament (L. calcaneoti- 
biale) from the internal malleolus to the three ad- 
jacent tarsal bones. 
4. External lateral, consisting of an anterior fasciculus 
(L. talofibulare), a middle bundle (L. calcaneo- 
fibulare), and a posterior limb (L. talofibulare) 
which stretches from the external malleolus to the 
talus and os calcis. Foot Subluxations 
327 
O'fr'o i v /or. 
LW.lONC.P0lU 
Astragalus 
External 
C'rutei/b rm. 
Boric 
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Cunei/orm 
f 
/'t 
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of Fit tears 
The plantar surface of the 
foot showing ligaments. 
The Tarsal articulations are connected by the following 
ligaments, viz.: 
External 
Internal 
Posterior 
1. Talco-calcaneal 
Superior 
Internal 
Long 
Short 
2. Calcaneocuboid 
3. Calcaneo-navicular 
Superior 
Inferior 
4. Talo-navicular ■ Superior 
5. Dorsal and Plantar. 
6. Interosseous. 328 
Doivning Principles and Practice of Osteopathy 
Movements of 
the Ankle Joint 
and Foot: 
The ankle joint is a ginglymus or hinge 
joint with rotation taking place about an 
oblique transverse axis. This allows the 
following movements: 
1. Flexion: the normal position of the foot is at right 
angles to the body plane and the joint is therefore 
in a state of flexion at rest. Any movement which 
increases the degree of this angle is forced flexion. 
2. Extension: likewise, any movement which tends to 
decrease the degree of this angle is extension. 
3. Lateral Flexion: slight lateral movement is pos- 
sible. 
The foot allows of the following movements: 
1. Plantar extension or dorsiflexion. This movement 
combined with extension of the toes causes a flat- 
tening or straightening of the plantar arch. 
2. Plantar Flexion: This movement together with 
flexion of the toes exaggerates the concavity of the 
plantar arch. 
1. Pronation or Eversion. 
2. Supination or Inversion. 
Conjoint and 
Combined 
Movement of 
the Ankle Joint 
and Foot: 
The foot is constructed in a series of 
arches formed by the tarsal and metatar- 
sal bones, strengthened by ligaments and 
tendons, and constitutes a firm basis of support in the erect 
position with a minimum of effort. The bones are arranged 
in an elliptical arch, supported on two pillars, a posterior or 
calcaneal pillar and an anterior or metatarsal pillar. 
Arches of 
the Foot: Foot Subluxations 
329 
foster/or haste ulus 
•* r/,f Cupsurle. 
/ r,^>U4 
Internal Cunciform 
Scaphoid. 
/nner Sesamoid 
done 
I*Moln'lX 
Internal view of the right foot showing articulations and ligaments 
of the ankle, tarsus, and metatarsus. 
The main arches are the antero-posterior arches which 
may be regarded as divisible into two segments—a medial 
and a lateral. The medial segment or arch is made up of the 
three metatarsal bones, the three cuneiforms, the navicular 
and the talus. Its summit is the superior articular surface of 
the talus. The lateral segment is made up of the fourth and 
fifth metatarsal bones, the cuboid, and the calcaneus. Both 
segments are supported posteriorly by a common calcaneal 
pillow. The summit of the lateral segment is the talo-cal- 
caneal articulation. 330 
Downing Principles and Practice of Osteopathy 
Both longitudinal arches are intimately concerned with 
ordinary locomotion. The medial is characterized by its 
great curvature and elasticity and sustains the more violent 
concussions in jumping and similar actions. The lateral, less 
curved, more rigid, comparatively inelastic, forms with the 
common pillars a firm, base for support in the upright static 
posture. Its chief joint is the calcaneo-cuboid which possesses 
a special mechanism for locking, and allows only limited move- 
ment. 
The joint most amenable to undue pressure is the talo- 
navicular articulation. It is fortunately reinforced by the 
elastic plantar calcaneo-navicular ligament, which is able to 
respond quickly and restore the arch to its normal position 
when the causative force is removed. It is, moreover, 
strengthened by the blending of this supporting band with 
the deltoid ligament medially, and inferiorly by the tendon of 
the tibialis posterior which passes beneath the joint. 
The fundamental longitudinal arch is made up of the cal- 
caneus, cuboid, third cuneiform, and third metatarsal. They 
are so arranged that all the other bones of the foot might be 
removed without destroying this arch. 
The foot is composed of a series of transverse arches. At 
the posterior part of the metatarsus and anterior part of the 
tarsus the arches are complete but in the middle of the tarsus 
they present the appearance of a sort of half-dome. 
Fracture of the tarsal bones is unlikely because of the 
large number of articulating surfaces and the strong liga- 
ments which serve to break the force of violence. Fracture 
of the neck of the talus or tuberosity of the calcaneus is 
usually produced by falls from a great height onto the feet. 
Fracture of the os calcis is rather common, comprising ap- 
proximately 2% of all fractures, according to Straus. The 
posterior fragment of the os calcis is driven upward by the Foot Subluxations 
331 
impact at the time and maintained in this position by the con- 
stant tone of the Achilles tendon. 
Art. surface tCtlk 
Scnpko calc Aig 
Middle Cuneiform. 
t*t pJial ■ 
2 n/i phnl 
Skeletal foot, internal border. 
Canes occasionally involves the bones of the feet, more 
especially the metatarsus, and particularly that of the big toe. 
The calcaneous and talus are sometimes affected. 
Talipes (club foot) is a permanent congenital or acquir- 
ed deviation of the foot into deformity. 
Talipes Equinus is a persistant extension of the foot due 
to shortening of the Achilles tendon. 332 
Downing Principles and Practice of Osteopathy 
Talipes Calcaneus is a persistent flexion of the foot due 
to shortening of the flexors and lengthening of the tendo- 
Achilles. 
Talipes Varus is a persistent adduction and inversion 
rarely met with and usually congenital. 
Talipes Valgus is a persistent abduction and eversion 
usually met with in organic flat foot. 
Certain of these deformities may be combined such as 
talipes equinovarus, talipes equinovalgus, talipes calcaneo- 
varus and talipes calcaneovalgus. The causes of talipes are: 
1. Congenital. 
(a) Persistance of fetal anomalies. 
2. Acquired. 
(a) Nervous, through infantile paralysis, spastic con- 
tractures from cicatrices, traumatism, etc. Hys- 
terical contractures. 
(b) Arrest of development. 
(c) Mechanical (intra-uterine pressure). 
Congenital club foot should be treated in infancy when 
bones can be moulded as desired and held in restored position 
by means of plaster of Paris bandages. In severe cases sec- 
tion of the anterior and posterior tibial muscles, plantar 
fascia, tendo-Achilles, and long flexors of the toes will 
facilitate correction. 
Pes Planus (flat foot) is a condition in which there is 
perversion of the arch of the foot, due to such factors as 
ligamentous and muscular weakening caused by prolonged 
strain of standing or trauma. Muscular paralysis sequent to 
rickets, overweight, improper shoeing, osteopathic lesions, 
etc. Da Costa mentions spurious flat foot, or inflammatory 
flat foot, which occurs in Pott’s disease and in inflammations 
of the ankle joint, or of the tendon of the peroneus longus 
muscle, and paralytic flat foot following infantile paralysis. Foot Subluxations 
333 
Different classifications of flat feet are given. The common 
categories are enumerated below: 
IntrsYAtscoux 
\Z-^/fJjturU 
5th' 
2^ 
4*' 
Oblique section of the articulations of the tarsus and 
metatarsus showing synovial membranes. 
1. Organic flat foot, a condition of such sufficiently 
confirmed character that deformity of the foot is apparent 
and constant at all times and in all positions—for example: a 
foot which, when off or on the ground, shows an inner con- 
vexity at the talonavicular joint with abduction of the foot 
may be thus classified. 
2. Functional flat foot, a condition not sufficiently 
confirmed to make deformity of the foot apparent and con- 
stant at all times and in all positions—for example: a foot 334 
Downing Principles and Practice of Osteopathy 
that looks normal when off the ground, but which shows an 
inner convexity of the talonavicular joint with abduction of 
the foot during weight-bearing. This is essentially a weak 
foot and its lesion is functional in character. 
For convenience, flat feet may be divided into rigid and 
flexible types. 
1. Flexible flat foot confirms its name. It is the ordi- 
nary relaxed, pronated foot and comprises a large proportion 
of all flat feet. A flexible flat foot may be functional or 
organic, depending upon its severity. It is very amenable to 
corrective exercise. 
2. Rigid flat foot is an acutely stiff, painful and pro- 
nated foot. Rigid flat foot can be made flexible by manipula- 
tive measures. 
Another classification much in use is as follows: 
1. First degree flat foot; a mild degree of perversion in 
which one or more of the three arches are involved but not 
sufficiently to be classified as 
2. Second degree flat foot, which is a more severe con- 
dition resulting from one or more of the three major arches 
being involved to the extent that they are comparatively flat- 
tened out and so that the weight-bearing foot touches at 
several points foreign to weight-bearing; and 
3. Third degree flat foot, in which one or more of the 
three major arches are involved so extensively that they are 
not only flattened out but may, in a sense, become acutely 
inverted. 
Static flat foot is a term applied to certain types of pedal 
osteopathology. This type is particularly noticeable when 
the patient is standing and is usually due to disproportion 
between body weight and provisions for the support of that 
weight. It must be recognized that in certain cases a static 
flat foot may be a fully functionating foot, free from pain Foot Subluxations 
335 
and disability, as, for example, the aboriginal foot, which is 
extremely flat when subject is standing; but immediately upon 
activity it becomes arched. A foot that has a low arch, but 
which is able to flex or grasp (prehensile function) and which 
under weight-bearing does not abduct, is comparatively 
normal. 
All children are born with pronated feet and the arches 
usually begin to form soon after birth, but sometimes never 
develop. So-called congenital flat feet are thereby produced. 
An imaginary straight line continued downward from 
the center of the leg would pass anterior and internal to the 
greater portion of the talus and calcaneus; hence body-weight 
presses on the inner side of the foot and normally tends to 
flatten the arch and cause outward rotation. This tendency is 
opposed by the action of the flexors of the toes and by the 
tibialis posticus muscle. 
A pronounced flat foot can be easily recognized by wet- 
ting the sole of the patient’s foot with a colored solution and 
instructing him to step firmly upon a white paper. Careful 
observation of the inner surface will detect slight cases when 
the patient is instructed to place weight upon the foot. The 
inner surface will descend as the arch falls. The Golding- 
Bird method of measurement is a very accurate way by 
which to determine the presence and extent of flat foot. The 
point of articulation of the internal cuneiform and the meta- 
tarsal bone of the great toe is taken as the middle of the nor- 
mal foot. In flat foot, the greatest change is in the posterior 
half of the line. The extent to which the posterior measure- 
ment exceeds the anterior is the degree of flat foot. It rarely 
exceeds three-fourths of an inch. 
Pain in flat feet is such that the patient complains of 
marked discomfort in the region of the ball of the toes when 
walking. Pain is immediately decreased if the individual re- 
moves shoes and relieves the foot from weight-bearing. 
Palpation of the metatarso-phalangeal articulations between 336 
Downing Principles and Practice of Osteopathy 
two fingers will elicit considerable pressure pain. This pain 
is possibly due to irritation of the nerve terminals of the 
joints, particularly the articular branches of the anterior 
tibial, brought about by an overstretching of ligaments and 
a consequent tension of and around the nerve terminals. Per- 
manent relief consists in correcting the arch difficulty so 
that weight on the ball of the foot may be shifted back to the 
middle of the foot. 
Contracture of the Achilles tendon in children is seldom 
recognized if slight; but in the adult, long periods of standing 
will precipitate acute symptoms of flat foot. It is more an 
acute plantar strain than an obvious tarsal disorder. One 
significant thing, however, in this connection is the pro- 
nounced flattening of the anterior longitudinal arch with 
marked extension of the phalanges. The tarsal lesions are 
usually confined to the middle and external cuneiform and 
the cuboid. Walking on the toes is painful, due, probably, to 
the fact that the toes are usually in a state of chronic exten- 
sion on account of the condition of the anterior arch. Pain is 
quickly alleviated by sitting down. Any contracture of the 
Achilles tendon demands a slightly higher heel than is cus- 
tomarily worn. 
Although a sacrifice of stability is en- 
tailed, there is a compensatory economy 
of energy in locomotion. Their basal 
area should always be large. For practical purposes, a heel 
should be from one to one and a half inches in height, as it 
permits of active use of calf muscles, does not throw weight 
too far forward and yet takes off considerable strain in 
walking. French or Louis heels are very impractical on 
account of mechanical curve and lack of support. Cuban 
heels are the best. 
Children require little height of heel; men slightly more; 
and women a still greater amount. This is due to the fact 
that corsets and skirts prevent freedom of movement of the 
The Use of 
Heels: Foot Subluxations 
337 
hips and therefore more action of the foot is demanded. 
Strain of the long arch is proportionately less as the height 
of the heel increases. The height of a heel for remedial pur- 
poses should not exceed two and one-half inches and house- 
shoes not less than one and one-quarter inches. Slippers, 
sneakers and moccasins should be avoided. 
Shoes should not be too narrow across the toes but should 
fit snugly behind the ball of the foot and maintain a good, 
firm grip on the instep. Thin and unyielding insteps, which 
bulge and break down after a few weeks’ wear, are injurious. 
In walking, avoid lurching and dipping (economy of ef- 
fort) and use both flexors and extensors alternately and 
fully. Place the whole foot, heel, ball and toes down together, 
and do not rest too much weight on the anterior portion of 
foot. 
Grouping No. 1. The weakest part of the 
foot is mid-tarsal or at the talo-navicular 
and calcaneo-cuboid articulations. The 
strain of muscle pull and leverage re- 
laxes these joints, muscle balance is unequal and broken, and 
abductors and extensors do not function coordinately with 
abductors and flexors. The fore-foot everts and pronates, 
causing the navicular to rotate on an antero-posterior axis 
about the head of the talus. As the fore-foot abducts and 
rotates the static leverage force of super-imposed body 
weight through the perpendicular plane is apparent and acts 
in such manner as to evert the tuberosity of the calcaneous 
and by means of that fulcrum to pry the bone farther from 
the perpendicular plane in which it is normally carried. 
Therefore, as the mesial border of the foot pronates and 
everts the tuberosity of the calcaneus turns out and the head 
of the talus dips down toward the plantar surface with mesial 
tilting. The mesial dipping of the head of the talus is more 
prominent as that portion of the talus describes the greater 
range of motion. The security of the anchorage of the talus 
The Mechanism 
of So-Called 
Flat Foot: 338 
Downing Principles and Practice of Osteopathy 
between the malleoli, fortified by short, strong ligaments and 
no musculature, prevents any very pronounced internal- 
lateral subluxation. 
The navicular in this case moves in a peculiar manner. 
Due to a spreading of the arch, a certain amount of arthrodial 
slipping is expected medialward and downward at the arch 
and as it is a distal portion of the fore-foot, rotation is ex- 
pected. This rotation, however, because of resultant forces, 
is conducted in such a manner as to cause the medial segment 
to rotate upward and the external segment to rotate down- 
ward; the latter describing a considerably greater arc of 
motion. The medial border (tuberosity) of the navicular is 
very prominent medially. 
The internal cuneiform slides downward and medial- 
ward. Secondarily a ptosed position of the cuboid often 
ensues, the mechanical reason for which is not clear unless 
it be in the character of a buckling strain. 
The first, second and third cuneiforms are conjointly in- 
volved with the navicular and also assume a ptosed position. 
This is productive of a flattened transverse arch at this point 
and is further aggravated by same. All three cuneiforms in 
turn create more distal mechanical anomalies as follows: 
(1) The proximal end of the metatarsal is elevated by 
the corresponding drop of the adjacent cuneiform. The distal 
end of this long bone is depressed as the transverse axis of 
motion passes through at an intermediate point midway of 
the shaft. This allows for an over-riding of the distal end of 
the metatarsal by the phalanx articulating with it. 
Hallux valgus is a possible resultant as the influence of 
body weight and the peculiar leverage force of this pronated 
foot acts at such an angle as to pry the phalangeal portion of 
the first metatarso-phalangeal articulation laterally. 
The fibula often rotates upon its long axis with its 
spatulate malleolar extremity directed along a backward arc Foot Subluxations 
339 
with concomitant rotation of the head backward and medial- 
ward. This force tends to act as a pry and separates the 
malleoli. (Comparative measurements will elicit this find- 
ing.) As a result of this indirect strain and the oblique plane 
of the articular surface of the talus, genu valgum is possible. 
Grouping II. (Very common but seldom recognized.) 
Muscle coordination is so unbalanced that the adductors 
and supinators dominate the abductors and pronators. This 
is possibly a sequence of frequently sprained ankles in which 
the deltoid ligament has become unduly weakened or in those 
cases wherein factors which tend to allow the perpendicular 
plane of body weight to pass lateral to its normal position are 
apparent, as in the case of excessive static strain of prolonged 
standing, over-weight, etc. Individuals thus affected usually 
walk on the lateral aspect of their feet and frequently toe-in 
to an exaggerated degree. They often complain of unduly 
weak ankles which have a tendency to turn frequently. Their 
shoes are badly run over on the outer side and they are unable 
to stand any length of time with comfort. 
The tuberosity of the calcaneous is inverted and this acts 
as a pry and forces the cuboid to assume a ptosed position in 
the lateral arch. Besides separative strain on the calcaneo- 
cuboid articulation, excessive static strain on the cuboid fol- 
lows as a natural sequence to the position assumed. The 
lateral arch receives more than its usual burden at an oblique 
angle and there is a tendency for the entire outer segment to> 
become weakened, although the cuboid is the main offender. 
The talus, en masse, assumes a more externo-lateral posi- 
tion with a slight tilting at a different inclination. 
The fibula is apt to rotate on its long axis, and its spatu- 
late malleolar extremity along a forward arc with a tendency 
of the head to rotate outward, and anteriorly. The third and 
fourth metatarsals, which articulate with the cuboid, are 
likewise involved in a manner similar to that previously de- 
scribed under grouping No. 1. 340 
Downing Principles and Practice of Osteopathy 
Grouping: III. A condition in which both longitudinal 
arches are involved to a greater or lesser degree. In other 
words, an implication of the fundamental longitudinal arch 
in which there is a spreading of the transverse arches with 
the virtual ptosis of the whole foot. 
It must be kept in mind that not all of the conditions 
mentioned in these groupings are consistently found. But 
their tendencies are constant. Other factors may creep in, 
in which event other findings will manifest themselves. We 
must, therefore, bear in mind the typical lesion and also 
be on guard continually against the atypical. 
Practically all adjustments, with the ex- 
ception of some general maneuvers, are 
directed to the bone in lesion. 
Subluxation of the Calcaneus. This is part of a compos- 
ite lesion involving the talus (talo-navicular articulation) 
and adjustment has the double purpose of correcting posi- 
tionally both bones at the same time with one procedure. Two 
types of lesions are found: 
1. A condition previously suggested in Grouping I, in 
which the medial longitudinal arch is involved with eversion 
•of the tuberosity of the calcaneus and the medial tilting and 
subluxation of the talus. The objectives, or the points 
through which the greatest corrective force may be applied 
in this case are the postero-lateral aspect of the heel and the 
mesial aspect of the head of the talus. Simultaneous force 
should be directed in a doubly transverse manner in opposite 
directions and with the foot under traction—that against 
the talus transverse laterally, and the calcaneus transverse 
mesially. 
2. A type included in grouping II, in which the lateral 
longitudinal arch is involved with inversion of the tuberosity 
of the calcaneus, and lateral tilting and subluxation of the 
talus. The objectives in this case are the postero-medial 
aspect of heel and the lateral aspect of the head of the talus. 
The Individual 
Lesion and Its 
Adjustment: Foot Siibluxations 
341 
Simultaneous force should be directed in a doubly transverse 
manner in opposite directions with the foot under traction: 
that against the talus transverse mesially, and that against 
the calcaneus transverse laterally. 
This is represented by a full range of 
motion under traction and completed with 
an exaggeration of traction—a quick, 
snappy pull. Minor subluxations and conditions in the ankle 
joint itself are amenable to this treatment. It is a general 
method and not designed to meet anything but a general need. 
The cuboid bone is one of the most fre- 
quent offenders in the foot. It is second 
only to the combined lesion of the middle 
and external cuneiforms. Marked sensitiveness can be elicited 
upon pressure, together with palpatory findings which indi- 
cate that the bone is in a ptosed position. Its constant asso- 
ciation with lateral arch conditions is pathognomonic. 
The objective should be the plantar aspect of the bone. 
The corrective force should be directed upward and medial- 
ward with the patient supine. Leverage force is acquired 
by flexing, abducting and pronating the forefoot. The in- 
strumentality of force is the flexed index finger, reinforced 
by fingers of the opposite hand. Counter force should be 
applied to the proximal end of the metatarsal by thumb pres- 
sure of the adjusting hand. The opposite hand controls lev- 
erage force. 
The above method is best and most universally effectual. 
Another maneuver is to place a firm, hard, small pillow 
over the knee or thumb over the knee cup, hold firmly the 
heel and the dorsal surface of the foot, and with the foot in 
an abducted, pronated position, to bring the bone in question 
over the reinforced, flexed knee as a fulcrum. Other methods 
have been devised and used by the author when these meth- 
The Talotibial 
Articulation: 
Subluxation of 
the Cuboid: 342 
Downing Principles and Practice of Osteopathy 
ods have failed, but the above have proven the most effective 
in the largest number of cases. 
This is probably third in relative patho- 
logic importance and frequency. It is 
common in Grouping I and in cases hav- 
ing a tendency toward hallux valgus. 
Sensitiveness and palpatory findings make diagnosis easy. 
Adjustment of this condition can best be effected by laying 
the patient on the side lesioned with the foot uppermost. 
Place a firm, hard pillow at the edge of the table, beneath 
the foot in such a manner that the lesioned articulation is at 
the edge of the cushion. Place index and second finger against 
the objective, which is the plantar aspect of the cuneiform, 
and rest heel of the hand on the lateral aspect of the ankle 
joint for fixation and protection. The forefoot should be 
flexed, adduction and spinated. This is leverage force and 
Is controlled by the opposite hand. Exaggeration of leverage 
force with strong pressure against cuneiform in an upward 
direction completes adjustment. 
The internal cuneiform articulating with the first meta- 
tarsal and navicular can be handled by this technique. If both 
joints are involved the objective should be intermediate. If 
the proximal articulation, then the objective should be nearer 
the joint involved (articulation with navicular); if the distal 
rarticulation, the objective should be nearer the articulation 
'with the metatarsal. 
The same leverage principle is applied as 
is used in making the adjustment of the 
internal cuneiform, excepting that differ- 
ent points of fixation are maintained, so that leverage force 
will be delivered against the navicular only. A slightly great- 
er element of rotation is made use of in both leverage and 
corrective forces, so adjustment of this lesion describes quite 
an arc of rotation around the head of the talus. 
Subluxation of 
the Internal 
Cuneiform: 
Subluxation of 
the Navicular: Foot Subluxations 
343 
Subluxation of 
Middle and 
External 
Cuneiforms: 
These are considered as one lesion as they 
are so intimately associated in the con- 
joint lesion movement. For all practical 
purposes then, they can be considered 
together. Moreover, because of their 
small surface area, both can be adjusted at the same 
time and with the same movement. In fact, it would be 
a superhuman feat to maintain a small enough surface con- 
tact to adjust one without adjusting its fellow. 
Technique I: Patient prone, grasp the foot in such a 
way that the interlocked fingers maintain a counter 
force against the dorsal aspect of the proximal ends 
of the metatarsals, particularly the second and third. Cor- 
rective force is made through the instrumentality of the 
thumbs, one reinforcing its fellow. Exaggerate flexion of 
the foot (plantar aspect) making the apex of this angle the 
point of lesion; then, with still further stress, direct a simul- 
taneous force against the plantar aspect of the cuneiforms, 
with increased pressure of the thumbs and proportionate 
counter pressure. 
Technique II: Patient prone, flex knee to right angle, 
grasp foot in such a manner that the heel of one hand 
rests against the postero-inferior aspect of the tuber- 
osity of the calcaneus and the heel of the opposite hand 
rests against the distal ends of the metatarsals (toes must be 
in extended position). With this purchase, attempt to ap- 
proximate heels of hands. This will cause the arch to buckle 
and give the operator the opportunity—with firm pressure on 
the cuneiforms with the tips of the index and second fingers 
and slight flexion—to force bones back into proper position 
in the arch. 
Technique III: Patient prone, so that forefoot is 
over the edge of the table. Place the adjustment pillow 
on the edge of the table, rest the forefoot over it in such 
a manner as to bring counter force against the dorsal aspect 344 
Downing Principles and Practice of Osteopathy 
Position of the foot for adjustment of a subluxat on of a fourth metatarsa- 
phalangeal articulation. Arrow C indicates direction of traction flexion leverage 
force. Arrow B points out head of the metatarsal against which adjustive force 
is directed. A indicates proximal extremity of metatarsal against which counter 
force is directed. Foot Subluxations 
345 
of the proximal ends of the metatarsals. The pisiform bone 
is the instrumentality through which corrective force is given. 
Force is directed against the plantar aspect of the cuneiforms. 
The applied force is the thrust, one hand reinforcing the 
other. 
Reference is made in this case to the sub- 
luxations of the phalangeal-metatarsal 
articulations. These lesions are in exact 
correlation with lesions of the tarsal bones with which they 
articulate. In other words a lesion of the cuboid is usually 
accompanied by a secondary lesion of the fourth and fifth 
metatarsals, internal cuneiform, first metatarsal; middle 
cuneiform, second metatarsal; and third cuneiform, third 
metatarsal. 
The phalangeal metatarsal lesion evinces a tendency for 
the proximal end of the phalanx to over-ride the distal end of 
the metatarsal. Here is a tilting of the metatarsal, distal end 
down, proximal end up, together with a ptosed position of the 
adjacent articulating tarsal bone. The toes are held in a 
chronic, extended position. 
Technique: Adjustment can best be carried out with 
the patient supine. Operator places the apex of the flexed 
index finger against the plantar aspect of the distal end 
of the metatarsal and the flexed thumb of same hand 
over the dorsal aspect of the phalanx. Support of the 
foot and counter force for the metatarsal is accomplished by 
grasping the forefoot with opposite hand in such manner as 
to bring strong dorsal pressure against the proximal end of 
the metatarsals. Leverage force is controlled by action of 
thumb against the phalanx. It consists of traction and 
flexion and at the moment of adjustment exaggeration of 
traction and flexion with strong corrective force against the 
distal end of the metatarsal with the flexed index finger. 
Using these same principles, adjustment can be made 
with the patient prone. 
Subluxation of 
the Metatarsals: 346 
Downing Principles and Practice of Osteopathy 
1. The general method for rigid flat foot: 
The purpose of this technique is not spe- 
cific adjustment, but rather a general 
method for freeing up a large number of 
articulations. It is as follows: 
The foot is grasped in the two hands, one holding the 
tuberosity of the calcaneum firmly under traction, the other 
grips the forefoot firmly, palm over the dorsum of the foot. 
Quick simultaneous exaggeration of traction with the hand 
holding the tuberosity of the calcaneus, together with strong 
flexion and adduction of the forefoot will usually break up a 
rigid condition of the longitudinal arches. 
2. Stretching the Achilles Tendon: 
With patient supine on the table, grip the tuberosity of 
the calcaneus firmly with both hands. Place apex of the 
flexed knee against plantar aspect of the distal ends of the 
metatarsals. Strong traction with the hands and pressure 
with the knee will serve to produce a marked stretching of 
the tendon. 
Extremely stiff Metacarpophalangeal joints can be 
gradually flexed with plaster and by the means of the so- 
called “retaining splint.” This flexion is maintained and can 
be increased from time to time. The joints should be given 
passive movement and massage at stated intervals. When 
they can flex voluntarily and retain this flexion, treatment 
is completed. 
Electrical treatment of foot musculature is sometimes 
beneficial, preliminary to voluntary exercise, for atonic and 
relaxed, pronated feet. 
Ankle joint injuries should be treated in such manner as 
to get rid of the effusion which separates the torn ends of tis- 
sues and immobilized in such a fashion as to prevent any 
movement which will stretch or tear newly repaired tissues 
and thus make conditions chronic. Apply a pad of adhesive 
plaster over the effusion and a similar pad over the tendon im- 
General 
Unclassified 
Measures for 
Varying Foot 
Conditions: Foot Subluxations 
347 
mediately above the inflamed area. This done, a bandage 
should be applied. Encourage free blood supply by massage, 
contrasted needle-spray baths, or hot and cold compresses. 
Minor subluxations of this bone, as pre- 
viously mentioned, are very common with 
allied foot conditions. They consist of 
rotations of the shaft of the fibula on its long axis. In the 
type associated with Grouping I the rotation is along an arc 
directed backward and medialward. In Grouping II the bone 
revolves upon an arc directed forward and outward. In both 
cases there is partial immobilization, particularly at the head. 
Corrective procedures must bring into play a full range of 
rotary movement, particularly at the head of the bone. The 
following procedure may be utilized: 
Technique: Patient seated, knee flexed, leg and foot ab- 
ducted and everted. Using the foot as a lever with one hand, 
strong extension and eversion are used. With the other hand, 
operator maintains firm counter force and adjustive tension 
against the postero-lateral aspect of the head of the fibula. 
This partially corrects the lesion, carrying the bone to its 
anatomic limit in a postero-medial arc. Counter force at this 
point is adjustive. Carrying the foot into strong extension 
and inversion, pressure of the adjusting hand shifts to the 
antero-lateral aspect of the head of the fibula where it main- 
tains both counter and corrective forces. From the previous 
position, the foot is quickly everted and knee extended, with 
increased pressure of the adjusting hand at the same moment. 
This completes the adjustment by carrying the bone as far 
as it will go in an antero-lateral arc. Counter force at this 
point is adjustive. 
This complete procedure is corrective in inverse order 
for both Group I and Group II conditions and this same in- 
verse action corrects the malleolar articulation inversely to 
the head, so that at completion both extremities are nor- 
malized. 
Adjustment of 
the Fibula: 348 
Downing Principles and Practice of Osteopathy 
'A 
1 
E 
Position taken for adjustment of the fibula immobilized in either forward or 
backward rotation on its long axis. Arrows A and B indicate combined objectives 
anterior and posterior to the head of the fibula. The leverage mechanism is 
largely controlled by the action of the foot which is carried in the direction indi- 
cated by the arrows E and D. Foot Subluxations 
349 
Dislocation of the Fibula at the superior tibiofibular 
articulation is due to extremely violent adduction of the foot 
with abduction of the knee, occasionally by direct force. The 
head of the fibula may be forward or backward. The knee 
is held in semi-flexion with limitation and impairment of both 
flexion and extension. There is a depression where the head 
is normally found. Continuation of the fibula superiorly will 
end in movable projection. 
Bend knee to relax biceps, and push bone 
into proper position. Place a compress 
over the head of the bone, bandage and place the limb in a 
position of easy double flexion (knee and thigh). A lacing 
knee support at the end of several weeks will hold the bone 
in position. 
This condition is not infrequent. It may 
be complete or incomplete. 
Lateral Dislocation inward and outward with rotation of 
the astragalus. It is caused by twisting of the joint and the 
foot presents a lateral twist or outward dislocation, associ- 
ated with Pott’s or Dupuytrin’s fracture. Flex leg on thigh, 
or thigh on pelvis, counter extension from the knee, extension 
from foot, rocking the talus into place. Complete treatment 
by use of the fracture box. 
Dislocation upward or Nelaton’s dislocation is rare. The 
talus is wedged between the widely separated tibia and fibula. 
It is caused by a fall upon the feet from a great height. 
Widening of ankle joint and flattening of 
the foot. Absolute rigidity. Malleoli on 
level with plantar surface of foot. The treatment is extension 
and counter extension. 
Antero-posterior dislocation of the joint is rare, produced 
usually by catching the foot in jumping or falling—direct 
violence. Forward dislocation, the foot is lengthened, heel 
Adjustment: 
Dislocation of 
Ankle Joint: 
Symptoms: 350 
Downing Principles and Practice of Osteopathy 
inconspicuous, tibia and fibula project against tendo Achilles. 
Dislocation backward: the foot is shortened, tibia and fibula 
project forward, heel is prominent. 
Treatment as in lateral dislocation: plaster of Paris 
dressing. 
Dislocation of Talus: may be separated from bones of the 
leg and at the same time those of tarsus. 
Antero posterior dislocation is caused by falls or twists. 
Symptoms: 
Forward dislocation; the talus projects strongly; 
shortening of foot; malleoli approach plantar as- 
pect, foot deviated; absolute rigidity. 
Backward Dislocation: No deviation of foot, bone pro- 
jects between malleoli and above calcaneus, and tendo 
Achilles is stretched over projection. Absolute rigidity. 
Lateral and Rotary Dislocations of Talus are rare, and 
associated with fracture. 
Rotary Dislocation. Talus remains in its normal habitat, 
but rotates on either its own horizontal or vertical axis. This 
lesion is caused by a twist of the foot when at right angles to 
the leg. 
Symptoms: Rigidity. 
Treatment: Flex knee to relax gastrocnemius, extend 
foot, and push bone into place. 
Subastragaloid Dislocation. Separation of talus from os 
calcis and scaphoid without separation from bones of leg. 
Dislocations are forward, backward, inward, and outward. 
The cause is twisting. The talus projects on the dorsum of 
foot; foot is everted outward; dislocation inverted inward. 
The foot is shortened in front, and lengthened behind; ankle 
joint is unaltered and not absolutely rigid. Foot Subluxations 
351 
Treatment: 
Make extension in direction opposite to that 
of displacement (forefoot). Counter ex- 
tension (hindfoot). Plaster of Paris 
dressing. 
Pes Cavus (Hollow Foot) 
7'i/tnA 
/J 
Groove /or 
TIB.P08T.& 
rt.LOMG.OIQ. 
Posterior view of the ankle joint with ligaments. 
Increase in the arch of the foot, due possibly to hypotonic 
state of peronei muscles. Adductors act unopposed and sec- 
ondary contraction of the plantar fascia follows. Wearing 
too short a shoe resulting in pressure on the toes, with result- 
ant spasm of plantar flexors. This condition can sometimes 
be overcome by wearing a shoe sufficiently long with a steel 
shank in sole and attached strapping over instep. 352 
Downing Principles and Practice of Osteopathy 
Hallux Varus 
and Valgus: 
Displacement of great toe, respectively, 
inward (varus) or outward (valgus). It 
is frequently encountered in elderly peo- 
ple, particularly women. Wearing pointed shoes, shoes too 
short or extremely high heels may predispose. Gtmt, rheuma- 
tism, and allied rheumatoid arthritis is provocative. In hallux 
valgus, bunion (bursitis) is apt to form over metatarso- 
phalangeal joint. Exostosis at the distal end of metatarsal 
bone is frequent. 
Flexion of one or more toes at the first 
interphalangeal joint due to contraction 
of the plantar fibers of the lateral ligaments of the joints. It 
usually begins in youth and may be congenital. Callous for- 
mations develop at pressure point and joint may be dis- 
located. Subcutaneous divisions of the lateral ligaments and 
flexor tendon or amputation is sometimes the only means 
of relief. 
(Morton’s disease). This is a painful con- 
dition due to jamming of the nerve be- 
tween the heads of fourth and fifth metatarsal bones. The 
head of the fifth, by lateral pressure, is forced against and 
below the neck of the fourth with the result that the super- 
ficial branch of the external plantar nerve and its branches 
are impinged. It is usually associated with flattening of the 
anterior arch. Loss of this arch may jam other nerves than 
those mentioned, with similar symptomatology. 
This is an inflammation of the bursa lying 
between the insertion of the Achilles ten- 
don and the tuberosity of the os calcis. 
Effusion sometimes occurs. The causative factors are as 
follows: 
Hammer Toe: 
Metatarsalgia: 
Retro-Calcanean 
(Achillo-Bursitis): Foot Subluxations 
353 
1. Functional—over use of the feet. 
2. Traumatic—pressure of improper shoeing. 
3. Bacterial—tuberculosis, gonorrhea, rheumatic in- 
fections, etc. 
Pain is localized at the junction of the Achilles tendon and 
the os calcis. Pain is greater on motion; rest alleviates. The 
foot is more comfortable when everted and the leg rotated 
outward. Tenderness and occasionally a doughy mass can be 
palpated on each side of the Achilles tendon. This condition is 
responsible for the associated pain in the tendon (Achillo- 
dynia). 354 
Downing Principles and Practice of Osteopathy 
CHAPTER XII. 
LUXATIONS, PARTIAL AND COMPLETE 
Forward 
Luxation of 
the Mandible: 
This condition is usually caused by mus- 
cular action such as yawning, laughing, 
crying, etc. It may be the result of forci- 
ble attempts to introduce a large object 
into the mouth or of direct violence. 
The synovial membrane has a very strong outer sheath 
which is known as the external lateral ligament. The inter- 
nal lateral ligament is not in immediate contact with the 
joint but extends from the spinous process of the sphenoid 
bone to the inferior dental foramen and by another portion 
known as the stylo-mandibular ligament from the styloid 
process of the temporal bone to the posterior border of the 
ramus of the mandible. The joint contains an inter-articular 
cartilage or meniscus which overlaps the upper surface of 
the condyle and accompanies it in its normal movement for- 
ward from the glenoid cavity to the eminentia articularis 
when the mouth is opened. The surface of the eminentia ar- 
ticularis is inclined slightly upward to become continuous 
with the narrower, lower surface of the zygoma. 
The chief movement of the joint is ginglymoid, acting in 
the nature of a hinge and accompanied by slight gliding 
movement when the mouth is opened or closed. When the 
mouth is opened, the condyle describes a hinge-like movement 
on the fibro-cartilage; at the same time the fibro-cartilage, 
together with the condyle, glides forward. If the condyle 
slips over the summit of the articular eminence, it slips into 
the zygomatic fossa, and the mandible is dislocated. In the 
closing movement the condyle revolves backward and the 
fibro-cartilage glides back, carrying the former with it. The 
horizontal gliding action by which the lower jaw is thrust 
forward and back again takes place in the outer compartment 
between the fibro-cartilage with the squama of the temporal Luxations, Partial and Complete 
355 
bone. In the above types of movement the joints of both sides 
act simultaneously and similarly. 
Inter CLrLf-uIAr- 
ea rtilagc 
£mrtuncntiei 
ArticuIaLris 
Vertical section of the temporomandibular articulation. 
A third type of movement is oblique and rotatory. This 
consists of a rotation in which the condyle revolves around 
the vertical axis of its neck. Such movement is confined to 
the lower compartment between the fibro-cartilage and the 
condyle itself. At the same time, the fibro-cartilage glides 
obliquely forward and inward on one side, and backward and 
inward on the other—each side acting alternately. The axis 
of motion shifts accordingly from one side to the other as the 
arc of motion reverses its direction. In the ordinary grinding 
movement, one condyle advances and the other recedes, and 
vice versa—slight rotation taking place in each one, mean- 
while. The axis of motion, therefore, in this movement, shifts 
from one condyle to its opposite fellow. A unilateral axis is 
possible, passing in an obliquely vertical direction through 
the long axis of the neck. In such a case the condyle revolves 
on this axis without an antero-posterior shift, allowing the 
opposite condyle and cartilage to glide forward and inward 
upon the glenoid fossa. 
The muscles which close the mouth are attached to the 
ramus and extend upward and forward with the exception 
of the deep posterior fibers of the masseter, which are ver- 
tical or inclined backward. 356 
Downing Principles and Practice of Osteopathy 
Due to the fact that the condyle moves forward when 
the chin descends, the center of motion of the jaw is not in 
the condyle, but at a point below and in front of it, in the 
region of the dental foramen. The angle of the mandible 
moves backward at the same time and consequently the 
ramus of the jaw noticeably shifts its relationship to the 
direction of the fibers of the masseter. This shift in the axis 
of the ramus brings the line of the posterior fibers behind 
the center of motion where their contraction tends to open 
the mouth, or keep it open. 
If the condyle advances beyond a normal point on the 
articular eminence, it may become fixed. If the reason for 
this fixation is muscular it is usually due to contracture of 
the external pterygoid and posterior fibers of the masseter 
aided by relaxation of the external lateral ligament. 
Occasionally the capsule may be ruptured. The coronoid 
process may also become engaged beneath the malar bone 
and act as an accessory cause to fixation. The meniscus, if 
torn, may be an additional partial factor in fixation and ren- 
der complete reduction manually impossible. 
The external lateral ligament, which forms the anterior, 
outer portion of the capsule, stretches from the articular 
eminence downward and backward to the neck of the con- 
dyle. This ligament is too short to remain in such a position 
when the condyle is dislocated, nor can the long axis of the 
neck coincide with that of the ligament. When the mouth is 
opened widely, therefore, the ligament relaxes as the con- 
dyle passes forward so that the neck is bisected by the long 
axis of the ligament with the condyle anterior. When the 
mouth is partially closed, the ligament becomes tense and if 
the condyle does not move past the point of the upper attach- 
ment of this ligament, before tension becomes too great, 
further movement backward is prevented by this mechanism. 
Any attempt to close the mouth merely further aggravates 
the tension of these ligaments and the associated powerful 
muscles of mastication. Luxations, Partial and Complete 
357 
larLitf. 
Ex/’em#/.LaLLig' 
(stylo Slo-v/l/oryLty. 
External view of the temporomandibular articulation. 
When the dislocation is unilateral, it is usually due to a 
violent shunting of the jaw forward when the mouth is open. 
Biting on a hard, round comparatively large object may be a 
sufficient fulcrum to act more or less as a rolling skid, shunt- 
ing the mandible anteriorly beyond its normal point of recov- 
ery. Direct violence, unilaterally applied against the angle 
of the jaw when the mouth is open is also a sufficient cause. 
A tendency to unilateral dislocation may likewise be due to 
an imbalanced position of the teeth, causing them to act in 
the nature of a pry. 
Fixation of one articulation, due to pathological influ- 
ences which are arthritic in character, necessarily requires 
hypermobility of the opposite articulation, which in turn 
renders the hypermobile articulation susceptible to subluxa- 
tion or dislocation. Extension of inflammation to the joint 
may result from otitis media, pharyngitis, parotitis, etc., with 
consequent restriction of the joint involved. 358 
Downing Principles and Practice of Osteopathy 
The symptoms are of such a character that the mouth 
is held open, the lower jaw immobilized and projected some- 
what forward. The condyle is in front of its normal posi- 
tion, rendering mastication impossible, articulation and de- 
glutition difficult. Complete dislocation is rare; incomplete, 
with fixation, common. 
First, depress the chin and, if possible, 
open the mouth widely so as to relax the 
lateral ligaments. After this is accomplished press the con- 
dyle backward, maintaining a fulcrum by downward pres- 
sure against the junction of rami and the body, closing the 
mouth under resistance to the point of the chin, as the con- 
dyle passes the articular eminence on its way back. The bone 
thus follows, in returning to its socket, the route by which 
it escaped from it. 
Ashmore gives as the treatment of a hypermobile or re- 
laxed articulation, the forcible replacement of the lesioned 
condyle and cartilage accompanied by pterygoid and liga- 
mentous stretching on the opposite side, the motion of which 
is restricted. The bilateral luxation is more common than 
the unilateral, although the mechanics of the corrective pro- 
cedure are the same in both. 
The sternal end of the clavicle is much 
larger than the clavicular notch of the 
sternum with which it articulates, so that 
it projects above it, and in front and be- 
hind. The joint is a diarthrosis, and its articular surfaces 
are separated from each other by an inter-articular carti- 
lage, on each side of which is a synovial cavity. The liga- 
ments of the joint are the capsular, posterior and anterior 
sterno-clavicular, costo-clavicular or rhomboid, and the inter- 
clavicular ligament. The inter-clavicular ligament extends 
across the upper border of the supra-sternal notch, attaching 
the end of one clavicle to that of the opposite side, also send- 
Treatment: 
Luxations of 
the Sternal End 
<of the Clavicle: Luxations, Partial and Complete 
359 
ing fibers into the meniscus or inter-articular fibro-carti- 
lage. The capsular ligament consists of a stratum of fibers 
which completely surrounds the articulation. These fibers, 
at the back of the joint, are called the posterior sterno-clavic- 
ular ligament, while the fibers in front are known as the 
anterior sterno-clavicular ligament. The rhomboid or costo- 
clavicular ligament extends from the sternal end of the first 
rib upward and outward to the under surface of the clavicle. 
With P* fab 
aSTtRHU 
KYOlO 
Arti/-ula turn 
wi tfi .Acromion. 
i 
liibercle for] 
Conoid Ltij 
Movements of the articulation are varied, though limit- 
ed, owing to the capsular ligament, which is moderately tense 
in all positions. Motion may be upward, downward, forward, 
backward, and circumductory. The upward and downward 
motions occur between the clavicle and the fibro-cartilage. 
If the arm is elevated, the upper edge of the clavicle and the 
associated fibro-cartilage are pressed into the sternal socket. 
If the limb is depressed, the lower edge of the clavicle presses 
on to the cartilage while the upper edge of the articular sur- 
face of the clavicle inclines outward. These movements 
take place on an antero-posterior axis drawn through the 
upper compartment of the joint. The forward and backward 
motions occur between the cartilage and sternum, the clav- 
The left clavicle, inferior surface. 360 
Downing Principles and Practice of Osteopathy 
icle with the cartilage moving backward upon the sternum 
when the shoulder is brought forward, and forward when the 
shoulder is forced backward. These movements occur on an 
axis drawn obliquely vertical through the sternal socket. 
Movement of the shoulder downward and backward is limited 
by contact of the clavicle with the first rib, and, if continued, 
this point of contact becomes a center of motion or fulcrum 
and the sternal end of the clavicle may be forced upward and 
forward out of its normal position. Dislocations may be com- 
plete or incomplete and may be upward, forward, backward; 
and if incomplete, inward toward the medial line. When dis- 
placement is either forward or backward, it is usually down- 
ward as well. 
Dislocation is most common in males between the ages 
of 30 and 50. The dislocation forward is usually caused by 
the shoulder being forced backward, or backward and down- 
ward. The anterior sterno-clavicular ligament is severely 
stretched and may be ruptured, in which case dislocation 
ensues. This is the most common type of luxation. 
Reduction is effected by drawing the shoulder outward 
and slightly backward, making pressure backward on the dis- 
located end of the bone, when it is in juxtaposition to the man- 
ubrium, after which the shoulder is earned slightly forward, 
and the bone is directed into its socket. Immobilize the 
shoulder well forward until repair of the torn ligaments has 
taken place. For this purpose use a Velpeau bandage, a 
plaster of Paris dressing or pressure pads. It may be 
necessary to keep the patient in bed for a time in order to 
prevent the weight of the shoulder from tending to reproduce 
the condition. 
Dislocation backward is the result of direct force applied 
to the end of the bone or indirectly by force which presses the 
shoulder forward and inward. Dislocation may be complete 
or incomplete. Reduction can be accomplished by drawing 
the shoulder outward and backward. Recurrence of this dis- Luxations, Partial and Complete 
361 
placement should be opposed by dressings that hold the shoul- 
der back and down. 
Dislocation upward is the result of sudden trauma, caus- 
ing a forcible depression of the shoulder at the acromial end 
of the clavicle; causing, usually, a rupture of the upper por- 
tion of the capsular ligament. Reduction is effected by draw- 
ing the shoulder outward and making direct pressure down- 
ward and outward upon the sternal end of the clavicle. Fix- 
ation of the shoulder and the recumbent position should be 
employed to maintain the reduction. 
The outer portion of the clavicle is attach- 
ed to the scapula at two points: by its ex- 
treme end to the inner margin of the acro- 
mion by the acromio-clavicular joint and 
more medially to the coracoid process by the coraco-clavicular 
ligament. The acromio-clavicular joint is surrounded by a 
capsular ligament which usually contains an inter-articular 
fibro-cartilage. The articular surfaces are flat and oval, 
their long axes being antero-posterior. The upper edge of 
the end of the clavicle is at a slightly higher level than the up- 
per surface of the acromion. The coraco-calvicular ligament 
consists of two parts, the conoid, which is postero-internal; 
and the trapezoid, which is antero-external. 
In movements of the shoulder girdle, the scapula moves 
beneath the outer end of the clavicle, and the clavicle in turn 
moves upon the sternum so that the entire scapula describes 
an arc of a circle the center of which is the sterno-clavicular 
joint and the radius of which is the clavicle. The acromio- 
clavicular joint allows the scapula to move upon the thorax, 
forward and backward, upward and downward, and in a ro- 
tary direction upon an axis drawn at right angles to the cen- 
ter of the bone. The glenoid cavity thereby maintains its 
obliquely forward direction, for by means of its articulation 
with the clavicle the scapula can be advanced upon the 
thorax and the glenoid cavity at all times kept facing directly 
outward. These two bones must move in unison at all times. 
Luxations of the 
Acromial end of 
the Clavicle: 362 
Downing Principles and Practice of Osteopathy 
Complete dislocation results in rupture of the ligaments 
of the joint proper. The conoid and trapezoid ligaments may 
also be involved. Dislocation is usually produced by direct 
displacement of one bone upon the other. The luxation of 
the clavicle may be upward, downward, or backward, and are 
respectively termed supra-acromial, sub-acromial, or sub- 
coracoid dislocations. The first is the most common. The 
dislocations may be complete or incomplete. 
The supra-acromial dislocation is usually the result of a 
blow received upon the point of the shoulder which is directed 
downward and with an inward, forward, or backward in- 
clination. Vigorous contraction of the trapezius prevents 
the clavicle from accompanying the acromion in its descent, 
as does also contact with the first rib. Diagnosis is easily 
accomplished by noting the marked change in the relations 
to the bones. To reduce, the shoulder should be drawn either 
directly upward, or with a slight outward or backward inclin- 
ation; at the same time counter force is directed to the outer 
end of the clavicle, pressing it directly back to its proper 
position. Fixation and retention of the reduction are there- 
after necessary. 
The Sub-acromial dislocations are rare. They may be the 
result of direct violence against the front of the shoulder. 
Voluntary movements of the arms are interfered with and 
sometimes entirely prevented. Persistent numbness and tin- 
gling may indicate pressure upon the brachial plexus. Reduc- 
tion is accomplished by drawing the shoulder outward and 
backward, maintaining the arm parallel to the trunk and se- 
curing counter extension with a bandage passed around the 
chest. The arms should be immobilized against the torso 
with the forearm supported by a body-bandage and sling. 
Sub-coracoid dislocations are characterized by ecchymo- 
sis and pain in the coraco-acromial region, depression over 
the normal point of the clavicle, with the bone inclined down- 
ward and outward and with the acromial end lodged in the Luxations, Partial and Complete 
363 
axilla. The whole shoulder is inclined downward and for- 
ward. Reduction can be made by disengaging the clavicle 
from under the coracoid process and at the same time forc- 
ing the shoulder backward and outward. 
This condition is a distinct fixation of the 
clavicle in which movement of the bone is 
considerably impaired, limiting to some 
extent the action of the shoulder-girdle and interfering with 
both circulatory and lymphatic drainage through the anterior 
portion of the cervical column. The anterior jugular vein 
may be particularly affected, in which case the thyroid may 
be involved through venus retardation. The clavicle is not 
necessarily luxated, though fixed and bound down by abnor- 
mal muscular and ligamentous tension. The object of treat- 
ment is to increase the mobility both of the sterno-clavicular 
and acromio-clavicular articulations. 
The method by which this can be accomplished is as 
follows: 
With the patient supine, the operator flexes the forearm 
at right angles with the upper arm and with the latter close 
to the body brings pressure against the point of the elbow. 
This raises the shoulder girdle and affords the operator an 
opportunity to fix a fulcrum behind the outer portion of the 
middle third of the collar bone by placing the fingers behind 
it at this point. The next step in the procedure is to bring 
the point of the elbow across the chest to the midline, still 
maintaining the elevation of the shoulder girdle and the ful- 
crum behind the clavicle. The next step is to elevate the point 
of the elbow to a level with the top of the shoulder, and at the 
same time bring a slight lift against the clavicle with the 
fingers. From this point sweep the point of the elbow direct- 
ly lateralward so that the upper arm is at right angles to the 
torso and in a position of abduction. Exaggerate the point of 
leverage force by bringing added pressure against the ful- 
crum and, at the same time, allow the forearm of the patient 
The Depressed 
Clavicle: 364 
Downing Principles and Practice of Osteopathy 
to rotate so that the fingers point directly downward—thus 
causing an inward rotation of the humerus on its long axis. 
The humerus at this time is in such a position that its long axis 
conforms nearly to the long axis of the clavicle and is there- 
fore a leverage influence to force the clavicle forward and 
outward. The point of the fulcrum can be shifted slightly, 
inward or outward, medialward or lateralward, depending 
upon toward which end of the clavicle the operator wishes to 
bring the greatest amount of leverage. 
The shoulder is a diathrodial ball-and- 
socket joint and is the most perfect and 
movable of all the joints. Atmospheric 
pressure and its muscles have as much to 
do with retaining it in position as its ligaments. Its construc- 
tion and position, together with the looseness of its capsule, 
render it especially liable to displacement. The ligaments of 
the shoulder joint are the capsular, gleno-humeral, coraco- 
humeral, and the glenoid. The capsular ligament is a loose 
sac attaching on one side to the edge of the glenoid cavity, the 
anatomical neck of the scapula and the rim of the glenoid 
ligament, and on the other to the anatomical neck of the 
humerus, above at the edge of the articulating surface, and 
below some distance from the articulating surface. The cap- 
sular ligament is comparatively weak, having two openings, 
one for the long tendon of the biceps, and the other for com- 
munication with its bursa. The capsule is strengthened by a 
reinforcement above called the gleno-humeral ligament. This 
is sometimes known as the superior gleno-humeral ligament 
to distinguish it from some bands on the lower anterior por- 
tion of the capsule which are known as the middle and in- 
ferior gleno-humeral ligaments. The coraco-humeral liga- 
ment is a strong band extending from the root and outer bor- 
der of the coracoid process over the top of the joint and at- 
taching to the neck of the humerus above the greater tuber- 
osity. The glenoid ligament is a wedge-shaped ring of fibrous 
Luxations of 
the Shoulder 
Joint: Luxations, Partial ayid Complete 
365 
3 
c 
a 
Position of patient and operator for raising the clavicles. B indicates fulcrum 
and pry action obtained by placing the fingers behind the clavicle. The long 
axis of the humerus and the clavicle are continuous so that forward rotation of 
the humerus on its long axis determines forward outward rotation of the clavicle. 
The forearm is flexed to a right angle with the upper arm and with this lever 
mechanism carried downward in the direction indicated by arrow A forward 
rotation of the humerus is assured. 366 
Downing Principles and Practice of Osteopathy 
cartilage which deepens the glenoid fossa and receives at its 
upper end the long tendon of the biceps which divides and 
blends with it on either side. 
Trapezoid Luj 
Conoid Luj^ 
Inferior acromio clovicu/ru 
'buj. 
Superior acromio do vu - 
Transverse 
Ly.\ 
tf'uprcL Scafnlltir 
jbrcunenA 
AeromiVn 
Tendon of 
v BICEPS 
Great 
\Ticberosdy 
M 
The left shoulder joint, scapulo-clavicular articulations and ligaments. 
The shoulder has two sets of muscles, one connecting the 
shoulder-girdle with the trunk, and the other the humerus 
with the shoulder-girdle. Any joint injury followed by con- 
sequent disuse leads to muscular paralysis and the muscles 
directly concerned with the joint atrophy so that the weight 
of the arm causes the head of the humerus to sag, giving rise 
to a marked depression beneath the acromion process. 
The muscular bellies of the subscapularis, supraspinatus, 
infraspinatus, and teres minor muscles constitute a muscular 
capsule to which the shoulder owes much of its stability. The 
muscular weakness of the joint is a pronounced factor in re- 
curring dislocations. Luxations, Partial and Complete 
367 
The movements of the shoulder joint consist of flexion, 
extension, adduction, abduction, rotation and circumduction. 
In flexion and extension the axis of motion is oblique and 
passes through the head and neck of the humerus and the 
center of the glenoid fossa. The head of the humerus re- 
volves upon the center of the fossa and allows an antero-pos- 
terior swinging of the arm, forward in flexion, and back- 
ward in extension. In abduction and adduction the humerus 
rolls up and down on the glenoid fossa, which is fixed. In 
circumduction the humerus describes a cone, the apex of 
which is at the shoulder joint and the base at its distal ex- 
tremity. Rotation occurs around a vertical axis passed from 
the center of the head to the inner condyle of the humerus 
and allowing, in forward rotation, the head of the bone to 
roll backward in the socket as the great tuberosity and shaft 
are turned forward, and in backward rotation the head of 
the bone to slide forward as the tuberosity and shaft are 
turned backward and outward. 
The shoulder joint is controlled largely by the following 
muscles: 
The pectoralis major adducts the bone, drawing it for- 
ward, inward and downward; the deltoid muscle abducts it; 
the latissimus dorsi is an abductor and also produces inter- 
nal rotation. The supraspinatus is an aid to the deltoid in 
producing abduction movement. The infraspinatus rotates 
the head of the humerus outward. The subscapularis rotates 
it inward. The coracobrachialis draws the bone forward. 
The pectoralis minor slightly flexes and adducts it. The 
serratus magnus and trapezius raise the shoulder girdle and 
the former steadies the scapula in order that the deltoid mus- 
cle may raise the humerus. The teres minor aids the infra- 
spinatus which is the chief external rotator of the arm. The 
teres major assists the latissimus dorsi as an adductor and in 
some positions acts as an internal rotator of the humerus. 
Dislocation of the shoulder-girdle is quite frequent due 
to its exposed situation, free mobility and anatomical con- 368 
Downing Principles and Practice of Osteopathy 
struction. It is encountered in the muscular adult, usually 
between the ages of 20 and 40. It is rarely found in the very 
old or very young. 
For general purposes of convenience, luxations of the 
articulation are divided into two gross types. The first type 
is the anterior dislocation in which the head of the humerus 
is either on or anterior to the long head of the triceps muscle 
at the lower edge of the glenoid fossa. This type of luxation 
is the most common. The second type is the posterior dis- 
location in which the head is posteriorly displaced. 
•UBSCAPU LARIS 
INFRA 
|SPI NATUS 
(,mi/rrjy>mMJ(y 
TERES 
hA » N0R 
Bicipital 
Groovv 
LATISSIMUS 
DO RSI 
TERES IflAJOa 
D E l ,T O l n 
me*m 
•cVpiaco e 
_ 0 R A c M I A L I AN T I CUT 
S “ p I NAT OR 
'JfutrutiYfj foram&l 
Pi 
y"Ao,i tcrcs 
OlGrra-non 
Depression^ 
Common \oryin of 
FLEX CARPI RADIAL IS PA L MARIS lONOUS 
FLEX DIO SUBLIMIS fLCX CARPI ULRARIS 
Right humerus, anterior and posterior surface. Luxations, Partial and Complete 
369 
Four chief varieties of shoulder-joint dislocation exist, 
two of which are forward and two backward. There are also 
two rarer luxations which are respectively known as the 
supra-coracoid and the luxatio erecta. 
As the head of the bone passes through the anterior por- 
tion of the capsule it slips beneath the coracoid process. If 
it moves inward from this point it is called subclavicular, and 
if downward and outward, subglenoid. Anterior subluxa- 
tions are produced in hyper-abduction and external rotation 
with the acromion process acting as a fulcrum to lift the head 
of the bone from its socket. The lower and anterior portion 
of the capsule is torn from the rim of the glenoid cavity. The 
subcoracoid dislocation is characterized by very slight length- 
ening of the limb with the elbow carried backward and slight- 
ly away from the side so that the head of the bone is not 
readily palpable in the upper and inner part of the axilla, 
which differs from the subglenoid type in which variety there 
is considerable lengthening with the elbow carried away from 
the trunk and slightly backward so that the head of the bone 
is easily palpable in the axilla. 
Probable dislocation is indicated by pain of a sickening 
character with marked rigidity for some particular combina- 
tion of movements and great pain on attempted motion. The 
shoulder is abnormally flattened and the head of the bone no 
longer bulges out the deltoid muscle. In fact, there is appar- 
ent projection of the acromion and a sinking in of the deltoid 
because of the empty socket. Anterior dislocations can be 
best reduced by Kocher’s method. This is a leverage method 
and consists of three steps: 1. The abducted elbow is slowly 
adducted against the side of the torso, with the forearm kept 
flexed at a right angle to the arm; (2) With the elbow 
touching the side of the body, and drawn slightly backward, 
the humerus is externally rotated through an arc of 90 de- 
grees until the forearm points outward from the body, by 
which maneuver the head of the bone is carried close to the 370 
Downing Principles and Practice of Osteopathy 
margin of the glenoid cavity. Gentle and gradual external 
rotation should be persisted in until all muscular resistance 
is overcome. The next step is to lift the elbow anteriorly as 
far forward as it will go so as to form a right angle with the 
long axis of the body. This brings the head of the humerus 
up from its low position to the level of the glenoid margin, 
just opposite the capsular tear, and at the same time relaxes 
the coracobrachialis muscle, thereby releasing the lesser 
tuberosity. (3) The third step to complete the reduction is to 
gradually sweep the forearm inward toward the opposite side 
of the chest with internal rotation, at the summit of which 
the hand is placed on the opposite shoulder and the arm 
brought down to the chest. This throws the bone into place. 
This method will fail if the posterior portion of the capsule 
Superior 
W'i 
PCCTORAUS' 
_ MINOR 
„ BICEPS AND 
CORACO BRACHiA liS 
•TRICE PS 
Groove for 
Dorsal Scapular'. Art. 
INFRA 
6PIRATUS 
TER £S 
MINOR 
Lateral aspect of the scapula viewed from the side. Luxations, Partial and Complete 
371 
is ruptured, for lack of a fulcrum. In the latter case reduc- 
tion can be effected only by direct measures utilizing trac- 
tion with the arm abducted and rotated and then pulling or 
pushing the bone into the socket. 
Posterior dislocations carry the head of the humerus be- 
neath some portion of the spine of the scapula and they are 
therefore called sub-spinous. If it lies under the posterior 
portion of the acromion process it is called sub-acromial. 
These dislocations are rare, and usually occur when the arm 
is abducted with strong internal rotation. They may result 
from direct violence against the anterior portion of the shoul- 
der. The posterior part of the capsule is torn and the arm is 
inverted so that rotation and abduction are impaired. Length- 
ening is intermediate, the elbow is raised from the side and 
carried forward, and the head of the bone is palpable beneath 
the spine of the scapula. The infraspinatus, teres minor and 
the subscapularis muscles may be ruptured. Reduction is 
best effected by direct measures, particularly using direct 
pressure from behind, forward upon the head of the humerus, 
with counter pressure upon the front of the acromion and an 
associated traction of the arm. 
A rare form of dislocation is the subclavicular in which 
the head of the humerus passes anteriorly and inward to 
rest between the coracoid process and the clavicle. In this 
particular case the elbow is carried outward and backward, 
the arm is shortened and the head of the bone can readily 
be palpated beneath the clavicle. 
The supra-coraccid luxation is infrequently found and 
is associated with fracture of the acromion or coracoid proc- 
ess. 
Luxatio erecta is characterized by marked abduction, 
with the forearm usually at rest behind the occiput or upon 
the head to avoid pain. It is an exaggerated form of sub- 372 
Downing Principles and Practice of Osteopathy 
glenoid luxation in which the head of the humerus has passed 
under the subscapularis muscle. 
The shoulder joint, like other joints, is 
subject to inflammation as the result of 
strains, trauma, rheumatic or infectious processes, and occa- 
sionally tuberculosis. The deltoid and subacromial bursae 
are intimately associated and adjoin each other so that when 
the arm is abducted the entire bursa is subacromial and when 
adducted is largely subdeltoid. Inflammatory effusion dis- 
tends the capsule and finally tends to escape at the weakest 
point. Codman describes three types of bursitis. The first 
is an acute or spasmodic type with local tenderness on the 
point of the shoulder, immediately below the acromion proc- 
ess and outside the bicipital groove. This authority further 
states that about ten degrees of abduction is possible with- 
out moving the scapula, after which the scapula is spasmod- 
ically locked and moves with the humerus. Pain is referred 
along the outer side of the arm and around the insertion of 
the deltoid. The patient may be unable to abduct the arm 
voluntarily because of the severe pain. 
The second type is a subacute or adherent variety in 
which there are adhesions which cause a definite mechanical 
block to abduction and external rotation. Abduction is mark- 
edly limited and movement beyond ten degrees causes the 
scapula to move. The pain is localized at about the same 
points as in the former type with the exception that the ten- 
der spot at the base of the bursa does not disappear under 
the acromion when the arm is abducted as it does in type 1. 
This is Dawbarn’s sign. 
The third type is chronic and non-adherent, with thick- 
ening and roughening of the bursae. If local tenderness is 
present Dawbarn’s sign can be elicited. There is slight limi- 
tation to abduction and external rotation, although there is 
usually a point at which this produces severe tenderness 
with some persistence of the pain after motion. The sub- 
Bursitis: Luxations, Partial and Complete 
373 
scapular and infraspinatus bursae usually communicate with 
the joint cavity and may be involved in joint inflammation. 
Acute cases of subacromial bursitis can best be treated 
by keeping the arm abducted in a splint, thus allowing for 
relaxation of the deltoid and the rotators, and keeping the 
base of the bursae from coming in contact with the acromion. 
In the chronic type adhesions, if present, should be brok- 
en up, passive and active movements employed with baking 
and other adjunctive measures. 
A very good way to break up the adhesions of a sub- 
acromial bursitis or of the shoulder joint in general is as 
follows: 
Flex the forearm to a right angle with the upper arm, 
grasp the wrist of the patient firmly with one hand and cup 
the point of the patient’s elbow in the palm of the other hand. 
Elevate the shoulder-girdle by bringing upward pressure 
against the point of the elbow. Bring the point of the elbow 
to the midline and forcibly supinate the forearm. Follow 
this with forcible pronation. Then abduct the upper arm, 
maintaining the shoulder elevation and the position of the 
hands. Forcibly pronate and supinate at this point, gradually 
forcing the abduction toward a right angle with the torso. 
The long axis of the humerus should be shifted to different 
points in relation to the glenoid cavity, following which the 
acts of supination and pronation of the forearm with the 
elbow fixed serve as leverage forces to cause the humerus to 
rotate on its long axis in both directions, the twisting or 
torsion effect of which is sufficient to break up any adhesions 
present. The object in view should be gradually to approach 
a degree of abduction in which the upper arm is parallel to 
and on a level with the shoulder and at this point to break 
up completely such adhesions as are present by forcible supin- 
ation and pronation of the forearm. 374 
Downing Principles and Practice of Osteopathy 
The long tendon of the biceps muscle is 
lodged in the bicipital groove between the 
two tuberosities of the humerus. With 
the arm hanging by the side, it passes directly forward. It 
runs over the head of the humerus and under the coraco- 
acromial ligament and at the upper part of the glenoid fossa 
is prolonged into the glenoid ligament which bifurcates and 
sends fibers right and left into the glenoid labrum. It is 
covered by a synovial sheath which passes with it through 
the opening in the capsule and a short distance along the 
bicipital groove. It is held in the groove by the transverse 
humeral ligament which is a fibrous expansion from the 
pectoralis major tendon. The tendon of the long head of the 
biceps habitually escapes rupture but when this occurs it re- 
tracts and becomes united with the bone. 
Derangement of 
the Biceps 
Tendon: 
Glenoid 
Liya merit 
Capsule 
Synovia/ $ax' 
contiruuTus with Join/. 
•/ot /// 
Ctenoid /.it/ 
Capsule 
Tendon a/’BlCEPS 
I/umorus 
Left shoulder joint, frontal section, from in front. Luxations, Partial and Complete 
375 
It is frequently subject to minor derangement, the exact 
characteristics of which are obscure. This is probably in the 
nature of a slight catch of the tendon due to a minor slip 
sideways from the center of the groove due to violent mus- 
cular action. Such combinations of movements as those as- 
sociated with throwing a baseball, or playing tennis, in 
which there is inward rotation of the humerus on its long 
axis, circumduction of the upper arm will allow sufficient 
play to permit a lateral deflection of the ligament. Forcible 
external rotation, with the upper arm elevated and drawn 
back, will produce lateral strain in the opposite direction. 
Any overhanded swing in which the upper arm is in an ele- 
vated position and the circumduction and rotation on its long 
axis violent, may under certain conditions produce this minor 
lesion; for although there is relaxation of the ligament be- 
cause of the elevated position of the upper arm there is also 
a lateral strain which the relaxed ligament cannot resist. The 
traumatic influence of this condition may result in an asso- 
ciated synovitis. Joint inflammations of a rheumatic type 
may, through extension, involve the sheath and synovial 
membrane covering the tendon. 
ytcnomio clavtcu^ftrJLig 
CotxjjCO clra ’icuZarJTihA 
Corucou//>m*f 
TcncLon ot'-Lonqfiecrd’ofSiceM>\ 
fcs'/M'M 
ILJH J j 
Left clavicle and scapula, seen from without. 376 
Downing Principles and Practice of Osteopathy 
Localized pain and tenderness over the tendon at the 
point where it passes under the transverse humeral ligament 
are characteristic. Pronation and supination aggravate this 
pain, particularly if a certain amount of circumduction of the 
shoulder is combined with these moves. Limitation of mo- 
tion, because of the pain induced, is present, although the arm 
can be passively moved to almost any point. The tendon is 
apparently fixed so that there is palpably decreased freedom 
and play of motion in the groove. 
Reduction is easy. With the patient supine, place the 
knee under the humerus close to the shoulder joint to act as 
a fulcrum. Fix the tendon between the finger and thumb. 
Abduct the upper arm to a right angle with the torso and 
the forearm to a right angle with the upper arm. Interlock 
the fingers with those of the patient and with this guiding 
influence strongly supinate the forearm. This will cause the 
humerus to rotate so that the groove will move forward, in- 
ward and slightly down. At the same time gradually extend 
the forearm. Before the completion of the extension, com- 
pletely and strongly reverse the arc of motion by bringing 
the forearm quickly into strong pronation. This causes the 
groove to move backward, outward and slightly upward. 
During the entire procedure the operator should hold the 
tendon so as forcibly to maintain it in as stationary a posi- 
tion as possible. The catch is thereby dislodged and the ten- 
don forced deeply into the groove. 
The elbow joint is a diathrodial joint of 
the ginglymus type and depends upon the 
structural conformation of its bones ra- 
ther than upon its ligaments for secur- 
ity and strength. The bones comprising it are the lower end 
of the humerus above and the upper ends of the radius and 
ulna below. The articular surface of the humerus is received 
partly by the great sigmoid cavity of the ulna and partly upon 
the cup-shaped superior surface of the head of the radius. 
Luxations of 
the Elbow 
Joint: Luxations, Partial and Complete 
377 
; l 
*1 
c 
2 
* 
Position for reduction of fixation of the tendon of the long head of the biceps. 
A indicates position of forearm. B indicates direction in which forearm is carried 
forward into position to obtain forward rotation of the humerus on its long axis. 
From C forearm is carried to D into supination and full extension. This latter 
move causes rotation of the humerus backward on its long axis. During the entire 
procedure the tendon is held firmly between the thumb and forefinger. 378 
Downing Principles and Practice of Osteopathy 
The articulating portions of the humerus are known respec- 
tively as the trochlea and the capitellum. On each side of the 
lower end of the humerus is a prominence known as an epi- 
condyle. The inner one is called the epitrochlea and is more 
prominent than the outer. Above the level of the epitrochlea 
on the posterior aspect of the humerus is a deep depression, 
the olecranon fossa, into which the tip of the olecranon pro- 
cess of the ulna is received when the joint is extended. Above 
it anteriorly is a small depression for reception of the cora- 
noid process of the ulna when the joint is flexed. The con- 
cave cylindrical head of the radius not only articulates with 
Munu'riut'A 
'iv\ i v j injji 
Wiripi'ml. I 
MMI 
Interosseous 
I.iqumeUt 
Anterior view of the right elbow joint showing anterior and internal ligaments. Luxations, Partial and Complete 
379 
the capitellum but also articulates with the sigmoid cavity on 
the outer side of the ulna. The outer border of the head of 
the radius can be palpated about three-quarters of an inch 
below the upper condyle and can be felt to move when the 
forearm is gently rotated. 
The ligaments form a large capsule which blends with 
the orbicular ligament and embraces the elbow and superior 
radio-ulna joint. The orbicular or annular ligament is placed 
like a loop about the head and neck of the radius, binding it 
to the lesser sigmoid cavity of the ulna. The ligaments are 
known as the anterior, posterior, internal and external. Ad- 
ditional fibers arising from the external condyle of the hu- 
merus strengthen the joint laterally. 
The movements of the elbow are those of a true hinge 
joint and consist of flexion and extension. These movements 
take place on an oblique axis. In flexion the forearm inclines 
inward and in extension outward. The radius rotates upon 
the humerus when following the ulna in all its movements. 
In extension and supination the head of the radius rotates 
backward markedly and is only partially in articular contact 
with the capitellum. In the position of midflexion the radius 
is sufficiently stabilized by the humerus to permit pronation 
and supination to take place without difficulty and at their 
maximum mechanical advantage. 
Dislocation of the elbow joint is fairly common, particu- 
larly in children. One or both bones may be dislocated and 
the dislocation may be complete or incomplete. The displace- 
ment is more commonly backward. The causes of backward 
dislocation are falls on the outstretched hand or an inward 
twist of the ulna. The forearm is flexed, supinated and 
shortened with marked projection of the olecranon and head 
of the radius. The changed relations of the olecranon, the 
head of the radius and the two condyles are diagnostic. 
To reduce the dislocation relax the triceps by extending 
the forearm, press upon the radius and ulna to direct their 380 
Downing Principles and Practice of Osteopathy 
return, apply counter pressure in front of the elbow joint 
and complete the adjustment with extension of the forearm 
and counter extension of the arm. The muscle leverage pro- 
duced by extension of the forearm superimposed to the other 
mechanical forces pulls the bones into place. 
In dislocation of both bones forward, the cause is usually 
a blow on the olecranon when the arm is flexed. The fore- 
arm is flexed and lengthened with the olecranon on a level 
with the condyles. Reduction consists of forced flexion, ex- 
tension, and direct pressure. 
Inward dislocation of the elbow is ordinarily incomplete, 
the head of the radius usually leaving the capitellum but the 
olecranon sliding only to the inner margin of the trochlea. 
Reduction consists of extension, counter extension with the 
arm slightly flexed, and at the same time of applying direct 
pressure on the humerus inward and counter pressure on 
the ulna outward. 
In outward dislocation the forearm is flexed, fixed and 
pronated; and the head of the radius projects externally, 
and the inner condyle internally. 
In inward dislocations the forearm is flexed, pronated 
and fixed and the ulna projects internally. 
After-support should consist of placing the arm in the 
Jones position with immobilization for at least two weeks, 
using passive movement to prevent permanent fixation. 
Dislocation of the ulna singly occurs infrequently and in 
a backward direction. The forearm is fixed in flexion and 
pronation with the head of the radius in its normal position 
and the olecranon projecting backward. 
Dislocation of the radius forward is the most frequent 
form of dislocation at the elbow. The forearm is fixed in 
semi-flexion and in very slight pronation. The head of the 
radius is palpable in front of the outer condyle. If the orbic- 
ular ligament is ruptured the condition is apt to recur. This Luxations, Partial and Complete 
381 
type of luxation is the result of direct trauma or falls upon 
the hand with the forearm in pronation. Reduction consists 
of flexion, counter extension and direct manipulation. The 
after treatment should consist of the Jones position and pas- 
sive movement. 
Backward dislocation of the radius is less common and 
is characterized by slight flexion of the forearm, fixation and 
pronation. The head of the radius is palpable behind the 
outer condyle. Reduction is effected by flexion, extension, 
counter extension and manipulation. 
OLccr<mo 11 
ijjlrftri/jri 
•w»l 
ulna' 
with humerus 
LeSSor 
SttymOuf, 
Ccn t/y fi 
FLEXOR SUBLlUiS 
DIGITORUM 
SUPINATOR 
Brevis 
lorrrts/o/t/tt orn/trt 
FLEXOR SUBL 
I OIOITORUM 
SUPI NATO B 
LON CU S 
Styloid proc 
Bones of the risjht forearm, anterior view. 382 
Doivning Principles and Practice of Osteopathy 
Dislocation of the radius outward is very rare. Reduc- 
tion is effected by extension, counter extension, pressure and 
manipulation with after treatment, immobilization in the 
Jones position and passive movement. 
This injury occurs frequently in children 
between two and four years of age. It is 
the result of traction of the hand or fore- 
arm with an incidental twist of the elbow 
in the direction of supination or pronation. Falls may pro- 
duce it. In the adult a slight forward subluxation of the 
radial head may occur as the result of an act of violent 
supination. When found in the adult the radial head is im- 
mobilized in forward rotation. This may be encountered in 
tennis-players, golfers, and baseball players. In children the 
condition is more severe. Complete flexion and extension 
are very painful, although easy movement is free from pain. 
Pain is localized around the elbow joint and pressure over the 
head of the radius aggravates it. Any considerable degree 
of pronation or supination is painful. An audible click may 
be sensed above the elbow or at the wrist in the child. In the 
adult there is apparent fixation of the head of the radius 
which fails to rotate under the orbicular ligament. The tuber- 
osity of the radius may be slightly locked behind the inner 
edge of the ulna and there may also be a complicating sub- 
luxation of the triangular cartilage of the wrist. Reduction 
in the child is best accomplished by flexing the forearm to a 
right angle with the arm, and forcibly supinating it. An 
anterior angular splint should be worn for four or five days. 
The reduction of the subluxation in the adult is in the 
following manner: 
First obtain a fulcrum or fixed point behind the head 
of the radius so that this point of contact can act both as a 
fulcrum and a pry to force the ulna and radius apart and 
break fixation. Superimposed to this the leverage force of 
Subluxation of 
the Head of 
the Radius: Luxations, Partial and Complete 
383 
the forearm is employed by using it either as a direct lever 
handle or with forcible pronation as a means of obtaining 
indirect muscular leverage. In either case the fulcrum should 
be at the same point and the operator’s fingers should be 
placed below the head of the radius on its inner border to 
'Head o 
Htuiiui 
Wi 
mm 
Right elbow joint, posterior view, showing posterior and external ligaments. 
effect a pry action on the articulation. If muscular leverage 
is to be utilized the operator should interlock his fingers with 
those of the patient and forcibly pronate, at the same time 
bringing the forearm into extension and adding a little trac- 
tion in the long axis of the bones. If the lower arm is to be 
used as a direct lever, lock the wrist slightly above the 
articulations with the hand between the torso and the upper 
arm or between the two knees. Bring the forearm into ex- 
tension and superimpose traction in the long axis of the bones, 384 
Downing Principles and Practice of Osteopathy 
at the summit of which bring corrective force against the 
radius with the fingers, and superimpose leverage force with 
the lever handle. 
The ulna may be dislocated backward by 
forcible pronation. The wrist is fixed in 
pronation, supination is impossible and 
the hand powerless. The head of the bone 
projects posteriorly on the radius. Reduce 
with forcible supination of the hand and pressure against the 
ulna. 
Dislocation forward is caused by forcible supination. The 
ulna projects anteriorly and pronation is impossible. Reduce 
by extension, forcible pronation and direct pressure. 
Dislocation of the 
Inferior Radio- 
Ulnar 
Articulation: 
Eternal 
ZateralZiq 
Internal. 
lateral Luj 
/sf 
- 
!r • /U 
ira 
w 
Ligaments of the wrist and hand, posterior view. 
Dislocation of the wrist is infrequent, and 
is caused usually by a fall upon the hand. 
If the dislocation is backward, it resem- 
bles Colles’ fracture. The carpus projects on the dorsal sur- 
Dislocation of 
the Wrist: Luxations, Partial and Complete 
385 
face of the forearm, fingers are flexed and the wrist bent 
backward. The relation of the styloid process of the radius 
to the styloid process of the ulna is unchanged, if the con- 
dition is a dislocation and not a fracture. 
If the dislocation is forward the carpus projects an- 
teriorly. Reduce by extension, counter extension and direct 
manipulation. Splint for two weeks, and employ meanwhile 
passive motion. Dislocation of the inferior radio-ulnar artic- 
ulation is very unusual and is practically always accompanied 
by fracture. The forearm is usually pronated; if forward, 
dislocation and supinated; if backward, dislocation. In both 
cases, the space between the stvloid processes is decreased. 
Carpal bones of the left hand, palmar surface. 
Dislocation of 
the Carpal 
Bones: 
Dislocation of the individual bones of the 
carpus is not frequent. The most com- 
mon type is the semilunar, and the sca- 
phoid, pisiform, trapezoid, trapezium, 
and unciform follow in the order named. The os magnum 
may be dislocated backward; the semilunar may be dislocated 
forward. Reduction can be effected by hyperextension, 
hyperflexion, over a fulcrum maintained with the thumbs 
against the bone in lesion. 
Dislocation of the metacarpal bones is usually confined 
to a backward dislocation of the first metacarpal. 386 
Downing Principles and Practice of Osteopathy 
Dislocation of a metacarpo-phalangeal articulation is 
uncommon and is usually backward. 
JfoLcbiu, 
I PLufornt 
Bone 
\pnctform Bone 
<4* 
If a mu la r 
.Process 
;'A' 
StmVnm 
Ligaments of the right wrist and hand, anterior view. 
Dislocation of a phalanx, complete or incomplete, is more 
common and is usually between the first and second 
phalanges. Reduction of these conditions is best effected by 
extension, counter extension and immobilization in a splint 
for a period of seven days. 
The hip joint is composed of the globular 
head of the femur and the cotyloid cavity 
or acetabulum of the os innominatum. It 
is a diarthrodial joint of the ball and socket order. Both artic- 
ular surfaces are covered with cartilage, the depression for 
the ligamentum teres being the only exception. The depth 
of the cavity is considerably increased by its fibro-carti- 
laginous rim. The ligaments of the joint are the capsular, 
transverse, ligamentum teres, and the cotyloid cartilage. 
Luxations of 
the Hip: Luxations, Partial and Complete 
387 
The capsular ligament is extremely strong, large, and 
somewhat loose. Accessory to the capsule are three auxiliary 
bands, the ilio-femoral ligament, attaching from below and 
behind the anterior superior spine to the anterior edge of the 
greater trochanter; the ischio-femoral ligament, attaching 
from a groove on the ischium to the outer posterior portion 
of the capsule; and the pectineo-femoral band which attaches 
to the pectineal eminence and pubic end of the cotyloid notch 
Titbo-t'cle. 
GLUTEUS 
MINIMUS 
VASTUS „ 
EXTfRNU6 
mm 
* u 5 
i Ontep 
V*6rrosi(y 
' Outer• 
Candy It- 
Jrt/tf*,, 
'uAerosity 
fbnOy%e- 
Left femur, anterior surface. 388 
Downing Principles and Practice of Osteopathy 
and to the neck of the femur via the ilio-femoral ligament with 
which it blends. 
Other strengthening bands are the ilio-trochanteric and 
tendino-trochanteric. 
The ligamentum teres is a short interarticular band at- 
taching from the acetabular notch to the head of the femur. 
The transverse ligament passes across the cotyloid notch, 
thereby completing the rim of the acetabulum and supporting 
the cotyloid fibro-cartilage. The cotyloid fibro-cartilage 
deepens the acetabulum and is thickest at the iliac and ischial 
margins. 
Movements of the hip joint are flexion, extension, abduc- 
tion, adduction, circumduction and rotation. Flexion is limit- 
ed by the hamstrings; extension by the ilio-femoral ligament; 
abduction by the pectineo-femoral ligament; external rota- 
tion by the ilio-femoral ligament and ligamentum teres; ad- 
duction by contact with the opposite limb, ischio-capsular and 
capsular ligaments; and inward rotation by the ilio-femoral, 
ischio-femoral ligaments and ligamentum teres. 
Dislocations of the hip are either anterior or posterior 
in their relation to Nelaton’s line, which is a line drawn from 
the anterior superior spine to the most prominent part of 
the tuberosity of the ischium. In the normal limb the top of 
the great trochanter touches this line. Bryant uses the fol- 
lowing method in deciding the position of the great trochan- 
ter. 
The patient being flat on his back, a line is dropped ver- 
tically from the anterior superior spine. From the top of the 
great trochanter a straight line is drawn in the long axis of 
the thigh to meet the first. To complete the triangle a line 
is drawn from the anterior superior spine to the top of the 
trochanter. The second line is subject to the greater varia- 
tions. This line practically coincides with Nelaton’s. 
When the head of the femur leaves its socket it passes Luxations, Partial and Complete 
389 
down anteriorly or posteriorly to Nelaton’s line and is there- 
fore an anterior or posterior luxation. Posterior and anterior 
luxations may be either high or low. 
A primary anterior luxation is low thyroid if the femoral 
head lies beneath the level of the fossa of the acetabulum. 
External rotation at this time allows it to rotate upward and 
forward and it thus becomes high anterior or pubic. 
A primary posterior luxation allows the head of the 
femur to rest on or near the spine of the ischium or in the 
sciatic notch and is a low reversed thyroid. If followed by 
internal rotation it becomes a posterior high luxation with 
the head of the femur resting on the dorsal aspect of the 
ilium. 
Congenital luxations are usually posterior and one-half 
of all dislocations are high posterior. Because of the position 
of the neck of the femur, at an approximate angle of 128 de- 
grees with the shaft of the bone, inward rotation of the 
shaft causes the head to rotate backward and outward, and 
outward rotation of the shaft causes the head to rotate for- 
ward and inward. Abduction produces a thyroid or obturator 
luxation as the head is raised out of its socket by the long 
lever action of the shaft of the femur and the fulcrum effect 
of the neck in contact with the upper rim of the acetabulum 
and thereby allows the short arm of the lever with the head 
at its distal extremity to be leveraged out of the socket and 
down. If, from the position of hyper-abduction, outward 
rotation of the shaft follows, the head passes forward into* 
a pubic position; while if, from this position, slight flexion 
and inward rotation follows, the head rotates into a posterior 
position. If the luxation occurs in adduction and flexion of 
the thigh with subsequent strong inward rotation, the ilio- 
femoral ligament locks around the neck of the bone and acts 
as a fulcrum so that as the shaft revolves on its long axis in- 
ward, the head rotates outward and downward and a dorsal 
luxation follows. 390 
Downing Principles and Practice of Osteopathy 
7*tt4S't*'oc7ian t&'i * -Line 
QUADRATUS FEMORlS 
leaser T^oeh. (trite* 
IPSOAS MAGNUS 
/ LI ACUS EXTER NUS 
PECTI N EUS 
GLUTEueV 
MAX I M U 9 \ 
ADDUCTOR BREVI9 
\A0DUCT0P L0N6US 
Short head 
BICEPS' 
PLANTAR IS 
Out 0 t* h* act o/’J 
GASTROCNEMIUS! 
/n.n.nr //«a<Z of 
GASTROC. 
NEM IU5 
POPLITEOS 
Wut*fr\ 
\ C<m4fa 
iOiner- = 
Left femur, posterior surface. 
The rent in the capsule is only sufficiently large to allow 
the head to escape and return. When the luxation is posterior 
there is inversion of the foot, adduction of the thigh, together 
with slight flexion and shortening. When luxated anteriorly 
there is eversion of the foot, marked, if pubic, and only slight 
if low thyroid or obturator, in contra-distinction to abduc- 
tion of the thigh, which is marked in the thyroid and less in Luxations, Partial and Complete 
391 
the pubic. There is no shortening and there may be a very 
slight lengthening. The thigh is flexed in the thyroid luxa- 
tion but not in the pubic. 
Reduction can be effected directly or indirectly by lever- 
age or by the utilization of both types. The ilio-femoral liga- 
ment is a powerful fulcrum for indirect methods. 
A direct method for posterior luxations is to place the 
patient on his back on a low hard surface. Flex the knee on 
the thigh and the thigh on the abdomen, in both cases to a 
right angle. Adduct the thigh slightly to relax the ilio- 
femoral ligament. With the ankle held, lift upward and in- 
ward in the apex of the flexed knee to raise the head to the 
level of the acetabulum. Rotate the thigh gently inward. 
An indirect method is to place the patient on his back, 
flex the leg on the thigh and the thigh on the abdomen, ad- 
duct across the midline and from this point exaggerate the 
flexion of the leg on the thigh. Gradually bring the flexed 
knee across the midline to a position of abduction. Return 
to a point wherein the flexion of the knee is at right angles 
with the thigh, and the thigh at right angles with the abdo- 
men, maintaining, meanwhile, the abduction. At this point 
perform external circumduction, lift under the head of the 
bone directly or establish a fulcrum against the greater 
trochanter to carry it to the level of the socket; and with com- 
pletion of the external circumduction and rotation bring the 
femur into extension. 
In anterior luxations, first slightly abduct the thigh and 
rotate the femur on its long axis inward. From this point 
flex the knee and thigh a bit beyond the right angle with the 
leg and thigh respectively. Lift up and out under the apex 
of the flexed knee, keeping the foot slightly inverted so that 
the shaft is in a slight degree of internal rotation. From this 
point make slight external circumduction of the knee using 
external rotation. The pelvis must be fixed in this procedure. 
At the completion of external circumduction bring the limb 
into extension straight down and in the long axis of the body. 392 
Downing Principles and Practice of Osteopathy 
Allis advises against too great a circular sweep of the 
knee because of the danger of catching up the sciatic nerve. 
If such occurs he advises redislocation of the femur and dis- 
engaging of the nerve by extension of the thigh, flexion of 
the leg on the thigh, and internal rotation of the femur by 
turning the ankle out. Shaking or jarring the nerve may 
remove entanglement. Abduction or adduction, or rotation 
of the femur in the socket without flexing the leg may free 
the nerve. If the above methods fail he advises operation to 
release the catch. 
The knee joint is grossly composed of two 
joints: that formed by the patella and 
femur, and that by the femur and tibia. 
The latter is subdivided into two articulating portions, each 
formed by one of the condyles of the femur and the opposing 
portion of the upper surface of the tibia. 
The ligaments which hold the femur to the tibia and 
fibula are the external and internal lateral, the posterior and 
the crucial. The internal lateral ligament attaches from the 
internal tuberosity of the femur to the inner side of the shaft 
of the tibia. The external lateral attaches from the external 
tuberosity of the femur to the head of the fibula. The short 
external lateral ligament extends from the side of the condyle 
to the styloid process of fibula. The posterior ligament ex- 
tends from the upper part of the intercondylar fossa of the 
femur to the posterior margin of the head of the tibia. The 
crucial ligaments attach from either side of the intercondylar 
notch, which is the line of separation of the condyles of the 
femur, to the depression in front of and behind the spine of 
the tibia which interrupts the depression between the con- 
dylar surfaces of the tibia at their center. 
The semilunar fibro-cartilages are intra-articular and 
attached to the head of the tibia at their outer margins and 
ends. They have free, smooth surfaces above and below. 
They are triangular in shape, their peripheral borders being 
Luxation of 
the Knee: Luxations, Partial and Complete 
393 
ifiv/’ 
Inner head 
GASTROCNEMIUS 
[nfftiion ot 
AOOUCTOR MAGNUS 
Outer head 
'gastrocnemiis 
popliteus 
/Tendon 
\LorwExternal 
\lateriilLu) 
\ Short Extern 
\lat.Lig. 
%1ukrfond(/lc 
Wof Tibia 
ZPbSt 
Tvbio-Tibidar 
Ligament 
Yibi 41 
I 
< : 
N 
The right knee joint, posterior view. 
thick and their central portions thin. They are hemispherical 
rings which leave the corresponding condylar surfaces of the 
tibia uncovered at the center. The internal one is semicir- 
cular, the external one is more nearly a complete circle. The 
external cartilage is slightly movable, this allowing greater 
outward rotation of the leg at the end of extension. The 
internal cartilage is fixed, serving to maintain a deeper de- 
pression for reception of the internal condyle. 
The synovial membrane frequently communicates with 394 
Doivning Principles and Practice of Osteopathy 
Spute 
IMij 
v\\v_ 4V 
A MI I C M rfr, 
BRtV>8 
ivt n er~ I 
malleolus \ 
hr attneh 
fcfAmL tifm/j 
ftitular tifoment- 
Anterior surface of right tibia and fibula. 
the bursa under the triceps tendon and is reflected to invest 
the crucial ligaments. It rests upon a mass of fat between 
the tibia and patella, forms two lateral folds, the alar liga- 
ments, and reflects backward from its middle another fold 
which attaches to the front of the intercondylar notch, divid- 
ing the joint into three freely communicating chambers. 
The femoro-tibial joint, by a combination of arthrodial 
and rotary movements, is functionally a ginglymo-arthrodial 
joint. The patella rests upon the upper part of the trochlear 
surface of the femur in extension, and moves downward and Luxations, Partial and Complete 
395 
slightly outward in flexion, so that it rests by its upper, outer 
facet on the front of the external condyle, and by its inner 
facet against the outer margin of the internal condyle. In 
extension the tibia undergoes slight outward rotation and 
flexion is accompanied by slight inward rotation of the tibia. 
Luxation of the knee or the femoro-tibial joint is rare. 
It may be complete or incomplete, simple or compound. 
Luxations may be divided into those types the classi- 
fications of which are dependent upon the direction in which 
the tibia is displaced. It may be displaced forward, back- 
ward, outward, inward, in outward rotation, and in inward 
rotation. Reduction is usually easy when attempted under 
traction with coaptative pressure upon the adjoining ends 
of the femur and tibia. If the dislocation is forward, use a 
very slight degree of extension—not forced extension be- 
cause of the possibility of injury to the popliteal vessels. 
If the dislocation is backward, adjust with slight flexion of 
the knee and hip; if the dislocation is lateral use a certain 
amount of lateral flexion. If the lesion is an outward rota- 
tion, reduce with internal rotation; if the lesion is an inward 
rotation, reduce with outward rotation. 
The limb should be immobilized for a period of six or 
eight weeks, at the least, in order that the torn ligaments 
may have a chance to reunite. A firm dressing should be 
maintained for at least six weeks. Massage and passive 
movement should be employed during this time to avoid the 
loss of normal mobility. Supportive measures must be 
utilized for at least a period of three months. 
Luxations of the patella are rare. It 
may be displaced to different points on 
the outer or inner side when the knee is 
in extension or partially flexed. This displacement may be 
accompanied with varying degrees of rotation through the 
longitudinal axis of the bone. 
Luxations of 
the Patella: 396 
Downing Principles and Practice of Osteopathy 
2,'jrfc/ts'o t 
Crurts 
' fyf Bursai, 
J*u/. PatelJxie 
Right patella, anterior surface. 
Left patella, posterior surface. 
Methods of adjustment which are productive of the best 
results are first to relax the quadriceps by flexion of the hip 
and full extension of the knee. Direct pressure can then be 
applied with the hands upon the patella. 
The fibula may be dislocated at either 
end as a result of external violence, mus- 
cular action, pathological influence or 
because of unequal growth or shape of the bones. Luxation 
of the upper end forward and outward, with rotation 
through the long axis of the bone is the most frequent. It 
occurs in children more frequently than in adults. It is us- 
ually caused by a fall with the leg bent under the body and 
the foot strongly inverted, and depressed. When purely mus- 
cular it is usually through forcible depression and inversion 
of the forefoot. 
Diagnosis of this condition is comparatively easy, as 
there is a depression where the head of the bone is normally 
situated, and palpation will reveal a freely movable upper 
extremity, ending in a projection, the head of the bone, which 
is anterior and forward to its normal location. The tendon 
of the biceps show plainly and its contour is abnormal. 
Walking is usually impossible because of the pain, although 
the patient can move the knee quite freely. 
Reduction is best effected by direct manipulation with 
knee partially flexed so as to relax the tendon of the biceps. 
Luxation of the 
Fibula: Luxations, Partial and Complete 
397 
Backward dislocation of the head is quite rare, and when 
found may be due to a forcible contraction of the biceps, or 
to some abnormal fall or twist in which the tension pull of 
the external lateral ligament of the knee may rupture the 
tibio-fibular attachments allowing the biceps to pull the bone 
backward. Reduction can best be affected in flexion of the 
knee followed by direct manipulative pressure upon the head 
of the fibula. 
«Spi ne 
Artr pitlct-tVQn 
urit7> mu let' 
SEMIMEMBRANOSUS 
TIBIALIS P O S T I C U S 
JtXT. lONO 010 
r i b i a l i s p o s r i c u ~s 
FLEXOR LO N S ii fi n i r " “* 
. IONS us dig.torum 
CXT. PROP POlu 
• PERONEOUS rCHTUli 
Jrits.u/ur /accL 
wifh 
for +rnns hty. 
for nruirffr /hstefc of 
r~ri lai. fig 
Postero-mesial aspect of left fibula and posterior view of left tibia. 
Luxations of the lower extremity are usually compli- 
cated with diastasis of the joint. They are comparatively 398 
Doivning Principles and Practice of Osteopathy 
rare and are usually associated with Pott’s fracture. Forc- 
ible inversion, or eversion may cause a dislocation of this 
nature. 
The type of dislocation and a study of the particular 
direction of traumatic force by which it was produced sug- 
gests the particular moves to be utilized in effecting reduc- 
tion. 
Subluxation of the fibula is considered in chapter on the 
feet. 
These conditions were once termed Hay’s 
derangement of the knee, as he was the 
first to call attention to them in 1803. 
They are usually traumatic in origin and more often en- 
countered in males. The tendency for displacement is for- 
ward upon the head of the tibia so that the thicker posterior 
margin lies between the condyle and the tibia at or slightly 
in front of the point where they tend to come in contact. 
External violence or a twisting of the lower limb when the 
knee is in flexion is the usual cause of this condition. 
The pathology of these luxations varies greatly. It may 
consist of only a slight slipping or subluxation of the carti- 
lage. The cartilage may be dislocated, lacerated or torn. It 
may be thickened and roughened, calcified, hypermobile or 
Derangement of 
the Semilunar 
Cartilages: 
Transverse L ig 
An/ crucial 
Lix). 
Post critfutlLuj 
Upper surface of the right tibia, showing attachment of crucial 
ligaments and semilunar cartilages. Luxations, Partial and Complete 
399 
atrophied. It may be fractured and absolutely torn from its 
basic attachment. It may occasionally be fringed and give 
rise to attachment of fatty tabs. Detached fragments float- 
ing in the joint cavities are known as traumatic loose bodies 
and produce more or less irritation and inflammation of a 
traumatic character. 
The symptoms and diagnostic features of this condition 
are: first the traumatic origin with a tendency to recurrent 
disability. The patient usually has a definite localized point 
of pain or tenderness over the palpable anterior border of 
the cartilage. Locking of the joint in flexion is present in 
less than fifty per cent of these cases, although the patient 
may feel that the knee is partially locked and complain of 
loss of power over the limb, which he can neither flex nor 
extend without effort. This sense of derangement and feel- 
ing of insecurity is characteristic. This condition is usually 
confined to the internal semilunar although a few rare cases 
have been reported of involvement of the external. The ratio 
is about seven to one. There may or may not be swelling 
in and around the cartilage. The cartilage is palpable when 
it is displaced forward and if not palpable, is not displaced 
in this direction. It must not be confused with swelling and 
tumefaction which usually follows. In some cases the car- 
tilage appears to be absent, in others there is no apparent 
change although there are probable evidences of its involve- 
ment. 
Reduction is not difficult providing the condition is not 
a complicated one. Surgery is demanded if there is consider- 
able structural damage, but is not at all necessary if the con- 
dition is amenable to manual methods—which is usually the 
case. 
Technique No. 1. With the patient sitting 
and the operator standing, facing the pa- 
tient, the latter locks the lower leg of the 
patient slightly above the ankle joint between his knees. 
There is a point at which adjustment should be made which 
Methods of 
Reduction: 400 
Downing Principles and Practice of Osteopathy 
mru/yle. : 
yZondylc, 
Left Knee Joint—Posterior Aspect. 
is in neither flexion nor extension—and is that point where 
the opposition of the flexors and extensors of the knee is so 
complete that there is no enforced tension limitation of either 
the hamstrings or quadriceps to a full range of lateral move- 
ment. At this point the lateral sweep is made toward the 
midline, holding the lower leg firmly between the knees as the 
lever to enforce gapping upon the joint, allowing plenty of 
room for the cartilage to return through the route by which 
it escaped from its normal position. At the same time this 
movement is carried out pressure should be directed against 
the projecting border of the cartilage, forcing it backward 
and inward toward the center of the joint. At the moment Luxations, Partial and Complete 
401 
this is accomplished the lateral swing of the knee is reversed, 
closing in on the cartilage, crowding it to its full limit in 
a corrective direction, and firmly locking it in that position. 
Technique No. 2. Patient supine. The operator stands on 
the same side as that of the limb involved. The knee is flexed. 
The operator grasps the foot and maintains it in an inverted 
position. Using the lower limb as a lever handle by which to 
enforce gapping upon the knee joint on its medial aspect, a 
fulcrum is established by bringing pressure of the torso 
against the lateral aspect of the knee. This gaps the joint on 
its inner side, and allows room for the cartilage to retrace 
its pathway. Force is then directed against the anterior 
outer border of the cartilage in a backward, inward direction 
toward the center of the joint. At the moment this pressure 
is at a point of culmination, an inward sweep of the foot is 
made, the lower limb is externally rotated so that the foot 
turns outward and at the same time the entire limb is carried 
toward the midline and the knee into extension. The ob- 
jective in mind is to gap the articulation, force the cartilage 
into its proper position, and lock it in that position by the 
combination of direct force and leverage force, using the 
lower limb as the lever handle. 
The after treatment may require stabilization by a pres- 
sure pad at the point where the cartilage tends to protrude, 
or occasionally a temporary brace that will limit the move- 
ments of the joint, as this will diminish the tendency to 
recurrence. Operative measures should be utilized when the 
condition is gross enough to warrant them and the path- 
ology such that manual adjustive measures will not suffice. 
The reported results from operation have been uniformly 
good, the removal of the meniscus appearing to create no 
permanent functional difficulty. 
The hyoid bone is held in suspension in 
the anterior cervical column between the 
mandible above and the larynx below. It 
is connected to the styloid processes of the temporal bones 
Derangement of 
the Hyoid: 402 
Doivning Principles and Practice of Osteopathy 
by the stylo-hyoid ligaments and is connected with the thy- 
roid cartilage of the larynx by the thyreo-hyoid ligaments 
and membrane. It is connected with the root of the tongue 
posteriorly through its intimate association with the epiglot- 
tis. It is “U” shaped and consists of a body, two greater 
cornua and two lesser cornua. It gives origin to several 
muscles, namely the genio-hyoid, omo-hyoid, sterno-hyoid, 
thyreo-hyoid, stylo-hyoid, and hyo-glossus muscles. 
Lesser cornu. 
jPo d y 
Imbalance of tensions of its connecting muscular and 
ligamentous tissues may cause the hyoid to assume a twisted, 
tilted or otherwise abnormal position. Irritation of the 
laryngeal nerves may follow with symptomatic disorder of 
the pharynx or larynx. 
Hyoid bone, seen from above. 
OENIO -HYOID 
OEN10 - HYO -OLOSSUS 
HYOO-LOSSUS 
Lesser cornu 
MIDDLE CONSTRICTOR 
Of | 
Great cornu 
STERNO-HYOID 
lOMO - HYOID 
THYRO- HYOID 
MY 10 HYOID 
STYLO HYOID 
Treatment consists in removing the muscular tensions 
producing the condition by stretching of the contractured 
tissues, using the hyoid as the leverage means. The hyoid 
will then assume its natural position providing the tissue im- 
balances are removed so that tensions are coordinate and 
equal. 
Hyoid bone, anterior view. Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: Notes: