In osteopathic diagnosis the spine is the first and greatest object
of interest, for on the result of its examination will depend the
treatment to be given which is in turn hoped to bring about recovery.
As it is the structure on which rests the weight of the body the
practiced eye is able to detect at a glance, by the poise and gait
of the patient, if there is an abnormal condition affecting any
considerable area of the spinal column. It is well to observe these
points, especially in the female, before having them prepare for
examination, as it will often give a clue to sources of trouble through
faulty carriage, improper dress, particularly corset and shoes. Slight
changes of gait, unnoticed by the patient may be of great aid in
determining the beginning of disease in the spinal cord.
No osteopath is justified in accepting a patient who will not permit
every examination deemed necessary, as remote and obscure lesions are
frequently the cause of disease, so preparation of the patient for the
first scrutiny is of importance. This cannot be made with the patient
fully clothed, as visual observation is second only to the touch in
making one’s deductions. Neither can palpation be made through more
than one thickness of clothing with accuracy, and examination next
to the skin is always preferable. This need in no way ever cause
complaint, for with the use of a loose fitting short kimono, with all
outer clothing removed except the knit undergarment, and with skirt
bands loosed, a complete survey of the whole dorsum from occiput to
coccyx can be had without the slightest unnecessary exposure. It is
well to remember that the patient has come for help and the osteopath
is not justified in sacrificing thoroughness for any exaggerated
feelings of modesty. With tact and care in the use of the garments the
most sensitive ones need feel no hesitation in coming for treatment.
A complete history of the case should be taken before the examination
begins, former methods of treatment, symptoms, environment, etc., as
it will aid in the final conclusions. It is well to have blanks for
keeping records of all cases.
Probably the most comfortable manner to begin physical examination is
to seat the patient on a table squarely with hands placed upon the
knees, then raise the garment and expose the whole back. Begin by
noting the texture of the skin, if it is clear, pigmented, blotched,
or has eruptions. Try the capillary reflex by pinching or stroking
quickly with the finger tips or the blunt end of a pencil. Find if it
is moist or dry and also outline the areas of changed temperature, if
any. Then observe the general contour of the spine with the patient
sitting upright, to find how near it is to the normal body curve.
Occasionally having the patient alternately sit and stand will, by
comparison, throw light upon the condition. With the patient bending
forward place the hands on the crest of the ilia and see if they are of
equal height.
Occupation may result in over development of one side or there may be
congenital asymmetry[26]. Note position of the scapulæ and habit of
posture in sitting and standing.
Before taking up the subject of a critical examination of each vertebra
there are certain points it will be well to consider. It is easy to
know instantly, without counting, the number of the vertebra causing
the lesion if these landmarks are remembered: First, the spine of the
third dorsal is on a level with the spine of the scapula. Second, the
spine of the seventh dorsal is on a level with the inferior angle of
the scapula. Third, the spine of the last dorsal is on a level with the
head of the last rib. It will save much time for the busy osteopath to
have these well in mind.
The =pathognomonic symptoms= of the osteopathic lesion are: (a)
maladjustment; (b) contracted muscles; (c) tenderness; (d) limited
movement. To these might be added changes in local temperature and
disturbance of function, but the former is not constant and the
latter may be remote. Here the primary lesion is considered, for an
osteopathic lesion may be, also, secondary or compensatory. Forbes
speaks of compensatory changes as being an important diagnostic sign.
Diagnosis of the position of a vertebra is sometimes difficult to the
beginner from its having longer or shorter spines than normal. Horsley
speaks of the occasional congenital absence of a spinous process.
They may be bent laterally, upward or downward and thus have all the
appearances of a marked displacement, while occasionally the body
itself seems much at fault. These present what might be termed normal
abnormalities and make it necessary for the osteopath to be very sure
of his diagnosis before attempting to correct what is not abnormal, for
disappointment, at least, and injury, perhaps, may follow.
To avoid mistake, carefully palpate the transverse processes and
determine if they are at right angles with the adjoining normal spine.
In the cervical and lumbar vertebræ it is possible to reach the tips of
the transverse processes, and on moderate pressure, if a lesion exists,
pain will be elicited. Further, where tenderness is associated with
other diagnostic points it can be safely assumed that a lesion exists,
and by outlining the suspected vertebra with the finger and localizing
the sensitive spot one can be sure of the point of greatest irritation
and the character of the displacement. Associated also with these signs
will probably be evidence of congestion, such as thickened tissues,
contracted muscles, etc.
After having examined the condition of the spinal column thoroughly by
inspection, begin at the first dorsal and examine the spinal column
down to the sacrum. Place the middle and ring fingers over the spinous
processes and stand directly back of the patient and draw the flat
surfaces of these two fingers over the spinous processes from the upper
dorsal to the sacrum in such a manner that the spines of the vertebræ
pass tightly between the two fingers, thus leaving a red streak where
the cutaneous vessels press upon the spines of the vertebræ. In this
manner slight deviations of the vertebræ laterally can be noted with
the greatest accuracy by observing the red line. When a vertebra
or a section of vertebræ are too posterior a heavy red streak is
noticed and when a vertebra or vertebræ are anterior the streak is
not so noticeable. Thus when suspicious points are noticed a special
examination of the localized point can be given. This examination
simply takes into consideration the contour and superficial condition
of disordered portions of the spinal column. In a few cases such an
examination will not be necessary, for the symptoms and signs of the
disease will be so clearly manifested that one’s attention will be
called directly to the cause. Still, great care should be taken in the
majority of cases, as the osteopath finds causes of disease remote from
the seat of complaint. We must always bear in mind the significance of
reflex stimuli and sympathetic radiation.
In making a critical and exhaustive diagnosis of the spinal condition
after the foregoing general examination has been made, it will be best
to have the patient lie on the side upon the operating table. When the
patient is in this position a more thorough examination can be made,
as then the spinal muscles are not contracted unless abnormally so,
for when a person is in the upright position muscles are continually
contracting first on one side and then on the other, as one of their
functions is to act as a support in keeping the spinal column erect.
The patient lying on his side, the physician should then stand in front
of him and reach over upon the back and make a thorough examination of
the affected portions of the spinal column, chiefly through the dorsal
and lumbar regions.
Consideration should be given the contraction of the muscles along the
back, chiefly the deeper layers of muscles. It may even be necessary
to relax some of the muscles before a thorough examination of the
vertebræ can be made. From a pathological point of view too much stress
should not be put upon the contracted state of the muscles; although
in a number of instances the contracted muscles may be the primary
cause of the patient’s trouble; especially so when the affection is
due to atmospheric and other changes. Contraction of the muscles may
be secondary to the lesions presented in the bony frame work. For
instance, a dislocated vertebra may be the cause of an irritation to
the innervation of certain muscles along the spinal column and thus
cause them to contract. Still, we must not lose sight of the importance
of the contracted muscles from a diagnostic point of view. They are
oftentimes prominent signs that a lesion exists in the immediate region
and are thus faithful guides in locating the cause of diseases.
In closing the general consideration of the spinal column it is
well to emphasize the importance of training the faculties to grasp
at a glance the story told by the back as a region, instinctively
placing the proper value on each physical sign and weaving them into
a composite whole so that the patient’s condition stands out a vivid
picture on the osteopath’s mind. When this is accomplished the more
detailed observations are but incidental. Relative to the examination
of the spinal column Clark[27] says: “To the osteopathic physician,
the most important part of the human body is the spinal column. By its
changes in contour and condition the various visceral diseases can be
diagnosed, in most cases. I believe that every disease is characterized
by extreme changes or signs, and I further believe that every chronic
visceral disorder is manifest by changes in the spinal column that can
be, by the practical eye and touch, readily interpreted. In short,
there are various signs along the spinal column that point out the
weakened or diseased parts of the body. This method of diagnosing
disease, that is by noting these spinal changes, is distinctly
osteopathic, and I believe the time will come when it will become such
an exact science that the character of the spinal change or lesion is
diagnostic not only of the viscus affected, but the way it is affected.”
Regional examinations and diagnosis will now be taken up.
=Neck, Head and Face.=—To make a thorough diagnosis of the condition of
the cervical vertebræ probably requires more skill and a more acute
sense of touch than of any other region of the body. The irregularities
and variations of the cervical vertebræ, the numerous muscles and the
passage of many vessels through the neck are very liable to mislead one.
One may examine the cervical vertebræ by having the patient either
lying down or in a sitting posture. The former position is preferable,
as then the muscles of the neck are passive, and besides it is much
easier to relax the muscles if such should be necessary. Also one has
better control of the field of examination.
It is undoubtedly best for the student when learning to examine the
cervical vertebræ to first examine along the base of the skull the
condition of the occipital muscles (after the patient has assumed the
dorsal position upon the treating table) for any contractions; for if
disorder exists in the upper five cervical vertebræ the condition will
be manifested by contraction of muscular fibres along the base of the
occipital bone. The muscles of the occiput are supplied by fibres from
the posterior branches of the upper five pairs of spinal nerves, and if
lesions exist to these upper nerves a contracted state of more or less
extent of the occipital muscles will occur, no matter how slight the
lesion. Thus the examiner after locating contracted fibres under the
occiput has a direct clue to lesions existing somewhere in the upper
five cervical vertebræ. After locating these contracted fibres of the
occipital region and then still keeping the finger upon the contracted
muscular fibres and following them downward until the contractions
are lost and seem to enter the spinal cord, one has then located the
exact point of disorder that is causing the irritation to the muscular
fibres involved, and most probably the cause of the affection from
which the patient is suffering, i. e., provided one has reason to
suspect the trouble is in the cervical vertebræ. Simply follow the
contracted muscular fibre downward until it seems to enter the spinal
cord and there one will find a lesion. After the osteopath has become
expert in diagnosis this will not be necessary unless he has to make
a very fine diagnosis or unless he is examining a stout neck where it
is hard to examine through the heavy muscles. With this method one has
a firm, flat, broad surface to work on (the occipital bone) making it
very easy first to locate contracted muscles and second to trace the
course of contracted muscles and thus find the disorder. Otherwise the
beginner is apt to get confused by trying to examine the condition of
the cervical vertebræ. Later, when a student becomes more expert such a
procedure will rarely be necessary only in cases that require special
work in the examination.
When the point of disorder has been located the diagnosis as to
the exact character of the maladjustment has to be determined. The
abnormal position of the vertebra, tenderness at the point involved,
local contracted muscles, and limited motion are the four diagnostic
points, although the temperature of the affected part as compared with
the general cutaneous temperature and the state of the local vascular
channels (blood and lymphatics) will occasionally be of aid.
Owing to the irregularity of the spinous processes of the cervical
vertebræ in regard to their length, great care has to be taken in the
examination. Probably there is no other region of the body that will
tax the patience of the osteopathic student so much in his practical
work as making a diagnosis of disorders in the cervical spine. It
requires patient and persistent work to become a fair diagnostician of
the cervical region, and it will take much experience to become expert
in both the examination and treatment.
One can depend that lateral deviations of the spinous processes are
abnormal in most instances. Placing the finger upon the spinous
processes of two consecutive vertebras the student can readily tell
whether or not there is any lateral displacement; but telling as to
other features is impossible as the spinous processes vary greatly in
length. When a vertebra is lateral, a slightly twisted condition will
be felt by the finger when placed upon and between the two spinous
processes.
To elicit the various degrees and combinations of rotation and
sidebending one should depend upon the symmetry of the transverse
processes. Reaching anterior to the sternocleidomastoid muscle, or
better still, pushing the cleido muscles forward and reaching posterior
to them upon the transverse processes, a very fair examination can then
be given the vertebras. When the vertebras are deranged, especially
anteriorly or posteriorly, that is the apposition of the articular
facets, a slight elevation will be felt, possibly not any larger
than a very small pea, either the anterior or posterior aspects of
the transverse processes, depending upon which way the vertebræ are
deranged. Remember that accompanying this slight elevation will be
degrees of sensitiveness of the vertebra at the point deranged. In
cases where the vertebra is lateral a slight eminence will be noted
along the outside of the process. Commonly disordered vertebræ are
not entirely deranged in one direction but are oftentimes slightly
rotated, so we may find them dislocated antero-laterally or in various
combinations of sidebending-rotation. Several consecutive vertebras
may be deranged in like manner of direction; this condition is chiefly
found in pathological curves of the spinal column. Probably the most
common general lesion is a strained condition of several consecutive
vertebræ, each one being nearly intact but all of them as a whole
somewhat strained or twisted. Thus there are many pathological states
to take into consideration, although it is not surprising to the
osteopath when he realizes that many of our pains and aches are due to
anatomical derangement. Frequently bending the head strongly forward
and downward, or downward pressure with slight rotation will produce
pain at the point of lesion.
Subdislocations of the =atlas= are probably among the most common
lesions presented to the osteopath. Owing to the articulation of the
atlas and occipital bone being an anatomically weak point and the
neck muscles being exposed constantly to atmospheric changes, besides
the articulation between the head and neck receiving the brunt of
many jars, falls and strains, the atlas is especially susceptible to
derangements. On account of the intimate relation of the atlas to the
superior cervical ganglion of the sympathetic and to the vertebral
blood vessels it is certainly very necessary that the atlas should
be well taken care of. No other tissue maintains such a significant
position in relation to the blood and nerve supply to and from the
brain. To diagnose correctly the position of an atlas and to be able to
correct it is undoubtedly one of the most essential achievements of the
practitioner of osteopathy.
The most common disorders of the atlas are anterior and lateral
displacements. Next in order come “rotary” lesions of the atlas, i. e.,
where the atlas has been deranged diagonally or simply twisted. It may
also be luxated anteriorly and laterally, or posteriorly and laterally,
etc. A posterior derangement of the atlas is comparatively a rare
disorder, although owing to the many lesions that are found in atlases
one has, during the course of a year’s practice, several to correct.
The atlas may occasionally be slightly tipped laterally, anteriorly, or
posteriorly, and in a few cases it may be somewhat impacted against the
occipital bone. Many times when the atlas is displaced the axis is also
deranged on account of the close relation between the atlas and axis by
the odontoid process of the axis.
To examine the atlas the patient may be either in the sitting or dorsal
posture; it matters but little which position is taken. Possibly the
dorsal position is better, as then the neck muscles are more relaxed
and if necessary an examination of the cervical spine, below the atlas,
can easily be made.
By placing the middle finger of either hand on the transverse processes
of the atlas when the patient is in the sitting posture, or the thumbs
on the transverse processes when the patient is in the dorsal posture
and comparing the two sides, undue prominence of one side or the
other can easily be noted. Remember the transverse processes of the
atlas are slightly above and posterior to the angle of the inferior
maxilla. Always, in examining one side of the patient, compare it
with the other; it may save considerable embarrassment. One side may
seem abnormal when by comparing it with the other side, both sides
may be found the same and still be normal. With the fingers still
on the transverse processes note the distance between the process
and angle of the jaw, besides take into consideration the tenderness
of the locality, and, also, what is of essential importance in all
interosseous lesions, its articular range of movements. There should
be room enough (approximately) to just comfortably wedge the end of
a medium sized middle finger between the transverse process of the
atlas and the angle of the inferior maxilla when both are normal. Thus
with the fingers on the transverse processes an expert will be able to
readily determine whether or not an atlas is lateral or anterior. If
an atlas is posterior the distance between the angles of the jaw and
the transverse process will be increased, besides the atlas will be
quite prominent posteriorly. In conjunction with the abnormality of the
tissues (prominence or depression of the bone and state of the muscles)
the sensitiveness of the locality is extremely significant.
Outside of displacements of the atlas, a lesion between the =axis=
and =third cervical= is most common; following next in frequency are
lesions of the =skull= and =atlas=. By that is meant where all the
cervical vertebræ are intact as far as their individual relation is
concerned, but the skull is forward, backward or lateral upon the
spinal column. This condition occurs quite frequently. To determine
its condition the same methods are employed as in diagnosing a
deranged atlas; for if the dislocations exist between the atlas and
skull the same diagnostic points are presented as far as the skull is
concerned as when the atlas, or atlas and axis, are dislocated from
the occipital bone or from the axis or third cervical. Following the
preceding examinations, additional examination will have to be made to
see whether or not the atlas is intact with the vertebræ below. If the
atlas is found to be intact with the vertebræ below and lesions are
presented between the atlas and the skull, then the disorder must be
between the atlas and the skull and nowhere else. Occasionally there
are cases where the skull is so far posterior upon the spinal column
that the angles of the jaw strike against the transverse processes of
the atlas when the jaw is opened widely.
Derangement of the =muscles= of the anterior and lateral regions of
the =neck= are common. Especially are contractions of the muscles on
either side of the larynx liable to occur. In examining the cervical
region do not pay too much attention to the superficial muscles,
but examine carefully the deeper muscles. It is from these that
impingements of nerves and constrictions of vessels are likely to take
place in the contracted fibres. Also, imbalance of muscular tension
may be the source of the resulting malalignment. In examining for
contracted muscles do not gouge into the muscle nor grasp the muscle
roughly, but bear down lightly (inhibitory) upon the muscles and then
gradually exert firmer pressure. By carefully and firmly exerting
pressure over muscular areas the deep muscles can then be felt beneath
the superficial ones. Otherwise when the muscles are manipulated
severely the superficial ones will contract to such an extent that the
deeper ones cannot be felt. The muscles contracting on either side
of the larynx tend to draw the larynx downward and thus there may
arise a source of irritation. The various muscles contracting in the
antero-lateral region of the neck are very often the source of chronic
irritations of the pharynx or throat. The omo-hyoid muscle may become
contracted and cause slight traction on the hyoid bone and thus produce
an irritating cough. To examine the muscles of the neck thoroughly it
is best to have the patient flat upon the back, for then all the normal
muscles are relaxed.
Lesions quite frequently occur in the =temporo-inferior maxillary=
articulation. The lesion may be either unilateral or bilateral, more
commonly the former. The disorder usually consists of a relaxation of
the muscles and ligaments about the articulation which allows a slight
but perceptible dropping of the inferior maxilla on the side involved.
In other cases there may be presented a spasticity of tissue, while in
still others some degree of joint infection may be found. Lesions of
this articulation particularly impinge upon fibres of the fifth cranial
nerve. The points of diagnosis are clicking and tenderness at the
articulation. These two points are the symptoms of which the patient
complains; those noticed by the osteopath are a slight deviation of the
jaw to one side or the other when the jaw is opened and a flinching
of the patient due to tenderness when pressure is exerted over the
articulation of the jaw. When the physician places his fingers around
the jaw, anterior to the angles, and the thumbs over the bridge of the
nose, having patient open the mouth, at the same time exerting pressure
with the fingers and thumb, a sharp click may be elicited by the return
of the jaw into its articulation.
In disease of the =scalp= the condition of the muscles of the scalp
should be taken into consideration. The muscles are usually found
contracted. The contraction of the muscles is generally due, as well
as the disease of the scalp, to derangement existing in the posterior
branches of the upper five pairs of the cervical spinal nerves.
In the =neck=, anteriorly the =hyoid= is the only bone to consider. It
is easily palpated by standing at the head of the table and with the
second finger of each hand outline both ends to ascertain its relation
with the thyroid cartilage. Note carefully any contracted tissue or
glandular enlargements which might cause undue tension. The tilting
of either end of the hyoid from these contractions is productive of
much throat irritation. At the same time the =larynx= may be examined.
It may be prolapsed, causing irritation of the laryngeal group of
nerves. The =thyroid= and =cervical= glands should be palpated for
enlargements, and all the muscles and ligaments for contractions.
Externally the =tonsil= may be felt by deep pressure in front of the
angle of the inferior maxilla.
=The Ribs.=—Under the osteopathic diagnosis of the ribs will be
included the examination of the clavicle and sternum. To be able
to diagnose intelligently, the position of the ribs in detail is
very necessary to the osteopath. Many of the diseases of the heart
and lungs, besides a large number of the diseases of the digestive
tract, may be traced to a deranged rib; also, occasionally diseases
of different regions of the head and neck may be due to dislocated
ribs. In making a thorough examination of the ribs each rib should be
carefully noted as to its position. The ribs may be examined when the
patient is sitting up; but it is better to have the patient flat upon
the back and especially so if the floating ribs are to be carefully
examined, because the muscular tissues of the side if contracted will
interfere with the diagnosis. In many instances the rib lesion is
secondary to a vertebral subluxation.
An expert osteopathic diagnostician will be able to detect at once
by a single passage of the hands down over the ribs if there are any
disorders of them. In passing the flat of the hand, especially the flat
part of the fingers over the ribs, carefully observe if the intercostal
spaces are too narrow or too wide, and if any of the ribs are unduly
prominent or depressed. If an intercostal space is too narrow it shows
that the ribs on either side of the intercostal space are too close
together. Then the question arises, which one of the ribs is crowding
upon the intercostal space, or whether both of the ribs are crowded
together. Usually when the sternal end of the rib is displaced upward,
the involved rib is prominent and when displaced downward the rib is
depressed. Thus it is commonly easy to diagnose which is the involved
rib. Besides finding an abnormal position of the rib there will be more
or less tenderness over the rib. Finding a rib prominent or depressed
and tender is generally quite conclusive that the rib is displaced.
Then the range of movement as expressed through the sense of resistance
is a helpful guide in diagnosis.
If a =typical rib= is placed upon a flat surface and one end of it
is depressed the other end will be elevated and _vice versa_. This
peculiarity holds true as well when the ribs (typical) are dislocated
in the living body. If the anterior end is elevated the posterior
end is commonly depressed and _vice versa_. Care should be taken in
examining the first rib and the false ribs, for in these ribs this
peculiarity is not found.
As a whole a very complete diagnosis can be made of the condition of
the ribs by examining the anterior part of the thorax, although it is
always best to examine along the angles of the ribs if for nothing more
than to confirm the diagnosis made at the sternal ends. Still it must
be remembered that the preceding only holds good when the entire rib is
dislocated. Many times simply one end of the rib is deranged and the
other end is practically intact.
Besides careful examination of the sternal end of the rib, attention
should be paid to the condition of the costal cartilages. The costal
cartilages may become deranged at either the articulation with the
rib or with the sternum. The same rule holds good when the costal
cartilages are dislocated as when the ribs are dislocated, i. e., when
the cartilages are prominent, they are usually displaced upward and
when depressed the cartilage is displaced downward toward its neighbor.
One is apt to think that a rib is only dislocated at its vertebral
end. Although lesions of the vertebral end are generally of greater
significance as far as the etiological factors are concerned, still
the sternal end of the rib must not be overlooked. In examining the
vertebral end of a rib attention should be paid the angles of the
ribs, for at the angles a better opportunity for examination is given
on account of the prominence. It will be necessary in many cases to
find out whether or not the vertebral end of the rib is lying between
the transverse processes instead of in front of them. In many severe
lesions of the ribs the vertebral end of the rib is dislocated upward
or downward from the transverse process of the vertebra and lies
between the transverse processes of the vertebræ above and below
its attachment. This certainly requires considerable skill in the
diagnosis, for oftentimes the point to be found is barely an eighth
of an inch in diameter. It is usually best before making such a close
examination to relax the tissues well over the field of examination.
The =ribs= as a whole may be too transverse or too oblique upon one
side. This is chiefly found in pathological curves of the spine, but
still such conditions may exist where there are severely contracted
muscles, especially in some cases of paralysis. Thus the contour of
the ribs must be taken into consideration by comparing one side with
the other.
In examining the =first rib= an examination somewhat different from
the other ribs should be given. It is best to have the patient assume
a sitting posture; then place the middle fingers of each hand upon the
first ribs near their centers and compare one with the other. Also note
the difference of the spaces between the ribs and clavicles. Generally
the first rib is dislocated upward, rarely downward. Besides finding an
abnormal prominence or depression of the rib at its center considerable
tenderness will be noticed. Examinations of this region are every day
experiences with the osteopath.
When diagnosing the position of the =floating ribs= it is best to
have the patient lie flat upon the back with the thighs flexed upon
the abdomen, so that the tissues about the lower ribs may be entirely
relaxed. Then by placing the flat of the fingers carefully over the
ribs the outline and position of them can be easily discerned. The
floating ribs are oftentimes found deranged and are the source of a
great deal of suffering through the iliac regions. These ribs may
become dislocated from the vertebral ends and drop down obliquely
toward the iliac crest, or else the free end may become locked beneath
the rib above. Occasionally both ends of the rib drop down quite
perceptibly and consequently is the cause of considerable distress. In
such instances the rib is depressed inward so that the normal contour
of the lower thorax is lost.
An examination of the =clavicle= should be carefully made. Always
compare the clavicle with its fellow and examine thoroughly its
articulation with the sternum as well as at the acromial prominence.
Often the sternal end of the clavicle is slightly dislocated
posteriorly to the sternum; although it may become completely luxated.
The acromial end may be dislocated upward or downward.
In examining the =sternum= special attention should be given the
articulation of the manubrium and gladiolus. This is due to the
crowding anteriorly of the articulation of the sternal parts. Normally
until well along in adult life there should be some movement here due
to its membranous attachment. Occasionally the ensiform cartilage
is turned inward, producing a tender point, but this rarely occurs.
Also the articulation of the cartilages in the region of the eighth,
ninth, and tenth ribs may be found considerably deranged, causing local
tenderness and even stomach trouble.
=Dorsal= and =Lumbar Spinal Region=.—With the patient sitting on the
table abnormal deviations can be readily noted. There may be lateral
swerves, from muscular weakness, or unilateral tension, involving
the whole spine or less, or a reversal of natural curves, i. e., the
spine depressed anteriorly between the shoulders and posteriorly
in the lumbar making the straight spine. There may be, also, an
exaggerated normal curve in the dorsal region producing a kyphosis with
a compensatory lordosis in the lumbar region sufficiently great to
change its relations with the pelvis. By the method previously given,
now outline the spinal column for lateral and bilateral scoliosis.
These, frequently, are at their incipiency, and to the casual observer
would pass unnoticed. It is well to make an outline of the spine
before beginning treatment, and at times following, that progress
may be observed. A simple method is lead tape which can be had from
any plumber shop and can be molded to the deformity and traced on
paper together with date of examination. H. F. Goetz has perfected
an appliance for outlining and recording these deviations. Observe
well the ligaments, as well as extent of joint movement, under deep
palpation; from irritation they may become thickened and more or less
fill the spaces about the spines and transverse processes, causing a
rigid, smooth spine.
To make a detailed examination the patient should be stretched out on
one side upon a treating table, although the general examination may
be sufficient. Then, standing in front of the patient and reaching
over him, a most careful diagnosis can be made. Do not stand back of
the patient as the flat of the fingers can not be used to advantage
in outlining the different vertebræ. The various contracted muscles
that may be found along the spinal column will be of valuable aid
in locating derangements of the vertebræ and vertebral ends of the
ribs. By using contracted muscles along the spinal column as a guide
for locating lesions, reference to the large superficial muscles is
not made, but to the small areas of contracted fibres of the deep
muscles. It is the deep muscles that become more or less contracted,
and even fibrotic, when lesions of the vertebræ and ribs exist. The
superficial muscles are generally contracted by atmospheric changes,
slumped postures, wrong habits, etc., and are not generally the result
of disorders in the osseous system. The preceding points in regard to
contracted muscles cannot be too carefully observed for there is a
tendency among many osteopaths to treat the contracted deep muscles
as primary lesions in nearly every case. Remember that if they are
not due to the motor nerve fibres of the muscles being irritated by
the spinal lesion, or to a reflex stimulus, or to a compensatory
change, that although the muscular tension may be the inception of
the almost certain interosseous lesion, still the leverages secured
through bony adjusting are very essential not only in correcting the
osseous malposition but in loosening and releasing fibrous muscles and
thickened ligaments.
=Thorax.=—Examination of the thorax as a region has been largely
gone over in speaking of the ribs and their sternal attachment,
cartilages, sternum and the clavicles, but its appearance as a whole
should be carefully noted for it will be a valuable aid in diagnosis.
Deviations from the normal, such as the emphysematous or barrel-shaped
chest in asthmatic affections, or chronic cough, or accompanying
kyphosis, the flat chest and its association with phthisis, the
rachitic, etc., should be considered. Spinal deformities are reflected
in the thorax by marked changes in contour, such as elevations and
depressions corresponding to the spinal changes. These result in marked
interference with the thoracic organs and in young subjects are of
particular interest. Rib changes are frequently the result of vertebral
deviations.
=Abdomen.=—The position for examination of the abdominal viscera is
usually with the patient supine, head slightly elevated, knees drawn up
partially and supported to relieve any muscular strain, and with the
hands at the sides. In this position complete relaxation is obtained.
Observe any enlargements from gas, fluid, or tumor, muscular changes,
color, etc. The patient may, also, be placed upon the side, and in the
knee-chest position for further verification of the diagnosis. Where
the abdominal wall is much relaxed, or there is a pendulous abdomen
with enteroptosis, there will be found a change of relations of the
viscera by these different positions, allowing them to be palpated in
another position. When there is marked tenderness it is often possible
to go deeper with less discomfort with the patient in the knee-chest
position. The Trendelenburg position may also be utilized. Where
ascites is suspected palpation should be made with the patient in
various positions in order to note changes of location of the fluid.
Frequently much can be learned by inspection with the patient standing.
Clues to visceral disturbance can often be had by tracing the nerve
connection from the spinal lesions to the suspected part.
In examining the =liver= care must be taken that any gouging or severe
bruising of the organ does not take place. The liver can be outlined
by percussion and also by palpation of its lower and inner borders
Congestions, atrophy, enlargement or hardening should be noted, also
any change in position.
A rather complete examination can be given the =biliary tract= from the
=gall-bladder= to the =duodenal orifice= of the =biliary duct=. By a
careful inhibitory pressure over the duct the outline of the tract can
be discerned providing the patient is not too stout. When the tract
is swollen considerable tenderness will be present. The patient will
complain of a stabbing or piercing pain upon pressure and manipulation
if the duct is inflamed.
Usually the tenderness is greatest nearer the =duodenal orifice=. The
duodenal orifice is about one and one-half inches diagonally downward
to the right from the umbilicus. In cases of impacted =gall-stones= the
osteopath as a rule has very little trouble in locating the stone.
The =spleen= may be percussed and when in a markedly enlarged condition
its lower border can be palpated. Great care must be used in the latter
condition as there is danger of rupture.
In examining the =stomach= the usual methods of inspection, palpation,
percussion, analysis of the contents, etc., are employed.
Palpation and manipulation over the =intestines= are practiced a great
deal by the osteopath in various intestinal diseases. By his educated
sense of touch he is usually able to locate at once any =impactions= of
=fecal matter=. Such impactions are generally found in the ilio-cecal
and sigmoid regions. In the various acute =obstructions= from
invagination, tumors, twists, adhesions, spasticity, knots, etc., many
times one is able to readily locate the seat of the disturbance. There
is one point to specially emphasize; that is, do not overlook prolapsed
regions of the intestines; such occur frequently and are a source of
considerable distress, especially constipation. Simple manipulation
will never do much good, neither will spinal treatment or injections,
as a rule. A specific treatment must be given and, that is, after
locating the exact point of prolapse, to reach carefully beneath the
fold and replace it.
In emaciated subjects the =kidneys= can be readily located, and in
a few instances when they are diseased one can feel the contracted
tissues about them. Be very careful not to injure the =capsule= about
the kidney. Do not punch or gouge them in the least; but locate the
kidneys by a careful inhibitory palpation.
=Lumbar and Pelvis.=—The intimate relation between the lumbar spine
and pelvis make a consideration of them as a region necessary. Outside
of ordinary curvatures involving both the dorsal and lumbar regions
there are certain conditions which involve but one structure and
require careful differential diagnosis to determine whether the lumbar
or pelvis is at fault. In the former the fifth vertebra is a weak
point and is most frequently at fault. The deviations are usually a
sidebending and frequently accompanied with some rotation. Occasionally
a malstructure of the lower lumbar or pathologically relaxed ligaments
will approximate the spines and be misleading as to the real condition.
A rotation or lateral tilting of the fifth lumbar may have the effect
of elevating the crest of the ilium so that the innominatum would
appear involved. There will be a difference in the length of the legs,
angles of feet when patient is lying on the back, anterior spines out
of line and tenderness of the muscles attached near them. However,
other diagnostic points of innominate lesions, i. e., tenderness of
symphysis and sacro-iliac articulation, and prominence of the posterior
spine, will be lacking. Marked deviation of other lumbar vertebræ may
produce practically the same effect, but the lesion will be so apparent
that there will be no doubt as to the cause.
To be able to diagnose accurately and intelligently the pelvic region
requires nearly as much skill as in examining the cervical region.
The pelvic bones are liable to many subdislocations, especially in
the female. However, it should be remembered that many apparent
innominate lesions are secondary or compensatory changes due to lumbar
lesions. The pelvis as a whole may be tipped anteriorly or posteriorly
upon the spinal column. It also may be twisted or rotated laterally
upon the spinal column. The most common lesions are subluxations of
an innominatum forward, backward, upward, or downward, or various
combinations of these displacements, such as a tipping forward and
downward of an innominatum, or a tipping backward and upward, but these
combinations do not always exist in the manner given. As a rule when
the ilium is anterior, the ischium posterior, then the innominatum as a
whole is downward; when the ilium is posterior, the ischium anterior,
then the innominatum as a whole is upward. This is only a rule, there
are exceptions to it; for in some few cases when the ilium is anterior,
the ischium posterior, the innominatum may be higher, and when the
ilium is posterior and the ischium anterior the innominatum may be
lower.
To be able to diagnose such derangements will require skill and
practice; still there are symptoms and signs that are characteristic
of such disorders. In examining the pelvic bones have the patient flat
upon the back at first. Be sure he is flat upon the back for a very
slight variation may make considerable difference in the relation of
the pelvic bones, one to the other, so far as the diagnostic points
are concerned. Then go to the feet of the patient and grasp the ankles
firmly, rotate laterally both legs, first to one side and then to the
other, as well as pull and push both limbs slightly, and then bring the
heels together directly in the median fine of the body and compare the
length of the limbs at the heels. If there is any disorder whatever
in one innominatum, and the thigh muscles have been relaxed thoroughly
by the preceding movements and the heels are brought together in the
median line of the body, a difference in the length of the limbs
will readily be observed at the inner malleoli or the heels. For if
the ilium is forward the ischium must be backward and as a rule the
innominatum is thrown downward, thus causing an apparent lengthening of
the limb which will be noticed by comparing the heels; if the ilium is
backward the ischium must be forward and as a rule the innominatum is
then upward, causing an apparent shortening of the limb on the affected
side. A very slight variation in the pelvis will make considerable
difference in an apparent lengthening or shortening of the limbs. Such
conditions are generally met with several times a day by osteopaths.
The object of the lateral rotary movement and the pushing and pulling
of the limbs is to make sure that all the thigh muscles are thoroughly
relaxed, for it is a very easy matter for contracted muscles in one
thigh to produce an apparent shortening of the limb. Also be very
careful in comparing the length of the two limbs at the heels where
they come together that they are exactly in the median line of the
body, for if they should be to one side or the other, however slightly,
there would be an apparent lengthening of the outer limb as compared
with the limb near the median line. While the patient remains flat
upon the back it is a good plan to compare the anterior spines of the
ilia. It may be readily noticed that one is higher or more depressed
than the other, which will help to confirm the diagnosis. It is a
good plan also to have the patient sit up squarely upon the table and
compare the crests and posterior spines of the ilia; thus one may be
seen to be higher than the other. Then, also, note the angles of the
feet when patient is supine; an everted foot usually means that the
limb is shorter due to the tilted pelvis; the opposite is commonly true
when the foot is inverted. However, this is not an absolute rule. Care
should be taken in differential diagnosis of possible old fracture of
leg, of infantile paralysis, of asymmetry, etc.
There are =three diagnostic points= exclusive of all other signs that
are quite conclusive when coupled with the preceding examination. If
an innominatum is dislocated or subdislocated there will be tenderness
over the symphysis pubis on the side affected, tenderness over the
ilio-sacral articulation on the side affected, and tenderness along
the crest of ilium where the abdominal muscles are attached. When
tenderness is found at these three points it is quite conclusive that
the innominatum is deranged, for at the symphysis pubis and ilio-sacral
articulation tenderness must exist if the innominatum is disturbed,
and by a change in the crest of the ilium the abdominal parietes
will be affected, provided they are not too much debilitated. Marked
tenderness of the external cutaneous nerve as it passes over the crest
of the ilium below the anterior spine will be noticed on the unaffected
side (Dr. Still). There will be, on rectal examination, marked tension
of the tissues on the affected side. Possibly the patient may complain
of pain exclusively in one side along the pelvis and limb which will be
a leading symptom telling which side is affected.
=Additional diagnostic= signs will be rigidity of muscles along the
ilio-sacral articulation and abnormal prominence or depression of the
ilium at its articulation with the sacrum, depending upon which way the
innominatum has slipped. Considerable deviation of the pubic bones may
be noticed. The pubic bone on the side affected may be either thrown
upward or downward.
Radiographs have repeatedly revealed subluxations of the innominate
bones in many instances. This is certainly quite conclusive in
confirmation of the osteopathic ideas in regard to the pelvic bones
becoming dislocated.
=Sacrum.=—Examination of the sacrum is best made with the patient lying
on the side, with the osteopath standing in front and with the hand
palpate its posterior surface. In the sitting posture its relation with
both innominates can be determined. It is displaced posteriorly but
seldom, the most frequent being anterior, downward, and a combination
of the two. In the anterior conditions tenderness at the sacro-iliac
articulations is a good point, but it must not be confounded with an
innominate lesion. The downward displacement is shown by comparison
with the lower lumbar vertebræ. Observe the relation between the two,
as a change in contour of the spine will also change the angle of the
sacrum and _vice versa_.
=Coccyx.=—With the patient and operator in same position as for the
sacral examination outline the coccyx, as to first, =contour=; second,
=rigidity=; third, =sensitiveness=. If abnormalities are detected go
to the other side of the table and with a well lubricated index finger
palpate its anterior surface. Changed contour, displacements, and
old fractures can be readily determined. The most common deviation
is anterior at its union with the sacrum. The lateral form generally
resulting from muscular contraction is next, with posterior but
seldom. “If the lower part of the sacrum is rotated backward, the
sacro-coccygeal articulation or angle is affected or becomes more
acute, since the tip of the coccyx is not displaced, but held in
position by structures attached to it. If the sacrum is displaced
downward the effect is about the same. Often this sort of sacral lesion
is mistaken for an anterior luxation of the coccyx.”[28] Remember
that normally there should be some movement of the coccyx. It has a
fibro-membranous articulation.
=Uterine=, =ovarian= and =rectal= examinations are largely of the same
nature as those given by other practitioners, although osteopaths find
that oftentimes other practitioners are mistaken in regard to the
etiology of many diseases to which these organs are subject.
=Arms= and =Legs=.—There is comparatively little that is exclusively
osteopathic in regard to the diagnosis of disorders of the arms and
legs. One important feature that the osteopath finds in examining the
arms and legs is that many of the disorders supposed to originate
in the affected member are found to be caused from vertebral or rib
dislocations. Innominate and lumbar lesions are particularly fruitful
sources of trouble in the legs and feet. Always carefully examine the
spine in the region of innervation to the arms and legs when they are
affected. The shoulder and hip joints, as well as all joints, are
subject to partial dislocations. Many times when pain or other symptoms
are presented in the arms or legs the trouble is at the shoulder or
hip joint or in the spinal column. There are two regions that are
very apt to be overlooked in the examinations of the arms and legs
and they are the elbow joint and the fibula. The small bones of the
=ankle= and =wrist= as well as of the foot and hand are subject to many
dislocations which are easily discerned upon examination and often
overlooked. Special emphasis should be given in regard to many supposed
diseases of the knee joints which are really caused by lesions in the
spine or at the hip joint.