The Practice and Applied
Therapeutics of Osteopathy
Charles Hazzard, D. O.
EXAMINATION OF THE NECK
INSPECTION and PALPATION are the two physical methods
used in examination of the neck.
INSPECTION reveals scars due to wounds, and suggests
a history of accident or operation. The general conformation of the
neck should be noted.
Upon the anterior aspect may be seen enlargement
due to increase in the size of the tonsils or of the lymphatic glands;
abnormal pulsations or engorgement of the blood-vessels; an enlarged thyroid
Upon the posterior aspect may be found enlargement
of the muscles or thickening of the tissues. Frequently an inequality
of the tissues in and below the sub-occipital fossae, due to thickening
or to bony lesion, occur.
This inequality often indicates the existence of
a typical cervical condition of much importance to the Osteopath.
So frequently does one meet this sort of a neck in practice, and of such
importance are the various lesions present, that its ready recognition
becomes necessary. Upon inspection, inequality is seen in the postero-lateral
aspects of the neck. One side will be somewhat hollowed, and the
other side full. In general examination of the spine one takes such
condition as an indication of slight curvature. Further examination
show such to be the case in the neck. The tissues are usually found,
upon palpation, to be tense and contractured upon. the full side.
They are as a rule tender. The tissues upon the hollow side may be
in a similar condition, not usually so marked. Palpation further
shows a swerving of the cervical vertebrae, convexity to the full side.
All or several of the vertebrae are involved, thus causing an extensive
cervical lesion, capable of producing the various ills due to bony lesion
of this region.
This cervical condition is often found associated
with, and may sometimes be due to. a swerve in the spine below or an innominate
lesion, changing the equilibrium of the spine and giving a one-sided tendency.
Any unnatural position in which the head may be
held should be noted.
PALPATION is here, as elsewhere, the important method
of examination. For convenience the anterior structures may be examined
first. The patient lies upon his back, relaxing the neck as much
as possible. This object may be aided by the practitioner, placing
one hand; upon the forehead and gently rolling the head from side to side,
while with the other he light manipulates the muscles of the neck.
A. ANTERIOR STRUCTURES
I. The tonsil is located by pressure of
the fingers just below the angle of the inferior maxillary bone.
Any enlargement or tenderness of the organ is to be noted. This examination
should be supplemented by inspection of the throat internally.
In palpation of the tonsil externally one often
feels an enlarged lymphatic gland below the angle of the may, accompanying
the enlargement of the tonsil, for which it should not be mistaken.
II. Tender points, frequent in catarrhal
conditions, are found by deep pressure behind the angles of the inferior
III. The hyoid bone is located
by pressing all the soft tissues just below the jaw toward the median plane
of the body. This causes a prominence of the greater cornu upon the
opposite side of the throat, which may be easily detected by the index
The finger remains upon the cornu and pushes it
back toward the first side, thus making prominent the greater cornu of
that side. With the index finger and thumb upon the cornua, the bone
may be moved about and a diagnosis of its position be made. Contracted
tissues may draw the bone upward, downward, or to one side.
IV. The hyoid muscles, superior and
inferior are now carefully palpated to discover contracture, hypertrophy,
congestion or tenderness in them. In public speakers, singers, and
others liable to throat disease the superior hyoid muscles are often in
V. From the hyoid region, palpation
is carried down over the thyroid and cricoid cartilages, noting whether
their condition be normal, and is extended along the throat structures
to the root of the neck. In this examination the parts are grasped
between the thumb and fingers of the examining hand and are moved from
side to side. At the same time, deep but gentle pressure is made
at either side of the larynx and trachea in order to note any undue tenderness
in the laryngeal nerves, as generally revealed by an impulse upon the part
of the patient to cough or swallow. Immobility or harshness of sound
upon motion of these parts as above indicates abnormal tension in the related
muscles and other tissues.
VI. Enlargement or wasting of the thyroid
gland or enlargement of the cervical lymphatic glands must be noted.
VII. The sterno-mastoid muscle is made
prominent by causing the patient to turn his head to the opposite side.
Pressure deep behind the anterior border of this muscle impinges upon the
pneumogastric nerve. Tenderness in it upon pressure may accompany
liver or stomach disease.
Its superior laryngeal branch is located by pressure behind the greater
cornu of the hyoid bone. Note whether the hyoid muscles are contractured
in such a way as to draw this bone back upon the nerve.
Its recurrent laryngeal branch may be impinged by
pressure near the anterior border of the sterno-mastoid muscle at the level
of the cricoid cartilage. This pressure irritates the larynx and
causes the patient to cough when the nerve is tender, as in various throat
affections. Note the condition of irritability of the nerve.
VIII. The phrenic nerve arises
from the third, fourth, and fifth cervical nerves, and may, at its points
of origin, be pressed backward against the bony column. It
may be stretched also by pressure, with tire thumb or finger in the angle
formed by the posterior edge of the sterno-mastoid muscle with the
upper margin of the clavicle. This pressure must be directed from
above diagonally downward and forward toward the sternum.
IX. Pressure of the head directly
downward upon the spinal column with rotation, will sometimes discover
deep pain at points of lesion.
X. With the patient lying on his
back, turn his head well to one side and to the other, noting any inequality
in the degree to which it readily turns. Contracted muscles, luxated
vertebrae, etc., often prevent its turning so far to one side as to the
Occasionally motion is so restricted (e. g., in
chronic muscular or articular rheumatism) that the head can be turned scarcely
a fraction of an inch.
XI. The posterior structures of the
neck may be tested for abnormal tension by flexing the head upon the thorax,
the patient upon his back.
The examining finger should follow the ligamentum
nuchae carefully up to its insertion at the skull, where deep soreness
and contracture are sometimes found associated with headaches.
XII. The palms of the hands may
be passed evenly over the surface of the neck to examine for variations
of temperature. Hot or cold areas may be found. It is common
to find an area of increased temperature at the base of the skull behind.
XIII. The state of the blood-vessels
should be noted. A strongly pulsating carotid artery is seen in aortic
regurgitation and in some nervous diseases. A venous pulse in the
jugular veins may accompany marked tricuspid regurgitation. Congested
veins of neck, chest, and face, especially if unilateral, may indicate
pressure of a thoracic aneurysm or tumor. Often one sees one external
jugular vein much fuller than its fellow, due to narrowing of the space
between clavicle and first rib. Hard, incompressible,
or rigid, carotid arteries indicate arteriosclerosis. They are commonly
accompanied by rigidity and tortuosity of the temporal arteries, and by
cardiac hypertrophy and valvular lesion.
B. POSTERIOR AND
I. With the patient sitting, the practitioner
passes the examining hand down along the back of the neck. Just below
the occiput is a depression in which he may feel the upper end of the ligamentum
nuchae and the inner borders of the trapezius muscles. With the head bent
slightly forward and the examining fingers pressed deeply into this space abnormal
tension of these structures may be noted.
II. The second cervical spine is the first
bony prominence felt below the occiput. The spines of the third, fourth
and fifth are made out with difficulty, as they recede from the surface anteriorly.
The next palpable spine is that of the sixth, the next of the seventh.
The latter is prominent, but not so much so as the first dorsal, from which
it must be carefully distinguished.
There are two ways to distinguish between them. The
sixth cervical spine is first located. While not at all prominent it may
easily be felt as a small point snugly resting upon the upper surface of the
seventh. Commonly a careful examination locates the sixth without difficulty,
thus the seventh is known to be the next below, and is distinguished from the
Anterior, posterior, or lateral deviations of the cervical
vertebrae may be diagnosed by this examination of the spinous processes.
III. Anterior dislocations of the upper
three cervical vertebrae may be sometimes noted by examining for the prominence
caused by the body upon the posterior wall of the pharynx. This is done
by passing the finger over these bodies.
IV. The position of the atlas is examined
as follows: The patient lies upon his back and the practitioner stands at the
head of the table. The transverse processes are located by thrusting the
palms of the examining fingers deeply into the space between the angle of the
inferior maxillary bone and the tip of the mastoid process. A finger is
placed upon each transverse process, which is usually prominent. Normally
these processes should be midway between the angle of the jaw and the tip of
the mastoid process. If they are too far forward, too far backward, to
one side, or if one be forward and the other backward, the diagnosis is readily
made by comparison of the position of the processes relatively to the points
mentioned, and the corresponding displacement of the atlas is discovered.
Occasionally the posterior tubercle of the atlas may be felt
in the space between the second cervical spine and the skull.
In palpating the transverse processes of the atlas, care
should be taken to feel out their shape and contour fully. They vary exceedingly
in size within normal limits, being sometimes so large as to extend below and
behind the mastoid processes.
If the relations of the atlas with the axis be unchanged,
while those of the atlas with the skull are altered, we must regard the head
as being displaced upon the atlas.
V. Lateral deviations of vertebrae in the
neck are best found by examining the articular processes.
The head, with the patient lying upon his back, is turned
to one side, making prominent the row of articular processes upon the opposite
side. The second cervical spine is now readily located by its prominence
behind, and the finger traces from it around to the articular process of the
second, lying at about the same level, but slightly above. A finger is
held upon this process and the head is turned to the opposite side. The
other articular process of the second is then located in the same way.
They are now compared while moving the head slightly from side to side, and
lateral deviations or tenderness in the tissues are easily made out. With
these two points fixed, the head may be gently turned from side to side, and
the examining fingers travel down over the successive articular processes, careful
examination being made of the position of each.
VI. Deep pressure may be made from the anterior
surface of the neck back upon the anterior aspect of the transverse processes
and diagnosis of anterior luxation be made.
VII. Crepitus and abnormal mobility of bony parts
VIII. The patient lies on his back, and the
practitioner stands at one side of the head, turns the head slightly to one
side and passes the examining hand transversely to the course of the muscle
fibers, noting any contractures of the muscles, superficial or deep.
IX. He then stands at the head of the table
and examines both sides of the neck at the same time, a hand upon each side,
carefully comparing both sides with especial reference to any abnormality either
of bone or of other tissue.
X. Careful examination should be made
for thickening of the tissues of the neck just below the occiput. Sometimes
these tissues may be felt like a thick transverse band across the back of the
neck just below the skull. Such a lesion is usually an indication of intense
XI. The scaleni muscles are made prominent upon one
side by drawing the head to the opposite side. They are normally hard
to the touch, and care should be taken in the diagnosis of contracture.
Tenderness is often found upon pressure, as in cases of rheumatism.
Their contracture often results in drawing the first two
ribs upward out of place.
XII. The brachial plexus of nerves emerging
from between the scalenus anticus and the scalenus medius muscles, below the
level of the fifth cervical vertebrae. The head is inclined to the side
to relax these muscles, and deep pressure is made at this point to impinge the
plexus. Tenderness is thus revealed. This plexus may be readily
traced downward behind the clavicle, and along the inner side of the arm.
XIII. Tender areas are often found upon pressure
in the suboccipital fossae. They are due to irritation of the great and
small occipital and great auricular nerves. It is through manipulation
of these nerves largely that effects are gotten upon the superior cervical ganglia
and upon the medulla. They are located at a point about two inches from
the middle of the posterior margin of the mastoid process, in a line at right
angles thereto extending toward the median plane of the neck posteriorly.
These nerves, when firmly pressed, carry a sensation pain to the top of the
head and over it to the brow.
XIV. The superior cervical ganglion lies
in front of the transverse processes of the second and third cervical vertebrae,
and may be reached by direct pressure through the tissues. The method
of locating the transverse process of the second cervical has been given under
V of this chapter. Deep pressure from the anterior aspect of the neck
may press this ganglion back against these processes. This ganglion lies
in front of the rectus capitis muscle, which is penetrated by its branches connecting
it with the first four cervical nerves.
The middle cervical ganglion, lying in front of the transverse
processes of the sixth and seventh cervical vertebrae, may be likewise reached.
This ganglion has branches connecting it with the fifth and sixth cervical nerves
The lower cervical ganglion lies in front of the first costo-vertebral
articulation, and is connected with the seventh and, eight cervical nerves.
The transverse process of the seventh cervical vertebra is
readily located by deep lateral pressure at the outer third of the supra-clavicular
Lesions of the atlas and axis are by far the most important
occurring in this region of the body, and account for many serious diseases
of the head and its parts, such as blindness, insanity, etc. The lesions
of the neck hold an important relation also to diseases in other parts of the
Comparatively little treatment is given directly to the head and its parts.
These are treated largely through the removal of lesion in the neck. Hence
the importance of most thorough and careful attention to its examination.
The value of gently moving a part while under examination
in order to relax tissues, to insinuate the examining fingers more deeply into
them, and to develop the latent lesion through investigation of its relations
to its neighboring parts during movement must not be overlooked.