The Practice and Applied Therapeutics of Osteopathy Charles Hazzard, D. O. 1905      CHAPTER III   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 gland.
    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 maxillary bones.
   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 finger.
    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 pathological condition.
   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 other.
    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 LATERAL STRUCTURES

    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 first
dorsal.                                        I
    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 indicate fracture.
  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 congestive headaches.
  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 fossae.
    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 body.
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.