The Practice and Applied
Therapeutics of Osteopathy
Charles Hazzard, D. O.
EXAMINATION OF THE THORAX
From an Osteopathic point of view, and not at present
considering the contents of the thoracic cavity, the examination of the
thorax consists mainly in discovering, by palpation and inspection, whether
its bony structures are all in position.
Ligamentous and muscular lesions, also lesions of
blood vessels, nerves, and centers are closely associated with bony lesions.
The relations of the thorax to the spine as a whole
and to its own contained viscera cause its lesions to be among the most
important ones found in the body. Lesion of the spine, especially
of its thoracic portion, often seriously affects the thorax proper.
INSPECTION reveals change in the general conformation
of the thorax. It is made with relation to the spine, and effects
of spinal irregularities are considered. Flattening or prominence
of the ribs, either in portions of the thorax or affecting it as a whole;
restriction or increase in the movements of the thorax, upon one or both
sides; color of the skin, eruptions. scars, etc., are all noted.
Change in the general conformation of the thorax
is significant of the presence of many lesions. Often a single glance
assures the examiner of the presence of many lesions which are closely
related, and which, as experience teaches, are all in a train of abnormalities,
so that he is practically sure from the beginning that he will find present
certain various lesions. A weakened condition of the spine, allowing
of lateral swerving of its vertebrae or of changes in its normal curves
is apt to be found causing a weakness of the costo-vertebral ligaments.
The ribs are therefore not held in their proper relation to the spine,
the whole thorax is weakened, and the ribs sag downward, narrowing the
antero-posterior diameter of the chest, or otherwise distorting it.
The foundation is thus laid for the various diseases of heart, lungs, etc.
The angles of the ribs are approximated and become prominent along the
postero-lateral aspects of the chest, or "stand out in rings under the
shoulders, " as Dr. Still says. This narrows the thorax so that a
lateral view of it shows the axillary and infra-axillary regions narrowed,
and the examining hand swept down along the angles finds the lateral span
of the chest much decreased. The two sides may differ. The
ilio-costal spaces are narrowed, sometimes to the extent of obliteration.
In case of a lateral swerve of the spine the ribs
upon the convex side are found to be more oblique, and their inter-spaces
are narrowed or obliterated. At the same time the whole thorax may
be altered in shape as above described.
The patient may sit, lie, or stand during inspection,
as most convenient.
PALPATION, the more important method, proceeds in
conjunction with further inspection, and is used in the detection of the
various special lesions to be described.
I. With the patient standing or sitting, the
palms of the hands are passed evenly over the anterior and posterior aspects
of the chest, comparing side with side; region with region. The temperature
is also noted.
II. The precordial region is examined for
any protrusion or retraction of the thoracic wall, significant with relation
to heart disease.
III. Each lateral half of the chest is examined
for change or lessening of its antero-posterior diameter, considering the
direction of the component ribs as well. Lessening of this diameter,
and a tenderness of the ribs to greater obliquity in direction, reveals
a flattened side or sides of the chest. This shows spinal lesion
generally, also disturbed ligaments, blood-vessels, nerves, etc., of all
related parts. In this case the whole side is dropped down and the
ilio-costal space is lessened.
People with such lesions are always poor breathers
because of the extra effort required of weakened muscles to raise the disarranged
ribs. They, therefore suffer, in addition to the results of specific
lesion, from the various evils of congestion and imperfect oxygenation
consequent upon poor rib, chest, and lung action.
IV. The same lesion may affect a portion of
the thorax. Often flattening of the ribs posteriorly beneath the
scapula is found.
Protrusions or retractions of one area of the chest
generally correspond with the reverse condition in the corresponding anterior
or posterior area. This is not true in case of slipping of the ribs
V. Marked depressions in the supra or infra-clavicular
regions are significant in the diagnosis of tuberculosis of the lungs.
VI. With the patient lying on his side, the
palm of the hands swept along the lateral and postero-lateral aspects of
the chest, from the shoulder downwards. Changes in the position of
the ribs individually, or in the combination of the side of the thorax
in question are thus readily made out, mainly by detection of changes in
the angles of the ribs from normal.
The STERNUM must be examined.
I. It may be as a whole, protruded or retracted
following a change in the general shape of the thorax.
II. Luxation between the first and second
parts, anteriorly or posteriorly may occur.
III. The ensiform may be displaced laterally.
THE CLAVICLE AND CORACOID
The latter is located as the first bony prominence
at the outer end of the infra-clavicular fossa. Its relation to the
clavicle is to be noted, also the condition of the tissues attaching to
The clavicle may be luxated at either its sternal
or acromial articulation. The sternal end may be upward, anteriorly
or posteriorly from its normal position. The acromial end may be
displaced downward toward the coracoid or upward upon the acromion process.
Sometimes the bone is tilted so that one's fingers may be thrust from behind
its upper edge. These lesions are generally easily detected by inspection
and palpation. The examination of the sternal end is often facilitated
by having the patient lie flat upon his back, then pressing the tip of
the examining finger down deeply upon the sterno-clavicular junction, at
the same time comparing it with its fellow, which should be felt out by
the other hand. Very slight depressions or elevations may be thus
detected, as may also tenderness.
Dr. Still points out that in diseases of the throat
the sternal end of the clavicle is often found displaced backwards against
the pneumogastric nerve, irritating it and causing the disease.
LUXATION OF RIBS
One of the main objects of examination of the thorax is
to locate misplaced ribs. Departures from normal conformation of spine
are at once indications of lesion of the several ribs. Hence, following
the general examination as outlined above, each rib in particular must be scrutinized.
Landmarks for the location of the various ribs should be employed.
I. Ribs are frequently separated or proximated beyond
normal limits. These conditions are discovered by placing the patient
upon his side and following the successive intercostal spaces with the tip or
side of the examining finger. In the latter lesion the tissues are tender
along the course of the intercostal space, due to irritation of the sensory
branches of the intercostal nerves.
II. The same examination would reveal rotation of a
rib upon its horizontal axis. In such case the intercostal space is unequally
widened or narrowed. As a rule the twisting is about the head as a fixed
point, and the lower margin of the rib is turned out prominently. Then
the intercostal space next below is narrowed anteriorly and widened posteriorly.
The anterior end is tended downward, luxating the costo-chondral and the chondro-sternal
articulations, as it deranges the costal cartilage. The reverse rotation
of the rib may take place, making prominent the upper edge, throwing the anterior
end upward, etc.
III. By various lesions of the ribs, the cartilages
are twisted, distorted or torn loose.
In such case tender points are found upon pressure at the costo-chondal or chondro-sternal
articulations. The cartilage may be bulged forward by protrusion of the
rib, causing a prominent tender point. It may be retracted, causing a
With the patient lying supine, the examining fingers may
be carefully passed over the successive pairs of cartilages and these lesions
IV. The heads of ribs are often luxated, and may sometimes
be easily felt near the transverse process of the adjacent vertebra. This
lesion is most readily found by carefully feeling along the shaft of the rib
upward toward its head, using deep pressure. It may be impossible to trace
the shaft by touch where it is covered by the thick erector spinae muscles.
In such case it is easy to follow the direction of the rib up to the spine.
Deep palpation may reveal the head to be prominent, depressed, or sore.
The FIRST RIB is located by deep pressure behind the middle
or inner one third of the clavicle. If the latter has been found in situ,
comparison with it may be made to determine whether the rib be up or down.
By deep pressure the rib may be traced back toward its head, which is masked
by the lateral cervical muscles. Pressure may be brought upon the head
at the level of the seventh cervical spine, one and one-half inch laterally
This pressure is deeply in the tissues over the region of'
the head of the rib. The latter is, not always easily felt by touch, but
may often be definitely felt out. Sometimes the head of the first rib
is separated from and drawn outward away from its spinal articulation, when
it may be easily felt. This sometimes occurs in cases of exophthalmic goitre.
Dr. A. T. Still points out that lesions of the first rib often cause goitre.
A more reliable method for definitely locating the head of
first rib is as follows: Find the tip of the transverse process of the seventh
cervical vertebra, (XIV, Chap. 3) and make firm
downward pressure just in front of it. As the head of the first rib lies
anterior to the transverse process of the first dorsal vertebrae, the first
bony part felt under this pressure is the first rib in the region of its head.
The sternal end of the rib is located just below the claviculo-sternal
articulation. Its cartilage and shaft may be traced well outward an inch
or more before disappearing beneath the clavicle.
In case it be luxated upward, the cartilage is retracted
leaving a flat area or a depression at the cartilage. If downward, a protrusion
of the cartilage at the edge of the sternum is usual.
In either case the cartilage and the tissues about the rib
are sensitive to pressure.
The first and second intercostal spaces are wider than the
The SECOND RIB is located opposite the junction of the first
and second parts of the sternum. Prominence or depression of its cartilage,
and tenderness in the tissues about it are caused in the same way as in the
case of the first. Its head is located and pressure brought upon its region
at a point one and one-half inches external to the first dorsal spine, upon
a level with the superior angle of the scapula.
THE ELEVENTH AND TWELFTH RIBS are more frequently luxated
downwards because of their anterior ends being unsupported and because of traction
upon the latter by the quadratus lumborum muscle. Their free ends are
readily located except when irritation from them, or other cause, has irritated
the overlying muscles, causing hypertrophy or contracture. In such case
they must be located from the tenth rib.
The free end of the eleventh lies well forward, thus distinguishing
it from the twelfth.
They may be so displaced downward as to be almost vertical; may overlap the
iliac crest, or may be luxated upwards, the free end of the twelfth lying beneath
the eleventh, or that of the eleventh beneath the tenth.
Frequently a luxated rib guides one to a spinal lesion.
Displaced ribs cause disease by mechanical interference with
internal viscera, by irritation of surrounding soft tissues, by dragging ligaments,
impinging nerves, or occluding blood-vessels. One must remember that in
probably most cases of displacement of a rib there is lesion at its head affecting
the related spinal nerves.