Principles of Osteopathy
Dain L. Tasker, D. O.
CHAPTER XIX - Position for Examination
Observation. - The method of examination should be
somewhat affected by one's getting a sense of the individuality of the patient.
There are many things which one should be trained to observe quickly, such as
the pose and movement of the patient, nutrition, character of the skin, etc.
All of these things give a sense of direction to the examination, i. e., odd
poses, compensatory movements, or cachexias lead one to try to determine the
causes of these very apparent abnormalities. Minor phases of these things
may escape our cursory glance, but it is unwise to commence any examination
without first determining the probable region or regions especially requiring
examination. This does not mean being particularly guided by the patient's
own statement, but rather seeking to exercise one's powers of observation and
We wish it distinctly understood that we are striving
here to explain a special form of examination which is only a part of general
diagnostic work. An examination which comprehends merely the use
of palpation would give a limited understanding of a patient's ailment,
but since this book is concerned with elucidating groups of phenomena which
can quite clearly be recognized by palpation, we will not use time or space
to describe other coordinate methods which are ably taught in other texts.
In order to be systematic in the examination of patients,
it is well to adopt the use of a certain routine of positions which will
best show the details of osseous structure.
Testing Alignment and Flexibility. - The first
position, as illustrated in Fig. 152, flexes the spinal column and makes
the spinous processes prominent. This position is valuable in examining
even very fleshy people. Approximation or separation of the spines
call be noted, also lateral deviation. If the amount of flesh over
the spines, as in fat people, precludes tile use of the
sense of sight, you can ascertain the relation by the sense of touch.
Sense of Touch. - We wish to emphasize the
necessity of the student's acquiring the habit of depending on the sense
of touch, rather than of sight. In all osteopathic examinations,
the sense of touch should be used to obtain those data concerning structure
which form the basis of all diagnosis. Remember that you can not
see bone, muscles and glands, but you call feel them.
Inspection. - While the patient is sitting
erect, ascertain tile flexibility of tile spinal column. Note the
position of the scapulae, whether near or far from the spinal column, whether
unevenly placed. Note the development of the trapezium, latissimus
dorsi, and erector spinae, i. e., observe their surface markings.
If the patient does not voluntarily relax while in the erect position,
ask him to assume his normal posture. This will illustrate the points
of greatest spinal stress and show how the spinal column acts in its normal
weight carrying capacity.
Palpation of the Ribs. - Fig. 153 illustrates
a method of bringing the ribs prominently into view, or in case of fleshy
persons, making it easy to palpate them. By pulling tile arm up and
across the chest, tile latissimus dorsi is stretched which brings the four
lower ribs into a good position for examination. The movement of
the scapula away from the vertebrae makes it easier for the examiner to
feel the angles of the fourth and fifth ribs. It is not well to depend
oil this position for evidence of rib subluxations, because the tension
of the latissimus dorsi brings at least the four lower ribs into proper
alignment. The spacing of these ribs will then be equal.
The chief value of this position is to give the examiner
better opportunity to palpate tile angles of the ribs above the ninth and
to note the changed relations which may take place at the anterior end
of the ninth, tenth, eleventh and twelfth ribs.
Palpation of the Spine. - After gathering
as much information as possible by observing the form of the back, position
of the scapulae and contour of the muscles, examine the spine by means
of your sense of touch. To do this, have the patient sit erect, being
careful not to exaggerate the normal posture i.e., bend the spine far forward
or backward in the lumbar region. A marked tendency to either position
is indicative of weak muscles. Use the index and middle finger of
either hand to carefully note the relations of the individual vertebrae,
as in Fig. 154. Begin at the first dorsal and work downward to the
sacrum. Lateral subluxations are easily noted with the patient in
this position. Gentle digital pressure may be made at the prominent
side of any subluxated vertebra to determine the degree of sensitiveness.
This information is best secured when the patient is reclining, because
the muscles are relaxed. While the patient is sitting there is usually
too much contraction of both intrinsic and extrinsic muscles of the back
to allow much examination, outside of mere study of alignment and normal
or abnormal curves.
Now have the patient recline on the right or left
side, which is most convenient, as in Fig. 155. Examine the condition
of the spinal muscles by using the ball of the fingers of one or both hands.
Be careful not to use the ends of the fingers. Commence your examination
at the first dorsal by noting the amount of sensitiveness directly on or
between. the spinous processes all the way to the coccyx. To elicit
this sensitiveness use a moderate pressure, equal to about six pounds.
With this much pressure the patient will be able to distinguish easily
between the sense of mere pressure and a painful or hypersensitive feeling.
Begin once more at the first dorsal and examine along
the sides of the spines and about three inches from them. This space
brings the internal and middle groups of intrinsic muscles under your fingers.
Extrinsic and Intrinsic Muscles of the Back.
- In speaking of extrinsic and intrinsic muscles of the back, we desire
you to bear in mind the different groups as they are noted in Gray's Anatomy.
Gray divides them into five layers. The first three layers are extrinsic,
i. e., arise from vertebrae and insert into the humerus, scapulae, or ribs.
They depend upon the intrinsic muscles of the fourth and fifth layers to
fix the spine so that operating from the spinal column as a fixed point,
they can move the upper extremities and ribs.
While palpating a back which is moderately well muscled,
you will be able to feel through the upper three layers and distinguish
the condition of the muscles of the fourth layer. It is important
that the student should learn to feel through the soft tissues to harder
ones below. Skill in detecting varying degrees of density and hardness
is an absolutely essential qualification of the diagnostician.
A careful dissection of the fourth layer will disclose
the fact that there are three parallel groups of muscles. The first
is the spinalis dorsi which lies on the side of the spines. The second
group lies more on the transverse processes. The longissimus dorsi
and its continuations make up this group. The sacro-lumbalis and
continuations make up the third group which lies at the angles of the ribs.
Careful palpation will distinguish these divisions.
The Diagnostic Value of Hyperaesthesia. -
Different points, along the line of the first group, which are hypersensitive,
may be evidence of direct strain of a single vertebral articulation, or
the result of a visceral reflex, or even in sympathy with a rib subluxation
which affects sensory
nerves reaching the same segment of the cord from which its nerves
arise. Hyperaesthesia directly upon the spines is usually found in
connection with depression or elevation of the spines, not lateral subluxation.
Hyperaesthesia at points in the second group of muscles,
i. e., the longissimus dorsi and continuations over the transverse processes,
may result from vertebral or costal subluxation, or muscular contraction
caused by visceral reflex.
When this excessive sensitiveness is found at the
angles of the ribs, in the short muscular divisions of the sacro-lumbalis
and continuations, it nearly always signifies an irritation from a costal
The examination of the ribs should be made while
the patient is in this reclining position. The fingers should follow
the angles of the ribs, noting the spacing, special prominence or depression
of an angle, then noting the compensatory changes at the chondro-costal
articulations. In this way the relation of the ribs to each other
can be determined.
When pain exists at any one of the points named,
or the digital pressure arouses a painful reflex, all of the sensory points
along the course of the spinal nerve should be tested in order to determine
the extent of the nerve irritation. Take for example, the point on
the spinal column between the fifth and sixth dorsal. After examining
these two spines and finding them well placed, our digital pressure at
the sides might cause a painful reflex, i. e., the patient might complain
of our pressure. Then we test the point over the transverse processes
and angles of the ribs, and even the junction of the ribs and costal cartilages.
If hyperaesthesia is present at all points in the distribution of the fifth
spinal nerve, we understand that the original irritation may be slight,
but long continued, or strong and of short duration. If no osseous
displacement is discoverable, which has a relationship with a hypersensitive
nerve, we must look for evidence of disturbed functioning by the viscus
most nearly related. The original irritation might have been an excessive
demand on the ability of the viscus, as in the case of the stomach being
In any case, the discovery of what appears to be
an osseous lesion, leads us to test the condition of its related nerves.
If they do not show undue excitability, the lesion is doubtful as a causative
factor. A careful examination of vertebral spinous processes may
show many deviations from symmetrical development, and the diagnostician
should guard against the false evidence of these distorted spines.
If a spine has been distorted by unequal development, there should be no
sensitiveness around it except as the result of a visceral reflex.
In case of such visceral reflex, the examiner can not help being misled
as to the value of the apparent osseous malformation. His fingers
can not inform him that what he considers an osseous lesion is in reality
bad development. The only way lie can escape from making a mistake
is by continuing his examination without holding a positive idea that he
has found the cause. The history and development of the case may
arouse strong doubts as to the value of his discovered spinal lesion.
Your attention is called to this possible mistake
in valuation of a lesion, so that you may not become wedded to the idea
that, when you have found what appears to be a misplacement, you are free
to end your examination and pronounce a competent judgment.
Test Muscular Tension. - While the patient
is on his side, examine carefully the amount of tension in these three
groups constituting the fourth layer. After considerable education
of the sense of touch, it will be possible for you to determine that the
points under your fingers are probably too sensitive. When these
muscles feel hard and unyielding, they are usually sore to pressure.
The contractured condition of the muscle has affected the sensory nerve
filaments in two ways: First, by direct pressure between the contracted
muscle bundles; second, by retention of metabolic waste products which
result in chemical poisoning.
Thoracic Flexibility. - Fig. 158 illustrates
a method of ascertaining the elasticity of the dorsal spine and thorax.
This procedure assists in estimating the general condition of the body.
If the thorax is fixed, inelastic, respiration can not be carried on properly.
Oxygenation of the blood will be imperfect. If desired we may palpate the
spinous processes and the musculature while the patient is in this prone
Examination of the Abdomen. - Fig. 159 shows
the proper position of the patient for examination of the abdomen.
The knees being drawn up allows relaxation of abdominal muscles.
Where the abdomen is very sensitive to the touch, either because of pain
or ticklishness, use the whole hand until the patient becomes somewhat
accustomed to the touch. Sometimes it is necessary for the physician
to lift the feet from the table and flex the knees quite close to the abdomen.
A steady, even pressure of the hand on the abdomen will soon become nonirritating
to the patient, and deeper palpation can be made.
If the examination is a general one, commence your
work, with the patient in this position, by palpating the thorax.
Note form and flexibility, especially the flexibility of the five lower
ribs. The free movement of these ribs is essential to many functions,
chiefly respiration, but it also affords a sort of rhythmical massage to
the liver and stomach.
Such observations of form and flexibility are very
general, but they lead invariably to some clue of especial value in the
search for effects and their causes.
Elevation or Depression of Ribs. - Note the
spacing of the ribs to determine whether any rib is elevated or depressed.
Palpate the chondro-costal articulations for misplacements, especially
note the articulations of the tenth ribs, they are frequently broken loose
and form additional floating ribs. They are usually depressed slightly
under the ninth.
After palpation of the chest, use percussion, then
auscultation, according to the methods outlined in the best textbooks on
diagnosis. By the use of all these physical methods it is possible
to arrive at a very definite conclusion of the state of the thoracic viscera.
The abdomen should be palpated, then percussed.
These two methods should make evident any organic change in the abdominal
Examination of the Rectum and Prostate Gland.
- Fig. 160 illustrates a position for examining the rectum and prostate
gland. Fig. 161 is the well-known Simm's position which may be used
for the same purpose as the preceding.
Other positions used by the osteopath for examination
and treatment are the well-known gynecological positions, genu-pectoral
Examination of the Neck. - For easy examination
of the neck, the patient should be recumbent, as in Fig. 159. The
muscles of the neck must have all tension removed so that the examiner's
fingers can feel the processes of the cervical vertebrae.
A flat table instead of the model shown in the illustration
is better. A hard small pillow may be used to support the head.
Since the spinous processes in the cervical region
are short and bifid, and oftentimes developed unevenly and are covered
with several layers of muscles and ligaments, it is not satisfactory to
use them as landmarks for relations of cervical vertebrae.
The tubercles on the transverse processes are easily
palpated, hence these serve as guides in the detection of slight misplacements
of cervical vertebrae.
The transverse processes of the atlas are usually
large and sufficiently prominent to enable the examiner to ascertain accurately
its position. When the atlas is in its true position, its transverse
processes will be found about midway between the mastoid processes of the
temporal bones and the angles of the jaw. This relationship may appear
untrue when the mastoid processes are quite large or small, or the angles
of the jaw are more or less obtuse. It is necessary to study the
relative development and positions in every case, on both sides, in order
to discover whether a subluxation exists. The fact that nearly all
subluxations of the atlas are twists instead of direct forward or backward
displacements, makes it comparatively easy to detect the inequalities and
understand the faulty position. Sensitiveness will be found in the
tissues on the side whose transverse process is posterior. In case
there is marked sensitiveness on both sides, that is, on the posterior
surfaces of both transverse processes, the atlas is probably drawn slightly
posterior on both sides by the severe contraction of its attached muscles.
The third cervical vertebra seems to be easily subluxated.
It is usually twisted, not sufficiently to lock its articular processes,
but just enough to make the dorsal surface of its inferior articular process
easily palpable through the muscles which lie over it. This prominent
point will be sensitive because the muscles over it are always tense.
Sometimes the sixth cervical vertebra is twisted.
When this condition exists, there is marked disturbance of circulation
in the head. The patient is usually wakeful and excitable on account
of the congested condition of the cerebral blood vessels, caused by the
pressure on the vertebral
Note the tone of all the cervical muscles, the flexibility
of the neck, the temperature of the skin on different part s of the neck.
Palpate the chains of lymphatic glands, the thyroid and the submaxillary
After a thorough palpation of the neck, look carefully
for any evidences of disturbed circulation in the head as may be evidenced
by the appearance of the skin, mucous membrane of the month, the tonsils,
conjunctiva or the wearing of glasses. Your knowledge of optics should
enable you to judge the general condition of the eyes by inspection of
the glasses worn.
Such an examination of the head and neck as herein
outlined should give the examiner a good understanding of the structural
and functional condition existing at the time of examination, and even
guide him to what other parts of the body may need special attention.
The History of Lesions. - All facts as to
structure and function, determined by your examination are historical,
that is, they have dates and circumstances which give them much or little
value. The experienced diagnostician delights in filling in the life
history of the patient to fit the structural and functional changes.
Herein lies the opportunity for the physician to bring to his aid all his
resource of experience and education in judging how these lesions have
been brought about and how they are now influencing other tissues.
The Extremities. - While the patient is in
the recumbent dorsal position, Fig. 159, the lower extremities can be examined.
Note the comparative length of the legs, but be careful to eliminate all
possibility of mistake by observing whether the patient is lying evenly
on the back, ilia same height, and muscles of both legs equally relaxed.
A measurement from the interior superior iliac spine to the internal malleolus
determines the length of the leg.
Palpate the great trochanter. Note its relation
to Nelaton's line. These general directions for examination will
determine the weak, disordered or diseased part of the body which requires
your further careful examination.
Subjective Symptoms. - You will observe that
thus far nothing whatever has been said about asking the patient concerning
his or her subjective symptoms. It is a general principle underlying
osteopathic diagnosis that objective symptoms are the only true facts upon
which the diagnostician dares base his judgment and final verdict, The
nearest approach to a subjective symptom thus far mentioned is hyperaesthesia.
This may frequently be judged by the feeling of the muscle when pressed
upon by the fingers. The muscular reaction to the painful sensory
impressions occasioned by the pressure can be felt. Usually we depend
upon the patient to indicate or corroborate our sense of touch.
In actual practice this process is not carried out in its
entirety. Time is a factor in the physician's life as well as in the life
of the business man. He cannot afford to go about his work in this detective-like
manner. It requires too much time. We hear a great deal of objection
to the physician's question to his patient: "What is your trouble?" But the
answer to it enables him to get quickly to work on the seat of disease or at
least leads him quickly to it. The physician who is a good questioner
saves much time. He does not accept the subjective symptoms, merely goes
to work to prove or disprove their verity by the standards of physical diagnosis.