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 deduction.

    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 subluxation.

    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 overloaded.

    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 position.

    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 viscera.

    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 and Trendetenburg.

    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
veins.

    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 salivary glands.

    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.