OSTEOPATHIC DIAGNOSIS AND PROGNOSIS
Osteopathic Diagnosis
In osteopathic diagnosis the spine is the first and greatest object of interest, for on the result of its examination will depend the treatment to be given which is in turn hoped to bring about recovery.
As it is the structure on which rests the weight of the body the practiced eye is able to detect at a glance, by the poise and gait of the patient, if there is an abnormal condition affecting any considerable area of the spinal column. It is well to observe these points, especially in the female, before having them prepare for examination, as it will often give a clue to sources of trouble through faulty carriage, improper dress, particularly corset and shoes. Slight changes of gait, unnoticed by the patient may be of great aid in determining the beginning of disease in the spinal cord.
No osteopath is justified in accepting a patient who will not permit every examination deemed necessary, as remote and obscure lesions are frequently the cause of disease, so preparation of the patient for the first scrutiny is of importance. This cannot be made with the patient fully clothed, as visual observation is second only to the touch in making one’s deductions. Neither can palpation be made through more than one thickness of clothing with accuracy, and examination next to the skin is always preferable. This need in no way ever cause complaint, for with the use of a loose fitting short kimono, with all outer clothing removed except the knit undergarment, and with skirt bands loosed, a complete survey of the whole dorsum from occiput to coccyx can be had without the slightest unnecessary exposure. It is well to remember that the patient has come for help and the osteopath is not justified in sacrificing thoroughness for any exaggerated feelings of modesty. With tact and care in the use of the garments the most sensitive ones need feel no hesitation in coming for treatment.
A complete history of the case should be taken before the examination begins, former methods of treatment, symptoms, environment, etc., as it will aid in the final conclusions. It is well to have blanks for keeping records of all cases.
Probably the most comfortable manner to begin physical examination is to seat the patient on a table squarely with hands placed upon the knees, then raise the garment and expose the whole back. Begin by noting the texture of the skin, if it is clear, pigmented, blotched, or has eruptions. Try the capillary reflex by pinching or stroking quickly with the finger tips or the blunt end of a pencil. Find if it is moist or dry and also outline the areas of changed temperature, if any. Then observe the general contour of the spine with the patient sitting upright, to find how near it is to the normal body curve.
Occasionally having the patient alternately sit and stand will, by comparison, throw light upon the condition. With the patient bending forward place the hands on the crest of the ilia and see if they are of equal height.
Occupation may result in over development of one side or there may be congenital asymmetry[26]. Note position of the scapulæ and habit of posture in sitting and standing.
Before taking up the subject of a critical examination of each vertebra there are certain points it will be well to consider. It is easy to know instantly, without counting, the number of the vertebra causing the lesion if these landmarks are remembered: First, the spine of the third dorsal is on a level with the spine of the scapula. Second, the spine of the seventh dorsal is on a level with the inferior angle of the scapula. Third, the spine of the last dorsal is on a level with the head of the last rib. It will save much time for the busy osteopath to have these well in mind.
The pathognomonic symptoms of the osteopathic lesion are: (a) maladjustment; (b) contracted muscles; (c) tenderness; (d) limited movement. To these might be added changes in local temperature and disturbance of function, but the former is not constant and the latter may be remote. Here the primary lesion is considered, for an osteopathic lesion may be, also, secondary or compensatory. Forbes speaks of compensatory changes as being an important diagnostic sign.
Diagnosis of the position of a vertebra is sometimes difficult to the beginner from its having longer or shorter spines than normal. Horsley speaks of the occasional congenital absence of a spinous process. They may be bent laterally, upward or downward and thus have all the appearances of a marked displacement, while occasionally the body itself seems much at fault. These present what might be termed normal abnormalities and make it necessary for the osteopath to be very sure of his diagnosis before attempting to correct what is not abnormal, for disappointment, at least, and injury, perhaps, may follow.
To avoid mistake, carefully palpate the transverse processes and determine if they are at right angles with the adjoining normal spine. In the cervical and lumbar vertebræ it is possible to reach the tips of the transverse processes, and on moderate pressure, if a lesion exists, pain will be elicited. Further, where tenderness is associated with other diagnostic points it can be safely assumed that a lesion exists, and by outlining the suspected vertebra with the finger and localizing the sensitive spot one can be sure of the point of greatest irritation and the character of the displacement. Associated also with these signs will probably be evidence of congestion, such as thickened tissues, contracted muscles, etc.
After having examined the condition of the spinal column thoroughly by inspection, begin at the first dorsal and examine the spinal column down to the sacrum. Place the middle and ring fingers over the spinous processes and stand directly back of the patient and draw the flat surfaces of these two fingers over the spinous processes from the upper dorsal to the sacrum in such a manner that the spines of the vertebræ pass tightly between the two fingers, thus leaving a red streak where the cutaneous vessels press upon the spines of the vertebræ. In this manner slight deviations of the vertebræ laterally can be noted with the greatest accuracy by observing the red line. When a vertebra or a section of vertebræ are too posterior a heavy red streak is noticed and when a vertebra or vertebræ are anterior the streak is not so noticeable. Thus when suspicious points are noticed a special examination of the localized point can be given. This examination simply takes into consideration the contour and superficial condition of disordered portions of the spinal column. In a few cases such an examination will not be necessary, for the symptoms and signs of the disease will be so clearly manifested that one’s attention will be called directly to the cause. Still, great care should be taken in the majority of cases, as the osteopath finds causes of disease remote from the seat of complaint. We must always bear in mind the significance of reflex stimuli and sympathetic radiation.
In making a critical and exhaustive diagnosis of the spinal condition after the foregoing general examination has been made, it will be best to have the patient lie on the side upon the operating table. When the patient is in this position a more thorough examination can be made, as then the spinal muscles are not contracted unless abnormally so, for when a person is in the upright position muscles are continually contracting first on one side and then on the other, as one of their functions is to act as a support in keeping the spinal column erect. The patient lying on his side, the physician should then stand in front of him and reach over upon the back and make a thorough examination of the affected portions of the spinal column, chiefly through the dorsal and lumbar regions.
Consideration should be given the contraction of the muscles along the back, chiefly the deeper layers of muscles. It may even be necessary to relax some of the muscles before a thorough examination of the vertebræ can be made. From a pathological point of view too much stress should not be put upon the contracted state of the muscles; although in a number of instances the contracted muscles may be the primary cause of the patient’s trouble; especially so when the affection is due to atmospheric and other changes. Contraction of the muscles may be secondary to the lesions presented in the bony frame work. For instance, a dislocated vertebra may be the cause of an irritation to the innervation of certain muscles along the spinal column and thus cause them to contract. Still, we must not lose sight of the importance of the contracted muscles from a diagnostic point of view. They are oftentimes prominent signs that a lesion exists in the immediate region and are thus faithful guides in locating the cause of diseases.
In closing the general consideration of the spinal column it is well to emphasize the importance of training the faculties to grasp at a glance the story told by the back as a region, instinctively placing the proper value on each physical sign and weaving them into a composite whole so that the patient’s condition stands out a vivid picture on the osteopath’s mind. When this is accomplished the more detailed observations are but incidental. Relative to the examination of the spinal column Clark[27] says: “To the osteopathic physician, the most important part of the human body is the spinal column. By its changes in contour and condition the various visceral diseases can be diagnosed, in most cases. I believe that every disease is characterized by extreme changes or signs, and I further believe that every chronic visceral disorder is manifest by changes in the spinal column that can be, by the practical eye and touch, readily interpreted. In short, there are various signs along the spinal column that point out the weakened or diseased parts of the body. This method of diagnosing disease, that is by noting these spinal changes, is distinctly osteopathic, and I believe the time will come when it will become such an exact science that the character of the spinal change or lesion is diagnostic not only of the viscus affected, but the way it is affected.”
Regional examinations and diagnosis will now be taken up.
Neck, Head and Face.—To make a thorough diagnosis of the condition of the cervical vertebræ probably requires more skill and a more acute sense of touch than of any other region of the body. The irregularities and variations of the cervical vertebræ, the numerous muscles and the passage of many vessels through the neck are very liable to mislead one.
One may examine the cervical vertebræ by having the patient either lying down or in a sitting posture. The former position is preferable, as then the muscles of the neck are passive, and besides it is much easier to relax the muscles if such should be necessary. Also one has better control of the field of examination.
It is undoubtedly best for the student when learning to examine the cervical vertebræ to first examine along the base of the skull the condition of the occipital muscles (after the patient has assumed the dorsal position upon the treating table) for any contractions; for if disorder exists in the upper five cervical vertebræ the condition will be manifested by contraction of muscular fibres along the base of the occipital bone. The muscles of the occiput are supplied by fibres from the posterior branches of the upper five pairs of spinal nerves, and if lesions exist to these upper nerves a contracted state of more or less extent of the occipital muscles will occur, no matter how slight the lesion. Thus the examiner after locating contracted fibres under the occiput has a direct clue to lesions existing somewhere in the upper five cervical vertebræ. After locating these contracted fibres of the occipital region and then still keeping the finger upon the contracted muscular fibres and following them downward until the contractions are lost and seem to enter the spinal cord, one has then located the exact point of disorder that is causing the irritation to the muscular fibres involved, and most probably the cause of the affection from which the patient is suffering, i. e., provided one has reason to suspect the trouble is in the cervical vertebræ. Simply follow the contracted muscular fibre downward until it seems to enter the spinal cord and there one will find a lesion. After the osteopath has become expert in diagnosis this will not be necessary unless he has to make a very fine diagnosis or unless he is examining a stout neck where it is hard to examine through the heavy muscles. With this method one has a firm, flat, broad surface to work on (the occipital bone) making it very easy first to locate contracted muscles and second to trace the course of contracted muscles and thus find the disorder. Otherwise the beginner is apt to get confused by trying to examine the condition of the cervical vertebræ. Later, when a student becomes more expert such a procedure will rarely be necessary only in cases that require special work in the examination.
When the point of disorder has been located the diagnosis as to the exact character of the maladjustment has to be determined. The abnormal position of the vertebra, tenderness at the point involved, local contracted muscles, and limited motion are the four diagnostic points, although the temperature of the affected part as compared with the general cutaneous temperature and the state of the local vascular channels (blood and lymphatics) will occasionally be of aid.
Owing to the irregularity of the spinous processes of the cervical vertebræ in regard to their length, great care has to be taken in the examination. Probably there is no other region of the body that will tax the patience of the osteopathic student so much in his practical work as making a diagnosis of disorders in the cervical spine. It requires patient and persistent work to become a fair diagnostician of the cervical region, and it will take much experience to become expert in both the examination and treatment.
One can depend that lateral deviations of the spinous processes are abnormal in most instances. Placing the finger upon the spinous processes of two consecutive vertebras the student can readily tell whether or not there is any lateral displacement; but telling as to other features is impossible as the spinous processes vary greatly in length. When a vertebra is lateral, a slightly twisted condition will be felt by the finger when placed upon and between the two spinous processes.
To elicit the various degrees and combinations of rotation and sidebending one should depend upon the symmetry of the transverse processes. Reaching anterior to the sternocleidomastoid muscle, or better still, pushing the cleido muscles forward and reaching posterior to them upon the transverse processes, a very fair examination can then be given the vertebras. When the vertebras are deranged, especially anteriorly or posteriorly, that is the apposition of the articular facets, a slight elevation will be felt, possibly not any larger than a very small pea, either the anterior or posterior aspects of the transverse processes, depending upon which way the vertebræ are deranged. Remember that accompanying this slight elevation will be degrees of sensitiveness of the vertebra at the point deranged. In cases where the vertebra is lateral a slight eminence will be noted along the outside of the process. Commonly disordered vertebræ are not entirely deranged in one direction but are oftentimes slightly rotated, so we may find them dislocated antero-laterally or in various combinations of sidebending-rotation. Several consecutive vertebras may be deranged in like manner of direction; this condition is chiefly found in pathological curves of the spinal column. Probably the most common general lesion is a strained condition of several consecutive vertebræ, each one being nearly intact but all of them as a whole somewhat strained or twisted. Thus there are many pathological states to take into consideration, although it is not surprising to the osteopath when he realizes that many of our pains and aches are due to anatomical derangement. Frequently bending the head strongly forward and downward, or downward pressure with slight rotation will produce pain at the point of lesion.
Subdislocations of the atlas are probably among the most common lesions presented to the osteopath. Owing to the articulation of the atlas and occipital bone being an anatomically weak point and the neck muscles being exposed constantly to atmospheric changes, besides the articulation between the head and neck receiving the brunt of many jars, falls and strains, the atlas is especially susceptible to derangements. On account of the intimate relation of the atlas to the superior cervical ganglion of the sympathetic and to the vertebral blood vessels it is certainly very necessary that the atlas should be well taken care of. No other tissue maintains such a significant position in relation to the blood and nerve supply to and from the brain. To diagnose correctly the position of an atlas and to be able to correct it is undoubtedly one of the most essential achievements of the practitioner of osteopathy.
The most common disorders of the atlas are anterior and lateral displacements. Next in order come “rotary” lesions of the atlas, i. e., where the atlas has been deranged diagonally or simply twisted. It may also be luxated anteriorly and laterally, or posteriorly and laterally, etc. A posterior derangement of the atlas is comparatively a rare disorder, although owing to the many lesions that are found in atlases one has, during the course of a year’s practice, several to correct. The atlas may occasionally be slightly tipped laterally, anteriorly, or posteriorly, and in a few cases it may be somewhat impacted against the occipital bone. Many times when the atlas is displaced the axis is also deranged on account of the close relation between the atlas and axis by the odontoid process of the axis.
To examine the atlas the patient may be either in the sitting or dorsal posture; it matters but little which position is taken. Possibly the dorsal position is better, as then the neck muscles are more relaxed and if necessary an examination of the cervical spine, below the atlas, can easily be made.
By placing the middle finger of either hand on the transverse processes of the atlas when the patient is in the sitting posture, or the thumbs on the transverse processes when the patient is in the dorsal posture and comparing the two sides, undue prominence of one side or the other can easily be noted. Remember the transverse processes of the atlas are slightly above and posterior to the angle of the inferior maxilla. Always, in examining one side of the patient, compare it with the other; it may save considerable embarrassment. One side may seem abnormal when by comparing it with the other side, both sides may be found the same and still be normal. With the fingers still on the transverse processes note the distance between the process and angle of the jaw, besides take into consideration the tenderness of the locality, and, also, what is of essential importance in all interosseous lesions, its articular range of movements. There should be room enough (approximately) to just comfortably wedge the end of a medium sized middle finger between the transverse process of the atlas and the angle of the inferior maxilla when both are normal. Thus with the fingers on the transverse processes an expert will be able to readily determine whether or not an atlas is lateral or anterior. If an atlas is posterior the distance between the angles of the jaw and the transverse process will be increased, besides the atlas will be quite prominent posteriorly. In conjunction with the abnormality of the tissues (prominence or depression of the bone and state of the muscles) the sensitiveness of the locality is extremely significant.
Outside of displacements of the atlas, a lesion between the axis and third cervical is most common; following next in frequency are lesions of the skull and atlas. By that is meant where all the cervical vertebræ are intact as far as their individual relation is concerned, but the skull is forward, backward or lateral upon the spinal column. This condition occurs quite frequently. To determine its condition the same methods are employed as in diagnosing a deranged atlas; for if the dislocations exist between the atlas and skull the same diagnostic points are presented as far as the skull is concerned as when the atlas, or atlas and axis, are dislocated from the occipital bone or from the axis or third cervical. Following the preceding examinations, additional examination will have to be made to see whether or not the atlas is intact with the vertebræ below. If the atlas is found to be intact with the vertebræ below and lesions are presented between the atlas and the skull, then the disorder must be between the atlas and the skull and nowhere else. Occasionally there are cases where the skull is so far posterior upon the spinal column that the angles of the jaw strike against the transverse processes of the atlas when the jaw is opened widely.
Derangement of the muscles of the anterior and lateral regions of the neck are common. Especially are contractions of the muscles on either side of the larynx liable to occur. In examining the cervical region do not pay too much attention to the superficial muscles, but examine carefully the deeper muscles. It is from these that impingements of nerves and constrictions of vessels are likely to take place in the contracted fibres. Also, imbalance of muscular tension may be the source of the resulting malalignment. In examining for contracted muscles do not gouge into the muscle nor grasp the muscle roughly, but bear down lightly (inhibitory) upon the muscles and then gradually exert firmer pressure. By carefully and firmly exerting pressure over muscular areas the deep muscles can then be felt beneath the superficial ones. Otherwise when the muscles are manipulated severely the superficial ones will contract to such an extent that the deeper ones cannot be felt. The muscles contracting on either side of the larynx tend to draw the larynx downward and thus there may arise a source of irritation. The various muscles contracting in the antero-lateral region of the neck are very often the source of chronic irritations of the pharynx or throat. The omo-hyoid muscle may become contracted and cause slight traction on the hyoid bone and thus produce an irritating cough. To examine the muscles of the neck thoroughly it is best to have the patient flat upon the back, for then all the normal muscles are relaxed.
Lesions quite frequently occur in the temporo-inferior maxillary articulation. The lesion may be either unilateral or bilateral, more commonly the former. The disorder usually consists of a relaxation of the muscles and ligaments about the articulation which allows a slight but perceptible dropping of the inferior maxilla on the side involved. In other cases there may be presented a spasticity of tissue, while in still others some degree of joint infection may be found. Lesions of this articulation particularly impinge upon fibres of the fifth cranial nerve. The points of diagnosis are clicking and tenderness at the articulation. These two points are the symptoms of which the patient complains; those noticed by the osteopath are a slight deviation of the jaw to one side or the other when the jaw is opened and a flinching of the patient due to tenderness when pressure is exerted over the articulation of the jaw. When the physician places his fingers around the jaw, anterior to the angles, and the thumbs over the bridge of the nose, having patient open the mouth, at the same time exerting pressure with the fingers and thumb, a sharp click may be elicited by the return of the jaw into its articulation.
In disease of the scalp the condition of the muscles of the scalp should be taken into consideration. The muscles are usually found contracted. The contraction of the muscles is generally due, as well as the disease of the scalp, to derangement existing in the posterior branches of the upper five pairs of the cervical spinal nerves.
In the neck, anteriorly the hyoid is the only bone to consider. It is easily palpated by standing at the head of the table and with the second finger of each hand outline both ends to ascertain its relation with the thyroid cartilage. Note carefully any contracted tissue or glandular enlargements which might cause undue tension. The tilting of either end of the hyoid from these contractions is productive of much throat irritation. At the same time the larynx may be examined. It may be prolapsed, causing irritation of the laryngeal group of nerves. The thyroid and cervical glands should be palpated for enlargements, and all the muscles and ligaments for contractions. Externally the tonsil may be felt by deep pressure in front of the angle of the inferior maxilla.
The Ribs.—Under the osteopathic diagnosis of the ribs will be included the examination of the clavicle and sternum. To be able to diagnose intelligently, the position of the ribs in detail is very necessary to the osteopath. Many of the diseases of the heart and lungs, besides a large number of the diseases of the digestive tract, may be traced to a deranged rib; also, occasionally diseases of different regions of the head and neck may be due to dislocated ribs. In making a thorough examination of the ribs each rib should be carefully noted as to its position. The ribs may be examined when the patient is sitting up; but it is better to have the patient flat upon the back and especially so if the floating ribs are to be carefully examined, because the muscular tissues of the side if contracted will interfere with the diagnosis. In many instances the rib lesion is secondary to a vertebral subluxation.
An expert osteopathic diagnostician will be able to detect at once by a single passage of the hands down over the ribs if there are any disorders of them. In passing the flat of the hand, especially the flat part of the fingers over the ribs, carefully observe if the intercostal spaces are too narrow or too wide, and if any of the ribs are unduly prominent or depressed. If an intercostal space is too narrow it shows that the ribs on either side of the intercostal space are too close together. Then the question arises, which one of the ribs is crowding upon the intercostal space, or whether both of the ribs are crowded together. Usually when the sternal end of the rib is displaced upward, the involved rib is prominent and when displaced downward the rib is depressed. Thus it is commonly easy to diagnose which is the involved rib. Besides finding an abnormal position of the rib there will be more or less tenderness over the rib. Finding a rib prominent or depressed and tender is generally quite conclusive that the rib is displaced. Then the range of movement as expressed through the sense of resistance is a helpful guide in diagnosis.
If a typical rib is placed upon a flat surface and one end of it is depressed the other end will be elevated and vice versa. This peculiarity holds true as well when the ribs (typical) are dislocated in the living body. If the anterior end is elevated the posterior end is commonly depressed and vice versa. Care should be taken in examining the first rib and the false ribs, for in these ribs this peculiarity is not found.
As a whole a very complete diagnosis can be made of the condition of the ribs by examining the anterior part of the thorax, although it is always best to examine along the angles of the ribs if for nothing more than to confirm the diagnosis made at the sternal ends. Still it must be remembered that the preceding only holds good when the entire rib is dislocated. Many times simply one end of the rib is deranged and the other end is practically intact.
Besides careful examination of the sternal end of the rib, attention should be paid to the condition of the costal cartilages. The costal cartilages may become deranged at either the articulation with the rib or with the sternum. The same rule holds good when the costal cartilages are dislocated as when the ribs are dislocated, i. e., when the cartilages are prominent, they are usually displaced upward and when depressed the cartilage is displaced downward toward its neighbor.
One is apt to think that a rib is only dislocated at its vertebral end. Although lesions of the vertebral end are generally of greater significance as far as the etiological factors are concerned, still the sternal end of the rib must not be overlooked. In examining the vertebral end of a rib attention should be paid the angles of the ribs, for at the angles a better opportunity for examination is given on account of the prominence. It will be necessary in many cases to find out whether or not the vertebral end of the rib is lying between the transverse processes instead of in front of them. In many severe lesions of the ribs the vertebral end of the rib is dislocated upward or downward from the transverse process of the vertebra and lies between the transverse processes of the vertebræ above and below its attachment. This certainly requires considerable skill in the diagnosis, for oftentimes the point to be found is barely an eighth of an inch in diameter. It is usually best before making such a close examination to relax the tissues well over the field of examination.
The ribs as a whole may be too transverse or too oblique upon one side. This is chiefly found in pathological curves of the spine, but still such conditions may exist where there are severely contracted muscles, especially in some cases of paralysis. Thus the contour of the ribs must be taken into consideration by comparing one side with the other.
In examining the first rib an examination somewhat different from the other ribs should be given. It is best to have the patient assume a sitting posture; then place the middle fingers of each hand upon the first ribs near their centers and compare one with the other. Also note the difference of the spaces between the ribs and clavicles. Generally the first rib is dislocated upward, rarely downward. Besides finding an abnormal prominence or depression of the rib at its center considerable tenderness will be noticed. Examinations of this region are every day experiences with the osteopath.
When diagnosing the position of the floating ribs it is best to have the patient lie flat upon the back with the thighs flexed upon the abdomen, so that the tissues about the lower ribs may be entirely relaxed. Then by placing the flat of the fingers carefully over the ribs the outline and position of them can be easily discerned. The floating ribs are oftentimes found deranged and are the source of a great deal of suffering through the iliac regions. These ribs may become dislocated from the vertebral ends and drop down obliquely toward the iliac crest, or else the free end may become locked beneath the rib above. Occasionally both ends of the rib drop down quite perceptibly and consequently is the cause of considerable distress. In such instances the rib is depressed inward so that the normal contour of the lower thorax is lost.
An examination of the clavicle should be carefully made. Always compare the clavicle with its fellow and examine thoroughly its articulation with the sternum as well as at the acromial prominence. Often the sternal end of the clavicle is slightly dislocated posteriorly to the sternum; although it may become completely luxated. The acromial end may be dislocated upward or downward.
In examining the sternum special attention should be given the articulation of the manubrium and gladiolus. This is due to the crowding anteriorly of the articulation of the sternal parts. Normally until well along in adult life there should be some movement here due to its membranous attachment. Occasionally the ensiform cartilage is turned inward, producing a tender point, but this rarely occurs. Also the articulation of the cartilages in the region of the eighth, ninth, and tenth ribs may be found considerably deranged, causing local tenderness and even stomach trouble.
Dorsal and Lumbar Spinal Region.—With the patient sitting on the table abnormal deviations can be readily noted. There may be lateral swerves, from muscular weakness, or unilateral tension, involving the whole spine or less, or a reversal of natural curves, i. e., the spine depressed anteriorly between the shoulders and posteriorly in the lumbar making the straight spine. There may be, also, an exaggerated normal curve in the dorsal region producing a kyphosis with a compensatory lordosis in the lumbar region sufficiently great to change its relations with the pelvis. By the method previously given, now outline the spinal column for lateral and bilateral scoliosis. These, frequently, are at their incipiency, and to the casual observer would pass unnoticed. It is well to make an outline of the spine before beginning treatment, and at times following, that progress may be observed. A simple method is lead tape which can be had from any plumber shop and can be molded to the deformity and traced on paper together with date of examination. H. F. Goetz has perfected an appliance for outlining and recording these deviations. Observe well the ligaments, as well as extent of joint movement, under deep palpation; from irritation they may become thickened and more or less fill the spaces about the spines and transverse processes, causing a rigid, smooth spine.
To make a detailed examination the patient should be stretched out on one side upon a treating table, although the general examination may be sufficient. Then, standing in front of the patient and reaching over him, a most careful diagnosis can be made. Do not stand back of the patient as the flat of the fingers can not be used to advantage in outlining the different vertebræ. The various contracted muscles that may be found along the spinal column will be of valuable aid in locating derangements of the vertebræ and vertebral ends of the ribs. By using contracted muscles along the spinal column as a guide for locating lesions, reference to the large superficial muscles is not made, but to the small areas of contracted fibres of the deep muscles. It is the deep muscles that become more or less contracted, and even fibrotic, when lesions of the vertebræ and ribs exist. The superficial muscles are generally contracted by atmospheric changes, slumped postures, wrong habits, etc., and are not generally the result of disorders in the osseous system. The preceding points in regard to contracted muscles cannot be too carefully observed for there is a tendency among many osteopaths to treat the contracted deep muscles as primary lesions in nearly every case. Remember that if they are not due to the motor nerve fibres of the muscles being irritated by the spinal lesion, or to a reflex stimulus, or to a compensatory change, that although the muscular tension may be the inception of the almost certain interosseous lesion, still the leverages secured through bony adjusting are very essential not only in correcting the osseous malposition but in loosening and releasing fibrous muscles and thickened ligaments.
Thorax.—Examination of the thorax as a region has been largely gone over in speaking of the ribs and their sternal attachment, cartilages, sternum and the clavicles, but its appearance as a whole should be carefully noted for it will be a valuable aid in diagnosis. Deviations from the normal, such as the emphysematous or barrel-shaped chest in asthmatic affections, or chronic cough, or accompanying kyphosis, the flat chest and its association with phthisis, the rachitic, etc., should be considered. Spinal deformities are reflected in the thorax by marked changes in contour, such as elevations and depressions corresponding to the spinal changes. These result in marked interference with the thoracic organs and in young subjects are of particular interest. Rib changes are frequently the result of vertebral deviations.
Abdomen.—The position for examination of the abdominal viscera is usually with the patient supine, head slightly elevated, knees drawn up partially and supported to relieve any muscular strain, and with the hands at the sides. In this position complete relaxation is obtained. Observe any enlargements from gas, fluid, or tumor, muscular changes, color, etc. The patient may, also, be placed upon the side, and in the knee-chest position for further verification of the diagnosis. Where the abdominal wall is much relaxed, or there is a pendulous abdomen with enteroptosis, there will be found a change of relations of the viscera by these different positions, allowing them to be palpated in another position. When there is marked tenderness it is often possible to go deeper with less discomfort with the patient in the knee-chest position. The Trendelenburg position may also be utilized. Where ascites is suspected palpation should be made with the patient in various positions in order to note changes of location of the fluid. Frequently much can be learned by inspection with the patient standing. Clues to visceral disturbance can often be had by tracing the nerve connection from the spinal lesions to the suspected part.
In examining the liver care must be taken that any gouging or severe bruising of the organ does not take place. The liver can be outlined by percussion and also by palpation of its lower and inner borders Congestions, atrophy, enlargement or hardening should be noted, also any change in position.
A rather complete examination can be given the biliary tract from the gall-bladder to the duodenal orifice of the biliary duct. By a careful inhibitory pressure over the duct the outline of the tract can be discerned providing the patient is not too stout. When the tract is swollen considerable tenderness will be present. The patient will complain of a stabbing or piercing pain upon pressure and manipulation if the duct is inflamed.
Usually the tenderness is greatest nearer the duodenal orifice. The duodenal orifice is about one and one-half inches diagonally downward to the right from the umbilicus. In cases of impacted gall-stones the osteopath as a rule has very little trouble in locating the stone.
The spleen may be percussed and when in a markedly enlarged condition its lower border can be palpated. Great care must be used in the latter condition as there is danger of rupture.
In examining the stomach the usual methods of inspection, palpation, percussion, analysis of the contents, etc., are employed.
Palpation and manipulation over the intestines are practiced a great deal by the osteopath in various intestinal diseases. By his educated sense of touch he is usually able to locate at once any impactions of fecal matter. Such impactions are generally found in the ilio-cecal and sigmoid regions. In the various acute obstructions from invagination, tumors, twists, adhesions, spasticity, knots, etc., many times one is able to readily locate the seat of the disturbance. There is one point to specially emphasize; that is, do not overlook prolapsed regions of the intestines; such occur frequently and are a source of considerable distress, especially constipation. Simple manipulation will never do much good, neither will spinal treatment or injections, as a rule. A specific treatment must be given and, that is, after locating the exact point of prolapse, to reach carefully beneath the fold and replace it.
In emaciated subjects the kidneys can be readily located, and in a few instances when they are diseased one can feel the contracted tissues about them. Be very careful not to injure the capsule about the kidney. Do not punch or gouge them in the least; but locate the kidneys by a careful inhibitory palpation.
Lumbar and Pelvis.—The intimate relation between the lumbar spine and pelvis make a consideration of them as a region necessary. Outside of ordinary curvatures involving both the dorsal and lumbar regions there are certain conditions which involve but one structure and require careful differential diagnosis to determine whether the lumbar or pelvis is at fault. In the former the fifth vertebra is a weak point and is most frequently at fault. The deviations are usually a sidebending and frequently accompanied with some rotation. Occasionally a malstructure of the lower lumbar or pathologically relaxed ligaments will approximate the spines and be misleading as to the real condition. A rotation or lateral tilting of the fifth lumbar may have the effect of elevating the crest of the ilium so that the innominatum would appear involved. There will be a difference in the length of the legs, angles of feet when patient is lying on the back, anterior spines out of line and tenderness of the muscles attached near them. However, other diagnostic points of innominate lesions, i. e., tenderness of symphysis and sacro-iliac articulation, and prominence of the posterior spine, will be lacking. Marked deviation of other lumbar vertebræ may produce practically the same effect, but the lesion will be so apparent that there will be no doubt as to the cause.
To be able to diagnose accurately and intelligently the pelvic region requires nearly as much skill as in examining the cervical region. The pelvic bones are liable to many subdislocations, especially in the female. However, it should be remembered that many apparent innominate lesions are secondary or compensatory changes due to lumbar lesions. The pelvis as a whole may be tipped anteriorly or posteriorly upon the spinal column. It also may be twisted or rotated laterally upon the spinal column. The most common lesions are subluxations of an innominatum forward, backward, upward, or downward, or various combinations of these displacements, such as a tipping forward and downward of an innominatum, or a tipping backward and upward, but these combinations do not always exist in the manner given. As a rule when the ilium is anterior, the ischium posterior, then the innominatum as a whole is downward; when the ilium is posterior, the ischium anterior, then the innominatum as a whole is upward. This is only a rule, there are exceptions to it; for in some few cases when the ilium is anterior, the ischium posterior, the innominatum may be higher, and when the ilium is posterior and the ischium anterior the innominatum may be lower.
To be able to diagnose such derangements will require skill and practice; still there are symptoms and signs that are characteristic of such disorders. In examining the pelvic bones have the patient flat upon the back at first. Be sure he is flat upon the back for a very slight variation may make considerable difference in the relation of the pelvic bones, one to the other, so far as the diagnostic points are concerned. Then go to the feet of the patient and grasp the ankles firmly, rotate laterally both legs, first to one side and then to the other, as well as pull and push both limbs slightly, and then bring the heels together directly in the median fine of the body and compare the length of the limbs at the heels. If there is any disorder whatever in one innominatum, and the thigh muscles have been relaxed thoroughly by the preceding movements and the heels are brought together in the median line of the body, a difference in the length of the limbs will readily be observed at the inner malleoli or the heels. For if the ilium is forward the ischium must be backward and as a rule the innominatum is thrown downward, thus causing an apparent lengthening of the limb which will be noticed by comparing the heels; if the ilium is backward the ischium must be forward and as a rule the innominatum is then upward, causing an apparent shortening of the limb on the affected side. A very slight variation in the pelvis will make considerable difference in an apparent lengthening or shortening of the limbs. Such conditions are generally met with several times a day by osteopaths. The object of the lateral rotary movement and the pushing and pulling of the limbs is to make sure that all the thigh muscles are thoroughly relaxed, for it is a very easy matter for contracted muscles in one thigh to produce an apparent shortening of the limb. Also be very careful in comparing the length of the two limbs at the heels where they come together that they are exactly in the median line of the body, for if they should be to one side or the other, however slightly, there would be an apparent lengthening of the outer limb as compared with the limb near the median line. While the patient remains flat upon the back it is a good plan to compare the anterior spines of the ilia. It may be readily noticed that one is higher or more depressed than the other, which will help to confirm the diagnosis. It is a good plan also to have the patient sit up squarely upon the table and compare the crests and posterior spines of the ilia; thus one may be seen to be higher than the other. Then, also, note the angles of the feet when patient is supine; an everted foot usually means that the limb is shorter due to the tilted pelvis; the opposite is commonly true when the foot is inverted. However, this is not an absolute rule. Care should be taken in differential diagnosis of possible old fracture of leg, of infantile paralysis, of asymmetry, etc.
There are three diagnostic points exclusive of all other signs that are quite conclusive when coupled with the preceding examination. If an innominatum is dislocated or subdislocated there will be tenderness over the symphysis pubis on the side affected, tenderness over the ilio-sacral articulation on the side affected, and tenderness along the crest of ilium where the abdominal muscles are attached. When tenderness is found at these three points it is quite conclusive that the innominatum is deranged, for at the symphysis pubis and ilio-sacral articulation tenderness must exist if the innominatum is disturbed, and by a change in the crest of the ilium the abdominal parietes will be affected, provided they are not too much debilitated. Marked tenderness of the external cutaneous nerve as it passes over the crest of the ilium below the anterior spine will be noticed on the unaffected side (Dr. Still). There will be, on rectal examination, marked tension of the tissues on the affected side. Possibly the patient may complain of pain exclusively in one side along the pelvis and limb which will be a leading symptom telling which side is affected.
Additional diagnostic signs will be rigidity of muscles along the ilio-sacral articulation and abnormal prominence or depression of the ilium at its articulation with the sacrum, depending upon which way the innominatum has slipped. Considerable deviation of the pubic bones may be noticed. The pubic bone on the side affected may be either thrown upward or downward.
Radiographs have repeatedly revealed subluxations of the innominate bones in many instances. This is certainly quite conclusive in confirmation of the osteopathic ideas in regard to the pelvic bones becoming dislocated.
Sacrum.—Examination of the sacrum is best made with the patient lying on the side, with the osteopath standing in front and with the hand palpate its posterior surface. In the sitting posture its relation with both innominates can be determined. It is displaced posteriorly but seldom, the most frequent being anterior, downward, and a combination of the two. In the anterior conditions tenderness at the sacro-iliac articulations is a good point, but it must not be confounded with an innominate lesion. The downward displacement is shown by comparison with the lower lumbar vertebræ. Observe the relation between the two, as a change in contour of the spine will also change the angle of the sacrum and vice versa.
Coccyx.—With the patient and operator in same position as for the sacral examination outline the coccyx, as to first, contour; second, rigidity; third, sensitiveness. If abnormalities are detected go to the other side of the table and with a well lubricated index finger palpate its anterior surface. Changed contour, displacements, and old fractures can be readily determined. The most common deviation is anterior at its union with the sacrum. The lateral form generally resulting from muscular contraction is next, with posterior but seldom. “If the lower part of the sacrum is rotated backward, the sacro-coccygeal articulation or angle is affected or becomes more acute, since the tip of the coccyx is not displaced, but held in position by structures attached to it. If the sacrum is displaced downward the effect is about the same. Often this sort of sacral lesion is mistaken for an anterior luxation of the coccyx.”[28] Remember that normally there should be some movement of the coccyx. It has a fibro-membranous articulation.
Uterine, ovarian and rectal examinations are largely of the same nature as those given by other practitioners, although osteopaths find that oftentimes other practitioners are mistaken in regard to the etiology of many diseases to which these organs are subject.
Arms and Legs.—There is comparatively little that is exclusively osteopathic in regard to the diagnosis of disorders of the arms and legs. One important feature that the osteopath finds in examining the arms and legs is that many of the disorders supposed to originate in the affected member are found to be caused from vertebral or rib dislocations. Innominate and lumbar lesions are particularly fruitful sources of trouble in the legs and feet. Always carefully examine the spine in the region of innervation to the arms and legs when they are affected. The shoulder and hip joints, as well as all joints, are subject to partial dislocations. Many times when pain or other symptoms are presented in the arms or legs the trouble is at the shoulder or hip joint or in the spinal column. There are two regions that are very apt to be overlooked in the examinations of the arms and legs and they are the elbow joint and the fibula. The small bones of the ankle and wrist as well as of the foot and hand are subject to many dislocations which are easily discerned upon examination and often overlooked. Special emphasis should be given in regard to many supposed diseases of the knee joints which are really caused by lesions in the spine or at the hip joint.
Osteopathic Prognosis
Everyone is of the opinion that to forecast the probable result of a disease is one of the most difficult problems the physician has to meet. To state the duration, course, and termination of an attack of disease as presented by its nature and symptoms implies an accurate knowledge of both disease processes and changes, and an insight into the individual’s idiosyncrasies backed by ripe clinical experience. And after each of these factors has been carefully considered to balance one against the other, nothing short of superhuman knowledge may present a sufficient insight in order to render an accurate prognosis. A prognosis represents the culmination of one’s learning, an understanding of disease characteristics, and an insight into temperament.
C. M. T. Hulett[29] says: “Only when we can know all the conditions, causative and sequential, with their possible complications and terminations, together with a full history of therapeutic results in a large number of similar cases, and carefully analyzing and weighing these various elements, are we prepared to really make a prognosis.” Nettie H. Bolles[30] writes as follows: “The prognosis depends upon the cause of the disease, the possibility of removing the cause, or the likelihood of recurrence of causes, and the chances of avoiding such recurrence. The circumstances to modify the outlook are various and deserve careful consideration.” It is not the purpose here to go into the many essential details, for that would mean an outline and forecast of all disease processes, and the effect of numerous extenuating circumstances. The medical profession have been gathering data for these three thousand years and prognosis with them is still inaccurate and incomplete. Osteopathic science will add just so much to the accuracy of prognosis as the sum total of the knowledge displayed in the fields of osteopathic etiology, diagnosis, pathology and therapeutics. Suffice it to give here a few salient practical hints as noted in the osteopathic treating room and at the bedside.
Osteopathically it may be said that prognosis depends, first, upon the true conception of osteopathy; second, upon the relative value of all factors pertaining to health and disease; and, third, upon the skill (technique and native ability) of the osteopath. The first and second being granted, the third includes a remarkably practical and pregnant field, for in no school does the physician get into as close touch and understanding of the actual condition of the patient’s disorder as in the osteopathic. Although the fundamentals and principles of the osteopathic conception of diseases are really broad, liberal, and all-inclusive, still owing to the fact that each individual (and thus each disease) is more or less a law unto himself should there not be absolute tables and prescriptions to be governed by; remember, however, this does not imply our fundamentals are not basic or our principles are not truths, but rather the application and execution of the same are as varied as the individual’s constitution, temperament, and disease. Herein rests the really difficult practical consideration of etiology, pathology, diagnosis, treatment, and prognosis. In other words, if the diagnosis and treatment are accurate the result rests entirely with the patient.
First, too much emphasis cannot be placed upon the fact that prognosis is dependent upon the osteopath—his education, training, ability, experience, and technique. One’s fitness is most important. And fitness and personality complement each other. An osteopath may know theory and still not be practical; still one cannot be practical unless he knows theory.
Second, osteopathic treatment frequently changes the usual course of acute disease. It is well known that many diseases have a certain regular course in their history. Many times the osteopath will be able to abort, lessen the severity, or cut short the ailment, thus changing the recognized symptoms and termination.
Third, the knack of treatment, or knowing how to treat, not only one region of the body but all regions, not only one temperament but all temperaments.
Fourth, the preparatory treatment before correcting the lesion. Prevention, palliation, or cure, and thus prognosis, may be dependent upon a necessary preparatory treatment. Here is where a study of the patient’s temperament is very essential.
Fifth, a prolonged treatment may defeat one’s purpose. As a rule a comparatively short, thoroughly indicated, specific treatment is best.
Sixth, much, relative to prognosis, can be told by the tone of the vertebral ligaments. When a lesion corrects too easily or does not remain well in place it shows a lack of tonicity on the part of the ligaments and muscles. Improvement is in direct ration to the increase of tonicity.
Seventh, special care should be taken with the irritable spine. This spine commonly precedes the debilitated spine. Unless precaution is taken to apply inhibition before treating specifically a cure may be prevented or at least the disorder prolonged.
Eighth, relaxation of muscles is not always essential, although the lack of it may prevent the correction of primary lesions. The relaxation should be carried out with care in order that all shock and irritation may be kept at a minimum.
Ninth, needless stretching, traction, extending, rotation, and snapping of the neck is not only useless but may be positively dangerous. Rarely is it necessary to go through the above “movements” as many are accustomed to do.
Tenth, it may be necessary, but not always, to give as additional treatment, after the anatomical defect has been specifically treated, a certain amount of stretching and moulding of the parts.
Eleventh, owing to the close personal relations of physician and patient, personality has a powerful influence on prognosis.
Twelfth, too much emphasis cannot be placed upon the uselessness and injurious effects of over and misapplied treatment.
All of the above have a positive bearing on prognosis. The osteopath should study his technique well. He will find that it gradually changes and improves from year to year. In a word, as he gains in experience he will become more skillful by giving careful attention to the development of the sense of touch, by noting the resistance of the tissues, and a score of details that are very hard to describe but the sum total of which determines and indicates the successful osteopath.
Another practical point that bears upon prognosis as well as upon the health of the osteopath is the manner of giving treatment. First, the height of the treating table should correspond to the height of the practitioner. The table should be made for the practitioner and not the practitioner fitted and warped according to a certain table. Second, give part of the treatments on a treating stool. Here there is greater freedom of movement on the part of the patient, hence greater and more effective leverage can be obtained. Suit your treatment to the patient, not your patient to the treatment. Third, make your weight count for energy expended in the treatment. As soon as one set of muscles become tired substitute another set, e. g., the back muscles and the arms, the arms and the hands. Fourth, whenever possible substitute the weight of the patient for expended energy. Fifth, when lifting keep the spinal column straight; do the bending of the body at the knees. Hence a better treatment and a more favorable prognosis, and besides that new occupation neurosis, the “osteopathic back,” will be materially lessened in both severity and frequency.