The Practice and Applied Therapeutics of Osteopathy Charles Hazzard, D. O. 1905      CHAPTER VI   EXAMINATION OF THE THORAX  
 
    From an Osteopathic point of view, and not at present considering the contents of the thoracic cavity, the examination of the thorax consists mainly in discovering, by palpation and inspection, whether its bony structures are all in position.
    Ligamentous and muscular lesions, also lesions of blood vessels, nerves, and centers are closely associated with bony lesions.
    The relations of the thorax to the spine as a whole and to its own contained viscera cause its lesions to be among the most important ones found in the body.  Lesion of the spine, especially of its thoracic portion, often seriously affects the thorax proper.
    INSPECTION reveals change in the general conformation of the thorax.  It is made with relation to the spine, and effects of spinal irregularities are considered.  Flattening or prominence of the ribs, either in portions of the thorax or affecting it as a whole; restriction or increase in the movements of the thorax, upon one or both sides; color of the skin, eruptions. scars, etc., are all noted.
    Change in the general conformation of the thorax is significant of the presence of many lesions.  Often a single glance assures the examiner of the presence of many lesions which are closely related, and which, as experience teaches, are all in a train of abnormalities, so that he is practically sure from the beginning that he will find present certain various lesions.  A weakened condition of the spine, allowing of lateral swerving of its vertebrae or of changes in its normal curves is apt to be found causing a weakness of the costo-vertebral ligaments.  The ribs are therefore not held in their proper relation to the spine, the whole thorax is weakened, and the ribs sag downward, narrowing the antero-posterior diameter of the chest, or otherwise distorting it.  The foundation is thus laid for the various diseases of heart, lungs, etc. The angles of the ribs are approximated and become prominent along the postero-lateral aspects of the chest, or "stand out in rings under the shoulders, " as Dr. Still says.  This narrows the thorax so that a lateral view of it shows the axillary and infra-axillary regions narrowed, and the examining hand swept down along the angles finds the lateral span of the chest much decreased.  The two sides may differ.  The ilio-costal spaces are narrowed, sometimes to the extent of obliteration.
    In case of a lateral swerve of the spine the ribs upon the convex side are found to be more oblique, and their inter-spaces are narrowed or obliterated.  At the same time the whole thorax may be altered in shape as above described.
    The patient may sit, lie, or stand during inspection, as most convenient.
    PALPATION, the more important method, proceeds in conjunction with further inspection, and is used in the detection of the various special lesions to be described.
    I.  With the patient standing or sitting, the palms of the hands are passed evenly over the anterior and posterior aspects of the chest, comparing side with side; region with region.  The temperature is also noted.
    II.  The precordial region is examined for any protrusion or retraction of the thoracic wall, significant with relation to heart disease.
    III.  Each lateral half of the chest is examined for change or lessening of its antero-posterior diameter, considering the direction of the component ribs as well.  Lessening of this diameter, and a tenderness of the ribs to greater obliquity in direction, reveals a flattened side or sides of the chest.  This shows spinal lesion generally, also disturbed ligaments, blood-vessels, nerves, etc., of all related parts.  In this case the whole side is dropped down and the ilio-costal space is lessened.
    People with such lesions are always poor breathers because of the extra effort required of weakened muscles to raise the disarranged ribs.  They, therefore suffer, in addition to the results of specific lesion, from the various evils of congestion and imperfect oxygenation consequent upon poor rib, chest, and lung action.
    IV.  The same lesion may affect a portion of the thorax.  Often flattening of the ribs posteriorly beneath the scapula is found.
    Protrusions or retractions of one area of the chest generally correspond with the reverse condition in the corresponding anterior or posterior area.  This is not true in case of slipping of the ribs downward.
    V.  Marked depressions in the supra or infra-clavicular regions are significant in the diagnosis of tuberculosis of the lungs.
    VI.  With the patient lying on his side, the palm of the hands swept along the lateral and postero-lateral aspects of the chest, from the shoulder downwards.  Changes in the position of the ribs individually, or in the combination of the side of the thorax in question are thus readily made out, mainly by detection of changes in the angles of the ribs from normal.
    The STERNUM must be examined.
    I.  It may be as a whole, protruded or retracted following a change in the general shape of the thorax.
    II.  Luxation between the first and second parts, anteriorly or posteriorly may occur.
    III.  The ensiform may be displaced laterally.
 
 
THE CLAVICLE AND CORACOID

    The latter is located as the first bony prominence at the outer end of the infra-clavicular fossa.  Its relation to the clavicle is to be noted, also the condition of the tissues attaching to it.
    The clavicle may be luxated at either its sternal or acromial articulation.  The sternal end may be upward, anteriorly or posteriorly from its normal position.  The acromial end may be displaced downward toward the coracoid or upward upon the acromion process.  Sometimes the bone is tilted so that one's fingers may be thrust from behind its upper edge.  These lesions are generally easily detected by inspection and palpation.  The examination of the sternal end is often facilitated by having the patient lie flat upon his back, then pressing the tip of the examining finger down deeply upon the sterno-clavicular junction, at the same time comparing it with its fellow, which should be felt out by the other hand.  Very slight depressions or elevations may be thus detected, as may also tenderness.
    Dr. Still points out that in diseases of the throat the sternal end of the clavicle is often found displaced backwards against the pneumogastric nerve, irritating it and causing the disease.
 
 
LUXATION OF RIBS

    One of the main objects of examination of the thorax is to locate misplaced ribs.  Departures from normal conformation of spine are at once indications of lesion of the several ribs.  Hence, following the general examination as outlined above, each rib in particular must be scrutinized.  Landmarks for the location of the various ribs should be employed.
    I.  Ribs are frequently separated or proximated beyond normal limits.  These conditions are discovered by placing the patient upon his side and following the successive intercostal spaces with the tip or side of the examining finger.  In the latter lesion the tissues are tender along the course of the intercostal space, due to irritation of the sensory branches of the intercostal nerves.
    II.  The same examination would reveal rotation of a rib upon its horizontal axis. In such case the intercostal space is unequally widened or narrowed.  As a rule the twisting is about the head as a fixed point, and the lower margin of the rib is turned out prominently.  Then the intercostal space next below is narrowed anteriorly and widened posteriorly.  The anterior end is tended downward, luxating the costo-chondral and the chondro-sternal articulations, as it deranges the costal cartilage.  The reverse rotation of the rib may take place, making prominent the upper edge, throwing the anterior end upward, etc.
    III.  By various lesions of the ribs, the cartilages are twisted, distorted or torn loose.
In such case tender points are found upon pressure at the costo-chondal or chondro-sternal articulations.  The cartilage may be bulged forward by protrusion of the rib, causing a prominent tender point.  It may be retracted, causing a slight depression.
    With the patient lying supine, the examining fingers may be carefully passed over the successive pairs of cartilages and these lesions be noted.
    IV.  The heads of ribs are often luxated, and may sometimes be easily felt near the transverse process of the adjacent vertebra.  This lesion is most readily found by carefully feeling along the shaft of the rib upward toward its head, using deep pressure.  It may be impossible to trace the shaft by touch where it is covered by the thick erector spinae muscles.  In such case it is easy to follow the direction of the rib up to the spine.  Deep palpation may reveal the head to be prominent, depressed, or sore.
    The FIRST RIB is located by deep pressure behind the middle or inner one third of the clavicle.  If the latter has been found in situ, comparison with it may be made to determine whether the rib be up or down.  By deep pressure the rib may be traced back toward its head, which is masked by the lateral cervical muscles.  Pressure may be brought upon the head at the level of the seventh cervical spine, one and one-half inch laterally therefrom.
    This pressure is deeply in the tissues over the region of' the head of the rib.  The latter is, not always easily felt by touch, but may often be definitely felt out.  Sometimes the head of the first rib is separated from and drawn outward away from its spinal articulation, when it may be easily felt. This sometimes occurs in cases of exophthalmic goitre.  Dr. A. T. Still points out that lesions of the first rib often cause goitre.
    A more reliable method for definitely locating the head of first rib is as follows: Find the tip of the transverse process of the seventh cervical vertebra, (XIV, Chap. 3) and make firm downward pressure just in front of it.  As the head of the first rib lies anterior to the transverse process of the first dorsal vertebrae, the first bony part felt under this pressure is the first rib in the region of its head.
The sternal end of the rib is located just below the  claviculo-sternal articulation.  Its cartilage and shaft may be traced well outward an inch or more before disappearing beneath the clavicle.
    In case it be luxated upward, the cartilage is retracted leaving a flat area or a depression at the cartilage.  If downward, a protrusion of the cartilage at the edge of the sternum is usual.
    In either case the cartilage and the tissues about the rib are sensitive to pressure.
    The first and second intercostal spaces are wider than the others.
    The SECOND RIB is located opposite the junction of the first and second parts of the sternum.  Prominence or depression of its cartilage, and tenderness in the tissues about it are caused in the same way as in the case of the first.  Its head is located and pressure brought upon its region at a point one and one-half inches external to the first dorsal spine, upon a level with the superior angle of the scapula.
    THE ELEVENTH AND TWELFTH RIBS are more frequently luxated downwards because of their anterior ends being unsupported and because of traction upon the latter by the quadratus lumborum muscle.  Their free ends are readily located except when irritation from them, or other cause, has irritated the overlying muscles, causing hypertrophy or contracture.  In such case they must be located from the tenth rib.
    The free end of the eleventh lies well forward, thus distinguishing it from the twelfth.
They may be so displaced downward as to be almost vertical; may overlap the iliac crest, or may be luxated upwards, the free end of the twelfth lying beneath the eleventh, or that of the eleventh beneath the tenth.
    Frequently a luxated rib guides one to a spinal lesion.
    Displaced ribs cause disease by mechanical interference with internal viscera, by irritation of surrounding soft tissues, by dragging ligaments, impinging nerves, or occluding blood-vessels.  One must remember that in probably most cases of displacement of a rib there is lesion at its head affecting the related spinal nerves.