A Manual of Osteopathic Manipulations and Treatment
Wilfred L. Riggs, D. O.
    ANY case that presents itself merits an examination as careful as can be made.  The urine, the sputum, the thorax and the abdomen should be examined according to the classic methods used for years by tile medical profession. Anything which will give an insight into the condition of your patient is yours to employ, and you are culpable  if you do not use it. But there is a deeper meaning to the word palpation than is commonly applied to it. That meaning is the osteopathic one. True palpation is par excellence the osteopathic method of examination. It is through his trained touch that the Osteopath determines a dislocation of bone, a tightening of tendon or cartilage, or a contracture of muscle. These are tile conditions to which he attributes disease in many instances.  These are the conditions which the Osteopath corrects in his treatment of readjustment The patient's clothing should be arranged so as to allow free access to the spine and to the thorax.
    That we may intelligently examine a spine we should be thoroughly acquainted with the general topography of the back. The normal spine has four curves, as follows: (1) The cervical, concave backward, extending from the apex of the odontoid process to the second dorsal. (2) Beginning at the middle of the second dorsal and extending to the twelfth, its concavity forward, is the dorsal curve. The most prominent point is at the seventh and eighth dorsal.  (3) The lumbar curve, from the middle of the twelfth dorsal down to the angle between the fifth lumbar and the base of the sacrum, its concavity being directed backward. (4) From the base of the sacrum to the tip of the coccyx, its concavity forward, is the pelvic curve.

    Care must be taken to become thoroughly familiar with the normal, in order that any variation from this type may be detected. There are variations within a limited range, even in health. The dorsal and pelvic curves are primary and are due to the shape of the vertebrae, while the cervical and lumbar are secondary and compensatory and exist only after birth, their existence being due to modifications in the form of the intervertebral discs.
    The lumbar curve, beginning at the sacro-vertebral articulation, drops forward very abruptly and if this should be further increased in appearance by well developed nates, the physician may be deceived. The test must be made by a careful examination for tenderness on pressure. The spines should lie in a perpendicular plane while the  patient is sitting or standing erect, though there is often a slight lateral curvature in the dorsal region, the convexity of which is directed toward the hand which is habitually used. The tips of the vertebral spines should lie in a perpendicular plane, which may be tested by bringing the hand briskly down over the spines either directly over them or with two fingers, one on each side of their prominences. By this method one may detect any deviation from the usual position, and if tenderness be present it is an evidence of a lesion; and, reasoning from cause to effect, the organ or organs affected may with certainty be determined. But care must be used in the matter of finding a lesion. The atlas has no spine, only a mere tubercle and no surprise should be manifested at finding it "forward." The second cervical is perhaps the most prominent feature in the cervical region of a normal spine, and its widely bifurcating and massive spinous process may give the beginner some uneasiness. The cervical spines are bifid from the second to the sixth inclusive. The vertebra prominens is close to the first dorsal, the latter very commonly being mistaken for it.

    To examine, bare the spine, have the patient sit erect. Note the curves, whether they be normal, diminished or accentuated. A flat region in the upper dorsal means lung and heart action impaired, and weakened vitality. If the fifth to tenth dorsal are anterior, or if the lumbar, dorsal and cervical are almost in line there is stomach or intestinal disorder. Any marked deviation from the normal curve in the lumbar region may result in constipation, ovarian or uterine disorder, or derangement of the function of the bladder. The sacral vertebrae are relative to each other always in place, but they may be slightly out of their true articulation with either the auricular processes of the ilium or with the lumbar vertebra above or the coccyx below. In lesions of the lumbo-sacral and sacroiliac articulations you will find pelvic disturbances.  The coccyx may by dislocation cause constipation, haemorrhoids and piles.  Detect any lateral curves that may be present by careful inspection. Friction will bring into view the spines and any marked separation or deviation from the perpendicular, the patient sitting erect, should call for careful palpation

    Locate the second cervical by its prominence. The first dorsal by the length of its spinous process.  The third dorsal by the level of the scapular spine. The seventh dorsal by the angle of scapula. The fourth lumbar by the fact that a line joining the iliac c rests will pass through its body.

    The twelfth dorsal may be conveniently located by having the patient fold his arms and lean forward thus throwing into prominence the trapezii, whose converging external borders will indicate the twelfth spine; or, better, by the articulation with the last rib; or, by the natural break between it and the first lumbar. After being satisfied with inspection, a careful examination with the hand will detect any irregularity that the eye may overlook. The spines are the key to the situation, but tenderness in addition to abnormal position must be found.

    Each operator will have his preference for position of the patient. For a thorough examination several positions may be necessary. The following order is suggested, the back being exposed in all cases:

    First.  Patient sits erect, operator standing behind.

    Second. Patient leans forward, sitting squarely, hands on knees.

    Third. The patient is placed facing operator, first on rigplaht and then on left side. The operator carefully examines each spine and transverse process in succession. During this examination patient must thoroughly relax. The operator uses arms and legs of patient as levers for movement in  examination.
    Fourth. Patient on back, body straight so that nose, chin and point between feet are in straight line, arms at sides. The operator now stands at head and examines both sides of vertebrae of neck. The spines of cervical vertebrae cannot be relied upon for diagnosis so we examine transverse processes.  Deviation from a straight line either antero-posteriorly or laterally indicates trouble at that point. An examination of its spine will usually confirm this result. The atlas can be examined only at its transverse process which should be easily felt about half way between mastoid process and the
descending ramus of the inferior maxilla. Tenderness is usually, if not always, most pronounced on the side of the slip. The end of the little finger may usually be passed between the transverse process and the ramus of the jaw if in normal position.

    The following facts are of importance in locating certain structures.

    The sixth cervical spine  is opposite the cricoid cartilage and the beginning of the oesophagus.

    The seventh cervical spine at the level of the apices of the lungs.
    The eighth thoracic spine marks the lowest level of the heart and the central tendon of the diaphragm.

    The ninth thoracic spine is at the level of the cardiac opening of the stomach.

    The tenth thoracic spine marks the lowest level of the lungs.

    The eleventh thoracic spine is at the lower border of the spleen and the upper border of the rigplaht kidney.

    The first lumbar spine is at the level of the renal vessels, and the pelvis of the kidney.

    The second lumbar spine is opposite the receptaculum chyli and the third portion of the duodenum.

    The third lumbar spine lies just above the umbilicus.
    The fourth lumbar spine is at the level of the aortic bifurcation and the iliac crests.

    The end of the coccyx marks the junction of the first and second portions of the rectum.

    The spinal nerves have their origplain from the spinal cord as follows:
    The eight cervical nerves come from the spinal cord above the level of the sixth cervical spine.
    The upper six dorsal nerves arise between the levels of the sixth cervical and the fourth dorsal spines. The lower six dorsal, between the fourth dorsal and the eleventh dorsal spines.

    The five lumbar nerves arise between the levels of the eleventh and twelfth thoracic spines.
    The sacral nerves take origplain between the last dorsal and the first lumbar spines.