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
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
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
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
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.