The Practice and Applied Therapeutics of Osteopathy
Charles Hazzard, D. O.
    Inspection, percussion and palpation are the physical methods employed by the examiner. Of these the latter is most important.  Attention must be given to the position of the patient, changing it as required for the best detection of the various lesions for which examination is being made.  For example, lateral deviations of vertebrae, and departures from normal curvature of the spine are best detected while the patient is sitting.  Points of separation between spinous processes, thickening of posterior spinal ligaments, rigidity of the spine, etc., are most readily made out while the patient is lying upon the side.
    The back must be bared in examination.  For ladies, a loose gown buttoned down the front and back may be conveniently used.
    By the methods mentioned above the examiner searches for certain definite lesions, as follows:
Inspection reveals the color of the skin; rashes, which may indicate disease; the presence of curvature or other deformity; unequal muscular development, or change of contour from whatever cause; scars, wounds; stains, and exhortations, leading to inquiry regarding accident, injury, operation, or the use of poultice; injected blood-vessels; tumors, enlargement of parts, etc.
Inspection may be made with the patient sitting.
    In any examination, care must be taken hot to so place the patient as to cause his position to mask the lesion.  An unnatural posture may be to him natural by reason of his condition.  If now an attempt be made to cause him to assume the usually natural position, the result may be to obscure that which would be a clew to his disability.
    Close inspection should be made of a patient's habitual posture, gait, etc., as a preliminary step.  One often gains thus valuable clews to his condition.
    Inspection often reveals inequalities of waist-lines and hips.  A waist-line deeper cut on one side, usually accompanied by a higher or larger contour of the corresponding hip, is a frequent indication of a swerved spine.
    PALPATION is our most important method of examination, the trained touch revealing to the Osteopath most of the lesions which he regards as the causes of disease.
With the patient sitting slightly bent forward, the arms folded loosely or the hands resting lightly on the knees, the examiner stands behind the patient and passes his two index fingers, or the index and second fingers of the examining hand, carefully down the opposite sides of the vertebral spines.  He notes:
    I.  Single vertebrae or groups of vertebrae which may be deviated laterally from normal position.  In such case there is usually, though not always, tenderness in the tissues upon the side of deviation, owing to the irritation by the process.
    In order not to mistake a bent spinous process for a lateral lesion of the vertebra, all such apparent lesions should be further tested by feeling out the transverse processes of the vertebra in question. Dr. Still uses these more than the spinous processes in identifying lateral lesions.  If the spinous process is merely bent the transverse processes have not changed their relations to the surrounding tissues.
    Lateral deviation of one or more vertebrae causes the transverse processes to rotate slightly backward on one side and forward on the other.  This alters the depth of the furrow running along the spine on either side of the spinous processes.  Pressure of the examining finger carefully into those furrows at the point of lesion will show that the furrow on one side is deeper, and on the other side shallower, than normal.
    Such observation of transverse processes and furrows will obviate error over bent spinous processes.
    II.  Lateral swerving or sagging of any portion of the spine.
    III.  Any exaggeration, deviation from, or lessening of the normal curves of the spine. The most common of these are a flattening of the spine anteriorly at the dorsal curve between the shoulders, and a flattening of the spine posteriorly at the lumbar curve, these two lesions together causing the so-called "straight spine."
    IV.  Sharp friction, made by passing the hand quickly down the spine, reddens the tips of the spinous processes so that one may then count them or note their alignment.
    V.  The flat of the hand is passed down over the posterior aspect of the sacrum and detects any flattening or bulging thereof.  It is also passed over the posterior superior lilac spines, noting their degree of prominence and comparing them with each other relatively to the sacrum.
    VI.  The cushions of the examining fingers are pressed deeply into the sacroiliac spaces to detect any abnormal tension or tenderness in the superficial or deep tissues.
    VII.  The index finger follows the course of the coccyx to its tip, noting any lateral, anterior, or posterior deviation.
    VIII.  The index finger is carefully passed down the spine upon the spinous process pressure being made firmly upon each, to detect either anterior or posterior projection of vertebrae.
    IX.  The temperature of the back is found by  passing the palm of the hand evenly over it.  Vasomotor disturbances, resulting in lowered or increased temperature of certain areas, may be thus discovered.  Frequently a cold area may be traced diagonally backward and upward along the course of the spinal nerves toward the seat of lesion.
    The patient is now placed upon his side in an easy position.  The examiner stands at the front of the patient and continues the examination.
    X.  The cushion of the examining finger, which is held at right angles to the spinal column, is carefully pressed deeply into the space between each successive pair of spinous processes.  It discovers any separation or approximation of processes, thus of vertebrae.
    Students often have difficulty in distinguishing a separation of processes from an anterior displacement, the former being often diagnosed as the latter condition.  One may avoid such errors by remembering that the separation is rarely so great as the space left by a marked anterior displacement of a vertebrae.  The latter condition is rare.  In case of doubt count the next two spinous processes above or below the point in question, and compare the space they occupy with the space occupied by the lesion and the spinous process next above or below it.  The comparison will at once aid in determining the point.
    Points of anatomical weakness are frequently found at the junction of the twelfth dorsal with the first lumbar vertebra, also at the junction of the fifth lumbar with the sacrum.
The fifth lumbar is often prominent posteriorly, but is also very apt to be luxated anteriorly or laterally.
    Separations occurring between the fifth and the sacrum are often mistakenly treated as anterior displacements of the fifth.  Separations at this point are common.  Marked tenderness is usually present.
    XI.  The examining hand is passed slowly along the spinal column to note any general or local thickening and increased tension in the posterior spinal ligaments which results in partially obliterating the spaces between the spinous processes, and in producing the so-called "smooth spinal column."
    XII.  The examining fingers are pressed firmly into the spinal muscles and moved transversely to the course of their fibres for the purpose of detecting any abnormal hardening or contracturing of them.  Contractures generally affect certain sets of fibres rather than the muscle as a whole.  They may be situated in the superficial or in the deep muscles, and may be primary or secondary according as they are produced by direct or indirect lesion of the fibres.
    XIII.  The body of the patient is braced against that of the practitioner, who places the fingers of both hands upon the under side of the row of spinous processes, (the patient lying on his side) and draws the spine forcibly toward him, noticing whether the spine be rigid, or too greatly relaxed.
It must be borne in mind that bony lesions are not alone important.  Ligamentous lesions are quite as much so, and though they are not so generally discernible as are the former, the student must not forget that following upon and consequent to bony lesion they may bring pressure upon important structures, may thus interfere with the functions of blood-vessels, nerves, etc., and become a fruitful source of ill.
    PERCUSSION, PRESSURE AND MOTION may be employed in the examination of the spine, and may sometimes reveal deep tenderness or pain in the tissues which has escaped notice by the other methods.
    Upon motion, certain sounds are heard in various parts of the column, due to the motion of parts upon each other.
    These seem to occur most frequently in the neck, between the articular processes, and in the lumbar region, between the bodies of the vertebra and between the articular processes.  Motion between the beads of the ribs and the bodies of the vertebrae, and between the tubercles of the ribs and the transverse processes is frequent.
    They may occur anywhere along the spine and are of diagnostic value in indicating relaxation of ligaments, interference with blood supply, resulting in insufficient secretion of synovial fluid, or malposition of bony parts.
    A motion which tends to separate the members of a joint may produce a suction sound therein.  A sharp, cracking or snapping sound may accompany the normal play of tendons.
    The examiner should not overlook the results of lesions which in any way alter the equilibrium of the spinal column.  When this occurs, the weight of the trunk no longer rests squarely upon the pelvis, but drives upon it at an angle, unequally contracting lumbar muscles and ligaments, tilting the pelvis, shortening a limb, etc.  Lumbago and sciatica often result from such condition, as do, likewise, various neck lesions, and even spinal curvatures.