BY
JOY M. LOBAN, D. C., Ph. C.
Professor of Anatomy and of Theory and Practice of Chiropractic at the Universal Chiropractic College. Formerly
Professor of Chiropractic Analysis at the
Palmer School of Chiropractic
SECOND EDITION
Revised and Enlarged
THIS BOOK IS
Dedicated
TO THE GIRL WHO HAS BEEN MY STAFF
AND LANTERN, AIDING AND LIGHTING
ME ON MY WAY IN THIS NEW FIELD
My Wife
This little work is offered to the profession without apology for its brevity or its form. It has been prepared because of an immediate and pressing need for such a guide in our colleges, and is offered abroad under the impression that many practicing Chiropractors feel the same need.
It is intended for handy reference and clinical use and is arranged as systematically as possible, style being everywhere sacrificed to utility.
The author lays no claim to the origination of any of the subject matter of this book nor to having invented any of the movements described under Technic of Adjusting. The arrangement and phraseology are in the main original. The intention has been merely to condense into practical and convenient form for students and practitioners certain knowledge now held and utilized in our profession.
The author feels himself indebted to the entire profession for the information embodied in this work, and to scientists of all time upon the results of whose infinite and painstaking research are based our present day advancement; to the many friends and co-workers whose valuable criticisms and suggestions have aided in this labor; and to his students, past and present, who have furnished the necessary encouragement and inspiration for the achievement of this, the author’s first text-book.
The chief merit of this effort—if merit there be—is its honesty. The author has endeavored to set forth fairly and simply the facts and hypotheses with which we have to deal. Its chief offense, in the eyes of many, will lie in its being just what it purports to be—a book on Chiropractic. Constructive criticism and suggestion are invited from all sources, for by our interchange of thoughts we grow.
J. M. L.
The republication of this book has been made possible by the sustained friendship of the profession for it, and the author’s thanks are due its many buyers and readers who, by their recommendation, have made it both possible and necessary that this book should live and grow.
The new edition has been somewhat enlarged by the introduction of additional matter into each section and by the addition of two entire new chapters on “Preferable Adjustments” and “Chiropractic Prognosis.” New plates have been added and old errors corrected. In every way an attempt has been made to express with conservatism the real advance made by Chiropractic since the first edition was put on the press.
J. M. L.
No two students, approaching for the first time the study of Chiropractic, approach from the same angle. Their viewpoints differ. In order that all may gain as nearly as possible the same viewpoint from which to consider in turn the sections of this book, it will be well if each student reads the entire book before beginning to memorize its parts and convert them into practical working knowledge.
An effort should be made, abandoning all other, to acquire the Chiropractic viewpoint. This accomplished, the rest of the task requires time and patience alone, without waste labor. The section on Vertebral Palpation should be studied step by step, the study of each step being combined with practice in it. Likewise the section on Nerve-Tracing, theory preceding practice. The study of the Technic of Adjusting should occupy those months immediately preceding the commencement of actual adjusting practice and continue during such practice. The chapters on Practice are intended for the student about to enter the field. The table of Spino-Organic Connection can be best understood by those who have studied or are studying the anatomy and physiology of the nervous system.
Let every page be studied with a good medical dictionary open at the elbow of the reader. Pass no word without comprehension, no detail without mastery. He who would seek to modify the life processes of the human body must fortify himself against fatal error with every bit of knowledge he can acquire.
Vertebral Palpation consists in the use of the tactile sense to determine the position, relation, size, shape, and as far as possible the condition, of the segments of the spinal column, in order thus to discover the primary causes indicative of disease.
Or, Vertebral Palpation is the name given the manual examination of spinal vertebrae.
Every palpation should be made with the adjustment of the vertebrae in mind. The record of palpation should be a correct guide as to direction of adjustment. No subluxation impossible of adjustment should be recorded.
The two essentials of correct palpation are accurate perception and correct reasoning. To secure the first, a certain approved manner of using the hands is herein laid down and a considerable amount of tactile sense development by practice is required. Correct reasoning depends upon knowledge of all the important facts concerning the spine and of the rules governing palpation.
Absolute concentration is required and to this end many of the following rules are directed.
Every palpater unconsciously forms habits of thought and action. These habits may be good or bad. We deliberately form a habit of holding the first three fingers closely together or the habit of using a downward glide, but we should avoid the habit of finding certain subluxations because they are usual and expected rather than because they are actually there. For instance, one may easily form a habit of listing every other vertebra in the spine, his whole record thus depending upon his first choice.
Because of this perfectly natural tendency to establish a routine of thought and action and to follow it precisely, it is best not to attempt palpation without the aid of an experienced teacher until after correct habits have been formed. Once formed, a palpation habit, right or wrong, is very hard to break. Many a teacher has expended himself uselessly in the effort to undo some technical fault acquired by the student in a blundering undirected trial.
The spinal column is composed of twenty-six segments called vertebrae, twenty-four movable and two fixed. The movable vertebrae are divided for convenience in study into three sections. There are seven Cervical vertebrae, twelve Dorsal, and five Lumbar in the normal individual. The number of Dorsals or Lumbars may vary by one in a rare case. These variations occur in about one spinal column in each five hundred and are usually in the Lumbar region, which may contain four or six vertebrae. A prominent first sacral spinous process may be mistaken for an extra Lumbar.
Five vertebrae have special names. The first Cervical is called Atlas; the second Cervical, Axis; the seventh Cervical is commonly known as Vertebra Prominens on account of its long and large spinous process, although this long process belongs to the sixth Cervical or first Dorsal instead in 35% of all cases; the large, irregularly fusiform vertebra just below the Lumbars and between the ilia is called the Sacrum; and the smaller one below it, the Coccyx. The latter is occasionally missing.
Each vertebra except the Atlas is composed of a body and an arch; the arch is made up of two pedicles, short, thick plates of bone extending outward and backward from the postero-lateral surface of the body nearer its upper than its lower border, two laminae, thin plates of bone extending backward and inward from their union with the pedicles and joining behind to form the spinous process, and has projecting from it seven processes, two transverse, one spinous, and four articular, two of which are superior and two inferior. The foramen enclosed by the body, pedicles, and laminae is called the neural or vertebral foramen and the canal formed by the connection of these foramina and completed by the ligaments which unite the arches is called the neural, vertebral, or spinal canal. It contains the spinal cord with its membranes and the roots of the spinal nerves. By means of the four articular processes each true vertebra except the first articulates with its fellows above and below.
The body of the vertebra is its largest portion and is joined to its fellows by fibrocartilaginous disks which are sufficiently elastic to permit some torsion and compression. Nine sets of ligaments, including the intervertebral substance just mentioned, bind the vertebrae firmly together. Many muscles are attached to the spinal column.
The intervertebral foramina are openings at the sides of the vertebrae, formed by the notching of apposed pedicles. These openings are surrounded by bone, cartilage, and ligaments and vary in shape in different sections of the spine. They permit the exit of the spinal nerves and their sheaths, the re-entrance of some nerve fibres into the neural canal, and the passage of blood-vessels to and from the cord. The entire philosophy of Chiropractic focuses at the intervertebral foramen because there we find the primary cause of all pathological changes in the body.
The spinous and transverse processes merit particular description since they are the levers by which vertebrae are adjusted and nerve impingements at the intervertebral foramina corrected. But it will be found easiest to describe these processes separately in different sections of the spine and before proceeding to this description, a brief picture of the peculiar vertebrae will be presented.
The Atlas is a bony ring composed of two arches, an anterior and a posterior, separated in the recent state by a transverse ligament. Its body is detached and appears as a tooth-like projection upward from the body of the Axis, the odontoid process, which articulates with the anterior arch of the Atlas and around which the Atlas rotates, a ring around a pivot. The Atlas supports the head upon its lateral masses, two wedge shaped bodies between the anterior and posterior arches, thinner internally than externally. It has no spinous process but merely a tubercle where the laminae join, so that it can be palpated only from the sides upon the tips of its long transverses. The first Cervical, or suboccipital, nerves emerge by a groove above the pedicles instead of through a foramen.
The Axis, or second Cervical, is distinguished by its large, strong spinous process, which is bifid at its tip, by its superior articular processes which rest upon body, pedicles, and transverses, and by its odontoid process, upreared from the body.
The Seventh Cervical, or Vertebral Prominens, usually has a large spinous process, presents no foramina in its transverse processes, or only one, the left, and shows no facets on body or transverse for the rib articulation, as do the Dorsals.
The Sacrum is the largest vertebra; is curved with its convexity backward; is commonly made up of five fused segments; has only rudimentary spinous and transverse processes except the first; and shows sixteen openings, eight anterior and eight posterior, or four on either side of the median line in front and the same number and arrangement behind. These openings permit the exit of the anterior and posterior primary divisions of the sacral nerves separately.
The Coccyx, usually composed of four fused segments, is a triangular bone which articulates with the Sacrum above and is free at its distal extremity. Its portion of the neural canal is open posteriorly and contains merely the thread-like termination of the cord membranes. It is frequently ankylosed to the Sacrum, sometimes in an abnormal position so as to impinge the single pair of coccygeal nerves.
The different regions of the spine show decided differences in structure, though all resemble each other. The Cervicals are smallest, the Dorsals next in size, and the Lumbars largest and strongest of the movable vertebrae. The Dorsals have facets and demi-facets for the articulation of the twelve pairs of ribs with their bodies and intervertebral substance, as well as oval facets upon the anterior aspect of their transverses for articulation with the tubercles of the ribs.
The spinous processes are smallest and usually bifurcated down to and including the fifth. The sixth may show a plain bifurcation, or on any Cervical the bifurcation may be so small as to be imperceptible to touch. The spinous process of the second overlies that of the third so as to make the latter very difficult of detection. Indeed, all cervical spinous processes down to the sixth are harder to palpate than those in other regions, owing to the anterior cervical curve. The processes lie in a groove between prominent muscle ridges.
Dorsal spinous processes are usually single, although the last four, three, two, or one may show plain bifurcation in certain individuals. They are somewhat pointed and overlap, except the lower ones, the obliquity being greatest in the mid-dorsal region and least at the first and last dorsals.
Lumbar vertebrae have broad, flat-tipped spinous processes much larger than the others. The last Dorsal may sometimes appear like a Lumbar in shape, so that the change in shape commonly supposed to mark a division between Dorsals and Lumbars is not always an infallible guide.
The transverse processes in the cervical region are very short and lie close in front of the articular processes. They are pierced by foramina for the vertebral artery and vein, except the seventh, which may have one foramen or none. They are difficult of access for palpation because of their shortness and the amount of overlying muscle, but may be reached from the front and side by drawing back the sternomastoid. They increase in length from the second to the seventh.
In the dorsal region the transverses are larger and stronger and more constant in size, shape, and direction, serving to support rib articulations. They extend in a curved direction outward, backward, and slightly upward from the union of laminae and pedicles and terminate in a large subcutaneous club-shaped extremity which may be readily palpated. The eleventh and twelfth dorsal transverses do not articulate with the ribs and must therefore be used with caution or not at all as levers for adjustment. The dorsal transverses are located on a higher level than the spinous processes. In the case of the upper three dorsals the transverse lies in a plane which would cross the mid-spinal line between its own and the next superior spinous. In the mid-dorsal region the transverse is even with the spinous of the vertebra above, though the relation may vary slightly. The lower dorsals return to the same relation as the upper.
The transverse processes of the Lumbars are relatively light compared with the general structure of the vertebrae and are found just even with the interspace between their own and the adjacent superior spinous process. They vary greatly in size, length and strength and may be used as levers for adjustment only when they are large enough to be clearly palpable through the muscle mass which separates them from the body surface.
In all cases where a complete spinal examination is intended the preparation is essentially the same. Have patient arrange clothing so that the spine is exposed to the touch throughout. Avoid bands of cloth across the spine, as these interfere with the necessary continuous gliding movement of the fingers. Advise the patient, if a female, to wear waist or dressing sack, reversed, and have skirts loosened at the waist. If a man, he should strip to the waist and wear coat or coat shirt reversed.
This varies widely according to circumstances but for general purposes use position:
(A) Place patient on stool, feet even on floor and body in an easy, relaxed position. This may be modified by asking him to lean forward and rest elbows on knees, evenly, to facilitate Lumbar palpation. Patient’s head may be erect or flexed forward or backward but should never be rotated or laterally flexed during Cervical palpation except for the purpose of locating some particular transverse process.
(B) In emergency cases, where haste is urgent or patient is unable to assume a sitting posture, or as a means of re-verifying previous palpation, place the patient on adjusting table prone, face down. (See Fig. 2.) Remember that with the head lying upon its side the upper dorsal vertebrae will assume a curve with its convexity away from the face. Palpation in position (B) should precede every adjustment and, to guard against error, should be considered as a necessary preliminary to the movement of any vertebra.
(C) For palpation preparatory to using the Rotary, the Break, and other moves, have patient lying on his back with his head projecting beyond upper end of bench and resting on the hands and wrists of the palpater, or have the patient’s head rest on the bench, a less accessible position.
Each spinal examination should begin with a general survey by which curvatures, marked prominences, etc., may be appreciated. Frequently some very important fact may be noted which would escape attention upon minute examination.
The record of spinal palpation, when completed, should be an accurate history of the irregularities found in the spine and an accurate guide to adjustment. It must be brief and concise as well as readily comprehensible. One should be able to see at a glance any desired point on the record, so that it may be used during the adjustment without undue loss of time or attention. Obviously the introduction of any useless mark or sign, such as the inclusion of a number and blank space for each vertebra of the spine, or all possible subluxations with indications as to which do or do not exist in the given case, is a mistake.
The record should contain three parallel columns. In the first column place the number of the vertebra chosen for adjustment. In the second, place the direction of subluxation. In the third, place the word or sign which stands for the indicated movement for correction.
The letter C is used to indicate Cervical, D Dorsal, L Lumbar, and S Sacrum in the record. Immediately following the letter which designates the region, place the number which shows the position in that region occupied by the vertebra in question, the relation of that vertebra to its fellows. For instance, the third Cervical vertebra is C 3, the eleventh Dorsal D 11. To the S for Sacrum append B or A to indicate that the Base or Apex is described as to position. This locates the subluxation. For a record of full spine palpation it is unnecessary to use the letters C, D, or L more than once, as subluxations are recorded in the order of their occurrence from above downward. A dash should always follow the number of the vertebra to separate it from the letters in the second column for convenience in reading.
The directions considered in palpating or recording subluxations are six in number, namely:
|
Name |
Abbreviation |
Meaning |
|
Posterior |
P |
Toward the rear (Dorsad) |
|
Anterior |
A |
Toward the front (Ventrad) |
|
Right |
R |
Toward the right hand |
|
Left |
L |
Toward the left hand |
|
Superior |
S |
Toward the head (Cephalad) |
|
Inferior |
I |
Toward the feet (Caudad) |
As the fingers glide down the spine the posterior vertebra is the one which interposes itself in the path of the fingers, forcing them to describe an outward curve. It is the hill on the automobile road which forces the surmounting of a curved departure from the evenness of the road. It is relatively posterior to its fellows above and below.
The anterior vertebra, to the gliding fingers, means a depression, a valley. It causes the fingers to dip inward from the level of their course.
The right or the left subluxation is appreciated by running the tips of the fingers down the sides of the spinous processes. It really indicates rotation of the whole vertebra more often than any other malposition.
We say that a vertebra is superior when its spinous process is nearer the one above than the one below. It requires a measuring of relative distances. The degree to which a vertebra is superior is measured, not by its actual closeness to its fellow, but by the relation between the space above and the space below.
Likewise a vertebra is inferior when it is closer to its fellow below than to its fellow above.
Anterior subluxations are rarely recorded as such, except of the Cervicals or the last Lumbar, because no means of properly adjusting them is known to Chiropractic.
In the second column, that devoted to direction of subluxation, the letter P or A should appear, if at all, as this antero-posterior relation is the first thing to be determined concerning any individual subluxation chosen except the Atlas. With the Atlas the first letter will be R or L. Next the laterality or rotation is indicated by R or L in every case except Atlas subluxation. Finally the S or I indicates the last point to be determined, the approximation of the vertebra to its fellows. This last letter usually shows thinning of intervertebral fibrocartilage, which will be discussed elsewhere.
If you desire to emphasize any direction as being more important than another, underscore the letter which stands for that direction with a single line. If two directions are to be emphasized, one more than another, underscore the one with two lines and the other with one. For example, if a vertebra is found to be quite decidedly posterior, more plainly to the right, and slightly superior, the record will show it thus: P R S.
This is indicated in the third column, separated from the second by a dash, by means of some brief word or words which describe a certain movement used in adjusting. The descriptive words and terms used in this work are all given and explained under Technic of Adjusting. (See p. 89.) Each word or term stands for a definite method of procedure. The best movement for the correction of any subluxation of any vertebra may be found by reference to the section on Preferable Adjustments, p. 155. If other terms are more familiar to the student, or in time replace those which are now common usage in the profession, they will be brief and clear and may be easily substituted for those given.
Palpation, fixing in the mind of the palpater the manner and direction of the subluxation, should also suggest as the obvious correction a movement calculated to reverse the procedure by which the subluxation was first produced. In other words, a certain kind of subluxation stands as the effect of a certain application of force along definite lines determinable by examination. Its correction should be made in a reverse direction along the same lines. By recording with the record of subluxation the desired correction, the adjuster may be reminded daily without new palpation of the movement best fitted to the case. If on trial it is decided that some other movement than the one first indicated will better overcome the abnormality, the record should be changed to correspond to the decision, and thereafter followed.
The completed record in three columns separated by dashes can be conveniently read. It contains no superfluous mark of any kind. It conveys all the necessary information leading to adjustment except diagnosis and case history. This palpation record should be a part of a more comprehensive record concerning the case in full and is best kept on a card, the reverse side of which carries case history. If kept in an indexed card file it may be referred to daily without loss of time and an accurate handling of each case be assured.
Have card perfectly blank on palpation record side. For convenience in reading draw a heavy line beneath the last Cervical subluxation recorded and another beneath the last Dorsal, thus dividing the record as the spine is divided, into three divisions.
Below follows a sample palpation record. It will be seen that here in a very small space may be recorded a great deal of information, for this record contains an accurate list of the primary causes of every disease, weakness, or tendency to disease with which the patient is afflicted, together with the methods for their removal.
|
C |
1 |
R |
Break |
|
|
4 |
P L S |
Double Contact |
|
|
7 |
L I |
Rotary |
|
——————————————————— |
|||
|
D |
3 |
P R |
Recoil |
|
|
7 |
L S |
Pisiform Single Transverse |
|
|
10 |
P S |
Heel Contact |
|
——————————————————— |
|||
|
L |
1 |
P L I |
Recoil |
|
|
4 |
R |
Lumbar Single Transverse |
The above record is made with patient sitting. It is to be used while patient is lying upon the adjusting bench. The most convenient way is to begin palpation in the Dorsal region after patient has been placed for adjustment, in this way. If first subluxation recorded is D 2—P R I, find the vertebra in the region of D 2 which appears P R I to the touch. To avoid error, let the fingers then glide downward to the next recorded subluxation. If this be found to agree in number and direction with the record, it is safe to assume that the first one found was correctly numbered in the palpater’s mind; if not, that an error was made. This can be quickly done. Before each adjustment the vertebra adjusted should be found to agree with the record; by doing this constant accuracy may be assured.
Having described the preparation of the patient and the different positions in which he may be palpated, noted that all records should be made in position A, mentioned that general observation which should immediately precede actual palpation, and interpolated a description of the record to be made during the palpation, with its use afterward, we are now ready to consider the technic of the palpation itself. This should begin with a count of the vertebrae and continue with Atlas palpation, general examination of a group of vertebrae, and special examination of individual subluxations in the group. Each of these tasks will be considered in turn.
This depends upon the position of the patient. The letters which follow correspond to the letters describing the position of the patient. q. v.
(A) If you desire to palpate with the right hand stand at patient’s left and face toward him with left hand resting on his shoulder or supporting his forehead as you palpate Dorsals or Cervicals respectively. To use left hand stand similarly at patient’s right. Have palpating arm relaxed and easy, extending as nearly as possible so that the forearm and hand make a right angle with the patient’s spine. Let the arm and hand remain close to the patient’s body at all times. Keep the elbow close to your own body and avoid flexion of wrist on forearm, or of forearm on arm at more than a right angle, since such flexion would bring about too great muscular tension for close appreciation of tactile impressions. If necessary lean sidewise and elevate shoulder and palpating arm in order to preserve the proper relation between hand and arm when hand must be elevated as in palpating upper Cervicals.
(B) As above, if you desire to use right hand stand on left side of patient and if left hand stand on right. If the patient lies on a bench so constructed that the head lies on one side, his face must be toward the palpater in order that the same hand may be used in Cervical as in other regions. It is inadvisable to change hands except when absolutely unavoidable. If the patient’s head must be turned from you palpate the Cervicals by standing with feet pointed away from patient and turn your body with one hand resting on patient’s head to hold it steady and the other palpating as if you were standing on the other side. This is difficult and it is rarely necessary to count Cervicals in position B if the record be used as advised on page 29.
(C) Palpation preparatory to the Cervical adjustment will be made in this position or in position A, according as you intend adjusting the Cervicals in the prone or the sitting posture. For the prone position have the patient’s head supported by either hand, while the other hand is applied with the tips of the first three fingers resting on the tips of the spinous processes, from which position they may glide smoothly down, noting deviations from normal in position as well as mentally numbering the vertebrae. While this method of palpation is not so accurate as those given elsewhere, and should be used only as an additional means after record has been made, it will always be necessary to make a count before adjusting any Cervical.
In general it may be stated that the first three fingers of one hand are used with an easy downward gliding movement in which only the tips of the three fingers, evenly placed, are in contact with the patient’s body. This concentrates the attention upon a very small tactile surface which may become extremely sensitive by the concentration. Indeed, it may be said that vertebral palpation only became an art through the application of the principle of concentration in practice. The gliding movement is always downward, because to palpate upward will mass the superficial tissues under the fingers and confuse the palpater. If there is uncertainty in the mind of the palpater, as he proceeds, as to the identity of any vertebra he should go back to the second Cervical, or to any certainly recognizable vertebra previously fixed in mind, and recount.
The use of the hands for Atlas palpation differs from their use elsewhere and will be described under separate head. The use of the hands with the patient lying face upward is also different. If the patient be lying prone, the same three fingers are used and the same downward glide as with patient sitting.
Fig. 1. Position of hands in palpation for record.
With patient sitting, the palpater should step from side to side, changing hands frequently and usually palpating each vertebra with each hand before reaching a conclusion. There are three reasons for this. More accurate records may be made by combining two different impressions on each vertebra; with frequent change of hands one may prevent tiring and consequent loss of sensibility of fingers; this practice develops the tactile organs of both hands equally so that if occasion demand the use of either hand alone it is fitted for the task. To be ambidexterous in all departments of Chiropractic is an invaluable attainment, too often neglected.
Commence at the second Cervical, the first spinous process below the occiput, and let the fingers glide smoothly downward over the tips or along the sides of the spinous processes, without interruption of motion, until they reach the Sacrum. The palpater notes each vertebra passed and its number—mentally—so that when he reaches the Sacrum he knows that he has passed every intervening vertebra and received a touch impression from each. The Sacrum itself may usually be recognized by its peculiar shape and also by its articulations with the ilia.
If the fingers are raised from their contact during the count, the palpater must recommence at the second Cervical. It is impossible to be accurate in replacing the hand, once removed, until the count has been established and the peculiarities of certain vertebrae remembered, together with their numbers.
To determine the location of the fourth Lumbar where, on account of obesity, lipoma, Cervical lordosis, etc., the count of Cervicals or Sacral palpation is difficult, drop on heels behind the patient and place the second finger of each hand on the crest of the ileum. Then let the thumbs meet in the mid-spinal line in the same horizontal plane as the two second fingers, which spot should correspond to the interspace between third and fourth Lumbars. This measurement is accurate in about 98% of all cases, when patient sits erect; when it varies it will vary by about half the width of a Lumbar spinous process.
The count should be repeated until the palpater is certain that he is able to palpate every spinous process distinctly or to locate accurately any impalpable one. In making the count, palpater may note the number of some very prominent and easily recognizable Dorsal or Lumbar vertebra to be referred to as a starting point for a recount if confusion arises later. This recounting from some prominent vertebra is permissible only after the first accurate count has been made, but then will save the full count, especially when the patient is in an unfavorable position, as lying on table during adjustment.
The commonest difficulties met with in counting are the following:
Inaccessibility of third Cervical, which lies closely beneath the spinous process of the second and, unless unusually large or somewhat out of its proper position, cannot be readily felt.
An occasional anterior fourth or fifth Cervical which may escape notice unless the head is flexed far toward or the transverse processes examined.
Lipoma or other adipose tissue covering part of the spine.
A missing epiphyseal plate resulting from fracture and absorption, which absence may simulate a wide interspace and be overlooked without careful and detailed observation.
Cervical or Lumbar lordosis. This difficulty may be at least partially overcome by having head bent far forward or body leaning forward with elbows resting on knees and a deliberate attempt on the patient’s part to render the dorsolumbar spine convex backward.
An anterior fifth Lumbar.
The occasional extra vertebra which confuses the palpater.
Finally, the greatest of all difficulties is the imperfect touch of the untrained palpater or the imperfect concentration of the trained. And this is always remediable.
With patient in position A stand behind him and place the tips of the second fingers on the tips of the transverse processes of the Atlas, or first Cervical. It can be felt on each side just anterior and inferior to the mastoid process of the temporal bone. Let the first and third fingers rest respectively above and below the transverses and determine whether the Atlas is subluxated as a whole to the Right or to the Left.
Another convenient method is:
Place first fingers on mastoid processes, second on Atlas transverses, and third on angle of jaw. The three fingers of each hand then constitute the points of a triangle. Imagine the base line between the first and third fingers and measure the altitude as a line at right angles to this base line and reaching to the tip of the second finger as the apex of the triangle. The relation of the two altitudes determines the laterality of the Atlas. Thus, if the altitude of the right triangle is less than that of the left, the Atlas is laterally displaced to the Right.
The second matter to determine is the rotation of the Atlas. This is done by using the first and third fingers as probes to determine the amount of space between the transverse and the mandible in front or the mastoid behind. The intention is to compare the laterally prominent side with the other so that the letter A or P on the record will indicate the position of the prominent transverse compared with its fellow.
Next decide as to tipping. Still comparing the prominent transverse with the other, decide whether it is above or below the level of the other by the following method. Placing first three fingers one above the other with the second finger on the tip of the process, note which transverse is highest in the space beneath the ear. List the prominent side as S or Superior, I or Inferior.
Atlas palpation is rendered especially difficult by the special technic and by the interposing tendons of the sterno-cleido-mastoid muscle.
There are three head positions for Atlas palpation. Head erect, face forward; head flexed forward on chest; head flexed backward. Sometimes it is necessary to test in all three positions in order to reach a decision, but ordinarily the first is sufficient.
In general palpation of the spine the author has had the greatest success and attained the greatest accuracy through which is called the Group Method. This consists in dividing the spine mentally into five groups or sections, each of which overlaps its fellows except the end groups. This is of advantage for several reasons.
It limits somewhat the attention of the palpater so that he may examine thoroughly and in detail the various vertebrae without holding his attention so closely to one that he fails to perceive its relation to its surroundings. It furnishes five or six vertebrae at a time for comparison so that one may determine which is most subluxated, and therefore most in need of adjustment, and then allows one to reason upon the remainder of the group with this major subluxation in mind.
The use of the Group Method may best be understood by the study of certain didactic instructions, which follow:
Never record or adjust two subluxations of contiguous vertebrae except in those unusual cases where they are equally subluxated and in the same direction; even then it is wisest to adjust them on alternate days. Let it be understood that only in exceptional circumstances should two adjacent vertebrae be listed. The Group Method is chiefly valuable because of this rule, to prevent the overlooking of the most important subluxation by selecting that one first.
Consider the spine as divisible into five groups; in the first group belong the Cervicals below the Atlas; in the second, the seventh Cervical and first five Dorsals; in the third, the vertebrae from the fourth to the eighth Dorsals inclusive; in the fourth, the last five Dorsals and sometimes first Lumbar; and in the last group, all of the Lumbars and the base of the Sacrum. Consider the first Sacral spinous process here rather than the whole Sacrum and remember that this process should seem to complete the regular Lumbar curve. This grouping may be modified somewhat by the exigencies of palpation in any given case, but the group considered should always include from four to seven vertebrae.
In each group proceed in the same manner to select subluxations. Let the fingers glide over the group, first on the tips and then along the sides of the spinous processes, and note that some one vertebra stands out as the sharpest, most abrupt deviation in the group, thus indicating its selection. Remember that neither the one above this nor the one directly below may be adjusted. This narrows your field of observation for this group to two, three, or four remaining vertebrae.
Select then such others in the group as need to be listed yet do not conflict with the rule against adjacent subluxations. Proceed to discover and record the exact direction of each. When this is done examine the next lower group in the same way and continue until the whole spine has been palpated.
The Atlas must be considered alone and not as a part of any of the above mentioned groups and its position is judged rather by its relation to the head than to other vertebrae; the Sacrum also requires individual attention, being compared with the Lumbar curve and with the ilia.
The one most pronounced subluxation in a group is often mentioned as the “key” to the group, since its correction would effectually loosen the entire group and sometimes partially correct the apparent abnormalities of the rest. It has also been called “major subluxation” to distinguish it from “minor subluxations” which are the others of less importance in the group. This term is not a good one because it suggests what is not always true, namely, that the mechanically greatest subluxation is more potent than any other. Occasionally a slighter subluxation irritates nerves so as to produce a disease more serious and immediately alarming than the condition following the greater displacement.
If, in the Cervicals, it is noticed upon gliding downward over the spinous processes that the fifth is badly subluxated and must be adjusted, this fact is held in mind for a moment while the palpater remembers that he cannot adjust and must not list the sixth or fourth. This leaves only the second, third and seventh for consideration, the Atlas having been separately examined. The seventh may best be included in the next group when such a selection is made, so that the palpater need only decide between the second and third Cervical, providing Atlas has not been chosen, as to which, if either, most requires attention. If Atlas has been listed, then there remains instead only the question as to whether the third is or is not subluxated.
In using the Group Method no preference is given to subluxation in any particular direction, save only that below the Cervicals we discriminate against the anteriors, because we cannot adjust them. The Group Method has to do with determining the points of greatest pressure on nerves and this depends upon one’s impression as to the interrelations between all the members of the group. (See p. 80 under Subluxations.)
Having prepared our patient, surveyed the entire spine, carefully counted the vertebrae to secure a proper orientation, and specially examined the Atlas, then divided the spine into groups and selected the vertebrae to be adjusted with regard to their degree of malposition, let us confine our attention definitely for the first time to the single vertebra below the Atlas.
Reread “Direction of Subluxation” under “The Record,” p. 25. Also read article on “Subluxations,” p. 76.
Bear in mind that each subluxation recorded is intended for adjustment and indicate nothing impossible on your record. For instance, an anterior subluxation in the Dorsal region cannot be corrected and should not be recorded for correction.
Remember the six capital letters used in describing a subluxation.
Use only the downward gliding movement of the three palpating fingers.
Keep in mind the count as you have established it for that particular spine, recalling one or two very prominent and noticeable vertebrae whose numbers you have noted.
Use a light touch. If necessary, change the patient’s position to make the vertebra more accessible instead of pressing with more force.
When in doubt as to direction, change sides and use the other hand. If still in doubt, take a longer glide, covering six vertebrae instead of three or four.
Keep your mind on your work, forgetful of everything else.
And picture to yourself the entire vertebra and its surroundings; its body, pedicles, and laminae, its transverse processes and all articulations; above all, mentally visualize the foramina and nerves. Estimate from the position of each vertebra the pressure at each foramen. Decide whether the vertebra is rotated, tipped, laterally displaced, anterior or posterior, or whether the subluxation partakes of several of these directions.
Decide in what direction movement of the vertebra would release most pressure and list accordingly.
Never hesitate to change your opinion if you discover evidence that you have made a mistake. Keep at all times an open mind in palpation.
The third Cervical, lying under the projecting spinous process of the larger second, may be hard to find, and therefore the full count is always required before listing any vertebra. By requiring the patient, who is in position A, to drop his head forward and rest its weight in the hand which is not palpating, the Cervicals may be more easily palpated. Remember that this posture widens the interspaces and also makes the spinous processes appear more posterior than they really are, this difference being most noticeable at the fourth.
One bifurcation of a Cervical spinous process may be longer than the other and prove confusing unless care be taken always to palpate both bifurcations and note their form. This can almost always be successfully accomplished.
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