Transcriber’s Note: Boldface text is enclosed in =equals signs=;
italics text is enclosed in _underscores_.
TECHNIC AND PRACTICE
OF
CHIROPRACTIC
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_
PUBLISHED BY
UNIVERSAL CHIROPRACTIC COLLEGE
DAVENPORT, IOWA
1915
COPYRIGHT 1915
BY
JOY M. LOBAN
HAMMOND PRESS
W. B. CONKEY COMPANY
CHICAGO
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=
TABLE OF CONTENTS
PAGE
=Preface to First Edition= 9
=Preface to Second Edition= 11
=Introduction= 13
=Vertebral Palpation= 15
Definition 15
General Propositions 15
Habits of Palpation 15
Facts Concerning the Spine 16
Preparation of Patient 22
Position of Patient 22
The Record 23
The Count 29
Atlas Palpation 35
The Group Method 37
The Individual Subluxation 40
Palpation in Position B 46
Palpation in Position C 48
Transverse Palpation 49
Curves and Curvatures 53
Difficulties in Palpation 59
Landmarks 61
Mental Attitude 63
=Nerve Tracing= 64
Organ Tracing 64
What Nerves are Traceable 64
Suggestion 67
Place in Diagnosis 67
Technic of Nerve Tracing 68
=Subluxations= 76
Definition--How Produced 76
Law Governing Location of 78
Varieties of Subluxations 80
=Technic of Adjusting= 89
General Principles of Adjusting 89
Special Technic (Thirty-two Moves) 99
Preferable Adjustments 155
=The Cause of Disease= 165
Simple Subluxation Disease 184
Secondary Causes 185
Germ Diseases 185
Diet 192
Poisons 194
Exposure 198
Bodily Excesses 201
Inflammation 202
The Process of Cure 208
Adjuncts 215
=Spino-Organic Connection= 217
General Discussion 217
Special Nerve Connections 235
Table of Diseases and Adjustments 257
=Practice= 276
Office Equipment 277
Schedule of Examination 292
Necessity for Correct Diagnosis 298
Frequency of Adjustments 302
Specific vs. General Adjusting 303
Talking Points 306
Promises to Patients 308
Retracing of Disease 309
Limitations of Chiropractic 312
The Use of Adjuncts 315
Personality 319
=Chiropractic Prognosis= 322
General Discussion 322
Practical Prognosis 323
Preface to First Edition
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.
Preface to Second Edition
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.
INTRODUCTION
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
Definition
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.
General Propositions
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.
Habits of Palpation
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.
Facts Concerning the Spine
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.
Preparation of Patient
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.
Position of Patient
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.
General Observation
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
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.
Number of Vertebra
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.
Direction of Subluxation
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.
Order of Letters
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_.
Movement for Correction
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.
Complete Record
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.
Sample Record
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
Use of Record
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.
THE COUNT
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.
Position of Palpater
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.
Use of Hands
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.
[Illustration: 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.
The Count
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.
Difficulties in Counting
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.
ATLAS PALPATION
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.
Position of Head
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.
THE GROUP METHOD
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.
Example of Group Method
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.)
THE INDIVIDUAL SUBLUXATION
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.
Cervical 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.
Sometimes the posterior neck muscles and ligaments will be rigid
so that they interfere with palpation and at the same time make it
impossible for the patient to flex his head forward. Having found that
this is due to real _contracture_ and is therefore not susceptible of
voluntary relaxation by the patient, support the head in front and push
aside the muscles with the fingers, gliding _underneath_ the muscle
layers as much as possible and close to the spinous processes.
Transverse palpation in the Cervicals is used to verify findings from
the spinous processes or to differentiate between rotated and laterally
displaced vertebrae and bent spinous processes when the spinous swerves
to right or left.
Dorsal Palpation
The Dorsals are usually considered in three groups. It must be
remembered that the form and obliquity of spinous processes vary
considerably in this region. The upper processes are very slightly
oblique, slanting downward, the middle Dorsals very oblique, and the
inferior ones again only slightly so. There is a form change, most
commonly at the eighth Dorsal, which may be mistaken for a posterior
subluxation. The process here becomes more horizontal and more blunt.
Among the first four Dorsals a bad lateral or rotated vertebra may
be listed as well as a posterior one, since we can readily adjust
it. In the middle group either the posterior or rotated vertebra is
chosen according to the estimate as to which causes greatest nerve
impingement, either being adjustable. In the lower group, however,
preference is usually given the posterior vertebra when possible,
because rotary subluxations indicate transverse adjustments and it is
somewhat dangerous in this region to use the transverses as levers.
Lumbar Palpation