patient erect, _should_ curve anteriorly and the first Sacral spinous
process should complete the regular curve. This is rarely found,
however; the normal is the exception in any part of the spine.
In the Lumbars we usually choose the rotated rather than the posterior
vertebra, but solely because rotation here produces the greatest
degree of impingement. The laterality of spinous processes, indicating
rotation of the whole vertebra around an axis lying in the transverse
line between the articular processes, can best be perceived, as a
rule, with patient sitting quite erect. If in doubt, have patient lean
forward and rest elbows on knees, which posture separates the Lumbars,
rendering the individual spinous process easier to discover but the
_relative_ position more difficult of determination.
The fifth Lumbar, if anterior, may be so listed, forming an exception
to the general rule.
Sacral Palpation--Pelvis
First palpate Sacrum as if part of Lumbar region. Note whether the base
(upper portion) is posterior or not. Then stand behind the patient and
use both hands to examine the sacroiliac articulations. Use palmar
surfaces with the flat hand toward patient’s body, and carefully
compare the two sides to detect inequalities, which indicate iliac
subluxation, or rotation of Sacrum between the ilia on a transversely
disposed axis passing through the two articulations, in which case
the Sacrum is to be adjusted. Do not mistake a dislocated hip with
compensatory tilting of the whole pelvis, or faulty sitting posture
with only one tuber ischii supporting the body, for pelvic subluxation.
Be not in undue haste to record pelvic subluxations lest your haste
bring its immediate reward in the difficulty of adjustment.
The Coccyx
The Coccyx may be detached from the Sacrum by various accidents and
later re-ankylosed thereto in an abnormal position so as to impinge
upon the rectum or other structures. Impingement of the coccygeal
nerves is usually unimportant. Chronic and intractable rectal
constipation, with its attendant train of evils, _may_ result from
coccygeal displacement with ankylosis. In spite of numerous treatises
to the contrary, the writer avers that other symptoms are extremely
rare.
To examine the Coccyx use a rubber covering on the second finger. Place
patient face down and insert second finger per rectum with the palmar
surface upward. If subluxated Coccyx be found, it must usually be
fractured with a sharp jerk, in order to relieve the condition. After
fracture, it may be absorbed or may re-ankylose to the Sacrum in a
better position, or it may remain freely movable.
PALPATION IN POSITION B
This is the position for the majority of adjustments, and as the
palpation of each vertebra to be adjusted is a necessary preliminary to
the adjustment, this method, though not so accurate as the one already
described, must also be used.
The use of the first three fingers of each hand and the relation of
hands to patient’s body is the same as in Position A, except for
palpating Cervicals when the patient’s face is turned away. It will be
found very difficult to make a correct full count, especially to count
Cervicals, in this position, and is better to use a record already
prepared.
Dorsals
Begin at, or near, the first Dorsal to palpate in this position.
Find the vertebra which agrees in direction with the first Dorsal
subluxation recorded; let the fingers glide downward until they reach
the vertebra which, according to the first decision, would correspond
in number with the _next_ subluxation on the record. If this also
agrees in direction with the record it may safely be assumed that you
are accurate in your numbering. Thereafter, during that adjustment, the
count can be made or repeated from any prominent vertebra the number
and identity of which are easily recognized.
[Illustration: Fig. 2. Palpation in Position B, preparatory to
adjustment.]
Lumbars
It may be difficult to count or otherwise to palpate the Lumbars in
this position because of the increase in the normal anterior curve
when patient is suspended between the two sections of the bench. This
will be obviated if a roll be placed under the thighs or if the bench
has an adjustable rear section.
Cervicals
If a solid front bench is used remember the spiral turn in the
Cervicals, which occurs because of the resting of the head on one side.
The curve due to this rotation of the head is compounded with the ever
present anterior curve to make a spiral. Do not expect the vertebrae in
this position to agree in apparent direction with a record made with
the head straight. It is better to make all decisions as to direction
of Cervicals in position A and merely to _count_ them in other
positions.
In position B, if the patient’s face be away from the palpater it will
be necessary to stand with back toward patient and body twisted, and to
change hands for counting, resting the free hand on patient’s head to
insure its steadiness.
Disagreements
If there be any apparent disagreement between findings in positions B
and A, re-examine carefully in both positions, whereupon that which
seemed a disagreement will probably prove to have been an error in
one or the other palpation. If apparent disagreement persists after
searching examination, position A furnishes the safest guide to
adjustment because the patient is in his most usual attitude as regards
the spinal curves, muscle tension, etc. But it is usually wisest when
in grave doubt not to adjust the doubtful vertebra at all.
PALPATION IN POSITION C
Since palpation in this position, patient lying on his back with head
supported by palpater’s hands, cannot be so reliable as that done in
position A, the chief point to be observed is an accurate count. Only
the Cervicals below the first can be properly palpated in this position.
Induce the patient to relax the neck muscles as much as may be, and use
in palpation the first three fingers of one hand if the count alone is
desired or the first three fingers of _both_ hands if you desire to
ascertain the _direction_ of any vertebra. In the former case let the
fingers press aside the muscles and glide _downward_ from the second
Cervical, being careful to lift the head high enough so that the third
Cervical is not overlooked beneath the overlapping second. In the
latter case let the fingers of both hands glide gently downward while
the patient’s head rests upon the palpater’s wrists or knee. Palpate
the transverses in much the same manner, paying special attention to
their _laterality_, felt as a prominence on one side lateral to a
transverse process and a corresponding depression on the opposite side.
Do not be deceived by exceptionally long transverses where both project
outward to an equal degree.
[Illustration: Fig. 3. Locative palpation of Cervical spinous processes
in Position C, preparatory to Rotary or Break.]
Since the greater mass of the vertebra is divided with fair equality
by the intertransverse line, laterality of transverses indicates
laterality of the whole vertebra with the possible exception of the
anterior portion of the body. Laterality of a Cervical _spinous_
process may indicate laterality of the entire vertebra or merely
rotation around its vertical axis, in which the one articular process
is separated from its fellow of the adjacent vertebra while the other
remains in partial apposition.
Disagreements
If disagreements appear between palpation made in positions A and C,
re-palpate in both positions. If still uncertain call a consultation or
follow finding in position A. The Rotary adjustment may sometimes aid
in deciding difficult questions if gently attempted and free movement
secured. With this adjustment a vertebra will not usually move without
rather extreme force unless the articular process on the side sought
to be moved has lost its apposition with its fellow of the adjacent
vertebra. In any case of disagreement nerve-tracing, the discovery of
sensitive nerves on one side only may aid in decision. A knowledge of
probabilities, previous experience, and the diagnosis may also serve as
partial guides.
TRANSVERSE PALPATION
Palpation of the transverse processes is easiest in the Cervical and
mid-dorsal regions and most difficult in upper Dorsal and Lumbar
regions. It has two uses: first, to assist in making a record by
verifying the work done on the spinous processes; second, to locate
a given transverse process in order to use it as a lever for the
adjustment of the vertebra.
It will be seen that fulfillment of the first purpose requires careful
examination of the _direction_ and _position_ of the transverses as
compared with each other and with the spinous process of the same
vertebra, while the second requires only the discovery of the exact
_location_ of some particular transverse. It will be best to consider
the three divisions of the spine separately, excluding from the present
chapter Atlas palpation, which has been thoroughly described.
Cervicals
These can be best palpated in the position for Atlas palpation; that
is, standing behind the patient and using the palmar surfaces of the
fingers of both hands. From the Atlas transverses follow the anterior
border of the sternomastoid muscle downward, and opposite each spinous
process draw the muscles backward and inward until the tips of the
transverses are found with the middle fingers. Their position on the
two sides may then be easily compared as well as their relation to
those above and below them.
[Illustration: Fig. 4. Locative palpation of Dorsal transverse
processes.]
The transverses of the second Cervical may sometimes be so prominent
laterally that they are, or one of them is, mistaken for an Atlas
transverse. As a rule, however, the width of the Cervicals increases
from the second downward, the second being narrowest. Chassaignac’s
tubercle, on the transverse process of the sixth Cervical and opposite
the lower border of the cricoid cartilage, is a prominent point easily
felt as a rule. The transverses of the fourth are usually opposite the
upper border of the thyroid cartilage.
The Cervical transverses lie very close to the articular processes and
the determination of their relation is a better guide to the condition
of the articulation than is spinous process palpation. It is also more
difficult.
Palpation of Cervical transverses to determine laterality of the
vertebra as a whole or its rotation is possible in position C and has
been described under that head.
Dorsals
Palpation for _direction_ can be done best in position B. Use three
fingers with a gliding movement along the line of the transverses,
passing over several to determine which is most posterior. Then
repeat the glide on the other side of the spine to determine whether
the transverse corresponding to the anterior one is posterior or
vice versa, showing that the entire vertebra is merely rotated or
is displaced backward. Some palpaters prefer using both hands and
palpating both transverses at once and there is no serious objection
to this method, if confined to palpation in position B. In many cases,
however, it leads to similar palpation of spinous processes, a most
execrable habit.
It should be remembered that with the first two Dorsals the transverse
will be found in a transverse plane which would pass between its own
spinous process and that above. This is also true of the last three
Dorsals, while in the middle Dorsals the transverse is usually (not
always) level with the tip of the spinous process of the next superior
vertebra.
Before adjusting, to determine the _location_ of a transverse process
in order to direct an adjustment against it, first palpate spinous
process and hold it with the tip of the middle finger. Then approximate
with the first finger a point even with the tip of the spinous process
above and about one inch from the spine--this of course in mid-dorsal.
Then let second and third fingers follow the first so that all three
rest on or near the transverse to be palpated. Pressing gently, but
firmly, move the three fingers until the process can be felt beneath
them. Hold the process with the middle finger so as to direct with
it the contact of the adjusting hand to a point exactly over the
transverse process.
Lumbars
The transverses of a Lumbar vertebra lie just even with the interspace
between their own and the adjacent superior spinous process. They are
deeply embedded in muscle tissue and very hard to palpate. They may
vary considerably in size or length and the last one or two may be
absolutely impalpable. It is sometimes advisable to adjust a rotated
Lumbar by using the transverse as a lever, but this should never be
attempted unless the process can be distinctly felt. The method of
locating in Lumbar is practically the same as in the Dorsal region.
Transverse Palpation with Patient Sitting
Palpation of Cervical transverses in position A has been described and
is frequently done. Palpation of Dorsal or Lumbar transverses in the
same position may sometimes be desirable. It can be done with the same
movement as spinous process palpation, and may serve to detect a bent
spinous process.
If it is necessary to palpate both transverses at the same time,
stand in front of the patient and lean over his shoulder, letting his
shoulders rest against your body. Use palmar surface of fingers of both
hands and note which transverse is posterior to its fellow, if either,
or whether both are posterior to the line of the others above and below
them.
It is rarely possible to find if a transverse process be superior or
inferior to its normal position, except the Atlas transverses, although
this may occasionally be detected. Fortunately this is a rare form
of subluxation, or appears rare, although it must be said that this
apparent rarity may be due to our comparative inability to detect it in
the living subject.
CURVES AND CURVATURES
For convenience, _curve_ is used to denote the normal curvilinear
deviation from a straight line naturally present in the normal spine
or naturally assumed in response to the need for equilibrium during
the erect position of the body: _Curvature_ means either the abnormal
increase of any normal curve or the appearance of any abnormal
curvilinear deviation of vertebrae from their normal position.
Deviations from normal must contain at least three vertebrae to be
considered curvatures.
Visual Examination
The general inspection of the spine which precedes the count should
bring to light, in addition to prominent subluxations, and general
symptoms observable by inspection of the back, any _marked curvatures_.
Their general locality and direction will be noted by this observation
and their details left to be discovered by closer examination.
During palpation with a long and rapid glide one may also note these
general points with respect to any curvature.
Do not mistake the four normal curves, the anterior Cervical and Lumbar
and the posterior Dorsal and Sacral, for curvatures. The normal Lumbar
curve is so unusual in practice that a novice has been known to name it
a lordosis.
Description of Curvatures
Four varieties of curvature are commonly described. _Kyphosis_ is
a curvature with its convexity directed backward, usually, but not
always, found in the Dorsal region. _Lordosis_, the opposite of
Kyphosis, is an anterior curvature, usually in the Lumbar in which
case it is an accentuation of the normal curve. _Scoliosis_ has its
convexity directed laterally either to the right or the left. It is
commonly also _Rotatory_, having its vertebrae rotated around their
vertical axes so as to make the outer or the inner transverses more
prominent than those on the other side.
In a Scoliosis the rotation may swing either the bodies or the spinous
processes toward the convex side of the curvature; the latter is much
the easier of adjustment while the former furnishes one of the most
intricate problems of adjustment.
Cause of Curvatures
Without entering here into a discussion of those disturbed metabolic
processes--themselves the result of subluxation--which result in
curvature by general softening of the bone, as in rachitis or
spondylitis deformans, we will simply state the general proposition
that almost all curvatures which are in any degree _angular_ result
from a single subluxation to be found at the point of the angle. It
has been demonstrated in such cases that adjustment at that point
will correct the curvature in time but it is usually wiser to hasten
matters by selecting other points of attack by a method to be presently
suggested.
Long, regular, but not pronounced, Scoliosis, usually in the Dorsal,
may be an example of _occupation curvature_, following the continued
use of muscles in a fixed position and not due to subluxation. Another
example is the mailman’s Lordosis. These in themselves are not
detrimental to health and are negligible unless some special point of
impingement through individual subluxation exists within them.
The sharp, angular kyphosis of Pott’s Disease, tubercular caries of the
vertebrae, the curvature involving three or four vertebrae which are
extremely tender to palpation, should warn against adjustment unless
one can be very certain that the vertebrae are sufficiently intact.
Fracture of a decayed vertebra is easily possible under adjustment. The
cause of Pott’s Disease is usually at the angle point, most frequently
the tenth Dorsal but possibly any Dorsal from fifth to twelfth.
Record on Curvatures
If it is the purpose of the examiner to straighten the curvature he
should choose for adjustment a series of non-adjacent vertebrae which
are most prominent in the direction of the curvature; thus in a right
scoliosis he should choose only those vertebrae most prominently out
to the _right_, and in a kyphosis only posterior ones. A lordosis as
such cannot be properly adjusted except in the Cervicals, but lordosis
is usually a compensating curvature (see below) and can be otherwise
corrected.
If the patient suffers from some disease which assumes more importance
than the curvature and demands attention, select the one vertebra
which is causing the disease, without reference to its position in the
curvature, and adjust that vertebra into a proper relation with the
adjacent ones, even though you adjust directly toward the convexity
of the curvature. Disease may often be relieved by _making a curvature
regular_ more quickly than by eliminating the entire curvature.
Sometimes both considerations may influence the selection of vertebrae.
In a curvature there is not necessarily pressure on nerves at every
foramen. In fact, such pressure is the exception rather than the rule
in curvature and a careful study of the spine must be made in order
that adjustments may be accomplished without _causing_ temporary
impingement here and there.
A foot-note describing curvature may be appended to the record of
palpation. It should contain the special name of the curvature, whether
simple or compound, and the numbers of the first and last vertebrae in
it. For instance, note may read: “Right rotary scoliosis from D 3 to L
1 inclusive.”
Compensatory Curvatures
When a primary curvature is present one or two secondary curvatures
usually appear to preserve the equilibrium of the body. With a Dorsal
kyphosis there is often a Lumbar lordosis and sometimes less marked
lordosis in both Cervical and Lumbar. With a primary right scoliosis
in the Lumbar there will be a secondary left scoliosis above. The
secondary curvature is called compensatory. In selecting vertebrae for
adjustment it is well to neglect the compensatory curvature as much as
possible, leaving it to right itself as the primary one is corrected.
If, however, the primary curvature be a lordosis, and not adjustable,
work on the secondary curvature may gradually aid in reducing the
primary, to a certain extent at least.
Ankylosis
This topic is discussed here partly because it is so often associated
with curvature.
Ankylosis can be appreciated only by detecting the lack of normal
movement between adjacent vertebrae. Place a finger in the interspace
between suspected vertebrae and ask the patient to perform the movement
calculated to separate the spinous processes in a normally movable
spine. If in the Dorsals, ask him to drop the head and shoulders as far
forward as possible without bending at the hips. Alternate repetitions
of this movement with straightening and the spinous processes should
alternately separate and approach each other. Test several successive
vertebrae so as to note that all change their position except two.
In the Lumbars have the patient repeatedly bend the body forward from
the hips striving to make his spine convex backward. In the Cervicals
forward flexion of the head will serve. Occasionally general ankylosis
is found with curvature, as in Spondylitis Deformans.
Many Chiropractors mistake failure to move a vertebra with an attempted
adjustment for evidence of ankylosis. In nine cases out of ten such
failure is due to other reasons, ankylosis being very infrequent. It is
a much abused excuse for incapability. Free movement between spinous
processes is _absolute proof_ that the vertebrae are not ankylosed.
DIFFICULTIES IN PALPATION
The chief difficulty arises from failure to observe some of the rules
herein laid down.
Carelessness or inattention precludes accuracy.
Pain may cause the patient to assume an unnatural or cramped attitude
simulating curvature, especially of the Cervicals. More errors occur
from this cause in judging the laterality of C 2 than with any other
vertebra.
The occasional bent spinous process in Cervical or Dorsal regions may
deceive the palpater unless transverse palpation is employed. But the
frequency of slightly bent processes in dry spines and a superficiality
of reasoning upon the subject have led to great overestimation of their
importance. As a matter of fact only a very few maladjustments arise
from deception of the palpater in this way, though the profession
contains few practitioners who make a routine method of verifying by
the transverses. The reason is simple. Bent processes are caused by
direct violence applied before the union of shaft and epiphysis is
complete. Sufficient force to produce a change of direction usually
produces subluxation _in the same direction_. Adjustment continued
until the offending process was quite aligned with its fellows would
constitute overadjustment, but adjustment is not usually continued
after all symptoms have subsided, so that actually small harm occurs
through failure to detect bending.
An epiphyseal plate may be absent, having been broken off by trauma and
absorbed. This can be discovered by noting the too-wide space between
apparently adjacent vertebrae, and careful palpation will disclose the
apparently much anterior vertebra, an appearance not borne out by the
position of the transverses. When an epiphysis is absent a patient has
a somewhat weak back from lack of muscular attachment.
Lipoma, or the heavy cicatrix following a burn or carbuncle, may render
palpation of two or three vertebrae impossible. In such a case only
the palpater’s experience and his knowledge of the characteristics of
various vertebrae will enable him accurately to number the remainder.
Patients with much adipose tissue may require palpating in several
positions in order to permit certainty.
A deep third Cervical which is absolutely impalpable may mislead one,
but a careful count which shows one vertebra overlooked indicates the
necessity for a careful re-examination of the Cervicals, by which the
gap at the third at least may be appreciated. If the Axis is very much
inferior the third is especially likely to be overlooked.