any object it is necessary first to have in mind a clear preconception
of the things to be accomplished, and second, to have a clear and
concise, yet complete, outline of the steps to be taken, their order or
sequence, and their relative importance in the accomplishment. These
two needs, as regards a Chiropractic diagnosis, we shall endeavor to
supply in this section.
Chiropractic Diagnosis properly consists of three parts, Vertebral
Palpation, Nerve-Tracing, and Symptomatology, together with the
reasoning necessary to properly weigh and summarize the facts
ascertained. Of these three divisions two fall properly under the head
of Physical Diagnosis and the third, symptomatology, should consist
principally of physical diagnosis.
Everywhere the physical or objective sign is given preference over the
subjective symptom. Before a single question is asked of the patient
relative to the case or its history, every other means of obtaining
information properly coming under the head of a Chiropractic diagnosis
should be utilized. The questions should come last and be very few and
direct. They should serve only to illuminate the few remaining doubtful
points in the mind of the examiner, points which perhaps exist only
because of some fault or weakness in his methods of examination.
The proper order of examination is as follows:
1. General Observation.
2. Vertebral Palpation.
3. Nerve Tracing.
4. Special Examination.
5. History of Case.
6. Summary.
General Observation
Observation of the patient with a view to determining any signs of
disease should begin with the moment the patient steps into the office.
It should continue during your conversation and during the Vertebral
Palpation and Nerve Tracing which follow. The mind of the examiner
should be constantly on the alert to note any sign on any exposed part
of the patient’s body, or any motion which may betray the nature of the
disease or diseases with which he suffers.
Before preparing the patient for palpation observe temperament,
position and carriage of head, body, and limbs, and facies.
Ask male patients to strip to the waist and female patients to remove
all clothing down to the waist except a loose gown or kimono, which
is worn reversed so that it opens behind and exposes the spine to
direct examination. No greater error can be committed than to attempt
examination of the vertebral column through clothing or other covering.
Examine with patient seated on a bench or stool with feet evenly placed
upon the floor. If the patient is for any reason unable to assume this
position the examination may be varied somewhat.
While in this position continue observation of points mentioned above
and observe also condition of skin, whether abnormal in color,
moisture or nutrition, or whether there is flushing, cyanosis, or
pallor, roughness, eruption, etc.; the condition of bones and joints
other than vertebral; general emaciation or obesity, local malnutrition
or hypertrophy; evidences of operation, scars etc.; and action of
muscles more in detail than is indicated under position and carriage of
parts.
Having observed these things discontinue general observation and all
other considerations for the time in favor of Vertebral Palpation.
Vertebral Palpation
The primary object of Vertebral Palpation is the location of
subluxations, or partial displacements, and the determination of the
relative degree and direction of those found. Next comes the recording
of subluxations in such a manner that a perusal of your record will
enable you to reconstruct at any time a mental picture of the spine, as
far as possible. (See Record.) With the making of the record the proper
form of adjustment for the correction of each subluxation is decided.
Finally, by _failing_ to find subluxation in certain segments you may
safely eliminate those segments from consideration and confine your
further attention to the remainder. (See Spino-Organic Connection.) It
must be borne in mind that while the finding of a subluxation is not
always positive evidence of the necessity for adjustment there, the
_absence_ of subluxation of any spinal segment is proof positive that
no disease exists in the corresponding somatic segment. Differential
diagnosis is thus often greatly aided by palpation.
Nerve Tracing
Having thus narrowed the field of operation, trace from spine to
periphery every nerve tender enough to be traced, noting the relation
of the tender nerves to the subluxations already found by palpation.
Whenever it is possible note the _degree_ of tenderness of the various
nerves and keep in mind through the remainder of the examination the
fact that greater tenderness in some one segment indicated either
greater or more acute disease in that segment.
It is best to use great caution about entirely eliminating any segment
from consideration because of negative findings in attempted nerve
tracing. The fact that no nerve is traceable is not always proof that
no impingement exists, but only that no _irritation_ exists. Only light
or acute impingement may irritate a nerve. In forty, and possibly
fifty, per cent of all cases no nerves are traceable at any time. (See
Nerve-Tracing.)
Special Examination
The examiner has by this time formed some concept of the case in
hand. He has a clue to the possible nature of the disease and he has
narrowed his observation to a few segments of the body or a few organs
which demand a more special examination. This may be accomplished by
Inspection, Palpation, Auscultation, and Percussion.
History of Case
Having determined by these methods every fact possible of determination
without information from the patient, it becomes necessary to go
somewhat into the history of the case. The history of falls, jars,
shocks, or injuries of any kind should be taken first and these should
be viewed in the light of their bearing upon the previously ascertained
condition of the spine. Sometimes the definite history of an accident
immediately preceding the development of disease symptoms suggests its
connection with the disease and the exact nature of the accident points
out to us some one of the several recorded subluxations as the one
involved. This in turn may aid a doubtful differential diagnosis. Each
step in the process of examination helps to explain and clarify the
facts elicited by other steps until the facts marshal themselves into a
complete and comprehensible picture.
At this point it will be possible to stop in some cases and rest upon
the evidence gathered. If you are able at this time to state clearly
the nature of the case, the manner of its cause, the site of disease
and of the subluxations causing it, the kind of subluxations, and
the chance of recovery under adjustment, it is preferable to do so.
You will thus have made a complete diagnosis without recourse to
information from the patient except the history of injuries.
Sometimes, however, it will be necessary to go further into the case
and ascertain the presence and nature of subjective symptoms. If this
be necessary, the examiner should confine his questions to the parts
indicated as diseased, and thus limit the number of questions and make
them all direct and essential. It is important to avoid trivial or
irrelevant questioning.
Summary
Finally, having ascertained all necessary facts, mentally summarize
them all, combining the results of Palpation, Nerve-Tracing, and
Symptomatology so as to reach a definite conclusion as to the location
and nature of the morbid process, the subluxation producing it, and the
exact form of adjustment necessary to correct it.
The examiner should be able at the end of the examination to state
exactly what he finds to be the condition of the patient, to give
reasons and nerve connections, and to demonstrate a subluxation to back
every statement.
The case record should contain all essential information relating to
the diagnosis and the correction to be applied.
Necessity for Correct Diagnosis
Diagnosis, in a restricted sense, means merely the naming of diseases.
But in the broader and more proper sense it means disease knowing and
includes a knowledge of the causal factors, the location and nature
of disease, the amount of damage to structure and of functional
disturbance, and the probable duration and outcome of the case either
with or without Chiropractic adjustments. In this broader sense we use
the term hereafter.
The object of diagnosis is correct adjustment. Including as it does
palpation, nerve-tracing, and symptomatology, the Chiropractor’s
diagnosis of a case should embrace all the knowledge upon which he
proceeds with his adjustment.
There are really two all-important questions which constantly recur
to confront the busy practitioner. One is, “What is the matter with
my patient?” and the other, “What can I do to relieve him?” Practice
resolves itself into these two divisions, diagnosis and adjustment.
The real question which should suggest itself to the thinking
Chiropractor is not, then, “Should a Chiropractor study diagnosis?”
but rather, “From what viewpoint should we study diagnosis? Upon what
portions of the subject shall we concentrate our attention?”
Undoubtedly the most important branch of diagnosis to us is vertebral
palpation. By its use we discover those facts about the spinal column
without which we are entirely unable to proceed as Chiropractors.
Knowledge concerning the spine is the _most essential_ part of
diagnosis.
Next in order of importance comes the study of physical or objective
signs throughout the body--the examination of the body for the
discovery of all the changes in the size, shape, position, etc., of
organs which indicate disease. This includes nerve-tracing, which in
some cases is the most important branch of physical diagnosis after
vertebral palpation.
Finally, a certain degree of examination for _subjective_ symptoms may
be necessary. But the Chiropractor of the future should become, and
probably will become, par excellence a _physical diagnostician_.
For many reasons we should be able to rely upon our own diagnoses.
Capability in diagnosis renders us independent of the errors or false
beliefs of others. Since it includes a knowledge of subluxations, not
included in medical training but still vital to correct interpretation
of morbid phenomena, it can be more accurate than any diagnosis which
ignores these causal factors. A habit of diagnosing one’s own cases
enables one, always resting on his own judgment, to correct and improve
himself through all errors, for which he is then alone responsible.
A general knowledge of medical diagnosis, of pathology, bacteriology,
etc., enables a Chiropractor to meet the physician on common ground; in
fact, it gives the Chiropractor a distinct advantage, since he knows
not only what his medical friend knows but also the all-important facts
regarding the spine which are unknown to others. Such knowledge and
the ability to discuss disease intelligently also furnishes common
ground with every patient. Each patient is a specialist in the disease
he believes himself to have and he expects from his doctor a greater
knowledge than his own.
The recognition of contagious or infectious diseases as such is an
absolute necessity in order to obey the laws and safeguard the public
health. The exact condition and degree of vitality of the patient
and the knowledge of the existence of abscess, gangrene, intestinal
obstruction, etc., often warns the Chiropractor that his adjustment
would be dangerous to the patient. Much possible injury is avoided by
accurate diagnosis. Even the frequency with which adjustments should be
given depends upon diagnosis.
Special Cases
There are certain cases which a Chiropractor is powerless to aid
and immediate recognition of such cases will save much trouble. In
intestinal obstruction from intussusception or from strangulated
hernia, for instance, it is best to advise the calling of a surgeon
immediately, while in obstruction from volvulus or intestinal paralysis
the adjustments may afford relief and should at least be tried first of
all.
Any internal abscess presents a possibility of rupture into a serous
cavity or the substance of a parenchymatous organ and is therefore
dangerous, while a superficial abscess, pointing toward the surface,
can best be cared for by adjustment. A badly ulcerated or gangrenous
appendix may rupture under adjustment and be followed by diffuse
peritonitis. The fragile walls of the ileum in typhoid may perforate
under adjustment, while in its earlier stages the disease is easily
curable. The rotted vertebral bodies in Potts’ Disease (spinal caries)
may be crushed under the heavy hand of an ignorant adjuster.
Intelligent case-taking _must_ include accurate diagnosis.
Frequency of Adjustments
The frequency of adjustments in practice should be determined entirely
by the nature of the case and the circumstances in which patient and
adjuster are placed. No hard and fast rules can be laid down but some
general advice may be profitable.
Acute fever cases may be adjusted, until the fever is broken, oftener
than any other type of cases. The chief object is the regulation of the
temperature, after which the body is able properly to repair itself.
Sometimes it may be necessary to give from two to six adjustments in
a day and in at least one tetanus case the adjustments were given
at intervals of about ten minutes for several hours until the fever
was under control. After such a series it is wisest to refrain from
adjusting again for several days so that the patient may recuperate
during the interval, providing the fever does not return. It has been
noticed that after a series of adjustments given at short intervals the
improvement of the patient often extends over a period of days or weeks.
In ordinary chronic cases, with good vitality and reactive power, the
daily adjustment is best at first. Then after a course of from six to
twenty-four adjustments according to the judgment of the practitioner,
the interval is lengthened and adjustments given on alternate days, a
day of rest intervening between each two. In weak patients or those who
are extremely sensitive, the shock of the daily adjustment, even at
first, and the demand on the body’s recuperative power may be greater
than can be met.
In this connection it may be mentioned that the author has encountered
several cases of dorsal lordosis produced by too heavy and too frequent
adjustments, straining the ligaments faster than they could be repaired
and continuing the strain over too long a period. It is possible
to _over-adjust_ a patient, producing a weakened spine and other
deleterious effects, just as it is possible to establish a “tolerance”
for a drug by long continued use.
During a long course of adjustments it is well to allow the patient
an occasional week of complete rest, or even more, and it may be wise
after a time to reduce the number of adjustments to two per week in
some cases.
On the other hand, the practice of giving one adjustment a week
from the beginning, as followed by some practitioners who maintain
offices in numerous localities and visit each one day per week, is not
generally productive of good results and it is the author’s practice
to refuse new cases who profess their inability to take more than one
adjustment weekly. The interval is so long that all repair work started
by each adjustment is completed and an involutionary change sets in
before the next.
Specific vs. General Adjusting
By specific adjusting is meant the selection and adjustment of the
vertebra or vertebrae which are known to be causing definite disease
or weakness. The term “specific adjustment” implies that there is a
particular reason existing and recognized for every vertebra adjusted.
General adjustment, on the other hand means either the adjustment of
all palpable subluxations, or of all the most noticeable ones, or of
all found providing that no two successive vertebrae be adjusted,
according to the beliefs of different elements in the profession.
Specific adjusting relies upon the diagnosis and requires correct
interpretation of disease. General adjusting considers only the
condition of the spine and is given upon the principle that if the
spine is right the man is right--a perfectly correct principle
regardless of whether or not the general adjustment is advisable. Let
us consider some of the arguments for and against each method and reach
a conclusion if possible.
The use of specific adjustment demands of the Chiropractor an accurate
diagnosis and compels him to get his mind into direct contact with the
exact condition of the patient in order to select the proper vertebrae.
Sometimes the less prominent subluxation causes a more acute or
dangerous disease than the more pronounced. Specific adjusting tends to
develop more discriminating and accurate palpation.
Specific adjusting weakens and shocks the weak or nervous patient
less than general adjusting. It also concentrates the recuperative or
reparatory power of the patient on the parts which _most need repair_.
The body possesses only a certain limited capacity for combating
disease or building weakened tissue. To scatter this force widely is to
weaken its effect in any particular locality.
The habit of specific adjustment and of selecting proper vertebrae
enables the Chiropractor to explain definitely at any time just what he
is doing and why he is doing it. We assert that in adjusting a vertebra
we are removing the primary cause of disease. It is sometimes awkward
to be asked if the patient has nine diseases or if it takes nine
subluxations to cause one case of acute coryza. A correct answer to
either question leaves an embarrassing discrepancy between theory and
practice.
In favor of the practice of general adjusting it has been said that
errors in diagnosis become unimportant if all subluxations be adjusted;
that if the spine be straightened the patient _must_ recover. Against
the first statement, which is forceful because diagnosticians are
so notably liable to err, it may be said that errors in palpation
are almost, if not quite, as frequent as errors in other branches
of diagnosis and that one’s tendency to err is less if all possible
methods be checked against each other than if one only is used. The
second statement is quite true; but it is based upon the assumption
that in ordinary practice the spine _may_ be straightened completely.
As a matter of fact this rarely, if ever, occurs. It is practically
impossible ever to thoroughly “line up” a spine. The best that has been
done as yet except in acute subluxations is to so modify subluxations
that disease disappears.
We may interject here the statement that no greater or more conclusive
betrayal of incompetency can be offered by a Chiropractor than the
declaration that he has completely “lined up” a spinal column in one,
six, or a dozen adjustments, as some have declared. If one be honest in
such statements it is proof positive that he is not capable of accuracy
in palpation or else lamentably liable to auto-suggestion. Clinicians
of proven ability, who have examined more than five thousand spines
each, agree that no perfectly normal spine has been discovered, whether
the spine has been adjusted or not.
But the chiefest argument against general adjusting is that it scatters
the reparatory forces of the body throughout many segments, some
of which are not really in need of attention, while the one or two
segments which need all possible concentration of energy receive only a
diluted share.
If my patient suffers from an acute pneumonia and nothing else and if
I require that he submit to a general adjustment including some eight
subluxations, two of which are Lumbars, I am unscientific and unwise.
What that case demands is an immediate localized improvement.
It is highly probable that the efficient Chiropractor of the future
will be a specific adjuster; that every recognized body condition will
suggest a definite and scientifically determined corrective measure;
and that guesswork will be largely eliminated.
Talking Points
The things which it is most important that the Chiropractor should
set before his patient are the theories and facts peculiar to
Chiropractic, perhaps adduced by Chiropractic investigations alone.
These theories and facts have been discussed elsewhere in detail: the
subluxation theory, easily demonstratable with a spinal column as an
object lesson, the relations between primary and secondary causes of
disease, the directness and completeness of the results of vertebral
adjustments, these explanations are more convincing than the display
of a wealth of knowledge of methods and theories used by other schools
of practice. Chiropractic has been builded not by virtue of previously
established truths but solely on the vitality of the new principles
enunciated by it.
These new ideas cannot hope for full and immediate credence and must be
presented carefully, with this fact in mind and with due consideration
for the degree of intelligence of the listener. Avoid argumentative
discussion with patients, seeking rather to enlighten them about those
facts peculiar to Chiropractic and unknown to them than to antagonize
them by contradicting their cherished beliefs. It is much wiser to
begin with that knowledge of disease which you hold in common with the
patient and advance with him, step by step, from that firm foundation
to new truths than to begin by attempting to tear down his beliefs.
Reason from the known to the unknown. Replace an old idea as to the
causation of disease by quietly inserting a new one of greater verity
and it will presently and painlessly crowd out the old. This process is
much the simplest and easiest.
Nevertheless in presenting Chiropractic we must be gently positive.
Chiropractic is known and provable. Always able to fall back upon the
clinical test as a final argument with supreme assurance that it will
not fail to vindicate our claims, we may present an unshaken front
before the most powerful and intelligent attack.
Promises to Patients
The majority of patients will require from the Chiropractor an
expression of his belief in his ability or inability to cure them. They
will desire a statement as to the probable time required for a cure.
They may even ask a guarantee of success.
These questions are hard to meet truthfully and convincingly, for
the truth is that every Chiropractor fails sometimes and is unable
to predict that failure in advance and that no one wise enough to
predict the length of time which will be required for the cure of any
given case has yet arisen. And these truths do not sound reassuring or
convincing.
Explain to the patient that nature alone is the curative agent and that
the cure depends not alone upon the skill of the adjuster but upon
the exact condition of the vertebrae, the exact amount or degree of
damage to tissue, the patient’s habits of living, etc. Any accidental
interjection of other factors into the case may have an important
bearing. You may assure him of the excellent results you have obtained
in other cases similar to his, or even cite individual cases if to
do so does not violate a professional confidence. But you had best
avoid a promise to cure or an exact statement of the time which will
be needed. State your belief or opinion but do not bind yourself to a
promise. Offer your best skill and closest attention; you can do no
more.
The patient should rely upon the skill of the Chiropractor as upon the
skill of his lawyer or his physician. Neither can honestly promise that
he will succeed in his efforts, even though all indications point that
way.
Re-Tracing of Disease