Part 2

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.

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