Part 3

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

The Lumbars and Sacrum are considered in one group. The Lumbars, with 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.

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.

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.

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.