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.
Anomalous cases have been found in which there were more or less than the usual number of movable vertebrae, the usual deviation being the presence of twenty-five, and the extra one being most commonly a Lumbar. In one case under my observation there were twenty-five movable vertebrae, apparently thirteen Dorsals according to shape, and only eleven pairs of ribs posteriorly, two pairs being dichotomous so that there appeared thirteen pairs anteriorly. Deviations in number occur, in my experience, about once in five hundred cases.