Technic and Practice of Chiropractic

by Joy Maxwell Loban

OFFICE EQUIPMENT

Value of First Appearance

The patient, upon first entering an office, consciously or unconsciously forms an estimate of the personality and standing in his profession of the occupant of that office. This impression is gathered from the kind and arrangement of the furniture and visible equipment, from the neatness or disorder of the room, from countless little things which play each their part in making up the whole appearance. This first estimate is sometimes the only one, for an unfavorable first impression may lead to the loss of a prospective patient. In any case it will play a part in all subsequent judgments which the patient may form concerning the Chiropractor and his work.

Many patients entering our offices have no previous knowledge of our profession; their minds are open and curious, alert for new impressions of some sort. We may impress them as we choose. Every good business or professional man realizes the value of the first impression and strives for a good one. Therefore, upon entering practice, choose for yourself every article which shall have a place in your office. Your surroundings will then truly reflect your personality and will attract those upon whom that personality can work in harmony and understanding. It is of no avail to attract the type of patients you cannot hold, to draw through the borrowed judgment or taste of another surroundings alien to yourself and thus to attract people who will at once sense the incongruity and be repelled by it.

Yet one may aspire. And if you are able to perceive and appreciate truly professional surroundings you may hope to school yourself by association and study to harmonize with them.

Choice of Articles

In choosing the contents of your office keep in mind good taste, utility, and the psychological effect upon all visitors. Remember that you expect to spend many hours each day in the company of your furniture, and select such things as will contribute to a proper professional state of mind in yourself. A Chiropractor’s profession is in many ways like, yet in many ways unlike, any other. Therefore his office equipment, while following in general the equipment of other professional offices, must be selected with an eye to the special and particular needs of the Chiropractor and his patients. Too little attention has been paid thus far by the profession to the selection of office equipment.

Furniture in General

The furnishing of an office depends upon the amount and disposition of the room at your command. One must have at least a waiting room and a private office even if a single rented room must be cheaply partitioned to make the division. A larger suite is a better investment when possible. In the waiting-room should be found easy chairs, library table, hall-rack, mirror, and an easy divan or couch. The floor should be covered with a good rug or carpet and the walls properly and cleanly decorated and hung with restful, pleasant pictures. A book-case filled with carefully selected books is a good addition.

On entering your private office the patient should see your diploma, which hangs in full view of the entrance and which bespeaks with no weak voice your fitness to practice, your professional ability. The importance of this point cannot be overestimated. The intelligent visitor expects you to have had careful training and to possess thorough knowledge of your work. If he notes the diploma as evidence of it and of your pride in your college he is assured.

If only two rooms are at your command the second must be at once consulting room, adjusting room, dressing room. As such it should contain your desk, desk chair, chairs for the patient or patients, adjusting table or tables, towel cabinet, lavatory, and a curtained recess for a dressing-table, chair, and hooks for hanging clothing. On the wall hang those charts from which it is at times necessary to explain a part of the human mechanism to the inquirer.

This room should convey a two-fold impression—business and professional. It should contain the special paraphenalia of your profession and some of the suggestive contents of the ordinary business office, such as desk, card-index file, typewriter, etc.

Let us consider these points more in detail.

Waiting Room

In your waiting room new patients wait and form their estimate of you before your appearance. They are tired patients, worn perhaps with years of disease, and their comfort must be considered. Some time is theirs for use in some way and the use of their minds during the waiting interval must be studied.

For these reasons first of all the waiting room should be furnished quietly, in perfect taste, but well furnished. A good dark rug for the floor rather than matting or linoleum with their suggestion of bareness, a tinted or papered wall done in a soothing shade, upholstered furniture pleasing to the eye and comfortable for tired, weak bodies, and a library table with proper literature for the occupation of the mind—these are the proper furnishings for a waiting room.

Let the table contain chiefly Chiropractic literature and select that literature with care. Be sure that it reflects the view-point toward your profession with which you wish your patients to be impressed. It must be scientific, well written, not sensational, not dealing coarsely or vulgarly with the revolting diseases or features of disease, but quietly convincing. Your literature must impress with the greatness of Chiropractic without setting forth extravagant claims which your patients will expect you to vindicate. Your selection of books for the book-case must convince all observers of your proper literary taste or the book-case had better be omitted. Likewise the pictures on the walls must suggest pleasant things, restful things, good to contemplate.

When possible secure a high-ceilinged room with good ventilation, plenty of fresh air without drafts. And then let all the articles in the room harmonize. One jarring note in form or color may mar the entire effect, which should be that of comfortable simplicity.

Private Office

Even more important than the contents of the waiting room is the equipment of your private office. It is in this room that your work is done. There your patients confide to you their weaknesses; there they determine finally whether to trust themselves to your knowledge and skill; in that room they form their judgment as to your cleanliness, your use of system; there they meet you.

Arrangement of Furniture

Every bit of furniture for the private office having been carefully selected its arrangement should be studied.

When the patient first enters the private office he should be able to see your diploma. He should also sit where he can notice it as he consults you and every other object within his vision during the consultation should be picked so as to avoid attracting his attention to anything foreign to his visit and its purpose.

Two chairs are placed near the desk, one an easy chair for yourself, a revolving chair being preferable, and a straight-backed leather-upholstered chair for the patient. In placing these chairs be careful of two things: let the strongest light shine over your own shoulder and bring the face of the patient out in clear detail; and let your own chair be higher than the patient’s so that he looks slightly upward to meet your direct gaze. For the last mentioned point there is a sound psychological reason; to control any dialogue with another person place yourself on a higher level than he and unconsciously he will obey the suggestion and lift his thought to meet yours, offering it rather than commanding with it. The light is arranged for its value in observing, as a matter of diagnosis, every indication in expression, gesture, and skin coloring.

Hanging back of the desk where it may be easily reached but where its gruesome suggestion will not obtrude itself upon the nerves of the sensitive without your deliberate intention, have a vertebral column for demonstration purposes. There are many times when it is necessary to show a subluxation as it would occur.

Beside the desk and within easy reach of your hand should be placed at least a single book-case section containing those reference works which you frequently consult. The contents of this section will be considered later; suffice now to say that they should be well bound and should be so placed that if a doubtful point arise they can be consulted at once without your rising. I am not of the opinion that a pretension of unlimited knowledge is a valuable professional asset. It seems better frankly to seek authoritative information, even in the presence of the patient, than to allow an error to creep into your work, and your more intelligent patients will appreciate your care. Furthermore, this placing of your books is convenient when you are alone and considering the cases which have passed before you during the day. It tempts to study.

The desk should hold a typewriter, significant of business methods, and a card file for case records. Incidentally, you should have neat bill-heads and printed stationery for all correspondence, though blank white paper is better than over-ornate design or profuse coloring.

On the wall hang a few good anatomical and physiological charts upon which may be pointed out certain facts for the instruction of patients. It may be suggested that these hang on racks so that the surface charts may be easily changeable and that those ordinarily exposed to view be such as will avoid unpleasant suggestion of any kind. For instance, an X-Ray chart of the body showing the skeleton is but one degree less repugnant to the average person than the bones themselves. Though your college training has robbed the subject of all emotion, for you, take thought for the feelings of your visitors.

Adjusting Tables

For all purposes the best type of bench now on the market is probably that composed of two sections, one fixed and the other—the rear one—sliding on a track. Both sections should be adjustable at various angles to the plane of the base and some of the best tables are made so as to permit changes in the distance from the floor to the entire top or to any part of the top, a great advantage in that the table height may thus be made to suit the height of the adjuster.

An abdominal support is now indispensable but must be so elastic as not to interfere with the adjustment. Leather upholstery is more sanitary than plush and has come into general use.

An opening in the front section such that the face may look downward through it and straighten the cervical and upper dorsal spine for palpation and adjustment has been proven a disadvantage instead of a help and will be entirely unnecessary to one who follows the technic laid down in this book.

The Roll

A desirable addition to this table is an upholstered roll of quite solid material and about eight inches in diameter. This can be placed under the patient’s thighs on the rear section, thus elevating the thighs and straightening the Lumbar region so as to separate the spinous processes. The roll is especially useful for the adjustment of posterior Lumbar subluxations, being inadvisable with rotation.

With a patient lying on the bifid bench in the ordinary adjusting position the Lumbar spinous processes are crowded together and the bodies separated. In rotation, since the adjustment works by using a short power arm against a long weight arm (distance from contact point to center of rotation against distance from center of rotation to anterior margin of body), and since the heaviest portion of the vertebra—the body—is to be moved most, this position of suspension secures the easiest adjustment. But if the vertebra be posterior and a spinous process contact is used the best adjustment can be secured over the roll or with a table adjustable to an angle equal to that which would be secured with the roll.

Cleanliness

Everything in the office should be kept scrupulously clean. A lavatory with towel racks well filled with clean towels is an absolute necessity. If no lavatory is inbuilt in the office a portable one may be secured which will answer every purpose. It will be well if the patient observes that you carefully cleanse your hands before giving an adjustment.

The office should contain a towel cabinet with a stack of clean towels and a compartment for used towels. Or tissue towels may be used to save laundry bills. Before each adjustment a clean towel should be unfolded and placed upon the front section of the bench so that the patient rests head and face upon a perfectly clean surface. When the adjustment is completed toss the towel into the used-towel compartment. This use of towels minimizes the risk of contagion or infection from a germ-infested upholstery, suggests care and cleanliness to your patient, and gives the patient greater trust in you.

Dressing-room

A curtained recess separated by a screen from the remainder of the room will serve if no separate room is available for a dressing-room. It is better, if possible, to have a separate dressing-room and better still to have separate dressing-rooms for men and women. If extra rooms are not at your command and you use a curtained recess be sure that it contains good light, a dressing-table with mirror, a small chair, and hooks for clothing. Provide also a few dressing-sacks for women though most of them will prefer to furnish their own.

The Rest Room

It is a known fact that the patient who can be kept in a quiet, restful, and relaxed state for some time following the adjustment derives the greatest benefit therefrom. Having loosened subluxated vertebrae by adjustment their tendency is to settle in their old abnormal position and every movement of the patient for a time aids this tendency. Quiet permits adaptation of surrounding tissues to the changed position of the vertebra; action facilitates the re-adaptation of the vertebra to the state of surrounding tissues.

If possible a special room should be provided in which patients may lie down in comfort for twenty or thirty minutes following an adjustment. If more than one patient at a time is to rest, separate rooms should be provided for men and women. The rest rooms should have high ceilings and excellent ventilation without drafts. The floors should be carpeted so as to soften footfalls and suggest quiet and rest. Potted plants adorn such a room very well and always afford a pleasant suggestion.

The patients lie on cots, foldable for convenience when not in use, and should lie on their backs as quietly as possible. Some prefer solid cots on rollers so that the cot may be noiselessly rolled beside the adjusting table after the adjustment, the patient may by one turn move himself upon it, and it may then be gently rolled into the rest room. This is a more finished, if more expensive, handling of the problem.

It may be well to furnish some occupation for the mind and to this end, since reading in such a position is injurious to the eyes, a good phonograph is a valuable addition. Equip it with a soft parlor needle and select only soothing, restful music. Just as you would avoid doing the walls of the rest room in striking or garish colors, exciting to a diseased mind, so avoid exciting or harsh music. The object of this room is rest for mind and body. Let every thought be directed to that end. With some patients the use of the phonograph or other amusement must be avoided. Study your cases with care.

The trip to the Chiropractor’s office is too often regarded in the light of an unpleasant necessity. If proper care be used in equipping an office and if such means as have been suggested for the rest room be employed, these in addition to the pleasing personality of the Chiropractor may make of the visit a pleasant thing, a part of the day to be anticipated with eagerness.

A Complete Suite

The number of rooms in a perfectly convenient suite depends upon the approximate number of cases to be handled daily. If it is needful to economize the practitioner’s time a greater number of rooms will be required than would be desirable with a small practice.

A waiting room, a consulting room, two or more adjusting rooms, and two rest rooms make probably the best number and employment of rooms. It is desirable if possible that the adjusting room be used for that purpose only and that there be separate rooms for men and women. Each adjusting room can then have its own dressing room or recess. Or in addition to the other rooms named above there may be many small rooms each containing an adjusting table and a rest cot and each serving as the rest room after the adjustment. If a sufficient number be provided as many patients can be handled in this way as time permits, the practitioner need lose no time at all, and each patient may have a room entirely to himself throughout his visit.

Reference Library

This should consist of those standard works to which you will necessarily refer most often. Gray, Morris, or other standard anatomical authority, Brubaker’s or Haliburton’s physiology, Butler or Osier on diagnosis, Delafield and Prudden on pathology, Morat on the physiology of the nervous system, Bing on regional diagnosis of nerve lesions, one or two good works on psychology, gynecology, histology, etc., a good medical dictionary, and any books on Chiropractic in which you have confidence make up an excellent list. Any standard works will suffice and this list is merely suggested for those who may be uncertain as to their own tastes. Always examine a book before buying it, even those named above. Next to works on Chiropractic no single book is as necessary or useful as a good medical dictionary, preferably a large and complete one.

Door Sign

Your door should bear a sign in gold or black, setting forth your name and business and perhaps your office hours. It may read, “W. R. Jones, Chiropractor,” or, “Jones & Jones, Chiropractors,” with office hours appended. Avoid repetitions such as “Dr. W. R. Jones, Chiropractor,” or “W. R. Jones, D. C., Chiropractor.”

Advertising

The word of a satisfied patient to his friend is the best advertisement. Beyond this, considerable diversity of opinion exists as to what constitutes proper, ethical, and wise advertising. I shall make no attempt to settle this question but shall simply suggest that while it is undoubtedly necessary often to explain to the public through various avenues what Chiropractic is and what it can do it is wise to be as reserved and dignified as possible and to avoid offense to any. Thus it is clearly unwise to advertise that your competitor is a fraud, much wiser to convince your readers by the logic and strength of your statements that you are not. Consider good taste and avoid unpleasant references to loathsome or vulgar diseases. Such advertising is associated in the public mind with quackery, with patent medicines and medical institutes, and no matter how sincere and right your motives may be it will be misinterpreted by those you wish to reach.

Consider also the legal side of advertising. Study the laws of your state and avoid any statement which will conflict with the law. In some states it is illegal to advertise with the term “Dr.” unless you hold a medical license. In others to advertise to “treat,” “cure,” or “heal” disease is to practice medicine technically. Such statements miss the truth, in any case, because the Chiropractor administers an adjustment and not a treatment and because Nature alone can cure or heal.

Collection Cards

Different communities respond to different collection methods. With one class of patients it may be better never to mention fees except to answer inquiry and simply to submit monthly statements of account to all patients. With another it is necessary to charge in advance. More Chiropractors use this method than any other and many use cards for the purpose.

These cards are best printed with name, address, telephone number, etc., on one side and on the other six or twelve spaces ruled off at one end for punching to indicate adjustments given, and the words, “Good for six (or twelve) Chiropractic adjustments at (office) (residence) when properly countersigned.” A line should be left below for your signature and at the bottom the price of the card should be printed plainly. If desired a space may be left for the patient’s name so that the card may be made non-transferable.

The card is issued at the beginning of a course of adjustments and a duplicate is kept on file. Each time the patient is adjusted he presents his card before leaving and one space is punched out. By this system both the patient and the adjuster may know exactly the number of adjustments given and accounts may be easily kept. Without it, a book entry of some sort must be made for every adjustment.

The best thing about this system is that it reminds the patient that you expect to be paid in advance without the necessity of your saying so, since the words “in advance” follow the statement of price on the card. At the time of payment you give him, as a receipt, a card entitling him to a certain amount of your service at a stipulated place.

Schedule of Examination

This method of procedure for the investigation of new cases is offered as a suggestion to be followed as far as the education of the Chiropractor will permit. If every practitioner adopts some such method of making his own diagnoses he will advance in ability much more rapidly than by accepting the diagnoses given his patients by physicians or others. We should remember, though without arrogance, that our special ability to discover subluxations and our knowledge of their significance as the primary causes of disease renders us better prepared for correct diagnosis than our medical friends, other education being equal.

It should be quite obvious that in attempting the accomplishment of 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.