Technic and Practice of Chiropractic

by Joy Maxwell Loban

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.

Fig. 1. Position of hands in palpation for record.

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.