VERTEBRAL PALPATION

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Definition

Vertebral Palpation consists in the use of the tactile sense to determine the position, relation, size, shape, and as far as possible the condition, of the segments of the spinal column, in order thus to discover the primary causes indicative of disease.

Or, Vertebral Palpation is the name given the manual examination of spinal vertebrae.

General Propositions

Every palpation should be made with the adjustment of the vertebrae in mind. The record of palpation should be a correct guide as to direction of adjustment. No subluxation impossible of adjustment should be recorded.

The two essentials of correct palpation are accurate perception and correct reasoning. To secure the first, a certain approved manner of using the hands is herein laid down and a considerable amount of tactile sense development by practice is required. Correct reasoning depends upon knowledge of all the important facts concerning the spine and of the rules governing palpation.

Absolute concentration is required and to this end many of the following rules are directed.

Habits of Palpation

Every palpater unconsciously forms habits of thought and action. These habits may be good or bad. We deliberately form a habit of holding the first three fingers closely together or the habit of using a downward glide, but we should avoid the habit of finding certain subluxations because they are usual and expected rather than because they are actually there. For instance, one may easily form a habit of listing every other vertebra in the spine, his whole record thus depending upon his first choice.

Because of this perfectly natural tendency to establish a routine of thought and action and to follow it precisely, it is best not to attempt palpation without the aid of an experienced teacher until after correct habits have been formed. Once formed, a palpation habit, right or wrong, is very hard to break. Many a teacher has expended himself uselessly in the effort to undo some technical fault acquired by the student in a blundering undirected trial.

Facts Concerning the Spine

The spinal column is composed of twenty-six segments called vertebrae, twenty-four movable and two fixed. The movable vertebrae are divided for convenience in study into three sections. There are seven Cervical vertebrae, twelve Dorsal, and five Lumbar in the normal individual. The number of Dorsals or Lumbars may vary by one in a rare case. These variations occur in about one spinal column in each five hundred and are usually in the Lumbar region, which may contain four or six vertebrae. A prominent first sacral spinous process may be mistaken for an extra Lumbar.

Five vertebrae have special names. The first Cervical is called Atlas; the second Cervical, Axis; the seventh Cervical is commonly known as Vertebra Prominens on account of its long and large spinous process, although this long process belongs to the sixth Cervical or first Dorsal instead in 35% of all cases; the large, irregularly fusiform vertebra just below the Lumbars and between the ilia is called the Sacrum; and the smaller one below it, the Coccyx. The latter is occasionally missing.

Each vertebra except the Atlas is composed of a body and an arch; the arch is made up of two pedicles, short, thick plates of bone extending outward and backward from the postero-lateral surface of the body nearer its upper than its lower border, two laminae, thin plates of bone extending backward and inward from their union with the pedicles and joining behind to form the spinous process, and has projecting from it seven processes, two transverse, one spinous, and four articular, two of which are superior and two inferior. The foramen enclosed by the body, pedicles, and laminae is called the neural or vertebral foramen and the canal formed by the connection of these foramina and completed by the ligaments which unite the arches is called the neural, vertebral, or spinal canal. It contains the spinal cord with its membranes and the roots of the spinal nerves. By means of the four articular processes each true vertebra except the first articulates with its fellows above and below.

The body of the vertebra is its largest portion and is joined to its fellows by fibrocartilaginous disks which are sufficiently elastic to permit some torsion and compression. Nine sets of ligaments, including the intervertebral substance just mentioned, bind the vertebrae firmly together. Many muscles are attached to the spinal column.

The intervertebral foramina are openings at the sides of the vertebrae, formed by the notching of apposed pedicles. These openings are surrounded by bone, cartilage, and ligaments and vary in shape in different sections of the spine. They permit the exit of the spinal nerves and their sheaths, the re-entrance of some nerve fibres into the neural canal, and the passage of blood-vessels to and from the cord. The entire philosophy of Chiropractic focuses at the intervertebral foramen because there we find the primary cause of all pathological changes in the body.

The spinous and transverse processes merit particular description since they are the levers by which vertebrae are adjusted and nerve impingements at the intervertebral foramina corrected. But it will be found easiest to describe these processes separately in different sections of the spine and before proceeding to this description, a brief picture of the peculiar vertebrae will be presented.

The Atlas is a bony ring composed of two arches, an anterior and a posterior, separated in the recent state by a transverse ligament. Its body is detached and appears as a tooth-like projection upward from the body of the Axis, the odontoid process, which articulates with the anterior arch of the Atlas and around which the Atlas rotates, a ring around a pivot. The Atlas supports the head upon its lateral masses, two wedge shaped bodies between the anterior and posterior arches, thinner internally than externally. It has no spinous process but merely a tubercle where the laminae join, so that it can be palpated only from the sides upon the tips of its long transverses. The first Cervical, or suboccipital, nerves emerge by a groove above the pedicles instead of through a foramen.

The Axis, or second Cervical, is distinguished by its large, strong spinous process, which is bifid at its tip, by its superior articular processes which rest upon body, pedicles, and transverses, and by its odontoid process, upreared from the body.

The Seventh Cervical, or Vertebral Prominens, usually has a large spinous process, presents no foramina in its transverse processes, or only one, the left, and shows no facets on body or transverse for the rib articulation, as do the Dorsals.

The Sacrum is the largest vertebra; is curved with its convexity backward; is commonly made up of five fused segments; has only rudimentary spinous and transverse processes except the first; and shows sixteen openings, eight anterior and eight posterior, or four on either side of the median line in front and the same number and arrangement behind. These openings permit the exit of the anterior and posterior primary divisions of the sacral nerves separately.

The Coccyx, usually composed of four fused segments, is a triangular bone which articulates with the Sacrum above and is free at its distal extremity. Its portion of the neural canal is open posteriorly and contains merely the thread-like termination of the cord membranes. It is frequently ankylosed to the Sacrum, sometimes in an abnormal position so as to impinge the single pair of coccygeal nerves.

The different regions of the spine show decided differences in structure, though all resemble each other. The Cervicals are smallest, the Dorsals next in size, and the Lumbars largest and strongest of the movable vertebrae. The Dorsals have facets and demi-facets for the articulation of the twelve pairs of ribs with their bodies and intervertebral substance, as well as oval facets upon the anterior aspect of their transverses for articulation with the tubercles of the ribs.

The spinous processes are smallest and usually bifurcated down to and including the fifth. The sixth may show a plain bifurcation, or on any Cervical the bifurcation may be so small as to be imperceptible to touch. The spinous process of the second overlies that of the third so as to make the latter very difficult of detection. Indeed, all cervical spinous processes down to the sixth are harder to palpate than those in other regions, owing to the anterior cervical curve. The processes lie in a groove between prominent muscle ridges.

Dorsal spinous processes are usually single, although the last four, three, two, or one may show plain bifurcation in certain individuals. They are somewhat pointed and overlap, except the lower ones, the obliquity being greatest in the mid-dorsal region and least at the first and last dorsals.

Lumbar vertebrae have broad, flat-tipped spinous processes much larger than the others. The last Dorsal may sometimes appear like a Lumbar in shape, so that the change in shape commonly supposed to mark a division between Dorsals and Lumbars is not always an infallible guide.

The transverse processes in the cervical region are very short and lie close in front of the articular processes. They are pierced by foramina for the vertebral artery and vein, except the seventh, which may have one foramen or none. They are difficult of access for palpation because of their shortness and the amount of overlying muscle, but may be reached from the front and side by drawing back the sternomastoid. They increase in length from the second to the seventh.

In the dorsal region the transverses are larger and stronger and more constant in size, shape, and direction, serving to support rib articulations. They extend in a curved direction outward, backward, and slightly upward from the union of laminae and pedicles and terminate in a large subcutaneous club-shaped extremity which may be readily palpated. The eleventh and twelfth dorsal transverses do not articulate with the ribs and must therefore be used with caution or not at all as levers for adjustment. The dorsal transverses are located on a higher level than the spinous processes. In the case of the upper three dorsals the transverse lies in a plane which would cross the mid-spinal line between its own and the next superior spinous. In the mid-dorsal region the transverse is even with the spinous of the vertebra above, though the relation may vary slightly. The lower dorsals return to the same relation as the upper.

The transverse processes of the Lumbars are relatively light compared with the general structure of the vertebrae and are found just even with the interspace between their own and the adjacent superior spinous process. They vary greatly in size, length and strength and may be used as levers for adjustment only when they are large enough to be clearly palpable through the muscle mass which separates them from the body surface.

Preparation of Patient

In all cases where a complete spinal examination is intended the preparation is essentially the same. Have patient arrange clothing so that the spine is exposed to the touch throughout. Avoid bands of cloth across the spine, as these interfere with the necessary continuous gliding movement of the fingers. Advise the patient, if a female, to wear waist or dressing sack, reversed, and have skirts loosened at the waist. If a man, he should strip to the waist and wear coat or coat shirt reversed.

Position of Patient

This varies widely according to circumstances but for general purposes use position:

(A) Place patient on stool, feet even on floor and body in an easy, relaxed position. This may be modified by asking him to lean forward and rest elbows on knees, evenly, to facilitate Lumbar palpation. Patient’s head may be erect or flexed forward or backward but should never be rotated or laterally flexed during Cervical palpation except for the purpose of locating some particular transverse process.

(B) In emergency cases, where haste is urgent or patient is unable to assume a sitting posture, or as a means of re-verifying previous palpation, place the patient on adjusting table prone, face down. (See Fig.2.) Remember that with the head lying upon its side the upper dorsal vertebrae will assume a curve with its convexity away from the face. Palpation in position (B) should precede every adjustment and, to guard against error, should be considered as a necessary preliminary to the movement of any vertebra.

(C) For palpation preparatory to using the Rotary, the Break, and other moves, have patient lying on his back with his head projecting beyond upper end of bench and resting on the hands and wrists of the palpater, or have the patient’s head rest on the bench, a less accessible position.

General Observation

Each spinal examination should begin with a general survey by which curvatures, marked prominences, etc., may be appreciated. Frequently some very important fact may be noted which would escape attention upon minute examination.

THE RECORD

The record of spinal palpation, when completed, should be an accurate history of the irregularities found in the spine and an accurate guide to adjustment. It must be brief and concise as well as readily comprehensible. One should be able to see at a glance any desired point on the record, so that it may be used during the adjustment without undue loss of time or attention. Obviously the introduction of any useless mark or sign, such as the inclusion of a number and blank space for each vertebra of the spine, or all possible subluxations with indications as to which do or do not exist in the given case, is a mistake.

The record should contain three parallel columns. In the first column place the number of the vertebra chosen for adjustment. In the second, place the direction of subluxation. In the third, place the word or sign which stands for the indicated movement for correction.

Number of Vertebra

The letter C is used to indicate Cervical, D Dorsal, L Lumbar, and S Sacrum in the record. Immediately following the letter which designates the region, place the number which shows the position in that region occupied by the vertebra in question, the relation of that vertebra to its fellows. For instance, the third Cervical vertebra is C 3, the eleventh Dorsal D 11. To the S for Sacrum append B or A to indicate that the Base or Apex is described as to position. This locates the subluxation. For a record of full spine palpation it is unnecessary to use the letters C, D, or L more than once, as subluxations are recorded in the order of their occurrence from above downward. A dash should always follow the number of the vertebra to separate it from the letters in the second column for convenience in reading.

Direction of Subluxation

The directions considered in palpating or recording subluxations are six in number, namely:

Name Abbreviation Meaning
Posterior P Toward the rear (Dorsad)
Anterior A Toward the front (Ventrad)
Right R Toward the right hand
Left L Toward the left hand
Superior S Toward the head (Cephalad)
Inferior I Toward the feet (Caudad)

As the fingers glide down the spine the posterior vertebra is the one which interposes itself in the path of the fingers, forcing them to describe an outward curve. It is the hill on the automobile road which forces the surmounting of a curved departure from the evenness of the road. It is relatively posterior to its fellows above and below.

The anterior vertebra, to the gliding fingers, means a depression, a valley. It causes the fingers to dip inward from the level of their course.

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.

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.

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

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.

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.

Fig. 3. Locative palpation of Cervical spinous processes in Position C, preparatory to Rotary or Break.

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.

Fig. 4. Locative palpation of Dorsal transverse processes.

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.

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.

LANDMARKS

The regional location of vertebrae by means of certain landmarks (so called) in or near the spine, is a much discussed question in the profession. Without discussing the various arguments in favor of this method, chief of which is the inability of the untrained to count vertebrae, let us set forth the principal landmarks used and the facts in regard to them.

The seventh Cervical, called Vertebra Prominens, is usually considered a guide to the count. In over three hundred cases examined for that purpose the seventh Cervical was found to be Vertebra Prominens in about 65%, the other 35% showing the sixth Cervical or first Dorsal to be the prominent one. This method is two-thirds as accurate as counting.

The tubercle (Chassaignac’s) of the sixth Cervical transverse is said to be directly opposite the lower border of the cricoid cartilage and this is a better guide than the above.

The third Dorsal spinous process is said to be on a level with the root of the spine of the scapula, and with arms hanging at sides, the upper angle of the scapula to be on a line between first and second Dorsal spinous process. This is not at all constant.

The inferior angle of the scapula is said by some writers to be on a line with the tip of the seventh Dorsal spine. Others locate it opposite the interspace between seventh and eighth Dorsals. Still others give it as opposite the eighth Dorsal spine. All are correct—sometimes. In truth, the inferior angle may be opposite any part of the spine between the sixth and ninth Dorsals. There is nothing constant about it.

The twelfth rib may be followed to its articulation with the twelfth Dorsal vertebra. This is a good guide, providing that the rib can be palpated. The lower margin of the last rib is usually even with the spinous process of D 12 about one inch and a half from the mid-spinal line. The humor lies in the fact that the patient upon whom the count is so difficult as to require this verification is usually obese and obesity renders the rib impalpable.

The line drawn between the iliac crests falls between the third and fourth Lumbar spinous processes in about 98% of all cases. This is our most reliable landmark. It is used as described under the Count.

All landmarks except the last two show such variance in different individuals as to be quite unreliable. The correct method of numbering spinous processes is the obvious and logical method—count them. The skill and accuracy of touch required for successful counting is invaluable in determining direction of subluxations.

MENTAL ATTITUDE

In order to secure that absolute concentration without which it is impossible to appreciate properly those tactile impressions for the very reception of which such continued practice is necessary, the hands should leave the spine as little as possible during palpation; a second person should record subluxations found so that the palpater need only state, and not write, his conclusions; light pressure on the spine should always be used, as a heavy pressure desensitizes nerve-endings in the fingers; and silence should be maintained except for the necessary statement of points to be recorded.

Palpate as rapidly as is consistent with good work. The more rapid the palpation, if concentration is absolute, the more accurate the impressions received.

The end and aim of palpation is to determine the means by which impingement of nerves may be removed with the greatest rapidity and success. Palpation includes such a study of the vertebral column as will fix in your mind a clear thought-picture of the impinged nerves throughout its length.

FINALLY

If you would achieve success in Vertebral Palpation, be persistent. Spare no labor to acquire that accuracy of detail which distinguishes the expert from the amateur. You can make of yourself what you will. There is no limit to the ability which may be acquired. Another may guide your hands but with you lies your success.


                                                                                                                                                                                                                                                                                                           

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