Fig. 2. Palpation in Position B, preparatory to adjustment.
Lumbars
It may be difficult to count or otherwise to palpate the Lumbars in this position because of the increase in the normal anterior curve when patient is suspended between the two sections of the bench. This will be obviated if a roll be placed under the thighs or if the bench has an adjustable rear section.
Cervicals
If a solid front bench is used remember the spiral turn in the Cervicals, which occurs because of the resting of the head on one side. The curve due to this rotation of the head is compounded with the ever present anterior curve to make a spiral. Do not expect the vertebrae in this position to agree in apparent direction with a record made with the head straight. It is better to make all decisions as to direction of Cervicals in position A and merely to count them in other positions.
In position B, if the patient's face be away from the palpater it will be necessary to stand with back toward patient and body twisted, and to change hands for counting, resting the free hand on patient's head to insure its steadiness.
Disagreements
If there be any apparent disagreement between findings in positions B and A, re-examine carefully in both positions, whereupon that which seemed a disagreement will probably prove to have been an error in one or the other palpation. If apparent disagreement persists after searching examination, position A furnishes the safest guide to adjustment because the patient is in his most usual attitude as regards the spinal curves, muscle tension, etc. But it is usually wisest when in grave doubt not to adjust the doubtful vertebra at all.
PALPATION IN POSITION C
Table of Contents 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
Table of Contents 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...
