Technic and Practice of Chiropractic. Joy Maxwell Loban
downward and outward to innervate back muscles.
Reference to the section on Spino-Organic Connection will make clear the tissues supplied by each nerve.
Slight deviations from the usual course of nerves are common; marked deviations very infrequent.
Use of Fingers
Use second finger of either hand for the palpating finger, choosing the hand which can be most conveniently used as determined by the position of patient and the part of the body to be examined. There is no set rule. Reinforce this second finger by the pressure upon it of the first and third and, if desired, by pressing thumb against it. (See Fig. 5.)
Apply the tip of the palpating finger to the nerve with a motion such that it crosses the path of the nerve at right angles back and forth. Meanwhile the probable path of the nerve must be kept in mind. As the finger crosses the nerve-path it makes steady and even pressure upon any structures passing beneath it. The motion of the hand is almost a rolling motion, the finger tip probing, as it were, for a tender spot.
Tenderness—How Recognized
The irritated condition of the nerve which has thus been rolled beneath the finger may be recognized in one of three ways; the patient may involuntarily flinch, betraying the hurt; or he may inform the palpater of the hurt; or the swollen, cord-like nerve may be felt.
The two former are the reliable guides, while the latter is only occasionally possible. In children and in feeble-minded, insane, or mute adults, the first mentioned method must be relied upon entirely. Muscular contraction is the unconscious or reflex response to pain and often occurs independently of the intelligence or state of mind of the subject.
Of all the three methods the one most commonly relied upon is the second—the statements of the patient.
Instruction to Patient
The patient should be informed of your intentions when palpation is begun and should be asked to answer every time you apply your finger, saying, “Yes,” if the spot is tender and, “No,” if not. He should speak promptly each time so as to avoid self-deception which might come with reasoning upon his sensations. Occasionally vary the steady rhythm of your movements by omitting one and note if the patient responds mechanically when you do not press.
At times during the tracing, it is well to depart from the probable nerve-path and to touch again a point marked as tender, to see if the patient’s information may be relied upon. Whenever you leave the nerve-path his answer should be, “No,” immediately changing to, “Yes,” when you re-cross the tender line.
Marking Tender Points
At each tender point noted a small mark should be made with an eye-brow pencil or other grease-paint, which leaves a distinct but easily removable mark. These tender points should be noted and marked at intervals of about an inch.
Connecting Line
When the entire nerve-path has been traversed in this way, draw a line with the eye-brow pencil, passing through all the marks indicating points of tenderness. This line should be a sufficiently accurate rough outline of the nerve-path to make clear the spinal connection with the diseased area. The significance of this connection will be better understood when the section on Spino-Organic Connection has been studied.
Fig. 6. Anterior half of completed nerve tracing.
Common Findings
In muscular rheumatism, neuralgia, neuritis, or in case of a local boil or abscess indicating local disturbance of the trophic influence of nerves, clear and definite tracings are common. Muscular spasm, such as wry-neck, usually has a very tender nerve associated. Localized painful disease of any kind is likely to be associated with a very definite nerve tenderness, as is the case frequently with appendicitis, ovaritis, hepatic colic, etc.
The painless disorders, or various disorders of spleen, diaphragm, heart, lungs, etc., though they be of a very serious nature, seldom are discoverable by nerve-tracing unless their serous membranes are involved. Tracings may be made from D 2 or 3 to anterior thoracic walls in heart or lung disease but are not common.
Any spinal nerve may be traceable at times through at least a part of its course.
Sources of Error
Several of these have been mentioned, such as the natural suggestibility of both examiner and patient. Among others are: failure in the back, thigh, or leg to reach the really tender nerve because of the interposition of several muscle layers between it and the finger, ignorance of nerve-paths, failure to apply equal pressure to all parts of a nerve, application of such heavy pressure that muscle tissue is bruised and hurt, and failure of full co-operation on the part of the patient. Let us consider these in turn.
If several muscle layers interpose themselves between the searching finger and the nerve, it is proper to push aside the intervening layers, using a twisting and rolling movement until the finger feels underneath the muscles. This done, and a tender nerve found underneath several muscle layers, the same amount of overlying tissue must be pushed aside each time the finger searches for the nerve. Only exhaustive study of the anatomy of the typical nervous system will enable the examiner to know exactly at what point a nerve will become more or less superficial. Unless he does know this it is best to follow the neutral rule that nerves tend to follow the long axes of ribs and limbs and to maintain their depth beneath the surface throughout their course. This statement is too general for accuracy.
Care should be taken that equal pressure be made on all points palpated on one nerve. If the nerve pass over a bone, less force is needed to exert the same pressure than if it overlie muscle or other soft structure. The force used varies constantly as the hand moves from place to place, according to the density and hardness of the structures overlying and underlying a nerve.
Sufficiently heavy pressure will elicit tenderness in all except anaesthetic patients. But if a nerve be irritated it will be tender without heavy pressure, when the finger really makes a close contact with it.
If the patient willfully attempts to deceive the palpater, nerve-tracing might as well be abandoned except in those extreme cases where the patient will flinch against his will on account of extreme sensitiveness.
Use of Second Hand
As far as possible, the second hand is placed opposite the tracing hand and steadily supports the body; its position changes with changes in the position of the first. If the arm is to be examined it had best be held away from the body, and the part to be examined held between the two hands.
Position of Patient
For tracing nerves in the neck, back, and upper extremities, the patient should sit easily. For lumbar, abdominal, or pelvic tracing, or for tracing in the lower extremities, have patient lie on side or back. Do not hesitate to change the position of the patient as often as is necessary to secure easy access to the part to be examined and relaxation of the patient’s muscles. Never allow the assumption of a strained position during tracing; the sensation of cramped muscles may be confused with sensations of nerve tenderness.
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