many who have been through the various diagnostic clinics where most elaborate tests have been made for chemical or bacterial disturbances, with the common summary that all tests are negative, the condition, therefore, being wholly functional, even where there are actual objective lesions present. When we consider the great changes which have occurred in the methods of examination of patients in the past decade, with the constant addition of "new" tests for "this or that," it is surprising what positive opinions in matters of prognosis are ventured. The many sheets of most carefully prepared papers showing the latest kidney or heart tests, the various blood tests, the basal metabolism, the intestinal contents, the visceral roentgenology, etc., which the patients so frequently thrust into our presence as a challenge, must either go further in the interpretation of the findings or most of the work must be considered purposeless. In studying many such records, that which has led to the greatest surprise is the limited space, or usual entire lack, to consider the anatomic structure or the general appearance of the patient. One of the basic principles in the study or teaching of medicine theoretically has always been proper foundation in anatomy, but with very few exceptions, this is still being taught on the basis of one human type, to which all must conform. It should cause little surprise that so little advance has come in the knowledge or treatment of chronic disease when the great variations from this textbook normal are appreciated and when, in so far as my own experience is concerned, practically none of the cases of chronic disease are of this normal structure. Sufficient studies have been made to take this variation in type out of the position of speculation, but in no textbook, in so far as I know, is it mentioned, nor is anatomy taught with reference to it. Not only do individuals vary in structure,-muscles, bones, viscera, and potentials of activity, but with considerable regularity such structure carries with it its own potential of disease. In the time that is available this evening, it is not possible to go into all the details of the differing anatomy. All that can be done is to offer a very few suggestions, hoping that you practitioners will put the matter to the test, in which case you will certainly contribute important knowledge to our understanding of these cases. Make your examinations none the less thorough than you have, but begin with the structure of the patient, basing the study of the physiology and the general function upon this special structure, and study its function both when standing as well as lying down. With such an approach, some of the former tests will take on new meaning. For one feature, the low back conditions probably lead more often than any other, to medical advice being sought for relief, which is not unreasonable when the great variations in structure are appreciated together with L 17 FIG. 1. SPINE OF INDIVIDUAL OF SLENDER ANATOMIC TYPE WITH RUDIMENTARY LAST RIB AND WITH PARTLY SACRALIZED LAST LUMBAR VERTEBRA Note the amount of space between the bodies of the vertebrae, the FIG. 2. SPINE OF INDIVIDUAL OF HEAVY ANATOMIC TYPE WITH BROADER Note the length of the articular processes, with the natural locking of FIG. 3. INDIVIDUAL OF EXTREME HEAVY TYPE WITH VERY Note the "pancake" shaped bodies of vertebrae, the FIG. 4. INDIVIDUAL OF SLENDER TYPE WITH LOW DIAPHRAGM, FIG. 5. MARKED PTOSIS OF DIAPHRAGM The level which should be between the eighth and ninth ribs is FIG. 6. SAME CASE AS FIGURE 5, WITH PATIENT LYING FLAT UPON EXCURSION OF DIAPHRAGM Note the long last rib, vertebrae similar to text book normal FIG. 7. THE SAME CASE AS FIGURE 4, SHOWING POSITION OF Base of the heart is here shown to be opposite the seventh rib FIG. 8. NORMAL HIGH POSITION OF DIAPHRAGM IN INDIVIDUAL OF THE HEAVY OR STOCKY TYPE |