the imperfect mechanics in use. With more attention given to the actual structure of the individual patient, the understanding of these cases will be much simplified. The narrow, high vertebra, with flat articular processes and long, transverse processes of the slender creature upon which its flexibility depends, can be easily demonstrated (fig. 1); as well as the broad, low vertebra, with deeply crescentic articular processes (figs. 2 and 3), upon which the lack of flexibility depends, can also be demonstrated as well as the textbook type of normal (fig. 4). That six lumbar vertebrae are not uncommon, and that at other times four vertebrae are seen in certain chronic conditions, receives no attention, any more than the position of the last lumbar with reference to the sacrum or the wings of the ilia, figures 1, 2 and 3, or the effect of this upon the sacro-iliac joint.

Similar variations in structure that are capable of demonstration exist at the dorso-lumbar region, and with the difference in the shape or position of the last rib, with reference to the varying shape of the transverse processes of the first lumbar (figs. 1, 2 and 3), require only slight thought, if studied, to explain some of the pains in the loin for which so many mysterious manipulations are performed or for which much "kidney medicine" is taken.

Of the abdominal viscera, the variations from the textbook normal are very great, and are wonderfully in keeping with the structure of the individual from the point of view of function. The loosely attached organs of the slender type of creature make the extreme flexibility of the body possible, without harm to the organs inside (fig. 4). It requires very little thought to see the possibilities for contusion of the liver, stomach, spleen, kidney, etc., that would exist in the free mobility of the body at the dorso-lumbar level (waistline) if these organs were of the large size of the so-called normal, or were not attached by the long, loose mesenteries or ligaments. If such thought is given, very few "pexies" will be performed in the slender type of individual.

On the other hand, when the very heavy organs of the heavy type of individual are considered, one is not surprised to find the heavier and more secure attachments and a relatively inflexible skeleton that would make harmful movement impossible.

Little attention is given, either from the point of view of structure or function, to the fact that the intestinal length varies, in these anatomic types which commonly have the chronic disease, from ten feet (the textbook normal is twenty feet) to nearly forty feet, while the variation in the length of the large intestine is from two to three feet.

Such elements must have some importance in the interpretation of the symptoms of the disabilities which the patients present.

Once such anatomic features are recognized, and the function of parts

considered in the varying ways in which the body is used, it requires very little imagination to at least see possibilities of difficulty.

For instance, if the position of the spleen is considered and if the blood supply is remembered, the main artery coming, as it does, from the right side of the spine, crossing to the left under and attached to the stomach, it is not hard to imagine that in some of the marked displacements of the stomach, the circulation of the spleen, either arterial or venous, might be interfered with, with natural disturbance of the function of that organ.

Also if the position of the pancreas is appreciated, and the marked downward displacements of the liver and stomach as part of the common visceroptosis, are considered, it is not difficult to imagine disturbances of function of that organ from this cause alone. Certainly the presence of sugar in the urine is not wholly due to irregularities of diet. Again, if the mobility of the kidneys is considered, as occurs especially in the cases of visceroptosis of the congenital type, it requires but little imagination to see that the blood flow to or from the organ, or the drainage of the secretion of the organ, may be easily interfered with. The many cases of orthostatic albuminuria are not hard to understand, and with the change that is taking place in the general structure of the race to more and more the slender type, should lead us to expect to find this more and more frequently as time goes on, unless the individuals are properly trained. The work of Scholter and Veith, showing that lordosis is the essential feature in producing this symptom, is suggestive, yet how few of the profession even know of such possibilities. The presence of albumin in the urine, which should be one of the frequent findings in our people today, is ordinarily considered indicative of serious disease by our profession, instead of many times a functional disturbance of little importance if rightly handled.

With the stomach and intestine, the many malpositions, with the possibilities of the maladjustment leading to disturbance of the physiology, should be too evident from the common roentgenological study to require mention here, but the fact that such physiological disturbances are capable of correction by mechanical means other than operation, does not seem to be so fully realized.

Still further, since with the visceroptotic patient there is always more or less ptosis of the diaphragm, and since the flow of blood from the abdomen back to the heart is almost entirely dependent upon the regular action of the diaphragm (milking the abdominal veins against the upwardly opening valves), it is fairly easy to believe that some of the abdominal symptoms or disturbances in the physiology are due to the disturbances in the circulation, resulting from this position in which the inaction of the diaphragm can be easily demonstrated by fluoroscopic examination (figs. 5 to 8).

In the symptoms which may result from this, it is probable that not

all will be referred to the abdomen, but that if the diaphragm does not act properly the regular supply of the blood to the heart may be interfered with. The last word has evidently not been said regarding the many cases with demonstrable disturbances of action of the heart, but with no detectable disease of the organ itself present. In the American Expeditionary Forces, the many cases of deranged action of the heart (D. A. H.) were, I think, never fully explained, but it is a significant fact that both in the British Army as well as in our own, it was realized that if the individual could be developed so that the body was held erect (in which the diaphragm acts freely), in contrast to the drooped habitual posture of these patients (in which the movement of the diaphragm is very slight), the heart symptoms disappeared. The British sent such cases to the Command Depots for physical development, and in our Army the

special training organizations and convalescent camps performed similar duty.

Another feature which is of importance in the examination of individuals is to determine the proportions between the lateral and antero-posterior diameters at the tip of the sternum. Normally the antero-posterior diameter ought to be about two-thirds of the lateral diameter (fig. 9 A). In this position the diaphragm can act freely both with reference to the lateral fibres, as well as the antero-posterior fibres. With the droop of the body, such as is shown in figure 9 B, the ribs have dropped in from the side, have pushed the sternum forward, the so-called pigeon-breast deformity, with the antero-posterior diameter nearly the same as the lateral diameter. In this body form, the diaphragm cannot perform its normal function.

In the other type of body commonly seen, shown in figure 9 C, the ribs

have simply dropped downward so that the antero-posterior diameter is very much below normal and in this type of condition the lateral fibres of the diaphragm are able to work but the antero-posterior fibres cannot.

Figure 9 D shows the chest of an individual very much crippled with progressive muscular atrophy, the tracing taken at the latter part of his treatment when he was nearly recovered, showing the very marked development of the chest.

The effect which such features of anatomic structure and the mechanical maladjustment of the parts has upon actual pathological conditions there is not time for us to go into this evening, nor is it possible, many times, with the knowledge which we possess today, to conclusively prove the relationship between the structural conditions and the symptoms. With some of the cases the cause and effect features can be quite definitely shown, with relief following such recognition. With others, much of the treatment today must be empirical, but justified by the results.

This fact should in no way embarrass us, because in practically all of the great advances of our profession the empirical teaching has preceded the demonstration of the laboratory. The common relief of symptoms by the use of measures based upon the study of the structure, the individual, must mean that some of the disturbance of the physiology seen in these cases is due to simple mechanical features. This should also mean that with continued study along such lines a more exact knowledge of the special features will be had.

As far as one can see from the studies thus far carried out, most of the cases which represent the bulk of the chronic patients must be primarily disturbances of the physiology with the pathologic features resulting from this. The fact that the disturbances of the physiology may be due to the mechanical feature mentioned above is too obvious to be dismissed without investigation. Certainly, the correction of the obvious mechanical conditions can do no harm, and I am sure, from my personal experience, that this alone will so relieve the physiologic distress, that a great many of the cases which otherwise would drift into the hopeless class, will recover. All that is asked of you in this regard is that you will study your cases in this way, and observe the results.

There is one feature in this consideration of the chronic patient that seems to me to need mention at this time, which is, that we do not allow ourselves to be misled in our cause and effect interpretation of our work. That which I have in mind especially, but which is presented as illustrative of a good deal of general reasoning, is the attitude held today regarding the chronic arthritic and focal infection. That the recovery from joint symptoms which follows the removal of teeth or tonsils is at times due to this specific treatment there can be no question, but that all of the cases which ultimately recover do so because of this, anyone who has seen much

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of such cases must question. We must never forget that the average case of "chronic rheumatism" (by whatever special term it may be designated) gets well and has gotten well long before these special surgical measures have been used. If this were not so, think of the numbers of cripples there would be today. Naturally, if the tonsils are diseased, or if the teeth are in bad condition, they should be treated as matters of general hygiene, but very rarely is the really serious case of chronic arthritis influenced by this. Most of these cases are due, as far as we can see today, to complex disturbances of the physiology as it concerns the abdominal structures, in which probably no one organ is wholly at fault. Imperfect drainage of the bowel may be a factor, but the imperfect drainage of the ducts of the other viscera may be as important, or the character of the secretion of the different glands or organs may be changed by disturbances of the blood supply.

Too rich a mixture in the gas supply of an automobile makes the motor stall; too weak a mixture leads to a similar result. It seems not improbable that in just such ways the balance which the normal physiology represents may be disturbed, and that because of this, bacteria may multiply, for instance, that would otherwise be controlled, or that other elements that are desired are not produced. Many disturbances are possible.

The problem of the chronic arthritic is an exceedingly complex one, but if studied with reference to the physiologic potentials of the special individual, should be most hopefully faced.

These, gentlemen, are simply a few of the suggestions which I should like to leave with you tonight. The chronic patient is offering a challenge to us, the answer to which will mean either the downfall of a large part of our work or the relief of a great many who now beg for relief, but who receive scant consideration at our hands. Study them, make the most thorough examination of them that is possible, but first study the anatomic structure of the individual with the special physiology that is peculiar to such special structure, as well as the disturbances of the physiology that should be expected, as the body is used by the special case, and see if some of the special tests or examinations do not take on new significance, so that the cases become understandable and relief can be offered.