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THE, 5HATTUCK LLCTURL 
 
 An Anatomic and Mechanistic 
 Conception of Disease 
 
 BY 
 
 JOEL E. GOLDTHWAIT, M. D. 
 
 BOSTON 
 
 REPRINTED PROM 
 
 THE BOSTON MEDICAL AND SURGICAL JOURNAL 
 
 JUNE SEVENTEEN 
 
 1915 
 

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 [Reprinted from the Boston Medical and Suroicai, Jotrxal, 
 Vol. clxxii, No. 2t, pp. 881-898, June 17, 1915.] 
 
 AN ANATOMIC AND MECHANISTIC 
 CONCEPTION OF DISEASE.* 
 
 By Joel E. Goldthwait, M.D., Boston. 
 
 The subject which ha.s been announced for 
 this, the twenty-sixth lecture given under the 
 conditions of the bequest made by Dr. Shattuck, 
 was chosen after much consideration as being of 
 broad general interest and as having to do with 
 the fundamentals of medical knowledge. It 
 seemed possible that such a consideration might 
 be of sufficient importance to be worthy of the 
 occasion, and if it be so considered it will be a 
 satisfaction to me, as being a slight return for 
 the honor which you have conferred upon me in 
 selecting me as your speaker. 
 
 The basis of that wliich is here presented is 
 M^ork which has been carried on for a number of 
 years in the attempt to find the cause of the 
 chronic disease conditions for which the ortho- 
 pedist is consulted. A fairly exhaustive patho- 
 logic investigation failing to show more than the 
 nature of the lesion, with similar experience 
 from the bacteriologic and the biochemical in- 
 vestigations, led to the study of the fundamental 
 anatomic conditions existing in patients afflicted 
 with these diseases, with results which have been 
 increasingly more suggestive the farther the 
 study has been carried. 
 
 * Delivered before The Massachusetts Medical Society at Boston, 
 June 8, 1915. 
 
 1 
 
.*/. : :.*• :'.'••••••• 
 
 It is this study which represents the first part 
 of this paper and which has been reported in 
 part from time to time by the w^riter in articles 
 which have called attention to the variations in 
 the formation of the viscera and skeleton, as well 
 as to the peculiarities of the particular function.^ 
 
 In this investigation it soon became evident 
 that the anatomic formation described in the 
 textbooks as normal to the human being, rarely 
 exists in the individual having the common 
 chronic disease, and in the study which natur- 
 ally followed not only were the different ana- 
 tomic types recognized, but in the hope of better 
 understanding the variations found, the struc- 
 ture of the lower orders of mammals was studied 
 with considerable care. 
 
 Recently, with the assistance of Dr. John 
 Bryant, not only have these anatomic findings 
 been verified in connection with his work,^ but 
 the literature has been carefully examined and 
 the fact that most of the elements to be presented 
 have already been recorded has served to in- 
 crease the belief that the observations here stated 
 are correct and that the appreciation of these 
 elements is absolutely essential if any impres- 
 sion is to be made by our profession upon the 
 great field of chronic medicine which today rep- 
 resents such a reproach to us. 
 
 The fact that no more has been accomplished 
 as the result of these numerous contributions to 
 medical literature in the past is probably due to 
 tlie fact that most of the work is fragmentary in 
 character and that it is only by piecing together 
 many of these separate contributions that the 
 significance of each with the great importance of 
 the whole is realized. 
 
 It is the hope, that in this communication, the 
 independent observations which have been car- 
 
ried on by the speaker, may be so strengthened 
 by the similar findings of these other observers 
 that this knowledge may be generally applied to 
 the study of our patients. 
 
 In such an investigation, while the first thing 
 that impresses one is that the so-called normal 
 type of human being rarely exists in the chronic 
 patient, the second is that the variations from 
 the normal group themselves into two general 
 types from which again there are many varia- 
 tions, but that if the original type is appreciated 
 the variations from it are easily traced and un- 
 derstood. 
 
 In order to understand better the types to 
 be described, it is well to consider for a moment 
 that which from the textbooks we call normal. 
 Normal Human Type. (Figs. 1, 2 and 3). 
 
 There is very little variation to be found in 
 the works of anatomy in that which is called nor- 
 mal. The torso is of moderate length and of 
 moderate breadth. The thorax is full, and 
 moderately rounded, the upper abdomen is 
 rounded and in circumference about the same as 
 that taken just above the nipple. The costal 
 border is formed in an angle from 70° to 90°. 
 The diaphragm is high and there is generous 
 space under the ribs for the viscera. All of the 
 abdominal viscera, except the lower portions of 
 the colon Math the sigmoid and part of the small 
 intestine, are above the umbilicus. Around the 
 viscera and representing a definite part of their 
 support, as well as giving much protection from 
 trauma to the sympathetic nerves, ganglia 
 and blood vessels, are well-defined masses of fat. 
 The lower abdomen is flat, while the upper abdo- 
 men is firm and rounded, there being no marked 
 depression under or inside the edge of the ribs. 
 The spine shows a mild curve forward in the lum- 
 
 3 
 
Fig. 1. 
 Tlie normal human type. 
 
FiQ. 2. 
 
 Xormal human type, showing the normal inclination of pelvis, 
 
 normal elevation of ribs, normal position of shoulders, etc. 
 
Fig. 3. 
 Normal human type, showing the moderate breadth of the body. 
 
 6 
 
bar region, with the inclination backward from 
 the mid-lumbar, this resulting in the general in- 
 clination of the abdominal cavity of 30° down- 
 ward and forward from the perpendicular. The 
 pelvis, in the axis of its cavity, is inclined down- 
 ward and backward about 60° from the perpen- 
 dicular so that the two axes form nearly a right 
 angle. 
 
 Of the special viscera, the stomach is of the 
 pear shape, and is placed well up under the ribs, 
 occupying the uppermost part of the abdominal 
 cavity upon the left side. In this position the 
 discharge of its contents into the duodenum re- 
 quires but little effort. 
 
 The small intestine is about 20 feet in length, 
 is of good calibre and muscular tone. The large 
 intestine, of five to six feet in length, is adherent 
 to the posterior abdominal wall upon the right 
 side until it reaches the region of the liver, 
 when it turns forward and inward, crossing with 
 a slight downward sag to tlie splenic flexure well 
 up in the left side of the abdomen behind the 
 stomach, from which point it is again attached 
 to the posterior wall (retroperitoneal) until it 
 reaches the sigmoid, where, after a few turns, it 
 becomes the rectum. The transverse part of the 
 colon is attached to the liver upon the right side 
 and to the stomach in the center of the body and 
 upon the left side. The stomach and liver are 
 naturally attached to the diaphragm, and the 
 suspensory ligament of the diaphragm is the 
 pericardium, especially the right side, which is 
 finally attached to the anterior part of the low 
 cervical spine. 
 
 In the upper part of the abdomen in the solar 
 plexus of the sympathetic system, the ganglia 
 being so placed that when the organs are in 
 
 7 
 
their proper position there can be the least possi- 
 ble pressure upon or irritation of them. 
 
 These and many other elements are described 
 in the anatomy as normal, and while this type 
 does exist very commonly among those who are 
 well, nevertheless, among the individuals who 
 consult the physician, especially with chronic 
 disease, this type is not often seen, and it must 
 be hard to understand the conditions present in 
 our patients unless their special structural for- 
 mation is known. 
 
 Of the variations from the normal there are 
 two well-marked types which are easy of recog- 
 nition and are here described. 
 
 Splanchn opt otic (Glennard) ; Congenital Vis- 
 ceroptotic ( Goldthwait,^ Smith^) ; Carnivorous 
 (Treves,* Werner,^ Bryant^) ; Hyper-o-nto- 
 morph (Bean**) ; Macroscelous (Montessori^) ; 
 ''Narrow-Backed" (Industrial). (Figs. 4, 5, 6 
 and 7). 
 
 The type of human being for Avhich the above 
 and other terms have been used is essentially dif- 
 ferent from the so-called normal in most of its 
 characteristics. The whole figure is lighter, not 
 only that there is less fat, but the skeleton is 
 lighter and more slender in form. The skin is 
 soft and delicate. The hair is more abundant in 
 the usual places and frequentlj^ shows on parts 
 where it is not normally seen. The individual 
 is usually either tall and slender or small and 
 delicate. The head is proportionately large, the 
 face and jaws are narrow. The palatal arch is 
 high. The adenoid and tonsillar tissue is apt 
 to be excessive. The ears are usually large and 
 prominent, projecting outward and forward. 
 The torso is longer in proportion than the so- 
 called normal and is also narrower. (Fig. 6). 
 
 8 
 
Kl(i. 4. 
 The slender congenital \iseeroptotic or carnivorous type, showing 
 the proportionately greater length of body, the increased low lum- 
 bar curve, forward inclination of pelvis, forward position of the 
 shoulder, flat chest, prominent lower abdomen, narrow upper ab- 
 domen, forward position of head, etc. 
 I 
 
 9 
 
Fio. 5. 
 Slender type, showing the same features as in Fig'. 4, except an 
 increase in the forward inclination of the pelvis and more 
 marked forward position of the shoulder, and a more completely 
 flattened chest. 
 
 10 
 
FiO. 6. 
 
 The congenitally visceroptotic type, showing the extremely 
 
 slender back. 
 
 11 
 
Fig. 7. 
 
 The slender or congenital visceroptotic type in child, showing the 
 
 same general characteristics as in adult. 
 
 12 
 
The increased length is partly in the thorax, 
 but chiefly in the lumbar region. The ribs are 
 usually longer than is normal, the tenth rib is 
 almost always free, aiid when seen in the adult, 
 the downward inclination of the lower ribs is 
 very marked, they at times, in the standing posi- 
 tion, touching the upper part of the ilia. The 
 spine is smaller in size than normal and the lum- 
 bar vertebrae are more like the so-called normal 
 dorsal vertebrae in shape, the body being of 
 about the same width laterally as it is deep 
 antero-posteriorly. (Fig. 8). There are fre- 
 
 FlG. 8. 
 
 Lumbar vertebra in slender tyi>e, showing small body to the bone, 
 
 with slender laminae and with flat articular processes. 
 
 quently six vertebrae in the lumbar region with 
 the full number of sacral vertebrae, this being 
 one of the reasons for the greater proportionate 
 length of the body. The transverse processes are 
 small and short and the articular processes are 
 usually flat (not crescentic). Because of this 
 
 13 
 
formation, the lumbar spine is much more flexi- 
 ble than the normal type and it is this anatomic 
 type from which the fancy dancer, the hurdler 
 and acrobat are developed. 
 
 The thorax is of fair size, the lungs are ap- 
 parently smaller than normal, and the smaller 
 size of the heart is easily demonstrated by the 
 x-ray. The abdominal viscera have peculiarities 
 in shape and attachment unlike the normal hu- 
 man. The stomach is long and tubular, instead 
 of the normal pear shape. Its attachments are 
 less firm, so that the possible downward displace- 
 ment in standing is much greater than normal. 
 The duodenum is usually attached to the normal 
 position, but this is not constant. The small 
 intestine as a whole is much shorter than normal, 
 containing from 10 to 15 feet instead of the nor- 
 mal 20 feet, the walls are less thick, and the lu- 
 men smaller. According to Bean,** the length is 
 from 12 to 15 feet ; Swaim^ from 10 feet up ; 
 Bryant^ from 10 to 15. The mesentery is longer 
 than normal, so that in standing the small in- 
 testine is almost entirely in the upper pelvis or 
 lower abdomen. The large intestine is shorter 
 than normal, from three to five feet, and much 
 more mobile. Almost always upon the right 
 side there is a free mesentery so that this por- 
 tion may change its position easily, and fre- 
 quently the left side also has a mesentery, so 
 that in the upright position the entire colon lies 
 below the crests of the ilia. The most common 
 condition, however, is with the normal retro- 
 peritoneal position upon the left side with the 
 right side free. The transverse part of the colon 
 is usually attached to the stomach, which means 
 that it will be found below the position of the 
 stomach, even though the stomach may have its 
 lower border in the pelvis. With the transverse 
 
 14 
 
colon, while it is usually attached to the stomach, 
 it frequently has an entirely free mesentery, as 
 is natural with even the purely normal type in 
 the early embryologie state. In this type the 
 vermiform appendix is usually well developed, 
 while in the next type to be described the ap- 
 pendix apparently is much less developed, which 
 may in part explain the common occurrence of 
 appendicitis in the thin, slender individuals. 
 With this type of anatomy there is very little 
 retroperitoneal fat, palpation of the flanks is 
 easy, the kidneys are naturally mobile, the liver 
 is smaller and is more loosely attached than nor- 
 mal. 
 
 It is this type of anatomy in which the sca- 
 phoid type of scapula (Graves^) is found. The 
 muscles are formed of the long and slender 
 fibres. The extremities vary in lengtii as one 
 would suppose in studying comparative anatomy, 
 the carnivora at times having very long legs, as 
 the greyhound, or very short legs, as the otter, 
 but they are usually longer than is considered 
 normal and both arms and legs are relatively 
 slender. The feet are slender and often of un- 
 naturally high arch. The hands are slender but 
 long, the fingers being very slender and tapering. 
 While this type is usually thin, at times there 
 is much accumulation of fat. If this is present 
 it usually develops rapidly, disappearing at 
 times equally rapidly, and the fat is always soft 
 with very little connective tissue and suggests 
 poor health. 
 
 Uerbivorous (Treves,* Werner,^ Bryant^) ; 
 
 "Broad Backed" (Industrial) ; Meso-onto- 
 
 niorph (Bean*') ; Brachyscelous (Montessori^). 
 
 (Figs. 9, 10, 11 and 12). 
 
 Upon the other side of the normal human type, 
 
 15 
 
t 
 
 Fio. 9. 
 The heavy or extreme herbivorous t.vi>e, showing the large, heavy 
 build of the body throughout, the relatively straight position of 
 the i)elvis, the backward bend occurring in the upper lumbar 
 region rather than in the low lumbar, showing the lound-shaped 
 liead, flat ear, broad neck, with the shoulder well back on the 
 thorax. 
 
 16 
 
Fig. 10. 
 The broad backed or herbivorous type, showing the extremely 
 
 broad body. ' 
 
 17 
 
Fig. 11. 
 
 The broad, heavy type, showing all the general characteristics of 
 
 Figs. 9 and 10. 
 
 18 
 
Fig. 12. 
 The broad, herbivorous type in the child, showing the same general 
 characteristics of position of pelvis, curves of spine, position of 
 shoulder, hiffh chest, prominent upper abdomen, broad face, flat 
 ears, as in Figs. 9, 10 and 11. Tlie position of hyperextension 
 at the dorso lumbar juncture is well shown in this figure. 
 
 19 
 
and in marked contrast to the slender, carnivor- 
 ous type, is the heavily built, broad backed type 
 of human, in which so many of the characteris- 
 tics are similar to those found in the herbivor- 
 ous creatures that this term has been used for 
 their designation. 
 
 In this type the body is built upon much 
 heavier lines throughout. The skeleton is larger 
 in proportion and heavier in structure. The 
 muscles are large with coarse fibres. The skin 
 is coarse with scant growth of hair, which is lost 
 early. There is an excess of fat throughout the 
 body, but this is bound together with much con- 
 nective tissue so that the flesh feels hard and firm 
 in contrast to the soft, flabby feel such as is 
 peculiar to the slender type. The head is round, 
 the face is broad, the jaw is square, the ears are 
 usually placed flat against the side of the head, 
 and as a rule are not very large. The neck is 
 short and thick, the shoulders are broad and 
 square. The body as a whole is broad and rela- 
 tively short. The chest is larger both in the later- 
 al and antero-posterior diameters than the nor- 
 mal. The diaphragm is high, the costal border 
 is formed in a broad angle, rarely less than 90° 
 and sometimes more. The tenth rib is usually 
 attached to the conjoined cartilages in front and 
 the last t"\yo ribs are relatively short. The lum- 
 bar region is short, partly because of the fre- 
 quent presence of only four lumbar vertebrae 
 and partly because the sacrum is set well down 
 between the wings of the ilia. The abdominal 
 cavity is broad and deep. The stomach is large 
 and pear shaped. The duodenum is attached as 
 in the normal. The small intestine as a whole is 
 much longer than the normal, and ranges from 
 25 to 39 feet (Bryant^). The large intestine is 
 larger and longer than normal, from five to eight 
 
 20 
 
and one-half feet (Swaim*), with the retroperi- 
 toneal attachment of the ascending and descend- 
 ing portions, the added length showing in the 
 longer transverse portion and in the sigmoid. 
 The liver is large but well up under the dia- 
 phragm. There is much retroperitoneal and 
 general abdominal fat so that the kidneys are 
 well held in place and the sympathetic ganglia 
 are well protected. 
 
 The joints in this type are much less flexible 
 than in either of the other types, the individuals 
 as a whole being strongly and heavily built. 
 
 The spine is broad and heavy throughout, but 
 in the lumbar region this is especially notice- 
 able. The lateral diameter of the vertebral 
 bodies in this region is considerably greater than 
 the antero-posterior (Fig. 13). the articular pro- 
 
 FlG. 13. 
 
 Lumbar vertebra of heavy or herbivorous type, showing the broad 
 
 body and the heavy laminae. 
 
 21 
 
cesses are strong and large and almost always 
 of the crescentic type. The transverse processes 
 are long and broad, and the process of the last 
 lumbar frequently forms an articulation (the 
 lumbo sacral transverse articulation) with the 
 top of the sacrum. The long and broad trans- 
 verse processes upon the lumbar spine are simi- 
 lar to that which is found in the herbivorous ani- 
 mals and which produces the lateral rounding 
 of the back seen in all the hoof-footed creatures. 
 This formation apparently furnishes protection 
 and attachment for the many coils of intestine 
 in the abdominal cavity. 
 
 Because of the shape of the vertebrae and the 
 character of the articulation with the sacrum, 
 there is less lumbar curve forward than is pres- 
 ent in either of the other types (Figs. 1 and 2 
 and 4 and 5 ) , and the forward inclination of the 
 pelvis is also less. The axis of the sacrum is 
 more nearly perpendicular. In this type not 
 only are the wings of the ilia higher than in the 
 normal so that the transverse process of the last 
 lumbar articulates not only with the sacrum, but 
 also at times with the ilium, and in a few cases 
 the transverse process of the vertebrae above 
 also rests against the ilium or has strong liga- 
 mentous attachment to it. 
 
 The extremities in this type vary in length as 
 one would expect from the study of the compara- 
 tive anatomy of the herbivorous creatures, but 
 are always heavy. The legs are large, the knees 
 are straight, the feet are broad in proportion to 
 length, and the arch, while it may be very strong 
 is usually quite low. The arms are heavily built, 
 and the shoulder attachment is well back upon 
 the thorax, giving the square shoulder appear- 
 ance. The hands are broad and "chubby," both 
 in the palmar portion and in the fingers. 
 
 22 
 
Spinal Motions of the Different Types. 
 
 Because of the different structure of the bones 
 of the spine, the motions must vary. In the nor- 
 mal, in bending forward the spine is well 
 rounded and laterally there is some motion be- 
 ginning at the lumbo sacral juncture and extend- 
 ing up to the low dorsal region, while in back- 
 ward bending considerable motion is allowed. In 
 the carnivorous type this is similar, only the 
 amount of motion is much greater, as would be 
 expected from the description of the bony 
 formation of the type. With the herbivor- 
 ous type, as must be apparent, the spinal mo- 
 tions are much less free. In this, the forward 
 bending is made largely at the hips, there be- 
 ing but little in the spine. Laterally practically 
 no motion is allowed except at the dorso lumbar 
 juncture, none whatever being allowed in the 
 low back if the lumbo sacral transverse joint 
 exists. If this exists upon one side, no motion 
 at that region will be allowed to that side, while 
 to the other side slight motion may be allowed. 
 In backward bending very little is allowed, and 
 if the lumbo sacral transverse joint exists, none 
 will be allowed at the lumbo sacral juncture. 
 
 Such are the three general types which are com- 
 mon in the human family, and as to the fact that 
 such tj'pes exist, there can be no question, if the 
 passersby upon the street are noticed, even if one 
 is not willing to accept the statements of those 
 who have studied anatomy in this way. The thin 
 carnivorous person is there side by side with the 
 broad, full-faced herbivorous person, with the 
 normal human also present, and the character- 
 istics are so distinct that nothing more than the 
 glance is necessary to recognize the special form. 
 The characteristics are equally apparent in child- 
 
 23 
 
hood as in adult life, as is indicated by the ac- 
 companying illustrations. 
 
 The difference in the types and the fitness of 
 each for different forms of work is already 
 known, and a person who is at the head of an 
 organization employing large numbers of labor- 
 ers states that when an order for laborers is 
 given it is expected that it will indicate so many 
 "broad backs" or so many "narrow backs." 
 The "broad back" is fitted for the ordinary 
 heavy work, while the "narrow back" is fitted 
 for the work requiring greater agility, such as 
 climbing poles or trees, prospecting, running the 
 lines, etc. The "broad back" carries the heavier 
 load, but the "narrow back" carries his lighter 
 load more rapidly. 
 
 The. difference in the anatomic types is also 
 recognized consciously or unconsciously, in art, 
 and nothing can be more perfectly normal than 
 the early (not always the late) Greek figures, or 
 Michael Angelo's "David," or "William Hunt's 
 "Bathers." The type which Rubens almost al- 
 ways depicts is the heavy, full-blooded herbivor- 
 ous type, while the slender, carnivorous type is 
 the one depicted by Botticelli and Fra Angelico, 
 or by Puvis de Chavannes of the modem school. 
 
 The fact that such types exist, but that they 
 also have different characteristics which should 
 be recognized in their training, is shown by Dr. 
 Montessori in her book, "Pedagogical Anthro- 
 pology," in which the pictures of the types 
 are shown and the intellectual characteristics 
 discussed. 
 
 In athletics also the appreciation of the dif- 
 ferent physical types is clearly understood. The 
 hurdler or the runner is usually of the normal or 
 the slender type, while the hammer thrower, the 
 shot putter or the wrestler is usually of the 
 
 24 
 
heavy type. The heavy men are usually found 
 in the line of the football team, while in the 
 backfield the more slender and agile persons are 
 found. 
 
 The types exist, and in a very large . number 
 of instances the types are pure, the carnivorous 
 being carnivorous throughout, the normal hu- 
 man being the normal human throughout, and 
 the same is true of the herbivorous. In other 
 instances, however, the types are mixed, and it is 
 here that the greatest difficulty exists in under- 
 standing the symptoms or in planning the treat- 
 ment. A carnivorous type in general build and 
 viscera may have an herbivorous type of spine, 
 a combination which is quite common in women. 
 A carnivorous type of stomach and intestine may 
 exist with a normal liver and kidneys, in so far 
 as shape and position are concerned. The normal 
 type in general may have one or many of the 
 characteristics of either the carnivorous or the 
 herbivorous. The herbivorous type may show 
 characteristics of either of the others and prob- 
 ably the most common variation in this type is 
 the smaller spine and the imperfectly attached 
 colon, but of the full length. 
 
 That such differences exist in the anatomic 
 formation of members of the human family there 
 can be no question, and it is not unreasonable 
 to expect such differences if the biologic princi- 
 ples of the development of the race are con- 
 sidered. The human being as the highest type 
 of mammal naturally inherits something of the 
 strains which have shown themselves in the vari- 
 ous species through which the advance of the 
 mammalian group has occurred, and it is only 
 by studying comparative anatomy that the vari- 
 ous differences of type can be understood. 
 
 From the purely medical point of view the 
 
 25 
 
recognition of these different types is important 
 since the types apparently carry their own po- 
 tential of disease. The tuberculous and the in- 
 fections in general, the nervous diseases and 
 acute mental disorders, the hyperglandular dis- 
 turbances, the progressive anemias, the atrophic 
 arthritis, many of the intestinal disorders, etc., 
 naturally are associated with the slender type. 
 The arterio-sclerosis, hypertrophic arthritis, 
 gout, diabetes (not the insipidus), chronic dis- 
 ease of the kidney, gall stones, the prostatic 
 hypertrophy, the degenerative mental disorders, 
 etc., are common to the heavy type. The sug- 
 gestiveness of this in treatment must be obvious. 
 
 Habits of Posture in the Different Types and the 
 Effect upon the Physiology. 
 
 Not only has the study of the chronic patient 
 shown that the different anatomic types exist, 
 but that this alone can hardly explain all the 
 phenomena. The more the problem is studied, 
 the more evident it becomes that the life of the 
 creature as an erect biped is a very different 
 thing from that of the quadruped in so far as the 
 function of the different parts is concerned. 
 
 One of the penalties that the human being is 
 forced to accept in his being the highest type of 
 mammal, is that in locomotion, with the body 
 used as an erect biped, gravity is constantly 
 operating to drag the organs downward out of 
 their normal position, as well as to draw the up- 
 per part of the body downward and forward 
 into positions which must mean strain and weak- 
 ness. This element, together with the anatomic 
 form, seems many times sufficient to cause the 
 conditions seen in chronic medicine. 
 
 The counteracting element, to offset such a 
 handicap and prevent the race from being irre- 
 
 26 
 
parably harmed, is the intelligence with which 
 the human being is peculiarly endowed. The 
 real purpose of such a paper as this is to help in 
 the training of tliis intelligence so that life may 
 be a period of wholesome, healthy development, 
 with the fullest possible energy available for 
 whatever stress to which the individual may be 
 subjected. 
 
 The way the body is used is of quite as much 
 importance as the structure of the body itself 
 Either type has the potential of good health i^ 
 used rightly, but each has an equally definite 
 potential of disease if the proper relationship 
 between the many parts is not preserved. With 
 the normal type it is naturally easier to maintain 
 this relationship, but the possibility of not main- 
 taining it is painfully apparent as one goes 
 among one's fellow men. With the other types 
 the special postures or the form of the malad- 
 justment naturally differs as one would expect 
 from the structure. 
 
 Since the pathologic changes which are seen 
 are apparently due very largely to this imper- 
 fect adjustment of the parts, it is of the first im- 
 portance that the postures or special elements 
 of maladjustment which are peculiar to the dif- 
 ferent types should be appreciated. It should 
 also be remembered that with the chronic pa- 
 tient the large majority of the cases fall into the 
 slender, congenital visceroptotic type or the 
 broad, herbivorous type. 
 
 The Normal Human. 
 
 When the body is used rightly (Fig. 1 or 2), 
 all of the structures are in such adjustment that 
 there is no particular strain on any part. The 
 physical powers are at their best, the mental 
 functions are performed most easily, and the 
 
 27 
 
personality or spirit of the individual possesses 
 its greatest strength. 
 
 When used rightly, or fully erect, the feet, 
 knees, hips, spine, shoulders, head and all the 
 portions which represent the frame of the body, 
 are used in balance, with the greatest range of 
 movement possible without strain. In this po- 
 sition the chest is held high and well expanded, 
 the diaphragm is raised, and the breathing and 
 heart action are performed most easily. The ab- 
 dominal wall is firm and flat, and the shape of 
 the abdominal cavity resembles an inverted pear 
 (Forbes, Williams^®') (Fig. 14), large and round- 
 ed above and small below. The ribs have only a 
 moderate downward inclination. The subdia- 
 phragmatic space is ample to accommodate the 
 viscera. In this position, also, there is no undue 
 pressure upon, or interference with, the pelvic 
 viscera or with the large ganglia at the back of 
 the abdomen and in the pelvis. 
 
 Relaxed Position. 
 
 If the body is drooped or relaxed, so that the 
 shoulders drag forward and downward, the 
 whole body suffers, the weight is thrown imper- 
 fectly upon the feet, so that the arch must be 
 strained ; the knees are slightly sprung, which 
 shows by the crepitating joints; the pelvis is 
 changed in its inclination, with strain to the 
 sacro-iliac joints and low back. The increased 
 forward curve of the upper dorsal spine results 
 not only in strain to the intraspinous ligaments, 
 but also forces the shoulders forward, with fre- 
 quent irritation of the bursae about the shoul- 
 ders, or compression of the brachial plexus, with 
 pain and neuralgias in the arms, while the cran- 
 ing forward of the head must result in strain to 
 the posterior part of the cervical spine. 
 
 28 
 
Fig. 14. (Williams.) 
 
 29 
 
 / 
 
In this position the chest is necessarily low- 
 ered, the lungs are much less fully expanded 
 than normal, the diaphragm is depressed, the ab- 
 dominal wall is relaxed, so that with the lessened 
 support of the abdominal wall, together with the 
 lowering of the diaphragm, the abdominal or- 
 gans are necessarily forced downward and for- 
 ward. When this occurs the possibility of me- 
 chanical interference with the function of the 
 organs is not difficult to imagine, and it becomes 
 apparently a mere matter of chance which organ 
 is affected. 
 
 The thing that is important in the interpreta- 
 tion of the many symptoms which the patients 
 describe is that the body is most intimately re- 
 lated in its different parts so that no one part 
 can be used wrongly without the body as a 
 whole suffering. For this reason, if these vari- 
 ous groups of symptoms are to be considered 
 as purely local and distinct lesions, the results 
 are sure to be unsatisfactory. The body as a 
 whole should be considered and not just the 
 chest or the abdomen or the feet or the back or 
 any one part, and it should be considered with 
 reference to use in the different positions in the 
 routine of life, especially those which are main- 
 tained for long periods, the occupational pos- 
 tures. In sitting it is perfectly possible to sit 
 so that the trunk is in practically the same shape 
 and with the different parts in practically the 
 same relation, as they are when the body is used 
 fully erect. At the same time in sitting it is 
 very common to have the body markedly 
 drooped, so that the body is rounded forward 
 with the lumbar spine entirely reversed in its 
 curve, with the ribs low, so that the thorax prac- 
 tically telescopes into the abdominal cavity. 
 When such a position is studied with reference 
 
 30 
 
to the mechanics of the function of the organs 
 the wonder is not that disturbances result, but 
 that the disturbances are not more marked. 
 
 In such a study of the mechanics of the 
 physiology, the positions assumed when the pa- 
 tient is lying down should be investigated. It 
 is perfectly possible to produce practically the 
 same effect upon the shape of the body and upon 
 the thoracic and abdominal cavities that is pres- 
 ent when the patient is sitting in the slouched 
 position, if when lying down several pillows are 
 placed under the head and shoulders, as is so 
 frequently seen. In such a position naturally 
 the breathing and circulation, the digestion, and 
 the other physiological functions cannot go on 
 rightly, and the restless, dreaming sleep is many 
 times due to no other cause than this. 
 
 The importance of the proper relationship of 
 the parts should be borne in mind under all 
 conditions, and especially at the times of occu- 
 pation or when the postures are assumed for 
 continuous periods. It is under such conditions 
 that naturally the greatest harm results, and 
 it should be remembered that irrespective of the 
 type, the postures which are assumed as the 
 body is used determine very largely whether 
 the individual is to be well or ill. The most 
 perfect, anatomically, may have the poorest 
 health, while the most imperfect, anatomically, 
 may have good health. Fig. 15 is of the normal 
 type as is shown when the body is held erect 
 (Fig. 16) but the posture commonly maintained 
 (Fig. 15) suggests very little of normal vigor- 
 ous health. 
 
 The postures which are assumed by the other 
 anatomic types are perfectly characteristic, so 
 that once they are appreciated, the posture it- 
 self very largely indicates the type of anatomy 
 
 31 
 
Flo. 15. 
 
 The normal human tyi>e, with acquired habits of bad posture, with 
 
 ni;irke<l visceroptosis, drooped shoulder, etc. 
 
 32 
 
Flo. 16. 
 
 The same case as Fijf. 15, except that the body is held at attention, 
 showing the way the viscera are drawn up under the diaphragm, 
 givinsr the normal lines of the body when the body is held erect. 
 
 33 
 
to be found in the individual. It is always to 
 be remembered that while the type is present at 
 the time of birth, that the extreme characteris- 
 tics which are seen in adult life are largely the 
 result of stretch and strain due to the downward 
 displacement which is the rule if the body de- 
 velops without guidance. As long as the child 
 remains a quadruped, as it is in the first two 
 or three years of life, the special peculiarities 
 are of very little concern, but as soon as it be- 
 gins to assume the erect posture for long inter- 
 vals the peculiar postures begin to show and the 
 symptoms which naturally result therefrom be- 
 gin to develop. 
 
 The Congenital Visceroptotic or Carnivorous 
 Type. 
 
 In the slender type, while the ideal standing 
 position is the same as with the normal human, 
 the natural position which will be assumed is 
 one in which the general relationship of the 
 parts is much disturbed (Figs. 4, 5 and 7). In 
 this type the chest is flat, the usual standing po- 
 sition being with the chest at full expiration so 
 that all breathing is done from the low point. 
 The sternum is more nearly perpendicular, in- 
 stead of the forward inclination, which is nor- 
 mal. The costal border is inevitably narrower 
 than in the normal type, the angle being usually 
 under 45,° while at times in adult life it is so 
 slight as to be hard to insert the fingers between 
 the costal cartilages of the two sides. Because 
 of this position of the ribs, the upper abdomen 
 is naturally very small and the abdominal vis- 
 cera must be in a different position from that 
 seen in the normal type. The general shape of 
 the abdominal cavity resembles the normal pear 
 (Forbes, Williams^"), large below and narrow 
 
Fig. 17. (Williams.) 
 
 35 
 
above. (Fig. 17). Because of this the liver is 
 displaced downward and it is usually rotated 
 to the right, so that the right border is fre- 
 quently below the crest of the ilium. The retro- 
 peritoneal fat is practically entirely lacking, 
 with the result that the kidneys are usually mo- 
 bile, the position occupied depending entirely 
 upon the position assumed by the individual at 
 the time of examination. Because of the ab- 
 sence of the retroperitoneal fat, the sympathetic 
 ganglia and the large blood vessels must lie un- 
 protected upon the anterior part of the spine, 
 and it is not improbable that the changing po- 
 sitions of the organs, in the changing positions 
 of the body, must at times lead to irritation or 
 harmful pressure of these ganglia or vessels. 
 The same thing is probably true of the adrenals, 
 which, being unprotected by fat pads, must be 
 pressed upon and irritated more than is normal, 
 this mechanical disturbance possibly explaining 
 the peculiarity of the structure of the adrenal 
 in this type of anatomy, which has been de- 
 scribed by Dr. Bryant. 
 
 In this type of anatomy, since the ribs are 
 lowered in front, the diaphragm must be lower 
 than is normal, and this is increased by the 
 drag of the loosely attached stomach, liver and 
 colon. Because of this, the movement of the 
 diaphragm in respiration must be less than nor- 
 mal, with, at times, practically no movement 
 whatever showing in the Roentgenological study. 
 The effect of this upon the breathing, as well as 
 upon the circulation, especially in the large ab- 
 dominal veins, to say nothing of the function of 
 the other organs, must be very apparent. 
 
 The constant position assumed by this type 
 is with the body inclined backward from the 
 low lumbar region, making a sharper curve in 
 
 36 
 
the low spine than is normal, the spine above 
 this point being relatively straight to the upper 
 dorsal region, from which point it bends sharply 
 forward to the midcervical region, where it 
 bends backward again to make the upright po- 
 sition of the head possible. (Figs. 4 and 5). 
 The general impression created by such a posi- 
 tion when the individual is dressed is often that 
 of being quite erect. In tliis position with the 
 ribs low in front there is imperfect support for 
 the shoulders, so that they are drooped forward' 
 (Figs. 4, 5 and 18), the scapulae being rotated 
 outward at the top, so that their long axis is 
 much more oblique than normal. In this posi- 
 tion the upper part of the scapulae does not 
 rest against the ribs, and since the position ex- 
 ists in childhood when the bones are soft, the 
 unsupported upper part usually is flexed for- 
 ward, this flexed portion rubbing over the ribs 
 when the shoulders are extended and gives rise 
 to the sensation of crepitation so commonly felt. 
 This irritation if continued naturally causes the 
 pain so frequently referred to this region. "With 
 this general posture there are two regions of the 
 spine, the low lumbar and the low or midcervi- 
 cal, in which the degree of hyperextension is 
 greater than is normal, and since in hyperexten- 
 sion the posterior portions of the vertebrae, must 
 be brought closer together than is normal, and 
 since the foramina through which the nerve 
 roots pass are posterior to the point of motion, 
 it is obvious that in this position the foramina 
 must be narrowed. Since this position is the 
 habitual one with this type it is not impossible 
 that some of the little understood symptoms re- 
 ferred to the arms and legs (the parts naturally 
 supplied with sensation and motor control from 
 these two hyperextended regions) or some of 
 
 37 
 
Fiii. IS. 
 
 The slender, congenital visceroptotic or carnivorous type, showing- 
 the forward position of the shoulder, with marked rotation of the 
 scapula. In this position the head of the humerus is lowered and 
 rotated inward so that it rests against the second rib, and the 
 possibilities of crowding the vessels of the arm or the nerves of 
 the arm leading to the circulatory disturbances, neuritis, or neu- 
 ralgias of the arTii, are evident. 
 
 3S 
 
the circulatory disturbances of the spinal cord 
 may be due to this anatomic position. 
 
 With this hyperextension of the lumbar re- 
 gion and the backward inclination of the upper 
 body, the longitudinal axis of the abdomen is 
 naturally moved backward at the top, but at the 
 same time the pelvis is tipped forward and 
 downward (Figs. 4 and 5), so that its longitu- 
 dinal axis is moved forward at the top (Fig. 19) . 
 The result of this is that the hips stick out at 
 the back more than is normal and the angle 
 
 Fio. 19. 
 
 Spine and pelvis, with left ilium removed, of slender or carnivorous 
 type, showing the marked forward inclination of sacrum. The 
 weight of body must be thrown upon the front of the sacrum, and 
 naturallv leads to sacro-iliac strain or displacement. 
 
 39 
 
formed by the intersection of the two axes, pel- 
 vis and abdomen, is less than is normal. In this 
 position the pelvis has its forward inclination 
 changed so that it at times is from 30° to 40^ 
 away from the so-called normal position. Natur- 
 ally in this position the upper part of the sac- 
 rum, upon which the spine rests, is moved for- 
 ward and downward and the weight of the body 
 constantly tends to increase this forward posi- 
 tion with resulting abnormal strain to the sacro- 
 iliac joints. This being the case, it is not sur- 
 prising that it is in this type of anatomy that 
 the strains and displacements of the sacro-iliac 
 joints are most commonly seen. 
 
 With this general peculiarity of poise, the 
 weight is naturally thrown upon the feet wrong- 
 ly, so that the usual high arched foot is marked- 
 ly pronated and the knees are sprung, usually 
 with some knock knee. 
 
 In considering the mechanics of the viscera, 
 naturally the same conditions as to position or 
 mode of use of the body apply as were indicate(i 
 with the normal human type. The special thing 
 to be borne in mind in this slender type is that 
 all the disturbances of poise are more easily 
 harmful than would be true with the normaf 
 human or the more stockily built types. Par- 
 ticularly it is desirable that the positions as- 
 sumed at night should be considered carefully. 
 The absence of the posterior abdominal fat pads 
 which fill up so much of the lateral spinal spaces 
 naturally allows the loosely attached organs to 
 drag backward much more than is possible in 
 the normal type. This, together with the lack of 
 protection of the ganglia and the blood vessels 
 upon the front of the spine makes mechanical 
 pressure more easily possible than occurs in 
 the normal. It is not improbable that it is this 
 
 40 
 
drag or pressure upon these structures during 
 the periods of complete relaxation in sleep that 
 explains the common subnormal temperature, 
 with the weak pulse, the low blood pressure, 
 and the general lack of vitality which is usually 
 present with this type of individual in the 
 morning. For this reason it is particularly de- 
 sirable that this type of individual should sleep 
 either face downward or upon the side, so that 
 the drag of the organs tends to pull away from 
 the spine rather than to press backward upon 
 the spine, as would be inevitable if the back 
 position were assumed. The same possibility of 
 backward pressure upon the ganglia or vessels is 
 to be carefully borne in mind at times of opera- 
 tion upon this type, and the back position after 
 operation be maintained as little as possible un- 
 less there is some support planned for the low 
 back and loins. 
 
 With this type it should be remembered that 
 good poise is possible (Fig. 20, the same child 
 as Fig. 7), but that it requires greater effort on 
 the part of the individual and greater patience 
 on the part of the helpers than would be re- 
 quired by the normal. 
 
 The Broad-Backed, Herhivorous Type. 
 
 With this type of anatomy the harmful dis- 
 turbances of poise as a rule develop much later 
 in life than with the slender type, because the 
 shape of the spine and the general structure of 
 the body withstand strain much longer than the 
 more lightly built creature. In childhood the 
 general posture is with the body erect and in 
 good poise, not unlike that assumed or consid- 
 ered desirable in the normal type. 
 
 With this heavy type the disturbances of pos- 
 
 41 
 
Fig. 20. 
 The same case as Fisy. 7, showing the possibility of the erect pos- 
 ture, but showing: the marked hollow under the ribs as the result 
 of the low position of the viscera. 
 
 42 
 
ture come about chiefly because of the abnor- 
 mally large and heavy abdominal viscera. This 
 leads to the backward inclination of the body as 
 the weight of the abdomen increases, but since 
 the formation of the low lumbar spine, with this 
 type, does not allow of backward bending, the 
 inclination takes place either from the hips or 
 at the dorso-lumbar juncture (Fig. 9). The 
 strain produced upon the low back as the result 
 of the posture may lead to marked sensitiveness 
 at the lumbo-sacral juncture, due either to the 
 crowding of the transverse process against the 
 top of the sacrum with the irritation of the 
 bursae which so commonly lie between, or to the 
 irritation of the articulations formed by the 
 articular processes, or by the crowding together 
 of the spinous processes with the pinching of 
 the intraspinous ligament. Many of the cases 
 of lumbago are undoubtedly to be explained by 
 such strain. 
 
 In this type of anatomy the inclination of the 
 pelvis is never forward more than is normal, 
 but is apt to be thrown backward at the top 
 since the pelvis moves with the low spine, and 
 since the backward inclination usually takes 
 place at the hip joints instead of in the lumbar 
 spine. With such a backward tendency, if one of 
 the transverse processes is larger tlian the other, 
 or if the lumbo sacral transverse articulation 
 exists upon one side, or is more marked upon 
 one side than the other, or if the articular pro- 
 cesses are peculiar in shape, so that one is cres- 
 eentic while the other is broad, it is obvious that 
 with the backward inclination, the body is 
 thrown to the side, with at times a marked 
 lateral deformity. It is in this type that the so- 
 called sciatic scoliosis is so often seen (Fig. 21). 
 The symptoms which would naturally result 
 
 43 
 
Fig. 21. 
 The broad backed, herbivorous type with the lunibo sacral transverse 
 joint upon the left side, with strain and irritation of this joint, 
 resulting in marked list of the body, with much pain in the left 
 leg, and ijartial paralysis of the anterior thigh muscles, the so- 
 called sciatic scoliosis. 
 
 44 
 
from this would be pain, not in the sacro-iliac 
 joints as in the other type, but at the lumbo 
 sacral juncture, and especially over the lumbo 
 sacral transverse regions. The referred pain 
 will be along the anterior cural nerve or the 
 distribution of the nerves coming from the 
 lumbo-sacral cord, that naturally being the 
 nerve most commonly irritated as it passes un- 
 der the transvei*se processes of the fifth lumbar 
 vertebra. 
 
 With this type of anatomy the sternum is al- 
 ways carried high so that the chest is more 
 rounded than in tlie normal human type and the 
 diaphragm is held high, largely because of the 
 bulky viscera which occupy the upper part of 
 the abdomen. As years go on the heavy organs 
 naturally lead to stretching of the abdominal 
 wall so that the viscera occupy a lower level 
 than is normal, but the degree of sag in this 
 type is markedly less than is seen in the slender 
 type with the loosely attached viscera. It should 
 be remembered, however, that the degree of dis- 
 placement is not that which determines the se- 
 verity of the symptoms, and that at times the 
 sag of an inch of an organ may produce more 
 serious difficulty than the sag of several inches. 
 
 As the organs sag downward, the ribs, while 
 lowered somewhat, are naturally flared at the 
 bottom because of the high attachment of the 
 organs and the fact that the amount of down- 
 ward displacement that is possible with them is 
 relatively slight. The antero-posterior diameter 
 of the upper abdomen in this type is relatively 
 but little changed by the drooped position over 
 that which would exist when the body is fully 
 erect. On the other hand, in the slender type 
 the antero-posterior diameter of the upper ab- 
 domen is much less when the body is drooped 
 
 45 
 
than when fully erect. The costal border in this 
 heavy type of anatomy is always broad and 
 usually is more than 90° rather than less. 
 
 With the heavy type the positions assumed 
 when sitting are as a rule much less serious 
 than with the slender type, since the structure 
 of the body as a whole makes the droop much 
 less marked, and since in the sitting position 
 the lower abdomen is partly supported on the 
 upper thigh and the downward drag of the or- 
 gans thereby somewhat lessened. 
 
 The position at night is naturally of import- 
 ance, and with this type the position upon the 
 face w^ould cause so much backward pi'essure 
 upon the viscera and structures at the back of 
 the abdomen that probably harm would result. 
 The back or the side position is naturally the 
 best. Since the lumbo sacral region is the part 
 most commonly strained in this type of anatomy, 
 the back ache in this type or the referred leg 
 pains are usually relieved by recumbency, the 
 reverse of this being true with the slender type, 
 in which with the sacral strain the day time is: 
 the time of greatest ease, the night being the 
 time of greatest discomfort. 
 
 Deductio7is. 
 
 If that which is here stated is correct, and 
 verification of the statements should not be diffi- 
 cult, it means, in the first place, that the teach- 
 ing and study of anatomy should have to do not 
 only Avith the normal type, but that the other 
 types should be given similar recognition. The 
 need of this broader anatomic training must be 
 obvious when one appreciates how rarely the 
 physician is consulted by the person having the 
 anatomy as it is commonly taught. 
 
 46 ' 
 
It means, also, that in the study of physiology 
 the elements which are peculiar to each type 
 should be investigated and appreciated. When 
 the elements which are easy of study, such as 
 the gastric secretions, the blood pressure, pulse 
 rate, temperature, etc., vary so markedly with 
 the different types there must be similar an9 
 perhaps more important variations in the other 
 features which are part of our physiology. To 
 study all individuals from the same point of 
 view must lead to much confusion and explains 
 in part the different reports which are made of 
 seemingly similar investigation. With the types 
 so widely different it is not difficult to believe 
 that there is wide variation in the function of 
 the different parts. The physiology as a whole 
 should be studied with this in mind. The tem- 
 perature, blood pressure, and other elements of 
 this sort should be observed, but also the prob- 
 lems, such as the mechanics and peristalsis of 
 the stomach and bowel, with the time involved 
 in the passage of food from one part to the 
 other. These must vary, and each type should 
 be studied by itself, since it is obvious that study 
 of one type would be of very little assistance in 
 interpreting the symptoms or functions of an- 
 other. This must be particularly true of the 
 chemical observations and it must be obvious 
 that in beings having so much the makeup of 
 creatures so widely different as the carnivora 
 and the herbivora there is probably enough of 
 difference in the body metabolism as to make 
 such studies of uncertain value unless the ana- 
 tomic type of the creature studied is stated. 
 
 It means that probably in this difference in 
 types is to be found the explanation of the vary- 
 ing effects of the same diet upon groups of 
 individuals. That one becomes fat while the 
 
 47 
 
other remains thin, or that one suffers distress 
 while the other thrives upon the same food must 
 be due to something other than the food. The 
 fact with which even the laity is familiar, that 
 meat in gout is harmful becomes a matter of 
 interest when it is realized that the herbivorous 
 type is the one that is subject to gout. Also 
 the fact that a few years ago so many of the 
 nervous invalids were helped by the diet of 
 chopped red meat and hot water of Dr. Salis- 
 bury becomes interesting, since this type of pa- 
 tient is almost always of the carnivorous type. 
 It apparently means that while all human be- 
 ings have elements within them which make 
 possible the digestion of the different kinds of 
 food, some are digested with greater ease than 
 others, and that this fact at times is of the 
 greatest importance in the interpretation of 
 symptoms and their treatment. 
 
 It means in the medical and surgical treat- 
 ment of our patients that the symptoms should 
 be interpreted in relation to that which is nor- 
 mal for the special type of anatomy represented 
 in our patient, and that the mechanical condi- 
 tions present in such a type should be carefully 
 studied. A blood pressure, for instance, that 
 would be normal for one type might be danger- 
 ously high or dangerously low for the other type. 
 A disturbance of circulation in the legs, the 
 varicose veins, or in the lower abdominal struc- 
 tures, varicocele, etc., should be thought of not 
 as a local condition, but investigation at once 
 started to see what is pressing upon or interfer- 
 ing with the veins above. Correction of sagging 
 organs, or the removal of some pelvic tumor may 
 wholly relieve the mechanical interference with 
 the veins with entire relief to the conditions be- 
 low. The treatment of the vein itself, since it 
 
 48 
 
is treating a symptom only, must necessarily be 
 unsatisfactory. 
 
 In thoracic conditions, it means that not only 
 should the disease of the organ itself be con- 
 sidered, but the conditions under which the 
 special organ works be also considered. In the 
 slender type, since the chest is used at full ex- 
 piration and since the movements of the dia- 
 phragm are also restricted, the lungs should not 
 be expected to become strong or to work rightly 
 until the conditions upon which the proper ac- 
 tion of the lungs depends are made possible. 
 With the tuberculous patient, which almost al- 
 ways is of this type, it should be made a part 
 of our work to see that the body is so used and 
 supported that the chest is raised, and the drag 
 upon the diaphragm removed, so that the nor- 
 mal rhythm of respiration is possi])le, as much as 
 to see that the patient is given fresh air. The 
 air cannot get into the lungs unless these me- 
 chanical elements are recognized. The same is 
 true of the heart action, if the chest is low, and 
 the diaphragm depressed so that the suspensory 
 ligament, which is the pericardium, is stretched. 
 Not only must the heart labor at a disadvantage 
 from its immediate enviroment, but the inter- 
 ference with the diaphragmatic action must be 
 of much importance, and for only one illustra- 
 tion, the unloading of the abdominal veins, 
 which is dependent so much upon the movement 
 of the diaphragm, must be disturbed. When the 
 mechanics of the heart action is considered one 
 is not surprised to find such work as the article 
 by M. Herz^" upon ' ' Interference with the Heart 
 Action by Stooping," reported. 
 
 In the abdominal conditions it means that 
 they should be given proper anatomic and 
 mechanistic consideration. It may be that the 
 
 49 
 
individual is simply receiving food that is de- 
 signed for an entirely different type, or it may 
 be that the organ or organs are so mechanically 
 out of adjustment that the normal function is 
 impossible. The imperfect action of the liver 
 or the formation of gall stones may be due to 
 mechanical interference Avith the structures upon 
 which the function depends. The fact that gall 
 stones are found so commonly in the heavy type, 
 while the cystic bladder is seen so commonly in 
 the slender type, probably means something 
 which has both a physiologic and a mechanistic 
 significance. The inability of the stomach to 
 empty itself, or the variations in the character 
 of its secretions, may be due to the position of 
 the organ itself or to interference with the ves- 
 sels or nerves supplying it. The function of the 
 bowel, both large and small, may be good or ill 
 in proportion as its structure is normal or its 
 position is correct. Kinks may occur, but it 
 should be remembered that while some are seri- 
 ous and require surgical interference, that many 
 times if the mechanistic features are appre- 
 ciated, that the kink can easily be released, while 
 if surgery is employed, the special kink may be 
 removed but the structural formation is such 
 that other kinks are possible, with a greater 
 probability of their developing because of the 
 post-operative adhesions which are sure to be 
 added to the structural peculiarities. The ulcers 
 of the stomach or duodenum may be due to 
 improper pressure, as has been fully described 
 by Codman.^^ 
 
 It means in the part of the study in which 
 the x-ray is used, that the difference in the po- 
 sition of the viscera that should be present when 
 the body is recumbent upon the side or back, as 
 
 50 
 
well as that which should exist when the body 
 is erect, should be fully understood. 
 
 It means that with the disturbances of the 
 kidneys, that those which are mobile should be 
 expected as a part of the anatomy of the slender 
 type, and that attempted suture of such organs 
 can hardly be successful unless there is much 
 postural training, since all of the mechanics 
 tend to redisplace them. In the so-called dis- 
 eases of the kidneys it should be remembered 
 that albumen and the other abnormal elements 
 are only symptoms of a condition, and may be 
 due to improper demand put upon them by the 
 wrong food, or may be due to some purely 
 mechanical condition. When the anatomic fea- 
 tures are considered as well as all the mechanis- 
 tic features, one is not surprised to find such 
 work as Scholder and Weith^- carried on at 
 Lausanne, showing that in 1254 school children, 
 in over 20% they were able to obtain albuminu- 
 ria by putting the children in certain definite 
 postures. Similar work by Fisehl and E. Pop- 
 per^^ upon albuminuria is of additional sugges- 
 tiveness. 
 
 With the presence of sugar in the urine it is 
 not impossible that as well as improper food 
 the pressure of the mobile, heavy organs upon 
 the pancreas, or its blood vessels, may be dis- 
 tinctly causative of the symptom. Certain it 
 is that when one has seen cases in which after 
 most careful dieting the sugar has persisted and 
 then after supporting tlie organs properly the 
 sugar has wholly disappeared, it is hard to be- 
 lieve that the mechanistic elements are not of 
 some importance. It should be remembered that 
 the diabetic is almost always the heavy type 
 and that sugar is rarely present in the slender 
 type, except occasionally in childhood, and then 
 
 61 
 
only in an evanescent manner. In this heavy 
 type the organs are heavy and are placed in the 
 upper abdomen, while in the slender type they 
 are much lower. One cannot help wondering 
 if the heavy organs, by sagging, may not crowd 
 the pancreas or the sympathetic ganglia of that 
 region with etiological importance. The sup- 
 ports or postures which are used should be 
 planned with reference to this. 
 
 It means, in considering the blood diseases, 
 especially the profound anemias, which cannot 
 be explained in other ways, that the position of 
 the spleen or the effect which other organs may 
 have upon its function should be considered. 
 The ease with which the blood supply of this 
 organ could be shut off or interfered with as 
 the other organs move about, must be apparent, 
 while the possibility of the spleen itself being 
 displaced or its vessels twisted, must be equally 
 evident as we come more and more to under- 
 stand the mobility of the various viscera. The 
 fact that the blood recovery has taken place 
 rapidly after mechanical treatment has been 
 applied, after the previous continuance of the 
 symptoms, in spite of the ordinary medical 
 measures, makes it seem probable that to make 
 it possible for the organ to work, is perhaps as 
 important a part of treatment as any other. 
 
 It means that with the disturbances of the 
 other abdominal organs that both the anatomic 
 and the mechanistic features should be consid- 
 ered; that the stomach and liver cannot work' 
 rightly if the ribs are contracted and narrowed" 
 so that there is practically no subdiaphragmatic 
 space ; that the pelvic organs cannot work right- 
 ly and must be congested if the loose abdominal 
 organs are crowded into the lower abdomen and 
 pelvis. 
 
 52 
 
It means that in studying the mental diseases 
 or the nervous disorders, since with the former 
 the acute conditions are usually seen in the 
 slender or carnivorous type, while the chronic 
 or degenerative conditions are usually seen in 
 the heavy type, in which the arteriosclerotic 
 changes are common, and since also the func- 
 tional nervous conditions are usually seen in 
 the slender type, that probably the anatomic 
 form is of distinct importance in the under- 
 standing of such conditions. It is not improb- 
 able that the acquired characteristics, with the 
 mechanical disturbance of the physiology which 
 is to be expected under such conditions, may be 
 of distinct etiological importance. 
 
 With epilepsy, the recent literature so strong- 
 ly suggests that many of the cases are due to 
 gastro-intestinal derangements that it is not un- 
 reasonable to wonder if, by studying the ana- 
 tomic condition fully, we may not find sugges- 
 tions that will be helpful in our treatment. 
 From the mechanistic point of view, when oc- 
 casionally one sees the convulsions stop instantly 
 by the mere change of position to that in which 
 there would be less pressure of the viscera upon 
 the ganglia and vessels in the posterior part of 
 the upper abdomen, it makes one question if 
 these mechanistic elements are not part of the 
 complex condition that shows itself in the con- 
 vulsion. 
 
 It means that in studying the disturbances 
 of the internal glands that since the hyper-thy- 
 roid conditions are usually seen in the slender 
 type, while the hypo-thyroid conditions so com- 
 monly occur in the heavy type, it is possible 
 that in the better understanding of the physi- 
 ology of the whole body with such an anatomic 
 
 5a 
 
basis, our treatment of these conditions may be 
 more satisfactory. 
 
 It means that in studying such local condi- 
 tions as the disturbances of the eye, it should be 
 appreciated that the circulation in the eye may 
 be so materially changed by postures which 
 interfere with the blood flow to the head that 
 the shape of the eye is changed, the near sighted 
 eye resulting (Howe^*). In such diseases as 
 cataract, since these commonly develop in the 
 heavy or herbivorous type, as is true of the 
 hypertrophic arthritis, perhaps there is some- 
 thing else to be done other than wait for suit- 
 able time for operation. With such understand- 
 ing of the anatomic types and their physiologic 
 potentials, one is encouraged in such hope by 
 work such as is reported by Connor.^^ 
 
 With some of the other inflammatory con- 
 ditions of the eye it is not improbable that the 
 function of the ophthalmologist will extend 
 much farther than the application of the local 
 remedies, but that a kink in the bowel leading 
 to an eye infection or the interference with the 
 circulation in the eye as a result of some local 
 mechanical feature may be the real cause of the 
 trouble and that his greatest function is seeing 
 that these conditions are corrected. 
 
 It means, in obstetrical work, that the differ- 
 ent types have very different potentials. The 
 slender type of woman is, as a rule, in better 
 health than usual during pregnancy, after pass- 
 ing the first month or two, undoubtedly in part 
 due to the support which the abdominal organs 
 receive from the enlarging uterus. The labor 
 also is usually easy with this type, as one would 
 expect from the small amount of pelvic fat, the 
 slender or small fibred pelvic muscles, and the 
 slender pelvis with the loose pelvic joints. In 
 
 54 
 
the last month of pregnancy the sacral pain with 
 frequent sciatica is easily understood by the 
 form of the pelvic joints, and the quick relief 
 from the pelvic joint strapping is not surpris- 
 ing. The possibility of increasing the diameters 
 of the pelvis in this type and thereby assisting 
 at the time of labor, by simply manipulating the 
 sacrum should be realized, as well as the greater 
 need of pelvic support, by swathe or strapping 
 while the involution is going on. Also with this 
 type, to maintain the higher position of the ab- 
 dominal organs, the upright position should not 
 be assumed until the abdominal wall has re- 
 gained its proper tone and suitable corsets, to 
 give low abdominal support, are fitted. It 
 should be appreciated that conception with this 
 type occurs easily and large families are com- 
 mon. With the heavy type childbearing is a 
 more difficult matter, conception occurs less fre- 
 quently, and the pregnancy is usually a time of 
 much discomfort, with distressing back ache due 
 partly to the relaxing of the broadly formed 
 sacro-iliac joints and partly to the strain of 
 the broadly formed lumbo-sacral joint, due to 
 the changing poise. The labor is usually diffi- 
 cult, partly because of the general lack of flexi- 
 bility of the pelvic girdle and the low back. It 
 is with this type that back ache with referred 
 leg pains often last for long after confinement 
 because of the chronic joint strain. 
 
 With the normal human type the obstetrical 
 condition is midway between these two types. 
 It is neither as easy as with the slender nor as 
 hard as with the heavy type. 
 
 It means that with the orthopedic conditions 
 not only should the special joint or part be 
 protected, but the type of the being as a whole 
 should be studied and the function of the dif- 
 
 55 
 
fereut parts assisted as much as possible. In 
 the fitting of apparatus this is particularly im- 
 portant, and anything that interferes materially 
 with the visceral function or with the proper 
 development of the body as a whole should be 
 most carefully avoided. This should be espe- 
 cially considered in some of the newer methods 
 for the treatment of lateral curvature. 
 
 It means that, in the treatment of the common 
 weak foot conditions, cure can hardly be ex- 
 pected unless the elements of faulty mechanics 
 which have led to the foot strain are corrected. 
 Of these, among the seemingly remote causes 
 of strain, it should be remembered that the ab- 
 normal drag of the abdominal viscera will neces- 
 sarily throw the body out of poise, so that the 
 balance of the feet will be disturbed. It means 
 that in the treatment of the common strains of 
 the sacro-iliac joints that cure is not to be ex- 
 pected unless the abnormal forward inclination 
 of the pelvis which has led to these strains is 
 overcome. It means that in the treatment of 
 the chronic joint diseases that the treatment of 
 the local condition is only part of the problem. 
 The joint symptoms are usually due to some 
 systemic disturbance. To find the primal cause 
 of the difficulty and see that it is corrected 
 is naturally the most important function of the 
 orthopedist. 
 
 It means, and this is apparently the most 
 sobering phase of the subject, that as the result 
 of the splendid work of our profession in pre- 
 ventive medicine, the slender type, which for- 
 merly because of its low resistance added so 
 much to the mortality of infancy and childhood, 
 is now being saved. It means also that with 
 this type growth without proper guidance in- 
 evitably produces a still weaker physique, with 
 
 56 
 
drooped figure, narrow chest, etc., etc. These 
 acquired characteristics added to the congenital 
 form accentuate the congenital elements to such 
 an extent that they are much more sure of being 
 present in the following generation, and it be- 
 comes a mere matter of biology to see that such 
 elements which represent physical instability 
 will become more and more marked in the sub- 
 sequent generations. This together with the 
 fact that the slender type is the most prolific, 
 makes evident that the stock from which the race 
 is recruited will become steadily less strong. 
 That this is actually taking place, one has only 
 to study any considerable group of school chil- 
 dren of the present time to see how commonly 
 the slender type is found. That this was not 
 formerly the case is suggested, at least, by the 
 study of the engravings of groups of individuals, 
 such as were so commonly made from 50 to 100 
 years ago, in which the broad or round faced 
 type is almost the only one shown. This is, of 
 course, equally true at the present time in those 
 countries in which modern medicine has exerted 
 but little influence, and consequently the infant 
 or child mortality is extremely high. The simi- 
 larity in the form of the Oriental is apparently 
 to be explained largely by this, as is true also 
 of the form of the pure African. The slender 
 type is not often seen among these races. 
 
 Since with the work of our profession and 
 the general development of our civilization, the 
 structure of the human family is being modified, 
 it certainly behooves us to see that the modifica- 
 tion is beneficial and not harmful. For this 
 reason the great opportunity for our profession 
 consists in not only saving the lives of those 
 who are physically delicate, but in seeing that 
 
 57 
 
they are developed into stronger and more 
 healthy individuals. 
 
 Similarly this is the great opportunity and 
 responsibility for the educator. The slender 
 child, if guided and trained rightly, becomes the 
 agile, quick moving, quick thinking type of in- 
 dividual. To obtain such a development means 
 most constant perseverance with the education 
 and training of such a child, and this training 
 should begin in the lowest grades of our school 
 system, insistance being put always upon poise 
 with its resulting efficiency. If the proper ex- 
 ercises are started in the lower grades and are 
 increased in vigor and complexity as the child 
 progresses, the children can be brought up to 
 adult life with very different physique from 
 that which is so commonly seen at the present 
 day. One of the most serious phases of the edu- 
 cational aspect of the problem is that since this 
 slender type is sensitively and nervously organ- 
 ized, with distinct nervous instability, intellec- 
 tual training must necessarily increase this in- 
 stability, unless with the intellectual training 
 the training of the body is insisted upon so that' 
 the proper physical support is given for the 
 mental development. If education is approached 
 in this manner it is a blessing, but if the intel- 
 lectual aspect alone is held it must, in so far 
 as this slender type is concerned, be harmful 
 both to the individual and to the race. 
 
 One would certainly be a pessimist of the 
 most profound type if he felt that tlie splendid 
 work of our profession along preventive medical 
 lines was a curse to the race by preserving the 
 lives of the slender or delicate physical type, 
 which Nature, in keeping with the law of the 
 survival of the fittest, would have thrown off, 
 or that the splendid work of the school and col- 
 
 5S 
 
lege is also harmful to the race by accentuating 
 qualities of weakness ; but such must be the fact, 
 unless something else is added to the mere sav- 
 ing of the lives and to the common system of 
 education as it exists today. If the physician 
 and the teacher recognize these facts and apply 
 the natural principles for the proper develop- 
 ment of these individuals, the result must be 
 inevitable — a stronger and finer race. 
 
 What higher incentive can there be for work 
 that that which benefits the individual and at 
 the same time by helping him gradually re- 
 moves the weaker elements, which if perpetu- 
 ated would surely lower the vitality of the race 
 as a whole ? The free will of choice with which 
 man is endowed and upon which his moral de- 
 velopment depends seems to find a similar re- 
 sponsibility in the development of a better and 
 Isetter creature along physical lines, and this 
 development, as is true with the other, follows 
 simple and understood laws. What greater in- 
 centive for one's best endeavor could a man de- 
 sire than to become conscious of the greatness 
 of this opportunity? In the moral choice man 
 is given great responsibility and in the physical 
 the responsibility is none the less great, unless 
 the development of the human family is to be 
 governed by the same law of survival of the fit- 
 test and natural selection which has governed 
 the development of the lower forms of life. That 
 man has for his future something better than 
 these laws would make possible, everyone must 
 feel who has thouglit at all beyond the needs of 
 the day, and in the hope of stimulating thought 
 and activities along these lines this contribu- 
 tion is presented. 
 
 59 
 
 ••• 
 
REFERENCES. 
 
 1 A Consideration of the Pelvic Articulations from an Anatomi- 
 cal, Pathological and Clinical Standpoint, iBostox Med. and Slug. 
 JouR.^ May 25, and June 1, 1905. The Pelvic Articulations, 
 ■four. A. M. A., Miii. 31, 1907, p. 768. A Consideration of the 
 Round or Stoop Shoulder Defomiity, Am. Jour. Orth. Surg., April, 
 1908. An Anatomic and Mechanical Study of the Shoulder .loint. 
 Explaining Many of the Cases of Painful Shoulder, Many of the 
 Heourrent Dislocations, and Many of the Cases of Brachial Neu- 
 ralgias or Neuritis, Am. Jour. Orth. Surg., May, 1909. The Rela- 
 tion of Posture to Human Efficiency and the Influence of J'oise 
 Upon the Support and Function of the Viscera, Am. Jour. Orth. 
 Surg., Feb., 1910, p. 371. The Cause of Gastroptosis and Entero- 
 ptosis, with Their Possible huportance as a Causative Factor in 
 the Rheumatoid Diseases, Boston Med. and Sdrg. Jour., May 26. 
 1910. The Lumbo-Sacral .\rticulatioii : .\n Explanation of Many 
 Cases of "Lumbago," "Sciatica," and Paraplegia, Bostox Med. 
 AXD SuRO. Join., March 16, 1911, p. 365. The Recognition of 
 Congenital Viscera! Ptosis in the Treatment of the badly Poised 
 and Poorly Nourished Oiild, .Im. Jour. Orth. Surg., Nov., 1911. 
 An Anatomic Explanation of Many of the Cases of Weak or Pain- 
 ful Backs, as well as Many of the Leg Paralyses, Boston' Med. 
 AND Siuci. JouR.j Jan. 23, 1913. 
 
 ^ Bryant, John: Stasis and Human Efficiency, International Ab- 
 stract of Surgery, May. 1914, p. 449. The Carnivorous and Her- 
 bivorous Types in Man, ,Bostox Med. and Sim;. Jour., March 4, 
 1915, p. 321. Poor Health in the Child, .Some Developmental 
 Influences and Their Importance to the Adidt, Bostox Med. and 
 Surg. Jour., May 21, 1914, p. 795. 
 
 ^ Smith, R. R. : A Study of Children with Reference to En- 
 teroptosis. Jour: .1. .1/. .1., Feb. 10. 1912, p. 385. Description of 
 Enteroptotic Woman., Surg., Gyn. and Obstct., Julv, 1913. 
 
 * Treves, F. : liritixh Med. Jour., 1885, Vol. 1, p. 414. Lancet. 
 October, 1888. 
 
 ^Werner: Biologisrhe Zentralbl., W'ien, 1894, xiv, p. 117. 
 
 " Bean, R. R. : Morbidity and Morphology, Johns Hopkins Bul- 
 letin, December, 1912. 
 
 ' Montessori : Pedagogical Anthropology. 
 
 ^ Swaini, L. T. : Thirty-nine Cases as Regards Intestinal Length 
 and Nutrition, Boston Med. and Surg. Jouh.. .\ug. 22, 1912. 
 
 ^ Graves, W. A. : The Clinical Recognition of the Scaphoid 
 Tvpe of Scapula and Some of its Correlations, Jour. A. M. A., 
 July 2, 1910, p. 12. 
 
 "Herz, M. : Therapie der Gegenwart, .Tunc, 1908, No. 6, p. 241. 
 
 '* Oodman, E. k. : Chronic Obstruction of the Duodenum by 
 the Root of the Mesentery, Boston Med. and Suro. Jour., April 
 16, 1908, p. 503. On the Importance of Distinguishing Simple 
 Round Ulcers of the Duodenum from those Ulcers which Involve 
 the Pvlorus or are Above it, Boston Med. and Surg. Jour., Sept. 
 2, 9, "16, 1909. 
 
 " Scholder and Weith: Archiv fiir Orthopiidie, Mechano therapie 
 und Unfallchirurgie, .xiii Bd., 2 Heft, 1914. 
 
 '* Fischl and E. Popper: Ix)rdotic Albuminuria Due to Me- 
 chanical Causes Plus Local and General Predisposition, Jahrbu-ch 
 fiir Kinderheilkunde, Belin, January, 1915. 
 
 '■'Howe: Transactions of the Fourth International Congress on 
 School Hygiene, Buffalo, August, 1913. 
 
 '' Connor: Proceedings of Ophthalmological Siction of A. .1/. A., 
 1907, p. 118. 
 
 '" Williams, John T. : Visceral Ptosis, A Review, Boston Med. 
 and Surg. Jour., Jan. 7, 1915, p. 37. 
 
 60 
 
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