Clinical Illustration. - As an illustration of the value of objective in preference to subjective symptoms, the following case is of considerable value.  The gentleman whose physical condition is practically illustrated in Figs. 20 and 21 was examined in the clinic of the Pacific College of Osteopathy.  He has been operated on surgically for a peculiar enlargement just above and external to the right knee . The line of the incision is shown, in Fig. 20.  He stated that he had suffered pain at this point during more than a year, and his physician had decided that there was a tuberculous condition of the bone.  The operation did not confirm this diagnosis.  No unhealthy tissue was found.

    Inspection. - We noted his peculiar handling of the leg when walking, compared both limbs from toe to hip and discovered a marked difference in size, as is indicated in the photograph.  By following the course of the nerves to the spinal column, we discovered that the muscles on the right side of the spine are atrophied in proportion to those of the extremity.  Fig. 21 shows the fact that the atrophied condition extends into the interscapular region, and the spinal column is bent.

    Patellar Tendon Reflex. - The patellar tendon reflex was lost on the right side, but present on the left.  The right leg was ataxic, but the left leg was normal, thus presenting what might be called a unilateral locomotor ataxia.  If this man's surgeon had taken the care to examine him from an objective structural standpoint rather than to depend on the subjective symptoms, it is highly probable that no operation would have been performed.  Our examination demonstrated that this man's structural condition was at fault and that the trophic influence of a part of his nervous system was being gradually lost.  Both the motor and sensory nerves were acting feebly.

    Gastric-spinal Reflex. - It might be asked, "How could one secure a spinal reflex from the stomach?" In what way would the finding of such a reflex surpass ordinary methods of examination?  The neurologist, when making examination of a patient suffering with some condition of the sensory or motor portion of the nervous system, must possess a definite knowledge of the origin, course and distribution of nerve trunks in order to locate accurately the position of the lesion.  The osteopath pursues the same method of examination, but follows it farther.  His investigation takes into consideration the dispersion of efferent fibers in the sympathetic system and the sensory impulses received by the spinal cord from that system.

    Sensation. - Edinger quotes Exner as follows: "One must not suppose that all the impulses reaching the spinal cord by the sensory roots are identical with what is ordinarily called 'sensation.' In order that an impression be perceived, it is not sufficient that it be conducted to the spinal cord, but it must be farther carried up, from the place where the peripheral part ends to the cerebral cortex.  There is, however, no doubt at all that all these higher connections are few in number, and that contrasted with the multitude of fibers in the posterior roots, the number of such cranial connections is quite small.  This alone makes the conclusion possible that there are, indeed, many sensory impressions which arrive at the spinal cord, but that we are aware of but few of them at the time.  All the viscera of the body, as the staining method has distinctly shown, are traversed by an altogether unexpectedly large number of nerves and their arrangement and course, their relations to blood vessels and glands, and to muscle fibers, bones and enamel, makes it more than probable that there is, in this connection, a large system which serves essentially to regulate impressions and reflex action."

    Visceral Sensation. - It is the reflexes mentioned in this quotation in which we are interested.  Sensation and perception are dissimilar.  Sensations from the viscera are co-ordinated in fairly well marked areas of the spinal cord and when these sensory impressions are intense the efferent fibers of the spinal cord manifest the condition existing in a visceral area by causing an abnormal condition of muscular tone in the intrinsic muscles of the back.  This contractured condition of the muscles is not the only evidence of the visceral reflex.  Pressure on the contracted muscle causes pain.  The intensity of the aesthesia is usually in proportion to the visceral irritation.  Even though the patient does not say in so many words that there is pain on slight pressure, the examiner, if his palpation is good, can detect the reflex in the action of the muscle.

    Dependence on Objective Symptoms. - A patient comes to an osteopath desiring to be examined.  He does not vouch-safe any information as to his condition, merely saying: "I want you to examine me and find out what is the matter with me." This is a challenge to the skill of the examiner and calls for something besides a long-distance catechising as to subjective feelings.  The osteopath proceeds with absolute precision to determine the condition of his patient's structural formation - (1) skeletal alignment, (2) muscular tone, and (3) segmental spinal reflex.  Each yields valuable information.  The examiner's fingers may develop a reflex around the sixth dorsal spine.  This is noted as a reflex from the gastric area.  Testing the segments above and below, this will show how great a section of the cord is irritated and will be an indication of the extent of the internal irritation, i.e., whether other portions of the digestive tract are affected.  The reflex might extend as far as the fourth dorsal and still indicate the gastric area.  Finding the reflex at the sixth dorsal spine has directed the attention of the examiner to the gastric area and has located a point from which further examination is to proceed.  Percussion over the stomach would reveal other facts, and then the examination would be pursued along general lines of physical diagnosis to determine the character of the gastric disorder.  The moment the examiner centers his examination on the stomach, the confidence of the patient is assured.  Is not this confidence greatly to be desired in every case?  Is it not a force which compels the patient to follow the directions of his physician in matters of diet and hygiene?  In this example we have illustrated the attributes of nerve tissue, (1) irritability, (2) conductivity.  Other conditions which make this illustration possible are (1) muscular contraction in response to nerve stimulation, (2) segmentation of the spinal cord, (3) reflex action.

    Depth and Extent of Lesions. - From the clinical standpoint lesions may be classified somewhat according to depth and extent; for example, the lesions which are due to trauma of somatic tissues, involving one spinal articulation, would be deep and as soon as the patient is placed in a position of rest, the extent of the muscular contraction would greatly decrease.  This is not the case when the lesion is due to a visceral irritation.  The viscus has a pluri-segmental connection with the nervous system and hence the contraction of muscles in the spinal area is usually of greater extent.  The position of rest, i.e., reclining, does not usually cause the muscles to relax.  This shows that the contraction is not a normal effort to maintain the upright position but a hyper-tension due to visceral disturbance.

    Lesion Picture in Autotoxemia. - As soon as we have an autotoxemia to deal with our lesion picture is greatly enlarged.  This is well illustrated in the various manifestations of indigestion.  In such cases, not only lesions in the areas segmentally associated, but also above and below, will be found.  Some cases will complain of the whole length of the spine while the autointoxication is at its height.  As the intensity of the autointoxication decreases the lesion areas become restricted to the physiologically associated spinal areas.  This is true in the infections as well.  The backache in tonsilitis, la grippe, smallpox, etc., are well known and evidently not located in physiologically associated areas.  The phenomena of spinal hypertension and hyperaesthesia are very prominent in these cases.  Nothing seems to palliate this spinal condition due to toxemia to the same extent as manipulation.  We say palliate because the toxemia which causes the tension is not overcome by relieving the spinal tension.

    Lesions Independent of Segmental Reflexes. - As soon as we find lesions that seem to have arisen independently of what we can readily recognize as segmental reflexes, they must be explained on the basis of some integration of the body other than nervous.  This is the case in the toxemias.  The circulating media are the integrating factors which explain the backache as well as many other aches in those cases where there is no visceral involvement which may reasonably be associated with them.  Increasing elimination will usually correct these spinal lesions due to toxemia.

    The Lesion as an Expression of Some Form of Integration. - Any spinal lesion may be analyzed from several standpoints, because it may be a partial expression of one or more integrating factors of the body, i.e., the structural, circulatory or nervous.  The traumatic lesion shows itself subject to position, i.e., can be rested and lessened by a position which mechanically lessens the strain.  The lesion due to nervous integration is not so quickly relieved by the means which relieve the traumatic lesion.  The fact that it is a reflex presupposes an adequate point of irritation elsewhere.  This point must be located before the lesion is adequately relieved.  This is well illustrated in the reflexes in the mid-dorsal area due to fermenting food in the stomach.  Emptying the stomach relieves the lesion.

    Circulatory Integration Lesion. - The lesion due to circulatory integration is hard to recognize because one naturally thinks of the other forms of integration and attempts to square his findings with these forces.  Then also the circulatory integration is largely under the direct influence of the nervous system.  It is a good plan to analyze lesions first on a basis of structural integration, then nervous and finally circulatory.  This evolutionary method of following a natural plan helps to keep ones mind working in a logical manner.

    Protective Reactions. - The protective reactions of the body are not all segmental nor even within small groups of segments.  So long as they are purely segmental we are reasonably certain that the condition is not constitutional because a constitutional ailment involves the whole fighting power of the body to such an extent that the clinician readily recognizes the seriousness of the situation.  Take for instance the progressive involvement of lung tissue in tuberculosis.  The early stages of the disease may show very little or no constitutional symptoms such as chill, fever, sweat and loss of flesh.  At this time somewhere in the interscapular area will appear a lesion, muscular contraction and tenderness to digital pressure.  This lesion is not distinctive of pulmonary tuberculosis any more than of any other irritation in its associated visceral area.  It merely indicates the segment or segments involved in the circulatory disturbance characterized by the congestion in the infected area.  As the pulmonary lesion involves larger areas the spinal lesion grows proportionately.  This is probably true except when the pleura is inflamed.  Then we have a protective rigidity of a vastly more pronounced character.  As soon as effusion takes place the intensity of the rigidity lessens because pain is lessened.  As soon as the tubercular process shows constitutional symptoms the spinal lesion picture varies from morning to night, that is, fluctuates with the varying intensity of the disease reactions.  The positive and negative phases of the body's reactions are reflexly evidenced in the spinal areas.  As the disease progresses and areas of pulmonary tissues are lost or fibrous tissue formed, with consequent lessening in antero-posterior diameter of the chest and decreased amplitude of the respiratory movements, lesions of a structural character appear in the spinal area, such as flattening of the dorsal curve and elevation of the angles of the ribs caused by the rotation downward of the anterior extremities of the ribs in the flattening of the chest.  The change in the chest causes a change in the tension of the scaleni muscles in the neck and in case only one pulmonary apex is involved there is unequal tension in the scaleni of the two sides of the neck, thus causing the extensors of the neck to exert a compensatory action.  The change in cervical vertebral alignment and muscular tension constitutes in this instance a spinal lesion which is properly compensatory and therefore not helped by corrective movements.  Many such lesions, profoundly compensatory in character, should receive no direct corrective manipulation.  Since they are dependent upon tissue involvement elsewhere we must make our diagnosis from cause to effect in order to get our therapeutics in right sequence.

    Pains Incident to Chill and Fever. - The headache, neckache, backache and legache of chill and fever are subjective symptoms prominent in a host of cases.  These symptoms are of varying intensity but even when not complained of, a tenderness in the neck and back is readily elicited by digital pressure.  As the fever subsides these areas of sensitiveness to pressure grow less and less, showing that their great extent in the beginning is a constitutional condition.  It is readily recognized that our spinal lesion in pulmonary tuberculosis has changed with each phase of the disease.  This is probably true of all diseases, hence there is no fixed lesion associated with any visceral or somatic disease.  A slightly varying set of reactions accompanies each disease process.  These reactions are usually true to type but not capable of classification except in a general way.  The organs of the body are innervated from fairly definite areas of the cord and we speak of these as nerve centers, but as before stated these centers consist of cells placed vertically and extending through several segments.  The spinal lesions found in visceral disease are hence pleuri-segmental and, if there is toxemia, there is a set of lesions expressive of this condition superimposed on the first, then, in case of destruction of tissue, compensatory changes in structure are noticeable.  The three major forms of integration are involved in any severe illness and hence the diagnostician must try to separate the various evidences of the body's protective reactions.  The greater variation will be in those symptoms due to circulatory integration.  This is evidenced by the rapid changes in cases of autointoxication.  The lesion which is characterized by its, persistence will be located in that seg-ment or segments most closely allied with the center of visceral disturbance.  The lesion of still more permanence will be the primarily traumatic or secondarily compensatory.

    The Practical Use of Knowledge. - We have added nothing new to the world's knowledge of nerve tissue, but we have applied general knowledge of this tissue to specific uses.  We have taken the results of laboratory experiments and made them practical methods in the detection and alleviation of disease.  It appears to us that sufficient research work has been done on the nervous system by medical men and sufficient general conclusions drawn from their investigations to justify all branches of the profession in making more extensive use of such data.  The correlaion of laboratory data with the results of clinical experience make the foundation of osteopathic diagnosis at the present time.  By this bold application of knowledge, which by the medical profession at large has been regarded as speculative and at least impracticable, osteopathy has gained an impregnable position in the healing arts.

    Laboratories make scientists, not physicians; hence physicians have not always grasped the full significance of the scientific discoveries in physiology and applied them to therapeutics.

    Whatever osteopathy may at present possess or gain in the future, is due solely to a close adherence to the facts of anatomy and physiology; and the application of these fundamental facts to scientific therapeutics.