Passing on to the consideration of the therapeutic measures employed for the relief of symptoms, it would not seem improbable that these tend to confirm the view here suggested tentatively. The relief of pain that sometimes follows the application of a belt is rapid, and corresponds exactly to the relief experienced by a patient, who has sustained fracture, as the muscular spasm subsides. The spasm, according to this view, would be protective, and would owe its origin to a reflex attempt to secure the patient against any movement which would tend further to tighten the "locking." Similarly, relief of the spasm would tend to "release" the "locking" spontaneously, provided it were not too firm.

The relief which follows manipulation is sometimes so rapid as to be instantaneous, and follows an audible "click" - dear to the heart of the bone-setter. But, to the medical man, the method of manipulation is of deep interest. In one school of osteopathy - as I should judge from my limited experience, unquestionably the best - the manipulation (speaking quite generally) aims at securing rotatory movement for relief in the lumbar region, and antero-posterior movement in the thoracic.

The following is a brief description of the manipulation practised in this school of osteopathy. The patient sits on a stool with the hands resting on the lap. Careful inspection may reveal inequality in contour of the two sides, and even exaggeration of the usual curves of the spine. The dimples in the region of the posterior superior spines of the ilia may be of unequal depth. The muscles of the back are then examined minutely to detect any difference in resilience. If resistance to palpation is increased at any spot, it is held to indicate that some of the muscular elements beneath the fingers are in a state of undue contraction or spasm. It is needless to mention that the variations to be noted are often very minute, as only some of the deeper muscles are affected in slight cases. I am quite prepared, therefore, to admit the claim made by many who practise osteopathy treatment - one is a well-known surgeon - that considerable skill is required to detect the differences which must be noted during palpation. Deeper palpation follows, and is performed with the object of detecting the presence of any painful spots. Firm palpation of a muscle which has been in spasm for any length of time is always painful to a greater or less degree, according to the severity of the spasm and its duration. The mobility of the spine is then noted during every conceivable variety of trunk movement. Any limitation is duly noted. One curious fact was demonstrated to me. If a movement was limited in any direction at some particular point, or if pain was felt at this point (even though no definite limitation of movement could be detected), the skin in this neighbourhood can often be seen to have flushed as a result of the previous palpation. This, to me, most unexpected demonstration seems to lend credence to the theory that "locking" or "displacement" has some definite effect on the sympathetic system.

Manipulation of the spine has, as its objective, a pushing towards the sensitive - perhaps it is well not to call it the "painful" - area, the tip of the spinous process nearest to the point of maximum sensitiveness. To effect this in the lumbar or sacro-iliac regions, the hands are folded on the back of the neck and the trunk is then swung round, as it were, the axis of a cone, the apex being situated at the tip of the coccyx. As soon as the patient submits to the movement (which is counterclockwise for a right-sided sensitiveness and clockwise for a left-sided) without definite opposition, pressure on the spinous process of the vertebra which is supposed to be at fault is made vigorously during that part of the swing of the trunk which is best calculated to assist the movement desired. In the thoracic region the patient sits on the stool, and the practitioner's knee, guarded by a pillow, is placed against the offending bone. He then passes his hands under the patient's axillae and clasps them behind the nape of the neck. The latter is then rolled rapidly forwards and downwards, while the whole trunk is drawn back forcibly on to the practitioner's knee, which effects a strong counter-pressure. In the cervical region the patient is placed recumbent, with his head and shoulders over the edge of the couch. The head is then grasped for examination and manipulation by the fingers of both hands, one on each side of the occiput, and by the thumbs just behind the angles of the jaw. It is surprising - I had almost written terrifying - at first to discover the enormous extent of the range of movement possible in this position. Lateral pressure is exerted with the finger-tips on the spinous process that is supposed to be at fault at some one point of the general mobilisation. The idea, of course, is to catch the muscles which are in spasm as far as possible off their guard.

The practice varies, though the objectives of all spinal treatment appear to be similar. Some try to "push the spinous process" of the offending vertebra "into place" by more direct and primitive means. In these schools the patient is placed prone for manipulation of any part of the back, except the cervical, and for treatment of this region the sitting posi-ion is chosen. The patient is then encouraged to relax - an impossible proposition in the latter instance. Having "secured relaxation," a sudden and sharp pressure is administered in the desired direction, perhaps with the tip of the thumb, with the ball of the thumb, or even with the knuckles of the clenched fist. Patients were practically unanimous in declaring that the former method of manipulation described above is practically painless - even when it is accompanied by the loud "click of reduction." This alternative method, however, is variously described; though only once, I believe, did I hear it referred to as "extremely painful."