Far otherwise, however, are the references I have heard to the manipulations of certain cheiropractors. "Torture" is by no means an uncommon expression to hear used. I never actually saw cheiropraxis in process of performance, and can only speak of experiences as narrated by patients. There seems to be a wide divergence of practice; but that of one school may, I imagine, be taken as typical. The patient is placed prone on two stools - one supports the chest, and the other the thighs. Vigorous percussion is then performed for ten minutes over that part of the back which is opposite the gap between the stools. Other cheiropractors add the second method of manipulation referred to above to their technique; while yet others seem to rely on this as the main remedial agent, and use the percussion as a sort of side-issue, for some reason which I have not been able to fathom. Still, in the background is the idea of "reducing a displacement," though how the plain percussion is supposed to effect this I do not know. A few patients have told me of the relief they had received in spite of what is almost universally regarded as, to say the least, this unpleasant treatment. Far more, however, reported failure to note improvement, while not a few were apparently rendered definitely worse.

It is hard to judge how many of those who appear to have received benefit recover in spite of, rather than because of, the treatment. I am inclined to think that, when sole reliance is placed on the percussion, the assistance received cannot be great, save in very exceptional circumstances. A certain number of patients will always recover as the result of any treatment, provided they have any faith in it. Others will, improve in spite of treatment, however deleterious we might reasonably expect it to be. Making due allowance for this number, cheiropraxis, which does not include manipulation, seemed to me to have done far more harm than good, while the manipulation of the spine in the prone position when dealing with the lower part, and in the sitting position when treating the upper, seems, on the whole, to be more unpleasant and to have less chance of conferring benefit than when the manipulation is performed in the manner first described.

Be these things as they may, this much is certain. There should be a place in treatment for manipulation and for belt-supports; and, until each remedial agent has been awarded its proper place, there will continue to exist a large amount of preventable suffering.

The use of a belt sometimes fails, sometimes relieves for a time, and yet, again, sometimes cures completely. When it cures, the only possible explanation is that the application of the belt has sufficed to relieve the spasm, and thereby has allowed the cause of the spasm - be it "displacement," "locking," or "strain" - to undergo spontaneous cure. Temporary relief, or permanent relief so long as the belt is worn, would be the result of relief of the spasm, which is not followed by spontaneous cure of the cause. It might be also due to relieving ligaments of undue "strain," which, in the absence of support, is the origin of the symptoms. A third alternative is that undue pressure between opposing surfaces has been relieved by support. This, of course, would particularly apply to the relief of those patients in whom the tilting of the sacrum has passed the normal limits, with the result that there is definite "strain" on the ligaments which connect the bone to the ilia and to the last lumbar vertebra. Failure, of course, can only mean that neither spasm nor "strain" has been relieved. Occasionally a belt increases the symptoms. This can only mean that its application either increases the tendency to "locking" or "displacement," and therefore increases the spasm; or it tends to add strain to the already overtaxed ligaments.

The same results follow manipulation. Spontaneous cure can only indicate relief of the "locking" or reduction of "displacement." Temporary relief would imply that the same occurs, but that the cause of the symptoms returns. Failure can only mean that the cause has not been remedied, and increase of symptoms that it has been aggravated. This might well happen if joints which are in a condition of acute inflammation, as, for instance, in acute osteo-arthritis, are manipulated. These reflections can be summarised as follows: - When symptoms appear to arise from some lesion connected with the lower part of the back: -

(i.) If there is any inflammation in the joints a belt should relieve, and, by enforcing a considerable degree of rest, should ultimately cure. Manipulation would augment the trouble.

(ii.) A case of strain would benefit by the use of a belt and not by manipulation.

(iii.) Mild cases of "locking" or "displacement" would probably do well with either treatment, though manipulation would be the more rational and scientific.

(iv.) Severe cases of this type would yield only to manipulation, and might well become worse with the application of a belt. After manipulation the use of a belt might act as a prophylactic measure.

X-ray examination should enable us to secure some help in forming a decision. Osteophytic outgrowths would indicate disease, and would caution us not to expect too much from manipulation, and, at the same time, would warn us to proceed with caution. The belt would then be our chief ally in securing relief; and, if it does not suffice, manipulation, cautiously administered, might be tried as an auxiliary.

If the articular processes seem to be of a different contour on the two sides of a lumbar vertebra, manipulation could be given a first trial. If relief followed, an early return of symptoms would indicate the prophylactic use of a belt. Otherwise, no further treatment is necessary.

If it is plain that the sacrum is unduly tilted backwards, a belt which secures it from any further tendency to backward rotation would probably prove efficacious rather than manipulation; if there is no undue tilting, there is no reason to suspect "strain" in the absence of injury, and manipulation seems to offer a better chance of relief.