Dutton’s Orthopaedic: Examination,

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TT
DUTTON’S ORTHOPAEDIC
EXAMINATION, EVALUATION,
AND INTERVENTION
 NOTICE
Medicine is an ever-changing science. As new research and clinical experience broaden
our knowledge, changes in treatment and drug therapy are required. T e authors and the
publisher o this work have checked with sources believed to be reliable in their e orts
to provide in ormation that is complete and generally in accord with the standards
accepted at the time o publication. However, in view o the possibility o human error
or changes in medical sciences, neither the authors nor the publisher nor any other party
who has been involved in the preparation or publication o this work warrants that the
in ormation contained herein is in every respect accurate or complete, and they disclaim
all responsibility or any errors or omissions or or the results obtained rom use o the
in ormation contained in this work. Readers are encouraged to con rm the in ormation
contained herein with other sources. For example and in particular, readers are advised
to check the product in ormation sheet included in the package o each drug they plan to
administer to be certain that the in ormation contained in this work is accurate and that
changes have not been made in the recommended dose or in the contraindications or
administration. T is recommendation is o particular importance in connection with new
or in requently used drugs.
 DUTTON’S ORTHOPAEDIC
EXAMINATION, EVALUATION,
AND INTERVENTION
FOURTH EDITION

Mark Dutton, PT
Allegheny General Hospital
West Penn Allegheny Health System (WPAHS)
Adjunct Clinical Instructor, Duquesne University
School of Health Sciences
Pittsburgh, Pennsylvania

New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney oronto
Dutton’s Orthopaedic Examination, Evaluation, and Intervention, Fourth Edition

Copyright © 2017 by McGraw-Hill Education. All rights reserved. Printed in China. Except as
permitted under the United States Copyright Act o 1976, no part o this publication may be
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system, without the prior written permission o the publisher.

Previous editions copyright © 2012, 2008, 2004 by he McGraw-Hill Companies, Inc.

1 2 3 4 5 6 7 8 9 DSS 21 20 19 18 17 16

ISBN 978-1-259-58310-0
MHID 1-259-58310-4

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he editors were Michael Weitz and Brian Kearns.
he production supervisor was Catherine Saggese.
Project management was provided by Amit Kashyap, Aptara, Inc.
RR Donnelley was the printer and binder.

Library of Congress Cataloging-in-Publication Data

Names: Dutton, Mark, author.

itle: Dutton’s orthopaedic examination, evaluation, and intervention / Mark
Dutton.
Other titles: Orthopaedic examination, evaluation, and intervention
Description: Fourth edition. | New York : McGraw-Hill Education, [2016] |
Preceded by Dutton’s orthopaedic examination, evaluation, and intervention
/ Mark Dutton. 3rd ed. c2012. | Includes bibliographical re erences and
index.
Identi iers: LCCN 2016011470 | ISBN 9781259583100 (hardcover) | ISBN
1259583104 (hardcover)
Subjects: | MESH: Orthopedics–methods | Physical Examination–methods |
Musculoskeletal Diseases–diagnosis | Orthopedic Procedures–methods
Classi ication: LCC RD734 | NLM WE 168 | DDC 616.7/075–dc23 LC record available at
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McGraw-Hill Education books are available at special quantity discounts to use as premiums and
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 For my parents,
Ron and Brenda, who have always helped, guided, and inspired me
and to my two daughters, Leah and Lauren, who provide me with such joy.
 Your Legacy

Will you have earned the respect o your peers and the admiration o your critics?
Will you have acted humbly during success and grace ully in the ace o adversity?
Will you be remembered or how o ten you brought smiles to the hearts o others?
Will you have looked or the very best, and done your utmost to build worth, in others?
Will you have le t this world a better place by the li e you have lived?

Modif ed rom The Legacy You Leave ©2000 by Rick Beneteau

 Contents

Pre ace ix
SECTION IV
Acknowledgments xi
Introduction xiii THE EXTREMITIES
16 The Shoulder 577
17 Elbow 711
SECTION I 18 The Forearm, Wrist, and Hand 779
ANATOMY 19 Hip 869
1 The Musculoskeletal System 3 20 The Knee 966
2 Tissue Behavior, Injury, Healing, and Treatment 29 21 Lower Leg, Ankle, and Foot 1081
3 The Nervous System 64

SECTION V
SECTION II THE SPINE AND TMJ
EXAMINATION AND EVALUATION 22 Vertebral Column 1191
4 Patient/Client Management 163 23 The Craniovertebral Region 1209
5 Dif erential Diagnosis 218 24 Vertebral Artery 1246
6 Gait and Posture Analysis 287 25 The Cervical Spine 1256
7 Imaging Studies in Orthopaedics 344 26 The Temporomandibular Joint 1340
27 The Thoracic Spine 1382
28 Lumbar Spine 1425
SECTION III 29 The Sacroiliac Joint 1529

INTERVENTION
8 The Intervention 369 SECTION VI
9 Pharmacology or the Orthopaedic
Physical Therapist 398 SPECIAL CONSIDERATIONS
10 Manual Techniques 417 30 Special Populations 1569
11 Neurodynamic Mobility and Mobilizations 445
12 Improving Muscle Per ormance 463 Index 1613
13 Improving Mobility 521
14 Improving Neuromuscular Control 557
15 Improving Cardiovascular Endurance 566

vii

T e ourth edition o this book is an update o in ormation
and bibliography provided in the previous versions together
with a reorganization o various chapters.
T e United States currently spends more money on
healthcare per person than any other country in the world,
with current projections indicating that 20% o the gross
domestic product o the United States will be spent on
healthcare by the year 2019.1 As the population continues
to age, the treatment o musculoskeletal conditions, and
their subsequent expenses, will also increase. T is will
place an increasing burden on the clinician to provide value
or money—the achievement o a health outcome relative
to the costs incurred. Gone are the days when a clinician
can rely on an expensive shotgun approach to treatment.
Instead, emphasis is now placed on outcomes such as patient
satis action and accurate measures o clinical outcomes, or
Comments about this book may be sent to me at pt@mcgraw-hill.com.
Pre ace
it is the consistent measurement and reporting o clinical
outcomes that is the most power ul tool in moving toward a
value-based system.2
o that end, the aim o this book is to provide the reader
with a systematic and evidence-based approach to the
examination and intervention o the orthopaedic patient.
Such an approach must be eclectic because no single method
works all o the time. T us, this book attempts to incorporate
the most reliable concepts currently available.
I hope that this book will be seen as the best available
textbook, guide, review, and re erence or healthcare students
and clinicians involved in the care o the orthopaedic
population.
Mark Dutton, P
ix

From inception to completion, the various editions span almost
12 years. Such an endeavor cannot be completed without the
help o many. I would like to take this opportunity to thank the
ollowing:
T e aculty o the North American Institute o Manual
and Manipulative T erapy (NAIOM )—especially, Jim
Meadows, Erl Pettman, Cli Fowler, Diane Lee, and the
late Dave Lamb.
T e exceptional team at McGraw-Hill, or their superb
guidance throughout this object. T ank you especially
to Michael Weitz or his advice and support and to other
members o the initial lineup. Special thanks also to Brian
Kearns.
Acknowledgments
o the production crew o Aptara, especially the project
manager Amit Kashyap.
Bob Davis or his creative eye and the excellent photography.
Leah or agreeing to be the photographic model.
T e sta o Human Motion Rehabilitation, Allegheny
General Hospital including roy Baxendell, Susan Berger,
Diane Ferianc, Leslie Fisher, Keith Galloway, Dave Hahn,
Dean Hnaras, John Karp, Ronald Klingensmith, Randi
Marshak, Dan McCool, Renee Nacy, Dan Norkiewicz,
Darcy Skrip, Jodi Weiher, Melissa Willis, and Joe Witt.
o the countless clinicians throughout the world who
continually strive to improve their knowledge and clinical
skills.
xi

“T e very f rst step towards success in any occupation is
to become interested in it.”
—Sir William Osler (1849–1919)
Until the beginning o the last century, knowledge about the
mechanism o healing and the methods to decrease pain and
su ering were extremely limited. Although we may sco at
many o the interventions used in the distant past, many o
the interventions we use today, albeit less radical, have still to
demonstrate much more in the way o e ectiveness. T at may
soon change with the recent emphasis within many healthcare
pro essions on evidence-based clinical practice. T e process
o evidence-based practice is outlined in Table I-1. When
combining clinical expertise with the best available external
clinical evidence, clinicians can make in ormed decisions
regarding patient management, including the selection and
interpretation o the most appropriate evaluation procedures.
Also, intervention strategies based on the best available
TABLE I-1 The Process of Evidence -Based Practice
1. Identi y the patient problem. Derive a specif c question.
2. Search the literature.
3. Appraise the literature.
4. Integrate the appraisal o literature with your clinical expertise,
experience, patient values, and unique circumstances.
5. Implement the f ndings.
6. Assess outcome and reappraise.
Data rom Sackett DL, Strauss SE, Richardson WS, et al. Evidence Based
Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh, Scotland:
Churchill Livingstone; 2000.
Introduction
evidence will have a greater likelihood o success with the
least associated risk.3,4
T e goal o every clinician should be to enhance patient/
client satis action, increase ef ciency, and decrease unproven
treatment approaches.4 T e management o the patient/client
is a complex process involving an intricate blend o experience,
knowledge, and interpersonal skills. Obtaining an accurate
diagnosis requires a systematic and logical approach. Such
an approach should be eclectic because no single method
works all o the time. For any intervention to be success ul,
an accurate diagnosis must be ollowed by a care ully planned
and speci c rehabilitation program to both the a ected area
and its related structures. In this book, great emphasis is placed
on the appropriate use o manual techniques and therapeutic
exercise based on these considerations. Electrotherapeutic
and thermal/cryotherapeutic modalities should be viewed
as adjuncts to the rehabilitative process. T e accompanying
DVD to this book contains numerous video clips o manual
techniques and therapeutic exercises, which the reader is
encouraged to view. T e ollowing icon is used throughout
the text to indicate when such clips are available. [VIDEO]
REFERENCES
1. Sisko AM, ru er CJ, Keehan SP, et al. National health spending
projections: the estimated impact o re orm through 2019. Health Af .
2010; 29:1933–1941.
2. Porter ME. What is value in health care? New Engl J Med. 2010; 363:2477–
2481.
3. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine:
what it is and what it isn’t. 1996. Clin Orthop Relat Res. 2007; 455:3–5.
4. Schroder JA. Manual therapy and neural mobilization: our approach and
personal observations. Orthop Pract. 2004; 16:23–27.
xiii
S EC TIO N I ANATOMY

C H AP TER 1 M s os
CHAPTER OBJECTIVES
At the completion of this cha pter,
the reader will be able to:
1. Describe the various types o biological tissue o the
musculoskeletal system.
2. Describe the tissue mechanics and structural di erences and
similarities between muscle, tendons, ascia, and ligaments.
3. Describe the di erent types o joints and their various
characteristics.
4. De ne the various terminologies used to describe the
joint position, movements, and relationships.
5. Give de nitions or commonly used biomechanical terms.
6. Describe the di erent planes o the body.
7. De ne the body’s center o mass and its location.
8. Describe the di erent axes o the body and the motions
that occur around them.
9. De ne the terms osteokinematic motion and
arthrokinematic motion.
10. Di erentiate between the di erent types o motion that
can occur at the joint sur aces.
11. Describe the basic biomechanics o joint motion in
terms o their concave–convex relationships.
12. De ne the terms close-packed and open-packed.
OVERVIEW
T e correct embryonic development o the musculoskeletal
system requires a coordinated morphogenesis o the un-
damental tissues o the body. T roughout the human body,
there are our major types o tissues:
Epithelial. Covers all internal and external body sur aces
and includes structures such as the skin and the inner
lining o the blood vessels.
T
ta
Syst m
Connective. Connective tissue (C ), which includes our
di erent classes: connective tissue proper, bone, cartilage,
and blood tissue. In the embryo, muscle tissue and its
ascia orm as a di erentiation o the paraxial mesoderm
that divides into somites on either side o the neural tube
and notochord. T e cartilage and bone o the vertebral
column and ribs develop rom the sclerotome which is the
anterior (ventral) part o the somite.1 T e dermomyotome,
which is the posterior (dorsal) part o the somite, gives
rise to the overlying dermis o the back and the skeletal
muscles o the body and limbs.1 Connective tissue
provides structural and metabolic support or other tissues
and organs o the body.
Muscle. Muscles are classi ed unctionally as either
voluntary or involuntary, and structurally as either
smooth, striated (skeletal), or cardiac. T ere are
approximately 430 skeletal muscles in the body, each o
which can be considered anatomically as a separate organ.
O these 430 muscles, about 75 pairs provide the majority
o body movements and postures.2
Nervous. Nervous tissue provides a two-way
communication system between the central nervous
system (brain and spinal cord) and muscles, sensory
organs, and various systems (see Chapter 3).
CONNECTIVE TISSUE
C proper has a loose, exible matrix, called ground substance.
T e most common cell within C proper is the broblast. Fi-
broblasts produce collagen, elastin, and reticular bers:
Collagen is a group o naturally occurring proteins. T e
collagens are a amily o extracellular matrix (ECM)
proteins that play a dominant role in maintaining
the structural integrity o various tissues and in
providing tensile strength to tissues. T e ECM is
ormed rom glycosaminoglycans (GAGs) subunits,
long polysaccharide chains containing amino sugars,
and are strongly hydrophilic to allow rapid di usion
o water-soluble molecules and easy migration o cells.
Proteoglycans, which are a major component o the ECM,
are macromolecules that consist o a protein backbone
3
 to which the GAGs are attached. T ere are two types
o GAGs: chondroitin sul ate and keratin sul ate.3,4 A
simple way to visualize the proteoglycan molecule is to
consider a test tube brush, with the stem representing the
protein core and the GAGs representing the bristles.5,6
Glycoproteins, another component o the ECM, consist o
bronectin and thrombospondin and unction as adhesive
structures or repair and regeneration.7
Elastic bers are composed o a protein called elastin. As
its name suggests, elastin provides elastic properties to the
tissues in which it is situated.8 Elastin bers can stretch,
A
but they normally return to their original shape when
N
the tension is released. T us, the elastic bers o elastin
A
T
determine the patterns o distention and recoil in most
O
organs, including the skin and lungs, blood vessels, and
M
Y
C . Bundles o collagen and elastin combine to orm a
matrix o C ascicles. T is matrix is organized within the
primary collagen bundles as well as between the bundles
that surround them.9
Reticular bers are composed o a type o collagen, which
is secreted by reticular cells. T ese bers crosslink to
orm a ne meshwork, called reticulin, which acts as a
supporting mesh in bone marrow, and the tissues and
organs o the lymphatic system, and the liver.
T e various characteristics o collagen di er depending
on whether it is loose or dense collagen. T e anatomic and
unctional characteristics o loose and dense collagen are
summarized in Table 1-1. Collagenous and elastic bers are
sparse and irregularly arranged in loose C but are tightly
packed in dense C .10
T e various types o C , as they relate to the musculoskeletal
system, are described as ollows:
Fascia
Fascia, or example, the thoracolumbar ascia and the plantar
ascia, is viewed as a loose C that provides support and protec-
tion to a joint, and acts as an interconnection between tendons,
aponeuroses, ligaments, capsules, nerves, and the intrinsic
components o muscle.11,12 Fascia may be categorized as brous
or non brous, with the brous components consisting mainly
o collagen and elastin bers, and the non brous portion con-
sisting o amorphous ground substance.13 T ree di erent types
o ascia have been identi ed, namely, super cial, deep, and vis-
ceral ascia. Various three-dimensional biomechanical models
o the human ascial system have been developed, which corre-
late dys unctional movement with various interrelated abnor-
mal amounts o tension throughout the network o ascia. In
TABLE 1-1 Loose and Dense Collagen
Joint Type Anatomic Location Fiber Orientation
Dense irregular connective Composes the external brous Parallel, tightly aligned bers Ligament: binds bones together and restrains
tissue layer o the joint capsule,
orms ligaments, bone,
aponeuroses, and tendons
Loose irregular connective Found in capsules, muscles, Random ber orientation
tissue nerves, ascia, and skin
4
particular, deep ascia has been implicated in being involved
with the deep venous return, in having a possible role in pro-
prioception, and responding to mechanical traction induced by
muscular activity in di erent regions.14 Histological studies o
deep ascia in the limbs show that it consists o elastic bers
and undulated collagen bers arranged in layers.15 Each colla-
gen layer is aligned in a di erent direction, and this permits a
certain degree o stretch as well as a capacity to recoil.16
Tendons
endons are dense, regularly arranged connective tissues,
composed o 70% water and 30% dry mass that attach mus-
cle to the bone at each end o the muscle. endons produce
joint motion by trans erring orce rom muscle to bone, and,
when stretched, store elastic energy that contributes to move-
ment. Also, tendons enable the muscle belly to be an optimal
distance rom the joint upon which it is acting. T e collagen
bers o tendons (70–80% o the collagen in tendons is type I,
with the remaining 20–30% o dry weight composed o pro-
teoglycans, GAGs, elastin, and other collagens—being type
III, V, and VII) are arranged in a quarter-stagger arrange-
ment, which gives it a characteristic banding pattern and pro-
vides high strength and stability.17 enoblasts, or immature
tendon cells, trans orm into tenocytes that synthesize colla-
gen and components o the ECM network.7 T e ECM sur-
rounds collagen and tenocytes and is composed o several
components or speci c unctions (e.g., glycoproteins, and
enascin-C, which may play a role in collagen ber orienta-
tion and alignment). endon structure is highly regular with
collagen- orming triple helices (tropocollagen), which pack
together to orm micro brils, which interdigitate to orm
brils, which coalesce to orm bers, which combine to orm
ascicles, which are bundled together to orm a tendon.18 T e
thickness o each tendon varies and is proportional to the size
o the muscle rom which it originates. Vascularity within the
tendon is relatively sparse and corresponds with the lower
metabolic/turnover rate o these tissues. Within the ascicles
o tendons, which are held together by loose C called endo-
tenon, the collagen components are oriented in a unidirec-
tional way. Endotenon contains blood vessels, lymphatics,
and nerves and permits longitudinal movements o individual
ascicles when tensile orces are applied to the structure. T e
C surrounding groups o ascicles, or the entire structure,
is called the epitenon. T e epitenon contains the vascular,
lymphatic, and nerve supplies to the tendon. A peritendinous
sheath (paratenon), which is composed o loose areolar con-
nective tissue in addition to sensory and autonomic nerve
bers, surrounds the entire tendon.19 T is sheath consists o
Mechanical Specialization
unwanted movement at the joints; resists
tension in several directions
Tendon: attaches muscle to bone
Provides structural support
two layers: an inner (visceral) layer and an outer (parietal)
layer with occasional connecting bridges (mesotenon). I
there is synovial uid between these two layers, the paratenon
is called tenosynovium; i not, it is termed tenovagium.9
endons are metabolically active and are provided with a
rich and vascular supply during development.20 endons receive
their vascular supply through the musculotendinous junction
(M J), the osteotendinous junction, and the vessels rom the
various surrounding tissues including the paratenon and meso-
tenon.18 endons in di erent areas o the body receive di erent
amounts o blood supply, and tendon vascularity can be com-
promised by the junctional zones and sites o riction, torsion, or
compression—a number o tendons are known to have reduced
tendon vascularity, including the supraspinatus, the biceps, the
Achilles, the patellar, and the posterior tibial tendon.18
T e mechanical properties o tendon come rom its highly
oriented structure. endons display viscoelastic mechanical
properties that con er time- and rate-dependent e ects on the
tissue. Speci cally, tendons are more elastic at lower strain rates
and sti er at higher rates o tensile loading (see Chapter 2).
endons de orm less than ligaments under an applied load and
are able to transmit the load rom muscle to bone.9 Material
and structural properties o the tendon increase rom birth
through maturity and then decrease rom maturity through
old age.18 Although tendons withstand strong tensile orces
well, they resist shear orces less well and provide little resis-
tance to a compression orce (see Chapter 2).
A tendon can be divided into three main sections:21
T e bone–tendon junction. At most tendon–bone
inter aces, the collagen bers insert directly into the
bone in a gradual transition o material composition. T e
physical junction o tendon and bone is re erred to as an
enthesis,22 and is an inter ace that is vulnerable to acute
and chronic injury.23 One role o the enthesis is to absorb
and distribute the stress concentration that occurs at the
junction over a broader area.
T e tendon midsubstance. Overuse tendon injuries can
occur in the midsubstance o the tendon, but not as
requently as at the enthesis.
M J. T e M J is the site where the muscle and tendon
meet. T e M J comprises numerous interdigitations
between muscle cells and tendon tissue, resembling
interlocked ngers. Despite its viscoelastic mechanical
characteristics, the M J is very vulnerable to tensile
ailure (see Chapter 2).24,25
Ligaments
Skeletal ligaments are brous bands o dense C that connect
bones across joints. Ligaments can be named or the bones
into which they insert (coracohumeral), their shape (deltoid
o the ankle), or their relationships to each other (cruciate).26
T e gross structure o a ligament varies according to location
(intra-articular or extra-articular, capsular), and unction.27
Ligaments, which appear as dense white bands or cords o
C , are composed primarily o water (approximately 66%),
and o collagen (largely type I collagen [85%], but with small
amounts o type III) making up most o the dry weight. T e
collagen in ligaments has a less unidirectional organization
than it does in tendons, but its structural ramework still pro-
vides sti ness (resistance to de ormation—see Chapter 2).28
Small amounts o elastin (1% o the dry weight) are present in
ligaments, with the exception o the ligamentum avum and
the nuchal ligament o the spine, which contain more. T e cel-
lular organization o ligaments makes them ideal or sustain-
ing tensile loads, with many containing unctional subunits
that are capable o tightening or loosening in di erent joint
positions.29 At the microscopic level, closely spaced collagen
bers ( ascicles) are aligned along the long axis o the liga-
ment and are arranged into a series o bundles that are delin-
eated by a cellular layer, the endoligament, and the entire liga-
T
h
ment is encased in a neurovascular biocellular layer re erred
e
to as the epiligament.26 Ligaments contribute to the stability
M
u
o joint unction by preventing excessive motion,30 acting as
S
guides or checkreins to direct motion, and providing proprio-
c
u
ceptive in ormation or joint unction through sensory nerve
l
O
endings (see Chapter 3) and the attachments o the ligament
S
to the joint capsule.31–33 Many ligaments share unctions. For
k
e
example, while the anterior cruciate ligament o the knee is
l
e
considered the primary restraint to anterior translation o the
T
A
tibia relative to the emur, the collateral ligaments and the pos-
l
terior capsule o the knee also help in this unction (see Chap-
S
Y
ter 20).26 T e vascular and nerve distribution to ligaments is
S
T
not homogeneous. For example, the middle o the ligament is
e
M
typically avascular, while the proximal and distal ends enjoy
a rich blood supply. Similarly, the insertional ends o the liga-
ments are more highly innervated than the midsubstance.
Cartilage
Cartilage tissue exists in three orms: hyaline, elastic, and
brocartilage.
Hyaline cartilage, also re erred to as articular cartilage,
covers the ends o long bones and permits almost
rictionless motion to occur between the articular sur aces
o a diarthrodial (synovial) joint.34 Articular cartilage
is a highly organized viscoelastic material composed o
cartilage cells called chondrocytes, water, and an ECM.
CLINICAL PEARL
Chondrocytes are specialized cells that are responsible or the
development o cartilage and the maintenance o the ECM.35
Chondrocytes produce aggrecan, link protein, and hyal-
uronan, all o which are extruded into the ECM, where they
aggregate spontaneously.4 The aggrecan orms a strong,
porous-permeable, ber-rein orced composite material with
collagen. The chondrocytes sense mechanical changes in
their surrounding matrix through intracytoplasmic laments
and short cilia on the sur ace o the cells.27
Articular cartilage, the most abundant cartilage within
the body, is devoid o any blood vessels, lymphatics, and
nerves.5,6 Most o the bones o the body orm rst as hya-
line cartilage, and later become bone in a process called
endochondral ossi cation. T e normal thickness o articu-
lar cartilage is determined by the contact pressures across
the joint—the higher the peak pressures, the thicker the 5
 cartilage.27 Articular cartilage unctions to distribute the
joint orces over a large contact area, thereby dissipating
the orces associated with the load. T is distribution o
orces allows the articular cartilage to remain healthy and
ully unctional throughout decades o li e. T e patellar has
the thickest articular cartilage in the body.
Articular cartilage may be grossly subdivided into our dis-
tinct zones with di ering cellular morphology, biomechani-
cal composition, collagen orientation, and structural proper-
ties, as ollows:
T e super cial zone. T e super cial zone, which lies
A
adjacent to the joint cavity, comprises approximately
N
10–20% o the articular cartilage thickness and
A
T
unctions to protect deeper layers rom shear stresses.
O
T e collagen bers within this zone are packed tightly
M
Y
and aligned parallel to the articular sur ace. T is zone
is in contact with the synovial uid and handles most o
the tensile properties o cartilage.
T e middle (transitional) zone. In the middle zone,
which provides an anatomic and unctional bridge
between the super cial and deep zones, the collagen
bril orientation is obliquely organized. T is zone
comprises 40–60% o the total cartilage volume.
Functionally, the middle zone is the rst line o
resistance to compressive orces.
T e deep or radial layer. T e deep layer comprises 30%
o the matrix volume. It is characterized by radially
aligned collagen bers that are perpendicular to the
sur ace o the joint, and which have a high proteoglycan
content. Functionally the deep zone is responsible or
providing the greatest resistance to compressive orces.
T e tidemark. T e tidemark distinguishes the deep
zone rom the calci ed cartilage, the area that prevents
the di usion o nutrients rom the bone tissue into the
cartilage.
Elastic (yellow) cartilage is a very specialized C ,
primarily ound in locations such as the outer ear, and
portions o the larynx.
Fibrocartilage, also re erred to as white cartilage,
unctions as a shock absorber in both weight-bearing
and nonweight-bearing joints. Its large iber content,
rein orced with numerous collagen ibers, makes
it ideal or bearing large stresses in all directions.
Fibrocartilage is an avascular, alymphatic, and
aneural tissue and derives its nutrition by a double-
di usion system.36 Examples o ibrocartilage include
the symphysis pubis, the intervertebral disk, and the
menisci o the knee.
Bone
Bone is a highly vascular orm o C , composed o collagen,
calcium phosphate, water, amorphous proteins, and cells. It
is the most rigid o the C s (Table 1-2). Despite its rigidity,
bone is a dynamic tissue that undergoes constant metabolism
and remodeling. T e collagen o bone is produced in the same
manner as that o ligament and tendon but by a di erent cell,
the osteoblast.10 At the gross anatomical level, each bone has a
distinct morphology comprising both cortical bone and can-
cellous bone. Cortical bone is ound in the outer shell. Can-
cellous bone is ound within the epiphyseal and metaphyseal
regions o long bones, as well as throughout the interior o
short bones.24 Skeletal development occurs in one o the two
ways:
Intramembranous ossi cation. Mesenchymal stem cells
within mesenchyme or the medullary cavity o a bone
initiate the process o intramembranous ossi cation. T is
type o ossi cation occurs in the cranium and acial bones
and, in part, the ribs, clavicle, and mandible.

TABLE 1-2 General Structure of Bone

Site Comment Conditions Result
Epiphysis Mainly develops under pressure Epiphyseal dysplasias Distorted joints
Apophysis orms under traction Joint sur ace trauma Degenerative changes
Forms bone ends Overuse injury Fragmented development
Supports articular sur ace Damaged blood supply Avascular necrosis

Physis Epiphyseal or growth plate Physeal dysplasia Short stature

Responsive to growth and sex hormones Trauma De ormed or angulated
Vulnerable prior to growth spurt Slipped epiphysis growth or growth arrest
Mechanically weak

Metaphysis Remodeling expanded bone end Osteomyelitis Sequestrum ormation

Cancellous bone heals rapidly Tumors Altered bone shape
Vulnerable to osteomyelitis Metaphyseal dysplasia Distorted growth
A ords ligament attachment

Diaphysis Forms sha t o bone Fractures Able to remodel angulation

Large sur ace or muscle origin Diaphyseal dysplasias Cannot remodel rotation
Signi cant compact cortical bone Healing slower than at metaphysis Involucrum with in ection
Strong in compression Dysplasia gives altered density and shape
Data rom Reid DC. Sports Injury Assessment and Rehabilitation. New York, NY: Churchill Livingstone; 1992.
6
 Endochondral ossi cation. T e rst site o ossi cation
occurs in the primary center o ossi cation, which is in
the middle o the diaphysis (sha ). About the time o
birth, a secondary ossi cation center appears in each
epiphysis (end) o long bones. Between the bone ormed
by the primary and secondary ossi cation centers,
cartilage persists as the epiphyseal (growth) plates
between the diaphysis and the epiphysis o a long bone.
T is type o ossi cation occurs in the appendicular and
axial bones.
T e periosteum is ormed when the perichondrium,
which surrounds the cartilage, becomes the periosteum.
Chondrocytes in the primary center o ossi cation begin
to grow (hypertrophy) and begin secreting alkaline phos-
phatase, an enzyme essential or mineral deposition. Cal-
ci cation o the matrix ollows, and apoptosis (a type o
cell death involving a programmed sequence o events
that eliminates certain cells) o the hypertrophic chon-
drocytes occurs. T is creates cavities within the bone. T e
exact mechanism o chondrocyte hypertrophy and apopto-
sis is currently unknown. T e hypertrophic chondrocytes
(be ore apoptosis) also secrete a substance called vascular
endothelial cell growth actor that induces the sprouting o
blood vessels rom the perichondrium. Blood vessels orm-
ing the periosteal bud invade the cavity le by the chondro-
cytes, and branch in opposite directions along the length
o the sha . T e blood vessels carry osteoprogenitor cells
and hemopoietic cells inside the cavity, the latter o which
later orm the bone marrow. Osteoblasts, di erentiated
rom the osteoprogenitor cells that enter the cavity via the
periosteal bud, use the calci ed matrix as a sca old and
begin to secrete osteoid, which orms the bone trabecula.
Osteoclasts, ormed rom macrophages, break down the
spongy bone to orm the medullary cavity (bone marrow).
T e unction o bone is to provide support, enhance lever-
age, protect vital structures, provide attachments or both
tendons and ligaments, and store minerals, particularly
calcium. From a clinical perspective, bones may serve as
use ul landmarks during the palpation phase o the exami-
nation. T e strength o bone is related directly to its density.
O importance to the clinician, is the di erence between
maturing bone and mature bone. T e epiphyseal plate or
growth plate o a maturing bone can be divided into our
distinct zones:37
Reserve zone: produces and stores matrix.
Proli erative zone: produces matrix and is the site or
longitudinal bone cell growth.
Hypertrophic zone: subdivided into the maturation
zone, degenerative zone, and the zone o provisional
calci ication. It is within the hypertrophic zone that
the matrix is prepared or calci ication and is here
that the matrix is ultimately calci ied. he hypertrophic
zone is the most susceptible o the zones to injury
because o the low volume o bone matrix and the
high amounts o developing immature cells in this
region.38
Bone metaphysis: the part o the bone that grows during
childhood.
Skeletal Muscle Tissue
T e microstructure and composition o skeletal muscle have
been studied extensively. T e class o tissue labeled skeletal
muscle consists o individual muscle cells or bers that work
together to produce the movement o bony levers. A single
muscle cell is called a muscle ber or myo ber. As muscle
cells di erentiate within the mesoderm, individual myo -
bers are wrapped in a C envelope called endomysium. Bun-
dles o myo bers, which orm a whole muscle ( asciculus),
are encased in the perimysium (Fig. 1-1). T e perimysium
is continuous with the deep ascia. T is relationship allows
T
the ascia to unite all o the bers o a single motor unit and,
h
e
there ore, adapt to variations in orm and volume o each
M
muscle according to muscular contraction and intramuscular
u
S
modi cations induced by joint movement.15 Groups o ascic-
c
uli are surrounded by a connective sheath called the epimy-
u
l
sium (Fig. 1-1). Under an electron microscope, it can be seen
O
S
that each o the myo bers consists o thousands o myo brils
k
e
(Fig. 1-1), which extend throughout its length. Myo brils are
l
composed o sarcomeres arranged in series.39
e
T
A
l
S
CLINICAL PEARL
Y
S
T
The sarcomere (Fig. 1 2) is the contractile machinery o
e
M
the muscle. The graded contractions o a whole muscle
occur because the number o bers participating in the
contraction varies. Increasing the orce o movement is
achieved by recruiting more cells into cooperative action.
All skeletal muscles exhibit our characteristics:40
1. Excitability, the ability to respond to stimulation rom the
nervous system.
2. Elasticity, the ability to change in length or stretch.
3. Extensibility, the ability to shorten and return to normal
length.
4. Contractility, the ability to shorten and contract in
response to some neural command. T e tension developed
in skeletal muscle can occur passively (stretch) or actively
(contraction). When an activated muscle develops tension,
the amount o tension present is constant throughout the
length o the muscle, in the tendons, and at the sites o the
musculotendinous attachments to the bone. T e tensile
orce produced by the muscle pulls on the attached bones
and creates torque at the joints crossed by the muscle. T e
magnitude o the tensile orce is dependent on a number
o actors.
One o the most important roles o C is to transmit
mechanically the orces generated by the skeletal muscle cells
to provide movement. Each o the myo brils contains many
bers called myo laments, which run parallel to the myo bril
axis. T e myo laments are made up o two di erent proteins:
actin (thin myo laments) and myosin (thick myo laments)
that give skeletal muscle bers their striated (striped) appear-
ance (Fig. 1-2).39
T e striations are produced by alternating dark (A) and
light (I) bands that appear to span the width o the muscle
ber. T e A bands are composed o myosin laments, whereas 7
 adduction and abduction o the arm or thigh; and
pronation and supination o the orearm usually occur
in the transverse plane around the vertical axis. Rotary
motions involve the curved movement o a segment
around a xed axis, or center o rotation (COR). When a
curved movement occurs around an axis that is not xed,
but instead shi s in space as the object moves, the axis
around which the segment appears to move is re erred to
as the instantaneous axis o rotation or instantaneous COR
(see Moment Arm).
Arm circling and trunk circling are examples o
circumduction. Circumduction involves an orderly
sequence o circular movements that occur in the sagittal,
rontal, and intermediate oblique planes, so that the
segment as a whole incorporates a combination o exion,
extension, abduction, and adduction. Circumduction
movements can occur at biaxial and triaxial joints.
Examples o these joints include the tibio emoral,
radiohumeral, hip, glenohumeral, and the spinal joints.
Both the con guration o a joint and the line o pull o the
muscle acting at a joint determine the motion that occurs at
a joint:
A muscle whose line o pull is lateral to the joint is a
potential abductor.
A muscle whose line o pull is medial to the joint is a
potential adductor.
A muscle whose line o pull is anterior to a joint has
the potential to extend or ex the joint. At the knee,
an anterior line o pull may cause the knee to extend,
whereas, at the elbow joint, an anterior line o pull may
cause exion o the elbow.
A muscle whose line o pull is posterior to the joint has
the potential to extend or ex a joint (re er to preceding
example).
Center of Gravity
Every object or segment can be considered to have a single
COG, or COM—the point at which all the mass o the object
or segment appears to be concentrated. In a symmetrical
object, the COG is always located in the geometric center o
the object. However, in an asymmetrical object such as the
human body, the COG becomes the point at which the line
o gravity balances the object. T e line o gravity can best be
visualized as a string with the weight on the end (a plumb-
line), with a string attached to the COG o an object.108 I the
human body is considered as a rigid object, the COG o the
body lies approximately anterior to the second sacral verte-
bra (S2). Since the human body is not rigid, an individual’s
COG continues to change with movement with the amount
o change in the location depending on how disproportion-
ately the segments are rearranged.108 During static standing,
the body’s line o gravity is between the individual’s eet (base
o support). T e BOS includes the part o the body in con-
tact with the supporting sur ace and the intervening area.109
I an individual bends orward at the waist, the line o gravity
moves outside o the BOS. T e size o the BOS and its rela-
tion to the COG are important actors in the maintenance o
balance and, thus, the stability o an object. T e COG must
be maintained over the BOS i an equilibrium is to be main-
tained. I the BOS o an object is large, the line o gravity is
less likely to be displaced outside the BOS, which makes the
object more stable.108
Degrees of Freedom
T e number o independent modes o motion at a joint is
re erred to as the available degrees o reedom (DOF). A joint
can have up to 3 degrees o angular reedom, corresponding
to the three dimensions o space.110 I a joint can swing in one
T
h
direction or can only spin, it is said to have 1 DOF.111–114 T e
e
proximal interphalangeal joint is an example o a joint with
M
u
1 DOF. I a joint can spin and swing in one way only, or it
S
can swing in two completely distinct ways, but not spin, it
c
u
is said to have 2 DOF.111–114 T e tibio emoral joint, temporo-
l
O
mandibular joint, proximal and distal radioulnar joints, sub-
S
talar joint, and talocalcaneal joint are examples o joints with
k
e
2 DOF. I the bone can spin and also swing in two distinct
l
e
directions, then it is said to have 3 DOF.111–114 Ball-and-socket
T
A
joints, such as the shoulder and hip, have 3 DOF.
l
S
Y
S
CLINICAL PEARL
T
e
M
Joint motion that occurs only in one plane is designated
as 1 DOF; in two planes, 2 DOF; and in three planes, 3 DOF.
Because o the arrangement o the articulating sur aces—
the surrounding ligaments and joint capsules—most motions
around a joint do not occur in straight planes or along
straight lines. Instead, the bones at any joint move through
space in curved paths. T is can best be illustrated using Cod-
man’s paradox.
1. Stand with your arms by your side, palms acing inward,
thumbs extended. Notice that the thumb is pointing or-
ward.
2. Flex one arm to 90 degrees at the shoulder so that the
thumb is pointing up.
3. From this position, horizontally extend your arm so that
the thumb remains pointing up, but your arm is in a posi-
tion o 90 degrees o glenohumeral abduction.
4. From this position, without rotating your arm, return the
arm to your side and note that your thumb is now pointing
away rom your thigh.
Re erring to the start position, and using the thumb as
the re erence, the arm has undergone an external rotation
o 90 degrees. But where and when did the rotation take
place? Undoubtedly, it occurred during the three separate,
straight-plane motions or swings that etched a triangle in
space. What you have just witnessed is an example o a con-
junct rotation—a rotation that occurs as a result o joint sur-
ace shapes—and the e ect o inert tissues rather than con-
tractile tissues. Conjunct rotations can only occur in joints
that can rotate internally or externally. Although not always
apparent, most joints can so rotate. Consider the motions o
elbow exion and extension. While ully exing and extend-
ing your elbow a ew times, watch the pisi orm bone and 19
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CHAPTER I.
 HEALTH.

[Contents]

A.—LESSONS OF INSTINCT.

Nature has guarded the health of her creatures by a marvelous

system of protective intuitions. The sensitive membrane of the eye
resents the intrusion of every foreign substance. An intuitive sense of
discomfort announces every injurious extreme of temperature. To the
unperverted taste of animals in a state of nature wholesome food is
pleasant, injurious substances repulsive or insipid. Captain Kane
found that only the rage of famine will tempt the foxes of the Arctic
coastlands to touch spoiled meat. In times of scarcity the baboons of
the Abyssinian mountains greedily hunt for edible roots, which an
unerring faculty enables them to distinguish from the poisonous
varieties. The naturalist Tschudi mentions a troop of half-tamed
chamois forcing their way through a shingle roof, rather than pass a
night in the stifling atmosphere of a goat stable.

Man in his primitive state had his full share of those protective
instincts, which still manifest themselves in children and Nature-
guided savages. It is a mistake to suppose that the lowest of those
savages [19]are naturally fond of ardent spirits. The travelers Park,
Gerstaecker, Vambery, Kohl, De Tocqueville, and Brehm agree that
the first step on the road to ruin is always taken in deference to the
example of the admired superior race, if not in compliance with direct
persuasion. The negroes of the Senegal highlands shuddered at the
first taste of alcohol, but from a wish to conciliate the good will of
their visitors hesitated to decline their invitations, which
subsequently, indeed, became rather superfluous. The children of
the wilderness unhesitatingly prefer the hardships of a winter camp
to the atmospheric poisons of our tenement houses. Shamyl Ben
Haddin, the Circassian war chief, whose iron constitution had
endured the vicissitudes of thirty-four campaigns, pathetically
protested against the pest air of his Russian prison cell, and warned
his jailers that, unless his dormitory was changed, Heaven would
hold them responsible for the guilt of his suicide. I have known
country boys to step out into a shower of rain and sleet to escape
from the contaminated atmosphere of a city workshop, and after a
week’s work in a spinning mill return to the penury of their mountain
homes, rather than purchase dainties at the expense of their lungs.

The word frugality, in its original sense, referred literally to a diet of

tree fruits, in distinction to carnivorous fare, and nine out of ten
children still decidedly prefer ripe fruit and farinaceous dishes to the
richest meats. They as certainly prefer easy, home-made clothes to
the constraint of fashionable fripperies. The main tenets of our dress-
reformers are [20]anticipated in the sensible garments of many half-
civilized nations. Boys, within reach of a free bathing river, can
dispense with the advice of the hydropathic school. They delight in
exercise; they laugh at the imaginary danger of fresh-air draughts,
and the perils of barefoot rambles in wet and dry. They would cast
their vote in favor of the outdoor pursuit of hundreds of occupations
which custom, rather than necessity, now associates with the
disadvantages of indoor confinement. The hygienic influence of
arboreal vegetation has been recognized by the ablest pathologists
of modern times; avenues of shade trees have been found to
redeem the sanitary condition of many a grimy city, and the eminent
hygienist, Schrodt, holds that, as a remedial institution, a shady park
is worth a dozen drug stores. But all these lessons only confirm an
often manifested, and too often suppressed, instinct of our young
children: their passionate love of woodland sports, their love of tree
shade, of greenwood camps, of forest life in all its forms. Those who
hold that “nature” is but a synonym of “habit” should witness the
rapture of city children at first sight of forest glades and shady
meadow brooks, and compare it with the city dread of the Swiss
peasant lad or the American backwoods boy, sickened by the fumes
and the uproar of a large manufacturing town. A thousands years of
vice and abnormal habits have not yet silenced the voice of the
physical conscience that recalls our steps to the path of Nature, and
will not permit us to transgress her laws unwarned. [21]

[Contents]

B.—REWARDS OF CONFORMITY.

The reward of nature-abiding habits is not confined to the negative

advantage of escaping the discomforts of disease. In the pursuit of
countless competitive avocations the Art of Survival is a chief secret
of success, but in this age of sanitary abuses our lives are mostly
half-told tales. Our season ends before the trees of hope have time
to ripen their fruit; before their day’s work is done our toilers are
overtaken by the shadows of approaching night. Sanitary reforms
would undoubtedly lengthen our average term of life, and an
increase of longevity alone would solve the most vexing riddles of
existence: the apparent injustice of fate, the disproportion of merit
and compensation, the aimlessness, the illusive promises and
baffled hopes of life. For millions of our fellow-men an increase of
health and longevity would suffice to make life decidedly worth living.
Health lessens the temptations to many vices. Perfect health blesses
its possessor with a spontaneous cheerfulness almost proof against
the frowns of fortune and the cares of poverty. With a meal of barley
cakes and milk, a straw couch, and scant clothing of homespun
linen, a shepherd-boy in the highlands of the Austrian Alps may
enjoy existence to a degree that exuberates in frolic and jubilant
shouts, while all the resources of wealth cannot recall the sunshine
which sickness has banished from the life of the dyspeptic glutton. If
happiness could be computed by measure and weight, it would be
found that her richest treasures are not stored in gilded walls, but
[22]in the homes of frugal thrift, of rustic vigor and nature-loving
independence. The sweetness of health reflects itself in grace of
form and deportment, and wins friends where the elegance of
studied manners gains only admirers. Health is also a primary
condition of that clearness of mind the absence of which can be only
partially compensated by the light of learning. Health is the basis of
mental as of bodily vigor; country-bred boys have again and again
carried off the prizes of academical honors from the pupils of refined
cities, and the foremost reformers of all ages and countries have
been men of the people; low-born, but not the less well-born, sons of
hardy rustics and mechanics, from Moses, Socrates, Epictetus,
Jesus Ben Josef, and Mohammed, to Luther, Rousseau, Thomas
Paine, and Abraham Lincoln.

[Contents]

C.—PERVERSION.

Habitual sin against the health-laws of Nature was originally chiefly a

consequence of untoward circumstances. Slaves, paupers,
immigrants to the inhospitable climes of the higher latitudes, were
forced to adopt abnormal modes of life which, in the course of time,
hardened into habits. Man, like all the varieties of his four-handed
relatives, is a native of the tropics, and the diet of our earliest
manlike ancestors was, in all probability, frugal: tree-fruits, berries,
nuts, roots, and edible herbs and gums. But the first colonists of the
winter lands were obliged to eke out an existence by eating the flesh
of their fellow-creatures, and a carnivorous diet thus became the
[23]habitual and, in many countries, almost the exclusive diet of the
nomadic inhabitants.

Alcohol is a product of fermentation, and the avarice of a cruel

master may have forced his slaves to quench their thirst with
fermented must or hydromel till habit begot a baneful second nature,
and the at first reluctant victims of intoxication learned to prefer
spoiled to fresh grape-juice. Sedentary occupations, however
distasteful at first, are apt to engender a sluggish aversion to
physical exercise, and even habitual confinement in a vitiated
atmosphere may at last become a second nature, characterized by a
morbid dread of fresh air. The slaves of the Roman landowners had
to pass their nights in prison-like dungeons, and may have
contracted the first germ of that mental disease known as the night-
air superstition, the idea, namely, that after dark the vitiated
atmosphere of a stifling dormitory is preferable to the balm of the
cooling night wind.

In modern times an unprecedented concurrence of circumstances

has stimulated a feverish haste in the pursuit of wealth, and thus
indirectly led to the neglect of personal hygiene. The abolition of the
public festivals by which the potentates of the pagan empires
compensated their subjects for the loss of political freedom, the
heartless egotism of our wealthy Pharisees, venal justice, and the
dire bondage of city life all help to stimulate a headlong race toward
the goal of the promised land of ease and independence—a goal
reached only by a favored few compared with the multitudes who
daily drop down wayworn and exhausted. [24]
But the deadliest blow to the cause of health was struck by the anti-
natural fanaticism of the Middle Ages, the world-hating infatuation of
the maniacs who depreciated every secular blessing as a curse in
disguise, and despised their own bodies as they despised nature,
life, and earth. The disciples of the world-renouncing messiah
actually welcomed disease as a sign of divine favor, they gloried in
decrepitude and deformity, and promoted the work of degeneration
with a persevering zeal never exceeded by the enlightened
benefactors of the human race. For a period of fifteen hundred years
the ecclesiastic history of Europe is the history of a systematic war
against the interests of the human body; the “mortification of the
flesh” was enjoined as a cardinal duty of a true believer; health-
giving recreations were suppressed, while health-destroying vices
were encouraged by the example of the clergy; domestic hygiene
was utterly neglected, and the founders of some twenty-four different
monastic orders vied in the invention of new penances and
systematic outrages upon the health of the poor convent-slaves.
Their diet was confined to the coarsest and often most loathsome
food; they were subjected to weekly bleedings, to profitless
hardships and deprivations; their sleep was broken night after night;
fasting was carried to a length which often avenged itself in
permanent insanity; and their only compensation for a daily repetition
of health-destroying afflictions was the permission to indulge in
spiritual vagaries and spirituous poisons: the same bigots who
grudged their followers a night of unbroken rest or a mouthful of
[25]digestible food indulged them in quantities of alcoholic beverages
that would have staggered the conscience of a modern beer-swiller.

The bodily health of a community was held so utterly below the

attention of a Christian magistrate that every large city became a
hotbed of contagious diseases; small-pox and scrofula became
pandemic disorders; the pestilence of the Black Death ravaged
Europe from end to end—nay, instead of trying to remove the cause
of the evil, the wretched victims were advised to seek relief in prayer
and self-torture, and a philosopher uttering a word of protest against
such illusions would have risked to have his tongue torn out by the
roots and his body consigned to the flames of the stake.

Mankind has never wholly recovered from that reign of insanity.

Indifference to many of the plainest health-laws of nature is still the
reproach of our so-called civilization. Our moralists rant about the
golden streets of the New Jerusalem, but find no time to expurgate
the slums of their own cities; our missionary societies spend millions
to acquaint the natives of distant islands with the ceremony of
baptism, but refuse to contribute a penny to the establishment of free
public baths for the benefit of their poor neighbors, whose children
are scourged or caged like wild beasts for trying to mitigate the
martyrdom of the midsummer season by a bath in the waters of the
next river. Temperance, indeed, is preached in the name of the
miracle-monger who turned water into alcohol; but millions of toilers
who seek to drown their misery in the Lethe of intoxication are
[26]deprived of every healthier pastime; the magistrates of our
wealthy cities rage with penal ordinances against the abettors of
public amusements on the day when nine-tenths of our laborers find
their only leisure for recreation. Poor factory children who would
spend the holidays in the paradise of the green hills are lured into
the baited trap of a Sabbath-school and bribed to memorize the stale
twaddle of Hebrew ghost-stories or the records of fictitious
genealogies; but the offer to enlarge the educational sphere of our
public schools by the introduction of a health primer would be
scornfully rejected as an attempt to divert the attention of the pupils
from more important topics.
[Contents]

D.—PENALTIES OF NEGLECT.

But the laws of Nature cannot be outraged with impunity, and the aid
of supernatural agencies has never yet protected our ghost-mongers
from the consequences of their sins against the monitions of their
physical conscience. The neglect of cleanliness avenges itself in
diseases which no prayer can avert; during the most filthful and
prayerful period of the Middle Ages, seven out of ten city-dwellers
were subject to scrofula of that especially malignant form that attacks
the glands and the arteries as well as the skin. Medical nostrums
and clerical hocus-pocus of the ordinary sort were, indeed, so
notoriously unavailing against that virulent affection that thousands
of sufferers took long journeys to try the efficacy of a king’s touch, as
recorded by the unanimous testimony of contemporary writers, as
well as in the still [27]current term of a sovereign remedy. A long foot-
journey, with its opportunities for physical exercise, outdoor camps,
and changes of diet, often really effected the desired result; but, on
their return to their reeking hovels, the convalescents experienced a
speedy relapse, and had either to repeat the wearisome journey or
resign themselves to the “mysterious dispensation” of a Providence
which obstinately refused to let miracles interfere with the normal
operation of the physiological laws recorded in the protests of
instinct. Stench, nausea, and sick-headaches might, indeed, have
enforced those protests upon the attention of the sufferers; but the
disciples of Antinaturalism had been taught to mistrust the
promptings of their natural desires, and to accept discomforts as
signs of divine favor, or, in extreme cases, to trust their abatement to
the intercession of the saints, rather than to the profane interference
of secular science.
The dungeon-life of the monastic maniacs, and the abject
submission to the nuisance of atmospheric impurities, avenged
themselves in the ravages of pulmonary consumption; the votaries of
dungeon-smells were taught the value of fresh air by the tortures of
an affliction from which only the removal of the cause could deliver a
victim, and millions of orthodox citizens died scores of years before
the attainment of a life-term which a seemingly inscrutable
dispensation of Heaven grants to the unbelieving savages of the
wilderness. The cheapest of all remedies, fresh air, surrounded them
in immeasurable abundance, craving admission and offering them
the [28]aid which Nature grants even to the lowliest of her creatures,
but a son of a miracle-working church had no concern with such
things, and was enjoined to rely on the efficacy of mystic
ceremonies: “If any man is sick among you, let him call for the elders
of the church, and let them pray over him, anointing him with oil in
the name of the Lord.” “And the prayer of faith shall cure the sick,
and the Lord shall raise him up.”

Thousands of the fatuous bigots who prayed for “meekness of spirit”

continued to gorge themselves with the food of carnivorous animals,
and thus inflamed their passions with the sanguinary, remorseless
propensities of those brutes. Luigi Cornaro, the Italian reformer,
assures us that it was no uncommon thing for a nobleman or prelate
of his century to swallow fourteen pounds of strong meats at a single
meal, and that, after invoking the blessing of Heaven upon such a
repast, the devourer of meat-pies would rise with his paunch
distended “like the hide of a drowned dog.” The “Love of Enemies,”
“forgiveness and meekness,” were on their lips; but those fourteen
pounds of meat-pie worked out their normal result; and among the
carnivorous saints of that age we accordingly find men whose
fiendish inhumanity would have appalled the roughest legionary of
pagan Rome. Cæsar Borgia, the son of a highest ecclesiastic
dignitary, a disciple of a priestly training-school, and himself a prince
of the church, seems to have combined the stealthy cunning of a
viper with the bloodthirst of a hyena. Four times he made and broke
the most solemn treaties, [29]in order to get an opportunity to invade
the territory of an unprepared neighbor. His campaigns were
conducted with a truculence denounced even by his own allies; with
his own hand he poisoned fourteen of his boon companions, in order
to possess himself of their property; twenty-three of his political and
clerical rivals were removed by the dagger of hired assassins or
executed upon the testimony of suborned perjurers. He tried to
poison his brother-in-law, Prince Alphonso of Aragon, in order to
facilitate his design of seducing his own sister; he made repeated,
and at last partly successful, attempts to poison the brother of his
mother and his own father, the pope.

The heartless neglect of sanitary provisions for the comfort of the

poor avenges itself in epidemics that visit the abodes of wealth as
well as the hovels of misery. A stall-fed preacher of our southern
seaport towns may circulate a petition for the suppression of Sunday
excursions, in order to prevent the recreation-needing toilers of his
community from leaving town on St. Collection Day; he may
advocate the arrest of bathing schoolboys, in order to suppress an
undue love of physical enjoyments, or to gratify a female tithe-payer
who seeks an opportunity of displaying her prudish virtue at the
expense of the helpless; he may vote to suppress outdoor sports in
the cool of the late evening, when the inhabitants of the tenement
streets are trying to enjoy an hour of extra Sabbatarian recreation—a
privilege to be reserved for the saints who can rest six days out of
seven, and on the seventh harvest the fruits of other men’s labor. But
epidemics refuse to recognize such distinctions, [30]and the vomit of
yellow fever will force the most reverend monopolist to disgorge the
proceeds of the tithes coined from the misery of consumptive factory
children. Nor can wealth purchase immunity from the natural
consequences of habitual vice. The dyspeptic glutton is a Tantalus
who starves in the midst of abundance. The worn-out tradesman,
whose restless toil in the mines of mammon has led to asthma or
consumption, would vainly offer to barter half his gold for half a year
of health. Thousands of families who deny themselves every
recreation, who linger out the summer in the sweltering city, and toil
and save “for the sake of our dear children,” have received Nature’s
verdict on the wisdom of their course in the premature death of those
children.

[Contents]

E.—REDEMPTION.

It has often been said that the physical regeneration of the human
race could be achieved without the aid of a miracle, if its systematic
pursuit were followed with half the zeal which our stock-breeders
bestow upon the rearing of their cows and horses. A general
observance of the most clearly recognized laws of health would,
indeed, abundantly suffice for that purpose. There is, for instance, no
doubt that the morbid tendency of our indoor modes of occupation
could be counteracted by gymnastics, and the trustees of our
education fund should build a gymnasium near every town school.
As a condition of health, pure air is as essential as pure water and
food, and no house-owner should be permitted to sow [31]the seeds
of deadly diseases by crowding his tenants into the back rooms of
unaired and unairable slum-prisons. New cities should be projected
on the plan of concentric rings of cottage suburbs (interspersed with
parks and gardens), instead of successive strata of tenement flats.
In every large town all friends of humanity should unite for the
enforcement of Sunday freedom, and spare no pains to brand the
Sabbath bigots as enemies of the human race. We should found
Sunday gardens, where our toil-worn fellow-citizens could enjoy their
holidays with outdoor sports and outdoor dances, free museums,
temperance drinks, healthy refreshments, collections of botanical
and zoölogical curiosities. Country excursions on the only leisure day
of the laboring classes should be as free as air and sunshine, and
every civilized community should have a Recreation League for the
promotion of that purpose.

In the second century of our chronological era the cities of the

Roman empire vied in the establishment of free public baths. Antioch
alone had fourteen of them; Alexandria not less than twelve, and
Rome itself at least twenty, some of them of such magnificence and
extent that their foundations have withstood the ravages of sixteen
centuries. Many of those establishments were entirely free, and even
the Thermæ, or luxurious Warm Baths, of Caracalla admitted visitors
for a gate-fee which all but the poorest could afford. Our boasted
civilization will have to follow such examples before it can begin to
deserve its name; and even the free circus games [32](by no means
confined to the combats of armed prize-fighters) were preferable to
the fanatical suppression of all popular sports which made the age of
Puritanism the dreariest period of that dismal era known as the
Reign of the Cross.

The preservation of health is at least not less important than the

preservation of Hebrew mythology; and communities who force their
children to sacrifice a large portion of their time to the study of Asiatic
miracle legends might well permit them to devote an occasional hour
or two to the study of modern physiology. We should have health
primers and teachers of hygiene, and the most primitive district
school should find time for a few weekly lessons in the rudiments of
sanitary science, such as the importance of ventilation, the best
modes of exercise, the proper quality and quantity of our daily food,
the significance of the stimulant habit, the use and abuse of dress,
etc.

Such text-books would prepare the way for health lectures, for health
legislation and the reform of municipal hygiene. The untruth that “a
man can not be defiled by things entering him from without” has
been thoroughly exploded by the lessons of science, and should no
longer excuse the neglect of that frugality which in the times of the
pagan republics formed the best safeguard of national vigor. Milk,
bread, and fruit, instead of greasy viands, alcohol, and narcotic
drinks, would soon modify the mortality statistics of our large cities,
and we should not hesitate to recognize the truth that the remarkable
[33]longevity of the Jews and Mohammedans has a great deal to do
with their dread of impure food.

[Contents]
CHAPTER II.
 STRENGTH.

[Contents]

A.—LESSONS OF INSTINCT.

Bodily vigor is the basis of mental and physical health. Strength is

power, and the instinctive love of invigorating exercise manifests
itself in the young of all but the lowest brutes. The bigot who
undermines the health of his children by stinting their outdoor sport
as “worldly vanity,” and “exercise that profiteth but little,” is shamed
by animals who lead their young in races and trials of strength. Thus
the female fox will train her cubs; the doe will race and romp with her
fawn, the mare with her colt. Monkeys (like the squirrels of our
northern forests) can be seen running up and down a tree and
leaping from branch to branch, without any conceivable purpose but
the enjoyment of the exercise itself; dogs run races, young lions
wrestle and paw each other in a playful trial of prowess; even birds
can be seen sporting in the air, and dolphins on the play-fields of the
ocean. In nearly all classes of the vertebrate animals the rivalry of
the males is decided by a trial of strength, and the female
unhesitatingly accepts the victor as the fittest representative of his
species.

Normal children are passionately fond of athletic sports. In western

Yucatan I saw Indian girls climb [34]trees with the agility of a spider-
monkey, and laughingly pelt each other with the fruits of the
Adansonia fig. The children of the South-sea Islanders vie in aquatic
gymnastics. Spartan girls joined in the foot-races of their brothers,
and by the laws of Lycurgus were not permitted to marry till they had
attained a prescribed degree of proficiency in a number of athletic
exercises. Race-running and wrestling were the favorite pastimes of
young Romans in the undegenerate age of the republic; and, in spite
of all restraints, similar propensities still manifest themselves in our
school-boys. They pass the intervals of their study-hours in
competitive athletics, rather than in listless inactivity, and brave frosts
and snowstorms to get the benefit of outdoor exercise even in
midwinter. They love health-giving sports for their own sake, as if
instinctively aware that bodily strength will further every victory in the
arena of life.

The enthusiasm that gathered about the heroic games of Olympia

made those festivals the brightest days in the springtime of the
human race. The million-voiced cheers that hailed the victor of the
pentathlon have never been heard again on earth since the manliest
and noblest of all recreations were suppressed by order of a
crowned bigot. The rapture of competitive athletics is a bond which
can obliterate the rancor of all baser rivalries, and still unites hostile
tribes in the arena of pure manhood: as in Algiers, where the
Bedouins joined in the gymnastic prize-games of their French
foemen: the same foemen whose banquets they would have refused
to share even at the bidding of starvation. In Buda-Pesth I once
[35]witnessed a performance of the German athlete Weitzel, and still
remember the irrepressible enthusiasm of two broad-shouldered
Turks who crowded to the edge of the platform, and, with waving
kerchiefs, joined in the cheers of the uncircumcised spectators.

[Contents]

B.—REWARDS OF CONFORMITY.
The “survival of the fittest” means, in many important respects, the
survival of the strongest. In a state of nature weakly animals yield to
their stronger rivals; the stoutest lion, the swiftest tiger, has a
superior chance of obtaining prey; the stouter bulls of the herd defy
the attack of the wolves who overcome the resistance of the weaker
individuals; the fleetest deer has the best chance to escape the
pursuit of the hunter.

A state of civilization does only apparently equalize such differences.

The invention of gunpowder has armed the weak with the power of a
giant; but the issue of international wars will always be biased by the
comparative strength of sinew and steadiness of nerve of the men
that handle those improved weapons. In the last Franco-Prussian
war the French were favored by an undoubted superiority of arms,
but they were utterly beaten by a nation whose sons had devoted
their youth to gymnastics. The arms of the Gothic giants were of the
rudest description: hunting-spears and clumsy battle-axes; but those
axes broke the ranks of the Roman legionaries, with their polished
swords and elaborate tactics. For the last two thousand years the
wars [36]that decided the international rivalries of Asia, Europe, and
North America nearly always ended with the victory of a northern
nation over its southern neighbors. The men of the north could not
always boast a superiority in science or arms, nor in number, nor in
the advantage of a popular cause; but the rigor of their climate
exacts a valiant effort in the struggle for existence, and steels the
nerves even of an otherwise inferior race. “Fortis Fortuna adjuvat,”
said a Roman proverb, which means literally that Fortune favors the
strong, and which has been well rendered in the paraphrase of a
modern translator: “Force begets fortitude and conquers fortune.”
Nor is that bias of fate confined to the battles of war. In the contests
of peace, too, other things being equal, the strong arm will prevail
against the weak, the stout heart against the faint. Bodily strength
begets self-reliance. “Blest are the strong, for they shall possess the
kingdom of the earth,” would be an improved variation of the gospel
text. The Germanic nations (including the Scandinavian and Anglo-
Saxon) who have most faithfully preserved the once universal love of
manly sports, have prevailed against their rivals in the arena of
industry and science, as well as of war.

An American manufacturer, who established a branch of his

business at Havre, France, hired American and British workmen at
double wages, maintaining that he found it the cheapest plan, since
one of his expensive laborers could do the work of three natives. In
the seaport towns, even of South America and Southern Europe, a
British sailor [37]is always at a premium. American industry is steadily
forcing its way further south, and may yet come to limit the fields of
its enterprise only by the boundaries of the American continent. From
the smallest beginnings, a nation of iron-fisted rustics has repeatedly
risen to supremacy in arms and arts. Two hundred years before the
era of Norman conquests in France, Italy, and Great Britain, the
natives of Norway were but a race of hardy hunters and fishermen. A
century after the battle of Xeres de la Frontera, the half-savage
followers of Musa and Tarik had founded high schools of science and
industry. And, as the fairest flower springs from the hardy thorn, the
brightest flowers of art and poetry have immortalized the lands of
heroic freemen, rather than of languid dreamers. The same nation
that carried the banners of freedom through the battle-storm of
Marathon and Salamis, adorned its temples with the sculptures of
Phidias and its literature with the masterpieces of Sophocles and
Simonides.

Physical vigor is also the best guarantee of longevity. Nature

exempts the children of the south from many cares; yet in the stern
climes of the higher latitudes Health seems to make her favorite
home; in spite of snowstorms and bitter frosts the robust
Scandinavian outlives the languid Italian. In spite of a rigorous
climate, I say, for that his length of life is the reward of hardy habits is
proved by the not less remarkable longevity of the hardy Arab and
the manful Circassian, in climes that differ from that of Norway as
Mexico and Virginia differ from Labrador. Men of steeled sinews
overcome disease [38]as they brave the perils of wars and the
hardships of the wilderness; hospital-surgeons know how readily the
semi-savages of a primitive borderland recover from injuries that
would send the effeminate city-dweller to the land of the shades.
Toil-hardened laborers, too, share such immunities. On the 25th of
March, 1887, Thomas McGuire, the foreman of a number of laborers
employed at the night-shift of the Croton Aqueduct, fell to the bottom
of the pit, a distance of ninety-five feet, and was drawn up in a
comatose condition, literally drenched in his own blood. At the
Bellevue Hospital (city of New York) the examining surgeon found
him still alive, but gave him up for lost when he ascertained the
extent of his injuries. Both his arms were broken near the shoulder,
both thighs were fractured, his skull was horribly shattered about the
left temple and frontal region, six of his ribs were broken and their
splinters driven into the lungs. There seemed no hope whatever for
him, and, after the administration of an anesthetic, he was put in a
cot and left alone to die. To the utter surprise of the attending
surgeon, the next morning found the mass of broken bones still
breathing. His fever subsided; he survived a series of desperate
operations, survived an apparently fatal hemorrhage, and continued
to improve from day to day, till about the middle of June he
recovered his complete consciousness, and was able to sit up and
answer the questions of the medical men who, in ever increasing
numbers, had visited his bedside for the last three weeks. As a
newspaper correspondent sums up his case: “His strong constitution
had [39]repulsed the assaults of death, till finally the grim monster
went away to seek a less obstinate victim.” And, moreover, the
exercise of athletic sports lessens the danger of such accidents: a