Normal:
The All-Absorbing First Question

When you know the differences between the normal and abnormal structure you have learned the all-absorbing first question, that you must take your abnormal case back to normal, lay it down, and be satisfied to leave it. Never leave your case until you have obtained such results. Thus it is far better to familiarize your eye and your hand with the normal before you can approach the abnormal intelligently.
                                     
                        -- A. T. Still

The concept of “normal” permeates Osteopathic philosophy at nearly every level. The conscious and dedicated understanding of normal is essential to practicing Osteopathy in an effective way. The deep appreciation of normal is sentinel to the integrated practice of all healing systems.

How do we interpret Dr. Still’s enigmatic observations on the quantitative and qualitative aspects of normal? We can approach his concept of normal in two distinct, but related ways. The first approach identifies the quantitative aspect of normal and the second distinguishes an appreciation of the qualitative experiences of normal.

The quantitative interpretation of normal in an Osteopathic context involves measuring and sensing the anatomic, material, and mechanical characteristics. Dr. Still said, “An Osteopath reasons from his knowledge of anatomy. He compares the work of the abnormal body with the work of the normal body.”

Anatomy is inseparably linked to any understanding of normal. If we know the applied anatomy of the normal individual, then we can appreciate when abnormal, or disease, is presented to us. There are two ways to “know” normal. The first is to study anatomy (from dissection and from anatomic textbooks). The second is to examine hundreds, if not thousands of patients.

To understand the “normal” range of motion of, for example, the shoulder, we must examine hundreds of “so-called normal” shoulders in every age group. To appreciate the “normal” sounds of respiration, we must listen to hundreds of people’s breathing with our stethoscopes. To know what a normal tympanic membrane looks like, we must see hundreds of normal eardrums with our otoscopes. The list of potential normals that can be examined in our patients is extensive.

We cannot understand, appreciate, or know what gross abnormal, or especially the insidious abnormal is until we have an experience of what is normal in many individuals in a wide variety of situations. The inquisitive student and young Osteopath will dedicate him or herself to the early study of normal to become a reasonably functional physician. The experienced Osteopath will dedicate him or herself to a life-long study of normal in order to become proficient and accomplished.

We must also recognize that normal is variable. A normal exam differs depending upon the age and sex of the person. Also, individual variations must also be taken into account. A ballet dancer has an extra-ordinary range of motion that must be compared to her normal not the normal of a non-dancer. The normal pulmonary exam of an elderly individual with longstanding chronic obstructive pulmonary disease must be compared with his personal best, not with the pulmonary functions of an eighteen year-old athlete. Normal must be individualized and rendered unique based upon the idiosyncrasies of each person.

The qualitative interpretation of normal in an Osteopathic context involves “looking between the lines” of Dr. Still’s teachings. Dr. Still revealed, “Of course “normal” does not simply mean a readjustment of bones to a normal position . . .” and he said, “If health is perfect, it only proves perfect harmony in the physiologic action of the body in all its parts and functions. Any variation from perfect health marks a degree of functional derangement in the physiological department of man. Efforts at restoration from the diseased to the healthy condition should present but one object to the mind, and that is to explore minutely and seek variation from normal.”

Normal is not just interpreted from a material or mechanical perspective. Normal is also synonymous with Health. The normal body is perceptually analogous to the texture, or the field of Health. Variations from normal, or variations from Health, are defined Osteopathically as abnormal. What is abnormal is in a state of disease or dysfunction. Normal is harmony. Abnormal is disharmony. Harmony is Health or the healthy and balanced condition of the organism.

When Dr. Still said, “To find health should be the object of the doctor. Anyone can find disease”, he gave us the authority to orient Osteopathy toward Health rather than to base our profession exclusively upon disease identification. To find variations from normal and to take what is diseased to what is healthy or vice versa, to take what is healthy to what is diseased allows for the organism to reorganize by using it’s inherent therapeutic processes.

To intelligently identify abnormal, the Osteopath must know normal anatomy, be willing to explore the full spectrum of mechanical variability, and have the perceptual sophistication to experience the subtle textures of Health. In Osteopathy, the abnormal is not our reference point. For the Osteopath, normal is what we reference and utilize as a practical resource in treatment.

The “All-absorbing first question” is, what is normal? When that question is respected and explored, then our work as Osteopaths has a foundation based upon Health.

Steve Paulus, DO