Osteopathy - No Physiology !
What is the story behind this quote of A.T. Still and does it reflect today's situation?
MORE THAN JUST AN ANECDOTE
I remember hearing a quote of A.T. Still: “No Physiology”. But lacking a reference, I always considered the possibility that it might be a questionable anecdote. Questionable because in his book “Philosophy of Osteopathy” page 16-19, A.T. Still describes what he means by anatomy. And at the bottom of page 17, unmistakably, he mentions physiology as “a knowledge of which no Osteopath can do without and be a success”. So apparently, this quote about physiology must be some urban legend that lives its own life. However, one fine day, Carol Trowbridge mentions this specific quote in her book “Andrew Taylor Still: 1828-1917”. She even gives the reference to it and clearly sketches the context of Still’s words.
In chapter “6-The old Doctor”, Trowbridge mentions under the subtitle “The littlejohns” that physiology began to push anatomy into a corner. J.Martin preferred a broader based osteopathy, founded on physiology rather than anatomy (Trowbridge, page 174). Trowbridge describes that Still became “irritated” by the Littlejohn-Smith influence (1899) that clearly led to a change of concept within the osteopathic education. Still noted publicly that he was not agreeing at all and even closed on several occasions the school to argue with the staff over the compatibility of medical diagnosis and osteopathy. It is in this context that at a certain moment Still stormed into a classroom and furiously wrote on the blackboard: “no physiology” (Trowbridge, page 176).
HISTORY KNOCKING LOUD AT OUR DOOR (again)
February 2023, I wonder in what mood Still would be at this very moment. Because looking at social media as well as other kinds of seminar announcements, we cannot deny the existence of a new-old hype: the run for physiological knowledge amongst osteopaths. And even more, on social media platforms of the osteopathic kind, the importance of anatomical knowledge (for osteopaths) is questioned (by osteopaths). It should even be emphasized that some distinguished colleagues feel themselves encouraged to support the former Littlejohn-Smith doctrine.
I am studying anatomy since the early eighties (in all of its dimensions – A.T. Still, “Philosophy of Osteopathy - What I mean by anatomy”, page 16-19). And since more than thirty years, some of my colleagues and I organize anatomy seminars where osteopaths can do the dissection completely by themselves from scratch. We also organize other postgraduate seminars, including clinical hands-on practice. In doing so, we meet numerous colleagues and students (from Europe as well as overseas), and we cannot deny that we have to conclude that the knowledge of anatomy amongst many of them is poor, if not even abominable bad! So please forgive me when I become irritated when I see this new-old tendency where anatomy becomes pushed into a corner once again in favor of the physiological indoctrination.
SIC TRANSIT GLORIA MUNDI
Yes, it is citated so often: Osteopathy is anatomy, anatomy and again anatomy. What hollow phrase it is when you notice the amount of anatomical knowledge many osteopaths have, certainly younger generations! Oh yes, they do have a large toolbox that contains many techniques (what irony, even so-called “Still techniques”!! – see next paragraph). For each symptom there seems to be a dysfunction, and for each dysfunction they have a proper tool to fix it. Forgive me my Latin background, but in this context the following remark comes to my mind: sic transit gloria mundi. Exchange the word “mundi” by “osteopathy” and you get: this is how osteopathy goes down the drain.
Did not Still tell us more than once that symptoms are merely effects? Did he ever use the term “dysfunction”? Was he not known for not showing techniques but principles (Philosophy of Osteopathy, Preface, page 2)? And did he not say that osteopathy is about reasoning, based on anatomical arguments? So, if all this is the case (please read his literature!!), then why are these osteopaths in their technical capacity not able to answer a simple question such as: why do you do this; what is your anatomical explanation? Why are they not able to answer these simple questions although they claim to be osteopaths and claim to know their anatomy?
THE NATURE OF ANATOMY
A first possible explanation to understand the severe shortcomings in anatomical knowledge and their consequences is the nature of this knowledge. Anatomy is not just any kind of anatomy. Over the centuries, the approach to study structures of the human body has changed. In the beginning, there was the “descriptive anatomy”. The observer simply described the shape of the structure, and he/she used comparative terms of Latin or Greek origin; when e.g. he/she saw a structure that looked like a knot, he/she simply called it a ganglion. This explains why the term ganglion is used to describe certain lymphatic as well as nervous structures. And often the observers used adjectives to describe the topography of the structure: e.g. Ganglion paravertebrale = a knot along the spine. It is clear.
As time passed by, when the observers started to ask themselves questions about the meaning of this structure for the body, this approach changed from descriptive to functional. The consequence is that the nomenclature started to become mingled: descriptive (shape and position) as well as functional (for instance flexor/bender and extensor/stretcher).
It is interesting to notice that with the change towards a functional approach, the observers began to study so-called “systems”. In doing so, they combined certain structures into a functional unity, such as for instance the locomotor system, the nervous system, or for instance the visceral (digestive) system. This approach might help the student to get an overview in the large number of different structures. However, there is a huge price that comes with this simplification of the anatomical study. The consequence of a systemic-functional approach of anatomy is that many relationships are not described and even not considered!
Allow me to demonstrate this with the following example. The digestive system contains several organs such as for instance the stomach, liver, pancreas and gut. The function of these organs is to digest a meal. The leg on the other hand is consisting of bones, joints, ligaments, muscles and much more. The function of the knee is to bend the leg. It belongs to the locomotor system. A question regarding the function (read “meaning”) of the right knee for digestion is faced with wide open eyes of “I-do-not-understand-what-you-mean”. Is there a (functional) relationship between that knee and the stomach or any other digestive organ (or vice versa)?! Answer: nooooo, there is not because they belong to “another” system! The chance, even to consider this positional/functional relationship as a possibility does not occur in most minds!! The functional-systemic approach has excluded this possible consideration! This functional-systemic description has excluded the possibility for anatomical reasoning based on principles, a reasoning that is characterizing the osteopathic philosophy!
Anatomy, ana-tomei: its very nature has led to a cutting up of the body into individual pieces
that become “functionally reassembled” into a for the student understandable mental construction,
which by definition is incomplete (see also Daston & Galison, Objectivity, 2017).
In the context of this kind of anatomical study, what about another famous quote that is mentioned by A.T. Still and so often repeated by the “self-declared true followers of osteopathy”: the body is a unity? Is not this kind of anatomical study a contradiction to these kinds of quotes? Even more! Studying anatomy in such a functional-systemic way that osteopathic institutions produce year after year for instance “cranial” osteopaths, or “visceral” osteopaths, the question is: to what end?! For sure the end of Osteopathy! And then I do not even mention these so-called “experts of the holistic kind” who organize specialized seminars of the strongest anatomical simplification. They are cutting the anatomical content into even smaller functional models, completed by sufficient techniques for combatting symptoms. It gives a slowly dying philosophy its final blow.
THE BLIND MEN AND THE ELEPHANT
Studying anatomy in and for an osteopathic reference frame definitely demands a different kind of approach. It is more than just learning numerous structures of “a specific system” by heart. Regardless the language that is used (Latin, Greek, English, French, …), studying anatomy to become an osteopath demands a different approach to fully understand the relationships between all structures in order to understand Form & Function. Consequently, anatomy cannot be thought by those who do not fully understand this. The founder of osteopathy A.T. Still was aware of this: Autobiography, chapter 12, page 152: To be qualified for a profession you must have a complete training from persons who understand the science thoroughly, and know how to teach it. … You must be thoroughly acquainted with all that is meant by anatomy – not merely familiar with the names of a few bones, muscles, nerves, veins, and arteries, but you must know them all as found in the latest standard authors. You should be familiar with at least ninety per cent of all the human body before you enter our clinics. …
Studying Still’s philosophy in front of the contemporary characteristics of anatomy, we have to emphasize that in order to become an osteopath, one needs not only books (and dissection!) but also a manual as guidance of “how to study anatomy”. This guidance should not so much come from written manuals. This guidance should mainly come from teachers who fully understand the philosophy, in theory and practice. Unfortunately, we cannot deny the tendency that in many osteopathic schools, the time for anatomical education is reduced to a “maximum of minimum” in favor of endlessly demonstrating and practicing techniques. This choice is often justified by the phrase: you can study anatomy by yourself at home, it is all in the books. Do they not know that (now for almost more than 100 years) the content in a majority of these anatomical books has been reduced to a minimal purpose for medical studies?! Do they not know that quite a lot of anatomical structures are no longer described in these books because they are of no purpose for medicine?! Allow me one example: Pernkopf Anatomie, in 1937 there were 7 books, in 1994 it was only 1 book. How barren the current anatomical landscape has become!
And when there still is guidance, we should not remain blind for the constatation that the background of most of these teachers is a “copy-paste” of the medical and/or physiotherapeutical approach of anatomy! So, teaching anatomy in such a reference frame for future osteopaths indicates that they are most likely not acquainted with what Still regards as essential for his osteopathy. They are not acquainted because they most likely did not study Still’s literature. And if they did, quite often it was done selectively scanned in search of recipes. Recipes that are titled by simplified slogans such as “the rule of the artery”, which are then very often supplemented with so-called specific techniques. This kind of anatomical knowledge may suit the M.D. and for instance the physiotherapist or chiropractors. However, it is inadequate and not usable for future osteopaths. But, as so often, in the land of the blind, the one-eye-person is regarded to be the king/queen; even when this one eye is squinting. Vanitas vanitatum et omnia vanitas; anatomy teachers of future osteopaths, please reflect before you act!
A LIVING PICTURE OF ANATOMY
The term of a “living picture of anatomy” is often used by A.T. Still. One example: Philosophy of osteopathy; Chapter 2, page 42: … , we should keep a living picture of the forms of each bone, how and where it articulates with others, how it is joined by ligaments, what blood vessels, nerves and muscles cross or range with it lengthwise, because to overlook a small nerve and blood vessel you may fail to remove a goitre, and all diseases… .
A question that kept my colleagues and me busy for a very long time is: what could he have meant with “living picture of anatomy”? In search for the answer, we dug deep into his literature and spent many hours discussing the different terms that he used. We have come to the conclusion that the answer lies in a profound insight of the unity of “Form & Function”. When we look for a definition for the (anatomical) form, we can formulate it as such (Höppner, Life as a Verb, chapter 2):
Form is the consequence of its structures and their positional relationships
in a certain environmental context.
Consequence – The first characteristic that we see in this definition is that a form is a consequence. A consequence of what? It is a consequence of the interaction between the form (its structures and their relationships) on one hand and the environmental conditions on the other hand. We can also describe this consequence as the outcome of a balance between load (the environmental influence/stress) and the load capacity (the structures and their positional relationships). Or with other words: the environmental conditions represent a stress for certain structures and their positional relationships. These structures and their positional relationships can and will resist this environmental influence. Consequently, the form is in a state that is characterized by a certain strain. It is a (momentary) state of being.
Structure – When we study the nature of this strain, it is important to emphasize that two main characteristics play an essential role: the structures and their positional relationships. The human body contains many structures, macroscopically as well as microscopically. A lack of knowledge of anatomy in all these dimensions already limits a required knowledge and insight in this characteristic (A.T. Still, Philosophy of osteopathy, page 16-19!). Unfortunately, we cannot deny that most osteopaths, certainly of the younger generations, remain in one single macroscopic reference frame! Consequently, they are selectively blind and therefore not able to fully understand the meaning of the submicroscopic dimension of physiology in a macroscopic context! They are simply lacking the dimensional and relational connections! They are jumping not from one dimension to the other (which you can do – see definition of Form), instead they jump over multiple dimensions at once as if they were able to grasp the nature and origin of a complete ocean by the study of a single drop of water!
Making such huge jumps due to the lack of knowledge of what is in between, it leads to incomplete and even incorrect conclusions. Literature in for instance the cranio-vertebro-sacral and visceral field are unfortunately full of dimension jumps that lead to questionable descriptions of for instance so-called mobility or motility: the kidneys ascend (based on which anatomical arguments?); the liver rotates to the right (what about the Vena cava and Vena porta?), the flexion-extension in the Synchondrosis spheno-basilaris (does this joint not always ossify?); … etc. etc. etc.. Anatomically, looking in all dimensions, many of these descriptions, often in form of models, make no sense because the reference frame is simply incorrect, no matter who has written the books (see other literature)!
In a comparable way, Rudolf Virchow (a founding member of “modern” medicine) has reduced the complexity of the human being to a single cell when he published in 1858 his concept of “cellular pathology”. He did numerous microscopic observations believing that he could catch the essence of disease. He was somehow convinced that he could catch the essence of a certain pathology by describing structural changes in the dimension of the cell. This concept narrows the complexity of human (dys)functioning down to a dimension that no longer represents the large number of relationships. It is a clear example of reductionistic reasoning – if reasoning at all. By copying this kind of approach into the education of osteopaths, this reductionistic simplification of knowledge leaves no space for the osteopathic philosophy. Even more, it has nothing to do with the osteopathic concept at all (see also below: example of fat digestion)!
The human body is characterized by many structures and studying anatomy should not take place in only one branch. Besides the macroscopic dimension it should also be studied in the branch of histology, cytology, and (bio)chemistry (A.T. Still, Philosophy of Osteopathy, page 16-19). So, is it not advisable to begin with a study of the first structural components of an organism? Is it not advisable to begin with the first elementary building stones of the human body: water, matrix, cells, and fibers? For those among you who are also acquainted with the branch of anatomy that is called histology, they will recognize the elementary structures of the connective tissue. Despite the term “connective”, this tissue is more than just connecting structures of different kinds and origin. It is also THE environmental space in which physiological processes take place while at the same time it is the structural component of other forms such as organs. Consequently, is it not advisable to study and fully understand all the different structures and positional relationships of the human form BEFORE we study the numerous physiological details that are described in a functional context? Is it not advisable to first contemplate on what the nature of function is? The term “function” is used so often and so easily and in such wide variety of meaning! Is it not more than advisable to give it a (at least second) thought? However, if you would like to do this, how can this be possible if you do not know which structures are involved??!! How can this be possible if you are limited by your anatomical knowledge of only one (often macroscopic) dimension?!
Positional relationship – Another essential characteristic is the fact that these elementary structures have positional relationships. Water and matrix are a solution in a liquid state, a fluid, and the positional relationships between the molecules is resulting in a functional characteristic: the ability to resist external influences. In physics, this phenomenon is called viscosity (Resnick & Halliday, Physics 1, chapter 17 & 18, 1966). A similar functional characteristic can be observed in the structural component called cell (= turgor) and fiber (= tension). There also exists a fourth expression of resistance against the environmental influences, which is called malleability. It is a situation when all structural components (water, matrix, cell, fiber) deliver a share of the resistance (consequently, in the case of malleability, the form has the highest density – see below).
With the definition and description of form in the back of our mind (see above), we come very close to the nature of what function is.
Function is the capacity to resist the environmental influence,
which leads to the capability to maintain the original form.
Note: some colleagues will define this as behavior. Changing it into a definition of function depends on the specific characteristics of the environment and the kind of positional relationships. These characteristics give the behavior a certain expression that is so specific under these circumstances.
The form will not change until the resistance, coming from the structures and their positional relationships, can be overcome by the environmental conditions. And consequently, the function will change as well. This change in Form & Function is defined as an “outside-inside-phenomenon” (Blechschmidt, Anatomie und Ontogenese des Menschen, 1978; Höppner, Life as a Verb, 2022).
Resilience – So, every form is in a state of strain. This should not be seen as a problem as such because there is another characteristic that we can observe: resilience. This characteristic shows us that each form is capable to reorganize internally the positional relationships between the structures of the same nature without having an immediate consequence for the form as such – the external characteristics do not change immediately nor automatically under the influence of the environment. However, here we must be careful! Because this is not entirely true. Because it will always change, but noticing it depends on what dimension we are looking in – and we should not forget that time is dimension related, which means that depending on the dimension that we are looking in that it takes more or less time before we can observe the change! So, it may be the case that momentarily the form of a cell does not change but in the underlying dimension, the dimension of water and matrix as a fluid, we do observe changes in positional relationship. This phenomenon is in physiological terms described as “metabolism”. And because the form of the cell does not change, although underlying there are changes taking place, we define this cell as being in a state of dynamic balance. It is this phenomenon that characterizes life (as a verb):
Metabolism can be seen as the basic expression of life, as a state of dynamic balance.
The capability and capacity of every form to resist environmental influences and to reorganize internally (resilience) is a basic functional characteristic of every form. It is a functional characteristic that brings each form to a living, a responding unity. A unity that is characterized by its specific structures and their positional relationships – in all dimensions!
Seeing these structures, seeing these positional relationships, and understanding their meaning, it turns anatomical structures into “living pictures”. To be able to see these living pictures, it requires another approach of our anatomical study. It requires the understanding that macroscopic anatomical structures such as bones, nerves, vessels, organs, etc. have different densities. Different densities mean different characteristics of resistance, different textures. Needless to say, but I do want to point it out: this cannot be learned from books; it requires dissection experiences Þso, it is NOT all present in the books, by far it is not!! Different functional characteristics are based upon the kind of structures and their proportional representation within the form. This requires an anatomical knowledge of all dimensions. And, it also means a knowledge of how these structures, macroscopically and microscopically are spatial aligned, three-dimensionally. This characteristic of spatial alignment results from a profound insight in the positional relationships between the structures (books + dissection!). The knowledge of these alignments helps us to see the directional features within a form. The knowledge and insight in texture and direction, as being the specific characteristics of a form, it creates a living picture of anatomy that shows us the capability and capacity of every form to deal with the environmental conditions that cause strain.
WHERE DOES PHYSIOLOGY FIT IN?
From Carol Trowbridge’s book we come to understand that A.T. Still was by far not fond of the shift that took place in the curriculum of “his” school. In the autumn of his life (his seventies), he had still enough energy to go on the barricades to defend the fundaments of his precious philosophy. And in doing so, he succeeded to preserve what he maybe could have meant at the end of his life by saying: “keep it pure boys”.
So, this leaves us with the question: what and where does the knowledge of physiology fit in the curriculum of an osteopath?
Physiology; a quick visit to Wikipedia gives us a definition:
- From ancient Greek: phusis (nature, origin) + logia (study) – the scientific study of functions and mechanisms in a living system.
- A subdiscipline of biology. It focuses on how organisms, organ systems, individual organs, cells and biomolecules carry out chemical and physical functions in a living system.
- Central to physiological functioning are biophysical and biochemical processes, homeostatic control mechanisms and communications between cells.
- A physiological state is the condition of normal function in contrast to a pathological state that refers to abnormal conditions, including human diseases.
LET’S GO CHEMICAL
From the definition of physiology, we learn that there are two aspects to the study of the function of an organism. There is the chemical and the physical aspect. Both have their meaning, and both should be well understood. However, what do we notice when we take a closer look at the curriculum regarding this branch of anatomy? Quite a lot of teachers of physiology, in the basic education of osteopaths as well as in postgraduate seminars, they seem to be eager in knocking down students and participants with the numerous details of chemical processes that take place in the human body. Comparing those teachers with each other, it seems as if they are competing to see who knocks students/participants down first and eventually wins the price of the most not-understandable authority in physiology for osteopaths. It might work impressive on the apprentice who will respond with respect, but nevertheless raises questions about the efficiency for the future practical application.
Some students and participants may eventually know the smallest biochemical details that take place in a cell, tissue, and organ. But nevertheless, all too often, they still remain incapable of making the link with the physical aspect that characterizes their daily work! The physical aspect is the osteopath’s manual reference frame. Osteopaths try to identify strain (and more – see later) that is causing the patients problem. Our manual approach can detect this strain. But this tool is not adequate for chemistry, it cannot measure concentration gradients. So, how to make a bridge between the chemistry and the physics? The majority of teachers of physiology that I met (and it is more than one!) is clearly lacking this insight. And it is not only I who comes to this conclusion. Talking and discussing with many osteopaths of different generations and countries, it becomes obvious that they as well come to the conclusion that there is something missing here. Yes, there are some few exceptions to the rule, some teachers are able to make that bridge between chemistry and physics. However, for a majority this is apparently not the case. This might sound harsh, and some readers might even feel offended. But if the latter should be the case, then please reflect first because it is simply a constatation in daily practice that cannot be denied. Do not shoot at the messenger but try to find the answer to the question that is on so many lips of unexperienced apprentices who dare not ask: how to make a bridge between the chemistry and the physics for osteopaths?
LET’S GO PHYSICAL
A.T. Still does not make it easy in his literature. Yes, like in the definition of physiology (see above), he as well does speak of the “normal” and “abnormal”. But, in his rhetorical style he almost hides what he means by those two characteristics of human being. Okay, even without consulting Still’s books, in a chemical reference frame, it seems to be understandable. We have measurable chemical values. In this context, we have established a range in which we consider the value as being normal. Any value lower or higher is considered abnormal. But what about the physical part of the story? This part is not included in the laboratory lecturers of the medical kind – I speak of my own experience here as well. It makes us wonder to what purpose we study these values by heart if we are not able to connect this information to the physical nature of our profession. Let us once again emphasize that our manual tool is incapable of measuring chemical values. And, even if we would be able to request a chemical test after sending body fluids to a laboratory, what to do with these results in practice? Can we translate this chemical fact into a physical reference frame (of strain)? And how should we define normal and abnormal in this frame? How can we describe normal and abnormal in an osteopathic context that is so physically characterized?
THE NOTION OF PATTERN
Unfortunately, to my opinion, for many readers of his literature, Still is not always rhetorically clear in defining what is normal and abnormal. Unfortunately, to my opinion, it requires besides intensive study of his literature also additional sources that do not come directly from his hand. For instance, in a paragraph of R.E. Becker’s book, “The Stillness of Life”, there is a quote of A.T. Still that might shed some light on the topic. Becker is giving us Still’s quote in reference to what Still himself wrote in his autobiography on page 148-149 (… I hope all who may read after … (till) … one eternal law of life and motion). The quote goes as follows (Becker, Ann Arbor Seminar, page 3-4):
Then Dr. Still says, “to make or furnish laws of self without patterns”. A healthy state is a state of no pattern. If you’ve got a pattern, you’ve got a strain, a disease, or a problem. If you haven’t got a problem, there’s no pattern. …”
This quote opened for some colleagues and me a door for more discussions and eventually, to an understanding of what he might have meant with normal and abnormal. In general, as well as in a physiological context. The key in Still’s quote that unlocked the riddle is the term “pattern”. In the beginning, this term was a point of many discussion (and still is for some colleagues today). What is meant by pattern? The answer to this question lies within the profound knowledge and insight regarding form, especially the living pictures of anatomy.
Let us see what Still has to say about this:
A.T. Still, Autobiography, chapter 1, page 13: “… We teach you anatomy in all its branches, that you may be able to have and keep a living picture before your mind all the time, …; … I feel free to say to my students, keep your minds full of pictures of the normal body all the time, while, treating the afflicted. …”
Still tells us that we require pictures of form that show us not only the structural components but also the positional relationships (textures and alignments) between them. He tells us that we should be able to visualize the capability and capacity of a form to resist the environmental influences. He tells us to visualize the ability of resilience that comes with a certain strain. So, Still tells us what we require to recognize the normal. But what about the abnormal?
The answer regarding the abnormal lies within the term “pattern” and its definition. Pattern should be understood as the (sequential) repeating of a number of certain structures. The repeating of structures that are characterized by the same texture, which results from their positional relationships. It is the repeating of structures that leads to a specific alignment. An alignment that shows us a specific direction. A direction that any form can use as an answer to an increasing stress coming from the environment. An increasing strain that is expressing itself with a directional characteristic. A directional characteristic that can be defined as the way of less resistance, the way of ease. It is a response of the form’s structural components and their positional relationships to deal with the strain that cannot be dealt with by one single relationship. A strain that can only be dealt with when the load is divided over more than one positional relationship between structures of the same nature. A strain that can be dealt with by an increasing number of relationships that leads to a higher load capacity. Or as the Belgians would say: l’union fait la force.
Strain is a normal characteristic of every form. A pattern of strain is something different. It is different because it has a larger impact on the characteristics of a form (texture & alignment). A pattern of strain could be regarded as normal because it is part of the answer of how the form is dealing with the environmental conditions. However, the directional characteristics of this kind of strain has a consequence for the future, nearby and/or distant. It is the fact that this direction becomes imprinted into the specific characteristics of the form. With other words: the pattern of strain reorganizes the positional relationships between the structures. And this leads to the consequence that certain directional characteristics begin to dominate. It leads to a loss of directional freedom. It leads to a loss of resilience of a form.
THE PHYSICAL IMPACT – DYNAMIC BALANCE UNDER SIEGE?
When we look into the conditions of chemical reactions, we can notice that the term permeability is an important characteristic. The higher the permeability, the easier the chemical reactions can take place. Especially the “transport” of chemicals in space. A transport is described as a change in positional relationship (resistance must be overcome!). A change such as the movement of molecules towards and from the cell as well as inside of the cell. These movements characterize a phenomenon that is defined as metabolism. Unmistakably, we can notice that this metabolism is directly dependent on the permeability of the region where the movement takes place. Unmistakably, we can notice that there exists an intimate relationship between this permeability and the density of the space (texture related) in which this metabolism occurs. With other words: the lower the density, the higher the permeability, the more metabolism. And: the higher the density, the lower the permeability, the less metabolism. This is physics and chemistry in the most logical rhetoric.
Consequently, we can ask ourselves what a strain (physical), and certainly a pattern of strain could mean for the metabolism (chemical) of an organism? What can a pattern of strain mean for the dynamic balance of an organism such as a cell, a tissue, an organ, and even a complete organism?
Basic knowledge of chemistry and physics shows us that a strain will change the density and consequently the permeability of the space in which the strain is present. With other words: a strain is very well able to change the metabolic expression of a dynamic balance. It becomes a metabolic expression under siege. That a strain leads to a change in metabolic behaviour, it should be obvious. However, it does not necessarily lead to discomfort or disease! Let us not forget that there is the characteristic of resilience. This characteristic allows any form to respond to the environmental condition without being defined as “abnormal”. In chemical terms: a strain will influence the chemistry of an organism but even a change of concentration gradient (chemical values) represents a certain “normal”.
It is when the strain increases in such a way that it becomes a pattern of strain (directional deviation into the way of less resistance) that the conditions for metabolism dramatically change. It is at this moment that the metabolic phenomenon goes to the boundaries of the normal. It is at that moment when the changed metabolism will turn into clinical signs. These clinical signs are not only characterized by a change of metabolism (function) but also by a change of the structural components in their positional relationships (form).
THE PATTERN OF STRAIN – THE SENTINELS
During the study of physiology, we are stumbling over the chapter of the communication systems (see earlier definition of physiology). In fact, what is described is the impact of a chemical interaction within a certain region of the organism on another region of the very same organism. The (physical) essence of this description is located within the “parameter space” that is present between the two regions. Is the distance quite short, the author will describe the chemical event as an autocrine or paracrine communication. As soon as the distance becomes larger, the interaction will be described as a telecrine communication. Regarding this telecrine type of communication, please notice that depending on the transport structure, the communication will be defined as endocrine or neurocrine (respectively fluid as a current in a tube or fluid as a current in the extension of a cell).
Note regarding the endocrine communication: it becomes obvious how detailed (= limited) and chemical the glasses of science have become. Everybody who has studied physiology will immediately respond to the term endocrine with the idea of hormones (molecules, chemical substrates of a metabolic event). But what about the fact that these so-called hormones have to be transported by fluid in order to arrive at a certain place?! Does this not play a significant role?! Especially when we consider that the venous blood flow can be influenced in its haemodynamic characteristics by a pattern of strain (Resnick & Halliday, Physics 1, chapter 17 & 18, 1966) when the direction of the pattern crosses the current! And let there be no doubt about it that the same “principle” is also valid for the function of a nerve (axoplasmatic transport of specific chemicals, which in neurophysiology are called neurotransmittors instead of hormones)!!
The chemical interaction between certain regions, close by or far apart, depends on the factor of permeability. With other words: how much resistance is given to the transport of a chemical information? A transport that is (eventually) provided by the fluid of the connective tissue. A transport that is determined by the level of density (gel-sol phase of connective tissue). A density that is determined by the strain that comes from the positional relationships between the structures in that region. And please notice that the strain can be located in relationship to any kind of structure of the connective tissue. So, it must not be that, because we are talking of permeability (fluid), the strain for instance cannot be located in the fibers. An increasing strain (resistance) in the dimension of the fibers (tension) leads to a push out of fluid in that region, which consequently leads to a change in density and permeability!
We can conclude that the strain as a physical event has an impact on the metabolism in the space in which the strain appears. As soon as we are dealing with a pattern of strain, we are dealing with a new situation: directional characteristics of the trajectorial kind. The term “trajectorial” means that there is now a “main direction” present, in space and time. This main direction has a steering impact on the metabolic event. The volume of the space in which the metabolism is influenced depends on the number of structures and relationships that are involved by the trajectorial characteristics of the pattern of strain.
We have seen previously that a pattern of strain turns the metabolism into so-called clinical signs. These clinical signs can be understood as the sentinels that warn us for future pathologies and other expressions of discomfort and disease. These clinical signs, these sentinels will tell us that something is not in order. Unfortunately, many colleagues (certainly younger generations) do not notice these signs while observing their patients. Instead, it looks as if they have become experts in planting flags of different colors: green, orange and red. Instead of being able to identify these sentinels and understand their meaning for the patient, they spent a lot of time in counting the colors before they are set to go with the “osteopathic part”. It makes you wonder what classes they have been taking. Seriously, who is it that organizes these kinds of lecturers for future osteopaths? Who is it that has this little confidence in the expertise of the osteopathic fundament? What is it that makes them so insecure that they desperately seek save haven on different shores before they continue their journey? It raises the question of what they have been studying in the context of osteopathy?
It raises the question: have they not read A.T. Still’s literature? Because if they did, would they have received enough guidance to become an expert on Form & Function, in sickness and in health? Yes. Different than an M.D. but therefore neither better nor worse! If they would have thoroughly studied Still’s literature, they certainly would have noticed the importance of these sentinels – which even some M.D.s give no attention! And even if they did read Still’s literature (A.T. Still, The philosophy and mechanical principles of osteopathy, chapter III – Mission of the doctor, page 72), how come that so often and so many do not notice these changes in their patient’s Form & Function? It seems as if they turn on their radio but fail to set the correct frequency so that they could hear the message of the broadcasting station that plays the metabolic tune with falsely set instruments. As it seems, in most cases, they only use their limited macroscopic anatomical reference frame! Some osteopaths of the younger generations (over time and often long after graduation) do become aware of the importance of recognizing these clinical signs. And hey, they even begin to understand that these clinical signs are expressing a metabolism that is under siege. But unfortunately, as so often, they seem to be unable to see or make the connection with the physical aspects because they are lacking the required and oh so important anatomical knowledge that Still is emphasizing all the time! Where are/were their teachers (A.T. Still, Autobiography, chapter 12, page 162)?!
IS IT REALLY THAT DIFFICULT?
SYMPTOM, CLINICAL SIGN = DYSFUNCTION = TECHNIQUE ?
It looks as if our dear Andrew must have had a crystal bowl. Or something comparable. Or is it simply of all times? Anyhow, in his “Philosophy of Osteopathy, page 205”, he dedicates a paragraph to the title “Mental degeneration makes it unpleasant for the original thinker”. In doing so he makes us aware that we should be careful not to waste time and effort on those fellow colleagues who have chosen the short cut. He gives us the advice to carry on by showing the fact and figures of osteopathy – hoping that some of them will open their eyes and ears for the facts of reason.
Dear Andrew, do you have any idea how big the mass of colleagues has become by now? Especially those colleagues who seem to prefer the short cut of “symptom-dysfunction-technique” because apparently, they are not willing to do the effort of studying anatomy in all dimensions. They are not willing to do the intellectual effort to give the meaning of anatomy a thought because all too often they are convinced that the formula [medical eduction/physiotherapy + some osteopathic techniques] equals [now I am an osteopath]. And this despite the fact that you, my dear Andrew, have urged us to do differently: A.T. Still, Autobiography, chapter 12, page 162, … Osteopathy cannot be imparted by books only. Neither can it be thought to a person intelligently who does not fully understand anatomy both from books and dissection. …He does not act from reason, because he does not know enough anatomy to reason from. … It is the philosophy of osteopathy that the operator needs; therefore it is indispensable that you know this philosophy or you will fail badly and get no further than the quackery of “hit and miss”. ….
Yes, it is quite easy to apply in practice the concept of “symptom-dysfunction-technique”. And this is not only a modern phenomenon, but also a phenomenon of all times (e.g. E.F. Ashmore, Osteopathic Mechanics, Kirksville, 1915). However, whatever the reductionistic mainstream might promote, it is not what osteopathy is about! And this does not come from me but from A.T. Still himself. And despite what some colleagues, some boards of schools or boards of professional associations may claim as “Still is outdated, osteopathy has evolved”, the principles as well as the fundament of anatomy (including physiology) is of all times and accurate. Or what comes next, that gravity no longer exist because look we can fly to the moon? Principles are elementary my dear Watson, elementary! (A.T. still, The Philosophy and Mechanical Principles of Osteopathy, Page 62, … Our science is young but the laws that govern life are as old as the hours of all ages. …)
Note: some schools and boards of professional associations even regard philosophy as not scientific. It is another argument of them to state that A.T. Still’s writings are no longer of this time. They label reading his literature as a waste of time, not to mention studying his philosophy. I truly wonder if they understand the meaning of philosophy. More than apparently not! They fail to see that there are two kinds of science: syllogistic and numeric. They fail to see that philosophy is the oldest science and has given birth to the set of rules for reasoning. It is the set of rules for reaching a conclusive conclusion that is used in the younger numeric science as well. It is clearly not known to them. They seem to know only one language, the language of numbers (even without reasoning), and this is enough for them to call A.T. Still “no longer of this time” where everything must be “evidence-based-science”. Please consider that the highest academical degree that a person can receive as an award and recognition by science is a Ph.D.. Do these distinguished colleagues of boards in schools and professional associations even know the meaning of this abbreviation?! Is not their condescending judging opinion regarding philosophy a “contradictio in terminis”?! So, who is calling A.T. Still’s science “Ph.oolishe.D.”?
PHYSIOLOGY IN AN OSTEOPATHIC PERSPECTIVE
Physiology is an important branch of anatomy for every osteopath, let there be no doubt about that. However, in a reference frame of the simplistic kind in square, [symptom = osteopathic technique]2, physiology cannot provide the so badly requested knowledge to fill up the gaps for the practical failures of some osteopaths. Certainly not when there is no connection between the knowledge of numerous chemical reactions and the physical (technical) work of the craftsman. So, my dear fellow colleagues, would it not be much more satisfying to stop running from technique course to technique course where one learns to copy “technique-variation-number-124bis”, completed with a so-called physiological explanation of the disconnected kind? Could it not be more satisfying to stop, sit down, study anatomy of the living-picture-kind and ask yourself the question: how can a pattern of strain express itself by certain clinical signs/symptoms/pathologies? How can we understand by reasoning (with anatomical arguments!) what the true meaning of a strain is for the discomfort of our patient?
We have already noticed that a pattern of strain has an impact on the metabolism of the cell, tissue, organ, and even the complete organism. And as long as the location of the pattern of strain corresponds with the location of the symptom, clinical sign, or even the so-called dysfunction, the osteopaths of the reductionistic nature will be happy and convinced that they got it right, that they are the best because they have found the cause for the effect. But tell me, when they are so convinced that they got it right, why do they still run from seminar to seminar in the attempt to find the “missing technique” for this particular symptom where it did not work out fine? Have they not wondered and asked themselves how it is possible that this technique works for this lumbar pain and not for that lumbar discomfort?! Have they not asked themselves how it is possible that a colleague does some incomprehensible head or belly massage and consequently the low backpain disappears? Do they really think that the answer lies in the fact that they do not know this or that specific technique (yet)? If the latter would be the case, instead of spending more time and money for additional courses, should this osteopath not go back to his/her teachers and demand a refund because they failed in their attempt to educate a proper and complete osteopath? Once again, I wish the reader to bring the following words of A.T.Still to his/her attention: Philosophy of Osteopathy, Preface, page 2, … It is my objective in this work to teach principles as I understand them, and not rules. I do not instruct the student to punch or pull a certain bone, nerve or muscle for a certain disease, but by a knowledge of the normal and abnormal, I hope to give a specific knowledge for all diseases. … Every principle herein laid down has been fairly well tested by myself, and proven true. …
So, instead of looking for another new technique to solve the problem, what about considering the following question: could it be that the pattern of strain is located in another part of the human body? So, not in the same space as we locate the symptom/clinical sign? Could it be that the symptom is indeed an effect as Still claims? An effect that should be understood as a metabolic event under siege by a pattern of strain? Yes, a fatty stool is a clinical sign that indicates that the physiology of the fat digestion is disturbed. Yes, it might be an indication that somehow the gall bladder could be involved. But does this automatically mean that the so-called “visceral dysfunction” must be located within the space of the gall bladder, or maybe the liver? Moreover, it might be correct that our physiological knowledge tells us that there is some specific hormone called CCK-PZ that influences the secretion of bile, or Secretin that influences the metabolism of the liver in producing bile. But does the clinical sign really mean that there must be something functionally wrong with the mucosa of the duodenum? Are we really convinced that in this context of physiological knowledge, a specific “duodenum-technique” will solve the visceral dysfunction and change the clinical sign? If this is the case, then why not always – if not to say exceptionally only once in a while? Are we lacking an adequate technique or is it simply a lack of anatomical knowledge? It is so obvious that these osteopaths fail to see that the physiological communication systems can be located in different parts of the body. So, what about this slogan “the body is a unity” when those osteopaths fail to understand that, on regular basis, these communication systems are far far away from the location of the actual metabolism that can be altered (by remote control) into a clinical sign and even a symptom or pathology! The impact of a pattern of strain on the vascularization and innervation of tissues, organs, and even the complete organism should not be underestimated! Especially when we consider that certain patterns of strain, a deviation of strain by aligned structures, can cross the course of blood vessels (veins!) and nerves. Lacking a knowledge and understanding of these so-called anatomical target zones of strain (crossing points for patterns) cannot be compensated by a specific technique. And neither by an increase of chemical colored physiological knowledge, no matter how many molecular details we are talking about!
We have to agree upon the fact that we must disagree with the approach on the fundaments for the osteopathic profession. Anatomy, histology, cytology, (bio)chemistry, and yes also physiology contains a lot of information that is shared with other medical and paramedical professions. But it is the difference in approach, it is the difference in connecting the dots, it is the philosophy of A.T. Still that determines how we should look at and deal with these facts and figures. Presenting this knowledge in a “copy-paste” formula of medicine and paramedicine (e.g. physiotherapy) is not useable for osteopaths. Unfortunately, this copy-paste behaviour has become mainstream in most institutes that spread knowledge among future (and present) osteopaths. The consequence is that every year osteopaths with a medical/physiotherapeutical mindset, armed with a toolbox of so-called osteopathic techniques, graduate from these institutions. Some institutions even benefit from this situation and offer additional programs to fill the therapeutical gaps. However, these shortcomings should not be located in the poor skills of the hand but in the poor reasoning by the brain. A poor reasoning that is resulting from a lack of (anatomical) arguments!
Many osteopathic schools as well as professional associations show a clear copy behaviour. They copy templates that are in common use within medical and paramedical institutions. This has led to the production of so-called cranial osteopaths, visceral osteopaths, paediatric osteopaths, etc.. Should it not be the aim to educate osteopaths who are able to work in the cranial field, the visceral field, the paediatric field, … the field of the human being as a whole?! How can someone be specialized in a certain field of human being if he/she does not fully understand the Form & Function of the whole to begin with?! Specialization without a broad basis, to what end?! Osteopaths of the present and the future require a broad knowledge of Form & Function in all dimensions before they look into specific aspects of human being.
Osteopathy: no physiology? No. Physiology is an important branch of the curriculum for present and future osteopaths. But as A.T. Still already stated, it should be banned whenever it is presented in a way that does not suit the osteopath in his/her understanding of Form & Function. And this is undeniable too often the case, in the basic education as well as in postgraduate seminars. It does not suit because the lectures fail to make the connection between physiology and the other dimensions of our anatomical human being. All too often the lecturers lack a profound knowledge and insight in the human anatomy. Most lecturers only know anatomy by books and have little and even no dissection experience at all (only looking does not count!). In most cases they have learned it in the old-fashion “ana-tomei” style as used in medicine and paramedicine (functional anatomy does not count!). Not or only scarcely having read the literature of Still (hear-saying does not count!) they cannot be regarded as being fully acquainted with the osteopathic philosophy. So, what purpose does their knowledge have when the so required philosophical context is not present?
Much more time and effort should be spent in the study and discussion of the osteopathic philosophy. More time and effort should be spent in the study and discussion to fully understand the principles of nature, which are far from outdated despite what some self-declared authorities may claim. Instead of increasing the number of techniques. Instead of “perfecting” the manual approach to the level of ridiculousness. Instead of wasting time by endless repetitions. Instead of running from seminar to seminar in the desperate hope to find the “missing osteopathic technique”. Instead of losing ourselves in endless details of chemistry. Instead … It would be much more useful for the future osteopath to use that time to contemplate on the philosophy of A.T. Still and how all this knowledge fits in the understanding of human Form & Function, in health and in sickness. In a way that is so different from medicine, physiotherapy, chiropractic, etc. that we have to agree that we disagree on the way how we are looking at the same human being. One is not better or worse than the other, but it is different. We should accept this and go our own way! If you desperately wish to become recognized by the medical profession, then please start to study medicine. If you wish to become recognized as an osteopath, then please start to study osteopathy.
The running back and forth to specific so-called specialized seminars, be it of the technical or new-old fashioned physiological/clinical indoctrination, it makes little to no sense at all. It makes little to no sense at all as long as the attendant is not acquainted with all branches of anatomy, as Still has stated so often in his literature. Neither a new manual approach nor a chemical-colored physiology fills the gaps in the osteopath’s knowledge of Form & Function as long as he/she does not see how structures and their positional relationships can be visualized in “living pictures of anatomy”. Pictures of the normal that help the osteopath to understand the abnormal. A guided study by teachers who fully understand the meaning of this is more than required. Instead of teachers who have perfected a certain hands-on demonstration of the dysfunctional kind. Instructors who cannot or do not want to recognize and acknowledge this, fail to see the responsibility and impact that their teaching has for the future of osteopathy. Looking at what osteopathy has become today, it does by far not look promising. On the contrary.
Note: the picture has been turned around 180° horizontally for editorial reasons.