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The science of osteopathy is the most exacting technical study in the world. The practical side of osteopathy is its technic. The spirit in which it should be approached is that of technical training. Good exponents of the science state that it requires not less than a year to be at all confident in the matter of diagnosis alone, except in the more obvious disorders; that is, it takes a year to make a good beginning in diagnosis, the first step in osteopathy. To develop a matured and efficient technic is a matter of years or a decade. Without adequate diagnosis, much can be done for a patient by stretching, passive motion and stimulation, the so-called general treatment, but this is not osteopathy. With the adequate diagnosis, some means can usually be found, even if slow and uncertain, to affect a restoration. But this is not true osteopathy. With adequate diagnosis, some means can u;sually be found, even if slow and uncertain, to affect a restoration. But this is not true osteopathy. True osteopathy consists of adequate diagnosis and adequate technic. Adequate diagnosis consists of thorough and practiced knowledge of the structures of the parts of the body, a trained perception of touch and muscle sense and other senses used in physical examination, and a trained imagination. Adequate technic consists of thorough and trained knowledge of the movements, tensions of ligaments and muscle, limitations to motion, changes of motion, leverages, etc., of the parts of the body; a trained muscle sense and a well cultivated mechanical instinct. This is the requisite for a foundation. To it must be added the mechanics of lesions, the principles of technic and some training in actual forms of technic that illustrate these principles. The student should be made acquainted with some of the different forms of technic developed by different operators, if possible. This is not a thing to be acquired in a term or from
a book. All of the time spent in the school is not too much to devote
to the subject. It requires also personally supervised and criticized
individual instruction. This may seem severe and exacting.
I venture to say, however, that the majority of experienced practicians
in the field will say that not less but rather more than this should be
required.
There are three reasons why the science of osteopathic technic is so exacting if it is to be at all efficient. The first is that it deals with structures covered by skin and muscle and often fat. Among these structures it is necessary to locate disorders, and having located to define them in all possible ways; and having located and defined to devise some logical technic of correction, using such few and narrow holds thereon as nature affords. The second reason is simply that the health, happiness and life itself of human beings depends on the skill that can be exercised in that narrow field. Our sole immediate contact with disease, the one thing that makes the rest of the knowledge that we have acquired effective at all, is this one thing—technical skill. The third reason is that the sense of touch and the muscle sense are but feebly developed in human beings. Dr. Still in training himself for the work of his life used to carry the bones in his pocket, where his hand could feel them, forming thus a sense-of-touch picture of them. Hour by hour he experimented with them until he had formed a moving picture of them in his mind. He also spent months and years in dissecting the bodies of the Indians, preserved in salt. The amount of time and concentration that he put into making mental pictures of the anatomy of the living body may be surmised from the fact that when he was seventy-five years old he still “camped in the liver” for a week or a month, and daily explored, as a research worked would explore, recesses in the human anatomy. Perhaps forty years was thus spent before he came before the world with his discoveries. A very large part of the training that he gave to
his immediate pupils, in the early days of the science, was in the practical
subject of technic.
Much of the technical training of Still survives in the profession, spreading hand-to-mouth as it were. The profession, however, and the schools have made no special effort to preserve it. They have not always kept clearly in view the exacting nature of the training necessary for true corrective work. They have been exceedingly busy the last decade in absorbing, digesting, adapting to osteopathic philosophy the accumulated medical learning (all, that is, except experimental medicine) and in meeting pre-existing standards in every way. This was perhaps a necessary phase of the evolution of the science and the profession. Technic, however, has remained an art, an individual and an empirical matter. There has been neither a model in the medical world nor a great leader among ourselves. The phrases that have been our rallying calls, such as “Find it, fix it, and leave it alone,” and “Ten-fingered osteopathy,” have been rallying calls for the purity of osteopathy, rather than for the development of technic. And yet osteopathic technic is the only medium between our scientific knowledge and the diseases it should benefit. A new rallying call is needed for the profession—“No osteopathic physician is any better than his technic.” The profession as a whole is no better than the standards that it sets in this, the practical side of its work. As the twig is bent the tree will incline; so the proportion of time spent on this subject in the schools will determine largely the amount of attention it will be given by practicians. There is another excellent reason for putting stress on technical training. That concerns itself with the parasitic imitators of osteopathy. First note that the philosophy of the matter is extremely
simple. Moreover those simple rallying calls of our past have emphasized
the simplicity of pure osteopathy, and rightly, no doubt. Note then
that much can be done by perfectly obvious methods, and perhaps every case
can be helped to some degree by measures dangerously simple and obvious.
The field is broad for the most superficial methods, so long as they simply
stimulate or “get motion”; and many there be that wander therein.
Lastly note that the exacting nature of the technical requirements for
true osteopathic work are by no means obvious to patients or to general
public; who wonder, therefore, whether it is worth the fees charged for
it. Add all these together and let them get planted in the public
mind, and we have the reason for the easy success and popular acceptance
of the shallow imitator, and a condition leading rapidly to the sinking
of genuine osteopathy. Says Dr. Fleck: “The corrective principle
is so potent that anybody practicing it on even a hit-or-miss basis is
sure to get some sort of results and so can get away with it.” Our
proper answer to the illegitimate practitioner and the fakir is to lay
increasing emphasis on the technical training requirement for doctors of
osteopathy, in schools and in publicity, until it has become generally
understood.
The ideal training in technic would be one that began with the first day in school and continued till the last. Knowledge of anatomy is presupposed before study of technic can begin; but it should be put to immediate use, the very day it is acquired, in relation with the sense of touch, the sense of measurement, the muscle sense, and in forming a living and moving picture of all the parts of the body. In this way the real object of the study is in view from the first. The study of anatomy for osteopathic students also should begin with the part where osteopathic thinking begins—with the spine. The student mind will take on the average just what is given it and no more—usually a little less—and in just the form in which it is given, and this it will try to utilize in therapeutics in the most obvious sort of way. There is little initiative in the average of human beings, and in any case it is unfair to demand it and rely upon it. It is therefore an ideal of technic that the parts of anatomy as they are studied should be immediately referred to the living body where alone the knowledge is useful; they should be outlined on the surface and practice in so outlining them should be given. Practice should include locating them by the sense of touch with the eyes blindfolded. The sense of measurement should be cultivated by measurements first with tape line, followed by examination with the fingers to verify the tape line examination. This should be done in erect and flexed position. The senses of touch and measurement being as a rule so weakly developed in human beings, it should be the constant endeavor to educate them to a state of osteopathic proficiency. Psychology tells us that some persons are eye-minded, some ear-minded, some touch-minded—the latter vastly in the minority. This sense then suffers an actual handicap in a curriculum that consists so largely of reading, of pictures and of lectures. Being so weak in civilized beings, this sense is subject to bizarre variations. Dr. White tells how he discovered by accident that things felt larger to his right hand than to his left. I have noted variations almost extreme between different osteopathic physicians in their interpretation of certain conditions. In justice to the student these anomalies should all be discovered and normalized or discounted. Training that would develop would also normalize. So numerous are the elements that go into a perfect technic that they should be taken up one at a time and woven gradually into the composite sense of technic. Those who leave the osteopathic schools bearing the
credentials of the profession, take its reputation in their hands.
It is the right of those who have labored to build that reputation to insist
that those into whose hands they put it shall be sufficiently well trained
in the distinctive osteopathic subjects to be able to uphold and advance
the cause of distinctive osteopathy.
The first principle of Osteopathic technic is not to hurt the patient. That this is at all times difficult and sometimes impossible will be admitted, since quite some force must at times be used, since the structures are held together by high tension, since in them for their protection nature has placed nerves that are quite sensitive to any threatening force; since also they are at times quite sensitive from the abnormal state they are in. a But this too must be evident, that it is at all times impossible without such a technical knowledge to use only the minimum force and to use it without awkwardness to the actual mechanical factors in the case, and that without this knowledge there is sure to be a very great amount of unnecessary pain and a great exaggeration of the really necessary pain. For this reason, experience in being treated is also a necessity in the preparation for osteopathic work, in order that the practician may be able to see from the patient’s point of view. I find that I am always more gentle with my patients after I have been myself recently treated. But familiarity breeds contempt. Not ourselves feeling the pain, and the patient feeling that it is “up to” him to endure what he believes to be necessary, we all allow our methods to grow more and more rough, intent only on the effort at correction and not on the feelings of the patient. And the second principle of osteopathic technic is not to hurt the patient. For in order to cure it is necessary to hold the patient. For every case that is lost to the profession through failure to cure there are many lost through roughness in handling, through pain caused by the treatment. A great many practicians in order not to hurt ignore the correction of lesions, or largely ignore it, and resort to simple stimulation. They at least hold the patients longer, only to lose them eventually through failure to cure, or through too great cost of the treatment. Some also follow the “general treatment” method through failure or ability to make diagnosis of mechanical disorders. It is safe to say that but for these two failures the profession would by this time have been immeasurably farther along the road to general acceptance. Both are failures in technic. The third principle of osteopathic technic also is not to hurt the patient. The success of technic depends on the relaxation of the patient, and this becomes impossible if fear or motor reflexes are excited by pain. It was Dr. Harry Still who used to remark facetiously that if the patient could relax sufficiently he could move any bone any distance. When God punishes us for our sins, it is not His punishments, but our resistance that hurts. So is it in the corrective work. With a proper technic the only pain that the patient need suffer in the majority of cases is such as comes from his own resistance. To secure that relaxation is the first art of the practitioner. If there be contractures, then must these of course be relaxed. But the voluntary contractions are always to be obviated. The success of a proper technic is in direct ratio to success in this. First there are the mechanical instincts of the body which oppose force with force. To offset this, the practician must endeavor to secure relaxation by gentleness, must win confidence with evidence of care—conspicuous carefulness, impressive caution; within the limits of positive and convincing work. With an assured technic this is not difficult. It is the bungler who excites the patient’s resistance. But often some definite training of the patient’s muscles in the art of relaxing is necessary. And the fourth principle of osteopathic technic is the same—not to hurt the patient, not to increase his nervous excitement by fear. There is such a thing as disease-fear, the fear of the subconscious mind when a state of disease exists in the body. Although sometimes this very fear enables the patient to yield to and endure things that it would be impossible to yield to in a state of self-confident health, yet also it may act to magnify the ill results of ungentleness on the part of the operator. The nervous system is always in a state of excitement in disease. The shock of correction may at times be unfavorable. The nerve strain from a continuing lesion is always greater than the shock of correction, provided correction is actually obtained. It is better to correct with shock if necessary than to allow the lesion to remain. But there is no excuse for making any more shock than is absolutely necessary at any time. It is usually desirable to make the first treatment as light as possible, an educative sort of a treatment. To the patient visiting a new doctor and trying a new form of treatment, this will seem heavy in any case. It seems wise to explain to the patient that there is likely to be some soreness or stiffness from the first manipulation of the deep tissures of his body, and to explain why—just as there is likely to be stiffness from the first day’s skating or any unaccustomed form of exercise. Following treatments may be made heavier at need, and little soreness from the treatment itself is to be looked for after the second or third treatment. |