Teachings in The Science of Osteopathy PDF
Teachings in The Science of Osteopathy PDF
Teachings in The Science of Osteopathy PDF
IN THE SCIENCE OF
OSTEOPATHY
To Adah Strand Sutherland
William Garner Sutherland, D.O., D.Sc.(hon.)
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TEACHINGS
IN THE SCIENCE OF
OSTEOPATHY
Rudra Press
ICl 1990 Sutherland Cranial Teaching Foundation, Inc.
All rights reserved. No part of this book may be reproduced in any fonn or by any
mcans, without permission in wricing from the publisher.
Preface XIll
Introduction XIX
VlI
ILL USTRAT I ONS
3. Coaxial cable 34
A. Lateral view 96
B. Medial view 97
Vlll
F OREWOR D
1 For a general description of osteopathy and the life of Dr. Still (1828-1917)
see: George W. Northup, Osteopathic Medicine: An American Reformation
(American Osteopathic Association, 1979).
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
x
Foreword
xi
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
XlI
PREFACE
X111
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
XlV
Preface
xv
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
XVI
Preface
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INTR O D UCTION
XIX
TEACHINGS IN THE SCIENCE OF OS TEOPATHY
Dr. Still spoke often of the design for motion in the articula
tions of the bones. Because of this emphasis, anatomical speci
mens were on view at the college where the students could
study them. Had this not been so, Dr. Sutherland would not
have come to that moment in his life when he experienced a
flash of insight which saw the articulation of the sphenosqua
mous suture as a design for motion that implied a respiratory
mechanism, "like the gills of a fish." Given the statements in
anatomical texts that the sutures and other articulations of the
cranium and face fuse, or ossify, in the adult, he had much skep
ticism and reservation about his own insight for years.
Eventually, in an effort to resolve the uncertainty by getting
the facts clear in his mind, Dr. Sutherland undertook a study of
the articular surfaces of the individual bones to prove to himself
that mobility between the bones of the cranium at the sutures
was impossible. He was unable to do this and therefore had to
confront the fact of a mobility that has no muscular agencies to
account for the motion.
He says in his lectures that anyone else undertaking the same
study will probably have the same shocks of understanding the
reality that he had. This kind of study of the mechanics of artic
ular mechanisms in the living human body led him to recognize
powers within his patients which could resolve problems and
heal strains. The nature of articular mechanisms in the endo
skeleton, the mechanical principles related to their problems,
and self-correction of such problems led to the invention of
ways to diagnose and treat patients.
From this growth in his understanding of the science of
osteopathy as it had been taught and envisaged by Dr. Still, came
his invention and development of his skills as a physician. Based
on what he learned from his patients, Dr. Sutherland developed
many ways of practicing osteopathy. When he found that at the
least his patients benefited from his treatments and at best got
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Introduction
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
included the use of the facilities at the Des Moines Still College
of Osteopathy and at the Chicago College of Osteopathy.2 In
addition, Dr. Sutherland traveled to regions that were conve
nient for those who wished to study his cranial concept. The
classes held in Providence, Rhode Island in 1948, 1949, and
1950 were among those regional courses.
As time went on, Dr. Sutherland realized the need for some
arrangement that would allow his teaching program to continue
under his associate faculty. The arrangement he made was the in
corporation of the Sutherland Cranial Teaching Foundation in
Denver, Colorado in September 1953.
The Sutherland Cranial Teaching Foundation, Inc. is an
educational organization whose purpose is the continuation of
Dr. Sutherland's organized teaching program. In 1960 the
Academy of Applied Osteopathy reorganized and changed its
name to the American Academy of Osteopathy. At the same
time the Osteopathic Cranial Association changed its relation to
the Academy from affiliate to component and changed its name
to the Cranial Academy.
The membership in all of these organizations has one thing
in common: the continuing study of the science of osteopathy,
and the development of further skills in its practice. There are
publications, study groups, seminars, and conferences as well as
programs that provide for visiting clinicians at the colleges of
osteopathic medicine and at osteopathic hospitals.
The Sutherland Cranial Teaching Foundation teaches and
trains members of the medical and dental professions in the
XXII
Introduction
* * *
XXlll
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ONE
Obtaining Knowledge
versus Information
HAVE YOU EVER HAD a thought strike you? I have told many times
of the thought that struck me before I graduated from the
American School of Osteopathy with the class of 1900. As I
looked at a disarticulated mounted skull that belonged to Dr.
Still, the detail in the articular surfaces of the sphenosquamous
sutures caught my attention. I became impressed with the idea
that tfiis suture was a display of a design for motion.
The squama of the temporal bones looked so much like the
gills of a fish that the next thought seemed only logical. It
struck me that this design for motion must represent a function.
Thus I came to the thought that this function must be a respira
tory mechanism. If you read the writings of Dr. Andrew Taylor
Still carefully, even between the lines, you will find that his
thinking was along these same lines. You will find that the cra
nial concept in the science of osteopathy was his, not mine.
The science of osteopathy came to Dr. Still in one of the sad
dest periods of his life. A prayer went out to his Maker for
Guidance. That is where osteopathy came from, the Master
Mechanic. That is the point of reference in all of his writings.
He asked, "How old is osteopathy?" He answered, "As old as
the cranium itself." He said that the science of osteopathy came,
as have other truths, to benefit mankind.
The thought that came to me, "beveled like the gills of a fish
and indicating a primary respiratory mechanism," not only struck
3
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
4
Obtaining Knowledge versus Information
5
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
6
Obtaining Knowledge versus Information
7
TEACHINGS IN THE SCIENCE OF OS TEOPATHY
8
Obtaining Knowledge versus Information
9
TEACHINGS IN THE SCIENCE OF OS TEOPATHY
the bones of the base of the skull through the use of experi
ments on the vault.
I sought some kind of mechanism through which I might
perform what I call the inhalation position of the sphenobasilar
junction. I found a football helmet in a sporting-goods store. I
took off the appendages - cut them right off. Then I hunted
for a choice piece of chamois skin, something that would not
stretch or pinch. When I had the helmet fitted on top of my
head, I put a bandage about two inches wide around it, leaving
two extensions that could be run up over the helmet. I fastened
the ends with hemostats so that I could roll the bandages and
clamp it. Visualize the bandage around and beneath with the
extensions coming up and over. As I turned the hemostats, the
helmet would lift the parietals laterally and upward. Then I
would release the tension. I would turn the cranium into the
inhalation position. I did not need to do anything to prove the
extension position in exhalation because it simply went back of
its own accord.
How was I to study the side-bending/rotation position? I
could not do it with that helmet. So I looked for some other
tools. I wandered around and found an old-fashioned wooden
butter bowl that some farmer's wife had used to mix the butter
after churning. I cut that down to the same size as the helmet,
but I left the convex portion of the bowl on one side and made
the other concave.
Then, with a flexible curved ruler such as draftsmen use, I
made an upward convexity like the clivus in the cranial base.
When I undertook to bend it to one side it would not do that
without rotation. Therefore I had the picture of side-bending/
rotation in the cranial base to guide me. Because of the rotation,
the side of the convexity is lower than the side of the concavity.
I named this position for the side of the convexity. I was ready
to use the butter bowl.
10
Obtaining Knowledge versus Information
I fastened the butter bowl to the skull this time with the ban
dage and brought the bandage around to the side of the concav
ity. By fastening the bandage I formed a concavity on one side
and a convexity on the other. I felt the side-bending/rotation of
the sphenobasilar junction to the right and to the left. I felt it. I
knew it. I had to have the knowledge.
Then I wanted to see a twist. I went back to the helmet and
arranged the bandages so that there would be a pull up on one
side in front and up on the other side in back. I wound them up
and clamped them with a hemostat. When I tested the arrange
ment, the greater wing of the sphenoid moved up on the right
as the basilar process of the occiput moved up on the left. So, I
had the pattern of torsion with the greater wing high on the
right. That is how I learned to move the base from the vault.
Some time ago, Dr. Howard Lippincott and I were permitted
to use an old skeleton that had been in a trunk at the college for
a long time. We cut a couple of windows in the vault so that we
could st.e the movement of the reciprocal tension membrane. I
put my fingers on the greater wings of the sphenoid and turned
them into the flexion position. Dr. Lippincott put his fingers on
the temporal bones so as to throw them into external rotation.
We saw that membrane - the reciprocal tension membrane of
the cranium in that old dried-up specimen - move. In the ani
mate specimen all you have to do is contact the sphenoid wings
and turn the sphenoid forward, into flexion, and it will move.
Turn it back and it will move unless there is something actually
preventing movement. You know when it is moving properly,
do you not?
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TWO
Primary Respiratory
Mechanism
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Primary Respiratory Mechanism
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Breath of Life that was breathed into this form of clay and man
became a living soul. 2
If you were to take a glass of water, place it on a table, and
shake the table, the water would spill therefrom. However, if I
took my hand and gave a transmitted vibration from my shoul
der to the table, you would see that water come up to the center
of the glass in a little quiver. That is what I want you to see in
the potency of the Tide in the cerebrospinal fluid. Not this up
and down fluctuation during inhalation and exhalation, but the
condition where you get the movement down to a balance point
between inhalation and exhalation, a midway point. This mid
way point is where you have a brief period where you observe
that the diaphragm is moving gently at a fulcrum point. Then
you get this vibration to the center of the Tide, the point where
you might say that you have come to what was known in a
hymn as "The Still Small Voice." You have heard the hymn, "Be
Still and Know that I Am."l Do you get the point? It is the still
ness of the Tide, not the stormy waves that bounce upon the
shore, that has the potency, the power. As a mechanic of the
human body you can bring the fluctuation down to that short
rhythmic period, that stillness, if you understand the mechani
cal principle of this fluctuation of the Tide.
Then you begin to understand something about the ground
swell of the ocean and differentiation of the tide, of the waves
and so forth. There is a sort of spiral movement. You have
heard of the different movements of the brain. Let us explore
another - a spiral movement of the Tide. Make a diagram with
a pencil on a piece of paper. Make a dot at a given point. Starting
with the dot, draw a line around in a curve and then around and
2 "And the Lord God formed man of the dust of the ground, and breathed
into his nostrils the breath of life, and man became a living soul." Genesis 2:7,
King James Version.
3 "And after the earthquake a fire; but the Lord was not in the fire: and
after the fire a still small voice." 1 Kings 19:12, "Be still, and know that I am
God." Psalms 46:10, King James Version.
16
Primary Respiratory Mechanism
around. Then, make a dotted line around the other way back to
the original dot. Let these illustrate a spiral movement.
If you want to use this diagram to represent a material mani
festation, designate a positive pole :,lnd a negative pole. Then we
get something in between the positive and the negative poles to
see in that slow movement of the Tide, that coil, a moving out
and a coming together. How many spiral movements can you
visualize in the Tide? How many little coils?
Go with me along a shore where there is a lot of seaweed
growing. Watch this seaweed moving rhythmically in a coiling
form, one going clockwise, another counterclockwise, spiralling
with the groundswell. Look at the hurricane. See the potency
in the eye of the hurricane, not the destruction around the out
side. See the potency of the eye, the stillness of the Tide, the
spiral movement.
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
membrane. They would pull it this way, they would pull it that
way, the rope would be under constant tension. Then, perhaps,
they would get a balance point, a still point, that would serve
like the fulcrum in a pair of scales. Not a lever. A lever operates
over a fulcrum, back and forth.
The fulcrum in the action of the reciprocal tension mem
brane in the membranous articular mechanism of the living
human cranium is a still point around which or over which the
constantly tense membrane operates the poles of articular
attachment.
You will note that I arranged a schematic way for describing
the attachments of the reciprocal tension membrane - the
attachments of the falx cerebri and the tentorium cerebelli. I
named a posterior pole (the occiput), two lateral poles (the
petrous ridges), an anterior superior pole (the crista galli), and
an anterior inferior pole (the clinoid processes). (See Figure 4.)
Note another articular pole at the sacrum, operated through the
mechanism. I have emphasized the tension, the pull, in the
reciprocal tension membrane between the poles of articular
attachment in the cranial mechanism. These schematic names
are simply to show that all the bones of the neurocranium are
attached to the mechanism that moves them. You can feel the
action when reducing cranial membranous articular strains. It is
the same mechanical principle that functions when you are
reducing a ligamentous articular strain in the vertebral column.
You can feel the action of the ligaments that hold an interverte
bral joint together and allow its range of motion.
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Primary Respiratory Mechanism
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TEACHINGS IN THE SC IENCE OF OSTEOPATHY
body of a bird. The central canal of the spinal cord can be the
tail of the bird. The two lateral ventricles look like the wings of
a bird. Where are they attached? Up where any wings are
attached on a bird: off the anterior superior angle of the body.
The third ventricle, as the front part of the body, is a chamber
for fluid. Now, during inhalation, I want you to see those ven
tricles moving the same as a bird does when it goes into flight.
As the wings spread they glide up a little more posteriorly than
they do in front. What does the bird wing do when the bird
lights on a twig? It folds down in exhalation.
Editor's Note: From time to time Dr. Sutherland was prevailed upon
to give an extemporaneous talk about the brain which he called a
"Tour of the Minnow." Another one is presented in Chapter 17. No
two were alike.
20
Primary Respiratory Mechanism
the bottom so he dives down through the fluid and meets the
hypothalamus. Let us leave him there. No. Let us have him do
something else.
We will have him go up to the reciprocal tension membrane,
to the falx cerebri, and ring the ethmoid bell. He can use it by
way of the crista galli to move the ethmoid like the bell on a
locomotive. With the rocking motion we can see what happens
to the olfactory bulbs as they rest on the cribriform plates with
the olfactory nerves hanging down. You know of the cerebro
spinal fluid in those bulbs, along those tracts that are said to
belong to the brain. That is a different formation than the usual
arrangement for the cranial nerves. You can read about the
experiments that Speransky did in this region.5 I call your atten
tion to this system that protects the nasal mucosa.
Let us go back to the third ventricle, that narrow chasm that
widens with inhalation. I want you to see the real stretch of the
roof during inhalation. See that choroid plexus upon the roof,
not in the ventricle. I want you to see that choroid plexus alter
nately stretching out and bunching up during inhalation and
exhalation. There is your mechanical principle for interchange
between the blood and the cerebrospinal fluid. Realize the
motility of the brain and the motility of the choroid plexus,
which is pia mater and a part of the blood vascular system, not
the nervous system. Go out into the walls of the lateral ventri
cles and find the same arrangement, a curtain between the
choroid plexus and the ventricle. Go back to the fourth ventri
cle and see the same mechanical picture.
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***
22
Primary Respiratory Mechanism
Ask your critics if they can find any muscular tissue running
from the sacrum to the ilia. Let them search for it. There are
no muscular agencies for articular mobility between the ilia and
the sacrum.
What they will find is that the sacrum is suspended beneath
the ilia by ligaments. The articular surfaces are L-shaped. In
two papers in the Journal of the American Osteopathic Association,
Walford A. Schwab, D.O., a professor at the Chicago College
of Osteopathy, called attention to the shape of these articular
surfaces. He noted not only the L-shape but also the little niche
in one surface and the little ridge in the other, all for a purpose
in its function.6
Consider the description of the osseous cranial bowl in stan
dard texts. You meet a statement pointing out that the bones of
the base of the skull are formed in cartilage and the bones of
the cranial vault are formed in membrane. When you look
down upon the bones that are formed in cartilage, your bump
of reasoning says, "articular mobility in the cranial bowl."
Then, you put a cap on the bowl. That cap (the vault), that
membranous cap, would interfere with the articular mobility of
the bones of the base of the skull unless it provided some com
pensation through the sutures. The peculiar dovetailed inter
lacing between the parietal bones in the sagittal suture, for
example, show features that can accommodate the mobility
between the bones of the base, which form in a cartilaginous
matrix. In the adult, the bones of the cranial vault have two
walls with diploe between them. They are flexible as well as
accommodative at the sutures.
This living human body is a mechanism. It includes the
osseous articulations, the flow of blood in the arteries and veins,
the intricate mechanism of the lymphatic system, and that great
6 The papers first appeared in 1928 and 1932 and were then reprinted:
Walford A. Schwab, "Anatomical Mechanics, Year Book, Academy of Applied
Osteopathy, 1952, pp.141-142.
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24
Primary Respiratory Mechanism
and those walls are moved as it does SO.7 You can see the sort of
mechanism that carries venous blood along as the reciprocal
tension membrane, which is attached to the bones, is shifting in
its regulation of the movement of one bone and another.
* **
The next subject for this study is the occiput. The first thing
to consider is the circumference of the occiput, which includes
appendages such as the basilar process, the condyles, and the
squama that displays a bend. The occiput forms most of the
back of the head and a large part of the cranial base. The fora
men magnum is located on the bottom in human beings. Look
at the bone as a wheel. Consider particular locations as spokes
of the wheel or points on the circumference. As the occiput cir
cumrotates during inhalation, it moves forward and up a little
so that the sphenobasilar junction in the clivus is carried for
ward and up. The foramen magnum does not remain at the
lower level. (See Figure 1.)
I am emphasizing the foramen magnum especially because
the dura mater is firmly attached to its rim. This is the upper
attachment of the intraspinal dura mater, which is a continua
tion of the inner layer of the cranial dura mater. The intraspinal
dura mater is not attached to the atlas. It is attached to the axis
and sometimes to the third cervical vertebra. From this upper
area it hangs somewhat loosely, like a hollow tube, until it
reaches the sacrum where it has another firm attachment to
bone. As the occiput moves forward in inhalation you can see
that the foramen magnum moves upward to a higher level. You
see the intraspinal dural membrane rising and taking the sacrum
along with it. Do you get the point? There is a movement of
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TEACHINGS IN THE SC IENCE OF OSTEOPATHY
Figure 1. The occipital bone pictured as a wheel, showing how various loca
tions change their position as the occiput circumrotates on its axis.
26
Primary Respiratory Mechanism
27
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
process. That is why I call the petrous portion the axle upon
which the temporal bone moves. Do not forget that the petrous
portions converge anteriorly and diverge posteriorly, thus fol
lowing the physiologic functional design in all of the articula
tions of the spine as well as the cranium.
This axle, the petrous portion of the temporal bone, turns
upon the jugular process of the occiput as on a pivot. The squa
mous portion of the temporal bone is set off so that when the
petrous portion rotates externally, it moves outward while the
mastoid process moves inward. Visualize the wheel, the disc of
the wheel, wobbling. In the other direction, in internal rotation,
the squamous portion moves inward and the mastoid process
moves outward. That is the picture of the wobbling wheel in
the internal and external rotation of the petrous portion as the
axle of the temporal bone.
I call the temporal bone the "mischief maker" or the "clown"
in the cranial articular mechanism. This comment points to
the fact that I have found more trouble originating from prob
lems with that little temporal bone than from any other in the
cranIUm.
As you think osteopathy with Dr. Still, think of the origins and
insertions of soft tissues, muscles, and fascias, not only bony tis
sues. Consider drags on the fascia and crowding of muscular tis
sue in certain positions of the petrous portions. Remember that
whenever the basilar process of the occiput is tipped up on its
side, the petrous portion on that side is always carried into
internal rotation. It then follows that the petrous portion on the
other side, the low side, is always carried into external rotation.
If the basilar process is in an extreme flexion position at the
sphenobasilar junction, both temporal bones will be in marked
external rotation.
Editor's Note: This law applies to the fact that the occiput carries the
temporal bones on the jugular processes. Therefore, if the occiput is
28
Primary Respiratory Mechanism
Figure 2. The sphenoid bone pictured as a wheel, showing how the landmarks
and processes change their position as the sphenoid circumrotates on its axis.
29
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
wheel turns to and fro. Note that the promontory of the sphe
noid does not move at its level. It does not move forward or
backward. It is a suspended wheel, circumrotating so that the
little spokes, or projections, are moved from place to place.
Follow them around. It will help you to visualize the point of
lesion in your technique.
You can study the cranial mechanism all the way through in
this way. You will find problems and the answers to problems.
Prove to any who may be skeptical, perhaps more skeptical
than I was in the beginning, that the living human head has
articular mobility, as well as protective stability. When they try
to prove that the bones of the human adult cranium cannot
move, they will get a shock, as I did, the more they study it.
They will find indications for mobility in every articular sur
face in that mechanism.
30
THREE
31
TEACHINGS IN THE SCIENCE OF OS TEOPATHY
The tide. You watch the tide of the ocean, and you watch that
ferry boat going across San Francisco Bay from Oakland. As the
ferry gets near Treasure Island it bumps up against something.
Time or tide? You will find that the pilot controls the wheel so
that the boat is on a balance point and is turned right around by
the potency of the incoming tide. Then, on the next trip, why
does the pilot steer another course a little further out from
Treasure Island? It is a different time of the tide. Or, maybe,
there is a meeting with a groundswell, with an undulating, up and
down. There are so many things to study in the tide of the ocean.
Compare it with this fluid in the living body, this Tide in the
body with its potency. That is what we have in this first princi
ple. The Intelligence in the power in the Tide. We refer to the
potent fluctuation of this Tide and to something that is intelli
gent, something invisible. We are referring to the Breath of Life
in that Tide.
You can visualize an X-ray that jumps from a positive to a
negative pole. You see the equipment, but you cannot see the
ray that exposes the film and makes the picture, the shadow pic
ture. There is a potency in something invisible. This is like the
fundamental principle in the primary respiratory mechanism,
that "highest known element" to which Dr. Still called your
attention. He didn't mean this material fluid that you can see,
but that element in the Tide, in that fluid.
I call your attention to the water, the clear water, in the bat
tery of your car. You have chemicals in that water, material
chemicals. But you cannot see the invisible element, the electri
cal "juice" that comes from that water, that passes along the
wire that runs to the motor of your car. That is the potency, the
power, that comes from the battery. From time to time you
have to replace the water in the battery.
There are interesting questions and remarks in the little text
entitled Dr. Still in the Living by Robert E. Truhlar, D.O.l One
32
The Fluctuation of the Cerebrospinal Fluid
2 "Possibly less is known of the lymphatics than any other division of the
life-sustaining machinery of man. . . . Finer nerves dwell with the lymphatics
than even with the eye." Still, Philosophy and Mechanical Principles of Osteopa
thy, p. 66.
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Insulation
Copper tube
Insulation
Coaxial cable
else. He wants us to see this "copper tube" and the wire within,
the potential. The principle is used in the material cable that
carries messages across the Atlantic Ocean. Messages, many dif
ferent messages, are runni�g over that copper tube.
Do you know anything about sheet lightning? You see its
manifestation all through the cloud, but it doesn't touch the
cloud. I want you to see this invisible "liquid light," or the
Breath of Life as sheet lightning and a transmutation; the sheet
lightning all through the nerves, not touching the "copper
tube." The transmutation is what Dr. Still pointed to in the
early days as "nerve force." He was trying to put across this
understanding using the example of the electrical force, or the
electrical "juice," that runs along the wire. That signal that runs
along has to have a tract to run on.
It is a push-button mechanism, an attunement within the
human body. Tuned to what? To that "highest known element,"
34
The Fluctuation of the Cerebrospinal Fluid
the Breath of Life, not the breath of air. Quoting another text:
in the creation of man, the Breath of Life was breathed into the
nasals of a form of clay, and man became a living soul.3
3 Adapted from Genesis 2:7. For the full quotation, see the footnote on
p.16.
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TEACHINGS IN THE SCIENCE OF OS TEOPATHY
When you send messages over that tube you have push-buttons
that function like the many radio stations that can be tuned in.
Only one "copper tube" with many wires within. Perhaps this
will help you understand the infundibulum.
* * *
4 This story is also told in a footnote in The Cranial Bowl. Dr. Sutherland
describes it as a case that" .. , appeared like that of shell-shock to the
meningeal area .. ," Sutherland, The Cranial Bowl, p. 54.
36
The Fluctuation of the Cerebrospinal Fluid
being within the brain stem. Within this body of fluid is that
"highest known element" to which Dr. Still pointed; and within
the brain stem, within the medulla oblongata, are the primary
centers controlling the physiology ?f the body, especially the
center for respiration.
After I had turned those bones, a sensation of warmth
occurred in my hands. Respiration began. I released the mecha
nism and it ceased. Someone kindly said, "Why don't you send
for a doctor?" I tried the experiment again and the same sensa
tion of warmth came back. His head gave a sudden jerk and he
spoke to his sister.
The man's physical mechanism had been dead, stalled. It was
locked in meningeal shock; the arachnoid membrane was locked
down upon the brain. Fortunately, however, the Breath of Life
was in this body of fluid. All I did was "crank the car." I have
known of two other cranial technicians who have been able to
perform a similar experiment under critical conditions.
You will understand, when you consider such critical condi
tions, why I have said from time to time, "When you do not
know what else to do, compress the fourth ventricle." Keep in
mind the Tide with its Intelligent potency, spelled with a capital
1. It is something you can depend upon. Something that knows
how. When you are somewhat doubtful of the diagnosis in some
conditions, consider the Tide and compress the fourth ventricle.
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FOUR
The Reciprocal
Tension Membrane
LOOK AT THE VERTEBRAL column to see the ligaments that hold the
spinal articulations together and also allow a certain range of
movement at these joints. Then look inside the skull to find
what does the very same thing as those spinal ligaments. There
is an interosseous membrane that holds the bones of the neuro
cranium together and allows a certain range of normal move
ment at the joints.
The interosseous membrane inside the skull is called the
dura mater. It is a tough, nonextensible, fibrous membrane that
has an outer and an inner wall. The outer wall serves as perios
teum. The inner wall has specializations that drop down in
folds between parts of the brain. The fold that drops down in
the sagittal plane between the cerebral hemispheres is called
the falx cerebri. The fold that is spread out over the cerebellum
is called the tentorium cerebelli. This whole membrane with its
folds is attached to all the bones of the neurocranium. The
name falx refers to the sickle shape of the falx cerebri. If you
look at one side of the tentorium cerebelli you see another
sickle shape. The other side looks the same. When you see it
this way, you see three sickles that meet in the back part of the
inside of the head.
The falx cerebri is fastened to the crista galli of the ethmoid
bone, to the frontal bone, the two parietal bones, and to the
interparietal occiput. It is tough, firm, and tense. I used to say
39
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Falx cerebri
Crista galli
Tentorium
cerebelli
that if you could get in there, you could pull on the falx and
ring the ethmoid bell. That is, swing it back and forth like the
bell on a locomotive. That is the anterior superior pole of
attachment for the falx cerebri.
When I look at the tentorium cerebelli, I am struck by the
shape of two sickles. That inclines me to call it the "falx tento
rium." You could say "falx cerebelli" because it rides above the
cerebellum, but I prefer "tentorium" as I have used the term. The
40
The Reciprocal Tension Membrane
two sickles make the "tent." The "tent" is attached all along the
inside of the occipital squama, in the middle. The lateral sinuses
are formed by this attachment. [Dr. Sutherland regularly
referred to the tentorium cerebelli as the "tent." -ED.]
Then the "falx tentorium" passes over the inside of the poste
rior inferior angles of the parietal bones. These are the mastoid
angles just above the parietomastoid sutures. After that, the
"tent" runs along on the superior borders of the petrous por
tions of the temporal bones. These attached borders of the
petrous portions are called, schematically, the lateral poles of
attachment of the tentorium cerebelli. They go forward to fas
ten to the posterior clinoid processes of the sella turcica of the
sphenoid bone. Because of the sickle shape, the "tent" has a free
border that forms the tentorial notch. This inner border makes
a turn before extending on to the anterior clinoid processes of
the sella turcica of the sphenoid.
This area, where the anterior reaches of the tentorium cere
belli attach to the four clinoid processes of the sella turcica, is
the area of the anterior inferior pole of attachment. The
diaphragma sella covers the sella turcica where the pituitary
body is located. The infundibulum from the hypothalamus
passes through to the posterior part of the pituitary. This situa
tion is one of the little things that may be a big thing in the sci
ence of osteopathy.
When we look at the two sickle-shaped halves of the "tent"
together with the falx cerebri, we see three sickles that meet at
the area of the straight sinus, where the falx adjoins the "tent."
On the two halv:es of the "tent," see that the curve has been cut
off, as it were, where the "tent" is attached to the superior bor
ders of the petrous portions of the temporal bones. Both sides
are the same and these lateral poles of attachment are an impor
tant part of the whole inside of the neurocranium. Note that the
petrous portions converge anteriorly and diverge posteriorly.
That is, they run diagonally forward.
41
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Look at the inside of the skull and see that the falx cerebri
and the "falx tentorium" (tentorium cerebelli) are attached to all
the bones of the neurocranium. The falx cerebri in the sagittal
plane carries the superior sagittal sinus; the tentorium cerebelli
carries the lateral sinuses across the middle where the conflu
ence of sinuses is located. At the internal occipital protuberance
the straight sinus brings venous blood from the inferior sagittal
sinus and the great cerebral vein of Galen to flow into the lateral
sinuses. This area is the posterior pole of attachment of both
the falx and the "tent" in this schematic description.
Note that the three sickles on the inside of the cranium, spe
cializations of the inner layer of the dura mater, constitute one
structure that holds all the bones together. I call this the recipro
cal tension membrane of the human cranium. It allows a normal
range of movement of the bones at the sutures. The tension in
this membrane is emphasized because you could not have a
reciprocal mechanism unless it were continually tense. This
applies not only to normal positions but also to strains. The
tension holds constantly just as the neural tube remains a tube
throughout life.
Consider a model that shows the three sickles fastened
together. Such a model can illustrate the schematic idea. But
what does this structure inside the cranium mean to you? What
does the sickle shape imply? If you have a scythe, which is noth
ing more than a big sickle, how do you use it? You don't use it
to chop the grass down. You use it as intended, as a tool to
swing around in a large circle close to the ground. You move
posteriorly as the whole comes forward. When you get around
to the anterior tips of the falx and the "tent," you see that they
move posteriorly. That is the advantage of the sickle shape for
these interior structures.
The falx cerebri draws the ethmoid backward as the crista
galli goes up. The clinoid processes of the sphenoid go back
ward as the "falx tentorium" goes forward. This shows how the
42
The Reciprocal Tension Membrane
Occipital axis
Sphenoidal axis
Ethmoidal axis
Axis of Vomer
Figure 5. The cranial base in flexion, showing the rotation that takes pl ace
about paral l el transverse axes. Note that the ethmoid and the occiput rotate
in the same direction whil e the sphenoid rotates in the opposite arc, as woul d
be the case with three intermeshed cog wheel s. T he dotted l ine represents
the vector of force transmitted from the movement of the sphenoid through
the vomer.
43
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
44
The Reciprocal Tension Membrane
45
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
* * *
48
The Reciprocal Tension Membrane
49
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
50
FIVE
51
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
close near the middle of the body very early and closure
advances progressively in both directions. The caudal end closes
off just after the rostral end, and at that stage the formation of
the neural tube is complete. The three primary brain vesicles
(the forebrain, midbrain, and hindbrain) are formed by the clo
sure and enlargement of the rostral end. The neural tube below
these vesicles is smaller in diameter and becomes the spinal cord.
At this early stage, the entire neural tube can be analyzed
both by concentric rings and longitudinal strips. The primitive
dorsal and ventral walls are primarily ependymal in structure
and do not participate in the thickening of the lateral walls.
They become the floor plate and the roof plate. The sulcus lim
itans marks the subdivision into the sensory dorsal plate and the
motor ventral or basal plate.
As the neural tube is forming into these basic arrangements
of the central nervous system, the surrounding mesenchyme is
becoming condensed and arranged into the outer coverings of
the brain and spinal cord. These are the meninges and the osse
ous neurocramum.
The dura is a hard fibrous enclosing membrane just beneath the
bony skull. The arachnoid bridges the brain's many crevices.
The pia mater is molded firmly and tightly to dip into every
irregularity on the surface of the brain.
There are ridges and valleys on the surface of the brain that
are called gyri and sulci. The cerebrospinal fluid is distributed
on the outside of the neural tube beneath the arachnoid mem
brane in the subarachnoid spaces. It is distributed inside the neu
ral tube in the lumen of the tube, the ventricles.
By the time the neural tube is developed and arranged within
the skull there are two hemispheres and four lobes of each hemi
sphere. These are like separate continents bounded by three fis
sures. It is useful to think of this cerebral geography as long as
one remembers that this map is not the territory.'
1 Adapted from: Richard Restak, The Brain (New York: Bantam Books,
1984), pp. 8-14.
52
The Motility ofthe Neural Tube
Cerebral
Interventricular
aqueduct
foramen
Medulla
oblongata
53
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
54
The Motility ofthe Neural Tube
The brain and spinal cord are of the consistency of soft cus
tard. The whole neural tube is in the protective surround of the
cerebrospinal fluid, inside and outside. This whole, wrapped in
the leptomeninges (the arachnoid-pia), lives within the osseous
neurocranium formed of bones held together by the dura mater
and its specializations, the falx cerebri and the tentorium cere
belli. At birth, the whole cranium resembles a soft-shelled egg
for there are no joints established between the bones except that
between the atlas and the occiput.
Through the functions of the primary respiratory mecha
nism, the physiologic centers in the medulla relate to the sec
ondary physiology of the living human body. Through this
great battery, the Tide, you find the "highest known element" is
transmuted to those physiologic centers. The nuclei of the cra
nial nerves also receive the transmutation from this Tide, from
the battery that contains the "juice," distilled from material ele
ments that man utilizes. Do you see all these things just lying
there static, as they are found in the cadaver? No. You watch
them in inhalation and exhalation, in mechanical functioning.
The living human body is a mechanism that includes not
only the osseous articulations but also the flow of the blood in
the arteries and veins, the intricate mechanism known as the
lymphatic system, the soft tissues, the viscera, and that great
hydraulic system, the cerebrospinal fluid.
55
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
3 "What gives a cell form may also control its genes. At first glance the
cytoskeleton of a mammalian cell would not appear to be closely related to
gene expression. The cytoskeleton, a complex network of proteins and other
molecules, endows the cell with form and enables it to move. Genes, on the
other hand, embody the information needed for making proteins. Contrary to
expectation, however, the cytoskeleton appears to be a crucial intervening
actor in the control of gene expression." John Benditt, "The Genetic
Skeleton," Scientific American 259 no. 1, Guly 1988), pAD.
56
The Motility ofthe Neural Tube
57
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
58
The Motility ofthe Neural Tube
Habenular
commissure
Anterior
commissure
Pineal body
Lamina Superior
terminalis --M!ITr--i/jJ, 4£"4:;::;�t- (quadrigeminal)
cistern
Pituitary body
Superior
colliculus
Inferior
colliculus
59
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
4 Adapted from: Henry Gray, Anatomy of the Human Body, 26th ed., ed.
Charles Mayo Goss (Philadelphia: Lea and Fabiger, 1954), pp. 891-898.
60
The Motility ofthe Neural Tube
61
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
He who is able to reason will see that this great river of life [the
cerebrospinal fluid] must be tapped and the withering field irri
gated at once, or the harvest of health be forever lost.5
Think of the distribution of the cerebrospinal fluid on the
outside of the brain stem and cerebellum. It is all around, peep
ing into every recess; it curls up and around and out, all the
time in the subarachnoid space on the outside of the brain.
Consider the cisterna basalis, the cisterna chiasmaticus, the cis
terna interpeduncularis, and the cisterna magna.
Think of the motility of the cerebellum in those little layered
tracts called the peduncles, in the roof of the midbrain, and the
pineal body. Think of the motility in the tracts running down
the spinal cord and going around the fourth ventricle and
beneath the pons. Can you now see the mechanical physiology
in the functioning of the primary respiratory mechanism?
Next, think of the picture of the membranous tissues that
form the venous channels. Think about restriction in these
channels that might lead to pathology in the brain. This think
ing indicates many of the possibilities offered through the prac
tice of the science of osteopathy as envisaged by Dr. Andrew
Taylor Still. Carry this picture in your professional mind as an
aid in the diagnosis and treatment of the problems that your
patients bring to you.
* * *
Another place where you can control the Tide is in the lateral
ventricles. The two ventricles are in the cerebral hemispheres.
They go beyond the lamina terminalis through the interven
tricular foramina. The motility of the brain stem and spinal
cord ends at lamina terminalis. These foramina are located high
in the end wall of the third ventricle. The lateral ventricles
extend out from the third ventricle along the neural tubes of the
62
The Motility ofthe Neural Tube
hemispheres. Note the spiral form that the cerebral cortex, the
telencephalon, makes on each side as it fits into the cranium
above the tentorium cerebelli. Remember that the falx cerebri is
placed in the middle between the cerebral hemispheres.
What is the mechanical significance of the spiral form? Do
you see the changes that coiling and uncoiling can produce?
Realize that the ventricular distribution of the cerebrospinal
fluid is inside the neural tube and that the subarachnoid distribu
tion is outside the neural tube. All of this is just under the cranial
vault that is easily accessible to manual contact. You can hold the
vault in the exhalation phase by holding the posterior inferior
angles of the parietal bones medially and having your patient
exhale. The principle is the same as the operation for compres
sion of the fourth ventricle. It is most practical, usually, to com
press the fourth ventricle because there you have :m influence on
all the physiologic centers, including that of respiration.
Now, think of that drug store that Dr. Still wrote of in his
autobiography:
[I] further proclaimed that the body of man was God's drug
store and had in it all liquids, drugs, lubricating oils, opiates,
acids, and antacids, and every sort of drug that the wisdom of
God thought necessary for human happiness and health.6
Consider the choroid plexuses where you have that inter-
change between all the chemicals, between the cerebrospinal
fluid and the arterial blood stream. See what you are getting: an
interchange between the chemicals in the cerebrospinal fluid
and those in the blood, if you can look at it in that manner. You
become the pharmacist in the drug store mixing the chemicals
in the cerebrospinal fluid and in the blood, all at the same time.
Then, don't forget that "highest kno�n element," that "fluid
within a fluid" that nourishes what? The nerve cells that carry
impulses along the nerve fibers by a transmutation. Also, don't
63
TEACHINGS IN THE SCIENCE OF OSTEOPATH Y
forget that "finer nerves dwell with the lymphatics." When you
tap the waters of the brain by compressing the fourth ventricle,
see what happens in the lymphatic system. Visualize the lymph
node that is holding some poison that has gathered there,
changing the constituency before the lymph is moved along
into the venous system.
Once more, think of the brain and spinal cord, the central
nervous system, as part of the primary respiratory mechanism.
Recognize the motility of the whole neural tube, the tracts as
well as the convolutions, in the living context of all the move
ments of the brain. See the change in the spinal cord, cerebel
lum, and brain stem up to the lamina terminalis. See the coiling
and uncoiling of the spirals of the cerebral hemispheres based at
the interventricular foramina.
Consider the cerebral aqueduct, for instance, and see that it
is not a hollow stationary tube, but the ventricle of the mid
brain, and that there is motion in its walls so that as it changes
its shape, fluid may move through it. As I have said, you can
reason with this mechanism and see no limit.
A cast of the ventricular system of the human brain looks like
a bird to me. It reflects the interior of the brain. The third and
fourth ventricles can be the body of the bird, and the central
canal of the spinal cord, the tail. The lateral ventricles look like
the wings of a bird and are attached up where the wings of a
bird would be, off the anterior superior angle of the body. Put a
hemisphere on each ventricle and you have two wings for this
bird. These are attached at the top of the lamina terminalis., the
front wall of the third ventricle, which is a chamber for fluid.
I want you to see those things in the inhalation phase, doing
the same as a bird does when it goes into flight. At that
moment, the wings glide up a little more posteriorly than they
do in front. What does the bird do when it lights on a twig but
fold down in exhalation?
64
SIX
65
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Editor's Note: The anatomists' study of the cadaver led to a view dif
ferent from Dr. Sutherland's study of a living mechanism:
It is, generally speaking, much more important to be familiar
with the skull as a whole than with the individual bones that
comprise it, because (except in the cases of the mandible and the
ossicles of the ear) the bones are united to each other by either
suture or synchondrosis and there is no movement between
them. Muscle attachments, bony fossae, bony lines and ridges,
blood sinuses, fasciae, and so on extend from bone to bone with
out respect to such joints, so the locations of the immovable
joints that outline the individual bones are of little account.2
66
The Mobility ofthe Cranial Bones and Sacrum
Editor's Note: The following excerpts from several texts cover the
basic anatomical information that Dr. Sutherland usually referred to
before lecturing on the subject of mobility between the cranial bones
at the sutures.
67
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Editor's Note: The junction between the sphenoid and the occiput in
the clivus is a synchondrosis. That is, initially there is an intervening
hyaline cartilage that later in life is converted into cancellous bone.
This conversion is generally not completed until 25 to 30 years of age.
Dr. Sutherland believed that the cancellous bone that was formed
maintained a degree of flexibility throughout life.
68
The Mobility of the Cranial Bones and Sacrnm
69
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Articular surface
for the frontal bone
Figure 8. The sphenoid bone, showing the L-shaped surface for articulation
with the frontal bone and the change in bevel in the sphenosquamal articu
lar surface.
70
The Mobility of the Cranial Bones and Sacrum
Above the midway point the greater wings are beveled at the
expense of the outer surface, and the squamous portions are
beveled at the expense of the inner surface. Below the midway
point the opposite form of beveling ?ccurs. The significance of
this characteristic of the sphenosquamal articulations should be
studied minutely.
This articular contact between the sphenoid and the tempo
ral bones presents a mechanical principle that, in itself, without
reference to other features, portrays the design for articular
mobility between the bones of the cranial base. This interesting
articular surface generated the initial thought that implied the
possibility of cranial articular mobility for me. The study of
minute characteristics is necessary for forming a mental picture
that will lead to the diagnosis of membranous articular strains
of the cranium and to their treatment.
71
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
The study of the skull cap begins with noting the sutures
around the parietal bones. The squamosal and parietomastoid
72
The Mobility of the Cranial Bones and Sacrum
73
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
74
The Mobility of the Cranial Bones and Sacrum
75
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
76
The Mobility of the Cranial Bones and Sacrum
77
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
78
The Mobility of the Cranial Bones and Sacrum
open and close the mouths of the auditory tubes. In the case of
a lesion fixation that limits the movement of the petrous por
tions of the temporals and the greater wings of the sphenoid,
the effect on the cartilaginous portion of the tubes may hold the
mouth of the auditory tubes open or dosed.
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LEFT BLANK
SEVE N
Editor's Note: In the courses that were recorded, Dr. Sutherland gave
two separate lectures on the subject of the facial mechanism. There is
some overlap in the two; however, both lectures are incorporated in
order to give the fullest picture.
81
TEACHINGS IN THE SC IENCE OF OSTEOPATHY
82
The Applied Anatomy of the Human Face
Study the parts of the walls of the orbits. Note the articula
tion of the greater wings of the sphenoid with the zygomatic
bones. Here is another mechanism to consider when observing
the face. When a little child gets a bump on the zygoma, please
correct it. Otherwise it might lead to pathology in the eye. The
zygomatic bone is frequently found in malalignment and as it
functions in the mechanics of the orbit, injuries to it may well
affect the eyes.
Think of the widening and narrowing of the sphenomaxillary
fissure. Then think of that other fissure, the sphenoidal fissure,
the superior fissure formed by the lesser and the greater wings
of the sphenoid. That will also demonstrate a widening and nar
rowing during inhalation and exhalation. Then think back to
what is attached to them: the walls of the cavernous sinuses. A
restriction of the flow of venous blood from that vascular organ,
the eyeball, could result from a little blow, a small traumatic
force upon the zygoma. Some of the most serious conditions of
the eye have followed from such events.
Let us look at the cavity in the body of the maxillary bone.
This will show more applied anatomy of the face. As the maxil
lae are formed in membrane, the walls of the maxillary sinuses
are an osseous membrane. There are conchae, or turbinates, on
the walls of the nose that curl and uncurl. The superior and
middle turbinates belong to the ethmoid. The sphenoidal con
chae and the inferior conchae are separate bones. The nasal
accessory sinus system consists of the cavity in the body of the
sphenoid, the frontal sinuses, the ethmoid air cells, the maxil
lary sinuses, the middle ears, and the mastoid air cells. All are
air sinuses, and the mucosa lining them is continuous. It seems
that there must be some process for changing the air in this sys
tem during inhalation and exhalation, otherwise there would be
a stasis of air and the organisms would be free to multiply.
What mechanism would accomplish such a process?
83
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
The Eyeball
Little things like the origin and insertion of the extrinsic
muscles of the eyeball will challenge your skill as an osteopath.
One of them originates in the roof of the orbit and another in
the floor. The other four originate in a cuff around the optic
foramen with attachments between the roots of the lesser wings
of the sphenoid and the greater wings of the sphenoid. The
optic nerves and the ophthalmic arteries come through this canal
into the apex of the orbits. The nerves that supply these four
muscles, the third and the sixth cranial nerves, emerge through
the superior orbital fissure. The shape of this fissure changes as
the relationship between the greater and the lesser wings of the
sphenoid changes during inhalation and exhalation.
If the orbit were a cavity with solid osseous walls, where in
the name of common sense would you find accommodation for
the circulatory physiology of the eyeball, a vascular organ?
Look into the cone-shaped space and see the two outstanding
fissures - the superior and inferior orbital fissures - and ask if
84
The Applied Anatomy of the Human Face
The Vasculature
There are many things to think about in the facial mecha
nism and its relation to the cranial base. Review your knowl
edge of the anatomy of the region. Note what nerves pass
through certain foramina and certain canals. Follow the course
of the nerves to the extrinsic muscles of the eyeball and consider
the advantage of their passage through the cavernous sinus.
Then, note that the carotid artery has walls like all arteries and
also a course in the cavernous sinus. Think about the protection
of the arterial supply to the brain and the difference in the
course of the venous blood on the way out of the cranium.
85
TEACHINGS IN THE SC IENCE OF OSTEOPATHY
86
The Applied Anatomy of the Human Face
87
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Let me tell you about the facial nerve. Where does it start?
Where is its nucleus? What course does it take? Where does it
go? Have you ever treated it through the temporal bones? Do
you recall its connections with other nerves? You know that it
supplies the muscles of facial expression in the face. In cases of
88
The Applied Anatomy of the Human Face
Bell's palsy you understand that the seventh nerve is not doing
its job or is sufficiently irritated to cause spasm. Entrapment
neuropathy explains either problem. Let us study osteopathy
along with Dr. Still and put our attention on the facial nerve.
The facial nerve is efferent from its motor nucleus in the
pons. The fibers pass laterally and leave the brain just medial
to the acoustic ganglion. From there they continue caudally
and are lost in the tissue of the hyoid branchial arch. The sen
sory. fibers of the facial nerve grow from the cells of the genic
ulate ganglion.
The facial nerve supplies derivatives of the second branchial
arch. In mammals these are muscles that move the skin and car
tilages of the eyelids, nostrils, mouth, and ear. The stylohyoid,
the posterior belly of the digastric, and the stapedius muscles of
the middle ear are also supplied by the facial nerve. The nerve is
in company with the acoustic nerve at the internal acoustic
meatus. Leaving the acoustic nerve it makes a sharp bend back
wards in the substance of the temporal bone to enter the facial
canal, which curves over the superior and dorsal aspect of the
middle ear. It quits the temporal bone at the stylomastoid fora
men on its lower surface.
Wit.�in the facial canal the facial nerve gives off a tiny branch
to the stapedius muscle, which tenses the oval window of the
middle ear to adapt for loud sounds. The main trunk curves for
ward and laterally over the mandible and in the substance of the
parotid gland. It breaks up into a number of twigs for the
frontalis, the buccinator, and those muscles around the eye,
nostril, and mouth. It is liable to injury resulting in Bell's palsy.
In that case the corner of the mouth droops, the nasolabial fur
row is smoothed out, and the palpebral fissure is widened.
Facial spasm is the reciprocal of Bell's palsy and may result from
irritation to the facial nerve somewhere on its course. It begins
with involuntary winking and spreads to other muscles, express
ing itself in rapid twitches.
89
TEACHINGS IN THE SCIENCE OF OS TEOPATHY
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The Applied Anatomy of the Human Face
91
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
-
--- --
-
-t..--- Perpendicular
plate
Figure 9. The posterior articular surface of the palatine bones and their
relationship to the pterygoid processes, showing the "ruts" on the posterior
palatine where the pterygoid plates glide. Note the orbital process of the
palatine bone.
92
The Applied Anatomy of the Human Face
The two furrows on the back of the palatine bone are not the
entire mechanism. The entire mechanism resembles that of a
sewing machine. There is a little shuttle in the mechanics of a
sewing machine that runs in a concavity and shuttles back and
forth. The pterygoid processes act iike shuttles in the concave
furrows on the palatine bones. The pterygoid processes, two of
them, hang down from the body of the sphenoid. Each has a
medial and a lateral plate. The tips of these are smooth and fit
into the medial and lateral grooves on the palatine bones. These
tips converge anteriorly and diverge posteriorly.
This delicate little shuttling movement between the tips of
the pterygoid plates on the sphenoid and the furrows on the
pala tine bones is one of the big things in the science of
osteopathy. It is one of the important mechanical principles
that you must understand and include in your knowledge of the
cranial mechanism.
Look at the human head as a whole and see that it converges
anteriorly and diverges posteriorly. Think of all the little places
within it where this design operates as a mechanical principle.
From the articular facets on the atlas and the occipital condyles
to the greater wings of the sphenoid, from the ethmoid notch in
the frontal bone(s) to the mandible, the anterior convergence/
posterior divergence is conspicuous. Consider the structural
and mechanical advantages of this design in terms of stability
and mobility.
***
93
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
you wanted to back up, the wheels would back up in the ruts.
One tire would be in its rut and the other in its own rut. The
ruts would be something that the wheels would rotate in.
Look at the tips of the medial and lateral pterygoid processes
on the sphenoid. Here is one bone that has two pterygoid pro
cesses, and on each there are two plates. These pterygoid pro
cesses converge in front and diverge in back. They are like the
tires on the wheels of that truck. The palatine mechanism is
where the tips of the pterygoid processes move in the ruts on
the back of the little palatine bones. That palatine bone articu
lates with the maxilla on each side of the face.
As the sphenoid bone makes its circumrotation, see these
pterygoids as spokes on the sphenoid wheel. As the wheel
rotates to a different level, they do the same thing to those little
palatine bones that the greater wings do to the ethmoid and
frontal bone(s): the movement of the sphenoid spreads them. As
the pterygoid processes ride in the ruts on the palatine bones,
they turn them outward into external rotation. The palatine
bones, in turn, turn the maxillae, which hang from the nasal
notch of the frontal bone(s), into external rotation.
Then, as the sphenoid circumrotates into its extension posi
tion, the pterygoid processes are backing up in the ruts of the
palatines and draw the palatine bones and the maxillae into
internal rotation. Do you see the picture? Do you see the mech
anism? It is a mechanism that is subject to mechanical strain
frequently. If you disturb the mechanism at the bottom of the
palatines, you are going to disturb the mechanism at the top.
The other relations there become affected and the physiologic
functioning of the sphenopalatine ganglion is most apt to be
disturbed. The place where the disturbance is most probable is
where the maxillary nerve goes around the little orbital pro
cess of the palatine bone at the back of the floor of the orbit.
This is the picture when you tackle some of the mechanical
strains in the mechanism of the facial bones.
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The Applied Anatomy of the Human Face
I have made the statement that if you did nothing more than
diagnose and treat appropriately the problems of the palatine
bones you could establish a successful specialty practice. Do you
see why? You, as a mechanic in the. art of knowing the mecha
nism and of applying the technical work through the rule of
the artery and nutrition, would be influencing the sphenopala
tine ganglion.
Most infections get into the system by passing through the
material breathing apparatus. That includes the throat, the lar
ynx, and so forth. What is fastened to these little palatine bones
but what we call the soft palate, a muscular tissue? From that we
have muscular tissue running to the pillars that surround the
tonsil, that little mischief maker that may be full of infection.
There is the anterior pillar running to the tongue and the
posterior pillar running to the pharynx - muscular tissue.
Entering the same soft palate are the levators and tensors of the
palate, muscles which have their origin back on and beneath the
cartilaginous portions of the auditory tubes. That is, on and
beneath the petrous portions of the temporal bones and the
greater wings of the sphenoid. You understand that you can dis
tort the origins and insertions of muscles. That particular prob
lem occurs with fracture of the arm, for instance. What does it
mean to the functioning of this mechanism to have a distortion
of the origins and insertions of related muscles?
Consider the situation in tonsillitis when infection has settled
there. This may be the case in influenza, the beginning of pneu
monia, or any acute respiratory infection when the little "bugs"
are multiplying. See the mechanical principle in the location of
that tonsil, lying between those pillars, that muscular tissue.
Then is the time to apply your art of knowing to that little pala
tine bone and see how the mechanism can arrest the process
and eliminate those little "bugs" in the area. I want you to try it
out. I am speaking from experience. It is not an idle statement.
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Maxillary nerve
Sphenopalatine
(pterygopalatine)
ganglion
96
The Applied Anatomy of the Human Face
Sphenopalatine
(pterygopalatine)
Lacrimal gland ganglion
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
sends branches to the mucosa that lines the entire upper respi
ratory system, including the mouth of the auditory tubes, the
tonsils, and elsewhere.
Suppose you get a blow over the frontal bone(s) or on the
zygomatic bones: see how that blow drives that little palatine
bone back onto the sphenopalatine ganglion and affects it in
the same way that contact on the ganglion of impar, the coc
cygeal ganglion, stimulates functions. Try a little experiment on
yourself. Place an index finger inside your cheek and move it
around the body of the maxilla so as to contact the lateral ptery
goid plate. Then tip your head down over the tip of your finger.
This brings your contact close to the root of the pterygoid pro
cess. Let your head rest there while your breathing produces
movement. Note the prompt response to the stimulation from
the lacrimal glands particularly. I call this copious supply of
tears "onion tears" because they are a response to an irritant.
This experimental response to a mechanical stimulation
demonstrates the effect caused by trauma to the sphenopalatine
ganglion. It is also an effect that is available for clinical use.
Realize that the cranial concept is not a specialty. It is working
in the science of osteopathy for the benefit of your patients. If
you master the mechanical problems in the facial mechanism,
you can do wonderful work.
Malalignments of the maxillae can be considered as etiologi
cal factors in nasal, postnasal, and pharyngeal affections. The
frontal process may be twisted so as to crowd the superior and
middle turbinates of the ethmoid as well as the inferior
turbinates. The malposition narrows the sphenomaxillary fis
sure in the orbital cavity and in extreme situations may crowd
the palatine bone and disturb the function of the sphenopala
tine ganglion.
The palatine bones are usually involved in injuries to the
maxillae. Also, as they form part of the articular portions of the
orbits, they need to be considered in eye complaints.
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The Applied Anatomy of the Human Face
***
2 Dr. Sutherland compares the contact that can be made on the spheno
palatine ganglion with "the contact you can make on the ganglion of impar
that changes circulation in the head."
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Considerations in Treatment
1 00
The Applied Anatomy of the Human Face
1 01
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
"--+-+-- Lateral
pterygoid plate
Medial
pterygoid plate
Pterygoid hamulus
Horizontal plate
of the palatine
Palatomaxillary suture
Figure 11. A view of the skull, showing the palatomaxillary suture. Note the
location of the hamulus on the medial pterygoid plate.
1 02
The Applied Anatomy of the Human Face
1 03
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
when and if you have turned your finger in the wrong direc
tion. You are experienced technicians in this art, and you will
know how to turn that bone laterally by turning your finger. It
does not matter whether the lesion is in internal rotation or
external rotation; you will have to turn the bone laterally to
conform with the posterior divergence of the pterygoid pro
cess. That is the point. You can use respiratory cooperation or
the Tide. Be simple, gentle, and expeditious. Use the frontal
bone(s) to turn the sphenoid into flexion with your other hand
at the same time.
When you use this procedure clinically and find out what a
help it is in the total plan of your operations, you will have a
reliable method for solving promptly the problems involving
the relations of the palatine bones. In any of your cranial lesions
there is no change in the factor of anterior convergence/poste
rior divergence. The palatine bone is subject to distortions and
misplacements. The hidden problem that needs help requires
realignment and adjustment. When you are turning the greater
wings with contact on the frontal bone(s) you can feel the
movement or the lack of movement of the pterygoid processes
in the furrows on the back of the palatine bones. You can know
when you have the right position.
Examine and study whether the beginning of a problem with
the palatine bone may not have been a problem with the maxil
la. Then consider the zygomatic bone in relation to the maxilla.
Visualize the mechanism between the zygomatic and the maxilla
that aerates the maxillary sinus. Recall that an L-shaped area on
each constitutes the articular function. Have you noticed how
many L-shaped areas enter into these several mechanisms? Not
only in the face, but also in the sacroiliac joints.
1 04
The Applied Anatomy of the Human Face
thin, but it has two layers, and they spread to form alae that fit
smoothly over the rostrum of the sphenoid. This connection is
under the body of the sphenoid that holds the sphenoidal sinus,
an air sinus that must have movement for the interchange of air,
otherwise, there would be a stasis of air. See that the vomer is
another plunger on the center line of the two chambers in the
body of the sphenoid, drawing air in and forcing it out.
Now, see the turbinates on the side of the nose as they are in
the living body, curling and uncurling during inhalation and
exhalation. Understand their function of warming and moistening
the air before it goes to the lungs. Consider the mechanical action
of the frontal bone(s) in its relation to the ethmoid. Realize the
conditions that occur during inhalation and exhalation.
Then, begin to think of the various problems that your
patients bring to you. The problems involve congestion in the
nasal accessory sinus system with excess secretions, inflamma
tion, stasis, and polyps. Think of the physiologic action of the
sphenoid in relation to the whole facial mechanism. What
would a malposition of the sphenoid mean to the facial physiol
ogy? Look at the nasal septum and think about deviations and
bulges of the perpendicular plate of the ethmoid and vomer. If
the "wagon-tongue" is forming a bulge, why not change the
"wagon" and see how the "tongue" moves back into line?
There is a treatment for the palatines and the vomer that I
call the "wagon-tongue." This is illustrated by the picture of a
wagon with wheels and a tongue. If you get a wooden horse and
put it under the tongue you have a fulcrum. Then, you get on
the end of the tongue, and up go the wheels of the wagon. Let
us call the pterygoid processes the wheels, the vomer the tongue,
and the finger of the operator the wooden horse, or fulcrum.
Place a finger on the roof of the mouth at the cruciate suture.
Ask the patient to gently drop his head down upon your finger.
When he does, the fulcrum operates to lift the pterygoids
upward into their extension position. (See Figure 5.) You can
instruct the patient to do that for himself. You can also get out at
1 05
TEACHINGS IN THE SC IENCE OF OSTEOPATHY
1 06
EIGHT
THE SUBJECT OF "BENT TWIGS" arises from Dr. Still's phrase "the
hole in the tree." 1 I suppose the foramen magnum to be that
"hole in the tree," and the reference is to the fact that the
occiput is in four parts at birth - namely, the two lateral or
condylar parts, the squama, and the basilar process. These parts
are located around the foramen and contribute directly to the
shape of the "hole." At birth the sphenoid is in three parts -
the body and the two greater wing-pterygoid units. The tempo
ral bones are also in three parts at birth. These parts are the
petromastoid, the squama, and the tympanic ring.
The living human head is a remarkable structure at birth,
when you come to think about it. At this age it is easy to see it
as a soft-shelled egg, or a modified sphere, while later in life it is
harder to visualize it as such. All these parts of bones are held
together by the dura mater, "mother dura," functioning as an
interosseous membrane. Because of this the newborn head can
hold together and adapt so as to allow a safe passage through
the birth canal. Think of it!
1 Dr. Still considered that part of the science of osteopathy which he pre
sented as simply a partial view. He put forth those concepts that people of his
day were most likely to apprehend. He emphasized that the science of
osteopathy had not been fully delivered, and likened it to a squirrel partially
seen within a hole in the tree.
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
108
"Bent Twigs:" The Condylar Parts of the Occiput
This meeting between the anterior ends of the condyles and the
posterior end of the basilar process is not a transverse articula
tion. The joint on the basilar process faces laterally; the one on
the condyles faces medially. In many cases the union here is
109
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
almost in the sagittal plane. The basilar part is fairly well formed
at birth; it is ossified, but there is cartilage between the three
parts. When the lateral parts come together, forced together by
the convergence of the pits of the atlas, the condyles are going to
squeeze in against the intervening cartilage between the basilar
process and the condylar parts.They tend to slide together.As
the pits of the atlas do not yield because of the transverse atlantal
ligament, a degree of compression results.
Distortions of the foramen magnum frequently appear as a
narrowing of the anterior part. Sometimes the distortion is mini
mal; at other times the contours show variations with consider
able warp.These are directly influenced by the position taken by
the basilar process when it was squeezed. There are rare occa
sions of developmental anomalies and deficiencies in this region.
Except for these there is hardly anything that can make the
condyles diverge when they have been compressed into the con
vergence of the atlas.
Compression or angulation can also occur at the posterior
end of the condylar parts, at the condylosquamal junction. The
shape of the squama of the occiput is circular with the inion at
the center. The landmark at the center of the posterior rim of the
foramen magnum is located at the end of a radius from the inion.
It is named the opisthion. The squama may turn clockwise or
counterclockwise around the inion. That action carries the opis
thion to the right or left. This information should be part of a
structural examination.
Depending upon how the squama has turned, the pressure on
the posterior end of the condylar parts can be analyzed. There is
anteroposterior pressure on one side and mediolateral pressure
on the other. The condylosquamal junction may also be angu
lated in relation to the condylar parts. That is, the angle between
the squama and the condylar parts may be more acute or more
obtuse than the usual normal curvature.
The various conditions that may arise in the relations
between the four parts of the occiput are sufficient to account
for the various shapes of the foramen magnum. Should these
110
"Bent Twigs:" The Condylar Parts of the Occiput
Squama:
-----,,"""""---::>"-:--1It-- Interparietal
Supraoccipital
Kerckring's
center
Condylar
part
Occipital
condyle
Figure 12. The occiput at birth, showing it to be in four parts within a carti
laginous matrix. Note that the articular condyles receive contributions from
both the condylar and basilar parts of the occiput.
111
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
The techniques that you can use for resolving problems cre
ated by such distortions of the infant cranium as Dr. Lippincott
has described are many. However, they all depend upon a cor
rect understanding of the mechanism, especially the reciprocal
tension membrane, for that is what moves the bones.
I have called attention to the similarity of the tentorium cere
belli to the falx cerebri, pointing out the three sickles that move
around a fulcrum. That is what you will utilize in reducing
compression of these condylar parts before the "gears" are
formed. It is also utilized as one of the agencies in reducing
compression in the adult skull.
I want you to see that if you put a little tension on the frontal
bone(s) in a certain direction on one side - say on the right -
there will be action at the back on the squama of the occiput
that will swing it around on the left so that the anterior end of
the condylar portion moves out. It is useful to study the picture
of the membranes in an anatomical specimen of an infant skull.
You can see the posterior pole of attachment of the reciprocal
tension membrane is located on the inside of the occipital
squama. The use of the membranes in conjunction with the
fluctuation of the cerebrospinal fluid provides a way for decom
pression and moving these parts away from the basilar process
so that it can assume its normal place and relations.
When the condyles have been driven downward or anteriorly
into the pits of the atlas, the relation between the condyles and
the atlas have been disturbed. An occipitoatlantal ligamentous
articular strain has been produced. It is first necessary to correct
this lesion. The ligaments are used to make the correction.
Because it is not possible to make a manual contact with the
atlas, the procedure for doing this aims to bring the atlas to
the operator. The operator slips his middle finger down along
the occiput from the inion towards opisthion. The patient's
head is thus cradled in the operator's hand and the operator's
hand remains still with the tip of the middle finger simply down
near the rim of the foramen magnum.
112
"Bent Twigs:" The Condylar Parts of the Occiput
Editor's Note: In the case of the newborn or infant who cannot cooper
ate by nodding, the operator may tip their head slightly forward using
a gentle contact on the frontal region.
113
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
end of the condylar part. This can be repeated on the other side
if indicated. Respiratory cooperation from the patient is often
precisely provided by lusty crying. A rebalancing of the occipi
toatlantal mechanism should follow.
The principle of the "bent twig" manifests most clearly in the
adult. Such distortion of the foramen magnum as may have
occurred in infancy or childhood is magnified by growth and
perhaps complicated by falls or other injuries along the way.
This problem in an adult patient often indicates the need for
a solution. The procedure for decompression is the same except
that the cooperation is postural as well as respiratory. Dorsi
flexion of both feet for bilateral or midline effect is a good way
to stabilize the field of operation. When working on a unilateral
problem, ask the patient to dorsiflex the diagonally opposite
foot. Build up the tension in your contact gradually and release
it gradually. It is even more important to rebalance the atlas
after the treatment of adults than of infants.
The management of distortions between the squama and the pos
terior ends of the condylar parts of the occiput follows the same
general principles of using the dural membranes, the Tide, res
piratory cooperation, and postural cooperation from the
patient. Precise manual design for each step of the way is neces
sary for successful manual operations. Many of the distortions
in the relations of the parts of the bones of the cranial base at
birth have been recognized in medical literature. However, the
full implications for the future of a child have not been appreci
ated and neither have procedures for restoring normal relations
been developed or described. The basic understanding of the
problems lies in the science of osteopathy.
Mothers are often distressed by the shape of their baby's head
immediately after birth. They are often reassured by nurses and
doctors with remarks to the effect that distortions will change
within a few days. It often happens that they do change toward
the normal shape that parents like to see. It is instructive to
consider what is at work in accomplishing such a change.
114
"Bent Twigs:" The Condylar Parts of the Occiput
Editor's Note: The remaining text of this chapter is adapted from Dr.
Sutherland's writings in Contributions ofThought.4
4 " BentTwigs - Infants and Children," pp. 144-146 and "The Hole in the
Tree," pp. 228-232.
115
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Pterygoid plates
lesser wings, and the other between the body and the greater
wing-pterygoid units. When the lesser wing union allows a
shifting of the lesser wings in relation to the orbital plates of
the frontal bone(s), the "bent twig" effect may influence the
appearance of the eyes or result in malalignments in the walls
of the orbits that are common to strabismus. In the various
types of strabismus the cranial diagnostician considers the ori
gins of the extrinsic muscles of the eyeball, around the optic
foramen and on the floor and roof of the orbits. The mechani
cal factors in the structure of the orbits, as they relate to the
muscles of the eyeball, should be considered in conjunction
with other aspects of the problems related to strabismus.
During prenatal and early childhood periods, the intra
osseous union between the lower area of the sphenoid body
and the greater wing-pterygoid units is said to be a gomphosis,
or tooth-and-socket mechanical connection. This connection
is later surrounded by an osseous formation that leaves the
116
"Bent Twigs:" The Condylar Parts of the Occiput
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
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Membranous Articular Strains
taut and tense. They form a balance that moves alternately for
ward and backward between the various articular poles. In their
reciprocating action we recognize a rhythm that is an important
characteristic of life's material manifestation.
The dural membrane of the cranium is that part of the total
mechanism that serves the same purpose as the ligaments in lig
amentous articular mechanisms. The membranes and the liga
ments move bones at joints.
Osteopathy recognizes vertebral ligamentous articular strains.
Likewise, we have cranial membranous articular strains. These
cause restriction of the normal membranous articular function
ing. Such restrictions alter cerebrospinal fluid fluctuation, the
physiology of arterial and venous blood activity in the cranium,
and also the physiology of lymph in the neck and head. At the
moment of restriction in functions, intracranial pathology
begins.
Because the sacrum is connected to the occiput by the
intraspinal reciprocal tension membrane (the core-link between
the cranial bowl and the pelvic bowl), traumatic events in the pel
vic mechanism, from falls and situations involving momentum
inertia, may manifest an injury more obviously in the cranium
than in the pelvis. This is particularly the case in postpartum
depression or psychosis. In fact, it is impossible for a physician
and osteopath to find the correct problem for his patients with
out considering and analyzing all the joints of the human body.
***
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TEACHINGS IN THE SC IENCE OF OSTEOPATHY
the sella turcica and the anterior end of the basilar process of
the occiput both move upward as they flex, or increase the
upward convexity of the clivus; and in extension both move
downward, or decrease the upward convexity of the clivus.
Extension is just the opposite of flexion.
The junction of the sphenoid and occiput in the clivus has
the shape of an arch. It is somewhat like the kind of bridge over
the Chicago River that opens up and closes down on both sides
simultaneously. Although it closes down, the bridge remains an
arch as it lowers. This point is important when visualizing the
action at the sphenobasilar junction in technique. This junction
is an area in the cranial mechanism that you cannot feel directly.
You must visualize it. It is like the vertebral bodies in the spine:
you cannot palpate the body of a vertebra, but you have a men
tal picture of it. You can touch the spinous and transverse pro
cesses and make an observation that tells you the position of the
body. You can learn to tell the position at the junction between
the body of the sphenoid and the basilar process of the occiput
by the senses of touch and proprioception. This is not difficult,
although it may seem so at first.
We might picture the falx cerebri and the tentorium cerebelli
as cooperating with cranial articulations in physiologic move
ments rhythmic with those of the diaphragm. In this movement
one might see the mastoid processes of the temporal bones
rotating outward while exhaling and then returning inward
while inhaling, with other cranial articulations cooperating. All
of this action is in accommodation to the flow of blood and
lymph in the body. The dovetail sutures in the cranium in some
instances and the beveled articulations in others, coupled with
experience, lead one further and further into the possibility of
discovering more about the Old Doctor's science of osteopathy.3
By digging on and on into the "holes" and the articulations in
3 In his later years, Dr. Still was respectfully referred to as the Old Doctor.
122
Membranous Articular Strains
the cranial bowl, we may come to grasp the tail of the Old
Doctor's "squirrel in the hole in the tree."
When we come to study the two temporal bones as they join
in the movement of the cranial base, we first consider their form
and their location between the sphe�oid and occiput. Next, we
note what the study of their articular surfaces tells us about the
mechanics of their motion when the sphenoid and occiput cir
cumrotate into flexion and extension at the sphenobasilar junc
tion. This mental picture will give us the understanding of
normal motion going on all the time in the cranial bowl.
From our understanding of the normal, we will be able to
observe and mechanically interpret variations and abnormalities
when they are present in our patients. For we need a working
diagnosis before we come to consider lesions of this area and
techniques for correcting them.
The temporal bones move like wobbling wheels. Note that
the petrous portions are located on a diagonal that points for
ward into the head. When you study a disarticulated skull, place
the temporal bones in the cranial base between the occiput and
the sphenoid. Fit the grooves on the petrous portions onto the
tongues on the sides of the basilar process of the occiput. This
is the picture for motion - that is, the sliding pattern of
motion that a tongue and groove articulation permits.
When the sphenoid and occiput move into flexion, the
petrous portions rotate externally. When the sphenoid and
occiput turn into extension, the petrous portions rotate inter
nally. There is evidence on the outside of the skull of the com
parative rotations of the petrous portions on the inside of the
skull. This evidence can be palpated and used in the construction
of a mental picture of the positions in the sphenobasilar area.
We can interpret the position of the basilar process of the occi
put from the temporal bone because of the tongue and groove
articulations between the basilar process and the petrous por
tions of the temporal bones. The mechanism of the movement
123
TEACH INGS IN THE SC IENCE OF OSTEOPATHY
***
124
Membranous Articular Strains
125
TEACH INGS IN THE SC IENCE OF OSTEOPATHY
***
126
TEN
Dysfunction in the
Vascular System
127
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
128
Dysfunction in the Vascular System
129
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
130
Dysfunction in the Vascular System
* * *
13 1
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
sinks downward elongate the neck and draw the mastoid pro
cesses simultaneously inward.2
According to my viewpoint, tensity in the falx cerebri and the
tentorium cerebelli with restriction of the physiologic movement
at the jugular foramina and in the postnasal tissues signifies
incomplete drainage of the brain and facial regions. Complete
drainage is as essential as complete drainage of old oil from the
crankcase of an automobile motor before adding pure oil.
Therefore, the importance of a pause after exhaling to allow the
venous blood to drain thoroughly before filling up the "think
tank." The pause holds the jugular foramina wide open and the
postnasal tissues in relaxation, which allows complete drainage.3
As the formation of the jugular canal is half and half between
the temporal bone and the occiput, it is likely that this provides
for the physiologic expansion service that separates through a
rotation movement of their articulations. The jugular foramen
can be seen as resembling the intervertebral foramina in artic
ular formation. Apparently, restriction in the rotation-articular
expansion service at the jugular foramina deserves an osteopathic
consideration equal to that given to the occipitoatlantal osse
ous luxation. In my view, the restriction at the jugular foramen
is of greater importance than the occipitoatlantal in relation to
restriction of venous drainage from the internal cranial region.4
* * *
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Dysfunction in the Vascular System
133
TEACHINGS IN THE SCIENCE OF OSTE OPATHY
When he butts into the boulder this time his hind heels flop
up. He backs up again, way up, and comes charging down the
mountain path and slams into the boulder so that "the whole
damn works flop up." (For a fuller discussion of this parable,
see p. 214.)
In this parable the mountain path is the aorta. The boulder is
the crura of the diaphragm where they cross above the aorta
and the receptaculum chyli. The goat represents the valves of
the heart behind the blood descending in the aorta. There is so
much in the study of the crura: a drag on the fascia, on the cen
tral tendon of the diaphragm, on the mediastinal fascia that
goes between the heart and lungs and then folds around back of
the muscles of the neck. Did you ever stop to think that the pre
vertebral fascia goes up around the same muscles? That same
fascia is in the area of the sympathetic ganglia that are the vaso
motor regulators. That same fascia is attached to the outside of
the basilar process of the occiput. You see that we are engineers
of the human mechanical body, engineers of the highest quality.
When we slap on the sphygmomanometer to measure the
blood pressure, we pump up the apparatus and back up the arte
rial stream. What have you up there in the instance of a cere
bral hemorrhage but an arterial stream? The only occasions
when I have used that apparatus have been to satisfy a life insur
ance company with figures for their records.
134
Dysfunction in the Vascular System
135
TEACHINGS IN THE SC IENCE OF OSTEOPATHY
136
Dysfunction in the Vascular System
Left
subclavian
"""",�_....�,L-II...-+---+ Sternum
Umbilicus
y
Figure 14. The areas of application for Dr. Sutherland's lymphatic treatment,
showing the location of the junction between the thoracic duct and subclavian
vein, the course of the thoracic duct, and the omentum.
137
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Editor's Note: C. Earl Miller, D.O., taught a method in about 1920 for
gently springing the upper rib cage with the intent of facilitating the
movement of lymph.
138
ELEVEN
Entrapment Neuropathy
139
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Editor's Note: This area is liable to torsional strain and strain by elon
gation or bending, thereby narrowing the lumen.
140
Entrapment Neuropathy
141
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Cut edge
of fascia
Anterior
tffl'fft--- longitudinal
ligament
I
Splanchnic
nerve
nerve
Superior
costotransverse
ligament
Figure 15A. The anterior surfacl; of the posterior thoracic wall, showing the
relationship of the sympathetic (lateral chain) ganglia to the costovertebral
junctions.
142
Entrapment Neuropathy
Fascia --..2�N'f:
( costal pleura)
Lung "'--
........
.. ... -Vertebral body
'NofR,.-."....,.- Splanchnic
nerve
Anterior longitudinal
ligament
Esophagus
143
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
144
TWELVE
Trauma
Editor's Note: There are three considerations when thinking about the
living human body, including the head. The first is the view of the
involuntary physiology that is going on all the time, including its
mechanical aspects. In this view we see the flexion and extension of
midline structures together with the external rotation and internal
rotation of paired lateral structures.
The second is the adaptation that this living structure makes to var
ious postural stresses and strains, thus creating patterns that are
observed in an osteopathic structural examination. Such patterns are
the expression in the adult of the small strains that occurred in infancy
and became larger with growth, the "bent twig" phenomenon.
The third consideration is trauma, in the sense of injury from the
impact of an external force upon the living head. If the head as a
whole can move with such a force in translation, the impact upon the
mechanism is minimized. However, the effects of momentum-inertia
(when a moving object meets with a stationary one) present a spec
trum of severity and also an infinite variety of extended consequences.
This short lecture by Dr. Sutherland does not exhaust what he had to
say on this subject over the years of his teaching.
145
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146
Trauma
147
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
148
Trauma
* * *
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THIRTEEN
DIAGNOSIS
THERE ARE SEVERAL PRINCIPLES that I have used in the process of
making a diagnosis of the situation in the living head. The first
consideration in this process is the use of your hands for palpa
tion and the tests for motion. You may use your sense of touch
as well as your sight to make observations of the shape of the
head and face as a whole and in detail. You may feel numerous
landmarks, the size and shape of individual bones, and outline
the sutures. This initial study is relatively superficial, but it is
the background within which you place further findings.
When palpating let your fingers light gently on the skull, on
the abdomen, or anywhere on the patient's body. Let your hands
be like the bird lighting on the branch of a tree, quietly touching
and then settling down over the area. While your fingers are
there feeling, seeing, thinking, and knowing, they can tell you
more in one minute than a firm grasp can gain in an hour's
observation. You will train them to observe without interfering.
If you try to grasp the vault firmly you are not going to learn
much because you will be mixing the sense of touch, the propri
oceptive sense, and the motive power of the hand.
Now, I will tell you about the use of contacts on the vault for
finding and understanding what is going on in the articular
mechanism of the cranial base. I must mention first that you
151
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Then you learn to use the muscles of the forearm, the flex
ors, to control your contacts on the patient. The operator uses
the flexor digitorum profundus and the flexor pollicis longus in
the development of his manual skills. Notice in my demonstra
tion of this vault contact that my fingers are not sticking out
way down on the sides of the patient's head. I cannot manage
the cranial base that way. My contact on the parietal bones is
with the palmar surface of the proximal parts of my digits up on
152
DiaIJIZosis and Treatment
153
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
SIDE-BENDING/ROTATION
Axis of rotation
Axes of rotation
154
Diagnosis and Treatment
155
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
In this case you just start the movement and observe that the
mechanism carries along to its full excursion in the direction
started. With one index finger lift the greater wing of the sphe
noid on one side, and with the little finger of the other hand lift
the occiput on the other side. [The direction of the lift is cepha
lad. -ED.] When this torsion pattern responds to your action,
you feel the response at the sphenobasilar junction right away.
Then you allow the mechanism to return to neutral and test for
torsion in the other direction. The response is observed in the
same way.
When these responses are back to neutral you make compar
isons of promptness, freedom, and range of excursion to draw
your diagnostic conclusions. The conclusions are determined by
the directions in which the bones move most promptly, freely,
and fully. When strains exist there is more movement in one
direction and limitation in the other. The strain pattern is
named for the direction of the freer, more extreme movement. I
have used this schematic routine so that my records tell me of
the diagnostic facts for each patient visit. It is also a scheme that
is useful in teaching. It is not an absolute way for the mecha
nism to work.
Observation of movement as well as of position and shape is
possible when you become familiar with the normal landmarks.
You can look at the living human head and see the bones mov
ing. In the flexion position you see the parietals moving exter
nally. With extension you see them coming into internal
rotation. If you are looking at the face, you see the orbits
widening and narrowing and the eyeballs coming forward when
the cranial base is in flexion and receding when the base moves
into extension.
When there is a side-bending/rotation pattern in the cranial
base, watch the zygoma on the side of the higher greater wing
move externally. Then see the zygoma on the other side,
where the greater wing is lower, coming into internal rotation.
156
Diagnosis and Treatment
Editor's Note: At the courses that were recorded, Dr. Sutherland gave a
second lecture on the subject of diagnosis. It is included here for the
further elaboration of some key concepts.
157
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
158
Diagnosis and Treatment
159
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
160
Diagnosis and Treatment
161
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
162
Diagnosis and Treatment
VERTICAL STRAIN
LATERAL STRAIN
\
Axes of rotation
163
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164
Diagnosis and Treatment
165
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
1 AdahStrandSutherland,
1 66
Diagnosis and Treatment
1 67
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
1 68
Diagnosis and Treatment
169
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
TREATMENT
170
Diagnosis and Treatment
17 1
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172
Diagnosis and Treatment
173
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
* * *
174
Diagnosis and Treatment
175
TEAC H I NGS IN THE SCIENCE OF OS TEOPATHY
3 Sti l
l, Philosophy and Mechanical Principles of Osteopathy, p. 66.
1 76
Diagnosis and Treatment
that you are examining. If you did nothing other than direct
that Tide, there would be, in time, a correction of the lesion.
* * *
Here is another thing you can do for treatment. Take the tem
poral bone, for example, and the occipital bone; visualizing the
movement at the occipitomastoid articulation, turn the temporal
bone very gently in one direction and the occiput in the other.
Hold this situation gently while you direct the Tide from the
diagonally opposite frontal area. There will be some surprising
experiences to observe under your gentle, feeling, seeing, think
ing, knowing fingers. You are going to be dealing with many
varieties of trauma in your practice. That is why I am stressing
this direction of the potency of the fluctuation of the cere
brospinal fluid in diagnosis and in the techniques of treatment.
* * *
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178
Diagnosis and Treatment
1 79
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
1 80
Diagnosis and Treatment
see that the sacrum may be balanced and reseated between the
ilia if the ilia are moved laterally. In the saddle the sides of the
horse hold the femurs laterally as the saddle rhythmically moves
the sacrum between them. At the bedside the operator can carry
or turn the ilia laterally but he may need to have a nurse turn
the sacrum.
The charter of the American School of Osteopathy, the first
osteopathic school, stated that its purpose was to teach methods
for improving the practice of surgery, obstetrics, and the treat
ment of diseases generally. Do you realize the full meaning of
that? You have that improvement because your skill is non
incisive through the use of thinking, seeing, feeling, knowing
fingers. You are nonincisive surgeons.
181
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FOURTEEN
WHEN I WENT OUT into the field to practice, I had nothing. When
I met up with some of those old dried-up chronic cases, all I
had to work with was the science of osteopathy. All I had to com
pete with the medical profession and their equipment then in
use was what I had been taught at the American School of Oste
opathy. I did succeed and began to find improvement in some of
those old chronic cases. That is why I have said, "If one can
think osteopathy one will find much in it. Don't twiddle away
with something else. Keep on digging and digging until you
have found the correct problem." If you do keep on digging you
will find the Old Doctor's "squirrel in the hole in the tree." I
think of this cranial concept as merely a "breech presentation"
of that squirrel.
The word osteopathy has been ridiculed as a misnomer. Those
who take that view lack perception of Dr. Still's thinking and are
not informed of the truths in his teaching. When Dr. Still
named the concept that he had decided to practice "osteopathy,"
he said that he chose the name because "you begin with the
bones." He considered this decision the birthday of osteopathy.
That was June 22, 1874.
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184
Clinical Experience in the Practice of Osteopathy
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1 This work originally appeared in 1863. John Hilton, Rest and Pain, ed.
E.W Walls, Elliot E. Philipp, 'and H.].B. Atkins (London: ].B. Lippincott
Company, 1950), p. 52.
2 Virgil Halladay, The Applied Anatomy of the Spine (Kirksville, MO:
Journal Printing Company, 1920).
186
Clinical Experience in the Practice of Osteopathy
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
it out with the toes. If, instead, you understand the mechanism
and the location of that external cuneiform in the mechanism,
you can just go right into the area and feel when you get the
balance point. All you have to do is to remember that the liga
ments allow a certain range of movement. It is easy to let them
realign the relations of the bones. You can also realize the func
tion of that little talocalcaneal interosseous ligament and see
that you can use it for realigning the relations between the talus
and the calcaneus.
The leg is a membranous articular mechanism. So is the fore
arm. There is the tibiofibular interosseous membrane and the
radioulnar interosseous membrane. You can use these mem
branes as you use ligaments to realign the relations between the
bones. This is because they function like ligaments in the
regional mechanisms.
Dr. Still gave me a lesson one day along with the rest of our
class. A member of the class had stepped on a rusty nail. All the
appropriate surgical management and cleansing had been used,
but the wound would not heal. It began to look an angry red, so
we called in the Old Doctor. He said, "You damn fools!" And
we were. We had not stopped to consider that when the patient
stepped on that nail he drew his leg up away from it. What
happened? The little fibular joint at the proximal end went pos
terior and the joint at the distal end went the other way. Thus
the blood supply down in the foot was disturbed, and that was
where the rusty nail had done its mischief. The lasting problem
was not the nail or the original wound; it was what occurred in
that sudden jerk of the patient that caused a membranous artic
ular strain between the fibula and the tibia. It was a strain at
both ends that also strained the interosseous membrane
between them.
You can take both ends of the fibula and balance the two
bones through the action of the tibiofibular interosseous mem
brane. The radioulnar interosseous membrane will also work
188
Clinical Experience in the Practice of Osteopathy
for you when you balance the mechanism with two contacts.
You can do the same with the clavicle, which has two articular
points. The clavicle may be tipped in at the sternal end and out
at the acromial end or vice versa. With the patient sitting, all
you have to do is to get a thumb under each end of the clavicle,
ask the patient to bend forward and thus lift both ends. The lig
aments do the balancing. This is why I treat fibular lesions with
a contact at both ends. It is a double lesion that may also hap
pen in the forearm. The radius and the ulna together make a
double swivel. When both ends are strained the interosseous
membrane is not only also strained but it is the agent that will
resolve the strain with two contacts. (For descriptions and illus
trations of these techniques, see the Appendix.)
When a patient complains of discomfort where the deltoid
muscle inserts, look to the origin of the muscle both on the
clavicle and on the scapula. See that type of lesion twisting the
tendon of the muscle rather than an irritation to the circumflex
nerve. See the twist in the muscle itself and a change in the dis
tance from the origin to the insertion.
189
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
190
FI F T EEN
191
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192
Osteopathy in General Practice
193
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194
Osteopathy in General Practice
You can use the principle of the fulcrum and postural cooper
ation in treating tibial or fibular lesions at the knee. (See
Appendix and Figures A.34-35.) The patient places the problem
leg over the opposite knee. The fulcrum is located where the
leg is placed. The operator is seated in front of the patient at a
slightly lower level. He can grasp the proximal end of the fibula
with one hand and the distal end with the other. Then, the
patient places his hands, one over the other, upon the knee and
pushes it toward the floor as he dorsiflexes the foot. The com
bined maneuver in action operates over the fulcrum so as to
rebalance the tibial, fibular, and femoral relations.
In a similar way, you can combine the cooperation of the
patient with the creation of a fulcrum in treating a ligamentous
articular strain at the hip joint. (See Appendix and Figures A.32-
33.) The patient is seated on the table with the operator seated
in front of him. The operator creates the fulcrum by placing his
opened hand as near as possible to the joint on the medial side
of the patient's thigh. The patient places his leg upon the other
thigh and his hands on the top of that knee. Then he leans for
ward, and falls to the side and backward in a circular motion,
coming forward again as the operator leans his weight into his
contact on the inner thigh near to the hip joint. Or the patient
may move around his femur in the other direction, depending
upon whether the strain was in internal or external rotation.
This is another use of the principle of the bolt and the nut. You
are holding the bolt (the femur) and the patient is turning the
nut (the acetabulum). I learned this procedure from the Old
Doctor. He knew the anatomicophysiologic mechanics so well
that he could put a patient up against a tree or anywhere he met
1 95
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
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Osteopathy in General Practice
the ligaments draw the ulna back into place. (See Appendix and
Figure A.23.) The ligaments will do that for you. You need to
understand the mechanism in order to understand the problem
and operate on it with its own mechanical possibilities. If you
bring the ulna up to a right angle, you can contact the process
at a place where, at a certain point, you simply pull it out into
position. With the olecranon process in its fossa you cannot
realign the parts.
Use the same principle for a problem at the other end of the
humerus, in the action of the shoulder joint. All you have to do
is understand the mechanism of using a fulcrum under the
humerus. Make a fulcrum by placing your hand close to the joint
between the inner arm and the side of the chest. Have your
patient place his hand on the other shoulder, which draws the
arm over the fulcrum. He can raise or lower his elbow slowly.
This will permit you to find a position of balanced ligamentous
tension in the shoulder joint, and the ligaments will do the work.
The Clavicle
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198
Osteopathy in General Practice
199
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
200
Osteopathy in General Practice
201
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
202
Osteopathy in General Practice
All the tissues of the body are fluid. The very bone itself is
fluid. When there is that interchange between all the fluids of
the body, I want you to see a "penetrating oil" working through
203
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
all the bony articulations. You can establish such a state through
compression of the fourth ventricle, lateral fluctuation of the
cerebrospinal fluid by contacts on the temporal bones, or con
tacts on the parietal bones, the greater wings of the sphenoid,
or' through a contact on the sacrum.
That is what I do in trying to correct old chronic spinal
lesions, primary spinal lesions. With the management of the
fluctuation of the cerebrospinal fluid you may observe many
secondary and compensatory spinal lesions resolving out to
their normal relations. That leaves the primary lesions on clear
display. Then you can treat them with "penetrating oil." I want
to impress upon you that bony tissue is fluid.
The late E. Tracy Parker, D. O., was an early student. He
experimented with various ways of using the Tide. He wrote
me frequently about the response of old chronic spinal lesions
to his endeavors. His patients were as happy as he was with
their improvements. He also noted a beneficial effect upon the
entire circulatory system with the reduction of congestion,
edema, and ischemia.
204
Osteopathy in General Practice
were more reliable. One day, however, the axle on the buggy
broke when I was on the way to a house call. It was only twenty
five miles, but it took me quite a while to get there, riding one
horse and leading the other.
Along the way I found my patient coming to meet me. I found
her in a mentally-strained, distraught state following the birth
of her child. After helping her onto the horse I was leading, we
finally reached her house. By the time we did arrive, her dis
turbed state had disappeared, and she was her usual calm self.
After examining her and thinking about her history, I con
cluded that her sacrum had sagged following delivery and thus
created a membranous articular strain in the cranium that
especially locked the cerebellum down upon the brain stem,
the fourth ventricle, and the cisterna magna in the posterior
cranial fossa. But what accounted for the change after riding
horseback?
It seemed that the sides of the horse held the femurs laterally
so as to provide a traction on the pelvic ligamentous articular
mechanism. Then, with the movement of the walking horse, the
sacroiliac ligaments could allow the sacrum to become reseated
and functional, thus fluctuating the cerebrospinal fluid in the
primary respiratory mechanism and relieving the reciprocal ten
sion membrane so that the fulcrum could shift.
Analysis of this experience led me to suggest that "sacral sag"
could be corrected from the front. Therefore, the anterior
approach to the alae of the sacrum, in an operation that would
hold the ilia or turn them laterally while the operator pushed,
was devised. It is another example of postural cooperation from
the patient combined with a specific and precise procedure
from the osteopath.
The framework of the technique is established by having the
patient seated on the table. The operator is seated on a stool in
front of the patient. The operator places his thumbs on the
inside of the crests of the ilia. The fascia provides a place right
205
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
along there, medial to the crest, where the thumbs can advance
toward the alae of the sacrum. The patient places his arms
across your shoulders and leans forward as you also lean for
ward, while advancing your thumbs. When the tension has built
up and balanced and the patient's respiratory cooperation is
working, the direction of your thumbs tends to move the sacral
base up and back. The patient is then asked to sit up and rock
the pelvis back in the process. While the patient does this the
operator draws the patient's knees medially with his knees so as
to keep the ilia from being drawn together in back of the sacral
base. The operator does not change the tension in his
approach; he maintains it as the patient sits up, for this is the
effective point in this operation. It sounds difficult, doesn't it?
But it is easy when you know how to have the patient put "the
glove on the finger," or thumb, in this instance, rather than
advance with force.
When you have advanced your thumb in the direction of the
sacral alae a ways, what do you meet? The iliacus muscle and
the psoas muscle merge to form a tendon that inserts into the
lesser trochanter of the femur. When you have your patient tip
forward and put those tissues on your thumbs gradually, where
are you? Down near the alae of the sacrum. When your patient
rises up, what happens? Can you visualize the action? The oper
ator must keep his contact intact at this step.
Editor's Note: Allowing the patient to put the "glove on the finger"
demonstrates a general principle that Dr. Sutherland applied consis
tently in all of his techniques. That principle was to have the greatest
respect for the tissues. Whenever possible in a technique, he would
position his finger(s) and then ask the patient to settle the tissue to be
treated down onto the finger.
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Osteopathy in General Practice
207
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Editor's Note: The viscera of the cervical region are enveloped in a fas
cial unit composed of the pretracheal fascia anteriorly and the buc
copharyngeal fascia posteriorly. The pretracheal fascia is suspended
from the hyoid bone, while the buccopharyngeal fascia is suspended
from the cranial base. This fascial unit extends into the thorax and blends
into the pericardial fascia, which, in turn, merges into the diaphragm.
Embryologically, this occurs because the cardiac bud develops at the
cephalad end of the embryo and subsequently migrates caudally to its
thoracic position. Traveling along with the cardiac bud is the mes
enchyme of the oropharyngeal plate and the septum transversum. The
mesenchyme develops into the liver and pancreas, which retain attach
ment to the septum transversum. The septum transversum receives
muscular elements from the somites of T6 through L2-3, and together
they form the diaphragm.
208
Osteopathy in General Practice
The Diaphragm
209
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
The Kidney
21 0
Osteopathy in General Practice
Later�1
arcuate
ligament
Quadratus
lumborum
muscle
21 1
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
The pelvic lift is a technique for lifting viscera off the pelvic
diaphragm. (See Appendix and Figure A.4S.) When the pelvis
is crowded due to ptosis the levator ani muscle becomes taut,
and discomfort, if not dysfunction, follows. As I have said, you
use the power of the diaphragm to do the lifting once the
operator's contact in the ischiorectal fossa is located so as to
hold the lift that goes with exhalation against the fall that
accompanies inhalation.
The operator arranges himself and the patient as circum
stances permit so that he can insert two fingers into the
ischiorectal fossa and advance them with exhalation of the
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Osteopathy in General Practice
thorax. When the patient lies on his left side the work is done
through the right ischiorectal fossa. When the patient lies on
his right side the work is done through the left ischiorectal
fossa. As the operator leans forw�rd his weight stabilizes the
procedure of holding his advance in the fossa when the patient
inhales. The lift occurs as the operator advances his contact as
the patient exhales and the diaphragm ascends into the thorax.
Once this action becomes effective the abdominal viscera are
lifted out of the pelvis by the thoracic diaphragm. At that time
the patient is asked to hold his breath out, which is then fol
lowed by a deep involuntary inhalation. Then the maximum lift
has occurred. The benefits of this technique are many. They
include rellef of discomfort in cases of hiatal hernia, spastic
sphincters, unrelieved vomiting, coughing, and some diarrhea
that persists beyond usefulness.
21 3
TEACHINGS IN THE SCIENCE OF OS TEOPATHY
21 4
Osteopathy in General Practice
area of the boulder is the crura of the diaphragm, which are the
attachment of the diaphragm to the anterior longitudinal spinal
ligament at the level of the upper lumbar vertebrae.
Let us study further this area of the posterior abdominal wall.
(See Figure 1 8.) The crura of th e diaphragm cross over the
midline. On either side there are two fascial structures called
the lumbocostal arches or the arcuate ligaments. The medial
lumbocostal arches pass over the psoas major muscles from the
transverse processes of the twelfth thoracic vertebra to blend
into the crura of the diaphragm. The lateral lumbocostal arches
pass over the quadratus lumborum muscles from the tips of the
twelfth ribs to the transverse processes of the vertebra.
Practically speaking, these structures are interlaced and stabilize
the whole back wall of the abdomen at this level. There are two
directions in the action here: the crura are lifting up, and the
psoas muscles, which go from the lowest vertebrae of the tho
racic spine to the lesser trochanters of the femurs, are working
down. When there is a strained situation here, as with a twist in
the capsule of the hip joint, it is difficult to release a lock at the
thoracolumbar junction. When you try to correct a strained
position of the mid-lumbar spine, you find it difficult. There is
much to be gained from Dr. Still's study of the fascia.
One way to release the "boulder" in the posterior abdominal
wall is to use the twelfth ribs as contacts, or handles, for the lat
eral lumbocostal arches. With the patient supine it is easy to use
his weight as a counterforce to your grasp, your plastic contact
on the outside of the twelfth rib. Then, all you have to do is
lean backward for a controlled lateral traction on the rib and
therefore on the lateral lumbocostal arch. This traction gradu
ally extends to the medial lumbocostal arch, and when the strain
releases, the diaphragm is released and rises into the rib cage,
and the lumbar spine springs free. The "boulder" has disap
peared. Then you can use balanced ligamentous tension for the
correction of the other strains that you find.
21 5
TEA CHINGS IN THE SCIENCE OF OSTEOPATHY
When you carry the floating ribs, the eleventh and the twelfth,
laterally you may succeed in relaxing spasm in the pyloric
sphincter and the sphincter of Oddi so that the digestive tract in
this area will function better. Hiccoughs may fade out with
work on strains in the splanchnic area of the thoracic spine as
well as on strains in the cervical spine.
Treatment of the ribs can be approached with the patient
lying on the side. You can make a sort of hammock of your
clasped hands below the rib cage. Standing straight above your
hands, you can supply a gentle lift of those ribs. This action
moves the heads of the ribs in relation to the vertebrae as the
breathing goes on and would be expected to smooth out dis
turbed function in the splanchnic area. It may be useful in some
instances to use fascial lifts of the abdominal viscera in this
combination of contacts and respiratory cooperation instead of
the pelvic lifts.
216
SIXTEEN
Problems of Infancy
and Childhood
WHEN YOU SEE A child with a misshapen skull, you wonder what
happened. Sometimes you can recognize a flexion base with an
extension vault, or the opposite, a flexion vault with an exten
sion base. I want to tell you some of the things to think about.
As you observe the outer landmarks and the evidence they
provide, consider the inside of the skull and the effect of the
warped spaces upon the brain and spinal cord. What has hap
pened to the reciprocal tension membrane and the fluctuation
of the cerebrospinal fluid? Do you see that there may be crowd
ing of the cerebral hemisphere on one side and an expanded area
on the other? What might happen to the pyramidal tracts with
growth, or to the cerebellum? Again, visualize the inside from the
analysis of the outside. It is comparatively easy to see the land
marks on a child, even if you can't clarify the evidence with
palpation. Remember that the pattern you see may not yet have
produced functional problems. There is more room in the
heads of infants and children for variations, but as the child
grows the lack of symmetry may begin to manifest stresses and
strains. It would be a matter of the particular facts and their
history to draw a connection with a current problem. This is
the "bent twig" phenomenon that is to be thought about. (See
Chapter 8.)
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
2 18
Problems of Infancy and Childhood
219
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
220
Problems of Infancy and Childhood
221
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
222
Problems of Infancy and Childhood
When you are ready to study and diagnose the cranial base,
you will want to know all that you can learn about the pattern at
the sphenobasilar junction. The systematic process of tests for
motion is challenging because of the delicate response in your
small patient. The usual routine is the same as in larger patients
- that is, flexion, extension, side-bending/rotation, torsion, ver
tical strain, and lateral strain. In addition to compression, either
of the whole base or of some particular area, you recognize the
complex combinations of the parts as they may have occurred at
this age.
It takes time for all of these observations to be made and
noted in an unhurried manner on the first visit. You are estab
lishing the general experience for your professional service, for
the patient, for the parents, and as a foundation for future visits.
Note your findings and impressions at the first visit precisely as
well as any operations that you may have performed together
with the response. You may not be satisfied with any accomplish
ment at this time, but the manner in which you work has signifi
cance for the patient and the parents. There is no substitute for
getting all the facts that are obtainable as clearly as possible. At
the next visit all concerned are prepared to start out according to
the manner established. The sequence of findings in your
records provides you with facts that are not otherwise available.
When you have a concept of the patient's cranium as a whole,
you will be ready to investigate the intraosseous situation, espe
cially in the occiput. The occipital squama is accessible. It will fit
right in the palm of your hand. Note the condylosquamal junc
tion on both sides; note whether it is a smooth contour or angu
lated. If angulated, note whether the angle is acute or obtuse.
Also note whether the opisthion is centered or positioned to the
right or left of center. It is easy to derotate the occipital squama
in early life, whether it is rotated clockwise or counterclockwise.
As this is done any compression of the condylar parts that may
be associated with it is released.
The occipital squama can have bent at the superior nuchal
line as well as at the condylosquamal junction. It may have
turned on its vertical axis so that one side is more anterior than
223
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
224
Problems of Infancy and Childhood
225
THIS PAGE INTENTIONALLY
LEFT BLANK
SEVENTEEN
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
228
A Tour of the Minnow
229
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
terminalis. There are two open doors in this wall, the interven
tricular foramina. He pushes into the right one and finds him
self in the right lateral ventricle. As he goes forward in this he
bumps into the frontal lobe, so he has to turn around. This
whole anterior area seems to have become a superior area. It is
where the neural tube folded up and back over along the top of
the head. The next part of his swim is where the motor cortex
of the brain surrounds the ventricle, where the orders go forth
to tell something to move. At the back of the cranium he finds
that the occipital lobe turns again, downward and forward. The
visual cortex is here, the part that does the seeing, close to the
falx cerebri and the tentorium cerebelli. The temporal lobes of
the brain are tucked forward into the inside of the greater wings
of the sphenoid. All of this lies above the "tent" (tentorium
cerebelli). What would happen if this angle between the falx
and the "tent" became acute and squeezed the visual cortex?
Once more he is in a place where he has to turn around. So
he swims back along the right lateral ventricle to enter the third
ventricle again. This whole swim has been a spiral path. The
left lateral ventricle must have one like it. The cerebral hemi
spheres folded up and over and back and forward from the front
end of the brain stem. So where is the outside found in the mid
dle? It must be the great transverse fissure of the brain. The
tentorium cerebelli is between the contents of the posterior cra
nial fossa and the occipital and temporal lobes. This place in the
middle is where the pineal body lies upon the superior colliculi
of the midbrain, on the outside of the neural tube.
But our minnow is inside, back in the third ventricle where
he has some fluid to swim in. He gets back to the fourth ventri
cle through the cerebral aqueduct and finds his way out of the
door into the subarachnoid space - into the cisterna magna.
There is room to swim in this lake, too. He can swim around
the medulla oblongata on the outside and see the cerebellum
like the bellows that blacksmiths use to blow air on their fire.
He can feel the tide coming in.
230
A Tour of the Minnow
The little minnow swims next under the brain stem and into
the water beds that the brain rests upon: the cisterna basalis. He
comes up around the pons to go above the cerebellum into the
superior cistern and there he is agaiJ.? right on the outside and in
the great transverse fissure. He can see not only the pineal body,
that little cone, but also the deep cerebral veins, the choroidal
veins, and the cerebellar veins, all converging and entering the
great vein of Galen just before it enters the straight sinus.
Then the little minnow wanders around the outside of the
hemispheres of the brain in the subarachnoid distribution of
the cerebrospinal fluid, beneath the arachnoid membrane and
outside the pia mater. He notes how closely the pia mater fits
to the surface of the neural tube carrying arterial blood. The
arachnoid membrane spans across the tops of the sulci and fis
sures. This arrangement provides him with the fluid in which
to swim.
He thinks, however, that it is not much in some places and
wonders what would happen if that arachnoid membrane
became locked down upon him while in one of these spaces.
The space would get smaller and he might not be able to get
into all that fluid around the outside of the brain or into the
fluid on the outside of the spinal cord. Could he get around the
medulla if it were jammed down into the foramen magnum?
What would have to happen to produce that situation?
He can see that if the occiput and the temporal bones were
not working right, the tentorium cerebelli could become locked,
and the shape of the posterior cranial fossa would be changed.
The shape of the jugular fossa would also be changed. Would
these changes affect the movement of the venous blood
toward and out of the jugular foramina? If the outflow of
venous blood from the cranium were restricted, would you
feel good? Would you have a headache? What events might
happen that would put a strain on the relations between the
occiput and the temporal bones?
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
Suppose a person were hit on the top of the head. Would that
blow jam down on the fluid there in front of the pituitary body
and around it? It seems that there are many spaces around the
outside of the brain where the fluid should not be disturbed.
What if the head became warped into a side-bending/rotation
shape so that one chamber of fluid became smaller and its like
on the other side became larger? Would there be more fluid
where there was more room and less fluid where there was less
room? Could that situation be straightened out?
This tour is long enough. He has been inside the cranium all
the time while touring on the inside and on the outside of the
living human brain. The little minnow has seen enough to pro
vide thought for a long time.
232
APPENDIX
T he Osteopathic Technique of
Wm. G. Sutherland, D.O.l
H. A. Lippincott, D.O.
GENERAL CONSIDERATIONS
1 This article was originally published in the 1949 Year Book of the
Academy of Applied Osteopathy.
233
T E A C H I N G S IN T H E S C I E N C E O F O S T E O PAT H Y
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Osteopathic Technique of Wm. C. Sutherland, D. O.
235
T EA C H I NGS I N T H E S C I E N C E O F O S T E O PAT H Y
CERVICAL VERTEBRAE
From the axis to the seventh cervical vertebra the articular surfaces
lie in a plane that is tipped anteriorly from the coronal, SO, in flexion,
the articular processes of one vertebra move upward and forward in
relation to the one below, and in rotation sidebending, the movement
is in that direction on the side that is anterior and convex. In extension
the articular processes move relatively downward and posteriorly as
does the one on the posterior and concave side in rotation sidebend
ing. The anterior convexity of the cervical curve is reduced or
straightened when the neck is bent forward in flexion, increasing the
distance from the occiput to the shoulders. That distance is also
increased on the anterior side in rotation sidebending and is reduced
in extension, as well as on the posterior side in rotation sidebending.
The technique for correction of cervical ligamentous articular strains
makes use of those principles. The articular processes that are rela
tively anterior or that move anterosuperiorly more easily, are held
anterosuperiorly to balance the tension of the capsular ligaments,
and the shoulders of the patient are placed so that the lesion position
is exaggerated.
The manner in which the patient holds the neck, especially in acute
lesions, and the altered bony relationships and soft tissue pathology
noted under palpation give evidence of the location and type of lesion.
The determining factor, however, is the freedom or restriction of
motion. The articulation moves more freely and usually with less dis
comfort to the patient in the direction of the lesion than in the oppo
site direction.
The technique is best applied with the patient supine and relaxed,
but when circumstances do not permit this, the physician can use his
ingenuity in adapting the technique to the position that can be
assumed. It is said that Dr. Still, meeting a patient on the street,
would even stand him against a tree to reduce a sacroiliac lesion.
There is considerable latitude in applying Dr. Sutherland's technique
providing the underlying principles are not violated. The position of
the shoulders is taken withou't appreciable strain or tension of the
muscles, the purpose being only to affect the ligamentous tension by
altering the relative position of the attachments of the ligaments.
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Osteopathic Technique of Wm. G. Sutherland, D.O.
Figure A.!, Cervical Technique: In this case the fingers are crossed to contact the
articular processes on the opposite side.
Flexion Lesions
The articular processes of the upper of the two vertebrae involved
are held anterosuperiorly by the tips of the operator's fingers, the
direction being in the plane of the articular surfaces. The patient low
ers both shoulders toward the hips avoiding any abduction of the
arms. The point of balanced tension is found by the operator and held
during respiratory cooperation in inhalation, which also tends to
reduce the anterior convexity of the cervical spine.
Extension Lesions
These are corrected with the processes of the lower of the two ver
tebrae held anterosuperiorly, the patient's shoulders moved cranial
ward, and respiration cooperation in exhalation.
237
T E A C H I N G S I N T H E S C I E N C E O F O S T E O PAT H Y
The one on the opposite side of the vertebra below is held anterosu
periorly under the inferior facet of the upper one, which is relatively
posterior and downward. The shoulder is lowered on the side of con
vexity to increase the separation of the facets and the opposite one is
elevated to carry the superior process of the lower vertebra anteriorly
and upward. The patient holds the breath either in or out, sometimes
depending on whether the strain is greater where the articular pro
cesses are separated or approximated. Respiratory cooperation follows
the general rule that inhalation is associated with flexion and external
rotation, exhalation with extension and internal rotation. The point of
balanced ligamentous tension may be rather elusive, making it neces
sary to slightly alter the degree of pressure on the articular processes
or the height of the shoulders. The greater strain may be in the liga
ments of either one side or the other, so the tension may have to be
varied to attain balance.
Condyloatlantal Lesions
The articular pits of the atlas converge anteriorly and inferiorly,
and they curve cranialward to a position anterior to the occipital
condyles. The motion permitted is a nodding of the head as the
condyles rock forward and back in the cup-shaped pits of the atlas.
Correction of the condyloatlantal lesion is made with the patient
supine as the position of choice. The operator places the tip of a fin
ger against the posterior tubercle of the atlas and holds that bone
anteriorly to prevent it from moving dorsally with the condyles as the
patient nods or tips his head forward, avoiding flexion of the cervical
spine. This rocks the occiput posteriorly in the pits, releasing the
condyles from the atlas, and tenses the ligaments. The right and left
articulations will find a point of balance between them, perceptible to
the operator as a slight springing or elastic resistance of the ligaments.
This position is held while the patient holds the breath in either
inhalation or exhalation. Release of the fixation is frequently percepti
ble to both the patient and the operator, usually during the respiratory
efforts just before the patient must resume breathing. This technique
238
Osteopathic Technique of Wm. G. Sutherland, D. O.
Atlanto-Axial Lesions
Dr. Sutherland finds that ligamentous strains of the atlanto-axial
articulation frequently become apparent following the successful
reduction of those of the condyloatlantal articulation, indicating that
they are of a compensatory nature. It occurs to him that the ligamen
tous agencies of that region function somewhat in the manner of the
hairspring of the balance wheel of a watch, causing motion of the
occiput to be reciprocated between the atlas and axis.
Although the articular structure and the motion are quite different
from those of the typical cervical vertebrae, the technique is similar. In
arriving at a ligamentous balance between the atlas and axis, it is to be
remembered that the motion is almost entirely rotation with little
sidebending, and that the superior facets of the axis face cranialward
and laterally. The shoulder and respiratory cooperation are employed
as in the technique for lesions of the typical cervical articulations.
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T E A C H IN G S IN T H E S C I E N C E O F O S T E O PAT H Y
THORACIC VERTEBRAE
Flexion Lesions
The processes of the upper ,Of the two vertebrae are held anterosu
periorly while the patient elevates both shoulders to balance the
ligamentous tension as determined by the operator. This position is
held while the patient inhales and holds the breath.
240
Osteopathic Technique of Wm. G. Sutherland, D.O.
Figure A. 3 . Thoracic Vertebra: The transverse process on only one side may be held
anterosuperiorly for exaggeration of the lesion position.
Extension Lesions
Extension lesions are corrected with the transverse processes of the
lower of the two vertebrae being held anterosuperiorly, and the
patient's shoulders lowered. Respiratory cooperation is in exhalation.
241
T E A C H IN G S I N T H E S C I E N C E O F O S T E O PAT H Y
posteriorly. The patient rests his elbows on the table and walks, or
inches, forward with them to carry the inferior articular processes cra
niad in relation to the superior ones of the vertebra below. The opera
tor palpates at the transverse process for limitation of motion and for
the point of balanced ligamentous tension.
Flexion
If the lesion is of the flexion type, a finger on each transverse pro
cess of the upper of the two vertebrae lightly encourages their
anterosuperior movement while palpating for the proper degree of
separation from the vertebra below as the patient steps forward with
his elbows on the table. When that point is reached the correction is
accomplished with the patient holding the breath in inhalation.
242
Osteopathic Technique of Wm. G. Sutherland, D. O.
Extension
The operator's fingers are placed on the transverse processes of the
lower of the two vertebrae involved, the patient steps forward with his
elbows until that vertebra is felt to move upward. The transverse pro
cesses are then held gently in an anterosuperior direction while the
patient steps backward with his elbows for an inch or two. This carries
the articular processes of the upper of the two vertebrae back to exag
gerate the extension position at the point of lesion. The correction is
made during exhalation.
Sidebending Rotation
In correcting these lesions, the forearm of the operator which is on
the side of the convexity holds the pelvis posteriorly. A finger of the
other hand is placed on the transverse process of the upper of the ver
tebrae involved, on the side of convexity. That finger gently holds the
process in an anterosuperior direction as the patient steps forward on
his elbows until tension is palpated with the finger. Then the patient
moves forward the elbow on the side of convexity, lowering the shoul
der on that side toward the table, as directed by the operator. The res
piratory cooperation may be in either inhalation or exhalation.
LUMBAR VERTEBRAE
243
T E A C H I N G S IN T H E S C I E N C E O F O S T E O PA T H Y
Figure A.S. Lumbar: Palpation of motion as the hips are elevated alternately.
Flexion
The patient moves forward with his elbows until the increase of
ligamentous tension is noted by the operator, the spinous process of
the upper of the two vertebrae is held in a cranial direction to exag
gerate the lesion position, and the patient then holds the breath in
inhalation for correction.
Extension
In the extension lesion the pelvis is steadied, the ligaments are
tensed as above, the operator holds the spinous process of the lower of
the two vertebrae anterosuperiorly, and the patient moves back on his
elbows to balance the tension in extension at the point of lesion. Then
the respiratory cooperation is in the exhalation phase.
Sidebending
The sidebending lesion position is exaggerated to the proper extent
by elevating the pelvis on the side of concavity. The arm of the opera
tor on the side of convexity holds the pelvis posteriorly as the patient
244
Osteopathic Technique of Wm. G. Sutherland, D.O.
Figure A.6. Lumbar Correction: Convexity to the left. The ilia are held posteriorly by
the fingers.
steps forward with his elbows to tense the ligaments. The operator
holds the spinous process of the lesioned vertebra toward the convexity
and the patient comes back with his elbows until the finger on the
spinous process notes a balancing of the ligamentous tension. Then
the patient inhales and holds the breath for correction which usually
occurs at the beginning of exhalation.
RIBS
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T E A C H IN G S IN T H E S C I E N C E O F O S T E O PAT H Y
rib. The technique is usually applied with the patient seated and the
operator on the side of lesion holding the rib. However, it may be
done with the patient lying on the back or on the side opposite the
lesion. The patient is instructed to keep his head erect and not twist
the neck as he turns the body slowly, carrying posteriorly the shoulder
on the side opposite the lesion. In other words, the operator holds the
"bolt" while the patient turns the "nut" to release the fixation. Sensing
the point at which the ligaments are tensed but not unduly stretched,
the operator instructs the patient to hold that position while he
inhales and holds the breath for correction of the lesion.
Diagnosis is made in the usual manner, considering history of trauma,
pain and tenderness, tissue tensity and induration, possible abnormal
ity of position, and restricted motion. If the first and the last two diag
nostic points indicate a rotation of the rib in a particular direction,
that position may be held in exaggeration for the correction; otherwise
simple disengagement of the costocentral articulation alone is used.
Fourth to Tenth
For lesions of the fourth to tenth ribs, inclusive, the middle finger
of one hand of the operator is on the angle, and the middle finger of
the other hand is on the anterior end of the shaft of the rib, and the
thumbs are placed laterally on the shaft. Firm contact is obtained by
the patient's leaning toward the operator. The rib is held to prevent
it from moving anteriorly, and the patient slowly rotates the upper
part of the body, carrying the opposite shoulder posteriorly, to the
point of balanced tension of the ligaments. He then inhales and
holds the breath.
246
Osteopathic Technique of Wm. G. Sutherland, D. O.
the patient. A finger of the same hand holds the anterior end of the
shaft, and a finger of the other hand holds the posterior part of the rib
near the point where it meets the transverse process. The thumb of
this hand is placed at the inferior part of the lateral border of the
scapula and holds that bone medially, posteriorly, and upward away
from the other thumb. The patient's elbow is allowed to drop close to
the body. Leaning toward the operator, the direction in which the rib
is held, rotation of the trunk and respiratory cooperation are similar to
the technique described above.
First Rib
When contact with the first rib cannot be made comfortably by
way of the axilla, it may be accomplished with the thumb starting lat
eral to the trapezius and following the rib medially under the muscle,
advancing as the patient inhales, and holding during exhalation to
arrive at the posterior surface of the rib. If necessary, the hold may be
through the muscle itself, but this is not as specific or effective. The
rest of the technique is as above.
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T E A C H I N G S I N T H E S C I E N C E O F O S T E O PAT H Y
Floating Ribs
There is no costotransverse articulation to serve as a fulcrum for
the eleventh and twelfth ribs. Consequently in correcting lesions of
the eleventh and twelfth, the rib is held as are the other middle or
lower ribs, but the finger which is placed posteriorly is held firmly
forward against the rib near the vertebra to act as a fulcrum. The
shaft is held posterolaterally while the patient rotates the trunk and
holds the breath.
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Osteopathic Technique of Wm. G. Sutherland, D.O.
Figure A.9. Rib Technique at the Bedside: Thumb holds the shaft of the rib in a poste
rior direction.
Figure A.lO. Eleventh and Twelfth Ribs: Middle finger acts as a fulcrum.
249
T E A C H I N G S I N T H E S C I E N C E O F O S T E O PAT H Y
Figure A.ii. Rib Lesions with Spinal Hyperextension: Two assistants elevate the
shoulders.
2 50
Osteopathic Technique of Wm. G. Sutherland, D.O.
PELVIC GIRDLE
The auricular surfaces of the sacrum and the ilium, covered by car
tilage, lie more or less in sagittal planes, but flaring anteriorly and
inferiorly. Their shape is that of a broad letter "L," the long arm being
directed dorsoventrally, and from its anterior end the short arm
extends cranially. Roughly following the line of this "L," there is usu
ally a curved ridge on the auricular surface of the ilium which fits into
a groove on the sacrum. They describe an arc around a transverse line
running approximately through the spinous process of the first or sec
ond sacral segment. The arrangement of the ligaments is such that the
sacrum can swing within limits between the ilia along the line of those
ridges without materially changing the tension. Meanwhile the liga
ments are limiting the tilt of the sacrum, downward and forward at the
base and backward and upward at the apex, caused by the weight of
the trunk through the lumbar spine when in the erect position. There
is a notable absence of muscles between the sacrum and ilia which
would control the motion of one upon the other.
Doctor Sutherland has called attention to an involuntary movement
of the sacrum between the ilia in contradistinction to the postural
mobility of the ilia upon the sacrum. This involuntary motion is associ
ated with what is termed in his cranial concept as the "primary respira
tory mechanism" which concerns a motility of the neural axis. The
dural membranes, the cerebrospinal fluid, and the cranial bones and
sacrum participate in this movement. The primary respiratory mecha
nism is fundamental to the pulmonary respiratory, the cardiovascular,
251
T E A C H I NG S I N T H E S C I E N C E O F O S T E O PAT H Y
2 52
Osteopathic Technique of Wm. G. Sutherland, D.O.
Respiratory Flexion
If the lesion be of the "respiratory flexion" type, with the sacral
base drawn upward and slightly posterior and the apex forward, the
operator steadies the pelvis with the forearm on the side of lesion,
avoiding a posterior pull upon it. The thumb of the other hand holds
the apex forward, swinging the base upward and posteriorly for exag
geration of the lesion position. The patient then steps forward with
his elbows or hands on the table, drawing the sacrum forward and,
because of the flexed position of the lumbar spine, slightly downward
from between the ilia. When the disengagement is palpated, the
patient is instructed to walk back a short distance with his elbows to
allow the sacral base to move posterosuperiorly and exaggerate the
lesion position. The operator, with his knees, changes the position of
the tuberosities of the ischia to find the point of balanced ligamen
tous tension, and holds for correction while the patient holds the
breath in inhalation.
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T E A C H IN G S IN T H E S C I E N C E O F O S T E O PAT H Y
Respiratory Extension
For "respiratory extension" lesions the operator holds the base of
the sacrum forward and downward on the side of the lesion with his
finger, and the apex posteriorly with his thumb under one side of the
apex. The forearm on the side of lesion holds the pelvis posteriorly
while the patient steps forward on the table with his elbows or hands.
The proper point of balanced tension depends upon the amount of
pull as the patient's shoulders move forward, the degree to which the
lesion position is exaggerated by the operator's thumb and finger, and
the relative position of the ischial tuberosities as they are moved by
the operator's knees. Correction occurs with the patient holding his
breath out as long as possible.
Bilateral
Bilateral flexion or extension lesions of the sacrum may be reduced
with one procedure or on one side at a time. If the sacrum be rotated so
that the ligamentous imbalance is toward flexion on one side and
extension on the other, it is simpler to correct each side separately.
2 54
Osteopathic Technique of Wm. G. Sutherland, D.O.
Postural Lesions
Postural sacroiliac or iliosacral lesions are diagnosed with the patient
seated on the operator's knees. The tuberischia are alternately elevated
and the motion between the sacrum and the posterior superior iliac
spines is palpated. If the motion is free as the tuberosity is elevated
and moved posteriorly and limited when moved the opposite direc
tion, the ligamentous articular strain denotes anterior rotation of the
innominate bone. Restricted motion when the tuberosity is moved
backward and upward indicates a posterior rotation lesion. The diag
nosis may be made with the patient seated on a Ritter stool, lowering
the pelvis on one side or the other. The diagnostic motion or its limi
tation is elicited as the patient abducts the knees alternately.
Correction of the postural lesions is made with the patient stand
ing, his hands on a stool which is placed on the table. The leg on the
side of lesion is crossed in front of the other one and the foot rests on
its outer edge, lateral to the one on which he stands. In this position
the weight is transmitted from the spine through the sacrum to the
innominate bone which is not directly concerned in the technique. The
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T EA C H I NGS I N T H E S C I E N C E O F O S T E O PAT H Y
Pubic Symphysis
The symphysis pubis is subject to ligamentous strain, frequently in
association with sacroiliac lesio'ns. There is an intervening cartilage
between the pubes denoting motion. The bones are bound together
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Osteopathic Technique of Wm. G. Sutherland, D. O.
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T E A C H I N G S IN T H E S C I E N C E O F O S T E O PAT H Y
UPPER EXTREMITY
Clavicle
The object of the technique for correction of lesions of the clavicle
is to hold it cranial ward and laterally while the patient lowers his
shoulders and rotates the trunk, disengaging the sternal, costal, cora
coid, and acromial articulations to tense their ligaments. The patient
sits on the table, and the operator sits facing him, a thumb under each
extremity of the clavicle. The fingers of one hand rest over the
acromioclavicular junction for the purpose of palpation, and a finger
of the other hand is placed medial to the sternal end of the clavicle to
hold it laterally. The patient, with his arm on the involved side lateral
to the operator's arm, rests his hand on the latter's shoulder. The
patient drops his weight forward on the thumbs of the operator, who
balances the ligamentous tension at the acromial end of the clavicle
by carrying his shoulder and the hand resting on it backward away
from the patient. Under direction, the patient draws his opposite
shoulder posteriorly to move the sternum away from the clavicle and
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Osteopathic Technique of Wm. G. Sutherland, D.O.
Humerus
Freedom of rotation of the humerus in the glenoid cavity is tested
with the arm at an angle of 45 to 90 degrees laterally from the body,
and the elbow flexed. Comparison of the motion on the two sides is
made by carrying the hand laterally and upward to test external rota
tion of the humerus, and medially and downward for internal rota
tion. Restricted motion in one direction indicates lesion in the
opposite position.
Correction is made with the patient seated, the operator standing
on the side of lesion, facing him and with the hand which is toward
the back of the patient palpating the shoulder joint. The other hand
under the axilla, against the ribs and as close to the head of the
humerus as possible, acts as a fulcrum for disengagement. The patient
places the hand of the involved side over the distal third of the oppo
site clavicle and holds that shoulder. The internal rotation lesion is
exaggerated by the patient elevating the elbow, external rotation by
lowering it, the operator directing to the degree necessary to arrive at
the point of balanced tension. The patient is instructed to move his
uninvolved shoulder posteriorly, carrying with it the hand of the
Figure A.19. Testing External Rotation Figure A.20. Testing Internal Rotation of
of the Humerus the Humerus
2 59
T E A C H I N G S I N T H E S C I E N C E OF O S T E O PAT H Y
lesioned side. This draws the lower end of the humerus across the
chest in order that the leverage over the fulcrum provided by the
operator's hand disengages the head of the humerus. Respiratory
cooperation is then employed to correct the lesion.
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Osteopathic Technique of Wm. G. Sutherland, D.O.
Ulna
The corrective technique for ulnar lesions is applied with the patient
seated facing the table, elbow flexed to about 90 degrees, and his hand,
palm down, on the table. The fingers are spread as widely as possible to
release the metacarpals and the distal row and possibly all of the carpal
bones. The operator sits on the side of lesion and rests his fingers over
the dorsum of the carpus and proximal ends of the metacarpals, and the
thumb on the styloid process of the ulna for palpation. The fingers of
the other hand grasp the olecranon process. The patient inverts and
everts the humerus, raising and lowering the elbow, while the operator
finds the direction in which the motion is limited and determines the
point of balanced ligamentous tension. The operator then holds the
proximal end of the ulna away from the humerus by means of the ole
cranon process, or the patient may steady the wrist with his other hand
while the operator holds both the olecranon and coronoid processes,
tending toward rotation of the ulna to the proper degree. The patient
then raises his shoulder to draw the humerus out of the semilunar
notch of the ulna for release and correction. The direction of the pull
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T E A C H IN G S I N T H E S C I E N C E O F O S T E O PAT H Y
Radius
Lesions of the head of the radius prevent free supination or prona
tion of the forearm. For correction the position is similar to that for
ulnar lesions, except that the patient's elbow is only slightly flexed.
The operator holds both ends of the radius with his fingers, palpating
for the ligamentous imbalance as the patient circum ducts his elbow
upward and downward and medially to rotate the humerus in relation
to the radius. When the point of balanced tension is found, the radius
is held firmly by the operator for stabilization, and the patient cir
cumducts the elbow a little farther for exaggeration and correction.
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Osteopathic Technique of Wm. G. Sutherland, D. O.
the metacarpal bones, narrowed on their volar aspect. The patient sits
with his hand on the table, palm down and fingers spread. Facing him,
the operator holds downward the dorsum of the distal end of the
metacarpal with his thumb, and he lifts and separates the proximal
heads of that and the metacarpal on either side of it with the ball of his
middle finger, placed under the palm between the proximal ends of
the shafts of the bone being held by the thumb and of the one on
either side. When the metacarpals are lifted dorsally and separated
they are also rolled on their long axes. The operator's other hand on
the dorsum of the wrist stabilizes the carpal bones. With this proce
dure the restriction is found and the ligamentous tension is brought
into balance and held. Then the patient spreads his fingers more wide
ly to disengage the lesioned articulation for correction. Lesions of the
carpal as well as the metacarpal bones may be reduced by this tech
nique. The procedure is completed by the operator holding and rotat
ing on their long axes the involved fingers, one at a time, while the
patient, keeping his fingers widely spread, slowly withdraws his hand,
raising and lowering his elbow.
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Osteopathic Technique of Wm. G. Sutherland, D. O.
muscles , Dr. Still found the point of balance at the exact location of
the lesion and allowed the bones to spring back into normal relation
ship as the patient relaxed his hand.
LOWER EXTREMITY
Hip Joint
The capsular ligament of the hip joint is strong , comparatively lax,
permits a wide range of motion , and is frequently subject to strain.
Diagnosis of lesions of this articulation is made with the patient stand
ing, the weight on one foot. Without turning the pelvis , he rotates
the leg that is not bearing his weight, pointing the foot laterally and
medially to determine the degree of external and internal rotation of
the head of the femur in the acetabulum. Comparison of the motion
in either direction on the right and left sides designates the lesion. In
another method of diagnosis, the patient is seated on the table with
one leg resting over the other knee. The operator, facing him , holds
the leg at the knee and ankle and rotates the femur in question by tilt
ing the leg in either direction over the knee on which it rests. Restric
tions caused by exostosis or other bony abnormalities are usually
indicated by a less resilient limit of motion than is present in ligamen
tous articular strains.
For the corrective technique , the patient sits across the table with
the uninvolved hip next to the end. The leg of the lesioned side is
crossed over the other knee , resting midway of the shaft of the fibula.
The operator sits at the end of the table , one hand medial to the shaft
of the involved femur near its head, holding it laterally. The other
hand reaches around in back of the pelvis to palpate the motion at the
greater trochanter.
In the case of an external rotation lesion , the patient holds his knee
laterally and downward with his hand for exaggeration , sidebends and
rotates his body away from the lesioned side and leans backward. The
operator firmly maintains his fulcrum against the shaft of the femur
and determines the point of ligamentous balance. The correction
occurs with exaggeration of the lesion position and disengagement of
the articulation.
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T E A C H I N G S I N T H E S C I E N C E O F O S T E O PAT H Y
Figure A.28. Testing External Rotation of Figure A.29. Testing Internal Rotation of
the Femur the Femur
Tibiofemoral
Tibiofemoral lesions, sometimes referred to as dislocated semilunar
cartilage, are caused by a sudden or forcible rotation of the tibia in
relation to the femur, usually in conjunction with a sidebending strain
upon the knee. In a majority of instances, the medial condyle of the
tibia has been rotated anteriorly when the foot was turned laterally
2 66
Osteopathic Technique of Wm. G. Sutherland, D. O.
and the knee bent medially, the lateral articulation of the knee joint
having acted as a fulcrum. History of the injury, location of the ten
derness, inability to fully extend the knee in most cases, pain and
restriction on attempting to reverse the lesion position, and palpation,
establish the diagnosis.
For correction, the patient is seated with the involved leg balanced
over the opposite knee. Facing him, the operator places one hand on
the knee and grasps the foot, just below the ankle, with the other
hand. If the lesion be of the medial condyles, the operator provides a
fulcrum on the lateral condyle of the tibia with his thumb, one or two
fingers are on the medial condyle of the femur for palpation, and the
knee is carried medially and upward, tipping the foot laterally and
downward, to disengage the lesioned joint surfaces and tense the
ligaments. The tibia is rotated externally or internally by the other
hand at the foot to exaggerate the lesion position to the point of bal
ance. The patient is then instructed to resist the turning of his foot and
the result of that effort is to glide the medial condyle of the femur into
its proper position on the tibia. When the lateral condyles of the knee
joint are involved, the fulcrum is on the medial condyle of the tibia, the
articulation is disengaged by tipping the leg over the knee on which it
rests so the knee moves downward and the foot upward. Exaggeration
of the lesion position by rotation of the foot and the correction by the
cooperation of the patient in resisting that movement follow the same
principle as is used in lesions of the medial condyles.
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T E A C H I N G S I N T H E S C I E N C E O F O S T E O P AT H Y
Figure A.32. Corrective Technique, External Rotation of the Femur, Variation from
the text.
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Osteopathic Technique of Wm. G. Sutherland, D. O.
Fibula
Most lesions of the fibula affect both its proximal and distal articu
lations and cause added tension through the interosseous membrane
which is in close proximity to the vessels of the leg. Tenderness, dis
turbances of the ankle joint and circulation of the foot, and limited
motion of the fibula in relation to the tibia give evidence of the lesion.
For correction the patient sits with his leg, near the ankle, over the
other knee. The operator holds both ends of the fibula anteriorly with
his fingers to the point of balanced tension of the ligaments. The
patient dorsiflexes and externally rotates the foot and presses down
ward on the knee or lifts it upward and medially with his hand. This
rotates the fibula and releases it at both ends from the tibia and from
the astragalus. Further disengagement and correction are accom
plished by the patient drawing the leg backward away from the opera
tor and moving it lengthwise of the fibula as the operator holds that
bone anteriorly with his fingers.
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T E A C H IN G S I N T H E S C I E N C E O F O S T E O PAT H Y
Tarsal Arch
Following the fibular correction, an effective technique for lifting
the tarsal arch is performed with the operator at the foot of the
patient. The fingers are interlaced over the dorsum of the foot, and
the crossed thumbs on the plantar surface hold the internal cune
iform and cuboid apart to spread the arch and exaggerate the trans
verse flattening to the point of balanced tension. For correction the
patient, with his foot in plantar inversion, dorsiflexes and then plantar
flexes it against the resistance of the operator's thumbs.
Tibio-Calcaneo-Astragalus
Lesions of the complex articular structure of the foot are corrected
by a method contrived by Dr. Sutherland based on the beneficial effects
of removing a tight boot by means of the old-fashioned bootjack. Each
time the device was used, the user gave himself a foot treatment.
Characteristic of the fallen arch are the anterior position of the
astragalus between the malleoli and in relation to the calcaneus, and
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Osteopathic Technique of Wm. G. Sutherland, D.O.
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T E A C H I N G S I N T H E S C I E N C E O F O S T E O P AT H Y
272
Osteopathic Technique of Wm. G. Sutherland, D. O.
grasp the posterior part of the calcaneus and hold it medially and
downward while the thumb lifts laterally and upward on the inferom
dial aspect of the cuboid. The operator rotates the anterior part of the
foot internally and externally to balance the ligamentous and fascial
tension, and continues to hold medially and downward on the
tuberosity of the calcaneus while the patient draws on the achilles ten
don for exaggeration and correction.
NON-OSSEOUS STRUCTURES
273
TEACHINGS I N T H E S C I E N C E O F O S T E O P AT H Y
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Osteopathic Technique of Wm. G. Sutherland, D. O.
275
T E A C H I N G S I N T H E S C I E N C E O F O S T E O P AT H Y
Diaphragm
Because of its relationships, the diaphragm deserves consideration
other than as a muscle of respiration. The pericardium is firmly
attached to it above, the peritoneum below, and the great vessels and
the esophagus pass through it. Being rather closely associated with the
organs of respiration, circulation, and digestion, it is important that
the full excursion of the diaphragm be unimpeded. This is prevented
by a "drag" on the abdominal fascia and may be restored by a tech
nique known as the diaphragmatic lift. The object of the treatment is
to draw the diaphragm cranially, elevating the floor of the thorax,
drawing upward on the abdominal contents, and promoting venous
and lymphatic drainage from the lower half of the body. Visceroptosis
and even internal hemorrhoids respond to it.
With the patient supine, the operator introduces his fingertips
under the costochondral junctions. If that area is particularly sensitive,
the patient hooks his own fingers under them, and the operator lifts
on his hands. As the patient exhales, the operator lifts the lower rim of
the thorax in a cranial and slightly lateral direction. The advancement
that is made is held during inspiration and is increased on exhalation.
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Osteopathic Technique of Wm. G. Sutherland, D.O.
The patient is instructed not to hold the breath in, but to exhale
immediately after inhalation. After several respiratory cycles there is
no further upward progress and the patient is told to breathe out,
close the throat and attempt to expand the chest.
Arcuate Ligaments
In a technique utilized for relaxation of the external arcuate liga
ments, the tension affecting the important structures passing through
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T E A C H I N G S I N T H E S C I E N C E O F O S T E O P AT H Y
the arches of the diaphragm is relieved. The patient seated, the opera
tor facing him from the front or at his side, starts his thumb under the
twelfth rib just lateral to the erector spinae mass. The right thumb is
used for the left side of the patient and vice versa. The patient bends
his trunk over the operator's thumb, which gently and gradually
advances upward and posteriorly as the patient exhales, and holds its
position as he inhales. When the thumb arrives at a point against or
under the ligament, it is drawn laterally with a rolling motion which
relaxes the external and often influences the internal arcuate ligament.
Liver Tum
A treatment to stimulate the liver to increase activity is given with
the patient lying on his back. The operator inserts the ends of the fin
gers of the right hand between the inferior border of the right costal
cartilages and the liver. The fingers of this hand should be slightly
flexed with the dorsum resting against the anterior border of the liver.
The left hand placed over them presses them downward, holding the
anterior border of the liver in a medial and caudal direction, while the
patient inhales and holds the breath. The diaphragm holds the body of
the liver caudally until, on the sudden exhalation, it elevates. Since the
anterior border is still held downward by the fingers, the liver makes a
turning movement probably attended by suction within its substance.
Biliary Drainage
In another treatment for sluggish liver, the patient is seated and the
operator holds his thumb firmly in the right hypochondrium. The
patient leans slightly forward and rotates the body to the left, causing
the thumb to advance further toward the inferior surface of the liver.
Closing his throat, he attempts to inhale after the manner of the mili
tary order, indelicately expressed as "suck in your guts." This drains
the bile passages and the pancreatic duct.
Abdominal Treatment
Treatment directly over the abdomen should be administered care
fully and with due respect for the viscera within. To lift and hold the
sigmoid flexure or raise the cecum from the pelvic bowl, the fingers of
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Osteopathic Technique of Wm. G. Sutherland, D. O.
one hand are introduced close to the ilium and are supported and
slowly lifted by the other hand. This permits use of a keen, tactile sense
and the ability to employ the various fingers as needed to restore proper
peristalsis, circulation, or drainage. Intestinal activity may be increased
by holding the left eleventh rib downward and medially to limit its
excursion during two or three respirations. The false ribs may be
treated similarly: Dr. Sutherland reported the passage of gall stones
without pain when the tenth rib on the left was held in that manner.
The effects are produced by way of the sympathetic chain lying in
close proximity to the heads of the ribs.
Psoas Muscle
Contractures of the psoas muscles exist in varying degrees, from
acute spasm to the mild cases which escape recognition. Usually the pa
tient is more comfortable with the thighs and the lumbar spine flexed
upon the pelvis, there is difficulty in arising directly from the supine
to the sitting position, and pain is referred down the leg because of
irritation of the nerves of the lumbar plexus passing through the belly
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T E A C H I N G S I N T H E S C I E N C E O F O S T E O P AT H Y
of the muscle. The psoas fascia has a connection with the diaphragm
by way of the internal crus, indicating a restricting influence upon the
excursion of the diaphragm. The course of the ureter is on the medial
side of the psoas major, and the technique for relaxation is an aid to
the passage of renal stones since the hand of the operator almost
reaches the ureter. The kidney, cecum, descending colon, and small
intestines rest upon the psoas and are affected by the technique which
lifts the muscle out and free from the underlying nerve ganglia and
vascular channels.
With the patient seated, the operator places his thumb along the
crest of the ilium, pointed posteromedially, and rolls it over the crest
into the iliac fossa. The thumb is held firmly in a medial, posterior and
slightly caudal direction, following the internal surface of the ilium
while the patient bends his body to bring the psoas muscle in approxi
mation with it. The operator is seated in front of the patient who bends
and leans laterally and forward to "put the glove on the thumb." The
patient may rest his arms on the operator's shoulders in which case he
leans forward, causing the thumb to advance to its position against and
2 80
Osteopathic Technique of Wm. G. Sutherland, D. O.
posterior to the psoas major, lifting the muscle forward. The patient
then inhales deeply, holds the breath, and on exhalation straightens
the trunk as the operator releases his pressure on the muscle. If the
patient is bedfast, he lies on his side with a pillow under the shoulder
to produce the sidebending, the rest of the technique following the
principles of that described above. When the treatment is given for its
influence upon the cecum, a chronic appendix, colon, small intestine,
kidney, or ureter, the psoas is held forward while the patient rotates
his thigh alternately internally and externally. In the bedside technique
this is done with the patient more or less in the Sims's position, lifting
the knee laterally and lowering it to the bed.
lliopsoas Tendon
The iliopsoas tendon may be lifted or stretched by holding it for
ward at a point just proximal to the lesser trochanter, the patient lying
on the back. This treatment relieves the anterior tension upon the
spine in lordosis, gives relief in the passage of renal calculi, and is an
effective measure for sciatica.
Pelvic Lift
The fascial connections from the neck to the diaphragm have been
mentioned. The direct attachment of the diaphragm to the liver and
the connections to the stomach, duodenum, psoas, and peritoneum
complete a chain embracing the viscera all the way down into the
pelvis. Fascial "drag" has an adverse influence on the support and
function of the organs and on the circulation and drainage of the
lower half of the body. The aorta lies against the bodies of the verte
brae and is crossed anteriorly by the crura of the diaphragm. Thus the
"drag" on the crura has a constricting effect upon the aorta, throwing
an extra load upon the heart and predisposing to cardiac insufficiency.
Dr. Still described this phenomenon with the parable of the goat and
the boulder. The boulder represented the crura, the path was the
aorta, and the valves of the heart were the tail, the heels, and the
whole goat. "The goat, finding the boulder in its path, backed up and
gave it a butt and his tail went up. Not to be outdone he backed up
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T E A C H IN G S I N T H E S C I E N C E OF O S T E O PAT H Y
further, came a-running and gave it another butt and his tail and heels
went up. Then he backed up further and with a supreme effort gave it
another butt and the whole d- works went up."
An effective technique for reducing the "drag" on the fasciae is
applied with the patient lying on the left side. His thighs are straight
and slightly flexed to the position in which the floor of the pelvis is
most relaxed. The operator stands in back of him and starts the tips of
the fingers medial to the right tuberischium and advances them
upward between the obturator membrane and the rectum while the
patient exhales. During inhalation the position of the fingers is held
gently, but firmly, not allowing them to recede. This hand may be
supported by the other hand to allow the fingers to hold more steadily
and to note more carefully the resistance of the tissues. After several
cycles of deep respiration, the resistance will be felt to diminish sud
denly and the tissues spring upward in advance of the fingers.
This technique is adaptable to the various pelvic prolapses that are
bound to cause a drag on the fascia and that persist partially because
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Osteopathic Technique of Wm. G. Sutherland, D.O.
the support of that agency has been reduced. The fingers may be
directed cranially and medially or anteriorly toward the cecum,
uterus, bladder, or prostate for specific effect upon those organs. It
will be found easier and less uncomfortable to the patient than local
treatment. If indicated, the technique may be applied to the left side
of the pelvis.
Popliteal Drainage
Movement of fluids from the popliteal space and below may be
accelerated by drawing apart the tendons of the biceps and semi
tendinosus muscles, just above the knee. The patient is supine with his
knee slightly flexed, and he alternately presses against the table with
the heel and relaxes. The effort to flex the knee tends to compress the
tissues of the popliteal space, and it expands when the patient relaxes
the leg and the operator separates the tendons. The effect is that of a
booster pump in the return of the fluids toward the heart.
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T E A C H I N G S I N T H E S C I E N C E O F O S T E O P AT H Y
CONCLUSION
2 84
GLOSSARY
285
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
a profound truth that applies to the human infant as well. Because the
bones of the cranium are in parts at birth, degrees of disarrangement
among them may occur. Such modest strains may become large with
growth to maturity.
BEVEL: The incline that one surface or line makes with another
when not at right angles.
286
Glossary
DIPLOE: The central layer of spongy bone between the two tables of
compact bone which comprise the flat cranial bones.
287
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
PALATE: a) The bony and muscular partition between the oral cavity
and the nasal cavity. b) Bony palate - horizontal plates of the palatine
bones and the maxillae; the roof of the mouth.
PINTLE: A pin or bolt upon which some other part pivots or turns.
288
Glossary
289
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
STRETCH: Make taut, tighten; extensible. The dura mater and liga
ments do not stretch.
290
BIBLIOGRAPHY
Magoun, Harold Ives, Sr. Osteopathy in the Cranial Field. 3rd ed.
Kirksville, MO: The Journal Printing Company, 1976.
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ABOUT THE EDITOR
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
298
Index
299
TEACHINGS IN THE SCIENCE OF OSTE OPATHY
300
Index
301
TEACHINGS IN THE SCIENCE OF OS TEOPATHY
302
Index
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TEACHINGS IN THE SCIENCE OF OSTEOPATHY
133
motility of, 18, 51 (chapter) Palate,288
Neuralgia or neuritis, intercostal, Palatine bones, 76
141 posterior articular surface, 92
Neuropathy,entrapment, 139 (chap illus.
ter) region, 91
Nerve or nerves treatment, 95, 100, 101
acoustic,89 Palpation, 288
cranial,84,89, 90, 139, 140, 185 acute abdomen, 213
facial,88 cervical area, 236
maxillary, 96,139 contacts, vault, 151, 220
304
Index
305
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
306
Index
307
TEACHINGS IN THE SCIENCE OF OSTEOPATHY
308
Index
309
TEACHINGS IN THE SCIENCE OF OS TEOPATHY
310
Index
31 1