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ISCO Principles and Practice of Connective Osteopathy

The Three Links I


The structure, tools and scope
of osteopathic treatment / Alain Abraham Abehsera Do Md

Early in my career as a practicing and teaching osteopath, I formulated a general


theory of osteopathic diagnosis and therapeutics, a theory named "the Three Links",
namely, the circulatory, the neurological and the mechanical link.
This theory offers a useful, rigorous and exhaustive framework for the osteopathic
physician.
I owe its development to two of the main thinkers of osteopathy in the XXth
century: J.M. Littlejohn DO and Irwin K. Korr PhD. As a student, I was exposed to
the writings of JM Littlejohn through the teaching of my master, SJG Wernham
D.O. John Wernham used to read in class pages upon pages of Littlejohn’s writings,
and we were exposed to an osteopathy which applied to all of medicine, something
very refreshing in view of the English osteopathy we had known, i.e., a technique
aimed at relieving pains and aches in the musculo-skeletal system. With Littlejohn,
we were introduced, for the very first time, to the osteopathic treatment of
pneumonia, of typhoid fever, of appendicitis, of goiter or of angina pectoris. To
understand what he actually meant in his descriptions of physiology, pathology and
osteopathic treatment was another question. This author has written abundantly but
in a very obscure style. We suspected that his writings and ideas were all very
precious, but could not understand what this was all about. One day, looking
through the library of our teacher, SGJ Wernham, I fell, by accident, on the second
determining author in my career: I.K. Korr, a physiologist who spent his career
doing research in osteopathic institutions and whose work was mentioned briefly in
my preceding lecture.
Unlike Littlejohn, Korr writes extremely well. Although not a clinician himself, he
has formulated the first "scientifically expressed", coherent and systematic model of
osteopathy. His system of thought provides the osteopath with the basic framework
needed by any therapist: diagnosis, therapy and prevention. However, and I came to
realize this early on, the model he proposed was somehow restrictive. It is almost
entirely centered on neurological disturbances and deals with other systems only in
so far as they are governed by the nervous system, and, more restrictively even, by
disturbances of the sympathetic branch of the nervous system. Circulatory
disturbances, for instance, are considered as secondary to sympathetic hyperactivity.
The laboratory evidence brought by Korr in favor of his "facilitation" model is
rather limited, as limited as the means that were at his disposal. His review and his
commentary on the deleterious effects of chronic sympathetic stimulation (which
results, in his model, from segmental facilitation) is exhaustive and of excellent
quality. It does leave out, however, major aspects of osteopathic principles and
standard physiology, two fields which cannot be reduced to neurological function.
It became clear to me that the aspects left out by Korr could be classified into two,
and only two, other categories: Solid Mechanics and Fluid Circulation. There are
very many reasons for such a classification. It appears clearly (although
unconsciously) in the writings of AT Still and in the entire osteopathic literature.
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In the present lecture, I will demonstrate the necessity of this wider model through a
logical, step by step definition of the scope, possibilities and limitations of
osteopathy.

With one hand in my pocket….

Indeed, what can an osteopath hope to achieve with his hands when he makes
contact with his patient? We are not talking here about complex effects such as
"increase the level of immunity", "raise the level of cortisolemia" etc. The osteopath
cannot do these things with his hands; he takes, possibly, manipulative measures
which will lead to such effects, but these are brought about indirectly. What the
osteopath can actually achieve directly with his hands is rather modest: he can only
modify neurological, mechanical, circulatory relationships between organs or
tissues.
In simple terms, the act of laying one's hands on the patient will lead to three
fundamental effects, immediately measurable by the patient and the operator:
• the operator will displace solid tissues (skin, artery, bones, nerves, muscles,
viscera) through pushing or pulling
• he will also displace fluids (blood, lymph, intra-ocular fluid etc.)
• he will set into play the nervous system (sensitive, motor and autonomic nerves)

The simple fact of laying one's hands on a patient will necessary lead to these three
effects, each one to a varying degree (very gentle touch will lead mainly to nervous
stimulation, whereas strong massage will produce marked circulatory, mechanical
and neurological changes).

It can thus be said that osteopathic touch


• mobilizes solid masses
• displaces fluids
• and stimulates nerves
That is a priori all that can be claimed. The osteopath with his hands does not cause
a secretion of hormones, does not selectively stimulate B lymphocytes and does not
increase the rate of bilirubin conjugation. The precise purpose of the science of
osteopathy is to achieve, through the three basic effects described above, all kinds of
complex physiologic effects.
For instance, an osteopathic treatment aimed at improving endocrine or
gynecological functions, will always resort to neurological, solid and fluid
mechanics. It cannot do otherwise since the skin always separates the operator from
the innards of the patient and shrouds every body function in secrecy. We do know
that massage and manipulation lead to the secretion of very many chemical
molecules behind the “curtain” of the skin, but this cannot be known by our hands.
Indeed, our hands cannot "feel" the differences between histamine, vasoactive
substance, endothelin or bradykinin. The osteopath can only feel solid and liquid
masses being moved, he can feel or see the patient feel that something is being done,
but no more than that.

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From this viewpoint, and temporarily at least, I am being a staunch defender of


Still's idea that the chemistry of the body tissues is none of our business. It is far too
complex for us to apprehend and we should only concentrate on bringing to tissues
the blood and nervous fluid they need; the chemistry will follow.

I propose to summarize the above with the following axiom:

The osteopath, with his hands, can only cause three effects: neurological
(stimulation of nerves), fluidic (displacement of fluids) and mechanical
(displacement of solids)1.

The slightest laying on of hands will cause some nervous stimulation, some minimal
displacement of cutaneous and sub-cutaneous tissues, some minor displacement of
blood, interstitial fluid, lymph etc. The secretion of neuromediators or other
chemicals will be a response of the body to the above basic "manipulations".
The axiom above seems the minimal definition of the osteopathic act, one that
seems of universal value. I propose it as the "cogito ergo sum" of osteopathic
practice.
Very much like Descartes then, we may proceed to build on this first axiom, and
follow with this other axiom:

The osteopath, with his hands, claims a therapeutic effect in most spheres of
human pathology. To achieve such a therapeutic effect, he must consider the
totality of body tissues as being exclusively made of three elements: neurological2,
solids and fluidic.

As a first, starting point for osteopathic principles of technique, I have suggested


that the only immediate, measurable and perceptible consequences of osteopathic
touch are neurological, fluidic and mechanic. On the other hand, osteopathy claims
that it can treat all organs and tissues of the body, i.e., osteopathy is not just skin or
muscular massage. This manipulative therapy believes it has an effect on all
structures, however deep. Osteopathy is thus very limited in its practice (it can only
move solids, fluids and stimulate) but very wide in its principles and claims. We can
make one clear deduction from the above: the osteopath, in order to treat any part or
organ of the body, must consider it as being made of neurological, mechanic and
fluidic elements.
If the osteopath can only move solids, liquids and stimulate nerves, he must
transform any tissue he intends to deal with into a solid, a liquid and an irritable
whole.
1
The distinction made here between “mechanical” and “fluidic” is rather improper from the semantic
point of view. Indeed, “mechanics” includes “fluid dynamics”, and these two should not be
distinguished as two separate entities. . A better choice would have been “hydrodynamic”, a word
which, although it still belongs to the vocabulary of mechanics, conveys the idea that we are
interested in the property of fluids and not of blood vessels as mechanical structures. Hydrodynamic
is too long a word and sounds rather inappropriate in an osteopathic text. We have thus created the
neologism “fluidic” (instead of fluid).
2
The same remark goes for “neurological”. Nerves are solids and contain fluids. As such they are
part of the mechanic and fluidic mobility discussed above. By “neurological”, I wish to designate
what is specific to nerves, i.e., their conduction of impulses.
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In other words, before he deals with any organ, the osteopath must transform it into
a substance that his hands can affect. This reduction distinguishes osteopathy from
all other therapies. This transformation of all organs into a fluid, solid or irritable
mass is the fundamental abstraction made by all osteopaths (see our lectures on
abstractions in CTh).
For example, I wish to treat some endocrine imbalance through some work on the
hypophysis. I cannot consider the hypophysis as a gland that secretes prolactine,
ACTH, FSH, ADH etc. This information is meaningless for my hands: they cannot
identify these elements and distinguish between them. Their distinction is certainly
useful for the endocrinologist, for the herbal therapist or the naturopath, but not for
the osteopath. His visualization of the hypophysis is unique and shared - partly –
only with surgeons. For both, the hypophysis is a tissular mass
• surrounded by, anchored to several solid tissues (mechanics) such as the
meninges, the brain etc.
• which possesses a specific blood supply (fluid)
• which is innervated by specific neural pathways (neurological)
My diagnostic and therapeutic approach will be directed towards an evaluation and a
balancing of these three aspects. Tissues become full of meaningful information for
my hands when they are turned into pure solid, fluid or irritable substances. Indeed,
hands can modify mechanical relationships, displace fluids or stimulate neural
pathways. The body of the patient, after the osteopathic manipulation, will "decide"
if the level of such and such hormone should be raised or lowered. In other words,
chemical effects are responses of the patient’s body to the osteopath’s coaxing of the
mechanics, the fluids and the irritability of the tissues.
Another example: the “osteopathic” liver is a tissular mass that is attached in
specific mechanical ways, vascularized (blood, bile, lymph etc.) and innervated.
The liver cannot be, for my hands, a mass that synthesizes albumin or glycogen.
This would be meaningless.
My osteopathic treatment of the liver will have to be directed only at the three
aspects discussed above, and I do not know if that treatment will lead to an increase
in parasympathetic tone, or a decrease in glycogen or albumin synthesis.

I wish to insist on this point: an osteopath must visualize, must translate the
structures he wants to affect, into structures he can affect.

Johnson’s Miracle Cure

Leon Page, an early osteopath, gave an interesting image about the fascia. I will
resort to that image, in a somewhat modified way, to illustrate the point I have made
above.
Suppose one of the major companies that makes chemical solvents comes out with a
strange product designed for a strange market. This company has invented a solvent
specifically active on human or animal flesh. Its particularity: when you dip a
cadaver into it, it dissolves everything but connective tissue. The indications on the
bottle state that when the cadaver is left to macerate into the product for about an
hour, all of the tissues melt away except for connective tissue, i.e., tendons, fascia,
aponeuroses, the mesenchyme around all cells etc

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The marketing claim about this product: it allows bereft families to keep a “lighter”
form of their dear ones.
Suppose a client has bought it and proceeded to macerate his recently and naturally
(?) deceased mother-in-law.

Question: how much resemblance is there between the macerated subject before and
after the maceration ? We are left with a “connective tissue woman”. How close to
the complete (i.e., the initial) woman is that creature?
The answer is unequivocal: there would be no difference, to our eyes, between the
two persons. Provided the lost substance was replaced with air or wax, the
connective tissue woman would be identical to the complete woman. Indeed,
connective fibers surround every single cell in the body as well as condense into
sheet and covers which surround every tissue. Consider that the body is made of
individual, framed pictures, grouped into bigger framed pictures. The small pictures
are the cells of the body, the larger ones, the organs. Connective tissue can be
considered as the frame of every single part - from the smallest to the largest - of the
body.
Should you remove all the pictures, the general shape will be preserved.
I propose to designate the substance of this connective tissue subject, the
mechanical link.

I suggest that the osteopath who wishes to work on the mechanical aspect of any
tissue or limb must resort to a visualization of the tissue similar to that obtained
with the solvent above. The osteopath must resort to an abstraction of his patient
equivalent to a mental “dissolving” of everything but the connective tissue. I shall
designate this mental dissolving, the “mechanical reduction” of the tissue. Indeed,
what is left is not “irritable” (the nervous system has been removed) and is not
“fluid” (the circulation has been removed). What is left is a tissue with purely solid
mechanics properties (stretch, torsion etc.).
I suggest that the osteopath must visualize, within his patient, a human being
entirely made of connective tissue, a kind of body frame that contains all the other
tissues and substances; the fact that all other tissues have melted away did not cause
any significant morphological difference.

A succession story

The commercial success of this solvent has led our chemical company to search for
alternative products. A new product is marketed. After two hours of maceration, it is
able to dissolve everything in the body, except nervous tissue. Owing to the
dissolution of the connective tissue, the resulting cadaver loses all rigidity. It
becomes a nervous blob, hardly recognizable for the family. In addition to the
solvent, the company decides to supply a special wax, one able to hold all nerves
into their original place3.

3
These distinctions hold only broadly speaking. It is obvious that nerves are made of connective
tissue, that the connective tissue is innervated etc. With respect to our hands, however, this distinction
holds.
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After the prescribed two hours of maceration, we are left with a purely neuronal
woman. Question: how resembling is that neuronal woman to her previous,
complete self? If some resemblance is obvious, is this neuronal woman a better or a
worse reproduction of the connective version?
Answer: the neuronal woman will be a faithful and exact reproduction of the
complete woman, as if nothing was missing. It will also be about as faithful a
reproduction as the connective woman. Nervous fibers are present everywhere,
reach almost every cell of the body. Indeed, our neuronal woman, to our eyes, will
look exactly the same as before.The shape of his nose, the swell of her cheeks, her
wrinkles will all be there. Some features may be lost, such as hair, but this will
happen with all our solvents.

Very much like we did for the “connective tissue man”, we can choose to see this
neuronal man as the essence of the human being, all our tissues being there only to
give it support.
We thus have found already two faithful copies of ourselves within our anatomy, a
neuronal and connective one, and each one can be considered as central.

Get yourself together

Our chemical company has found a flourishing market: people are interested in
keeping their dear ones in a state that respects entirely their form, but using as little
of their original substance as possible. In other words, they are looking for the
“lightest” possible versions of their deceased.
A member of the marketing division, obviously a man of considerable medical
culture, thinks of a third solvent. This product is able to melt every tissue except for
the endothelial linings of all vessels and their fluid content. Nerves, connective
tissue etc. disappear leaving a purely “vascular man”. This is, again, a rather
difficult feat since blood vessels are surrounded by connective tissue and our
“vascular man” would also need some deep-freezing or wax to hold its shape. This
technical feat is achieved.
Question as above: how faithful a reproduction is our “vascular man”? Would he be
recognized by his close ones? Without a shadow of a doubt, yes, this vascular man
will constitute an exact copy of the person, with all his folds, valleys, elevations,
asymmetries. A microscope would certainly and immediately reveal the weirdness
of this creature, but his family looks at him with their eyes and not with a
microscope.
Indeed, blood vessels, lymphatic vessels and many other types of vessels reach and
surround every cell of the body, perfuse all tissues. Again, we can see this vascular
network as the true skeleton of the body, the rest having been created to support it.

The three me’s

So far, we have found three exact copies of ourselves, side by side, in our body. All
are equally faithful copies. Their only differences lie in the amount of stiffness, the
color etc. I have designated these three copies as the “neuronal”, the “vascular” and
the “connective” human.

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This holds for the body as a whole or for its parts: the liver, for instance, includes a
“neuronal”, a “vascular”, a “connective” liver.

Fig 1. The three internal copies of the liver.

The liver contains “three copies” of itself, which have an internal and external shape
identical to the original organ.
In Still’s writings, we can certainly find these three essences, these three readings of
the human body and its organs. He mentions them in a confused way, but it is clear
to me that osteopathy was a three-stage discovery for Still: he first had the intuition
of this art whilst considering the vascular system and its “rule” over the body. He
later realized the importance of the nervous system and had it “rule” over all other
tissues. In his later years, he became attached to the connective tissue (the “fascia”
in his terminology) and consecrated it as the “House of God” in the body. I believe
that Still’s recurrent notion of “ruling over other tissues” attributed in succession to
the vascular, the nervous or connective tissue system is a reflection of the model
proposed here.

The reader may protest that there are other ubiquitous cellular or molecular systems
in the body, systems that could, should we dissolve everything but those cells or
molecules, leave a conform copy. Take, for instance, the immune or endocrine
systems. They indeed are everywhere. And we certainly could imagine a
“lymphocyte man” or an “insulin man”, since there are lymphocytes everywhere and
receptors to insulin on every cell. These are not, however, continuous anatomic
systems. They are discontinuous. Only the connective tissue, the vascular and
nervous system offer a “continuous copy” of the animal body. We shall see that
other systems, such as the immune or endocrine one, can be included, but not at this
stage of our development. The only ubiquitous and continuous systems of the body
are the nervous, vascular and connective tissues.
These three possible “readings” of the body have another interesting and common
characteristic. Each of them possesses a central and a peripheral part:
• the vascular system (blood and lymph) is centered by the heart. At the
periphery are found all the vessels.
• the nervous system is centered by the brain, spinal cord and plexuses. From
these centers, nerves densely branch out to the periphery
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• the center of the connective system is the skeleton, with connective fibers
irradiating to all the body from our bones.
I shall summarize the above with the following axiom:

Within each and every tissue mass of the body, three anatomical networks of
equivalent importance may be found: a vascular network, a neurological network,
a connective (or mechanic) network. Each network reproduces the exact external
and internal shape of that organ and can be said to “contain” that organ
(including the other two networks).

These networks are normal anatomical features of our organs. They are, however, of
great pathological significance. Indeed, each of these networks can be said to
contain the rest of the organ like a womb. In other words, each network marks the
internal and external limits of each organ. But just like a womb can become a tomb
or prison, these networks can become three traps that threaten the cellular tissue
they surround. For instance, the cells of the liver are normally surrounded by a
connective, neurological and vascular network. As pathology sets in, each of these
can become a “trap” for liver cells.

When the osteopath restores mobility to a tissue, he is actually freeing it from these
three possible traps. Remember, the osteopath does not deal directly with the
chemistry inside the cell - something done by conventional physicians or
homeopaths - he can only deal with the effects of these three “extra- cellular
skeletons” on tissue function. Having increased total tissue mobility, having freed
the tissue from these three possible entrapments, body chemistry will proceed as it
sees fit, away from our eyes.

We may now return to our first axiom, the one which stated that the osteopath, with
his hands, can only move solids, liquids and stimulate nerves. From the discussion
above, we may see that the three fundamental “skeletons” found in every tissue are
made of the very substances that the osteopath can have an effect upon (nerves,
solids and liquids). There is thus conformity between what the osteopath can do and
what all of the tissues of the body -however deep - are made of.

This systematization applies to all parts of the body.


All tissues are accessible to osteopathic treatment - however distant they may be
from our hands - so long as the osteopath seeks the skeleton of the tissue and not its
chemical functions4. Below, we shall see that the osteopath may also have an
intracellular effect. We have drawn this conclusion from the simplest possible
anatomo-physiological laws.

I will summarize the above in the following axiom:

All the tissues of the body may be accessible to osteopathic treatment provided
they are reduced to their triple “component skeletons”: neurological, mechanical
and vascular.

4
Below, we will see that the osteopath can also have an intracellular effect.
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The Three Links II


Definition of the Osteopathic Lesion
In my preceding lecture, I dealt mainly with the normal structure of tissues. I
mentioned the three “static” skeletons that build any tissue. These are part of the
structure of the tissue.
The osteopath, however, has to deal with tissues in a dynamic state. They can either
be freely mobile or in “osteopathic lesion”, i.e., a state of “disturbed mobility”. I
propose to travel inside a tissue in lesion and see what happens to the cells and
networks I have described above.
Imagine you are in a dissecting room. In front of you, on a lab table, lies a (dead)
animal and you are asked to dissect it so as to expose the anterior aspect of the
vertebral column (or posterior abdominal wall). To achieve that, you must first
remove all the contents of the abdominal cavity: large and small intestine, stomach,
pancreas etc. You do not need to be too delicate with the viscera you have to remove
since you are only interested in exposing the vertebral column. You just need to
introduce one hand under the diaphragm and another hand, above the pubis, both as
deep as possible, and then pull all the viscera away.
Obviously, several structures will prevent us from separating the content of the
abdominal cavity from the posterior abdominal wall. The stomach, for instance is
prolonged by the esophagus and the latter will have to be cut. The same goes for the
rectum which ends in the anus. After having cut these vertical connections, you are
left with the intra-abdominal connections.
First and foremost, you will have to cut all the connective tissue bands, ligaments,
aponeurosis, fascia etc. which attach the viscera to each other and to the abdominal
walls: e.g. the fascia of Treitz, the fascia of Toldt, the omenta, the mesocolon or
mesentery, the falciform ligament, the urachus etc. These are powerful structures
which will offer considerable resistance.
This strong mechanical link is made of a dense network of connective tissue bands,
attaching the content of the abdominal cavity to the surrounding walls. This
particular link exists, in fact, between all articulated tissues of the body. In the figure
below, I have illustrated the link between a muscle and a bone as well as between a
bone and a viscera. We shall call this type of articulation, this ”restraining factor”
between tissues, the mechanical link.

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Fig. Two sets of tissue in the body: a muscle and a bone, a viscus (here the colon,
and a neighboring bone)

Fig. We see the “mechanical link” between the bone and the muscle, the colon and the
pelvis. This is highly schematic. The mechanical link of the muscle, for instance, attaches
along the bone but only at the two ends of the muscle, to allow shortening and lengthening.
Likewise, the colon is attached through its peritoneal sheath to the iliac bone.

Fig. Parts of the mechanical link in the abdominal cavity. The various peritoneal
folds that envelop and anchor the intestines may be seen.

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The nerves are the second type of tissue that will prevent you from tearing easily the
content of the abdomen away from its supporting walls. Indeed, nerves run
everywhere, come out of the brain of the spinal cord to spread to the muscles, the
viscera, the glands etc. When I try to pull on some structure in the body to separate
from some other, I will always end up stretching or tearing some nerve trunks.
Nerves are thus also “restraining ropes” that hold all tissues together. We shall
consider that, as such, they act as “links” and call this type of articulation, the
neurological link. Obviously, as mentioned at the beginning of this lecture, the
neurological link is basically made of “mechanical tissue” (i.e., the connective tissue
that holds nerve fibers together). We discussed this issue before and have proposed
to see in the neurological system a “network” and a “link” which cannot be reduced
to its connective tissue or vascular envelopes. In other words, there is something
“unique” to the neurological link between tissues, different to the “mechanical” one.
This uniqueness is due to the “irritability” of the nervous tissue, one that is mobile
and connective, i.e., through the nerves, the irritability of one tissue is linked to the
irritability of another one (in fact of any other one, through the central nervous
system). This linked irritability is the essence of the neurological link.

Fig. The “neurological link” between two contiguous tissues and articulated tissues.

The third type of tissue that will resist my efforts at pulling away the contents of the
abdomen will be the blood and lymphatic vessels that vascularize and drain the
abdomen and its musculo-skeletal casing. This constitutes our third link, the “fluidic
link”.
Blood vessels act as ropes because they contain connective tissue (i.e., the
mechanical link). Here again, however, we propose to see the vascular link as
having an essence different from the mechanical one. Liquids have a mobility and
carry an information that is different from the mobility and information
characteristic of the other two links. They are able to relate organs through their
unique mobility and information.

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Fig. The vascular link between adjacent tissues.


These three types of “ropes” that connect tissues together, each one in its own
unique way, form what I have proposed to call “the three links”.

Fig. Composite drawing of the three links between a muscle and a bone, or between
a viscus and a bone.

We shall posit that all tissues of the body are connected through these three links.
As we mentioned earlier, there are other possible links between tissues, but the three
links discussed here are the only anatomically ubiquitous and continuous links
between all tissues of the body. It can be said that these three links articulate or bind
contiguous tissues such as the ones drawn in our figures, but it can also be said, in a
more inclusive way, that any tissue is connected to any other tissue through the three
links. For instance, there is a mechanical connection between the colon and the
bones of the foot (through the fascia), but there is also a neurological connection
(through the CNS), and a vascular (blood/lymph) connection.

We shall summarize the above with the help of the following axiom:

All tissues of the body - both contiguous and non-contiguous - are connected
through three links: mechanical, neurological, fluidic.

It must be emphatically stated again that although these three links are themselves
linked to each other, each one is irreducible to the other two. There is something
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specific to the binding of connective tissue, to the linkage through nervous traffic
and the exchanges due to fluid circulation.

The above axiom suffers no exception and will form the basis of our therapeutic
approach. Its first and foremost interest is that it allows a rigorous definition of the
notion of “articulation” between any given two tissues and its corollary, the
“osteopathic lesion”, i.e, a disturbance of the mobility of that articulation.
We have seen that in the early formulation of osteopathy by Still and its foremost
students, the human body was considered as a mass of tissues which could be
apprehended and treated in its entirety through osteopathic means. We saw that from
this broad, initial apprehension, osteopathy was progressively reduced to a system
that dealt with one tissue only: the musculo-skeletal system.
Our “three links” will allow us to redefine in the broadest and most exhaustive way
the osteopathic understanding of “articulation”.
We propose to consider that the human body is made of tissue masses that are
articulated to each other in three ways: mechanical, neurological and fluidic. This
definition supplies us with the next axiom:

An osteopathic articulation is the sum of the mechanical, neurological and


vascular links between two tissues of the body.

Fig. A schematic representation of the three links between any two tissues. From
above downwards, the vascular, the neurological and the mechanical links

This definition offers, I believe, the widest possible framework for our
understanding and our practice of traditional osteopathic medicine.
Indeed, the term “articulation” is extremely misleading. It makes us think of a
specific type of connection: that of two bones and their ligaments. That is only one
- the mechanical - of three types of connections - mechanical, neurological and
vascular - between the two bones. And moreover, not only bones are connected in
three ways, but any other tissues too, i.e., soft tissues for which the term
“articulation” is generally not employed. For instance, the kidney is articulated to
the other kidney through the three links but also to the posterior abdominal wall,
again in three ways. The liver has also a threefold link with the structures that
surround it. A neural plexus, for instance, the brachial plexus, is articulated to its
surroundings in this way. A blood vessel like the aorta is connected to the posterior
thorax and abdomen in this threefold manner; the uterus in the pelvis etc. Whichever
the organ or tissue, we will always be able to qualify three links through which this
tissue articulates with other tissues. In case we do not find any direct ligaments,

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nerves or vessels between two contiguous tissues (for instance in tissues that are
freely mobile in relation to their surrounding), we need only go a little further up
and we shall find the three links, i.e. that some nerve fibers are shared by the two
tissues, some blood vessel or some fascial sheath. I wish to insist on this point: the
restricted framework through which the notions of “articulation” and “lesion” are
usually defined must be abolished and “articulation” should be applied to every
single tissue of the body, whether or not a bone is involved. There is thus an
extremely large number of articulations in the body, as many as there are distinct
“tissues” or structures with some degree of autonomy. Each articulation is always
threefold.
Let us take a simple example, the articulation between the heart and the lungs.
This articulation is made of three links:
• mechanical, e.g., the pleuro-pericardic ligament
• vascular, e.g., the pulmonary arteries and veins
• neurological, e.g., the vago-sympathetic plexuses shared by these two organs.
A systematic osteopathic treatment of the cardiopulmonary system will have to deal
with these three levels of articulation. We are thus far away from the reductive
manipulation of the 4th thoracic vertebra proposed in the treatment of cardiac and/or
respiratory disease by the more restrictive chiropractic and osteopathic schools of
thought. This remains certainly an important highlight of osteopathic practice but it
cannot be exclusive.

We can draw two main conclusions from this chapter:


1. First, we have affirmed that, within each tissue, one may find three systematic,
continuous, anatomical networks of equal importance.
2. Second, we have proceeded to show that any two tissues in the body are linked in
three ways.
It is obvious that:
• the three networks that may be found within each tissue
• and the three links that are found between all tissues
belong to the same category of tissue: the mechanical, neurological and vascular.
This identity of structure between the networks and the links suggests that those
networks are continuous with the links. In other words, there must be a continuity
between the totality of the internal structure of any given tissue and the links that
connect this tissue to its neighboring structures. The three webs that unite organs to
each other are made of the same substance than - and are thus continuous with - the
three webs that run through these very organs.
At present, let us introduce in this description the notion of “mobility” and “lesion”
(i.e., “disturbed mobility”). It is obvious that if one of the tissues moves in relation
to the other, the three links will be stretched (mechanical aspect) or brought into
play (in the case of the neurological link). It is also clear that this stretching will not
stop at the surface of the organs or tissues since the mechanical, neurological and
vascular links become the mechanical, neurological and vascular “webs” that run
through those two tissues.
If we transform the term “mobility” into that of “lesion” (which is defined not as a
tissular destruction but as an abnormal mobility), we may then understand that a

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lesion that causes a permanent stretch5 of some link will have repercussions right
through the involved tissues.

Fig. Between these two stylized tissues, one may distinguish the three links. Within
each of the two tissues, one may see the three networks. One may also see that the
links and the networks are strictly continuous with each other.

From the above, we may infer, that the osteopathic lesion is not a “lesion” of the
inter-articular tissues (i.e., ligaments, muscles etc) but a phenomenon that penetrates
right through the tissues. Indeed, a tension of the mechanical link between any two
tissues will be prolonged, through the mechanical web of both tissues, to all parts of
the two involved tissue (to a degree and amplitude that will depend on the amount
of stretch). We shall see how important this notion is in terms of visualization. We
must not forget that, generally, in structural osteopathic technique, the operator
tends to think of the osteopathic lesion as a phenomenon that “pulls on ”, “strains”
the ligaments that join bones. The pain is generally felt on the area of insertion of
the ligament,
e.g., the internal collateral ligament of the knee, a frequent victim of sprain. He
would not tend to think it important to consider the prolongation of this ligamentous
tension right through the tibia. This would be even meaningless to him since
structural osteopathy cannot manipulate the mass of the tibia, it can only manipulate
the tibia with relation to another bone (femur, fibula, talus). This prolongation of the
links right through the linked tissues is, however, fundamental to our technique
since we believe that we can act on the mass of the tibia itself. It is thus very
important, in any lesion, to have a visualization of the involved tensions as complete
as possible. The tension of the articulatory tissues (ligaments) is only part of the
picture; how this tension involves the femur, the foot, the muscles etc. is no less
important.

5
I use the term “stretch” all three links although it should be applied only to the mechanical link and
the mechanical part of the neurological and vascular tissue. The vascular and neurological links are
brought into play in their own typical way. For the sake of brevity, however, I use the word “stretch”
to designate the implication of all three links.

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The osteopathic lesion, as I understand it, must therefore not be understood as an


“articulatory” problem, it is also a “tissular” problem.
We will include this notion in the following axiom:

The osteopathic lesion is both articular and tissular. In other words, in one’s
visualization, one must not stop the effects of the lesion at the surface of the bone
or the viscus. In the operator’s mental image, the effects of the osteopathic lesion
must be prolonged well into the articulating organs or tissues.

Fig. The continuity of the three links between and three webs inside two schematic tissues.
During a mobilization of the two articulated tissues, the three links are stretched and this
stretch runs deep into the tissues. This fig. shows also one possible kind of osteopathic
lesion and its deep tissue effects. Again, one aspect of the three links is emphasized, the
mechanical one. Indeed, what is stretched in the three figures above is the “mechanical
component” of nerves and blood vessels. We must understand however that stretch has
distinct neurological, mechanical and hydrodynamic effects (see below).

We remember that in our chapter on “the three facilitations”, we had proposed a


wider definition of the term “mobility” in osteopathy.
We had proposed that this notion had to include:
• mechanical mobility, i.e., the classical understanding of the word “mobility”.
This defines the ability of tissue masses to change their relationship in space: for
instance, mobility of the liver in relationship to the diaphragm, mobility of the
anterior tibial artery in relation to the interosseous membrane.
• neurological mobility, the variability of the membrane potential of neurons
(individuals or groups). From the fig. above, and our discussion of the three
links, it could have been understood that we have discussed so far the “mobility”
of nerve trunks as a mechanical structure. Although a very important element, the
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stretching of a nerve trunk belongs to the “mechanical link”, i.e., here, the
mechanical aspect of the nervous system. This would be a restrictive
understanding of the theory of the three links. By neurological link, we imply the
actual “neurological articulation” between the liver and the heart, i.e., the
mobility of one tissue mass in relation to the other (both organs are innervated by
the vagus making their articulation rather obvious. We can discuss also the
neurological articulation between the flexor and extensor muscles of the spine.
All these “articulations” are largely in the CNS and have a certain mobility, i.e.,
flexor tonus can exceed extensor tonus and vice-versa according to the needs of
the moment. The two tissue masses symbolized above can thus represent
extensive muscle complexes, two distant organs (heart and kidney) etc.

• vascular mobility, i.e., the variability of fluid pressure and flow in a tissue or in
contiguous tissues, or in tissues who, although distant, have correlated rates of
flow according to metabolic or thermal needs. Vascular mobility includes all
types of fluids in the body: blood, lymph, bile, intra-ocular fluid etc. The same
remark holds for vascular mobility and neurological mobility. Indeed, from the
figures used above, one may think that in an osteopathic lesion, the blood vessels
and nerve trunks are mechanically stretched leading to electrical and
hydrodynamic disturbances. This indeed occurs and is an important part of the
lesion syndrome. This effect is however due to the mechanical aspect of blood
vessels and nerves (since both contain connective tissue). The vascular link and
its “vascular mobility” has its own, additional role, i.e. the variability of flow
between contiguous and distant beds.
All tissues of the body possess this triple mobility within themselves and between
them.
In health, this triple mobility is maximal, in disease, it is disturbed.
We shall summarize the above through the following axiom:

An osteopathic lesion between two contiguous or distant but related tissues always
presents itself as the disturbance of mechanical, neurological and vascular
mobility between and within these tissues.

As we shall see below, in any osteopathic lesion, one the mobilities is


predominantly disturbed depending on the etiology. Whenever one is affected,
however, the other two will automatically be affected due to the extreme
connectivity of structures and functions in the human body. We remember that
blood vessels are innervated and are made of connective tissue, that connective
tissue is vascularized and innervated, that nerves are vascularized and made also of
connective tissue. In acute lesions, one of the mobilities is predominantly affected.
In chronic lesions, with time, this predominance decreases. A systematic
osteopathic treatment of any given tissue or group of tissues will thus have to deal
with all three mobilities.

This will allow us to formulate the following axiom, one that summarizes all the
preceding ones:

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The human body is made of countless tissues articulated through the three links,
endowed with a mobility characteristic of each link. As a result of some
pathological input, this mobility can be affected, leading to an osteopathic lesion.
The number of osteopathic lesions is thus equal to that of articulations. These
lesions always affect the three links. The strict anatomo-physiological continuity
between those three links and the three “webs” that make up each of the body’s
tissues, extend the effects of osteopathic lesions deep within the tissues. A
thorough osteopathic treatment is one that bears upon the three links. It will
normalize not only the articulation between the affected tissues but also their
structural fabric.

We shall see below that each link possesses its own corrective techniques, hence the
importance of their systematic separation.

Etiology of Osteopathic Lesions

We have tried so far to determine a common denominator between the abilities of


the hand of the osteopath and the characteristics of the osteopathic lesion. Our hand
can only have three effects: it can displace solids, fluids or stimulate. Body tissues
have three distinct forms of articulations: solid with solid, fluid with fluid, neuronal
input to input (or output). Osteopathic lesions always imply those three types of
articulation. We may then conclude that the hand of the osteopath and the object on
which it is applied (the osteopathic lesioned tissue) are made of the same substance,
are homogeneous. Our hand can affect the lesion complex.
We may now deal with the origin of the osteopathic lesions, i.e., what has disturbed
the mobility of the three links in the first place? In other words, what is the etiology
of the osteopathic lesion? A detailed answer to this question is way beyond the
limits of these lectures. Indeed, the state of a tissue at any moment is conditioned by
so many factors, chemical, biochemical, genetic, physical etc. that to reduce a given
pathology to a single cause would be very preposterous. But our text here is not a
textbook of pathology. We are interested in defining “principles” that may lead to
general “frameworks” for our therapeutic techniques. In the case of pathology and
etiology, we are interested in finding the classification of etiologic factors according
to how tissues are made and what our hands can do about it. Since our hands cannot
remove directly chemicals or genes by pinching them between thumb and fingers,
the chemical or genetic etiologic factor cannot be included in an osteopathic
discussion. They can be modified in an indirect way, as a result of our work on the
three links. We have already seen that to affect directly the chemical and genetic
factor, a major change is needed in osteopathic thinking and its conditions will be
described at a later stage. At present, we are concerned with acquiring an
understanding of the etiopathology of the osteopathic lesion that is homogeneous to
what my hands can achieve. A therapist who uses osteopathy for the treatment of
lumbago and homeopathy for the relief of gastro-duodenal ulcer has clearly
renounced to have a unified vision of his work. He has two distinct etiologic
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understandings of the body. Although it can be useful and effective clinically, I


believe that the eclectic approach is very destructive for each profession. Ideally, as
patients ourselves, we would wish that the practitioner we go to for treatment, has
gone as far as possible in exploiting the possibilities of his approach. We suppose
here that every approach, such as Acupuncture, Homeopathy, Naturopathy etc.
represents an essentially original “reading” of human pathology, irreducible to the
others. The fact that some - many - practitioners resort to acupuncture needles,
manipulation and herbal/homeopathic prescriptions on the same patient, in the same
session, should not be condemned only for the sake of purity of principles. One must
teach, however, to students a given therapeutic method as if no other method exists.
Even if within a given school, several therapeutic approaches are taught, it is of the
highest importance that each approach should be taught as isolated. Not only will
that lead to the formation of highly skilled practitioners but also to highly creative
ones, i.e., to original syntheses between distinct techniques within the same
approach or distinct approaches.
This discussion is most critical when dealing with the subject of etiology. Indeed,
my visualization of the causative factor of disease (a particular one, a set of diseases
etc.) will largely determine my technique. Do I think that all problems are “psycho-
somatic”? Due to poor or adulterated nutrition? Bad posture? Often, practitioners
have strong beliefs about the psycho-emotional origin of that type of problem and
the nutritional cause of that other type of problem etc. We are not interested in that
eclectic approach. We are interested in finding the widest application of the notion
of etiology to the principles of osteopathy, as if no other approach existed.
Repetitive clinical failure using such principles would then possibly indicate that
another approach is needed, that what is occurring in this patient is not
homogeneous to what I can achieve with my hands and my osteopathic principles,
that the etiology, the source of the problem the patient came for, is beyond my
apprehension.

We therefore propose to define which “minimal” statements can be made about


etiology so far as an osteopath, practicing only manipulative medicine, is concerned.
Osteopathy sees the body as a complex of articulated masses. We have defined this
articulation as being of a triple nature. From the choice of the word “osteopathy”, it
is clear that Still favored the mechanical link. Indeed, that link is the most obvious
to the eye: everything in the body seems to be made of parts articulated by
ligaments. We can compare the body to one of those “mobiles” made of little pieces
of wood that are linked by strings to some central piece. The solid pieces move in all
sorts directions, dangling from their string, when the “mobile” is shaked.
Let us now give a blow to that mobile. All the pieces will move wildly. The parts of
the mobile that will take up most of the force of the blow are the little strings. They
may even tear. For the pieces of wood to break we would need a very considerable
force.
In other words, in a “connected mechanism”, external strains are first absorbed by
the “links” between the parts. In mechanical models, they are the first to stretch.
The human body is also a “mechanical mobile”, it is full of parts that are held by
strings. All external strains are first and foremost absorbed by these mechanical

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links. Forces that exceed the absorbing ability of those strings will break and destroy
the parts themselves
I suggest that this simple observation, obvious in the case of the mechanical system,
should be extended to the vascular and neurological links. We would then be able to
describe three possible “mobiles”, which are made of “pools of fluid” (vascular
link), “pools of irritability” (neurological link), “pools of inertia” (mechanical link).
The various pools have their own type of “strings” that unite them to some central
piece or to each other. Obviously only in the case of the mechanical link, do these
connections look like actual strings. In the other two links, they have a form that
cannot be “drawn” as a link (for instance, strings of information in the neurological
link, strings of trophicity in the vascular link)
From the example of the mechanical mobile, we have seen that when a strain is
applied to a mobile - i.e. a complex of mobile masses linked by strings -, the strain
is absorbed and buffered by the strings or links. We suggest the same applies to a
complex made of “neurological parts” or “vascular parts”. Any strain applied to
these mobiles will first and foremost be absorbed by the links. Beyond, they will
tear and parts will begin to break down, leading to permanent loss of information
(neurological) or fluid (vascular). We can thus say that in any given articulated
structure, “links” are generally the point through which strains are absorbed and
buffered. We can qualify our last axiom: links do not transmit integrally the forces
they receive to the internal tissue networks with which they are continuous. Links
have a protective role towards the tissue.
Our model of the three links will allow us to define three categories of strains which
will penetrate the body through their specific link These strains constitute the
etiologies specific to each link and therefore of each of the “networks” that make up
the tissues of the body.

Mechanical Etiology
All physical forces, all mechanical strains, trauma are absorbed by the mechanical
link between all tissues. A given shock will move one structure with relation to the
other and the tissue that suffers most is the “linking tissue”. Only when the strain is
important, repeated or constant, will the tissues that are linked be affected in their
own structure (see preceding axiom). Most probably, links absorb minor strains
almost completely, leaving tissues undisturbed.

Neurological Etiology
One of the main types of strain here is obviously psycho-emotional strain. Anxiety
is able to literally “move” neurological relationships (as well as mechanical and
vascular ones, obviously). Another type is metabolic strain which will be “recorded”
in the nervous system and, through its own links, lead to manifestations at a distance
(for instance, referred pain, osteopathic reflexes etc.)

Fluidic Etiology
A “vascular strain” will also penetrate through the vascular link. The stress to which
fluids are extremely sensitive - much more than the solids - is gravity. Gravity
determines largely the distribution of fluid masses in the body. Factors that amplify
these tendencies are markedly pathogenic.

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We have thus defined, for the three links, the existence of specific etiologies,
although the connectivity between the three links forbids the drawing of clear lines.
We can only say that the fluid system is more immediately sensitive to gravity than
some bone or some group of well supported neurons. Likewise neurons are more
directly sensitive to emotional difficulties than fluids of the knee. Clearly, however,
any strain will affect all other links with severity or time. Initially only, it can be said
that specific strains will penetrate in our “mobile” through the links that are
homogeneous to them.
We will formulate the above in the following axiom:
The body absorbs stresses and strains through the three links, each of the link
absorbing those stresses that are homogeneous to it. “Osteopathic lesions” occur
when this absorbing and buffering ability is permanently disturbed. Except for
major destructive processes (trauma, infection), the link is always affected
primarily, before the linked structures.

How can we use these notions clinically?


When a patient comes to our consultation with a given symptom, one of the most
crucial questions for the osteopath is: what shall I treat? Practitioners, with time,
acquire diagnostic skills and acumen; they are often able to recognize a given
problem before they examine the patient, from sheer experience.
Such wizzards know that for this type of sciatic pain in this type of patient, the
second cervical vertebral vertebra will have to be adjusted, something that baffles
the young student that may happen to witness the scene.
Before he acquires that skill, a time-consuming procedure, a student or young
practitioner will have to resort to more intellectual solutions, i.e., he will have to use
his wits on what he has learned. I have found that, if for no other reason, the theory
of the three links offers a good initial framework of osteopathic diagnosis and
treatment.
Let us take a simple, common example. A patient comes to our consultation
complaining of knee pain. From his description of symptoms, we can often
determine which “link” is predominantly affected.
For instance, he says that his pains are only moderately aggravated by knee motion.
Standing still or sitting for a while typically bring on a diffuse pain. He often has
pains at night in bed, whilst lying still. There may also be a feeling of “heaviness” in
the knee.
We would obviously suspect here a disturbance of the “fluid link” in the knee
region. The pain syndrome strongly evokes fluid stasis and is aggravated by factors
that lead to fluid stasis. Treatment will have to concentrate on the vascular system of
the knee: most probably treating the vein/lymphatic drainage of the knee.

Another patient may come with knee pains that are localized in some specific area,
are somewhat aggravated by motion but only at the extremes. The pain comes in
waves and can stay for a long spell irrespective of motion or posture (such as
standing or sitting). Even at times when there is no pain, the patient, with
concentration, can feel some local sensitivity. This clinical picture is strongly
evocative of the neurological link. The pain may be a projected, “reflex” pain from
some other area or organ (foot, ovary, colon etc.), it can come from a local

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“neurological scar” (previous disease or physical trauma, surgical scar, somatization


of some psycho-emotional trauma etc.).
Treatment will have to concentrate on the neurological link, something that can take
us far away from the knee.
A third case, will be the common presentation of knee pain mainly upon motion,
and lack of pain at rest. This evokes obviously the mechanical link and should be
treated accordingly.
One could multiply examples of this kind for all articulations of the body
(articulations in the wider sense proposed in this text). Most pathologies that come
to the osteopath’s office can be integrated, classified within the three links. In many
cases, it certainly supplies us with a framework: what to treat mainly or first. In all
cases, where the “lesion” is known to be primarily biochemical/genetic, this model
largely fails, as most other therapeutic models do.
Often, however, this simple classification helps to devise the treatment program. We
remember that, according to the principles formulated here, no tissue is out of reach
of osteopathic treatment so long as we has reduced all tissues to their “fundamental
network” and found their “links”. So that, if a patient comes with a problem that
seems (or is known) to be due to “problems” (non-chemical in nature) in some deep
artery, we would be able to reach this artery and adjust it. In other words, problem is
not “will we be able to adjust?” but “what to adjust”. In the type of osteopathy we
describe here, unlike the more structural type, it is postulated that every single tissue
of the body can be directly accessed. The limit is then not so much our technique but
our ability to determine what should be treated. This determination is often an
intellectual process, i.e., it requires general medical and specific osteopathic
knowledge, to determine what functions are disturbed in this patient. Again, I wish
to differentiate that from “diagnostic skills” that stem from the development of the
senses of touch or vision, and which take time and constant exercising. Here, we
propose a working model that allows the practitioner to transform what he has
learned of anatomy, physiology and osteopathic principles into a treatment
procedure.
This can only be achieved through a solid grounding in principles osteopathy and
basic medical knowledge. Although nothing equals diagnostic skill and acumen, it is
my experience that impeccable knowledge and application of principles has time
and again shown that it could help in clinical problems unsolved by intuition and
skill.

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General Principles
of Osteopathic Technique
on the Three Links.

I have proposed so far to distinguish


• three fundamental actions of the osteopath’s hand
• three fundamental webs in all tissues
• three fundamental links between tissues
• three fundamental etiopathological processes

We have found the strict continuity between all four levels, owing to their common
nature: neurological, fluid and mechanical. The first distinction, the one we used as
a foundation stone of our analysis, dealt with the abilities of the hand of the
osteopath. In other words, it implicitly indicates the possibilities and limits of
osteopathic manipulation. We have already discussed these in general. We can,
however, further refine this initial distinction in the therapeutic abilities of the
osteopathic hand. It is possible, indeed, to classify all osteopathic techniques
according to which link it can work on. Again this classification will not be clear-cut
since the three links are thoroughly interrelated and the hand of the osteopath affects
the three links at the same time when it is laid on somebody’s skin. It remains
clinically important, however, to introduce a distinction between the three
links/webs present in our tissues. Let us admit this distinction and let us admit that,
from the pathological standpoint, in a given disease process, one of the three links
has been predominantly affected. It follows then that the osteopath must have, at his
disposition an arsenal of therapeutic
measures specific to that link. In other words, he must be able to apply a measure
that will reverse the etio-pathological process. We are dealing again with a “pure
osteopath”, accordingly a mythical figure, i.e., one that does not allow himself to
think of any pathology in chemical terms and would not give an anti-inflammatory
drug, potion, homeopathic preparation or diet when confronted with an
inflammation. Such an osteopath would make all possible efforts to find and apply
the irreducibly osteopathic contribution to therapeutics, something that would not
prevent him, for the sake of his patients to work in a team where other approaches
are used in an equally rigorous way. Such an osteopath, having identified through
his interrogation of the patient, through his clinical experience and physical
examination that a particular link has been predominantly affected will have to
apply a technique specific to that link.
For example, a patient comes for a sprained ankle. The articulation is painful and
swollen. The patient sprained his ankle when he strongly kicked a football. This

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piece of information combined with palpatory evidence suggesting that one of the
bones of the ankle joint has been moderately “derailed”, imposes an obvious
measure: the “displaced” bone has to be set back to its proper position. The swelling
is secondary. A treatment centered on the “fluid link” would be rather symptomatic
and, here, the mechanical link is crucial. An orthopedic surgeon who receives a
patient with a dislocated shoulder would certainly not propose as a main course of
treatment ice-packs to reduce the inflammation or a benzodiazepin to allay the
anxiety. He would propose to reduce the dislocation.
In another instance, a lady who would come with pain in the lower limbs due to
poor venous return, an elderly man with pain evocative of arteritis should receive a
treatment centered on the fluid link. The value of ankle or knee manipulation would
be rather doubtful in their case. A more classical osteopath or a chiropractor would
suggest that in those cases, one should treat the mechanics of the spine or the pelvis,
with the hope of affecting the innervation of the blood vessels of the lower limb. In
other words, a “vascular problem” has been reduced to a “mechanical” and a
“neurological” disturbance. At the beginning of this chapter, I have proposed that
although it may be clinically effective, this approach is reductive. Indeed, the strong
interrelation of all three links allows us to affect any one or two of them through the
third one. This is an “indirect” procedure, however, one chosen not by true choice
or principle but by the limitations of the technique used. An osteopath will always
try and reduce the pathology of his patient to what his hands have learned to
achieve. I believe that an osteopathic treatment that will address a chronic sinusitis
or a trigeminal neuralgia with cranio-sacral and vertebral manipulations is better,
more encompassing, than a treatment that will be content with modulating the
innervation of the sinus mucosae through manipulation of the upper dorsal
vertebrae. Chronic sinusitis certainly supposes neuro-vegetative disturbances but
also poor mechanics of the bones that bear the sinuses, poor venous and lymphatic
drainage etc.
An osteopath should thus possess a palette of techniques that will allow to address
directly all the pathologies in which his skills are indicated.
We propose to make a brief review of the main techniques available in osteopathy
and classify them according to their affinity to one of the three links.
Early in osteopathic history, however, a major distinction has occurred between so-
called “functional” and “structural” techniques. These two basic forms have reached
such a degree of independence of principles and practice (although they still share
the initial Stillian model) that their affinity for the three links has to be treated
separately.
There are a great number of osteopathic techniques nowadays and the distinction
between “functional” and “structural” is often blurred. I propose to classify all
osteopathic techniques under these two headings according to the following criteria:
• functional techniques are those osteopathic approaches where the
intervention of the operator, voluntary or involuntary, is minimal and that of
the patient, voluntary or involuntary, is maximal
• structural techniques are those osteopathic procedures where the
intervention of the operator, voluntary or involuntary, are maximal and those
of the patient, voluntary or involuntary, are minimal.

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According to these criteria, a technique like “muscle energy” (authored by Fred


Mitchell Sr. D.O.) would be clearly functional although it implies much voluntary
motion and stretching since that motion is enacted by the patient. Manipulations
(whether thrusts or passive articulatory techniques) are clearly “structural” since the
operator does all the work and asks his patient to be as relaxed as possible, i.e., as
unobtrusive as possible.
We call “thrusts” those manipulative procedures where the operator applies a
sudden force (or a series of sudden forces) to a passive patient. When applied to
articulations, this often produces a “popping noise”.
For each of the three links, various specific osteopathic procedures have developed
over time, either “structural” or “functional”. Confronted with any given clinical
situation, an osteopath, according to his capacities, his preferences or his formation,
will thus resort to one of the following approaches.
For a full description of each of the techniques, please consult the Year Books of the
American Academy of Osteopathy.

Neurological Link
Functional technique: Hoover’s, Bowles and Johnson’s “Functional Technique”,
Lawrence H. Jones’s “Strain and Counterstrain”, Fred Mitchell’s “Muscle Energy”,
Rollin Becker’s “Fluid Reciprocal Balance Technique”, John Upledger’s
“Unwinding” A. Abehsera’s “Connective Osteopathy”.
Structural Technique: all reflexologies (such as Chapman’s reflexes). Through its
specificity, a reflex treatment is equivalent to a “thrust” of the nervous system.

Fluidic Link
Functional technique: A. Abehsera’s Connective Osteopathy on vessels
Structural technique: all “pumping” and “manual drainage” techniques. Thoracic
pump, liver pump, anterior throat pump, thymus pump etc. All these procedures are
equivalent to “thrusting” the vascular system.

Mechanical Link
Functional Technique: WG Sutherland cranio-sacral and general technique, all
techniques based on the “exaggeration of the lesion”.
Structural Technique: massage, traction, direct manipulations of all kinds including
“thrusts”.

I must reiterate that these distinctions are tenuous at best and artificial at worst,
owing to the systematic inter-relationship of body structures. It is clear that “thrusts”
have an effect on the nervous and vascular system. It is clear also that a technique
like “Mitchell’s Muscle Energy” moves the bones and as such has an effect on the
mechanical link. The same goes for “exaggerating the lesion” techniques. These
very clear overlaps should not make us forget, however, the irreducible specificity of
each technique, and it is in virtue of that specificity that I have proposed this
classification. “Thrusts” are the most specific way of returning a structure to its
original position, first and foremost a mechanical effect, which will be followed by
neurological and vascular repercussions. Mitchell’s Muscle Energy is a kind of
“neurological reeducation” procedure mainly enacted by the patient. Pumping
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procedures are definitely aimed at moving directly fluids and not the bones that may
overly them (e.g. the ribs in case of the thoracic pump). “Exaggerating the lesion”
techniques definitely use a “mechanical” terminology in their procedure. The bone
or articulation has to be “moved” in a certain direction for the release to occur. The
classification is less obvious in techniques such as R. Becker’s “Reciprocal
balance”, Upledger’s brand of unwinding technique and the the present author’s
“Connective Osteopathy”. Their functional nature is obvious, their affinity is less so.
I can only speak clearly for “Connective Osteopathy” , and I believe that it is the
only “functional approach” for the fluid link since it allows the specific treatment of
any blood or other fluid-carrying vessel. Regarding this particular approach, there is
however an inconsistency in the criteria used for distinguishing “functional” from
“structural” technique. Indeed, in this approach, it looks like the operator is
intervening in a minimal way, leaving the patient’s tissues to do the corrective work.
This is only correct part of the times since, when the operator makes a surgical
procedure in his visualization field, he is indeed very active although an observer
would see no motion. In other words, at times, what looks like a functional
technique is actually a structural one in its principles.

As a pedagogic guide to osteopathic practice, the above classification seems fairly


correct. If we associate what we have discussed on “etiology” and “technique”, we
see that the practitioner may, from his diagnosis and understanding of the etiology
of his patient’s problem, choose the technique that is homogenous, first to his taste
and capacities, and second, to the affected link(s).
Obviously, we will not develop here the use of techniques such as “structural” or
“cranio-sacral” osteopathy which have been abundantly described elsewhere. The
specificity of the type of osteopathy we are interested in developing here over the
other techniques mentioned in our classification is clear: “connective osteopathy”
allows for a highly specific anatomic approach, meaning that we can reach and treat
any anatomical structure directly, something not generally possible with most of the
other techniques which, often, are either indirect or incapable of treating a too deep
or too small anatomical structure. This specificity stems from the simples principles
we have formulated until this point: all parts of the body, whatever their size, depth
and texture are accessible to osteopathic treatment as long as
• we reduce tissues to the three “substances” which our hands can affect
• we reduce all possible links between tissues to the three that our hands can
affect
• we reduce all etiologic factors to the three that our hands can affect

When the patient comes with a specific complaint, the above principles will be
applied in the following axiom:
Confronted with any pathology - known to be treatable by osteopathy - the
therapist will ask himself the following question: what links the organ or tissue
that suffers to the rest of the body from a neurological, fluidic or mechanical
point of view?

We suppose again that it is not the tissues themselves that are primarily affected but
the links. Since the links are continuous with the internal “webs” of all tissues, a
treatment of the links will extend into the tissues. The main lesion process, however,
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or better, that part of the lesion process that is the indication of osteopathic
treatment is the link and its extension as the internal web of the tissue, but not the
cellular substance of the tissue.
Let us take two examples, a medical one, chronic sinusitis, and a surgical one, anal
fistulae. These are commonly encountered in practice, making useful pedagogic
examples.

Chronic sinusitis
The osteopath, as an individual or as part of a team, is asked to offer his contribution
to the treatment of a patient with chronic sinusitis. We suppose that all other
etiologic factors are taken care of (smoking, poor diet etc.). We are left with having
to make a pure osteopathic analysis.

We are not interested here in the exact details of diagnosis or of etiology (allergy,
infection from an apical granuloma, tooth,etc.). We are interested in devising an
osteopathic treatment to the sinuses that are affected, whatever the reason. The first
question that we must ask ourselves is: what structures link the symptomatic
sinus(es) to the rest of the body. The information derived from this question must be
separated into three categories:
• all the connective tissue structures that unite the sinus (es) to its neighboring
tissues
• all the nerve fibers that unite the sinus(es) to the rest of the body
• all the vessels (blood, lymph or other) that drain or irrigate the sinus(es)
We consider that these "links" are the weak points through which pathology has
settled in the sinuses and they must be our initial target for treatment. The
classification above has produced three "boxes of information", each box having its
own types of etiology and osteopathic procedures.
The mechanical link is naturally affected by physical trauma in which one (or more)
of the sinuses have been slightly but significantly displaced or immobilized (blow,
falls, tooth extraction etc.). The fluid link is naturally affected by poor drainage and
irrigation in the anterior throat and superior thoracic inlet. The neurological link
would be affected by nociceptive stimuli coming from many centers, neurological
and visceral. Again, the inter-relationships between all these links is marked and
will not be developped.
The interrogation of the patient may bring out clearly one of the etiologies above:
the sinusitis began after a period of intense dental treatment, after a hepatitis, after a
period of recurring throat infections.
Often, even most often, no clear etiological factor may be brought to light.
Frequently, for example, the therapist is confronted with a person who is a heavy
smoker and/or suffers from chronic upper respiratory tract allergies since he was a
young child. In all of these cases, particularly in the case of the smoker who has no
intention of stopping to smoke, we are left with the necessity to treat directly,
osteopathically, i.e., to evaluate and balance the anatomical relationships of the
patient's sinus system. Relieving the sinuses of a heavy smoker may sound like a
useless or even unethical act in the long run since we are actually making it easier
for him to continue indulging in his habits. I certainly do not agree with this kind of
thinking and every therapist should advise his patient as to what is best in the long

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run but, at the same time, he owes him the best symptomatic treatment he can offer,
so long as it is given ethically.
The three "boxes" we have just created thus contain facts of etiological relevance -
sometimes not - but mainly anatomy, i.e., anatomy of the three links. An anatomical
picture can be read as a description of relationships (links) and as such, of weak
points. These anatomical facts can be immediately transformed into osteopathic
techniques. In other words, the path taken by an artery or a nerve, the structures that
surround it during its path supply me with the necessary information as to
• where I should lay my hands, for instance, at both ends of its path
• what my visualization will consist of
Defined in the broadest possible way, osteopathic technique is the application of my
hands or my visualization on every one of the relationships that make up anatomical
structures.
Anatomical textbooks are thus my primary osteopathic technique textbooks. They
contain as many osteopathic techniques as there are relationships ("links") in the
body.
I am returning to a fundamentally Stillian approach of osteopathy, since the Old
Doctor used to say that osteopathy is only anatomy and more anatomy. An
osteopathic student should thus consider that his first and foremost osteopathic
technique texbook is his anatomical textbook and that he should be able to derive
alone the necessary techniques for sinusitis or any other pathology for which
osteopathy is an indication by carefully studying anatomical drawings.
We will formulate this in the following axiom:

An osteopathic lesion is primarily a lesion of the three links. Osteopathic


technique must aim at restoring mobility to the lesioned three links. Anatomical
textbooks give the detailed description of the three links. Anatomical textbooks
may thus be read as osteopathic textbooks, i.e., every anatomical relationship is,
potentially, an osteopathic technique.

Let us return to the treatment of sinusitis and try and apply the above axiom for each
of the links.

Neurological link
Looking at an anatomical description of the sinuses, two sets of nerves will draw our
attention
• the Vth cranial or trigeminal nerve
• the cervical and stellar plexuses in the neck and upper dorsal region
The pathway of these nerves will have to be treated as well as some of their key
structures. For instance, for the trigeminal nerve, a key point is the ganglion of
Gasser that lies on the petrous portion of the temporal bone. For the cervical and
stellar plexuses, the anterior tissues of the neck, the domes of the pleura, the various
vertebral articulations will have to be treated, thus addressing the “mechanical”
aspect of the neurological link. For the neurological link proper, reflexes to the sinus
area can come from as far below as the gall-bladder, the liver or even the uterus.

Fluidic link

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Again, our treatment will deal with the “mechanical aspect” as the fluidic aspect of
that link. Anatomic textbooks will show us the venous and lymphatic drainage of
the sinuses and all the mechanical structures that may prevent proper circulation in
them. In sinus pathologies, it is not so much the arterial supply which is at fault as
the fluid drainage, since sinusitis is, almost by definition, accompanied by
congestion, oedema and thickening of the mucosa. The direct work on the fluid link
will consist in encouraging flow along the drainage routes.

Mechanical link
Whilst looking at an anatomical textbook, the question will be: what are the
mechanical links of the sinuses to the rest of the body? The most obvious answers
will be: the various articulations of the cranial bones that contain the sinuses: the
ethmoid, the sphenoid, the frontal, the maxillary bones. Beyond these bones, various
fascial bands or ligaments relate the sinuses to higher and lower structures (e.g. the
stylohyoid ligament, the muscles that insert on the hyoid bone and beyond etc.

In other words, as soon as I have asked myself the question as to what relates the
sinuses to the rest of the body, three boxes of information appear: neurological,
vascular and mechanical relationships. Each of these relationships can be visualized
and thus transformed into an osteopathic technique. A systematic treatment, one that
will use the information from all three boxes, may be considered as a thorough
osteopathic treatment of the sinuses.

At first sight, this approach seems to turn every treatment into a formidable task
since it proposes to relate, ultimately, all parts of the body to the sinuses. In the
absolute, this is true and it should be so since the body is an organism made of
highly interrelated parts. We may thus find, in a given patient, that the pain and
congestion will respond best to the treatment of the mechanical link between the
colon and the left frontal sinus, or the neurological link between the right maxillary
sinus and the uterus. Generally, we need only treat the “local” three links. The more
“distant” and unusual link will be resorted to when there is a clear clinical indication
of a particular relationship (“the sinusitis began a month after I had my gall-bladder
removed” ) or when, with experience, the operator finds that his hands are drawn
towards some distant organ6.
Quite often too, there is no clear etiological indication or one that is extremely
general (such as smoking in the case of sinusitis). In those cases, we can simply go
through the three links, one after the other. As mentioned above, we first treat the
link itself (for instance the Vth nerve) and then its extension into the tissues that are
linked (the medullary centers of the Vth nerve in the brain stem, the mucosa of the
sinuses and, through their innervation, any organ that is linked to the sinusitis). We
remember that the link and the “network” inside the organ are continuous. A recent
and moderate lesion will basically affect the link, whereas the older and the greater
the amplitude of the lesion, the more involved the “linked” tissues themselves will
be.For instance, in a recent trauma of the knee, we suppose that, at the beginning,

6
This is part of diagnostic procedures, a subject to be discussed further.
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the strain will concern mainly the ligaments that link the tibia and femur. With time,
the lesion pattern will penetrate progressively deeper into the actual bones of the
tibia and the femur, reaching, with time, all the way down to the foot and all the way
up to the hip and beyond.
The elements of time and amplitude of the causing stress play also an important role
in the degree of involvement of the three links. As we mentioned above, a recent
lesion tends to implicate one link (the one through which the disturbance has
penetrated the body), but with time, all three links are implied. This means that,
when confronted with well entrenched pathologies like chronic esophagitis,
sinusitis, prostatitis or cystitis, the osteopath will find it useful to resort to the
treatment of all three links as a matter of routine.

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Practice of Connective Osteopathy I


Rollin Becker DO
“Listening Technique”

At the very beginning of this course, I conveyed to you the difficulties posed by
teaching the type of osteopathic practice we had set out to learn together. The main
difficulty lies in the fact that it is, at least at first sight, a completely subjective form
of practice, i.e., there is no “technique” involved. Whether we use our hands or not,
no actual manipulation occurs. The actual treatment is enacted in the mind of the
operator and whether he treats this or that pathology, this or that anatomical
structure, the operator is never seen moving, doing something with his hands.
Teaching such a form of therapy comes down to teaching how to think in an
effective way. How does one teach someone else “how to think” ? Apart from the
ethical dangers involved, the pedagogic challenges are immense. I therefore
suggested, at the beginning of the course, that I will take a historical approach, i.e.,
that I would take you step by step through the various stages that led me to such a
practice.
We have so far surveyed the theoretical background, i.e., we have dissected the
various theoretical elements that fed and inspired osteopathic practice in general and
my own practice in particular. We have now to dissect the practical background, i.e.
the actual technical approaches from which I derived “connective osteopathy”. This
will be achieved through a progressive series of exercises.
The first series of exercises will be “hands on”, followed by a second series of
“hands off” exercises.

Some Biographical Notes

Before we proceed with these exercises, I wish to give their biographical


background. This will allow us to pinpoint as precisely as possible the location of
this approach in the map of osteopathic practice.
My initial practice of osteopathy, that of my early student years, was so-called
“structural osteopathy”. As I mentioned before, in my late student years (3rd and 4th),
I was exposed to other approaches. I can see two reasons for my early rejection of
structural osteopathy and my search for other approaches:
• there seemed to be a large disparity between the art of Medicine, in general,
with all its wealth of information in human pathology and the osteopathy we
were taught. For most pathologies, the same basic corrective mechanism
was suggested: manipulating such and such a vertebra. The manipulation of
D4 and D5 for instance was the choice measure for the treatment of all
cardiac and pulmonary diseases. These limitations seemed to be vindicated
by the scope of osteopathic practice: back pain seemed to make up 90% of
osteopathic consultations. In other words, osteopathy claimed it was a
general medicine but was actually practiced as a highly specialized system.
In practice and in principle, it seemed to fall short of its ideals.
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• there seemed to be a major problem of “objectivity” in the practice of


structural osteopathic technique. I was never convinced that two structural
osteopaths can find the same lesions on the same patient. Structural
osteopathy is grounded on the assumption that the body is made of matter
and, as such, it can be measured as an object, i.e. objectively.
The trained osteopath is he who can feel the objective state of, for instance,
intervertebral relationships. Although possible in principle, I could never
achieve myself any measure of agreement with my colleagues, probably a
reflection of my incompetence, but neither could I see such agreement
amongst others. It became clear to me, then, that the “subjective” element in
osteopathy was paramount and that osteopathic technique should be
grounded on it. Although I do not claim that it is impossible to achieve
objectivity in osteopathy (such as: everybody agreeing on the lesion pattern
of a particular patient), I decided, very early, to leave that possibility to
others. There is a notion in the principles of structural osteopathy, however,
that I could not reject and it is in-built in connective osteopathy: the notion
of “adjustment”, to be discussed below.

My early disappointment with structural technique must be understood as a


reflection of my understanding, my philosophical choices and limitations. I have the
greatest admiration for those of my colleagues who believe that they have reached
some form of objective practice. This personal disappointment led me to a frantic
consumption of osteopathic approaches other than structural. I would adopt with
great enthusiasm a particular approach, learn how to practice it with some
proficiency to abandon it later, after having discovered that it did not solve the
problems I had had with structural osteopathy. The fact that I learned various
techniques and abandoned them over short periods of time, betrays, more than
anything else, my psychological fabric: that of a butterfly, a Jack of all trades and a
master of none. I was certainly being superficial but I felt, with no less of a
certainty, that I was driven by “philosophical insatisfaction”.
The osteopathic bulimia of those years had, however, several advantages: I had the
opportunity to meet some of the major developers of osteopathic principles and
technique of my time, get friendly with them, help spread their teaching to Europe
and form my mind to all possible forms of osteopathic thinking.
The year after my graduation, in 1976, I felt I had exhausted all possibilities in
osteopathy. More correctly, I felt that I had exhausted all the osteopathic subjects
and approaches that could awaken some interest in me. Osteopathy had become a
dead end for me. I had, several times before, gone through similar crises; I
remember that this crisis felt like the deepest and most painful one. As usual on
these occasions, I would take, at random, one of the Year Books of the American
Academy of Osteopathy, the text that had become my “osteopathic bible”. I opened
it and fell on an article, seen several times before but never read, by Rollin Becker. I
can say that this article was the single most important turning point in my career as a
practicing osteopath. It set me on a path that I never left since then. In retrospective,
I can say that this loyalty to one approach showed that my earlier instability betrayed
not just superficiality but also some deep thirst and search.
I advise you to consult that article. Reading it, after the introduction above, you may
be quite disappointed. Written in the usual - wordy - American osteopathic style, the
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author only seems to discuss his understanding of the principles of osteopathy.


There is no obvious description of a technical approach. For the deeply confused
young osteopath that I was, however, this article seemed to describe a very precise
technical approach, the one I was searching for all those years. I wish to somewhat
underline this point for the sake of historical precision. From my later encounters
with Rollin Becker and his students, it was suggested to me that I had not
understood at all the article above. For years, I had claimed that I was practicing
“Becker’s technique”, only to be told later that this was a misunderstanding. It is
possible, even very likely, that what I will present to you as “Becker’s teaching or
practice”, is my own reading of his ideas, in fact, of what I wanted to read in my
confused state.
It is possible that R. Becker proposed the ideas that were closest to what was in
gestation within me, and that he became the the midwife of an osteopathic child I
was pregnant with. From this initial -incorrect- understanding of Becker, was born
in 1982, “connective osteopathy”.
Misunderstanding an author has often been, in history, the source of new ideas and I
am deeply grateful to Rollin Becker for having given me the opportunity of
developing new principles and approaches in osteopathic care.
In recognition of this debt, I propose to summarize in a series of seven statements,
the salient points of the seminal article mentioned above. They represent a personal
reading of the content of that article. You are invited to consult the original.

1. In the anatomo-physiological mechanisms of the patient are inscribed all his


problems and their solutions.
2. We must learn how to read, with our fingers, these problems in our patient’s
tissues, without interfering with what these tissues have to say to us.
3. In some of our patients, although all degrees of mobility are relatively free,
there is considerable suffering. Isn’t there something more intimate than
“limitations of flexion or rotation” to the tissues which can explain their
suffering?
4. Tissues are characterized by a “potency”, which, when it expresses itself, “never
errs” in so much as it is the innermost expression of those tissues
5. This potency possesses a central point, a “still point”, which is, to this potency
what the “eye” is to the cyclone. When the eye of the cyclone closes and
disappears, all the potency of the cyclone disappears. Such cyclones can be
constantly recognized in human tissues. Therapy consists in “finding their eye”
(i.e. their “still point”) and the tissular cyclone disappears, i.e., tissues recover
their equilibrium.
6. Each still point represents the expression of the entire lesion pattern of the
patient, a pattern in its pure state and not one modified by the forces introduced
by the operator (as occurs in structural osteopathic approaches).
7. These notions have a universal application: all tissues of the body express this
potency.

I have selected above what seem to me the salient points of Rollin Becker’s article
“Diagnostic touch”, Part I, American Academy of Osteopathy Year Book, 1963.
I insist on the fact that the above represents what I read in this article.

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These simple seven statements came as a shock to me. I thought I had understood -
and exhausted - the value of all possible osteopathic principles. This felt totally new
to me and exactly what I was searching: an approach which was completely tailored
to the patient and not to my limitations, an approach where technique is totally new
every time since it seeks the expression of forces unique to that patient and not the
reproduction of standard maneuvers adapted to the patient.

The seven points brought above, at first sight, seem to be a reiteration of Still’s and
Sutherland’s principles of osteopathy. Once I asked Rollin Becker himself: “what do
you think is original in your approach compared to Still?” He answered: “Nothing!
Nothing more than Still ”. As for Sutherland, R. Becker reports that shortly before
the death of the Master, he had informed him of his reflections. Sutherland
answered: “ this is a true bale of cotton!”.
With time, it became obvious to me (cf. our lectures on the history of osteopathy)
that, indeed, the seven statements above existed already in an outspoken or germinal
form in Still’s and Sutherland’s writings.
If the principles do not seem fundamentally original, the technique derived from
those principles is revolutionary. I believe that it was not practiced by any osteopath
earlier than Becker.
I remember that after having read the article in the Year Book, I had felt that a
technique was clearly explained in those lines7. I happened to have some pain in my
calf that evening. I laid my hands on my calf and proceeded to look for the
“potency”, the “cyclone”, the “still point” mentioned above. I had a remarkable
experience, I could feel exactly what the principles suggested. The “still point” was
followed by a feeling of deep relief in the calf.
In other words, I was in the situation where I had learned an osteopathic approach,
principles and technique, in about 10 minutes, without the necessary previous 10
years of practice in cranio-sacral osteopathy or 25 years in structural osteopathy as
the rumor had it in those days (and even until now).
Without any references other than those few lines read in the Year Book, I began a
period of intensive practice of this approach, feeling these “tissular movements”
everywhere I would lay my hands. This was a truly remarkable experience. I did not
know if, from the standpoint of Beckerian orthodoxy, I was doing the right thing but
the clinical results were far superior to all the techniques I had tried before. More
than anything else, every treatment was a new experience every time and I felt
excitement every time, never the boredom of routine that followed quickly my
previous practices.
Progressively, I acquired my own clinical experience with this technique since an
attempt at contacting Rollin Becker and learning more from him was met with a
refusal to teach me. He suggested that I had not understood him and, upon my
insistence, sent me an unpublished article of his, which, I felt, was not of particular
interest.
During a period of six months, I was thus left on my own, experiencing with this
approach. I would stay sometimes three hours on a given patient, going through
layer after layer of “cyclones”, of “still points”.

7
Something that was not obvious to those colleagues or students of mine to whom I showed the
article.
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There seemed to be no end to this expression of life. One can imagine that patients
came out in a rather “strange” state after such long sessions!

These six months of grace ended brutally. One day, on a particular patient, it seemed
to me that I could feel these motions less distinctively. Initially, I thought that this
loss of sensitivity was due to fatigue. Days went by and the sensitivity did not
return... I had to realize that I had “lost” the ability to feel these motions. Later,
when treated by people who had learned with Becker, I realized how different my
technique had been. I understood that I had experienced something completely new.
The following year was a true “crossing of the desert” for me. I did not know how to
treat patients. Out of despair, I began to learn other therapies such as homeopathy
since I could not return to my previous osteopathic approaches. They felt tasteless
compared to what I had experienced. Further despair led me to taking up the study
of conventional medicine at Paris Medical School.

In search of lost paradise

All the while I was studying other fields, I never ceased to try and recover the
feeling of those “lost motions”, always hoping that I would wake up from some
“nightmare”. Nothing happened.
Through anecdotal circumstances, in 1980, I was forced to practice again as an
osteopath. I could not practice structural or other techniques and I had no other
choice than returning to the practice of “Becker’s technique”. Whilst working on
patients, I understood that I had not “lost” my palpation. I simply had become like
everyone else. I felt what other persons feel when they lay their hands on someone’s
tissues. This means, retrospectively, that for the first six months after I had read
Becker’s article, I had been in some “unusual state” of exacerbated palpatory ability.
When confronted with patients who came for osteopathic care, I found that I had
two resources:
• palpatory ability of an average person, i.e., when I laid my hands on people, I
could not feel those remarkable spontaneous motions that seemed to take me
on a “voyage”, that seemed to transform the hardest matter (such as bone)
into the softest one. Laying my hands, I would feel, at worst, nothing, and at
best, a confused mixture of pulses, undefined, short-range motions but more
than anything else, I felt that whatever I perceived seemed completely
subjective, i.e., any motion felt could be suppressed, increased, diminished,
reoriented etc. an obvious proof to me that I was dealing with my
imagination.
• on the other hand, I knew, from my early successful experience, what should
be felt. I knew intellectually and in my memory, what those remarkable
motions feel like: their direction, amplitude, qualities, intensity, timing etc. I
knew that there was a dimension where tissue motions feel completely
objective in a sense that one feels that they are imposed on us, that one can
only follow them, that they are the true expression of the patient’s tissues and
not my imagination

In other words, I possessed the starting point (the “usual” or “common” palpatory
ability of most operators) and the end point (the exacerbated state I had lived for
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some unknown reason). There was an abyss between these two abilities. I had no
other choice than embark on a specific task: to reduce the distance between what I
could feel and what I should feel. The permanent feeling that I had to share whatever
I discovered in osteopathy constituted another motivating force for this search.
For about two years, I therefore searched for -literally- the “therapeutic use of the
weak palpatory abilities possessed during the average or normal waking state”. In
other words, what can I do in terms of therapeutics with the feeble, the confused, the
seemingly imagined perceptions felt when I lay my hands on someone. It took hours
upon hours, days, months of patience, of pain, of despair, of mainly failure and
sometimes success to come to the conclusion that, somehow, provided some basic
rules are followed, something can be achieved with the principles I had read into
Becker’s article. It was clear to me, by then, that what I had been doing at first had
little to do with Becker and that I would obtain no information of use from him or
his closest students.
The exercises that follow are the result of my researches of those years. They are the
“inventory” of what can be felt over the tissues of a patient: both what is usually felt
and what should be felt ideally.
Laying hands softly on someone:
• the operator may feel nothing or a very non-specific feeling that he is on live
tissue rather than on a piece of inert matter
• the operator may have feelings like “hot”, “warm” “cold”, “tough” “soft”
• the operator may feel pulses (of defined or undefined frequencies and
regularities)
• the operator may feel short-range motions, a rather confused feeling of some
“activity” under our hands, with no definite direction or rather of motions going
into many directions. Whilst feeling these confused motions, various pulses may
be picked up
• all kinds of other feelings, some of which will be discussed further.

The above is what I consider the palpatory starting point of the vast majority of
subjects who lay for the first time their hands on someone and are asked what they
feel.

These confused feelings were the very few and uninspiring bricks with which I had
to rebuild the therapeutic technique I knew existed. We remember that from the
seven principles understood in Becker, it is clear that just “listening” to the potency
in tissues is effective. There is no actual technique involved, i.e., no movements of
the hands. I therefore had to find a way to be effective by just “listening” to those
poor and confused perceptions both as a practitioner (what should I feel on my
patients that is effective therapeutically?) and as teacher ( how can I explain to
others what, I feel, is an effective feeling?). This forced me to formulate in words, in
as much a detailed way as possible, what is felt under a lying hand8.
For instance, I had to try and formulate the qualities of those motions that seem to
be effective when they are felt, and those whose perception was ineffective. Here, an
undescribed or rather “undescribable” intuition had to be dissected in terms of

8
The ambiguous meaning of “lying hand” is not fortuitous at all when it describes what our hand
perceives.
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ISCO Course in Connective Osteopathy 37

distance, timing and duration, speed, amplitude, force, diagnostic vs. therapeutic
relevance etc.
This effort of dissection and its results make this technique, in principle and
practice, significantly different from Becker’s approach. It seems that Becker
proposed a reduction of body matter to a “fluid” whereas I continued to preserve
both the “hardness” of matter and its plurality through the notion of the “three
links”. “Fluidity” is characteristic of the fluid link, but does not represent the
essence of the mechanical or neurological link.

The comparative description of therapeutic vs. non-therapeutic motion perceptions


comes down to bringing rigor into the world of subjectivity, a rather paradoxical
attempt. This implies that the operator will have to learn how to be critical about his
own perceptions, disbelieving more than believing into them. An operator will thus
have to avoid two extremes: excessive criticism leading some paralysis of
perception, insufficient criticism leading to “delirium” or “self delusion”. The only
solution I have to offer as to when one has fallen into one of these two extremes is
the efficacy on the patient. The effective perceptions are truly and immediately
effective on certain simple but extremely common pathologies (such as
uncomplicated musculo-skeletal pain), supplying the beginning operator with an
excellent tool of verification.
The “technique” to be proposed here will be presented in a graduated series of
exercises, aimed at “feeding” and “habituating” our nervous system to this new
approach of living matter. Its novelty lies chiefly in the unusual fact that “to listen”
is to be “effective”. Not to “do”, but to “listen”.....
From now on, I shall revert to calling this approach “Connective Osteopathy” or
“Connective Therapy” (CTh) since I believe that calling it “Becker’s technique” (as
I did for a long time) is historically and technically incorrect.

General description

The seven points brought out above contain the essential principles of the technique
we are about to learn. We will only have to learn their practical implications.
Before we can proceed, however, I must remind you of the earlier exercises on the
various physiological pulses felt over living tissues. The entire technique is built on
the assumption that these exercises have been practiced. Having felt with precision
the various pulses - we have seen how difficult it was to perceive some of them - is
not the point here. It is important to have looked for those pulse and understood the
implication of their existence for the practicing osteopath. These pulses are an
integral part of the “inventory” of basic feelings over living tissues. Our purpose
now will be to differentiate those motions that are the expression of permanent
physiological rhythms from those motions that are the expression of “lesional”,
“tensile” forces. These last motions are supposedly “physiopathological” and will
retain our attention since, perceiving them, of itself, has a remarkable therapeutic
effect. These motions are the “hurricanes” hinted at by Rollin Becker.
I mentioned, in our first lectures on palpation of the rhythms, that both types of
motion are very similar to the palpating hand. Their differences are not obvious at

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ISCO Course in Connective Osteopathy 38

all. The whole art of osteopathic technique will consist in differentiating them. The
better the differentiation, the more powerful the technique.
I remember that during my earlier months of practice of this technique, I would let
myself be carried away, “rocked”, for half an hour and sometimes more, by these
rhythms. This is of very little therapeutic value for the patient and is often the sign
that we are not concentrated on the technique. If you are content with following the
rhythms of the patient, you may be sure that the patient will get up feeling just the
same or, at best, a little relaxed. The many times this happened to me, I would
suddenly realize that nothing had been achieved, and the fact that the next patient
was coughing in the waiting room ( the usual alarm signal), would challenge me to
do something. I would then spend a few minutes of proper technique, and often,
this was enough to achieve some clinical effect.

It is therefore of a fundamental importance that you remember and continue to


practice identifying the various rhythms we mentioned.
The following exercises are the result of fifteen years of teaching of this method.
They have been built dynamically, i.e., they have been changed many times to suit
my evolving understanding of the principles and practice of osteopathy, as well as
the difficulties met by the students who are exposed to it. I have taught it to
experienced osteopaths, to regular physicians and even to lay people and their
reactions. Over the years, made me add and expand here or suppress there.
Obviously, some people feel “instantly”, whilst for others, things take time.

These exercises have not been devised so much for the “gifted” amongst you, they
are aimed at giving the information that allows for a minimal therapeutic effect.
That “minimal” to me, means, first and foremost, to be able to feel something else
than physiological rhythms.

Key concept

We shall take some time palpating the basic three physiological rhythms mentioned
at the beginning of the course: the arteriolar, the ventilatory and “cranio-sacral”
pulses.
Supposing that this has been done, it may be obvious to you, both intellectually and
intuitively, that for two reasons these rhythms are difficult to perceive:
• either we do not feel anything
• or we do feel some motion, but it is not regular, as if there was some “chaos” in
the tissues
Let us set aside the first option, since I believe that concentration always leads to
some minimal perception. The second option is far more relevant to those of us who
are used to lay our hands on people. When I try to feel a rhythm in the body, I often
feel that other types of motions, of undefined character, tend to distract me. To feel a
regular rhythm, I will constantly have to “fight” against these distracting influences.
This we have tried to achieve in our first series of exercises on the pulses. Our key
concept will be the exact opposite at present:
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ISCO Course in Connective Osteopathy 39

From now on, we will try to deliberately search for, select and amplify all those
motions or even “tendencies”, that distracted us from feeling the physiological
rhythms of living tissues.

In the following series of exercises, we will take thus the opposite approach: instead
of looking for and cultivating regularity, we shall look for, and amplify irregularity.

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