380 • JAOA • Vol 100 • No 6 • June 2000 Introduction to special reprints
What is at the root of true osteopathic medical practice?
What did the early practitioners of osteopathy regard
as the real uniqueness of the profession? This month, we
present three short articles, one written in 1903, the second
in 1917 (just before A.T. Still’s death), and the last written in
1932. These articles have a common theme: osteopathic pal-pation
and what it means. The central theme of each article
is that osteopathic technique, while important, is of little use
if practiced in a mechanical or “shotgun” way without prop-er
diagnosis to establish each patient’s unique problem.
H.E. Bernard, DO, at the request of the publication
committee of the American Osteopathic Association (AOA),
wrote the first paper. Bernard had grown up with Still’s sons
and had observed Still developing many of his ideas in the late
1870s and early 1880s. He surely had keen insight into what
Still considered important.
The last two articles were written by Carl P. McConnell,
DO, who was well acquainted with Still, having graduated in
one of the early classes and having written his first book on
osteopathic practice (Notes on Osteopathic Technique) in
1898! He wrote several other books on osteopathy and was
president of the AOA from 1904 to 1905. These three arti-cles
are important reading for the profession today.
Bernard’s article presents a picture of an osteopathic
physician who was keenly aware of the importance of know-ing
how normal and abnormal tissue felt and the relationship
of tissue function to manipulative treatment. He emphasizes
the importance of locating the “hindering mechanism” before
using manipulative treatment. He cautions against being too
smug with success, but advises recalling a failure once in a
while to keep “cranial enlargement” from occurring.
He warns against “shotgun treatments” of “one-half
hour’s duration.” Instead, find the tissue malfunction and
treat that. He states, “If general treatment were all there is in
osteopathy, then by a demonstration of simple imitation of
movements I could teach it to any one in three week’s time.”
Obviously, he had a jaundiced view of those who did not truly
understand the importance of palpatory diagnosis.
McConnell’s articles flesh out the thoughts begun by
Bernard. He makes it very clear that Still viewed palpation as
the bedrock of osteopathic technique. He states, “...the adjust-ment
in itself is a minor problem. The crux of the matter
rests on one’s definite knowledge of anatomical data.” By
“anatomical data,” he clearly meant the ability of the palpating
physician to interpret palpatory signs. He goes on to say that
knowing the living body is to know something vastly differ-ent
from structure. It is the importance of the vital machine.
McConnell points out that early in the life of the Amer-ican
School of Osteopathy, Still himself did almost all the
examining of patients. He was not concerned with symp-toms,
but with signs: the things his palpatory sense told him
of function of the individual. He required early students to
have months of daily practice in palpation before they could
begin to diagnose. This was to Still and to McConnell the
essence of osteopathic treatment. With proper tissue diag-nosis,
no treatment could be routine. Each treatment had to
be tailored to the individual patient’s presenting signs. Here,
we can truly see why Still insisted in his autobiography that
diseases did not exist as diseases but were only effects, the cause
being tissue dysfunction. It also gives a clear view as to why
Still was so reluctant to have technique codified. The third arti-cle,
written 15 years later, expounds on these observations.
Is it possible that the profession has strayed too far
from these insights? Do we spend too much time teaching our
students techniques and not enough time teaching them to
observe tissue and interpret signs of tissue malfunction? It is
easy to teach technique. It is difficult to teach interpreta-tion.
Students rightly want to “practice,” to treat. That is a
normal response of budding osteopathic physicians. Rush-ing
to treatment techniques, however, will certainly lead to
“cookbook” osteopathic medicine in which treatments
become routine applications of simple moves and thrusts.
Technicians can do this.
The essence of being a physician is understanding. That
takes much more time and effort. Osteopathic medicine can
be relegated to the technician, and the busy physician can write
a script for osteopathic treatments if it is viewed as a series of
movements, thrusts, and pulls. If, however, it is recognized as
the intimate understanding of the patient by the physician, and
as an intimate dance between patient and physician, orches-trated
by a sympathetic understanding of tissue response,
then osteopathic diagnosis and treatment can never be dele-gated
to technicians or prescriptions.
Michael M. Patterson, PhD
JAOA Associate Editor
Palpation: What is its role in osteopathic medicine?
Special reprints begin on page 387.
