Structural Diagnosis and Manipulative Medicine History
Manual medicine is as old as the science and art of medicine itself. There is strong evidence of the use of manual medicine procedures in ancient Thailand, as shown in statuary at least 4,000 years old.1 The ancient Egyptians practiced the use of the hands in the treatment of injury and disease. Even Hippocrates, the father of modern medicine, was known to use manual medicine procedures, particularly traction and leverage techniques, in the treatment of spinal deformity. The writings of such notable historical figures in medicine as Galen, Celsus, and Oribasius refer to the use of manipulative procedures.2 There is a void in the reported use of manual medicine procedures corresponding to the approximate time of the split of physicians and barber-surgeons. As physicians became less involved in patient contact and as direct hands-on patient care became the province of the barber-surgeons, the role of manual medicine in the healing art seems to have declined. This period also represents the time of the plagues, and perhaps physicians were reticent to come in close personal contact with their patients.
The 19th century found a renaissance of interest in this field. Early in the 19th century, Dr. Edward Harrison, a 1784 graduate of Edinburgh University, developed a sizable reputation in London utilizing manual medicine procedures. Like many other proponents of manual medicine in the 19th century, he became alienated from his colleagues by his continued use of these procedures.3
The 19th century was a popular period for “bonesetters” both in England and in the United States. The work of Mr. Hutton, a skilled and famous bonesetter, led such eminent physicians as James Paget and Wharton Hood to report in such prestigious medical journals as the British Medical Journal and Lancet that the medical community should pay attention to the successes of the unorthodox practitioners of bone setting.4 In the United States, the Sweet family practiced skilled bone setting in the New England region of Rhode Island and Connecticut. It has also been reported that some of the descendants of the Sweet family emigrated west in the mid-19th century.5 Sir Herbert Barker was a well-known British bonesetter who practiced well into the first quarter of the 20th century and was of such eminence that he was knighted by the crown.
The 19th century was also a time of turmoil and controversy in medical practice. Medical history of the day was replete with many unorthodox systems of healing. Two individuals who would profoundly influence the field of manual medicine were products of this period of medical turmoil. Andrew Taylor Still, MD, was a medical physician trained in the preceptor fashion of the day, and Daniel David Palmer was a grocer-turned-self-educated manipulative practitioner.
Still (1828 to 1917) first proposed his philosophy and practice of osteopathy in 1874. His disenchantment with the medical practice of the day led to his formulation of a new medical philosophy, which he termed “osteopathic medicine.” He appeared to have been a great synthesizer of medical thought and built his new philosophy on both ancient medical truths and current medical successes, while being most vocal in denouncing what he viewed as poor medical practice, primarily the inappropriate use of medications then in use.6
Still’s strong position against the drug therapy of his day was not well received by his medical colleagues and was certainly not supported by contemporary osteopathic physicians. However, he was not alone in expressing concern about the abuse of drug therapy. In 1861, Oliver Wendell Holmes said, “If all of the MATERIA MEDICA were thrown into the oceans, it will be all the better for mankind, and worse for the fishes.”7 Sir William Osler, one of Still’s contemporaries, stated: “One of the first duties of the physician is to educate the masses not to take medicine. Man has an inborn craving for medicine. Heroic dosing for several generations has given his tissues a thirst for drugs. The desire to take medicine is one feature which distinguishes man, the animal, from his fellow creatures.”8
Still’s new philosophy of medicine in essence consisted of the following:
The unity of the body.
The healing power of nature. He held that the body had within itself all those things necessary for the maintenance of health and recovery from disease. The role of the physician was to enhance this capacity.
The somatic component of disease. He felt that the musculoskeletal system was an integral part of the total body and alterations within the musculoskeletal system affected total body health and the ability of the body to recover from injury and disease.
Structure-function interrelationship. The interrelationship of structure and function had been espoused by Virchow early in the 19th century,9 and Still applied this principle within his concept of total body integration. He strongly felt
that structure governed function and that function influenced structure.
The use of manipulative therapy. This became an integral part of Still’s philosophy because he believed that restoration of the body’s maximal functional capacity would enhance the level of wellness and assist in recovery from injury and disease.
It is unclear when and how Dr. Still added manipulation to his philosophy of osteopathy. It was not until 1879, some 5 years after his announcement of the development of osteopathy, that he became known as the “lightning bonesetter.” There is no recorded history that he met or knew the members of the Sweet family as they migrated west. Still never wrote a book on manipulative technique. His writings were extensive, but they focused on the philosophy, principles, and practice of osteopathy.
Still’s attempt to interest his medical colleagues in these concepts was rebuffed, particularly when he took them to Baker University in Kansas. As he became more clinically successful, and nationally and internationally well known, many individuals came to study with him and learn the new science of osteopathy. This led to the establishment in 1892 of the first college of osteopathic medicine at Kirksville, Missouri. In 2014, there are 35 osteopathic training sites (including five branch campuses) in the United States graduating more than 4,500 students per year.10 Osteopathy in other parts of the world, particularly in the United Kingdom and in the commonwealth countries of Australia and New Zealand, is a school of practice limited to structural diagnosis and manipulative therapy, although strongly espousing some of the fundamental concepts and principles of Still. Osteopathic medicine in the United States has been from its inception, and continues to be, a total school of medicine and surgery while retaining the basis of osteopathic principles and concepts and continuing the use of structural diagnosis and manipulative therapy in total patient care.
Palmer (1845 to 1913) was, like Still, a product of the midwestern portion of the United States in the mid-19century. Although not schooled in medicine, he was known to practice as a magnetic healer and became a self-educated manipulative therapist. Controversy continues as to whether Palmer was ever a patient or student of Still’s at Kirksville, Missouri, but it is known that Palmer and Still met in Clinton, Iowa, early in the 20th century. Palmer moved about the country a great deal and founded his first college in 1896. The early colleges were at Davenport, Iowa, and at Oklahoma City, Oklahoma.
Although Palmer is given credit for the origin of chiropractic, it was his son Bartlett Joshua Palmer (1881 to 1961) who gave the chiropractic profession its momentum. Palmer’s original concepts were that the cause of disease was a variation in the expression of normal neural function. He believed in the “innate intelligence” of the brain and central nervous system and believed that alterations in the spinal column ( subluxations) altered neural function, causing disease. Removal of the subluxation by chiropractic adjustment was viewed to be the treatment. Chiropractic has never professed to be a total school of medicine and does not teach surgery or the use of medication beyond vitamins and simple analgesics. There remains a split within the chiropractic profession between the “straights,” who continue to espouse and adhere to the original concepts of Palmer, and the “mixers,” who believe in a broadened scope of chiropractic that includes other therapeutic interventions such as exercise, physiotherapy, electrotherapy, diet, and vitamins.
In the mid-1970s, the Council on Chiropractic Education (CCE) petitioned the U.S. Department of Education for recognition as the accrediting agency for chiropractic education. The CCE was strongly influenced by the colleges with a “mixer” orientation, which led to increased educational requirements both before and during chiropractic education. Chiropractic is practiced throughout the world, but the vast majority of chiropractic training continues to be in the United States. The late 1970s found increased recognition of chiropractic in both Australia and New Zealand, and their registries are participants in the health programs in these countries.11
The 20th century has found renewed interest in manual medicine in the traditional medical profession. In the first part of the 20th century, James Mennell and Edgar Cyriax brought joint manipulation recognition within the London medical community. John Mennell continued the work of his father and contributed extensively to the manual medicine literature and its teaching worldwide. As one of the founding members of the North American Academy of Manipulative Medicine (NAAMM), he was instrumental in opening the membership in NAAMM to osteopathic physicians in 1977. He strongly advocated the expanded role of appropriately trained physical therapists to work with the medical profession in providing joint manipulation in patient care.
James Cyriax is well known for his textbooks in the field and also fostered the expanded education and scope of physical therapists. He incorporated manual medicine procedures in the practice of “orthopedic medicine” and founded the Society for Orthopedic Medicine. In his later years, Cyriax came to believe that manipulation restored function to derangements of the intervertebral discs and spoke less and less about specific arthrodial joint effects. John Bourdillon, a British-trained orthopedic surgeon, was first attracted to manual medicine as a student at Oxford University. During his training, he learned to perform manipulation while the patient was under general anesthesia and subsequently used the same techniques without anesthesia. He observed the successful results of non-medically qualified manipulators and began a study of their techniques. A lifelong student and teacher in the field, he published five editions of a text, Spinal Manipulation. Subsequent to his death in 1992, a sixth edition of Spinal Manipulation was published with Edward Isaacs, MD, and Mark Bookhout, MS, PT, as coauthors.
The NAAMM merged with the American Association of Orthopaedic Medicine in 1992 and continues to represent the United States in the International Federation of Manual Medicine (FIMM).
PRACTICE OF MANUAL MEDICINE
Manual medicine should not be viewed in isolation nor separate from “regular medicine” and clearly is not the panacea for all ills of humans. Manual medicine considers the functional capacity of the human organism, and its practitioners are as interested in the dynamic processes of disease as those who look at the disease process from the static perspective of laboratory data, tissue pathology, and the results of autopsy. Manual medicine focuses on the musculoskeletal system, which constitutes more than 60% of the human organism, and through which evaluation of the other organ systems must be made. Structural diagnosis not only evaluates the musculoskeletal system for its particular diseases and dysfunctions but can also be used to evaluate the somatic manifestations of disease and derangement of the internal viscera. Manipulative procedures are used primarily to increase mobility in restricted areas of musculoskeletal function and to reduce pain. Some practitioners focus on the concept of pain relief, whereas others are more interested in the influence of increased mobility in optimizing joint stability and function of the musculoskeletal system. When appropriately used, manipulative procedures can be clinically effective in reducing pain within the musculoskeletal system, in increasing the level of wellness of the patient, and in helping patients with a myriad of disease processes.
GOAL OF MANIPULATION
In 1983, in Fischingen, Sweden, a 6-day workshop was held that included approximately 35 experts in manual medicine from throughout the world. They represented many different countries and schools of manual medicine with considerable diversity in clinical experience. The proceedings of this workshop represented the state of the art of manual medicine of the day.12 That workshop reached a consensus on the goal of manipulation: The goal of manipulation is to restore maximal, pain-free movement of the musculoskeletal system in postural balance.
This definition is comprehensive but specific and is well worth consideration by all students in the field.
ROLE OF THE MUSCULOSKELETAL SYSTEM IN HEALTH AND DISEASE
It is indeed unfortunate that much of the medical thinking and teaching look at the musculoskeletal system only as the coat rack on which the other organ systems are held and not as an organ system that is susceptible to its own unique injuries and disease processes. The field of manual medicine looks at the musculoskeletal system in a much broader context, particularly as an integral and interrelated part of the total human organism. Although most physicians would accept the concept of integration of the total body including the musculoskeletal system, specific and usable concepts of how that integration occurs and its relationship in structural diagnosis and manipulative therapy seem to be limited.
There are five basic concepts that this author has found useful. Since the hand is an integral part of the practice of manual medicine and includes five digits, it is easy to recall one concept for each digit in the palpating hand. These concepts are as follows:
Concept of Holism
The concept of holism has different meanings and usage by different practitioners. In manual medicine, the concept emphasizes that the musculoskeletal system deserves thoughtful and complete evaluation, wherever and whenever the patient is seen, regardless of the nature of the presenting complaint. It is just as inappropriate to avoid evaluating the cardiovascular system in a patient presenting with a primary musculoskeletal complaint as it is to avoid evaluation of the musculoskeletal system in a patient presenting with acute chest pain thought to be cardiac in origin. The concept is one of a sick patient who needs to be evaluated. The musculoskeletal system constitutes most of the human body, and alterations within it influence the rest of the human organism; diseases within the internal organs manifest themselves in alterations in the musculoskeletal system, frequently in the form of pain. It is indeed fortunate that holistic concepts have gained increasing popularity in the medical community recently, but the concept expressed here is one that speaks of the integration of the total human organism rather than a summation of parts. We must all remember that our role as health professionals is to treat patients and not to treat disease.