Got together like love and marriage, like horse and carriage, like peanut butter and blue cheese.
I’ve long been interested in what I call ‘virtual relationships’ around the body. Places where things appear together to such an extent that they probably have to have some kind of symbiotic and functional relationship.
I also happen to have a passion for undertaking very detailed and fine dissections where I can spend time seeing how tissues both weave together and separate. It’s not something I generally have a lot of time to do in a class, and any opportunity to spend time alone in a dissecting room will find me undertaking a task on my long list of “I wonder ifs…”
The fibrous pericardium of the heart is generally shown as being continuous with the top of the diaphragm. In open heart surgery (as far as I can ascertain) the pericardium is opened and then not closed up. I presume because it will close itself. I haven’t been able to confirm this with a heart surgeon by the way, so any corrections will be gratefully received. This picture whilst showing the connection of the pericardium to the diaphragm, also happens to show the beauty of the blood vessel network and gossamer nature of this structure.
In any event the linking of the heart to the diaphragm tells us that every time we breath in and out 15-20,000 times a day, our heart rides up and down on our diaphragm, probably contributing to the momentum of heart movement and blood flow. From a geeky perspective I wondered as to the extent of this connection. Could the heart be separated from the diaphragm intact? After a few false starts and some holes in the pericardium, I managed to perfect this dissection which you can see here.
I regularly show how the fascia of the diaphragm is to all intents and purposes, continuous with the fascia of transversus abdominus and that there is also a continuation of the parietal pleura over the diaphragm and incidentally both these pictures don’t make clear that there is another lining over the top of the diaphragm which is parietal pleura. It’s pretty difficult to separate this although I have done it in sections. Perhaps another challenge?
What does it prove? I have yet to postulate any ideas regarding function, just that it is incredibly interesting and does show these two structures as complete and independent of each other from a biological standpoint. Sometimes the applications come after the demonstration possibility. A starting point would be to name the junction. Diaphragmatic pericardial raphe perhaps? Answers on a postcard please!
At a fascia conference in Berlin in November 2018, I was accosted by a lady who pointed at me and accused me of being the man who “doesn’t believe in Anatomy Trains.” Slightly taken aback I pointed out that in the face of evidence, belief is not required. Bring me the evidence and I will not require faith.
Before we go any further, allow me to place a very firm stake in the ground here. I consider Tom Myers to be one of the greatest teachers, orators, therapists and thinkers that we have seen in the last 100 years. Anatomy Trains is a work of absolute genius and one of the most important contributions to the world of body work and anatomy that stands alongside Job’s Body for importance. I for one would not be in the place I am without Tom and his work. I consider him to be a friend and a colleague and someone for whom I have an endless amount of respect and gratitude. I have taught with him back in 2007 where we ran a dissection workshop in St George’s hospital in London and took him on a tour to teach my Bowen people. I like Tom. A lot.
As you might guess, there is a however coming up and you would be right. It’s actually more about how people have taken the AT work on rather than about Tom, but I offer you a quote from the man himself where he explains Anatomy Trains as “imaginary lines of strain in the body.” If we stayed here, with the word imaginary, then I would have no need for my belief system to be questioned and no need to be accused of several counts of Myers heresy. Simply put, Anatomy Trains do not exist. There, I’ve said it. They are imaginary and like many things imaginary, serve an excellent purpose when used to illustrate an idea. Anatomy has needed a model to remind us that there are continuities and connections all over the body that have functional connection and relationships and there is little better in the way of models than the imaginary ATs. Why spoil a good thing?
In the years since I first encountered Tom and the ATs, there has been much dissecting of many cadavers and along the way, the lines have been dissected out and held up as proof that “yes here they are, they do indeed truly exist.” They do not and to suggest they do demeans the originality of the work and its designer. Apart from the basic idea that the lines are physiologically impossible, cutting something out of a dead body just means that you have a sharp knife, a keen eye and a good imagination. My blog on confirmation bias is a reminder that what we seek to verify we probably will, even at the expense of good science, logic and common sense.
John Webster from California is an ice carver (and a pretty good masseur), renowned for his carvings of swans from ice. When asked how he performs such feats he claims it is very simple. “Just take some ice and cut away anything that doesn’t look like a swan.” Anatomy has been creating non-existent structures out of dead bodies for hundreds of years, giving us things like the Iliotibial band and various retinacula, all of which are carvings in the same vein as the ATs and John’s swans. Certainly instructive and interesting and definitely worth doing, as long as you see the nature of the model you are creating.
I do believe however that I have found an actual unicorn in the shoulder blade. No really.
The all encompassing word fascia holds some degrees of confusion and variation. Fascia is a lot of things to a lot of people and depending on what you have read or what your field of thinking or science is, your view of fascia may vary accordingly. As a connective tissue, it has a lot of properties and is described in many ways. There are the sheet like structures that form aponeuroses around the body: the iliotibial tract or band (ITB) and the galea aponeurotica or scalp fascia to name but two.
Fascia however has lots of different presentations and formations and it’s worth remembering that as a connective tissue, its primary purpose is to connect. Sounds obvious I know, but fascia gets imbued with lots of strange properties that in turn generate stories and fantasies around what it is and what it can do.
The main thing to remember about all connective tissues is that they are mostly non-cellular in their make up. That doesn’t mean to say there are no cells in fascia, just that mostly the fascia is the product of the cell. This is pretty important as if fascia were mostly composed of cells they would need to consume a lot of energy and would also need to be replaced. As it is, fascia is mainly protein in the form of collagen and acts as both as a scaffolding and a separator. The images reproduced here show this really clearly.
The muscle fibres are kept both separated and connected by the connective tissue that runs in between them and around them. This gives the fibres both strength, integrity but also allows space for fluid and (probably) information to run between and around them. The fluid is the important bit in all of this. Fluids in the body not only allow for movement to take place on every level, but also allow for nutrients and waste to be carried around the entire system.
The idea of ‘releasing’ fascia is something that I struggle to get my head around, but is probably best explained as being a method of encouraging movement of fluids through and around connective tissues, where poor fluid movement has become an issue or results in presentation of pain.
Dissection, from Latin dissecare “to cut to pieces,” is the dismembering of cadavers, and it has a long history.
Greek physicians in the 200s BCE seem to have been the first to medically dissect human bodies. The dismembering of bodies was forbidden in the Roman Empire, so people such as Galen used the corpses of primates. In both Islamic and medieval Christian cultures, it was a strict taboo. Although, the work of individuals such as Ibn al-Nafis in the 1200s shows that human dissection took place regardless.
Modern medicine would not be where it is without this important practice, but it’s not only doctors who benefit from it. Acupuncturists, Osteopaths, and even artists can garner valuable insights – many called Leonardo Da Vinci mad for cutting up cadavers, but had he not done so his artwork would likely be far inferior.
Hands-On Experience Is Irreplaceable
You can spend months watching the cooking channel, but if you don’t pick up a knife and cook, you’ll never be as good as you could be. Human Dissection is a similar concept; Textbooks are a great accompaniment, but they are no substitute for the physical thing.
Arguments have been made that the same results are gained from images of dissected corpses, but there are several reasons why the real thing is better.
As humans, information is generally retained longer if it comes from sensory experience, as opposed to reading. Plus, due to the adrenaline that you’re more than likely to feel, you should have an easier time remembering details.
We’re All Different
An overused quote, but the majority of people do not realize how accurate it is. All humans have the same basic anatomy, but unlike textbooks, a cadaver will show you that vital details can vary wildly.
There are the obvious differences, such as healthiness and gender, but there’s also a host of other differences that make us unique individuals. Some organs might be slightly larger or a different shape depending on the person – some could have discolourations or harmless growths.
You may also end up putting together the fragments of the person’s life. Discolouration of the fingernails and deterioration of lung tissue might indicate a heavy smoker – while severely calloused hands might suggest a life of intense physical labour. It’s easy to begin to care for who the person was when you start to notice these details; Which brings us to our next point.
Dissecting A Human Enhances Respect For The Human Body
In addition to gaining an advanced understanding of human anatomy, dissection also helps people appreciate the value of life. Those who have dissected corpses usually claim that it taught them how great a gift a cadaver is.
Dissecting bodies helps the living continue to live comfortable lives, or simply to continue living. Despite the usefulness provided, many people aren’t comfortable with the idea of their bodies being used after death. Still, someone wouldn’t keep a pair of shoes once they’ve outgrown them, so why would they not donate their body to science?
Learn More About The Human Body
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I’ve spent most of my adult life convincing myself that what I do works and that my own particular brand of therapeutic intervention has some kind of mechanism that makes people ‘better’, whatever that means.
It stands to reason that I need to have some level of conviction that what I practice, teach, write about and study has some level of efficacy. This conviction however comes with little real evidence to back it up, save for the thousands of other people who have the same conviction. This conviction sometime extends way beyond what we might often think of as a reasonable confidence and is mirrored in the behaviour that we indulge ourselves in all through life.
We tend to surround ourselves with this who agree with us and who confirm our view of the world. Whether it be through religion, culture, politics, therapy or science, we associate and fraternise with those who’s world view closely resembles our own. In science this is called confirmation bias; we tend to confirm as fact what we want to be true.
As I’ve got older and more cynical, it’s hard to separate fact from fiction when it comes to therapeutic intervention, but I still regularly face fierce conviction from those who are utterly convinced that what they do has a clearly defined mechanism of action, even when it is is patently obvious that any such mechanism or at least an understanding of it, is entirely absent.
These people will send me emails that contain pages of research documents that back up their stance and confirm their strongly held belief that what they do is scientifically proven beyond doubt, an excellent demonstration of confirmation bias. Much as the evangelist will use the bible to demonstrate proof of the word of god, anything that might directly contradict or question this view has not been sought out or researched and someone like this is unlikely to have a balanced view.
Whilst understandable, it often makes for uncomfortable conversation. Whilst I totally believe, having had the same experiences, that the most incredible things happen with unerring regularity in treatment rooms all over the world, I have yet to be presented with anything that remotely resembles evidence to support an understanding of how these events actually occur.
Accepting something as part of a faith or a deep belief is one thing, but trying to justify that faith against a world of counter intuitive evidence is going to end badly. Placebo, meaning ‘to please’, is a word often used to bash the therapist by those with a sceptical axe to grind, conveniently ignoring the simple truth that ALL medicine is to some degree placebo by its very nature. You can’t take the doctor out of medicine.
Derren Brown’s ‘Miracle’ available on Netflix, makes for uncomfortable watching for those who might feel that what they do is something more than contextual, yet should be required viewing for anyone who aspires to be a therapist. Does it prove that all healing, or anything without a paper is hocus? No. Brown is a consummate showman and demonstrates the power of hypnotism and mass hysteria in a great show. It would be naive to suggest that what takes place in a treatment room is the same.
Manual therapy has many benefits and the power of touch can and should never be underestimated. But the actual mechanisms by which we change things and how this takes place is very poorly understood, however hotly debated.
Subjects like fascia have become popular and widely bandied around, but are often used by those who have little grasp of the subject to support or justify approaches which have little evidence to validate them. Science and scientists aren’t immune from this self justification as human nature takes over easily, even where deeply held principles of scientific objectivity might be expected to take precedent. It’s hard for anyone to have their work or understanding contradicted.
We are all prejudiced to some degree. We all have deeply held personal beliefs and convictions that will always have the potential to influence even the most guarded of principles. Owning this truth as a starting point for trying to understand our approaches would be a great start.