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.
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
Want to learn more about dissection and the human body? Discover our range of human dissection courses including our five day, ten day and one-day courses.
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.
How does that feel then? Any better?
I have spent years around therapists, doctors surgeons and practitioners of all kinds and have been one myself for most of my life.
The key motivation of being a therapist is that you want to help people. To improve the quality of their lives, to relieve pain and to alleviate suffering.
Every year I run a class where therapists from all over the world converge to take part in a dissection class at medical school in Scotland. The facilities include an extensive clinical skills suite where therapy tables are available and the swapping of treatments and ideas is a popular pastime.
I have been fortunate to be the recipient of many of the therapeutic approaches that are brought to the class and as a touch junkie, it’s no hardship for me to lie down and let someone work their magic on me.
What I struggle with however, is answering the question that I generally get asked at the end of the session, which might include, “How does that feel? Better? Is that easier? Is that less stiff?” and so forth.
It begs the return question of, “What do you think the mechanism of action might be whereby what you have done might change the way that I am physiologically responding?” In other words, how in hell’s name is what you have just done going to change 45 years of structural development to the point that my shoulders don’t hurt any more?
The feeling I am left with is that I am almost expected to say that it feels better in order not to hurt the feelings of the person who is working on me. The trouble is that humans are not cars or machines that have specific, duplicatable problems that can be fixed by addressing, changing or removing one part.
It’s also led me to ask, “Is this something I do as a therapist?” I hope not. What actually happens during a hands on session in terms of a change in the physiology of an individual is…? Probably not that much!
We can be reasonably sure that in the space of 45-60 minutes and with the usual degrees of mechanical force, using hands, equipment or needles, fascia isn’t going to change, muscle isn’t going to change and bone isn’t going to change.
So what’s left? The central and autonomous nervous systems are being prompted to be involved for sure and there may well be physiological responses in respect of a change in blood pressure and heart rate. But actual changes are going to take quite some time: weeks maybe months before sessions are truly integrated and absorbed into the structural behaviour of an individual.
To my mind, the changes happen after the session, not during it and anything a hands on therapist does is not a means to an end, but a contribution to a process that is on going.
Put simply, the therapist is not the ‘fixer’. The therapist does not get someone ‘better’ whatever that means. The therapist simply provides information to a system that then gets interpreted and hopefully acted upon in some way.
So no, right now I don’t feel better, but it was a very nice/painful/boring/intense/interesting/awesome session thank you and I’ll let you know if I notice anything.
When is a door not a door? When it’s a jar.
There has been a lot of activity on Facebook recently, with John Sharkey stating that bone is fascia. I have a problem with this in a couple of ways. Firstly because it’s not a discussion point that is being raised, but a statement. BONE IS FASCIA.
This statement of fact doesn’t leave anyone with any option except to agree or disagree and creates a polarisation that I find uncomfortable and unhelpful.
Instead of a reasoned argument that follows a hypothesis, we are instead faced with a crowd of people in a video, chanting “bone is fascia, bone is fascia”, as if saying something factually questionable over and over again makes it true.
So let’s ask the question and discuss the possibilities, raise some relevant points and let the reader make up their own mind.
Before I dive in here, this kind of discussion/argument, whilst reasonable and vital in a scientific forum, has the tendency to be seen as confrontational when addressed to a more ‘touchy feely’ audience. So please let me state that none of this is about personality or personal enmity. I like John Sharkey and have an enormous amount of respect and time for him. That I disagree with him and feel able to do so publicly is a mark of that respect.
Here is a picture of a railway track.
Here is a picture of a road.
They are different things, but have some elements in common. They are both surfaces for transport and the things that travel on them have wheels. They both convey people from one place to another. There are different gauges of railway and sizes of trains. The railway track can carry different types of trains at different speeds to different places. The road can support different types of vehicles and there are different types of road, road surface and classification.
However even though they have things in common a railway track is not a road and a road is not a railway track and confusing the two would be both unwise and potentially dangerous.
Now I’ve rather laboured that comparison, let’s talk about bone and fascia. They are both connective tissues, and have things in common. Lots of collagen for one. There are two types of bone, cancellous (or trabecular) and cortical, that do different things and have different purposes and functions.
If as John suggests, bone is just “starched fascia” then “starched fascia” should be able to do the job of bone. Let’s reverse the bone is fascia statement, say that fascia is bone and see how it stands up.
If it were true, it should be able to have the cells within it to allow it to regulate calcium levels in the body, which lets face it is one of the more important jobs that bone has. It should be able to store calcium. Yet 97% of the calcium reserves in the body are in bone. Original osteoblasts get trapped in newly forming bone and mature into osteocytes which cannot divide further.
Osteocytes stay in contact with each other in the bone via gap junction and maintain the integrity of bone by releasing calcium ions which then get incorporated in to bone tissue. Fascia does not have this capacity.
Bone contains about 33% collagen and 39% calcium. The remainder is made up of phosphate, carbonate and other mineral salts.
Collagen allows bone to bend slightly and resist stretching forces. Without collagen bone would be too brittle and without mineral salts, bone would be too rubbery.
For fascia to be bone, the starched fascia should have a balance of both collagen and calcium and contain heamapoetic stem cells within its structure that would then give rise to red blood cells. No prizes for guessing that it doesn’t.
If fascia were bone, then it would receive signals from the parathyroid gland when there was a fall in calcium levels in the blood and would be able to release calcium from its starchy insides to balance out blood calcium levels.
The list is pretty endless in terms of the differences, and this is why bone has its own classification as a connective tissue, along with cartilage, blood and proper (within which the stuff we refer to as fascia has several entries). The classifications of connective tissues may not be very extensive and certainly there is a lot of tissue that is poorly described and understood. Much more work is needed to expand some of the tissues that are only given a few words in anatomy books. Bone however is not one of these tissues.
All connective tissue is mostly inert. This means that it is mostly made up of non-cellular material. That doesn’t mean that connective tissue doesn’t have any cells, but that it mostly isn’t cellular. The non cellular stuff in connective tissue is however as important and interesting as the cells that are there and components within the extra cellular (ie non cellular) matrix are infinitely interesting and important.
In blood plasma for instance, there is a range of elements vital for every breath we take and every move we make; yet plasma is essentially a non-cellular connective tissue. Please bear in mind that none of this is my opinion, just that boring old stuff we call science and fact.
So is bone fascia? Is a railway a road? Having things in common doesn’t make them the same.