Obesity, a Risk Factor for Back Pain

Sean M. Powell, MMS, PA-C

This is the first of a series of articles to allow the reader to better understand various issues.  I will have guest writers on this site, as well as my own.  Our first author is Mr. Sean Powell, my physician assistant, who has performed exhaustive research on back pain and obesity.  The issue at hand is, can being overweight cause back pain.  You will be able to read what the literature has suggested.

              Dr. Steingart


 Back pain is one of the most prevalent medical conditions for which people seek treatment.  It is recognized as the leading cause of occupational injury in developed countries (1).  Despite acute injuries with a pathologic or biomechanical cause of the pain, certain individual factors are also hypothesized as causes of back pain.  Obesity is one factor that has shown to be increasing in the population and has shown to be related to the development of back pain (3,5, 8).

Changes in body mass are known to occur during the aging process, particularly a decrease in the lean body mass and an increase in fat are characteristic of the aging process (2).  Obesity is proposed by many to be one of the risk factors leading to the development of back pain.  Since obesity is increasing in the American population and it is estimated that 80% of the population will experience back pain at some point in their lifetime, the relationship between the two needs to be investigated (7). It is generally accepted that obesity and back pain are somewhat related.  A high waist-hip ratio (WHR) was reported to be associated with chronic low back pain (1).  A high WHR is indicative of central obesity and has been shown to be related to back pain (8).

Hellsing has found a relationship between obesity and back pain as well (2).  There was a significant difference in the study group considered to be obese and the incidence of back pain.  This study has shown a significant relationship between the two.  Those with a body mass index (BMI) greater than 25 showed a significant increased risk for the development of musculoskeletal problems at follow-up, particularly back pain (2).

Obesity is a modifiable risk factor that is associated with back pain (4).  Multiple studies including prospective and cross-sectional designs have shown the relationship between obesity and the development of back pain.  A sedentary lifestyle and the consumption of foods high in fat have become widespread (8).  In general, this combination predisposes the population to obesity.  This, in effect, leads to the “fattening of America” and will in all likelihood continue to perpetuate back pain. 

The population should be encouraged to decrease their consumption of high fat foods and to exercise regularly (4).  Obesity and a sedentary lifestyle have been associated with other medical conditions.  These include cardiovascular disease, stroke, hypertension, and cancer (6).  The link has also been established between obesity and back pain (1-8).   Lifestyle modification should be encouraged to reduce the occurrence of obesity and back pain.  Additionally, given the public health importance of these conditions, the benefits of weight control and exercise should be encouraged to limit or even prevent the incidence of back pain (6). 

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References

Han, TS, Schouten JS, Lean ME, Seidell JC.  The prevalence of low back pain and associations with body fatness, fat distribution and height. 
International Journal of Obesity and Related Metabolic Disorders.  1997; 21: 600-607.

Hellsing A, Bryngelsson I. Predictors of musculoskeletal pain in men.  Spine.  2000; 25, No. 23: 3080-3086.

Fransen M, Woodward M, Norton R, Coggan C, Dawe M, Sheridan N.  Risk factors associated with the transition from acute to chronic occupational back pain.  Spine.  2002; 27, No. 1: 92-98.

Lahad A, Malter AD, Berg AO, Deyo RA. The effectiveness of four interventions for the prevention of low back pain. JAMA, The Journal of the American Medical Association. Oct 26, 1994; 272, No. 16: 1286-1291.

Levine DB, Leipzig JM. The painful back. In: McCarty DJ, Koopman WJ, eds. Arthritis and Allied Conditions. 12th ed. Philadelphia, PA. Lee & Febiger; 1993: 1583-1600.

Rissanen A, Fogelholm M. Physical activity in the prevention and treatment of other morbid conditions and impairments associated with obesity:  current evidence and research issues. Medicine and Science in Sports and Exercise, Official Journal of the American College of sports Medicine. Nov 1999; 31(1): 635.

Roubenoff R, Rall LC. Hormonal mediation of changing body composition during aging and chronic inflammation. Nutrition Review. 1993; 51: 1-11.

Yoshitaka T, Segal N, Tamami T, Tadanobu M, Ogawa R. Lean body mass and body fat distribution in participants with chronic low back pain. Archives of Internal Medicine. Nov 27, 2000; 160,  21: 3265.

Weight can contribute to an already compromised back problem.   Back pain  is  more difficult to handle with an overweight patient.  For example: If you have a weight problem and undergo a discectomy of any kind, their is a higher incidence that you may re-herniate the disc and need another surgery.  This is because the weight is added to an already compromised back, which causes more pressure to build up in the lumbar area.

 Additionally, wound healing with most surgeries becomes more difficult.  In Endoscopic Surgery wound healing is rarely a problem since it is a minimal incision surgery. Weight also contributes more of an anesthetic risk, in most surgeries since the fat absorbs many of the gases the patient is exposed to through a general anesthesia.  This again becomes less of a problem with Endoscopic Surgery, since it is performed under local anesthesia.

Overweight patients have a harder time losing weight since the joints are under more pressure.  This may become a problem with rehabilitation following any type of back surgery.  Just as a reminder for those of you who are overweight.  Skinny people get herniated discs, too.

                   Michael Steingart

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What is the best test to have if I suspect I have a back problem?
Is the MRI ever wrong?

 

A patient consulted with the doctor. The patient asked if he had hemorrhoids.  The doctor examined him and confirmed the fact that this man had a case of hemorrhoids.  The patient dressed, then asked,  “Doc, how can you be sure I have hemorrhoids?”  The doctor  replied that she had seen them, felt them, and that the symptoms corresponded to hemorrhoids.  The patient  looked quizzically at her and said, “Yeah, that’s ok too, but can you do an MRI to be sure anyway?”    

Unfortunately this is the state of medicine today.  The doctor takes second fiddle to a test  And, unfortunately for the patient, many doctors have lost the ability to diagnosis without a test. Tests, such as MRIs, CT Scans, Myelograms, and Discograms, are only as good as those people reading  and performing them.  Additionally, tests rarely make the definitive diagnosis. The doctor does that.  Tests are useful  by  confirming what the doctor has already thought the problem is. Tests may not tell the whole truth  about the underlying condition. They are only a one aspect of medical care.

Now that I have set the stage, let’s look at some of these actors (“tests,”) and see how they can help us in diagnosing lumbar spine pain.  The MRI scan is basically a big magnet.  Our body can be considered one big magnetic field.   When our body is put through this big magnet  electrons are realigned. Different signals in the body absorb differently  based on the water content, calcium deposition, and other biological  agents.  These images are “weighted” as T1 and T2 images.   The MRI helps us see disc tissue in a static manner  .  It may demonstrate a herniation of nucleus, or show disc desiccation or drying.  It is highly sensitive but not very specific.  In other words it can suggest annular disc problems but cannot show the actual tear. It is able to pick up soft tissue tumors relatively well, However, the MRI does a poor job demonstrating bony detail, annular disc tears, and arthritis of the lumbar spine. 

Myelograms on the other hand are more invasive.  The patient lies on the radiological table and a needle punctures into the thecal sac surrounding the plexus of nerves.  An iodine base contrast agent is injected.  Real time x-rays (fluoroscopy) is used to watch the dye move, and see if there is any impedance.  Blockage of motion of the dye may be caused by a bone or disc.  The dye may narrow in certain areas which is what is referred to as stenosis.  Myelograms can have serious adverse side effects, including post spinal headaches and infection.  Many spine surgeons believe that the myelogram combined with a CT scan will define the patients pathology better than any other test.

The CT scan alone allows one to see the bony detail.  It is not a commonly used test for backs, since simple office radiographs can demonstrate much of the bony pathology.  However, a CT scan is useful to delineate a bone tumor .  Combined with the myelogram, the CT scan may give more detail to why the contrast agent is being blocked.  It has  it’s drawbacks too.  Radiation exposure is one of them.  Additionally, it is difficult to see a far lateral herniated disc, because the nerve root sleeves do not always fill with contrast.  A Myelogram-CT scan does not give any direct information on the status of the disc. Only indirect evidence of a herniation.

A  Discogram in my opinion is the best test to delineate the damage.  Performed with the patient awake, yet lightly sedated, radio-opaque contrast is injected into the disc.  This is the evocative part of the procedure.  The discogram is a dynamic test. The discogram demonstrates the pathology flouroscopically, and will evoke the symptoms causing the back problem.  The discogram is performed in an operating suite with the patient lying prone. If the disc (annulus and nucleus)  is not causing the problem, then the patient will not experience symptoms during the injection.  The contrast agent into the disc will demonstrate a normal pattern.  One can readily identify annular disc tears and  herniations with the discogram.  The discogram may be combined with an MRI or CT scan.  There is a 1% chance of an infection from the test.

Tests are only guides.  And the best test for any good clinician is a good history and physical examination.  As one surgeon explained to his patient when asked, “Do you think I need an MRI, doc?” 

“I was diagnosing the same problems well before the MRI was even invented.”  

                   Michael Steingart

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Why does my back hurt, even though I did not injure it?

 

This is one of the most common questions I am asked.  Yet it is one of the most frustrating questions to answer because the  back is a complicated structure. Pain is a very definite yet a nebulous entity which is difficult to quantify.

To begin to attempt to answer this question one must understand the natural history of the formation of the spine.  At a very early age in gestation the neural elements of the spine are formed.  The bony elements eventually form separately. Together the spine is formed.  The baby is born with a completely straight spine.  Only when the baby begins to walk, does the adult curve begin.  The lower back forms into a lordotic curve (backward bend), the  mid back into a kyphotic curve (forward bend), and the neck into a lordotic curve.  Gravity influences the spines growth plates.  As we develop the disc between the bony elements is fluid filled.  Water makes up about 85% of the natural disc.  The disc (named after a discus, since this is the way it looks), has two parts, the outer fibrous annulus and the soft gelatinous nucleus.  The nucleus moves as we move.  The annulus is the outer casing that controls the amount of motion of the nucleus. 

As we develop, the lumbar spine adjusts.  The greatest pressures put upon the disc is when we sit down.  The least amount of pressure we put upon a disc is when we are lying down. Walking, bending, stooping, squatting, and lifting all take a toll on the lumbar spine.  The human walks upright, yet we have the same basic constituents in our spine as a dog, cat, giraffe, and other mammals. Needless to say our activities are not as protective as our mammalian counterparts.

As we age the water content of our entire body diminishes.  The lumbar spine is no exception.  The hydrophobic nucleus starts to shrink.  The hard thick tenacious annulus begins to fissure.  Metabolites such as histamines and interlucins are expressed from the tissue.  These are called inflammatory metabolites.  They intercept nerve fibers networked into the spine, and send impulses of discomfort to the brain.  The body makes some minor adjustments; laying down more bone to increase surface area, tightening the ligaments to disallow excessive motion, muscles shorten and contract to give the body more support.  We continue our everyday activity, with barely a perceptible ache.  The lumbar spine has a great ability to compensate to allow our active lifestyle.  As A.T. Still  MD DO  stated in 1876 the body is self healing.

The lumbar spine is like a punching bag, it takes a lot of hits, yet keeps going.  At some juncture which is individualized by each one of us, the body cannot repair itself. Incidental micro trauma, may be enough to precipitate pain.  This accumulation of mini-trauma leads to macro-trauma.  Sometimes, the trauma has reached the point of no return, and surgery is necessary to correct the problem.  When this occurs it may be too late to make the necessary changes in our life style to accommodate the lumbar spine.  Since very few of us have a healthy spine here are ways to improve your spine: Yoga classes, to learn how to  stretch and breath properly, visit with a physical therapist to learn how to lift properly and strengthen the important lifting muscles, stop smoking since the nicotine and tars affect the vascularity and effect healing, exercising daily in the sunlight for at least 20 minutes per day in order to prevent osteoporosis, flip your mattress which should be done every 60 days, eat what the council for nutrition recommends – three meals with at least two fresh vegetables or fruits with each serving per day, drink eight, eight ounce glasses of water per day, maintain your ideal body weight, and getting a massage for stress relaxation.

So, to answer your question as to why my back hurts even though I didn’t injure it; somewhere along the line you did, but it may not have been enough to cause a problem at the time.

                   Michael Steingart
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"Sources of Low Back Pain"

The back is a very complicated structure.  The lumbar spine is a complex organization of nerves, muscles, discs, and bone.   The lumbar spine is at a mechanical disadvantage  while upright.   Finding the pain generator (s) is the key to understanding how to treat the back. I have divided back pain into four anatomical areas: Muscle, Bone-Joint, Disc, and Nerve.  Understanding the causes of  low back pain will allow you to understand the  different options in treatment.

The lower back muscles are  weaker than most .  The muscles along the spine are meant to  guide the back in ranges of motion.  These “strap” muscles also prevent gravity from pulling you forward and down. They are  located on your back side. The  muscles can spasm with abnormal stresses.  The pain is self limiting, and will resolve over a few  days to weeks.  The antagonist to the Para vertebral strap  muscles are the front muscles  called the Psoas;  Psoas Major and Psoas Minor.  These muscles are contracted while sitting down, since they also are the strongest hip flexors. They connect the bodies of the vertebra to the hip.  One of the major problems in chronic low back pain is that the Psoas are overly strong pulling the lumbar spine anteriorly, overpowering the light strap muscles.   This creates  abnormal stresses on the bony elements of the lumbar spine. Treatment is instituted to stretch these muscles, while strengthening the “strap” muscles .

The lumbar spine has two major joints called officially as the Xygophoseal Joints of Von Luska.  You may have heard them referred to as the facets.  These joints guide the lumbar spine in flexion and extension. They also help turn you from side to side.  Tiny nerves innervate the facet joints.  They have a rich supply of sensation.  A.T. Still the founder of Osteopathic Medicine in 1892 would manipulate these joints to relieve pain and discomfort.  Facet pain is localized as back pain.  It is accentuated with motion of the lumbar spine.  The pain will sometimes travel to the sacroiliac joint and into the gluteal (buttock) area.  These joints can easily become arthritic, due to their small size and large weight bearing load.

Discogenic pain can be divided into annular pain or pain from actually herniating its contents and touching a nerve.  Discogenic pain may cause back pain or leg pain. The leg pain may go to the foot.  The outer annulus has many small pain fibers.  These nerves are very sensitive.  Just touching the outside of the annulus with a needle can produce pain. The annulus tears. It secretes  “pain chemicals”.  These metabolites are called prostaglandins, histamines, and interlucins.  The annulus is made up of a hard fibrous tissue which supports the load of your back.  The annulus encircles the  inner  nucleus.  The nucleus has hardly any pain fibers.   It is softer and more gelatinous. The nucleus produces pain by “herniating” or “protruding” into the canal touching the nerve.  Pain can go to the toes.  Weakness in the limb may occur, but not always.  Sometimes the pain can be so incapacitating that the patient is unable to straighten. 

Nerve pain can mimic all of the above.  If the nerve is damaged enough, scar tissue can drape itself inside and around the nerve leading to a permanent impairment.  Nerves envelop the entire lumbar spine.  Sympathetic nerve damage causes the toes to feel hot or cold.  The sympathetic chain is located on the anterior aspect of the vertebral bodies.  Motor nerve damage causes permanent weakness to the limb.  Sensory nerve damage causes numbness or tingling.  If it is a painful numbness we call that dysethesia.  Shooting pain aggravated by certain activities is usually indicative of nerve irritation.

There are other causes of low back pain and leg pain; Sacroiliac Joint and Trochanteric Bursa. 

By understanding the anatomy of the lumbar spine  one can define the treatment.  Although we have anatomically divided the back into four essential areas. It is like a Venn diagram where each area interacts with the other.

 Diagnosing  the pain generator (s) in the lumbar spine is critical. Only then, can treatment commence.

                   Michael Steingart

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"Osteopathic Medicine"

 

"A man’s mind, stretched by a new idea, can never go back to its original dimension." Oliver Wendell Holmes Jr.

Osteopathic Medicine was started by a physician who saw the failures in medicine of his time. It was founded on the principle that the body is self-healing. Osteopathy emphasized unity of the mind and body. "Osteopathy is a system of healing which considers the fundamental relating of structure to function and the co-ordination function of all body structures acting together as a unit. (17) The osteopathic physician is thoroughly schooled in human anatomy and physiology. The osteopath recognizes the human as a complex relationship of different organ systems working together co-dependently similar to the workings of a well-oiled engine. Every part of the engine is dependent on the other part for proper function and the ultimate end result. The osteopath is "a human engineer who should understand all the laws governing his engine and therefore master disease." (1). Osteopathy was founded in the farmlands and coalmines of the Midwest. It was as much a philosophy on life as it was a science to heal. (54). The science was that physical restrictions impeded blood flow, lymphatic drainage, and central spinal fluid return. The philosophy was that the sum of life in and of itself was from the living cellular parts of the human body working in harmony. "First the material body, second the spiritual being, third a being of mind which is far superior to all vital motions and material forms, whose duty is to wisely manage this great engine of life. (56). Osteopathic medicine was frontier medicine that has lasted over 150 years. The foundation of osteopathy is the same as it was back then: The body heals itself and will heal by natural laws. The physician is a facilitator of this natural process.

Osteopathic medicine has stood the test of time. Osteopathy includes specialists in every field of medicine; family practice, cardiology, orthopedic surgery, internal medicine, general surgery, psychiatry, obstetrics and gynecology, radiology, etc. Osteopaths are also neonatologists, oncologists, and researchers in every scientific field. The osteopath continues to study all aspects of the human being. Advances in medicine are accepted and pursued by the osteopath. Physicians are still taught to rely secondarily on drugs or surgery, and emphasize manipulation, nutrition, and more natural means to heal. An osteopath is taught to focus on the cause of the disease rather than the symptoms of disease.

A.T. Still MD was the founder of Osteopathic Medicine. Still practiced conventional medicine prior to his thoughts that the body is self-healing. After medical school he enlisted in the Civil War. Surgeon/physician Still became the master of a one-minute amputation and expert at treating wounds of the day. During these times he witnessed the failures of medicine and surgery. Still saw that death on the battlefield came more from diseases rather than gunshot wounds. He understood the limitations of surgery and wrote about the exorbitant number of deaths and permanently disabled people caused by the knife and ether. (2) Thirty years later the first school of osteopathy opened in a small Missouri town called Kirksville. Still’s teachings rested on the idea that God, through infinite wisdom, created a human body. The human body had the capacity to heal through natural means. This he called "natural way". (3)

Dr. A. T. Still, a licensed, practicing physician and surgeon, began speaking out against the "old school" of medicine. "In all ages, the Doctor has for lack of knowledge of the true cause of disease combated effects with his remedies. He treats pain with remedies to deaden pain…" (4). This was probable an emotional reaction as two of his sons died from disease at a young age.

Still left the ranks of his allopathic brethren. He wrote, "The explorer for truth must first declare his independence of all obligation or brotherhoods of any kind whatsoever. He must be free to think and reason. He must establish his observatory upon hills of his own; he must establish them above the imaginary planes of rulers, kings, professors of schools of all kinds and denominations. He must be the Czar of his own mental empire, unencumbered (sic) with anything that will annoy while he makes his observations. Thus this is addressed to the independent man or woman that can, will and does reason." (5) Still’s renaissance of medicine began in 1874. In that year he started his osteopathic crusade by putting theories of disease to the test. Keep in mind this was before Koch’s Germ theory, the advent of Lister's aseptic technique Dr. Roentegram’s great discovery, the Freudian issues of psychoanalysis, the stethoscope, and antibiotics. Medicine was still in the stages of putting hot oil in open wounds, chilling the febrile, locking up the insane, trying to hypnotize the hysterical, and bleeding the sick. Modern medicine consisted of cults and isms. Magnetism and transference of healing power were trends as was the galvonists, who maintained that newly discovered electricity cured. Modern science had created great elixirs and potions. Many of these were made from alcohol and its derivatives. It is no wonder why the traditionalists of medicine felt that osteopathy was just another great hoax. The ringleader and major crank they said was Dr. A.T. Still.

Realizing that osteopathy was not in the mainstream of medicine, Still responded and charged that, "Allopathy, a school of medicine known and fostered by all nations, drove on with its exploring teams: gave up the search, went into camp and built temples to the god who purged, opiated, drank whiskey and other stimulants; destroyed its thousands, ruined nations, established whiskey saloons, opium dens, insane asylums, naked mothers and hungry babies, and still cries aloud and says: Come unto me and I will give you rest. I have opium, morphine, and whiskey by the barrel. I am the god of all healing knowledge and want to be so recognized by people and stature. I do not wish to be annoyed by Eclecticism, Homeopathy, Christian Science, massage, Swedish movements, nor Osteopathy." (6)

In 1899 The Merck Manual of Therapeutics listed 68 different treatments for diabetes mellitus. The authors wrote: Arsenic should be used for thin subjects, codeine, a most efficient remedy, be pushed to the extent of 10 grams per day, iron was most useful with morphine, and for the effects of belladonna, the full dosage needed. (7). Dr. Still continued his one-man crusade stating that the allopathic medical doctors were no better than criminals in prescribing these substances to their patients. "{Allopathic doctors} believe in tonics and sedatives, and many other little things." "…the eclectic {doctors} believe in purgatives, his sweats, his pukes, and his burns; he believes in the hypodermic syringe." (8). Here is an example of what occurred when Dr. Still visited a young boy with croup, in the presence of a medical doctor.

Still asked, "{Doctor} what do you have in your hand?"

The doctor replied, "Oh, a little quinine … and whiskey."

Dr. Still: "How long does it take a boy to learn that whiskey tastes better without the quinine? You can get drunk and call it holy if you want to" (9)

North American physicians in the 1800s borrowed from earlier administrators of medicine believing that humerus controlled the body; blood, phlegm, yellow and black bile. Health depended on the harmony of these elements. The American brand of medicine followed the theory of Benjamin Rush (1745-1818), a signer of the Declaration of Independence, and an advocate of "modernism". His thoughts pervaded the American medical community. "The basis of all disease was physiological tension" The disharmony of the humoral elements caused physiological tension. (10)

Calomel was used as a powerful cathartic, arsenic, opium, colchicine, and quinine was used in toxic dosages for everything from rheumatism to headaches. It was a common practice to administer strychnine after surgery; to speed the heart rate and reduce the chance of infection. (11). Physicians thought disease was the sum total of symptoms. They reasoned such things as the faster each symptom was removed the more rapid the patients recovery. Treatment meant to reduce those symptoms not eradicate the disease. All of this led an elder American spokesman to say, " If the whole material medica as now used could be sunk to the bottom of the sea, it would be better for mankind, --- and all worse for the fishes ---." (12)

It was this setting in America that led Dr. Still to his deep and philosophical thoughts on mankind. The basics of osteopathy lie in the fact that, "The body itself contains within itself all the chemicals all the medicies necessary for the cure of disease." (13) Still reasoned that no disease kills all the individuals it attacks. He stated, "Indeed the vast majority of human beings and animals are normally in the act of continuously "curing" themselves of disease by which they are continually being "attacked". If this were not true all the races including man would swiftly be destroyed by various biological reactions which ignorance had named disease." When Still was asked, "Why do the sick recover?" He would reply, "Because the body is self healing." (14)

Dr. Still was the first of his time to describe homeostasis. He reasoned that the body must have the necessary chemical and structural elements in order to resist disease in the body. The symptoms that the body exhibited such as the temperature elevation, lethargy, and nausea, during the sickness were natures way of trying to help the body heal. The fight for the body in sickness was to get back to normal state. Osteopathy, became the facilitator in that fight. To do this the osteopathic physician required a thorough knowledge of the sciences. "I wish to impress upon your minds that you begin with anatomy, and that you end with anatomy, a knowledge of anatomy is all you want or need, as it is all you can use or ever will use in your practice..." (56. ) For the body to function correctly free of disease, all parts must be working together. Still also said this:

"The philosophy is not intended for the minds not thoroughly well posted by dissection and otherwise of the whole human anatomy. You must know its physiological laboratories and workings with the brain as the battery, the lungs as the source or machine that renovates the blood from all impurities, and the heart as the living engine or quarter-master, whose duty is to supply the commissaries with blood and other fluids to divisions and sub-divisions of the human body, which is busily engaged producing material suited to the production of bone and muscle, and all other substances necessary to keep machinery of life in full force and action." (15) Dr. Still was an integrator; he was the first physician to combine human anatomy and physiology; the structure, the function, and its purpose.

Dr. Still greatly discounted the leaders of his field who believed and promulgated the theory that substances called medicines put into the body will heal the body.(16)

It was Hahnemann, the teacher of homeopathy who theorized that minute amounts of certain substances when introduced into the body would produce symptoms similar to those of the diseases. The body would be able to build a resistance to these substance and cure. The smaller the amount of the drug used the more vigorous the effect of the drug would be. Ironically, this school of thought, advocating small dosages, led to the increasing use of drugs in the United States. The druggists of the day would increase the amount of medications and increase the dosage of medications. Although homeopathy was not accepted by the allopathic majority, the concepts of drugs curing ailments, was accepted. This contrasted directly with Still’s desire to help the body naturally heal by activating natural defenses, later called immunity.

It was in this "age of reason" that osteopathy was born; on the premise that function follows structure, on clear and concise physiological and anatomical grounds.

William Harvey, the 16th century scientist of the circulatory system, influenced osteopathy. The artery, according to Still, ruled supreme. (18) It was contended that when the artery was disturbed, a chemical imbalance would be initiated and a cascade of deleterious affects would occur. By effectively controlling the arterial flow to an organ, the body could begin a healing process. "The nerves were the source of constant disturbance of the circulation of the blood." Still believed that the toxic build up of wastes in the body must be removed, for this to happen. "… Life be aided in the process of removing all hindrances to health, just what power to apply to call for the lymph, fibrin, albumen, uric acid, muriotic acid, and any other fluid from the great chemical human laboratory that has within itself all reasoning qualities and never fails in the grand show…" (19)

"A full and complete supply of arterial blood must be generated and delivered to all parts, organs and glands by channels called arteries. We must know some delay of fluids has been established on which nature begins the work of renewal by increase action…" (28). Still wrote that when the arterial supply to a diseased area is affected, the structure may change back to normal. In treating an eye condition called pterygium, an inflamed growth from the inner canthus of the eye extending to the pupil, the narrator had this to say: "Dr. Still examined her eyes thoroughly, then examined her neck and her spine, in fact the whole length of it. ‘But Dr. Still how are you going to take these growths off unless you put something in there to eat them off, or cut them off by operation?’ Then I received my first lesson in osteopathic fundamentals. Calling me by my first name, he replied, "Arthur, the same law of nature which has been obstructed, permitting these growths to form, when re-established, will absorb them." Treatment began by removing congestion in the upper neck and head. "Treatment would be applied to correct faulty structure in the neck." "… when that part of the work was completed, he would lift those eyelids and dip his finger in vaseline and crease his fingernail across what he called the little feeders (arteries) that could be seen trickling from above downward over the sclerotic coat of the eyeballs into the growths. There were three of those arteries, on each eye—one central and two lateral." (20)

Osteopathy also borrowed and was influence by Rudolph Virchow. The German medical officer introduced the fundamental dictum regarding cellular reproduction in the mid 1800s; omnis cellula e cellula (all cells from cells). The cell was the basic structure for life. Dr. M.A. Lane writes, "Neither scientist nor physician had the slightest suspicion that many diseases were caused by growth in the tissue or the blood. Tumors were mere lumps, skin eruptions were considered impurities of the blood … and people swallowed oceans of drugs believed to be "blood purifiers.""(21)

The osteopathic approach to disease relied on the cellular level to effect a change through drugless means. Dr. Deason wrote in General and Osteopathic Physiology, "Function can be defined as a specific work of an organ or tissue. Any abnormal structural relation that exists may affect the blood or nerve supply in some way to interfere with developmental growth, or activities on the cellular level. Osteopathic physiology. is a branch of general physiology, which considers the relations of structure and function and the unity of combined function. (22)

Still emphasized that the doctor must look for the source of the disease. "Disease is nothing but a reaction to stimulation however diverse." (39) Regarding fevers: "When we reason for causes we must begin with facts, and hold them constantly in line for action, and use, all the time. As we line up to learn something of the cause of fever, we are met by heat, a living fact. Does that put the machinery of your mind in motion? If not, what will arouse your mental energy?" (23)

It was through "refined touch", and the knowledge obtained in the basic sciences, that separated the osteopathic physician from the rest. Emphasis was placed on basic anatomy first, then physiology, and finally the element of human reasoning and observation.

"Know the normal – and you will recognize the abnormal when you find it. Unity must be in the mind and the body." (24) Still stated, "The average well taught practitioner makes far too little use of his own hands; exhibits a marked distaste for personal manipulation. Relatively few are equipped with tactile appreciation of morphological variants, minor differences in resistance, density, temperature, balance, position, tension, relaxation, rigidity, mobility… All this exceedingly significant data, obtained by means of refined touch, exert a direct bearing on most clinical problems." (25)

Manipulation was another facet of osteopathy. The physician in North America was not accustomed to touching the patient. According to the osteopath, the physical touch could effect physiological change in sickness. Manipulation could be subcategorized into articulation and soft tissue. The "hands on approach" to medicine was new to America. It served as the osteopaths guide to understand the disease process and then to treat the disease in full. Therapeutic manipulation was not a new concept. Hippocrates did it and wrote about it. In 1871, a British apprentice of Paget, Dr. Wharton Hood, wrote of manipulation, "The art of overcoming by sudden flexion or extension any impediments to free motion of the joints that may be left behind after the subsidence of the early symptom of disease or injury." (26). Edgar Dick MD, in his text Source Book of Orthopedics stated that manipulative therapy was buried in "the obscurity of secret practices of an indefinite period preceding the 19th century." Still utilized manipulation, which included soft tissue massage, lymphatic pump techniques, and articulation of the joints, to help the body heal. He understood that manipulation played a part in normalizing tissue. Regarding the sacrum, he wrote, "Vasomotor centers controlling circulation of the uterus are located in the lumbar region, these plexes are switching stations for impulses from the S2-S4." (27). However, it was the osteopath who believed the spinal lesion was a cause to interfere with the "normal" conduct of the body. It was also the osteopath, Dr. Still, who wrote, " … if we are to succeed as healers, we must know that normal does not simply mean to place bone in a normal position."

Not only could nerves affect the sensory component of pain, but also the viscera. The osteopathic physician calls this a viscera-somatic response. This means that disease in the stomach may result in a reflex muscular response at the levels of T5 and T6. The fascia around the area also may be congested. Should a patient show signs of pain in the heart, an osteopathic physician may find increased tonicity of the muscles and congestion of the fascia at T4 or T5. Dr. Hildreath, one of the first students to study under Dr. Still wrote, "Every cure came as the result of removing the cause of the condition. Nerves must be freed of physical interference in order for nature to do her cure." It was through manipulation that the nerves could be affected. Hildegrath wrote, "The abdominal plexus of nerves may be influenced by irritation to nerves as high up as the first cervical vertebra and as low down as the last lumbar, not directly but indirectly through the ramifications of the sympathetic nervous system. Dr. Still called the abdominal plexus the "abdominal brain." "… {The osteopath} must know which of the various ganglia of nerves situated at various levels of the spinal cord was responsible for the condition found." It was the osteopathic physician, attuned to musculo-skeletal changes, who could effect change, and hopefully a cure. (28)

The primary emphasis of osteopathy was placed on the functional anatomy of the human body. Osteopathy was the first discipline to realize the importance of the sympathetics and their influence in everyday functional affairs of the body. "In causalgia accompanying peripheral nerve injury, there is a burning pain, hyperesthesia, trophic and vaso-motor disturbance. This may give rise to symptoms of muscle weakness, sharp darting neuralgic pains, sensory perversions and tenderness along the course of the nerve. It may set up by adjacent inflammations, injuries, exposure, infections, metabolic or diathetic diseases, and poisons." (40) Still wrote that the third and fourth dorsal vertebra affected the sympathetic ganglia on the right side and was a cause for asthma. Dr. Still said, "interference with the function of the sympathetic nerves by lesions in the region from the fifth dorsal vertebrae down to the sacrum was the cause of diseases of the stomach, spleen, kidneys, intestines, and pelvic organs. Joint disturbances anywhere in the region of the fifth to twelfth vertebrae, through their effects on the great splanchnic nerve, altered the blood supply and venous drainage of the stomach, pancreas, spleen and kidneys. To the least splanchnic nerve (first to third lumbar), he gave credit for the control of circulation to the descending colon, rectum, bladder, and genitalia." (29)

At the time a cure could be obtained through manipulation. It was understood that not every disease or ailment could benefit from the osteopath. " He {Still} did not find time enough to treat all adequately. Many of those who came had been pronounced hopeless by other physicians. Some of them were hopeless. But he was able to cure enough of these so-called hopeless cases to keep adding to his reputation and his fame, which extended into ever-widening circles."(30). It was the osteopathic who was taught that identifying the disease in its early stage lead to a better outcome. To relieve the problem the osteopath would have to find the contracted tissue, then identify the origin of the nervous innervation, and follow the nerve to it’s periphery. This required hands on approach by the osteopath. While treating an intercostal neuralgia: "And that by doing you not only corrected the functioning of the intercostal nerves, but through their relationship with the sympathetic nerves, by their connection of fibers over the rami communicants with the sympathetic ganglia at that point, one could reach and relieve the function of the visceral nerves, which were the splanchinic and had to do with the circulation of blood…" (31) Arterial supremacy, guided the osteopath. The phrase that the artery ruled supreme was the osteopathic motto. The osteopath is guided when all the obstructions to circulation are gone. Regarding continual and ongoing treatment, it was Dr. Still who said, "Find it, fix it and let it alone". (32). Over manipulating was like spanking a crying baby to make it stop crying. Constant treatments would only inflame further inflamed tissue.

The success of the osteopath as a therapeutic adjuvant to healing was founded in the premise that a specific pathological process or processes would cause mechanical perversions. The recognition that spinal tenderness was an attendant of disease, but was not the cause of the disease, allowed the osteopath to treat. McConnell stated about an osteopath’s ability to palpate and sense: "A wealth of phenomena, unknown to those who have not attained such a skill. Nothing short of a disciplined sense of touch thoroughly versed in the feel of tissues can either palpate, diagnose, or adjust the lesions." (41) It was the osteopath’s ability to treat through natural means, which set him/her apart from the rest of the medical community. Physiological checks on tissue texture; warmth, pigmentary changes, proliferation of connective tissue, roughness, and painful points led to the treatment of the disease. Functional checks on the articulations of the joints, namely the restriction of motion, was imperative to the treatment as well. The palpating practitioner must recognize the compensatory mechanisms of tissue in response to the joint restriction; contracture of tissue and fascia, muscle guarding, and hypermobility above and below the lesioned area. However, "the exact anatomical detail of positional derangement of bony structures is essential to the proper classification of the lesion as well as the correct adaptation of bony leverage technique." (42)

It was the osteopath who proved, through manipulative techniques, that the sacrum moves in relation to the ileum. "Any lesion involving the sacrum and inducing an increase in forward tilt or inclinations may be termed either a flexion or anterior lesion. … causing a backward tilt or inclination may be termed extension or posterior."(43) Illustrations were made to show the muscular effect of the rectus femoris and hamstrings on the dynamic motion of the pelvis on the sacrum. Attention to the psoas major was made and along with its position near the lumbar plexus and the gangliated trunk of the sympathetics. "Since the lumbar plexus is imbedded in the substance of the psoas muscle, passing immediately in front of the sacroiliac joint, trauma or infection of the sacroiliac joint may create an edematous reaction in the psoas muscle affecting the nerves imbedded. A myositis or fibrosis involving the psoas or pyriformis musculature, may give rise to definite sciatic symptoms." (44)

The body works through interrelationships of structures. The osteopath is an investigator. He/she must try and find the altered mechanisms in the body by understanding the mechanics entirely. The osteopathic physician by virtue of his/her training becomes an engineer, a biomechanical expert, a detective, and a physician all in one. Referred pain through nervous innervations could confuse the osteopath. Not only could an altered sacroiliac joint mimic lumbago or Potts disease, but an alteration in the mechanism could cause be referred pain from appendicitis at "Baer’s sacroiliac point, a sensitive area two inches away from the umbilicus and in line with McBurney’s appendicitis point." (45) It was the osteopathic physician who brought the terms agonist and antagonist muscle groups to the forefront. The principles of kinesiological and physiological laws of human motion were emphasized. "All living motion is subject to change. Normality is never twice alike, yet the relation between structure and function must be relatively constant since both develop together and maintain interdependence throughout every manifestation." (46) In other words, it is the synchronization of muscle and joint movement, the rhythm of the movement, and the timing of the forces, which are essential for proper execution for normal. The osteopath was taught that the body works in unity. On metatarsalgia: "In metatarsalgia the cause is usually a mechanical condition of the cuboid and forth metatarsal articulation. On the back: Sciatica, a lumbosacral or sacroiliac articular strain is probably the outstanding single cause. It may impose torsion strains upon the coccyx or the latter structure may be implicated by direct injury." (47) One must understand that these osteopathic concepts go back over 100 years and were severely curtsied by the allopathic community.

The osteopath was the first to believe that structural irregularities such as spina bifida, sacalization, spondylolysis, etc., may not always be corrected by manual means. Pain may be generated from above and below the pathological segment. "Structural irregularities may not only cause direct mechanical trouble but give rise to eccentric movement." (48) By effecting one muscle group around the pathological area, would cause a reflex effect. This effect could come from many sources including the arterial, nervous, or muscular contractions. For example, a patient with the diagnosis of sciatica: "Symptoms are usually confined to the same side as a muscular overstrain or static anomaly." (48) The tissue around the area would show some type of abnormality that would be obvious to the osteopath. Once the primary cause of the muscular strain was found, the patient could be treated correctly.

The osteopathic community for the most part, valued medical advances based on sound principles. For example, in 1898, osteopathic medical school bought an X-ray machine, only the second one west of the Mississippi. It was incorporated immediately into the realm of treating patients. Two articles were published by Dr. William Smith, a teacher from the school, about injecting radiopaque contrast agent in cadaveric veins and arteries to demonstrate circulation. (49) However, it was the osteopath trained as a clinical anatomist who believed "a demonstration of living dynamics – including the finer degrees of that intangible thing staticity or hypermobility – can be elicited by functional test only. The X-ray is not a scientific criteria for diagnosis of functional misbehavior. It cannot confirm the clinical evidence." (50) It was this belief that contributed to the split between MD and DO.

Allopathic medicine maintained and to some extent today believes that the disease complex must be quantified. Without "objective findings" the osteopathic lesion does not exist. Sacroiliac torsion, pelvic rotations, myofascial trigger points, spinal asymmetry cannot be visualized by the X-ray machine nor lab tests. Additionally, since pain can generally not be quantified, many physicians believe that it is made up in the minds of the patient. It is the osteopathic approach to find the source of pain, before giving into the malady of saying, "the patient is a malingerer." Today we understand that there are biomechanical mediators of pain. These are released as a result of tissue injury. Hyperalgesia, is caused by the serotonins, bradykinins, histamine, prostaglandin’s, and substance P. We understand that through the nociceptors these substances are activated. We understand also that the immune system is involved with the initiation of pain. Yet all above-mentioned items cannot be seen or quantified by the clinical physician. But the changes evoked structurally by their cumulative effects can be palpated by the osteopathic doctor.

Still wrote of the medical schooling of his day: " The schools of modern medicine have been built on textbooks written largely in medieval times. Lectures were given explaining these textbooks… students were tested on their abilities to memorize. Any departure from what had been taught in the book or the lecture was penalized." (33) Osteopathy was taught differently. Not only was the osteopathic student schooled in the basic sciences, the clinical application was emphasized during the first year of training. Still stressed to his students that the application of principle was more important than rote memory. (51)

The Osteopathic College was the first medical school to require entrance exams. This occurred in 1902. In 1903, the osteopaths adopted standards of approval for osteopathic medical schools. The allopathic schools began their inspections when the Council of Medical Education was formed in 1904. Pharmacology was not included in the early osteopathic curriculum. Due to the great advances in healing with drugs, the osteopath is taught pharmacology. As the MD counterpart, DOs' have full rights in America to write prescription drugs.

Today, osteopathic programs train surgeons. In its infancy, osteopathy spoke out against surgeons. It was the osteopath who believed that a painstaking diagnosis of a condition should be made and treated non-operatively. However, should osteopathic treatment fail, surgical intervention was justified. Still believed though that surgeons did not get the proper training to operate. An example of such a case follows: A boy, who dropped a hammer on his knee, resulted in a deep cut. Three doctors consulted after the knee became inflamed and swollen. The doctors decided an amputation was needed but the mother of the boy refused. The mother wanted Dr. Still to see the boy and make the final decision. " …he went into the room, looked at the boy, and examined his knee for a few minutes. Then he sat down in a chair by the side of the bed, put his feet up on another chair, and pulled his hat down over his eyes. He sat there so long in contemplation that the family became alarmed, and they were afraid he was not going to do anything. Evidently having satisfied himself as to procedure, he arose and went to work. He manipulated the thigh and the pelvic bone on the side, gently rotating the thigh, and stretching the limb, a little, thus causing relaxation of the contracted and inflamed tissues around the knee. By morning the swelling had materially decreased and by afternoon …they found there was absolutely no necessity for an operation." (34) For whatever the reason, it seemed as though many surgeons around the turn of the century were poor diagnosticians.

In the early 1900s, the first surgical training program was instituted in Kirksville.

Emphasis was placed on the diagnostic skills of the doctor, rather than the mechanics of his hands. The osteopathic surgeon was taught early on that structure must be intact to permit normal function. The student of osteopathy was required to complete the osteopathic standardized training program first. Only then, could the osteopath participate in the other training programs.

Presently there are 19 osteopathic medical schools. The student’s medical training is similar to the allopathic physicians. Courses are divided into two years of a basic science cirriculum and two years of clinical studies. Osteopathic students are also taught manipulation. Edgar Beck MD writes, " It is unfortunate that it remains an art whose technic is difficult to define properly in writing. To a large extent its unpopularity is due to this fact. Personal instruction has almost invariably been convincing to the student who takes the pains to seek it." (53) For the first two years, the students are taught the basic biological basis of osteopathic medicine. After the two years they are given the opportunity to train further in the area. A total of 4 years of schooling is necessary. A required year of internship is mandatory. Should a specialty be desired, the student must then fulfill his/her obligation based on the specialty of choice.

Osteopathy has been the founder of many:

The first profession to offer woman educational equality to that of a man without distinctions of sex. The first graduating class, Kirksville in 1894, had many woman physicians.

The first profession to treat medically mentally impaired. A sanatorium was set up in the 1920s to actively treat mentally impaired patients osteopathically. The Still-Hildreth Osteopathic Sanatorium studied dementia praecox and treated. Treatment during this period for those considered insane was hypnosis, bleeding, whipping to get the devil out of them, and lock ups. Osteopathic treatment included non-of these methods. In keeping with the osteopathic philosophy that the mind was intimately associated with the body, treatment was begun by both a psychiatrist and an osteopath. Results were promising, demonstrating a positive effect of the osteopathic treatment resulting in the reduction of symptoms.

Osteopathy was first profession who popularized in America, a "hands on" approach to the patient. Osteopathic physicians were trained to take a very detailed history. It was emphasized to look for the source of the pain. Therefore, avoidance of surgical intervention was well-documented on cases of previously diagnosed as, "appendicitis", "renal disease", "breast tumors", etc.

The osteopath was first profession, which believed in the premise that the body can heal naturally.

The osteopath was the first profession to apply anatomy to function.

The osteopath was first profession to realize that the central nervous system can be influenced by mechanical means such as manipulation. It was osteopathy that understood by stimulation or inhibition of the ganglia, created a change in the in the nerves supplying the organs.

The osteopath was the first profession to realize that the spinal nerves control the function to all the organs and can influence the function of the organs.

Anatomically, it was the Osteopath who believed and published in 1898 that motion existed in the sacroiliac joint, and treated it. Goldwaith, an MD, in 1905, made it his discovery.

Osteopaths were the first to understand and reason "referred pain"; specifically sacroiliac joint disease can cause sciatica.

Osteopathy always maintained that the fascia was more than just a sheet separating the muscles from the skin. "It being that principle that sheathes, permeates, divides and sub-divides every portion of all animal bodies: surrounding and penetrating every muscle and all its fibers – every artery, and every fiber … upon the venous system with its great company of lymphatics, which supplies the water of life, used to reduce too heavily thickened blood of the veins. As it approaches the heart on its journey…" (35)

Osteopaths were the first to reason the power of nerves and understood that both a sensory nerve and a motor nerve distribute from the spine. "The blood supply come under the motor system of nerves, and delivers at proper places for the convenience of the nerves of nutrition. The sensory nerves limit the supply of arterial blood to the quantity necessary…" (36) Concerning the intervertebral disc, "Nerve stimulus and circulation … it carries segmental conditioning in its train. The apposition of bones, their weight – bearing factors, and the muscular and ligamentous support and the spinal disc are not only related functionally, but are indispensably associated with the nervous impulse." (52)

It was the Osteopath who learned that proper homeostasis in the body was needed for proper function. This meant good drainage of all organ systems. "… five known kinds of nerves, namely: sensation, motion, nutrition, voluntary, and involuntary, all of which you must labor to keep in perpetual harmony while treating any disease of the head, neck, chest, abdomen, pelvis, spine, and limbs." (37)

Osteopaths were the first to reason that diseased tissue caused body chemicals to mediate pain. We now know of histamine, prostaglandins, and other substances that are pain producing body chemicals. For the body to heal, these substances had to be removed from the area.

Osteopathy developed from a man who felt that many hopeless conditions of nature could be cured. What made Dr. Still stand out among the crowd was his ability to be open minded, his general intelligence, and the sensitivity of listening to his patients. Dr. Still believed that the mind needed to be trained to see beneath the surface. He maintained that a diagnosis needed to be made, before a series of tests were performed. He was quoted as saying, "The x-ray by tremendously increasing the vibrations brings to light what is beneath the surface. Why can we not train our minds to do it?" Dr. Still’s experience and life had taught him not to depend on others, rather his own intuitive skills.

Osteopathic medicine developed into a field of medicine through investigations and discoveries. Its laboratories were patient’s homes. Its study halls were the vast frontier land of middle America. It grew from a one room medical school in the 1890s to many state funded universities. Osteopathic medicine was based on sound fundamental principles, that functional damage is irrevocably related to structural damage. This was ignored by the medical people of A.T. Still’s day. Osteopathic medicine continued to grow and expand into areas of medicine again founded on sound fundamental principles.

The Industrial Revolution of the 20th century swept the countryside. Osteopathic medicine early on, decidedly went against those of industry. Still was considered a renegade by re- introducing the human touch to medicine. Machines he felt could not fix patients. Osteopathy scorned the "medical men", and re-discovered what Hippocrates maintained to be reason to treat. Advances in machinery, telecommunications, travel fueled medicine to enter into the 20h century. The osteopath would not use drugs that did not cure, would make house calls no matter the distance, and would not perform a surgery based on guess. The osteopath was taught to heal the body and the mind. It won the approval of the masses and became an alternative to the "modern industrial way". Today, physicians are still trained to formulate opinions based solely on the lab tests and X-rays, neglecting the human element of combining doctor intuition and compassion for the individual with the above mentioned. Doctoring according to Still, was more than just a photograph, a static imagery of the patient, rather " …I want you to carry a living picture of all or any part of the body in your mind as a ready painter carries the picture of the face, scenery, beast or anything he wishes to represent by his brush." (57). Just as the painter adds his personal touches to what is painted, the osteopathic physician must do the same.

Difficulties face the osteopathic physician of today. Even the most radical among us must admit that the most challenging aspect of doctoring is simply treating the patient. How can an osteopathic physician treat to "preserve health, and the life of my patients to retain their confidence and respect both as a physician and a friend who will guard their secrets with recognized methods of treatment consistent with good judgement and with my skill and ability, keeping in mind always nature’s law and the body’s inherent capacity to recover." (58) As can be expected, modernization marches on, the "hands on" approach by the physician is going the way of the horse and carriage. Instead, medicine has adopted the Henry Ford early 1900s shop room line assembly method of treatment; Don’t touch and keep it cheap. This means spending less time with patients, using a drug as a cure, and concentrating more on the symptoms of the disease rather than the cure.

Entering the millenium, the osteopathic physician must look inward and remember their roots. The last 100 years have produced a variety of modifications to the traditional osteopath. Yet, the fundamental principles still exist.

                   Michael Steingart

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REFERENCES:

Bick, Edgar MD (1948). Source Book of Othopaedics Hafner Publishing Co., New York, New York.

Deason, J. ScB. MD DO (1913). Phsysiology, General and Osteopathic. The Journal Printing Company, Kirksville, Mo.

Downing, Carter MD DO (1935). Osteopathic Principles. Ricardo J. Orozco, San Francisco, Ca.

Foundations for Osteopathic Medicine (1997). Williams and Wilkens, Baltimore, Md.

Genvitz, Norma (1982). The D.Os Osteopathic Medicine. John Hopkins University Press,

Hildreth,Arthur Grant (1938). The Lenghthening Shadow of Dr. Andrew Taylor Still. Arthur Hildreth publisher, Macon, Mo.

Holmes, Oliver Wendell (1892). Essays 1842-1882. Houghton Mifflin, Boston, Ma.

Hood, Wharton (1871). On Bone Setting So Called and its Relation to the Treatment of Joints. Macmillan, London

*Hubbard, Elbert (1912). A.T. Still. self publisher, New York, New York.

Lane, M.A. (1925). A.T. Still Founder of Osteopathy. Buntining Publication, Waukegan, Ill.

Masiello, Dominick J.(1999) Osteopathy – A philosophical perspective. AAO Journal.

Still, A.T.(1908). The