Letters to the Editor  |   April 2006
Still's Concept of Connective Tissue: Lost in “Translation”?
Author Affiliations
    Osteopathic Center of the Four Corners Durango, Colo
Article Information
Gastroenterology / Neuromusculoskeletal Disorders
Letters to the Editor   |   April 2006
Still's Concept of Connective Tissue: Lost in “Translation”?
The Journal of the American Osteopathic Association, April 2006, Vol. 106, 176-177. doi:
The Journal of the American Osteopathic Association, April 2006, Vol. 106, 176-177. doi:
To the Editor:  
I read the May 2005 special focus issue of The Journal with great interest. I thank the editors of JAOA—The Journal of the American Osteopathic Association for their insight and initiative in the creation of this publication. 
I have a small dispute with a central assumption present in the special communication article by Felix J. Rogers, DO, however (“Advancing a traditional view of osteopathic medicine through clinical practice.” 2005;105: 255–259). 
As William Garner Sutherland, DO,1 once said, “we might readily observe the `little things' as `big things' to be seen in the science of osteopathy.” 
Although Dr Rogers' piece is very meaningful—it is an article that I learned from and harmonize with—I dispute his use of the word “musculoskeletal” as a defining element of osteopathic principles and practice when he reminds readers of the first of “two key features” of the 2002 Proposed Tenets of Osteopathic Medicine2: “an emphasis on the primary role of the musculoskeletal system in health and disease.” 
One of the conundrums that awaits osteopathic medicine's philosophers lies in the interpretation of the writings of our founder, Andrew Taylor Still, MD, DO. Still's work has often been interpreted to represent the “musculoskeletal system,” though he himself did not use this term. An alternative interpretation of his work would lead us to the term “connective tissue.” Depending on which interpretation any given philosopher of osteopathic medicine favors, there is a slight shift in perspective that may contain profound implications for the way he or she conceives of the practice of osteopathic medicine. 
Dr Still not only reset his patient's hips, he also successfully treated goiters and acute appendicitis using manual techniques. Assuredly, he worked with muscles, bones, and joints, but, beyond that, he worked with the fascia, which he described as the dwelling place of the soul.3 
From a fascial perspective, muscles, bones, and joints are all included within the connective tissue. 
The extracellular matrix, the microscopic aspect of connective tissue, is inherently a gel. It is only because of the movement of calcium ions (ie, calcium waves) that nutrients and waste products flow to and from the cells. Calcium ions depolymerize and make watery this otherwise unyielding gel. 
Similarly, when osteopathic manipulative treatment is used to treat patients with somatic dysfunction, it decongests the connective tissues to restore their acidic, gel-like character to a healthy, fluid quality. Then blood, lymph, and nerve function can operate efficiently. 
Without the chemical details, Dr Still knew that congestion is anti-thetical to life when he said, to paraphrase, that the fascia, “the frame-work of life,” is where we live and die.3 According to Still,3 because “anyone can find disease,” the goal of osteopathic medicine is to “find health” in the tissues. 
This goal means that practitioners of osteopathic medicine must look for ways to support the healthy metabolic activity of the connective tissues in which cells reside. If a muscle, bone, or joint dysfunction is present, we can be sure that an underlying metabolic disturbance is also present. 
Emphasizing the primary role of the connective tissue (rather than the musculoskeletal system) in health and disease recognizes the importance of the whole body down to the cellular level. When approaching the practice of osteopathic medicine with a concept of the primacy of connective tissue “in hand,” the physician acknowledges and supports the osteopathic principle of the interrelationship between structure and function. 
For example, the extracellular matrix and the cytoskeleton operate as an unified electromechanical and chemomechanical system to turn cell functions on and off. All the necessary elements for the health and maintenance of the organism exist in, and pass through, the extracellular matrix. Thus, we can say that the connective tissues are holistic, demonstrating a structure-function interrelationship and containing all the necessary resources for self-healing. 
Connective tissue is osteopathic tissue. This is where the focus of osteopathic manipulative treatment resides—not just in the musculoskeletal system of muscles, bones, and joints. 
Sutherland WG. Contributions of Thought: The Collected Writings of William G. Sutherland, DO. Fort Worth, Tex: Sutherland Cranial Teaching Foundation; 1998.
Rogers FJ, D'Alonzo GE Jr, Glover JC, Korr IM, Osborn GG, Patterson MM, et al. Proposed tenets of osteopathic medicine and principles for patient care. J Am Osteopath Assoc. 2002;102:63–65. Available at: Accessed May 25, 2005.
Still AT. The Philosophy and Mechanical Principles of Osteopathy. Kansas City, Mo: Hudson-Kimberly Publication Co; 1902. Available at: Accessed February 7, 2006.