In accordance with the fair use exception to copyright for teaching purposes, I am engaging with it here to bring out points that are directly relevant educationally to stakeholders in the massage community, and to provide links to clarify specialized knowledge as needed.
Where did the idea that massage promotes metastasis, and therefore, we shouldn't offer massage to patients living with cancer, come from?
What is the current best practices recommendation for massaging someone with a history of cancer, and on what basis is that best practices recommendation formed?
Why is the idea that we shouldn't massage someone with a history of cancer, because it might promote metastasis, so persistent in the face of what we actually know?
We're going to discuss meaning a great deal in this post, so it's useful for understanding if we're all on the same page about that.
That way, when we're trying to navigate among terms, concepts, and referents in discussing this article to get at what it all means, we have the advantage of a shared vocabulary and approach to help us work together with each other.
ANNALS of SURGERY VOL. LXXV FEBRUARY, 1922 No. 2
THE RELATIONSHIP OF MASSAGE TO METASTASIS IN MALIGNANT TUMORS*
* From Columbia University, Institute of Cancer Research, F. C. Wood, M.D., Director, New York.
BY LEILA CHARLTON KNOX, M.D. OF NEW YORK, N. Y.
CLINICAL
One of the most important aspects of the practical study of tumors is the determination of the anatomical and biological conditions which facilitate or prevent metastases. These phenomena have long been studied in man without much definite information having been collected. About all we know is that, in general, carcinomata are prone to metastasize through the lymph-channels and sarcomata through the blood-vessels, and that metastases do not always follow in the direction of flow of the current, but in a certain proportion of instances the emboli travel by a retrograde course or the tumors progress by direct extension, the so-called permeation of the lymphatics.
What are the important points that Knox is making here?
Structually, what part of the research article that you would expect to see here is missing? What might be a reason that this research review article does not have the structure that you would normally expect?
It has been generally assumed, without direct experimental proof, that a number of the factors favoring the production of metastasis are purely physical, for instance, the size and connective-tissue relations of the tumor cells, the pulsating or contractile movements of the organs in which they are implanted, the number of the blood-vessels and the thickness of their walls, with consequent susceptibility to trauma by pressure or massage. On the other hand, accurate clinical study and experimental work as well have caused the occult and convenient theories of tissue predispositions and specific "immunity" of organs to assume a less creditable position than they formerly held, and quite properly, for until it is shown that simple mechanical and biological facts do not account for the peculiarities in the occurrence and distribution of metastases vague theories should not be substituted.
What exactly is she saying here about material mechanical and biological facts?
Is she arguing from a realist position or not? How do you know?
At this point, unless we have some specific knowledge of particular claims about metastasis made at this time in history, it's unclear exactly what she means by "occult and convenient theories of tissue predispositions and specific "immunity" of organs". At a very general level, however, what does she appear to be talking about? Remember this point--she'll clarify it later in her discussion.
Where does she use Occam's Razor in her argument here, and why?
The importance of vascular embolism in the spread of tumors has long held an unchallenged position in instances in which the pulmonary veins were known to be grossly involved and the arterial circulation in that way obviously open to a supply of tumor cells. A valuable contribution on this phase of the subject was made when M. B. Schmidt showed that not infrequently the tumor cells readily pass the pulmonary capillaries and are deposited elsewhere before macroscopic growth appears in the lung. In a study of forty-one cases of primary abdominal carcinomata without extensive gross metastases, the lungs of fifteen were found to contain microscopic arterial emboli of tumor cells, showing that once the cells gain entrance to the blood stream they may reach any portion of the body and are not necessarily always retained or destroyed within the lungs. This may, however, be their fate, for Schmidt found many small thrombosed vessels with degenerating tumor cells entangled in the clot. These phenomena have been duplicated experimentally by Takahashi and by Iwasaki, both of whom injected tumor cells into the blood stream of animals. Both these authors have well shown that although embolic cells are frequently treated as foreign bodies and phagocyted, many, on the contrary, survive the adverse conditions, and invade and replace the vascular endothelium or undergo mitosis even before they become implanted on the vessel wall.
What does she mean by "the pulmonary veins were known to be grossly involved and the arterial circulation in that way obviously open to a supply of tumor cells"? Describe the relationship between pulmonary veins and arterial circulation that she is referring to.
What is M.B. Schmidt's valuable contribution on the subject, and why is it so valuable?
What did Takahashi and Iwasaki show, and what does it mean?
Notice the unusual term "phagocyted"; it means the same thing as "phagocytosed", which is the term you see more often nowadays, as in this example from Wikipedia:
Phagocytosis (from Ancient Greek φαγεῖν (phagein) , meaning "to devour", κύτος, (kytos) , meaning "cell", and -osis, meaning "process") is the cellular process of engulfing solid particles by the cell membrane to form an internal phagosome by phagocytes and protists...Bacteria, dead tissue cells, and small mineral particles are all examples of objects that may be phagocytosed.
For purely physical reasons, however, we must suppose that cells of small size accomplish this more readily than do larger ones, and experience shows that the large spindle and giant cells, or those distended with mucus as many from the gastro-intestinal tumors are, do not find their way through the pulmonary capillaries except in small numbers. Whether or not the ameboid motion of the cells is a factor in facilitating this is not known. That such motion exists was shown by Carmalt in 1872 and later by Lambert and Haynes.
What are two possible physical explanations that could account for smaller cells establishing metastases beyond the lungs more successfully than larger cells do?
The localization and growth of embolic tumor cells within the dilated capillaries of the bone-marrow have been explained as due to the physiological hyperaemia which is practically constant in that situation. Slowing of the blood current and adhesion of the tumor cells to the endothelium seems to produce circumstances favorable to the growth of such emboli.
Is she saying that bone marrow is particularly susceptible to metastasis from tumors that originated elsewhere in the body? Why or why not?
Lymphatic embolism, either direct or retrograde, has also been unquestionably a frequent and important means of tumor dissemination; but the status of lymphatic permeation, although very convincingly demonstrated by Handley in certain cases, is perhaps a less constant phenomenon than he at first believed.
Notice the British spelling of "tumour", and beware the typo in "pulmonary"--this image was probably created by a non-native English speaker, but is factually correct with regard to the referent, although they misspelled the term.
Tell me what we're looking at here--what structures and processes do you see?
The process, as Handley described it, consists in the proliferation of tumor cells which, having gained access to the superficial lymphatics in the proximity of the tumor, continue to grow within them and to extend through their branches, often appearing in the skin, where they form cutaneous nodules. Secondarily, there often occurs an inflammatory fibrosis and obliteration of portions of the lymph-channel, a process analogous to the thrombosis which is common in invaded vascular channels. Handley studied especially breast carcinomata and melanomata--two of the tumors which most frequently exhibit regional cutaneous recurrences and extensions; and it is on the basis of his evidence that one may perhaps regard some of the recurrences in surgical scars as accidental occurrences due to the proliferation of tumor cells present in the lymphatics prior to the incision, though possibly accelerated in growth by the increased vascularity of the wound area. Probably, however, a majority of the local recurrences are due to a mechanical transplantation from an infected to a non-infected field.
What metastases do breast cancer and melanoma frequently exhibit?
What is the connection between metastasis and surgical scars?
What are 2 possible mechanisms for their occurrence?
Notice the use of "infected" to refer to cancer cells here.
FIG. 1.-Metastasis of breast carcinoma in pectoralis muscle following massage in man.
What different kinds of cells and other material physical things do you see there?
What indicates that you are looking at muscle cells?
What, particularly, indicates the pectoralis muscle?
In the case of the melanomata this mechanical transfer by operation is not a completely adequate explanation, for the nodules are often found far from the region of the incision, and, indeed, are frequently seen in unoperated cases, giving a striking illustration of the fact that tumor cells, especially those of moderate size, have the capacity to invade the cutaneous lymphatics for long distances and to spread against the direction of flow of the lymph. When the vessel is large, as in the abdominal trunks, permeation would not be expected to occur, and it is probable that extensive backward spread of tumor cells is due to a combination of several processes. Vogel has described two such cases, one a carcinoma of the gall-bladder, which extended into the left kidney hilus [RST: This is an old name; it means the same thing as "hilum"] and there perfectly outlined the perivascular lymphatics of that region; the other a pancreatic carcinoma which extended directly along the mesenteric and aortic trunks into these nodes.
What are two explanations that Knox provides for why surgery is not the only thing that accounts for metastasis?
Vogel described two cases where the spread was far away, and it travelled retrograde to the direction of lymphatic flow.
In what direction did the gall bladder tumor have to travel to reach the hilum of the kidney?
How far did it have to travel?
What did it have to pass through to get there?
Where have we seen a hilum of an organ before in this discussion? What do they have in common with each other?
It is well known also that oesophageal carcinomata are prone to spread longitudinally along the lymphatics of the submucosa and that small secondary nodules often appear considerably below and separated from the oldest portion of the tumor by uninvolved mucosa. It used to be the fashion to describe these as implantation growths, but this view is now generally abandoned. Zahn has even described one situated as high as the tracheal bifurcation, but associated with three small carcinomatous nodules beneath the mucosa on the gastric side of the cardia. This occurred also in an oesophageal carcinoma with tracheal fistula (St. Luke's Hospital, No. 1309), the secondary nodule being 4 cm. from the main mass of the neoplasm. The mechanism of the formation of these multiple nodules, as well as of multiple papillary gastric carcinomata, has not been shown to be necessarily a process of permeation, although theoretically this would readily explain their occurrence.
"Oesophageal" is an older, Latin/Greek-based, spelling for "esophageal".
Why does the esophagus have carcinomata?
If you're a tumor cell, how far away is 4 cm in proportion to your size?
At the time Knox wrote this, did they know the mechanism by which these secondary metatastic tumors got away from the primary tumors?
On the other hand, emboli are, no doubt, prevented from growing by the mechanical activity of muscles and muscular organs. Metastases are singularly rare in the cardiac muscle, being practically never seen except in the case of extremely vascular tumors with scanty stroma from which the loosened cells spread and overwhelm the whole arterial circulation with countless emboli. The aortic valves must also act to deflect emboli from the mouths of the coronary arteries. Benecke, studying the invasion of the walls of vessels from carcinomatous thrombi, believed that the infrequency of metastasis in the muscular coat was due to the physiological tonus of the muscle. This is a reasonable conclusion, and the principle holds good for striated muscle as well. Metastases into the latter are extremely rare, due in part to the contractility of the fibres, a condition which offers considerable resistance. The fact that lymphatics are lacking within striated muscle bundles is certainly not the reason for the rarity of metastases, for if the emboli were lymphatic, not vascular, and if the motion did not play so large a part in preventing their growth, they should be present in tendons where lymphatics are very numerous. Direct permeation of both striated and unstriated muscle is, however, frequently seen, showing that the soil is not unsuitable provided the cells once gain access to the tissue.
What protects muscles, and muscular organs like the heart, against metastasis?
Does this protection always work perfectly?
How do we know that it's not just the lack of lymphatic vessels in skeletal muscle that protects them?
Normal peritoneum has been shown by Jones and Rous to possess a high resistance to the implantation of tumor cells, but when it was injured by a mechanical irritant, tumor growth was at once made possible. This offers an explanation for the frequently observed fact that carcinoma of the stomach often metastasizes into the ovary, producing the so-called Krukenberg tumor of the latter organ, without any intermediary deposits on the peritoneal surface. That such deposits will eventually occur in late stages of carcinomatosis is, of course, well known, but it is probable that the constant motion of the opposed serous surfaces is an important factor in destroying whatever cells may find their way to it. It has long been recognized that it is the gelatinous carcinomata of the ovary, stomach, and intestine that are most widely distributed in the abdominal cavity. This is, of course, as would be expected, for the bulk and consistency of the mucus make it in a sense a foreign body and must keep the cells in contact with the peritoneum and also irritate it, and so indirectly facilitate adhesion and ultimate vascularization, whereas a few free cells would be more likely to be destroyed.
Is peritoneal tissue normally relatively vulnerable or relatively resistant to metastasis?
What is a proposed mechanism that could account for that tendency?
What can change that tendency?
Post-operative human results have occasionally shown the remarkable persistence which cells from malignant tumors may exhibit. During the quiescent period the cells are probably most frequently inactive in the lymph-nodes, occasionally for as long as ten to twenty years. Late recurrences usually appear first in the nodes to which drainage was directed, and if the morphology of the tumor is that of the primary growth there can be no question that these are really late recurrences from previous metastatically deposited cells. For example, small groups of living cells from a gastric carcinoma have been observed by Rohdenburg in the liver and omentum ten years after the operation on the primary tumor, with a clinical cure. Such a case may be the result, like many of the very late cutaneous recurrences from breast tumors, of slow permeation along the efferents of a node or even from a small group of cells for years quiescent in the tissue spaces.
How long after a tumor is removed can a recurrence or metastasis happen?
How can it do that, since the tumor was removed?
How can they tell it was a recurrence of the old cancer, rather than the development of a brand-new different cancer?
A spindle-cell sarcoma has occasionally recurred after a very long period. A tumor of this type, originating in the cervical fascia, has been seen by the writer recurring as a mass the size of a walnut twelve years after the first operation, the patient being free from symptoms during the greater part of the period. Such a phenomenon is difficult to explain, since only rarely does this type of sarcoma metastasize into the lymphnodes, and there form a focus for new growth. As this recurrence was in the centre of a large skin graft made at the first operation, it seems more probable that it was a recurrence in situ of very slowly growing cells situated in the deep fascia below the graft.
What happened in this case?
Was it what you would usually expect?
How does Knox explain it?
Other rare and late metastases which give no hint as to the mechanism of their localization and long course are cited by Schmidt and Goldmann, who observed a cerebral metastasis four years after a rectal carcinoma with no local or lymphatic return. Schmidt believes that such tumors are derived from latent intravascular cell groups in the pulmonary vessels. Another still more remarkable observation is that of Crouzon, who described a cerebral metastasis eighteen to twenty years after operation on a bilateral breast carcinoma. Gathmann and Schmidt have each observed cases in which four years after operation on similar tumors, with apparent cure, widespread skeletal metastases appeared. In such a case a general emboli distribution of cells by the blood into the capillaries of the myeloid canals must have occurred fairly early, and the growth processes have been very slow.
What happened in these cases?
Why are they so surprising?
How does Knox explain these events?
The frequency of skeletal metastases is so much greater than can possibly be demonstrated by clinical or röntgenological means until a very advanced stage that the high percentage of such growths is not often appreciated. Although the vascularity of the marrow is great, the stroma reaction may be here as marked as elsewhere and the metastasis of a scirrhous breast carcinoma be only a sclerotic nodule of the same appearance as the primary growth. When the bones are noticeably eroded or spontaneous fractures occur the process is far advanced and statistics drawn from such cases only give misleading data as to the frequency of the process.
"Röntgenological" is an old-fashioned word for "x-ray", because in 1895 the German physicist Wilhem Röntgen was the first person to discover x-rays in nature.
Is the skeleton particularly resistant to metastasis?
What does that translate to in clinical observations?
This view of the localization of metastases has not, however, been universally accepted, and many convenient hypotheses have had to give way to the increasing weight of pathological and experimental evidence. The theory of the specific adaptation of some tissues, as the liver, for neoplastic cells, and the relative immunity of others, as the brain, has been prevalent in the literature for many years. Virchow stated that organs in which carcinoma is never primary do not serve as a site for metastases. Recent observation has shown these conclusions to be wholly incorrect, as the brain is the site of secondary metastatic carcinomatous deposits in at least 0.3 per cent. of all autopsies (Krasting). Adherents to this theory point out, however, that some types of tumors have distinctly greater capacity to metastasize into certain organs than others, since not all tumor cells readily grow within the bones, but others very commonly do so, as those of the breast, thyroid, adrenal and ovary. Von Recklinghausen even advanced the idea that breast and prostatic carcinomata were apt to form metastases in similar regions because they were in a sense analogous organs, each being a part of the genital system. Bamberger and Paltauf believed that there was some specific organ susceptibility, and offer as evidence the fact that not only the small-cell carcinomata of the prostate metastasized to the bones, but the large-cell medullary carcinomata of the gland behaved in the same way.
Remember earlier, when she mentioned "occult and convenient theories of tissue predispositions and specific "immunity" of organs"?
What are some of those theories?
Rudolph Carl Virchow is called the "father of modern pathology", because of all the discoveries and knowledge contributions he made. Was he correct about metastasis sites? Why or why not?
When it comes to the concepts and terms of a big name, versus material physical referents, which do we believe, and why?
What is the other choice of belief called? Is it a logical fallacy?
The spleen also has been called "immune" to metastases by various writers because gross tumors in it are not especially frequent and microscopic ones often escape detection; but late stages of breast carcinoma are not infrequently accompanied by palpable enlargement of that organ due to a diffuse carcinomatosis, while E. E. Goldmann demonstrated that animal tumors inoculated into the spleen grow as readily there as elsewhere. While the vascularity of the organ exposes it to numerous emboli, yet as it possesses no efferent lymphatics and is in practically constant motion, embolic cells can not proliferate within it with as much facility as in some other organs. The great vascularity of the adrenals, as well as their protected position and absence of intrinsic motion, provides a suitable location for the secondary growths so often found in them. It is possible that the wide vascular sinuses of the pituitary, which resemble those in the adrenal, facilitate the location of metastatic tumors in this organ as well.
Again, this is an example of the "occult and convenient theories of tissue predispositions and specific "immunity" of organs" she referred to earlier.
Is the spleen immune to metastases? What does the evidence say?
How about the immunity or vulnerability of the adrenal glands and the pituitary? What might explain their situations?
External mechanical influences have for some years been recognized as an important factor in dealing with any malignant tumor. Gerster, in 1885, discussed the apparent breakdown of the forces which keep a malignant tumor for a time localized, and believed them to be largely mechanical. He pointed out the need, for example, of high amputation, not alone for the purpose of obtaining an uninfected field, but in order that the neoplasm itself should be free from manipulations, and so facilitate cellular dissemination. This writer further compared the results of malignant tumor massage to that which is sometimes effected by massaging a sprained joint--a process which certainly disseminates inflammatory exudate rapidly and widely. The effect of pressure, rubbing, or active massage on the tumor has been frequently observed in human beings as the result of osteopathic or massage treatment of malignant tumors, and many examples have been seen in recent years of wide dissemination of a primary growth very effectively accomplished by this procedure.
What were the two reasons Gerster advocated amputation in the case of cancer?
What is the analogy he drew with massage?
Does the evidence back up that analogy?
Such an instance has recently occurred at St. Luke's Hospital, and furnishes one of the rare instances in which extensive gross metastatic invasion of muscle could be observed. The patient stated that massage treatment had been regularly employed for some time previous to admission. When the breast tumor was examined there was found a fairly extensive area of eczema overlying a large very hard tumor which was fixed to the pectoralis fascia. Small white tumor nodules were scattered widely throughout the muscles, even invading the individual fibres. (See Fig. 1.)
What was unusual about this patient's case?
Does the evidence back up Knox's claim that massage accomplished this metastasis?
EXPERIMENTAL
While, therefore, much interesting and important information has thus been obtained by clinical, operative, and post-mortem studies, the number of cases is too small to enable final conclusions to be drawn.
Is this consistent with everything that Knox said earlier?
The determination of the weight of a factor in producing metastases can not be judged from single experiences on man, as it is impossible to eliminate conflicting conditions. Only by the use of a homogeneous material in which the size of the cells, their histological and biological qualities, and the vascularity of the surrounding tissue, etc., are practically constant can valid conclusions be drawn, and this elimination of variables is possible to obtain only by the use of animal tumors of a long transplanted strain, so that the morphological and biological characters are well known. The possibility of obtaining by inoculation in a single day more tumors than any one surgeon observes in a lifetime of active practice also eliminates the occurrence of errors due to random sampling affecting the result--a condition never possible in human material. For example, following the discussion produced by the publication from the Crocker Fund of a paper on the results of the incision of tumors, many surgeons brought forward individual instances which they thought were of value in proving the danger of diagnostic incision, not realizing that from a statistical aspect a single instance is of no value. Even from a basis of reasoning, so remote from the complexities of mathematics as what is ordinarily termed common sense, many of those who cited these single instances were unable to deny on cross examination that pre-operative manipulation by the patient, or that dragging or pressure on the tumor during the operation might have equally well caused the evident dispersal of tumor particles, as evinced by the subsequent course of events.
What is she saying here about individual observations? About confounds?
It was not until Tyzzer, in 1913, demonstrated that gentle massage of a transplanted carcinoma in a mouse greatly increased the number of metastases observed in the lung that definite evidence was brought forward to substantiate these occasional clinical observations. The number of Tyzzer's experiments was small, and he obtained results with only one tumor, a highly malignant neoplasm of the Japanese waltzing mouse. With the Ehrlich mouse tumor No. 11 and the Jensen rat sarcoma he was unable to obtain metastases artificially by massage of the implanted tumors. Rous states that his experiments in massaging rats with adenocarcinoma resulted in the death of all the animals, but did not cause more than the ordinary number of metastases.
What did Tyzzer's and Rous' studies demonstrate? Were they definitive?
Several recent clinical experiences of the writer in which after the removal of a very small primary tumor of the breast by perfect surgical technic (no involvement of the axillary nodes being present), the patient died of generalized carcinoma in a short period thereafter, pointed to the desirability of further extension of Tyzzer's experimental results. We will say, in passing, that in one of these human tumors which had been somewhat vigorously palpated by a number of physicians, a small hemorrhagic area was found in the middle of the growth, and in the vessels surrounding the tumor numerous emboli of cancer cells were present.
What is the clinical relevance of Tyzzer's and Rous' studies?
What did the physical evidence show in one case?
What does this table tell us?
A considerable variety of transplantable carcinomata or sarcomata of the mouse and rat were used for the experiment. Some of these tumors under normal conditions, especially the spindle-cell sarcomata, do not produce spontaneous metastases in the animals in any number. Others, especially the carcinomata, are apt to metastasize early.
What were they comparing in this experiment? What is the internal validity likely to be?
The following tumor strains were employed: Crocker Fund mouse carcinomata, Nos. 5, 11, and 48, the Borrel mouse carcinoma, the Ehrlich mouse carcinoma and the Flexner rat carcinoma; Crocker Fund mouse sarcomata Nos. 7 and 180, and the Ehrlich mouse sarcoma.
The method employed was as follows, with the exception of the two series described separately below: The animals were inoculated subcutaneously in the inguinal or axillary region with a tumor particle weighing about 0.003 gm. When the tumor reached a diameter of approximately 5 mm. it was gently massaged for half a minute every other day for about two weeks. The tumor was then removed by operation to prevent further metastasis, in order to obviate the difficulty of having to decide whether embolic masses in the vessels of the lung were really growing tumor particles, or only recently deposited emboli which might ultimately die without giving rise to a tumor nodule. In the final results only those masses are considered as true metastases in which the vessel wall was invaded, a separate column giving the number of instances in which emboli were found in the lumen of the pulmonary vessels.
What were they studying in this experiment? What did the method provide?
In one series, mouse carcinoma No. 11, the experiment was repeated, and the technic was varied as follows: The tumor was massaged vigorously for one minute on each of two consecutive days. After the second massage treatment all tumors, both controls and those which had been manipulated, were excised and the animals all killed twenty-seven days later. (No. 11, Series II.)
In order to check the results a third series of mice were inoculated two years after the first lot with the Crocker Fund mouse sarcoma No. 180. The mice were all of the same breed, and the conditions were kept as nearly as possible the same as in the preceding experiments. This time the mice were inoculated in the right axillary region, and as soon as the tumors were easily palpable the massage was begun on one-half of the mice, the others being reserved for controls. As before, the massage was carried out for thirty seconds on alternate days for about two weeks. The tumors were then very large, and many of the mice died at this time. In those surviving the tumors involved the thoracic wall too extensively to make removal feasible, so the aninmals were, therefore, allowed to die and then were autopsied. The results of this experiment are recorded as No. 180, Series II.
What does the variation in the method mean for the validity of the study?
In all the series the lungs were carefully removed, distended through the trachea with 4 per cent. formaldehyde, and hardened, and six sections from each animal were examined. Much difficulty was experienced in determining microscopically whether a mass of cells in a vessel should be considered as a true metastasis or merely an embolus. When emboli cease to be capable of forming a tumor we do not know. Careful morphological studies have been made by Takihashi and others to determine the early degenerative and proliferative changes which occur in emboli of tumor cells, but the two processes are frequently coincident, and, as many groups showed no evidence of either process even after being in the vessels many days, we cannot be too cautious in deciding whether a death point has been reached. Such emboli were found, for example, in specimens 9515, 6363, 6359, thirty-two, twenty-seven, and twenty-six days after removal of the primary tumor and no local recurrence at the site of inoculation had taken place from which such emboli could have been derived. Presumably such cells are dead; hence these groups have been called emboli, not metastases. In one sense, however, they are just as important as a growing lung tumor in showing that emboli of cancer cells can be set free in the blood stream by massaging a tumor, and any embolus in its early stage carries the potentiality of metastasis formation.
What is the meaning of the different kinds of things they found in the animal's lungs?
What do they tell us about massaging a tumor?
How meaningful is that for the kind of massage that we would do for someone living with cancer?
Only six sections of the lungs were studied, for it was found after a few complete sets of serial sections had been examined that the gain in number of emboli or small tumors discovered was unimportant.
This means that the distribution of emboli and small tumors was relatively uniform throughout the lungs they studied, and they were able to work with a smaller data set than they had originally thought they would need.
The tabulated records of the experiments are self-explanatory and need no further elucidation.
No, I disagree. Remember, a lot of the statistical tests that we presently use to interpret studies were being developed at about the same time as Knox wrote this article.
While I don't fault her for not using something that she didn't have access to in her time, it remains true that without those tools to interpret her results with, we necessarily have to consider them weaker than we would similar results that had stood up to robust statistical testing.
The point of these tests is to make sure that we are, in reality, seeing what we think we see. Without the assurance provided by those tests, such as tests of statistical significance, confidence level, and the like, we just cannot consider these results as explanatory and self-evident as she considers them.
DISCUSSION
Examination of the chart (Fig. 2) shows that, in general, with nine tumor strains, there was a more or less distinct increase after massage in the number of embolic particles in the lungs, the increase varying from 1 to 37 per cent.
FIG. 2.-Chart showing percentage of emboli (hatched areas) and of metastases (solid areas), and their relative numbers in controls and massaged animals. In each case the column at the right represents the massaged animals, that at the left, the controls.
Tell me, what does this bar mean?
What does this one mean?
What does this one mean?
What does this one mean?
What does this one mean?
Can you find any cases where the control animals had more emboli or metastases than the study animals did? How does Knox explain these unexpected results?
The actual percentages can be considered of little importance, and it is even surprising to find that the tendency is so general. With the carcinomata the results are in many cases unequivocal; for example, the Ehrlich carcinoma, at the time showing no regression and 75 per cent. of takes, in other words, in its positive phase, formed more than twice as many metastases after massage as without it. A similar condition obtained with the Borrel carcinoma, at that time spontaneously regressing in 50 per cent. of inoculations, but still showing numerous metastases after massage. The ratio is probably artificially high as the number of control animals which survived was very small.
"The actual percentages can be considered of little importance"? Well, no; they are vitally important to the question we are trying to answer.
You can see here a cultural shift in how science used to be interpreted from how it now is.
The emboli are found in both lymph-and blood-vessels, frequently in both locations in the same lung. The perivascular space can frequently be seen filled with cells from which the parenchyma is invaded, but the primary process is evidently in the vessels, as it is seen in all stages within them. The lymphatic system of the mouse being developed to a much less extent than in man, it may also be expected to show relatively less tumor involvement. One reason for this may very probably be, as is pointed out by Murray, that the lymphatics are so delicate and quickly obscured by an inflammatory reaction that metastatic particles apparently freely growing in the tissues may have originated from an embolus either in a lymph-vessel or the nodal capsule. In these studies, however, there is seldom room for doubt that the emboli are vascular in the great majority of cases. Multiple emboli nearly filling both large and small vessels of a lobe are occasionally found, in the controls as well as in the massaged animals, but cell groups are much more frequent in the treated ones.
The illustration (Fig. 3) is from a massaged animal which died twenty-four days after inoculation. Both proliferation and degeneration are seen, and most of the stages described by Takahashi may be found in some area.
FIG. 3.-Multiple emboli of tumor cells in pulmonary vessels of a massaged mouse tumor.
Which things in this slide are the vessels? Which are the emboli?
How can you tell the difference?
Fig. 4 (No. 18363) and Fig. 5. (No. 18319) each show a small embolus which is certainly undergoing dissolution, as the surrounding lung is well preserved, but the tumor cells stain poorly. The outlines of cell walls and the nuclear membrane are indistinct, and the cytoplasm granular.
FIG. 4.-Degenerative changes in cells of a tumor embolus in pulmonary vessels.
Can you see the embolus clearly?
What is different about the pulmonary vessel the tumor embolus is in, compared to the other blood vessels in this slide?
FIG. 5.-Embolus of tumor cells in pulmonary vessel. Embolic cells are undergoing early degenerative changes. The lung tissue is well preserved.
What is the meaning of her explanation here?
On the other hand, occasionally even small emboli may be seen in which the actively invasive tendency of the tumor cells is plainly demonstrated.
Fig. 6 (No. 18322) shows a small embolus which has apparently lifted up the endothelium from the vessel wall and so given itself a fibrous surface upon which to obtain a footing.
FIG. 6.--Endothelium of vessel containing embolic tumor cells stripped from wall. Early stage of attempt to localize.
Tell me, what do you see here?
What do you see here?
What looks to you like an "attempt to localize"?
Another phase of apparently successful implantation is shown in Fig. 7 (No. 18343), where a number of well preserved tumor cells are growing in direct continuity with the endothelium.
FIG. 7.--Later stage in implantation of embolic tumor cells. A few have replaced the endothelium.
What do you see here? Where do you think the emboli have replaced the endothelium?
Figs. 8 and 9 show two small pulmonary emboli from a case of carcinoma of the stomach in a human being. In Fig. 8 there is no adhesion of the embolus to the endothelium, although nearly a third of the mass is made up of mucus produced by the epithelial cells;
FIG. 8.--Small embolus from case of carcinoma of stomach in man, showing invasion of pulmonary vessels. Nuclei surround a central mass of mucus.
Where do you see the vessel here? The nuclei? The mucus?
in Fig. 9 one cell only appears to have invaded the endothelium.
FIG. 9.--Beginning adhesion of tumor cells to endothelium in pulmonary capillary from case of carcinoma of stomach in man.
What structures and processes do you see here?
Another lung furnishes a picture of a more advanced stage of invasion, Fig. 10 (No. 18384). The endothelium can no longer be distinguished, as practically the whole circumference of the muscularis is lined with the tumor cells, and the lumen is almost filled with a carcinomatous embolus in which early degenerative or thrombotic changes have occurred [sic]. Similiar parietal thrombi were examined by Schiedat throughout their length and were found to extend for some distance along the surface of the wall and eventually to break through it.
FIG. 10.-Embolic tumor cells replacing endothelium of pulmonary vessel.
What do you see happening here?
The same process is illustrated in Fig. 11(a) where a large vascular sinus is shown containing many embolic cells from a bone sarcoma in man. The nuclei already show pycnosis, swelling, agglutination by fibrin, and are being surrounded by polymorphonuclear and lymphocytic cells. In (b) is another large blood-vessel from the same tumor with a giant cell among the red blood-cells. This, although of the "endothelial" type and not itself likely to invade other tissues, is of interest in showing that all types of cells may gain access to the blood stream.
FIG. 11.--(a) Embolus from bone sarcoma in man. Cells are of several types and illustrate early degenerative changes and phagocytosis. (b) Giant cell in blood-vessel in bone sarcoma.
That most of the small vascular emboli are derived from larger ones in the main vessel, and not from primary lymphatic involvement, is seen from such an extensive embolus as appears in Fig. 12 (No. 18343), a fairly frequent picture. A very large mass is found in one of the main pulmonary veins and many of its cells are degenerating, the nuclei are pycnotic, and some of the cells have been phagocyted.
FIG. 12--Larger tumor embolus in pulmonary artery.
Figure 13 shows a smaller group of cells surrounded by a thrombotic mass containing many polymorphonuclears, as would be expected in such a situation.
FIG. 13.-Polymorphonuclear cells surrounding a few embolic tumor cells; probably an early stage of thrombus formation.
It may only occasionally be seen that the cells break into the lymphatics and there grow freely, but it is shown in Fig. 14(No. 18307).
FIG. 14--Large embolus of tumor cells in perivascular lymph space; probably an extension from a vascular thrombus.
Not infrequently, as in tissues from human beings with tumors, multiple emboli are found in the vessels which may be densely crowded with cells, most of them small, and though hyperchromatic only with difficulty to be distinguished from lymphocytes--in fact, to make a differential diagnosis is very hazardous in spite of the absence of inflammation elsewhere in the section (Fig. 15).
FIG. 15.--Multiple emboli of small cells in pulmonary vessels, possibly tumor cells, but resembling lymphocytes.
Inspection of Table III shows that among the controls metastases and emboli were coincident only four times in twenty-one animals, or in 19 per cent., while among the massaged this occurred nine times in twenty-five animals, or in 36 per cent. of the cases. The average duration of life was the same in each case. There seems little doubt but that the massage has effected a wider distribution of the tumor even though it is impossible to decide in all the cases just what the ultimate fate of the scattered cells may be, whether they will die or succeed in establishing themselves in the vessel wall.
TABLE III
Crocker Fund No. 180
Total number metastases in controls = 23
Total number emboli in controls = 24
Total number metastases in massaged = 41
Total number emboli in massaged = 38
On the whole, the polyhedral-cell sarcomata (Crocker Fund No. 180 and Ehrlich mouse sarcoma) seemed just as apt to produce metastases as the carcinomata. In the spindle-cell tumors, metastases are apt to be scanty. This may be explained upon mechanical grounds, from the fact that the cells of most fibro-or spindle-cell sarcomata are more definitely intermingled with and attached to the surrounding connective tissue than in the case of the free-lying cells of the carcinomata. This sustains the view that anatomical relationships of the cells are important in determining metastases.
It would be incorrect, however, to assume that the mechanical factor is of so great importance in determining the ultimate production of a growing tumor as distinct from an embolus as the biological characteristics of the tumor itself. Examination of the chart shows that the correlation between the percentages of total metastases in controls and massaged animals is negative, that is, that those tumors which metastasize spontaneously in a high percentage do not show as great an increase after massage as do those in which spontaneous metastasis is low. For example, the Crocker Fund carcinoma No. 5 shows a smaller increase in its percentage of metastases than does the Flexner rat carcinoma. The same is true of the Ehrlich sarcoma, a strain in which Haaland also found a high percentage of spontaneous metastases; in fact, this writer reports approximately the same percentage of metastases in the twenty-three mice which he observed (60 per cent.) as were seen in the twenty-six animals used in this experiment (58 per cent.).
What is she claiming in her discussion here?
In these freely metastasizing highly vascular tumors the organism is evidently flooded with emboli before manipulation, and hence many tumor cells may be found in the pulmonary capillaries at all times. Less difference, therefore, can be detected following the massage.
What is the effect of massage in these cases, and why?
There can be no question under these circumstances that concomitant immunity has any influence on the prevention of appearance or growth of the metastases.
Is it clear what she means here?
CONCLUSIONS
1. Study of human material in many ways suggests, but does not finally prove, the importance of massage as a means of inducing metastasis of tumor cells. In animals, on the contrary, very gentle massage for a total period of from two to five minutes, distributed over a number of days, has been shown to set free numerous particles of tumor which form emboli in the lungs.
Is this the correct approach to take in studying the question?
Does the study show what she states that it shows?
2. Such emboli produce metastatic tumors in a variable proportion of instances, depending upon the growth activities of the tumor. Tumors which take in low percentages when implanted in the subcutaneous connective tissues give much fewer metastases than those of high virulence.
Is this consistent with what you would expect to see?
3. Carcinomata and also sarcomata of the loose polyhedral-cell type are easily generalized, but sarcomata of the compact spindle-cell variety are not influenced.
How do we know this from the information in her article?
4. The importance of avoiding diagnostic or operative manipulation of a tumor in man is obvious.
I agree it's a good idea in general. Does the evidence show that it's as obvious as Knox says it is?
No, it cannot. Massage of a solid tumor site should be avoided, but there is more to a person than a tumor site.
An old myth warned that massage could, by raising general circulation, promote metastasis since tumor cells travel through blood and lymph channels. We now recognize that movement and exercise raise circulation much more than a brief massage can, and that routine increases in circulation occur many times daily in response to metabolic demands of our tissues. In fact, physical activity usually is encouraged in people with cancer; there is no reason to discourage massage or some form of skilled touch. Massage is practiced widely at the Dana-Farber Cancer Institute, Memorial Sloan-Kettering, and growing numbers of hospitals around the country. Metastasis is not a concern; instead, patients and researchers report countless benefits.
BIBLIOGRAPHY
Bamberger and Paltauf: Wein klin. Wchnschr., 1899, vol. xii, p. 1100.
Benecke: Beitr. z. path. Anat. u. z. allg Path., 1890, vol. vii, p. 95.
Carmalt: Virchow's Arch. f. path. Anat., 1872, vol. lv, p. 481.
Crouzon: Bull. et mém. Soc. méd. d. hôp. de Par., 1920, vol. xlvi, p. 500.
Ernst: Beitr. z. Path. Anat., 1905, Supp., vol. vii, p. 29.
Ewing: Neoplastic Diseases, Philadelphia, 1920.
Gathmann: Ein Fall von allgeimeinen Karzinome des Knochensystems, Leipzig, 1902.
Gerster: New York M. J., 1885, vol. xli, p. 233.
Goldmann: Bruns Beitr. z. klin. Chir, 1897, vol. xviii, p 595.
Goldmann: Bruns Beitr. z. klin. Chir., 1911, vol. cxxii, p. 1.
Haaland: Berl. klin. Wchnschr., 1906, vol. xxxiv, p. 1126.
Handley: Arch. Radiol. and Electroth., 1919, vol. xxiv, p. 137.
Handley: Cancer of the Breast and Its Operative Treatment. London, 1906.
Handley: Lancet, 1907, vol. i, p. 927.
Iwasaki: J. Path. and Bacteriol., 1915-16, vol. xx, p. 85.
Jones and Rous: J. Exper. M., 1914, vol xx, p. 404.
Krasting: Ztschr. f. Krebsforsch., 1906, vol. iv, p. 315.
Lambert and Haynes: J. A. M. A., 1911, vol. vi, p. 791.
Murray: Seventh Scientific Report, Imperial Cancer Research Fund, London, 1921, p. 63.
Poirier et Charpy: Traite D'Anatomie Humaine, Paris, 1909, Tome II.
Rohdenburg: Proc. New York Path. Soc., 1920, n. s., vol. xx, p. 141.
Rous: J. A. M. A., 1913, vol. lx, p. 2021.
Sabin: The Harvey Lectures, 1915-16, Series xi, p. 124.
Schiedat: Ueber den Untergang maligner Geschwulstmetastasen in der Lung, Leber, und Lymphdrusen, Inaug.-Diss., Königsberg, 1908.
Schmidt: Die Verbreitungswege der Karzinome und die Beziehung generalisirter Sarkome zu den leukämischen Neubildungen, Jena, 1903.
Takahashi: J. Path. and Bacteriol., 1915-16, vol. xx, p. 1.
Tyzzer: J. M. Res., 1913, vol. xxiii, p. 309.
Van Raamsdonk: Nederlandsch Tijdschrift v. Geneeskunde, 1921, vol. i, p. 3355.
Virchow: Die Krankhaften Geschwulste, Band 2. Berlin, 1864-5.
Vogel: Virchow's Arch. f. path. Anat., 1891, vol. cxxv, p. 495.
Von Recklinghausen: Virchow's Arch. f. path. Anat., 1885, vol. c, p. 503.
Wood: J. A. M. A., 1919, vol. lxxiii, p. 764.
Zahn: Virchow's Arch. f. path. Anat., 1899, vol. cxvii, p. 30.
What have we learned from this discussion?
At the beginning of this post, I asked you the following questions:
Where did the idea that massage promotes metastasis, and therefore, we shouldn't offer massage to patients living with cancer, come from?
What is the current best practices recommendation for massaging someone with a history of cancer, and on what basis is that best practices recommendation formed?
Why is the idea that we shouldn't massage someone with a history of cancer, because it might promote metastasis, so persistent in the face of what we actually know?
Have your answers to them changed over the course of this discussion? If they have changed, then in what way have they done so?
What else did you learn during this discussion? Can you explain it to someone else now?
How relevant is this discussion to what we practice as MTs?
From Latin embolus (“piston”), from Ancient Greek ἔμβολος (embolos, “peg, stopper”).
embolus (plural emboli)
(pathology) An obstruction causing an embolism: a blood clot, air bubble or other matter carried by the blood stream and causing a blockage or occlusion of a blood vessel.
endothelium
Wiktionary "endothelium", accessed 27 December 2012
endothelium (plural endothelia)
(anatomy) A thin layer of flat epithelial cells that lines the heart, serous cavities, lymph vessels, and blood vessels.
In medicine, a fistula (/ˈfɪstjʊlə/;[1][2] pl. fistulas (/ˈfɪstjʊləz/), or fistulae (/ˈfɪstjʊli/ or /ˈfɪstjʊlaɪ/)) is an abnormal[3] connection or passageway between two epithelium-lined organs or vessels that normally do not connect.
A highly malignant epithelial tumour with a fulminant [quick, intense, and severe] clinical course, bizarre histologic appearance and poor prognosis [predicted outcome]; it is most common in the lung and thyroid, but is well-described in the endometrium, breast and elsewhere.
From Ancient Greek ὑπέρ (huper, “over”) + αἷμα (haima, “blood”).
hyperemia
excess of blood in a body part.
lymphocyte
Wiktionary "lymphocyte", accessed 29 December 2012
A lymphocyte is a type of white blood cell in the vertebrate immune system.
Under the microscope, lymphocytes can be divided into large lymphocytes and small lymphocytes. Large granular lymphocytes include natural killer cells (NK cells). Small lymphocytes consist of T cells and B cells.
A Krukenberg tumor refers to a malignancy in the ovary that metastasized from a primary site, classically the gastrointestinal tract, although it can arise in other tissues such as the breast. Gastric adenocarcinoma, especially at the pylorus, is the most common source. Krukenberg tumors are often (over 80%) found in both ovaries, consistent with its metastatic nature...
Pathogenesis
There has been debate over the exact mechanism of metastasis of the tumor cells from the stomach, appendix or colon to the ovaries. Classically it was thought that direct seeding across the abdominal cavity accounted for the spread of this tumor, but spread by way of the lymphatic is considered more likely.
Latin, from Ancient Greek μέλας (melas, “black, dark”) and -oma (“disease, morbidity”).
melanoma (plural melanomas or melanomata)
(oncology, pathology) A dark-pigmented, usually malignant tumor arising from a melanocyte and occurring most commonly in the skin.
metastasis
Wiktionary "metastasis", accessed 27 December 2012
From Late Latin, from Ancient Greek μετάστασις (metastasis, “removal, change”), from μεθίστημι (methistemi, “to remove, to change”)
Pronunciation
metastasis (plural metastases)
(medicine) The transference of a bodily function or disease to another part of the body, specifically the development of a secondary area of disease remote from the original site, as with some cancers.
obliteration
Wiktionary "obliteration", accessed 27 December 2012
Latin permeātus, participle of permeāre, meaning to pass through.
permeate (third-person singular simple present permeates, present participle permeating, simple past and past participle permeated)
To pass through the pores or interstices of; to penetrate and pass through without causing rupture or displacement; -- applied especially to fluids which pass through substances of loose texture; as, water permeates sand.
To enter and spread through; to pervade.
phagocytosis
Wikipedia "phagocytosis", accessed 29 December 2012
Phagocytosis (from Ancient Greek φαγεῖν (phagein) , meaning "to devour", κύτος, (kytos) , meaning "cell", and -osis, meaning "process") is the cellular process of engulfing solid particles by the cell membrane to form an internal phagosome by phagocytes and protists...Bacteria, dead tissue cells, and small mineral particles are all examples of objects that may be phagocytosed.
Wiktionary "phagocytosis", accessed 27 December 2012
From the German Phagocytosis; equivalent to phagocyte + -osis; compare the French phagocytose.
phagocytosis (countable and uncountable; plural phagocytoses)
(immunology, cytology) The process where a cell incorporates a particle by extending pseudopodia and drawing the particle into a vacuole of its cytoplasm.
Pyknosis (from Greek pyknono meaning "to thicken up, to close or to condense"), or karyopyknosis, is the irreversible condensation of chromatin in the nucleus of a cell undergoing necrosis[1] or apoptosis.[2] It is followed by karyorrhexis, or fragmentation of the nucleus.
polymorphonuclear cells
Wikipedia "Granulocyte", accessed 29 December 2012
Granulocytes are a category of white blood cells characterized by the presence of granules in their cytoplasm. They are also called polymorphonuclear leukocytes (PMN or PML) because of the varying shapes of the nucleus, which is usually lobed into three segments. In common parlance, the term polymorphonuclear leukocyte often refers specifically to neutrophil granulocytes, the most abundant of the granulocytes. Granulocytes or PMN are released from the bone marrow by the regulatory complement proteins.
Wiktionary "retrograde", accessed 27 December 2012
From Middle English < Latin retrogradus.
retrograde (comparative more retrograde, superlative most retrograde)
Directed backwards, retreating; reverting especially inferior state, declining; inverse, reverse; movement opposite to normal or intended motion, often circular motion.
serous (comparative more serous, superlative most serous)
(medicine) Containing, secreting, or resembling serum; watery; a fluid or discharge that is pale yellow and transparent, usually representing something of a benign nature. (This contrasts with the term sanguine, which means blood-tinged and usually harmful.)
Spindle cell sarcoma is a type of connective tissue cancer in which the cells are spindle-shaped when examined under a microscope. The tumors generally begin in layers of connective tissue such as that under the skin, between muscles, and surrounding organs, and will generally start as a small lump with inflammation that grows...Spindle cell sarcoma can develop for a variety of reasons, including genetic predisposition but it also may be caused by a combination of other factors including injury and inflammation in patients that are already thought to be predisposed to such tumors. Spindle cells are a naturally occurring part of the body's response to injury. In response to an injury, infection, or other immune response the connective tissues will begin dividing to heal the affected area, and if the tissue is predisposed to spindle cell cancer the high cellular turnover may result in a few becoming cancerous and forming a tumor.
(anatomy) Of, pertaining to, or containing vessels that conduct or circulate fluids, such as blood, lymph, or sap, through the body of an animal or plant.
Minimum scientific knowledge needed for this discussion
What anatomical system (or systems, depending on how you count them) do we and other complex animals (like dogs, cats, bears, elephants, and tigers) use for movement?
Easy question straight out of Anatomy 101, right? But did you ever think about how organisms or organism parts that don't have muscles and bones are still able to solve the challenge of moving from one place to another?
The Free Dictionary "ameboid movement", accessed 27 December 2012
movement like that of an ameba, accomplished by protrusion of cytoplasm of the cell.
Amoeboid movement is a crawling-like type of movement accomplished by protrusion of cytoplasm of the cell involving the formation of pseudopodia. The cytoplasm slides and forms a pseudopodium in front to move the cell forward. This type of movement has been linked to changes in action potential; the exact mechanism is still unknown. This type of movement is observed in amoeboids, slime molds and some protozoans, as well as some cells in humans such as leukocytes. Sarcomas, or cancers arising from connective tissue cells, are particularly adept at amoeboid movement, thus leading to their high rate of metastasis.
While several hypotheses have been proposed to explain the mechanism of amoeboid movement, the exact mechanism is still unknown.
What it comes down to, then, is that sarcomas and other cells use a method of movement very similar to the amoeba (or ameba: a one-celled animal-like microscopic organism) you see in this video:
As the definitions mentioned, in the video, you saw the cytoplasm slide to stick out (protrude) in the direction the amoeba moved.
Like the amoebas, individual cells in multi-cellular organisms (like us) can also move in a very similar way. Watch how nimbly responsive the human neutrophils (white blood cells) in this video are to the presence of a chemical attractant (this response is called chemotaxis):
As the Wikipedia definition mentioned, the ability of sarcomas to move in this way--although not yet fully explained--is thought to be a factor in their ability to metastasize aggressively.
The esophagus (oesophagus, commonly known as the gullet) is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach. The word esophagus is derived from the Latin œsophagus, which derives from the Greek word oisophagos, lit. "entrance for eating."...
Histology
The layers of the oesophagus are as follows:
mucosa
nonkeratinized stratified squamous epithelium: is rapidly turned over, and serves a protective effect due to the high volume transit of food, saliva and mucus.
lamina propria: sparse.
muscularis mucosae: smooth muscle
submucosa: Contains the mucous secreting glands (esophageal glands), and connective structures termed papillae.
muscularis externa (or "muscularis propria"): composition varies in different parts of the esophagus, to correspond with the conscious control over swallowing in the upper portions and the autonomic control in the lower portions:
From German Mitosis, from Ancient Greek μίτος (mitos, “thread”) + -osis, probably in reference to the thread-like chromatin seen during mitosis.
mitosis (plural mitoses)
(cytology) The division of a cell nucleus in which the genome is copied and separated into two identical halves. It is normally followed by cell division.
Occam's razor
Wikipedia "Occam's razor", accessed 29 December 2012
Occam's razor (also written as Ockham's razor, Latin lex parsimoniae) is the law of parsimony, economy, or succinctness. It is a principle stating that among competing hypotheses, the one that makes the fewest assumptions should be selected.
In animal tissue, stroma (from Greek στρῶμα, meaning “layer, bed, bed covering”) refers to the connective, supportive framework of a biological cell, tissue, or organ.
The stroma in animal tissue is contrasted with the parenchyma...Stromal cells are the non-tumor cells in tumors.
Parenchyma is the bulk of a substance. In animals, a parenchyma comprises the functional parts of an organ and in plants parenchyma is the ground tissue of nonwoody structures.
The term parenchyma is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour".[1]
The parenchyma are the functional parts of an organ in the body. This is in contrast to the stroma, which refers to the structural tissue of organs, namely, the connective tissues.
In cancer, the parenchyma refers to the actual mutant cells of the single lineage, whereas the stroma is the surrounding connective tissue and associated cells that support it.
Early in development the mammalian embryo has three distinct layers: ectoderm (external layer), endoderm (internal layer) and in between those two layers the middle layer or mesoderm. The parenchyma of most organs is of ectodermal (brain, skin) or endodermal origin (lungs, gastrointestinal tract, liver, pancreas). The parenchyma of a few organs (spleen, kidneys, heart) is of mesodermal origin. The stroma of all organs is of mesodermal origin.
The peritoneum (pron.: /ˌpɛrɨtənˈiəm/) is the serous membrane that forms the lining of the abdominal cavity or the coelom—it covers most of the intra-abdominal (or coelomic) organs—in amniotes and some invertebrates (annelids, for instance). It is composed of a layer of mesothelium supported by a thin layer of connective tissue. The peritoneum both supports the abdominal organs and serves as a conduit for their blood and lymph vessels and nerves.
The abdominal cavity (the space bounded by the vertebrae, abdominal muscles, diaphragm and pelvic floor) should not be confused with the intraperitoneal space (located within the abdominal cavity, but wrapped in peritoneum). The structures within the intraperitoneal space are called "intraperitoneal" (e.g. the stomach), the structures in the abdominal cavity that are located behind the intraperitoneal space are called "retroperitoneal" (e.g. the kidneys), and those structures below the intraperitoneal space are called "subperitoneal" or "infraperitoneal" (e.g. the bladder).
When we look at it from the outside, the brain appears to be composed of two major regions: the larger cerebrum and the smaller cerebellum.
In this brain photograph--which, if it were still connected to its eyes, you would see that you are viewing it from the left side--the cerebrum is the larger region, superior to (above) the smaller cerebellum, which has been stained a light purple color.
The cerebrum controls the processing of sensory input, complex cognitive processes such as using language and decision-making (such as consciously deciding to move skeletal muscles), and memory, among many other things. We'll talk about it later in its own dedicated post.
The cerebellum, on the other hand, tends to operate with different aspects of movement than the cerebrum does, at an involuntary or unconscious level. Its most well-understood function is in controlling aspect of movement that we don't think about consciously, such as coordination, balance, and motor control.
Loca, the pug who couldn't run, shows what happens when the cerebellum is damaged or otherwise impaired--what you see in this video appears to be some kind of damage to the cerebellum that permits her to walk relatively normally, but severely disrupts her running.
You can use Loca as a mnemonic (a memory aid) to remember the functions of the cerebrum compared to those of the cerebellum--watch her movement, coordination, balance, and motor control as she tries to run, and you'll see what happens to those functions when the cerebellum doesn't work quite right.
Yet, as far as we can see from the video, there is no indication of any disorder of the cerebrum--she decides to run at appropriate times, when other dogs are running and playing.
The decision to run--made in Loca's cerebrum--seems perfectly normal, at least, as far as we can tell from a short movie.
It's the non-voluntary parts of the running, such as her balance and her coordination, where the difficulty lies. And those non-voluntary aspects of movement go back to her cerebellum.
Scope of practice note
I cannot diagnose, but as a anatomy/physiology teacher, Loca's movement disorder looks to me like cerebellar damage or impairment of some kind.
I checked with my cats' veterinarian, Dr. Davis, to make sure that I wasn't overlooking something that a clinician would see right away.
As an ethical practitioner, she would never definitively diagnose any animal only at a distance through a video alone, without an examination and a thorough history, but she agrees that--as far as we can see from the small sample contained in this video--the way that Loca runs is certainly consistent with some type of condition in which the cerebellum is damaged.
Cultural note
There is a word used for emphasis in the video which is a very strong and emphatic curse or swear word in American English.
In Irish English, on the other hand, the word "feckin" is used much more easily and casually by many people, and is not nearly so shocking as the American English equivalent is in context.
You should know that before you listen to the video, or show it to someone else, so that if strong language is something you want to avoid, you're not taken by surprise.
cheers, to Anne Davis, and to Loca and her family!
Diane Jacobs, talking about dermoneuromodulation (DNM)--a practice that she has developed, and that we'll talk more about here later--answered that intellectual property question first, and better than I could have come up with off the top of my head.
When asked:
What's a good name for working top down and bottom up?
she answered:
Dermoneuromodulation.
It covers the manual territory from skin cell to self of self and leaves out the mesoderm entirely. It is not a copyright term.
Anyone can use it, to describe what they do, manually, if they want. This made-up word is not copyright. I give it away. Please take it. Use it to get away from words like "fascia" and "muscles" and "joints" and "bones" and "ligaments" and "tendons".
In the same way as Diane practices with regard to her development of DNM, I don't claim any restrictions on anyone's access to use of the term through copyright or ownership over the term "biopsychsocial massage (BPSM)".
I give it away to the community to use freely, in the same spirit of open access and Creative Commons licensing that POEM is founded on.
There is only one condition of usage--you cannot apply the term to something it is not, any more than someone can make a dog into a cat, just by calling it one.
In a similar way, you can't make non-BPSM practices into BPSM simply by slapping that label on them.
Diane explains that, although she gives the term away freely, that
It should contain only nervous system considerations though, because really, when push comes to shove, only the nervous system can respond (short term, OR, and ESPECIALLY, long term) to what we "do" to another person, manually. Of that I'm convinced.
Similarly, if you're not practicing biopsychosocial massage, the term does not apply to what you actually are doing.
You have every right under principles of freedom of conscience to reject classical Newtonian physics, for example, and to say that it does not apply to the work that you are doing. But that claim is inconsistent with the principles of BPSM, and so that inconsistency means, beyond the shadow of a doubt, that your practice is not a biopsychosocial massage practice. Which is fine in itself; you are entitled to practice any way you want to, subject to professional ethics and to regulations in your jurisdiction. All it really means is that you don't get to label it something that it is not--no more, no less.
There is a Cambodian saying that men are like diamonds and women are like silk--if you drop them in the mud, you can wash the diamond and it's as clean as it ever was, but the silk is stained forever.
«បុរសជាមាសទឹកដប់ ទោះធ្លាក់ចូលភក់ ហើយលើកមកវិញ ក៏នៅតែជាមាសទឹកដប់ដដែល តែនារីវិញ ប្រៀបបាននឹងកំណាត់សំពត់ស បើកាលណាធ្លាក់ចូលភក់ជ្រាំហើយ ទោះខំប្រឹងបោកគក់លាងសម្អាតយ៉ាងណា ក៏មិនដូចដើមដែរ» (courtesy of Frank Smith)
Let's put aside for the moment the blatant sexism in that proverb ("dropping them in the mud" is a metaphor for their being sexually active, and this is the classic embodiment of the double standard against women in so many traditional societies), and see if there is any useful imagery there for us to communicate a distinction in a totally different domain, without being insulting to more than half of the population.
The term "biopsychosocial massage" refers to massage practiced in an evidence-based, science-based, client-centered way, that understands health, wellness, and disease in terms of natural (not supernatural) processes in the material physical universe among biological, psychological, and sociocultural aspects of life, as well as their interactions and the emergent effects that arise from them.
Anyone who practices massage in this way is practicing BPSM.
If that term is consistently applied to only those practices, then it is a clean and brilliant diamond that clients and other massage stakeholders can use as a baseline to understand exactly what BPSM has to offer.
If the term is (figuratively) dropped in the mud by applying it to anything and everything, no matter whether or not it is consistent with the principles of BPSM, then--like the silk--it is stained forever, and it becomes useless for clients and other massage stakeholders to use as a guide to understand what BPSM has to offer.
So I give the terms "biopsychosocial massage" and "BPSM" to the community to use freely, on the one condition that they not be diluted by applying them as mere buzzwords to massage or other practices that are not massage practiced in an evidence-based, science-based, client-centered way, that understands health, wellness, and disease in terms of natural (not supernatural) processes in the material physical universe among biological, psychological, and sociocultural aspects of life, as well as their interactions and the emergent effects that arise from them.
(Not yet clear on what that means in actual practice? That's ok; there's a great deal of rich material there to explore in depth. We're going to spend some quality time connecting the dots, and translating them into what they mean for actual practice. I just want to get that general principle out there; now that it is, we can do some real work on establishing what it means in practice.)
So the answer to the question in the post title, "Who owns BPSM?" is: It is entrusted to the responsible and sustainable stewardship of the massage community.
cheers, to Diane Jacobs!
UPDATE, 18 November 2012, 10:57 AM PT:
Gayla Coughlin points out that some of my statements above, as written, are unclear in what they mean for actual practice, and might result in outcomes that I don't want.
I thank her for giving me the opportunity to correct my inaccuracies, and to get closer to my intended outcome.
I am thus taking out a Creative Commons license on biopsychosocial massage (BPSM), and here are the conditions attached to that license.
The particular form of the Creative Commons license that most suits my intent for this work is Attribution-ShareAlike CC BY-SA.
Their blurb explains:
This license lets others remix, tweak, and build upon your work even for commercial purposes, as long as they credit you and license their new creations under the identical terms. This license is often compared to “copyleft” free and open source software licenses. All new works based on yours will carry the same license, so any derivatives will also allow commercial use. This is the license used by Wikipedia, and is recommended for materials that would benefit from incorporating content from Wikipedia and similarly licensed projects.
What this means is that you can build on, develop, and grow biopsychosocial massage, but only on the condition that you share your work with the community in the same way ("license their new creations under the identical terms")--you cannot take the work that I and others have done on biopsychosocial massage, and trademark or copyright it for yourself. This license thus protects biopsychosocial massage for use by the entire community, rather than having someone seize it away from us in a proprietary way.
to Share — to copy, distribute and transmit the work
to Remix — to adapt the work
to make commercial use of the work
This means it is approved for Free Cultural Works
Under the following conditions:
Attribution — You must attribute the work in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work).
Share Alike — If you alter, transform, or build upon this work, you may distribute the resulting work only under the same or similar license to this one.
With the understanding that:
Waiver — Any of the above conditions can be waived if you get permission from the copyright holder.
Public Domain — Where the work or any of its elements is in the public domain under applicable law, that status is in no way affected by the license.
Other Rights — In no way are any of the following rights affected by the license:
Your fair dealing or fair use rights, or other applicable copyright exceptions and limitations;
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Notice — For any reuse or distribution, you must make clear to others the license terms of this work. The best way to do this is with a link to this web page.
If my statements above sounded like I objected to commercial use on anyone's part, then that was due to my inaccuracy--I have no objection to anyone earning a living by teaching classes, writing books, or anything like that, as long as you honor the moral rights that attach to my Creative Commons licensing of biopsychosocial massage. And by "mere buzzwords", I was not objecting to using the term to market your works based on biopsychosocial massage. I specifically meant slapping the label on practices where it does not apply, in order to market something that is incompatible at its core with biopsychosocial massage.
By "moral rights", I specifically mean that I do not want anyone to use the label "biopsychosocial massage" to endorse practices that are anti-scientific or pseudoscientific, or that are not client-centered. Those violate the spirit of biopsychosocial massage, and are an infringement of my moral right to delineate a set of massage practices and theory that are consistent and compatible with modern science and with evidence in the material physical world.
If you respect that moral right, then you are free to build on and develop biopsychosocial massage for non-commercial or commercial uses, but you cannot take it away from the community by trademarking or copyrighting it for yourself.
So I believe that the conditions of this license protect my intent to release it to the responsible and sustainable stewardship of the community, at the same time that it protects the content from being distorted by misuse of the label to apply to something that contradicts the heart of biopsychosocial massage.
There is grandeur in this view of life, with its several powers, having been originally breathed into a few forms or into one; and that, whilst this planet has gone cycling on according to the fixed law of gravity, from so simple a beginning endless forms most beautiful and most wonderful have been, and are being, evolved.
Their many letters to each other over the years (preserved online in the Darwin Correspondence Project) stand as a testament to how much they thought, cared, and worried about each other.
The state of mind that I wish to preserve with respect to you, is to feel that while you are acting conscientiously & sincerely wishing, & trying to learn the truth, you cannot be wrong; but there are some reasons that force themselves upon me & prevent my being always able to give myself this comfort.
--Darwin Correspondence Project, Darwin, Emma to Darwin, Charles [c. Feb 1839] accessed 17 November 2012
She wants to feel secure that, if she (or he, or anyone) is really trying diligently and sincerely to learn what is true, that that effort guarantees that she cannot possibly be mistaken about what she is learning. The reason she is so concerned about this is that she was devoutly religious, and she knew that Charles had doubts about religion.
To be impossible to be wrong, through sheer effort and sincerity, is a lovely wish--and yet, in the same sentence, she admits to her beloved husband that even she herself cannot always keep up that belief.
She was right to be concerned about that issue--the history of science at that time in England contains many examples of geologists, paleontologists, biologists, and other scientists who set out on a journey to find evidence in the materialphysicalnatural world that proved the stories in the Bible to be literally true.
For example, if the story of Noah's Ark and the Flood were literally true, you would find evidence of it in the layers of rock in that part of the world. The scientists who set out to find it discovered that that evidence is not there, but other evidence, showing that other things happened, is indeed there.
The scientists who set out to demonstrate that the earth is literally only a bit more than 6000 years old demonstrated instead that they would have to reject all the other multiple sources of repeatable, verifiable evidence that showed the earth to be much older than that.
Darwin himself demonstrated that--rather than the Genesis creation story that species were created one time in their present and unchanging form--species actually change over time to better adapt to the environments they find themselves in.
When the evidence these scientists found contradicted what they wanted it to say about the literal truth of the Bible, they faced a test of their own moral character in deciding what to do next about that fact:
Some of the most solid scientific knowledge that we rely on every day came from people who had the courage to face the implications for their beliefs that the evidence presented them, and the integrity to not turn away from or deny the contradictions, but rather to engage with them.
To take a more contemporary example of that same spirit, this quotation from Julie Onofrio is, for me, the essence of the courageous engagement that we so urgently need to participate in if we really want to become a profession:
Having an open forum and getting some help in analyzing research is really needed in our profession. Yes, I have to say it disturbs me when the researchers say things like traditional modalities don't work--it's like a slap in the face to all who are doing energy work, or reiki, or Rolfing, and having results and success. It's very hard not to take it personally, but also to set emotions aside and remain in communication. But that is why I support it. I want to learn more and to support the profession in understanding research.
This willingness to remain engaged, even when it's difficult because it contradicts what we've been taught, is nothing short of admirable. Julie is showing the courage of facing difficult dilemmas that evidence presents us about how massage actually works, and she is actively engaging with that process, and in that, she is going the extra mile.
Like Emma and Charles Darwin, most MTs are good, decent, caring, and loving people, who want to understand the truth.
If just wanting it sincerely, and working hard at it, were enough by themselves to avoid error, most of us would be there already.
Sadly, in this material physical universe, those good intentions are not sufficient to help us to be correct.
The Board has undertaken a major revamp of policies and procedures, one which is causing a great deal of disruption among nationally certified MTs and continuing education providers.
Its CEO, Mike Williams, states that the purpose and effects of this change are
streamlined online processes, enhanced communications, and improved programs that elevate the profession and better serve the public.
Some of those changes may well have that effect--I am not personally nationally certified, and I have not yet examined the changes in depth as other MTs and bloggers such as Laura Allen have.
Q: Will NCBTMB continue to accept alternative courses like energy work, aromatherapy, animal massage, etc?
A: Yes. Massage therapy is part of the holistic profession as are several other modalities and techniques. NCB will continue to accept modalities and techniques that can be legally practiced by a massage therapist without another healthcare provider, (i.e., DC, MD, PT) present. As long as the technique or modality can be shown to be embedded in the lineage of massage, it will be accepted. This means that if the core information of the technique or modality can be referenced as a derivative of another technique or modality that is within the massage therapy scope of practice it will be accepted.
The argument over the relationship between massage and "energy work" is nothing new.
In the early 1990s, when I was in massage school, the NCBTMB was developing the first national certification exam--the National Certification Examination for Therapeutic Massage and Bodywork (NCETMB). Eventually, as a result of consumer pressure, they were forced to offer an energy-free alternative, the National Certification Examination for Therapeutic Massage and Bodywork (NCETM), for those MTs who did not want to be coerced into an anti-evidential belief system as the price of their professional training and licensure.
Although the argument is nothing new, there was a fresh opportunity to do something innovative here among the other disruptive changes--but NCBTMB did not take that opportunity.
Instead, they opted to permit teaching any information (which includes misinformationand malinformation) as approved continuing education, as long that that can be shown to be "embedded in the lineage of massage". Considering the long history of "massage myths", documented by Laura Allen (here and here), Lee Kalpin, Paul Ingraham, and many others, it is clear that just because an idea has been embedded in massage, even for a very long time, that does not mean the idea is correct.
NCBTMB had an opportunity to stand up for the principle that, in the therapeutic encounter, a professional should provide only validated warranted (justified or justifiable) high-quality information to the client.
They did not take the opportunity to stand up for that principle, and as a result of that decision, I cannot participate in their new process. I will not go on to apply for national certification as a practitioner, nor will I become an approved continuing education provider under those standards.
I regret those facts, as I consider them massive missed opportunities. But I cannot do it, because our first principles on these matters are so far apart as to be irreconcilable.
Don't misunderstand me here--I am positive that the NCBTMB members are well-intentioned, and that they wanted to do the right thing. I genuinely believe that they were attempting to have the best of both worlds for the benefit of all massage stakeholders, and to not hurt anyone's feelings.
I respect them as the kind, caring, motivated, passionate people that they clearly are.
If that, by itself, were enough to be right, as Emma Darwin wished, we would not have to have this very serious and difficult discussion.
But evidence doesn't work like that--you can't pick and choose which evidence you accept, and which you reject. Either you accept all the evidence, and you go courageously wherever those implications take you, or you just don't accept the evidence.
If they are going to accept massage's traditional explanation of "energy work"--no matter how many times that explanation has been shown by the evidence to be mythical--as validated approved continuing education with their official imprimatur, then they are not preparing MTs who are taught that explanation for modern translational science. Holding on to old ideas even after they have been disproven is an active obstacle to understanding these new developments.
The environment of massage is exhibiting selection pressures toward a type of massage that is integrated with validated high-quality information, and that prepares MTs for understanding advances in neuroscience, cognitive science, endocrinology, and pain science, and translating that understanding into clinical practices that are client-centered and effective.
As a direct response of those pressures, biopsychosocial massage is breaking off from the main lineage of massage to provide a new massage lineage that is fully consistent with those principles.
You can consider this the official birth announcement of a new lineage of massage.
Biopsychosocial massage (BPSM) is massage understood and practiced in a biopsychosocial model. It understands massage, health, wellness, and illness, and the knowledge bases underpinning those concepts in an evidence-based, natural (meaning, not supernatural), organic way that draws on what we know about biology and other natural sciences, psychology, sociocultural aspects of being human, and the emergent effects that arise from interactions among these various factors.
Psychosocial and cognitive approaches don't require that you become a clinical psychologist but that you have a broad concept of the influence of those factors and that you account for them in your encounters with your patients. Know the literature and be able to give management advice based on evidence. When people come to see you they want a plan. Have a plan that is defensible and that works toward their goals. Address concerns, fear avoidance, other stress, and unhelpful beliefs with compassion, understanding, empathy, and informed knowledge.
Understanding why people hurt is part of our professional responsibility and should change most everything we do on a daily basis away from traditional methods and towards methods defensible with modern science.--Jason Silvernail accessed 5 August 2011
An example of a biological factor in health could be increased cortisol in the bloodstream in response to chronic stress. The interaction of that biological factor with the increased daily stress in modern society would be an example of interactions among biological factors and sociocultural factors.
An example of a psychological factor in health could be a man who is less likely to seek professional treatment for pain than a woman is, because of his perception that stoically enduring pain is what men do in the society he grew up and lives in. The increased structural damage that can occur as a result of ignoring symptoms and delaying treatment is an example of the interactions among psychological factors and biological factors.
An example of a social factor in health could be the relative stigmatization of mental or behavioral illness, as compared to how more clearly structural conditions are regarded. This stigmatization can drive psychological conditions underground--say, for example, if someone did not get needed psychological treatment because they didn't want it to show up in their medical record. That would be an example of interactions among sociocultural factors and psychological factors.
Biopsychosocial massage is client-centered. That means that the psychological and social factors in the client's unique experience, as well as the universal biological factors we are all subject to, is the center of where we focus our attention and caring. It doesn't mean that we accept everything in someone else's experience is literally true. It does mean that we recognize that, for them it feels true, and for that reason alone, it is important in where we meet the client in the therapeutic encounter.
Biopsychosocial massage welcomes self-expression and the art of massage. It is clear, however, that sometimes our need for self-expression can come into conflict with clients' immediate healthcare needs, and--when that happens--we recognize that, in order to act as healthcare professionals, our ethical fiduciary duty is to put the clients' needs first, ahead of ours if necessary.
Biopsychosocial massage is wholistic, integrative, and evidence-based. That means that it does not draw upon supernatural explanations of mechanisms, and it builds upon foundational knowledge in the sciences to evaluate and validate the evidence for or against particular claims of effectiveness or mechanisms.
That means that we understand and practice it in a holistic, complementary, and integrative way, integrated with other domains of human knowledge and with the natural universe we find ourselves in, rather than silo'ed off in an alternative universe that denies material physical reality, and isolates us away from members of the client-centered biomedical healthcare team.
If a proposed explanation for an effect requires us, for example, to reject physics, as the explanation of "energy work" embedded in massage tradition does, then we face that contradiction head on, and we work to resolve it. If that means updating old beliefs in the light of new evidence, then that is the consequence of practicing biopsychosocial massage.
Michael Hamm is another contemporary example of courageous engagement, facing the evidence head-on and seeking to better understand. I'm paraphrasing his quote here, and I trust that he'll correct me if I've gotten it wrong. If I can find the original quote, I'll replace the paraphrase, but it was something to this effect:
I understand and accept that the traditional anatomical explanation behind craniosacral therapy doesn't hold up in light of the evidence. At the same time, I can't deny that I feel something when I am doing that work, something that I can't explain. I want to better understand what is going on when I do that work.
In the absence of clear evidence of what is exactly going on, this suspension of previous belief that has been disproven (and not yet replaced) is totally in line with the principles of BPSM. We don't have to always know everything; we just have to know what we do know, what we don't know, and how strong the evidence is behind our knowledge.
Since our encounters with clients will always run ahead of the available high-quality evidence, we don't limit ourselves only to what has been rigorously validated by studies and nothing else. We take our professional experience into account, and we actively seek to understand and incorporate the clients' preferences, whenever possible, in treatment. But in all these cases, in developing our approach to caring for the client, we remain clear on what is evidence, what is speculation, what is science, what is art, what is literal, and what is metaphor.
Understanding the material physical universe around us, and the centuries of cumulative human knowledge about that universe, give us powerful tools to draw upon. That understanding, combined with the caring that characterizes so many people who choose to go into massage as a career, is the heart of biopsychosocial massage.
Neil deGrasse Tyson sums it up almost perfectly:
I am driven by two main philosophies, know more today about the world than I knew yesterday. And lessen the suffering of others. You'd be surprised how far that gets you.
--Neil deGrasse Tyson
That quotation demonstrates the core of massage in a biopsychosocial model.
Over time, here at POEM, we will be following that evidence where it leads, and courageously engaging with the meanings that it shows for the practice of massage therapy. I expect intense, passionate, and fruitful discussions here over the next few years.
I can't really say much about the article itself until I get to the University later this week, and can get behind the paywall, but the abstract certainly served its purpose--it alerted me that this is a potentially interesting and very useful article, and that I should go to the effort to get the entire article and read it.
Massage therapists encounter skin on a daily basis and have a unique opportunity to recognize potential skin cancers. The purpose of this study was to describe the skin cancer education provided to massage therapists and to assess their comfort regarding identification and communication of suspicious lesions. An observational retrospective survey study was conducted at the 2010 American Massage Therapy Association Meeting. Sixty percent reported receiving skin cancer education during and 25% reported receiving skin cancer education after training. Massage therapists who examine their own skin are more likely to be comfortable with recognizing a suspicious lesion and are more likely to examine their client's skin. Greater number of clients treated per year and greater frequency of client skin examinations were predictors of increased comfort level with recognizing a suspicious lesion. Massage therapists are more comfortable discussing than identifying a potential skin cancer. Massage therapists may be able to serve an important role in the early detection of skin cancer.
Once again, we have an invitation to up our game, to commit to the shared body of knowledge of the client-centered healthcare team, and to contribute in a specific way to that team and to the client's well-being.
What are some concrete steps we could take--individually, through our organizations, both ways, or some other way--that would demonstrate that we are serious about wanting massage to become a healthcare profession, and to take steps toward accepting that invitation?
Is this something that we really want to do? What are the risks and benefits of doing so?
The images above show the 3 classic types of skin cancer. Reading from left to right, what are the names of the skin cancers in the photographs?
Reading from left to right, do the types of cancer you see in the images get more common or less common in occurrence in the general larger population?
Reading from left to right, do the types of cancer you see in the images get more deadly or less deadly?
If you saw a skin lesion on a client during a session, and the lesion looked exactly like one of the types of cancer you see in the images, what words would you choose to talk to the client about what you saw?
I always looked forward to my trip over the bridge to see my client, Mrs. Ford, in her skilled nursing facility in West Seattle.
Mrs. Ford had a long history of smoking before the stroke that took away most of her ability to speak and to move, so she was quite frail and had difficulty breathing. Despite the fact that she couldn't talk to me, and that she was mostly paralyzed, she was a sweet, cheerful lady, who managed to communicate a lot of meaning without being able to speak.
We worked out a system, much like "20 Questions", where I'd ask a yes-or-no question, and--based on the answer to that question--I'd choose the next question to ask. Depending on the quality of her sigh in response, I knew the answer was "yes" or "no", and then we'd proceed to the next question, until I was sure she was comfortable, securely positioned, and ready for her massage.
It was a laborious method, but it met her communication needs in the absence of her being able to speak.
Since I was so used to communicating with her in this way, I was totally blown away one day when, lying supine on the table, she grabbed my wrist in a death grip, and pulled me close to her face.
In a breathy whisper, she slowly forced her lips to form the words "Shheee's.......hurrttingg......mmmeeeee."
One of the nursing assistants had been abusing her, knowing that she was unable to defend herself.
Do you know what the laws are in the state regarding your status as a mandated reporter--one who is required to report cases of suspected abuse or neglect of a member of a vulnerable population?
Are you considered a mandated reporter?
If so, what populations are you responsible for making reports about, if you suspect that someone is being abused or neglected?
What counts as abuse? Physical? Sexual? Emotional? Financial? Neglect?
They seem pretty good, but it would also not hurt to check them against other information sources, such as the local chapter of your professional organization, for example.
The reason I'm not sure it's right is that, for my state (Washington), it lists MTs as mandated reporters for elder abuse, but not for children.
It's not impossible that that's the way the law really reads, but I want to double-check that before assuming.
In a way, it doesn't matter, because I am not about to sit on my hands and say, oh, well, a child's being abused, but I'm not required to report it, la la la. So it won't change what I would ever do if I did learn that a child was being abused.
But on the other hand, it does seem odd that elder abuse reporting is mandated, but child abuse is not.
So for the moment, at least, I'd treat this source much as I treat Wikipedia--a good portal or jumping-off place, but not the be-all and end-all of necessary information that I depend on to get exactly right.
What happened with Mrs. Ford was this: I asked her daughter what she might be talking about, because I did not fully understand. Her daughter suspected she knew who her mother was talking about, and confirmed it with her mother.
We then went to the director of the skilled nursing facility to report it.
It turned out that this nursing assistant had a checkered track record, and was on probation. Abusing Mrs. Ford was the last straw, and the nursing assistant was let go after an investigation of the accusation.
I continued to work with Mrs. Ford for a couple of years after that, and when I returned to school, she was the only client that I kept on working with while trying to adjust to the grad school environment and the course load.
I stayed her MT until she passed away.
But except for that one time, she never tried to speak verbally to me again.
We're all clear (I hope) on the principle that MTs--at least in the US--do not diagnose or prescribe. It would be a massive overreach to do so, and we'd deserve the smackdown that would result if we got caught doing it.
It would never be right for us to inform someone that they have a particular disease, nor to prescribe to them what they should do about any condition they have.
But we do observe during a session, and as a result, we sometimes see things that need to have prompt action taken, in order to protect the client from harm.
So we need to be skillful about reporting what we observe to the client--we may need to balance the urgency of making it clear to the client how serious it is to follow up, versus not diagnosis, prescribing, or unnecessarily frightening them.
There are many anecdotal cases of MTs telling clients that they should get a suspicious skin lesion checked out. When the diagnosis turns out to be melanoma, which--if it remained undetected--would very likely disfigure and then kill them, then the MT rightly gets the credit for saving the client's life.
Melanoma accounts for only 4% of all skin cancers; however, it causes the greatest number of skin cancer–related deaths worldwide. Early detection of thin cutaneous melanoma is the best means of reducing mortality.--Medscape, "Cutaneous Melanoma" accessed 20 August 2012
Sometimes, that early detection that is the best means of reducing mortality (the death rate) comes from an MT who observes something, and tells the client "I think you ought to get that checked out with your primary healthcare provider.".
This case report is similar, yet the lesion the MT observed and recommended follow-up for to the client came from a very different condition.
Syphilis is a horrible way to die.
Source: "Portrait of Gerard de Lairesse by Rembrandt van Rijn, circa 1665–67, oil on canvas - De Lairesse, himself a painter and art theorist, suffered from congenital syphilis that severely deformed his face and eventually blinded him." http://upload.wikimedia.org/wikipedia/commons/4/42/Rembrandt_Harmensz._van_Rijn_095.jpg accessed 20 August 2012
The man in this picture was born with ("congenital") syphilis, and you can see, even in a painting, how disfigured his face is from the disease.
The bacteria that cause syphilis, Trepomena pallidum, are spirochetes--spiral-shaped--as you can see in this electron micrograph from Wikipedia, and are spread mainly by direct sexual contact, and also from mother to child at birth:
Although syphilis is referred to as "protean" (versatile, flexible, changeable) in the article we're about to review, because it can take so many forms, there is a typical presentation that's considered classic of the disease:
Stage I--Primary syphilis: A chancre (painless sore). Usually occurs about 3 weeks after initial exposure to infection.
Stage II--Secondary syphilis: Widespread rash, often involving hands and feet, possibly including other symptoms of infection such as fever, headache, weight loss. Usually occurs about 4-10 weeks after Stage I.
Stage III--Latent syphilis: Asymptomatic. Usually occurs around a year after initial infection.
Stage IV--Tertiary syphilis: Ulcerated lesions, neurological symptoms (loss of balance, apathy, seizures, dementia), cardiac symptoms (inflammation of aorta, aneurysms). Usually occurs anywhere from 3 to 45 years after initial infection.
The disease has been recorded in art and literature in Europe since about the 1500s. That fact, and the discovery of thousand-year-old tombs in Peru, where mummies and bones showed signs of the disease, reinforce the hypothesis that the disease originated in the New World, and was brought back to Europe by the crews of explorers and conquerors.
Syphilis goes back in recorded history for centuries--most of that time without effective treatment--and devastated people of all classes and walks of life. Those facts, along with the intimate linkage of the disease with love and sex, means that it figures largely in literature and art of the 18th and 19th centuries.
Keats' poem, "La Belle Dame Sans Merci (The Beautiful Lady Without Pity)" is often interpreted to represent the disease as a beautiful lover, who coldly strikes down kings, princes, and knights with no regard for their suffering:
I met a lady in the meads,
Full beautiful—a faery’s child,
Her hair was long, her foot was light,
And her eyes were wild.
...
I made a garland for her head,
And bracelets too, and fragrant zone;
She look’d at me as she did love,
And made sweet moan.
...
She found me roots of relish sweet,
And honey wild, and manna dew,
And sure in language strange she said—
“I love thee true.”
She took me to her elfin grot,
And there she wept, and sigh’d fill sore,
And there I shut her wild wild eyes
With kisses four.
...
I saw pale kings and princes too,
Pale warriors, death-pale were they all;
They cried—“La Belle Dame sans Merci
Hath thee in thrall!”
Twentieth-century medicine--specifically, the discovery of the antibiotic penicillin--made enormous inroads into the suffering caused by syphilis, and in the developed world, the disease is much more under control than it used to be. (It's a different story in the developing world, and that's a big enough topic to deserve its own post later on.)
But cases still occur, and although it's unlikely that you'll ever have a client suffering from untreated syphilis, it's not totally impossible, either.
Here's a case report of an MT who observed something suspicious, acted upon that suspicion, and probably saved the client's life, sparing him a great deal of suffering from the later stages of the disease, as well.
Syphilis is a disease with protean manifestations that often goes undetected in its early stages. Recently an upsurge in syphilis has been reported amongst gay men in various parts of the UK despite changes in sexual behaviour towards safer sex as a consequence of the HIV epidemic. We report a case of syphilis in which transmission occurred despite safer sex in which the diagnosis was flagged up by the observations of a complementary therapist.
Important take-home points:
Syphilis is "protean"--changeable, variable, flexible. It can take many forms.
Because it can be so changeable, its early stages--where it's most treatable--can go undetected. If the disease is missed in the early stages, that lays the groundwork for the devastating later stages that can include neurosyphilis and cardiac involvement.
The HIV epidemic has led to safer sex practices, which is turn had led to a decrease in syphilis rates, BUT recently (2003, as of this article) syphilis rates have surged higher--why this is the case, they do not say.
The MT was the one who observed the symptoms of syphilis in this client and referred him for diagnosis and treatment of what turned out to be a very serious disease.
Case report
A 50-year-old HIV-positive gay man attended a complementary therapist on the infectious diseases ward for a massage in July 2001.
Here's an example of where massage is incorporated into a hospital ward in a National Health Service (NHS) hospital in England.
We know the client is HIV-positive, so opportunistic infections--ones that take the opportunity of establishing themselves, with the immune system weakened by HIV--are always something to keep in mind as a risk for this client.
The masseuse noticed a rash on the patient’s feet that was not present on previous visits and referred him directly to the HIV clinic the same day.
Important take-home points:
Although the rash on the feet is part of the classic symptomatic presentation in Stage II syphilis, there are many other things it could be as well, and we never diagnose.
The MT referred the client directly to the HIV clinic (where there are primary healthcare providers to diagnose and treat), where he was seen the same day.
Without diagnosing, and without panicking the client, what might you say to get the client to follow up with their primary healthcare provider in a case like this?
If you think about what you might say, and rehearse it, then--if you ever need it--you won't be struggling to come up with words on the spot.
Six weeks previously he had noticed an infection around the nail on his left middle finger which had responded only partially to antibiotics from his general practitioner. He was otherwise well with an undetectable viral load, CD4 count of 640 cells/mL and was taking trizivir and efavirenz as antiretroviral therapy.
Again, we don't diagnose, and would never say so to the client--but it's pretty clear that that was the classic Stage I chancre (painless sore) presentation of syphilis.
It is interesting that it responded only partially to antibiotics from the GP. Did the GP miss anything? Would we comment on that to the client?
He had a long-term male partner with whom he practised oral sex only. Six weeks previously he had contact with a casual male partner in a sauna in London where he had practised active digital rectal penetration but did not have penile penetrative anal sex.
Would we ever ask for this information in an intake or history?
Might this information ever come to us in a different way? If so, in what ways?
What would we do with this information?
If we have a problem with this behavior, would we tell the client?
What is the ethical way for a healthcare provider to deal with aspects of a client's sexual history that might make us uncomfortable?
On examination, he had a maculopapular rash over his trunk and the soles of his feet. A soft tissue swelling was apparent around the nail of his left middle finger, which was not ulcerated and resembled a paronychia (Figure 1). General examination was otherwise unremarkable.
Although the article did not include a picture of the client's rash, this is an example from Wikipedia of what a secondary syphilitic rash can look like:
He underwent a sexual health screen, including urethral, pharyngeal and rectal swabs and syphilis serology. All results were negative except syphilis serology which showed: rapid plasma reagin test: positive 1:64, Treponema pallidum particle agglutination assay: positive, > 1280, syphilis IgM enzyme-linked immunosorbent assay (ELISA) positive, Syphilis IgG ELISA Positive.
Important take-home points:
His bloodwork tested negative for everything else, and positive for syphilis.
He was reviewed five days later with the results of these tests. The rash over his trunk had increased and he had developed painful papules over the palms of his hands. The apparent paronychia on his left middle finger remained. A diagnosis of secondary syphilis was made and he received an uneventful 14-day course of procaine penicillin 600,000 U by intramuscular injection. His regular partner received a full sexual health screen that was negative. The casual sexual contact was untraceable.
Discussion
The case is of interest for a number of aspects. It is probable that this patient’s primary chancre was the lesion noted on his left middle finger. Syphilitic chancres involving the hand with a paronychia have been reported but are uncommon[1,2]. Since the decline of syphilis in the 1980s there are no reports of syphilitic paronychias. This man developed syphilis despite practising 'safer sex'. Recently there has been an increase in syphilis in gay men in the UK. Most cases appear to be acquired from casual sexual contacts in meeting places where anonymity is a feature.
This is the sentence that stands out the most for me in this article, as it shows what real and important value our observations can provide to the client:
The abnormal rash was identified initially by a complementary practitioner who advised that a medical opinion be sought without delay.
The rest of the article is a summation of the situation at the time the article was written:
The Public Health Laboratory Service reports that the number of cases of syphilis in the UK has increased over the last 2 years[3]. In 2000 there were 321 cases of syphilis in England and Wales, and between 1998-2000 an increase of 191% was observed in males. A greater proportion of syphilis infections are transmitted amongst men who have sex with men than any other sexually transmitted infection. The risk of HIV transmission in gay men is also increased when a syphilis infection is present. Since 1997, there have been a number of outbreaks of syphilis in major cities, including Manchester and Brighton. In Manchester nearly half the cases diagnosed were in HIV-positive gay men[4].
Oral sex is quoted as an important factor in the transmission of syphilis in these outbreaks, although our case report highlights another potentially high-risk sexual practice. Whilst the risk of transmission of syphilis can be minimized by using a condom for oral and anal sex, other sexual practices perceived as low risk may still carry a risk of infection.
And, once again, the MT's role in observing something unusual and referring the client to a primary healthcare provider is re-emphasized:
The case also reinforces the need for all staff working within the field of HIV/genitourinary medicine and indeed, other health care professionals, to be vigilant for clinical signs in patients who otherwise appear asymptomatic. In this case it was the masseuse not the clinicians who identified the abnormal rash of secondary syphilis.
The importance of the MT's action should not be underestimated. We've seen what effects undetected and untreated syphilis can have over the course of decades.
By getting the client diagnosed and treated, the MT took action that probably saved the client years of suffering, followed by a dismal death.
Starzychi Z. Primary syphilis of the fingers. Br J Vener Dis 1983;59:169-71.
Fenton KA, Nicoll A, Kinghorn G. Resurgence of syphilis in England: time for more radical and nationally coordinated approaches. Sex Trans Inf 2001;77:309-10.
Lacey HB, Higgins SP, Graham D. An outbreak of early syphilis: cases from North Manchester General Hospital. Sex Transm Infect 2001;77:311-13.
The poem on the surface explores violation of nature and its resulting psychological effects on the Mariner, who interprets the fates of his crew to be a direct result of his having shot down an albatross.----Wikipedia, "The Rime of the Ancient Mariner: Interpretations", Samuel Taylor Coleridge, 1798 accessed 18 August 2012
Spoiler alert! (although there's a decent chance you already had to read this poem in elementary school, so in that case, you already know what happens to the Ancient Mariner and his crew).
The Ancient Mariner is a sailor who commits an unnecessary act of cruelty, even a crime in Coleridge's estimation--with his bow and arrow, he shoots the albatross (a water bird, like a seagull) who had led his lost ship out of dangerous waters.
With his cruel bow he laid full low
The harmless Albatross.
After the killing of the bird, more bad things continue to happen to the ship and crew. All the other crew members are eventually killed, but his punishment is to remain alive, tormented, and to wander the earth telling his story as a warning to others.
He partially redeems himself when--seeing the sea creatures that he had earlier despised, he recognizes how beautiful they really are. He wanders the earth eternally, trying to reach others with his lesson before it's too late for them to learn from it.
There is a metric boatload of things we could discuss about this poem, anywhere from conservation biology, history, psychology, and literature aspects, just to scratch the surface--but I want to talk about my trip to Padilla Bay estuary today, and what living in a littoral environment means for kidney function in animals--and Coleridge's observation about water is the perfect jumping-off point for that discussion.
An estuary is a body of water where fresh water from rivers and oceanic saltwater come together and mingle. So it's a complex transition zone, and organism functions that work one way in fresh water and another way in saltwater have to be covered in both cases there.
The littoral zone is the area of a body of water closest to the shoreline. So in an estuary, the littoral zone is where the fresh water and the saltwater mix--it's saltier than the fresh water is, but it's also less salty than the ocean water.
You probably know that, if you're ever lost on a boat on the ocean, you shouldn't drink seawater--not even a little bit, not even if you're very, very thirsty.
The reason is that your body tries to maintain a balance between the concentration of solutions (like dissolved salt) inside your cells and outside of them. Globetrooper has some good diagrams of what the process looks like, both when it's going right and when it's not.
Globetrooper's diagram shows what it looks like when things are balanced inside the cell and outside of it: a situation called "isotonic": the "same pressure" by water on the cell membrane from both sides.
The large gray circles represent salt ions (to be more specific, sodium ions and chloride ions), and the small blue circles represent water. The proportion of salt dissolved in the water--the concentration--inside the cell is about the same as the proportion of salt dissolved in the water outside the cells. The inside and the outside of the cell are in equilibrium (isotonic), and there is no pressure from the water either to leave or to enter the cell.
Globetrooper's next illustration shows a situation that is no longer isotonic. Salt ions (the gray circles) are dissolved in the water (the blue circles) inside the cell, but outside the cell, there are no salt ions--the water outside the cell is pure water, with no salt in it. This situation is called a hypotonic solution.
Since the inside and the outside of the cell are no longer in balance, a process called osmosis occurs--the movement of fluid (in this case, water) across a semipermeable membrane (a membrane that substances can move through) from an area of lower concentration (in this case, of salt) to a area of higher concentration.
The effect is to bring the concentrations more into balance (isotonic).
The green arrow in this figure shows the movement of water (its osmotic pressure) from the area of low salt concentration outside of the cell to the area of higher salt concentration inside the cell. That movement of water into the cell dilutes the salt concentration, making it lower inside the cell.
This is what happens when we drink fresh water.
The opposite situation occurs when the water outside the cell is more salty (has a higher salt concentration: lots of gray circles, very few little blue circles) than the water inside the cell. This situation is called a hypertonic solution.
In a hypertonic solution, water flows out of the cells--the osmotic pressure of the water is toward the higher concentration of salt.
So you see what would happen? If you drank even a little salt water, it would draw water out of your cells. Instead of quenching your thirst, salt water would leave you more dehydrated than you were when you started.
At the cellular level, this is what it would look like:
In the hypertonic solution, the osmotic pressure comes from the water leaving the cells, leaving behind shriveled, badly dehydrated, cells (left side of image).
In the isotonic solution, the osmotic pressure balances out to zero, as equal amounts of water enter and leave the cells. The red blood cells in an isotonic state look normal and healthy with the indentation in the center that is typical of them.
In the hypotonic solution, the osmotic pressure pushes water into the cells, stuffing and waterlogging them--the normal indentation starts to disappear as the cell is too full of water.
These microphotographs of real red blood cells show how they really look, as they react to the different solutions we just described.
So now that we've discussed how cells behave in different kinds of solutions (hypertonic, isotonic, and hypotonic), does Coleridge's verse
And all the boards did shrink;
make even more sense now?
Why is that?
What is he describing, and why did the boards shrink as a result?
Osmoregulation (the control of osmotic pressure in body fluids, such as blood) is controlled in humans and other vertebrates by the kidneys--that's an important function they have in addition to production and excretion of urine.
Hormones produced by the pituitary gland and the adrenal glands, among others, signal to the kidneys what state the solutions in the blood are--hypertonic, isotonic, or hypotonic--and the kidney responds accordingly by reserving water or by releasing it to restore the balance.
As we are land animals, our kidneys have to respond to fluids we drink or take in in other ways (like an IV solution in the hospital, for example), but that's basically it. Fish, on the other hand, are surrounded by fluid, and their kidneys have to respond to that fluid and balance the water that their cells take in.
Too much water, and the cells swell up and get waterlogged--the hypotonic solution in the previous pictures.
Too little water, and the cells shrink and dehydrate and rupture--the hypertonic solution in the previous pictures.
The fish kidneys have to get the solution just right, and in a situation where the fish is surrounded by fluid of a different concentration.
So freshwater fish and ocean fish have adapted to this problem in pretty much opposite ways--that would seem to make a lot of sense.
But salmon live part of their lives in fresh water, and part of the time in salt water--so how can they have adapted to both, when the adaptations are the opposite of each other?
Salmon have adapted to both lifestyles--they can barely drink and urinate a lot when they live in fresh water, and then change to drinking a lot and barely urinating when they're out in the ocean.
Specialized cells in their body can work in opposite ways, depending on what they need at which stage they are in their lives.
But they can't turn it on a dime--they need days or weeks to make the transition between fresh water and ocean water.
And that's where the importance of the estuarine environment, like Padilla Bay, comes in--as an intermediate zone between the two other environments, it provides a place where salmon can make the transition.
In a region where the salmon can move around in the littoral zone to find the right amount of salt concentration they need, estuaries ensure the survival of those salmon leaving the fresh water where they were born, to go out and spend a large part of their lives in the ocean.
And they also ensure a place where--when it's time to go back up the freshwater river and breed--salmon have a place to adjust back from the ocean to the river environment, so that they can give birth to the next generation, and continue the cycle.
So often, in massage school, we don't have time to teach anatomy this deeply, and that's a real shame. If you just have time to memorize the fact that the kidneys control osmoregulation, so that you can recognize it when the MBLEX or the NCBTMB/NCBTM asks you about it, then that doesn't give you any particular preparation for clinical practice.
But if, at a deeper level, you understand what is going on, and you can draw a line from how the kidneys are involved in salt balance to what happens when that balance gets out of control one way or another, then you can understand what is going on with people living with renal failure or other kidney disease, and you are better equipped to know whether or not it's safe for you to provide massage under the circumstances.
Gnathostomata is the group of vertebrates [back-boned animals] with jaws. The term derives from Greek γνάθος (gnathos) "jaw" + στόμα (stoma) "mouth". Gnathostome diversity comprises roughly 60,000 species, which accounts for 99% of all living vertebrates. In addition to opposing jaws, living gnathostomes also have teeth, paired appendages, and a horizontal semicircular canal of the inner ear, along with physiological and cellular anatomical characters such as the myelin sheathes of neurons. Another is an adaptive immune system that uses V(D)J recombination to create antigen recognition sites, rather than using genetic recombination in the Variable lymphocyte receptor gene.
The group is traditionally a superclass, broken into three top-level groupings: Chondrichthyes, or the cartilaginous fish [sharks and rays]; Placodermi, an extinct clade of armored fish; and Teleostomi, which includes the familiar classes of bony fish, birds, mammals, reptiles, and amphibians.
The Gnathostomata first appeared in the Ordovician period (about 450 million years ago) and became common in the Devonian period (about 360 million years ago).--Wikipedia, "Gnathostomata" accessed 15 August 2012
Fast-forward about 360 million years to France, where, as the story has it**, a young apprentice chocolate maker accidentally pours boiled cream into a batch of chocolate, provoking his master to fly into a fury, and to rebuke him for being a slack-jawed moron--a "ganache", since they were, of course, speaking French.
But the apprentice was redeemed--long after his abusive master has been forgotten, "ganache"--that versatile mixture of chocolate and cream--lives on in confections worldwide.
** Is this legend true? No idea, but it's a widely-told story in chocolatier circles, in any case.
The word "ganache" is rooted in the Greek γνάθος (gnathos) "jaw", and that's how fossilized jawed fishes are connected indirectly through a fluke of history to delicious chocolate treats.
How to make chocolate ganache
A good working ratio is 8 ounces of chocolate to a cup of heavy cream, but this isn't brain surgery, or even baking--chocolate is tolerant of variation, and you can use more chocolate/less cream to make it firmer if you like, or less chocolate/more cream to make it more liquid.
Before you start, you should decide what you want to use your ganache for.
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The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.
William Osler
Mind your boundaries and be tolerant of the uncertainty that is clinical practice.
Jason Silvernail
Absolutely you need to think carefully about the ideas you pass along to your patients. Are they accurate scientifically? Do they serve the patient's best interest given your responsibility to them?
Jason Silvernail
Being a teacher is a little bit like being a psychotherapist. It turns out that you get much more than you give. I am eternally grateful for what I have been given.
